The Role of Infections in Mental Illness

28 03 2012

This time I am “hosting” the Director of the National Institute of Mental Health Thomas Insel. I find this line of research very important and promising.

“In a visit to a mental asylum in 1912 you would have seen many patients with “general paresis.” The word “paresis” is Latin for weakness. General paresis was a form of psychosis with delusions, hallucinations, and memory problems often of rapid onset and thought to be due to a general constitutional weakness. At least that was the explanation until 1913, when general paresis was shown to be caused by syphilitic infection of the brain. The first treatments were awarded a Nobel Prize in 1917. The advent of antibiotics 30 years later led to the virtual eradication of neuro-syphilis, as the disorder came to be called, in this country.

The idea that mental or behavioral disorders could be due to infection is, therefore, not new but it remains surprisingly difficult to accept. When I was in training in the 1970’s, peptic ulcer disease was the prototype of a “biopsychosocial” disorder, with stress and a Type A personality considered the causes and psychodynamic therapy recommended as the treatment. Although helicobacter pylori was identified as the cause of peptic ulcer disease by Australians Robin Warren and Barry Marshall in the 1980’s, there was very little awareness (within the mental health community) that the disorder could be cured with antibiotics until Warren and Marshall received the Nobel Prize in 2005.

We may be looking at a similar reluctance to accept an infectious cause of pediatric sudden onset obsessive compulsive disorder (OCD) – in a debate that has been ongoing for almost two decades. In the early l990s, pediatrician Dr. Susan Swedo identified a subgroup of children whose OCD symptom onset didn’t fit the typical pattern. Instead of emerging gradually over weeks or months, they experienced ferocious bouts of compulsive behaviors and other symptoms “overnight and out of the blue.” As a pediatrician, Swedo’s familiarity with the ways of infectious agents and autoimmune mechanisms, together with her careful observations in the child psychiatry clinic of the NIMH Intramural Research Program, sparked the surprising hypothesis that a strep infection could trigger OCD symptoms via an autoimmune process.

This proved more complicated than syphilis or helicobacter. Part of the problem has been that strep is very common in childhood, making it methodologically difficult to prove a causal connection between the microbe and the OCD symptoms. The onset has not always been linked precisely with a strep infection and the critical increase in antibodies to strep has not been evident consistently. Nevertheless, immune-based treatments have proven successful, leading to the growing acceptance of the concept of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS).

Fortunately, the field is moving toward consensus on some of the larger issues, such as a broader concept of “acute and dramatic” onset of the same profile of psychiatric symptoms identified in PANDAS – but of unknown cause. There is also consensus on the need to establish a centralized registry to facilitate data analysis, so that causes and appropriate treatments can eventually be pinpointed.

This rapprochement recently took form in criteria for a broadened syndrome of acute onset OCD, published last month by Swedo, James Leckman at Yale and Joel Rose at Johns Hopkins. Their proposed Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) builds on and subsumes PANDAS. It embraces youth who experience acute onset of OCD or anorexia symptoms, mixed with a varying profile of other neuropsychiatric symptoms – cause unspecified.

Meanwhile, to strengthen evidence in support of immune-based treatment for the subset of youth whose illness is strep-related, Swedo, Leckman, and Madeleine Cunningham of the University of Oklahoma, and colleagues, are collaborating on a multi-site, double blind, placebo-controlled trialExternal Link: Please review our disclaimer. It is testing intravenous immunoglobulin (IVIG) for OCD symptoms in PANDAS. IVIG, an infusion of normal antibodies, restores normal immune function by neutralizing errant antibodies. A similar pilot study testing IVIG and another immune-based treatment more than a decade ago found that all treated children with PANDAS improved, with more than half completely cured or experiencing only subclinical symptoms after one year.

Despite doubt in some quarters, hints of possible involvement of infectious agents and/or autoimmune processes in other serious brain disorders, such as autism, have spurred interest in PANDAS as a model for a type of illness process that may be more informative than widely assumed.

MRI scans of a PANDAS patient, showing reduced inflammation in the caudate nucleus(area circled just to the left of black area in center of brain), part of the basal ganglia, following IVIG treatment. Evidence suggests that this brain structure is targeted by errant anti-brain antibodies, triggered by a strep infection, in PANDAS”.


Swedo, SE, Leckman JF, Rose, NR. From Research Subgroup to Clinical Syndrome: Modifying the PANDAS criteria to describe PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). Feb 2012, Pediatrics & Therapeutics.

Studying brain from inside out

21 03 2012

“How many brain scientists have been able to study the brain from the inside out? I’ve gotten as much out of this experience of losing my left mind as I have in my entire academic career.” (Jill Bolte Taylor)

One morning, a blood vessel in Jill Bolte Taylor’s brain exploded. As a brain scientist, she realized she had a ringside seat to her own stroke. She watched as her brain functions shut down one by one: motion, speech, memory, self-awareness …

Amazed to find herself alive, Taylor spent eight years recovering her ability to think, walk and talk. She has become a spokesperson for stroke recovery and for the possibility of coming back from brain injury stronger than before. In her case, although the stroke damaged the left side of her brain, her recovery unleashed a torrent of creative energy from her right. From her home base in Indiana, she now travels the country on behalf of the Harvard Brain Bank as the “Singin’ Scientist.”

By all means, please view her lecture uploaded by TED


The British Social Model of Disability

17 03 2012

“We believe that the claim that everyone is impaired, not just ‘disabled people’, is a far-reaching and important insight into human experience, with major implications for medical and social intervention in the twenty-first century” (Shakespeare and Watson, 2002)

I had previously written about the different perspective on disabilities. This time I want to refer to an interesting paper by Shakespeare and Watson (2002) that describes the  British social model of disability while proposing alternative theoretical perspectives, particularly those of post-structuralism and post-modernism.

I find this paper highly important to our understanding of disability, to the ways we should study the impact of disability and to the ways that we should develop and implement interventions to enhance social inclusion of people with disability. What do you think about this approach?





New therapy for anxiety disorders in children

15 03 2012

This time I want to present an interesting study that investigated whether a computer based treatment for anxiety disorders – attention bias modification (ABM) – induces greater reductions in pediatric anxiety symptoms and symptom severity than multiple control training interventions. This fascinating study that was conducted by researchers at Tel Aviv University in Israel carried out a clinical trial on ABM as an outcome of a three-year collaboration with scientists at the National Institute of Mental Health and the University of Maryland, College Park, Maryland. The study enrolled 40 children, 8 to 14 years old, who had sought help for anxiety. For children receiving ABM, after faces appeared on a screen, two dots appeared on the screen; children had to determine whether the dots were side by side, or one above the other. In every case, dots appeared only where the neutral face had been. There were also two control groups: in the first, dots appeared equally frequently where angry and neutral faces appeared; in the second, the only faces that appeared throughout were neutral, so the dots always appeared in the location of a neutral face. The object of the second control group was to help confirm that any therapeutic effect was from the ABM training, and not from desensitizing the children to threatening faces. Children in the study were randomly assigned to receive treatment, or to be in one of two control groups. All children had four training sessions over 4 weeks, with 480 dot-probe trials per session.

Although the trial was small, there was a “reasonably robust” decrease in the severity of anxiety, according to the authors. Following ABM, both the number and severity of symptoms were reduced.

Given the fact that longitudinal studies that follow children into adulthood suggest that most chronic mood and anxiety disorders in adults begin as high levels of anxiety in children, the ability to influence attention biases early in development might provide a powerful means of prevention for both of these disorders later in life. The approach requires no medication and in practical terms, the computer-based nature of ABM lends itself to large-scale dissemination, in a medium children are comfortable with.

This study was published at the American Journal of Psychiatry. To read the full article please click here.




How can we build a great career?

13 03 2012

First we need to decide we want one and abandon the excuses we invent when we fail to pursue our passions! Check out this nice lecture about it by Larry Smith, a professor of Economics at the University of Waterloo in Canada. Enjoy!




Who is the big brother?

11 03 2012

HaAh HaGadol  is the Israeli version of Big Brother reality-television series where a group of people live together in a large house, isolated from the outside world for 3 months and in some countries for 6 months (!). These [poor, if I may say] fellows are continuously watched by television cameras and they are all connected to microphones so that the audience could hear what they are saying. In order to win the final cash prize (1,000,000 Shekels in Israel), all the contestants have to do is survive periodic evictions and be the last one standing.

For some reason/s, this show is very popular, worldwide; Millions of people watch it, vote for their favorite housemates, and are strongly connected to the life in the Big Brother’s house. What a celebration to humanity!

Over the past week, Israel is in turmoil. No, it is not the Iranian threat, it is not the huge economy gap between rich and the poor in Israel, it is not even the stormy winter that we have, it is the big brother SCANDAL! One of the people who participated in this show two years ago revealed that the actual big brother in the house is a famous psychiatrist that ask, and sometimes demands, that some of the housemates will take psychiatric medications (anti psychotic and anti-depressant) while providing mentoring assistance (e.g., you should kiss that girl, you should be more aggressive etc). Furthermore, this psychiatrists told to some housemates what is going on outside of the house and even promised that if they will follow his suggestions (and prescriptions…) they will rich the finals. WOW!

I don’t know if it is all true, but I know that this case illustrated, again, how deep and strong are the public’s negative perceptions about psychiatric medications and how one irresponsible mental health provider can destroy our strong efforts to reduce mental illness stigma (including the stigma that psychiatrists are crazy…).

International Women’s Day 2012

8 03 2012

This post is dedicated to the International Women’s Day, which is held today, worldwide. While the aim of this global day is to celebrating the economic, political and social achievements of women past, present and future, I wish to focus (how surprising…) on the  women with disability.

Frida Kahlo (July 6, 1907 – July 13, 1954) is known throughout the world for her unusual and colorful paintings and for her activities in Mexican political causes which led to her joining the Communist Party. Ms. Kahlo is remembered because of her courageous, ambitious and colorful personality. The fact that she had a disability (a disability that stemmed from childhood polio and a bus accident when she was eighteen) is mainly refered when people discuss her art which sometimes reflected the physical pain she suffered through most of her life.

Unlike Ms. Kahlo, many women (with or without a disability) can not actual their potential and to achieve their life goals due to exclusion, discrimination, prejudice etc, let alone women with disabilities that double stigma/exclusion/discrimination significantly reduce their life opportunities and their chances to actual their potential. That is to say, not only that women with disabilities have to cope with the objective difficulties of the disability, they have to deal with disability-related stigma and gender-related stigma.

This is the problem. The possible solutions would be presented in the next post. In the meantime you are more than welcome to suggest ways to improve the situation.

Happy International Women’s Day and Happy Purim!





Social inclusion from the perspective of persons with disability

5 03 2012

The professional literature indicates that social inclusion means full and fair access to community-based resources and activities, having relationships with family, friends and acquaintances, and having a sense of belonging to a group. Furthermore, this approach claims that it is not enough that people with disabilities would be in the community, they should be part of the community. That is to say, social inclusion represents more than the mere physical presence, but the participation and engagement in the mainstream society.

While the literature on social inclusion is vast, there is no one consensual definition of social inclusion. Furthermore, we still don’t really understand what social inclusion means and there is still no real way to determine and measure whether service providers are successful in facilitating or achieving social inclusion for the persons they support.

Given the fact that in the disability field we can not fully understand social inclusion or any other topic without asking the notion of people with disabilities, it is encouraging to see studies that examined the perspective of people with disability on social inclusion. For example,  in her meta-analysis, Hall* describes the elements and experiences of social inclusion for people with disabilities. Furthermore, she identified six dimensions of social inclusion:

  • being accepted and recognized as an individual beyond the disability
  • having personal relationships with family, friends, and acquaintances
  • being involved in recreation, leisure and other social activities
  • having appropriate living accommodations
  • having employment
  • having appropriate formal (service system) and informal (family and caregiver) supports.

What can be learn about these dimensions and how you think that they could help us promote social inclusion of people with disability?

* Hall SA. The social inclusion of people with disabilities: a qualitative meta-analysis.

J Ethnogr Qual Res 2009; 3:162–173.

Autism news by NIMH

3 03 2012

Here is a very interesting video about Autism. In this nine minutes video, researchers, advocates, and parents of children with autism talk about the importance of taking part in autism research and contributing to the National Database for Autism Research.


Why do we stigmatize?

2 03 2012

In order to answer this challenging question one can argue that there is a need to first define stigma, differentiate between stigma types and components and to refer to the specific characteristics of the stigmatized groups. I promise to refer to these issues and others in the near future. For now, I will just say that I adopt Link and Phelan stigma conceptualization which apply the term stigma when “elements of labeling, stereotyping, separation, emotional reactions, status loss and discrimination co-occur in a power situation that allows them to unfold” (Link and Phelan, 2001).

Many researchers, from different disciplines (Sociology, Anthropology, social and personality Psychology and Social neuroscience to name few) have sought to explain the roots of stigma. While reviewing all the available explanations is out of the scope of this post I wish to propose an assumption of my own: Stigma is a consequence of [mostly unconscious] fear and it is aimed to protect ourselves from unwanted states and situations. That is to say, stigma is a defense mechanism aimed to protect our ego (dynamically speaking) and sometimes our lives (evolutionary speaking) from unwanted conditions (e.g., disability or an illness) and/or situations (e.g., social disadvantages).

When referring to health conditions and disability I wish to argue that conditions that represent loss of control over one’s inner and outer world are more likely to elicit stigma than those who do not represent loss of control. This argument is based on the assumption that the control reflects a fundamental need that is biologically motivated and adaptive for survival (Leotti et al, 2011), and that situations that jeopardise this need may lead to automatic fear and ego defense activation (stigma) in return. Does it makes sense to you? can you try to apply it on health and disability-related stigma?

Have a great weekend!