Thursday, June 18, 2015

Autism Spectrum Disorders and Aspergers Disease, Hot Topics in Psychiatry, Dublin, Ireland

The College of Psychiatrists of Ireland have established a monthly 2 CPD credit, symposium at Ashling Hotel Dublin. This is in   response to the increasing time pressures on psychiatrists whose practice demands conflict with the honest desire for continuing medical education.  They just can’t get away for more extensive workshops and symposiums.   This Thursday evening congenial collegial meeting was similar to a monthly Canadian psychiatry meeting I  so enjoyed in Victoria British Columbia.
I was interested in this meeting because my interest in trauma and head injury has resulted in more referrals of Autism Spectrum Adults for assessment and management.  While I knew that this area was particularly explosive in interest and research in children and adolescents I was not at all aware of what was being done regarding adults.  I’d not seen anything similar in this years CME offerings to what these Irish psychiatrists had put together and am very thankful I was able to attend.
Prof Louise Gallagher, MB MRCpsych PHD was a very bright and very attractive young woman in her thirties who presented in the conventional dynamic power point manner with excellent photocopy handouts of her slides showing the natural progression of material from basic science to clinical caveats. I was quite mesmerized by her obvious love for her subject and care for her patients.  She spoke of the original genome mapping costing a billion euro whereas today individuals can have a genome mapped for as little as a thousand or two making this extraordinary technology clinically relevant and competitive with other breakthrough technologies such as MRI’s.
Research has shown that there are significant patterns of error in the genes associated with synatogenesis. Dr. Gallagher shared a particularly insightful vignette involving Neurexin.  Neroligin,CNTNAP2, and Shank are others possibly to be considered as ‘usual suspects’.  The aetiology of ASD from neuroimaging suggest early brain overgrowth followed by premature neural growth.  Interestingly while ASD ‘runs in family’s, 75% of aetiology remains unexplained and parents benefit from ‘genetic counselling’ because they tend to “overestimate" the genetics of the condition.
While I was listening to the very eloquent, though lilting,  Dr. Gallagher, I was certainly well informed about the NRXNI CNV deletions and rare variants and systems biology.  Now I know I’d have to hear these ’new ideas' several times more before they’d ’stick’ in my increasingly teflon jaded hippocampus.  The young psychiatrists sitting behind me however were truly gaga over the implications of what Dr. Gallagher was sharing while I was searching my brain for what else I knew about the Glutamatergic synapses.  I was thankful that “in my day’ we didn’t have these particular ‘details’.   The younger psychiatrists apparently didn’t have to struggle with the terminology as I did.  Brain structure and function vary over time and this ’neuroplasticity’ is affectedby family income, parent education such that socioeconomic disparities  can negatively affect the ASD.
I specifically perked up when she shifted in a timely way to the really important take home clinical message  that Early Intervention really was very effective.  Treatment could increase IQ in ASD by 20 points and mean the difference between a person needing residential care for life  to one living independently. A review of the extraordinary costs, billions of dollars, for the lifelong care of autistic individuals was quite staggering making the  rewards to society of therapy imperative.
Specifically Dr. Gallagher presented a video of the Early Start Denver Model (ESDM) a particular therapy that ‘motivated children’ with relational social rewards.  ESDM is an effective evidenced based early intervention for ASD and early behavioural intervention is associated with normalized brain activity.  That said Dr. Gallagher’s other take home point was that ASD young people have other co morbidities and that these needed to be treated as one would in others. Anxiety disorders are most concerning.
Personally, the presentation was sufficient for me with the one slide on indications of psychotropic use in ASD summarizing the systematic review of Siegal and Beaulieu, 2011.  This discussed the efficacy and usefulness of specifically rispiridone, abilify, methylphenidate, naltrexone.  Coming to such a conference to hear one of the leading authorities recommendations of clinical resources is one of the simplest most important parts of continuing medical education.  If I were to have had the opportunity to hear Max Planck I’d certainly be delighted to know which authors he found most relevant.  I now look forward to having our brilliant British Columbian College of Physicians and Surgeons librarian find me this resource for handy day to day clinical use.   Before this night I had never heard of Siegal and Beaulieu’s systematic review.  Now I know that to ASD, in a way,  this is what Star D protocols were to mood disorder. This information alone was well worth the price of admission.
It was overall an exciting presentation and I couldn’t help but think that Dr. Louise Gallagher is the very best kind of balanced symposium presenter who would inspire researchers and clinicians and be a drawing card for the next generation of psychiatrist who are in the process of building our understanding of psychiatry from the bottom up.
Now Dr. Eimer Philbin Bowman was a wholly different kettle of fish whose presentation was as different as night and days from Dr. Louise Gallagher.  Dr. Bowman, a very very bright understated attractive consummate clinician in her 50’s began by joking that her presentation would be the ‘cooler’ of the ‘hot topics’.  Personally I loved it.
In Canada, yesterday on our CBC  radio, a collection of doctors were interviewed about ‘mandatory retirement’ and challenged by the young reporter about the relevance of older physicians.  Personally I’m an older physician  and was quite taken aback by the somewhat suggestion of ‘anyone over thirty’ should be euthanized, not that I didn’t think this myself when I was younger.  It has cropped up with some surgeons physical decline wanting some competency review in later sixties and seventies. However,  the idea that separates ‘knowledge’ from ‘wisdom’ , especially in psychiatry, is a whole other matter.  I fear mostly fascist/communist medical ‘authorities’ wanting young ‘warm’ bodies to fill their Pink Floyd meat grinder insane obsession with cheapness.  They are terribly annoyed at us older folk who can’t help but point out how their ‘new latest  cost saving strategies" were tried, failed and cost countless lives and dollars in the long run, besides being just plain stupid.
So I truly loved hearing Dr. Bowman’s talk which might well be said to be more of the ‘art’ of medicine.  Whereas Dr. Gallagher could be said to have focussed on the ‘genotype’ , Dr. Bowman addressed the ‘phenotype’.  Her talk was more ’traditional psychiatry’ and reminded me of one of my all time favourite presentations, given at the World Congress of Psychiatry in Athens by the then head of Moscow psychiatry,  critical of the foundations and limitations of a particularly arrogant bit of the american DSM.    Dr. Bowman described the history of the development of the Asperger diagnosis.  She poignantly captured it’s relevance by pointing out that the Nazi’s were gassing “black starred”  "asocial women’ .  Many of these ‘asocial’ were were likely ASD.  Dr. Bowman felt that while the present statistics suggest quite a predominance of males over females that this was to her mind a reflection of convention and culture.
In contrast to her ‘cool’ idea I couldn’t help but reflect that in Canada right now “Physician Assisted Suicide” is the truly scalding topic. It’s come up at a time when  it’s become increasingly apparent from the Holland experience that a huge percentage of their ‘euthanasia’ cases are simply  ‘depressed’ psychiatric cases.  The new ‘scientific efficiency’ is in distinct contrast to the other Canadian movement of noble note, created by Vanier, son of Canada’s former Governor General, L’Arche.  Vanier  and L’Arche in sharp contrast to the Nazis argued that a society gains special benefits from the care of it’s disabled.  I loved that Dr. Bowman stressed that the diagnosis of Aspergers came out of the very consideration of the ‘social value of an individual’.
Dr. Bowman talked of the pioneering work of Dr. Lorna Wing , the social psychiatrist, who began the National Autistic Society.  She discussed the criteria of the diagnosis  and elucidated the points of distinction pointing specifically to the speech abnormalities,  She  presented a recording illustrating these peculiarites that we as clinicians  know so well but have difficulty describing.  She described the denial, intellectualizations and rationalization and pointed out how often the IQ testing of a Asperger's person shows a characteristic scatter with disconnect between verbal and non verbal reporting.  She spoke of the 2007 Comprehensive Guide to Aspergers and discussed the pros and cons of the new DSMV.
It was a highly rewarding presentation which I thoroughly appreciated because frankly, I knew by her frontline experience and case presentation and discussion, she ‘knew’ what she was talking about from years of talking with patients and their families. She stressed how important the interview with family was and her audio presentation showed how detailed her interviewing techniques were amassing vast amounts of insight with specifically structured questions.
I especially loved that she pointed out that the so called ‘negative’ aspects of schizophrenia sounded so like much of the Aspeger’s description.  I couldn’t help but think of her a very foxy lady for that bon mot.  The youngest members of a profession can never know how much the ‘naming’ of things is the product of ‘back room’ politics. With only a cross section analysis we can go blithely off cliffs like fat lemmings.  An aging old bat like me is jaded by the knowledge of how ‘turf’ wars as much as anything elegantly scientific has changed the face of psychiatric diagnosis, ICD and DSM over the years.  I rather liked that Dr. Bowman was quietly diagnosing with obvious specificity a group of people who were made better for this simple attention to detail.  There was obvious disdain for the ‘one brush fits all’ approach  that so appeals to managers who would rather exclude those things and people that don’t fit their desire for neat and inhuman ‘models’.   The politics of mental illness hasn’t really changed much since the 40’s recognition that these poor ‘asocial’ individuals potentially have an underlying genetic/environmental condition that if early recognized can be ‘normalized’ . Even as adults these individuals can be symptomatically helped and their anxieties ameliorated with psychotherapies and psychotropics.  
It was apparent that both Dr. Gallagher and Dr. Bowman loved their patients and their work. I left the meeting thankful to be a member of this odd tribe of doctors who have made it their life work to help the marginalized.  As I walked out into the Dublin night and hailed a taxi I felt good to be a psychiatrist.   Not a bad take home message.
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