Deficiency Disorder


It’s easy to appreciate the seasonality of winter blues, but web searches show that other disorders may ebb and flow with the weather as well.

Google searches are becoming an intriguing source of health-related information, exposing everything from the first signs of an infectious disease outbreak to previously undocumented side effects of medications. So researchers led by John Ayers of the University of Southern California decided to comb through queries about mental illnesses to look for potentially helpful patterns related to these conditions. Given well known connections between depression and winter weather, they investigated possible connections between mental illnesses and seasons.

Using all of Google’s search data from 2006 to 2010, they studied searches for terms like “schizophrenia” “attention deficit/hyperactivity disorder (ADHD),” “bulimia” and “bipolar” in both the United States and Australia.  Since winter and summer are reversed in the two countries finding opposing patterns in the two countries’ data would strongly suggest that season, rather than other things that might vary with time of year, was important in some way in the prevalence of the disorders.

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“All mental health queries followed seasonal patterns with winter peaks and summer troughs,” the researchers write in their study, published in the American Journal of Preventive Medicine. They found that mental health queries in general were 14% higher in the winter in the U.S. and 11% higher in the Australian winter.

The seasonal timing of queries regarding each disorder was also similar in the two countries. In both countries, for example, searches about eating disorders (including anorexia and bulimia) and schizophrenia surged during winter months; those in the U.S. were 37% more likely and Australians were 42% more likely to seek information about these disorders during colder weather than during the summer. And compared to summer searches, schizophrenia queries were 37% more common in the American winter and 36% more frequent during the Australian winter. ADHD queries were also highly seasonal, with 31% more winter searches in the U.S. and 28% more in Australia compared to summer months.

Searches for depression and bipolar disorder, which might seem to be among the more common mental illnesses to strike during the cold winter months, didn’t solicit as many queries: there were 19% more winter searches for depression in the U.S. and 22% more in Australia for depression. For bipolar, 16% more American searches for the term occurred in the winter than in the summer, and 18% more searches occurred during the Australian winter. The least seasonal disorder was anxiety, which varied by just 7% in the U.S. and 15% in Australia between summer and winter months.

Understanding how the prevalence of mental illnesses change with the seasons could lead to more effective preventive measures that alert people to symptoms and guide them toward treatments that could help, say experts. Previous research suggests that shorter daylight hours and the social isolation that accompanies harsh weather conditions might explain some of these seasonal differences in mental illnesses, for example, so improving social interactions during the winter months might be one way to alleviate some symptoms. Drops in vitamin D levels, which rise with exposure to sunlight, may also play a role, so supplementation for some people affected by mood disorders could also be effective.

 

The researchers emphasize that searches for disorders are only queries for more information, and don’t necessarily reflect a desire to learn more about a mental illness after a new diagnosis. For example, while the study found that searches for ‘suicide’ were 29% more common in winter in America and 24% more common during the colder season in Australia, other investigations showed that completed suicides tend to peak in spring and early summer. Whether winter queries have any relationship at all to spring or summer suicides isn’t clear yet, but the results suggest a new way of analyzing data that could lead to better understanding of a potential connection.

And that’s the promise of data on web searches, says the scientists. Studies on mental illnesses typically rely on telephone or in-person surveys in which participants are asked about symptoms of mental illness or any history with psychological disorders, and people may not always answer truthfully in these situations. Searches, on the other hand, have the advantage of reflecting people’s desire to learn more about symptoms they may be experiencing or to improve their knowledge about a condition for which they were recently diagnosed. So such queries could become a useful resource for spotting previously undetected patterns in complex psychiatric disorders.  “The current results suggest that monitoring queries can provide insight into national trends on seeking information regarding mental health, such as seasonality…If additional studies can validate the current approach by linking clinical symptoms with patterns of search queries,” the authors conclude, “This method may prove essential in promoting population mental health.”

 

Capt. Susan Carlson was not a typical recruit when she volunteered for the Army in 2006 at the age of 50. But the Army desperately needed behavioral health professionals like her, so it signed her up.

Though she was, by her own account, “not a strong soldier,” she received excellent job reviews at Fort Leavenworth, Kan., where she counseled prisoners. But last year, Captain Carlson, a social worker, was deployed to Afghanistan with the Colorado National Guard and everything fell apart.

After a soldier complained that she had made sexually suggestive remarks, she was suspended from her counseling duties and sent to an Army psychiatrist for evaluation. His findings were shattering: She had, he said in a report, a personality disorder, a diagnosis that the military has used to discharge thousands of troops. She was sent home.

She disputed the diagnosis, but it was not until months later that she found what seemed powerful ammunition buried in her medical file, portions of which she provided to The New York Times. “Her command specifically asks for a diagnosis of a personality disorder,” a document signed by the psychiatrist said.

Veterans’ advocates say Captain Carlson stumbled upon evidence of something they had long suspected but had struggled to prove: that military commanders pressure clinicians to issue unwarranted psychiatric diagnoses to get rid of troops.

“Her records suggest an attempt by her commander to influence medical professionals,” said Michael J. Wishnie, a professor at Yale Law School and director of its Veterans Legal Services Clinic.

Since 2001, the military has discharged at least 31,000 service members because of personality disorder, a family of disorders broadly characterized by inflexible “maladaptive” behavior that can impair performance and relationships.

For years, veterans’ advocates have said that the Pentagon uses the diagnosis to discharge troops because it considers them troublesome or wants to avoid giving them benefits for service-connected injuries. The military considers personality disorder a pre-existing problem that emerges in youth, and as a result, troops given the diagnosis are often administratively discharged without military retirement pay. Some have even been required to repay enlistment bonuses.

By comparison, a diagnosis of post-traumatic stress disorder is usually linked to military service and leads to a medical discharge accompanied by certain benefits.

In recent weeks, questions about whether the Army manipulates psychiatric diagnoses to save money have been raised at Joint Base Lewis-McChord near Tacoma, Wash., where soldiers undergoing medical evaluations before discharge complained that psychiatrists rescinded PTSD diagnoses, leaving the soldiers with diagnoses like personality disorder that did not qualify them for medical discharges.

In a memorandum, an Army ombudsman wrote that a doctor from the base hospital, Madigan Army Medical Center, said that one diagnosis of post-traumatic stress disorder can cost $1.5 million in benefits over a soldier’s lifetime. The doctor also counseled his colleagues to be good stewards of taxpayer money by not “rubber-stamping” such diagnoses.

In the wake of those complaints, the Army has removed the head of Madigan and suspended two doctors at a special forensic psychiatric unit. It has also reviewed the cases of 14 soldiers and reinstituted PTSD diagnoses for 6 of them.

Some senior military officials have raised concerns that PTSD is overdiagnosed. Still, the Defense Department has denied that it uses psychiatric diagnoses either to weed out injured or low-performing troops, or to save money.

“Our goal is to provide the most accurate diagnosis,” said Maria Tolleson, a spokeswoman for the Army Medical Command.

On Captain Carlson’s case, the Colorado National Guard declined to comment. Officials at Womack Army Medical Center at Fort Bragg, N.C., said the psychiatrist who evaluated Captain Carlson in Afghanistan, Maj. Aniceto Navarro, was not available for an interview.

But in a statement, the hospital said: “No commander may order a credentialed clinician to make a particular diagnosis. Dr. Navarro did not feel he was being ordered by the service member’s command to make a particular diagnosis. The sentence referenced was written in terms of the commander asking to evaluate for a personality disorder, i.e. asking if one existed, not ordering to diagnose a personality disorder.”

Though it is impossible to know how many veterans are disputing their personality disorder discharges, Vietnam Veterans of America, an advocacy group, with help from the Yale veterans legal clinic, has sued the Defense Department seeking records they say will show that thousands of troops have been unfairly discharged for personality or adjustment disorder since 2001.

“We believe that many of the people who received personality disorder discharges were wrongly diagnosed and that in fact they were suffering from PTSD or traumatic brain injury,” said Thomas Berger, executive director of Vietnam Veterans of America’s health council.

Although the number of personality disorder discharges is small relative to the total number of troops who have served since 2001, Congress was concerned enough about the issue to hold hearings in 2007 after reading reports that troops with post-traumatic stress and other combat-related injuries were being discharged for personality disorder.

The Defense Department then tightened its requirements, partly to ensure that troops who had served in combat zones and had PTSD were not discharged for personality disorder. Personality disorder discharges subsequently declined, to 1,078 in 2010 from 4,264 in 2007, data obtained by Vietnam Veterans of America show.

But the Government Accountability Office said in 2010 that the Defense Department had not proved that it was in full compliance with its rules. And Captain Carlson’s case shows that the military continues to issue personality disorder diagnoses in questionable ways, according to veterans’ advocates and her lawyers, Stephen H. Carpenter Jr. and Daniel C. Russ.

Unlike the soldiers at Madigan, Captain Carlson has not been given a diagnosis of PTSD. But the personality disorder diagnosis could complicate her ability get a medical discharge for a back injury and other problems. Perhaps more significant, the diagnosis will be listed on her discharge papers, which employers typically review when they are considering veterans for a job.

“It may have a significant impact on her ability to find employment,” Mr. Carpenter said.

Captain Carlson, now 55, signed up with the Army after a co-worker at a Milwaukee trauma hospital, a surgeon in the National Guard, told her that the Army badly needed therapists and social workers. Intrigued, she got an age waiver and joined through a program that commissions officers based on their specialized training.

At Fort Leavenworth, where she served for three years, supervisors called her “highly talented,” “outstanding” and “a dedicated officer,” according to a 2008 evaluation.

After leaving active duty, Captain Carlson moved to Colorado Springs in 2010 to take a civilian job as a substance abuse counselor at Fort Carson. But she soon learned that the Colorado National Guard, which she had just joined, would deploy to Afghanistan in early 2011. She told her commander she wanted to go.

“I wanted to experience what soldiers experience,” she said in an interview.

But her problems began soon after she arrived in Afghanistan last February. She got lost outside a combat outpost and wore shorts when she should have been in combat uniform. Then a junior enlisted soldier accused her of sexual harassment, citing an off-color remark she made during a game of Scrabble with several soldiers at a combat outpost.

Captain Carlson contends the remark was innocent, but the Army sent her back to Bagram Air Base near Kabul and opened an investigation. A major general eventually gave her a memorandum of reprimand, a potentially career-ending action. But she says it was the psychological evaluation she received at Bagram that upset her the most.

In notes from that evaluation, Dr. Navarro wrote that “it is very difficult to draw absolute conclusions for a personality disorder.” But he noted that her command had asked for the diagnosis and, in his final report dated three days later, Dr. Navarro did just that.

Captain Carlson has “a very dramatic style” and “chronic difficulty in adjusting,” Dr. Navarro wrote in that report, concluding that she had “personality disorder NOS” — not otherwise specified — “with histrionic traits.” He recommended that the Army move swiftly to discharge her if she did not comply with counseling from her commander.

Experts say personality disorder is generally evident in a person’s youth, leaving a telltale pattern across failed jobs and broken relationships. For that reason, they generally recommend that diagnoses include reviews of patients’ medical records and interviews with people who have known them for years. Dr. Navarro says in his notes that he did not have access to her records.

Dr. Andrew E. Skodol, research professor of psychiatry at the University of Arizona and an expert on personality disorder who was not familiar with Captain Carlson’s case, said it would not be surprising for a person who entered the Army in middle age to have trouble adapting to the stresses of military life and deployment. But that would not necessarily qualify as a personality disorder, Dr. Skodol said.

After leaving Afghanistan last year, Captain Carlson went to Joint Base Lewis-McChord, where a psychiatrist gave her a diagnosis of adjustment disorder, her lawyers said. That psychiatrist has since been suspended as part of the Army’s investigation into Madigan.

It will be up to the Colorado National Guard to decide how Captain Carlson will be discharged, a process that could take months. At the least, Captain Carlson wants the personality disorder diagnosis removed from her record.

“It’s a bad label,” she said. “I’m a broken soldier. I’m old. And they just want to get rid of me.”

 

By , NYT, February 24, 2012

 

 

IS THE KING OF POP AILING?: A journalist says that Michael Jackson, pictured here in 2001, is suffering from a debilitating disease and needs an emergency lung transplant to survive.

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Michael Jackson, the moonwalking pop star whose health problems have often shared the spotlight with him, is reportedly wracked with severe emphysema and potentially deadly internal bleeding.

According to Ian Halperin, an investigative journalist who is writing an unauthorized biography of the singer, Jackson, 50, has been fighting the genetically inherited disorder alpha-1 antitrypsin deficiency for several years.

Last year he was seen in a wheelchair near his home in Las Vegas. And earlier this month, photographers snapped a shot of him outside a doctor’s office with his face hidden beneath a mask and a fedora.

If Jackson has alpha-1 antitrypsin deficiency, it means he cannot protect his lungs from his body’s own defenses against bacteria. The disease eventually leads to difficulty breathing, and some forms of the illness can affect the liver and skin. Halperin told the British newspaper Sunday Express that Jackson needs a lung transplant to survive but that he may be too physically frail to endure such an operation. The biographer did not describe his sources in the article but said that the singer can barely speak and has lost 95 percent of the vision in his left eye.

Jackson’s public health troubles began soon after the release of his chart-topping album Thriller in the early 1980s when the 5′ 11″ singer reportedly weighed just 105 pounds, and some speculated that he was suffering from anorexia. He was later diagnosed with vitiligo—which results in a loss of skin pigmentation—and the potentially lethal autoimmune disease lupus in which the body’s immune system gets out of whack and attacks healthy tissue. In 2005, when he was tried and cleared in California of child molestation charges, he became dependent on morphine and the painkiller Demerol, according to his attorneys.

The star’s older brother Jermaine told Fox News that the singer is not doing well, but on Monday a Jackson rep issued a statement dismissing the alpha-1 antitrypsin deficiency reports as “total fabrication.”

“Mr. Jackson is in fine health,” the statement said, “and finalizing negotiations with a major entertainment company and television network for both a world tour and a series of specials and appearances.”

To find out more about the condition, we spoke with James Stoller, a pulmonary critical care doctor at the Cleveland Clinic who has studied alpha-1 antitrypsin deficiency for more than 20 years.

An edited transcript of the interview follows.

What is alpha-1 antitrypsin deficiency?

It is a genetic defect in the production of a protective protein called alpha-1 antitrypsin, which is made in the liver and circulates in the bloodstream. This protein primarily protects the lungs against an enzyme known as neutrophil elastase, which our body uses to break down bacterial cell walls, but it also has the collateral damage of breaking down elastin, the support protein of the lung. This results in the development of emphysema. Some individuals with a genetic disposition for the disease go through life and never develop emphysema; others develop early-onset severe emphysema in their 40s and 50s. The disease is exacerbated by smoking and exposure to other noxious inhaled stimuli that lead to inflammation of the lungs.

How common is it, and how is it diagnosed?

It is very much under-recognized. The best estimate in the U.S. is there are probably about 100,000 severely affected Americans. If one looks at carriers of the disease, that probably affects 3 percent of Americans. It’s quite common—one of the most common genetic variants in the U. S.

It can be diagnosed by checking blood at birth, but that has not been the usual practice here. It is usually diagnosed because one presents manifestations of the disease, most commonly emphysema and liver disease, or because one has a family member who is affected.

If confirmed, does Michael Jackson’s case sound serious?

It’s hard to know. I’m not aware of any association with eye disease, at least any direct link. The gastrointestinal bleeding may be unrelated to alpha-1 antitrypsin deficiency, but to the extent that the deficiency is associated with liver and lung disease, one could develop stomach bleeding.

If he needs a lung transplant on the basis of alpha-1 antitrypsin deficiency, it would bespeak of a fairly advanced degree of emphysema. Such transplants are regrettably not very rare. Of all lung transplants listed in the database of the International Society for Heart and Lung Transplantation, 8 to 11 percent are performed on the basis of emphysema for alpha-1 antitrypsin deficiency.

What type of medications would Jackson have been taking to treat it?

The treatment of emphysema related to alpha-1 includes all the usual medications: medicines to open up the airways, broncodilators; preventive strategies like influenza vaccine, pneumonia vaccine; occasionally oxygen when the individual’s oxygen level is specifically low enough to justify using oxygen pulmonary rehab; sometimes inhaled cortical steroids [to reduce inflammation]. There are also some specific therapies for alpha-1 antitrypsin deficiency, including so-called augmentation therapy. This involves the weekly or monthly intravenous infusion of purified human alpha-1 antitrypsin, which causes the levels in the blood to rise above the protective threshold. The best available studies suggest that this medication can slow the rate of decline of lung function.

* By Brendan Borrell  (Dec. 2008)