PTSD: Agony and Ecstasy

In November of 2016, the US Food and Drug Administration (FDA) gave permission for the commencement of large-scale Phase 3 clinical trials into the use of MDMA (Ecstasy) in the treatment of PTSD. If successful, the trials could see an illicit street substance become a potent treatment for PTSD by 2021.

Post-Traumatic Stress Disorder (PTSD) is a mental disorder that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare, traffic collisions, or other threats on a person’s life.

In the typical case, the individual with PTSD persistently avoids trauma-related thoughts and emotions, and discussion of the traumatic event, and may even have amnesia of the event. However, the event is commonly re-lived by the individual through intrusive, recurrent recollections, flashbacks, and nightmares.

Drug abuse and alcohol abuse commonly co-occur with PTSD. Recovery from posttraumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, by medication or substance use. There is also a high risk of suicide associated with the condition.

Existing pharmacological and psychotherapeutic treatments for PTSD are effective for many, but prove ineffective for 30-40 percent of sufferers. Due to the rate of treatment resistance, research into more effective treatment is necessary.

The Multidisciplinary Association for Psychedelic Studies (MAPS) funded 6 Phase 2 studies treating a total of 130 patients diagnosed with PTSD with the stimulant commonly known as Ecstasy, 3,4-Methylenedioxymethamphetamine (MDMA). It will also fund the Phase 3 research, which will include at least 230 patients.

The first major study was conducted on 20 adult patients who met DSM-IV criteria for crime or war-related PTSD and who had exhibited treatment-resistant symptoms with a minimum score of 50 on the Clinician Administered PTSD Scale (CAPS). Patients had, on average, struggled with their symptoms for 17 years.

The study consisted of two phases: an initial double-blind, placebo-controlled phase in which all patients received psychotherapy accompanied by either MDMA or placebo, followed by an open-label, cross-over phase in which patients assigned to the placebo arm were given the opportunity to receive additional therapy that included MDMA administration.

At 3–5 days following the second of two treatment sessions, the MDMA group showed an average reduction of 49.9 points on their CAPS score. The placebo group showed an average reduction of only 12.8 points on their CAPS score.

Results showed that after three doses of MDMA administered under a psychiatrist’s guidance, the patients reported a 56 percent decrease in severity of symptoms. By the end of the study, two-thirds no longer met the criteria for having PTSD. Follow-up studies found that 17-74 months after therapy, positive improvements were still evident.

Research has shown that the drug causes the brain to release a flood of hormones and neurotransmitters that evoke feelings of trust, love and well-being, while also muting fear and negative emotional memories that can be overpowering in patients with post-traumatic stress disorder.

MDMA is not only a monoamine releaser with particularly prominent effects on serotonin, but it also elevates serum oxytocin, which is a neuropeptide believed to play a role in affiliation and bonding in mammals. Brain imaging studies show there is reduced amygdalar activity after MDMA administration, plus changes in the response to angry and happy facial expressions.

These effects may combine to increase the effectiveness of psychotherapy for PTSD, by increasing self-acceptance, promoting interpersonal trust with therapists and catalyzing the effective processing of emotionally-distressing material. It is believed the treatment acts as a catalyst that speeds-up the natural healing process.

In interviews, study participants said MDMA therapy had not only helped them with painful memories, but also helped them stop abusing alcohol and other drugs and put their lives back together.

These initial findings provide hope that the addition of a few low doses of MDMA (ie, around 2 mg/kg or less) to established psychotherapeutic approaches may be beneficial to patients with chronic treatment-resistant PTSD. Other potential applications of MDMA-assisted therapy include depression and substance abuse.

It is notable that no subjects reported any harm from study participation and all of them reported some degree of benefit.

Research suggests that MDMA can be administered in a clinical setting with minimal risk that the subjects will subsequently seek out and self-administer “street ecstasy,” or become dependent on the drug.

As it is the emotional distress of PTSD that often contributes to the use of intoxicants as an escape or an attempt at self-medication, when that emotional distress is reduced, it follows that the subject’s motivation for drug abuse would be reduced as well.

Even though no major adverse events have thus far been reported in PTSD patients who received MDMA, we cannot rule out the possibility of subtle long-term neurological consequences that might require extensive neuropsychological testing and/or brain imaging to detect.

Virtually all medications involve some degree of risk, and as such, standard medical practice requires that the benefit obtained from a drug significantly outweighs the risk to the patient.

MDMA was first synthesized in 1912 by Merck chemist Anton Köllisch. At the time, Merck was interested in developing substances that stopped abnormal bleeding.

In 1927, Max Oberlin studied the pharmacology of MDMA while searching for substances with effects similar to adrenaline or ephedrine, the latter being structurally similar to MDMA.

The chemist Alexander Shulgin first realized the euphoria-inducing traits of MDMA in the 1970s, and introduced it to psychologists he knew.

Before formal clinical trials could start, “Adam” spread to dance clubs and college campuses under the name “Ecstasy”, and in 1985, the Drug Enforcement Administration made it a Schedule 1 drug, barring all legal use.


The National Center for Biotechnology Information

US National Library of Medicine National Institute of Health

Kratom: Medicinal or Criminal

The U.S. Drug Enforcement Agency (DEA) moved earlier this year to list the herbal supplement kratom as a Schedule 1 drug under the Controlled Substances Act. This would place kratom alongside Heroin, LSD, Morphine, and Ice as substances that have a high potential for abuse and a risk to public health.

The ban, proposed to come into effect in October 2016 would make it illegal to purchase or possess kratom and would suddenly place the estimated 3-5 million regular users in the U.S. on the wrong side of the law.

Overwhelming disapproval to the proposed ban from the public and lawmakers saw the DEA suspend the listing and call for public comment on the pros and cons of kratom. Submissions closed on December 1 with over 100,000 comments received, mostly calling for more scientific research into the benefits of the herb.

Kratom is not an opioid, but instead belongs to the coffee family and produces a similar mild stimulating effect. The active molecules in kratom however, mitragynine and 7-hydroxymitragynine (7-HMG) bind to the same neuronal receptors as opioids like heroin, codeine, oxycodone, and morphine which leads the DEA to have concerns over the potential of addiction.

Millions of people use kratom for pain relief, anxiety, PTSD, depression, addiction to prescription painkillers, opioid addiction, period pain and even fibromyalgia. There are calls for kratom to be listed as a natural supplement under the Food, Drug and Cosmetic Act, joining other herbs such as St. Johns Wort and Valerian.

Kratom can be purchased at herbal supplement stores or sourced online. The leaves can be chewed but are quite bitter. Dried leaves can be boiled to make a sort of tea. The dried leaves are also powdered and added to tea or other liquids such as orange juice. The powder is often placed into capsules and taken this way.

The FDA started working with other US agencies to seize shipments of imported kratom in 2014, as the product was being marketed as a dietary supplement but had never been shown to be part of the US diet nor to be Generally Recognized as Safe.

As of May 2016, Alabama, Arkansas, Indiana, Tennessee, Vermont, and Wisconsin had made kratom illegal, and the US Army had forbidden soldiers from using it.

Description

Mitragyna speciosa Korth. (commonly known as kratom, also ketum), is a tropical evergreen tree in the coffee family (Rubiaceae) native to Southeast Asia in the Indochina and Malaysia phytochoria (botanical regions). M. speciosa is indigenous to Thailand, Indonesia, Malaysia, Myanmar, and Papua New Guinea.

In cultures where the plant grows, it has been used in traditional medicine. The leaves are chewed to relieve musculoskeletal pain, increase energy, appetite, and sexual desire in ways similar to that of coca.

The leaves or extracts from them are used to heal wounds and as a local anesthetic. Extracts and leaves have been used to treat coughs, diarrhea, and intestinal infections. Kratom is often used by workers in laborious or monotonous professions to stave off exhaustion as well as a mood enhancer and/or painkiller.

In 1836, kratom was reported to be used as an opium substitute in Malaysia. Kratom was also used as an opium substitute in Thailand in the nineteenth century.

Across Southeast Asia and especially in Thailand, in the 2010s a tea-based cocktail known as 4×100 became popular among some younger people. It is a mix of kratom leaves, cough syrup, Coca-Cola, and ice. As of 2012, use of the cocktail was a severe problem among youth in three provinces along the border with Malaysia.

Adverse Effects

Minor side effects may include nausea, vomiting, and constipation. More severe side effects may include seizure, addiction, and psychosis. Other side effects include high heart rate and blood pressure, liver toxicity, and trouble sleeping. When use is stopped withdrawal may occur.

When mixed with other substances, kratom use has resulted in death. In the United States, there were fifteen kratom-related deaths between 2014 and 2016, although in none was kratom the sole factor.

Regulation

As of 2015 there was a growing international concern about a possible threat to public health from kratom use. In some jurisdictions its sale and importation have been restricted, and a number of public health authorities have raised alerts. Sometimes the finished product is mixed into cocktails with other opioids.

United States

The FDA started working with other US agencies to seize shipments of imported kratom in 2014, as the product was being marketed as a dietary supplement but had never been shown to be part of the US diet nor to be Generally Recognized as Safe.

On 30 August 2016, the Drug Enforcement Administration (DEA) announced its intention to place the active materials in the kratom plant into Schedule I of the Controlled Substances Act. This drew strong protests among those using kratom to deal with chronic pain or wean themselves off opioids or alcohol.

A group of 51 members of the US House of Representatives and a group of 9 senators each sent letters to Acting DEA Administrator Chuck Rosenberg protesting the listing and around 140,000 people signed an online White House Petition protesting it.

In October 2016, the DEA withdrew its notice of intent while inviting public comments over a review period ending 1 December 2016.

As of May 2016, Alabama, Arkansas, Indiana, Tennessee, Vermont, and Wisconsin had made kratom illegal, and the US Army had forbidden soldiers from using it.

United Nations (UN)

As of January 2015 neither the plant nor its alkaloids were listed in any of the Schedules of the United Nations Drug Conventions.

Europe

In Europe as of 2011 the plant was controlled in Denmark, Latvia, Lithuania, Poland, Romania and Sweden.

ASEAN

As of 2013, kratom was listed by ASEAN in its annex of products that cannot be included in traditional medicines and health supplements that are traded across ASEAN nations.

Australia and New Zealand

As of January 2015 kratom was controlled as a narcotic in Australia and under the Medicines Amendment Regulations of New Zealand.

Thailand

Possession of kratom leaves is illegal in Thailand. In 1943, the government passed the Kratom Act 2486, which made planting the tree illegal. This was in response to a rise in its use when opium became very expensive. In 1979, kratom along with marijuana were placed in Category V of a five category classification of narcotics. Kratom accounted for less than 2% of arrests for narcotics between 1987 and 1992. The government considered legalizing kratom in 2004, 2009, and 2013.

Malaysia

The use of kratom leaves, known locally as ‘ketum’, is prohibited in Malaysia under Section 30 (3) Poisons Act 1952 and the user may be fined with a maximum amount of MYR 10,000 (USD 3,150) or up to 4 years imprisonment. Certain parties have urged the government to penalize the use of kratom under the Dangerous Drugs Act instead of the Poisons Act, which carry heavier penalties.

Substance Use Disorder (SUD)

Alcohol and drug misuse and related disorders are major public health challenges that are taking an enormous toll on individuals, families, and society. Neighborhoods and communities as a whole are also suffering as a result of alcohol- and drug-related crime and violence, abuse and neglect of children, and the increased costs of health care associated with substance misuse.

Ongoing health care and criminal justice reform efforts, as well as advances in clinical, research, and information technologies are creating new opportunities for increased access to effective prevention and treatment services.

Most people know someone with a substance use disorder (SUD), and many know someone who has lost or nearly lost a family member as a consequence of substance misuse. Yet, at the same time, few other medical conditions are surrounded by as much shame and misunderstanding as substance use disorders.

Historically, our society has treated addiction and misuse of alcohol and drugs as symptoms of moral weakness or as a willful rejection of societal norms, and these problems have been addressed primarily through the criminal justice system.

Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. Further, over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder.

Many factors contribute to this “treatment gap,” including the inability to access or afford care, fear of shame and discrimination, and lack of screening for substance misuse and substance use disorders in general health care settings.

About 40 percent of individuals who know they have an alcohol or drug problem are not ready to stop using, and many others simply feel they do not have a problem or a need for treatment—which may partly be a consequence of the neurobiological changes that profoundly affect the judgment, motivation, and priorities of a person with a substance use disorder.

Criteria for Diagnosing Substance Use Disorders

  • Using in larger amounts or for longer than intended
  • Wanting to cut down or stop using, but not managing to
  • Spending a lot of time to get, use, or recover from use
  • Craving
  • Inability to manage commitments due to use
  • Continuing to use, even when it causes problems in relationships
  • Giving up important activities because of use
  • Continuing to use, even when it puts you in danger
  • Continuing to use, even when physical or psychological problems may be made worse by use
  • Increasing tolerance
  • Withdrawal symptoms

Notes:

  • Fewer than 2 symptoms = no disorder
  • 2-3 = mild disorder
  • 4-5 = moderate disorder
  • 6 or more = severe disorder.

Source: American Psychiatric Association, (2013).30

Binge drinking is defined as being:

  • Men – drinking 5 or more standard alcoholic drinks
  • Women – drinking 4 or more standard alcoholic drinks

on the same occasion on at least 1 day in the past 30 days.

Categories and Examples of Substances:

Alcohol:

  • Beer
  • Wine
  • Malt liquor
  • Distilled spirits

Illicit Drugs:

  • Cocaine, including crack
  • Heroin
  • Hallucinogens, including LSD, PCP, ecstasy, peyote, mescaline, psilocybin
  • Methamphetamines, including crystal meth
  • Marijuana, including hashish
  • Synthetic drugs, including K2, Spice, and “bath salts”

Prescription-Type Medications that are Used for Nonmedical Purposes:

  • Pain Relievers – Synthetic, semi-synthetic, and non-synthetic opioid medications, including fentanyl, codeine, oxycodone, hydrocodone, and tramadol products
  • Tranquilizers, including benzodiazepines, meprobamate products, and muscle relaxants
  • Stimulants and Methamphetamine, including amphetamine, dextroamphetamine, and phentermine products; mazindol products; and methylphenidate or dexmethylphenidate products
  • Sedatives, including temazepam, flurazepam, or triazolam and any barbiturates

Over-the-Counter Drugs and Other Substances:

  • Cough and cold medicines
  • Inhalants, including amyl nitrite, cleaning fluids, gasoline and lighter gases, anesthetics, solvents, spray paint, nitrous oxide.

NEUROBIOLOGY

Substance use disorders result from changes in the brain that can occur with repeated use of alcohol or drugs. The most severe expression of the disorder, addiction, is associated with changes in the function of brain circuits involved in pleasure (the reward system), learning, stress, decision making, and self-control.

Every substance has slightly different effects on the brain, but all addictive drugs including alcohol, opioids, and cocaine, produce a pleasurable surge of the neurotransmitter dopamine in a region of the brain called the basal ganglia. Neurotransmitters are chemicals that transmit messages between nerve cells.

This area is responsible for controlling reward and our ability to learn based on rewards. As substance use increases, these circuits adapt. They scale back their sensitivity to dopamine, leading to a reduction in a substance’s ability to produce euphoria or the “high” that comes from using it. This is known as tolerance, and it reflects the way that the brain maintains balance and adjusts to a “new normal”—the frequent presence of the substance.

However, as a result, users often increase the amount of the substance they take so that they can reach the level of high they are used to. These same circuits control our ability to take pleasure from ordinary rewards like food, sex, and social interaction, and when they are disrupted by substance use, the rest of life can feel less and less enjoyable to the user when they are not using the substance.

Repeated use of a substance “trains” the brain to associate the rewarding high with other cues in the person’s life, such as friends they drink or do drugs with, places where they use substances, and paraphernalia that accompany substance-taking. As these cues become increasingly associated with the substance, the person may find it more and more difficult not to think about using, because so many things in life are reminders of the substance.

Changes to two other brain areas, the extended amygdala and the prefrontal cortex, help explain why stopping use can be so difficult for someone with a severe substance use disorder. The extended amygdala controls our responses to stress.

If dopamine “bursts” in the reward circuitry in the basal ganglia are like a carrot that lures the brain toward rewards, “bursts” of stress neurotransmitters in the extended amygdala are like a painful stick that pushes the brain to escape unpleasant situations. Together, they control the spontaneous drives to seek pleasure and avoid pain and compel a person to action.

In substance use disorders, however, the balance between these drives shifts over time. Increasingly, people feel emotional or physical distress whenever they are not taking the substance. This distress, known as withdrawal, can become hard to bear, motivating users to escape it at all costs.

As a substance use disorder deepens in intensity, substance use is the only thing that produces relief from the bad feelings associated with withdrawal. And like a vicious cycle, relief is purchased at the cost of a deepening disorder and increased distress when not using. The person no longer takes the substance to “get high” but instead to avoid feeling low. Other priorities, including job, family, and hobbies that once produced pleasure have trouble competing with this cycle.

Healthy adults are usually able to control their impulses when necessary, because these impulses are balanced by the judgment and decision-making circuits of the prefrontal cortex. Unfortunately, these prefrontal circuits are also disrupted in substance use disorders. The result is a reduced ability to control the powerful impulses toward alcohol or drug use despite awareness that stopping is in the person’s best long-term interest.

This explains why substance use disorders are said to involve compromised self-control. It is not a complete loss of autonomy—addicted individuals are still accountable for their actions—but they are much less able to override the powerful drive to seek relief from withdrawal provided by alcohol or drugs. At every turn, people with addictions who try to quit find their resolve challenged.

Even if they can resist drug or alcohol use for a while, at some point the constant craving triggered by the many cues in their life may erode their resolve, resulting in a return to substance use, or relapse.

RISK FACTORS

One of the major questions about addiction is why it takes hold only in some people. The changes in the brain associated with addiction do not progress in the same way in everyone who uses alcohol or drugs.

For a wide range of reasons that remain only partially understood, some individuals are able to use alcohol or drugs in moderation and not develop addiction or even milder substance use disorders, whereas others—between 4 and 23 percent depending on the substance—proceed readily from trying a substance to developing a substance use disorder.

Understanding the factors that raise people’s risk for substance misuse (risk factors) and those that may offer some degree of protection from these risks (protective factors) and then using this knowledge to design interventions aimed at steering people away from substance misuse are the goals of prevention science.

Although research has shown strong heritability of substance use disorder, we now know that individual, family, community, and environmental risk factors play an important role in both substance misuse and substance use disorders.

Being raised in a home in which the parents or other relatives use alcohol or drugs raises a child’s chances of trying these substances and of developing a substance use disorder. Living in neighborhoods and going to schools where alcohol and drug use are common, and associating with peers who use substances, are also risk factors.

Another important risk factor is age at first use. The earlier people try alcohol or drugs, the more likely they are to develop a substance use disorder. For instance, people who first use alcohol before age 15 are four times more likely to become addicted to alcohol at some time in their lives than are those who have their first drink at age 20 or older.

Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder in the next 7 years, compared with 27 percent of those who first try an illicit drug after the age of 17.

Although substance misuse problems can develop later in life, preventing or even just delaying young people from trying substances is important for reducing the likelihood of more serious problems later on.

PREVENTION

Few would disagree with the notion that preventing substance use disorders from developing in the first place is ideal. Prevention programs and policies are available that have been proven to do just that. If a person does develop a substance use disorder, treatment is critical.

Prevention interventions aim to support or bolster protective factors, which give people the resources and strengths they need to avoid substance use. Having strong and positive family ties and social connections, being emotionally healthy, and having a feeling that one has control over one’s successes and failures are all protective factors.

Given the overwhelming tendency for substance use to begin in adolescence (ages 12 to 17) and peak during young adulthood, most prevention interventions have focused on teens and young adults. However, effective prevention policies and programs have been developed across the lifespan, from infancy to adulthood.

It is never too early and never too late to prevent substance misuse and substance-related problems. A growing number of interventions designed to reduce risk and enhance protective factors have been scientifically tested and shown to improve substance use and other outcomes.

These include interventions for all age groups (including early childhood), for specific ethnic and racial groups, and for groups at high risk for substance misuse, such as youth involved in the criminal justice system. These interventions may focus all individuals in a group (universal interventions) or specifically on at-risk individuals (selective interventions).

Evidence-based prevention interventions can also address a wider range of potential problems beyond just substance misuse. Alcohol and drug use among adolescents are typically part of a larger spectrum of behavioral problems, including mental disorders, risky and criminal behaviors, and difficulties in school.

Many interventions address the common underlying risk factors for these issues and show benefits across these domains, making them powerful and, in many cases, highly cost-effective investments that pay off in reduced health care, law enforcement, and other societal costs.

An intervention should be a professionally delivered program, service, or policy designed to prevent substance misuse or treat an individual’s substance use disorder. It should not be an arranged meeting or confrontation intended to persuade a friend or loved one to quit their substance misuse or enter treatment—the type of “intervention” sometimes depicted on television.

Confrontational approaches in general, though once the norm even in many behavioral treatment settings, have not been found effective and may backfire by heightening resistance and diminishing self-esteem on the part of the targeted individual.

TREATMENT

Substance use disorders share some important characteristics with other chronic illnesses, like diabetes. Both are chronic conditions that can be effectively managed with medications and other treatments that focus on behavior and lifestyle.

As with other chronic conditions, people with substance use disorders need support through the long and often difficult process of returning to a healthy and productive life.

As with other chronic illnesses, the earlier treatment begins, the better the outcomes are likely to be.

Research on alcohol and drug use, and addiction, has led to an increase of knowledge and to one clear conclusion: Addiction to alcohol or drugs is a chronic but treatable brain disease that requires medical intervention, not moral judgment.

Healthcare systems have not given the same level of attention to substance use disorders as it has to other health concerns that affect similar numbers of people. Substance use disorder treatment remains largely segregated from the rest of healthcare and serves only a fraction of those in need of treatment.

Treatment for substance use disorders can take many different forms and may be delivered in a range of settings varying in intensity. In all cases, though, the goals of treatment for substance use disorders are similar to treatment for any medical condition: to reduce the major symptoms of the illness and return the patient to a state of full functioning.

Ideally, services are not “one size fits all” but are tailored to the unique needs of the individual. Treatment must be provided for an adequate length of time and should address the patient’s substance use as well as related health and social consequences that could contribute to the risk of relapse, including connecting the patient to social support, housing, employment, and other wrap-around services.

Residential treatment was designed to provide a highly controlled environment with a high density of daily services. Ideally, people who receive treatment in residential settings participate in step-down services following the residential stay.

Medications are also available to help treat people addicted to alcohol or opioids. Research is underway to develop new medications to treat other substance use disorders, such as addiction to marijuana or cocaine.

The available medications do not by themselves restore the addicted brain to health, but they can support an individual’s treatment process and recovery by preventing the substance from having pleasurable effects in the brain, by causing an unpleasant reaction when the substance is used, or by controlling symptoms of withdrawal and craving.

As with other chronic, relapsing medical conditions, treatment can manage the symptoms of substance use disorders and prevent relapse. Rates of relapse following treatment for substance use disorders are comparable to those of other chronic illnesses such as diabetes, asthma, and hypertension.

However, many people seek or are referred to substance use treatment only after a crisis, such as an overdose, or through involvement with the criminal justice system. With any other health condition like heart disease, detecting problems and offering treatment only after a crisis is not considered good medicine.

RECOVERY

Support services such as mutual aid groups, recovery housing, and recovery coaches are increasingly available to help people in the long and often difficult task of maintaining recovery after treatment.

Because the brain can take a long time to return to health following a long period of heavy substance use, risk of relapse is high at first. It can take a year of abstinence before an individual can be said to be in remission.

For people recovering from an alcohol use disorder it can take 4 to 5 years of abstinence for the risk of relapse to drop below 15 percent—the level of risk of individuals in the general population developing a substance use disorder during their lifetime.

In addition, successful recovery often involves making significant changes to one’s life to create a supportive environment that avoids substance use or misuse cues or triggers. This can involve changing jobs or housing, finding new friends who are supportive of one’s recovery, and engaging in activities that do not involve substance use.

Recovery has become an increasingly important concept for researchers and practitioners in the substance use disorder field, as well as in the community. It is central to a movement to bring greater awareness to the struggles and the successes of people fighting addiction and increase solidarity in overcoming the discrimination, shame, and misconceptions historically associated with substance use disorders.

A large body of research has clarified the biological, psychological, and social underpinnings of substance misuse and related disorders and described effective prevention, treatment, and recovery support services. Future research is needed to guide the new public health approach to substance misuse and substance use disorders.

INDIVIDUALS AND FAMILIES

In the past, many individuals and families have kept silent about substance-related issues because of shame, guilt, or fear of exposure or recrimination. Breaking the silence and isolation around such issues is crucial, so that individuals and families confronting substance misuse and its consequences know that they are not alone and can openly seek treatment.

Recognizing that substance use disorders are medical conditions and not moral failings can help remove negative attitudes and promote open and healthy discussion between individuals with substance use disorders and their loved ones, as well as with their health care professionals.

Overcoming the powerful drive to continue substance use can be difficult, and making the lifestyle changes necessary for successful treatment—such as changing relationships, jobs, or living environments—can be daunting.

Being compassionate and caring does not mean that you do not hold the person accountable for their actions. It means that you see the person’s behaviors in the light of a medical illness. Love and support can be offered while maintaining the boundaries that are important for your health and the health of everyone around you.

We typically show empathy when someone we know is ill, and we celebrate when people we know overcome an illness. Extending these kindnesses to people with substance use disorders and those in recovery can provide added encouragement to help them realize and maintain their recovery. It also will encourage others to seek out treatment when they need it.

Become informed, from reliable sources, about substances to which your children could be exposed, and about substance use disorders, and talk openly with your children about the risks.

Some tips to keep in mind:

  • Be a good listener
  • Set clear expectations about alcohol and drug use, including real consequences for not following family rules
  • Help your child deal with peer pressure
  • Get to know your child’s friends and their parents
  • Talk to your child early and often
  • Support your school district’s efforts to implement evidence-based prevention interventions and treatment and recovery support.

ACADEMIC INSTITUTIONS

Schools represent one of the most effective channels for influencing youth substance use. Many highly effective evidence-based programs are available that provide a strong return on investment, both in the well-being of the children they reach and in reducing long-term societal costs.

Prevention programs for adolescents should target improving academic as well as social and emotional learning to address risk factors for substance misuse, such as early aggression, academic failure, and school dropout.

When combined with family-based and community programs that present consistent messages, these programs are even more powerful. Interventions that target youth who have already initiated use of alcohol or drugs should also be implemented to prevent escalation of use.

Teachers, professors, and school counselors play an obvious and central role as youth influencers, teaching students about the health consequences of substance use and misuse and about substance use disorders as medical conditions, as well as facilitating open dialogue.

They can also promote non-shaming language that underscores the medical nature of addiction—for instance avoiding terms like “abuser” or “addict” when describing people with substance use disorders.

HEALTH CARE PROFESSIONALS

All health care professionals including:

  • Physicians
  • Physician assistants
  • Nurses
  • Nurse practitioners
  • Dentists
  • Social workers
  • Therapists
  • Pharmacists

can play a role in addressing substance misuse and substance use disorders, not only by directly providing health care services, but also by promoting prevention strategies and supporting the infrastructure changes needed to better integrate care for substance use disorders into general health care and other treatment settings.

Moreover, although 45 percent of patients seeking treatment for substance use disorders have a co-occurring mental disorder, most specialty substance use disorder treatment programs are not part of, or even affiliated with, mental or physical health care organizations.

HEALTH CARE SYSTEMS

Health care systems can help prevent prescription drug misuse and related substance use disorders by holding staff accountable for safe prescribing of controlled substances, training staff on alternative ways of managing pain and anxiety, and increasing use of PDMPs by pharmacists, physicians, and other providers.

Effective integration of behavioral health and general health care is essential for identifying patients in need of treatment, engaging them in the appropriate level of care, and ensuring ongoing monitoring of patients with substance use disorders to reduce their risk of relapse.

COMMUNITIES

Civic and advocacy groups, neighborhood associations, and community-based organizations can all play a major role in communication, education, and advocacy efforts that seek to address substance use-related health issues.

Prevention research has developed effective community-based prevention programs that reduce substance use and delinquent behavior among youth. Research shows that for each dollar invested in research-based prevention programs, up to $10 is saved in treatment for alcohol or other substance misuse-related costs.

An essential part of a comprehensive public health approach to addressing substance misuse is wider use of strategies to reduce individual and societal harms, such as overdoses, motor vehicle crashes, and the spread of infectious diseases.

The implementation of needle/syringe exchange programs, successfully reduce the spread of HIV and Hepatitis C without seeing an increase in injection drug use.

PRIVATE SECTOR

Manufacturers and sellers of alcohol, legal drugs, and related products have a role in reducing and preventing youth substance use. They can discourage the sale and promotion of alcohol and other substances to minors and support evidence based programs to prevent and reduce youth substance use.

Pharmaceutical companies and pharmacies can continue to collaborate with Government Departments to identify and implement evidence-informed solutions to the current opioid crisis. This collaboration may include:

  • Examining and revising product labeling
  • Funding continuing medical education for providers on the appropriate use of opioid medications
  • Developing abuse-deterrent formulations of opioids
  • Prioritizing development of non-opioid alternatives for pain relief
  • Conducting studies to determine the appropriate dosing of opioids in children and safe prescribing practices for both children and adults.

GOVERNMENTS

Coordinated federal, state, local, and tribal efforts are needed to promote a public health approach to addressing substance use, misuse, and related disorders. Widespread cultural and systemic issues need to be addressed to reduce the prevalence of substance misuse and related public health consequences.

Government agencies have a major role to play:

  • Improving public education and awareness
  • Conducting research and evaluations
  • Monitoring public health trends
  • Providing incentives, funding, and assistance to promote implementation of effective prevention, treatment, and recovery practices, policies, and programs
  • Addressing legislative and regulatory barriers
  • Improving coordination between health care, criminal justice, and social service organizations
  • Fostering collaborative initiatives with the private sector

For example, federal and state agencies can implement policies to integrate current best practices guidelines for prescribing opioids for chronic pain or mandatory use of Prescription Drug Monitoring Programs (PDMPs).

The criminal justice and juvenile justice systems can play pivotal roles in addressing substance-related health issues across the community. Less punitive, health-focused initiatives can have a critical impact on long-term outcomes.

The criminal justice system is engaged in efforts to place non-violent drug offenders in treatment instead of jail, to improve the delivery of evidence-based treatment for incarcerated persons, and to coordinate care in the community when inmates are released.

Law enforcement should work closely with citizens’ groups, prevention initiatives, treatment agencies, and recovery community organizations to create alternatives to arrest and lockup for nonviolent and substance use-related offenses.

Prevention and treatment also reduce criminal-justice-related costs, and they are much less expensive than alternatives such as incarceration. Implementation of evidence-based interventions can have a benefit of more than $58 for every dollar spent; and studies show that every dollar spent on substance use disorder treatment saves $4 in health care costs and $7 in criminal justice costs.

RESEARCHERS

Scientific research should be informed by ongoing public health needs. This includes research on the basic genetic and epigenetic contributors to substance use disorders and the environmental and social factors that influence risk:

  • Basic neuroscience research on substance use-related effects and brain recovery
  • Studies adapting existing prevention programs to different populations and audiences
  • Trials of new and improved treatment approaches.

Focused research is needed to help address the significant research-to-practice gap in the implementation of evidence-based prevention and treatment interventions. Closing the gap between research discovery and clinical and community practice is both a complex challenge and an absolute necessity if we are to ensure that all populations benefit from the nation’s investments in scientific discoveries.


U.S. Department of Health and Human Services

The Surgeon General’s Report on Alcohol, Drugs, and Health

Borderline Personality Disorder (BPD)

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder, is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self, and unstable emotions.

There is often an extreme fear of abandonment, frequent dangerous behavior, a feeling of emptiness, and self-harm. Symptoms may be brought on by seemingly normal events.

The behavior typically begins by early adulthood, and occurs across a variety of situations.

Substance abuse, depression, and eating disorders are commonly associated with BPD.

About 10% of those with BPD die by suicide.

BPD’s causes are unclear, but seem to involve genetic, brain, environment, and social factors. It occurs about five times more often in a person who has an affected close relative. Adverse life events also appear to play a role.

The underlying mechanism appears to involve the frontolimbic network of neurons. BPD is recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a personality disorder along with nine other such disorders.

Females are diagnosed about three times as often as males. It appears to become less common among older people. Up to half of people improve over a ten-year period. There is an ongoing debate about the naming of the disorder, especially the suitability of the word “borderline”.

Signs and Symptoms

Borderline personality disorder may be characterized by the following signs and symptoms:

  • Markedly disturbed sense of identity
  • Frantic efforts to avoid real or imagined abandonment and extreme reactions to such
  • Splitting (“black-and-white” thinking)
  • Severe impulsivity
  • Intense or uncontrollable emotional reactions that often seem disproportionate to the event or situation
  • Unstable and chaotic interpersonal relationships
  • Self-damaging behavior
  • Distorted self-image
  • Dissociation
  • Frequently accompanied by depression, anxiety, anger, substance abuse, or rage.

The most distinguishing symptoms of BPD are marked sensitivity to rejection or criticism, and intense fear of possible abandonment. Overall, the features of BPD include unusually intense sensitivity in relationships with others, difficulty regulating emotions, and impulsivity.

Other symptoms may include:

  • Feeling unsure of one’s personal identity, morals, and values
  • Having paranoid thoughts when feeling stressed
  • Dissociation and depersonalization
  • Stress-induced breaks with reality or psychotic episodes.

People with BPD feel emotions more easily, more deeply, and longer than others do. In addition, emotions may repeatedly resurge and persist a long time. Consequently, it may take more time for people with BPD than others to return to a stable emotional baseline following an intense emotional experience.

They often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment.

With BPD, they are often exceptionally enthusiastic, idealistic, joyful, and loving.

However, they may feel overwhelmed by negative emotions (“anxiety, depression, guilt/shame, worry, anger, etc.”), experiencing:

  • Intense grief instead of sadness
  • Shame and humiliation instead of mild embarrassment
  • Rage instead of annoyance
  • Panic instead of nervousness.

People with BPD are also especially sensitive to feelings of rejection, criticism, isolation, and perceived failure. Before learning other coping mechanisms, their efforts to manage or escape from their very negative emotions may lead to self-injury or suicidal behavior.

They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, they shut them down entirely.

While people with BPD feel joy intensely, they are especially prone to dysphoria, depression, and/or feelings of mental and emotional distress.

Since there is great variety in the types of dysphoria experienced by people with BPD, the amplitude of the distress is a helpful indicator of borderline personality disorder.

In addition to intense emotions, people with BPD experience emotional lability; or in other words, changeability. Although the term emotional lability suggests rapid changes between depression and elation, the mood swings in people with this condition actually fluctuate more frequently between anger and anxiety and between depression and anxiety.

Impulsive behavior is common, including substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending, and reckless driving.

Impulsive behavior may also include leaving jobs or relationships, running away, and self-injury.

People with BPD act impulsively because it gives them immediate relief from their emotional pain. However, in the long term, people with BPD suffer increased pain from the shame and guilt that follow such actions.

A cycle often begins in which people with BPD:

  • Feel emotional pain
  • Engage in impulsive behavior to relieve that pain
  • Feel shame and guilt over their actions
  • Feel emotional pain from the shame and guilt
  • Experience stronger urges to engage in impulsive behavior to relieve the new pain.

As time goes on, impulsive behavior may become an automatic response to emotional pain.

The lifetime risk of suicide among people with BPD is between 3% and 10%. There is evidence that men diagnosed with BPD are approximately twice as likely to complete suicide as women diagnosed with BPD. There is also evidence that a considerable percentage of men who complete suicide may have undiagnosed BPD.

Self-harm, such as cutting, is common and takes place with or without suicidal intent. The reported reasons for non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts.

Nearly 70% of people with BPD self-harm without trying to end their life.  Reasons for NSSI include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.

In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide. Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.

People with BPD can be very sensitive to the way others treat them, by feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.

Their feelings about others often shift from admiration or love to anger or dislike after a disappointment, a threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called “splitting”, includes a shift from idealizing others to devaluing them.

Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers. Self-image can also change rapidly from healthy to unhealthy.

While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships.

BPD, like other personality disorders, is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction on the part of romantic partners, abuse, and unwanted pregnancy.

They often view the world as dangerous and malevolent.

People with BPD tend to have trouble seeing a clear picture of their identity. In particular, they tend to have difficulty knowing what they value, believe, prefer, and enjoy.

They are often unsure about their long-term goals for relationships and jobs. This difficulty with knowing who they are and what they value can cause people with BPD to experience feeling “empty” and “lost”.

The often intense emotions experienced by people with BPD can make it difficult for them to control the focus of their attention—to concentrate. In addition, people with BPD may tend to dissociate, which can be thought of as an intense form of “zoning out”.

Dissociation often occurs in response to experiencing a painful event (or experiencing something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from that event, presumably to protect against experiencing intense emotion and unwanted behavioral impulses that such emotion might otherwise trigger.

Although the mind’s habit of blocking out intense painful emotions may provide temporary relief, it can also have the unwanted side effect of blocking or blunting the experience of ordinary emotions. This reduces access to the information contained in those emotions, which helps guide effective decision-making in daily life.

Diagnosis

The DSM-5 defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships, self image, and affect, as well as markedly impulsive behavior.

The World Health Organization’s ICD-10 defines a disorder that is conceptually similar to borderline personality disorder, called (F60.3) Emotionally Unstable Personality Disorder.

F60.3 is categorized by two subtypes – Impulsive and Borderline.

  • F60.30 Impulsive Type
    At least three of the following must be present, one of which must be (2):
  1. Marked tendency to act unexpectedly and without consideration of the consequences
  2. Marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized
  3. Liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions
  4. Difficulty in maintaining any course of action that offers no immediate reward
  5. Unstable and capricious (impulsive, whimsical) mood.
  • F60.31 Borderline Type
    At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:
  1. Disturbances in and uncertainty about self-image, aims, and internal preferences
  2. Liability to become involved in intense and unstable relationships, often leading to emotional crisis
  3. Excessive efforts to avoid abandonment
  4. Recurrent threats or acts of self-harm
  5. Chronic feelings of emptiness
  6. Demonstrates impulsive behavior, e.g., speeding, substance abuse.

Comorbidity

Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other personality disorders, people with BPD showed a higher rate of also meeting criteria for:

  • Mood disorders, including major depression and bipolar disorder
  • Anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)
  • Other personality disorders
  • Substance abuse
  • Eating disorders, including anorexia nervosa and bulimia
  • Attention deficit hyperactivity disorder
  • Somatoform disorders
  • Dissociative disorders

A 2008 study found that at some point in their lives, 75 percent of people with BPD meet criteria for mood disorders, especially major depression and Bipolar I, and nearly 75 percent meet criteria for an anxiety disorder.

Nearly 73 percent meet criteria for substance abuse or dependency, and about 40 percent for PTSD.

There are marked gender differences in the types of comorbid conditions a person with BPD is likely to have. A higher percentage of males with BPD meet criteria for substance-use disorders, while a higher percentage of females with BPD meet criteria for PTSD and eating disorders.

In one study, 38% of participants with BPD met the criteria for a diagnosis of ADHD. In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had significantly more frequent suicide attempts).

Many people with borderline personality disorder also have mood disorders, such as major depressive disorder or a bipolar disorder. It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder or vice versa.

The mood swings of BPD and bipolar disorder tend to have different durations. In some people with bipolar disorder, episodes of depression or mania last for at least two weeks at a time, while the moods of people with BPD can change in minutes or hours.

The moods of bipolar disorder do not respond to changes in the environment, while the moods of BPD do respond to changes in the environment. That is, a positive event would not lift the depressed mood caused by bipolar disorder, but a positive event would potentially lift the depressed mood of someone with BPD.

Similarly, an undesirable event would not dampen the euphoria caused by bipolar disorder, but an undesirable event would dampen the euphoria of someone with borderline personality disorder.

Management

Long-term psychotherapy is currently the treatment of choice for BPD. There are six such treatments available:

  1. Dynamic Deconstructive Psychotherapy (DDP)
  2. Mentalization-Based Treatment (MBT)
  3. Transference-Focused Psychotherapy
  4. Dialectical Behavior Therapy (DBT)
  5. General Psychiatric Management
  6. Schema-Focused Therapy.

Medications are useful for treating comorbid disorders, such as depression and anxiety.

Typical Antipsychotics:

  • Haloperidol may reduce anger
  • Flupenthixol may reduce the likelihood of suicidal behavior.

Atypical Antipsychotics:

  • Aripiprazole may reduce interpersonal problems and impulsivity
  • Olanzapine may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety.

Mood Stabilizers:

  • Valproate semisodium may ameliorate depression, interpersonal problems, and anger
  • Lamotrigine may reduce impulsivity and anger
  • Topiramate may ameliorate interpersonal problems, impulsivity, anxiety, anger, and general psychiatric pathology.

Antidepressants:

  • Amitriptyline may reduce depression.

Prognosis

With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years. In addition to recovering from distressing symptoms, people with BPD also achieve high levels of psychosocial functioning.

Mental Health Disorders Redefined

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association’s (APA) classification and diagnostic tool.

The DSM-5 was published on May 18, 2013, superseding the DSM-IV-TR, which was published in 2000. In most respects DSM-5 is not greatly changed from DSM-IV-TR, however some changes are worth noting.

Notable changes include:

  • Dropping Asperger syndrome as a distinct classification.
  • Loss of subtype classifications for variant forms of schizophrenia.
  • Dropping the “bereavement exclusion” for depressive disorders.
  • Revised treatment and naming of gender identity disorder to gender dysphoria.
  • Removing the A2 criterion for posttraumatic stress disorder (PTSD) because its requirement for specific emotional reactions to trauma did not apply to combat veterans and first responders with PTSD.

Listed below is a summary of the changes from DSM-IV to DSM-5. If a specific disorder (or set of disorders) do not appear, it means that the diagnostic criteria for those disorders did not change significantly from DSM-IV to DSM-5.

Neurodevelopmental Disorders

  • “Mental retardation” has a new name: “intellectual disability (intellectual developmental disorder).”
  • Phonological disorder and stuttering are now called communication disorders—which include language disorder, speech sound disorder, childhood-onset fluency disorder, and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder.
  • Autism spectrum disorder incorporates Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) –
  • A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome.

Schizophrenia Spectrum and other Psychotic Disorders

  • All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual).
  • A major mood episode is required for schizoaffective disorder (for a majority of the disorders duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met).
  • Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder.
  • Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.

Bipolar and Related Disorders

  • New specifier “with mixed features” can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called “NOS”, not otherwise specified) and MDD.
  • Allows other specified bipolar and related disorder for particular conditions.
  • Anxiety symptoms are a specifier (called “anxious distress”) added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).

Depressive disorders

  • The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.
  • New disruptive mood dysregulation disorder (DMDD)[9] for children up to age 18 years.
  • Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.
  • Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality.
  • The term dysthymia now also would be called persistent depressive disorder.

Anxiety Disorders

  • For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) “must recognize that their fear and anxiety are excessive or unreasonable”. Also, the duration of at least 6 months now applies to everyone (not only to children).
  • Panic attack became a specifier for all DSM-5 disorders.
  • Panic disorder and agoraphobia became two separate disorders.
  • Specific types of phobias became specifiers but are otherwise unchanged.
  • The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.
  • Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).

Obsessive-Compulsive and Related Disorders

  • A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition.
  • Trichotillomania (hair-pulling disorder) moved from “impulse-control disorders not elsewhere classified” in DSM-IV, to an obsessive-compulsive disorder in DSM-5.
  • A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and “absent insight/delusional” (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).
  • Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance.
  • The DSM-IV specifier “with obsessive-compulsive symptoms” moved from anxiety disorders to this new category for obsessive-compulsive and related disorders.
  • There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder.

Trauma- and Stressor-Related Disorders

  • Posttraumatic stress disorder (PTSD) is now included in a new section titled “Trauma- and Stressor-Related Disorders.”
  • The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV.
  • Separate criteria were added for children six years old or younger.
  • For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity.Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events.
  • Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.
  • Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.

Dissociative Disorders

  • Depersonalization disorder is now called depersonalization/derealization disorder.
  • Dissociative fugue became a specifier for dissociative amnesia.
  • The criteria for dissociative identity disorder were expanded to include “possession-form phenomena and functional neurological symptoms”. It is made clear that “transitions in identity may be observable by others or self-reported”.
  • Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma).

Somatic Symptom and Related Disorders

  • Somatoform disorders are now called somatic symptom and related disorders.
  • Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.
  • Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.
  • Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy).
  • A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention”.
  • Criteria for conversion disorder (functional neurological symptom disorder) were changed.

Feeding and Eating Disorders

  • Criteria for pica and rumination disorder were changed and can now refer to people of any age.
  • Binge eating disorder graduated from DSM-IV’s “Appendix B — Criteria Sets and Axes Provided for Further Study” into a proper diagnosis.
  • Requirements for bulimia nervosa and binge eating disorder were changed from “at least twice weekly for 6 months to at least once weekly over the last 3 months”.
  • The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
  • “Feeding disorder of infancy or early childhood”, a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.

Sleep–Wake Disorders

  • “Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition” were deleted.
  • Primary insomnia became insomnia disorder, and narcolepsy is separate from other hypersomnolence.
  • There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation.
  • Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type. Jet lag was removed.
  • Rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder, instead of both being listed under “dyssomnia not otherwise specified” in DSM-IV.

Sexual Dysfunctions

  • DSM-5 has sex-specific sexual dysfunctions.
  • For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.
  • Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria.
  • A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
  • Sexual aversion disorder was deleted.
  • Subtypes for all disorders include only “lifelong versus acquired” and “generalized versus situational” (one subtype was deleted from DSM-IV).
  • Two subtypes were deleted: “sexual dysfunction due to a general medical condition” and “due to psychological versus combined factors”.

Gender Dysphoria

  • DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added.
  • Subtypes of gender identity disorder based on sexual orientation were deleted.
  • Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one’s gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents.
  • The grouping has been moved out of the sexual disorders category and into its own.The name change was made in part due to stigmatization of the term “disorder” and the relatively common use of “gender dysphoria” in the GID literature and among specialists in the area.
  • The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.

Disruptive, Impulse-Control, and Conduct Disorders

  • Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders.
  • Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter “Impulse-Control Disorders Not Otherwise Specified”.
  • Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).
  • Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity.
  • Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited “prosocial emotion”, showing callous and unemotional traits.
  • People over the disorder’s minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify “impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences”.

Substance-Related and Addictive Disorders

  • Gambling disorder and tobacco use disorder are new.
  • Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new “addictions and related disorders” category. “Recurrent legal problems” was deleted and “craving or a strong desire or urge to use a substance” was added to the criteria.
  • The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added.
  • New specifiers were added for early and sustained remission along with new specifiers for “in a controlled environment” and “on maintenance therapy”.

DSM-5 substance dependencies include:

  • Alcohol dependence
  • Opioid dependence
  • Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence)
  • Cocaine dependence
  • Cannabis dependence
  • Amphetamine dependence (or amphetamine-like)
  • Hallucinogen dependence
  • Hallucinogen dependence
  • Inhalant dependence
  • Polysubstance dependence
  • Phencyclidine (or phencyclidine-like) dependence
  • Other (or unknown) substance dependence
  • Nicotine dependence

There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.

Neurocognitive Disorders

  • Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. “New separate criteria are now presented” for major or mild NCD due to various conditions. Substance/medication-induced NCD and unspecified NCD are new diagnoses.

Paraphilic Disorders

  • New specifiers “in a controlled environment” and “in remission” were added to criteria for all paraphilic disorders.
  • A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).

Personality Disorders

  • Personality disorder (PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained.
  • There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities.
  • The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap.There is also concern as to which model is better for the DSM – the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality.The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases.

The following conditions have been listed for further research and documenting:

  • Attenuated psychosis syndrome.
  • Depressive episodes with short-duration hypomania.
  • Persistent complex bereavement disorder.
  • Caffeine use disorder.
  • Internet gaming disorder.
  • Neurobehavioral disorder associated with prenatal alcohol exposure.
  • Suicidal behavior disorder.
  • Non-suicidal self-injury.

Oppositional Defiant Disorder (ODD)

Oppositional Defiant Disorder (ODD) is a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months.

Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit.

A diagnosis of ODD is also no longer applicable if the individual is diagnosed with reactive attachment disorder (RAD).

Signs and Symptoms

According to the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) the child must exhibit four out of the eight following signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder.

Signs and symptoms were:

  1. actively refuses to comply with majority’s requests or consensus-supported rules;
  2. performs actions deliberately to annoy others;
  3. is angry and resentful of others;
  4. argues often;
  5. blames others for their own mistakes;
  6. frequently loses temper;
  7. is spiteful or seeks revenge;
  8. is touchy or easily annoyed.

These patterns of behaviour result in impairment at school and/or social venues and must be perpetuated for longer than six months. They must be considered beyond normal child behavior.

The fifth and latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) redefines the diagnostic criteria for oppositional defiant disorder as follows:

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Angry/Irritable Mood

1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.

Argumentative/Defiant Behavior

4. Often argues with authority figures or for children and adolescents with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months.

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic.

For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8).

For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8).

While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture.

B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Specify current severity:

Mild: Symptoms are confined to only one setting (e.g. at home, at school, at work, with peers).

Moderate: Some symptoms are present in at least two settings.

Severe: Some symptoms are present in three or more settings.

Causes

The actual cause of ODD is unknown but the following may be contributing factors.

Genetic Influences

Research indicates that parents pass on a tendency for externalizing disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems.

This heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behavior is attributable to heredity for both males and females.

ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD.

Prenatal Factors and Birth Complications

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning, and mother’s use of alcohol or other substances during pregnancy may increase the risk of developing ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological Factors

Deficits and injuries to certain areas of the brain can lead to serious behavioral problems in children. Brain imaging studies have suggested that children with ODD may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control.

Children with ODD are thought to have an overactive behavioral activation system (BAS), and underactive behavioral inhibition system (BIS). The BAS stimulates behavior in response to signals of reward or non punishment. The BIS produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of nonreward or punishment.

Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.

Social-Cognitive Factors

As many as 40 percent of boys and 25 percent of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behavior, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act.

Environmental Factors

Negative parenting practices and parent–child conflict may lead to antisocial behavior, but they may also be a reaction to the oppositional and aggressive behaviors of children. Factors such as a family history of mental illnesses and/or substance abuse as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behavior disorders.

Insecure parent–child attachments can also contribute to ODD. Often little internalization of parental and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance abuse.

Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.

Low socioeconomic status is associated with poor parenting, specifically with inconsistent discipline and poor parental monitoring, which are then associated with an early onset of aggression and antisocial behaviors.

Externalizing problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighborhoods.

Diagnosis

For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations.

These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Management

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training.

According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents.

Several preventative programs have had a positive effect on those at high risk for ODD.

Both home visitation and programs such as Head Start have shown some effectiveness in preschool children.

Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD.

For adolescents at risk for ODD, cognitive interventions, vocational training and academic tutoring have shown preventative effectiveness.

There is also limited evidence that the atypical antipsychotic medication risperidone decreases aggression and conduct problems in youth with disruptive behavioral disorders, such as ODD.

New Research Shows Benefits of High-Intensity Statins

In a study publishing this week in JAMA Cardiology, Stanford researchers show that taking high-intensity statins could increase heart patients’ chances of survival over taking moderate-intensity statins.

There are currently seven main types of statins prescribed in the United States. A set of guidelines put forth by the American College of Cardiology and the American Heart Association categorizes them into low-intensity, moderate-intensity, and high-intensity statins based on their strength for reducing bad cholesterol.

Some prior studies have shown that powerful, high-intensity statins increased the rates of side effects such as diabetes or muscle damage, creating controversy around the types of statins doctors should prescribe to their patients, if at all.

As Paul Heidenreich, MD, professor of cardiovascular medicine and the study’s senior author, told me:

“Previously, there was a certain amount of fear on the patient’s part because most people don’t like taking medication.”

For this study, Heidenreich and his colleagues studied the medical records of 509,766 patients in the Veterans Affairs Health Care System. Over a one-year duration, they found that patients on higher-intensity statins had a 9 percent higher survival rate as compared to those on moderate doses.

Even in patients over 75 — a population that is largely ignored in studies — higher-intensity statins led to a 9 percent higher survival rate.

As Fatima Rodriguez, MD, a cardiology fellow at Stanford and the study’s lead author, said in our release:

“This suggests to practitioners that instead of starting a patient on a low dose, just to go ahead and put them on the maximum dose they can tolerate.”

The researchers said their next step is to find out why some patients who should be on high-intensity statins are not. And: The researchers also hope to follow up on longer-term data from these patient populations.

“Not only do we hope to continue studying this population, but we also hope to study patients without prior cardiovascular disease but who are at high risk for it,”

said Rodriguez.


on November 9, 2016 | Photo by Shutterstock

This article was published by Stanford Medicine | Read the original article

Fetal Alcohol Spectrum Disorder (FASD)

Fetal Alcohol Spectrum Disorders (FASDs) are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy.

During the first trimester of pregnancy, alcohol interferes with the migration and organization of brain cells, which can create structural deformities or deficits within the brain.

During the third trimester, damage can be caused to the hippocampus, which plays a role in memory, learning, emotion, and encoding visual and auditory information, all of which can create neurological and functional central nervous system (CNS) impairments as well.

How Alcohol Affects the Fetus

The placenta allows free entry of ethanol and toxic metabolites like acetaldehyde into the fetal compartment. The so-called placental barrier is no barrier with respect to ethanol.

The developing fetal nervous system appears particularly sensitive to ethanol toxicity. The latter impacts negatively on proliferation, differentiation, neuronal migration, axonic outgrowth, integration and fine tuning of the synaptic network. In short, all major processes in the developing central nervous system appear compromised.

Fetal tissues are quite different from adult tissues in function and purpose. For example, the main detoxicating organ in adults is the liver, whereas fetal liver is incapable of detoxicating ethanol as the ADH and ALDH enzymes have not yet been brought to expression at this early stage.

Up to term, fetal tissues do not have significant capacity for the detoxification of ethanol, and the fetus remains exposed to ethanol in the amniotic fluid for periods far longer than the decay time of ethanol in the maternal circulation.

Generally, fetal tissues have far less antioxidant protection than adult tissues as they express no significant quantities of ADH or ALDH, and far less antioxidant enzymes like SOD, glutathione transferases or glutathione peroxidases.

Types

  • Fetal Alcohol Syndrome (FAS), the most severe condition,  refers to individuals who have a specific set of birth defects and neurodevelopmental disorders characteristic of the diagnosis.
  • Partial Fetal Alcohol Syndrome (pFAS) refers to individuals with a known, or highly suspected history of prenatal alcohol exposure who have alcohol-related physical and neurodevelopmental deficits that don’t meet the full criteria for FAS.
  • Alcohol-Related Neurodevelopmental Disorder (ARND) a subtype of pFAS
  • Alcohol-Related Birth Defects (ARBD) also a subtype of pFAS

In addition to FAS, pFAS, ARND, and ARBD, any other conditions believed to be related to prenatal alcohol exposure, such as spontaneous abortion and sudden infant death syndrome (SIDS), are also considered to be on the spectrum of related disorders.

While functional abnormalities are the behavioral and cognitive expressions of the FASD disability, CNS damage can be assessed in three areas: structural, neurological, and functional impairments.

Problems may include an abnormal appearance, short height, low body weight, small head size, poor coordination, low intelligence, behavior problems, and problems with hearing or seeing.

Functional Impairments

Functional impairments are deficits, problems, delays, or abnormalities due to prenatal alcohol exposure (rather than hereditary causes or postnatal insults) in observable and measurable domains related to daily functioning, often referred to as developmental disabilities.

Those affected are more likely to have trouble in school, legal problems, participate in high-risk behaviors, and have trouble with alcohol or other drugs.

Primary Disabilities

The primary disabilities of FAS are the functional difficulties with which the child is born as a result of CNS damage due to prenatal alcohol exposure.

Often, primary disabilities are mistaken as behavior problems, but the underlying CNS damage is the originating source of a functional difficulty, rather than a mental health condition, which is considered a secondary disability.

Learning impairments are associated with impaired dendrites of the hippocampus. Impaired motor development and functioning are associated with reduced size of the cerebellum. Hyperactivity is associated with decreased size of the corpus callosum.

Functional difficulties may result from CNS damage in more than one domain, but common functional difficulties by domain include:

  • Achievement: Learning disabilities
  • Adaptive behavior: Poor impulse control, poor personal boundaries, poor anger management, stubbornness, intrusive behavior, too friendly with strangers, poor daily living skills, developmental delays
  • Attention: Attention-Deficit/Hyperactivity Disorder (ADHD), poor attention or concentration, distractible
  • Cognition: Intellectual disability, confusion under pressure, poor abstract skills, difficulty distinguishing between fantasy and reality, slower cognitive processing
  • Executive functioning: Poor judgment, Information-processing disorder, poor at perceiving patterns, poor cause and effect reasoning, inconsistent at linking words to actions, poor generalization ability
  • Language: Expressive or receptive language disorders, grasp parts but not whole concepts, lack understanding of metaphor, idioms, or sarcasm
  • Memory: Poor short-term memory, inconsistent memory and knowledge base
  • Motor skills: Poor handwriting, poor fine motor skills, poor gross motor skills, delayed motor skill development (e.g., riding a bicycle at appropriate age)
  • Sensory processing and soft neurological problems: sensory processing disorder, sensory defensiveness, under-sensitivity to stimulation
  • Social communication: Intrude into conversations, inability to read nonverbal or social cues, “chatty” but without substance

Secondary Disabilities

The secondary disabilities of FAS are those that arise later in life secondary to CNS damage. These disabilities often emerge over time due to a mismatch between the primary disabilities and environmental expectations; secondary disabilities can be ameliorated with early interventions and appropriate supportive services.

Six main secondary disabilities were identified in a University of Washington research study of 473 subjects diagnosed with FAS, pFAS (partial fetal alcohol syndrome), and ARND (alcohol-related neurodevelopmental disorder):

  1.  Mental health problems: Diagnosed with ADHD, Clinical Depression, or other mental illness, experienced by over 90% of the subjects
  2.  Disrupted school experience: Suspended or expelled from school or dropped out of school, experienced by 60% of the subjects (age 12 and older)
  3.  Trouble with the law: Charged or convicted with a crime, experienced by 60% of the subjects (age 12 and older)
  4.  Confinement: For inpatient psychiatric care, inpatient chemical dependency care, or incarcerated for a crime, experienced by about 50% of the subjects (age 12 and older)
  5.  Inappropriate sexual behavior: Sexual advances, sexual touching, or promiscuity, experienced by about 50% of the subjects (age 12 and older)
  6.  Alcohol and drug problems: Abuse or dependency, experienced by 35% of the subjects (age 12 and older)

Two additional secondary disabilities exist for adults:

  1. Dependent living: Group home, living with family or friends, or some sort of assisted living, experienced by 80% of the subjects (age 21 and older)
  2. Problems with employment: Required ongoing job training or coaching, could not keep a job, unemployed, experienced by 80% of the subjects (age 21 and older)

Overlapping Characteristics

The following table presents the overlapping behavioural characteristics found between FASD and related mental health diagnoses. Click to open in pdf format.

fasd-overlap

Treatment of FASD

FASD causes lifelong disability and cannot be cured. Programs exist that can assist with learning and behavioural difficulties. Such assistance can enable a person to maximise their independence and achievements.

Developmental pediatricians will tailor and coordinate individualized treatment programs best suited to each individual.

A wide range of educational and behavioural strategies have been shown to be effective in children with FASD. Stimulant medication may be helpful for the management of attention-deficit/hyperactivity disorder.

Prevention

Fetal alcohol syndrome usually occurs when a pregnant woman has more than four standard drinks per day. Milder symptoms have been found with two drinks per day during the early stages of pregnancy. Among those who are alcoholic, about a third of children have FAS.

Evidence of harm from less than two drinks per day or 10 drinks per week is not clear. While small amounts of alcohol do not cause an abnormal appearance, it may cause behavioral issues.

The only certain way to prevent FAS is to avoid drinking alcohol during pregnancy. In the United States, in 1981 and again in 2005, the Surgeon General recommended that women abstain from alcohol use while pregnant.

Abstinence was also recommended while planning a pregnancy to avoid damage even in the earliest stages (even weeks) of a pregnancy, as the woman may not be aware that she has conceived.

Genetic Damage Caused By Smoking

Scientists have measured the catastrophic genetic damage caused by smoking in different organs of the body and identified several different mechanisms by which tobacco smoking causes mutations in DNA.

Researchers at the Wellcome Trust Sanger Institute, the Los Alamos National Laboratory and their collaborators found smokers accumulated an average of 150 extra mutations in every lung cell for each year of smoking one packet of cigarettes a day.

Reported in the Journal Science, the study provides a direct link between the number of cigarettes smoked in a lifetime and the number of mutations in the tumour DNA. The highest mutation rates were seen in the lung cancers but tumours in other parts of the body also contained these smoking-associated mutations, explaining how smoking causes many types of human cancer.

Tobacco smoking claims the lives of at least six million people every year and, if current trends continue, the World Health Organization predicts more than 1 billion tobacco-related deaths in this century. Smoking has been epidemiologically associated with at least 17 types of human cancer, but until now no-one has seen the mechanisms by which smoking causes many of these cancer types.

Cancer is caused by mutations in the DNA of a cell. In the first comprehensive analysis of the DNA of cancers linked to smoking, researchers studied over 5,000 tumours, comparing cancers from smokers with cancers from people who had never smoked.

They found particular molecular fingerprints of DNA damage – called mutational signatures – in the smokers’ DNA, and counted how many of these particular mutations were found in the different tumours.

The authors found that, on average, smoking a pack of cigarettes a day led to 150 mutations in each lung cell every year. These mutations represent individual potential start points for a cascade of genetic damage that can eventually lead to cancer.

The numbers of mutations within any cancer cell will vary between individuals, but this study shows the additional mutational load caused by tobacco.

Dr Ludmil Alexandrov, first author from Los Alamos National Laboratory said,

“Before now, we had a large body of epidemiological evidence linking smoking with cancer, but now we can actually observe and quantify the molecular changes in the DNA due to cigarette smoking.”

“With this study, we have found that people who smoke a pack a day develop an average of 150 extra mutations in their lungs every year, which explains why smokers have such a higher risk of developing lung cancer.”

tobacco_image1

Other organs were also affected, with the study showing that a pack a day led to an estimated average 97 mutations in each cell in the larynx, 39 mutations for the pharynx, 23 mutations for mouth, 18 mutations for bladder, and 6 mutations in every cell of the liver each year.

Until now, it has not been fully understood how smoking increases the risk of developing cancer in parts of the body that don’t come into direct contact with smoke. However, the study revealed different mechanisms by which tobacco smoking causes these mutations, depending on the area of the body affected.

As stated by Professor David Phillips, an author on the paper and Professor of Environmental Carcinogenesis King’s College London,

“The results are a mixture of the expected and unexpected, and reveal a picture of direct and indirect effects. Mutations caused by direct DNA damage from carcinogens in tobacco were seen mainly in organs that come into direct contact with inhaled smoke.”

“In contrast, other cells of the body suffered only indirect damage, as tobacco smoking seems to affect key mechanisms in these cells that in turn mutate DNA.”

The study revealed at least five distinct processes of DNA damage due to cigarette smoking. The most widespread of these is a mutational signature already found in all cancers. In this case, tobacco smoking seems to accelerate the speed of a cellular clock that mutates DNA prematurely.

Professor Sir Mike Stratton, joint lead author from the Wellcome Trust Sanger Institute added,

“The genome of every cancer provides a kind of ‘archaeological record’, written in the DNA code itself, of the exposures that caused the mutations that lead to the cancer.”

“Our research indicates that the way tobacco smoking causes cancer is more complex than we thought. Indeed, we do not fully understand the underlying causes of many types of cancer and there are other known causes, such as obesity, about which we understand little of the underlying mechanism.”

“This study of smoking tells us that looking in the DNA of cancers can provide provocative new clues to how cancers develop and thus, potentially, how they can be prevented.”


This article was published by the Wellcome Trust Sanger Institute

Read the Original Article

What Is Carpal Tunnel Syndrome?

The carpal tunnel is a narrow passageway on the palm side of your wrist made up of bones and ligaments.

The median nerve, which controls sensation and movement in the thumb and first three fingers, runs through this passageway along with tendons to the fingers and thumb.

When it’s pinched or compressed, the result is numbness, tingling, weakness, or pain in the hand, called carpal tunnel syndrome.

Symptoms: Pain and Tingling

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Carpal tunnel develops slowly. At first, you’re most likely to notice it at night or when you first wake up in the morning. The feeling is similar to the “pins-and-needles” sensation you get when your hand falls asleep.

During the day, you may notice pain or tingling when holding things, like a phone or a book, or when driving. Shaking or moving your fingers usually helps.

Symptoms: Weakness

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As carpal tunnel syndrome progresses, you may begin to notice weakness in the thumb and first two fingers, and it may be difficult to make a fist or grasp objects.

You may find yourself dropping things, or you may have trouble doing things like holding a utensil or buttoning your shirt.

Symptoms: Sensation Problems

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Carpal tunnel syndrome can also cause a feeling of numbness in the hands. Some people feel like their fingers are swollen, even though no swelling is present, or they may have trouble distinguishing between hot and cold.

What Causes Carpal Tunnel Syndrome?

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There usually isn’t one definitive cause of carpal tunnel syndrome. Because the carpal tunnel is narrow and rigid, anytime there is swelling or inflammation in the area, the median nerve can be compressed and cause pain.

Symptoms may be present in one or both hands (usually symptoms develop in the dominant hand first).

Who Gets Carpal Tunnel Syndrome?

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Women are three times more likely than men to get carpal tunnel syndrome. Certain conditions can also increase your risk. These include:

  • Diabetes, gout, hypothyroidism, and rheumatoid arthritis
  • Pregnancy
  • Sprain or fracture of the wrist

Could Your Job Be to Blame?

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It’s a common belief that frequent typing can lead to carpal tunnel syndrome. But it’s actually three times more common among assembly line workers than it is among data-entry personnel — and frequent use of vibrating hand tools increases the risk.

In contrast, one study found that even heavy computer use — up to seven hours a day — did not make people more likely to develop carpal tunnel syndrome.

What Happens Without Treatment?

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At first, symptoms of carpal tunnel syndrome come and go, but as the condition worsens, symptoms may become constant.

Pain may radiate up the arm all the way to the shoulder. Over time, if untreated, carpal tunnel syndrome can cause the muscles on the thumb side of your hand to waste away (atrophy).

Even with treatment, strength and sensation may never be completely restored.

Carpal Tunnel or Something Else?

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A few conditions have symptoms that can mimic carpal tunnel syndrome. These include:

  • Injury to a muscle, ligament, or tendon
  • Arthritis of the thumb or wrist
  • Nerve problems such as diabetic neuropathy

Your doctor will do tests to rule out other health conditions.

Diagnosing Carpal Tunnel Syndrome

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There are several tests your doctor will perform to see if you have carpal tunnel syndrome. The Tinel test involves tapping on the median nerve to see if it causes tingling in the fingers.

In the Phalen test, the doctor will have you press the backs of your hands together for a minute to see if this causes numbness or tingling.

Electrodiagnostic Tests

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To confirm the diagnosis, your doctor will order a nerve conduction study. In this test, electrodes are placed on the hands and wrists, and small electric shocks are applied to measure how quickly the median nerve transmits impulses.

Another test, called electromyography, uses a fine needle inserted into a muscle to measure electrical activity and assess damage to the median nerve.

Treatment: Rest and Immobilization

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Underlying causes such as diabetes or arthritis will need treatment. Then your doctor may advise resting the hand and wrist and wearing a brace to limit movement.

Night use is important to prevent the wrist from curling during sleep, which can make symptoms flare up. Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen, along with cold compresses, may reduce pain.

Medications for Carpal Tunnel

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When carpal tunnel symptoms are more severe, your doctor may recommend corticosteroids by injection or by mouth. Steroids can temporarily reduce inflammation around the median nerve and ease symptoms.

Injection of a local anesthetic such as lidocaine can also relieve symptoms. Other things that may help include diuretics, also known as “water pills,” which reduce swelling, and vitamin B6 supplements.

Surgery for Carpal Tunnel Syndrome

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If surgery is needed, it’s typically done on an outpatient basis under local anesthesia (meaning you’re awake during surgery). The ligament overlying the top of the carpal tunnel is cut to relieve pressure.

The healed ligament will allow more space in the carpal tunnel. Sometimes the procedure is done endoscopically, using a tiny camera inserted through a very small incision to guide the procedure.

What to Expect After Surgery

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There may be some swelling and stiffness right after surgery, which can be relieved by elevating your hand over your heart and moving your fingers frequently.

You may need to wear a wrist brace for a few weeks while you heal, but will still be able to use your hands. Pain and weakness usually resolve within two months after surgery, but it may take six months to a year to recover completely.

Strengthening Exercises

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Once carpal tunnel symptoms subside, a physical therapist can teach you stretching and strengthening exercises to help prevent pain, numbness, and weakness from coming back.

A physical or occupational therapist can also teach you the correct ways to perform tasks so that the median nerve is less likely to become inflamed again, causing symptoms to return.

Complementary Treatments

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Some studies suggest that chiropractic manipulation of the wrist, elbow, and upper spine can improve carpal tunnel syndrome. There is also some evidence that acupuncture may help restore nerve function and relieve symptoms.

It’s important to speak with your doctor before starting these or any other complementary or alternative treatments.

Can Yoga Ease Carpal Tunnel?

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There’s strong evidence that yoga can reduce pain and improve grip strength.

In one small study, participants who did an eight-week yoga regimen of 11 postures designed to strengthen, stretch, and balance the joints of the upper body had better outcomes than participants who wore wrist splints and participants who were given no treatment at all.

Can Carpal Tunnel Be Prevented?

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Though there is no definitive way to prevent carpal tunnel syndrome, these things can help:

  • Good posture
  • Ergonomic tools and workstations
  • Stretching hands and wrists regularly
  • Taking frequent rest breaks to shake arms and legs, lean back, and change position throughout the work day

This article was published by WebMD | Read the Original Article

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