FASD and Mental Illness: Correlations.
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In spite of many, and increasing, correlations the possibility/probability that pre conceptual and prenatal alcohol exposure is a key component in the CAUSE of mental illnesses has never been explored or excluded. Slides taken from Fetal Alcohol Spectrum Disorder Symposium: Seeing The Other Perspective. DA DWA DA DEHS NYE>S September 9, 2014
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FASD and Mental Illness: Correlations.
- 1. FETAL ALCOHOL SPECTRUM DISORDER SYMPOSIUM SEEING THE OTHER PERSPECTIVE DA DWA DA DEHS NYE>S SEPTEMBER 9, 2014 Barry Stanley. www.barrystanleyfasd.com. Docstoc bstanley31
- 2. CORRELATION – CAUSE AND EFFECT Because there is a correlation it can not be assumed that there is a cause and effect. But, there cannot be cause and effect without correlation. Where there is a strong, significant correlation relating to the health of individuals and society the medical profession has a moral and ethical duty to investigate possible cause and effect. barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 3. FOLIC ACID AND SPINA BIFIDA 1970s- 1980s Correlation – Spina Bifida was related to Folic Acid deficiency in the mothers. 1991 – Cause and Effect confirmed - Publication of the results from the Medical Research Council Vitamin Study [U.K.] 1992, 14 months later the Centers of Disease Control and Prevention [U.S.A.] recommended Folic Acid to reduce incidence of Spina Bifida barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 4. MENTAL ILLNESS AND PAE/FASD Streissuguth et.al 1996 barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 5. barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 6. FAS @ Street Level. Conference. Toronto, 2003. The Incidence and Prevalence of Fetal Alcohol Syndrome and Alcohol-Related Neurodevelopmental Disorder – Implications for Mental Health Workers. “So what are the implications for mental health workers.? The diagnosis of FAS/ARND should be considered for those clients who have a history of secondary disabilities. Especially those diagnosed with chronic mental health problems.” barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 7. • Review of Canadian and American Journals of Psychiatry C.J.P- Feb.1996 – Oct.2006 Only one article on FASD = 0.O8 per cent of all articles published A.J.P.- Jan.1996 – Sep.2007 Only one article on FASD [ 3 – 2014] = 0.03 per cent of all articles published barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 8. PSYCHIATRIC ASSESSMENT (Calgary Consultation practice) O’Malley , 2001 ( CDC), O’Malley 2007 57 Patients, 3 to 32 Years 40 Males, 17 Female AXIS I ADHD 58%, Mood Disorder 44% Personality Change: Labile/Aggressive 36% AXIS II Avoidant Personality 14% Dependent Personality 13% Passive/ aggressive personality 9% Schizoid Personality 8% barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 9. Parallel Tracks The Brain of Mental Illness The Brain of Fasd barry stanley www.barrystanleyfasd.com docstoc bstanley31 Psychiatry and PAE/FASD are on parallel tracks. The psychiatric train is a closed train. Those on the PAE/FASD train are reaching out but are not seen or heard.
- 10. Correlations between Prenatal Alcohol Exposure and Mental Illnesses Those parts of the brain known to be affected in attention, mood and personality disorders are also know to be affected in FASD The functions of these parts of the brain correlate with the disturbed behaviors of mental illness and those afflicted with fasd. barry stanley www.barrystanleyfasd.com docstoc bstanley31
- 11. > The brain is a complex system PAE creates a complex chaotic system Manipulation of a complex system by a simple system leads to unintended consequences The more complex the system is the greater the unintended consequences barry stanley www.barrystanley.com docstoc bstanley 31
- 12. Epigenetics explains the many puzzling and contradictory observations about FASD. The brain dysfunctions of PAE are only part of the disease effect of PAE The factor of the mother drinking in a pregnancy no longer stands alone. The term “prenatal” for any given pregnancy has to include alcohol exposure from both parents, including previous generations. The nomenclature of FASD needs to be changed to reflect our understanding of epigenetics without diminishing acknowledgment and treatment of FASD, as occurs at present. Disorders of mood and personality need to be redefined in the context of environmental factors that cause changes in gene expression- alcohol being a major factor. Society needs to be aware that the manipulation of gene expression will result in harmful unintended consequences CONCLUSIONS barry stanley www.barrystanleyfasd.com docstoc bstanley 31
Editor's Notes
- Barry Stanley This presentation is about FASD and the effects of PAE from the perspective of the history and ongoing abuse of alcohol, the ongoing and rapid development of our understanding of brain function, and the explosive, exponential growth of epigenetics. Do not be put off by the complexity of each of these. We do not have to be experts on these subjects, we do have to have an understanding of their significance for FASD. We especially need to have this understanding because those who are experts in neurology and epigenetics do not pay any consideration to PAE and FASD. Disorders of neurogenesis of cortical and subcortical structures in rat brain limbic system during fetal alcohol syndrome formation. Morfologiia. 2012;141(2):18-22. Abstract “Disorders of neurogenesis of cortical and subcortical structures in rat brain limbic system were studied in the offspring of rats that received ethanol during pregnancy. The methods used included the staining of histological sections with cresyl violet, in vitro culture, and electron paramagnetic resonance. Prenatal alcohol intoxication was shown to induce the disturbances in proliferative activity of granular layer cells in the hippocampal dentate gyrus, neuron- and glioblast migration, enhancement of free NO and lipoperoxide production and cell death. This resulted in the changes in the number of neurons in cortical and subcortical structures of rat brain limbic system and in fetal alcohol syndrome formation.”
- Barry Stanley The correlations between PCAE, PAE, and FASD to Brain pathology and Mental Illness are numerous. It is immoral and unethical to ignore these correlations.
- Barry Stanley This is how it should be. Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. The Lancet. Volume 338. Issue 8760, 20 July 1991. Pages 13`-137 Recommendations for the Use of Folic Acid to Reduce the Number of Cases of Spina Bifida and Other Neural Tube Defects. Centers for Disease Control and Prevention. September 11, 1992 / 41(RR-14);001 “Recommendations for the Use of Folic Acid to Reduce the Number of Cases of Spina Bifida and Other Neural Tube Defects Summary Spina bifida and anencephaly are common and serious birth defects. Available evidence indicates that 0.4 mg (400 ug) per day of folic acid, one of the B vitamins, will reduce the number of cases of neural tube defects (NTDs). In order to reduce the frequency of NTDs and their resulting disability, the United States Public Health Service * recommends that: All women of childbearing age in the United States who are capable of becoming pregnant should consume 0.4 mg of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other NTDs. Because the effects of higher intakes are not well known but include complicating the diagnosis of vitamin B((12)) deficiency, care should be taken to keep total folate consumption at less than 1 mg per day, except under the supervision of a physician. Women who have had a prior NTD-affected pregnancy are at high risk of having a subsequent affected pregnancy. When these women are planning to become pregnant, they should consult their physicians for advice.
- Barry Stanley The connections and correlations of PAE/FASD to DSM diagnoses are there for the viewing. Mood and Personality diagnoses from the DSM have to be caused by brain dysfunction; dysfunctions that are the same as those caused by PAE. Fledgling pathoconnectomics of psychiatric disorders. Mikail Rubinov and Ed Bullmore. Special Issue: The Connectome - Trends in Cognitive Sciences, December 2013, Vol. 17, No. 12 “Conceptual challenges of pathoconnectomics Sufficient phenotypes of psychiatric disorders Objective delineation of psychiatric disorders is a central and perennial problem of psychiatry. In the current absence of such definitions, psychiatrists define psychiatric disorders using convenient, but not biologically validated, clinical phenotypes or groupings of symptoms and signs”
- Barry Stanley The DSM presentations in FASD are extensive. Multiple diagnoses are not uncommon. Frontal–subcortical neuronal circuits and clinical neuropsychiatry An update. Sibel Tekina, Jeffrey L. Cummingsb. Journal of Psychosomatic Research 53 (2002) 647– 654 Abstract Frontal–subcortical circuits form the principal network, which mediate motor activity and behavior in humans. Five parallel frontal–subcortical circuits link the specific areas of the frontal cortex to the striatum, basal ganglia and thalamus. These frontal– subcortical circuits originate from the supplementary motor area, frontal eye field, dorsolateral prefrontal region, lateral orbitofrontal region and anterior cingulate portion of the frontal cortex. The open afferent and efferent connections to the frontal–subcortical circuits mediate coordination between functionally similar areas of the brain. Specific chemoarchitecture and multiple neurotransmitter interactions modulate the functional activity of each circuit. Dorsolateral prefrontal circuit lesions cause executive dysfunction, orbitofrontal circuit lesions lead to personality changes characterized by disinhibition and anterior cingulate circuit lesions present with apathy. The neurobiological correlates of neuropsychiatric disorders including depression, obsessive–compulsive disorder, schizophrenia and substance abuse, imply involvement of frontal–subcortical circuits.” “Summary There are five frontal–subcortical circuits providing the neuroanatomical basis for movement and behavior. Each of the circuits shares the same member structures including the frontal cortex, striatum, globus pallidus/substantia nigra and thalamus. Neurotransmitters like DA, acetylcholine, glutamate and serotonin mediate and modulate the neurotransmission through the circuits. Frontal–subcortical circuits are named according to their cortical site of origin. The dorsolateral circuit conveys executive function. Executive dysfunction is one of the main characteristics of subcortical dementia. The orbitofrontal circuit mediates empathic and socially appropriate behavior. Personality change with disinhibition is evident in orbitofrontal circuit dysfunction. Anterior cingulate circuit is involved in generating motivated behavior and apathy is observed in lesions of this circuit. OCD, depression, psychosis and substance abuse are some of the neuropsychiatric disorders associated with frontal–subcortical circuit dysfunction. The frontal–subcortical circuits comprise an integrative framework for understanding motor, cognitive and emotional functions in a variety of neurological and psychiatric disorders.”
- Barry Stanley FASD should be excluded for individuals who have multiple DSM diagnoses; this would mean a full psychological assessment, rarely done in psychiatry. Children diagnosed with ADHD should have FASD excluded, with a cardiac assessment, before being prescribed psychostimulants. This is because those with FASD are at risk for cardiac defects, and suicide. FAS @ Street Level. Conference that was held on November 24 and 25th, 2003 in Toronto. The Incidence and Prevalence of Fetal Alcohol Syndrome and Alcohol-Related Neurodevelopmental Disorder - Implications for Mental Health Workers. How many of us know, directly or indirectly, of a person with FAS or ARND between the ages of 1 and 16 years? - How many of us know of a person with FAS or ARND, directly or indirectly, between the ages of 35 or 50 years? FAS was first described in North America in 1973. Prior to that there had been two studies in France in 1960 and 1967, that described physical and psychological abnormalities in children, following the taking of alcohol during pregnancy. FAS has been with us since men and women first consumed alcohol. Aristotle apparently described the relationship between alcohol taken during pregnancy and the birth of defective children. Aristotle also said - “It is not once nor twice, but times without number, that the same ideas make their appearance in the world. What we forget or ignore from the past, we pay for in the future. - From the Bible - “Behold, thou shalt conceive and bear a son; and now drink no wine or strong drink”. In Carthage, there was a prohibition against the bridal couple drinking on their wedding night, for fear of producing a defective child. Navajo tradition states that women who drink crazy water when bearing a child will give birth to a child crazy in body and mind. A report to the British House of Commons in 1834, stated that infants of alcoholic mothers often have a starved, shriveled and imperfect look. Incidence is the number of new cases born or detected each year - in a hospital, a province or a country. Prevalence is the total number of cases in the population at any time, in a geographical area. A prevalence of FAS of 40.5 to 46.4 per 1000 children between the ages of 5 and 9, has been reported in one community of the wine growing area of South Africa. The parents of these children labour in the wine industry. The children grow up to labour in the wine industry. Before we condemn the South Africans, let us acknowledge that many of those afflicted with FAS in North America end up in the menial, dirty and boring jobs - if they are able to work at all. The highest rate recorded in Canada for FAS - in a small native community - is 120 per 1000 Children. FAS, neo natal growth deficiency, characteristic facial abnormalities and CNS dysfunction, was the first to be investigated statistically - with difficulty. Accurate statistics require an accurate diagnosis. Initially the diagnosis was made by a few concerned physicians, mostly pediatricians. Opinions might vary as to the diagnosis. We now have more accurate, standardized assessments, that can be reproduced and verified, leading to - - more accurate diagnoses, - more appropriate patient care. -earlier intervention with reduced severity of secondary disabilities -and more accurate statistics regarding incidence and prevalence of the condition. St. Michaels Hospital, Toronto, has a Diagnostic Clinic that uses such a system. Each major city in Ontario should have one. There are basically three methods by which Incidence and Prevalence are determined. The first is Passive Surveillance , which was the first to be used. It is the least expensive but also the least accurate. Criteria for the diagnosis would be first established -(we have noted that historically the diagnosis tended to be inaccurate) - and then retroactive studies of records would be done - records such as birth certificates, hospital and physician records etc. The problem with this method was that most of those making the records knew nothing of the condition. It was therefore under reported, and still is, depending on the knowledge and diligence of those writing the records. Two retired obstetricians recently told me that they had never diagnosed a single case, during all the years that they practiced. In fairness, the facial features are not so noticeable at birth, which is one of the problems of maternity unit records of course, - if indeed FAS is considered at all. No matter how smart we are, we can only diagnose what we know. Incident rates of 0.2 to 0.67 per 1000 births have been determined with the Passive Surveillance method. The second method of obtaining statistics, clinic based, is pro-active and more accurate. Here, appropriately designed studies are established in prenatal clinics. Relevant data can be obtained regarding the mother’s health, alcohol intake etc. before, during and after pregnancy, and assessment of the infant can be made at birth. At the same time, this method allows for a degree of control over the variables, without which conclusions may be inaccurate. There are, however, certain problems with this method. Mothers who are most risk for FAS tend not to use such clinics. Those attending the clinic may not be representative of the general population, depending on the location of the clinic. Finally, the FAS features are less noticeable at birth, and the CNS dysfunction often not apparent. The diagnosis is most accurately diagnosed after 3 years of age. Clinic based studies give Incident rates of 1.9 to 2.2 per 1000 births. The third method for estimating the Incidence and Prevalence of FAS is through Active Case Centers. Here, Active Case Centers search for mothers and their children who are at risk. Referrals are encouraged, and referral networks developed. The diagnosis is made by a number of individuals, each an expert in a particular aspect of FAS. St. Michael’s is an example of such a Centre. As far as I know, St. Michael’s is the only Center in Canada that assesses individuals of all ages. Because these Centers are so pro-active, early intervention for those children at greater risk is more likely. The main objection to this method is the expense. The answer to that is that we can no longer afford the cost to society that this condition creates. The cost to society for the life span on one FAS child is estimated to be 1.4 million dollars. The annual cost of FAS in the U.S. in 1998 was estimated to be 2.8 Billion dollars. Active Case Centers provide the most accurate statistics for the referral area they serve. The greater the community is at risk, the higher the Incidence . From Active Case Centers, the overall rate for North America lies somewhere between 2 and 4 per 1000 births. However, following the description of FAS, it soon became apparent that some children did not have the facial features although they were otherwise effected. The term, Fetal Alcohol Effects was used to cover these cases. Because different people would have different definitions of FAE, the term has been dropped in favour of Alcohol Related Neurodevelopmental Disorder (ARND), for which there are standard diagnostic criteria, including a history of alcohol consumption during the pregnancy. Research has shown that the facial features only develop when alcohol is consumed during the first trimester of pregnancy - possibly in only one week and yet brain damage from alcohol occurs throughout the pregnancy. The most critical damage occurs in the first few weeks, when often the mother does not know she is pregnant. It follows then, that there are going to be more cases of ARND than FAS. When we look at the Incidence of FAS and ARND combined, then the rates become more alarming. The estimated rate for FAS and ARND combined is 9.1 per 1000 births in the U.S. - i.e. almost one in a hundred. This is considered to be a conservative estimate. There is no reason to believe that it is any less in Canada. Why is this an underestimation? First of all, the diagnosis of ARND is only made if there is a history of alcohol intake during the pregnancy. So often it is not possible to obtain such a history for various reasons. Secondly, there are very few Centers that have the ability to make the diagnosis. Thirdly, there is a tremendous lack of knowledge on the part of all professionals, regarding FAS and ARND. If it has been difficult to diagnose FAS with the facial features how much more difficult is it to diagnose ARND without the facial features? Lastly, an unknown number of stillborn deliveries, that would have FAS/ARND, are not included in these statistics. All of these estimations of Incidence and Prevalence relate to children. They are not a true estimation of the Prevalence in all of the population. Mysteriously these conditions seem to disappear around the age of 16 - 18..Which brings us to our original question. How many people between the ages of 35 and 50 do we know that are FAS/ARND? So what do we call these children, once they have become adults? In 1996 a report was published by Ann Streissguth and others from the University of Washington, Seattle. They had followed afflicted children and determined that they developed secondary disabilities. - Mental Health Problems, -Disrupted School Experience, -Trouble with the Law, -Confinement, -Inappropriate Sexual Behaviour, -Alcohol and Drug Problems, -Dependant Living, -and Problems with Employment. Over 90% went on to have mental health problems - Attention Deficit Disorder, Depression Suicide Threats, Suicide Attempts, Panic Attacks, Hearing Voices, /Seeing Visions,/Behaviour Problems, Assaulting Behaviour. Conduct Disorder, Sexual Acting Out, psychotic behaviour. ADHD is the most frequent mental health secondary disability. 60% of FAS/ARND children go on to be diagnosed as ADHD between the ages of 6yrs.- 20yrs. According to Stats Canada, 10% of Canadians are diagnosed as having mental health problems. If 1% of Canadians have FAS/ARND and 95% of those with FAS/ARND have mental health problems, then we can conclude that almost one in ten patients that mental health professionals see, must be FAS/ARND. These are conservative figures. The question is - what diagnosis are we giving these patients when they present as adults with mental health problems? The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association. The Manual sets the diagnostic standards for all mental health workers - psychiatrists, psychotherapists, social workers, nurses. FAS and ARND are not mentioned in the Manual. Yet one in ten mental health patients have these conditions. The closest reference, under Predisposing Facts - Mental Retardation, states that early alterations of embryonic development may be caused by toxins such as alcohol. However, if we look at the list of Mental Health problems that those with FAS and ARND suffer from, and compare them to the criteria used in the Manual, we can see where FAS and ARND patients might fit in. Examples in childhood - Mental Retardation, Learning Disorders, Pervasive Developmental Disorders, Attention Deficit Disorder, Reactive Attachment Disorder. Examples in adulthood - Substance Related Disorders, Mood Disorders, Anxiety Disorders, Impulse Control Disorders, Attention Deficit Disorder And Personality Disorders. Not all of those with these disorders are FAS/ARND. But it is surely amongst these cases that the lost FAS/ARND will be found. ADD and FAS/ARND. Since Ann Streissguth’s report was published in1996, Clair Coles, Director, Fetal Alcohol Centre, Emory University, Atlanta, has published work that clarifies the difference between FAS/ARND and ADHD. They are two distinct conditions and may be mutually exclusive. Whatever the final conclusions regarding the relationship of these conditions, the fact is that ADHD is the most common mental health problem that FAS/ARND individuals are diagnosed with, at this time. It is not surprising then, that many individuals diagnosed as FAS/ARND have previously been diagnosed with ADHD. I would like to share with you my personal experience. It is anecdotal and not at all conclusive, but does seem to confirm the points raised. In my practice, I see adults, but more recently, through my involvement with FASworld, I am seeing some FAS/ARND children with their parents. FAS/ARND children create stress in a marriage. It is not uncommon to see a couple who have an adopted child. In talking to the parents it often seems likely that the child might be FAS/ARND and when the child is subsequently assessed for FAS/ARND, the diagnosis has been confirmed. These children have usually previously been diagnosed as ADHD. In other cases, the diagnosis of FAS has been made before the family comes to see me, and the history also includes previous diagnosis of ADHD. Some adult patients who come for depression, anxiety, anger, often give a history of FAS/ARND secondary disabilities. They have often been diagnosed as borderline personality disorder, and their depression is of a chronic, intractable nature. A previous diagnosis of ADHD is not uncommon. In some of these cases it can be established that the mother drank during the pregnancy, and the diagnosis of FAS/ARND confirmed. If I had to choose one word to describe those who are afflicted with FAS/ARND it would be “chaos”. Their lives are chaotic and when one looks back over the life of an adult with this problem, that is what one sees - a life of continuous chaos. Often, there are moments when they say or do something that resonates with the potential that they would have had, were they not FAS/ARND. Tragically, they seem to be in some way aware of these potentials. Their struggle is reconciling what they feel they should be able to achieve, with the fact that they are not able to achieve it. So what are the implications for mental health workers.? The diagnosis of FAS/ARND should be considered for those clients who have a history of secondary disabilities. Especially those diagnosed with chronic mental health problems. The importance of making the correct diagnosis of course is that the FAS/ARND person needs to be handled in ways unique for that condition. - which is another topic. Dr. Barry Stanley M.B. Ch.B., F.R.C.S.( C ) References- Estimating the Prevalence of Fetal Alcohol Syndrome. P.A. May et.al., Alcohol, Research & Health., Vo. 25, No 3, 2001. Incidence of Fetal Alcohol Syndrome and Prevalence of Alcohol - P.D.Sampson et.al., Teratology 56:317-326 [1997] The History of Alcoholic Fetopathies [1997] Paul Lemoine, M.D., Nantes, France. JFAS Int. 2003, April 2003 Fetal Alcohol Syndrome- The South African Nightmare I.Fayez et.al., Hospital for Sick Children, Toronto.Scientific News - 2003. On The Heavens - Aristotle, 340 B.C. Bible - Judges 13-7, 1000 B.C. Statistics Canada.- Mental Health Diagnosing The Full Spectrum of Fetal Alcohol-Exposed Individuals: Introducing The 4-digit Diagnostic Code.Susan J. Astley and Sterling K. Clarren. Alcohol and Alcoholism. Vol. 35, No. 4, 2000. Fetal Alcohol Syndrome: Implications For Correctional Service. F.J. Bolland et.al. Research Report, Research Branch, Correctional Service Canada. The 10th. Special Report to the U.S. Congress On Alcohol and Health. An Introduction to the Problem of Alcohol Related Birth Defects. www.med.unc.edu/alcohol/ed/fas/slides Fetal Toxicology Division, Bowles Centre for Alcohol Studies, University of North Carolina. Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome [FAS] and Fetal Alcohol Effects [FAE] Final Report, August 1996.Ann P. Streissguth et.al. Fetal Alcohol and Drug Unit, University of Washington School of Medicine. Fetal Alcohol Exposure and Attention: Moving Beyond ADHD.. Claire . Coles, Director, Fetal Alcohol Centre, Marcus Institute, Emory University, Atlanta Georgia.Alcohol Research and Health, Vol.25, No 3, 2001. SEE ALSO - DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 15: 176–192 (2009) PREVALENCE AND EPIDEMIOLOGIC CHARACTERISTICS OF FASD FROM VARIOUS RESEARCH METHODS WITH AN EMPHASIS ON RECENT IN-SCHOOL STUDIES Philip A. May,1,2,3* J. Phillip Gossage,3 Wendy O. Kalberg,3 Luther K. Robinson,4 David Buckley,3 Melanie Manning,5 and H. Eugene Hoyme6 Personal Comment This is an excellent up to date review of the Incidence and Prevalence of FAS, PFAS, ARND and FASD. Points to note- -The authors refer to FASD as a diagnosis - The importance of diagnostic centers in the estimation of the incidence and prevalence -The alarming upward adjustments of these estimations. Barry Stanley- November, 2012.
- Barry Stanley The number of publications about FASD in the Psychiatry journals reflects the Psychiatry’s recognition of PCAE, PAE and FASD. Psychiatry trainees' training and experience in fetal alcohol spectrum. Acad Psychiatry. 2011 Jul-Aug;35(4):238-40.disorders. Abstract Alcohol is a teratogen. Fetal alcohol spectrum disorders (FASDs) affect about 1% of live births, causing severe impairment. Individuals affected by FASDs are overrepresented in psychiatric settings. This study reports on the education and experience of psychiatry trainees in approaching FASDs. Data were collected from psychiatry trainees throughout the country by use of a webbased questionnaire. A representative sample (N=308) of psychiatry trainees responded; 19% rate their education on FASDs as "good" or "excellent," and 89% report that they would like more education on FASDs: 6%, 15%, and 30%, endorsed the statement "It is safe to drink some alcohol" during the 1st, 2nd, and 3rd trimesters, respectively. Only 31% correctly report that individuals with an FASD are at equal risk for adverse outcomes as individuals with full-blown fetal alcohol syndrome. results reveal that training on FASDs is inadequate. Psychiatry trainees poorly understand the importance of abstinence throughout pregnancy. Trainees who report receiving supervision specifically addressing FASDs also report making the diagnosis much more frequently, suggesting that supervision in clinical settings is effective teaching. Results reveal that FASDs are Under recognized, resulting in missed opportunities for prevention and intervention. Psychiatric conditions associated with prenatal alcohol exposure. Dev Disabil Res Rev. 2009;15(3):225-34. Abstract Since the identification of fetal alcohol syndrome (FAS) over 35 years ago, mounting evidence about the impact of maternal alcohol consumption during pregnancy has prompted increased attention to the link between prenatal alcohol exposure (PAE) and a constellation of developmental disabilities that are characterized by physical, cognitive, and behavioral impairments. These disabilities include a continuum of developmental disorders known as fetal alcohol spectrum disorders (FASDs). Longitudinal studies suggest that individuals with FASDs are at a greatly increased risk for adverse long-term outcomes, including mental health problems and poor social adjustment. This review summarizes the existing literature on mental health outcomes for individuals with PAE across the lifespan, including findings in infancy and early childhood, middle childhood, and adolescence and early adulthood. Research on the psychiatric disabilities suffered by individuals with FASDs throughout development highlights the need for training of mental health professionals in the identification and the provision of specific treatments to address the unique features of this developmental disability since early identification and treatment have been demonstrated to be protective against more serious secondary disabilities. It is hoped that with greater awareness of the mental health problems experienced by individuals with FASDs, these individuals can receive appropriate and early treatment resulting in more adaptive and rewarding lives.
- Barry Stanley There are a few psychiatrists who recognize the connections between mental illness and PAE/FASD Fledgling pathoconnectomics of psychiatric disorders. Mikail Rubinov and Ed Bullmore. Special Issue: The Connectome - Trends in Cognitive Sciences, December 2013, Vol. 17, No. 12 “Schizophrenia studies show some evidence for correlations between structural [68] and functional [74,77] whole-brain connectivity and cognitive ability, consistent with previous work in healthy populations [101,102]. Cognition is increasingly recognized to be a key component of schizophrenia and indeed some call the disease a cognitive illness” “ Three autism studies examine and show correlations between whole-brain network organization and traits relevant to autism” Improving Awareness And Treatment Of Children With Fetal Alcohol Spectrum Disorders And Co-Occurring Psychiatric Disorders. The Disability Service Center JBS International, Inc. June 2013
- Barry Stanley Psychiatry and PAE/FASD are on parallel tracks. The psychiatric train is a closed train, those on the PAE/FASD train are reaching out but are not seen or heard. Developmental brain dysfunction: revival and expansion of old concepts based on new genetic evidence. Andres Moreno-De-Luca*, Scott M Myers*, Thomas D Challman, Daniel Moreno-De-Luca, David W Evans, David H Ledbetter. www.thelancet.com/neurology Vol 12 April 2013. “For many years, neurodevelopmental disorders have been recognised as clinically and aetiologically heterogeneous, to have overlapping symptoms, and to frequently co-occur. Despite these observations and extensive epidemiological data supporting the notion of a neurodevelopmental continuum, current diagnostic and classification systems are based on descriptive criteria, which were developed to improve the reliability of diagnosis and are largely atheoretical in terms of cause and pathophysiology. However, recent genetic evidence from whole genome copy number variant analyses and sequencing studies shows that identical genetic causes are common among apparently diff erent disorders, as predicted by the developmental brain dysfunction model. These findings provide strong evidence in support of not only reviving the old concept of minimal brain dys function or minimal cerebral dysfunction but also expanding the scope to include a broad spectrum of neurodevelopmental and neuropsychiatric disorders, which could be encompassed by the term developmental brain dysfunction.
- Barry Stanley We only see what we look for. We only diagnose what we know. REVIEW Mental health issues in fetal alcohol spectrum disorder. JACQUELINE PEI, KENNEDY DENYS, JANET HUGHES, & CARMEN RASMUSSEN. Journal of Mental Health, 2011; 1–11. “ Discussion and conclusions Researchers consistently report high levels of mental health problems within the FASD population. Although externalizing disorders such as ADHD are identified most frequently, many internalizing disorders such as depression and anxiety disorders are also disproportionately identified in those affected by FASD. Conceptualization of mental health disorders in this population appears to be gradually moving toward an integrated multifactorial model incorporating several overlapping and related factors including environment, brain impact due to PAE, and genetics. As such, screening for mental illness early in the lives of those affected by FASD is an important support strategy. Additionally, it is possible that, in some cases, presentation of a given disorder may vary from that within the general population, thereby requiring unique screening and intervention approaches. Moreover, it appears that problems that emerge in childhood do not disappear with age, but rather form the foundation for the development of additional, and possibly more severe, disorders later in life. The strong connection between PAE and issues such as substance abuse and suicide underscore the increasing impact of these disabilities as individuals age. However, without further longitudinal study it is difficult to know whether there is an increasing severity of mental health deficits and consequences with age and, if there is, whether this reflects increasingly deteriorating environmental factors or brain-based factors.” Jun Tanji, Eiji Hoshi. Role of the Lateral Prefrontal Cortex in Executive Behavioral Control. Physiological Reviews. 1 January 2008; Vol. 88 no: 37-57 ABSTRACT The lateral prefrontal cortex is critically involved in broad aspects of executive behavioral control. Early studies emphasized its role in the short-term retention of information retrieved from cortical association areas and in the inhibition of prepotent responses. Recent studies of subhuman primates and humans have revealed the role of this area in more general aspects of behavioral planning. Novel findings of neuronal activity have specified how neurons in this area take part in selective attention for action and in selecting an intended action. Furthermore, the involvement of the lateral prefrontal cortex in the implementation of behavioral rules and in setting multiple behavioral goals has been discovered. Recent studies have begun to reveal neuronal mechanisms for strategic behavioral planning and for the development of knowledge that enables the planning of macrostructures of event-action sequences at the conceptual level. Shazia Vegar Siddiqui, Ushri Chatterjee, Devvarta Kumar, Aleem Siddiqui, Nishant Goyal. Neuropsychology of prefrontal cortex. Indian Journal of Psychiatry. 2008; Jul- Sept; 50[3]: 202-208 Abstract The history of clinical frontal lobe study is long and rich which provides valuable insights into neuropsychologic determinants of functions of prefrontal cortex (PFC). PFC is often classified as multimodal association cortex as extremely processed information from various sensory modalities is integrated here in a precise fashion to form the physiologic constructs of memory, perception, and diverse cognitive processes. Human neuropsychologic studies also support the notion of different functional operations within the PFC. The specification of the component ‘executive’ processes and their localization to particular regions of PFC have been implicated in a wide variety of psychiatric disorders. CONCLUSION Large-scale distributed networks coordinate all complex behavior domains. The performance of a relevant task engages all components of the pertinent network, and damage to any network component can impair behavior in the relevant domain. Experimental data and lesion based-behavioral analyses and functional imaging observations demonstrate that the appropriate and skilled execution of higher-order tasks depend not only on PFC, but also on the integrity of other cortical and subcortical structures that are interconnected with the PFC. DISORDERS ASSOCIATED WITH DAMAGE TO PFC—Apathy---Depression---Social behavior---Prefrontal syndromes---Dorsal convexity Dysexecutive syndrome---Medial frontal apathetic syndrome---Orbitofrontal disinhibition syndrome---Association with expression of psychiatric disorders---Mania---Depression---Dementia Requirement of hippocampal neurogenesis for the behavioral effects of antidepressants. Science. 2003 Aug 8;301(5634):805-9. Abstract Various chronic antidepressant treatments increase adult hippocampal neurogenesis, but the functional importance of this phenomenon remains unclear. Here, using genetic and radiological methods, we show that disrupting antidepressant-induced neurogenesis blocks behavioral responses to antidepressants. Serotonin 1A receptor null mice were insensitive to the neurogenic and behavioral effects of fluoxetine, a serotonin selective reuptake inhibitor. X-irradiation of a restricted region of mouse brain containing the hippocampus prevented the neurogenic and behavioral effects of two classes of antidepressants. These findings suggest that the behavioral effects of chronic antidepressants may be mediated by the stimulation of neurogenesis in the hippocampus. Functional Disturbances Within Frontostriatal Circuits Across Multiple Childhood Psychopathologies Rachel Marsh; Tiago V. Maia; Bradley S. Peterson Am J Psychiatry 2009;166:664-674. doi: 10.1176/appi.ajp.2009.08091354 “A current controversy in nosology is whether mental disorders, particularly developmental psychopathologies, are best characterized using a categorical or dimensional approach (124). The shared phenotypic characteristics that self-regulatory disturbances produce and the shared involvement of frontostriatal circuits across these varied disorders support, to some extent, a dimensional conceptualization of these predispositions, capacities, and manifest illnesses. However, if differing portions of frontostriatal circuits are indeed responsible for the development of one rather than another of these disorders, then categorical distinctions among them may still be most appropriate. Additional research on the neural bases of these disorders may help provide a biological resolution to this important nosological debate. Reasoning, Learning, and Creativity: Frontal Lobe Function and HumanDecision-Making. Anne Collins, Etienne Koechlin. doi:10.1371/journal.pbio.1001293.s008 Author Summary Reasoning, learning, and creativity are hallmarks of human intelligence. These abilities involve the frontal lobe of the brain, but it remains unclear how the frontal lobes function in uncertain or open-ended situations. We propose here a computational model of human executive function that integrates multiple processes during decision-making, such as expectedness of uncertainty, task switching, and reinforcement learning. The model was tested in behavioral experiments and accounts for human decisions and their variations across individuals. The model reveals that executive function is capable of monitoring three or four concurrent behavioral strategies and infers online strategies' ability to predict action outcomes. If one strategy appears to reliably predict action outcomes, then it is chosen and possibly adjusted; otherwise a new strategy is tentatively formed, probed, and chosen instead. Thus, human frontal function has a monitoring capacity limited to three or four behavioral strategies. The results support a model of frontal executive function that explains the role and limitations of human reasoning, learning, and creative abilities in decision-making and adaptive behavior. Frederick L Hitti, Steven A Siegelbaum. The Hippocampal CA2 region is essential for social memory. “Abst” Nature.com 2014 Squire L.R. Memory and the hippocampus: a synthesis from findings with rats, monkeys, and humans. Psychology. Review. 1992; April, 99 [2]: 195-231 Burgess N, Maquire E.A, O’Keefe J. The human hippocampus and spatial and episodic memory. Neuron 2002; 35 [ 4 ]: 625-41 Jinzhao Ji, Stephen Maren. Hippocampal involvement in contextual modulation of fear extinction. Hippocampus 2007, Vol. 17, Issue 9: 749-758. James F Brennan, Carolyn A Cohen, Peter A Bertucci. Maturaturational Influences on Perseveration of Avoidance and Reversal Learning after selected brain damage in rats. Acta Neurobiologiae Experimentalis. 1988; 48: 193-214 Buckholtz J W, Meyer-Lindenberg A. Psychopathology and the human connectome:toward a transdiagnostic model of risk for mental illness. Neluron 2012 June 21; 74[6]: 990-1004 Neuron Review The Role of Medial Prefrontal Cortex in Memory and Decision MakingDavid R. Euston, Aaron J. Gruber, and Bruce L. McNaughton. “In particular, mPFC likely relies on the hippocampus to support rapid learning and memory consolidation.”
- Barry Stanley Society needs to proceed with caution in applying epigenetics in an attempt to cure all ills. The first step is to acknowledge and understand the role of alcohol in epigenetics. Annick Lesne Multiscale modeling of living systems and their regulation.Proceedings of the Ist Conference CoMMISCo’10 on Mathematics and Computer Modelling of Complex Systems. Institut de recherché pour developpement, Bundy, France. 2010: p13 “A possible definition of a complex system Acknowledged features of a complex system are the following: -- the system is composed of a large number of elements; -- the elements are often of different types and have an essential internal structure; -- the elements are related by nonlinear interactions, often of several different types; -- the system experiences inputs at several scales. But I argue that the main hallmark of complex systems is circular causality, namely, the presence of feedbacks of (macroscopic) collective properties and emergent features on the behavior of (microscopic) elements. Elements collectively modify the surroundings, which in turn exerts constraints on them and endow them with different possible states or behaviors. In complex systems, knowing the features and behavior of the single components in isolation is not sufficient to predict the behavior of the system as a whole. Methods To capture the mechanistic processes responsible for the system's behavior, it is necessary to dissect and explicitly describe the elementary components and their interactions. But such a reductionnist study has to be done within the context provided by emergent properties, i.e. one has to investigate the properties of single components, but not in isolation. Methods for unravelling multiscale feedbacks loops have thus necessarily to consider jointly several levels of organization. For the determination of emergent properties, in the bottom-up direction, I suggest to introduce effective parameters (e.g. homogenized diffusion coefficient, or apparent kinetic rates and coupling constants) retaining from microscopic details only what is essential to the macroscopic behavior. Conversely, in the top-down direction, effective inputs, fields and constraints allow to account for macroscopic influences in the microscopic description. Bridging these two approaches yields an integrated and consistent multilevel description.” Complex systems science and brain dynamics. FRONTIERS IN COMPUTATIONAL NEUROSCIENCE. Hava T Siegelmann. Published online: 10 September 2010 Complex system science, both mathematically and computationally, gives us the tools to dissect, quantify and analyze organic life’s most complex system set: the brain. In addition to aiding diverse fields of brain research by following brain system dynamics over time, we can detect systemic changes prior to them becoming problems or diseases. Additionally, medicine today tends to approach illness with a “fix-it-when-it’s-broken” mentality; using dynamical systems to analyze and monitor brain systems results in a broader, more detailed view, and one that shows changes over time. These same attributes provide the means for early identification of disease, enable preventative measures, earlier fixes, and the identification of alternative methods and strategies for remedying problems. Ultimately, using these tools to follow the dynamics of individuals may provide the best approximation of their health, and the most exact picture of when their health is affected by different agents or ameliorated by specific treatments. It is possible then, that a dynamic understanding of the complex brain will yield early disease detection, novel treatments, and individual approaches in medical sciences. Cortical dynamics revisited. Special Issue: The Connectome ‘Recent discoveries on the organisation of the cortical connectome together with novel data on the dynamics of neuronal interactions require an extension of classical concepts on information processing in the cerebral cortex. These new insights justify considering the brain as a complex, self-organised system with nonlinear dynamics in which principles of distributed, parallel processing coexist with serial operations within highly interconnected networks. The observed dynamics suggest that cortical networks are capable of providing an extremely high-dimensional state space in which a large amount of evolutionary and ontogenetically acquired information can coexist and be accessible to rapid parallel search.” Frontal Lobe Contributions to Theory of Mind Valerie E. Stone University of California, Davis Simon Baron-Cohen University of Cambridge Robert T. Knight University of California, Davis. “Theory of mind,” the ability to make inferences about others’ mental states, seems to be a modular cognitive capacity that underlies humans’ ability to engage in complex social interaction. It develops in several distinct stages, which can be measured with social reasoning tests of increasing difficulty. Individuals with Asperger’s syndrome, a mild form of autism, perform well on simpler theory of mind tests but show deficits on more developmentally advanced theory of mind tests.” “To make an inference as complex as what another person may be thinking, many areas of the brain must work together.”
- Barry Stanley Epigenetics explains the many puzzling and contradictory observations about FASD. The brain dysfunctions of PAE are only part of the disease effect of PAE The factor of the mother drinking in a pregnancy no longer stands alone. The term “prenatal” for any given pregnancy has to include alcohol exposure from both parents, including previous generations. The nomenclature of FASD needs to be changed to reflect our understanding of epigenetics without diminishing acknowledgment and treatment of FASD, as occurs at present. Disorders of mood and personality need to be redefined in the context of environmental factors that cause changes in gene expression- alcohol being a major factor. Society needs to be aware that the manipulation of gene expression will result in harmful unintended consequences Epigenetic modulation at birth - altered DNA-methylation in white blood cells after Caesarean section. Schlinzig T , Johansson S, Gunnar A, Ekström TJ, Norman M. Acta Paediatr. 2009 Jul;98(7):1096-9. “Abstract Delivery by C-section (CS) has been associated with increased risk for allergy, diabetes and leukaemia. Whereas the underlying cause is unknown, epigenetic change of the genome has been suggested as a candidate molecular mechanism for perinatal contributions to later disease risk. We hypothesized that mode of delivery affects epigenetic activity in newborn infants. A total of 37 newborn infants were included. Spontaneous vaginal delivery (VD) occurred in 21, and 16 infants were delivered by elective CS. Blood was sampled from the umbilical cord and 3-5 days after birth. DNA-methylation was analyzed in leucocytes. Infants born by CS exhibited higher DNA-methylation in leucocytes compared with that of those born by VD (p < 0.001). After VD, newborn infants exhibited stable levels of DNA-methylation, as evidenced by comparing cord blood values with those 3-5 days after birth (p = 0.55). On postnatal days 3-5, DNA-methylation had decreased in the CS group (p = 0.01) and was no longer significantly different from that of VD (p = 0.10). DNA-methylation is higher in infants delivered by CS than in infants vaginally born. Although currently unknown how gene expression is affected, or whether epigenetic differences related to mode of delivery are long-lasting, our findings open a new area of clinical research with potentially important public health implications.”