Jancar memorial lecture


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The Joze Jancar memorial lecture on Neurodevelopmental psychiatry given at the 2012 Annual residential conference of the Faculty of Intellectual Disability of the Royal College of Psychiatrists

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Jancar memorial lecture

  1. 1. Joze Jancar Memorial Lecture:Neurodevelopmental psychiatry Digby Tantam Professor Emeritus, University of Sheffield Honorary Senior Visiting Research Fellow, University of Cambridge Director, Septimus Ltd Honorary Consultant Psychiatrist and Psychotherapist, Sheffield Health and Social Care NHS Foundation Trust
  2. 2. Joze Jancar•  Cross country ski champion in Slovenia•  Protegee of Iris Murdoch•  Burden Research Gold Medal and Prize•  Vice-President and Honorary Fellow, RCPsych•  Freeman of the City of London
  3. 3. •  2011, Dr Sylvia Carpenter•  2010, The Health of Children with Intellectual Disabilities and their Families’, Professor Sheila Hollins (Immediate Past President, Royal College of Psychiatrists)•  2009, ‘Health inequalities: a focus on the remote and rural areas of the UK’, Professor Richard Collacott•  2008, Professor Gregory O’Brien, Northgate Hospital, Northumberland•  2007 Professor Tony Holland, Rights of people with intellectual disability•  2006, ‘Medical self-regulation in the 21st Century – hallmark of the profession or archaic artefact’, Dr John Hillery•  2005, ‘Past, present and future: from stethoscope to crystal ball’, Dr J Calvert.•  2004,‘People with learning disability: who really cares?’, Dr R A Collacott, Western Isles Hospital, Stornoway.•  2003, ‘History of Faculty of Learning Disability as seen through the eyes of Dr Alan Heaton-Ward’, Dr Alan Heaton-Ward•  2002, ‘The limits of psychiatry’, Dr Mike Shooter, President, The Royal College of Psychiatrists, London.•  2001 Professor Michael Gunn, Nottingham Law School, Nottingham (no available abstract).•  2000, Dr Leila Cooke, Phoenix NHS Trust Bristol Central (no available abstract).
  4. 4. Me?•  General psychiatrist, rehabilitation, intensive care unit, community mental health team founder, service for transgender people, service for people who repeatedly self-wound, group analyst, consultant psychotherapist, director of general psychiatry training, psychiatrist to University of Warwick…•  FBPsS•  providing assessment service for people, especially adults, suspected of having ASD since 1981
  5. 5. Anunashamedplug
  6. 6. •  From the Description of Mike Shooter’s Joze Jancar Memorial Lecture:•  “At the same time, the lecture suggests ways in which Psychiatry has shifted the borders between itself, politics and social morality - in its lack of clarity between social problems, psychiatric need and service possibilities, and in systems of classification (ICD and DSM) that hover uncertainly over the inevitable consequences of deprivation (conduct disorder), the normal reactions to catastrophe (grief and PTSD) and a hotch-potch of mysticism, philosophy and historical empire-building (personality disorder)”.
  7. 7. Psychiatry is a medical speciality•  We are not primarily, and we are not trained to be:•  Social workers, or sociologists•  Ethicists•  Politicians•  Leaders and managers (well, not so many of us)•  Historians•  Service planners•  Counsellors or psychotherapists•  Psychologists
  8. 8. Clinical pathology in mental retardation Eastham, R. and Jancar, J.•  Nonspecific Laboratory Findings in Mentally 5•  Disorders of Lipid Metabolism 100•  Disorders of Carbohydrate Metabolism 133•  Disorders of Endocrine Metabolism 165•  Disorders of Metabolism of Connective Tissue 184•  Chromosomal Anomalies 195•  Other Conditions known to cause Mental handicap 208•  210 Infections 216 Disturbance of Immunity 263 Disorders of Liver Metabolism 268 Disorders of Pancreatic function 281 Disorders of Folic Acid and Related Anaemias 299 Erythrocyte Abnormalities 305 Leucocyte Abnormalities 309•  Conditions known to be associated with Mental disorder 335
  9. 9. Intellectual disabilities•  Are of interest as forms of existence, of interest in itself, and not just as a sign of underlying derangement•  Inborn errors of metabolism giving way to SNPs •  Recent reports of SNPs on random trawls with microarrays suggest frequencies of people with ID and SNPs to be between 0.8 and 8% (the latter with ADHD)•  Very many possible SNPs, if ASD is anything to go by—so no small number of pathologies
  10. 10. •  Some of us become these things, of course•  Some of us even have further training to become these things•  So what are we primarily?•  In the past, this has been a problem because what is there to psychiatry that is over and above being wise and decent?•  Not pathology
  11. 11. Where the wetware meets thesoftware•  Where the neuroscientists and the neurogeneticists are—•  And where the medicine of intellectual disability needs to be
  12. 12. Why medicine and not psychology?•  A reliance on observation and deduction, and not testing•  The importance of emotion in altering cognitive states•  Mess?
  13. 13. Montague PR, Dolan RJ, Friston KJ, Dayan P. Computational psychiatry.Trends in Cognitive Sciences. 2012;16(1):72-80
  14. 14. •  Working memory•  Narrative and theory of mind•  The interbrain
  16. 16. Working memory•  Perceptual and verbal•  Processed (links with perceptual cortex) but still short- term memory•  Required for pre-processing memories for hippocampal and then cortical storage•  Not correlated with intelligence•  Affected by anxiety•  Affected by practice
  17. 17. Working memory•  Verbal working memory involved in parsing phrases (Fernell, E., Norrelgen, F., Bozkurt, I. et al, 2002;Adams, A. M. and Gathercole, S. E., 2000), language learning {Cohen, 2000 #14361}, mental arithmetic, following instructions, returning to a task after an interruption, ‘multitasking’ (actually switching attention from one task to another, but maintaining a ‘tab’ on each task to mark progress so that switching goes back to the point of the time and money budgetting, organization and planning•  Dysexecutive problems, secondary to reduced working memory, are common causes of failure of independent living•  Improved by practice•  Splinted by note pads, personal organizers, phones
  18. 18. •  These results suggest that when presented with a complex scene consisting of items from a variety of categories, the underlying representations of those categories will compete for representation. When those representations do not overlap, there is little to no competition and an increase in behavioral performance is obtained. However, when those representations do overlap, they interact in a mutually suppressive manner, which leads to difficulty remembering the items•  http://tech.groups.yahoo.com/group/boston-neurotalks/message/6820
  19. 19. NARRATIVE
  20. 20. Narrative•  IQ 60•  Recent severe hypoxic episode•  Parents rowed, sometimes about him•  He said, ““I do get worried about something happening to mum… I’ve got fits haven’t I, I can’t protect my mum, what if she’s old”.
  21. 21. Animals that gaininformation fromconspecifics gazedirection
  22. 22. Narrative impairment•  Narrative• 
  23. 23. The orbitofrontal cortex as cache? fNIRS evidenceBrink, T. T., Urton, K., Held, D., Kirilina, E., Hofmann, M. J., Klann-Delius, G., et al. (2011). The role oforbitofrontal cortex in processing empathy stories in 4- to 8-year-old children. Front Psychol, 2, 80. Negative affective empathy Positive affective empathy Logical cognitive empathy Non- logical cognitive empathy
  24. 24. Two kinds of empathy: fNIRS evidenceBrink, T. T., Urton, K., Held, D., Kirilina, E., Hofmann, M. J., Klann-Delius, G., et al. (2011). The role oforbitofrontal cortex in processing empathy stories in 4- to 8-year-old children. Front Psychol, 2, 80. Similar picture for auditory stimuli
  26. 26. Atttention direction
  27. 27. Brain regions showing positive change in coupling with the right pSTS (red to yellow) and FG (blue to turquoise) while viewing gaze shifts versus opening/closing the eyes. Nummenmaa L et al. Cereb. Cortex 2010;20:1780-1787© The Authors 2009. Published by Oxford University Press.
  28. 28. Perlman, S. B., Hudac, C. M., Pegors, T., Minshew, N. J., & Pelphrey, K. A. (2011). Experimentalmanipulation of face-evoked activity in the fusiform gyrus of individuals with autism. SocNeurosci, 6(1), 22-30.
  29. 29. Schurmann M, Hesse MD, Stephan KE, Saarela M, Zilles K, Hari R, et al. Yearning to yawn: the neural basis of contagious yawning. Neuroimage. [doi: DOI: 10.1016/j.neuroimage.2004.10.022]. 2005;24(4):1260-4.
  30. 30. ReflectiveNVC Reflexive NVC
  31. 31. •  Neurons are linked by electrical impulses and chemicals into a network•  Our brains can be linked to other brains the way that one computer can be linked to another via the internet•  These links are the nonverbal communications that pass between us, principally consisting of imitation and of gaze following•  Imitation and gaze following are automatically initiated by local brain networks apparently specialized for this
  32. 32. Morishima Y, Schunk D, Bruhin A, Ruff CC, Fehr E. Linking BrainStructure and Activation in Temporoparietal Junction to Explain theNeurobiology of Human Altruism. Neuron. 2012;75(1):73-9.
  34. 34. •  Psychiatry needs to overcome its identity crisis•  And shrug off its alienist function•  Needs, in fact, to have an organ or physical function in which it specializes•  The interface between wetware and software/ brain and consciousness provides this•  Intellectual disability stands to gain particularly•  Let’s dust off our observational skills•  Add a pinch of wisdom about emotions•  Start to identify ‘modules’ of higher order functioning