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Evolutionary thought about AN,BN.

The prevalence of eating disorders poses
an apparent paradox to evolutionary theory,
because prevalence rates correlate inversely  
with the availability of food, and because 
amenorrhoea counteracts reproductive success.



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AN,BN,VHM

The ventromedial hypothalamus (VMH),  by contrast,is criticalin evaluating the organism's
 energy balance. The VMH contains insulin-sensitive  cells and is able to integrate information about the status of peripheral energy stores. This
 function is mediated,in part, by secretion of leptin and other neuropeptides. The hypothal-
 amus is anatomically close to the pituitary gland, which secretes hormonally active
 neuropeptides involved in energy regulation of the body such as thyroxine, growth
 hormone (GH), cortisol, and leptin.In AN,there is usually an excess of GH activity,
 whereas the insulin-like growth factor I is often found to be reduced. GH interacts in
 complex ways with somatostatin, and may also be influenced by leptin and ghrelin secre-
 tion (the latter being a gastric somatotropin-stimulating hormone). Other neuropeptides
such as orexin and neuropeptide Y are involved in regulation of food intake. Neuropeptide
Y has been found elevated in the cerebrospinal fluid (CSF) of patients with BN. Stress
increases the level of neuropeptide Y, which may cause abdominal fat deposition. Moreover,
cholecystokinin, Wトich is secreted by the gut to signal satiety,is decreased in BN. This
reduction in satiety signalling may,therefore, be part of the pathology of binge eating.
   Interestingly,in terms of the AN phenotype,the VMH is not only involved in the regu-
lation of food intake. The VMH also controls female sexual receptivity, which may
explain why patients with AN experience reduced sexual interest when starving. Also,
hypertrichosis, amenorrhoea and a more male-type physiognomic phenotype are the
result of complex dysregulations of the neuroendocrine circuits, which remit upon
restoration of a sufficient amount of body fat. This suggests that most pathophysiological
mechanisms in AN and BN are the result rather than the cause of the disorder.
  Similarly, at the anatomical level, chronic reduction of food intake to the point of
starvation may lead to cortical atrophy and ventricular enlargement. This is believed to
be a consequence,rather than cause of eating disorders, and partly remits following
weight gain.


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anxiety disorders


Behavioural observation of patients with anxiety disorders suggests that these disor-

ders--as a group--reflect exaggerated responses to

internal or external signals

of perceived danger or

threat.

The autonomic part of the anxious response pattern prepares the organism

for one of several behavioural options to terminate the anxiety-eliciting situation,

namely flight,immobility, submission, or aggression.

In gregarious species like primates and humans, some fear reactions may have an altruistic

connotation in that a fear reaction of one individual may alarm others about impending

danger.

Alarm calls are found in many primate species and can be truly seen as altruistic

behaviour because the call is clearly at the cost of the alarming individual, which runs the

risk of attracting the attention of predators, and because the alarming individual has no

immediate pay-off from warning its conspecifics.

In any event,fear(the term referring best to the 'normal' adaptive variant) and anxiety

(reflecting pathologically exaggerated fear in terms of duration,intensity

or situational appropriateness) clearly belong to a

group of defence mechanisms, much like submission and depression do.In contrast to

depression,it is intrinsic to the anxiety disorders that anxiety attacks usually cease

automatically, and often aim more directly at eliciting care from others (like in PD or

agoraphobia). Moreover, situations causing anxiety can better be avoided than those

leading to depression. Whether or not some form of altruistic behaviour is reflected in

anxiety disorders is open to speculation. Arguably, altruism is part of OCD-associated

pathology, where others (usually closely related individuals) may benefit from exagger-

ated hygiene or repetitive control of potentially dangerous situations.

Phobic fears of specific situations, objects or persons are so widespread that they

inevitable constitute a significant part of human nature, much of which is inherited from

our primate ancestors. For example, during normal human ontogeny, separation from

the primary caregiver, heights, or strangers are among the strongest fear-evoking situa-

tions,to which the human infant is biologically prepared to respond. Not only are these

fear responses particularly prevalent during certain developmental periods; separation

distress occurs soon after birth,fear of heights emerges when the infant starts to crawl,

fear of strangers when the toddler begins to give up physical closeness to the mother for

brief periods of time, and so forth. These fear reactions are operate on actual sources of

fear that were persistent enough in the environment of evolutionary adaptedness (EEA)

to be selected. Their way of functioning has been likened to the principle of a 'smoke

detector' mechanism, which works optimally if the threshold is low enough to reliably

produce a response to potentially life-threatening Stimuli at the cost of some raise alarms,

but high enough to limit the costliness of too many energetically

expensive false alarms. Here,it needs to be emphasized that not responding to a genuine threat

(for instance, in a predation situation)is most expensive, because

it may cause death of the individual;thus, behaviour too dauntless would readily be

eliminated by natural selection, and a lack of fearfulness would not translate into greater

reproductive fitness.

In primates including humans, phobic fear reactions are not only acquired through

direct conditioning experiences, but also through vicarious experiences,in which an

individual witnesses the response of another individual to fear-relevant stimuli. These

are probably the most important mechanisms of how biologically predisposed fears

become actually manifest. For example,fear of snakes is most likely not 'innate' in

primates, but requires observation of fear responses of conspecifics to the sight of a

snake. However, although conditioning seems to be necessary, biological preparedness is

also likely involved, because no such reactions can be experimentally conditioned when

using flowers instead of snakes as conditioned stimuli. Even though these conditioning

models may be more valid for between-species fears than same-species (social) phobic

fears,it is most obvious that normal fear-conditioning and pathological phobia and

other anxiety disorders lie along a continuum. This is true for all psychopathological

signs and symptoms, and anxiety disorders are paradigmatic in this respect.

Normal fear conditioning takes place early in life. For example, a young primate may

easily acquire fear of snakes through attending to its mother's reaction. The extraordinary

importance of physical closeness for young primates and humans supports the assump-

tion that individual differences in attachment exert long-lasting effects on how young infants and children learn to cope with fear-inducing situations.If,for instance,the

primary caregiver is unresponsive to the infant's needs or even unavailable,insecure

attachment is likely to develop. Consequently,

ambivalently or avoidantly attached infants are

more vulnerable to develop anxiety disorders later

in life. In line wlth this, patients with various forms

of anxiety disorders have experienced early losses

more often than controls,report rejection by parents

more frequently, or have experienced extremely

inadequate caregiving more often compared

to controls. This makes sense in light of the hypothesis that insecurely attached

individuals are prepared through adverse early experiences to develop mistrustful inner

working models and to see the world as a hazardous place.

Gene-environment interactions leading to anxiety disorders seem to predispose these

individuals to assume behavioural strategies aiming at harm avoidance and acquiring

defence strategies associated with internalizing symptoms (which explains the frequent

comorbidity of anxiety disorders with depression).In line with this assumption, carriers

of the short polymorphic version of the serotonin transporter gene have been found

to develop depression or anxiety disorder after negative life events more often than

individuals who lack this allele variant.

Early experiences may,therefore, 'shape' the responsivity of neurobiological circuits

involved in fear responses. For example, evidence from brain imaging studies suggests

exaggerated sensitivity of the amygdalae to fearful stimuli in patients with PTSD or SAD.

In addition,the reduced control over fear responses may be augmented by a diminished

emotional evaluation of threat signals (projected from the amygdala to prefrontal cortex

areas), and insufficient integration of representation of past experiences (via the

hippocampal formation).In other words,in sensi-

tized individuals,irrespective of whether sensitiza-

tion is genetically predisposed, acquired through

aversive experience or both,the amygdala may lose

the inhibitory control through which it normally contains the approach of novel objects I

or other organisms (including individuals of the same species).Instead the amygdala,

responds in a dysregulated or hyperactive fashion such that benign environmental

stimuli may be perceived dangerous. All this may result in exaggerated avoidance behav-

iour and subjectively overwhelming feelings of intense fear in vulnerable individuals.

Conceivably, humans may be particularly susceptible to dysregulation of fear circuits

for several reasons, which may account for the high prevalence rates of anxiety disorders.

Firstly, since humans are exceptionally social, but physically vulnerable,they may be

inclined to constantly check their environment for potential sources of threat(both from

outside and from within the social group). This may not only include predatory or phys-

ical threat, but also threat of social status and loss of resources.In support of this

assumption,the neuroanatomical structures involved in the evaluation of potentially

dangerous situations have increased in size over evolutionary time, WⅡich underscores

theirimportance in terms of survival and reproductive success. Secondly, newborn

humans critically depend on intense nurturance and care, such that a stable affectional

bond with a primary caregiver is outstandingly vital for survival.If, however, stability of

an affectional bond is unattainable or disrupted (for example, by loss of the primary

caregiver), a hypersensitive and constantly overaroused fear system may result. Such a

situation may dramatically worsen,if physical or

emotional abuse is involved with which an imma-

ture human infant can hardly cope. Thirdly, humans

have evolved the capacity to anticipate future

scinario, which on one hand, was certainly highly

adaptive with regards to foreseeing food shortages

or other potentially perilous situations including

changing alliances between contenders ; on the other

hand, exaggerated anticipation of threat and danger

seems to be immanent to various forms of anxiety

disorders , which may ,in part , explain why patients often report fear of recurrence of

anxiety (anticipatory anxiety). Finally,it could be that in modern societies the dimin-

ished necessity to cope with fear-inducing situations--simply due to a reduced number

of dangerous encounters with poisonous animals or predators--renders the neurobio-

logical system involved in evaluation of potential hazards more labile and 'unprepared' to

accurately respond to real-life confrontation with spiders, snakes or heights. However, a

notable exception could be potential or actual harm caused by conspecifics.In modern

societies,individuals frequently meet other people, whom they have seen never before,

and whose intentions are much harder to determine than in familiar people. This may

cause particular problems for those individuals who have developed mistrustful inner

working models and are cognitively biased towards assuming malicious intents in others.

In fact, patients with anxiety disorders frequently complain that others can virtually see

what is wrong with them, and feel being observed or stared at(in contrast to delusional

beliefs, patients with anxiety disorders do not report in corrigible conviction that this is

true; continua between extreme anxiety and paranoid ideation may, however, exist).

  Although the preceding paragraphs have dealt with anxiety disorders as if they were

different manifestations of a singular diathesis,they differ,to some extent,in neurobiol-

ogy and precipitating events.

  PD is perhaps the most primitive of the anxiety disorders. For example, PD has been

interpreted as false suffocation alarm, because carbon dioxide inhalation or lactate

infusion may produce panic attacks in vulnerable

(healthy)individuals. Moreover, PD occurs more

frequently in individuals with heightened PCO2 levels, e.g. during sleep, during the

premenstrual period and in patients with respiratory disorders. On the other hand, PD is

less common in physiological states associated with lowered PCO;,including pregnancy

and delivery. Although there is some evidence that the genetic vulnerability is most prominent in PD compared to other anxiety disorders, additional environmental factors

such as loss of an attachment figure may be equally important in that such events may

lower the suffocation alarm threshold. Panic attacks may therefore be seen as the extreme

version of a preparatory set of physiological changes typical of immediate flight or

escape behaviours. Anticipatory anxiety is often the result of recurrent panic attacks.

Thus, at the cognitive level PD involves the mental representation of future negative

events.In neurobiological perspective, PD probably involves hyperexcitability of norepi-

nephrine pathways and reduced serotonergic and GABA-ergic dampening of limbic

structures.In light of the putative association of PD with separation distress, a link with

abnormal oxytocin turnover is conceivable.

 Agoraphobia, which often accompanies PD,reflects an exaggerated response to avoid

(claustrophobia). Agoraphobia,like PD,IS probably

the pathological extreme of an evolutionarily

conserved behavioural pattern that is common to many animal species and helps to

protect the organism from entering unknown terrain that could yield a predatory threat

or hostile attacks from conspecifics. Whether or not agoraphobia differs from PD in

neurobiology or simply represents a more severe and complex form of PD is debatable.

Shared genetic vulnerability between agoraphobia and PD and associations with similar

precipitating life events may support  the latter assumption.

SAD is characterized by intense fear of social situations in the presence of an authorita-

tive person. Social phobia can be interpreted as an exaggerated submissive gesture

triggered by situations that may potentially lead to humiliation and loss of social status.

There are some phenomenological parallels

lap with normal blushing, which,in extreme forms,

develop into erythrophobia,the fear of reddening

of the skin as a visible signal of the subjective

state of embarrassment. SAD causes a dilemma, especially in its generalized form, because

fear and anxiety usually elicit care and comforting behaviour in others, which the affected

individual cannot tolerate In fact, heightened attention from others may even aggravate

the phobic reaction. The difference to other anxiety disorders is that in SAD patients tend

to exaggerate the evaluation of mental states of others. Unlike patients with autism or

schizophrenia who have difficulties in representing mental states of others (reduced

mentalizing in the former,inaccurate hyper-mentalizing in the latter), patients with social

phobia are well able to appropriately reason about other persons' mental life;in specific

situations, which are perceived as posing a threat to social status and reputation, however,

they negatively interpret social signals of others and may over-anticipate a personally

appalling outcome of social encounters. Research in animals and humans strongly suggest

a central role of amygdala dysfunction in SAD. This dysfunction may be mediated by

reduced availability of GABA and serotonin as well as by impaired regulation of affiliative

behaviour and social attachment via oxytocin. Moreover,reduced inhibition of amygdalar

function through glutamatergic prefrontal efferents (via GABA-ergic interneurons) has

been identified as potential proximate causation of SAD.


GAD is,in contrast to phobic anxiety, not explicitly associated with particular precipi-

tating events. GAD rather reflects an overall tendency towards hypervigilance, probably

forming a continuum with avoidant personality

disorder.It is the least heritable anxiety disorder

and therefore depends even more than the other

anxiety disorders on early aversive subjective experiences and learned behaviour. Chronic

hyper-excitability,restlessness and increased muscle tension is likely to involve the HPA

axis, which may induce secondary physical problems including chronic arterial hyperten-

sion and other stress-related disorders.

Within the broader spectrum of anxiety disorders, OCD stands out by its marked

repetitive and stereotyped behavioural subroutines. From an ethological perspective,

OCD-associated behaviours resemble displacement activities (compare Chapter 5) and

stereotyped behaviours observed in animals under physical restraint.In OCD, however,

the repetitively displayed behaviours clearly address harm-avoidance by checking,

washing, ordering or hoarding.Interestingly, OCD manifests or worsens in biologically

relevant situations such as pregnancy and following childbirth. OCD-associated behav-

iours are thus abnormal by their excessiveness, but probably qualitatively not distinct

from adaptive harm avoidance strategies. Even though anticipation plays an important

role in many anxiety disorders,the cognitive mechanism of mentally generating future

scenarios that may cause harm to self or others is decisively at the core of OCD. Humans,

unlike most other animals, have evolved the capacity to cognitively represent imagina-

tions of past and future events by using semantically and autobiographically stored

memories. This is certainly selectively advantageous, because future threats or needs can

be dealt with in advance (e.g. by collecting food without being hungry). The difference to

hibernating animals is that the cognitive represen-

tation of possible future scenarios is not instinct-

driven (hibernators collect food even if they have

never experiences winter time before), yet much more flexible.In other words,this kind

of cognitive representation is independent of situation and content,i.e. one can create

social or non-social future events as mental images.In the case of OCD,it would seem

that it is exactly this mechanism that is over-active and--despite insight into the

bizarreness of obsessive thoughts and compulsive behaviours--difficult to control.

 At the neurophysiological level, OCD not only involves abnormal serotonergic activity,

but also increased dopaminergic transmission, which may cause an imbalance of phylo-

genetic older 'habitual' systems and phylogenetic younger 'flexibility' systems. Flexible

responses involve the capacity of selecting the relevant sensory input, shifting the atten-

tional focus, making the best choice of behavioral alternatives, and sometimes suppress-

ing salient responses in favour of less salient ones.In primates and humans,the

dorsolateral prefrontal cortex,the orbitofrontal cortex,the cingulate cortex,the supple-

mentary motor cortex, pallidostriatal structures, and parts ofthe thalamus contribute to

the execution of flexible behaviour, where striatum and thalamus operate as filter of

incoming information and project back to different areas of the frontal cortex. These

brain regions have been found hyperactive in OCD. Moreover, enhanced brain activity in the anterior cingulate cortex,in the prefrontal cortex,the dorsolateral prefrontal cortex,

and dorsal prefrontal cortex has been shown to be associated with episodic memory

retrieval in healthy individuals,'prospective memory,that is,the ability to keep in mind

something that needs to be carried out in the future, and,in part, with anticipatory anxi-

ety These findings underscore the assumption of a significant role of exaggerated cogni-

tive risk anticipation in OCD.

Similar mechanisms may also contribute to PTSD, however, with the difference that the

manifestation of PTSD is, by definition , proceed by

a severe traumatic event---in OCD,real danger ma

have never been encountered. Furthermore,in

PTSD,re-experiencing a traumatic event that lies in the pastis at the core of the sympto-

matology, and much less so the mental imagination of future (novel)traumatizing scenar-

ios. Remembering past situations associated with threat or actual harm is certainly

adaptive in that it helps to avoid similar future negative experiences;in PTSD, however,

this mechanism is pathologically hyperactive to the extent that it may actually preclude

adaptive responses, but instead gives why to phylogenetically primitive fear reactions such

as 'freezing' and dissociative states (regarding catatonic/dissociative behaviours, compare

Chapter10). Similarto OCD, however,in PTSD intrusive thoughts and memories are

perceived as uncontrollable, and usually generate strong autonomic arousal, chronically

heightened vigilance, and persistentfeelings ofimpending danger.It would seem that

individuals with PTSD are unable to disentangle past, present, and future threat scenarios

in that they re-experience in the present what frightened them in the past. Hence, at the

physiological level, PTSD represents a hyperactivity of the alarm system associated with

chronic up-regulation of the HPA axis, which,in turn,impairs integration of traumatic

experiences and appropriate memory consolidation. Moreover, even though the amygdala

is hyperactivated during recollection of traumatic events, normal threat evaluation is

impaired such that the affected individual is less well able to distinguish between relevant

and irrelevant stimuli as potential sources of danger.In addition,the communication

between right('emotional') and left('rational') hemisphere seems to be functionally

disrupted in PTSD, such that traumatic memories may be experienced as ego-alien,

because the emotional aspects of the traumatic experience cannot be appropriately

verbalized.It is plausible to assume that the changes at the physiological and

neuroanatomical level in PTSD are the more severe the earlier the individualis confronted

with a traumatic experience. Early childhood trauma,for instance, may induce pervasive

alterations of neural circuits underlying emotion processing and emotion regulation.In

light of the lateralization of the functions, severe early traumatization may affect more

strongly the right rather than the left brain.

In summary, anxiety disorders represent pathologically exaggerated defence mecha-

nisms, which primarily manifest at the emotional, but also at the corresponding and

interconnected behavioural and cognitive level. Anxiety disorders differ to some extent in

their genetic underpinnings and environmental causation. All anxiety disorders have in

common, however,that they can be triggered by social experiences and are influenced by

different modalities of associative (social)learning. Unlearning the conditioned response

is sometimes hard to manage , such that preventive measures including prevention

of early traumatization and strengthening of resilience are crucial aspects of any

therapeutic effort.






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Schizophrenia evolutionary synthesis

Schizophrenia spectrum disorders comprise so many divergent findings at the clinical behavioural, neuroanatomical, physiological, and genetic level that a unifying theory covering all facets of these disorders cannot be expected.
One of the hallmarks of schizophrenia is, however, that patients have profound difficulties in social interaction, which often precede the manifestation of the first psychotic episode.
Children who as adults develop schizophrenia not only present with neurological
soft signs, but also with increased prevalence of socially abnormal behaviour including extreme shyness, withdrawal or aggression towards peers.
These behavioural abnormalities may be paralleled by children's difficulties in understanding other people's behaviour in terms of their mental states.

Ethological research into non-verbal behaviour of schizophrenic patients has revealed that they are reduced in their ability to promote Social interaction
even in one-to-one interview situations.

Schizophrenic patients with pronounced negative symptoms more often display behavioural patterns suggestive of avoidance or 'cutting-off' social contact altogether, whereas others, particularly those with paranoid ideation may be more likely to show subtle cues signalling threat such as 'staring'.
Interestingly,the non-verbal behaviour of patients with schizophrenia may sometimes appear indistinguishable from behavioural patterns found in depression, which in a general vein can be interpreted as correlates of submissive behaviour.
Whether or not children who later develop psychosis are more frequently insecurely
attached to caregivers is a matter of debate; as adults,the majority of  shizophrenia patients report early attachment bonds in a dismissive or unresolved style, which correspond to insecure-avoidant or disorganized attachment.
It is, however, conceivable, similar to the case of autism,that disruptive  neurodevelopment in the child exerts negative effects on early social interaction including the formation of an affectional bond between infant and primary caregiver.If such gene-environment correlations play a role early in childhood development of individuals who later become psychotic, additional aversive events to the point of physical or emotional abuse may be more likely to occur in problematic familial environments, and,in turn, may increase vulnerability for psychosis via chronic activation of the hormonal stress axis.
Evolutionary hypotheses regarding schizophrenia have revolved around the apparent paradox why such devastating disorders exist at all, despite the marked reproductive disadvantage of affected individuals by 30 to 70 percent particularly males.
Similar to other disorders, it has been proposed that a selective advantage of traits
may exist, of which only the extremes of variation are disadvantageous.
The number and diversity of evolutionary hypotheses of schizophrenia, however, are unparalleled in other major psychiatric disorders. They span as divergent aspects as advantages of schizotypal traits in relation to group selection, schizophrenia as a trade-off of human language acquisition or creativity,reduced risk of cancer in relatives of schizophrenic patients, schizophrenia as extreme negative variation of sexually selected traits, and effects of maternally imprinted genes.
Many of these explanatory approaches are implausible because they implicitly assume that schizophrenia is a homogenous 'disease entity', or that the risk for schizophrenia is conveyed by a single gene or several genetic polymorphisms with large effect size.
Neither assumption is currently supported by empirical evidence.
For example, schizophrenia is probably not the result of a single balanced polymorphism where the risk for schizophrenia (and reduced fecundity of affected individuals) is compensated by advantageous effects within the brain (e.g. benefit for the social group conveyed by schizotypal personality traits in relalives of affected individuals), or outside the brain (e.g.reduced cancer risk, greater resistance against infectious diseases or increased survival rates in relatives of schizophrenia patients).
However,there is some evidence for a recent positive selection in the human lineage at several loci including those coding for DISCI, dysbind in and neuregulin, of which the exact functional significance is as yet unknown.
An intensely discussed evolutionary hypothesis of schizophrenia has linked the disorder to a failure to establish functional dominance and language in one or the other hemisphere of the brain.
It has been proposed that cerebral dominance is under control of only a few regulatory genes, and that polymorphisms at one or several of these loci would not only reduce cerebral dominance but also convey a risk for schizophrenia.
In support of this hypothesis it has been found that children who later develop psychotic disorders are more often ambidextrous and have more language disorders and behavioural disturbances than children who as adults do not become psychotic.
Moreover, some studies have revealed a reduced cerebral asymmetry in schizophrenic adults compared with healthy subjects, and sex differences in normal asymmetry have been found disrupted in schizophrenia.
With regards to the representation of language,it is assumed that under normal conditions the organization of language is segregated such that the spatial or 'logical' component is represented in the non-dominant hemisphere and the temporal or 'phonetic' aspect in the dominant hemisphere, both of which normally interact via the corpus callosum.
Accordingly,'firstrank' symptoms in schizophrenia could reflect a disruption of the
normal transcallosal connection of the two hemispheres.Imprecise coordination of the logical and the phonetic aspect of language could produce symptoms such that an individual perceives his or her own thoughts as alien.
However,there is no unequivocal link of handedness and language, nor has cerebral dominance been successfully linked to oligogenetic effects. Furthermore,this hypothesis does not explain symptoms other than formal thought disorder or delusional beliefs.
In any event,the hypothesis points to the interesting observation that sexual selection could be involved in the pathogenesis of schizophrenia, since age at onset and symptom severity differs between the sexes.
Age at onset is usually earlier, and symptom severity is greater in men, and both features may be associated with the normally greater asymmetry between the cerebral hemispheres in men, which fails to be established in schizophrenia.
Several studies have shown that developmental instability is pronounced in patients
with schizophrenia. Normally, genes involved in neurodevelopment help to 'buffer'
against negative effects of multiple mutations, pathogens and toxins. Variation at these loci may lead to increased 'fluctuating asymmetry' (FA),that is, a near-normally distributed asymmetry of bilateral characters that are on average symmetrical in the population.
In schizophrenia, FA is greater in twin pairs concordant for schizophrenia than in
discordant pairs, which suggests that greater FA may indicate an imprecise expression of the developmental design due to genetically or environmentally caused developmental disruption.
This could explain,for example, why patients with schizophrenia have a greater number of minor physical abnormalities such as hypertelorism that could be indicative of an incomplete early cell migration.
Other characteristics putatively associated with a developmental instability in schizophrenia are greater homozygosity of blood alleles,lower premorbid intelligence,reduced cortical volume, and a relative instability of functional and anatomical lateralization of brain functions in schizophrenia.
FA is under partial control of sexual selection, as small FA is usually perceived more attractive than large FA.
It could therefore be that,in a very general vein,the broad spectrum of schizophrenia represents the unattractive extreme of variation of sexually selected traits including FA,language,intelligence, and social cognitive capacities that may be important for successful courtship behaviour.
In fact, many behavioural signs and symptoms and epidemiological findings seem to support this assumption,including the onset of the disorder at the point when mating and courtship behaviour normally peaks.

Competition for potential mates is pronounced for males compared with females, and the peak of mating effort is at a younger age for males, which could explain the earlier onset of schizophrenia and the more severe course and outcome in men.
By contrast,the need to attract suitable mates reaches a second peak in women near the end of their reproductive cycle, which may account for the higher prevalence of erotomanic delusions in women .
If the schizophrenia phenotype represents the low-fitness extreme of sexually selected traits,it is also plausible why patients with schizophrenia have lower than average reproduction rates.
In line with this hypothesis,it has recently been discovered that age at onset of schizophrenia varies with proximity to the equator:the closer people live,the earlier the onset.
One possibility for this finding could be that factors such as increased exposure to pathogens and higher levels of polygyny create a pressure towards mating at a younger age.
This, in turn, may lead to earlier expression of schizophrenic signs and symptoms produced by a stress-induced dopamine overshoot in the ventral striatum, where the need for intensified (premature) courtship behaviour serves as non-specific stressor.
Such a scenario may also explain why the search for replicable allelic variation involved in the pathogenesis of schizophrenia has been unsuccessful.
Since stabilizing selection tends to reduce deleterious mutations,it could be that an individual's higher than average number of fitness-reducing alleles leads to the expression of the schizophrenia phenotype, but that many of these alleles are evolutionarily transient.
However,the emergence of new fitness-decreasing mutations may contribute to an
equilibrium through which the average prevalence of schizophrenia in a population is maintained.
Taken together,the polygenetic inheritance of schizophrenia and the heterogeneity of the disorder can be understood as the negative side of sexually selected fitness-enhancing additive genetic variance.
Consistent with,though not identical to the hypothesis of schizophrenia as the
maladaptive extreme variation of sexually selected traits, some physical and behavioural characteristics indicate that genomic imprinting may play a role in the expression of schizophrenia-associated features. Generally speaking, several characteristics seem to support the assumption that maternal imprinting leads to a pattern of general undergrowth and 'Femaleness' of the brain in schizophrenia.
This could include reduction of grey matter,reduced lateralization, and overactive mechanisms involved in social cognition--- the opposite of what is found in autism.
These general evolutionary hypotheses of schizophrenia are,in part,flawed by the fact that they hardly cover all clinical aspects of schizophrenia. Thus, in addition to these broad approaches to understand the heterogeneous nature of the schizophrenia spectrum phenotype,it is useful to analyse individual symptoms based on evolutionary theory. Of note,it is explicitly assumed that signs and symptoms are pathological exaggerations of variation of adaptive mechanisms that arise from a disturbed interplay between one or more levels of the triune brain .
The distinct deficit in social competence in schizophrenia, which often precedes the
manifestation of the first psychotic episode,is paralleled by deficits in social cognition.
This deficit is perhaps triggered by a dopaminergic overstimulation of mesolimbic circuits, which one-sidedly influences the emotional positive symptoms of schizophrenia,for example, tend to be hypervigilant , in particular regarding
gaze monitoring of others, and to interpret social cues as threat.
They may also over-attribute mental states of others, often in a way that they falsely infer malicious intents of others, clinically expressed as persecutory delusion or delusion of reference.
Excessive mental state attribution may also contribute to some aspects of formal thought disorder.
For example, a patient who incorrectly assumes that his or her interlocutor shares his or her knowledge--- perhaps due to the patient's fragile ego-boundaries associated with thought transference--- may present with loose associations or derailment. Moreover,the tendency in some patients to form too many hypotheses about the mental states of others, while at the same time being unable to choose among these hypotheses the most plausible one, may lead to secondary negative symptoms, perhaps as self-protection from over-stimulation and arousal.
Consistent with this assumption, patients with schizophrenia fail to correctly attribute mental states 'on the spot' despite their tendency to over-infer mental states.
Over the course of the illness, negative symptoms often increase (whereas positive symptoms are still present, but less emotionally valent), accompanied by a decreased potential of the prefrontal cortex to be activated by dopamine.
Thus,in chronic schizophrenia, patients evaluate social situations less, and have even more difficulties in inferring mental states of self and others.It is at present unclear whether this 'mentalizing' deficit in schizophrenia is as selective as it seems to be in autism.
There is at least convincing evidence that patients with schizophrenia also have difficulties in integrating contextual and autobiographical information when judging mental states on the basis of observed behaviour.
Another frequent clinical finding in schizophrenia is the striking lack of awareness of
illness and insight.It would seem that impaired insight is related to patients' difficulties to reflect upon their own states of mind.
Patients also frequently experience so-called passivity symptoms,for example,that a patient's own action is perceived as being influenced by an external agent.
Thus,it is conceivable that disturbances in the neural network underlying the representation of self and others may be central to many 'core' symptoms associated with schizophrenia.
The neural basis for the ability of mental state attribution or 'mentalizing' and self-
representation is now well known It comprises several interconnected regions of the frontal,temporal, and parietal lobes, among which adaptations, perhaps unique to primates, such as the mirror neuron system, play a crucial role in simulating actions and behavioural dispositions of significant others.
In addition,it has been speculated that the paracingulate sulcus, which separates the anterior cingulate cortex (ACC) from the medial wall of the prefrontal cortex and is inconsistently present in humans, represents an evolutionary novelty involved in social cognitive processes. Furthermore,the infraparietal lobule, which consists of the angular gyrus and the supramarginal gyrus, is probably involved in self-other distinction and representation of the self as acting agent.
Similar to prefrontal cortical midline structures,the infraparietal lobule myelinates late during ontogeny and is only rudimentary in great apes, suggesting that selection has operated on these particular brain areas involved in self-reflexivity and mental state attribution.
These brain regions have been found to be functionally and/or structurally damaged in patients with schizophrenia.
Apart from formal thought disorder, many aspects pertaining to the content of delusional beliefs appear to be tightly linked to scenarios that were selectively important in the human evolutionary past.
This does certainly not preclude influences on delusion formation from an individual's personal background, but the uniformity of delusional content across cultures suggests that universal patterns relating to survival and reproduction are mirrored in delusions.
For example,the content of persecutory delusions differs between men and women
regarding the number and sex of persecutors, as well as regarding the degree of familiarity with the perceived persecutor.
Whereas men usually feel more often threatened by groups of strange males, women more often feel persecuted by individuals from their personal environment. Both deluded men and women primarily report fears of being physically injured or assaulted. The rationale for these sex differences in persecutory delusional content could be that the main source of ancestral threats for men in the environment
of evolutionary adaptedness (EEA) were indeed strange males from other
tribes; by contrast, women, under ancestral conditions,formed the core of the kin-based highly cooperative social group, such that expulsion from the community was a real threat for women living in the EEA.
This assumption is further supported by data from chimpanzees, our closest living relatives,in which territorial competition and warfare between troops of rivalling males has been reported to be high, perhaps similar to what happened in ancestral human conditions. Moreover, until quite recently, similar scenarios were described in extant hunter-gatherer or horticultural societies, where a substantial number of men (up to 25 per cent) and women (up to 13 per cent) died premature violent deaths.

Similarly, delusions relating to mating effort and reproduction differ markedly
between men and women, and again,these patterns are highly uniform across cultures.
Since parental investment differs between men and women with women investing more than men in potential offspring,the former were selected to be choosier in terms of mate choice.In other words, women are, on average, more likely to seek socially high-ranking men as potential partners who are willing to invest in offspring.
In contrast,in established pair-bonds, paternity is less certain than maternity
such that strategies to ensure sexual fidelity were more strongly selected in males. These divergent selection pressures for males and females are strikingly mirrored in erotomania, the delusional conviction of being loved by another person, and delusional jealousy.
Erotomania is much more common in women, who usually choose socially high-standing men (politicians, physicians, actors, sportsmen, etc.) as 'love objects'.
Women with erotomania often try to 'convince' their love objects of their own mate value and tend to harass them. This form of following is, however, different from what is found in stalking behaviour. Stalkers are much more often men who pursue their victims sometimes using violent means.
Erotomania is uncommon among stalkers, however, jealousy (both delusional
and non-delusional)is frequently involved in stalking.
There is probably some
phenomenological overlap between stalking behaviour and delusional jealousy.
Delusional jealousy is much more frequently observed in men compared with women.
It can be seen as the counterpart to erotomania, aimed at partner retention and securing sexual fidelity.

Finally, many signs and symptoms commonly subsumed under the term catatonia can be interpreted as  contextually abnormal and exaggerated  fear response,fight-flight ambivalence, or behavioural patterns relating to submission or assertive behaviour.
Catatonic stupor,for example, strongly resembles a primitive fear reaction,
which markedly resembles tonic immobility seen in many animal species.In tonic
immobility, which is most likely elicited by impeding predatory threat where flight is
impossible,the animal stops moving to avoid detection. At the same time,it shows
heightened alertness,reduced vocalization, unfocused gaze, analgesia, and abrupt onset and offset of the behaviour,followed by a ferocious struggle to escape. Further similarities are found regarding autonomic instability.
In tonic immobility, heartrate initially rises and then drops below baseline, which can also be observed in catatonic stupor.
The parallels between catatonic stupor and tonic immobility as (primitive) fear responses---represented in the most ancient parts of the triune brain--- are also supported by the fact that catatonia responds well to anxiolytic treatment with benzodiazepines and can be worsened by dopamine depleting drugs.
In addition, patients with catatonic stupor often report in retrospect extreme feelings of overwhelming anxiety during the catatonic state.
Catatonic stupor may be preceded or followed by states of extreme hyperactivity or
excitement, sometimes associated with assaultive behaviour. However, catatonic excitement is usually poorly coordinated, which may reflect a primitive behavioural escape response in situations in which the source of the perceived danger is hard to recognize.
Other behavioural symptoms labelled catatonic, such as waxy flexibility, abnormal
imitation and echoing movements including automatic obedience, can be interpreted as contextually abnormal submissive behaviours,the counterpart of which are represented by behaviours suggestive of exaggerated resistance to requests such as negativism.
The pathophysiological underpinnings of these inappropriate expressions of fear,
fight-flight ambivalence, and communicative behaviours are incompletely understood.
Dysfunction of the prefrontal cortex is probably involved, as bilateral lesions to the ACC produce akinetic mutism. Inhibition of imitative behaviour also implicates the distinction from self and other, such that it is conceivable that dysfunction of the infraparietal lobule contributes to catatonic behaviours. Moreover,there is possibly a lack of inhibitory control of the amygdala via the orbitofrontal cortex, which is reciprocally connected with the limbic system.
Little is currently known about the role of the amygdala in catatonia, but given its impact on fear and aggression related behaviour, and the response of catatonic symptoms to anxiolytic treatment,it can be presumed that this structure is central to the aetiology of catatonia.
In addition to the assumption of an inhibitory deficit it could also be that catatonic behaviours can be elicited in individuals Who are vulnerable to overstimulation of these brain areas.
In this context , it is important to note that many catatonic symptoms are indistinguishable from catatonic symptoms are phenomenologically dissociative symptoms, and that a terminological indistinguishable from dissociative symptoms, and that a terminological distinction is more due to convention rather than neurophysiological differences.
This notion is essential, because it throws light on the possibility that patients with early traumatization are perhaps more susceptible to develop dissociative/catatonic states  if experiencing retial, because it throws light on the possibility that traumatization or other situations associated patients with early traumatization are perhaps more susceptible to develop dissociative/catatonic states if experiencing re-traumatization or other situations associated with unbearably intense fear.
Finally, catatonic behaviours (like all symptoms found in schizophrenia) can frequently be observed in other psychiatric disorders,foremost depression and bipolar affective disorder, which is,from an evolutionary point of view not surprising, given the importance of these behaviours for submission and appeasement strategies.


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neurotransmitter: glutamate receptors:schizophrenia

It is believed that neuregulin and dysbindin influence the
expression of glutamate receptors. Substances with antagonistic effects at the glutamatergic
NMDA receptor such as ketamine and memantine are known to produce psychotic symptoms
in healthy subjects. Glutamate is the most widespread excitatory transmitter in the
mammalian brain.In the human cortex it is released from cortical pyramidal cells and
hippocampal neurons with extensive projections to the limbic system and basal ganglia.In physiological concentrations, glutamate facilitates cognition and memory formation; nonphysiologically
high concentrations, of glutamate are, however, neurotoxic.

It is likely that many other neurotransmitter substances are in one or the other way
involved in the pathophysiology of schizophrenia and related disorders. Current research
focuses on neurotrophins and their regulatory power of repair mechanisms and apoptosis
via expression of glutamate receptors, which may also open new therapeutic avenues in
the future.


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Aを理解していなかったことを理解した

見込み唯物論いうものがあって、
今現在で全てを唯物論で説明することはできないけれども、
将来きっと出来るだろう、
という考え方であり、
自意識の発生を唯物論的に説明できるか、という問題の時に
紹介されることがある
(しかし、全く説得力がない)

原子力発電所の問題についても
見込み技術発展論だろう
六ケ所村の核廃棄物最終処理場なども
新技術はこれから開発されるだろうと
考えるしかなかったのだと思う

ーーーーー
たとえば
原子力発電所は安全だと理解していたことを理解した。
原子力発電所は安全だと理解していなかったことを理解した。
原子力発電所は安全だと理解していたことを理解しない。
原子力発電所は安全だと理解していなかったことを理解しない。
と並べてみて
論理を考えてみるとどうだろう。

分かっていることが分かった
分かっていないことが分かった
分かっていないことがわからない



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精神療法

心理社会的ストレスがあるから抗うつ薬よりも精神療法がよいということではなく、神経症性うつ病の状況で心理社会的ストレスがあるなら精神療法がよいし、再発性単極性うつ病の状況で心理社会的ストレスがあるなら第一には抗うつ薬が必要である。

共通テーマ:日記・雑感

うつ病患者の2週間以内の改善とその後の治療アウトカム:CRESCEND study

うつ病患者の2週間以内の改善とその後の治療アウトカム:CRESCEND study
Improvement within 2 weeks and later treatment outcomes in patients with 
depressive disorders: the CRESCEND study.
J Affect Disord 2011; 129: 183-190
Kim JM,  Kim SY,  Stewar t  R,  Yoo JA,  Bae KY,  Jung SW,  Lee MS,  Yim HW,  Jun TY
背景 : 抗うつ薬の反応性を判定するために、通常、4 ~ 6 週間の投与が行われる。しかし、いくつかの報告では初期の改善度によりその後の治
療アウトカムが予測可能であることが示唆されている。自然観察的な国民コホート研究により、初期のハミルトンうつ評価尺度(HAM-D)スコアに
おける改善が、その後のアウトカム(うつ病(HAM-D)、不安(HAM-A)、全体的な重症度(CGI-s)、社会職業的機能(SOFAS))を予測できるか
否かを検討し、さらに初期の改善と関連する社会人口学的 ・ 臨床的因子について検討した。
方法 : 韓国全土の 18 の病院から参加者を募集した。全例がうつ病性障害の DSM-IV 診断基準を満たしており、HAM-D スコアが 14 点以上で
12 週間以内の抗うつ薬治療を受けていた。治療は自然観察的であり、各臨床医が自由に抗うつ薬および併用薬の種類、用量、投与計画を決
定した。治療開始 2 週間以内に HAM-D スコアがベースラインと比較して 20% 以上低下した場合を初期の改善と定義した。その後の治療アウト
カムは 4 週、8 週、12 週の時点で評価された。
結果 : 研究に参加した患者 568 例において、初期の改善は 12 週後の治療アウトカムを高い感度および高い陰性適中率をもって予測した。
HAM-D および HAM-A を指標にした 12 週後の反応に対する予測値(ROC 曲線下面積)は、CGI-s および SOFAS を指標にした反応に対する
予測値よりも高かった。初期の改善と関連がみられた因子は、高月収、ベースライン時の不安症状が低いこと、社会職業的機能レベルが高いこ
とであった。初期に改善が認められた患者は、抗うつ薬の単剤療法を受けていることが多かった。
限界 : 本研究は観察研究であり、かつ治療法が自然主義的であった。
結論 : 抗うつ薬による初期の改善はその後のアウトカムを強力に予測し、高収入、不安の程度が低いこと、社会職業的機能レベルが高いことと
関連した。


共通テーマ:日記・雑感

最初の抗うつ薬治療に失敗した後のうつ病治療:STAR*D研究における抗うつ薬の切り替えと 強化療法の直接比較

最初の抗うつ薬治療に失敗した後のうつ病治療:STAR*D研究における抗うつ薬の切り替えと
強化療法の直接比較
Treating depression after initial treatment failure:Directly comparing switch and 
augmenting strategies in STAR*D
J Clin Psychopharmacol 2012;32:114-119
Gaynes BN,  Dusetzina SB,  El l is AR,  Hansen RA,  Far ley JF,  Mi l ler  WC,  Sturmer  T.
目的:抗うつ薬の強化療法および切り替えは、最初の薬物治療に失敗したうつ病患者に対して次に行われる最も一般的な2つの治療戦略である
が、これらのアプローチの直接比較は行われていない。そこで、大うつ病性障害患者を対象としたSequenced Treatment Alternatives to 
Relieve Depression (STAR*D)試験において、抗うつ薬の強化療法による治療アウトカムと抗うつ薬切り替えによる治療アウトカムを比較するこ
とを目的とした。
方法: STAR*D研究において最初の治療で寛解に至らなかった18~75歳の非精神病性うつ病(DSM-IV)患者(n=1,292)に対する後ろ向き解
析を行った。選択バイアスを最小限にするために傾向スコアマッチングを行い、各試験アームにおける試験参加者のうつ症状の寛解、反応、
QOLを比較した。
結果:傾向スコアでマッチさせた強化療法群(n=269)と切り替え群(n=269)は、患者背景の諸項目に関して十分な均衡が確保された。寛解(リ
スク比1.14、95% CI 0.82‐1.58)あるいは反応の確率(リスク比1.14、95% CI 0.82‐1.58)のみならず寛解(log-rank検定、p=0.946)あるいは反応ま
での期間(log-rank検定、p=0.243)も、治療戦略により差はみられなかった。同様に、QOLに関しても差はみられなかった。Post hoc解析によ
り、強化療法は、12週間以上の最初の抗うつ薬治療に対して忍容性のあった患者および部分反応がみられた患者においてアウトカムを改善す
ることが示唆された。
結論:積極的な最初の抗うつ薬治療を受け、それに対して忍容性のある患者においては、次の段階の治療としての抗うつ薬の強化療法と切り替
えとの間に明確な優劣はなかった。本知見は暫定的ではあるものの、12週間以上の最初の抗うつ薬治療を完了した患者や、軽症のうつ症状が
残存する部分反応がみられた患者では、切り替えよりも強化療法のほうが相対的に有用であることを示唆している。


共通テーマ:日記・雑感

単極性うつ病における抗うつ薬治療抵抗性と双極性障害との関連:コホート研究

単極性うつ病における抗うつ薬治療抵抗性と双極性障害との関連:コホート研究
Association between antidepressant resistance in unipolar depression and 
subsequent bipolar disorder: cohort study
Br J Psychiatry 2012;200:45-51
Li  CT,  Bai  YM,  Huang YL,  Chen YS,  Chen TJ,  Cheng JY,  Su TP
背景:十分な抗うつ薬治療によっても反応がみられない大うつ病性障害患者では、背後に双極性障害が隠れている可能性がある。
目的 :本研究の目的は、8年間のフォローアップ期間中に、大うつ病性障害患者に対する診断が双極性障害に変更される割合について抗うつ
薬への反応性で階層化して比較することであった。
方法 :台湾の医療保健の利用者1,000,000例からなる全国規模の代表的なコホートから、2000年(コホート2000、n=1,485)、2003年(コホート
2003、n=2,459)に同定された大うつ病性障害患者に関する情報を収集した。抗うつ薬治療に対して良好に反応した患者を、十分な抗うつ薬治
療にも関わらず反応が悪かった患者と比較した。
結果:単極性大うつ病性障害と診断された患者の7.6~12.1%では、平均1.89~2.98年後に診断が双極性障害へ変更された。治療抵抗性の患
者は、治療反応性の良好な患者に比べ、診断が双極性障害へ変更される割合が高かった(治療抵抗性の患者ではコホート2000で25.6%、コホ
ート2003で26.6%、治療反応性の良好な患者ではコホート2000で8.8~8.9%、コホート2003で 6.8~8.6%、p< 0.0001(chi-squared tests))。回帰
分析により、診断の変更と最も強く関連した因子は、抗うつ薬の服用歴であることが示された。治療抵抗性の患者は診断の変更と最も強く関連
した〔コホート2000でオッズ比(OR)=1.88 (95% CI 1.12‐3.16)、コホート2003でOR= 4.94 (95% CI 2.81‐8.68 )〕。
結論: 本研究は、抗うつ薬治療に対する反応性の履歴と大うつ病性障害から双極性障害への診断変更との関連性を報告する最初の大規模試
験である。以上の知見は、単極性うつ病において抗うつ薬への反応性が悪かったという治療歴は、双極性障害の素因を見出すための有益な予
測因子となり得るという見方を支持している。


共通テーマ:日記・雑感

東電株価10年経過

9501.gif

共通テーマ:日記・雑感

出生率

歴史上、戦争とか疫病とか飢饉で滅亡した民族はいたかもしれないが
出生率が低下して高齢者ばかりになり滅亡しましたという例は
あるものだろうか

共通テーマ:日記・雑感

瀬戸際外交

ミサイル打ち上げの話で
瀬戸際外交という言葉がニュースで用いられている

瀬戸際外交をしているパーソナリティ障害の人がいる

共通テーマ:日記・雑感

青年期の性行動

青年期における性行動を考えてみると
全般的な対人関係に困難がある場合
性的行動により自己効力感を補完している場合があると観察される

そのことでもまた
妊娠と出産はできるので
遺伝子は保存されることになるだろう

共通テーマ:日記・雑感

蘭が4、5、8

IMG_0066-2.jpg

 4つ

IMG_0068-2.jpg

 5つ

IMG_0072-2.jpg

 うっかりしていたら8つ

 



共通テーマ:日記・雑感

日銀印刷物

日銀印刷物
ただの印刷物なんだから
いくらでも刷ればいいだろう
という意見

そうかも知れんなあ

共通テーマ:日記・雑感

日内変動

本を読んでいたら
定型うつ病では日内変動のパターンは
朝が一番気持ちが良くて、夕方になるに連れて次第に気分が悪くなるという

一方、メランコリータイプうつ病の場合には
朝に一晩気分が悪くて、夕方になるに連れて次第に気分が改善していくという

日本の多くの教科書には
うつ病の特徴として朝に一晩気分が悪くて、夕方から夜にかけて楽になるパターンの
日内変動を内因性うつ病の特徴としてあげていたものが多いと思う

ーーーーー
気分の日内変動が目印になるというのは
普通の気分変動は朝に清々しく夜に疲れるのとは逆に
朝に一番悪くて夜に楽になるという点が不思議だから 
診断の目安になるということだ

エネルギーの原則から言えば
サラリーマンでも子供でも高齢者でも
朝のラジオ体操の時間には元気いっぱいで
昼に動いて疲れて夜には眠くなるわけだ

どういうわけか時間が経つにつれて段々楽になるというので
不思議、そこに診断価値がある

ーーーーー
我々が今まで診察してきた日内変動はメランコリータイプというような
比較的重症型のものだったのだろうか

あるいは都会型生活パターンなどが関係しているのだろうか

DSMのような世界基準を作るという場合には
人々の生活は実に様々であることも考慮しないといけない

電気がなければ実質、夜になったら寝るしかないだろう




共通テーマ:日記・雑感

診断階層表

DSM-IVでは、統合失調症の診断の時に大うつ病、躁病、混合性エピソード、統
合失調感情障害は除外することとなっていて、
診断階層としては、これら感情障害が優先、そのあとで統合失調症というシス
テムになっている。

気分障害の項目では精神病性うつなどが『特定せよ』に分類されている。
また気分障害の中に緊張病が組み入れられていて、それも『特定せよ』に分類
されている。
カタトニーは昔はシゾフレニーの一つのタイプだったんですけどね。

ーーー
そんなわけで
統合失調症かなと思って実は大うつ病がありましたという場合は
DSMマニュアルに従って
気分障害に飛ぶ

気分障害かなと思ったけれども
身体病があったというときにも
続発性で処理

パーソナリティ障害の時はⅡ軸として立てている

ーーー
という具合で、
診断階層表としては
まさに
気分障害が一番上という構造でよいらしい


共通テーマ:日記・雑感

高2の2割「抑うつ傾向」…北海道教委調査

北海道教委は22日、道内の高校2年生の約2割が抑うつ傾向にあるとする北海道学校保健審議会(会長=長瀬清・道医師会長)の「児童生徒の心の健康に関する調査報告書」を公表した。
調査は2011年7~8月、札幌市を除く道内の公立学校から80校を無作為に抽出、小学3、5年生、中学2年生、高校2年生の児童・生徒計3735人を対象に実施した。「抑うつ傾向にある」と判定された割合は全体で12・4%で、小学生の2学年は約4%だったが、中学生では13・3%、高校2年生では19・4%に上り、年齢とともに高くなる傾向があった。高校2年生で「抑うつ傾向」と判定されたうち、4・2%が「重度うつ」とされた。

調査は簡易判定であり、医師の診断による「うつ病」とは異なるが、北海道大の伝田健三教授(児童精神医学)は「うつ病の予備軍であることは事実であり、学校現場での対策を考えていく必要がある」と指摘している。

(記事提供:読売新聞)
ーーーーー
おやおや


共通テーマ:日記・雑感

統合失調症への集団アートセラピー

統合失調症の症状は薬物療法によって軽減されるが、多くの患者はメンタル面の回復や社会復帰を果たせずにいる。そうした統合失調症患者への補助療法として行われている集団アートセラピーの臨床的な効果について、英国・インペリアル・カレッジ・ロンドンのMike J Crawford氏らによる多施設での介入無作為化試験による検証が行われた。これまで、同療法のベネフィットについての検討はほとんど行われていなかった。BMJ誌2012年3月10日号(オンライン版2012年2月28日号)掲載報告より。
集団アート療法、活動療法、標準治療の3群で比較

研究グループは、統合失調症患者への集団アートセラピーの臨床的効果を評価し、そのベネフィットについて検証するため、3アーム評価者盲検介入無作為化比較試験を行った。被験者は、英国の二次的ケアサービスを提供する15病院で募集された、統合失調症の診断を受け、研究への参加について文書で説明了解を得た18歳以上の417例だった。

参加者は病院ごとに分けられ、12ヵ月間にわたって、週1回集団アートセラピー+標準治療を受ける群(140例)、週1回集団活動療法+標準治療を受ける群(140例)、標準治療のみ群(137例)の3群に無作為化された。アートセラピー群と活動療法群のグループ構成は最大8人とし、1セッションは90分間。アートセラピー群のメンバーには、芸術材料は限定されず、自由に自己表現するよう促された。活動療法群のメンバーには、芸術と工芸関係を除くさまざまな活動が提示され、続けたいと思う活動を共同で選択して行うよう勧められた。

主要評価項目は、無作為化24ヵ月後の、総合機能スケールを使って計測した全般的な機能状態と、陽性・陰性症状評価スケールで測定したメンタル症状とした。副次評価項目は、12ヵ月時点と24ヵ月時点の出席状況、社会参加、治療に対する満足度とした。

3群間でアウトカムに差はみられず

結果、3群間で主要評価項目に格差は認められなかった。

24ヵ月後の総合機能スケール評価は、アートセラピー群と標準治療群との補正平均差は-0.9(95%信頼区間:-3.8~2.1)で、陽性・陰性症状評価スケールは0.7(同:-3.1~4.6)だった。

12ヵ月時点と24ヵ月時点の副次評価項目については、アートセラピー群と標準治療群との間で格差は認められなかった。アートセラピーと活動療法への出席レベルは低調だった。

研究グループは、「統合失調症と診断された患者に集団アートセラピーを受けさせても、全体的な機能状態、メンタル面ほか健康関連アウトカムは改善しなかった」と結論づけている。

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何をどう評価したか


共通テーマ:日記・雑感

signs and symptoms

自他覚症状= signs and symptoms

ステッドマン医学辞典(メジカルビュー社)には、signとは「医師が患者を診察して見出しうるもの、疾病の主観的徴候である"症状symptom"に対し、疾病の客観的症状を言う」とある。

つまりsignは他覚症状であり、symptomは自覚症状を主に指すことばである。

しかし、しばしばそのような区別なしに用いられているケースもあるように思われる。Merriam-Webster Online Dictionary  でsymptomを調べてみると、"subjective evidence of disease or physical disturbance; broadly : something that indicates the presence of bodily disorder."とあり、広い意味ではsignと同義的にも使われているようである。


共通テーマ:日記・雑感

認知症の対応例

採録

ーーーーー
あるグループホームに入所していた認知症のおじいさんが
自殺をほのめかす言葉を残して、外出しました。

後を追った介護士。
引き留めても感情が高ぶるだけなので、雑談をしながら一緒に歩きました。

歩道橋の上で「ここがいいか」というおじいさんに
「いや、もっと他の場所がいいですよ」。

ビルの屋上に来ると「もっといい場所を探しましょうよ」。
そのうちに、おじいさんは当初の目的を忘れ、介護士と散歩している気分になっていきました。

夕暮れ近く、
おなかがすいたおじいさんは、
目に付いたハンバーガーショップに入りました。

注文をして、
レジの女性に「いくらだ」とポケットから取り出したのは、
くしゃくしゃのティッシュペーパー。

介護士は一瞬、青ざめました。
他人から間違いを指摘されると、
認知症の人は逆上して不安定になることがよくあるからです。

でも、レジの若い女性は落ち着いて、
笑顔でこう答えました。

「申し訳ありません。当店においては現在、
 こちらのお札はご利用できなくなっております」

おじいさんは
「そうか、ここでは、この金は使えんのか」と、
あらためてポケットの小銭を取り出しました。




共通テーマ:日記・雑感

IPT

IPTは、うつ病に対して、認知行動療法と同等以上に有効であることが証明されている精神療法で、最近は月1回の治療で寛解維持にも有効と報告されている。
IPTは、よく効くと言われていた常識的な治療をまとめたものと言うことができ、どういう人がどういう時にうつになるかというエビデンスのみに基づいていて、原因の仮説はたてない。
以下に、IPTの特徴ややり方を、断片的に記す。
 
期間限定(依存、退行を防ぐ)
焦点化(4つの問題領域の1つに絞る)
現在の対人関係に絞る
精神内界、認知、パーソナリティーなどは取り扱わず、対人関係のみに焦点を当てる
防衛規制の解釈もしない
目標は認知を変えることでなく、対人関係のパターンを変えること
(否定的認知などはうつ病の症状として理解する)
知的な議論でなく、感情に根ざしていないといけない。そのために具体的なエピソードをなるべく引き出す。
IPTは技法ではなく戦略
医学モデルを使う
治療関係(転移)を扱うのは、治療の妨げになるときだけ
 
具体的な方法としては、
 
まず、対人関係の4つの領域のうち一つに焦点を当てることを患者との話し合いの上で決める。
悲哀(重要な人の死に限る)
対人関係上の役割を巡る不和(不一致)
役割の変化
対人関係の欠如(これはなるべく選ばないようにする)
 
*       例えば、なかなか妊娠できない、というような内容は「役割の変化」と捉える。身体疾患もしかり。
治療者は患者の代弁者となる。提案はするが指示はしない。指示するかわりに質問をすることで本人の力を引き出す。共感的に接し、評価を下さない。楽観的、希望的に接し、患者との共同作業を進める。
 このように、ロジャース的な部分が強いが、唯一積極的に関わるのは、焦点がそれたら必ず対人関係に焦点を当てるように工夫するということ。また、昔の話にこだわり出したら、昔の体験を思い出したきっかけは…という風に、今の問題に戻す。
 
初期: 
病者の役割(病人という社会的役割)を与える。義務や責任が免除される代わりに、改善を助けてくれる人には協力する、など。
対人関係についての質問。全ての重要な他者(亡くなった人を含む)との関係を具体的に。頻度、共にする活動など。関係における期待の程度。満足できる、できない。どう変えたいのか。納得できるまで聞く。
両者の合意によって重要な領域を決定。
 
中期:
前回お会いしてから如何ですか、と前回の面接以後今回までの内容に絞ることを伝える。
気分を話すようならそれを出来事のレベルとして具体的に語ってもらい、出来事を語るようならそれを気分と結びつけていく。そして問題領域と関連づけていく。ロールプレイなどを行う。
悲哀、を領域に選定した場合、死者に対する怒り、裏切られた感じなどは、こちらからさりげなく取り上げた方が良い。
不和を領域に選定した場合、治療が途中で行き詰まった場合、交渉を再開させるために、あえて不調和を起こさせることもありうる。その場合は事前にそうなることを予言しておかないと、ドロップしてしまう。不和は期待の違いとして理解される。現状を把握し、選択肢を検討した上、ロールプレイなどを行う。(具体例が提示された)
ワークショップは、時間の関係で終結まで行き着かなかった。
 
全体に、いつもの臨床でやっているような内容に近く、納得しやすいものであった。治療上、ちょっと迷った時などに思い出せば、指針になる部分がたくさんあると感じた。
現在の精神医学では、心理との分業の推進ということもあり、力動的精神療法をそれほど熱心に教育しているとはいえないだろう。IPTは、ヒア&ナウしか取り上げないことや、精神内界よりも行動の変容を目指す点など、現代的な精神療法特有の特徴を持ち、保険診療の中でも何とか行える現代的な力動的精神療法のエッセンスとして有用だと感じた。ただ、精神分析やロジャースの来談者中心療法を取り込んではいるものの、認知行動療法とは一線を画している。将来的には、認知行動療法の良い点も取り入れた、より総合的な精神療法へと進化していくことに期待したいと思った。IPTは技法ではなく戦略である、ということなので、カウンセリングの技法や、最小限の精神分析の知識などと合わせて学ぶ必要はあるだろうが、精神医学研修で取り上げる精神療法としては、最も適しているのではないだろうか?


共通テーマ:日記・雑感

美女と躁病

美女がいるとして美女がどんな男性を選ぶのかは問題だけれど
男性の側の判断として
自分が美女にふさわしい人間であるかどうかを判断する場面があるだろう

するとうつ病系の人はすぐに諦めると思う
躁病系の人は自分は美女にふさわしいと思うのかもしれない

美女にラブレターを出したりメールを頻繁に送って誘ったりするのは
躁病だからできることなんだろうと思う

自分の魅力を客観的に判断するとすれば
自分の欠点を自分はよく知っているのだから
自分が美女にふさわしいなどとは思わないはずだろう

躁病だから当然のように自分が美女にふさわしいと思えるし
行動もできるということになる

そうすると美女の周りに集まるのは躁病傾向の人が多いだろうということになる

そのような環境に生きていれば
美女は人間はたいてい躁病的だと思うようになるはずだろう

そもそも美女って何と言われそうだが
躁病に常時囲まれて生きている人が美女だと逆に定義できるだろう

共通テーマ:日記・雑感

2012031426.PNG

共通テーマ:日記・雑感

適応

この社会に適応することが「必要」と
どうして考えるんだろう

合わない人もいるに決まっているんだし

それが遺伝子のバリエーションというもので
いろいろなものがあるから
変化に対応できるはず

そのなかで
現在の環境に適合しないものがあるのは
当たり前なのに

困ったものだ

共通テーマ:日記・雑感

春の夜をあと何度経験できるのだろう

春の夜をあと何度経験できるのだろう
私の寿命が先か
大地震が先か
と思う

老人になると偏見も強くなるが
余計な欲がなくなる部分もあって
正直になったりもする

共通テーマ:日記・雑感

国内総生産(GDP)

国内総生産(GDP)で高校生の時に習ったことを思い出す

統計数字というものはどんどん膨らむことがある
たとえば
自給自足で畑を作ったりしている場合と
食料をスーパーで全部買う場合とで随分違う

お隣におすそ分けするか
販売するかで違う
物々交換すると表面的には貧しい
自分で作ったキャベツを近所におすそ分けして
お返しに魚をもらったりすると
それは経済活動ではないが
案外豊かだろう

役所がゼネコンに3億円発注
下請けに2億円
孫受けに1億円
以下延々と続ければどうなるんだろう

食事は外食、掃除も洗濯も外注、お金で解決という社会は
国内総生産は大きくなるが
家族とか地域で助けあうと数字には現れない

たぶん今はもっと進歩していて
そのあたりは補正されているのだろうけれども
経済活動というものの性質を考える

またたとえば
貿易障壁を大きくして
物価を高く維持して給料も高く維持すれば
数字としての見かけの豊かさは作ることができそうだ

日本のように税収の倍の予算を組んで使ったりすれば
経済規模は拡大できるけれど
どういうものだろう

共通テーマ:日記・雑感

NHK9時のニュースで 体言止めを多用し こわもての女性の声

NHK9時のニュースで
体言止めを多用し
こわもての女性の声で
なんだか雰囲気が硬い

共通テーマ:日記・雑感

千年に一回の地震

千年に一回の地震として
まあ、次は西暦3000年くらいなのだろうが
その時に備えて
膨大な設備をする?

2012年3月14日水曜日午後9時すぎ千葉県東方沖M6.1、最大震度5+
午後6時すぎ三陸沖M6.8、最大震度4

気持ちが落ち込む
地震情報を見てみると
小さな地震はもっとたくさん起こっている 

3月12日熊本県でM3.9、震度3.9とか



共通テーマ:日記・雑感