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THE NEWSLETTER
Winter 2008
O F T H E J O H N S H O P K I N S D E PA R T M E N T O F P S Y C H I AT RY A N D B E H AV I O R A L S C I E N C E S
VO L U M E 4 , N U M B E R 2
T R A N S L AT I O N S
Adding Insult to Burn Injury
Model of a Muddle
“It’s like you’re in a phone
booth late at night in a bad
neighborhood. You don’t know
how to get home. The floor’s
littered with cigarette butts.
It’s hard to see out the filthy
windows but no one out there
would help you anyway.
A voice on the receiver tells
you you’re in danger.” That’s
one patient’s description of
post-trauma distress. But if
you’re a burn survivor and
have slipped further, into posttraumatic stress disorder
(PTSD), there’s a street gang
with a snarling mastiff outside
the booth. And you know
they’re not going away.
T
he physical results
of severe burns are
well-documented,
says psychologist James
Fauerbach, Ph.D., who
sees roughly 400 seriously
burned adult patients at
Hopkins Bayview’s burn
center each year. But the
mental aspects—the potential anxiety disorders,
altered body image, the
downswing in mood that
social stigma and isolation,
chronic pain, itching and
insomnia can bring—are
less well understood. And
Fauerbach and his colleagues are remedying that.
Ironically, their studies are
crucial because new approaches
to wound care and more effective rehab have cut hospital
stays for survivors by more
than half. “So it’s imperative
that we identify patients at risk
for problems after discharge,”
says Fauerbach.
Burn survivors are especially prone to PTSD and other
anxiety disorders. Roughly a
third of those severely burned
George Abucevicz, who was burned when an electric panel exploded, “has the hallmarks of psychological resilience
that bode well for his recovery,” says Jim Fauerbach. “He sees the good in these most trying circumstances.”
meet PTSD criteria the year
after injury: they show the
classic symptom clusters of
intrusive distressing thoughts
of the traumatic event, suppression of anything that calls
it to mind and hyperarousal,
with its insomnia, anxiety and
irritability.
For the past decade, Fauerbach—head psychologist for
the burn unit—and his team
have run defining studies on
survivors’ mental health, both
immediate and long term.
They’ve shown, for example,
that patients with previous
psychiatric disease do less well
long term after their injury.
And those who develop
PTSD while hospitalized find
the disorder harder to shake
after discharge.
They’ve also examined the
anxiety process. “The immediate reaction to burn trauma is
usually shock and helpless-
ness,” says Fauerbach. How
could that be otherwise? Pain
is excruciating. Patients might
see their skin hanging in sheets
or see others react to their
appearance with horror. In the
next days, they begin to replay
what happened, to have nightmares or intrusive memories or
flashbacks, even. All are
unpleasant; all reopen the initial event.
“What’s especially unsettling,” he adds, “is that these
thoughts and feelings come
automatically, without the
patient willing them to occur.
That can be part of the healing process. However, in
many, a kind of cycling takes
place. As thoughts intrude,
patients try to suppress them
to manage the anxiety. And
this bouncing back and forth
between intrusions and avoidance—this way of coping,
we’ve found—seems to get
Withdrawal
Is Withdrawal
The Incredible
Shrinking Brain
Marijuana, too, can
be hard to kick.
Chronic, untreated
depression could
change the brain.
PAGE 2
PAGE 3
people stuck. They’re most
likely to develop acute anxiety
and PTSD problems.”
Help, however, appears to
come from an unusually close
overlap of psychology and psychiatry. Fauerbach’s psychology-based team works closely
with psychiatric specialists in
anxiety disorders led by Una
McCann, M.D. They integrate
use of medications with cognitive behavioral therapy (CBT)
that Fauerbach’s tailored to
burn survivors. "We help
them evaluate thinking that
undermines confidence, that
interferes with recovery,” he
says. His five-year study of the
specialized CBT—it encourages resilience and empowerment—has just begun. “It
should clarify what’s protective, what’s therapeutic.” ■
E-mail [email protected] for
information.
More Than Spare Parts
Transplant’s resident
psychologist aims for the
doable.
PAGE 4
Psychiatrist Una McCann is deeply
interested in post-traumatic stress disorder because treatment for the vile, often
lasting condition isn’t foolproof.
But, as a neuroscientist, McCann sees
PTSD in rather a different light: Not only
is she eager to map out its biology, but
she believes it could prove useful to
understand the workings of one of its
most helpful treatments—cognitive
behavioral therapy—and thus put the
technique to best use.
McCann, who heads Hopkins’ Anxiety
Disorders Clinic, has nudged cognitive
therapy’s status in the clinic upward, combining it more routinely with medications.
“Both,” she says, “are empirically proven
for anxiety disorders.” She’s brought in psychologist James Fauerbach (story, left),
who’s sharpened his CBT expertise from
years of working with burn patients at
Hopkins Bayview. Fauerbach now trains all
of Psychiatry’s residents in the technique.
“PTSD is almost the perfect model
for the behavioral medicine approach
to psychiatric problems,” McCann
explains, especially, she says, as it affects
the burn survivors she and Fauerbach
treat. “There’s a definite event—the
burn trauma—with a before and an after.
So you can follow patients and see who
had a preexisting problem, see who
develops an anxiety disorder, see who
responds to which nuance of therapy.”
Soon, she hopes, PET, fMRI and other
forms of imaging will bring hard data on
these patients.
But questions about PTSD itself linger.
Studies suggest that two brain areas concerned with emotion, the amygdala and
the anterior cingulate cortex, respond
abnormally to stimuli seen as threats.
Other data hint that the hippocampus, a
memory-linked area, may change size in
chronic patients. “We’d like to identify
brain markers for people at risk of the disorder and, ideally, use targeted therapies—including cognitive ones—before
PTSD sets in,” McCann explains.
Clarifying the biology will be especially
satisfying, McCann says, because controversy dogs PTSD. “Even within Hopkins
ranks, some psychiatrists see it as a
natural response to trauma or, in some
instances, evidence of a personality
vulnerability. Science is a perfect way to
get to the heart of the matter.” ■
For information: 410-550-2596.
Coercing With
Compassion
A
gaunt Darice Caine*, 41, came to
Hopkins’ Eating Disorders Program
weighed down by nearly three decades of
anorexia nervosa. She’d been hospitalized at least
22 times at four different inpatient programs
and a state psychiatric hospital, among others.
Weighing 60 pounds, Caine was in grave danger.
She carried the wounds of her illness: osteoporosis, sluggish heart rate, bruised, thinning skin,
teeth eroded from vomiting. And she sat in
admissions, telling director Angela Guarda,
M.D., “I really don’t need to be here.”
Denying illness and ambivalence toward treatment, Guarda says, are hallmarks of anorexia. Most
people with AN, in fact, never seek specialized treatment. It’s in the nature of eating disorders—in line
with substance abuse or sexual disorders—to promote personal sabotage. The drive to continue starving stems from the gut feeling—Guarda uses the
word egosyntonic—that it’s the right thing to do.
“You could say these are diseases of self-deception,”
she says. And that self-deception’s severe, given that
more patients die from anorexia nervosa than from
From a patient letter to Angela Guarda
any other major psychiatric illness—as high as 10
percent over 10 years.
So Guarda became interested in seeing how necessary being motivated for treatment is to recovery. She
also wanted to see if patients pressured into treat-
ment change
their feelings and
accept the need
for it later on.
Her study,
recently published, hinges on
the fact that coercion figures into
most admissions
to an eating disorders inpatient
program. It can
be pressure from
family, friends,
bosses, therapists.
Or, occasionally,
if the situation’s life-threatening, there’s involuntary
admission—a court-based process to protect psychiatric patients in immediate danger. Caine’s father, for
example, brought her to Hopkins under an ultimatum: Go or you can’t live at home. She signed herself
in only after hearing that her severe condition warranted her being involuntarily admitted if she
refused.
“Pressuring patients into treatment is very controversial,” Guarda explains. “It’s widely held that they
have to feel ‘ready’ for treatment in order to benefit.”
Or the idea’s there that if you pressure patients,
they’re somehow harmed. “But we don’t see that,”
says Guarda.
Patients do come reluctantly and I-don’t-need-tobe-here is the rule, she says. “They typically lack
insight.” Within a week, however, “once they’ve
engaged with their peers and formed an alliance with
our clinical team, we often hear, ‘I know I need
this.’” They gain weight and learn to eat more normally. That’s the trend her research supports.
In the study, Guarda’s team asked 139 teen-toadult patients with eating disorders to complete a
modified version of the MacArthur Inventory—a
tool given psychiatric patients to measure perceived
coercion—when first admitted and again two weeks
later. Nearly half of patients who denied needing
treatment had “converted” in the two weeks, with
more adults switching over. Now the team’s collecting data on a larger group for a longer time period..
“All this suggests that judicious, thoughtful persuasion and leverage can be valuable and may be
necessary to help people with eating disorders,” says
Guarda. As for Caine, who’s now become a nurse,
her letter (left) says it best. ■
*
Not her real name.
For information, call 410-955-6115.
“The number of people going to clinics for
marijuana addiction has doubled in a decade,”
says Vandrey. “And the distress they undergo
in withdrawal is significant.”
A Double Take on Withdrawal
A side-by-side look at marijuana and nicotine withdrawal underscores the need to
consider both in the clinic.
Myths about marijuana use are plentiful and
hard to squelch: It’s an innocuous, friendly little drug; it isn’t addictive and is easy for any
user to quit; there’s little interplay between it
and other illicit drug use. Such ideas have likely been around as long as the drug itself, perhaps, in part, because hard research has been
relatively scarce.
But in the past decade, a small cluster of
scientists has made marijuana studies a specialty, describing use of the drug and the range
of its effects and, more recently, pinning it
down as an addictive substance with a genuine
withdrawal syndrome. One of the group,
Hopkins behavioral pharmacologist Ryan
Vandrey, Ph.D., began marijuana research as
a graduate student at the University of
Vermont, home of some early definitive work.
As the evidence mounts, he and colleagues
are hoping to change perceptions of marijuana
as harmless for everyone. “Recent research
suggests as many as one in 10 who try the
drug develop problems tied either to its use
or to quitting it,” he says. “We need better
ways to treat those seeking help.”
Vandrey’s latest work, reported in the
January issue of Drug and Alcohol Dependence,
aims to extend his earlier research on marijuana withdrawal by comparing it to that of a
drug already well understood in the lab and by
the man in the street—nicotine. “Ultimately,
we hope to clarify withdrawal’s role in the
subset of teen and adult users who find abstinence so difficult,” says Vandrey. “If it turns
out to be clinically important—as our results
suggest—we’ll have a therapeutic target.”
Marijuana withdrawal is marked by
increased anger and aggression, anxiety,
depressed mood, irritability, restlessness,
insomnia, strange dreams and decreased
appetite. Less commonly, there are
headaches, physical tension, sweating, stomach pain and general malaise. “The typical
effects are probably the ones most related to
relapse in patients,” says Vandrey. They’re
common, he adds, to all drugs of abuse.
In the new study, Vandrey and colleagues
recruited heavy users of tobacco and marijua-
na. Each followed a schedule that involved
usual use alternating with periods of “cold
turkey” abstinence from either drug as well as
both at the same time. All filled out daily surveys of marijuana withdrawal and nicotine
withdrawal. “Our earlier studies on withdrawal in marijuana smokers and withdrawal in
tobacco smokers showed that what they go
through is fairly similar,” says Vandrey.
Because comparing different people introduces an element of apples versus oranges,
however, the new study’s look at same-person
withdrawals of both substances is stronger
scientifically. It also sheds light on simultaneous withdrawal—the first such study of its
kind. “This is important,” Vandrey says,
“because roughly half of heavy marijuana
users are also tobacco addicted. And among
heavy smokers, about 9 percent have a daily
marijuana habit.”
In the end, withdrawal appeared similar in
intensity and quality from all the angles in
the study. Data from quitting both marijuana
and nicotine reflect an odd turn, though:
Half of participants reported it was easier to
quit both substances at once; the others
found it harder. While that needs looking
into, Vandrey says, it at least suggests drug
treatment programs should address clients’
simultaneous tobacco use, something rarely
done today. ■
For information: 410-550-4036.
INSIGHTS: JAMES POTASH
Shrinkage, Not the Shrinks
“Intriguing” is how Potash describes work that adds to depression’s hottest hypothesis.
“Those who call psychiatrists head shrinkers
have it wrong,” says psychiatric geneticist
James Potash, M.D. In a recent departmental Grand Rounds, Potash described new evidence for an idea he finds intriguing: that
chronic depression—and not clinicians—
whittles the volume of specific brain areas,
notably the hippocampus. It’s certainly plausible, he says, given known ties between depression, stress and the ample science that shows
stress hormones can shrink that brain site.
The idea of basing therapy on reversing the
shrinkage of an area devoted to memory and
emotion, he adds, is equally intriguing.
While Potash is by no means the first to relate
depression, stress and hippocampal change, his
take on a possible mechanism is new. In his talk,
he cited recent results from GenRED I, a large,
nationwide genetics-of-depression study: A gene
appeared whose workings may fit the hippocampal hypothesis like the proverbial glass slipper.
In past work, Potash has found probable
psychosis genes, those common to psychosis in
both bipolar disorder and schizophrenia.
Currently, he’s one of a handful of psychiatrists
nationwide studying epigenetic phenomena—
unconventional ways of controlling conventional
gene expression. Epigenetics may explain how
environmental cues like day length, for example,
might affect patients with mood disorders.
As director of research for Hopkins’ Mood Disorders Center, Potash has helped conduct large
studies to link the risk of those illnesses with specific chromosomal areas. Now he hopes to identify culprit genes via gene chip assays of thousands
of patients and their family members.
You’re focusing on the hippocampus in depression?
Yes. Imaging studies show that the
frontal cortex—which we know behaves
differently in depression—is connected
with deeper limbic regions, especially
the hippocampus.
Is there evidence it shrinks in
depressed people?
More than 20 studies suggest the hippocampus is smaller in patients with
major depression than in those without
illness, about 10 percent, on average.
Some work says it’s not just depression
but how long depression’s untreated that
correlates with brain loss.
How do you know that depressed
people aren’t born with smaller
hippocampi?
We don’t. And there’s some evidence
that hippocampal volume can be inherited. One monkey study showed it’s 54
percent heritable. On the other hand,
we know definitively that the hippocampus is a brain area that makes
new neurons throughout life. And that
ability can vary. It decreases with age, for
example.
So you’re leaning toward shrinkage.
What does it?
Stress. Stress sets off a cascade of steroid
hormones that likely alters the hippocampus. The hormones also appear to
retard its new growth.
So the hypothesis ...
... is that stress encourages depression. Brain
and endocrine sites for
our response to stress—
circuitry called the HPA
axis—become overactive
in depression. And while
the subsequent wash of
steroid hormones doesn’t
destroy hippocampal
neurons, it likely prunes
them back, changing
their activity in brain circuits and perhaps producing symptoms of
depression. Or maybe it’s
the hormones’ slowing
new growth that’s the
cause. Perhaps it’s both!
Can depression therapy restore the hippocampus?
In animal models it can, both with
antidepressants and with electroconvulsive therapy. The few studies in people
suggest that too, though evidence is
less clear.
nine genes in that vicinity that we analyzed, one, NTRK3, piqued our interest. It codes for receptors for a natural
agent—a neurotrophin—that encourages nerve cell growth in the brain.
What’s next?
How?
Nobody knows. Perhaps it’s by reducing
stress. Or it could, we believe, affect the
hippocampal neuron factory. Recently,
from our genetic studies on families
with major depressive disorder, we’ve
marked a narrow area on chromosome
15 as having some tie to depression. Of
We’ve just launched a study about 2,000
times more powerful than the last to
make the suspect genes far more obvious, one that should clarify what
NTRK3 and others are doing. For the
first time, we have the potential to
understand the truth about what sets
depression in motion. ■
SUPPORTING THE CAUSE
For Her, Stigma’s Just a Word
You look at Joan Denny’s delicate, gold-flecked
scarf. Her perfume tugs at your subconscious
as she leans forward; you listen as she tells of
a rich and full life—despite high odds for the
opposite—and it seems that even the leaves
outside her picture window have arranged
their color scheme at her bidding. Denny
exudes stability and capability. Bipolar disorder
(BP) doesn’t come to mind.
But Denny, long a supporter of Hopkins’
annual mood disorders symposium, is quick to
own up to her illness and explain how it’s driven her efforts to improve Psychiatry’s outlook.
She’s helped the symposium for all of the 22
years it’s existed. And her willingness to talk
about having bipolar illness—she does so to a
degree unusual even in this day and age—
advances the cause.
“Mental illness has been a part of my life
since birth, probably in utero, even,” she says.
“I don’t ever remember a time without it.”
That doesn’t mean Denny suffered it gladly.
“The last thing I wanted when I was 18 was to
admit I had a problem.” And as a theater
major in college, she says, she learned to disguise BP to an extent. “But I couldn’t hide it
when I was married. You couldn’t do that with
five children under the age of 7, when you
were in and out of treatment,” she explains.
“They all knew what their mother was going
through.” So it’s far easier, she says, to be
honest about her disorder.
She’s been equally forthcoming with good
works. In addition to the symposium, Denny
co-led a church-based volunteer peer support
group. Her experience as a model patient,
submitting to interviews, helps Hopkins psychiatrist Philip Slavney and others evaluate
professionals for board certification. “It’s great
fun. Other than interpreting ‘A rolling stone
gathers no moss,’ I’ll answer about anything
I’m asked.”
“This illness ruined my life in many ways,”
says Denny. “But if you can give back in some
manner—of yourself or with money—it helps.
It really does bring joy.” ■
Want to Help Us
Help You?
If you’re thinking of participating in a research study,
visit www.hopkinsmedicine.
org/psychiatry/research/
volunteers and click
Research Volunteers
Needed to read about
studies currently recruiting
participants. Hopkins needs
healthy volunteers as well as
those diagnosed with a psychiatric disorder.
More Than Spare Parts
Patients going through
Hopkins’ transplant service
for a new heart, lung, liver
or kidney are, by definition,
gravely ill. So it’s natural
that many are demoralized
by their physical weakness
and shocked at the possibility of having to sit out life’s
dance. There’s the anxiety of
finding a donor or facing
high-risk surgery or the
uncertainties of life on
mega-medication. Distress
can shade into depression or
anxiety disorders, especially
in patients already cognitively compromised from low
oxygen or other effects of
their illnesses.
Helping patients with life
adjustment problems and
referring those with major
depression or anxiety are
clearly part of David Edwin’s
work. As psychologist for
Hopkins hospital’s transplant service, he also screens
potential donors and recipients. “I’m not here to winnow people out so much as
to make it safer to transplant
them,” he says. But transplant’s no typical event, and
the issues and pressures
these patients face make
what Edwin encounters far
from predictable.
“Transplants don’t occur
in a vacuum,” he says. “Life
in all its variety encroaches.”
It’s only the discipline of
what he calls “a psychological imagination” that helps
him sift through layers of
patient problems using the
perspectives of his field.
For example:
The medical work-up
stalled for a man awaiting a
heart transplant when he
■
“When I started this 20 years ago,” says Edwin, “I thought, they’ll need a
psychiatrist. But my friends in medicine and transplant surgery were generous with their teaching, my colleagues in psychiatry unfailingly supportive.”
Hopkins
This issue of Hopkins BrainWise is
published by Johns Hopkins Medicine
Marketing and Communications for
the Department of Psychiatry and
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It is distributed to the scientific community,
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SAVE THE DATE!
This year's 22nd Annual Mood
Disorders Symposium has
Mood Disorders in Women and
Adolescents as its focus.
Olympic skater Dorothy Hamill and
actress Mariette Hartley are featured.
Tuesday, April 15, 1-6 p.m. at
Hopkins' Turner Auditorium.
Call 443-287-3480 for information.
Some of the research in this newsletter has corporate ties. For full disclosure information, call the
Office of Policy Coordination at 410-223-1608.
J. Raymond DePaulo, Jr., M.D.
© The Johns Hopkins University 2008
Chief of Psychiatry
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couldn’t make clinic
appointments. Earlier, he’d
had a defibrillator implanted
and its firings became terrifying. He found himself
unable to undergo pre-transplant dental work because
he feared the device would
fire while he sat in the chair,
and his anxiety generalized
to the point that he rarely
left home.
“The agoraphobia-like syndrome behind his “noncompliance” isn’t uncommon in
defibrillator patients,”
Edwin explains,“but, for
him, it was life threatening.”
Colleagues at Hopkins
Community Psychiatry
stepped in and he’s now in
treatment with a psychiatrist
and behavior therapist.
■ A Chicago woman flew
to Hopkins to be considered
for an incompatible-donor
transplant after her kidneys
deteriorated from complications of lithium therapy. Her
home psychiatrist had diagnosed bipolar disorder and
the woman had a history of
becoming psychotic on the
prednisone normally given
transplant patients.
“I didn’t see the patient at her
evaluation visit,” says Edwin,
but records suggested more
than bipolar illness. The discharge notes I requested from
her previous psychiatric hospitalization described a
schizoaffective disorder, which
makes her a more worrisome
transplant candidate. But if
she had appendicitis, we’d
operate for that, wouldn’t we?
The question is, Is a transplant doable for her? If we
don’t advocate for mentally ill
people, who will?
“The transplant team was
concerned about steroid psychosis—many medications
post-transplant aren’t benign
in patients with mental illness. And while we knew we
could address any acute postop problems here, we found
we also had to organize adequate psychiatric care for her
at home. In this case, our
patient has done well.”
A man with alcoholic liver
disease from years of abuse
was dropped from the waiting list after a weekend binge
brought him to the hospital.
He went “clean” for the six
months required to get relisted, but admitted that he still
smoked marijuana.
■
“It’s not unusual for patients
to dive off the transplant list
because they can’t stay abstinent,” says Edwin. “Substance
disorders are a chronic part of
life on the service.” Relapsing
post-transplant is difficult to
predict, however, and a number of patients resume some
level of drinking. But marijuana drastically increases
relapse risk in recovering
addicts, he explains,”so we’ve
become active in testing for it.
We look at this not as something to rule people out permanently but as part of planning their care.” ■
Stealth Mental Health
“I had no interest in psychology until I worked at
Bloomingdale’s.”
That’s an unorthodox but telling start to
Jacquelyn Duval-Harvey’s career—first as an
on-site clinician for East Baltimore school children,
then as head administrator for the same Hopkinslinked mental health programs that include the
schools. It’s telling because well before her clinical
psychology studies in college, Duval-Harvey
learned how effective mental health care could be
outside the traditional clinic.
Working at Bloomie’s, she observed women of
a certain age who “kept coming back. They’d buy
and return, day after day, until it dawned on me
that this was loneliness.” Duval-Harvey’s attention
to the ladies made the store somehow therapeutic.
After doctoral work at Penn State and a job
heading children’s programs in a New York City
hospital, she came to Hopkins, where, for the
first of her decade here, she was a school-based
clinician. Embedded in an elementary school,
Duval-Harvey became a keen advocate for mental
health services in that setting.
“There’s no stigma in getting psychological or
psychiatric help in a school,” she says. “It’s not a
place people are automatically identified as mentally ill. Also, you learn faster about issues children
have—watching them in the classroom and the
cafeteria can tell you if they’re socially and emotionally adjusted. Most of all, you’re in a position
to intervene where it’s most critical. Success in
school turns these kids’ lives around.”
Duval-Harvey became head of the East
Baltimore umbrella program, Community-Based
Services, part of Child and Adolescent Psychiatry.
A liaison between the Hopkins effort and the city,
state and federal bodies that target kids at risk,
she refined ways to extend the school clinicians’
reach. In addition to one-on-one therapy, they also
do preventive work—offering schoolwide behavior
management or leading small, tailored groups that
take on topics like anger management or coping
with addicted, parents.
“The schools work is intense; You know
pretty fast if you want to keep doing it. I had no
doubt.” ■
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