Providentia

Intimate Partner Violence and African American HIV-positive Women.

The medical outcomes of women infected with HIV are typically worse than those of HIV-positive men. HIV-positive women report high rates of intimate partner violence, and there is evidence that traumatic events have a negative impact on health status. In addition, African American women make up 1 of the fastest growing groups of HIV-positive individuals. A study recently published in Psychological Trauma: Theory, Research, Practice, and Policy examined the impact of intimate partner violence on HIV medication adherence, HIV-related physical health outcomes, and health-related quality of life in 40 HIV-positive African American women. The results were that women who had experienced intimate partner violence had worse HIV-related health as indicated by reduced CD4 counts and increased HIV viral load. In addition, posttraumatic stress disorder symptoms were related to both intimate partner violence and health-related quality of life. Lastly, HIV medication adherence mediated the relationships between intimate partner violence and the HIV-related health outcomes. Implications for further work and clinical interventions to address intimate partner violence, medication adherence, and health-related quality of life in this population are discussed by the authors.

For the abstract.

Treating Chronic Fatigue Syndrome

A new study published online in the Lancet presents the results of a comprehensive research project examing the benefits of cognitive behaviour therapy and graded exercise therapy in the treatment of chronic fatigue syndrome.  Despite ongoing controversy over its nature, cause and treatment, chronic fatigue syndrome (CFS) is believed to affect millions of people worldwide.  Generally defined by a persistent fatigue unrelated to exertion, not substantially relieved by rest and accompanied by the presence of other specific symptoms for a minimum of six months, the disease (or diseases) appears multi-systemic in  nature and is classified by the World Health Organization as a disorder of the nervous system.   There is currently no reliable diagnostic test or biomarker. 

To examine the comparative benefits of four different treatments in treating CFS patients, a prospective research project was launched by a team of researchers from the University of  London and the University of Edinburgh.  Known as the PACE study (Pacing, Graded Activity, Cognitive Behaviour Therapy: a Randomized Evaluation), the project was designed as a parallel-group randomized trial comparing the relative benefits of cognitive behaviour therapy (CBT),  graded exercise  therapy (GET),  adaptive pacing therapy (APT),  and standardised specialist medical care (SSMC).   SSMC  typically involves providing patients with information on their condition and advice on coping strategies.  APT focuses on helping patients structure their activities to match their reduced energy levels.

Using a sample of 640 patients meeting Oxford criteria for CFS,  the study participants were randomly assigned to treatment groups receiving SSMC alone or SSMC in conjunction with one of the other three treatments.    Patients in the parallel treatment groups received monthly individual therapy sessions as well as group therapy sessions every three months.  Approximately 75 per cent of the study participants were women with a mean age of 38 years.  Average duration of CFS symptoms was 32 months.  Results after one year have shown that  those  participants who received CBT and GET in conjunction with conventional medical care showed  moderate  improvement over the participants in the other two groups.  Over 60 per cent of patients reported reduced fatigue and improved functioning while 30 per cent reported no change.  Despite the preliminary nature of the results, the study authors emphasize that it provides robust evidence of the  value of CBT and GET in  treating chronic fatigue patients.  The results also show that adaptive pacing strategies, often advocated by patient groups, have no apparent benefit in treating CFS.

In an accompanying Lancet editorial, Dr. Gijs Bleijenberg and Dr. Hans Knoop of Radboud University Nijmegen (Netherlands) Medical Centre stated that, "Although the PACE trial shows that recovery from chronic fatigue syndrome is possible, there is clearly room for improvement with both interventions (cognitive behaviour therapy and graded exercise therapy)"    They also emphasize that CBT and GET provide symptom relief only but do not address the underlying cause of CFS. 

For the study

Sniffing Glue

Although volatile substance inhalation is prevalent in many contexts and presents a serious threat to public health, this pernicious form of substance misuse remains poorly understood.   In the United States alone, nearly 16% of 8th graders report lifetime inhalant abuse and the long-term consequences can be dire given the neurotoxic nature of many of these substances.  The question of why people seek and misuse inhalants may be addressed by examining phenomenological accounts of inhalant intoxication, yet few investigations of inhalant intoxication experiences are reported in the literature. An article published in a recent issue of Experimental and Clinical Psychopharmacology employed a structured interview to assess inhalant intoxication experiences of 267 low-, moderate-, and high-frequency inhalant users. Low-frequency inhalant users reported predominately hedonic (pleasureful) experiences during inhalant intoxication, whereas high-frequency users reported a mixture of hedonic and aversive experiences. Aversive experiences such as depressed mood, suicidal ideation, and chest pain were commonly reported by high-frequency users but were relatively rare among low-frequency users. High-frequency users also experienced significantly more euphoria, talkativeness, and grandiosity during inhalant intoxication than low-frequency users. Hedonic and aversive experiences during episodes of inhalant intoxication are relatively common among high-frequency adolescent inhalant users.

For the abstract

U.S. Lawmakers Seeking Psychoactive Bath Salts Ban

Should certain brands of bath salts be banned as narcotics?

Although legal in most jurisdictions, the bath salt packets marketed under brand names such as "Ivory Wave" and "Vanilla Sky" contain ingredients including mephedrone and methylenedioxypyrovalerone.    Since the packets carry warning labels describing the contest as "not safe for human consumption", they are not subject to federal regulation.  Following hundreds of incidents nationwide involving bath salt consumption over the past several years, formal bans on the selling of  implicated bath salt products have already gone into effect in the states of Kentucky, Florida, Louisiana, and North Dakota, among others. 

New York Senator Charles Schumer has proposed a bill to make bath salts a federally controlled substance. In  a February 1 statement, Senator Schumer stated that "These so-called bath salts contain ingredients that are nothing more than legally sanctioned narcotics, and they are being sold cheaply to all comers, with no questions asked, at store counters around the country.  The longer we wait to ban the substance, the greater risk we put our kids in,  These so-called bath salts are dangerous drugs masquerading as a harmless product. They offer a cheap and deadly high, and we need to move immediately to get them off the shelves."  

Officials at the Office of National Drug Control Policy have reported that bath salt intoxication can result in hallucinations, paranoia, suicidal thoughts, and even death in some recent cases.  Mimicking the effects of cocaine and LSD, the variable chemical content of the bath salt products sold can often have unpredictable results despite their popularity as a source of legal "highs".  The versatile nature of the bath salts means that they can be ingested in a variety of ways including snorting, injecting, smoking, or eating.   In the first month of 2011 alone, there have been 248 bath salt-related calls to poison centres nationwide (up from 291 calls in all of 2010).  Hospitalizations, suicides, and cases of criminal assault relating to bath salt intoxication have also been reported.   

Emergency room physicians treating patients admitted for mephedrone and methlenedioxypyrovalerone intoxication have reported on the severe nature of the psychosis presented.  Use of sedatives such as Valium have had little success in some cases.  Mark Ryan, director of the Louisiana Poison Center has commented that ""If you take the very worst of some of the other drugs -- LSD and Ecstasy with their hallucinogenic-delusional type properties, PCP with extreme agitation, superhuman strength and combativeness, as well as the stimulant properties of cocaine and meth -- if you take all the worst of those and put them all together this is what you get. It's ugly".   Although the ban in Louisiana has had some success in reducing calls relating to bath salt ingestion, Ryan has noted that calls are resuming.  Given that the products are still legally available in other states, users often circumvent bans through online vendors and interstate shipping. 

Despite calls for federal regulation, it may take years for a comprehensive nationwide ban to go into effect.

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Soldier's Disease (Part 2)

Continued from Part 1

Not only did the demand for morphine create a steady market for the drug, it also created a strong demand for hypodermic needles as well.  The 1897 Sears and Roebuck catalogue advertised a hypodermic kit (including a syringe, two needles, two vials, and a carrying case) for a mere $1.50 (quite a bargain, really).   Patent medications, largely unregulated at the time, were advertised for the treatment of a wide variety of complaints and, naturally, morphine and opium were popular ingredients.  The self-medication that these patent medications made possible certainly aggravated the problem of substance abuse but the lack of formal government controls helped drive sales.

It seems inevitable that alternatives to morphine would become available as medical researchers learned more about the chemical composition of opium.  Codeine was first isolated in 1832 by French chemist, Pierre Robiquet, although it proved not to be as popular as morphine.  The real breakthrough came in the 1870s when  English chemist C.R.A. Wright first isolated the opiate compound that would later be marketed under the brand name of heroin.  When Bayer Pharmaceuticals released their product some time later (the name heroin was taken from the German word for heroic, heroisch), it was billed as a perfectly safe alternative to morphine. 

And heroin was hardly the only new product available.  With the development of chloroform, nitr0us oxide, and vari0us other anesthetics, pain-free surgery and dentistry became all the rage.  At the same time, however, there was a growing fear of the social dangers surrounding opiates (including morphine and heroin).  Following the Spanish-American War and the American annexation of the Philippines in 1898,  public alarm over opium addiction became even more widespread.   As a result of U.S. pressure,  the first International Opium Commission was held in Shanghai in 1909.  A sec0nd meeting was held in 1911 and the first c0mprehensive policy regulating opiate use was signed.

In the United States, anti-drug lobbyists began agitating from more stringent safeguards.  Hamilton Wright was appointed as America's first Opium Commissioner in 1908 and, after attending the Shanghai meeting, would comment that "Of all the nations of the world, the United States consumes most habit-forming drugs per capita. Opium, the most pernicious drug known to humanity, is surrounded, in this country, with far fewer safeguards than any other nation in Europe fences it with".    Once again, drug abuse was linked to racial unrest as Wright went on to comment that "cocaine is often the direct incentive to the crime of rape by the Negroes of the South and other sections of the country" (while cocaine is not an opiate, the drug reformers insisted on classifying it as a narcotic as part of their platform). 

Newspaper editors and academics alike weighed in on the dangers of drug addiction and the horrendous social costs involved.   Racism was readily apparent and the editorials were filled with accounts of "drug-crazed, sex mad negroes" and "Chinamen" seducing white women on drugs.  Various drug "experts" testified on the proliferation of drug-addicted "Negroes" stalking and attacking white women while under the influence.     By 1914, forty-six states had passed legislation regulating or banning opium, morphine, or heroin. The fact that World War One had just broken out in Europe became a factor as well since experts began raising c0ncerns about the cases of Soldier's  Disease that had arisen from the Civil War and the possibility of American involvment in the new year leading to more cases.  

In 1915, Jeannette Marks published a highly influential article in the American Journal of Public Health describing the "hydra-headed drug curse" following the Civil War and expressed alarm that the problem would shortly resurface.  She was als0 the first to suggest that there had been as many as 400,00 morphine addicts following the war although she was given to exaggeration (she had also estimated there being 4,000,000 drug addicts in the U.S. in 1915).    While other experts disputed her estimate, the consensus that drug regulation was needed seemed clear enough.  After quiet deliberation, the Harrison Narcotics Tax Act was signed into law on December 17, 1914.  Technically focusing on taxing narcotics (again, cocaine was included), the act also imposed still penalities for the sale and importation of all narcotics.  Although morphine and other opiates could still be prescribed by a physician, the anti-drug era had begun in force.  

As for Soldier' Disease, its popularity as a diagnosis began to level off during the 20th century when substance abuse in the military became better understood.  Despite the role of the diagnosis in helping to shape U.S. drug policy and the numerous wars that have been fought in the past century, the use of a distinct diagnosis for returning soldiers addicted to pain medication has been largely discarded in the clinical literature.   While drug experts continue to disagree on the actual number of Civil War morphine addicts (the estimates range from 45,000 to 400,000).  Still, the controversy remains over how any valid estimate could ever be made given the lack of reliable data from that era. 

What isn't in dispute however, is that substance abuse among military personnel continues to be a political minefield regardless of the actual medical needs of soldiers dealing with chronic pain or posttraumatic stress.  Despite research initiatives by the National Institute on Drug Abuse and the Department of Veteran's Affairs,  the substance abuse problems that returning soldiers face are still waiting to be solved.

Counting Suicides

In a recent editorial by Ian Rockett published in Crisis: The Journal of Crisis Intervention and Suicide Prevention, he notes that relatively few countries credibly keep statistics relating to how their citizens die. Thus, differential sophistication as well as sociopolitical and economic support of healthcare and systems to investigate deaths inevitably leave a large gulf between richer and poorer countries in accurately registering manner and cause of death. And when suicide is in question, the  stigma of self-harm combined with limited resources for conducting forensic death investigations likely produce large registration gaps among richer nations as well. In higher-income democratic countries, and probably in most other countries too, logic strongly suggests that suicide misclassification is overwhelmingly one-way. False negativity (i.e., undercounting) appears far more problematic for suicide etiology and prevention than false positivity. The editorial also discusses issues related to the documentation of suicide, both in highly developed and less developed countries, including suicide data reliability and validity and the importance of awareness of suicide as a public health problem. As the capacity for measuring, characterizing, and disseminating the true dimensions of this universal tragedy improves, so will the prospects for securing more adequate funding for research and prevention.

For the abstract

'Psychotic' Afghan Asylum Seeker Embroiled in Foster Child Controversy

When the Afghan refugee known only as "C.J." was found by British customs officers at the Port of Dover in 2008, he told them that he was only fifteen.  He told officials a thrilling tale of escaping from Afghanistan and spending eight months traveling overland, including hiding under a lorry in Calais, France.  He entered the United Kingdom when a kindly stranger gave him a train ticket to London.  Despite inconsistencies in his story and questions about his true age, CJ was "dispersed" to Cardiff, Wales and placed with a Welsh foster family which included young children. 

In a case presented to London's High Court, testimony about C.J.'s time with the foster family included reports of his extremely violent behaviour.  On one occasion, he was forcibly removed from the home by three officers and needed to be controlled with leg irons and handcuffs (he assaulted one of the officers).  After being taken to the Psychiatric Intensive Care Unit at Whitchurch Hospital, C.J. was diagnosed as being "floridly psychotic" including delusions of grandeur.  Even in the first week that he was in the foster family's care, he reportedly threatened to take the family's youngest daughter to Iran. 

Despite documents which C.J. had brought with him from Afghanistan, medical authorities and foster family members feel that he appears much older than his claimed age and is actually in his early twenties.  The legal case surrounding C.J. has been complicated by the question of whether he is in fact an adult.  The Cardiff City Council  has spent thousands of  pounds gathering expert evidence to prove his adult status.   While C.J. is adamant that he was born in 1993, the judge presiding over the case, Justice Duncan Ouseley, is openly skeptical about the birth documents that have been presented.  He has further stated that "he could be between 18 and 22, but I found just 17 impossible to accept and untruthfully alleged".   Following the three-day hearing, the judge concluded that C.J. is over 20 years of age. 

The case is still ongoing.

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Soldier's Disease (Part 1)

The American Civil War (a.k.a. The War Between the States) was long and terrible.  Beginning in 1861, the four-year war is still the deadliest in American history with an estimated 620,000 soldiers killed and an indeterminate number of civilian casualties. Approximately ten percent of all Northern males and 30 per cent of all Southern males were killed in the fighting and the social and political costs left their mark on the United States for generations afterward. 

As one of the first "modern" wars with heavy artillery and other weapons of mass destruction, physicians on both sides of the conflict were faced with unprecedented medical challenges in dealing with wounded soldiers.  Military surgery was still in its infancy and antiseptic practices were largely unknown so casualities remained high despite the best efforts of doctors and nurses.  To deal with patient suffering, doctors relied on two medical innovations that had only become available a few years previously:  the hypodermic needle and morphine sulphate.    First developed in 1804, the opium derivative received its name from the Greek god of dreams, Morpheus, and widely advertised to physicians as a safe and effective analgesic.   Given that surgery was often traumatic due to the lack of proper anesthesia, the use of morphine (spurred on by the development of the hypodermic needle in 1857) began to spread. Opium pills were also widely dispensed when hypodermic needles were unavailable.    During the Civil War, solders were often dosed with enormous amounts of morphine or opium to kill the pain of amputations and other surgeries.    While the potential for addiction was already known at the time, simple humanitarian concerns ensured that soldiers remained liberally dosed with morphine and whatever other analgesics were available.

Anecdotal accounts of Civil War doctors on both sides dispensing opium seem descriptive enough.  One Confederate doctor, William H. Taylor, gave a plug of opium to every patient reporting pain depending of whether or not they were constipated.  A Union doctor, Nathan Mayer, diagnosed patients from horseback.  If the wounded soldier needed morphine, Mayer would pour out an "exact quantity" into his hand and had the patient lick it off  (not a recommended method, by the way). 

Since medical epidemiology was still unknown, actual statistics relating to morphine addiction remain scarce.  Some sources have suggested that as many as 400,000 veterans were left addicted to morphine due to their wartime experiences.  These addicts were readily identified by the characteristic leather thong around their necks to which a small bag was attached.  The bag carried a supply of morphine sulphate tablets as well as  a hypodermic needle.  Upon their discharge from the army, this was all that was given to the returning soldiers to ease their return to society (no Veterans' Administration services in those days).  In recognition of the medical issues that these veterans faced, the term "Soldier's disease" was coined  (as opposed to "Soldier's Heart" which was an early name for Posttraumatic Stress Disorder). 

But how prevalent a problem was Soldier's Disease?  As some historians have noted, there were few descriptions of widespread morphine addiction during the 19th century.  The existence of thousands of morphine addicts in the United States following the end of the Civil War would have likely made far more of an impact than later medical authorities noted.  Veterans certainly had good reason to conceal their addiction since public exposure might have cost them their service pension (drug addiction was not a recognized medical condition).  The greatest social impact of the war and the addicts who survived it was likely from 1865 to 1900 when most addicts had died off. 

While the explosive growth of opium addiction from 1865 to 1895 was certainly noted,  the few drug addiction surveys undertaken during this period showed that women were more likely to be addicts than men.  Many of these women addicts had become addicted to the opiates that had been legally prescribed for them by their physicians (often as treatment for "female problems").  Although 19th century newspaper editorials expressed alarm over substance use, it almost always focused on opium and the insidious "opium dens" which were seen as a threat to American society (there were often racist overtones to these editorials given that they focused on how "white women" could be ensnared into smoking with "Chinese men").

Despite concerns relating to morphine addiction (and the thousands of addicts who had supposedly been released into society after the war), physicians continued to prescribe morphine for their patients.  As a catch-all medical solution for a wide variety of problems (which could range from headaches to diarrhea),  hypodermic-wielding physicians likely created more addicts than the typical opium den.   In an 1880 medical text titled The Hypodermic Injection of Morphia, the author stated that "here is no proceeding in medicine that has become so rapidly popular; no method of allaying pain so prompt in its action and permanent in its effect; no plan of medication that has been so carelessly used and thoroughly abused; and no therapeutic discovery that has been so great a blessing and so great a curse to mankind than the hypodermic injection of morphia".   

Continue to Part 2

 

What Causes Obsessive-Compulsive Disorder?

It is unknown whether various types of obsessive-compulsive (OC) symptoms have a common genetic or environmental etiology. For example, it is unknown whether hoarding is etiologically associated with prototypic OC symptoms, such as washing, checking, and obsessing. Also unknown is whether particular OC-related symptoms are etiologically linked to the general tendency to experience emotional distress (negative emotionality).  A recent issue of the Journal of Abnormal Psychology presents the results of a study examining a community sample of 307 pairs of monozygotic and dizygotic adult twins provided scores on 6 OC-related symptoms (obsessing, neutralizing, checking, washing, ordering, and hoarding) and 2 markers of negative emotionality (trait anxiety and affective lability). Genetic factors accounted for 40%–56% of variance in the 8 phenotypic scores (M = 49% of variance for OC-related symptoms). Remaining variance was due to nonshared (person-specific) environment. More detailed analyses revealed a complex etiologic architecture, where OC-related symptoms arise from a mix of common and symptom-specific genetic and environmental factors. A general genetic factor was identified, which influenced all symptoms and negative emotionality. An environmental factor was identified that influenced all symptoms but did not influence negative emotionality. Each of the 6 types of symptoms was also shaped by its own set of symptom-specific genetic and environmental factors. The importance of genetic factors did not vary as a function of age or sex, and the architecture of general and specific etiologic factors was replicated for participants having relatively more severe OC symptoms. Gene–environment interactions were identified.  The authors discuss the mplications for an etiology-based classification system.

For the abstract.

Brazilian Man Imprisons "Mentally Ill" Wife in Cellar for Eight Years

Following a telephone tip, police in Sorocabo, near Sao Paolo, Brazil, arrested a  man for alleging imprisoning his wife in their cellar for eight years.  According to police reports, 64-year old Joao Batista Groppo had kept his wife of 40 years confined due to concerns relating to her mental illness.  He stated that he initially locked her up in 2003 due to concerns relating to her mental illness and aggressive behaviour.  Although he originally told the police that he had kept his wife confined for 16 years, he later revised this to eight years.  Their son, who admited to being aware of his mother's confinenment, confirmed the story.

Groppo's girlfriend, Maria Furquim, has been arrested as an accomplice.  The son, Joao Batista Groppo Junior, may also be facing charges for "failing to come to the aid of someone in need" as he admitted to police that he was aware of his mother's circumstances.   While he had his mother stay at his house on several occasions, his father inevitably took her back to his own house. 

In justifying his actions, Groppo, a retired industrial consultant insisted that confining his wife in the cellar was the only way to prevent her from "wandering off and getting lost".   When police entered the house, they found Sebastiana Aparecida Groppo, naked on a concrete bed in the unlit, unventilated cellar where she had been confined.  According to police reports, the cellar was only 130 feet square with "feces and dead cockroaches".    It was kept unlit since her husband was worried about wasting electricity.  The arresting officer, Jaqueline Coutinho, described it as the most "degrading" case she had worked on in her career.  Coutinho added that "It was horrifying.  There were dogs and animals free in the backyard while the old woman was locked in the cellar with bars and padlocks".    There were no signs of aggression whcen she was removed from the cellar and taken to hospital for tests.  She has since been released to her son's custody.

 Groppo has denied that he negledcted his wife and insisted that they had been seen by her psychiatrist once a month.  Neighbours have reported that Sebastiana was well-treated and that Maria Furquim helped take care of her.  The phone tip that led police to the house had been made by a neighbour who reported hearing Sebastiana crying.  Police have charged Groppo and Furquim with false imprisonment.   If convicted, they face up to eight years imprisonment.    The case has generated widespread outrage in Brazil. 

 

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