On This Day … 15 February

People (Births)

  • 1856 – Emil Kraepelin, German psychiatrist and academic (d. 1926).
  • 1940 – Vaino Vahing, Estonian psychiatrist, author, and playwright (d. 2008).

Emil Kraepelin

Emil Wilhelm Georg Magnus Kraepelin (15 February 1856 to 7 October 1926) was a German psychiatrist. H. J. Eysenck’s Encyclopaedia of Psychology identifies him as the founder of modern scientific psychiatry, psychopharmacology and psychiatric genetics.

Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated psychiatry at the start of the 20th century and, despite the later psychodynamic influence of Sigmund Freud and his disciples, enjoyed a revival at century’s end. While he proclaimed his own high clinical standards of gathering information “by means of expert analysis of individual cases”, he also drew on reported observations of officials not trained in psychiatry.

His textbooks do not contain detailed case histories of individuals but mosaic-like compilations of typical statements and behaviours from patients with a specific diagnosis. He has been described as “a scientific manager” and “a political operator”, who developed “a large-scale, clinically oriented, epidemiological research programme”.

Vaino Bahing

Vaino Vahing (15 February 1940 to 23 March 2008), was an Estonian writer, prosaist, psychiatrist and playwright. Starting from 1973, he was a member of Estonian Writers Union.

Vaino Vahing has written many articles about psychiatry, but also literature – novels, books and plays with psychiatric and autobiographical influence. He has played in several Estonian films.

On This Day … 13 February

People (Deaths)

  • 1964 – Werner Heyde, German psychiatrist and academic (b. 1902).

Werner Heyde

Werner Heyde (aka Fritz Sawade) (25 April 1902 to 13 February 1964) was a German psychiatrist. He was one of the main organisers of Nazi Germany’s T-4 Euthanasia Programme.

Early Life

Heyde was born in Forst (Lausitz), on 22 May 1902, and completed his Abitur in 1920. From 1922-1925, he studied medicine in Berlin, Freiburg, Marburg, Rostock and Würzburg and after short placements at the General Hospital in Cottbus and the sanatorium Berlin-Wittenau became assistant doctor at the Universitätsnervenklinik (university psychiatric hospital) in Würzburg. He obtained his licence to practice medicine in 1926, having completed all courses throughout his studies with top marks.

Career until 1945

In 1933, Heyde made the acquaintance of Theodor Eicke, and became a member of the NSDAP. One year later, he was appointed director of the polyclinic in Würzburg. In 1935, he entered the SS as medical officer with the rank of SS-Hauptsturmführer, and became commander of the medical unit in the SS-Totenkopfverbände. There he was responsible for establishing a system of psychiatric and eugenic examinations and research in concentration camps, and for the organisation of the T-4 Euthanasia Program. Additionally, he also worked as a psychiatric consultant for the Gestapo. He also was leader of the Rassenpolitisches Amt in Würzburg, Seelbergstraße 8, 97080 Würzburg. Later he was accompanied by his Rassenpolitisches Amt assistant, Mr. Johannes Riedmiller aka Kurt Riethmüller aka Hans Riedmüller/Hans Riedmiller.

In 1938, he was appointed chief of staff of the medical department in the SS-Hauptamt (headquarters); in 1939, he became professor for psychiatry and neurology at the University of Würzburg, and from 1940 on he also was director of the psychiatric hospital.

He was replaced as head of the T4 programme by Paul Nitsche in 1941, but continued his involvement as member of the “department Brack” (after the end of World War II, it was never found out what his role there was).

He worked at Buchenwald, Dachau concentration camp and Sachsenhausen concentration camps.

In 1944, he was awarded the SS-Totenkopfring, and before the end of the war and reached the rank of SS-Standartenführer (Colonel).

Life after 1945

After World War II, Heyde was interned and imprisoned, but escaped in 1947. He went underground using the alias Fritz Sawade and continued practicing as a sports physician and psychiatrist in Flensburg. Many friends and associates knew about his real identity, but remained silent even as he was an expert witness in court cases.

His true identity was revealed in the course of a private quarrel, and on 11 November 1959 Heyde surrendered to police in Frankfurt after 13 years as a fugitive. On 13 February 1964, five days before his trial was to start, Heyde hanged himself at the prison in Butzbach.

Literature

  • Klee, Ernst, Das Personenlexikon zum Dritten Reich. S. Fischer Verlag 2003. ISBN 3-10-039309-0.
  • Godau-Schüttke, Klaus-Detlev, Die Heyde/Sawade-Affäre. Nomos Verlagsgesellschaft 1998. ISBN 3-7890-5717-7.

Films

  • 1963 (GDR): The Heyde-Sawade Affair (Category: biography/drama) (Produced in the DEFA-studios for movies, Potsdam, Babelsberg/Eastern Germany. Produced by Bernhard Gelbe; script by Wolfgang Luderer, Walter Jupé and Friedrich Karl Kaul and directed by Wolfgang Luderer. Available via the Foundation German TV and Broadcast Arkhive Babelsberg. Arkhive-No. IDNR 03581. Length: 101 minutes, First run: 03 June 1963 in the television programme No.1 of the German Democratic Republic).

Paintings

In 1965, German artist Gerhard Richter painted Herr Heyde, based on a photo of Heyde’s 1959 arrest.

What is Adjustment Disorder?

Introduction

Adjustment disorder (AjD) is a maladaptive response to a psychosocial stressor that occurs when an individual has significant difficulty adjusting to or coping with a stressful psychosocial event. The maladaptive response usually involves otherwise normal emotional and behavioural reactions that manifest more intensely than usual (taking into account contextual and cultural factors), causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.

Diagnosis of AjD is quite common; there is an estimated incidence of 5-21% among psychiatric consultation services for adults. Adult women are diagnosed twice as often as are adult men. Among children and adolescents, girls and boys are equally likely to receive this diagnosis. AjD was introduced into the Diagnostic and Statistical Manual of Mental Disorders in 1980. Prior to that, it was called “transient situational disturbance.”

Signs and Symptoms

Some emotional signs of AjD are:

  • Sadness;
  • Hopelessness;
  • Lack of enjoyment;
  • Crying spells;
  • Nervousness;
  • Anxiety;
  • Desperation;
  • Feeling overwhelmed and thoughts of suicide; and
  • Performing poorly in school/work etc.

Common characteristics of AjD include:

  • Mild depressive symptoms;
  • Anxiety symptoms; and
  • Traumatic stress symptoms, or
  • A combination of the three.

According to the DSM-5, there are six types of AjD, which are characterised by the following predominant symptoms: depressed mood, anxiety, mixed depression and anxiety, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. However, the criteria for these symptoms are not specified in greater detail. AjD may be acute or chronic, depending on whether it lasts more or less than six months. According to the DSM-5, if the AjD lasts less than six months, then it may be considered acute. If it lasts more than six months, it may be considered chronic. Moreover, the symptoms cannot last longer than six months after the stressor(s), or its consequences, have terminated. However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing mental disorder.

Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. The condition is different from anxiety disorder, which lacks the presence of a stressor, or post-traumatic stress disorder and acute stress disorder, which usually are associated with a more intense stressor.

Suicidal behaviour is prominent among people with AjD of all ages, and up to one-fifth of adolescent suicide victims may have an adjustment disorder. Bronish and Hecht (1989) found that 70% of a series of patients with AjD attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression. Asnis et al. (1993) found that AjD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. According to a study on 82 AjD patients at a clinic, Bolu et al. (2012) found that 22 (26.8%) of these patients were admitted due to suicide attempt, consistent with previous findings. In addition, it was found that 15 of these 22 patients chose suicide methods that involved high chances of being saved. Pelkonen et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues.

One hypothesis about AjD is that it may represent a sub-threshold clinical syndrome.

Risk Factors

Those exposed to repeated trauma are at greater risk, even if that trauma is in the distant past. Age can be a factor due to young children having fewer coping resources; children are also less likely to assess the consequences of a potential stressor.

A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. The stressors that cause adjustment disorders may be grossly traumatic or relatively minor, like loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighbourhood. It is thought that the more chronic or recurrent the stressor, the more likely it is to produce a disorder. The objective nature of the stressor is of secondary importance. Stressors’ most crucial link to their pathogenic potential is their perception by the patient as stressful. The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made.

There are certain stressors that are more common in different age groups:

  • Adulthood:
    • Marital conflict.
    • Financial conflict.
    • Health issues with oneself, partner or dependent children.
    • Personal tragedy such as death or personal loss.
    • Loss of job or unstable employment conditions e.g. corporate takeover or redundancy.
  • Adolescence and childhood:
    • Family conflict or parental separation.
    • School problems or changing schools.
    • Sexuality issues.
    • Death, illness or trauma in the family.

In a study conducted from 1990 to 1994 on 89 psychiatric outpatient adolescents, 25% had attempted suicide in which 37.5% had misused alcohol, 87.5% displayed aggressive behaviour, 12.5% had learning difficulties, and 87.5% had anxiety symptoms.

Diagnosis

DSM-5 Classification

The basis of the diagnosis is the presence of a precipitating stressor and a clinical evaluation of the possibility of symptom resolution on removal of the stressor due to the limitations in the criteria for diagnosing AjD. In addition, the diagnosis of AjD is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with AjD and major depressive disorder (MDD) and generalised anxiety disorder (GAD).

Some signs and criteria used to establish a diagnosis are important. First, the symptoms must clearly follow a stressor. The symptoms should be more severe than would be expected. There should not appear to be other underlying disorders. The symptoms that are present are not part of a normal grieving for the death of family member or other loved one.

Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20-50% of the sufferers go on to be diagnosed with psychiatric disorders that are more serious.

ICD-11 Classification

International Statistical Classification of Diseases and Related Health Problems (ICD), assigns codes to classify diseases, symptoms, complaints, social behaviours, injuries, and such medical-related findings.

ICD-11 classifies Adjustment disorder (6B43) under “Disorders specifically associated with stress”.

Treatment

There has been little systematic research regarding the best way to manage individuals with an adjustment disorder. Because natural recovery is the norm, it has been argued that there is no need to intervene unless levels of risk or distress are high. However, for some individuals treatment may be beneficial. AjD sufferers with depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders. One study found that AjD sufferers received similar interventions to those with other psychiatric diagnoses, including psychological therapy and medication.

In addition to professional help, parents and caregivers can help their children with their difficulty adjusting by:

  • Offering encouragement to talk about their emotions;
  • Offering support and understanding;
  • Reassuring the child that their reactions are normal;
  • Involving the child’s teachers to check on their progress in school;
  • Letting the child make simple decisions at home, such as what to eat for dinner or what show to watch on TV; and/or
  • Having the child engage in a hobby or activity they enjoy.

Criticism

Like many of the items in the DSM, adjustment disorder receives criticism from a minority of the professional community as well as those in semi-related professions outside the health-care field. First, there has been criticism of its classification. It has been criticised for its lack of specificity of symptoms, behavioural parameters, and close links with environmental factors. Relatively little research has been done on this condition.

An editorial in the British Journal of Psychiatry described adjustment disorder as being so “vague and all-encompassing… as to be useless,” but it has been retained in the DSM-5 because of the belief that it serves a useful clinical purpose for clinicians seeking a temporary, mild, non-stigmatising label, particularly for patients who need a diagnosis for insurance coverage of therapy.

In the US military there has been concern about its diagnosis in active duty military personnel.

References

Asnis, G.M., Friedman, T.A., Sanderson, W.C., Kaplan, M.L., van Praag, H.M. & Harkavy-Friedman, J.M. (1993) Suicidal Behavior in Adult Psychiatric Outpatients, I: Description and Prevalence. American Journal of Psychiatry. 150(1), pp.108-112. doi:10.1176/ajp.150.1.108.

Bolu, A., Doruk, A., Ak, M., Özdemir, B. & Özgen, F. (2012) Suicidal Behavior in Adjustment Disorder Patients. Dusunen Adam. 25(1), pp.58-62.

Bronish, T. & Hecht, H. (1989) Validity of Adjustment Disorder, Comparison with Major Depression. Journal of Affective Disorders. 17, pp.229-236.

Pelkonen, M., Marttunen, M., Henriksson, M. & Lönnqvist, J. (2005) Suicidality in Adjustment Disorder: Clinical Characteristics of Adolescent Outpatients. European Child & Adolescent Psychiatry. 14(3), pp.174-180. doi:10.1007/s00787-005-0457-8.

On This Day … 12 February

People (Births)

  • 1861 – Lou Andreas-Salomé, Russian-German psychoanalyst and author (d. 1937).
  • 1918 – Norman Farberow, American psychologist and academic (d. 2015).

Lou Andreas Salome

Lou Andreas-Salomé (born either Louise von Salomé or Luíza Gustavovna Salomé or Lioulia von Salomé, Russian: Луиза Густавовна Саломе; 12 February 1861 to 5 February 1937) was a Russian-born psychoanalyst and a well-travelled author, narrator, and essayist from a Russian-German family. Her diverse intellectual interests led to friendships with a broad array of distinguished thinkers, including Friedrich Nietzsche, Sigmund Freud, Paul Rée, and Rainer Maria Rilke.

Norman Farberow

Norman Louis Farberow (12 February 1918 to 10 September 2015) was an American psychologist, and one of the founding fathers of modern suicidology. He was among the three founders in 1958 of the Los Angeles Suicide Prevention Centre, which became a base of research into the causes and prevention of suicide.

Career

Farberow served as a World War II Air Force Captain. The war years were a time in the United States of relatively low suicide rates, a wartime phenomenon commonly observed when a nation’s armed forces and citizens unite under feelings of common purpose and mutual goals.

After completing his tour of duty in World War II, Farberow enrolled in the University of California, Los Angeles. UCLA’s doctoral programme in psychology afforded Farberow an opportunity to study suicide against centuries of shifting attitudes. With few relevant references to draw upon for his 1949 dissertation, Farberow saw the potential for reawakening “interest in a long-neglected, taboo-encrusted social and personal phenomenon.” Farberow earned his doctoral degree from UCLA in 1950 while working with veterans in the Veterans Administration Mental Hygiene Clinic. He helped found the suicide prevention centre along with Robert E. Litman.

In the decade after the war, suicide rates rose quickly as the sense of unity and shared purpose began to disappear. Wrenching social and personal readjustments were often needed, and these needs were further complicated by the emotional distress and mental health problems of returning veterans. Many expressed their deepening inner turmoil in unhealthy ways, through suicidal impulses and acts. Suicide’s continuing taboo, embedded in cultural and religious condemnations of shame, guilt, self-blame and cowardice, magnified an underlying sense of worthlessness and hopelessness.

Farberow saw the effects of these dynamics and how they compounded the misery of those who were suffering. His vision for solutions grew to include fundamental and humanitarian changes to the way in which communities treated the suicidal. Soon his time as a psychotherapist became eclipsed by his continuing research on suicide with Dr. Edwin Shneidman, a colleague equally passionate about changing the understanding and prevention of self-inflicted death.

During the 1950s, the men worked together at the Veterans Administration (VA) in Los Angeles and sought answers for another jump in suicide rates – the sudden doubling of suicides among the VA’s neuropsychiatric hospital patients. At the same time, a survey they had conducted of L.A.-area hospitals, clinics, and emergency rooms revealed that no provisions existed for the follow-up care of suicide attempters. Farberow and Shneidman shared their findings with the National Institute of Mental Health and the VA and proposed the creation of two agencies: a community-based Referral Centre for treating the psychological problems of the suicidal, and a Central Research Unit for assessing and investigating suicide among veterans within the VA.

What is Seasonal Affective Disorder?

Introduction

Seasonal affective disorder (SAD) is a mood disorder subset in which people who have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year, most commonly in winter. Common symptoms include sleeping too much and having little to no energy, and overeating. The condition in the summer can include heightened anxiety.

In the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and DSM-5, its status was changed. It is no longer classified as a unique mood disorder but is now a specifier, called “with seasonal pattern”, for recurrent major depressive disorder that occurs at a specific time of the year and fully remits otherwise. Although experts were initially sceptical, this condition is now recognised as a common disorder.

In the United States, the percentage of the population affected by SAD ranges from 1.4% of the population in Florida, to 9.9% in Alaska. SAD was formally described and named in 1984 by Norman E. Rosenthal and colleagues at the National Institute of Mental Health.

Brief History

SAD was first systematically reported and named in the early 1980s by Norman E. Rosenthal, M.D., and his associates at the National Institute of Mental Health (NIMH). Rosenthal was initially motivated by his desire to discover the cause of his own experience of depression during the dark days of the northern US winter. He theorised that the reduction in available natural light during winter was the cause. Rosenthal and his colleagues then documented the phenomenon of SAD in a placebo-controlled study utilising light therapy. A paper based on this research was published in 1984. Although Rosenthal’s ideas were initially greeted with scepticism, SAD has become well recognised, and his 1993 book, Winter Blues has become the standard introduction to the subject.

Research on SAD in the United States began in 1979 when Herb Kern, a research engineer, had also noticed that he felt depressed during the winter months. Kern suspected that scarcer light in winter was the cause and discussed the idea with scientists at the NIMH who were working on bodily rhythms. They were intrigued, and responded by devising a lightbox to treat Kern’s depression. Kern felt much better within a few days of treatments, as did other patients treated in the same way.

Signs and Symptoms

SAD is a type of major depressive disorder (MDD), and sufferers may exhibit any of the associated symptoms, such as feelings of hopelessness and worthlessness, thoughts of suicide, loss of interest in activities, withdrawal from social interaction, sleep and appetite problems, difficulty with concentrating and making decisions, decreased libido, a lack of energy, or agitation. Symptoms of winter SAD often include oversleeping or difficulty waking up in the morning, nausea, and a tendency to overeat, often with a craving for carbohydrates, which leads to weight gain. SAD is typically associated with winter depression, but springtime lethargy or other seasonal mood patterns are not uncommon. Although each individual case is different, in contrast to winter SAD, people who experience spring and summer depression may be more likely to show symptoms such as insomnia, decreased appetite and weight loss, and agitation or anxiety.

Bipolar Disorder

With seasonal pattern is a specifier for bipolar and related disorders, including bipolar I disorder and bipolar II disorder. Most people with SAD experience major depressive disorder, but as many as 20% may have a bipolar disorder. It is important to discriminate between diagnoses because there are important treatment differences. In these cases, people who have the With seasonal pattern specifier may experience a depressive episode either due to MDD or as part of bipolar disorder during the winter and remit in the summer. Around 25% of patients with bipolar disorder may present with a depressive seasonal pattern, which is associated with bipolar II disorder, rapid cycling, eating disorders, and more depressive episodes. Differences in biological sex display distinct clinical characteristics associated to seasonal pattern: males present with more Bipolar II disorder and a higher number of depressive episodes, and females with rapid cycling and eating disorders.

Cause

In many species, activity is diminished during the winter months in response to the reduction in available food, the reduction of sunlight (especially for diurnal animals) and the difficulties of surviving in cold weather. Hibernation is an extreme example, but even species that do not hibernate often exhibit changes in behaviour during the winter. Presumably, food was scarce during most of human prehistory, and a tendency toward low mood during the winter months would have been adaptive by reducing the need for calorie intake. The preponderance of women with SAD suggests that the response may also somehow regulate reproduction.

Various proximate causes have been proposed. One possibility is that SAD is related to a lack of serotonin, and serotonin polymorphisms could play a role in SAD, although this has been disputed.[20] Mice incapable of turning serotonin into N-acetylserotonin (by serotonin N-acetyltransferase) appear to express “depression-like” behaviour, and antidepressants such as fluoxetine increase the amount of the enzyme serotonin N-acetyltransferase, resulting in an antidepressant-like effect. Another theory is that the cause may be related to melatonin which is produced in dim light and darkness by the pineal gland, since there are direct connections, via the retinohypothalamic tract and the suprachiasmatic nucleus, between the retina and the pineal gland.[citation needed] Melatonin secretion is controlled by the endogenous circadian clock, but can also be suppressed by bright light.

One study looked at whether some people could be predisposed to SAD based on personality traits. Correlations between certain personality traits, higher levels of neuroticism, agreeableness, openness, and an avoidance-oriented coping style, appeared to be common in those with SAD.

Pathophysiology

Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright-light therapy. SAD is measurably present at latitudes in the Arctic region, such as northern Finland (64°00′N), where the rate of SAD is 9.5%. Cloud cover may contribute to the negative effects of SAD. There is evidence that many patients with SAD have a delay in their circadian rhythm, and that bright light treatment corrects these delays which may be responsible for the improvement in patients.

The symptoms of it mimic those of dysthymia or even major depressive disorder. There is also potential risk of suicide in some patients experiencing SAD. One study reports 6-35% of sufferers required hospitalization during one period of illness. At times, patients may not feel depressed, but rather lack energy to perform everyday activities.

Subsyndromal Seasonal Affective Disorder is a milder form of SAD experienced by an estimated 14.3% (vs. 6.1% SAD) of the US population. The blue feeling experienced by both SAD and SSAD sufferers can usually be dampened or extinguished by exercise and increased outdoor activity, particularly on sunny days, resulting in increased solar exposure. Connections between human mood, as well as energy levels, and the seasons are well documented, even in healthy individuals.

Diagnosis

According to the American Psychiatric Association DSM-IV criteria, Seasonal Affective Disorder is not regarded as a separate disorder. It is called a “course specifier” and may be applied as an added description to the pattern of major depressive episodes in patients with major depressive disorder or patients with bipolar disorder.

The “Seasonal Pattern Specifier” must meet four criteria: depressive episodes at a particular time of the year; remissions or mania/hypomania at a characteristic time of year; these patterns must have lasted two years with no non-seasonal major depressive episodes during that same period; and these seasonal depressive episodes outnumber other depressive episodes throughout the patient’s lifetime. The Mayo Clinic describes three types of SAD, each with its own set of symptoms.

Management

Treatments for classic (winter-based) seasonal affective disorder include light therapy, medication, ionized-air administration, cognitive-behavioural therapy (CBT) and carefully timed supplementation of the hormone melatonin.

Light Therapy

Photoperiod-related alterations of the duration of melatonin secretion may affect the seasonal mood cycles of SAD. This suggests that light therapy may be an effective treatment for SAD. Light therapy uses a lightbox which emits far more lumens than a customary incandescent lamp. Bright white “full spectrum” light at 10,000 lux, blue light at a wavelength of 480 nm at 2,500 lux or green (actually cyan or blue-green) light at a wavelength of 500 nm at 350 lux are used, with the first-mentioned historically preferred.

Bright light therapy is effective with the patient sitting a prescribed distance, commonly 30-60 cm, in front of the box with her/his eyes open but not staring at the light source for 30-60 minutes. A study published in May 2010 suggests that the blue light often used for SAD treatment should perhaps be replaced by green or white illumination. Discovering the best schedule is essential. One study has shown that up to 69% of patients find lightbox treatment inconvenient and as many as 19% stop use because of this.

Dawn simulation has also proven to be effective; in some studies, there is an 83% better response when compared to other bright light therapy. When compared in a study to negative air ionization, bright light was shown to be 57% effective vs. dawn simulation 50%. Patients using light therapy can experience improvement during the first week, but increased results are evident when continued throughout several weeks. Most studies have found it effective without use year round but rather as a seasonal treatment lasting for several weeks until frequent light exposure is naturally obtained.

Light therapy can also consist of exposure to sunlight, either by spending more time outside or using a computer-controlled heliostat to reflect sunlight into the windows of a home or office. Although light therapy is the leading treatment for seasonal affective disorder, prolonged direct sunlight or artificial lights that don’t block the ultraviolet range should be avoided due to the threat of skin cancer.

The evidence base for light therapy as a preventive treatment for seasonal affective disorder is limited. The decision to use light therapy to treat people with a history of winter depression before depressive symptoms begin should be based on a persons preference of treatment.

Medication

SSRI (selective serotonin reuptake inhibitor) antidepressants have proven effective in treating SAD. Effective antidepressants are fluoxetine, sertraline, or paroxetine. Both fluoxetine and light therapy are 67% effective in treating SAD according to direct head-to-head trials conducted during the 2006 Can-SAD study. Subjects using the light therapy protocol showed earlier clinical improvement, generally within one week of beginning the clinical treatment. Bupropion extended-release has been shown to prevent SAD for one in four people, but has not been compared directly to other preventive options in trials.

Modafinil may be an effective and well-tolerated treatment in patients with seasonal affective disorder/winter depression.

Another explanation is that vitamin D levels are too low when people do not get enough Ultraviolet-B on their skin. An alternative to using bright lights is to take vitamin D supplements. However, studies did not show a link between vitamin D levels and depressive symptoms in elderly Chinese nor among elderly British women.

Other Treatments

Depending upon the patient, one treatment (e.g. lightbox) may be used in conjunction with another (e.g. medication).

Negative air ionisation, which involves releasing charged particles into the sleep environment, has been found effective with a 47.9% improvement if the negative ions are in sufficient density (quantity).

Physical exercise has shown to be an effective form of depression therapy, particularly when in addition to another form of treatment for SAD. One particular study noted marked effectiveness for treatment of depressive symptoms when combining regular exercise with bright light therapy. Patients exposed to exercise which had been added to their treatments in 20 minutes intervals on the aerobic bike during the day along with the same amount of time underneath the UV light were seen to make quick recovery.

Of all the psychological therapies aimed at the prevention of SAD, cognitive-behaviour therapy, typically involving thought records, activity schedules and a positive data log, has been the subject of the most empirical work, however, evidence for CBT or any of the psychological therapies aimed at preventing SAD remains inconclusive.

Epidemiology

Nordic Countries

Winter depression is a common slump in the mood of some inhabitants of most of the Nordic countries. It was first described by the 6th century Goth scholar Jordanes in his Getica wherein he described the inhabitants of Scandza (Scandinavia). Iceland, however, seems to be an exception. A study of more than 2000 people there found the prevalence of seasonal affective disorder and seasonal changes in anxiety and depression to be unexpectedly low in both sexes. The study’s authors suggested that propensity for SAD may differ due to some genetic factor within the Icelandic population. A study of Canadians of wholly Icelandic descent also showed low levels of SAD. It has more recently been suggested that this may be attributed to the large amount of fish traditionally eaten by Icelandic people, in 2007 about 90 kilograms per person per year as opposed to about 24 kg in the US and Canada, rather than to genetic predisposition; a similar anomaly is noted in Japan, where annual fish consumption in recent years averages about 60 kg per capita. Fish are high in vitamin D. Fish also contain docosahexaenoic acid (DHA), which help with a variety of neurological dysfunctions.

Other Countries

In the US, a diagnosis of SAD was first proposed by Norman E. Rosenthal, M.D. in 1984. Rosenthal wondered why he became sluggish during the winter after moving from sunny South Africa to (cloudy in winter) New York. He started experimenting increasing exposure to artificial light, and found this made a difference. In Alaska it has been established that there is a SAD rate of 8.9%, and an even greater rate of 24.9% for subsyndromal SAD.

Around 20% of Irish people are affected by SAD, according to a survey conducted in 2007. The survey also shows women are more likely to be affected by SAD than men. An estimated 3% of the population in the Netherlands suffer from winter SAD.

On This Day … 11 February

People (Births)

  • 1925 – Virginia E. Johnson, American psychologist and academic (d. 2013).

People (Deaths)

  • 1958 – Ernest Jones, Welsh neurologist and psychoanalyst (b. 1879).

Virginia E. Johnson

Virginia E. Johnson, born Mary Virginia Eshelman (11 February 1925 to 24 July 2013), was an American sexologist, best known as a member of the Masters and Johnson sexuality research team. Along with her partner, William H. Masters, she pioneered research into the nature of human sexual response and the diagnosis and treatment of sexual dysfunctions and disorders from 1957 until the 1990s.

Early Life

Virginia Johnson was born in Springfield, Missouri, the daughter of Edna (née Evans) and Hershel “Harry” Eshelman, a farmer. Her paternal grandparents were members of the LDS Church, and her father had Hessian ancestry. When she was five, her family moved to Palo Alto, California, where her father worked as a groundskeeper for a hospital. The family later returned to Missouri and farming. Virginia enrolled at her hometown’s Drury College at age 16, but dropped out and spent four years working in the Missouri state insurance office. She eventually returned to school, studying at the University of Missouri and the Kansas City Conservatory of Music, and during World War II began a music career as a band singer. She sang country music for radio station KWTO in Springfield, where she adopted the stage name Virginia Gibson.

Johnson moved to St. Louis, Missouri, where she became a business writer for the St. Louis Daily Record. Eschewing a singing career, Johnson enrolled at Washington University in St. Louis, intending to earn a degree in sociology but never attaining one.

Sexological Works

Johnson met William H. Masters in 1957 when he hired her as a research assistant at the Department of Obstetrics and Gynecology at Washington University in St. Louis. Masters trained her in medical terminology, therapy, and research during the years she worked as his assistant. Together they developed polygraph-like instruments that were designed to measure sexual arousal in humans. Using these tools, Masters and Johnson observed and measured about 700 men and women who agreed to engage in sexual activity with other participants or masturbate in Masters’ laboratory. By observing these subjects, Johnson helped Masters identify the four stages of sexual response. This came to be known as the human sexual response cycle. The cycle consists of the excitement phase, plateau phase, orgasmic phase, and resolution phase. In 1964, Masters and Johnson established their own independent non-profit research institution in St. Louis called the Reproductive Biology Research Foundation. The centre was renamed the Masters and Johnson Institute in 1978.

In April 2009, Thomas Maier reported in Scientific American that Johnson had serious reservations about the Masters and Johnson Institute’s programme to convert homosexuals into heterosexuals, a programme which ran from 1968 to 1977.

Personal Life

By her early 20s, Johnson had married a Missouri politician; the marriage lasted two days. She then married a much older attorney, whom she also divorced. In 1950, Johnson married bandleader George Johnson, with whom she had a boy and a girl, before divorcing in 1956. In 1971, Johnson married William Masters after he divorced his first wife. They were divorced in 1993, though they continued to collaborate professionally. Johnson died in July 2013 “of complications from several illnesses”.

Masters, who married again after his divorce from Johnson, died in 2001.

In Popular Culture

The American cable network Showtime debuted Masters of Sex, a dramatic television series based on the 2009 biography of the same name, on September 29, 2013. The series stars Lizzy Caplan as Johnson.

Ernest Jones

Alfred Ernest Jones FRCP MRCS (01 January 1879 to 11 February 1958) was a Welsh neurologist and psychoanalyst. A lifelong friend and colleague of Sigmund Freud from their first meeting in 1908, he became his official biographer. Jones was the first English-speaking practitioner of psychoanalysis and became its leading exponent in the English-speaking world. As President of both the International Psychoanalytical Association and the British Psycho-Analytical Society in the 1920s and 1930s, Jones exercised a formative influence in the establishment of their organisations, institutions and publications.

Early Career

After obtaining his medical degrees, Jones specialised in neurology and took a number of posts in London hospitals. It was through his association with the surgeon Wilfred Trotter that Jones first heard of Freud’s work. Having worked together as surgeons at University College Hospital, he and Trotter became close friends, with Trotter taking the role of mentor and confidant to his younger colleague. They had in common a wide-ranging interest in philosophy and literature, as well as a growing interest in Continental psychiatric literature and the new forms of clinical therapy it surveyed. By 1905 they were sharing accommodation above Harley Street consulting rooms with Jones’s sister, Elizabeth, installed as housekeeper. Trotter and Elizabeth Jones later married. Appalled by the treatment of the mentally ill in institutions, Jones began experimenting with hypnotic techniques in his clinical work.

Jones first encountered Freud’s writings directly in 1905, in a German psychiatric journal in which Freud published the famous Dora case-history. It was thus he formed “the deep impression of there being a man in Vienna who actually listened with attention to every word his patients said to him…a revolutionary difference from the attitude of previous physicians…”

Jones’s early attempts to combine his interest in Freud’s ideas with his clinical work with children resulted in adverse effects on his career. In 1906 he was arrested and charged with two counts of indecent assault on two adolescent girls whom he had interviewed in his capacity as an inspector of schools for “mentally defective” children. At the court hearing Jones maintained his innocence, claiming the girls were fantasising about any inappropriate actions by him. The magistrate concluded that no jury would believe the testimony of such children and Jones was acquitted. In 1908, employed as a pathologist at a London hospital, Jones accepted a colleague’s challenge to demonstrate the repressed sexual memory underlying the hysterical paralysis of a young girl’s arm. Jones duly obliged but, before conducting the interview, he omitted to inform the girl’s consultant or arrange for a chaperone. Subsequently, he faced complaints from the girl’s parents over the nature of the interview and he was forced to resign his hospital post.

Psychoanalytical Career

Whilst attending a congress of neurologists in Amsterdam in 1907, Jones met Carl Jung, from whom he received a first-hand account of the work of Freud and his circle in Vienna. Confirmed in his judgement of the importance of Freud’s work, Jones joined Jung in Zurich to plan the inaugural Psychoanalytical Congress. This was held in 1908 in Salzburg, where Jones met Freud for the first time. Jones travelled to Vienna for further discussions with Freud and introductions to the members of the Vienna Psychoanalytic Society. Thus began a personal and professional relationship which, to the acknowledged benefit of both, would survive the many dissensions and rivalries which marked the first decades of the psychoanalytic movement, and would last until Freud’s death in 1939.

With his career prospects in Britain in serious difficulty, Jones sought refuge in Canada in 1908. He took up teaching duties in the Department of Psychiatry of the University of Toronto (from 1911, as Associate Professor of Psychiatry). In addition to building a private psychoanalytic practice, he worked as pathologist to the Toronto Asylum and Director of its psychiatric outpatient clinic. Following further meetings with Freud in 1909 at Clark University in Worcester, Massachusetts, where Freud gave a series of lectures on psychoanalysis, and in the Netherlands the following year, Jones set about forging strong working relationships with the nascent American psychoanalytic movement. He gave some 20 papers or addresses to American professional societies at venues ranging from Boston, to Washington and Chicago. In 1910 he co-founded the American Psychopathological Association and the following year the American Psychoanalytic Association, serving as its first Secretary until 1913.

Jones undertook an intensive programme of writing and research, which produced the first of what were to be many significant contributions to psychoanalytic literature, notably monographs on Hamlet and On the Nightmare. A number of these were published in German in the main psychoanalytic periodicals published in Vienna; these secured his status in Freud’s inner circle during the period of the latter’s increasing estrangement from Jung. In this context in 1912 Jones initiated, with Freud’s agreement, the formation of a Committee of loyalists charged with safeguarding the theoretical and institutional legacy of the psychoanalytic movement. This development also served the more immediate purpose of isolating Jung and, with Jones in strategic control, eventually manoeuvring him out of the Presidency of the International Psychoanalytical Association, a post he had held since its inception. When Jung’s resignation came in 1914, it was only the outbreak of the Great War that prevented Jones from taking his place.

Returning to London in 1913, Jones set up in practice as a psychoanalyst, founded the London Psychoanalytic Society, and continued to write and lecture on psychoanalytic theory. A collection of his papers was published as Papers on Psychoanalysis, the first account of psychoanalytic theory and practice by a practising analyst in the English language.

By 1919, the year he founded the British Psychoanalytical Society, Jones could report proudly to Freud that psychoanalysis in Britain “stands in the forefront of medical, literary and psychological interest” (letter 27 January 1919 (Paskauskas 1993)). As President of the Society – a post he would hold until 1944 – Jones secured funding for and supervised the establishment in London of a Clinic offering subsidised fees, and an Institute of Psychoanalysis, which provided administrative, publishing and training facilities for the growing network of professional psychoanalysts.

Jones went on to serve two periods as President of the International Psychoanalytic Association from 1920 to 1924 and 1932 to 1949, where he had significant influence. In 1920 he founded the International Journal of Psychoanalysis, serving as its editor until 1939. The following year he established the International Psychoanalytic Library, which published some 50 books under his editorship. Jones soon obtained from Freud rights to the English translation of his work. In 1924 the first two volumes of Freud’s Collected Papers was published in translations edited by Jones and supervised by Joan Riviere, his former analysand and, at one stage, ardent suitor. After a period in analysis with Freud, Riviere worked with Jones as the translation editor of the International Journal of Psychoanalysis. She then was part of a working group Jones set up to plan and deliver James Strachey’s translations for the standard edition of Freud’s work. Largely through Jones’ energetic advocacy, the British Medical Association officially recognised psychoanalysis in 1929. The BBC subsequently removed him from a list of speakers declared to be dangerous to public morality. In the 1930s Jones and his colleagues made a series of radio broadcasts on psychoanalysis.

After Adolf Hitler took power in Germany, Jones helped many displaced and endangered Jewish analysts to resettle in England and other countries. Following the Anschluss of March 1938, Jones flew into Vienna at considerable personal risk to play a crucial role in negotiating and organising the emigration of Freud and his circle to London.

The Jones-Freud Controversy

Jones’s early published work on psychoanalysis had been devoted to expositions of the fundamentals of Freudian theory, an elaboration of its theory of symbolism, and its application to the analysis of religion, mythology, folklore and literary and artistic works. Under the influence of Melanie Klein, Jones’ work took a new direction.

Klein had made an impact in Berlin in the new field of child analysis and had impressed Jones in 1925 when he attended her series of lectures to the British Society in London. At Jones’s invitation she moved to London the following year; she soon acquired a number of devoted and influential followers. Her work had a dramatic effect on the British Society, polarising its members into rival factions as it became clear that her approach to child analysis was seriously at odds with that of Anna Freud, as set out in her 1927 book An Introduction to the Technique of Child Analysis. The disagreement centred around the clinical approach to the pre-Oedipal child; Klein argued for play as an equivalent to free association in adult analyses. Anna Freud opposed any such equivalence, proposing an educative intervention with the child until an appropriate level of ego development was reached at the Oedipal stage. Klein held this to be a collusive inhibition of analytical work with the child.

Influenced by Klein, and initiating what became known as the Jones-Freud controversy, Jones set out to explore a range of interlinked topics in the theory of early psychic development. These included the structure and genesis of the superego and the nature of the feminine castration complex. He coined the term phallocentrism in a critique of Freud’s account of sexual difference. He argued together with Klein and her Berlin colleague, Karen Horney, for a primary femininity, saying that penis envy arose as a defensive formation rather than arising from the fact, or “injury”, of biological asymmetry. In a corresponding reformulation of the castration complex, Jones introduced the concept of “aphanisis” to refer to the fear of “the permanent extinction of the capacity (including opportunity) for sexual enjoyment”.

These departures from orthodoxy were noted in Vienna and were topics that were featured in the regular Freud-Jones correspondence, the tone of which became increasingly fractious. Faced with accusations from Freud of orchestrating a campaign against him and his daughter, Jones sought to allay Freud’s concerns without abandoning his new critical standpoint. Eventually, following a series of exchange lectures between the Vienna and London societies, which Jones arranged with Anna Freud, Freud and Jones resumed their usual cordial exchanges.

With the arrival in Britain of refugee German and Viennese analysts in the 1930s, including Anna Freud in 1938, the hostility between the orthodox Freudians and Kleinians in the British Society grew more intense. Jones chaired a number of “extraordinary business meetings” with the aim of defusing the conflict, and these continued into the war years. The meetings, which became known as the controversial discussions, were established on a more regular basis from 1942. By that time, Jones had removed himself from direct participation, owing to ill health and the difficulties of war-time travel from his home in Elsted, West Sussex. He resigned from the presidency of the British Society in 1944, the year in which, under the presidency of Sylvia Payne, there finally emerged a compromise agreement which established parallel training courses providing options to satisfy the concerns of the rival groups that had formed: followers of Anna Freud, followers of Melanie Klein and a non-aligned group of Middle or Independent Group analysts. It was agreed further that all the key policy making committees of the BPS should have representatives from the three groups.

Later Life

After the end of the war, Jones gradually relinquished his many official posts whilst continuing his psychoanalytic practice, writings and lecturing. The major undertaking of his final years was his monumental account of Freud’s life and work, published to widespread acclaim in three volumes between 1953 and 1957. In this he was ably assisted by his German-speaking wife, who translated much of Freud’s early correspondence and other archive documentation made available by Anna Freud. His uncompleted autobiography, Free Associations, was published posthumously in 1959.

Jones was made a Fellow of the Royal College of Physicians (FRCP) in 1942, Honorary President of the International Psychoanalytical Association in 1949, and was awarded an Honorary Doctor of Science degree at Swansea University (Wales) in 1954.

Jones died in London on 11 February 1958, and was cremated at Golders Green Crematorium. His ashes were buried in the grave of the oldest of his four children in the churchyard of St Cadoc’s Cheriton on the Gower Peninsula.

What is Orthorexia Nervosa?

Orthorexia nervosa (also known as orthorexia) is a proposed eating disorder characterised by an excessive preoccupation with eating healthy food.

The term was introduced in 1997 by American physician Steven Bratman, M.D. He suggested that some people’s dietary restrictions intended to promote health may paradoxically lead to unhealthy consequences, such as social isolation, anxiety, loss of ability to eat in a natural, intuitive manner, reduced interest in the full range of other healthy human activities, and, in rare cases, severe malnutrition or even death.

In 2009, Ursula Philpot, chair of the British Dietetic Association and senior lecturer at Leeds Metropolitan University, described people with orthorexia nervosa as being “solely concerned with the quality of the food they put in their bodies, refining and restricting their diets according to their personal understanding of which foods are truly ‘pure’.” This differs from other eating disorders, such as anorexia nervosa and bulimia nervosa, where those affected focus on the quantity of food eaten.

Orthorexia nervosa also differs from anorexia nervosa in that it does not disproportionally affect one gender. Studies have found that orthorexia nervosa is equally found in both men and women with no significant gender differences at all. Furthermore, research has found significant positive correlations between ON and both narcissism and perfectionism, but no significant correlation between ON and self esteem. This shows that high-ON individuals likely take pride over their healthy eating habits over others and that is the driving force behind their orthorexia as opposed to body image like anorexia.

Orthorexia nervosa is not recognised as an eating disorder by the American Psychiatric Association, and so is not mentioned as an official diagnosis in the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM).

Brief History

In a 1997 article in the magazine Yoga Journal, the American physician Steven Bratman coined the term “orthorexia nervosa” from the Greek ορθο- (ortho, “right” or “correct”), and όρεξις (orexis, “appetite”), literally meaning ‘correct appetite’, but in practice meaning ‘correct diet’. The term is modelled on anorexia, literally meaning “without appetite”, as used in the definition of the condition anorexia nervosa. (In both terms, “nervosa” indicates an unhealthy psychological state.) Bratman described orthorexia as an unhealthy fixation with what the individual considers to be healthy eating. Beliefs about what constitutes healthy eating commonly originate in one or another dietary theory such as raw foods veganism or macrobiotics, but are then taken to extremes, leading to disordered eating patterns and psychological and/or physical impairment. Bratman based this proposed condition on his personal experiences in the 1970s, as well as behaviours he observed among his patients in the 1990s. In 2000, Bratman, with David Knight, authored the book Health Food Junkies, which further expanded on the subject.

Following the publication of the book, in 2004 a team of Italian researchers from La Sapienza University of Rome, published the first empirical study attempting to develop a tool to measure the prevalence of orthorexia, known as the ORTO-15.

In 2015, responding to news articles in which the term orthorexia is applied to people who merely follow a non-mainstream theory of healthy eating, Bratman specified the following: “A theory may be conventional or unconventional, extreme or lax, sensible or totally wacky, but, regardless of the details, followers of the theory do not necessarily have orthorexia. They are simply adherents of a dietary theory. The term ‘orthorexia’ only applies when an eating disorder develops around that theory.” Bratman elsewhere clarifies that with a few exceptions, most common theories of healthy eating are followed safely by the majority of their adherents; however, “for some people, going down the path of a restrictive diet in search of health may escalate into dietary perfectionism.” Karin Kratina, PhD, writing for the National Eating Disorders Association, summarises this process as follows: “Eventually food choices become so restrictive, in both variety and calories, that health suffers – an ironic twist for a person so completely dedicated to healthy eating.”

Although orthorexia is not recognised as a mental disorder by the American Psychiatric Association, and it is not listed in the DSM-5, as of January 2016, four case reports and more than 40 other articles on the subject have been published in a variety of peer-reviewed journals internationally. According to a study published in 2011, two-thirds of a sample of 111 Dutch-speaking eating disorder specialists felt they had observed the syndrome in their clinical practice.

According to the Macmillan English Dictionary, the word is entering the English lexicon. The concept of orthorexia as a newly developing eating disorder has attracted significant media attention in the 21st century.

Signs and Symptoms

Symptoms of orthorexia nervosa include “obsessive focus on food choice, planning, purchase, preparation, and consumption; food regarded primarily as source of health rather than pleasure; distress or disgust when in proximity to prohibited foods; exaggerated faith that inclusion or elimination of particular kinds of food can prevent or cure disease or affect daily well-being; periodic shifts in dietary beliefs while other processes persist unchanged; moral judgment of others based on dietary choices; body image distortion around sense of physical “impurity” rather than weight; persistent belief that dietary practices are health-promoting despite evidence of malnutrition.”

Cause(s)

There has been no investigation into whether there may be a biological cause specific to orthorexia nervosa. It may be a food-centred manifestation of obsessive-compulsive disorder (OCD), which has a lot to do with control.

Diagnosis

In 2016, formal criteria for orthorexia were proposed in the peer-reviewed journal Eating Behaviours by Thom Dunn and Steven Bratman. These criteria are as follows:

  • Criterion A:
    • Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue, but this is conceptualised as an aspect of ideal health rather than as the primary goal.
    • As evidenced by the following:
      1. Compulsive behaviour and/or mental preoccupation regarding affirmative and restrictive dietary practices believed by the individual to promote optimum health. (Footnotes to this criteria add: Dietary practices may include use of concentrated “food supplements.” Exercise performance and/or fit body image may be regarded as an aspect or indicator of health.)
      2. Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.
      3. Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy food.
  • Criterion B:
    • The compulsive behaviour and mental preoccupation becomes clinically impairing by any of the following:
      1. Malnutrition, severe weight loss or other medical complications from restricted diet.
      2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviours about healthy diet.
      3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behaviour.

A diagnostic questionnaire has been developed for orthorexia sufferers, similar to questionnaires for other eating disorders, named the ORTO-15. However, Dunn and Bratman critique this survey tool as lacking appropriate internal and external validation.

Epidemiology

Results across scientific findings have yet to find a definitive conclusion to support whether nutrition students and professionals are at higher risk than other population subgroups, due to differing results in the research literature. There are only a few notable scientific works that, in an attempt to explore the breadth and depth of the still vaguely-understood illness, have tried to identify which groups in society are most vulnerable to its onset. This includes a 2008 German study, which based its research on the widespread suspicion that the most nutritionally-informed, such as university nutrition students, are a potential high-risk group for eating disorders, due to a substantial accumulation of knowledge on food and its relationship to health; the idea being that the more one knows about health, the more likely an unhealthy fixation about being healthy can develop. This study also inferred that orthorexic tendencies may even fuel a desire to study the science, indicating that many within this field might suffer from the disorder before commencing the course. However the results found that the students in the study, upon initial embarkation of their degree, did not have higher orthorexic values than other non-nutrition university students, and thus the report concluded that further research is needed to clarify the relationship between food-education and the onset of ON.

Similarly, in a Portuguese study on nutrition tertiary students, the participants’ orthorexic scores (according to the ORTO-15 diagnostic questionnaire) actually decreased as they progressed through their course, as well as the overall risk of developing an eating disorder being low at 4.2%. The participants also answered questionnaires to provide insight into their eating behaviours and attitudes, and despite this study finding that nutrition and health-science students tend to have more restrictive eating behaviours, these studies however found no evidence to support that these students have “more disturbed or disordered eating patterns than other students” These two aforementioned studies conclude that the more understanding of food one has is not necessarily a risk factor for ON, explaining that the data gathered suggests dietetics professionals are not at significant risk of it.

However, these epidemiologic studies have been critiqued as using a fundamentally flawed survey tool that inflates prevalence rates. Scholars have questioned both the reliability and validity of the ORTO-15.

Most scientific findings tend to agree, however, young adults and adolescents are extremely susceptible to developing eating disorders. One study found that there was no relationship between BOT score and college major, which may indicate the prevalence of mental health issues and eating disorders on college campuses and that health and science majors are no longer the only ones affected More studies have also been conducted on the link between increased Instagram use and Orthorexia nervosa. The social media based healthy community has recently grown in popularity especially on platforms such as Instagram. The hashtag #food is one of the top 25 most popular hashtags on Instagram. A study that investigated this relationship found that increased use of Instagram correlated between symptoms of ON with no other social media platform having the same effect. With young adults and adolescents making up the majority of social media users, exposure to this type of content can lead to developing unhealthy behaviour.

What is the Taylor Manifest Anxiety Scale?

Introduction

The Taylor Manifest Anxiety Scale, often shortened to TMAS, is a test of anxiety as a personality trait, and was created by Janet Taylor in 1953 to identify subjects who would be useful in the study of anxiety disorders. The TMAS originally consisted of 50 true or false questions a person answers by reflecting on themselves, in order to determine their anxiety level. Janet Taylor spent her career in the field of psychology studying anxiety and gender development.

Her scale has often been used to separate normal participants from those who would be considered to have pathological anxiety levels. The TMAS has been shown to have high test-retest reliability. The test is for adults but in 1956 a children’s form was developed. The test was very popular for many years after its development but is now used infrequently.

Refer to Zung Self-Rating Anxiety Scale.

Development and Validation

The TMAS has been proven reliable using test-retest reliability. O’Connor, Lorr, and Stafford found there were five general factors in the scale: chronic anxiety or worry, increased physiological reactivity, sleep disturbances associated with inner strain, sense of personal inadequacy, and motor tension. This study showed that persons administered the test could be display different anxiety levels across these areas. O’Connor, Lorr, and Stafford’s realisation allows patients and their doctors to better understand which dimension of anxiety needs to be addressed.

Childhood and Adolescence

The Children’s Manifest Anxiety Scale, sometimes shortened to the CMAS, was created in 1956.

This scale was closely modelled after the Taylor Manifest Anxiety Scale. It was developed so that the TMAS could be applied to a broader range of people, specifically children.

Kitano tested the validity of the CMAS by comparing students who were placed in special education classes versus those placed in regular classrooms. Kitano proposed the idea that children who were in special education classes were more likely to have higher anxiety than those in regular classrooms. Using the CMAS, Kitano found boys tested in the special education classes had higher anxiety scores than their regular classroom counterparts.

Hafner tested the reliability of the CMAS with the knowledge that the TMAS had a feminine bias. Hafner found that the CMAS did not have a female bias. He only found two questions that females always scored higher on than their male counterparts.

As the test stands now, the suggestion is to compare the female and male participants separately. Castaneda found significant differences across different grade levels, indicating that as students develop they are affected differentially by various stressors.

Gender Differences

Although the CMAS proved to not have a feminine bias, Quarter and Laxer found that females tend to score higher on the TMAS than their male counterparts. An example of these questions endorsed more frequently by females is, “I cry easily”. Similarly, Goodstein and Goldberger found that 17 of the 38 questions were more likely to be endorsed by females than males. Gall found that when she tested the femininity versus masculinity qualities of men and women, then compared them to the TMAS score, the people that were more feminine, either male or female, were more likely to have a positive correlation with their anxiety level score. Based on this, Gall agreed with previous research that stated the TMAS is more strongly female based. Hafner, however, found that the CMAS does not reflect the gender difference as the girls that took the children’s test only scored higher than the boys consistently on two of the questions.

Cultural Differences

Since the TMAS was introduced in 1953, comprehensive research has been done regarding the validity of the scale. across different cultures. In 1967, a study of cross-cultural differences in the scale was done between 9 year-old Japanese, French, and American students. The data concluded that Japanese and French students tested significantly lower on anxiety scores compared to the American students. Thus, there are strong cross-cultural differences related to the scores on the TMAS. Additional studies of the validity of the TMAS include a study between South African Natives and South African Europeans in 1979. Both groups included individuals with varying levels of education. This study found that the TMAS is sensitive to certain cross-cultural differences, but precautions should be taken when interpreting scores from the scale in non-Western cultures, regardless of the individual’s education level.

The Adult Manifest Anxiety Scale

In 2003, the Adult Manifest Anxiety Scale (AMAS) was introduced. It was made for three different age groups. The AMAS takes into account age-related situations that affect an individual’s anxiety. The divisions include:

  • One scale for adults (AMA-A);
  • One scale for college students (AMAS-C), and
  • The other for the elderly population (AMAS-E).

Each scale is geared towards examining situations specific to that age group. For example, the AMAS-C has items pertaining specifically to college students, such as questions about anxiety of the future.

The AMAS-A is geared more toward mid-life issues, and the AMAS-E has specific anxieties the older population deals with, such as fear of aging and dying. The AMAS-A contains 36 items. It has 14 questions relating to worry/oversensitivity, nine questions about physiological anxiety, seven questions about social concerns/stress, and six questions about lies. An example of an age appropriate item for this scale is, “I am worried about my job performance”. The AMAS-C contains 49 items about the same topics, but incorporates 15 items related specifically to test anxiety. Questions relating to the items on this scale include, “I worry too much about tests and exams”. This scale is similar in structure to the CMAS discussed above. The AMAS-E contains 44 items related to worry/oversensitivity, physiological anxiety, lying, and the fear of aging. Twenty-three of the questions on the AMAS-E are related to worry/oversensitivity, but The Fear of Aging category of this scale includes items such as, “I worry about becoming senile”. Similar to the TMAS, the AMAS can be given in a group or individual setting, and the person responds either yes or no to each item listed according to if it pertains to themselves or not. The more items that are answered yes, suggest a higher level of anxiety. The scale has been said to be easy to complete and practical, because it takes only about 10 minutes to complete and just a few minutes to score.

Applications and Limitations of AMAS

The AMAS has a broad range of applications, but also a number of limitations. The AMAS can be used in clinical settings, career counselling centres on campuses, hospices, nursing homes, and to monitor the progress and effectiveness of psychotherapy and drug treatment. Effective psychotherapy is indicated by a decrease in AMAS. Almost all college students will experience some type of stress in their academic career. Examples of their stress range from text anxiety to worry of the future after graduation. The AMAS-C items can provide psychologists with a statistical reference point to judge the student’s level of anxiety compared to other college students. A limitation of the AMAS-C is that it does not lend insight into the factors that are influencing the students anxiety, such as lack of studying and social factors. A more formal and extensive level of testing is necessary to resolve this limitation.

Utility

The utility of the TMAS is that it is a way to relate anxiety directly to performance in a certain area. The scale is able to measure anxiety levels and use the scores to determine performance on certain tasks. In some studies, researchers found that high anxiety (high drive) participants would make a greater number of mistakes, therefore taking longer for the participants to reach the learned criterion, whereas participants with low anxiety (low drive) would reach the learned criterion quicker. The TMAS was able to measure that anxiety, so the researchers could make inclusions or exclusions of the participants for their specific studies. This would allow them to achieve the results they want. The TMAS was also a way to relate intelligence to anxiety. Studies have shown there is a possible correlation between anxiety and academic achievement, but they do not recommend it be the sole predictor of achievement. It should be paired with other tests in order to make an accurate prediction.

Decline

The TMAS scale was frequently used in the past, however, its use has declined over the years due to problems with the validity of this self-report measure. Participants use their own judgement when answering questions, which causes internal and construct validity issues, which makes the interpretation of results difficult. Another possible reason this scale has declined in its use over the years is that researchers seemed to only get results of anxiety from participants under threat conditions and not under non-threat conditions, which again questioned the scale’s validity.

Awards

The Association for Psychological Science established an award in honour of Janet Taylor Spence for her contributions to psychology. Receiving this award means that the psychologist made honourable, new, creative, and cutting edge contributions to research and impact in the early years of their career, as Janet Taylor did during her career. The award is named the Janet Taylor Spence Award for Transformative Early Career Contributions.

Reference

Taylor, J. (1953). A Personality Scale of Manifest Anxiety. The Journal of Abnormal and Social Psychology. 48(2), pp.285-290. doi:10.1037/h0056264.

What is the Zung Self-Rating Anxiety Scale?

Introduction

The Zung Self-Rating Anxiety Scale (SAS) was designed by William W. K. Zung M.D, (1929-1992) a professor of psychiatry from Duke University, to quantify a patient’s level of anxiety.

Background

The SAS is a 20-item self-report assessment device built to measure anxiety levels, based on scoring in 4 groups of manifestations: cognitive, autonomic, motor and central nervous system symptoms. Answering the statements a person should indicate how much each statement applies to him or her within a period of one or two weeks prior to taking the test. Each question is scored on a Likert-type scale of 1-4 (based on these replies: “a little of the time,” “some of the time,” “good part of the time,” “most of the time”). Some questions are negatively worded to avoid the problem of set response. Overall assessment is done by total score.

The Anxiety Index

The total raw scores range from 20-80. The raw score then needs to be converted to an “Anxiety Index” score using the chart on the paper version of the test that can be found on the link below. The “Anxiety Index” score can then be used on this scale below to determine the clinical interpretation of one’s level of anxiety:

  • 20-44: Normal Range.
  • 45-59: Mild to Moderate Anxiety Levels.
  • 60-74: Marked to Severe Anxiety Levels.
  • 75 and above: Extreme Anxiety Levels.

You can find an online version of the SAS here.

Refer to Zung Self-Rating Depression Scale and Taylor Manifest Anxiety Scale (TMAS).

PDF version of test with Raw Score-Index Score Conversion Table.

References

Zung, W.A.K. (1974). The Measurement of Affects: Depression and Anxiety. Modern Problems of Pharmacopsychiatry. 7(0), pp.170-188. doi: 10.1159/000395075.

Zung, W.A.K. (1971) A Rating Instrument for Anxiety Disorders. Psychosomatics. 12(6), pp.371-379. doi: 10.1016/S0033-3182(71)71479-0.

What is the Zung Self-Rating Depression Scale?

Introduction

The Zung Self-Rating Depression Scale (SDS) was designed by Duke University psychiatrist William W.K. Zung MD (1929-1992) to assess the level of depression for patients diagnosed with depressive disorder.

The Levels

  • 20-44: Normal Range.
  • 45-59: Mildly Depressed.
  • 60-69: Moderately Depressed.
  • 70 and above Severely Depressed.

The SDS has been translated into many languages, including Arabic, Azerbaijani, Dutch, German, Portuguese, and Spanish.

You can find an online version of the SDS here.

Refer to Zung Self-Rating Anxiety Scale.

Reference

Zung, W.A.K. (1965) A Self-Rating Depression Scale. Archives of General Psychiatry. 12(1), pp63-70.