Vol 11 No 4 Issue 37 - November 2013

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Neuroscience Newsletter

16778

The interface between science and the patient

ANXIETYSmokingcessation

S5 ARICEPT. (Reg. No’s: Aricept 5 mg tablets: 32/5.3/0315; 10 mg tablets: 32/5.3/0316). PHARMACOLOGICAL CLASSIFICATION: A 5.3 Cholinomimetics (cholinergics). COMPOSITION: Each Aricept5 mg and 10 mg tablet contains 5 mg and 10 mg donepezil hydrochloride, respectively. REGISTERED LICENSE HOLDER: PFIZER LABORATORIES (PTY) LTD. Reg. No. 1954/000781/07; P O Box 783720, Sandton, 2146. Tel. No. 0860 PFIZER (734937). S5 CHAMPIX® 0,5 mg and 1 mg fi lm-coated tablets. (Reg. no’s: 41/34/0573;4). COMPOSITION. Each fi lm-coated tablet contains 0,5 mg or 1 mg of varenicline (as tartrate), respectively. PHARMACOLOGICAL CLASSIFICATION: A 34 Other. LICENCE HOLDER: Pfi zer Laboratories (Pty) Ltd. Reg. No. 1954/000781/07. P O Box 783720, Sandton, 2146.Tel. No.: 0860 PFIZER (734937). S5 EFEXOR® XR 75 mg (capsule) EFEXOR® XR 150 mg (capsule). (Reg. No.: 32/1.2/0318/9). PHARMACOLOGICAL CLASSIFICATION: A 1.2 Psychoanaleptics (antidepressants). LICENCE HOLDER: PFIZER LABORATORIES (PTY) LTD. Reg. No. 1954/000781/07; P O Box 783720, Sandton, 2146. Tel. No. 0860 PFIZER (734937). S5 GEODON® 20 mg, 40 mg, 60 mg and 80 mg capsules.(Reg. No’s: 32/2.6.5/0584 - 0587). COMPOSITION: Each capsule contains ziprasidone hydrochloride monohydrate equivalent to 20 mg, 40 mg, 60 mg and 80 mg ziprasidone, respectively. PHARMACOLOGICAL CLASSIFICATION: A 2.6.5 Central nervous system depressants: Miscellaneous structures. LICENCE HOLDER: Pfi zer Laboratories (Pty) Ltd. Reg. No. 1954/000781/07. P O Box 783720, Sandton, 2146.Tel. No.: 0860 PFIZER (734937). S5 LYRICA® 25 mg, 75 mg and 150 mg capsules. (Reg. No’s: A39/2.5/0264, 0266, 0268). COMPOSITION: Each hard capsule contains 25 mg, 75 mg, or 150 mg of pregabalin respectively. PHARMACOLOGICAL CLASSIFICATION: A 2.5 Central nervous system depressants – Anticonvulsants, including anti-epileptics. LICENCE HOLDER: Pfi zer Laboratories (Pty) Ltd.Reg. No. 1954/000781/07. P O Box 783720, Sandton, 2146. Tel. No.: 0860 PFIZER (734937). S5 SERTRA™ TABLETS 50 mg (Reg. no: A39/1.2/0308). COMPOSITION: Each SERTRA™ tablet 50 mg contains sertraline hydrochloride equivalent to 50 mg sertraline. PHARMACOLOGICAL CLASSIFICATION: A 1.2 Psychoanaleptics (Antidepressants). LICENCE HOLDER: Pharmacia South Africa (Pty) Ltd, 85 Bute Lane, Sandton, 2196. Please refer to detailed package inserts for full prescribing information. 03/NSC/10/11/JA.

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3Volume 11 No 4 November 2013

Dr E AllersPsychiatristLife GlynnviewBenoniGauteng

Bipolar Disorder in South Africa

he diagnosis of Bipolar Disorder has increased over the past few years and many members of the public, medical schemes and doctors have noticed the phenomenon and have been asking questions.

The Council for Medical Schemes have been keeping a record of the utilisation of services since 2004 for the Prescribed Minimum Conditions – Chronic disease list, which includes Bipolar Disorder. Unfortunately, the data was not captured for 2007 and 2008 as Bipolar Disorder was then not seen as a chronic condition as the algorithm for Bipolar Disorder was not yet published.

The data is presented in the graph below:

The increase from 2004 to 2005 was -9%, 2005 to 2006 was 75%, 2006 to 2009 was 67% over the 3 years, thus 22% per year on average, 2009 to 2010 was 40%, from 2010 to 2011 it was 16% and from 2011 to 2012 it was 11% . It seems thus the increase has been getting less and less over the past few years. The increase from 2004 to 2012 was thus 200%. There was a slight increase in the utilisation of the benefit in 2010, probably reflecting the access

to the benefit as the algorithm was published in December 2009, but not necessarily out of line with the increase over the past 8 years.

The increase could seem high, but internationally the 12 months prevalence of Bipolar Disorder is up to 2.8% in the USA. It is lower in other countries but has an average 12 months prevalence of around 1.4%. This is also the expected 12 months prevalence of Bipolar Disorder in South Africa.

If the 12 month utilisation of benefits reflects the 12 months prevalence of Bipolar Disorder in South Africa, the current 12 months prevalence would relate to 0.629%. This is approximately half of the expected prevalence of Bipolar Disorder in South Africa. It is thus expected that the figure should rise at least another 100% over the next few years to reflect the true prevalence of Bipolar Disorder in South Africa.

The increase in the utilisation of the benefit with a diagnosis of Bipolar Disorder thus probably does not reflect an over diagnosis of the disorder, but rather an increase in the diagnosis been accepted due to a decrease in the stigma of psychiatric conditions over the past decade. The problem is that we started off with a very incorrect low figure which has now been corrected at an accelerated pace.

CPD Accreditation

Psychiatrists, Neurologists, General Practitioners with an interest in Psychiatry and Members of SASOP can acquire CPD points with this newsletter by visiting www.sasop.co.za, www.mynasa.co.za or www.mycpd.co.za and completing an online form of 15 questions. Accreditation is available only for a limited time on the site. Should you have any queries regarding the accreditation, please contact E2 Solutions at: 011 340 9100 or gertrude@e2.co.za

Request for contributionsWe welcome submissions of articles from psychologists, pyschiatrists and doctors etc for publication in this newsletter as well as submissions regarding interesting hobbies or special interests for our “Hobby Corner”. Please write to: lakeann@mweb.co.za or contact us on: 011 802 8847.

Production Editors: Ann Lake Publications: Ann Lake Helen GonçalvesDesign: Jane GouveiaSponsor: PfizerEnquiries: Ann Lake Publications Tel:(011) 802 8847 Fax: 086 671 9397 Email: lakeann@mweb.co.za; www.annlakepublications.co.za

Cover image:The Friends of the Rails Class 24 locomotive just after sunrise at her home depot, Capital Park Locomo-tive Shed, Tshwane/Pretoria. The temperature is just above freez-ing and the result is the wonderful steam exhaust. Date: 9 June 2012. See page 11 for more.

The views expressed by the editor or authors in this newsletter do not necessarily reflect those of the sponsors or publishers.

4 Volume 11 No 4 November 2013

• Food deprivation leading to severe malnutrition. • Water deprivation with access limited to surface

water, or water sources far from home.• No access to sanitation facilities (toilets/latrines)• Health deprivation (no immunizations or medical

treatment).• Shelter deprivation (including overcrowding).• No access to professional education of any kind.• Information deprivation e.g. the media.• Deprivation of access to basic services.• Living more than 20 km from the nearest school

or more 50km from the nearest health facility with doctors.

In 2005 UNICEF reported that of the 2.2 billion children living on Earth, approximately 1 billion children were surviving on $1 (USA) a day. Of the 1.9 billion children living South of the equator, 1 in 3 do not have adequate shelter, 1 in 5 did not have access to safe water and 1 in 7 did not have access to health services.

Poverty can be regarded as being the result of the interaction of a multitude of factors including:

• Labour markets• Government policies• Family efforts• Political conflicts • Social discrimination and • Personal strategies

Children are particularly affected by poverty as they are usually dependent on their parents or other adults in a powerless and vulnerable social position.

The effects of poverty on the developing brainThe higher prevalence of neuro-developmental disabilities and lower educational achievement in poor children can be linked to:

• Protein-energy malnutrition which in turn contributes to structural brain abnormalities

• Dietary micronutrient deficiencies• Exposure to toxins• Decreased sensory stimulation • Anaemia due to parasites• Sequelae of infectious diseases

Poverty and the familyFamily vulnerability is heightened by numerous stressors and disruptive transitions. Multiple traumas, losses and dislocations overwhelm coping efforts. Recurrent crises and persistent demands drain resources, especially for single parents. Family organization, patterns of interaction and relationships can become fragmented and chaotic, contributing to abuse and neglect, youth substance

‘“Poverty is the worst form of violence”. Mahatma Ghandi

Although we are all familiar with the concept of poverty, this article discusses various definitions of poverty and how it affects those living in this predicament. Those who have managed to break the so-called circle of poverty may still retain emotional after-effects.

Definitions of povertyPoverty can be defined in many ways. Ravallion (2010) describes the poverty line as the cut-off point that separates the poor from those earning what is considered to be an adequate level of income in any given country.

The World Bank perceives poverty as having two different lines: i. a relative poverty line depends on the income

distribution within a given country and varies according to purchasing power. Often set at 50% of a given country’s mean income

ii. the absolute poverty line (also called the extreme poverty line) is often determined according to the average cost of basic survival in the poorest 10 – 20 countries of the world and previously referred to households earning less than one US dollar per day. More recently this figure has risen to less than two US dollars per day. In a similar light, in 2008 about one quarter of the world population was earning an income of less than 1.25 US dollars a day.

The United Nations International Children’s Emergency Fund (UNICEF) regards poverty to be more than just a lack of income. It regards living in poverty as having deprivation in two or more areas of basic childhood needs:

Prof R.J.Nichol MBChB,DTM&H, DPH,

MMED(Psych),Ph.DPsychiatristHead, Child

and AdolescentUnit, Free State

Psychiatric ComplexBloemfontein

Surviving poverty: The effects of deprivation in the

formative years of children and how it affects their mental health

5Volume 11 No 4 November 2013

abuse and conduct disorder. Families in poor communities are most likely to be destabilised by frequent crises, traumatic losses, abrupt transitions and chronic stresses of unemployment, housing and health care.

In 2011, Park, Fertig and Allison studied 5000 families in 20 different cities in the USA having a low income. The researchers noticed that homelessness and precarious living conditions were associated with more internalising and externalizing problems among 3 year olds compared to their peers living in more stable environments.

Najman and co-workers conducted a longitudinal study in Australia to determine the effects of poverty on child development. Subjects who had been exposed to poverty in utero, at 18 months of age, at 5 years and at 14 years, were all associated with increased rates of anxiety and depression in adolescence and early adulthood. The researchers realised that repeated experiences of poverty were directly associated with poorer mental health outcomes.

Caspi et al. (2002) followed a group of 440 young males in New Zealand from birth to the age of 26 years. Violent behaviour, Conduct Disorder and Anti- social Personality Disorders (APD) were associated with abusive situations that had occurred before they had reached the age of 11 years.

Both adoption and molecular genetic studies indicate that there is greater susceptibility to adverse environmental factors in genetically vulnerable individuals. For instance, among adopted children whose biological parents were diagnosed with APD, children who had both biological vulnerability (family history of APD) and environmental risk (i.e. adverse adoptive environment) were found to have higher levels of aggression than children with biological vulnerability who were raised in more stable environments as well as those with environmental but not biological risk.

Poverty as a chronic stressor to the developing brainThis mechanism is not clearly understood, but 3 factors should be considered .

i. Stimulation of the hypothalamic- pituitary-adrenal axis (HPA)

The body is geared to coping physiologically in stressful situations in order to survive. The HPA axis plays a major role. There are individual variations in the thresholds above which an individual perceives an experience to be stressful and in the response to the stress. These individual differences in stress responsiveness are partly genetically determined and partly based on prior experiences (Garralda &

Raynaud 2012). Children who have been exposed to various stressful situations (increased stress responsiveness), are innately more reactive to stress and more vulnerable to its consequences.

Besides the well-known physical effects which follow activation of the sympathetic nervous system, due to suprarenal medulla activation, with secretion of Noradrenalin and Adrenalin (as part of the fight or flight response), the brain also secretes increased levels of Noradrenalin and Dopamine. The cerebellar vermis exerts strong modulatory effects on these regions including the locus coeruleus. Significantly raised levels of these neurotransmitters in the prefrontal cortex interfere with executive functioning. The HPA axis is regulated by a negative feedback loop namely the diurnal variation in cortisol secretion with higher levels in the morning than in the late afternoon. It has been found that during the first year of life, there is a progressive decrease in cortisol responsiveness to stress, returning to the subsequent response early in early childhood which apparently buffers the brain from the harmful effects of cortisol. This dampening of the cortisol stress response does not occur in infants who have received insensitive and unresponsive caregiving. Babies having negative emotional temperaments with poorer self-regulation skills are particularly vulnerable.

ii. Architectural changes in the brainAnother response to stress is an increased rate of cortisol secretion affecting different parts of the body. Regions in the brain with a high density of glucocorticoid receptors are particularly vulnerable to adversity.

Excessive stress levels in childhood are associated with architectural changes in the developing brain including in: the amygdalae, hippocampus, cerebellar vermis and the prefrontal cortex, which are involved in emotional experience, stress regulation, learning and the ability to cope with adversity. Cortisol also suppresses glial cell division reducing myelization of the brain.

iii. EpigeneticsThe concept of epigenetics is classically defined by Renthal and Nestler (2012) as the interaction between genes and the environment that gives rise to a specific phenotype. Mechanistic insight into this process has been gained over the past two decades and involves the transduction of unique environmental signals into precise and highly stable alterations in chromatin structure that ultimately gate access of transcriptional machinery to specific gene programs, thereby providing unique gene expression profiles in response to specific environmental cues.

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Kaufman and co-workers (2004; 2006) stated the occurrence of depression in maltreated children was modulated by poly-morphisms of brain derived neurotrophic factor (BDNF) and serotonin transporter genes as well as social support that tended to be protective.

In the Caspi study previously mentioned, regarding abuse before the age of 11years with acting out behaviour and APD, functional polymorphisms of MAOA were regarded as possible modifying factors (Garralda & Raynaud 2012). 5 HT Transporter genes have also been implicated

Gene-environment correlations (rGE) The measured gene/measured environment ap-proach may be used to investigate main effects of both genes and environment, or to understand more complex interactions whereby environments may moderate genetic effects or visa versa.

A key principle in modern research on developmental psychopathology suggests that psychopathology and individual differences in normal development are the joint products of both biological and social influences (Kindler 2011, Rutter et al 2006). Theories of person-environment describe how peoples’ behaviour, personality or cognitive abilities shape their environment. Three main rGE’s have been described by Plomin (1977) namely:

1. Passive2. Evocative (reactive) and 3. Active processes

1. In Passive rGE genetic relatedness between parent and child accounts for observed correlations between partially heritable traits, such as the child’s behaviour and the child’s environment. Apparently children who are physically disciplined are more likely to be more aggressive than children who are disciplined in other ways. The reason for this may be that parents transmit a genetic risk for aggressive behaviour that increases both the probability that their children will be more aggressive and the likelihood that they will choose physical chastisement above other forms of discipline.

Although not unique to poverty, teenage childbearing is internationally recognized as a public health problem associated with a range of risks for both young mothers and their children. Adolescence is a transitional period marked by social, psychological and biological changes and childbearing during this period interferes with normative developmental processes. Teenage childbirth from ten years of age disrupts young mothers’ educational achievement and limits

employment opportunities, increasing their risk for substance abuse, mental healthcare problems and criminal convictions later in life, often aggravating the cycle of poverty. In turn the offspring born to these young mothers also experience poor developmental outcomes, including low birth weight, preterm delivery and behavioural and developmental problems.

An association between the offspring of adolescent mothers and antisocial behaviour was found in a Swedish study conducted by Coyne and co-workers (2013). However, there was little evidence for genetic confounding due to passive gene-environment correlation. It remains unclear if maternal age at first birth is causally associated with offspring antisocial behaviour or if this association is due to selection factors that influence both the likelihood that a young woman gives birth early and that her offspring engage in antisocial behaviour.

2. In evocative rGE, partially heritable traits or

behaviours evoke reactions from others in the environment. Children who are shy and withdrawn may appear aloof to their peers, who will, as a result be less likely to make friendly overtures.

3. In active rGE, individuals actively select or create environments that are associated with their genetic propensities. Youth who tend to follow rules and who adhere to social norms will be more prone to seek like-minded peers.

Resilience Despite the harmful effects of poverty, some chil-dren are able to develop resilience and learn effec-tive coping strategies. A longitudinal study on a mul-tiracial cohort of children exposed to chronic poverty also demonstrated the importance of their role with-in the community, along with the presence of social networks and personal resources. Although used in the context of child abuse, Joshi et. al (2010), iden-tify several dispositional/temperamental attributes found in children having higher levels of resilience. These include:

• Above-average intelligence • High self-esteem• Internal locus of control• External attribution of blame• Presence of spirituality• Ego resilience• High ego control • Familial cohesion (including competent foster

parent care)

Extra familial support such as a positive school experience promotes resilience which in turn likely increases individual self-worth and a sense of control over one’s destiny.

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Rutter (1990) argued that rather than focussing on single resilience factors, developmental processes that promote adaptive factors should be considered. He suggested that resilience is not a fixed state but is rather a malleable and organic trait, which can be enhanced within a nurturing environment.

Remarkably, children can be regarded as agents of their own development and, even in situations of adversity and chronic poverty, they can consciously act upon and influence the environments in which they live. For example a child can choose to use meagre financial resources to buy food for himself and his siblings or he may opt for sniffing glue with his peers to relieve his hunger. Although the contribution of one sensible decision may seem miniscule in contributing to the way out of poverty, functional decisions often contribute to functional coping skills and other ways of escaping poverty.

Case exampleI have been inspired by a young man, Thabo, (obviously not his real name) who recently started working as a medical officer. His father deserted the family many years ago and his mother died of a chronic illness. Thabo took responsibility for their ‘child-headed household’. Although living in relative poverty, Thabo was determined to become a surgeon one day. He developed novel ways of finding food for the family including attending many funerals where the food was readily available for everyone present. He soon learned to ask if a sheep or an ox had been slaughtered to feed the mourners. In the latter situation, he and his siblings would form part of the cortẻge and enjoy the meal after the funeral. He instructed his siblings to eat as much as they possibly could in order not to go hungry for the next week! His elderly neighbours also helped with food when they were able.

In spite of many setbacks and disappointments Thabo managed to gain a place in medical school. With the help of bursaries and benefactors he was able to achieve his goal. He plans to become a surgical registrar soon. Sadly, his sister became pregnant and dropped out of school. Perhaps she will never be able to escape from the cycle of poverty without Thabo’s help.

Therapeutic approached to help families move out of povertyA parent may have been powerless as a child in a troubled family but can learn from that experience to become a more effective parent. It is very important to understand how symptoms and catastrophic fears are fuelled by a ‘pile up’ of stresses, trauma and losses. When therapy is overly problem-focused, it grimly replicates the patient’s problem-saturated experience! A resilience –orientated perspective seeks to empower multi-crisis families to manage their stress-laden lives.

Interventions that enhance positive interactions, support coping efforts and build resources are more effective in reducing stress and enhancing pride and more effective functioning.

A more compassionate understanding of struggles can engage parents in efforts to break dysfunctional cycles and raise their children well. All parents want a better life for their children even when a myriad of difficulties blocks their ability to act on these intentions. They often know what they need to change in their lives and will take active steps if clinicians value their potential and support their best efforts (Walsh 2006). By strengthening the family, the home becomes a more solid foundation for at-risk youth. Action-orientated, concrete approaches work best, with clear objectives and small manageable steps to build on successes.

Where parents have been able to escape the cycle of poverty by becoming financially viable, rates of conduct problems and Oppositional Defiant Disorder decrease in their offspring, but symptoms of anxiety and depression may persist needing professional intervention.

ConclusionAlthough many government agencies, faith-based organizations, NGO’s and NPO’s work hard to alleviate poverty, there never seem to be enough resources to help everyone. Mental health care workers also have a vital role to play in this process. Hopefully, in the next decade the emphasis will shift from not only alleviating poverty, but also to the utilization of measures to protect developing brains in young children.

References available on request.

A more compassionate understanding of struggles can engage parents in efforts to break dysfunctional cycles and raise their children well. All parents want a better life for their children even when a myriad of difficulties blocks their ability to act on these intentions.

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Treating dreams

ven if she be not harmed, her heart may fail her in so much and so many hor-rors; and hereafter she may suffer - both in wak-

ing, from her nerves, and in sleep, from her dreams.”

- Bram Stoker, Dracula

Dreaming is a universal human phenomenon. Sometimes dreams are strange, sometimes they are happy events, but often they are distressing.

For some patients, recurring upsetting or anxiety-provoking dreams may lead to significant distress and cause particular headaches for the treating physician. These dreams may be an important symptom in various psychiatric conditions, but are often neglected when planning a treatment strategy.

What are dreams?The scientific study of dreams is called oneirology and dreams may be defined as successions of images, ideas, emotions and sensations which occur involuntarily during sleep. The content and purpose of dreams are not definitively understood and remains a controversial topic in especially the field of Psychiatry.

Nevertheless, man has always tried to ascribe some meaning to dreams and even in ancient times, the Mesopotamians and Egyptians described dreams as divine manifestations by which the gods communicated their wishes to humans.

Plato, for some reason, believed that the liver was the site of dream prophecy. He did describe an interesting psychological observation in that he considered dreams the expression of bestial desires normally suppressed. Aristotle stated that the

predictive value of dreams was a mere coincidence and that dreams were the result of various impressions which are more apparent during sleep due to the suspension of normal perception and judgment.

Over the centuries, various other authors have tried to describe a better understanding of dreams with very limited understanding of the physiological processes involved. These would include influential minds like Freud and Jung in the 20th century.

It was only later in the 20th century that Aserinsky, Kleitman and Dement started to describe the neurobiological processes involved in dreaming. Hobson and McCarley promoted the idea that dreams are fundamentally physiological and not psychologically driven – clearly not Freudians or Jungians by nature!

Their conclusions were that the forebrain makes the best of a bad job in producing partially coherent dream imagery from the relatively noisy signals sent to it from the brainstem and that dreams are not instigated by unfulfilled infantile wishes, but by automatically generated random sensory stimuli.

They proposed the activation-synthesis hypothesis, which states that during sleep the brain is activated by random pontine stimuli. This input is compared with existing sensorimotor data and that dream content is “synthesized” in an attempt by higher cortical structures to make sense.

We now know that although dreams are strongly associated with REM sleep, we do also dream during non-REM sleep, although remembered dreams during NREM sleep are normally more mundane in comparison.

Although most dreams only last 5 to 20 minutes, during a typical lifespan a person would spend a total of about six years dreaming (about 2 hours/night).

Dream contentOver a period of many decades, Calvin Hall (1940’s to 1985) collected more than 50 000 dream reports and he found the following:

• People all over the world dream mostly the same things

• Dreams are often of a phantasmagoric visual nature (locations & objects blend into each other)

• Anxiety is the most common emotion experienced whilst dreaming

• Negative emotions are experienced more than positive

Dr Chris VersterSpecialist psychiatrist

Strikland HospitalBellville, Western

Cape

9Volume 11 No 4 November 2013

NightmaresThe word ‘nightmare’ derives from the Old English “mare” which refers to a mythological demon who torments humans with frightening dreams.

According to the ICSD-2, nightmare disorder is a parasomnia usually associated with REM sleep and requires the following for diagnosis:

• Recurrent episodes of awakenings from sleep with recall of intensely disturbing dream mentations, usually involving fear or anxiety, but also anger, sadness, disgust and other dysphoric emotions.

• Full alertness on awakening, with little confusion or disorientation. Recall of sleep mentation is immediate and clear.

• At least one of the following associated features is present: ₋ Delayed return to sleep after the episodes ₋ Occurrence of episodes in the latter half of

the habitual sleep period.

Nightmares almost always occur during REM sleep and usually later at night when longer REM periods are present.

10-20% of children experience regular nightmares (peak 3-6 years) and 5% of adults (F>M).Sleep studies have demonstrated that patients with regular and distressing nightmares have short REM latency with increased total REM sleep, repeated REM arousals, sympathetic activation and increased REM density (increase in eye movements).

The following are common causes of nightmares:

• PTSD/Acute stress disorder/Trauma• Sickness or fever• Ongoing stress• Relationship issues• Drugs/alcohol (Alcohol causes REM rebound

after effect wears off)

Dreams and psychiatryDepression is usually associated with fewer or less detailed dreams with shorter dream length. The dreams of depressed patients often have content that reflect the mood state. It may also be important to note that changes in dream pattern to repetitive and frightening nightmares may predict suicidal tendencies.

Manic patients often have bizarre and improbable themes and changes in their dream content precede upward shifts in mood.

In PTSD, dreaming has diagnostic and prognostic implications and relates to severity. More than 70% of PTSD patients suffer from nightmares.

It is postulated that during sleep in these patients, increased CNS adrenergic activity stimulates α1 adrenergic regulation of the prefrontal cerebral cortex, which leads to disrupting of cognitive processing, increasing fear responses.

Medication and dreamsThe following may induce disturbing dreams:

• Selegeline/Rasagiline• Mirtazepine• Antipsychotics (may decrease recall)• Discontinuation of antidepressants (especially

MAOI’s)/benzo’s• Alcohol withdrawal• Dopaminergic drugs• Digitalis• ARV’s• Cholinesterase inhibitors• Sildafenil• Varenicline (23%)• Antihypertensives• ß blockers• Reserpine

Treating dreams

Pharmacological measuresIn theory, inducing less REM sleep would lead to less awareness of dreams and less awakenings. Any drug which suppresses or modifies REM sleep or REM density should decrease dream recall.

Slow wave sleep (SWS) - which would also be associated with less dream recall - is generated in the

The word ‘nightmare’ derives from the Old English “mare” which refers to a mythological demon who torments humans with frightening dreams.

10 Volume 11 No 4 November 2013

basal forebrain where GABA release would suppress wakefulness. Drugs acting on the GABA receptors should also therefore decrease dream recall.

In PTSD patients, decreasing α-adrenergic activity in the PFC should lead to a decrease in fear and anxiety responses during sleep.

Taking these theories into consideration, the following pharmaceutical interventions have been suggested:

• Tricyclic antidepressants – these drugs reduce frequency of dreams and increase positive dream recall.

• Benzodiazepines Although they could increase SWS, some reports have also suggested more disorganized and distressing dreams, most likely because of decrease in central inhibition.

• SSRI’s Treatment with these drugs suppresses dream recall frequency but increases subjective dream intensity in some subjects.

• Clonidine There are some data available in children with PTSD, but in adults there have been reports of increased dreaming. Interestingly, low doses clonidine has been reported to increase REM sleep and at higher dose it decreases it.

• Trazodone A substantial percentage of patients have reported decrease in nightmares on this drug, but daytime sedation and other side-effects impacts on its use.

• Anticholinergics These may in fact worsen vivid dreaming, but galantamine has been linked to an increase in lucid dreaming, enabling psychotherapeutic interventions (see below).

• Prazosin This drug has shown particular promise in PTSD and a number of studies have been done in this population. Total sleep time is increased with significant decrease in trauma-related nightmares. Sleep fragmentation is also improved.

• Atypical antipsychotics Limited data are available, but despite some efficacy, cost and potential side-effects would limit the usefulness of these drugs

Non-pharmacological interventions

Lucid dreaming treatmentLucid dreaming is when one becomes aware that one is asleep and dreaming. It occurs with further activation of the frontal cortex (DLPFC), allowing secondary consciousness. Lucid dreaming treatment is used to help clients feel empowered by gaining control of their dreams. It has not shown to decrease nightmares, but decreases the emotional content.

It is suggested that when nightmares turn into lucid dreams, the client should attempt to wake up! The idea is also to look beyond the fear and guide the dream in a more positive way.

The client should keep a dream diary and try to identify recurring themes, e.g.• Being chased• Feeling pain• Crying• Hiding

The aim is then to imagine the scenarios and when they occur during dreaming, ask the question: “Am I dreaming?”

One should also attempt to perform a reality check (e.g. pushing fingers through solid object) and this should create instant lucidity.

Dream imagery rehearsal therapy (IRT)This is a cognitive-behavioural treatment which helps people with PTSD “rescript” or alter the endings of their nightmares while they are awake. When you come up with an alternative, less distressing outcome, nightmares in theory become less upsetting and debilitating.

Patients are presented with information on sleep, nightmares and what IRT entails. They are required to learn how to monitor their nightmares. Detailed, alternative, non-distressing endings for nightmares are then considered and while awake, each nightmare is rehearsed with the altered ending.

This is a time-limited therapy and does not address any other symptoms of PTSD.

Although various other interventions such as CBT, relaxation techniques and hypnosis have been suggested in the literature, little evidence for efficacy has been forthcoming.

References on request.

In PTSD, dreaming has diagnostic and prognostic implications and relates to severity. More than 70% of PTSD patients suffer from nightmares.

11Volume 11 No 4 November 2013

CornerTravel/Hobby Dr David Benn on steam train photography

What does it involve?A knowledge of photography. The genre is a combination of landscape photography and action photography as the trains are usually moving through the landscape. It also involves a lot of travel, frequently to remote locations seldom visited by tourists. In 1997 I did a trip to North-Eastern China to photograph some of the last steam locomotives on China Rail. More recently (this year) I travelled to Zimbabwe and Botswana to see some of the last steam locomotives in Southern Africa that are still in regular service. This said, most of my photography has been done in South Africa.

How did you become interested in this hobby? I grew up in Witbank in the 1960s and was surrounded by steam trains. They were actually quite scary for a young child and I had a recurring nightmare of being in a car on a level crossing with a train bearing down on me. My dad was a good photographer and bought me my first camera during this time. I have taken pictures ever since, although it did not occur to me in the 60s to point a camera at a train.

How long have you been involved or interested in it? I took my first pictures of Steam Trains in the early 1970s and by the end of the decade I was hooked. At the time there were over 2000 steam locomotives in service on the South African Railways. There are now fewer than 40 in service, kept running by volunteer enthusiast groups for day trips and the occasional enthusiast tours operated for overseas groups.

What do you enjoy about it, what rewards do you find in it? I love the travel and the companionship of like-minded friends. It is something really different from what I do and is thus a complete break from work. I love being out on the veld and also have an interest in the history of the Anglo-Boer South African War, much of which was fought on or near railway lines.

What have been some of the highlights of this hobby? A recent highlight was seeing a National Railways of Zimbabwe Garret steam locomotive at sunrise on the Victoria Falls Bridge. One of the most remarkable features of steam locomotives is the exhaust effects created by cold conditions on winter mornings. The steam is

superheated (That is heated to well above 100 degrees Celsius) and this creates the most wonderful condensation effects. On a really cold morning the steam trail can be longer than the train itself. It also has an abstract quality that constantly changes.

What advice would you give to others who are interested in taking up the hobby? Where would they start? Be prepared to get really cold! You need to contact others interested in the hobby. You learn from them and you hunt in packs! Anybody can be a photographer and with digital cameras it is so much easier than it was when only film was available.

Do you do this competitively? If so, what competitions have you entered into and if applicable, what awards have you received?Yes. I am an active member of a Photographic Club and hold a Fellowship of the Photographic Society of Southern Africa for a panel of 36 transparency (slide) pictures of steam locomotives. I also post pictures on a large American website (Railpictures.com) and have a number awards on that website. One of the more satisfying competitions I took part in was an exhibition held during the 1991 Steam Festival in Kimberley. I came second and was presented with a steam locomotive number plate by David Shepherd, famous wildlife and railway painter.

In 2012 and 2013 three calendars were published using a selection of my photographs.

Do you have friends or family that share this hobby with you?I inflicted my hobby on all three of my children. I think they had fun, and my son still humours me by accompanying me sometimes on my expeditions.

Other interesting information? The steam locomotives was once referred to as “The most charismatic land machine ever devised by man”. It is basically a mobile hearth.

Other interests and hobbies? History (Especially the Anglo-Boer South African War), building models (airplanes, boats and railways), old furniture (not the exotic stuff, but more everyday items), air shows, listening to audio books, classic cars...

Above: Class 15F No 2916 leaving Koornberg, near Malmesbury with a mixed goods and passenger train. The mist had rolled in from the cold West Coast. This photograph is one of Dr David Benn’s favourites. It was originally taken on

slide film and the slide was scanned and digitally processed. Date: 17 June 2002.

Right: National Railways of Zimbabwe Class 15A Garrett No 395 crosses the Victoria Falls Bridge as the sun rises through the

spray rising from the Falls. View from the grounds of the Victoria Falls Hotel.

Date: 23 May 2013

Above: The class 25NC was the most modern mainline steam design on the South African Railways and was

the standard motive power on this highly scenic Eastern

Free State line. The train has just crossed the level crossing near Fouriesburg

Station and the snow-capped Maluti Mountains

are seen in the background. The locomotive is No 3472.

Date: 28 May 2006.

Below: The crew of Friends of the Rails Class 24

locomotive clean and build up the fire in preparation for the day’s activities during a recent enthusiast weekend. Location: Cullinan Station.

Date: 16 June 2013

LYRICA® confi rmed as a fi rst-line treatment option in Expert Panel Recommendation for South Africa1

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Reference: 1. Chetty S, Baalbergen E, Bhigjee AI, Kamerman P, Ouma J, Raath R, et al. Clinical practice guidelines for management of neuropathic pain: expert panel recommendations for South Africa. S Afr Med J 2012; 102(5):312-325.

S5 LYRICA® 25 mg, 75 mg and 150 mg capsules (Reg. No’s: A39/2.5/0264, 0266, 0268). Each hard capsule contains pregabalin 25 mg, 75 mg and 150 mg, respectively. LICENCE HOLDER: Pfi zer Laboratories (Pty) Ltd. Reg. No. 1954/000781/07. 85 Bute Lane, Sandton, 2196, South Africa. Tel. No.: 0860 PFIZER (734937). Please refer to detailed package insert for full prescribing information. 14/LYR/05/12/JA.

LYRICA® indicated for:

• Painful Diabetic Peripheral Neuropathy • Post-herpetic Neuralgia

18082 Lyrica GuidelineA4Serenity.indd 1 2012/07/25 12:47 PM