Australian & New Zealand Journal of Psychiatry

While there is now strong evidence that psychological therapies can alter the activity of individual brain regions, their impact on the functional integration between regions has not yet been systematically evaluated. This area is important given that brain dysconnectivity has been implicated across almost all psychiatric disorders. Accordingly, we sought to establish connectivity predictors and mechanisms of effective psychological therapies. We further establish whether connectivity changes represent normalisation of disorder pathophysiology or compensatory changes.

We reviewed studies examining structural and functional connectivity longitudinally as either a predictor or outcome variable of successful psychological therapies across psychiatric disorders.

Fifteen studies met our inclusion criteria. All but three related to cognitive behavioural therapy. Of these, five assessed resting state, nine probed affective processing and one probed cognitive processing. Twelve studies reported evidence of functional connectivity as a significant predictor or outcome of cognitive behavioural therapy, with prefronto-limbic circuitry most commonly implicated. Only six studies included healthy participants, limiting direct inferences about normalisation as opposed to compensatory changes. Anxiety disorders were overrepresented, totalling 13 of the studies reviewed. No studies examined structural connectivity or utilised analyses allowing the directionality of functional connectivity to be inferred.

While the evidence base is still in its infancy for other therapy approaches, there was clearer evidence that functional connectivity both predicts and is altered by cognitive behavioural therapy. Connections from prefrontal cortex appear especially key, perhaps given their role in cognitive appraisal of lower order affective, motivational and cognitive processes. A number of recommendations are made for this rapidly developing literature.

(1) To collect, analyze and synthetize the evidence on muscle dysmorphia diagnosis as defined by Pope et al. and (2) To discuss its appropriate nosology and inclusion as a specific category in psychiatric classificatory systems.

A systematic search in the MEDLINE, the PsycNET, the LILACS and SciELO databases and in the International Journal of Eating Disorders was conducted looking for articles published between January 1997 and October 2014 and in EMBASE database between January 1997 and August 2013. Only epidemiological and analytical studies were considered for selection. The methodological quality of included studies was assessed according to the Evidence-Based Mental Health and the National Health and Medical Research Council’s guidelines. The support for inclusion of muscle dysmorphia in psychiatric classificatory systems was examined against Blashfield et al.’s criteria.

Thirty-four articles were considered eligible out of 5136. Most of the studies were cross-sectional and enrolled small, non-clinical samples. The methodological quality of all selected papers was graded at the lowest hierarchical level due to studies’ designs. Forty-one percent of the publications considered the available evidence insufficient to support the inclusion of muscle dysmorphia in any existing category of psychiatric disorders. The current literature does not fulfill Blashfield et al.’s criteria for the inclusion of muscle dysmorphia as a specific entity in psychiatric diagnostic manuals.

The current evidence does not ensure the validity, clinical utility, nosological classification and inclusion of muscle dysmorphia as a new disorder in classificatory systems of mental disorders.

We aimed to investigate sex-dependent alterations in resting-state relative cerebral blood flow, amplitude of low-frequency fluctuations and relative cerebral blood flow–amplitude of low-frequency fluctuations coupling in patients with schizophrenia.

Resting-state functional magnetic resonance imaging and three-dimensional pseudo-continuous arterial spin labeling imaging were performed to obtain resting-state amplitude of low-frequency fluctuations and relative cerebral blood flow in 95 schizophrenia patients and 99 healthy controls. Sex differences in relative cerebral blood flow and amplitude of low-frequency fluctuations were compared in both groups. Diagnostic group differences in relative cerebral blood flow, amplitude of low-frequency fluctuations and relative cerebral blood flow–amplitude of low-frequency fluctuations coupling were compared in male and female subjects, respectively.

In both healthy controls and schizophrenia patients, the males had higher relative cerebral blood flow in anterior brain regions and lower relative cerebral blood flow in posterior brain regions than did the females. Compared with multiple regions exhibiting sex differences in relative cerebral blood flow, only the left middle frontal gyrus had a significant sex difference in amplitude of low-frequency fluctuations. In the females, schizophrenia patients exhibited increased relative cerebral blood flow and amplitude of low-frequency fluctuations in the basal ganglia, thalamus and hippocampus and reduced relative cerebral blood flow and amplitude of low-frequency fluctuations in the frontal, parietal and occipital regions compared with those of healthy controls. However, there were fewer brain regions with diagnostic group differences in the males than in the females. Brain regions with diagnostic group differences in relative cerebral blood flow and amplitude of low-frequency fluctuations only partially overlapped. Only the female patients exhibited increased relative cerebral blood flow–amplitude of low-frequency fluctuations couplings compared with those of healthy females.

The alterations in the relative cerebral blood flow and amplitude of low-frequency fluctuations in schizophrenia are sex-specific, which should be considered in future neuroimaging studies. The relative cerebral blood flow and amplitude of low-frequency fluctuations have different sensitivity in detecting changes in neuronal activity in schizophrenia and can provide complementary information.

Alcohol use disorder may very well increase the likelihood of affective episodes in bipolar disorder, but prospective data on survival are inconsistent.

The authors examined the prevalence of alcohol use disorders and their impact on the risk of relapse. A total of 284 consecutively admitted International Classification of Diseases-10 bipolar I (n = 161) and II (n = 123) patients were followed up naturalistically over a period of 4 years.

The prevalence of alcohol use disorders was higher in bipolar II disorder than in bipolar I disorder (26.8% vs 14.9%; χ² = 5.46, p = 0.019), with a global prevalence of alcohol use disorders of 20.1% in the whole sample. A total of 8.7% of bipolar I patients suffered from alcohol abuse and 6.2% from alcohol dependency, whereas 13% bipolar II patients had alcohol abuse and 13.8% alcohol dependency. Male bipolar subjects had a higher prevalence of alcohol use disorders than female patients (38.3% vs 12.8%; χ² = 21.84, p-value < 0.001). The presence of alcohol use disorders was associated with an increased risk of depressive relapse in bipolar I patients (Cox regression analysis hazard ratio = 2.7, p = 0.005). The increased risk was not modulated by medication.

Our data underline the negative long-term impact of alcohol use disorders on bipolar disorder with more depressive bipolar I episodes and the importance of its detection and treatment.

Information on the rates and predictors of polypharmacy of central nervous system medication in older people with intellectual disability is limited, despite the increased life expectancy of this group. This study examined central nervous system medication use in an older sample of people with intellectual disability.

Data regarding demographics, psychiatric diagnoses and current medications were collected as part of a larger survey completed by carers of people with intellectual disability over the age of 40 years. Recruitment occurred predominantly via disability services across different urban and rural locations in New South Wales and Victoria. Medications were coded according to the Monthly Index of Medical Specialties central nervous system medication categories, including sedatives/hypnotics, anti-anxiety agents, antipsychotics, antidepressants, central nervous system stimulants, movement disorder medications and anticonvulsants. The Developmental Behaviour Checklist for Adults was used to assess behaviour.

Data were available for 114 people with intellectual disability. In all, 62.3% of the sample was prescribed a central nervous system medication, with 47.4% taking more than one. Of those who were medicated, 46.5% had a neurological diagnosis (a seizure disorder or Parkinson’s disease) and 45.1% had a psychiatric diagnosis (an affective or psychotic disorder). Linear regression revealed that polypharmacy was predicted by the presence of neurological and psychiatric diagnosis, higher Developmental Behaviour Checklist for Adults scores and male gender.

This study is the first to focus on central nervous system medication in an older sample with intellectual disability. The findings are in line with the wider literature in younger people, showing a high degree of prescription and polypharmacy. Within the sample, there seems to be adequate rationale for central nervous system medication prescription. Although these data do not indicate non-adherence to guidelines for prescribing in intellectual disability, the high rate of polypharmacy and its relationship to Developmental Behaviour Checklist for Adults scores reiterate the importance of continued medication review in older people with intellectual disability.

Little work has examined Community Treatment Order processes, including mode of termination. This paper aimed to examine service utilisation and legal status following the Community Treatment Order termination by a review board, treating psychiatrist or expiry of order.

Data-linkage study following the service utilisation of those discharged from a Community Treatment Order of at least 3-month duration for the subsequent 2 years. We used the state-wide database of all contacts with state-funded mental health services in Victoria, Australia.

Of the 1478 patients who were discharged, 5% were discharged by the review board, 88% were discharged by the treating psychiatrist and in 7% the order expired. Logistic regression indicated that those discharged by the treating service were less likely to be subsequently placed under an involuntary order than those discharged by the Mental Health Review Board or those whose order had expired (odds ratio = 0.61).

Poorly planned discharge as a result of expiry of the Community Treatment Order or abrupt discharge by the review board may be associated with a more severe relapse and subsequent need for compulsory treatment. The likelihood of being readmitted as an involuntary patient is greater for younger adults and those living in urban settings. In order to minimise the risk of major relapse, strong community engagement with treating services should be supported.

The frequency and emotional response to bullying victimisation are known to be associated with adolescent mental ill health. A potentially important under-investigated factor is the form of bullying. Four common forms of bullying behaviours are name-calling, physical threats or harm, rumour spreading and social exclusion. To more comprehensively understand bullying victimisation in adolescence, we examined the association of all three factors (frequency, emotional response, form) to psychological distress and emotional wellbeing.

A stratified, random sample of adolescents (n = 10, 273; mean age = 14.33 years, standard deviation = 1.68 years) completed validated measures of bullying victimisation (Gatehouse Bullying Questionnaire), psychological distress (K10) and emotional wellbeing (Mental Health Inventory) in classroom time. Associations between the form of bullying victimisation and mental health outcomes were examined.

Adolescents reported a high prevalence of all four forms of bullying: teased or called names (30.6%), rumour spreading (17.9%), social exclusion (14.3%) and physical threats or harm (10.7%). Victimisation was independently associated with significantly higher levels of psychological distress and reduced levels of emotional wellbeing for all forms of bullying. In particular, social exclusion had a strong association with mental ill health. Adolescents who experienced frequent bullying that was upsetting reported higher psychological distress and reduced emotional wellbeing.

Different forms of bullying victimisation were independently associated with psychological distress and reduced emotional wellbeing. In particular, frequent and upsetting social exclusion requires a targeted and measured response by school communities and health practitioners.