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Progressive Changes in the Development Toward

Progressive Changes in the Development Toward Schizophrenia: Studies in Subjects at Increased Symptomatic Risk

Posted 04/23/2008

Stephen J. Wood; Christos Pantelis; Dennis Velakoulis; Murat Yücel; Alex Fornito; Patrick D. McGorry
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Abstract and Introduction

Abstract

Although the underlying neurobiology of emerging psychotic disorders is not well understood, there is a growing conviction that the study of patients at clinical high risk for the illness will provide important insights. Further, a better understanding of the transition period may help the development of novel therapies. In this review, we summarize the extant neuroimaging and neuropsychological studies of people at clinical high risk for psychosis. By and large, there are few definitive markers that distinguish those who go on to develop the illness from those who do not. The 2 most consistently abnormal brain regions in schizophrenia research, the hippocampi and the lateral ventricles, are not significantly different from healthy controls prior to psychosis onset. However, frontal lobe measures (eg, cortical thickness in the anterior cingulate) do show promise, as do cognitive measures sensitive to prefrontal cortex dysfunction. Further, longitudinal magnetic resonance imaging findings in individuals at ultrahigh risk for developing a psychotic illness show that there are excessive neuroanatomical changes in those who convert to psychosis. These aberrant changes are observed most prominently in medial temporal and prefrontal cortical regions. While the pathological processes underlying such changes remain unclear, speculatively they may reflect anomalies in genetic and/or other endogenous mechanisms responsible for brain maturation, the adverse effects of intense or prolonged stress, or other environmental factors. Active changes during transition to illness may present the potential to intervene and ameliorate these changes with potential benefit clinically.

Introduction

The longitudinal investigation of individuals at increased clinical risk for developing psychosis has provided clinical, cognitive, and neuroimaging insights into the period of transition from the at-risk state to the illness/psychosis state. The identification of such cohorts has either focused on positive symptoms (eg, Yung and McGorry^[1]) or the German approach of self-recognized "basic symptoms"^[2] (for review, see Philips et al^[3] and Olsen and Rosenbaum^[4]). In both strategies, there is a focus on "help-seeking" adolescents, who by definition may already be manifesting established signs of attenuated onset of psychosis, because these state-based criteria are thought to identify an at-risk mental state.^[5] These approaches reflect a "close-in" method for identifying a high-risk cohort,^[6] where an individual must meet a number of criteria to be included in the high-risk group. Importantly, this maximizes the number of participants who make the transition to psychosis (30%-40% over 12 months^[5,7]), allowing targeted, indicated prevention strategies which are likely to have the greatest effect on outcomes.^[8-10]

Studies using the close-in approach have been referred to as "ultrahigh risk" (UHR) or clinical high-risk studies to differentiate them from traditional genetic high-risk studies that rely on family history as the primary inclusion criterion. The terms "at-risk mental state" or "UHR" do not imply that a full-threshold psychotic illness, such as schizophrenia, is inevitable but suggest that an individual is displaying a "need-for-care" and is at increased risk of developing a psychotic disorder by virtue of his or her mental state. The UHR diagnostic criteria have been articulated and refined by researchers at the University of Melbourne^[1,5] and Yale University.^[11] These researchers have developed sets of criteria for identifying UHR individuals based on the presence or onset of one or more of the following criteria: attenuated psychotic symptoms (ideas of reference, magical thinking, perceptual disturbance, paranoid ideation, and odd thinking and speech), brief limited intermittent psychotic symptoms too short in duration to meet Diagnostic and Statistical Manual of Mental Disorder criteria for psychosis (symptoms spontaneously resolved within 1 week) and family history (first degree) of a psychotic or bipolar disorder, or a personal history of schizotypal personality disorder, and significant recent functional decline.

It is still unclear exactly what pathophysiological process underlies the transition from UHR to frank psychosis (or if there are many such processes) and whether this can be detected prior to illness onset. In this review, we discuss potential predictive markers of later psychosis from both neuroimaging and neuropsychological studies, focusing specifically on studies of individuals at clinical high risk. The vast majority of these studies are our own, although there are reports from other centers now being published. This article does not review studies of people solely at genetic high risk.

We begin by examining the extant cross-sectional neuroimaging and neuropsychological studies that aimed to distinguish UHR patients who later developed psychosis from those who did not. The majority of this work has focused on either the medial temporal or frontal lobes, and discussion of these findings make up the bulk of the review. We then briefly examine the evidence for the involvement of other brain regions, followed by a review of the 3 existing longitudinal studies of UHR patients. To aid the reader, we have included a summary table of all neuroimaging studies in UHR cohorts (provided they contain data concerning transitions) ( table 1 ).

sectional Studies

Medial Temporal Regions

Our initial studies in schizophrenia and early psychosis focused on medial temporal structures, particularly the hippocampus, because various meta-analyses have consistently reported this region to be reduced in volume,^[12-15] as well as showing neuropathological abnormalities.^[16] Furthermore, cognitive abilities thought to rely on the integrity of this region are also impaired.^[17] This evidence suggested that hippocampal abnormalities such as reduced size and impaired episodic memory were potential premorbid markers of illness. However, such predictions have not been borne out in our data. Although our early cross-sectional study reported smaller hippocampal volumes in the UHR group as a whole,^[18,19] our recent, much larger study did not support this.^[20] Furthermore, no differences were identified between those participants who later developed psychosis (UHR-P) and those who did not (UHR-NP), suggesting that smaller hippocampal volume may not be predictive of later psychosis, but instead be a result of non-illness-specific events, such as obstetric complications.^[21] These findings are supported by 2 further studies from our group. First, we found that hippocampal volumes tended to be smaller in UHR patients without a family history of schizophrenia, indicating nonspecific environmental influences on the region.^[22] Second, using magnetic resonance spectroscopy (MRS), we (and others) have shown that, compared with control subjects, the UHR group do not exhibit any reduction in left hippocampal N-acetylaspartate (NAA), a marker of neuronal integrity.^[23,24]

We have also examined hippocampal function through cognitive testing, specifically through paired-associate learning. In such tasks, 2 unrelated stimuli (eg, semantically unrelated words or an object and a location) are presented together, and the subject must remember the association.^[25] Our published work on verbal paired-associate learning demonstrates no impairment in the UHR group,^[26] while unpublished data from a visuospatial paired-associate task also indicate normal hippocampal function prior to transition (L. C. Simpson, unpublished Dpsych thesis).

Despite these findings, a very recent voxel-based morphometry (VBM) study does show hippocampal abnormalities in a UHR population. Borgwardt and colleagues^[27] used VBM to compare 22 controls and 35 UHR patients (12 of whom developed psychosis over the following 2 years). Significantly reduced gray matter (GM) volume was found in a number of regions, including the left hippocampus, but there were no hippocampal differences between those who did and those who did not later develop psychosis. It should be noted, however, that these hippocampal differences were only apparent after relaxing the significance level of the analysis and that the use of VBM has been criticized because of its inadequacy in dealing with problems of brain registration.^[28] The choice of smoothing kernel is also important, because the size of the kernel should be roughly the size of the difference one expects to see,^[29] and varying it may give markedly differing results.^[30]

Frontal Cortex

The prefrontal cortex seems the most promising brain region in terms of prediction of later psychosis. The most consistent cognitive findings are of impairments on tasks tapping prefrontal cortical function, such as spatial working memory,^[31] antisaccade eye movements,^[32] olfac-tory identification,^[33] and tasks requiring rapid processing of information such as story recall.^[26,34] UHR-P patients show specific deficits on all these tasks when compared with those who do not become ill. This pattern of deficits may be the result of reduced GM density in prefrontal regions^[35] (although this has not been replicated^[27]). There is also evidence for hypofunction of the prefrontal cortex, both from a large (n = 30) MRS study^[23] and from a functional imaging study using a visual oddball task.^[36] However, these 2 findings are not reported to be specific to those who make the transition to psychosis.

One prefrontal region that has been the focus of great interest in schizophrenia research is the anterior cingulate cortex (ACC), owing to its role in cognitive and emotional processing^[37] and strong data from neuropathological studies.^[38] Our initial investigations concentrated on the pattern of cortical folding in this region because this is typically established during the early stages of neurodevelopment (mostly in utero), and so any abnormalities would be consistent with an early neurodevelop-mental insult.^[39,40] We found that, compared with healthy controls, the UHR group was more likely to have interruptions in the course of the cingulate sulcus and less likely to have a well-developed paracingulate sulcus in the left hemisphere.^[41] This pattern represents a loss of the "normal" leftward bias that we previously identified^[42] and is similar to that observed in patients with chronic schizophrenia.^[43] However, there was no difference in any of the ACC surface morphological measures between UHR-P and UHR-NP patients. This suggests that the presence of such abnormalities may not confer specific risk for schizophrenia or psychosis but rather reflect a more general vulnerability to psychopathology. This line of argument is supported by our recent finding of ACC folding abnormalities in people with bipolar affective disorder,^[44] although this patient group showed a bilateral, rather than left-lateralized folding reduction. It should also be noted that neurocognitive tests sensitive to cingulate dysfunction, such as the Stroop^[45] and the continuous performance test-identical pairs,^[46] do not show differential impairments in UHR patients depending on psychosis outcome.^[34,47] However, these measures are not especially good indicators of cingulate function,^[48] and additional study using other tasks is warranted.

There are a number of reports where anterior cingulate related measures do provide predictive markers. The first is an MRS study of 19 UHR patients that found significant reduction in NAA in the cingulate region bilaterally.^[24] NAA reductions were not predictive of later transition to psychosis—instead, trimethylamines were higher in the later psychotic group indicative of higher rates of cell membrane turnover.^[49] Because only 3 patients developed psychosis in this study, it is unclear how reliable the finding is and, furthermore, the metabolite ratios were not corrected for differences in GM contribution to the voxel, potentially confounding the results. Nonetheless, the idea that the cingulate might be somehow different in those who make the transition to illness is supported by our own cross-sectional VBM study, which demonstrated significantly reduced GM density in UHR-P patients compared with UHR-NP.^[35] Similar (although more posterior) findings have been reported recently in a somewhat smaller sample.^[27] However, one limitation of this work is that significant group differences in ACC GM may be an artifact of variations in cortical folding patterns because variability in local sulcal and gyral anatomy has been shown to influence morphometric estimates in and around the region.^[50,51] Coupled with findings that patients and controls do indeed show different patterns of gyrification in the ACC, any case-control comparisons may be seriously biased unless such folding variations are accounted for. To address this problem, we recently matched UHR individuals to control for morphology of the paracingulate sulcus and tested for differences in the cortical thickness of various subdivisions of the ACC (A. Fornito, A. R. Yung, S. J. Wood, L. J. Phillips, B. Nelson, S. Cotton, D. Velakoulis, P. D. McGorry, C. Pantelis, M. Yücel, unpublished data). We found that, relative to healthy controls, UHR-P individuals showed bilateral thinning of a rostral paralimbic ACC region, and this thinning was correlated with an increased level of negative symptoms. Similar results were found when UHR-P and UHR-NP patients were compared, although in this analysis the thinning was in the limbic region. Interestingly, analysis of subdiagnostic differences in our ACC data suggested that these changes were largely driven by individuals who developed a schizophrenia-spectrum psychosis, with no differences being noted in those that developed a nonschizophreniform (primarily affective) psychosis.

Other Brain Regions

A number of other regions have been investigated as potential markers of later transition. Enlargement of the lateral ventricles has been suggested, given that it is the first and most consistently reported brain abnormality in schizophrenia research.^[52] However, our data from 135 UHR patients (39 of whom transitioned to psychosis) reveal no such enlargement prior to the onset of illness.^[53] Similarly, amygdala involvement has been proposed, based on reductions in chronic illness^[52] and its role in emotional processing.^[54] We have reported that amygdala volume is not significantly smaller in UHR patients, with no difference between UHR-P and UHR-NP patients.^[20] These nonsignificant reductions are larger than those seen for the hippocampus, but this may merely reflect the high prevalence of affective symptomatology in this cohort.

Some unexpected brain regions have been identified as markers of later transition. In both published VBM studies of GM,^[27,35] right superior temporal gyrus and right insula GM volumes were found to be smaller in the UHR-P group compared with the UHR-NP patients. Further, there were large regions of significantly greater GM volume in the UHR-P individuals, covering the parahippocampal, fusiform, and medial occipital gyri bilaterally, as well as the thalamus, right supramarginal gyrus, and the posterior temporal, inferior parietal, and postcentral cortex bilaterally.^[27] Similarly, we have identified greater white matter volume in UHR-P individuals in left superior frontooccipital fasciculus (near premotor cortex) and left superior longitudinal fasciculus (near frontal operculum), compared with UHR-NP individuals.^[55] However, it is unclear what role volumetric increases might play in vulnerability to psychosis, and these findings will need to be replicated in larger samples

Longitudinal Changes

All the studies referred above were cross-sectional in design. However, as with detecting dementia, it is possible that change over time may turn out to be the most important metric with regard to the later onset of psychosis. Our first study reported significant neuroanatomical changes over the transition to psychosis in cingulate, me-dial temporal, and orbitofrontal regions, using VBM.^[35] Although these changes were not found in UHR patients who did not develop psychosis between the 2 scans, the group-by-time interaction term was not significant. In a similar VBM study of white matter, we have found reductions in deep left parietal white matter near the frontooccipital fasciculus and left occipital white matter sub-adjacent to calcarine cortex, along with increases in the posterior cerebellum bilaterally.^[55] It should be noted, however, that there are a number of methodological limitations to both studies, including small numbers, the use of relatively thick slices that may hinder detection of subtle changes, and the aforementioned problems of brain registration. We have attempted to deal with these limitations by using a different approach that assesses expansion or retraction at every point on the lateral surface of the cerebral hemispheres, combined with cortical pattern matching techniques developed by Toga and Thompson.^[56] These more sensitive analyses demonstrated significantly greater brain contraction in the right prefrontal region specific to the UHR-P group, indicative of an accelerated rate of GM retraction in prepsychotic UHR individuals during the transition to psychosis.^[57] Interestingly, the pattern of longitudinal change seen in the UHR-P group was similar to that observed in healthy controls, albeit exaggerated in magnitude, suggesting that the transition to psychosis is associated with an exacerbation of normal neurodevelopmental processes.^[58] Further, the rate of GM retraction was significantly associated with proximity to the transition point to psychosis. Such work awaits replication with larger cohorts—in particular, the addition of a control group and investigation of possible medication-related effects would be important advances.

The progressive changes we have identified across the transition to psychosis in the right prefrontal region are reflected in a small longitudinal study of cognitive performance.^[59] Sixteen UHR patients (7 of whom developed psychosis) were assessed neuropsychologically at baseline and after transition to psychosis (or after 12 months). While performance on most tests was stable or improved, we found that visuospatial memory, verbal fluency, and attentional switching all showed significant decline over the transition to psychosis. These progressive impairments were not seen in the nonpsychotic UHR group. These data indicate that the onset of psychotic disorder is associated with additional impairment in visuospatial and executive abilities that mirrors the progressive changes identified on neuroimaging.

It remains unclear what might cause these progressive changes. One possibility is that they result from stress around the time of illness onset and an associated disturbance of hypothalamic-pituitary-adrenal (HPA) axis function.^[60] There is good evidence for an association between stress hormones, such as cortisol, and structural damage to medial temporal regions,^[61-63] as well as the ACC.^[64] In recent preliminary analyses in a small UHR sample, we have identified that cortisol levels were associated with the level of depression and anxiety, but not psychotic symptoms.^[65] An alternative, indirect index of HPA axis dysfunction can be obtained by examining pituitary volumes on MR images.^[66] We measured the pituitary in 94 UHR individuals (selected from our larger sample in order to exclude effects of medication) and 49 control subjects. UHR subjects who later went on to develop psychosis had pituitaries that were 12% larger on average than UHR-NP subjects—furthermore, the risk of developing psychosis during the follow-up period increased by 20% for every 10% increase in baseline pituitary volume. This work suggests that abnormal HPA axis function around the time of transition to psychosis and during its earliest phases may drive some of the brain changes seen in prefrontal and medial temporal regions. Further longitudinal studies as well as investigations assessing the impact of stress and other etiological factors around the time of illness onset will be important to understand the mechanisms underlying the changes in brain structure; some of these are already underway, including studies from our group that are assessing limbic and other cortical regions in detail.

and Conclusions

As yet, there are no convincing, replicated, reports of neuroimaging measures that predict the subsequent onset of psychosis. Instead, the most promising findings have been in the neuropsychological domain, with strong evidence for impairments of prefrontal cortex function in later psychotic patients. However, there are still no clear replications of previously published studies (for review, see Brewer et al^[67]), and there is insufficient evidence to recommend a specific screening instrument. Longitudinal studies show promise but raise questions about exactly when the changes in brain structure and function occur with respect to the development of psychopathology.

The relative failure of neuroimaging measures to predict transition to psychosis suggests that standard volu-metric techniques are incapable of capturing the subtle differences between UHR individuals with different outcomes. Indeed, the findings with the best predictive power are those looking for small changes in cortical thickness (Fornito et al, unpublished data).^[57] Spectroscopy has the potential to detect differences in brain metabolites, including neurotransmitters such as glutamate and gamma-aminobutyric acid, and is therefore a plausible technique for predicting transition. There is a large range of normal physiologic variation, however, so its capacity for separating 2 groups who may only differ marginally may be limited.^[68] The most promising technique is functional magnetic resonance imaging because it combines neuro-biology with cognition. However, to date, there has only been one study in a UHR cohort, with no data about transitions,^[36] and in any case, it is still unclear whether an activation/deactivation paradigm (as opposed to resting state^[69]) will be successful in predicting transition. The combination of functional imaging with spectroscopy has proved informative in other disorders, such as addiction^[70] and OCD^[71]—incorporating additional modalities, such as diffusion tensor techniques,^[72] and alternative analysis methods, such as machine learning (eg, Chen et al^[73]) seems warranted.

Overall, the investigation of symptomatic high-risk groups has challenged the prevailing models of schizophrenia.^[74,75] The initial results are suggestive of excessive (including neurodegenerative) brain changes that may be consistent with the clinical changes manifest in these individuals as they develop frank psychosis. However, potential markers of impending psychosis need to be considered cautiously and in the context of normal changes occurring at this illness stage. These changes are evident in more posterior regions during childhood and progress anteri-orly with the greatest impact apparent in prefrontal regions during adolescence and early adulthood, including increased myelination, synaptic proliferation and pruning, as well as subtle loss of GM volume.^[76,77]

Further, we have previously suggested that there may be a number of processes underlying the observed abnormalities and dynamic changes in early psychosis.^[75] In particular, we have argued for 3 processes that would be consistent with the findings to date, including early neuro-developmental anomalies, progressive changes around the time of transition to illness related to the effects of stress hormones, and changes during the early stages of psychosis relating to alterations of the normal maturational processes (in both cognitive and neuroanatomical measures). Further studies are required to establish the veracity of this proposal and the degree of interaction between these processes and the genetic and social environment.

If there are active brain changes occurring as the illness itself is emerging, it is possible that these changes could be prevented, ameliorated, or at least delayed by early intervention, eg, to reduce the impact of stress and stress-related hormones.^[60] Preliminary studies suggest that intervention at this early stage may reduce transition to psychosis,^[8-10] including a promising pilot study of low-dose lithium that demonstrates beneficial changes in the hippocampus in an UHR sample.^[78] Such data will require replication and increased numbers of subjects

 

St. John's Wort Found Ineffective for Childhood ADHD

St. John's Wort Found Ineffective for Childhood ADHD CME

News Author: Marlene Busko CME Author: Penny Murata, MD Disclosures

Release Date: June 12, 2008; Valid for credit through June 12, 2009

June 12, 2008 — A randomized, controlled 8-week trial found that Hypericum perforatum (St. John's wort) was no more effective than placebo for improving symptoms of attention-deficit/hyperactivity disorder (ADHD) in 54 children and adolescents.

The findings by Wendy Weber, ND, PhD, MPH, a naturopathic doctor at Bastyr University in Kenmore, Washington, and colleagues, are published in the June 11 issue of the Journal of the American Medical Association.

The group writes that, to their knowledge, this is the first placebo-controlled trial of H perforatum in children and adolescents with ADHD and concludes that their results do not support further research of this formulation of this botanic agent for the treatment of ADHD symptoms. Adverse events were similar in the treatment and placebo groups.

Seeking Alternative Therapy for ADHD

Up to 30% of children with ADHD do not respond to pharmaceutical treatment, or they have adverse effects such as nausea, insomnia, or weight loss from the medications, the group writes. Parents of these children often seek alternative therapies, and in the United States, the most common herbal treatments used by children with ADHD are St. John's wort, Echinacea species, and Ginkgo biloba, they add.

In the last decade, atomoxetine, a new nonstimulant selective norepinephrine reuptake inhibitor, was approved by the US Food and Drug Administration (FDA) for ADHD. Because H perforatum is believed to act as a norepinephrine reuptake inhibitor, the group hypothesized that it might show benefit for ADHD, Dr. Weber told Medscape Psychiatry.

The researchers filed an Investigational New Drug application with the FDA for a clinical trial that aimed to determine if H Perforatum was effective in lessening the severity of ADHD symptoms.

They recruited participants from the general population and randomized 54 healthy children aged 6 to 17 years old who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for ADHD and who were not currently taking a pharmaceutical medication for ADHD.

After a 1-week placebo run-in, adherent participants were randomized to 8 weeks of the drug (which was standardized to contain 0.3% hypericin, a derivative of H Perforatum) or placebo. Participants were instructed to take a 300-mg capsule 3 times a day, ideally before school, after school, and at bedtime.

The 3 primary study outcomes were the following:

• Changes in ADHD symptoms, as measured by the ADHD Rating Scale-IV (ADHD RS-IV).
• Reduction in ADHD symptoms, as measured by the Clinical Global Impression (CGI) Improvement Scale.
• Adverse events.

The 27 children (20 boys) randomized to the treatment group had a mean age of 9.9 years, and the 27 children (14 boys) randomized to placebo had a mean age of 9.7 years.

The researchers did not find any significant difference in the change in the ADHD RS-IV scores from baseline to week 8 between the treatment and placebo groups.

Table. Change in ADHD RS-IV Scores After 8 Weeks of Placebo or H perforatum

ADHD RS-IV*	Placebo Group Mean Score (95% CI)	H perforatum Group Mean Score (95% CI)	P
Hyperactivity score	–2.0 (–4.1 to 0.1)	–1.8 (–3.7 to 0.1)	.89
Inattentiveness score	–3.2 (–5.7 to –0.8)	–2.6 (–4.6 to –0.6)	.68
Total score	–5.2 (–9.4 to –1.1)	–4.4 (–7.9 to –0.9)	.76

*ADHD RS-IV indicates ADHD Rating Scale-IV, which assesses ADHD symptoms. A maximum total score is 54, and a 13-point reduction in total score has been cited as a clinically meaningful change.

There was also no statistical difference between the 2 groups in the proportion of participants who were rated as much or very much improved on the CGI scale (44.4% in the treated group vs 51.9% in the placebo group).

Similarly, there was no significant difference between the 2 groups in the proportion of participants who experienced 1 or more rash, nausea or vomiting, headache, or sunburn adverse event during the trial (40.7% in the treated group vs 44.4% in the placebo group).

Would a Different Formulation Be Effective?

"The results of this study do not support further research on the use of H perforatum as formulated in this study for the treatment of ADHD in children," the researchers write.

The H perforatum that was used in this study was formulated to contain 0.3% hypericin at the beginning of the study. Analysis revealed that at the end of the study, it contained only 0.13% hypericin and 0.14% hyperforin (another derivative of H perforatum, which is available in a "high hyperforin" format containing 3% to 5% hyperforin).

Hyperforin is very unstable and quickly oxidizes and becomes inactive. Most H perforatum products on the market are at risk for oxidation because of their delivery as 2-part capsules, the group writes.

"If an H perforatum product with a stable and high hyperforin content became available for investigation, it would be worthwhile to conduct a study to determine whether a clinically meaningful benefit could be achieved," they conclude.

Dr. Weber noted that their sample was too small to provide evidence that there are no adverse effects associated with the use H perforatum in children. It is important to remember that St. John's wort acts to decrease the circulating levels of other medications that are metabolized by the same isoenzymes in the liver, she added.

"A Noteworthy Example of a High-Quality Trial"

"Not only is this the first reported study of Hypericum for ADHD in children and adolescents, but it is also a noteworthy example of a high-quality randomized controlled trial evaluating a specific complementary and alternative medicine therapy in children," Eugenia Chan, MD, MPH, from Harvard Medical School, in Boston, Massachusetts, writes in an accompanying editorial.

Although it is challenging to design rigorous studies for complementary and alternative medicine therapies, this is what is needed to develop a strong evidence base, she concludes.

JAMA. 2008;299:2633-2641, 2685-2686.

Clinical Context

Children with ADHD might not respond to medication or might have adverse effects from the medication. Subsequently, the parents might turn to complementary or alternative treatment. Cala and colleagues reported in the February 2003 issue of Pharmacotherapy that St. John's wort, Echinacea species, and Gingko biloba are the most common herbal treatments used by children with ADHD.

Atomoxetine, a selective norepinephrine reuptake inhibitor, is used to treat ADHD in children. St. John's wort, known as H perforatum, also appears to inhibit reuptake of norepinephrine, as noted by Muller and colleagues in the September 1997 issue of Pharmacopsychiatry.

This randomized, placebo-controlled, double-blind trial evaluates the efficacy and safety of H perforatum in the treatment of children with ADHD.

Study Highlights

• Of 146 children aged 6 to 17 years recruited from offices and advertisements, 59 eligible children entered the placebo run-in phase.
• Inclusion criteria were score of more than 1.5 SD above age and sex norms on the ADHD RS-IV, ability to read English, ability to attend all visits, and ability to swallow pills.
• Exclusion criteria were severe depression, active suicide plan, bipolar disorder, severe conduct disorder, psychotic symptoms, risk for pregnancy, use of products metabolized by the cytochrome P3A4 isoenzyme of the cytochrome P450 system, or previous H perforatum use for more than 2 weeks.
• Children less than 80% adherent or who had placebo response during the placebo run-in phase were also excluded.
• 27 children were randomized to receive one 300-mg H perforatum capsule containing 0.3% hypericin and no heavy metals, pesticides, or adulterants 3 times a day for 8 weeks.
• 27 children received placebo capsules of rice protein powder and activated charcoal.
• Subjects had to discontinue stimulant medication for 1 week or other medications for 2 weeks before the start of the study.
• Permitted treatments were multivitamins, essential fatty acid supplements, and counseling if used for at least 3 months with no plans to change.
• Mean age of the children was 9.7 to 9.9 years.
• Previous ADHD medications were used by 41% of the H perforatum group and 44% of the placebo group.
• More boys were in the H perforatum vs placebo group (74.1% vs 51.9%).
• Baseline co-occurring oppositional defiant disorder was more common in the placebo vs the H perforatum group (55.6% vs 33.3%).
• Medication adherence was similar for both groups.
• Primary outcome measures were changes in ADHD symptoms measured by the ADHD RS-IV from baseline to week 8, changes in global functioning measured by the CGI Improvement Scale, and safety measured by the Monitoring of Side Effects Scale.
• Improvement in ADHD RS-IV scores from baseline to week 8 was not significantly different for the placebo vs H perforatum groups (5.2 vs 4.4 points).
• Changes in ADHD RS-IV hyperactivity and inattentiveness scales were not significantly different between groups.
• CGI Improvement Scale rating of much or very much improved occurred in a similar proportion of the placebo vs the H perforatum group (51.9% vs 44.4%).
• At least 1 or more adverse event (rash, nausea or vomiting, headache, sunburn) occurred for a similar proportion of the placebo vs the H perforatum group (44% vs 41%).
• Rash occurred in more subjects in the placebo vs the H perforatum group (15% vs 0%).
• Weight gain was similar for the placebo vs the H perforatum group (1.0 vs 1.5 kg).
• Change in height was similar for both groups.
• Adjustment for age, sex, household income, parental rating of ADHD severity, and co-occurring oppositional defiant disorder did not affect results.
• Placebo and H perforatum groups showed no differences in other measures of behavior: Parent-Reported Child Behavior Checklist or Child Behavior Checklist-Youth Self Report Form for ages 11 years and older (internalizing, externalizing, total, DSM-IV Affective, Anxiety, Oppositional, or Conduct scales), Conners Parent Rating Scale, and parent-report and child-report forms of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales.
• Blinding was adequate: medication status was correctly identified 52.9% of the time by parents, 43.1% of the time by children, and 56.9% of the time by the principal investigator.
• Limitations of the study included use of a product relatively low in hyperforin, baseline group differences, short duration, and small sample size.

Pearls for Practice

• Children with ADHD who use H perforatum for 8 weeks show no reduction in ADHD symptoms or improvement in global functioning.
• Frequency of adverse events is similar for H perforatum vs placebo in children with ADHD.

I N T U I T I A

- al 6-lea simt - combina cunoasterea cu afectivitatea - combina vointa cu inteligenta - judecata sintetica, rapida, care scurtcircuiteaza deliberarea analitica rationala - de la atenie-perceptie direct la convingerea irationala a adevarului - echivaleaza ca mecanism cu perceptia deliranta si intuitia deliranta,cu delirul - Wahnwahrnemung, Wahneinfall, das Wahn - indispensabila in creatie, imaginatie, imaginar-fantasme, halucinatie, falsificare, iluzionism - Bergsonism, durata, subiectivism, esenta artei - clipele de revelatie, de gratie, descinderea sfintului duh - comunicarea cu transcendentul - extazul - inspiratia - discovery-evrika! - unicitatea, incomunicabilitatea, ruptura, neintelegerea, ostracizarea, excluderea, suprimarea - conceptie, aperceptie, apriorism, transcedentalitate - geniala dar si periculoasa daca nu e stapinita de o minte superioara - lumea ignora descoperitorii desi profita in orice moment de ei - este fructul cel mai fin al confruntarii sex-spirit -- Publicat de către Aurel Romila la PSYCHIATRY , 2/07/2008 12:52:00 AM

E M P I R I S M

subiect - senzatia, reflexul, impulsiunea - perceptia, gestalt, semiologie, sintaxa - reprezentarea, aperceptia, apriori, transcendental - intuitia, irationalul, bias, tendinta, trendul, inconstientul - cuvintul, expresia, semnul, semnificatia - ideea, noiunea, conceptul, categoria, semanticatextualism, deconstructie, hermeneutica - imaginea fotografica, neocreata, cliseu, original, pastisa, pattern - conceptia, weltanschaung, partizanat, sectarism, fanatism - credinta, traire, absurditate, traditie, folklor - atitudineacategorica, ambigua, dilematicasex - verificare, respingere, failibilitate -- Publicat de către Aurel Romila la PSYCHIATRY , 2/03/2008 11:57:00 PM

S I N E - I N T U I T I E

- notiuni dificile,discutabile - sunt inexplicabile prin stiinta curenta - sunt totusi utile intelegerii fenomenolor mai complexe ale psihicului - sinele ar putea fi baza inconstienta,valorica a egoului - intuitia este convingerea instantanee a egoului - intuitia ar fi expresia sinelui - sinele contine si parte din sinele universal(Dumnezeu e in noi-Maister Eckart) - sinele este insine(Hegel) dar poate deveni pentru sine,adica pentru ego,prin introspectie - sinele este diacronic.intuitia este sincrona - sinele este transcedental,aprioric,aperceptiv(Kant) - sinele este matricea categoriala(Aristotel) - sinele conditioneaza trecerea persoanei in persona;itate - sinele e personal,inconstientul e de specie (Jung) - sinele se proecteaza prin testele de proectie,personalitate(Ivana) - sinele e structural,arhitectonic,intuitia e functionala - sinele si intuitia duc la descifrarea inconstientului post freudian,peste libido si destrudo - sinele si intuitia sunt elemente ontologice - psihologia clasica explica diferenta prin masuratori cognitive -- Publicat de către Aurel Romila la PSYCHIATRY , 2/15/2008 11:51:00 PM

D I N A M I S M

- Toata lumea vrea dinamism - primul e sportul - al doilea e politica(Obama,chiar Guse),liberalismul - afacerile(advertising) - talk-show informing - teatru(Piersic,Stela) - tabloidele cu nuduri - hip-hop,invirtitul pe cap - TGV, high tech, mobilele, u-tube, formula I - instant coffee - sex o luna-tantra - vreau toata noaptea! - tinerete fara batrinete - slabire cu parametri de top model - detectorul de minciuni - gigabiti - card - normal Klages: spiritul lupta cu sufletul - in nevroza sufletul sufera, se framinta, oboseste, se panicheaza, nu-si poate stapini emotiile - in psihoza sufletul se pierde, nu stie ce vrea,nu termina, nu are copuri mari,indepartate - in dementa sufletul se uita,vrea clipa fiziologica - in psihopatie sufletul terorizeaza, e agresiv, face demonstratie de forta - dinamismul e sinonim cu temperamentul, natura, sinele, intuitia, conceptia, stilul, marca, brandul -- Publicat de către Aurel Romila la PSYCHIATRY , 2/16/2008 11:56:00 PM

C U S A N U S

- coincidentia opositorum - extremele se ating - docta ignorantia(stim ca nu stim -Socrate) - depasirea dedublarii in one brahmanic - contradictia e motorul(Hegel) - unitatea contrariilor(Marx) - unitatea e contradictorie - laturile contradictorii se presupun - structura,infra si supra se presupun - corp si suflet sunt coprezente si interdependente - Heraclit si Parmenide - Kant si Hegel - normal si dezechilibrat se presupun - psihopatia si nevroza coexista - dementa si psihoza pot coexista - tratamentul este un amestec de inhibare si stimulare - diagnosticul e sindromologic si nozologic - managementul e psihosocial - individualul e universal si invers(Noica) -- Publicat de către Aurel Romila la PSYCHIATRY , 2/21/2008 12:58:00 AM

D I N A M I S M = energie

- Toata lumea vrea dinamism - primul e sportul - al doilea e politica(Obama,chiar Guse),liberalismul - afacerile(advertising) - talk-show informing - teatru(Piersic,Stela) - tabloidele cu nuduri - hip-hop,invirtitul pe cap - TGV,high tech,mobilele,u-tube,formula I, - instant coffee - sex o luna-tantra - vreau toata noaptea! - tinerete fara batrinete - slabire cu parametri de top model - detectorul de minciuni - gigabiti - card - normal Klages: spiritul lupta cu sufletul - in nevroza sufletul sufera,se framinta,oboseste,se panicheaza,nu-si poate stapini emotiile - in psihoza sufletul se pierde, nu stie ce vrea,nu termina, nu are copuri mari,indepartate - in dementa sufletul se uita,vrea clipa fiziologica - in psihopatie sufletul terorizeaza,e agresiv,face demonstratie de forta - dinamismul e sinonim cu temperamentul,natura,sinele,intuitia,conceptia,stilul,marca,brandul -- Publicat de către Aurel Romila la PSYCHIATRY , 2/16/2008 11:56:00 PM

I N C O N S T I E N T U L

- Inconstientul personal-Es, Id, libido si destrudo-Freud - Inconstientul colectiv cu complexe, arhetipuri, animus si anima, umbra, self-Jung - Deus sive natura-Spinoza, teologie negativa-Eckarth, Barth - Colocviul dela Bonnvale-Ey, Lacan, Ajaruieguerra - Automatismele psihologice-Janet - Delay:memoria instrumentala, neurologica(fazie, gnozie, praxie) - Minkowski: memoria neurologica, autista, comuna - Romila:sex si spirit, functiile diacrone, ego si sine, sine personal si universal - concentrare, imprastiere, disociere - normal, ca stapinire a inconstientului - psihiatria ca dominare a inconstientului - cu constiinta faptului greu de stapinit, nevroza - fara constiinta defectului, psihoza si dementa - autoacuzarea depresiva fata de heteroacuzarea paranoida - creatia irepresibila, explozia, intuitia, revelatia, miracolul, suprarealismul - impulsivitatea, enervarea, nelinistea, obsesia, fobia, delrul, halucinatia, regresia, suicidul, aneantizarea - automatul visceral-Romila, vegetativ-Danielopolu - inconstientul sub normal si supranormal - inconstientul si istoria - istoria artei, succesiunea modelor, trendul, snobismul.originalitatea, noutatea, amnezia trecutului - forta temperamentala, antisocialul, , lookul, supraomul, geniul - c`est la vie! - ciclicitatea, eternel retour, maia.samsara, destin, karma, ereditate, genetica, statistica, hazard, game, copilarie - putere, importanta, valoare, impresie, demonstratie, senzational, tv, dans, nud -- Publicat de către Aurel Romila la PSYCHIATRY , 2/24/2008 11:17:00 PM

C O N T R A P U N C T

- 2 serii aparent independente insa inercorelate - model : cintatul la pian,cu mina dreapta si stinga - acompaniamentul actual este o pastrare a ritmului,armonica - psihicul pentru corp e mina dreapta dar pentru social e mina stinga - important e ca nicio lume nu e solo ci e contrapunctica sau chiar polifonica - conteaza structura izomorfa contrapunctica - ginditi acum psihopatologia cu contrapunctul neurostiintelor - jazz cool Thelonius Monk sau Yancy Korossy - pesrsonaliatea pe fondul constiintei - cunoastere pe fondul afectivitatii - expresie comportamentala pe fondul egoului - logica pe fondul istoriei - perceptie pe fond de aperceptie,interpretare,conceptie - nu te speria,lumea nu e simpla,academica,are si logica simpla dar si pe cea dialectica,polivalenta - rezulta o intuitie globala,holista,valorizanta de adaptare sau criza -- Publicat de către Aurel Romila la PSYCHIATRY , 2/23/2008 08:39:00 AM

E M P I R I S M

subiect - senzatia, reflexul, impulsiunea - perceptia, gestalt, semiologie, sintaxa - reprezentarea, aperceptia, apriori, transcendental - intuitia, irationalul, bias, tendinta, trendul, inconstientul - cuvintul, expresia, semnul, semnificatia - ideea, noiunea, conceptul, categoria, semanticatextualism, deconstructie, hermeneutica - imaginea fotografica, neocreata, cliseu, original, pastisa, pattern - conceptia, weltanschaung, partizanat, sectarism, fanatism - credinta, traire, absurditate, traditie, folklor - atitudineacategorica, ambigua, dilematicasex - verificare, respingere, failibilitate - 9 empirisme: - 1.naturalismul presocratic. Nominalismul medieval(Ocam), modern:Nietsche, Poincare, Quine - 2.empirismul englez:Bacon, Hobbes, Locke, Hume, Bentham, Mill, Spencer, Darwin - 3.iluminismul francez:Diderot, Montesquieu, Rousseau, Voltaire, La mettrie, Helvetius, Holbach, cu germanii Lessing, Schiller, Goethe, Herder - 4.pozitivism : Conte, Cousin, Durkheim, Tarde, Lombroso, Morel, Cl.Bernard, Pasteur, Moreau de Tours, Magnan - 5.empiriocriticism:Mach, Avenarius, -Lenin - 6.empirismul logic, cercul dela Viena, pozitivismul logic: Carnap, Godel, - 7.filozofia analitica:Russel, Wittgenstein, Quine - 8.pragmatism:Peirce, Dewey, James, Parsons, Moreno, Merton, Mead - 9. economie politica:Marx, Engels, Lenin, Pareto, Max Weber, Keynes, C.Schmitt, Strauss - 10.democratie si liberalism-libertinismul este antisocial - 11.organicism:Broca.Wernicke, Virchow, Marinesco, Bocq, Charcot - 12.fiziologism:Jackson, Sherington, Loewi, Danielopulo, Regis, Janet, Freud, Pavlov - 13.Neurostiinte : imagistica, neurotransmitatori ; Carlsson - 14.neuropsihofarmacologie ; Delay, Deniker, Tolefson - 15.inconstient :Scopenhauer, Ed.von Hartmann, Janet, Freud, Jung - 16.structuralism.gestalt, holism :Ey, Romila -- Publicat de către Aurel Romila la PSYCHIATRY , 2/03/2008 11:57:00 PM

PSIHIATRIA intre PARANOIA si DEMENTA

extremele conceptuale - dela obiectul maxim la obiectul minim-dela dumnezeu la instinct - dela dominare la dependenta si sclavie - dela ambitie laindiferenta - dela importanta la nimicnicie - dela afirmare la negare - dela putere la impotenta - dela cucerire la deposedare - dela imperativ la obedienta si oportunism - dela neicredere la sugestibilitate si non critica - dela suprapreciere orgolioasa la devalorizare degradata - dela expresie la tacere - dela asumare istorica la amnezie,afazie,agnozie,apraxie - dela scopuri marete supraindividuale,la interese meschine,fiziologice,de supravietuire automata - dela responsabilitate maxima la iresponsabilitate animala - extremele se ating in violenta - dela rigoare la dezordine, - dela datorie la placere,sex,evacuare - dela lupta sistematica(Kampf paranoia) la impulsivitate imprevizibila - dela inteligenta concentrata,perseverenta la perceptie pasiva,cu atentie spontana,intimplatoare - dela victorie la umilire - dela ura la acceptare - dela pasiune la indiferenta - dela prorrietate la indiferenta invaziei si ocupatiei - dela precizie la confuzie - dela suranta la indecizie - dela ego la id - ego supradimensionat,baroc in superego fata de id zoologic,tiritor - dela claritate,coerenta la incoerenta,vag,ininteligibil - dela cinste la tradarer si lasitate - dela atlet la obez - dela sectarism,mafiotism laegalitarism,devalmasie,nediferntiata - dela fanatism la ignoranta - dela prevalenta la reflexe - dela isitem la camelionism - intre profit maxim si looser - look si hip-hop - brand si contrafacere - interes si demagogie,pacalirea prostilor - adepti,prozeliti si ruda nedorita - intre bogatie si saracie - intre moralism intransigent si libertinaj ieftin - intre goliciunea provocarii luxului si renuntare la orice stisfactie - intre razbunare exagerata si iertare neconditionata - intre psihopatie si psihoza fata de deteriorare si mizerie fiziologica - intre valoare si fosta valoare - intre geniu si gunoi - intre renastere si decadenta,dependenta - intre impostura,pastisare,furt,simulare si lipsa discernamintului - dela paranoia tarilor la paranoidul slabilor,cu urmarire,relatie,influentaredeposedare,mostenire,invidie,concurenta,joc necinstit,blat - dela delir la halucinatii - dela heteroacuzarela autoacuzare,la suicid - dela stramosi,descendenta inalta la anonim - dela valoare planetara la kitsch submediocru - dela aroganta si pretentia elitista la clochard,vagabond,hippy,aurolaci,cersetori - dela Belu la Trei Coceni,sau mormint necunoscut - ignorarea intentionata a trecutului cu exagerarea rezultatelor prezente,redescoperirile - afectarea,manierismul fata de pierderea continutului - multe neologisme,multe neaosisme fata de saracirea limbajului - nu se lasa fara iacht,avion personal,bodygard,arme,masini de cursa,galerii,Grigoresti ,etc. - schimba tot prin chirurgie cosmetica,hormoni,intinerire,slabire - cei mai dotati copii,fata de copii plecati,abandonati,nerecunoscuti - snobi ignoranti,nu mai au ce vedea,dupa turul lumii,fata deun camin spital -- Publicat de către Aurel Romila la PSYCHIATRY , 2/28/2008 02:11:00 AM

Dramaturgia pretului emotional

- interna - inerparanoiaca(proprietari de partide, cluburi, companii, profesii, ierarhii, campionate, titluri, topuri, vip) - interhisterice (modeling, look, cosmetica, diametre, fashion, stylist, show, cd, cv, cover-girl, nud­ity, fite, labels, hot mode, haute couture, shous, bad, intime lengerie, parfumerie, machiaj, silicoane, liposuctie, lifting, creme-cameritati-aparitia, legatyra, ruptura, scandalul, separarea, impartirea bunurilor, lupta pentru copii, genializarea copiiloratacul la nevasta, - interantisociali, monopolul teritoriului, superspecializarea, diviziunea muncii, omerta, compromiterea autoritatii, coruperea pazei, controlul efectorilor, spalarea banilor - interhipomaniacali, laudorosenia, rapiditatea, instabilitatea, disponibilitatea­, bascalia, lejeritatatea, infatigabilitatea, bancurile, distantele, agenda mare, iubire neincetata si raspindita, serviabili, saritori, milosi, familisti, multi copii, mincaciosi, bautori, jucatori - interparanoiac-isteric - interparanoiac-antisocial - interparnoiac-hipomaniacal - interparanoiac normal - interparanoiac-depresiv - interparanoiac-anxios - interparanoiac-astenic - interparanoiac-obsesiv - interparanoiac-fobic - interparnoiac-paranoid - interparanoiac -schizoid, schizotim - interparanoiac-schizofren - interparanoiac - deteriorat - interparanoiac - oligofren - interparanoiac - dement - interparanoiac - handicap AAA - -- Publicat de către Aurel Romila la PSYCHIATRY , 2/29/2008 12:47:00 AM

D I L E M E L E FILOZOFIEI

- Intre materialism si idealism - Intre metafizica si pozitivism,scientica - Intre spiritualism si sexualism - Intre unu si multiplu - Intre intreg si parte - Intre vechi si nou,clasic si modern - Intre ontologie si ontica - Intre determinism cauzal si finalism - Intre empirism si rationalism - Intre analitic si continental - Intre naturalism si teologie - Intre istorie si logica - Intre ego si sine - Intre corp si suflet - Intre creer si psihic - Intre perceptie si conceptie - Intre normalitate si extreme - Intre elemente si sistem - Intre esenta si fenomen - Intre impresie si diagnostic - Intre tratament si resocialzare - Intre ura si pretuire - Intre axiologie si confuzia dementiala - Intre stapinire si impulsivitate - Intre etica si antisocialitate - Intre libertate si responsabilitate - Intre controlul discernamintului si tracul disociativ - Intre constructie si razboi - Intre conflict si intelegere - Intre intelegere si explicatie - Intre pedeapsa si iertare - Intre inconstient si credinta - Intre dualism si monism - Intre iubire si bani - Intre adevar si simulare.fals,pastisa,minciuna,furt,crima - Intre claritate si confuzie - Intre lumina si intuneric - Intre sens si absurd - Intre stapinire si automatism - Intre viata si moarte - INtre eternitate si glorie - Intre clipa si destin - Intre experienta si existenta - Intre aptitudine si caracter - Intre inteligenta si caracter - Intre vointa si realizare - Intre plan si opera - Intre vorba si fapta - Intre selectie si eclectica - Intre creatie si invidia imitaiei neputincioase - Intre rautate si pervertirea binelui - Intre betie si luciditate - Intre visare si scopuri ascunse - Intre performanta si cantitate nesemnificativa - - -- Publicat de către Aurel Romila la PSYCHIATRY , 3/03/2008 12:56:00 AM

lupta de clasa psihopatologica

Tarii se bat cu toti.Invinsii devin o parte normali,mediocrii, iar ceilalti devin slabi si supusi,dependenti. Atmosfera e de seminebunie.victimele sunt scoase din lupta si normalii devin modesti pe cind slabii se nevrozeaza,se chinue,se vaicaresc,reclama.Tarii socot ura normala iar slabii spera la pace. Normalii critica,dar psihopatilor nu le pasa si nu recunosc ca sunt cauza nevrozelor.Nevrozele aspira la normalitate,care le socoate concurenta nedorita. Schizofrenii sunt exclusi din joc si nu le pasa ca parintii sunt deprimati din cauza lor.Normalii se gindesc la salvarea lor,dar nu stiu cum.Pentru tari ei nu exista decit ca accidente antisociale. Tarii socot ca batrinii trebuie sa dispara,sunt prea multi,normalii vor sa-i ajute dela distanta,iar slabii se agata de drepturile care le-a mai ramas. Dementii sunt parasiti si sunt invinovatiti de ce au fost,desi ei au uitat ce au facut. Absurditateaa e generalizata iar corectarea e minima si imprevizibila. Religia incearca o calmare supraomeneasca,o ordine supranaturala la care o parte din normali si nevrotici se conforma. Arta o fac cei tari pentru uimirea normalilor si consolarea nevroticilor. Toti rateaza in moartea egalizatoare,cu o dira de valori persistenta istoric. Sensul e apnajul celor tari si a onor normali ,care nu-l reduc la imobiliara. Cultura asteapta cu rabdare sa fie inteleasa,nu memorata si sa faca psihoterapie continua. Darwin zimbeste,toti il neaga,dar inconstientul merge mai departe. Normalii trebuie sa frineze pe tari si sa ajute pe slabi.Asta e morala ,nu turismul,proprietatea si contul. Ne pierdem in jazz , dar ne asteapta requiemul. nu disperati,intotdeauna a fost asa,mai bine faceti cite ceva,pentru echilibru. -- Publicat de către Aurel Romila la PSYCHIATRY , 3/04/2008 07:40:00 AM

reductia verbala a varietatii umane

Suntem bolnavi/sanatosi ; somatici,neurologici/psihici ; acuti/cronici ; reactivi/incurabili ; portabili/handicapati ; linistiti /periculosi ; singuri/cu familie ; cu casa/fara casa ; cu identitate/fara identitate ; cu plata /fara bani ; cu constiinta bolii/fara ; violenti/sinucigasi ;Internati voluntar/fortat ; externabili/definitiv hospitalizati ; lucratori /ostili ; comozi/dificili ; prieteni/dusmani ; te lauda /te reclama ; - sunt cardiaci,vasculari,diabetici,hepatici,renali,digestivi,urinari,ginecopate,v­enerici,dermatologici,senzoriali,paralizati;cazuti,in coma,in soc,in reanimare,in final,decerebrati,accidentati,transplantabili.operati,radiati,chimiotratati­,stabili/instabili,ameliorati/agravati ; succes/esec ; - variabilele tinar/batran sau femee/barbat,conteaza mai mult la sanatosi decit la bonavi - atuuri:b au,stiu,au discernamint ,sunt economi,prudenti,conservatori de trecut,traditii,identitate,,religiosi,istorici,axiologi,filozofi,politici,c­orupti,compromisi,vulnerabili,victimizabili - atuuriile t:forta,dinamism,energie,temperament,razboinici,competitivi,saraci dar visatori,veleitari,fanatici,paranoici,grabiti,necrutatori,sexuosi,frumosi,f­otomodel,tobosari,chitaristi,cascadori,legiune straina,sportivi,fani,risipitori,party,entertainement,tivi extrim,corporali,ombilicali,abdominali,dopati,antisociali,vitezisti,penali,­bodygarzi,suporteri,interneti,bluetoothici,liberi dar iresponsabili, - barbatii conduc,poseda,violeaza,idealisti,risca,pierd,iau plasa,dau gauri,construesc,violenti,borderline,frustrati,viseaza mingiere,intretin,fac cadouri scumpe,importanti,solemni,manieristi,patetici,actiune,extraterestri ; - femeile seduc,atrag,se expun,sugereaza nonverbal,disimuleaza,top,cool,trend,Swarovski,impresioneaza cu nunta,vila,copii,cardul,telenovela,dramatismul,emotia,plinsul,ochii,tocul,p­ersevereaza,divorteaza,iau copii si averea,dansul,sfidarea,scumpe,boli rare,cosmetica,intinerirea,virstofobia,spovedania,mormintul grandios -- Publicat de către Aurel Romila la PSYCHIATRY , 3/05/2008 01:11:00 AM

S I N E - E G O

- sunt emergente diacronice - sunt structuri - functiile aferente sunt vointa si inteligenta - sinele este instinctivo-axiologic - sinele este intuitiv - egoul mediaza si adpteaza sinele la realitate - sinele creaza,egoul organizeaza - sinele e baza egoului,dar egoul contine si controleaza sinele - sinele e mai vechi si mai inconstient decit egoul - in psihopatie sinele dicteaza unui ego ipocrit - in psihoze sinele trece peste ego - in nevroze sinele e slab si egoul nesigur - in demente sinele regreseaza la instinct - sinele care simte sinele universal capata credinta - sinele e dedublat in halucinatie si delir - Jung a descoperit sinele in arhetipuri - sinele personalizeaza corpul si inconstientul in corp-psihic Ey - egoul e stresat de ceilalti,sinele rezista pina la sfirsit - sinele e uzina de energie,economicul,materialul,continutul.egoul e forma,stilul,managerul --

TRIADELE SPIRALEI

- comportament=afectivitate . cunoastere - meserie=vointa . inteligenta - opera = self . ego - destin = spirit . sex - rol = statut . circumstante - functie = valoare . selectie - maintenance = endurance . resilience - succes = popular.shocking - Cristos = Dumnezeu . gratia - motivatia = constiinta de sine . datorie - challenge = amenintare si creatie - creatia = imaginatie . originalitate - visul = imaginar . imaginatie - viziune = sitematizare . vis - paranoia = mania grandorii . inteligenta - paranoidul = ambitie . persecutie -- Publicat de către Aurel Romila la PSYCHIATRY , 4/04/2008 08:05:00 AM

C O N F U Z I E

- confuzie mentala, onirism,delirium,amentia - confuzie oneiroida,pasiva,mnesticca,saistematica,tematica - confuzie halucinatorie,dialog dedublat cu un alter-ego - confuzie deliranta,proectie persecutorie - confuzie deprimanta,descurajanta - confuzie extenuanta - confuzia ignorantei,dismneziei,inatentiei,superficialitatll - confuzia veseliei,sarbatorii,petrecerea succesului - confuzia pripelii,ripostei impulsive,furiei - confuzia exagerat a demonstratiei - confuzia imporatantei, a primplanului,pseudovaloarea - confuzia visarii,imaginarului imaginat - confuzia fricii infantile - confuzia adolescenta pasionala - confuzia matura a intereselor - confuzia apararii involutive - confuzia mortii -- Publicat de către Aurel Romila la PSYCHIATRY , 4/09/2008 12:58:00 AM

Pierderea controlului

- pierderea controlului emotional:inrosirea,albirea,palpitatiile,transpiratiiile,anxietatea,scadere­a atentiei - tracul - pierderea controluli activitatii.al organizarii experientei,zapaceala,dezordinea - pierderea contolului caracterului,impulsivitatea - pierderea controlului aptitudinilor,scaderea performantelor - pierderea controlui temperamental,enervarea - pierderea controlului atentiei,distractia - pierderea controlului perceptiei,insuportabilitate,falsificare,absenta - pierderea controlului gindirii,incoerenta,invazia deliranta,incetinirea - pierderea contrlului memoriei,fixarea dificila,evocare imposibila - pierderea cotrolului imaginatiei,minciuna,platitudinea,p;astografia - pierdrea capului - pierderea caracterului - pierderea discernamintului - pierderea autonomiei - pierderea increderii in sine - pierderea functiei - pierderea sanatatii - pierderea averii - pierderea apropiatilor - pierderea timpului - pierderea sensului - pierderea linistii - pierderea tineretii - pierderea placerii - pierderea poftelor - pierderea socotelii - pierderea dreptului - pierderea libertatii - pierdere financiara - pierderea momentului - pierderea existentei - pierderea sperantei - pierderea credintei - pierderea increderii - pierderea caii - pierderea puterii - inconstienta pierderii - durerea pierderii - rectia razbunarii - conflictul interior al pierderii - suferinta sau indiferenta - strategia depasirii pierderii - cistigul pierderii - resturi ale pierderii - repetarea pierderii - obsesia pierderii - frica repetarii pierderii - simularea pierderii - exagerarea pierderii - ratacirea ca pierdere - regasirea pierderii - revendicarea pierderii - cererea de daune materiale si morale - hipercontrolul neincrederii si al fanatismului - vigilenta,urmarirea,dovezile,demonstrarea probelor - ierarhia controlului - competenta controlului - prevenirea pierderii,semne de avertizare - pierderea invizibila,indescriptibila,inefabila,nostalgica,ireparabila,irecuperabila,d­efinitiva - ususrarea prin pierdere,eliberarea de o povara -- Publicat de către Aurel Romila la PSYCHIATRY , 4/09/2008 01:41:00 AM

Treimele fundamentale

- treimea prfunda: satisfacerea,frustrarea.apararea sublimata sau proectata - treimea exprimata:emtiitraite dramatic,sentimente visate romantic,actiuni efctuate pasional,energic,viguros - treimea conducatoare,geranta,manageriala:tntegranta in spiritul universal,coerenta in ibtreg ,coeziva in holismul dragostei - treimea b.m.:confuzia,pierderea controlui spiritual,Haosul,neantul dezorganizarii dementiale - sfinta treime conduce treimea corp,psihic=suflet,ratiune-inteligenta - spirit,corppsific si cosmos -- Publicat de către Aurel Romila la PSYCHIATRY , 4/13/2008 02:47:00 AM

Determinantii comportamentului si coduitei

- 12 nivele de constiinta - 4 ipostaze ontogenetice de personalitate - dedublarea ontologica in sisteme empirice sau rationaliste - variante empiriste: pozitivism, empiriocriticism, empirism logic, pragmatism, textualism, deconstrutivism, semiotica, semantica, gramatica germinativa, hermeneutica, utilitarism, materiaismdialectic, istoric, vulgar, logica cercetarii, scientica, darvinism, evolutionism, sociologism, psihologism, psihanaliza, organicism, neurostiinta, neurotransmitatori, cibernetica, media, biosociologie, psihosociologie, economie politica, politica, ecologie, energetica, corpul psihic, automatul visceral, robotica, high-tech, discovery, film documentar sau artistic, arta concreta, stiintele fizice, chimice, naturale, astronomia, cosmos, ateismul, revolutia, bombsuicidul, depresia, psihopatia, dementa, medicina somatica, filozofia analitica, sportul, afcerismul, finantele, petrolul, gazul, sexul, longevitatea, hiv, cancer, rrealism, locuinta, divort, copii, proprietate, justitie, catastrofe naturale, competitii, top, razboi, handicap, batrinete, urgente, masini, civilizatie, net, mobil, transport, accident, guvernare, educatie - hedonism, epicureism, liberalism, dictatura, fascism, hile, cimp si substanta, creationism , determinism emotivism, pasionalitate, impulsivitate, experienta, existenta, fetisism, reductionism, regres, tehnica, tehnologie, statisticasamsara, filozofia stiintei, filozofia vietii, vitalism, freudomarxism, functionalism, instrumentalism, explicatie, karma, logistica, maltusianism, munca, nihilism, ontic, oportunismpopor, practica, problemazgomot - rationalism, idealism, spiritualism, iluminism, cartezianism, kantianism, hegelianism, platonism, aristotelism, fenomenologie, structuralism, panteism, crestinism, hinduism, taoism, shinto, islamism, existentialism, transcendent si transcedental, axiomatica, cultura, retorica, devenire, dialectica, aufhebung, negarea negatiei, categorii, concept, diferenta specifica, unversalii, realism, trinitate, divinitate, relism, esenta, eidos, noumen, ousia, dinamism, elan - vital, spirit, apolinic, , dreptate, dumnezeu, durata, echilibru, eidetic, entuziasm, epistemologie, epoche, estetism, eul, extrapolare, factori, fantezie, fiinta, filozofie, fundament, homeostazie, imaginatie, imperativ categoric introspectie, irational, izomorfism, intelegere, intelepciune.indoiala, lege, legatura, libertye si responsabilitate, logica, logos, noesa si noema, obligatie, ontologie, principiu, proces, proect, prototip, pattern, paradigma, quiditate, sacru, serendipitate, simbolica, semnificatie, sine, sinteza, sistem, stoic, suflet, supraom, substanta, teorie, teologie, totalitate, tropi, unitate, umanism, valoare unul/viata, verificare viziune, vointa, zen -- Publicat de către Aurel Romila la PSYCHIATRY , 4/20/2008 11:17:00 PM

ANTINOMII IZOMORFE

- Creer - psihic - somatic - psihic - neurotransmitatori - constiinta - inconstient - constienta - self - ego - corp psihic - ego - ego - controlul realitatii - instinct - ratiune - suflet - minte - corp - cap - afectivitate - cunoastere - afectivitate - senzorialitate - afectivitate - gindire - afectivitate - onstiinta de sine - constiinta de sine - conceptie - ontic - ontologic - memorie - atentie - atentie - perceptie - interes - atentie - placere - motivatie - vointa - inteligenta - libertate - responsabilitate - temperament - caracter - deprinderi - meserie - talent - aptitudine - opera - valoare - baza,structura - suprastructura - biologicul - socialul - economicul - politicul - politicul - cultura - cultura - religiosul - conceptia - sensul - limbajul - gramatica - gramatica - semantica - semantica - hermeneutica - hermeneutica - deconstructia - viata - arta - sexul - spiritul - Dumnezeu-Hristos - spiritul - moment - eternitate - short term -long term - co - personalitate - persoana - personalitate - talent - geniu - jos-sus,inferior-superior,orizontal-vertical - accidental,conjectural,circumstantial - esential,fundamental,determinant,diferenta - perisabil - enduranta,mentenanta - sensibil - rezilient - iresponsabil,spontan,involuntar - discenamint ,responsabilitate - premiza -concluzia - corolarul,consecinta - material - ideal - credinta - speranta - iubirea - moartea - agresiunea - ura - disocierea,confuzia,risipirea,inprastierea,zapacirea,emotionalitatea - echilibru,sanatatea,armonia - separare - participare - simulare - asimilare -- Publicat de către Aurel Romila la PSYCHIATRY , 5/01/2008 06:57:00 AM

ANTINOMIILE PSIHOPATOLOGIEI(citind Kant) Options

- Psihicul e limitat de creer si nelimitat de spirit - Psihicul e simplu din p.d.v.comportament dar e complex ca motivatie - Psihicul e liber ca imaginatie dar e determinat de circumstante - Psihicul are un inceput in copilarie si un sfirsit in Dumnezeu - Psihicul are o baza biologica dar un control spiritual - Psihicul pina la adevar si realizare trece prin confuzie,disociere si minciiuna - Psihicul originar se converteste in sine si ego sau vointa si inteligenta -- Publicat de către Aurel Romila la PSYCHIATRY , 5/02/2008 06:51:00 AM

UNITATE CONTRADICTORIE

- curge diacronic, programata genetic si la chalengiul mediului, in trendul curbei existentiale - experienta sincrona e contradictorie:suprastructura egoului sta pe structura selfului:baza cu infrastructura in somatic - egoul are o forma caracterial-temperamentala si un continut aptitudinal-axiologic - egoul are o expresie actuala de constiinta( cu o claviatura sindromatica sub , normala si supranormala) si un potential de personaliate matur( depasind copilaria, ado;escenta si sfidind involutia) - egoul controleaza dizarmonia psihopatica, disocierea nevrotica hipoaptitudinala si disocierea psihotica delirant-halucinatorie si e dominat de selful somatic-neurologic-instinctual cu uitare si fara viitor, intregul e anticonfuzie, gestalt holist, logic, cu gindire, intelect, inteligenta , ratiune, intelepciune, sens si strategie managerial de realizare, succes, cu destin eternizat istoric - egoul introjecteaza, asimileaza egoul epocii si al istoriei, avind un self umanizat, personificat(customizat) - egoul controleaza selful, constient-inconstient, somatic-neurologic, vointa de putere si reprezentare, interesele identitatii - egoul e simfonic nu usor, domina recesivitatea distractiei, divertismentului, sexului, organizind supravietuirea, alegerea, decizia, drumul.enduranta, mentenanta si resilianta - egoul responsabilizeaza libertatea, discerne, lupta, cistiga sau pierde - egoul se apara refulind selful, proectind pe dusmani, sublimind demonstrativ in matchul vietii - egoul e constructiv, imaginativ, domina imaginarul oniric sau dedublat, tristetea, anxietatea, abuzul de interpretare, impulsiunile, emotiile simulate si expansiunea axiologica exagerata sau falsa ca si confabulatila povestei pseudolog-fantastica - egoul, iubeste, asociaza, e coeziv, coerent, integrat, unifica multiplicitatea selfului in unul rational, unitas multiplex, coincidentia opositorum cusanesca - e transcendent tutic si transcedental kantic, in spirala hegel, iana subiectiv-obiectiv si sinteza subiectv-absoluta, e dasein heidegerian, adica fiinta prezenta in timpul ireversibil. - e angajat camusian, antineantul sartrian, cu weltanschaungul jaspersian.hermeneutica ricoeuriana, decomstructia structurala Derrida, sacralitatea eliadesca, scepticismul cioranesc, bascalia caragiale, Ionescu -- Publicat de către Aurel Romila la PSYCHIATRY , 5/09/2008 07:57:00 AM

Profesor Aurel Romila -- Blog

http://www.aurelromila.blogspot.com/ R E S O C I A L I Z A R E - locul in terapeutica - practica si conceptia - istoric - diagnostic pozitiv - esenta economic umanista - diagnosticul diferential - cu neurostiintele - cu psihanaliza - cu terapia cognitiv comportamentala - cu organo=dinamismul - cu structuralismul - cu existentialismul - cu antipsihiatria - cu ergoterapia si terapia ocupationala - cu terapia familiala - cu drepturile omului - cu wpa-terapia persoanei - cu ajutorul de stat,sponsorizarea,asocierea - meseria - banii,casa,transportul.familia - iresponsabilitatea non angajarii,desfiintarii,simularii,demagogiei - concurenta chimioterapiei - viitorul si libertatea - modelul rominesc E t i c a p s i h i a t r i c a etica,morala,deontologia - etica,filozofia,estetica - imperativ categoric - amoralitatea relativa a sportului - relatia cu legea penala .civila,bun simt - egoismul si celalalt - axiologia-valorile - caracterul si temperamentul - psihopatia - relatiile intrafamiliale - relatiile intracolegiale - relatiile cu bolnavii - relatiile cu autoritatea - discernamintul.binele si raul - promovarea.pedepsirea,excluderea - dreptatea si nedreptatea - cinstea,corectitudinea - coruptia,mafia,birfa,persecutia - tinuta,conduita,vorba - sexul.banii,averea,familia,strainatatea - tradarea,minciuna - afectare,manierism - afectivitatea,cunoasterea - inteligenta,vointa - credinta

PROVERBE

**viaţa salvează*You can't escape from life, you escape into it.
* -Kitty Carliste Hart*
Nu poţi să scapi de viaţă, scapi în ea.


**credinţa*
The lord illumined the hearts of the pious with the light of certainty that gave them the vision to comprehend the light of all the faiths of the world.
-Abu' I-Hasan, ''The Kashf al-Mahjub
Domnul a iluminat inimile milei cu lumina certitudinii care le dă lor viziunea să înţeleagă lumina credinţei lumii.


It's better to light a candle than to curse the darkness. -- Chinese Proverb

La France du Moyen Age est une construction germanique, élevée par une aristocratie militaire germanique avec des matériaux gallo-romains. Le travail séculaire de la France a consisté à expulser de son sein tous les éléments déposés par l'invasion germanique, jusqu'à la Révolution, qui a été la dernière convulsion de cet effort.
--Ernest Renan


L' humanité est depuis quinze ans dans un de ses plus audacieux élans. La science du bien et du mal est à jamais acquise; la foi se reconstruit, le respect des choses saintes nous est rendu, et si le monde ne se fait pas tout à fait bon, il se fait du moins meilleur.
--Alexandre Dumas Fils


J'avais envoyé une chose faite au Havre, de ma fenetre; du soleil dans la buée, et, au premier plan, quelque mâts de navires pointant... On me demanda le titre pour le catalogue, çà ne pouvait vraiment pas passer pour une vue de Havre; je répondis: ''Mettez: Impression.'' On en fit impressionnisme et les plaisanteries s'épanouirent.
--Claude Monet
source: Dictionnaire Robert, Paris, 2002

have found that if you love life, life will love you back.
*--Arthur Rubinstein* Am găsit de cuviinţă că, dacă iubeşti viaţa, viaţa la rândul ei te va iubi.

**eşti ca cel pe care îl alegi*
Show me the man you honor, and I will know what kind of man you are.
* --Thomas Carlyle* Arată-mi omul pe care îl stimezi şi voi şti ce fel de om eşti.

**minunea simplităţii*
It is the simple things in life that are the most extraordinary.
*--Paulo Coelho*
Există lucruri simple în viaţă care sunt cele mai extraordinare


**de acord*
The first step towards the solution of any problem is optimism.
*--John Bainess*
Primul pas către soluţia oricărei probleme este optimismul.

**curajul e o fragilitate* **
Courage is not the towering oak that sees storm come and go; it is the fragile blossom that opens in the snow.
*--Alice Mackenzie Swaim*
Curajul nu este impunătorul stejar care vede furtuna venind şi plecând; este fragila floare care se deschide în zăpadă

To belive in yourself is to set your spirit free.
Să crezi în tine însuţi înseamnă să-ţi laşi spiritul liber.
I have never had an affliction wich was not turned into a poem. --Goethe Nu am avut niciodată o nefericire care să nu fie schimbată într-un poem.
DAILY THOUGHT. org


**un dream*
Imagine all the people living life in peace. You may say I'm a dreamer, but I'm not the only one. I hope someday you'll join us, and the world be as one.
--*John Lennon* ** Imaginează-ţi întreaga lume trăind viaţa în pace. Puteţi să spuneţi că sunt un visător, dar nu sunt singurul. Sper ca într-o zi să vă bucuraţi cu noi şi lumea să fie ca una.

**rugăciunea transcende* ** Prayer is not asking for what you think you want, but asking to be changed in ways you can't imagine.
--*Kathleen Norris* ** A te ruga nu este să ceri pentru ceea ce crezi că vrei, ci să fii schimbat în căile pe care nu ţi le poţi imagina



I am too blessed to be stressed! *-Anonymous

L'instruction accroît la valeur innée.* ( Horace )*

L'arbre qui porte des fruits a beaucoup à souffrir. Variantes: *On ne jette de pierres qu'à l'arbre chargé de fruits, Il se trouve toujours quelqu'un pour jeter des pierres à l'arbre lourd de fruits.*

Il ne faut pas laisser croître l'herbe sur le chemin de l'amitié.
* Proverbe français* * *

Change de ciel, tu changera d'étoile.
*Proverbe corse* * *

La perfection est un chemin, non une fin.
*Proverbe coréen* **
source: Internet, PROVERBES ET DICTONS DIVERS

Rezidenta

Indatoririle rezidentului

Pe linga prezentarea de caz de martea, din septembrie, in fiecare saptamina se va prezenta cite o conceptie psihiatrica.

Incepem cu psihanaliza.

Cititi Manualul de psihiatrie.

Un rezident:

- trebuie sa participe la un curs complet de psihiatrie
- trebuie sa parcurga o bibliografie minima
- trebuie sa particpe la prezentari de cazuri
- sa faca cit mai multe foi de observatie
- sa prezinte sefului sau cit mai multi bolnavi
- sa fie la curent cu noutatile in specialitate
- sa participe la congrese interne si internationale
- sa-si perfectioneze limbile straine
- sa aspire sa dezvolte o tema de doctorat
- sa invete sa faca o comunicare
- sa stie sa tina o statistica
- sa nu faca compromisuri cu firmele de medicamente
- sa-si pastreze statutul de medic cu cadrele mediii si familiile
- sa aibe o familie armonioasa
- sa nu aspire la o avere mare
- sa ajute pe cei care vin dupa el,precum si el a fost ajutat sa se ridice
- sa repecte pe cei care l--au invatat meseria
- sa comunice pe internet

http://aplr-doctorat.blogspot.com/2008/08/psihopatologie.html

http://aplr-doctorat.blogspot.com/2008/08/tratament.html