Welcome to the Loony Bin

Welcome to the Loony Bin tracks attitudes and approaches in psychiatry and the law over 55 years. The cases illustrate miraculous cures as well as blundering repetition of harmful excesses. Bell's book (autobiography) is certainly does not shun from calling the whatever, whatever. For decades he has taken iconoclastic and often unfashionable positions in relation to what he has regarded as fads and unscientific trends of the day.

Dr David Bell is a well known Sydney neuro-psychiatrist, who has run a psychiatric research unit, developed a therapeutic community, pioneered addiction rehabilitation, been a driving force in forensic studies.

Can depressive disorder be the outcome of an infectious disease

One in five Australians aged 16-85 experience a mental illness in any year. The most common mental illnesses are depressive, anxiety and substance use disorder. These three types of mental illnesses often occur in combination. For example, a person with an anxiety disorder could also develop depression, or a person with depression might misuse alcohol or other drugs, in an effort to self-medicate. Of the 20% of Australians with a mental illness in any one year, 11.5% have one disorder and 8.5% have two or more disorders. Almost half (45%) Australians will experience a mental illness in their lifetime.

Recently Psychiatric News ran a story with at least one researcher asking if major depressive disorder is the outcome of an infectious disease? This question arises from the belief that a variety of infectious pathogens affect the central nervous.

Patients with depression exhibit sickness behavior. Also, depression is significantly associated with infectious agents, including viruses like Borna disease virus, herpes simplex virus-1, varicella zoster, and Epstein-Barr virus. Parasites like Toxoplasma gondii may play a role. And even if every case of depression isn’t caused by an infectious agent; given its prevalence, even a subset of patients would still add up to a large number of cases. We know, for example, infectious agents have been known to affect the brain and cause psychiatric disorders. Syphilis helped fill America’s mental asylums in the late 19th century.

It’s said that among patients with diagnosed major depression or bipolar disorder, those with a history of suicide attempt had higher Toxoplasma gondii antibody titers.

Another possibility is the “leaky gut” hypothesis, suggesting that cytokines increase intestinal-tract permeability to lipopolysaccherides from gram negative bacteria and that antibodies to the LPS are found at higher levels in depressed patients.

The key may not be a disease, however, rather an inflammatory reaction caused by disease given that higher levels of pro-inflammatory cytokines are found in people with depression. A recent report, drawing on data from the Avon Longitudinal Study of Parents and Children in Great Britain, found that children with the highest levels of the systemic inflammatory marker IL-6 at age 9 were more likely to be depressed at age 18.

Side Effects

The early autumn afternoon makes for the perfect time for films and hot drinks. I wondered how I might have missed Side Effects. It was released almost a year ago.

Side Effects is a psychological thriller directed by Steven Soderbergh and co-produced by real-life forensic psychiatrist, Dr. Sasha Bardey. Isn’t interesting how the stories elicited through the everyday practice of Psychiatry makes for a life much much stranger fiction.

The stories we hear behind closed doors; the experience of transference and counter-transference; the complex dynamics driving thoughts, feelings and behaviors in individuals and systems. The popularity of these films helps us escape, perhaps our own personal Psychiatry, and into the world of others – lives bared open by the voyeurism only Hollywood can ply open.

The relationship between psychiatrists and their patients, the law as well as the pharmaceuticals that connect the dots is intriguing.

Mindfulness 5 4 3 2 1

Jack Dikian

April 2012

Five Four Three Two One Mindfulness

Mindfulness, also awareness or a path to enlightenment meditation according to the teaching of the Buddha can be traced back to the Upanishads, part of Hindu scriptures and a treatise on the Vedas.

And modern clinical psychology and psychiatry have developed a number of therapeutic applications based on the concept of mindfulness typically referring to a psychological quality that involves bringing one’s complete attention to the present experience on a moment-to-moment basis, and/or paying attention in a particular way: on purpose, in the present moment, and non judgmentally.

What’s 5 4 3 2 1

Think about a time when you are overcome with restlessness, feeling too distracted, unable to focus on anything, overwhelmed, and/or confused. This can be at work, at a conference, at home, on the train… perhaps the 5 4 3 2 1 method can help.

Five:

Relax and focus on 5 objects around you. These could be buildings, windows, pictures, clouds,. Consider their shape, colors, consider how they relate to each other, are they geometric, symmetric, follow their lines all along trying to keep your mind from wandering off into thoughts. The Buddha said, "In seeing, only seeing." That's the essence of this part of the exercise.

Four:

Now do the same with hearing. You can close your eyes if you're in a place where that would be appropriate. Try and listen to 4 different sounds. This might be the quiet hum of an air conditioner, the roaring wheels of a train, the distant noise of traffic, a birds chirping high above. The Buddha said, "In hearing, only hearing." That's the essence of this exercise.

Three:

Now try and focus on 3 bodily sensations. This might be the pressure of the chair against your back. The tight fit of your shoe against your feet, the soft stream of air through your hair, the warmth of the sun on your face. The Buddha said, "In feeling, only feeling." That's the essence of this exercise.

Two:

Now, try and focus on 2 odors you can smell. It might be the remains of the perfume you used when leaving home, a snack, freshly cut grass.

One:

And finally focus on a taste in your mouth.

Psychiatric classifications over the years

Jack Dikian

November 2011

Not long ago I came by a 1968 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II). The first thing that struck me, although I wasn’t too surprised, was its size. It’s 134 pages in total and lists 182 disorders. Compare this to what is on my desk - DSM-IV (1994) 886 pages and 297 disorders. The next version of the DSM, DSM-5 will be due for publication in May 2013.

Over the years the DSM has attracted controversy and criticism as well as praise. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. I for one am interested in how those involved in reaching consensus and publishing the DSM over the years have had to react to, and be informed by evolving social norms, public perceptions, labels, and of course field trials, diagnoses reliability checking and other influences.

I wanted to put together a time-line reflecting key milestones or versions of the DSM, its size, estimate of the number of classifications as well as key historic backdrops. This is in no way comprehensive, however may be useful nevertheless.

Version	Year	Pages	No of Diagnoses	Remarks
	1840		1	The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census which used a single category, "idiocy/insanity".
Guide	1917		22	A new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane",
DSM-I	1952	130	106	World War II saw a large-scale involvement of US psychiatrists in the selection, processing, assessment and treatment of soldiers – thus shifting the focus away from mental institutions and traditional clinical perspectives. At the same time an APA Committee undertook to standardize the diverse and confused usage of different documents.
DSM-II	1968	134	182	The DSM-II as in earlier versions reflected the predominant psychodynamic psychiatry. Symptoms mostly seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis.
DSM-II Seventh Printing	1974			The seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder and the diagnosis was replaced with the category of "sexual orientation disturbance".
DSM-III	1980	494	265	A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy. “Neurosis” was reinserted in parentheses after the word “disorder” in some cases. Also, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".
DSM-III-R	1987	567	292	Controversial diagnoses such as pre-menstrual dysphoric disorder and masochistic personality disorder were considered and discarded. Also, “Sexual orientation disturbance" was also removed and was largely subsumed under "sexual disorder not otherwise specified".
DSM-IV	1994	886	297	A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
DSM-IV-TR	2000			The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD.

DSM-5

It will be interesting to see the final product, its size, and more importantly the handling of a large number of revision areas. I look forward to, for example, the treatment of Neurodevelopmental Disorders, previously under Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence and Anxiety Disorders.

The American Psychiatric Association provides an official DSM-5 Development Website at: http://www.dsm5.org/pages/default.aspx