201101_israel journal of psychiatry and related sciences

israel journal of

psychiatry

Vol. 48 - Number 1 2011

ISSN: 0333-7308

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Editorial: The Treatment of Depression During Pregnancy

Deborah Kim and John P. O’Reardon

Volume 48, Number 1, 2011 Israel Journal of Psychiatry and Related Sciences

6

!‫הבחירה בידיים שלך‬ ‫מהיום הזרקה גם בכתף בשריר הדלטואיד‬ ‫כעת תוכל לבחור עבור המטופל שלך את אתר ההזרקה המתאים עבורו‬ :‫קל ונוח למתן‬

1

‫ מחט קצרה ודקה‬ ‫ דורש רק הפשלת שרוול החולצה‬ ‫ אין צורך במיטה או חדר נוסף‬

:‫מחזק את הקשר הטיפולי‬ ‫ מאפשר בחירה של אתר ההזרקה‬ ‫ מאפשר קשר עין עם המטופל‬ 1 ‫ פחות סטיגמה‬ 1 ‫ פחות בושה‬ 1 ‫ מעורר כבוד ואמון‬

Better Adherence Stable Plasma Level Assured Delivery 2

‫ה ה י ד ר ד ר ו ת‬

‫מ ע ג ל‬

2

‫א ת‬

The Use of Electroconvulsive Therapy in Pregnancy

Omer Saatcioglu and Nesrin B. Tomruk

12

Gelotophobia in Israel

Orly Sarid, Willibald Ruch and René T. Proyer

19

Heart Rate Variability during a Continuous Performance Test in Children with Problems of Attention Jacques Eisenberg and Rafael Richman

25

Benign and Time-Limited Visual Disturbances in Heavy Cannabis Smokers Arturo G. Lerner et al.

30

A Case of Klingsor Syndrome Ranjan Bhattacharyya et al.

34

Mothers of Children with Inflammatory Bowel Disease Nathan Szajnberg et al.

42

Predictors of Early Psychiatric Rehospitalization Nelly Zilber et al.

49

Students’ Interest in Psychiatry at School of Medicine Belgrade, Serbia

2

‫ע ו צ ר י ם‬

Nadja P. Maric et al.

54

Comorbidity of Insomnia Detected by the Pittsburgh Sleep Quality Index with Anxiety, Depression and Personality Disorders Hakan Atalay

60 .‫*למידע מפורט יש לעיין בעלון לרופא כפי שאושר ע”י משרד הבריאות‬

Ref: 1. Geerts et al. Poster presented at WPA, September 20–25 2008, Prague, Czech Republic. Poster WCP3864 2. E. Parellada Current Medical Research and Opinion® Vol.2 22, No. , 2006, 241–255 Risperdal CONSTA indicated for the treatment of schizophrenia or schizoaffective disorder.

Idiom of distress or delusional state? Cultural clash as the cause of misdiagnosis Anne-Marie Ulman and Faina Bar

israel journal of

psychiatry and related sciences EDitor

David Greenberg DEPUTY EDITORS

David Roe Rael Strous Gil Zalsman

Book reviews editor

Yoram Barak PAst Editor

Eli L. Edelstein Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Zvi Zemishlany International Advisory Board

Yoram Bilu Aaron Bodenheimer Carl Eisdorfer Julian Leff Margarete Mitscherlich-Nielsen Peter Neubauer Phyllis Palgi Leo Rangell Melvin Sabshin Robert Wallerstein Myrna Weissman

3 > Editorial: The Treatment of Depression During Pregnancy Deborah Kim and John P. O’Reardon

6 > The Use of Electroconvulsive Therapy in Pregnancy: A Review Omer Saatcioglu and Nesrin B. Tomruk

12 > Gelotophobia in Israel: On the Assessment of the Fear of Being Laughed At

Orly Sarid, Willibald Ruch and René T. Proyer

19 > Heart Rate Variability during a Continuous Performance Test in Children with Problems of Attention Jacques Eisenberg and Rafael Richman

25 > Benign and Time-Limited Visual

Disturbances (Flashbacks) in Recent Abstinent High-Potency Heavy Cannabis Smokers: A Case Series Study Arturo G. Lerner,Craig Goodman, Dmitri Rudinski and Avi Bleich

30 > A Case of Klingsor Syndrome: When There is no Longer Psychosis Ranjan Bhattacharyya, Debasish Sanyal and Krishna Roy

34 > Mothers of Children with Inflammatory Bowel Disease: A Controlled Study of Adult Attachment Classifications and Patterns of Psychopathology

Nathan Szajnberg, Melanie Elliott Wilson, Theodore P. Beauchaine and Everett Waters

The Official Publication of the Israel Psychiatric Association Vol. 48 - Number 1 2011

42 > Predictors of Early Psychiatric Rehospitalization: A National Case Register Study Nelly Zilber, Tsipi Hornik-Lurie and Yaacov Lerner

49 > Change of Students’ Interest in Psychiatry over the Years at School of Medicine, University of Belgrade, Serbia

Nadja P. Maric, Dragan Stojiljkovic, Bojana Milekic, Marko Milanov, Jovana Bijelic and Miroslava Jasovic-Gasic

54 > Comorbidity of Insomnia Detected by the Pittsburgh Sleep Quality Index with Anxiety, Depression and Personality Disorders Hakan Atalay

60 > Idiom of distress or delusional state? Cultural clash as the cause of misdiagnosis: A case report Anne-Marie Ulman and Faina Bar

65 > Correspondence, Book Reviews and Correction

Large, Nielssen, Babidge,Ozan, Oral, Deveci, Kırpınar, Greenberg

Hebrew Section

69 > News and Notes 72 > Abstracts

Assistant Editor

Joan Hooper

Marketing: MediaFarm Group

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Emi Shufman - Bond Oil on linen

Emi Shufman is a psychiatrist, director of the Jerusalem Institute for the treatment of drug abuse. "One morning I went out to discover a baby crow in the garden. Without thinking, I stroked it, an error, as for the next two weeks whenever I went out, the mother crow flew down screeching aggressively. But an error can be a mixed blessing as the mother's response was the inspiration for this painting."

Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Editorial: The Treatment of Depression During Pregnancy According to the World Health Organization, major depression is the second leading contributor to the global burden of disease in people 15-44 years old.

Unfortunately, pregnancy is not protective against depression with 5-7% of pregnant women suffering significant symptoms (1, 2). Women who are depressed during pregnancy are less likely to get prenatal care and more likely to abuse drugs and alcohol (3-5). Depression during pregnancy is associated with poorer obstetrical outcomes such as preterm birth and low birth weight (6). Importantly, depression during pregnancy often continues into the postnatal period (7) and maternal depression is known to have adverse effects on maternal-infant bonding as well as child development and behavior (8-11).

In 2009, the American Psychiatric Association (APA) and American College of Obstetricians and Gynecologists (ACOG) published consensus guidelines regarding the treatment of women with depression during pregnancy (12). The guidelines recommend that psychotherapy be used for pregnant women with mild to moderate depression and antidepressants be prescribed for pregnant women with moderate to severe depression. Both interpersonal psychotherapy and cognitive behavioral therapy have been shown to be efficacious during pregnancy. Also, pregnant women report psychotherapy is the most acceptable treatment option (13).

The large advantage of prescribing psychotherapy during pregnancy, aside from treatment preferences, is that the fetus is not exposed to medications that permeate the placenta. The drawback is that psychotherapy is timeintensive and requires adequately skilled practitioners.

In addition, it may not be as effective for more severely depressed women.

For pregnant women with moderate to severe depression, antidepressant medication should be considered alone or in conjunction with psychotherapy.

Antidepressants are unlikely to cause major congenital malformations with first trimester use. However, their use has been associated with third trimester risks such as preterm birth (14), poor neonatal adaptation syndrome (15) and persistent pulmonary hyperten3

sion (PPHN) of the newborn (16). On average, infants exposed to third trimester antidepressant use are born a week early and poor neonatal adaptation syndrome generally resolves within a week making these two adverse effects clinically minor. PPHN is more serious but has been associated with only a small (<1%) risk when antidepressants, particularly serotonin reuptake inhibitors, are used in the third trimester. The APA has stated in their depression treatment guidelines that in PPHN â&#x20AC;&#x153;the preponderance of evidence from published studies on this topic does not support an associationâ&#x20AC;?

(17) because the data have been conflicting. The use of the different classes of antidepressants is beyond the scope of this editorial but we refer the reader to reviews on the topic (12, 18). The long-term impact on children exposed to antidepressants during pregnancy has been incompletely explored but the data to date are reassuring. In general, the use of antidepressants for moderate to severe depression during pregnancy outweighs the risk but this must be decided by each individual patient and her physician. We recommend that patients who are concerned about the use of antidepressants during pregnancy consult with a physician who specializes in reproductive psychiatry.

The recently published APA/ACOG guidelines briefly mention that electroconvulsive therapy (ECT) is safe and effective in pregnancy but do not include specific recommendations for its use in pregnancy. However, in 2001, the APA published guidelines regarding the use of ECT in pregnancy (19). ECT is an effective and safe treatment for severe depression. Its use remains somewhat stigmatized, especially during pregnancy. To determine whether ECT should be prescribed during pregnancy, the physician should consider the psychiatric presentation first and foremost. The trimester of pregnancy should guide the precautions that should be used. ECT is recommended for patients who are acutely suicidal, psychotic, have medication-resistant symptoms or severe depressive symptoms such that the mother is failing to make expected weight gains. In our institution, medication resistance in the context of severe psychiatric symptoms (i.e., self neglect or acute suicidality)

Deborah Kim and John P. O’Reardon

is the most common reason for referral for ECT. ECT is effective for depression during pregnancy. In a review of the literature by Anderson and Reiti, 84% of the pregnant women for whom efficacy data was available (N=37) had at least a partial response (20).

Overall, the risk of ECT in pregnancy appears to be small. The general maternal risks of ECT regardless of pregnancy status are those of memory loss, confusion and headache. Pregnant women receiving ECT should be monitored to make sure they continue taking their prenatal vitamins and attending obstetrical visits which may require the involvement of the women’s support system. If she is mothering other children, her cognition also needs to be closely monitored on the day of treatment and in between treatments.

The fetal risk of ECT is the focus of most published case reports and case series. These reports point to five main concerns: fetal bradyarrhythmias, preterm birth, anesthesia risk, maternal aspiration, and maternal seizure. These concerns can be addressed by maternal and fetal monitoring as per the APA guidelines. Fetal heart rate changes are the most common fetal effect of ECT but tend to be self-limited. After 14 weeks gestational age, fetal heart rate monitoring should be done before and after ECT treatments. Preterm birth is a leading cause of long-term morbidity and mortality in children.

In 3.5% of reported cases in the Anderson literature review, preterm contractions and labor were observed. In the majority of those cases, a normal neonate was born.

Monitoring of uterine contractions is recommended before and after ECT once the fetus is viable (generally agreed to be after 24 weeks GA). An additional case of delayed premature contractions was reported in 2010 but the neonate was born healthy after tocolytics were used to stop premature labor (21). The most commonly used anesthetics, methohexital and propofol, are non-teratogenic but fetal monitoring should be performed to assess fetal heart rate. Succinylcholine, often used as a muscle relaxant, is also non-teratogenic. Pregnant women are at increased risk in the second and third trimesters for gastric reflux. This could lead to aspiration during ECT. Therefore, premedication with an antacid such as H2 blocker should be considered. In the 3rd trimester the risk of aspiration is higher so pregnant women should be intubated during the procedure. If ECT causes status epilepticus, vascular supply to the fetus could be compromised even resulting in fetal death. Pregnancy is a time of increased seizure threshold so the risk of prolonged seizure during pregnancy is low.

The most common reason for avoiding ECT during pregnancy is likely to be stigma among psychiatrists, obstetricians and patients. Education about the low risk procedure is necessary and is best done by a psychiatrist that has experience performing ECT. Other neuromodulation treatments such as transcranial magnetic stimulation may provide patients with another alternative in the future (22). The education of psychiatrists regarding the treatment of depression during pregnancy is an important step in allowing patients to understand the full range of treatment options. Depression can be understood as an endogenous toxin to the maternal and fetal environment. When assessing risk with a patient, it is helpful to remind her that she should not compare her individual risk to a non-depressed, pregnant woman.

She should compare the risk of treatment with the risk of remaining depressed. If her depression is mild and not interfering with functioning, she may elect to try psychotherapy or take a “wait and see” approach. If her depression is moderate to severe, she should consider medications and psychotherapy together. If she is suicidal, psychotic or treatment resistant, hospitalization and/or ECT should be strongly considered.

In summary, depression during pregnancy is a common illness and knowledgeable counseling regarding the risk of untreated illness and treatment options should be made available to women and their supports. Psychotherapy, antidepressants and ECT are all reasonable options during pregnancy. The prescribing physician should consider the psychiatric presentation as primary in decision-making regarding treatment.

Lastly, a collaborative approach will require that the treating psychiatrist provide accurate psychoeducation to all team members which will allow the pregnancy to be safely monitored during depression treatment.

Deborah Kim, MD, and John P. O’Reardon, MD Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

drkim@mail.med.upenn.edu

References 1. Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, et al. Perinatal depression: Prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess 2005;119:1-8.

2. Vesga-Lopez O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008;65:805-815.

3. Flynn HA, Chermack ST. Prenatal alcohol use: The role of lifetime problems with alcohol, drugs, depression, and violence. J Stud Alcohol Drugs 2008;69:500-509.

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Editorial: The Treatment of Depression During Pregnancy

4. Hanna EZ, Faden VB, Dufour MC. The motivational correlates of drinking, smoking, and illicit drug use during pregnancy. J Subst Abuse 1994;6:155-167.

5. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt) 2003;12:373-380.

6. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry 2010;67:1012-1024.

7. Soderquist J, Wijma B, Thorbert G, Wijma K. Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG 2009;116:672-680.

8. Hollins K. Consequences of antenatal mental health problems for child health and development. Curr Opin Obstet Gynecol 2007;19:568-572.

9. McGrath JM, Records K, Rice M. Maternal depression and infant temperament characteristics. Infant Behav Dev 2008;31:71-80.

10. Moehler E, Brunner R, Wiebel A, Reck C, Resch F. Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother-child bonding. Arch Womens Ment Health 2006;9:273-278.

11. Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early child development. BJOG 2008;115:1043-1051.

12. Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, et al. The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:703-713.

13. Kim DR, Sockol L, Barber JP, Moseley M, Lamprou L, Rickels K, et al.

A survey of patient acceptability of repetitive transcranial magnetic stimulation (TMS) during pregnancy. J Affect Disord 2011; 129: 385-390.

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14. Einarson A, Choi J, Einarson TR, Koren G. Adverse effects of antidepressant use in pregnancy: An evaluation of fetal growth and preterm birth. Depress Anxiety 2010;27:35-38.

15. Boucher N, Bairam A, Beaulac-Baillargeon L. A new look at the neonate's clinical presentation after in utero exposure to antidepressants in late pregnancy. J Clin Psychopharmacol 2008;28:334-339.

16. Chambers CD, Hernandez-Diaz S, Van Marter LJ, Werler MM, Louik C, Jones KL, et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med 2006;354:579-587.

17. Treatment of patients with major depressive disorder, third edition [Internet].; 2010. Available from: http://www.psychiatryonline.com/ pracGuide/pracGuideTopic_7.aspx.

18. Udechuku A, Nguyen T, Hill R, Szego K. Antidepressants in pregnancy: A systematic review. Aust N Z J Psychiatry 2010;44:978-996.

19. American Psychiatric Association. Committee on electroconvulsive therapy. use of electroconvulsive therapy in special populations. The practice of electroconvulsive therapy, recommendation for treatment, training and privileging: A task force report of the American Psychiatric Association. 2nd ed. Washington, D.C.: American Psychiatric Association, 2001.

20. Anderson EL, Reti IM. ECT in pregnancy: A review of the literature from 1941 to 2007. Psychosom Med 2009;71:235-242.

21. Pesiridou A, Baquero G, Cristancho P, Wakil L, Altinay M, Kim D, et al. A case of delayed onset of threatened premature labor in association with electroconvulsive therapy in the third trimester of pregnancy. J ECT 2010;26:228-230.

22. Kim DR, Gonzalez J, O'Reardon JP. Pregnancy and depression: Exploring a new potential treatment option. Curr Psychiatry Rep 2009;11:443-446.

Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

The Use of Electroconvulsive Therapy in Pregnancy: A Review Omer Saatcioglu, MD, and Nesrin B. Tomruk, MD Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey.

ABSTRACT Treating psychiatric disorders during pregnancy poses a challenge. Both medication and maternal illness may have adverse effect on the fetus and balancing the risks and benefits of symptoms and treatments is crucial.

Medications may affect the fetus adversely, especially in the first trimester. Electroconvulsive therapy (ECT) is not known to have adverse fetal effects and therefore may be preferred. A review of the literature and our clinical experience highlight the role of ECT during pregnancy, sometimes offering advantages over pharmacotherapy.

Introduction Despite its well-established efficacy, ECT still remains the most controversial treatment in clinical psychiatry.

The debate about use of ECT in special populations, as in young, pregnant, elderly or medically ill patients, is an important aspect. Despite more than 70 years of experience, there are many differences in ECT’s indications, guidelines, and how to optimize outcomes. The controversial nature of professional and public attitudes has narrowed its use, mainly as a last resort in severely ill patients or in situations where other treatments have failed or carry greater risk.

Besides diagnosis, several other factors are taken into account in the decision to use ECT in treatment, such as prior treatment response, the severity of illness, the need for rapid response, the risks and benefits of ECT compared to other treatments, and the patient’s preference. In this context, ECT in pregnancy is controversial

because it may be preferable in risk-benefit assessment, but still pregnancy is a period where associated risks may be substantially higher (1-4).

Treating psychiatric disorders during pregnancy poses a challenge. Both medication and maternal illness may have adverse effect on the fetus and balancing the risks and benefits of symptoms and treatments is crucial. The severity of the mental illness may increase during pregnancy. Malnutrition, substance abuse, aggression, appetite changes, despair and delirium are features that cause more injury to the fetus than to the patient herself.

The optimal treatment for depressive disorders in pregnancy remains controversial. Clinicians are often hesitant to prescribe pharmacological agents during pregnancy, especially in the first trimester. ECT has long been considered to have a role in the more severe cases of perinatal depressions. Partly due to issues of stigma and possibility of relapse it tends to be reserved for severe cases where there is poor nutritional intake, a high risk of suicide or a high level of tormenting thoughts. Recent evidence confirms ECT’s effectiveness in perinatal mood disorders (1).

The morbidity from illness and the potential adverse effects of psychotropic drugs increase the attractiveness of ECT as a treatment option for pregnant patients.

Greater experience with ECT in pregnancy has influenced our attitudes towards its more lenient use.

Indications for ECT During Pregnancy In patients with previous psychiatric history, an exacerbation may occur in pregnancy although the risk is considerably more in the postpartum period (5, 6). Depression in pregnancy is frequent. At least one quarter of postnatal depressions have their onset during pregnancy (5 - 10).

ECT is mostly used to treat depression and it is the fastest acting, the most acutely effective treatment available.

Address for Correspondence: Dr. Omer Saatcioglu, Atakoy, 9. Kısım, A5-A Blok, Kat 12, Daire:61, 34750 Istanbul, Turkey osaatcioglu@superonline.com

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Omer Saatcioglu and Nesrin B. Tomruk

It is also at least as effective as drug treatment, if not superior (11, 12). All psychotropic drugs cross the placenta and may exert unwanted side effects on the fetus.

Morphological teratogenicity, perinatal syndromes and behavioral teratogenicity are the main adverse effects of pharmacotherapy in pregnancy (13- 15).

ECT is effective in major depressive episodes in unipolar, bipolar and mixed cases (16). Acute suicidality, psychotic features, life threatening conditions as in rapidly deteriorating physical status due to poor oral intake, history of poor response to medications or good response to ECT, psychomotor retardation, stupor, and catatonia, patient preference and risks of standard antidepressant treatment outweighing risks of ECT are the main uses of ECT (17).

A case of twin gestation with severe psychotic depression was treated with ECT later in the course of pregnancy. No adverse fetal outcome was reported in this case (18). Another case of psychotic depression was treated with 13 sessions of ECT in the second trimester of pregnancy, followed by three monthly maintenance ECTâ&#x20AC;&#x2122;s with no complications except pelvic pain and transient fetal arrhythmias. The baby born was healthy (19).

Particularly in major depression and acute mania, catatonia, certain acute schizophrenic exacerbations substantial clinical improvement often occurs soon after the start of ECT. ECT indications in first trimester are suicide risk, excitement, stupor, catatonia and aggression. When a rapid or a higher probability of response is needed, as when patients are severely medically ill or at risk to harm themselves or others, primary use of ECT should be considered in second trimester. Other considerations for the first-line use of ECT involve the patientâ&#x20AC;&#x2122;s medical status, treatment history and treatment preference. The most common use of ECT in third trimester is in patients who have not responded to other treatments. During the course of pharmacotherapy, lack of clinical response, intolerance of side effects, deterioration in the psychiatric condition, or the appearance of suicidality are reasons to consider the use of ECT (2).

Recurrence in bipolar disorders is frequent in pregnancy (20). The rate of relapse during the first 40 weeks after lithium discontinuation in pregnant women is similar to non-pregnant women (21). ECT is effective also in mania. It is recommended in mania when there is acute suicidality, psychotic features, rapidly deteriorating physical status, history of good response to ECT/ poor response to medications, patientâ&#x20AC;&#x2122;s preference, risk of standard antimanic treatments outweighing risks of ECT,

catatonia, extreme and sustained agitation and delirium (16). ECT is a treatment option in patients with severe mania during pregnancy particularly when there is concern about the teratogenic effects of medications. ECT has an important role in the management of symptomatic pregnant women with severe mania (22, 23).

Although antipsychotics are the first-line treatment for schizophrenia, and teratogenicity potential for antipsychotics are reported to be relatively low, there is sparse data regarding the second generation antipsychotics. When there is concern about the teratogenicity and adverse effects of antipsychotics and anticholinergics, ECT may be preferred. ECT is also an option in treatment refractory cases (20).

In addition, ECT is indicated and administered in patients with neuroleptic malignant syndrome and malignant catatonia. When these conditions occur in pregnancy, ECT is a first-line treatment (24). A case of neuroleptic malignant syndrome was diagnosed at the seventh month of pregnancy. The syndrome did not respond to treatment with dantrolene. ECT was administered and the patient was discharged with clinical improvement (25).

A Risk-Benefit Analysis ECT is safe during all trimesters of pregnancy (16). Yet, treatments should be given in a hospital with facilities to manage a fetal emergency (26). An obstetric consultation should be considered in high-risk patients. External fetal cardiac monitoring during the procedure is not obligatory since generally no alteration in fetal heart rate has been observed. In high-risk cases, the presence of an obstetrician during the procedure is recommended (17, 27). In the third trimester, intubation is not a routine procedure but it is recommended to reduce the risk of pulmonary aspiration. Using intubation and fetal monitoring would limit the use of ECT to facilities where such procedures can be performed, thus weighing against the use of ECT (19).

During pregnancy, gastric emptying is prolonged, increasing the risk of aspiration of regurgitated gastric contents. Standard procedure requires the patient to take nothing by mouth after midnight the night preceding ECT. In the pregnant patient, however, this is often insufficient to prevent regurgitation (4, 28). In addition, administering a non-particulate antacid, such as sodium citrate, to raise gastric pH, may be considered as optional adjuvant therapy, but its usefulness is debated (29).

Later in pregnancy, as the uterus increases in size and weight, it may limit ventilation when the patient is in 7

The Use of Electroconvulsive Therapy in Pregnancy: A Review

the supine position; a common procedure is to elevate the patientâ&#x20AC;&#x2122;s right hip, thereby preventing the movement of the uterus, relieving pressure on the diaphragm.

Assuring hydration with adequate fluid intake or intravenous hydration with Ringerâ&#x20AC;&#x2122;s lactate or normal saline before ECT treatment may reduce this risk of reduced placental perfusion (27).

Numerous reports show the efficacy of ECT in all three trimesters of pregnancy (26, 30-33). Many of the newer antidepressants and atypical antipsychotics lack this data.

ECT is considered as a relatively safe and effective treatment (20). No controlled studies were found about the rate of complications of ECT compared to other treatments during pregnancy. Knowledge is based on case reports revealing favorable outcomes. Several early reviews of the effects of ECT during pregnancy did not reveal an increase in risk of labor and delivery complications (34).

The Collaborative Perinatal Project did not find an excess of malformations in fetuses exposed to methohexital, succinylcholine and atropine (33). No alterations of fetal heart rate, fetal movement or uterine tone during ECT have been reported (35, 36).

Because of the release of oxytocin by ECT-induced seizures and potential resultant stimulation of uterine contractions and induction of labor, the potential use of tocolytic therapy (with ritudrine or magnesium) has been suggested in patients developing persistent uterine contractions during or shortly after ECT (33). Rather than routine monitoring of mother and fetus during ECT, it is advised to reserve it for high risk pregnancies (36, 37). Besides tocolytic therapy, anesthesia with sevoflurane is also recommended in patients developing premature labor or uterine contractions in the third trimester (28, 38). Premature labors were not related to ECT treatment. Also, the temporal relationship between ECT and miscarriages was not identified. A miscarriage rate of 1.6 percent (26) is still not higher than such events in the untreated general population, indicating that ECT does not increase the risk of miscarriage.

Miller reviewed 300 cases of ECT in pregnancy between 1942 and 1991. In 14 (4.7%) of these cases ECT was used during the first trimester, in 36 (12%) it was started in the second trimester and in 31(10.3%) in the third trimester. Complications were reported in 28 (9.3%) and most did not show any temporal relationship to the administration of ECT (26). The incidence of genetic malformations after ECT, in comparison to a historical control population, was lower (39, 40). No information on other potential teratogenic exposures 8

was included in five instances (1.6%) of congenital abnormalities (26). Based on the number and pattern of congenital anomalies in these cases, ECT does not appear to have an associated teratogenic risk.

In a 24-year-old patient with schizophrenia for whom pharmacotherapy was ineffective, ECT was administered, and at the third treatment uterine contractions refractory to tocolysis were observed for six minutes with accompanying fetal bradycardia. At the sixth treatment, general anesthesia was induced and the uterine contraction was reported to diminish and fetal heart rate remained constant during the procedure (38). The authors suggested inhalation anesthesia in later stages of pregnancy because of potential uterine relaxant effect of anesthetics (38, 41). In another 26-year-old patient, primagravida at 35 weeks of gestation in whom ECT was administered in the third trimester, following the second, third and sixth treatments, uterine contractions were experienced and tocolytic therapy was needed after the third treatment.

Also after this treatment fetal heart variability and uterine contraction-related late cardiac deceleration was observed (42). Transient, benign and self-limited cardiac effects in ECT during pregnancy were hypothesized to have been in response to barbiturate anesthetic. The babies born were healthy (26). Another example of fetal arrhythmia resolved spontaneously during ECT in third trimester (43).

In a 36-year-old patient with a severe case of treatment refractory obsessive-compulsive disorder, ECT was administered. Late deceleration on the fetal cardiotocogram occurred during the second treatment and abnormal uterine contraction ceased with rapid IV ritodrine administration. Two courses of ECT diminished her symptoms markedly and the patient delivered a healthy baby (44). Brief fetal heart rate deceleration was reported in another case (45). Abdominal pain of unknown etiology after ECT was reported in three cases. The babies born were healthy in all of the cases (46).

In a patient with severe psychotic depression unresponsive to pharmacotherapy, ECT was accompanied by uterine contractions and vaginal bleeding occurred.

Transient acute hypertension episodes (between 180/90 and 190/100mmHg) were also observed simultaneously (47). Five cases of mild known or suspected vaginal bleeding related to ECT occurred with no adverse effects on the infants (26). Vaginal bleeding leading to spontaneous abortion was reported in an eight-week pregnancy after third ECT treatment (48).

In a 23-year-old patient at 27 weeks of gestation treated for depression comorbid with generalized anxiety

Omer Saatcioglu and Nesrin B. Tomruk

disorder and panic attacks, unresponsive to antidepressant treatment, ECT was administered and premature labor risk occurred in the third treatment which subsided with hydration and tocolytic therapy with ritodrine hydrochloride (42). In another example premature labor occurring after the first ECT was treated successfully with ritodrine and indomethacin (49). ECT was administered to a 32-year-old seven month pregnant patient with a diagnosis of psychotic major depression unresponsive to drug treatment. Uterine contractions were observed in the fourth ECT session and the patient was referred to a hospital equipped with newborn intensive care unit.

The patient had premature labor at 34 weeks of gestation and the baby born was healthy (50). Stillbirth or neonatal death in patients undergoing ECT during pregnancy was not related to ECT but to medical risks (26). No direct temporal relationship between the onset of labor and ECT treatment was noted.

Prolonged seizure, occasionally interpreted as status epilepticus, is an uncommon event in ECT. One is reported in a 31-year-old bipolar patient, primagravida at 22 weeks of gestation after third ECT treatment. An attempt was made to control the seizure activity with high doses of benzodiazepines, thiopental, propofol and diphenylhydantoin, but the fetus died in this complicated course (51).

The physiological changes associated with pregnancy may increase the anesthesia risks including pulmonary aspiration, and aortocaval compression which can reduce placental perfusion and fetal hypoxia due to maternal hypoxia (26, 52-54).

Pinette et al. (55) reported that primagravida underwent multiple ECT during pregnancy for the diagnosis of major depression. The infant was subsequently born with multiple deep interhemispheric infarcts. They suggested that although a cause-and-effect relationship cannot be established in this case, the multiple ECT treatments this patient received in pregnancy and the final neonatal outcome are temporally related.

Use of Psychotropic Medications The morbidity from continued illness and the incompletely understood adverse effects of psychotropic drugs have increased ECTâ&#x20AC;&#x2122;s attractiveness for pregnant patients with severe mental illness, especially when they have associated high-risk conditions. Medications that pose some teratogenic risk during the first trimester include benzodiazepines, antipsychotics, lithium and other mood stabilizers (20, 46), but not tricyclic antidepres-

sants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) (51, 56). Later in pregnancy, antipsychotics have been noted to cause neonatal motor abnormalities, and benzodiazepines are associated with neonatal hypotonia, apnea, and temperature dysregulation (46, 56). TCA treatment has been reported to cause anticholinergic effects and withdrawal symptoms in neonates. Lithium is associated with premature labor, polyhydramnios, neonatal hypothyroidism or lithium toxicity (20). In terms of teratogenic risk, ECT use in pregnancy is considered relatively safe. In the NICE review of extensive data from randomized controlled trials about ECT in depressive disorders, it is stated that although the use of ECT during pregnancy is known to cause some complications, the risks associated with ECT need to be balanced against the risks of using alternative drug treatments (1, 15).

Effects of ECT Procedures in Pregnancy Muscle relaxants

Succinylcholine, the muscle relaxant most commonly used to induce paralysis for anesthesia for ECT, does not cross the placenta in detectable amounts (14, 57).

Succinylcholine is inactivated by the enzyme pseudocholinesterase. Approximately 4% of the population is deficient in this enzyme and could, consequently, have a prolonged response to succinylcholine. In addition, during pregnancy, pseudocholinesterase levels are low, so this prolonged response may occur (52).

In the Collaborative Perinatal Project (58), 26 births to women exposed to succinylcholine during the first trimester of pregnancy were assessed after birth. No abnormalities were noted. However, several case reports noted complications in the use of succinylcholine during the third trimester of pregnancy. The most notable complication studied in women undergoing caesarian section was development of prolonged apnea of mother that required continuous ventilation and lasted several hours to days.

In nearly all the infants, respiratory depression and low Apgar scores were seen after birth (59).

Anticholinergics

Increased pharyngeal secretions and vagal bradycardia may occur and to prevent these effects during the procedure, anticholinergic agents are usually administered.

The two anticholinergics of choice are atropine and glycopyrrolate (53).

In the Collaborative Perinatal Project (58), 401 women received atropine, and four women received glycopyrrolate 9

The Use of Electroconvulsive Therapy in Pregnancy: A Review

during their first trimester pregnancy. In the women who received atropine, 17 infants (4%) with malformations were born, while in the glycopyrrolate group, no malformations occurred. The incidence of malformations in the atropine group was not greater than would be expected in the general population. Likewise, studies of these two anticholinergics used in the third trimester pregnancy or during labor did not reveal any adverse effects.

Anesthetics

To induce sedation and amnesia prior to the treatment, a short-acting barbiturate is typically used. The agents of choice, methohexital, thiopental, and thiamylal, have no known adverse effects associated with pregnancy.

The only known exception is that administration of a barbiturate to a pregnant woman with acute porphyria may trigger an attack (52). The barbiturates used for brief anesthesia have not been fully studied, but the short exposure period is unlikely to cause teratogenicity (60). For the same reasons, neonatal toxicity is relatively low with ECT in the third trimester of pregnancy (61).

The recommended dose of methohexital for nonpregnant adults is considered effective during the third trimester of pregnancy (62). The risks of anesthetic agents to the fetus are likely to be less than those of pharmacologic alternatives. Nonetheless, potential teratogenic effects and neonatal toxicities should be discussed in the informed consent process.

Conclusion When a pregnant woman suffers a severe mood disorder or psychosis, antidepressant and antipsychotic drugs are usually not prescribed, especially during the first trimester of pregnancy because their use is associated with congenital abnormalities. ECT may be a safer treatment during the first trimester of pregnancy. In the second and third trimesters, ECT is recommended when medications do not control the illness or when the patient has had a good result with ECT in an earlier episode (12, 52).

Many clinics ask for consultation with the patientâ&#x20AC;&#x2122;s obstetrician. Routine fetal monitoring is not recommended. Beyond the first trimester, risk of regurgitation is high, so intubation should be considered on a case-bycase basis (17, 27). The facilities in which ECT is administered during pregnancy should have the resources to manage obstetric and neonatal emergencies.

ECT has been reported as a treatment with high 10

efficacy and low risk in the management of psychiatric disorders during all trimesters of pregnancy, as well as postpartum. Consequently, ECT use in psychiatric disorders during pregnancy is an effective and safe treatment in many cases.

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25. Verwiel JM, Verwey B, Heinis C, Thies JE, Bosch FH. Successful electroconvulsive therapy in a pregnant woman with malignant neuroleptic syndrome. Ned Tijdschr Geneeskd 1994; 138:196-199 (in Dutch).

26. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Comm Psychiatry 1994; 45:444-450.

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Management of psychiatric disorders in pregnancy. London: Oxford, Arnold, 2001: pp. 82-104.

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30. Oates MR. The treatment of psychiatric disorders in pregnancy and the puerperium. Clin Obstet Gynaecol 1986;13:385-95.

31. Wisner KL, Peril JM. Psychopharmacologic agents and electroconvulsive therapy. In: Cohn REL, editor. Psychiatric consultation in childbirth settings: Parent and child-orientated approaches. New York: Plenum, 1988: pp. 165-206.

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37. Remick RA, Maurice WL. ECT in pregnancy. Am J Psychiatry 1978; 135:761-762.

38. Ishikawa T, Kawahara S, Saito T, Kemmotsu O, Hirayama E, Ebina Y, Fujimoto S, Inoue T, Koyama T. Anesthesia for electroconvulsive therapy during pregnancy - a case report. Masui 2001; 50:991-997 (in Japanese).

39. Greenhalgh J, Knight C, Hind D, Beverley C, Walters S. Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: Systematic reviews and economic modelling studies. Health Technol Assess 2005; 9: 11-47.

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Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Gelotophobia in Israel: On the Assessment of the Fear of Being Laughed At Orly Sarid, PhD,1 Willibald Ruch, PhD,2 and RenĂŠ T. Proyer, PhD2 1

Social Work Department, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel Department of Psychology, University of Zurich, Zurich, Switzerland

2

ABSTRACT Gelotophobia is defined as the fear of being laughed at. Empirical studies revealed that it is a valid and useful concept which deserves further attention.

Furthermore, gelotophobia is of relevance among nonclinical groups, and it should be best conceptualized as an individual differences phenomenon that ranges on a dimension from low to high fear of being laughed at. The present study presents the first empirical data on the fear of being laughed at in Israel (N = 220). It describes the adaptation of an instrument for the subjective assessment of gelotophobia to Hebrew. The translation yielded good psychometric properties in terms of high reliability (Îą = .89). The Hebrew-GELOPH<15> is best described with a one-dimensional factor solution. Items referring especially to the avoidance of places where one has made an embarrassing impression yielded higher endorsements. Gelotophobia was more prevalent among younger participants, females, and participants who were not in a relationship. Approximately 6% exceeded a cut-off score indicating at least a slight expression of gelotophobic symptoms. Results are discussed with respect to further application of the questionnaire in research and practice. If confirmed by additional studies it will have a significant implication on the understanding of gelotophobia in relation to social phobia and related phobias.

INTRODUCTION Gelotophobia is defined as the fear of being laughed at (1). Gelotophobes do not experience laughter and smiling from their interaction partners as something positive but

as a means to put them down. Furthermore, they do not experience laughter as relaxing or positive but as aggressive acts by others. For example, when they are with other people they become very observant and suspicious while hearing laughter from others. These ideas are accompanied by the conviction of actually being ridiculous and therefore being laughed at for a good reason.

The first evidence of the existence of gelotophobia as a distinct phenomenon stems from observations by clinicians in single-case studies (2). In these studies a subgroup of patients was identified and seemed primarily worried with being laughed at. Titze (2) relates the fear of being laughed at to shame-bound anxiety (i.e., avoiding behaving inappropriately and being laughed at). He suggests that gelotophobes are ashamed of their perceived shortcomings and inferiorities as compared to others. His initial observations enabled scientific studies that focused on the examination of the experiential world of those who exceedingly fear being laughed at (gelotophobes). In the first of those studies a group of clinically diagnosed gelotophobes could be separated by means of a self-report measure from groups of shamebased, non-shame-based neurotics (3) and normal controls. The criteria Titze used for diagnosing gelotophobia were: (a) shame experiences are not restricted to objective causes in circumscribed areas of life, (b) shame experiences are connected with a (poor) selfevaluation, which regularly can be reinforced by those social encounters where laughing or smiling is included, and (c) the patient shows a restrained (stiff) posture, combined with awkward movements, gaze aversion, and other forms of inappropriate behavior in situations where laughing or smiling is included. The latter refers to a specific wooden appearance that resembles a loss of deliberate control over body movements (seem motionless) when confronted with potentially shame-

Address for Correspondence: Dr. Orly Sarid, Department of Social Work, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel. â&#x20AC;&#x2020; orlysa@bgu.ac.il

12

Orly Sarid et al.

ful incidents. All of the above led to the initial idea of gelotophobia being a distinct clinical phenomenon.

A recent study suggests that gelotophobia can be found in groups of normal controls as well (4). Ruch and Proyer (4) empirically derived cut-off points indicating slight, pronounced, and extreme expressions of gelotophobia in a questionnaire (GELOPH<15>). This is the standard instrument for the subjective assessment of gelotophobia which has been previously used in the German- and English-speaking worlds (5). The questionnaire allows rating of the severity of gelotophobia.

The criteria used for the definition of the cut-off scores were: a) the answer format of the questionnaire (the scale mid-point is 2.50 and a person with this score has agreed to at least half of the items), b) a score of two standard deviations above the mean in the group of normal controls, and c) the score at which the distribution curves of normal controls and diagnosed gelotophobes intersected. Interestingly, the application of the cut-off scores showed that there were a considerable number of normal controls that showed at least a slight expression of gelotophobia (11.65% in a German sample).

Therefore, Ruch and Proyer concluded that gelotophobia is of relevance within the range of normality as well and that it should be studied best as an individual difference phenomenon that ranges on a continuum from low to high gelotophobia. Nevertheless, studies in clinical contexts were further endorsed. For example, Forabosco and colleagues (6) found that, primarily, patients with personality disorders and patients with schizophrenic disorders yielded higher expressions of gelotophobia compared to normal controls, but also compared to other psychiatric groups entered in the study such as anxiety disorder, eating disorder and mood disorder. In general, psychiatric conditions were related to higher expressions of gelotophobia. Additionally, it was shown that the number of years spent in care was also related to higher expressions of gelotophobia. However, more studies are needed to fully understand the relation of gelotophobia to different psychiatric diagnoses.

Thus far, gelotophobia was mainly based on research among non-clinical samples. For example, a recent study focused on the gelotophobesâ&#x20AC;&#x2122; reaction towards two different kinds of laughter-related situations: harmless and playful teasing among colleagues and friends vs. mean-spirited bullying type of laughter and ridicule.

Gelotophobes are unable to differentiate between these situations and they experience negative emotions not only in the mean-spirited ridicule but also in the good-

natured kind of teasing (7). In a recent study, gelotophobes turned out to be introverted and neurotic and scoring higher in Psychoticism-scales, which reflect paranoid tendencies, as compared to scales that intend to measure Psychoticism within the range of normality (8). Other studies looked at gelotophobia as a personality feature which is negatively related to hope/optimism, curiosity, bravery, love and zest, and positively linked to modesty, prudence (9) or emotion-related skills among gelotophobes (10). Furthermore, the fear of being laughed at exists, to a large degree, independently from life events such as actual experiences of being laughed at; this fear is related to a higher intensity of actual experiences of being laughed at (11).

Gelotophobia and anxiety-related disorders

It is evident that gelotophobia shares common features with anxiety-related disorders (e.g., social withdrawal in extreme expressions) and mostly with social phobia (12-16). However, expressions of gelotophobia and social phobia in specific patients might differ. For example, people with severe gelotophobia may be uncomfortable with smiling and laughter but experience no difficulty in social situations, while people with severe social phobia may have no fear of being laughed at. Currently, several studies are being conducted that examine these relations empirically. First data analyses seem to provide support for the previously formulated hypothesis. It is important to note that gelotophobia is conceptualized on a dimension ranging from low to high scores of fear of being laughed at (5). The highest scores are related to pathology while the lowest describe behavior at a sub-clinical level.

Though extreme expressions of gelotophobia and social phobia are similar, there are differences between the two. Titze (2), who interprets gelotophobia as a pathological category only, argues that gelotophobia is a specific variant of shame-bound anxiety. He traces gelotophobia back to the biased belief that the self is experienced as â&#x20AC;&#x153;intolerably ridiculousâ&#x20AC;? (p. 30). He further argues that the DSM-IV (17) guidelines for diagnosing social phobia focus on specific incidents (e.g., failures, mishaps and inexcusable failures of the person, 18). Thus, a main distinction is that gelotophobes are convinced of being ridiculous, strange, curious, queer, etc., as compared to others. Therefore, they expect to be laughed at by others, as they think there is something wrong with them. Titze also formulated guidelines that should be met for the diagnosis of gelotophobia (2).

Several empirical results support the distinct charac13

Gelotophobia in Israel: On the Assessment of the Fear of Being Laughed At

ter of gelotophobia. For example, Ruch, Altfreder and Proyer (19) acoustically presented their subjects different forms of laughter (with different emotional qualities, e.g., positive vs. negative). Gelotophobes, identified via the GELOPH<15>, rated the positively motivated laughter as more unpleasant than the non-gelotophobes. While non-gelotophobes reported a higher positive mood before and after listening to different kinds of laughter, the gelotophobesâ&#x20AC;&#x2122; level of mood was not changed. To the best of our knowledge there are no similar studies with groups of social phobics. However, it seems as if the literature on social phobia does not concur with predicting these outcomes. Social phobics, or patients with other social anxiety disorders, should not necessarily feel unease when hearing others laugh or relate this laughter to them. However, further research is required to examine the above.

Almost all of the studies on gelotophobia have used the GELOPH<15> so far. Ruch and Proyer (4) have worked on the refinement of this questionnaire, starting from a set of prototypical statements of gelotophobes provided by Titze and his group. The items cover contents like paranoid sensitivity towards mockery of others, fear of the humor of others, general response to the smiling and laughter of others, or discouragement and envy when comparing the humor competence of others. Psychometric analyses suggest that these items are highly one-dimensional and do not seem to cover different facets but rather a single dimension. There is strong empirical evidence from different data sources (e.g., experiments, questionnaire studies, semi-projective tests, scenario tests) that this dimension should be interpreted as fear of being laughed at (4).

Furthermore, a set of psychometric studies support the notion that gelotophobia is related to measures of social phobia without being a redundant concept. In a recent study 211 students filled in a Spanish language version of the GELOPH<15>, the social avoidance and distress and fear of negative evaluation scales (20), which are well-used scales for measuring social anxiety and social avoidance behavior in social interactions. Fear of negative evaluations (FNE) represents a core component of social phobia. As expected, the GELOPH<15> correlated strongly and positively with the FNE (21). Lower scores in the FNE tended to go along with low scores in the GELOPH<15> but individuals with high scores in FNE tended to have both low and high scores in the fear of being laughed at. This seems to imply that fear of negative evaluation is a necessary but not sufficient 14

condition for the fear of being laughed at. Without a fear of negative evaluation there is no fear of being laughed at. Possibly a history of being ridiculed or laughed at is a factor that transforms a fear of negative evaluation to an actual fear of being laughed at.

High and positive correlation were found between the GELOPH<15> and the Social Avoidance and Distress Scale (SAD; 20) and between the GELOPH<15> and the German version (21, 22) of the Social Phobia Inventory (SPIN, 23). A principal components analysis of the FNE, the SAD and the GELOPH<15> was performed and yielded three factors. These were rotated obliquely to simple structure. All items of the GELOPH loaded on one factor easily identified as the fear of being laughed at.

Fear of negative evaluation emerged as a separate factor that covered all, except four items of the FNE, and all except two items formed a separate social avoidance and distress factor. The intercorrelation among the SAD and FNE factors was low, 0.29, and both correlated higher with gelotophobia (SAD: 0.53; FNE: 0.43).

Phobias in Israel

Previous studies found a rather high prevalence of fears and various phobic symptoms among Israeli young adults. Fodor (24) suggested a higher frequency of phobic disorders exists in some societies. Therefore, masculinetough and nervous-stressful societies will be characterized by higher rates of phobic disorders (25). Israelis live in a masculine and stressful psychological atmosphere.

According to Arrindell et al. (25) high masculinity countries are characterized by clearly differentiated roles in society: dominant values in society of material success and progress, dominance of men in most settings, and assertive behavior by men. Israel is characterized by many of these features and therefore the rates of various phobias are higher as compared to Eastern societies (26, 27). Iancu and colleagues (28) found that 4.5% of a normal, non-clinical population (soldiers from the Israeli army) showed social phobic symptoms (i.e., scores above 80 in the Liebowitz Social Anxiety Scale).

The current study intends to examine gelotophobia and the role of laughter and ridiculing in Israel. To the best of our knowledge, no prior study relates to or measures the expression of the fear of being laughed at in Israel.

Aims of the present study

The aims of the present study were threefold. Firstly, the psychometric properties of the gelotophobia-scale in the Hebrew translation were examined. Therefore, reli-

Orly Sarid et al.

ability analyses and factor analyses were computed. The results were compared with the original German form (4).

Furthermore, the correlations of each item and the total score for gelotophobia with age, sex and marital status were computed. Secondly, the relevance of single items (i.e., symptoms) in terms of low vs. high agreements in the sample were evaluated. Thirdly, the application of the cutoff scores (4) allows estimating how many gelotophobes were in the sample (i.e., exceeding the cut-off scores).

Method Sample

Participants were recruited from the southern part of Israel, mostly from Beer-Sheva and its surroundings and from cities in the center of Israel, namely Tel Aviv and Holon. The data were collected between February and March 2007. Respondents were recruited through advertising, face-to-face, and snowball methods. Similar methods of recruitment were reported with other instrument development (29). The sample consisted of 220 participants. Fifty-one percent (n = 112) were males. The mean age of the participants was 36.97 (SD = 16.10) and ranged from 18 to 86 years. Seventy-five participants were not married (single) and the others were either married or in a relationship.

All participants provided informed consent and were told that their participation in the study was voluntary and anonymous. All participants voluntarily filled in the questionnaire and did not receive any remuneration for their participation. The complete administration including the instructions took approximately 10 minutes.

Measure

The GELOPH<15> (4) is a 15-item questionnaire for the subjective assessment of gelotophobia. All items are positively keyed and the 4-point answer format ranges from 1 = “strongly disagree” to 4 = “strongly agree.”

The GELOPH<15> is the standard instrument for the subjective assessment of gelotophobia and was used in previous research (1, 6, 7). The Hebrew version of the questionnaire may be obtained from the first author.

Procedure

The GELOPH<15> was translated from English to Hebrew and an independent bilingual person translated the Hebrew version to English. The two English versions were compared and modifications were applied.

The authors of the original version helped in critical

cases. This procedure not only ensured that the original version was correct but also that cultural specifications could be taken into account. The questionnaire was originally constructed in German and several studies were conducted using this form (2). Soon, the research plan was extended to an international scope and a standard English form was established. This form has been used in several studies so far (7, 30) and has proven excellent psychometric properties. Since then, the authors of the questionnaire use the English version as a starting point in foreign language versions.

Results The reliability analysis indicated that the Hebrew version yielded a high internal consistency (α = 0.89). We also computed mean scores and standard deviations for each item separately and a total score. The items and the mean score in gelotophobia were correlated with age, sex and marital status of the participants (see Table 1).

Table 1 shows that the corrected item-total correlations ranged between 0.44 and 0.67 (M = 0.56).

Gelotophobia was negatively correlated with age (i.e., the younger the participants the higher the expression of gelotophobia), positively with gender (i.e., higher among females), and higher in participants who were not in a relationship. Item 5 (“When others make joking remarks about me I feel paralyzed”) especially reflected these relationships.

For the examination of the factorial structure (unidimensionality) of the scale, a principal components analysis for the 15 items was computed. The analysis revealed one strong first factor. The eigenvalues were 5.99, 1.11, and 1.00, respectively. The first factor explained 39.92% of the variance. The loadings of the items on the first factor ranged between 0.51 (item 13, “While dancing I feel uneasy because I am convinced that those watching me assess me as being ridiculous”), and 0.73 (item 12, “It takes me very long to recover from having been laughed at”). The median of the loadings on the first factor was 0.63. Overall, a one-dimensional solution did fit the data best.

The answer categories of the questionnaire provide a possibility of estimating the relative importance of single items (symptoms). Therefore, we computed a total score of the two answer categories indicating agreement to an item (i.e., “agree” and “strongly agree”) and the frequency of the endorsement to each item was computed. The average item endorsement was 15

Gelotophobia in Israel: On the Assessment of the Fear of Being Laughed At

Table 1. Descriptive Statistics, Corrected Item Total Correlations, and Correlations with Age, Gender, and Marital Status for the Israeli form of the 15-item GELOPH M

SD

CITC

Age

Sex

Ms

Item 1

1.72

0.87

.47

-.20**

.08

-.17*

Item 2

1.21

0.55

.49

-.09

.06

-.02

Item 3

1.46

0.74

.59

-.21**

.17*

-.19*

Item 4

1.26

0.56

.54

-.05

.15*

-.05

Item 5

1.60

0.74

.63

-.25**

.28**

-.14*

Item 6

1.64

0.56

.58

-.11

.04

-.18**

Item 7

1.46

0.76

.60

-.15*

-.01

-.17*

Item 8

1.33

0.88

.50

-.04

-.03

-.09

Item 9

1.91

0.74

.56

-.13

.17*

-.08

Item 10

1.71

0.88

.65

-.08

.10

-.14*

Item 11

1.79

1.00

.53

-.06

.18*

-.18**

Item 12

1.73

0.88

.67

-.19**

.23**

-.11

Item 13

1.67

0.91

.44

-.26**

.11

-.10

Item 14

1.18

0.89

.49

.06

-.00

-.07

Item 15

1.34

0.69

.64

-.10

.14*

-.11

Total

1.53

0.49

.56

-.21**

.16*

-.28**

Note. N = 219-220. M = mean, SD = standard deviation; CITC = corrected item-total correlation (total = median CITC); Age = correlation with age, Sex = correlation with sex (1 = males, 2 = females), Ms = correlation with marital status (1 = single; 2 = in a relationship). *p < .05; **p < .01.

13.28% and the range was between 4.09% (item 2, “I avoid expressing myself in public because I fear that people could become aware of my insecurity and could make fun of me,” and item 14, “Especially when I feel relatively unconcerned, the risk is high for me to attract negative attention and appear peculiar to others”) and 21.82% (item 9, “When I have made an embarrassing impression somewhere, I avoid the place thereafter”).

The results so far show that there are single items that are relevant in Israel but we also need information on how many persons in the sample exceeded the cut-off scores for gelotophobia. In the present sample there were 5.91% of the participants that exceeded the score, indicating that gelotophobic symptoms apply (i.e., a mean score ≥ 2.50) (see reference 4 for more information on the cut-off scores). Of the participants 4.09% were characterized with slight and 1.36% with pronounced expressions, and .45% yielded extreme expressions of the fear of being laughed at.

Discussion The present study shows that gelotophobia is of relevance in Israel. Slightly less than 6% of the sample 16

exceeded the cut-off scores for at least slight expressions of the fear of being laughed at. This score is lower than the one reported for Germany (11.65%), (4) but also slightly lower than those of self-reported specific phobia symptoms in samples from Israel (i.e., 8.7%), (28).

Interestingly, gelotophobia was more prevalent among younger participants and females. In samples from the German-speaking world there were no age or gender differences (4). Further data will be needed to examine these relations in more detail; the present sample differed from the ones used in the studies in Germany as it included more aged persons. At the moment it cannot be decided whether gelotophobia declines with higher age or whether this is a countryspecific result. Currently there are several studies on their way that allow comparing data from large data sets (some samples provide the possibilities of retesting in the future for longitudinal observations) and from data sets out of multinational studies. Also, the role of partnerships has yet to be fully studied. In the present sample, gelotophobia was higher among participants who were not in a relationship. It seems evident that romantic partnerships, love and sexuality are in some way related to the fear of being laughed at (6). For exam-

Orly Sarid et al.

ple, there is empirical evidence that people with higher scores in gelotophobia remember, to a higher degree, having been laughed at for reasons that are related to (problems in) partnership and/or marriage in the past 12 months (11). Another interpretation would be that people with high fear of being laughed at have more difficulties finding a partner (6). More research is needed in that direction.

The Hebrew version of the GELOPH<15> yielded good psychometric properties and the factorial structure is highly comparable to the one reported in the German form (4). It seems to be a useful instrument for the assessment of the fear of being laughed at in Israel.

One of the aims of this article is to stimulate interest among researchers in Israel in the topic of gelotophobia. There are numerous studies on anxiety-related concepts. Humor, humorlessness or the fear of being laughed at as a special variant of humorlessness and their relation to social phobia, though, have not gained much attention in clinical research. Hence, we believe that the consideration of the fear of being laughed at might also help enrich the understanding of social phobia and related conditions.

It should be noted that social anxiety and gelotophobia seem to have a common ancestor. In 1901 the French psychiatrist Paul Hartenberg published a book on Les Timides et la Timidité (31). Hartenberg’s account of “timidité” was rediscovered recently by Fairbrother (25) who recognized that Hartenberg’s understanding of its phenomenology is surprisingly similar to modern conceptualizations of social phobia, and that Hartenberg anticipated the criteria for social anxiety as used in the DSM and ICD. For example, Hartenberg noted that both shame and fear occur in situations where there is no actual danger, and that these emotions occur only in the presence of others. Most importantly, Hartenberg suggested that one of the main reasons timid people (i.e., social phobics according to Fairbrother, 32) are fearful of self-disclosure and expressing their opinions is a fear of ridicule. Thus, in Hartenberg’s view, the fear of being laughed at is one of the main motivations for the social inhibition of timid individuals. This factor obviously is central to gelotophobia but did not receive much attention in research on social phobia.

Hartenberg listed a variety of etiological factors, but actual traumatic experiences of being laughed at during childhood or adolescence are not among them (25).

More research is needed here especially involving social anxiety patients. It will be crucial to examine whether

or not these patients have a disturbed perception of laughter (7, 20).

The study of humor and related traits might reveal symptoms or behavioral facets in disorders that have not yet gained much attention. This might, for instance, be helpful in setting up differential diagnoses. Another field of potential use is related to treatments. Those who extremely fear being laughed at need special care in treatment situations such as group settings. Knowing that a patient fears to be laughed at might be a good starting point for treatment by learning to appreciate humor and smiling as something positive. Titze suggests humor drama as one potential treatment for gelotophobia (2).

Research conducted on gelotophobia so far has mainly focused on individual differences (5, 33) but there are a lot of open questions relating to psychiatry that should be addressed in the future. Studies are needed that disentangle in which psychiatric groups the fear of being laughed at is more prevalent. A first study (6) showed interesting results that seem well worth following. Generally, humor and humor-related concepts seem to be fruitful concepts in psychiatry with implications on both research and treatment (34).

The major limitation of this study is that it is based on a convenient sample. Although the study shows valid psychometric properties, further studies using larger and more representative samples are needed to assess the sensitivity of the scale with regard to diverse populations. Furthermore, future research is called for to assess the consequences of being gelotophobic on medical parameters, co-morbidity and quality of life.

Acknowledgements The authors are grateful to Mr. Yaacov Doron who helped with the data collection.

References 1. Ruch W, Proyer RT. The fear of being laughed at: Individual and group differences in Gelotophobia. Humor 2008; 21:47-67.

2. Titze M. Gelotophobia: The fear of being laughed at. Humor 2009; 21: 27-48.

3. Nathanson DL. Shame and pride. New York: W.W. Norton; 1992.

4. Ruch W, Proyer RT. Who is gelotophobic? Assessment criteria for the fear of being laughed at. Swiss J Psychol 2008; 67: 19-27.

5. Ruch W. Gelotophobia: The fear of being laughed at. Humor 2009; 22, 1-25.

6. Forabosco G, Ruch W, Nucera P. The fear of being laughed at among psychiatric patients. Humor 2009; 22: 233-251.

7. Platt T. Emotional responses to ridicule and teasing: Should gelotophobes react differently? Humor 2008; 21: 105-128.

8. Ruch W, Proyer RT, Who fears being laughed at? The location of gelotophobia in the Eysenckian PEN-model of personality. Pers Indiv Differ 2009; 46: 627-630.

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Gelotophobia in Israel: On the Assessment of the Fear of Being Laughed At

9. Ruch W, Proyer RT. Extending the study of gelotophobia: On gelotophiles and katagelasticists. Humor 2009; 22: 183-212.

10. Papousek I., Ruch W, Freudenthaler HH, Kogler E, Lang B, Schulter G. Gelotophobia, emotion-related skills and responses to the affective states of others. Pers Indiv Differ 2009; 47: 58-63.

11. Proyer RT, Hempelmann CF, Ruch W. Were they really laughed at? That much? Gelotophobes and their history of perceived derisibility. Humor 2009; 22: 213-231.

12. Beidel DC, Turner SM. Shy children, phobic adults’ nature and treatment of social anxiety disorder. Washington, D.C.: American Psychological Association, 2007.

13. Furmark T. Social phobia: overview of community surveys. Acta Psychiatr Scand 2002; 105: 84-93.

14. Heimberg RG, Liebowitz MR, Hope DA, Schneider FR, editors. Social phobia: Diagnosis, assessment, and treatment. New York: Guilford, 1995.

15. Liebowitz MR, Gorman JM, Fyer AJ, Klein DF. Social phobia-review of a neglected anxiety disorder. Arch Gen Psychiatry 1983; 42: 729-736.

16. Mendlowicz MV, Stein MB. Quality of life in individuals with anxiety disorders. Am J Psychiatry 2000; 157: 669-682.

17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th ed. Washington, D.C.: American Psychiatric Association, 1994.

18. Lewis M. Shame: The exposed self. New York: The Free Press, 1992.

19. Ruch W, Altfreder O, Proyer RT. How do gelotophobes interpret laughter in ambiguous situations? An experimental validation of the concept. Humor 2009; 22: 62-89.

20. Watson D, Friend R. Measurement of social-evaluative anxiety. J Consult Clin Psychol 1969; 33: 448-457.

21. Sosic Z, Gieler U, Stangier U. Screening for social phobia in medical inand outpatients with the German version of the Social Phobia Inventory (SPIN). J Anxiety Disord 2008; 22: 849-859.

22. Stangier U, Steffens M. Social Phobia Inventory (SPIN) Deutsche Fassung [German version]. Frankfurt am Main Germany: Department

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of Psychology, University of Frankfurt, 2002.

23. Connor KM, Davidson JR, Churchill LE, Sherwood A, Foa E, Weisler RH. Psychometric properties of the Social Phobia Inventory (SPIN).

New self-rating scale. Br J Psychiatry 2000; 176: 379-386.

24. Fodor IG. The phobic syndrome in women: Implications for treatment.

In: Franks V, Burtle V, editors. Women in therapy: New psychotherapies for a changing society. New York: Brunner/Mazel, 1974.

25. Arrindell WA, Eisemann M, Richter J, Oei TPS, Caballo VE., van der Ende J, et al. Masculinity-femininity as a national characteristic and its relationship with national agoraphobic fear levels: Fodor’s sex role hypothesis revitalized. Behav Res Ther 2003; 41: 795-807.

26. Iancu I, Levin J, Dannon P, Poreh A, Ben-Yehuda Y, Kotler M. Prevalence of self-reported specific phobia symptoms in an Israeli sample of young conscripts. J Anxiety Disord 2007; 21: 762-769.

27. Marom S, Hermesh H. Cognitive behavior therapy (CBT) in anxiety disorders. Isr J Psychiatry Relat Sci 2003; 40: 135-144.

28. Iancu I, Levin J, Hermesh H, Dannon P, Poreh A, Ben-Yehuda Y, Kaplan Z, Marom S, Kotler M. Social phobia symptoms: prevalence, sociodemographic correlates, and overlap with specific phobia symptoms.

Compr Psychiatry 2006; 47: 399-405.

29. Walsh A, Edwards H, Fraser J. Parents’ childhood fever management: Community survey and instrument development. J Adv Nurs 2008; 63: 376-388.

30. Platt T, Ruch W. The emotions of gelotophobes: Shameful, fearful and joyless? Humor 2009; 22: 91-110.

31. Hartenberg P. Les timides et la timidité (The socially anxious and social anxiety). Paris: Félix Alcan, 1901.

32. Fairbrother N. The treatment of social phobia – 100 years ago. Behav Res Ther 2002; 40: 1291-1304.

33. Proyer RT, Ruch W. How virtuous are gelotophobes? Self- and peerreported character strengths among those who fear being laughed at.

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34. Falkenberg I, Klügel K, Bartels M, Wild, B. Sense of humor in patients with schizophrenia. Schizophr Res 2007;95; 259-261.

Jacques Eisenberg and Rafael Richman Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Heart Rate Variability during a Continuous Performance Test in Children with Problems of Attention Jacques Eisenberg, MD, and Rafael Richman, PhD Children’s Clinic, Community Mental Hearth Center, Herzog Hospital, Jerusalem, Israel

ABSTRACT Background: Children with impulsive behavior and poor self regulation have been shown to have low parasympathetic tone. High vagal tone is associated with attention to novel stimuli.

Objective: To study if Heart Rate Variability, an index of vagal tone, is a mediator of attention.

Method: 77 children who performed a Continuous Performance test (TOVA test) had their EKG recorded for Heart Rate Variability Measurements. Subjects were assigned to groups according to their performance on the TOVA test and a general linear model for repeated measures applied. Pearson Correlations were applied for TOVA scores and HRV Values at four epochs.

Results: No individual correlations were found between Attention Scores and HRV. However, there was a significant group difference showing that good performers had a higher "vagal" tone than poor performers.

Conclusion: The parasympathetic system as measured through HRV is not a mediator of attention. HRV may be an indicator of better health and ability to self regulate.

Introduction Heart rate variability (HRV) has received considerable attention as a promising and potentially informative measure of emotional and physical health. Research on HRV has been wide-ranging, encompassing such areas as cardiac diseases, emotional regulation, information processing, optimal performance and social interaction (1- 4). The basic underlying concept is that a range Address for Correspondence:

of behaviors are dependent on the ability to regulate visceral homeostasis. Specifically, autonomic nervous system flexibility might be a marker of health, whereas a lack of autonomic nervous system adaptation might be a marker or mediator of psychopathology.

Heart rate variability reflects the amount of heart rate fluctuations around the mean heart rate. In general, low HRV frequencies (0.03Hz,-0.15Hz) reflect sympathetic nervous system activity or mixed sympathetic-parasympathetic nervous system activity, while high HRV frequencies (>0.15Hz), or what is termed respiratory sinus arrhythmia (RSA), primarily reflect vagal activity.

Kleiger et al. (5) showed that in normal subjects, measures of cardiac autonomic control for quiet resting periods constitute highly stable individual characteristics.

HRV, Vagal Tone and Behavior

High vagal tone is associated with the ability to self-regulate, and with greater behavioral flexibility and adaptability; whereas low vagal tone is associated with poor self-regulation and with a lack of behavioral flexibility (6, 7). For instance, children who have difficulty modulating their “vagal tone” in response to environmental changes also experience difficulty in social interactions, especially those that require reciprocal engagement and disengagement (8). Allen et al. (9) reported that decreased cardial vagal control is correlated with increased impulse control problems. This finding was only significant in males. In other studies, boys who exhibited high levels of aggression and antisocial behavior showed deficiencies in measures of executive control functions (10) and also deficient vagal modulation of HRV (11). In contrast, children with behavioral inhibition and shyness show evidence of enhanced sympathetic function and higher HRV (12).

High HRV has been associated with attention to novel stimuli (13). Hansen et al. (14), in their study of the effect of vagal tone on performance during a CPT task of sustained

Jacques Eisenberg, MD, Herzog Hospital, POB 3900, Jerusalem 91035, Israel

jaques@cc.huji.ac.il

19

Heart Rate Variability during a Continuous Performance Test in Children with Problems of Attention

attention, found that subjects in their high HRV group had a significantly higher number of correct responses compared to subjects in their low HRV group. High HRV group subjects also had faster reaction times and fewer errors. Further, they found that higher HRV is associated with better performance on working memory tasks.

Attention, ADHD and measurement of attention

Attention Deficit disorders (ADHD and ADD) are currently reported to be the most prevalent disorders of childhood and also the most studied syndrome in the field of child psychiatry (15). Despite these facts, the pathophysiology of ADHD and ADD is far from being understood.

Precisely which type of neuropsychological impairment is associated with deficits in attention remains controversial, but there is growing evidence that there is a heterogeneity of underlying mechanisms for the ADHD phenotype. Possible explanations include: executive dysfunctions and in particular deficient inhibitory control (16); dysfunction in the distribution of cognitive -energetic resources to meet the changing demands of different situations (17); and motivational dysfunction, an emotional reaction to the imposition of delay, or the failure of an impulsive child to engage successfully with delay rich situations elicits delay aversion (18).

Nigg et al. (19) demonstrated that scores on tests of executive functioning such as CPT, Wisconsin cardsorting test, and the Tower of London are abnormal in only 50% of ADHD subjects, and that the scores may be abnormal in subjects who do not have ADHD. These measures, when taken individually or separately, seem to lack adequate specificity and sensitivity. Among the neuropsychological tasks studied in ADHD research, the continuous performance test is one of the most common, and the derived measure of variability (i.e., reaction time standard deviation) yields the greatest effect size for ADHD (20). The TOVA (Test of Variables of Attention) is one of these continuous performance test and is currently in widespread use in Israel. However, its validity and utility has been questioned as a diagnostic test for ADHD. Preston et al. (21) found that the TOVA did not discriminate between an ADHD group and a sub-clinicalADHD control group. The TOVA had a 37% sensitivity and a 61% specificity only, compared to the 80% sensitivity and specificity rate of ADHD vs. normal controls that was claimed by the researchers who developed the TOVA (22). This seems to indicate that subjects diagnosed with an attention disorder according to the DSM-IV criteria exhibit a complex set of behaviors, and 20

that this is only partially captured by the measure of attention provided by the TOVA test.

The present study examined HRV fluctuations in subjects while they performed a continuous performance test (CPT) of sustained attention. In particular, we explored whether children’s HRV profiles differentiated those who performed well on the CPT (“good performers”) from children who performed poorly on the CPT (“poor performers”). If this turned out to be the case, it would suggest that the autonomic nervous system is a mediator of attention. We deliberately chose not to limit subjects to include ADHD children only. The purpose of the study is not to differentiate ADHD from controls, but to study whether autonomic nervous system function is a mediator of attentional performance.

We hypothesize that: 1. HRV will vary at different phases of the CPT, according to demand on attentional effort: i.e., that there will be a time effect; 2. there will be an overall difference in HRV between the poor and the good TOVA performers.

3. HRV will correlate positively with attentional performance.

Methods Subjects and Procedure

All children referred for TOVA test administration at the outpatient mental health ADHD clinic, during an eight-month period, were offered the opportunity to participate in the research. All subjects were a priori suspected of having attentional difficulties, and possibly an attention disorder, as they were usually referred by their school counselor or by a pediatric neurologist.

None of the subjects received stimulant medication or any other type of medication during the test and for 24-hours prior to the testing. In total, 90 children consented to participate in the study. The TOVA Score is a combination of highly predictive score for attentional problems: Mean response time, D’prime (measure the deterioration of performance over time) and variability Since the TOVA score of –1.80 is advertised by the developer (22) as a cutoff score for assignment to the ADHD group with 80% specificity, we adopted this score for group assignment. It does not mean, however, that the bad performers had a diagnosis of ADHD or that the good performers did not have a diagnosis of ADHD: a score of less than -1.80 on the TOVA for the “poor performer” group; a score of greater than -1.80 on the TOVA

Jacques Eisenberg and Rafael Richman

for the “good performer” group. Fifty-six children were assigned to the poor-performer TOVA, and 21 children were assigned to the good-performer TOVA group.

EKG data from 13 of the original subjects were rejected because of poor technical quality. Data from the remaining 77 subjects were analyzed. Demographic data are summarized in Table 1. The protocol was accepted by the hospital’s Helsinki review board.

During the administration of the TOVA to the chilTable 1. Demographic Data by Groups Good performers

Bad performers

n

21

56

Gender

13 boys, 8 girls

40 boys, 16 girls

Age

10.54+_2.99

10.34 +/-2.54

Sig. ( 2-tailed)

ns

dren, the parents were asked to complete a questionnaire that assesses symptoms of ADHD (Conners’ Parent Questionnaire [23]) and the presence of co-morbidity.

EKG was measured by three separate electrodes which were placed on the subjects arms; two on the left arm and one on the right arm. A two-minute baseline EKG measurement was recorded.

The TOVA Task

The visual TOVA is a 21-minute continuous performance test (CPT) in which subjects are instructed to press a button on an electronic micro-switch for every target and inhibit their response for every non-target. Stimuli (targets and non-targets) are presented at the rate of one every two seconds. Each stimulus appears for 100 milliseconds.

Subjects are given a three-minute practice trial, followed by the 21-minute test. The 21-minute test consists of four parts. The first two parts include 36 targets and 126 nontargets each, and the second two parts each consist of 126 targets and 36 non-targets, for a total of 648.

Scores recorded on the TOVA include omission errors (failure to press the switch for a target), commission errors (erroneously pressing the switch for non-target), response time for correct responses (time in milliseconds for response after presentation of stimulus), response time variability for correct responses. Scores are recorded for quarters, halves and total performance and are converted from raw scores to standard scores based on normative data for age and gender provided by the test developers (22, 24).

The EKG data were measured by the Thoughtech Procomp Infiniti device and software. A special script was

written to collect data from five different time-intervals of the procedure: 1 - baseline; 2 - the first two minutes of the test to measure the HRV adaptation to the task; 3 - the last two minutes of the (low frequency stimuli presentation) “boring” part of the TOVA; 4 - the beginning two minutes of the high frequency stimuli section of the TOVA; 5 - the last two minutes of the TOVA. Statistical Analysis The IBI (inter-beat interval) data were exported to an Excel file, and artifacts in the data were “cleaned” using a custom-designed program. When an artifact of approximately double the expected IBI value was noted, the program divided the value into two separate beats.

When an artifact of approximately half the expected IBI value was noted, the program combined two IBI beats.

When a long/high value was followed by a short/low IBI value, the program averaged the two values. Results were analyzed with HRV Analysis Software 1.1 for Windows developed by The Biomedical Signal Analysis Group, Department of Applied Physics, University of Kuopio, Finland. The software is distributed free of charge upon request at http://venda.uku.fi/research/biosignal.

Heart Rate, RRMSSD (root mean square of successive differences), PNN50 , very low frequency (VLF), low frequency (LF), high frequency (HF), power mean, and LF/ HF-ratio values were obtained from the IBI values.

Scores on the Conners’ questionnaire were summarized into 14 clinical scales.

A general linear model with repeated measures (SPSS) was used where the within-group factor was time and the between-group factor was poor-performer/TOVA versus good-performer/TOVA. Pearson correlations were assessed for relationships between the HRV score and the scores on the Conners’ questionnaire scales or the TOVA scores. Scores on the Connors’ parent scales for both groups and TOVA scores are summarized in Table 2.

Results No statistically significant differences were found for the effect of sex or age on any of the HRV variables.

There was an age X omission errors correlation at all four times (O1: .231, p=.03 – O2: .335, p=.00 - O3: .404, p=.00 O4 : .244, p=.03).

At baseline the mean heart-rate of the poor-performer TOVA subjects (89.9+/-10.7) was slightly higher than the mean heart-rate of the comparison-group/ 21

Heart Rate Variability during a Continuous Performance Test in Children with Problems of Attention

Table 2. Mean Value of the Parent Conners’ Rating Scale and the TOVA values by Groups – Good versus Bad Performers CONNERS’

good performers

S.D

bad performers

SD

t

sign.)2 tailed)

opposition

11.35

6.23

11.22

6.89

076.-

ns

cognitive

15.19

7.19

15.39

6.71

109.

ns

hyperactive

8.90

6.09

8.09

5.39

535.-

ns

anxiety

3.62

4.08

4.52

4.48

835.

ns

perfection

4.67

3.29

5.17

4.18

546.

ns

social

1.90

2.84

3.06

2.65

1.604

ns

psychosomatic

2.90

3.65

2.52

2.86

486.-

ns

ADHD index

18.00

8.96

17.13

7.83

391.-

ns

impulsivity

9.05

5.11

8.25

4.99

604.-

ns

emotion instable

3.10

2.64

3.04

2.33

088.-

ns

general

16.86

24.7

11.3

6.83

1.016-

ns

DSM inattention

11.90

6.25

11.94

5.71

025.

ns

DSM Hyperactive

10.33

7.02

8.93

6.14

807.-

ns

DSM general

21.95

12.17

20.59

10.31

453.-

ns

104.19

3.89

92.45

22.32

2.38-

01.

TOVA omission1 omission2

99.24

9.29

90.63

23.25

1.64-

ns

omission3

100.57

12.77

83.84

25.25

2.89-

005.

omission4

98.81

11.04

80.45

22.82

3.52-

001.

Commission1

104.29

9.89

101.48

15.26

781.-

ns

Commission2

100.71

13.65

100.88

13.68

046.

ns

Commission3

101.24

8.49

102.29

16.05

369.

ns

Commission4

101.76

16.16

104.54

16.11

672.

ns

Reaction time1

107.76

12.41

79.95

21.61

5.53-

000.

Reaction time2

98.90

12.25

83.36

16.78

6.62-

000.

Reaction time3

98.71

10.85

75.61

20.47

5.72-

000.

Reaction time4

103.38

13.02

75.88

20.42

5.73-

000.

Variability1

100.3

11.39

82.46

19.01

4.03-

000.

Variability2

98.90

12.23

83.36

16.78

4.46-

000.

Variability3

98.71

10.84

75.61

20.47

4.90-

000.

Variability4

100.05

10.24

76.50

21.98

4.70-

000.

good-performer (87.8+/-12.3). This difference was not statistically significant (t=-.73, p=.466).

1. Time domain The measure of PNN50 (the percentage of absolute difference between consecutive IBIs that are greater than 50 ms) shows that the mean reactivity of the good-performer subjects was higher than the mean reactivity for the poor-performer subjects (time effect: F=3.36, p<.01; group effect, F=3.98, p< .049).

Another time domain measure which reflects the parasympathetic component of HRV is RMSSD (root mean 22

square of successive differences between IBIs). On this measure there was a significant overall between-groups effect, collapsed over all five two-minute time intervals [F=7.55, p=.008]. Broken down by two-minute time intervals, the following data were attained: time 1 (t=1.9, p=.053), time 2 ( t=2.7,p=.041), time 3 (t=1.4, p=.15), time 4 (t=2.01. p=.047), and time 5 ( t=2.19, p=.031). In comparison to the poor-performer, the good-performer subjects had a higher mean HRV at baseline (91.5± 57 vs. 69.4± 37, p=.053). Moreover, in comparison to the poor-performer TOVA subjects, the good-performers showed a decrease in HRV during the boring (low fre-

Jacques Eisenberg and Rafael Richman

Fig. 1: Percentage of absolute difference between two IBI >50ms: Pnn 50 time effect: F=3.36, p<.01; group effect, F=3.98, p< .049 PNN 50

High Frequency Power 100

46%

90

43%

poor perf. good perf.

41%

poor perf. good perf.

80 70

39%

60 ms2

37%

50

35%

40

33%

30

31%

20

29%

10

27% 25%

Fig. 2: High Frequency Power Spectrum (Respiratory Sinus Arrhythmia) between group effect: F=4.0, p=.048

0 1

2

3 2 min epoch

4

5

quency stimulus presentation - time 3) segment of the TOVA, whereas the poor-performer TOVA subjects did not exhibit this variation. At this point during the TOVA (time 3) the earlier difference between the groups disappears. This may well reflect the extra mental effort required and used by children in the good-performer group to attend and accurately respond to the stimuli during this part of the test. Another way of looking at this is that in the boring phase of the CPT, the goodperformers are similar to the poor-performers.

2. Frequency domain On the high frequency (HF) power variable, mean scores in the good-performer group were significantly higher than the poor-performer (between group effect: F=4.0, p=.048). This suggests that there is a lower overall degree of flexibility in the poor-performer TOVA subjects, as their HRV was lower implying that the poor-performer TOVA subjects did not recruit parasympathetic activation throughout the duration of the TOVA. There is a significant time X group interaction [F= 2.43, p=.048].

On the variable of LF power, the mean score for good performers was higher than the mean for poor performers. This difference did not reach statistical significance (F=3.5, p= .065).

Discussion In the present study, autonomic nervous system regulation was assessed via measures of Heart Rate Variability

1

2

3 2 min epoch

4

5

in relation to subjects’ performance on a test of attention (TOVA). The first hypothesis - that HRV fluctuated at different phases of the CPT according to the attentional demands - was confirmed for the “good-performer” subjects. We found a significant group difference in HRV between the good and poor performers: subjects performing well on the TOVA had higher HRV as a group. However, the fact that no significant correlations between individual values of HF and the TOVA scores were found is disturbing. One possible explanation is that HRV is not a direct mediator of attention performance but is a trait marker of better health and adaptation. Therefore it would explain why as a group the better performer on the TOVA had higher HRV but individually it is not the parasympathetic system which mediates the attention. Another explanation would be that the group difference found reflects a type-1 error.

The study’s population sample, as a whole, consisted of children suspected of having an attentional problem.

When Connors’ scores for the poor performers and good performers (as groups) were compared, no significant differences were noted suggesting that we had in fact two groups quite similar clinically.

No statistically significant correlations were found between the TOVA scores and the scores on the subscales of the Conners’ Parent Checklist. This seems to confirm that what the Conners’ scores are capturing or measuring and what the TOVA scores are capturing or measuring is not the same dimension of functioning, a finding quite similar to Preston et al. (21).

It is possible that a different attentional task or more 23

Heart Rate Variability during a Continuous Performance Test in Children with Problems of Attention

dissimilar groups, i.e., a well defined ADHD group and a non-ADHD control group, would have generated different data.

The data from the present study appear to be consistent with Mezzacappa et al. (10) who found that superior or higher performance on tasks of executive functioning (e.g., stop-signal task) was associated with higher RSA. This consistency between the two studies seems to be valid in spite of the fact that the method of data collection during task performance in the present study differed from Mezzacappa et al., who used physiological provocation (standing). Our sample is similar to theirs since they examined a mixed population of children from mainstream and therapeutic schools and did not formally diagnose them.

In contrast, Borger et al. (7) found that ADHD participants had higher HRV than controls. Their study included children with a DSM-III diagnosis of ADHD who had no co-morbidity, and normal controls only.

Moreover they examined the 0.10 Hz component as an index of effort allocation whereas the present study used the HF component (0.14 – 0.25 Hz), which reflects more parasympathetic activity. This may account for the different findings.

Within the poor-performer TOVA group, low effort allocation is pronounced in the inattentive sub-type children/participants, and this manifests primarily during the low-frequency (boring) segment of the TOVA test.

These results confirm Porges’ (4) claim that HRV reactivity, linked to vagal recruitment, correlates with increased self-regulation capacities. In the current study, however, children’s performance on all of the segments of the TOVA was not correlated with its HRV correlate.

This seems to support the caveat stated by Bernston (25) that psychophysiological relations and biomarkers like RSA are often multi-determined.

It does appear, though, that both the TOVA and HRV are measures of degree of health in children. Moderate flexibility, as measured by HRV scores on the TOVA may be a valid indicator of healthy emotional and psychological functioning in children, and may be a skill worthy of practice.

Follow-up research may further clarify the association between HRV and attention, and rectify some of the limitations in the current study. Future studies should select the control group from a non-clinical sample; examine a clearly defined and diagnosed ADHD group compared with a normal population and include other objective measure of degree of attentiveness .

24

References 1. Bernston G.G, Bigger Jr. J, Eckberg DL, Grossman P, Kaufmann PG, Malik M, Nagaraja HN, Porges SW, Saul JP, Stone PH, Van Der Molen MW. Heart rate variability: Origins, methods and interpretive caveats.

Psychophysiology 1997; 34:623-648.

2. Friedman BH, Thayer JF. Autonomic balance revisited: Panic anxiety and HRV. J Psychosom Res 1998; 44:133-151.

3. Maliani A, Pagan M, Lombard F, Cerrito S. Cardiovascular neural regulation explored in the frequency domain. Circulation 1991; 84: 82-492.

4. Porges SW. The polyvagal perspective. Biol Psychol 2007; 74:116-143.

5. Kleiger, R.E,Bigger JT, Bosner MS, Chung MK, Cook JR., Rolnitzky LM., Steinman R.and Fleiss JL. Stability over time of variables measuring heart rate variability in normal subjects, Am J Cardiol 1991; 68:629-630.

6. Thayer JF, Lane RD. A model of neurovisceral integration in emotion regulation and dysregulation. J Affect Disord 2000; 61: 201-216.

7. Borger N, Van der Meere JJ, Ronner A, Alberts E, Geurzel R, Bogte H. Heart rate variability and sustained attention in ADHD children. J Abnorm Child Psychol 1999; 27: 25-33.

8. Porges SW, Doussard Roosevelt JA, Portales AL, Greenspan SI. Vagal tone and the physiological model of social behavior. Dev Psychobiol 1996; 29:697-712.

9. Allen MT, Matthews KA, Kenyon KL. The relationships of resting baroreflex sensitivity, heart rate variability and measures of impulse control in children and adolescents. Int J Psychophysiol 2000; 37:185-194.

10. Mezzacappa E, Kindlon D, Philip Saul J, Earls F. Executive and motivational control of performance task behavior and autonomic heart rate regulation in children: Physiologic validation of two factor solution inhibitory control. J Child Psychol Psychiat 1998; 39: 525-531.

11. Mezzacappa E. Anxiety antisocial behavior and heart rate regulation in adolescent males. J Child Psychol Psychiatry 1997; 38: 457-469.

12. Goto M, Nagashima M,Baba R, Nagano Y, Nishibata K, Tsuji A. Analysis of heart rate variability demonstrates effects of development on vagal modulation of heart rate in healthy children. J Pediatr 1997; 130: 725-729.

13. Porges SW. HRV: An autonomic correlate of reaction time performance.

Psychonomic Soc 1973; 1:270-272.

14. Hansen AL, Johnsen BH, Thayer JF. Vagal influence on working memory and attention. Int J Psychophysiology 2003; 40: 306-313.

15. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rhode,LA. The worldwide prevalence of ADHD: A systematic review and metaregression analysis. Am J Psychiatry 2007; 164:942-948.

16. Barkley RA. Behavioral inhibition, sustained attention and executive function: Constructing a unified theory of ADHD. Psychol Bull 1997; 21:65-94.

17. Sergeant JA ,Oosterlaan J, Van der Meere J. Information processing and energetic factors in ADHD. In: Quay HC, Hogan A, editors. Handbook of disruptive behavior disorders. N.Y. :Plenum, 1999: pp. 75-104.

18. Sonuga-Barke EJS. Psychological heterogeneity in ADHD – A dual pathway model of behavior and cognition. Behav Brain Res 2002; 130: 29-36.

19. Nigg JT, Willcutt E, Doyle AE, Sonuga-Barke EJS. Causal heterogeneity in Attention Deficit Disorder. Do we need neuropsychologically impaired subtypes? Biol Psychiatry 2005; 57: 1224-1230.

20. Klein C, Zendling K, Huettner R, Ruder H, Peper M. Intra subject variability in ADHD. Biol Psychiatry 2006; 60:1088-1097.

21. Preston AS, Fenell EB, Bussing R. Utility of a CPT in diagnosing ADHD among a representative sample of high risk children: A cautionary study.

Child Neuropsychology 2005; 11: 459-469.

22. Greenberg LM, Waldman ID. Developmental normative data on a Test of Variables of Attention (T.O.V.A.). J Child Psychol Psychiatry 1993; 34: 1019-1030.

23. Conners CK. Rating scales in attention deficit hyperactivity disorder: Use in assessment and treatment monitoring. J Clin Psychiatry 1998; 59: 24-30.

24. Greenberg LM, Kindschi RN, Corman CM. T.O.V.A.: Test of Variables of Attention. Los Alamitos, Cal.: Universal Attention Disorders, 2000.

25. Bernston GG, Cacioppo JT, Grossman P. Whither vagal tone. Biol Psychol 2007; 74: 295-300.

Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Arturo G. Lerner et al.

Benign and Time-Limited Visual Disturbances (Flashbacks) in Recent Abstinent High-Potency Heavy Cannabis Smokers: A Case Series Study Arturo G. Lerner, MD,1,2 ,Craig Goodman, PhD, 1 Dmitri Rudinski, MD, 1 and Avi Bleich, MD1, 2 1

Lev Hasharon Mental Health Medical Center, Pardessya, Israel Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel

2

ABSTRACT Eight high-potency heavy cannabis smokers who fulfilled DSM-IV-TR criteria for cannabis dependence sought treatment for outpatient detoxification.

During routine psychiatric interview they reported the presence of visual disturbances when intoxicated and no prior history of LSD use. They all communicated the persistence of visual disturbances after ceasing cannabis use. Seven categories of visual disturbances were described when staring at stationary and moving objects: visual distortions, distorted perception of distance, illusions of movement of stationary and moving objects, color intensification of objects, dimmed color, dimensional distortion and blending of patterns and objects. Patients reported having 2-5 different categories of flashbacks up to 3-6 months after cessation of cannabis use. The described phenomena may be interpreted as a time-limited benign side effect of high-potency cannabis use in some individuals. A combination of vulnerability and use of large amounts of high–potency cannabis seem to contribute to the appearance of this condition.

Conclusions from uncontrolled case series should be taken with appropriate caution.

Introduction Hallucinogens encompass a group of naturally-occurring substances from vegetable (1) and animal (2) origins as well as synthetic chemical agents (3) which

may induce a state of intoxication popularly referred to as a “trip” (4). These “trips” or substance-induced experiences are generally transient and reversible states that are typically accompanied by perceptual disturbances. The mind-altering effects are experienced in a clear sensory-conscious state, while awake and alert and generally in the absence of confusion (5-8). A well known, unique and intriguing side effect associated with the use of synthetic hallucinogens such as lysergic acid diethylamide-LSD and LSD-like substances is the partial or total recurrence of the perceptual disturbances which previously appeared during intoxication, in the absence of recent use (9-11). These experiences are accompanied by full insight and can be short or longterm (10, 11). The original intoxicating experience may be “good” (pleasant) or “bad” (unpleasant). In the same way, the perceptual recurrences recapitulate the prior “trip” or intoxication that was experienced as either “good” or “bad.” A previous “good” trip, however, does not always predict or ensure a “good” recurrence (10, 11). Common recurrent visual disturbances attributed to this complex syndrome are geometric hallucinations, false perception of movement in the peripheral visual fields, flashes of colors, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia and micropsia (12).

At least two subtypes of this syndrome have been reported. The first is flashback. It is a short term, transient, recurrent, spontaneous, reversible and generally visual benign experience. Experienced LSD users generally look at these recurrences as a “free trip,” an aspect of the psychedelic dimension, and do not seek psychiatric assistance after experiencing these types of episodes.

Certain individuals may experience the recurrence of

Address for Correspondence: Arturo G. Lerner, MD, Lev Hasharon Mental Health Medical Center, POB 90000, Netanya 42100, Israel alerner@lev-hasharon.co.il ; lerneram@internet-zahav.net

25

Benign and Time-Limited Visual Disturbances (Flashbacks) in Recent Abstinent High-Potency

the same single flashback while other perhaps more suggestible subjects may have a variety of them. The second is hallucinogen persisting perception disorder (HPPD). This is long-term, spontaneous, intermittent or continuous, pervasive and either slowly reversible or irreversible. This disorder is entirely different from the benign flashback (10, 11). HPPD is a condition in which the re-experiencing of one or more perceptual symptoms causes significant distress or impairment in social, occupational or other important areas of functioning (12). HPPD often occurs in individuals with no prior psychopathology, and may be extremely debilitating. Hallucinogen users are usually aware of these severe, intruding and disabling consequences of LSD consumption and generally actively seek psychiatric help. HPPD seems to be part of a large spectrum of non-psychopathological and psychopathological experiences reported by hallucinogen users (10, 11).

Whether or not the use of cannabis alone can be associated with persisting perceptual abnormalities has been debated. Investigators tend to agree that cannabis can precipitate perceptual recurrences in subjects who had previously used LSD and that it is unlikely that cannabis alone can provoke recurrent perceptual disturbances (13-15). However, there are reports of depersonalization (16, 17), perceptual symptoms experienced during cannabis intoxication (18, 19) and short-term spontaneous recurrent visual disturbances (20) after the suspension of cannabis use alone. Reliability of recurrent cannabis associated visual experiences has been critically questioned. It should be noted that according to DSMIV-TR the diagnostic criteria of cannabis intoxication allows for a diagnosis of “with perceptual disturbances” (12). If perceptual disturbances can be observed during intoxication by cannabis alone (12, 21), it is plausible that some predisposed and susceptible cannabis heavy smokers using high concentrated cannabis (22) may partially or totally recapitulate the previous perceptual experience in the absence of present cannabis use. We present the cases of eight high-potency heavy users of cannabis without a prior history of LSD use who reported the presence of benign persisting visual disturbances after stopping cannabis consumption.

Method Clinical data

Eight patients were examined after seeking treatment for cessation of chronic cannabis use. Four of them 26

attempted to stop cannabis use in the past without professional assistance. Patients included in the report met the DSM-IV-TR criteria for cannabis dependence (12). They reported the need for markedly increased amounts of cannabis to achieve desired effect, cannabis was smoked over longer periods than was intended, there were unsuccessful efforts to stop or control its use, a great deal of time was spent to obtain cannabis and finally social, occupational and recreational activities were impaired (12).They communicated cannabis intoxication with perceptual disturbances (12), the intake of high concentrated cannabis (22) since starting cannabis use, a smoking period of at least five years and a daily consumption (“joints” and water pipes) of at least three times a day (i.e., morning, noon or afternoon and evening). They had no prior use of LSD or other hallucinogenic substances. All patients had previous compulsory military service, no prior police or criminal records, and were not married. Four of the patients reported smoking cannabis alone. The other four reported occasional use of cocaine, MDMA, and also fulfilled full criteria for nicotine dependence (12).

Visual disturbances during intoxication were reported only after being interviewed for treatment and were not accurately recalled. Treatment was not sought due to visual disturbances. They associated the precipitation of visual disturbances only and strictly by cannabis smoking. Other consumed legal (nicotine and alcohol) and illegal (ecstasy and cocaine) substances were not associated with the perceptual disturbances. None of the patients had any co-morbid medical disease or co-occurring psychiatric disorders. Neurological and ophthalmologic examinations were intact. Two patients had a family history of schizophrenia.

Demographic data

Mean age of patients was 29.25 years old (S.D.=2.25), mean education was 13.13 years (S.D.=1.55), mean duration of non-use was 82.25 days (S.D.=40.6), mean duration of cannabis use was seven years (S.D.=1.69), and mean number of previous attempts of cessation or detoxifications was 0.625 (S.D.=0.74). All patients were white males of Jewish Israeli descent, were currently employed, and had a middle class socioeconomic status.

Detoxification and follow-up

Tetrahydrocannabinol (THC) was present in urine samples prior to initiation of detoxification. No other psychoactive substances were identified. All patients

Arturo G. Lerner et al.

underwent uncomplicated outpatient cannabis detoxification using only minimal symptomatic medication like small doses of clonidine (23) and careful use of benzodiazepines. They continued working when undergoing treatment reflecting low severity or control of the detoxification process. After detoxification and followup, substances of abuse were not identified in random urine samples. Two out of eight patients relapsed after two months. One of the relapsing subjects reported having visual disturbances again when intoxicated. The remaining six abstinent patients reported flashbacks up to six months after stopping cannabis use. Interestingly, two patients who had a family history of schizophrenia reported longer duration of recurrences. None of the subjects were interested in pharmacological treatment for the flashbacks or psychotherapy. None of the six abstinent patients revealed the presence of flashbacks at the one-year follow-up visit.

Flashbacks

The term flashback is used instead of HPPD, due to the benign nature of the visual recurrences (9-11).

Individuals reported the presence of flashbacks similar to those visual disturbances which appeared during intoxication. There was not a clear period of latency between the appearance of visual disturbances during intoxication and the continuation of flashbacks during detoxification and follow-up. The average time of persisting visual disturbances experienced by the participants following detoxification was 11.75 weeks (S.D.=5.80). Flashbacks were perceived as benign, generally short term (from a fraction of a second up to several minutes), spontaneous (without identified triggers), recurrent, non-distressing and entirely reversible. The accompanying affect was pleasant. Prodromal symptoms (aura) did not precede the flashbacks (11). Flashbacks started with a frequency of a few times a day (mean=11.75, S.D.=5.80) and their intensity was not experienced as disturbing or painful. After initial presentation, flashbacks usually decreased in frequency and intensity, with a tendency to slowly wear off.

The accompanying affect usually disappeared along with the recurrence. Full insight, reality testing and judgement were always maintained. Users looked upon the flashback as a kind of “free trip” or curious experience. Patients reported having from two up to five different categories of flashbacks which appeared when staring at stationary and moving objects. Distortions were described as minimal, "almost imperceptible" and very slight in nature.

Seven categories of visual disturbances were described

when staring at stationary and moving objects: visual distortion (slightly blurred object), distorted perception of distance (objects were slightly seen closer or distant), illusion of movement of stationary and moving objects (slow movement), color intensification of objects (slightly more intensified), dimmed color (slightly less intensified), dimensional distortion (objects were slightly seen smaller – micropsia, or larger – macropsia) and blending of patterns and objects. All eight of the patients experienced visual distortions of objects, six had distorted perception of distance from the object, five of the eight reported having illusions of movement of stationary and moving objects, two reported color intensification of objects, two reported dimmed color, two slight dimensional distortion of objects and two patients reported blending of patterns and objects. Number of flashbacks from each category and overall number were difficult to calculate.

The most frequently reported type of flashback and the last to disappear was visual distortions of objects.

Discussion While the precise mechanisms underlying cannabisassociated perceptual disturbances are unknown, there is some knowledge indicating similarities with some proposed mechanisms related to LSD associated perceptual disturbances. Serotonin neurotransmission appears to be involved in the genesis of both acute and persisting LSD-induced perceptual disturbances. The acute effects of LSD seem to be mediated through a 5-HT2 postsynaptic partial agonist activity (24). Similarly, the acute effects of cannabis appear to be related to serotonergic systems. Although the main acute pharmacological effects of cannabis are mediated through cannabinoid receptors, it is known to severely disrupt serotonergic neurotransmission. This disruption could be responsible for most of the cannabis effects on cognition and perception (25, 26) and could be associated with the ability of marijuana to produce perceptual disturbances such as depersonalization (16, 27). Moreover, marijuana smoking, but not placebo smoking, was able to produce depersonalization in healthy subjects (28).

Therefore this mechanism could also attempt to explain acute cannabis associated visual disturbances.

The chronic and persisting effects of LSD, hallucinogen persisting perception disorder and flashbacks (10, 11), may closely resemble the previous hallucinogenic experience, implying that a mechanism related to the original one may be involved. The basic mechanism 27

Benign and Time-Limited Visual Disturbances (Flashbacks) in Recent Abstinent High-Potency

underlying this syndrome appears to be a vulnerability or a predisposition of LSD users to continue the central process of visual imagery after the image has been removed from the visual field (29). An LSD-generated intense current (30) may provoke the destruction or dysfunction of cortical serotonergic inhibitory interneurons with GABA-ergic outputs and lead to the persistence of the visual imagery due to chronic disinhibition of visual processors (8). Thus, it is plausible that high-potency cannabis (22) that affects serotonergic neurotransmission (25, 26) could provoke a similar effect in some vulnerable and predisposed subjects.

There is more data indicating the possible serotonergic involvement in the genesis and perpetuation of visual disturbances. The appearance of visual phenomena resembling flashbacks (palinopsia) in patients without a previous history of cannabis or hallucinogen exposure after risperidone, nefazodone and trazodone administration (31-33) has been reported. These transient visual disturbances have been attributed to the 5HT2A blocking properties of these agents. Heightened sensitivity to side effects and reduced 5HT2A serotonin receptor stimulation rather than increased 5HT2c stimulation have been proposed as explanations for these intriguing phenomena (31).

Medications shown to be beneficial in the treatment of persisting visual disturbances may provide additional support for serotonergic involvement. Alleviation of persisting visual disturbances after administration of sertraline was attributed to the down regulation of 5-HT2 receptors (29). Reboxetine also appears to be helpful in the treatment of some subjects complaining of persisting visual recurrences with depressive features (34).

Reboxetine may have an Îą2 adrenoreceptor modulating effect on both noradrenaline and serotonin release (35).

Reboxetine may also affect the reuptake of serotonin and lead to down regulation of 5-HT2 receptors resembling the improvement of persisting visual disturbances after administration of SSRIs (29, 34). Benzodiazepinesâ&#x20AC;&#x2122; effectiveness in the treatment of persisting visual disturbances may be related to benzodiazepine activity at cortical serotonergic inhibitory interneurons with GABAergic outputs (5, 6). Clonazepam which may improve persisting visual occurrences (10), HPPD with anxious features (11) and depersonalization (36) may also affect serotonergic system and enhance serotonergic transmission (37). This effect may secondarily lead to down regulation of 5-HT2 receptors, which may contribute to the HPPD symptoms remission (29). This amelioration 28

may also support the estimation that persistent visual disturbances may be related to disinhibition of visual processors via impairment of GABA transmission by inhibitory interneurons. It is still unclear how serotonin systems are involved in the phenomena.

Cannabis-related compounds and the anandamidergic system seem to be involved in areas of visual information processing (38). Impairment of visual sensory data has also been suggested (38).The physiological and pathophysiological roles of the central nervous endogenous cannabinoid system are not completely understood (39). The suspected influence and participation of psychoactive cannabinoids on acute and persistent visual perception and central information processing need to be elucidated.

High-potency cannabis may have some influence in the development of the presented visual side effects.

The THC content varies between different sources and preparations of cannabis (22). Sophisticated cultivation such as hydroponic farming and plant-breeding techniques have greatly increased the potency of cannabis products (22). In the 1960s and 1970s an average joint contained about 10 mg of THC. Now a joint made out of potent subspecies may contain around 150 mg of THC or 300 mg if laced with hashish oil (22). Given the fact that the effects of THC are dose related (25) and most of the research on cannabis was carried out in the 1970s using doses of 5-26 mg of THC (40), modern predisposed and vulnerable cannabis smokers may be exposed to doses of THC greater than in the past and risks and consequences might be greater (41).

Cannabis-induced flashbacks appear to be a benign side effect. It remains unclear if it is an uncommon and infrequent associated feature or if it has been underreported by patients due to its benign nature or underdiagnosed by clinicians. A combination of vulnerability and use of large amounts of high-potency cannabis seem to contribute to the appearance of this condition.

Additionally, those predisposed individuals seem to present a returning pattern of visual disturbances whenever cannabis is smoked. The return of visual disturbances in relapsing subjects and the continuation of visual disturbances in those who suspended cannabis intake for short periods in the past and during treatment may support the existence of this suggested pattern. It should be reiterated that patients only applied for cannabis detoxification treatment. Information regarding the presence of visual disturbances was identified and collected during routine clinical interview.

Arturo G. Lerner et al.

We suggest that clinicians actively investigate the presence of visual disturbances in cannabis users. Clinical psychiatrists should be aware of this persisting visual side effect. Due to the fact that these phenomena may be also attributable to misinformation or unreliable self reports, conclusions from uncontrolled case series should be taken with appropriate caution.

Acknowledgement The authors would like to thank Ms. Rena Kurs for her support and assistance in the preparation of the manuscript.

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30. Garrat J, Alreja M, Aghajanian GK. LSD has high efficacy relative to serotonin in enhancing the cationic current Ih: Intracellular studies in rat facial motorneurons. Synapse 1993;13:123-134.

31. Lauterbach EC, Abdelhamid A, Annandale JB. Posthallucinogenlike visual illusions (palinopsia) with risperidone in a patient without previous hallucinogen exposure: Possible relation to serotonin 5HT2a receptor blockade. Pharmacopsychiatry 2000;33:38-41.

32. Schwartz K. Nefazodone and visual side effects. Am J Psychiatry 1997; 154:1038.

33. Hughes MS, Lessell S. Trazodone-induced palinopsia. Arch Ophthal 1990;108:399-400.

34. Lerner AG, Shufman E, Kodesh A, Kretzmer G, Sigal M. LSD-induced hallucinogen persisting perception disorder with depressive features treatment with reboxetine. Isr J Psychiatry Relat Sci 2002; 39: 100-103.

35. Lucca A, Serreti A, Smeraldi E. Effects of reboxetine augmentation in SSRI resistant patients. Hum Psychopharmacol Clin Exp 2000; 15: 143145.

36. Stein MB, Uhde TW. Depersonalization disorder: Effects of caffeine and response to pharmacotherapy. Biol Psychiatry 1989;26: 315-320.

37. Hewlett WA, Vinogradov S, Agras WS. Clomipramine, clonazepam, and clonidine treatment of obsessive compulsive disorder. J Clin Psychopharmocol 1992;12: 420-430.

38. Leweke FM, Schneider U, Thies M, Munt TF, Emrich HM. Effects of synthetic delta 9- tetrahydrocannabinol on binocular depth inversion of natural and artificial objects in man. Psychopharmacology 1999; 142: 230-235.

39. Leweke FM, Schneider U, Radwan M, Schmidt E, Emrich HM. Different effects of nabilone and cannabidiol on binocular depth inversion in man. Pharmacology, Biochemistry and Behavior 2000; 66: 175-181.

40. World Health Organization. Program on substance abuse. Cannabis: A health perspective and research agenda. Geneva: WHO, 1997.

41. Gold MS. Marihuana. In: Miller NS, editor. Comprehensive handbook of alcohol and drug addiction. New York: Marcel Decker, 1991.

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Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

A Case of Klingsor Syndrome: When There is no Longer Psychosis Ranjan Bhattacharyya, MD, DNB, Debasish Sanyal, MD, and Krishna Roy, MD Calcutta National Medical College and Hospital, Kolkata, India

ABSTRACT The following case report describes an act of genital self mutilation. An employed, unmarried male suffering from schizophrenia paranoid type, autocastrated his genitalia during a period of illness when his psychotic symptoms were absent. Sufficient attention may not have been paid to his depressive symptomatology which may be primary as a core feature or secondary, in what can be called post-psychotic depression. The vulnerability of committing such an act increases when the person appears to be symptom-free and regaining insight. After a review of the available literature, it is considered that this case best fits the description for Klingsor Syndrome.

Introduction Self mutilation has been defined as the deliberate destruction or alteration of body tissue without conscious suicidal intent (1). It has been performed by individuals of all races, religions and cultures. The first report in English medical literature of genital self mutilation (GSM) was in 1901 by Strock (2). GSM may involve injuring, or even partial or total removal of the external genitalia, and is mentioned in Greek and Roman mythology (3, 4). Reported cases of GSM are rare. Stunnel et al. found only 122 reported cases and that most occur during psychosis (5). The associated psychiatric illnesses differ across gender. In females, GSM is mostly associated with personality disorders (predominantly Borderline type), whereas in males, psychosis is present in up to 80% of cases (2). Aboseif

et al. estimated that only 65% of patients had psychotic illness and that 31% of them made repeated attempts of GSM (6). Others concluded that psychosis was not present in one-third of cases (7). Greilsheimer and Groves identified three general patient groupings: psychotic individuals, nonpsychotic individuals with significant personality disorders, and individuals influenced by sociocultural factors and religious beliefs (8). Religious delusions, themes of guilt and sexual conflict, a history of depression with past suicide attempts and having been abused in childhood are associated with increased risk for committing GSM (4, 9). The causes, antecedents and associations for GSM are multidimensional (10). These range from transsexuals trying to reassign their gender on their own, secondary to alcohol or drug abuse like amphetamine, suicide attempts, etc. (11-13).

Waugh et al. suggested that GSM most commonly occurs in men with chronic delusions or with guilt for sexual wrongdoing (14).

Self-mutilation of the external genitals in psychiatric patients is also known as Klingsor Syndrome which includes self-inflicted castration because of religious delusions. Schweitzer proposed that the syndrome should also include cases which involve genital self mutilation associated with all delusional syndromes (4).

The name “Klingsor” was based on a fictitious character in Wagner’s opera where Klingsor was a magician who castrated himself in an unsuccessful attempt to gain acceptance from the Knights of the Grail.

Case Vignette S.B., a 31-year-old Hindu, unmarried male residing in central Kolkata, India, attended the psychiatry outpatient department (OPD), and was brought by his older brother in January, 2008 with the following chief complaints:

Address for Correspondence: Dr. Ranjan Bhattacharyya, MD, Medical Officer, 29 Anandasree, Garia, Kolkata 700084, India. rankholders06@yahoo.co.in

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Ranjan Bhattacharyya et al.

1. Hearing voices for one year of an unknown female asking him to marry her.

2. Frightening male voices threatening to kill him for ten months.

3. Suspiciousness that people have been conspiring against him for ten months.

His problem had started one year before while living in a rented house with his brother and mother after the death of his father in a traffic accident. He started hearing voices of an unknown woman when nobody was around, asking that he marry her. At the beginning it was pleasant but later these experiences became distressing due to the fact that the woman was trying to excite him sexually as if she was touching his private parts. It was then he started hearing male voices threatening that he must obey the commands of the female voice otherwise they would kill him. He ran away from home once in the middle of the night and was found in a small abandoned police outpost in his locality. He was then brought to the psychiatric outpatient department and was diagnosed as suffering from schizophrenia, paranoid type. He was prescribed olanzapine 10 mg at bedtime and asked to return in four weeks. On subsequent follow up, the psychotic features improved and auditory hallucinations completely disappeared within three months. He disclosed his hatred of marriage following a broken love affair one year earlier.

He started visiting a temple for an hour each day. He was regular in follow up and attended the outpatient department at two week intervals. The family members ensured regular compliance and showed empty strips of the tablet olanzapine (10 mg) on each visit. The three specialists independently agreed that this was the optimum dose with best therapeutic benefit and with least chance of producing extra-pyramidal side effects. He responded well with this regimen as evident from reduction of PANSS and BPRS scores. Unfortunately at the fourth month of his symptom-free period (seventh month of his illness) he presented to the emergency department with severe self-inflicted injuries to his scrotal sac and total amputation of the penis. It was revealed that he had castrated his genitalia with a razor and a sharp knife without applying any anesthesia. He was brought to the emergency operation theater and the revision of the penis with closure of the scrotal wound was performed by the attending urosurgeon. Microsurgical reimplantation, the most widely practiced approach by surgeons in these cases, could not be performed as the patient was brought to the hospital over 18 hours after the incident when most of the tissues were not viable (15).

He had never required psychiatric consultation in the past. He did not show any body image disturbances anytime during his period of illness. He was able to perform his job as a clerk in the postal department.

There was no history of substance abuse or any contact history. He had no relationship with other women nor had he dated women other than his ex-girlfriend at any time. The family history was non-contributory. He used to be a jovial, energetic, charming and well-to-do person who loved listening to music. He used to mix with people easily and was always very popular in his peer group because of his helping attitude. No definite traits or personality disorder were diagnosed from his premorbid personality.

During mental status examination at the time of admission with GSM, he was alert, conscious but uncooperative, eye contact was poor, speech was inaudible and detailed examination could not be done at that point. He was guarded initially, did not appear to be overtly psychotic, and his trust of the staff gradually increased. After 24 hours, rapport could be established with difficulty. Speech was relevant and coherent; affect was sad, mood irritable; no formal thought disorder and perceptual disturbances were noted. There was no suicidal intent. Tests of higher cognitive functions were satisfactory. He acknowledged he was sick but attributed his illness to an unknown factor (Grade 4 insight).

Apart from mild pallor, local examination revealed the penis was totally amputated, catheterized with oozing of blood and raised temperature. Other systemic examinations and routine laboratory tests were within normal limits. CT scan of brain showed mild ventricular dilatation.

On query why he had performed such a drastic act, the patient disclosed that he was feeling intense guilt and sadness for his past psychotic illness which had caused significant emotional and financial burden on his family members. He further expressed that he had not slept well for the past few nights and could not recall what was his state of mind just before this act. The act was preceded by feelings of hopelessness and social avoidance. The family members revealed retrospectively that for the last week he had been staying home and not going to work.

The patient had told his brother that he had taken leave for a week due for his working overtime in the past.

Extensive clinical interviews did not reveal any clear psychotic processes. The Wechsler Adult Intelligence Scale (WAIS) showed full-scale IQ was 98. The BPRS and PANSS scores were borderline (40 and 55 respec31

A Case of Klingsor Syndrome: When There is no Longer Psychosis

tively) to overtly psychotic. However, the HAMD-17 score was 28, which fell in the severe depression category. The diagnosis was revised as post-psychotic depression (F20.4) as per ICD-10 criteria and other possible diagnoses such as affective disorders, substance use disorders, personality disorders and obsessive compulsive disorders were ruled out. Some schizophrenic symptoms in the form of negative symptoms and change in personal behavior, lack of interest, social withdrawal were still present in absence of delusion or hallucination which supports the diagnosis.

Discussion Predicting GSM is exceedingly difficult. The best predictor of future behavior is probably past behavior. GSM is often a one-off act but in some cases there are examples of prior self harm behavior. With psychotic patients it can be very difficult in much the same way as suicide is more usually unpredictable in schizophrenia.

GSM is not necessarily associated with psychosis as reported in the previous case reports. In all follow up visits, our patient did not show any psychotic symptoms and possibly was able to mask his depressive symptoms for long periods until he carried out such a drastic act.

He denied that the autocastration was an attempt to atone for past sins or an attempt to change his sex.

Unlike previous published reports, this case report is interesting in formulating a hypothesis that a combination of antecedent factors can lead to the act of GSM. Remaining unmarried at the age of 31 is unusual for his ethnic background (16). The patient had an unsuccessful love affair and witnessed the unexpected death of his father and could not cope with these two significant life stressors. One of the symptoms associated with GSM is the presence of religious psychotic experiences (4). Here the patient could have been trying to attain a pure form of existence by amputating his penis without any features of psychosis at the time of commission of this act, as mentioned in previous case reports (17). The increased visit to temples in comparison to his premorbid period could be an indicator of his intense guilt, a mode of confession and an attempt to attain purity. The sexual hatred probably was due to overgeneralization and other cognitive errors.

The current case of autocastration by a man recovering from a psychotic episode with possible sexual guilt, religiosity and intense hatred towards women is one of the rare antecedents of reported acts of GSM and a care32

ful search for possible post-psychotic depression is warranted in order to prevent this act of self harm. Duggal et al. offer an interesting inversion of the commonly accepted relationship between psychosis and autocastration: they speculate that psychosis can be an effect rather than a cause (18). It is essential to identify patients at risk for GSM so that the act can be prevented. Psychosis with delusions of sexual guilt is an obvious warning sign in the causation of GSM. But at the same time during the recovery from psychosis, when the patient is regaining his insight and in the phase of post-psychotic depression he is vulnerable to commit such an act. Due to the rarity of the event, however, more precise identification of individuals at risk remains difficult.

Previous case reports on autocastration have identified individuals as having significant dysfunction of ego integrity and the occurrence of such an act is more common in men (19). A few reports described initial denial by the patients of having committed such act themselves.

Some patients cut or maim their genitalia by violent methods, while others performed the act very meticulously. It is sometimes difficult to assess whether it was a failed suicide or successful male self-amputation. Even a case of autophagia of the amputated penis has been published. One patient himself had attempted surgically to reconstruct a foreskin (20). The reports described the influence of media in a susceptible individual with borderline intellectual functioning to undertake this act (21).

Auto-aggressive actions can be prevented by adequate pharmacotherapy and psychotherapy. In schizophrenia six possible risk factors for GSM have been mentioned (22): 1) psychotic experiences, 2) presence of personality disorder, 3) past history of GSM, 4) alcohol or drug dependence, 5) sexual guilt feeling and 6) early loss of father. Depressive symptoms complicate the course of schizophrenia in as many as 25% cases and post-psychotic depression is complicated by an overlap with the negative symptoms of schizophrenia.

The post-psychotic depression can be early (within six months of an acute episode) or late (persists more than six months after an acute episode). In early cases depression resolves more slowly than other symptoms of acute episode but in late cases depressive symptoms develop in the aftermath of an acute psychotic episode or persist for more than six months (23). The present case is compatible with the diagnosis of late post-psychotic depression which warrants antidepressant treatment, preferably a SSRI. It seems that post-psychotic depression could be one of the warning signs for committing an act of GSM.

Ranjan Bhattacharyya et al.

Inferences It appears that the number of reports of genital selfmutilation is on the rise. Whether this is due to a true increase in the incidence is not known. The high rate of repeated mutilation is due to the fact that patients do not come under the scrutiny of psychiatric services.

A general awareness of GSM should be promulgated among medical practitioners so that it can be prevented and treated effectively. The careful assessment during follow up and family education to recognize early warning signs could be two important interventions to prevent such dreadful acts.

This case is unique as at the time of the autocastration the psychotic features were well under control. This case raises the question of whether the act of autocastration, in the absence of clear psychotic symptoms, justifies labeling an individual as psychotic. Perhaps future reports will help to elucidate the complex relationship between the GSM and associated psychopathology.

References 1. Coons PM. Self-amputation of the breasts by a male with schizotypal personality disorder. Hosp Comm Psychiatry 1992; 43:175-176.

2. Eke N. Genital self-mutilation. There is no method in this madness. BJU Int 2000; 85:295-298.

3. Alao AO, Yolles JC, Huslander W. Female genital self-mutilation.

Psychiatr Serv 1999; 50: 971.

4. Schweitzer I. Genital self-amputation and the Klingsor syndrome. Aust NZ J Psychiatry 1990; 24:566-569.

5. Stunnell H, Power RE, Floyd M, Quinlan DM. Genital self-mutilation.

Int J Urol 2006; 13: 1358-1360.

6. Aboseif S, Gomez R, McAninch JW. Genital self-mutilation. J Urol

1993; 150:1143-1146.

7. Romilly CS, Isaac MT. Male genital self-mutilation. Br J Hosp Med 1996; 55:427-431.

8. Greilsheimer H, Groves JE. Male genital self-mutilation. Arch Gen Psychiatry 1979; 36:441-446.

9. Nerli RB, Ravish IR, Amarkhed SS,Manoranjan UD, Prabha V, Koura A. Genital self-mutilation in nonpsychotic heterosexual males: Case report of two cases. Indian J Psychiatry 2008;50:285-287.

10. Yip K. A multi-dimensional perspective of adolescentsâ&#x20AC;&#x2122; self-cutting.

Child Adolesc Ment Health 2005;10:80-86.

11. Balitieri Da, de Andrade AG. Transexual genital self-mutilation. Am J Forensic Med Pathol 2005;26: 268-270.

12. Israel JA, Lee K. Amphetamine usage and genital self-mutilation.

Addiction 2002;97:1215-1218.

13. Kratofil PH, Baberg HT, Dimsdale JE. Self-mutilation and severe selfinjurious behavior associated with amphetamine psychosis. Gen Hosp Psychiatry 1996; 18: 117â&#x20AC;&#x201C;120.

14. Waugh AC. Autocastration and biblical delusions in schizophrenia. Br J Psychiatry 1986; 149:656-659.

15. Young LD, Feinsilver DL. Male genital self-mutilation: Combined surgical and psychiatric care. Psychosomatics 1986 ; 27: 513-517.

16. http://www.unicef.org/india/AGE-AT-MARRIAGE.pdf last accessed on June 14, 2009.

17. Bhatia MS, Arora S. Penile self-mutilation. Br J Psychiatry 2001; 178: 86-87.

18. Duggal HS, Jagadheesan K, Nizamie SH. Acute onset of schizophrenia following autocastration. Can J Psychiatry 2002; 47: 283-284.

19. Walter G, Streimer J. Genital self-mutilation: Attempted foreskin reconstruction. Br J Psychiatry 1990; 156: 125-127.

20. Martin T, Gattaz WF. Psychiatric aspects of male genital self-mutilation.

Psychopathology 1991; 24: 170-178.

21. Catalano G, Morejon M, Alberts VA, Catalano MC. Report of a case of genital self-mutilation and review of the literature, with special emphasis on the effects of the media. J Sex Marital Ther 1996; 22: 35-46.

22. Agoub M, Battas O. Male genital self-mutilation in patients with schizophrenia. Can J Psychiatry 2000; 45: 670.

23. Mulholland C, Cooper S. The symptom of depression in schizophrenia and its management. Adv Psychiatr Treat 2000; 6: 169-177.

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Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Mothers of Children with Inflammatory Bowel Disease: A Controlled Study of Adult Attachment Classifications and Patterns of Psychopathology Nathan Szajnberg, MD,1 Melanie Elliott Wilson, PhD,2 Theodore P. Beauchaine, PhD,3 and Everett Waters, PhD4 1

Sigmund Freud Center, The Hebrew University, Jerusalem, Israel Department of Psychology, East Carolina University, Greenville, North Carolina, U.S.A. 3 Department of Psychology, University of Washington, Seattle, Washington, U.S.A. 4 Department of Psychology, The State University of New York at Stony Brook, Stony Brook, New York, U.S.A. 2

ABSTRACT We inquire into parental correlates of illness expression in three pediatric diagnoses: Inflammatory Bowel Disease, cancer and renal disease. Children with cancer and renal disease were the comparison groups, using valid pediatric measures for comparison across diagnostic categories in chronic illness. We found compromised parental support in families with IBD children, comparing relations among child’s medical adjustment, parental attachment and psychopathology profiles. Higher rates of insecure attachment are found in mothers of children with IBD; these mothers exhibit increased psychiatric symptoms. The results emphasize: 1) supporting the parent-child relationship, 2) parental well-being, and 3) possible precipitants of gene-regulated onset of IBD contributing to illness severity and course. We offer a theoretical model considering four factors for IBD gene-regulated onset. This preliminary study should encourage longitudinal studies of attachment in chronic illness, particularly IBD.

*The authors have no fiscal investment in this research. **Repeated measures analysis of variance was not employed because many of the MCMI-II scales are comprised of partially overlapping sets of items, and are thus not independent. This violates a basic assumption of repeated measures ANOVA, and renders participants with an elevated score on one scale more likely to obtain elevated scores on additional scales. Readers are encouraged to keep this in mind when interpreting the presented pattern of results.

Ulcerative colitis (UC) and Crohn’s Disease (CD), together known as Inflammatory Bowel Disease (IBD), are painful and debilitating conditions characterized by chronic intestinal irritation. Symptoms include persistent diarrhea, nausea, vomiting, low grade fever, joint pain, weight loss, and incapacitating abdominal pain (1, 2). IBD often presents in adolescence (3, 4) and symptom profiles range from mild to severe, with a clinical course ranging from episodic to nearly continuous.

Familial tendencies suggest a genetic component to IBD, such as an increased incidence of IBD in the first degree relatives of probands (5-7). There is approximately 75-80% same-disease concordance within a family; concordance rate in monozygotic twins is higher for Crohn’s Disease than Ulcerative Colitis (8-10). Family genome-screening studies have identified links to IBD on specific chromosomal regions; some regions are disease specific (11-14). The IBD2 locus on chromosome 12 has been identified as the sole UC-specific region identified to date (7). A major breakthrough came with the detection of NOD2 (now called CARD15), the first CD-specific susceptibility gene (14).

Although genetics play a key role in IBD onset, researchers have elaborated on the concomitant influence of environmental factors, including regulation of gene onset. Environmental influences affect the severity, course, and possible genomic expression of structural genes (15-18). Laharie et al. (19) investigated conjugal cases of IBD and the likelihood of IBD in the offspring of these couples. The authors divided the couples into three groups: 1) both couples had IBD symptoms before living together, 2) one spouse had symptoms before and one

Address for Correspondence: Nathan Szajnberg, MD, Visiting Professor, Columbia University, Dept. of Child Psychiatry, 40 Haven St., New York, New York, U.S.A. nmoshe@gmail.com

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Nathan Szajnberg et al.

spouse had symptoms after living together, and 3) both spouses developed symptoms after living together. The number of offspring in the third group was significantly greater than would be found by chance. This finding supports the role of environmental factors in IBD etiology, as well as possible assortative mating based on personality and/or attachment factors underlying the physical manifestations of IBD. Other environmental factors such as acute daily stress are significantly correlated with symptoms (20). Szajnberg et al. (18) reported severe stress in the one year prior to IBD illness onset in children.

Strained or broken relationships with loved ones are particularly potent psychosocial determinant of symptom severity, relapse, and perhaps illness onset. Engel (21) reported that real or imagined loss of a loved one frequently precedes the development of ulcerative colitis. In an extension of this finding, Szajnberg et al. (18) found insecure adult attachment classifications in 78% of the mothers of children with newly diagnosed IBD, as assessed by the Adult Attachment Interview (22). This figure is more than 50% higher than in normative samples (23). Insecurely attached mothers are less supportive and either affectively aloof or enmeshed than securely attached mothers (24-26); this suggests that an unsupportive family environment places children with IBD at risk for more severe episodes of illness. Moreover, children of insecurely attached mothers are more negative and angry, as well as less enthusiastic (25, 26), and more likely to be insecurely attached (e.g., 26). These characteristics may render children more vulnerable to separation anxiety and depression (27, 28), and less able to utilize family members in order to cope with a debilitating illness such as IBD. A brief note about adult attachment classification.

This interview has been used and validated across thousands of adults in several cultures, including Israel. The interview results in classification as Securely attached (approximately 65% of a population), and two types of Insecurely attached – Dismissive/Defended and Angry/ Enmeshed (approximately 35% of a population). There is a very infrequent form of Unresolved “mourning” classification found within one year of the death of a loved one, or after severe trauma. Consistent with the theory of attachment, both Securely and Insecurely attached individuals have working models of achieving and maintaining closeness; attachment theorists have avoided calling Insecurely attached individuals as “abnormal,” reserving such a term for those rare individuals who have no successful working models of attachment. Nevertheless, those who are Insecurely

attached have greater anxiety about achieving/maintaining closeness and therefore may be at-risk for difficulties.

This current controlled study inquires into the parental correlates of illness expression. It clarifies and extends findings suggesting compromised parental support in families with IBD children. Thus, the relations between child adjustment, parental attachment status, and parental psychopathology profiles were contrasted in families of children with IBD, and in families of children with either cancer or renal disease.

This design intends to address two shortcomings in the literature on IBD. First, a control group was employed to address the possibility that raising a child with a chronic, possibly life-threatening disease may have caused the high rate of insecure attachment classifications of mothers of IBD children. Second, indices of maternal psychopathology were included in addition to Adult Attachment Interview assessments, to clarify potential parental contributions to child adjustment and illness expression.

We hypothesize a four-factor multigenomic model from which researchers and physicians may work in order to understand the onset and potential exacerbation of IBD symptoms.

Methods Participants

Child-onset IBD patients and chronically ill controls within two years of illness diagnosis were recruited from the Department of Pediatrics of a major Midwest hospital. All recruited families agreed to participate. This represents a complete population study at this Children’s Hospital, the only major pediatric hospital in the area.

Therefore, the sample represents all or nearly all hospitalized pediatric IBD patients within the community.

A total of 21 IBD patients (16 with Crohn’s Disease, 5 with Ulcerative Colitis) and 20 age-matched controls (14 with cancer and 6 with hemodialysis-dependent renal disease) were included. Because of the measures (below) designed by Stein and Jessop, researchers are now able to compare disease course and psychiatric/ psychological status across pediatric diagnostic categories. Cancer and Renal disease case were selected as they are serious chronic illnesses, like IBD, and are prevalent in our pediatric regional hospital. Control children were selected for comparable age, gender, length of illness, family size, and socio-economic status. The sample was primarily Caucasian, with one African American family in the IBD group. Descriptive characteristics of the 35

Mothers of Children with Inflammatory Bowel Disease: A Controlled Study of Adult Attachment

sample are presented in Table 1. There were no significant differences on any demographic measures.

Table 1. Descriptive Characteristics of Sample by Group IBDa (n = 21)

Cancer/Renal (n = 20)

F

p

Child’s age at assessment

12.8

12.3.

81.

37

Duration of illness (months)

14.4

18.8

1.19 .28

Child’s KBITb IQ

107.8

106.9

.15.

69

Mother’s age at assessment

37.3

40.2

.13

.72

35.8

37.0

.03.

87

Family income (thousands)

Inflammatory Bowel Disease. Kaufman Brief Intelligence Test.

a

b

Procedures

One interviewer conducted the adult interviews, while a second interviewer conducted the child interviews. Both interviewers were blind to the diagnostic status of participants, although some of the mothers did reveal the child’s diagnosis during the course of the interview.

Parent Measures

Adult Attachment Interview (AAI): (22). The primary caretaker of the child (the mother in all cases) completed the AAI, a one to two hour semi-structured interview that assesses the respondent’s state of mind regarding their childhood attachment experiences and current attitude towards significant others, including their child.

Participants are asked to describe in detail their childhood relationships with parents, to elaborate on experiences of separation, feelings of rejection, and significant losses throughout their lives. They are asked to outline their current relationships with parents, offer interpretations of their parents’ behavior when the respondent was a child, elaborate on the impact of their childhood experiences on their current functioning, and elaborate on their concerns and behaviors in parenting their own children. Interviews were audio taped, then transcribed and edited with all references to pediatric diagnosis removed. Transcriptions were scored by a trained rater blind to the child’s diagnostic status.

Based on interview transcripts, adult attachment classifications are derived from rater-coded childhood experiences of parental warmth, rejection, neglect, pressure to achieve, and parent-child role reversal (29).

The respondents’ current state of mind regarding their attachment experiences is then rated on several dimensions, including: coherency, idealization of parents, inability to recall parental behaviors, speech passivity, and angry preoccupation with parents. Based on their 36

current state of mind regarding childhood experiences with parents and attachment, respondents are then classified as either Secure, or Insecure Dismissive, or Insecure Preoccupied with respect to attachment (29).

SECURE AAI classifications are rated when: descriptions of childhood events are coherent and they acknowledge importance of early experiences on development and current functioning. INSECURE Dismissive AAI classifications are rated when: descriptions of childhood events are incoherent, when they exhibit idealization of parents or difficulty recalling attachment-relevant experiences, and when they de-emphasize the importance of these experiences on current functioning. INSECURE Preoccupied AAI classifications are rated when: descriptions of childhood events are incoherent, but differ from dismissing individuals by either expressing ambivalence or passivity regarding their relationships with parents or expressing continued anger toward parents.

Impact on the Family Scale. The IOF (30) is a 24-item parent-report checklist that assesses the impact of children’s illness on family functioning. The scale yields four factors, including Financial (e.g., the illness is causing financial problems for the family), Social/Familial (e.g., we see family and friends less because of the illness), Personal Strain (e.g., nobody understands the burden I carry), and Mastery (e.g., learning to manage my child’s illness has made me feel better about myself). Internal consistency is acceptable for all factors (30). This scale is the counterpart to the Clinician’s Objective Burden of Illness Scale (COBI: see below).

Millon Clinical Multi-Axial Inventory-II. Mothers completed the MCMI-II (31), a 175-item inventory that yields continuous scores on 20 clinical scales, most of which correspond to Axis I and Axis II disorders represented in the Diagnostic and Statistical Manual of Mental Disorders (32). While formal diagnoses should not be rendered based on elevated scale scores in the absence of corroborating behavioral evidence of psychopathology (33), the MCMI-II can help formulate hypotheses about symptoms (Axis I), and personality traits (Axis II).

Physician Measures

Clinician’s Objective Burden of Illness Index. The COBI (34) is a 44-item questionnaire designed to compare the severity of physical illness across diagnostic categories.

Questions address the degree of symptom severity in areas such as seizures, bladder and bowel control, need for surgery, prognosis, age-appropriate self-care, need for medication, route of administration, need for wound

Nathan Szajnberg et al.

care, need for physical therapy, etc. Scores correlate with need for hospital care and the frequency of urgent care.

The instrument was included in order to obtain an independent estimate of illness severity among IBD, cancer and renal patients.

Child Measures

Kaufman Brief Intelligence Test. The K-BIT (35) is an abbreviated intelligence test that was administered to rule out disparities in IQ as an alternative explanation for potential group differences in illness expression. The K-BIT requires roughly 30 minutes to administer and score. Test-retest reliability coefficients for Composite IQ scores averaged .94 in the standardization sample, and correlations with Full Scale IQ scores obtained from the Wechsler Intelligence Scale for Children – Revised (36) averaged .80.

All subjects asked agreed to participate and complete data was obtained on all subjects.

Results Child Illness Severity

Children in both the IBD and control groups were first compared on indices of illness severity in order to assess the impact of any group difference on the outcome measures. On the IOF, where data were missing for one IBD participant, a series of one-way ANOVAs revealed no significant differences on any of the four factors (all F’s(2,38) < .53, all p’s > .50). Thus, the subjective impact of child illness on family members did not differ significantly across groups according to maternal report.

On the COBI, where data were missing for two IBD patients and four controls, a one-way ANOVA revealed a significant group difference (F(1,33) = 8.04, p < .008).

Participants in the IBD group scored significantly higher (M = 100.74, SD = 37.63) than controls (M = 57.19, SD = 52.99). Thus, according to physician report, IBD participants were more symptomatic than children in the Cancer/Renal group. This is despite subjective ratings by parents that showed no differences between the diagnostic groups.

Maternal Attachment

First, attachment classifications were dichotomized into secure and insecure groups. As is customary in the attachment literature, the insecure was comprised of both preoccupied and dismissing mothers.

In the IBD sample, 5 mothers were classified as

secure (24%) and 16 as insecure (76%). In the Cancer/ Renal group, 11 were classified as secure (55%) and 9 as insecure (45%).

As predicted, the IBD mothers’ group had a higher proportion of insecurely attached (z=2.57, p< .049).

A clarification about the rate (45%) of insecure attachment in CA/renal group: this is comparable to those found in normative populations across thousands of adults in several cultures. This may be of concern, but does not differentiate the CA parents from adults studied with the AAI in studies over many years.

Maternal MCMI-II Profiles

Relations between child diagnostic status, maternal attachment classification, and maternal MCMI-II profiles were compared by conducting a series of one-way ANCOVAs. In each analysis, MCMI-II scale scores served as criterion variables, with COBI scores employed as a covariate to control for the possible impact of child illness severity on maternal psychiatric symptoms. Table 2 outlines results for both the clinical syndrome scales, which correspond most closely with Axis I psychopathology, and the personality scales, which correspond most closely with Axis II psychopathology. Complete MCMI-II data were missing for 4 mothers in the IBD group and 2 mothers in the Cancer/Renal group.

As Table 2 reveals, significant Maternal Attachment Classification vs Child Diagnostic Status interactions were uncovered for 2 of the 9 Clinical Syndrome Scales (Alcohol Dependence and Major Depression), and for 6 of the 13 Personality Scales (Avoidant, Antisocial, PassiveAggressive, Self-Defeating, Schizotypal and Borderline).

Although several main effects of attachment classification were also revealed, they will not be interpreted due to the significant interaction effects, where in each case insecurely attached mothers of IBD children obtained higher scores than mothers of the other two groups. The only main effect that was significant in the absence of an interaction was for the Somatoform scale, where mothers of control group children scored significantly higher than mothers of IBD children. This finding should be interpreted cautiously, as it represents the only significant diagnostic group effect among 22 comparisons.

Discussion This controlled study clarifies and specifies the previous reports of higher rates of insecure attachment in mothers of children with IBD, supporting our first hypoth37

Mothers of Children with Inflammatory Bowel Disease: A Controlled Study of Adult Attachment

Table 2. Relations between Maternal Attachment Classification, Child Diagnostic Status and Maternal MCMI-II Scale Scores.

Maternal Attachment Effecta

Child Diagnostic Status Effectb

Interaction Effect

F(1,30)

F(1,30)

F(1,30)

Anxiety

.04

1.12

3.30

MCMI-II Scale Clinical Syndrome Scales Somatoform

.01

4.22*

1.69

Bipolar: Manic

.01

.39

.18

Dysthymia

.43

.04

3.21

Alcohol Dependence

3.80

.66

4.21*

Drug Dependence

2.32

.87

2.87

Thought Disorder

1.49

.01

1.87

Major Depression

1.63

.51

8.43**

Delusional Disorder

.30

.01

.36

.16

.74

2.74

Personality Scales Schizoid Avoidant

4.78*

.01

5.98*

Dependent

.66

1.39

.08

Histrionic

.28

1.55

.06

Narcissistic

.71

.69

.04

Antisocial

3.45

.80

7.02**

Aggressive-Sadistic

3.00

.01

.68

Compulsive

.02

3.59

.04

Passive-Aggressive

5.81*

.06

6.53*

Self-Defeating

6.53*

.22

6.33*

Schizotypal

.96

1.31

4.51*

Borderline

10.26**

1.37

11.60**

Paranoid

.78

.09

.97

esis. It supports our second hypothesis, that insecurely attached mothers of children with IBD would exhibit increased psychiatric symptoms compared to mothers of children with either cancer or renal disease. However, none of the group means fell in the clinical range on any of the MCMI-II scales (i.e., base rate scores 75). Thus, although insecurely attached mothers of IBD children were more symptomatic according to self-report, they may not be diagnosable with psychiatric disorders.

Nevertheless, their elevated scores on the MCMI-II Major Depression, Avoidant, Antisocial, PassiveAggressive, Schizotypal and Borderline scales are consistent with the affectively aloof and less supportive parenting style observed in some of those with insecure 38

attachment classifications.

Given the relationship between parental attachment status and childhood IBD, family or individual intervention and education may attenuate illness expression.

Parent work should focus on attachment-related themes in those who show risk-factors for insecure attachment: improved parental responsiveness and availability.

We paid special attention to comparisons of the Cancer/Renal control group verses the IBD group on COBI (clinician) and IOF (parent) illness severity scores. Do cancer/renal patients serve as a valid control group for IBD? Higher scores on the COBI were obtained by IBD participants, which suggest greater physician-rated illness severity. The nature of IBD requires that afflicted children follow a strict medication regimen, engage in dietary restrictions, and monitor their bowel habits continually. In addition, parents must attend closely to their children, who frequently miss school with debilitating abdominal pain. While cancer and renal disease patients are likely to require similar levels of care before, during and after treatment, they often experience higher functioning at other times. All patients were in remission, but the COBI/IOF measures permit comparability across disease categories (whether remission or not). Because of these measures, we appear to be seeing group and not phase differences. But, this is an empirical question that should be investigated further. Moreover, differences in maternal MCMI-II profiles were found after variance attributable to COBI scores was statistically removed. As a result, the finding that cliniciansâ&#x20AC;&#x2122; assessments of illness impact was higher in the IBD group compared to the Cancer/Renal group was not surprising. However, parents of IBD children did not rate their experience of the childrenâ&#x20AC;&#x2122;s illness as more stressful than parents of children with cancer or renal disease. This result provides evidence that a pediatric cancer/renal control group is an acceptable control group with which to compare IBD children.

Most research on psychosomatics has been done with adults; however, research on IBD in children and adolescents has been increasing over the past decade (1-4). Very little is known about the relation between interpersonal relationships, specifically the relation between attachment and pediatric psychosomatic illness. In order to shed light on this phenomenon, it is important to have a working theoretical model. When developing a model of psychosomatic illness, we suggest a developmental systems transactional approach and include the investigation of biological, social and

Nathan Szajnberg et al.

cognitive vulnerabilities (37).

Alexander and French (38) hypothesized three factors necessary for adult onset of psychosomatic illness (specifically, ulcerative colitis, asthma, allergic dermatitis, duodenal ulcer, essential hypertension, rheumatoid arthritis and hyperthyroidism). First, they proposed that a physiological factor was needed to contribute to illness onset, e.g., elevated pepsinogen or helicobacter pylori in duodenal ulcer. Second, they hypothesized that recent increased life stress was a necessary agent for disease onset. Third, they identified disease-specific intra-psychic conflict as a necessary factor for the onset of a psychosomatic illness. However, their study, performed in the early 1950s, demonstrated no statistically significant findings.

Unfortunately, statistical methods available at the time were inadequate to draw conclusions.

We present a four-factor model for child-onset IBD, using Dobzhansky’s concept of regulatory and structural genes: 1) A multigenomic factor; 2) Peripubertal developmental vulnerability (a critical period); 3) Recent increased life stress; 4) Attachment vulnerability in the primary caretaker. While this model is speculative, it provides an approach to empirically-designed studies such as has been done with childhood asthma for testing.

1. The multigenomic factor. Dobzhansky and Gould (16) postulated variable genomic expression or penetration. Ginsburg, Szajnberg and Buck (39), citing animal and twin behavioral research, demonstrated the mechanism for variable genomic expression in MZ twins primed via affect: regulator genes can be turned on/off by environmental events.

We postulate a comparable set of mechanisms in the model postulated below: insecure maternal attachment can up-regulate pre-existing, quiescent structural gene(s) for IBD expression, whereas secure attachment will not. If there were variable loading – for instance, hypothetically five genes associated with IBD onset – then someone with one or two genes would have necessary, but not sufficient loading for expression. Someone with sufficient genetic loading can develop IBD with less input from the remaining three factors (peripubertal age, increased life stress, attachment). This multigenomic model is testable.

Controlled studies and accounts in the popular press discuss causal associations between the path of serious physical illness and psychological state, for instance, in differential breast cancer survival between women in support groups verses those who

are not (40). In childhood physical illness, Lavigne and Faier-Routman’s (17) meta-analytic study shows differential psychological symptomatology among different pediatric illnesses, with IBD and neurological disorders showing greater psychological morbidity.

This disease-specificity of psychological difficulty runs counter to earlier studies by Stein and Jessop (34), which, however, did not include IBD in their cohorts. Mrazek and colleagues (41) performed an elegant and powerful study of expectant mothers with asthma and onset of wheezing in their infants.

Mothers with insecure attachment were more likely to have infants who developed wheezing. Fritz and colleagues (42) and Burke and Engstrom (43) have extended work on asthma in children as an interaction between soma and psyche (42-45).

2. Peripubertal developmental vulnerability factor. This factor is based simply on an empirical observation that most children experience the onset of IBD around the time of puberty. However, we build on the concept of “critical periods” first described in the animal literature (46). Scott and Fuller (46), in landmark animal behavior studies with dogs, demonstrated that the absence of socialization to people or other animals by 12 weeks will disrupt dog behavior. We can hypothesize in IBD, that the normative endocrinological events of peripuberty, may also prime certain vulnerable genes for IBD expression, particularly if these may have been primed by previous factors of recent life stress and attachment disorder (a more chronic, diffuse form of life stress).

Attachment insecurity may be a form of life stress termed strain or cumulative (47).

3. Life stress factor. Both physical and psychological stress can exacerbate bowel symptoms. One study of the rat colon provides supporting evidence for the interaction between vulnerability to stress due to previous inflammation and subsequent inflammation. In this study, rats with a history of inflammation in the colon experienced an increase in inflammation and a reduction of function when stressed with a restraint procedure compared to the stressed control rats (48). This study illustrates the need to consider the complex interactions between a vulnerable diathesis and stressors that precipitate reactions in the colon. However, studies illustrating the effects of stress on the colon are not unique to animals, many human studies also illustrate similar effects.

In a study of patients with Ulcerative Colitis, Levenstein and colleagues (49) found that high levels of perceived stress over long periods tripled the risk 39

Mothers of Children with Inflammatory Bowel Disease: A Controlled Study of Adult Attachment

of exacerbation of symptoms; whereas short-term stress did not increase experience of symptoms. The stress associated with maintaining an insecure working model of attachment occurs across the lifespan without intervention. Therefore, this highlights the need for researchers to include attachment within the biopsychosocial model of disease in order to understand how an incoherent working model and stress in relationships can contribute to vulnerability to symptom exacerbation and relapse. The study also reported a trend toward significance for the relation between relapse and number of stressors in the month prior to relapse. The results from these studies, among others, point to the clear relation between stress and disease vulnerability in IBD; however, the exact relation between type and level stress and colon symptoms requires further research and clarification.

In our first study, not only were life stress scores extremely high, but also some parents downplayed stress. For instance, one mother said there was no “unusually” high stress. The past year, she later reported, the child discovered her father dead in bed when she was dropped off alone on a weekend custody visit. In addition, the child’s brother was almost killed in a drive-by shooting.

4. Attachment vulnerability factor. Attachment vulnerability, along with the previous factors, may be a mediating variable for genomic regulation of illness onset.

Attachment influences both social relationships as well as cognitive models of the self and interpersonal relationships (50). Therefore, being insecurely attached and having a genomically-vulnerable GI tract may be all that is necessary to set into motion the onset of IBD. Our postulated model can be used empirically to assess the factors associated with the illness onset. In addition, we suggest that insecure attachment may be an aggravating factor in illness maintenance/relapse. To the degree that IBD itself puts stress on a family, or a parent-child system, then insecure attachment is a more vulnerable social system being further stressed and reciprocally may stress the ill child. Further research using this model can shed light on the focus areas for which specific therapeutic intervention can be provided over and above physical illness stabilization. This model includes genetic predisposition, “critical period” (peripubertal onset), life stress and attachment, with variable loading of the factors. This model can be tested empirically.

Finally, if attachment vulnerability is a factor in IBD illness onset, then families who have predisposing histo40

ries can gain a sense of control over the illness. Treating and controlling this variable in their relationship with their children may delay, ameliorate, or prevent illness onset as well as alleviate disease course.

Our conclusions are tempered by the relatively small sample size and the greater severity of physical illness among IBD children (although this was not significantly contributory to explain attachment variance).

Our results should prod us to explore new psychological approaches to this painful, debilitating disease. For example, future studies should include observations of mother-child interactions in the home, laboratory and hospital setting. These observations should assess additional variables that may contribute to illness onset such as affect regulation and socialization skills.

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41

Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Change of Students’ Interest in Psychiatry over the Years at School of Medicine, University of Belgrade, Serbia Nadja P. Maric, MD, PhD,1,2 Dragan Stojiljkovic, MD,2 Bojana Milekic, MD,2 Marko Milanov, MD,2 Jovana Bijelic, MD,2 and Miroslava Jasovic-Gasic, MD, PhD1, 2 1

Clinic for Psychiatry, Clinical Center Serbia, Belgrade, Serbia School of Medicine, University of Belgrade, Belgrade, Serbia

2

Introduction

ABSTRACT Introduction: The present study examines how, during the course of medical education, students in Serbia change their attitude and affinity towards choosing psychiatry as their future residency.

Method: Medical students (MS) in the 2 nd year (sophomores, n=105), and in the 5th year (seniors, n=75) of the medical school participated in the survey. A 23-item questionnaire was administered to evaluate their attitude towards psychiatry and was compared to their attitude towards other medical specialties (internal medicine, surgery, pediatrics, gynecology, general medicine).

Results: Attitude towards psychiatric residency changed during the course of medical studies. The 5th year students exhibited lower attitude scores regarding psychiatry when compared to their junior colleagues and when weighted on their socio-demographic background and attitude towards other residencies. Positive attitude was evident in 15% sophomores and 16% seniors, while negative attitude was 25% in sophomores and 47% in seniors, markedly differing in their statement that they would never consider psychiatry as the choice residency (χ²(3)=11.9; p<.01). Attitude toward psychiatry was not predictable from the socio-demographic parameters.

Discussion: The data from Serbia show increase in negative attitude towards psychiatry over the course of medical studies, although level of interested students is one of the highest in the world as reported in recent literature.

Address for Correspondence: nadjamaric@yahoo.com

42

In the western world, the number of psychiatry residents has been in steady decline over the last decades of the 20th century. In a recent U.K. survey medical students viewed psychiatry as the least desirable clinical specialty for their future career (1). As a result, there is a shortage of psychiatrists in many countries. For example, 12% of all available psychiatrist positions remain vacant in U.K. (2), whereas in U.S.A. that percent is 7.1% (3). This observation triggered research interest in many countries to identifying factors associated with this decrease in interest in psychiatry (4-8), often asking questions such as “How to win the hearts and minds of students in psychiatry?”(9).

Data suggest that the decrease in interest in psychiatry is evident both over the last decades, as well as over the course of studies in medical school (10, 11). A questionnaire, introduced by Feifel et al. in 1999, given to the first year medical students in California and Texas, showed that only 0.5 % of medical students chose psychiatry as their future residency, and only 7.2 % of students considered it a possible choice. The same authors noticed that during a single decade (1988–1998) the number of U.S. medical students matching to psychiatric residencies declined by 42.5% (12). In contrast, about 10% of medical students in their pre-clinical studies at the Hebrew University in Israel (2000-2002) expressed a strong interest in psychiatric residency, and 23% of them considered it a possible choice (13), representing one of the most affirmative attitudes towards psychiatry in the world. However, psychiatry was ranked the least attractive specialty by the same population of Hebrew

Nadja P. Maric, MD, PhD, Clinic for Psychiatry CCS, Pasterova 2, Belgrade 11000, Serbia

Nadja P. Maric et al.

University students now in their clinical years (4th-6th year), with an average of only 14.9% of students choosing psychiatry as a possible career choice (14).

Similar research has never been conducted in former Yugoslavia or Serbia. In Serbia, medical education is concurrent to undergraduate education and lasts six years. Per traditional curriculum, psychiatry is taught in the fourth year of medical school as a single 30-week clinical course organized in 30 hours of theoretical lectures and 60 hours of alternating smaller group sessions at clinical sites. Students listen to lectures on neurobiology, diagnostic features, course of illness, epidemiology and treatment of the core psychiatric disorders, and are exposed to psychiatric clinical practice through the mental status exam and psychiatric interviewing. Clerkship assignments are available in both inpatient units and day hospital programs. The ratio of psychiatrists is 10 per 100,000 citizens in the general population.

The aim of this study is to explore the change of students’ affinity for choosing psychiatry as their future residency by comparing the affinity of sophomores with that of seniors, as it relates to the two years prior and two years following the exposure to the psychiatry course and limited clinical practice in their medical education.

Method The Questionnaire

Adapted, modified and translated version of the questionnaire originally created by Feifel et al. (12) was used as a poll. The questionnaire consists of 23 items. The majority of answers were offered in 4-point Likerttype scales, three- and six-grade scale forms, and some were presented in open answer form. Students were questioned by means of an anonymous survey about their opinions of the following six residencies: family medicine, internal medicine, surgery, pediatrics, gynecology and psychiatry. The questionnaire included the following areas: 1. Social and demographic characteristics of students; 2. General factors influencing the choice of residency (lifestyle, societal recognition, salary, dynamic and challenging job, opportunity to help others, importance of having a “lobby” in the career field, interest in research, diagnostic/therapeutic procedures and quality of doctor-patient relationship); 3. Personal affinity toward the six offered residencies; 4. Opinions on miscellaneous aspects of professional

life, such as: lifestyle, salary, professional satisfaction, characteristics of the residency itself, professional and social recognition, intellectual challenge, probability of successful treatment, technological progress of diagnostic and therapeutic procedures, prospective, strong scientific foundation, comfort and networks within the medical field; 5. Students’ perception of societal opinion on different specialists.

Sampling Methods and Procedures

An unpublished pilot-study on a smaller sample of 4th year students was conducted to calculate the required sample size to obtain the power of 1-β=.80 at α=.05.

Approximately 80 students per sample were found to be sufficient.

There were 413 students attending second year studies at the School of Medicine, Belgrade University (SM BU), in the academic year 2007/08. They were divided into five groups, based on surname alphabetical order, and then into four subgroups for the total of 20 subgroups. We randomly selected four groups to receive questionnaires during the physiology classes. The required number of participants to provide 80 valid subjects was 120, expecting a 70% response rate, as in the pilot-study.

Similarly, 415 students attended the 5th year of SM BU in the 2007/08 academic year. Like the sophomores, we divided them into five groups based on surname alphabetical order. The only available method of sampling seniors was to survey all students attending forensic medicine lectures during one week, thus acquiring a portion of students from each of the five alphabetical groups. Each day, another group attended the same lecture, so there was no overlap. The sampling design was non-probabilistic, accidental, and it yielded a sample which was not representative in strict statistical terms. Nevertheless, since no selection criteria other than presence in the forensic medicine amphitheater were used to sample the senior population, we did not expect the sample to be biased in any way.

The Departments of Physiology and Forensic Medicine gave their consent for conducting this survey at the beginning of teaching sessions. The survey was permitted by the Department of Psychiatry and the local Ethics Committee.

Participants and Missing Data

Out of 122 sophomores (29.5% of the total), 119 participated in the survey (97.5%). One hundred and fourteen sophomores filled out their questionnaires. Seven cases 43

Change of Students’ Interest in Psychiatry over the Years at School of Medicine, University of Belgrade

(6.1%) contained missing values for attitude ratings and two scores were identified as outliers, leaving 105 valid cases for further analysis.

Out of 90 senior students (21.7% of total number of seniors) who participated in the survey, 81 (90%) provided filled out questionnaire sheets, of which four (4.9%) were discarded due to missing data and two were omitted as outliers.

Variables and Statistical Procedures

1. The academic year of the student (2nd year vs. 5th year) is considered the independent variable in MANCOVA. 2. Social and demographic parameters such as gender, type of completed high school (grammar school vs. nursing high school), the population size of student’s hometown (<10,000; 10,000-100,000; 100,000500,000 and >500.000 inhabitants), religious affiliation (Orthodox Christian, Catholic Christian, Islamic, Other and Unaffiliated) and student’s current average academic grade (6.0 - 10.0 scale) were measured to be used as covariates in MANCOVA. To avoid non-linear relationships, the size of student’s hometown was dichotomized at the cut-off point of 100,000 inhabitants. Gender, type of high school and hometown size are considered reliable as students would have no reservation in reporting them. The reliability of reporting academic grade average, on the other hand, was questionable, partly due to the ever-changing nature of this variable (some students simply do not keep track and provided a guess), and more so because of the large number of missing values which would have had to be estimated or omitted (seven cases [6.5%] in the sophomore group and 12 cases [15.6%] in the senior group). MANCOVA with or without the academic grade average as a covariate showed no discrepancy, implying that this covariate added little specific adjustment. Religious affiliation was unsuitable to be used as covariate, having a split more extreme than 90/10.

These two potential covariates were, therefore, omitted from the main MANCOVA, but described for each sample and compared.

3. Students’ opinions on each of the six clinical residencies in terms of 14 aforementioned aspects of the profession (see Method; “Instrument”) were given as ratings from 1 to 4 in range of Rating scores (or attitude scores) for each residency and calculated by summing individual ratings. A square-root-type transformation was applied to the rating scores to correct the skew and kurtosis. Transformed atti44

tude scores were analyzed as dependent variables in MANCOVA. Students were also asked to report their personal affinity toward each of the six residencies.

Consistency between reported “affinity” and “attitude score” was assessed regarding each residency through Cronbach’s alpha statistic, where values above .7 indicate a good internal reliability of the questionnaire.

4. The importance of having an active “lobby” (students’ private network of individuals willing and able to help promote his/her career in the given specialty, often referred to as “connections” in our society) for the clinical specialty of choice was measured on a three-point scale as reported by students and analyzed using Mann-Whitney’s U-test.

5. Three aspects of medicine (research, diagnostics/ therapy and doctor-patient relationship) were ranked according to their importance to a student and analyzed with Mann-Whitney’s U-test.

6. The analyses were performed using SPSS for Windows 16.0.1 and G*Power 3.0.8.

Results The study samples consisted of 105 sophomore and 75 senior students’ survey sheets, after discarding those with missing data and outliers. The assumptions of normality, linearity, homogeneity of variance-covariance matrices and absence of multicollinearity were all met.

Socio-demographic data for the two groups are presented in Table 1.

Students in both samples enrolled in Medical School at the age of 19. Sophomores were 20 and seniors approximately 24 years old at the time of the survey. The academic grade averages were not significantly different between the groups (t(151)=-1.854, p=.066), though the effect size indicated a small effect of difference and relative lack of power (d=.29, 1-β=.43). Both samples showed similar degrees of female predominance, namely 7:3. In terms of religious affiliation, students of both samples declared themselves predominantly as Orthodox Christian. There were significantly more grammar school graduates in the senior (χ²(1)=10.105, p=.001) than in the sophomore group (in Serbia, only grammar school and nursing secondary school graduates are eligible to study medicine).

Students were asked how much they relied on their lobbies for entering their desired clinical specialty. Fifty-four percent of sophomores answered “not at all” compared to 38% of seniors. A similar percentage of students in both

Nadja P. Maric et al.

Table 1. Descriptive data on the samples and populations Sophomores

Seniors Count

%

N (sample)

105

25.4

75

18.1

N (population)

413

Gender (population) Religious affiliation

27

25.7

23

30.7

Pediatrics

Gynecology

General Medicine

Female

78

74.3

52

69.3

Male

104

25.2

125

30.1

Female

309

74.8

290

69.9

5

6.7

Other

0

.0

0

.0

Atheist

4

3.8

6

8.0

Missing

1

1.0

0

.0

Total valid

104

0%

Attractiveness:

Chosen Career

Strong Possibility

Unlikely

seniors

.0

sophomores

0

seniors

Islamic

20%

sophomores

.0 seniors

85.3

0

seniors

64

seniors

96.2 .0

40%

sophomores

100 0

60%

seniors

Orthodox Christian Catholic Christian

80%

sophomores

Pre-finished secondary school

Psychiatry

415

Male

Less than 10,000 Size of students’ 10,000 to 100,000 hometown (by number of 100,000 to 500,000 inhabitants) More than 500,000

Surgery

100%

percent

Gender (sample)

Clinical Residency Internal medicine

sophomores

%

sophomores

Count

Figure 1. Comparison of attractiveness of the six given clinical residencies between sophomore and senior students

No way

75

38

36.2

19

25.3

13

12.4

8

10.7

33

31.4

43

57.3

21

20.0

5

6.7

Valid total

105

75

Grammar-school

64

61.0

63

84.0

Nursing secondary school

41

39.0

12

16.0

Valid total

105

75

Mean

SD

Mean

SD

Age at entering the Medical School

18.87

.52

18.87

.55

Age at the time of the survey

20.09

.65

24.35

1.39

Academic marks average

8.11

.86

8.34

.70

samples answered “to a small extent” (30% and 31%, respectively). Interestingly, while only 15% of sophomores said that they relied on their lobby “to a large extent,” 31% of seniors did so (U=3062, Z=2.609, p=.009).

Seniors attributed more importance than sophomores to psychiatric diagnostics and therapy. Namely, 42% of sophomores thought that diagnostics and therapy were the most important aspects of medicine, while 59% of seniors thought so (U=2477, Z=2.456, p=.014).

The opposite was seen concerning the importance of research since 24% of sophomores and 13% of seniors gave their prime choice to medical research (U=2565, Z=2.005, p=.045). The two groups shared similar views on the relative importance of the quality of the doctorpatient relationship. Thirty-five percent of sophomores and 29% of seniors thought it the most important (U=2880, Z=.654, p=.513).

Fifteen percent of sophomores and 16% of seniors stated that psychiatry was their career choice. On the other hand, while 25% of sophomores felt a strong aversion toward psychiatry, 47% of seniors declared that there was “no way” they would specialize in it (Figure 1). Distributions across the two groups of students were statistically different (χ²(3)=11.9; p<.01).

Table 2 presents raw attitude scores by median and interquartile range, whereas transformed scores are given as means and standard deviations. Mean differences with their 95% confidence intervals are also presented.

The average Cronbach’s alpha of .716 across the six given residencies (ranging from .596 to .794) indicates a good level of internal consistency between personal affinity toward a particular residency and the attitude score regarding that same residency.

1. Do attitudes toward the offered six clinical residencies (internal medicine, surgery, psychiatry, pediatrics, gynecology, general medicine) differ between pre-clinical and clinical medical students, after controlling for socio-demographic parameters?

The combined dependent variables were significantly related to the main effect (academic year, i.e., sophomores vs. seniors) (F(6,170)=4.074, p=.002) after adjustment for covariates (gender, type of high school and hometown size). The size of effect according to Cohen was medium to large, having obtained the partial η²=.13 with 95% confidence interval ranging from .03 to .19 (15). Therefore, we concluded that student attitudes toward different residencies changed during the course of their medical studies.

45

Change of Students’ Interest in Psychiatry over the Years at School of Medicine, University of Belgrade

Table 2. Attitude scores toward the six given medical residencies in sophomore and senior group SOPHOMORES (N=105) Untransformed attitude scores

Difference of means of the transformed attitude scores

SENIORS (N=75)

Transformed attitude scores

Untransformed attitude scores

Transformed attitude scores

Residency

Median 25th

75th

Mean

SD

Median 25th

75th

Mean

SD

Mean Difference (seniors minus sophomores)

Internal medicine

47

42

51

3.80

1.03

50

45

53

4.29

1.03

0.49

0.18

0.79

Surgery

48

45

51

4.04

0.82

48

44

50

4.00

0.86

-0.04

-0.29

0.21

Psychiatry

38

32

43

2.66

0.93

34

27

40

2.19

0.90

-0.47

-0.74

-0.19

Pediatrics

43

40

48

3.36

0.95

45

38

49

3.56

1.05

0.20

-0.09

0.50

Gynecology

42

38

47

3.26

1.01

42

37

47

3.28

1.04

0.02

-0.29

0.32

General medicine

36

30

40

2.41

0.91

37

29

42

2.48

0.94

0.06

-0.21

0.34

Interquartile range (percentiles)

Interquartile range (percentiles)

2. Upon completion of the 30-week course, does psychiatric residency become more or less attractive to medical students when accounting for the variance shared with both socio-demographic factors and other residencies?

The two groups had significantly different attitude toward psychiatry (Roy-Bargman step-down analysis (F(1,170)=9.721, p=.002): the seniors had lower attitude scores regarding psychiatry in comparison to sophomores, when weighted on their socio-demographic background and attitude toward other residencies.

The unique explained variance was 5.4% (η²=.05 with 95%CI from .01 to .13), i.e., small to medium effect.

3. How do socio-demographic parameters (gender, size of student’s hometown and completed secondary school) influence students’ attitudes toward internal medicine, surgery, psychiatry, pediatrics, gynecology and general medicine in pre-clinical vs. clinical phase of the studies?

The influence of background variables on students’ attitudes was assessed using the sequential multiple regression on separate groups. The priority in the sequence of entry of the predictors was given to the more general ones, i.e., gender > size of hometown > type of high school. Upon entering, the predictors were tested for significance of model improvement by contrasting the zero-level model, and then either retained in the model, or excluded, accordingly. The direction of the association and the strength of the variable to serve as a predictor were measured by standardized coefficients (βi) and adjusted R2. Positive βi indicated a positive association while R2 equals to the percent of variance explained by the predictor.

46

95% CI of the Mean Difference

In the sophomore group, attitude toward surgery, psychiatry and gynecology could not be predicted from the socio-demographic parameters. However, completing nursing high school was associated with a more positive attitude to internal medicine (t=2.450, p=.016, βi=.235, R²=.046), pediatrics (t=2.827,p=.006, βi=.268, R²=.063) and general medicine (t=2.452, p=.016, βi=.235, R²=.046). Gender and hometown size did not show any associations with the preferences. In the senior group, completing grammar school was associated with a more positive attitude toward internal medicine (t=2.338, p=.006, βi=-.264, R²=.057). Preference for surgery and pediatrics was stronger in students originating from larger cities (t=2.665, p=.010, βi=.297, R²=.076) and (t=2.824, p=.006, βi=.314, R²=.086), respectively.

Gynecology and general medicine were seen as more attractive to female students (t=2.555, p=.013, βi=.286, R²=.069) and (t=2.187, p=.032, βi=.248, R²=.049), respectively. The attitude toward psychiatry was not influenced by the background factors among seniors.

Discussion Medical students at the University of Belgrade, Serbia, show a stronger affinity towards psychiatry (~15%) when compared to their peers in other countries such as United Kingdom (16, 17), United States (18, 19), France (20), Germany (21), Australia (22, 23) and Denmark (24). Nevertheless, there is a decrease in interest in psychiatry among medical students after they have completed the psychiatric clerkship. The observed change is not due to a decrease in the number of interested students over the course of medical education, but to

Nadja P. Maric et al.

an increase in the number of students who show a negative attitude toward psychiatry (typical answer: “I would never choose psychiatry for my future residency”), view psychiatry unfavorably, and lack confidence and respect for both psychiatrists and the field.

In both groups, attitude toward psychiatry was not predicted from the socio-demographic parameters: gender, size of student’s hometown or type of completed high school. However, some studies suggest that female students have a significantly more positive attitude towards psychiatry as a subject (25) and that their positive attitude about treatment of mental illness predicts less stigmatizing attitudes towards mentally ill (26).

Interestingly, it seems that Serbian psychiatry is a good illustration of the aforementioned findings. Our own recent survey points out that about 80% of young psychiatrist in the country are females (27), and this trend is likely to continue: gender ratio in School of Medicine in Belgrade, as evident from our samples, is persistently asymmetric, in both seniors and sophomores.

Inevitably, the question is raised as to what factors, over the course of medical education, contribute to the worsening of psychiatry’s image in the eyes of medical students?

In our survey focused on sophomores, we discovered that their aversion to psychiatry was based mostly on their prejudices towards psychiatric patients, and the idea that this field is extremely emotionally challenging with high exposure to stress and frequent unpleasant situations. And indeed, during psychiatry classes, students may easily find justification for such thinking. Psychiatry classes are organized in a manner that too frequently exposes them to interactions with severely ill and hospitalized patients. Students have little if any contact with more common out-patients. Therefore, their insight into patients’ treatment and rehabilitation is quite poor. Such experience and insight acquired during medical school provide the foundation for thinking of psychiatry as a field with a low probability of successful treatment.

On the other hand, there is no doubt that psychiatry gained its great popularity in the last century due to the “couch” therapy, conversational therapy and the “aura of wisdom” ascribed to psychiatrists over time. Some of the studies show that psychotherapy-oriented classes increase popularity of the subject (28-30). However, modern psychiatry is changing its character, so today we have many different approaches such as biological, behavioral, sociopsychological, “eclectic,” etc. This variety of approaches inevitably decreases perceived coherence of the field, as well as the ability of students to understand it after a fairly

short course of only 90 hours.

Nevertheless, an important and encouraging fact arising from our study is that medical students interested in psychiatry and the human psyche at the beginning of medical school maintain their interest over the years of their education.

Still, only 4.4% of the total medical school graduates actually apply for residency in psychiatry (2006 data, Department of Post-Graduate Studies at the School of Medicine, University of Belgrade). These data raise another question: Are students’ preferences during medical school predictors of eventual career choice? According to Cameron and Persad, who evaluated residents’ decisions to enter psychiatry, 14% of students make their decision before entering medical school, 28% as medical students and 58% after graduation (31). On the contrary, recent data by Manasis and colleagues, although limited by the small sample size of residents, suggest that positive clerkship experience and participation in psychiatry electives may be modifiable programmatic factors that could enhance recruitment to psychiatry (32).

Since our study included only medical students from the University of Belgrade, and not other smaller universities, we can not make more general conclusion regarding the whole country. Additionally, our survey took place during the transitional and reforming period of our medical school curriculum where sophomores’ program followed the requirements of the Bologna Declaration (a process of unifying European higher education by making academic degrees and quality assurance standards compatible throughout Europe, started in Serbia in 2005), whereas the seniors’ classes still followed the old curriculum. The difference in curriculum may have affected comparability of these two groups. Although most of the general parameters for sophomores and seniors were similar, we are aware of the fact that the unpaired sample in our cross-sectional study is a limitation, which could be overcome by performing a longitudinal follow-up study. Finally, a variety of methodological approaches applied in other studies and presented with numeric results on sometimes incompatible scales may have prevented us from presenting the matter unambiguously. We nevertheless believe that these restrictions do not reduce the value and importance of our study.

Conclusion The present study is the first of its kind in Serbia that used a precise and internationally comparable methodological 47

Change of Students’ Interest in Psychiatry over the Years at School of Medicine, University of Belgrade

instrument. We believe that it will become a reference for further research in this direction. Instead of a conclusion, we would like to ask a question: Do data from our study justify the need for reforming the way students are taught psychiatry in the medical school in Serbia? Currently, even with the described lack of interest in psychiatry there are still enough applicants to meet government quotas in Serbia. Therefore, we agree with the suggestion of Gat and colleagues (14) that “educational programs need to target those who show initial curiosity and interest in the workings of the mind and spirit.” Results from several studies show that elective classes and special seminars for interested students have the greatest effect on students’ favorable view of psychiatry (28, 29, 33, 34). However, negative beliefs based on inaccurate perceptions of objective evidence (e.g., success rate of psychiatric treatments) should be specifically targeted in the teaching curriculum and psychiatric clinical practice.

Declaration of interest: None

Acknowledgement: We thank Dr. Svetlana Stepanovic for critical reading and editing of the manuscript.

References 1. Rajagopal S, Rehill K, Godfrey E. Psychiatry as a career choice compared with other specialities: A survey of medical students. Psychiatr Bull 2004; 28:444-446.

2. Pidd S. Recruiting and retaining psychiatrists. Adv Psychiatr Treat 2003; 9:405-413.

3. National Residents Matching Program Match Results, 1999-2003.

Washington, DC, National Residents Matching Program.

4. Syed E, Siddiqi M, Dogar I, et al. Attitudes of Pakistani medical students towards psychiatry as a prospective career: A survey. Acad Psychiatr 2008; 32:160-164.

5. Ndetei D, Khasakhala L, Ongecha-Owuor F, et al. Attitudes toward psychiatry: A survey of medical students at the University of Nairobi, Kenya. Acad Psychiatry 2008; 32:154-159.

6. Baptista T, Pérez CS, Méndez L, et al. The attitudes toward psychiatry of physicians and medical students in Venezuela. Acta Psychiatr Scand 1993; 88:53-59.

7. Chung KF, Chen EYH, Liu CSM. University students’ attitudes towards mental patients and psychiatric treatment. International J Soc Psychiatry 2001; 47:63-72.

8. Pailhez G, Bulbena A, Balon R. Attitudes to psychiatry: A comparison of Spanish and US medical students. Acad Psychiatry 2005; 29:82-91.

9. El-Sayeh HG, Budd S, Waller R, et al. How to win the hearts and minds of students in psychiatry. Adv Psychiatr Treat 2006; 12:182-192.

10. Pardes H. Medical education and recruitment in psychiatry. Am J Psychiatry 1982; 139:1033-1035.

11. Brockington I, Mumford D. Recruitment into psychiatry. Br J Psychiatry 2002; 180:307-312.

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12. Feifel D, Moutier C, Swerdlow N. Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry 1999; 156:1397–1402.

13. Abramowitz M, Bentov-Gofrit D. The attitudes of Israeli medical students toward residency in psychiatry. Acad Psychiatry 2005; 29:92-95.

14. Gat I, Abramowitz M, Bentov-Gofrit D, et al. Changes in the attitudes of Israeli students at the Hebrew University Medical School toward residency in psychiatry: A Cohort Study. Isr J Psychiatry Relat Sci 2007; 44:194-203.

15. Cohen J. Statistical power analysis for the behavioural sciences, 2nd ed.

Hillsdale, N.J.: Lawrence Erlbaum, 1988.

16. Zimny GH, Sata LS. Influence of factors before and during medical school on choice of psychiatry as a specialty. Am J Psychiatry 1986; 143:77-80.

17. Singh S, Baxter H, Standen P, et al. Changing the attitudes of “tomorrow’s doctors” towards mental illness and psychiatry: A comparison of two teaching methods. Med Educ 1998; 32:115-120.

18. Balon R, Franchini G, Freeman P, et al. Medical students’ attitudes and views of psychiatry: 15 years later. Acad Psychiatry1999; 23:30-36.

19. Eagle P, Marcos L. Factors in medical students’ choice of psychiatry. Am J Psychiatry 1980; 137:423-427.

20. Samuel-Lajeunesse B, Ichou P. French medical students’ opinion of psychiatry. Am J Psychiatry 1985; 142:1462-1466.

21. Strebel B, Obladen M, Lehrmann E, et al. Attitude of medical students to psychiatry: A study with the German translated, expanded version of the ATP-30. Nervenarzt 2000; 71:205–212.

22. Yellowlees P, Vizard T, Eden J. Australian medical students’ attitudes towards specialities and specialists. Med J Aust 1990; 152:587-592.

23. Malhi G, Parker G, Parker K, et al. Attitudes toward psychiatry among students entering medical school. Acta Psychiatr Scand 2003; 107:424-429.

24. Holm-Petersen C, Vinge S, Hansen J, et al. The impact of contact with psychiatry on senior medical students’ attitudes toward psychiatry. Acta Psychiatr Scand 2007; 116:308-311.

25. Kuhnigk O, Strebel B, Schilauske J, et al. Attitudes of medical students towards psychiatry: Effects of training, courses in psychiatry, psychiatric experience and gender. Adv Health Sci Educ Theory Pract 2007;12:87-101.

26. Savrun BM, Arikan K, Uysal O, Cetin G, Poyraz BC, Aksoy C, Bayar MR.Gender effect on attitudes towards the mentally ill: A survey of Turkish university students. Isr J Psychiatry Relat Sci. 2007;44:57-61.

27. Maric NP, Jasovic-Gasic MM, Lecic-Tosevski D. Has psychiatry become a female profession? European Psychiatry 2008; 23:S385.

28. Weintraub W, Plaut M, Weintraub E. Recruitment in psychiatry: Increasing the pool of applicants. Can J Psychiatry 1999; 44:473-477.

29. Sturgeon D. Outcome variables for medical students who take on psychotherapy patients. Proceedings of the15th European Conference on Psychosomatic Research. London: John Libbey, 1986: pp. 363-366.

30. Yakeley J, Shoenberg P, Heady A. Who wants to do psychiatry? The influence of a student psychotherapy scheme - a 10-year retrospective study. Psychiatr Bull 2004; 28:208-212.

31. Cameron P, Persad E. Recruitment into psychiatry: A study of the timing and process of choosing psychiatry as a career. Can J Psychiatry 1984;29:676-680.

32. Manassis K, Katz M, Lofchy J, Wiesenthal S. Choosing a career in psychiatry: Influential factors within a medical school program. Acad Psychiatry 2006; 30:325-329.

33. Alpert JE, Schlozman S, Badaracco MA, et al. Getting our own house in order: Improving psychiatry education to medical students as a prelude to medical school education reform. Acad Psychiatry 2006; 30:170-173.

34. Lofchy J, Brunet A, Silver I. The psychiatry institute for medical students: A novel recruitment strategy. Acad Psychiatry 1999; 23:151-156.

Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Nelly Zilber et al.

Predictors of Early Psychiatric Rehospitalization: A National Case Register Study Nelly Zilber, D. ès Sc., Tzipi Hornik-Lurie, MA, and Yaacov Lerner, MD The Falk Institute for Mental Health Studies, Jerusalem, Israel

Introduction

ABSTRACT Background: Inconsistent results have been published on variables affecting readmission to psychiatric hospitals, in particular length of hospitalization before discharge. The objective of the present study was to develop a predictive model for 30-days readmission after discharge, as the latter is one of the performance indicators in the pending mental health reform in Israel.

Method: The data were extracted from the Israeli national psychiatric case register. They concerned all patients discharged from psychiatric hospitals in Israel during a six-month period (January 1,-June 30, 2004). A follow-up since the first discharge during this period (discharge from “index hospitalization”) until November 30, 2005 was performed for each patient. A Cox regression allowed constructing a multi-factorial prediction model for readmission within 30 days from discharge.

Results: The readmission rate within 30 days was 13%.

The variables predicting early readmission were age up to 45, history of prior hospitalization, short time between index and prior hospitalization and being discharged from a hospital in the Tel Aviv-Center district. Length of hospitalization was not a predictor of early readmission, except for the very short ones (up to eight days) which predicted earlier readmission.

Conclusion: The policy of shortening hospitalizations, which potentially could lead to premature discharge, was not found to be associated with early readmission, except for extremely short hospitalizations.

Address for Correspondence: falk1@012.net.il

During the last decades, deinstitutionalization has led to impressive changes in the use of psychiatric services all over the western world (1). Length of stay (LOS) in psychiatric hospital has decreased dramatically (1), but claims have been made by some that readmission occurs consequently earlier (2-6). Other studies have not confirmed such a relationship (7, 8). The discrepancies may be due to the fact that only few studies (9, 10) are based on national representative data and that the follow-up periods for assessing readmission vary widely across studies, extending from 30 days to as much as five years.

The Israel Psychiatric Case Register, which includes both demographic and cumulative clinical and administrative information on all patients admitted to a psychiatric hospital in Israel since 1950 (11), makes it possible to aggregate all episodes of inpatient care for each patient in a nation-wide sample.

The structural mental health reform, which started in Israel in 2001 and aimed at an overall reduction of psychiatric inpatient stay, chose as one of its performance indicators the 30-day hospital readmission rate.

This is also one of the indicators recommended by the OECD (Organization for Economic Co-operation and Development) Mental Health Panel (12). Studying readmission within a short time from discharge strengthens the probability that it will reflect the impact of the care during the previous hospital stay. It is assumed that, for a longer period of follow-up, other factors than hospitalization come into play, such as the natural course of the illness, environmental stressors, access to community services.

The objective of the present study was thus to develop a prediction model for 30-day hospital readmission after discharge, examining specifically the effect of the length of the inpatient stay preceding the discharge. This

Dr. Yaacov Lerner, Falk Institute, Kfar Shaul Hospital, Givat Shaul, Jerusalem 91060, Israel

49

Predictors of Early Psychiatric Rehospitalization: A National Case Register Study

addresses the present concern prevailing in the professional community that the current pressure to shorten length of inpatient stay may lead to premature discharge with increased risk of readmission (8).

Material and Methods Database and study population

The data (without any identifying information on patients) were extracted from the Israel Psychiatric Case Register. They concerned all patients discharged from psychiatric hospitals in Israel, during a six-month period (January 1-June 30, 2004). A follow-up since the first discharge during this period (discharge from “index hospitalization”) until November 30, 2005 was performed for each patient.

For each index hospitalization, demographic, clinical and administrative data were extracted.

Study variables

The dependent variable was the probability of readmission within 30 days from discharge. If readmission occurred within three days from discharge, the next hospitalization was considered as the continuation of the previous one. This allowed excluding administrative leaves, such as transfer to another hospital or leaves for weekends. The independent variables were: demographic data (gender, age, ethnic group), clinical data (ICD-10 diagnosis), history of prior hospitalization, time between discharge from former hospitalization and admission to index hospitalization, legal status at admission to the index hospitalization (compulsory vs. voluntary), length of index hospitalization and district of hospitalization.

The six districts differ in the availability of community services (measured by the number of mental health agents per 10,000 adult population). The rates are the following: in the North 0.7 (the lowest), in Haifa 1.4, in Jerusalem 1.7, in the Center 1.4, in Tel Aviv 2.3 and in the South 1.1 (Internal Report of Mental Health Services, Ministry of Health, Israel, 2003). As hospitals in Tel Aviv and the Center admit patients from both districts, the two districts were combined in the analysis.

The ICD-10 diagnoses were recoded into five diagnostic groups according to the main diagnosis: Disorders due to alcohol and drug abuse (F10-F19), schizophrenia and other functional psychoses (F20-F29), organic mental disorders (F00-F09), mood disorders (F30-F39) and neurotic and personality disorders (F40-F48 and F60-F69). Only 1.3% of the cases did not belong to any 50

of these categories and were not included in the analysis. Comorbidity was not considered because only the main diagnosis is recorded in the Case Register.

Data analysis

Since the studied variable (time to readmission) revealed a decaying exponential rather than a normal distribution (data available on request), a survival analysis was preferred to ANOVA procedures, which assume that the dependent variable is normally distributed (cf. 13). In addition, survival analysis has the advantage of including censored cases (patients not readmitted by November 30, 2005). We performed a Kaplan–Meier analysis, in which time to readmission was the time-to-event variable, while the “event” was readmission. A Cox regression allowed constructing a multi-factorial prediction model for readmission within 30 days from discharge, controlling for various independent variables, which were entered simultaneously in the analysis.

Data analyses were carried out using SPSS/PC version 15.0.

Results The study population consisted of 6,868 psychiatric discharges from hospitalization. The main characteristics of the discharged patients can be seen in Table 1. The median length of the index hospitalizations was 25 days.

As shown in Fig. 1, the median time to readmission was 444 days and the readmission rate within one month was 13%. In Table 1, the predictors of readmission within 30 days are given. Regarding the demographic characteristics of the hospitalized patients, gender and ethnic origin were not found to be significantly related to the probability of readmission, while age was. Patients aged up to 45 years had a higher probability of readmission than older patients; no significant difference was found between patients aged 45-65 and 66+. Diagnosis and legal status were not found to be significantly related to the probability of early readmission. A significant predictor of early readmission was the recency of prior hospitalization: the more recent the previous hospitalization, the higher the probability of early readmission. Another significant predictor of 30-day readmission related to hospitalization was an index hospitalization of up to eight days; no statistically significant difference was found between all other groups with various longer lengths of hospitalization.

We then examined the interaction between two predictors of readmission, length of index hospitalization

Nelly Zilber et al.

and time in the community between former and index hospitalizations. For both short and longer hospitalizations, the shorter the time since former hospitalization, the higher the probability of rehospitalization (Figure

2). On the other hand, the effect of the length of index hospitalization is dependent on the time in the community prior to the index hospitalization. As seen in Figure 2, one group is significantly different from all others,

Table 1. Cox Regression Results for Predictor Variables of Readmission within 30 Days from Discharge N

Exp(B)*

95% C.I.

p.

Up to 45 years

3873

1.00

45 to 65 years

1928

0.85

0.73

-

0.99

0.038

66 years or more

657

0.75

0.57

-

0.99

0.040

Male

3666

1.03

0.89

-

1.18

Female

2792

1.00

Age

0.030

Gender

0.683

Ethnic origin

0.688

Jewish

5469

1.00

Arab

695

0.93

0.73

-

1.18

Unknown

294

0.88

0.62

-

1.26

Diagnosis

0.942

Schizophrenia or other psychosis

4153

1.00

Organic Disorder

311

1.05

0.74

-

1.49

0.773

Affective Disorder

1036

1.05

0.86

-

1.30

0.620

Neurotic and Personality Disorder

753

1.08

0.86

-

1.34

0.505

Drugs and Alcohol

239

0.94

0.64

-

1.39

0.771

Legal Status at Admission

0.293

Compulsory Admission

1523

1.00

Voluntary Admission

4935

1.10

0.92

-

1.30

No prior hospitalization

1627

0.38

0.30

-

0.47

0.000

> 365 days since former hospitalization

2174

0.45

0.37

-

0.55

0.000

91-365 days since former hospitalization

1751

0.59

0.49

-

0.71

0.000

<=90 days since former hospitalization

906

1.00

2-8

1247

1.00

9 â&#x20AC;&#x201C; 30

2299

0.81

0.68

-

0.98

0.030

31 - 60

1377

0.70

0.56

-

0.87

0.002

61

1535

0.75

0.61

-

0.92

0.007

Hospitalization History

0.000

Length of Index Episode (days)

+

0.009

Hospital District

0.001

Northern district

674

1.26

0.92

-

1.71

0.144

Haifa district

1207

1.02

0.77

-

1.35

0.901

Jerusalem district

722

1.09

0.80

-

1.47

0.593

Tel Aviv and Center districts

3090

1.43

1.13

-

1.81

0.003

Southern district

765

1.00

Total

6458

* The analysis is based only on the hospitalizations for which none of the values of the variables was missing.

51

Predictors of Early Psychiatric Rehospitalization: A National Case Register Study

1.0

0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Time to readmission since discharge (days)

Figure 2. Probability of Readmission within 30 Days from Discharge 1.0 Length of index Episode (days)

0.9

Hazard ratios

0.8

p=0.006 {

p=0.000

2-8 9+

0.7 0.6 0.5

p=0.000

0.4

0.2

p=0.035

N.S { p=0.017

0.3 < 90

90-365

N.S

> 365

Time since former hospitalization (days) Each point in the graph represents the hazard ratio relative to the reference group (time since former hospitalization <90 and length of index episode 2-8 days) Each p value between two points relates to the significance of the difference between the hazard ratios at these two points.

with a significantly quicker readmission (hospitalization of up to eight days and previous hospitalization within 90 days). This particular group concerns only a small number of patients (1.5% of all discharged patients and 7.3% of those with short hospitalizations).

Another predictor of early readmission was being discharged from a hospital in the Tel Aviv and Center districts. Interestingly, although the highest proportion of the very short hospitalizations was found in the southern district (28.2% vs. 16.8% in the Northern district, 16.7% 52

in the Haifa district, 20.5% in the Jerusalem district and 20.9% in the Tel Aviv and Center districts), the southern district showed the lowest risk of readmission (Table 1).

0.9

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510 540 570 600 630 660 690 720

% of patients remaining in the community after discharge

Figure 1. Kaplan Meier Survival Curve for Time to Readmission

Discussion The main strength of the present study is an analysis based on cumulative national data from the Israel National Psychiatric Hospitalization Register, which enables an analysis of non-biased nationwide data. The findings are important, even with the following limitations: lack of detailed information about individual patients’ clinical characteristics - other than diagnosis - and quality of treatment. Gathering such data, however, is not feasible for a nationwide study, as individual clinical patient characteristics and quality of treatment are not registered in a standard form and differ greatly from hospital to hospital. As stated by Kolbasovsky et al. (7), “There is… a need for the development of a practical predictive model…using only information easily obtainable from administrative databases.”

Prior hospitalization was found to be related to earlier readmission in accordance with the literature (9, 10, 14, 15). The more recent the prior hospitalization was, the sooner the readmission. Recent hospitalization can possibly be considered as a proxy for severity of psychopathology and/or poor social support in the community.

The findings in the literature regarding the relationship between length of hospitalization and readmission are inconsistent. Some authors (8-10, 16, 17) reported that patients with longer stay are more likely to be readmitted, suggesting that longer stays may act as a proxy for the patients’ severity of illness. The cutting point defining longer stay was 60 days (17), 30 days (10) and even 20 days (8). In contrast, others (3, 18) reported that shorter stay is associated with earlier readmission, possibly because of a premature discharge. Similarly, Heeren et al. (4) found that, over the years (between 1993 and 1997), the mean LOS decreased and, in parallel, the rate of readmission increased. Wickizer and Lessler (6) found that restriction on LOS imposed by utilization management programs in the U.S.A. lent to an increase in re-admissions during the 1990s. In these studies, the mean LOS was 7-15 days. These different studies seem to support the association between very short hospitalization and early readmission.

In the present study, we examined a full spectrum of LOS, from very short to very long, after adjusting for variables that may reflect severity of pathology and were

Nelly Zilber et al.

found to be associated with the probability of readmission (diagnosis of schizophrenia, existence and recency of a previous history of hospitalization and compulsory hospitalization). Our study results did not confirm the claim that shortening length of inpatient stay, after controlling for other variables, leads to earlier readmission, except for those patients who had been hospitalized during the 90 days preceding the index hospitalization, and whose length of index hospitalization was less than nine days. In our study, they represent a small number of discharged patients (1.5%).

Interestingly, there was no significant association between early readmission and the rate of mental health professionals in the community in the different districts.

The fate of the patient in the community at later stages depends of course on supportive networks and ongoing community services, which require a sufficient number of professionals.

It should be noted that the Southern district, which was found to have the lowest readmission risk, is the district with the highest proportion of short hospitalizations, probably due to its lowest bed ratio (19). A possible explanation is that hospitals in different districts differ in their discharge programs and in their interaction with the community services, which may be related to the bed pressure. Well-planned discharge programs and good interaction between hospital and community services seem to affect early readmission (20, 21). This of course should be preferably the result of good planning and not only of bed pressure.

Conclusion The policy of shortening the hospitalizations, which potentially could lead to premature discharge, was not found to be associated with early readmission, except for extremely short hospitalizations (up to eight days).

Preventing early readmission apparently depends mainly on effective discharge programs and pre-discharge contacts with outpatient services.

References 1. Fakhoury W, Priebe S. The process of deinstitutionalization: An international overview. Curr Opin Psychiatry 2002;15:187-192.

2. Lieberman PB, Witala ST, Elliott B, McCormick S, Goyette SB. Decreasing length of stay: Are there effects on outcomes of psychiatric hospitalization? Am J Psychiatry 1998;155:905-909.

3. Figueroa R, Harman J, Engberg J. Use of claims data to examine the impact of length of inpatient psychiatric stay on readmission rate.

Psychiatr Serv 2004;55:560-565.

4. Heeren O, Dixon L, Gavirneni S, Regenold WT. The association between decreasing length of stay and readmission rate on a psychogeriatric unit.

Psychiatr Serv 2002;55:76-79.

5. Heggestad T. Operating conditions of psychiatric hospitals and early readmission â&#x20AC;&#x201C; effects of high patient turnover. Acta Psych Scand 2001;103:196-202.

6. Wickizer TM, Lessler D. Do treatment restrictions imposed by utilization management increase the likelihood of readmission for psychiatric patients? Medical Care 1998;36:844-850.

7. Kolbasovsky A, Reich L, Futterman R. Predicting future hospital utilization for mental health conditions. J Behav Health Serv R 2007;34:34-42.

8. Thompson EE, Neighbors HW, Munday C, Trierweiler S. Length of stay, referral aftercare, and rehospitalization among psychiatric inpatients.

Psychiatr Serv 2003;54:1271-1276.

9. Hodgson RE, Lewis M, Boardman AP. Prediction of readmission to acute psychiatric units. Soc Psychiatry Psychiatr Epidemiol 2001;36:304-309.

10. Korkeila JA, Lehtinen V, Tuori T, Helenius H. Frequently hospitalized psychiatric patients: A study of predictive factors. Soc Psychiatry Psychiatr Epidemiol 1998;33:528-534.

11. Lichtenberg P, Kaplan Z, Grinshpoon A, Feldman D, Nahon D. The goals and limitations of Israelâ&#x20AC;&#x2122;s psychiatric case register. Psychiatr Serv 1999;50:1043-1048.

12. Hermann R, Mattke S. The members of the Organization for Economic Co-operation and Development (OECD) Mental Health Care Panel.

Selecting indicators for the quality of mental health care at the health system level in OECD countries. Organization for Economic Cooperation and Development, 2004.

13. Stevens A, Hammer K, Buchkremer G. A statistical model for length of psychiatric in-patient treatment and an analysis of contributing factors.

Acta Psychiat Scand 2001;103:203-211.

14. Bernardo AC, Forchuk C. Factors associated with readmission to a psychiatric facility. Psychiatr Serv 2001;52:1100-1102.

15. Moran PW, Doerfler LA, Scherz J, Lish JD. Rehospitalization of psychiatric patients in a managed care environment. Ment Health Serv Res 2000;2:191-199.

16. Mojtabai R, Nicholson RA, Neesmith DH. Factors affecting relapse in patients discharged from a public hospital: Results from survival analysis. Psychiatr Q 1997;68:117-129.

17. Qiesvold T, Saarento O, Sytema S, et al. Predictors for readmission risk of new patients: The Nordic comparative study on sectorized psychiatry.

Acta Psychiat Scand 2000;101:367-373.

18. Lin H-C, Tian W-H , Chen C-S, Liu T-C, Tsai S-Y, Lee H-C. The association between readmission rates and length of stay for schizophrenia: A 3-year population-based study. Schizophr Res 2006;83: 211-214.

19. Hospitalization Institutes 2007. Department of Information and Computerization, Ministry of Health, Jerusalem 2008.

20. Olfson M, Mechanic D, Boyer CA, Hansell S. Linking inpatients with schizophrenia to outpatient care. Psychiatr Serv 1998;49, 911-917.

21. Durbin J, Lin E, Layne C, Teed M. Is readmission a valid indicator of the quality of inpatient psychiatric care? J Behav Health Serv Res 2007;34, 137-150.

53

Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Comorbidity of Insomnia Detected by the Pittsburgh Sleep Quality Index with Anxiety, Depression and Personality Disorders Hakan Atalay, MD Department of Psychiatry, Yeditepe University Hospital, Istanbul, Turkey

ABSTRACT Background: The comorbidity of insomnia with various psychiatric conditions, such as anxiety, depressive and some personality disorders has been repeatedly shown in previous studies, although research investigating these disorders together is scarce.

Method: Two hundred and sixty five patients were interviewed individually. Two hundred and twelve of them completed the Pittsburgh Sleep Quality Index.

They were also given the Beck Depression Inventory (BDI), the Spielberger State and Trait Anxiety Inventory (STAI-1 and 2), the Severity of Psychosocial Stressors Scale of DSM-III-R, and the Structured Clinical Interview of DSM-III-R for Personality Disorders (SCIDII) Personality Questionnaire.

Results: There were no significant correlations between the patients’ insomnia scores and their gender, marital status, education, depression and trait anxiety scores, and stress levels. There were, however, significant associations of patients’ PSQI scores with their ages and STAI-1 scores.

Conclusions: When age, BDI scores, STAI-1 and 2 scores, education and stress level during the last year are accepted as factors that may have an impact on PSQI scores, it appears that a patient’s age and STAI-1 score best estimates his or her PSQI scores.

Introduction Insomnia is an important public health issue because it has a significant negative impact on individuals’ physical and social performance, their ability to work and their quality of life (1). It is the most prevalent sleep disorder in both the general population and among psychiatric patients (2). Epidemiologic-based studies estimated that 7.5% to 15% of the general adult population suffers from chronic insomnia, and an additional 25% to 35% experience insomnia on a transient or occasional basis (3). The clinical diagnostic criteria for insomnia are contained in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (4), the International Classification of Disease, 10 th edition (5) and the International Classification of Sleep Disorders guidelines (ICSD) (6).

Insomnia, as described in the DSM-IV, is characterized by complaints of difficulty initiating or maintaining sleep, or nonrestorative sleep lasting for at least one month, in association with clinically significant distress or the impairment of psychosocial or physical functioning.

The DSM-IV and ICSD guidelines provide essential distinctions between insomnia as an independent disorder (primary insomnia) and insomnia as a symptom related to other factors such as a psychiatric or other medical comorbidity (secondary or comorbid insomnia).

The most common factors shown to be associated with insomnia include various demographic characteristics such as age, gender, education level, socioeconomic status, employment status, and marital status as well as having a psychiatric or somatic illnesses or experiencing other stressful life events (7-9). Epidemiological and clinical studies have shown that a high number of people with insomnia also suffer from a concomitant

Address for Correspondence: Hakan Atalay, MD, Department of Psychiatry, Yeditepe University Hospital, Devlet Yolu Ankara Cad 102/104, Kozyatağı TR-34752, Istanbul, Turkey hakanatalay2005@gmail.com

54

Hakan Atalay

mental disorder, mainly depressive or anxiety disorders: with between 40% and 60% of insomnia complainers falling into this category (7, 10, 11). Additionally, there is a growing body of evidence suggesting that there is a significant relationship between substance abuse and insomnia (12, 13). Moreover, insomnia has also been suggested to be associated with some personality patterns, such as perfectionism and the tendency to internalize emotions (14).

The present paper aims to investigate the relation of insomnia with sociodemographic features, such as age, gender, marital status and education level, on the one hand, and with psychological factors, such as stress and anxiety levels, history of substance use, comorbid psychiatric disorders and personality disorders on the other.

Method Two hundred and sixty five consecutive patients were interviewed by the author between in January 1, 2006, and June 30, 2006, in the outpatient setting in the Department of Psychiatry of a University Hospital. The patients were informed about the content of the study by the author and each patient gave verbal approval of participation in the study. The protocol of the research project was approved by the Ethics Committee of the University where the work was undertaken. Through a questionnaire, data were obtained of the sociodemographic characteristics of 234 patients, including their age, duration of marriage, educational level, and history of physical illness and psychoactive substance abuse; 212 patients (76 men and 136 women) who completed the Pittsburgh Sleep Quality Index (15, 16) were also given the Beck Depression Inventory (17, 18), the Spielberger State and Trait Anxiety Inventory (STAI-1 and 2) (19, 20), the Severity of Psychosocial Stressors Scale of DSMIII-R, and the Structured Clinical Interview of DSMIII-R for Personality Disorders (SCID-II) Personality Questionnaire (21, 22).

After removal of the data of patients under 18 years of age, all of the data were summarized as descriptive statistics. Due to the type of variables, analyses were carried out by parametric or nonparametric statistical methods. For numeric variables that were not distributed normally, the Mann-Whitney U test was used in the comparisons between two groups, and the Kruskal Wallisâ&#x20AC;&#x2122; test was used in the comparisons among more than two groups. The Mann-Whitney U test was used to test the difference between two groups. To differentiate

variables thought to be responsible for differences in more than two groups, we used the post hoc test, which takes the Bonferroni correction into account; p<0.05 was used as the value of significance. Finally, the effect of various numeric variables, such as age, marital and educational status, stress levels, and depression and anxiety scores on the PSQI was computed using a regression analysis model.

Results The descriptive statistics of 224 patients (81 men and 143 women) are shown in Table 1. According to the DSM-IV, they were predominantly diagnosed with anxiety disorder (n: 80; 36.5%), including panic disorder (n: 30; 13.7%) and other anxiety disorders (n: 43; 19.6%). This was followed by depression (n: 62; 28.3%).

Adjustment disorders and alcohol and substance abuse were also fairly common (n: 12; 5.4% and n: 8; 3.6%, respectively) in this group.

Among the patients who were included in statistical assessments because they had completed the PSQI, there were no associations between the insomnia score and gender (z:-0.212; p: 0.832), marital status (p:0.609), or educational level (r: -0.063; p: 0.353) (Table 2). Level of the psychosocial stressors (r: 0.034; p:0.615), depression (r: 0.123; p:0.066) and trait anxiety (r: 0.096; p: 0.152) did not reveal any significant differences. However, our findings demonstrated that insomnia increased with age, as is shown by the significant correlation between Table 1. Descriptive statistics of the patients whose data are available (STAI-1: Spielberger State Anxiety Inventory; STAI-2: Spielberger Trait Anxiety Inventory; BDI: Beck Depression Inventory; PSQI: Pittsburgh Sleep Quality Inventory). n

Average

Mean

SD

Min

Max

Age

226

38.5

35

16.1

18

90

Marriage duration

132

19.9

16

14.8

0.4

60

Number of sibling(s)

195

2

2

1.6

0

9

No. of children

137

1.6

2

1.2

0

10

Education (yrs)

223

11.7

12

3.9

0

17

Severity of the stressors

226

3.3

4

1.6

1

7

STAI-1

222

32.9

32

9.8

0

67

STAI-2

222

28.4

24

9.5

0

67

BDI

223

10.5

8

8.0

0

45

PSQI

224

8.7

8.5

4.1

1

19

55

Comorbidity of Insomnia Detected by the Pittsburgh Sleep Quality Index

Table 2. Relationships between the PSQI scores and sociodemographic characteristics of the patients. n

Average

Mean SD

Min

Max

Male

81

8.6

9

4.0

2

18

z:-0.229

Female

143

8.8

8

4.1

1

19

p:0.819

Single

91

8.5

8.0

4.0

1

16

Married

109

8.7

8

4.1

1

19

Divorced

18

10.0

10

4.1

3

17

Widowed

6

9.0

9.5

4.6

2

16

230

11.6

12

3.9

0

17

r:-0.068 p: 0.944

No

150

8.5

8

4.0

1

19

z:-0.931

Yes

74

9.1

9

4.2

1

17

p:0.352

Gender

Marital Status p:0.571

Education Level (yrs)

Physical Illness

the PSQI scores and patientsâ&#x20AC;&#x2122; age (r: 0.174; p: 0.009) (Table 3). Duration of marriage was also significantly correlated with the insomnia score (r: 0.228; p: 0.009).

Unexpectedly, there was no significant correlation between PSQI score and the severity of psychosocial stressors experienced in the previous year (r: 0.034; p: 0.615) and between PSQI score and the Beck Depression Inventory score (r: 0.123; p: 0.066) (Table 3). STAI-1 (i.e., state anxiety) scores had a significant relationship with the PSQI scores (r: 0.206; p: 0.002), but the traitanxiety scores did not (r: 0.096; p: 0.152) (Table 3). The PSQI scores were also higher in patients with OCD or bipolar disorder than in patients with other diagnoses, although this did not reach statistically significant levels (p: 0.058 and p: 0.054, respectively) (Table 4).

Table 4. The PSQI scores compared with the diagnoses of the patients.

Psychoactive Substance Abuse No

179

8.4

8

4.1

1

19

z:-2.678

Yes

34

10.3

11

3.3

3

18

p:0.007

Table 3. Correlations between the PSQI scores of the patients and their sociodemographic and psychological characteristics such as age, marriage duration, education level, severity of psychosocial stressors, BDI and STAIs scores.

n

Average

Mean

SD

Min

Max

Depression

p: 0.351

No

157

8.6

8

4.1

1

19

Yes

62

9.2

9

4.0

1

18

Panic Disorders

p: 0.869

No

189

8.8

8

4.2

1

19

PSQI

Yes

30

8.8

9

3.0

4

15

R

0.174

Obsessive Compulsive Disorder

P

0.009

No

212

8.9

9

4.1

1

19

n

224

Yes

7

6.1

7

1.9

3

8

R

0.228

Other Anxiety Disorders

P

0.009

No

176

8.8

8.5

4.0

1

19

n

130

Yes

43

8.6

9.0

4.2

1

17

R

-0.063

Adjustment Disorder

P

0.353

No

207

8.8

9

4.1

1

19

n

221

Yes

12

8.8

8

4.0

4

16

R

0.034

Psychotic Disorder

P

0.615

No

211

8.7

8.0

4.1

1

19

n

224

Yes

8

9.6

10

4.3

3

15

Beck Depression Inventory

R

0.123

Bipolar Disorder

P

0.066

No

210

8.7

8

4.0

1

19

N

223

Yes

9

11.6

12

4.3

5

17

STAI-1

R

0.206

Psychoactive Substance Abuse

P

0.002

No

211

8.7

8.5

4.1

1

19

n

222

Yes

8

10.3

11

4.1

3

15

R

0.096

Other Diagnoses

P

0.152

No

194

8.8

9

4.0

1

18

n

222

Yes

25

8.4

8

4.6

2

19

Age

Marriage Duration

Education level

Severity of the psychosocial stressors during the last year

STAI-2

56

MW-U

p: 0.058

p: 0.890

p: 0.934

p: 0.471

p: 0.054

p: 0.254

p: 0.471

Hakan Atalay

Discussion

Table 5. The PSQI scores compared with the personality clusters of the patients (KW: Kruskal Wallis, MW-U: Mann Whitney U test).

Personality N

Average Mean SD

Min Max

Cluster A

17

11.1

5

Cluster B

40

9.3

Cluster C

129 8.4

11

2.8

9.5

4.0 2

18

8

4.2

19

1

p (KW)

17 0.024

A vs. B

P: 0.123 (MWU)

A vs. C

P: 0.008 (MWU)

B vs. C

P: 0.246 (MWU)

Patients were also assessed for axis II personality disorders. To make the statistical procedures simpler, they were accepted as fulfilling diagnostic criteria for only one personality disorder even when they met the criteria for more than one. Thus, of 212 patients, 186 (84%) met the DSM-IV diagnostic criteria for a personality disorder, the most common of which was a cluster C personality disorder (n = 129, 59%). A significant relationship was found between sleep quality and the cluster of the personality disorder (p: 0.024).

When we compared the three clusters as a whole with each other, however, we found that in fact this significance was essentially based on the difference between cluster A and cluster C personality disorders (Table 5).

The model built on variables such as age, BDI scores, anxiety scores (STAI-1 and 2), education level and the stress level during the last year demonstrated that the age and STAI-1 scores best predicted PSQI scores (R=0.406, R²=0.165). It should be noted, however, that when the model was applied to married subjects only, the duration of the marriage and the STAI-1 score best estimated patients’ PSQI scores (R=0.436, R²=0.190) (Table 6).

Relatively few studies have simultaneously investigated the relationships between insomnia and psychosocial and clinical factors. In the present study, we found positive correlations between the insomnia scores of the patients and their ages, anxiety scores and personality types. Although female gender has been described as a risk factor in almost all studies, the lack of a correlation between the patients’ gender and their insomnia scores in our study is consistent with recent surveys (23), suggesting that there are comparable rates of insomnia in both genders. The significant association between PSQI score and the duration of marriage may be explained by the age-related increase of insomnia scores and is in accordance with some previous as well as recent epidemiological studies (24). Because some studies have shown that more education was associated with better sleep (25), the lack of a correlation between insomnia scores and the educational levels of our patient sample may also be explained by the fact that our patient population is not representative of average Turkish people because their average educational level (11.7 years) was higher than that of the normal Turkish population (3 to 4 years on average).

The patients with alcohol and drug abuse problems had significantly higher insomnia scores as measured by the PSQI than those without these problems. However, the relationship between psychoactive substance use disorders and insomnia may be complicated by the presence of other psychiatric issues such as mood, anxiety, and depression (13). Therefore, this difference has been ignored in this analysis. Although stressful life events have also been viewed as major factors relating to onset of insomnia (26), we could not find any association

Table 6. Regression analysis of the correlations between the PSQI scores and the patients variables (STAI-1: Spielberger State Anxiety Inventory; STAI-2: Spelbierger Trait Anxiety Inventory; BDI: Beck Depression Inventory).

STAI-2 STAI-2

1.000

Age

0.072

Age

BDI

Stress Level

Education (yrs)

STAI-1

Marriage Duration (yrs)

1.000

BDI

0.036

0.064

1.000

Stress Level

0.039

0.160

-0.092

1.000

Education

0.050

0.097

0.139

0.061

1.000

STAI-1

0.598

0.106

-0.033

-0.235

-0.047

1.000

Marriage Dur. (yrs)

0.107

0.858

-0.077

-0.145

0.081

0.035

R

R2

p

0.406

0.165

0.039

1.000

57

Comorbidity of Insomnia Detected by the Pittsburgh Sleep Quality Index

between psychosocial stresses experienced by a patient in the last year and his or her insomnia score. This result may be due to the recent conclusion by Roth and Drake (9) that insomnia patients generally do not experience stressful events more frequently but that stressful events have a significantly greater impact on insomnia patients compared with normal-sleeping subjects.

There is evidence in the literature suggesting that certain types of personalities are more likely to have insomnia than others (27). Therefore, we investigated the personality characteristics of our patients. We found that there is a significant association between the insomnia scores of the patients and the cluster of personality disorders into which they fell. Given the suggested role of anxiety-induced arousal in the etiology of insomnia, it may not be surprising to find that the greatest significance was seen between cluster A (including paranoid, schizoid and schizotypal personality disorders) and cluster C (including avoidant, dependent, obsessive compulsive) personality disorders (i.e., anxious group).

Epidemiological and clinical studies have shown that a high number of insomnia patients also suffer from a concomitant mental disorder, mainly depressive or anxiety disorder: with between 40% and 60% of insomnia complainers falling into this category (7, 11). A recent study (28) also found a moderate to strong lifetime association between insomnia and anxiety disorders, on one hand, and between insomnia and major depression, on the other. Although the present study was carried out in a clinical sample of patients, it appears to confirm the significant association between insomnia and anxiety, as shown in the state anxiety scores (measured by STAI-1).

This relationship has not been demonstrated for depression in our study. It is probably the case because the association of depression with insomnia may manifest itself in various ways (29-32). Instead of looking for simple cause and effect relationships between insomnia and depression, a broader view that places the insomnia into the context of a syndrome that is known to include other symptoms that all result from a common vulnerability of the pathophysiological process is needed (33).

There are some limitations in this study. The most important one is the lack of a control group. In addition, the cross-sectional design does not allow the establishment of a cause-and-effect relationship. The same interviewers assessed insomnia complaints and psychiatric diagnoses, and this lack of blinding can lead to experimenter bias (34). Second, our sleep quality data 58

were self-reported. Although research studies sometimes need to apply specific quantitative definitions, such measures can be misleading in clinical practice (35-37). Third, we were not able to examine the different dimensions of the insomnia. For example, we did not have separate data on difficulty initiating, difficulty maintaining sleep and on early morning awakening.

Nonetheless, Hohagen et al.â&#x20AC;&#x2122;s findings (38) illustrate that cross-sectional studies focusing on subtypes of insomnia (e.g., sleep-onset insomnia), may even lead to erroneous results. Finally, it should be accepted that there may be a significant overlap between insomnia and depression and anxiety scores of the patients since their insomnia may be an essential part of their mood states. However, we found a relationship between the state anxiety and the insomnia score of the patients without a relationship between the trait anxiety and depression scores.

Therefore, viewing sleep difficulties as a result of the interactions between insomnia and state anxiety, not depression, may be an alternative explanation.

Practical clinical consequences can be drawn from the results of our study. First, establishing risk factors such as age, history of substance abuse, high anxiety scores, and some personality categories may be useful to achieve the diagnosis of insomnia within a primary health care or outpatient setting. Second, the association of insomnia with anxiety and some personality features suggests a need for therapeutic consequences.

References: 1. Billiard M, Bentley A. Is insomnia best categorized as a symptom or a disease? Sleep Med 2004;5:S35-S40.

2. Szelenberger W, Soldatos C. Sleep disorders in psychiatric practice.

World Psychiatry 2005;4:186-190.

3. Leger D, Poursain B. An international survey of insomnia: Underrecognition and under-treatment of a polysymptomatic condition. Curr Med Res Opin 2005;21:1785-1792.

4. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Publishing, Inc., 1994.

5. World Health Organization (WHO). International Classification of Disease, 10th Edition, Chapter V (F). Mental and behavioral disorders (excluding disorders of psychological development). Clinical descriptions and guidelines. Geneva: World Health Organization, 1994.

6. International Classification of Sleep Disorders, Revised (2001).

(Diagnostic and Coding Manual) American Academy of Sleep Medicine. http://www.absm.org/PDF/ICSD.pdf. (Downloaded in June 2004) 7. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbance and psychiatric disorders: an opportunity for prevention? JAMA 1989;62:1479-1484.

8. Käppler C, Hohagen F. Psychosocial aspects of insomnia: Results of a study in general practice. Eur Arch Psychiatry Clin Neurosci 2003;253:49-52.

9. Roth T, Drake C. Evolution of insomnia: Current status and future direction. Sleep Med Rev 2004;5:S23-S30.

Hakan Atalay

10. Roth T. The relationship between psychiatric diseases and insomnia. J Clin Pract 2001;116:3-8.

11. Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res 2003;37:9-15.

12. Johnson EO, Breslau N. Sleep problems and substance use in adolescence.

Drug Alcohol Depend 2001;64:1-7.

13. Teplin D, Raz B, Daiter J, Varenbut M, Tyrrell M. Screening for substance use patterns among patients referred for a variety of sleep complaints.

Am J Drug Alcohol Abuse 2006;32:111-120.

14. de Carvalho LB, Lopes EA, Silva L, de Almeida MM, Almeida e Silva T, Neves AC, do Prado LB, do Prado GF. Personality features in a sample of psychophysiological insomnia patients. Arq Neuropsiquiatr 2003;61:588-590.

15. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatr Res 1989;28:193-213.

16. Ağargün MY, Kara H, Anlar O. Validity and reliability of the Pittsburgh Sleep Quality Index in Turkish sample (Pittsburgh uyku kalitesi indeksinin geçerliği ve güvenirliği). Turk Psikiyatri Derg 1996;7:107-115.

17. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-571.

18. Hisli N. The reliability and validity study of the Beck Depression Inventory in a Turkish sample. Turk Psikoloji Derg 1988;6:118-122.

19. Spielberger CD. Manual for the State-Trait Anxiety Inventory (STAI).

PaloAlto, Cal.: Consulting Psychologists Press, 1983.

20. Oner N, Le Compte A. Durumluk-Surekli Kaygi Envanteri Elkitabi, Istanbul: Boğaziçi Űniversitesi Yayınlari, 1985.

21. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R Axis II Disorders(SCID-II). Washington, DC: American Psychiatric Press, 1990.

22. Sorias S, Saygılı R, Elbi H, Vahip S, Mete L, Nifirne Z, Örnek I, Aydin C, Aktener E . DSM-III-R Kişilik Bozuklukları Için Yapılandırılmış Klinik Gőrűşme Formu (SCID-II). (SCID-2 Turkish Version) Ege Üniversitesi Basımevi, Izmir, 1990.

23. Voderholzer U, Al-Shajlawi A, Weske G, Feige B, Riemann D. Are there gender differences in objective and subjective sleep measures? A study of insomniacs and healthy controls. Depress Anxiety 2003;17:162-172.

24. Roth T, Jaeger S, Jin R, Kalsekar A, Stang PE, Kessler RC. Sleep problems, comorbid mental disorders, and role functioning in the national comorbidity survey replication. Biol Psychiatry 2006;60:1364-1371.

25. Moore PJ, Adler NE, Williams DR, Jackson JS. Socioeconomic status and health: The role of sleep. Psychosom Med 2002;64:337-344.

26. Healey ES, Kales A, Monroe LJ, Bixler EO, Chamberlin K, Soldatos CR. Onset of insomnia: Role of life-stress events. Psychosom Med 1981;43:439-451.

27. Sierra JC, Zubeidat I, Ortega V, Delgado-Dominguez CJ. Assessment of the relationship between psychophysiological personality traits and sleep quality. Salud Mental 2005;28:13-21.

28. Johnson EO, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: Exploration of the direction of risk. J Psychiatr Res 2006;40:700-708.

29. Brunello N, Armitage R, Feinberg I, Holsboer-Trachsker E, Leger D, Linkowski P, Mendelson WB, Racagni G, Saletu B, Sharpley AL, Turek F, Van Cauter E, Mendlewicz J. Depression and sleep disorders: Clinical relevance, economic burden and pharmacological treatment.

Neuropsychobiology 2000;42:107-119.

30. Morawetz D. Insomnia and depression: Which comes first? Sleep Res Online 2003;5:77-81.

31. Riemann D, Voderholzer U. Primary insomnia: A risk factor to develop depression? J Affect Disord 2003;76:255-259.

32. Lustberg L, Reynolds III CF. Depression and insomnia: Questions of cause and effect. Sleep Med Rev 2000;4:253-262.

33. Hall M, Buysse DJ, Nowell PD, Nofzinger EA, Houck P, Reynolds III CF, Kupfer DJ. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med 2000;62:227-230.

34. Rocha FL, Hara C, Rodrigues CV, Costa MA, e Costa EC, Fuzikawa C, Santos VG. Is insomnia a marker for psychiatric disorders in general hospitals? Sleep Med 2005;6:549-553.

35. Sateia M, Doghramji K, Hauri PJ, Morin CM. Evaluation of chronic insomnia. Sleep 2000;23:1-66.

36. Hailey D, Tran K, Dales R, Mensinkai S, McGahan L. Recommendations and supporting evidence in guidelines for referral of patients to sleep laboratories. Sleep Med Rev 2006;10:287-299.

37. Wilson S, Argyropoulos S. Antidepressants and sleep. Drugs 2005;65:927-947.

38. Hohagen F, Kaepler C, Schramm E, Riemann D, Weyerer S, Berger M. Sleep onset insomnia, sleep maintaining insomnia and insomnia with early morning awakening – temporal stability of subtypes in a longitudinal study on general practice attenders. Sleep 1994;17: 551-554.

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Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011)

Idiom of distress or delusional state? Cultural clash as the cause of misdiagnosis: A case report Anne-Marie Ulman, MD, and Faina Bar, MD Beer Yaakov Mental Health Center and Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel

ABSTRACT The “Beta Israel” (House of Israel) represent a total number of more than 100,000 individuals.

Ethiopian-Jewish culture is based on a tribal cultural model. With their arrival in Israel, many difficulties surfaced. Ethiopian Jews had to deal with cultural choices that challenged their traditions. It has been suggested that the trauma of their journey coupled to the difficulties of the adaptation process to Israeli society, “the culture shock,” was directly responsible for psychopathology found among this population. It also appeared that culture plays a central role in the construction of the clinical picture, blurring at times the boundary between expressions of distress and pathology. It became increasingly difficult to draw the line between culturally normative behavior and psychopathology. The following case report underlines the importance of socio-cultural considerations in both staff and patients, and illustrates the dangers of misdiagnosis due to patient-therapeutic team cultural clash. A 41-year-old woman of Ethiopian origin was hospitalized for suspected schizophrenia. Because of the striking contrast between the patient’s behavior, responses and so-called “psychotic content,” possible misunderstanding based on cultural differences was considered by the clinical management team. This case underlines the dangers of the psychiatric diagnostic process, emphasizes the important role of sociocultural backgrounds of both staff and patients in patient management and encourages the consideration of cultural factors in all patient evaluations.

Beginning in 1977, and followed by the much publicized airlift in 1984 and 1991, a process of emigration brought the Ethiopian Jewish community to Israel. Today the “Beta Israel” (House of Israel) represent a total number of more than 100,000 individuals (1). Ethiopian Jews preserved their cultural integrity, living in isolated communities spread throughout hundreds of villages in the northwestern rural areas of the country, especially in the Gondar and Tegray regions. Ethiopian-Jewish culture is based on a tribal cultural model. With their arrival in Israel, many difficulties inherent in transition from traditional village culture to Western society surfaced (2).

Ethiopian Jews had to deal with cultural choices that challenged their traditions. It has been shown that immigration is associated with increased risk of mental and physical health problem. (3). Among Operation Moses immigrants, a parallel appeared between the trauma of the immigration process, the interface with Israeli reality and the appearance of symptoms such as anxiety, depression with suicidal ideation, and sleep disturbance. Arieli and Ayeheh (4, 5) concluded that the trauma of the journey coupled with the difficulties of the adaptation process to Israeli society (“minority status” and difficulties due to the language barrier), “the culture shock,” was directly responsible for psychopathology found among this population. Brief reactive psychosis was the most common severe psychopathology accounting for psychiatric hospitalization (6). Another issue was the non-readiness of clinicians in the face of unfamiliar clinical phenomena including brief psychotic episodes among members of a traumatized group in place of a classical PTSD picture (6), dissociative reactions with stupor and trance-like states lasting minutes to hours among adolescents (7, 8) and eating arrest (with no connection to anorexia nervosa) in the context of social distress (9). The incidence of both suicidal behavior and general practitioner visits for somatoform disorders has been noted to be inordi-

Address for Correspondence: Anne-Marie Ulman, MD, Beer Yaakov Mental Health Center, POB 1, Beer Yaakov 70350, Israel byulman@beer-ness.health.gov.il

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Anne-Marie Ulman and Faina Bar

nately high in this population as compared to the general Israeli population (10, 11). Most who have written on the subject would agree that culture plays a central role in the construction of the clinical picture, blurring at times the boundary between idioms of distress and pathology.

Thus the issue of communication between medical practitioners, including psychiatrists, and patients coming from developing countries has become critical for those taking care of the Beta-Israel community. Studies have shown that many patients with psychiatric problems are not diagnosed as such in primary care clinics. Rather, it becomes manifested as a patient-doctor communication gap due to differences in cultural background and thus differences in the definition of illness and its expression (12) In a world of immigration and breakdown of social cultural barriers, it becomes increasingly difficult to draw the line between culturally normative behavior and psychopathology. The following case report underlines a further aspect of the importance of socio-cultural considerations in both staff and patients, and illustrates the dangers of misdiagnosis due to patient-therapeutic team cultural clash.

Case report Mrs. S, a 41-year-old woman of Ethiopian origin and mother of eight children (the last born six months prior to hospitalization) was brought to the psychiatric emergency room by a male social worker of Ethiopian origin. He diagnosed an “acute psychotic paranoid state,” with suspicion of schizophrenia. Symptoms included sleep disturbances, wandering behavior outdoors at night, ideas of reference as well as paranoid and bizarre delusions: she believed that her husband wanted to kill her based on the fact that he had brought home a bottle of wine in addition to recently buying her a gift of a purse. Mrs. S said that in the past her husband would never have done such a thing and that she sensed that the wine and the present had negative magical properties. The family was not known to social services as problematic and the social worker did not report on past marital conflict or violence. Furthermore, at the time, there was no concern as to the mother’s capacity to function as a parent. He did not report any changes in Mrs. S’s behavior that could indicate any possible post-partum psychopathology. As he emphasized, it was Mrs. S who turned to him asking for help.

Since the patient did not speak any Hebrew, the initial ward intake took place in front of all the staff with

the help of a translator. There was a striking contrast between the patient’s behavior, her answers and the socalled “psychotic content.” The patient explained that she would never leave her home while there was nobody there to watch the children, thus all her attempts at escape were made at night. Mrs. S at all times remained calm, answered in an organized way, was oriented with mood congruent responses and was able to cope with the frustration caused by the language barrier. She was offended that the help provided was labeling her as a “lunatic” as she believed her distress was caused by a deteriorating marital relationship. She was disappointed by the attitude of the social worker as she expected him to find a solution for the couple instead of sending her to the hospital. While we were trying to develop a discussion of her marital life, she seemed reluctant to speak and her answers became laconic. The only reference made to the so-called “psychotic thoughts” was when the team tried to mull over with her a solution to her marital conflict. Mrs. S was interested only in separation, her reason being her husband’s “death wish” toward her. When Mrs. S was further interviewed by the “white female” doctor who was assigned to treat her (once again with the help of a translator) she described her situation in more detail: she complained about a change in her husband’s behavior since the birth of their eighth child six months earlier. The husband’s lack of interest in her was obvious. He neglected to visit her in hospital and was absent when she was discharged from the obstetric ward. He did not provide for his family needs and proceeded to empty the family bank account without explanation. But she held on to the “psychotic” explanation as the reason why her husband wished for her death and tried to put her under a spell. The eldest daughter of Mrs. S was contacted and confirmed the patient’s complaints concerning the status of the marriage, the financial situation and the husband’s behavior at the time of the last childbirth.

The staff observing Mrs. S in the ward during the next few days noticed her well-adjusted behavior and the whole team agreed that there was no evidence indicating the existence of a psychotic state. Her ADL functioning was high compared to the rest of the ward. Her affect was congruent, behavior organized and appropriate, with no sign of agitation, hallucinatory behavior or signs indicating presence of paranoid thoughts or disorganized thoughts (as reported by Amharic speakers in the team). Though Mrs. S didn’t speak Hebrew she could relate to the staff and turn to Amharic speakers 61

Idiom of distress or delusional state? Cultural clash as the cause of misdiagnosis: A case report

when they were on duty. Her concern with the wellbeing of her children was the main issue discussed apart from her will to separate from her husband. The theme of witchcraft, the “paranoid core,” was not expressed unless she was specifically asked what her reasons for separation were.

The option that the whole situation resulted from a misunderstanding based on cultural differences seemed more and more appropriate. In order to further verify current clinical status, a female nurse of Ethiopian origin was consulted to further evaluate Mrs. S. This evaluation took place without the presence of any member of the staff that could represent the “Western medical” establishment orientation. The nurse was aware of the psychotic thoughts expressed by the patients in previous examinations. During this conversation, Mrs. S did not mention any magic spells or any of her husband’s homicidal intentions, but she did refer to many details regarding her prolonged marital problem (husband’s lack of responsibility toward the family, financial concerns, etc.). The nurse maintained that Mrs. S did not express any psychotic thoughts, and the only answer provided to explain the so-called psychotic content was her wish to divorce from her neglecting husband. Mrs. S explained her attempt at escaping the house as a way to express her wish to leave the area where she was living with her three youngest children and move closer to her oldest daughter. The Ethiopian origin nurse confirmed the team’s suggestion about the potential role that the cultural background could play.

Several attempts were made to contact the husband, urging him to contact the ward, all without success. The situation was reported to the social worker. Mrs. S’s reaction to her husband’s lack of cooperation was appropriate. She expressed deep disappointment concerning his neglect of the family and not paying attention to the fact she was hospitalized. However, she did not resort to any psychotic interpretation of his behavior. Furthermore, she did not understand his indifference as a confirmation of his criminal wishes but rather as an example of his lack of interest in the family wellbeing.

The eldest daughter was willing to receive Mrs. S with her youngest children and affirmed that there was room for her mother in the absorption center where she lived with her own family. After less than a week in the ward Mrs. S was sent for a trial in her new environment, with the agreement of the absorption center director who was made aware of the complex situation. The social worker was advised that the core-problem seemed to be 62

on the social/marital level and that treatment in an acute psychiatric ward was of no current benefit. It was also specified that Mrs. S was not interested in any further psychiatric intervention, but requested help with her marriage. It was suggested to the social worker to try and convince the couple to meet in a less stigmatizing environment than the hospital and have them treated by a family therapist in an ambulatory capacity.

Following a successful experience in the absorption center and no further reports of any pathological behavior, she was discharged after two weeks. Mrs. S did not receive medication of any kind during the hospitalization and there remained no indication to prescribe drug treatment at discharge. It should be noted that despite firm recommendations to maintain follow-up, the patient decided unilaterally that there was no need to any further treatment. Despite the team’s misgivings on this issue, this decision was respected.

Discussion It is now well known that the communication gap between doctors and immigrants is due not only to language barriers but also to differences in defining illness and to beliefs about health and illness. These factors contribute to difficult encounters between medical practitioners and members of the Ethiopian immigrant community. The Israeli medical system is heavily influenced by Western cultural assumptions. Western culture is based on concepts like mind-body duality and scientific objectivity, whereas in many non-Western cultures, illness is viewed and treated in an integrated way that involves the body, mind, spirit, community, family and cosmos (3, 12).

Furthermore, Ethiopian culture, similar to other cultures, provides a cognitive map characterizing the members of the community. It comprises a framework of orientation of values, knowledge, belief and verbal and non-verbal language facilitating processes of reciprocity, mutual aid and a feeling of security (13). Social representations are a social group’s common knowledge of language, images, ideas, values, attitudes, actions, orientations, norms and behaviors. Some beliefs might appear to an outsider (such as a clinician from a different cultural background) to be improbable while they are accepted within a specific cultural frame of reference. Henry Murphy, an early cultural psychiatrist, termed those beliefs “delusory cultural beliefs” (14). Studies show that social representations are quite stable and are constructed with a core and a periphery (15). The non-verbal transla-

Anne-Marie Ulman and Faina Bar

tion of intimate feelings represents one of the cultural norms of the Beta-Israel community (16).

The case of Mrs. S is of particular interest because it comes in contrast to the knowledge regarding expression of psychological distress among members of the Ethiopian immigrant community in Israel. Somatic complaints among members of the Beta-Israel often represent the bodily expression of an emotion. There was no translation of the emotional problem into physical problems: the clinical picture was not built with the traditional and now known somatic complaints that usually are the expression of psychological discomfort such as a feeling of burning in the chest and/or the stomach, headache and generalized unlocalized pain (17). In addition, her complaint did not take the form of a classic Zar possession which is the name given to a certain category of spirits responsible in Eastern Africa for many physical and mental diseases. Certain situations are seen as particularly attractive to the Zar, especially when related to social-psychological stressors (10, 11, 18). The Ethiopian immigrant community in Israel is in the midst of an integration process and is still considered by many other Israelis as a separate group.

It is clearly difficult to define normality in a community which is undergoing rapid change. With migration traditional patterns lose their significance, the old systems fail and new crises define fresh groups of vulnerable people. Standards of normality and abnormality change.

Behavior once accepted as desirable becomes unusual if not reprehensible. Individuals may be forced to use quite different standards of behavior at the same time resulting in a confusion of roles (19).

The possibility that Mrs. S suffered from post-partum pathology was soon eliminated. Her last delivery did not qualify as a traumatic experience due to the differences between the Israeli approach to the delivery process (mainly bio-medical) and the traditional Ethiopian childbirth practice as it was not her first delivery in Israel. Though delivering a baby in Israel was described as a lonely and isolating experience lacking personal control and modesty (in contrast to the traditional experience allowing a woman in labor to chose female family members and neighbors as her personal circle of support), Mrs. S, similar to other women of Ethiopian origin, have come to trust Israeli health care providers in the field of obstetrics based on experience (20).

Our attention was drawn to the striking contrast between the so-called “psychotic syndrome” and the behavior of the patient in the ward that did not match

a classic psychotic disorder diagnosis. We understood the difference of attitudes toward the social worker, the doctor and the nurse as dictated by socio-cultural factors. Psychotic thoughts as expressed by Mrs. S were understood as a mode of expressing a given psychological and existential state. Every idiom of distress is based on cultural symbols, but the way in which these symbols are employed on a given occasion may be idiosyncratic (21). The use of psychotic thoughts by members of the Ethiopian immigrant community is less frequent in a context of social-psychological distress, though in such a culture, it might be that an individual with predisposing personality traits would react to extreme stress by exhibiting an exaggeration of the culturally accepted response in form of a brief reactive psychosis (6). As hypothesized, the fact that the nurse was female and belonged to the same community assisted Mrs. S to talk with no reservations. Mrs. S might have been reluctant to talk openly of her marital problem to a male of Ethiopian origin despite him being a social worker just as she may have been suspicious of a white physician despite her being a female.

With an appropriate interlocutor, a female Ethiopian immigrant nurse, she did not need any codes and symbols. Furthermore, in this case, as noted by Murphy, distinction between delusions and culturally held belief cannot be made by belief content alone but rather due to the low intensity of belief (14).

This case underlines the potential dangers of the psychiatric diagnostic process in an immigrant community.

To use a diagnosis is to try to condense the vast amount of information we find out about someone. Picking a single label is felt to lead to a dehumanized and isolated conception of the individual with an inadequate picture of her feelings and experiences (19).

Additional factors accounting for the misdiagnosis of the Ethiopian immigrant social worker include his role not only as a translator, but also as a cultural mediator. Thus it could be that his life in Israel, his studies at the university and his integration process played a role in this case. Young people from the Ethiopian immigrant community in Israel lack grounding in traditional Ethiopian culture and might lack certain finesse characterizing his community of origin, while not yet rooted in the Israeli culture and familiarity with Western psychiatric jargon (17). It could be due to the fact that adopting the values of a new society involves discarding the old, as discarding “superstitions” enables the successful immigrant to measure his integration against his “primitive” compatriots. Mrs. S expressing herself with 63

Idiom of distress or delusional state? Cultural clash as the cause of misdiagnosis: A case report

such a traditional belief as the belief in witchcraft may have been a serious threat to his own efforts of integration (19). Furthermore, the possibility of him having a subconscious reluctance to preserve a certain frame of social codes, which are in contradiction with the dynamic of change his community and he personally may be experiencing, should not be dismissed.

The issue of the psychiatrist’s attitude to the minority patient is not less important. Are their backgrounds and education likely to make them particularly sympathetic to psychological difficulties in ethnic minorities? A psychiatrist’s attitude to the minority patient is known to be formed by his own personal issues, conscious or unconscious biased assumptions and the particular setting in which the two meet. Outsiders challenge our tendency to see our society as the natural milieu and ourselves as the measure of normality (19). It might be that the heterogeneity of the ward team (four to five different ethnic backgrounds) made possible the avoidance of an ethnocentric approach to Mrs. S case.

Observations from this case report emphasize the important role of socio-cultural background of both staff and patients in patient management and encourage the consideration of cultural factors in all patient evaluations.

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3. Reiff M, Zakut H, Weingarten MA. Illness and treatment perceptions of Ethiopian immigrants and their doctors in Israel. Am J Public Health 1999; 89: 1814-1818.

4. Arieli A, Aycheh S. Psychopathology in Ethiopian Jewish immigrants.

Harefuah. 1991; 121: 417-421 (Hebrew).

5. Arieli A, Aycheh S. Psychopathology among Jewish Ethiopian immigrants to Israel. J Nerv Ment Dis 1992; 180: 465-466.

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6. Grisaru N, Irwin M, Kaplan Z. Acute psychotic episodes as a reaction to severe trauma in a population of Ethiopian immigrants to Israel. Stress Health 2003; 19: 241-247.

7. Ratzoni G, Apter A, Blumensohn R, Tyano S. Psychopathology and management of hospitalized Ethiopian immigrant adolescents in Israel.

J Adolescence 1988; 11: 231-236.

8. Ratzoni G, Ben Amo I, Weizman T, Weizman R, Modai I, Apter, A. Psychiatric diagnoses in hospitalized adolescent and adult Ethiopian immigrants in Israel. Isr J Med Sci 1993; 29: 419-421.

9. Ben-Ezer G. Anorexia nervosa or an Ethiopian coping style? Mind Human Interaction 1990; 2: 36-39.

10. Witztum E, Grissaru N, Budowski D. The Zar possession syndrome among Ethiopian immigrants to Israel: Cultural and clinical aspects. Br J Med Psychol 1996; 69: 207-225.

11. Grissaru N, Budowski D, Witztum E. Possession by the “Zar” among Ethiopian immigrants to Israel: Psychopathology or culture-bound syndrome? Psychopathology 1997; 30: 223-233.

12. Youngmann R, Zilber N, Kaveh N, Zere M, Worknesh F, Bekele Y, Giel R. Development of a culturally sensitive psychiatric screening instrument for detecting emotional problems among Ethiopian immigrants in Israel. Harefuah 2002; 14: 10-16 (Hebrew).

13. Durst R, Minuchin-Itzigsohn S, Jabotinsky-Rubin K. “Brain Fag” syndrome: Manifestation of transculturation in an Ethiopian Jewish immigrant. Isr J Psychiatry Relat Sci 1993; 30: 223-232.

14. Murphy HBM. Cultural aspects of the delusion. Studium Generale 1967; 10: 684-692.

15. Levin-Rozalis M. Social representations as emerging from social structure: The case of the Ethiopian immigrants to Israel. Papers on Social Representations 2000; 9: 1.1-1.22.

16. Friedmann D, Santamaria U. Identity and change: The Falachas between assimilation in Ethiopia and integration in Israel. Arch Europ Sociol 1989; 30: 90-119 (French).

17. Youngmann R, Minuchin-Itzigson S, Barasch M. Manifestations of emotional distress among Ethiopian immigrants in Israel: Patient and clinician perspectives. Transcult Psychiatry 1999; 36: 45-63.

18. Kahana Y. The Zar spirits, a category of magic in the system of mental health in Ethiopia. Int J Soc Psychiatry 1985; 31: 125-143.

19. Littlewood R, Lipsedge M. Aliens and alienists, ethnic minorities and psychiatry. London and New York: Routledge, Third edition, 1999.

20. Granot M, Spitzer A, Arian K J, Ravid C, Tamir B, Noam R. Pregnancy and delivery practices and beliefs of Ethiopian immigrant women in Israel. Western J Nursing Res 1996; 18: 299-313.

21. Witztum E, Goodman Y. Narrative construction of distress and therapy: A model based on work with ultra-Orthodox Jews. Transcult Psychiatry 1999; 36: 403-436.

Isr J Psychiatry Relat Sci - Vol 48 - No.1Correspondence, (2011) Book Reviews and Correction

Correspondence Untreated psychosis is the main cause of major self-mutilation

W

e read with interest the recent article describing a series of four men who had amputated their own genitals (1). All four patients were diagnosed with psychotic illness and from the information provided it seems three of the patients had never been treated with antipsychotic medication and were therefore in the first episode psychosis. However, the discussion in the paper largely considered aspects of the patient’s early life and the concept of atonement for sexual guilt as the reasons for genital mutilation, and overlooked the role of the gross disturbance in reasoning ability associated with severe psychotic illness, especially never treated psychosis.

The attribution of causality to common developmental difficulties and psychological states can be a form of the logical error known by the Latin phrase “post hoc ergo propter hoc,” meaning that just because one event followed another it did not mean the first event caused the second. Drawing causal inferences from single cases histories and even small series carries the danger of propagating these false inferences, which is evident in the continued attribution of self inflicted eye injuries to the effects of an Oedipus complex, despite these events occurring in many parts of the world and being almost always associated with psychotic illness. We recently reviewed all the cases of ocular self-enucleation published in English since 1960 (2). Despite frequent references to the effect of an Oedipus complex, in no case did this appear to be particularly relevant to the actual patient, all of these patients were acutely psychotic with gross abnormalities of perception, belief and thought processes and many had not received treatment with antipsychotic medication.

In a second paper we reviewed all the cases of major self-mutilation, defined as the amputation of a limb above the hand or foot, the amputation of the penis, or the complete removal of an eye or a testicle, that had been published since 1960 (3). More than half the cases were of genital mutilation and three quarters were reported to have overt psychotic illness, usually with frightening delusional beliefs and bizarre explanations for their behaviour. Fewer than 20% were taking antipsychotic medication at the time of the event and in the cases where the treatment status was reported, 54% had never had antipsychotic medication. There were some case histories

documenting themes of religious guilt and a third made a reference to various religious texts, but many others did not. Most had come to see their organ as a threat to their lives or the lives of others and their motivation in removing the body part was to protect themselves or some other person, and in no cases could the patients’ actions be reasonably described as a wish for atonement.

Establishing causal links between factors in which an association has been identified has a long and chequered history in mental health research. In our second paper we considered possible explanations for major self-mutilation using Bradford-Hill’s guidelines for establishing causality in epidemiology (4). This examination demonstrated that psychosis, and in particular, never treated psychosis, can reasonably be considered to be a cause of major self-mutilation. We consider it to be highly unlikely that common historical factors, such as early adversity or a degree of sexual guilt are either sufficient or necessary causes of genital self-amputation.

References 1. Ozan E, Deveci E, Oral M, Yazici E, Kirpinar I. Male genital self-mutilation as a psychotic solution. Isr J Psychiatry Relat Sci 2010;47:297-303.

2. Large M, Andrews D, Babidge N, Hume F, Nielssen O. Self-inflicted eye injuries in first-episode and previously treated psychosis. Aust N Z J Psychiatry 2008;42:183-191.

3. Large M, Babidge N, Andrews D, Storey P, Nielssen O. Major selfmutilation in the first episode of psychosis. Schizophr Bull 2009;35:10121021. Epub 2008 May 20.

4. Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965;58:295–300.

1. Matthew M. Large, MBBS, FRANZCP, Conjoint Senior Lecturer,1 Psychiatrist2 2. Olav B. Nielssen, MBBS, FRANZCP, Conjoint Senior Lecturer,1 Psychiatrist3 3. Nicholas Babidge, MBBS, FRANZCP, Psychiatrist4 1 School of Psychiatry, University of New South Wales, Sydney NSW, Australia 2 Prince of Wales Hospital, Sydney NSW, Australia 3 Clinical Research Unit for Anxiety and Depression, St. Vincent’s Hospital, Sydney NSW, Australia 4 Mental Health Service, Sutherland Hospital, NSW, Australia

Authors’ reply: Why we need to formulate the meaning of religious delusions?

Dear Editor, e would like to thank Large et al. for putting emphasis on psychosis as a primary cause for major self-

W

65

Correspondence, Book Reviews and Correction

mutilation. As we indicated in our paper (1), all four patients mentioned were in active psychotic states when they performed genital self-mutilation (GSM) and they were primarily treated with psychotropics. Our intention in this paper was not to suggest that common developmental difficulties and psychological states are a major cause of self-mutilation but rather discuss the association between the patients’ premorbid experiences and their delusions, since, as suggested, secondary delusions are influenced by a person’s background such as ethnic or sexual orientation, religious beliefs as well as superstitious beliefs (2). During the formulation process, we thought that it would be helpful to include the proposed minor risk factors (3) that might have contributed to the act of GSM, since a comprehensive approach is suggested within the multi-axial diagnostic system in the formulation of patients with any mental disorder. Since we reported on four cases, we had a chance to obtain detailed information about their history and discuss how the patients’ minds work. As a result, this approach helped us to have a better understanding of the patients in an attempt to establish further therapeutic alliance and develop targets to work on during remission. A growing body of evidence supports the use of cognitive behavior therapy for the treatment of schizophrenia. In a recent review by Turkington et al.

(4), it is indicated that establishing a therapeutic alliance based on the patient’s perspective, developing alternative explanations of schizophrenia symptoms, reducing the impact of positive and negative symptoms, and offering alternatives to the medical model to address medication adherence are key stages of cognitive behavior therapy for psychosis. On the other hand, reviews that discuss major self-mutilation may have difficulties in getting into details as far as the case histories are concerned due to their large-scale nature. Thus, making a reductive conclusion by focusing only on the diagnoses may become inevitable for these kinds of large-scale reviews.

As for the comments regarding the concept of atonement, two of our patients repeatedly verbalized delusions of sin and guilt and that they were in a continuous search for atonement to banish their perceived sins and feelings of guilt. This observation inspired us to gain a new perspective in formulating religiously themed psychotic male GSM. References 1. Ozan E, Deveci E, Oral M, Yazıcı E, Kırpınar İ. Male genital self-mutilation as a psychotic solution. Isr J Psychiatry Relat Sci 2010; 47: 297-303.

2. Jaspers, Karl. General Psychopathology - Volumes 1 & 2; translated by

66

J. Hoenig and Marian W. Hamilton. Baltimore and London: Johns Hopkins University Press, 1997; ISBN 0-8018-5775-9.

3. Siddiquee RA, Deshpande S: A case of genital self-mutilation in a patient with psychosis. German J Psychiatry 2007; 10: 25-28.

4. Turkington D, Kingdon D, Weiden PJ. Cognitive behavior therapy for schizophrenia. Am J Psychiatry 2006; 163: 365-373. Review.

Erol Ozan, Meltem Oral, Erdem Deveci, İsmet Kırpınar Atatürk University, School of Medicine, Department of Psychiatry, Erzurum, Turkey erolozan@gmail.com

Book reviews Spiritually Integrated Psychotherapy

by Kenneth I. Pargament, Guilford Press, xiv + 374 pages, 2007

K

enneth Pargament has been researching religion and its impact on mental health for many years. Judging from his allusion in the introduction to his mother, who "loved nothing better than to ’kvell’ on the accomplishments of her children," Pargament is Jewish, but the book is not written from the vantage point of any specific religion. It is not only written by a single author with the consistency of style this brings, but, for a textbook, it has two other major advantages: it is very personal, including details of his own life, with colorful clinical vignettes throughout, and it is completely jargon-free.

His first point is that patients have spiritual lives that are very important to them. Since many therapists do not share these values, many patients learn not to talk about these important aspects of themselves. The book is full of clinical gems: “I want to stress that spiritually integrated therapy is not grounded in religious authority or legitimacy. Unlike the pastoral counselor, the therapist cannot claim to offer absolute truth or to deliver the rituals and sacraments of a religious tradition” (p.19). True to current terminology, the book is about spirituality rather than religion, and therefore he seeks the aspects that unite all members of religions and many other people: spirituality, which he defines as “a search for the sacred.” In discussing what is sacred, he brings an impressive range of sources, while adding that for many people the sacred is not necessarily associated with formal religion. He then discusses what is involved in such searching and its effects on people.

The positive impact of the many aspects of spirituality has been well researched: a positive association has been found with well-being, optimism, meaning in life,

Correspondence, Book Reviews and Correction

self-esteem, a sense of social support, less depression, anxiety and psychosis, lower rates of suicide, alcohol and drug abuse, less delinquency and greater marital stability (p. 90). Nevertheless, the search for the sacred is not an easy path. At times of crisis, people may look to their spiritual sources (termed here “spiritual coping”), but may also find them challenged, times when previous values do not help, and there is a need for change, times of spiritual struggle. Change, however, can be for the better or otherwise, and along the negative way may be what Pargament calls: small gods, false gods, self-degradation or demonization of the self or others. (A gem on small gods that I responded to particularly: “One of the oddest things about religious education is that it often ends just when it should be beginning. For many adolescents, religious confirmation signals the culmination of formal religious education. And yet adolescence is the time when young adults are able to replace child-like conceptions of divinity and the sacred with more sophisticated spiritual understandings that are better suited to the complexities of adult life” (pp.137-138).

Pargament’s approach is ever very orderly and compartmentalized while never loosing his thread, so that the problems that can arise on the spiritual path are divided into problems of breadth and depth, problems of fit, including extremism and hypocrisy, and problems of continuity and change. In this section, he quotes a 2007 book by Brenner on interfaith marriages, warning about attempts by Jewish and Christian spouses to bring up a “Chewish” child: “the only way you can have a dual religion is to cut the heart out of both.”

The second half of the book is devoted to psychotherapy. In discussing orientation, he is honest at the outset that spiritual problems can cause psychological problems, and vice versa, and that spirituality can help find solutions but may also be a hindrance. Therapists, like patients, do not leave their spirituality outside the office, although those antagonistic to spirituality clearly have to examine their position and its impact on their clinical work – and the same applies to the therapist who mistakes common religious identity for shared spiritual interests. In Pargament’s approach, therapists require knowledge about spirituality “that transcends any particular set of spiritual teachings, beliefs, and practices” (p.190), tolerance, self-awareness and authenticity.

During the process of assessment, he recommends the following questions: Do you see yourself as a religious or spiritual person?

If so, in what way?

Are you affiliated with a religious or spiritual denomination or community? If so, which one?

Has your problem affected you religiously or spiritually? If so, in what way?

Has your religion or spirituality been involved in the way you have coped in your problem? If so, in what way? (p.211) Despite years of working with religious patients, I found these questions quite searching. Do I always know the answers to these questions? Would they not help me and give a great sense of relief to many that I interview? To an extent the issue is made more complicated in the meetings of Jewish religious patients and therapists, as the external signs of religiosity may suggest erroneous answers to these questions.

If the answers to these questions suggest the importance of spirituality to a client, Pargament prescribes explicit spiritual assessment. While presenting ways of helping patients draw on their spiritual resources, he comments that it is important to work within one’s own professional and personal boundaries: we are therapists and not clergy, and can only discuss spiritual issues as a mental health professional. He continues: “though I encourage many of my patients to pray, I do not pray together with my clients in therapy – not because I believe prayer has no place in counseling, but because one-to-one prayer is not a part of my own religious tradition and background” (p. 245). One must understand that Pargament’s suggestions proceed from a detailed understanding of the role of prayer for each particular client, but is it the role of the therapist to encourage prayer, and even to join in prayer with the client? Is a boundary being crossed? I was sorry this moment was not discussed in more detail.

When dealing with the problems of spiritual pathways, and specifically inflexibility if the patient thinks they are betraying their religious beliefs, “therapists should be able to call on clergy from a variety of religious traditions who value psychotherapy and are willing to collaborate in treatment, by reassuring clients that psychotherapy is not antithetical to religious commitment” (p. 301). In the ultra-orthodox Jewish context, this is less under the control of the therapist than a therapist might wish, as patients have their own rabbis and we cannot impose those whom we know to be sympathetic. However, he then quotes Ano who recommends while working with Christian patients that they be encouraged “to seek out respected leaders and teachers for their opinions” (p. 301).

In the concluding section he presents the manualized spiritually integrated psychotherapies that have 67

Correspondence, Book Reviews and Correction

emerged in the last years and evaluates the studies of their effectiveness to date, a task to which he is suited, being that rare combination of committed therapist and developer and researcher of such methods.

I found this book a very enriching experience. The style is accessible, warm and personal, full of the wisdom of years as a therapist. The literature on spirituality in general and on psychotherapy specifically is exhaustive and quoted up to 2007. Considering his background

in U.S. culture, the applicability of his observations to the work of religious Jewish therapists is remarkable, a statement about his ability to analyze into components what most perform without such contemplation. Most important of all, for many mental health therapists it is a wake-up call to the centrality of spirituality in the lives of most people, among them most of our clients.

David Greenberg, Jerusalem

Correction and apology: On page 306 of Predictors of Cumulative Length of Psychiatric Inpatient Stay over one year: A National Case Register Study, by Yaacov Lerner and Nelly Zilber, in volume 47, 2010, in error the numbers on Figure 1 were omitted. The corrected version appears below. Our apologies to our readers and the authors.

Figure 1: Survival Function of Cumulative Length of Stay in Hospital (Cumulative LOS) Cumulative Proportion of Patients*

1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 00

0

25

75

100 125

125 150

175

200 225 250 275 300 325 350 375

Cumulative Time in Hospital (Days) * Proportion of patients for whom the cumulative length of stay in hospital is greater than the corresponding x.

68

‫סיכום ישיבת ועד האיגוד הפסיכיאטרי ‪-‬‬ ‫ינואר ‪2011‬‬ ‫‪ .1‬גובשה עמדת האיגוד לגבי מיקום הפסיכותרפיה בעיסוק‬ ‫הפסיכיאטרי‪ .‬עמדה המעוגנת בקוריקולום ההתמחות ובבחינה‬ ‫על גוף הידע הנדרש בסיומה‪.‬‬ ‫‪ .2‬עמדת האיגוד לכשירות הפסיכיאטרים המומחים להערכת‬ ‫מסוכנות לעברייני מין‪ ,‬על כי אין צורך בכל הכשרות או‬ ‫התנסויות נוספות‪ .‬תועבר פניה מתאימה ללשכה המשפטית‬ ‫בהר"י‪ ,‬לבקשת שינוי התקנות במשרד הבריאות‪ ,‬לקבלת‬ ‫הכשירות להערכת המסוכנות‪.‬‬

‫‏‪ 16‬בינואר ‪2011‬‬

‫‪ .5‬ועדת סל התרופות של האיגוד מבקשת מר' שרותי ברה"נ‬ ‫במשרד הבריאות לדאוג להשתתפות נציג מתחום הפסיכיאטריה‬ ‫בוועדה העליונה בוועדת סל התרופות לשנים הבאות‪ .‬זאת‬ ‫על רקע התוצאות העגומות של אי־אישור חברי הוועדה את‬ ‫ההמלצות לתרופות פסיכיאטריות בסל לשנת ‪.2010‬‬ ‫‪ .6‬הוועדה הפרסונלית של האיגוד תמשיך את פעילותה‬ ‫מול משרד המשפטים לאישור מתן חוו"ד נגד המדינה על ידי‬ ‫הפסיכיאטרים עובדי המדינה‪.‬‬

‫‪ .3‬גובש טופס כתב ההסכמה מדעת לטיפול בנזעי חשמל מטעם‬ ‫האיגוד‪ .‬הומלץ להפעיל יחידת ‪ ECT‬בכל מוסד העוסק בתחום‪.‬‬ ‫הוועדה לארגון הטיפולים הנוירופיזיולוגיים בפסיכיאטריה‬ ‫תגבש את הצעתה לגבי כלל הטיפולים ומתכונתם‪.‬‬ ‫‪ .4‬הוועדה המדעית לכנס התלת־שנתי תביא לאישור הוועד את‬ ‫הצעתה לנושא המרכזי לכנס‪.‬‬

‫ ‬ ‫ ‬

‫פרופ' זאב קפלן‬ ‫יו"ר‬

‫איגוד הפסיכיאטריה בישראל‬ ‫ההסתדרות הרפואית ‪ -‬המועצה המדעית‬

‫‪Israeli Psychiatric Association‬‬

‫יו"ר‪ :‬פרופ' זאב קפלן ‪President: Prof. Z. Kaplan /‬‬ ‫‪Zeev.kaplan@pbsh.health.gov.il‬‬ ‫מזכיר‪ :‬ד"ר נמרוד גריסרו ‪Secretary: Dr. N. Grisaru /‬‬ ‫‪grisarun@gmail.com‬‬ ‫גזבר‪ :‬ד"ר בוריס נמץ ‪Treasurer: Dr. B. Nemets /‬‬ ‫‪nemetz@bgu.ac.il‬‬ ‫יו"ר נבחר‪ :‬פרופ' משה קוטלר ‪Elected President: Prof. M. Kotler /‬‬ ‫‪Moshe.kotler@beerness.health.gov.il‬‬

‫יו"ר יוצא ואחראי קשרי חו"ל‪ :‬פרופ' אבי בלייך ‪/‬‬ ‫‪President Emeritus and Foreign Affairs: Prof. A. Bleich‬‬ ‫‪lean@bgu.ac.il‬‬

‫ ‬

‫‪ableich@lev-hasharon.co.il‬‬

‫‪69‬‬

‫המרכז לבריאות הנפש באר שבע‬ ‫‪Beer-Sheva Mental Health Center‬‬

‫ טל'‪ ;08-6401606 :‬פקס‪08-6401621 :‬‬ ‫ רח' הצדיק מירושלים ‪ ,2‬באר שבע‪ ,‬ת"ד ‪ 4600‬‬ ‫ ‪Hazadik from Jerusalem St. P.O. Box 4600‬‬ ‫ ‪www.psychiatry.org.il‬‬

‫ומדדי הדחק‪ .‬החוקרים מצאו מתאם מובהק בין הציון בסולם‬ ‫פיטסברג והגיל של הנבדקים וציוני ‪.state anxiety‬‬ ‫מסקנות‪ :‬בעוד הגיל‪ ,‬ציון הדיכאון על פי בק‪ ,‬מדדי החרדה‬ ‫בסולם שפילברגר (מצב ותכונה)‪ ,‬החינוך והדחק בשנה האחרונה‬ ‫נחשבים כגורמים שמשפיעים על איכות השינה‪ ,‬נראה שרק הגיל‬ ‫והחרדה המצבית מנבאים בצורה הטובה ביותר את הציון בסולם‬ ‫פיטסברג לאיכות השינה‪.‬‬ ‫שפת מצוקה או מצב דלוזיונלי? הבנה תרבותית‬ ‫שגויה כסיבה לאבחנה מוטעת‪ :‬תיאור מקרה‬ ‫א"מ אולמן‪ ,‬פ' בר‪ ,‬באר יעקב‬

‫קהילת "בטא–ישראל" (בית ישראל) מונה יותר מ–‪ 100,000‬נפשות‪.‬‬ ‫תרבות יהודי אתיופיה מבוססת על מודל תרבותי שבטי‪ .‬הגעתם‬ ‫לארץ לוותה בקשיים רבים‪ .‬בני העדה האתיופית נאלצו להתמודד‬ ‫עם סוגיות במישור התרבותי שהעמידו את מסורתם במבחן‪ .‬נמצא‬

‫שטראומת המסע בשילוב עם קשיי תהליך הקליטה לתוך החברה‬ ‫הישראלית‪ ,‬דהיינו ה"הלם התרבותי"‪ ,‬אחראים באופן ישיר להופעת‬ ‫פתולוגיה נפשית בקרב הקהילה האתיופית‪ .‬כמו כן‪ ,‬נמצא שלתרבות‬ ‫תפקיד מרכזי בבנייה של התמונה הקלינית‪ ,‬תוך כדי טשטוש הגבולות‬ ‫בין ביטויי מצוקה ופתולוגיה‪ .‬כתוצאה מכך נוצר קושי רב להבדיל‬ ‫בין התנהגויות נורמטיביות מבחינה תרבותית ופסיכופתולוגיה‪.‬‬ ‫תיאור המקרה מדגיש את חשיבותו של הרקע החברתי–תרבותי הן‬ ‫בקרב הצוות והן בקרב המטופלים‪ ,‬ומדגים את הסכנות הקשורות‬ ‫להפרעות במפגש ובתקשורת הבין–תרבותיים בעת מתן אבחנה‪.‬‬ ‫אישה בת ‪ 41‬ממוצא אתיופי אושפזה עקב חשד לסכיזופרניה‪ .‬בשל‬ ‫הפער הניכר בין התנהגותה של המטופלת ותשובותיה לבין התוכן‬ ‫ה"פסיכוטי" לכאורה‪ ,‬הועלתה על ידי הצוות האפשרות שהמצב‬ ‫נובע מאי–הבנה על רקע של הבדלים תרבותיים‪ .‬מקרה זה מבליט‬ ‫את הסכנות הטמונות בתהליך האבחנתי‪ ,‬מדגיש את חשיבות‬ ‫הרקע החברתי–תרבותי של כל המעורבים (צוות ומטופל) ומעודד‬ ‫התייחסות למרכיב התרבותי במהלך הערכת המטופלים ואבחנתם‪.‬‬

‫‪70‬‬

‫מתואר מקרה של סירוס־עצמי אצל רווק‪ ,‬עובד שאובחן כסובל‬ ‫מסכיזופרניה פראנואידית‪ .‬הוא סרס את עצמו בתקופה שלא היו לו‬ ‫כל סימפטומים פסיכוטיים‪ .‬יתכן שלא שמו לב מספיק לאבחנה של‬ ‫דיכאון או שפיתח דיכאון פוסט־פסיכוטי‪ .‬יתכן שהסיכון למעשה‬ ‫כזה גובר כשאין למטופל כבר סימפטומים ויש לו כבר תובנה‪.‬‬ ‫אחרי שנידונה סקירת הספרות‪ ,‬נראה למחברים שהמקרה מתאים‬ ‫לאבחנה של תסמונת קלינגסור‪.‬‬

‫פסיכיאטרית לאורך תקופה של שישה חודשים (ינואר עד יוני‬ ‫‪ .)2004‬עבור חולים אלו נעשה מעקב עד ‪ 30‬בנובמבר ‪ 2005‬מאז‬ ‫השחרור הראשון בתקופת המדגם‪ .‬רגרסיה מסוג ‪ Cox‬אפשרה‬ ‫לבנות מודל רב–משתנים לניבוי חזרה לאשפוז תוך ‪ 30‬יום‬ ‫מהשחרור‪.‬‬ ‫תוצאות‪ :‬אחוז החזרות תוך ‪ 30‬יום היה ‪ .13%‬המשתנים שניבאו‬ ‫חזרה לאשפוז תוך פרק זמן קצר היו‪ :‬גיל עד ‪ ,45‬קיום אשפוז‬ ‫פסיכיאטרי בעבר‪ ,‬פרק זמן קצר בין האשפוז הפסיכיאטרי‬ ‫האחרון לאשפוז הפסיכיאטרי הקודם לו‪ ,‬משך אשפוז קצר מאוד‬ ‫(עד ‪ 8‬ימים)‪ ,‬שחרור מאשפוז פסיכיאטרי במחוז תל אביב–מרכז‪.‬‬ ‫מסקנות‪ :‬קיצור משך האשפוזים כמדיניות‪ ,‬שעלול להביא‬ ‫לשחרור מוקדם מדי‪ ,‬לא נמצא קשור לחזרה לאשפוז תוך פרק‬ ‫זמן קצר‪ ,‬פרט לאותם משכי האשפוז הקצרים באופן מיוחד‪.‬‬

‫נ' שיינברג‪ ,‬מ' אליוט וילסון‪ ,‬ת' בוצ'יין‪ ,‬א' ווטרס‪ ,‬ירושלים‬

‫שינויים בהתעניינות סטודנטים לרפואה‬ ‫בפסיכיאטריה באוניברסיטת בלגרד‪ ,‬סרביה‬

‫תסמונת קלינגסור‪ :‬בזמן שכבר אין פסיכוזה‬ ‫ר‪ .‬בטצ'וריה‪ ,‬ד‪ .‬סניל‪ ,‬ק‪ .‬רוי‪ ,‬קולקטה‪ ,‬הודו‬

‫אימהות לילדים הסובלים ממחלת הקוליטיס‪:‬‬ ‫מחקר מבוקר של מיון סגנונות התקשרות‬ ‫מבוגרים ודפוסים פסיכופתולוגיים‬

‫אנו חוקרים קורלציה בין התקשרות הורית ופרופיל פסיכולוגי‬ ‫הורי לבין ביטוין של ‪ 3‬מחלות שונות אצל ילדים‪ :‬קוליטיס (מחלת‬ ‫מעי)‪ ,‬סרטן ומחלת כליה‪ .‬הילדים החולים בסרטן ובמחלת כליה היו‬ ‫קבוצות השוואה‪ ,‬תוך שימוש במדידות רפואיות ובשאלונים להורים‪,‬‬ ‫התקפים להשוואה בקטגוריות דיאגנוסטיות בין מחלות כרוניות‪.‬‬ ‫מצאנו תמיכה הורית חלשה יותר בקרב ילדים הסובלים מקוליטיס‪,‬‬ ‫כאשר השווינו יחסים סטטיסטיים בין הסתגלות רפואית של‬ ‫הילד‪ ,‬התקשרות הורית ופרופיל פסיכופתולוגי‪ .‬נמצא שיעור גבוה‬ ‫יותר של התקשרות לא בטוחה בקרב אמהות לילדים עם קוליטיס;‬ ‫אמהות אלה הראו יותר סימפטומים פסיכיאטריים‪ .‬התוצאות‬ ‫מדגישות‪ )1 :‬צורך בתמיכה במערכת היחסים הורה–ילד; ‪ )2‬רווחה;‬ ‫‪ )3‬קיום אפשרי של משקע המפעיל ויסות גן התוקף במחלת‬ ‫הקוליטיס ותורם למהלכה ולהחרפתה של המחלה‪.‬‬ ‫אנו מציעים מודל תיאורטי המערב ‪ 4‬גורמים בתהליך אקטיבציה‬ ‫של גן במחלת הקוליטיס‪ .‬על מחקר מקדמי זה לעודד עריכת‬ ‫מחקרים ארוכי טווח על התקשרות במצב של מחלה כרונית‪,‬‬ ‫בעיקר בהקשר למחלת הקוליטיס‪.‬‬ ‫מנבאים ל"אשפוז פסיכיאטרי חוזר" תוך פרק‬ ‫זמן קצר‪ ,‬על פי נתונים ארציים מהקובץ‬ ‫הפסיכיאטרי הלאומי‬ ‫נ' זילבר‪ ,‬צ' הורניק־לוריא‪ ,‬י' לרנר‪ ,‬ירושלים‬

‫רקע‪ :‬מחקרים קודמים הצביעו על ממצאים סותרים באשר‬ ‫למשתנים המשפיעים על ההסתברות לאשפוז פסיכיאטרי חוזר‪,‬‬ ‫במיוחד באשר להשפעת משך האשפוז האחרון‪ .‬מטרת המחקר‬ ‫הנוכחי לפתח מודל המנבא חזרה לאשפוז תוך ‪ 30‬יום לאחר‬ ‫השחרור‪ ,‬היות שמדד זה הוא אחד המדדים שנבחרו לבחינת טיב‬ ‫הביצוע ברפורמה הפסיכיאטרית בישראל‪.‬‬ ‫שיטה‪ :‬הנתונים נשלפו מהקובץ הפסיכיאטרי הלאומי הישראלי‪.‬‬ ‫במדגם נכללו כל החולים ששוחררו ממסגרת אשפוזית‬ ‫‪71‬‬

‫נ' מאריק‪ ,‬ד' סטויליקוביץ'‪ ,‬ב' מילקיץ'‪ ,‬מ' מילנו‪ ,‬ג' בייליק‪,‬‬ ‫מ' יאסוביק־גאסיץ'‪ ,‬בלגרד‪ ,‬סרביה‬

‫המחקר בוחן כיצד סטודנטים לרפואה משנים את גישתם‬ ‫והתעניינותם בבחירת פסיכיאטריה כתחום התמחות מועדף לאורך‬ ‫שנות לימודי הרפואה‪ .‬סטודנטים לרפואה בשנה שנייה ובשנה‬ ‫חמישית השתתפו במחקר‪ ,‬שבמהלכו הועבר שאלון המעריך את‬ ‫עמדתם והתעניינותם בפסיכיאטריה בהשוואה לתחומי התמחות‬ ‫אחרים ברפואה‪ .‬מהשוואה הנתונים עולה כי הסטודנטים בשנה‬ ‫חמישית הראו פחות התעניינות בפסיכיאטריה בהשוואה‬ ‫לעמיתיהם הצעירים‪ ,‬תלמידי השנה השנייה‪ .‬נתונים אלו לא נמצאו‬ ‫מושפעים ממשתנים סוציו–אקונומיים‪ .‬המחקר מלמד כי במהלך‬ ‫לימודי הרפואה בבית הספר לרפואה בבלגרד‪ ,‬סרביה‪ ,‬קיימת עלייה‬ ‫בנטייה השלילית של הסטודנטים לפסיכיאטריה במהלך הלימודים‪.‬‬ ‫תחלואה כפולה של אינסומניה על פי סולם‬ ‫פיטסברג לאיכות השינה עם דחק‪ ,‬חרדה‪,‬‬ ‫דיכאון והפרעות אישיות‬ ‫ה' אטאלאי‪ ,‬איסטנבול‪ ,‬טורקיה‬

‫רקע‪ :‬הופעה של אינסומניה בשילוב עם דיכאון וחרדה‪ ,‬ואף‬ ‫עם הפרעות אישיות מסוימות‪ ,‬דווחה בספרות הפסיכיאטרית‬ ‫בהרחבה‪ ,‬אך מעטים המחקרים שבדקו את ההופעה של כל‬ ‫ההפרעות הנ"ל יחדיו‪.‬‬ ‫שיטות‪ 265 :‬מטופלים רואיינו ו–‪ 212‬מהם מילאו את סולם‬ ‫פיטסברג לאיכות השינה‪ .‬עוד נעשה שימוש בשאלון להערכת‬ ‫דיכאון על שם בק‪ ,‬בשאלון שפילברגר לחרדה‪ ,‬בסולם אירועי‬ ‫דחק פסיכו–סוציאליים של ה–‪ DSM-III-R‬ובשאלון ‪SCID-II‬‬ ‫להערכת הפרעות אישיות‪.‬‬ ‫תוצאות‪ :‬לא נמצאו מתאמים בין התוצאה בסולם אינסומניה‬ ‫והמין‪ ,‬המצב המשפחתי‪ ,‬החינוך‪ ,‬הדיכאון‪ ,‬ציון ה–‪trait anxiety‬‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫שימוש בנזעי חשמל בזמן היריון‪ :‬סקירה‬ ‫ע' סאטסיוגלו‪ ,‬נ"ב טומרוק‪ ,‬איסטנבול‪ ,‬טורקיה‬

‫טיפול בהפרעות פסיכיאטריות בזמן היריון מציב אתגר‪ .‬הן‬ ‫תרופות והן מחלות אמהיות עלולות להשפיע לרעה על העובר‪,‬‬ ‫ועל כן איזון בין סכנות הטיפול והתועלת המופקת ממנו הינו‬ ‫הכרחי‪ .‬תרופות מסוימיות עשויות להשפיע לרעה על העובר‪,‬‬ ‫במיוחד בשליש הראשון של ההיריון‪ .‬לטיפול בנזעי חשמל (‪)ECT‬‬ ‫לא ידועות תופעות לוואי העלולות לסכן את העובר‪ ,‬ועל כן טיפול‬ ‫זה עשוי להיות מועדף‪ .‬סקירת הספרות הקיימת‪ ,‬לצד ניסיוננו‬ ‫הקליני‪ ,‬מבהירים את תפקידו של הטיפול בנזעי חשמל‪ ,‬העשוי‬ ‫להיות עדיף במקרים מסוימים על טיפול תרופתי בזמן היריון‪.‬‬ ‫גלטופוביה בישראל‪ :‬אומדן רמת‬ ‫החשש "שיצחקו עליך"‬ ‫א' שריד‪ ,‬ו' רוש‪ ,‬ר"ט פויר‪ ,‬באר שבע‬

‫גלטופוביה מוגדרת כחשש או פחד של היחיד פן יצחקו עליו‪.‬‬ ‫מחקרים אמפיריים קודמים הראו כי המושג גלטופוביה הינו‬ ‫תקף וראוי לבחנו במחקרים נוספים‪ .‬יתרה מזאת‪ ,‬המשגת‬ ‫הגלטופוביה עשויה לתרום בזיהוי קבוצות שאמנם אינן בעלות‬ ‫תסמינים קליניים‪ ,‬אולם ניתן לזהות בהן טווח של תגובות‬ ‫גלטופוביות‪ ,‬החל בחשש קל וכלה בפחד רב של היחיד פן יושם‬ ‫לצחוק ולקלס‪ .‬המחקר הנוכחי מציג נתונים אמפיריים על החשש‬ ‫מפני צחוקם של אחרים‪ 220 .‬משתתפים השיבו על שאלון‬ ‫שתורגם לעברית ומטרתו לאמוד חשש מפני צחוקם של אחרים‪.‬‬ ‫עם תרגומו‪ ,‬נבדקה רמת המהימנות הפנימית של היגדי השאלון‬ ‫ונמצאה גבוהה (‪ .)α=0.89‬הגרסה העברית של השאלון משתמשת‬ ‫ב–‪ 15‬היגדים הניתנים לתיאור במשתנה אחד‪ ,‬שהינו החשש‬ ‫מפני צחוקם של אחרים‪ .‬בבדיקת מידת ההסכמה של הנחקרים‬ ‫להיגדים השונים‪ ,‬נמצאה תמיכה מרבית להיגדים האומדים את‬ ‫המידה שבה היחיד נמנע ממקומות שבהם הוא סבור כי התנהג‬ ‫באופן מביך‪ .‬מהממצאים עולה כי גלטופוביה שכיחה יותר‬ ‫בקרב נחקרים צעירים‪ ,‬בודדים ובקרב נשים‪ .‬כ–‪ 6%‬נמצאו מעל‬ ‫לנקודת חתך המהווה סמן להיותו של היחיד בעל תסמינים קלים‬ ‫של גלטופוביה‪ .‬הדיון מתייחס ליישומו של השאלון במחקרים‬ ‫נוספים ובתחום הקליני‪ .‬אם יאוששו במחקרים נוספים‪ ,‬ממצאים‬ ‫אלה יתרמו להבנתה של הגלטופוביה בהקשר של חרדה חברתית‬ ‫ופוביות דומות‪.‬‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,48‬מס' ‪2011 ,1‬‬

‫השתנות קצב הלב בזמן ביצוע מבחן קשב‬ ‫מתמשך בילדים עם קשיי קשב וריכוז‬ ‫ז' אייזנברג‪ ,‬ר' ריצמן‪ ,‬ירושלים‬

‫רקע‪ :‬ילדים אשר סובלים מהתנהגות אימפולסיבית ומקשיי‬ ‫ויסות מראים גם פעילות פאראסימפטתית נמוכה‪ .‬לעומת זאת‪,‬‬ ‫בזמן הקשבה לגירוי חדש פעילות המערכת הפאראסימפאטתית‬ ‫מתגברת‪.‬‬ ‫מטרה‪ :‬לבדוק אם השתנות קצב הלב (‪)heart rate variability‬‬ ‫(הק"ל) אשר משקפת את הפעילות הפאראסימפטתית הינה‬ ‫מתווכת של קשב‪.‬‬ ‫שיטה‪ :‬נבדק אק"ג ב–‪ 77‬ילדים בעת שביצעו מבחן של קשב ממושך‬ ‫(‪ .)TOVA‬הילדים חולקו ל–‪ 2‬קבוצות על פי ביצועיהם במבחן‬ ‫והושוו נתוני ההק"ל בין הקבוצות‪ .‬כמו כן נבדק המִתאם בין‬ ‫הביצוע במבחן ‪ TOVA‬ובין הק"ל ב–‪ 4‬זמנים שונים של המבחן‪.‬‬ ‫תוצאות‪ :‬לא נמצא מתאם יחידני בין ביצועי הקשב וההק"ל‪.‬‬ ‫נמצא הבדל משמעותי בהק"ל בין שתי הקבוצות‪ :‬המבצעים‬ ‫הטובים אופיינו בפעילות פאראסימפטתית גבוהה יותר‬ ‫בהשוואה למבצעים הפחות טובים‪.‬‬ ‫מסקנה‪ :‬המערכת הפאראסימפטתית‪ ,‬כפי שמשתקפת בהשתנות‬ ‫קצב הלב‪ ,‬אינה מתווכת של קשב‪ .‬עם זאת‪ ,‬ייתכן שהיא מסמנת‬ ‫יכולת טובה לוויסות עצמי‪.‬‬ ‫הפרעות ויזואליות (פלשבקים) שפירות‬ ‫ומוגבלות בזמן בקרב מעשני קנביס‬ ‫בריכוז גבוה אשר הפסיקו לעשן‬ ‫לאחרונה‪ :‬סדרת הצגת מקרים‬ ‫א' לרנר‪ ,‬ק' גודמן‪ ,‬ד' רודינסקי‪ ,‬א' בלייך‪ ,‬לב השרון‬

‫‪ 8‬מעשני קנביס בריכוז גבוה אשר עונים לקריטריונים של‬ ‫‪ DSM-IV‬לתלּות בקנביס בליווי הפרעות תפיסתיות וללא‬ ‫שימוש קודם באל–אס–די‪ ,‬חיפשו טיפול אמבולטורי לגמילה‪.‬‬ ‫כולם דיווחו על הפרעות ויזואליות לאחר הפסקת השימוש בסם‪.‬‬ ‫‪ 7‬קטגוריות של עיוותים הופיעו כאשר הביטו בחפצים נייחים‬ ‫וניידים‪ .‬חולים דווחו על ‪ 5-2‬קטגוריות שונות של פלשבקים עד‬ ‫לתקופה של ‪ 6-3‬חודשים לאחר הפסקת השימוש בקנביס‪ .‬ניתן‬ ‫לפרש את התופעה כמוגבלת בזמן או כתופעת לוואי שפירה של‬ ‫קנביס בריכוז גבוה בקרב אנשים מסוימים‪ .‬ככל הנראה‪ ,‬שילוב של‬ ‫פגיעות ושימוש בקנביס בריכוז גבוה תרם להופעתה של תופעה‬ ‫זו‪ .‬מסקנות גורפות מפרשות מקרא אלו מצריכות זהירות מובנת‪.‬‬ ‫‪72‬‬