Autism Spectrum Disorder
In a world where being socially active, well spoken, and communicative is the standard, those who are not socially comfortable would fall by the wayside. One of the collective groups that are usually identified with social interaction problems is known to be those who have autism spectrum disorder (ASD).
What is ASD?
ASD is a spectrum of life long neurodevelopmental disorders that frequently appears during childhood and impacts social skills negatively1 4. It is characterised by repetitive behavioural patterns or interests and problems with social interactions and communication2. Other well known characteristics attributed to this spectrum are having difficulty with the transition of activities, focusing on details and reacting unusually to sensations3 . These symptoms can affect the ability to function in work, school, and other fields of life5
Over the world, approximately 1 in 100 children has autism3. The primary cause of ASD is still unknown; however, it is suspected that the cause may be both genetic and environmental. Factors that can increase the likelihood of developing this disorder are having older parents and/or a sibling with ASD, having Down syndrome, or having a low birth weight5 .
Types of Autism6
There are several types of autism.
• Autistic disorder: this is characterised by difficulties in accepting being touched, repetitive behaviour, sensory overload and communication issues
• Asperger’s syndrome: it is one of the mild ASDs. People with Asperger's have unusual behaviours, interests and social challenges; however, their language and intellectual abilities are not impaired. Usually, these people do well academically.
• Pervasive developmental disorder not otherwise specified (PDD NOS): this is usually reserved for individuals that meet some criteria of the other two types but not all requirements. The symptoms are milder or fewer, and they typically suffer only from social challenges.
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How to interact with a child who has ASD?7
To successfully try and interact with a child with ASD, you must understand that ASD is not an illness. It just means that the brain works differently. Children with ASD may not understand your nonverbal communication in the way that people without ASD interpret it. They also take things literally. Therefore, you should be careful to say what exactly you mean. They usually talk about one thing they are fascinated by and might talk about it repeatedly. Some tips that may improve communication and interaction are to be patient, to stay positive, to explain to the child how to express anger and avoid being too aggressive, to interact through physical activity, to be affectionate and respectful, to learn from your child, and to show your love and interest.
Author: Yong Xin Cao
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Eating Disorders
Food is an essential aspect of our daily lives. Food is the fuel of our human bodies. Food intake will provide us with nutrients such as carbohydrates, proteins, fats, vitamins, and minerals needed for growth, protection through maintaining our immune system, and energy for basic and non basic activities1. Eating is necessary to continue survival; however, if there is a disbalance in how much food is taken in or the type of food, eating can have disastrous consequences for our bodies.
Eating disorders are an umbrella term defined by psychological conditions that cause the development of unhealthy eating habits2,3. It can be presented as a severe psychiatric illness and is associated with high rates of mortality4. The extreme focus on food and weight clouds other aspects of life. Symptoms associated with eating disorders are alterations in weight, disruptions in eating patterns, variability in mood, use of laxatives or diuretics, preoccupation with nutrition, and preoccupation with body image5
Causes of eating disorders3
The causes of eating disorders are still being investigated. Still, experts believe that the leading cause of eating disorders is a result of attempting to cope with painful feelings and overwhelming emotions with food. Not rarely, in the end, one’s physical and emotional condition will be damaged, self esteem will decrease, and control of food will be lost6 .
People with first degree relatives with an eating disorder are more prone to developing the disorder. Biological factors such as genetics may play a role as well. A study has shown a 50% chance of developing a feeding or eating disorder if the other twin suffers from it7. In addition, a disbalance of serotonin levels may contribute to a variety of appetite and mood regulation. Psychological factors such as perfectionism, obsessive compulsiveness, and neuroticism are often associated with eating disorders8. Furthermore, the socio cultural preference for slimness also influences our view on food
Types of eating disorders3
The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) presents eight categories of eating disorders:
(1) Anorexia nervosa
It often develops during adolescence and is seen more frequently in women. It is characterised by extreme underweight, fear of weight gain, distorted body image, and compensatory such as vomiting, behaviours to prevent or avoid gaining weight.
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(2) Bulimia nervosa
It is more common than anorexia and typically starts in adolescence or early adulthood. It is characterised by eating a lot of food in a short period and the inability to control oneself during binge eating. Usually, after binge eating, compensatory behaviour is seen to prevent gaining weight. People with bulimia maintain near normal weight but continue to fear weight gaining.
(3) Binge eating disorder
This is the most common eating disorder and starts in adolescence in most cases. More females are affected than males. It is characterised by binge eating as they are taking a lot of food in a short period. While there is a loss of control over eating and the feeling of guilt, no compensatory behaviours are seen, which leads to a risk of developing obesity.
(4) Pica
This disorder is characterised by cravings for non food items such as soap, hair or paper. It has been observed commonly in children, pregnant women and intellectually disabled persons. In most cases, it is self resolving. The consumption of these non food items can increase the risk of parasitic infections, intestinal obstruction, metal poisoning and nutrient deficiency.
(5) Avoidant or restrictive food intake disorder (AFRID)
AFRID is new terminology for feeding disorders of infancy, toddlers and childhood, typically occurring in the first seven years of life. AFRID can result from losing interest in eating, excluding picky eating behaviours in early childhood. As a result, it can cause underweight and deficiency of micronutrients such as vitamins and minerals.
(6) Rumination
It is characterised by regurgitating already swallowed food, chewing it again before swallowing it once more or spitting it out. It can lead to weight loss and malnutrition.
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(7) Other specified feeding and eating disorders
(8) Unspecified feeding and eating disorders.
Management of eating disorders3
Management of eating disorders can be varied and tailored to the patient’s needs. It can compromise psychotherapies, nutritional counselling, and pharmacotherapy. Examples of psychotherapy are enhanced cognitive behaviour therapy, interpersonal psychotherapy, and family based treatment. Pharmacotherapy usually consists of medication from drug classes, such as antidepressants, antipsychotics, or mood stabilisers, which can treat coexisting psychiatric illnesses. Only fluoxetine has been approved to treat bulimia and binge eating disorders.
Author: Yong Xin Cao
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Stress and Anxiety
Stress is a term that engineers first used to describe the forces that applies strain on structures. In 1936 this term was introduced to medicine by the Austrian scientist Hans Selye1 , who defined it as “the non specific response of the body to any demand for change”2,3
According to Selye, the stress response is an adaptive response to threats. However, prolonged stress responses can damage health and provoke diseases4 .
Stress physiology
Stress arises as a response to stressful situations, and this response is characterised by the activation of the hypothalamus pituitary adrenal axis (HPA) and the release of stress hormones, which are the following2,5:
1 Adrenalin and noradrenalin
2- Corticosteroids
Those hormones will temporarily alter body functions to cope with the threatening situation. However, chronic stress responses have devastating effects on health in the long term.
Many factors influence the response to stressors during our lives, such as genetics, environment, and health conditions. Studies performed on animals showed that animals grown up in a loving and nurturing environment had higher Serotonin levels. Serotonin is a neurotransmitter that leads to more expression of central glucocorticoid receptors in the limbic system, therefore, better glucocorticoid feedback and fewer stress responses. Meanwhile, animals who missed this environment or lived separated from their mothers had more active hypothalamic pituitary adrenocortical axis and hyperactivity in the sympathetic nervous system6,7
Stress impact on health
Chronic stress leads to chronic cortisol release, which has many effects on different systems in the body, such as:
1 Central nervous system: the prolonged release of cortisol deteriorates cognitive functions. Cortisol is a liposoluble molecule. Therefore, it can easily cross the blood brain barrier and act on brain regions responsible for learning and memory, such as the hippocampus, the amygdala, and the frontal lobes, consequently reducing these abilities.
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Figure 1
Cortisol Chemical
structure
Corticosteroids might also lead to changes in the structure of the hippocampus2 .
2 Immune system: Stress has a negative impact on the immune system. In fact, the immune system is activated in acute responses to stressors. However, chronic responses lead to the deterioration of the system, owing to the increased concentrations of glucocorticoids7
3- In the gastrointestinal system, stress can induce anorexia and reduce the intake of foods or drinks, and it can also cause problems in digestion and gastrointestinal movements9 .
4 Stress promotes cancer development, mainly by reducing the immune system's functionality and exacerbating the inflammatory response, which can lead to more advanced cancer stages. More mechanisms are accumulating DNA damage and increasing the degradation of the P53 tumour suppressor protein.10
5- Stress increases the risk of coronary heart diseases and cardiac events11 .
6 Stress increases the risk of developing anxiety disorders and depression12 .
Anxiety disorders
While stress is a response to an external stimulus or threat, anxiety is more internal; it translates into an exaggerated reaction to a stressful situation, such as persistent fear and dread, even if no immediate threat is faced. According to the American Phycological Association, “Anxiety is an emotion characterised by feelings of tension, worried thoughts and physical changes like increased blood pressure”13. Anxiety disorders are a broad spectrum of disorders such as panic disorders, phobias, generalised anxiety disorders and social anxiety disorders14 .
Anxiety disorders have genetic and environmental contributions, where stress, particularly in early life, such as being raised by anxious parents, drug abuse, and microbiota, are considered important risk factors15
Prenatal stress is firmly related to anxiety disorders. Studies showed that pregnant women with post traumatic stress disorder and other anxiety disorders gave rise to more anxiety-predisposed children. This was shown to be strongly related to epigenetic changes in the brain regions responsible for stress management, especially the amygdala. Offspring of those mothers were also shown to have a more sensitive and dysregulated HPA, which leads further to alterations in brain connections and synapsis15. Early life stress, in addition to chronic adulthood stress, has been shown to be significantly related to developing anxiety behaviours as they increase the activation of the HPA axis.
How to cope with stress12,16
Stress consequences, especially those related to mental health disorders such as anxiety and depression, are more related to coping strategies than the stressor itself. When someone copes with stress by:
•
•
•
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Seeking social support
Doing physical exercise
Meditating • Positive thinking
• Having plans and work strategies
• Having time for self, leisure, and relaxation
• Finding a hobby and doing outdoor activities, meeting people, and going out with friends Will have a lower risk of developing anxiety disorders or depression
On the other hand, coping with stress by Self blaming, denial, giving up, smoking and alcohol intake are more related to depression and anxiety, among other health risks.
Management of anxiety14 Cognitive behavioural therapy is considered the first line in managing anxiety disorders. Some other psychological strategies are also helpful, such as mindfulness, breathing exercises and focusing on interpersonal relationships.
Regarding pharmacological treatment, it can be used in combination with psychological treatment or can be used alone
Antidepressants are considered the first line pharmacological therapy, spatially selective serotonin reuptake inhibitors (SSRI) and Serotonin and Noradrenalin reuptake inhibitors (SNRI). Other antidepressants, benzodiazepines, atypical antipsychotics, and β adrenergic, such as propranolol or atenolol, can also be used.
The time to seek help in people suffering from anxiety disorders is found to vary from 3 to 30 years. However, seeking an early intervention is extremely important, as untreated conditions increase the risk of depressive disorders and substance use.
Author: Rahaf Alsayyed
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Figure 2 Anxiety management is
characterised by psychological therapy,
meditation, and pharmacological
therapy (made using Canva)
Obsessive Compulsive Disorder
What is obsessive-compulsive disorder?
According to the National Institute of Mental Health, Obsessive Compulsive Disorder (OCD) is “a common, chronic, and long lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and/or behaviours (compulsions) that he or she feels the urge to repeat over and over”1 .
OCD was previously classified under the list of anxiety disorders. However, it is now classified into a different category: Obsessive Compulsive and Related Disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5)2 .
OCD appears at any time in life, but most adults report its onset in childhood or adolescence. According to the World Health Organization (WHO), OCD is among the 20 most disabling diseases. It can have drastic consequences on a person's life, like students abandoning their studies at school and many housebound adults. Recent epidemiological studies showed that this disorder occurs in 8 of each 1000 adults and 2.5 of each 1000 children aged between 5 15 years old3 .
OCD symptoms1,3
As the definition of OCD states, this disorder is characterised by obsessions and compulsions, where obsessions are self generated thoughts and images that can be exhaustively repeated over time, provoking anxiety. Some examples are fear of microbes and contamination, hidden beliefs and taboos, fears of harming self or others, and the need to keep things symmetric (see infographic).
As a response to anxiety generated obsessions, patients start performing ritual movements and acts to alleviate this anxiety. These acts are called compulsions, aiming to temporarily relieve stress, as this stress will come back again with other obsessions.
Examples of compulsions are excessive cleaning, keeping things in a specific order, checking things up repetitively, and compulsive counting (see infographic).
It is essential to know that those rituals are not a pleasant experience for patients, and although many patients, especially adults, know that they don’t make sense, they keep doing them.
OCD consequences
OCD is considered a very debilitating disorder, and it leads to many alterations and impairments in4:
• Cognitive flexibility is the ability to adapt thinking and behaviour to changes in the environment and surrounding conditions5 .
• Response inhibition: the ability to suppress acts which are not appropriate in a determinant situation or that interfere with an action or behaviour to achieve goals6 .
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• Fear processing and extinction. Some studies exposed participants to a conditional stimulus linked to an intensive stimulus. Later, participants were exposed only to the conditional stimuli and eventually could learn that the conditional stimulus was not related to the harmful one. However, people with OCD had impaired fear extinction7
• Planning skills, working memory, reward processing, disgust processing, and emotion regulation.
Genetics or environment, what is involved? Both genetics and environmental factors contribute to the appearance of OCD. Environmental factors can be stress, trauma, perinatal events or neuroinflammation. These factors, in collaboration with genetic ones like genetic variants or alterations in gene expression, are found to be related to OCD8. In addition, many genes were found to be involved, such as the genes coding for glutamatergic and serotonergic neurotransmission. That means that this disorder has a polygenetic nature7
Diagnosis
Specific questionnaires are used to diagnose this disorder, as patients are asked questions regarding repetitive movements, thoughts that bother them, and how long it takes to achieve daily activities held3 .
Management
Cognitive behavioural therapy, especially exposure response prevention and Selective Serotonin Reuptake Inhibitors (SSRIs) such as citalopram and fluoxetine, are considered the first line in treating OCD. Then the selection of one over the other depends on some criteria, such as patient preferences and contraindications of SSRI in some patients, like bipolar patients. In the copresence of depression, SSRIs are considered a good option as they kill two birds with one stone.
When the first fails, other pharmacological classes can also be used as a second line. Some examples are: combining two different SSRIs, Serotonin Noradrenalin Reuptake Inhibitors (SNRIs), Glutamate modelling agents, and Clomipramine4
OCD-related disorders9 OCD related disorder share many characteristics with OCD. Patients in both disorders are obsessed with something, but those disorders still have significant differences. Some examples are inserted below:
1 Hoarding disorder is characterised by difficulties in disposing of things, so keeping and accumulating them with no limits. This behaviour hurts many aspects of the life of individuals and the people sharing space with them. The points shared with OCD are a long time spent collecting and organising things. Differences: individuals don’t see any problem with their behaviour and don’t respond to traditional therapeutic regimes such as Exposure Response Prevention (ERP)
2- Trichotillomania: the recurrent behaviour of hair pulling in response to discomfort. Hair pulling is understood to give comfort and relieve stress in these people.
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While people with OCD have obsessions about a wide variety of things and do rituals to get rid of them, people with OCD related disorders have obsessions about specific aspects of their bodies, like how they smell, look and sound. These obsessions generate stress, leading to ritual behaviours and movements to get rid of these obsessions.
Author: Rahaf Alsayyed
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References:
Autism spectrum disorder
1. Mughal S, Faizy RM, Saadabadi A. Autism Spectrum Disorder. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan . Available from: https://www.ncbi.nlm.nih.gov/books/NBK525976/
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7. University of Rochester Medical Center. Interacting with a Child Who Has Autism Spectrum Disorder. [Online]. Available at: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=160&c ontentid=46. [Accessed on 2022 June 5].
Image: https://unsplash.com/photos/C2zX9DEVSDs by Peter Burdon
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Eating disorders
1. Tapsell LC, Neale EP, Satija A, Hu FB. Foods, Nutrients, and Dietary Patterns: Interconnections and Implications for Dietary Guidelines. Adv Nutr. 2016 May 16;7(3):445 54.
2. Healthline. 6 Common Types of Eating Disorders (and Their Symptoms). [Online]. Available at: https://www.healthline.com/nutrition/common-eating-disorders. [Accessed on: 2022 June 19].
3. Balasundaram P, Santhanam P. Eating Disorders. 2022 Jan 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan .
4. Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep. 2012 Aug;14(4):406 14.
5. The Meadows Ranch. Eating disorders warning signs. [Online]. Available at: https://www.meadowsranch.com/about us/eating disorder warning signs/ [Accessed on: 2022 June 19].
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7. Klump KL, Miller KB, Keel PK, McGue M, Iacono WG. Genetic and environmental influences on anorexia nervosa syndromes in a population based twin sample. Psychol Med. 2001 May;31(4):737 40.
8. Cassin SE, von Ranson KM. Personality and eating disorders: a decade in review. Clin Psychol Rev. 2005 Nov;25(7):895 916.
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9. European Medicines Agency. ANNEX II SCIENTIFIC CONCLUSIONS AND GROUNDS FOR AMENDMENT OF THE SUMMARIES OF PRODUCT CHARACTERISTICS, LABELLING AND PACKAGE LEAFLETS PRESENTED BY THE EMEA. Available at: https://www.ema.europa.eu/en/documents/referral/prozacarticle 6 12 referral annex i ii iii_en.pdf. [Accessed on: 2022 June 19].
Image: https://unsplash.com/photos/DDyMG1LZaHo by Annie Spratt.
Stress and Anxiety
1. Tan, S., & Yip, A. (2018). Hans Selye (1907 1982): Founder of the stress theory. Singapore Medical Journal, 59(4), 170–171. https://doi.org/10.11622/smedj.2018043
2. Lupien, S. J., Maheu, F., Tu, M., Fiocco, A., & Schramek, T. E. (2007). The effects of stress and stress hormones on human cognition: Implications for the field of brain and cognition. Brain and Cognition, 65(3), 209 237. https://doi.org/10.1016/j.bandc.2007.02.007
3. What is Stress? (n.d.). The American Institute of Stress. Retrieved 3 June 2022, from https://www.stress.org/what is stress
4. Schneiderman, N., Ironson, G., & Siegel, S. D. (2005). Stress and Health: Psychological, Behavioral, and Biological Determinants. Annual Review of Clinical Psychology, 1(1), 607 628. https://doi.org/10.1146/annurev.clinpsy.1.102803.144141
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6. Meaney, M. J., Bhatnagar, S., Diorio, J., Larocque, S., Francis, D., O’Donnell, D., Shanks, N., Sharma, S., Smythe, J., & Viau, V. (1993). Molecular basis for the development of individual differences in the hypothalamic pituitary adrenal stress
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response. Cellular and Molecular Neurobiology, 13(4), 321–347. https://doi.org/10.1007/BF00711576
7. Ladd, C. O., Huot, R. L., Thrivikraman, K. V., Nemeroff, C. B., Meaney, M. J., & Plotsky, P. M. (2000). Long-term behavioural and neuroendocrine adaptations to adverse early experience. In Progress in Brain Research (Vol. 122, pp. 81 103). Elsevier. https://doi.org/10.1016/S0079 6123(08)62132 9
8. Vitlic, A., Lord, J. M., & Phillips, A. C. (2014). Stress, ageing and their influence on functional, cellular and molecular aspects of the immune system. AGE, 36(3), 9631 https://doi.org/10.1007/s11357 014 9631 6
9. Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI Journal; 16:Doc1057; ISSN 1611 2156. https://doi.org/10.17179/EXCLI2017 480
10. Dai, S., Mo, Y., Wang, Y., Xiang, B., Liao, Q., Zhou, M., Li, X., Li, Y., Xiong, W., Li, G., Guo, C., & Zeng, Z. (2020). Chronic Stress Promotes Cancer Development. Frontiers in Oncology, 10, 1492. https://doi.org/10.3389/fonc.2020.01492
11. Steptoe, A., & Kivimäki, M. (2012). Stress and cardiovascular disease. Nature Reviews Cardiology, 9(6), 360 370. https://doi.org/10.1038/nrcardio.2012.45
12. Mahmoud, J. S. R., Staten, R. “Topsy”, Hall, L. A., & Lennie, T. A. (2012). The Relationship among Young Adult College Students’ Depression, Anxiety, Stress, Demographics, Life Satisfaction, and Coping Styles. Issues in Mental Health Nursing, 33(3), 149–156. https://doi.org/10.3109/01612840.2011.632708
13. Anxiety. (n.d.). American Psychological Association. Retrieved 26 June 2022, from https://www.apa.org/topics/anxiety
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14. Craske, M. G., Stein, M. B., Eley, T. C., Milad, M. R., Holmes, A., Rapee, R. M., & Wittchen, H. U. (2017). Anxiety disorders. Nature Reviews Disease Primers, 3(1), 17024. https://doi.org/10.1038/nrdp.2017.24
15. Bartlett, A. A., Singh, R., & Hunter, R. G. (2017). Anxiety and Epigenetics. In R. Delgado Morales (Ed.), Neuroepigenomics in Aging and Disease (Vol. 978, pp. 145 166). Springer International Publishing. https://doi.org/10.1007/978 3 319 53889
16. Steiner Hofbauer, V., & Holzinger, A. (2020). How to Cope with the Challenges of Medical Education? Stress, Depression, and Coping in Undergraduate Medical Students. Academic Psychiatry, 44(4), 380 387. https://doi.org/10.1007/s40596 020 01193 1
Figure 1: https://pubchem.ncbi.nlm.nih.gov/compound/Cortisol 9_11_12_12 d4
Obsessive Compulsive Disorder
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4. Stein, D. J., Costa, D. L. C., Lochner, C., Miguel, E. C., Reddy, Y. C. J., Shavitt, R. G., van den Heuvel, O. A., & Simpson, H. B. (2019). Obsessive compulsive
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disorder. Nature Reviews Disease Primers, 5(1), 52. https://doi.org/10.1038/s41572019 0102 3
5. MacDonald, C. (2020, December 1). What Is Cognitive Flexibility and How Do I Help My Child With It? FOOTHILLS ACADEMY. Retrieved 6 June 2022, from https://www.foothillsacademy.org/community/articles/cognitive-flexibility
6. Mostofsky, S. H., & Simmonds, D. J. (2008). Response Inhibition and Response Selection: Two Sides of the Same Coin. Journal of Cognitive Neuroscience, 20(5), 751 761. https://doi.org/10.1162/jocn.2008.20500
7. Dougherty, D. D., Brennan, B. P., Stewart, S. E., Wilhelm, S., Widge, A. S., & Rauch, S. L. (2018). Neuroscientifically Informed Formulation and Treatment Planning for Patients With Obsessive Compulsive Disorder: A Review. JAMA Psychiatry, 75(10), 1081. https://doi.org/10.1001/jamapsychiatry.2018.0930
8. Pauls, D. L., Abramovitch, A., Rauch, S. L., & Geller, D. A. (2014). Obsessive compulsive disorder: An integrative genetic and neurobiological perspective. Nature Reviews Neuroscience, 15(6), 410 424. https://doi.org/10.1038/nrn3746
9. Disorders Related to OCD. (n.d.). International OCD Foundation. Retrieved 10 June 2022, from https://iocdf.org/about-ocd/related-disorders/
10. Dai, S., Mo, Y., Wang, Y., Xiang, B., Liao, Q., Zhou, M., Li, X., Li, Y., Xiong, W., Li, G., Guo, C., & Zeng, Z. (2020). Chronic Stress Promotes Cancer Development. Frontiers in Oncology, 10, 1492. https://doi.org/10.3389/fonc.2020.01492
Other images
Front page image: https://unsplash.com/photos/6x2iKGi6SPU by Fernando @cferdophotography.
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