Conferences and Queen's Psychiatry Residents

The Canadian Psychiatric Association, CPA, and the Canadian Academy of Child and Adolescent Psychiatry, CACAP, annual conferences were held in Montreal this year. Queen's psychiatry residents represented their university well. We had several presentations and posters at both the conferences.

Dr. Mitra Monir Abbasi had a poster presentation at the CPA. 

Dr. Nazanin Alavi did two presentations. The effect of Cognitive Behavioural Therapy (CBT) via email on depression : Sept 29th, Oral Presentation CPA and PTeR Efficacy Evaluation Survey: Sept 27th, Oral presentation CPA

Dr. Alavi also had a poster presentation at the Canadian Academy of Child and Adolescent Psychiatry, CACAP. Intensive day treatment for children with pervasive developmental disorders, Oct 1st, Poster Presentation CACAP

Dr. Varinderjit Parmar was the Queen's representative at COPE. He also presented two posters: 

Poster 1 - Reasons for Referrals to Psychiatry in Emergency in a Tertiary Care Hospital Setting and Utilization of Resident Resources. 

Poster 2 - Comparison of actual time spent on management of psychiatric emergency presentations in Tertiary Care Hospital Settings with psychiatric residency training program’s teaching curriculum.

Dr. Nishardi  Wijeratne presented at both the CPA and CACAP. At the CPA she had a paper poster presentation on Somnabulism Secondary to Olanzapine Treatment of Acute Mania: A Case-Based Review - Clinical and Research Report. 

Dr. Wijeratne's second poster presentation was: Sociodemographic correlates and psychopathology in abused children:A pilot study Wijeratne N, Alavi Taberi N, Roberts, N. (poster presented at the CACAP conference-immediately following the CPA)

Great work Dr. Abbasi, Dr. Alavi, Dr. Parmar and Dr. Wijeratne. We are all so proud of you.

Social Media and Medicine

A great article relating to the issues surrounding social media for Canadian physicians can be found on the URL below.

http://www.cma.ca/advocacy/social-media-canadian-physicians

Neuroskeptic about who discovered autism.

Who Invented Autism? The concept of "autism" is widely believed to have been first proposed by Leo Kanner in his 1943 article, Autistic Disturbances Of Affective Contact. But did Kanner steal the idea? That's the question raised in a provocative paper by Nick Chown: ‘History and First Descriptions’ of Autism: A response to Michael Fitzgerald. The piece stems from a debate between Chown and Irish autism expert Michael Fitzgerald, who first made the accusation in a book chapter. On the evidence presented, I don't think there's good reason to believe that Kanner did "steal" autism, and Chown doesn't seem convinced either. But there's an interesting story here anyway. Fitzgerald says that in 1938, Hans Asperger - of Asperger's Syndrome fame - gave a series of lectures in Vienna. These were published in a Vienna journal called Wiener Klinischen Wochenzeitschrift as an article called "Das psychisch abnorme kind" ("The mentally abnormal child"). In this article, Asperger put forward the concept of autism. The term was coined by Eugen Bleuler in 1911 in reference to symptoms seen in 'schizophrenia' (he came up with that word too), but that was nothing to do with children. In 1943, Kanner published his landmark paper, in which he did not mention Asperger. Asperger published his first major description of 'autistic psychopathy' in 1944. The big question, then, is - had Kanner read or heard of Asperger's ideas before 1943? Asperger was working in Austria while Kanner, although Austrian-born, was in the USA. WW2 would have made it impossible for them to have communicated directly - however, word of Asperger's ideas could have reached Kanner via one of the many European doctors who fled to America, over that period. There is however no direct evidence that this happened. Fitzgerald makes much of the fact that Kanner opened his 1943 paper by saying "Since 1938, there have come to our attention a number of children..." This could be a reference to Asperger's 1938 work - but Kanner said it referred to his first "diagnosis" of autism, Donald T. This leaves us with a fluke: two Austrian-born psychiatrists independently discovered the syndrome we now call childhood autism, decided to borrow Bleuler's term "autism" for it, made their first observations in 1938 and first published properly in 1943-1944. Personally, I think that while that is a remarkable coincidence, such things are not uncommon in science. I see no reason to think that Kanner plagiarized Asperger, although it remains possible. If someone were to discover a copy of Asperger's 1938 article tucked away in one of Kanner's old notebooks, then I'd change my mind, but not before... Chown, N. (2012). ‘History and First Descriptions’ of Autism: A response to Michael Fitzgerald Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-012-1529-5

Queen's Psychiatry Book Club (update)

Queen's Psychiatry has recently started a book club for its residents. Books are selected by the members in their assigned order. Both attending and residents are part of the book club and we currently even have an ER resident on board.

First book: People of the Lie by M. Scott Peck

Queen's Psychiatry Book Club recently read People of the Lie by M. Scott Peck. The book explores the evils that exist in human nature via a series of case reports. At the end of the book Dr. Peck suggests adding "evil" as a diagnosis into the DSM. A great discussion generating book for any book club.

Second book: Long Day's Journey into Night by Eugene O'Neill

Queen's Psychiatry Book Club's most recent read was Long Day's Journey into Night by Eugene O'Neill. This is Mr. O'Neill's best work according to some. Published three years after his death, it was his present to his wife on their eleventh wedding anniversary. The book explores the complexities in family relationships riddled with addictions. An interesting read from a psychiatric point of view.


Third book: A Million Little Pieces by James Fry

A Million Little Pieces by James Frey is a great book to read for those who work with addictions or those who know someone who has an addiction. This book gives one a candid view of the experience of an addict both in rehab and before rehab. For someone who has had little exposure to addictions, I found the book enlightening. 

The World Mental Health Missionaries?



SATURDAY, 3 MARCH 2012


Is research on the global distribution of mental health problems a kind of modern-day missionary work?


Maybe, says Australia's Dr Stephen Rosenman in a provocative paper: Cause for caution: culture,sensitivity and the World Mental Health Survey Initiative.

The World Mental Health Survey (WMHS) is a huge World Health Organization project that aims to measure the rates of various psychiatric disorders in countries around the world. The WMHS has produced a great deal of data, but Rosenman points out that this assumes that people all over the world suffer from the same psychiatric disorders (and display them in the same ways) as the Americans and Europeans about whom the diagnostic manual was originally written.

The surveys translated the diagnostic criteria into the local languages, of course, but that doesn't mean they were appropriate to the local cultures.

He suggests that all this is a bit like missionaries who went around translating the Bible and trying to convince people to read it -
Looked at with a less admiring eye, the [WMHS] resembles in some ways the missionary movements of the last two centuries. Like the missionaries, the organisers are committed, selfless people of extraordinary goodwill who have come to poor countries from cultures at the apogee of their wealth, prestige and intellectual power.
They bring an evolved and highly developed system of thought. They set about delivering the fruits of that to the people. The survey initiative has engaged the leaders of the profession in the countries and, in a sense, has converted them to this view of psychopathology.
It is difficult to know if their success is due to the power of the ideas they brought, or the power and prestige of the cultures they came from, or from their technique of taking over both the centre and the contours of the beliefs of a culture. Missionaries brought a ‘colonisation of consciousness’... etc.
He does goes on to say though, "I do not want to push the missionary analogy too far" which is wise I think; there are important differences and other analogies are equally apt.

The paper's a good read though. It refers to Crazy Like Us, a book I'm fond of.

Although Rosenman doesn't cite another important source (cough cough): he points out that the WMHS national estimates of rates of depression don't correlate at all with national suicide rates, which is seriously odd -
According to the CIDI [the psychiatric interview used in the WMHS], Japan, for example, has one-third the rate of mood disorders (3.1%) seen in the USA (9.6%). At the same time, Japan’s suicide rate (20.3/100,000) is twice that of the USA (10.8/100,000). Suicide rates seem to have almost no relationship with CIDI diagnoses of affective disorder... Suicide, of course, is complexly shaped by the culture but are we to believe that answers to the CIDI are any less culturally determined and which is to be considered the better index of disorder?
I made the very same point using the very same datasets in 2009 (although I looked at 'all mental illness' rather than 'mood disorders').

Rosenman, S. (2012). Cause for caution: culture, sensitivity and the World Mental Health Survey Initiative Australasian Psychiatry, 20 (1), 14-19 DOI: 10.1177/1039856211430149

SUNDAY, 5 FEBRUARY 2012

Mystery Joker Parodies Neuroscience


Someone has created a hilarious spoof paper poking fun at neuropsychoanalysis (but all of fMRI takes some hits too): A Triple Dissociation of Neural Systems Supporting ID, EGO, and SUPEREGO.

Featuring gems such as


Authors "Steven Z. Fisher and Stephen T. Student" with contact details "mother@amaliastate.edu".
"Twenty-four healthy participants (all 19-year-old white, male undergraduates who sat near each other in an Introductory Psychology course and were raised in upper middle class suburban New
England neighborhoods) were scanned but 17 were excluded for not following instructions or falling asleep in the scanner."
"If you’re like us, you’ve probably been thinking that Social Neuroscience, Neuroeconomics, and Developmental Social Cognitive Affective Clinical Neuroscience are just not cutting edge enough
anymore. Do not despair. This study represents the first of what is likely to be a productive and active new field of Psychoanalytic Neuroscience."


It really is very funny, but it's also deadly accurate in its highlighting serious problems that plague a certain genre of neuroimaging papers. Who made it? The PDF appeared on Dropbox a couple of weeks ago and, while a few people have Tweeted about it, no-one has claimed ownership, yet.

For the record, it wasn't me.

Diagnostics tome comes under fire.the reliability found in the field studies of DSM-5, is pretty poor (as measured using the Kappa coefficient). Omino

NATURE | NEWS

Diagnostics tome comes under fire

Field tests of new criteria are flawed, critics argue.

•Heidi Ledford
31 January 2012

Diagnoses of certain mental illnesses could rise significantly from next year, say some mental-health experts — but not because of any real changes in prevalence. Instead, the critics blame what they say is a flawed approach to testing the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard reference used by researchers and mental-health professionals in the United States and many other countries to assess patients, inform treatment, design studies and guide health insurers.
Changes to the diagnostic criteria in the fifth edition of the manual, DSM-5, due to be published in May 2013 by the American Psychiatric Association (APA) in Arlington, Virginia, have raised concerns that some disorders will be overdiagnosed (see Contentious proposals for DSM-5). Critics say that the analysis of field tests of the new criteria won’t settle those concerns.
Trials of DSM-5 conducted at 11 academic centres were completed last October. In a Commentary published in the American Journal of Psychiatry (H. C. Kraemer et al. Am. J. Psychiatry 169, 13–15; 2012), members of the task force explained that the aim was not to focus on the frequency of a given diagnosis under the proposed DSM-5 criteria compared with that under the previous criteria. Because there is no accepted prevalence for most psychiatric disorders, they argued, it would be impossible to tell whether a rise in diagnoses reflects a true increase in the sensitivity of the revised criteria or simply a rise in the number of false positives.
That raised the hackles of some researchers, who say that without such comparisons it will be impossible to flag up the possibility that some categories will show an increased prevalence. “It’s a real step back,” says Thomas Widiger, a psychologist at the University of Kentucky in Lexington, who notes that trials of DSM-IV were careful to compare old and new diagnostic criteria to see which performed better.
Allen Frances, emeritus professor of psychiatry at Duke University in Durham, North Carolina, led the 1994 DSM-IV revision and is an outspoken critic of DSM-5. Frances acknowledges that the field trials for DSM-IV were far from perfect. For example, his trials failed to identify the dramatic surge in diagnoses of attention-deficit/hyper¬activity disorder that followed changes made in DSM-IV. The trials suggested that there would be an increase of about 15% in the disorder. Instead, says Frances, the diagnosis rose threefold. “We missed the boat,” he says. “But at least we had some sense that there would be an increase.”
Results from the DSM-5 academic field trials have yet to be presented, but early calculations suggest that, in general, there will be no big differences in the frequency of diagnoses, says Darrel Regier, vice-chair of the DSM-5 task force and APA director of research. That claim has done little to alleviate concerns, however, because the trials enrolled patients who were initially diagnosed under DSM-IV standards. This leaves untested the possibility that the DSM-5 criteria will capture many more patients who were previously deemed healthy, notes Widiger.
Observers are also alarmed by the statistical thresholds that the trials used to assess reliability, or the likelihood that two or more clinicians would arrive at the same diagnosis using the proposed criteria. This likelihood is often expressed as a statistical term called ‘Cohen’s kappa’. A kappa of 0 means that there is no agreement between the clinicians; a value of 1 means that the clinicians agree totally.
Researchers in the field often strive to reach a kappa of 0.6–0.8, indicating that the independent diagnoses agree more often than not. But in the Commentary, lead author Helena Kraemer, an emeritus statistician at Stanford School of Medicine in California, argued that a kappa of 0.2–0.4 could sometimes be acceptable. Kraemer later elaborated to Nature that the task force was largely aiming for a kappa of 0.4–0.6, but that it wanted to prepare the field for seeing values as low as 0.2 in particularly rare diagnoses or in those without biological markers.
Unlike tests on the previous edition, the reliability tests on DSM-5 were performed on separate occasions, so that the clinicians involved were unaware of each other’s diagnoses. Widiger says that he supports the more rigorous approach, but that accepting a value as low as 0.2 gives him pause. “I’ve never seen anybody argue that a kappa of 0.2 is acceptable,” he says. “You just can’t get much lower than that.”
Not everyone is worried about a surge in diagnoses. Thomas Frazier, a paediatric psychologist at the Cleveland Clinic in Ohio, has carried out his own study of DSM-5 criteria for autism spectrum disorder. His results, published online last year (T. W. Frazier et al. J. Am. Acad. Child Adolesc. Psychiatry 51, 28–40; 2012), suggested that the new definition would omit some patients with autism, but that this could be easily corrected by requiring one less symptom to meet the threshold for a positive diagnosis. “Unfortunately, the DSMcommittees are not systematically doing these kinds of studies,” he says.
Nature Volume: 482, Pages: 14–15 Date published: (02 February 2012) DOI: doi:10.1038/482014a