Review of Psychiatric Mother-Baby Unit in Postpartum Period / 신경정신의학

With the development of the attachment theory and perinatal psychiatry, the joint admission of the mother and her baby in hospitals began in the 1950s, and this has developed into the establishment of specialized Mother-Baby Units (MBUs). MBUs were operated mainly in the United Kingdom and France. Subsequently, the concept gradually expanded to Belgium, Australia, and the United States, and recently, it is also spreading to Hungary, Sri Lanka, and India. The MBU is a specialized inpatient ward that operates 24 hours a day and comprises multidisciplinary personnel who can give specialized care to mothers with mental illnesses and their babies. Various psychosocial interventions, as well as pharmacotherapy, are used to achieve the MBU’s goal. These include a secure attachment bond between a mother and her baby and psychiatric care for the mother’s mental problems. According to most previous studies about MBU, the outcomes relating to clinical symptoms and the mother-baby interaction have been promising. Currently, there is no MBU in South Korea even though the obvious benefits have been identified. Further studies for the establishment of MBUs in our clinical environment are desperately and urgently needed.

The Evolutionary Medicine of Birth Decision:Psycho-Socio-Ecological Explanations / 정신신체의학

A key factor in evolution is reproduction, which is also a major concern in medicine. Evolutionists have proposed many theories and hypotheses to explain the low fertility rates of modern industrial societies, which are contrary to maximization of biological fitness. Given that childbirth is the most significant factor affecting re-productive fitness, it is likely that a variety of psychological modules related to childbirth behavior and intentionevolved over time. Several evolutionary psychological modules have been proposed in relation to reproduction, including sexual desire, status-seeking, a need for nurturing, and the desire for children. Previously adaptive psychological modules may now be expressed maladaptively due to the discrepancy between the Environment of Evolutionary Adaptedness (EEA) and the environment of modern industrial society. Several evolutionary ecological factors influence childbirth intention in modern society, including individual personality factors, childhood life his-tory experiences, and socioecological factors throughout reproductive life. By focusing on mental, social, and ecological factors, this review examines several hypothetical models relating to evolutionary psychological factors and childbirth decisions in modern industrial society, as well as a possible explanation for the low birth rate.

Evolutionary Model of Depression as an Adaptation for Blocked Social Mobility

Objectives@#In regard to the social competition hypothesis, depression is viewed as an involuntary defeat strategy. A previous study has demonstrated that adaptation in microenvironments can result in a wide range of behavioural patterns including defense activation disorders. Using a simulation model with evolutionary ecological agents, we explore how the fitness of various defence activation traits has changed over time in different environments with high and low social mobility. @*Methods@#The Evolutionary Ecological Model of Defence Activation Disorder, which is based on the Marginal Value Theorem, was used to examine changes in relative fitness for individuals with defensive activation disorders after adjusting for social mobility. @*Results@#Our study examined the effects of social mobility on fitness by varying the d-values, a measure of depression in the model.With a decline in social mobility, the level of fitness of individuals with high levels of defense activation decreased. We gained insight into the evolutionary influence of varying levels of social mobility on individuals’ degrees of depression. In the context of a highly stratified society, the results support a mismatch hypothesis which states that high levels of defence are detrimental. @*Conclusions@#Despite the fact that niche specialization in habitats composed of multiple microenvironments can result in diverse levels of defensive activation being evolutionary strategies for stability, decreased social mobility may lead to a decrease in fitness of individuals with highly activated defence modules. There may be a reason behind the epidemic of depression in modern society.

Evolutionary Anthropological Considerations of Suicide:How Has the Suicide Evolved? / 신경정신의학

Since suicide ends the life of the individual, it is difficult for suicidal behavior to evolve. All humans are prone to suicide, however. In addition to being a human idea, it is ubiquitous across cultures. The high inheritability of suicidal behavior suggests that suicide does not only occur following a trauma that is socio-cultural in nature. In the past, a number of psychological, social, cultural, biological, and psychiatric explanations have attempted to explain the causes and mechanisms of suicidal behavior, but none of these explanations resolved its evolutionary puzzle. Several genetic approaches are discussed in this paper regarding the evolution of suicidal behavior. These approaches include mutation-selection balance, genetic drift, neutral evolution, balancing selection, and directional selection. A previous discussion detailed the inclusive fitness hypothesis and the by-product hypothesis. Taking them all together, suicide might be one of the by-products of the evolution of Homo sapiens. Also, the differences in suicide-related epidemiology between men and women are likely due to balancing selection, more specifically, sexually antagonistic selection. Hopefully, in the future, evolutionary simulation models and empirical data on suicide’s evolution may shed some light on some of these evolutionary explanations.

Review of the Impact of Parental Mental Illness on Infant Development and Intervention Plan / 신경정신의학

The impact of maternal mental health on parenting and infant development is significant. Infants of mothers who have experienced perinatal mental health problems have genetic risks as well as risks in establishing a stable mother-child relationship, which interferes with the infants’ emotional, cognitive, and social development. Biological, psychological, and inpatient treatments, such as mother-baby unit at the highest risk after childbirth, have been attempted to minimize the negative consequences of perinatal mental disorder. Mother-child psychotherapy is also helpful in improving a mother-child relationship and strengthening the parenting ability.

Evolutionary Ecological Model of Defence Activation Disorders Via the Marginal Value Theorem

Objective@#Excessive activation of defence modules leads to some dysfunctional outcomes, which can be broadly classified to defence activation disorders. Defence activation disorders have high mortality, low fertility, high prevalence and high heritability. In this study, agent-based simulation model is formulated for solving this evolutionary paradox. @*Methods@#The emotional system is considered as a superordinate cognitive module for grasping the average resource amount and the average diminishing returns of resources, based on the Marginal Value Theorem. Under the assumption, the evolutionary ecological model was proposed and analysed. @*Results@#Individuals utilising suboptimal strategies can be stably maintained in agent-based evolutionary simulation environments. Individuals were adapted to have different d-values according to the local niche. The simulation runs stably within the calibrated range of the variables for a long time. Agents establish locally optimal strategies based on their given d-values, and the relative proportion of subpopulation maintained stably in the heterogeneous habitat with the resource gradient. @*Conclusion@#This study verifies the evolutionary mechanism of defence activation disorders in computer-simulated environments by using agent-based modelling with the Marginal Value Theorem. Balancing selection appears to be a plausible evolutionary mechanism that makes the suboptimal levels of defence activation the evolutionarily stable strategies.

Cultural Tradition of School Excursion and Collective Trauma of the Motor Vessel Sewol Accident

The Motor Vessel Sewol accident was a horrible accident, and it had complex ripple effects in various areas such as politics, economy, and culture. In particular, the psychological impact of each individual in Korean society was great, and various explanations for the causes of such psychological mass trauma would be possible. One of these important causes is the historical memory about common cultural custom. Therefore, the historical and cultural memory of the school trips shared by members of Korean society may be one of the causes of the psychological trauma. This paper aims to explain the cultural and social functions of school trips in East Asian societies from a historical point of view. In addition, we will also analyse the reasons why shared cultural memories contributed to the formation of collective trauma of the accident from a cultural, anthropological and psychiatric point of view.

Evolutionary Model of Individual Behavioural Variations / 정신신체의학

The behavioural patterns of individuals in the same species are very diverse. The phenomenon in which different behavioural phenotypes are maintained in the same species for long time can be explained by niche specialization or frequency dependent selection, but it has not been proven yet. Especially, the high prevalence of mental illnesses as extreme behaviour patterns is one of the challenges of evolutionary psychology. From an evolutionary point of view, several frameworks for studying various patterns of behaviours or psychopathologies may be proposed. In this paper, I briefly explain animal models, personality factor models, DSM-IV multiaxial models, FSD models, and RDoC models, and discuss their advantages and disadvantages, focusing on the evolutionary approach to behavioural variation among individuals.

Evolutionary Genetic Models of Mental Disorders

Psychiatric disorder as dysfunctional behavioural syndrome is a paradoxical phenomenon that is difficult to explain evolutionarily because moderate prevalence rate, high heritability and relatively low fitness are shown. Several evolutionary genetic models have been proposed to address this paradox. In this paper, I explain each model by dividing it into selective neutrality, mutation-selection balance, and balancing selection hypothesis, and discuss the advantages and disadvantages of them. In addition, the feasibility of niche specialization and frequency dependent selection as the plausible explanation about the central paradox is briefly discussed.

Evolutionary Hypotheses of Mental Disorder and Their Limitations / 생물치료정신의학

Like the body of Hominin, mind is the result of natural selection. Therefore, an evolutionary approach in the biological aspects is essential for an intrinsic understanding of mental disorders. However, the evolutionary medical approach to mental disordershas not been well researched because evolutionary psychiatry is not widely accepted, and the conceptual paradigm has not been unified. Nevertheless, some evolutionary hypotheses about some mental disorders have been proposed, including the following: 1) thesimple disease argument that mental disorder is a mere disease, 2) the genomic lag hypothesis that current genes are incompatible with evolutionary environmental changes, 3) the developmental mismatch hypothesis that brain development cannot reflect entire-information of surrounding environment, 4) the trade-off hypothesis that costs are offset by other adaptive benefits, 5) the by-product hypothesis that mental disorders are inevitable outcome of evolutionary design, 6) the cliff-edge model that the encephalizationin the Hominin caused mental disorders, 7) the inclusive fitness hypothesis that costs of individual are compensated by benefits of kinship, 8) the antagonistic polymorphism hypothesis that differential costs and benefits according to sex or age cause ofpolymorphic psychological traits 9) the heterozygote advantage hypothesis that the heterozygous genotypes have higher relative fitness, so they can persist even though homozygous genotypes cause mental disorders, and 10) a genomic imprinting hypothesis that conflicts between maternal genes and paternal genes cause mental disorders. I will summarize and compare the evolutionary hypotheses of mental disorders and present the lim itations of each hypothesis.

Current State of Vocational Rehabilitation Program for Individuals with Disabling Mental Illness in Korea / 정신신체의학

OBJECTIVES: There has been long lasting trend of deinstitutionalization and public health centered care in management of individuals with disabling mental illness. We aimed to investigate current vocational rehabilitation state and effectiveness of system in korea. METHODS: We carried basic survey via telephone and e-mail beforehand to figure out how many and which institutions are operating vocational rehabilitation programs to psychiatric patients. A questionnaire packages were sent to total of 108 institutions in Korea which were operating occupation rehabilitation program. RESULTS: Of 108 institutions, 40.74% were returned with answers. The person in charge of vocational rehabilitation at each institution was mainly mental health social worker(48.8%), and the budget under \1,000,000 was the majority(61.5%) among surveyed institutions. The most commonly used vocational rehabilitation programs was case management(23.1%), followed by psychosocial rehabilitation program(21.2%), and on-the-job training(17.9%). The most effective program was case management(27.4%), followed by psychosocial rehabilitation program(19.8%), on-the-job training(17.9%). The main barrier of occupation rehabilitation to be conducted widely was ‘worries about being excluded from beneficiary of National Basic livelihood Protection Act’. CONCLUSIONS: Our results suggest that, in spite of high demand in vocational rehabilitation programs, government financial support is still lacking.

A Case of Clozapine-Induced Anemia and Thrombocytosis / 신경정신의학

Clozapine is a well-known antipsychotic which causes hematologic adverse effects, specifically neutropenia and agranulocytosis (1-3% of patients). However, reports on blood dyscrasias like anemia and thrombocytosis after clozapine treatment are extremely rare. In some cases re-challenge of clozapine could lead to hematopoietic abnormality related to thrombocytopenia or thrombocytosis, which may be a result of an immune reaction. This case report suggests that clinicians should monitor platelet count after re-treatment with clozapine.

Research Methodologies of Evolutionary Psychiatry / 신경정신의학

Evolutionary psychiatry is a branch of medical science concerning mental disorders, and also a multidisciplinary research field with close relation to psychology, anthropology, evolutionary biology, neuroscience, and ethology. Although evolutionary psychiatry is a promising area for further psychiatric studies, it is still in its infancy. Thus, there are no certain research methods using evolutionary approaches toward mental diseases. It is still at the level of adopting and applying the research methods of the aforementioned adjacent fields. We aim to investigate a variety of research methods proposed to date and then compare them, which will provide a glimpse of the future of evolutionary psychiatry in the upcoming era.

Evolutionary Approaches toward Psychiatry / 신경정신의학

Evolutionary anthropology is the multidisciplinary field of social and natural sciences regarding the physiology and behavior of Homo Sapiens, and the relationship between human and other Hominoids like primates or ancient human species. Evolutionary anthropological approach toward psychiatry is a promising way to resolve the inter-disciplinary conflicts between different fields of study of the human mind. Evolutionary psychiatry is the specialized part of applied biologic anthropology and clinical psychiatry dealing with the biological causes of mental disorders, the impacts of cultural change toward the evolution of the human mind by studying the ancestry of mankind. I attempted to overview the history of evolutionary anthropology or neuroanthropology related to brain and mind, and the possibility of evolutionary psychiatry by showing the progress of academic and social issues regarding the ultimate causes of several mental illnesses.

A Case of Delayed Encephalopathy of Carbon Monoxide Intoxication / 신경정신의학

Occurrence of carbon monoxide intoxication has decreased due to decline in use of coal briquettes (anthracite) in Korea. However, suicide attempt by use of a coal fire lighter (beon-gae-tan) has shown a rapid increase over the past five years with relevance to imitated suicide. Acute carbon monoxide intoxication is a dangerous problem affecting the brain, kidney, lung, and other major organs. Sometimes, delayed encephalopathy after carbon monoxide intoxication makes clinical psychiatric diagnosis and treatment puzzling because neuropsychiatric sequelae are ambiguous with premorbid psychiatric problems, such as mood disorder, psychotic disorder, or other substance dependence. We report on a case of delayed encephalopathy of carbon monoxide intoxication and discuss its diagnosis and management.

High-Dose Zolpidem Dependence and Detoxification from Withdrawal Symptoms Using Diazepam / 신경정신의학

Zolpidem is a nonbenzodiazepine hypnotic for the treatment of insomnia, and known as a relatively-safe medication. However, there have been several case reports of zolpidem abuse aand dependence these days. Even though some withdrawal symptoms like seizures can occur, there has not been any standard detoxification method until now. A high dose of zolpidem has similar pharmacological properties as the rest of the benzodiazepines, even though the usual dose of zolpidem has a selectivity to the type 1 benzodiazepine receptors. We report a rare case of high-dose addiction and successful detoxification by cross-titration with diazepam.

A Randomized Controlled Pilot Study of Cognitive Behavioral Social Skills Training (Korean version) for Middle- or Older-Aged Patients with Schizophrenia : A Pilot Study / 신경정신의학

OBJECTIVES: Cognitive behavioral therapy and social skills training have been proposed as a promising modality for treatment of patients with schizophrenia. The objective of this study was to evaluate the effectiveness of Cognitive Behavioral Social Skill Training (CBSST) in patients with chronic schizophrenia. METHODS: Twenty six middle- or older-aged hospitalized patients with schizophrenia were selected in a mental hospital. Eleven participants were randomly assigned to undergo treatment with CBSST and 15 participants were assigned to receive the usual treatment. CBSST was administered in a single group over 12 sessions for a period of weeks, and the participants were assessed by blinded raters at base line and end point, and end of treatment. RESULTS: Compared to patients who received the usual treatment, those who received treatment with CBSST showed a significant reduction of Hamilton Rating Scale for Depression score, however, scores for other psychiatric symptoms did not differ significantly. In terms of Quality of life (QoL) analysis, scores for overall quality of life showed a more significant increase in the CBSST group, compared with the group of patients who received the usual treatment. According to results of the Independent Living Skill Survey, patients receiving CBSST showed significantly greater involvement in social activities than patients receiving usual treatment group. CONCLUSION: Psychosocial intervention for patients with chronic schizophrenia is very important, not only for management of primary psychiatric symptoms, but also for QoL and social rehabilitation. The results of this study, showing improvement of depressive mood, overall life quality, and social activities, suggest that CBSST could be an effective treatment for these patients. This study is a pilot study performed in an inpatient treatment setting. Further studies are required in order to clarify the advantage of CBSST in treatment of patients with chronic schizophrenia, esp. under outpatient settings.

Patient Characteristics in Cases of Misdiagnosed Delirium upon Psychiatric Consultation in a University Hospital: A Pilot Study / 신경정신의학

OBJECTIVES: The misdiagnosis of delirium may result in a delay of correct diagnosis and appropriate treatment of the delirium. Additionally, aggravation of physical illnesses can occur. The objective of this study was to investigate patient characteristics in cases of misdiagnosed delirium upon psychiatric consultation in a university hospital. METHODS: Subjects included patients with delirium among all who we had consulted over a 12 week span. Psychiatric diagnosis was made by two well-trained psychiatrists by means of the DSM-IV-TR. Cognitive function, level of delirium, and physical function were evaluated by the Korean version of Mini Mental Status Examination (MMSE-K), the Delirium Rating Scale-Revised-98 (DRS-R-98), the Clinical Global Impression-Severity (CGI-S), the Eastern Cooperative Oncology Group Performance Status (ECOG-PS), and the Global Assessment of Functioning Scale (GAF). In addition, we collected socio-demographic information, date of admission and consultation, present causes of consultation, and speculated psychiatric diagnoses made by referring physicians. RESULTS: Among 45 subjects with delirium, only 28 patients (62%) were diagnosed with delirium by referring physicians at the time of consultation. The remaining 17 patients (38%) had been diagnosed with other illnesses. The group of misdiagnosed patients tended to have a longer duration of formal education than those that had been correctly diagnosed. CONCLUSION: Early diagnosis and intervention of delirium can minimize subsequent problems related to delayed diagnosis. Therefore, it is vital to identify the factors related to misdiagnoses by referring physicians. This study showed that a longer duration of formal education is a contributing factor for the misdiagnosis of delirium. Longer education may cover up the typical symptoms of delirium. This can keep referring physicians from making a correct diagnosis. This study was a pilot study investigating diagnostic accuracy of delirium by referring physicians. Additional, well-controlled studies are warranted.

Attitudes of Korean Psychiatrists Toward Treatment Long-acting Injectable Antipsychotic / 신경정신의학

OBJECTIVES : Long acting injectable antipsychotic medication have the ability to sustain the drug effect for a long duration, thus enabling advances in the management of those psychiatric patients who have poor compliance or who have difficulty getting the oral form of their antipsychotic medications. Despite their benefits, previous studies have reported that depot antipsychotics have a much lower prescription ratein the treatment of schizophrenia or schizoaffective disorder. Psychiatrist's attitude toward depot antipsychotics clearly has an influence on the decision-making process regarding the selection of medications. Until now, there has been no data with respect to psychiatrists' attitudes regarding long-acting injectable antipsychotics in Korea. This study examined these attitudes toward antipsychotic depot medications as well as the factors which could contribute to their choice of depots. METHODS : We questioned 347 psychiatrists, who had been attending a conference, about their attitudes toward depot antipsychotic treatment. RESULTS : The most important factor causing reluctance with respect to prescribing depot treatment (for both classes of antipsychotics) was a presumed sufficient level of compliance with available oral antipsychotic treatments. In addition, typical depots are not considered to be an appropriate treatment option for first-episode patients, and as a result, they are used sparingly. Lastly, atypical longacting injectable drugs are avoided due to their strict criteria of insurance and high treatment costs. CONCLUSION : Aversions to prescribe depot treatment are frequent among psychiatrists and appear to be unrelated to the antipsychotic class. The stated reasons for not choosing depots are generally not supported by the current literature. Further research is required to clarify the advantages using depot treatments.

A Case Report of Propofol Dependence in a Layman / 대한정신약물학회지

Propofol is a well-known ultra-short acting intravenous anesthetic agent for induction and maintenance of general anesthesia. Since its introduction into the market in the mid 1980s, this is the seventh report on propofol dependence in the literature. Of these, only two cases of propofol abuse have been previously reported in laypersons. We are reporting the case of a lay female who has dependence on propofol, and this is the first lay case in Asia.