RESEARCH at the Institute of Psychiatry by LondonGlobal

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Research: understand, prevent, cure.

                                  Institute of
                              Scientists and researchers who                                                                                                                                                                                                                                                 Alcohol addiction                   4

                                                                                                                                What’s in a brain?
                                                                                                                                                     The human brain is probably the most                  The number of cells is just the start of the   a protein. So when we say ‘the gene for the
                                                                                                                                                     complex structure in the known universe.           complexity of the brain. Not only are there       D1 dopamine receptor,’ what we really mean
                              work at the Institute of Psychiatry                                                                                    That is why understanding brain function
                                                                                                                                                     – and brain dysfunction – presents such
                                                                                                                                                                                                        billions of neurons, each neuron has as many
                                                                                                                                                                                                        as a thousand contacts with other neurons.
                                                                                                                                                                                                                                                          is ‘the bit of chromosomal DNA that carries the
                                                                                                                                                                                                                                                          instruction of how and when to make the D1
                                                                                                                                                                                                                                                                                                             Alzheimer’s disease                 6

                              (IoP) in south London are dedicated                                                                                    a challenge.
                                                                                                                                                        Perhaps the simplest concept to begin
                                                                                                                                                                                                        The result is a brain with computing power
                                                                                                                                                                                                        IBM can only dream of. Information is carried
                                                                                                                                                                                                                                                          receptor protein.’ Proteins vary enormously
                                                                                                                                                                                                                                                          in their function: they include enzymes
                                                                                                                                                                                                                                                                                                             Antisocial behaviour                10

                              to finding out more about mental                                                                                       with is that the brain is composed of billions
                                                                                                                                                     of cells, each smaller than the full stop at the
                                                                                                                                                                                                        by axons in the form of electrical signals,
                                                                                                                                                                                                        but the signals are not the same ‘electricity’
                                                                                                                                                                                                                                                          that assist in making (or inactivating) the
                                                                                                                                                                                                                                                          neurotransmitters, or in transmitting the
                                                                                                                                                                                                                                                                                                             Attention deficit
                                                                                                                                                                                                                                                                                                             hyperactivity disorder (ADHD)       14
                              health problems and diseases of                                                                                        end of this sentence. There are more types
                                                                                                                                                     of brain cells than we can even count, but
                                                                                                                                                                                                        that runs through a power socket. They
                                                                                                                                                                                                        take the form of a slower current carried by
                                                                                                                                                                                                                                                          signal from the synapse to the rest of the
                                                                                                                                                                                                                                                          neuron. Any problem with the gene is likely        Autism spectrum disorder            15
                              the brain.Their ultimate goal is to                                                                                    they all fall into one of two groups. They
                                                                                                                                                     are either neurons, the ‘communicating’
                                                                                                                                                                                                        electrically-charged sodium, potassium and
                                                                                                                                                                                                        calcium atoms: one reason why we need such
                                                                                                                                                                                                                                                          to transmit itself to the protein, which in turn
                                                                                                                                                                                                                                                          results in altered activity. Out of that emerges   Batten disease                      16
                              develop treatments and services                                                                                        cells, or glia, the ‘support’ cells. Two
                                                                                                                                                     types of glia – astrocytes and microglia
                                                                                                                                                                                                        substances in our diet. The contacts between
                                                                                                                                                                                                        neurons are called ‘synapses’. This is where
                                                                                                                                                                                                                                                          altered brain function. It is these changes that
                                                                                                                                                                                                                                                          probably ultimately explain the brain changes
                                                                                                                                                                                                                                                                                                             Chronic fatigue syndrome/ME         18
                                                                                                                                                     – are immensely important in the brain’s           the axon from one neuron connects with the        associated with disease. But as well as being
                              that can cure or dramatically                                                                                          response to injury and disease.                    next nerve cell to create neural networks or      the essence of the problem, these changes also
                                                                                                                                                                                                                                                                                                             Depression                          19
                                                                                                                                                        The neurons carry information around            ‘brain circuits’ that drive thought, emotion,     hold out the prospect for diagnosis. This is the
                              improve people’s quality of life, and                                                                                  the brain and beyond. For example, nerve           memory and all mental activity, and govern        concept of ‘biomarkers’ – detectable changes
                                                                                                                                                                                                                                                                                                             Eating disorders                    21
                                                                                                                                                     fibres (called ‘axons’) from neurons in the         all the physical activity of our bodies.          in proteins in blood or some other body fluid
                              to eventually prevent mental illness                                                                                   spinal cord have to reach all the way to the
                                                                                                                                                     toes in order to move muscles, or bring back
                                                                                                                                                                                                           As the electrical signal moving along
                                                                                                                                                                                                        an axon arrives at the synapse, it performs
                                                                                                                                                                                                                                                          that might allow us to measure otherwise
                                                                                                                                                                                                                                                          invisible disease processes.                       Epilepsy                            24
                              and brain disease from developing.                                                                                     sensations of touch, temperature or pain.
                                                                                                                                                     The brain is divided into different regions
                                                                                                                                                                                                        a complicated trick. The ‘electrical’ signal
                                                                                                                                                                                                        is converted into a ‘chemical’ signal. The
                                                                                                                                                                                                                                                             We already know that some mental illnesses
                                                                                                                                                                                                                                                          are partly caused by genes inherited from          Learning abilities                  26
                                                                                                                                                     (such as the cerebral cortex, the thalamus         chemical produced – a ‘neurotransmitter’          parents, and partly caused by environmental
                                                                                                                                                     and the hippocampus) with different                 – diffuses across the small gap that separates     factors such as stress, drug-taking or brain       Military health                     27
                              Many of them also work directly                                                                                        responsibilities and functions, and all
                                                                                                                                                     are connected by tracts of millions of
                                                                                                                                                                                                        the two neurons at the synapse, so causing
                                                                                                                                                                                                        the next neuron in the chain to ‘fire’, thus
                                                                                                                                                                                                                                                          injury. We are beginning to learn more about
                                                                                                                                                                                                                                                          epigenetic factors, chemical changes to the        Mobile phones                       30
                              with people who have mental ill                                                                                        such axons. The precision of this wiring
                                                                                                                                                     is what assures normal brain function, and
                                                                                                                                                                                                        propagating the signal. The receiving neuron
                                                                                                                                                                                                        in the synapse recognises the neurotransmitter
                                                                                                                                                                                                                                                          genes that do not change the genetic code
                                                                                                                                                                                                                                                          itself, but do influence how the code is
                                                                                                                                                                                                                                                                                                             Parkinson’s disease                 31
                              health and neurological disorders                                                                                      it is the loss of this precision that underlies
                                                                                                                                                     brain disease. Sometimes the dysfunction
                                                                                                                                                                                                        signal by means of ‘receptors’ on its surface.
                                                                                                                                                                                                        There are many different neurotransmitters
                                                                                                                                                                                                                                                          read, and can themselves be caused by
                                                                                                                                                                                                                                                          environmental factors, such as diet and
                                                                                                                                                                                                                                                                                                             Post traumatic stress disorder      32
                                                                                                                                                     is a subtle disruption of information flow,         (like dopamine and serotonin) used by             maternal care.
                              in clinics and wards run by South                                                                                      as in schizophrenia, autism or depression.         brain cells, each with their own receptors.          In the past, scientists relied on studying
                                                                                                                                                                                                                                                                                                             Psychosis                           35
                                                                                                                                                     Sometimes, however, the cause is the               Indeed, most neurotransmitters have               the anatomy of the brain to try to understand
                              London and Maudsley and King’s                                                                                         death of the neurons themselves, as
                                                                                                                                                     happens in neurodegenerative diseases.
                                                                                                                                                                                                        multiple different receptors – D1, D2,
                                                                                                                                                                                                        D3, and D4 for dopamine, for example
                                                                                                                                                                                                                                                          more about function and dysfunction. Today,
                                                                                                                                                                                                                                                          grasping its complexities is made easier thanks    Stigma                              38
                              College Hospital NHS Foundation                                                                                        Unlike tissues such as liver or skin, the
                                                                                                                                                     brain has a very limited capacity to replace
                                                                                                                                                                                                        – adding even more to the complexity.
                                                                                                                                                                                                           Brain cells, synapses, neurotransmitters,
                                                                                                                                                                                                                                                          to modern imaging technology that allows
                                                                                                                                                                                                                                                          us to literally see the brain in action, and       Stroke                              40
                              Trusts. In turn, many of these service                                                                                 lost cells. So once neurons are lost, they
                                                                                                                                                     are gone for ever. However, there is hope
                                                                                                                                                                                                        receptors, and indeed every element required
                                                                                                                                                                                                        to construct a human body, are made up
                                                                                                                                                                                                                                                          sophisticated machinery that can analyse
                                                                                                                                                                                                                                                          proteins and DNA. Finding out more about           Suicide                             41
                              users and their families participate                                                                                   that neural stem cells might provide a
                                                                                                                                                     therapy for neurodegenerative diseases
                                                                                                                                                                                                        of proteins. A third of all the proteins that
                                                                                                                                                                                                        contribute towards the whole are exclusive
                                                                                                                                                                                                                                                          how cells work at the most basic level while
                                                                                                                                                                                                                                                          at the same time learning about the role of        Teenage minds                       42
                              in the IoP’s research projects, some                                                                                   precisely because they can replace lost
                                                                                                                                                     brain cells.
                                                                                                                                                                                                        to the brain. A gene is essentially the set
                                                                                                                                                                                                        of instructions required for a cell to make
                                                                                                                                                                                                                                                          environmental factors takes us ever closer
                                                                                                                                                                                                                                                          to prevention and cure.I                           About the Institute of Psychiatry   44
                              of which are highlighted in the pages                                                                                                                                                                                                                                          Last word: the Dean                 46
                              of this publication.

                                          The contents of this report are not a
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                                          comprehensive list of the work carried
                                          out by the IoP: its portfolio also includes,
                                          for example, research into motor neurone
                                          disease, obsessive compulsive disorder,
                                                                                         Dennis Potokar/Science Photo Library

                                          personality disorder, the mental health
                                          needs of children who are adopted and
                                          fostered, amnesia, depersonalisation,
                                          the mental health of people with cancer
                                          and other physical illnesses, including
                                          chronic pain and insomnia.
                                          For information about all of the work                                                                                                                                                                                                                              The Institute of Psychiatry is a
                                          of the IoP, visit                                                                                                                                                                                                                                School of King’s College London.
                              4 | Alcohol addiction |                                                                                                                                                                                                                                                       | Alcohol addiction | 5

                                                                                                                                                                                 of panic attacks students experienced        teachers can be trained to deliver the              lessons. By measuring the drinking habits

                       Preventing teenage binge drinking                                                                                                                         went down and there was a positive
                                                                                                                                                                                 effect on truancy, and on shoplifting too.’
                                                                                                                                                                                   What’s more, the students really approve
                                                                                                                                                                                 of the programme. ‘The feedback has been
                                                                                                                                                                                                                              programme, or whether independent
                                                                                                                                                                                                                              professional psychologists and counsellors
                                                                                                                                                                                                                              are the only ones who can successfully lead
                                                                                                                                                                                                                              the two confidential group sessions. ‘Students
                                                                                                                                                                                                                                                                                  of all year 9s, the research team wants to
                                                                                                                                                                                                                                                                                  discover if targeting those at greatest risk
                                                                                                                                                                                                                                                                                  for alcohol misuse has a knock-on effect
                                                                                                                                                                                                                                                                                  on all pupils, including those with no
                                                                                                                                                                                 very positive,’ said Dr Conrod. ‘They        may not feel comfortable about being entirely       personality risk. They will also be
David Hoffman Photo Library

                                                                                                                                                                                 said they really liked thinking about        honest about their lifestyles with the same         monitoring behaviour at school and
                                                                                                                                                                                 how to have control, how to consider         person who has the job to enforce the school        academic performance to see if there
                                                                                                                                                                                 their actions, realising it was up to them   rules,’ said Dr Conrod. ‘On the other hand,         are any patterns or links to be made.
                                                                                                                                                                                 to make decisions, and that they have        only school staff can be available to work              The teachers are being trained at three-day
                                                                                                                                                                                 choices in how they behave. So the next      with students on a regular basis, and as            workshops, and then supervised by trained
                                                                                                                                                                                 step for us is to work out how to help       real-life situations arise.’                        therapists in practice sessions and ‘passed out’
                                                                                                                                                                                 every school deliver this programme,           Twenty-four schools in London have                before they run the real programme. The
                                                                                                                                                                                 in an effective and sustainable way.’         signed up to the new trial, called Adventure.       rules agreed are that anything confidential
                                                                                                                                                                                   The Preventure programme involves                                                              revealed in a session must stay confidential.
                                                                                                                                                                                 grouping young people with similar           ‘British youth are among                               ‘The schools we are working with are
                                                                                                                                                                                 personality traits together. Until now,      the heaviest drinkers and                           really enthusiastic,’ said Dr Conrod. ‘If
                                                                                                                                                                                 a qualified therapist has helped them         binge drinkers in Europe’                           this works, if the results are as good when
                                                                                                                                                                                 explore their personality and ways of                                                            teachers are delivering the programme,
                                                                                                                                                                                 coping with potentially problematic          The research team in Addictions at the IoP          we would feel extremely comfortable to
                                                                                                                                                                                 behaviour that arises as a result of the     is training teachers to deliver the programme       put a lot of pressure on the UK government
                                                                                                                                                                                 specific risk trait, including discussions    in 12 of them. The students in the other            to roll this out nationally.
                                                                                                                                                                                 of real-life experiences and possible        half will carry on receiving information               ‘British youth are among the heaviest
                                                                                                                                                                                 scenarios to encourage them to think         about the dangers of alcohol and advice             drinkers and binge drinkers in Europe.
                                                                                                                                                                                 about why they drink heavily or binge        about general coping strategies through             Yet the maturing adolescent brain is highly
                                                                                                                                                                                 drink. ‘We incorporate evidence-based        the national curriculum. In the schools where       vulnerable to the effects of alcohol. We
                                                                                                                                                                                 cognitive behavioural techniques used        the programme is being delivered, students are      know that the earlier the onset of alcohol
                                                                                                                                                                                 to treat depression, anxiety and ADHD        recruited on the basis of a simple questionnaire,   misuse, the more likely young people are
                                                                                                                                                                                 (attention deficit hyperactivity disorder),   developed to measure their personality traits.      to use other substances and engage in risky
                                                                                                                                                                                 and motivational interviewing,’ she said.    All year 9s in all participating schools will be    sexual behaviour. Of particular concern
                                                                                                                                                                                   Dr Conrod and her colleagues want to       followed up for two years, so the research team     is the strong relationship between early
                                                                                                                                                                                 find out if Preventure can be incorporated    can find out about the drinking behaviour            onset drinking and alcohol dependence
                                                                                                                                                                                 into secondary schools using existing staff   of those with risk traits, and compare what         in adulthood. It has been estimated that
                                                                                                                                                                                 resources rather than bringing in outside    happens to those who take part in a teacher-        we could potentially reduce the rate of adult
                                                                                                                                                                                 experts. An Action on Addiction-funded       led programme with what happens to those            alcohol dependence by 10 per cent for each
                                                                                                                                                                                 project now aims to discover whether         who attend classroom-based drug education           year that adolescent drinking is delayed.’I

                                                                                                                                                                                 Cutting down on alcohol before
                              Practical support and counselling to make
                              young people understand more about their
                                                                              These traits, she says, are the product
                                                                              of an interaction between genetic and
                                                                                                                                participated in the programme’s two
                                                                                                                                90-minute group sessions at school.
                                                                                                                                                                                 serious health problems take hold
                              personalities, and why they feel the urge to    environmental factors, which ‘converge              The trial has shown that those with the
                              behave in a certain way, can help them steer    during a critical period in adolescence           thrill-seeking trait who were given only                                                                                                          About one in four adults regularly exceeds the
                              themselves away from binge drinking and         to influence personality and behaviour.’           regular curriculum-based drugs education                                                                                                          UK government’s sensible drinking guidelines,
                              alcohol dependency.                               The Preventure programme targets young          were twice as likely to be binge drinking                                                                                                         yet regular and heavy consumption of alcohol
                                The school-based Preventure programme         people who are full of hopelessness, who          than their peers with the same personality                                                                                                        causes liver disease and contributes to strokes,
                              has been proven in two studies to cut down      are depression-prone and expect the worst         feature who had been randomly allocated                                                                                                           cancers, heart disease and mental health
                              on drinking and improve mental well-being       to happen; those who are full of anxiety,         to the programme 12 months previously.                                                                                                            problems. About 70 per cent of the people
                              in teenagers at risk of misusing alcohol        fearful, shy, and keep away from public           The research team continues to follow up                                                                                                          who visit accident and emergency departments
                              because of certain personality traits.          attention or anything that puts them centre       all the 800 14-year-olds who have participated                                                                                                    in England between midnight and 5am do so
                                ‘There has been a lot of research looking     stage; those who are the impulsive type,          in this trial to see what effect Preventure                                                                                                        because they have injuries or illnesses caused
                              at psychological risk factors for addiction,    for whom alcohol over-use is one of a spate       has had after two years. But the results a                                                                                                        as a result of alcohol consumption: excessive
                              concentrating on temperament and                of behavioural problems, who put no stops         year after the first wave of students joined                                                                                                       drinking contributes to violence and death.
                              personality,’ said Dr Patricia Conrod, an       on their behaviour; and those who are the         the programme show dramatic effects not                                                                                                               Now a £3.2 million programme of research,
                              Action on Addiction Research Fellow who         thrill-seeking type – not necessarily impulsive   only on their drinking habits, but also on                                                                                                        funded by the Department of Health, aims
                              developed and successfully evaluated the        but consistently looking for new and exciting     other mental health problems associated                                                                                                           to find the best way to help people who are
                              programme in Canada before joining the IoP.     experiences. The latter are those most likely     with the four personality traits. ‘The number                                                                                                     drinking too much cut down before serious
                                ‘We know there are four personality traits    to binge drink in early adolescence, she said,                                                                                                                                                      problems caused by alcohol take hold. SIPS
                              that are risk factors for alcohol misuse, and   and the most recent London-based trial of         ‘There are four personality                                                                                                                       (Alcohol Screening and Brief Intervention
                              that they are very strong predictors of who     Preventure is showing a ‘robust effect’ on this    traits that are risk factors                                                                                                                      Trailblazers Research Programme) is being
                              goes on to have problems in later life.’        harmful behaviour one year after teenagers        for alcohol misuse’                                                                                                                               led by Professor Colin Drummond here at
                                                                                                                                                                                                                                                                                                     continues over the page ¡
6 | Alcohol addiction |                           | Alzheimer’s disease |                                                                                                                                                                                                                                                               | Alzheimer’s disease | 7

                                                                                                                                                       Photofusion Picture Library
the IoP and its results will inform national                                                                                                                                         using techniques involved in ‘proteomics’,         advances in proteomics – something

                                                                                                                                                                                                                                                                                          Ronald Grant Archive
strategies designed to prevent the numerous                                                                                                                                          the name given to the study of proteins.           called isobaric tagging in the mass
health problems people who drink excessively                                                                                                                                           Working in collaboration with Proteome           spectrometer machine, for example,
can face as a result of misuse or dependency.                                                                                                                                        Sciences plc, which has its UK laboratory          is able to see 100 proteins and identify
   More than 2,600 people will be recruited                                                                                                                                          at the IoP, the research team used a               all of them.’
through GP surgeries, accident and emergency                                                                                                                                         proteomics technique called 2DGE                      Initially funded by the Alzheimer
departments and services that are part of the                                                                                                                                        (two dimensional gel electrophoresis),             Research Trust, the search for biomarkers
criminal justice system to allow the research                                                                                                                                        routinely used to analyse complex samples          in the blood has so far involved some 1,500
team to gauge how effective and acceptable                                                                                                                                            of proteins in blood or postmortem brain           volunteers who donated blood for analysis
different screening questionnaires – designed                                                                                                                                                                                            and regularly help the work of Professor
to spot those who are drinking in a potentially                                                                                                                                      ‘The search for biomarkers                         Lovestone’s team by participating in
harmful way – are. Staff working within these                                                                                                                                         has so far involved some                           research projects.
services will be asked for feedback on how                                                                                                                                           1,500 volunteers who donated                          Now European Commission funding
easy it is to incorporate these screening tools                                                                                                                                      blood for analysis’                                has widened the scope of the biomarker
into their everyday work.                                                                                                                                                                                                               work, and volunteers from six cities in
   Researchers will keep in touch with                                                                                                                                               tissue. Proteins are first separated horizontally   Europe are giving blood several times
the 2,600 participants for six months to                                                                                                                                             by their electric charge, then vertically by       a year. Some volunteers are also having
find out whether their drinking patterns                                                                                                                                              their size or molecular weight. The resulting      regular brain scans so researchers can
have changed after receiving advice and                                                                                                                                              patterns of protein ‘spots’ were stained to        correlate what the candidate proteins
information about the dangers of alcohol                                                                                                                                             allow researchers to compare the patterns          are doing in the blood with what’s
consumption, or support designed to                                                                                                                                                  in the blood of those with Alzheimer’s             happening inside the brain as the
motivate them. They will be testing                                                                                                                                                  and those without. ‘This comparison                disease progresses.
different ways of offering help to find                                                                                                                                                 showed that on the simplest level there               AddNeuroMed is the name of this
out which ones work best: one method                                                                                                                                                 were differences in the amount of certain           pan-European project, led by King’s
is to give people How much is too much?,
a Department of Health publication
containing information and advice
                                                  Canblood revealwhat’s                                                                                                              proteins in the blood of people with
                                                                                                                                                                                     Alzheimer’s and healthy people,’
                                                                                                                                                                                     said Professor Lovestone.
                                                                                                                                                                                                                                        College London, and one of two pilot
                                                                                                                                                                                                                                        projects funded under the umbrella of
                                                                                                                                                                                                                                        the European Commission’s Innovative

                                                  happening in thebrain?
on sensible drinking. Another way is                                                                                                                                                    The task then was to try to identify            Medicine Initiative. This initiative brings
to supplement this leaflet by training                                                                                                                                                which ‘spot’ represented which protein.            together pharmaceutical companies,
                                                                                                                                                                                     To do this, the proteins were effectively           academic institutions and private enterprises
‘We aim to recommend the most                                                                                                                                                        ‘weighed’ in a mass spectrometer machine.          – including Proteome Sciences plc – from
cost-effective method of helping                                                                                                                                                     Identification is possible because each amino       across Europe. The aim of AddNeuroMed
people who are drinking in a                      Imagine a blood test for Alzheimer’s disease.     proteins in the blood can indicate whether                                       acid involved in a protein has a unique mass.      is to look for biomarkers in Alzheimer’s
hazardous or harmful way’                         One that could be used for diagnosis, but         a person has Alzheimer’s or not. At the                                             As a result, the research team now              that in future can lead to the development
                                                  perhaps more importantly, could tell doctors      moment, Alzheimer’s disease is detected by                                       has a panel of proteins that show up in            of more effective medication, but with the
health and criminal justice professionals         about the progress of the disease and inform      memory tests and brain scans, but a definite                                      abnormal amounts in the blood of people            help of a huge investment in technology
to work with individuals for five minutes,         treatment decisions; one that could be used       diagnosis can only be given at postmortem.                                       with Alzheimer’s that could be important           to facilitate research and collaboration
giving them personal advice. A third              in trials to monitor the effect of new drugs;       Researchers think proteins have a central                                      in the progression of the disease. One             across countries. ‘The technology means
approach being evaluated in casualty              one that could even predict the likelihood        role to play in the development of Alzheimer’s                                   of these is CFH (complement factor H),             the research is much quicker and more
departments and criminal justice services         of the disease developing.                        disease. Our bodies manufacture thousands                                        a protein that is involved in the immune           effective,’ said Professor Lovestone,
– prisons, youth offending services and              It seems far-fetched that a vial of blood       of them, each made up of a sequence of amino                                     system, and researchers are now exploring          ‘and gives researchers in collaborating
probation services, for example – is a            could tell doctors what is happening in the                                                                                        its potential role in the creation of the          teams access to the same information
longer session of lifestyle counselling           brain, and therefore it was a ‘leap of faith’     ‘The research team now has                                                       plaques and tangles that develop in the            and sophisticated software that can
with a specialist Alcohol Health Worker,          when Professor Simon Lovestone and                a panel of proteins that show                                                    structure of the brain prior to the actual         analyse it.’                                                             Dame Judi Dench won critical acclaim
specially trained to help people change           his team started searching in the blood of        up in abnormal amounts in the                                                    death of cells.                                                                                                             for her portrayal of writer Iris Murdoch’s
their patterns of drinking.                       patients with Alzheimer’s for biomarkers          blood of people with Alzheimer’s’                                                   ‘What’s really interesting about this           ‘An investment in technology                                             journey into dementia in the film Iris.
  SIPS is being carried out in collaboration      – changes associated with disease – five                                                                                            discovery is that people with age-related          means the research is much                                               Dame Judi is a patron of both the
with the Universities of Newcastle and            years ago. It’s still very early days, but so     acids, each with crucial, different roles to play                                 macular degeneration (AMD) are more                quicker and more effective’                                              Alzheimer’s Society,
York, St George’s and Imperial College,           far it looks like Professor Lovestone’s hunch     almost everywhere – from building bones and                                      likely to get Alzheimer’s, and AMD is                                                                                       and the Alzheimer Research Trust,
University of London, and Alcohol                 was a good one, that the amount of certain        skin to regulating neural pathways. Scientists                                   associated with the genes responsible                 Looking for biomarkers of Alzheimer’s                       
Concern and its results will help shape                                                             have known for some time that two proteins                                       for producing CFH,’ said Professor                 is a big field of research around the world,                              Both charities provide information
the development and the implementation                                                              – tau and beta-amyloid – are involved in the                                     Lovestone. ‘AMD is a degenerative                  but the only other large-scale study collecting                          and advice, and support research.
of the government’s National Alcohol Harm                                                           creation of the ‘tangles’ and ‘plaques’ found                                    condition of the central retina and                detailed clinical and imaging information
Reduction Strategy in England. ‘We aim to         and...                                            in the brains of people with Alzheimer’s.                                        when you look into the eye, you see                as well as samples for biomarker analysis
be able to recommend to the government            The 10/66 Dementia Research Group                   The search for biomarkers in the                                               deposits of proteins there. One of those           is the USA-based Alzheimer’s Disease
the most cost-effective method of helping          is a network of scientists based around           blood will enable scientists to understand                                       proteins is beta-amyloid, the same protein         Neuroimaging Initiative, with which
people who are drinking in a hazardous or         the globe which is affiliated to Alzheimer’s      more about other proteins involved in the                                        that deposits on the outside of brain cells        the IoP-based team is in close contact.
harmful way,’ said Professor Drummond.            Disease International and co-ordinated by         progressive damage to the brain, leading                                         in Alzheimer’s, forming plaques.’                     ‘Most other people are looking in
  Previous research has shown that                Martin Prince, Professor of Epidemiological       ultimately, they hope, to the development                                           As well as investigating CFH, the               cerebrospinal fluid (CSF),’ said Professor
interventions like those being tested             Psychiatry at the IoP. The Group works to         of medication that can inhibit or prevent their                                  research team wants to try out different            Lovestone, ‘but we felt uncomfortable                                    and...
can make a difference, he said. ‘What              find out more about dementia in developing        destructive action and potentially reverse                                       proteomics techniques to analyse blood             about asking elderly, frail people to have                               According to the Dementia UK Report (February
SIPS will do is show how best to implement        countries, and has interviewed thousands          or improve the symptoms of the disease.                                          samples, techniques that could see and             a spinal tap to remove a sample of the                                   2007), commissioned by the Alzheimer’s Society
them into routine work in GP surgeries,           of older people in Cuba, Brazil, the Dominican      The first foray by the research team, based                                     identify many more proteins, much more             fluid on a regular basis. A spinal tap is,                                and prepared by the IoP and the London School
casualty departments and criminal justice         Republic, Venezuela, Mexico, Peru, Argentina,     in the MRC Centre for Neurodegeneration                                          quickly. ‘2DGE is very labour intensive            at best, uncomfortable, and it’s also costly                             of Economics and Political Science, there are
services in order to reach a large number         China and India. The researchers hope the         Research at the IoP, was to look for differences                                  and sees only the proteins that are more           because it has to be done in hospital. It                                nearly 420,000 people with Alzheimer’s disease
of people at risk from the effects of prolonged    results of their studies will inform policy and   in the blood of patients with Alzheimer’s                                        abundant in the blood,’ said Professor             was a bit of a leap of faith to look in the                              in the UK. These figures are forecast to increase
and excessive consumption of alcohol.’I           future service development around the world.      compared with the blood of healthy people,                                       Lovestone. ‘There has been a slew of               blood...but so far, it’s looking promising.’I                            dramatically over the next 50 years.
8 | Alzheimer’s disease |                                                                                                                                                                                                                                       | Alzheimer’s disease | 9

      Albert Smith had been a London black                                          ‘I had to lock him in then, and he would try to
      cab driver, like his father before him,
and his passion was the history of the capital.
He even wrote a book called Dictionary of City of
London Street Names, published in 1970 and still a
                                                                                 get out, stand at the door and pull at it for two
                                                                                 hours at a time. Sometimes he would wake up
                                                                                 in the middle of the night and try to go out, and
                                                                                 pull me out of bed.’
                                                                                                                                                                                       Untangling tau protein
point of reference on websites. ‘He first started                                   After three years, Vivienne tried working from
having problems when he was 63,’ says his wife                                   home, then two years later, gave up her job with                                                      The symptoms of Alzheimer’s disease               of known sites where phosphorylation
Vivienne. ‘He was vague, and kept repeating his                                  a specialist travel company that arranged trips                                                       are caused by the death of brain cells and        occurs on tau in Alzheimer’s up to 39.
words and his actions, and wasn’t really aware                                   for schools, in order to become a full-time carer.                                                    the synapses that connect them. In a quest           At the same time, the team has been
that he was doing it.’                                                              ‘Albert could become quite agitated and                                                            to find out why the cells die and cause the       looking for enzymes (or kinases) – proteins
                                                                                 needed to be supervised, even in the house,                                                           brain to atrophy, scientists are trying to        involved in the everyday workings of the
                                                 Photo courtesy Vivienne Smith
                                                                                 so I had to put locks on all the internal doors.                                                      discover what makes the characteristic            brain – that might be involved in the
                                                                                    ‘As the disease progressed, he didn’t know who                                                     ‘tangles’ and ‘plaques’ of Alzheimer’s form       abnormal build-up of phosphate.
                                                                                 I was, or who my daughters were. Sometimes he                                                         in and around the cells prior to their death.        Previous work from Dr Hanger’s laboratory
                                                                                 would say to me: “I think we should get married”.                                                       A team led by Dr Diane Hanger in                had already found that GSK3 was an enzyme
                                                                                    ‘In the last year he couldn’t speak at all. He                                                     the MRC Centre for Neurodegeneration              that appeared to add phosphate to tau at
                                                                                 became immobile, practically couldn’t walk,                                                           Research is concentrating on what happens         several different sites, but this latest piece
                                                                                 and was doubly incontinent. He lost so much                                                           to tau, the protein involved in the creation      of research also discovered that another
                                                                                 weight, because he lost the ability to know                                                           of tangles inside the cells.                      enzyme, CK1 (or casein kinase 1), could
                                                                                 when to swallow, so all his food had to be                                                                                                              also add phosphate in 33 places on tau.
                                                                                 puréed so it was safe to eat.                                                                         ‘Tangles in the brain are                            ‘These results confirmed the likely role
   Albert had to take early retirement from his                                     ‘I wanted to care for him because I loved                                                          created when an abnormal                          of CK1 as an important enzyme in the
job in traffic control in a London local authority                               him. Right at the beginning, you have no idea                                                         amount of phosphate becomes                       creation of tangles in Alzheimer’s,’ said
where he had worked for the previous decade                                      of what is ahead of you. I felt that I could cope                                                     attached to the protein tau’                      Dr Hanger. ‘Together, GSK3 and CK1 may
and Vivienne took him to their GP. ‘There was a                                  and I wanted to cope on my own. I cared for                                                                                                             be responsible for putting on the majority
degree of anxiety in Albert’s behaviour, and the                                 him with the help of my daughters for eight                                                              Thousands of different proteins – organic       of phosphate but it is likely that there will
GP gave him calming medication first of all and                                  years, and then had support from Social                                                               molecules made up of chains of amino acids        be other kinases involved and a combination
then suggested he go for further mental agility                                  Services, with a carer coming in for half                                                             – are involved in many different crucial roles     of enzymes makes the extra phosphate stick.’
tests. Eventually he was diagnosed. He stayed                                    a day here and there so I could get out. It                                                           in our bodies, and the code for making               Much of this research has involved the
on the calming medication, but if he was given                                   became more and more difficult at home,                                                               them all is stored in our genes. Plaques in       analysis of tau extracted from postmortem
too many, he would be in a semi-drugged state.                                   and eventually we found a nursing home                                                                Alzheimer’s are created when beta-amyloid         Alzheimer’s brains, donated by patients
   ‘His behaviour became more and more                                           that could care for him in a way that I wasn’t                                                        proteins behave abnormally, ‘sticking’ together   to the IoP-based MRC London Brain
strange. There came a time when it became                                        able to any more. The staff were caring and                                                           and forming clumps on the outside of brain        Bank for Neurodegenerative Disease.
obvious he could not go out unsupervised.                                        lovely and I was able to visit almost every day.                                                      cells. Tangles are created when an abnormal       The research team also worked with
If we went out together, it became more and                                         ‘During that last year, when he was in the                                                         amount of phosphate becomes attached to tau.      synthetic tau created in the laboratory:
more stressful. I would have to lead him and                                     home, his eyes never flickered when I came in,                                                           Phosphate is a chemical in the brain that      they added the candidates GSK3 and
hold on to him, otherwise he might approach                                      there was no recognition of me, he just looked.                                                       is needed for lots of everyday functioning.       CK1 and observed the phosphorylation
people and try to grab them or start speaking                                    But on the day he died, he gave me the most                                                           In healthy brains, it attaches in the right       of many of the sites they had identified
to them in an odd way. If he went out on his                                     precious gift. I was at his bedside and had been                                                      amount, when needed, to help tau hold             in the analysis of tau involved in
own, he went missing. There was one time                                         talking to him all that day, and I told him I loved                                                   the scaffold of a brain cell together. But         Alzheimer’s tangles.
on a very cold day in February when he went                                      him. And he put his mouth together in a kiss, and                                                     when too much phosphate becomes                      The work continues to uncover other
out without a coat, bus pass or money, about                                     gave me three kisses, one for me and one for                                                          attached, tau is no longer able to behave         enzymes and tau phosphorylation sites
midday, and didn’t come back. We had to ring                                     my two daughters, and I felt he knew who I was.’                                                      as it should, and the cell destabilises.          that may have a part to play. Each result
the police and eventually he was found at about                                     Albert died in 2007. He and Vivienne                                                                  Finding a way to stop the phosphate            is a small contribution to unlocking the

9pm on the other side of London.                                                 had been married for 41 years.                                                                        build up on tau might be a good treatment         mystery of cell death in Alzheimer’s and
                                                                                                                                                                                       for preventing or reversing some of the effects    in other disorders where tau forms tangles,
                                                                                                                                                                                       of Alzheimer’s, says Dr Hanger, but in order      such as progressive supranuclear palsy,
                                                                                                                                                                                       to do that, scientists need to understand why     and a step on the path to developing new,
and...                                                                                                                                                                                 the phosphate sticks when it shouldn’t.           more effective, targeted medication.
Sube Banerjee, Professor of Mental Health                                                                                                                                                 For some years, Dr Hanger’s team has
and Ageing, has been appointed to jointly                                                                                                                                              been looking for sites on the tau molecule        ‘It’s a small contribution
lead the development of the UK government’s                                                                                                                                            where the phosphate abnormally collects,          to unlocking the mystery
first ever strategy to improve dementia services                                                                                                                                       taken from brains affected by Alzheimer’s.         of cell death in Alzheimer’s’
in England, plans for which were unveiled by                                                                                                                                           As the proteomics technology available
Health Minister Ivan Lewis in August 2007. The                                                                                                                                         for scrutinising and analysing the 441              ‘If we can identify all the enzymes
strategy, to be announced in 2008, will include                                                                                                                                        amino acids in the tau chain has become           involved in putting the extra phosphate
ways of tackling the stigma associated with                                                                                                                                            more sophisticated, more sites have been          on tau, we could develop drugs that target
dementia which stops people seeking help;                                                                                                                                              identified. To find these sites, parts of tau       the right ones, and inhibit their action,’
ways of helping families recognise the early                                                                                                                                           affected by Alzheimer’s are ‘weighed’ in           said Dr Hanger. ‘These enzymes do
signs; a plan to enable early diagnosis and                                                                                                                                            a mass spectrometer machine to detect the         have a normal function though, so it

                                                                                                                                                                         Rehan Jamil
treatment by professionals; and a focus on                                                                                                                                             position of the phosphate along the chain.        will be important in future to develop
making sure people are offered high-quality                                                                                                                                            The latest piece of research, carried out in      inhibitors that may not necessarily
treatment and support, from diagnosis to the                                                                                                                                           collaboration with Proteome Sciences plc          knock them out altogether but perhaps
end of life. Professor Banerjee is working with                                                                                        A mass spectrometer machine                     and funded by the Medical Research                only dampen their action, so the tau
the Alzheimer’s Society and representatives                                                                                            in the laboratory of Proteome                   Council, the Alzheimer’s Society and              would no longer sit there as a tangle
from a range of professional bodies, service                                                                                           Sciences plc, based at the IoP,                 the Progressive Supranuclear Palsy                but get on with doing what it’s
providers and voluntary organisations.                                                                                                 ‘weighs’ proteins.                              Association, has brought the total number         supposed to do.’I
10 | Alzheimer’s disease |                           | Antisocial behaviour |                                                                                                                                                                                                                       | Antisocial behaviour | 11

                                                                                                                                                                         behaviour, lying and stealing – will continue     and which ones are set on a path towards            based in New Zealand keeps in touch with

Treating                                             Genes and events of                                                                                                 in this manner for the majority of their lives.
                                                                                                                                                                            The Dunedin boys who were convicted
                                                                                                                                                                         of violent crimes in their 20s were more
                                                                                                                                                                         likely to have been brought up in homes
                                                                                                                                                                                                                           antisocial adulthood.
                                                                                                                                                                                                                             Another analysis of the information
                                                                                                                                                                                                                           gathered from assessments of the Dunedin
                                                                                                                                                                                                                           men when they were aged 32 showed that
                                                                                                                                                                                                                                                                               them, and every time a follow-up takes place,
                                                                                                                                                                                                                                                                               they are flown home and spend a day being
                                                                                                                                                                                                                                                                               assessed by different groups of researchers.
                                                                                                                                                                                                                                                                               ‘There are lots of interviews, assessments

agitation                                            childhood can predict                                                                                               with harsh and inconsistent parenting.
                                                                                                                                                                         They were more likely to have had reading
                                                                                                                                                                         difficulties and symptoms of hyperactivity
                                                                                                                                                                                                                           family history can help clinicians predict
                                                                                                                                                                                                                           which children who behave in an antisocial
                                                                                                                                                                                                                           way when they are very young are likely to
                                                                                                                                                                                                                                                                               and tests,’ she said. ‘They come in and go
                                                                                                                                                                                                                                                                               from room to room, which are staffed by
                                                                                                                                                                                                                                                                               different research teams.’ Those behind

                                                     antisocial behaviour
                                                                                                                                                                         as children. They were more likely to have        go on and develop lifelong problems. The            bars are either escorted to the assessment
                                                                                                                                                                         been raised by a single parent, or a teenage      research team collected information from            venue, or sometimes researchers visit
Alzheimer’s disease not only causes the ability                                                                                                                          mother. As they reached their 30s, they           4,000 members of the 526 men’s families –           them in prison.
to remember, understand, communicate and                                                                                                                                 were more likely to be abusing alcohol,           parents, grandparents and siblings. Those              The Moffitt/Caspi team is now preparing
reason to decline. About a quarter of people                                                                                                                             have mental health problems, be violent           who had become persistently antisocial in           for the 2010 follow-up. This time their
with Alzheimer’s who live at home, and about                                                                                                                             towards their families and less supporting                                                            assessments will include a new set of
half who live in residential care, also have         One thousand men and women who turn               of the enzyme monoamine oxidase in                                of their children. As adults, they are more       ‘Lifelong antisocial behaviour has                  genetic measures – they want to compare
agitation, a cluster of symptoms that include        38 in 2010 have helped researchers find           the brain were more likely to develop                             likely to be in low-income, low-status jobs,      an impact on physical health too’                   the length of telomeres, stretches of DNA
anxiety, irritability, pacing, wandering, shouting   out about the biological and life causes of       antisocial personality traits if they were                        unemployed or homeless.                                                                               at the end of chromosomes that protect the
and aggression. These symptoms are very              antisocial behaviour since they were born.        maltreated during the first 10 years of life                          The most recent follow-up, when the            adulthood were more likely to have parents          genetic information that sustains a cell, and
distressing for both patients and their carers.      They are part of the Dunedin Multidisciplinary    – if they were rejected by their mothers,                         cohort was aged 32, showed too that lifelong      and grandparents who had been antisocial            stop the chromosome ends from fraying.
  Agitation has traditionally been treated           Health and Development Study which started        or suffered physical or sexual abuse, for                          antisocial behaviour has an impact on physical    themselves, who had had ADHD (attention             But each time the cell divides and the DNA
with tranquillisers, many of which have              in New Zealand in 1972, and they have given       example. The enzyme is responsible for                            health. In addition to problems associated with   deficit hyperactivity disorder), had been            replicates – to grow new skin, blood or bone,
unpleasant side effects. The Committee                information about their health, circumstances     maintaining a healthy balance of several                          heavy alcohol and drug use, the men who had       dependent on alcohol or drugs, and had              for example – the telomeres become shorter.
for the Safety of Medicines has now                  and lifestyles at regular intervals since then.   different neurotransmitters, including                             been consistently behaving in an antisocial       smoked. The research team found the                 When they are too short, the cell can no
warned about the increased incidence                   The information they share, along with          serotonin and dopamine, and is produced                           way since the age of five were more likely         worst prognosis of lifelong antisocial              longer divide and becomes inactive or dies.
of stroke when tranquillisers are given to           their family histories and samples of their       by the MAOA gene. Boys whose genes                                to be at risk for heart disease (high blood       behaviour could be predicted if both                Studies elsewhere have shown this process
patients with Alzheimer’s. ‘It is becoming           DNA, has helped different research teams           produced high levels of the enzyme were                           pressure, high cholesterol), more likely          biological parents and grandparents had             to be associated with cancer and ageing.
increasingly clear that tranquillisers are           based in the UK, Canada and New Zealand           unlikely to develop antisocial problems,                          to have sexually transmitted diseases,            drinking problems. ‘Family history may              ‘It’s not yet known if shorter telomeres are
not an adequate treatment for managing               to investigate the effects of nature and           even if they had similar experiences.                             gum disease, immune system problems               be an additional tool for predicting which          a sign of ageing, or contribute to the ageing
distressing behaviour in Alzheimer’s                 nurture on a plethora of health and                 The longitudinal study has confirmed                             and signs of precocious ageing. ‘Their            children will go on to develop a lifelong           process,’ said Professor Moffitt. ‘What we
patients, and their use is associated with           behaviour problems, from childhood                that antisocial behaviour is much more                            bodies are deteriorating at a faster rate         disorder,’ said Professor Moffitt.                    want to find out is if shorter telomeres are
serious potential side effects,’ said Rob             to adulthood. Here at the IoP, a team             common in boys, and that such behaviour                           than their peers,’ said Professor Moffitt.            The majority of the original 1,000 Dunedin        related to the stressful life experiences of the
Howard, Professor of Old Age Psychiatry              led by Professors Terrie Moffitt and                around the time they start primary school                            One of the problems for professionals          participants are still taking part in the study –   men with persistent antisocial behaviour,
and Psychopathology.                                 Avshalom Caspi, has concentrated                  can be a normal part of development. ‘Many                        designing interventions to steer children         even though 60 per cent have since emigrated        and whether they have something to do
  The search is on then for safer alternative        on antisocial behaviour, mental and               boys have problematic behaviour in early                          away from this sort of future is working          elsewhere. ‘They are now scattered all over         with the accelerated ageing we started
treatments: one candidate was donepezil,             general physical health.                          childhood,’ said Professor Moffitt, ‘but most                       out which ones will grow out of problems,         the world,’ said Professor Moffitt. A team            to see at age 32.’I
part of a family of drugs called cholinesterase        And over the years, the Moffitt/Caspi             settle into school and grow out of it as they are
inhibitors, an anti-dementia medication used         team has discovered genetic influences             socialised by teachers and peers.’ Adolescent
to slow down loss of mental ability in the early     and identified risk factors that exist in          bad behaviour – ‘teenage delinquency’ – can

                                                                                                                                                                         Neighbours’ role in next generation
stages of Alzheimer’s. But when a team of UK         childhood that can predict a life of crime        also be normal and end in early adulthood.
researchers led by Professor Howard carried          and multiple problems as an adult.                But a small group of children who start to
out a major Medical Research Council and               An early Dunedin study found that               display antisocial behaviour in childhood –
Alzheimer’s Society-funded trial, they found         boys whose genes produced low levels              aggression, violence, disobedience, reckless
that donepezil made no difference to the

                                                                                                                                                           Rehan Jamil
symptoms of agitation.
  They worked with almost 300 Alzheimer’s                                                                                                                                Where you live and what your neighbours           families were approached and asked to fill           to achieve a better understanding
patients with severe agitation, many of whom                                                                                                                             are like can be hugely influential on whether     in an anonymous questionnaire measuring             of how young people become involved
were in nursing homes. Doctors at eight                                                                                                                                  children develop antisocial behaviour.            ‘social cohesion’ – would they get involved         in crime.
clinical centres prescribed half of them                                                                                                                                   Professors Terrie Moffitt and Avshalom            in a campaign to save a local amenity?,                ‘It seems the willingness of neighbours
with 10mg of donepezil a day for 12 weeks,                                                                                                                               Caspi set up a second birth cohort with the       would they intervene to help stop trouble           in poorer areas to look out for each other
and gave the other half a placebo. There                                                                                                                                 support of the Medical Research Council           on the streets?, for example.                       and intervene when trouble arises can
was a small improvement in memory and                                                                                                                                    here in the UK in 1997, this time using twins        ‘We found the weaker the social cohesion,        have a potentially protective effect on
attention in those patients who took the                                                                                                                                 to help them study the role environment and       the more likely kids were to have antisocial        a child’s development,’ said Professor
donepezil, but there was no significant                                                                                                                                   genetic factors have in the development of        behaviour, regardless of their individual           Moffitt. ‘This is a significant relationship
difference between the effects of the placebo                                                                                                                              antisocial behaviour.                             circumstances, or of what was going on              in deprived neighbourhoods and policies
and the drug on the symptoms of agitation.                                                                                                                                 The Environment Risk Study is tracking          in their own homes and families,’ said              designed to build and enhance a community
‘Sadly, but importantly, our results show                                                                                                                                1,100 pairs of twins born in 1994 and 1995        Professor Moffitt.                                    could make a real difference.’
that while donepezil may improve memory                                                                                                                                  to a representative sample of families in            Strongly united neighbourhoods in                   The Environment Risk Study, run
and attention in some patients, it is not                                                                                                                                England and Wales – from the richest of the       deprived areas that share the same values           under the umbrella of the IoP-based
effective in the management of agitation,’                                                                                                                                rich to the poorest of the poor. Researchers      and supportive attitudes had lower levels           Twins Early Development Study (TEDS),
said Professor Howard.                                                                                                                                                   have visited them in their homes at age five,      of antisocial behaviour. But the analysis of        is assessing the participating twins at key
  ‘For severely agitated patients, we                                                                                                                                    seven and 10 – and are just finishing an           information collected from more affluent              times in the development of antisocial
desperately need to find treatments that                                                                                                                                  assessment at age 12.                             areas showed that social cohesion had no            behaviour – before and after they join
work. Improving cognition in Alzheimer’s                                                                                                                                   A recent study with colleagues at Harvard       effect on how children behaved.                      primary school, before and after they
patients is important, but there are often                                                                                                                               University in the USA looked at the effect of         The study was part of the Social Contexts        join secondary school, and then at 16
other neglected features of the disease.                                                                                                                                 neighbourhood attitudes on the behaviour          of Pathways in Crime (SCoPIC) Network,              and finally at 18. At each follow-up,
Research to provide effective and safe                                                                                                                                    of children in this sample. Twenty close          a five-year Economic and Social Research             the child’s behaviour is assessed with
treatments for agitation is a huge priority.’I                                                                                                                           neighbours of each of the participating           Council research programme which aims               the help of parents and teachers.I
12 | Antisocial behaviour |                                                                                                                                                                                                                                                                                     | Antisocial behaviour | 13

                                                                                                                                                                                                                                                                                                                                              Photofusion Picture Library
                                                                                                                                                                                   levels of criticism and hostility from their         had problems, and their parents were invited

Why improving parenting skills                                                                                                                                                     parents, for example.
                                                                                                                                                                                     In the early 1990s, inspired by parenting
                                                                                                                                                                                   programmes developed in the USA, Professor
                                                                                                                                                                                   Scott ran a controlled trial to see whether
                                                                                                                                                                                                                                        to join a group which met for three terms at
                                                                                                                                                                                                                                        their child’s school. In the first term, there
                                                                                                                                                                                                                                        was a relatively intensive 12-week Incredible
                                                                                                                                                                                                                                        Years programme; in the second term, the

can help children’s life chances                                                                                                                                                   a group parenting programme could make
                                                                                                                                                                                   a difference to antisocial behaviour in
                                                                                                                                                                                   children aged three to eight years. The
                                                                                                                                                                                   children involved had been referred to
                                                                                                                                                                                                                                        group work focused on how parents can help
                                                                                                                                                                                                                                        children to read; and the third term covered
                                                                                                                                                                                                                                        problem-solving and how to help resolve
                                                                                                                                                                                                                                        disputes without violence and aggression.
                                                                                                                                                                                   child and adolescent mental health services             ‘The group met for a total of 26 weeks and

                                                                                                                                                     Photofusion Picture Library
                                                                                                                                                                                   because their behaviour was so severe.               most parents stuck at it,’ said Professor Scott.
                                                                                                                                                                                   ‘They were completely disobedient at                 ‘Three-quarters came to the majority of
                                                                                                                                                                                   home, kicking and stealing, fighting, lying,          sessions – it was impressive how committed
                                                                                                                                                                                   refusing to go to bed, sticking compasses            they were.’ And once again, the trial proved
                                                                                                                                                                                   into people at school,’ said Professor Scott.        successful: parents felt more competent, their
                                                                                                                                                                                     The research team dubbed English accents           children’s antisocial behaviour decreased
                                                                                                                                                                                   onto one of The Incredible Years videotape           while concentration increased, and their
                                                                                                                                                                                   programmes developed by Carolyn Webster-             reading age went up by six months. ‘This
                                                                                                                                                                                   Stratton, Director of the Parenting Clinic           trial suggested again that an intervention
                                                                                                                                                                                   at the University of Washington, which had           with parents could improve a child’s life
                                                                                                                                                                                                                                        chances,’ he said. A five-year follow-up of
                                                                                                                                                                                   ‘SPOKES made parents feel more competent,            the group is currently being undertaken to
                                                                                                                                                                                   their children’s antisocial behaviour                see if the intervention has made a difference
                                                                                                                                                                                   decreased while concentration increased’             in the long term.
                                                                                                                                                                                                                                           Then came the UK government’s RESPECT           successful programmes that have been
                                                                                                                                                                                   proved highly successful in trials there. The        agenda, a cross-department strategy to             tried and tested.
                                                                                                                                                                                   group of parents met for two-hour weekly             tackle bad behaviour and nurture good,                The research arm of the Academy will
                                                                                                                                                                                   sessions over a period of three months: the          to work towards a society where antisocial         include four trials of interventions: family
                                                                                                                                                                                   programme covered play, praise and rewards,          activity is rare. Professor Scott joined the       therapy based at home for teenagers with
                                                                                                                                                                                   setting boundaries and handling misbehaviour.        RESPECT taskforce, and at the same time            antisocial behaviour; a wider trial of SPOKES;
                                                                                                                                                                                   Participating parents also discussed their own       started lobbying for the need for some sort        Fostering Changes, a support programme
                                                                                                                                                                                   child’s behaviour and were supported while           of parenting centre to promote evidence-           for foster parents developed by Professor
                                                                                                                                                                                   they practised alternative ways of managing it.      based interventions, and to make sure those        Scott’s team; and a programme developed
                                                                                                                                                                                   The therapists came from a range of disciplines      leading the programmes were well-trained.          to engage and help hard-to-reach families.
                                                                                                                                                                                   and were trained to lead the sessions.               ‘What we know from our studies is that             In addition, the research team will be looking
                                                                                                                                                                                     And at the end of the trial, the behaviour of      the skill of the practitioner working with
                                                                                                                                                                                   children of parents who had been part of the         the parents really counts,’ he said. ‘Having       ‘The aim is to help all parents raise
                                                                                                                                                                                   group had improved. ‘When we followed the            filmed group sessions during our research,          their children to be happy, healthy,
                                                                                                                                                                                   families up a year later, there were still gains,’   we discovered that the least skilled therapists    safe, ready to learn, and to make
                                                                                                                                                                                   said Professor Scott. ‘This was the first trial       had no effect at all, and possibly made the         a positive contribution to society’
                                                                                                                                                                                   in Europe of this kind of thing, carried out         children worse.’
                                                                                                                                                                                   by regular clinicians, not specialists, and it          His campaigning was successful: in January      at programmes already in use that have
                                                                                                                                                                                   worked. The programme had an effect on                2006, the then Department for Education            not yet been evaluated. The team will
Improving the skills of parents can make             individual families and the communities         the IoP who are part of the King’s Parenting                                  the competence of parents, and it was the            and Skills (now the Department for Children,       investigate what skills are needed by people
a real difference to the antisocial behaviour        in which they live. The Academy, officially       Unit. Both his research and his clinical                                      toughest and most difficult cases whose                Schools and Families) announced plans to set       working with parents, and find the best
of children. Research by Child and Adolescent        called the National Academy for Parenting       work at South London and Maudsley                                             behaviour improved the most.’                        up such a body and the consortium of King’s        possible training methods. And they will
Psychiatrist Professor Stephen Scott and             Practitioners, was launched at the end of       NHS Foundation Trust’s Conduct                                                  Next, the team members turned their minds          College London (the IoP), the Family and           develop ways of measuring parenting – both
colleagues has shown that the right programmes,      2007 and is a collaborative venture between     Problems Clinic and Adoption and                                              to the concept of early interventions – work         Parenting Institute, and Parenting UK              ‘good’ and ‘bad’ – and ways of gauging the
delivered by skilled practitioners, can help steer   the IoP at King’s, the Family and Parenting     Fostering Clinic led him to believe that                                      to address the behaviour of young children           successfully competed against other                success of professionals working in the field.
children away from the path that is likely to lead   Institute, and Parenting UK, an umbrella        evidence-based parenting interventions                                        before patterns became established and more          bids to take plans forward.                          In the longer term, the Academy plans
to a life of crime, unemployment and loneliness.     body that brings together organisations         were worth investing in, that they could                                      difficult to challenge. In addition to parenting          Over recent years, there has been a             to give parents the knowledge and support
   ‘Research in the IoP’s MRC Social, Genetic                                                        change behaviour patterns for the benefit                                      styles, risk factors identified for persistent        rapid increase in self-help books, reality         they need to bring up children in the best
                                                     ‘The new Parenting Academy will train
and Developmental Psychiatry (SGDP) Centre                                                           of the individual child and society.                                          antisocial behaviour throughout life include         TV programmes offering advice, government           way they can – through the media, through
                                                     professionals who work with parents and
by Professor Terrie Moffitt has discovered                                                               ‘Until about 20 years ago, treatment                                        lack of concentration and symptoms of                initiatives like SureStart, voluntary schemes      publications, through schools and through
                                                     develop and test support packages that
that children who display antisocial behaviour                                                       was always directed at the child,’ he                                         attention deficit hyperactivity disorder,             and support groups, all aimed at giving parents    health services. The aim is to help all parents
                                                     can really make a difference’
tend to carry on in the same way throughout                                                          said. ‘Various therapies were based on                                        and difficulties reading and learning at school.       the help they need to raise their children well.   raise their children to be happy, healthy,
life,’ he said. ‘There is a really high risk         providing services to parents. Professor        the thinking that there must be something                                       Working with Educational Psychologist              Professor Scott says much of this support          safe, ready to learn, and to make a positive
of offending, drugs, violent behaviour,               Scott is its research director and almost       deep inside the child, that you needed to                                     Professor Kathy Sylva at Oxford University,          is simply not effective in changing behaviour.      contribution to society, said Professor Scott.
limited and unsatisfactory relationships,            half the money is to be invested in research    get to the bottom of what that was. But these                                 another trial began, this time based in eight        The task of the Academy, based on the                All this, he said, makes economic sense
unemployment and social exclusion.’                  aimed at developing and trialling practical,    therapies didn’t seem to improve behaviour.’                                  primary schools in Lambeth in south London.          Strand in central London, is huge: to              too. Another study carried out by the King’s
   Now the government has invested                   easy-to-deliver programmes that really            Research at the SGDP Centre and elsewhere                                   The Supporting Parents on Kids Education in          reach organisations and individuals                Parenting Unit showed that the public cost
£10 million a year for three years to                work for families, including those that         has shown that temperament and genes                                          Schools (SPOKES) intervention was designed to        working with parents and disseminate               for individuals aged 28 who had displayed
launch a new Parenting Academy based                 are hard-to-reach, and foster families.         do play a part in antisocial behaviour.                                       improve parenting skills, antisocial behaviour,      information about programmes that are              antisocial behaviour when they were 10-
at King’s College London. Its remit is to              The foundations of the Academy                But studies have also illustrated that                                        concentration and reading ability. Teachers          proven to work. One of the plans is to             years-old is up to 10 times higher than for
train professionals who work with parents,           were laid nearly a decade ago by a series       family factors, and the way children are                                      and parents of children in reception class and       develop a very visible web presence,               their peers. The costs mount because of
and to develop and test support packages             of research projects carried out by Professor   brought up, play a major role: children with                                  year 1 were asked to fill in questionnaires to        an authoritative site for both practitioners       crime, extra educational provision, foster
that can really make a difference to both             Scott and the team of researchers based at      antisocial behaviour often live with high                                     help the research team identify children who         and parents, offering a seal of approval to         and residential care, and state benefits.I
14 | Attention deficit hyperactivity disorder (ADHD) |                                                                                                                                                                                                                                                                                | Autism spectrum disorder | 15

Missing link in the search for genes?                                                                                                                                      Separating the triad of autism traits
The search for specific genes that contribute to                                                                        he said, when cell replication and growth are      People are currently diagnosed with autism           Ronald and colleagues have already found a                                             who are able socially, but have rigid and

                                                                                                       Jenny Matthews
mental health problems has not been as fruitful                                                                         at their busiest during bursts of developmental    when they have a triad of traits – impaired          considerable number of children who have                                               repetitive behaviour.’
as some scientists expected when they first                                                                             change: gestation, puberty and menopause,          social ability, difficulties with communication,     difficulties in only one area of the autistic                                              The new Medical Research Council-funded
started to study the human genome. A new area                                                                           for example.                                       and restricted and repetitive behaviour. But         ‘triad.’ What’s more, the comparison of the                                            twin study seeks to find out more about the
of research is now exploring what makes genes                                                                             In ADHD then, previous research has              are all three characteristics inextricably linked?   development of identical and non-identical                                             causes of the triad’s individual traits as well
switch on and off: controlling mechanisms ‘above                                                                        shown children of mothers who smoke                Dr Francesca Happé thinks not: studies of people     TEDS twins when they were aged seven and                                               as their interaction in autism. Two hundred
the genome’ called epigenetic factors, which                                                                            and drink alcohol during pregnancy are             with autism and their relatives over almost two      eight suggests that, while each different aspect                                        of the participating families have at least one
determine the function and expression of the                                                                            more likely to develop the disorder.               decades have led her and her colleagues to           of the triad is highly heritable, separate genes                                       twin with a diagnosis on the autism spectrum.
genes. And one of the first studies in this field                                                                         Dr Mill is looking for different patterns         believe each of the three features of autism         contribute to each individual trait. ‘It looks                                         ‘We will be visiting families and interviewing
at the IoP will concentrate on changes to these                                                                         of DNA methylation in the brains of rats           are caused by largely independent genes, are         as if largely independent genetic influences                                            them about symptoms and current functioning,
controlling mechanisms in the womb that may                                                                             exposed to nicotine and alcohol pre-natally        associated with different brain regions and are      operate on the three different traits,’ said                                            asking about childhood illness and other health
make children more susceptible to developing                                                                            who then go on to develop symptoms of              related to different cognitive characteristics.      Dr Happé. ‘If this is correct, the search for                                          problems in order to identify environmental
attention deficit hyperactivity disorder (ADHD).                                                                        ADHD. Sophisticated techniques in the                 A Cognitive Psychologist, Dr Happé has                                                                                                   factors that may have played a part, and
  ‘In the past, we have concentrated on                                                                                 SGDP Centre’s laboratories allow researchers       spent some 20 years trying to work out               ‘Research suggests separate genes                                                      undertaking cognitive testing of the twins
looking for specific genes and how they                                                                                  to study samples of DNA and analyse patterns       why people with autism view the world                contribute to each individual trait’                                                   to look for different psychological processes
interact with environmental factors in                                                                                  of DNA methylation across the genome.              so differently. ‘People with autism have                                                                                                     that underpin the triad traits.’
our search for the causes of mental health                                                                                This research is being carried out in            striking social difficulties,’ she said. ‘They find     genes “for” autism may be far less effective                                              The TEDS twins are now aged between 12
problems. While this research has produced                                                                              collaboration with colleagues at the IoP, and      it hard to recognise other people’s thoughts and     than searching for genes affecting, for example,                                        and 14. ‘Because we have information about
some interesting findings, we are still a long                                                                           in Brazil and Norway. Dr Mill is planning to       feelings. At the same time, they have superior       social skills specifically, or those contributing                                       them that families and teachers gave when
way from discovering those causes,’ said Dr                                                                                                                                cognitive processing in terms of eye for detail.     to rigid and repetitive traits.’                                                       they were younger, we will be able to check
Jonathan Mill, who heads a new team in the                                                                              ‘Children of mothers who smoke                     We have been looking at the underlying causes          This conclusion has been supported by                                                back for precursors to the development of
MRC Social, Genetic and Developmental                                                                                   and drink alcohol during pregnancy                 of these different aspects of autism, searching       other studies that illustrate how individual                                           the characteristics during the early years,’
Psychiatry (SGDP) Centre which is dedicated                                                                             are more likely to develop ADHD’                   for a parsimonious explanation, but try as           traits run in families of people with autism –                                         she said. The researchers will eventually
to epigenetic studies of psychiatric disease.                                                                                                                              we might, we have been unable to find one.’           close family members often share just one of                                           use the information they gather to help
The DNA sequence is in fact very stable,                                                                                expand this line of study to look at the effects       So instead of continuing to search for a          the triad of traits, to a lesser or greater degree.                                    search for genetic, environmental and
he said, and neither it, nor environmental                                                                              of diet and toxins on DNA methylation during       single cause of autism, they are now trying          ‘Many fathers of children with autism in                                               cognitive influences underlying each
influences, simply explain behavioural                                                                                   gestation and the development of not just          to understand more about what causes the             particular show the same sort of focus on detail,                                      of the individual features.
differences between individuals: ‘you                                                                                    ADHD, but also other psychiatric illnesses.        three individual characteristics, and why            rather than the bigger picture,’ she said, ‘and                                          ‘What we want to do is to understand
can often find identical twins, who share                                                                                  It’s still early days, and all the research is   they co-occur. To this end, Dr Happé and             social difficulties can also be found in family                                          how the triad hangs together in autism,’
exactly the same genes, who are raised in                                                                               currently being carried out with rats. At the      her IoP colleague Professor Patrick Bolton           members who may not show an eye for detail.’                                           she said. ‘Most importantly, as we abandon
a similar way, but who have real differences                                                                             moment, they are searching for changes to          have launched the largest ever community-              If the theory is correct, she says, many                                             the search for a single cause for autism
in behaviour and development,’ he said.             tumours growing have been suppressed                                the epigenetic profile in brain cells, but it may   based twin study of the autism spectrum              individuals may possess one characteristic                                             and increase our understanding of the
‘One may have ADHD for example, and                 because they have been over-methylated.                             be that different patterns of DNA methylation       with the help of 300 families who are part           of the triad, but do not meet the diagnostic                                           three distinct characteristics, we may
the other may not.’                                 The products of other genes that promote                            could be detected in other tissues. If changes     of the IoP-based Twins Early Development             criteria for autism. ‘There may be people                                              need to abandon the search for a single
  Our epigenetic profile – factors that              tumour growth have been over-expressed                              were detectable in blood, for example,             Study (TEDS). Using information gathered             who have pretty poor social skills, but have                                           “cure” for autism, and instead tackle the
essentially tell genes to stop or go – could        as a result of under-methylation.                                   researchers could then easily measure              from TEDS families, Dr Happé, Dr Angelica            no problems with communication, or people                                              individual traits of the triad.’I
be the missing link in the quest to understand         So the question Dr Mill and others working                       epigenetic differences in humans.

why the same set of genes lead to mental illness    in this emerging arena want to answer is: what                        Proving that smoking and drinking

                                                                                                                                                                                                                                                                                      Photos courtesy of Angie Perks
in one person and not in another. ‘We want to       influences the DNA methylation? It seems that                        during pregnancy changes DNA methylation                  When I found out I was pregnant in                                                                                                     ‘Thomas goes to a really good special
find out how and why factors controlling gene        lifestyle and life circumstances are crucial.                       and gene expression to make children more                 1998, I was over the moon,’ says Angie                                                                                               school and they write me a letter every
expression are influenced by the environment,’          ‘We think that epigenetic factors like DNA                       vulnerable to developing ADHD would have           Perks. ‘Then I had a scan, which confirmed                                                                                                  day to say what he’s done as he can’t tell
he said.                                            methylation can be changed by both the                              a clearly preventative benefit, he said. But        that I was having twins. At 37 weeks, I gave                                                                                                me. He loves his routine and he stays in
                                                    environment and random events in cells,’ he                         in future, if epigenetic factors are proven to     birth by C-section to Kylie, who weighed                                                                                                    his room for hours and hours. Kylie is his
‘Our epigenetic profile could be                     said. ‘So we think things like diet, medication,                    be instrumental in the whys and wherefores         5lb 9oz, and then Thomas who was 6lb 3oz.                                                                                                   big sister and always will be. When other
the missing link in the quest to                    hormones and radiation, for example, can                            of the development of an illness, scientists          ‘By 14 months, Kylie was walking and talking.                                                                                            children ask her about her brother,
understand why the same set                         affect the amount of DNA methylation and                             could potentially develop ways of altering         At 18 months, Thomas finally began to walk,                                                                                                 she tells them he’s got autism and
of genes lead to mental illness                     the physical structure of the chromosomes.’                         the DNA methylation process and re-adjusting       but he never played with his twin sister and                                                                                                what that means. Children can be
in one person and not in another’                   Psychosocial factors also have a part to play:                      gene expression to help prevent or cure            wasn’t talking, so I asked my health visitor,                                                                                               cruel, and if they don’t understand,
                                                    one Canadian study showed that young rats                           psychiatric problems.                              who was also concerned about him. She                                                                                                       she doesn’t want to know them.
  DNA methylation is a chemical modification         who weren’t cared for affectionately by their                          Scientists also think it’s possible that         got in contact with the Child Development            what the symptoms were. After an assessment                                              ‘People don’t realise they are twins
process that regulates the expression of genes      mothers had altered DNA methylation around                          epigenetic profiles can be passed down              Centre and a lady came to see us. Penny              at hospital, Thomas was diagnosed with severe                                          because they are nothing alike at all. They
throughout life by attracting methyl-binding        genes linked to coping with stress.                                 through the generations, that parental             came to our house to watch Thomas.                   autism. The twins are now nine, and Thomas                                             look different and they have completely
proteins that alter the physical structure of          ‘We also think that once DNA has been                            methylation marks may be inherited by              I remember he was sat on the floor lining            is still non-verbal and still in nappies. He can                                       different personalities. I used to be really
the genome. Epigeneticists think that too           epigenetically modified, these changes are                           their children or grandchildren. ‘If that          his bricks in a row and making sounds. She           be destructive and it is sometimes hard                                                upset at the stares that Thomas would get,
much or too little DNA methylation, along           passed on in the body as cells replicate. So                        were the case, it would shatter existing ideas     sat writing in her book, then she looked at          work looking after him and making sure                                                 but now I just take no notice. People just
with other changes that affect the structure         if changes occur in the womb, for example,                          about inheritance,’ said Dr Mill. ‘If you could    us and said, “I think Thomas may have autism.”       Kylie doesn’t lose out. My mum helps a lot                                             see him as a naughty boy. They really
of the chromosomes, can lead to long-term           gene expression may be altered for the rest                         inherit a change in gene expression caused         I actually had an idea that she might say that       and Kylie has now started going dancing                                                don’t understand about autism, and

changes in gene expression.                         of your life and make you more susceptible                          by the environment independently of the DNA        as I had looked on the internet and came             and has some shows coming up, though                                                   they certainly don’t understand why
  Epigenetic research in the field of cancer         to developing certain illnesses, even though                        sequence, it would mean the environment            across this website which explained to me            Thomas won’t be able to sit through them.                                              one twin can have it and the other not.
has shown, for example, that genes that             the genetic sequence itself is not mutated.’                        of one generation could affect the health
produce proteins whose job it is to stop            Epigenetic changes are most likely to occur,                        of future offspring.’I                              The National Autistic Society, provides information and advice about autism and supports research.
16 | Batten disease |                                                                                                                                                                                                                                                                              | Batten disease | 17

                                                                                                                                                                 know what the proteins made by these                which control the environment around brain        enzymes in the lysosomes; that would

Brains yield clues in the quest                                                                                                                                  genes should normally do, let alone what
                                                                                                                                                                 happens when they go wrong,’ said Dr Cooper.
                                                                                                                                                                 One study with colleagues elsewhere in King’s
                                                                                                                                                                 College London is using fruit flies to investigate
                                                                                                                                                                                                                     cells, become active particularly early and we
                                                                                                                                                                                                                     are working to understand if this is a positive
                                                                                                                                                                                                                     or negative event,’ he said. And working with
                                                                                                                                                                                                                     colleagues at the University of Rochester in
                                                                                                                                                                                                                                                                       give a new copy of the faulty genes; or
                                                                                                                                                                                                                                                                       that would break down the build-up of
                                                                                                                                                                                                                                                                       waste material in the cells. But for any
                                                                                                                                                                                                                                                                       of these treatments to be successful,

to find a cure for Batten disease                                                                                                                                what the CLN3 protein normally does in the
                                                                                                                                                                 brain. ‘We can do simple but powerful genetic
                                                                                                                                                                 tricks in these fruit flies to help answer this
                                                                                                                                                                 mystery,’ said Dr Cooper.
                                                                                                                                                                                                                     the US, the PSDL has shown that there is an
                                                                                                                                                                                                                     autoimmune response in one form of Batten
                                                                                                                                                                                                                     disease. Numerous types of autoantibodies –
                                                                                                                                                                                                                                                                       scientists must first understand the
                                                                                                                                                                                                                                                                       nature of the neurodegeneration.
                                                                                                                                                                                                                                                                          ‘By finding out about the processes
                                                                                                                                                                                                                                                                       inside the brain in each form of Batten
                                                                                                                                                                    In the PSDL, the research team is studying       ‘One in every 7,000 children will                 disease, we now have landmarks to

                                                                                                                                                   Rehan Jamil
                                                                                                                                                                 the brains of sheep, another species that           have one of these genetic diseases.               measure how successful new treatments
                                                                                                                                                                 naturally gets Batten disease. ‘We have             At the moment, there is no known                  are by studying the effect they have –
                                                                                                                                                                 found out that some brain cells are far             cure for most of them’                            do they slow things down, or even stop
                                                                                                                                                                 more vulnerable than others,’ he said.                                                                them?,’ said Dr Cooper. ‘All the new
                                                                                                                                                                 ‘It seems immune responses within the               that instead of protecting against infection      information we are finding out is telling
                                                                                                                                                                 brain that start long before brain cells            can attack – have been found in brains            us a great deal about how the disease
                                                                                                                                                                 start to die are important, and it is also          affected by the juvenile disease, getting          attacks the brain and will help us to
                                                                                                                                                                 clear that the synapses, through which              in through a leaky blood-brain barrier.           target therapies to where they can be
                                                                                                                                                                 brain cells talk to one another, are also           ‘If these autoantibodies directly contribute      most effective in halting the relentless
                                                                                                                                                                 targeted early in the disease, and are              to the disease, this could be something we        progress of the disease.’
                                                                                                                                                                 re-arranged before they too are lost.’              could block,’ he said.                               The PSDL also work closely with
                                                                                                                                                                    The researchers have discovered that                All this work involves painstaking study       charities that support families of children
                                                                                                                                                                 most forms of the disease start deep inside         of sections of brains affected by Batten           with Batten disease – the Batten Disease
                                                                                                                                                                 the brain, rather than on its surface in the        disease in order to yield clues about the         Family Association (BDFA) here in the
                                                                                                                                                                 cortex. ‘Although the cortex is severely            early stages of the disease that are vital        UK and the Batten Disease Research
                                                                                                                                                                 affected by the end of the disease, we have          for developing treatments.                        and Support Association in America.
                                                                                                                                                                 found that the neurons start dying in the              Transplanting human neural stem cells          Both charities have given financial
                                                                                                                                                                 thalamus, right in the middle of the brain,’        is one hypothetical treatment: either to          support to the PSDL’s work, and Dr
                                                                                                                                                                 said Dr Cooper. ‘The thalamus is like               replace dying neurons or to be a source of        Cooper is an advisor to, and sometimes
                                                                                                                                                                 a general post office where information               enzymes that are missing in some forms of         spokesperson for, the BDFA. Keeping
                                                                                                                                                                 of all kinds is sorted. It receives this            NCL. The PSDL has been involved with the          families informed of progress in research
                                                                                                                                                                 information and sends it to the right               work leading up to the first clinical trial of     is a high priority for him and the laboratory
                                                                                                                                                                 places. We’ve discovered that the thalamus          human stem cell treatment for infantile and       organises regular open days for these families.
                                                                                                                                                                 is the epicentre of the disease – so it’s a bit     late infantile Batten disease, now being             ‘Sadly, a diagnosis of Batten disease
                                                                                                                                                                 like an earthquake spreading upwards to             carried out at Oregon Health and Science          is currently a death sentence,’ he said.
                                                                                                                                                                 the cortex.’ The PSDL team has found too            University in collaboration with Stem Cells       ‘I hope we are gradually moving towards
                                                                                                                                                                 that glial cells in the brain seem to play an       Inc in the USA. Other research is focusing        the day when these children will get the
                                                                                                                                                                 important role. ‘Star-shaped astrocytes,            on treatments that would replace missing          chance to have a future.’I

                                                                                                                                                                                                                                                                                                                         Photofusion Picture Library
At least 10 children born in Britain every      disease have no symptoms at all until          role of genes and the proteins they produce,
year will be diagnosed with Batten disease.     they are aged between five and nine but         and others work to develop therapies, the
These children will become blind, have          will die at any time between late teenage      PSDL is concerned with what happens
seizures that become increasingly more          years and early adulthood.                     inside the brain.
severe, lose the ability to walk, speak                                                           ‘For a long time, people thought the
and feed themselves and will then die.          ‘Painstaking study of sections of brains       waste build-up inside the cells was the
Scientists have known for some time             affected by Batten disease yields clues        key to understanding the disease,’ said
that inheriting two mutated genes from          about the early stage of the disease           Dr Cooper. ‘Our work has led us to believe
parents who are carriers prompts the            that are vital for developing treatments’      this is really a by-product of Batten disease
progressive deterioration of the brain                                                         and there are other, more crucial events,
and nervous system. But they still don’t          There are at least 50 other similar rare     that happen within the brain. These events
fully understand what effect the mutations      disorders where lysosomes malfunction          may be different in each form of NCL.’
in these genes have, and how this causes        and fill with waste products: altogether,          For many years, scientists have known very
the devastating symptoms.                       one in every 7,000 children will have one      little else about Batten disease except that it
   Batten disease, or neuronal ceroid           of these genetic diseases. At the moment,      is inherited, that waste material collects inside
lipofuscinosis (NCL), is a collective name      there is no known cure for most of them,       cells, that the brain progressively shrinks as
for at least 10 different disorders in which     and research teams around the world are        neurons die, and that the retina degenerates,
the lysosomes, tiny waste disposal units        working together to understand more about      leading to blindness. Even though separate
inside every cell, stop working. As a result,   the process of the diseases, and to develop    genes have been identified for most types
the cells become full of waste material and     treatments that can save children’s lives.     of Batten disease, some of them still remain
then die. The many types of NCL are all           One of those teams is based at the           a mystery. There are two types of Batten
genetically different, have similar symptoms,    IoP: the Paediatric Storage Disorders          disease genes – one sort that should make
and start at different ages. Infantile Batten    Laboratory (PSDL) is in the MRC Centre         an enzyme to consume the waste material
disease, for example, starts when a child is    for Neurodegeneration Research and the         inside the lysosomes, and others whose roles
between six months and two years old: a         dedicated, newly-equipped, state-of-the-art    remain unknown. These include CLN3,
diagnosis means inevitable death in mid-        facility is led by Dr Jon Cooper. While some   the mutated version of which leads to the
childhood. Children with juvenile Batten        research teams are trying to understand the    juvenile type of Batten disease. ‘We don’t                        The Batten Disease Family Association website is at
18 | Chronic fatigue syndrome/ME |                                                                                                                                                                      | Depression | 19

                                                                                                                                                           Rehan Jamil
Developing and testing sometimes                                                                                                                                         Those with
controversial treatmentprogrammes                                                                                                                                        stressful
People with chronic fatigue syndrome (CFS)/ME
(myalgic encephalomyelitis) are often ill for
                                                     Unit based at the IoP, jointly run with King’s
                                                     College Hospital, and headed by Professor
                                                                                                          evidence that showed CBT and GET –
                                                                                                          involving an individually-designed home
                                                                                                                                                                         jobs more
a very long time. In addition to the chronic,
disabling fatigue, symptoms can include
headaches, short-term memory problems,
pain in the joints, disturbed sleep and difficulty
                                                     Trudie Chalder, who says she thinks people’s
                                                     beliefs may have an important part to play
                                                     in the recovery process. ‘No-one knows
                                                     what causes CFS/ME, though we do think
                                                                                                          exercise programme – to be beneficial,
                                                                                                          but insufficient evidence to support the
                                                                                                          use of antidepressants, dietary supplements,
                                                                                                          prolonged rest, homeopathy, evening primrose
                                                                                                                                                                         likely to be
with concentration. About half of people with
CFS/ME are unemployed, and those who
are in work have 10 times more sick leave
than other general medical outpatients.
                                                     some viruses can give people an increased
                                                     risk of developing it, and that a period of stress
                                                     and over-activity may somehow be involved.’
                                                        Clinical experience and previous research
                                                                                                          oil and other alternative therapies.
                                                                                                            The NICE Guidelines, published in August
                                                                                                          2007, say there is not yet enough evidence
                                                                                                          to judge whether pacing makes a difference.
   CFS/ME has been an enigma to researchers          has now prompted Professor Chalder and               Hence the PACE Trial, which seeks to find
and doctors for more than two decades since          the Unit’s team to search for common patterns        out not only whether treatments work, but                      High-pressure jobs with high-demand workloads
it first emerged as an illness: the symptoms         of beliefs amongst patients which they think         why they work for some people and not                          and tight deadlines are twice as likely to lead
are still medically unexplained, there is no         may hinder recovery, including a fear that           for others. All participants – who will be                     to depression and anxiety. Research based
specific test, and diagnosis is by exclusion         exercise or activity may make symptoms               randomly allocated to CBT, pacing, GET,                        on information given by nearly 1,000 32-year-
– when the profound fatigue is not caused            worse, and a dwelling on, and catastrophising        or specialist care (followed by treatment                      olds shows that young people who experience
by anything else. The research effort in             of, their symptoms. ‘Beliefs and attitudes           of their choice) – will be assessed 10 weeks                   stress at work have double the risk of developing
this field has concentrated on treatments            towards illness are important in many                                                                               symptoms of depression and anxiety disorder
aimed at reducing the fatigue and helping            conditions, both physical and mental,’ she           ‘A fear of the danger of activity and exercise                 than young people with less demanding jobs.
patients reclaim their lives, but treatment          said. ‘It is possible that a fear of the danger      may inadvertently perpetuate the symptoms’                       The research team, based in the MRC
programmes for CFS/ME have attracted                 of activity and exercise may inadvertently                                                                          Social, Genetic and Developmental
controversy over the years, the choice               perpetuate the symptoms of CFS/ME.’                  after treatment, then again at six months and                  Psychiatry Centre at the IoP, ruled out the
between rest and activity sometimes                     Shifting beliefs that may make recovery           finally after a year. The IoP’s Centre for the                 possibility that other factors – like a previous
being at the core of the debate.                     more difficult is one of the aims of the             Economics of Mental Health is analysing                        history of mental illness – had a part to play.
   The National Institute for Health and             cognitive behaviour therapy used within the          the cost-effectiveness of all the treatments.                    The link between stress at work and
Clinical Excellence (NICE) Guidelines                Unit. ‘CBT for CFS/ME encourages people to              Meanwhile other research projects in                        mental ill health was made in an analysis
for CFS/ME recommend cognitive behaviour             build up activity and establish a sleep routine,     the Unit here are trying to understand                         of information collected in the longitudinal
therapy (CBT) and graded exercise therapy            and tackles beliefs like “I can’t get better” or     more about the psychological mechanisms                        Dunedin Multidisciplinary Health and
(GET), both of which encourage patients to           “this will make my symptoms worse”.’ Over            involved in CFS/ME in order to hone and                        Development Study based in New Zealand,
become active again. Some patients have              recent years, Professor Chalder has adapted          develop treatments. Recently, members of                       which includes a cohort of 1,000 men and
expressed concern, however, that GET and             this therapy and developed a family-based            the team carried out a brain scanning study,                   women who regularly give information
CBT may make their symptoms and disability           cognitive behaviour programme as a treatment         comparing the activity of neural circuits of                   about their health and lives.
worse. Now the largest ever trial of treatments      for children and young people, aged 11 to 18.        people with CFS/ME and healthy volunteers                        Fourteen per cent of working women and 10
                                                     For them, the consequences of CFS/ME are             while they completed tasks testing working                     per cent of working men had had a first episode
‘CFS/ME has been an enigma to researchers            dire, impacting on their education and on            memory and concentration, problems with                        of depression or anxiety at age 32. Forty-five
and doctors for more than two decades’               their physical and social development as a           which are reported by patients.                                per cent of these new cases of depression and
                                                     result of long periods out of school.                   Both groups performed equally well on the                   anxiety were attributable to stress at work.I
for CFS/ME is underway. Funded by the                   An initial trial of the therapy, which            tests, but the brains of people with CFS/ME
Medical Research Council, the five-year              involves the whole family at each session,           ‘lit up’ in a different way to the brains of
PACE (Pacing, graded activity and cognitive          showed it to be very successful. Six months          the healthy group.‘The differences in the
behaviour therapy: a randomised evaluation)          after the therapy had ended, 83 per cent of          activation of the working memory network                       The IoP’s Professor of Psychology David Clark
trial compares different types of treatment          the young people were back at school 75 per          could be for a number of reasons,’ explained                   has been campaigning alongside Lord Richard
with the help of 600 volunteer patients, in          cent of the time, felt less fatigued, were more      Professor Chalder. ‘The results of the CFS/ME                  Layard at the London School of Economics and
the care of six different specialist clinics. The    socially adjusted, less depressed and less fearful   group are similar to those seen in previous                    Political Science for more trained therapists to
trial will provide evidence to either reassure       of exacerbating their symptoms. ‘The pilot           research when sleep-deprived healthy adults                    treat the one in six people who have depression
or confirm patients’ doubts about the efficacy       showed family-based CBT, which encourages            perform similar tasks. Many patients                           or chronic anxiety in the UK. They were among
and negative effects of CBT and GET, and             them to start doing things again, helped them        with CFS/ME have disturbed sleep, so the                       the signatories to The Depression Report,
will include the first scientific evaluation of      to rebuild their lives,’ she said. The Unit has      differences may be as a consequence of that.’                  published in 2006 and calling for wider access
pacing – or APT (adaptive pacing therapy)            run a bigger trial, comparing family-focused            It could also theoretically be because more                 to evidence-based psychological treatment,
– the treatment of choice for many patients.         CBT with psycho-education sessions, giving           effort was involved in the tasks by those with                 in particular cognitive behaviour therapy.
Pacing is based on the concept of an organic         the same sort of messages. The young people          CFS/ME, who characteristically are extremely                   The Report said only a quarter of people
disease, and is about balancing activity and         have been followed up a year later to see which      conscientious and have high expectations of                    with depression or anxiety received any
rest to help manage CFS/ME. It is supported          treatment has been more effective: the results       themselves, she said. Investigating common                     kind of treatment – and the only barrier to
by patient organisations like the UK charity         are still being analysed.                            characteristics in patients and the role they                  helping them was lack of investment in services.
Action for ME, which is involved in the trial.          All sorts of treatments have been advocated       potentially play in the development and                           In 2007, Health Secretary Alan Johnson
   One of the collaborators in PACE is the           for CFS/ME over the years: a review of the           maintenance of CFS/ME is a future area                         announced a government decision to train
Chronic Fatigue Research and Treatment               scientific literature by the Unit team found         of research.I                                                  and employ 3,600 new therapists by 2010/2011.
20 | Depression |                                                                                                                                                                                                       | Depression |                                                                                | Eating disorders | 21

                                                                                                                                                       Mother & Baby Picture Library
Can GP-based care for the mind                                                                                                                                                                                                            Anorexia and autism
also help benefit heart disease?                                                                                                                                                                                                          share personality traits
Can treating the mind also help the                  pressure, so it makes sense for them to care       The new treatment will be tested in                                                                                               When Professor Janet Treasure likened             involved in these individual characteristics
heart? A package of work funded by                   for patients’ mental health at the same time,   a clinical trial involving up to 20 group                                                                                            anorexia to Asperger’s syndrome in The            could be a much easier task than hunting
the UK government’s National Institute               said Professor Tylee.                           practices in south London, recruited                                                                                                 Times newspaper, many people with the             for specific ‘anorexia’ genes.
for Health Research aims to find out more              The information-seeking first stage will       through the Greater London Local                                                                                                     eating disorder responded in agreement.             ‘We know that anorexia is heritable,’ she
about the link between depression and                include tracking 800 patients with heart        Research Network. Professor Tylee                                                                                                    ‘I have struggled with anorexia in varying        said, ‘but finding the genes involved is very
heart disease – and whether treatment                disease recruited from three south London       said the programme will involve stepped                                                                                              degrees of severity for the past 10 years,’       difficult. There may be dozens and dozens

from GP-based nurses could help save lives           GP practices for four years to find out about    care tailored to individual patients – starting                                                                                      wrote one correspondent to the timesonline.       that contribute to its development, and
at risk from coronary problems.                      symptoms and treatment, detailed interviews     with self-help materials and advice about                                                                                            ‘A few years ago I began to notice how            these may interact with each other, and
  There is some evidence to show that                with 50 patients randomly selected from         diet and exercise through to medication and                                                                                          many similarities the illness has with autism     interact with brain chemistry, brain structure
depression worsens the cardiac prognosis,            this cohort, and interviews with GPs and        psychological treatments. Practice nurses will                                                                                       /Asperger’s, and was so struck by the             and the environment – social pressure and
said Professor André Tylee, who is leading
the Up-Beat research programme: scientists
think depression may exacerbate the
symptoms of heart disease because of
                                                     practice nurses.

                                                     ‘People with heart disease
                                                     are twice as likely to get
                                                                                                     be trained to deliver the programme and the
                                                                                                     results evaluated by following up some 180
                                                                                                     patients, half registered with GPs where the
                                                                                                     treatment is being trialled and half continuing
                                                                                                                                                                               linked to                                                  sheer number that I actually wrote down
                                                                                                                                                                                                                                          a list of them.’
                                                                                                                                                                                                                                            A number of shared personality traits and
                                                                                                                                                                                                                                          similarities in the thought processes of people
                                                                                                                                                                                                                                                                                            culture, for example – in a plethora of ways.
                                                                                                                                                                                                                                                                                              ‘Because the genetic basis of an individual
                                                                                                                                                                                                                                                                                            endophenotype is less complicated and less
                                                                                                                                                                                                                                                                                            complex, identifying them can help us break
biological mechanisms associated with
the inflammatory response of the immune
system and the hormonal stress response
system. Twenty per cent of people with
                                                     depression as other people’

                                                       ‘We want to find out what professionals
                                                     currently do, how they treat someone
                                                                                                     to see their GP and practice nurse as usual.
                                                                                                        If it makes a difference, the treatment
                                                                                                     could be made widely available at GP
                                                                                                     surgeries across the country.
                                                                                                                                                                               early birth                                                with anorexia and people with autism have
                                                                                                                                                                                                                                          been highlighted by the research team led
                                                                                                                                                                                                                                          by Professor Treasure and her colleague
                                                                                                                                                                                                                                          Professor Ulrike Schmidt in the Section
                                                                                                                                                                                                                                                                                            down different mental illnesses into parts
                                                                                                                                                                                                                                                                                            that are easier to understand. So once we
                                                                                                                                                                                                                                                                                            have identified an endophenotype, we
                                                                                                                                                                                                                                                                                            can look for genes that contribute to its
heart disease also have depression, double           who has both conditions,’ said Professor           ‘We know that people with heart disease                                                                                           of Eating Disorders at the IoP. They think        presence, which may in turn contribute
the rate of people without heart problems.           Tylee. ‘Do they treat the depression            are twice as likely to get depression as other                                    Treating depression during pregnancy could         that these ways of mental processing may          to the development of anorexia.’
  What’s more, depression is associated              differently? – do they say it’s understandable   people,’ said Professor Tylee. ‘What’s more,                                      prevent thousands of premature births each         be inherited and somehow make someone
with a 50 per cent increase in the costs             that because you’ve had a heart attack          a lot of people with heart trouble may                                            year, says Dr Veronica O’Keane, who specialises    more prone to developing anorexia.                ‘We know that anorexia is heritable, but
of long-term medical care for conditions             you’ve become depressed, for example,           be depressed and not know it – and the                                            in perinatal psychiatry: a study carried out         ‘People with anorexia tend to be                finding the genes involved is very difficult’
such as heart disease, stroke and diabetes           and then not treat the depression as            depression is probably making their heart                                         by Dr O’Keane and her colleagues showed            perfectionists, have obsessive compulsive
– depression has a knock-on effect on diet,           rigorously as they should? We’ll also           disease a lot worse. We want to find out                                           that mothers-to-be who are diagnosed               traits and worry about mistakes,’ said              A series of projects funded by charities,
lack of exercise, lack of compliance with            be able to find out about how they feel          about that, and what we can do about it.                                          with depression are more likely to give            Professor Treasure. ‘They concentrate             European grants and NHS money has
self-care regimes and other behaviour that           about different treatment options, which         If we treat the depression, can we improve                                        birth before 37 weeks.                             on detail rather than the bigger picture,         already led the field in the search for
can contribute to worsening of symptoms,             will help us develop the trial treatment.’      the heart as well as the mind?’I                                                     The study measured the stress hormones          and find it difficult to change rules they        candidate endophenotypes. The next
said Professor Tylee.                                                                                                                                                                  in pregnant women and found those with             have set themselves once they have fixed          stage is to investigate traits researchers
  The five-year research plan starts with                                                                                                                                               depression had higher levels, and were             them in their brain. These are personality        think to be potential endophenotypes.
an information-gathering exercise that                                                                                                                                                 more likely to deliver their babies earlier        traits shared by people with autism and we        They are doing this with the help of
will inform the development of a ‘stepped’                                                                                                                                             or prematurely: babies born before 37              are now investigating whether some of them        people with anorexia and their families
treatment programme for depression that
could be given by practice-based nurses.
Nurses already regularly see patients with
                                                     Old age not as good in                                                                                                            weeks are more likely to die in the first
                                                                                                                                                                                       few weeks of life, and are at risk of developing
                                                                                                                                                                                       lung disease, cerebral palsy, blindness or
                                                                                                                                                                                                                                          may be caused by inherited anomalies in
                                                                                                                                                                                                                                          the neural networks and brain mechanisms
                                                                                                                                                                                                                                          responsible for information processing.’
                                                                                                                                                                                                                                                                                            who are willing to complete puzzles that
                                                                                                                                                                                                                                                                                            throw light on their thought processing
                                                                                                                                                                                                                                                                                            styles, have scans which show what’s

                                                     France,Italy and Spain
heart conditions to monitor their physical                                                                                                                                             deafness. The researchers think increased            A major tranche of research is being            going on inside their brains, and give
symptoms, such as cholesterol and blood                                                                                                                                                stress hormones somehow prompt early birth.        undertaken to discover whether any of the         samples of their DNA for analysis.
                                                                                                                                                                                          Babies born to depressed mothers were more      similarities in information processing could      Correlating all this information will
                                                                                                                                                                                       likely to have higher levels of stress hormones    be ‘endophenotypes’ of anorexia – genetically     enable researchers to conclude whether
and...                                                                                                                                                                                 themselves: tests on two-month-old babies          influenced characteristics present in an          certain characteristics are indeed
The Up-Beat research programme is funded                                                                                                                                               showed those whose mothers had been                individual and their close family members         endophenotypes – these include what
by one of six programme grants made to               Older people living in France, Italy and          Twenty-two thousand people in the                                               depressed during pregnancy produced                that may have no direct relation to the           scientists call ‘impaired set shifting’,
South London and Maudsley NHS Foundation             Spain are more likely to be depressed           10 countries, on average aged 65, were                                            higher levels of cortisol when they were           eating disorder. Researchers theorise that        ‘weak central coherence’ and ‘weak
Trust in 2007 by the National Institute for Health   than their peers living in Sweden, Austria,     interviewed in their homes. Those living                                          given routine inoculations. ‘These higher          certain endophenotypes – particular styles        Theory of Mind’.
Research. The total amount of UK government          Denmark, Germany, Switzerland, Greece           in France, Italy and Spain had the highest                                        levels may mean children will be more              of thinking, for example – may make people          Set shifting is the ability humans have
money awarded was £12 million and all six            and The Netherlands.                            depression scores and were more likely                                            prone to developing depression themselves          more susceptible to developing one of many        to swap between different tasks or mindsets.
programmes aim to increase understanding               The differences were revealed by              to report loss of interest, pessimism and                                         in later life,’ said Dr O’Keane.                   mental health problems. It may be that eating     Previous studies have shown that people with
of mental health problems and to develop             SHARE (Survey of Health, Ageing and             lack of enjoyment than older people                                                  ‘Depression is more common during               disorders, autism spectrum disorder, attention    anorexia and their close family members have
new treatments. Academics from the IoP               Retirement in Europe), an ongoing               in the other participating countries.                                             pregnancy than after birth, but mothers            deficit hyperactivity disorder (ADHD) and         difficulties with set shifting, which means they
are the chief investigators on each of the           European Commission-funded study                They were also less well-educated                                                 who suffer depression during pregnancy              obsessive compulsive disorder all share           find it hard to multi-task, deal with change,
programmes: the other five focus on treatments       which is gathering information about            than older people elsewhere and                                                   receive virtually no support from doctors.’        some endophenotypes, which could                  and tend to be rigid and inflexible in their
for people with anorexia; treatments for people      the health and wealth of people as              performed less well on cognitive tests.                                              The small study involved 25 pregnant            challenge current thinking that these             thoughts. Because this trait is found in family
with intellectual disabilities and mental health     they grow older.                                  Researchers think national social and                                           women who had a diagnosis of major                 are all separate, unrelated disorders.            members who do not have an eating disorder,
problems; improving the physical health                The SHARE team includes researchers           economic policies affecting older people                                          depression, and 35 healthy women. Three              Identifying endophenotypes is important,        researchers think it fulfils some of the criteria
and decreasing cannabis use in people with           from the participating European countries:      could help to account for the differences                                         of the women with depression gave birth            says Professor Treasure, because it could         of an endophenotype.
severe mental illness; reducing stigma and           the IoP’s Professor Martin Prince leads         in symptoms of depression between                                                 before 37 weeks, and all gave birth on average     help unravel the genetic conundrum                  Weak central coherence is a principal
discrimination; and improving inpatient care.        on mental health issues.                        countries.I                                                                       three days earlier than the other group.I          of anorexia: searching for the genes              characteristic of the way people with autism
                                                                                                                                                                                                                                                                                                                      continues over the page ¡
22 | Eating disorders |                                                                                                                                                                                                                                                                                  | Eating disorders | 23


                                                                                                                                                          Rehan Jamil
spectrum disorder think, and refers to an           with eating disorders. The underlying neural        Professor Treasure. ‘We want to develop                                                                                                                                        Caring for a loved one with an eating
information processing style where there is         networks that lead to difficulties in registering   treatments that address the mechanisms                                                                                                                                         disorder is a frightening and stressful
a tendency to concentrate on the minutiae           emotions may be one of the endophenotypes           inside the brain that help cause or prolong                                                                                                                             experience,’ says Pam Macdonald, whose
rather than the bigger picture. ‘Excessive          for both anorexia and autism, suggested             the illness, and moderate the thought                                                                                                                                   daughter had anorexia. ‘Looking back
attention to detail is an enduring personality      Professor Treasure.                                 processes that might contribute towards                                                                                                                                 on that bleak journey still evokes strong
trait found in people with anorexia,’ said            Discovering cognitive characteristics,            problems.’ So finding out how people                                                                                                                                    memories of a long, dismal tunnel littered
Professor Treasure. ‘In terms of the illness,       which may or may not be endophenotypes,             think and learn can lead to treatment                                                                                                                                   with countless pitfalls.
people are so focused on the detail of                                                                  tailored to their specific style, treatment                                                                                                                                ‘A major uncertainty was my own role in
maintaining their eating behaviour that             ‘Thinking styles can be an obstacle                 that, for example, tackles perfectionism                                                                                                                                the process. Quickly discarding those initial
they are unable to see the bigger, severe           to patients getting better – gaining                or inflexibility. One small study has                                                                                                                                   feelings of guilt as futile, I nevertheless
consequences that the anorexia has on their         weight doesn’t change the way you think’            already shown that people did better                                                                                                                                    desperately craved information on how
lives.’ Some of the research already carried                                                            on tasks measuring set shifting ability                                                                                                                                 to react to the present situation. I wanted
out is showing that people with anorexia fare       can, very importantly, influence the                after cognitive remediation therapy that                                                                                                                                knowledge and guidance on how to react
less well in tests that demand global strategies,   development of better psychological                 specifically targeted the way they think                                                                                                                                to the alien that had invaded my daughter’s
but excel in tasks that require bias to detail.     treatments for anorexia that are tailored           rather than the contents of their thoughts.                                                                                                                             body. I needed to know that I was handling
   And ‘Theory of Mind’ (ToM) refers to             to particular styles of thinking. The                 As new treatments are pioneered, there                                                                                                                                the situation in a way that was conducive
social cognitive abilities that help humans         research team is already designing                  will be long-term studies to measure their                                                                                                                              to a healthy outcome. In my search for
engage in complex social interaction and to         experimental new treatments with                    success. In 2007, the UK Department of                                                                                                                                  these answers, I stumbled across Professor
recognise emotion in others. ToM is impaired        the help of their increased knowledge.              Health’s National Institute for Health                                                                                                                                  Janet Treasure’s work in skills-based learning
in people with autism and recent studies              ‘Thinking styles can be an obstacle to            Research awarded £2 million to help                                                                                                                                     for carers of those with eating disorders.’
are highlighting poor social communication          patients getting better – gaining weight            translate new understanding about                                                                                                                                          Pam is now working on the project that
skills and small social networks in people          doesn’t change the way you think,’ said             anorexia into treatment.I                                                                                                                                               is testing the effectiveness of a package

                                                                                                                                                                  Home-based support
                                                                                                                                                                                                                                                                                of DVDs offering this training to carers,
                                                                                                                                                                                                                                                                                wherever they live, for her PhD.
                                                                                                                                                                                                                                                                                   ‘The DVDs and manual illustrate motivational

Therapy to change thinking styles
                                                                                                                                                                                                                                                                                techniques and strategies used to manage

                                                                                                                                                                  and training for carers
                                                                                                                                                                                                                                                                                common problems that arise frequently
                                                                                                                                                                                                                                                                                when caring for a loved one,’ she says.
                                                                                                                                                                                                                                                                                ‘Animal analogies encourage carers to
                                                                                                                                                                                                                                                                                consider their own unique responses to
                                                                                                                                                                                                                                                                                the symptoms, and the possibility that
Consultant Clinical Psychologist Dr Kate            to go on to engage in psychotherapies that          themselves didn’t feel like “therapy”                                                                                                                                   some of these may be maintaining or
Tchanturia started working in the Eating            focus on what they are thinking about –             sessions,’ said one, ‘but kind of one-to-one                    When someone has anorexia, the whole family           to carers, wherever they live, through a          even aggravating the symptoms. Safely
Disorders Service run by South London               food and eating.                                    workshops. It was so nice that there was                        can be put under immense strain. Watching             DVD package and on the internet. Both             tucking my offspring in the maternal pouch
and Maudsley NHS Foundation Trust (SLaM)              The data are still being analysed, but            no connection to the eating disorder and                        someone you love starve themselves is terrifying      the DVDs and website are based on the             may have worked when she was aged six,
10 years ago and at first found it a challenge      all of the 30 patients who participated             that I was able to concentrate on other                         and extremely stressful: carers have to deal with     successful workshops but can be worked            but perhaps kangaroo-type behaviour
to help. ‘Patients who are admitted to a            in the pilot are now willing to continue            aspects of me.’                                                 difficult behaviour, stigma and shame, anger, guilt   through in carers’ own time, at their             wasn’t entirely beneficial to the healthy
ward are extremely ill, physically weak             with psychological work around their core              The next step is a bigger trial of cognitive                 and self-blame. What’s more, they may struggle        own pace.                                         emotional development of a 16-year-old.
and extremely unmotivated. The last thing           symptoms. And it seems as if the cognitive          remediation for inpatients, to be carried out                   to get the professional help or information they         Both illustrate the communication,                ‘I strongly believe that this type
they want to do is to talk about their eating       remediation has had an effect on their              in collaboration with Stanford University                       need, says Gill Todd, Clinical Nurse Leader in        assessment and motivational skills carers         of family research and the tools
when they are like this,’ she says.                 thought processes: measures completed               in the USA. At the same time, Dr Tchanturia                     the Eating Disorders Service at South London          need to help reduce the symptoms of               taught are desperately important
   ‘I started to get interested in how people       at the end of the 10 sessions show the              and her colleagues are looking at ways                          and Maudsley NHS Foundation Trust (SLaM):             anorexia, and to cope better with caring –        in supporting someone

with anorexia processed information, and            styles of all participants has shifted,             of incorporating and testing the success                        research into eating disorders at the IoP is          how to support people at meal times, for          with an eating disorder.
wondered if there were any underlying                                                                   of cognitive remediation in outpatient                          closely interwoven with these clinical services.      example, how to facilitate weight gain and
thought processes to their extremely                ‘The therapy is not designed to be a cure           treatment services run by SLaM, and                                It’s not surprising that the atmosphere            re-establish healthy eating, how to manage
rigid eating behaviour.’ She put together           or even to tackle life-threatening eating           running workshops for health professionals                      at home can become tense, and that hostile            crises and conflict, and how to assess and         beat (formerly the Eating Disorders
a battery of tests to measure cognitive             behaviour. What it does is address thinking         in the field wanting to find out more.                          and critical comments sometimes spill out,            manage risk. Information is also included         Association) offers information and
abilities that could be used in research            styles that keep people trapped in anorexia’           ‘The pilot study is promising, but                           she said. Yet negative emotions like these            about the use of the Mental Health Act,           support to people with eating disorders
looking for evidence of common styles                                                                   there is a long, long way to go,’ she                           can inhibit recovery from anorexia: research          the role of different health professionals,        and their carers. Visit
of thinking among people in the acute               indicating a move towards less inflexibility        said. ‘The real challenge is to formulate                       has shown that the positive support of families       and about NHS and voluntary services.
stages of the illness, then in people who           in their thoughts and less attention to detail.     and incorporate cognitive remediation                           can be crucial in the recovery process.                  The five-DVD package comes with a
had recovered, and later, in collaboration            The cognitive remediation sessions, run           into the whole treatment package, to                               ‘Carers need both emotional and practical          manual giving theoretical and practical
with other members of the Eating Disorders          by volunteer therapists supervised by Dr            work out how to put it into practice.                           support from their network of family and              information and 100 carers are currently
Service team, in close family members.              Tchanturia, are a starting point in the process         ‘This has generated a lot of interest                       friends, and also from professionals,’ she            helping the research team test what
   After almost a decade of observing and           of therapy, she explains. Food and eating           around the world. It shows how professionals                    said. ‘The skills they need at home are               difference it makes to them and the                and...
researching a rigid mindset that kept patients      don’t play a part: instead individuals are          and families in different countries are all                     similar to those needed by professionals              person they are caring for.              is a website developed
with anorexia on the path towards starvation,       asked to complete a series of puzzles and           desperate to find something that can help.                      working on specialised units.’                           The web-based programme – developed            for families and friends of people with eating
she has piloted specially-designed cognitive        games that help them think about how they           We know that family therapy is very good                           Successful three-day workshops                     in collaboration with beat (formerly the          disorders by the research team at the IoP
remediation with inpatients. The 10 45-minute       are thinking, and whether that style helps or       for adolescents, but there is no medication                     developed by the Eating Disorders                     Eating Disorders Association), Dr Chris           and staff at South London and Maudsley NHS
sessions, which start shortly after admission,      hinders them. After the last session there is       that helps and even though different sorts                      research team offer carers just that –                 Williams from the University of Glasgow,          Foundation Trust’s Eating Disorders Service.
are not designed to be a cure, or even to tackle    an exchange of letters about the process, and       of psychotherapy can be successful, there                       relevant information and the chance                   Media Innovations and patients and carers –       The site offers up-to-date information about
life-threatening eating behaviour. What             those written by both patients and therapists       is a group of patients who don’t get                            to develop skills they can use to manage              is being tested both off and on line by families   research into the causes of anorexia, bulimia
they do is address thinking styles that             are being analysed to help measure the success      better despite therapy, and many still                          better at home, give appropriate care and             of people with anorexia who are being treated     and other eating disorders, details of projects
help keep people trapped in anorexia                of the pilot. The feedback is good, she said,       relapse. Processes of thinking may play                         at the same time reduce their own levels              at SLaM’s Eating Disorders Service. This is a     developing new and better treatments and
and may contribute to its development               with patients particularly liking the fact that     a part in this. Cognitive remediation                           of distress.                                          small preliminary study, which will inform        projects designed to support carers. There
in the first place. By changing the way they        they did not have to speak about their eating       before treatment begins may simply                                 Now the research team is testing                   the development of a larger trial to test the     are pages about how to volunteer to participate
think, she said, patients may be more likely        disorder during the sessions. ‘The sessions         help move people on.’I                                          ways of making that training available                efficacy of the programme.I                         in research, as well as news and events listings.
              24 | Eating disorders |                                                                                           | Epilepsy |                                                                                                                                                                                                    | Epilepsy | 25

Rehan Jamil

                                                                                                                                                      My first proper seizure was when I was
                                                                                                                                                      17, just after I had passed my driving
                                                                                                                                                test,’ says Nicola Bryant, who is now 35 and
                                                                                                                                                an accountant. ‘I was in the office but I don’t
                                                                                                                                                really remember very much about it because
                                                                                                                                                                                                     Seeking to create an implant to
                                                                                                                                                when my epilepsy became very bad, it wiped
                                                                                                                                                out loads of my memory.
                                                                                                                                                   ‘That first seizure was totally unexpected,
                                                                                                                                                and I carried on having them, with no real
                                                                                                                                                                                                     revolutionise epilepsy treatment
                                                                                                                                                warning, until 2000, when I had brain surgery
                                                                                                                                                to remove scarring that the doctors thought          Seizures experienced by people with epilepsy         lasting for a few minutes, but they can            used pending natural remission. For the
                                                                                                                                                was causing them. I’d been on medication,            strike when millions of neurons in the brain         continue for hours, days, and sometimes,           20-30 per cent of people who don’t respond
                                                                                                                                                which was helping to control the seizures, and       ‘fire’ simultaneously. This unexpected electrical    but very rarely, weeks. They can start at          to medication, surgery can be a cure, and
                                                                                                                                                I took a year off work and went to Australia.        over-drive can produce many different symptoms       any age, and tend to go into remission after       constant mild electrical stimulation that seeks
                                                                                                                                                When I came back in 1997, I tried to come            – convulsions, blank staring, visual or other        a few years: studies in developing countries       to regulate the electrical activity of the brain
                                                                                                                                                off the tablets, but then my epilepsy went           sensory disturbances, jerking arms and legs,         show that epilepsy often stops without any         is a possibility if an operation is not feasible.
                                                                                                                                                haywire. I had a lot of seizures – I would           for example. Mood, memory, behaviour,                treatment.                                         The stimulator is a device like a pacemaker,
                                                                                                                                                lose consciousness and be wiped out for              movement and consciousness can all be                   In the UK, one in every 131 people has          attached to the vagus nerve in the neck.
                                                                                                                                                two days at a time. It was impossible to work        affected because the abnormal patterns of            epilepsy and each year 1,000 people die as            ‘Surgery can be a cure if we can pin down
                                                                                                                                                and my whole life was messed up, everything          electrical activity disrupt function in the area     a result of accidents during a seizure – the       in which part of the brain the seizures start,
                                                                                                                                                went horribly wrong. I had to give up my job         in which they start, and sometimes spread            most common being drowning in the bath –           and if that part of the brain can be safely
                                                                                                                                                and my house in London and move back in              to different parts of the brain.                     or the seizure itself. ‘Some seizures switch off    removed without detrimental effect,’ said
                                                                                                                                                with my parents in Oxfordshire so my mum               A major tranche of research at the IoP seeks       the brain mechanisms that control breathing        Professor Richardson.
                                                                                                                                                could look after me.                                 to learn how to predict when the repetitive          and heart rate,’ said Professor Richardson.           To help assess the suitability for surgery,
                                                                                                                                                   ‘The surgery removed the scar on the left         bursts of electricity will occur, and ultimately        The unpredictability of when the seizures       electrodes are routinely implanted in the
                                                                                                                                                side of my brain. I don’t know why the scar          work out ways of stopping them in their tracks,      will occur is a sword of Damocles hanging
                                                                                                                                                                                                     thus preventing a seizure from happening.            over patients’ heads, he said. ‘You try to live     ‘The unpredictability of when seizures

                                                                                                              Photo courtesy of Nicola Bryant
                                                                                                                                                                                                       Scientists currently don’t know what               a normal life, but you live in fear of what         will occur is a sword of Damocles hanging
                                                                                                                                                                                                     prompts the electrical disturbance that results      might happen.’                                      over patients’ heads’
                                                                                                                                                                                                     in a seizure happening at any particular time.          Much of his team’s research is carried
                                                                                                                                                                                                     ‘For some people, it’s connected with lack           out with the help of patients from all over        brain to measure electrical surges and thus
                                                                                                                                                                                                     of sleep,’ said Professor Mark Richardson,           the country, referred to a specialist clinic       discover the area where seizures start. Once
                                                                                                                                                                                                     who is leading the research programme,               at King’s College Hospital. Researchers            in place, they can be used for research
                                                                                                                                                                                                     boosted in 2007 by a £1 million donation             monitor the electrical signals that allow          tracking electrical activity in response
                                                                                                                                                                                                     from John Paul Getty III. ‘Some women get            neurons to communicate by stimulating              to electrical stimulation, measuring the
                                                                                                                                                                                                     them according to the time of their menstrual        them and measuring their response                  neurons’ responses in a very detailed way.
                                                                                                                                                                                                     cycle, and strobe lighting can precipitate           through electrodes implanted in                       And uniquely outside the USA, the IoP
                                                                                                                                                was there: it might have come from an accident       seizures. It looks like there are multiple           the brain, or by non-invasive TMS                  team is using tiny microwires inserted through

          Writing may help bulimia                                                                                                              I had when I was young and fell on my head, or
                                                                                                                                                from accidents I had when I used to horse ride.
                                                                                                                                                   ‘The operation made a real difference.
                                                                                                                                                It didn’t stop the epilepsy, but the seizures
                                                                                                                                                                                                     factors involved, and what they are, and
                                                                                                                                                                                                     why they cause the disturbance, is uncertain.’

                                                                                                                                                                                                     ‘In the UK, one in every 131 people has epilepsy.
                                                                                                                                                                                                                                                          (transcranial magnetic stimulation):
                                                                                                                                                                                                                                                          this technique generates electrical
                                                                                                                                                                                                                                                          stimulation by focusing an alternating
                                                                                                                                                                                                                                                          magnetic field over a patient’s scalp.
                                                                                                                                                                                                                                                                                                             these electrodes to record detailed electrical
                                                                                                                                                                                                                                                                                                             activity of individual brain cells. ‘This will
                                                                                                                                                                                                                                                                                                             allow us to understand much more not only
                                                                                                                                                                                                                                                                                                             about epilepsy, but also about normal brain
                                                                                                                                                came a lot less often and were a lot less            Each year, 1,000 people die as a result of              ‘What we do is measure the firing                function,’ said Professor Richardson. ‘If the
              Can writing about thoughts, feelings and         to seek help and the anonymity of email                                          severe. After the surgery, I was prescribed a        accidents, or the seizure itself’                    of nerve cells in response to stimulation          neurons we are monitoring are in an area of
              moods for a short period each day make           may help to overcome the potential issues                                        new drug and the seizures stopped altogether.                                                             and analyse how it changes over time.              brain involved in a seizure, we can look at
              a difference to the symptoms of bulimia?         of shame and embarrassment,’ said student                                        The last one I had was in 2001. Every year I ask       What the research is concentrating                 We know that in a seizure, lots of nerve           their excitability both before and afterwards.
                Previous studies have shown that               Clinical Psychologist Olwyn Johnston who                                         to come off the tablets, but it’s recommended        on, then, is measuring the patterns of the           cells are stimulated to fire. What we find           But we can also find out the way they fire
              therapeutic writing can make a positive          is carrying out the study. ‘This research                                        that I stay on them: it’s not worth risking losing   electrical signals emitted from neurons to           is if you stimulate cells, you can see a slow      when people are doing normal activities –
              difference to both the physical and              will explore why therapeutic writing leads                                       my job, my driving licence, my memory. There’s       search for warning signs. ‘If we can identify        change in the increase of their excitability:      like memory tests, or moving. This will help
              emotional health of people who are               to improvements in some people’s health,                                         no telling if the epilepsy has definitely gone.      what happens leading up to a seizure, we             there is a bigger response from the neurons        us understand more generally about how
              not well. Structured writing tasks               and also look at why it may work for some                                           ‘But thanks to the surgery and the                could then develop and design some sort of           each time. The theory is that this response        neurons encode thoughts and actions, and
              are already used in the treatment                people and not for others.’                                                      medication, I have been able to rebuild              device that constantly tracks electrical activity,   gets bigger and bigger, and then a seizure         how different parts of the brain talk to each
              programme at the Eating Disorders                   Previous research has shown that                                              my life. I’m working again – though when             recognises the warning signs, and then stops         occurs.’ Researchers also measure the              other while doing different tasks.
              Outpatient Clinic run by South London            psychological factors play a role in the                                         I was ready to return to work and started            the seizure before it starts by stimulating a        passive electrical activity of the brain              ‘What we hope to do is to pull information
              and Maudsley NHS Foundation Trust                development of bulimia: people may                                               going for interviews, I was turned down for          return to a normal pattern. An implant such          via EEGs (electroencephalograms),                  from different measurements together and
              at the Maudsley Hospital and are being           have low self-esteem, difficult family                                           a couple of jobs when I mentioned my epilepsy        as this could revolutionise treatment of             hooking electrodes to the scalp, allowing          find the common patterns which indicate a
              piloted elsewhere with patients who have         and social relationships, and may be                                             – and am studying to finish my qualifications.       epilepsy,’ said Professor Richardson.                them to analyse the change in signals              seizure is about to occur,’ he said. ‘If we can
              cancer, asthma, cystic fibrosis and HIV.         lonely or depressed. Some people have                                            Last year I ran the London Marathon for the            Anyone can, out of the blue, have a                leading up to seizures.                            find them, the next step is to start developing
                Now a study seeks to find out if therapeutic   had traumatic life experiences and the                                           National Society for Epilepsy, which has really      single seizure at some point in their life:             The first choice for current treatment is        an implant that would be able to spot them
              writing could be beneficial for people who       bulimia is an outlet for their emotions,                                         helped and supported us. My memory is                a diagnosis of epilepsy is given when that           medication that dampens down electrical            and immediately kick-start the brain back
              are binge eating and vomiting but who are        helping them to cope with life.                                                  not brilliant and there are large parts of my        seizure is not an isolated incident. Epilepsy        activity throughout the brain, and can             into normal patterns. It would be a high-
              not receiving any treatment.                        Ninety people are being recruited to help                                     life that I can’t remember. Sometimes I get          can arise as a result of head injury, brain          make people feel sedated or unsteady.              tech solution, but there is the potential for
                Instructions will be sent by email, as will    with the study: half of them will be asked                                       frustrated, irritated and a bit upset because        tumour, stroke or illness, or be genetically         For the majority of patients, drugs are            something like this to be put into clinical
              questionnaires designed to measure the effects   to write about everyday things rather than                                       it is really hard to remember simple things          inherited. Seizures are usually quite short,         successful and often only need to be               practice within a decade.’I
              of the task on the symptoms of bulimia and       their emotions to find out whether it is the                                     like routes to places. I have to take
              emotional well-being. ‘People with bulimia       act of writing itself or the content of the                                      the pills every day but I am just so                 The National Society for Epilepsy provides information and support to people with epilepsy, and care for people with epilepsy through medical and
              are often too ashamed of their behaviour         task that makes a difference.I                                                   thankful not to have the seizures.                   residential services. Visit to find out more about the organisation.
              26 | Learning abilities |                                                                                                                                                                                                                                                                           | Military health | 27

                                                                                                                                                                      IWM CO874
              New technologies discover genetic
              variations behind learning ability
              Reading ability has been found to be highly           Professor Plomin and his colleagues studied    polymorphisms. Three of them were
              heritable in the largest study of twins ever        the DNA of a group of TEDS children identified    not in traditional genes and the next
              carried out in the UK, and based here at            by tests and teacher assessments as having       challenge for researchers is to find
              the MRC Social, Genetic and Developmental           reading difficulties at age seven, and the DNA     out what influence those other DNA
              Psychiatry Centre. ‘What we think is that the       of a group identified as being higher achieving   sequences may have.
              genes involved are generalist, and contribute       readers, to look for DNA differences between         A second study of TEDS children using
              not just to reading, but also to language skills,   the two groups.                                  microarrays was the first genome-wide scan
              maths and science ability, and general cognitive      They used ‘microarrays’, a slide the size      for differences associated with general
              ability,’ said Research Professor Robert Plomin.    of a postage stamp that can assess hundreds      cognitive ability, also previously proven in
                 TEDS (Twins Early Development Study)             of thousands of DNA differences throughout        family and twin studies to be highly heritable,
              tracks the genetic and environmental                                                                 and a major factor in predicting how well
              influences on the development of 15,000              ‘The point of all this is working towards        children fare in the education system and
              pairs of twins born in England and Wales            the time when we will be able to predict         job market during later life. The research
              in 1994, 1995 and 1996 and is supported by          problems and intervene early’                    team looked for differences between one
              the Medical Research Council. Research                                                               group of children who had scored highly
              carried out with the help of the twins’             the whole genome – all the hereditary            on tests measuring general cognitive ability
              families has consistently illustrated that          material encoded in the DNA that includes        – verbal, spatial and memory skills as well
              heritable factors are at least as influential        traditional genes but also billions of other     as processing speed – when they were aged
              as environmental influences.                         DNA sequences. For this reason, such studies     seven, and another group who did less well.
                 ‘Given our studies have proven the               are called ‘genome-wide association scans’.      This time they found six SNPs.
              substantial heritability of learning abilities,       And in the first genome-wide association           ‘A genome-wide scan is better than focusing
              it makes sense to look for the genetic variations   scan of reading, supported by the US             on a small number of candidate genes,’ said
              responsible,’ said Professor Plomin, who set        National Institute of Child Health and           Professor Plomin, ‘and we will be developing
              up TEDS. ‘We think many genes contribute            Human Development, they found 10                 this work in future. There is so much else in
              to reading ability, but that each gene has only     variations in the DNA sequence that were         the genome other than traditional genes that
              a small effect, which makes them hard to find.’       different in the two groups and therefore         has an effect that we don’t know about.
              So researchers are now using new and more           associated with individual differences in            ‘The point of all this is working towards the
              sophisticated DNA techniques in a bid to            reading at age seven. These DNA variations       time when we will be able to predict problems
              identify them.                                      are called SNPs – single nucleotide              and intervene early to stop the problems rather
                                                                                                                   than waiting until it is often too late to help.        Lessons from the trenches are
Rehan Jamil

                                                                                                                      ‘Identifying the genetic influences will

                                                                                                                                                                           of relevance to today’s conflicts
                                                                                                                   help us develop new ways of thinking about
                                                                                                                   effective education – to understand that
                                                                                                                   children create their own experience within
                                                                                                                   the educational process partly because of
                                                                                                                   their genetic propensities.
                                                                                                                      ‘If you simply put lots of money into
                                                                                                                   schools, people still don’t understand that                    Mild traumatic brain injury (MTBI) is being        Shell shock caught the popular imagination       Jones. ‘On the other hand, they may divert
                                                                                                                   the kids who learn faster are the ones who                     dubbed the ‘signature’ injury of the Iraq and    and attention of the media then, he said, just     attention from more easily treatable disorders
                                                                                                                   will profit the most. Our studies have shown                    Afghanistan conflicts. But Professor Edgar       as MTBI has done today. But without modern         such as depression and post traumatic stress
                                                                                                                   that not only aptitude, but also appetite to                   Jones in the King’s Centre for Military Health   investigative techniques and knowledge, the        disorder,’ he said. And labels themselves can
                                                                                                                   learn are inherited. More money just increases                 Research says this is not a new disorder:        British army struggled to understand and treat     affect prognosis – studies have shown that
                                                                                                                   the differences because the best take advantage                 its symptoms – amongst them headache,            shell shock properly.                              strongly held negative beliefs can help
                                                                                                                   and the poorer performing ones don’t. What                     dizziness, irritability, amnesia and poor          In World War II, the term ‘shell shock’          perpetuate symptoms.
                                                                                                                   we need to do, therefore, is to target the                     concentration – are similar to those             was banned by British authorities worried            US army personnel returning from Iraq
                                                                                                                   children who are more likely to be at risk:                    of shell shock in World War I.                   about another spate of hard-to-treat casualties:   and Afghanistan are being diagnosed with
                                                                                                                   therefore understanding more about genetic                        In a historical review of the World War I     but military personnel continued to report         MTBI, though to date fewer British soldiers
                                                                                                                   and environmental influences is crucial.                        ‘signature’ injury that baffled doctors at the     headache, dizziness, fatigue and other similar     have reported symptoms. ‘US personnel have
                                                                                                                      ‘One of the most important things we                        time, he suggested that ‘hard-won lessons’       symptoms. This time, they were described           a range of symptoms that also meet the criteria
                                                                                                                   have learned so far is that “abnormal”                         from nearly a century ago have relevance         as ‘postconcussional syndrome’.                    for post traumatic stress disorder,’ he said.
                                                                                                                   is “normal”, that there are no learning                        today. Professor Jones said that head wounds       Shell shock was initially thought to be a          ‘There are dangers not only in assuming that
                                                                                                                   disabilities, just a low end of a normal                       and concussion were common battle injuries       neurological disorder, caused by head injury or    MTBI is novel, but in characterising it solely as
                                                                                                                   distribution of learning abilities. In other                   in both the 1914-1918 war, and in Iraq and       exposure to toxic substances, but subsequent       an organic injury. The evidence of the last two
                                                                                                                   words, low performance in reading, writing,                    Afghanistan. What’s more, the military           research suggested that psychological factors      World Wars is that brain injury often arises in
                                                                                                                   maths and science is simply the extreme                        context is similar: the recent conflicts          contributed to its symptoms. ‘It may be that       a context of psychological distress, requiring us
                                                                                                                   of the same genetic and environmental                          became wars of attrition, just as the one        labels such as shell shock reduce stigma and       to consider the physical but also the mental
                                                                                                                   influences that operate in everyone.’I                          at the beginning of the last century did.        encourage people to seek help,’ said Professor     health of those with concussive injuries.’I
                                                                                       28 | Military health |                                                                                                                                                                               | Military health | 29
Photograph by: WO2 Giles Penfound; Crown Copyright/MOD, image from

                                                                                                                                                                                                                                       No repeat of ‘war syndrome’ in Iraq

                                                                                                                                                                                                                                                                                                                     Photograph by: Cpl Mike Fletcher; Crown Copyright/MOD, image from
                                                                                                                                                                                                                                       The war in Iraq has not taken its toll on the
                                                                                                                                                                                                                                       health of the armed forces serving there in
                                                                                                                                                                                                                                       the same way that the 1991 Gulf War did. A
                                                                                                                                                                                                                                       team of researchers from the King’s Centre
                                                                                                                                                                                                                                       for Military Health Research has shown there
                                                                                                                                                                                                                                       has been no increase in psychological problems
                                                                                                                                                                                                                                       among those who took part in the invasion of
                                                                                                                                                                                                                                       Iraq in 2003, when compared to those who
                                                                                                                                                                                                                                       were deployed elsewhere.
                                                                                                                                                                                                                                          The Health and Well-Being Study started
                                                                                                                                                                                                                                       soon after the end of Operation Telic 1, as the
                                                                                                                                                                                                                                       initial invasion of Iraq was called. The research
                                                                                                                                                                                                                                       team tracked – through questionnaires and
                                                                                                                                                                                                                                       interviews – more than 10,000 members of the
                                                                                                                                                                                                                                       armed forces and compared the experiences
                                                                                                                                                                                                                                       of those who had been in Iraq with those
                                                                                                                                                                                                                                       serving elsewhere.
                                                                                                                                                                                                                                          ‘The first analysis of the information showed
                                                                                                                                                                                                                                       there has been no “Iraq War syndrome”,’ said
                                                                                                                                                                                                                                       Professor Simon Wessely, Co-director of the
                                                                                                                                                                                                                                       Centre which is jointly run by the IoP with the
                                                                                                                                                                                                                                       Department of War Studies in the sister School
                                                                                                                                                                                                                                       of Social Science and Public Policy at King’s
                                                                                                                                                                                                                                       College London.
                                                                                                                                                                                                                                          ‘About 20 per cent of those coming back
                                                                                                                                                                                                                                       from Iraq showed symptoms of common
                                                                                                                                                                                                                                       mental health problems – stress, poor sleep,
                                                                                                                                                                                                                                       unhappiness, worry, anxiety. But that figure
                                                                                                                                                                                                                                       is lower than in the general population. We
                                                                                                                                                                                                                                       also found, not surprisingly, that people were
                                                                                                                                                                                                                                       more likely to have subsequent problems if
                                                                                                                                                                                                                                       they had been in combat, exposed to enemy
                                                                                                                                                                                                                                       fire, or handled dead and wounded colleagues.’
                                                                                                                                                                                                                                          Overall levels of mental health problems in
                                                                                                                                                                                                                                       the UK armed forces were lower than media
                                                                                                                                                                                                                                       reports suggest, and also lower than those
                                                                                                                                                                                                                                       experienced by US forces, he said. ‘Rates
                                                                                                                                                                                                                                       of post traumatic stress disorder among US
                                                                                                                                                                                                                                       personnel returning home were considerably
                                                                                                                                                                                                                                       higher and there are many reasons for this.

                                                              Lengthy tours of duty affect health
                                                                                                                                                                                                                                       They were doing more fighting and taking
                                                                                                                                                                                                                                       more casualties. US military personnel sent
                                                                                                                                                                                                                                       to Iraq were younger with less experience
                                                                                                                                                                                                                                       of deployment and were more likely to be
                                                                                                                                                                                                                                       reservists. They also served there for at least
                                                                                                                                                                                                                                       twice as long.’
                                                                                       Public debate has raged about whether           A research team from the King’s Centre        ‘We showed guidelines on maximum length              The team from the Centre had previously
                                                                                       UK armed forces have been ‘overstretched’    for Military Health Research collected         of deployment are sensible for the sake of both     carried out extensive research into the health
                                                                                       by simultaneous operations in Iraq and       information about the frequency and            an individual and their families,’ said Professor   of armed forces who fought to liberate Kuwait
                                                                                       Afghanistan.                                 duration of deployments from 5,500             Simon Wessely, Co-director of the Centre.           in the 1991 war. The research had shown
                                                                                         But research has shown that UK Ministry    regulars in the army, navy and air force       ‘The guidelines aren’t often broken, but if         veterans of the Gulf War were twice as
                                                                                       of Defence Harmony Guidelines designed       over a three-year period, and compared         they are, there is an effect on mental health.’      likely to be fatigued, have chest pains and
                                                                                       to safeguard against excessive deployments   that with information given about their          The number of deployments within the              other unexplained symptoms, and twice as
                                                                                       are mostly working well. However, when       mental and physical health.                    past three years made no difference to people’s      likely to develop a psychiatric disorder as
                                                                                       they have been violated, there has been         They found that personnel who had           psychological well-being: many who had              services colleagues who were not involved.
                                                                                       an increase in mental health problems.       had tours of duty lasting for 13 months        been deployed on several occasions within           Seventeen per cent of all UK service men and
                                                                                         And if a tour of duty has continued        or more were more likely to report mental      the three years had been sent for short             women who served in the campaign believed
                                                                                       for longer than expected, individuals        ill health and problems at home. The Harmony   periods of time. The intervals in between           they had Gulf War syndrome as a result
                                                                                       are much more likely to report increased     Guidelines differ for each of the services,     each tour of duty may act as a buffer against        of being there. These health problems first
                                                                                       use of alcohol and symptoms of post          but for the army equate to a maximum           the development of psychological symptoms,          started to be reported some three years after
                                                                                       traumatic stress disorder afterwards.        12 month deployment within three years.        said Professor Wessely.I                            the conflict had ended, however.
                                                                                                                                                                                                                                                                continues over the page ¡
30 | Military health |                             | Mobile phones |                                                                                                                                                                                                                                         | Parkinson’s disease | 31

  ‘Whilst the findings from Iraq are                                                                                                                                                                                                                                                            Amanda Osborne was 28 when she was
encouraging, it is premature and ill-advised
to say there will be no longer-term health
consequences of the war,’ said Professor
                                                   Beliefs about signals                                                                                           Understanding more                                                                                                          diagnosed with Parkinson’s eight years ago.
                                                                                                                                                                                                                                                                                      ‘I had been ill for a few years – I was very tired
                                                                                                                                                                                                                                                                                      all the time, my legs hurt a lot, I had terrible

                                                   may trigger symptoms
Wessely, ‘and it’s important to continue to                                                                                                                                                                                                                                           fatigue. When I first went to see a neurologist, he
monitor changes over time.’ All participants
in the original Health and Well-Being Study
are being contacted again, and a new group
                                                                                                                                                                   about depression and                                                                                               said I probably had ME. I went back to work, but
                                                                                                                                                                                                                                                                                      had more time off, and then my hands started
                                                                                                                                                                                                                                                                                      shaking. When I went back to the neurologist,

                                                                                                                                                                   Parkinson’s disease
of armed forces personnel have been recruited                                                                                                                                                                                                                                         he referred me on to Charing Cross Hospital
to boost the numbers of individuals giving                                                                                                                                                                                                                                            where they diagnosed Parkinson’s. When the

                                                                                                                                                     Rehan Jamil
information about their experiences to 20,000.                                                                                                                                                                                                                                        doctor first told me, I was glad to have a name
This is now the biggest ever study of the                                                                                                                                                                                                                                             for what was wrong. But then it hit me later, and
health of the armed forces, is funded by                                                                                                                                                                                                                                              I was shocked and just stayed in bed for while.
the UK Ministry of Defence, and includes                                                                                                                                                                                                                                                 ‘Charing Cross put me in touch with a
personnel who have been deployed more                                                                                                                              More than a third of people with Parkinson’s                   and the north-east of England, Liverpool            Parkinson’s nurse, and I rang her, and she put me
recently on military operations in Afghanistan.                                                                                                                    disease have depression or low mood. But                       and north Wales.                                    in touch with the Younger Parkinson’s Network,
  ‘Originally, it was anticipated that Iraq                                                                                                                        doctors often find it hard to recognise it                        They will be interviewed about their             a volunteer group within the Parkinson’s Disease
was going to be a short, limited conflict, but                                                                                                                      because many of the symptoms are similar                       general health, their Parkinson’s symptoms          Society. I went with my mum on a weekend
things haven’t turned out as expected,’ said                                                                                                                       to those of Parkinson’s itself – and when it                   and management of them, and they will be            away organised for younger people who
Professor Wessely. ‘There has been counter                                                                                                                         is diagnosed, treatment is not necessarily                     assessed for symptoms of depression and other       had Parkinson’s and first of all, when I saw
insurgency and peace enforcement duties,                                                                                                                           the best it could be, says Professor Richard                   mental health problems. Each participant            wheelchairs in the foyer, I thought: “oh no”... and
and we want to find out what effect this has                                                                                                                         Brown who is based in the MRC Centre for                       will be interviewed once a year for five years,      I kept staring at everyone. Then there were talks
had on people’s health. Because operations                                                                                                                         Neurodegeneration Research. Antidepressants                    to allow researchers to find out what happens        by doctors, and I started talking to the people
in Iraq have become prolonged, a health                                                                                                                            tend to be prescribed, but there have been                     to those who are depressed, and if and when         there, and as I found out more, it was easier. I
effect may become apparent with time.                                                                                                                               no long-term studies to find out how effective                 depression develops in those who are not            joined the national committee for the Younger
The possibility of a delayed effect cannot                                                                                                                          they are for patients already taking medication                depressed at the beginning of the study.            Parkinson’s Network and did that for six years.
be ignored.’                                                                                                                                                       for Parkinson’s.                                                  ‘We want to find out if there is more than           ‘I had to finish work (at Barclays Bank) in 2001
  Between January and June 2003, about                                                                                                                               ‘Because it’s difficult to assess, depression                  one type of depression, why some people             on health grounds.
46,000 UK service personnel were deployed                                                                                                                          in people with Parkinson’s can be under-                       become depressed and others don’t, why                 ‘I’m on medication for the Parkinson’s – I take
to Iraq for Operation Telic 1. Since June 2003,                                                                                                                    diagnosed or misdiagnosed,’ he said. ‘Patients                 some recover while others remain chronically        tablets four times a day, and I have learned how
UK forces have continued to be deployed in                                                                                                                         themselves may fail to recognise symptoms                      depressed,’ he said. ‘This will also help us        to manage it. I’m 36 and single and should be
south-eastern Iraq and neighbouring areas,                                                                                                                         as depression because they overlap with the                    understand more about how depression in             going out in the evening, but if I’m very tired,
and by the end of 2005, 100,000 UK military                                                                                                                        symptoms of the disease. Or they may be                        Parkinson’s should be assessed and diagnosed.       it triggers the dyskinesia – the involuntary
personnel had served there.                                                                                                                                                                                                       At the moment, we are unable to effectively          moving – and I hate doing that in public.
                                                                                                                                                                   ‘If depression is diagnosed, doctors                           identify which patients are depressed, let             ‘If I’m tired and anxious, I can get the shakes,
‘Reserve troops in Iraq experienced                                                                                                                                currently rely on antidepressants, but                         alone which ones are at risk of becoming so.        so I do have to pace myself. The other day I
more mental ill health than regulars’              Reports of electromagnetic sensitivity –              ‘We found no evidence to indicate that                    their effectiveness has not been tested’                          ‘If depression is diagnosed, doctors currently   pruned a rose bush and the next day my hand
                                                   symptoms like headache, nausea and tingling        self-reported sensitivity to mobile phone                                                                                   rely on antidepressants, but their effectiveness     wouldn’t move.
   Members of the Territorial Army and             caused by electrical devices – have increased      type signals has a biological basis,’ said                   reluctant to raise depression with their                       has not been tested in clinical trials,’ he said.      ‘I had a bad bout of depression when I was
other reserve troops who were sent to Iraq         dramatically in Britain over recent years. It      James Rubin from the Unit, who led the                       doctor, believe it’s to be expected, or                        ‘We need more research into other approaches        about 20, and went on antidepressants at the
experienced more mental ill health than            is estimated that four per cent of people in the   research. ‘This is in line with the results                  think it’s irrelevant when they and their                      to treatment as an alternative to medication,       time.
regulars who were deployed there.                  UK have these medically unexplained problems       from the majority of previous studies testing                doctors are concentrating on managing                          and we can only do that when we know more              ‘I think Parkinson’s and depression are
   The study found reserve troops who had          when near power lines or mobile phone masts,       for electromagnetic sensitivity – that there is              their physical symptoms. They may also                         about the nature, causes and consequences of        linked. I get good days and bad days. I see the
served in Operation Telic 1 were more likely       or when using computers and mobile phones,         no difference in the severity of the symptoms                 be reluctant to take more drugs on top of                      depression in Parkinson’s.’                         consultant every six months and he can tell
to have depression and anxiety, and twice as       for example.                                       elicited by active or sham exposure to                       their already complicated treatment regimes.                      The study of Mood States in Parkinson’s          what frame of mind I’m in. He prescribed me
likely to have symptoms suggestive of post           The Mobile Phone Research Unit at the            electromagnetic fields.’                                        ‘But evidence suggests depression in                         Disease is being carried out in collaboration       with antidepressants which I take in addition
traumatic stress disorder than their full-time     IoP carries out a programme of research to            But if an electromagnetic field does not                   Parkinson’s disease is associated with a                       with Newcastle University and the University        to the Parkinson’s medication.
colleagues who were on active duty.                find out more about reported symptoms of            cause the symptoms, what does? Dr Rubin                      greater disability and cognitive impairment,                   of Liverpool.                                          ‘When I’m down, I can be really horrible but
   ‘Regulars are constantly with their peers       sensitivity to both mobile phone signals and       thinks the problems may be the result of a                   with reduced quality of life and even increased                   About 10,000 people in the UK are diagnosed      there’s nothing I can do about it. I don’t cry
and can wind down and share experiences            other electromagnetic fields. The work is           ‘nocebo’ phenomenon – an ill effect caused                    mortality. If a patient has depression, it is also             with Parkinson’s disease each year: symptoms        a lot, but I do dwell on things, and little things
with each other,’ said Professor Wessely.          supported by research grants from the UK           by the suggestion or belief that something                   more likely that their family care-givers will                 on average first appear when a patient is older      really get to me.
‘Reservists return to civilian life after only a   Mobile Telecommunications and Health               is harmful. ‘Psychological factors could play                be depressed or distressed,’ he said.                          than 50, although one in 20 people diagnosed           ‘If I’m stressed, or get worked up, or
couple of days of demobilisation and become        Research programme.                                a part,’ he said.                                              Now Professor Brown is leading a large                       is aged under 40.I                                  worry about being ill, I can get very miserable.
an individual again. They are no longer part         And so far, the studies have found that             Another explanation is that chronic                       Parkinson’s Disease Society-funded study to                                                                        Sometimes I hate myself – I’m on my own and

                                                                                                                                                                                                                        Rehan Jamil
of a unit and are instead spending time with       people who report symptoms when using              illness or another health problem might                      find out more about the nature of depression                                                                        I’ve got a horrible illness. I saw a counsellor for
family, friends and work colleagues who may        a mobile phone do not react any differently         cause the symptoms. A study carried out                      experienced by patients: the results will be a                                                                     two-and-a-half years and I think that did me good.
have little understanding of their experience.     to genuine or sham signals in testing sessions.    by the Unit compared the health of 71                        springboard for future research on treatments                                                                         ‘I accept the depression though. When it comes
   ‘On return from the invasion of Iraq, they        One study carried out by the Unit showed         people who reported sensitivity to mobile                    specifically tailored to the needs of people                                                                        I know it will pass again. I think it’s all

also no longer had access to military medical      that 63 per cent of participants who said          phones with the health of 60 people who                      with Parkinson’s. ‘The most limiting factor in                                                                     part of the course of the illness.
services. Any health problems they had would       they reacted to mobile phones believed a           experienced no problems. Nineteen of those                   finding the best treatments is our inadequate
have been dealt with by the NHS, and the           signal to be present when in fact it wasn’t.       sensitive to mobile phone signals also had                   basic knowledge of the condition itself,’ he
number of NHS doctors with experience of           These sham signals triggered symptoms in           symptoms triggered in the presence of other                  said. ‘Until now, no large-scale or long-term
the military is small.’ When the results of        the same way that mobile phone signals did         electromagnetic fields. Those who reported                    studies have been carried out.’                                                                                    The Parkinson’s Disease Society supports
this research were published, the government       during the testing sessions, carried out under     the greatest electrosensitivity also experienced               At least 500 people with Parkinson’s are                                                                         people with Parkinson’s, their families,
immediately revised its policy: military health    ‘double blind’ conditions, when neither the        greater depression and worse general health,                 being recruited to the study through hospital-                                                                     friends and carers, and funds research
services are now available to reservists who       researchers nor the participants knew whether      and were more likely to worry about things                   based neurology or care of the elderly services                                                                    into the progressive neurological condition.
have been demobilised since 2003.I                 signals were really being transmitted.             like tainted food.I                                          in London and south-east England, Newcastle                                                                        Visit
32 | Post traumatic stress disorder |                                                                                                                                                                                                                                    | Post traumatic stress disorder | 33

                                                                                                                                                                                                                                                                                                                        P A Photos
Communication with friends and
family vital in aftermath of tragedy
Ordinary people are very resilient and               to travel less on public transport and would        The first survey showed that 71 per cent of
generally don’t need professional help to            cut down on visits into central London.          those interviewed had spoken to family and
cope with tragedy and disaster if they                  But six months later, a follow-up telephone   friends about the attacks. Less than one per
haven’t been directly involved or affected.          survey of the same people found the level of     cent had sought professional help and only
That’s the view of Professor Simon Wessely,          distress had dropped considerably.               12 people said they needed it.
Professor of Epidemiological and Liaison                Those who remained seriously worried             ‘The theme running through this is that
Psychiatry, informed by various studies,             and concerned were the ones who had              people don’t crack up, and psychological help
the most recent of which surveyed                    had difficulty contacting family and               for everyone from mental health professionals
Londoners’ reactions in the wake of                  friends on the day, said Professor Wessely.      is not necessary. Resources should therefore
the July 2005 tube bombings.                         Following the bombings, this stressful           be concentrated on the small number of people
   Working with MORI (Market and Opinion             experience had been exacerbated by the           who do need it.
Research International), a team of researchers       mobile phone networks’ inability to cope.           ‘Our research has shown that it was the
from the IoP carried out a random telephone             ‘The surveys showed that in the aftermath     same with population reactions in the Blitz –
survey to find out how the terrorist attacks          of a tragedy, people want to talk to family      people’s morale does not collapse. But some
had affected the emotional well-being of              and friends, to mobilise their own social        things have changed since then – in our more
people who had read about or seen TV                 networks, and therefore in emergencies,          individual-focused world of today, we tend
footage of the carnage. The Home Office-               communication is important and should            to forget that when bad things happen, we are
funded survey took place 10 days after the           be encouraged,’ he said. ‘Instead of telling     supposed to feel bad. Unlike during the Blitz,
bombing and finished a few days before the            people not to use their phones, we should        nowadays all of us have almost instant media
second failed attack on the transport network.       be saying “keep it short.”                       exposure to people in severe distress, and so
   Thirty-one per cent of the 1,010 people              ‘There have been similar findings in Israel    feel the need to “do something”. Hence the
interviewed said they were very distressed,          where population surveys have shown the          knee-jerk response to send in the “trained
55 per cent felt they were in danger and 58          vast majority of people find checking on the      counsellors”. It makes us feel better, even
per cent feared for the safety of their family and   whereabouts of their family and friends to       if the research shows it does little good for
friends. Thirty-two per cent said they planned       be a helpful coping strategy after an attack.’   those directly affected.’I

Cognitive behaviour therapy can
help lay traumatic memories to rest
Cognitive behaviour therapy (CBT) has been           for PTSD, for example, shows that 75 per           Their first step in developing a CBT            ‘After a trauma, it’s normal to have intrusive     said Professor Clark. ‘If they felt as if they were   ‘People’s view of themselves can change,
much in the news over recent years and has           cent of people no longer have the diagnosis      programme for a particular problem is            memories that cause distress, but it’s natural     going to die during the trauma, they feel as if       they may seriously worry because they start
been recommended by the UK National Institute        after treatment and a further 15 per cent        to find out why people aren’t getting better      for those memories to wane over a period of        they are going to die every time the memory           to believe they are not as able, competent,
for Health and Clinical Excellence (NICE) as an      improve, but don’t get fully better. Work is     naturally. ‘Most people, for example, recover    time. It’s a similar process to getting over the   comes. What we do is to try to help them              good or kind as they thought they were.’
effective treatment for all sorts of mental health   now underway to investigate ways of helping      from anxiety without the need for treatment.     loss of a loved one. The natural course is         elaborate that memory by making it connect            These self-doubts and faulty beliefs can
problems. The umbrella of CBT embraces a wide        people with remaining symptoms further.          They are able to work out themselves that        towards recovery.’                                 in their minds with the information “I didn’t         seriously affect the way people lead their lives.
range of treatments, however, and the ones              ‘There are a lot of different techniques       their thoughts are unrealistic, that they are      In PTSD, Professors Clark and Ehlers think       die” and “I am still alive” here in the present.’       The therapist’s role is once again to help the
that work best are those designed specifically       and versions of CBT for PTSD,’ said Professor    over-estimating how much danger there is.        something goes wrong with the processing                                                                 patient find a more balanced perspective, to
to address the particular symptoms of a              Clark. ‘Some look at stress management, for      So in the first instance, we carry out detailed   ability of memory, making it impossible for        ‘People with PTSD actually feel                       help an individual search for evidence to show
disorder or problem.                                 example, but the most effective versions are      interviews with patients to discover what        individuals to put the traumatic experience        their memories as if they were                        them that their behaviour was all that could
  Professors David Clark and Anke Ehlers             trauma-focused. The NICE review of PTSD          prevents their thinking from self-correcting.’   behind them.                                       present reality’                                      be expected of them in the circumstances.
have done just that, developing and evaluating       treatments has shown that you really have          For PTSD, they needed to study the               One of the planks of the CBT programme                                                                   ‘If after a terrorist attack someone feels
treatment programmes for people with panic           to tackle the trauma directly, otherwise the     characteristic all-consuming intrusive           they have developed is based on the premiss          People with PTSD also often have very               guilty because they think they should have
disorder, social phobia, and people with post        outcome won’t be as good. The problem            memories that haunt an individual,               that individuals are unable to ‘elaborate’ their   negative thoughts about themselves and their          done more to help others, we explore the
traumatic stress disorder (PTSD).                    is that working with the memory of the           flashbacks that make it feel like the             memories of the event – to process them as         own capabilities. ‘People blame themselves for        reasons why they could not do more – they
  Both psychologists say this targeted               trauma is painful, and patients will not         assault, accident or disaster is happening       something that has happened in the past and        what happened, or think they didn’t do the            were in shock, or injured, for example, or were
approach leads to the very best results:             be able to go through with treatment if          to them time and time again.                     store them, rather than constantly experience      right thing, or feel shame because they didn’t        already helping other people and could not
the research they have carried out to test           the work is not done in a sensitive way.           ‘A sizeable number of people cope with         them. ‘People with PTSD actually feel their        resist an attack, or guilt because they didn’t        be in two places at the same time. We may
the efficacy of their programme of CBT                 But it can be done.’                             trauma by themselves,’ said Professor Clark.     memories as if they were present reality,’         stop what happened,’ said Professor Ehlers.           also ask other people what they would have
                                                                                                                                                                                                                                                                                            continues over the page ¡
34 | Post traumatic stress disorder |                                                                                                                                                                                                                                                                         | Psychosis | 35

done in the same situation and feed their            violent crimes, attacks and disaster in the          The service was set up in the immediate
answers back to the patient,’ said Professor
  Tackling the triggers of the intrusive
memories is another important aspect of
                                                     1990s. More recently, they have successfully
                                                     used the programme to help victims of terror.
                                                       The Omagh-based Northern Ireland Centre
                                                     for Trauma and Transformation (NICTT)
                                                                                                          aftermath and everyone known to the police
                                                                                                          and accident and emergency services was
                                                                                                          contacted and sent a questionnaire, which
                                                                                                          screened for symptoms of PTSD: those who
                                                                                                                                                                           How do ingredients of cannabis
the therapy. Smells, sounds or things in the
environment that are seemingly unrelated
can suddenly and unexpectedly prompt the
realistically vivid images, said Professor Ehlers,
                                                     was set up in 2002 to offer CBT to people who
                                                     had PTSD as a result of civil conflict in earlier
                                                     decades: some people referred there were still
                                                     experiencing vivid, intrusive memories from
                                                                                                          needed help were offered quick referral for
                                                                                                          a two-year period. ‘This two-year outreach
                                                                                                          programme was necessary because sometimes
                                                                                                          more severe or complex cases take longer to
                                                                                                                                                                           induce symptoms of psychosis?
and detective work is sometimes called for to                                                             come forward for treatment,’ said Professor
make the link so an individual can understand        ‘CBT is an effective treatment for PTSD              Ehlers. People could also self-refer to the                      What does cannabis do to the brain and

                                                                                                                                                                                                                                                                                                                                 Rehan Jamil
why that is happening. ‘If someone were              related to terrorism for both civilians              screening team and all GPs in the capital                        how does it contribute to the symptoms
involved in a road traffic accident at night,          and people in the military’                          were sent information about the service.                         of psychosis? Some 50 healthy volunteers
and the last thing they saw was the glare of                                                                Different centres used their own form of                        are helping researchers find out more about
headlights, they might be sitting in the garden      40 years ago. The whole Centre was set up            CBT: here at the Centre for Anxiety Disorders                    the effects of the drug on both the chemistry
and suddenly feel terrified because the sun           as a controlled trial, the results of which have     and Trauma, the Clark/Ehlers model was used.                     of the brain and their thoughts in a series
unexpectedly breaks through the clouds.              proved that CBT is an effective treatment for         In total, some 200 people received treatment,                    of laboratory-based projects.
This sort of trigger, that isn’t at all obvious,     PTSD related to terrorism for both civilians         and improvement in symptoms was measured                           The links between cannabis and
might make them think they are “going                and people in the military.                          at the end of each session to enable a future                    schizophrenia have regularly hit the
mad”,’ said Professor Clark.                            ‘Some of the people referred to the Centre        analysis of its success.I                                        headlines for the past couple of years.
  The CBT programme Professors Clark and             were multi-traumatised and had been victims                                                                           IoP researchers have already shown that
Ehlers’ team has developed stretches over            of terrorism several times,’ said Professor Clark.                                                                    people who have a pair of one type of the
three months, with 12 90-minute weekly               ‘Many had tried previous therapies that had                                                                           ‘COMT’ gene are more likely to develop
sessions. Professor Ehlers and her colleagues        been unsuccessful.’
                                                                                                          and...                                                           schizophrenia if they smoke cannabis
have recently been testing the success of a            In addition to its continuing caseload,            Research into the psychological consequences                     regularly during teenage years, and that
programme with the same number of hours              the Centre now has the remit to train other          of war, political violence, torture and natural                  people with psychosis who continue to smoke
condensed into a week: the idea is to offer a         therapists in CBT for PTSD throughout Ireland.       disaster is undertaken in collaboration                          cannabis can make their symptoms worse.
shorter treatment for people whose memories          Professor Clark continues to be the Clinical         with the Istanbul Centre for Behaviour                             Now Dr Paul Morrison is exploring the
impinge so much that their lives seem about          and Research Advisor there.                          Research and Therapy in Turkey. Dr Metin                         acute effects of cannabis on the brain, giving
to implode because of the resulting anger, fear,       The experience gained in Omagh was                 Basoglu is both Head of the Trauma Studies                       each of his volunteers an injection of pure,
nightmares and lack of sleep. The Wellcome           invaluable when the team from South London           Research Group at the IoP and founder                            synthetic THC, the psychoactive ingredient
Trust-funded trial is being carried out in           and Maudsley NHS Foundation Trust’s Centre           and Director of the Centre. The research                         of cannabis that produces the ‘high’. He is
collaboration with Oxford University’s               for Anxiety Disorders and Trauma teamed              focuses on developing effective treatments                       then scanning their brains and asking them
Department of Psychiatry, and results                up with Professor Chris Brewin at University         for survivors of mass trauma who have                            to describe how they feel while having the
from a pilot study are promising.                    College London and other trauma centres in           post traumatic stress disorder, and to                           equivalent to a joint of street-strength skunk       ‘By comparing the information from            attached to the head and hooked by wires to
  Professors Clark and Ehlers first started           the capital to offer therapy to people directly       promote the evidence-based treatment to                          cannabis in their system. ‘The idea is to         the scans with the descriptions of what          a computer. This will allow researchers to see
developing CBT for PTSD following accidents,         affected by the tube bombings on July 7 2005.         disaster-struck countries around the world.                      explore how THC produces the symptoms             the volunteers are feeling, we will find          if there are any changes in the normal pattern
                                                                                                                                                                           of acute psychosis,’ he said.                     out if the activity of dopamine is related       of communication between brain cells when
                                                                                                                                                                             And he’s found that about 40 per cent of the    to the temporary psychosis experienced           the volunteers are asked to do a simple task
                                                                                                                                                                           volunteers get symptoms of psychosis during       by some. We will also be looking to see          like tapping with one finger or saying ‘ah’.

Public unperturbed by polonium
                                                                                                                                                                           the two hours they are under the influence         if those people who did experience symptoms         ‘We want to find out whether THC has an
                                                                                                                                                                           of the drug. ‘Some people have delusions,         of psychosis share the same types of COMT        effect on the synchronised firing of neurons
                                                                                                                                                                           for example, believing their minds are being      genes,’ said Dr Morrison. This work is           needed to make something happen in our
                                                                                                                                                                           read, and some feel that something else is        to continue in future with PET (positron         bodies. If there is an effect, it might explain
                                                                                                                                                                           controlling their movements and thoughts,’        emission tomography) scanners at St Thomas’      why sometimes people don’t know if they
                                                                                                                                                            Getty Images   he said. ‘Some are no longer aware if they        Hospital, which give more information and        have spoken something or just thought it,
When former Russian spy Alexander Litvinenko         the risk to the general public was low. The                                                                           are merely thinking or are actually speaking      better images of the brain’s chemistry.          the apparent disconnection between the
died from polonium 210 poisoning in London           Agency briefed the press on an almost daily                                                                           out loud.’ There is no marked change in the          A second project is looking at the effects     will to do something and actually doing
in November 2006, the public were not overly         basis and similarly updated its website.                                                                              behaviour or perception of the other 60 per       of THC on attention, memory and reasoning.       it, and knowing that you have done it,
worried about the possible effects of the            Seventy-one per cent of those interviewed                                                                             cent: a few are really bored, he says, while      Following the injection, volunteers are asked    which we usually experience as one
radioactive substance on their health, even          by phone said they knew there was no risk                                                                             the others feel completely in control but         to carry out pencil and paper tests designed     event,’ said Dr Morrison.
though traces were discovered in the heart           unless they had spent time in a contaminated                                                                          altered in a way ‘that’s very enjoyable’.         to measure these cognitive abilities, and once      THC is one of more than 60 molecules
of the capital.                                      area, and 80 per cent felt the HPA’s response                                                                           Each of the volunteers in this study have                                                        found in the cannabis plant: another molecular
   An analysis of a telephone survey of 1,000        had been appropriate.                                                                                                 SPET (single-photon emission tomography)          ‘40 per cent of volunteers get symptoms          candidate for inducing altered behaviour is
Londoners carried out by a research team from           Members of the public who had been in a                                                                            scans at University College Hospital in           of psychosis during the two hours they           CBD, which reduces anxiety. Dr Morrison
the IoP concluded this was because people            contaminated area were advised to telephone                                                                           central London, before and after the injection,   are under the influence of the drug’              and colleagues are about to start work on
assumed the death was an act of espionage            NHS Direct, and many received follow-up calls                                                                         to measure what’s happening to the dopamine                                                        similar information-gathering projects to
rather than an act of terrorism, and because         from the HPA. People who were potentially at                                                                          systems in their brains. Scientists studying      more to talk about how they are feeling. The     assess this molecule’s effect on the brain,
they were re-assured by information about            risk were offered a urine test. The research                                                                           schizophrenia think disturbance of this           research team wants to find out if those people   injecting a synthetic version, then scanning,
the minimal risk to public health issued by          team also carried out in-depth interviews                                                                             chemical neurotransmitter is somehow              who experience transient psychosis while the     testing and talking to healthy volunteers.
the UK Health Protection Agency (HPA). Only          with 86 people who had been in places that           of the incident as a “spy story” and partly                      instrumental in psychotic mental states.          drug is in their system also have difficulties        At the same time, they are designing a
12 per cent interviewed thought they might           had been contaminated. ‘Most were satisfied           due to successful communication about                            Dr Morrison’s research team is then               remembering and concentrating.                   tool that accurately measures the symptoms
be in danger: those who did mostly believed          with the contact they had had with the HPA,’         low risk. It’s important in similar incidents                    correlating the experiences of the volunteers       And another group of healthy volunteers is     of short-term psychosis caused by cannabis
the contamination was targeted against the           said James Rubin who led the research.               to give members of the public access to                          with the activity of the dopamine receptors.      soon to have an EEG (electroencephalogram)       alone, informed by the volunteers’ descriptions
wider public rather than an individual.                 ‘The polonium incident caused limited             detailed, comprehensible and relevant                            All volunteers are also giving a sample of        while under the influence of THC. This test       of how they are feeling. To date they have
  Polonium 210 must be ingested or inhaled           public concern about potential health risks.         information about any risk they might                            their DNA to allow researchers to find out         measures and records the electrical activity     been using existing measures designed for
to cause harm and the HPA continually stressed       This is partly due to the public’s perception        have been exposed to.’I                                          which types of COMT genes they have.              of the brain, and involves electrodes being      people with schizophrenia.I
                 36 | Psychosis |                                                                                                                                                                                                                                                                         | Psychosis | 37

                                                                                                                                                                   regions of the brain, are the most critical for    have a chemical effect on the brain on the           who gets side effects. We can then correlate

             Insight from brain scans helps hone                                                                                                                   ameliorating the symptoms of psychosis,’
                                                                                                                                                                   said Professor Kapur.
                                                                                                                                                                      Interfering with dopamine transmission
                                                                                                                                                                   in some areas of the brain can help to alleviate
                                                                                                                                                                                                                      first day of taking them.
                                                                                                                                                                                                                        The brain imaging technique he uses is
                                                                                                                                                                                                                      positron emission tomography (PET) and
                                                                                                                                                                                                                      the ongoing IoP-based research is being
                                                                                                                                                                                                                                                                          this information to what is happening inside
                                                                                                                                                                                                                                                                          the brain.’
                                                                                                                                                                                                                                                                            Listening to patients is as important as
                                                                                                                                                                                                                                                                          the metabolic information gleaned from

             the use of antipsychotic medication                                                                                                                   the symptoms, but blocking the transmission
                                                                                                                                                                   in other pathways can result in side effects.
                                                                                                                                                                   Blocking D2 receptors in areas of the brain
                                                                                                                                                                   involved in motor movement, for example,
                                                                                                                                                                                                                      carried out in collaboration with the PET
                                                                                                                                                                                                                      Imaging Centre at St Thomas’ Hospital on the
                                                                                                                                                                                                                      South Bank in London. The Centre is part of
                                                                                                                                                                                                                      both Guy’s and St Thomas’ NHS Foundation
                                                                                                                                                                                                                                                                          the PET scans, he said. Their personal
                                                                                                                                                                                                                                                                          experiences are crucial to the research.
                                                                                                                                                                                                                                                                          Through this process the research team
                                                                                                                                                                                                                                                                          has learned that the medications don’t
                                                                                                                                                                   can lead to tremors and involuntary muscle         Trust and King’s College London’s School of         simply eradicate the delusions and the
                 The majority of people with schizophrenia           Understanding more about how                Are some receptors they bind linked to            movements. Professor Kapur and his team’s          Medicine, a sister School of the IoP.               hallucinations – they often help patients
                 are, at some time after diagnosis, prescribed     and where the medications interact            other receptors in different parts of the brain?   research has shown that some drugs also                                                                to detach themselves from the symptoms,
                 antipsychotic drugs, medication given not         with the natural chemicals inside the         And why is it that antipsychotic medication       block D3 receptors, but never D1 and D4.           ‘Ultimately, this research will allow the           to push them ‘to the back of their minds’.
                 to cure, but to alleviate the symptoms of         brain can help doctors refine dosages          has no effect at all on some people?               What effect then does that action have              design of more effective medication’                  ‘All the research is about yielding
                 psychosis – hallucinations, delusions,            and use existing drugs in a more effective        Professor Shitij Kapur, newly-recruited        on the symptoms of psychosis, and what                                                                 information that allows us to refine the
                 agitation and confusion.                          way, with fewer resulting side effects.        Psychiatrist and Neuroscientist at the IoP,       unwanted symptoms does it cause?                      PET scans illustrate the chemistry of our        drugs, to allow better use of the medications
                   No one fully knows, however, how                  Researchers already know that the           is working with volunteer patients, brain            ‘We also need to find out the amount             bodies, and can be designed to highlight one of     currently available, and ultimately to design a
                 the family of drugs used as antipsychotic         abnormal production of too much of            scans and funding from the Medical Research       of medication we need to use,’ he said.            the thousands of different neurotransmitters in      totally new, more effective set of medications,’
                 medication achieve their effects. Just as          the brain chemical dopamine can lead          Council to find the answers to the many            ‘We have already observed that if you block        the brain, and show its activity at any one time.   said Professor Kapur.
                 scientists do not yet have a complete picture     to hallucinatory experiences, delusions       hows, wheres and whys about antipsychotic         65 per cent of the dopamine system, people            The scan involves the injection of a very          In the long term, then, increased knowledge
                 of what happens inside the brain to cause the     and disordered thoughts. The chemical         medication. It’s a continuation of work           get relief from hallucinations and delusions.      small amount of a radioactive tracer designed       about the neurochemical processes involved
                 symptoms of psychosis, they do not yet have       structure of antipsychotic medication         previously carried out when Professor             But if 80 per cent or more of the system           to search and lock on to a specific chemical         could lead to the development of more
                 a full understanding of the mechanisms of         allows it to bind with dopamine receptors     Kapur was Chief of Research at the Centre         is blocked, people get stiffness or tremors.        like dopamine. The scanner has cameras that         specifically targeted drugs that do the job
                 antipsychotic drugs, also called neuroleptics.    and block their function. It seems that       for Addiction and Mental Health in Toronto,       They also report a subjective dysphoria            detect the rays emitted from the radiotracers       they are designed to do, and that job only.
                   There are about two dozen different types                                                      Canada, looking at the role of brain receptors    – they say they feel like a “zombie”. So           and turn them into electrical signals that are        It may be that a new, third generation of
                 of antipsychotic medication, all of which alter   ‘Scientists do not yet have a full            and neurotransmitters like dopamine,              while the existing drugs can improve the           processed by a computer to generate images          antipsychotic medication will be designed
                 the levels of chemicals inside the brain. The     understanding of the mechanisms               and how these are affected by the drugs.           symptoms of psychosis, if too many receptors       of different ‘slices’ of the brain. The greater      to affect only, and very accurately, the levels
                 first were used in the 1950s and both this         of antipsychotic drugs’                       He and his team have shown that most              are blocked, it seems the more negative side       the concentration of the chemical, the greater      of very specific chemicals in just the parts
                 original generation of drugs (called typical                                                    antipsychotics, both old and new, block           effects a patient has. This has important           a signal it gives.                                  of the brain that are involved in creating
                 antispsychotics) and a second generation          by stopping the transmission of dopamine      dopamine D2 receptors, one type of                implications for the prescribed dosage.’              ‘We scan patients before they take the           the symptoms of psychosis.
                 used since the 1990s (atypical) can cause         from one nerve cell to another, the drugs     the group of receptors involved in the               Another finding emerging from this               medication, and then again afterwards to              As well as bringing direct benefits to
                 side effects in a significant number of patients.   dampen these symptoms.                        transmission of the chemical around the brain,    work has challenged the perceived wisdom           measure the chemical effects in their brain          patients, understanding how antipsychotic
                 These include drowsiness, muscle stiffness,          But does the medication stand in the        but to different degrees in different patients.     that antipsychotic medication doesn’t start        of different dosages, different drugs and after       drugs work also gives greater knowledge
                 a dry mouth, shaking, restlessness, increased     way of other neurotransmitters, in addition      D2 receptors are used in different pathways     working for up to three weeks. With the            different periods of time,’ said Professor Kapur.    about the chemical machinations of the
                 appetite, blurred vision and sexual difficulties,   to dopamine? Which receptors do they          in different parts of the brain for different       help of scores of patients and the insight         ‘At the same time, we keep records of their         brain that cause the symptoms of psychosis,
                 and are often one of the reasons why people       block, and in which parts of the brain?       functions. ‘One of the questions we want          given by brain scans, Professor Kapur              symptoms to find out whether the medication          helping to add more pieces to the jigsaw puzzle
                 stop taking their medication.                     Do the drugs block too many receptors?        to answer is which D2 receptors, in which         and his colleagues found that the drugs            is making a difference, who gets better and          of how and why schizophrenia develops.I
Michael Munday

                                                                                                                                                                                                                                                                                           These PET scans show
                                                                                                                                                                                                                                                                                           the level of dopamine
                                                                                                                                                                                                                                                                                           inside the brain before
                                                                                                                                                                                                                                                                                           and after treatment with the
                                                                                                                                                                                                                                                                                           antipsychotic drug haloperidol.
                                                                                                                                                                                                                                                                                           The first scan shows the level
                                                                                                                                                                                                                                                                                           of dopamine transmission
                                                                                                                                                                                                                                                                                           before drug treatment.
                                                                                                                                                                                                                                                                                           The second scan shows
                                                                                                                                                                                                                                                                                           how the medication blocks
                                                                                                                                                                                                                                                                                           the D2 receptors, thereby
                                                                                                                                                                                                                                                                                           decreasing the transmission
                                                                                                                                                                                                                                                                                           of dopamine signals from
                                                                                                                                                                                                                                                                                           one cell to another.
38 | Stigma |                                                                                                                                                                                                                                                                                                                     | Stigma | 39

                                                                                                                                                                                         advisory group will at the same time draw          The advantage of regular public attitude           severe mental health problems are in work

Massive campaign to stamp out                                                                                                                                                            on experience from across the world to
                                                                                                                                                                                         inform the campaign’s on-the-ground
                                                                                                                                                                                         activities, and the Moving People team
                                                                                                                                                                                         will work closely with the UK government-
                                                                                                                                                                                                                                          surveys is that they can measure trends over
                                                                                                                                                                                                                                          time. As well as using this information to help
                                                                                                                                                                                                                                          evaluate the overall success of Moving People,
                                                                                                                                                                                                                                          the IoP team will be finding out about the
                                                                                                                                                                                                                                                                                               and many people with mental illness won’t
                                                                                                                                                                                                                                                                                               even apply for a job because they anticipate
                                                                                                                                                                                                                                                                                               discrimination, he said.
                                                                                                                                                                                                                                                                                                  Moving People will produce material

discrimination against mental illness                                                                                                                                                    funded SHiFT campaign, also challenging
                                                                                                                                                                                         stigma and discrimination in England.
                                                                                                                                                                                            The IoP’s role is one of evaluation: the
                                                                                                                                                                                         consortium members charged with making
                                                                                                                                                                                                                                          experiences of people with mental health
                                                                                                                                                                                                                                          problems, whether they find others’ attitudes
                                                                                                                                                                                                                                          towards them actually do change, and whether
                                                                                                                                                                                                                                          that in turn has an impact on discriminatory
                                                                                                                                                                                                                                                                                               specifically for employers, including
                                                                                                                                                                                                                                                                                               guidance on how to implement the Disability
                                                                                                                                                                                                                                                                                               Discrimination Act. The campaign team
                                                                                                                                                                                                                                                                                               also plans to mount legal challenges to help
                                                                                                                                                                                         Moving People happen are three charities –       practice. ‘There’s a difference in what people        highlight and change discriminatory policy.

                                                                                                                                                            Peter Bush/NZ Rugby Museum
                                                                                                                                                                                         Mental Health Media, MIND and Rethink.           say when they are asked questions in a survey        Educating employers about the reality
                                                                                                                                                                                         Some of these organisations’ existing local      and how they behave in real life,’ said Professor    of mental illness is crucial, said Professor
                                                                                                                                                                                         activities are to be immediately expanded to     Thornicroft. ‘Part of our evaluation will            Thornicroft. A survey carried out by the
                                                                                                                                                                                         bring people with and without mental health      be to assess changes in the experience of            Shaw Trust showed that all 550 employers
                                                                                                                                                                                         problems together on a regular basis, with a     discrimination and we will start with a              asked said none of their workforce had
                                                                                                                                                                                         focus on physical activity – from football to    baseline survey of 1,000 people in England           a mental health problem. But, statistically,
                                                                                                                                                                                         conservation projects.                           using a scale we have developed to measure           50 per cent of them are likely to be employing
                                                                                                                                                                                                                                          the discrimination they encounter. By                people with mental ill health, he said. ‘The
                                                                                                                                                                                         ‘Many people have strong, stereotyped            repeating this survey over four years, we            problem is, when companies believe these
                                                                                                                                                                                         views about mental illness, often formed         will be able to see if the campaign does             issues don’t affect them, they are not interested
                                                                                                                                                                                         in childhood’                                    affect the reality of everyday experience.’           in help with employment practices.’
                                                                                                                                                                                                                                            The bottom line, he says, is that people with         He is made optimistic, however, by recent
                                                                                                                                                                                            There will be periodic high-profile            mental illness have as much right as everyone        research from New Zealand, Scotland and
                                                                                                                                                                                         mass activity events like sponsored              else to full citizenship, to have relationships      Australia that shows outlooks can be changed,
                                                                                                                                                                                         walks to both raise awareness and bridge         and jobs. ‘They should feel able to disclose         that stereotypical beliefs are not set in stone.
                                                                                                                                                                                         the gap between those with mental health         their mental illness to potential employers and      ‘We know we won’t eradicate stigma and
                                                                                                                                                                                         problems and those without. A programme          not fear doing so, as many currently do, and         discrimination in four years,’ he said. ‘Think
                                                                                                                                                                                         of training in medical schools and teacher       should be able to get full entitlements under        about kneeling buses for wheelchair users –
                                                                                                                                                                                         training colleges, led by service users, will    the Disability Discrimination Act in the same        it took 20 years to make them a reality after
                                                                                                                                                                                         aim to inform young professionals’ views         way that people with physical disabilities do.’      continued campaigning and advocacy. None
                                                                                                                                                                                         before they take the first steps on the career      Research has shown that employment can             of us involved in Moving People thinks the task
                                                                                                                                                                                         ladder: discrimination in education and          promote good mental health, but a diagnosis of       will be complete within the time plan. This
                                                                                                                                                                                         even health services is well-documented.         mental illness counts against applicants for jobs.   is the start of a long-term concentrated and
                                                                                                                                                                                            The four-year project has £18 million         Only about 20 per cent of people with more           persistent campaign.’I
                                                                                                                                                                                         worth of funding: ‘an award of this scale
                                                                                                                                                                                         is a once in a lifetime opportunity,’ said
                                                                                                                                                                                         Professor Thornicroft. He does not,
                                                                                                                                                                                         however, underestimate the difficulties
                                                                                                                                                                                         in ‘changing knowledge, attitudes and,
                                                                                                                                                                                         most importantly, behaviour.’
                                                                                                                                                                                            Since March 1993, the Department of
                                                                                                                                                                                                                                          ‘Risk’ from patients
                                                                                                                                                                                                                                          is based on anecdote
                                                                                                                                                                                         Health has funded national surveys of public
                                                                                                                                                                                         attitudes toward mental health. The most
                                                                                                                                                                                         recent 2007 survey found that some attitudes
                                                                                                                                                                                         have deteriorated over the last decade and
                                                                                                                                                                                         that, in particular, the perceptions of danger
                                                                                                                                                                                         posed by people with mental health problems
Former All Blacks player John Kirwan is one of a host of New Zealand celebrities who have spoken about their                                                                             have worsened.                                   Local communities are often up in arms               away from the unit by a patient who had
mental health problems in a series of TV adverts made for the national Like Minds Like Mine anti-stigma campaign.                                                                           Much of this deterioration may be to          about the prospect of having a secure forensic       absconded. No patients were convicted of
                                                                                                                                                                                         do with the way in which mental illness          psychiatric unit sited in their neighbourhood:       violent or sexual crimes during the five years.
England’s biggest ever nationwide anti-stigma       the national charity Rethink to find ways             experience of discrimination can make                                           is portrayed in the media, said Professor        so much so, they may mount legal campaigns           There were a number of incidents that were
campaign in the field of mental health is to        of combating stigma and discrimination,              a real difference to the attitudes of police                                     Thornicroft.                                     against them, quoting risk of violence and           investigated by police but did not lead to a
be launched in 2008, and the IoP is part of         and works internationally in this field.              and secondary school children. Now research                                        ‘There is evidence that media coverage        criminal activity by patients.                       conviction – a patient with a history of arson
the consortium leading it.                            ‘Many people have strong, stereotyped              from around the world is demonstrating how                                      reinforces stereotypes and perpetuates             But research has shown that this perception        was found not guilty of deliberately starting
  Funded by the Big Lottery and Comic               views about mental illness, often formed in          successful national anti-stigma campaigns can                                   misinformation. Previous research has            of risk is based on anecdotes alone, and that        a fire in supermarket toilets, for example.
Relief, Moving People is the working title          childhood. Direct contact with individuals           also be. A carefully orchestrated campaign                                      shown that two-thirds of news items              communities worry unnecessarily.                       The research had set out to discover the
of the campaign which will involve thousands        means they can learn the truth, become more          in New Zealand, for example, says Professor                                     about mental illness are about risk,               Secure forensic psychiatric inpatient units        true nature and level of risk posed by patients
of service users up and down the country            informed about the reality of mental illness         Thornicroft, has led to a gradual improvement                                   violence and threat. Fewer than 10 per           assess, treat and rehabilitate offenders with         in medium secure units in the south-east
and aims to change attitudes that lead to           and find out that people with mental health           in public attitudes over the past 10 years, and                                 cent of news stories are about service           mental health problems. As part of their             of England. ‘Our results clearly demonstrate
discrimination against people with mental           problems are people just like anyone else.’          has included a series of TV adverts which put                                   users, and people with psychosis are rarely      rehabilitation, patients are offered supervised       medium secure units in this study did not
health problems in almost every aspect of             Countless studies have highlighted people          the spotlight on celebrities talking about their                                interviewed or quoted: they are wrongly          and unsupervised leave from the units.               have an impact on serious crime rates in
their lives.                                        with mental illness reporting discrimination         experience of mental ill health.                                                assumed not to be able to speak on their own       A study of four secure units, carried out          the local communities,’ said Professor Fahy.
  ‘The strong evidence is that an effective          in work, marriage, parenting, relationships,           Moving People will also include a                                             behalf.’ Part of Moving People’s campaign will   by Professor of Forensic Mental Health               ‘Acts of severe violence committed by patients
way to reduce stigma is through direct              housing, leisure and religious activities.           media campaign, but only after a detailed                                       be targeted at the press, and the research       Tom Fahy with West London Mental Health              on these units are rare, and even rarer in the
personal contact,’ said Professor Graham              And yet Professor Thornicroft’s research           consultation has been carried out with service                                  team will be monitoring press cuttings,          Trust, showed that over five years, there             vicinity of the units. Our findings show that
Thornicroft, who has been involved for              has shown that just two short sessions where         users throughout England to shape its content                                   analysing the nature of coverage – sources       was only one conviction – and that was for           the units do a good job in managing the risk
some years in a research partnership with           service users talk about their lives and their       and help develop a ‘brand’. An international                                    used, balance, focus, language and tone.         a burglary, carried out more than five miles          that some patients in these units may pose.’I
40 | Stroke |                                                                                                                                                                                                                                                                           | Stroke |                                      | Suicide | 41

                                                                                                                                                          Photo courtesy of Andy McCann
                                                                                                                                                                                                                                               of the brain, which had bled and clotted

Harnessing the power of neural                                                                                                                                                                                                                 over time. ‘We don’t know why it split –
                                                                                                                                                                                                                                               there have been reported cases of it doing
                                                                                                                                                                                                                                               so because of trauma, or sneezing, or even
stem cells to help repair brains
                                                                                                                                                                                                                                               bending your head the wrong way,’ says Andy.
                                                                                                                                                                                                                                                  The stroke was ‘almost chance’ and
                                                                                                                                                                                                                                               completely unexpected. ‘There was no
                                                                                                                                                                                                                                                                                                      rising suicide
                                                                                                                                                                                                                                                                                                      in Taiwain
                                                                                                                                                                                                                                               history in the family, I was very healthy,
                                                                                                                                                                                                                                               I was a keen sportsman, had played rugby
                                                                                                                                                                                                                                               in my youth and skied. I had competed in
Finding ways to use neural stem cells to help       the brain tissue to where the damage lies and       what happens. It may be this is the way                                                                                                karate at international standard,’ he says.
repair the brain after a stroke or fix damage       replace what’s missing. But when we engraft         to make regeneration and replacement                                                                                                      ‘I found having a stroke physically and
caused by disease is the main plank of the          stem cells, the proportion of tissue replaced       happen, as we’ve already discovered that                                                                                               psychologically a traumatic experience. It
work of Professor Jack Price’s laboratory in        is tiny. So we need to find out what the stem        stem cells alone don’t do that,’ he said.                                                                                              was difficult to continue to play sport and            In Taiwan, 10 people in every 100,000 take their
the Centre for the Cellular Basis of Behaviour      cells are doing to block the neurodegenerative         Another project, funded by the                                                                                                      the consultant’s advice was to give up teaching        own lives: suicide is on the increase, and is now
(CCBB) at the IoP.                                  process. Instead of replicating, are they turning   Biotechnology and Biological Sciences                                                                                                  because of the potential stresses of the job.          the ninth leading cause of death in the country.

  After a stroke, billions of brain cells           into a different type of brain cell? Could they      Research Council and in collaboration                                                  Andy McCann was 37, a PE teacher and            The Local Education Authority wanted me to                Two PhD students, supervised by senior
die as the blood clot in the brain deprives         be inducing change in what’s left? Are they         with Nottingham University, is also                                                    assistant head teacher of a secondary           retrain to another subject because of what             researchers at the IoP, are attempting to
them of oxygen. What follows is ongoing             secreting something?’                               concerned with developing a ‘smarter                                              school in south Wales when he had a stroke           the consultant had said, but I didn’t want to          find out more about why people commit
neurodegeneration as the dead cells, now               Another conundrum is why neural stem             milieu’ for engrafted stem cells, which                                           in the middle of an after-school class in the        do that after 17 years in teaching. PE was my          suicide or deliberately harm themselves –
unable to send signals to other parts of the        cells stored in the brain in a ‘niche’ don’t        could help them better integrate.                                                 gym. The parent who was helping out happened         love and subject. My career had been mapped            an important predictor of suicidal intent.
brain, impact on other regions.                     galvanise to target damaged areas in the            ‘Experiments to date have involved                                                to be a policeman, and had first aid training.       out and suddenly it went pear-shaped. I was               The first PhD research project is a study
  Working with neuroimaging scientists              same way that engrafted stem cells grown            injecting neural stem cells in a simple                                           He cleared the gym, called for an ambulance          on Incapacity Benefit for two years, and in the        of people living in Nantou County where
led by Dr Michel Modo and also based                in the laboratory do.                               solution into the brain. But given we                                             and Andy was taken to casualty, then admitted        early days thought that was it, that I was now         the Chi-Chi earthquake struck in September
at the CCBB, the research team has found               Even though scientists have known                are trying to get these cells to integrate                                        to hospital. ‘The stroke was very violent,’          unemployable.’ But he became curious about             1999, with a death toll of nearly 1,000. In the
that engrafting just thousands rather than          about niches of organ-specific stem cells            into the most complex tissue you can                                              says Andy, four years later. ‘I suddenly             why, physically, the stroke had happened and           wake of the natural disaster, between 2000
billions of neural stem cells can have an           in other parts of the body – in bone marrow,        imagine, there must be a better way                                               collapsed and couldn’t move or talk. While           started a personal research project, which             and 2002, Nantou County had the highest
efficacious effect on both structure and               for example – for some time, the discovery          of doing it,’ said Professor Price.                                               waiting for the ambulance, I was vomiting            culminated in the publication of his book, Stroke      suicide rate in Taiwan.
function of the brain after a stroke.               of a niche of neural stem cells, lying against         The team at Nottingham are materials                                           violently and starting to choke because I had        Survivor, A Personal Guide to Recovery, in 2006.          Dr Chin-Hung Chen is analysing
  Neural stem cells are ‘multipotent’ –                                                                 engineers and, together with Professor                                            lost my swallow reflex. I couldn’t open my eyes         ‘By then, I had started to take stock and           information collected on a Suicide Register
they have the ability to become any of the          ‘Neural stem cells have the ability                 Price’s laboratory, they are trying to                                            because they were too light-sensitive. Strangely     think about my transferable skills and interests       at the time to understand more about what
specialised cell types found in the brain.          to become any of the specialised                    construct a matrix that resembles brain                                           at the time I wasn’t scared, it was an unreal        – sports psychology, stress management, for            prompted people to attempt – or succeed at
  But the studies show that instead of              cell types found in the brain’                      structure and will hold both neural stem                                          experience and I disassociated from it.’             example,’ he says. He trained and qualified            – killing themselves. The Register was kept
straightforward replacing and rebuilding,                                                               cells and other components like proteins                                            The diagnosis was made on the second day           as a Clinical Hypnotherapist and then set up           by a community mental health centre, set up
the neural stem cells help the damaged              the brain ventricle, is a relatively recent         and growth factors. ‘The artificial matrix                                         on the ward, following a CT scan that showed         a brand new training consultancy, which now            for survivors of the earthquake by Taiwan’s
brain to recover by somehow blocking                one. In the niche, the neural stem cells            will be a scaffold and we want to design                                           the part of the brain affected by the stroke         offers 30 different courses about health, well-        Department of Health. It contains records
the ongoing neurodegeneration.                      sit closely together with blood vessels             it so that it will dissolve and disappear                                         was the cerebellum, at the back, responsible         being and personal development tailored to             not only of deaths and attempts, but
  ‘We simply don’t know how they do                 branching into them.                                once engrafted,’ he said.                                                         for muscle and movement co-ordination.               the needs of different clients from the public,        information gathered in interviews with
that,’ said Professor Price, a Professor of            Now a large project funded by the US                All these experiments are at the                                               ‘The damage to the cerebellum matched                private and voluntary sectors. In January 2008,        those who did not succeed – about their
Developmental Neurobiology and Director             National Institute of Biomedical Imaging            moment carried out with rats and the                                              the symptoms I’d shown,’ he says. ‘The speech        the business was nominated for a new business          intent, mental health and circumstances.
of the CCBB. Finding out how that happens,          and Bioengineering (NIBIB – part of the             help of neuroimaging techniques and                                               deficit and inability to swallow were because I      start-up award.                                           A second Taiwan-based PhD study is
and refining the process of engrafting neural        National Institutes of Health) Quantum              behavioural tests to monitor the effects                                           was physically unable to co-ordinate my tongue          Andy also donates his time, giving talks about      based in the Mackay Memorial Hospital
stem cells in the light of that knowledge, is       Grants Program seeks firstly to understand           of the engrafted neural stem cells on the                                         due to the damage caused by the blood clot.’         his experience at conferences and other events         in Taipei where between 40 and 50 people
what his laboratory’s programme of work,            more about the niche and how the stem               brain. Research of this kind is, however,                                           His speech came back relatively quickly and        organised by the Stroke Association, the UK            are admitted to the emergency department
funded by the Charles Wolfson Charitable            cells and blood vessels interact, and then          bringing the concept of neural stem cell                                          high doses of aspirin helped the clot to disperse.   charity that funds research and supports               every month after attempting suicide or
Trust, is all about.                                to copy its architecture in the laboratory.         transplantation for human therapy closer                                          After eight days in hospital, he was discharged      patients and their families.                           deliberately harming themselves. Chia-Yi
  ‘Originally, we thought stem cells would be       The idea is that the reconstituted niche            to reality.                                                                       and his ongoing medical care transferred to a           The biggest long-lasting deficits are fatigue and   Wu is interviewing 300 of them to try
regenerative,’ he said. ‘The idea was that if we    could be implanted into a cortex damaged               In future, neural stem cells manipulated                                       hospital nearer to his home in Cardiff. There,       lower energy levels, he says. ‘After a busy day        to trace any common warning signs,
put stem cells in, they would migrate through       by stroke, providing both neurons and               in the laboratory could be used to help brains                                    after numerous tests showed Andy was fit             or two, I feel more wiped out and have to pace         and to find out if they had tried to seek
                                                    vascular cells to help with repair. The             repair and recover not only after a stroke, but                                   and healthy in every other way, his consultant       myself. My speech will go a bit if I am very busy.     any sort of help before they had acted.
                                                    NIBIB Quantum Grants Program is                     also in neurodegenerative conditions like                                         guessed by a process of elimination that the         My balance is not what it once was – you would         If they did, she’s asking what influence
and...                                              designed to fund research for developing            Parkinson’s disease, Alzheimer’s disease                                          stroke had been caused by vertebral artery           notice nothing to see me walking, but I know it’s      that help had; if they didn’t, she wants
The Centre for the Cellular Basis of Behaviour      new technology for diagnosis, treatment             and Huntington’s disease.                                                         dissection – a split in one of the vertebral         not right. I’m much more aware                         to find out why not.

(CCBB) is based in the newly built James            and prevention, and Professor Price’s team             But there are wider moral and ethical                                          arteries in the neck, leading to the back part       of looking after myself now.                              The results of both sets of research will
Black Centre next to the King’s College             is collaborating with the Baylor College            issues raised by the potential to harness                                                                                                                                                     help Taiwan health authorities develop
Hospital campus. The £30 million building           of Medicine in Houston, Texas on this,              the power of stem cells, said Professor                                                                                                                                                       policies designed to prevent suicide,
was opened in 2007 and is purpose-designed          the first project to be funded under                 Price. He is part of BIONET, a network                                                                                                                                                        and services to help people who may
for scientists at both the IoP and King’s College   the programme.                                      led by the London School of Economics                                                                                                                                                         be contemplating it. The supervisors
London School of Medicine. The CCBB is part            ‘We think the niche environment                  and Political Science and funded by                                                                                                                                                           include Professor Martin Prince and
of the IoP’s Department of Neuroscience             is supportive, that the neural stem cells           the European Commission to consider                                                                                                                                                           Dr Rob Stewart: their team at the IoP
and its new laboratories, equipped with             there have the potential to do things,              the bioethical implications of stem cell                                                                                                                                                      undertakes community-based research
state-of-the-art equipment, will be responsible     but don’t do them on their own, that                research in an international context.                                                                                                                                                         around the world. They and their colleagues
for almost doubling the amount of research          the combination of neural stem cells                ‘In Britain, the use of human stem cells                                                                                                                                                      supervise many PhD students from overseas
carried out in basic neuroscience, helping          and cerebral blood vessels is somehow               for research is strictly regulated, but                                                                                                                                                       who carry out research in their home
to understand more about neurodegenerative          important,’ said Professor Price. ‘What             many countries do not yet have explicit                                           Stroke Survivor, A Personal Guide to Recovery by Andy McCann                                                country, seeking to understand more
and psychiatric diseases and to develop             we want to do then is to recreate the niche         laws regulating human stem cell research,’                                                                                         about the causes of mental illness and
new treatments.                                     in vitro and engraft it into the brain to see       he said.I                                                                         The Stroke Association,                                                                   evaluate culturally appropriate therapies and
                                                                                                                                                                                                                                                                                                      treatments, as well as to influence policy.I
                              42 | Suicide |                                                                             | Teenage minds |                                                                                                                                                                             | Teenage minds | 43

                                                                                                                                                                            secondary school pupils who need               care trusts in the south of England,
David Hoffman Photo Library

                                                                                                                                                                                                                                                                                                   Veronique Black has been working as

                                                                                                                         Enhancing                                          it. If proved to be successful, the new
                                                                                                                                                                            training package will be available to
                                                                                                                                                                            more than 2,100 school nurses across
                                                                                                                                                                            the UK, mostly employed by the NHS,
                                                                                                                                                                                                                           serving both inner city and suburban
                                                                                                                                                                                                                           catchment areas. A randomised controlled
                                                                                                                                                                                                                           trial, led by the IoP’s Professor André
                                                                                                                                                                                                                           Tylee, will gauge the success of the
                                                                                                                                                                                                                                                                                                   a school nurse since 1996. For the past
                                                                                                                                                                                                                                                                                            four years, she’s worked for Sutton and
                                                                                                                                                                                                                                                                                            Merton Primary Care Trust. As well as
                                                                                                                                                                                                                                                                                            supporting students, she works closely with

                                                                                                                         the skills                                         who work in state schools.
                                                                                                                                                                               Two school nurses are involved with
                                                                                                                                                                            planning and shaping the QUEST project
                                                                                                                                                                                                                           package by assessing and comparing
                                                                                                                                                                                                                           the skills and knowledge of school nurses
                                                                                                                                                                                                                           who have been trained with a group
                                                                                                                                                                                                                                                                                            teachers and parents: ‘I go to most parents’
                                                                                                                                                                                                                                                                                            evenings and have an appointment system
                                                                                                                                                                                                                                                                                            where parents can arrange to see me,’

                                                                                                                         of school
                                                                                                                                                                            along with representatives from professional   who have not yet attended workshops                              she says. ‘I also go to new parents’ welcome
                                                                                                                                                                            bodies – the Royal College of Nursing,         or accessed resources.                                           evenings so parents know who I am and
                                                                                                                                                                            the Community Practitioners’ and Health           The UK Department of Health has                               know how to make contact if they need help.’
                                                                                                                                                                            Visitors’ Association, and the School and      recommended that school nurses be                                   The brief of the team in which she works

                                                                                                                         nurses                                             Public Health Nurses Association.
                                                                                                                                                                               Funded by the Health Foundation,
                                                                                                                                                                            the research is starting with a national
                                                                                                                                                                            consultation exercise: a survey of school
                                                                                                                                                                                                                           better trained to assess the mental health
                                                                                                                                                                                                                           needs of pupils. ‘Our starting point is to
                                                                                                                                                                                                                           build the confidence and skills base of
                                                                                                                                                                                                                           school nurses so they can detect mental
                                                                                                                                                                                                                                                                                            is to ‘support the health of school age
                                                                                                                                                                                                                                                                                            children and to support their families
                                                                                                                                                                                                                                                                                            in dealing with health issues’. In Sutton
                                                                                                                                                                                                                                                                                            and Merton, a typical caseload for a
                                                                                                                                                                            nurses by post will make sure the training     health problems and provide necessary                            full-time school nurse includes one high
                                                                                                                                                                            will be developed to meet their needs and      support and signposting,’ said Professor                         school and three to four primary schools.
                                                                                                                         Depression during teenage years can lead to        suit the demands of the job. Rethink is        Tylee. ‘Some problems may require                                   ‘We screen all five-year-olds in reception
                                                                                                                         poor academic performance at school, social        charged with the creation of the programme,    referral to specialist services, but for                         for height and weight, and send a health
                                                                                                                         difficulties, and drug and alcohol misuse. Yet     likely to involve workshops, web-based         many problems, support, educational                              questionnaire to parents. We do further
                                                                                                                         mental health problems during adolescence          resources, printed material and DVDs,          materials and interventions like guided                          work with children where there is concern
                                                                                                                         often go undetected and untreated, making          and sessions for teachers so they can          self-help may be most appropriate.                               – about obesity, behavioural problems,
                                                                                                                         them more likely to continue into adulthood.       spot and signpost pupils who may                  ‘Mental health problems limit                                 asthma, epilepsy, for example – and work
                                                                                                                            Now a project led jointly by the IoP            need support from school nurses.               young people’s ability to cope, and                              with teachers to make sure care plans
                                                                                                                         and the mental health charity Rethink                 A team of school nurses working for         to fulfil their potential during school                           are in place in schools.
                                                                                                                         is developing and testing a programme              Sutton and Merton Primary Care Trust           years. They disrupt educational and                                 ‘School nurses are involved in immunisations
                                                                                                                         of training and a portfolio of resources           in south London will pilot the training        social development and limit future                              at both primary and high schools – giving them
                                                                                                                         for school nurses to help them offer               which will then be evaluated with the help     achievement. School nurses are ideally                           in high school, and ensuring parents are fully
                                                                                                                         appropriate help or a referral to                  of schools nurses working for 13 primary       placed to make a difference,’ he said.I                           informed about vaccinations and their children
                                                                                                                                                                                                                                                                                            are up to date with them in primary schools.
                                                                                                                                                                                                                                                                                            We work with the Child Protection Team and
                                                                                                                                                                                                                                                                                            contribute to PHSE (Personal Health and Social

                                                                                                                                                                                                                                                                              Rehan Jamil
               More people take own Exploring
                                                                                                                                                                                                                                                                                            Education) sessions.’
                                                                                                                                                                                                                                                                                               In addition, Veronique and her colleagues
                                                                                                                                                                                                                                                                                            run confidential help and advice drop-in sessions
                                                                                                                                                                                                                                                                                            in high schools, and also in the local Connexions

               lives in hotter weather minds of
                                                                                                                                                                                                                                                                                            Centre and sports centre. ‘Often the teachers
                                                                                                                                                                                                                                                                                            will refer a pupil to us,’ she said. ‘Sometimes
                                                                                                                                                                                                                                                                                            parents contact us too if they are worried.’
                                                                                                                                                                                                                                                                                               Many of the young people who come

                              As temperatures rise, so do the number
                              of suicides in England and Wales.
                                                                            during excessively hot weather. The
                                                                            research team used information about
                                                                                                                                                                                                                                                                                            to these sessions have behavioural or
                                                                                                                                                                                                                                                                                            emotional problems, she says.
                                                                                                                                                                                                                                                                                               ‘The number of young people we are
                                                                                                                                                                                                                                                                                            seeing with emotional and mental health
                                 Research led by the IoP’s Dr Lisa Page     the number of deaths due to suicide from                                                                                                                                                                        problems is increasing. Self-harming has
                              and carried out in collaboration with the     the UK Office for National Statistics,                                                                                                                                                                            escalated dramatically, and there is more
                              London School of Hygiene and Tropical         and about daily temperatures from            Two thousand 14-year-olds from the UK,             the five-year IMAGEN project, which is            The young people will carry out some of                        depression and anxiety. The clear-cut cases
                              Medicine looked at the relationship between   the Met Office.                                Ireland, France and Germany will take part         funded by the European Commission.             the tests focusing on personality and thinking                   are easy – if we know we can help, we continue
                              temperature and suicide counts on a daily        They found that suicide increased by      in a pan-European collaborative project              Previous studies have shown the teenage      styles at home on a computer. They will                          to see them on a regular basis. But there are
                              basis from the beginning of 1993 to the end   46.9 per cent during a heatwave in 1995,     co-ordinated by the IoP which will help            brain to be particularly vulnerable to drugs   each visit a research centre once or twice,                      some cases when we need to know whether
                              of 2003.                                      but there was surprisingly no rise during    scientists understand more about the               and stress, and the idea is to identify both   after school or at weekends, for interviews,                     we can realistically work with them, or whether
                                 Even though they found acts of suicide     similar weather in August 2003. This may     developing teenage mind.                           the psychological and biological factors       brain scans and to give blood samples.                           we should refer them on. Sometimes you
                              occurred most frequently in January, their    be due to a period of very hot days a few      The participating teenagers, recruited           involved in the processing of emotions,        Their parents or guardians will also be                          wonder if you are doing the right thing working
                              analysis showed an overall increase on days   weeks earlier, allowing people to adapt to   through schools, will complete a battery           decision-making, risk-taking and behaviour     interviewed about themselves, and their                          with a pupil, or whether specialist services
                              when temperatures soared above 18°C.          higher temperatures, said Dr Page. If that   of tests designed to measure their attitudes       at this time, as the brain prepares for        child, and their teachers will be asked for                      should be involved.’
                                 For every one degree increase in mean      is the case, a sudden soar in temperature    and thinking styles, their mental health, their    adulthood.                                     information. Two years later, each of the                           Veronique and her colleague Belinda Shear
                              temperature above 18°C, there was a 3.8 per   could lead to a greater number of deaths     use of drugs and alcohol, and their behaviour.       ‘We aim to learn about biological            original 2,000 will be interviewed again                         are helping to steer the QUEST project. ‘There
                              cent rise in death by self-poisoning, and     than a gradual and sustained increase.       They will also give samples of their DNA and       and environmental factors that might           by telephone to find out if their attitudes                       is no doubt that more specific training around
                              a five per cent rise in violent suicide.          During the 11 years studied, there        have MRI scans so researchers can correlate        influence mental health in teenagers            and behaviour have changed.                                      assessment and treatment is needed. This
                                 More research needs to be carried out      were 53,623 deaths as a result of suicide    information about their brain structure,           and their subsequent mental health as            The consortium behind IMAGEN is made                           work will benefit school nurses and the
                              to discover why high temperatures affect       in England and Wales. The largest number     brain activity and genetic traits with their       they grow older,’ said Professor Schumann.     up of leading experts in the field of genetics,                   young people they work

                              daily suicide counts, said Dr Page. The       of suicides took place on Mondays, with      psychological profiles. ‘Adolescence is a           ‘Ultimately, that knowledge will be used       behavioural and neuropsychological studies,                      with across the country.
                              team speculates that the most likely cause    numbers declining as the week wore on.       central point for development, and many            to help develop therapies and prevention       neuroimaging, bioinformatics and biostatistics,
                              is a psychological one – previous studies     1 January had the highest suicide count.     mental health problems, including drug             strategies. The DNA samples and other          from both the public and private sector. Part of
                              have shown that people behave in a more       The mean temperature was recorded            abuse, start during these years,’ said the IoP’s   databases we create will also be powerful      the project is a huge investment in technology,
                              aggressive, violent and less inhibited way    above 18°C on 222 days.I                     Professor Gunter Schumann, who is leading          resources for future investigations.’          so collaborators can easily share information.I
              44 | About the Institute of Psychiatry |                                                                                                                                                                                                                                                        | About the Institute of Psychiatry | 45

                                                                                                                                                                 Rehan Jamil
       Research and teaching                                                                                                                                                                                 I The IoP is the Lead World Health               I The King’s Centre for Military Health        I The IoP co-ordinates, along with the

                                                                                                                                                                                             More about us
                                                                                                                                                                                                             Organisation (WHO) Collaborating Centre          Research is jointly run by the IoP and         University of Manchester, the Department
                                                                                                                                                                                                             for Mental Health Research in Europe             the Department of War Studies in the           of Health-funded UK Mental Health
                                                                                                                                                                                                             and part of an international network             sister School of Social Science and            Research Network (MHRN), a collaboration

       of international renown                                                                                                                                                                               that carries out projects in support of
                                                                                                                                                                                                             the WHO programme on mental health.

                                                                                                                                                                                                             I International Mental Health at the Institute
                                                                                                                                                                                                                                                              Public Policy at King’s College London.
                                                                                                                                                                                                                                                              The Centre’s research team focuses
                                                                                                                                                                                                                                                              on war and health, war and psychiatry,
                                                                                                                                                                                                                                                              military personnel issues and social
                                                                                                                                                                                                                                                                                                             that supports large-scale projects and
                                                                                                                                                                                                                                                                                                             brings together service users, academics,
                                                                                                                                                                                                                                                                                                             doctors, nurses and therapists from
                                                                                                                                                                                                                                                                                                             around the nation.
                                                                                                                                                                                                             of Psychiatry promotes and undertakes            policy. Much of its work is funded by
              The Institute of Psychiatry (IoP), based          researchers and advisors. A specialist                                                                                                       collaborative work in developing and             the UK Ministry of Defence.                    I The research arm of The National
              in Camberwell, south London, is a School          Biomedical Research Centre in Mental                                                                                                         restructuring countries.                                                                        Academy for Parenting Practitioners,
              of King’s College London and its raison           Health, funded by the UK government’s                                                                                                                                                         I The Cancer Research UK London                a government-funded collaborative
              d’être is two-fold – research and teaching,       National Institute for Health Research,                                                                                                      I Two Medical Research Council (MRC)-            Psychosocial Group, supported by Cancer        venture between the IoP, the Family
              both in the field of mental health.               is based at the IoP and SLaM. It is one                                                                                                      funded centres are based here – the MRC          Research UK, studies psychological and         and Parenting Institute, and Parenting
                 People who work at the IoP carry               of 11 such Centres set up in April 2007,                                                                                                     Centre for Neurodegeneration Research,           social aspects of cancer.                      UK, is led by researchers here (see
              out research in order to have a greater           all located within University and NHS                                                                                                        which investigates Alzheimer’s disease,                                                         page 12).
              understanding of mental health problems,          partnerships, to carry out ‘translational                                                                                                    vascular dementia, motor neurone disease         I The MRC-funded Twins Early
              diseases of the brain and how the mind            research’ that will help patients benefit more                                                                                                and other neurodegenerative diseases,            Development Study (TEDS), the largest          I The Centre for the Economics of
              works, and to then use that knowledge
              to develop effective treatments and services.
                                                                quickly from new scientific breakthroughs.
                                                                The IoP (King’s College London)/SLaM              Sharing our                                                                                both in the laboratory and through clinical
                                                                                                                                                                                                             studies; and the MRC Social, Genetic and
                                                                                                                                                                                                                                                              study of twins in the UK, tracks the
                                                                                                                                                                                                                                                              development of 15,000 pairs of twins
                                                                                                                                                                                                                                                                                                             Mental Health, which works in partnership
                                                                                                                                                                                                                                                                                                             with research teams here, elsewhere
              They undertake this research using a range
              of methodologies and techniques – brain
                                                                Centre partnership won the status through
                                                                open competition: the successful 11 bids for
                                                                                                                  knowledge                                                                                  Developmental Psychiatry Centre, which
                                                                                                                                                                                                             seeks to understand more about the
                                                                                                                                                                                                                                                              and helps researchers find out about
                                                                                                                                                                                                                                                              common disorders of childhood.
                                                                                                                                                                                                                                                                                                             in the UK and across the world, evaluates
                                                                                                                                                                                                                                                                                                             the economic effectiveness of treatments
              scanning; interviews with service users           Centre status were chosen by an independent       The Mental Health Knowledge Centre                                                         effects of ‘nature’ and ‘nurture’.                                                              and services to inform mental health
              and their families; statistical analysis;         panel of international experts.                   at the IoP aims to share the results of                                                                                                     I The Service User Research Enterprise         policy making and the allocation of
              proteomics (the study of proteins)                   The work of the IoP is also funded by          research with wider audiences. The                                                         I The King’s Motor Neurone Disease               (SURE) undertakes research to test the         resources. It is the only centre of
              technology; randomised controlled                 the Higher Education Funding Council for          Centre works collaboratively, for example,                                                 Care and Research Centre is one of               effectiveness of services and treatments       its kind outside of the USA.
              trials; and sophisticated machinery               England, grant-giving bodies like the Medical     with the European Dana Alliance for the                                                    several in the UK funded by the MND              from the perspective of people with mental
              that studies DNA.                                 Research Council and the Wellcome Trust,          Brain to organise public events where                                                      Association. It offers clinical services         health problems and their carers. SURE         I The MRC London Brain Bank for
                 Their second mission is to equip               the European Union, charities, organisations      IoP researchers join other professionals                                                   at King’s College Hospital and carries           involves service users in a collaborative      Neurodegenerative Diseases provides
              the next generation of scientists and             in the private sector and other UK government     to speak about their work on a range of                                                    out research at the IoP.                         way in the whole research process: from        research teams here at the IoP, and at
              researchers with the skills they need             departments. Research teams bid successfully      mental health problems.                                                                                                                     design to data collection, through to data     centres across the country, with samples
              to continue this work in future, through          for some £130 million of funding for their                                                                                                   I The Sainsbury Centre for Mental Health         analysis and dissemination of results. It is   of brain tissue obtained, with consent, at
              PhD study and taught programmes in                work each year: the competitive bidding  is a website                                                   is one of the IoP’s academic partners.           one of the largest units within universities   postmortems. The Bank holds collections
              different aspects of psychiatry, psychology        system operated by funding organisations          for carers, families and friends of people                                                 The Centre works to influence policy and         in Europe to employ people who have both       of brains affected by Alzheimer’s disease,
              and neuroscience. Turn to the inside back         ensures money available is awarded to the         with mental illness, developed by the IoP,                                                 practice, focusing on criminal justice and       research skills and first-hand experience      motor neurone disease and schizophrenia,
              cover for a full list of programmes on offer.      highest quality research. Ethics approval given   SLaM and the mental health charity Rethink.                                                employment in the field of mental health.        of mental health services and treatments.      as well as healthy brains.
                 The IoP is sited next to the Maudsley          either nationally or locally for every research   It contains information about mental health
              Hospital and both organisations are known         study also guarantees the highest standards.      problems and research news.

                                                                                                                                                                               Rehan Jamil
              throughout the world for their pioneering            Many research projects are carried out
              work. The Maudsley is run by South
              London and Maudsley NHS Foundation
                                                                in collaboration with colleagues in other
                                                                King’s College London Schools and at
                                                                                                         has been developed
                                                                                                                  by the eating disorders research team at the
                                                                                                                                                                                                                                                                                                         Participate in
              Trust (SLaM), the IoP’s closest NHS partner:
              many of the IoP’s staff work in SLaM’s services
                                                                King’s College Hospital NHS Foundation
                                                                Trust; with other teams based in universities
                                                                                                                  IoP. Many of the team also work in SLaM’s
                                                                                                                  Eating Disorders Service. The site contains
                                                                                                                                                                                                                                                                                                         our research
              and clinics, putting theory into practice and     and mental health services around the UK          comprehensive information about anorexia                                                                                                                                               The research teams at the IoP rely
              keeping in close contact with the service users   and overseas; and with charities offering          and bulimia, as well as resources for carers                                                                                                                                           on the help of about 5,000 volunteers
              their academic work seeks to serve. Service       specialist support to service users and their     and health and education professionals.                                                                                                                                                a year who take part in their studies.
              users are also involved in many projects as       families, as well as with private companies.I                                                                                                                                                                                            MindSearch is a volunteer database
                                                                                                                                                                                                                                                                                                         supported by the IoP-based Psychiatry
Rehan Jamil

                                                                                                                                                                                                                                                                                                         Research Trust. You can register your
                                                                                                                                                                                                                                                                                                         details if you are interested in participating
                                                                                                                                                                                                                                                                                                         in research studies by visiting
46 | Last word: the Dean |                                                                                                                                                                                                                                                                             Straplinestraplinestraplinestrapline |

                                                                                                                                                                         Director of Research Quality:                                         Chairs of Research Groups:
                                                                                                                                                                                                                                                                                                           Taught courses
Dean Peter McGuffin writes:                                                                                                                                              Gill Dale,

                                                                                                                                                                         Public Relations Officer:
                                                                                                                                                                                                                                               Professor Gunter Schumann

                                                                                                                                                                                                                                               Antisocial Behaviour
                                                                                                                                                                                                                                                                                                           at the IoP
                                                                                                                                                                                                                                                                                                           For more information, visit
                                                                                                                                                                         Camilla Palmer,                                                       Professor Sheilagh Hodgins                        
                                                                                                                                                                                                                                               Disorders of Childhood                                      Doctorate (DClinPsy)
                                                                                                                                                                         Chairs of Research Groups:                                            Professor Eric Taylor                                       Clinical Psychology
                                                                                                                                                                         Professor Gunter Schumann                                             Common Mental and Somatic Disorders                         Masters (MSc)

                                                                                                        Rehan Jamil
                                                                                                                      one of the things that makes the Institute                                                                               Professors David Clark and Simon Wessely                    Child and Adolescent Mental Health
                                                                                                                      of Psychiatry a wonderful place to work is         Antisocial behaviour                                                                                                              Clinical & Public Health Aspects of Addiction
                                                                                                                      that there is such a range of expertise that       Professor Sheilagh Hodgins                                            Health Service and Population Research                      Clinical Forensic Psychiatry
                                                                                                                      goes all the way across neuroscience and                                                                                 Professor Graham Thornicroft                                Clinical Forensic Psychology
                                                                                                                      mental health research, from the social            Disorders of Childhood                                                                                                            Clinical Neuroscience
                                                                                                                      environment to the molecular and cellular          Professor Eric Taylor                                                 Military Health                                             Epilepsy
                                                                                                                      basis of behaviour and disease.                                                                                          Professor Simon Wessely                                     Family Therapy
                                                                                                                         What underpins all of these areas is a          Common Mental and Somatic Disorders                                                                                               Forensic Mental Health Science
                                                                                                                      rigorous adherence to scientific method.            Professors David Clark and Simon Wessely                              Neurodegeneration and Brain Injury                          Health Psychology
                                                                                                                      One of the prime difficulties of studying                                                                                  Professor Brian Anderton                                    Mental Health in Learning Disabilities
                                                                                                                      psychiatric and neurological disorders is          Health Service and Population Research                                                                                            Mental Health Services Research
                                                                                                                      that, in life, the brain and the central nervous   Professor Graham Thornicroft                                          Psychosis                                                   Mental Health Social Work with Children & Adults
                                                                                                                      system are the body’s most inaccessible organs.                                                                          Professor Tony David                                        Mental Health Studies
                                                                                                                      Historically this has meant that nervous and       Military Health                                                                                                                   Mental Health Studies (Organisational Psychiatry
                                                                                                                      mental disorders have suffered more from            Professor Simon Wessely                                               Social, Genetic and Developmental Psychiatry                & Psychology)
                                                                                                                      mythologising than any other types of illness.                                                                           Professor Robert Plomin                                     Neuroscience
                                                                                                                      There are still areas where the myth-making        Neurodegeneration and Brain Injury                                                                                                Psychiatric Research
                                                                                                                      has not entirely ceased and the damage             Professor Brian Anderton                                                                                                          Social, Genetic & Developmental Psychiatry
                                                                                                                      done by the alleged but spurious association                                                                                                                                         War and Psychiatry
                                                                                                                      between the measles, mumps and rubella             Psychosis
                                                                                                                      vaccine and autism is one sorry example.           Professor Tony David                                                                                                              Postgraduate Diploma (PgDip)
As Dean, I have discovered that one                  is packed with advances in knowledge that                        At the least, however, no one nowadays                                                                                                                                               Cognitive Behavioural Therapies
recompense for the many tribulations                 have depended on the latest technologies                         tries to assert, as was the case in my youth,      Social, Genetic and Developmental Psychiatry                                                                                      Cognitive Behavioural Therapies for Children
of the job is that occasionally one really           in brain sciences that range from visualising                    that illnesses such as autism or schizophrenia     Professor Robert Plomin                                                                                                           & Adolescents
does get to have the last word. It is a particular   the living, thinking brain to tracking down                      are themselves purely social constructions or                                                                                                                                        Cognitive Behavioural Therapy (CBT) for
pleasure to have that privilege in the context       precise variations in genes and discovering                      ‘myths’. The disorders studied at the Institute                                                                                                                                      Psychosis
of this research report. Reading it, I am struck     the ways they interact with the environment.                     do, however, still carry stigma and one of                                                                                                                                           Family Interventions in Psychosis
by the pace of progress in research here at the      Moreover, one of the real strengths of the                       the areas highlighted in this research report
Institute of Psychiatry, King’s College London.      Institute is that all of these high-tech methods                 is how stigma can be combated. Stigma is                                                                                                                                             Short Courses
I first arrived at the Institute three decades        are being applied by scientists and clinicians                   most often attached to disorders that appear                                                                                                                                         Dual Diagnosis
ago as a senior house officer who already had          working side-by-side, striving to discover                       frightening and about which little is known.                                                                                                                                         Enhanced Skills for Inpatient Mental Health
earnest aspirations as a clinician researcher        ways of making things better for patients.                       All of the scientific endeavours described                                                                                                                                            Professionals
– although my own field, genetics, was then           Having said that, one can become dazzled                         in this report are about understanding                                                                                                                                               Introductory Course for Overseas Psychiatrists
highly unfashionable. There was no such              by molecules and machinery, but many of the                      the causation of disorders or about making                                                                                                                                           Medication Management
thing as molecular genetics in psychiatry            advances presented in this report depend on                      them tractable to treatment. I hope this
and the modern era of brain imaging had              much less expensive but no less sophisticated                    report in itself will contribute to better                                                                                                                                           Graduate Certificate (Grad Cert)
scarcely begun. It is extraordinary to reflect        tool kits such as those used by epidemiologists                  public understanding that these are ‘real’,                                                                                                                                          Family Therapy
on how things have changed. This report              or cognitive behavioural therapists. Indeed,                     and no longer mysterious, illnesses.I
                                                                                                                                                                                                                                                                                                           Membership of the Royal College of Psychiatrists
                                                                                                                                                                                                                                                                                                           Membership of the Royal College of Psychiatrists

                                                                                                                                                                         Published by the Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF       Written and designed by Jane Smith and Sophie Gibson, Inside Out, 020 7655 0885.
                                                                                                                                                                                                                                              Printed by Calverts
                                                                                                                                                                         Thanks to Professor Jack Price for writing the what’s in a brain? article on page 2.            February 2008
To find out more
about the work of the Institute of Psychiatry,

Websites developed by the IoP
for people with mental health problems
and their carers include:

To volunteer to take part
in research at the IoP,

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