Wednesday, May 30, 2007

A community study of the presence of anxiety disorder in people with epilepsy.

 
Epilepsy Behav. 2007 May 24; [Epub ahead of print] Related Articles, Links
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A community study of the presence of anxiety disorder in people with epilepsy.

Mensah SA, Beavis JM, Thapar AK, Kerr MP.

Academic Department of Neuropsychiatry, Whitchurch Hospital, Cardiff, Wales, UK.

Anxiety represents a major problem for people with epilepsy, and it is important to understand why it arises and how to reduce its potential debilitating and adverse effects. The aim of this study was to determine the prevalence of anxiety in a community-identified sample of people with epilepsy and to identify which demographic and clinical factors are most closely associated with anxiety and which factors predict the presence of anxiety among people with epilepsy. Adults with epilepsy in the community (n=515) were identified through primary care records and sent validated questionnaires, which included the Hospital Anxiety and Depression Scale (HADS). The mailout also included items on demographic and clinical variables. The prevalence of anxiety (HADS score >11) in this sample was 20.5% (95% CI: 16.9-24.1%) and was associated with a current history of depression, perceived side effects of antiepileptic medication, lower educational attainment, chronic ill health, female gender, and unemployment. It was not associated with the duration of epilepsy. The findings from this study suggest that anxiety disorders in a community population with epilepsy are most strongly predicted by factors independent of epilepsy-related variables, with the exception of patient-reported side effects. It is important to be aware of these factors when evaluating an individual with epilepsy.

PMID: 17532266 [PubMed - as supplied by publisher]

Multiple sclerosis as a painful disease.

 
Int Rev Neurobiol. 2007;79:303-21.
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Multiple sclerosis as a painful disease.

Kenner M, Menon U, Elliott DG.

Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71103, USA.

Pain is a common problem of patients with multiple sclerosis (MS) and may be due to central/neuropathic or peripheral/somatic pathology. Rarely MS may present with pain, or pain may herald an MS exacerbation, such as in painful tonic spasms or Lhermitte's sign. In other patients, pain may become chronic as a long-term sequela of damage to nerve root entry zones (trigeminal neuralgia) or structures in central sensory pathways. Migraine headache may develop as a consequence of MS, and headache can also be a side effect of interferon treatment. The pathophysiology of pain in MS may be linked to certain plaque locations which disrupt the spinothalamic and quintothalamic pathways, abnormal impulses through motor axons, development of an acquired channelopathy in affected nerves, or involve glial cell inflammatory immune mechanisms. At this time, the treatment of pain in MS employs the use of antiepileptic drugs, muscle relaxers/antispasmodic agents, anti-inflammatory drugs, and nonpharmacological measures. Research concerning cannabis-based treatments shows promising results, and substances which block microglial or astrocytic involvement in pain processing are also under investigation.

PMID: 17531847 [PubMed - in process]

Friday, May 18, 2007

Association between trauma exposure and delusional experiences in a large community-based sample.

 
Br J Psychiatry. 2007 Apr;190:339-43. Related Articles, Links
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Association between trauma exposure and delusional experiences in a large community-based sample.

Scott J, Chant D, Andrews G, Martin G, McGrath J.

Kids in Mind Research, Mater Children's Hospital, South Brisbane and Queensland Centre for Mental Health Research, Wacol, Queensland.

BACKGROUND: Surveys have found that otherwise well individuals report delusional experiences. Previous studies have shown an association between psychotic symptoms and exposure to trauma. AIMS: To explore the association between trauma and delusional experiences in a community sample. METHOD: Respondents (n=10 641) were assessed for delusional experiences, exposure to various types of traumatic experiences and the presence of post-traumatic stress disorder (PTSD). The endorsement of delusional items was examined in people exposed to traumatic events who did or did not have PTSD. RESULTS: Exposure to any traumatic event but without the development of PTSD was associated with increased endorsement of delusional experiences (relative risk 2.68, 95% CI 2.18-3.30) and there was a significant dose-response relationship between the number of types of traumatic events and endorsement of such experiences (chi(2) =26.74, d.f.=2, P<0.001). A diagnosis of PTSD further increased endorsement of delusional experiences (RR=9.24, 95% CI 6.95-12.27). The association between PTSD and delusional experiences remained significant after adjusting for factors associated with psychotic symptoms. CONCLUSIONS: Further investigation into the pathways between trauma, delusions and psychosis may provide insights into shared aetiological mechanisms underpinning these conditions.

PMID: 17401041 [PubMed - in process]

Multivitamin use and risk of prostate cancer in the National Institutes of Health-AARP Diet and Health Study.

 
J Natl Cancer Inst. 2007 May 16;99(10):754-64. Related Articles, Links
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Multivitamin use and risk of prostate cancer in the National Institutes of Health-AARP Diet and Health Study.

Lawson KA, Wright ME, Subar A, Mouw T, Hollenbeck A, Schatzkin A, Leitzmann MF.

Division of Cancer Prevention, National Cancer Institute, Bethesda, MD, USA. lawsonka@mail.nih.gov

BACKGROUND: Multivitamin supplements are used by millions of Americans because of their potential health benefits, but the relationship between multivitamin use and prostate cancer is unclear. METHODS: We prospectively investigated the association between multivitamin use and risk of prostate cancer (localized, advanced, and fatal) in 295,344 men enrolled in the National Institutes of Health (NIH)-AARP Diet and Health Study who were cancer free at enrollment in 1995 and 1996. During 5 years of follow-up, 10,241 participants were diagnosed with incident prostate cancer, including 8765 localized and 1476 advanced cancers. In a separate mortality analysis with 6 years of follow-up, 179 cases of fatal prostate cancer were ascertained. Multivitamin use was assessed at baseline as part of a self-administered, mailed food-frequency questionnaire. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated by use of Cox proportional hazards regression, adjusted for established or suspected prostate cancer risk factors. RESULTS: No association was observed between multivitamin use and risk of localized prostate cancer. However, we found an increased risk of advanced and fatal prostate cancers (RR = 1.32, 95% CI = 1.04 to 1.67 and RR = 1.98, 95% CI = 1.07 to 3.66, respectively) among men reporting excessive use of multivitamins (more than seven times per week) when compared with never users. The incidence rates per 100,000 person-years for advanced and fatal prostate cancers for those who took a multivitamin more than seven times per week were 143.8 and 18.9, respectively, compared with 113.4 and 11.4 in never users. The positive associations with excessive multivitamin use were strongest in men with a family history of prostate cancer or who took individual micronutrient supplements, including selenium, beta-carotene, or zinc. CONCLUSION: These results suggest that regular multivitamin use is not associated with the risk of early or localized prostate cancer. The possibility that men taking high levels of multivitamins along with other supplements have increased risk of advanced and fatal prostate cancers is of concern and merits further evaluation.

Publication Types:
PMID: 17505071 [PubMed - in process]

Insomnia in Parkinson's disease: frequency and progression over time.

J Neurol Neurosurg Psychiatry. 2007 May;78(5):476-9. Epub 2006 Nov 10. Related Articles, Links
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Insomnia in Parkinson's disease: frequency and progression over time.

Gjerstad MD, Wentzel-Larsen T, Aarsland D, Larsen JP.

Department of Neurology, Stavanger University Hospital, Stavanger, Norway. gjmi@sus.no

OBJECTIVES: To examine the development of nocturnal sleeping problems in patients with Parkinson's disease (PD) over an 8-year period and to study the clinical and demographic correlates of insomnia. METHODS: 231 patients were included in a population-based prevalence study in 1993, and re-examined in 1997 and 2001. At all study visits, we applied semi-structured interviews to obtain information on clinical and demographic data, as well as on nocturnal sleeping problems. Standardised rating scales of parkinsonism, depression and cognitive impairment were used. The relationship between insomnia and demographic and clinical variables was analysed using population-averaged logistic regression models for correlated data. 231 patients were included at baseline, 142 were available for re-evaluation in 1997 and 89 patients in 2001. RESULTS: Most nocturnal sleeping problems varied little in prevalence over time, whereas problems related to turning in bed and vivid dreaming or nightmares increased. Insomnia was present in 54-60% of the patients at each of the three study visits and varied considerably in individual patients over time. The presence of insomnia was closely related to disease duration, higher Montgomery-Asberg Depression Rating Scale scores and female sex. CONCLUSION: Insomnia is a highly frequent complaint in patients with PD. It fluctuates over time in individual patients, and its origin seems to be multifactorial. Physicians should be aware of the high prevalence of insomnia in patients with PD and should examine their patients for a possible coexisting depression.

PMID: 17098844 [PubMed - indexed for MEDLINE]

Acupuncture, a promising adjunctive therapy for essential hypertension: a double-blind, randomized, controlled trial.

 
Neurol Res. 2007;29 Suppl 1:S98-103. Related Articles, Links

Acupuncture, a promising adjunctive therapy for essential hypertension: a double-blind, randomized, controlled trial.

Yin C, Seo B, Park HJ, Cho M, Jung W, Choue R, Kim C, Park HK, Lee H, Koh H.

Department of Acupuncture, CHA Biomedical Center, College of Medicine, Pochon CHA University, Seoul 135-081, Korea.

BACKGROUND: This study assessed effects of acupuncture as an add-on to conventional antihypertensive managements such as medication or lifestyle modification for hypertensive or pre-hypertensive subjects. METHODS: A randomized, double-blind, placebo-controlled trial was conducted at Kyung Hee University Hospital. Forty-one hypertensive or pre-hypertensive (systolic BP> or =120 mmHg or diastolic BP> or =80 mmHg) volunteers were recruited and randomly assigned into real or sham acupuncture groups. The hypertensive subjects on antihypertensive medication continued their medication. Acupuncture point prescriptions were partially individualized, based on the Saam acupuncture theory. Park's sham needle method was adopted for the sham procedure. Measurements were performed at baseline, weeks 4 and 8. BP, scales of overall health and pain, and anticipation or satisfaction for the treatments, were recorded. RESULTS: Thirty subjects completed the intervention, all of whom were on antihypertensive medication. The sham acupuncture group showed no significant change in mean BP, while the real acupuncture group showed a significant (p<0.01) decrease in mean BP after 8 weeks of intervention from 136.8/83.7 to 122.1/76.8 mmHg. Other factors showed no difference between the groups throughout the study. CONCLUSION: Acupuncture seems to offer an additional benefit to the treatment of hypertensive patients.

Publication Types:
PMID: 17359649 [PubMed - indexed for MEDLINE]

Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial.

Headache. 2007 May;47(5):654-61. Related Articles, Links
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Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial.

John PJ, Sharma N, Sharma CM, Kankane A.

Department of Zoology, University of Rajasthan, Jaipur (Rajasthan), India.

Background.-Numerous studies have explored the effectiveness of complementary and alternative medicine in the treatment of migraine but there is no documented investigation of the effectiveness of yoga therapy for migraine management. Objectives.-To investigate the effectiveness of holistic approach of yoga therapy for migraine treatment compared to self-care. Design.-A randomized controlled trial. Methods.-Seventy-two patients with migraine without aura were randomly assigned to yoga therapy or self-care group for 3 months. Primary outcomes were headache frequency (headache diary), severity of migraine (0-10 numerical scale) and pain component (McGill pain questionnaire). Secondary outcomes were anxiety and depression (Hospital anxiety depression scale), medication score. Results.-After adjustment for baseline values, the subjects' complaints related to headache intensity (P < .001), frequency (P < .001), pain rating index (P < .001), affective pain rating index (P < .001), total pain rating index (P < .001), anxiety and depression scores (P < .001), symptomatic medication use (P < .001) were significantly lower in the yoga group compared to the self-care group. Conclusion.-The study demonstrated a significant reduction in migraine headache frequency and associated clinical features, in patients treated with yoga over a period of 3 months. Further study of this therapeutic intervention appears to be warranted.

PMID: 17501846 [PubMed - in process]

Thunderclap headache as the presenting symptom of myocardial infarction.

Headache. 2007 May;47(5):724-5. Related Articles, Links
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Thunderclap headache as the presenting symptom of myocardial infarction.

Broner S, Lay C, Newman L, Swerdlow M.

The Headache Institute, New York, USA.

Headache as the presenting symptom of myocardial ischemia has been reported in more than 20 cases. These headaches have been described as of gradual onset, associated with exertion and with EKG changes. We present herein the first case of thunderclap headache occurring at rest as the sole symptom of an acute myocardial infarction.

PMID: 17501856 [PubMed - in process]

Feeling bad in more ways than one: comorbidity patterns of medically unexplained and psychiatric conditions.

J Gen Intern Med. 2007 Jun;22(6):818-21. Related Articles, Links
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Feeling bad in more ways than one: comorbidity patterns of medically unexplained and psychiatric conditions.

Schur EA, Afari N, Furberg H, Olarte M, Goldberg J, Sullivan PF, Buchwald D.

Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA. ellschur@u.washington.edu

BACKGROUND: Considerable overlap in symptoms and disease comorbidity has been noted among medically unexplained and psychiatric conditions seen in the primary care setting, such as chronic fatigue syndrome, low back pain, irritable bowel syndrome, chronic tension headache, fibromyalgia, temporomandibular joint disorder, major depression, panic attacks, and posttraumatic stress disorder. OBJECTIVE: To examine interrelationships among these 9 conditions. DESIGN: Using data from a cross-sectional survey, we described associations and used latent class analysis to investigate complex interrelationships. PARTICIPANTS: 3,982 twins from the University of Washington Twin Registry. MEASUREMENTS: Twins self-reported a doctor's diagnosis of the conditions. RESULTS: Comorbidity among these 9 conditions far exceeded chance expectations; 31 of 36 associations were significant. Latent class analysis yielded a 4-class solution. Class I (2% prevalence) had high frequencies of each of the 9 conditions. Class II (8% prevalence) had high proportions of multiple psychiatric diagnoses. Class III (17% prevalence) participants reported high proportions of depression, low back pain, and headache. Participants in class IV (73% prevalence) were generally healthy. Class I participants had the poorest markers of health status. CONCLUSIONS: These results support theories suggesting that medically unexplained conditions share a common etiology. Understanding patterns of comorbidity can help clinicians care for challenging patients.

Publication Types:
PMID: 17503107 [PubMed - in process]

Thursday, May 17, 2007

Childhood Trauma in Film: Undzere Kinder (Our Children) at the 30th International Congress on Law and Mental Health, Padua

On the Occasion of the 30th International Congress on Law and Mental Health

(University of Padua 2007, June 25-30)

 

Co-chaired and Discussed by:

 

Maurice Preter, M.D., Columbia University

and

Harold J. Bursztajn, M.D., Harvard Medical School

         

Childhood Trauma in Film: Undzere Kinder (Our Children)

אינדזערע  קינדער

Poland 1948. In Yiddish language with English subtitles

 

Date: Tuesday, June 26, 2007 (Please refer to final program for exact time)

         

Place: Congress Venue

 

In what has become a tradition during medical-psychiatric and psychoanalytic conferences around the world, Drs. Preter (www.psychiatryneurology.com) and Bursztajn (www.forensic-psych.com) continue their exploration of post-Shoah psychological trauma and its representation in film.

 

As in previous years (e.g., World Psychiatric Association, Istanbul 2006; International Psychoanalytic Association, Rio de Janeiro 2005; International Society for Traumatic Stress Studies, Buenos Aires 2004 and American Psychiatric Association, Philadelphia 2002), this workshop will screen and discuss the last Yiddish-language movie made in Poland, Undzere Kinder (Our Children), 1948.

From the program:

In 1945, after the end of World War II and the slaughter of the European Jews, some 250,000 Jewish survivors temporarily returned to Poland, where actors Shimon Dzigan and Yisroel Schumacher, director Natan Gross and producer Shaul Goskind teamed up to make Our Children. In this last Yiddish-language feature made in Poland, part docu-drama, part melancholic comedy, famous Yiddish comedians Dzigan and Schumacher visit the Helanowek orphanage near the city of Lodz to perform for an audience of Jewish orphans who survived the Holocaust. Their theatrical performance, however well-intentioned, stirs up painful memories of recent events, but also offends the children by the sentimentalized and naïve depiction of wartime conditions. Having all lived through the reality of separation and loss, the children take over the stage, outdo the performers, and tell their stories…

The little actors in Our Children were all residents of the Helanowek orphanage, many of them the sole survivors of their families.

 

For more background on the history of this workshop, and contact information, go to:

www.psychiatryneurology.com (Dr. Preter)

www.forensic-psych.com (Dr. Bursztajn)

 

Co-sponsored by the Harvard Medical School Program in Psychiatry & the Law

Tuesday, May 15, 2007

PTSD rates dropped 3 years postwar and rose again 17 years later; 23% of veterans without combat stress reaction reported delayed PTSD.

 
Am J Psychiatry. 2006 Apr;163(4):659-66.
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Trajectories of PTSD: a 20-year longitudinal study.

Solomon Z, Mikulincer M.

Bob Shappel School of Social Work, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel. solomon@post.tau.ac.il

OBJECTIVE: This study assessed the psychopathological effects of combat in veterans with and without combat stress reaction. METHOD: Veterans (N=214) from the 1982 Lebanon War were assessed in a prospective longitudinal design: 131 suffered from combat stress reaction during the war, and 83 did not. They were evaluated 1, 2, 3, and 20 years after the war. RESULTS: Combat stress reaction is an important vulnerability marker. Veterans with combat stress reaction were 6.6 times more likely to endorse posttraumatic stress disorder (PTSD) at all four measurements, their PTSD was more severe, and they were at increased risk for exacerbation/reactivation. A qualitative analysis of the profile of PTSD symptoms revealed some time-related changes in the symptom configuration of veterans who did not suffer from combat stress reaction. In both groups, the course fluctuated; PTSD rates dropped 3 years postwar and rose again 17 years later; 23% of veterans without combat stress reaction reported delayed PTSD. CONCLUSIONS: These findings suggest that the detrimental effects of combat are deep and enduring and follow a complex course, especially in combat stress reaction casualties. The implications of aging and ongoing terror in impeding recovery from the psychological wounds of war are discussed.

Publication Types:
PMID: 16585441 [PubMed - indexed for MEDLINE]

Dissociative disorders were highly prevalent in this clinical population and typically had not been previously diagnosed clinically.

 
Am J Psychiatry. 2006 Apr;163(4):623-9. Related Articles, Links
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Prevalence of dissociative disorders in psychiatric outpatients.

Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D.

Klau-1 Psychiatric Outpatient Department, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467, USA. jbfoote@aol.com

OBJECTIVE: The purpose of the study was to assess the prevalence of DSM-IV dissociative disorders in an inner-city outpatient psychiatric population. METHOD: Subjects were 231 consecutive admissions (84 men and 147 women, mean age=37 years) to an inner-city, hospital-based outpatient psychiatric clinic. The subjects completed self-report measures of dissociation (Dissociative Experiences Scale) and trauma history (Traumatic Experiences Questionnaire). Eighty-two patients (35%) completed a structured interview for dissociative disorders (Dissociative Disorders Interview Schedule). RESULTS: The 82 patients who were interviewed did not differ significantly on any demographic measure or on the self-report measures of trauma and dissociation from the 149 patients who were not interviewed. Twenty-four (29%) of the 82 interviewed patients received a diagnosis of a dissociative disorder. Dissociative identity disorder was diagnosed in five (6%) patients. Compared to the patients without a dissociative disorder diagnosis, patients with a dissociative disorder were significantly more likely to report childhood physical abuse (71% versus 27%) and childhood sexual abuse (74% versus 29%), but the two groups did not differ significantly on any demographic measure, including gender. Chart review revealed that only four (5%) patients in whom a dissociative disorder was identified during the study had previously received a dissociative disorder diagnosis. CONCLUSIONS: Dissociative disorders were highly prevalent in this clinical population and typically had not been previously diagnosed clinically. The high prevalence of dissociative disorders found in this study may be related to methodological factors (all patients were offered an interview rather than only those who had scored high on a screening self-report measure) and epidemiological factors (extremely high prevalence rates for childhood physical and sexual abuse were present in the overall study population).

Publication Types:
PMID: 16585436 [PubMed - indexed for MEDLINE]

Monday, May 14, 2007

Safety and tolerability of repetitive transcranial magnetic stimulation in patients with epilepsy: a review of the literature.

 
: Epilepsy Behav. 2007 May 8; [Epub ahead of print] Related Articles

Safety and tolerability of repetitive transcranial magnetic stimulation in patients with epilepsy: a review of the literature.

Bae EH, Schrader LM, Machii K, Alonso-Alonso M, Riviello JJ Jr, Pascual-Leone A, Rotenberg A.

Department of Neurology, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Repetitive transcranial magnetic stimulation (rTMS) is emerging as a new therapeutic tool in epilepsy, where it can be used to suppress seizures or treat comorbid conditions such as mood disorder. However, as rTMS carries a risk of inducing seizures among other adverse events, its safety and tolerability in the population with epilepsy warrant distinct consideration, as this group is especially seizure-prone. Accordingly, we performed a review of the literature to estimate the risk of seizures and other adverse events associated with rTMS in patients with epilepsy. We performed an English-language literature search, and reviewed all studies published from January 1990 to February 2007 in which patients with epilepsy were treated with rTMS, and complemented the literature search with personal correspondence with authors when necessary. We identified 30 publications that described patients with epilepsy who underwent rTMS, and noted total number of relevant subjects, medication usage, incidence of adverse events, and rTMS parameters including stimulus frequency, number of stimuli, train duration, intertrain interval, coil type, and stimulation sites. The data were analyzed for adverse events related to rTMS. Crude per-subject risk, as well as per-subject mean risk weighted by sample size and risk per 1000 stimuli weighted by number of stimuli in each study, were computed for seizures and for other adverse events. Adverse events or lack thereof was reported in 26 studies (n=280 subjects). Adverse events attributed to rTMS were generally mild and occurred in 17.1% of subjects. Headache was most common, occurring in 9.6%. The most serious adverse event was seizure during treatment, which occurred in four patients (1.4% crude per-subject risk). All but one case were the patients' typical seizures with respect to duration and semiology, and were associated with low-frequency rTMS. A single case of an atypical seizure appearing to arise from the region of stimulation during high-frequency rTMS is reported. No rTMS-related episodes of status epilepticus were reported. We cautiously conclude that the risk of seizure in patients with epilepsy undergoing rTMS is small, and the risk of other mild adverse events is comparable to that seen when rTMS is used to treat other diseases. Status epilepticus or life-threatening seizures have not been reported in patients undergoing rTMS treatment. rTMS thus appears to be nearly as safe in patients with epilepsy as in nonepileptic individuals, and warrants further investigation as a therapy in this population.

PMID: 17493877 [PubMed - as supplied by publisher]

Sunday, May 13, 2007

[The neurobiological dimension of meditation--results from neuroimaging studies]

 
Psychother Psychosom Med Psychol. 2006 Dec;56(12):488-92. Related Articles, Links
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[The neurobiological dimension of meditation--results from neuroimaging studies]

[Article in German]

Neumann NU, Frasch K.

Klinik fur Psychiatrie, Psychotherapie und Psychosomatik am Bezirkskrankenhaus Gunzburg, Abt. Psychiatrie II der Universitat Ulm.

Meditation in general can be understood as a state of complete and unintentional silent and motionless concentration on an activity, an item or an idea. Subjectively, meditative experience is said to be fundamentally different from "normal" mental states and is characterized by terms like timelessness, boundlessness and lack of self-experience. In recent years, several fMRI- and PET-studies about meditation which are presented in this paper have been published. Due to different methods, especially different meditation types, the results are hardly comparable. Nevertheless, the data suggest the hypothesis of a "special" neural activity during meditative states being different from that during calm alertness. Main findings were increased activation in frontal, prefrontal and cingulate areas which may represent the mental state of altered self-experience. In the present studies, a considerable lack of scientific standards has to be stated making it of just casuistic value. Today's improved neurobiological examination methods - especially neuroimaging techniques - may contribute to enlighten the phenomenon of qualitatively different states of consciousness.

Publication Types:
PMID: 17160792 [PubMed - indexed for MEDLINE]

Listening to Turkish classical music decreases patients' anxiety, pain, dissatisfaction and the dose of sedative and analgesic drugs during colonoscopy: a prospective randomized controlled trial.

 
World J Gastroenterol. 2006 Dec 14;12(46):7532-6. Related Articles, Links
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Listening to Turkish classical music decreases patients' anxiety, pain, dissatisfaction and the dose of sedative and analgesic drugs during colonoscopy: a prospective randomized controlled trial.

Ovayolu N, Ucan O, Pehlivan S, Pehlivan Y, Buyukhatipoglu H, Savas MC, Gulsen MT.

Gaziantep University, School of Medicine, Department of Internal Medicine, 27310 Gaziantep, Turkey.

AIM: To determine whether listening to music decreases the requirement for dosages of sedative drugs, patients' anxiety, pain and dissatisfaction feelings during colonoscopy and makes the procedure more comfortable and acceptable. METHODS: Patients undergoing elective colonoscopy between October 2005 and February 2006 were randomized into either listening to music (Group 1, n = 30) or not listening to music (Group 2, n = 30). Anxiolytic and analgesic drugs (intravenous midazolam and meperidine) were given according to the patients' demand. Administered medications were monitored. We determined their levels of anxiety using the State-Trait Anxiety Inventory Test form. Patients' satisfaction, pain, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. RESULTS: The mean dose of sedative and analgesic drugs used in group 1 (midazolam: 2.1 +/- 1.4, meperidine: 18.1 +/- 11.7) was smaller than group 2 (midazolam: 2.4 +/- 1.0, meperidine: 20.6 +/- 11.5), but without a significant difference (P > 0.05). The mean anxiety level in group 1 was lower than group 2 (36.7 +/- 2.2 vs 251.0 +/- 1.9, P < 0.001). The mean satisfaction score was higher in group 1 compared to group 2 (87.8 +/- 3.1 vs 58.1 +/- 3.4, P < 0.001). The mean pain score in group 1 was lower than group 2 (74.1 +/- 4.7 vs 39.0 +/- 3.9, P < 0.001). CONCLUSION: Listening to music during colonoscopy helps reduce the dose of sedative medications, as well as patients' anxiety, pain, dissatisfaction during the procedure. Therefore, we believe that listening to music can play an adjunctive role to sedation in colonoscopy. It is a simple, inexpensive way to improve patients' comfort during the procedure.

Publication Types:
PMID: 17167846 [PubMed - indexed for MEDLINE]

Electroconvulsive Therapy: Administrative Codes, Legislation, and Professional Recommendations

 
 J Am Acad Psychiatry Law 34:3:406-411 (2006)
Copyright © 2006 by the American Academy of Psychiatry and the Law.
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ANALYSIS AND COMMENTARY

Electroconvulsive Therapy: Administrative Codes, Legislation, and Professional Recommendations

Victoria Harris, MD, MPH

Dr. Harris is Medical Director of Psychiatric Services, Stevens Hospital, Edmonds, WA. Address correspondence to: Victoria Harris, MD, MPH, Stevens Hospital, 9 West, 21601 76th Avenue West, Edmonds, WA 98026. E-mail: vharris@u.washington.edu

Government regulatory involvement in electroconvulsive therapy (ECT) is due to several factors, including patient advocate groups, prior abuse by psychiatrists, and a general trend of state authority to move into areas traditionally governed by medical authorities. Regardless of the specific reasons, ECT is both highly effective in the treatment of many psychiatric disorders and heavily regulated by state administrative codes and legislation. The purpose of this article is to conduct a systematic review of the state administrative codes and legislation for the 50 states, the District of Columbia, and Puerto Rico and to compare the findings with professional recommendations for the administration of ECT.

Downward Departures in the Post-Booker Era.

 
 J Am Acad Psychiatry Law 35:1:128-130 (2007)
Copyright © 2007 by the American Academy of Psychiatry and the Law.
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LEGAL DIGEST

Downward Departures in the Post-Booker Era

How Is Diminished Capacity Defined?

In U.S. v. Valdez, 426 F.3d 178 (2nd Cir. 2005), the United States Court of Appeals for the Second Circuit reviewed the sentencing of Felix Valdez by the District (trial) Court for the Southern District of New York to determine if the court had incorrectly applied the insanity defense legal standard rather than the diminished-capacity downward-departure legal standard when denying the defendant's request for a downward departure.

Facts of the Case

Valdez confessed to obtaining and selling telephone calling cards in other people's names. He was recorded on a public pay phone while opening calling card accounts by offering various false explanations such as posing as a building owner attempting to obtain numbers on behalf of his tenants. The government estimated that Valdez had obtained over 1,176 calling card numbers and suggested that he was even able to obtain phone access to countries that had fraud protection mechanisms in place.

Upon his guilty plea, Valdez was convicted of wire fraud by the U. S. District Court for the Southern District of New York. At sentencing he requested a downward departure from the recommended sentence secondary to his diminished capacity. He based his petition for a diminished-capacity departure on his IQ of 55, documented learning difficulties, history of special education classes provided as a result of brain injury and severe emotional disturbance, history of dependency on others, and family psychiatric history. The defense's psychiatric expert opined that as a result of Valdez's generalized anxiety disorder, "marked dependency needs ... overly compliant" behavior, low IQ, and essential illiteracy, he was easily manipulated by his coconspirator (Guillermo) into performing the fraud with the belief that he, the defendant, would then have access to calling cards to call his son. The defense asserted that without Guillermo, Valdez would have been incapable of developing the fraud that led to his indictment; therefore, Valdez's diminished capacity was causally linked to the commission of the offense as a result of his vulnerability to Guillermo's manipulation. However, on cross-examination the defense's expert psychiatrist testified that Valdez knew that what he was doing was wrong and that he could have written the hundreds of names and calling card numbers himself. The expert's report also documented that Valdez had refused to pay his co-conspirator, Guillermo.

The district court denied Valdez's petition for a downward departure and sentenced the defendant according to the Federal Sentencing Guidelines. The court concluded that the defendant did not meet the definition of "significantly reduced mental capacity" (one prong necessary in defining diminished capacity) as evidenced by information that contradicted the defendant's contention that he had trouble understanding the wrongfulness of his actions. The court also dismissed the validity of the nexus between any psychiatric or cognitive impairment that Valdez had and his fraudulent behavior.

Valdez appealed this decision to the U. S. Court of Appeals for the Second Circuit. He contended that the district court had incorrectly applied the criteria for the insanity defense rather than the criteria for the diminished capacity departure when considering him for a downward departure from the Federal Sentencing Guidelines. Valdez asserted that the court, in doing so, had thereby failed to make use of the availability of this departure when a defendant understands the stark difference between right and wrong but has significantly impaired ability to understand the wrongfulness of his conduct.

Valdez also appealed on the grounds that the court's holding was based on clearly erroneous fact finding, asserting that the court based its holding on its own lay opinion of Valdez's mental capacity, which was contrary to evidence submitted by medical professionals.

Ruling

The U. S. Court of Appeals for the Second Circuit affirmed the district court's calculation of the defendant's sentence and found that the district court did not apply an incorrect legal standard in denying a downward departure and had not erred in fact finding. The court remanded the case to the district court to consider whether the defendant's sentencing would have been different if the district court had understood the Federal Sentencing Guidelines to be advisory rather than mandatory.

Reasoning

The appeals court agreed with the defendant's assertion that the insanity defense standard, in which the defendant does not recognize the difference between right and wrong, is not the appropriate standard when considering a downward departure based on diminished capacity. The appeals court agreed that the standard for granting a downward departure on the basis of diminished mental capacity requires significant impairment in a defendant's judgment or ability to understand the wrongfulness of his actions. Therefore, the standard for diminished capacity does not require that a defendant lack criminal intent.

However, the appeals court held that the district court did not confuse the insanity defense standard with the diminished-capacity downward-departure standard in denying a downward departure for Valdez. The court found that the district court had considered his understanding of right and wrong only to assess at which point along the continuum his understanding fell. Furthermore, the appeals court noted that the lower court had rejected the diminished-capacity departure based on both Valdez's ability to carry out a complex crime and its perception of a lack of evidence supporting Valdez's having a psychiatric diagnosis.

The appeals court remanded the case to the district court as a result of the possibility that the district court had made a procedural error in imposing a sentence on the assumption that the Federal Sentencing Guidelines (FSG) were mandatory rather than advisory. The appeals court opined that a court properly sentences even if it decides to depart from the FSG, providing it first considers them. However, to avoid procedural error (e.g., failing to attend to the various factors contained in 18 U.S.C. § 3553 (a) of the guidelines that sentencing courts must take account of in deciding on an appropriate sentence), the court must be aware of its authority to depart from the guidelines. Therefore, the appeals court remanded the case for the district court judge to consider if the sentence rendered would be different if the guidelines were recognized as advisory.

Further, the appeals court found that the district court had not made clearly erroneous fact findings. It reasoned that the district court based its findings of the defendant's mental capacity on various pieces of proof, including Valdez's success in performing the complex fraudulent scheme. The appeals court also ruled that the rejection of the defense expert's opinion is not an error of law, because there is no rule that obliges a trial court to adopt expert testimony.

Discussion

According to the Federal Sentencing Guidelines Policy Statement that defines diminished capacity (18 U.S.C.S. Appx 5K2.13), a downward departure may be warranted if (1) the defendant committed the offense while suffering from a significantly reduced mental capacity and (2) the significantly reduced mental capacity contributed substantially to the commission of the offense. Significantly reduced mental capacity is defined as a "significantly impaired ability to understand the wrongfulness of the behavior comprising the offense or to exercise the power of reason or control the behavior that the defendant knows is wrongful." As stated in U.S. v. Leandre, 132 F.3d 796 (D.C. Cir. 1998), and in reference to the definition of reduced mental capacity, "... little substantive guidance has been provided by the Sentencing Commission, either in the language of the guidelines themselves or in the commentary or application notes." In light of this history of the difficulty with the definition of reduced mental capacity, U.S. v. Valdez helped to clarify the distinction between the more narrowly defined insanity defense standard (the absolute lack of knowledge of wrong-doing) and the more broadly defined diminished capacity relevant to the downward-departure legal standard (the significantly impaired ability to understand the wrongfulness of the behavior).

In remanding this case to the district court, the appeals court underscored the court's relatively new ability (following the Supreme Court's decision in U.S. v. Booker, 543 U.S. 220 (2005)) to sentence a defendant outside the Federal Sentencing Guidelines and therefore to sentence a defendant without applying a mandated, rigid application of the sentencing committee's policy statements. Therefore, the courts may now be less constrained by the guidelines in their determinations of which defendants can qualify for a downward departure. Without having to rely on the language of a policy statement, courts may become more open to the testimony and recommendations of mental health expert witnesses. This case may, therefore, represent a nascent trend toward an increase in influence of effective and credible psychiatric expert witnesses regarding a defendant's diminished capacity and an increase in the number of downward departures.

Sarah L. Xavier, DO

Forensic Fellow
Yale University School of Medicine
New Haven, CT