Some surprising results follow when you search for the names of Dubya and his top advisors in the genome database. (Seed)

Seed Magazine coverage of this year’s prizes for the demise of the un-fittest.

This University of Texas website is a wonderful compendium of neuroscience lectures from a variety of sources. Requires a broadband connection.

I was recently pointed to the Wikipedia article on this fascinating Japanese phenomenon. Hikikomori is a Japanese term referring to acute social withdrawal by adolescents or young adults.

Middle class affluence allows many families to support their isolative child indefinitely. There may be a contribution from the particularly Japanese codependent collusion (amae) between mother and son, making an effective response to the isolationism more difficult. And the decreasing job security in the Japanese corporate environment, combined with extreme performance pressure, may contribute to making social withdrawal rampant.

There appears to be considerable debate about whether hikikomori should be considered a sociological or psychological phenomenon. A variety of psychological diagnoses could contribute to its phenomenology, including anxiety disorders including agoraphobia and social phobia (social anxiety disorder); avoidant personality disorder; and depression. I think the social vs. psychological debate is a specious one, as there is likely a coalescence of internal and social factors at play here. There are a number of so-called “culture-bound syndromes” in which a behavioral symptom pattern appears to be particularly prevalent, and unique, in a given culture. These include amok, latah, wendigo, etc. I usually see them as variants of common psychiatric disturbances brought to the fore by the particular social stresses of a given culture.

These are the findings of a study by a group of researchers at the pharmaceutical firm Eli Lilly. I haven’t read the study, only the press coverage to which this link points, but their findings are summarized thus: “Of the 866 patients who stopped treatment, 36% (315/866) did so because the treatment was felt not to be effective or because their symptoms worsened. Only 12% of patients who stopped treatment early did so because of adverse events such as dizziness, fatigue, vomiting or weight gain.” They make the point that discontinuation due to patient perception of poor response tends to occur early in the course of treatment and that patients who experience an early response were 80% more likely to complete treatment.

I would point out the likelihood of significant bias in this industry-sponsored study. Eli Lilly are the manufacturers of Zyprexa [olanzapine], one of the most-used ‘atypical’ [new-generation] antipsychotic medications which were touted as wonder drugs solving all the substantial toxicity issues of the older generation of antipsychotics, until we recognized that worrisome side effects such as drastic weight gain and glucose intolerance were common with this newer generation of agents. It is in Lilly’s interest in selling antipsychotic medications, of course, to establish, as the current study concludes, that side effects are not as worrisome as they are usually considered and that treatment should be more aggressive from the outset. But of course patient discontinuation early in the course of treatment is not likely to be from concern about side effects, because the worrisome metabolic changes caused by these medications are insidious and slow to develop!

I agree with the need for treating terrifying psychotic symptoms with alacrity to relieve distress and establish a treatment alliance. Certainly a schizophrenic patient beset by tormenting voices or paranoid ideation will not stick with treatment that does not offer rapid relief. However, I suspect the crucial variable which the study does not address is that patients who do not perceive that their treatment is effective are often patients with one particular symptom of severe psychotic illness — anosognosia, the denial of illness and lack of recognition of need for treatment at all. A patient cannot recognize benefit from a medication treatment if s/he does not recognize the symptoms and the need for treatment in the first place. Psychiatrists are very familiar with psychological denial, but I also think anosognosia has a neurologically-based, organic component as part of the brain dysfunction in schizophrenia and other psychotic illnesses, although this is controversial within my field.

In any case, it is emphatically not drug treatment, aggressive or not, which treats this symptom. Instead of funding research trying to sell more drug doses, Eli Lilly should be endowing a foundation for the dying art of talking to the sickest of our patients, creating and maintaining a relationship allowing skillful and sustained entry into the world of a terrified and tormented soul. This is itself the most important healing tool.

Those English; always masters of understatement!