26
lsjm 15 june 2009 volume 01
EDITORIAL
Recreational drugs are a significant starting point in psychiatric research. Firstly they are interesting in that they might contribute to the aetiology of some mental illnesses (the ongoing debate of cannabis and schizophrenia for example)1. Secondly, in understanding them as part of the pathology of a mental illness, we indirectly learn more about what might be going on in the brains and hence the minds of patients. Even if there is no immediate application of knowing the neurochemical changes that occur in an illness, appreciating these as well as the social and psychological factors contribute to the psychiatrist’s understanding of how to treat a patient. The explanation of a drug as a cause or treatment of a mental illness cannot alone answer the question of why someone has a particular mental illness. As the mind emerges not only from its physical and chemical make-up but also from the experiences that have moulded it, so does mental illness. Physiological but also psycho-social factors must all contribute to an illness, as exemplified by Schilderman’s review of amphetamine abuse and self harm. Despite this, there is much hope in recent literature that neuropsychiatry will bring psychiatry forward as a discipline. It will hopefully provide us with new ways of approaching treatment for mental illness as Craddock et al2, and more recently Bullmore et al3 have argued in The British Journal of Psychiatry. For example, it has been suggested that depressive illness in adolescents may alone be a cause of substance use in adolescents. However it has been shown recently that by testing for stress (measuring cortisol levels) it now seems possible that we were missing stress as a key link. However, the greatest hope from this perspective is that it will provide better targeted treatments. For example, last month Ross and Margolis argued that the basis of the major psychiatric illnesses – schizophrenia, bipolar disorder and depression - may all stem from alterations in the cell signalling systems of neurons altered during neuronal development.5 Targeting these pathways with more effective treatments and fewer side effects may therefore become possible. It is important to remember however, that not only are such innovations a long way off but also research into them should not come at the expense of research into the other contributing factors of mental illness – the sociological and psychological elements. In fact, where possible, neuropsychiatric research should try to integrate the existing aetiological models that are based on these factors.4 It is in this context that our section hopes to publish new student writing in psychiatry. It is the fact that psychiatry meets at the crossroads of all of these disciplines that makes it so interesting. We want to publish work that focuses on sociological factors - like Baigel et al’s paper on the impact of ethnicity upon the reporting of depression in London medical students - as well as papers on psychological and even neuropsychiatric factors. This includes work in the form of research but also as literature reviews, news articles and case studies from students of any of the health sciences. Samuel Ponnathurai Section Editor Psychiatry References
Illustration: Robert Hare
1. 2. 3. 4. 5.
Arsenault, L. et al The British Journal. of Psychiatry, Vol 184, (2004), 110-117 Craddock N, Antebi D, Attenburrow M-J, Bailey A, Carson A, Cowen P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6 –9 Ed Bullmore and Peter Jones. Why psychiatry can’t afford to be neurophobic. The British Journal of Psychiatry (2009) 194: 293-295. Rao et al . Mechanisms underlying the comorbidity between depressive and addictive disorders in adolescents: interactions between stress and HPA activity. Am J Psychiatry. 2009 Mar;166(3):361-9. Epub 2009 Feb 17. Christopher A. Ross1 & Russell L. Margolis. Schizophrenia: A point of disruption. Nature 458, 976-977 (23 April 2009)
lsjm 15 june 2009 volume 01
27
RESEARCH REPORT
Massively Multiplayer Online Roleplaying Games (MMORPGs) addiction Amin Golmohamad BSc(Hons) Year 4 Medicine, St. George’s University of London m0400037@sgul.ac.uk doi:10.4201.lsjm/psy.002 Screenshot from the online game EVE
For the full article and references see thelsjm.co.uk. Conflicts of interest: Amin is a panellist for LSJM Psychiatry.
28
In the electronic age, computers and the internet continue to be further integrated into day-to-day activities. Facilities such as email, social networking sites and online games are ubiquitous and a norm. The available literature on the subject of computer-related disorders has grown exponentially over the last decade, resulting in coined terms such as ‘internet addiction’, ‘problematic internet use’ and ‘pathological internet use’. 4, 5, 6 However it is not the internet itself that is addictive, rather that it is the interactive applications that seem to play the prime role in the development of problematic use.7 One such interactive application of particularly addictive potential currently in ascendance is the genre of online game, the ‘Massively Multiplayer Online Roleplaying Game’.
These computer games, also referred under the acronym ‘MMORPG’, represent a new paradigm in computer gaming that now immerses tens of millions of players worldwide. A typical MMORPG consists of a complex, persistent virtual environment that facilitates real-time interaction between large numbers of players in geographically different locations. They are a relatively new phenomenon, having only been in existence in their current form for just over a decade. Examples of such games include titles such as ‘World of Warcraft’, ‘Eve Online’, ‘Guild Wars’ and ‘Everquest’. Their unique formula combines the allure of traditional stand-alone video games with that of the social networking capacity afforded by ever more accessible high speed internet connectivity. Their appeal is reflected in the near exponential rise in subscription numbers, with the growth rate reported to be
lsjm 15 june 2009 volume 01
RESEARCH REPORT several-fold faster when compared to that of ‘traditional’ electronic game genres such as arcade, PC and console video games. 8,9 A ‘strong multi-faceted appeal’ How can their appeal be explained? The extensive work of Yee10 concluded, “MMORPGs have a strong multi-faceted appeal to a diverse demographic, motivating individual users in very different ways”. While some traditional stereotypes may associate affiliation with ‘computer games’ with people of teenage years, Yee also demonstrated in a study of 30,000 MMORPG users that the age ranged from 11 to 68 years, with the average lying between 25-27 years, underscoring their broad appeal and weakening the cogency of such views. Upon exploratory factor analysis, Yee identified a five factor model of user motivations: achievement, relationship, immersion, escapism and manipulation - motivations that typically carried different import to players of a different demographic. According to this model, the motivating factors external to the game define the degree to which inherent ‘attractive factors’ offered by a MMORPG act as an ‘outlet’. MMORPG users can immerse themselves into worlds that are rich, varied and detailed; detail that can provide fulfilling game-play experiences varied playstyle preferences; that may vary from casual socialising to combat, strategy, commerce and fantasy role-play. The goals are only limited by player ambition, with instant and measurable rewards available at progressively lengthening cycles. The perceived ability to supersede limitations present in the real world by using the adapted identity in the virtual world can be appealing where life cannot offer these options. Social activity derived from an MMORPG is another dominant motivating factor. Characterised by anonymity, users can avoid real world prejudices of colour, gender, age and physical attractiveness. These prejudices are partially replaced by an order of meritocracy based on gaming aptitude and behaviour. This can be an added attraction for people who face difficulty in the real world on account of these factors. Furthermore, a player can discard their identity and assume a new one by creating another avatar, should their relationships or online ‘reputation’ not be to their liking. Social interactions can be controlled, taking place in structures similar to chat rooms, online forums and 3rd party voice communication. As the relationships accrue over time, increasing obligations to them emerge. Social contact has also been postulated to be used as ‘self-medication’ to compensate for the lack of family or social support in a player’s real life11. Negative sequelae and comorbidities To play MMORPGs requires lots of time investment; they are not games that one can play for a short period of time.12 In-game advancement encourages increased use, which can be excessive.13 Chronic MMORPG addiction can lead to self-maintaining factors.12 For instance, where playing an MMORPG is used to escape a difficult situation in the real world, it acts only as a temporary nepenthe. When the player logs out of the game, problems may have been further compounded due to resultant neglect. Chronic usage can also lead to isolation, loss of friends and contacts. Mental and physical health co-morbidities have been postulated.5
Can it qualify as an addiction? While research into the concept of MMORPG ‘addiction’ continues to proliferate, there remain no agreed diagnostic criteria or treatments, with recognition of the disorder pending. In July 2007 the American Psychiatric Association released a statement stipulating that they did not recognise any type of ‘video game addiction’ as a mental disorder.14 The DSM IV criteria for addiction require three or more of the following: • • • • •
Tolerance Withdrawal Large amounts over a long period Unsuccessful efforts to cut down Time spent in obtaining the substance replaces social, occupational or recreational activities • Continued use despite adverse consequences The term ‘addiction’ does not require a substance of abuse, it can include non-physical, behavioural addictions. Examples include pathological gambling, eating disorders and sex addiction.15, 16, 17 Studies have identified self-reported usage despite adverse consequences, withdrawal, tolerance and that it is difficult to quit playing even with intent to do so. The frequency of these findings was found to be proportional to the number of hours spent playing per week. It would be a misconception to consider these games as a niche, for they represent a rapidly growing problem. It could be labelled as a ‘silent’ addiction, only presenting in extremis. An ideal addiction in a time of a poor economic climate in that it is rewarding, constantly available, legal and requires relatively low investment. As successful treatment is predicated upon the medical professional being aware of the nature of this 21st century problem, it is important that research into this area continues to help provide answers for the lack of widely agreed methods for screening, diagnostic criteria or treatment approaches. References 1.
2.
3.
4. 5.
6.
7. 8.
9. 10.
lsjm 15 june 2009 volume 01
BBC news article (2005), S Korean dies after games session, Retrieved from http://news.bbc.co.uk/1/ hi/technology/4137782.stm, on 28/4/2009 Gamespot.com article, Couple’s online gaming causes infant’s death, Retrieved from http://uk.gamespot.com/ news/2005/06/20/news_6127866.html, on 28/4/2009 BBC news article, (2005), ‘Game theft’ led to fatal attack, Retrieved from http://news.bbc.co.uk/1/ low/technology/4397159.stm, on 28/4/2009 Freeman C.B., (2008), Internet Gaming Addiction, The Journal for Nurse Practitioners, vol.4, no.1, pp42-47 Yen J.Y., Ko C.H., Yen C.F., Wu H.Y., Yang M.J., (2007), The Cormorbid Psychiatric Symptoms of Internet Addiction: Attention Deficit and Hyperactivity Disorder (ADHD), Depression, Social Phobia and Hostility, Journal of Adolescent Health, Vol.41, no.1, pp93-98 Shapira N.A., Lessig M.C., Goldsmith T.D., Szabo S.T., Lazoritz M., Gold M.S. Stein D.J., (2003), Problematic Internet use: proposed classification and diagnostic criteria, Depression and Anxiety, vol.17, pp207-216 Young K.S., (1998), Internet addiction: The emergence of a new clinical disorder, CyberPsychology & Behavior, vol.3, pp237-244 Woodcock, B.S. (2008), An Analysis of MMOG Subscription Growth, MMOGCHART.COM 22.0, retrieved from http://www.mmogchart.com on 27/4/2009 Harding-Rolls P., (2007), Western World MMOG Market: 2006 Review and Forecasts to 2011, Screen Digest Yee, N., (2006), The Demographics, Motivations and Derived Experiences of Users of MassivelyMultiuser Online Graphical Environments, PRESENCE: Teleoperators and Virtual Environments, 15, 309-329.
29
SHORT CASE
Narcissistic Personality Disorder
Jeremy Hoffman BSc (Hons)*, Adiele Hughes BSc (Hons), Andrew Allard BA (Cantab), Sarah Greenough BSc (Hons) Image: Actor Johnny Depp as Captain Jack Sparrow in Pirates of the Caribbean
All Year 4 Medicine, University College London j.hoffman@ucl.ac.uk doi:10.4201.lsjm/psy.004 Introduction Captain Jack Sparrow displays numerous attributes of Narcissistic Personality Disorder (NPD), which affects approximately 1% of the population. Captain Jack Sparrow is a 33-year-old male pirate with no previous contact with psychiatric services. He presented with a multitude of symptoms including visual and auditory hallucinations, alcohol intoxication and grandiose delusions. He was found by colleagues wandering alone on an island responding to visual and auditory autoscopic hallucinations (see Table 1), talking to several versions of himself. Little is known about the events leading up to this episode however, it is thought from collateral history that this is not the first hallucinatory episode and his colleagues regularly hear him talking, apparently, to himself. There is no significant psychiatric family history, however he has never been close to his father who is also a pirate in his mid-sixties and carries around the shrunken head of his deceased mother. JS is not currently taking any medication. His alcohol use is bordering on dependence with stereotyped drinking of only rum. He is known to drink when in stressful situations such as when under attack, shows binge drinking behaviour and drinks first thing in the morning. He also craves alcohol and shows agitation when rum is not available. He is a non-smoker and denies other recreational drug use.
Autoscopic hallucinations
These are a blend of visual and proprioceptive hallucinations. In these cases, the vision is of one’s double, like in a mirror, sometimes repeating one’s gestures, and on occasions busy with other activities.
Ego-syntonic
A term referring to behaviours, values, feelings, which are in harmony with or acceptable to the needs and goals of the ego, or consistent with one’s ideal self-image.
Lilliputian hallucinations
Hallucinations in which the patients see imaginary people of a small size.
Pressured speech
The patient keeps talking, with no interruption between thoughts or sentences. The speech may be loud and rapid, with creative, amusing, or trivial and irrelevant content.
Circumstantiality
In conversation, the use of excessive and irrelevant detail in describing simple events, the speaker eventually reaches his goal only after many digressions.
Table 1: Definitions of psychiatric terms referred to in text
30
He has been a pirate all his working life, however, little is known about his birth, childhood and education history. A significant life-event occurred 10 years ago in which the crew of his ship mutinied and left him on an island. At this point he showed low risk suicidal ideation as he was left a gun with just one bullet, which he considered using but was protected by a revenge motive. Following this event he became very fixated on revenge and there is concern over risk of harm to others, however he does not appear to deliberately self harm or have any current suicidal ideation. One previous long-term relationship is confirmed, although he is known to have had many other sexual partners, most of which ended ‘badly’. His forensic history is extensive and includes mugging, wilful crimes against the crown, impersonating a cleric of the Church of England and a member of the Royal Navy, arson, kidnapping, pilfering, depravity and before absconding, he was sentenced to be hung by the neck until dead. On presentation he appeared to be a scruffy Caucasian pirate in his mid-30s with ‘questionable personal hygiene’. He was unshaven, with dread-locked hair and clearly had not changed his clothes for many days. He was dressed in grand 18th century pirate attire, congruent to that expected. Although appropriate his attire was eccentric, slightly outside boundaries of normality with added femininity including make-up, beads in his hair and many rings on his fingers. His behaviour was markedly socially and sexually disinhibited with invasion of personal space and inappropriate and lewd comments such as “You need to get a girlfriend” and “Are you a eunuch?” He made good, often intense eye contact. He also had an ataxic gait, explainable by alcohol consumption but no psychomotor abnormalities His speech was pressured, suggested by quotes such as “Me? I’m dishonest. And a dishonest man you can always trust to be dishonest. Honestly, it’s the honest ones you want to watch out for, because you can never predict when they’re going to do something incredibly... stupid”. It was also at times over-inclusive with circumstantiality, for example “No! If we don’t have the key, we can’t open whatever it is we don’t have that it unlocks. So what purpose would be served in finding whatever need be unlocked, which we don’t have, without first having found the key what unlocks it?” It was of normal volume and tone. His mood was, objectively, persistently elevated with situational incongruence, for example inappropriate laughter when his life was
lsjm 15 june 2009 volume 01
SHORT CASE in serious danger. He was reactive to his surroundings. He clearly had a grandiose sense of self-importance, believing himself to be special as the greatest of all pirates and requiring excessive admiration, insisting on being called ‘captain’ although he did not technically have his own ship. He is selfish and lacks empathy towards others, always thinking about saving himself with no consideration for others, using friends for his own gain for example holding them at gunpoint. He is also constantly preoccupied with ideas of questionable success and power regarding treasure and The Black Pearl ship. He embellished stories about himself, making himself sound grander or more daring than in reality. His perceptions were disordered as he described many episodes of ego-syntonic hallucinations. One described involved a Lilliputian hallucination of small versions of himself and another episode of multiple autoscopic hallucinations. These could potentially be related to alcohol withdrawal. Collateral history suggests many other episodes of him having conversations with ‘himself’. He was orientated in time, place and person, however had limited insight into his hallucinations, unsure as to what was real and what a hallucination was. Our impression is that JS is suffering from NPD, possibly with hypomania and/or alcohol withdrawal. Discussion Captain Jack Sparrow is arrogant to the extreme of grandiosity – he believes he is far more superior than he actually is. He makes constant reference to being called “Captain” Jack Sparrow and does not let people forget that he can out-think others: “Today will be the day that you will always remember that you almost caught Captain Jack Sparrow”. He sees himself as special or unique, and constantly requires admiration from others around him. He exploits others to his own personal benefit and is constantly preoccupied on his quest for success. These personality traits interfere with Jack’s life and constantly lead him astray, developing a significant forensic history in the process; he only just managed to escape the hangman’s noose. As a result of this, we believe it is possible to diagnose him with NPD. The term “narcissism” comes from the Ancient Greek mythological story of Narcissus.1 Narcissus, a Greek hero from Thespiae, was famous for his beauty. After rebuking the nymph Echo who tried to embrace him, he fell in love with his own reflection in a pool and killed himself when he realised that he could not act upon his love. Freud, who often used mythology to aid his theories of psychopathology, formally introduced the term “narcissism” into the psychiatric literature in his 1914 paper On Narcissism.2 Since then, NPD has become a formal psychiatric diagnosis as defined by the American Psychiatric Association in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, which outlines the diagnostic criteria.3 To receive the diagnosis of a NPD, a person must meet these diagnostic criteria (Table 2). It is evident that Jack meets at least five and arguably all nine of these criteria. It should be noted that that the ICD-10 does not specifically code for NPD, but instead categorises it in “Other specific personality disorders”.4 Other authors suggest various “dominant features” of NPD.5 These include “Pathology of the self; pathology of the relationship
lsjm 15 june 2009 volume 01
with others; pathology of the superego; and a chronic sense of emptiness and boredom, resulting in stimulus hunger and a wish for artificial stimulation of affective response by means of drugs or alcohol that predisposes to substance abuse and dependency.” Patients typically present with the complications of their disorder as opposed to their primary symptoms. This includes drug dependence and alcoholism, sexual promiscuity or disinhibition, suicidal ideation, and when under extreme stress, brief psychotic symptoms.
Image: Caravaggio’s Narcissus
The prevalence of NPD is approximately 1%, rising to between 2 and 16% in clinical situations, with up to 75% of those diagnosed being male. The aetiology of the disorder is largely unknown but various risk factors have been identified. These are mainly childhood parenting and developmental factors such as parental overindulgence or overvaluation, excessive admiration, learned manipulative behaviour and early severe emotional abuse. 6 Medication and hospitalisation are indicated in NPD only for co-morbid conditions such as anxiety or affective disorders. The management therefore largely involves a multi-disciplinary approach with psychosocial interventions such as supportive psychotherapy, cognitive behavioural therapy and social skills training.7 A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1
Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
4
Requires excessive admiration
5
Has a sense of entitlement, i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations
6
Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
7
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
8
Is often envious of others or believes that others are envious of him or her
9
Shows arrogant, haughty behaviours or attitudes
Table 2: DSM-IV criteria for Narcissistic Personality Disorder
References 1. 2. 3.
4.
5.
6.
7.
Ovid, AD 8, Metamorphoses III. 340 - 350, 415 – 510. Freud S. On narcissism: An introduction. SE, 14: 67-102. 1914 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th Edition, revised. American Psychiatric Association, Washington, 2000. World Health Organisation. ICD-10 : The ICD-10 Classification of Mental and Behavioural Disorders : Clinical Descriptions and Diagnostic Guidelines. World Health Organisation, Geneva. 2007 Kernberg O, Pathological narcissism and narcisstic personality disorders; Theoretical background and diagnostic classification in Disorders of Narcissism; Diagnostic, Clinical, and Empirical implications, ed. E. F. Ronningstam. Washington, DC: American Psychiatric Press, pp. 29-51. 1997 Groopman L and Cooper A. “Narcissistic Personality Disorder”. Personality Disorders - Narcissistic Personality Disorder. Armenian Medical Network. 2006. http://www.health.am/psy/ narcissistic-personality-disorder/. Retrieved on 8/03/2009. Davison S E. Principles of managing patients with personality disorders. Advances in psychiatric treatment 2002 8:1-9
31
ARTICLE
Time to take Seasonal Affective Disorder seriously Neil Graham1, Prof Anne Farmer2 Medical Student, University College London 2 Institute of Psychiatry, King’s College London
1
Conflicts of interest: None declared.
When we labour through the short days and long nights of the British winter, the perennial column-filler, Seasonal Affective Disorder (‘SAD’ - which lends itself to puns like few other illnesses), is never far from headline-hungry newspaper pages. Skepticism is a key facet of modern, evidenced-based practice, but is the prolific cynicism about SAD (‘the winter blues’, or ‘seasonal depression’) justified? And is there any mileage in the debate over whether this is a true ‘illness’? What is seasonal affective disorder? The American Psychiatric Association’s Diagnostic and Statitistical Manual of Mental Disorders (DSM-IV) characterises SAD as a ‘specifier’: a cohort of features which can occur within major depressive or bipolar disorders, emphasising seasonality and prominence over non-seasonal depressive episodes, for at least two years. Symptoms occur in autumn and winter, accompanied by full remission, mania or hypomanias in summer. Depressed mood, diminished interest, psychomotor agitation, loss of energy, feelings of worthlessness, guilt, and thoughts of death may be experienced in addition to what appear to be SAD specific features – increased appetite with associated weight gain, tiredness and over-sleeping.1 Critics who argue that aspects of SAD are likely to be experienced by most people at this time, and disagree with the concept in the most general terms, fail to appreciate a key feature of this, and many other psychiatric ailments: for diagnosis and treatment to be indicated, symptoms must be of a given severity, quantity, duration and pattern. One could read entire books about the ‘medicalisation’ of benign phenomena, and there is a place for this debate. In respect of seasonal depression, however, it seems that many have been too quick to apply labels – obviously not everyone who is miserable in winter has an illness, and nobody is claiming that they do. Epidemiology and the nature of the disorder The population prevalence of the disorder is highly variable and has been shown to increase with latitude. Landmark research by Rosen
32
et al. in the USA found incidence of 1.4% in Florida increasing to 9.7% in New Hampshire.2 This may be compared with estimates at non-seasonal mood disorder prevalence of between 8% and 20%.3 Genetic factors are implicated in the aetiology of winter depression, and concordance studies found correlations in dizygotic twins to be fewer than half those observed in monozygotic twins.4 Identification of specific mutations associated with the disease has generally been unfruitful – though an association has been established with serotonin transporter polymorphisms.5 Management While evidence fails to support light therapy for unipolar depression, other than as an adjunct to classical therapies,6 over seventy therapeutic trials, and two meta-analyses have found light therapy to be effective in the treatment of seasonal depression, with a dose-response relationship observed in the control of some symptoms.7,8 Best outcomes are achieved with light of sufficient brightness (10,000 lux) and duration (15-90 min per day), which is timed appropriately: morning exposure is usually most effective.9 Treatment may produce a range of transient side effects (headache, eye strain) but appears to be safe in patients without ocular abnormalities.10 Evidence to support the use of traditional antidepressants is weak, though the selective serotonin reuptake inhibitor drugs appear to help in established episodes. Recently, the FDA licensed bupropion hydrochloride (a noradrenaline-dopamine reuptake inhibitor), specifically for prevention of winter depression, after convincing results in three placebo controlled trials.11 Pathophysiology Finding an inactive placebo treatment in trials of phototherapy has contributed to the uncertainty about winter depression, and the
lsjm 15 june 2009 volume 01
ARTICLE Source: Wellcome Images
mechanism of action of many therapies is not entirely clear. Diverse pathophysiological explanations exist, but irrespective of their ingenuity and logical appeal, little evidence exists to conclusively support any one over another. Rosenthal et al originally proposed the ‘melatonin hypothesis’, which argues that an abnormal secretion or sensitivity underlies the phenomenon. Winter depression has often been portrayed as a disorder of delayed circadian rhythms; and more recently, as a product of dopaminergic system dysfunction.12 That a clear mechanism of action is yet to be elucidated ought not to empower doubters to ignore this phenomenon. Indeed, squabbling over whether seasonal depression merits the label ‘illness’ is quite unnecessary. Life after semantics The facts are that this experience affects the quality of life of a significant number of individuals, in a stereotyped, recurrent manner. Safe, low cost, effective treatments exist which can ameliorate these symptoms. Withholding these for the sake of word-play is hardly the enlightenment thinking that detractors imagine it represents. The time has come for us to update their practice to keep pace with the research in this field.
3.
4.
5.
6.
7.
8.
9.
10.
11.
References 1.
2.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:317-91. Rosen LN, Targum SD, Terman M, Bryant MJ, Hoffman H, Kasper SF,
lsjm 15 june 2009 volume 01
12.
Hamovit JR, Docherty JP, Welch B, Rosenthal NE. Prevalence of seasonal affective disorder at four latitudes. Psychiatry Res. 1990 Feb;31(2):131–144. Blazer D. Mood disorders: epidemiology. In: Kaplan, H.I., Sadock, B.J. (Eds.), Comprehensive Textbook of Psychiatry, 6th ed. 1995. Vol. 1, pp. 1079–1089. Madden PAF,Heath AC, Rosenthal NE,Martin NG. Seasonal changes in mood and behavior. The role of genetic factors. Arch. Gen. Psychiatry. 1996. 53, pp. 47–55 Rosenthal, N.E., Mazzanti, C.M., Barnett, R.L., Hardin, T.A., Turner, E.H., Lam, G.K., Ozaki, N. and Goldman, D. Role of serotonin transporter promoter repeat length polymorphism (5-HTTLPR) in seasonality and seasonal affective disorder. Mol. Psychiatry 3, pp. 175–177 Even C, Schröder CM, Friedman S, Rouillon F. Efficacy of light therapy in nonseasonal depression: a systematic review.. J Affect Disord. 2008 May;108(1-2):11-23. Epub 2007 Oct 22. Terman, J.S. Terman, F.M. Quitkin, P.J. McGrath, J.W. Stewart and B. Rafferty, Light therapy for seasonal affective disorder. A review of efficacy, Neuropsychopharmacology 2 (1989), pp. 1–22. Lee and Chan, 1999 T.M. Lee and C.C. Chan, Dose–response relationship of phototherapy for seasonal affective disorder: a meta-analysis, Acta Psychiatr. Scand. 99 (1999), pp. 315–323. Thompson et al 1999 C. Thompson, I. Rodin and J. Birtwhistle, Light therapy for seasonal and non-seasonal affective disorder: A Cochrane meta-analysis, Society for Light Treatment and Biological Rhythms Abstracts (1999), p. 11. Gallin et al., 1995 P.F. Gallin, M. Terman, C.E. Reme, B. Rafferty, J.S. Terman and R.M. Burde, Ophthalmologic examination of patients with seasonal affective disorder, before and after bright light therapy, Am. J. Ophthalmol. 119 (1995), pp. 202–210. Modell JG, Rosenthal NE, Harriett AE, Krishen A, Asgharian A, Foster VJ, Metz A, Rockett CB, Wightman DS (2005). “Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL”. Biol Psychiatry 58 (8): 658–67 Lee TM, Blashko CA, Janzen HL, Paterson JG, Chan CC. Pathophysiological mechanism of seasonal affective disorder. J Affect Disord. 1997 Oct;46(1):25-38.
33
RESEARCH
Does ethnicity impact upon reporting of depression in London medical students?
Rachel Baigel*, Robert Freudenthal, Deborah Ragol Levy, Daniel McNaughton, Sara Taha All Year 4 Medicine, University College London rachel.burns@ucl.ac.uk doi:10.4201.lsjm/psy.003 For the full article and references see thelsjm.co.uk. Conflicts of interest: Rachel is a panellist for LSJM Psychiatry.
Abstract An online questionnaire was distributed to preclinical medical students in UCL, Kings college London and Barts and the London Medical School and students were asked to respond to four case vignettes. These were constructed based on the ICD-10 criteria for mild, moderate and severe depression and one vignette that acted as a control group presenting with subclinical symptoms of depression. Students were asked how likely they were to seek help from several different services and the reasons that would prevent them from going to these services. Statistical analysis was performed using chi squared tests. With regard to ethnicity, we found that African students were less likely to seek help from friends for either subclinical (p=0.032) or mild depression (p=0.043) and less likely to seek help from relatives in subclinical depression (p=0.047) that other ethnicities. South East Asians were more likely to seek help from a counsellor in mild depression (p=0.025) and from a university tutor in subclinical depression (p=0.04) than students of other ethnicities. When students were asked about the factors deterring them from seeking help for depression 31% said they definitely would not seek help because they believed their grades would suffer as a result, 35% said the same because they would not want the label of depression, and 33% said the same because they believe that seeking help for depression could affect their medical career. We believe that these are significant and that greater effort should be made elucidate at the start of medical school. Introduction Mental illness, particularly depression, is responsible for a significant proportion of the world’s health burden. The World Development Report 1993 states that depression ranks fifth amongst women and seventh amongst men as a cause of morbidity, whilst the World Health Organization has predicted that by 2020 depression will be the most common cause for disability worldwide, second only to ischaemic heart disease.1 Depression is massively under-diagnosed with an estimated 56% of people worldwide exhibiting clear-cut features of clinical depression but receiving no treatment and an estimated 74% of Europeans are affected by mental illness but remain untreated.2
34
Prevalence of depression varies across different socio-economic and occupational groups. There is evidence that young people have the highest population prevalence rates for mental health problems and substance abuse, however, their use of primary care and specialist services tends to be low when compared to other population age groups.3 This remains true amongst university students, where the high prevalence of anxiety and depression is thought to be related to social and academic factors – indeed, one study of Oxford University students reported higher rates of suicide than in the general population. Half of these students had clinical depressio students, particularly in London, are a heterogeneous group with a large proportion from ethnic minority backgrounds. It has been shown that presentations of depression are culturally dependent with somatic complaints dominating over psychological symptoms amongst non-Western cultures.5 Within the UK it is unclear if the prevalence of Depression is higher amongst ethnic minorities, with one study showing that whilst London Punjabi populations have a lower rate of diagnosis, they do experience more depressive thoughts than their white counterparts.6 The interaction between ethnicity, culture, clinical depression and its symptomatology amongst London students is complex however this study aims to ascertain how this interaction impacts on the likelihood of self-presentation to healthcare services when experiencing features of clinical depression. As discussed above, previous studies have shown that Depression is prevalent in both student groups and ethnic groups in the UK. In this study London medical students will be used as subjects, as this group is a culturally diverse high risk group. Methods To study the impact of ethnicity upon an individual’s likelihood in seeking help for symptoms of depression, four vignettes were prepared (Appendix 1). One vignette describes a person with no symptoms of depression with another three representing scenarios of mild, moderate and severe degrees of depression according to the ICD-10 classification of depression. In relation to each vignette presented, participants were asked to rate how likely they were to use any one of a range of services and were asked to score them regarding the likelihood of their using each service for that vignette (box 1). Participants were asked about different factors affecting
lsjm 15 june 2009 volume 01
RESEARCH their decision to attend these services and asked to score these factors (box 2). This questionnaire was distributed to preclinical medical students at University College London Medical School, King’s College Medical School and Bart’s and The London School of Medicine. The questionnaire was hosted online at http://www.surveymonkey. com and a link to the questionnaire was provided in an e-mail to students. The survey was left open to access for a period of three weeks. An incentive of £20 was made available to encourage responses. On entering the online domain, participants were presented with contact details of the counselling services of the respective institutions and were given the chance to opt out of the study at any point. Ethical approval, data protection and research governance for this study was granted by University College London. Ethnicities were grouped together under 6 categories and chi squared tests were performed to analyse if there was significant differences between the attitudes of people of different ethnicities to seeking help for sub-clinical, mild, moderate and severe depression from internet/books, friends, relatives, their GP, university counsellor, other counsellor or university tutor. Chi squared tests were also used to identify statistical differences between ethnicities regarding factors that would affect them seeking help for depression. Results • This questionnaire was sent to 1760 students. 311 (18% of the study population) completed it. • Approximately 56% were second year students and 44% first year students. 10% of the students had suffered from clinical depression beforehand. • Of the students who had suffered depression: 31% mild, 25% moderate 9% severe (75% White, 9% Chinese, 6% African, 6% Asian, 3% South East Asian). See figure 1 for more demographics. • Of the students who completed the questionnaire: 58% female, 41% male and all were aged 18-30 with 64% aged 19-20. • The representation of ethnicities in the study was: White 62% Asian 16% Chinese 8% Mixed Race 5% South East Asian 5% African 3% • Statistical significance of the results was calculated at the 5% significance level.
and the ICD-10 criteria (either unaffected by clinical depression or mild, moderate or severe Depression) and whose help would be sought. Four bars are displayed for each ethnic group representing the percentage of that group who selected each response (seek key). The degree of significance is indicated in the title of each graph. Reasons for students experiencing symptoms of depression for presenting to welfare or healthcare services are complex. This study attempted to ascertain what factors lead to some students presenting earlier than others, and to identify any correlations between the ethnicity of the students and their presentation. The results for the students responding to the vignettes representing moderate and severe Depression did not show significant differences between the ethnic groups in their likelihood of presenting to different welfare or healthcare services with symptoms of depression. However there were some significant differences between the attitudes of different ethnic groups in the mild depression group and the control group. When asked about seeking help from friends, people of African origin were far less likely to seek help than people of other ethnicities in both of the above groups (control p=0.032, mild Depression p=0.047). In mild depression, Asian, South East Asian and Chinese participants were significantly more likely to seek help from friends. When unaffected by clinical depression, it seems that students would consider turning to their relatives for help, but the African students were significantly resistant to this avenue p=0.047. Consulting University tutors and counsellors was universally an unpopular service to access for depression. However, students of White, South East Asian and Asian origin were more inclined to consult a university tutor for subclinical symptoms of depression. A similar pattern was seen for consulting a counsellor in mild depression. In this study, the African students seemed more reluctant to seek help from any cause. However, our study population of African students was small and therefore may not be representative of the African population as a whole. If it were to be confirmed that Africans were less likely to seek help for depression, then steps should be taken to increase African awareness of services at university of a confidential nature in order to increase help seeking in this ethnic group.
The graphs 1-5 illustrate the statistically results that were significant at the 5% significance level. There were 5 instances where there were significant differences between ethnic populations concerning the degree of depression as established by the vignette
The study found that despite the diversity of the respondents to the questionnaire there were some unifying factors across all groups that prevented presentation of the depressive symptoms. Seeking help from friends and family was always more popular than seeking help from tutors or counselors:63% of respondents had concerns
Type of depression within each ethnic group (%) Ethnicity
Percentage of each ethnicity who had been depressed
Unknown
Mild
Moderate
Severe
African
25
50
50
0
0
Chinese
12
33
67
0
0
Indoasian
4
50
50
0
0
South East Asian
6
0
0
100
0
White
11
29
29
29
13
Mixed
0
50
50
0
0
lsjm 15 june 2009 volume 01
Figure 1: This tabulates the demographics of our findings. Overall, the South East Asian population suffered the highest morbidity with all of the subjects who partook claiming to have experienced moderate depression. The only cases of severe depression were found in the White population. In the African, Chinese, IndoAsian and Mixed populations, all participants classified their depression as either mild or unknown.
35
RESEARCH Graph 1: Unaffected - seeking help from a friend p = 0.032
that seeking help for depressive symptoms would affect their medical career whilst 69% of students were concerned that seeking help would result in an unwanted label of ‘depression’.
Keys for graphs 1-5:
Graph 1 & 2: these graphs show that the majority of students of african origin would not seek help from a friend if they experience symptoms of sub-clinical depression or mild depression. In contrast, chinese, south east asian and mixed race students are more likely to seek help from a friend in the case of sub-clinical depression, but this likelihood is slightly reduced amongst white students. Graph 2 shows that all students, with the exception of africans, are inclined to seek help from a friend if they experience mild depression
Graph 2: Mild depression - seeking help from a friend p = 0.043
Graph 3: Unaffected - seeking help from a relative p = 0.047
Graph 3: This bar chart shows that the majority of students would consider hep from a relative if they experience sub-clinical depression. This affirmation is higher among Chinese and Asians. Africans were particularly unlikely to seek help from relatives when experiencing sub-clinical effects of depression.
Graph 4: Unaffected - seeking help from a university tutor p = 0.04
Graph 4: Help seeking for subclinical depression from a university tutor appears universally unpopular. However students of White, Chinese, Asianand South east Asian origin were more likely to present than those of African or mixed race.
Graph 5: Mild depression - seeking help from a counselor p = 0.025
Graph 5: Seeking help from a conselor in this instance seems to be universally unpopular. However, students of Chinese, White, South East Asian and Asian origin were morel ikely to present than those of mixed or of African origin.
36
Previous research into students’ attitudes to Depression showed a lack of knowledge about the illness and the implications that a diagnosis and its subsequent treatment may (or may not) have.7 These statistics are concerning as they highlight the stigma that exists within the medical world and implications for the presentation of depression in students. This carries a significant risk of under-diagnosing the condition in this group and subsequent poor management. There are some confounding factors that mean that these results cannot be extrapolated to the remainder of the London student population. In using medical students as a study population, we surveyed a highly educated, medically interested subsection of society, who have all been trained in the importance of confidentiality in a professional setting. We would expect that this group would have greater immunity to society’s stigmatisation of depression than other social groups. Therefore, our results showing such a high tendency to question seeking help due to stigmatisation of depression on the grounds that it could affect their careers are worrying. We would suggest that action should be taken in medical schools to promote a better understanding of the issues on confidentiality. This would impact both on the care of future patients and the unwillingness of medical students to seek help in the knowledge that their disclosure would remain completely confidential. Further research needs to be done as to why these attitudes persist amongst the London medical student population. Improvements/Further Work Study Design: 1. 18% of the students who received our e-mail completed the questionnaire. Whilst this response was good, it could have been improved by going into lecture theatres and asking all present to fill out a handwritten form. 2. Feedback from students made us aware that students responded to the cases set out in the vignette in different ways. Students did not always base their answers on the symptoms of depression laid out in the vignette, but responded on the significance of the ‘trigger’ eg. Grandparent dying versus breaking up with a boyfriend. For this reason it would be particularly important to analyse the data with respect to history and family history of depression. Statistical analysis: 1. 34 chi squared tests is a large number of tests to run and it is possible that running this number of statistical tests, will by chance, procure some statistically valid results. Therefore better planning should have taken place in order to minimise the number of tests performed and the amount of data collected. 3. For some of the chi squared tests, the expected values were under 5. This has been said to reduce the validity of this statistical method and in future we would either try and increase the number of respondents to the questionnaire or group several ethnicities together to achieve higher expected values. 9 Ideal Study Design Our study asked theoretical questions about the likelihood of
lsjm 15 june 2009 volume 01
RESEARCH students seeking help for depression. The majority of the students we assessed claimed to have had no history of depression and therefore the study largely surveyed the attitudes of healthy students as to whom they would go to for help. To accurately address the question of how likely students are to present for help with depression, it would be important to interview and identify students who were depressed, classify their depression according to ICD-10 criteria and then ask them how likely they would be to present to each service. These results would be far more accurate than the results obtained in our study, but would require a larger study population and large amounts of time as each student would need to be interviewed to assess their mental state. Conclusion Having achieved these results, we feel that it is important to address the negative attitudes of medical students to seeking help for depression, We propose a further study where information is provided to students about confidentiality in the services available to help people suffering from depression and to assess if this information could improve the attitudes of students to seeking help.
of weeks running up to your first big set of exams. You wake earlier in the morning in order to make it to lectures, but oversleep a couple of days a week. Your eating habits have changed – you haven’t had much time to cook for yourself and find yourself skipping breakfast due to the morning rush and consequently eat more during the day. Sometimes, especially towards the end of the day, you find it hard to concentrate in lectures. One evening in the last week you felt a bit down, and so you decided to go to the cinema and watch an upbeat film. Vignette 4 – Moderate depression Since your boyfriend/girlfriend broke up with you over a month ago, you’ve started to notice some changes. Your appetite has gone and you notice that your clothes are starting to look increasingly baggy. You feel tired a lot of the time, but still wake most mornings at about 5am. Things take you a lot longer than they used to, so often you just stay in your room. You begin to feel guilty about this and think that you don’t deserve anything better anyway. Your friends have been out partying and normally you would have loved to join them, but just don’t seem to enjoy the things you used to anymore.
If you believe your experiences can help others in a similar situation please write to the editor with a short 350 word response.
References 1.
Box 1: For each vignette students were presented with the following statement:
2.
If you were experiencing these problems how likely would you be to see help from: please fill in 1-4 where 1 = wouldn’t go, 2 = might go, 3 = would probably go, 4 = would definitely go)
3.
a) Internet/books b) A friend c) A relative d) GP e) University counsellor f) Other counsellor g) University tutor h) Someone else not on this list, please specify ________
4.
Appendix 1 – Case Vignettes Vignette 1 – Severe depression Since your grandma passed away three months ago, you have noticed some changes in your daily routine. You wake at 5am despite feeling tired all the time. You have little energy and rarely cook for yourself. You are feeling down and have little interest in your university course. You remember an incident from the beginning of the summer when you left a shop with an apple and forgot to pay for it. You feel very guilty about this and feel that you have brought shame on your family. Sometimes you hear voices talking about you and to you saying that you are worthless and you should turn yourself in to the police for stealing the apple. Vignette 2 – Mild depression Since starting university over three weeks ago you have been feeling quite low. You are struggling to make it in for your 9am lecture, despite getting a reasonable night of sleep and you find that you are eating less and rarely make your own food. You find that you are going out a bit less in the evenings, but are finding it harder than usual to concentrate in lectures, and you no longer enjoy some of the things that you used to. Vignette 3 – Unaffected by clinical Depression You have noticed that a few things have changed in the last couple
lsjm 15 june 2009 volume 01
5. 6.
7.
8.
9.
Bhugra et al. Globalisation and mental disorders. Overview with relation to depression. The British journal of psychiatry : the journal of mental science (2004) vol. 184 pp. 10-20 Thornicroft. Most people with mental illness are not treated. Lancet (2007) vol. 370 (9590) pp. 807-8 National Mental Health Report 1996, Fourth Annual Report. Changes in Australia’s Mental Health Services Under the National Health Strategy 1995–96. 1998 Canberra : Dept. of Health and Family Services, 1998. Hawton et al. Suicide in Oxford University students, 1976-1990. The British journal of psychiatry : the journal of mental science (1995) vol. 166 (1) pp. 44-50 Minhas FA, Nizami AT. Somatoform disorders: Perspectives from Pakistan. Feb 2006; International Review of Psychiatry. 18(1) (55-60) Bhugra D, Mastrogianni A. Globalisation and mental disorders. Overview with relation to depression. 2004 Jan, British Journal of Psychiatry. 184:10-20 Merritt RK; Price JR; Mollison, J, et al. A cluster randomized controlled trial to assess the effectiveness of an intervention to educate students about depression. Psychological medicine (2007) vol. 37 (3) pp. 363-72 Roness A, Mykletun A, Dahl AA. Help-seeking behaviour in patients with anxiety disorder and depression. Acta Psychiatr Scand. 2005 Jan;111(1):51-8. Armitage P, Berry G and Matthews JNS. Statistical Methods in Medical Research, Wiley-Blackwell 2001
Box 2: at the end of the questionnaire the participants were asked: How likely would it be that the following factors prevented you from seeking help from the list above? 1-3 where: 1 = wouldn’t prevent me at all, 2 = might prevent me 3 = would definitely prevent me a) They would think less of me. b) I wouldn’t want other people interfering with my business. c) Wouldn’t want to waste their time. d) This could affect my career as a doctor. e) This could affect my grades or go on my university record. f) Wouldn’t want to have a label of “depression”. g) The opening hours wouldn’t suit me/I wouldn’t have time. h) The service is too far away. i) Another reason ___________
37
REVIEW
Amphetamines Marcela Schilderman BSc (Hons)
Year 4 Medicine, St. George’s University of London m0401306@sgul.ac.uk doi:10.4201.lsjm/psy.001
For the full article and references see thelsjm.co.uk.
Abstract A relationship between amphetamine misuse and deliberate self-harm has been cited1, yet few epidemiological or research studies have been carried out to verify or nullify this link. The author explores the relationship between these behaviours through examination of the neurobiological, sociological and psychological similarities in their effects and occurrence, with a view to suggesting why the two might co-exist in the same patient and the implications of this relationship. Introduction The term amphetamine misuse is used here to refer to any nonprescribed (and therefore illicit) amphetamine administration from single use to complete dependence; whilst self-harm and self-injury are used interchangeably to denote deliberate infliction of injury (most commonly poisoning or skin laceration)2, to an individual’s own body in the absence of the intention to die from the damage caused. Epidemiology Amphetamine misuse and self-harm are significant problems in their own rights. 16% of the 4713 11-35 year olds interviewed in the 1996 UK National Drugs Campaign Survey had used amphetamines.11 Amphetamines are the second most popular illicit substance after cannabis in the UK and Australia, and fourth most popular.3,11 Self-harm is estimated at between 400 and 1400 per 100,000 population per year. 4 In conjunction, drug misusers have a greater incidence of suicide and self-harm than the rest of the population.5 But amphetamines have especially been related to severe self-harm such as self enucleation and removal of the hands,6 with three documented cases of repetitive genital self-injury.7 The Department of Psychiatry belonging to the University of California reports encountering serious self-harm with amphetamine induced psychosis, and recommends screening for amphetamine use in cases of unusual or serious self-harm.6
38
Demographic factors Gender Self-harm is an estimated four times more frequently reported in females than males, though self-poisoning (and therefore the use of drugs to procure injury) is greater in women.8 Contrarily, surveys place amphetamine use as 1.25 to 2 times greater in males than in females, both in the preceding year to the surveys and over the participant’s lifetime. 9,44 The latter could be explained by the recent discovery that men release more dopamine in the ventral striatum (including the reward-associated NAcc [nucleus accumbens]) and report a significantly more positive experience on amphetamine administration than females. 10 Age The greatest percentage of amphetamine misusers are aged 16 to 24 based on their amphetamine consumption in the preceding month (4% of a total 4647 respondents of a general drug survey), three months (7%), year (13-14%) and entire lifetime (22-26%).11 Similarly, self-harm is more frequently reported in the younger population, those aged 12 to 30, with figures as large as 61% ascribed to adolescents.12,13 Ethnicity Surveys in the USA have shown the prevalence of self-harm, stimulants, and particularly methamphetamine use to be amongst the greatest in Hispanic and white groups, and the lowest in the black subpopulation. 14,15,44 Biological Factors: Biochemistry and Neurophysiology Higher doses of amphetamines elicit stereotypical self-mutilatory behaviour in rats (such as biting and gnawing)16 dogs 17 and horses.18 This would suggest a biochemical theory of causation. Dopamine Differences in transmission of dopamine are thought to underlie variance in the Behavioural Approach System (BAS) within the population. BAS is stimulated in positive or negative appetitive reinforcement, and those with high BAS are thus considered more likely to enter into, and respond positively to, reward- related
lsjm 15 june 2009 volume 01
REVIEW behaviour including substance abuse.19 Experiential avoidance such as self-harm is a form of negative reinforcement via distancing the self from unpleasant emotional responses to stimuli; and may therefore also be associated with greater degrees of BAS; with the impulsivity and novelty-seeking aspects of a BAS trait personality likewise linked to such avoidance.20,21 Amphetamines are sympathomimetic. 22 They function as indirect agonists by acting on intracellular vesicles, instigating the reversal of catecholamine transporters at the vesicle and the release of noradrenaline and dopamine.23,24,25 Amphetamines also inhibit the re-uptake of dopamine released in the Nucleus Accumbens (NAcc.). Both of these mechanisms thus lead to a rise in the amount of this neurotransmitter acting on its postsynaptic receptors in the NAcc, an occurrence deemed essential to the reward sensation in the ‘dopamine reward hypothesis’ of drug addiction.26 An ‘addiction’ to self-harm hypothesis, has been put forward suggesting that the release of endogenous opiates onto μ receptors (β endorphin in particular) in response to pain, results in pleasure.27 Opioids active at the μ receptors block the action of GABA interneurones on neurones of the Ventral Tegmental Area (VTA). The disinhibition of VTA neurones causes them to increase their firing rate, and thus increase dopamine function in the NAcc upon which they synapse.28,30 Furthermore, a defective dopamine mechanism has been recorded in half of self-harming patients with Tourettes’ syndrome.22,29
with OFC lesions.40 This is likewise true for patients with borderline personality disorder patients and history of violent behaviour inclusive of self-injury. 48 Further research is required to determine whether or not amphetamine induced 5-HT depletion, particularly in the orbitofrontal region, leading to the typical decision-making abnormalities (a tendency to make delayed, ineffective choices) of an OFC lesion, may result in self-harming behaviour, or at the least aggression and a propensity towards it. Caudate As well as the NAcc; self-harm and amphetamine use may share the caudate in their instigation. Lesion of the caudate using 6-hydroxydopamine terminated the stereotypical amphetamineinduced gnawing and biting in rats.26 Whilst Yaryura J.A. et al proposed a possible neuronal circuit responsible for self-harming behaviour wherein the caudate and other basal ganglia, in addition to the thalamus, are involved with mediations between rageregulation of the amygdala, fear and appetite regulation of the hypothalamus, and the activity of the frontal lobe. 22,39 Sleep deprivation Sleep-related problems were reported in 93.4% of methamphetamine users in one survey.40 A quantity of research exists to suggest that self harm in amphetamine abusers may be a result of the lack of REM sleep obtained by some misusers of the drug.1
Serotonin Serotonin may also be a mediator. Several reports associate p-chloro-N-methylamphetamine abuse with a significant depletion in serotonin levels. 20,31,32 Conditioned preference for amphetamine-associated places by rats was inhibited with the administration of the 5-HT transmission amplifier zimelidine, but increased with the administration of the serotonin antagonist ritanserin.33 Sekine et al. found density of 5-hydroxytryptamine (5-HT) transporters decreased inversely with length of methamphetamine abuse in universal areas of the brain; and that their density in the anterior cingulate, orbitofrontal, and temporal regions was highly connected with the raised levels of aggression they documented in methamphetamine abusers. 34
Genetics Incidence of substance misuse was shown to be greater in monozygotic than dizygotic twins, indicating a genetic component.41 Whilst the A779 allele for tryptophan hydroxylase was more frequently encountered in deliberate self-harmers than controls in one survey, which supports a serotonin hypothesis for the disorder, as well as suggesting a genetic basis for it.42 It may therefore be that some amphetamine users who self-harm have a genetic predisposition towards it.
Aggression has been listed as one causative factor in self-harm; and self-injury may frequently be the major presenting symptom of an aggressive disorder. Studies in humans and animals have shown a link between self-harm and problems in 5-HT regulation. 22,35 The efficacy of selective-serotonin reuptake inhibitors in the treatment of self-harming and aggressive behaviour supports 5HT’s role in their genesis.22
Borderline Personality Disorder The DSM-IV requires a minimum of five out of the nine criteria listed for a diagnosis of Borderline Personality Disorder (BPD). Criterion 5 refers to recurring self-harm or threats of it, (occurs in an estimated 48-79% of sufferers 43,44,45) and criterion 4 refers to two or more other impulsive and possibly self-injuring acts such as substance misuse (57.4% of BPD patients also have a substance use disorder).46,47 Thus amphetamine misuse and self-harm can easily co-exist in a BPD individual, since they are common to, and relate to, fundamental aspects of the psychiatric disorder.48
Serotonin and Decision Making Serotonin appears to have a role in decision-making ability. Experimentally reduced serotonin function resulted in slow, maladaptive deliberation in subjects akin to that displayed in patients with orbitofrontal cortical (OFC) lesions. 36 Evidence has indicated that abnormal decision making is central to substance abuse. 37 Recent research shows that the problems in decision-making exhibited in chronic amphetamine abusers are also very similar to the decision-making problems seen in individuals
lsjm 15 june 2009 volume 01
Psychiatric factors There is an increased prevalence of both self-harm and substance abuse in certain psychiatric disorders.
Conduct Disorder Those with conduct disorder are at increased risk of self-harm (12.6% prevalence)49 and substance misuse.50 A study of delinquent adolescent boys concluded that they all achieved modified criteria for conduct disorder, and found a significant association between the number of conduct disorder symptoms and self-harming history. 51
39
REVIEW Children suffering from conduct disorder have a greater probability of discord with their contemporaries,52 of association with delinquent and rejection by non-delinquent contemporaries. It could be that the psychological impact of rejection and conflict, and deviant peer influence guide a person with conduct disorder towards self-harm and amphetamine use. Post Traumatic Stress Disorder (PTSD) PTSD has been linked to an increased probability of both substance abuse and self-harm.1, 10 Jacobson et al comment on the large amount of data supporting a pattern where substance misuse occurs secondary to PTSD as a means of altering the symptoms of PTSD (the self-medication hypothesis); they propose that the high level of comorbidity in this area is indicative of a functional similarity between the two disorders.53 Prospective and analytical studies by Chilcoat H.D. and Breslau N. are in favour of this hypothesis over the two alternatives: namely, that substance abuse occurs prior to PTSD and is causative of it, either through placing the individual at increased risk of exposure to traumatic events, or through increasing their susceptibility to PTSD on exposure to trauma .54 In terms of more general stress, chronic stress caused development of sensitisation to the stimulatory behavioural effects of amphetamines in mice of particular strains (DBA/2 but not C57BL/6) , 55 thus suggesting a plausible hypothesis that individuals of some genotypes are susceptible to amphetamine sensitisation on prolonged or repeated exposure to stressors Self harm as a means of feeling some sensation to overcome numbness (automatic positive reinforcement), was found to be associated with PTSD.89 Study findings have shown that serotonin (SERT) gene knockout mice have greater vulnerability to predator stress,56 and that persons with low-functioning forms of this gene are more susceptible to depression and anxiety (and thus, symptoms of PTSD) following traumatic incidents.57,58,59 Inactivation of the serotonin SERT gene, although leading to increased 5HT2A receptor binding density in the amygdala,60 leads to a decrease in 5HT1A receptor binding density in numerous areas of the brain as well as the amygdala.61 Decreased binding density might suggest decreased response to serotonin. In light of the aforementioned associations between self-harm, amphetamine use and 5HT, it could be postulated that an underlying SERT gene malfunction affecting 5HT receptors, exacerbated by the effects of amphetamine use, may make some individuals vulnerable to anxiety and depression in response to stressful life events, and therefore PTSD and/or self-harm. Eating Disorders Amphetamines, being appetite suppressants, are open to common abuse amongst individuals with bulimia nervosa.62 The level of severity that those with an eating disorder limit their calorie intake has been shown to correlate with their likelihood of amphetamine use. 63 An association between self-harm and eating disorders has likewise been noted, with epidemiological research placing self-injury at a 25% for inpatient and outpatient bulimics, and 23% for outpatient anorexics.64,65
40
It may be that the lack of esteem in the self, particularly the body, which can direct an individual towards taking amphetamines in the propagation of an eating disorder, may also direct them towards self-harm (see later, under self-esteem.) Depression Depression has been associated with amphetamine misuse and very much so with self-harm .66,67 Major depressive disorder was diagnosed in 67% of self-poisoners in a study by Kerfoot et al.68 The vast majority of deliberate self-harmers in another survey achieved scores on the Beck Depression Inventory indicating moderate to severe depression. 73 There was a significant decrease in the 5HT binding capacity in the individuals of one study who had self-harmed, which would suggest a reduced response to 5HT in these patients. 69 Evidence, including lower concentrations of serotonin metabolites in the cerebrospinal fluid and serotonin in post-mortem brain tissue, reduced numbers if serotonin transporters in such tissue and the efficacy of selective serotonin reuptake inhibitors in depressed individuals all suggest that depression is likewise affiliated with impaired 5HT function. 70 Self-medication with amphetamines in order to combat depression occurs commonly; typically one user in a qualitative study recounted being “so low in morale� that she was drawn into the habit to resolve this. 71,72 In another such survey, those respondents who were also administering the drug for this purpose did report the desired elevation of affect on initial use; however, over 66% of the overall 450 questioned described depression as a serious result of chronic use. 73 It is not clear where precisely causality might lie. Whilst it appears pre-addiction depression might instigate either behaviour, and thus possibly both in the same individual, either simultaneously, or sequentially; it is also plausible that dysphoria produced by amphetamine withdrawal 50 or the effect on neurotransmitters of its chronic use, or the impact of sociological factors (such as unemployment) resulting from its misuse, may produce a depression that leads to self-harming behaviour. Sociological Factors There are several cofactors in substance misuse and self-harm in young people, including those following. Peer Influence Peer pressure is viewed as a possible reason for commencement of self-injury, and the negative influence of self-harming individuals among peer groups has been noted.74,75 Amphetamine use by peers significantly raised the likelihood of amphetamine use reported in a large sample of adolescents in America.76 Childhood Abuse Review of both retrospective and prospective research suggests most of the research indicates that childhood physical and sexual abuse is a risk factor for substance abuse, often through generation of depression and anxiety which put the victim at greater risk of such behaviour. 77 In one survey of self-harmers, 25% reported childhood physical abuse, and 49% childhood sexual abuse, as factors in the distress that caused them to self-harm. 78
lsjm 15 june 2009 volume 01
REVIEW Family problems Single parent status and one third of divorces have been linked to substance abuse , whilst over 50% of those self-harming under the age of 16 have divorced or separated parents.79,80,81 American research has categorised victims of emotional abuse as being at risk of substance use;82 and emotional abuse was cited in 43% respondents in one survey as a factor for their self-harm.109 Lack of warmth has been associated with both self-harm and advancement from experimental to more frequent substance use.83,84 Connections have been made between family disruption and dissension, and both self injury and substance misuse.85,110,114 The object relations theory hypothesises that people, objects and fantasies in the environment of a child will form the basis from which the child acquires their sense of self. In cases of childhood abuse and family turmoil and lack of warmth, the child’s environment is unstable, love is conditional, and trust may be abused.86 Van der Kolk proposes that this may cause the child to envision themselves as lacking in trustworthiness and unable to be loved unconditionally leading to self-injury as a form of punishment or a need to re-enact the trauma.87,88 The child’s emotional system may also be sensitised to future traumas by these earlier experiences, making them more difficult to withstand, and perhaps therefore necessitating self-injury and amphetamine use as coping strategies for the emotions (experiential avoidance). Conclusion Both self-harm and amphetamine misuse are significant medical issues in their own rights in terms of their high popularity and negative effect on multiple aspects of quality of life. It is clear that there is a paucity of research into the exact relationship between amphetamine misuse and self-harm in humans. Currently, only animal studies have provided firm evidence of a link between amphetamines and self-mutilatory behaviour though many possible explanations for a human association are plausible. There is a need for further research in this area to establish causality, which will be beneficial in establishing the extent of comorbidity or sequential morbidity with these disorders, and vital in planning the treatment approach; for example, an underlying neurobiological problem would favour pharmacological treatment, a psychiatric problem might favour a problem-solving emendation approach. Unified nomenclature would help make research studies comparable with each other.
It is likely that not just biological but also psychosocial factors mediate. From the factors involved in relation to self-harm and amphetamine misuse, it is clear that there is scope for further research studies into combined treatment involving 1. Raising of self-esteem. 2. Family therapy to resolve conflict and care issues. 3. Amendment of poor problem-solving abilities 4. Amendment of poor decision-making capabilities 5. Alternative medicine The high physical, psychological, financial and social health costs of amphetamine use and self-harm, and its popularity in an age group of individuals expected to be at the peak of their health, and at critical junctures of their educational or working lives, make research into the incidence and co treatment of it prudent. Routine screening for amphetamine use in self-harmers and vice versa may also be worthwhile given the apparent relationship between them. Where there is a diagnosable underlying medical condition, such as PTSD, then recommendation is made to treat the cause. Cotreatment of amphetamine use is considered advisable, to ensure amphetamines do not mask an underlying psychiatric condition, and so that physical harm is limited. References 1.
2. 3.
4. 5.
6.
7. 8. 9.
10.
Much of the research into amphetamine and self-harm focuses on the adolescent to 30 year old age group since this is the one with the highest prevalence of both disorders. This is inadequate for a full understanding of the populations with these disorders and ought to be addressed in future studies, particularly as possible contributing psychosocial factors such as life events and education status tend to show variance with age.
Lara-Lemus A., Perez de la Mora M., et al.,(1997) Effects of REM sleep deprivation on the d-amphetamine induced self-mutilating behaviour, Brain Research, 770;60-4 Patton G.C., Harris R., et al.,(1997) Adolescent suicidal behaviours: a population-based study of risk, Psychol. Medicine, 27(3);715-24 Yoshida T., Use and misuse of amphetamines: An international overview. In: Klee H, ed. Amphetamine Misuse, International Perspective on Current Trends, The Netherlands: Harwood Academic Publishers, 1997;43-59 Favazza A.R., Rosenthal R.J., (1993) Diagnostic issues in selfmutilation, Hospital and Community Psychiatry, 44(2);134-40 Hasin D., Grant B., Endicott J.,(1988) Treated and untreated suicide attempts in substance abuse patients, Journal of Nervous and Mental Disease, 176;289-94 Kratofil P.H., Baberg H.T., Dimsdale J.E. (1996) Self-mutilation and severe self-injurious behaviour associated with amphetamine psychosis, General Hospital Psychiatry, 18;117-20 Israel J.A., Lee K.,(2002) Case Report: Amphetamine usage and self-mutilation, Addiction, 97(9);1215-18 McAllister M.,(2003) Multiple meanings of self harm: a critical review, International Journal of Mental Health Nursing, 12;177 Grahame-Smith D., Barlow J., et al., Drug Misuse and the Environment, A Report by the Advisory Council on the Misuse of Drugs, Norwich: Her Majesty’s Stationery Office, 1998;15-6 Munro C.A., McCaul M.E., et al.(2006) Sex differences in striatal dopamine release in healthy adults, Biological Psychiatry, Article in press, corrected proof accessed via www.sciencedirect.com at 23:14 hrs on 21/04/06
Evidence is strongest for a neurobiochemical link between behaviours, specifically serotonin depletition and dopamine mediated reward. It could be that in the future, there may be the opportunity of development of one pharmaceutical therapy to treat both conditions.
lsjm 15 june 2009 volume 01
41