bluuebunny/crossref_metadata_2025 huggingface dataset:
Module 10: Home Point Systems
Authors: Chronis-Tuscano Andrea , O’Brien Kelly , Danko Christina M.
Published: September 2020

When parents have tried everything and their child is still struggling with compliance, routines, and other serious behaviors, you can suggest a more intensive point/token system. The rationale for this type of system is that children with attention-deficit/hyperactivity disorder (ADHD) respond better to frequent, immediate rewards over delayed rewards. The overall goal of the home point/token system is to make the expected behaviors very explicit and to provide more frequent rewards or consequences contingent on an explicit set of behaviors, using a more structured system of reinforcement. For a system like this to work effectively, it must be implemented consistently across caregivers, which is challenging for many parents. Keeping the system simple and straightforward tends to work best, especially as parents are first learning the principles. It may also be helpful to begin by focusing on one time of day to acclimate parents to the system, later expanding to other times of the day.
Introduction
Authors: Ruhoy Ilene S. , McBurney John W.
Published: September 2020

Over the past decade, there has been increasing interest in alternative methods of treatment for many diseases. Physicians have recognized the limitations in the conventional use of pharmaceuticals and surgical intervention. Integrative approaches to patient care combine evidence-based conventional care with the best of evidence-based alternative care. Neurologists, in specific, manage many difficult-to-treat symptoms and disorders and can greatly benefit from integrative medicine. Many neurologists in practice have been incorporating alternative means of treatment in conjunction with current standards of care and experiencing improved patient response and satisfaction. This text covers some of the more common disease states in neurology and discusses integrative approaches to treatment and management. It also addresses the importance of self-care for the neurologist as stress and burnout are problematic for neurologists, further impairing patient care and the critical patient–doctor relationship.
Stress and Burnout in Neurology
Authors: Snyder Marsha W.
Published: September 2020

Stress and burnout are epidemic in medicine in general and neurology in particular. This has resulted in a healthcare crisis because burned-out physicians are subject to multiple adverse personal outcomes and are more likely to make mistakes in their work. The seeds of this crisis are found in the earliest stages of medical education and acculturation. Resilience is produced by a set of cognitive skills that can be taught and nurtured, building on a strengths-based rather than a deficit-based approach. Positive health and well-being is built on positive affect, engagement, positive relationships, meaning, and accomplishment (PERMA for short) according to the formulation of Martin Seligman, the father of positive psychology. PERMA and positive psychology form the framework for combating stress and burnout in neurology.
Management of Headache Using an Integrative Approach
Authors: Murinova Natalia , Schorn Melissa , Krashin Daniel
Published: September 2020

Headache is among the most common and disabling of all neurological conditions but is far more treatable than is commonly thought. This chapter focuses on the recognition and precise diagnosis of the most significant headache types, including episodic and chronic migraine, posttraumatic headache, and cluster headache. Through precise questioning, the provider can quickly identify the headache as well as significant comorbidities and develop a treatment plan. Treatment outcomes are optimized by determining the most effective treatments for the specific headache conditions and developing a multimodal, comprehensive treatment plan that considers the patient’s diagnosis, other health issues, preferences, and lifestyle. New treatments are being developed in many areas, including medications, supplements, physical treatments, lifestyle modifications, and behavioral treatments. The newest headache treatments using neuromodulation and antibodies are also discussed, with recommendations for how to use them most effectively.
Neuropathy and Neuropathic Pain
Authors: Rowin Julie
Published: September 2020

Complementary and alternative treatment modalities are commonly used by patients for neuropathy and neuropathic pain due to perceived lack of benefit from conventional medical treatment. As the association between metabolic syndrome and neuropathy is increasingly recognized, diet and lifestyle interventions are becoming important components in the management of neuropathy. Progress in the understanding of the gut–immune interaction highlights the roles that the gut microbiome and inflammation play in the modulation of neuropathy and neuropathic pain. Evidence for nutritional interventions, exercise, supplements, acupuncture, and mindfulness-based practices in the treatment of neuropathic pain is also encouraging. This chapter reviews the available evidence supporting the safe use of complementary and alternative treatments as adjunctive or preferred options to symptomatic treatment with pharmaceuticals in commonly encountered conditions associated with neuropathy and neuropathic pain.
Ayurvedic Medicine in Neurology
Authors: Ehrlich Gillian , Dhru Dhaval
Published: September 2020

Ayurveda, the 5,000-year-old system of medicine originating in India, offers the evolving field of neurology unique insights into assessment and treatment in patient care. This chapter introduces the Ayurvedic approach and treatment options for neurological diseases. The authors review the origin of this ancient science through the five elements; the three biological doshas (vata, pitta, and kapha); the three mental qualities (sattva, rajas, and tamas); the four lenses of the mind; and the critical importance of consciousness and digestion in our daily physiology. We discuss the Ayurvedic approach to patient care, including principles of treatment based on the prakruti (birth constitution) and vikruti (current constitution), especially as relevant to the nervous system tissues and the mind (majja dhatu and majja vaha srotas). This chapter concludes with unique insights into the root causes of complex neurological disease. Ayurveda, being truly holistic in its approach to disease prevention and management, achieves the maximum benefit for patients by personalizing care for the individual’s body, mind, and spirit complex.
Autism Spectrum Disorder: A Framework for Integrative Pediatric Medicine
Authors: Gbedawo Hatha
Published: September 2020

Autism spectrum disorders are complex, diverse neurodevelopmental and behavioral disorders that are characterized by the presence of impaired social communication with restricted stereotypical patterns of behavior and interests. The cause remains elusive and multifactorial, including a sophisticated interplay of genetics and environmental factors. Standard treatment options are limited to behavioral therapies, including applied behavioral analysis, and pharmacological treatment for significant behaviors such as aggression. Families are increasingly turning to alternative medical practices for support in managing their children’s care. By using an integrative medical model with a focus on investigating for and treating underlying inflammation and oxidative stress, integrative practitioners can help families navigate the complex world of autism management and treatment.
Endocrine-Disrupting Chemicals: Brain–Behavior Effects on Thyroid and Sexual Differentiation
Authors: Zoeller R. Thomas , vom Saal Frederick S.
Published: September 2020

The human population is exposed to literally hundreds of industrial chemicals. Studies show that, on average, there are well over 100 industrial chemicals in cord blood samples taken from babies born in the United States. This observation may be disregarded if it were not for solid—and growing—evidence that many of these chemicals interfere with hormone systems that play important roles in human brain development. For example, thyroid hormone is known to be essential for normal brain development and the human brain is much more sensitive to thyroid hormone insufficiency than believed 50 years ago. Chemicals such as perchlorate, polychlorinated biphenyls, and polybrominated flame retardants are associated with cognitive deficits in humans, and the experimental literature reveals a complex interaction with the thyroid system that can account for these effects. Likewise, estrogenic chemicals like bisphenol A (BPA) can affect the development of many organ systems, including sexually dimorphic regions of the brain. There is now convincing evidence that even slight perturbations in hormonal systems caused by endocrine-disrupting chemicals can impact brain development, reducing cognitive function and gender-specific behaviors throughout the remainder of life. The consequences of such chronic exposures at low doses typical of human exposures had, until relatively recently, not been appreciated due to safety testing strategies that are designed to identify overt toxicities, not endocrine disruption and its consequences.
Acupuncture in Neurological Disorders: An Evidence-Based Overview
Authors: Dimitrova Alexandra
Published: September 2020

Over the past 20 years acupuncture has been rapidly gaining in popularity both in clinical practice and in research. New evidence for the benefits of acupuncture in various disorders is emerging seemingly every week, and recent large-scale systematic reviews and meta-analyses have suggested that acupuncture’s benefits in pain conditions can be maintained long term. At present the strongest evidence for acupuncture in the treatment of neurological disorders is in the fields of migraine, tension headaches, diabetic neuropathy, carpal tunnel syndrome, and Bell’s palsy. Recent trials suggest that acupuncture may be used as an adjunct in stroke rehabilitation and in improving the quality of life in patients with Parkinson’s disease and dementia. Despite recent mechanistic research advances, much remains unknown about acupuncture’s mechanism of action and there are common misconceptions about the origins of modern-day acupuncture. As acupuncture is being rapidly integrated into mainstream medical practice and increasingly being sought by patients, healthcare providers and neurologists in particular need to be educated about its applications and benefits for various neurological disorders. Our hope is that this chapter will serve toward this educational goal.
The Need to Fathom Overlapping Pain and Psychiatric Syndromes
Authors: Incayawar Mario
Published: September 2020

There is a wide overlap of chronic pain conditions and psychiatric disorders. Pain and psychiatric comorbidity is frequent in the population, yet it is poorly understood, research is scarce, the diagnosis is challenging, and the treatment that follows is often less than appropriate. Pain conditions and psychiatric disorders have customarily been understood and treated as different and separate clinical entities, to the detriment of patients’ well-being. The societal burden of mental illness and pain is enormous; it could approach $1 trillion annually in the United States. There are very limited data on the epidemiology and scope of the overlap between mental disorders and chronic pain. Compounding to the economic burden are the liability related to stigma, shame, bias, discrimination, health disparities, inequities in care, and health injustice. Recent scientific and technological developments in digital medicine, artificial intelligence, pharmacogenetics, genetics, epigenetics, and neuroscience promise beneficial quality changes to medical care and education. The pain medicine and psychiatry of the future will consider patients as human beings embedded in their physical and social environments. Health professionals are headed toward person-centered care and biologically individualized/personalized therapy or precision medicine.
Shared Brain Synaptic Mechanisms of Pain and Anxiety
Authors: Yalcin Ipek , Zhuo Min
Published: September 2020

Uncontrolled and persistent pain strongly associates with anxiety and depressive disorders and is the most common cause of disability impairing quality of life. In the past decade, a growing number of studies have focused on chronic pain comorbidities, aiming at modeling them and at understanding the pathophysiology of chronic and mood disorder comorbidity. These studies offer a unique opportunity to test cellular and molecular hypotheses, whereas human clinical investigations provide critical neuroanatomical insights, particularly through functional imaging studies. Altogether, the results point out that there are shared neural mechanisms between chronic pain and anxiety/depression, such as shared neuroanatomical substrates, changes in monoaminergic system, and neuroimmune and neuroendocrine responses. Based on recent studies, chronic anxiety triggered by chronic pain is mediated through presynaptic long-term potentiation (LTP) in the anterior cingulate cortex (ACC), a key cortical region for pain perception. Conversely, N-methyl-d-aspartate (NMDA) receptor–dependent postsynaptic LTP plays a more important role in behavioral sensitization in chronic pain. Thus, postsynaptic and presynaptic LTP in ACC neurons are likely the key cellular mechanisms for causing chronic pain and its associated anxiety, respectively.
Neuroimaging Correlates for Psychological and Chronic Pain Experiences
Authors: Sturgeon John A. , Martucci Katherine T.
Published: September 2020

Psychological factors play a key role in the pain experience. Clinical and experimental research has highlighted altered behavioral, cognitive, and emotional responses as endemic in chronic pain populations, which contribute to physical dysfunction and to depression, anxiety, and other psychiatric disorders. Neuroimaging research has complemented the knowledge in this domain by identifying how neural structure and function are altered in chronic pain. Brain processes related to mental illness, emotion, memory, and cognition are distributed throughout the brain and modulate pain processing in both the acute and chronic states. These processes can be targeted both behaviorally and neurophysiologically through noninvasive and nonpharmacological psychological therapies, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction. Psychological therapies are further supported by emerging neuroimaging research that demonstrates changes in brain structure and function associated with positive changes in patients’ responses to pain and overall improved quality of life.
The Clinical Neuroscience of the Insomnia–Fibromyalgia Link
Authors: McCrae Christina S. , Curtis Ashley F. , Kay Daniel B.
Published: September 2020

The high rate of chronic insomnia (>50%) in fibromyalgia is likely attributable to reciprocal influences of each disorder’s pathophysiological mechanisms. Because common pharmacological and behavioral approaches to treating pain often fail to provide effective long-term pain relief, interest in sleep and related central mechanisms as targets for improving central pain processing/modulation and clinical pain is high. This chapter reviews those mechanisms, describes how insomnia and fibromyalgia confer reciprocal risk, and considers how interventions that target sleep and related central mechanisms can improve pain processing/modulation and clinical pain in fibromyalgia. More research examining sleep’s potential to exert positive, sustained influence on central pain mechanisms and clinical pain is needed.
Catastrophizing in Comorbid Chronic Pain and Mental Illness
Authors: Townsend Cynthia O. , Townsend Donald R.
Published: September 2020

Catastrophizing, or the tendency to emphasize and exaggerate the occurrence of negative consequences in a specific situation, has been shown to play an important role in the development and maintenance of chronic pain. Dynamically viewed as a contributor, mediator, and result of chronic pain suffering, catastrophizing has notable importance for clinicians treating patients’ comorbid chronic pain and mental illness. Exciting research on catastrophizing and neuroplasticity in persons with chronic pain promises to expand our understanding of pain catastrophizing, pain chronification, and cortical structural neuroplasticity in response to psychological interventions. This chapter provides a selective review of the assessment and neural correlates of pain catastrophizing as well as the role of catastrophizing as a prognostic factor for pain-related outcomes. The interactions between catastrophizing and chronic pain are also explored in the context of key comorbid mental conditions: depression and insomnia. Clinical implications for the practicing clinician are discussed.
The Many Faces of Chronic Urogenital Pain
Authors: Harlow Bernard L. , Haviland Miriam J. , Bergeron Sophie
Published: September 2020

Chronic vulvar pain, or vulvodynia, is a highly prevalent condition among women of reproductive age. Although the pathogenesis of vulvodynia is unknown, it is generally believed to be the result of an altered immune-inflammatory response mechanism. Psychiatric comorbidities—most significantly depression and anxiety—are highly prevalent among women with vulvodynia, and research has shown that these conditions may cause or mediate vulvodynia. This association necessitates treatment plans that include both medical and psychological components. In this chapter, the authors discuss current research on the biological link between vulvodynia and psychiatric comorbidities and clinical treatment for both conditions.
Understanding and Managing Personality Disorders in Chronic Pain
Authors: Weisberg James N. , Twyner Channing , Paul Christopher
Published: September 2020

This chapter provides an overview of historical perspectives on personality and pain, distinguishing between personality characteristics and personality disorders and the multiple factors affecting their assessment. The authors address the epidemiology of personality disorders both in the general population and in chronic pain patients and provide a brief overview of recent research of treatment of personality disorders to optimize outcomes in this difficult population. In addition, the comorbidity of individuals with personality disorders and both chronic pain and substance use disorders is addressed. The authors note that understanding the role personality disorders may play in the expression of behaviors observed in a substantial proportion of chronic pain sufferers should result in the tailoring of multimodal treatments for chronic pain that emphasize nonopioid medical management and cognitive behavioral and physical therapies.
Pain and Comorbid Psychiatric Illnesses in Elderly People
Authors: Davis Mellar P. , Shuster John L.
Published: September 2020

Chronic pain is often associated with anxiety, depression, and frailty. The relationship between pain and mental illness is complex and bidirectional. In elderly people, poor self-rated health is strongly associated with pain severity, and pain-related interference with daily activities leads to depression. There is a shared neural substrate within the central nervous system (CNS) between pain and depression, which have a common neuroanatomical organization within the CNS. The close association between pain and depression means that assessment of pain should be accompanied by assessment of depression even if by the single question, “Are you depressed?” The physiological changes in aging influence the pain experience and analgesic tolerance, which diminishes in the presence of comorbidities. Tolerance to antidepressants is also diminished, with a greater risk for drug–drug interactions due to polypharmacy, which accompanies older age.
Acknowledging the Clinical Effects of Words in Pain Medicine and Psychiatry
Authors: Bouchard Lise , Incayawar Mario
Published: September 2020

Despite the importance and widespread presence of words in our life, the study of their effects on biological systems and the brain per se has been largely neglected. This chapter draws from biomedical and psychiatric research to illustrate the underlying biological effects of words used in a wide spectrum of human activity, such as writing, verbal communication, and reading, as well as the purposeful use of words during bullying and racist attacks, the triggering of placebo and nocebo effects, the words expressed during emotional and physical pain and psychopathology, and talkative psychotherapy. The authors conclude that words have a concrete impact on biological systems and the brain. This could be beneficial or deleterious. Therefore, positive doctor–patient communication is essential for achieving a high-quality medical encounter. It is suggested that medical linguistics could contribute to the development of clinical conversational strategies useful to physicians and psychotherapists treating patients suffering from pain and psychiatric disorders.
Impulsivity and Cue Reactivity in Substance Misuse
Authors: Gerard Moeller F.
Published: September 2020

There is a growing clinical literature linking impulsivity to drug cue reactivity in individuals with substance misuse. Evidence supporting this link comes from studies using a variety of behavioral laboratory measures of impulsivity and drug cue reactivity. This link is not surprising considering the nature of impulsivity and drug cue reactivity, which both have elements of a stimulus driven reaction to the environment. This chapter describes in detail the literature supporting this link and discusses the potential neurobiology of the overlap based on brain imaging. Last, some potential treatments that target both impulsivity and drug cue reactivity are discussed.
Stress and Substance Misuse
Authors: Bjork James M. , Thomson Nicholas D.
Published: September 2020

Stress is both a critical contributor and consequence of substance use disorder (SUD). First, exaggerated subjective stress responses are characteristic of affective symptomatology such as depression, bipolar disorder, generalized anxiety, and posttraumatic stress disorder (sometimes stemming from histories of abuse) that have been prognostic of development of addiction in longitudinal studies. Substance use is negatively reinforced in many at-risk and addicted individuals because it may acutely alleviate stress. Second, chronic administration of commonly abused substances alters physiological stress response systems, especially during acute withdrawal. Third, acute stress responses blunt the addicted individual’s frontocortically mediated behavioral repertoire (solution space) in favor of reflexive behavioral biases toward relief-based substance use. Therefore, acute stress responses are a strong trigger for relapse to substance use during extended recovery. These findings have collectively led to approaches to SUD relapse prevention that pharmacologically blunt components of the stress response, but these agents have not reliably shown success in human clinical trials. This chapter reviews these different relationships between stress and addiction and offers future avenues for additional research.
Evidence-Based Pharmacotherapy for Alcohol Use Disorders
Authors: McNally Donald , Arias Albert J.
Published: September 2020

Pharmacotherapy is a vital component of alcohol use disorder (AUD) treatment. From a biopsychosocial perspective, the use of pharmacotherapy alone and in combination with various therapeutic and psychosocial modalities to reduce harmful drinking behaviors is supported by a strong evidence base. This chapter presents an overview of the use of both US Food and Drug Administration (FDA)-approved and off-label treatments for AUD, and it provides practical information and evidence for the use of pharmacotherapy. Comprehensive reviews of medications are undertaken with an emphasis on evidence-based practice and clinical utility to aid in the treatment of AUD and harmful drinking behaviors.
What Is Hope?
Authors: Snyder Jeremy
Published: September 2020

Chapter 3 turns to academic analyses of hope. The author largely adopts Adrian Martin’s account. She proposes what she calls the incorporation analysis of hope where hoping entails being attracted to an outcome, seeing it as possible, treating this attraction as licensing a reason for certain ways of feeling, thinking, and acting toward that outcome, and treating this attraction as giving sufficient reason for these feelings, thoughts, and actions. Hope can be false as derived from misinformation or failures in autonomous decision-making, but it need not be so. Fantasizing and planning for the hoped-for outcome is consistent with understanding the actual probabilities of this outcome, including in cases of hoping against all expectation, and active fantasizing about these outcomes can improve health and welfare. At the same time, false hope creates a vulnerability to exploitation, as does persevering in hope at the expense of other, more obtainable options.
Legislating Hope
Authors: Snyder Jeremy
Published: September 2020

In Chapter 7, the author discusses the promise of early access to unproven interventions through so-called right-to-try legislation. This legislation was designed with the stated intent of expanding access to new medical interventions undergoing clinical trials where individuals could not participate in these trials. In practice, very few people have benefitted from this law and there is evidence that it was motivated largely be an interest in eroding regulatory authority over new medical interventions. While policymakers and political leaders are typically understood to exaggerate or misrepresent their achievements, in this case specific claims about the promise and achievements of this policy trade on the hope of seriously ill individuals for political gain.
Multilevel interactions and the dappled causal world of psychiatric disorders
Authors: Kendler Kenneth S. , Gyngell Christopher
Published: September 2020

Despite substantial advances in our understanding of many somatic diseases, the nature of many psychiatric disorders remains elusive. This chapter shows how an appreciation of the multilevel causal nature of psychiatric disorders can move these debates forward. It first examines the ways in which genetic risk factors interact with environmental factors in the aetiology of depression and substance use disorders. Second, it discusses the implications of these findings for philosophical debates about the nature of psychiatry. It argues that the non-additive relationship between risk factors at different causal levels provides reasons to resist hard reductionist models of psychiatric disorders. Similarly, it argues that psychiatry should resist attempts to base classification schemes on a hard medical model. Instead psychiatry should embrace the fuzzy and complex causal picture that research suggests reflects the true nature of mental illness. The chapter ends by charting a path forward for psychiatric research, based on a rich multilevel framework.
A developmental approach to understanding psychiatric disorders: Mapping aetiological pathways
Authors: Haller Simone P.W. , Kadosh Kathrin Cohen
Published: September 2020

Advances in paediatric neuroimaging in the last two decades have provided us with a plethora of evidence on how age-related changes in brain function and structure may contribute to changes in behaviour during adolescence. This has given us a better appreciation of the dynamic and protracted neuro-maturational processes during the second decade of life. Yet, we are still a long way from turning brain evidence into strategies that could help with navigating specific developmental challenges more successfully. As adolescence is also a period of increased risk for psychiatric disorders, harnessing this knowledge for early interventions and preventions has long been a goal, but not a reality. To make significant progress, we first need to map individual developmental trajectories more continuously. This will enable us to delineate unique changes and understand how environmental experiences affect neural trajectories. We can then focus on discerning typical variability in developmental change, and assess what represents a risk factor. As risk correlates can be conditional on the presence or absence of other risk factors (e.g. genetic predispositions, social experiences), it is important to model risk factors at multiple levels. These data could then provide a framework in which we can explore aetiological pathways to psychiatric conditions to understand equifinality (i.e. how and when different pathways can result in the same outcome) and, vice versa, multifinality (i.e. how and when the same risk factors can result in different outcomes). Such an approach would necessitate that we move away from cross-sectional multigroup designs towards building comprehensive, continuous longitudinal samples of change across development. It is only then that we will finally be able to use brain-based data effectively to develop targeted intervention approaches and make recommendations about the timing of interventive efforts. This chapter uses two examples and reviews the literature to illustrate how critical longitudinal developmental data are in achieving these aims.
The case for a preventative approach to mental health: Childhood maltreatment, neuroimaging, and the theory of latent vulnerability
Authors: McCrory Eamon J.
Published: September 2020

This chapter addresses the well-established association between childhood maltreatment and increased risk for psychopathology. Recent functional magnetic resonance imaging research has demonstrated that childhood maltreatment is associated with altered functioning in a range of neurocognitive systems, including threat and reward processing. Such changes are observable even in the absence of psychiatric disorder and in some cases, predict future symptomatology. According to the theory of latent vulnerability they are thought, in part, to reflect adaptations to early adverse environments. The evidence from clinical studies suggests that these changes are strikingly consistent with those observed in individuals presenting with psychiatric disorder, suggesting such neurocognitive ‘adaptations’ embed latent vulnerability to future psychiatric disorder. Ultimately, this growing body of work is establishing a compelling case to develop a more precise, mechanistic understanding of the pathogenesis of psychiatric disorder following maltreatment, and the need to invigorate efforts to build a preventative clinical approach.
Biopsychosocial pathways to mental health and disease across the lifespan: The emerging role of epigenetics
Authors: Cecil Charlotte A.M.
Published: September 2020

The biopsychosocial (BPS) model of psychiatry has had a major impact on our modern conceptualization of mental illness as a complex, multi-determined phenomenon. Yet, interdisciplinary BPS work remains the exception, rather than the rule in psychiatry. It has been suggested that this may stem in part from a failure of the BPS model to clearly delineate the mechanisms through which biological, psychological, and social factors co-act in the development of mental illness. This chapter discusses how epigenetic processes that regulate gene expression, such as DNA methylation, are fast emerging as a candidate mechanism for BPS interactions, with potentially widespread implications for the way that psychiatric disorders are understood, assessed, and, perhaps in future, even treated.
Ignoring faces and making friends
Authors: Parrott Matthew
Published: September 2020

Experimental evidence shows that experiencing maltreatment in early childhood affects the way a person responds to angry faces. This is viewed by many developmental psychologists as an adaptive response to an abusive or hostile environment. However, it is also widely thought that, in a non-abusive environment, these alterations to the way a person responds to angry faces also puts an individual at greater risk than average for developing psychiatric disorders. Why is this the case? This chapter develops a potential explanation suggested by Eamon McCrory and Essi Viding in 2015 for why maltreatment-induced alterations to neurocognitive systems increase a person’s vulnerability to developing psychiatric disorders. According to their general approach, spectators visually code or classify angry faces as ‘threat cues’. This type of response makes sense in a hostile or abusive environment, because, in such an environment, angry faces are reliable indicators of an environmental threat. However, this chapter argues that in ordinary non-abusive environments, angry faces do not reliably indicate the presence of an environmental threat and that, for this reason, a person cannot visually identify another person as a threat on the basis of their facial expression.
The proper place of subjectivity, meaning, and folk psychology in psychiatry
Authors: McConnell Doug
Published: September 2020

‘The proper place of subjectivity, meaning, and folk psychology in psychiatry’ argues that Steven Hyman’s vision for psychiatry is excessively bioreductive. Hyman wrongly assumes that conceptual mental content is reducible to brain state descriptions and mistakes the neural vehicle of content for the content itself. Once we see that conceptual content, including the referents of folk psychology, shape brain activity, it becomes clear that content itself (or a lack of it) can be pathological. Therefore, treatment will sometimes be effective, even curative, by addressing that content through discursive interaction with the patient qua person. Diagnosis and effective treatment of mental disorders cannot just focus on neurobiology, as Hyman claims, both processes must also consider conceptual content and the complex interactions between content and the neurobiology instantiating it.
The biopsychosocial model, DSM, and neurobiology
Authors: Ghaemi S. Nassir
Published: September 2020

This chapter explores the need for a new approach in psychiatry other than the biopsychosocial (BPS) model, the Diagnostic and Statistical Manual of Mental Disorders (DSM), and neurobiology. Pierre Loebel and Julian Savulescu, in their introduction to this book, laid out an honourable purpose, seeking to make sense of psychiatric conditions holistically. They hoped the BPS model could serve this purpose. The model has done so in part, but also, after half a century of effort, it has failed to do so in the end. The goals are worthy and the seekers of those goals have integrity. But perhaps their intentions will be best served by something else, a successor to the past BPS model, built on a rejection of a false DSM diagnostic system as well as a purely neurobiological approach to research. In the end, what Loebel and his colleagues want to do is to preserve a place for humanism in psychiatry, and to link clinical practice to solid scientific research. These laudable principles can be achieved only by a radical departure from the DSM-based neurobiological conventional wisdom of the present and the past.
How to adopt the biopsychosocial model
Authors: Roache Rebecca
Published: September 2020

This chapter focuses on how the biopsychosocial psychiatrist can most appropriately take account of the fact that mental illness has biological, psychological, and social aspects. Commitment to the biopsychosocial model should not involve an a priori acceptance of the view that mental illness always has biological, psychological, and social causes. Adopting the biopsychosocial model should involve recognizing that the understanding of any given mental illness may best be advanced by considering explanations at each of the biological, psychological, and social levels. Often, explanation at one of these levels may be more elucidating than explanations at the other levels, but considering all of them combined is likely to maximize one's understanding. Psychological and social explanations are not eliminable in favour of biological ones, largely because of the way that mental illnesses are conceived and diagnosed. Moreover, commitment to a biopsychosocial approach should not involve commitment to the view that treatment of mental illness should always involve interventions at every level. Which treatment is most effective in any given case—that is, whether a biological, a psychological, or a social approach—can best be decided empirically.
Specifying the best conception of the biopsychosocial model
Authors: McConnell Doug
Published: September 2020

‘Specifying the best conception of the biopsychosocial model’ builds on the themes developed in this volume by detailing the relationship between the biopsychosocial model and the aetiology, treatment, nosology, and constitution of mental disorders. It argues that, for the foreseeable future, we should expect all mental disorders to be caused by a conjunction of biological, psychological, and social factors. However, they are not necessarily most effectively treated by a conjunction of biological, psychological, and social interventions. The biopsychosocial model offers minimal guidance regarding how mental disorders are constituted or how they should be classified but it does rule out bioreductive approaches to these issues. Finally, the biopsychosocial model integrates biological, psychological, and social sciences with a concern for subjective experience, meaning, and values-based care, so it doesn’t just count against bioreductive approaches to psychiatry but all forms of scientific reductionism.
DNAR: To Resuscitate or Not to Resuscitate?
Authors: Biggs Hazel
Published: September 2020

‘Do not attempt resuscitation (DNAR)’ or ‘do not attempt cardiopulmonary resuscitation (DNACPR)’ orders have been regarded as the best way to ensure that patients are not resuscitated in clinically inappropriate circumstances, or against their wishes. However, the use of DNAR orders has become contentious in situations where individuals have not been informed or consulted before an order has been made, and recent legal cases have highlighted the need for good communication and record keeping. This chapter considers the legal and ethical issues associated with DNAR and DNACPR orders, including the rights of patients, ethical guidance and policies associated with their use, and regional and national variations in practices surrounding their use and implementation. After discussing evidence of misinterpretation and misunderstandings of the implications of such orders in clinical practice, which have an impact on patients’ autonomy and well-being, the chapter will conclude that compliance with ethical and professional guidance must be consistent and mandatory, and suggest the introduction of legal sanctions for non-compliance.
Adults Who Lack Capacity to Consent and Deprivation of Liberty
Authors: Bryden Daniele
Published: September 2020

The basic presumption of the Mental Capacity Act that an individual has capacity to make decisions regarding treatment is frequently challenged within intensive care practice where individuals are often incapacitated due to the nature of their condition or treatment for it. Because many conditions are life-threatening, treatment is frequently administered on the basis of an assumption that it provides an overall benefit to the person and that their interests are best served by preservation of life. There is now a statutory definition of best interests although factors in its determination can at times be opaque, which suggests a gradual move towards the US-based ‘substituted judgement’ test. An individual can be lawfully prevented from leaving the intensive care unit while receiving intensive care treatment provided that treatment is given in good faith and is materially the same as would be given to a person of sound mind with the same physical illness.
Promoting the Best Possible Death
Authors: Newdick Christopher , Danbury Christopher
Published: September 2020

What are the best interests of terminally ill patients in intensive care who lack capacity to decide for themselves? At what stage should their care be considered futile? Although this important question arises at a crucial moment in a person’s life, there is room for a considerable range of responses. What is the relevance, for example, of a belief in the sanctity of life, the likelihood that the patient will get better, the suffering and indignity caused by treatment, the wishes of patients and their relatives, or the interests of other needy patients? In the past, these difficulties were often quietly settled by doctors, guided, when possible, by patients and by their relatives. Now, when disagreement leads to dispute, the courts have been required to provide solutions of their own. In doing so, they grapple with the balance between the patient’s subjective beliefs and wishes (assisted by their relatives), and doctors’ experience of the challenges further treatment may cause the patient. We consider how the law and clinical practice have evolved and the framework of procedures and values within which these troubling cases should be considered.
Doing What’s Best
Authors: Austin Louise , Coggon John
Published: September 2020

This chapter explores whether controlled non-heart-beating organ donation (NHBOD) can be in the best interests of an intensive care patient who has expressed a wish to become an organ donor. It begins with an acknowledgment of the concerns health professionals may have about NHBOD before providing an analysis of medical law in the context of decision making and best interests. It concludes that the law’s interpretation of best interests means there will be some situations where NHBOD will be in the best interests of patients in intensive care. It also considers the lack of legal certainty regarding the necessary observation time between the cessation of heart beat and the commencement of organ retrieval.
Conflicts of Interest
Authors: Soni Neil , Lawson Andrew , Waldmann Carl
Published: September 2020

Definition of conflict of interest: ‘When an individual, a group of individuals or an organization has competing interests or loyalties.’ This simple definition has applications in most aspects of daily living, so it is unremarkable that in almost every aspect of the administration of healthcare it becomes a significant consideration. Identification or recognition of where a conflict of interest exists is not always easy. Once identified, in many if not most circumstances it necessitates compromise. In all cases the overall intention should not be subsumed by the interest of the individual or the organization. The two outstanding areas usually highlighted in medicine are those of nepotism in the job market and the interactions between medicine and industry. The former is allegedly of only historic interest due to rigorous, almost draconian, selection procedures. The latter has recently become both a recognized problem and the bête noire of the profession.
OSCE 2
Authors: Hersey Peter , O’Connor Laura , Sams Tom , Sturman Jon
Published: September 2020

Divided into 13 stations on professionalism, resuscitation, data, and equipment, OSCE 2 is mapped to the Fellowship of the Faculty of Intensive Care Medicine (FFICM) and Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) curricula. Structured to reflect the real exam, answers are accompanied by syllabus references for the FFICM and CoBaTrICE domains for self-assessment, along with further reading for self-assessment.
Genetic counselling
Authors: Elliott Perry , Lambiase Pier D. , Kumar Dhavendra
Published: September 2020

Genetic counselling is one of the major tools in managing inherited cardiac conditions (ICCs) including single gene disorders such as hypertrophic cardiomyopathy and long QT syndrome to multifactorial conditions such as coronary artery disease (CAD) and congenital heart disease (CHD). This chapter deals with genetic counselling for ICCs that are typically transmitted in a Mendelian fashion, for example cardiomyopathies, arrhythmias, Marfan syndrome, as well as inherited lipid disorders. Typically, a genetic counsellor works within a multidisciplinary team including cardiologists, clinical geneticists, nurses, social workers, and psychologists. This chapter covers the role of genetic counsellors, process, consent and confidentiality, communication, and outcomes.
Metabolic disease and neuromuscular disorders
Authors: Elliott Perry , Lambiase Pier D. , Kumar Dhavendra
Published: September 2020

This chapter covers metabolic diseases and neuromuscular disorders. A number of inherited neuromuscular disorders may manifest with cardiac symptoms or signs. This chapter covers the most common muscular dystrophies with prominent cardiac involvement (including Duchenne, Becker, myotonic dystrophy, Emery–Dreifuss muscular dystrophy (EDMD) 1 and EDMD2, and limb girdle muscular dystrophy 2I along with clinical presentation, family history, and investigations. The chapter then goes on to general issues in inherited metabolic diseases, and their associated cardiac features. Clinical features, diagnosis, and treatment are described for each example.
Pulmonary arterial hypertension
Authors: Elliott Perry , Lambiase Pier D. , Kumar Dhavendra
Published: September 2020

This chapter covers pulmonary hypertension (PH), including its definitions and classifications. Pulmonary arterial hypertension (PAH) is a pre-capillary form of PH, and its clinical features and signs are described. The 2019 updated clinical classification of PH is included, along with hereditable PAH, associated genetic mutations, and clinical screenings.
The heart and inherited haematological disorders
Authors: Elliott Perry , Lambiase Pier D. , Kumar Dhavendra
Published: September 2020

This chapter covers inherited haematological disorders. It explains the pathophysiology, genetics, and iron overload of thalassaemia; cardiac disease in both β‎ and α‎thalassaemia; the pathophysiology, genetics, and iron overload in haemochromatosis; the evaluation of patients; and finally the management of patients at risk of cardiac iron overload.
The descriptive epidemiology of rheumatoid arthritis
Authors: Gwinnutt James , Symmons Deborah
Published: September 2020

This chapter describes the incidence, prevalence, and mortality of rheumatoid arthritis (RA) in adult populations around the world. Studies can only be compared if they have used the same case definition. The characteristics of the 1987 American College of Rheumatology (ACR) and the 2010 ACR/European League against Rheumatism (EULAR) classification criteria sets are discussed. In recent times several epidemiological studies have been set in large healthcare databases and have used physician diagnosis together with disease-modifying antirheumatic drugs (DMARD) prescription as the case definition. Most incidence and prevalence data on RA come from North America and Europe. Considerable insight into the relative frequency of RA has come from modelling studies in the Global Burden of Disease project 2010. The occurrence of RA is highest in the Pima and some other Native American groups; and lowest in low- and middle-income countries of Africa, South and East Asia, and the Middle East. The mortality of RA is increased relative to the general population. The mortality is falling with time, but in parallel with falls in the general population.