Medicolegal aspects of non-rapid eye movement parasomnias

INTRODUCTION@#In a subset of adults with non-rapid eye movement (NREM) parasomnias, clinical variants might be violent in nature and can potentially result in unintentional but considerable harm. As such, there is substantial interest on the forensic ramifications of these sleep behaviours.@*METHODS@#This review examined the diagnostic criteria for parasomnias established in the context of international classification systems; medicolegal case reports; legal frameworks; and court cases in and outside of Singapore, to provide an overview of the implications of NREM parasomnias.@*RESULTS@#Violent or injurious behaviours that occurred in the context of somnambulism, otherwise known as sleepwalking, have challenged traditional legal theories of criminal culpability. Yet little has changed in the application of sleep science to criminal responsibility. In Singapore, the defence of somnambulism has hitherto not been directly raised. Nonetheless, sleep medicine practitioners may increasingly be requested to render their opinions on legal issues pertaining to violent or injurious behaviours allegedly arising during sleep. Although the understanding of NREM parasomnias has improved, there is still a dearth of evidence to support both medical and legal decisions in this area.@*CONCLUSION@#NREM parasomnias come with disquieting legal and forensic implications for adjudicating criminal responsibility. There is a need to critically examine legal perspectives on behaviours occurring during sleep. More reliable empirical studies investigating the pathophysiology of NREM parasomnias can offer clearer diagnostic guidelines and address complex behaviours of NREM that often come with medicolegal implications.

Therapeutic Misconception in Psychiatry Research: A Systematic Review

Therapeutic misconception (TM) denotes the phenomenon in which research subjects conflate research purpose, protocols and procedures with clinical treatment. We examined the prevalence, contributory factors, clinical associations, impact, and collated solutions on TM within psychiatric research, and made suggestions going ahead. Literature search for relevant empirical research papers was conducted until February 2015. Eighty-eight reports were extracted, of which 31 were selected, summarised into different headings for discussion of implications and collated solutions of TM. We found variable and high rates of TM (ranging from 12.5% to 86%) in some psychiatry research populations. Contributory factors to TM included perceived medical roles of researchers, media, research setting and subject factors. Greater TM in affective, neurodevelopmental and psychotic spectrum conditions were associated with demographic variables (such as lower education, increased age), clinical factors (such as poor insight, cognitive deficits, increased symptoms, poorer self-rated quality of health), and social functioning (such as decreased independence). Inattention to TM may lead to frustration, negative impression and abandonment of participation in psychiatry research. Strategies such as the employment of a neutral educator during the informed consent process and education modules may be effective in addressing TM. Further research is warranted to examine the different TM facets, specific clinical correlates and more effective management strategies.

Diffusion Tensor Imaging Findings of White Matter Changes in First Episode Schizophrenia: A Systematic Review

Earlier structural magnetic resonance imaging in schizophrenia have noted smaller white matter volumes in diverse brain regions and recent diffusion tensor imaging (DTI) studies have allowed better elucidation of changes in brain white matter integrity within the illness. As white matter abnormalities have been reported to occur early in the course of schizophrenia, we systematically review extant DTI studies of anomalies of white matter integrity in first episode schizophrenia (FES) up till October 2011. Overall, disruptions of white matter integrity were found in the cortical, subcortical brain regions and white matter associative and commissural tracts, suggesting that changes of cortical-subcortical white matter integrity were found at an early stage of the disorder. These changes in white matter integrity were correlated with specific cognitive deficits (verbal and spatial working memory) as well as psychopathology (positive more than negative symptoms) in patients with FES. The correlation of these white matter integrity changes with cognitive and phenomenological factors may shed light on neurobiological substrates underlying these clinical manifestations. Future studies need to validate these findings in larger samples of subjects and in different populations as well as chart the progress of these cerebral white matter changes over time so as to better appreciate their trajectory with illness course, treatment and chronicity.

Neuropsychiatry--an emerging field

Neuropsychiatry is an emerging field at the intersection of neurology and psychiatry, driven by the unprecedented advances in neuroscience. The arbitrary demarcation between neurology and psychiatry, which largely existed only in the last century and a half, has become less tenable. We discuss the definition and scope of this emerging field. We also review the development of clinical neuropsychiatry in Singapore in the context of historical developments and recent changes in the field from other countries. At a more practical level, we discuss a few of the clinical settings in which neuropsychiatry operates, in particular, the stigma associated with psychiatric disorders locally, and the significant number of patients with psychiatric or psychosomatic symptoms presenting to neurology and general practice clinics. The stigma may be ameliorated by better understanding of the neurobiological basis of psychiatry. We see the future of neuropsychiatry in Singapore, as in other developed countries, as one approach to understand and manage complex brain disorders. We advocate training for both psychiatry and neurology residents in their counterpart fields, which will lead to greater understanding of both fields, and enhance collaboration in clinical care and research.

Hypnotherapy for sleep disorders

Hypnosis can be defined as a procedure during which changes in sensations, perceptions, thoughts, feelings or behaviour are suggested. Hypnosis can be used to amplify whatever it is about therapy that makes it therapeutic. It permits a wide range of choices regarding where and how to intervene in the patient's problems. In this paper, we set out to examine the rationale of using hypnotherapy to manage various types of sleep disorders, and to explore the techniques, strategies and hypnotic scripts employed by various hypnotherapists. We also examine the research data available on the efficacy of hypnosis in the treatment of sleep disorders. Acute and chronic insomnia often respond to relaxation and hypnotherapy approaches, along with sleep hygiene instructions. Hypnotherapy has also helped with nightmares and sleep terrors. There are several reports of successful use of hypnotherapy for parasomnias, specifically for head and body rocking, bedwetting and sleepwalking. Hypnosis is a specialised technique, not a therapy itself, and should be used as an adjunctive intervention within a complete psychological and medical treatment package. Most of the literature is limited to case reports or studies with such a small sample that at times it is very difficult to interpret the results. There is a major placebo effect, so uncontrolled trials are of limited value. It is hard to perform a randomised, double-blind, controlled trial to evaluate hypnotherapy given that cooperation and rapport between patient and therapist is needed to achieve a receptive trance state.

Abuse of prescription buprenorphine, regulatory controls and the role of the primary physician

<p><b>INTRODUCTION</b>Buprenorphine is an opioid partial agonist approved in several countries for the treatment of opioid dependence. It was approved in Singapore in 2002 for this indication, and is more widely available in the primary care setting and can be prescribed by all licensed physicians who have undergone designated training. There is limited literature addressing the risk of its illicit abuse via intravenous self-administration.</p><p><b>CLINICAL PICTURE</b>We report 2 such cases of the abuse of prescription buprenorphine in the psychiatric consultation-liaison service of a general teaching hospital, the treatment approaches and outcomes.</p><p><b>CONCLUSION</b>We also briefly review the indications, uses and abuses of buprenorphine in Singapore, and as reported in other countries, and the roles of primary care physicians, in order to stimulate greater awareness and understanding among specialists and general practitioners, who would encounter these patients in various settings.</p>