Cerebellar gray matter volume correlates with duration of cocaine use in cocaine-dependent subjects.

This study was conducted to explore differences in gray and white matter volume between cocaine-dependent and healthy comparison subjects using optimized voxel-based morphometry (VBM). Brain magnetic resonance imaging (MRI) and neuropsychological function tests were performed for 40 cocaine-dependent subjects (41.4+/-6.9 years, 27 men) and 41 healthy age- and sex-matched comparison subjects (38.7+/-8.8 years, 26 men). Optimally normalized whole brain MR images were segmented, modulated, smoothed, and compared between groups with statistical parametric mapping. The cocaine-dependent group had lower gray matter volumes in bilateral premotor cortex (Brodmann area (BA) 6, 8; 16.6%), right orbitofrontal cortex (BA 10, 15.1%), bilateral temporal cortex (BA 20, 38; 15.9%), left thalamus (12.6%), and bilateral cerebellum (13.4%) as well as lower right cerebellar white matter volume (10.0%) relative to the comparison group at a corrected p<0.05 for multiple comparisons. Duration of cocaine use negatively correlated with right and left cerebellar gray matter volumes (r=-0.37, r=-0.39, respectively). In cocaine-dependent subjects, lower cerebellar hemispheric gray and white matter volumes were correlated with deficits in executive function and decreased motor performance. This study reports that cocaine-dependent subjects have lower gray matter volumes in cerebellar hemispheres as well as in frontal, temporal cortex, and thalamus. These findings are the first to suggest that the cerebellum may be vulnerable to cocaine-associated brain volume changes, and that cerebellar deficits may contribute to neuropsychological deficits and motor dysfunction frequently observed in cocaine-dependent subjects.     

Integration and working through in art therapy

Kernberg and Kramer) notes that the majority of defense operations mobilized in the neurotic personality organization are mature defenses such as repression. Early object relations are repressed into the unconscious and are not available for recall in maturity. The projection of the fabric of early internalized object relations onto figures in the present takes place gradually and in a controlled manner. In the therapeutic process, the therapist is perceived primarily as a figure that wishes to help and benefit the patient, and the development of the transference is slow and restrained. By contrast, in the borderline personality organization, the defense operations are mostly primitive. The primary object relations are not repressed, but remain available in the present in their crude form. The transference towards the therapist is a chaotic and stormy mixture of an intense longing for a true bond to the object on the one hand, and extreme rage on the other hand. Right from the very first encounter with the patient, the therapist is perceived alternately as a totally good figure and as an inimical persecutory one.Michael displayed interest and motivation in the therapy and expressed his hope that the therapist would help him with his difficulties. He came willingly and worked intensively and with enjoyment. In the initial stages of the therapeutic relationship, Michael was pleasant in his manner, but reserved and self-controlled. He gradually became freer and began to dare to express his feelings of anger and closeness towards the therapist. Michael’s internal object relations were whole. He could simultaneously express both negative and positive emotions about himself and about the therapist. Michael’s therapy focused on working through issues surrounding what he termed “revolting things,” particularly anger and aggression.In the initial stages of the therapy, Michael stuck rigidly to inflexible patterns of creating pleasing works of art, which led to poor, schematic emotional expression. Following the therapist’s interventions, and his suggestion to work with poster paints, Michael began to create “cute things” in a more varied manner. The repeated creation of the “cute things” in their varying forms enabled Michael to work through his need to be purely a disciplined and pleasant mannered child and enabled him to dare express feelings that had previously seemed forbidden. Michael began to examine to what extent he could reveal the aggressive side of himself through the creations he termed “revolting things.” This repeated and varied creation of the “revolting things” enabled Michael to work through his fear of expressing anger and aggression and allowed him to express phallic themes for the first time. He involved himself with making monsters, dragons, and weapons out of wood, poster paints and charcoals. For the first time, he allowed himself to be naughty at school and thus gain acceptance among his classmates.By contrast, Alan was excited about coming to therapy right from the first session, but at the same time, from the moment he first entered the therapy room he displayed animosity and contempt towards the therapist. Likewise, he often expressed his longings towards the therapist and would even bring her bouquets of flowers at the Festivals, while in the sessions themselves he would repeatedly try to destroy the equipment in the room and even attack the therapist with paintbrushes laden with paint. Alan’s internalized object relations were split and disconnected. The feelings he expressed towards himself and the therapist were a chaotic and stormy confusion of all good feelings or all bad feelings. To enable future working through, therapy with Alan focused on integrating the split self and object representations in the ego towards the consolidation of whole object relations.Although Alan came to therapy eagerly and found it hard to wait for the beginning of each session, he nevertheless behaved violently towards the equipment in the room and the therapist. To enable Alan to express his destructive impulses in a more controlled manner, the therapist suggested to Alan that he use syringes to spray the green potion he had made on to a large sheet of cardboard, the potion that he had previously splattered and spilt all over. This repeated controlled spraying of materials onto the same sheet of cardboard enabled Alan to channel his destructive impulses onto a defined, fixed, and durable surface. He enjoyed discovering how the different colors mixed to form new shades. He began to create new shades by deliberately mixing the colors sprayed on the cardboard. On completion of the work after a few weeks, Alan slashed through the finished work of art using a modeling knife. The repeated creation of new colors on the same sheet of cardboard and its subsequent deliberate slashing with a knife enabled Alan to channel his constructive creative impulses and his destructive impulses onto the same surface. The therapist subsequently suggested to Alan to work in wood carving, with the aim of channeling his destructive impulses to slash and hack into creative avenues. This repeated creative activity in wood carving and the painting of the finished product using poster paints enabled Alan to moderate his destructive impulses and to integrate them with his drive towards construction, channeling both aspects onto one common surface. For the first time, Alan related to the finished product and was excited by the esthetic value of his work. His capacity to create a work of art that held expressive value in his eyes, allowed Alan to ‘contribute’ through a channel that was not exclusively laden with primitive contents. The wood carving, the creation of which had been originally motivated by destructive impulses, enabled Alan to go through a form of ‘reparative experience’, while there was a concomitant significant drop in his anxiety levels. The channeling of both the creative constructive activity and Alan’s destructive behavior onto one common surface enabled the beginning of the process of integration between the good and bad self and object representations. Alan abandoned his previous violent behavior towards the equipment and the therapist and involved himself for the first time in organized creative work, from which he gained satisfaction.For both Michael and for Alan, it was the repeated interconnection made in the therapy between the concrete visual products of their making and the collection of emotions that surfaced during the creative process that enabled each of them gradually to master their hitherto warded off primitive impulses and fantasies, while simultaneously strengthening ego functions. The consistent and ongoing link made between the creative process using art materials and the associated affective states brought about a higher level of integration in the ego of themes, the origins of which were in earlier stages of development.     

“I was more her Mom than she was mine:” Role Reversal in a Community Sample*

Family processes associated with childhood role reversal and related adult outcomes were examined in a community sample (128 adults) using a semistructured interview exploring family, friend, and romantic relationships. Women showed stronger role reversal than men, and role reversal was stronger with mothers than with fathers. Role reversal of women with mothers was associated with parental divorce, neglect, and rejection. Only parental divorce was consistently associated with men's role reversal. Role reversal was not associated with current symptoms for either men or women, nor with attachment orientations for women. Three patterns with distinct family dynamics and outcomes—guardians/protectors, pleasers/compliants, and spousified—emerged from qualitative analyses of 16 women who experienced high levels of childhood role reversal.     

The Effect of Restraint Stress on the Normal Colon and on Intestinal Inflammation in a Model of Experimental Colitis

Stress may induce development of inflammation in animal models of colitis. The effects of restraint stress on oxidative damage and on antioxidants in the normal colonic mucosa were studied. The effect of stress on the severity of indicators of inflammation, as well as the importance of mucosal substance P (SP) as a mediator of this effect were investigated in the TNBS-colitis model. Restraint stress significantly increased malondialdehyde levels and reduced levels of low-molecular-weight-antioxidants in the normal colon. ATP and the mucosal “energy charge” decreased substantially with chronic stress. Chronic stress worsened the extent of inflammation in 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis. Mucosal SP content was not affected by exposure to chronic stress but increased after induction of colitis. The increase was greater when colitis was induced after exposure to stress. We conclude that chronic restraint stress causes oxidative damage to the normal colon and aggravates intestinal inflammation induced by TNBS. This effect may be mediated by SP. E. Israeli and T. Hershcovici contributed equally to this work.     

The longitudinal variability of serum 25(OH)D levels

BackgroundThe extent to which a single serum 25(OH)D measurement represents long-term vitamin D status remains unclear. This study aims to assess the variability of serum 25(OH)D between tests taken at different time intervals.MethodsUsing the computerized database of the largest healthcare provider in Israel, we identified subjects in whom a serum 25(OH)D test was performed on at least two different occasions between January 2008 and September 2011 (n = 188,771). For these subjects we selected the first and the last dated tests, then we identified those who were not treated with supplements during the last 6 months before the first and before the last test (n = 94,418). Of these we analyzed subjects in whom the first and the last tests were performed in the same month of the year (n = 8881).ResultsThe mean serum 25(OH)D level at the first test was 51.7 ± 24.0 nmol/L and was 56.7 ± 24.7 at the last test (P < 0.001); the overall correlation was 0.63 (P < 0.001). For vitamin D status in two categories (< 50 versus ≥ 50 nmol/L), the percentage of agreement between the first and last tests was 74.4%, and was 50.8% for vitamin D status in four categories (< 30, 30–49.9, 50–74.9, and ≥ 75 nmol/L). The correlation decreased with increasing time between the tests ranging from 0.83 for tests done at the same year to 0.55 after 3 years. The more the first levels were higher or lower, the more likely subjects remain in their first category (≥ 50 versus < 50 nmol/L).ConclusionsLong-term month specific serum 25(OH)D levels are relatively stable.     

Shared decision-making in Israel: status, barriers, and recommendations

ABSTRACT: Shared decision making (SDM) - involving patients in decisions relevant to their health - has been increasingly influential in medical thought and practice around the world. This paper reviews the current status of SDM in Israel, including efforts to promote SDM in the legislation and healthcare system, its influence in medical training and the national health plans, and funding for SDM-related research. Published studies of SDM in Israel are also reviewed. Although informed consent and patients' right to information are regulated by Israeli law, little provision is made for SDM. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase public awareness. A review of the limited research literature suggests that although patients and physicians express a desire for greater patient involvement, they often have reservations about its implementation. Research also suggests that despite the positive effects of SDM, such an approach may only infrequently be applied in actual clinical practice. In conclusion, though not actively promoting SDM at present, Israel's universal coverage and small number of health plans make rapid, widespread advances in SDM feasible. Israeli policymakers should thus be encouraged to nurture burgeoning initiatives and set plausible milestones. Comparing the status of SDM in Israel with that in other countries may stimulate further advancement.     

Dialogues in No Man's Land

Abstract

This article attempts to lose the abyss between the offspring of victims and perpetrators. In chronicling a journey from New York to Berlin to Jerusalem, the author seeks to engage not only the contemporary legacy of the Holocaust but also the roots of her own othering of Germans and Palestinians. She seeks answers to controversial but crucial questions: Will Germans and Israelis move towards a less confining and ideological notion of their identity, or will they instead find themselves unintentionally perpetuating a cycle of fear, hate, and oppression? Can Israeli Jews and Palestinians break down the walls of blindness between them? The article proposes that mutual recognition and acknowledgement of intersections of experiences can undo the process of dehumanization done by former and present generations on each side.