israel journal of psychiatry and related sciences by MEDIC

israel journal of

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In schizophrenia, how do you get from here

Vol. 48 - Number 3 2011

ISSN: 0333-7308

150

Missed Chances: Primary Care Practitioners' Opportunity to Identify, Treat and Refer Adolescents with Mental Disorders

Volume 48, Number 3, 2011 Israel Journal of Psychiatry and Related Sciences

Ivonne Mansbach-Kleinfeld et al.

to here? Xeplion , a new once-monthly injectable schizophrenia therapy,1 significantly reduces relapse.2 With early onset of efficacy3,4 and good tolerability,1–6 Xeplion can help your patients shape a future in a way that they wish. ®

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Posttraumatic Stress Disorder in Former “Comfort Women” Sung Kil Min et al.

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Psychosomatic symptoms among hospital physicians during the Gaza War: A repeated cross sectional study Menachem Ben-Ezra et al.

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Burnout Among General Hospital Mental Health Professionals and the Salutogenic Approach Stanley Rabin et al.

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Role of Life Events in Obsessive Compulsive Disorder Sujit Sarkhel et al.

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Holocaust Student Tour: The Impact on Spirituality and Health Alan L. Nager et al.

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Pisa Syndrome and Laryngeal Dystonia Induced by Novel Antipsychotics Chanoch Miodownik et al.

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Psychiatric Hospitalization by Court Observation Order in Israel: A Ten-Year Follow-up Study Alexander Grinshpoon et al.

207 Preventing relapse, enabling futures

For comprehensive information please refer to full Prescribing information as approved by the Israeli Health Authority. References: 1. Xeplion prescribing information. 2. Hough D et al. Schiz Res 2010; 116: 107-117. 3. Pandina GJ et al. J Clin Psychopharmacol 2010; 30: 235-244. 4. Kramer M et al. Int J Neuropsychopharmacol 2010; 13: 635-647. 5. Gopal S et al. J Psychopharmacol Online First, published on July 8, 2010 as doi:10.1177/0269881110372817. 6. Hoy SM et al. CNS Drug Rev 2010; 24(3): 227-244.

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150 > Missed Chances: Primary Care Practitioners' Opportunity to Identify, Treat and Refer Adolescents with Mental Disorders Ivonne Mansbach-Kleinfeld, Hava Palti, Anneke Ifrah, Daphna Levinson and Ilana Farbstein

157 > Commentary: Missed chances: Why so many for so long? Tami Kramer and Elena Garralda

159 > Commentary - H. Munitz 160 > Authors’ response - Ivonne

Mansbach-Kleinfeld, Hava Palti, Anneke Ifrah, Daphna Levinson and Ilana Farbstein

161 > Posttraumatic Stress Disorder in Former “Comfort Women” Sung Kil Min, Chang Ho Lee, Joo Young Kim and Eun Ji Sim

170 > Psychosomatic symptoms among hospital physicians during the Gaza War: A repeated cross-sectional study

Menachem Ben-Ezra, Yuval Palgi Jonathan Jacob Wolf and Amit Shrira

175 > Burnout Among General Hospital Mental Health Professionals and the Salutogenic Approach

The Official Publication of the Israel Psychiatric Association Vol. 48 - Number 3 2011

186 > Holocaust Student Tour: The Impact on Spirituality and Health

Alan L. Nager, Sarah M. Nager, Priya G. Lalani and Jeffrey I. Gold

195 > Pisa Syndrome and Laryngeal Dystonia Induced by Novel Antipsychotics

Chanoch Miodownik, Vladimir Lerner and Eliezer Witztum

201 > Psychiatric Hospitalization by Court Observation Order in Israel: A Ten-Year Follow-up Study Alexander Grinshpoon, Razek Khawaled, Jacob Polakiewicz, Paul S. Appelbaum and Alexander M. Ponizovsky

207 > Internet-Related Psychosis – A Sign of the Times?

Uri Nitzan, Efrat Shoshan, Shaul Lev-Ran and Shmuel Fennig

212 > Night Eating Syndrome Among Patients With Depression

Fatma Özlem Orhan, Ufuk Güney Özer, Ali Özer, Özlem Altunören, Mustafa Çelik and Mehmet Fatih Karaaslan

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Obsessive Compulsive Disorder Sujit Sarkhel, Samir Kumar Praharaj and Vinod Kumar Sinha

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Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Missed Chances: Primary Care Practitioners' Opportunity to Identify, Treat and Refer Adolescents with Mental Disorders Ivonne Mansbach-Kleinfeld, PhD, MPH,1 Hava Palti, MD, MPH,2 Anneke Ifrah, MA, MPH,3 Daphna Levinson, PhD,1 and Ilana Farbstein, MD4 1

Mental Health Services, Ministry of Health, Jerusalem, Israel The Braun School of Public Health and Community Medicine, Hadassah-Hebrew University of Jerusalem, Jerusalem, Israel 3 The Israel Center for Disease Control, Ministry of Health, Tel Hashomer, Ramat Gan, Israel 4 Department of Child and Adolescent Psychiatry, Ziv Hospital, Safed, Israel 2

ABSTRACT Background: Few adolescents with mental disorders consult mental health professionals or informal care providers, but many visit primary health care services. Primary care practitioners (PCP) have then the opportunity to identify and refer these adolescents to specialist services. Methods: The Israel Survey of Mental Health among Adolescents conducted in 2004-2005 interviewed 957 adolescents and their mothers using the Development and Well-Being Assessment (DAWBA) diagnostic inventory and questions related to mental health and primary health care service use. Response rate in the located sample was 80%. Results: Nearly 70% of adolescents had visited a PCP, more among adolescents with mental disorders and among those belonging to the Jewish majority group. Among adolescents with mental disorders whose mothers did not consult any mental health specialist, 76.5% visited a PCP. Conclusions: Over 75% of adolescents with a mental disorder, who did not seek help from any mental health service provider in the past 12 months, visited a PCP in that period. The PCP's potential to identify, treat or refer untreated adolescents in need of mental care to specialized services is discussed.

Introduction Nearly 12% of adolescents in Israel were found to have a mental disorder (1) and only about 40% of these adolescents or their mothers had consulted a mental health professional or an informal caregiver in the year preceding the study (2). Unmet needs in Israel, like in other societies, varied along ethnic and socio-economic lines, with under-privileged and minority groups presenting higher treatment gaps (2). This paper will examine the characteristics of adolescents with a mental disorder who visited a Primary Care Practitioner (PCP) in the year preceding the survey and will focus on those who consulted no other professional or informal care giver regarding their emotional or behavioral problems. This information is necessary for mental health policy makers who wish to assess the potential benefit of enabling PCPs to participate in the delivery of mental health services. Studies have reported that between 15% and 50% of children seen in primary care had significant psychopathology (3-7), and one study showed that 65% of them were not currently receiving specialty mental health treatment (8). Kramer and Garralda (9) found that only 2% of the adolescents in their study presented with psychiatric complaints when attending primary care, although 38% were found to have a psychiatric disorder in the previous year, of which the majority were internalizing disorders and among which half were moderately impaired. Studying adolescents diagnosed with psychological problems, a Dutch study found that 80% had visited a PCP in the year preceding the survey (10).

Address for Correspondence: Ivonne Mansbach-Kleinfeld, Mental Health Services, Ministry of Health, Ben Tabai 2, P.O.Box 1176, Jerusalem 91010, Israel â&#x20AC;&#x2020; ivonne.mansbach@moh.health.gov.il

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Ivonne Mansbach-Kleinfeld et al.

In view of the accessibility of the PCP in the Israeli health system, which provides universal health care to all citizens according to the National Health Insurance Law (NHI) of 1995 (11), and the high treatment gap for Israeli adolescents with mental disorders (2), it seems important to examine the feasibility of involving PCPs, with specialist backup, in the identification, referral and monitoring of children and adolescents with mental problems, a policy supported by other countries (12-14). The aim of this paper is to describe the adolescent population that visited a PCP in the year preceding the interview, their socio-demographic characteristics, prevalence of psychiatric disorders, use of mental health services and treatment gap and to discuss selected issues related to the involvement of PCPs in the identification and care for adolescents with mental disorders and concerns. Methods The ISMEHA’s design, methods, and sample have been previously described in detail in the Israel Journal of Psychiatry (15) and thus are only briefly presented here. Sample and Procedures

The sample included 957 adolescents aged 14-17 and their mothers, who were interviewed between January 2004 and March 2005. The sampling frame used was the National Population Register (NPR), which included data on all legal residents of Israel born between July 2, 1987 and June 30, 1990 (N=317,604). Due to budgetary constraints, only locations with more than 2,000 inhabitants were included; these comprise 90% of the target population. One child from each family was included in the sample and there were no replacements. Mothers and adolescents were interviewed separately, at home, by two trained lay interviewers, in Hebrew, Arabic or Russian. The interviews took 45 - 90 minutes. Out of the total sample (N=1,402), 15% (N=207) could not be located, whereas 17% (N=238) refused to participate. Thus, response rate was 80% in the located sample (N=1,195) and 68% (N=957) in the total sample. Non-response was higher among Jews (24%, N=218) than among Arabs (7%, N=20), but no differences by gender or immigrant status were noted. The results were weighted back to the total population to compensate for clustering effects and non-response. Informed consent: Parents provided written informed consent for their own and their child’s participation in

the study, as approved by the Helsinki Ethics Committee of the Schneider Children’s Medical Center. Assessment of Services Utilization

Visits to the PCP were reported by mothers. The concept of PCPs includes, in Israel, general practitioners, pediatricians and internists (16). Service use for emotional and behavioral problems of adolescents during this same period was also reported by mothers, as mental health care is mainly dependent on parents to access the system, make appointments, transport their children and pay for services (17). Diagnostic Assessment

Adolescents and their mothers completed the DAWBA (18) inventory, which assessed 12-month and point prevalence rates of psychiatric disorders according to DSM-IV (19). DAWBA is a multi-informant instrument which produces a preliminary computerized diagnosis, according to an algorithm that weighs the responses of all the informants. Each computerized diagnosis was verified by two child and adolescent psychiatrists who reached a consensual decision regarding the final diagnosis based on the comments recorded verbatim by the interviewers. The specific disorders were categorized as internalizing (separation anxiety, specific phobia, social phobia, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, major depressive disorder and dysthymia) or externalizing disorders (attention deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder). In addition to symptoms, the impact of these disorders on the respondent’s daily life and family was a critical component in determining the final diagnosis. Socio-demographic information included age, gender, population group (Israel-born Jews and Jewish immigrants; vs. Muslims, Christian Arabs and Druze), locality of residence (Jewish or mixed locality; vs. mainly Arab/Druze locality), country of origin (Israel; abroad), marital status of parents, number of children in the family, maternal education (below 12 years of schooling; 12 years of schooling with matriculation; 13+ years [i.e.= some post-high school education]), paternal employment status, and whether the family has additional medical insurance. The four major HMOs offer additional services and medication, not included in the basic National Health Insurance basket, for a fee. 151

Adolescents with mental disorders in primary care

Data analysis

Cross-tabulations were used to calculate prevalence of visits to PCP by socio-demographic and mental health traits. Raw numbers and weighted percentages are presented, as well as standard errors. Statistical significance was based on the adjusted F, a variant of the second-order Rao-Scott adjusted chi-square statistics, and its degree of freedom. Logistic regressions were used for the multivariate analysis of the associations between visits to a PCP, clinical-diagnostic characteristics and socio-demographic data; odds ratios (OR) and 95% confidence intervals (CI) are presented. All analyses were performed using the SPSS-14 software package (SPSS, Inc. Chicago, IL) for complex sample designs. Results Study population: Table 1 shows that 77% of the subjects were Jewish and 23% Arab or Druze, 82% were born in Israel, 14% lived with a divorced or single parent, more than half had three or more siblings, 23% had a father not in the work force and 76% of adolescents had additional health insurance to obtain services not included in the NHI basket. Data regarding age, gender, population group, type of locality of residence and country of origin were NPR-based, while the remaining socio-demographic information was respondent-based. This explains the different denominators for the various variables. Visits to PCP

Table 2 presents the percentage of PCP visits by adolescents in the preceding 12 months, by selected sociodemographic characteristics and mental health status. Significant differences were found by population group, type of locality, country of origin, number of children in the family, maternal years of schooling, paternal employment and additional health insurance. Higher PCP-visit rates were found among Jewish adolescents, among immigrants, among those who had one or no siblings, among adolescents whose mothers had a post high school education, whose fathers were employed, and who had additional health insurance. In addition, we found that 81.2% of adolescents with any mental disorder visited the PCP and among those with externalizing disorders the percentage who visited was even higher: 83.8%. The socio-demographic variables significantly associated with PCP visits are strongly interrelated among themselves: population group is strongly associated with type of locality 152

Table 1. Selected socio-demographic characteristics of study population (raw numbers and weighted percentages) Characteristic

Age* 14-15 16 17

285 447 225

33.5 33.3 33.2

Gender* Boys Girls

497 460

51.2 48.8

Population group* Jewish Muslim and Christian Arab, Druze

657 300

77.0 23.0

Type of locality* Jewish or mixed city Arab city

689 268

80.1 19.9

Country of origin* Israel Abroad

826 131

81.5 18.5

Marital status of parents** Married Single/divorced/widowed

813 122

85.6 14.4

Number of children in family** 1-2 3 4 or more

174 230 533

22.6 25.9 51.4

Maternal years of schooling** 0-11 12 13 and over

299 277 325

27.3 32.8 39.9

Employment status of father** Employed Unemployed

661 214

77.0 23.0

HMO Additional Health Insurance** Insured Not insured

681 240

76.5 23.5

* National Population Register-based data ** Respondent-based data

(100% of Jews live in Jewish/mixed localities and 86.7% of Arabs/Druze live in mainly Arab localities); with number of children in the family (71.5% of Jews have three or more children compared to 96.6% among Arabs/Druze); with maternal years of schooling (48.8% of Jewish mothers have a post high school education compared to 9.5% among Arab/Druze mothers); with employment status (16.9% of Jewish fathers were unemployed compared to 43% among Arab/Druze fathers); and with additional health insurance (85.8% of Jews have additional health insurance compared to 46.1% among Arabs/Druze). We therefore included in the logistic regression analysis only population group, presence of any mental disorder and paternal employment, as an additional measure of socio-economic status. The multivariate analysis presented in Table 3 shows that population group and presence of any mental

Ivonne Mansbach-Kleinfeld et al.

Table 2. Percentage of adolescents who visited a PCP in the preceding 12 months, by selected demographic characteristics and mental health status (raw numbers and weighted percentages) Socio-demographic characteristics and mental disorders (Total sample)

Visited PCP N

(s.e.)

Age* 14-15 (279) 16 (421) 17 (207)

187 269 144

66.0 68.4 72.7

3.9 2.4 3.2

Gender* Boys (473) Girls (434) Population group* Jewish (634) Muslim and Christian Arab, Druze (273)

306 294

67.6 70.4

2.8 2.2

478 122

75.8 44.7

1.9 4.3

Type of locality* Jewish or mixed city (665) 494 Arab city (242) 106

75.4 41.7

1.9 4.5

Country of origin* Israel (779) Abroad (128)

66.9 77.7

2.1 3.8

Marital status of parents** Married (786) Single/divorced/ widowed (118) Number of children in family** 1 – 2 (172) 3 or more (734)

501 99

511 89

67.9 76.6

128 472

76.4 66.8

2.2 3.9

3.0 2.3

F=1.1;df=2;p=.318

F=0.9; df=1;p=.357

F=48.9;df=1;p=.001

F=52.4;df=1;p.001

F=5.6;df=1;p.019

F=3.2;df=1;p=.076

F=5.87;df=1;p.016

Socio-demographic characteristics and mental disorders (Total sample)

Visited PCP N

(s.e.)

Maternal years of schooling** 0 – 11 (282) 12 (267) 13 and over (322)

152 183 242

56.1 71.1 76.0

4.7 3.2 2.8

F=7.7;df=2;p=.001

Employment status of father** Employed (644) Unemployed (202)

443 118

72.0 59.8

2.0 4.5

F=7.6;df=1;p=.006

Additional health insurance through HMO** Yes (666) No (225)

470 117

72.0 55.5

2.0 4.2

F=14.1;df=1;p=.001

Any mental disorder*** Yes (111) No (794)

90 508

81.2 67.2

3.6 2.3

F=7.7;df=1;p=.006

Internalizing disorder*** Yes (81) 64 No (824) 534

75.9 68.3

4.8 2.1

F=1.67;df=1;p=.197

Externalizing disorder*** Yes (41) No (864)

83.8 68.1

5.4 2.1

F=4.79;df=1;p=.03

Total Visited Did not visit

33 565 600 307

69.0 31.0

2.0 2.0

* National Population Register-based data ** Respondent-based data ***Respondent-based data according to computerized diagnosis + psychiatrist's corroboration

adolescents with any mental disorder were 2.3 times more likely than those without a mental disorder to visit a PCP (95% CI 1.32-3.90).

Table 3. Multivariate analysis (logistic regression) of adolescents' likelihood to visit a PCP, by selected demographic variables and mental disorder Adolescents' visits to PCP Variable

95% CI

Population group Jewish Arab/Druze

3.4 1.0 [reference]

2.27 - 5.04 -

<.001

Mental disorder Present Absent

2.4 1.0 [reference]

1.32 – 3.98 -

<.01

Paternal employment status Employed Unemployed

1.3 1.0 [reference]

.86 - 2.00 -

.209

disorder remained significantly associated with PCP visits, over and above the effect of the socio-economic variables: Jewish adolescents were 3.4 times more likely than Arab/Druze to visit a PCP (95% CI 2.27-5.04), and

PCPs opportunities to identify adolescents with mental disorders

Figure 1 shows that 11.8% (115) of the adolescents in the study population had a diagnosed mental disorder. Of these, 60% (69) had not consulted a mental health professional or an informal care provider. However, 76.5% of the latter had visited a PCP. Among Jewish adolescents this rate was 82.2% while among Arabs/ Druze adolescents it was 60.1%. Discussion The major finding of the study is that 69% of adolescents in Israel visited their PCP during the 12 months preced153

Adolescents with mental disorders in primary care

Figure 1. Adolescents by mental health status, by consultation for mental health concerns and by visits to PCP (raw numbers and weighted percentages) Number of adolescents in study (N=954)

Had a diagnosed mental disorder 11.8% (N=115)

Consulted professional caregiver in past 12 months 40% (N=42)

Visited PCP 88.2% (N=42)

Didn't Visit PCP 11.8% (N=5)

Had no diagnosed mental disorder 88.2% (N=839)

Didn't consult professional caregiver in past 12 months 40% (N=69)

Visited PCP 76.5% (N=53)

Didn't Visit PCP 23.5% (N=16)

ing the interview and that among those who met criteria for a psychiatric disorder the proportion was even higher. Moreover, more than 75% of adolescents with a mental disorder, whose mothers had not asked for advice concerning their mental health concerns from any other service provider, did visit the PCP in that period. These are the adolescents who could be potentially identified and helped by the PCPs. Among Jewish adolescents this proportion was 82.2%, while among Arab/Druze adolescents the proportion was 60%. The universal NHI law enacted in Israel, which functions in the primary health care system (11), should have facilitated service utilization, but despite universal access to health care, we found significantly fewer PCP visits among minority than among mainstream adolescents. Underutilization of health services in general, and mental health services in particular, by minority populations and among parents who live in poverty and have a low education, is well documented (2, 20, 21). In Israel, service underutilization among ethnic minorities has been explained by referral bias, or lack of access to or availability of Arabic-speaking mental health specialists/counselors in the Arab localities (2). Parents from minority groups are especially at risk of underutilization of services as there is a strong association between minority status, poverty and low education of parents. In 2004 about 50% of Arab households were below the poverty line, as compared with 20% among Jewish 154

Consulted professional caregiver in past 12 months 7.2% (N=55)

Visited PCP 86.4% (N=47)

Didn't Visit PCP 13.6% (N=8)

Didn't consult professional caregiver in past 12 months 92.7% (N=744)

Visited PCP 69.5% (N=460)

Didn't Visit PCP 34.1% (N=276)

households (22). Cultural elements related to stigma that might be attached to the adolescent and his/her family also may play a part (2). However, it is encouraging that 60% of these minority adolescents diagnosed with a mental disorder, who did not seek help from any professional mental health provider, contacted a PCP who then had the opportunity to assess their mental health needs. Our finding, that there was an excess of PCP visits among adolescents with mental disorders and that their visit rate was higher than 80%, corroborated othersâ&#x20AC;&#x2122; reports (9, 10). It has been theorized that the increased GP attendance of school children with psychiatric disorders may be, in part, a result of maternal stress focused on the disturbed child and a decrease in confidence of the parent (23). In addition, it might be a result of higher need for primary care consultations among children with chronic illnesses or disabilities, which have been associated with mental disorders in other studies (24). Among adolescents with a mental disorder we found that 60% had not consulted any professional mental health service provider in the 12 months preceding the interview. Studies on help-seeking for mental health problems show that more parents seek help for externalizing disorders, which cause a significant burden on family and teachers, than for internalizing disorders, which may go undetected (2, 25). We found that among those underserved adolescents more than 3/4 visited the PCP.

Ivonne Mansbach-Kleinfeld et al.

These visits provide the opportunity to probe for the more elusive internalizing disorders since, as reported by Kramer and Garralda (9), the majority of those attending primary care who had a psychiatric disorder, had an internalizing disorder. That is, although more parents seek help for their children’s obvious externalizing disorders, it is probable that those adolescents who approach a PCP have a higher prevalence of undetected internalizing disorders. Among Arab adolescents the case for action is even stronger since the treatment gap, that is the percentage of adolescents with a mental disorder whose mothers did not seek or receive help from any professional mental health service, reached 91% (2). In order to take full advantage of adolescents’ visits to primary care, a number of conditions must be filled. One is that, as children and adolescents are dependent on key adults to perceive problems and seek help on their behalf, efforts should be aimed at improving parents’ and PCPs’ awareness of adolescents’ problems (26). Another is that medical undergraduate teaching and postgraduate training in teenage health should be improved (27). An Israeli study (16) reported that “health care policy makers have an ambivalent attitude to strengthening the role of primary care” (p. 73) due to lack of faith in PCPs’ capacities, training and availability. Another Israeli study confirmed that some of the barriers to PCPs’ identification and treatment of mental disorders were lack of knowledge regarding diagnosis and treatment, lack of specialists’ support, lack of interest and personal difficulty in relating to mental health problems (28). The treatment of youth depression in primary care settings is undergoing thorough examination and results are encouraging (29). However, the question of motivation for treatment, which has been found to be lower for youth identified through primary care than for those seen in specialty care, particularly when they have not perceived themselves as requiring treatment, must be considered (5). In addition, the expectations of older children and adolescents differ from those of parents and healthcare providers and their demands, particularly as related to their involvement in decisions made about them and for services staffed by those they are able to trust, should be heard (30). Limitations of the study

One of the limitations of this study is that mothers were not specifically asked what the reasons for the visit were and therefore we do not know how many presented to the PCP with a mental health concern.

Another potential limitation is the possibility of selection bias. If mothers who suspected that their adolescent child had a mental health problem or who were consulting someone for their own or their child’s mental problems were less likely than others to agree to participate in the survey, the level of service use for mental health problems would be underestimated. Another potential limitation is that changes in PCP visiting patterns might have occurred since the data were collected some six or seven years ago. However, although this possibility needs to be considered, we have no reason to assume this is so. Conclusions This epidemiological study is the first of its kind to assess Israeli adolescents’ PCP visits in relation to mental health care needs. It provides strong evidence that the majority of Israeli adolescents with a mental disorder, who have not consulted any mental health care provider, have contacted the PCP during that period. This visit provides the PCP with the opportunity to identify adolescents at risk, to carry out preventive measures or refer them to specialist care. The primary care setting, together with the specialty mental health services and health policy makers, should make it a priority to examine the viability of adopting a model of integrated care (31) for detection, during the course of routine clinical work, of children and adolescents with mental problems and of referral of those most likely to be disturbed. The school setting has an important role, as it is widely agreed that mental health intervention with children and adolescents is best targeted at the child's environment. A comprehensive approach needs to be adopted, which includes mental health professionals, parents, teachers, PCP and, primarily, the adolescent him/herself. These goals should become a major focus for public health research. References 1. Farbstein I, Mansbach-Kleinfeld I, Levinson D, et al. Prevalence and correlates of mental disorders in adolescents: Findings from the Israeli Survey on Mental Health among Adolescents (ISMEHA). J Child Psychol Psychiatry 2010;51:630-639. 2. Mansbach-Kleinfeld I, Farbstein I, Levinson D, et al. Use of services for mental disorders and unmet needs: Results from the Israel Survey on Mental Health among Adolescents (ISMEHA). Psychiatr Serv 2010; 61:241-249. 3. Connor DF, McLaughlin TJ, Jeffers-Terry M, et al. Targeted child psychiatric services: A new model of pediatric primary clinician-child

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psychiatry collaborative care. Clin Pediatr 2006;45:423-434. 4. Costello EJ, Edelbrock C, Costello AJ, et al. Psychopathology in pediatric primary care: The new hidden morbidity. Pediatrics 1988; 82:415-424. 5. Ford T, Sayal K, Meltzer H, Goodman R. Parental concerns about their child's emotions and behavior and referral to specialist services: A general population survey. BMJ 2005; 331:1435-1436. 6. Glazerbrook C, Hollis C, Heussler H, et al. Detecting emotional and behavioural problems in paediatric clinics. Child Care Health Dev 2003; 29: 141-149. 7. Sayal K. Annotation: Pathways to care for children with mental health problems. J Child Psychol Psychiatry 2006; 47:649-659. 8. Gardner W, Kelleher KJ, Wasserman R, et al. Primary care treatment of pediatric psychosocial problems: A study from Pediatric Research in Office Settings and Ambulatory Sentinel Practice Network, 2000. http://www. pediatrics.org/cgi/content/full/106/4/e44 (retrieved December 1, 2009). 9. Kramer T, Garralda ME. Psychiatric disorders in adolescents in primary care. Br J Psychiatry 1998;173: 508-513. 10. Zwaanswijk M, Verhaak PFM, van der Ende J, et al. Consultation for and identification of child and adolescent psychological problems in Dutch general practice. Fam Pract 2005;22: 498-506. 11. Rosen B. Health care systems in transition: Israel. In Thomson S, Mossialos E, editors. Health care systems in transition. Copenhagen, European Observatory on Health Care Systems, 2003;5(1). http://www.euro.who. int/_data/assets/pdf_file/0003/85449/E81826.pdf. Accessed 13.6.10. 12. Farmer EMZ, Burns BJ, Phillips SD, et al. Pathways into and through mental health services for children and adolescents. Psychiatr Serv 2003;54:60-66. 13. Thornicroft G, Tansella M. What are the arguments for communitybased mental health care? Copenhagen, WHO Regional Office for Europe Health Evidence Network Report, 2003. http://www.euro.who. int/document/E82976.pdf. Accessed 26.7.10. 14. Ani C, Garralda E. Developing primary mental healthcare for children and adolescents. Curr Opin Psychiatry 2005;18:440-444. 15. Mansbach-Kleinfeld I, Levinson D, Farbstein I, et al. The Israel Survey of Mental Health among Adolescents: Aims, methods, strengths and limitations. Isr J Psychiatric Relat Sci 2010; 47:244-253. 16. Tabenkin H, Gross R. The role of the primary care physician in the Israeli health care system as a “gatekeeper” – the viewpoint of health care policy makers. Health Policy 2000;52:73-85. 17. Rickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med J Aust

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2007;187:35-39. 18. Goodman R, Ford T, Richards H, et al. The Development and WellBeing Assessment: Description and initial validation of an integrated assessment of child and adolescent psychopathology. J Child Psychol Psychiatry 2000; 41: 645-656. 19. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association. 20. Al Krenawi A. Mental health service utilization among the Arabs in Israel. Soc Work Health Care 2002;35:577-589. 21. Kataoka SH, Zhang L, Wells KB. Unmet need for mental health care among US children: Variation by ethnicity and insurance status. Am J Psychiatry 2002;159: 1548-1555. 22. Manna A. (ed.). Arab society in Israel – Population, society, economy. Jerusalem: The Van Leer Jerusalem Institute/Hakibbutz Hameuchad Publishing House, 2008. 23. Coverley C, Garralda ME, Bowman F. Psychiatric intervention in primary care for mothers whose schoolchildren have psychiatric disorder. Br J Gen Pract 1995;45:235-237. 24. Lewinsohn PM, Seeley JR, Hibbard J, et al. Cross-sectional and prospective relationships between physical morbidity and depression in older adolescents. J Am Acad Child Adolesc Psychiatry 1996;35:1120-1129. 25. Sayal K, Taylor E. Detection of child mental health disorders by general practitioners. Br J Gen Prac, 2004;54:348-352. 26. Wu P, Hoven CW, Bird HR, et al. Depressive and disruptive disorders and mental health service utilization in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999;38:1081-1090. 27. Jacobson L, Churchill R, Donovan C, et al. Tackling teenage turmoil: Primary care recognition and management of mental ill health during adolescence. Fam Pract 2002;19:401-409. 28. Goldfracht M, Shalit C, Peled O, Levin D. Attitudes of Israeli primary care physicians towards mental health care. Isr J Psychiatry Relat Sci 2007;44:225-230. 29. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics. JAMA 2005;293:311-319. 30. Dogra N. What do children and young people want from mental health services? Curr Opin Psychiatry 2005;18:370-373. 31. Cerimele JM , Strain JJ. Integrating primary care services into psychiatric care settings: A review of the literature. Prim Care companion J Clin Psychiatry 2010;12(6). doi:10.4088/PCC.10r0097whi.

Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

H. Munitz

Commentary: Missed chances: Why so many for so long? Tami Kramer, MBBCH, MRCPsych, and Elena Garralda, MD, MPhil, FRCPsych, FRCOCH, DPN Academic Unit of Child & Adolescent Psychiatry, Imperial College, St. Mary's Campus, London W2 1PG, U.K.

The study by Mansbach-Kleinfeld et al. (2011) in Israel delivers a number of clear messages which mirror findings in other countries. Most adolescents attend primary care within the course of a year. This is contrary to the perception by many primary care practitioners (PCP) that they do not (1). The presence of a mental disorder increases the likelihood that they will attend and rates of depressive symptoms in attenders are increased when compared with non-attenders (2). Few of these are detected and only a minority receive any mental health intervention. The majority of mental health problems among attenders are internalizing disorders which are essentially treatable (3, 4), hence the chance is missed. What are the implications of the missed opportunity? The undetected disorders are by definition associated with suffering and impairment. Anxiety and depressive disorders display persistence, recurrence and strong continuity with adult disorder, suggesting an opportunity for secondary prevention. Half of the adolescents attending their PCP in the UK with (mainly undetected) depression have been shown to remain depressed at 6-month follow-up (5). Adolescent depression has been associated with functional impairment (6, 7), health risk behaviors (8) and increased health service use (9, 10). Why then are the chances missed? Repeatedly, health policy globally has highlighted and emphasized the crucial role of primary care in addressing unmet health need (11). This stated policy commitment has failed to translate into altered practice in the consulting room and the reasons are complex. Firstly, parents and adolescents rarely present with emotional and behavioral concerns to the PCP and both PCPs and adolescents fail to raise psychological concerns even when they are aware they are present (12). Secondly, earlier research suggested that adolescents viewed their PCPs as unsympathetic; subsequent research has indicated that many feel satisfied with the care they receive although they have concerns about confidentiality. Others do not believe that PCPs are adequately trained to deal with such problems (13) and they may have fears of stigma-

tization. The relevance of attitudes is further supported by the study by Ferrin et al. (2) showing that consultations of girls with depressive symptoms are influenced by whether they regard doctors as only interested in physical symptoms or not. Thirdly, Jacobson (14) demonstrated that adolescents receive shorter consultations than adults which reduces the chances of raising psychological issues though this study was carried out some years ago and now requires replicating to see whether this persists. Lastly many adolescents may require their parents to raise concern on their behalf although particularly with regard to internalizing disorders parents may not always be fully aware of their need. In order to better understand the role of the PCP in the failure of detection, we explored the perceptions of family physicians (GPs) in the U.K. regarding adolescents, and particularly in relation to recognizing and responding to depression. Adolescents were perceived by them as qualitatively different in the way they consulted. GPs viewed adolescents as more complex and difficult, intermittently and impulsively using services. GPs also expressed difficulty in differentiating between disorder and â&#x20AC;&#x153;normalâ&#x20AC;? developmental changes: they fear stigmatizing adolescents with diagnostic labels and the burden of time constraints for this work (1). Many PCPs remain skeptical about the diagnostic validity of psychiatric disorders and believe that other psychiatric conditions such as hyperkinetic disorder are over-diagnosed (15). Many report lack of confidence in diagnosis and management (16), worry about overmedicalizing adolescentsâ&#x20AC;&#x2122; lives (17, 18) and some advocate that responsibility lies with other agencies such as schools, community organizations and specialist services. However, it is important to note that even within developed countries specialist mental health services remain a scarce resource and in practice this translates into PCPs wishing to make referrals to specialist services expressing concern about the delays in getting help (19). It seems highly unlikely that specialist services will be in a position to attend to the range of adolescent depressive dis157

Commentary: Missed chances: Why so many for so long?

orders and for many of those a primary care intervention might the most appropriate option. Seizing the chance! We welcome the call from Mansbach-Kleinfeld et al. (20) to Israel’s policy makers, primary and secondary services for an integrated model of care which should follow improved identification within primary care. It is a message to be echoed across countries. Nevertheless, as outlined above, real change within the primary care setting will require attention to a range of areas. Not least parents and adolescents need information about the evidence for intervention for mental disorders and the role of the PCP so that they start to request help more actively and consistently (21). PCPs require education and training which addresses attitudes, knowledge and skills. Although PCPs are able to detect the more severe disorders (19) detection of the less severely impaired needs improvement and may require an approach which employs systematic screening and clinical enquiry. Brief interventions which can be delivered within primary care need further development. An intervention of this nature for depression, the TIDY program, has been developed by our group and piloted and field tested in a number of practices in London. TIDY trained GPs to systematically screen and identify depressive disorder, and provided initial management within a ten-minute appointment. Management of mild to moderate depressive disorder included psycho-education, promotion of self-help, and advice about coping strategies; information was given both verbally and in leaflets. It was shown to be feasible, acceptable to adolescents and it increased detection of depression among attenders (22, 23). A comprehensive approach across the spectrum of disorders will require multifaceted programs that integrate improvements in detection, treatment and follow up, and include combinations of clinician and patient education, nurse case management, enhanced support from specialist services and monitoring of medication. Asarnow et al.’s randomized trial of a quality improvement program, along these lines, demonstrated improved quality of care, increased access to evidence based treatments and favorable outcomes for depressive disorder (24). For the most severely affected, in addition to this, new models of collaboration between primary care and specialist care are required in order to facilitate and improve access to specialist services. Innovative models that have been described share a number of features: rapid access by primary care workers to mental health specialist for discussion of cases, access to con158

sultation where appropriate, short delay to specialist assessment, good communication of treatment needs, collaboration in delivery of intervention and treatment monitoring. These models serve to decrease the barriers often encountered between primary and secondary services and facilitate improved contact between professionals allowing for continuing education of PCPs in recognition and management of psychological problems and disorders (19, 25, 26). Finally, the evidence base for interventions addressing adolescent mental health in primary care remains limited (27, 28). Further research is needed and this should address educational interventions for PCPs, the detection and management of disorders by the primary care team, and health service programs which improve collaboration with specialist services and other sectors. This will ensure we are able to effectively stop missing so many chances. t.kramer@imperial.ac.uk, e.garralda@imperial.ac.uk

References 1. Iliffe S, Williams G, Fernandez V, Vila M, Kramer T, Gledhill J, et al. General practitioners’ understanding of depression in young people: Qualitative study. Prim Health Care Res Dev 2008;9:269-279. 2. Ferrin M, Gledhill J, Kramer T, Garralda E. Factors influencing primary care attendance in adolescents with high levels of depressive symptoms. Soc Psychiatry Psychiatr Epidemiol 2009;44:825-833. 3. Harrington R. Systematic review of efficacy of cognitive behaviour therapies in childhood and adolescent depressive disorders. BMJ 1998;316:1559-1563. 4. Cartwright-Hatton S, Roberts C, Chitsabesan P, Fothergill C, Harrington R. Systematic review of the efficacy of cognitive behavioural therapies for childhood and adolescent anxiety disorders. Br J Clin Psychol 2004;43:421-436. 5. Gledhill J, Garralda E. The short-term outcome of depressive disorder in adolescents attending primary care: A cohort study. Soc Psychiatry Psychiatr Epidemiol 2010 Sept. 4 [Epub ahead of print]. 6. Asarnow JR, Jaycox LH, Duan N, Laborde AP, Rea MM, Tang L, et al. Depression and role impairment among adolescents in primary care clinics. J Adolesc Health 2005;37:477-483. 7. Rao U, Hammen C, Daley S. Continuity of depression during the transition to adulthood: A 5-year longitudinal study of young women. J Am Acad Child Adolesc Psychiatry 1999;38:908-915. 8. Fernandez V, Kramer T, Doig A, Fong G, Garralda E. Depressive symptoms and behavioural health risks in young people attending an urban sexual health clinic. Child Care Health Dev 2009;35:799-806. 9. Melzer H, Gatwood R, Goodman R, Ford T. The mental health of children and adolescents in Great Britain. London: HMSO, 2000. 10. Yates P, Kramer T, Garralda E. Depressive symptoms amongst adolescent primary care attenders: Levels and associations. Soc Psychiatry Psychiatr Epidemiol 2004;39:588-594. 11. World Health Organisation. Mental health: Facing the challenges, building solutions. Denmark: WHO, 2005. 12. Martinez R, Reynolds S, Howe A. Factors that influence the detection of psychological problems in adolescents attending general practice. Br J Gen Pract 2006;56:529.

H. Munitz

13. Biddle L, Donovan JL, Gunnell D, Sharp D. Young adults’ perceptions of GPs as a help source for mental distress: A qualitative study. Br J Gen Pract 2006;56:924-931. 14. Jacobson L, Wilkinson C, Owen P. Is the potential of teenage consultations being missed? A study of consultation times in primary care. Fam Pract 1994;11:296-299. 15. Klasen H, Goodman R. Parents and GPs at cross-purposes over hyperactivity: A qualitative study of possible barriers to treatment. Br J Gen Pract 2000;50:199-202. 16. Churchill RD. Child and adolescent mental health. In: Cohen A, ed. Delivering mental health for primary care: An evidence-based approach. London: Royal College of General Practitioners, 2008. 17. Iliffe S, Gledhill J, da Cunha F, Kramer T, Garralda E. The recognition of adolescent depression in general practice: Issues in the acquisition of new skills. Prim Care Psychiatry 2004;9:51-56. 18. MacFarlane A, McPherson A. Primary health care and adolescence. BMJ 1995;311:825-826. 19. Connor DF, McLaughlin TJ, Jeffers-Terry M, O’Brien WH, Stille CJ, Young LM, et al. Targeted child psychiatric services: A new model of pediatric primary clinician-child psychiatry collaborative care. Clin Pediatr 2006;45:423-434. 20. Mansbach-Kleinfeld I, Palt H, Ifrah A, Levinson D, Farbstein I. Missed chances: Primary care practitioners' opportunity to identify, treat and refer adolescents with mental disorders. Isr J Psychiatry Relat Sci 2011;48:150-156. 21. Haller D, Sanci L, Sawyer S, Patton G. The identification of young people’s emotional distress: A study in primary care. Br J Gen Pract 2009;59:e61-70. 22. Gledhill J, Kramer T, Iliffe S, Garralda E. Training general practitioners in the identification and management of adolescent depression within the consultation: A feasibility study. J Adolesc 2003;26:245-250. 23. Kramer T, Iliffe S, Gledhill J, Garralda E. Recognising and responding to adolescent depression in general practice: Developing and implementing the Therapeutic Identification of Depression in Young People (TIDY) programme. Clin Child Psychol Psychiatry, in press. 24. Asarnow JR, Jaycox LH, Duan N, LaBorde AP, Rea MM, Murray P, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial. JAMA 2005;293:311-319. 25. Campo JV, Shafer S, Strohm J, Lucas A, Cassesse CG, Schaeffer D, et al. Pediatric behavioural health in primary care: A collaborative approach. J Am Psychiatr Nurses Assoc 2005;11:276-282. 26. MacDonald W, Bradley S, Bower P, Kramer T, Sibbald B, Garralda E, et al. Primary Mental Health Workers in child and adolescent mental health services. J Adv Nurs 2004;46:78-87. 27. Bower P, Garralda E, Kramer T, Harrington R, Sibbald B. The treatment of child and adolescent mental health problems in primary care: A systematic review. Fam Pract 2001;18:373-382. 28. Kramer T, Garralda E. Primary healthcare psychiatry. In: Rutter M, editor. Rutter’s Child and Adolescent Psychiatry. 5th ed. Oxford: Blackwell, 2008.

Commentary H. Munitz, MBBS, MRCPsych Mental Health Division, Clalit Health Fund, Arlozorov 10, Tel Aviv, Israel

This is a very important article. It provides us with data about adolescents’ use of PCP services and indicates that

this group can be seen as high utilizers of primary care services. This is in keeping with our knowledge that people in distress tend to seek help from primary care physicians. This is in contrast to the use of PCP services by adults suffering from depression and/or anxiety (1, 2). This issue has been dealt with less in adolescents worldwide and in Israel particularly. As a high proportion of psychopathology begins in adolescence it is of paramount importance that we are able to plan the optimal approach to detection and treatment in this group. The information in this work could certainly be used to develop such a plan. However, there are some limitations to this article. It is not clear who is included in the term PCP. Does it include the pediatrician or only the family physician? It is possible that the choice of the medical caregiver could affect the help seeking behavior. The authors use the diagnostic terms used for minors. It is not clear if this is the best approach. For instance, concepts like separation anxiety or oppositional disorder are included. But, major issues in adolescence like eating disorders, schizophrenia, bipolar disorders and somatoform disorders are omitted. We are aware of the burden of these disorders on mental health care and the fact that they tend to appear in early adolescence and the importance of early intervention. These omissions could affect any public health plan. Though this article does not state so overtly, it implies that diagnosed patients should be looked after by mental health professionals. But due to shortage of manpower this is practically impossible and it is even questionable if it is desirable. Moreover, it is not clear if the reason of a visit to the PCP by a patient with a mental health problem is psychiatric or due to a concomitant physical complaint (3). The increase in the rate of visits might be due to the tendency to seek help in other stressful situations other than the overt symptoms of their mental health program. Therefore it would be helpful in planning to have information about the reasons leading to the consultation. This is the first study of PCP service utilization in Israel by adolescents with mental health problems. It teaches us of the high utilization rate by this group and points out that like in the adult population the PCP plays a major role in the help seeking behavior of adolescents. In spite of its limitation this study can serve us in the future planning of the management of mental health problems in this age group. The role of the PCP is complex and can be divided into the following stages: 159

Commentary: Missed chances: Why so many for so long?

1. Recognition of a mental health problem 2. Diagnosis 3. Treatment 4. Referral to secondary mental health services Future planning should refer to each stage. The way to use the fact that adolescents in distress tend to turn to the PCP in their help seeking would be influenced by future research based on the methodology of this work. In spite of its limitations this work should serve as the basis of any such work. ilanits@clalit.org.il

References 1. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 1988;45:1100-1106. 2. Mansbach-Kleinfeld I, Farbstein I, Levinson D, et al. Use of services for mental disorders and unmet needs: Results from the Israel Survey on Mental Health among Adolescents (ISMEHA). Psychiatr Serv 2010;61:241-249. 3. Lacovides A, Siamouli M. Comorbid mental and somatic disorders: An epidemiological perspective. Curr Opin Psychiatry 2008;21:417-421.

Authors’ response I. Mansbach-Kleinfeld, H. Palti, A. Ifrah, D. Levinson and I. Farbstein

We are grateful to Prof. Kramer and Prof. Garralda for their most enlightening commentary, which adds further depth and dimensions to the issues raised in our article. We also thank Prof. Munitz for his comments and the questions he raises, and we would like to clarify some of the issues brought up by him. 1. In the Methods section of our article (paragraph 5, “Assessment of Services Utilization”), the term “primary care practitioner” is clearly defined as including general practitioner, pediatrician and internist. This definition is one utilized in previous Israeli studies (1) and by the Israel Central Bureau of Statistics (2). 2. With reference to the diagnostic categories, we used the Development and Well-being Assessment inventory (DAWBA) (3), a well known instrument to detect mental disorders among adolescents and one widely used in epidemiological studies. We used the version created in 2000, which did not include eating disorders, Tourette’s syndrome and other mental disorders. Versions of the 160

DAWBA created subsequently, which are currently being translated into Hebrew, do include these disorders, and can certainly be used in future studies. 3. We do not claim, even implicitly, that all diagnosed adolescents should be cared for by mental health professionals. On the contrary, in the Introduction section of the article, our stated aim includes a discussion of “…issues related to the involvement of PCPs in the identification and care for adolescents with mental disorders and concerns”; and in the “Conclusions” we clearly state that “…The school setting has an important role, as it is widely agreed that mental health intervention with children and adolescents is best targeted at the child’s environment. A comprehensive approach needs to be adopted, which includes mental health professionals, parents, teachers, PCP. …” 4. With regard to the fact that information about the specific reason for the PCP visit is lacking, we certainly agree that this is a limitation, and one that we clearly list as such in our article. However, we do wish to point out that data is presented from other studies indicating that although a very small percentage of adolescents present with psychiatric complaints when attending primary care, more than one third of them were found to have a psychiatric disorder in the previous year (4). Therefore, whether or not the reason for the visit is overtly presented as an emotional or behavioral concern does not affect our claim that the PCP has an opportunity to detect, during the course of routine clinical work, adolescents with mental problems who are not being cared for by any professional source of care. Again, we thank our commentators for their thoughtprovoking insights and their encouraging remarks, which provide welcome support and recognition of the vital importance of addressing the mental health needs of adolescents in Israel in the framework of a comprehensive model. References 1. Tabenkin H, Gross R. The role of the primary care physician in the Israeli health care system as a “gatekeeper” – the viewpoint of health care policy makers. Health Policy 2000;52:73-85. 2. Statistical Abstract of Israel 2002. Central Bureau of Statistics. Jerusalem, Israel. http://www.cbs.gov.il/shnaton53/shnatone53.htm (Retrieved on June 18, 2009). 3. Goodman R, Ford T, Richards H, et al. The Development and WellBeing Assessment: Description and initial validation of an integrated assessment of child and adolescent psychopathology. J Child Psychol Psychiatry 2000; 41: 645-656. 4. Kramer T, Garralda ME. Psychiatric disorders in adolescents in primary care. Br J Psychiatry 1998;173: 508-513.

Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Sung Kil Min et al.

Posttraumatic Stress Disorder in Former “Comfort Women” Sung Kil Min, MD, PhD, Chang Ho Lee, MD, Joo Young Kim, MD, and Eun Ji Sim, MS Department of Psychiatry and the Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea

ABSTRACT Objective: This study investigated the mental health of former “comfort women,” who serviced the Japanese Imperial Military during the Second World War. Method: We evaluated 26 former comfort women’s life histories, cognitive functioning, DSM-IV diagnosis of posttraumatic stress disorder (PTSD), depression, paranoid state, anger, and Rorschach test results, and compared the data with those of 24 healthy women. Results: Cognitive functioning was not significantly different between former comfort women and the comparison group. All 26 former comfort women had undergone traumatic experiences such as sexual slavery, and had suffered PTSD symptoms at least once in their lives. Of the 26, 8 (30.8%) were diagnosed as having PTSD, as opposed to none in the comparison group. The women’s PTSD symptoms were characterized by avoidance behavior, intrusive and distressing recollections, and anger. There were no significant differences in depression or paranoid state between the two groups, but former comfort women had impairments in anger control. Former comfort women with PTSD were more depressed. On the Rorschach test, former comfort women revealed characteristic responses related not only to sex and morbidity but also to anger and violence. Limitations: The small number of subjects might not represent all former comfort women. Some data collected by self-report might limit the objectivity of the results. Conclusions: The results suggest that former comfort women are still suffering from traumatic memories, symptoms of PTSD, including avoidant behavior, and anger control impairment, even 60 years after the end of the war.

Introduction Sexual violence not only harms its victims’ immediate physical and mental health but may also cause longterm psychiatric sequelae for the rest of their lives (1). Among various forms of sexual violence, one extreme type which exploits women specifically is sexual slavery during wartime. The Economic and Social Council of the United Nations (UN) (2) defined “slavery” as the status or condition of a person over whom another exercises any or all of the powers attaching to the right of ownership, including sexual access through rape or any other forms of sexual violence. The UN Commission on Human Rights (3) suggested that forced prostitution at “comfort stations,” which the Japanese Military managed during World War II, were an egregious example of sexual slavery. It suggested also that the phrase “comfort women” was not proper, and the term should be “military sexual slavery,” meaning “victims of forced prostitution, carried out by the military, for the military” (3). Former “comfort women” for the Japanese Army during WWII suffered from, not only the trauma of being sexual slaves, but also torture, wounding, diseases, starvation, and other war-related physical and psychological traumas (4-7). The use of sexual slavery and sexual violence as tactics and weapons of war is all-too-common yet often overlooked. Such atrocities demand consistent and committed action on the part of the global community (2). Nevertheless, not only have former comfort women hidden themselves, but the society surrounding them has also declined to uncover this historical war crime. Their shame regarding their past and the social stigma attached to the victims of rape have constituted additional traumas for these women. Consequently, they have lived forgotten lives, being isolated within society for the 60 years since the end of the war.

Address for Correspondence: Sung Kil Min, MD, PhD, Seoul Metropolitan Eunpyeong Hospital, 63 Baengnyeonsan-gil, Eunpyeong-gu, Seoul, 122-012, Korea skmin518@yuhs.ac

161

Posttraumatic Stress Disorder in Former “Comfort Women”

In 1991, Ms. Kim Hak-Soon of Korea revealed to the public that she was a former comfort woman. Subsequently, the Korean government and many NGO activists in Korea began investigating this concealed problem, collecting these women’s histories, and providing them with social welfare assistance (4-7). Since then, other former comfort women in Korea have followed her lead; 151 former comfort women have registered with the Korean government. Nevertheless, the exact number of former comfort women who are alive in Korea remains unknown, as most of them still seem to wish to hide. In addition, international organizations, such as the UN, have included this issue in their reports on wartime sex slavery (2, 3). However, no one has conducted any systemic research on these women’s mental health problems or psychiatric sequelae. There have been only a few survey reports, revealing several cases of posttraumatic stress disorder (PTSD) among Chinese (8) and Korean comfort women (9-12). The number of former comfort women still alive is decreasing, as several former comfort women die of old age and/or diseases every year. Therefore, active and systematic research is urgently needed to identify their medical and psychiatric problems and find proper ways to help them before it is too late. This study investigated the psychiatric sequelae of former Korean comfort women, including PTSD and other related emotional problems, and compared them with age-matched healthy women. Subject and Methods Subjects

Of the 151 former comfort women who registered with the government, we could locate 35. However, three of them did not want to expose their pasts, and six were unable to cooperate with the study due to memory issues related to old age. Eventually, 26 women agreed to participate in this study and provided their written informed consent. The comparison group consisted of 24 age- and education-matched healthy women attending a community welfare center for the elderly in Seoul. This research project protocol was approved by the Ethics Committee of the Yonsei University Medical Center, where the work was performed. Methods

Three psychiatrists (Min, Lee and Kim) and a clinical psychologist (Shim) interviewed the subjects at special care centers for former comfort women or at 162

Yonsei University Medical Center. We evaluated each participant’s cognitive functioning via the Korean version of the Mini-Mental State Examination (K-MMSE) (13) and obtained their demographic data and past life history using a semi-structured interview schedule. To determine the participants’ psychiatric diagnoses, we utilized mental examinations and the Korean version of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (14). All subjects rated themselves on the Korean version of the Geriatric Depression Scale (GDS) (15), the paranoid state (PS) scale (composed of 22 items from the MMPI) (16), and the Korean version of the State and Trait Anger Expression Inventory (STAXI) (17). The Rorschach test was administered to the subjects by the psychologist. Statistical Analysis

To determine the participants’ PTSD symptom frequencies, we used the SCID-I; Table 1 shows this informaTable 1. Frequency of endorsed items in DSM-IV criteria for posttraumatic disorder in former comfort women

Symptoms Recurrent and intrusive distressing recollection of the events.

Number of patients N = 26

96.1

Recurrent distressing dreams of the events

92.3

Acting or feeling as if the traumatic events were recurring

30.7

Intense psychological distress at exposure to internal or external cues

76.9

Physiological reactivity on exposure to internal or external cues

84.6

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

100

Efforts to avoid activities, places, or people that arouse recollections of the trauma

96.1

Inability to recall an important aspect of the trauma

42.3

Markedly diminished interest or participation in significant activities

38.4

Feeling of detachment or estrangement from others

50.0

Restricted range of affect

42.3

Sense of foreshortened future

96.1

Difficulty falling or staying sleep

96.1

Irritability or outburst of anger

92.3

Difficulty concentrating

69.2

Hypervigilance

76.9

Exaggerated startle response

69.2

Sung Kil Min et al.

tion. We used T-tests to examine the mean score differences on the MMSE, PS, GDS, and STAXI between former comfort women and the comparison group and also between former comfort women with and without PTSD. We employed Exner’s methodology (18) to analyze all the Rorschach test results. To conduct the statistical analysis, we used SPSS version 11.0 for Windows. Results Age and cognitive functioning

The ages of the former comfort women ranged from 72 to 87 years, and their mean age, 79.35 years (SD = 3.95), was not significantly different from that of the comparison group (77.04 years, SD = 5.78). The comfort women’s mean years of education (3.12 years, SD = 3.82) was not significantly different from that of the comparison group (2.75 years, SD = 3.74). The comfort women’s mean MMSE score (mean = 23.0, n = 26, SD = 3.06) was not significantly different from that of the comparison group (mean = 22.5, n = 24, SD = 4.06). History of traumatic experiences

The 26 former comfort women reported that, at ages ranging from 13 to 26 years, they were deceived, forcibly drafted, or kidnapped by Japanese government officers or their representatives and sent to comfort stations in Taiwan, China, Manchuria, or Southeast Asia. The age at the time when they were sent to the stations is as follows: four were 13 years old, one was 14 years old, seven were 16 years old, nine were 17 years old, two were 18 years old, and the remaining three women were ages 19, 22 and 26. According to the former comfort women, they were extremely scared when they were taken to the Japanese military camp. They were forced to prostitute themselves repeatedly, more than 20 times per day, to Japanese soldiers and officers. At all times, they suffered from fear, disgust, pain, humiliation, and anger. They were paid with Army scrip, which could not be used outside of Army camps. They also reported experiencing physical traumas, including beatings and torture (16 women, 61.6%), confinement (nine women, 34.6%), starvation (nine women, 34.6%), repeated threats (eight women, 30.8%), witnessing scenes of death (people dying, being killed, etc.) (eight women, 30.8%), and venereal disease infections (three women, 11.6%). After the war, the Army released the women, but each then had to find her own way home. All 26 barely man-

aged to return to Korea, but most found that they could not stay in their hometowns with their families, because of their feelings of shame and guilt. Only three women (11.6%) reported that they had lived with their families at least once after returning to Korea. Furthermore, 16 (61.5%) had once married, but they eventually lost their spouses to divorce or death; eight (30.8%) had given birth; and one had adopted a boy, who left her after he turned 16. Eventually, they all came to live solitary, hidden, poor, and difficult lives, isolated from society. At the time of our study, nine were living independently, 11 were receiving financial support from the government for their care, and six were living at a special care center for former comfort women (Nanum-ui-jib meaning “the house of sharing” in Korean). Physical disorders

All the former comfort women reported that they suffered from various physical health issues: 19 (73.1%) reported pains related to joint or spinal disease; 13 (50.0%) reported stomach pain and difficulty with digestion; 13 (50.0%) reported a “pushing-up” feeling in their epigastria, with a hot feeling (typical symptoms of hwa-byung, a Korean culture-related syndrome of anger [19]); eight (30.8%) reported nervous system disorders; seven (26.9%) reported respiratory disorders; five (19.2%) reported difficulty in urination; in four (15.4%) reported diabetes; and four (15.4%) reported sequelae of physical injuries. Mental state at interview

Most of the former comfort women were reluctant to talk about themselves. Usually, at the beginning of the interviews, they would smile and thank the interviewers for showing concern for their issues, but they also would generally show some shyness and hesitation. As the interview went on, each woman eventually became enthusiastic, very eager, and frank about telling her story in detail. Many women repeatedly burst into tears whenever talking about the traumatic experiences the Japanese soldiers inflicted on them. Some impulsively expressed hatred and anger, using abusive words, when talking about Japanese politicians who seemed to be trying to minimize the issue of sex slavery. Posttraumatic Stress Disorder (PTSD)

According to the SCID-1 evaluation results, eight former comfort women (30.8%) met the criteria for PTSD. However, their histories revealed that all 26 former com163

Posttraumatic Stress Disorder in Former “Comfort Women”

fort women had had PTSD or partial PTSD at least once in their lives. No one in the comparison group had PTSD. Table 1 shows the frequencies of the former comfort women’s PTSD symptoms (as per the DSM-IV description of PTSD). The most common symptom was “efforts to avoid thoughts, feelings, or conversations associated with the trauma,” which all 26 women reported (100%). Next, 96% of the women reported “efforts to avoid activities, places, or people that arouse recollections of the trauma,” “recurrent and intrusive distressing recollection of the events,” a “sense of (a) foreshortened future,” and “difficulty in falling or staying asleep.” In addition, more than 92% reported “recurrent distressing dreams of the events” and “irritability or outbursts of anger.” More than 70% reported “intense psychological distress at exposure to internal or external cues,” “physiologic reactivity upon exposure to internal or external cues,” and “hyper-vigilance.” However, only 30-40% of these women reported symptoms of “acting or feeling as if the traumatic event (was) recurring,” “markedly diminished interest or participation in significant activities,” “inability to recall an important aspect of the trauma,” and “restricted range of affect.” Those with higher levels of education or other persons whom they could depend on, and those who had married or had a child, reported fewer symptoms. However, these differences were not significant. A case vignette: Kim YS, a 77-year-old former comfort woman. At age 17, a village officer suggested she should go to work at a factory in Japan. She traveled by train and ship for 15 days. When she arrived at the workplace, she realized she was not in Japan but at a military camp in Taiwan. She was forced to live at a “comfort station” with about 15 other Korean girls and a few Chinese women. Every day, she and the other comfort women had to prostitute themselves. She had to service more than 20 soldiers a day. It was painful and disgusting. When soldiers approached her for sex, they appeared to her as beasts. To Kim, the soldiers seemed to behave like “proud winners riding a horse.” Some soldiers would place the barrel of a firearm into her vagina. If a comfort woman refused to submit to the soldiers, she would be confined, beaten, starved, or tortured by soldiers. Eventually, she contracted venereal disease. In addition, she had to watch other girls being beaten or even forced to have abortions. She saw girls die of wounds or diseases. Some tried to escape the camp, but there was 164

no place for them to hide. When she was “off duty,” she would climb a small hill, gaze beyond the ocean horizon toward home, and cry. She remembers an officer who was kind to her and used to accompany her to the hill. (During her interview with one of this study’s authors, Kim sang a Japanese song that he had taught her.) One day, after several bombings, she found that she and the other comfort women had been abandoned by the soldiers. The war had ended. She had to find her own way home. At one port, she was able to take the ship with other Korean laborers who had worked for the Japanese Army. After a voyage of several days, she arrived at Busan, a southern port city in Korea. However, she did not dare go home because she felt so ashamed that her body had become “dirty.” She settled in another small city and began earning her living as a peddler. She decided to live alone and not marry. Kim avoided personal relationships with neighbors due to the fear of her past being disclosed. After she opened a small grocery, she adopted a boy, a Korean War orphan who was roaming around in her area. However, when he was 16 years old, he left her. Since leaving the comfort station, Kim has suffered from pains on her entire body, including her back and joints. She has recently begun suffering from hypertension and diabetes mellitus. Furthermore, in the past she has suffered from insomnia, social anxiety, and depressed mood. She suffered every night from nightmares of being pursued, falling, shells exploding, or being attacked by soldiers. Whenever she saw soldiers in the street or read news regarding Japan or the Japanese, she felt her heart pounding and “rising” anger with a hot flush in her head and upper chest. Physicians and herb doctors used to examine her, but their help was limited because she felt she could not let them know her life history. In 1991, when Ms. Kim Hak Soon disclosed to the public that she was a former comfort woman, Kim decided to follow her suit. She reported her history to an NGO office, which has been giving her health and living support. Now, every Wednesday, she actively participates with many other volunteer activists in demonstrations on behalf of former comfort women in front of the Japanese Embassy in Seoul. During our recruitment of study participants, Kim voluntarily visited the Department of Psychiatry, Severance Hospital, Yonsei University in Seoul. During her interview for this study, she thanked the authors for their recognition of the comfort women’s hidden psychological pains, including hers, and for their attempt

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to help them. Moreover, she revealed a long and painful history, complicated by regret and anger, and reported various symptoms: insomnia, nightmares, avoidance behavior, and anxiety attacks cued by news regarding wars or Japan or the sight of soldiers. She was diagnosed as having PTSD. Ever since, she has received regular psychiatric treatment over the course of four months. Kim has shown gradual improvement. Depression, paranoid symptoms and anger

Former comfort women scored slightly higher on the GDS and PS than the comparison group did, but the differences were not significant (Table 2). On the STAXI, former comfort women scored lower on trait anger and state anger and higher scores on anger suppression and anger expression than the comparison group, but the differences were not significant. However, the score of former comfort women was significantly lower on anger control than that of the comparison group (t = ‑2.38, df = 48, p < 0.05) (Table 2). Former comfort women with PTSD and without PTSD

Among the eight women with PTSD and the 18 women without PTSD, there were no significant differences in demographical variables or results on the MMSE, PS, STAXI, and Rorschach test. However, the total GDS score of comfort women with PTSD (mean = 25.13, SD = 3.14) was significantly higher than that of comfort women without PTSD (mean = 20.22, SD = 4.75) (t = 3.11, df = 24, P < 0.05). Table 2. Differences between former comfort women and the healthy comparison group in depression, paranoid symptoms, and anger Former comfort women (n = 26) Mean(S.D.)

Comparison group (n = 24) Mean(S.D.)

GDS

21.73(4.84)

20.50(7.59)

.68

.50

48.00

27.69(8.81)

24.83(13.59)

.87

.38

38.51

Anger Trait

24.58(5.55)

24.92(6.76)

-.20

.84

48.00

Anger State

10.73(2.20)

11.88(4.10)

-1.22

.23

34.61

Anger Suppression

19.58(4.78)

17.00(6.04)

1.68

.10

48.00

Anger Expression

14.42(6.03)

13.67(4.97)

.48

.63

48.00

Anger Control

21.58(4.52)

24.17(2.93)

-2.38*

.02

48.00

STAXI

GDS: Geriatric Depression Scale; PS: paranoid Scale; STAXI: State and Trait Anger Expression Inventory *p < .05

Rorschach Test

The former comfort women’s responses to the Rorschach cards were generally intense, straightforward, and generally related to violence, sex organs, sexual behavior, or injury. The following are a few of their typical responses to certain Rorschach cards. I. Japanese are dragging virgin girls violently. Two Japanese bring six Korean women. Men are pulling women’s arms; they are bringing the women to satisfy their sexual desires, riding on horses, and wearing military clothes. II. The upper part is the head and the lower part is the vagina. The head is injured, too. Why is the nose bleeding? Medicine was used to wash the sex organs. III. It looks like two men pulling a woman’s vagina. Beasts! IV. This is women’s secret part, but these legs look like a man’s penis, because the belly is facing down, but I don’t know. Japanese are beating us. It looks like they are attacking us. If we resist a little bit, we will get bloody noses, because they will beat us. The lower part is a vagina; the upper part is a Japanese soldier. This is a scene of sexual intercourse. V. Japanese are attacking us, because we don’t follow their orders. So they beat us and scare us. Legs are pulled this much apart and arms are moved this way. Their heads are like those of venomous snakes filled with the poison of anger. It looks like a person is being tortured and treated like a pig. Women are bound to a tree. Their eyes are blinded. Japanese always cut the neck. It looks like they are wetting themselves because they are too scared. Balls are curled upward. They are behaving as a king or famous person. It looks like a protruding belly. They can’t breathe. It looks like two men are putting a gun into a woman’s vagina. VI. It looks like someone peeing. There is a buttock at the bottom. It looks like a man or a woman. This is a woman’s vagina, but a little weird. In some way it looks like a man’s penis. A Korean’s neck is cut with a steel string. VII. A vagina is bleeding. They look delighted, and mount on a woman. They look so proud of themselves. VIII. Vomiting blood. They put their penis into a woman’s mouth. They do whatever they want to do. They dance and feel happy. It looks like they are exhausted and lying down. 165

Posttraumatic Stress Disorder in Former “Comfort Women”

Table 3. Differences in Rorschach test responses between former comfort women and the comparison group Former comfort women (n = 26) Mean (S.D.)

Comparison group (n = 24) Mean (S.D.)

Affective Ratio

.38(.16)

.46(.12)

-1.76

.85

48.00

.22(.59)

.08(.28)

1.14

.26

36.60

.62(.80)

.13(.45)

2.69

.01

39.78

Space

1.08(1.65)

.21(.41)

2.50*

.01

48.00

Cooperative movement

.42(.58)

.21(.41)

1.51

.13

45.35

Aggressive movement

1.73(2.51)

.04(.20)

3.42**

<.01

25.36

Anatomy

.92(2.08)

.13(.45)

1.91

.06

27.51

Blood

.19(.69)

.00(.00)

1.41

.17

25.00

Sex

1.27(2.31)

.04(.20)

2.70*

.01

25.42

Morbid

1.27(2.07)

.25(.74)

2.35*

.02

31.69

TC/R

.38(.45)

.04(.10)

3.66**

<.01

27.80

IX. This is a woman’s vagina. Both sides are legs, but they are not healthy, with many scars on the body. Are these like cancer in the vagina? Women have bumps in their vaginas. A man and a woman are drinking each other’s blood. Table 3 shows the results of using the Exner method (18) to analyze the participants’ responses on the Rorschach test. There were no significant differences between former comfort women and the comparison group on the affective ratio or the form-color (FC) responses that reflect emotional control. However, the former comfort women had a significantly higher score on the color-form (CF) response (P < 0.05), which reflects impulsive emotions. In addition, the comfort women had a significantly higher score on the space response (P < 0.05), which reflects anxiety. There was no significant difference between two groups in cooperative movement content, which reflects perception of interpersonal relationships. However, former comfort women scored significantly higher on aggressive movement content than the comparison group did (P < 0.05). Former comfort women recorded significantly higher mean scores than the comparison group on sex response (P < 0.05), morbid response (P < 0.05), and trauma content index (TC/R) (P < 0.01). On the other hand, there were no significant differences between the groups in either anatomy or blood responses. 166

Discussion The history of former comfort women, which has been previously reported or witnessed (3-12), is confirmed by our study results. Former comfort women in this study had been drafted at a young age and traumatized as sex slaves of soldiers as well as experiencing other traumas of war. After the war, they lived difficult lives, being isolated from society and suffering from various psychiatric sequelae, including PTSD and suppressed anger, for more than 60 years. This study suggests that trauma as a sexual slave in wartime may cause PTSD at any time of life, even 60 years after the traumatic experience. In women who have been sexually assaulted, PTSD usually develops during the acute phase of adjustment, after which symptoms diminish in most victims. However, some victims may manifest chronic PTSD for many years post-assault (20). In these chronic cases, though the severity of the stressor is the primary determinant of acute PTSD, researchers have argued that pre-existing personality factors, resilience (21), and relational capacity (22) are important contributors to the development of chronic PTSD. Accordingly, based on these research findings, we can speculate upon why PTSD in former comfort women has persisted for 60 years after the trauma. First, the primary stressor of sexual slavery was so extreme and egregious it may have overwhelmed the victims’ pre-existing personalities and capacity for resilience. Second, the shameful stigmatization of sex crime victims in the context of Korea’s traditional culture may have aggravated the trauma. Third, the avoidance symptoms of PTSD, the “effort to avoid thoughts, feelings, conversations, activities, places, or people associated with the trauma,” which we found in all former comfort women, might have prevented them from rebuilding social relationships. Previously, their isolated lives have generally been explained as due to their feelings of shame and guilt. However, this study suggests their isolated lives were also due to PTSD-related avoidance behaviors. Finally, one characteristic reason for persistent PTSD in former comfort women may be anger, which was originally a reaction to their victimization by sexual slavery and other forms of violence. However, official non-admittance of the historical facts pertaining to comfort women, by the Japanese people and the Japanese government, has continuously stimulated these women’s anger. Similarly, Lagos and Kordon (23) reported that torture survivors’ trauma sequelae could

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continue when their torturers were declared not guilty. Therefore, psychiatrists and others treating these former comfort women’s PTSD should deal with other contributing factors, including the shameful stigmatization of sex crime victims and the victims’ limited abilities to create social relationships and their anger, and supporting the victims’ resilience. This study also suggests PTSD’s symptom profile might differ according to the nature of the trauma. PTSD symptom profiles of former comfort women were characterized by avoidance, recollection, and anger. The most common symptoms of victims of a single rape are recurrent intrusive recollection (100%), decline in interest (100%), and constricted affect (97%) (24), or re-experience and numbness (25). Most former comfort women in this study were engaged in daily life, showing interest in and affective reaction to social phenomena surrounding them, especially, enthusiastically participating in anti-Japanese activities. Kurayama (8) pointed out that comfort women who were drafted at younger ages later showed PTSD symptoms that were of greater severity. However, this study found no such difference. There were no significant differences in depression, paranoid symptoms, state anger, anger suppression, or anger expression between former comfort women and the comparison group. This suggests that former comfort women may have almost controlled or hidden their emotional reactions and maintained a calm and mild emotional life, like healthy elderly people. However, we found they had impaired anger control. Given stimulation, their deep-seated anger seemed easily provoked, and, in fact, the projective Rorschach test vividly revealed this. Responses on the Rorschach test were characterized by sex, trauma, impulsiveness, aggressiveness, and morbidity. The responses appeared much more morbid than the responses shown by victims of a single episode of rape (26). In practice, these women often failed to control their anger when they were stimulated. For example, some of them explosively expressed their anger and hatred, with outbursts of crying, when talking about the Japanese government, which was still trying to officially avoid admitting this past crime committed against the comfort women, or about the Japanese Prime Minister, who had visited and worshipped at the Yaskuni Shrine where the enshrined names include those of war criminals. Another clinical characteristic of former comfort women was sadness. PTSD is frequently co-morbid with depression. We found this frequent co-morbidity in

former comfort women. As an additional characteristic finding of the mental state examination, former comfort women had frequent outbursts of tearing or crying while they talked about how much anger and “ukwool” ([uhgool], a feeling that the environment is unfair or unjust) they felt. PTSD in former comfort women, which was found to be co-morbid with anger, sadness, and feelings of unfairness, may be so-called complex PTSD. Herman (1) has reported complex PTSD or other disorders of extreme stress presented by incest or childhood sexual abuse survivors who showed more severe symptoms. Researchers have hypothesized that the risk factors for this complex PTSD are early age onset, exposure to interpersonal stress, and prolonged duration. In complex PTSD, traumatic experiences have a profound impact on self-regulation, self-definition, interpersonal functioning, and adaptation style. Typical clinical features of complex PTSD include problems with anger modulation (selfdestructive and impulsive behavior), dissociative symptoms, somatization, feelings of ineffectiveness, shame, despair or hopelessness, impaired relationships with others, and loss of previously sustaining beliefs. Etiological factors and symptom profiles of complex PTSD appear to partly overlap with the PTSD of former comfort women, as described in this study. In the case of complex PTSD in former comfort women, the disorder correlated to repetitive exposure to trauma for a certain period at young age and included characteristics of avoidance, anger, impaired relationships with others, and shame. This study showed that anger and feeling of unfairness may complicate PTSD. This clinical profile seems to have elements in common with so-called hwabyung ([huat-byung]) (19, 27). The Korean word hwa means “anger” (or “fire”), and byung means “disease.” Hwa-byung is a known Korean culture-related anger syndrome. The basic clinical feature of hwa-byung is suppression of reactive anger to unfair social trauma. Generally, patients with hwa-byung had to suppress their anger in order not to jeopardize a harmonious interpersonal relationship. However, as traumatic experiences repeat, the continuously-suppressed anger accumulates, and finally hwa-byung develops. Symptoms of hwa-byung are characterized by suppressed anger, expressed anger, and feelings of unfairness, hatred, and the “hot feeling” (27). In particular, hwa-byung is common in women who as the socially weaker gender must suppress their anger in reaction to unfair and violent environments (28). Interestingly, many former comfort women said they have suffered from hwa-byung. 167

Posttraumatic Stress Disorder in Former “Comfort Women”

PTSD in comfort women is comparable to the PTSD found several decades after victimization in victims of the Nazi Holocaust (29, 30), prisoners of war (31), veterans of wars (32, 33), victims of political torture, and refugees (34). All these findings suggest that PTSD can develop several decades after trauma. However, there has been no systematic research on the similarity or difference between the PTSD of former comfort women and other types of chronic PTSD. While society has openly and officially sought, located, studied, and supported survivors of the Nazi Holocaust, victims of political torture, and veterans of wars, former comfort women have so far remained hidden for a long time, obscured not only by their own choice but by society surrounding them, probably because of stigmatization arising from the sex-relatedness of their ordeal. Accordingly, they have lost opportunities to be located, studied, helped, or treated properly in a timely manner. This study was limited by the small number of participants and the fact that these participants might not represent all former comfort women. However, former comfort women have admittedly tried to avoid social exposure. Our participants might be more positive and more courageous than typical former comfort women, since they were willing to expose their pasts. Meanwhile, non-participant former comfort women might be more strictly avoiding social relationships and, therefore, might be suffering from more serious PTSD, anger, and depression. Hence, this study’s findings may not be less significant than they would have been had all former comfort women participated. Another limitation is that we obtained the data on anger, depression, and paranoid state via self-rating scales. This subjectivity in the responses may have limited the objectivity of our findings. Moreover, we used a rather simple comparison in the statistical analysis. Unfortunately, further research with more participants, objective evaluations, and advanced statistical analysis methods seems extremely unlikely to take place in the future, because the number of former comfort women is rapidly decreasing. More than half a century has passed since these women returned home from the comfort stations. Furthermore, some survivors have been reported in other countries, including China (8, 9). This study found that former comfort women who had accepted psychiatric treatment had shown some improvement. Regretfully, in Korea, though social support began immediately after their registration as former comfort women, a very long time had passed before these 168

women actually came out to the public. Several registered former comfort women die every year due to old age and/or disease. Before it is too late, the international community must begin locating hidden former comfort women, officially recognizing their suffering, minimizing their further suffering, and supporting them for a better life from this point forward. Acknowledgements This work was supported by a grant from the Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, to S.K. Min Conflict of interest: None This paper was previously published in Korean in the Journal of the Korean Neuropsychiatric Association, vol. 43, page 740-748, in 2004. The editorial committee of the Korean Neuropsychiatric Association allowed us to publish this paper in the Israel Journal of Psychiatry.

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15. Chung IK, Kwak DI, Shin DK, Lee MS, Lee HS, Kim JY. The reliability and validity of the Geriatric Depression Scale. J Korean Neuropsychiatr Assoc 1997;36:103-112 (in Korean). 16. Lee HJ, Won HT. The reliability and validity of a paranoid scale. Korean J Psychol Clinical 1995;14: 83-94 (in Korean). 17. Chun KK, Han DW, Lee JH, Spielberger CD. The Korean version of STAXI. Korean J Psychol Health 1997;2:60-78 (in Korean). 18. Exner JE. The Rorschach: A comprehensive system. Vol. 1. Basic foundations (3rd ed). New York: Wiley & Sons, 1993. 19. Min SK, Suh SY. Anger syndrome, hwa-byung and its comorbidity. J Affect Dis 2009;124:211-214 20. Kilpatrick D, Saunders B, Amick-McMullan A. Best C, Veronen L, Resnick H. Victim and crime factors associated with the development of crimerelated post-traumatic stress disorder. Behav Ther 1989;20:199-214. 21. McFarlene A. The longitudinal course of posttraumatic morbidity. J Nerv Ment Dis 1988;176:30-39. 22. Regehr C, Marziali E. Response to sexual assault. A relational perspective. J Nerv Ment Dis 1999;187:618-623. 23. Lagos D, Kordon D. Psychological effects of political repression and impunity in Argentina. Torture 1996;6:54-56. 24. Bownes IT, Oâ&#x20AC;&#x2122;Gorman EC, Sayers A. Assault characteristics and posttraumatic stress disorder in rape victims. Acta Psychiatr Scand 1991; 83:27-30. 25. Zlotnick C, Zimmerman M, Wolfsdorf BA, Mattia JI. Gender differences in patients with postttraumatic stress disorder in a general psychiatric practice. Am J Psychiatry 2002;158:1923-1925.

26. Kamphuis JH, Kugeares SL, Finn SE. Rorschach correlates of sexual abuse: Trauma content and aggression indices, J Pers Assess 2000; 75:212-224. 27. Min SK. Hwa-byung and haan. J Korean Med Assoc 1991; 34:1189-1198 (in Korean). 28. Chung HK. Struggle to be the sun again. Maryknoll, N.Y.: Orbis Books, 1991. 29. Kuch K, Cox B. Symptoms of PTSD in 124 survivors of the Holocaust. Am J Psychiatry 1992; 149:337-340. 30. Yehuda R, Kahana B, Schmeidler J, Southwick SM, Wilson S, Giller EL. Impact of cumulative lifetime trauma and recent stress on current posttraumatic stress disorder symptoms in Holocaust survivors. Am J Psychiatry 1995;152:1815-1818. 31. Port CL, Engdahl B, Fraizer P. A longitudinal and retrospective study of PTSD among older prisoners of war. Am J Psychiatry 2001; 158;14741479. 32. Sutker PB, Winstead DK, Galina ZH, Allain AN. Cognitive deficits and psychopathology among former prisoners of war and combat veterans of the Korean conflict. Am J Psychiatry 1991;148:67-72. 33. Brenner JD, Southwick SM, Darnell A, Charney DS. Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse. Am J Psychiatry 1996;153:369-375. 34. Weine SM, Vojvoda D, Becker DF, McGlashan TH, Hodzic E, Laub D, Hyman L, Sawyer M, Lazrove S. PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. Am J Psychiatry 1998;155:562-564.

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Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Psychosomatic symptoms among hospital physicians during the Gaza War: A repeated cross-sectional study Menachem Ben-Ezra, PhD,1 Yuval Palgi, PhD,2 Jonathan Jacob Wolf, BA,3 and Amit Shrira, PhD4 1

School of Social Work, Ariel University Center of Samaria, Ariel, Israel Department of Gerontology, University of Haifa, Haifa, Israel 3 Department of Psychology, Trinity College Dublin, Dublin, Ireland 4 Department of Psychology, Tel Aviv University, Tel Aviv, Israel 2

ABSTRACT Research regarding psychosomatic symptoms among hospital physicians during armed conflict is scarce. The current study compared psychosomatic symptoms of exposed and unexposed hospital physicians in two studies. The studies were conducted during 2009 and included a survey of two random samples of hospital physicians, one conducted during the Gaza War and the other conducted six months later. Each sample included hospital physicians who were directly exposed to war-related stress and others who were not (Study 1: N = 54; Study 2: N = 31). In Study 1, exposed hospital physicians did not differ from unexposed physicians in the level of psychosomatic symptoms during the war (Psychosomatic Problems Scale 6.48 vs 4.09). However, in Study 2, exposed physicians reported a higher level of psychosomatic symptoms (10.33 vs 3.21). Moreover, analysis of covariance revealed a significant interaction effect of Exposure X Study (F = 7.976; p = .006; Îˇp2 = .100). Exposure to war-related stress takes a toll on psychosomatic symptoms among hospital physicians. This late onset of psychosomatic symptoms is discussed in light of the cognitive-energetical model.

Introduction Physicians who practice in general hospitals face heavy workloads, occupational stress, ethical dilemmas, and conflicting demands as part of their everyday life (1). Address for Correspondence: â&#x20AC;&#x2020; menbe@ariel.ac.il

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These may result in psychological stress, psychosomatic symptoms and psychiatric morbidity (1, 2). Studies from the Second Lebanon War have shown that Israeli hospital physicians who faced an overwhelming mass of casualties and severe injuries when the hospital itself was targeted by rockets and missiles reported high levels of posttraumatic stress and depressive symptoms (3-5). Most studies on hospital personnel during extreme conditions emphasized posttraumatic stress disorder (PTSD) and depression, thus neglecting other types of psychiatric morbidity such as psychosomatic symptoms. As previous studies found an association between stress and somatization (6-8), there is a rationale to investigate somatization among hospital personnel who work under extreme circumstances (e.g., working in an unsheltered hospital targeted by rockets during war). Moreover, since the potential for impairment in functioning as a result of the psychosomatic symptoms has not been studied among physicians, it is very important to do so as physicians make life and death decisions on a regular basis. Indeed, there is paucity in the study of psychosomatic symptoms among physicians in times of extreme stress during which they are subject to immediate threat to life along with a sharp increase in the hospital workload due to the emergency or disastrous situation. Hospital physicians exposed to war-related stress represent a highly selective population. The goal of the current study was to compare the psychosomatic symptoms of randomly sampled hospital physicians directly exposed to war-related stress during the Gaza War to unexposed hospital physicians. Based on previous research (3-5), it was hypothesized that during the war, physicians exposed to direct stress would show a higher level of psychoso-

Dr. Menachem Ben-Ezra, School of Social Work, Ariel University Center of Samaria, Ariel 40700, Israel

Menachem Ben-Ezra et al.

matic symptoms compared to unexposed physicians. In addition, based on the cognitive-energetical model (9, 10), which postulates that performance may be protected under stress by the recruitment of further resources, but at the expense of post-task increased physiological and psychological costs, it was hypothesized that exposed physicians would show an increased level of psychosomatic symptoms six months after the war ended. Method Design

Two studies were conducted in different periods thus forming a repeated cross-sectional design. The first study took place three weeks after the beginning of the war while the war was still raging (Study 1); the second study took place six months after the end of the war (Study 2). Participants

Two studies with separate groups of participants were conducted. In Study 1, participants were comprised of hospital physicians selected at random from two hospitals during the week of January 12-15, 2009 (three weeks after the war began). The two hospitals were the Barzilai Medical Center in Ashkelon (Exposed) and the Sourasky Medical Center in Tel Aviv (Unexposed). Only participants who volunteered and gave their consent were interviewed. During the Gaza War (11), more than 750 rockets were launched into southern Israel, approximately 100 of which targeted the city of Ashkelon. During this time, the unsheltered Barzilai Medical Center in Ashkelon treated 616 people (193 Israeli soldiers, and 423 Israeli and Palestinian civilians) admitted as a result of the armed conflict while under direct rocket attack. Apart from southern Israel, the rest of the country was not within missile range. Therefore, the Sourasky Medical Center in Tel Aviv and its personnel were not exposed to war-related stress during the Gaza War. The total number of hospital physicians who were interviewed in both studies was 85. The response rate for Study 1 was 85% in the exposed and 90% in the unexposed group. A lack of time was the most frequent reason given for declining to participate. Thus, in Study 1, 21 exposed physicians and 33 unexposed physicians participated. In Study 2, participants were physicians randomly selected from the same two hospitals during the week of July 19-22, 2009, six months after the war ended. The response rate was 82% at Barzilai Medical Center (previously-exposed) and 87% at Sourasky Medical Center

(unexposed). Again, lack of time was the most frequent reason given for declining to participate. The participants in Study 2 included 12 previously-exposed physicians (i.e., exposed during the war but did not participate in Study 1) and 19 unexposed physicians from Sourasky Medical Center. Exposed physicians and their families (in both Study 1 and Study 2) resided in the greater Ashkelon area, while the unexposed physicians and their families resided in the greater Tel Aviv area. All physicians from Barzilai Medical Center who participated in both studies had worked there during the war and had been exposed to direct rocket attacks. Except for the previouslyexposed group in Study 2, none had a prior exposure to war-related stress. Each participant was interviewed in person and guaranteed complete anonymity. Instruments Independent variables

The instruments used in both studies were identical for the purpose of replication. Each participant was interviewed for background characteristics (age, gender, marital status, religiosity, income, years of education, and perceived social support). The following demographic variables were coded as following: Gender (0 = men; 1= women), marital status (0 = married; 1 = not married), religiosity (0 = secular; 1 = conservative; 2 = religious), and income (0 = below average; 1 = average; 2 = above average). War-related exposure was coded as (0 = unexposed, Sourasky Medical Center; 1 = exposed, Barzilai Medical Center). Perceived social support was assessed by rating the sentence: “I get the emotional help and support I need from my family and friends” on a five-point Likert scale (1 = not at all, 2 = a little bit, 3 = moderately, 4 = much, 5 = very much). Subjective well-being was assessed on a four-point Likert scale by the question: “All things considered, how satisfied are you with your life these days?” (1 = not at all, 2 = a bit, 3 = much, 4 = very much). Perceived coping was assessed by the question: “How well do you think you are handling the situation given the circumstances?” on a five-point Likert scale (1 = not at all, 2 = a little bit, 3 = moderately, 4 = much, 5 = very much). These items were based on modified items from the Short-Form Health Survey (SF-36) (12). Dependent variable

Psychosomatic symptoms were measured by the Psychosomatic Problems Scale (PSP) (13). The PSP is 171

Psychosomatic symptoms among hospital physicians during the Gaza War

an eight-item scale and it is scored by summation of responses (raw scores) across the following eight items: “had difficulty in concentrating,” “had difficulty in sleeping,” “suffered from headaches,” “suffered from stomach aches,” “felt tense,” “had little appetite,” “felt sad” and “felt giddy.” The response categories for all of these items, which are in the form of questions, are 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = very often. The categories are ordered in terms of implied frequency in the past week and the greater the frequency, the greater the psychosomatic distress. Justification of the scoring procedure was examined by psychometric analysis using the Rasch model (13). Cronbach’s alpha coefficient was .932 and .953 for Study 1 and 2 respectively. Statistical analysis

In both studies the two groups (exposed vs. unexposed) were compared for psychosomatic symptoms using t-tests. Following the basic examination, changes in psychosomatic symptoms in each group were examined (Study 1 vs. Study 2 for the exposed and unexposed groups respectively) using t-tests. Analysis of covariance (ANCOVA) was then conducted, with the PSP score as the dependent variable. The independent variables were exposure to warrelated stress (exposed vs. unexposed) and Study (Study 1

vs. Study 2). The covariates were background demographics (age, gender, marital status, profession, religiosity, income, and years of education) as well as perceived social support, subjective well-being and perceived coping). The ANCOVA included effect size estimates (partial eta square). All analyses were performed using SPSS statistical software (version 18.0, SPSS Inc, Chicago, IL). Results Comparison of exposed and unexposed physicians

None of the participants in either study had a history of severe health problems, mental disorders (including stress-related disorders or prior depression) or substance abuse. In Study 1, the two groups did not differ in background demographics (Table 1 and Table 2, respectively) except in age, for which the physicians from the exposed group were older (t= 2.602; p =.012). In Study 2, as well, the two groups did not differ in background demographics, except for age, with subjects from the exposed group also being significantly older (t= 4.426; p <.001). In Study 1, there was a significant differences between perceived coping showing lower perceived coping among the exposed group (t = -3.959; p<.001). However, no significant difference in psychosomatic

Table 1. Descriptive Statistics for Exposed and Unexposed Physicians in Study 1 Exposed (Barzilai Medical Center)

Unexposed (Sourasky Medical Center)

Study 1 (n=21)

Study 1 (n=33)

Test statistics

Age, years (SD)

45.71 (11.07)

38.67 (9.92)

t = 2.602

.012

Gender, Women, N (%)

9 (42.9)

14 (42.4)

χ2 = 0.031

.975

Marital status, Married, N (%) Unmarried Married/Cohabitation Divorced/Separated Widowed

9 (42.8) 11 (52.4) 1 (4.8) 0 (0.0)

9 (27.2) 22 (66.7) 2 (6.1) 0 (0.0)

χ2 = 1.040

.298

Religiosity, N (%) Secular Conservative Religious

19 (90.4) 1 (4.8) 1 (4.8)

30 (90.9) 2 (6.1) 1 (3.0)

χ2 = 0.071

.944

Income, N (%) Below average Average income in Israel (8113NS = 2134US) Above average

5 (23.8) 2 (9.5) 14 (63.6)

7 (21.2) 10 (30.3) 16 (48.5)

χ2 = 0.889

.374

Years of education, mean (SD)

19.33 (1.16)

19.88 (1.73)

t= -1.275

.208

Perceived social support, mean (SD(

3.57 (1.12)

2.94 (1.58)

t = 1.593

.117

Subjective well-being, mean (SD)

3.24 (0.54)

3.48 (0.51)

t= 1.700

.095

Perceived coping, mean (SD)

3.86 (1.01)

4.67 (0.48)

t= -3.959

<.001

PSP Scale, mean (SD)

6.48 (7.17)

4.09 (6.47)

t = 1.266

.211

Abbreviations: PSP, Psychosomatic Problems Scale

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p value

Menachem Ben-Ezra et al.

Table 2. Descriptive Statistics for Exposed and Unexposed Physicians in Study 2 Exposed (Barzilai Medical Center)

Unexposed (Sourasky Medical Center)

Study 2 (n=12)

Study 2 (n=19)

Test statistics

p value

Age, years (SD)

46.92 (10.88)

34.69 (6.60)

t = 4.226

<.001

Gender, Women, N (%)

4 (42.9)

11 (57.9)

χ2 = 1.311

.190

Marital status, Married, N (%) Unmarried Married/Cohabitation Divorced/Separated Widowed

2 (12.5) 8 (75.0) 2 (12.5) 0 (0.0)

9 (47.4) 10 (52.6) 0 (0.0) 0 (0.0)

χ2 = 0.759

.448

Religiosity, N (%) Secular Conservative Religious

10 (83.4) 1 (8.3) 1 (8.3)

19 (100.0) 0 (0.0) 0 (0.0)

χ2 = 1.809

.070

Income, N (%) Below average Average income in Israel (8113NS = 2134US) Above average

1 (8.3) 4 (33.3) 7 (58.4)

6 (31.6) 3 (15.8) 10 (52.6)

χ2 = 0.765

.444

Years of education, mean (SD)

19.17 (0.39)

19.42 (0.77)

t= -1.059

.298

Perceived social support, mean (SD(

3.42 (1.17)

3.25 (1.13)

t = 0.010

.992

Subjective well-being, mean (SD)

3.00 (0.60)

3.44 (0.51)

t= 2.340

.026

Perceived coping, mean (SD)

4.33 (0.88)

4.38 (0.72)

t= -0.308

.760

PSP Scale, mean (SD)

10.33 (11.67)

3.21 (2.95)

t = 2.556

.016

Abbreviations: PSP, Psychosomatic Problems Scale

Comparison between studies

There was no significant difference in psychosomatic symptom scores when comparing the exposed groups during the war (in Study 1) and six months later (in Study 2) (t = -1.181; p=.247), or when comparing the two unexposed groups (t = .559; p=.579). The ANCOVA revealed one main effect of coping: physicians who reported better coping with their condition had lower levels of psychosomatic symptoms (F = 20.840; p = .001; ηp2 = .224). In addition, a significant interaction effect was found (Exposure X Study): while unexposed physicians reported a decrease in psychosomatic symptoms from Study 1 to Study 2, the reverse was found for exposed physicians, who reported increased psychosomatic symptoms from Study 1 to Study 2 (F = 7.976; p = .006; ηp2 = .100). See Figure 1.

Figure 1. Psychosomatic symptoms among exposed and unexposed physicians in Study 1 and Study 2. 12 10 8 6 6.48 4 4.09 2 0 Study 1

PSP scores

symptoms was found between exposed and unexposed physicians (t = 1.266; p=.211). In Study 2 a significant difference in psychosomatic symptoms was found between the groups (t = 2.556; p=.016), indicating lower psychosomatic symptom scores in the unexposed group. Additionally, the exposed group reported lower subjective well-being (t = -2.340; p=.026).

hysicians

Exposed p

10.33

Unexposed physicians 3.21 Period

Study 2

Discussion The results suggest that exposure to war-related stress takes its toll on hospital physicians’ mental health by increasing psychosomatic symptoms. Contrary to the first hypothesis, hospital physicians did not differ in the level of psychosomatic symptoms during the Gaza War. This finding can be explained by the cognitive-energetic framework (9, 10) that attributes compensatory control when there is a need to perform adequately under extreme stress by extensive use of resources, at the cost of late onset fatigue that can be seen in increased psychosomatic symp173

Psychosomatic symptoms among hospital physicians during the Gaza War

toms. Indeed, six months after the armed conflict ended, traces of the effects of war-related stress were still present in the form of elevated psychosomatic symptoms among previously-exposed hospital physicians. The current study has several limitations: First and foremost, the small number of physicians that participated in the study. Due to the war situation in southern Israel, it was extremely difficult to find and interview physicians. This problem is reported in other studies (3-5). Moreover, the small size of some groups was due to the fact that a total of only 40 physicians work in Barzilai Medical Center. The second limitation is that no longitudinal study was conducted due to the need for anonymity, specifically requested by the study participants. However, the use of random sampling in the two studies may have reduced this limitation to some extent. Indeed, participants at Study 1 and Study 2 did not differ in their demographic background. Moreover, the fact that exposed physicians had similar exposure history (all exposed physicians in both studies were working at the hospital during the war) may also lend strength to this study’s conclusions. The third limitation is that no validated psychiatric diagnosis was made. Time constraints and the raging war did not enable a thorough clinical assessment of psychosomatic symptoms, and also affected the scope of the questionnaire battery that was used. On the other hand, as psychiatric symptoms were assessed in an unsheltered hospital that was being targeted by rockets, it is possible that the extreme circumstances enhanced the validity of the Psychosomatic Problem Scale, reducing the former limitation to some extent. The fourth limitation was the significant differences in age leading to a potential confounding. The exposed group was older than the unexposed group. In that case, there is always the possibility that age was a possible cause of the results. However, some studies in the epidemiology of trauma and PTSD have shown that being older was less associated with life time trauma (14). Additionally, the results of the ANCOVA presented above showed no significant association between age and psychosomatic symptoms (when controlling for demographic variables). Although hospital personnel are not frequently exposed to prolonged war-related stress with actual threat to their lives, its consequences are severe. As it is likely that hospital physicians will be affected by similar crises in the future, longitudinal studies targeting the same hospital personnel are needed. Future studies should perform prospective assessments of hospital personnel during wartime crisis and investigate ways to enhance their resilience 174

and reduce their vulnerability, as recommended by other studies (15-17). For example, pre-disaster preparation to extreme strain among physicians will include: enhancing social support, team-building and supervisory support, selection and training of physicians, general emergency preparedness along with the use of mental health professionals as facilitators in disaster preparation (15-17). Future studies should also document the nature of wartime exposures (patient contact versus personal threat of injury or death) in order to assess the relative effect of different exposure types. References 1. Bergman B, Ahmad F, Stewart DE. Physician health, stress and gender at a university hospital. J Psychosom Res 2003; 54: 171-178. 2. Pilowski L, O’Sullivan G. Mental illness in doctors. BMJ 1989; 298: 269-270. 3. Ben-Ezra M, Palgi Y, Essar, N. Impact of war stress on posttraumatic stress symptoms in hospital personnel. Gen Hosp Psychiatry 2007; 29: 264-266. 4. Palgi Y, Ben-Ezra M, Langer S, Essar N. The effect of prolonged exposure to war stress on the comorbidity of PTSD and depression among hospital personnel. Psychiatry Res 2009; 168: 262-264. 5. Ben-Ezra M, Palgi Y, Wolf JJ, Shrira A. Psychiatric symptoms and psychosocial functioning among hospital personnel during the Gaza War: A repeated cross sectional study. Psychiatry Res, 2011 Feb. 25 [Epub ahead of print]. 6. Andreski P, Chilcoat H, Breslau N. Posttraumatic stress disorder and somatization symptoms: A prospective study. Psychiatry Res 1998; 79: 131–138. 7. Van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL. Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma. Am J Psychiatry 1996; 153: 83-93. 8. Van der Kolk BA. The body keeps the score: Approaches to the physiology of posttraumatic stress disorder. In: Van der Kolk BA, McFarlane AC, Weisaeth L, editors. Traumatic stress: The effects of overwhelming experience on mind, body and society. New York: Guilford, 1996: pp. 214-241. 9. Hockey GR. Cognitive-energetical control mechanisms in the management of work demands and psychological health. In: Baddeley A, Weiskrantz L, editors. Attention: selection, awareness, and control: A tribute to Donald Broadbent. Oxford: Clarendon, 1993: pp. 328-345. 10. Hockey GRJ. Compensatory control in the regulation of human performance under stress and high workload: A cognitive-energetical framework. Biol Psychol 1997; 45: 73-93. 11. Wikipedia, 2008–2009 Israel–Gaza conflict. (http://en.wikipedia. org/wiki/2008%E2%80%932009_Israel%E2%80%93Gaza_conflict.) Accessed 4 January 2009. 12. Ware JE Jr, Snow KK, Konsinski M, Gandek B. SF-36 Health Survey: Manual and interpretation guide. Boston, Mass.: The Health Institute, New England Medical Center, 1993. 13. Hagquist C. Psychometric properties of the psychosomatic problems scale – a Rasch analysis on adolescent data. Soc Indic Res 2008; 86: 511-523. 14. Norris FH. Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol 1992; 60: 409-418. 15. Dekel R, Hantman S, Ginzburg K, Solomon Z. The cost of caring? Social workers in hospitals confront ongoing terrorism. Br J Soc Work 2007; 37: 1247-1261. 16. Fain RM, Schreier RA. Disaster, stress and the doctor. Med Educ 1989; 23: 91-96. 17. Tattersall A, Bennett P, Pugh S. Stress and coping in hospital doctors. Stress Health 1999; 15: 109-113.

Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Stanley Rabin et al.

Burnout Among General Hospital Mental Health Professionals and the Salutogenic Approach Stanley Rabin, PhD, Yuval Shorer, MD, Meir Nadav, MA, Jonathan Guez, PhD, Mali Hertzanu, MSW, and Asher Shiber, MD Department of Psychiatry, Soroka University Medical Center and Division of Psychiatry, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel

ABSTRACT Professionals working in mental health often exhibit high levels of strain leading to poor psychological wellbeing, emotional exhaustion and depletion of personal resources. Even under tight global economic conditions preventing burnout should be given high priority among mental health providers. This paper looks at the wide spectrum of stressors found in specialists working in the mental health area and examines, with the salutogenic approach in the background, ways to relieve professional burnout among general hospital mental health providers. Guidelines for managers and staff to alleviate their professional strain are suggested so as to improve the quality of life in the workplace.

The nature and consequences of burnout Burnout is a set of symptoms associated with chronic stress in a variety of occupations (1, 2). These symptoms include emotional exhaustion, physical fatigue and cognitive weariness (3, 4). Burnout has been consistently related to work performance, job satisfaction, quality of life, and psychological well-being, and positively related to withdrawal behavior. It may, in some cases, precipitate health professionals leaving the profession completely. Other consequences include lowered productivity, increased absenteeism, increased health care costs, role and professional conflicts, and difficulties of making decisions in a changing health system (5, 6). Occupational stress has been recognized as being detrimental for emotional and physical well-being (2). It has been associated with a variety of negative emotions such Address for Correspondence: â&#x20AC;&#x2020; stanleyra@clalit.org.il

as anxiety, depression and anger, being the causal factors in a variety of work-related conditions including absenteeism and job related, interpersonal conflicts. Stress has been found to be related to cardiovascular illness, gastrointestinal conditions and may alter immune functioning (7). The outcome of prolonged strain can culminate in exhaustion and depletion of personal resources. It can lead to substance abuse and self-medication and ultimately to possible professional errors and even medical misconduct. Suicide and external injury and poisoning (8, 9), for example, have been found to be some of the reasons for doctorsâ&#x20AC;&#x2122; deaths. Evidence has also shown that male doctors (aged 20-74) have a significantly higher proportional mortality ratio for viral hepatitis, liver cancer and cirrhosis, and women doctors (aged 20-74) have a higher ratio for cancer of the pancreas (10). Burnout in mental health professionals There is growing evidence to support the claim that mental health professionals, by the nature of their work, are particularly vulnerable to stress with all its detrimental effects on service delivery and quality of care. (11-13). Differences have been found between mental health staff working in community mental health clinics and psychiatric hospital settings. In the latter, strain includes feelings of lack of autonomy, responsibility without authority (14) and possible restriction in ability to develop independent psychotherapeutic roles. Community mental health workers, on the other hand, have reported finding their contacts with patients highly rewarding, yet their sources of strain may involve feelings of over-responsibility for the well-being of their patients. Mental health workers working in the private sector perceive more control over their professional lives. However, the sources of stress in this group may

Stanley Rabin, PhD, Psychiatric Department, Soroka Medical Center, POB 151, Beer Sheba, Israel.

175

Burnout Among General Hospital Mental Health Professionals and the Salutogenic Approach

involve other factors, like the loneliness of private practice and networking for new referrals. On a broader system-level perspective, health policy may affect professional stress when there are sometimes insufficient resources available for mental health. Long waiting lists, due to manpower shortages, often make professionals in the field feel that they are doing piecemeal work, giving unsatisfactory treatment or overusing pharmacological treatment. Problematic features in the clinician-colleague-boss triad, and workers’ personal home-work conflicts may be stressful areas (15, 16). Mental health workers sometimes perceive administrators and health financial advisors as over-managing decision-making (10). Too much control may lead mental health workers to feel helpless in controlling their own professional lives. The Salutogenetic Approach More than three decades ago, Aaron Antonovsky looked at factors allowing individuals to stay healthy and manage stress in the face of adversities (17, 18). He claimed that people who remain relatively healthy in the face of threats have within themselves a certain approach to looking at the world. He formulated his now well known Sense of Coherence Concept (SOC). SOC involves a particular orientation, a certain view of the world and comprises of three main components: comprehensibility, manageability and meaningfulness. Comprehensibility refers to the way in which the person is always in a mutual relationship with his/her environment, gaining understandable structure from it. This involves placing one’s environment in order, to classify it and structure the stream of information and stimuli, which often overwhelm us. Comprehensibility is the cognitive component. Manageability, the behavioral component of the SOC, is the way we influence and cope with the environment, using positive resources to control it. Meaningfulness, the emotional component, is what makes sense to us. It involves those demands that the person sees as challenges, perceives as worthy of investment and engagement and the pursuit of finding meaning in committing oneself to the task. Antonovsky (17) used the concept of “generalized resistance resources” (GRRs) each of which can facilitate avoiding or combating a wide variety of stressors; examples are money, shelter and food; intelligence and knowledge; social support; and rituals and religion. GRRs help persons understand and make sense out of the many 176

stressors they constantly have to face (17). When the person regularly experiences the availability of GRRs, a strong SOC develops. Much research worldwide has been done in the area of SOC, especially in the health area. In a review article (19) which included 458 scientific publications and 13 doctoral theses about SOC it was found that regardless of age, sex, ethnicity, nationality and study design, SOC was strongly related to perceived health, especially mental health. Here it was reported that evidence substantiates the salutogenic model as a health promoting resource that improves resilience. It was also found to develop a positive subjective state of both physical and mental health, quality of life and well-being. In the mental health area a recent study by Griffiths (20) found substantial evidence indicating that sense of coherence plays a central role in coping with stressors in the rehabilitation/recovery process and that it contributes to mental health and psychosocial functioning. They maintain that if rehabilitation services adopt a salutogenic approach and seek to enhance a client’s sense of coherence this can be beneficial in the client’s rehabilitation and recovery. Among psychotherapists, the SOC concept has been found to be positive in combating professional stress. In a study by Linley et al. (21) the sense of coherence personality construct was found to be the factor most protective against negative psychological changes and compassion fatigue, while sense of coherence and the therapeutic bond were the factors most protective against burnout. Linley and Joseph (22) later report that sense of coherence was associated with therapist well-being. The salutogenic approach, in contrast to the pathogenic one, asks: what are the factors that induce an individual to preserve his or her health in times of tranquility and stress in order to develop a sense of coherence? To reach a sense of coherence regarding burnout of mental health professionals in the workplace, we may also ask ourselves various questions which include: What are the reasons for professional stress for this professional group? How can these professionals manage their stress? How can they find meaning in the workplace? Is burnout neglected among those who constantly provide help to others, and who focus on others’ well-being? In order to answer some of these issues, we initially engaged in a process of self-exploration where we looked at practical interventions for relieving professional burnout. It can be assumed that the strengthening of SOC is possible, and that it can serve as a framework for initiated and planned positive change in the health systems.

Stanley Rabin et al.

Rabin et al. (10) kept this approach in mind when suggesting many of their possible intervention strategies. They suggested that by implementing some of their proposed strategies a better sense of coherence could be achieved, leading to reduced burnout. The relationship between SOC and burnout has been described in various articles in the professional literature (23-25). In a recently published article, Van der Colff and Rothman (26) found in their sample of 818 registered nurses that the experience of depletion of emotional resources and feelings of depersonalization (related to burnout) were associated with a weak sense of coherence. Work engagement was predicted by strong SOC approach coping strategies. We now propose several possible interventions for burnout based on the SOC framework. We will illustrate each approach with a case vignette or details from our own experience. Integrated team meetings

The differentiation of professions into specialized sectors (psychiatrists, psychologists, clinical social workers and paramedical staff) often leads mental health specialists to estrange themselves from other professional groups. This may keep them isolated in their psychotherapeutic rooms, often leading to feelings of loneliness and professional estrangement. Every sector may see patient issues in its own well-defined and restricted way, without considering the perspective or enrichment that the other sector may provide. The setting up of interdisciplinary team meetings may serve as a venue for professional discourse and collaboration, helping different professionals to learn to understand the dilemmas of the other. A case vignette, being a real experience of the authors, will now be discussed Case vignette. At a multidisciplinary team meeting, a psychologist spoke about the psycho-diagnostic tests that she had performed. Other psychologists in the team suddenly and rather unexpectedly expressed their reservations about the time consuming aspects of psychological testing, and questioned even if they were at all worthwhile. This surprised the other professionals of the team. It brought into the open a secret not expressed explicitly to other sectors before. A discussion about the usefulness of testing in diagnosing patients and the use of pharmacological treatment by the psychiatric sector then ensued. The psychiatrist in the team then expressed the difficulties and frustrations he sometimes had in the pharmacological treatment of PTSD patients. The interdisciplinary team

allowed these “forbidden” secret subjects to be openly revealed. This allowed for candid interdisciplinary discussion about professional secrets that were never spoken about before, with professionals from “the other side.” It also broke down the myth that “the other side” has some special, secret trick, “that they have something better than us, something that really cures.” By understanding “the other side’s dilemmas” (comprehensibility) the team became more cohesive and the subsequent interactions between the professionals more meaningful. Balint group work

Talk about job stress, corridor consultation and passageway chats are other ways in which health workers often relieve their frustrations. These are informal encounters between clinicians, where cases are discussed for a few moments, and temporary relief acquired. While these are not ideal solutions for discussing staff burnout, it may be seen to be effective in some instances. However, these are often sporadic and chance meetings, lacking the formal and containing aspects present in organized group meetings. Channeling feelings in a group setting allows members of staff to understand common dilemmas and learn to manage and share their similar emotionallyladen work with one another. One such type used in the health area as an effective way of treating burnout is the Balint group (27). Balint groups were at first seen as essentially dynamic work discussion groups with the doctor–patient relationship as the focus (28). While they lead to a deeper understanding of patients’ psychosocial issues, they may change the way the clinician perceives him- or herself. This is done when clinicians, with the guidance of one or two leaders, discuss various aspects of the clinician-patient relationship. The group encourages its members to listen to the patient instead of using the traditional style of history-taking (29). The supportive and non-threatening aspects of the group allow clinicians to legitimately discuss their emotions within the context of their work and to manage stress in the face of their difficulties, in the salutogenic mode. Balint groups have been largely run for general practitioners. However, primary care physicians (general practitioners and other medical specialists working in the community) have also benefited from these groups (30), as well as clinical psychologists (31) and psychiatrists (32, 33). We propose that Balint groups be formed for mental health personnel too to be run by outside leaders who are not part of the team, in line with the first groups set 177

Burnout Among General Hospital Mental Health Professionals and the Salutogenic Approach

up by Michael Balint himself as he gathered together GPs from their various practices in the Greater London area. These groups help in sharing and reflection and it should be pointed out that professional interchange between colleagues in a group setting empowers participants, leading to possible reduction of feelings of burnout (30, 34). Balint group evaluation. Pilot study

Although the above reviews and recommendations are base on theoretical data and the authors’ experiences, we add some initial data collected from two groups, one a physician group and the other a multi-professional hospital ward group in which outcome measures were taken. It should be noted that it is often difficult to get the participants’ cooperation to evaluate the intervention due to time demands, work pressures and the mental effort necessary for doctors completing questionnaires. We found that doctors are the “hardest to get.” Thus we present here a partial picture of those participants who were willing to answer our anonymous questionnaire. The first set of data was collected from a group of doctors participating in a Balint group. Two psychotherapists from the Psychiatric Department were asked to assist setting up a group in a very demanding peripheral clinic where the manager felt that her doctors were exhausted and burned out. The therapists accepted the challenge. We explained to the manager that he could not participate in the group or involve himself with the processes within the group meeting. In order to formulate the group setting, doctors met for one hour in a quiet setting where they would take a break from their work and secretaries were informed and respected this initiative. The therapists determined 10-12 meetings for intervention. Notwithstanding the difficult and at times the varied conditions, the group ran well through the process. Out of eight participants, six filled in the short questionnaire (10 items, 1-5 Likert scale), relating to five domains. See table 1. The results cautiously suggest that the participants evaluated the goup positively. Table 1. Means and standard deviations for the five domains Mean SD contribution and change in me as a result of the group

3.1

0.6

supportive and accepting atmosphere

3.5

0.7

relevance for the participants

3.8

0.47

necessity of the group

3.4

0.54

general assessment

4.25

0.5

178

The second Balint group was multi-professional, made up of doctors, nurses and the social worker from our Nephrology Unit. The ward nurses and the social worker and the staff met once weekly on the ward for 12 meetings with a monthly follow-up session after the completion of the initial sessions. A burnout questionnaire was given to the participants before and after the Balint group. This questionnaire contains 14 items (1-7 Likert scale) with a high score presenting high levels of burnout. The pilot data, taken from two doctors and five nurses, showed a tendency for decreased feelings of burnout after the intervention. Mean score before the intervention was 37.8 (17.5) and 34.2 (13.9) after the group ended. No statistical analysis was done due to the low number of participants. Co-leadership of patient groups on the psychiatric ward

Setting up specific patient groups for well defined problems (for example: eating disorder groups, midlife crisis groups) may be another way to prevent professional stress. The group leaders came from different disciplines that were themselves supervised in regular ongoing leadership group meetings. Co-leadership of these patient groups by different mental health professionals helped to contain the often monotony of treating regular individual patients for psychotherapy. It diversified their work by enabling them to function together in a group context, working for a common goal. For example, we have a group of patients with eating disorders supervised by a social worker and a psychologist. Usually, the social work perspective emphasizes the system of which the individual is part, while (in our case) the psychologist emphasizes the inter- and intrapsychic conflicts. The co-leadership needed to feel this gap and that was done in many hours of discussing the group and the interventions that were used. This kind of interaction enhances the need to think of what you are doing and not do things just because “that is the way I/you studied it.” After five years of co-leadership both therapists evaluated this co-leadership as the highlight of their work in those years. Managerial support in interventions

The SOC concept has been used in studying managers’ SOC dispositions in carrying out their work effectively. It has rarely touched on the SOC characteristics that can produce change in organizations. Strumpfer (35) argued that in an organizational

Stanley Rabin et al.

environment, persons with an orientation towards a strong sense of coherence would experience productive performance and recognition. In such an environment such individuals will cognitively comprehend workplace intricacies and stressors in the SOC mode, so that they may make sense of the workplace complexities, perceiving its stimulation and information as clear, ordered, structured, consistent and predictable. This will help them to recognize their work demands as consisting of experiences that are manageable with which they can cope. This will help them to make sense of stressors meaningful to them and make emotional and motivational sense of work demands. Being equipped with high SOCs allows them to consider them as welcome challenges, worthy of engaging in and investing their energies in work. Later Semmer (36) summarized a number of studies, indicating that a sense of coherence is positively related to a number of indicators of well-being and health, as well as with working conditions. In this context, we maintain that managers in mental health may be seen to be good containers of stress in understanding and carefully listening to their workers’ issues. This requires them to adopt careful listening skills, to comprehend workers’ stressors and work problems in order for them to be understood. Listening here does not mean interpreting process or providing psychodynamic explanations for staffs functioning, since this may be counterproductive in the sophisticated milieu of the mental health team. “Deep listening” allows managers to take special note of the possible underlying motives and meanings of the behavioral outcomes of professional stress expressed in worker absenteeism, late arrival at work, low productivity and frequent sick leave. This requires them hearing “the language of professional stress” and “listening to the unspoken words” of burnout, often played down and subtle. Detection of burnout may be looking at it primarily as “the external story,” ignoring alternative, untold systemic or personal narratives since the dominant story of “burnout” is sometimes used as a wastepaper basket, into which all descriptions and explanations of problems in “everyday life in the workplace” are thrown. By so doing, individual and shared experiences are not taken into account, which may be unexpressed, and unrecognized as possible alternatives for solutions to problems. Comprehensibility in the SOC mode involves managers carefully deciphering why workers may not want to engage other colleagues in their stressors. This may be, for example, because of mental health workers diffi-

culties in openly expressing weakness within the social context of their work, or their assumption that these issues are not acceptable for discussion in their working milieu. Therefore, it is very important for managers to try to understand these cues since immediate intervention in helping distressed employees may be done through managerial intervention. In more severe cases, workers can be referred to an Employee Assistance Program (EAPs), a service provided by some employers. This service, maintained by professional mental health specialists, helps employees through short-term therapy, to effectively manage personal problems that might have a negative effect on their well-being and consequently adversely affect their work performance. By understanding their employees’ difficulties managers can help their workers to appropriately manage their conflicts. Referral of employees to EAPs may be one such meaningful manageable intervention here. Mental health managers often realize how psychotherapists are over-demanding of themselves and their abilities, searching for the ultimate cure and perfect success in treating their patients. In this context managers should try to help their workers manage some of these subjective stressors. This can be done by guiding psychotherapists to uncover more realistic attitudes about expectations of cure and treatment, in order to consider patients’ change (and their own expectations) in a more appropriate, realistic light. Understanding the loneliness of psychotherapeutic work may help managers become aware of the emotional drain incumbent in constantly treating patients. This often creates feelings of isolation and seclusion by psychotherapists in their psychotherapeutic work. A way in which managers could help psychotherapists manage their difficulties and overcome these feelings may be to encourage them to rise above profound isolation by seeing patients together, for example, through joint scheduling mentioned earlier. This activity enables managers to realize the importance of adhering to an inter-professional cultural approach, rather than complying with a narrow uni-professional culture (37). In this context, joint cases may be seen together, treatment modes discussed and considered from different perspectives, enriching therapeutic skills by increasing professional competency and bolstering enthusiasm. Consultation and liaison with community-based HMOs and other community agencies can be considered by managers as another way of preventing professional loneliness and stagnation in their workers. This involves 179

Burnout Among General Hospital Mental Health Professionals and the Salutogenic Approach

being open to hearing other professionals’ viewpoints, attitudes and language. It requires a shared philosophy of care, a flexibility and openness in listening and attitude. The strength of effective teamwork and consultation, collegial support and liaison with other medical personnel units and outside agents may be seen as an effective buffer against feelings of professional loneliness and isolation. Another reason for burnout may be related to workers (often older ones) not feeling updated in terms of their professional skills. Comprehending this deficit may help managers understand that feeling professionally competent may be seen as a way of gaining fulfillment too (38). This may help them to provide these workers with ongoing individual case supervision or didactic teaching modules, since educational interventions, emphasizing and enhancing professional skills and competency of staff have been found to be another effective way of reducing stress (38, 39). Overload may have detrimental effects on the psychological equilibrium of staff. Therefore a more reasonable and balanced caseload may be seen to be effective in reducing such stress. Balancing the case allocation, for example, involves providing staff with a mixture of difficult and easier cases, and acute and chronic ones. Where broader, system intervention is necessary the importance of calling on external professionals for help may be encouraged. This may involve, for example, turning to organizational psychologists to provide their expertise and professional guidance for organizational change. Staff should be encouraged, of course, to partake in regular exercise, eat-right programs and regular leisure time activities and should be supported to take regular vacations, as a way of keeping a well-balanced psychological equilibrium. Joint team activities outside the clinic are also suggested. But it should be pointed out that the basic thrust of our paper is to look at the burnout phenomenon and its interventions within the professional group itself and not only reducing stress through providing some of the external activities described above. Conclusion This paper focuses on the “language of professional stress” for the mental health worker. As suggested, we found that these professional groups have unique variables that lead them to more vulnerability to burnout. Through adopting the salutogenic approach one can draw guidelines for intervention with suggestions for both managers and workers to improve their working 180

environment. One aspect of primary prevention of professional stress and burnout may be to lecture about the subject in academic courses related to psychotherapeutic interventions. Furthermore, a professional trainer with knowledge of burnout may also be considered helpful to young professionals at the beginning of their careers. Also, the very writing of this paper by professionals from a wide spectrum of mental health disciplines (psychologists, psychiatrists and social worker) can be seen as a meaningful way to inject a particular, creative challenge into our mental health profession. While we did collect some initial outcome data regarding the proposed interventions, it is important to note that our data are mainly descriptive, and therefore we cannot conclude that there was any direct impact (positive or negative) on burnout or occupational stress. In the future, we propose that researchers consider collecting more data on the proposed intervention or interventions, such as the MBI (Maslach Burnout Inventory) or other markers of occupational stress among participants, along with demographic data. The field could be benefited by a more systematic and scientific approach toward studying such interventions. References 1. Farber BA. Introduction: A critical perspective on burnout. In: Farber B, editor. Stress and burnout in human service professions. New York: Pergamon, 1983. 2. Kushnir T, Rabin S, Azulai S. A descriptive study of stress management in a group of pediatric nurses. Cancer Nurs 1997; 20: 414-421. 3. Shirom A. Burnout in work organizations. In: Cooper CL, Robertson I, editors. International review of industrial and organizational psychology. New York: Wiley, 1989. 4. Rabin S, Maoz B, Shorer Y, Matalon A. Meishiv haruach (Rekindling the spirit: Creativity, passion and the prevention of burn-out in the medical profession). Tel Aviv, Israel: Tel Aviv University, Ramot, 2010 (in Hebrew). 5. Johnson JV, Hall EM, Ford DE, Mead LA, Levine DM, Wong N, Klog M. The psychosocial work environments of physicians. J Occup Med 1995; 37: 1151-11582. 6. Felton JS. Burnout as a clinical entity-its importance in healthcare. J Occup Med 1998; 48:237-250. 7. Di Martino V. Preventing stress at work. Overview and analysis. In: Di Martino V, Casaneuva B, Ishi J, et al., editors. Conditions of work digest. Geneva: International Labor Office, 1992: p. 11. 8. Juel K, Mosbech J, Hansen E. Mortality and causes of death among Danish medical doctors 1973-1992. Int J Epidemiol 1999; 28:456-460. 9. Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks J. Suicide in doctors: A study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001; 55:296-300. 10. Rabin S, Matalon A, Maoz B, Shiber A. Keeping doctors healthy: A salutogenic perspective. Fam Syst Health 2005; 23:94-102. 11. Rabin S, Feldman D, Kaplan Z. Stress and intervention strategies in mental health professionals. Br J Med Psychol 1999; 72: 159-69.

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12. Evans S, Huxely P, Gately C, Webber M, Mears A, Pajak S, Medina J, Kendall T, Katona C. Mental health, burnout and job satisfaction among mental health social workers in England and Wales. Br J Psychiatry 2006; 18:75-80. 13. Nayoung N, Eun KE, Hyunjung K, Eunjoo Y , Sang M . Individual and work-related factors influencing burnout of mental health professionals: A meta-analysis. J Employment Couns 2010; 47:86-97. 14. Clark H, Clark Jr, Vaccaro J. Burnout among CMH psychiatrists and the struggle to survive. Hosp Community Psychiatry 1987; 38; 843-847. 15. Maslach C. Burnout: The cost of caring. New Jersey: Prentice Hall, 1982. 16. Maslach C, Leiter M. The battle about burnout: How organizations cause personal stress and what to do about it. San Francisco: Josse-Bass, 1997. 17. Antonovsky A. Health, stress and coping. San Francisco: Jossey-Bass, 1979. 18. Antonovsky A. Unraveling the mysteries of health. San Francisco: Jossey-Bass, 1987. 19. Eriksson M, Lindstrom B. Validity of Antonovsky’s sense of coherence scale — a systematic review. J Epidemiol Community Health 2005; 59: 460466. 20. Griffiths C. Sense of coherence and mental health rehabilitation. Clin Rehabil 2009; 23: 72-78. 21. Linley PA, Joseph S, Loumidis K. Trauma work, sense of coherence, and positive and negative changes in therapists. Psychother Psychosom 2005; 74: 185-188. 22. Linley P, Joseph S. Therapy work and therapists’ positive and negative well-being. J Soc Clin Psychol 2007; 26: 385-404. 23. Rabinowitz S, Kushnir T, Ribak J. Preventing burnout by increasing professional self-efficacy in primary care nurses in a Balint Group. Amer Assoc Occupational Health Nurses 1996; 44: 28-32. 24. Gilbar O. Relationship between burnout and sense of coherence in health social workers. Soc Work Health Care 1998; 26: 39-49. 25. Rabin S, Saffer M, Weisberg E, Krontnizer-Enav T, Peled I, Ribak J. A multifaceted mental health training program in reducing burnout among occupational social workers. Israel J Psychiatry Relat Sci 2000; 37:12-19.

26. Van der Colﬀ J, Rothmann S. Occupational stress, sense of coherence, coping, burnout and work engagement of registered nurses in South Africa. South African J Industrial Psychology/SA Tydskrif vir Bedryfsielkunde 2009; 35: 423-433. 27. Maoz B, Rabinowitz S, Herz M, Katz H. Doctors and their feelings. New York: Praeger, 1992. 28. Balint M. The doctor, his patient and the illness. London: Pitman, 1957. 29. Salinsky J. Balint training: Does it help the patient or does it only make the doctor feel better? J Balint Society 1984; 12: 26-29. 30. Rabin S, Maoz B, Shorer Y, Matalon A. Balint groups as “shared care” in the area of mental health in primary care medicine. Ment Health Fam Med 2009; 6:139-143. 31. Blackwell C, Clarke G, Dagmar D, Rimmer E, Sheikh A. Carrying coals to Newcastle? The Balint group experience as part of reflective practice on the Newcastle clinical psychology course. Clin Psychol Forum 2005; 156: 33-37. 32. Graham S, Gask L, Swift G, Evans M. Balint-style case discussion groups in psychiatric training: An evaluation. Acad Psychiatry 2009; 33: 198-203. 33. Das A, Egleston P, El-Sayeh H. Trainees experiences of a Balint group. Psychiatr Bull 2003; 27: 274-275. 34. Kjeldmand D, Holmström I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Ann Fam Med 2008;6:138-145. 35. Strumpfer D. Salutogenesis: A new paradigm. South African J Psychology 1990; 20:264-276. 36. Semmer NK. Individual differences, work stress and health. In: Schabrach MJ, Winnubst JAM, Cooper CL, editors. The handbook of work and health psychology. U.K.: John Wiley, 2003. 37. Norman I, Peck E. Working together in adult community mental health services: An interprofessional dialogue. J Ment Health 1999; 8:217-230. 38. Thomsen S, Soares J, Nolan P, Dallender J, Arnetz B. Feelings of professional fulfillment and exhaustion in mental health personnel: The importance of organizational and individual factors. Psychother Psychosom 1999; 68:157-164. 39. Gilbody S, Cahill J, Barkham M, Richards D. Can we improve the morale of staff working in psychiatric units? J Ment Health 2006; 15: 7-17.

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Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Role of Life Events in Obsessive Compulsive Disorder Sujit Sarkhel, MD, DPM, Samir Kumar Praharaj, MD, DPM, and Vinod Kumar Sinha, MD, DPM Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

ABSTRACT Background: There are very few studies examining the role of life events in obsessive compulsive disorder (OCD). Moreover, these studies have methodological limitations and have reported contradictory findings. Objective: To examine the frequency of life events in patients with OCD as compared to normal healthy controls. Methodology: 10 patients fulfilling ICD-10 DCR criteria of OCD were rated with Yale Brown Obsessive Compulsive Scale (YBOCS), Hamilton Rating Scale for Depression (HAM-D) and Presumptive Stressful Life Events Scale (PSLES). A group of 10 normal controls were also rated on PSLES. Finally, both groups were compared in terms of life events. Results: The frequency of life events, six months (t=3.95, p=.001) and lifetime (t=5.53, p<.001), were significantly higher in patient group in comparison to controls. PSLES scores showed significant correlation with YBOCS scores. However, there was no correlation between PSLES and HDRS scores. Stepwise linear regression analysis showed PSLES scores significantly positively predicted obsessive and compulsive scores. Conclusion: Life events were significantly more frequent in OCD patients both six months and lifetime, as compared to healthy controls. The severity of OC symptoms was found to be directly proportional to the number of stressful life events experienced in the last six months prior to onset.

INTRODUCTION Obsessive compulsive disorder (OCD) is a chronic disorder with a waxing and waning course which causes significant impairment in socio-occupational functioning. The etiology is multifactorial; besides biological causes, several psychosocial factors contribute towards vulnerability to OCD. According to Selye (1), life events may act as stressors causing increased susceptibility to illness. There is substantial evidence to suggest that stressful life events may precipitate psychiatric disorders, particularly mood disorders (2) though only a few studies have specifically investigated the role of such events in OCD. Some of these studies (3-5) had methodological shortcomings. Moreover, some of the relatively well-designed studies (6-9) reported conflicting results. According to McKeon et al. (6) and Kulhara and Rao (8), OCD patients reported a significant excess of events over the year prior to onset of illness in comparison to healthy subjects. Similarly, Gothelf et al. (9) found significantly more life events in the year preceding onset of OCD in comparison to normal controls in children. Gershuny et al. (10) investigated the role of trauma in treatment outcome of OCD and found that 82% of patients with treatment resistant OCD reported a history of trauma. Moreover, a high rate of childhood sexual abuse has been reported in OCD patients (1113). On the contrary, few studies (7, 14) reported no difference in life events between obsessive patients and healthy subjects over one year before onset of OCD, although Khanna et al. (7) found an excess of life events in the six months prior to onset of the disorder. a recent study comparing life events in subjects with OCD, Tourette syndrome and healthy controls reported significantly more stressful life events in OCD patients as compared to others (15). In a recent study on women subjects, pregnancy and childbirth were found to be frequently associated with the onset of OCD or worsening of symptoms in those with preexisting disorder (16). In

Address for Correspondence: Dr. Sujit Sarkhel, MD, DPM, Senior Resident in Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India 834006. â&#x20AC;&#x2020; sujitsarkhel@gmail.com

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the backdrop of lack of consensus in previous studies, the current study was undertaken with the objective of examining the frequency of life events in patients with OCD as compared to normal healthy controls. We undertook the null hypothesis, i.e., there would be no significant difference in the frequency of life events in patients with OCD as compared to normal healthy controls. METHODOLOGY This was a cross-sectional hospital-based study conducted at the Central Institute of Psychiatry, Ranchi, India. The study was approved by the institutional review board. Ten consecutive patients of either sex between 18 and 60 years of age fulfilling ICD-10-DCR (17) criteria for OCD and giving informed consent were selected from the patients attending the out-patient department. Those having severe medical illness, mental retardation or any comorbid psychiatric disorder other than depression were excluded. Ten healthy controls, with scores less than one in GHQ-5 (18) were chosen from among the staff of the institute. The patient group was rated on Yale Brown Obsessive Compulsive Scale (YBOCS) (19), to assess the severity of OCD, and Hamilton Rating Scale for Depression (HAM-D) (20) to assess the severity of depression. Both groups were assessed for the presence of significant life events using Presumptive Stressful Life Events Scale (PSLES) (21) in the form of a semi-structured interview. It covers 51 defined life events and is scored 0 and 1 for the absence and presence of particular life events (maximum possible score being 51). It has been well-standardized in the Indian population. PSLES was developed from Social Readjustment Rating Questionnaire (SRRQ) of Holmes and Rahe (22) which is a standard rating instrument for assessment of life events and used worldwide. The modification was meant to serve two purposes: first, to remove those items which were symptoms of illness and thereby increasing the content validity, and secondly, to modify certain items to suit our unique cultural values. The life events occurring “six months” prior to the onset of illness and over “lifetime” were recorded. Statistical Analysis

The data obtained were analyzed with Statistical Package for Social Sciences-version 10.0 for Windows (SPSS Inc., Chicago, IL, U.S.A.). Normality of data was assessed using histogram and Shapiro-Wilk test. Both

groups were compared using independent t-test and chi-square test, wherever applicable. Pearson’s correlation and point biserial correlation were done between PSLES scores with continuous and categorical sociodemographic and clinical variables respectively. Linear stepwise regression analysis was carried out using YBOCS total score, obsession and compulsion scores as dependant variables. Age, age of onset, HAM-D score, and PSLES six months and lifetime scores were entered in the model in a stepwise manner. Adjusted R square was reported as it controls for the number of independent variables. Multicollinearity was assessed using tolerance statistic: values below .2 suggest bias in regression model because of multicollinearity and lack of autocorrelation was checked using Durbin-Watson statistic. The alpha level of p<.05 was considered significant. RESULTS Socio-demographic and clinical characteristics of the sample have been summarized in Table 1. There was no difference between the two groups in terms of age, education, sex, marital status, socio-economic status and habitat. Significantly more subjects in the control group were employed (χ2 = 16.36, p < .001). There were significantly higher life events, both six months (t = 3.95, p = .001, r = .681) and lifetime (t = 5.53, p < .001, r = .793), in patient group as compared to controls. In the patient group, PSLES six-month scores positively correlated with YBOCS total (r = .82, p = .004), obsession (r = .70, p = .025) and compulsion (r = .81, p = .004) scores whereas PSLES lifetime scores positively correlated with YBOCS total (r = .68, p = .03) and obsession (r = .85, p = .002) scores. There was no correlation between HDRS scores with either lifetime or six months PSLES scores. PSLES lifetime scores showed significant positive correlation with female sex (rpb = .65, p = .043). However, no significant correlation emerged with any other socio-demographic and clinical variable. Table 2 shows predictors of YBOCS scores using stepwise linear regression analysis. PSLES six months scores positively predicted YBOCS total (B = 1.85, p < .01) and compulsion scores (B = 1.11, p < .01). The models explained 63.1% and 61.9% of variance in YBOCS total and compulsion scores respectively. PSLES lifetime scores positively predicted YBOCS obsession scores (B = 0.49, p < .01). The model explained 68.1% of variance in YBOCS obsession scores. 183

LIFE EVENTS IN OCD

Table 1. Socio-demographic and Clinical Characteristics Variables

Patients N=10 Mean (SD)

Controls N=10 t Mean (SD) (df=18) p

Age

27.6 (3.89)

31.5 (5.64)

-1.80

.089

Education years

11.5 (1.84)

13 (2.75)

-1.43

.169

Duration of illness in years

3.3 (2.5)

Age of onset

23.3 (4.57)

YBOCS Total Score

19.6 (4.4)

YBOCS Obsession Score

9.6 (2.07)

YBOCS Compulsion Score

10 (2.67)

HDRS Total Score

16.2 (3.46)

PSLES (6 months)

7.3 (1.95)

4.4 (1.26)

3.95*

.001

PSLES (Lifetime)2

13 (3.56)

6.5 (1.08)

5.53**

<.001

N (%)

Fisher’s exact significance†

Male

7 (70)

6 (60)

p=1

Female

3 (30)

4 (40)

Sex

Occupation Unemployed

3 (30)

Employed

1 (10)

10 (100)

Housewife/ Student

6 (60)

Marital status

Unmarried

6 (60)

2 (20)

Married

4 (40)

8 (80)

SES

Lower

5 (50)

2 (20)

Middle

5 (50)

8 (80)

Rural

3 (30)

Urban

7 (70)

10 (100)

Present

2 (20)

Absent

8 (80)

Habitat

Family history

p<.001

p = .17 p = .35 p = .21 -

Note: *p<.01, **p<.001 (2-tailed); YBOCS: Yale-Brown Obsessive Compulsive Scale; HDRS: Hamilton Depression Rating Scale; PSLES: Presumptive Stressful Life Event Scale; SES: Socio-economic status; 1 Effect size Cohen’s d = 1.77; 2 Effect size Cohen’s d = 2.47; † Fisher’s exact test statistic was computed as more than 20% cell had expected count less than 5.

Table 2. Linear Stepwise Regression Analysis of Predictors of YBOCS Scores in Patients (N=10) Dependent variable

Predictors

Adjusted R2 B

YBOCS Total

Constant

.631

YBOCS Obsession

Constant

PSLES six months .681

PSLES lifetime

YBOCS Constant .619 Compulsion PSLES six months

SE (B)

6.07 3.45

t 1.76

1.85

0.46 0.82 4.04**

3.21

1.47

0.49 .011

2.19 0.85 4.50**

1.87

2.12

0.88

1.11

0.28 0.81

3.96**

Note: *p<.05, **p<.01; Yale-Brown Obsessive Compulsive Scale; PSLES: Presumptive Stressful Life Events Scale

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DISCUSSION Our study revealed that there were significantly more life events, both six months (p=.001) and lifetime (p<.001), in patient group compared to controls. The effect size of the findings was large (23). This is in agreement with several previous studies (6, 8, 9, 15). Our results revealed positive correlation between YBOCS and PSLES scores. Furthermore, six-month PSLES scores prior to OCD positively predicted severity of obsessive and compulsive symptoms as reflected in YBOCS total and compulsion scores. Similarly, Khanna et al. (7) found an excess of events in the six months prior to onset of OCD. This suggests that stressful life events may play a more important role in precipitating OCD. Moreover, the number of stressful life events experienced by the subjects seemed to have a dose-response relationship with OCD, i.e., the greater the number of stressful life events, the more severe the OC symptoms. The cumulative effect of stressful life events experienced over a lifetime also had an effect on severity of obsessions. However, there was no correlation between HDRS scores with either lifetime or six-month PSLES scores. This finding apparently contradicts existing literature on the role of life events in depression (e.g., 24). Depression in our patient group was probably secondary to OCD and, hence, correlation with life events was found with obsessive compulsive and not depressive symptoms. The PSLES used in our study (also in 8) was developed and standardized on an Indian population. This eliminates the influence of local and cultural factors. Khanna et al. (7) had used Paykel’s Life Events Schedule, which has not been validated in our population. The PSLES was a modification of SRRQ (22), which has been used across cultures in several studies. Thus, PSLES retains the universality of SRRQ (22) while accommodating the cultural variations unique to the Indian population, thereby increasing the generalizability of our findings to other cultures. Inclusion of a normal healthy comparison group allowed us to examine the association of life events with OCD. In comparison to the study by Khanna et al. (7) which assessed life events in the previous one year prior to the onset of illness, we assessed life events in the previous six months as well as the entire lifetime. This gave us a broader picture of the cumulative role of life events in the onset of OCD. The small sample size was one of the major limitations of our study which undermines the generalizability of our findings. Also, the role of the specific nature of life

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events was not assessed in the current study. However, certain life events, like change of residence and taking an examination, were more common among OCD patients. There are certain inherent problems which are encountered in life event research. The recall of events which occurred several years ago would invariably be subject to bias (25). Moreover, it has been reported that individuals with high neuroticism are prone to report greater stress with similar life events than most normal individuals (21). Furthermore, the possibility remains that patients with more severe OCD may have a greater propensity for recalling stressful life events (25). Also, the cause and effect relationship between life events and disorder is not apparent from these studies. Future studies involving larger samples should attempt to establish the link between stressful life events and types of OC symptoms, preferably in a prospective design. Author contribution: SS and SKP designed the study. Data was collected by SS. Analysis and interpretation of data was carried out by SS and SKP. Initial draft was prepared by SS and SKP and was finally approved by all three authors.

References 1. Selye H. The stress of life. New York: MacGraw Hill, 1956. 2. Paykel ES, Dowlatshahi D. Life events and mental disorder. In: Fisher S, Reason J, editors. Handbook of life stress, cognition and health. New York: Wiley, 1988. 3. Lo WH. A follow-up study of obsessional neurotics in Hong Kong Chinese. Br J Psychiatry 1967; 113:823-832. 4. Rasmussen SA, Tsuang MT. Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. Am J Psychiatry 1986;143: 317-322. 5. Neziroglu F, Anemone R, Yaryura-Tobias JA. Onset of obsessive compulsive disorder in pregnancy. Am J Psychiatry 1992;149:947-950. 6. McKeon J, Roa B, Mann A. Life events and personality traits in obsessivecompulsive neurosis. Br J Psychiatry 1984;144:185-189. 7. Khanna S, Rajendra PN, Channabasavanna SM. Life events and onset of obsessive compulsive disorder. Int J Soc Psychiatry 1988;34:305-309. 8. Kulhara P, Prasad Rao G. Life events in obsessive compulsive neurosis. Indian J Psychiatry 1986;28:221-224.

9. Gothelf D, Aharonovsky O, Horesh N, Carty T, Apter A. Life events and personality factors in children and adolescents with obsessivecompulsive disorder and other anxiety disorders. Compr Psychiatry 2004;45:192-198. 10. Gershuny BS, Baer L, Parker H, Gentes EL, Infield AL, Jenike MA. Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder. Depress Anxiety 2008;25:69-71. 11. Nicolini H, Weissbecker K, Mejia JM, Sanchez de Carmona M. Family study of obsessive-compulsive disorder in a Mexican population. Arch Med Res 1993;24:193-198. 12. Lochner C, du Toit PL, Zungu-Dirwayi N, Marais A, van Kradenburg J, Seedat S, et al. Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depress Anxiety 2002;15:66-68. 13. Caspi A, Vishne T, Sasson Y, Gross R, Livne A, Zohar J. Relationship between childhood sexual abuse and obsessive-compulsive disorder: Case control study. Isr J Psychiatry Relat Sci 2008;45:177-182. 14. Grabe HJ, Ruhrmann S, Spitzer C, Josepeit J, Ettelt S, Buhtz F, et al. Obsessive-compulsive disorder and posttraumatic stress disorder. Psychopathology 2008;41:129-134. 15. Horesh N, Zimmerman S, Steinberg T, Yagan H, Apter A. Is onset of Tourette syndrome influenced by life events? J Neural Trans 2008;115:787-793. 16. Forray A, Focseneanu M, Pittman B, McDougle CJ, Epperson CN. Onset and exacerbation of obsessive-compulsive disorder in pregnancy and the postpartum period. J Clin Psychiatry 2010;71:1061-1068. 17. World Health Organization. The ICD-10 classification of mental and behavioural disorders - Diagnostic criteria for research. Geneva: World Health Organization, 1993. 18. Shamsunder C, Sriram TG, Muraliraj SG, Shanmugham V. Validity of a short 5-item version of general health questionnaire. Indian J Psychiatry 1986;28:217-219. 19. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown Obsessive Compulsive Scale, I: Development, use, and reliability. Arch Gen Psychiatry 1989;46:1006-1011. 20. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62. 21. Singh G, Kaur D, Kaur H. Presumptive stressful life events scale - a new stressful life events scale for use in India. Indian J Psychiatry 1984;26:107-114. 22. Holmes TH, Rahe RH. The Social Readjustment Rating Scale. J Psychosom Res 1967;11:213-218. 23. Cohen J. Statistical power analysis for the behavioral sciences. New Jersey: Lawrence Erlbaum, 1988. 24. Laugharne J, Lillee A, Janca A. Role of psychological trauma in the cause and treatment of anxiety and depressive disorders. Curr Opin Psychiatry 2010;23:25-29. 25. Maina G, Albert U, Bogetto F, Vaschetto P, Ravizza L. Recent life events and obsessive-compulsive disorder: The role of pregnancy/delivery. Psychiatry Res 1999;89:49-58.

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Holocaust Student Tour: The Impact on Spirituality and Health Alan L. Nager, MD, MHA,1 Sarah M. Nager, BA,2 Priya G. Lalani, BA,3 and Jeffrey I. Gold, PhD 4 1

Department of Pediatrics, Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A. 2 University of Southern California, Los Angeles, California, U.S.A. 3 Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A. 4 Departments of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A.

ABSTRACT Background: “March of the Living” is a 2-week excursion to Poland and Israel for high school students to learn and experience sites of Holocaust destruction. Methods: This study looked at the effect of their experience on spirituality and health. The sample consisted of 134 Jewish students, ages 16-19 years. Students were assessed initially (before MOTL=time 1) by completing a background survey (i.e., demographics, “Jewishness,” and Holocaust related information), a World Health Organization, Quality of Life-Spirituality, Religion, and Personal beliefs field-test instrument, and the Child Somatization Inventory. Surveys were repeated end-Poland (time 2) and again (after MOTL=time 3) approximately 3-4 months after the trip. Results/Conclusions: Most facets of spirituality significantly increased between time 1 and time 2, and varied from time 2 to time 3, while strength and hope remained elevated. Faith increased from time 1 to time 2 and was maintained at time 3. Fear of dying rose at time 2, decreasing significantly at time 3. A positive correlation between spirituality and “Jewishness” was found.

Introduction The Holocaust, the systematic destruction of European Jewry that resulted in the killing of roughly 6 million Jews between the years of 1939 and 1945, is an event

about which great effort is made to commemorate. One of the largest attempts to educate the current generation of youth about the Holocaust is a program called “March of the Living” (1). This program was established in 1988, functions in North America under the auspices of the International MOTL and is comprised of a 2-week group trip to Poland and Israel. Delegations from countries and regions worldwide participate in the program, including groups from the United States, Canada, Australia, South Africa, Latin America, France, Germany, Belgium, Israel and Poland. The staff is comprised of educators, medical professionals, community and political leaders, and Holocaust survivors. The most recent high school MOTL included 7,500 international high school students; 5,000 of whom were Jewish and 2,500 of whom were non-Jewish participants from Poland, Hungary, Austria and the Czech Republic. The purpose of MOTL is to educate high school students about the Holocaust, not only from a historical viewpoint, but also from a personal and emotional perspective. The Holocaust survivors tell their life stories at various points throughout the journey in Poland, and students are encouraged to have discussions with the survivors, as well as with other students and staff members. In Poland, the delegations visit a number of Jewish and Holocaust-related sites, including Warsaw (Warsaw Ghetto, the Jewish cemetery, and the restored Nozyck Synagogue), Krakow (including the Jewish quarter and the Ramah synagogue), and Lublin (the historical center of ultra-Orthodox Judaism, i.e., Hassidism). Additionally, the students visit major concentration camps (Auschwitz, Birkenau, Majdanek) and death camps

Address for Correspondence: Alan L. Nager, MD, MHA, Children's Hospital Los Angeles, Division of Emergency & Transport Medicine, 4650 Sunset Blvd, Mailstop #113, Los Angeles, CA 90027, U.S.A. nager@chla.usc.edu

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(Treblinka, Belzec). Some of the sites were fully destroyed in the Nazis’ final attempt to obliterate evidence of the Holocaust, while others remain virtually intact. The students visit sites of genocide, something completely outside the realm of the typical high school experience. Many of these students are the descendants of Holocaust survivors and victims. The impact of MOTL is particularly heightened by the presence of the Holocaust survivors who accompany the delegation. Several of the survivors speak directly from the places they were during the Holocaust; for example, from their particular barracks at Auschwitz or from the gas chambers at the camp in which their family members perished. These stories bring the devastation of the Holocaust to a personal, rather than abstract level. Instead of solely learning the statistics and history of the Holocaust, the students hear the emotional account of a person who was, and still is, personally and deeply affected by such horror. The students gain insight into the long-lasting effects of the survivors’ traumatic experiences. Oftentimes, the Holocaust survivors rely on the students to provide support and encouragement to help them while they recount their traumatic stories. One of the most affecting sites the students visit is the Zbilagovska Gora mass grave, the location where 850 Jewish children from the city of Tarnow were beaten and buried alive in June of 1943. All that remains at this forested site is a foot-high blue fence surrounding the uneven, shifting ground from where the living children struggled to escape. Another part of MOTL is when the delegation enters the gas chambers and crematoria at Majdanek, where thousands of Jews were murdered daily with poisonous gas. The “March of the Living” is the culminating point of the delegations’ journey in Poland. It occurs on “Yom HaShoah,” the Holocaust Remembrance Day in the modern Jewish tradition. In this event, all of the participating delegations march three kilometers from Auschwitz to Birkenau. This march commemorates and serves as a counterpoint to the “death marches” during the Holocaust, in which Jews were forced to march in freezing conditions to the gas chambers at Birkenau, for extermination. At the end of the march, students write personal notes and place them on the railroad tracks along which thousands of Jews were transported by cattle car to the Birkenau death camp. The event closes with a large memorial service held outside the gas chambers and crematoria. The second week of the trip takes place in Israel. In this part of MOTL, students travel from the vanished Jewish world of Poland to Israel, where Judaism exists in the modern world. This part of the trip contrasts

with the atmosphere of Poland. The students travel around the country and visit historical and modern sites, including Jerusalem, Masada, Tel Aviv, the Golan Heights, the Galilee and the Negev desert. They also participate in several events, one of which is another march through Jerusalem to celebrate “Yom Ha’atzmaut,” Israel’s Independence Day. MOTL is, overall, an expedition through which high school students observe the historical devastation of the Holocaust, as well as the vivacity of the State of Israel today. MOTL aims to strengthen the students’ connection to their own spiritual and religious identity through the tragedy of the Holocaust. Since approximately 65 years have passed since the occurrence of the Holocaust, it is theoretically possible that this lapse in time has resulted in the diminution of students’ spirituality. Alternatively, the intensity of MOTL may liberate hidden or suppressed emotions. Research is warranted in order to examine the specific effects, if any, the MOTL experience has on students’ spirituality and personal beliefs. In addition, as stress may be inherent on a trip of this magnitude, health may be impacted and students may be prone to somatization. In the current study, it is hypothesized that spirituality and personal beliefs will be strengthened during MOTL, and remain elevated several months after the trip concludes. A secondary hypothesis is that somatization will increase during the students’ time in Poland, and will decrease after the trip as the student’s readjust to their “normal lives” at home. Thirdly, strengthened spirituality and personal beliefs will correlate with a decrease in somatization, over time. Participants and Recruitment

All attendees (Jewish-American high school students) were approached regarding the study and asked to participate voluntarily. If any participants were not interested in the study, they were removed from further involvement. Attendees participated in three informational and preparatory meetings about MOTL. The trip in general was discussed and educational materials were provided to the students regarding the Holocaust. These sessions were part of the trip preparation and not specific to the study methodology. At the third informational meeting, participants, along with their parent(s)/guardian(s), discussed final trip plans. During this last pre-tour meeting, participants and their parent(s)/guardian(s) were educated on the nature of the study and asked to verbally consent to the proposed study according to Institutional Review Board policy. 187

Holocaust Student Tour: The Impact on Spirituality and Health

Materials and Methods After the background and basis for the study were conveyed, and the consenting process was completed, participants were given instructions regarding the requisite surveys and the time course for completion (before MOTL=time 1, April 5, 2009) (end-Poland=time 2, April 24, 2009) and (after MOTL=time 3, July–August 2009). “Before” and “end-Poland” surveys were paper questionnaires distributed at designated times, during which the students were given ample time to respond. A complete set of questionnaires was administered at the third pre-tour meeting, at which time participants completed a background survey, the World Health Organization, Quality of Life-Spirituality, Religiousness, and Personal Beliefs (WHOQOL-SRPB) field-test instrument, and the Child Somatization Inventory

(CSI). On the last day the participants were in Poland, the WHOQOL-SRPB and the CSI were administered for a second time, using the same administration procedure as time 1. Approximately 3-4 months after the conclusion of MOTL, the final surveys were administered, at which time participants were asked to complete the WHOQOL-SRPB and the CSI on Survey Monkey, an online survey tool. This online format was utilized in order to enhance ease of participation and to achieve maximal responses among participants. Study Measures

Background survey: 19-item investigator-developed questionnaire that was used to collect information, such as age, school, religious affiliation/practices, Holocaust knowledge and personal connectedness to the Holocaust (relationships with survivors) (Table 1).

Table 1. Frequency and Percentages from Background Survey Questions Questions

Frequency

Percentage

Questions

Frequency

Percentage

Age

16: 4 17: 56 18: 72 19: 2

3.0 41.8 53.7 1.5

Formal services attended/year

Gender

Female – 28 Male – 106

20.9 79.1

0: 3 1 – 10: 88 11 – 20: 21 21 – 30: 9 31 – 40: 13

2.2 65.7 15.7 6.7 9.7

High School type

Secular public – 13 Secular private – 20 Religious private – 101

9.7 14.9 75.4

Personal prayers/month

0: 44 1 – 10: 58 11 – 20: 5 21 – 30: 25 > 30: 2

32.8 43.3 3.7 18.7 1.4

Prior Holocaust Education

Yes – 132 No – 2

98.5 1.5

Holocaust books read

0: 2 1 – 5: 113 > 5:19

1.5 84.3 14.2

Father’s Judaism (classified by student)

Relative(s) deceased in Holocaust

Yes – 38 No – 96

28.4 71.6

Reform – 41 Conservative – 60 Orthodox – 6 Cultural/Spiritual/not religious – 10 Jewish, cannot categorize – 8 Non–believer – 4 Other – 5

30.6 44.8 4.5 7.5 6.0 3.0 3.7

Relative(s) survived Holocaust

Yes – 37 No – 97

27.6 72.4

Mother’s Judaism (classified by student)

Relative(s)/close friend(s) deceased within last 12 months

Yes – 38 No – 96

28.4 71.6

Reform – 40 Conservative – 70 Orthodox – 4 Cultural/Spiritual/not religious – 11 Jewish, cannot categorize – 8 Non–believer – 0 Other – 1

29.9 52.2 3.0 8.2 6.0 0.0 00.7

Parents separated/ divorced

Yes – 17 No – 116 Unanswered – 1

12.7 86.6 .01

Visited Israel previously

Yes – 105 No – 29

78.4 21.6

Judaism (self-classification)

Reform – 38 Conservative – 57 Orthodox – 4 Cultural/Spiritual/not religious – 22 Jewish, cannot categorize – 11 Non-believer – 2

28.4 42.5 3.0 16.4 8.2 1.5

Bar/Bat Mitzvah

Yes – 131 No – 3

97.8 2.2

188

Greatest influence to Self – 98 go on MOTL Parent – 5 Other relative – 12 Teacher – 3 Friends/past participants – 10 Other – 6

73.1 3.7 9.0 2.2 7.5 4.5

Greatest benefit to go on MOTL

Feel more Jewish – 18 Increase education/awareness – 84 Feel connected to the group – 11 Understand family’s history – 20 Other – 1

13.4 62.7 8.2 14.9 .01

Marriage partner/ spouse preference

Jewish – 110 Any religion – 23 Other – 1

82.1 17.2 .01

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Spirituality/Religion/Personal Beliefs (SRPB): portion of the World Health Organization, Quality of Life-Spirituality, Religiousness, and Personal Beliefs (WHOQOL-SRPB) field-test instrument, consisting of 40 questions. The SRPB consists of 11 facets, including a total spirituality domain and 10 subscales: 1) spirituality/ religion/personal beliefs, 2) connectedness to a spiritual being or force, 3) meaning of life, 4) awe, 5) wholeness and integration, 6) spiritual strength, 7) inner peace/ serenity/harmony, 8) hope and optimism, 9) faith, and 10) death and dying. A 5-point Likert response format scale was used in the questionnaire as follows: 1=not at all, 2=a little, 3=a moderate amount, 4= very much, and 5=an extreme amount (2). This instrument has been previously validated among multiple cultures, with a range of spiritual, religious, and personal beliefs (3). Somatization: the Child Somatization Inventory (CSI), a 35-item self-report survey that consists of questions pertaining to physical or psychosomatic complaints. Responses were reported on a 5-point Likert scale: 0=not at all, 1=a little, 2=some, 3=a lot and 4=a whole lot (4). The CSI has been shown to be a reliable and valid self-report measure for assessing somatization symptoms in children and adolescents by measuring frequency and intensity of physical symptoms. For purposes of analysis, CSI data was further divided into three subcategories (pain, gastrointestinal and pseudoneurologic) based on established criteria (5). Analysis

Data analysis included outcome data from all completed surveys, including the background survey, WHOQOLSRPB, and CSI over three time periods. Summary statistics were performed for the background survey, the WHOQOL-SRPB, and the CSI. A one-way within subjects analysis of variance (ANOVA) was conducted to compare the effects of MOTL on spirituality and somatization across times 1, 2 and 3. An alpha level of .05 was used for all statistical tests. One domain score and 10 facet scores were derived from the WHOQOL-SRPB data. The domain score which indicates how spirituality, religion, and personal beliefs relate to a personsâ&#x20AC;&#x2122; quality of life is made up of nine facets: spirituality, spiritual connection, meaning and purpose in life, experience of awe and wonder, wholeness and integration, spiritual strength, inner peace, hope and optimism, and faith. The tenth facet (death) was calculated independently and was not included in the calculation of the domain score. When significant differences were identified, post-hoc Bonferroni pairwise comparisons were

performed. Further correlational analyses were conducted in order to examine the influence of identified covariates on spirituality and somatization. Results The research sample consisted of 136 Jewish-American students, two of whom were excluded because of failure to consent, resulting in a total sample size of 134 students. One hundred and twenty-one (90%) completed all three surveys. The data obtained from the background survey examining the participantsâ&#x20AC;&#x2122; Jewish, cultural and Holocaust background, found in Table 1, showed that the mean age was 18 years, with 21% female and 79% male, 38 (28%) had a relative who died in the Holocaust, 37 (28%) had a relative survive the Holocaust, 38 (28%) classified themselves as Reform, and 57 (43%) called themselves Conservative, 88 (66%) went to formal synagogue services 1-10 times/year, 44 (33%) did not perform any personal prayers prior to MOTL, 98 (73%) reported that they made the decision to participate in MOTL by themselves, and 84 (63%) went on MOTL to increase their education/awareness of the Holocaust. Overall, the analysis of facet scores revealed the following results as presented in Table 2. There was a significant main effect of MOTL on spirituality, F (2,132)=6.72, p<.05. Significant main effects of MOTL on all facets of spirituality were noted between time 1 and time 2 for connection F (2,132)=6.60, p<.05, awe F (2,132)=7.54, p<.05, wholeness F (2,132)=10.59, p<.05, peace F (2,132)=4.25, p<.05, and faith F (2,132)=3.42, p<.05. Bonferroni pairwise comparisons showed a significant difference for connection between time 1 (M=2.706, SD=1.02) and time 2 (M=3.02, SD=1.03) as well as between time 2 and time 3 (M=2.81, SD=1.04). The facet of awe had a significant difference across time 1 (M=3.01, SD=.95) and time 2 (M=3.68, SD=.99). Wholeness was significantly lower at time 1 (M=3.44, SD=.67) than in time 2 (M=3.68, SD=.73). Peace had a significant difference between time 1 (M=3.27, SD=.78) and time 2 (M=3.46, SD=.88). The difference for the domain of spirituality between times 1 (M=3.47, SD=.69) and 2 (M=3.63, SD=.62) was also statistically significant. There was no significant difference in faith across time. There were also no significant differences for the facets of awe, wholeness, peace or the domain of spirituality between time 2 and 3. The facets of spirituality/religion/ personal beliefs, meaning, strength, hope and death had neither a significant main effect nor a statistically significant difference across all three times studied (Table 2). 189

Holocaust Student Tour: The Impact on Spirituality and Health

Table 2. Mean scores, F values, and Mean Differences Among Time 1, Time 2, and Time 3 Means (standard deviation)

Mean Differences

WHOQOL-SRPB

Time 1

Time 2

Time 3

F Values

Time 1-2

Time 2-3

Time 1-3

Spirituality/religion/personal beliefs

3.83 (0.69)

3.88 (0.62)

3.82 (0.70)

7.56

-0.05

0.01

0.06 NS

Spiritual connection

2.71(1.01)

3.02 (1.03)

2.81 (1.04)

6.6

-0.32**

-0.1 NS

0.22*

Meaning in life

4.08 (0.64)

4.15 (0.73)

4.08 (0.74)

1.12

.08

0.00

0.08 NS

Awe

3.01 (0.95)

3.31 (0.99)

3.16 (0.92)

7.54

-.30***

-0.15 NS

0.15 NS

Wholeness and integration

3.44 (0.67)

3.68 (0.73)

3.55 (0.75)

10.59

-.23***

-0.11

0.12 NS

Spiritual strength

3.87 (0.58)

3.98 (0.65)

3.99 (0.69)

2.77

-.11 NS

-0.12 NS

-0.01 NS

Inner peace

3.27 (0.78)

3.46 (0.88)

3.35 (0.86)

4.25

-.20*

-0.08

0.11 NS

Hope and optimism

3.51 (0.74)

3.57 (0.78)

3.66 (0.81)

2.74

-.06 NS

-0.15 NS

-0.09 NS

Faith

3.45 (0.74)

3.6 (0.79)

3.6 (0.80)

3.42

-.15

-0.14

0.01 NS

Death and dying

3.2 (1.04)

3.06 (1.14)

3.07 (1.25)

1.66

.14 NS

0.13 NS

-0.01 NS

Domain 6 (spirituality)

3.47 (0.59)

3.64 (0.63)

3.57 (0.64)

6.72

-.16**

-0.09

0.07 NS

Mean symptom intensity

0.26

0.3

0.18

13.05

-.05 NS

.12***

.08***

Frequency of symptoms

6.06

6.69

4.53

8.44

-.63 NS

2.16**

1.53**

Total symptom intensity

9.02

10.62

6.28

13.05

-1.59

4.33***

2.74***

Mean pain symptoms

0.23

0.28

0.15

9.51

-0.05 NS

0.13**

0.08**

Mean gastrointestinal symptoms

0.41

0.42

0.27

15.57

-0.02

0.15**

0.13***

Mean pseudoneurologic symptoms

0.09

0.18

0.1

6.54

0.09**

0.00 NS

Child Somatization Inventory (CSI)

*p<.05; **p<.01; ***p<.001

Data from the CSI (Table 2) demonstrated that MOTL had a significant main effect on mean intensity of symptoms F (2,132)=13.05, p<. 05, with significant differences between time 1 (M=1.03, SD=.88) and time 2 (M=1.211.11) and time 1 and time 3 (M=.72, SD=.84). MOTL also had a significant effect on the number of physical symptoms reported, F (2,132)=8.44, p<.05, with a significant difference between time 1 (M=6.06, SD=4.77) and time 2 (M=6.69, SD=5.60) and time 1 and time 3 (M=4.53, SD=4.63). Frequency of symptoms and symptom intensity showed parallel differences across time, increasing at time 2 and dropping at time 3. The three CSI subcategories consisting of pain, gastrointestinal and pseudoneurologic symptoms (Table 3) showed the following: a significant difference in mean pseudoneurologic symptoms from time 1 to time 2, F (2,132)=.09, p<.05 and for all three subcategories between time 2 and time 3. There was also a significant difference in mean pain symptoms between time 1 and time 3, F (2,132)=.08, p<.05. Data from the background survey, which identified socio-demographic variables, demonstrated that there was a strong correlation between spirituality and selfclassifications of “Reform,” “Conservative,” “cultural/ 190

Table 3. Relationships Between Spirituality and Judaism Over Time Variable

Correlation Coefficient

Self-classification (Judaism)

Spirituality Spirituality (Time 1) (Time 2)

Spirituality (Time 3)

Reform

0.65

Conservative

0.81

Cultural/spiritual/not religious

0.48

Jewish, cannot categorize

0.83

Formal services attended per year

0.22

0.31

*p<.05; **p<.01; ***p<.001

spiritual/not religious,” and “Jewish, cannot categorize” at time 1 and time 3 (Table 3). In addition, spirituality and the number of times participants attended formal religious services had a significant moderate correlation at time 1 (r=.22, p<.05) and time 3 (r=.31, p<.05). Likewise, the relationship between spirituality and the performance of personal prayers was also significant at time 1 (r=.35, p<.05) and time 3 (r= .24, p<.05). Mean spirituality at all three time points was negatively correlated with the mean intensity and frequency

Alan L. Nager et al.

Table 4. Relationships Between Physical Complaints and Spirituality Correlation Coefficient Spirituality (Time 1)

Spirituality (Time 2)

Spirituality (Time 3)

Severity

-0.23**

-0.21*

-0.25**

Frequency

-0.26**

-0.27**

-0.30**

Severity

-.02 NS

-.00NS

-.10 NS

Frequency

.00 NS

-.00 NS

-.08 NS

Severity

-.08 NS

-.07 NS

-0.20*

Frequency

-.14

-0.32**

Variable CSI (Time 1)

CSI (Time 2)

CSI (Time 3) NS

*p<.05; **p<.01; ***p<.00

of somatization symptoms (Table 4). There were significant negative correlations between mean CSI severity and mean frequency of symptoms at time 1 and spirituality at times 1, 2, and 3. In addition, there was a significant correlation between mean intensity and frequency of symptoms at time 3 and with spirituality at time 3, r=-.20, p<.05 and r=-.32, p<.05, respectively. Discussion Research on MOTL has been primarily anecdotal or descriptive regarding the educational value of the trip (6-8). While the stated mission of MOTL is to create a greater sense of Jewish identity among participants, as well as to educate the next generation about the effects of intolerance (1), this study evaluated the effect MOTL has on students’ spirituality and personal beliefs. Because the trip has inherent stressors, the intensity and frequency of somatization were also evaluated. Spirituality, in general, increased while the students were in Poland and decreased 3-4 months following the students’ return home. This trend was consistent across most facets of spirituality demonstrating the impact of MOTL on spirituality and personal beliefs. In addition, somatization followed the same trend, increasing while the students were in Poland and decreasing as indicated by the results of the final assessment measurement. More than likely, the predominant reason for this was the level of emotional and spiritual engagement that the students experienced while in Poland. It was here that students actively examined their own feelings with regard to suffering and death, loss of possessions,

destruction of family, culture, and Judaism, and the very existence of God or other spiritual power. The students conversed with each other, the staff, and survivors about a number of theoretical and practical dilemmas related to spirituality and personal beliefs. They sought guidance and attempted to reconcile for themselves the destructive forces that overwhelmed a people, culture and religion that once flourished. It is likely that this resulted in the observed increase in spirituality among the study subjects while in Poland. Another potential reason that spirituality increased in Poland was that the students were highly removed from their daily lives. They were in an unfamiliar, foreign country with new people, and constantly viewing and hearing unimaginable things. This removal of the students from their “comfort zones” perhaps allowed them to focus on more complex personal issues such as those measured by the WHOQOL-SRPB. The contemplation and discussion of personal issues that impact spirituality, such as connectedness, inner peace and hope, likely led to the students reporting a greater level of spirituality while in Poland. There are several reasons for the observed decrease in spirituality 3-4 months after the trip ended. As the students returned from the trip, they readjusted to life at home. They likely thought less about the major spiritual themes, which they reflected upon while in Poland, and became immersed in college preparation and planning, thus decreasing their level of attention and focus on their spirituality and personal beliefs. In addition, students may have grappled with loneliness after they had become accustomed to being in a large group of peers. Likewise, students may have felt spiritually disconnected from their friends who had not gone on the trip. This feeling of isolation and inability to share in a common life experience could have contributed to a decreased level of spirituality among the trip participants at time 3. Although difficult to prove, one Jewish communal leader expressed the idea in 1964, that “the unrelieved recital of massacres, mass murder, persecution and disabilities inflicted upon Jewish communities, engenders in the minds of the Jewish youngster, deep-seated feelings of inferiority and emotional insecurities” (9), possibly referring to the concept that overwhelming tragedy can create long-lasting feelings of uneasiness and disengagement. This concept was also touched on by Chaitin, who interviewed 10 Israeli families in which each family consisted of three generations: Holocaust survivors, their children and their grandchildren. She 191

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found, among other conclusions, that while some younger people were knowledgeable about the past, they appeared to have no emotional connection to it. In some other cases, young adults were so overwhelmed by the topic of the Holocaust that they became emotionally paralyzed when discussing it (10). In the current study, it likewise seems apparent among participants that the exposure to this wide-scale tragedy had an overwhelming impact on the students’ vulnerabilities creating a sense of discomfort and detachment. Although unproven in the current study, it is theoretically possible that the consuming nature of the trip to Poland may have had an effect on participants’ emotions and, in a circuitous way, their spirituality. Interestingly, although a number of facets decreased from time 2 to time 3 as shown in table 2 (spirituality/ religion/personal beliefs, meaning, wholeness, peace and awe) and contrary to the hypothesis that all facets of spirituality would be sustained months after the trip, several facets actually increased from time 2 to time 3 (strength and hope) or stayed virtually the same (faith). This increase in strength and hope and stability of faith from time 2 to time 3 is likely a result of the students’ perceived inner strength, the desire to “soul search” common among teenagers, and/or a reflection of the specific personality traits among participants. For instance, collegebound students may truly have felt “spiritual strength” in difficult times, “hopeful” regarding upcoming new adventures, and “faithful” in their sense of wellbeing, comfort and enjoyment of life, despite the previous observance of Holocaust sites. These findings are similar to those found in a study by Romi and Lev, in which various parameters, including, “expression toward the Holocaust” was studied among three separate groups: recent participants (journeyed to Poland 1-3 years prior to the research), veteran participants (journeyed to Poland 4-5 years prior to the research) and a group of those who had never traveled to Poland. They found that recent participants felt more feelings of strength, hope and pride than did veterans or those who had never participated (11). Thus, it appears that although these emotions are heightened in the relative short-term (though this time period is longer in the referenced study), some emotions ultimately seem to dissipate with time. Death was another facet of particular interest, as the week in Poland was filled with stories of horror and devastation, images of shattered lives and families, and the loss of control over one’s destiny. The questions regarding 192

death in the WHOQOL-SRPB specifically asked about being “afraid, scared, fearful and concerned,” regarding one’s own death. Responses, initially very elevated at time 1, dramatically decreased at time 2, and stayed at nearly the same level at time 3. This change is probably the result of the students’ substantial “exposure” to the subject of death throughout the week. Realistically, most students do not think about, or discuss death regularly in their daily lives. In contrast, the MOTL experience bombarded students with an inordinate amount of discussion regarding death. It is possible that this openness and discussion, along with near-complete immersion in the subject, caused the students’ fear of dying to decline. In fact, the extreme frequency with which death was mentioned on MOTL may have desensitized students, leaving them less emotionally affected by, and thus less fearful of dying. Although, this acceptance of death among participants seems to contradict the increase in strength, hope and faith, it is likely that the significant and profound theme of death common throughout the week in Poland overshadowed these emotions. The background survey analysis showed varying degrees of strength between spirituality and self-classifications of Judaism, the number of times participants attended formal religious services and performed personal prayers, at time 1 and 3, but not at time 2 when spirituality was at its prime. Difficult to objectively prove, this “baseline” level of spirituality, influenced by the participants “Jewishness,” showed up before and after the trip, as demonstrated by their responses, but not while they were in Poland. Even though the students’ Jewish classification and practices regarding prayer were probably established earlier in their lives, this level of commitment did not correlate with spirituality at time 2. This may be interpreted to mean that, although a person’s Jewish identity and practices are powerful, influential and meaningful, these “spirituality-correlated constructs” may have been over-shadowed by the uniqueness, power and emotional stress of the MOTL experience. Religion and spirituality have a generally positive relationship with physical health, according to the literature. People who are more spiritually or religiously involved tend to report higher rates of overall well-being and life satisfaction and lower rates of depression, suicide, divorce and drug abuse (12). There is evidence that spiritual or religious factors positively influence health through different combinations of social support, psychodynamic/ cognitive behavioral effects, and supernatural effects (13). In addition, possible psychosocial explanations for

Alan L. Nager et al.

the religious-health connection can best be explained by cognitive/motivational factors, i.e., self perception of worth, perceived self-efficacy and beliefs of competence; behavioral, interpersonal factors, i.e., having friends with similar spiritual or religious beliefs and practices; and sociocultural processes, i.e., beliefs and symbols about illness and suffering (14). Furthermore, research suggests that there is a very strong correlation between religious service attendance and longevity. In general, it was found that the more spiritual or religious people are, the less likely they are to complain. This is because their belief system provides a sense of coherence and meaning to their life, which in turn, creates personal fortitude, enabling individuals to endure suffering (12). Although, religion and spirituality may offer some degree of protection generally, the trip nonetheless created anxiety among participants that was felt more acutely and intensely. In large part, this may be related to the overpowering theme throughout the week in Poland, consisting of persecution, evil and destruction. Even if religion and spirituality offer mind-body protection in the long term, the traumatic and overwhelming influence of death lessened this protection and sustained anxiety among participants. The current study showed an increase in frequency and intensity of somatization (pain, gastrointestinal and pseudoneurologic) along with an increase in spirituality while the students were in Poland. In addition, the study also showed a decrease in somatization along with a drop in spirituality at time 3. Although all subcategories of symptoms on the CSI changed similarly over time, no one specific category changed dramatically over the other subtypes. In addition, our hypothesis was justified in that there was a negative correlation within times studied when spirituality and CSI results were compared; that is, as spirituality increased, physical somatization decreased. There are several explanations or theories which may account for the clinicallyobserved findings. Before the students embarked on the trip, they may have had anticipatory stressors such as being away from home, visiting sites of death and destruction, and/or worry over the impact this would have personally. These stressors escalated once the students were in Poland, causing an increase in somatization at time 2. The physical stressors of traveling to a foreign country such as jet lag, unusual food, frequent shifting of living quarters every 1-3 days, and possible exposure to illnesses could have also been potential contributing fac-

tors resulting in physical symptoms. Any one or more of these environmental factors may have contributed to an increase in physical symptoms among study subjects. Additionally, a cause of an increase in somatization, along with an increase in spirituality may have been a result of the stress and grief inherent in visiting Holocaust sites, such as death camps, crematoria, and gas chambers, as well as hearing horrific survival stories. The impact and devastation endured by so many Jewish people may have created an empathic response within the students, and connected them to a worldwide tragedy on a personal level. As a result, the Poland portion of the trip may have created an emotional “rollercoaster” for students, contributing to the increase in the number and intensity of reported physical complaints. After the students returned home from the trip, a decrease in somatization was observed. This was perhaps due to a natural readjustment to their home lives, a return to normal living conditions such as friends, family, food and school. This readjustment to home life may have decreased the stress once felt by students in Poland. Limitations As the study was a descriptive analysis of MOTL participants, no control group was utilized, thus eliminating comparative results between participants and nonparticipants. Factors related to stress and coping were not specifically studied, but may have influenced students’ responses. Although this type of study required the use of repeated measures (WHOQOL-SRPB and CSI at three separate times), this may have caused response fatigue, frustration, resentment or boredom affecting students’ responses to questions. The survey instruments are validated tools used for a novel purpose (MOTL) different than their intended use in prior studies. The responses from participants may have been influenced by others (i.e., peers, staff, survivors), including the first author who accompanied the delegation on the trip. As the majority of the questionnaires were paper-based, students may have felt that staff, the author and survivors would have easy access to their answers, thus influencing responses. Students’ preconceived notions of MOTL being a “Jewish” and “spiritual” trip may have also swayed their responses. In addition, this study evaluated various correlations and did not attempt to study or determine causal relationships (i.e., an increase in spirituality caused a decrease in somatization); such a goal may be meaningful in future studies. 193

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Final measurements were performed 3-4 months after the trip concluded; additional data points may have yielded additional and/or different results. Lastly, study participants consisted of predominantly males, selfdetermined Conservative Jews, etc., which may have influenced their responses on the measures utilized.

but showed no relationship while the students were in Poland. Lastly, somatization negatively correlated with spirituality, increased while in Poland and substantially dropped after returning home. Taken as a whole, MOTL had a significant impact on students’ spirituality and somatization over time.

Future Directions

References

Conclusions Students who participated in MOTL had a rise in spirituality while in Poland and a decrease in most facets of spirituality upon returning home. Strength and hope increased while in Poland and remained elevated and faith similarly increased in Poland and was maintained after returning home. Fear of death among participants was elevated while in Poland and significantly lessened after the trip concluded. Participants’ “Jewishness” was correlated with spirituality before and after the trip,

1. March of the living international [homepage on the Internet]. New York, N.Y. Available from: http://www.motl.org/index.htm 2. WHOQOL-SRPB: Mental health: Evidence and research. World Health Organization, Geneva, Switzerland, 2002. 3. WHOQOL SRPB Group. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Soc Sci Med 2006; 62:1486–1497. 4. Walker LS, Garber J. Children’s somatization inventory: Preliminary manual. Nashville, Tenn.: Vanderbilt University Medical Center, 1992. 5. Meesters C, Muris P, Ghys A., Reumerman T, Rooijmans M. The children’s somatization inventory: Further evidence for its reliability and validity in a pediatric and a community sample of Dutch children and adolescents. J Pediatric Psychology 2003; 28:413-422. 6. Feldman J. Marking the boundaries of the enclave: Defining the Israeli collective through the Poland experience. Muse 2002; 7:84-114. 7. Lazar A, Chaitin J, Gross T. A journey to the Holocaust: Modes of understanding among Israeli adolescents who visited Poland. Educational Review 2004; 56:13-31. 8. Sheramy R. From Auschwitz to Jerusalem, re-enacting Jewish history on the March of the Living. Polish Studies in Polish Jewry 2007; 19:307325. 9. Franck I. Teaching the tragic events of Jewish history. Jewish Education 1964; 34: 173-180. 10. Chaitin J. Facing the Holocaust in generations of families of survivors: The case of partial relevance and interpersonal values. Contemporary Family Therapy 2000; 22:289-313. 11. Romi S, Lev M. Experimental learning of history through youth journeys to Poland: Israeli Jewish youth and the Holocaust. Research in Education 2007; 78:88-102. 12. George LK, Larson DB, Koenig HG, McCullough ME. Spirituality and health: What we know, what we need to know. J Soc Clin Psychol 2000; 19:102-116. 13. Oman D. Personal communication, Stanford University, February 22, 1999. 14. Miller WR, Thoresen CE. Spirituality and health: In Miller W, editor. Integrating spirituality into treatment: Resources for practitioners. Washington, D.C.: American Psychological Association, 1999.

The impact of MOTL on students is challenging to measure. Although this study examined spirituality and somatization, there are a variety of variables that were not examined in the current study. Possibly altering the MOTL curriculum or emphasis may allow future investigations to assess such areas or topics as: What sustained survivors who lost religion, family, security, shelter, etc.? How did survivors adapt to a new culture and country without family? How can the Holocaust teach tolerance for others? How can optimism and success be perpetuated or taught in the face of monumental tragedy and sacrifice? What are the ethical and religious considerations that can be taught in order to enhance “Jewishness” (aside from the cohesion that is created by having a common plight and perpetual struggle)? And, what can individuals do to stop current worldwide atrocities from happening again?

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Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Chanoch Miodownik et al.

Pisa Syndrome and Laryngeal Dystonia Induced by Novel Antipsychotics Chanoch Miodownik, MD, Vladimir Lerner, MD, PhD, and Eliezer Witztum, MD Division of Psychiatry, Ministry of Health, Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel

ABSTRACT Objectives: Psychopharmacotherapy with antipsychotics frequently leads to different undesirable extrapyramidal side effects. Tardive dystonia is one of them and some of its forms can be dangerous. Usually tardive dystonia occurs during treatment with typical antipsychotics. The new novel drugs raised great expectations, but this adverse event also has been found among patients treated with different kinds of atypical antipsychotics. Publications about tardive movement disturbances induced by these medications become more and more frequent. Our report does not address the management of the patient’s tardive dystonia but only illustrates the phenomenon. Method: We describe here three patients suffering from chronic schizophrenia treated with second generation antipsychotics, who developed dystonic symptoms: one with laryngeal dystonia and two others - Pisa syndrome. In the patient with laryngeal dystonia these symptoms appeared after restarting risperidone treatment, in the other patient after diminishing the dosage of risperidone and adding sertindole, and in the third patient the syndrome appeared after beginning ziprasidone. Conclusions: This case series suggests that atypical antipsychotics may have a causal relationship in the development of different forms of tardive dystonia. Physicians should be aware of this problem and always obtain information about the medication used prior to the appearance of movement disturbance.

Address for Correspondence: lernervld@yahoo.com

Dystonia is a clinically and genetically heterogeneous movement disorder characterized by sustained muscle contractions affecting one or more sites on the body. Frequently it causes twisting and repetitive movements or abnormal postures. Dystonia can be classified as primary or secondary. In primary forms, dystonia is a single symptom; it occurs spontaneously or as familial disturbance. It is often termed as primary torsion dystonia. In secondary forms, dystonia develops due to a known environmental or metabolic cause, or associated with other hereditary neurodegenerative disorders. Primary torsion dystonia is the most prevalent form of dystonia and has a wide clinical spectrum including generalized, multifocal, segmental and focal dystonia (1). Psychopharmacotherapy with antipsychotics frequently leads to different undesirable extrapyramidal side effects. One of them is tardive pharyngolaryngeal dystonia, a potentially dangerous condition, which may occur in patients in long-term neuroleptic treatment and can mimic several physical diseases (2). Mouth, tongue and truncal dyskinesias may affect breathing. Acute respiratory distress caused by laryngeal intermittent obstruction has occasionally been described during neuroleptic treatment. Another is the Pisa syndrome, or pleurothotonus. It is a rare kind of dystonia. The first time this condition was described was in 1970s by Ekbom and colleagues in three patients treated with haloperidol (3). Pisa syndrome usually occurs during treatment with typical antipsychotics. However, this adverse event also has been found in treatment with atypical antipsychotics, such as aripiprazole (4-6), clozapine (4, 7-10), olanzapine (11, 12), risperidone (13-18), sertindole (19) and ziprasidone (20-25). Some antipsychotics such as risperidone or clozapine which caused Pisa syndrome may also ameliorate this disturbance (11, 26). Besides antipsychotic-induced Pisa syndrome, this side effect

Prof. Vladimir Lerner, MD, PhD, Be’er-Sheva Mental Health Center, POB 4600, Be’er-Sheva 84170, Israel

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Pisa Syndrome and Laryngeal Dystonia Induced by Novel Antipsychotics

was also described in patients taking valproic acid (27), cholinesterase inhibitors (donepezil and rivastigmine) (28), antidepressants (29, 30), and in those who do not receive medication (idiopathic Pisa syndrome), and in those with neurodegenerative disorders (31-33). The syndrome is characterized by abnormally sustained posturing, with lateral tonic flexion and slight axial rotation of the trunk and head to one side and pharyngolaryngeal dystonia. The dystonic symptoms mainly develop in elderly patients with a history of neuroleptic treatment. Other risk factors are previous treatment with classical antipsychotics, combined pharmacological treatment, female gender, and the presence of an organic brain disorder (33). The prevalence of tardive dystonia is 0.421.6% (mean 5.3%, SD = 6.4) of patients who are treated with neuroleptics (34). Acute dystonia as well as tardive dystonia cause pain and physical and emotional disability (35-37), and therefore it is difficult to differentiate between these two entities. Clinical characteristics suggest that the underlying pathophysiology of drug-induced Pisa syndrome is complex. A dopaminergic-cholinergic imbalance or serotonergic or noradrenergic dysfunction may be those factors, which play the main role in appearance of this syndrome (9, 33, 38-41). The case series presented below describes long-term neuroleptic treated patients suffering from chronic schizophrenia. These patients developed dystonic symptoms: one of them laryngeal dystonia and two others with Pisa syndrome. In one patient, these symptoms appeared after restarting risperidone treatment, in the other patient after diminishing risperidone dose and adding sertindole, and in the third patient after beginning of ziprasidone. Case 1 A 58-year-old man, Mr. A, has suffered from paranoid schizophrenia for 35 years. He had neither a history of alcohol nor drug abuse. This patient had no history of any head injury or any neurological symptomatology. A neurological exam revealed nothing. He had no history of extrapyramidal side effects except a tremor when he was treated with high doses of first generation antipsychotics. From the onset of illness, he received different kinds of antipsychotic medications (chlorpromazine, haloperidol, perphenazine, and zuclopenthixol) with partial beneficial effect only. During that time he devel196

oped negative symptoms of schizophrenia, but still had positive signs too. His recent treatment before his last hospitalization included haloperidol 15 mg/day (caused significant extrapyramidal symptoms), amisulpride 1000 mg/day, and olanzapine 15 mg/day. However, he had irregular drug compliance due to poor insight. His last psychiatric admission was due to a florid psychotic state, showing severe formal thought disorder, auditory hallucinations, delusions, irritability, agitation and aggressiveness. On admission, treatment with risperidone, 3 mg/day, was initiated without improvement after three weeks, and therefore the dose was gradually increased to 6 mg/day with minimal ameliorative effect. Due to non-responding, the treatment was changed to sertindole, starting with 4 mg/day, while the risperidone dose was reduced to 5 mg/day. During the next four weeks, according to the sertindole treatment policy, the dosage was increased to 16 mg/day and risperidone gradually diminished to 2 mg/day. After these changes, the psychotic symptoms began slowly to improve. However, in the 6th week of the treatment, Mr. A was observed walking with a tilt toward the left. His physical examination showed tonic flexion of the spine toward the left, along with a slight rotation. His pulse and blood pressure were 86/minute and 120/77 mmHg, respectively, and no other extrapyramidal symptoms were evident. Since the patient was diagnosed as having Pisa syndrome, sertindole was stopped while risperidone was continued. After two weeks, all signs of dystonia had fully resolved without any other treatment. Case 2 Mr. B, a 38-year-old male patient, was admitted for treatment due to an exacerbation of his schizophrenia (meeting DSM-IV criteria), which he had been suffering from for 15 years. He had no history of perinatal or developmental abnormalities, general medical disease and drug or alcohol abuse. From 1997 to 2008, six different antipsychotics were used, including haloperidol 15 mg/day, olanzapine 20 mg/day, zuclopenthixol 150 mg/day, risperidone 5 mg/day, sulpiride 1000 mg/day, and quetiapine 600mg/day. However, he was a poor adherent due to disturbed insight and intolerable side effects, including extrapyramidal symptoms and weight gain. Since he frequently stopped taking medications, his psychotic symptoms episodically returned. Two months prior to the present hospitalization, he was treated in the outpatient clinic with zuclopenthixol 150

Chanoch Miodownik et al.

mg/day and before that with haloperidol 15 mg/day. During this treatment an oculogyric crisis appeared and Mr. B stopped this treatment and his mental condition gradually deteriorated until admission to a closed ward. On admission quetiapine was started, without positive effect, therefore it was changed to ziprasidone 40 mg/ day. Being aware of his past extrapyramidal side effects, the ziprasidone dose was slowly increased over three months, to 80 mg twice daily. On day 16 of this dose, the patient developed truncal dystonia, with predominantly unilateral distribution that led to a right-sided lean and backward rotation, classically referred to as the Pisa syndrome. Ziprasidone was tapered to 20 mg twice daily at day 20 and discontinued on day 24, without improvement in motor abnormality. Successive treatment with amisulpride began (day 21, 200 mg; day 24, 400 mg). Blood tests, an electroencephalogram, and a tomography (CT) of the brain revealed no abnormal findings. After an additional 14 days, the patient began to respond to withdrawal and symptoms disappeared. Case 3 Mr. C is a 48-year-old male, diagnosed as suffering from schizoaffective disorder for 29 years. His illness was characterized by manic exacerbations, controlled by haloperidol up to 10 mg/day or chlorpromazine 300 mg/day. Over 20 years, he was hospitalized three times. Eight years ago, due to extrapyramidal side effects (parkinsonian symptoms), this therapeutic regimen was changed to risperidone up to 3 mg/day in combination with 1500 mg/day of lithium. During this period, Mr. C was mentally stable until he stopped all medications following his mistaken idea that he was healthy. In a few weeks, his condition deteriorated: affect became manic accompanied by grandiose and persecution delusions with auditory hallucinations. The patient was admitted to a psychiatric hospital. During hospitalization, risperidone was restarted in a dose of 3 mg/day and gradually (over four months) elevated to 8 mg/day. His mental condition was stabilized but he complained about tiredness and sleepiness, therefore the dose of risperidone was gradually (in a month) tapered to 5 mg/day. Although his mental state was good, new psychomotor disturbances appeared after eight weeks on this treatment. The patient demonstrated lingual dystonia, difficulty in swallowing solid and semi-solid food and a feeling of choking. His speech was slurred. He was examined twice in the emergency room. Physical examination did not reveal any

anatomic pathology. There was no asymmetry in protrusion of his tongue. Neurological examination was within normal range and did not reveal other abnormal movements or extrapyramidal signs except tongue involuntary movement. Intravenous injection of biperidin 5 mg had no benevolent effect while treatment with parenteral diazepam led to partial improvement in dysphagia and dystonia only. Five weeks after diminishing the risperidone dose to 3 mg/day, Mr. Câ&#x20AC;&#x2122;s dystonia was completely resolved without any additional medications. Discussion The term â&#x20AC;&#x153;dystonia tardaâ&#x20AC;? was introduced in 1973 to describe involuntary sustained muscular contractions that cause repetitive movements or abnormal postures (42). Dystonia can be divided into three forms: focal (one body part), segmental (from two to four body parts) and generalized (involving face, neck, trunk, at least one upper and one lower extremity) (35, 43). Tardive dystonia is a rare movement side effect of psychotropic treatment. This phenomenon may be produced after a variable period of time following the beginning of this treatment. Tardive dystonia is a neurological syndrome consisting of sustained, involuntary muscular contractions resulting in abnormal postures or repetitive movements. It is a very persistent disorder often mis- or underdiagnosed. The importance of tardive dystonia should be taken into account, since it may be life threatening, e.g., tardive pharyngolaryngeal dystonia, a potentially dangerous condition, which can mimic several physical diseases. The prevalence of tardive dystonia among chronic psychiatric patients is reported as 0.4% to 5% in most studies (34, 43), but when mild cases are also included, the prevalence may increase up to 21% (44). Prior to development of second generation antipsychotic agents, tardive movement disorders were widespread among patients treated with neuroleptics. There were great expectations of the novel, new drugs. Unfortunately, reports about tardive movement disturbances induced by these medications have become more and more frequent, although they have been in use for less than two decades, and the number of publications about Pisa syndrome and tardive pharyngolaryngeal dystonia has not decreased in comparison to the past (4-25, 30). It should be emphasized that these references deal only with tardive dystonia and not with other types of tardive movement disorders. Here we presented another three cases of patients suffering from uncommon kinds of tardive dystonia, which 197

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appeared during treatment with different atypical antipsychotics (sertindole, ziprasidone and risperidone). Two patients demonstrated pleurothotonus, or Pisa syndrome, and another one with laryngeal dystonia. All patients met the operational criteria for the diagnosis of tardive dystonia as defined by Burke and colleagues (35). For diagnosis of Pisa syndrome we used criteria elaborated by Harada and Saito (26, 32). It is fundamentally based on modified criteria for tardive dystonia (35): a) presence of persistent dystonia of the trunk; b) presence of lateral flexion and mildly backward axial rotation of the trunk; c) absence of other dystonic region; d) history of medication (mainly with psychotropic drugs) preceding or concurrent with the onset of dystonia; (e) absence of known causes of secondary dystonia; f) negative family history of dystonia. These authors suggest also additional items for diagnosis of the syndrome such as: (a) exacerbation of abnormality of the posture while walking; (b) indifference to abnormality of the posture without agony (anosognosia); and (c) improvement in abnormality of the posture on withdrawal of the causal agents. Our cases fulfilled basic items from (b) to (f) and additional item (c), and, therefore, we could define cases 1 and 2 as Pisa syndrome. All three patients were previously treated with different kinds of first generation antipsychotic agents with some extrapyramidal side effects, but none of them suffered from dystonic reaction during this treatment. Dystonic reactions appeared only 2-8 weeks following the switch to novel antipsychotics. This was a basis for our assumption that the novel antipsychotics were responsible for these motor disturbances. In contrast to acute dystonia patients, in whom the movement disturbance appeared within a short time from the beginning of treatment, in our cases dystonic movements appeared after at least 2 to 8 weeks while patients were on constant doses of antipsychotics. Anyway, the term â&#x20AC;&#x153;tardive disturbanceâ&#x20AC;? should not mislead us to understand it as a delay of long-time like tardive dyskinesia. Kiriakakis and coworkers in a follow-up study of 107 cases found that tardive dystonia could develop at any time, ranging from 4 days to 23 years after the introduction of antipsychotics (mean 6.2 Âą 5.1 years) (45). Dystonia has been a well-known entity for almost a century. It was described as a neurological disturbance characterized by sustained involuntary muscle contractions, often causing twisting and repetitive movements or abnormal posture (46). This phenomenon may be 198

primary, in which there is no certain underlying cause, or secondary to other neurological conditions, which include structural lesions of the basal ganglia, exposure to drugs and toxins, and cerebral palsy. In this article, we discuss only secondary dystonia induced by antipsychotic drugs, more specifically the tardive type in contrast to the acute common type, with which we do not deal. The most widespread explanation of dystonic movements is involvement of central dopaminergic pathways (47), but it still remains unclear. Since the tardive type of dystonia reacts to anticholinergic agents, some researchers concluded that cholinergic mechanisms take part in this movement disturbance (48, 49). Recent publications suggest also the possibility of serotonin and noradrenalin involvement in pathogenesis of tardive dystonia and the Pisa syndrome.(39) Another theory suggests that distractive involvement of free radicals in the nervous system produce neural damage leading to these movement disturbances (50). Since the Pisa syndrome positively reacts to diminishing or withdrawal antipsychotics, in contrast to tardive dystonia, some researchers assume that there are different pathophysiologic mechanisms underlying this pathology (40). Despite treatment, the dystonia often persists, especially if antipsychotics have to be continued (51). However, the treatment of tardive dystonia is often unsuccessful (37). Among identified risk factors of tardive dystonia are younger age, male sex, mental retardation and convulsive therapy (52-54). Drug-induced Pisa syndrome develops predominately in females and older patients with organic brain disorder treated with combined pharmacological treatment (9, 33). It sometimes occurs following changes in antipsychotic therapy, addition of another antipsychotic drug to an established regimen of antipsychotics, or an insidious rise in antipsychotictreated patients for no apparent reason. However, until now no specific risk factors for tardive laryngeal dystonia have been detected. In contrast to the known risk factors for development of the Pisa syndrome, our two patients (Case 1 and Case 2) were middle-aged males without a history of brain damage. However, this small sample cannot be a base for far-reaching implications. At the same time, we can see that this syndrome is not exclusive to females and clinicians should be aware to this diagnostic option. In both patients, movement disorders appeared after a change of their pharmacotherapy. Some authors assume that the Pisa syndrome may be connected with antipsy-

Chanoch Miodownik et al.

chotic discontinuation, which may lead to dopaminergiccholinergic imbalance (33, 38). In Case 1, Pisa syndrome appeared after reduction of the risperidone dose, and therefore we cannot exclude it as a pathogenetic reason, although sertindole was added. However, discontinuation of sertindole treatment led to the disappearance of this phenomenon, which cannot be excluded as a causal connected factor. It should be mentioned that in both cases all signs of the movement disturbance disappeared only after total discontinuation of sertindole and ziprasidone without treating with anticholinergic agents. Laryngeal dystonia is a very rare form of tardive dystonia and the cause of its appearance is unknown. It is manifested by inappropriate hyperadduction and/or hyperabduction of the vocal cords, resulting in a forced, strained, strangled quality of voice (55). Some researchers suppose that basal ganglia pathology is implicated in its origin. In psychiatric practice this disturbance is described as a side-effect of antipsychotic medications (56). In our case, laryngeal dystonia was induced by restarting risperidone treatment and changing its dose. We found in the literature only one report describing this disturbance caused by a low-dose of risperidone treatment (55). Although the Pisa syndrome and laryngeal dystonia are different entities, we have combined them in one report, since both were induced by novel second generation agents. Movement disorders are not new in patients with schizophrenia and they are known as antipsychotic drug side effects. However, greater awareness of this adverse phenomenon is desirable. Such awareness is more important since relatively new medications were highly hoped to be innocent agents, especially in the field of movement disorders. Elevating incidence of tardive dyskinesia induced by second generation antipsychotics has already been reported (57, 58). Physicians should be aware of this problem and always obtain information about the medication used by patients. Further publications on this issue could help in understanding the connection between atypical antipsychotics and tardive dystonia. It is very relevant to any discussion about the significance of the novel antipsychotics. References 1. Grundmann K, Laubis-Herrmann U, Bauer I, Dressler D, VollmerHaase J, Bauer P, Stuhrmann M, Schulte T, Schols L, Topka H, Riess O. Frequency and phenotypic variability of the GAG deletion of the DYT1 gene in an unselected group of patients with dystonia. Arch Neurol

2003;60:1266-1270. 2. Havaki-Kontaxaki BJ, Kontaxakis VP, Christodoulou GN. Treatment of tardive pharyngolaryngeal dystonia with olanzapine. Schizophr Res 2004;66:199-200. 3. Ekbom K, Lindholm H, Ljungberg L. New dystonic syndrome associated with butyrophenone therapy. Z Neurol 1972;202:94-103. 4. Duggal HS, Sivamony S, Umapathy C. Pisa syndrome and atypical antipsychotics. Am J Psychiatry 2004;161:373. 5. Rota E, Bergesio G, Dettoni E, Demicheli CM. Pisa syndrome during aripiprazole treatment: a case report. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:286-287. 6. Pinninti NR, Mago R, Adityanjee. Tardive dystonia-associated prescription of aripiprazole. J Neuropsychiatry Clin Neurosci 2006;18:426-427. 7. Kurtz G, Kapfhammer HP, Peuker B. [Pisa syndrome in clozapine therapy]. Nervenarzt 1993;64:742-746 (in German). 8. Bruneau MA, Stip E. Metronome or alternating Pisa syndrome: A form of tardive dystonia under clozapine treatment. Int Clin Psychopharmacol 1998;13:229-232. 9. Stubner S, Padberg F, Grohmann R, Hampel H, Hollweg M, Hippius H, Moller HJ, Ruther E. Pisa syndrome (pleurothotonus): Report of a multicenter drug safety surveillance project. J Clin Psychiatry 2000;61:569-574. 10. Hung TH, Lee Y, Chang YY, Chong MY, Lin PY. Reversible Pisa syndrome induced by clozapine: A case report. Clin Neuropharmacol 2007;30:370-372. 11. Arora M, Praharaj SK, Sarkar S. Clozapine effective in olanzapineinduced Pisa syndrome. Ann Pharmacother 2006;40:2273-2275. 12. Dunayevich E, Strakowski SM. Olanzapine-induced tardive dystonia. Am J Psychiatry 1999;156:1662. 13. Fdhil H, Krebs MO, Bayle F, Vanelle JM, Olie JP. [Risperidone-induced tardive dystonia: a case of torticollis]. Encephale 1998;24:581-583 (in French). 14. Jagadheesan K, Nizamie SH. Risperidone-induced Pisa syndrome. Aust N Z J Psychiatry 2002;36:144. 15. Harada K, Sasaki N, Ikeda H, Nakano N, Ozawa H, Saito T. Risperidoneinduced Pisa syndrome. J Clin Psychiatry 2002;63:166. 16. Vercueil L, Foucher J. Risperidone-induced tardive dystonia and psychosis. Lancet 1999;353:981. 17. Duggal HS, Mendhekar DN. Risperidone-induced tardive pharyngeal dystonia presenting with persistent Dysphagia: A case report. Prim Care Companion J Clin Psychiatry 2008;10:161-162. 18. Krebs MO, Olie JP. Tardive dystonia induced by risperidone. Can J Psychiatry 1999;44:507-508. 19. Padberg F, Stubner S, Buch K, Hegerl U, Hampel H. Pisa syndrome during treatment with sertindole. Br J Psychiatry 1998;173:351-352. 20. Duggal HS. Acute pisa syndrome and pharyngolaryngeal dystonia due to ziprasidone. J Neuropsychiatry Clin Neurosci 2008;20:108-109. 21. Mason MN, Johnson CE, Piasecki M. Ziprasidone-induced acute dystonia. Am J Psychiatry 2005;162:625-626. 22. Weinstein SK, Adler CM, Strakowski SM. Ziprasidone-induced acute dystonic reactions in patients with bipolar disorder. J Clin Psychiatry 2006;67:327-328. 23. Ziegenbein M, Schomerus G, Kropp S. Ziprasidone-induced Pisa syndrome after clozapine treatment. J Neuropsychiatry Clin Neurosci 2003;15:458-459. 24. Papapetropoulos S, Wheeler S, Singer C. Tardive dystonia associated with ziprasidone. Am J Psychiatry 2005;162:2191. 25. Tsai CS, Lee Y, Chang YY, Lin PY. Ziprasidone-induced tardive laryngeal dystonia: A case report. Gen Hosp Psychiatry 2008;30:277-279. 26. Harada K, Saito T. Pisa syndrome-like peculiar posture occurred while running was successfully improved with risperidone. Psychiatry Clin

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Neurosci 2006;60:771-772. 27. Yohanan M, Aulakh JS, Weith J, Hawkins JW. Pisa syndrome in a patient in a wheelchair taking valproic acid. Am J Psychiatry 2006;163:325-326. 28. Kwak YT, Han IW, Baik J, Koo MS. Relation between cholinesterase inhibitor and Pisa syndrome. Lancet 2000;355:2222. 29. Suzuki T, Kurita H, Hori T, Sasaki M, Baba A, Shiraishi H, Piletz JE. The Pisa syndrome (pleurothotonus) during antidepressant therapy. Biol Psychiatry 1997;41:234-236. 30. Bilen S, Saka M, Ak F, Oztekin N. Persistent dystonia induced by fluoxetine. Intern Med J 2008;38:672-674. 31. Bhattacharya KF, Giannakikou I, Munroe N, Chaudhuri KR. Primary anticholinergic-responsive Pisa syndrome. Mov Disord 2000;15:12851287. 32. Harada K. Pisa syndrome without neuroleptic exposure in a patient with Parkinsonâ&#x20AC;&#x2122;s disease: A case report. Mov Disord 2006;21:2264; author reply 2264-2265. 33. Suzuki T, Matsuzaka H. Drug-induced Pisa syndrome (pleurothotonus): Epidemiology and management. CNS Drugs 2002;16:165-174. 34. van Harten PN, Kahn RS. Tardive dystonia. Schizophr Bull 1999;25:741748. 35. Burke RE, Fahn S, Jankovic J, Marsden CD, Lang AE, Gollomp S, Ilson J. Tardive dystonia: late-onset and persistent dystonia caused by antipsychotic drugs. Neurology 1982;32:1335-1346. 36. Ford B, Greene P, Fahn S. Oral and genital tardive pain syndromes. Neurology 1994;44:2115-2119. 37. van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ 1999;319:623-626. 38. Villarejo A, Camacho A, Garcia-Ramos R, Moreno T, Penas M, Juntas R, Ruiz J. Cholinergic-dopaminergic imbalance in Pisa syndrome. Clin Neuropharmacol 2003;26:119-121. 39. Remington GJ. The Pisa syndrome: Possible role for serotonin and noradrenaline. J Clin Psychopharmacol 1988;8:228-229. 40. Suzuki T, Hori T, Baba A, Abe S, Shiraishi H, Moroji T, Piletz JE. Effectiveness of anticholinergics and neuroleptic dose reduction on neuroleptic-induced pleurothotonus (the Pisa syndrome). J Clin Psychopharmacol 1999;19:277-280. 41. Suzuki T, Koizumi J, Moroji T, Sakuma K, Hori M, Hori T. Clinical characteristics of the Pisa syndrome. Acta Psychiatr Scand 1990;82:454457. 42. Keegan DL, Rajput AH. Drug induced dystonia tarda: Treatment with L-dopa. Dis Nerv Syst 1973;34:167-169. 43. Adityanjee, Aderibigbe YA, Jampala VC, Mathews T. The current status

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of tardive dystonia. Biol Psychiatry 1999;45:715-730. 44. Burke RE. Neuroleptic-induced tardive dyskinesia variants. In: Lang AE,Weiner WJ, editors. Drug induced movement disorders. New York: Futura, Mount Kisco, 1992: pp. 167-198. 45. Kiriakakis V, Bhatia KP, Quinn NP, Marsden CD. The natural history of tardive dystonia. A long-term follow-up study of 107 cases. Brain 1998;121 ( Pt 11):2053-2066. 46. Fahn S, Marsden CD, Calne DB. Classification and investigation of dystonia. In: Marsden CD, Fahn S, editors. Movement disorders. London: Butterworths, 1987: pp. 332-358. 47. Warner TT, Jarman P. The molecular genetics of the dystonias. J Neurol Neurosurg Psychiatry 1998;64:427-429. 48. Burke RE, Fahn S, Marsden CD. Torsion dystonia: A doubleblind, prospective trial of high-dosage trihexyphenidyl. Neurology 1986;36:160-164. 49. Greene P, Shale H, Fahn S. Analysis of open-label trials in torsion dystonia using high dosages of anticholinergics and other drugs. Mov Disord 1988;3:46-60. 50. Lohr JB, Cadet JL, Lohr MA, Jeste DV, Wyatt RJ. Alpha-tocopherol in tardive dyskinesia. Lancet 1987;1:913-914. 51. Kang UJ, Burke RE, Fahn S. Tardive dystonia. Adv Neurol 1988;50:415429. 52. Friedman JH, Kucharski LT, Wagner RL. Tardive dystonia in a psychiatric hospital. J Neurol Neurosurg Psychiatry 1987;50:801-803. 53. Gimenez-Roldan S, Mateo D, Bartolome P. Tardive dystonia and severe tardive dyskinesia. A comparison of risk factors and prognosis. Acta Psychiatr Scand 1985;71:488-494. 54. Raja M. Tardive dystonia. Prevalence, risk factors, and comparison with tardive dyskinesia in a population of 200 acute psychiatric inpatients. Eur Arch Psychiatry Clin Neurosci 1995;245:145-151. 55. Armstrong L, Randal P. Spasmodic dysphonia, a rare form of tardive dystonia, induced by low-dose risperidone? Aust N Z J Psychiatry 2004;38:174. 56. Davis RJ, Cummings JL, Hierholzer RW. Tardive dystonia: Clinical spectrum and novel manifestations. Behavioural Neurology 1988;1:41-47. 57. Tenback DE, van Harten PN, Slooff CJ, van Os J. Incidence and persistence of tardive dyskinesia and extrapyramidal symptoms in schizophrenia. J Psychopharmacol 2010;24:1031-1035. 58. Woods SW, Morgenstern H, Saksa JR, Walsh BC, Sullivan MC, Money R, Hawkins KA, Gueorguieva RV, Glazer WM. Incidence of tardive dyskinesia with atypical versus conventional antipsychotic medications: A prospective cohort study. J Clin Psychiatry 2010;71:463-474.

Isr J Psychiatry Relat Sci - Vol. 48 - No 3 (2011)

Alexander Grinshpoon et al.

Psychiatric Hospitalization by Court Observation Order in Israel: A Ten-Year Follow-up Study Alexander Grinshpoon, MD, MHA, PhD,1 Razek Khawaled, MA,2 Jacob Polakiewicz, MD,3 Paul S. Appelbaum, MD,4 and Alexander M. Ponizovsky, MD, PhD2 1

Sha'ar Menashe MHC, Hadera, Israel Mental Health Services, Ministry of Health, Jerusalem, Israel 3 Tirat Carmel MHC, Tirat Carmel, Israel 4 Columbia University College of Physicians and Surgeons, New York, New York, U.S.A 2

ABSTRACT Objectives: To explore the proportion of defendants hospitalized by court observation order (COO) who were diagnosed as having a psychiatric disorder during: 1) the COO period, or 2) a 10-year follow-up period. Methods: Data on all adult defendants, who underwent psychiatric hospitalization by COO between 1991 and 1995, were extracted from the National Psychiatric Case Registry of the Israel Ministry of Health, and rehospitalizations over the next ten years were identified. ANOVA and Wilcoxon signed-rank test were used for comparing the diagnosed and undiagnosed defendant cohorts. Results: Only 17% of defendants hospitalized by COO received a psychiatric diagnosis (N=316), while the remaining referred defendants (N=1,532) were not diagnosed as suffering from any psychiatric disorder. Although 56% of the initially undiagnosed group (N=863) were rehospitalized and received a psychiatric diagnosis during the next ten years, 36% of the original cohort never received a diagnosis subsequent to hospitalization (N=556). Significant median differences in inpatient days associated with a follow-up diagnosis of psychotic disorder were found between the diagnosed and undiagnosed defendant cohorts (z=4.89, p<.001). Conclusions: The high rate of diagnosis of defendants who were undiagnosed at the index hospitalization suggests that the COO is ineffective and tends to discharge without diagnosis defendants who are later

found to be psychotic. Therefore, an independent examination of the accuracy of the forensic psychiatric evaluation (FPE) process is called for, to determine whether actual disorders are being missed. There should be a professional and public debate on the unnecessary use of court-ordered hospitalizations and ways of their prevention.

Introduction Psychiatric hospitalization for forensic psychiatric evaluation (FPE) may be ordered by a court in most Western countries when questions arise about a defendant’s mental state (1, 2). In Israel, the court observation order (COO) provisions are embodied in the Mental Health Act, 1991 (3, 4) (see Appendix). Defendants can be referred for assessment of their competence to stand trial or for evaluation of their criminal responsibility, the latter often triggered by defendants’ assertions that the criminal acts they are accused of committing were the result of psychotic symptoms (5, 6). In Israel, annually nearly 3% of all cases in the criminal courts are referred to psychiatric hospitals for inpatient FPE and the rate of referral has been growing over time (www.police.gov.il/mehozot/agafAHM/mahleketTviot). Israeli law provides defendants with the FPE if s/he states that s/he is suffering from mental illness at the time of the court hearings or that s/he had mental illness already at the time of the offense. The situation where the FPE concludes

Address for Correspondence: A. M. Ponizovsky, MD, PhD, Mental Health Services, Ministry of Health, 2 Ben Tabai St., Jerusalem 93591, Israel. alexander.ponizovsky@moh.health.gov.il

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Psychiatric Hospitalization by Court Observation Order in Israel: A Ten-Year Follow-up Study

that a defendant was suffering from mental illness at the time of the offense is similar to the plea in the U.S.A., “not guilty by reason of insanity” (NGRI), whereas the case in which defendants have been recognized as suffering from mental illness at the time of the court hearings resembles the plea in the U.S.A., “guilty but mentally ill” (GBMI). The verdict of NGRI, implying the absence of criminal responsibility because of a mental disorder, is followed by hospitalization, the length of which is determined by how rapidly the person responds to treatment, after which a defendant can be released to outpatient care. Under the GBMI verdict, a defendant is considered criminally responsible and is sentenced as if no mental disorder were present; the court then determines whether and to what extent the defendant requires treatment for mental illness. When, and if, the defendant is deemed no longer to need treatment, s/he is required to serve out the rest of the sentence. In general, the main force in the Israeli adversary criminal juridical system is the position taken by the conflicting sides. Disagreements or agreements between the defense and the prosecution could affect directly the length of psychiatric forensic hospitalization, as well as future rehospitalizations of recidivist criminals. It is also not a rare sight in everyday practice that courts send criminals to hospitalization via COO because of their over vigilance and/or wishing to share a responsibility for their verdicts with other professionals. There is a vast international literature on insanity defense outcomes (7-9), outcomes of forensic psychiatric examination for defendants who committed homicide (10), matricide and patricide (11), or infanticide (12), prevalence of serious mental illness among prisoners (13) and factors associated with the severity of violent behavior (14-16), clinical and neuropsychological characteristics of insanity acquitted individuals (17), and community based programs that provide clinical, rehabilitative, and supervisory services to them (18, 19). For instance, a major epidemiological study conducted by the National Institute of Mental Health in 1991 found that less than 1% of county court cases involved the insanity defense and that 90% of the insanity defendants had been diagnosed with a mental illness (20). To our knowledge, however, no longitudinal study has been conducted to explore the extent to which the COO process is used by defendants who have serious mental disorders, as opposed to those who may simply be looking for a way out of a difficult legal situation. This question, however, is of great importance for assessing the effectiveness of the COO process and for planning public psychiatric services. 202

The present study was undertaken with the goal of exploring the proportion of defendants hospitalized by COO in Israel between 1991 and 1995 (the index hospitalization) who were diagnosed as having a psychiatric disorder during: 1) the COO period, or 2) a 10-year follow-up period. A secondary goal was to compare the two follow-up cohorts of defendants: 1) those who were rehospitalized and received a psychiatric diagnosis (diagnosed group) and 2) those who were rehospitalized and did not receive a psychiatric diagnosis combined with those who were not rehospitalized at all (undiagnosed group), by their sociodemographic characteristics, duration of the index hospitalization, and total number of rehospitalizations. Methods Study design

We identified in the National Psychiatric Case Registry of the Israel Ministry of Health (“the Registry”) all inpatients, aged 18 years and older, who underwent psychiatric hospitalization by COO from January 1, 1991, to December 31, 1995 (the index hospitalization). The Registry is the national databank of all psychiatric admissions and discharges since 1950 (21). Approximately 21,000 hospitalizations in psychiatric hospitals or psychiatric units of general hospitals are recorded annually and nearly 25% of all hospitalizations are by involuntary treatment order. The proportion of admissions by COO has been stable over time at approximately 5% of all admissions (22). All subsequent rehospitalizations and associated ICD-10 diagnoses (23) for each of the COO patients were identified over a 10-year follow-up period between January 1, 1996, and December 31, 2005. In addition, information on gender, age, marital status, years of education, place of origin (Americas, Europe, Asia, Africa and Australia), and diagnosis upon discharge was extracted from the Registry. Data analysis

Continuous variables were compared using the two-tailed t-test, or the Wilcoxon signed-rank test for assessing the difference in medians. Differences in the frequency of categorical variables were examined with chi-square tests. In addition, analysis of variance (ANOVA) was used to examine: 1) duration of the index hospitalization; and 2) diagnostic category according to ICD-10 criteria (23). These included organic brain disorder [F00-09, F80-89, and F90-99], personality disorder [F10-19, F40-49, and

Alexander Grinshpoon et al.

F60-69], and psychotic disorders [F20-29, and F30-39]. When significant differences between groups were identified by ANOVA, post-hoc analyses were carried out using the Tukey-Kramer method for unequal group sizes. Given a substantial variability in means, Wilcoxon rank-sum test for median values was used to test ANOVA results. For all analyses, the level of statistical significance was set at alpha < .05. All statistical analyses were performed with the NCSS software package (Number Cruncher Statistical Systems: Kaysville, Utah, 2006). Figure 1. The flow of patients through the study. 526 (61%) psychotic disorders 863 (56%) received follow-up diagnosis

1,532 (83%) discharged without diagnosis

669 (44%) received no follow-up diagnosis

1,848 admitted for forensic psychiatric evaluation

234 (27%) personality disorders 103 (12%) organicbrain disorders

279 (88%) psychotic disorders

316 (17%) discharged with diagnosis

10 (3%) personality disorders 27 (9%) organicbrain disorders

Results Figure 1 depicts the flow of patients through the study. Of all defendants hospitalized by COO during the study period, 83% were discharged from the index hospitalization without a psychiatric diagnosis, and only 17% received a psychiatric diagnosis. Of the latter, 88% were diagnosed as having a serious mental disorder (schizophrenia, schizoaffective or mood disorder), 9% as having organic brain disorders, and the remaining 3% received a diagnosis of personality disorder. Over the next ten years, of all defendants who were discharged from the index hospitalization without a psychiatric diagnosis, 36% were not rehospitalized at all, whereas the remaining 64% had at least one rehospitalization. Of those who were rehospitalized, 54% received diagnoses of psychotic disorders, 24% of personality disorders, and 10% of organic brain disorders. The remaining 12% were rehospitalized for repeated FPEs from which they were released without diagnoses. Thus, 44% of defendants received no diagnosis over the follow-up period. Table 1 presents selected sociodemographic characteristics of individuals from the initial cohort, and the two follow-up groups (diagnosed with a mental disorder and undiagnosed). As can be seen, the two follow-up groups were quite comparable on sex and age but there was a higher proportion of single and a lower proportion of married individuals among the defendants who later received a diagnosis of mental disorder compared with their undiagnosed counterparts (χ2=8.1, df=2, p=.012).

Table 1. Demographic characteristics of defendants hospitalized by court observation order and discharged without diagnosis, and received no psychiatric diagnosis over a 10-year follow-up. Defendants without diagnosis at index hospitalization (n=1532) Characteristic

without follow-up diagnosis (n=669)

with follow-up diagnosis (n=863)

Male

1361

88.8

605

90.4

757

87.7

Female

171

11.2

9.6

106

12.3

Age (yr.), mean ± SD

33.6±12.3

Significance test* p

Gender

33.6±13.0

33.6±11.7

x2=3.0, df=1

.082

t=0.06

.95

x2=8.1, df=2

.012

Marital status Single

762

55.4

316

51.5

446

58.5

Married

399

28.0

202

33.0

197

25.8

divorced/widowed

215

15.6

15.5

120

15.7

missing data

156

100

*Chi-square test and two-tailed t-test

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Psychiatric Hospitalization by Court Observation Order in Israel: A Ten-Year Follow-up Study

ANOVA results showed a significant difference between the group that would later be rehospitalized and receive a psychiatric diagnosis and the group that would not later be diagnosed in inpatient days during the index hospitalization (16.3 days, SD= 18.3 vs. 12.7 days, SD=14.3; ANOVA, F=15.7, d.f.=2, p<.001). This difference remained significant after controlling for a potential confounding effect of marital status. Wilcoxon rank-sum test supported the ANOVA results, demonstrating significant median differences in inpatient days between the groups (z=4.89, p<.001). Table 2. Number of inpatient days at the index hospitalization by court observation order and number of rehospitalizations over a 10-year follow-up by ICD-10 diagnostic category* Inpatient days during index hospitalization*

Number of follow-up rehospitalizations**

Follow-up diagnosis

Mean

Psychotic disorders

526

19.5

0.9

2.4

.05

Personality disorders

234

12.2

1.4

2.0

.08

Organic brain disorders

103

16.6

2.3

2.0

.05

ANOVA

863

F(3)=10.9, p<.0001

F(3)=8.5, p<.0001

ICD-10 diagnostic category: organic brain disorder (F00-09, F80-89, and F90-99); personality disorder (F10-19, F40-49, and F60-69); psychotic conditions (F20-29, and F30-39) Post-hoc Tukey-Kramer single comparisons (p<.05): * - psychotic disorders>personality disorders; ** - psychotic disorders>personality disorders and psychotic disorders>organic brain disorders

In addition, defendants who would later be diagnosed as having a psychotic disorder (schizophrenia or mood disorder) had longer index hospitalizations, compared to those receiving other diagnoses (F=10.0, df=2, p<.0001), as well as more follow-up rehospitalizations (F=8.5, df=2, p<.0001) (Table 2). Discussion To our knowledge, this is the first study to explore an epidemiologically-defined cohort of defendants who were hospitalized for FPE by COO in Israel. Examining all defendants hospitalized over a 5-year period, we found only 17% of defendants hospitalized by COO received a psychiatric diagnosis, while the vast majority (83%) of referred defendants was diagnosed as not suffering from any psychiatric disorder. Although an additional 47% of the original cohort (56% of the initially undiagnosed 204

group) were hospitalized and received a psychiatric diagnosis during the next ten years, 36% of the original cohort never received a diagnosis subsequent to hospitalization. Moreover, of those who were subsequently diagnosed, 27% (13% of the original cohort) were given diagnoses of personality disorders, which would not have qualified them for an NGRI verdict. Thus, our hypothesis that most defendants sent for COO would not be diagnosed with serious mental illnesses was confirmed. However, the huge difference between the diagnoses found in our sample and those of epidemiological community surveys of mental disorders should be addressed. While community surveys report lifetime prevalence rate for all psychotic disorders as 3.5% (24), in our initial sample the rate of psychotic disorders was 15% and there was no diagnosis of common mental disorders. According to the Israel National Health Survey, however, a lifetime occurrence of a mood or anxiety disorder was 17% and the 12-month prevalence rate was near 10% (25). Two explanations may be suggested for these disparities. The first, regarding excess of psychotic disorders in our sample, is that we did not deal with a community sample, but with the highly selective sample of defendants who were hospitalized by COO for a 5-year period, during which they yielded cumulatively the 15% rate of psychotic disorders. The second explanation, concerning the absence of common mental disorders in our sample, is that the forensic evaluators considered information on common mental disorders as irrelevant to the main FPE task â&#x20AC;&#x201C; to determine whether the individual under test was psychotic or not â&#x20AC;&#x201C; and therefore discarded it. It is of interest that at the time of index hospitalization, the group that would later be diagnosed as having a mental disorder had significantly longer hospitalizations than the group that would not receive diagnoses during the follow-up period. Moreover, this increase in inpatient days was associated with a follow-up diagnosis of psychotic disorder. There are several possible explanations for this finding. The group that would later be diagnosed may have initially presented with mild signs and symptoms as precursors of a future full-blown psychosis. These manifestations may have attracted the attention of the evaluators and required more time for examination and collection of collateral information. However, these symptoms appear to have been below the diagnostic threshold required for any specific disorder, and, hence, no diagnosis was made. Another putative explanation for this association could be that the group that would later be diagnosed

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included many cases of partially malingered disorders. In a legal context, malingering may be motivated by the desire to avoid or at least mitigate a criminal sentence (26). Differentiation between malingered and actual disorders may be difficult and time-consuming (27, 28), requiring the evaluator to assemble evidence of a personâ&#x20AC;&#x2122;s past and current functioning, with corroboration from clinical records and collateral information from multiple sources. This may be especially true when malingering occurs in the context of some background level of symptomatology, and consists of exaggerating the nature and extent of symptoms. Neuropsychological tests may also be helpful in these cases (29, 30). The need for careful differentiation of partially malingered presentations from full-blown disorders may have resulted in prolonged periods of hospitalization. Among the limitations of this study is our reliance on diagnoses made by the evaluating clinicians during the index hospitalization and by the treating clinicians during the follow-up period, which are of uncertain validity and reliability. We cannot rule out the possibility that legitimate diagnoses were missed during the index evaluation, or that successful malingering then or during follow-up may have inflated the proportion of subjects diagnosed as having a mental disorder. Recall also that there is an inevitable difference between medical and legal approaches to mental illness definition: while the former implies a wider definition, the latter restricts mental illness to exclusively psychotic condition. Another limitation is intrinsic to the Registry: information about diagnoses assigned during the 10-year follow-up period was drawn exclusively from a database containing records of inpatient hospital stays; to the extent that members of this sample were diagnosed with psychiatric disorders in outpatient settings and never rehospitalized, we would not know about those diagnoses. The findings of the present study point to problems associated with the COO process as it currently operates in Israel, and permit the formulation of some recommendations to prevent unjustified and unnecessary use of court-ordered hospitalizations. More careful evaluation for competence to stand the trial or/and criminal responsibility of defendants by the District Psychiatrist prior to referral for inpatient evaluation might reduce the number of referrals of persons found not to have mental disorders. In this respect, a special survey of all the District Psychiatrists in the country could be useful to understand how they decide who should be sent for COO and who for CMHC evaluation. Likewise, the development of cri-

teria that are associated with levels of impairment likely to support an NGRI plea could help attorneys and judges to play a more assertive role in weeding out unnecessary referrals. However, the high rate of diagnosis of defendants who were undiagnosed at the index hospitalization also suggests that the COO is ineffective and tends to discharge without diagnosis defendants, who later are found to be psychotic. Therefore, an independent examination of the accuracy of the forensic psychiatric evaluation process is called for, to determine whether actual disorders are being missed. Such an in-depth investigation should take into account data concerning sources of collateral information, history of past treatments, evidence of assessment of non-psychotic disorders, as well as to include the relevant court reports to better understand which information has been considered and which not in the diagnostic decision-making process. Finally, there should be a professional and public debate on the unnecessary use of court-ordered hospitalizations and means for their prevention. Acknowledgements Dr. A.M. Ponizovsky was supported in part by the Ministry of Immigrant Absorption of Israel. Authors thank the Department of Information and Evaluation, Ministry of Health (Head Mrs. R. Yoffe) for the provision of the datasets, Prof. M.S. Ritsner for useful statistical advice and Prof. P.S. Appelbaum for his help in preparing an earlier version of the paper. We also wish to thank anonymous reviewers for their valuable comments.

References 1. Bauer A, Rosca P, Grinshpoon A, Khawaled R, Mester R, Yoffe R, Ponizovsky AM. Trends in involuntary psychiatric hospitalization in Israel 1991-2000. Int J Law Psychiatry 2007; 30:60-70. 2. Salize HJ, Dressing H. Epidemiology of involuntary placement of mentally ill people across the European Union. Br J Psychiatry 2004;184:163-168. 3. Mental Health Act, the State of Israel, 1991. 4. Bauer A, Rosca P, Grinshpoon A, Khawalled R, Mester R. Monitoring long-term court order psychiatric hospitalization: A pilot project in Israel. Med Law 2006:25:83-99. 5. KrĂśber HL, Lau S. Bad or mad? Personality disorders and legal responsibility - the German situation. Behav Sci Law 2000;18:679-690. 6. Lim LE, Chan KL, Tan LL, Sung M, Loh MI, Straughan PT. A review of offenders remanded in a State Psychiatric Hospital. Singapore Med J 2000;41:114-117. 7. Janofsky JS, Dunn MH, Roskes EJ, Briskin JK, Rudolph MS. Insanity defense pleas in Baltimore City: An analysis of outcome. Am J Psychiatry 1996;153:1464-1468. 8. Borum R, Fulero SM. Empirical research on the insanity defense and attempted reforms: evidence toward informed policy. Law Hum Behav 1999;23:375-393. 9. Skipworth J, Brinded P, Chaplow D, Frampton C. Insanity acquittee outcomes in New Zealand. Aust N Z J Psychiatry 2006;40:1003-1009. 10. Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J. Homicide and mental illness in New Zealand, 1970-2000. Br J Psychiatry 2004;185:394-398.

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11. Liettu A, Säävälä H, Hakko H, Räsänen P, Joukamaa M. Mental disorders of male patricidal offenders: a study of offenders in forensic psychiatric examination in Finland during 1973-2004. Soc Psychiatry Psychiatr Epidemiol 2009;44:96-103. 12. Friedman SH, Hrouda DR, Holden CE, Noffsinger SG, Resnick PJ. Child murder committed by severely mentally mothers: An examination of mothers found not guilty by reason of insanity. J Forensic Sci 2005;50:1466-1471. 13. Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of serious mental illness among jail inmates. Psychiatr Serv 2009;60:761-765. 14. Stompe T, Ortwein-Swoboda G, Schanda H. Schizophrenia, delusional symptoms, and violence: The threat/control override concept reexamined. Schizophr Bull 2004;30:31-44. 15. Monahan J, Steadman HJ, Robbins PC, Appelbaum P, Banks S, Grisso T, Heilbrun K, Mulvey EP, Roth L, Silver E. An actuarial model of violence risk assessment for persons with mental disorders. Psychiatr Serv 2005;56:810-815. 16. Rosca P, Bauer A, Grinshpoon A, Khawaled R, Mester R, Ponizovsky AM. Rehospitalizations among psychiatric patients whose first admission was involuntary: A 10-year follow-up. Isr J Psychiatry Relat Sci 2006;43:57-64. 17. Nestor PG, Haycock J. Not guilty by reason of insanity of murder: Clinical and neuropsychological characteristics. J Am Acad Psychiatry Law 1997;25:161-171. 18. Steadman HJ, Gounis K, Dennis D, Hopper K, Roche B, Swartz M, Robbins PC. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv 2001;52:330-336. 19. Bertman-Pate LJ, Burnett DM, Thompson JW, Calhoun CJ Jr, Deland S, Fryou RM. The New Orleans Forensic Aftercare Clinic: A seven year review of hospital discharged and jail diverted clients. Behav Sci Law 2004;22:159-169.

20. Callahan LA, Steadman HJ, McGreevy MA, Robbins PC. The volume and characteristics of insanity defense pleas: An eight-state study. Bull Am Acad Psychiatry Law 1991;19:331-338. 21. Lichtenberg P, Kaplan Z, Grinshpoon A. The goals and limitations of Israel’s Psychiatric Case Register. Psychiatr Serv 1999;50:1043-1048. 22. Mental Health in Israel. Statistical Annual 2008. Ministry of Health, Jerusalem, 2009. 23. World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva: WHO, 1993. 24. Perälä J, Suvisaari J, Saarni SI, Kuoppasalmi K, Isometsä E, Pirkola S, Partonen T, Tuulio-Henriksson A, Hintikka J, Kieseppä T, Härkänen T, Koskinen S, Lönnqvist J. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry 2007;64:19-28. 25. Levinson D, Zilber N, Lerner Y, Grinshpoon A, Levav I. Prevalence of mood and anxiety disorders in the community: Results from the Israel National Health Survey. Isr J Psychiatry Relat Sci 2007;44:94-103. 26. USA v. Dammeon Binion - U.S. Court of Appeals for the 8th Cir. - May 23, 2005, Federal Circuits, Docket 04-1546 - vLex. vlex.com. http://vlex. com/vid/19469412. Retrieved 2008-12-15. 27. Kucharski LT, Ryan W, Vogt J, Goodloe E. Clinical symptom presentation in suspected malingerers: An empirical investigation. J Am Acad Psychiatry Law 1998;26:579-585. 28. Resnick PJ. The detection of malingered psychosis. Psychiatr Clin North Am 1999;22:159-172. 29. Simon MJ. The use of the Rey Memory Test to assess malingering in criminal defendants. J Clin Psychology 1994;50:913-917. 30. Ganellen RJ, Wasyliw OE, Haywood TW, Grossman LS. Can psychosis be malingered on the Rorschach? An empirical study. J Pers Assess 1996;66:65-80.

Appendix Hospitalization or Outpatient Treatment of an Accused Under a Court Order a. S hould an accused person have been indicted on a criminal charge and the court considers, either on the basis of evidence submitted to it by one of the parties to the proceedings or on the basis of evidence introduced on the court’s own initiative, that the accused is incapable of standing trial because of illness, the court may order that the accused be hospitalized or receive outpatient treatment; should the court decide to inquire into the accused’s guilt under Article 170 of the Criminal Procedure Act [Consolidated Version], 1982 (hereafter – the Criminal Procedure Act), the said order shall remain in effect until the end of the said inquiry, and should the inquiry be completed or halted and the accused not acquitted, the court shall then decide on the question of the hospitalization or outpatient treatment.

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b. S hould an accused person have been indicted on a criminal charge and the court finds that he did commit the criminal act of which he is accused but decides, either on the basis of evidence submitted to it by one of the parties to the proceedings or on the basis of evidence introduced on the court’s own initiative, that the accused was ill at the time of the act and therefore not criminally responsible, and that he is still ill, the court shall order that the accused be hospitalized or receive outpatient treatment. c. A court shall only issue an order under Clauses (a) or (b) above after obtaining a psychiatric opinion, and for that purpose it shall order that the accused be brought for psychiatric examination; should the District Psychiatrist inform the court that the psychiatric examination can only be carried out under hospital conditions, then the court may order the accused admitted to a hospital for examination and observation, for the period of time prescribed in the order.

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Uri Nitzan et al.

Internet-Related Psychosis – A Sign of the Times? Uri Nitzan, MD, Efrat Shoshan, MD, Shaul Lev-Ran, MD, and Shmuel Fennig, MD Shalvata Mental Health Care Center, Hod Hasharon, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel

Introduction

ABSTRACT Background: The psychopathological implications of the Internet are slowly being revealed as its use becomes increasingly common. This paper’s aim is to call attention to computer-mediated communication (CMC), such as Facebook or chats, and alert to its possible relation to psychosis. Data: We describe three individuals, with no prior major psychiatric disorder, who presented for psychiatric treatment, due to psychotic symptoms which appeared de novo while they were immersed in CMC. All three patients pointed to the contribution of specific CMC features to the gradual emergence of their psychotic symptoms. They described a "hyperpersonal" relationship with a stranger, mistrust of the aims and identity of the other party, blurred self boundaries, misinterpretation of information, and undesirable personal exposure in cyberspace. The patients had little prior experience with computers or the Internet, and their vulnerability was intensified due to difficulties in deciphering the meaning of various elements of CMC and in managing its technical aspects. Conclusions: The cases we present support the assumption that unique features of CMC might contribute to the formation of psychotic experiences. The use of the Internet is vast, and, as such, we propose that medical staff members might consider routinely questioning patients about their use of it, especially CMC.

“That tree over there could be a cyberimage. I don't think so. But you can't say you know this for sure. I have no problem saying I know it for sure. A man with no doubt? I didn't say that.” (1)

Address for Correspondence:

Since the 1980s, the personal computer (PC) has found its way into a large proportion of households in the western world. Cyberspace, where Internet-based interactions occur, has evolved into a kind of parallel universe in which people spend much of their time communicating with each other. Technological advances, such as the Internet with its tremendous cultural implications, have a direct effect on the psychopathology of the population in general and of psychiatric patients in particular (2, 3). Internet addiction is gradually being recognized as a novel form of impulse control disorder (4). Internet delusions have been well described in the literature (5-8), and are becoming increasingly common as Internet use expands (8). The hallmark of these delusions is the direct relation of their content to general computer use, and especially to the Internet. Delusions are traditionally characterized by form (subtypes, such as persecutory, grandiosity) and content (such as being persecuted by the CIA, having messianic powers) (9). Despite their distinct characteristics, Internet delusions do not seem to constitute a new form of delusions (5, 6), but they should be perceived as a novel content of the already well-known delusion forms - a new wine in an old bottle (7, 8). This approach is complementary to the notion that a specific delusional content is a derivative of the patient’s cultural environment and subjective life experience (7). The focus of this observational paper is not the influence of Internet use on the nature of the psychotic experience, in terms of whether it is the delusional form or content. Rather, we are interested in the unique features of computer-mediated communication (CMC), the mental environment they create, and their possible contribution to the development of a psychotic experience among vulnerable subjects. CMC refers to any communicative transactions that occur between two or more networked computers. This includes chat rooms, Facebook, and other similar modes of communication in which the user retreats from sub-

Uri Nitzan, MD, 5 Aliyat Hanoar, Hod Hasharon 45100, Israel

urini@clalit.org.il

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stantial interpersonal relationships to the virtual reality of cyberspace. Individuals engaged in CMC are “electronically linked together while physically separate in different locations” (10). There are several unique features of CMC, one of which is the distortion of spatial perception and geographical distance. A neighbor and a stranger overseas are simultaneously accessible and intangible, with the corporeal existence of the other gradually fading (11). In this situation, “one’s experience is of being dislocated and disembodied” (12). Another distinguishing feature of CMC is the detachment of human language from a face and the absence of non-verbal cues. The ability to decipher input is negatively affected by this phenomenon, increasing the potential for uncertainty and misinterpretation. CMC users are strangers and acquaintances at the same time. Over three decades ago, Simmel showed that this paradoxical experience enables a total stranger to become a special confidant who is privy to the most intimate confidences (13). Intense feelings are calmly formed in this relationship, dependency develops without a firm grip of reality, and disappointment or suspiciousness might follow. Walther defines this mode of communication as ”hyperpersonal” (14). He claims that the absence of prior acquaintance enables Internet users to form an idealized perception of the receiver and/or a grandiose self-presentation of the sender, eventually forming a feedback loop that allows the intensity of the relationship to be magnified. Thus, people can become intimate with each other without ever looking into one another’s eyes, without knowing if the “other” is telling the truth or, at times, if he actually exists. The notion of “truth” is fluid in CMC, and one is entitled to believe words and images instead of facts. Another feature of CMC is the fluidity of information that can lead, at times, to the blurring of the barrier between the public and the private (15). One cannot control the information one receives (e.g., the requests for friends on Facebook), and is sometimes unable to protect the most intimate secrets one is willing to disclose only to selected recipients from being revealed to others, thereby gradually developing a stressful sense of transparency. One’s sense of responsibility is weakened on the web and potential harmful consequences are ignored (16). The sense of transparency, as well as repetitive and humiliating CMC experiences can directly contribute to the sense of distress. These essential features of CMC have been discussed to a greater and lesser extent in the scientific and psychoanalytic literature, as were some of their ramifications on the “nature of experience, the body, and the 208

sense of self ” (17). Our extensive search of the medical and psychological electronic databases failed to produce any published attempt to link CMC to the loosening of reality testing and to the development of psychosis. Presented below is a case series of patients who sought psychiatric treatment, due to psychotic symptoms, for the first time in their lives, which appeared de novo while they were immersed in CMC. On the basis of this accumulated experience, we hypothesize that the unique features of CMC might play a role in the formation of psychotic experiences, among vulnerable individuals, which we labeled “Internet-related psychosis.” We will list the specific CMC features in relation to the gradual evolvement of our patients’ anxiety and psychotic experience. We will also characterize these vulnerable patients, and propose some appropriate therapeutic approaches. Data The patients described in the following case studies were treated by psychiatrists in the outpatient clinic of the Shalvata Mental Health Center, affiliated to the Sackler Faculty of Medicine at Tel Aviv University. They all met the DSM-IV-TR criteria for either “Brief Psychotic Episode” or “Schizophreniform Disorder,” and their psychotic symptoms appeared de novo while they were immersed in CMC. We have changed relevant personal information of these patients to protect their anonymity. Case Reports Case 1

A 45-year-old female sought psychiatric treatment while she was in the midst of an acute psychotic episode. She had no prior psychiatric history and denied any past alcohol or drug abuse. She described herself as the one who always took care of family members in distress. She reported never having had a long-lasting relationship with a man. During the years prior to the index episode, she had been working as a caregiver of an old man who had died two months before the episode. Having no one to take care of and experiencing a feeling of emptiness, she became involved in CMC for the first time in her life. Her intention was to make friends and eventually find someone with whom she could have an intimate relationship, but she felt confused and disoriented in cyberspace. “You don’t see a human being in front of you… I didn’t know who I was communicating with and who was communicating with me…” In addition,

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she described a sense of anxiety resulting from her loss of control over the ability to keep her personal and intimate feeling for herself and not to reveal them to others. She described the consequences of her ignorance of using the technological apparatus as, “I sent my mail to someone and it was passed on to many others… I hadn’t known that other people could see what I’m writing…” She came by herself to the psychiatric emergency room, and was diagnosed as suffering from an acute psychotic state. In her psychiatric assessment she expressed ideas of reference regarding her correspondence with other CMC users. “I felt that he was sending me hidden messages… That he knows things about me that I never revealed…” She also described paranoid delusions towards people on the web who are “investigating my past and are after me…,” and the paranoid delusions were generalized to the television, the radio, and to people in her immediate environment. She willingly consented to be hospitalized in an open ward and was started on perphenazine (12 mg/d). Ten days later she was released from the hospital in full remission, diagnosed as having suffered a “Brief Psychotic Episode.” She continued psychiatric follow-up in our out-patient clinic, remaining in full remission and with no further hospital admissions. Case 2

A 30-year-old female sought psychiatric treatment while she was in the midst of an acute psychotic episode. She denied any past alcohol or drug abuse. Ten years earlier she had been treated with a combination of Prozac and psychoanalytic psychotherapy, after experiencing anxiety related to taking examinations at the university. She had undergone psychotherapy for four years, and describes an ongoing ambivalence about her relationship with the man who later became her husband. Three years after ending psychotherapy, she and her husband separated, and she then started communicating with a married man who lived abroad via Facebook, a technological tool with which she was almost entirely unfamiliar. The man routinely posted video-clips on his Facebook page, and she erroneously thought he was sending them only to her. She gradually started giving important meanings to the colors, words, and music of the clips, convinced that intimate messages were hidden behind these details, and that these messages were intended for her alone. As she later recalled: “I was totally drawn into a relationship that was nice in the beginning, and then I began fantasizing about that

man and developing hopes…I reached a point where correspondence with him occupied most of my day.” She replied with private messages, only to realize later, with dread, that because of her ignorance of technology, her messages might well have been accessible to other recipients. She eventually began to mistrust the man and his motivations, and became suspicious as to whether he was actually sending the messages, or perhaps it was his wife or some other member of his family. When the man rejected her in their virtual relationship her mental condition continued to deteriorate. During her initial psychiatric evaluation in our outpatient clinic, she was found to be in an acute psychotic state. Her mental status examination was noted for ideas of reference regarding the man she was communicated with via CMC, including additional hints about their relationship beyond cyberspace, such as on the radio and in advertisements. She also suffered from paranoid delusions and became increasingly anxious, suspecting that the man or his family might harm her. She was prescribed olanzapine (15 mg/d) and after three months only a partial remission was achieved. In addition, the patient suffered from weight gain and was therefore switched to perphenazine (28mg/d). Several weeks later she was re-assessed and considered as having a complete remission with no residual symptoms. She was diagnosed as having suffered from a “Schizophreniform” disorder. Case 3

A 30-year-old female sought psychiatric treatment due to a psychotic episode. She had no prior contact with mental health services and denied past drug or alcohol abuse. She was currently in a relationship with a man and worked as a nurse in a small community clinic. She had been fired from her job a few months earlier, because of financial constraints, and was now encountering difficulties in finding a new one. She received little emotional support from her boyfriend, and other close friends were unaware of the distress she was suffering from being unemployed. She had little experience with the Internet when she began to enter blogs and chat rooms looking for both employment and social contacts. Shortly thereafter, she began communicating with a man and developed intimate feelings towards him. She felt supported and understood by the “intimate stranger” and was emotionally drawn into their CMC. At a certain point, while interacting with the man, she reported, “I actually felt his hand touching me… on my stomach.” This hallucinatory experience 209

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reoccurred a number of times, and was accompanied by enormous anxiety and restlessness. In the initial psychiatric evaluation she was excited and anxious, clinging, and perplexed about her experience. She was certain that the man she contacted through the web was really touching her, claimed she felt his hand touching her back, and could not explain the improbability and the impossibility of the event. She was found to be in an acute psychotic state, and was started on risperidone (2 mg/d). Within a few days she achieved full remission with no residual symptoms. Her final diagnosis was “Brief Psychotic Episode.” Discussion The three patients presented here sought treatment for psychotic symptoms which appeared during an ongoing, continuously escalating involvement in CMC. These cases exemplify how specific features of CMC might contribute to a gradual break with reality and the development of psychotic phenomena among vulnerable individuals. None of our patients had any history of Axis 1 or Axis 2 psychopathology, nor did they report a history of substance abuse. All three patients had 15 years of education, including a bachelor’s degree in their professional field. They arrived willingly to our facilities for psychiatric treatment and were diagnosed as suffering from an acute psychotic state for which they were started on antipsychotic medications. It is essential to delineate specific characteristics of our patients in order to identify what could have made them especially vulnerable to the pathological effects of CMC. First and foremost, all three turned to CMC as a refuge from emotional distress and loneliness. Their attempt to generate intimacy by means of CMC was successful at first, with all three having become intensely involved with a total stranger and developing a dependency on an intangible object. This connection was followed by feelings of confusion and anxiety, and breaking of the “relationship” led to the experience of bitter disappointment and betrayal. All three of them had minimal prior experience with computers or the Internet, and encountered considerable difficulties in understanding the symbols by which people communicate in cyberspace. Their misinterpretation of the nature of the messages they were receiving led two of them to question the true identity and intentions of the “man” with whom they were “having a relationship”. 210

Indeed, two of the patients felt that they had exposed themselves more than they intended, and were appalled that the information they had given about their private lives could now be freely accessed over the web. One of the patients experienced tactile hallucinations (“I felt that he touched my stomach”), and the blurring of the boundaries of the self. Among certain vulnerable populations, such as those suffering from “Borderline Personality Disorder” 18, 19), a strong transferential interaction can sometimes lead to short psychotic episodes. This does not apply to our patients, since they had turned acutely psychotic from a state of normalcy. We also considered the possibility that these women suffered from an “Erotomanic Delusional Disorder,” but none of them met the DSM-IV criteria for this disorder. Likewise, they did not meet the DSM-IV criteria for schizophrenia or schizoaffective disorder. Psychotic episodes usually develop in specific circumstances, and are accompanied by emotional turmoil, anxiety, and interpersonal difficulties (20, 21). Our patients described their psychotic experience as related to their involvement in CMC. Each was capable of understanding the contribution of specific CMC features to the eventual development of her psychotic experience. In addition, the gradual development of the psychotic symptoms of each of our patients coincided with the intensifying involvement in CMC. This case series led us to further our interest in those phenomena. Based on our personal experience, and from sporadic questioning of colleagues, it is our impression that CMC is capable of generating a very broad spectrum of psychopathological phenomena, ranging from brief dissociative experiences to true psychotic phenomena. We assume that the majority of these conditions are self-limiting and that they become contained sooner or later by the affected persons and their families without professional intervention. We are now in the process of a systematic study of patients and controls regarding Internet usage habits and their experiences while involved in CMC. Conclusions The spiraling use of the Internet and its potential involvement in psychopathology are new consequences of our times. We wish to raise the level of awareness of medical staff members to the development of Internetrelated psychotic phenomena. These professionals might consider routinely querying patients who pres-

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ent to the psychiatric Emergency Department about a possible link to the Internet, and be alert to signs of vulnerability to a negative influence of CMC in certain populations. Further research is warranted to validate our hypothesis and to enhance our understanding of these phenomena. Acknowledgements Esther Eshkol is thanked for editorial assistance. Disclosure of Conflicts of Interest The authors have no interests to disclose.

References 1. Bollas C. Cyberspace. Psychoanal Rev 2007;94:7-10. 2. Sher L. Social events and scientific innovations may affect the content of delusions. South Med J 2000;93: 440-441. 3. Stompe T, Ortwein-Swoboda G, Ritter K, Schanda H. Old wine in new bottles? Stability and plasticity of the contents of schizophrenic delusions. Psychopathology 2003;36:6-12. 4. Oreilly M. Internet addition: A new disorder enters the medical lexicon. Can Med Assoc J 1996;154:1882-1883. 5. Catalano G, Catalano MC, Embi CS, Frankel RL. Delusions about the internet. South Med J 1999;92:609-610. 6. Bell V, Grech E, Maiden C, Halligan PW, Ellis HD. Internet delusions: A case series and theoretical integration. Psychopathology 2005;38:144-150. 7. Lerner V, Libov I, Witztum E. “Internet Delusions”: The impact of technological developments on the content of psychiatric symptoms. Isr J Psychiatry Relat Sci 2006;43: 47-51.

8. Compton MT. Internet delusions. South Med J 2003;96:61-63. 9. Jaspers K. General psychopathology. Translated by J Hoenig & MW Hamilton (7th edition). Manchester: Manchester University, 1963. 10. Zhao S. The digital self: Through the looking glass of telecopresent others. Symbolic Interaction 2005;28:387-405. 11. Zizek S. What can psychoanalysis tell us about cyberspace? Psychoanal Rev 2004;91:801-830. 12. Dimitrijevic A. Narrating postmodern selfhood: Autobiographical, existential, and cyberspace aspects. Symbolic Interaction 2006;29:587-594. 13. Simmel G. George Simmel on individuality and social forms. Levine DN, editor. Chicago: University of Chicago, 1973. 14. Walther JB. Computer-mediated communication. Impersonal, interpersonal, and hyperpersonal interaction. Comm Res 1996;23:1-43. 15. Curtis AE. The claustrum: Sequestration of cyberspace. Psychoanal Rev 2007;94:99-141. 16. Parker I. Psychoanalytic cyberspace, beyond psychology. Psychoanal Rev 2007;94:63-84. 17. Goren E. America’s love affair with technology: The transformation of sexuality and the self over the 20th Century. Psychoanal Psychol 2003;20:487-508. 18. Pope HG, Jonas JM, Hudson JI, Cohen BM, Tohen M. An empirical study of psychosis in borderline personality disorder. Am J Psychiatry 1985;142:1285-1290. 19. Chopra HD, Beatson JA. Psychotic symptoms in borderline personality disorder. Am J Psychiatry 1986;143:1605-1607. 20. Raune D, Kuipers E, Bebbington P. Stressful and intrusive life events preceding first episode psychosis. Epidemiol Psichiatr Soc 2009; 18: 221-228. 21. Freeman D, Garety PA. Connecting neurosis and psychosis: The direct influence of emotion on delusions and hallucinations. Behav Res Ther 2003; 41: 923-947

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Night Eating Syndrome Among Patients With Depression Fatma Özlem Orhan, MD,1 Ufuk Güney Özer, MD,2 Ali Özer, MD, 3 Özlem Altunören, MD,4 Mustafa Çelik, MD,5 and Mehmet Fatih Karaaslan, MD1 1

Kahramanmaras Sutcuimam University Medical Faculty, Psychiatry Department, Kahramanmaras, Turkey Anatolian Medical Centre, Family Medicine, İstanbul, Turkey 3 Kahramanmaras Sutcuimam University Medical Faculty, Public Health, Kahramanmaras, Turkey 4 Kahramanmaras State Hospital, Psychiatry Department, Kahramanmaras, Turkey 5 Kahramanmaras Sutcuimam University Medical Faculty, Family Medicine, Kahramanmaras, Turkey 2

ABSTRACT Objective: The purpose of this study was to identify the rate of night eating syndrome (NES) in a depressed population. Method: The study sample was composed of 162 depressed patients and 172 healthy control participants. Results: The rates of night eating in our sample with depression (35.2%) was higher as compared with healthy control participants (19.2%) (p < .05). In addition, in the depression group, the rate of NES-positive patients did not differ in accordance with body mass index (BMI) classification (p > .05). However, in the control group, the rate of NES-positive patients was significantly different with regard to BMI classification, and NES diagnosis was highest in the obese members of the control group (p < .05). Multiple logistic regression analysis was then used to evaluate the relationships of four variables – depression, gender, education status and BMI – with the diagnosis of NES. Results showed that significant independent predictors of NES were depression (β = 2.64; p = .001; 95% confidence interval = 1.52-4.57); male gender (β = 2.34; p = .002, 95% confidence interval = 1.37-4.03); and a BMI of 25 or greater (β = 1.83; p = .022; 95% confidence interval = 1.09-3.08). Discussion: This is the first study to find that depressed patients are at a significantly greater risk for NES. Depression, male gender and BMI may account for the high rate of NES found in this population.

Background Night eating syndrome (NES) is emerging as a potential candidate for a new eating disorder diagnosis. It was first described in 1955 by Stunkard and colleagues (1) in obese outpatients, but it was largely neglected for 30 years. However, interest in NES has slowly reemerged. Night eating syndrome is characterized by a delay in the circadian pattern of food intake that is manifested by evening hyperphagia (i.e., the consumption of ≥25% of the total daily food intake after the evening meal) and nocturnal awakenings accompanied by the ingestion of food (2). The defining features of NES have been identified as evening hyperphagia, morning anorexia, and sleep disturbance (3). Despite recent advances, the field has lacked a standardized research diagnostic criteria set. On April 26, 2008, the First International Night Eating Symposium was held at the University of Minnesota in Minneapolis; the goals of this symposium were to share research findings among eating and sleep disorder experts and to develop research diagnostic criteria for NES (4). These aims were accomplished, and the proposed criteria have recently been peer reviewed and published. Proposed research diagnostic criteria for NES (4) The First International Night Eating Symposium brought together expert investigators in this area, who reached a consensus regarding a set of provisional diagnostic criteria for the condition: A. The daily pattern of eating demonstrates a significantly increased intake in the evening and/or nighttime, as manifested by one or both of the following:

Address for Correspondence: Fatma Özlem Orhan, MD, Assistant Professor, Kahramanmaras Sutcuimam University Faculty of Medicine, Department of Psychiatry, 46100 Kahramanmaras, Turkey. fozlemorhan@yahoo.com

212

Fatma Ă&#x2013;zlem Orhan et al.

1. At least 25% of food intake is consumed after the evening meal 2. At least two episodes of nocturnal eating occur per week. B. Awareness and recall of evening and nocturnal eating episodes are present. C. The clinical picture is characterized by at least three of the following features: 1. Lack of desire to eat in the morning and/or breakfast is omitted on four or more mornings per week 2. Presence of a strong urge to eat between dinner and sleep onset and/or during the night 3. Sleep onset and/or sleep maintenance insomnia are present four or more nights per week 4. Presence of a belief that one must eat to initiate or return to sleep 5. Mood is frequently depressed and/or mood worsens in the evening. D. The disorder is associated with significant distress and/or impairment in functioning. E. The disordered pattern of eating has been maintained for at least 3 months. F. The disorder is not secondary to substance abuse or dependence, a medical disorder, a medication, or another psychiatric disorder. Night eating syndrome was first noted among obese patients. The association between NES and obesity has also been supported, with rate estimates suggesting that NES is more common among obese persons (6%-16%) (5, 6) compared to the general population (1.5%) (7). Despite the elevated incidence that is found among obese sample individuals, not all persons with NES are obese or overweight (8-11). Additionally, the original description of NES noted that psychosocial stressors were common and closely coincided with exacerbations of night eating (12). Furthermore, NES is common among patients with mental illness. Night eating syndrome is prevalent among psychiatric clinic outpatients, within this group 12.3% met the criteria for NES (13). This rate is significantly higher than the rate of NES in the general population (1.5%) (7), and it is similar to the rate of NES among obese sample individuals (6%-16%) (6, 14). Depressed mood has also been linked to NES in several studies (2, 8, 9, 15). For example, Birketvedt et al. (8) studied the behavioral and neuroendocrine characteristics of NES and participants with NES had mood scores that were lower compared to those of obese controls. The mood scores were shown on visual analog scales. Interestingly, there was

a circadian decline in mood scores after 4 p.m. for NES subjects, which is opposite to the pattern observed with melancholic depression in which mood improves across the day (8). Moreover, among obese patients, the participants with NES have higher depression scores on the Zung Depression Inventory and lower self-esteem ratings on the Rosenberg Self-Esteem Scale (15). The serotonin system may be active in the pathophysiology of NES, as shown by single photon emission computed tomography has shown significant elevation of serotonin transporters in the midbrain of night eaters (16). Elevations in serotonin transporter levels lead to decreased postsynaptic serotonin transmission and should impair circadian rhythms and satiety. These deficits suggest that improvement in serotonin function should alleviate night eating syndrome, therapeutic response of NES to sertraline (1719) and to other selective serotonin reuptake inhibitors (20). Topiramate, which enhances GABA, was found to be effective in two cases (21). Controlled clinical trials are needed before determining the safety and efficacy of topiramate in NES. Symptoms of depression have been more frequent among individuals with NES and the rate of NES in a population seeking treatment for psychiatric disorders is of interest. However, as there is presently no study regarding the rate of NES in depressive patients, this descriptive study was conducted to fill that research gap. Methods Participants

The study sample was comprised of 162 depressed patients and 172 healthy control participants who were consecutively recruited from the outpatient clinics of the Departments of Psychiatry and of Family Medicine by the Faculty of Medicine at Kahramanmaras Sutcuimam University in Turkey. Depressed patients The diagnosis of depression was made in accordance with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, classification system using the Turkish version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Axis I Diagnosisâ&#x20AC;&#x201C;Clinician Version (22). The interview was performed by a psychiatrist (Ă&#x2013;.A.), and it was used to determine whether patients had a lifetime diagnosis of major depression. One hundred and sixty-two patients with major depressive disorders (single episode 213

Night Eating Syndrome Among Patients With Depression

or recurrent) were recruited from the outpatient clinic of the Department of Psychiatry. Patients were excluded if they had a comorbid psychiatric diagnosis, a history of neurological illness, or any major medical disorders. In addition, and on the basis of self-report, patients with a current issue or a previous diagnosis involving psychoactive substance abuse were excluded from participation. Control participants Control participants were recruited from among the healthy participants who applied for a yearly checkup at the university’s family medicine outpatient clinic. One hundred and seventy-two control participants (including no current or past psychiatric disorder or treatment) were enrolled in the study. They were interviewed, and they were excluded if there was any evidence of psychiatric history, neurological history, or psychoactive substance abuse. The control group was selected to match the depressed patients as closely as possible in the areas of age and body mass index (BMI). The diagnosis of NES was made in accordance with the proposed research diagnostic criteria for NES. These criteria are listed above (4). Ethical considerations

The written informed consent was obtained from the depressed patients and the control individuals before enrollment. This study was approved by the ethics committee of the Faculty of Medicine of Kahramanmaras Sutcuimam University. Procedures

The demographic questionnaire obtained information about each participant’s age, gender, marital status, education, and occupation. Height and body weight were measured by a medical examiner. The height and weight were recorded with participants wearing light clothing and with their shoes removed. Body Mass Index (BMI) was calculated as the weight in kilograms divided by the height in meters squared. Obesity was defined as a BMI of ≥30 kg/m2. Participants with BMIs between 25 kg/m2 and 29.9 kg/m2 were accepted as overweight, and participants with BMIs of less than 25 kg/m2 were accepted as being of normal weight. Statistical and data analyses

For the comparison of continuous variables, Student’s t-test was used. The values were presented as the mean ± the standard deviation (SD) and as percentages. For proportion comparison between the groups, the chi214

square test and Fisher’s exact test were used. Multiple linear regression analysis was performed to identify factors that were independently associated with NES. The odds ratios and the 95% confidence intervals (CIs) were calculated, and a P value of < .05 was considered as statistically significant. Data were computerized with the use of the Statistical Packages for the Social Sciences software (SPSS v.15.0; SPSS Inc., Chicago, IL, USA). Results No significant differences were found between the depressed group and the control group in terms of age (mean = 35.03 and 35.87, respectively; SD = 13.21 and 11.49, respectively; p > .05) and BMI (mean = 25.94 and 24.99 kg/m2, respectively; SD = 4.93 and 4.72, respectively; p > .05). However, there was significiant difference between the two groups in terms of gender, education and occupation (p < .05). Of the enrolled participants, 63.8% (n = 213) are women; 68.3% (n = 228) are married; and 49.4% (n = 165) had a highschool education or more. Participants’ BMIs ranged from 16.53 kg/m2 to 39.06 kg/m2 (mean = 25.45; SD = 4.84). The demographic characteristics of the patient and control groups are presented in Table 1. Table 1. Sociodemographic variables of the depressed and control groups Sociodemographic variables

Depressed group (n = 162)

Control group (n = 172)

p value

Gender Women Men

117 (72.2%) 45 (27.8%)

96 (55.8%) 76 (44.2%)

0.002

Marital status Married Single Divorced or widowed

117 (72.2%) 42 (25.9%) 3 (1.9%)

111 (64.5%) 53(30.8%) 8 (4.7%)

0.182

Occupation White collar worker Laborer Housewife Unemployed Retired Self-employed Student

10 (6.2%) 12 (7.4%) 95 (58.6%) 5 (3.1%) 11 (6.8%) 10 (6.2%) 19 (11.7%)

54 (31.4%) 23 (13.4%) 48(27.9%) 17 (9.9%) 12 (7.0%) 13 (7.6%) 5(2.9%)

<0.001

Education Secondary school or less Beyond secondary school

109 (67.3%) 53 (32.7%)

60 (34.9) 112 (65.1)

<0.001

BMI (kg/m2) Normal Overweight Obese

74 (45.7%) 53 (32.7%) 35 (21.6%)

95(55.2%) 49(28.5%) 27(15.7%)

0.168

Age (years)

35.03 ± 13.21

35.87 ± 11.49

0.535

Fatma Özlem Orhan et al.

When the patients who met the criteria for NES (n = 90) were compared by t-testing with those who did not meet the criteria for NES with regard to gender, marital status, education, and occupation, no statistically significant differences were found (p > .05) except in the area of gender (p < .05) between two groups. Men were much more likely to be night eaters than women (Table 2). The rate of NES-positive patients in the depressed group (n = 57; 35.2%) was significantly higher than the rate of NES-positive patients in the control group (n = 33; 19.2%; p = .001). In the depressed group, the rate of patients who met the criteria for NES (n = 90) was not different on the basis of BMI classification (p > .05). In the control group, though, the rate of NES-positive patients was significantly different according to BMI classification. NES diagnosis was highest among the obese members of the control group (p < .05; Table 3). Table 2. Descriptive findings for participants with and without NES NESpositive individuals (n = 90)

NESnegative individuals (n = 244)

p value

Gender Women Men

48 (22.5%) 42 (34.7%)

165 (77.5%) 79 (65.3%)

0.016

Marital status Married Single Divorced or widowed

63 (27.6%) 24 (25.3%) 3 (27.3%)

165 (72.4%) 71 (74.7%) 8 (72.7%)

0.909

Education Secondary school or less Beyond secondary school

49 (29%) 41 (24.8%)

120 (71%) 124 (75.2%)

0.393

Occupation White collar worker Laborer Housewife Unemployed Retired Self-employed Student

17 (26.6%) 8 (22.9%) 35 (24.5%) 7 (31.8%) 8 (34.8%) 5 (21.7%) 10 (41.7%)

47 (73.4%) 27 (77.1%) 108 (75.5%) 15 (68.2%) 15 (65.2%) 18 (78.3%) 14(58.3%)

0.585

Total

244

Groups

NES-negative individuals (n = 244)

Depression Normal Overweight Obese

27 (36.5%) 20 (37.7%) 10 (28.6%)

47 (63.5%) 33 (62.3%) 25 (71.4%)

Control Normal Overweight Obese

9 (9.5%) 14 (28.6%) 10 (37.0%)

86 (90.5%) 35 (71.4%) 17 (63.0%)

Discussion This study assessed NES among a particularly vulnerable group: depressed patients. Within this group, 35.2% met the criteria for NES. Night eating syndrome has been linked with psychiatric comorbidity in several studies. However, depression rates in NES patients were searched in the previous studies and the symptoms and diagnosis of depression have generally been more frequent among individuals with NES (8, 15, 23). In a descriptive study of NES, de Zwaan and colleagues (9) found that 56% of patients had a lifetime history of major depressive disorder, which was likely higher than the rate seen among the healthy control group. Lifetime rates of 17.5% for generalized anxiety disorder and of 18% for posttraumatic stress disorder were reported in that study (9). Lundgren and colleagues (24) reported that 52% of nonobese night eaters met lifetime criteria Table 4. Multiple logistic regression analysis of the independent variables affecting the NES diagnosis.

Table 3. Comparison of the rates of NES-positive individuals and NES-negative individuals according to the classification of weight in the depressed and control groups NES-positive individuals (n = 90)

Multiple logistic regression analysis was then used to evaluate the relationships of four variables – depression, gender, education status and BMI – with the diagnosis of NES. The results demonstrated that significant independent predictors of NES were depression (β = 2.64, p = .001, 95% CI = 1.52-4.57); male gender (β = 2.34, p = .002, 95% CI = 1.37-4.03); and a BMI of at least 25 (β = 1.83, p = .022, 95% CI = 1.09-3.08). These results are summarized in Table 4. The depressed patients (n = 162) were 2.64 times more likely (Wald = 12.00; p = .001) to meet the criteria for NES than the members of the healthy control group. Overweight and obese participants (i.e., those with a BMI of ≥25 kg/m2) were 1.83 times more likely (Wald = 5.25; p = .022) to meet the criteria for NES than were participants of normal weight.

p value

0.645

0.001

Factors

Odds Ratio

% 95 Confidence Interval

p value

Group Control Depression

1.00 2.64

1.52-4.57

0.001

Gender Women Men

1.00 2.34

1.37-4.03

0.002

Education Secondary school or less Beyond secondary school

1.00 0.96

0.55-1.67

0.889

BMI ≤24 ≥25

1.00 1.83

1.09-3.08

0.022

215

Night Eating Syndrome Among Patients With Depression

for unipolar mood disorders and that 47% met lifetime criteria for anxiety disorders; both of these rates were significantly higher than the lifetime rates of these same disorders among nonobese control participants. In the current study, the rate of NES (35.2%) is higher than that which has been reported among general psychiatric samples of all BMIs (12.3%) (13) and among obese individuals with severe mental illness (25%) (25). Caution should be used, though, when comparing the current findings to those of previous studies because of the various criteria that have been used to diagnose NES in those previous studies. Several factors may explain the high rate of NES in the current sample, including stress, sleep disturbance, and the properties of patients’ medications. Night eating syndrome has long been associated with stress and psychological comorbidity (12, 15, 24, 26). The relationship between depressive symptoms and sleep complaints has been described previously. The sleep of individuals with depression is often disturbed, which may increase the likelihood of the nocturnal ingestion of food. It is also well documented that psychotropic medications (particularly antidepressants) affect hunger and satiety, which could put an individual at increased risk for NES. It is quite plausible that these factors interact to put an individual at an even greater risk than a member of a nonpsychiatric population. When the parameters that correlated with NES were evaluated with the use of multivariate analysis, the presence of depression and male gender were the strongest predictors of NES, followed by the individual being overweight or obese. Data regarding the relationship between gender and NES are limited. The original night eaters in the studies by Stunkard and colleagues (12) and Greeno and colleagues (27) were women. Two studies have reported NES to be more common among men than among women (28, 29), whereas all others have not demonstrated any gender differences. The current findings were similar to those of Aronoff and colleagues (28): men were more likely to have NES, which implicates maleness as a risk factor for NES. The degree of BMI was also found to be a risk factor for NES. However, night eating was not associated with BMI in the depressed group of our study sample, but it was associated with BMI in the control group. Reviews frequently note that obesity or higher BMI is a common clinical correlate of NES and an indicator of the clinical significance of the syndrome (30). In studies that have compared NES with non-NES obese participants, BMI 216

was greater in the NES group in only one study. Body Mass Index was not found to be significantly different between NES and non-NES obese participants in the remaining studies when this was reported (6, 14, 15, 31-33). The study by Colles and colleagues (26) (n = 431) showed a significant increase in NES rate across five BMI categories from 18 kg/m2 to 22 kg/m2 and up through 40 kg/m2 (χ2 = 22.7; P < .001). The previously mentioned study by Aronoff and colleagues (28) also showed a strong relationship between overweight status and NES (χ2 =7.1; P = .008). Lundgren and colleagues (13) reported that, although their sample was, on average, overweight (mean BMI = 29.1 kg/m2), obese psychiatric patients (i.e., those with a BMI of ≥30 kg/m2) were five times more likely to meet the criteria for NES than nonobese psychiatric patients (i.e., those with a BMI of 18.5 kg/m2-25.9 kg/m2). Future studies are needed to examine prospective changes in weight among depressed individuals with NES of all weight ranges. Limitations The primary limitation to be considered is the definition of NES. As noted previously, no established DSM-IV criteria for the symptoms of NES exist and only provisional criteria have been established. A lack of consistent definitions complicates the comparisons between studies. Another limitation to be considered is that no assessment of depression severity and anxiety was made in our study. Further, the sample was small and unfortunately there was significant difference between depression and control group in the context of gender, education and occupation. Therefore, these findings warrant replication with matched large samples and assessment of depression type (melancholic vs atypical) one may expect there to be a significant difference since hyperphagia is a criterion in atypical depression. In spite of the limitations discussed above, the strengths of this study are that the rate and classification of NES in this sample were not based solely on two behaviors (i.e., Evening hyperphagia or Nocturnal ingestions) but rather on the recently proposed research diagnostic criteria (4). In summary, this is the first study to assess the rate of NES among individuals with depression in Turkey. The rate of night eating in our sample with depression (35.2%) was higher as compared with previous studies that involved psychiatric patients. Arguably, night eating syndrome may simply be part of the depression and may

Fatma Özlem Orhan et al.

disappear if depression is resolved. Overall, discrepancies in NES rates also may be attributable to the varying diagnostic criteria sets used in different studies of NES. This study also suggests that depression, male gender, and BMI are risk factors for NES. Future studies are needed to replicate these findings, to understand why this population is at increased risk for NES, and to determine the effects of NES on health outcomes among individuals with depression. It is recommended that patients with depression be screened for symptoms of night eating (e.g., evening hyperphagia, nocturnal eating). References 1. Stunkard AJ, Grace WJ, Wolf HG. The night eating syndrome. JAMA 1955;19:78. 2. O’Reardon JP, Ringel BL, Dinges DF, Allison KC, Rogers NL, Martino NS, et al. Circadian eating and sleeping patterns in the night eating syndrome. Obes Res 2004;12:1789-1796. 3. Striegel-Moore RH, Franko DL, Thompson D, Affenito S, May A, Kraemer HC. Exploring the typology of night eating syndrome. Int J Eat Disord 2008;41:411-418. 4. Allison KC, Lundgren JD, O’Reardon JP, Geliebter A, Gluck ME, Vinai P, et al. Proposed diagnostic criteria for night eating syndrome. Int J Eat Disord. 2010;43:241-247. 5. Adami GF, Campostano A, Marinari GM, et al. Night eating in obesity: A descriptive study. Nutrition 2002;18:587-589. 6. CerÚ-Björk C, Andersson I, Rössner S. Night eating and nocturnal eating - two different or similar syndromes among obese patients? Int J Obes Relat Metab Disord 2001;25:365-372. 7. Rand CSW, Macgregor MD, Stunkard AJ. The night eating syndrome in the general population and among post-operative obesity surgery patients. Int J Eat Disord 1997;22:65-69. 8. Birketvedt G, Florholmen J, Sundsfjord J, Osterud B, Dinges D, Bilker W, et al. Behavioral and neuroendocrine characteristics of the nighteating syndrome. J Am Med Assoc 1999;282:657-663. 9. de Zwaan M, Roerig DB, Crosby RD, Karaz S, Mitchell JE. Nighttime eating: A descriptive study. Int J Eat Disord 2006;39:224-232. 10. de Zwaan M, Roerig DB, Crosby RD, Karaz S, Mitchell JE. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35, 217-222. 11. Striegel-Moore RH, Franko DL, Thompson D, Affenito S, Kraemer HC. Night eating: Prevalence and demographic correlates. Obes Res 2006;14:139-147. 12. Stunkard AJ, Grace WJ, Wolff HG. The night-eating syndrome; a pattern of food intake among certain obese patients. Am J Med 1955;19:78-86. 13. Lundgren JD, Allison KC, Crow S, O’Reardon JP, Berg KC, Galbraith J, et al. Prevalence of the night eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-158. 14. Adami GF, Campostano A, Marinari GM, Ravera G, Scopinaro N. Night eating and binge eating disorder in obese patients. Int J Eat Disord 1999;25:335-338. 15. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less

weight loss in obese outpatients. Obes Res 2001;9:264-267. 16. Lundgren JD, Newberg AB, Allison KC, Wintering NA, Ploessl K, Stunkard AJ. 123I-ADAM SPECT imaging of serotonin transporter binding in patients with night eating syndrome: a preliminary report. Psychiatry Res 2008;162:214-220. 17. O’Reardon JP, Stunkard AJ, Allison KC. Clinical trial of sertraline in the treatment of night eating syndrome. Int J Eat Disord 2004;35:16-26. 18. O’Reardon JP, Allison KC, Martino NS, Lundgren JD, Heo M, Stunkard AJ. A randomized placebo controlled trial of sertraline in the treatment of the night eating syndrome. Am J Psychiatry 2006;163:893-898. 19. Stunkard AJ, Allison KC, Lundgren JD, Martino NS, Heo M, Etemad B, et al. A paradigm for facilitating pharmacotherapy research at a distance: Treatment of the night eating syndrome. J Clin Psychiatry 2006;67:1568-1572. 20. Miyaoka T, Yasukawa R, Tsubouchi K, Miura S, Shimizu Y, Sukegawa T, et al. Successful treatment of nocturnal eating/drinking syndrome with selective serotonin reuptake inhibitors. Int Clin Psychopharmacol 2003;18:175-177. 21. Winkelman JW. Treatment of nocturnal eating syndrome and sleeprelated eating disorder with topiramate. Sleep Med 2003;4:243-246. 22. First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). Washington, DC: American Psychiatric, 1995. 23. Allison KC, Grilo CM, Masheb RM, Stunkard AJ. Binge eating disorder and night eating syndrome: A comparative study of disordered eating. J Consult Clin Psychol 2005;73:1107-1115. 24. Lundgren JD, Allison KC, O’Reardon JP, Stunkard AJ. A descriptive study of non-obese persons with night eating syndrome and a weight matched comparison group. Eat Behav 2008;9: 343-351. 25. Lundgren JD, Rempfer MV, Brown CE, Goetz J, Hamera E. The prevalence of night eating syndrome and binge eating disorder among overweight and obese individuals with serious mental illness. Psychiatry Res 2010;175:233-236. 26. Colles SL, Dixon JB, O’Brien PE. Night eating syndrome and nocturnal snacking: association with obesity, binge eating, and psychological distress. Int J Obes 2007;31:1722-1730. 27. Greeno CG, Wing RR, Marcus MD. Nocturnal eating in binge eating disorder and matched-weight controls. Int J Eat Disord 1995;18:343-349. 28. Aronoff NJ, Geliebter A, Zammit G. Gender and body mass index as related to the night-eating syndrome in obese outpatients. J Am Diet Assoc 2001;101:102-104. 29. Grilo CM, Masheb RM. Night-time eating in men and women with binge eating disorder. Behav Res Ther 2004;42:397-407. 30. Stunkard AJ, Allison KC, Geliebter A, Lundgren JD, Gluck ME, O’Reardon JP. Development of criteria for a diagnosis: lessons from the night eating syndrome. Compr Psychiatry 2009;50:391-399. 31. Napolitano MA, Head S, Babyak MA, Blumenthal JA. Binge eating disorder and night eating syndrome: Psychological and behavioral characteristics. Int J Eat Disord 2001;30:193-203. 32. Allison KC, Wadden TA, Sarwer DB, Fabricatore AN, Crerand CE, Gibbons LM, et al. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: Prevalence and related features. Surg Obes Relat Dis 2006;2:153-158. 33. Jarosz PA, Dobal MT, Wilson FL, Schram CA. Disordered eating and food cravings among urban obese African American women. Eat Behav 2007;8:374-381.

217

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aving observed in my lifetime the fall of communism in Eastern Europe and the Soviet Union I have always been fascinated by what might have caused this historic upheaval. Until the rise of the Iranian nuclear threat I was always comforted by the thought that the end of communism had significantly increased the chances of survival of the human race in general and my own children in particular. Surprisingly, I found few scholarly articles or books to have come out on this subject over the last 20 years. The present volume is therefore a milestone in my own thinking and an intellectual treat as well. The author is a Professor of Politics at Oxford who has studied communism for his whole career. Luncheon table conversation on this topic usually includes three theories for the fall of communism, all of which are refuted in detail in this scholarly and readable book: The Economic Theory: Clearly the Soviet Union and Eastern Europe were failing economically during the 1980s and before. However, many countries have failed more dramatically economically without a change of regime. Brown emphasizes the power of the KGB, the Communist Party and the Soviet military and convincingly argues that the regime could have survived another 50 or 100 years even with a failing economy. The Arms Race Theory: President Reagan of the USA greatly increased military spending and the Soviet Union attempted to maintain parity with the USA on a much smaller economic base, resulting in an increasing percentage of the Soviet economy going to military spending. Again, Brown shows that the power of the KGB, the Communist Party and the Soviet military plus the additional factor of the Russian peopleâ&#x20AC;&#x2122;s pride in their military parity with the USA allowed economic sacrifices to support the huge Soviet military establishment and that this was not a likely cause of the Soviet Unionâ&#x20AC;&#x2122;s collapse. Nationalism: The Soviet Union contained numerous ethnic minorities, and Russians made up, as is well known,

Book Reviews

only about half of the population. Ethnic minorities were often not happy under Russian domination but Brown convincingly demonstrates, republic by republic and East European country by East European country, how the power of Soviet troops and the KGB was an effective control of these nationalisms and that they presented no threat to the continuation of the Soviet communist system. The theory that Brown convincingly proposes relates to us as psychiatrists. Cognitive therapy has shown increasing efficacy in many psychiatric disorders and cognitive measures have shown the best correlations with biologic and imaging data of any observational paradigm so far. Brown proposes a cognitive explanation for the fall of Communism: Individuals at the highest levels of the Soviet Union stopped believing in the justice of their cause and in the truth of MarxismLeninism. Apparently, there were always such individuals in the research institutes studying the USA in Moscow and many of them were promoted over the years in the Communist Party. Usually they kept their opinions to themselves. By the 1980s the generations of Russian leadership who could remember the oppression of the czarists and capitalist system from their parents’ stories were no longer alive. In 1939 less than 10 percent of the Russian population had a high school education and by 1980 this had increased to almost 90 percent. More and more individuals, including members of the Communist Party, had access to and some understanding of Western literature and news. The highest Russian leadership was exposed by traveling to Western democracy and its high standard of living. Brown describes the cognitive switch that occurred in Gorbachev himself and how this developed from the time he was chosen in 1985 as First Secretary of the Communist Party of the Soviet Union until the final stages of the dismantlement of the Communist Party and the Soviet Union in 1990. While he was elected by the Politburo as a reformist and an anti-Stalinist, the extent of the changes that he would lead were clear neither to those who elected him in the Politburo nor to himself. Gorbachev’s views evolved over time like a patient in therapy. His views led to the changes in his actions. Numerous other members of the Politburo and the highest levels of the Communist Party were open to these cognitive changes (although some were not and Gorbachev’s political skills were clearly a part of the success of this enterprise). The Khrushchev denunciation of Stalin 30 years before had seared in the hearts of most Soviet communist leaders that they never again wanted to be in a situation where close friends

and colleagues within the party would be in constant danger of physical liquidation. Gorbachev consciously took this one step further and decided that never again would Soviet troops be used to enforce communism on an unwilling population as in Czechoslovakia, Hungary and Poland. These ideas developed to where Gorbachev and his closest colleagues abandoned Marx, Lenin and the essential doctrines of Soviet economic and political thinking. Brown emphasizes that while this explanatory framework is useful, it could not be seen as inevitable. As with all psychological or historical processes there were several points at which the transition of the Soviet Union out of communism could have been derailed. The experience of psychiatry in the last 100 years has been that we are part of the intellectual ferment and paradigm shifting that takes place in all of science. This has been a bidirectional influence: Freudianism in the first half of the 20th century and biological psychiatry in the second half of the 20th century both had large influences on literature, cinema, philosophy and government social policy. Clearly cognitive therapy in our field is part of a much larger zeitgeist and reading this historical analysis based on cognitive changes was an experience that I can recommend to my psychiatry colleagues without reservation. RH Belmaker, Beersheva

Spirituality and Psychiatry Chris Cook, Andrew Powell and Andrew Sims RCPsych Publications 2009, 318 pages ISBN: 978-1-904671-71-8, £25

t first glance, this was not a book I looked forward to reading. As a researcher on religion and psychiatry, the term “spirituality” ever seemed vague, especially in a country like Israel where religion covers most areas of life, from culture to politics, inviting strong opinions and reactions. The second reason was that the book was gathered by psychiatrists in the Royal College of Psychiatrists of the United Kingdom who formed a special interest group on the subject in 1999. Written in my birthplace, by the college I still belong to, but after decades in the Holy Land, just how relevant will I find their discussions? The result surpassed all my expectations, and I encourage every psychiatrist to read it. To open, spirituality is 219

Book Reviews

defined: “a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions.” Have I already lost your interest? “It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth and values” (p. 4). Aha! The importance of spirituality in our lives (to give a scene-setting example, 64% of Americans pray every day) led the American College of Physicians to recommend the inclusion in every assessment interview of the following questions as a spiritual history: Is faith (religion/spirituality) important to you in this illness? Has faith (religion/spirituality) been important to you at other times of your life? Do you have someone to talk to about religious/spiritual matters? Would you like to explore religious/spiritual matters with someone? Do we ask our patients such questions? If these issues are important, and deeply so, are we missing something that leaves us with an impoverished evaluation? The book presents its thesis in a very careful and thoughtful manner. After defining terms, and a chapter on assessment, as each topic appeared I found myself saying: well, of course. On psychosis, the view of madness as a spiritual journey is considered, many have found the experiences enriching, while on recovery it may be crucial to look again so as not to devalue what occurred, and it can be the therapist who helps this discourse. The studies of E. Peters and M. Jackson on the complexity of trying to distinguish the normal and the pathological in delusions and hallucinations are presented. In this subject, as in all those that follow, the role of the therapist, the difficulties in discussing such subjects, and when to consider bringing in a spiritual counselor, and the effects on the family and the therapist are considered. The subjects that followed were suicide, childhood, psychotherapy, intellectual disability, substance abuse, and the final chapter on ageing. As they appeared I found myself settling down to a careful reconsideration of a subject I thought I knew, to discover an entirely new way of looking at it, and a way that was so appropriate. Of course, people with intellectual disabilities have spiritual concerns, thoughts of why, as have their parents and carers, and seeking for meaning within their existences. Thus far, I have presented a very enthusiastic account.

220

However, to return to the definition of spirituality, I omitted a sentence: “It may be experienced as relationship with that which is intimately ‘inner,’ immanent and personal, within the self and others, and/or as relationship with that which is wholly ‘other,’ transcendent and beyond the self ” (p. 4). Purpose in life is an accessible and immediately meaningful concept, but immanence, transcendence? And so we arrive at other aspects of the book, which I think many will find difficult, yet are a part of the world of spirituality for many patients. A form of psychotherapy that incorporates spirituality is transpersonal psychotherapy, based on Jung, Grof and Assagiloi. And so (p.116): “the psychiatrist asked her to find an image for the emotion that flowed within her and she chose a heart made of gold. Then she was invited to picture a sunbeam falling on this golden heart so she could see it in all its beauty.” Aspects of yoga and meditation have been incorporated by Kabat-Zinn in CBT mindfulness therapy and in dialectical behavior therapy. Similarly, Peter Fenwick writes a very challenging chapter on the influence of the prayer of others, and miracles. The chapter on pathological spirituality deals solely with cults, the effects of joining them, growing up in them, leaving them, and the authors have extensive therapeutic experience. One might consider the subject could be broader than this (the problem of religious extremism merits one sentence in the book), and the same criticism might be voiced on the chapter on substance misuse, which deals exclusively with the twelve step programs. However, the presentation is authoritative and a mine of references. To complete the discussion, there are excellent chapters on spiritual care in the NHS, and the role of spiritual counselors. In short, for me reading this book was an experience and a voyage. The editors have done a wonderful job, in that there is no repetition of material, the references are thorough and up-to-date, and the book climbs to a crescendo as it reaches the task of the psychiatrist of the aged, with patients losing their abilities, their looks, their independence, facing death, and considering, as do their carers, what it was all about. I am not sure if I would have thought so carefully about these issues were it not for this superb collection. David Greenberg, Jerusalem

‫‬

‫סיכום ישיבת ועד האיגוד הפסיכיאטרי ‪ -‬יולי ‪2011‬‬ ‫‪ 13‬ביולי ‪2011‬‬

‫‪1 .1‬סוכם על החלפת אתר האינטרנט של האיגוד והפעלתו‬ ‫דרך ההסתדרות הרפואית‪ ,‬באמצעות חברת "מדיהפארם"‪,‬‬ ‫בדומה לאתרי האיגודים המדעיים של הר"י‪.‬‬ ‫‪2 .2‬סוכם עם החברה המארגנת של הכנס התלת–שנתי של‬ ‫האיגוד על תוכנית העבודה לקראת הכנס‪.‬‬

‫ •תנאים סביבתיים לא הולמים במסגרות בקהילה‬ ‫ובאשפוז‪.‬‬ ‫‪5 .5‬הוצגו הסתייגויות האיגוד מהצעת החוק "הגנה על הציבור‬ ‫מפני עברייני מין" ומהדרישה שגובשה בכנסת להסמיך‬ ‫פסיכיאטרים מומחים לטיפול בעברייני מין‪.‬‬

‫הצעות למרצים מחו"ל‪ ,‬לנושאי הרצאות ולפגישות דיון יש‬ ‫להעביר בהקדם לוועדה המדעית של הכנס‪.‬‬

‫‪6 .6‬הצעות והמלצות ל"אות מפעל חיים" לפסיכיאטרים יתקבלו‬ ‫עד נובמבר ‪.2011‬‬

‫‪3 .3‬חּודש הניסיון‪ ,‬מול הלשכה המשפטית בהר"י‪ ,‬לכלול את‬ ‫הפסיכיאטריה בין המקצועות שבהם ניתן להגיש חוות–‬ ‫דעת נגד המדינה‪ ,‬לאחר שיותר מ–‪ 657( 50%‬מתוך ‪)1184‬‬ ‫מהפסיכיאטרים בישראל זוהו כעובדי מדינה‪.‬‬

‫‪7 .7‬לאור אי–התקדמות הרפורמה הביטוחית בבריאות הנפש‬ ‫למרות התחייבויות משרד הבריאות‪ ,‬הוועד המרכזי של‬ ‫האיגוד בודק מחדש את עמדתו בנושא‪.‬‬

‫‪4 .4‬נושאי תלונות הציבור בתחום הטיפול הפסיכיאטרי בשנים‬ ‫‪ 2011-2010‬רוכזו והוצגו בישיבה‪ .‬נושאים אלו כוללים‪:‬‬ ‫ ‬ ‫ ‬ ‫ ‬ ‫ ‬ ‫ ‬

‫•תהליכי האשפוז הכפוי וגישת המטפלים‪.‬‬ ‫•סוגיית ההגבלה במהלך האשפוז‪.‬‬ ‫•אי–שיתוף המטופל ומשפחתו בתוכנית הטיפול והצגת‬ ‫כלל אפשרויות הטיפול‪ ,‬כולל אלו שאינן בסל‪.‬‬ ‫•עריכת בדיקות בנוכחות סטודנטים וקבלת הסכמה של‬ ‫הנבדקים לכך‪.‬‬ ‫•מעקב אחר המצב הרפואי–גופני ומניעת סיבוכי הטיפול‬ ‫התרופתי‪.‬‬

‫הוצע כי האיגוד ימשוך את ידיו מהמשך הדיון ברפורמה‪,‬‬ ‫המעכב מתן פתרון מעשי למצוקה ולפערים בשירות‬ ‫הפסיכיאטרי‪.‬‬ ‫האיגוד מבקש ממשרד הבריאות להציג בדחיפות תוכנית‬ ‫ומשאבים שיאפשרו להציל את מערך בריאות הנפש הקורס‬ ‫בישראל‪.‬‬

‫בברכה‪,‬‬ ‫פרופ' זאב קפלן‬ ‫יו"ר האיגוד הפסיכיאטרי‬

‫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

‫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

‫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

‫‪221‬‬

‫לחברנו יובל מלמד‬ ‫ברכות לקבלת הפרופסורה‬ ‫גאים ואוהבים ‪ -‬ועד האיגוד הפסיכיאטרי‬

‫נלקחו מקובץ האשפוזים הפסיכיאטרי של משרד הבריאות‪ .‬כמו‬ ‫כן בוצע מעקב אחרי אשפוזים חוזרים בעשר השנים שלאחר מכן‪.‬‬ ‫מבחני ‪ ANOVA‬ו־‪ Wilcoxon‬שימשו להשוואה בין הנאשמים‬ ‫אשר קיבלו אבחנה פסיכיאטרית בסוף ההסתכלות לבין אלה שלא‬ ‫קיבלו אבחנה פסיכיאטרית‪.‬‬ ‫תוצאות‪ :‬רק ‪ 17%‬מהנאשמים אשר אושפזו בבית החולים בעקבות‬ ‫‪ COO‬קיבלו אבחנה פסיכיאטרית (‪ ,)N = 316‬ואילו שאר הנאשמים‬ ‫(‪ )N = 1,532‬לא אובחנו כסובלים מהפרעה פסיכיאטרית כלשהי‪.‬‬ ‫‪ 56%‬מהנאשמים בקבוצה שלא אובחנה בתחילה (‪ )N = 863‬הגיעו‬ ‫לאשפוז חוזר וקיבלו אבחון פסיכיאטרי במהלך עשר השנים הבאות‪,‬‬ ‫ו־‪ 36%‬מהנבדקים המקוריים לא קיבלו מעולם אבחנה לאחר אשפוז‬ ‫(‪ .)N = 556‬נמצאו הבדלים מובהקים בין שתי הקבוצות בממוצע ימי‬ ‫האשפוז בתקופת המעקב (‪.)Z =4.89, p<.001‬‬ ‫מסקנות‪ :‬שיעור גבוה של אבחון פסיכיאטרי אצל הנאשמים‬ ‫בתקופת המעקב מעיד כי ‪ COO‬אינו יעיל וכי קיימת נטייה לשחרר‬ ‫אנשים מצו הסתכלות ללא אבחנה‪ ,‬אף כי מאוחר יותר נמצא כי‬ ‫אנשים אלו פיתחו מצב פסיכוטי‪ .‬לכן בדיקה עצמאית ומדוקדקת‬ ‫של תהליך ההערכה הפסיכיאטרית–משפטית במהלך ההסתכלות‬ ‫הוא חיוני כדי לקבוע אם מחמיצים קיום של הפרעות בפועל‪ .‬יש‬ ‫לקיים דיון מקצועי ופומבי על השימוש המיותר באשפוזים על פי‬ ‫צו הסתכלות של בית המשפט ועל דרכי המניעה שלהם‪.‬‬ ‫פסיכוזה הקשורה באינטרנט ‪-‬‬ ‫סימן היכר של העידן הנוכחי?‬ ‫א‪ .‬ניצן‪ ,‬א‪ .‬שושן‪ ,‬ש‪ .‬לב־רן וש‪ .‬פניג‪ ,‬הוד השרון‬

‫רקע‪ :‬במקביל לעלייה החדה בשכיחות השימוש באינטרנט הולכות‬ ‫ונחשפות ההשלכות הפסיכופתולוגיות שיש לכך‪ .‬המאמר מבקש‬ ‫להפנות את תשומת הלב לתקשורת–מתווכת–מחשב (תמ"מ)‪ ,‬כגון‬ ‫פייסבוק או צ'אטים‪ ,‬ולהתריע על קשר אפשרי שלה לפסיכוזה‪.‬‬ ‫נתונים‪ :‬במאמר מתוארות שלוש מטופלות‪ ,‬ללא היסטוריה של‬ ‫תחלואה נפשית מז'ורית‪ ,‬שפנו לטיפול פסיכיאטרי על רקע‬ ‫תסמינים פסיכוטיים שהופיע בפעם הראשונה בתקופה שבה‬ ‫עסקו באופן אינטנסיבי בתמ"מ‪ .‬שלוש המטופלות הצביעו על‬ ‫התרומה של מאפייני תמ"מ ספציפיים להתפתחות ההדרגתית‬ ‫של התסמינים הפסיכוטיים‪ .‬הן תיארו מערכת יחסים "היפר־‬

‫אישית" עם גבר זר‪ ,‬חוסר אמון באשר למטרות של אותו גבר‬ ‫ולזהותו‪ ,‬גבולות עצמי מטושטשים‪ ,‬פרשנות לא מדויקת של‬ ‫מידע ברשת וחשיפה אישית לא נשלטת ובלתי־רצויה במרחב‬ ‫הווירטואלי‪ .‬למטופלות היה ניסיון קודם מועט בשימוש‬ ‫במחשבים ובאינטרנט‪ ,‬והפגיעות שלהן התעצמה נוכח קשיים‬ ‫בפענוח המשמעות של אלמנטים שונים בתמ"מ וההתמודדות עם‬ ‫ההיבטים הטכניים שלה‪.‬‬ ‫סיכום‪ :‬המקרים שאנו מציגים תומכים בהנחה שמאפיינים ייחודיים‬ ‫של תמ"מ עלולים לתרום להתפתחות של חוויות פסיכוטיות‪.‬‬ ‫השימוש ברשת הוא נרחב‪ ,‬ואנו מציעים למטפלים בתחום בריאות‬ ‫הנפש לתשאל מטופלים באופן שגרתי באשר לשימוש באינטרנט‬ ‫בכלל ובתמ"מ בפרט‪.‬‬ ‫תסמונת אכילה לילית בקרב‬ ‫מטופלים הלוקים בדיכאון‬ ‫פ‪.‬א‪ .‬אורהן‪ ,‬א‪.‬ג‪ .‬אוזר‪ ,‬א‪ .‬אלטונורן‪ ,‬מ‪ .‬סליק ומ‪.‬פ‪ .‬קראאסלן‪,‬‬ ‫איסטנבול‪ ,‬טורקיה‬

‫מטרה‪ :‬מטרת המחקר הייתה להעריך את שכיחות תסמונת‬ ‫האכילה הלילית (‪ )NES‬בקרב מטופלים הלוקים בדיכאון‪.‬‬ ‫שיטה‪ :‬במדגם השתתפו ‪ 162‬מטופלים שלקו בדיכאון ו–‪172‬‬ ‫משתתפים בריאים‪.‬‬ ‫תוצאות‪ 35.2% :‬מן המטופלים שלקו בדיכאון סבלו מ־‪NES‬‬ ‫לעומת ‪ 19.2%‬בקבוצת הביקורת (‪ .)p <.05‬אצל המטופלים שלקו‬ ‫בדיכאון לא היה קשר בין ‪ NES‬ובין מדד ה־‪BMI‬נ (‪ .)p <.05‬לעומת‬ ‫זאת‪ ,‬בקבוצת הביקורת ‪ NES‬היה שכיח יותר אצל אנשים שמנים‬ ‫(‪ .)p <.05‬לשם בדיקת הקשר בין ‪ NES‬לבין ארבעה משתנים ‪-‬‬ ‫דיכאון‪ ,‬מגדר‪ ,‬רמת החינוך ו–‪ ,BMI‬נעשה שימוש ב־‪multiple‬‬ ‫‪.logistic regression analysis‬‬ ‫המנבאים העצמאיים המשמעותיים היו דיכאון (‪;β = 2.64‬‬ ‫‪ ,)p = .001; 95% confidence interval = 1.52-4.57‬מגדר זכר (‪;β = 2.34‬‬ ‫‪ )p = .002, 95% confidence interval = 1.37-4.03‬ו–‪ BMI 25‬או‬ ‫יותר (‪.)β = 1.83; p = .022; 95% confidence interval = 1.09-3.08‬‬ ‫דיון‪ :‬מחקר זה הוא הראשון שבו נמצא שיש סיכון מוגבר ל‪NES-‬‬ ‫אצל מטופלים בדיכאון‪ .‬דיכאון‪ ,‬מגדר זכר ו–‪ BMI‬גבוה יכולים‬ ‫להסביר את השכיחות הגבוהה של ‪ NES‬באוכלוסייה זו‪.‬‬

‫‪222‬‬

‫שחיקה נפשית בקרב אנשי מקצוע בריאות הנפש‬ ‫בבית החולים והגישה הסלוטוגנית‬ ‫ס‪ .‬רבין‪ ,‬י‪ .‬שורר‪ ,‬מ‪ .‬נדב‪ ,‬י‪ .‬גז‪ ,‬מ‪ .‬הרצנו־לאטי וא‪ .‬שיבר‪ ,‬באר שבע‪.‬‬

‫אנשי מקצוע שעובדים בבריאות הנפש חווים לעתים קרובות רמה‬ ‫גבוהה של דחק‪ ,‬שמוביל להרגשה נפשית גרועה‪ ,‬לתשישות נפשית‬ ‫ולדלדול משאבים אישיים‪ .‬למרות תנאים של קיצוץ כלכלי גלובלי‪,‬‬ ‫מניעת שחיקה נפשית צריכה לקבל עדיפות גבוהה בקרב מטפלים‬ ‫בבריאות הנפש‪ .‬המאמר בוחן את מגוון גורמי הדחק שקיימים אצל‬ ‫אנשי מקצוע שעובדים בתחום בריאות הנפש‪ ,‬ובודק בעזרת הגישה‬ ‫הסלוטוגנית דרכים להפגת שחיקה מקצועית בקרב אנשי מקצועות‬ ‫בריאות הנפש שעובדים בבית חולים כללי‪ .‬במאמר מוצעים לדרג‬ ‫הניהולי ולאנשי הצוות קווים מנחים‪ ,‬על מנת לשפר את איכות‬ ‫החיים במקום העבודה‪.‬‬ ‫תפקיד אירועי חיים בהפרעה כפייתית אובססיבית‬ ‫ס‪ .‬סרקל‪ ,‬ס‪.‬ק‪ .‬פרהרג' וו‪.‬ק‪ .‬סינהה‪ ,‬קנקה‪ ,‬הודו‬

‫רקע‪ :‬רק מעט מחקרים בדקו את הקשר בין אירועי חיים‬ ‫להפרעה כפייתית טורדנית (‪ .)OCD‬למחקרים אלה היו מגבלות‬ ‫מתודולוגיות והתקבלו בהם ממצאים סותרים‪.‬‬ ‫מטרה‪ :‬לבחון את השכיחות של אירועי חיים אצל מטופלים עם‬ ‫‪ OCD‬לעומת קבוצת ביקורת של אנשים בריאים‪.‬‬ ‫שיטות‪ 10 :‬מטופלים עם ‪ OCD‬העונים לקריטריוני ‪ICD-10 DCR‬‬ ‫דורגו על פי המדד להפרעה כפייתית טורדנית ע"ש ייל־בראון‬ ‫(‪ ,)YBOCS‬שאלון לדיכאון ע"ש המילטון (‪ )HAM-D‬ושאלון‬ ‫אירועי חיים המשוערים כגורמי דחק (‪ .)PSLES‬קבוצת השוואה של‬ ‫‪ 10‬אנשים נורמליים דורגה אף היא על פי שאלון ‪ .PSLES‬אירועי‬ ‫החיים הושוו בין שתי הקבוצות‪.‬‬ ‫תוצאות‪ :‬נמצאה שכיחות גבוהה יותר של אירועי חיים בתקופה‬ ‫של שישה חודשים (‪ )t=3.95, p =.001‬ולאורך כל החיים‬ ‫(‪ )t=5.53, p <.001‬אצל המטופלים לעומת קבוצת הביקורת‪ .‬נמצאה‬ ‫קורלציה משמעותית בין תוצאות ‪ PSLES‬ובין תוצאות ‪.YBOCS‬‬ ‫לא נמצאה קורלציה בין תוצאות ‪ PSLES‬ובין תוצאות ‪.HDRS‬‬ ‫בניתוח מסוג ‪ stepwise linear regression‬נמצא שתוצאות‬ ‫‪ PSLES‬היו מנבא חיובי משמעותי למדדי הטורדניות והכפייתיות‪.‬‬ ‫מסקנה‪ :‬אירועי חיים הופיעו יותר באופן משמעותי אצל מטופלים‬ ‫עם ‪ OCD‬גם לאורך תקופה של שישה חודשים וגם לאורך כל‬ ‫החיים‪ ,‬לעומת קבוצת הביקורת של אנשים בריאים‪ .‬נמצא יחס‬ ‫ישיר בין חומרת הסימנים של ‪ OCD‬ובין מספר אירועי חיים גורמי‬ ‫דחק שדווחו בששת החודשים האחרונים לפני פרוץ ההפרעה‪.‬‬ ‫סיור שואה של סטודנטים‪:‬‬ ‫השפעה על הרוחניות ועל הבריאות‬ ‫א‪ .‬נגר‪ ,‬ש‪ .‬נגר‪ ,‬פ‪ .‬ללני וג'‪ .‬גולד‪ ,‬לוס אנג'לס‪ ,‬ארה"ב‬

‫רקע‪" :‬מצעד החיים" הוא סיור של שבועיים בפולין ובישראל‬ ‫לתלמידי תיכון‪ ,‬ובמהלכו התלמידים לומדים על אתרי ההשמדה‬ ‫של השואה‪.‬‬ ‫‪223‬‬

‫שיטות‪ :‬במחקר זה נבדקה ההשפעה של החוויה הזאת על‬ ‫הרוחניות ועל הבריאות של המשתתפים‪ .‬במדגם נכללו ‪134‬‬ ‫תלמידים יהודים‪ ,‬בני ‪ 16‬עד ‪ .19‬לפני "מצעד החיים" (זמן ‪ )1‬בוצעה‬ ‫לתלמידים הערכה על ידי השלמת סקר רקע (נתונים דמוגרפיים‪,‬‬ ‫מדד יהודיּות‪ ,‬וכן ידע בנושא השואה)‪ ,‬וסקר של ארגון הבריאות‬ ‫העולמי שכלל איכות חיים‪ ,‬רוחניות‪ ,‬דת‪ ,‬אמונות אישיות‪ ,‬וגם את‬ ‫ה־‪ .Child Somatization Inventory‬בסוף הסיור בפולין (זמן ‪)2‬‬ ‫התלמידים מילאו את הסקרים פעם שנייה‪ ,‬ולאחר כ־‪ 4-3‬חודשים‬ ‫פעם שלישית (זמן ‪.)3‬‬ ‫תוצאות ומסקנות‪ :‬רוב ההיבטים של רוחניות עלו באופן משמעותי‬ ‫בין זמן ‪ 1‬לזמן ‪ .2‬בין זמן ‪ 2‬לזמן ‪ 3‬התקבלו תוצאות שונות בהקשר‬ ‫זה‪ ,‬אך 'כוח' ו'תקווה' נותרו גבוהים‪ .‬תחושת 'אמונה' עלתה מזמן ‪1‬‬ ‫לזמן ‪ 2‬ונשמרה בזמן ‪' .3‬פחד ממוות' עלה בזמן ‪ ,2‬אך ירד משמעותית‬ ‫בזמן ‪ .3‬נמצא קשר חיובי בין רוחניות לתחושת יהודיּות‪.‬‬ ‫"תסמונת פיזה" ודיסטוניה לרינגיאלית כתופעות‬ ‫לוואי של נוגדי פסיכוזה מהדור החדש‬ ‫ח‪ .‬מיודובניק‪ ,‬ו‪ .‬לרנר וא‪ .‬ויצטום‪ ,‬באר שבע‬

‫רקע‪ :‬הטיפול התרופתי בתכשירים נוגדי פסיכוזה עלול לגרום‬ ‫לעתים קרובות לתופעות לוואי חוץ־פירמידליות‪ .‬דיסטוניה‬ ‫מושהית היא תופעה מסוג זה‪ ,‬העלולה להוות סכנה של ממש‪.‬‬ ‫באופן מסורתי נהוג היה לחשוב שתופעות כאלו נגרמות מנוגדי‬ ‫פסיכוזה מהדור הראשון‪ ,‬ועל כן תקוות רבות נתלו בתרופות‬ ‫מהדור השני‪ .‬למרות זאת‪ ,‬הדיווחים על הפרעות בתנועה לאחר‬ ‫נטילת התרופות החדשות‪ ,‬הפכו שכיחות יותר ויותר‪.‬‬ ‫שיטות‪ :‬במאמר זה מתוארים שלושה מטופלים הסובלים‬ ‫מסכיזופרניה כרונית‪ ,‬אשר טופלו בתכשירים נוגדי פסיכוזה מהדור‬ ‫השני ופיתחו תסמינים של דיסטוניה‪ .‬אחד מהם פיתח דיסטוניה‬ ‫פרינגולרינגיאלית‪ ,‬והשניים האחרים פיתחו "תסמונת פיזה"‪.‬‬ ‫תופעות אלו נראו אצל מטופל אחד לאחר שקיבל ריספרידון‪ ,‬אצל‬ ‫השני לאחר הורדת ריספרידון והוספת סרטינדול‪ ,‬ואצל השלישי‬ ‫לאחר מתן זיפרזידון‪.‬‬ ‫מסקנה‪ :‬סדרת מקרים זו מעלה את האפשרות שקיים קשר סיבתי‬ ‫בין ההופעות השונות של דיסטוניה מושהית לבין תרופות נוגדות‬ ‫פסיכוזה מהדור השני‪ .‬לדעתנו על הרופאים המטפלים להיות ערים‬ ‫לאפשרות זו‪ ,‬שעשויה להיות לה משמעות קלינית‪.‬‬ ‫אשפוז פסיכיאטרי על פי צו הסתכלות של בית‬ ‫משפט בישראל‪ :‬מחקר מעקב למשך עשר שנים‬ ‫א‪ .‬גרינשפון‪ ,‬ר‪ .‬חאלד‪ ,‬ע‪ .‬פוליאקביץ'‪ ,‬א‪ .‬פוניזובסקי‪,‬‬ ‫ופ‪ .‬אפלבאום‪ ,‬ירושלים‬

‫מטרות‪ :‬לבחון מהו שיעור הנאשמים‪/‬חשודים המאושפזים על פי‬ ‫צו הסתכלות של בית משפט (‪ ,)COO‬אשר אובחנו כבעלי הפרעה‬ ‫פסיכיאטרית במהלך תקופת ההסתכלות או במשך תקופה של ‪10‬‬ ‫שנות מעקב‪.‬‬ ‫שיטות‪ :‬נאספו נתונים על כל הנאשמים המבוגרים שעברו אשפוז‬ ‫פסיכיאטרי בעקבות ‪ COO‬בין השנים ‪ 1991‬ל־‪ .1995‬הנתונים‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫הזדמנויות מוחמצות‪ :‬מקומם של רופאי‬ ‫משפחה ורופאי ילדים בזיהוי מתבגרים‬ ‫בעלי הפרעות נפשיות וטיפול בהם‪,‬‬ ‫או הפנייתם לטיפול נפשי מקצועי‬ ‫א‪ .‬מנסבך־קליינפלד‪ ,‬ח‪ .‬פלטי‪ ,‬א‪ .‬יפרח‪ ,‬ד‪ .‬לוינסון וא‪ .‬פרבשטיין‪,‬‬ ‫ירושלים‬

‫רקע‪ :‬רק מיעוט מקרב המתבגרים הסובלים מהפרעות נפשיות‬ ‫פונה לעזרת אנשי מקצוע או מטפלים אחרים‪ ,‬בשעה שרובם‬ ‫מבקרים אצל רופאי המשפחה‪ .‬לרופאי המשפחה יש הזדמנות‬ ‫לזהות מקרים אלה ולהפנות את מטופליהם לקבלת טיפול מקצועי‪.‬‬ ‫שיטות‪ :‬הסקר הישראלי לבריאות הנפש בקרב בני נוער (‪)ISMEHA‬‬ ‫שנערך בשנים ‪ 2005-2004‬כלל ‪ 957‬מתבגרים ואמהותיהם אשר‬ ‫ענו על שאלוני האבחון הפסיכיאטרי ה־‪DEVELOPMENT AND‬‬ ‫(‪ WELL BEING ASSESSMENT (DAWBA‬והשיבו לשאלות‬ ‫הקשורות לשימוש בשירותי הבריאות הכללית ושירותי בריאות‬ ‫הנפש‪ .‬שיעור ההיענות בקרב הנדגמים שאותרו היה ‪.80%‬‬ ‫ממצאים‪ :‬כ־‪ 70%‬מהמתבגרים ביקרו אצל רופאי משפחה‪ .‬השיעור‬ ‫היה גבוה יותר אצל מתבגרים שאובחנו כבעלי הפרעות נפשיות‬ ‫ובקרב המתבגרים היהודים‪ .‬שיעור הפניות לרופאי משפחה בקרב‬ ‫מתבגרים שלא פנו לעזרה נפשית מקצועית כלשהי‪ ,‬אף על פי‬ ‫שסבלו מהפרעה נפשית‪ ,‬היה ‪. 76.5%‬‬ ‫מסקנות‪ :‬מעל ‪ 75%‬מהמתבגרים שלא פנו לעזרה נפשית מקצועית‬ ‫בשנה שקדמה לסקר‪ ,‬אף על פי שסבלו מהפרעה נפשית‪ ,‬ביקרו אצל‬ ‫רופא משפחה או רופא ילדים‪ .‬המאמר דן בהזדמנות שהוחמצה‬ ‫לזהות את המתבגרים אשר נזקקו לטיפול‪ ,‬לטפל בהם או להפנותם‬ ‫לגורמים מקצועיים‪.‬‬ ‫הפרעת דחק פוסט־טראומתית אצל שפחות מין‬ ‫לשעבר בצבא היפני במלחמת העולם השנייה‬ ‫ס‪.‬ק‪ .‬מין‪ ,‬ג'‪.‬ה‪ .‬לי‪ ,‬ג'‪.‬י‪ .‬קים וי‪.‬ג'‪ .‬סים‪ ,‬סיאול‪ ,‬קוריאה‬

‫מטרה‪ :‬מחקר זה בודק מדדים של בריאות הנפש אצל נשים‬ ‫שנאלצו לשרת את הצבא היפני המלכותי כשפחות מין במהלך‬ ‫מלחמת העולם השנייה‪.‬‬ ‫שיטה‪ :‬נבדקו סיפור החיים‪ ,‬התפקוד הקוגניטיבי‪ ,‬אבחנה לפי‬ ‫‪ DSM-IV‬של ‪ ,PTSD‬דיכאון‪ ,‬מצב פרנואידי‪ ,‬כעס ותוצאות מבחני‬ ‫רורשך אצל ‪ 26‬שפחות מין לשעבר‪ .‬התוצאות הושוו למדגם של ‪24‬‬ ‫נשים בריאות‪.‬‬ ‫תוצאות‪ :‬לא נמצא הבדל משמעותי בתפקוד הקוגניטיבי בין נשים‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,48‬מס' ‪2011 ,2‬‬

‫אלו לבין קבוצת הביקורת‪ .‬כל ‪ 26‬הנשים חוו חוויות טראומתיות‬ ‫כמו עבדות מינית‪ ,‬וסבלו מסימנים המעידים על הפרעת דחק פוסט־‬ ‫טראומתית לפחות פעם בחייהן‪ .‬מתוך ה־‪ )30.8%( 8 ,26‬אובחנו‬ ‫כסובלות מהפרעת דחק פוסט־טראומתית לעומת אפס בקבוצת‬ ‫הביקורת‪ .‬סימני הפרעת דחק פוסט־טראומתית אופייניים הם‬ ‫התנהגות הימנעותית‪ ,‬זיכרונות חודרניים ומציקים וכעס‪ .‬לא היו‬ ‫הבדלים משמעותיים בדיכאון או במצבים פרנואידיים בין שתי‬ ‫הקבוצות‪ ,‬אך אצל שפחות מין לשעבר נמצאו הפרעות בריסון כעס‪.‬‬ ‫שפחות המין לשעבר שסבלו מהפרעת דחק פוסט־טראומתית היו‬ ‫יותר מדוכאות‪ .‬בתוצאות מבחני הרורשך נמצאו אצלן תגובות‬ ‫אופייניות הקשורות למין ולמורבידיות‪ ,‬וכן לכעס ולאלימות‪.‬‬ ‫מגבלות‪ :‬ייתכן שהמדגם הקטן אינו מייצג את מצבן של הנשים‬ ‫האלה‪ .‬כמו כן‪ ,‬חלק מהנתונים מבוססים על דיווח עצמי‪ ,‬ודיווח‬ ‫כזה יכול להשפיע על האובייקטיביות של הממצאים‪.‬‬ ‫סימפטומים פסיכוסומאטיים בקרב‬ ‫רופאים בבתי חולים במהלך מבצע‬ ‫עופרת יצוקה‪ :‬מחקר רוחב חוזר‬ ‫מ‪ .‬בן־עזרא‪ ,‬י‪ .‬פלגי‪ ,‬י‪ .‬י‪ .‬וולף‪ ,‬וע‪ .‬שרירא‪ ,‬אריאל‬

‫גוף הידע הנוגע לתגובות פסיכוסומאטיות בקרב רופאים בבתי‬ ‫חולים במהלך מצב לוחמה הוא חלקי‪ .‬מטרת מחקר זה הייתה‬ ‫להשוות בין הסימפטומים הפסיכוסומאטיים של רופאים שנחשפו‬ ‫למצב לוחמה לבין הסימפטומים של רופאים שלא נחשפו למצב‬ ‫כזה בשני מחקרים‪ .‬המחקרים נערכו במהלך שנת ‪ 2009‬וכללו שני‬ ‫מדגמים אקראיים של רופאים בבתי חולים‪ .‬המחקר הראשון נערך‬ ‫במהלך מבצע עופרת יצוקה‪ ,‬והשני נערך כחצי שנה לאחר מכן‪.‬‬ ‫בכל מחקר נכללו רופאים שנחשפו ישירות לירי טילים ורקטות וכן‬ ‫רופאים שלא נחשפו לכך‪ .‬במחקר ‪ 1‬גודל המדגם הוא ‪ ;54‬במחקר ‪2‬‬ ‫גודל המדגם הוא ‪ .31‬במחקר הראשון‪ ,‬שנערך במהלך מבצע עופרת‬ ‫יצוקה‪ ,‬רופאים בבתי חולים שנחשפו למצבי לוחמה לא הפגינו‬ ‫רמות שונות של סימפטומים פסיכוסומאטיים בהשוואה לרופאים‬ ‫שכן נחשפו למצבים אלו (הציון הממוצע בסולם סימפטומים‬ ‫פסיכוסומאטיים היה ‪ 6.48‬לעומת ‪ 4.09‬בהתאמה)‪ .‬אולם במחקר‬ ‫השני‪ ,‬שנערך לאחר כחצי שנה‪ ,‬רופאים בבתי חולים שנחשפו למצבי‬ ‫לוחמה דיווחו על רמה גבוהה יותר של סימפטומים פסיכוסומאטיים‬ ‫(‪ 10.33‬לעומת ‪ 3.21‬בהתאמה)‪ .‬יתרה מזאת‪ ,‬תוצאת ניתוח השונות‬ ‫המשותפת הראתה אינטראקציה מובהקת של חשיפה ‪ X‬מחקר‬ ‫(‪ .)F = 7.976; p = .006; ηp2 = .100‬נמצא קשר חיובי בין חשיפה‬ ‫למצב לוחמה לבין סימפטומים פסיכוסומאטיים בקרב רופאים בבתי‬ ‫חולים‪ .‬העלייה המאוחרת ברמת הסימפטומים הפסיכוסומאטיים‬ ‫נדונה לאור המודל הקוגניטיבי־אנרגטי‪.‬‬ ‫‪224‬‬