Providentia

What Depressive Symptoms and Disorders Are Linked to Adolescent Suicide?

A study reported in the April 2008 issue of the Journal of Affective Disorders examines the role of depressive symptoms and disorders as potential predictors of suicidal behaviour in adolescents. The authors used a representative sample of 2464 Norwegian school students (average age 13.7 years) who were initally tested (T1).  These same subjects were followed up and reassessed a year later (T2). All subjects who scored significantly high on the depresson questionnaire at the one year mark (T2) were matched with low- or middle-scoring respondents according to age and gender.  A subset of 345 subjects were diagnostically assessed by face-to-face interviews (mean age=14.9 years) and then reassessed after five years (T3) using telephone interviews and questionnaires. There were 265 subjects tested with a participation rate of 76.9%. The results indicated that cognitive symptoms were predominant among suicide attempters, regardless of age. Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts. Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associated with suicidal acts among older adolescents. Perceived worthlessness by the age of 15 was a significant predictor of suicidal acts between 15 to 20 years.  Major depression was significantly associated with suicidal acts among younger adolescents, while dysthymia by the age of 15 years remained a significant predictor of suicidal acts between 15 to 20 years, even when controlling for depressive symptoms. The authors conclude that acts of self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.

Click here for the abstract.

Homeless Woman Found Not Guilty by Reason of Insanity in Fatal Fire

A homeless woman charged with starting an arson fire that killed four people in a Chicago apartment building last year was found not guilty Friday by reason of insanity.  Mary Smith, aged 51, had been accused of starting debris on fire to keep warm in a stairwell of an apartment building on March 10.  She was charged with four counts of first-degree murder and one count of aggravated arson and, after a three-day trial, Cook County Circuit Court Judge James ordered her transfer to a mental-health facility where she will be evaluated

Evidence in the case included a videotape of an interview with police in which Smith initially denied starting the fire, but later admitted to using matches to ignite debris, including a dollar bill.   acqueline Ross, Smith's defense attorney, said of the verdict: "It doesn't mean she didn't do it, [but] she was unable to appreciate the criminality of what she was doing." " [The judge] did what was right in this case," Ross said. "It's just very tragic. Mary's family is distraught."

Dr. Peter Lourgos, a forensic psychiatrist with the county court, testified for the defense and said Smith did not comprehend her acts to be criminal. He said he based his opinion on her long schizophrenic history and the videotape of her interview with police. Her lawyer contended that Smith was legally insane when the fire occurred and continues to suffer from severe mental illness. In remarks to the judge Thursday, Ross did not address whether Smith started the fire but instead focused on her mental state.

Click here for more information.

When the Martians Invaded

It was meant to be a special Halloween night episode of the American radio program, Mercury Theatre on the Air. Directed by 23-year old Orson Welles, the program was an adaptation of H.G. Wells' classic novel The War of the Worlds. The screenplay for the show introduced an unprecedented innovation for American radio: use of a fake newscast to provide listeners with the experience of actually living through an alien invasion.

Broadcast from a studio in New York City on October 30, 1938, the program was presented as an ordinary music program that was frequently interrupted by news bulletins. After first describing strange explosions on Mars (Welles played a prominent astronomer), listeners were then told of the landing of a strange "meteorite" in Grover's Mills, New Jersey. The meteorite turns out to be a Martian capsule which then destroys hundreds of onlookers with "heat rays". As the episode continued, more Martian ships land and devastation is unleashed across the entire United States.

Despite military resistance, the Martian invaders prove too strong and unleash terrible weapons including "poison gas" sprayed into the air. New York City is invaded by "great machines" wading across the Hudson River. Coverage of the invasion is provided by a "news reporter" who describes "people dropping like flies" until he is killed by the poison gas himself. The broadcast ends with Welles (in his role as the astronomer) telling listeners about the devastation and how the Martians were destroyed by Earth's bacteria.

Later reports came out about the"panic" the resulted from the broadcast but there is still debate over how widespread it really was. Although disclaimers that the invasion was fictional were inserted at several points in the program, many listeners were still convinced that the invasion was real . Later estimates placed the number of listeners at six million with 1.2 million believing it to be "genuinely true". Incidents of actual panic remain scarce although reports of people fleeing their homes or hiding in their cellars to avoid the "poison gas" came out afterward.

Grover's Mill was largely deserted when the broadcast began but this changed rapidly as people rushed to the area. Police needed to be called in to control the crowds and reinforced the impression that something catastrophic was happening. In the town of Concrete, Washington, there was a power failure that occurred during the broadcast plunging almost all of the town's 1,000 residents into darkness. While there were reports of mass panic due to the blackout, actual incidents were limited. Police in cities across the country were swamped with calls from worried listeners trying to get more information. Given the tense international situation of the time with the rising Nazi threat in Europe, the idea of Martians invading didn't seem so farfetched. As one witness stated afterwards, "if the Germans could invade, why not Martians?"

Hours after the programme ended, the public outcry began. Newspapers across the country carried headlines such as "Mars Invasion in Radio Skit Terrifies U.S." and "Radio Fake Scares Nation". Thousands of protest letters were written to CBS and the Mercury Theatre and over six hundred complaints were made to the newly-formed Federal Communications Commision (FCC).

Millions of other listeners however enjoyed the program. Most of the letters sent to CBS and the FCC were complimentary and some expressed amazement that anyone could have been fooled. None of the other radio stations carried reports of an invasion and most of the actors participating in the broadcast were already well-known (younger listeners had no problem recognizing Orson Welles from his other radio work as the voice of The Shadow).

One week after the show aired, Hadley Cantril, a media psychologist at Princeton University, launched a detailed study of its impact. Over three weeks, Cantril and his researchers interviewed 135 people, of whom 100 had been upset by the broadcast. The people interviewed gave different reasons for believing the program including complaints that "it didn't sound like a play" and the convincing nature of what they had heard. The fact that the events of the broadcast were taking place in familiar locations made it seem very real. Cantril published his results in 1940 as The Invasion from Mars: A Study in the Psychology of Panic (The book included the complete script of the broadcast).

While the broadcast is still given as an example of the power of the mass media in shaping popular belief, there seems to be little consistent evidence that it actually was "The Night that Panicked America" (the title of a 1975 television movie about the events of that night). Newspapers and later commentators played the panic up in reporting about the broadcast and media classes continue to present it as a textbook illustration of mass hysteria.

The Mercury Theatre's ratings went up afterwards and Orson Welles' reputation as a wunderkind was reinforced. Grover's Mill (now part of West Windsor Township) continues to have a modest tourist trade and even hosted a festival in 1988 to mark the 50th anniversary of the broadcast. The program remains one of the most well-known dramatizations in radio history.

Could it happen again? While there have been other examples of mass panic due to fake broadcasts (including a 1949 War of the Worlds broadcast in Quito, Ecuador that caused an enraged mob to burn down the radio station and kill several employees), audiences appear to have become more skeptical regarding what they see and hear in the media. Availability of alternate information sources including television and the Internet mean a reduced dependence on individual news sources to shape beliefs.

There have been numerous remakes of War of the Worlds including movies, a television series and even a musical, but none of them have ever had the impact of that fateful broadcast in 1938. It may well be Orson Welles' greatest legacy and a warning about human susceptibility to panic.

Click here to download the broadcast.

How Prevalent is Body Dysmorphic Disorder?

Body dysmorphic disorder (BDD) is a mental disorder involving excessive preoccupation with imagined or minor bodily imperfections. It has been linked to OCD-spectrum disorders and can manifest itself in s range of ways including anorexia nervosa, substance abuse and suicide. Estimates of actual prevalence vary widely. The April 2008 issue of CNS Spectrums presented the results of a national survey to estimate the prevalence of BDD in the United States. Using a random sample national household telephone survey conducted in 2004, 2,513 adults were contacted, of whom 2,048 qualified for administration of computer-assisted, structured interviews, addressed DSM-IV criteria for BDD. Information on psychological, financial and demographic factors was also collected. Respondents included a higher percentage of women and people >55 years of age than in the US adult population, and a lower percentage of Hispanics. Results showed an estimated prevalence of DSM-IV BDD among respondents as 2.4% (49/2,048) (by gender: 2.5% for women, 2.2% for men), exceeding the prevalence of schizophrenia and bipolar disorder type I and about that of generalized anxiety disorder. BDD prevalence decreased after 44 years of age, and a larger proportion of BDD respondents were never married. Of those meeting DSM-IV criteria for BDD, 90% (45/49) met the DSM-IV distress criterion, and 51% (25/49) met the interference-with-functioning criterion. The researchers concluded that further research is needed to evaluate these results and to determine more effective treatment approaches.

Click here for the abstract.

Indian Health Ministry Reports 16,000 Student Suicides In The Past Three Years

A representative of India’s Health Ministry has reported that over 16,000 school and college students in India have committed suicide in the last three years and announced plans to deal with the problem by reforming the national health care system.

According to the ministry, there were 5,857 student suicides in 2006, 5,138 in 2005 and 5,610 in 2004. While some private schools have started providing counselors to address the problem, government-run schools have been slow to follow suit.

Cherian Verghese, a specialist with the Indian branch of the World Health Organization, said: "The mental health system needs an overhaul. Our schools might be giving good education but we need education in life skills. From counseling to increasing the number of mental health workers, the strategy should be holistic.  Students are a vulnerable group. Age, competition and relations in the family are all contributing to the growing cases of suicide among school goers”.

"There is a gamut of problems; India lacks the required number of psychiatrists as well. The social taboo around mental health also fuels the problem. A country which houses a huge number of youngsters must not take mental health lightly," Verghese added.

Potential factors that have limited greater access to counseling include social stigma surrounding mental illness, the high doctor-patient ratio, and societal pressures. Despite India’s burgeoning population, there are only 3,500 psychiatrists for a population of more than a billion people.

The health ministry is planning to modernize psychiatric hospitals, expand community mental health services, and introduce counseling in schools.

Click here for more information.

The Mercury Mavens

George Washington had the finest medical care available. Unfortunately, given the primitive medicine of the era, that wasn't nearly enough to save him. While it is probably unlikely that he would have survived his final illness, the aggressive treatment that the great statesman received certainly didn't help. His doctors blistered his skin (to draw off "humours"), gave him frequent bleedings (Martha Washington had objected to the bleedings but her husband overrode her), and applied poultices of wheat bran. They also purged him with mercurous chloride to empty his bowels. After growing weaker and finally asking his doctors to leave him alone, George Washington died on December 14, 1799 at the age of 67. The exact nature of his final illness remains unclear but modern historians believe it may have been diphtheria or strep throat. The medical care that he received almost certainly played a role as well (not that he would be the last U.S. president to be killed by well-intentioned doctors).

Mercury, a.k.a. quicksilver or hydrargium, has always fascinated philosophers, chemists, and healers alike. Its silvery appearance, tendency to stay liquid at room temperature, and chemical properties made it a natural ingredient for numerous remedies. Records show that it was used in medicine as early as the second century AD when the Chinese philosopher Pao Pu Tzu recommended mixing pills combining cinnabar (mineralized mercury sulphide) and honey to make patients immortal (the absence of immortals these days would suggest that this hopeful concoction didn't work). The great Greek healer, Hippocrates swore to mercury's medical value and it was also used in traditional remedies for diseases such as smallpox and syphilis.

Thomas Dover (1660-1742) wrote that "to take an ounce of quicksilver every morning is the most beneficial thing in the world".  Mercury was the treatment of choice for syphilis (despite the fact that it did nothing to prevent the onset of dementia or death) but was most widely used in the form of mercurous chloride (better known as calomel). For centuries, the calomel "blue pills" were dispensed by physicians to children and adults as an all-purpose diuretic and laxative. Benjamin Rush, the 18th century dean of American medicine, marketed a personal concoction that he often prescribed for his patents. His "bilious pills" were made up of mercury and jalap (a popular purgative) and Rush swore by their effectiveness (although contemporary critics noted the increased mortality rate in his patients). A journalist of the time referred to Rush's work as "one of those great discoveries which have contributed to the depopulation of the earth".

The effect of mercury-based remedies on patients was certainly noted by physicians and medical horror stories became common. In one medical text published in 1835, several case histories of mercury poisoning were reported: "a boy, about eleven years old, had a sore on once cheek, occasioned by a dentist extracting a tooth; a physician was consulted, who immediately prescribed a course of mercury. In a short time, ulcerations in the throat appeared, the nose sunk and one eye was nearly destroyed; while the general health was so injured, that death followed in a few months". Despite the warnings surrounding mercury use, physicians were slow to accept that they were poisoning their own patients and would continue using calomel well into the 20th century.

Mercury use was hardly limited to medicine. There have been countless industrial applications for mercury compounds although this has declined in recent decades as the neurotoxic aspects of mercury became better known. Mercury continues to be an ingredient in some medications despite ongoing controversy over safe levels of exposure. I won't even try to get into the controversies surrounding mercury exposure in dental amalgams and vaccines. It does seem ironic that activists have attempted to link mercury to autism despite the syndrome being first identified in 1943. Given that children were routinely dosed with dangerous levels of mercury for centuries, it's hard not to wonder why autism cases are rising now despite mercury exposure in children being so greatly reduced.

While many European nations have called for a total ban on mercury use, it's unlikely that the silvery metal's influence will end any time soon.

Is There a Link Between Brain Injury and Psychiatric Problems?

An interesting analysis in the December 2007 issue of Brain Injury looks at the role of traumatic brain injuries (TBI) in the development of severe, long-term psychiatric disorders.

While a clear causal link remains unclear, the authors found that psychiatric syndromes are consistently present at an elevated rate following TBI. Survivors of TBI are particularly susceptible to major depression, generalized anxiety disorder and post-traumatic stress disorder. While evidence of a direct link is lacking, the authors suggest that there may be consistent critical periods for the post-injury development of psychiatric disorders that have yet to be identified. There is evidence, however, that TBI cases remain at risk for years following injury. Non-organic factors, including pre-morbid personality traits and post-injury psychological reactions to disability and trauma, seem to play a role in the development of post-TBI psychiatric disorders. Treatment professionals dealing with TBI cases needed to be aware of the potential for the development of post-TBI psychiatric problems.

Click here for the abstract.

Mother Convicted In Munchausen Syndrome Case

A Harris County jury has convicted a Texas woman accused of subjecting her young son to at least two unnecessary surgeries. Laurie Williamson, 44, was convicted Thursday of injury to a child in connection with the surgeries for implantation of a nerve-stimulation device and insertion of a gastric feeding button. She now faces the possibility of a life sentence. The punishment phase of the trial started Thursday and will resume next Tuesday.

State child welfare officials and prosecutors said Williamson has Munchausen syndrome by proxy, a rare disorder in which a person fabricates or induces symptoms in others to gain attention. Prosecutor Mike Trent said Williamson manipulated doctors and her son's condition to get the surgeries. They added that over ten years, Williamson took her three children to at least 500 medical appointments.

Child Protective Services took custody of the children in March 2006. Defense attorney Allen Isbell denied that his client has the syndrome. He said doctors told Williamson that her son needed the procedures.

Click here for more information.

The Beast Within

It was in the autumn of 1572, following a rash of animal attacks in the woods near Dole, France, that the local peasants were authorized to seek out the werewolf assumed to be responsible. There were few actual sightings of the animal but the "loup garou" had carried off several small children and attacked horsemen who had driven it away " only with great difficulty and danger to their persons". The peasants were instructed "to assemble with pikes, halberts, arquebuses, and sticks, to chase and to pursue the said were-wolf in every place where they may find or seize him; to tie and to kill, without incurring any pains or penalties". Despite their search, it was only on November 8 of that year that peasants came upon a "monstrous creature" attacking a young girl. The creature was driven off although the girl later died of her injuries. Even in the darkness, some of the peasants thought they recognized the creature as a local hermit named Gilles Garnier.

Garnier was not popular in the region and was arrested after fifty witnesses filed depositions against him. Whatever protests of innocence he had were quickly ended by a session on the rack which "persuaded" him to confess to the charges. Garnier was sentenced to be burned alive at the stake and "that his ashes be then scattered to the winds". He was also ordered to bear all court costs and the sentence was carried out on January 18, 1573.

A similar case was brought to trial in 1603 involving a mentally disturbed (and possibly intellectually challenged) boy named Jean Grenier. Following reports of animal attacks on children in Gascony, France, Grenier confessed to all of the attacks and claimed to have eaten some of the children involved. He also stated that he was part of a werewolf "coven" and transformed himself using a "wolf's skin" given to him by a mysterious stranger. Survivors of the attacks confirmed Grenier's testimony and he was found guilty. In a remarkable move for the time, the court concluded that Grenier was mentally ill (but possessed) and he was sentenced to a Franciscan monastery for the rest of his life. When visited in the monastery years later, he was reported to be "diminutive in stature, very shy, and unwilling to look anyone in the face. His eyes were deep set and restless; his teeth long and protruding; his nails black, and in places worn away; his mind was completely barren; he seemed unable to comprehend the smallest things". Jean Grenier died at the age of 20.

There were an estimated 30,000 cases of lycanthropy reported in Europe between 1520 and 1630 alone. The epidemic of werewolf hysteria that plagued Europe seemed to be linked to the witchcraft mania occurring during the same period. Witches were frequently accused of changing themselves into cats or rabbits and attending demonic Sabbaths to meet Satan. Werewolves, in turn, were accused of transforming themselves with the Devil's aid. Convicted werewolves and witches were often condemned to be burned alive (except in England where they were merely hanged).

The werewolf hysteria seemed to be largely fuelled by lurid stories of wolf attacks (which were more likely to be due to wild dogs) and only subsided when wolves were hunted to virtual extinction across Europe. The growing recognition that testimony obtained through torture was basically unreliable probably played a role as well (waterboarding advocates take note). The last major werewolf panic was in Gevaudan, France following a series of killings by a "wolflike creature" between 1763 and 1767. The killings were never solved.

While clinical lycanthropy (the delusion of changing into an animal) remains a recognized psychiatric condition, actual cases tend to be rare (I've never encountered a case myself, alas, although I remain hopeful). Reports in the forensic literature of clinical lycanthropy patients committing violent acts are even rarer (but they have happened). Modern cases of lycanthropy tend to be part of broader psychiatric conditions such as schizophrenia. Along with the classic werewolf delusion, there have also been reported cases of patients believing that they have been changed into other types of animals including dogs, frogs, and bees. While werefrogs do not evoke the same superstitious terror associated with werewolves, the unusual nature of the psychopathology makes for fascinating case histories in the clinical literature.

Treatment seems to be straightforward as lycanthropic delusions respond well to medication (no burning necessary). Despite the popularity of werewolf movies in the past few years, there has been no evidence of any upsurge of cases and the condition remains rare. Although werewolves live on as a cultural phenomenon, the hysteria that condemned Gilles Garnier to death has mercifully subsided (I hope).

Click here for a recent case history.

Ten Years After Traumatic Brain Injury

A research study published in the March 2008 issue of the Journal of the International Neuropsychological Society presents the results of a 10-year study examining the long-term effects of traumatic brain injury (TBI). Previous research investigating long-term has yielded mixed results linking severity of injury, demographic factors, and psychiatric problems. In the present study, a sample of 60 participants who had sustained TBI 10 years previously was used. Participants were tested with the Extended Glasgow Outcome Scale (GOSE) as well as neuropsychological measures of attention, speed of processing, memory and executive function and a measure of anxious affect. Outcome on the GOSE ranged from upper good recovery (32%) to lower severe disability (2%). Factors associated with poorer outcome on the GOSE included duration of posttraumatic amnesia, level of education, poor performance on cognitive measures of information processing speed, attention, memory, and executive function as well as showed higher levels of tested anxiety.

Click here for the abstract.