Anxiety Disorders: GKT School of Medicine

Rutter M. · Social, Genetic and Development Psychiatry Centre, Institute of Psychiatry, London, UK. · J Child Psychol Psychiatry. · Pubmed #14531576 No free full text.

This publication has no abstract.

Lader M, Tylee A, Donoghue J. · Institute of Psychiatry, King's College London, London, England. · CNS Drugs. · Pubmed #19062773 No free full text.

Abstract: The use of benzodiazepine anxiolytics and hypnotics continues to excite controversy. Views differ from expert to expert and from country to country as to the extent of the problem, or even whether long-term benzodiazepine use actually constitutes a problem. The adverse effects of these drugs have been extensively documented and their effectiveness is being increasingly questioned. Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. The potential for dependence and addiction have also become more apparent. The licensing of SSRIs for anxiety disorders has widened the prescribers' therapeutic choices (although this group of medications also have their own adverse effects). Melatonin agonists show promise in some forms of insomnia. Accordingly, it is now even more imperative that long-term benzodiazepine users be reviewed with respect to possible discontinuation. Strategies for discontinuation start with primary-care practitioners, who are still the main prescribers.This review sets out the stratagems that have been evaluated, concentrating on those of a pharmacological nature. Simple interventions include basic monitoring of repeat prescriptions and assessment by the doctor. Even a letter from the primary-care practitioner pointing out the continuing usage of benzodiazepines and questioning their need can result in reduction or cessation of use. Pharmacists also have a role to play in monitoring the use of benzodiazepines, although mobilizing their assistance is not yet routine. Such stratagems can avoid the use of specialist back-up services such as psychiatrists, home care, and addiction and alcohol misuse treatment facilities.Pharmacological interventions for benzodiazepine dependence have been reviewed in detail in a recent Cochrane review, but only eight studies proved adequate for analysis. Carbamazepine was the only drug that appeared to have any useful adjunctive properties for assisting in the discontinuation of benzodiazepines but the available data are insufficient for recommendations to be made regarding its use. Antidepressants can help if the patient is depressed before withdrawal or develops a depressive syndrome during withdrawal. The clearest strategy was to taper the medication; abrupt cessation can only be justified if a very serious adverse effect supervenes during treatment. No clear evidence suggests the optimum rate of tapering, and schedules vary from 4 weeks to several years. Our recommendation is to aim for withdrawal in <6 months, otherwise the withdrawal process can become the morbid focus of the patient's existence. Substitution of diazepam for another benzodiazepine can be helpful, at least logistically, as diazepam is available in a liquid formulation.Psychological interventions range from simple support through counselling to expert cognitive-behavioural therapy (CBT). Group therapy may be helpful as it at least provides support from other patients. The value of counselling is not established and it can be quite time consuming. CBT needs to be administered by fully trained and experienced personnel but seems effective, particularly in obviating relapse.The outcome of successful withdrawal is gratifying, both in terms of improved functioning and abstinence from the benzodiazepine usage. Economic benefits also ensue.Some of the principles of withdrawing benzodiazepines are listed. Antidepressants may be helpful, as may some symptomatic remedies. Care must be taken not to substitute one drug dependence problem for the original one.

Salcioğlu E, Başoğlu M. · Section of Trauma Studies, Institute of Psychiatry, King's College London, UK. · World J Pediatr. · Pubmed #18822924 No free full text.

Abstract: BACKGROUND: Treatment of child earthquake survivors is a relatively less investigated issue in disaster research. A review of the evidence on the mental health effects of earthquakes, risk factors, and findings from treatment studies may provide useful insights into effective treatment of traumatized children. DATA SOURCES: Studies of child and adolescent earthquake survivors included the PILOTS database (electronic index for literature on psychological trauma) and relevant evidence from various studies of adult earthquake survivors. RESULTS: Evidence points to elevated rates of posttraumatic stress disorder (PTSD), depression, and earthquake-related fears in children and adolescents. Traumatic stress appears to be mediated by loss of control over fear induced by exposure to unpredictable and uncontrollable earthquakes. This implies that interventions enhancing sense of control over fear are likely to be most effective. Recent studies indeed show that a control focused behavioral treatment (CFBT) involving mainly encouragement for self-exposure to feared situations is highly effective in facilitating recovery from earthquake trauma. Evidence also suggests that CFBT can be delivered through booklets and similar media. CONCLUSIONS: Pilot studies suggest that CFBT has promise in effective treatment of PTSD in children. Further research is needed to confirm these preliminary findings and to develop self-help tools for children.

Marshall EJ. · National Addiction Centre, Institute of Psychiatry, King's College London, London, UK. · Occup Med (Lond). · Pubmed #18676427 No free full text.

Abstract: The literature describing the diagnostic process in the addicted doctor is scant. Figures from North America indicate that the prevalence of alcohol problems in doctors may be no higher than in the population as a whole, whereas high rates of prescription drug use have been recognized. This practice of self-treatment with controlled drugs is a 'unique concern' for doctors. The development of substance misuse problems in doctors cannot be reduced to a single factor: Anxiety and depression, personality problems, stress at work, family stress, bereavement, an injury or accident at work, pain and a non-specific drift into drinking have been implicated. Early diagnosis is critical because doctors are often reluctant to seek help and colleagues reluctant to intervene. Medical schools and continuing medical education programmes must give greater emphasis to addiction and substance misuse in doctors with a view to reducing the incidence of 'impaired physicians' and promoting and encouraging early treatment and rehabilitation. The relationship between the addiction psychiatrist and the occupational physician is key given that these problems occur at the interface between occupational health and regulatory systems. The need for individually tailored back to work programmes requires careful coordination and monitoring and may be difficult to implement without their involvement. Generally, the prognosis for doctors' recovery is good and it is possible to predict which doctors will 'make it'.

Lader M. · P056, Institute of Psychiatry, King's College, London, Denmark Hill, London, SE5 8AF, UK. · Expert Rev Neurother. · Pubmed #18671662 No free full text.

Abstract: The benzodiazepines have been extensively prescribed for decades for vague indications such as anxiety, sleeplessness and muscle tension. Despite increasing knowledge of their adverse effects, such as sedation, psychomotor and cognitive impairment, and dependence on long-term use, and the recent advent of better alternatives, their use continues largely unabated. The paper under review assesses the sparse high-quality data related to efficacy (denoted by the dropout rate for failure to respond), effectiveness (dropout rate for any reason) and dropout for adverse effects. The conclusion is that efficacy was significantly higher for the drugs as compared with placebo; by contrast, no convincing evidence was found of any short-term effectiveness: and adverse effects were 1.5-times more frequent in the drug-treated patients. Various reasons for these results are discussed. I point out the changes in diagnostic criteria over the years and the lack of accepted methods of assessing estimates of effectiveness in clinical practice. Excessive prescribing of these controversial drugs is likely to continue.

Reinders AA. · King's College London, Institute of Psychiatry, Division of Psychological Medicine, London, UK. · Neurocase. · Pubmed #18569730 No free full text.

Abstract: Dissociative identity disorder (DID) is probably the most disputed of psychiatric diagnoses and of psychological forensic evaluations in the legal arena. The iatrogenic proponents assert that DID phenomena originate from psychotherapeutic treatment while traumagenic proponents state that DID develops after severe and chronic childhood trauma. In addition, DID that is simulated with malingering intentions, but not stimulated by psychotherapeutic treatment, may be called pseudogenic. With DID gaining more interest among the general public it can be expected that the number of pseudogenic cases will grow and the need to distinguish between traumagenic, iatrogenic or pseudogenic DID will increase accordingly. This paper discusses whether brain imaging studies can inform the judiciary and/or distinguish the etiology of DID.

Fleminger S. · Kings College London, Institute of Psychiatry, London, UK. · Eur J Anaesthesiol Suppl. · Pubmed #18289429 No free full text.

Abstract: In the long term after traumatic brain injury, the most disabling problems are generally related to neuropsychiatric sequelae, including personality change and cognitive impairment, rather than neurophysical sequelae. Cognitive impairment after severe injury is likely to include impaired speed of information processing, poor memory and executive problems. Personality change may include poor motivation, and a tendency to be self-centred and less aware of the needs of others. Patients may be described as lazy and thoughtless. Some become disinhibited and rude. Agitation and aggression can be very difficult to manage. Anxiety and depression symptoms are quite frequent and play a role in the development of persistent post-concussion syndrome after milder injury. Depression may be associated with a deterioration in disability over time after injury. Psychosis is not unusual though it has been difficult to confirm that traumatic brain injury is a cause of schizophrenia. Head injury may, many years later, increase the risk of Alzheimer's disease. Good rehabilitation probably minimizes the risk of psychiatric sequelae, but specific psychological and pharmacological treatments may be needed.

Treasure J, Sepulveda AR, MacDonald P, Whitaker W, Lopez C, Zabala M, Kyriacou O, Todd G. · Psychological Medicine Department, King's College London, Institute of Psychiatry, London, UK. · Eur Eat Disord Rev. · Pubmed #18240125 No free full text.

Abstract: The National Institute for Clinical Excellence (NICE) guidelines for eating disorders recommend that carers should be provided with information and support and that their needs should be considered if relevant. The aim of this paper is to describe how to structure an assessment of carers needs so that the family factors that can contribute to the maintenance of eating disorder symptoms are examined. We describe in detail the pattern of interpersonal reactions that can result when a family member has an eating disorder. Shared traits such as anxiety, compulsivity and abnormal eating behaviours contribute to some of the misperceptions, misunderstandings and confusion about the meaning of the eating disorder for family members. Unhelpful attributions can fuel a variety of emotional reactions (criticism, hostility, overprotection, guilt and shame). Gradually these forces cause family members to accommodate to the illness or be drawn in to enable some of the core symptoms.

Bhattacharyya S, Chakraborty K. · Section of Neuroimaging, Box 67, Division of Psychological Medicine, Institute of Psychiatry, King's College London, SE5 8AF, UK. · Recent Pat CNS Drug Discov. · Pubmed #18221217 No free full text.

Abstract: Despite widespread use and validation of their efficacy, about 40-60% of obsessive compulsive disorder (OCD) sufferers do not respond to appropriate courses of treatment with serotonin reuptake inhibitors (SRI) and even with the combination of pharmacotherapy and cognitive behaviour therapy a substantial number of patients remain dramatically symptomatic. Recently, there has been increasing interest in investigating glutamatergic dysfunction in OCD. Multiple lines of evidence point toward glutamatergic dysfunction being related to the pathophysiology of OCD, with glutamate modulating drugs being an alternative pharmacological strategy for treating OCD. In this article we focus in detail on the rationale for targeting glutamatergic agents as well as review the recent important patents for compounds that have emerged from these studies.

Sierra-Siegert M, David AS. · Depersonalization Research Unit, Institute of Psychiatry, King's College, London, UK. · J Nerv Ment Dis. · Pubmed #18091192 No free full text.

Abstract: It has been proposed that highly individualistic cultures confer vulnerability to depersonalization. To test this idea, we carried out a comprehensive systematic review of published empirical studies on panic disorder, which reported the frequency of depersonalization/derealization during panic attacks. It was predicted that the frequency of depersonalization would be higher in Western cultures and that a significant correlation would be found between the frequency of depersonalization and individualism scores of the participant countries. As predicted, the frequency of depersonalization during panic was significantly lower in nonwestern countries. There was also a significant correlation between frequency of depersonalization and Individualism (rho = 0.68, p < 0.0001), and between fears of losing control (rho = 0.57, p = 0.005) and individualism. These findings are interpreted in light of recent studies suggesting that individualistic cultures are characterized by hypersensitivity to threat and by an external locus of control. Two features may be relevant in the genesis of depersonalization.

Kanaan RA, Lepine JP, Wessely SC. · King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK. · Psychosom Med. · Pubmed #18040094 links to  free full text

Abstract: OBJECTIVE: To review the evidence for overlap in the phenomenology of the Functional Somatic Syndromes (FSS). The FSS show considerable comorbidity, leading some to suggest they may be aspects of the same disorder. METHODS: We conducted a selective review of peer-reviewed articles on the co-occurrence of FSS symptoms and diagnoses. RESULTS: Considerable evidence of overlap was found at the level of symptoms, diagnostic criteria, and clinical diagnoses made. CONCLUSIONS: Phenomenological commonalities support a close relationship between the FSS, although differences remain in other domains. Whether the FSS may best be considered the same or different will depend on the pragmatics of diagnosis.

de Zulueta CF. · Traumatic Stress Service, Maudsley Hospital and Institute of Psychiatry, King's College, London. · Int Rev Psychiatry. · Pubmed #17566900 No free full text.

Abstract: This article focuses on post-traumatic stress disorder (PTSD) as both one of the most important mental health consequences of mass violence and as the manifestation of a disrupted human attachment system. The implications are many in terms of treatment and prevention. For instance, since the vulnerability to PTSD appears to be transmitted down the generations via the psychobiological manifestations of the parents' attachment system, prevention requires the effective treatment of afflicted communities within a context of strong social support. More specific guidelines for intervention are outlined focusing on the role of psychosocial workers and their need to be carefully selected, trained and supervised. Failure to tackle the effects of mass violence and to prevent further psychological damage through political action has serious implications in terms of the future of mankind.

Ridsdale L, Massey R, Clark L. · Department of Clinical Neuroscience, Institute of Psychiatry, King's College London, UK. · Pract Neurol. · Pubmed #17430877 No free full text.

This publication has no abstract.

Garety PA, Bebbington P, Fowler D, Freeman D, Kuipers E. · Department of Psychology, Institute of Psychiatry, King's College London, London, UK. · Psychol Med. · Pubmed #17335638 No free full text.

Abstract: BACKGROUND: Cognitive models of the positive symptoms of psychosis specify the cognitive, social and emotional processes hypothesized to contribute to their occurrence and persistence, and propose that vulnerable individuals make characteristic appraisals that result in specific positive symptoms. METHOD: We describe cognitive models of positive psychotic symptoms and use this as the basis of discussing recent relevant empirical investigations and reviews that integrate cognitive approaches into neurobiological frameworks. RESULTS: Evidence increasingly supports a number of the hypotheses proposed by cognitive models. These are that: psychosis is on a continuum; specific cognitive processes are risk factors for the transition from subclinical experiences to clinical disorder; social adversity and trauma are associated with psychosis and with negative emotional processes; and these emotional processes contribute to the occurrence and persistence of psychotic symptoms. There is also evidence that reasoning biases contribute to the occurrence of delusions. CONCLUSIONS: The benefits of incorporating cognitive processes into neurobiological research include more sophisticated, bidirectional and interactive causal models, the amplification of phenotypes in neurobiological investigations by including emotional processes, and the adoption of more specific clinical phenotypes. For example, there is potential value in studying gene x environment x cognition/emotion interactions. Cognitive models and their derived phenotypes constitute the missing link in the chain between genetic or acquired biological vulnerability, the social environment and the expression of individual positive symptoms.

Tylee A, Walters P. · Section of Primary Care Mental Health, Health Services Research Department, Institute of Psychiatry, Kings College, London, United Kingdom. · J Clin Psychiatry. · Pubmed #17288504 No free full text.

Abstract: Despite current debate on the methodology of existing research into depression and anxiety disorders, there is still general agreement that recognition rates of these conditions in primary care could be improved. This review examines the factors that influence recognition of these disorders from both the patients' perspective and the primary care givers' perspective. Approaches and methods for improving recognition in primary care, including guidelines, mental health skills training, screening, and increasing public awareness, are considered in detail.

Freeman D. · Department of Psychology, Institute of Psychiatry, King's College London, Denmark Hill, London, UK. · Clin Psychol Rev. · Pubmed #17258852 No free full text.

Abstract: At least 10-15% of the general population regularly experience paranoid thoughts and persecutory delusions are a frequent symptom of psychosis. Persecutory ideation is a key topic for study. In this article the empirical literature on psychological processes associated with persecutory thinking in clinical and non-clinical populations is comprehensively reviewed. There is a large direct affective contribution to the experience. In particular, anxiety affects the content, distress and persistence of paranoia. In the majority of cases paranoia does not serve a defensive function, but instead builds on interpersonal concerns conscious to the person. However, affect alone is not sufficient to produce paranoid experiences. There is also evidence that anomalous internal experiences may be important in leading to odd thought content and that a jumping to conclusions reasoning bias is present in individuals with persecutory delusions. Theory of mind functioning has received particular research attention recently but the findings do not support a specific association with paranoia. The threat anticipation cognitive model of persecutory delusions is presented, in which persecutory delusions are hypothesised to arise from an interaction of emotional processes, anomalous experiences and reasoning biases. Ten key future research questions are identified, including the need for researchers to consider factors important to the different dimensions of delusional experience.

Hunot V, Churchill R, Silva de Lima M, Teixeira V. · Institute of Psychiatry, Section of Evidence Based Mental Health, Health Services Research Department, PO Box 32, De Crespigny Park, London, UK, SE5 8AF. · Cochrane Database Syst Rev. · Pubmed #17253466 No free full text.

Abstract: BACKGROUND: Generalised anxiety disorder (GAD) is a highly prevalent condition, characterised by excessive worry or anxiety about everyday events and problems. The effectiveness and effectiveness of psychological therapies as a group has not yet been evaluated in the treatment of GAD. OBJECTIVES: To examine the efficacy and acceptability of psychological therapies, categorised as cognitive behavioural therapy (CBT), psychodynamic therapy and supportive therapy, compared with treatment as usual/waiting list (TAU/WL) and compared with one another, for patients with GAD. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, LILACS and controlledtrials.com in February 2006. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials conducted in non-inpatient settings, involving adults aged 18-75 years with a primary diagnosis of GAD, assigned to a psychological therapy condition compared with TAU/WL or another psychological therapy. DATA COLLECTION AND ANALYSIS: Data on patients, interventions and outcomes were extracted by two review authors independently, and the methodological quality of each study was assessed. The primary outcome was anxiety reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of symptom reduction, using the standardised mean difference (SMD), with 95% confidence intervals. MAIN RESULTS: Twenty five studies (1305 participants) were included in the review, of which 22 studies (1060 participants) contributed data to meta-analyses. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.63, 95%CI 0.55 to 0.73), and also in reducing anxiety, worry and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however significant heterogeneity was indicated, which was partly explained by the number of therapy sessions. AUTHORS' CONCLUSIONS: Psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective. Further studies examining non-CBT models are required to inform health care policy on the most appropriate forms of psychological therapy in treating GAD.

Murtagh FE, Addington-Hall J, Higginson IJ. · Department of Palliative Care and Policy, Kings College London, London, UK. · Adv Chronic Kidney Dis. · Pubmed #17200048 No free full text.

Abstract: Symptoms in end-stage renal disease (ESRD) are underrecognized. Prevalence studies have focused on single symptoms rather than on the whole range of symptoms experienced. This systematic review aimed to describe prevalence of all symptoms, to better understand total symptom burden. Extensive database, "gray literature," and hand searches were undertaken, by predefined protocol, for studies reporting symptom prevalence in ESRD populations on dialysis, discontinuing dialysis, or without dialysis. Prevalence data were extracted, study quality assessed by use of established criteria, and studies contrasted/combined to show weighted mean prevalence and range. Fifty-nine studies in dialysis patients, one in patients discontinuing dialysis, and none in patients without dialysis met the inclusion criteria. For the following symptoms, weighted mean prevalence (and range) were fatigue/tiredness 71% (12% to 97%), pruritus 55% (10% to 77%), constipation 53% (8% to 57%), anorexia 49% (25% to 61%), pain 47% (8% to 82%), sleep disturbance 44% (20% to 83%), anxiety 38% (12% to 52%), dyspnea 35% (11% to 55%), nausea 33% (15% to 48%), restless legs 30% (8%to 52%), and depression 27% (5%to 58%). Prevalence variations related to differences in symptom definition, period of prevalence, and level of severity reported. ESRD patients on dialysis experience multiple symptoms, with pain, fatigue, pruritus, and constipation in more than 1 in 2 patients. In patients discontinuing dialysis, evidence is more limited, but it suggests they too have significant symptom burden. No evidence is available on symptom prevalence in ESRD patients managed conservatively (without dialysis). The need for greater recognition of and research into symptom prevalence and causes, and interventions to alleviate them, is urgent.

Schmidt U, Treasure J. · Section of Eating Disorders, Institute of Psychiatry, De Crespigny Park, PO Box 59, London SE5 8AF, UK. · Br J Clin Psychol. · Pubmed #17147101 No free full text.

Abstract: Anorexia nervosa (AN) is highly valued by people with the disorder. It is also a highly visible disorder, evoking intense emotional responses from others, particularly those closest to the person. A maintenance model of restricting anorexia nervosa, combining intra- and interpersonal factors is proposed. Four main maintaining factors (perfectionism/cognitive rigidity, experiential avoidance, pro-anorectic beliefs, response of close others) are suggested and the evidence supporting these is examined. These factors need to be integrated with what is known about starvation-related maintenance factors. This model departs from other models of AN in that it does not emphasize the role of weight and shape-related factors in the maintenance of AN; that is, it is culture-free. Implications for clinical practice and research are discussed.

Fleminger S, Greenwood RJ, Oliver DL. · Maudsley Hospital, Lishman Brain Injury Unit, Denmark Hill, London, UK. · Cochrane Database Syst Rev. · Pubmed #17054165 No free full text.

Abstract: BACKGROUND: Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management. OBJECTIVES: To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other electronic databases. We also searched the reference lists of included studies and recent reviews. In addition we handsearched the journals Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. The searches were last updated in June 2006. SELECTION CRITERIA: Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. DATA COLLECTION AND ANALYSIS: We independently extracted data and assessed trial quality. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused. MAIN RESULTS: Six RCTs were identified and included in this review. Four of theses evaluated the beta-blockers, propranolol and pindolol, one evaluated the central nervous system stimulant, methylphenidate and one evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking. AUTHORS' CONCLUSIONS: Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.

Hirsch CR, Clark DM, Mathews A. · Institute of Psychiatry, King's College, University of London, De Crespigny Park, UK. · Behav Ther. · Pubmed #16942974 No free full text.

Abstract: Cognitive-behavioral models of clinical problems typically postulate a role for the combined effects of different cognitive biases in the maintenance of a given disorder. It is striking therefore that research has tended to examine cognitive biases in isolation rather than assessing how they work together to maintain psychological dysfunction. The combined cognitive biases hypothesis presented here suggests that cognitive biases influence each another and can interact to maintain a given disorder. Furthermore, it is proposed that the combined effects of cognitive biases may have a greater impact on sustaining a given disorder than if the biases operated in isolation. The combined cognitive biases hypothesis is examined in relation to imagery and interpretation in social phobia. Individuals with social phobia experience negative images of themselves performing poorly in social situations, and they also interpret external social information in a less positive way than those without social anxiety. Evidence of a reciprocal relationship between imagery and interpretations is presented, and the mechanisms underlying the combined effects are discussed. Clinical implications and the potential utility of examining the combined influence of other cognitive biases are highlighted.

Heyman I, Mataix-Cols D, Fineberg NA. · National and Specialist OCD Service for Young People, Children's Department, Maudsley Hospital, London. · BMJ. · Pubmed #16931840 No free full text.

This publication has no abstract.

Murtagh FE, Addington-Hall JM, Donohoe P, Higginson IJ. · Dept of Palliative Care & Policy, Kings College London, UK. · EDTNA ERCA J. · Pubmed #16898102 No free full text.

Abstract: Increasing numbers of patients with chronic kidney disease Stage 5 (GFR <15ml/minute) are being managed without dialysis, either through their own preference or because dialysis is unlikely to benefit them. This growing group of patients has extensive health care needs. Their overall symptom burden is high, and symptom prevalence matches or exceeds that in other end of life populations, both with cancer and other non-cancer diagnoses. These symptoms may often go unrecognised and under-treated. Regular symptom assessment is necessary, together with pro-active management of identified symptoms. Pain can be managed using the principles of the World Health Organisation analgesic ladder. Not all opioid medications are recommended for these patients. Paracetamol, tramadol, and fentanyl are the most appropriate medications for steps 1, 2 and 3 respectively. There is limited evidence on the use of buprenorphine, oxycodone and hydromorphone. Methadone is safe but should only be prescribed by a clinician experienced in its use. Morphine and diamorphine are not recommended because of metabolite accumulation. Pruritus is also challenging to manage. The evidence for pharmacological interventions to alleviate pruritus is summarized, and a pragmatic approach to management suggested. Emollients, capsaisin cream, antihistamines, thalidomide and ondansetron may be helpful, according to the extent and pattern of pruritus. Symptoms may frequently be due to co-morbid conditions, not renal disease itself, and managing them is difficult because of the constraints on the use of medication which kidney failure imposes. Collaboration between renal and palliative specialists can help identify ways to achieve best care for these patients.

Kuipers E, Garety P, Fowler D, Freeman D, Dunn G, Bebbington P. · King's College London, Institute of Psychiatry, Department of Psychology, PO Box 77, London SE5 8AF, UK. · Schizophr Bull. · Pubmed #16885206 links to  free full text

Abstract: Psychosis used to be thought of as essentially a biological condition unamenable to psychological interventions. However, more recent research has shown that positive symptoms such as delusions and hallucinations are on a continuum with normality and therefore might also be susceptible to adaptations of the cognitive behavioral therapies found useful for anxiety and depression. In the context of a model of cognitive, emotional, and social processes in psychosis, the latest evidence for the putative psychological mechanisms that elicit and maintain symptoms is reviewed. There is now good support for emotional processes in psychosis, for the role of cognitive processes including reasoning biases, for the central role of appraisal, and for the effects of the social environment, including stress and trauma. We have also used virtual environments to test our hypotheses. These developments have improved our understanding of symptom dimensions such as distress and conviction and also provide a rationale for interventions, which have some evidence of efficacy. Therapeutic approaches are described as follows: a collaborative therapeutic relationship, managing dysphoria, helping service users reappraise their beliefs to reduce distress, working on negative schemas, managing and reducing stressful environments if possible, compensating for reasoning biases by using disconfirmation strategies, and considering the full range of evidence in order to reduce high conviction. Theoretical ideas supported by experimental evidence can inform the development of cognitive behavior therapy for persistent positive symptoms of psychosis.

Bhangoo P, Parfitt A, Wu T. · St Thomas' Hospital, London, UK. · Emerg Med J. · Pubmed #16794106 links to  free full text

Abstract: A short cut review was carried out to establish whether nitrates are better than benzodiazepines in the treatment of cocaine induced chest pain. Seven citations were reviewed of which two answered the three part question. The clinical bottom line is that in patients with cocaine induced chest pain it appears that nitrates or benzodiazepines are effective in combination or alone in resolving chest pain and improving cardiac performance. We recommend that the agent of choice may be influenced by the presence or absence of concurrent CNS symptoms.