Loyola McLean

Fear and the Defense Cascade: Clinical Implications and Management

AbstractEvolution has endowed all humans with a continuum of innate, hard-wired, automatically activated defense behaviors, termed the defense cascade. Arousal is the first step in activating the defense cascade; flight or fight is an active defense response for dealing with threat; freezing is a flight-or-fight response put on hold; tonic immobility and collapsed immobility are responses of last resort to inescapable threat, when active defense responses have failed; and quiescent immobility is a state of quiescence that promotes rest and healing. Each of these defense reactions has a distinctive neural pattern mediated by a common neural pathway: activation and inhibition of particular functional components in the amygdala, hypothalamus, periaqueductal gray, and sympathetic and vagal nuclei. Unlike animals, which generally are able to restore their standard mode of functioning once the danger is past, humans often are not, and they may find themselves locked into the same, recurring pattern of response tied in with the original danger or trauma. Understanding the signature patterns of these innate responses—the particular components that combine to yield the given pattern of defense—is important for developing treatment interventions. Effective interventions aim to activate or deactivate one or more components of the signature neural pattern, thereby producing a shift in the neural pattern and, with it, in mind-body state. The process of shifting the neural pattern is the necessary first step in unlocking the patient’s trauma response, in breaking the cycle of suffering, and in helping the patient to adapt to, and overcome, past trauma.

The association of depression with platelet activation: evidence for a treatment effect

Summary.  Background: Depression is associated with an increased risk of cardiovascular disease (CVD). Although the mechanism is uncertain, prothrombotic and inflammatory factors may play a role. Objectives: As platelets play a key role in CVD, we determined first, whether depressed individuals had more activated platelets than non‐depressed individuals and second, whether treatment of depression reduced platelet activation levels. Patients/methods: We recruited 108 depressed outpatients and 45 control subjects all without a history of CVD. After psychological assessment, the depressed patients were offered treatment with medication and/or psychotherapy. Flow cytometric markers of platelet activation and level of depression were assessed at baseline and at 4 weeks and 6 months after treatment. Results: Depression was associated with increased platelet activation with a higher number of circulating CD62p (0.76 × 109 L−1 vs. 0.46, P = 0.019) and CD63 (P = 0.05) positive platelets compared with controls. Patients with depression also had more circulating platelet‐leukocyte aggregates than controls (P < 0.001). There was a positive correlation between the severity of depression and the level of platelet activation. Platelets from depressed patients were also hyperreactive to adenosine 5´‐diphosphate (ADP) stimulation with increased CD62p and CD63 exposure (P = 0.003 and 0.019, respectively). Six months of treatment resulted in a reduced number of circulating CD62p and CD63 positive platelets (29.84% and 53.38% decrease) and a 20.9% reduction in CD63 exposure after ADP activation. Conclusions: Depression is associated with increased in vivo platelet activation and resolution of depression using psychotherapy and/or medication reduces platelet activation. These findings provide insights into the link between depression and cardiovascular risk.

The impact of emotions on coronary heart disease risk.

Background Coronary heart disease is now well recognized as a psychosomatic illness. Emotional disturbance increasingly appears to have an impact on both the development of coronary artery disease over time and the precipitation of acute coronary heart disease events. Method This descriptive review is based on systematic literature reviews from 1980 to 2000 with an emphasis on predictive and prospective studies. Results The empirical evidence linking emotional disturbances such as anxiety, depression and anger to coronary heart disease is now robust. There is also increasing evidence for the underlying pathophysiology that may link emotions to coronary heart disease. Conclusions Emotional disorders and coronary artery disease commonly coexist. Emotional disorders often follow events of coronary heart disease. Prospective studies, however, now show that emotional disturbance is also a significant risk factor for coronary artery disease and especially in those with pre-existing disease. It is important both to diagnose emotional disorders early in coronary heart disease patients and implement effective treatments with the likelihood of reducing subsequent morbidity and mortality. J Cardiovasc Risk 2001, 8:175-183

Reduction of autonomic regulation in children and adolescents with conversion disorders.

Objective Conversion symptoms—functional neurological disturbances of body function—occur in association with extreme arousal, often in the context of emotional distress. The mechanisms that determine how and why such symptoms occur remain unknown. In this study, we used cardiac measures to assess arousal and cardiac autonomic regulation in children and adolescents who presented with acute conversion symptoms. Methods Heart rate was recorded in 57 children and adolescents (41 girls; 8.5–18 years old) with acute conversion symptoms and 57 age- and sex-matched healthy controls, during a resting condition and then during tasks involving cognitive and emotional activation. Arousal and autonomic regulation were assessed by measures of heart rate and heart rate variability. Psychological measures included attachment and emotional distress. Results Children and adolescents with conversion symptoms displayed higher autonomic arousal than did the controls, both at baseline and during task conditions (higher heart rate: baseline mean [standard deviation] = 82 [9.49] versus 74 [10.79] beats/min, p < .001; lower root mean squared successive differences–heart rate variability: 45.35 [27.97] versus 58.62 [25.69] ms2, p = .012; and lower high-frequency heart rate variability: 6.50 [1.19] versus 7.01 [0.95] ln[ms2] p = .017), and decreased autonomic regulation (attenuation of heart rate increases across tasks). The baseline pattern of increased autonomic arousal was especially pronounced in children with coercive-preoccupied patterns of attachment. Autonomic measures were not correlated with measures of emotional distress. Conclusions High autonomic arousal may be a precondition for generating conversion symptoms. Functional dysregulations of the cardiac, respiratory, and circulatory systems may mediate fainting episodes and nonepileptic seizures, and aberrant patterns of functional connectivity between motor areas and central arousal systems may be responsible for generating motor conversion symptoms.

Ongoing ethical issues concerning authorship in biomedical journals: an integrative review

Health professionals publishing within the field of health sciences continue to experience issues concerning appropriate authorship, which have clinical, ethical, and academic implications. This integrative review sought to explore the key issues concerning authorship from a bioethical standpoint, aiming to explore the key features of the authorship debate. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases of peer-reviewed research, published between 2009 and 2014, limited to English language research, with search terms developed to reflect the current issues of authorship. From among the 279 papers identified, 20 research papers met the inclusion criteria. Findings were compiled and then arranged to identify themes and relationships. The review incorporated a wide range of authorship issues encompassing equal-credited authors, honorary (guest/gift) and ghost authorship, perception/experiences of authorship, and guidelines/policies. This review suggests that the International Committee of Medical Journal Editors’ (ICMJE) recommended guidelines for authorship are not reflected in current authorship practices within the domain of health sciences in both low-and high-impact-factor journals. This devaluing of the true importance of authorship has the potential to affect the validity of authorship, diminish the real contributions of the true authors, and negatively affect patient care.

Exploring Christians' explicit attachment to God representations : the development of a template for assessing attachment to God experiences

Assessment of attachment to God (ATG) has generally focused on tapping the construct via self-report measures. Little, if any attention has been paid to assessing ATG via independent ratings of Christians’ relationship with God narratives, obtained at interview. The current study addressed this deficit. It documents the development of a template for assessing Christians’ relationship with God narratives for specific ATG experiences. Three theoretically-derived ATG profiles, labeled as secure-autonomous, insecure-anxious/preoccupied and insecure-dismissing ATG were operationally defined as a series of relational markers. Thirty-one Christians participated in a God Attachment Interview Schedule (GAIS), a semi-structured interview which taps Christians’ past and present relationship with God experiences. Participants’ narratives were analyzed using the template, this revealing relational evidence supportive of the hypothesized relational markers. Validation of the template is an important milestone in the development of a scoring protocol to assign an overall ATG profile based on the narrated experiences of Christians.

The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment

Background Throughout development and into adulthood, a person’s face is the central focus for interpersonal communication, providing an important insight into one’s identity, age, sociocultural background, and emotional state. The face facilitates important social, including nonverbal, communication. Therefore, sustaining a severe burn, and in particular a facial burn, is a devastating and traumatizing injury. Burn survivors may encounter unique psychosocial problems and experience higher rates of psychosocial maladjustment, although there may be a number of potentially mediating factors. Objectives The purpose of this phenomenological study was to examine the early recovery experience of patients with a facial burn. In particular, this study focused on how the injury impacted on the participants’ relationship with their own body and the challenges of early psychosocial adjustment within the first 4 months of sustaining the injury. Methods In 2011, six adult participants encompassing two females and four males ranging from 29 to 55 years of age with superficial to deep dermal facial burns (with background burns of 0.8%–55% total body surface area) were recruited from a severe burn injury unit in Australia for participation in a Burns Modified Adult Attachment Interview. Narrative data were analyzed thematically and informed by Colaizzi’s method of data analysis. Results Three overarching themes emerged: relationship to self/other, coping, and meaning-making. Themes identified related to how the experience affected the participants’ sense of relationship with their own bodies and with others, as well as other challenges of early psychosocial adjustment. All participants indicated that they had experienced some early changes in their relationship with their body following their burn injury. Conclusion These findings highlight the struggle burn survivors experienced with postburn adjustment, but expressed altruism and optimism around their recovery. Past trauma was observed to be a significant finding in this sample. Understanding the “lived experience” supports the way clinical and family systems can foster positive adjustment and coping. Consequently, multidisciplinary burn teams and health care professionals need to understand the principles of trauma-informed care and translate these into practice in the treatment of this group of patients.

Getting depression clinical practice guidelines right: time for change?

As part of a series of papers [‘Chronobiology of mood disorders’ Malhi & Kuiper. Acta Psychiatr Scand 2013;128(Suppl. 444):2–15; and ‘Its time we managed depression: The emerging role of chronobiology’ Malhi et al. Acta Psychiatr Scand 2013;128(Suppl. 444):1] examining chronobiology in the context of depression, this article examines recent western clinical practice guidelines (CPGs) for the treatment of depression with respect to the recommendations they make, in particular as regards chronobiological treatments, and briefly considers the implications of their methodology and approach.

Human Borna disease virus infection in Australia: serological markers of infection in multi-transfused patients.

Borna disease virus (BDV) causes neurological disease in horses, however, there is no consensus as to the extent or significance of human infection. BDV antigen levels in plasma (BDVpAg) and anti-BDV were measured by ELISAs. Confirmation was by Western blot (WB), immunofluorescence assay (IFA) or BDV-peptide-epitope ELISA. For 42 volunteers psychiatrically-defined as non-depressed (82 samples) neither BDVpAg nor anti-BDV was detected. For 104 patients with diagnosed depression (290 samples) 1 was BDVpAg positive and 5 anti-BDV positive, one epitope-e8 positive and 4 IFA positive, with 96% concordance for repeat samples. No BDVpAg was detected in 214 pregnant women, 2 were anti-BDV positive, one WB-confirmed (p24/p40). For 219 donors 2 were BDVpAg positive with anti-BDV detected in 5 (2.3%) one IFA 1:10, another IFA 1:40/epitope-e8 positive. In multitransfused patients, 3/168 were BDV pAg positive, with 14/168 anti-BDV positive, 1 epitope-e8 positive, 2 WB positive and 1 IFA 1:10. In BDVpAg positive multi-transfused patients there was an elevated risk of transaminitis. In one case, a patient BDV-negative prior to transfusion was BDVpAg positive for several months posttransfusion (associated with transaminitis). These data provide serological evidence, supported by confirmatory assays and repeat-sample concordance, of BDV infection in Australia, particularly in multi-transfused patients.

To BD or not to BD: functional neuroimaging and the boundaries of bipolarity

Bipolar disorders are major mood disorders defined by the presence of discrete episodes of depression and either mania, in bipolar I disorder, or hypomania, in bipolar II disorder. There is little contention that both are serious psychiatric conditions or that they are associated with substantial suffering, disability, risk of suicide and cost to the community. Recently, focus has shifted away from classic manic-depressive illness toward a ‘bipolar spectrum’ model, which allows for much softer presentations to be conceptualized as bipolarity, but the boundaries of this concept remain contentious. In this article, we will consider the contribution of neuroimaging to delineating the bipolar phenotype and differentiating it from similar disorders.