Israel Journal of Psychiatry and Related Sciences by MEDIC

israel journal of

psychiatry

Vol. 50 - Number 1 2013

ISSN: 0333-7308

Editorial: Fit to be Tied Pesach Lichtenberg

Seclusion Room vs. Physical Restraint in an Adolescent Inpatient Setting: Patients’ Attitudes Sergey Vishnivetsky et al.

Commentary

Abraham Rudnick

Voting of Patients with Mental Disorders in Parliamentary Elections Yuval Melamed et al.

Dissociative Symptoms as a Consequence of Traumatic Experiences Ariel Gaon et al.

Initial Validation of the Russian Version of the World Mental Health Structured Clinical Interview for DSM-IV Zinoviy Gutkovich

Epigenetic Transmission of Holocaust Trauma Natan P.F. Kellermann

Changes in Heart Rate Variability in ECT in Major Depressive Disorder Ali Bozkurt et al.

Correlates of Physical Activity with Intrusive Thoughts, Worry and Impulsivity in ADHD Amitai Abramovitch et al.

Analysis of quality of Life and Anxiety in Patients with Epilepsy Sreten Vićentić et al.

Recalling the Threat: Dental Anxiety in Patients Waiting for Dental Surgery Ehud Bodner and Iulian Iancu

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israel journal of

psychiatry and related sciences EDitor

David Greenberg DEPUTY EDITORS

David Roe Rael Strous Gil Zalsman

Book reviews editor

Yoram Barak PAst Editor

6 > Seclusion Room vs. Physical Restraint in an Adolescent Inpatient Setting: Patients’ Attitudes

Sergey Vishnivetsky, Gal Shoval, Vadim Leibovich, Lucas Giner, Marsel Mitrany, Dorit Cohen, Aliza Barzilay, Louisa Volovick, Abraham Weizman and Gil Zalsman

> Commentary: Can Seclusion and Restraint be Person-Centered?

Abraham Rudnick

Founding Editor

Heinz Z. Winnik Editorial Board

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

Yoram Bilu Aaron Bodenheimer Carl Eisdorfer Julian Leff Phyllis Palgi Robert Wallerstein Myrna Weissman

Vol. 50 - Number 1 2013

> Editorial: Fit to be Tied Pesach Lichtenberg

Eli L. Edelstein

The Official Publication of the Israel Psychiatric Association

> Voting of Hospitalized and Ambulatory Patients with Mental Disorders in Parliamentary Elections

Yuval Melamed, Liora Donsky, Igor Oyffe, Sigalit Noam, Galit Levy, Marc Gelkopf and Avi Bleich

> Dissociative Symptoms as a Consequence of Traumatic Experiences: The Long-term Effects of Childhood Sexual Abuse Ariel Gaon, Zeev Kaplan, Tzvi Dwolatzky, Zvi Perry and Eliezer Witztum

24 > Initial Validation of the Russian Version of the World Mental Health Structured Clinical Interview for DSM-IV

> Changes in Heart Rate Variability before and after ECT in the Treatment of Resistant Major Depressive Disorder

Ali Bozkurt, Cem Barcin, Mehmet Isintas, Mehmet Ak, Murat Erdem and K. Nahit Ozmenler

47 > Correlates of Physical Activity with Intrusive Thoughts, Worry and Impulsivity in Adults with Attention Deficit\Hyperactivity Disorder: A Cross-sectional Pilot Study Amitai Abramovitch, Gil Goldzweig and Avraham Schweiger

55 > Analysis of quality of Life and Anxiety in Patients with Different Forms of Epilepsy

Sreten Vićentić, Milutin Nenadović, Nenad Nenadović and Periša Simonović

> Recalling the Threat: Dental Anxiety in Patients Waiting for Dental Surgery

Ehud Bodner and Iulian Iancu

68 > Cultural Psychiatry in Tel Aviv: how relevant! Hans Rohlof, Anne-Marie Ulman

Zinoviy Gutkovich

> Epigenetic Transmission

of Holocaust Trauma: Can Nightmares Be Inherited? Natan P.F. Kellermann

Hebrew Section

71 > News and Notes 74 > Abstracts

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Rena Kurs Assistant Editor

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Pirhiya by Judy Pirhiya (literally, flower of God) was the name my parents wanted to call me. I associate the picture with the verse: "whose leaf shall not wither" (Ezekiel 47:12) which I understand in two ways. The simple meaning is that the leaves will remain fresh and alive forever, while a second possible meaning is euphemistic, that the leaves will wither for Him, symbolizing self sacrifice. Painted with acrylic colors on a pink sponge pad.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Editorial: Fit to be Tied The psychiatric inpatient unit is generally not a place one would choose to spend time. For people struggling with severe emotional distress or cognitive aberrations, admission to the psychiatric ward may need to take place against their will. The reasons for this are not hard to fathom. Many psychiatric institutions feature inpatient units that are understaffed, offer too few therapeutic activities, and provide an atmosphere where the threat of coercion is ever present. Over half a century after Erving Goffman (1) described a total institution as a place where the lives of people interned therein are fully controlled by the administering staff, many psychiatric wards continue to fit the description. This can lead to a deep sense of disempowerment and selfstigmatization which can haunt the patient long after his release and hamper subsequent efforts to seek care and achieve rehabilitation or even recovery (2). The potential of the psychiatric institution’s control over people confined within its walls is exemplified by its legal right to lock someone in a room (seclusion) or even to tie her or him to a bed (restraint). To work in such a ward and to speak with its inmates is to realize that the availability of this “treatment” option, even when not applied, presents an ever-present threat, which staff may permit themselves to express in their efforts to instill compliance (“stop that or we’ll put you in seclusion!”). The adverse effects of physical restraints range from stigmatization and post-traumatic stress disorder to physical injury and, on rare occasion, death (3). Various methods for restraining those perceived as mentally aberrant have been employed for thousands of years; indeed, restraints may be the single constant, unvarying feature of psychiatric “treatment” throughout history. The prophet Jeremiah, whose diatribes were not appreciated by the powers that be and led to his own incarceration, records government policy towards the insane as follows: “For every man that is mad, and acts the prophet, that thou shouldst put him in the stocks, and in the collar” (Jeremiah 29:26) (4). Some date the start of psychiatry as a separate specialty to Philippe Pinel’s liberation of inmates from restraints in 1793. In the United States, in 1838, Robert Gardener Hill, a proponent of moral therapy, proudly announced that in his asylum he had succeeded in eliminating all coercive measures. He further declared that “in a properly 4

constructed building, with a sufficient number of suitable attendants, restraint is never necessary, never justifiable, and always injurious, in all cases of lunacy whatever” (5). Since then the issue has periodically risen to the awareness of the general public, and engendered discussions amongst practitioners. Our local legal sources are laconic in this area. The 1991 Israeli Mental Health Act, 34:b, states that a hospitalized psychiatric patient may be secluded or restrained “only to the extent necessary for purposes of medical care or to prevent a danger to oneself or to others” (6). The law does not direct that the least coercive form of restraint be used, nor does the law specify what measures be taken to seek less harsh alternatives for controlling the patient, though these would presumably be mandated by the Patients’ Rights Law of 1996. This issue of the Israel Journal of Psychiatry features an article which turns a spotlight on this dark area of the psychiatric hospital experience. Vishnvetsky and colleagues (7) asked hospitalized adolescents whether they would prefer to be secluded, meaning locked in a room, or restrained, meaning tied to a bed. Unsurprisingly, most preferred the former, which was also reported to produce less anger and shame. The authors are to be commended for investigating this difficult area. Still, one wonders what the results would have been had the respondents been able not only to compare seclusion and restraint with each other, but with neither as well. Qualitative approaches to research in this area have revealed that patients consider physical restraints to be demeaning and stigmatizing, and a form of punishment rather than therapy (8). We still have little knowledge about the extent and effectiveness of physical restraints. Only two countries, Norway and Finland, bother to maintain a registry of restraints (9). The others do not have clear records of how often and under which circumstances restraints are used. Israel is not alone in this unhappy situation. A 2000 Cochrane review yielded no careful research about the benefits and effects of restraints (10). Subsequent reports and research have been meager and produced mixed results. In some places, like the state of Pennsylvania in the United States, the practice has been virtually eliminated (11), with an unanticipated reduction in the use of medication (12). In the Netherlands, on the other hand, an

Pesach Lichtenberg

ambitious program failed to meet the modest goal of a 10% reduction in physical restraints (13). Restraints , of course, can take many forms besides shackles and barricaded doors, prominent amongst them today the chemical restraints (i.e. neuroleptic medication), which can also be perceived as more efficient and less labor-intensive than alternatives. Yet chemical restraints are not necessarily morally or therapeutically superior to physical restraints, and are considered by some to be more invasive and degrading (9). (Personally, I have left instructions with the staff in my department that were it ever to come to that, I would prefer that they tie me down rather than come at me with a haloperidolfilled syringe). Through all this uncertainty, a consensus emerges from efforts to reduce the use of restraints that it requires personnel (14), and they need to be motivated and well trained to identify and defuse incipient sources of tension before they turn violent. The prevention of overcrowding and the provision of private space are also helpful (15). The person pinned down to a bed in a psychiatric hospital is the outcome of a long and complex chain of causality, of which his aggression is only one link. To see only that patient’s aggression is to willfully use tunnel vision. Before that comes an understaffed, undertrained department. And long before that come bureaucratic decisions about what the staffing needs are for inpatient departments, with the concomitant funding, which falls deplorably short of what would be necessary to produce an environment which respects human rights and dignity. To better understand this complex situation, the Ministry of Health would be well advised, as a first step, to establish a registry which would record the use of physical restraints. For every such incident, data would be provided about the demographics, diagnosis, cause for restraint, form of restraint, duration of restraint, concomitant medication, number of patients present in the unit, number of staff on duty, and their level of training. This initiative, which might in itself lead to a reduction in the use of physical restraints, would also reveal disparities between institutions, which might provide clues about how some manage to use these measures less frequently. Subsequently, it would be possible to gauge the effect of initiatives to reduce the use of physical restraints. It is disheartening to see how little things have changed. While Robert Gardener Hill, the progressive 19th century reformer referred to earlier, trumpeted his accomplishments in eliminating coercive practices in his asylum, a contemporary visitor was less sanguine, and

wrote why he doubted the program which succeeded in Hill’s asylum would be adopted elsewhere: …for not only must the premises be enlarged in consequence, and much of the interior localities altered; but the number of keepers must be augmented, and all of them must be better paid, in order that they may be obtained from among a far better class of people than that which has hitherto supplied this order of attendants in a lunatic asylum (16). One would hope that almost two centuries later, we have progressed far enough to provide the means to treat without the resort to violence. References 1. Goffman, Erving. Asylums: essays on the social situation of mental patients and other inmates. Garden City, N.Y.: Anchor Books, 1961. 2. Slade M: Personal recovery and mental illness. A guide for mental health professionals. Cambridge: Cambridge University, 2009. 3. Mohr WK, Mohr BD. Mechanisms of injury and death proximal to restraint use. Arch Psychiatr Nurs 2000;14:285-295. 4. The Holy Scriptures, Koren Publishers: Jerusalem, 1977. 5. Belkin GS. Self-restraint, self-examination: A historical perspective on restraints and ethics in psychiatry. Psychiatr Serv 2002;53:663-664. 6. The Israeli Law for the Treatment of the Mentally Ill from 1991; In: Shazman H, Katz N, Oren H, editors. Care of the mentally ill. TelAviv: Dyunon, Tel Aviv University, 1999: pp. 279-301. 7. Vishnivetsky S, Shoval G, Leibovich V, et al. Seclusion room vs. physical restraints in an adolescent inpatient setting: Patients’ attitudes. Isr J Psychiatry Relat Sci 2013; 1: 6-10. 8. Meehan T, Vermeer C, Windsor C. Patients’ perceptions of seclusion: A qualitative investigation. J Adv Nurs 2000;31:370-377. 9. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, Keski-Valkama A, Mayoral F, Whittington R. Incidence of seclusion and restraint in psychiatric hospitals: A literature review and survey of international trends. Soc Psychiatry Psychiatr Epidemiol 2010;45:889-897. 10. Sailas EES, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001163. DOI: 10.1002/14651858.CD001163. 11. Smith GM, Davis RH, Bixler EO, Lin HM, Altenor A, Altenor RJ, Hardentstine BD, Kopchick GA. Pennsylvania State Hospital system’s seclusion and restraint reduction program. Psychiatr Serv 2005;56:1115-1122. 12. Barton SA, Johnson MR, Price LV. Achieving restraint-free on an inpatient behavioral health unit. J Psychosoc Nurs Ment Health Serv 2009;47:34-40. 13. Vruwink FJ, Mulder CL, Noorthoorn EO, Uitenbroek D, Nijman HL. The effects of a nationwide program to reduce seclusion in the Netherlands. BMC Psychiatry 2012;12:231. 14. Janssen WA, Noorthoorn EO, Nijman HL, Bowers L, Hoogendoorn AW, Smit A, Widdershoven GA. Differences in seclusion rates between admission wards: Does patient compilation explain? Psychiatr Q 2013;84:39-52. 15. van der Schaaf PS, Dusseldorp E, Keuning FM, Janssen WA, Noorthoorn EO. Impact of the physical environment of psychiatric wards on the use of seclusion. Br J Psychiatry 2013;202:142-149. 16. Granville AB. The spas of England. London: Henry Colburn, 1841: p. 89.

Pesach Lichtenberg, MD Herzog Hospital and the Hebrew University of Jerusalem Pesach.Lichtenberg@mail.huji.ac.il

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Seclusion Room vs. Physical Restraint in an Adolescent Inpatient Setting: Patients’ Attitudes Sergey Vishnivetsky, RN,1 Gal Shoval, MD,1,2 Vadim Leibovich, RN, MPA,1 Lucas Giner, MD, PhD,3 Marsel Mitrany, RN, BA,1 Dorit Cohen, RN, MPH,1 Aliza Barzilay, RN, MPH, MA,1 Louisa Volovick, MD,1 Abraham Weizman, MD,1,2,4 and Gil Zalsman, MD1,2,5 1

Geha Mental Health Center, Petach Tikva, Israel Psychiatry Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 3 Department of Psychiatry, University of Seville, Seville, Spain 4 Felsenstein Medical Research Center, Tel Aviv University, Petah Tikva, Israel 5 Division of Molecular Imaging and Neuropathology, Psychiatry Department, Columbia University, New York, N.Y., U.S.A. 2

Abstract Background: The use of physical restraints or a seclusion room for the treatment of adolescents in a psychiatric inpatient setting raises ethical dilemmas. We investigated the attitudes of adolescents towards these two means of confinement. Method: We used a structured questionnaire to collect data on the attitudes of 50 adolescent patients, hospitalized in a closed psychiatric ward, towards the use of physical restraint vs. a seclusion room. Results: Seventy per cent of the participants in the study preferred seclusion in the seclusion room over bed restraint, whereas 22% preferred physical restraint. Eighty-two percent described seclusion in the seclusion room as less frightening than restraint. Seventy-four per cent reported that seclusion in the seclusion room improved their mental state to a larger extent than restraint. The inpatient adolescents reported feeling the time they needed to reach a state of calm was shorter when they were confined to the seclusion room than when they were physically restrained (p<0.001). Conclusions: The use of a seclusion room may be preferable compared to physical restraint for inpatient adolescents.

Introduction Treatment of adolescents in a psychiatric inpatient setting presents complex professional challenges. One of them is the use of physically confining means, including restraining patients to their beds and secluding them in a seclusion room. Whereas in Israel the use of bed restraints is common in adult wards as well, the use of a seclusion room is more typical to adolescent wards. Prevalence rates of seclusion and physical restraint in adolescent inpatients units have been found to be relatively high. Some authors reported that more than a third of the adolescent patients had to be restrained or secluded during their hospitalization in psychiatric units (1). It has been reported that seclusion is used more often in high-risk inpatients (2). However, there is little knowledge about the effectiveness of these types of interventions even in those with severe psychopathology or higher levels of aggression (3). It has been suggested that potential psychological or physical harm might result (1). Most of the factors that have been associated with seclusion are related to inpatients’ characteristics, such as male gender, diagnoses of disruptive behavior disorder, and history of physical abuse, past history of aggression or violence, suicidal behavior, emergency admissions and non-white ethnicity (1, 4). Factors related to the nursing staff have also been studied. Most studies demonstrated no correlation between staff ’s experience or education level and the frequency of the use of confining methods (4), although some disagree (5). In any

Address for Correspondence: Gal Shoval, MD, Division of Child and Adolescent Psychiatry, Geha Mental Health Center, Sackler Faculty of Medicine, Tel Aviv University, POB 102, Petah Tikva 49 100, Israel shovgal@tau.ac.il

Sergey Vishnivetsky et al.

case, it was recommended that, in order to obtain better cooperation and response (6), the adolescent inpatients be given explanation about why restraint or seclusion is necessary. A recent randomized study of these two confinement methods in an adult psychiatric inpatient ward (n=105) did not demonstrate statistical differences in satisfaction with the received psychiatric care between those who had been confined to the seclusion room and those who were physically restrained (7). In another study from New Zealand, duration of seclusion of the inpatients was found to be inversely related to their level of pharmacological treatment (8). None of the published studies examined the adolescent patients’ attitudes to these methods of confinement. The current study aimed to investigate adolescents’ attitudes towards confinement by restraint to the bed versus seclusion in a seclusion room. We have used the definitions of seclusion and physical restraint proposed by the Committee on Pediatric Emergency Medicine, in which seclusion is defined as “the involuntary confinement of a patient alone in a room, from which the patient is physically prevented from leaving, for any period of time.” Physical restraint implies the “use of physical or mechanical devices to restrain movement” (6). The nursing staff of closed wards is often required to cope with patients behaving in a manner that may endanger themselves or the safety of others. Physical confinement means are often used despite patients’ opposition. Such treatments, which aim to decrease the level of a patient’s aggressive or disorganized behavior and to prevent damage to both the patient and his/her surroundings, adheres to the Israeli Mental Health Act (1991) (9) and the recommendations of the Committee on Pediatric Emergency Medicine (6), both in accordance with bio-ethical principles. The vast majority of countries have special laws for the safe and healthy management of those suffering a mental disorder who may not be responsible to take decisions concerning their own health (10). Modern societies undertake, when necessary, the responsibility for the care of these patients. Still, serious dilemmas often arise from the stigmatized perception that psychiatric patients are on one hand violent and dangerous, and on the other hand helpless and in need of protection. Consequently, laws are intended to protect society from hazardous behavior by patients and at the same time prevent the denial of these patients’ rights by the society and medical system (8). The 1991 Israeli Mental Health Act allows medical staff in mental health institutions to deny a psychiatric patient

his physical freedom when he endangers himself or others around him. The law, however, describes in detail the circumstances required to allow use of such means (9). Of note, neither the law nor the relevant ministerial regulations distinguish between adult and adolescent patients with regard to confinement. No special consideration is required for confining children and adolescents by a physical restraint or by seclusion in a seclusion room. Four bio-ethical principles have been suggested as guidelines for the treatment of psychiatric patients: preserving the individual’s autonomy, acting in the best interest of the individual, avoiding damage, and ensuring justice (11). A paternalistic approach towards psychiatric patients has been recommended in certain cases, namely when the patient poses clear and immediate danger to himself or to his close environment (12). However, when the caretaking staff and an inpatient in a psychiatric ward disagree on the best treatment method, the patient is not necessarily mistaken or irrational. In such situations critical thinking and reliance on these bio-ethical principles is vital (13, 14). The aim of this study was to investigate the attitudes of psychiatric adolescent patients in closed adolescent wards of the use of physical confinement. Since we could find no previous study that evaluated patients’ attitudes toward the different confining methods, our hypotheses were based on our clinical experience rather than the literature. We hypothesized that: Patients would prefer seclusion in a seclusion room than physical restraint. Restraint would be experienced by the patient as more threatening than seclusion in the seclusion room. Patients would consider seclusion in a seclusion room to be more efficacious than physical restraint in calming down the patients. Methods The sample consisted of 50 consecutive admissions of patients to the adolescent inpatient ward of a university affiliated mental health center. The participants were required to have had at least one episode of confinement by both seclusion in a seclusion room and by physical restraint during their hospital stay. The unit’s indication for confinement was the patient constituting a hazard to himself or to his surroundings, as evaluated by one of the unit’s child and adolescent psychiatrists. The mean age of the subjects was 16.8±2.1 years, with a range from 13 to 24 years. Twenty-six (52%) were female. The mean length of the episodes of physical restraint was 7

Seclusion Room vs. Physical Restraint in an Adolescent Inpatient Setting: Patients’ Attitudes

5.2±5.6 hours, while seclusion episode mean time was 5±4.4 hours. Almost half of the sample (23 subjects; 46%) had four or more episodes of restraint and/or seclusion. Sixteen (32%) of the subjects were hospitalized due to psychotic symptoms, 20 (40%) due to an exacerbation in mood disorders and 14 (28%) due to other psychiatric disorders. Data were collected via a structured questionnaire that included social and demographic information as well as quests regarding the level of fear experienced during each episode, preferred procedure (seclusion or restraint) and the efficacy of the procedure as perceived by the patient. Data of the number of physical restraint/ seclusion episodes were collected from the medical record. A self-rating, subjective questionnaire was used to obtain data on feelings of shame/humiliation, discomfort and anger. The participants completed the questionnaire towards the end of their hospitalization period, after their mental state had stabilized. All subjects participated with informed, voluntary, written consent signed by themselves and their parents. Capability to decide on research participation was determined clinically by a certified child and adolescent psychiatrist (GZ). All patients who were approached enrolled in the study. The study was approved by the Geha Mental Health Center’s Human Subjects Review Committee. Data Analysis

Statistical analyses were conducted using an SPSS-17 complex sample analysis module (IBM-SPSS Inc, Chicago, IL). Student’s paired t-test was employed to compare means of patient ratings between the two patients groups (independent variable), where the grouping was done by means of experienced confinement. Chi square analyses were used for categorical variables. Level of significance was set to 0.05. All tests were two tailed. Results Thirty-five (70%) of the participants preferred the use of a seclusion room over restraint to their beds as a physical means of confinement, eleven (22%) preferred restraint, two (4%) expressed no preference of either method, and two (4%) did not answer. No significant association was found between the patients’ attitudes and any of the following factors: age, sex, the number of times the patient had been confined during the current hospital stay, and his psychiatric diagnosis. 8

Thirteen (26%) of the adolescent inpatients described the stay in the seclusion room as “not at all threatening,” twenty-two (44%) described it as “much less threatening than being restrained,” six (12%) said it was “a bit less threatening than being restrained,” two (4%) said it was “equally threatening,” five (10%) claimed it was “a bit more threatening than being restrained,” and two (4%) described it as “a lot more threatening than being restrained.” Altogether 82% of respondents described the stay in the seclusion room as less threatening than being restrained, while 14% claimed the opposite. No significant correlation was found between these findings and age, gender, number of times the individual was restrained during the hospital stay, number of times the individual was secluded in a seclusion room and the psychiatric diagnosis. Forty-four per cent of the participants stated that seclusion in the seclusion room resulted in “a major improvement” in their mental state, as compared to being restrained; 30% described their mental state after seclusion in the seclusion room as “somewhat improved”; 20% reported no impact of the seclusion in the seclusion room on their mental state; and 6% reported a deterioration in their mental state resulting from seclusion in the seclusion room. In all, 74% of subjects described seclusion in the seclusion room as a treatment that resulted in an improvement to their mental state. We also investigated factors that may have influenced the adolescent inpatients’ attitudes toward the confinement methods. One of the factors that was associated with the choice of restraint vs. seclusion was the level of comfort pointed out by the subject (3+1 vs. 1.3+1.3, t=7.72, p<0.001). In addition, higher level of anger (3+1 vs. 1.45+0.65, t=5.96, p<0.001), and of shame and humiliation (2.72+1.1 vs. 1.6+0.69, t=4.04, p=0.007) during the procedure were associated with the choice of the other confinement method (Table 1). Table 1. A Comparison of Confinement Means Preference by the Reported Feelings Aroused by the Confinement Preferred procedure of confinement (scale 1-4) mean (s.d.) Feelings

Seclusion n=35

Restraint n=11

t-test df

Shame

1.6 (0.69)

2.72 (1.10)

4.04 44

0.007 *

Discomfort

1.31 (1.31)

3.00 (1.00)

7.72 44

<0.001 ***

Anger

1.45 (0.65)

3.00 (1.00)

5.96 44

<0.001 ***

*p<0.05, ***p<0.001

Sergey Vishnivetsky et al.

When analyzing the efficacy of both procedures of confinement, adolescents reported the feeling of shorter time needed to reach a calm state when they were secluded in the seclusion room compared to being physically restrained (χ2=30.81, df=1, p<0.001). This perception was correlated with the number of times an individual had to be confined during the hospitalization (r=0.363, p=0.01). Discussion This study found that inpatient adolescents preferred the use of a seclusion room over bed restraint as confinement means in situations in which they may have endangered themselves or their surroundings. They considered confinement by physical restraints to be more threatening than seclusion in a seclusion room. This preference and perception were not related to age, gender, psychiatric diagnosis or the number of episodes of confinement during the current hospitalization. Adolescent patients perceived the seclusion to be more effective than physical restraint in order to achieve a calm state and to control the situation for which the confinement episode was indicated. This perception was also not associated with age, gender, psychiatric diagnosis or the number of seclusions in a seclusion room during current hospitalization, but was correlated with the number of restraint episodes during hospitalization. The attitudes the participant adolescents expressed towards the type of physical confinement may had been formed based on their subjective feelings of comfort, on the length of time it took to reach a calm state, and individual’s feelings of anger, humiliation and shame when confined. Previous studies reported rates and associated factors regarding the use of confinement, including being restrained and being secluded in a seclusion room. To the best of our knowledge, no previous study investigated the patients’ attitudes towards physical restraint compared to seclusion in a seclusion room. According to Fisher (15) and Gair (16), seclusion of an adolescent in a seclusion room is a reasonable and efficient method for preventing self-harm or harm to the surroundings. A study by Plutchik et al. (17) investigated patients’ feelings toward seclusion in a seclusion room. Time in the seclusion room was reported to help patients relax and regain the feeling of self-control. In that study, patients complained about the vague and confusing criteria used to seclude them in the seclusion room and to determine the length of time. However, as mentioned before, it is

recommended to explain to the patient and his family the particular reason for confinement and its desired goals (6). We agree with the authors claiming that a seclusion room is an efficient treatment method of coping with adolescents hospitalized in psychiatric wards who pose immediate danger to themselves or to their surroundings (18). It is noteworthy that preference toward the seclusion room over bed restraint was associated with the number of times a patient was confined during his hospital stay. The more times the patient was restrained the less he or she perceived the seclusion room to be effective in improving his mental state, compared to bed restraint. Since this group of patients was hospitalized due to particularly complex psychiatric states, it seems that the seclusion room may not help as much as physical restraint in these severe cases. The latter may partially explain why seclusion rooms are not prevalent in adult psychiatric wards in Israel. In another study, patients reported seclusion time in a seclusion room as too lengthy (19). They suggested it be an effective treatment option should seclusion be limited to no more than 15 minutes. In line with this finding, prolonged stay in a seclusion room seemed to be associated with anger and frustration (20) and to complicate the caretaker-patient relationship (21). We did not study specifically this perception of the length of stay in the seclusion room, but we did compare their feelings about the length of time to calm down in the seclusion room and bed restraint. Participants in the present study perceived the seclusion room as a method that calmed them faster than bed restraint. Patients previously reported they felt anger, helplessness, sadness and shame from being physically restrained (22). Perceiving restraint as a punishment rather than a treatment, they developed behaviors of non-cooperation and doubting the staff ’s intentions (23). It was reported that patients may adjust their behavior in order to meet the expectations of the caretaking staff and obtain their freedom (19). This study concluded that the staff viewed their efforts as a sign that the patient had reached a calmer state, without understanding the underlying conditions and the patient’s true emotional state. In another study patients described feelings of anger, primarily towards the staff, as well as feelings of frustration and humiliation resulting from dealing with a system that denies their freedom. We have found that these negative feelings are less intense when secluded than when restrained. The use of physical confinement means in children and adolescents may result in mental stress and evoke 9

Seclusion Room vs. Physical Restraint in an Adolescent Inpatient Setting: Patients’ Attitudes

fear. Thus, physical confinement should be an exceptional option for adolescent inpatients. Our results show that physical restraint was perceived as more threatening than seclusion in a seclusion room. This finding is consistent with their preference of the seclusion room over the physical restraint. Limitations: This study had a retrospective nature and therefore there could have been a recall bias. It is based on cross-sectional design, which limits conclusions concerning the directionality between either restraint or seclusion room and the attitude of the patient. Moreover, the sample represents only one inpatient ward. The sample size may have been too small to detect minor differences. Finally, the psychometric properties of this questionnaire are unknown since it was developed specifically for this study and thus used for the first time. Larger multi-center studies are needed to substantiate our findings. Conclusions Based on the findings of the present study, we recommend consideration of a seclusion room as an effective method of treatment for situations in which the patient may endanger himself or his surroundings. Seclusion room should be considered as a preferable treatment compared to physical restraint option for adolescents in situations in which confinement is necessary. An essential part of this confinement procedure is to reduce fear and anxiety. It is necessary to explain to the patient the reason and the goals of the confinement, to maintain constant contact with him, to try to reduce to the minimum the length of confinement, and to give a feedback of the episode when the patient’s status and behavior improve. Seclusion may be also based on a positive reinforcement, such as “time out,” which is used in token economy behavioral schemes. Acknowledgements Funding of this study was provided by the Judie and Marshall Polk Research Fund for Children at Risk.

Authors’ Contributions Sergey Vishnivetsky, Vadim Leibovich, Marsel Mitrany, Dorit Cohen, Aliza Barzilay, Louisa Volovick, Abraham Weizman and Gil Zalsman were responsible for conceptualization of this study and its design. Sergey Vishnivetsky, Vadim Leibovich and Marsel Mitrany conducted the study. Gal Shoval, Lucas Giner, Abraham Weizman and Gil Zalsman managed the statistical analyses. All authors participated in the interpretation of the results. Sergey Vishnivetsky, Gal Shoval, Vadim Leibovich and Lucas Giner wrote the first

draft of the paper and all authors reviewed and approved the final manuscript.

References 1. De Hert M, Dirix N, Demunter H, Correll CU. Prevalence and correlates of seclusion and restraint use in children and adolescents: A systematic review. Eur Child Adolesc Psychiatry 2011;20:221-230. 2. Gullick K, McDermott B, Stone P, Gibbon P. Seclusion of children and adolescents: Psychopathological and family factors. Int J Ment Health Nurs 2005;14:37-43. 3. Larson TC, Sheitman BB, Kraus JE, Mayo J, Leidy L. Managing treatment resistant violent adolescents: A step forward by substituting seclusion for mechanical restraint? Adm Policy Ment Health 2008;35:198-203. 4. Fryer MA, Beech M, Byrne GJ. Seclusion use with children and adolescents: An Australian experience. Aust N Z J Psychiatry 2004;38:26-33. 5. Earle KA, Forquer SL. Use of seclusion with children and adolescents in public psychiatric hospitals. Am J Orthopsychiatry 1995;65:238-244. 6. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. The use of physical restraint interventions for children and adolescents in the acute care setting. Pediatrics 1997;99:497-498. 7. Huf G, Coutinho ES, Adams CE, TREK-SAVE Collaborative group. Physical restraints versus seclusion room for management of people with acute aggression or agitation due to psychotic illness (TREC-SAVE): A randomized trial. Psychol Med 2012; 12: 1-9. 8. Tyrer S, Beckley J, Goel D, Dennis B, Martin B. Factors affecting the practice of seclusion in an acute mental health service in Southland, New Zealand. The Psychiatrist 2012; 36: 214-218. 9. The Israeli Law for the Treatment of the Mentally Ill from 1991. In: Shazman H, Katz N, Oren H, editors. Care of the mentally ill. Tel Aviv: Dyunon Publishers, Tel Aviv University, 1999: pp. 279-301 (Hebrew). 10. Munitz H. The Israeli Law for the Treatment of the Mentally Ill. In: Munitz H, editor. Selected chapters in psychiatry. Tel Aviv: Papyrus Publishing House, Tel Aviv University, 2000: pp. 591-598 (Hebrew). 11. Leung WC. Why the professional-client ethic is inadequate in mental health care. Nurs Ethics 2002;9:51-60. 12. Beauchamp TL, Childress JF. Principles of biomedical ethics. 3rd ed. Oxford: Oxford University, 1989. 13. Breeze J. Can paternalism be justified in mental health care? J Adv Nurs 1997;28:260-265. 14. Balevre P. Is it legal to be crazy: An ethical dilemma. Arch Psychiatr Nurs 2001;15:241-244. 15. Fisher WA. Restraint and seclusion: A review of the literature. Am J Psychiatry 1994;151:1584-1591. 16. Gair DS. Guidelines for children and adolescents. In: Tardiff K, editor. The psychiatric uses of seclusion and restraint. Washington, DC: American Psychiatric Press, 1984: pp. 69-85. 17. Plutchik R, Karasu TB, Conte HR, Siegel B, Jerrett I. Toward a rationale for the seclusion process. J Nerv Ment Dis 1978;166:571-579. 18. Heyman E. Seclusion. J Psychosoc Nurs Ment Health Serv 1987;25:9-12. 19. Wadeson H, Carpenter WT. Impact of the seclusion room experience. J Nerv Ment Dis 1976;163:318-328. 20. Soliday SM. A comparison of patient and staff attitudes toward seclusion. J Nerv Ment Dis 1985;173:282-291. 21. Aschen SR. Restraints: Does position make a difference? Issues Ment Health Nurs 1995;16:87-92. 22. Martinez RJ, Grimm M, Adamson M. From the other side of the door: Patient views of seclusion. J Psychosoc Nurs Ment Health Serv 1999;37:13-22. 23. Meehan T, Vermeer C, Windsor C. Patients’ perceptions of seclusion: A qualitative investigation. J Adv Nurs 2000;31:370-377.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Abraham Rudnick

Commentary: Can Seclusion and Restraint be Person-Centered? Physical confinement – particularly seclusion and restraint – of people with mental illness is associated with a longstanding debate about coercion of these individuals for the sake of (protecting) others and themselves. Vishnivetsky et al. (1) report a study that examined what are some attitudes (and their predictors) of adolescents toward seclusion and physical restraint in an Israeli inpatient setting. Their main finding that participants preferred seclusion to physical restraint is important, primarily by raising more questions rather than providing definitive answers. For instance, how would such participants respond if given the option to generate effective alternatives to any form of coercion, be it physical confinement (such as the studied seclusion or physical restraint) or chemical restraint? This question may require a more qualitative data collection and analysis approach, such as using semi-structured individual interviews and focus groups. Furthermore, would such attitudes change per individual over time, both in the short term and in the long term (particularly considering the participants studied were adolescents, whose attitudes in general may change as they mature)? This question may require a longitudinal study design. And would such attitudes differ across cultures? This question may require a multi-site study design. Coercion in mental health care raises additional questions, such as ethical and political ones. Relevant policy makers to date have usually been people without formally identified (or at least publicly disclosed) mental illness; excluding people with mental illness from full participation in such policy making may risk ignoring some of their rights as well as their valuable input on strategies to provide mental health care while addressing the safety of all involved. Such participation can enhance a person-centered approach to mental health care (2), in line with the recent recovery movement’s influence on mental health reform, which is in progress in various countries (3-5). Being person-centered is both a (humanistic) end in itself and a means to other valued ends, such as more effective care; for instance, shared (health care) decision making with people who have mental illness can result in their enhanced adherence to beneficial treatment, although the benefits of shared

decision making for adherence to mental health care are less conclusive than in general medicine (6). A personcentered approach may mean various things; one way to address this complexity is to characterize a personcentered approach as a multi-dimensional construct, which may consist of self-determination as well as other ways of addressing a person’s needs when he or she cannot self-determine his or her needs in a fully capable manner (7). Using a multi-dimensional approach may facilitate and maintain respect for persons with mental illness while accommodating realistic constraints, such as legislation that defaults to coercion for safety and that may not change in the near future (recognizing that advocacy for more progressive legislation may be required in many jurisdictions). A person-centered approach that goes beyond selfdetermination addresses dimensions such as contextsensitivity, which refers to the person’s past and present circumstances and experiences, as well as his or her anticipated future circumstances and experiences and their likely alternatives when these are predictable (as they often are). This approach may facilitate the consideration of the person’s preferences even when that person is constrained internally as well as externally, resulting in mental health care planning and provision that is person-centered and realistic. When the person poses a significant safety risk to others or to him or herself, due to his or her mental illness, using such a person-centered approach may reduce if not eliminate the need for seclusion and restraint, particularly if this approach is used proactively and regularly. For instance, a person-centered approach may apply knowledge of past cognitive cuing and social support that helped a person with mental illness in order to reduce if not eliminate dangerous behavior. And when seclusion or restraint is considered necessary, it can be done in the least disruptive manner possible if it is informed by the person’s past, present and anticipated future, e.g., if the person was traumatized by men, his or her seclusion or restraint can be conducted by women staff as much as possible. Indeed, such person-centered mental health care planning is coming to the fore lately (8). Although robust data on the outcomes and processes 11

Commentary

of this approach are not yet available, particularly in relation to risk reduction and alternatives to seclusion and restraint, it can be considered promising, based on conceptual argumentation and emerging evidence. For instance, Multisensory environmental intervention (Snoezelen) has been shown to calm agitated patients and reduce the length of time and number of seclusions and restraints in an Israeli study (9), which may be particularly relevant to Vishnivetsky et al.’s report (1), as the latter was also conducted in Israel. More generally, a multitude of clinical and other interventions may be required as a sound alternative to seclusion and restraint. Such a multi-pronged approach may include state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare (10). Much of this involves advance planning, so some of it may not help in the short term, but in the long term it may reduce if not eliminate seclusion and restraint; after all, prevention is often more effective than treatment. Coercion may be applied to intents other than safety. For instance, some have argued that it applies to rehabilitation too (11). Psychiatric rehabilitation typically aims at assisting people with (usually serious) mental illness to establish and achieve their life goals (12). It has been counter-argued that psychiatric rehabilitation cannot involve coercion, as – by definition – life goals are personally determined and hence cannot involve coercion (13). A caveat may be when, by law, a person with mental illness may be deemed incapable to decide on his or her housing, which is the case in Ontario, Canada. Still, this situation may be related to safety (of maintaining activities of daily living required for survival, such as eating), in which case it does not refute the argument that psychiatric rehabilitation as such cannot involve coercion. Be that as it may, even when

safety is addressed, and even if coercion is deemed necessary, such as in situations that are still viewed by some as requiring seclusion and restraint, a person-centered approach may be applicable, using a multi-dimensional construct (7). Further theoretical and empirical study of this approach is needed. Acknowledgement/Disclosure: The author reports no relevant conflict of interests.

References 1. Vishnivetsky S, Shoval G, Leibovich V, Giner L, Mitrany M, Cohen D, Barzilay A, Volovick L, Weizman A, Zalsman G. Seclusion room vs. physical restraint in an adolescent inpatient setting: patients’ attitudes. Isr J Psychiatry 2013. 2. Rudnick A, Roe D (editors). Serious mental illness: person-centered approaches. London, Radcliffe, 2011. 3. Davidson L, Rowe M, Tondora J, O’Connell MJ, Staeheli Lawless M. A practice guide to recovery-oriented practice: Tools for transforming mental health care. New York, Oxford University Press, 2008. 4. Slade M. Personal recovery and mental illness: A guide for mental health professionals. Cambridge: Cambridge University Press, 2009. 5. Amering M, Schmolke M. Recovery in mental health: reshaping scientific and clinical responsibilities. Chichester: Wiley, 2009. 6. Thompson L, McCabe R. The effect of clinician-patient alliance and communication on treatment adherence in mental health care: A systematic review. BMC Psychiatry 2012; 12: 87. 7. Rudnick A, Roe D. Foundations and ethics of person-centered approaches to individuals with serious mental illness. In: Rudnick A, Roe D, editors. Serious mental illness: Person-centered approached. London: Radcliffe, 2011: pp. 8-18. 8. Hall A, Wren M, Kirby S. Care planning in mental health: Promoting recovery. Oxford: Wiley-Blackwell, 2008. 9. Teitelbaum A, Volpo S, Paran R, Zislin J, Drumer D, Raskin S, Katz G, Shlafman M, Gaber A, Durst R. Multisensory environmental intervention (snoezelen) as a preventive alternative to seclusion and restraint in closed psychiatric wards. Harefuah 2007; 146: 11-14. 10. Gaskin CJ, Elsom SJ, Happell B. Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. Br J Psychiatry 2007; 191: 298-303. 11. Siris SG, Bermanzohn PC. Two models of psychiatric rehabilitation: a need for clarity and integration. J Psychiatr Pract 2003; 9: 171-175. 12. Rudnick A. The goals of psychiatric rehabilitation: An ethical analysis. Psychiatric Rehab J 2002; 25: 310-313. 13. Rudnick A. Coercion and psychiatric rehabilitation: A conceptual and ethical analysis. BMC Psychiatry 2007; 7: S22.

Abraham Rudnick, MD, PhD, CPRP, FRCPC Associate Professor, Department of Psychiatry, University of British Columbia, Canada. harudnick@hotmail.com

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Yuval Melamed et al.

Voting of Hospitalized and Ambulatory Patients with Mental Disorders in Parliamentary Elections Yuval Melamed, MD, MHA, 1,2 Liora Donsky, MD,1 Igor Oyffe, MD,1 Sigalit Noam, RN, MA,1 Galit Levy, RN, MA,1 Marc Gelkopf, PhD,1,3 and Avi Bleich, MD, MPA1,2 1

Lev Hasharon Mental Health Center, Netanya, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 3 Department of Community Mental Health, University of Haifa, Haifa, Israel 2

Abstract The authors examined the voting rate among psychiatric inpatients and the voting rate of outpatients, in relation to the severity of their illness. On Election Day the number of inpatients that voted was recorded in one psychiatric hospital in Israel. For two weeks following the elections outpatients were asked if they voted: 100/271 (36.9%) inpatients and 131/181(72.4%) ambulatory patients voted; 53.8% of the inpatients and 4.7% of the ambulatory patients could not vote because they had no identity cards. Ambulatory patients with no prior hospitalizations had the highest voting rates. The most common reason for not voting among inpatients in Israel is lack of identity cards.

Background Participation of the mentally ill in parliamentary elections is an important and fundamental issue. The right to vote is a basic citizen’s right. Thus, the Law of Elections in Israel allows every citizen of Israel, age 18 or older, listed in the voting registry and physically present in Israel on Election Day, to vote. The law does not limit voting rights, and this differs for example from the United States where a large number of states limit the right to vote of the mentally ill (1). Prior to 1996, citizens could vote only in designated ballot boxes nearest their place of residence. This requirement prevented hospitalized individuals (in either general

or psychiatric hospitals) from exercising their right to vote. To the best of our knowledge, this law was not appealed and was not debated in Court. In 1996 the law was amended and the concept of mobile ballots in hospitals was introduced to enable physically and mentally ill patients to vote, while hospitalized (2). Accordingly a permanent ballot box is placed in every hospital, and larger hospitals also have a mobile ballot box. The mobile ballot passes through the various departments, but not among the beds. The patient must approach the ballot in order to vote, and if he is unable to do so physically or mentally, he cannot vote. Granting accessibility to the ballot for the mentally ill is a step forward in the process of returning the patients to the community, their empowerment and avoiding a marginal life (3). This process caused some public interest and gave rise to the question of the capacity of mentally ill to vote. There is an understanding that if the right to vote of the mentally ill is limited, it is a slippery slope. Who decides what the “sane” correct choice is? Even a mentally ill patient in a closed ward can make rational decisions regarding certain issues, and on the other hand, a healthy individual might make what some would consider irrational decisions. Literature on voting among the mentally ill is not extensive; however three areas should be considered when discussing the topic: mental capacity, importance of the issue to the individual and to society, and accessibility to the polls. In the United States, despite legal protections, persons with mental illness continue to experience difficulties that prevent them from voting in elections. Some states adopted methods to determine the mental capacity to vote. A 2001 Federal court decision offered “the Doe standard” which is clear criteria for determining voting capacity based on understanding the nature and effect

Address for Correspondence: Yuval Melamed MD, MHA, Deputy Director, Lev Hasharon Mental Health Center, POB 90000, Netanya 42100, Israel ymelamed@post.tau.ac.il

Voting of Hospitalized and Ambulatory Patients with Mental Disorders in Parliamentary Elections

of voting. The Doe standard was operationalized with the Competency Assessment Tool for Voting (CAT-V) along with measures of reasoning and appreciation (4). Regarding importance to the individual, independent decision making for issues that determine the political landscape and execution of rights on par with the healthy population is a significant therapeutic value (5). Concerning accessibility, in 1991 Dyer (6) performed a study on the subject of voting among mentally ill inpatients in England. He found that in 1984, only 6.3% (319) of the inpatient population (6,196 patients) in seven psychiatric hospitals were registered to vote. In 1987 the percentage of voters declined to 4.8%, and in two hospitals not even one patient registered to vote. In Israel, in a survey performed prior to the 1996 Parliamentary Elections, the voting patterns were examined in two departments in a psychiatric hospital. It was found that the distribution of votes was similar to that of the general population (7). The rate of participation of the mentally ill in elections was rather low (30% among psychiatric inpatients, compared to 79% in the general population) (8). In Israel today, most of the psychiatric hospitals have mobile ballot boxes that go through the various departments and remain in each department for about two hours. The departmental staff is responsible for making sure that the patients have identity cards and that they are aware of the elections and that they have the right to vote. In a previous study, in 2006, 38.6% of the inpatients participated in the elections (compared to 63.8% of the general population); 49(16%) more patients expressed the desire to vote, but due to technical reasons were not able to vote (45 patients did not have identity cards). Most of the patients who voted expressed positive feelings, after participating in the voting process, and patients who did not vote expressed anger concerning their hospitalization, and some expressed paranoid thoughts such as â&#x20AC;&#x153;at any rate they will throw out our votesâ&#x20AC;? (9). Thus there was difficulty in voting at the stationary ballot box. Following that study, for the next elections (2009) two ballot boxes were placed in the hospital, one stationary and one mobile. Aim of the Study

1. To examine the rate of voting among inpatients at Lev Hasharon Mental Health Center, in comparison to the 2006 elections, after introduction of the mobile ballot. 2. To examine the rate of voting of the mentally ill who live in the community and are treated in the hospital clinic, in relation to the severity of their illness. 14

The study was approved by the Internal Review Board of Lev Hasharon Mental Health Center. Methods On Election Day (2009) the number of patients in each department and the number of patients who requested leave to vote in the polls in their place of residence was recorded. Sample - eligible voters in Lev Hasharon Mental Health Center and among patients who attended the Lev Hasharon Outpatient Clinic during the two weeks following the elections. All participants provided written informed consent for participation in the study. Throughout the two weeks following the elections the number of patients who visited the outpatient clinic was recorded by nurses appointed to the task. The patients completed a two question self-report form. The first question was whether or not they had voted in the elections. The patients who had not voted were then asked the reason for not voting (in an open question). The patients who had voted were asked to respond to a multiple choice question about how they felt after voting (proud, belonging, responsible, no special feeling). Results Inpatients

On Election Day there were 271 patients in the hospital. Seventy-nine patients voted in the hospital and twentyone patients voted in the polls near their homes. That is, 36.9% of the total number of inpatients voted (a rate similar to the previous elections that was 38.6%). Voter turnout in the general population was 64.7%. One hundred forty-six patients (53.8%) indicated that they had wanted to vote, but did not. Seventy-three patients (26.9%) did not have identity cards and could therefore not vote. Sixty-five patients (23.9%) were in unstable mental states that precluded their capacity to vote; 7 (2.5%) patients boycotted the elections, and one patient (0.3%) had been transferred to a general hospital due to physical illness. Twenty-five (9.2%) of the inpatients reported that they were not interested in voting. Ambulatory patients

During the study period 316 patients attended the outpatient clinic. For technical reasons, the investigators did not succeed in approaching all patients who attended the clinic. They did not record the number of the patients that refused to participate in the study. Only Israeli citizens age

Yuval Melamed et al.

18 or older who were eligible to vote were approached. Among the ambulatory patients, 181 patients completed the two question study questionnaire. Of them, 131 patients (72.4%) voted in the elections; 92.8% of them reported that they had voted in previous elections. Among the patients who did not vote the most common reasons for not voting were: 1. There was no suitable candidate (32.6%). 2. 20.9% did not feel well. 3. 18.6% were not interested in politics. Only two patients (4.7%) reported that they had not voted because they did not have identification cards. Most of the patients who voted (84.7%) reported that they voted because they felt a sense of responsibility and belonging to the community. Ambulatory patients with no prior hospitalizations revealed a higher rate of voting than those with previous hospitalizations (89.7% vs. 67.6%, respectively). Similarly, a difference was found between the rate of voters among patients classified as suffering from a severe psychiatric disorder (schizophrenia, psychotic disorder, affective disorder) in comparison with patients classified as suffering from a mild psychiatric disorder (all other psychiatric disorders) (70% vs. 89.3%, respectively). Comparison between inpatients and ambulatory patients revealed: 1. The voting rate was higher among ambulatory patients than among inpatients. 2. The patients who according to our definition suffer from severe psychiatric disorder (schizophrenia, psychotic disorder, affective disorder) or who were previously hospitalized had a lower voting rate than other patients, but a higher rate than inpatients. 3. Among inpatients there was a high rate of patients with no identification cards. Though we cannot conclude that they did not vote precisely for that reason, there is no doubt that the lack of identification cards prevents them from voting. 4. Among ambulatory patients the rate of patients that did not vote because they did not have identification cards was negligible. Discussion The right to vote is a basic democratic right that can be denied only in rare cases. Limiting the right to vote of handicapped individuals might result in a slippery slope argument that might not be possible to stop. If it were determined, for example, that hospitalized patients with schizophrenia cannot vote, what about the individual with

schizophrenia who is not in hospital? What about a patient in remission as compared to a patient in exacerbation or an individual living in the community who is ill but was never diagnosed? Thus the accepted approach is to enable every citizen to vote. As we have seen in our study self limitations are imposed concerning voting. Only 36% of the inpatients voted, as compared to 64% of the general population. Compared to previous parliamentary elections the introduction of a mobile ballot to our hospital did not improve the voting rate. Israeli law requires every Israeli citizen above the age of 16 to carry an identification card called te’udat zehut in Hebrew or biþāqat huwîya in Arabic (Law for carrying and presenting an Identity Card, 5743-1982, http:// www.fridmanwork.com/X6086.html). Application for an identification card is made at the Ministry of Interior closest to the citizen’s place of residence. Required items for a new Israel identity card include: 1.Valid document of identification including a photo (Israeli passport, immigrant identity card, military ID, or Israeli marriage certificate), 2.Two identical passport-size photos, 3.110 NIS, 4.Completed identification card request form, 5. Declaration of a lost identification card . Prior to elections the hospital staff contacted the families of patients who had no Israeli identification cards to see if the cards existed. The patients who had not voted because they did not have cards did not have cards at home or at the hospital. Thus, it should be noted that as far as the patients are concerned it can be assumed that the problem is not merely technical, but rather is related to the fact that many patients did not have the required identity cards, which testifies to their lack of social involvement, indifference, fear of the establishment and so forth. Among the inpatients, the relatively low rate of voting among the mentally ill indicates a fundamental problem. Perhaps it is an expression of lack of interest, hostility, inability or lack of desire to influence or a marginalized existence. Compared to the inpatient voter turnout in the 2006 parliamentary elections in Israel, the mobile ballot box did not significantly increase the rate of voting among inpatients (10). Thus, the technical difficulty of leaving the department was not the problem that affected voting. However, while only two ambulatory patients did not have identity cards, more than one quarter of the inpatients could not vote because they did not have identity cards. This is a technicality typical to inpatients that can be overcome with the active intervention of the therapists. Indeed, following this study, the hospital staff initiated a project to remedy the 15

Voting of Hospitalized and Ambulatory Patients with Mental Disorders in Parliamentary Elections

situation by assisting the patients with the technical difficulties involved in attaining identity cards. The finding that the most common reason for not voting among inpatients was lack of identity cards, which was not a limiting factor for outpatients, emphasizes the need to empower inpatients by helping them get identity cards so that they can exercise their civil rights to participate in the electoral process. Limitations of the study

The study took place in one hospital and does not necessarily represent the entire population of individuals with mental disorders. However, it sheds light and encourages discussion and awareness of this important subject. References 1. Appelbaum PS. “I vote. I Count”: Mental disability and the right to vote. Psychiatr Serv 2000; 51: 849-850, 863.

2. Instructions for elections - voting procedures and instructions regarding voting in hospitals –1996: http://www.knesset.gov.il/elections18/heb/ law/HospitalVotes.pdf). 3. Nash M. Voting as a means of social inclusion for people with a mental illness. J Psychiatr Ment Health Nurs 2002; 9: 697-703. 4. Raad R, Karlawish J, Appelbaum PS. The capacity to vote of persons with serious mental illness. Psychiatr Serv 2009;60:624-628. 5. Duckworth K, Kingsbury SJ, Kass N, Goisman R, Wellington C, Etheridge M. Voting behavior and attitudes of chronic mentally ill outpatients. Hosp Community Psychiatry 1994;45:608-609. 6. Dyer L. Citizens’ rights v voting wrongs. Health Serv J 1991;15:101, 22-23. 7. Melamed Y, Nehama Y, Elizur A. Hospitalized mentally ill patients voting in Israel. J Forensic Psychiatry 2000;11:691-695. 8. Melamed Y, Shamir E, Solomon Z, Elizur A. Hospitalized mentally ill patients in Israel vote for the first time. Isr J Psychiatry Relat Sci 1997; 34: 69-72. 9. Melamed Y, Solomon Z, Elizur A. Voting by Israeli patients. Psychiatr Serv 1997; 48: 1081. 10. Melamed Y, Doron A, Finkel B, Kurs R, Behrbalk P, Noam S, Gelkopf M, Bleich A. Israeli psychiatric inpatients go to the polls. J Nerv Ment Dis 2007;195:705-708.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Ariel Gaon et al.

Dissociative Symptoms as a Consequence of Traumatic Experiences: The Long-term Effects of Childhood Sexual Abuse Ariel Gaon, MD, 1,2 Zeev Kaplan, MD, 1,2 Tzvi Dwolatzky, MBBCh, 1,2 Zvi Perry, MD, 2 and Eliezer Witztum, MD 1,2 1

Mental Health Center, Beersheva, Israel Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel

Abstract Background: The purpose of this study was to assess the prevalence of dissociative symptoms and post-traumatic experiences in an ambulatory setting. Method: The study was conducted in the ambulatory outpatient clinic of the Beersheva Mental Health Center. Over a period of six months new patients over 18 years of age were asked to participate in this survey. Patients completed questionnaires including the Dissociative Experience Scale, Trauma History Questionnaire, Impact of Event Scale, and Post-Traumatic Diagnostic Scale. Results: A total of 505 patients were enrolled in the study, and 456 completed questionnaires were analyzed. Of these, 442 (97%) participants reported at least one traumatic event during their lifetime. The traumatic events were experienced as meaningful and severe at the time of occurrence. The effects of sexual and childhood emotional abuse remained very intense throughout the victimâ&#x20AC;&#x2122;s life and were viewed as powerful, significant experiences. On the other hand, traumatic experiences such as natural disasters and battle trauma were associated with longterm effects of relatively low intensity. Conclusions: The presence of undiagnosed posttraumatic stress disorder (PTSD) among patients in outpatient mental health clinics suggests that screening and diagnostic procedures for this condition be more carefully defined. Our most important finding is the large impact of childhood trauma, especially sexual abuse, on later life. Thus the prevention, early detection and treatment of child abuse in preventing long term psychopathology must be emphasized.

INTRODUCTION Numerous studies have shown that dissociative and post-traumatic phenomena are much more common than previously believed (1). Most studies have evaluated either inpatients (2-4) or community samples (5-7). The few studies specifically evaluating an ambulatory clinic population have revealed that a large percentage of these patients had experienced various traumatic events (1). Of interest is that therapists were often unaware of these prior traumatic experiences and thus no therapeutic measures had been initiated. The only previous study examining this subject in Israel was performed in a mental health clinic in Jerusalem, where the authors found a relatively high rate of posttraumatic and dissociative phenomena (8). Studies in other countries have found a link between childhood and adult traumatic experiences and the existence of post-traumatic and dissociative phenomena (9-11). The diagnostic criteria of dissociative disorders include a disturbance or change in memory function, identity or consciousness. These functions are normally integrative. The disorder may begin either suddenly or gradually, and may be transient or chronic. Dissociation can be expressed as five different symptom groups: amnesia, de-personalization, de-realization, mixed identity and identity fragmentation. The most extreme form of the disorder is dissociative identity disorder. Over a century ago in 1889, Pierre Janet defined the term dissociation as a situation where certain functions and ideas are removed from conscious supervision and occasionally out of conscious awareness. These functions and ideas can include systems of sensory images, feeling, emotions, thoughts and physical phenomena (12). Janet saw dissociation as a psychopathological process.

Address for Correspondence: Tzvi Dwolatzky, MBBCh, Department of Geriatrics and Memory Clinic, Mental Health Center, POB 4600, Beersheva 84170, Israel. â&#x20AC;&#x2020; tzvidov@bgu.ac.il

Dissociative Symptoms as a Consequence of Traumatic Experiences

However, the neo-dissociative theories point to the routine nature of dissociation in everyday life (13). Hilgard views dissociation as a continuum, ranging from normal to pathological, with dissociation regarded as pathological only when the dissociated experience interferes with the personâ&#x20AC;&#x2122;s normal level of function (14). Many authors and researchers at the beginning of the twentieth century have established that there is an association between dissociative phenomena and the existence of traumatic events in the personâ&#x20AC;&#x2122;s life (12, 15, 16). Research performed over the past two decades has confirmed that traumatic events resulting from both manmade and natural disasters may cause not only emotional, biological, behavioral and inter-relationship changes but also dissociative symptoms (17, 18). A number of explanations for this renewed interest in dissociation and trauma have been proposed (19), including the acceptance of post-traumatic stress disorder (PTSD) as a specific diagnostic entity, and a greater awareness of the effect of early life traumatic events on dissociative disorders. It is important to note that until recently post-traumatic and dissociative disorders were usually researched separately. Most researchers tended to investigate PTSD as it related to a single traumatic event, and dissociative disorders as resulting from long lasting early onset childhood trauma (20-22). Today, an increasing number of researchers consider these disorders to be related, with dissociative symptoms being a part of the range of posttraumatic responses, and dissociative disorder being a central feature of chronic post-traumatic disorders. However, this assumption has not yet been confirmed by comprehensive research. Research has established that dissociative and posttraumatic disorders are much more common than previously assumed (13, 21, 23). Ross et al. found that 8% of the population in general had significant dissociative symptoms and that 5% have a possible dissociative disorder (24). Chu and Dill found that 25 of 100 (25%) hospitalized psychiatric patients showed significant dissociative symptoms (25). Graves conducted one of only two studies evaluating ambulatory clinical populations (26). Although his study has methodological limitations it is still noteworthy that more than 20% of those studied had dissociative symptoms. A study conducted in the Netherlands (27) showed similar results. In the only study to date performed in Israel designed to determine the extent of PTSD in a clinical ambulatory population, Brom and Witztum found that 30% of the subjects reported some kind of trauma in the two years prior to the research (20). Significant post-traumatic 18

symptoms were found that could justify a diagnosis of post-traumatic disorder. These findings were similar to those of Davidson and Smith who studied a similar group of patients in the U.S.A. (28). The importance of a proper diagnosis is crucial for patients suffering from a dissociative or post-traumatic condition. Accuracy in diagnosing PTSD is essential in order for the patient to get appropriate treatment without delay (20, 26, 29, 30). In order to prevent incorrect diagnoses, clinicians must become more aware of the nature and frequency of these phenomena. We believe that it is particularly important to study these disorders in Israel, where the exposure to potentially traumatic events, especially those related to conflict, is more common than in most Western societies. As described above, research has shown that PTSD symptoms are relatively common in Western societies and we can thus expect to find at least a similar level of PTSD is Israel. Differences in prevalence, if present, will be of considerable interest and will demand a more comprehensive evaluation of the possible causative factors. Also, by increasing awareness among clinicians it may be possible to achieve more precise diagnoses and this should lead to the improved treatment of patients suffering from dissociative disorders and PTSD. The aim of our study was to determine the prevalence of dissociative and post-traumatic phenomena in an adult ambulatory population in Israel. We also aimed to evaluate to what extent the existence of post-traumatic and dissociative phenomena correlate with a history of traumatic events during the lives of patients. METHODS The study was performed at the adult outpatient clinic of the Mental Health Center in Beersheva in the southern district of Israel. The majority of residents in this area are immigrant Jews from western and North African countries, as well as from the former Soviet Union. The study was approved by the ethics committee of the Soroka Medical Center and the patients provided written informed consent for participation in the study. PARTICIPANTS The research population included males and females older than 18 years of age seeking treatment at the clinic over a period of six months. All subjects underwent a full psychiatric evaluation. A total of 505 patients agreed to participate in the study. Of these, 49 were excluded for

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the following reasons: two patients were diagnosed as having mild mental retardation, seven were diagnosed as suffering from organic disorders, 13 suffered from an acute psychotic condition during the interview and were unable to concentrate and complete the questionnaires, 21 participants filled out the questionnaires incorrectly probably due to misunderstanding the instructions, and six patients using illicit drugs were excluded. Thus 456 patients were included in the study. MEASURES Dissociative symptoms. We evaluated the presence of dissociative symptoms by means of the Dissociative Experience Scale (DES). This instrument is a self report questionnaire developed by Bernstein and Putnam and measures the intensity of dissociative experiences in clinical and normal populations (31). The DES has 28 items, describing various dissociative symptoms. The respondents are instructed to indicate to what degree and frequency they have experienced each symptom. The score is the mean rating of all 28 items. The DES is not considered to be diagnostic but rather a screening tool. A score of 20 and over is considered to represent the clinical threshold for dissociative disorder. Scores of 30 and over are usually considered to be highly indicative of dissociative disorder (29). A number of studies have shown this scale to have a very high level of validity (23, 24, 26, 31, 32). Traumatic experiences. The presence of previous traumatic experiences was determined by means of the Trauma History Questionnaire (THQ), which has been validated in many clinical situations (33). It consists of 24 items addressing a range of trauma events in three areas: crime-related events (e.g., robbery, mugging), general disaster and trauma (e.g., injury, disaster, witnessing death), and unwanted physical and sexual experiences. For each item, the subject indicates whether or not he or she experienced it, and if so, the number of times and approximate age of occurrence. For the sexual and physical abuse questions, the subject is asked whether the experience was repeated, and if so, approximately how often and at what age. The questionnaire differentiates between a single traumatic event and continuous trauma, and the degree of trauma is classified from mild to severe. The use of the THQ has been described previously in an ambulatory population (8). Post-traumatic symptoms. The presence and level of post-traumatic symptoms was measured using the Impact Of Event Scale (IOES), which consists of 15 items com-

prising three scores, namely an intrusion score, avoidance score and total score (34). This is a sensitive tool that specifically assesses ways of responding to harsh events. The scale was found to be reliable and valid (20). Post-traumatic stress disorder. The likelihood of possible PTSD was determined using the Post-traumatic Diagnostic Scale (PDS) (35). This is a new version of the original PTSD symptoms self report scale (PDS-S). Unlike other self report questionnaires the PDS accords with DSM-IV criteria for PTSD and also measures the intensity of post-traumatic symptoms. The scale has high sensitivity. The PDS consists of three parts: the first being a list of traumatic events, including information on event background, nature and intensity; the second refers to the DSM-IV-R symptoms required to diagnose PTSD; the third part contains questions regarding the traumatic event and its influence on function over the past month. DATA ANALYSIS Data analysis was performed using the SPSS11.0 for windows software. Descriptive statistics were calculated for the sample, followed by single variable data analysis (T- test, non-parametric tests) and finally regression and correlation analyses were performed. RESULTS Table 1 presents the demographic characteristics of the sample. A total of 456 patients were studied, of whom 50.2% were men. Mean age was 40.05 years (SD 12.21; range 18-76). The geographical region of origin of the patients was the Middle East and northern Africa (48.0%), the former Soviet Union (33.8%), South America (9.0%), Asia (1.5%) and other regions (7.7%). With regard to the degree of religious observance, 59.4% described themselves as secular and 13.4% as religiously observant. The psychiatric diagnoses of the subjects were predominantly affective disorders (24.3%), psychotic disorders (31.6%), anxiety disorder (18.9%) and PTSD (6.6%) (Table 1). The diagnoses were obtained from the patientsâ&#x20AC;&#x2122; medical records. Of the subjects, 442 (97%) reported at least one traumatic event during their life time (Table 2). The effects of sexual and childhood emotional abuse remained very intense throughout the victimâ&#x20AC;&#x2122;s life and were viewed as powerful, significant experiences. On the other hand, traumatic experiences such as natural disasters and battle trauma were associated with long-term effects of relatively low intensity. A negative correlation was 19

Dissociative Symptoms as a Consequence of Traumatic Experiences

Table1. Demographic characteristics of the sample (n=456) Variables Age

Gender

Area of origin

Diagnoses

Frequency

Table 2. Number (%) of subjects reporting a moderate to severe effect of traumatic events (n=456)

Mean age (years) 40.05 Standard deviation 12.21 Range 18-76

Event frequency

Effect at time of event

Effect current

Prolonged effectb

Natural disasters

116 (25.4)

54 (11.8)

17 (3.7)

14.7

Car accident

155 (34.0)

97 (21.3)

54 (11.8)

34.8

Holocaust survivors

9 (2.0)

5 (1.1)

3 (0.6)

33.3

Independence Day War

18 (3.9)

3 (0.6)

16.7

Sinai War (1952)

28 (6.1)

3 (0.6)

2 (0.4)

7.1

Six Day War (1967)

92 (20.2)

18 (3.9)

5 (1.1)

5.4

Kippur Day War

154 (33.8)

48 (7.5)

11 (2.4)

7.1

Lebanon War

140 (30.7)

46 (32.8)

13 (9.5)

9.3

Gulf War

282 (61.8)

87 (19.1)

25 (5.5)

8.9

Sexual Abuse Under age 16 Over age 16

85 (18.6) 57 (13.0) 45 (9.9)

58 (12.7) 48 (10.6) 38 (8.3)

49 (10.7) 35 (7.9) 22 (4.9)

59 61.4 48.9

Childhood Emotional Abuse

132 (28.9)

110 (22.4)

71 (15.6)

53.8

Physical Abuse

51 (11.2)

39 (8.6)

19 (4.1)

37.3

Terror Victim

20 (4.4)

16 (3.5)

7 (1.6)

Robbery Victim

92 (20.2)

67 (30.3)

28 (6.1)

30.4

Type of traumaa 229 217 10

Male Female Missing data

50.2 47.6 2.2

Former USSR Middle East/ Northern Africa South America Asia Other Missing data

154 219 41 7 29 6

33.8 48.0 9.0 1.5 6.4 1.3

Affective Disorder Major Depression Bipolar Disorder Psychotic Disorder Anxiety Disorder (Excluding PTSD) PTSD Borderline Personality Disorder Other Personality Disorder Other Psychiatric Disorder Diagnosis not determined

111 79 32 144 86 30 14 24 10 37

24.3 17.3 7.0 31.6 18.9 6.6 3.1 5.3 2.1 8.1

271 61 10 114

59.4 13.4 2.2 25

Religiosity Secular Observant Other Missing Information

Abbreviations. PTSD: Post-Traumatic Stress Disorder

found between the age of occurrence of the traumatic event and the duration of the influence of this event for those reporting early emotional neglect (r=-0.506, p<0.001). Regarding early physical neglect, there was a positive correlation between the intensity of the traumatic experience at the time of occurrence and its influence at the time of the interview (r = 0.451, p<0.001). Also, a negative correlation was found between the age of

Subjects may have multiple traumatic events % of those with event reporting a moderate to severe effect at the time of the study a

exposure to physical neglect and its influence (r=-0.675, p<0.001), indicating that the earlier the physical neglect the greater the traumatic influence on the person. We found a correlation between the IOES and the level of influence at the time of the event (r=0.492, p<0.001) and currently (r=0.490, p<0.001), suggesting that the more intrusive the symptoms, the more significant the impact at both time periods. Of the 456 patients who participated, 363 completed the DES questionnaire adequately (Table 3). As mentioned previously, a score of 20 is regarded as the threshold sug-

Table 3. Comparison of DES scores, grouped by diagnosis, between this study and previous studies This study

Brom et al (20)

Putnam et al (13)

Diagnosis

Subjects (N)

Mean DES score (SD)

Subjects (N)

Mean DES score (SD)

Subjects (N)

Mean DES score (SD)

Affective Disorder

111

11 (10)

11.6 (11.8)

103

13.2 (12.6)

Psychotic Disorder

144

13 (13)

18.7 (18.1)

17.6 (16.0)

Anxiety Disorder

11 (10)

11.6 (11.8)

11.0 (10.2)

PTSD

20 (18)

22.7 (33.0)

116

31.5 (18.3)

Abbreviations. DES: Dissociative Experience Scale; PTSD: Post-Traumatic Stress Disorder

Ariel Gaon et al.

gesting the need for a more comprehensive examination in order to ascertain whether the person suffers from a dissociative disorder, and scores of 30 or more are usually considered strongly indicative of dissociative disorder (29). Based on these values a total of 283 respondents (78%) reported no apparent dissociative disorder. DES score was consistent with a possible dissociative disorder in 46 respondents (12.7%), and in 34 (9.3%) a clinical dissociative disorder was likely. Clear differences in intensity of dissociation were found for the different diagnostic groups. For those 21 participants with a diagnosis of PTSD, 10 (47.6%) had a DES level over 20. Among the anxiety disorder group only 14 of 75 (18.7%) had scores over 20. In addition, only 15 (16%) of subjects with affective disorder had scores over 20. Some 27 out of the 115 subjects (23.5%) diagnosed as suffering from psychotic disorder showed DES scores over 20. For all diagnostic groups a correlation was found between the DES index and the exposure index at the time of the trauma (r=0.454, p<0.001) which signifies an association between the level of influence of the childhood traumatic event and the degree of dissociation. A comparison of the DES scores in this study to those of previously published studies is presented in Table 3. There were no significant differences in the presence of post-traumatic symptoms between males and females. Based on the IOES, 179 of 324 (55.2%) subjects who completed the questionnaire rated the impact of the traumatic event as moderate to severe. According to diagnostic groups, a rating of moderate to severe impact was found in 43 of 84 (51.2%) with affective disorder, in 42 of 92 (45.7%) with psychotic disorder, in 66 of 97 (68%) with anxiety disorder, and in 17 of 32 (53.1%) with personality disorder. It is important to emphasize that no significant correlation was found between DES questionnaire results and that of the IOES questionnaire. This indicates that dissociative symptoms are not clearly associated with higher trauma scores. We used a regression model to examine the relationship between full and subscale IOES scores and traumatic experiences. We found a positive correlation between losing a child and the re-experience index in the IOES questionnaire (r=0.455, p<0.001). For losing a child the correlation between the influence of the event at the time of occurrence and the time of interview was significant (r=0.505, p<0.001). There was a positive correlation between battle trauma and DES results (r=-0.565, p<0.001). The PDS questionnaire was completed by only 79 participants due mainly to language limitations (the PDS

was not available in either Russian or Spanish) and to the fact that many participants claimed that the questions were not relevant to them. Also, since the PDS is relatively long and complicated and demands more language skills than the other scales the subjects were more reluctant to complete this questionnaire. Of those completing the PDS, 17.7% suffered from affective disorders, 19% were diagnosed as suffering from psychotic disorder; 25.3% of the applicants were diagnosed as anxiety disorders (not including PTSD) and 20.3% had been diagnosed as PTSD. Overall, the PDS score was consistent with a diagnosis of PTSD in 44 (55.7%) patients. Of note is that in four of 16 (25%) of those with a diagnosis of PTSD the PDS did not support this diagnosis. Among the participants of the study, 83 (18.9%) reported being subject to sexual abuse. The frequency of reported sexual abuse according to psychiatric diagnosis is reported in Table 4. The age at which the sexual abuse first occurred is significant, with 57 (67%) being under the age of 16 at the time of the abuse (Table 2). Patients reported that sexual abuse continued to exert moderate to severe effects on them over the long term. As many as 35 of 57 (61.4%) of those where the abuse occurred under the age of 16 years reported that the abuse continued to effect them. Sexual abuse was much more common in female respondents, reported by 28.1% women compared to 10.5% men. We found a positive correlation between sexual abuse by a close relative and its influence both at the time of the event (r = 0.501, p=0.676) and at the time of completing the questionnaire (r =0.700, p<0.001). We also found a positive correlation between sexual abuse as adults and its influence at the time of completing the questionnaire (r = 0.426, p<0.001). There were several predictors of sexual abuse, including female sex, prior Table 4. Number (%) of each diagnostic group responding regarding sexual abuse (n=438) Diagnosis

No sexual abuse

Sexual abuse

Major depression

62 (78.5)

17 (21.5)

Psychotic disorder

116 (80.6)

28 (19.4)

Bipolar disorder

26 (81.2)

6 (18.8)

Anxiety disorder

72 (83.7)

14 (16.3)

PTSD

29 (96.7)

1 (3.3)

Personality disorder

19 (79.2)

5 (20.8)

Borderline personality disorder

8 (57.1)

6 (42.9)

Other

23 (79.3)

6 (20.7)

Abbreviations. PTSD: Post Traumatic Stress Disorder

Dissociative Symptoms as a Consequence of Traumatic Experiences

arrests, family violence, emotional neglect, experience of war in other countries, and exposure to prior criminal violence. DISCUSSION We found that as many as 97% of patients in an outpatient clinic of a psychiatric hospital reported a traumatic event during their lifetime. Our results are consistent with those of another study based in a community mental health clinic in Jerusalem (8), where 95% of the participants reported a traumatic event. Similar results have been reported in other countries. For example, Mueser et al. found that among mental health clinic patients, 98% of the participants reported a traumatic event (36). In a mental health clinic in South Carolina, 91% of participants reported a traumatic event (37). The type of trauma differs between countries and settings, possibly related to diverse social and political conditions. For example, in areas with harsh economic realities, there is a higher incidence of criminal traumatic events (37, 38). In Israel, the exposure to potentially traumatic events, especially those related to conflict, is more common than in most Western societies. In our study population, it was found that the most common traumatic experiences were wars, followed by car accidents, natural disasters, and emotional or sexual abuse. An important issue is whether traumatic events continue to effect people over time. This study provides important information in clarifying this issue. We found that sexual abuse in childhood had very clear long-term effects, as did childhood emotional abuse. These forms of trauma have a lasting intensity and influence on the patient. This suggests that the younger the exposure to trauma the more lasting the effects of the traumatic experience. This was also supported by finding a correlation between the IOES questionnaire and the strength of impact at the time of exposure to trauma. The prolonged effects of childhood traumatic events, including physical neglect, emotional neglect and sexual abuse, are possibly related to these events occurring during the stages of early development. The long-term effects of abuse at a young age may have other consequences, such as a higher risk of addictions (39, 40), a higher risk of sexual abuse (41), changes in hormonal and physical reactions, and a reduction in hippocampal volume (42, 43). Behavior and personality are also affected, subjects may be more prone to mental illness (44, 45) and experience a reduction in quality of life. Thus, the negative effects of childhood abuse on adult psychopathology 22

should not be ignored (46), and a high index of suspicion of abuse in early life should be adopted by professionals. We found that 30 subjects (6.6%) of the total sample had a diagnosis of PTSD. This percentage is similar to that found in other studies carried out in clinical populations. A further 8% were found to have PTSD according to the PDS questionnaire, with the diagnosis confirmed according to DSM-IV-R criteria. The finding that almost 15% of the participants in the study suffered from PTSD is comparable to the finding of other studies, suggesting that PTSD in mental health clinic populations is more common than usually reported. Also, the IOES scale was high in 35% of the participants, indicating the existence of post-traumatic stress symptoms (47). It is important to note that high results on the IOES index are associated with a high DES score and that high scores on the IOES questionnaire suggest PTSD. However, high scores on the DES questionnaire for dissociative symptoms are not necessarily associated with PTSD. There are some limitations to this study. The assessment of traumatic events and dissociative symptoms was based on self-administered questionnaires. The use of a clinical interview in a randomized sample of our subjects to confirm accurate reporting was not performed. However, all the questionnaires used are validated and acceptable scales. While our patient population was heterogeneous from many countries of origin and speaking many languages, this also limited our ability to use the PDS questionnaire, which was not available in Russian and Spanish. Another limitation was that a number of the participants did not manage to complete all the questionnaires, since the large number of questions was quite demanding and time consuming. In spite of these limitations the study has clear benefits, examining a relatively large number of patients from various countries of origin over a wide range of ages. CONCLUSIONS The study has a number of important repercussions on future research. The presence of undiagnosed PTSD among patients in outpatient mental health clinics suggests that screening and diagnostic procedures for this condition should be more carefully defined. Since many of the participants in our study found it easier to describe their traumatic events in a questionnaire than in an interview, the option of the use of questionnaires in clinical settings should be examined further. Our most important finding is the large impact of childhood trauma, especially sexual abuse, on later life. Thus the prevention,

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early detection and treatment of child abuse in preventing long term psychopathology must be emphasized. References 1. Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D. Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry 2006; 163: 623-629. 2. Friedl MC, Draijer N. Dissociative disorders in Dutch psychiatric inpatients. Am J Psychiatry 2000; 157: 1012-1013. 3. Friedl MC, Draijer N, de Jonge P. Prevalence of dissociative disorders in psychiatric in-patients: The impact of study characteristics. Acta Psychiatr Scand 2000; 102: 423-428. 4. Gast U, Rodewald F, Nickel V, Emrich HM. Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic. J Nerv Ment Dis 2001; 189: 249-257. 5. Johnson JG, Cohen P, Kasen S, Brook JS. Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res 2006; 40: 131-140. 6. Korfine L, Hooley JM. Detecting individuals with borderline personality disorder in the community: An ascertainment strategy and comparison with a hospital sample. J Pers Disord 2009; 23: 62-75. 7. Sar V, Akyuz G, Dogan O. Prevalence of dissociative disorders among women in the general population. Psychiatry Res 2007; 149: 169-176. 8. Dominguez DV, Cohen M, Brom D. Trauma and dissociation in psychiatric outpatients. Isr J Psychiatry Relat Sci 2004; 41: 98-110. 9. Sar V, Islam S, Ozturk E. Childhood emotional abuse and dissociation in patients with conversion symptoms. Psychiatry Clin Neurosci 2009; 63: 670-677. 10. Tamar-Gurol D, Sar V, Karadag F, Evren C, Karagoz M. Childhood emotional abuse, dissociation, and suicidality among patients with drug dependency in Turkey. Psychiatry Clin Neurosci 2008; 62: 540-547. 11. Watson S, Chilton R, Fairchild H, Whewell P. Association between childhood trauma and dissociation among patients with borderline personality disorder. Aust N Z J Psychiatry 2006; 40: 478-481. 12. van der Kolk BA, van der Hart O. Pierre Janet and the breakdown of adaptation in psychological trauma. Am J Psychiatry 1989; 146: 1530-1540. 13. Putnam F. Diagnosis and treatment of multiple personality disorder. New York: Guilford, 1989. 14. Hilgard ER. Divided consciousness multiple controls in human thought and action. New York: Wiley, 1977. 15. Taylor E. William James on exceptional mental states. Amherst: University of Massachusetts, 1984. 16. Prince M. Hysteria from the point of view of dissociated personality. J Abnorm Psychol 1906-1907; 1: 170-187. 17. Spiegel D. Recognizing traumatic dissociation. Am J Psychiatry 2006; 163: 566-568. 18. Spiegel D. Multiple personality as a post-traumatic stress disorder. Psychiatr Clin North Am 1984; 7: 101-110. 19. Spiegel D, Cardena E. Disintegrated experience: The dissociative disorders revisited. J Abnorm Psychol 1991; 100: 366-378. 20. Brom D, Witztum E. Recent trauma in psychiatric outpatients. Am J Orthopsychiatry 1992; 62: 545-551. 21. Ross CA. Epidemiology of multiple personality disorder and dissociation. Psychiatr Clin North Am 1991; 14: 503-517. 22. Walker EA, Katon WJ, Neraas K, Jemelka RP, Massoth D. Dissociation in women with chronic pelvic pain. Am J Psychiatry 1992; 149: 534-537. 23. Ross CA, Heber S, Norton GR, Anderson G. Somatic symptoms in multiple personality disorder. Psychosomatics 1989; 30: 154-160. 24. Ross CA, Joshi S, Currie R. Dissociative experiences in the general population. Am J Psychiatry 1990; 147: 1547-1552.

25. Chu JA, Dill DL. Dissociative symptoms in relation to childhood physical and sexual abuse. Am J Psychiatry 1990; 147: 887-892. 26. Graves SM. Dissociative disorders and dissociative symptoms at a community health center. Dissociation 1989; 3: 119-127. 27. Nijenhuis ER, Spinhoven P, van Dyck R, van der Hart O, Vanderlinden J. Degree of somatoform and psychological dissociation in dissociative disorder is correlated with reported trauma. J Trauma Stress 1998; 11: 711-730. 28. Davidson J, Smith R. Traumatic experiences in psychiatric outpatients. J Trauma Stress 1990; 3: 459-475. 29. Steinberg M, Rounsaville B, Cicchetti DV. The Structured Clinical Interview for DSM-III-R Dissociative Disorders: Preliminary report on a new diagnostic instrument. Am J Psychiatry 1990; 147: 76-82. 30. Bremner JD, Steinberg M, Southwick SM, Johnson DR, Charney DS. Use of the Structured Clinical Interview for DSM-IV Dissociative Disorders for systematic assessment of dissociative symptoms in posttraumatic stress disorder. Am J Psychiatry 1993; 150: 1011-1014. 31. Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986; 174: 727-735. 32. Franklin J. The diagnosis of multiple personality disorder based on subtle dissociative signs. J Nerv Ment Dis 1990; 178: 4-14. 33. Green BL. Psychometric review of Trauma History Questionnaire (Self-report). In: Stamm BH, Varra EM, editors. Measurement of stress, trauma and adaptation. Lutherville, Md.: Sidran, 1996. 34. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: A measure of subjective stress. Psychosom Med 1979; 41: 209-218. 35. Foa EB, Riggs DS, Dancu CV, Rothbaum BO. Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. J Trauma Stress 1993; 6: 459-473. 36. Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher C, Vidaver R, et al. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol 1998; 66: 493-499. 37. Cusack KJ, Frueh BC, Brady KT. Trauma history screening in a community mental health center. Psychiatr Serv 2004; 55: 157-162. 38. Switzer GE, Dew MA, Thompson K, Goycoolea JM, Derricott T, Mullins SD. Posttraumatic stress disorder and service utilization among urban mental health center clients. J Trauma Stress 1999; 12: 25-39. 39. Epstein JN, Saunders BE, Kilpatrick DG, Resnick HS. PTSD as a mediator between childhood rape and alcohol use in adult women. Child Abuse Negl 1998; 22: 223-234. 40. Triffleman EG, Marmar CR, Delucchi KL, Ronfeldt H. Childhood trauma and posttraumatic stress disorder in substance abuse inpatients. J Nerv Ment Dis 1995; 183: 172-176. 41. Rodgers CS, Lang AJ, Laffaye C, Satz LE, Dresselhaus TR, Stein MB. The impact of individual forms of childhood maltreatment on health behavior. Child Abuse Negl 2004; 28: 575-586. 42. Bremner JD. Does stress damage the brain? Biol Psychiatry 1999; 45: 797-805. 43. Bremner JD, Narayan M. The effects of stress on memory and the hippocampus throughout the life cycle: Implications for childhood development and aging. Dev Psychopathol 1998; 10: 871-885. 44. Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study. Am J Psychiatry 2003; 160: 1453-1460. 45. Carlin AS, Kemper K, Ward NG, Sowell H, Gustafson B, Stevens N. The effect of differences in objective and subjective definitions of childhood physical abuse on estimates of its incidence and relationship to psychopathology. Child Abuse Negl 1994; 18: 393-399. 46. Bargai N, Shalev AY. Child abuse and adult psychopathology. Isr J Psychother 2001; 15: 180-195 (Hebrew). 47. Shalev AY, Freedman S, Peri T, Brandes D, Sahar T. Predicting PTSD in trauma survivors: Prospective evaluation of self-report and clinicianadministered instruments. Br J Psychiatry 1997; 170: 558-564.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Initial Validation of the Russian Version of the World Mental Health Structured Clinical Interview for DSM-IV Zinoviy Gutkovich, MD Columbia University College of Physicians and Surgeons St. Luke’s Roosevelt Hospital, Department of Psychiatry, New York, New York, U.S.A.

Abstract Background: The Structured Clinical Interview for DSMIV (SCID) is a highly reliable diagnostic instrument used worldwide. However, there is little data as to its reliability and validity outside of the U.S. Objective: To create a Russian version of the World Mental Health (WMH) SCID and to test its validity among Russian Jewish émigrés in the U.S. Method: The author, a bilingual Board Certified psychiatrist who has been trained in the application of the original English SCID and WMH SCID, supervised the translation and adaptation of the WMH SCID into Russian. A convenience sample, consisting of 35 subjects, was interviewed by two clinicians trained by the author, yielding 54 diagnoses. All interviews were audio taped and blindly reviewed by the author, who served as the gold standard. Results: 32 subjects met criteria for one or more of 11 DSMIV depressive and anxiety disorder diagnoses. There was very good inter-rater agreement; median kappa was 0.75; seven disorders had kappas ranging from .65 (Depressive Disorder Not Otherwise Specified) to 1.0 (dysthymia and agoraphobia). Sensitivity was 88.9% and specificity was 77.1 %, compared to the “gold standard” diagnosis. Conclusion: Initial data suggest that the Russian version of the WMH SCID is a valid instrument.

INTRODUCTION Over the past decades, structural clinical interviews for mental health disorders, e.g., the Diagnostic Interview Schedule (DIS) (1) and Schedule for Affective Disorders and Schizophrenia (SADS) (2) have been developed to improve the accuracy of clinical diagnoses. The Structured Clinical Interview for DSM (SCID) had been developed in the late 1980s (3). It has been explicitly described (3) and validated (4) in English in the early 1990s. As opposed to the DIS, which is a fully structured instrument used in large-scale epidemiological research by trained lay interviewers, SADS and SCID are used by trained clinicians. The SCID proved to be a very reliable psychometric instrument for establishing accurate psychiatric diagnoses. A Multisite Test-Retest Reliability study (4) showed that for most major diagnostic categories, kappas for current and lifetime diagnoses in the patient samples were above 0.60, with an overall weighted kappa of 0.61 for current and 0.68 for lifetime diagnoses. Kranzler et al. (5) assessed the concurrent, discriminant and predictive validity of substance use disorders and common co-morbid SCID diagnoses. The study showed good-toexcellent validity for substance use disorders, moderate validity for major depression, and poor validity for anxiety disorder diagnoses. It is of note that the creators of the SCID warn that “because SCID relies on clinician’s judgment, its reliability is highly dependent on the training and skills of the interviewer” (3, 4). Some studies, (e.g., 6), reported good reliability for anxiety disorders as well — probably due to the high level of skill of the interviewers.

Conflict of interests: The author does not have any financial or intellectual proprietary conflict of interest. The study was supported by a grant from The Van Ameringen Foundation. This paper was presented in part at The 61st Institute on Psychiatric Services, American Psychiatric Association, October 8-11, 2009, New York. Address for Correspondence: Zinoviy Gutkovich, MD, Assistant Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, St. Luke’s Roosevelt Hospital, Department of Psychiatry, 1090 Amsterdam Avenue, 17th Floor, New York, NY 10025, U.S.A. zgutkovi@chpnet.org

Zinoviy Gutkovich

SCID is a state of the art tool, efficiently reviewing criteria for multiple psychiatric disorders within a span of about 90 minutes. It had been widely used in clinical and epidemiological research around the globe (3-5). The SCID incorporates overview, screening questions, and specific questions within diagnostic modules, guidelines about additional probes, operational criteria for DSM-IV, and a system of rating for the severity of symptoms. The critical feature of the SCID is its decision tree design that guides clinicians through hypothesis testing while the interview is underway. The instrument skip structure maximizes coverage and time efficiency. The interviewer arrives at a final diagnosis based on the results of the testing and on clinical judgment. The application of the SCID requires familiarity with the “Diagnostic and Statistical Manual of Mental Disorders” and training in its application. Since the original English version of SCID was created there have been multiple modifications of the instrument to address different tasks or settings. Those modifications include in particular Patient vs. non-Patient versions, versions for Axis I Disorders vs. Axis II Disorders. Also, SCID has been modified as a more advanced classification of Mental Disorders — DSM-IV — replaced the previous classification (the DSM-III R for which the original version of SCID had been created). However, every version of SCID, including WMH SCID (7) translated by us into Russian retains its major features described above, which makes it an excellent diagnostic tool. The translation and validation of the SCID into foreign languages remains a very important task for several reasons. It is important in its provision of data on the prevalence of mental illness abroad that would be comparable to the epidemiological data in the U.S. and other countries. These versions are also important in their use in high risk populations of non-English speaking immigrants within the U.S.; in particular the Russian version is an important assessment of mental disorders in the population of Russian Jewish émigrés. In a previous study, we showed that older Russian-Jewish émigrés living in the U.S. were extremely vulnerable to depressive disorders (8), thus demonstrating the applicability of DSM-IV concepts to a Russian-speaking population. It had been noted that the adequacy of a diagnostic instrument in a given culture does not guarantee its reliability or validity in another population (9). Valid use of diagnostic instruments across cultures requires a careful adaptation process that goes beyond mere language translation (10). Use of the diagnostic instrument in a culture different from the culture for which the instrument was

created presents multiple challenges. We used an adaptation model which evaluates the cultural equivalency of the instrument in five dimensions (9-11). These dimensions are: (1) semantic (the meaning of each item is to be similar in the language of each culture); (2) content (each item is to assess a content which is relevant to each culture under investigation); (3) technical (a similar effect is to be achieved by the measuring techniques in the different cultures); (4) criterion (the interpretation of the results of the measure is to be similar when evaluated in accordance with the established norms of each culture); and (5) conceptual (the same theoretical construct is to be evaluated in the different cultures). Literature is available on the cultural adaptation of fully structured non-clinician administered diagnostic instruments such as DIS (10), as well as semi-structured clinician administered instruments such as Kiddie SADS (12). Wilson and Young pointed out difficulties in applying SCID interviews to non-Western populations: specifically in application to Chinese patients due to the large cultural differences (13). Hence, it is even more striking that despite its worldwide use, studies on cultural adaptation and the reliability of non-English versions of SCID are practically non-existent. We have been able to identify the study addressing cultural adaptation and reliability of the Portuguese version of SCID (14), and the study addressing adaptation of only one module, namely Anxiety Disorder module of the SCID, into Hungarian (15). Inter-rater reliability for the SCID in Norway has been reported, but the relevant study did not provide data on the translation and cultural adaptation of the SCID (6). To our knowledge there is one non-validated Russian translation of the classic version of SCID (Michael First, personal communication). This version had been used in the study of PTSD among Russian Afghan War veterans (16). Previous research has shown that the level of psychopathology is increased among Russian Jewish émigrés (e.g., 8, 17). There is a need, therefore, for reliable diagnostic instruments for practitioners to be able to accurately diagnose these disorders. As a collaborator in the World Mental Health (WMH) initiative (or WMH Survey) (18) the author was responsible for producing a professionally translated Russian version of the “WMH SCID” (7) (Russian WMH SCID). The author translated the patient version of the SCID for Axis I Disorders, which included the following diagnoses: Major Depressive Disorder (MDD), Dysthymic Disorder, Depressive Disorder Not Otherwise Specified, Depressive Disorder due to a General Medical 25

Initial Validation of the Russian Version of the Wmh Structured Clinical Interview for DSM-IV (Scid)

Condition, Substance Induced Depressive Disorder; Panic Disorder, Agoraphobia without History of Panic Disorder (AWOPD), Social Phobia, Specific Phobia, Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), Anxiety Disorder due to a General Medical Condition, Substance Induced Anxiety Disorder, and alcohol abuse/dependence or substance abuse/dependence. Initial validation of the Russian WMH SCID assessing 12 month prevalence of above mentioned diagnoses among Russian Jewish émigrés (“Russian SCID project”) in the United States, in New York City, have been undertaken. Main indexes used in the evaluation of an assessment tool are inter-rater reliability (or “diagnostic agreement”) and indexes that involve comparison of the diagnoses derived by raters to a “gold standard” diagnosis. The “gold standard” diagnosis is typically an “expert” diagnosis or a “consensus” diagnosis. The aforementioned indexes establish “diagnostic accuracy”: or the percent of diagnoses consistent with “gold standard” diagnosis, “sensitivity”: or the agreement on diagnoses present as determined by “gold standard” diagnosis, and “specificity,” which is agreement on diagnoses absent as determined by “gold standard” diagnosis. It has been important to create an efficient training program. As the author did not have prior familiarity with the SCID, it had been decided to train the author during the first phase. For the training of the raters we used procedures similar to those utilized by other researchers. In particular, in the study by Ventura et al. (19) aimed to create and assess high quality SCID training program, a User Guide for SCID was utilized by trainees. Training videotapes, including videotapes with the “gold standard” consensus ratings, and tapes observing an experienced rater interviewing the patients were viewed. Symptoms and items elicited by SCID on a training video were judged as present or absent with consensus rating being a gold standard. Diagnostic accuracy after completion of training was 82%. In the study on Portuguese adaptation of the SCID (13), the training of raters included reading the interview translated into Portuguese, discussion of the material being read, role playing, and applying interviews to the inpatients. The last step of training was repeated until 70% agreement on the main diagnosis has been reached. Authors report that agreement between results obtained with SCID was statistically significant for 10 of the 12 specific diagnostic categories studied. Both above mentioned studies implemented practice interviews at the end of training. In the current paper 26

we present a detailed report on the initial validation of the Russian WMH SCID for Axis I Mental Disorders. METHODS Sample

The subjects were recruited through the Russian Language Health Services (RLHS) and the Department of Psychiatry at Beth Israel Medical Center (BIMC), New York. RLHS is a triage program in the primary care setting. The program is run by a licensed full time social worker, and assists Russian émigrés who are not fluent in English and are seeking mental health and/or other health services by providing them with an initial assessment. Many of the clients using RLHS services are older non-English speaking Russian émigrés and, consistent with our previous study (7), are very vulnerable to the stress of immigration and have high prevalence of undiagnosed psychiatric disorders, in particular depressive disorders. Since the focus of the project was to assess the validity of the Russian SCID administered by trained interviewers, efforts were made to identify and recruit the clients who were suspected by RLHS staff to have psychiatric disorders even if they did not receive psychiatric services per se (e.g., seeing internist only). A total of 35 subjects were recruited and interviewed yielding 54 diagnoses due to high comorbidity in the sample. Seventeen were current clients of RLHS. Three were active clients in the Outpatient Division of the Department of Psychiatry at BIMC, formally known to RLHS. Three subjects were recruited from the pool of callers who used the “September 11 hotline” opened by RLHS for Russian émigrés soon after the September 11 terrorist attack. One subject was an inpatient in the Psychiatry Unit at BIMC. Eleven subjects learned about the study by word of mouth from other respondents living in the same housing project and volunteered to participate. All subjects were not known to the interviewers or to the author and a great majority of them (31 out of 35) had never been assessed psychiatrically. Except for one inpatient subject, the interviewers and the expert were blind to the source of subject referral. The subjects in our study had been resident in the US for varied lengths of time: from one year to more than 20 years. They came from different regions of the former Soviet Union: mostly from the Slavic Republics (Russia, Ukraine and Belarus) and the Middle Asia region of the former Soviet Union (e.g., Uzbekistan). For all the subjects, Russian was a primary language. We did not notice

Zinoviy Gutkovich

differences in the flow of the interview depending on the part of the former Soviet Union the subjects came from or based on their length of stay in the U.S. The project was approved by the Institutional Review Boards of the BIMC and SUNY at Stony Brook. All participating subjects signed informed consent, which included separate consents for interview and for audio taping. All interviews were audio taped. One interview could not be completed because the subject became physically exhausted. Since by this time most of the assessment was completed, the subject was included into the analysis. Instrument

The mental health interview on which interviewers had been trained and which had been administered to the subjects was the Russian version of the Structured Clinical Interview for DSM-IV (SCID) for the Axis I disorders, WMH version (18). Like other versions of SCID, the WMH SCID includes an introductory overview followed by a screening module. It then focuses on depressive disorders, anxiety disorders and alcohol and substance disorders; an overall Clinical Global Impression score is given. Thus, if a respondent answers positively to the screening item, the corresponding diagnostic module is then assessed. The severity scales incorporated into WMH SCID were also translated and back translated, in the same way as the rest of WMH SCID, including Montgomery-Asberg Depression Rating Scale (MADRS) for MDD and Dysthymia (20), the Panic Disorder Severity Scale (PDSS) (21), Liebowitz Social Anxiety Scale for Social Phobia (22), Marks Fear Questionnaire for Agoraphobia and Specific Phobia (23) and Structured Interview for the Hamilton Anxiety Rating Scale (SIGH-A) (24, 25) for GAD. The validation of the diagnostic instrument, such as the Russian version of WMH SCID, applied to the validation of the instrument as a whole and did not include separate validation of the above mentioned severity scales. Training of the author in English SCID. The first step was the training of the author in the use of the original English versions of SCID — both the classic version and the WMH version. The author of the project is a bilingual Board Certified psychiatrist, originally from the former Soviet Union, who is intimately familiar with Russian culture. Prior to the Russian SCID Project, the trainer received extensive training on the SCID, which included the following (stepwise). 1) Preparatory selftraining using materials such as the User Guide, reviewing

teaching videotapes including separate videotapes on introduction and on particular modules as well as teaching cases. The author rated videotaped interviews and then compared his rating with the gold standard rating provided on the videotape. 2) In-person full-day training by Dr. Michael First (one of the creators of the SCID) that included demonstration interview rated simultaneously by the author with extensive discussion and feedback provided by Dr. First. 3) Two full-day training in the Massachusetts’s General Hospital on the WMH SCID which included didactics, rating teaching videotapes, and feedback from Dr. Molly Howes (the developer of the modified SCID for WMH Survey). 4) Role play interviews with “subjects” (Stony Brook employees) who received pre-script scenario of their “Mental Disorders” (component of teaching materials). Translation and cultural adaptation of the WMH SCID. The second step was the translation of the instrument. The English WMH version and quantitative scales were translated into Russian jointly by a professional translator working together with the author, back-translated to English by another translator and checked and corrected by the author. Below we provide some examples of overcoming challenges in different dimensions to achieve cultural equivalence. Examples of semantic and technical challenges are applicable to both immigrant and non-immigrant (residing in Former Soviet Union) population. Examples of content and criterion challenges are relevant only to non-immigrant population. I. Semantic: 1. While the word that would be a literal translation of “functioning” exists in the Russian language, it is never used in the particular context such as its use in DSM. (It is used to say, e.g., “normal functioning of cardiovascular system,” “normal functioning of machinery,” etc.). Therefore, adequate semantic translation required using two different words. One word needed back translates as “function,” e.g., in Panic Disorder Severity Scale “impairment/interference in carrying out function at work, or social function as a result of Panic Disorder.” The second word back translates as “activities of living,” as it is used numerous times for DSM criteria of impairment in functioning for multiple disorders: “symptoms cause …impairment of social, occupational, or other important areas of functioning.” 2. The word “discouraged” is impossible to translate 27

Initial Validation of the Russian Version of the Wmh Structured Clinical Interview for DSM-IV (Scid)

precisely into Russian without using two-sentence phrasing (in general English is a more laconic language than Russian): “[did you ever feel] that all your efforts are futile and there in no sense to continue trying?” Since semantically precise translation would disrupt the flow of the interview, as a compromise we translated “discouraged about how your life is going” as “feeling down about how your life is going,” thus conveying meaning by preserving part of the sentence “about how your life is going.” Culturally relevant idioms were used when appropriate (e.g., translation of the question about panic attacks), “Have these attacks ever come on completely out of the blue…” was translated using similar Russian idiom: “As if a thunderstorm from the clear sky.” II. Content: in the English SCID, the screening question for alcohol disorders sounds, “Has there been any time in your life when you had five or more drinks (beer, wine, or liquor) (on one occasion/at the one time)?” Adequate Russian translation would back translate the word “drink” as “portion.” However, due to cultural patterns of drinking in Russia, “portion” could mean as much as 100-200 grams of vodka. Therefore, the cultural equivalent utilized reflected the absolute amount of alcohol, rather than “drinks” (“150 gram of hard liquor or equivalent amount of other alcoholic beverages”). III. Technical: Russian respondents suffering from depression tend to express emotional distress in somatic terms (7). Thus, in training, we have emphasized that raters should be aware of this cultural tendency and make a special effort to elicit depressive symptoms other than, e.g., sleep disturbance or fatigue, through adequate probing. IV. Criterion: the societal tolerance to heavy alcohol consumption is significantly higher in Russian culture; also many people don’t have cars. Thus, the value of certain items is not the same as it is in the American culture: the item related to “problems with a law” is less applicable because arrest for disorderly conduct would be much less likely. The item related to driving while intoxicated is much less relevant as is the possibility for trouble with a law for “Driving While Intoxicated” (DWI), so common in the U.S. However, we preserved all the items from the English version of SCID, and because only one item is sufficient for meeting symptom criteria we put heavy reliance on the item related to intra familial conflict — which is very common in the families of people with alcohol problems (26). 28

V. Conceptual: we didn’t face challenges related to conceptual equivalence. Procedure

Raters. Two psychiatry trainees participated in the project. Both trainees were bilingual and worked as physicians in the former Soviet Union prior to coming to the U.s. Both trainees had knowledge of the American psychiatric diagnostic system (DSM-IV). Training Program. During the preparation phase prior to in-person training, the trainees reviewed the training materials. These materials included teaching videotapes and a User Guide in English. 1. Days 1-3 of training included an introduction of the SCID-IV structure: the role of the overview section, flexibility vs. adherence to format, scoring system (skip-outs, symptom ratings), and discussion of particular modules. This training has been conducted in Russian and utilized the translated Russian version of the WMH SCID. It also included role-playing in Russian in which one of the trainees would act as a “subject” based on a prewritten scenario with a history and responses to critical questions. Trainees’ performances during the role play was supervised by the trainer and guided as necessary. All arising questions were immediately discussed. 2. On day 4 training videotapes (in English, produced in Harvard University) of the SCID-IV, the WMH version, were reviewed. Trainees had to rate the symptoms and make diagnoses. One of the videotapes presented a full length interview and the other videotapes presented segments demonstrating use of severity scales for depression, panic disorder and generalalized anxiety disorder. Ratings of trainees were compared to those of Harvard University raters and discrepancies were discussed. 3. On day 5 of training, each trainee conducted practice interviews in English with the actual patients in the in-patient psychiatry unit. Trainees were blind to the patients’ diagnoses. Two interviews were conducted by trainee A and one interview was conducted by trainee B. Interviews were supervised by the method of a joint interview (13), i.e., the author observed interviews directly and was allowed to ask additional questions only after the interview had been completed and the ratings were done. Then, interviews and ratings were carefully analyzed and extensive feedback was provided. The feedback included comments on the technique and accuracy of ratings by the trainees. In all cases, trainees were able to make the same diagnosis

Zinoviy Gutkovich

as the author — operationalized as a “gold standard” diagnosis. Interviews of the study. Trainee A conducted 23 assessments and trainee B conducted 12 assessments. Raters filled a hard copy of the SCID and all interviews were audio taped. All audiotapes were blindly reviewed by the author. Trainees’ diagnoses had been compared to the “gold standard” diagnosis by the author. Data Analysis

Inter-rater reliability of the instrument was assessed by analyzing agreement between diagnoses assigned by a rater and the author. Inter-rater agreement was calculated as Cohen’s kappa (27, 28). Kappa coefficients represent the amount of agreement between pairs of ratings (e.g., agreement on diagnosis five out of 10 times) adjusted for chance agreement. Chance is based on the likelihood that a specific diagnosis will occur in a sample. For example, if in the sample of 100 patients, 50 are given diagnoses of depression, a rater is going to be correct at least 50% of time if he or she arbitrarily gives everybody a diagnosis of depression. Criteria proposed by Landis and Koch (29) were used to interpret the Kappa coefficients: excellent reliability (Kappa > 0.75) good reliability (Kappa = 0.59-0.75), fair reliability (Kappa = 0.40 - 0.58), and poor reliability (Kappa < 0.40). RESULTS Twenty-two females and 13 males participated in this study. The age of the subjects ranged from 43 to 77 years with the majority of subjects (69%) being in their 50s or 60s. The results are shown in Table 1. Agreement was good to excellent for all diagnoses, with the exception of social phobia and specific phobia. These were the least prevalent disorders in this sample (one case of each), which made it difficult to estimate inter-rater agreement for these diagnoses precisely. Four subjects known to the mental health system (three referred from psychiatric outpatient clinic and one referred from inpatient unit) had a chart diagnosis consistent with the “gold standard” diagnosis (MDD, dysthymia, Panic Disorder, Generalized Anxiety Disorder). This provides additional support for the validity of the Russian WMH SCID. Comparative data to other studies are shown in Table 2. The WHO SCID allows deriving diagnoses from ratings or from the clinical impression indicated by the interviewer at the end of the SCID worksheet (in the

Table 1. Number of diagnoses and agreement (Kappa) for individual diagnoses in the sample (N=35)

Diagnosis

Kappa Full (N=35)

Kappa Screen+ (N=32)

Major Depressive Disorder

0.76

0.75

***

Dysthymic Disorder

1.00

***

Depressive Disorder NOS

0.65

***

Panic Disorder

0.75

0.74

***

Generalized Anxiety Disorder

0.70

0.69

***

Post-Traumatic Stress Disorder

0.87

0.84

***

Specific Phobia

-0.04

-0.05

Social Phobia

0.48

Agoraphobia

1.00

***

“Kappa full” applies to all the subjects in the study, including three subjects who screened negative for all the disorders. “Kappa Screen+” applies to subjects who screened positively and therefore were assessed for at least one disorder. **p<.01, ***p<.001, NS p>.05

Table 2. Comparison of the Kappa values for the present study with the values obtained by others for specific diagnoses:

Diagnosis

Adaptation to Russian (N = 35)

Adaptation to Norwegian (N =54)

Original classic English version (N = 592) (lifetime/actual)

Major Depression

0.76

0.93

0.64/0.69

Dysthymia

1.00

0.88

0.40

Panic disorder

0.75

0.88

0.58 (0.54)

Generalized Anxiety Disorder

0.70

0.95

0.56

Post-traumatic stress Disorder

0.87

0.77

No data

Specific Phobia

-0.04

0.70

0.52 (0.60)

Social Phobia

0.72

0.48

0.47 (0.57)

Agoraphobia

1.00

0.32

0.43(0.48)

great majority of the cases it would be the same diagnosis as the one produced by ratings). For the purposes of this report, we used the diagnoses based on clinical impressions made by the trainees and compared them to the diagnoses made by the author after listening to the audiotapes. Different studies use different ways to assess inter-rater agreement; some studies use more than one approach. We chose to assess reliability on specific diagnoses (6, 13), (i.e., if participant had three diagnoses, we would make three assessments for this participant), as opposed to agreement on specific items (16), or combined diagnosis (6), or main diagnosis (13) because it was most consistent with the objectives of our study. 29

Initial Validation of the Russian Version of the Wmh Structured Clinical Interview for DSM-IV (Scid)

Only three subjects did not have any positive responses to any of the screening questions and did not have symptoms of any psychiatric disorders over the past 12 months. Thirty-two subjects had positive responses to one or more screening questions and had at least sub-syndromal symptoms of any psychiatric disorder. Twenty-four subjects met the DSM criteria for one or more psychiatric diagnoses according to the author’s opinion. There were a total of 54 diagnoses (varying from one to six diagnoses per subject). Probably because of the nature of the sample, no subject required assessment for the past 12 months for alcohol or a substance use disorder. There was very good agreement on the diagnoses that did not differ significantly for the two trainees. Overall diagnostic accuracy was 77.4%. There was an excellent sensitivity of 88.9 %. For the 54 cases, when the author made a diagnosis of a particular disorder, the trainees made the same diagnosis in 48 cases. In the six remaining cases, trainees did not arrive at the gold standard diagnosis. In five of these cases, trainees did not diagnose a disorder. In one case, a trainee made a very similar but different diagnosis of depressive disorder due to general medical condition instead of the diagnosis of Major Depressive Disorder (subject developed depression after being diagnosed with colon cancer. In that case, however, the depression was not due to the physiological effect of her cancer). There was a higher accuracy on the diagnosis of depressive disorders — 84.4% and a lower but acceptable accuracy on the diagnosis of anxiety disorders — 73.8%. DISCUSSION There are different ways of checking the reliability of a psychometric instrument in general and particularly in a foreign language. Major methods include use of audiotapes (6), videotapes (16), joint interviews (13), and test-retest design (4). Test-retest design has limitations in that it is not a naturalistic diagnostic procedure. In particular, subjects would recognize the structure of the interview and on repetition could have chosen to deny symptoms formally reported in order to cut the interview short (4). The method of the joint interview (6) entails the trained rater conducting the interview and making the diagnosis, while the expert, who is present during the interview, may ask additional questions after the interview is completed and may arrive at his own expert diagnosis. Although audio taping as opposed to videotaping precludes the expert from the opportunity to observe the patient, in particular to evaluate visible emotional 30

distress due to psychiatric disorder, our method of checking reliability of the SCID using non-selective listening of audio-tapes by the expert has been utilized in other studies (6) and is a valid method of checking reliability of the psychometric instrument, in particular the foreign language version. It is of note that the unique feature of the SCID WMH version is that it incorporates within the modules quantitative clinician-rated scales for many of the disorders which then are used as a “back-up”— while the SCID-directed interview is underway, thereby decreasing the chance of obtaining insufficient information. All audio-taped interviews, in the opinion of the author, provided sufficient information for arriving at a diagnosis. The discrepancies emerged as a result of differences in interpreting and rating available data, in particular overdiagnosing by raters of “near-threshold” cases. In our opinion, from a clinical point of view, the advantage of an audio-taped one-to-one interview as opposed to a joint interview is that one-to-one interviews increase the comfort and ease of both the interviewer and respondent alike. Direct comparison with other studies on English, and Portuguese study on non-English SCID, is complicated due to the fact that different versions of SCID had been used in different populations and different diagnoses were assessed (in particular Psychotic Disorders, which were not included into WMH SCID); so such comparison should be treated with caution. Diagnostic accuracy in our project was 77.4% and in a study by Ventura et al. (16) of the English SCID, striving to create a state-of-the-art training program, accuracy was 82% — which was classified by the authors as “very good” (16). Table 2 provides direct comparison of inter-rater agreement on specific diagnoses with other studies. Apparently, these data show very favorable results compared to other studies. Study on the reliability of the Portuguese version of SCID is not included as it assessed a different range of diagnoses; it did provide kappa coefficient for MDD 0.88 which is only slightly better than the 0.76 in our study. As diagnosis of MDD is highly common in our sample we also calculated the sensitivity and specificity for MDD which was 86% and 90 % respectively in our study compared to 84% and 91% accordingly in the study by Basco et al. on the English SCID (30). We suggest that the success of the project of the adaptation of SCID to the Russian language was facilitated by the fact that the principal investigator is a bilingual psychiatrist with many years of clinical experience, knowledgeable about both DSM-IV and Russian culture. It is of note that, consistent with our previous work (7), only a small proportion of participants with psychiatric

Zinoviy Gutkovich

disorder(s) (4 out of 32) had been receiving psychiatric services, thus illustrating high unmet needs in this population. The study has certain limitations and the results should be considered as preliminary. The major limitation is the small size of our sample. However, we believe that this limitation is compensated in part by high “caseness”; that is to say the high total number of diagnoses in this very sick population. Another potential sample limitation is that it was a particular group of people, with very limited age range as well as with unusually high comorbidity (54 diagnoses). Also, due to the nature of the sample, no subjects in our study were diagnosed with alcohol or substance use disorders. Another potential limitation of the study is that initial validation had been done in Russian speaking subjects living in the U.S. as opposed to their country of origin. Potential language issues could also be applied to the main three clinicians in the study as their working language is English. The research shows (31) that in order for tests to be effectively translated and adapted in different cultural contexts they need to have demonstrated validity and reliability in their home countries. A further limitation of the study was that pre-training materials such as the User Guide and teaching videotapes were in English and practice interviews were conducted with English speaking patients. CONCLUSION The initial results suggest that the Russian version of the WMH SCID is a valid instrument. The Russian SCID can improve diagnostic accuracy in Russian Jewish émigrés. Future studies should use larger samples of Russian speaking émigrés from the former Soviet Union, as well as Russian speaking subjects living in their country of origin. Also, future research should address different populations, in particular those with alcohol and substance use disorders. Future research should use more rigorous methodology: utilizing higher standard translation and back translation procedures (independent translation by two translators, then creating one edited version, and back translation by two independent translators), as well as using consensus diagnosis as opposed to expert diagnosis as a “gold standard.” Interviews should be evaluated by several equally trained SCID experts in Russia. Future studies should also utilize scales such as Rater Applied Performance Scale (32), thus providing more objective data.

The Russian version of the SCID WMH version is available from the author upon request. Acknowledgements The author is very thankful to Dr. Charles Webb and Dr. Igor Galynker for their assistance with organizing the project and their very valuable suggestions; to Dr. Evelyn Bromet for invaluable comments and assistance in the preparation of the manuscript; to Roman Kotov for his help with statistics; and the author expresses deep thanks to the raters: Drs. Natalia Osmanova and Alisa Shakhverdi.

References 1. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule. Its history, characteristics, and validity. Arch Gen Psychiatry 1981; 38:381-389. 2. Endicott J, Spitzer RL. A diagnostic interview: The schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1978; 35:837-844. 3. Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 1992; 49: 624-629. 4. Williams JB, Gibbon M, First MB, Spitzer RL, Davies M, Borus J, et al. The Structured Clinical Interview for DSM-III-R (SCID). II. Multisite test-retest reliability. Arch Gen Psychiatry 1992; 49: 630-636. 5. Kranzler HR, Kadden RM, Babor TF, Tennen H, Rounsaville BJ. Validity of the SCID in substance abuse. Addiction 1996; 91: 859-868. 6. Skre I, Onstad S, Torgersen S, Kringlen E. High inter rater reliability for the Structured Clinical Interview for DSM-III-R Axis I (SCID-I). Acta Psychiatr Scand 1991; 84: 167-173. 7. First, MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders – Patient Edition (SCID-I/P, Version 2.0, 9/98 revision). Biometrics Research Department New York State Research Institute 722 West 168th Street New York, New York 10032. 8. Gutkovich Z, Rosenthal RN, Galynker I, Muran C, Batchelder S, Itskhoki E. Depression and demoralization among Russian Jewish immigrants in primary care. Psychosomatics 1998; 39: 295-306. 9. Canino G, Bravo M. The translation and adaptation of diagnostic instruments for cross-cultural use. In Shaffer D, Lucas CP, Richters JE, editors. Diagnostic assessment of child and adolescent psychopathology. New York: Guilford, 1999. 10. Bravo M, Canino GJ, Rubio-Stipec M, Woodbury-Farina M. A crosscultural adaptation of a psychiatric epidemiologic instrument: the diagnostic interview schedule’s adaptation in Puerto Rico. Cult Med Psychiatry 1991; 15:1-18. 11. Flaherty, JA. Appropriate and inappropriate research methodologies for Hispanic mental health. In Gaviria M, editor. Health and Behavior: Research Agenda for Hispanics. Chicago: University of Illinois, 1987: pp. 177-186. 12. Lauth B, Magnusson P, Ferrari P, Petursson H. An Icelandic version of the Kiddie-SADS-PL: Translation, cross-cultural adaptation and interrater reliability. Nordic J Psychiatry 2008; 62: 379-385. 13. Wilson LG, Young D. Diagnosis of severely mentally ill patients in China. A collaborative project using the Structured Clinical Interview for DSM-III (SCID). J Nerv Ment Dis 1988; 176:585-592. 14. Del-Ben, C M. Rodrigues, C R. Zuardi, A W. Reliability of the Portuguese version of the structured clinical interview for DSM-III-R (SCID) in a Brazilian sample of psychiatric outpatients. Braz J Med Biol Res 1996; 29:1675-1682. 15. Gerevich, J, Bacskai E, Matuszka B, Czobor P. The Hungarian adaptation of anxiety disorder module in the SCID-I/NP research version. [Hungarian]. Psychiatria Hungarica 2010; 25: 394-406. 16. Zelenova ME, Lazebnaia EO, Tarabrina NV. Psychological characteristics of post-traumatic stress states in Afghan war veterans. J Russian East Eur Psychology 2001; 39: 3-28.

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17. Zilber N, Lerner Y, Eidelman R, Kertes J. Depression and anxiety disorders among Jews from the former Soviet Union five years after their immigration to Israel. Int J Geriatr Psychiatry 2001; 16:993-999. 18. Kessler RC, Haro JM, Heeringa SG, Pennell BE, Ustun TB. The World Health Organization World Mental Health Survey Initiative. Epidemiologia e Psichiatria Sociale 2006; 15:161-166. 19. Ventura J, Liberman RP, Green MF, Shaner A, Mintz J. Training and quality assurance with the Structured Clinical Interview for DSM-IV (SCID-I/P). Psychiatry Res 1998; 79:163-173. 20. Montgomery SM, Asberg M. A new depressive scale designed to be sensitive to change. Br J Psychiatry 1979; 134: 382-389. 21. Shear M, Brown T, Sholomskas D, Barlow D, Gorman J, Woods S, Cloitre M. The Panic Disorder Severity Scale. Department of Psychiatry University of Pittsburgh School of Medicine, 1992. 22. Liebowitz MR. Social phobia. Modern Problems of Pharmacopsychiatry 1987; 22; 141-173. 23. Marks IM, Mathews AM. Brief standard self-rating for phobic patients. Behav Res Ther 1979; 17:263-267. 24. Hamilton M. The assessment of Anxiety States by Rating. Br J Med Psychology 1959; 32: 50-55.

25. Shear MK, Vander Bilt J, Rucci P, Endicott J, Lydiard B, Otto MW, et al. Reliability and validity of a structured interview guide for the Hamilton Anxiety Rating Scale (SIGH-A). Depress Anxiety 2001: 13:166-178. 26. Leonard KE, Eiden RD. Marital and family processes in the context of alcohol use and alcohol disorders. Ann Rev Clin Psychology 2007; 3:285-310. 27. Cohen J. Weighted Kappa: nominal scale agreement with provision for scaled disagreement or partial credit. Psychological Bull 1968; 70: 213-220. 28. Fleiss JL. Statistical methods for rates and proportions (2nd Ed.). New York: John Wiley, 1981. 29. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33:159-174. 30. Basco MR, Bostic J, Davies DRN, Rush AJ, Witte BBS, Hendrickse W, et al. Methods to improve diagnostic accuracy in a community mental health settings. Am J Psychiatry 2000; 157: 1599-1605. 31. Butcher J, Derksen J, Sloore H, Sirigatti S. Objective personality assessment of people in diverse cultures: European adaptations of the MMPI-2. Behav Res Ther 2003; 41:819-840. 32. Lipsitz J, Kobak K, Feiger A, Sikich D, Moroz G, Engelhard A. The Rater Applied Performance Scale: Development and reliability. Psychiatry Res 2004; 127:147-155.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Natan P.F. Kellermann

Epigenetic Transmission of Holocaust Trauma: Can Nightmares Be Inherited? Natan P.F. Kellermann AMCHA, the National Israeli Center for Psychosocial Support of Survivors of the Holocaust and the Second Generation, Jerusalem, Israel

Abstract The Holocaust left its visible and invisible marks not only on the survivors, but also on their children. Instead of numbers tattooed on their forearms, however, they may have been marked epigenetically with a chemical coating upon their chromosomes, which would represent a kind of biological memory of what the parents experienced. As a result, some suffer from a general vulnerability to stress while others are more resilient. Previous research assumed that such transmission was caused by environmental factors, such as the parents’ childrearing behavior. New research, however, indicates that these transgenerational effects may have been also (epi) genetically transmitted to their children. Integrating both hereditary and environmental factors, epigenetics adds a new and more comprehensive psychobiological dimension to the explanation of transgenerational transmission of trauma. Specifically, epigenetics may explain why latent transmission becomes manifest under stress. A general theoretical overview of epigenetics and its relevance to research on trauma transmission is presented.

Some children of Holocaust survivors have terrible nightmares in which they are chased, persecuted, tortured or annihilated, as if they were re-living the Second World War over and over again. At these times, they suffer from debilitating anxiety and depression which reduce their ability to cope with stress and adversely impact their occupational and social function. It seems that these individuals, who are now adults, somehow have absorbed the repressed and insufficiently worked-through Holocaust trauma of their parents, as if they have actually inherited the unconscious minds of their parents. Address for Correspondence:

Apparently, not only children of Holocaust survivors, but offspring of other PTSD parents are also vulnerable to such a burdensome legacy, including descendants of war veterans (1), survivors of war trauma and childhood sexual abuse, refugees, torture victims and many others (2). Moreover, the transmission may continue beyond the second generation and also include the grandchildren, great grandchildren and perhaps others as well. This process of transgenerational transmission of trauma (TTT) has been repeatedly described in the academic literature for more than half a century (3). Generally speaking, TTT refers to the process in which a trauma that happened to the first generation was passed on to the second generation. Such a process is deeply connected with the general theme of heredity – the transmission of characteristics from parents to their offspring. Despite more than 500 studies published, however, we are still unable to sufficiently explain exactly how the unconscious trauma of a PTSD parent can be genetically transmitted to a child and to verify this idea with sufficient empirical evidence. Such a notion evades any simple and logical explanations. How can a repressed memory be passed on from one person to another? Can a child really “inherit” the unconscious mind of a parent? Is it possible for a child to remember what the parent has forgotten? Will we ever be able to produce “hard” neurobiological evidence of such far-fetched and preposterous assumptions and perhaps see traces of the unconscious trauma of a PTSD parent in a blood specimen or an MRI scan of the child? Probably not. But even though we still know very little about the level of specific inheritance of trauma, new research indicates that traumatic experiences of parents may indeed lead to a general disposition to PTSD in the offspring. Family and twin studies have found that risk for PTSD is associated with an underlying genetic vulnerability and that more than 30% of the variance associated with PTSD is related to a heritable component (4). Perhaps this heritable component can

Natan P.F. Kellermann, AMCHA, POB 2930, Jerusalem 91029, Israel.

natank@netmedia.net.il

Epigenetic Transmission of Holocaust Trauma: Can Nightmares Be Inherited?

be observed in the epigenetic marks that affect gene expression patterns in the nervous system? Four major theoretical approaches to understanding trauma transmission have been earlier suggested by Kellermann (5): (1) psychodynamic relational models (6); (2) sociocultural and socialization models (7); (3) family systems and communication models; and (4) biological or genetic models. Children are of course influenced by their parents in a variety of ways, either through upbringing or heredity, or through both (8) and such an integrative view of trauma transmission seems to make perfect sense. Upon further inspection however, these theories are too general to sufficiently explain the specific process of how the impact of trauma can cross generations and how social and biological influences interact to produce TTT. As emphasized by Jablonka and Lamb (9), genetic mechanisms alone cannot explain how some cellular traits are propagated and heritable changes in gene expression and regulation that have little to do with DNA sequence seem to be more relevant to explain TTT. Any theory explaining transgenerational transmission of trauma must therefore take into account the powerful hereditary variations which would explain how parental trauma may be biologically passed on to the child before birth. These theories should explain how children who have not themselves been traumatized tend to manifest inherited emotional problems. Even though empirical data are still poor in comparison to the ideas presented here and my assumptions may sound bold, speculative and unfounded at this point in time, I suggest that epigenetics may introduce a promising new and more comprehensive explanatory variable of TTT than the earlier ones. Since it includes both hereditary and environmental factors, it may add a significant psychobiological dimension which could confirm clinical observations with empirical research. The purpose of this paper is therefore to explore what epigenetics can teach us about TTT and to review some of the prevalent empirical research in this field. Finally, I will show how the inclusion of epigenetics would explain some of the discrepant findings from previous research on the transgenerational transmission of Holocaust trauma. Epigenetic Transmission More than two centuries ago, the founder of evolution, Jean-Baptiste Lamarck, suggested that acquired characteristics may be transmitted from one generation to another. Ever since, evolutionary developmental biology 34

has continued to study this assumption. Recent advances in the field of epigenetics are now revealing a molecular basis for how heritable information other than DNA sequence can influence gene function (10, 11). These advances may add greatly to our understanding of trauma transmission and may even establish a promising new research paradigm in the field, as recently pointed out by Yehuda and Bierer (12): “Epigenetic modifications, such as DNA methylation, can occur in response to environmental influences to alter the functional expression of genes in an enduring and potentially, intergenerationally transmissible manner. As such, they may explain interindividual variation, as well as the long-lasting effects of trauma exposure. Although there are currently no findings that suggest epigenetic modifications that are specific to posttraumatic stress disorder or PTSD risk, many recent observations are compatible with epigenetic explanations” (p. 427). Naturally, various questions remain regarding such assumptions, and we still know too little about where to draw the line between PTSD based on a single traumatic event, complex and chronic PTSD, as well as individuals who have largely overcome their responses to overwhelming stress. Epigenetics is typically defined as the study of heritable changes in gene expression that are not due to changes in the underlying DNA sequence. Such heritable changes in gene expression often occur as a result of environmental stress or major emotional trauma and would then leave certain marks on the chemical coating, or methylation, of the chromosomes (13). The coating becomes a sort of “memory” of the cell and since all cells in our body carry this kind of memory, it becomes a constant physical reminder of past events, our own and those of our parents, grandparents and beyond. “The body keeps the score” (14), not only in the first generation of trauma survivors, but possibly also in subsequent ones. Because of their neurobiological susceptibility to stress, children of Holocaust survivors may thus easily imagine the physical suffering of their parents and almost “remember” the hunger, the frozen limbs, the smell of burned bodies and the sounds that made them scared. In the same way as parents can pass on genetic characteristics to their children, they would also be able to pass on all kinds of “acquired” (or epigenetic) characteristics, especially if these were based on powerful life-threatening experiences, such as survival from starvation, torture or persecution. Such environmental conditions would leave an imprint on the genetic material in eggs and sperm and pass along new traits even in a single generation.

Natan P.F. Kellermann

Such an explanation of TTT can be described in computer terminology in which the genome would represent a kind of hardware that remains fixed, while the epigenome would represent the variable software with all the memory files. The epigenome thus would function like a “switch,” which has the inherent ability to turn certain functions “on” or “off.” From such a point of view, offspring of trauma survivors would be somehow “programmed” to express a specific cognitive and emotional response in certain difficult situations. In effect, these children of PTSD parents would be suffering from a kind of “software bug,” an error in a computer program or system that produces incorrect or unexpected results, or causes it to behave irrationally. This bug would for example switch on a panic attack and instruct the genes to prepare for “fight and flight” when triggered, as if the individual were thrown into a Nazi persecution manuscript of catastrophic proportions, even in a relatively non-threatening situation. Metaphorically, such an epigenetic coating would affect the child of survivors in a way which is similar to a computer infected with a malicious virus, a malware that inflicts harm at certain unpredictable points in time. Any such explanation in epigenetic terms of how the Holocaust trauma can “run in families” must first show that the PTSD parent was somehow “damaged” with some kind of brain short-circuit or constitutional “PTSD bug” and then demonstrate that the child was born with this same “bug.” Among children and grandchildren of Holocaust survivors as well as offspring of other traumatized populations, this “bug” would be manifested as a latent susceptibility to (secondary) PTSD and would cause increased vulnerability to stress under certain conditions, such as when a new stress becomes the trigger to a past traumatic event. At such times the epigenetic switch would turn the survival strategy “on” and activate a specific neuro-biological response. Initially, most affected offspring would not be aware of its origin or even of its existence until a new trauma occurs, and then be surprised that some old trauma of the parents would suddenly be surfacing. If any specific past memory can be epigenetically transmitted or not, however, must be left open to speculation and we should be careful not to slip from reasonable assumptions to fantastic and unsupported scenarios. While a general tendency for having frightening nightmares may well be epigenetically transmitted, and the persecution nightmares of children of Holocaust survivors may be colored by their Holocaust imagery, we are obviously still unable to show that the content of a specific

nightmare is affected by epigenetic marks transmitted in a reproductive cell or in the womb. Eva Jablonka (personal communication) writes: “We have good reasons to believe that epigenetic marks can be inherited between generations, including marks that affect gene expression patterns in the nervous system. Of course, we need evidence that this actually happens in the case of human PTSD, but we do know that the effects of psychological stress are inherited in mice and rats. It would therefore not surprise me if we find out that the disposition to PTSD is inherited via an epigenetic route, and that traumatic experiences of parents lead to extra-sensitivity to traumatic inputs in offspring, and this may linger for some generations. If the effects of trauma are inherited we shall have to find out for how many generations (this may vary, depending on genetic background, type of trauma, and the persistence of traumatic experiences) and whether the effects make the descendants more prone to develop PTSD. Even if the disposition to develop PTSD is found to be increased in descendants, it is important to emphasize that the specific trauma is unlikely to be inherited. So the fact that children of Holocaust survivors dream of the Holocaust was not transmitted through gametic epigenetic inheritance (as a mark on the chromosomes of the parental sex cells). What could have been inherited is the disposition to have nightmares, and of course if they know something about the Holocaust through primary exposure, from stories and so on, the nightmares will take this form. What we know about epigenetic marks is that they can dispose one towards developing some behaviors, but the specific behavior depends on specific inputs the person gets in its own lifetime.” Epigenetic Research The field of epigenetics is becoming increasingly more accepted by the scientific community and there has been a large increase in studies conducted during the last decade. A comprehensive review of more than hundred studies of transgenerational epigenetic inheritance was compiled by Jablonka and Raz (15) who described the phenomena in a wide range of organisms, including bacteria, plants and animals. These studies included various kinds of adverse conditions, early stress and “emotional trauma” of the “first generation” which altered the gene expression in the subsequent generations. Reik, Dean and Walter (16) also reviewed what is known about reprogramming in mammals and discussed how it might relate to developmental potency and imprinting. More 35

Epigenetic Transmission of Holocaust Trauma: Can Nightmares Be Inherited?

recently, Franklin et al. (17) showed that chronic and unpredictable maternal separation induces depressive-like behaviors, not only in the first generation of mice, but also in their offspring. Empirical evidence of epigenetic transmission in human beings, however, is very scarce because of the difficulties in gathering relevant data from human as compared to animal subjects. Some of these will be summarized here briefly. One of the first epigenetic studies on human beings was carried out by Bygren et al. (18) in Överkalix in Northern Sweden. He found that overeating as a youngster could initiate a biological chain of events that would lead one’s grandchildren to die decades earlier than their peers did (19). Thus it was shown – perhaps for the first time – that a famine or overeating at critical times in the lives of the grandparents could influence the life expectancy of the grandchildren. In their efforts to replicate this astounding finding, Pembrey et al. (20) conducted another transgenerational study which showed that sons of men who smoke in pre-puberty were found to be at higher risk for obesity and other health problems than sons of non-smoking fathers. Much later, a series of unique post-mortem studies on the brains of men who had committed suicide in Canada (21) found that the chemical coating on genes seem to have been influenced by exposure to childhood abuse. Additional indirect evidence came from the Dutch Famine Birth Cohort study (22) who concluded that exposure to acute, severe famine during pregnancy alters the distribution of birth weights of both the women born at the time of the famine and, through a phenotypic response, that of their own offspring. Even though it is clearly difficult to separate phenotypic (i.e., potentially modifiable) and genotypic (i.e., immutable) effects across generations, the complex mechanisms by which transgenerational transmission of stress responsiveness occur are rapidly becoming a focus of investigation (23). Rachel Yehuda and her team from the Mount Sinai School of Medicine have been at the forefront of this research for more than a decade (24). Having found that parental PTSD appeared to be a relevant risk factor for the development of PTSD in adult offspring of Holocaust survivors with PTSD, Yehuda and Bierer (25) summarized recent neuro-endocrine studies in offspring of parents with PTSD. These studies indicated that offspring of trauma survivors with PTSD had significantly lower urinary cortisol excretion and salivary cortisol levels as well as enhanced plasma cortisol suppression than offspring of survivors without PTSD. In all cases, neuro-endocrine 36

measures were negatively correlated with severity of parental PTSD symptoms, even after controlling for PTSD and other symptoms in offspring. Though the majority of their work focused on adult offspring of Holocaust survivors, more recent observations in infants born to mothers who were pregnant on 9/11 demonstrated that low cortisol in relation to parental PTSD appears to be present early in the course of development and may be influenced by gluco-corticoid programming in unborn children. Lower cortisol levels were found in mothers who developed PTSD after exposure to the attacks on September 11 compared with similarly exposed mothers who did not develop PTSD (26). Pregnant women, who had been close to the World Trade Center on September 11th, 2001, gave birth to babies who had elevated levels of stress agents in their saliva (27-29). These data suggest that effects of maternal PTSD on cortisol can be observed very early in the life of the offspring and highlight the in utero effects as contributors to biological risk factor for PTSD (30). Since low cortisol levels are particularly associated with the presence of maternal PTSD, the findings suggested the involvement of epigenetic mechanisms. In a more recent study on combat war veterans with and without PTSD, this line of research was continued and the PTSD+ group again showed greater cortisol and ACTH suppression (31, 32). In an early study of maternal Hypothalamic-PituitaryAdrenal Axis (HPA-axis) functioning, Schechter et al. (33) measured maternal salivary cortisol within a clinical sample of mothers before and after a mother-child interaction protocol involving separations and reunions. The study showed modest, but significant associations between pre-separation cortisol as well as cortisol reactivity with the severity of maternal PTSD, dissociative symptoms, and atypical care giving behavior. Later studies of gene environment interactions focused on environmental stressors such as interpersonal violence and the regulatory effects of the serotonin transporter gene and other genes with which it is known to interact on the HPA axis (34). Apparently, parenting itself may be epigenetically transmitted from parent to child. In a fascinating study of gene-environment interaction, Beaver and Belsky (35) recently found a significant interaction between parenting quality and cumulative genetic plasticity in the prediction of parental stress during adulthood. Depending on genotype, parenting quality was thus shown to differentially affect future parental stress. Exposure to maternal

Natan P.F. Kellermann

parenting was measured prospectively when respondents were adolescents and parental stress was measured when they were parents themselves, some 14 years later. Some genes that seem to affect neural plasticity were shown to be involved and the variation in these genes affected parental behavior and the response to stressful parenting. Finally, a range of different neurotransmitters have been investigated, from serotonin and dopamine to neuro-peptide Y, brain-derived neuro-trophic factor, and the gluco-corticoid receptor in the predisposition to PTSD. In their review of molecular genetic studies relating to PTSD, Broekman, Olff and Boer (36) found inconsistent results among eight major genotypes: serotonin (5-HTT), dopamine (DRD2, DAT), gluco-corticoid (GR), GABA (GABRB), apolipoprotein systems (APOE2), brain-derived neuro-trophic factor (BDNF) and neuropeptide Y (NPY). According to Binder et al. (37), several single-nucleotide polymorphisms (SNPs) in FK506 binding protein 5 (FKBP5) interact with childhood trauma to predict severity of adult PTSD. These findings suggest that individuals with these SNPs who are abused as children are more susceptible to PTSD as adults (38). As can be seen from the above examples, the potential for creative research in this field is huge. However, though it is widely accepted that epigenetic factors can play an important role in the development and transmission of PTSD, “there have been no empirical demonstrations of epigenetic modifications per se in association with PTSD or PTSD risk” (12, p. 430). Uncovering the heritable biomarkers that are involved in TTT would thus be an important task for future research. Many years of brain research has shown that human beings are “hard-wired” for stress through an intricate pattern of neural pathways designed for the fight-orflight response. Research also suggests that chronic stress appears to destroy brain tissue, specifically the hippocampus and much of research on the fear response in humans has focused on the activating of the amygdala in subjects with PTSD (39). Intergenerational effects related to PTSD and HPA-axis stress reactivity are also likely via epigenetic mechanisms (26). New techniques are investigated to search the genome or gene modifications that have been identified as epigenetic risk factors. But while the majority of the initial investigations into main effects of candidate genes hypothesized to be associated with PTSD risk have been negative (40), promising avenues of inquiry into the role of epigenetic modifications have been proposed and future studies of PTSD epigenotypes may help to elucidate the

neurobiology of inherited PTSD. Epigenomic studies that look at patterns of methylation in many loci and particularly on candidate genes are presently conducted in various places. Similar to the Human Genome Project (41), a new public/private collaboration has initiated a Human Epigenome Project which aims to “identify, catalogue and interpret genome-wide DNA methylation patterns of all human genes in all major tissues” (42). This project is searching for a particular form of a gene variation on a specific chromosome which makes some people more likely to develop PTSD than others. While simplified biological models may not properly capture the complex etiology of PTSD (43), and though studies of genotype may only present a limited picture of the molecular biology of this disorder, there seems to be a clear rationale for examining genetic factors in PTSD in conjunction with environmental factors, such as trauma exposure. The examination of epigenetic mechanisms together with gene expression might help refine models that explain how PTSD-risk and recovery are mediated by the environment (32). Conclusion Presenting such verifiable data of TTT would have far reaching consequences. First of all, it would continue to reinforce the paradigm shift in scientific thinking that underscores the impact of stressful events on the physiology not only of the trauma survivors themselves, but also of their offspring (23). Furthermore, improved understanding of epigenetic transmission of PTSD in children of trauma survivors would allow a more accurate diagnosis, improved prevention and more targeted treatment interventions of such clients, possibly leading to a sort of “epigenetic medicine” (44). Specific epigenetic therapies could hold promise for a wide range of biological applications, from cancer treatment to the development of induced stem cells (45), as well as for a more targeted treatment of TTT. Finally, any such verifiable data of trauma transmission would have legal consequences for generations of trauma survivors who may want to claim reparation for their epigenetically inflicted wounds. Most importantly, however, new epigenetic data have the potential to settle some controversies from previous research. Recent overviews of such research (46-49) concluded that the contrasting forces of vulnerability and resilience were both present in Holocaust survivors and their children. But how did the first generation of severely traumatized survivors achieve so much, and how 37

Epigenetic Transmission of Holocaust Trauma: Can Nightmares Be Inherited?

can their children function so well when bearing such a heavy burden? And how can we explain that offspring who came to psychotherapy complained so much about various kinds of secondary traumatization effects, while epidemiological studies repeatedly failed to show that they were any different from comparable populations? Clinical observations and controlled research were consistently divided in their assessment of this population for many decades. With the added use of epigenetics, however, this dispute becomes much more reconcilable. Epigenetic transmission models make the discrepant findings regarding the presence or absence of specific psychopathology as well as the simultaneous presence of both frailty and hardiness in this population much more explicable. Because from the point of view of epigenetics, any inherited (genetic) dispositions can be either turned on or off, and thus activate either overwhelming anxiety or sufficient coping in the same person at different times, according to certain aggravating and mitigating (environmental) factors (3). As emphasized by Yehuda and Bierer (12), “integrating epigenetics into a model that permits prior experience to have a central role in determining individual differences is also consistent with a developmental perspective of PTSD vulnerability” (p. 432). Finally, epigenetics opens up a potentially more optimistic view of health and disease in offspring of trauma survivors. Since epigenetics conveys that human beings are not only predestined, but also highly malleable creatures, they are able to reverse the deleterious effects of trauma and find some closure to the endless multigenerational saga. This may be achieved either through a variety of established psychotherapeutic interventions or through new psycho-pharmacological drugs, or a combination of both. Even though such offspring might still be more or less influenced by their genes and despite their physiological predestination, they might realize that it’s up to them to decide what to do with all of it. Instead of succumbing to the emotional effects of the past tragedies, they might search and find some kind of personal transformation journey that gives new meaning to their legacy. References 1. Dekel R, Goldblatt H. Is there intergenerational transmission of trauma? The case of combat veterans’ children. Am J Orthopsychiatry 2008;78:281-289. 2. Danieli Y. (editor) International handbook of multigenerational legacies of trauma. New York: Plenum, 1998. 3. Kellermann NPF. Holocaust trauma: Psychological effects and treatment. New York: iUniverse, 2009. 4. Skelton K, Ressler KJ, Norrholm SD, Jovanovic T, Bradley-Davino B. PTSD

and gene variants: New pathways and new thinking. Neuropharmacology 2011. Available from http://userwww.service.emory.edu/~kressle/papers/ skeltonPTSDgenevariantsReview2011Neuropharmacology.pdf 5. Kellermann NPF. Transmission of Holocaust trauma: An integrative view. Psychiatry: Interpersonal and Biological Processes 2001;64:256267. Hebrew translation: In Solomon Z, Zeitin J, editors. Childhood in the shadow of the Holocaust. Tel Aviv: HaKibbutz HaMeuchad, 2007. 6. Gampel Y. Those parents who live through me: Children of war. Jerusalem: Keter, 2010. (Hebrew). 7. Kellermann NPF. Perceived parental rearing behavior in children of Holocaust survivors. Isr J Psychiatry 2001;38:58-68. 8. Maccoby E. Parenting and its effects on children: On reading and misreading behavior genetics. Ann Rev Psychol 2000;51:1-27. 9. Jablonka E, Lamb M. Evolution in four dimensions. Cumberland, R.I.: MIT, 2005. 10. Bernstein BE, Meissner A, Lander ES. The mammalian epigenome. Cell 2007;128:669-681. 11. Eccleston A, DeWitt N, Gunter C, Marte B, Nath D. Introduction to epigenetics. Nature 2007;447:395. 12. Yehuda R, Bierer L.M. The relevance of epigenetics to PTSD: Implications for the DSM- V. J Trauma Stress 2009;22:427-434. 13. Meaney MJ, Szyf M. Environmental programming of stress responses through DNA methylation: Life at the interface between a dynamic environment and a fixed genome. Dialogues Clin Neuroscience 2005;7:103-123. 14. Van der Kolk B. The body keeps the score: Memory and the evolving psychobiology of post traumatic stress. Harv Rev Psychiatry 1994;1:253-265. 15. Jablonka E, Raz G. Transgenerational epigenetic inheritance: Prevalence, mechanisms, and implications for the study of heredity and evolution. Quart Rev Biol 2009;84:131-176. 16. Reik W, Dean WL, Walter J. Epigenetic reprogramming in mammalian development. Science 2001;293:1089-1093. 17. Franklin T, Russig H, Weiss IC, Gräff J, Linder N, Michalon A, Vizi S, Mansuy IM. Epigenetic transmission of the impact of early stress across generations. Biol Psychiatry 2010;68:408-415. 18. Bygren LO, Kaati G, Edvinsson S. Longevity determined by paternal ancestors’ nutrition during their slow growth period. Act Biotheoretica 2001;49:53-59. 19. Cloud J. Why genes aren’t destiny. Time 2010, January 6. Available from: http://www.time.com/time/health/article/0,8599,1951968,00.html 20. Pembrey ME, Bygren LO, Kaati G, Edvinsson S, Northstone S, Sjöström M, Golding B. Sex-specific, male-line transgenerational responses in humans. J Eur J Hum Gen 2006;14:159–166. 21. McGowan PO, Sasaki A, D’Alessio AC, Dymov S, Labonté B, Szyf M, Turecki G, Meaney MJ. Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. Nature Neuroscience 2009;12:342-348. 22. Lumey LH, Stein AD, Ravelli CJ. Timing of prenatal starvation in women and birth weight in their offspring: The Dutch famine birth cohort study. Eur J Obstet Gynaecol Repro Biol 1995;61:23-30. 23. Matthews SG, Phillips DI. Minireview: Transgenerational inheritance of the stress response: A new frontier in stress research. Endocrin 2010;151:7-13. 24. Yehuda R, Schmeidler J, Labinsky E, Bell A, Morris A, Zemelman S, Grossman RA. Ten-year follow-up study of PTSD diagnosis symptom severity and psychosocial indices in aging Holocaust survivors. Acta Psychiatr Scand 2009;119:25-34. 25. Yehuda R, Bierer LM. Transgenerational transmission of cortisol and PTSD risk. Progr Brain Res 2008;167:121-35. 26. Yehuda R. Current status of cortisol findings in post-traumatic stress disorder. Psychiat Clin N Am 2002;25:341-368. 27. Yehuda R, Cai G, Golier JA, Sarapas C, Galea S, Ising M, Rein T, Schmeidler J, Müller-Myhsok B, Holsboer F, Buxbaum JD. Gene expression patterns associated with posttraumatic stress disorder following exposure to the

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World Trade Center attacks. Biol Psychiatry 2009;66:708-711. 28. Chemtob CM, Nomura Y, Rajendran K, Yehuda R, Schwartz D, Abramovitz R. Impact of maternal posttraumatic stress disorder and depression following exposure to the September 11 attacks on preschool children’s behavior. Child Dev 2010;81:1129-1141. 29. Sarapas C, Cai G, Bierer LM, Golier JA, Sandro G, Marcus I, et al. Genetic markers for PTSD risk and resilience among survivors of the World Trade Center attacks. Disease Markers 2011;30:101-110. 30. Yehuda R, Engel SM, Brand SR, Seckl J, Marcus SM, Berkowitz GS. Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. J Clin Endocr Metab 2005;90:4115-4118. 31. Yehuda R, Golier JA, Bierer LM, Mikhno A, Pratchett LC, Burton CL, Makotkine I, Devanand DP, Pradhaban G, Harvey PD, Mann JJ. Hydrocortisone responsiveness in Gulf War veterans with PTSD: Effects on ACTH declarative memory hippocampal [(18)F]FDG uptake on PET. Psychiat Res 2010;184:117-127. 32. Yehuda R, Koenen KC, Galea S, Flory JD. The role of genes in defining a molecular biology of PTSD. Disease Markers 2011;30:67-76. 33. Schechter DS, Zeanah CH, Myers MM, Brunelli SA, Liebowitz MR, Marshall RD, Coates SW, Trabka KT, Baca P, Hofer MA. Psychobiological dysregulation in violence-exposed mothers: Salivary cortisol of mothers with very young children pre- and post-separation stress. Bull Men Clin 2004;68:319-337. 34. Kochanska G, Philibert RA, Barry RA. Interplay of genes and early mother-child relationship in the development of self-regulation from toddler to preschool age. J Child Psychol Psychiatry 2009;50:1331-1338. 35. Beaver KM, Belsky J. Gene-environment interaction and the intergenerational transmission of parenting: Testing the differentialsusceptibility hypothesis. Psychiat Quart 2011. Springer. Published online 06 May 2011. http://www.ncbi.nlm.nih.gov/pubmed/21553075 36. Broekman BFP, Olff M, Boer F. The genetic background to PTSD. Neuroscience Biobehavioral Rev 2007;31:348-362. 37. Binder EB, Bradley RG, Liu W, Epstein MP, Deveau TC, Mercer KB, Tang Y, Gillespie CF, Heim CM, Nemeroff CB, Schwartz AC, Cubells

JF, Ressler KJ. Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. JAMA 2008;299:1291-1305. 38. Newton P. From mouse to man: What the latest basic science research is telling us about the human mind. Psychol Today 2008, November 16. Available from: http://www.psychologytoday.com/blog/mouse-man/200811/ gene-anxiety-depression-and-posttraumatic-stress-disorder-fkbp5 39. Ressler KJ. Amygdala activity, fear, and anxiety: Modulation by stress. Biol Psychiatry 2010;67:1117-1119. 40. Segman RH, Shalev AY. Genetics of posttraumatic stress disorder. CNS Spectrums 2003;8:693-698. 41. Wise J. Consortium hopes to sequence genome of 1000 volunteers. BMJ 2008;336:237. 42. HEP: Human epigenome project. Available from: http://www.epigenome.org. 43. Videlock EJ, Peleg T, Segman R, Yehuda R, Pitman RK, Shalev AY. Stress hormones and post-traumatic stress disorder in civilian trauma victims: A longitudinal study. Part II: the adrenergic response. Int J Neuropsychopharm (CINP) 2008;11:373-380. 44. Church D. The genie in your genes: Epigenetic medicine and the new biology of intention. Fulton, Cal.: Elite Books, 2nd Edition, 2009. 45. Hamm CA, Costa FF. The impact of epigenomics on future drug design and new therapies. Drug Disc Today 2011, May 5. Available from: http://www.sciencedirect.com/science/article/pii/S1359644611001346 46. Kellermann NPF. Geerbtes Trauma: Die Konzeptualisierung der transgenerationalen Weitergabe von Traumata. Tel Aviver Jahrbuch für Deutsche Geschichte 2011;39:137-160. Göttingen: Wallstein Verlag. [German: Inherited trauma: The conceptualization of transgenerational transmission of trauma]. 47. Barel E, Van IJzendoom MH, Sagi-Schwartz A, Bakermans-Kranenburg MJ. Surviving the Holocaust: A meta-analysis of the long-term sequelae of a genocide. Psych Bull 2010;136:677-698. 48. Seligman ME. Building resilience. Harv Bus Rev 2011;89:100-106. 49. Shmotkin D, Shrira A, Goldberg SC, Palgi Y. Resilience and vulnerability among aging Holocaust survivors and their families: An intergenerational overview. J Intergen Rel 2011;9:7-21.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Changes in Heart Rate Variability before and after ECT in the Treatment of Resistant Major Depressive Disorder Ali Bozkurt, MD,1 Cem Barcin, MD,2 Mehmet Isintas, MD,1 Mehmet Ak, MD,1 Murat Erdem, MD,1 and K. Nahit Ozmenler, MD1 1

Department of Psychiatry, Gülhane School of Medicine, Ankara, Turkey Department of Cardiology, Gülhane School of Medicine, Ankara, Turkey

Abstract Background: In this study, we aimed to evaluate the effects of electroconvulsive therapy (ECT) on cardiac autonomic functions (CAF) in patients with major depressive disorder (MDD) using heart rate variability (HRV) analysis. Method: Fourteen men joined the study. Nine ECTs were administered. Holter monitoring was performed before treatment and at the end of the first, third and sixth weeks of the treatment. The Hamilton Depression Rating Scale (HAM-D) was used to assess symptom severity. Results: Seven patients responded to ECT. There was a change of 2-hour resting HF, pNN50 and RMSSD scores between week 0 and week 6. This change was not significant after week 1 and week 3. HRV values did not differ when we grouped the patients as responders and non-responders to ECT except the 2-hour resting HF value of responders between week 0 and week 6 and the 24-hour HF value of non-responders between week 1 and week 6. All observed changes showed a decrease in parameters. Overall, the LF/HF ratio did not change significantly in either analysis. HRV values did not correlate with HAM-D scores and no relation was found between treatment response and HRV analysis. After Benferroni-adjustment none of the changes were found statistically significant. Limitations: The limitations of the study are the small sample size and the absence of healthy controls.

Conclusions: A consistent change in HRV was not observed in response to ECT in patients with MDD. Accepting the HRV as a promising surrogate marker of autonomic activity, ECT does not cause a significant change in nine male treatment resistant MDD patients cardiac autonomic functions.

Introduction During electroconvulsive therapy (ECT) there are changes in autonomic nerve system activity, most of which are related to parasympathetic outflow and restricted to several minutes. After parasympathetic stimulation, the sympathetic output increases and may cause a rise in heart rate and blood pressure. This is not only due to electrical stimulation but also to the release of catecholamines from the adrenal gland. Several studies have shown dysrhythmias and transient ST-segment changes. In a study by Huuhka et al. ECT caused increases in bigeminy/trigeminy and supraventricular tachycardia, but did not increase other arrhythmias (1). The term heart rate variability (HRV) is used to characterize fluctuations in the length of the interbeat intervals that are typical for normal cardiac rhythm and can be used to assess the cardiac autonomic nervous system (2-4). The determinants of HRV are multifactorial and include the autonomic nervous system (ANS), central nervous system functioning, and emotional stressors (5, 6). The HRV

Address for Correspondence: Ali Bozkurt, MD, Chairman Department of Psychiatry, Near East University, School of Medicine, Near East Boulevard, Nicosia TRNC 922022 bozkurt30@yahoo.com

Ali Bozkurt et al.

can be measured as time domain or frequency domain. Standard deviation of normal interbeat (SDNN), standard deviation of means of all NN intervals (the time intervals between consecutive normal beats) measured from successive five minute recording segments over a 24-hour period (SDANN), the square root of the mean of the sum of the squares of differences between all adjacent NN intervals (RMSSD) and the proportion of pairs of adjacent interbeat intervals differing from each other by more than 50 milliseconds divided by the total number of recorded R-R intervals (pNN50) are time domain measures. Frequency domain measures provide an estimate of the frequency of rhythmic oscillations in heart rate. Four main ranges of frequencies are used: High frequency (0.15-0.4 Hz), low frequency (0.04-0.15 Hz), very low frequency (0.0030.04 Hz) and ultra low frequency (less than 0.003 Hz). Power (variance) of fluctuations within each frequency range is referred to as high frequency power (HF), low frequency power (LF), very low frequency power (VLF) and ultra low frequency power (ULF). HF, RMSSD and pNN50 are strongly influenced by the parasympathetic nervous system. LF might be related to sympathetic or both sympathetic/parasympathetic systems. The LF/HF ratio is a mirror of the sympathovagal balance (2, 6). SDNN and SDANN are also related to both sympathetic and parasympathetic systems. Cardiac autonomic involvement in depression in the form of decreased parasympathetic activity and increased sympathetic activity with lower HRV is known even among cardiac-healthy persons (7-9). Since it has been suggested that depression may be associated with decreased parasympathetic activity, it could be expected that treatment of depression with ECT would result in a relative increase in cardiac vagal activity (10). Nevertheless, studies on depression and HRV, mostly performed on psychiatric inpatients, have revealed conflicting results. Several studies reported a reduction of HRV while other studies reported no HRV difference in depressed patients compared to non-depressed controls (11). Some researchers suggest that depressive symptoms are associated with autonomic dysfunction in elderly men. But the rising risk of cardiovascular mortality with the increasing magnitude of depressive symptoms is not explained by its relation to autonomic dysfunction (12). In a review on the effects of ECT and antidepressants in HRV, van Zyl et al. (13) concluded that tricyclic antidepressants (TCAs) are associated with a substantial decrease in HRV and an increase in HR. The effect of selective serotonin reuptake inhibitors (SSRIs) is weaker

than that of TCAs, with a small decrease in HR but an increase in one measure of HRV. It was also concluded that no relationship between ECT and HRV had been established in the literature. Electroconvulsive therapy is an effective treatment of depression, and it is a strong stimulus to the ANS, especially in terms of the effects on the heart. An association between improvement in depression after ECT and changes in HRV has been reported by several groups of researchers. Schultz found a decrease in the HF component of HRV (reflecting decreased vagal activity) following a course of ECT in nine patients diagnosed with major depressive disorder (MDD) (mean age 42.2 years). This was in contrast to the hypothesis that ECT would cause an increase in vagal activity (10). Based on a significant correlation between changes in HRV and an improvement in the Hamilton Rating Scale for Depression (HAM-D) scores, they suggested that these findings might be related to the resolution of depression rather than to the effect of ECT. Agelink reported a significant increase in time domain measures of HRV (mean coefficient of variance and the root mean square of successive differences of R-R intervals) in eight patients (mean age 44.1 years) who favorably responded to ECT (14). Nahshoni found that cardiac vagal modulation increased significantly after ECT treatment in 11 elderly depressed inpatients (mean age 70 Âą 7 years) (15, 16). Karpyak et al. reported that standard deviation of interbeat intervals (SDNN, a measure of HRV) increased in subjects who improved with ECT but not in those who became confused and agitated (6). Although these studies showed some changes in HRV after ECT, the results were conflicting. The effects of ECT on the heart have been evaluated in other studies. Rasmussen et al. found that ECT does not have an effect on heart rate, frequency of ventricular or supraventricular events or in ST segments (17). Solimene studied 47 young adults and 38 individuals older than 50 who underwent ECT. Observed among the younger individuals was an increase in blood pressure and in heart rate, both of which returned to normal within 25 minutes. In the older group, however, the heart rate remained elevated even after one hour. These results show that while ECT may cause an increase in sympathetic activity, it is still a safe procedure for the heart (18). This study aims to evaluate the effects of ECT on cardiac autonomic functions (CAF) in patients with major depressive disorder (MDD) using HRV analysis. Our hypothesis is that ECT is a safe procedure that does not have an effect on HRV. 41

Changes in Heart Rate Variability in ECT in the Treatment of Resistant Major Depressive Disorder

Subjects and methods Subjects

The subjects were recruited from the MDD patients who were hospitalized in the inpatient unit of the Department of Psychiatry at the Gülhane School of Medicine. Fifteen patients were initially selected for the study, but one patient who used a cardio-selective β blocker during the study was left out. The patients completing the study consisted of 14 men aged 30–54 (mean 37.78 ± 6.12 years) with major depressive disorder. The diagnosis of MDD was established according to DSM-IV criteria following the guidelines of the Turkish version of the Structured Clinical Interview for Axis I DSM-IV Disorders (SCID-I/P) (19). To be included in the study, the patients had to fit the following criteria: they had to have MDD according to the SCID I; they had to have scores 19 or higher in the HAM-D-17 test; they could not have any physical risks associated with ECT; they had to be between 18 and 60 years of age; they had to join the study willingly and were asked to sign a consent form; they could not have diabetes or any known neurological, cardiac or cardiovascular disease. Patients who had normal findings on physical examination, electrocardiography (ECG) and routine blood tests and had no history, signs or symptoms of cardiovascular or neurologic disorders were included in the study. All patients were taking antidepressant medications other than tricyclics and were subjected to ECT because of non-response to pharmacotherapy. The institutional review board approved the study. After receiving a complete description of the study, written informed consent was obtained from each subject. Patients had at least two adequate trials of antidepressant medications and were considered as treatment resistant to depression. All patients were ECT naïve. The average period of their illness was 0.5–7 years (mean 3,23 ± 2.17years) since their first episodes. The patients were included in the decision making process. Any possible risks and benefits and the number of ECTs were discussed with the patients and mentioned in the informed consent. Non-responders were given the opportunity to have extra sessions of ECT after completing the study. The ECT sessions were planned to stop after the 6th ECT, assuming that there would be signs of response or remission. Since none of the patients showed signs of response or remission by the end of week 2 (6th ECT), all patients received up to 9 ECTs. Since the course length of ECT cannot be predicted, 9-10 treatments are considered to be the response criteria. Kellner et al. found that in 15 patients with major depression who were randomized to receive 3 ECT at 1/wk or 9 ECT at 3/wk, 42

the latter schedule had significantly greater reduction in depression level (20). Janakiramaiah et al. had found that all patients in three times weekly ECT (8.7±1.9) group remitted but only 11 (out of 20) remitted in once weekly group (21). They have used a mean of 8.7 ECTs. Since the number 9 and 10 are the most used frequency in literature and three times weekly usually causes more remission we have scheduled 9 ECTs for this protocol. All patients were hospitalized and then discharged after the 9th ECT. They were reevaluated after week 6. Medications

Over the course of the study all patients continued to take their antidepressants (either selective serotonin reuptake inhibitor, n=13, or trazadone, n=1) (9 patients sertraline, 2 patients paroxetine, 1 patient fluoxetine, 1 patient escitalopram). Since one inclusion criterion was non-use of tricyclic or tetracylic antidepressants, none of the patients were using those. No other psychotropic medications (neither anxiolytics nor antipsychotics) were allowed during the study period. Electroconvulsive therapy

Bilateral ECT was administered three times a week and all patients underwent a total of 9 ECTs. Electrical stimulus was provided by a Mecta Spectrum 5000Q ECT device. The seizure threshold was terminated at the first treatment. Stimuli were given by increasing intensity until a generalized seizure was induced. The anesthetic medications were thiopental (5 mg/kg) and succinylcholine (0.5 mg/kg). All patients were oxygenated by positive pressure ventilation via mask until resumption of spontaneous respiration. Treatments were given three times a week. Heart rate recording

Twenty-four-hour Holter monitoring was performed at the following times during the study: one day before ECT started, at the end of the first week; the day after the patient completed his first 3 ECTs, the day after the last ECT, three weeks after the last ECT, which is also the end of the sixth week of the study. Subjects also had a complete rest in bed between 1 and 3 pm during the 24-hour monitoring. In this way it was possible to evaluate the acute and sub-acute effects of ECT on HRV. Clinical measures

The 17-item Hamilton Rating Scale for Depression (HAM-D) was used to assess symptom severity. HAM-D was developed in 1960 by Max Hamilton at the University

Ali Bozkurt et al.

of Leeds. The scoring is based on 17 items. Eight items are scored on a 5-point scale ranging from 0 (not present) to 4 (severe). Nine are scored 0 to 2. The sum of the scores from the 17 items are described as following: 0 to 7 (normal), 8 to 13 (mild depression), 14 to 18 (moderate depression), 19 to 22 (severe depression), ≥ 23 (very severe depression). HAM-D is frequently used in clinical practice and has become a standard in trials. Rating scales were obtained before ECT sessions, weekly during ECT sessions and three weeks after the completion of the ECT course. Clinical response to ECT was defined as 50% or more decrease of HAM-D scores from baseline to endpoint of the clinical trial. Statistical analysis

Since the data was not normally distributed, Friedman and Wilcoxon signed rank tests were used to analyze the continuous variables. The relationship between the values of HRV and HAM-D scores was evaluated by Spearman correlation coefficients. A “p” value of less than 0.05 was considered significant in all analyses. For adjustment the significance level using Bonferroni’s correction we have divided the p values by the number of comparisons. Results The mean HAM-D score of patients before treatment was 27.64 ± 4.71 and decreased to 14.64 ± 4.14 after ECT treatment (p<0.01). Of the 14 patients with major depressive

disorder, 7 patients responded to ECT. In patients who responded to ECT, the mean HAM-D score decreased from 25.85 ± 3.97 to 11.00 ± 0.81 (p<0.01, Z= -2.14). The mean scores of responders and non-responders are given in the Table 1. Three patients responded to treatment at the end of week 3 (after ECT 9), and by the end of week 6, three more responded. One of the first three responders had a relapse, but then four additional patients responded. When we analyzed 14 subjects together (Table 2), the HF scores decreased significantly at the end of the treatment compared to the pre-treatment scores (baseline 239. 41 ± 128. 47; end of study 178. 57 ± 112. 11; Z= -2.14, p=0.033). The change in HF scores is seen during the 24-hour recording that occurred between week 0 and week 6. The change of HF is also significant between week 0 and week 6 in the two-hour resting scores (baseline 223.29 ± 100.69; end of study 137.29 ± 75.43; Z= -2.42, p=0.016). There is a similar decrease seen in the pNN50 and RMSSD scores. But the changes are significant only in the 2-hour resting scores between week 0 and week 6 (baseline 9.14 ± 7.05; end of study 5.38 ± 4.23; Z= -2.14, p=0.032; baseline 29.86 ± 7.94; end of study 24.50 ± 6.56; Z= -2.36, p=0.018 respectively). All parameters show a decrease, which actually shows a decrease in parasympathetic tonus. But the change was not significant after the first 3 ECT procedures in week 1 and after the 9 ECT procedures at the end of week 3. Pre- and post-treatment HRV values did not differ when we grouped the patients

Table 1. Changes in Mean HAM-D Scores of All Patients Before Treatment

Week 1 After 3 ECT

Week 3 After 9 ECT

Week 6 End of Treatment

Statistic

Responders

25,86 ± 3,98

23,57 ± 4,79

16,00 ± 4,69

11,00 ± 0,82

Z= -2.371 p= 0.018a

Non- responders

29,43 ± 5,00

27,14 ± 4,85

21,00 ± 5,32

18,29 ± 2,36

Z= -2.371 p= 0.018a

Difference between week 0 and week 6.

Table 2. Changes in Mean HRV Scores of All Patients Before Treatment

Week 1 After 3 ECT

Week 3 After 9 ECT

Week 6 End of Treatment

Statistic

pNN50

9.93 ± 7.42

12.07 ± 6.80

8.92 ± 6.47

7.30 ± 6.18

RMSSD

30.21 ± 9.48

33.36 ± 8.24

29.29 ± 8.12

27.29 ± 7.13

1091.54±1331±02

765.57±382.84

708.86±313.31

718.21±352.54

239.41±128.47

256.71±134.42

201.00±118.79

178.57±112.11

Z= -2.14 p= 0.033a

LF/HF

3.42±1.20

3.17±1.09

3.94±1.72

4.43±1.88

Difference between week 0 and week 6. NS: Not significant

Changes in Heart Rate Variability in ECT in the Treatment of Resistant Major Depressive Disorder

Table 3. Changes in Mean HRV Scores of Responders and Non-Responders to Treatment

pNN50 RMSSD LF

LF/HF a

Before Treatment

Week 1 After 3 ECT

Week 3 After 9 ECT

Week 6 End of Treatment

Statistic

Responders

11.00±7.33

13.00±8.00

11.67±7.45

9.86±7.06

Non-responders

8.86±7.93

11.14±5.84

6.57±4.86

4.33±3.50

Responders

31.71±9.18

34.57±9.59

32.00±9.07

30.29±7.57

Non-responders

28.71±10.26

32.14±7.20

26.57±6.58

24.29±5.65

Responders

1438.37±1815.61

697.57±228.91

776.86±212.02

818.86±304.28

Non-responders

744.71±511.29

833.57±504.34

640.86±396.15

617.57±391.23

Responders

233.24±102.82

215.57±82.69

201.29±99.99

200.86±127.97

Non-responders

245.57±158.43

297.86±168.40

200.71±143.44

156.29±98.48

Z= -2.37 P=0.018a

Responders

3.49±1.16

3.54±1.40

4.58±2.10

4.78±1.73

Non-responders

3.34±1.33

2.80±0.54

3.30±1.02

4.07±2.08

Difference between week1 and week 6. NS: Not significant

as responders and non-responders to ECT except the resting 2-hour HF value of responders between week 0 and week 6 (baseline 206.86 ± 95.43; end of study 122.86 ± 34.29; Z= -2.03, p=0.043) and the 24 hours HF value of non-responders between week 1 and week 6 (baseline 297.86 ± 168.40; end of study 156.29 ± 98.48; Z= -2.37, p=0.018) (Table 3). Again, there was a decrease of parasympathetic tonus. There were no significant changes in other time domain measures. Overall the LF/HF ratio did not change significantly in either analysis. HRV values did not correlate with HAM-D scores and no relation was found between treatment response and HRV analysis (p>0. 05). Discussion The results of this study revealed that in nine male treatment resistant MDD patients, ECT had no major and consistent impact on HRV parameters that were used as surrogate markers of CAF. Some studies reported variable changes in HRV after ECT (6, 10, 14, 15), but none of them used 24-hour ECG monitoring, which is important because circadian rhythms may influence HRV. We used 24-hour Holter monitoring in order to avoid circadian rhythm bias and repeated the HRV recordings one week after the initial ECT, immediately after ECT sessions and three weeks after sessions ended to evaluate both acute and sub acute effects of ECT on HRV. Although we have analyzed the HRV three weeks after the last ECT we cannot interpret that these changes are related to the delayed effects of ECT. We also used a resting period between 1 and 3 pm 44

in every recording. This gave us the chance to compare full resting HRV changes. As pointed out by Karpyak et al. (6), in some studies there were specific restrictions applied on patients’ activities, such as on breathing and talking (10, 14, 15). Such restrictions may affect HRV measures and were avoided in this study. The findings reveal only a few HRV changes. One is the difference of HF during resting between pre-treatment and the end of study measures. First of all, these changes were seen in both resting and 24-hour recordings at the end of week 6. But they were not seen after the 3 ECTs at end of week 1 and after 9 ECTs at the end of week 3. The last ECT was at the end of week 3 and the last Holter monitoring at the end of week 6. So the Holter monitoring changes at the end of week 6 cannot be interpreted as an immediate effect of ECT. We know that response rates to ECT are very high, but relapse after discontinuation is also high. A possible cause could be that patients who responded to ECT were likely candidates for relapse, and the first signal of this could be the decreasing parasympathetic tonus. But neither the HAM-D nor the clinical interview showed any indication of relapsing. We cannot explain this finding as Schultz et al. did (10). They suggested that such a finding might be related to the resolution of depression, or the treatment of depression with ECT may be associated with cardiac vagal withdrawal. But in our study there was no correlation between HAM-D scores and changes of parasympathetic tonus markers (HF, RMSSD, pNN50). The mechanism of action is not clear. When we analyzed all subjects (responders and nonresponders) together, there was a decrease in parasympa-

Ali Bozkurt et al.

thetic tonus too. This was seen in both 24-hour recording and resting recordings of HF, resting recordings of pNN50 and RMSSD. But the change was only significant between pre-treatment and end of week 6. There were no changes observed during week 1 and week 3 compared to pretreatment values. It may be suggested that the effect of ECT was not directly responsible for those changes, or, as suggested by Schultz et al. (10), at least in some patients there might have been a vagal withdrawal, which was observed late (in week 6) in this study. Grouping subjects as responders and non-responders did not show changes related to the theoretical point that cardiac autonomic involvement in depression should decrease parasympathetic activity, which increases after treatment. The change in pre- and post-treatment HRV values is only seen in the resting 2-hour HF value of responders between week 0 and week 6 and the 24-hour HF value of non-responders between week 1 and week 6 that does not show an increase in parasympathetic activity. Here again the changes did not occur immediately after ECT. When we compare results with similar studies, Karpyak et al. (6) reported SDNN increase in patients which acutely responded to ECT. The increase has continued in subjects with sustained response but not in subjects who relapsed. Nahshoni et al. (15) reported that cardiac vagal modulation increased after ECT and was associated with symptom improvement. Different from these findings Schultz et al. (10) found cardiac vagal withdrawal (decreased parasympathetic activity) after treatment of depression with ECT. They concluded that this could be found in some patients. Comparing all studies with our study there were different approaches used in data analysis. Karypak et al. used SDNN, Nahshoni et al. LF/HF proportion and Shultz et al. respiratory sinus arrhythmia and RR interval. Rasmussen et al. (17), although methodologically very different, used heart rate, frequency of ventricular or supraventricular events or in ST and found no change in these parameters before and after ECT. Since the discrepancy between results might be related to different parameters we have used a broader number of parameters including time domain variables SDNN, SDANN, RMSSD, and pNN50, and the frequency domain variables HF and LF. We did not find major and consistent changes in all HRV parameters which we have used in our study. Overall we can conclude that ECT does not have direct effects on HRV in 9 male treatment resistant MDD patients since the mirror of sympathovagal balance (LF/HF) did not change. One of the important findings that Karpyak et al. addressed was that the SDNN was significantly lower at

baseline in the group of subjects that relapse within three weeks after ECT compared with the group with sustained response. We have found that the SDNN, SDANN, RMSSD, pNN50, LF, HF and LF/HF are not different at baseline when we compare groups as responders or non-responders. Since the data were not normally distributed nonparametric tests were used. Bonferroni correction is necessary in order to correct for multiple testing in the same data set. We divided the p values by the number of comparisons. Since there were four tests being compared we divided p value (0.05/4=0,125). After Bonferroniâ&#x20AC;&#x2122;s correction found no significant difference in any parameters that were compared. This supports our hypothesis that ECT does not have an effect on HRV. In taking a closer look at the results, we found that none of our subjects had a clinical response after the 6th ECT at the end of week 2. Only subject 4 had a decrease of HAM-D from 22 to 12 at that point. Three other subjects, 1, 3 and 6, had a decrease more than 25% at end of week 2 (26%, 31%, and 28% respectively). All other 10 subjects had a decrease in HAM-D of less than 25% at end of week 2. Subjects 2, 4 and 6 had a decrease of more than 50% at the end of week 3 (9th ECT). The changes of SDNN of those three subjects are 59-59, 65-52 and 52-61; so one did not change, one increased and one decreased slightly. These results may be compared with those of responders of whom four had a decrease (58-50, 49-36, 71-58, 60-48), three had an increase (43-50, 49-58, 34-40), and four had a slight change (58-61, 41-42, 71-69, 59-62). Therefore SDNN cannot predict an early response relation. When we compare RMSSD, pNN50, LF and HF changes in these early responders, changes are similarly in different directions. When we compare responders and non-responders at end of week 6 we cannot find a specific type of change as described by Karypak et al. (6). For example, SDNN decreased in four responders and increased in three. It increased in one of non-responders and decreased in six non-responders. This suggests that the changes of different parameters cannot be used as possible predictors of response. One limitation of this study is the fact that the patients were taking psychotropic medications. Studies on the effects of psychotropic medications on HRV revealed that TCAs were associated with a decline in most measures of HRV and a significant increase in HR in studies with short recording intervals. No significant changes were found for longer recording times (13). Treatment effects with SSRIs were more variable. Short recording studies revealed a significant decrease in HR and an increase 45

Changes in Heart Rate Variability in ECT in the Treatment of Resistant Major Depressive Disorder

in one HRV measure. In two 24-hour recording studies no significant changes were observed (13). In this study, patients were mostly treated with SSRIs (13 of 14 patients; one patient taking trazadone), and they all continued to take their medications throughout the study. Another limitation of the study is that we did not compare depressive patients who are not treated with ECT or subjects who are healthy. In conclusion a consistent change was not observed in HRV in response to ECT in patients with MDD. This result was true for both responders and non-responders to ECT as reflected in the HAM-D scores. Accepting the HRV as a promising surrogate marker of autonomic activity, we may speculate that ECT does not cause an immediate significant change in cardiac autonomic functions. There was also no change three weeks after the last ECT, but to evaluate the delayed effects of ECT we need reevaluation of HRV after longer periods. However, the sample size in this study is too small to make a definite conclusion and further research with larger sample sizes is necessary to clarify the relationship between ECT and HRV. References 1. Huuhka MJ, Seinela L, Reinikainen P, Leinonen, VJ. Cardiac arrhythmias induced by ECT in elderly psychiatric patients: Experience with 48-hour holter monitoring. J ECT 2003; 19:22–25. 2. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation 1996;93:1043–1065 3. Low PA, Pfeifer MA. Standardization of autonomic function. In: Low PA, editor. Clinical autonomic disorders. Boston: Little, Brown, 1997: pp. 287– 295. 4. Sztajzel J. Heart rate variability: a noninvasive electrocardiographic method to measure the autonomic nervous system. Swiss Med Wkly 2004; 134: 514–522. 5. Berntson GG, Bigger JT, Jr, Eckberg DL, Grossman P, Kaufmann PG, Malık M, Nagaraja HN, Porges SW, Saul JP, Stone PH, Van Der Molen MW. Heart rate variability: Origins, methods, and interpretive caveats. Psychophysiology 1997; 34: 623-648. 6. Karpyak VM, Rasmussen KG, Hammill SC, Mrazek DA. Changes in heart rate variability in response to treatment with electroconvulsive therapy. J ECT 2004; 20:81–88.

7. Agelink MW, Majewski T, Wurthmann C, Postert T, Linka T, Rotterdam S, Klieser E. Autonomic neurocardiac function in patients with major depression and effects of antidepressive treatment with Nefazodone. J Affect Disord 2001; 62: 187–198. 8. Tulen JHM, Bruijn JA, de Man KJ, Van Der Velden E, Pepplinkhuizen L, Man In‘t Veld AJ. Anxiety and autonomic regulation in major depressive disorder: an explorative study. J Affect Disord 1996; 40: 61–71. 9. Udupa K, Sathyaprabha TN, Thirthalli J, Kishore KR, Raju TR, Gangadhar BN. Modulation of cardiac autonomic functions in patients with major depression treated with repetitive transcranial magnetic stimulation. J Affect Disord 2007; 104: 231–236. 10. Schultz SK, Anderson EA, van de Borne P. Heart rate variability before and after treatment with electroconvulsive therapy. J Affect Disord 1997; 44:13–20. 11. Van der Kooy KG, van Hout HPJ, van Marwijk HWJ, de Haan M, Stehouwer CDA, Beekman ATF. Differences in heart rate variability between depressed and non-depressed elderly. Int J Geriatr Psychiatry 2006; 21: 147–150. 12. Kamphuis MH, Geerling MI, Dekker JM, Giampaoli S, Nissinen A, Grobbee, DE, Kromhout D. Autonomic dysfunction: a link between depression and cardiovascular mortality? The FINE study. Eur J Cardiovasc Prev Rehabil 2007; 14: 796-802. 13. Van Zyl LT, Hasegawa T, Nagata K. Effects of antidepressant treatment on heart rate variability in major depression: A quantitative review. Biopsychosoc Med 2008; 2: 1-10. 14. Agelink MW, Lemmer W, Malessa R, Zeit T, Klieser E. Improvement of neurocardial vagal dysfunction after successful antidepressive treatment with electroconvulsive therapy (ECT). Eur Psychiatry 1998; 13:259s. 15. Nahshoni E, Aizenberg D, Sigler M, Zalsman G, Strasberg B, Imbar S, Weizman A. Heart rate variability in elderly patients before and after electroconvulsive therapy. Am J Geriatr Psychiatry 2001; 9:255–260. 16. Nahshoni E, Aizenberg D, Sigler M, Strasberg B, Zalsman G, Imbar S, Adler E, Weizman A. Heart rate variability increases in elderly depressed patients who respond to electroconvulsive therapy. J Psychosom Res 2004; 56, 89-94. 17. Rasmussen KG, Karpyak VM, Hammil SC. Lacks of effect of ECT on holter monitor recordings before and after treatment. J ECT 2004; 20, 1: 45-47. 18. Solimene MC. Electroconvulsive therapy and heart. Int J Cardiol 2007; 114:103. 19. Koroglu E. Turkish version of DSM-IV-TR. Translated from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000. 20. Kellner CH, Monroe RR Jr, Pritchett J, Jarrel MP, Bernstein HJ, Burns CM. Weekly ECT in geriatric depression. Convuls Ther 1992; 8: 245-252. 21. Janakiramaiah N, Motreja S, Gangadhar BN, Subbakrishna DK, Parameshwara G. Once vs. three times weekly ECT in melancholia: A randomized controlled trial. Acta Psychiatr Scand 1998; 98: 316-320.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Amitai Abramovitch et al.

Correlates of Physical Activity with Intrusive Thoughts, Worry and Impulsivity in Adults with Attention Deficit/Hyperactivity Disorder: A Cross-sectional Pilot Study Amitai Abramovitch, PhD,1 Gil Goldzweig, PhD,2 and Avraham Schweiger, PhD2 1

Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, U.S.A. Department of Behavioral Sciences, the Academic College of Tel Aviv, Israel

Abstract Background: Physical exercise is known to produce numerous psychological beneficial effects in healthy and clinical populations. Nevertheless, little is known about the relationship between exercise and ADHD symptoms, let alone among adults with ADHD. This study examines the association between exercise and three ADHD symptoms: (1) behavioral impulsivity; (2) intrusive unwanted thoughts and (3) worry. The latter two are cognitive facets of anxiety, a prominent symptom of ADHD. Methods: Physical activity was measured using a selfreport questionnaire. Thirty participants with a diagnosis of ADHD were divided into two groups: Participants engaging in frequent aerobic activity (“high activity” group), and participants engaging in non-frequent physical activity (“low activity” group). Results: Adults with ADHD engaging in frequent aerobic physical activity report significantly less behavioral impulsivity and experience significantly less worrisome and intrusive thoughts. Conclusions: Our results reflect an association between physical activity and reduced symptoms of impulsivity and intrusive and worrisome thoughts in an adult ADHD sample. The results of this pilot study may encourage further investigations emphasizing the causal link between physical activity and ADHD symptoms. Suggested underlying neurobiological mechanisms, clinical implications and limitations are discussed.

Introduction Attention Deficit/Hyperactivity Disorder is a neurodevelopmental disorder characterized prominently by inattention, impulsivity and hyperactivity (1) that persist into adulthood (2-4). This debilitating and burdensome condition has a worldwide estimated prevalence of approximately 5.3% in children and adolescents (5) and 4.4% in adults (2). Physical activity: psychological and cognitive correlates. Research indicates that together with improving physical health, physical activity reduces anxiety, depression and enhances general psychological functioning in clinical and non-clinical populations (6-11). Wipfli and colleagues (12) conducted a meta-analysis of randomized controlled trials examining the anxiolytic effects of exercise. The authors found that an overall significant reduction of anxiety was observed in exercise groups in comparison with non-treatment control groups. Moreover, the authors reported that the exercise groups demonstrated greater reduction in anxiety in comparison with other forms of anxiety-reducing treatments (12). Notably, research reveals that physical activity may be also associated with improvement of cognitive functioning (13). In an attempt to elucidate the nature of the effects of physical activity, a growing body of literature suggests that physical activity may alter monoamines transmission (13, 14). In brief, physical exercise causes a change in the metabolism of the three monoamines: Serotonin, Dopamine and Norepinephrine. This alteration of monoamine metabolism may underlie the physiological mecha-

Address for Correspondence: Amitai Abramovitch, PhD, Department of Psychiatry, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, U.S.A. aabramovitch@partners.org

Physical Activity with Intrusive Thoughts, Worry and Impulsivity in Adults with Adhd

nisms that are associated with psychological, behavioral and emotional effects of exercise (15-17). Anxiety, intrusive thoughts and worry Anxiety disorders and symptoms of anxiety are highly associated with ADHD in childhood as well as in adulthood (2, 18-20). Kessler and his colleagues (2) analyzed results from the U.S. national comorbidity survey replication and found that within the adult ADHD population, 47.1% were diagnosed with an anxiety disorder compared with only 19.5% in the non-ADHD group. However, investigations addressing the association between anxiety and ADHD typically focus on the affective facet of anxiety, either by examining anxiety disorders as a separate comorbid entity associated with ADHD (2, 21), or by examining symptoms of anxiety (22). Regardless of the methodology used, the majority of studies predominantly examined the affective aspect of anxiety in ADHD, but not its cognitive expression. Worrisome and intrusive thoughts are two cognitive features of anxiety. Perrin and Last (23) compared three groups of children: a non-clinical group, a group diagnosed with anxiety disorder, and a group diagnosed with ADHD. The authors found a significant difference between the nonclinical group and both clinical groups in the total number of intense worries. No difference was found between the anxious group and the ADHD group (23). Borkovec et al. (24) defined worry as “thoughts or images that generate a negative affect and are relatively uncontrollable.” Wells (25) outlined three aspects of worry: meta-worry, social worry, and health worry. Meta-worry is defined by Wells as “worry about worry...worry about the controllability of thoughts and the appraisal of thoughts as intrusive.” Similar to meta-worry, intrusive thoughts are associated with the cognitive aspect of anxiety (26). Unwanted intrusive thoughts are typically attributed to an internal origin and are defined as repetitive, unacceptable or unwanted thoughts, images or impulses (27). It has been argued that intrusive thoughts and worry are functionally similar and share common processes over much of a continuum (28), and are systematically associated (29). Turner et al. (30) suggest that there are some differences between the two phenomena. Among them are that worry is more ego-syntonic than intrusive thoughts, and that worry occurs as verbal thoughts, whereas intrusive thoughts occur as thoughts, images and impulses (30). To our knowledge, only one study examined worrisome and intrusive thoughts in adults diagnosed with ADHD. Abramovitch and Schweiger (31) 48

compared healthy controls with a group of young adults with ADHD and found that the ADHD group experienced significantly more social and meta-worries, and a significantly greater frequency of intrusive unwanted thoughts. In the same study, individuals in the ADHD group were found to be significantly more disturbed and sad regarding the intrusive thoughts and images they experienced and showed significantly greater difficulty in removing those thoughts from their minds. The authors suggested that given the prominent inhibitory deficit characteristic of this syndrome, individuals with ADHD may experience difficulties inhibiting those thoughts (31). Attention Deficit/Hyperactivity Disorder is considered a neuropsychiatric disorder, and extensive body of neurobiological research suggests that ADHD is characterized with a pattern of under-activity in prefrontal and striatal regions of the brain, as well as deficiencies in dopaminergic frontostriatal connectivity systems (32-36). An abundance of research also suggests that individuals with ADHD are characterized with impairments in tests of response inhibition (37, 38), defined as the ability to inhibit an already activated motor response (39). A common explanation for this deficit was motivated by neuroimaging research on ADHD, in which metabolic under-activity of specific prefrontal and striatal regions were identified (32, 34). Thus, behavioral impulsivity and deficient response inhibition in ADHD are thought to stem from metabolic under-activity of the inhibitory/ executive control system (37, 40). During the past twenty years, researchers and clinicians have been advocating physical activity for ADHD individuals as an adjunct treatment (41, 42). This fairly widespread notion has been usually supported by the combination of intuitive and scientific arguments (e.g., physical activity is scientifically proven to be healthy, and hyperactive individuals should exercise in order to dispose of excess energy). Nevertheless, even today, there is a dearth of research on the impact of physical activity in ADHD. In fact, to our knowledge only two studies investigated the correlates of physical activity in ADHD, and specifically the psychomotor and cognitive correlates. In an attempt to investigate the impact of physical activity in children with ADHD, Tantillo and her colleagues (43) examined the effect of treadmill walking on spontaneous and acoustic startle eye blink response and motor impersistence in 18 children diagnosed with ADHD. Whereas the authors reported mixed results, a significant effect of physical exercise was demonstrated, prompting the author’s conclusion that physical activ-

Amitai Abramovitch et al.

ity has an impact on behavioral and cognitive function in children with ADHD. Interestingly, this effect was not found in non-ADHD matched controls (43). In the second study, Hopkins and his colleagues (44) examined the impact of physical activity on attentional orienting, social interactions and locomotor activity in a rat model of ADHD. Results points to an impact of physical activity on attentional orientation and social interaction. The authors of both studies conclude that their findings, while not without limitations, are significant as well as novel and should encourage additional research in this field. In sum, the existing data on the effects of physical exercise on depression and anxiety, along with evidence of the impact of exercise on dopamine and norepinephrine modulation and recent pioneering work on ADHD, increases the likelihood that exercise may have a positive impact on cognitive, behavioral and emotional symptoms in ADHD. Nevertheless, to our knowledge the association between physical activity and adult ADHD symptomatology has never been empirically investigated, let alone its impact on the cognitive aspects of anxiety (e.g., intrusive and worrisome thoughts). Therefore, this study aims at examining the association between physical exercise and impulsivity, intrusive unwanted thoughts and worrisome thoughts in adults with ADHD. We hypothesized that individuals diagnosed with ADHD that engage in frequent physical activity will report less behavioral impulsivity, intrusive and worrisome thoughts than individuals with ADHD that do not, or infrequently engage in physical activity. Method Subjects

Thirty-seven male college students diagnosed exclusively with ADHD (the inclusion criterion) enrolled in a support center for students with learning disabilities and ADHD at a college in northern Israel volunteered to participate in this study. The preliminary screening process included the selection of participants for which a board psychiatrist formal diagnosis of ADHD was on file. Subsequently, all participants were pre-screened using a detailed semi-structured interview to rule out other comorbid psychiatric disorders. Exclusion criteria were as follows: 1) any formal diagnosis of any other DSM-IV psychiatric disorders, 2) any history of prescribed psychiatric medications and hospitalization, 3) any history of a neurological disorder or insult 4) any known or reported history of other learning disabilities. Only males were used in this study due to the relative

small number and difficulty in recruiting adult females with ADHD (45). Of the original 37 participants, only 30 participants fulfilled the diagnosis of ADHD using DSM-IV criteria (and confirmed by the Continuous Performance Test II [46]), and met inclusion/exclusion criteria. This final group constituted the experimental group and all participants were not taking stimulant medication. Diagnoses were established additionally by the third author, an experienced clinical neuropsychologist. The mean age for the group was 27.29 (SD = 5.87). This study was approved by the Institutional Review Board. All participants signed an informed consent in accordance with the declaration of Helsinki. Measures A DSM IV based questionnaire (1) was created covering all the necessary diagnostic criteria for ADHD diagnosis. Participants were asked to indicate whether they exhibited each presented behavior in the past six months and/or in childhood (before the age of 7). Of note, research suggests that DSM-IV-based self-report measures have sound psychometric properties in terms of diagnostic validity, and do not differ significantly from structured ADHD rating scales (47). The Conners’ Continuous Performance Test, 2nd edition (CPT-II) (46) was used as a secondary assessment tool for the ADHD diagnostic process. The CPT-II is a computer based sustained attention test. Respondents are required to press the mouse button when any letter except the target letter “X” appears. The CPT-II was administered using a laptop personal computer and took approximately 14 minutes to complete. The CPT-II has adequate reported reliability (Split half coefficients on all measures ranging from 0.73 to 0.95[46]). The Distressing Thoughts Questionnaire (DTQ), (48), measures 6 prominent anxious thoughts and 6 depressive thoughts, each along 5 dimensions; frequency, sadness, worry, removal and disapproval. The latter 5 are compiled by summing their values in each criterion (e.g., depressive and anxious). The DTQ subscales are reported to have internal consistency coefficients above .70 (48). The DTQ was found to correlate with State Trait Anxiety Inventory-State scale (r’s from .23 to .62) (49), with the Cognitive and Somatic subscale of the Cognitive-Somatic Anxiety Questionnaire (r’s from .33 to .57;(49)) and with the Beck Depression Inventory (r’s from .31 to.79 [49]). In addition the DTQ correlated with the Eysenck Personality Questionnaire – Neuroticism Scale (r’s from .36 to .59) (50). 49

Physical Activity with Intrusive Thoughts, Worry and Impulsivity in Adults with Adhd

The Anxious Thoughts Inventory (AnTI, Wells, 25) evaluates three dimensions of worry: social worry, health worry and meta-worry (i.e., worry about the controllability of thoughts and appraisal of thoughts as intrusive) (51). The AnTI which was translated into Hebrew, has 22 items; 9 items related to social worry, 6 items related to health worry and 7 items related to meta-worry. The responses are given on a 1 (almost never) to 4 (almost always) Likert scale. The AnTI was reported to have good psychometric properties (25). Cronbach alpha coefficients of the subscales reported by the authors were all .75 and above (25). All four subscales of the AnTI (e.g., social worry, health worry, meta-worry and total worry) were reported to have significant correlations with the Spilberger Trait Anxiety subscale, Eysenck Neuroticism subscale and the Self-Consciousness Inventory (25). The Eysenck Impulsivity-Venturesomeness-Empathy questionnaire (IVE) (52) is a 63 item questionnaire designed to assess impulsivity venturesomeness and empathy. The items from the latter scale were added in order to be used as buffer items (52), and were not included in our statistical analyses. The IVE has reported reliability coefficients of .79 and .85 for venturesomeness and impulsivity, respectively (52). Investigation of this scale’s construct validity was conducted by the authors and showed that impulsivity correlated moderately with psychotism (r =.52), and venturesomeness with extraversion (r = .46) of the Eysenck Personality Scale. Measure of physical activity

In order to assess physical activity, a leisure time activities questionnaire was constructed. Our decision to create a novel questionnaire was due to the fact that a similar published questionnaire did not use buffer items and was very explicit in terms of its face validity (53). We considered this explicit nature of the questionnaire as being a potential bias, producing undesirable demand characteristics for the participants. This questionnaire contained 30 items compiled into 4 subcategories: sport and physical activities, general leisure time activities, book reading preferences and movie preferences. The latter three subcategories were used as filler and distracter items in order to conceal the true focus of the study on physical activity, and thus minimizing the potential response bias. The physical exercise subscale contained seven common physical activities with a major aerobic component (e.g. walking, jogging, competitive sports and bicycling). All activities were defined as lasting at least 30 minutes each time it was performed. Participants were asked to select 50

the average number of times each activity was performed each week for the past six months. The IVE, DTQ and the AnTI questionnaires were administered to a group of Hebrew native speakers, agematched normal controls, to ensure the equivalence of the translations. When comparing this group’s results to the original and other control samples published in the scientific literature, no significant differences were found. Procedure

Participants completed initially the DTQ, AnTI, and the DSM questionnaire, following careful instructions. They were told that no time limit is imposed on completion of the questionnaires. All subjects subsequently completed the CPT-II individually. The completion of the five questionnaires took approximately 35-45 minutes. Next, participants were given a 10 minute break, and then were directed to another secluded classroom where they completed the CPT-II. Each participant was seated in front of a computer and was given instructions concerning the test completion. The completion of the CPT-II took an average of 14 minutes. Statistical analysis

Using the physical activity section of the leisure-time activity questionnaire, we divided the participants into two main groups: “high (physical) activity” and “low activity.” Low activity was defined as engaging in any physical activity up to once a week. High activity was defined as engaging in any aerobic physical activity at least twice a week. This cut off is based on studies demonstrating that substantial psychological improvement was found to occur in study groups engaging in physical activity for at least twice a week (54, 55). In fact, research suggests that even lower doses of physical activity may improve psychological well-being, depressive and anxious symptoms (10, 56, 57). A univariate analysis of Variance (ANOVA) was performed in order to examine differences in years of age between the groups. A Multivariate Analysis of Variance (MANOVA) was conducted in order to examine the overall difference between the ADHD participants in the “high activity” group and “low activity” group on the IVE, AnTI and DTQ subscales (e.g., impulsivity, venturesomeness, social worry, health worry, meta-worry, total worry, frequency of intrusive thoughts, sadness about intrusive thoughts, feeling disturbed regarding the thoughts, removal difficulty, disapproval, overall index of intrusive thoughts with anxious content and the overall index of intru-

Amitai Abramovitch et al.

Lambda = .332, F(12, 16)= 2.686, p = .034). The univariate analyses presented in Table 1 reveal that the group reported to frequently engage in aerobic physical activity, scored significantly lower than the low physical activity group on the meta-worry scale (p =.012), as well as on the impulsivity scale (p =.033). Subjects from the “high activity” group also scored significantly lower on most of the DTQ subscales: the “sadness about unwanted thoughts” scale (p =.013), the “worry about intrusive thoughts” scale (p =.022), on “difficulty in removal of intrusive thoughts” scale (p =.037), and on the “total anxious intrusive thoughts” scale (p =.005). No significant differences between the groups were found on the social worry, health worry, total worry, venturesomeness, the frequency of intrusive thoughts scale and on total depressive intrusive thoughts scale. In order to examine the relative weight of the dependent variables’ association with physical activity, a subsequent Discriminant Function Analysis (DFA) was performed. In this analysis, only variables found to significantly differ between the groups were entered. As expected, a significant overall discriminant effect was found between the groups, Wilk’s Lambda= .342, Chi-Square (8) = 25.764, p =.001). The DFA standardized discriminant function coefficients of each variable entered are presented in Table 2.

sive thoughts with depressive content). Subsequently, a multivariate discriminant function analysis (DFA) was performed to assess the relative partial association between the target variables and the extent to which they differentiate the two groups. Since the empathy scale was originally used in order to provide buffer items in the IVE questionnaire and was not relevant to the present study, it was removed from all statistical analyses. Alpha level of 0.05 was used throughout the study. Results A univariate analysis of variance revealed a significant difference in years of age between the “high activity” (M =30.63, SD =8.00) and the “low activity” (M =25.62, SD =3.68) groups, F(1,28)= 5.621, p =.025. Accordingly, we controlled the age variable on subsequent analyses. A MANOVA was conducted to assess overall difference between the two groups of participants with ADHD. We used 14 variables (impulsivity, venturesomeness, social worry, health worry, meta-worry, total worry, intrusive thoughts’ frequency, sadness, worry, removal difficulty, disapproval, total anxiety and total depressive) as dependent variables. Controlling for age, the MANOVA results revealed an overall significant difference between the “high activity” and the “low activity” groups, Wilks’

Table 1. Means and standard deviations of the AnTI, IVE and the DTQ questionnaire subscales for the ADHD physical activity groups Low Activity (N=20) Variable AnTI

IVE DTQ

High Activity (N=10)

F (1,28)

Sig.

Adjusted R²

Social worry

21.5

6.9

17.9

6.53

1.032

N/S

.001

Health worry

9.1

3.5

8.7

3.33

0.039

N/S

-.069

Meta-worry

17.2

5.2

11.7

4.49

7.231

.012

.170

Total worry

47.8

38.3

12.12

2.693

N/S

.051

Impulsivity

15.7

3.4

12.3

3.5

5.081

.033

.163

Venturesomeness

13.8

3.3

12.1

3.2

0.553

N/S

-.026

Frequency

49.4

14.8

37.4

17.2

2.378

N/S

.072

Sadness

54.3

17.8

34.8

16.5

7.105

.013

.174

Worry

50.8

17.1

33.5

16.8

5.920

.022

.140

Removal difficulty

49.1

16.9

31.4

18.3

4.816

.037

.142

Disapproval

49.6

18.1

33.3

16.3

3.678

N/S

.119

Total anxious a

126.3

28.3

81.1

36.6

9.454

.005

.300

Total depressive b

127.2

86.3

45.7

3.521

N/S

.081

AnTI= Anxious Thoughts Inventory; IVE= Eysenck’s Impulsivity-Venturesomeness-Empathy Questionnaire; DTQ= Distressive Thoughts Questionnaire. aTotal rating of six anxious intrusive thoughts. bTotal ratings of six depressive intrusive thoughts.

Physical Activity with Intrusive Thoughts, Worry and Impulsivity in Adults with Adhd

Table 2. Discriminant function analysis of the IVE, DTQ and AnTI subscales Variablea

DFA coefficients

DTQ Total Anxious IT

.510

DTQ Sadness

.394

AnTI Meta Worry

.388

IVE Impulsivity

.374

DTQ Worry

.358

DTQ Removal Difficulty

.357

DTQ Disapproval

.325

DTQ Total Depressive IT

.295

a Only variables that significantly differ between the groups were included in this analysis. IT = Intrusive Thoughts; AnTI= Anxious Thoughts Inventory; IVE= Eysenck’s Impulsivity-VenturesomenessEmpathy Questionnaire; DTQ= Distressive Thoughts Questionnaire.

Discussion In a previous study, Abramovitch and Schweiger (31) found that young adults diagnosed with ADHD experience significantly more intrusive and worrisome thoughts than normal controls. In the present study we compared two groups of adults with ADHD engaging in frequent and infrequent physical activity. Our results reveal that adult individuals diagnosed with ADHD engaging in frequent aerobic physical activity reported significantly less meta-worry (e.g., worry about worry), less worry about the experienced intrusive thoughts, less difficulty in removing intrusive thoughts, less sadness about experiencing intrusive thoughts and generally less overall anxious intrusive thoughts. Another important finding was that ADHD participants in the “high physical activity” group reported significantly less behavioral impulsivity, one of the most prominent symptoms of ADHD. Our results also suggest that the experience of anxious content intrusive thoughts has the strongest relative association with physical activity. This was as opposed to intrusive thoughts with depressive content which showed to hold the weakest association. Moreover, it appears that physical activity is not associated with lower frequency of intrusive thoughts, but more with meta-perceptions about them (e.g., sadness regarding the experience of intrusive thoughts and meta-worry). Finally, we found that lower rates of behavioral impulsivity are associated with physical activity more than with other intrusive thoughts subscales (e.g., worrisome intrusive thoughts, removal difficulty and disapproval with intrusive thoughts). 52

Physical activity is known to alter monoamine transmission (13, 14, 16, 17) and converging scientific evidence suggests that aerobic physical exercise causes structural as well as functional changes in the brain that are associated with improvement in the cognitive, emotional, behavioral and physical domains (58). As discussed above, research provides evidence for therapeutic effects of exercise on depression and anxiety disorders and recently with regards to ADHD (6, 8, 10, 12, 43, 44, 56, 58). In light of the above, it is plausible that our findings reflects positive effects of exercise on the overall symptoms of ADHD in a fashion that mimics (or perhaps even adds to) the effect of medication therapy. Administration of stimulants and other prescription drugs for ADHD individuals generates improvement in cognitive functioning and positive behavioral changes. Studies examining the impact of methylphenidate treatment on ADHD adult individuals found that compared with placebo, medicated ADHD individuals exhibited significant reduction of inattentive, hyperactive and impulsive symptoms (59, 60). Stimulants also reduce impulsivity in adults with and without ADHD (61, 62). It is plausible that the combined effect of modulation of monoamine neurotransmitters associated with physical activity would result in the reduction of worry, intrusive thoughts and impulsivity. No significant differences were found between the “high activity” and “low activity” groups in health and social worry and venturesomeness. The non-significant difference in venturesomeness might stem from the fact that the items examining this property are based on future intention or hypothetical declarations (e.g., “would you enjoy parachute jumping”; “would you like to go scuba diving,” etc.). Thus, ADHD individuals that engage in frequent physical activity may declare they will act in a certain way, but in real life this may be different. We suspect that a direct measurement of this variable will yield different results. We also suspect that the non-significant difference in social worry and the “frequency of intrusive thoughts” variables might stem from the small sample size Notably, our findings are correlational and do not reflect causation. An alternative explanation to our result may be that individuals with ADHD that are able to maintain a continuous stable physical activity regime, are able to do so due to a more moderate preexisting symptom severity. Limitations

This exploratory study is not without limitations. First, the small sample used in this research requires cautious interpretation. Second, the difference in group

Amitai Abramovitch et al.

sizes seems to be problematic. This is usually due to the assumption that smaller groups will produce inflated variance. However, in this study, both groups show strikingly similar variance on most variables. Furthermore, in examining ADHD undergraduate students, there is an inherent limitation that is almost unavoidable because of the relatively low prevalence of young adults with full-blown ADHD symptoms who attend and graduate from college. Finally, this cross-sectional pilot study is based on self-reports. Conclusion Research suggests that together with improving general health, physical exercise promotes psychological wellbeing in a variety of ways in clinical as well as non-clinical populations. As mentioned above, clinicians, educators and researchers believe that physical activity may be beneficial specifically to individuals diagnosed with ADHD. The results of this pilot study demonstrate this association in an adult sample. However, in light of the correlational nature of our findings and the small sample size, interpretation should be approached with caution. Nevertheless, the results of the current exploratory study, together with reports of the beneficial effect of physical exercise in other psychiatric populations, give rise to the possibility that physical exercise may contribute to the overall psychological well-being of adult individuals with ADHD. Future research using larger samples is warranted in order to investigate the causal relationship between physical activity and ADHD symptoms as well as the specific underlying mechanisms. Acknowledgements The authors thank Mrs. Yael Meltzer, the Head of the Office for Students with Disabilities at Tel Hai Academic College, Israel, for her assistance in the recruitment of participants and making her facility available for testing.

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Physical Activity with Intrusive Thoughts, Worry and Impulsivity in Adults with Adhd

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Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Sreten Vićentić et al.

Analysis of quality of Life and Anxiety in Patients with Different Forms of Epilepsy Sreten Vićentić, MD, MSc,1 Milutin Nenadović, MD, PhD,2 Nenad Nenadović, MD,3 and Periša Simonović, MD, MSc4 1

Department of Psychiatry, General Hospital, Sabac, Serbia Special Psychiatric Hospital Laza Lazarevic, Belgrade, Serbia 3 Military Medical Academy, Belgrade, Serbia 4 Institute of Mental Health, Belgrade, Serbia 2

Abstract Background: Anxiety symptoms may have significant implications on the quality of life of patients with epilepsy. The aim of our research is a comparative analysis of the quality of life, i.e., of the level of disability in patients with different forms of epilepsy. Method: In this cross-sectional study, the sample consisted of three groups of 30 patients each - with recently diagnosed generalized epilepsy, temporal and extratemporal epilepsy. The anxiety level in these groups was compared with the control group of 30 healthy subjects. Beck Anxiety Inventory (BAI) was used for assessment of anxiety. Level of functional disability due to anxiety was measured according to the Sheehan Disability Scale (SDS). Results: Patients with extratemporal epilepsy had the greatest level of functional disability, while patients with generalized epilepsies had the lowest average of scores on the Sheehan scale. The correlation between the BAI and the SDS was highly statistically significant. Conclusions: Our results clearly indicate the need for a broader concept of therapy - neurological (antiepileptic therapy) and psychiatric (pharmaco-, psycho- and social therapy) when it comes to anxiety in patients with epilepsy.

INTRODUCTION Anxiety symptoms, especially if they are noticeable, may have significant implications on the quality of life of patients with epilepsy, primarily because of the tendency of patients Address for Correspondence:

with anxiety disorders to overestimate the risks associated with situations which trigger their anxiety, but underestimate their own ability to cope with anxiety (1, 2). The consequence may be a disabling combination of anticipatory anxiety, related to seizures in unfamiliar situations, causing evasive behavior and isolation. About 20-30% of patients exhibit a specific fear of attack, i.e., phobia of epileptic seizures, while the percentage of patients who are afraid to leave their home and have anticipatory anxiety is even higher (3). A more recent study looking for psychopathology in inpatients with all types of epilepsy obtained: the 1-year prevalence of anxiety disorders was 25%, and that of mood disorders, 19% (4). However, in some secondary care and specialist settings, the prevalence of anxiety disorder may exceed 50% (5). In one large study based on diagnoses in primary care records, the rate of anxiety disorders was 11% in 5,834 people who had epilepsy, compared with 5.6% in 831,163 without epilepsy (6). Excessive anxiety undermines the purpose-serving effectiveness and is disabling to all, since it disrupts coordinated behavior and successful work efficiency (7, 8). Several intertwined factors may be responsible for the increased incidence of anxiety in patients with epilepsy. A child with epilepsy is particularly vulnerable to an attack, thus an inadequate reaction of parents and/or social environment can have adverse effects on development of personality and prevent conflict resolution (9). In the case of an epilepsy onset in young adult and adult life, fear of unexpected attacks with falls, loss of consciousness and other symptoms and limited activity because of the attack, may trigger different neurotic manifestations in patients (10). Inability to control their own body and physical functions during the attack and fear of repeated attacks increase the tendency in patients to develop anxiety-depressive conditions (11). Patients with primary panic disorder may develop nocturnal panic attacks at any time of the night; they occur in the state

Sreten Vićentić, MD, MSc, Višegradska 12/14, Belgrade 11000, Serbia.

sretenvicentic@gmail.com

Analysis of quality of Life and Anxiety in Patients with Different Forms of Epilepsy

of alertness, and with symptoms identical to those of daily panic attacks, while patients with ictal anxiety often describe nocturnal panic. However, in these cases, panic awakens the patient from an otherwise peaceful sleep, which certainly undermines the quality of life (12, 13). Interictal anxiety, among other things, is a consequence of psychological concerns about the primary disease and its complications. Patients often worry about the risks of possible injury due to a seizure, possible brain damage, memory impairment, prognosis of epilepsy and issues related to working ability and employment (14, 15). The theory of a common pathophysiological mechanism of anxiety attacks and epilepsy is based on the observation that epileptic activity in certain areas of the brain directly causes paroxysmal anxiety (16, 17). The amygdala seems to be a particularly important structure for the production of anxiety symptoms and epileptic discharges in partial epilepsy. Patients with partial epilepsy and anxiety symptoms have been found to have a reduced amygdala volume (18, 19). The main hypothesis was that patients with focal temporal epilepsy and focal extratemporal epilepsies would have worse anxiety state and worse functional state than the patients with generalized epilepsy due to the theory described above. Another hypothesis was that patients with epilepsy, with pronounced anxiety, would have a higher degree of disability and thus a poorer quality of life. The primary aim of our research was a comparative analysis of the quality of life, i.e., the level of disability in patients with generalized epilepsies, focal temporal epilepsies and focal extratemporal epilepsies, when it comes to family life, work, social life and relationships with other people. The secondary aim was the analysis of the influence of anxiety on the quality of life in patients with epilepsy. METHODS The sample consisted of three groups of 30 patients each with recently diagnosed generalized epilepsy, temporal lobe epilepsy and extratemporal lobe epilepsy, from the Department of Epilepsy and Clinical Neurophysiology at the Institute of Mental Health in Belgrade, type of research being the analytical cross-sectional study. The study was approved by the local ethical committee. The anxiety level in all three groups of patients with epilepsy was compared with the level of anxiety in the control group of 30 healthy subjects. Data about the precise number of seizures prior to the study showed insufficient reliability, the patients’ answers had high levels of uncertainty. Thus 56

we decided not to analyze that information, although it might be a factor influencing the anxiety. The questionnaires were given out before starting with medication, in the moment of definite confirmation of diagnosis of epilepsy, because our idea was to investigate the anxiety before any influence of the therapy. All groups consisted of patients paired by age and gender, similar social status, ages from 18 to 65. The criteria for inclusion were: 1) generalized epilepsy, 2) focal epilepsy, 3) symptomatic epilepsy, 4) remote symptomatic epilepsy, 5) idiopathic epilepsy, 6) age of patients – adults from 18 to 65 years. The exclusion criteria were: 1) existence of major depression, schizophrenia or bipolar disorder, 2) Addison’s disease, active thyroid disease or unstable diabetes, 3) existence of intensive renal, cardiological, hepatic or gastrointestinal disease, 4) existence of intensive neurological disorders, including parkinsonism and dementia, 5) pheochromocytoma, 6) urinary retention or glaucoma, 7) alcohol or drug abuse, 8) isolated seizures of any origin, 9) epilepsy in mental insufficiency. We formed our groups according to these exclusion criteria, which also relate to the functional status of patients prior to the epilepsy diagnosis. Beck Anxiety Inventory (BAI) (20) was used for quantitative assessment of anxiety. BAI was primarily designed to measure generalized anxiety and distinguish the symptoms of anxiety from those of depression. It consists of 21 items, and the questions are ranked on a scale from 0 - 3 (0 = no, 1 = mild, 2 = moderate, 3 = severe). The maximum score is 63. Scores 0-7 correspond to minimal anxiety, 8-15 to mild, 16-25 to moderate and 26-63 to severe anxiety. Qualitative analysis of anxiety was related to determination of presence/absence of some anxiety symptoms, based on the list of comprehensive anxiety symptoms. Level of functional disability due to anxiety was measured according to the Sheehan Disability Scale (SDS) (21). The SDS is an instrument for assessment of functional impairment of the three domains of functioning – work / school, social life and family life. All the three domains are assessed on a scale of 1 to 10. Specifically, 1-3 signifies mild, 4-6 moderate, 7-9 severe and 10 signifies extreme impairment of abilities. Description of the numerical characteristics in our paper was done by classical methods of descriptive statistics (mean and median, standard deviation, coefficient of variation and standard error). Relative numbers are used in all the tables. In the analysis of results depending on the nature of the variables themselves Pearson’s χ2-test was used in the form of tests of agreement and contin-

Sreten Vićentić et al.

gency tables for comparing the differences between the frequency of nonparametric characteristics, namely for one or two features. With numerical limitations Fisher’s exact test was applied. In order to compare the average values of the parametric features we used t-test for two groups of data. We used analysis of variance by Fisher in order to compare the average values of parametric features for more than two sets of data. ANOVA by Kruscal-Wallis was used as an addition to the nonparametric independent samples. When analyzing the correlation properties we applied methods of single-parametric correlation and regression, and nonparametric correlation. In all the applied analytical methods, the significance level was 0.05. RESULTS Statistical analysis of demographic variables showed that age was in the range of 18-65 years, and among the examined groups there was no statistically significant difference [F(3; 116)] = 1.309, p = 0.275. Analysis by gender also showed that among the examined groups there was no statistically significant difference (Chi-square = 0.133, df = 3, p = 0.988). The next important area of this study was to assess the degree, i.e., the level of impairment in functioning of patients with certain types of epilepsy with the Sheehan scale. Patients with extratemporal epilepsy have the greatest level of functional disability measured by the Sheehan scale, with mean score of 9.80. Slightly lower scores were demonstrated in a group of patients with temporal epilepsy (mean 8.56), while patients with generalized epilepsies have the lowest average scores on the Sheehan scale, 3.80 (Table 1). The next level of comparison was made in relation to functional disability in certain areas of functioning, including work, social life and leisure, as well as family life and home life. From the data in Table 2 it can be concluded that there are statistically significant differences in terms of impairment of functioning in three different areas between the three groups of patients with epilepsy. Patients with Table 1. The level of disability based on the total scores on the Sheehan scale in some form of epilepsies Scale

Group

Mean

Min

Max

Extratemporal epilepsies

9.80

8.22

0.00

27.00

Sheehan

Temporal epilepsies

8.57

8.78

0.00

30.00

Scale

Generalized epilepsies

3.80

4.82

0.00

23.00

Total

7.39

7.84

0.00

30.00

Table 2. Comparison of impairment of functioning in various spheres according to the group of patients with certain type of epilepsy Sheehan Scale

Group N

Mean

Work

1 2 3 Total

30 30 30 90

1.37 2.87 4.00 2.74

2.06 3.18 3.23 3.04

1 2 3 Total

30 30 30 90

1.40 2.80 3.30 2.50

1.97 2.82 2.98 2.72

1 2 3 Total

30 30 30 90

0.80 3.00 2.67 2.15

1.27 3.35 2.96 2.82

Social life

Family life/ functioning at home

6.34

0.003

4.20

0.018

5.85

0.004

Group 1- generalized epilepsies Group 2- temporal epilepsies Group 3- extratemporal epilepsies

extratemporal partial epilepsy have the greatest degree of occupational functioning impairment (mean score was 4.0), significantly more than patients with temporal lobe epilepsy (mean score was 2.86) and generalized epilepsy (mean score was 1.36). These differences are highly statistically significant (F = 6.339, p <0.01). When it comes to social life domain and leisure activities, the patients with extratemporal and temporal lobe epilepsy have a higher degree of disability than patients with generalized epilepsy. The differences were statistically significant (F = 4.203, p <0.05). When it comes to family life and functioning at home the patients with temporal lobe epilepsy have the largest impairment (mean 3.0), the patients with extratemporal epilepsy have a slightly smaller one (mean 2.66), while patients with generalized epilepsy have the least expressed disability in this area of functioning (mean 0.80). The differences are highly statistically significant (F = 5.848, p <0.01). Two main tools used in the study were the Beck Anxiety Inventory and Sheehan Disability Scale. Comparison of the results obtained from these two scales and calculated measures of linear dependence (the Pearson correlation coefficient) showed a high degree of correlation between these two instruments, and this correlation was highly statistically significant - p <0.01(Table 3). DISCUSSION Epileptic seizures can also be predicted with psychological triggers such as stress, anxiety, anger and other 57

Analysis of quality of Life and Anxiety in Patients with Different Forms of Epilepsy

Table 3. Correlation between the instruments – BAI and Sheehan Disability Scale (SDS) Scale

Min

Max

Mean

Pearson correlation

BAI

0.00

88.00

12.91

13.61

0.01

SDS

0.00

30.00

7.39

7.84

0.76

0.01

strong emotions, as well as with various mental tasks and thoughts (22). It is known that the presence of psychiatric phenomenology is an important predictor of poorer quality of life in patients with epilepsy (2325). Our starting idea was to investigate the degree of impairment of functioning in the patients with epilepsy and to correlate these findings with the present anxiety symptoms. The Sheehan Disability Scale was used for these purposes, which is a very reliable instrument for measuring degrees of impairment of abilities in a wide range of disorders. The analysis of the results obtained by the Sheehan Disability Scale showed that patients with extratemporal focal epilepsy and with temporal lobe epilepsy have greater functional deficits than the patients with generalized epilepsies (Tables 1, 2 and 3). In particular, patients with extratemporal epilepsy have the greatest level of functional disability measured by the Sheehan scale, with the mean score of 9.80. A group of patients with temporal epilepsy had slightly lower scores (mean 8.56), while patients with generalized epilepsies have the lowest average of scores on the Sheehan scale, i.e., 3.80. The patients with extratemporal epilepsy have the most noticeable impairments in the field of professional activities and social life, while patients with temporal lobe epilepsy have a maximum of functional interference in family functioning and home chores. Since the patients with partial epilepsies also have more pronounced general anxiety, as well as frequent and intense anxiety symptoms, it becomes clear that the share of the phenomenology of anxiety is very important in the impairment of the functioning of patients and in deteriorating the quality of life in patients with epilepsy. Finally, high and significant correlation was found between the results obtained by the Beck Inventory and the Sheehan Scale further confirming the starting point that anxiety symptoms significantly disturb the functional ability of people with epilepsy in all the three observed domains (work, social life, family life). Anxiety and depression are significant predictors of impairment of the quality of life in patients with epilepsy (26, 27). An important factor associated with anxiety and depression 58

is certainly the experience of stigma in these patients, especially younger ones (28-32). To the best of our knowledge, this is the first study which analyzes anxiety in different forms of epilepsy by simultaneously using the Beck Anxiety Inventory and the Sheehan Disability Scale. As for the relation between extratemporal epilepsy, quality of life and anxiety, data in the literature are somewhat scarce. One of the possible contributions of our study lies in the results which indicate that the difference in the degree of impairment of occupational functioning in the patients with extratemporal epilepsy is highly statistically significant, in comparison to the patients with temporal and generalized epilepsy. Also, a high statistical significance was found in the variable which measures family life and functioning at home – the patients with generalized epilepsy had minimum disability in this area of functioning. Possible explanations for these values and differences in extratemporal and generalized epilepsies could be based on the fact that anxiety is not only a feature of temporal lobe seizures with involvement of the amygdala, but is also associated with seizures arising in the anterior cingulate or orbitofrontal cortex or other limbic structures (19). The involvement of the amygdala, according to the theory referred to in the Introduction, seems to be more important in the production of anxiety symptoms for partial, than generalized epilepsies. Some limitations of the present study should be noted. The sample size was relatively small, due to short period of monitoring. We plan to undertake a large, nation-wide study, which would be designed according to experiences of the present research, but with a “follow up” instead of a cross-sectional design. In that study we also intend to measure the depression level, by means of the Beck Depression Inventory, since depression might be at least one of the reasons (except for anxiety) for the functional disability. Several recent studies have attempted to examine the relative contribution of anxiety symptoms to reduced health-related quality of life in patients with epilepsy. In a study from South Korea, anxiety was the most significant predictor of reduced health-related quality of life, explaining 27% of the variance compared with 12% for depression (33). These findings, beside the small sample sizes, influenced us to investigate only the anxiety level in the present study. With reference to the significant degree of anxiety in patients with temporal and extratemporal epilepsy, and considering the significant impact of anxiety on impairment of quality of life, which this research clearly shows,

Sreten Vićentić et al.

it is important to determine the therapeutic approach to this problem. Antiepileptic therapy in itself would not be able to sufficiently resolve anxiety symptoms or functional deficits in these individuals. Therefore, it would be useful to add some options for anxiety and anxiety disorders treatment, which are primarily selective serotonin reuptake inhibitors – SSRI, however they may exacerbate seizures (34). In some cases, benzodiazepine anxiolytics would be used, especially in shorter therapies. it is also important to offer psychotherapy, particularly cognitive-behavioral therapy (35). Certain cognitive activities, such as performing certain mental tasks, driving or specific emotions can provoke epileptic seizures through activation of specific groups of neurons around the epileptic focus. Therapeutic countermeasures which are designed to stop the seizure activity as quickly as possible, after the registration of the attack, prevent the attack from fully developing (36). Cognitive-behavioral therapy that could be used in patients with epilepsy should primarily involve interventions that teach patients to identify such stress and control it thereby reducing the effects of stress as a potential trigger for epileptic seizures (37). Also, cognitive-behavioral strategies for “stress management” may be potentially effective in improving control of the seizures (38-40). CONCLUSION The degree of impairment of functioning was higher in patients with partial extratemporal and temporal lobe epilepsy than in those with generalized epilepsy. The differences were highly statistically significant. Also, there was a highly significant statistical correlation between the Beck Anxiety Inventory and the Sheehan Disability Scale, clearly showing the important influence of anxiety on the functional ability and quality of life in patients with epilepsy. The results of this study indicate the need for a broader concept of therapy – neurological (antiepileptic therapy) and psychiatric (pharmaco-, psycho- and social therapy) when it comes to anxiety in patients with epilepsy, i.e., an integrative approach to this problem. References 1. Austin B, Wagner E, Hindmarsh M, Davis C. Elements of effective chronic care: A model for optimizing outcomes for the chronically ill. Epilepsy Behav 2000; 1: 15-20. 2. Ettinger AB, Kanner AM (eds.). Psychiatric issues in epilepsy: A practical guide to diagnosis and treatment. Philadelphia: Lippincott Williams & Wilkins, 2007. 3. Newsom-Davis I, Goldstein LH, Fitzpatrick D. Fear of seizures – an

investigation and treatment. Seizure 1998; 7:101-106. 4. Swinkels WA, Kuyk J, de Graaf EH, van Dyck R, Spinhoven P. Prevalence of psychopathology in Dutch epilepsy inpatients: A comparative study. Epilepsy Behav 2001; 2:441-447. 5. Jones JE, Hermann BP, Barry JJ, Gilliam F, Kanner AM, Meador KJ. Clinical assessment of Axis I psychiatric morbidity in chronic epilepsy: A multicenter investigation. J Neuropsychiatry Clin Neurosci 2005;17:172-179. 6. Gaitatzis A, Carroll K, Majeed A, Sander JW. The epidemiology of the comorbidity of epilepsy in the general population. Epilepsia 2004;45:1613-1622. 7. Collings JA, Chappel B. Correlates of employment history and employability in a British epilepsy sample. Seizure 1994; 3:255-262. 8. Lassouw G, Leffers P, De KM, Troost J. Epilepsy in Dutch working population: Are employees diagnosed with epilepsy disadvantaged? Seizure 1997; 6:95-98. 9. Martinović Ž, Krstić N, Martinović J. Behavioural and emotional disorders in children with epilepsy. Psihijatrija Danas 2001; 33:189-197. 10. Kanner AM, Nieto JC. Depressive disorders in epilepsy. Neurology 1999; 53: 26-32. 11. Brandt C, Schoendienst M, Trentowska M, et al. Prevalence of anxiety disorders in patients with refractory focal epilepsy - a prospective clinic based survey. Epilepsy Behav 2010;17: 259-263. 12. Kolar D, Starčević V. Odnos između paničnog poremećaja i epilepsije – opšta razmatranja i prikaz slučaja. Psihijatrija danas 2001; 33: 223227 (in Serbian). 13. Merritt-Davis O, Balon R. Nocturnal panic: Biology, psychopathology, and its contribution to the expression of panic disorder. Depress Anxiety 2003; 18: 221-227. 14. Edeh J, Toone B. Relationship between interictal psychopathology and the type of epilepsy. Br J Psychiatry 1987; 151: 95-101. 15. Moore DP. Partial seizures and interictal disorders: the neuropsychiatric elements. Oxford: Butterworth-Heinemann, 1997. 16. Chapouthier G, Venault P. A pharmacological link between epilepsy and anxiety? Trends Pharmacol Sci 2001; 22:491-493. 17. Charney DS. Neuroanatomical circuits modulating fear and anxiety behaviors. Acta Psychiatr Scand 2003; 417:38-50. 18. Adolphs R, Tranel D, Damasio H, Damasio A. Impaired recognition of emotion in facial expressions following bilateral damage to the human amygdala. Nature 1994; 372:669-672. 19. Biraben A, Taussig D, Thomas P, et al. Fear as the main feature of epileptic seizures. J Neurol Neurosurg Psychiatry 2001; 70:186-191. 20. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol 1988; 5: 893-897. 21. Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. Int Clin Psychopharmacol 1996;11: 89-95. 22. Petrovski S, Szoeke CE, Jones NC, Salzberg MR, Sheffield LJ, Huggins RM, O’Brien TJ. Neuropsychiatric symptomatology predicts seizure recurrence in newly treated patients. Neurology 2010; 75:1015-1021. 23. Beyenburg S, Mitchell AJ, Schmidt D, et al. Anxiety in patients with epilepsy: Systematic review and suggestions for clinical management. Epilepsy Behav 2005; 7: 161-171. 24. Chi-Wan Lai, Xishung Huang, Yen-Huei C, Zhiqung Zhang, Goujon Liu, Meng-Zhang Yang. Survey of public awareness, understanding and attitudes to towards epilepsy in Henan province, China. Epilepsia 1990; 31:182-187. 25. Strine TW, Kobau R, Chapman DP, et al. Psychological distress, comorbidities, and health behaviors among U.S. adults with seizures: Results from the 2002 National Health Interview Survey. Epilepsia 2005; 46:1133-1139. 26. Murphy JM, Horton NJ, Laird NM, et al. Anxiety and depression: A 40-year perspective on relationship regarding prevalence, distribution, and comorbidity. Acta Psychiatr Scand 2004; 109:355-375.

Analysis of quality of Life and Anxiety in Patients with Different Forms of Epilepsy

27. Baker GA, Jacoby A, Buck D, Stalis C, Monnet D. Quality of life of people with epilepsy: A European study. Epilepsia 1997; 38:353-362. 28. Baker GA, Brooks J, Buck D, Jacoby A. The stigma of epilepsy: A European perspective. Epilepsia 1999; 41: 98-104. 29. Austin JK, Dunn DW, Caffrey HM, et al. Recurrent seizures and behavior problems in children with first recognized seizures: A prospective study. Epilepsia 2002; 43: 1564-1573. 30. Testa SM, Schefft BK, Szaflarski JP, Yeh H-S, Privitera MD. Mood, personality, and health-related quality of life in epileptic and psychogenic seizure disorders. Epilepsia 2007; 48: 973-982. 31. Dahl J. Epilepsy â&#x20AC;&#x201C; A behaviour medicine approach to assessment and treatment in children. Seattle: Hogrefe Huber, 1992. 32. Vazquez B, Devinsky O. Epilepsy and anxiety. Epilepsy Behav 2003; 4: 20-25. 33. Choi-Kwon S, Chung C, Kim H, et al. Factors affecting the quality of life in patients with epilepsy in Seoul, South Korea. Acta Neurol Scand 2003;108:428-434. 34. Scicutella Đ?, Ettinger AB. Treatment of anxiety in epilepsy. Epilepsy

Behav 2002; 4: 10-12. 35. Tan S-Y, Bruni J. Cognitive behavior therapy with adult patients with epilepsy: A controlled outcome study. Epilepsia 1986; 27: 255-263. 36. Goldstein LH, McAlpine M, Deale A, et al. Cognitive behaviour therapy with adults with intractable epilepsy and psychiatric co-morbidity: Preliminary observations on changes in psychological state and seizure frequency. Behav Res Ther 2003; 41: 447-460. 37. Ramaratnam S, Baker GA, Goldstein L. Psychological treatments for epilepsy. Cochrane Database Syst Rev. 2001; 4: 20-29. 38. Au A, Chan F, Li K, et al. Cognitive-behavioral group treatment program for adults with epilepsy in Hong Kong. Epilepsy Behav 2003; 4: 441-446. 39. Ben-Arush O, Wexler JB, Zohar J. Intensive outpatient treatment for obsessive-compulsive spectrum disorders. Isr J Psychiatry Relat Sci 2008; 45:193-200. 40. Herman BP, Dickmen S, Schwartz MS, Karnes WE. Interictal psychopathology in patients with ictal fear: A quantitative investigation. Neurology 1982; 43:341-346.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Ehud Bodner and Iulian Iancu

Recalling the Threat: Dental Anxiety in Patients Waiting for Dental Surgery Ehud Bodner, PhD,1 and Iulian Iancu, MD2 1

The Interdisciplinary Department of Social Sciences and the Music Department, Bar-Ilan University, Ramat Gan, Israel Yavne Mental Health Clinic, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Abstract Objective: The tendency of patients with high levels of anxiety to easily recall threatening stimuli has not been examined in relation to dental anxiety. The current study was aimed to examine the effect of pre-treatment anxiety levels and of information given prior to dentistry surgical procedures on free recall of threatening words. Methods: Forty-two subjects attending a private dental clinic were recruited. While awaiting root-canal treatment or tooth extraction, patients were asked to proofread a list of 32 words, which contained mental and physical threat-related words, as well as positive and neutral words. Only half of the subjects received information on the forthcoming surgical procedure. Pre-treatment anxiety levels using the Dental Anxiety Scale (DAS) and word recall were evaluated. Results: Only subjects with high dental anxiety (above median score) recalled more mental and physical threatrelated words, than positive words. Moreover, the dental anxiety score as a continuous variable predicted the mean number of mental threat-related words recalled. No significant differences were noted between those who did or did not receive information prior to the surgical procedures, on the recall of the four types of words. Conclusions: Similar to other anxiety disorders, patients with dental anxiety display a tendency for free recall of threatening stimuli presented to them before a threatening event. Preliminary information given prior to dentistry surgical procedures does not decrease anxiety. Suggestions for intervention in the dentist’s clinic are given.

Address for Correspondence:

Introduction Dental procedures frequently evoke considerable degrees of anxiety (1-3), especially when preceded by anxious waiting in the dental clinic and lack of information on the dental procedures (4). It is in such a context that dental anxiety or even dental phobia (which also includes avoidance from dental treatment) may develop. Swedish women aged 38 to 54 (N=1,462) assessed themselves as “very afraid” or “terrified” when visiting the dentist (5.6% to 12.8%) (5). The prevalence of dental anxiety in a representative sample of Australians was 14.9% (6). Similar rates were reported in a telephone survey of a random sample of 7,312 Australian residents with a rate of dental fear as high as 16.1% (7). In a survey of 300 German residents the rate of dental anxiety was 11% (8). Another study reported that extreme dental anxiety was found in 4.2% of a sample of 645 Danish adults, while another 6% reported moderate anxiety (9). It is estimated that 5% to 15% of the adult population of the world is afflicted with high anxiety from dental procedures, to the level of refraining from regular dental treatment. Many of these receive only emergency dental treatments. Patients with dental anxiety from diverse cultures (i.e., Israel, Sweden and the U.S.A.) present a homogeneous socio-demographic profile and a similar etiology, with personality traits and environmental factors serving as the main factors (10, 11). Also, adults with dental anxiety present constant fear (11), high levels of social anxiety (12), frequent negative thoughts resistant to suppression (13), sensitivity for pain after implant insertion (14) and a tendency to experience threatening thoughts concerning their dental treatment (15). In short, as regards their dental treatment, dental anxiety patients pay attention to threats and concentrate on negative cognitions. Main causes for dental anxiety are negative indirect learning experiences (e.g., vicarious learning/modeling)

Dr. Iulian Iancu, Yavne Mental Health Clinic, 4 Hadekel Street, Yavne, Israel.

Iulian1@bezeqint.net

Recalling the Threat: Dental Anxiety in Patients Waiting for Dental Surgery

that attest that dental treatment is dangerous, and threatening experiences which become associated with dental treatment (11, 15). The treatment and the pre-treatment experiences in the dentistâ&#x20AC;&#x2122;s office may then be cognitively processed as threatening, and the near encounter with the dentist may be perceived as a stressful encounter. Whereas dental anxiety leads to reduced visits to the dentist (16), it also leads to the use of sedatives (e.g., benzodiazepines) (17), the use of hypnosis (18) and to preference in some cases for general anesthesia especially among children (19). A potential method for reducing dental anxiety stems from the cognitive psycho-educational perspective and consists of the simple and economic provision of pertinent details about the intended treatment procedures. This might enable a cognitive switch from nonrealistic fears to a sense of mastery. Studies of the effect of preliminary information on dental anxiety present contradictory results. While there are findings supporting a significant reduction in dental anxiety (20), some studies show that a rational explanation may not be sufficient in alleviating anxiety (21), while others even show that the provision of preliminary information correlates with high levels of state anxiety (22). Due to a limited ability of dental patients to process relevant information while waiting for dental surgery, it is possible that relevant information given to patients immediately before planned treatment may not be efficiently processed. Indeed, additional studies (15, 23, 24) have found an increased interference to process relevant information (i.e., difficulties in naming the color in which threat-related words were presented). For example, subjects with relatively high dental anxiety were slower in color naming dentist-related words than subjects with relatively low dental anxiety (25). All these effects have been studied in the laboratory, and not in dental anxiety patients in the dental clinic. The interference was explained to result from a bias for mood-congruent stimuli in anxiety (24), or as stemming from an attentional bias (25). Such a bias was only found under conditions of shallow presentation of the threatening information (25-28), that promoted a minimal semantic encoding of targets (e.g., a request to sort items, to find target letters or target words, or to colorname threatening words). The shallow and non-semantic encoding provides a greater opportunity for emotional factors to influence the encoding of mood-congruent information. Thus, this provides a suitable basis for the emergence of a free recall bias in anxiety. The present study aimed: (1) to examine if a moodcongruent explicit memory bias (i.e., elevated recall of 62

threat-related target words) found in high trait anxiety subjects in the laboratory, is also evident in patients in the dental setting. If found, this bias could be potentially anxiety-provoking; (2) to inquire if information given prior to dentistry surgical procedures affects the free recall of threatening words. We hypothesized that: (1) subjects classified as having dental anxiety would recall more threat-related words than positive words in comparison to subjects without dental anxiety, who will not demonstrate differences between the types of words recalled; (2) subjects who received information on the dental procedures would recall more positive words and less mental and physical threat-related words, as compared with subjects who did not receive such information; (3) In addition, we examined the relative contribution of dental anxiety, provision of information about the treatment, type of surgical treatment (root canal/tooth extraction) and subjectsâ&#x20AC;&#x2122; demographic characteristics (gender and age) to the explained variance of mean recalled words. We hypothesized that dental anxiety will contribute most to the recall of threat-related target words. Methods Sample: The sample included 42 consecutive patients, 25 men and 17 women, at a central dental clinic in Tel Aviv. The age of the subjects ranged between 18 and 78. The mean age was 40.30 (SD = 16.00). Exclusion criteria consisted of history of mental problems and physical disabilities and lack of fluency in Hebrew. Tooth extraction or root canal treatments are considered as the most common anxiety-provoking treatments (29). Therefore, the sample consisted only of patients waiting in the dental clinic for tooth extraction (n = 14) or for root canal treatment (n = 28). The patients received these dental treatments for the first time (did not habituate to these treatments). Two patients refused to participate and another three did not speak Hebrew fluently and were therefore excluded (a response rate of 89.4%). Measures:

A 32-items list (see Appendix 1) of threatening and nonthreatening words was based on a list of Hebrew words (30). The threatening words consisted of eight mentalthreat (e.g., despair, failure) and eight physical-threat (e.g., flu, bleeding) related words. The non-threatening words consisted of eight positive-reinforcing items (e.g., happiness, love), and of eight neutral items (e.g., stairs,

Ehud Bodner and Iulian Iancu

table). The list was administered to 19 undergraduate students, nine males and ten females, aged 25-55 (M = 35.00, SD = 8.20), who were asked to evaluate the words for their frequency (i.e., the frequency they are used in daily life) on a scale ranging from 1 (not at all) to 7 (very often). The four types of items did not differ in neither their frequency (F (3, 16) = 2.81, p > 0.05; the means were in the range of 4.30 to 5.67, with standard deviations between 1.24 to 1.51), nor in their length, F <1 (the mean word length of the four lists ranged from 4.75 to 5.00 letters per word). These comparison norms for words (frequency and length) are based on the norms of Kucera and Francis, which are commonly used (see 31). The 32 words were randomly mixed in the list given to the subjects. Two additional items were added to the beginning of the list and two items were added at the end of the list in order to prevent primacy and recency effects, and were not included in the analyses. This is a standard procedure in studies of memory recall (32). The subjects’ dental anxiety level was assessed with the Dental Anxiety Scale (DAS) (33). This questionnaire includes four questions with answers ranging from 1 (calm) to 5 (very anxious). The DAS score is computed by summing responses on all items and therefore ranges from 4 to 20 (33). The DAS was developed as a specific measure for dental anxiety and has been shown to have a high predictive validity rate (33, 34). The DAS has been used in many studies (13, 35-39) and has a Hebrew version (22). It displayed a high Cronbach alpha (over 0.80). In the current study it had a Cronbach alpha of 0.82 displaying high reliability. We used a median-split procedure for defining those with dental anxiety, a method commonly used in DAS studies (40-42). In these studies, the cutoff points were between 9-9.5 according to their samples. In this study, the DAS scores ranged from 5 to 16, with a mean of 10.19 (SD =2.75), and a median of 10. Hence, in the current study dental anxiety scores of 10 or higher indicated dental anxiety (n=23; M=12.13, SD=2.01, range 10-16), while lower anxiety scores were not considered as indicating the existence of such anxiety (n=19; M=7.84, SD=1.30, range 5-9). Procedure: The IRB of the Bar-Ilan University approved the study. Patients undergoing tooth extraction or root treatment were sampled over a 3-month period, according to the sequence of their arrival and were randomly allocated to the information and no-information groups. Before the treatment, patients were asked if they were willing to take part in a short study about dental treatments. Patients who

provided written informed consent were given the items list and were asked to see if the items had been written correctly (a two minute task). Next, subjects fulfilled the DAS and after two additional minutes entered the dentist’s room. Before being given an injection of local anesthesia, 21 randomly-selected subjects received similar information on the forthcoming procedure from the dentist (e.g., aim of treatment, procedure, possible complications, and treatment alternatives), and 21 subjects were not provided with any information. Among the patients who received information about the dental procedure, 13 were above the DAS cutoff point and 8 were below. Out of the patients who were not provided with information 10 were above the cutoff point and 11 were below. No gender and age differences were found regarding the distribution of the participants in the four groups, dental anxiety × information, ps > 0.05. Then, we asked the subject to recall items from the list of words provided to them in the waiting room. The unexpected request to recall the items is according to an incidental learning paradigm (43-45). Unlike recognition memory tasks, this sudden request for a free recall enables the detection of subtle effects of mood on memory (46). Finally, the group that was not provided with information received the same information immediately before the dental intervention (as a regular procedure before every surgical process). Data analysis: A power analysis showed that the sample size was adequate for the study. In order to examine the hypotheses, a 3-way repeated MANCOVA and multiple regression analyses were conducted. The 3-way repeated MANCOVA included age as a covariate (in order to control for age), information provision (yes/no), dental anxiety (yes/no), types of words (positive/mental threat/physical threat/neutral) as independent variables and mean number of recalled words as the dependent variable. In order to examine hypothesis 3 in particular, we conducted four multiple regression analyses, with the DAS scores as a continuous variable, receiving information about dental treatment (yes/no), type of dental procedure (root canal, tooth extraction), and demographic variables (age and gender). The types of words recalled served as dependent variables in this regression. Results The 3-way repeated MANCOVA that was conducted to test hypotheses 1 and 2 yielded a main-effect for the mean number of words recalled by word type across subjects, F (3, 35) = 4.58, p < 0.01, ή²=0.28. As shown in Table 1(last 63

Recalling the Threat: Dental Anxiety in Patients Waiting for Dental Surgery

row) all participants recalled more mental and physical threat words (ps < 0.05) than positive and neutral words. In addition, an interaction effect was found between the type of word and dental anxiety, F (3, 35) = 3.11, p < 0.05, ή²=0.21. That is, the main effect findings were clarified by the interaction effect (i.e., the differences in the means of recalled words within the dental anxiety subjects). The interaction is displayed in Figure 1. Figure 1. Mean number of words recalled by type and group Dental anixiety group Control group

of preceding information about the dental procedure had no significant effect on the words recalled, F (1, 37) = 0.76., p > 0.05, ή²=0.02. In addition, the interactions of the information × dental anxiety, information × type of word, and information × dental anxiety × type of word were not significant (p > 0.05). Age, a covariate in the analysis, was also found as not significant (p > 0.05). Hypothesis 2 regarding the effect of preceding information about the dental procedure was not confirmed. In order to examine the relative contribution of dental anxiety, provision of information about the treatment, type of surgical treatment (root canal/tooth extraction) and subjects’ demographic characteristics (gender and age) to the prediction of mean recalled words we conducted four multiple regression analyses. Table 2 presents the results of the regression analysis for the mental threat-related words. The other three regression analyses did not display significant results. Table 2. Multiple regression of predictive variables for the recall of mental threat-related words

Mentalthreat

Physicalthreat

Positive

Negative

Table 1. Means and standard deviations of the four types of words by DAS Mentalthreat

Physicalthreat

Positive

Neutral

With dental anxiety

1.26±0.86

1.18±1.08

0.29±0.56

0.69±0.70

Without dental anxiety 0.47±0.61

0.83±1.16

0.37±0.68

1.04±1.08

Total

1.05±1.12

0.33±0.61

0.86±0.89

As shown in Figure 1 and in Table 1, the high DAS group recalled on average more mental-threat and physical-threat related words than positive words. Pairwise comparisons based on Bonferroni correction were significant (p < 0.05). The mean recall of neutral words did not differ significantly from threatening-related words and positive words (p > 0.05). In contradistinction, the differences in recalled words by type within the control group were not significant (p > 0.05), although they recalled on average more neutral words than threatening words or positive words. These findings confirmed hypothesis 1 that maintained that subjects with dental anxiety would recall more threateningrelated words than positive words in comparison to subjects without dental anxiety, who will not demonstrate differences between the types of words recalled. The provision 64

Constant

-0.47

0.97

Dental anxiety (DAS score)a

0.12

Provision of informationb Type of surgical procedurec Gender Age

Group

0.91±0.85

Variables

0.05

0.38

2.53**

0.35

0.27

0.21

1.23

-0.18

0.28

-0.10

-0.65

-0.48

0.18

0.28

0.11

0.64

0. 00

0.01

0.02

0.11

Note. Regressions were run after a listwise deletion of cases with missing data. aDAS coded as a continuous variable. binformation 1=provided, 2= not provided. cType of surgical procedure coded as 1= tooth extraction, 2=root canal treatments. dGender coded as 1 = male, and 2 = female. **p < 0.01

The percent of variance explained by the analysis in Table 2 was R2 = 23%, p < 0.05. The regression indicated that the only significant predictor for the recall of mental threat-related words was the DAS score, while the other predictors did not reach significance. The β coefficient for the DAS score was positive, indicating that the higher the dental anxiety, the higher the mental threat-related words recalled. These findings partially confirmed hypothesis 3, as dental anxiety scores predicted mental threat related words only, and did not predict the recall of the other three types of words (i.e., physical threat, positive and neutral words). Discussion The current study examined if the bias for mood-congruent stimuli in anxiety (24) can be also found in regard to

Ehud Bodner and Iulian Iancu

dental anxiety in the dental setting, and if preliminary information about the intended dental procedure affects this bias. In line with the first hypothesis, only subjects in the dental anxiety group recalled more mental-threat and physical-threat words than positive words. In contradistinction, the controls showed a better recall for neutral words and not for threat-related words. The results of the multiple regression analysis support the results of the MANCOVA regarding the role that dental anxiety plays in the recall of threat related words. Specifically, we demonstrate that the dental anxiety score was a significant predictor for recall of mental threat-related words, so that higher scores of dental anxiety predicted higher number of mental threat-related words recalled. These findings confirmed hypothesis 3, and reconfirmed hypothesis 1. These results reflect a tendency of subjects with dental anxiety for a mood-congruent bias in the context of the waiting room, an anxiety-provoking context for these subjects (1, 16). Patients with dental anxiety retrieve threat-related words more easily. The current findings confirm findings of previous studies that also used various types of relatively shallow incidental learning tasks, and demonstrated the tendency of individuals with dental anxiety to free recall threat-related words (26, 27). The fact that subjects with a low dental anxiety score demonstrated an improved recall of neutral words (but not of threatrelated words), may imply that unlike subjects with dental anxiety, they perceived the content of the waiting room as neutral, and not as anxiety provoking. Future studies can inquire if differences between patients with and without dental anxiety already appear in the waiting room at the encoding phase of information processing, or only at the retrieval phase. For such purpose, researchers should not only measure the retrieval of words, but also monitor the extent of attention directed toward threatening and neutral stimuli by patients with and without dental anxiety, while waiting for their dental treatment. Previous studies have demonstrated the devastating influence that dental anxiety has on the self-image of these patients, making them more sensitive to negative social evaluations (47) and undermining their self-esteem and morale (48). In accordance with these studies, it is possible that low self-esteem acted as a mediating variable between the score of dental anxiety (the predictive variable) and the number of mental threat-related words recalled (the predicted variable), and contributed to the enhanced retrieval of mental threat-related words. In order to test this assumption, a self-esteem questionnaire can be delivered to patients waiting for their dental treat-

ment (in addition to the DAS), and a structural equation analysis can estimate the contribution of this variable to the retrieval of mental threat-related words. The second hypothesis, that provision of information will lead to better recall of positive words and worse recall of threatening words, was not corroborated. These results support the claims of Auerbach et al. (49) and Miller et al. (50) that not all individuals would benefit from provision of information about a future event. Auerbach et al. (49) found that persons with internal locus of control did better than those with external locus of control when receiving information on their future dental treatment. The researchers explained this finding as stemming from the tendency of persons with internal locus of control to actively search for relevant information insituations in which the behavior-outcome contingencies are not clear. Future studies may add a measurement of locus of control, in order to examine if the provision of information will lead to a differential recall of threat-related words among patients with high and low locus of control, while waiting for the dentist. The results can also be explained by the argument of Schwartz et al. (22), that the stressful pre-surgical situation may decrease the ability of patients to process relevant information. The current study does not allow us to conclude why the provision of information did not affect the retrieval of words. That is, we cannot conclude if this finding results from the stressful character of the pre-surgical situation, or from individual differences in the management of preliminary information given, or from an interaction between these two factors. Several limitations of the study should be considered. First, the attentional bias for mood-congruent stimuli of the subjects was not measured, and hence we cannot determine if the sensitivity of subjects with dental anxiety to threatening words already occurred during the encoding phase (and thus should be regarded as an attentional bias) or only appeared in the retrieval phase (therefore should be regarded as stemming from a heightened availability of mood-congruent stimuli in memory). Additional limitations include a relatively small sample, a self-report anxiety questionnaire associated with faking good bias, a non-random presentation of the words (lack of counterbalancing), and lack of consideration for variables such as age, education level, general mood before coming to the clinic, all factors that could affect the process of recall. Last but not least, although we tried to provide similar information in all cases, we could not neutralize non-verbal communications between doctor 65

Recalling the Threat: Dental Anxiety in Patients Waiting for Dental Surgery

and subject, which is also important in the determination of the anxiety level of the individual. Conclusions and Recommendations

In spite of these limitations, this is an in vivo inquiry of the impact of anxiety on sensitivity to threat and an inquiry that used an incidental learning paradigm, which is not subjected to social desirability bias (43-45). The results of the current study may provide ideas on how dentists could alleviate the tension of their patients in their clinical practice. First, we know that up to 15% of dental patients report considerable levels of dental phobia (6). Second, it is well-known that the dental condition of patients with dental anxiety is generally worse than the condition of those without dental anxiety (35, 51). Thus, it may be important for the dentist to use the DAS in order to identify those patients who suffer from high dental anxiety. The dentist has to bear in mind that for these patients, the waiting time in the clinic is not wasted time, but is actually an “exposure time” in which incidental learning of threatening stimuli is considerably enhanced. One option to decrease dental anxiety may be to plan the dentist’s clinical practice so as to shorten waiting time, thus patients will have less time to absorb negative experiences. While this could be to some extent avoidance, we believe that for the sake of dental treatment, this is fairly warranted. Another possibility would be desensitizing the anxiety by teaching patients to concentrate on relaxing stimuli (i.e., relaxing music, nature films, or pleasant images). Finally, there is also the option of referring these patients to a CBT therapist who will gradually expose them to threatening dental stimuli and strengthen their self-efficacy, thereby decreasing their tendency to avoid dental treatments in the future (52). References 1. Stabholz A, Peretz B. Dental anxiety among patients prior to different dental treatments. Int Dent J 1999; 49:90-94. 2. Pak JG, White SN. Pain prevalence and severity before, during, and after root canal treatment: A systematic review. J Endod 2011; 37: 429-438. 3. Georgelin-Gurgel M, Diemer F, Nicolas E, Hennequin M. Surgical and nonsurgical endodontic treatment-induced stress. J Endod 2009; 35:19-22. 4. Fox C1, Newton JT. A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children. Community Dent Oral Epidemiol 2006; 34:455-459. 5. Hagglin C, Berggren U, Hakeberg M, Hallstrom T, Bengtsson C. Variations in dental anxiety among middle-aged and elderly women in Sweden: A longitudinal study between 1968 and 1996. J Dent Res 1999; 78:1655-1661. 6. Thomson WM, Stewart JF, Carter KD, Spencer AJ. Dental anxiety among

Australians. Int Dent J 1996; 46:320-324. 7. Armfield JM, Spencer AJ, Stewart JF. Dental fear in Australia: Who’s afraid of the dentist? Aust Dent J 2006; 51:78-85. 8. Enkling N, Marwinski G, Johren P. Dental anxiety in a representative sample of residents of a large German city. Clin Oral Investig 2006; 10:84-91. 9. Moore R, Birn H, Kirkegaard E, Brodsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993; 21:292-296. 10. Eli I, Uziel N, Baht R, Kleinhauz M. Antecedents of dental anxiety: Learned responses versus personality traits. Community Dent Oral Epidemiol 1997;25:233-237. 11. Berggren U, Pierce CJ, Eli I. Characteristics of adult dentally fearful individuals - A cross cultural study. Eur J Oral Sci 2000; 108:268-274. 12. Economou GC. Dental anxiety and personality: Investigating the relationship between dental anxiety and self-consciousness. J Dent Educ 2003; 67:970-980. 13. Eli I, Baht R, Blacher S. Prediction of success and failure in Behavior Modification as Treatment for Dental Anxiety. Eur J Oral Sci 2003; 112: 311-315. 14. Eli I, Schwartz-Arad D, Baht R, Ben-Tuvim, H. Effect of anxiety on the experience of pain in implant insertion. Clin Oral Implants Res 2002; 14:115-118. 15. de Jongh A, Muris P, ter Horst G, Duyx MP. Acquisition and maintenance of dental anxiety: The role of conditioning experiences and cognitive factors. Behav Res Ther 1995; 33:205-210. 16. Sohn W, Ismail AI. Regular dental visits and dental anxiety in an adult dentate population. J Am Dent Assoc 2005; 136:58-66. 17. Dionne RA, Yagiela JA, Cote CJ, et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. J Am Dent Assoc 2006; 137:502-513. 18. Roberts K. Hypnosis in dentistry. Dent Update 2006; 33:312-314. 19. MacCormac C, Kinirons M. Reasons for referral of children to a general anaesthetic service in Northern Ireland. Int J Paediatr Dent 1998; 8:191-196. 20. Soh G. Effects of explanation of treatment procedures on dental fear. Clin Prev Dent 1992; 14:10-13. 21. Peretz B, Katz J, Zilburg I, Shemer, S. Treating dental phobic patients in the Israeli Defense Force. Int Dent J 1996; 46:108-112. 22. Schwartz-Arad D, Bar-Tal Y, Eli I. Effect of stress on information processing in the dental implant surgery setting. Clin Oral Implants Res 2007; 18:9-12. 23. Williams JMG, Mathews A, MacLeod C. The emotional Stroop task and psychopathology. Psychological Bulletin 1996;120:3-24. 24. Williams JMG, Watts FN, MacLeod C, Mathews A. Cognitive psychology and emotional disorders. 2nd edn. Chichester, U.K.: Wiley, 1997. 25. Muris P, Merckelbach H, De Jongh A. Colour-naming of dentist-related words: Role of coping style, dental anxiety, and trait anxiety. Pers Individ Dif 1995, 18: 685-688. 26. Friedman BH, Thayer IF, Borkovec TD. Explicit memory bias for threat words in generalized anxiety disorder. Behavior Therapy 2000; 31:745-756. 27. Russo R, Fox E, Bellinger L, Nguyen-Van-Tam DP. Mood-congruent free-recall bias in anxiety. Cogn Emot 2001; 15:419-433. 28. Russo RM, Whittuck D, Roberson D, Dutton K, Georgiou G, Fox E. Mood-congruent free recall bias in anxious individuals is not a consequence of response bias. Memory 2006; 14:393-399. 29. Eli I, Bar-Tal Y, Fuss Z, Silberg A. Effect of intended treatment on anxiety and on reaction to electric pulp stimulation in dental patients. J Endod 1997; 23:694-697. 30. Henik A, Rubinstein O, Anaki D. Hebrew Association Norms. BeerSheva: Ben-Gurion University, 2005 (in Hebrew). 31. Vitevitch MS, Luce PA. A web-based interface to calculate phonotactic probability for words and nonwords in English. Behav Res Methods

Ehud Bodner and Iulian Iancu

Instrum Comput 2004; 36:481-487. 32. Neath I, Hellwig KA, Knoedler AJ. The shift from recency to primacy with increasing delay. J Exp Psychol Learn Mem Cogn 1999; 25: 474-487. 33. Corah NL. Development of a dental anxiety scale. J Dent Res 1969; 48:596. 34. Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc 1978; 97:816-819. 35. Berggren U, Meynert G. Dental fear and avoidance: Causes, symptoms, and consequences. J Am Dent Assoc 1984; 109:247-251. 36. Frazer M, Hampson S. Some personality factors related to dental anxiety and fear of pain. Br Dent J 1988; 24; 165:436-439. 37. Berggren U, Carlsson SG. Psychometric measures of dental fear. Community Dent Oral Epidemiol 1984; 12:319-324. 38. Berggren U, Carlsson SG. Usefulness of two psychometric scales in Swedish patients with severe dental fear. Community Dent Oral Epidemiol 1985; 13:70-74. 39. Locker D, Liddell AM. Correlates of dental anxiety among older adults. J Dent Res 1991; 70:198-203. 40. Klages U, Kianifard S, Ozlem U, Wehrbein H. Anxiety sensitivity as predictor of pain in patients undergoing restorative dental procedures. Comm Dent Oral Epidemiol 2006; 34, 139-145. 41. Kent G. Memory of dental pain. Pain 1985; 21, 187-194. 42. Kent G. Anxiety, pain and type of dental procedure. Behav Res Ther 1984; 22, 465-469. 43. Majerus S, Van Der Linde M, Mulder L, Meulemans T, Peters F. Verbal short-term memory reflects the sublexical organization of the phonological language network: Evidence from an incidental phontactic learning paradigm. J Mem Lang 2004; 51:297-306. 44. Jayawardhana B. Free recall in the incidental learning paradigm by adults with and without severe learning difficulties. Br J Dev Disabil 1997; 43:108-121. 45. Bender T, Shoptaugh CF. Classroom uses of a demonstration of the incidental-learning paradigm. Teach Psychol 1996; 23:184-187. 46. Arntz A, Van Eck M, Heijmans M. Precitions of dental pain: the fear of any expected evil, is worse than the evil itself. Behav Res Ther 1990; 28, 29-41.

47. Moore R, Brodsgaard I, Rosenberg N. The contribution of embarrassment to phobic dental anxiety: A qualitative research study. BMC Psychiatry 2004; 19:4-10. 48. Locker D. Psychosocial consequences of dental fear and anxiety. Comm Dent Oral Epidemiol 2003; 31:144-151. 49. Auerbach, SM, Kendall PC, Cuttler HF, Levitt NR. Anxiety, locus of control type of preparatory information and adjustment to dental surgery. Clin Psychol 1976; 44:809-819. 50. Miller SM, Leinbach A, Brody DS. Coping style in hypertensive patients: Nature and consequences. J Consult Clin Psychol 1989; 57:333-337. 51. Kaufman E, Rand RS, Gordon M, Cohen HS. 1992. Dental anxiety and oral health in young Israeli male adults. Community Dent Health 1992; 9:125-132. 52. Klepac RK. Fear and avoidance of dental treatment in adults. Ann Behav Med 1986; 8:17-22.

Appendix 1. Lists of items used in the study* Neutral

Mental Threat

Physical Threat

Positive

stairs

despair

migraine

rest

table

blame

flu

creation

chair

imperviousness

diabetes

vacation

library

suffocation

burn

fulfillment

ground

failure

dizziness

happiness

weather

disappointment

jaundice

love

floor

danger

itch

compliment

shop

loneliness

bleeding

agreement

*The list is translated from Hebrew and sorted to the four types of words.

Isr J Psychiatry Relat Sci - Vol. 50 - No 1 (2013)

Cultural Psychiatry in Tel Aviv: how relevant! Report of the First International Conference on Cultural Psychiatry in Mediterranean Countries, Tel Aviv, 5-7 November, 2012.

The First Mediterranean Conference on Cultural Psychiatry took place in Tel Aviv, Israel. This conference was a great success. With about 200 participants, mostly from Israel but with also 46 participants coming from 13 other countries: Mediterranean countries, Europe, North America and Australia. It contained three intensive days of plenary lectures and symposia, and a very impressive film, â&#x20AC;&#x153;Waltz with Bashir.â&#x20AC;? The proceedings included 88 lectures, and there were 8 posters, which meant that nearly half of the attending persons were giving a lecture, as is always the case in real scientific conferences. Four parallel programs were running at the same time, which made it very difficult to choose which to attend. Inevitably, this report reflects only a part of the conference. We were privileged that Afzal Javed (U.K.), the Section Secretary of the World Psychiatric Association, attended and opened the conference. He thanked the Local Organizing Committee and the Section for their efforts and their resoluteness in the organization of the conference. The opening lecture was given by Ron Wintrob (U.S.A.), co-chair of the conference. He gave a good definition of transcultural psychiatry: the comparative study of mental health and mental illness among different societies, nations and cultures, and the inter-relationships of mental disorders with cultural environments. He stressed the point that in the U.S.A. the minorities of today will become the majorities of tomorrow, rendering the Caucasian population a large minority population. This makes cultural psychiatry in the States more relevant: every psychiatrist has to deal with patients from quite different cultural origins. He focused on the need for cultural case formulation, in order to identify different explanatory models, different acceptance of care, different communication styles. Kamaldeep Bhui (U.K.) looked at this statement from a British point of view. There is great emphasis on equality nowadays in the U.K. However, reduction of psychiatric beds goes together with increase of specialized prison beds: who is the winner here? Marginalization is always bad for mental health, but especially for young people. He stressed that refugees in the U.K. have a low use of mental health care, which is bad for their mental health. Cultural consultation services do benefit general mental health care, and result 68

in a mean of 500 pounds in care costs. This means that we have to disseminate this kind of consultation. Robert Kohn (U.S.A.) gave a lecture about Cultural Psychiatry in the U.S.A. In a literature search 3,655 abstracts were found concerning transcultural psychiatry in the U.S.A. in the last decades. Large epidemiological studies showed remarkable results: for example, the prevalence for depression is higher in Whites than in African Americans. Native Americans also show more alcohol addiction and post traumatic stress disorders. Asian Americans demonstrate lower levels of psychopathology. And there is a clear connection between self-perceived discrimination and psychopathology. Francois Bourke (Canada, U.K.) developed this last topic in his presentation on migration and psychosis. He recently published a large meta-analysis of all the studies in this field, and concluded that the risk of migrants developing a psychosis is about three times higher than in natives. Post-migration factors are more important in this respect than pre-migration or migration factors. He mentioned a probable vitamin D deficiency, but also the lack of support because of low ethnic density, discrimination and maybe child abuse. There was a symposium on cultural consultation in Canada. Laurence Kirmayer gave an overview of his service in Montreal. Many questions related to this service about different aspects of migrants and refugees and their home culture: so-called knowledge questions. Dilemmas about ethnic matching between therapists and patients and about the use of interpreters are quite often discussed. And there are questions about guidelines in primary care, which appeared on www.ccrirh.uottawa.ca. Kirmayer stressed the point that different epistemologies are used by patients, depending on different ontologies of the person: egocentric, sociocentric, ecocentric and cosmocentric. This results in different healing modes, and different outcomes. For instance: the egocentric mode uses talking about the self, which results in more self-esteem and self-efficacy, while the sociocentric approach uses interventions in the family or community and attempts to result in harmonious relationships with others. Cultural competence in clinical work, which is sometimes rather technical, would be better transformed into

cultural safety, according to Kirmayer. By this term he means: an understanding of the social, economic and political contexts, a respectful and inclusive relationship, a good communication method, and a recognition of diverse knowledge fields. The film “Waltz with Bashir,” shown on the first evening of the conference, evoked many emotions. In this film, presented as a cartoon film for adults, Israeli soldiers explore their involvement and own trauma during the Lebanon war Sabra and Shatila massacre (where 3,500 Palestinians were killed in a genocide by Falangists, while Israeli troops surrounded the camps). The next day, in a plenary shared with Ahmed Hankir (U.K.), Eliezer Witztum (Israel) spoke about dissociation in PTSD patients, which occurs in about 5% of the patients he examined, and which can disrupt their memories. Another discussion on dissociation came from Marjolein van Duijl (Netherlands) who studied this phenomenon in Uganda. Dissociation and possessive states are quite common there. They occur in the context of poverty, trauma and suppression. Possessing agents are seen as spirits of the dead who speak through the living, because rituals have not been performed. This can be seen as the result of unresolved conflicts which the spirits try to settle. Van Duijl thoroughly investigated the different symptoms of dissociative states. She concluded that the DSM-5 diagnosis of dissociative identity disorder has shortcomings which should be resolved in order to capture the dissociative state in Africa. The Israeli anthropologist Yoram Bilu spoke about Dybbuk, a Jewish possession syndrome, very rare now, but quite similar to Djinn possession in Morocco. He stated that the Zar which occurs in Ethiopia is different: while the Dybbuk and the Djinn need exorcism, the Zar needs domestication! More news from Israeli researchers came from Rachel Bachner-Melman. She showed that orthodox Jews are more prone to eating disorders which relates to their obsession with food, on Shabbat evenings and celebrations, and the strict rules for its preparation. Diddy Mymin (Israel) gave an interesting lecture on Eritrean women who entered Israel through the Sinai desert and requested refugee status. Many of these women had been raped, some by Eritreans, others by Rashaida men (the Bedouin smugglers). She interviewed 14 of these women. She found they had little need to talk of their experience, had a surprisingly good level of functioning, and only a threat of stigmatization if they became pregnant. Many of the babies were offered for adoption.

Silence as a coping mechanism is something which is more often described in African women. In the general discussion it was suggested that it may be a temporary fruitful coping. Limore Racin (Israel) spoke about the voluntary return programs for the approximately 60,000 refugees in Israel from Africa. Voluntary return is a result of traumatization and flight problems on the one hand, and continuous post migration problems on the other hand. Many refugees tend to choose to return, but this is of course dependent on the security situation in their country of origin. There were two well attended symposia focussing on spirituality and mental health. The first covered important issues in the protective effects of religion on mental health (Simon Dein and Kate Loewenthal). The second focused upon Judaism and mental health with lectures by Ron Wintrob, Micol Ascoli and Simon Dein. The conference ended with a presentation by Eva Illouz, giving new perspectives on psychotherapy and its evolution within Western society. This provocative but challenging way of reconceptualizing our profession was representative of the general atmosphere during those very intensive three days. The conference brought together researchers and clinicians from all over the world, and was a great start for more attention for cultural psychiatry in Israel itself. Israel is a real multicultural country, with inhabitants who originate in quite different countries, in addition to the large Arabic minority. Appearing at the same time as the conference was a special issue of the Israel Journal of Psychiatry containing various articles on cultural psychiatry. Of great interest was the article by Khawla Abu-Baker about families of suicide killers during the intifada period, describing the respect they got, but also the bereavement they experienced. The conference in Tel Aviv was a small step towards paying attention to cultural differences, albeit to an audience that probably did not have to be persuaded. But every little step can bring a society forwards! Hans Rohlof, MD Chair of the Transcultural Section of the World Psychiatric Association, The Netherlands, Centrum ’45, National Institute for Psychotrauma, Oegstgeest, The Netherlands h.rohlof@centrum45.nl

Anne-Marie Ulman, MD Co-chair person of the congress in Tel Aviv, Beer Yaacov Mental Health Center, Beer Yaacov, Israel

‫חברי איגוד יקרים‬ ‫יש לנו איגוד אחד‪ ,‬איגוד יפה ‪ -‬וכוחו באחדותו!‬ ‫אנו זקוקים לכם כדי להמשיך ולהיות הגוף המייצג של הפסיכיאטריה בישראל‪.‬‬ ‫כל העוסקים בעבודת האיגוד עושים את עבודתם בהתנדבות מתוך כבוד לפעילות ציבורית עבור מגזר‬ ‫הפסיכיאטריה‪.‬‬ ‫אנו מזמינים את כולכם לקחת חלק במאמץ האקטיבי‪ .‬כל הצעה ורעיון יתקבלו בברכה‪ .‬ניתן לפנות לכל אחד‬ ‫מאיתנו וכן לאתר איגוד הפסיכיאטריה בישראל‪.‬‬

‫בברכה‪ ,‬הנהלת איגוד הפסיכיאטריה בישראל‬ ‫ ‬ ‫פרופ' משה קוטלר‬ ‫ ‬ ‫יו"ר האיגוד‬

‫ ‬ ‫ד"ר טל ברגמן לוי‬ ‫ ‬ ‫מזכ"ל האיגוד‬

‫ד"ר שמואל הירשמן‬ ‫גזבר האיגוד‬

‫איגוד הפסיכיאטריה בישראל‪ :‬ההסתדרות הרפואית ‪ -‬המועצה המדעית ‪Israeli Psychiatric Association -‬‬

‫יו"ר‪ :‬פרופ' משה קוטלר ‪president: Prof. M. Kotler /‬‬ ‫‪Moshe.kotler@beerness.health.gov.il‬‬ ‫מזכיר כללי‪ :‬ד"ר טל ברגמן לוי ‪Secretary General: Dr. T. Bergman–Levy /‬‬ ‫‪Tal.Bergman–Levy@beerness.health.gov.il‬‬ ‫גזבר‪ :‬ד"ר שמואל הירשמן ‪Treasurer: Dr. S. Hirschmann /‬‬ ‫‪shmuelhirschmann@yahoo.com‬‬

‫מרכז לבריאות הנפש באר יעקב‬

‫‪Beer Yaacov Mental Health Center‬‬

‫ ת‪.‬ד‪ 1 .‬באר יעקב‬ ‫‪Beer Yaacov Mental Health Center, P.O.B 1 ,‬‬ ‫‪Beer Yaacov, Israel, 70350‬‬

‫יו"ר נבחר‪ :‬פרופ' חיים בלמקר ‪President Elect: Prof. H. Belmaker /‬‬ ‫‪belmaker@bgu.ac.il‬‬ ‫יו"ר יוצא‪ :‬פרופ' זאב קפלן ‪President Emeritus: Prof. Z. Kaplan /‬‬ ‫‪Zeev.kaplan@pbsh.health.gov.il‬‬

‫‪70‬‬

‫סיכום ישיבת הוועד המרכזי‬ ‫מכנס הוועד המרכזי ‪10-12.1.2013‬‬ ‫כנס הוועד המרכזי‪" ,‬חזון ומנהיגות"‪ ,‬שארגנה הנהלת איגוד‬ ‫הפסיכיאטריה בישראל התמקד השנה בעבודתן ובעשייתן‬ ‫המבורכת של ועדות המשנה של האיגוד‪ .‬במהלך חודשים‬ ‫ארוכים עמלנו יחדיו‪ ,‬הנהלת האיגוד ויושבי ראש ועדות‬ ‫המשנה‪ ,‬על רענון הוועדות ועל הרכבתן‪ .‬בכנס השתתפו כ־‪60‬‬ ‫פסיכיאטרים חברי איגוד הפסיכיאטריה בישראל‪ .‬חברי ועדות‬ ‫המשנה ואנו גאים בהרכב מאוזן אשר כולל נציגי מתמחים‪,‬‬ ‫נציגי מומחים צעירים‪ ,‬אנשי הנהלה ואנשי אקדמיה‪ ,‬תוך‬ ‫שיתוף מלא של כל מחוזות הארץ וסניפי האיגוד‪ .‬הוועדות‬ ‫התכנסו לשעות ארוכות במהלך ימי הכנס על מנת למפות את‬ ‫הבעיות העיקריות של הפסיכיאטריה בישראל ולהציע דרכים‬ ‫אופרטיביות לפתרונן‪.‬‬ ‫אנו מבקשים להודות לכל העוסקים במלאכה‪ ,‬המרצים‬ ‫וראשי ועדות המשנה פרופ' יורם ברק‪ ,‬פרופ' חיליק לבקוביץ‪,‬‬ ‫פרופ' יובל מלמד‪ ,‬ד"ר אלכס גרינשפון‪ ,‬ד"ר יעל נחמה‪ ,‬ד"ר צבי‬ ‫פישל וד"ר בוריס נמץ על תרומתם הרבה‪ ,‬החדשנות המקוריות‬ ‫והיצירתיות הרבה שהושקעו בהכנת ההרצאות והתכניות‬ ‫שהוצגו במליאה‪.‬‬ ‫אנו מבקשים להודות לכל משתתפי הכנס‪ ,‬לרבות נציגי ועדת‬ ‫הביקורת של האיגוד‪ ,‬שעשו עבודה נפלאה בלמידה והשתתפות‬ ‫במהלך הכנס‪.‬‬ ‫אנו מבקשים להודות גם לראשי הסניפים של איגוד‬ ‫הפסיכיאטריה בישראל‪ :‬ד"ר טייטלבאום‪ ,‬ד"ר פישל‪ ,‬ד"ר‬ ‫גרינשפון וד"ר גריסרו ‪ -‬על תמיכתם הרבה בכנס‪.‬‬ ‫כמו כן‪ ,‬תודה מיוחדת לעורך אתר איגוד הפסיכיאטריה ד"ר‬ ‫יוליאן ינקו שאי אפשר בלעדיו‪ ,‬ולחברי ועד סניף ירושלים על‬ ‫ההגעה לכנס למרות תנאי מזג האוויר הקשים‪.‬‬

‫‪3 .3‬החברה תצרף לישיבות הוועד שלה משקיף מטעם איגוד‬ ‫הפסיכיאטריה בישראל שימונה על ידי הנהלת איגוד‬ ‫הפסיכיאטריה‪.‬‬ ‫‪4 .4‬הנהלת האיגוד עדכנה את חברי הוועד המרכזי על בעיות‬ ‫שונות בביטוחי אחריות מקצועית של רופאים‪ .‬במהלך‬ ‫הכנס הוכן מסמך הבהרות על עבודתנו הפרטית לחברת‬ ‫מדנס‪ ,‬והנהלת האיגוד תתעמק בסוגיות ביטוחם של‬ ‫פסיכיאטרים ותעדכן בהמשך את הוועד המרכזי לגבי‬ ‫הטיפול בנושא‪.‬‬

‫יו"ר הסניפים עדכנו את חברי הוועד‬ ‫על יוזמות שונות של הסניפים‪:‬‬ ‫ ‬

‫ ‬ ‫ ‬ ‫ ‬

‫סיכום ישיבת הוועד המרכזי‪:‬‬ ‫‪1 .1‬אושרה בהצבעה הקמתה של חברה לפסיכיאטריה בקהילה‬ ‫כחברת בת של איגוד הפסיכיאטריה בישראל (‪ 20‬תומכים‪,‬‬ ‫מתנגד אחד ושני נמנעים שנבצר מהם להגיע לכנס)‪ .‬רק‬ ‫חברים משלמים של איגוד הפסיכיאטריה בישראל יוכלו‬ ‫להיות חברים מן המניין בחברה זו‪ .‬הקמת החברה מחייבת‬ ‫אישור והצבעה מקבילה באיגוד הפסיכיאטריה של הילדים‬ ‫והנוער‪ ,‬על סמך הגדרת התנאים של חבר מן המניין בתקנות‬ ‫החברה‪.‬‬ ‫‪2 .2‬החברה תסייע לאיגוד הפסיכיאטריה בישראל להרחיב את‬ ‫מעגל חברי האיגוד ותסייע לחיזוק איגוד הפסיכיאטריה‬ ‫בישראל‪.‬‬ ‫‪71‬‬

‫‪12.1.2013‬‬

‫ ‬

‫•ד"ר טייטלבאום ביקש מהנהלת האיגוד לסייע ולגייס‬ ‫משתתפים לכנס משותף של פסיכיאטרים צרפתים וישראלים‬ ‫שייערך בירושלים בתאריכים ‪ .8/5/2013-6/5/2013‬העברת‬ ‫המידע והחומרים הנחוצים למזכ"ל האיגוד באחריות ד"ר‬ ‫טייטלבאום‪ .‬נוסף לכך‪ ,‬ד"ר טייטלבאום העלה הצעה לעריכת‬ ‫כנס חד–שנתי בפסיכיאטריה‪ ,‬והיא תידון עם ראשי שאר‬ ‫סניפי האיגוד‪.‬‬ ‫•ד"ר פישל וד"ר ברגמן עדכנו לגבי פרויקט משותף להנהלת‬ ‫האיגוד ולסניף ת"א של האיגוד ‪ -‬אסיפה במתכונת ערב‬ ‫עיון ב־‪.5/3/2013‬‬ ‫•ד"ר גריסרו עדכן כי בתאריך ‪ 23/5/2013‬יתקיים יום עיון‬ ‫ייחודי לכלל חברי איגוד הפסיכיאטריה בישראל בנושא‬ ‫טראומה וסטרס‪.‬‬ ‫•ד"ר גרינשפון עדכן כי סניף צפון הוא כעת סניף צפון וחיפה‪,‬‬ ‫וכי בכוונתו לערוך שני ימי עיון‪ ,‬האחד בנושא בטיחות‬ ‫החולה והטיפול והשני בתחום הפסיכיאטריה המשפטית‪.‬‬ ‫תאריכים לימי עיון אלו ייקבעו בהמשך‪.‬‬ ‫•לאור כנסים מרובים ויוזמות שונות הועלה הצורך לתאם‬ ‫תאריכים וליצור לוח שנה מעודכן ליוזמות של האיגוד‪.‬‬ ‫ראשי הסניפים התבקשו לעדכן את ד"ר ברגמן מזכ"ל‬ ‫האיגוד בתאריכים‪.‬‬ ‫•לבקשת פרופ' בלמייקר לקבל מידע על הכנסות והוצאות‬ ‫האיגוד‪ ,‬הסביר הגזבר ד"ר הירשמן כי מטעמים חשבונאיים‬ ‫לא ניתן להפריד את האינפורמציה בחילופי הקדנציה של‬ ‫הוועדים לכדי יצירת דוח עצמאי על החודשים מאז נכנסנו‬ ‫לתפקידנו‪ .‬ד"ר הירשמן הציע כי השניים יבחנו את הנתונים‬ ‫במסגרת פגישה בהר"י‪.‬‬

‫טורדניות ודאגנות במדגם של בוגרים עם ‪ .ADHD‬תוצאות‬ ‫מחקר חלוץ זה עשויות לעודד מחקרים נוספים בדגש על קשר‬ ‫סיבתי בין פעילות גופנית לבין סימפטומים של ההפרעה‪.‬‬ ‫המנגנונים הנוירוביולוגיים המשוערים‪ ,‬ההשלכות הקליניות‬ ‫ומגבלות המחקר נדונים‪.‬‬ ‫אנליזה של איכות חיים וחרדה אצל מטופלים עם‬ ‫צורות שונות של אפילפסיה‬

‫מ‪ .‬ננדוביץ'‪ ,‬ס‪ .‬ויטנצ'יץ'‪ ,‬נ‪ .‬ננדוביץ'‪ ,‬ופ‪ .‬סמנוביץ'‪ ,‬בלגרד‪ ,‬סרביה‬

‫רקע‪ :‬תסמיני חרדה עלולים להשפיע משמעותיות על איכות‬ ‫החיים של חולי אפילפסיה‪ .‬מטרת המחקר היתה לערוך ניתוח‬ ‫השוואתי של איכות החיים והערכת רמה תפקודית עקב חרדה‬ ‫בקרב חולים עם צורות שונות של אפילפסיה‪.‬‬ ‫שיטה‪ :‬המדגם כלל שלוש קבוצות של ‪ 30‬חולים‪ :‬חולים עם‬ ‫אבחנה חדשה של אפילפסיה כללית‪ ,‬חולים עם אפילפסיה של‬ ‫טאמפוראל וחולים עם אפילפסיה של אקסטראטאמפוראל‪ .‬רמת‬ ‫החרדה של הקבוצות הללו נבחנה בהשוואה לקבוצת הביקורת‬ ‫של ‪ 30‬מתנדבים בריאים‪ .‬להערכת החרדה נעשה שימוש ב–‪BAI‬‬ ‫‪ .- Beck Anxiety Inventory‬רמת הנכות התפקודית עקב חרדה‬ ‫נמדדה ב–‪.SDS - Sheehan Disability Scale‬‬ ‫תוצאות‪ :‬בחולים עם אפילפסיה של אקסטראטאמפוראל‬ ‫נמצאה הרמה הגבוהה ביותר של נכות תפקודית‪ ,‬בעוד‬ ‫שלחולים עם אפילפסיה כללית היה הממוצע הנמוך ביותר של‬ ‫ציונים בסולם ‪ .Sheehan‬המתאם בין ‪ SDS‬ל–‪ BAI‬היה משמעותי‬ ‫‪ NTUS‬מבחינה סטטיסטית‪.‬‬ ‫מסקנות‪ :‬תוצאות המחקר מצביעות בבירור על הצורך‬ ‫בתפישה רחבה יותר של הטיפול‪ ,‬נוירולוגית (טיפול‬ ‫אנטיאפילפטי) ופסיכיאטרית (טיפול תרופתי‪ ,‬טיפול פסיכולוגי‬ ‫וחברתי)‪ ,‬כשמדובר על חרדה אצל חולים עם אפילפסיה‪.‬‬

‫להיזכר באיום‪ :‬חרדה דנטלית של מטופלים‬ ‫הממתינים לניתוח דנטלי‬

‫בודנר‪ ,‬י‪ .‬יאנקו‪ ,‬רמת גן‬

‫רקע‪ :‬הנטייה של מטופלים שרמות החרדה שלהם גבוהות‬ ‫להיזכר בגירויים מאיימים לא נבחנה בהקשר של חרדה‬ ‫דנטלית‪ .‬מטרתו של מחקר זה הייתה לבחון את ההשפעה של‬ ‫רמת החרדה ושל המידע הניתן לפני טיפול כירורגי דנטלי על‬ ‫זכירה חופשית של מילים מאיימות‪.‬‬ ‫שיטות‪ 42 :‬משתתפים שפנו לקליניקה פרטית לטיפול שיניים‬ ‫גויסו למחקר‪ .‬בעת ההמתנה לטיפול שורש או לעקירה כירורגית‬ ‫התבקשו המטופלים להגיה רשימה של ‪ 32‬מלים שכללה מילים‬ ‫בעלות משמעות של איום מנטלי ושל איום פיזי‪ ,‬כמו גם מלים‬ ‫בעלות משמעות חיובית או משמעות ניטרלית‪ .‬רק מחצית‬ ‫מהנבדקים קיבלו מידע לגבי ההליכים הכירורגיים שהם צפויים‬ ‫לעבור‪ .‬החוקרים מדדו את רמות החרדה לפני הטיפול באמצעות‬ ‫סולם החרדה הדנטלית ואת מספר המלים שנזכרו‪.‬‬ ‫תוצאות‪ :‬נבדקים שהייתה להם חרדה דנטלית גבוהה זכרו‬ ‫יותר מילים המתקשרות לאיום מנטלי ולאיום פיזי‪ ,‬בהשוואה‬ ‫למילים חיוביות‪ .‬יתרה מזו‪ ,‬ציון החרדה הדנטלית כמשתנה‬ ‫רציף ניבא את מספר המילים הממוצע שהתקשרו לאיום מנטלי‬ ‫אשר נזכרו על ידי הנבדקים‪ .‬לא נמצאו הבדלים מובהקים‬ ‫בין נבדקים שקיבלו הסבר לנבדקים שלא קיבלו הסבר לפני‬ ‫ההליכים הכירורגיים בכל הקשור לזכירת ארבעת סוגי המלים‪.‬‬ ‫מסקנות‪ :‬בדומה לסוגים אחרים של הפרעות חרדה‪ ,‬אצל‬ ‫מטופלים הסובלים מחרדה דנטלית נראתה נטייה לזכירה‬ ‫חופשית של גירויים מאיימים המוצגים בפניהם לפני אירוע‬ ‫מאיים‪ .‬מידע מוקדם שניתן לחולים לפני ההליכים הכירורגיים‬ ‫לא הפחית את רמת החרדה‪.‬‬

‫‪72‬‬

‫מטרה‪ :‬במחקר זה נוצרה לשאלון גירסה בשפה הרוסית והתאמתו‬ ‫נבדקה‪.‬‬ ‫שיטות‪ :‬המחבר‪ ,‬פסיכיאטר מומחה בילינגואלי‪ ,‬עם ניסיון בהעברת‬ ‫הראיון באנגלית‪ ,‬פיקח על תרגומו והתאמתו לרוסית‪.‬‬ ‫‪ 35‬מרואיינים עברו ראיון חצי–מובנה על ידי שני קלינאים שאומנו‬ ‫על ידי המחבר וייצרו ‪ 154‬אבחנות שונות‪ .‬כל הראיונות הוקלטו‬ ‫ונבדקו על ידי המחבר ששימש כאבן הבוחן הסטנדרטית‪.‬‬ ‫תוצאות‪ 32 :‬מרואיינים התאימו לקריטריונים של אחת או יותר‬ ‫מ–‪ 11‬האבחנות של ה־‪ .SCID‬הסכמה בין שופטים הגיעה לרגישות‬ ‫של ‪ 88.9%‬ולסגוליות של ‪ .77.1%‬הקאפא המדיאני היה ‪ .0.75‬שבע‬ ‫אבחנות היו בקאפא הנע בין ‪ 0.65‬ל–‪.1‬‬ ‫מסקנות‪ :‬הגירסה הרוסית של ה–‪ SCID‬מתאימה וישימה‪ .‬ניתן‬ ‫להשתמש בגירסה זו לראיון מהגרים יהודים מרוסיה‪.‬‬ ‫העברה אפיגנטית של טראומת השואה‪:‬‬ ‫האם אפשר לרשת סיוטים?‬

‫נתן קלרמן‪ ,‬עמך‬

‫השואה הותירה סימניה גלויים וסמויים לא רק על הניצולים אלא‬ ‫גם על ילדיהם‪ .‬אבל במקום מספרים מקועקעים על זרועותיהם‪,‬‬ ‫בני הדור השני סומנו בצורה אפי־גנטית על ידי ציפוי כימי על‬ ‫הכרומוזומים אשר מייצג סוג של זיכרון ביולוגי של חוויות‬ ‫ההורים‪ .‬כתוצאה מכך‪ ,‬חלקם סובלים מפגיעות כללית ללחצים‬ ‫בעוד שאחרים הם עמידים יותר‪ .‬מחקרים קודמים הניחו כי‬ ‫העברה בין־דורית כזאת נגרמת על ידי גורמים סביבתיים‪ ,‬כגון‬ ‫התנהגות ההורים בגידול ילדיהם‪ .‬מחקרים חדשים‪ ,‬לעומת‬ ‫זאת‪ ,‬רומזים כי השפעות בין־דוריות אלו יכולות להיות גם‬ ‫מועברות בתורשה אפי־גנטית לדור השני‪ .‬אפיגנטיקה משלבת‬ ‫גורמים תורשתיים וסביבתיים וכך מוסיפה מימד פסיכו‪-‬ביולוגי‬ ‫חדש ומקיף יותר להסבר של העברה בין דורית‪ .‬באופן ספציפי‪,‬‬ ‫האפיגנטיקה עשויה להסביר מדוע העברה בין דורית סמוי‬ ‫מתגלה תחת לחץ‪ .‬כאן מוצגת סקירה תיאורטית ומחקרית של‬ ‫אפיגנטיקה והרלוונטיות שלה למחקר על העברת בין־דורית‪.‬‬ ‫שינויים בקצב הלב לפני ואחרי שימוש‬ ‫בעת טיפול בדיכאון מז'ורי קשה (‪)MDD‬‬

‫ב־‪ECT‬‬

‫ע‪ .‬בוזקורט‪ ,‬ס‪ .‬ברסין‪ ,‬מ‪ .‬איזנץ‪ ,‬מ‪ .‬אק‪ ,‬מ‪ .‬ארדם‪,‬‬ ‫ק‪ .‬נחיט אוזמנלר‪ ,‬אנקרה‪ ,‬תורכיה‬

‫רקע‪ :‬במחקר זה אנו מעריכים את ההשפעה של שימוש ב–‪ECT‬‬ ‫(‪ )ElectroConvulsive Therapy‬על תפקוד לבבי עצמאי‪CAF ,‬‬ ‫(‪ ,)Cardiac Autonomic Functions‬בקרב מטופלים המתמודדים עם‬ ‫דיכאון מ'זורי קשה (‪ )MDD‬באמצעות הערכת שונות קצב הלב‪HRV ,‬‬ ‫(‪.)Heart Rate Variability‬‬ ‫שיטות‪ 14 :‬גברים השתתפו במחקר‪ .‬נערכו תשעה טיפולי ‪.ECT‬‬

‫נעשתה הערכה של קצב הלב באמצעות הולטר לפני ואחרי השבוע‬ ‫הראשון של ‪ ,ECT‬השבוע השלישי של ‪ ECT‬והשבוע השישי של‬ ‫‪ .ECT‬נעשה שימוש בסולם של המילטון להערכת סימפטומים‬ ‫דכאוניים (‪The Hamilton Depression Rating Scale -‬‬ ‫‪73‬‬

‫‪.)HAM-D‬‬ ‫ממצאים‪ :‬שבעה מטופלים הגיבו לטיפול של ‪ .ECT‬היה שינוי של‬ ‫שעתיים מנוחה ב–‪ ,HF‬ב–‪ pNN50‬ובציוני ה–‪ RMSSD‬בין שבוע ‪0‬‬ ‫(תחילת טיפול) לבין השבוע השישי‪ .‬שינוי זה לא היה מובהק לאחר‬ ‫השבוע הראשון ולאחר השבוע השלישי‪.‬‬ ‫ערכי ‪ HRV‬לא השתנו כאשר חילקו את המשתתפים לכאלה‬ ‫שמגיבים ל–‪ ECT‬ולכאלה שאינם מגיבים ל–‪ .ECT‬הדבר היחידי‬ ‫שהשתנה לאחר חלוקה זו של משתתפים היה הערך של ‪ HF‬לאחר‬ ‫שעתיים של מנוחה בין שבוע ‪ 0‬לבין השבוע השישי‪ ,‬וכן ערך ה–‪HF‬‬ ‫של ‪ 24‬שעות של אלה שלא הגיבו לטיפול ה–‪ ECT‬בין השבוע הראשון‬ ‫לבין השבוע השישי‪ .‬כל יתר המדידות הנצפות הראו ירידה בערכיהן‪.‬‬ ‫באופן כללי‪ ,‬יחס ה–‪ LF/HF‬לא השתנה באופן מובהק‬ ‫בניתוחים הסטטיסטיים השונים‪ .‬ערכי ‪ HRV‬לא תאמו לציוני‬ ‫ה–‪ HAM-D‬ולא נמצא קשר בין התגובה לטיפול ב–‪ ECT‬לבין‬ ‫ניתוחי ‪ .HRV‬בניתוחי המשך מסוג בנפרוני לא נמצא שום הבדל‬ ‫מובהק סטטיסטית בין הקבוצות השונות‪.‬‬ ‫מגבלות המחקר‪ :‬מדגם קטן (‪ )n = 14‬והעדר קבוצת ביקורת‬ ‫בריאה‪.‬‬ ‫מסקנות‪ :‬שינוי עקבי ב–‪ HRV‬לא נצפה בתגובה ל–‪ ECT‬בקרב‬ ‫אנשים המתמודדים עם ‪ .MDD‬בהתחשב בעובדה ש–‪HRV‬‬ ‫נחשב ברפואה לכלי שמצביע על פעילות אוטונומית (של הלב‪,‬‬ ‫י‪.‬ז‪.‬א‪ ,).‬שימוש ב–‪ ECT‬לא גרם לשינוי משמעותי בתפקוד הלבבי‬ ‫של תשעה גברים עם ‪.MDD‬‬ ‫קורלטורים של פעילות גופנית עם מחשבות‬ ‫פולשניות‪ ,‬דאגנות ואימפולסיביות בקרב בוגרים‬ ‫עם הפרעת קשב וריכוז (‪ :)ADHD‬מחקר חתך חלוץ‬

‫א‪ .‬אברמוביץ'‪ ,‬ג‪ .‬גולדצוייג‪ ,‬א‪ .‬שוייגר‪ .‬בוסטון‪ ,‬ארצות הברית‬

‫רקע‪ :‬לפעילות גופנית מספר רב של השפעות פסיכולוגיות‬ ‫מיטיבות‪ ,‬כפי שהודגם באוכלוסיות קליניות ובאוכלוסיה הכללית‪.‬‬ ‫עם זאת‪ ,‬מעט מאוד ידוע על הקשר בין פעילות גופנית לבין‬ ‫סימפטומים של הפרעת קשב וריכוז (‪ ,)ADHD‬לא כל שכן בקרב‬ ‫בוגרים‪ .‬מחקר זה בוחן את הקשר בין פעילות גופנית ושלושה‬ ‫סימפטומים של‪)1( :‬נ‪ ADHD‬אימפולסיביות התנהגותית‪)2( ,‬‬ ‫מחשבות טורדניות פולשניות‪ )3( ,‬ודאגנות‪ .‬שני האחרונים הם‬ ‫היבטים קוגניטיביים של חרדה‪ ,‬סימפטום בולט של ‪.ADHD‬‬ ‫שיטה‪ :‬פעילות גופנית נמדדה באמצעות שאלון דיווח עצמי‪.‬‬ ‫‪ 30‬משתתפים עם אבחנה של הפרעת קשב וריכוז חולקו לשתי‬ ‫קבוצות‪ :‬משתתפים העוסקים בפעילות אירובית תכופה (קבוצת‬ ‫פעילות גבוהה) ומשתתפים העוסקים בפעילות גופנית שאינה‬ ‫תכופה (קבוצת פעילות נמוכה)‪.‬‬ ‫תוצאות‪ :‬מבוגרים עם ‪ ADHD‬העוסקים בפעילות אירובית‬ ‫תכופה דיווחו על פחות אימפולסיביות התנהגותית ועל פחות‬ ‫מחשבות טורדניות ודאגנות באופן מובהק בהשוואה לקבוצת‬ ‫הפעילות הנמוכה‪.‬‬ ‫מסקנות‪ :‬התוצאות משקפות את הקשר בין פעילות גופנית‬ ‫לבין סימפטומים פחותים של אימפולסיביות ומחשבות‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫חדר בידוד לעומת הגבלה פיזית במחלקת נוער‬ ‫סגורה ‪ -‬עמדות המטופלים‬

‫ס‪ .‬וישנייבסקי‪ ,‬ג‪ .‬שובל‪ ,‬ו‪ .‬לייבוביץ'‪ ,‬ל‪ .‬גינר‪ ,‬מ‪ .‬מיטראני‪ ,‬ד‪ .‬כהן‪,‬‬ ‫ע‪ .‬ברזילי‪ ,‬ל‪ .‬בולוביק‪ ,‬א‪ .‬ויצמן‪ ,‬ג‪ .‬זלצמן‪ ,‬פתח תקוה‬

‫רקע‪ :‬השימוש בהגבלה פיזית ובחדר בידוד לטיפול במתבגרים‬ ‫במסגרת אשפוז פסיכיאטרי מעורר דילמות אתיות‪.‬‬ ‫מטרת המחקר היתה לחקור את יחסם של בני נוער כלפי‬ ‫שתי שיטות הגבלה אלו‪.‬‬ ‫שיטות‪ :‬נעשה שימוש בשאלון מובנה לאיסוף נתונים על‬ ‫העמדות של ‪ 50‬בני הנוער‪ ,‬מאושפזים במחלקה פסיכיאטרית‬ ‫סגורה‪ ,‬כלפי השימוש בהגבלה פיזית לעומת חדר בידוד‪.‬‬ ‫תוצאות‪ 70% :‬מהמשתתפים במחקר העדיפו סגירה בחדר‬ ‫בידוד על פני הגבלה פיזית למיטה‪ ,‬בעוד ש–‪ 22%‬העדיפו את‬ ‫ההגבלה הפיזית‪ 82% .‬תיארו את הסגירה בחדר בידוד כפחות‬ ‫מפחידה מהגבלה‪ 74% .‬דיווחו על שיפור גדול יותר במצבם‬ ‫הנפשי בעקבות סגירה בחדר בידוד מאשר בעקבות הגבלה‬ ‫פיזית‪ .‬שימוש בחדר בידוד דווח כמרגיע מהר יותר מאשר‬ ‫הגבלה פיזית‪.‬‬ ‫מסקנות‪ :‬השימוש בחדר בידוד נראה עדיף על פני הגבלה‬ ‫פיזית למתבגרים מאושפזים‪.‬‬ ‫הצבעה לכנסת ישראל של חולי נפש‬ ‫אמבולטוריים ומאושפזים‬

‫י‪ .‬מלמד‪ ,‬ל‪ .‬דונסקי‪ ,‬א‪ .‬אויפה‪ ,‬ס‪ .‬נועם‪ ,‬ג‪ .‬לוי‪ ,‬מ‪ .‬גלקופף‪,‬‬ ‫א‪ .‬בלייך‪ ,‬נתניה‬

‫מטרות‪ :‬המחברים בדקו את אחוזי ההצבעה בקרב חולי נפש‬ ‫מאושפזים וחולי נפש אמבולטוריים‪ ,‬ביחס לחומרת המחלה‪.‬‬ ‫שיטות‪ :‬ביום הבחירות (‪ )2009‬נרשם מספר המאושפזים‬ ‫אשר הצביעו בבית חולים אחד בארץ‪ .‬במשך שבועיים לאחר‬ ‫הבחירות‪ ,‬חולים אמבולטוריים אשר הגיעו לביקורים במרפאה‬ ‫נשאלו אם הם הצביעו בבחירות‪.‬‬ ‫תוצאות‪ )36.9%( 100/271 :‬חולים מאושפזים ו–‪131/181‬‬ ‫(‪ )72.4%‬חולים אמבולטוריים הצביעו‪ 53.8% .‬מהחולים‬ ‫המאושפזים ו–‪ 4.7%‬מהחולים האמבולטוריים לא יכלו להצביע‬ ‫כי לא היו להם תעודות זהות‪ .‬לחולים אמבולטוריים ללא‬ ‫אשפוזים קודמים היו אחוזי ההצבעה הגבוהים ביותר‪ .‬הסיבה‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,50‬מס' ‪2013 ,1‬‬

‫השכיחה ביותר לאי הצבעה בקרב חולים מאושפזים היתה‬ ‫העדר תעודת זהות‪.‬‬ ‫תסמינים דיסוציאטיביים כתוצאה מאירועים‬ ‫טראומטיים‪ :‬ההשפעה לאורך זמן של ניצול מיני‬ ‫בילדות‬

‫א‪ .‬גאון‪ ,‬ז‪ .‬קפלן‪ ,‬צ‪ .‬דוולצקי‪ ,‬צ‪ .‬פרי‪ ,‬א‪ .‬ויצטום‪ ,‬באר שבע‬

‫מטרות‪ :‬הערכת שכיחות תסמינים דיסוציאטיביים ובתר‬ ‫חבלתיים באוכלוסיית מרפאה לבריאות הנפש‪.‬‬ ‫שיטות‪ :‬המחקר התבצע במרפאה לבריאות הנפש של המרכז‬ ‫לבריאות הנפש באר שבע‪ .‬במשך תקופה של שישה חודשים‪,‬‬ ‫כל הפונים החדשים בין הגילאים ‪ 65-18‬התבקשו להשתתף‬ ‫בסקר‪ .‬המטופלים מילאו שורה של שאלונים הכוללים הערכת‬ ‫תסמינים דיסוציאטיביים (‪ ,)DES‬שאלון להערכת היסטוריה‬ ‫של טראומה (‪ ,)THQ‬שאלון להערכת השפעת אירועים (‪)IOES‬‬ ‫ושאלון לאבחון הפרעה בתר חבלתית (‪.)PDS‬‬ ‫תוצאות‪ :‬למחקר גויסו ‪ 505‬פונים‪ 456 ,‬מתוכם השלימו‬ ‫את מילוי השאלונים‪ .‬בבחינת השאלונים נמצא כי ‪)97%( 442‬‬ ‫דיווחו על לפחות אירוע טראומטי אחד במשך החיים‪ .‬אירוע‬ ‫טראומטי זה נחווה כמשמעותי וחמור בזמן שהתרחש‪.‬‬ ‫האפקט של ניצול מיני ופגיעות רגשיות בילדות נשאר‬ ‫אינטנסיבי לאורך חיי הנפגע ונתפש כמשמעותי ורב עוצמה‪,‬‬ ‫זאת לעומת השפעתם של אירועים טראומטיים כמו אסון טבע‬ ‫או טראומה הקשורה לקרב‪ ,‬הקשורים לאפקט ארוך טווח אך‬ ‫בעל אינטנסיביות נמוכה‪.‬‬ ‫מסקנות‪ :‬נוכחותם של מטופלים שלקו בהפרעה בתר‬ ‫חבלתית באוכלוסיית המחקר מצביעה על כך שיש צורך‬ ‫בהגדרה מדויקת יותר של ההליכים לסינון ואבחון‪.‬‬ ‫הממצא החשוב ביותר של מחקר זה הוא ההשפעה הגדולה‬ ‫והמשמעותית של טראומה בילדות‪ ,‬ובמיוחד פגיעה מינית‪ ,‬על‬ ‫המשך החיים‪ .‬לכן‪ ,‬חשוב ביותר להדגיש כי גילוי והתערבות‬ ‫מוקדמים ככל האפשר במקרים של ילדים שעברו פגיעה‬ ‫והתעללות בילדות יכולים למנוע פסיכופתולוגיה ארוכת טווח‪.‬‬ ‫ישימות הגירסה הרוסית של הראיון הפסיכיאטרי‬ ‫המובנה (‪ )SCID‬בקרב מהגרים יהודים ממוצא רוסי‬ ‫ז‪ .‬גוטקוביץ'‪ ,‬ניו יורק‪ ,‬ארצות הברית‬

‫רקע‪ :‬השאלון החצי–מובנה לאבחון פסיכיאטרי (‪ )SCID‬הוא כלי‬ ‫אבחוני מהימן ביותר ותורגם לשפות רבות‪ .‬אולם‪ ,‬חסר מידע לגבי‬ ‫מהימנותו בשפות שאינן אנגלית‪.‬‬ ‫‪74‬‬

‫‪www.doctorsonly.co.il‬‬

‫רבע מהמטופלים שינו את‬ ‫הטיפול שהרופא קבע לאחר‬ ‫שגלשו באתרים רפואיים‬ ‫מערכת דוקטורס אונלי | ‪25/4/2011‬‬

‫לעיתים מגיע המטופל לרופא לאחר שכבר גיבש לעצמו מסקנה‬ ‫ממה הוא סובל‪ .‬לרוב הוא לא יחשוף מידע זה מול הרופא‪,‬‬ ‫וזאת בין היתר כדי "לבדוק" את הרופא‪ .‬ייתכנו מצבים שבהם‬ ‫המטופל מקדים במידע את הרופא > לידיעה המלאה‬

‫אתר‬ ‫אינטרנט‬ ‫חדש מבית‬ ‫הר"י‬

!‫חדש‬

‫סירק‬ ‫ הת‬,‫דין‬ ‫ר‬ ‫ו‬ ‫פ‬ ‫ה‬ ‫היחי‬ ‫המ‬ ‫אושרת לשימו דה להפ‬ ‫ר‬ ‫ע‬ ‫ו‬ ‫ת‬ ‫שינה‬ ‫ש לפרק‬ ‫עד‬ ‫זמן של‬

3 1 ‫ש‬ ‫ב‬ ‫ו‬ * ‫עות‬

,‫סירקדין‬ !‫לישון כמו שצריך‬ :‫סירקדין מספק למטופלים שלך בדיוק מה שהם צריכים‬ .‫ לשחזור מבנה השינה התקין במהלך כל שעות הלילה‬,‫מלטונין בשחרור מושהה‬ :‫סירקדין מכוון לענות על צרכי המטופלים שלך‬ ‫הירדמות קלה ומהירה‬ ‫שינה רצופה ומרעננת‬ ‫שיפור משמעותי באיכות החיים‬ ,‫כשאתה רושם לו סירקדין‬ !‫אתה מאפשר לו לישון כמו שצריך‬ .‫ שבועות בלבד‬4 ‫ מאושרות לשימוש עד‬, ‫) להן אינדיקציה לטיפול בנדודי שינה בישראל‬Z-‫* כל התרופות ההיפנוטיות (בנזודיאזפינים ותרופות ה‬ References: 1). Fourtillan J. B. Role of melatonin in the induction and maintenance of sleep. Dialogues Clin Neurosci 2002;4:395-401. 2). Wade A. G. et al. Efficacy of prolonged release melatonin in insomnia patients aged 55–80 years: quality of sleep and next-day alertness outcomes. Curr Med Res Opin 2007;23(10):2597-2605. 3). Otmani S. et al. Effects of prolonged-release melatonin, zolpidem, and their combination on psychomotor functions, memory recall, and driving skills in healthy middle aged and elderly volunteers. Hum Psychopharmacol Clin Exp 2008; Published online in Wiley InterScience. 4). Luthinger R. et al. The effect of prolonged release Melatonin on sleep measures and psychomotor performance in elderly patients with insomnia. Int Clin Psychopharmacol 2009. 5). Paul M. A. et al. Sleep-Inducing Pharmaceuticals: A Comparison of Melatonin, Zaleplon, Zopiclone, and Temazepam. Aviation Space Environmental Med 2004;75(6):512-519. 6). Lemoine P. et al. Prolonged release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects. J Sleep Res 2007;16:372-380.