Mental illness and well‐being: an affect regulation perspective

Mental health crucially depends upon affective states such as emotions, stress responses, impulses and moods. These states shape how we think, feel and behave. Often, they support adaptive functioning. At other times, however, they can become detrimental to mental health via maladaptive affect generation processes and/or maladaptive affect regulation processes. Here, we present an integrative framework for considering the role of affect generation and regulation in mental illness and well‐being. Our model views affect generation as an iterative cycle of attending to, appraising and responding to situations. It views affect regulation as an iterative series of decisions aimed at altering affect generation. Affect regulation decisions include identifying what, if anything, should be changed about affect, selecting where to intervene in the affect generation cycle, choosing how to implement this intervention, and monitoring the regulation attempt to decide whether to maintain, switch or stop it. Difficulties with these decisions, often arising from biased inputs to them, can contribute to manifestations of mental illness such as clinical symptoms, syndromes and disorders. The model has a number of implications for clinical assessment and treatment. Specifically, it offers a common set of concepts for characterizing different affective states; it highlights interactions between affect generation and affect regulation; it identifies assessment and treatment targets among the component processes of affect regulation; and it is applicable to prevention and treatment of mental illness as well as to promotion and restoration of psychological well‐being.     

A National Survey of United States-Based Endocrinologists Who Prescribe Gender-Affirming Hormone Therapy

ObjectiveThe World Professional Association for Transgender Health Standards of Care Version 7 recommended that before initiating gender-affirming hormone therapy (GAHT), patients should seek a psychosocial evaluation from a mental health professional documenting a diagnosis of persistent gender dysphoria. The Endocrine Society published guidelines in 2017 recommending against an obligatory psychosocial evaluation, which was affirmed in the recently published World Professional Association for Transgender Health Standards of Care Version 8 from 2022. Little is known about how endocrinologists ensure appropriate psychosocial assessment for their patients. This study assessed the protocols and characteristics of U.S.-based adult endocrinology clinics that prescribe GAHT.MethodsAn anonymous electronic survey sent to members of a professional organization and the “Endocrinologists” Facebook group was responded by 91 practicing board-certified adult endocrinologists who prescribe GAHT.ResultsThirty-one states were represented by the respondents. Overall, 83.1% of GAHT-prescribing endocrinologists reported accepting Medicaid. They reported working in university practices (28.4%), community practices (22.7%), private practices (27.3%), and other practice settings (21.6%). Overall, 42.9% of the respondents reported that their practice required documentation of a psychosocial evaluation from a mental health professional before initiating GAHT.ConclusionEndocrinologists who prescribe GAHT are divided about requiring a baseline psychosocial evaluation before prescribing GAHT. Further work is needed to understand the impact of psychosocial assessment on patient care and facilitate the uptake of new guidelines into clinical practice.     

Wait times in the emergency department for patients with mental illness

Background:

It has been suggested that patients with mental illness wait longer for care than other patients in the emergency department. We determined wait times for patients with and without mental health diagnoses during crowded and noncrowded periods in the emergency department.

Methods:

We conducted a population-based retrospective cohort analysis of adults seen in 155 emergency departments in Ontario between April 2007 and March 2009. We compared wait times and triage scores for patients with mental illness to those for all other patients who presented to the emergency department during the study period.

Results:

The patients with mental illness (n = 51 381) received higher priority triage scores than other patients, regardless of crowding. The time to assessment by a physician was longer overall for patients with mental illness than for other patients (median 82, interquartile range [IQR] 41–147 min v. median 75 [IQR 36–140] min; p < 0.001). The median time from the decision to admit the patient to hospital to ward transfer was markedly shorter for patients with mental illness than for other patients (median 74 [IQR 15–215] min v. median 152 [IQR 45–605] min; p < 0.001). After adjustment for other variables, patients with mental illness waited 10 minutes longer to see a physician compared with other patients during noncrowded periods (95% confidence interval [CI] 8 to 11), but they waited significantly less time than other patients as crowding increased (mild crowding: −14 [95% CI −12 to −15] min; moderate crowding: −38 [95% CI −35 to −42] min; severe crowding: −48 [95% CI −39 to −56] min; p < 0.001).

Interpretation:

Patients with mental illness were triaged appropriately in Ontario’s emergency departments. These patients waited less time than other patients to see a physician under crowded conditions and only slightly longer under noncrowded conditions.In a 2008 report, the Schizophrenia Society of Ontario recommended adding a psychiatric wait times component to the Ontario government’s Emergency Room Wait Times Strategy.¹ They suggested that patients who present to the emergency department in psychiatric distress wait longer for care than other patients and that they are given a low priority triage score² (all patients are assigned a triage score when they first arrive at the emergency department, which may determine when and where they are seen by a physician).³ The Kirby Report, a senate report on mental illness and addiction in Canada, also decried differential emergency care for patients with mental illness.⁴A recent study found that patients with acute myocardial infarction are given lower priority care in the emergency department if they have a charted history of depression.⁵ However, whether patients who present to the emergency department for mental illness receive slower care than other patients is not known. In this study, we compared the emergency department wait times and triage scores for patients with affective and psychotic disorders to those for other patients, both in noncrowded conditions and during periods of crowding. Because we believe that triage nurses apply triage principles consistently to all emergency patients while physicians may be less likely to adhere to the guidelines, we hypothesized that there would be no “down-triage” (assigning a lower priority triage score) of these patients, but that patients with mental illness would have longer delays to see a physician, relative to other patients.     

Disease and illness Distinctions between professional and popular ideas of sickness

The dysfunctional consequences of the Cartesian dichotomy have been enhanced by the power of biomedical technology. Technical virtuosity reifies the mechanical model and widens the gap between what patients seek and doctors provide.Patients suffer illnesses; doctors diagnose and treat diseases. Illnesses are experiences of discontinuities in states of being and perceived role performances. Diseases, in the scientific paradigm of modern medicine, are abnormalities in the function and/or structure of body organs and systems. Traditional healers also redefine illness as disease: because they share symbols and metaphors consonant with lay beliefs, their healing rituals are more responsive to the psychosocial context of illness.Psychiatric disorders offer an illuminating perspective on the basic medical dilemma. The paradigms for psychiatric practice include multiple and ostensibly contradictory models: organic, psychodynamic, behavioural and social. This melange of concepts stems from the fact that the fundamental manifestations of psychosis are disordered behaviours. The psychotic patient remains a person; his self-concept and relationships with others are central to the therapeutic encounter, whatever pharmacological adjuncts are employed.The same truths hold for all patients. The social matrix determines when and how the patient seeks what kind of help, his compliance with the recommended regimen and, to a significant extent, the functional outcome. When physicians dismiss illness because ascertainable disease is absent, they fail to meet their socially assigned responsibility. It is essential to reintegrate scientific and social concepts of disease and illness as a basis for a functional system of medical research and care.Harvard Medical School     

Bacillus and relatives in foodborne illness

Species of Bacillus and related genera have long been troublesome to food producers on account of their resistant endospores. These organisms have undergone huge taxonomic changes in the last 30 years, with numbers of genera and species now standing at 56 and over 545, respectively. Despite this expansion, relatively few new species have been isolated from infections, few are associated with food and no important new agents of foodborne illness have been reported. What has changed is our knowledge of the established agents. Bacillus cereus is well known as a cause of food poisoning, and much more is now understood about its toxins and their involvement in infections and intoxications. Also, although B. licheniformis, B. subtilis and B. pumilus have occasionally been isolated from cases of food‐associated illness, their roles were usually uncertain. Much more is now known about the toxins that strains of these species may produce, so that their significances in such episodes are clearer; however, it is still unclear why such cases are so rarely reported. Another important development is the use of aerobic endosporeformers as probiotics, as the potentials of such organisms to cause illness or to be sources of antibiotic resistance need to be borne in mind.     

Detection of 65 kD heat shock protein in cerebrospinal fluid of tuberculous meningitis patients

Background  

Diagnosis of tuberculous meningitis (TBM) is difficult. Rapid confirmatory diagnosis is essential to initiate required therapy. There are very few published reports about the diagnostic significance of 65 kD heat shock protein (hsp) in TBM patients, which is present in a wide range of Mycobacterium tuberculosis species and elicits a cellular and humoral immune response. In the present study we have conducted a prospective evaluation for the demonstration of 65 kD hsp antigen in cerebrospinal fluid (CSF) of TBM patients, by indirect ELISA method using monoclonal antibodies (mAb) against the 65 kD hsp antigen, for the diagnosis of TBM.     

Pena in the Ecuadorian Sierra: A psychoanthropological analysis of sadness

In highland Ecuador, pena refers to a state of mind characterized by a mixture of sadness and anxiety as well as to an illness state resembling depression. This paper attempts to illustrate, through an analysis of the discourse on pena, how the ideology in which it is embedded serves to interpret a bodily problem at the same time as it reflects a more global attitude toward life. In essence, the folk theory states that the physical complaints caused by suffering are the result of a disturbance of the heart, the central organ of man, and of the emotional life which it controls. Because this suffering is often attributed to the immediate family group of the victim, the community at large often formulates accusations against one of its members. Though the therapy is limited to a cure of the symptoms through herbal remedies, a formal request can be made to a perceived wrongdoer to amend his behavior. The pena is also a state which can lead to colerin, a dangerous and sometimes lethal illness which is characterized by a sudden explosion of anger or madness and which will follow an unattended state of pena.     

Theory of emotional stress and mental illness

A theoretical study of emotion in human beings yields results which are potentially useful in a practical way. Two variables are used—the total amount of healthy emotionr and the total amount of emotional stresss. A stabilizing factor in the value ofr is the interrelationship between it ands. Differential equations forr ands are readily solved simultaneously with the use of the Laplace transform. Onset of emotional illness is signaled in a feasible way by development of a relationship between the parameters which causess to increase indefinitely with the passage of time. Among the potentially useful conclusions which arise from this relationship is that the presence of psychosomatic disease protects against emotional illness.     

Hippocampal and Left Subcallosal Anterior Cingulate Atrophy in Psychotic Depression

Background

Psychotic depression is arguably the most diagnostically stable subtype of major depressive disorder, and an attractive target of study in a famously heterogeneous mental illness. Previous imaging studies have identified abnormal volumes of the hippocampus, amygdala, and subcallosal region of the anterior cingulate cortex (scACC) in psychotic depression, though studies have not yet examined the role of family history of depression in these relationships.

Methods

20 participants with psychotic depression preparing to undergo electroconvulsive therapy and 20 healthy comparison participants (13 women and 7 men in each group) underwent structural brain imaging in a 1.5 T MRI scanner. 15 of the psychotic depression group had a first-degree relative with diagnosed affective disorders, while the healthy control group had no first-degree relatives with affective disorders. Depression severity was assessed with the Hamilton Depression Rating Scale and duration of illness was assessed in all patients. Automated neural nets were used to isolate the hippocampi and amygdalae in each scan, and an established manual method was used to parcellate the anterior cingulate cortex into dorsal, rostral, subcallosal, and subgenual regions. The volumes of these regions were compared between groups. Effects of laterality and family history of affective disorders were examined as well.

Results

Patients with psychotic depression had significantly smaller left scACC and bilateral hippocampal volumes, while no group differences in other anterior cingulate cortex subregions or amygdala volumes were present. Hippocampal atrophy was found in all patients with psychotic depression, but reduced left scACC volume was found only in the patients with a family history of depression.

Conclusions

Patients with psychotic depression showed significant reduction in hippocampal volume bilaterally, perhaps due to high cortisol states associated with this illness. Reduced left scACC volume may be a vulnerability factor related to family history of depression.     

Pain as abnormal illness behaviour

In this article, the concept of abnormal illness behaviour is described, and chronic pain syndromes which represent variants of such behaviour are reviewed. Research using the Illness Behaviour Questionnaire has helped to elucidate aspects of chronic pain states, especially where a discrepancy exists between the patient's illness behaviour and the objectively assessed somatic pathology. Some comments are offered concerning the management of patients showing abnormal illness behaviour.     

X‐linkage and manic‐depressive illness: A reassessment

Abstract

Genetic‐epidemiological data and linkage studies with chromosomal markers are reviewed from the vantage point of X‐linked inheritance. The results overall suggest that a gene predisposing to manic depression (bipolar affective illness) localized on the X‐chromosome may exist in a subgroup of bipolar cases. However, in light of conflicting findings and methodological uncertainties in studying a disorder with unclear phenotype and complex inheritance, this issue is not yet closed. Additional research, including new linkage data and extension and re‐evaluation of published data, is required to further our understanding of this intriguing hypothesis.     

Health,illness, and immigration. East Indians in the United States.

East Indian immigrants to the United States represent the diversity in religion, language, and culture that exists in India, so it is difficult to make unequivocal statements about their health beliefs and behaviors. Despite the diversity, an understanding of Ayurvedic humoral concepts of health and illness provides a key to some pervasive and persistent ideas and practices. India has a pluralistic medical system in which Western medicine, which is increasingly popular for some ailments, is one option among many. Even those who are familiar with the "Western" medical system in India may find American medicine alien.     

Hwabyung: The construction of a korean popular illness among korean elderly immigrant women in the United States

The cultural construction of Hwabyung, a Korean culture-bound syndrome, is explored among a sample of 20 elderly Korean immigrant women in the United States. Hwabyung results when distressed emotions associated with the specifically Korean way of perceiving and reacting to intolerable and tragic life situations cause bodily symptoms by interfering with the harmony of Ki (vital energy). Korean elderly immigrants report a broad range of symptoms associated with Hwabyung; they less frequently report the epigastric mass, which had been considered the cardinal symptom by cosmopolitan and traditional medical writers. Hwabyung is treated holistically with psychosocial support from family, spiritual comfort, home and popular remedies, traditional Korean medicine, and biomedical treatments. Hwabyung provides a way of conceptualizing and resolving emotional distress through somatization among Korean elderly immigrant women.     

Psychological status and coping with illness in patients with malignant melanoma

Melanoma patients are subject to different degrees of psychosocial distress. The emotional impact of malignant melanoma can be long lasting and profound, with the most common reactions to melanoma being depression, anxiety and deterioration in quality of life. Coping styles have been shown to have a significant influence on patients' quality of life and their emotional reaction to the illness. The aim of this paper was to investigate the quality of life, emotional status and coping styles in patients with melanoma. 31 patients suffering from malignant melanoma were included in the study. Results of this study show that melanoma has a medium influence on patients' psychological status and quality of life. The most "constructive" coping style--problem focused coping is the mostly used style by the patients, which might be one of the reasons why the illness didn't have a more severe influence on patients' psychological status.     

Parents' difficulties and information needs in coping with acute illness in preschool children: a qualitative study.

OBJECTIVES: To identify and explore difficulties parents experience with acute illness in young children and the information they seek to help them. DESIGN: Qualitative study using semi-structured one t one and group interviews with parents of preschool children. SETTING: Disadvantaged inner city community. SUBJECTS: 95 parents of preschool children. RESULTS: Parents felt disempowered when dealing with acute illness in their children because of difficulties making sense of the illness. Central to parents'' difficulties were their experiences of inadequate information sharing by their general practitioners and variations in their doctors'' decisions and behaviour. Disparity between parents'' beliefs and expectations about illness and treatment and professionals'' behaviour further frustrated parents'' attempts to understand illness. Parents expressed a need for a range of accessible and specific information to support them through their negotiation of children''s illness. CONCLUSIONS: Communication with parents requires greater recognition of parents'' difficulties. Professionals have considerable potential to empower parents by sharing more information and skills. Such information should be consistent and address parents'' concerns, beliefs, and expressed needs if this potential is to be realised.     

The Obligation to Negotiate in the Philippines v. China Case: A Critique of the Award on Jurisdiction

The two states in the Philippines v. China Case have continually reaffirmed in multiple documents and the 2002 Declaration on the Conduct of Parties in the South China Sea that they agreed to resolve their disputes in the South China Sea through consultations and negotiations. However, the Arbitral Tribunal in its Award on Jurisdiction held that no obligation of negotiation was provided for in these instruments because they were not legally binding agreements. Moreover, the Tribunal found that the Philippines had satisfied the “obligation to seek a solution through pacific means, including negotiation.” There are problems and deficiencies in the reasoning of the Tribunal respecting these findings.     

Decision tree algorithms predict the diagnosis and outcome of dengue fever in the early phase of illness

Background

Dengue is re-emerging throughout the tropical world, causing frequent recurrent epidemics. The initial clinical manifestation of dengue often is confused with other febrile states confounding both clinical management and disease surveillance. Evidence-based triage strategies that identify individuals likely to be in the early stages of dengue illness can direct patient stratification for clinical investigations, management, and virological surveillance. Here we report the identification of algorithms that differentiate dengue from other febrile illnesses in the primary care setting and predict severe disease in adults.

Methods and Findings

A total of 1,200 patients presenting in the first 72 hours of acute febrile illness were recruited and followed up for up to a 4-week period prospectively; 1,012 of these were recruited from Singapore and 188 from Vietnam. Of these, 364 were dengue RT-PCR positive; 173 had dengue fever, 171 had dengue hemorrhagic fever, and 20 had dengue shock syndrome as final diagnosis. Using a C4.5 decision tree classifier for analysis of all clinical, haematological, and virological data, we obtained a diagnostic algorithm that differentiates dengue from non-dengue febrile illness with an accuracy of 84.7%. The algorithm can be used differently in different disease prevalence to yield clinically useful positive and negative predictive values. Furthermore, an algorithm using platelet count, crossover threshold value of a real-time RT-PCR for dengue viral RNA, and presence of pre-existing anti-dengue IgG antibodies in sequential order identified cases with sensitivity and specificity of 78.2% and 80.2%, respectively, that eventually developed thrombocytopenia of 50,000 platelet/mm³ or less, a level previously shown to be associated with haemorrhage and shock in adults with dengue fever.

Conclusion

This study shows a proof-of-concept that decision algorithms using simple clinical and haematological parameters can predict diagnosis and prognosis of dengue disease, a finding that could prove useful in disease management and surveillance.     

Neurasthenia and depression: A study of somatization and culture in China

The author reviews conceptual and empirical issues regarding the interaction of neurasthenia, somatization and depression in Chinese culture and in the West. The historical background of neurasthenia and its current status are discussed, along with the epidemiology and phenomenology of somatization and depression. Findings are presented from a combined clinical and anthropological field study of 100 patients with neurasthenia in the Psychiatry Outpatient Clinic at the Hunan Medical College. Eighty-seven of these patients made the DSM-III criteria of Major Depressive Disorder; diagnoses of anxiety disorders were also frequent. Forty-four patients were suffering from chronic pain syndromes previously undiagnosed, and cases of culture-bound syndromes also were detected. For three-quarters of patients the social significances and uses of their illness behavior chiefly related to work. Although from the researchers' perspective 70% of patients with Major Depressive Disorder experienced substantial improvement and 87% some improvement in symptoms when treated with antidepressant medication, fewer experienced decreased help seeking, and a much smaller number perceived less social impairment and improvement in illnes problems (the psychosocial accompaniment of disease including maladaptive coping and work, family and school problems). These findings are drawn on to advance medical anthropology and cultural psychiatry theory and research regarding somatization in Chinese culture, the United States and cross culturally. The author concludes that though neurasthenia can be understood in several distinctive ways, it is most clinically useful to regard it as bioculturally patterned illness experience (a special form of somatization) related to either depression and other diseases or to culturally sanctioned idioms of distress and psychosocial coping.