Philip E. Mosley

Bigorexia: bodybuilding and muscle dysmorphia

Muscle dysmorphia is an emerging condition that primarily affects male bodybuilders. Such individuals obsess about being inadequately muscular. Compulsions include spending hours in the gym, squandering excessive amounts of money on ineffectual sports supplements, abnormal eating patterns or even substance abuse. In this essay, I illustrate the features of muscle dysmorphia by employing the first-person account of a male bodybuilder afflicted by this condition. I briefly outline the history of bodybuilding and examine whether the growth of this sport is linked to a growing concern with body image amongst males. I suggest that muscle dysmorphia may be a new expression of a common pathology shared with the eating disorders.

The Psychiatric and Neuropsychiatric Symptoms After Subthalamic Stimulation for Parkinson’s Disease

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an established treatment for the motor symptoms of Parkinsons disease (PD). Nonmotor features of PD, however, may not improve with STN DBS, and a specific constellation of neuropsychiatric symptoms may emerge in the postoperative period. Mania, impulsivity, depression, and apathy may curtail the potential gains from surgery. In this paper, the authors discuss surgical candidacy, postoperative management of neuropsychiatric issues, and clinical dilemmas for the psychiatrist at the DBS center. A paradigm that considers stimulation effects and dopamine replacement therapy to be key drivers of postoperative neuropsychiatric problems is presented.

Management of impulse control disorders in Parkinson's disease.

BACKGROUND Impulse control disorders (ICDs) have become a widely recognized non-motor complication of Parkinsons disease (PD) in patients taking dopamine replacement therapy (DRT). There are no current evidence-based recommendations for their treatment, other than reducing their dopaminergic medication. METHODS This study reviews the current literature of the treatment of ICDs including pharmacological treatments, deep brain stimulation, and psychotherapeutic interventions. RESULTS Dopamine agonist withdrawal is the most common and effective treatment, but may lead to an aversive withdrawal syndrome or motor symptom degeneration in some individuals. There is insufficient evidence for all other pharmacological treatments in treating ICDs in PD, including amantadine, serotonin selective reuptake inhibitors, antipsychotics, anticonvulsants, and opioid antagonists (e.g. naltrexone). Large randomized control trials need to be performed before these drugs can be routinely used for the treatment of ICDs in PD. Deep brain stimulation remains equivocal because ICD symptoms resolve in some patients after surgery but may appear de novo in others. Cognitive behavioral therapy has been shown to improve ICD symptoms in the only published study, although further research is urgently needed. CONCLUSIONS Further research will allow for the development of evidence-based guidelines for the management of ICDs in PD.

Caregiver Burden in Parkinson Disease: A Critical Review of Recent Literature:

Burden is a negative psychological state induced in caregivers by the demands of providing care to a person with an illness or a disability. Managing caregiver burden in Parkinson disease (PD) is significant because informal caregivers make a substantial contribution to the well-being of persons with PD, incurring financial, social, and personal losses. Failure to recognize and manage caregiver burden may lead to burnout and premature institutionalization of the person with PD. We conducted a comprehensive literature review to identify and summarize factors that may amplify burden, including motor and nonmotor symptoms of PD, caregiver psychiatric symptoms, and caregiver coping style. We review instruments designed to sample the construct of burden among caregivers and evaluate interventions that may reduce burden, either by directly targeting caregivers or by treating PD symptoms associated with burden. We aim to provide a concise synopsis of these issues for the clinician or researcher working with this population in order to facilitate recognition of caregiver burden, provide accurate assessment, administer appropriate interventions, and stimulate further research in this area.

Deep brain stimulation for depression: Scientific issues and future directions

Objective: Deep brain stimulation is an experimental intervention for treatment-resistant depression. Open trials have shown a sustained response to chronic stimulation in many subjects. However, two recent randomised, double-blind, placebo-controlled trials failed to replicate these results. This article is a conceptual paper examining potential explanations for these discrepant findings. Method: We conducted a systematic review of the published studies obtained from PubMed and PsycINFO. Studies were selected if they directly examined the impact of deep brain stimulation on depressive symptoms. We excluded case reports and papers re-describing the same cohort of patients. We compared them with data from the placebo-controlled trials, available from Clinicaltrials.gov and abstracts of the American Society for Stereotactic and Functional Neurosurgery. We supplemented our investigation by reviewing additional publications by the major groups undertaking deep brain stimulation for mood disorders. Results: We selected 10 open studies reporting on eight cohorts of patients using four different operative targets. All published studies reported positive results. This was not replicated in data available from the randomised, placebo-controlled trials. Many studies reported suicide or suicide attempts in the postoperative period. Conclusion: We consider the placebo effect, the pattern of network activation, surgical candidacy and design of a blinded trial including the length of a crossover period. We suggest a greater focus on selecting patients with melancholia. We anticipate that methodological refinements may facilitate further investigation of this technology for intractable depression. We conclude by noting the psychiatric adverse events that have been reported in the literature to date, as these will also influence the design of future trials of deep brain stimulation for depression.

Caregiver burden and caregiver appraisal of psychiatric symptoms are not modulated by subthalamic deep brain stimulation for Parkinson’s disease

Subthalamic deep brain stimulation is an advanced therapy that typically improves quality of life for persons with Parkinson’s disease (PD). However, the effect on caregiver burden is unclear. We recruited 64 persons with PD and their caregivers from a movement disorders clinic during the assessment of eligibility for subthalamic DBS. We used clinician-, patient- and caregiver-rated instruments to follow the patient–caregiver dyad from pre- to postoperative status, sampling repeatedly in the postoperative period to ascertain fluctuations in phenotypic variables. We employed multivariate models to identify key drivers of burden. We clustered caregiver-rated variables into ‘high’ and ‘low’ symptom groups and examined whether postoperative cluster assignment could be predicted from baseline values. Psychiatric symptoms in the postoperative period made a substantial contribution to longitudinal caregiver burden. The development of stimulation-dependent mood changes was also associated with increased burden. However, caregiver burden and caregiver-rated psychiatric symptom clusters were temporally stable and thus predicted only by their baseline values. We confirmed this finding using frequentist and Bayesian statistics, concluding that in our sample, subthalamic DBS for PD did not significantly influence caregiver burden or caregiver-rated psychiatric symptoms. Specifically, patient–caregiver dyads with high burden and high levels of psychiatric symptoms at baseline were likely to maintain this profile during follow-up. These findings support the importance of assessing caregiver burden prior to functional neurosurgery. Furthermore, they suggest that interventions addressing caregiver burden in this population should target those with greater symptomatology at baseline and may usefully prioritise psychiatric symptoms reported by the caregiver.Deep brain stimulation: negligible effect on caregiver burdenUsing subthalamic deep brain stimulation (DBS) to treat patients with advanced Parkinson’s disease (PD) does not alleviate caregiver burden. Continuous electrical stimulation of deep brain nuclei has been shown to improve motor symptoms, reduce the need for dopaminergic medication and generally enhance patients’ quality of life. However, DBS can also produce psychiatric side effects, including depression and impulsivity potentially increasing the strain on caregivers. An Australian study led by Philip E. Mosley at Neurosciences Queensland followed the pre- and postoperative status of 64 patients and their caregivers for 26 weeks. They found that DBS did not influence caregiver burden nor caregiver-rated psychiatric symptoms. This study highlights the importance of assessing the well-being of caregivers prior to the patients’ surgery and the need to manage their expectations about the benefits of DBS treatment.

The site of stimulation moderates neuropsychiatric symptoms after subthalamic deep brain stimulation for Parkinson's disease

Deep brain stimulation of the subthalamic nucleus for Parkinsons disease is an established advanced therapy that addresses motor symptoms and improves quality of life. However, it has also been associated with neuropsychiatric symptoms such as impulsivity and hypomania. When significant, these symptoms can be distressing, necessitating psychiatric intervention. However, a comprehensive analysis of neurocognitive and neuropsychiatric outcomes with reference to the site of subthalamic stimulation has not been undertaken. We examined this matter in a consecutive sample of 64 persons with Parkinsons disease undertaking subthalamic deep brain stimulation. Participants were assessed with a battery of neuropsychiatric instruments at baseline and at repeated postoperative intervals. A psychiatrist identified patients with emergent, clinically-significant symptoms due to stimulation. The site of the active electrode contact and a simulated volume of activated tissue were evaluated with reference to putative limbic, associative and motor subregions of the subthalamic nucleus. We studied anatomical correlates of longitudinal neuropsychiatric change and delineated specific subthalamic regions associated with neuropsychiatric impairment. We tested the ability of these data to predict clinically-significant symptoms. Subthalamic stimulation within the right associative subregion was associated with inhibitory errors on the Excluded Letter Fluency task at 6-weeks (p = 0.023) and 13-weeks postoperatively (p = 0.0017). A cluster of subthalamic voxels associated with inhibitory errors was identified in the right associative and motor subregions. At 6-weeks, clinically-significant neuropsychiatric symptoms were associated with the distance of the active contact to the right associative subregion (p = 0.0026) and stimulation within the right associative subregion (p = 0.0009). At 13-weeks, clinically-significant symptoms were associated with the distance to the right (p = 0.0027) and left (p = 0.0084) associative subregions and stimulation within the right associative subregion (p = 0.0026). Discrete clusters of subthalamic voxels associated with high and low likelihood of postoperative neuropsychiatric symptoms were identified in ventromedial and dorsolateral zones, respectively. When a classifier was trained on these data, clinically-significant symptoms were predicted with an accuracy of 79%. These data underscore the importance of accurate electrode targeting, contact selection and device programming to reduce postoperative neuropsychiatric impairment. The ability to predict neuropsychiatric symptoms based on subthalamic data may permit anticipation and prevention of these occurrences, improving safety and tolerability.

Ethical, Social and Clinical Challenges in using Deep Brain Stimulation to Treat Addiction and Other Impulsive and Compulsive Disorders

Addiction to alcohol, tobacco and other drugs, and other compulsive disorders, such as pathological gambling and overeating, are major causes of preventable disease burden globally.1 Addictions also cause significant personal distress to individuals and their loved ones. Effective long-term treatments for most addictions remain elusive, with the possible exception of substituting a drug of addiction with a similar less harmful drug (e.g. methadone for heroin addiction). Growing interest in the neurobiological mechanisms of addiction, and the successful application of deep brain stimulation (DBS) for neurological disorders, such as Parkinson’s disease and dystonia, as well as some psychiatric disorders (e.g. depression), has led to calls for trials of DBS to treat addictive and compulsive disorders.2 The medicalization of compulsion has also seen an expansion in the range of behaviours being labelled as “addictions”. The list now includes: eating or “food addiction”, gaming and Internet use, sex and gambling.3 The status of these conditions as “medical” disorders is often justified by an appeal to neuroscience to the claim that these behaviours are the result of “brain diseases”.4 The aim of such arguments is often to garner public support, reduce stigma and increase access to treatment for people suffering intractable behavioural disorders. Nonetheless one unintended consequence may be the inappropriate use of an invasive and expensive neurological technology that carries the potential risk of iatrogenic harm. In this chapter, we critically examine the evidence supporting the use of DBS in addictive and impulsive/compulsive disorders, and discuss key ethical, social and clinical challenges that this proposed use of DBS raises. We compare three compulsive behaviours for which DBS has been advocated and in some cases trialled: drug addiction, obesity and obsessive-compulsive disorder (OCD). By comparing these

Establishing a Deep Brain Stimulation Trial for Patients with Anorexia Nervosa

Background: Natural disasters affect the health and wellbeing of adults throughout the world. There is some debate in the literature as to whether older persons have increased risk of mental health outcomes after exposure to natural disasters when compared to younger adults. To date, no systematic review has evaluated this. Objectives: We aimed to synthesise the available evidence on the impact of natural disasters on the mental health and psychological distress experienced by older adults. Methods: A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, and adjustment disorder. Findings: We identified six papers with sufficient data for a random effects meta-analysis. Older adults were 2.11 times more likely to experience PTSD symptoms when exposed to natural disasters when compared to younger adults. Conclusions: Recent decades have seen a global rise in the numbers of older adults affected by natural disasters, implying that an increasing number of the older adults will find themselves “in harm’s way” amid community disruption and distress. Mental health service providers need to be prepared to meet the mental health needs of older persons, and be particularly vigilant after natural disasters to ensure, in particular, early detection and management of PTSD.Abstract of a poster presentation at the RANZCP 2015 Congress, Brisbane, Australia, 3-7 May 2015. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Dawes, K., Lethbridge, A. & Pai, N. (2015). Does clinical placement location affect medical student exam performance in psychiatry?. Australian and New Zealand Journal of Psychiatry, 49 (Suppl. 1), 107-108. This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/2780 Poster Presentations RANZCP 2015 CONGRESs, Brisbane Convention and Exhibition Centre, 3–7 May 2015 Does Clinical Placement Location Affect Medical Student Exam Performance in Psychiatry? K Dawes, A Lethbridge, N Pai University of Wollongong, Wollongong, Australia Background: One of the many challenges in managing student clinical placements is trying to ensure equity of opportunity and experience in regards to meeting the curriculum objectives. Students often complain that they have been disadvantaged by their clinical placement due to variations in patient population and acuity, the availability of consultants, registrars and other health care staff to guide learning, and the presence of other students from all disciplines who compete for opportunities. Objectives: To identify if there is a relationship between psychiatry placement location in the Illawarra Shoalhaven Local Health District (ISLHD) and end of year psychiatry exam results for medical students from the University of Wollongong. Methods: We compared psychiatry oral and written exam results for six cohorts of students, from 2009 to 2014, across four different placement locations in the ISLHD (N = 450) using one-way multivariate analysis of variance. Findings: The multivariate effect of placement location was not significant (Pillai’s Trace = .013, F(6,892) = .994, p = .428). Univariate ANOVAs on the individual outcome variables were also non-significant (written exam scores, F(3, 446) = 1.373, p = .250; oral exam scores F(3,446) = .789, p = .501). Conclusions: Maintaining the quality and consistency of clinical placements will always be a challenge due to limited and varied opportunities, student numbers, and the dynamic nature of both the workforce and the patient populations. However, based on our findings, within our region there is no difference in placement location in regards to end of year psychiatry exam results.Background Australia and New Zealand both have mandated systems for routine outcome measurement within public mental health services. A comprehensive 2014 review of the Australian system highlighted both support for routine outcome measurement and a need to spread good practice in the use of the mandated measures in practice. At the same time, the mandated measures are under evaluation in Australia for inclusion within activity based funding processes. The RANZCP has completed two online modules to assist trainees in improving their knowledge and skills in this important area of practice.

Predicting psychiatric symptoms after subthalamic deep brain stimulation for Parkinson's disease

IntroductionLead movement after deep brain stimulation (DBS) may occur and influence the area of stimulation. The cause of the displacement is not fully understood. The aim of the study was to inve ...Objective: We here investigated the effect of bilateral 6-hydroxydopamine (6-OHDA) lesions, a rat model for Parkinsons disease (PD), on impulsivity and attention in an auditory oddball paradigm. In PD, the progressive loss of dopamine (DA) neurons in the substantia nigra leads to disturbed motor function, but cognitive disturbances, including attentional deficits and impulsivity, are increasingly recognized as disabling factors. Rats with 6-OHDA induced nigrostriatal lesions of dopamine neurons show significant motor impairment reminiscent of PD, and recent studies also indicate cognitive impairment in this model. Methods: Rats were trained in a 3-class auditory oddball paradigm, where they had to nose poke a hole after an infrequent correct tone, which was rewarded by a pellet, but to ignore a frequent standard tone and infrequent distractor tone. After reaching a criterion of 90% correct hits, retrograde degeneration of DA neurons in the substantia nigra were induced by bilateral striatal injection of 6-OHDA (10 μg in 1μl PBS; n=12), sham-lesioned rats (controls; n=8) received vehicle. Four weeks after surgery the rats were re-tested in the oddball paradigm. Results: After 6-OHDA lesions, rats show deteriorated attention, as indicated by a significant decrease in the hit rate to the correct tone. Additionally, the number of impulsive nose pokes was reduced compared to controls, which would indicate less impulsive behavior. Conclusion: We conclude that rats with bilateral 6-OHDA lesions may be used to investigate the biological basis of attentional deficits in PD, and to develop and test new therapeutic strategies for these symptoms ranging from pharmacological treatment to neurosurgical intervention.Introduction: Chronic electric deep brain stimulation (DBS) has been proposed to enable consciousness recovery, targeting mainly the central thalamus. Our aim was to study clinical effects of bilateral pallido-thalamic low frequency stimulation intended to overdrive neuronal activity in continuing disorders of consciousness. Methods: Five patients were included in a prospective, monocentric, 12-month clinical observational study, with blind crossover period (NCT01718249): P1 male, 32 y/o, 12 years after traumatic brain injury (TBI), vegetative status (VS); P2 female, 62 y/o, 14 months after intracerebral hemorrhage (ICH), minimally conscious state (MCS); P3 male, 24 y/o, 3 years after TBI, MCS; P4 female, 22 y/o, 4 years after TBI, MCS; P5 female, 47 y/o, 27 months after ICH, MCS. Four phases were individualized: (1) Baseline, at least 2 months; (2) DBS surgery and titration, 1 month; (3) blind, random, 3-month cross over (CO) period with 1.5month ON (CO-ON) and OFF (CO-OFF) conditions; (4) unblinded, at least 5 months, DBS period (DBS-ON). Electrodes (DBS 3389, Medtronic, USA) were placed within the right and left targets accounting for the lesions of patients. Two neuropacemakers (ACTIVA, Medtronic, USA) were implanted. Primary outcome was the analysis of scores of the Coma Recovery Scale Revised (CRS-R; 0-23): assessments 2 times per week; for the 5 patients, n=419, scores ranging from 1 to 18. Statistical analyses were conducted for a two-sided Type I error of 5% using random-effects models accounting between and within patient variability due to repeated measurements. Results: No mortality related to surgery and DBS. By individual we observed statistically significant improvement of CRS-R during DBS-ON versus baseline (P1, P3) and CO-On versus baseline (P3). For the 5 patients (group analysis) auditory, visual, motor, oromotor-verbal, communication subscores of CRS-R were significantly improved during DBS-ON versus baseline. Cross-over analysis did not show statistically significant improvement of CRS-R and subscores during CO-ON versus CO-OFF, except P2 and P3 motor sub scores. Conclusion: Bilateral low frequency DBS in severe continuing disorders of consciousness improved patients on the short term without irreversible adverse effects. Individual analysis seems preferable facing the complexity of clinical features and pathophysiology. Given the current state of knowledge, expectations of relatives, caregivers and physicians should be weighted.