by admin | Feb 24, 2014 | Suicide
There has been a major controversy in the media because of the relationship between suicidality in children and adolescents and SSRI antidepressants. The FDA (Food and Drug Administration) in America state that antidepressants increase the risk of suicidal thinking and behaviour (suicidality) in children and adolescents with major depressive disorder and other psychiatric disorders. Anyone considering the use of an SSRI or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour. Families and care givers should be advised of the need for close observation and communication with the prescriber. Pooled analyses of short term placebo / controlled trials of nine antidepressants (SSRIs and others) in children and adolescents with major depressive disorder, Obsessive Compulsive Disorder, or other psychiatric disorders have revealed a greater risk of adverse events representing suicidal thinking or behaviour (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events on drugs was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. This is a good and reasonable summary of the current situation. It emphasises close monitoring in the early weeks and suggests close attention to risks / benefit of the medication. Clearly the benefits will outweigh the risks in those with more severe depressive states.
It is interesting that efficacy could not be established for the SSRIs except for Fluoxetine in paediatric usage. It is important as well to note that major depression increases the risk of childhood suicide about 12 fold. More than half of the kids with this disease try to kill themselves, and about 7% do complete suicide according to USA Today 2004. One has to measure this against the fact that 2 in 100 children on antidepressants become more suicidal because of the pills and there were no reported suicides again according to USA Today 2004. The reasons for the increased suicidality might be due to the fact that the medications can increase impulsiveness and that as the children who have been depressed become more energetic this increases the likelihood of suicidality. It is interesting that there isn’t evidence for the tricyclic antidepressants in children but the current controversy might drive clinicians because of the concerns about the SSRIs to go back to prescribing the tricyclic antidepressants which are generally regarded to have higher side effect rates. This would be a retrograde step. The worry is now is that some severely depressed children wont get the antidepressant treatment they require because of the current controversy. Indeed a report in USA Today states that some doctors ‘fear kids could be denied needed care’. This is where the good clinician comes in who is able to weigh up the risks and the benefits, who is able to identify a depression as being severe and in need of antidepressant treatment. Clearly mild depressions should be treated with psychotherapy. The British Medical Journal 2004 came to a reasonable conclusion that doctors should not hesitate to use antidepressants for clearly defined depressive disorders but they should carefully monitor patients in the first weeks of treatment. There is a signal for suicidality when you look at studies of antidepressants that is the SSRIs nevertheless a report in the Journal of the American Academy of Child and Adolescent Psychiatry 2004 stated that ‘none of the reported differences with regard to suicidality between any of the drugs and placebo are statistically significant’. This report claims that there has been an underestimation of the reduction of suicidality in patients treated with antidepressants. My own personal conclusion is that there is a signal for suicidality but this can be managed within the context of the doctor patient relationship and careful monitoring in the early weeks after prescription. It is difficult to communicate this common sense approach in the context of media controversy.
by admin | Feb 24, 2014 | Suicide
About 80% of all suicides are male. Alcohol and substance misuse is commoner in males and unemployment may be a more significant risk factor in males who complete suicide. It appears that it may be harder for males to find their role and identity in our society where ‘a credit card is all you need’.
It is hardly surprising then that the unemployed male who may see themselves at the bottom of the male hierarchy is more likely to suicide.
Unemployed males would appear to suffer significant identity diffusion, be on a different track to other males, employed and driving their BMWs.
Indeed the difficulties with the male finding a role and being lost are particularly a feature of young male adulthood. The Sunday Times in 2004 stated that ‘the sperm bank is the perfect father’ and had another statement as follows ‘women longing for a baby (but) decide to go it alone’. The male has become more marginalized in our society in recent times. Females have entered the workplace in great numbers but still have retain their fundamental biological role that is in reproduction.
The male brain has strengths in mechanics, engineering, and mathematics. These talents do not help in the mental processing of psychological distress. In addition males tend to be more aggressive, impulsive, and are therefore at increased risk of engaging in fatal suicidal behaviour. Simon Baron-Cohen points out that good systematisers are also skilled at understanding and exploiting natural systems. The males are therefore good as hunters and trackers. The male is good at mechanical systems and constructing tools. The male is good at making weapons and fighting. Good systematising helps the male to be good at working on the stock markets. Males are particularly good at climbing hierarchical poles. The combination of low empathising (male) and high systematising (male) means a rapid ascent to the top of the ‘social pile’. Males are more single minded. Nevertheless all these feature may make suicide more likely.
Males in severe psychological distress using the ‘stiff upper lip’ strategy are particularly at risk. It is possible that some of them feel that being in distress is to be unmasculine is to be lacking machismo, which is experienced as intolerable, who then in this highly distressed state undertake suicide. Males are better at map reading. The male language is sometimes more egocentric. Males are more aggressive and get involved in more crime and homicide. Systematising is our most powerful way of understanding and predicting the law – governed inanimate universe. Understanding the inanimate universe is not much good when a human being male is highly stressed and contemplating suicide. A great deal of this material is also covered in my book Autism and Creativity: Is there a link between Autism in Men and Exceptional Ability? Published by Brunner-Routledge, 2004. The extreme male brain theory of autism is based on superior systematizing.
The female brain according to Simon Baron-Cohen is hard wired for empathy, and the male to understand and build systems. In the long term it is likely that the human genome will pinpoint multiple genes of small effect that control empathising and systematising. Females are better at sharing and turn taking, at responding empathically to distress of other people, are better at being sensitive to facial expressions, and value relationships more.
Empathising is the drive to identify another person’s emotions and thoughts, and to respond to these with appropriate emotion. Females are high in empathising and low in systematising. Females are much better than males at reciprocal communication. Females are also better at reading non-verbal behaviour. Females tend to be more compassionate and tolerant. Females have superior capacity at communication and interpersonal relationships which may mean that they are less vulnerable to completing suicide.
The female has a more clearly defined role with reproduction and rearing children. Females are more developed human beings in terms of empathy and interpersonal skills. They have better social skills. They have better capacity to make social connections and are therefore less alienated and socially disconnected. This may reduce their suicide risk. (Prof. Fitzgerald is Chairman of the Irish Association of Suicidology)
by admin | Feb 24, 2014 | ADHD
The prevalence of Adult Attention Deficit Hyperactivity Disorder is between 1 and 5%. Both DSM-IV and ICD-10 criteria recognise that symptoms of Attention Deficit Hyperactivity Disorder and Hyperkinetic disorder persist beyond childhood into adulthood. However neither classification gives fixed thresholds for the number of symptoms required to make a diagnosis in adults. DSM-IV criteria suggests that adults with only some of the symptoms of Attention Deficit Hyperactivity Disorder should be given a diagnosis of Attention Deficit Hyperactivity Disorder in partial remission; however, this diagnosis seems to underplay the significant impairments seen in adults no longer meeting the full DSM-IV criteria. There is no doubt that symptoms of adult Attention Deficit Hyperactivity Disorder should be judged with reference to developmentally appropriate norms. The expression of Attention Deficit Hyperactivity Disorder in adults is different from that in children and the diagnostic descriptions of symptoms are not easily applicable to adults. For example physical activity in children is replaced by constant mental activity, feelings of restlessness and difficulty engaging in quiet sedentary activities in adults. Compared to the diagnosis in children, a diagnosis of Attention Deficit Hyperactivity Disorder in adults is also heavily dependent on self-reporting symptoms. For that reason an independent informant particularly one who had knowledge of the adult in childhood is particularly important. In addition school reports can be most helpful. Girls particularly with Attention Deficit Disorder without the hyperactivity tend to be under diagnosed and under treated. In Adult Psychiatry Attention Deficit Hyperactivity Disorder is probably one of the commonest missed diagnosis, the second most commonly missed diagnosis being Asperger’s syndrome. What is treated is the comorbid anxiety, depression, or drug abuse and the underlying Attention Deficit Hyperactivity Disorder is left untreated with serious consequences.
The key element in diagnosis is the lifetime and persistent history of symptoms with impairment in either school, work, home, or interpersonal relationships. This was emphasised at a recent meeting of the European Network for Attention Deficit Hyperactivity Disorder in Frankfurt.
Treatment should focus on psychoeducation for persons with Attention Deficit Hyperactivity Disorder, as well as pharmacotherapy, and in addition the treatment of comorbid disorders. Stimulants like Methylphenidate are used in the treatment of adults. Long acting Methylphenidate for example Concerta is being used off label for adult Attention Deficit Hyperactivity Disorder. Atomoxetine (Strattera) which is licensed for adults in the United States and is available in Ireland on a named patient basis is being used for the treatment of Attention Deficit Hyperactivity Disorder. It is the first non-stimulant medication for Attention Deficit Hyperactivity Disorder. I have found that the tricyclic antidepressants are unfortunately rather ineffective. The core symptoms of Attention Deficit Hyperactivity Disorder require pharmacological treatment. The other behavioural associated problems or disorders can benefit from psychotherapy, cognitive, supportive, etc..
It is possible that Adult Attention Deficit Hyperactivity Disorder may belong to a more severe and more genetically effected condition. Morbidity and mortality are both increased in adults with Attention Deficit Hyperactivity Disorder. It appears that Attention Deficit Hyperactivity Disorder can result in more accidents including traffic accidents and alcohol and drug abuse. There is evidence that where Attention Deficit Hyperactivity Disorder has been adequately treated the rate of substance abuse was less. It is important to reiterate that in adulthood the features of Attention Deficit Hyperactivity Disorder that are most common are inattention, impulsivity, poor organisation, and restlessness. Attention Deficit Hyperactivity Disorder can be associated with creativity for example Kurt Cobain who had diagnosed Attention Deficit Hyperactivity Disorder in childhood, Oscar Wilde, Lord Byron, Ernest Shakleton, and Richard Brinsley Sheridan.
Adult Attention Deficit Hyperactivity Disorder is of critical importance in services treating drug problems, personality disorders, and forensic services. The rate of Attention Deficit Hyperactivity Disorder in Mountjoy Prison is much higher than in a non-prison population. A recent edition of the Journal (2003) Drugs: Education Prevention and Policy emphasised the association of adult Attention Deficit Hyperactivity Disorder, Antisocial Personality Disorder and substance misuse. Despite this clinicians have a reluctance to take Attention Deficit Hyperactivity Disorder into account at the diagnostic and therapeutic level. The reluctance to accept the diagnosis is even more puzzling because of its very high heritability which is higher than many conditions psychiatrists treat. There should be regional centres for the treatment of adult Attention Deficit Hyperactivity Disorder but this is not possible with the catchment area arrangement. Therefore one Consultant Psychiatrist in each catchment area should take a special interest in adult Attention Deficit Hyperactivity Disorder.
by admin | Feb 24, 2014 | Aspergers, Autism
There are few conditions that have received as much coverage in the popular press in recent times or have been the subject of as much controversial debate as autism. Public awareness regarding the condition has grown exponentially but many healthcare professionals may still lack confidence in making the diagnosis of autism according to Dr. Louise Gallagher who has conducted genetic research in autism at Trinity College Dublin.
This article aims to give an overview of the disorder of autism staring off with a clinical description and diagnostic criteria. Theories on causation and a review of the current accepted interventions will also be outlined.
It can be associated with ability of genius proportions. Examples include Godel, Hans Christian Andersen, Gregor Mendel, Archimedes, and Charles Lindberg.
Autism is very commonly associated with low functioning and Learning Disability. This is a false conception of the condition. High Functioning Autism or Asperger’s syndrome can occur in persons with very high I.Q.
Clinical Description
Autism is a neuro-developmental disorder of childhood that was first described by Leo Kanner. He described a group of children with impaired language, lack of eye contact, lack of social interaction and repetitive behaviour. In 1944, Hans Asperger published a paper describing a pattern of behaviours in several young boys who had normal intelligence and language development, but who also exhibited autistic-like behaviours and marked deficiencies in social and communication skills. Asperger’s syndrome went largely unrecognised until the 1980s. Now it is commonly used to describe individuals with an Autistic Spectrum Disorder and normal intellectual functioning.
Asperger’s syndrome, and described the following difficulties in the first two years of life of children with the condition:
(a)Â Â Â Â Â Â A lack of normal interest and pleasure in people around them.
(b)Â Â Â Â Â Â A reduction in the quality and quantity of babbling.
(c)Â Â Â Â Â Â A significant reduction in shared interests.
(d)Â Â Â Â Â A significant reduction in the wish to communicate verbally or non-verbally.
(e)Â Â Â Â Â Â A delay in speech acquisition and impoverishment of content.
(f)Â Â Â Â Â Â No imaginative play or if it does occur it is confined to one or two rigid patterns.
Gillberg’s diagnostic criteria for Asperger’s syndrome: social impairments; narrow interests; repetitive routines; speech and language peculiarities; non-verbal communication problems; motor clumsiness.
High Functioning Autism or Asperger’s syndrome is not uncommonly misdiagnosed as Schizoid, Narcissistic Borderline or Obsessive Compulsive Personality Disorder or Schizophrenia.
Genetic of Autism
Heritability estimates of over 90% have been made in relation to autism. Louise Gallagher points out that approaches to genetic studies have involved candidate gene studies and genome-wide, affected, sib-pair linkage studies. Association studies with variants within the Serotonin transporter gene have been conducted based on the well-established findings of elevated platelet Serotonin. Findings between studies have been inconclusive to date. Other genes, which have been studied, include UBE3A, GABRB HOXA1/B1, all of which have had conflicting reports of association. Reelin and WNT have had initial studies reporting association but these require replication.
Seven genome-wide linkage studies have been published to date and a large number of regions of putative linkage have been identified. The most convincing evidence has been found on Ch2q and 7q. Efforts are underway to narrow these regions down to find candidate genes.
Interventions
A comprehensive management plan should be put in place once the diagnosis has been established. Management involves a multidisciplinary approach involving the following:
(a)Â Â Â Â Â Â Speech and Language Therapy.
(b)Â Â Â Â Â Â Psychological assessment for appropriate school placement.
(c)Â Â Â Â Â Â Education interventions.
(d)Â Â Â Â Â Educational interventions.
(e)Â Â Â Â Â Â Pharmacotherapy.
(f)Â Â Â Â Â Â Theory of mind and empathy training (higher intellectual functioning).
Speech and Language Therapy is essential and should be provided regularly (at least once a week) for children with speech and language delay. Pharmacotherapy has limited application but Ritalin may be considered in the presence of marked hyperactivity although children with autism are reported to be more sensitive to the side effects. Risperidone has been shown to have some beneficial effects on global assessments of psychiatric morbidity but not on individual autistic symptoms. Naltrexone has been reported to have beneficial effects on self-injury and stereotyped behaviours but well-controlled clinical trials are still required. SSRIs are widely used in the US but not in Europe. There are some reports of improvements in repetitive behaviours but randomised, controlled trials (RCTs) are required. The use of Melatonin in sleep disorders including those associated with autism, has been reported as beneficial by a number of groups. Again there is an absence of well-controlled RCTs.
As mentioned above, the evidence supporting a casein and gluten-free diet is limited. Knivsber et al. report an overall benefit in their review of the area but the studies in question have a number of methodological flaws including small sample sizes. Secretin has not been shown to be helpful.
The following examples of people with High Functioning Autism or Asperger’s syndrome and contributors of genius.
Kurt Godel was very much a loner and a genius. He was fascinated by mathematics and contributed greatly to it. He was a linguist and an autodictat. Even in junior school he was fascinated by mathematics and physics. He was socially immature and had severe difficulties in social relationships. He had non-verbal behaviour difficulties and had a tremendous capacity for focus on mathematical problems. He was extremely naïve. He suffered from severe depression. His verbal contributions are characterised by extreme brevity. He was also quite paranoid and fearful of emissions from refrigerators.
Mendel was a genius who was also very much plodding in his work, hard working, and completely single minded. He proposed laws of inheritance that ultimately became the underpinning of the science of genetics. He had severe difficulties in social relationships. He was extremely shy. In front of a class he was an extremely poor teacher. In teaching he never was fully certified and was always a substitute teacher. He was a man of absolute routines. He regarded his plants as his children. He was a monk who became rather paranoid and saw his fellow monks as traitors.
Hans Christian Andersen was a great storyteller. He was socially immature. He had very significant social interactional problems. He was very much a loner. He never married. He was a great writer of fairytales and showed enormous creativity in this area. He read an enormous amount of books. He was bullied and called names at school. He was very much an outsider. He spoke with a high pitch tone of voice. He was extremely obsessive. He was very ritualistic in his behaviour. He was very controlling and at meal times his food had always to be served first. He suffered very much from depression throughout his life. He had identity diffusion. He wrote endlessly and compulsively.
Archimedes was a great Greek mathematician and inventor. He was a loner. He was mechanically and mathematically minded. He hyper focussed on his researches. His interests were extremely narrow. He would forget to eat his meals. He was regarded as extremely eccentric.
Charles Lindberg was a great aviator. He was a loner as a child. He was painfully shy in social relationships, he was naïve in accepting an award from Hitler. He liked solitude. He was extremely logical and obsessed with aviation. He also worked on the issues in high altitude flying and on a pump that blood could be pumped if the heart was being operated upon. This work was carried out at the Rockerfeller Institute. His greatest achievement and one that he was well suited for was in flying solo across the Atlantic over Ireland to Paris. The link between psychiatric disorders and genius has often been made and these are further examples of that link.
by admin | Feb 24, 2014 | Autism
Autism is very commonly associated with low functioning and Learning Disability. This is a false conception of the condition. High Functioning Autism or Asperger’s syndrome can occur in persons with very high I.Q. and indeed ability of genius proportions. The following people demonstrate this high ability as well as High Functioning Autism:
Kurt Godel was very much a loner and a genius. He was fascinated by mathematics and contributed greatly to it. He was a linguist and an autodictat. Even in junior school he was fascinated by mathematics and physics. He was socially immature and had severe difficulties in social relationships. He had non-verbal behaviour difficulties and had a tremendous capacity for focus on mathematical problems. He was extremely naïve. He suffered from severe depression. His verbal contributions are characterised by extreme brevity. He was also quite paranoid and fearful of emissions from refrigerators.
Mendel was a genius who was also very much plodding in his work, hard working, and completely single minded. He proposed laws of inheritance that ultimately became the underpinning of the science of genetics. He had severe difficulties in social relationships. He was extremely shy. In front of a class he was an extremely poor teacher. In teaching he never was fully certified and was always a substitute teacher. He was a man of absolute routines. He regarded his plants as his children. He was a monk who became rather paranoid and saw his fellow monks as traitors.
Hans Christian Andersen was a great storyteller. He was socially immature. He had very significant social interactional problems. He was very much a loner. He never married. He was a great writer of fairytales and showed enormous creativity in this area. He read an enormous amount of books. He was bullied and called names at school. He was very much an outsider. He spoke with a high pitch tone of voice. He was extremely obsessive. He was very ritualistic in his behaviour. He was very controlling and at meal times his food had always to be served first. He suffered very much from depression throughout his life. He had identity diffusion. He wrote endlessly and compulsively.
Archimedes was a great Greek mathematician and inventor. He was a loner. He was mechanically and mathematically minded. He hyper focussed on his researches. His interests were extremely narrow. He would forget to eat his meals. He was regarded as extremely eccentric.
Charles Lindburg was a great aviator. He was a loner as a child. He was painfully shy in social relationships, he was naïve in accepting an award from Hitler. He liked solitude. He was extremely logical and obsessed with aviation. He also worked on the issues in high altitude flying and on a pump that blood could be pumped if the heart was being operated upon. This work was carried out at the Rockerfeller Institute. His greatest achievement and one that he was well suited for was in flying solo across the Atlantic over Ireland to Paris. The link between psychiatric disorders and genius has often been made and these are further examples of that link.
