Robin Williams and Lewy Body Disease

In a post last week, I highlighted a recent study examining clinical issues in the diagnosis of Lewy body dementia (LBD).

This study examined differentiating clinical and neuropsychological factors between LBD, Alzheimer's dementia and Parkinson's disease.

You can access this post by clicking HERE.

This topic received significant attention following the description of comedian Robin Williams' last years by his wife in the journal Neurology.

Robin Williams suffered from LBD and like many, his diagnosis was not made until autopsy.

I want to review some of the key clinical features shown by Robin Williams described by his widow's in his last few years.

Psychological symptoms/signs

• Anxiety
• Fear 
• Panic attacks
• Depression
• Paranoia
• Delusions
• Suicide

Cognitive symptoms/signs

• Memory impairment
• Fluctuating levels of memory/orientation

Physical symptoms/signs

• Constipation
• Urinary problems
• Heartburn
• Insomnia
• Poor sense of smell
• Sensitivity to anti-psychotic medications
• Tremor left hand
• Freezing of gait

Lab/Imaging

• Elevated serum cortisol levels
• Normal brain imaging (CT or MRI?)

Neuropathology

• 40% loss of dopamine neurons
• Lewy bodies throughout brain
• High concentration of Lewy bodies in brain amygdala

A clinical diagnosis of Parkinson's disease had been made for Robin and he had been placed on anti-Parkinson's medication. 

Signs and symptoms of LBD as outlined by Mayo Clinic staff  include:

• Visual and other hallucinations
• Movement disorder (signs of Parkinson's disease)
• Autonomic nervous system dysregulation (tachycardia, sweating, constipation, dizziness, falls)
• Cognitive problems (confusion, visuospatial problems, memory loss, fluctuating levels of attention)
• Sleep problems (REM sleep behavior problems)
• Depression/Apathy

As noted in Mrs. Williams' description, Robin Williams never reported visual hallucinations, a key symptom in LBD.  However, his clinical team felt is was quite possible visual hallucinations could have been present and simply not disclosed due to fear of how others would perceive the hallucinations.

The high concentration of Lewy bodies in the brain amygdala could explain some of the panic, fear and depression noted in the case history.

Suicide is not commonly noted in LBD although it has not been studied in great detail. I will examine this issue in a separate post.

Mrs. Williams has done a great service in writing this clinical history. She urges increased research into the causes and treatment for LBD. Additionally, her report again underscores the need for clinicians to be vigilant for the signs and symptoms of LBD.

I highly recommend reading about the clinical history of Robin Williams. You can access the free full-text report by clicking HERE.

Access the Mayo Clinic description of Lewy body dementia by clicking HERE.

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Photo of Robin William's Hollywood star is from a Creative Commons Wikipedia file authored by:
CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=2710421

Williams SS (2016). The terrorist inside my husband's brain Neurology, 87 (13), 1308-1311

Genetics of Depression: Secondary Markers

In my previous post, I highlighted a recent study of genetics and major depression from the 23andMe database.

I have had a chance to review this manuscript in more detail. One of the findings of interest involved secondary marker or secondary phenotypes.

Fifteen genetic loci were identified in this 23andMe sample using a discovery and replication data set.

Secondary phenotypes with the highest correlation with the 17 SNPs identified in the study included (effect) :

• Taking a selective serotonin reuptake inhibitor (SSRI) (.448)
• Any medication for mental health reasons (.421)
• Self-reported anxiety (.323)
• Self-reported panic attacks (.319)
• Early age of onset depression (.283)
• Insomnia (.272)
• Prescription pain medication (.236)
• Obesity with BMI>30 (.216)
• Overweight BMI >27 (.212)

The research team was able to identify one SNP (rs12552 in the OLFM4 or olfactomedin 4 region) that correlated with reporting of panic attacks, use of medication for mental health, pain, insomnia problems, BMI >27 and early age of onset of depression.

This study supports use of self-report of depression diagnosis or treatment of depression for genetic studies. Such approaches may open large data sets for understanding the genetics of neuroscience medicine disorders like depression.

Click on the PMID link to access the study abstract.

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Photo of fisherman at sunset is from my files.

Hyde CL, Nagle MW, Tian C, Chen X, Paciga SA, Wendland JR, Tung JY, Hinds DA, Perlis RH, & Winslow AR (2016). Identification of 15 genetic loci associated with risk of major depression in individuals of European descent. Nature genetics PMID: 27479909

Alzheimer's Disease Behavioral Checklist: Link

Yesterday I posted on a research effort to develop a more behavioral-based screening process for early detection of Alzheimers and other dementia.

You can access that post by clicking HERE.

Since I posted that I have come across a proposed 34 item screening scale. The link to that scale is HERE.

This is not validated scale for clinical use but is in the development stage. I wanted readers who were interested in this research to have access to a PDF copy of the scale.

Follow the author on Twitter HERE (WRY999)

Photo of Etruscan burial statue is from my personal file of a trip to Italy last year.

Behavioral Warnings in Early Alzheimer's Disease

There are some interesting research updates coming out of the Alzheimer's Association International Conference in Toronto.

One finding that caught my eye was a report on behavioral changes that might precede significant cognitive impairment in Alzheimer's and other dementia.

This is being labelled "mild behavioral impairment" and like mild cognitive impairment may precede the clinical presentation of a dementia.

The Alzheimer's Association has put together a committee to formalize these criteria. The behavioral changes must be not characteristic of the individual and be present for at least six months.

The slide accompanying this post lists some of the behavioral warning signs being considered for "mild cognitive impairment".

Read about this effort in the Medical Xpress story HERE.

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Parenting Moderates Childhood Brain Stress Response

Child brain development benefits from a positive parenting style and environment.

The mechanism for this positive effect is unclear but moderation of the stress response in the growing child is an area of research interest.

Haroon Sheikh and colleagues from the University of Ontario in Canada recently published results on a study of parenting and brain development in children.

In their study, a cohort of 46 six year old girls underwent brain imaging using a technique known as diffusion tensor imaging or DTI. DTI provides a measure of brain white matter integrity.

This study is informative because all the girls participated in an earlier study of stress reactivity at three years of age. High stress reactivity as measured by serum cortisol response is known to be linked to vulnerability to mood and anxiety disorders.

The key elements in the design of this study including the following:

• Subjects: 45 six year old girls from a larger ongoing longitudinal study of children
• Stress response status: At three years of age participants underwent a two phase study of stress response. A baseline salivary cortisol assay was collected. A second cortisol level was obtained during a stressful task. Subjects were grouped in four categories based on levels of cortisol.
• Parenting assessment: Parents and child participated in a play task. Parents were rated on a measure of parental negative and positive affect.
• MRI scanning: A 3 Telsa brain imaging scan was completed on average two and one-half years following the baseline cortisol and parenting assessment

The main findings from the study included the following:

• High stress reactivity at baseline was linked to lower white matter integrity in prefrontal and basal brain regions (left thalamus, right anterior cingulate cortex and right superior frontal gyrus)
• Positive parental affectivity reduced the brain white matter effects of stress (cortisol) response in the right anterior cingulate cortex and right superior frontal gyrus
• Children with high stress responses at baseline but a positive parental affect environment showed brain integrity findings similar to low stress reactivity children

This is an important study because it suggests an interaction between parental environment and adverse effects of a high stress response in three year old girls. Genetic factors likely contribute to level of stress response in three year old girls. A positive parental style appears to reduce or eliminate adverse effects of high stress reactivity on critical white matter brain development.

The implications of the study are important. High-risk children for mood and anxiety disorders may benefit from early identification and parental training to reduce risk for later psychological morbidity.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link below.

Photo of hawk in flight is from the author's files.

Follow the author on Twitter @WRY999

Sheikh HI, Joanisse MF, Mackrell SM, Kryski KR, Smith HJ, Singh SM, & Hayden EP (2014). Links between white matter microstructure and cortisol reactivity to stress in early childhood: evidence for moderation by parenting. NeuroImage. Clinical, 6, 77-85 PMID: 25379418

Smoking in Pregnancy and Child Brain Development

Smoking during pregnancy produces significant and diverse effects on prenatal development.

These adverse effects include dysfunction in prenatal and early childhood brain development.

Hanan El Marroun and colleagues from the Netherlands recently published an important childhood brain imaging study of smoking during pregnancy.

One hundred and thirteen children exposed to tobacco during pregnancy were compared to a control group of unexposed children.

Both groups of children between 6 and 8 years of age were compared on a variety of measures including:

• Nonverbal IQ
• Birth weight and gestational age
• Child Behavior Checklist scores
• Structural brain imaging measures using MRI structural brain imaging

The key findings from this study included the following:

• Birth weight: exposed infants had a significantly lower mean birth weight than non-smoking exposed infants 3194 grams vs 3475 grams (7.04 pounds vs 7.66 pounds)
• Total brain volumes: exposed children showed smaller total brain volumes and smaller brain white matter volumes
• Brain cortex measures: exposed children showed thinner brain cortex measures in multiple brain regions including frontal, temporal and parietal regions
• Behavioral and emotional problems: exposed children had higher measures of mood and anxiety problems at 6 to eight years

An additional important finding was a statistically significant correlation between mood symptoms and thinning of cortical thickness in the superior frontal cortex and the precentral cortex regions.

Children of women who stopped smoking immediately after learning of pregnancy displayed similar brain development as the non-exposed children.

Although key covariates were controlled in this study, the authors do note they cannot rule out a potential contribution of smoking epiphenomenon in their findings. Such potential epiphenomenon linked to the smoking group could include higher parental psychopathology, effect of other substances and differences in paternal nutritional profiles.

This study does support early pregnancy identification in smoking women and aggressive smoking cessation treatment efforts.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link below.

Photo of altamira oriole is from the author's files.

Follow the author on Twitter @WRY999

El Marroun H, Schmidt MN, Franken IH, Jaddoe VW, Hofman A, van der Lugt A, Verhulst FC, Tiemeier H, & White T (2014). Prenatal tobacco exposure and brain morphology: a prospective study in young children. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 39 (4), 792-800 PMID: 24096296

Melatonin For Tinnitus Clinical Trial

Tinnitus, or persistent ear ringing, has no definitive treatment.  I had recently posted a summary of the status of this disorder based on a research review.

Since that post, a small but important placebo-controlled clinical trial examined the effect of melatonin on a group of subjects with tinnitus.

Here are the key elements of the study design from this clinical trial:
Subjects: Chronic tinnitus of at least 6 months duration as primary complaint (subjects ranged in age from 34 to 86)
Clinical Trial Design: 3 mg melatonin versus placebo for 30 days switchover to other assignment for an additional 30 days
Outcome Measure: Improvement defined as improvement in at least two tinnitus rating scales from 3 administered (Tinnitus Matching, Tinnitus Severity Index, Self-Rated Tinnitus)

In the analysis of the outcome of the trial, 57% of subjects were rated as improved during the melatonin phase while 25% were rated as improved during the placebo phase.   This was a statistically significant difference for the active drug.

Subjects who reported improvement with the melatonin trial were more likely to have the following clinical features:

• male gender
• bilateral tinnitus
• history of loud noise exposure
• no history of previous treatment for tinnitus
• no comorbid anxiety or depression
• higher Tinnitus Matching and Tinnitus Severity Index scores prior to the study

One of the problems with the design in this study is controlling for the potential confounding effect of improved sleep on tinnitus severity reporting.  Individuals who have improvement in sleep with melatonin may generally feel better and report improvement in a variety of domains.  An active non-melatonin comparator hypnotic, i.e. Ambien (zolpidem) would need to be included to determine if melatonin specifically contributes to reducing tinnitus.

The authors note potential mechanisms for melatonin in tinnitus include it's antioxidant effect, autonomic nervous system effects, effects on blood pressure or muscle tone. 

Larger multicenter studies confirming this study result are needed before a significant change in clinical practice can be recommended.  Since melatonin is a generic drug, such a study will likely need public research funding to be completed.

Molecular model of the compound melatonin from the Wikipedia Creative Commons authored by sbrools under the GNU Free Documentation License.

Hurtuk A, Dome C, Holloman CH, Wolfe K, Welling DB, Dodson EE, & Jacob A (2011). Melatonin: can it stop the ringing? The Annals of otology, rhinology, and laryngology, 120 (7), 433-40 PMID: 21859051

Is Insomnia a Risk Factor for Suicide?

Sleep is known to be important for physical as well as emotional well-being.  Mood and anxiety disorders commonly present with a variety of sleep problems including initial, middle and early morning insomnia.  Although the association of mood disorders and anxiety disorders in suicide is established, the independent contribution of insomnia to suicide risk is less well studied.

Bjorngaard and colleagues recently published a results of a Norwegian study on this issue in the Journal Sleep.  Using data from the HUNT epidemiologic study, they conducted an analysis of suicide risk over a twenty year follow-up period.

Over 75,000 subjects completed baseline assessment of sleep problems as assessed by a single question: "During the last month have you had any problems falling asleep or sleep disorders?  This question had four levels of response listed below with the prevalence of endorsement in (parentheses):

• almost every night (3%)
• often (5%)
• sometimes (31%)
• never (62%)

Endorsing sleep problems almost every night or often was more common among women (10% vs 5% for men) and for those over 50 years of age (11% versus 5% for those 50 and under.

After controlling for sociodemographic variables, those respondents endorsing sleep problems almost every night had a four fold increase in risk for suicide over the follow up period.  Controlling for alcohol use and self-report of anxiety and depressive symptoms reduced the size of this effect by about 50% but did not eliminate the independent effect of sleep problems and suicide risk.

The authors noted the link between sleep problems and suicide risk appeared stronger in those younger and the index assessment.  Interestingly, the link also appeared primarily in those not taking sleeping pills or sedatives.  Individuals reporting regular use of sleeping aids did not have an association between self-reported sleep problems and suicide rates.

Physical illnesses and chronic pain increase risk for sleep problems as well as for suicide.  The study did control for presence of a long-standing medical illness, body mass index and decreased functional ability.  Of note, suicide risk was not increased for those respondents who endorsed regular use of "painkillers".

This study supports further research into the independent association of sleep problems in suicide risk.  In an accompanying editorial, Dr. W. Vaughn McCall notes the need for exploring  "physiologic/neurochemical and psychological mechanisms" for link between sleep problems and suicide risk.  Further understanding of the role of sleep apnea in this association is also needed.

New Mexico wildflowers and butterflies from author's private collection.

Bjørngaard JH, Bjerkeset O, Romundstad P, & Gunnell D (2011). Sleeping Problems and Suicide in 75,000 Norwegian Adults: A 20 Year Follow-up of the HUNT I Study. Sleep, 34 (9), 1155-9 PMID: 21886352

Obesity, Inflammation and Depression

Obesity commonly occurs in the context of markers of inflammation.  Additionally, there is increasing evidence of a link between depression and systemic markers of inflammation such as the cytokine marker interleukin-6 (IL-6).  How these three conditions might tie together is an important research question.

Capuron and colleagues from France recently published a manuscript that looked at a specific group with obesity--women who were severely or morbidly obese and were waiting for gastric obesity surgery. The study published in Psychological Medicine prospectively followed these women after gastric surgery and monitored serum markers of inflammation as well as psychological function.

The research team focused on neuroticism as a key measure of personality as potentially related to systemic inflammation and potentially improved following bypass surgery.  Using the NEO-PI-R inventory, neuroticism can be broken down into components of anxiety, hostility, depression, self-consciousness, impulsiveness and vulnerability.

Baseline obesity levels as measured by the body mass index (BMI) in the sample correlated with baseline inflammatory markers IL-6 and C-reactive proteins.  These inflammatory markers also correlated with anxiety and depression---the higher the level of these inflammatory markers, the higher the level of self-reported anxiety and depression.

The women in the study lost approximately 30% of their body weight in the year following bypass surgery (mean weight reduction 47 kg = 103 pounds) with significant reductions in the blood markers of inflammation.  NEO-PI-R markers of depression and anxiety also dropped significantly over the one year following gastric surgery.  Reduction in C-reactive protein levels correlated with the reductions in the levels of anxiety.

This type of study is a association and not a causation study.  Nevertheless, it suggests that severe obesity is a disorder associated with systemic inflammation.  This systemic inflammation may contribute to adverse affective symptoms such as depression and anxiety.  Reducing inflammation through reducing obesity (via methods such as bypass surgery) may have additional central nervous system benefits.  Psychological benefits of weight loss may also be at work through improved body and self-esteem.

The role of inflammation in a variety of disorders including heart disease and diabetes is becoming better understood.  This study suggests inflammatory mechanisms should be explored for anxiety and depressive disorders, particularly in populations with obesity and diabetes mellitus.  

Photo of Juno Beach sunrise through filter from the author's collection.

Capuron, L., Poitou, C., Machaux-Tholliez, D., Frochot, V., Bouillot, J., Basdevant, A., Layé, S., & Clément, K. (2010). Relationship between adiposity, emotional status and eating behaviour in obese women: role of inflammation Psychological Medicine, 41 (07), 1517-1528 DOI: 10.1017/S0033291710001984

Vilazodone: A Novel Antidepressant

Vilazodone was approved by the Food and Drug Administration in the U.S. earlier this year, but is just now becoming available in pharmacies for prescription use.  The drug is marketed in the U.S. under the trade name Viibyd.  It is novel in that it the only antidepressant that combines two mechanisms that can increase serotonin in the brain cortex: selective serotonin reuptake inhibition and partial agonism of the 5HT1A receptor.  There are multiple selective serotonin reuptake inhibitors, i.e. fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro).  

There are also compounds that have an agonistic effect on the 5HT1A receptor.  These include:
Antidepressants: trazodone, nefazodone
Antianxiety drugs: buspirone
Atypical antipsyhotics: aripiprazole, ziprasidone, clozapine, asenapine
Illicit drugs/compounds: MDMA (ecstasy), LSD, psylocybin, cannabidiol (cannabis)
Antimigraine compounds: ergotamine
Other compounds: yohimbine

The combination of SSRI and 5HT1A agonist effect may synergistically increase serotonergic transmission.  

Two published clinical trials on vilazodone are available on PubMed.  The table below summarizes some of the key findings from the two published trials.

The dose of vilazodone studied was 40 mg in both studies.  Because of the common occurrence of gastrointestinal side effects, doses are typically initiated at a smaller level and increased to 40 mg over the first week or so.  The pattern and prevalence of gastrointestinal side effects with vilazodone appears similar to levels seen in previous SSRI trials.  Although headache was commonly reported with vilazodone, the rate did not differ from the rate endorsed by placebo.  Dizziness, dry mouth, insomnia and abnormal dreaming were endorsed at a higher level with vilazodone but by less than 10% of the subjects.

Although vilazodone was statistically superior to placebo on almost all depression measures, it was not statistically superior in remission rates in the Kahn study.  This finding along with the relatively low absolute response rate of 27.3% in the vilazodone group is a little disappointing.

The response and remission rates found in these two studies were similar to SSRIs.  Head to head comparison with an SSRI would be informative to see if vilazdone has any effectiveness or adverse event superiority.  Sexual side effects are common with the SSRIs and the two randomized vilazodone studies reported no difference in sexual side effects between vilazodone and placebo.  Additionally, the Rickels study showed some evidence for anxiety symptom reduction.  Clinical trials examining the effectiveness of vilazodone for anxiety disorders will likely be soon completed.

Disclosure:  The author has no stock in the parent company of vilazodone (Forest Labs).  Additionally no honoraria or research grant support has been received related to this drug.  The author received no reimbursement for writing this post and the comments are entirely those of the author.

Information on the agonists for the 5HT1A receptor obtained from Wikipedia.

Chemical molecular structure of vilazodone from Creative Commons file at Wikepedia by author Meodipt.

Rickels K, Athanasiou M, Robinson DS, Gibertini M, Whalen H, & Reed CR (2009). Evidence for efficacy and tolerability of vilazodone in the treatment of major depressive disorder: a randomized, double-blind, placebo-controlled trial. The Journal of clinical psychiatry, 70 (3), 326-33 PMID: 19284933


Khan A, Cutler AJ, Kajdasz DK, Gallipoli S, Athanasiou M, Robinson DS, Whalen H, & Reed CR (2011). A randomized, double-blind, placebo-controlled, 8-week study of vilazodone, a serotonergic agent for the treatment of major depressive disorder. The Journal of clinical psychiatry, 72 (4), 441-7 PMID: 21527122

Brief Behavioral Therapy for Insomnia in Older Adults

Insomnia is a common complaint in the general population and among patients treated by primary care physicians.  This is particularly true for older adults who experience physiological changes in sleep with aging.  Clinicians commonly prescribe hypnotics for insomnia and the use of these types of drugs is increasing in the United States and elsewhere.  Behavioral and psychological interventions may be overlooked or bypassed in the sequencing of interventions for complaints of insomnia.

 I had previously posted on the promise of cognitive behavioral therapy for insomnia.  This therapy appears to be effective across a variety of patient groups including those with an underlying psychiatric diagnosis.  Now, a recent study in elderly subjects finds support for an even briefer intervention for those with primary insomnia.

Buysse and colleagues from the University of Pittsburgh and the Cleveland Clinic have recently published a randomized control trial of brief behavioral therapy intervention (BBTI) for primary insomnia in a group of adults averaging 71-72 years of age.  The brief intervention included direct contact with a single masters level nurse practitioner for an initial 45 to 60 minute session followed by a 20 minute direct contact session in 2 weeks.  Two 20-minute phone sessions were scheduled at one and three weeks following the initial contact session.  The authors note the sessions focused on customizing for each subject the four key elements of sleep education and stimulus control:

1. reduce the total amount of time in bed
2. get up at the same time daily regardless of sleep duration
3. do not go to bed unless feeling sleepy
4. do not stay in bed unless asleep

The control group was provided educational material that included information related to behavioral treatment of insomnia but did not include personalized contact session with the nurse practitioner.  Outcome was measured by whether subjects continued to meet criteria for insomnia as well as other secondary measures.

The BBTI group demonstrated a 67% response rate compared to only 25% response in the control group.  Remission of an insomnia diagnosis was noted in 55% of the BBTI group compared to only 13% of the control.  Most psychometric, sleep diary and actigraphy measures improved more in the BBTI group more than the control group.  Interestingly, there were no differences between the groups in polysomnography sleep lab measures including sleep latency, total sleep time and sleep efficiency.

The authors note attractive features of BBTI including:

• it is easily taught to nurse practitioners and other clinicians
• it includes a workbook that allows patients to follow exercises aimed at reducing insomnia
• the strict behavioral approach limits some of the stigma associated with psychological treatment approaches in primary care

This study supports a stepped care approach for older adults with primary insomnia.  Following careful assessment to rule out another sleep disorder, i.e. sleep apnea or an untreated psychiatric disorder, i.e. depression or anxiety disorder, a trial of brief behavioral therapy may be a good first step.  Patients who fail to respond to this step may be candidates for consideration of hypnotic or other pharmacological interventions.

Photo of Lilly Pad Flower Bloom from Maui Courtesy of Yates Photography

Buysse, D., Germain, A., Moul, D., Franzen, P., Brar, L., Fletcher, M., Begley, A., Houck, P., Mazumdar, S., Reynolds, C., & Monk, T. (2011). Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults Archives of Internal Medicine, 171 (10), 887-895 DOI: 10.1001/archinternmed.2010.535

Women's Health: Illness and Prevention

A previous version of this article first published as Women's Health: Survey Highlights Illnesses, Care and Prevention onTechnorati.


The Henry J. Kaiser Family Foundation recently published their Women's Health Care Chartbook--Key Findings from the Women's Health Survey.  This report provides a snap shot of women's health in the U.S.  Chapters in the Chartbook cover a Profile of Women's Health, Health Coverage, Delivery System, Prevention and Screening, Access and Affordability and Work, Family and Caregiving.

Here are some of the highlights from the report:

The most common chronic health conditions reported by women in the survey include: arthritis 22%, hypertension 22%, high cholesterol 20%, obesity 16%, asthma/other respiratory disorder 15%, thyroid disorders 11%, diabetes 9%, and heart disease 5%.

Depression and anxiety problems are common.  Twenty six percent of women in the survey report being diagnosed with depression or anxiety in the past five years by a physician.  Depression and anxiety diagnosis is highest in women between 45 and 64, white women and women at less than 200% of the poverty income level. 

The leading causes of self-reported stress by women include: financial concerns 26%, job/career 23%, health problems of family member 16% and managing own health needs 13%.

Rates of going without health insurance for at least the past four years rose to 27% of all women in 2008 compared to 20% in 2004.

Use of mental health care in the last year was endorsed by 12% of all women in the survey.  This rate increased to 21% in those who reported their health status as fair or poor.

Seventy five percent of women reported receiving a mammogram in the past two years.   Pap smear, blood pressure screening and blood cholesterol screening were also reported by a majority of women.  However, only 40% of women over age 50 reported receiving colon cancer screening in the last two years.

A recently published CDC survey of preventive health screening confirms low rates for colon cancer screening in women.  The chart shows the percentage of women between 50 and 75 who were screened for colon cancer by one of three criteria: 

• Fecal occult blood test in last year or
• Flexible sigmoidoscopy in last 5 years or
• Colonoscopy in last 10 years

This lack of screening shows significant geographic variability.  The chart shows the highest rates for colon cancer screening are in the northeast with the lowest rates in the south and western U.S.

Percent of U.S. Women 50 to 75 Screened for Colon Cancer

Women commonly reported delaying or going without care due to a variety of reasons.  The most commonly reported reasons for delaying or going without care were: couldn't find the time 23%, couldn't take time off work 18%, no insurance 15%, child care problems 13%, and no doctor 13%.

A significant number of women (19%) spend 40 or more hours per week providing care for a sick or disabled family member.  Thirty two percent of women report they feel a lot of stress from their caregiving responsibilities.

This report is a great source of information about the most recent data on women's health and health care needs.  The complete report can be accessed at: http://www.kff.org/womenshealth/upload/8164.pdf

Henley SJ, King JB, German RR, Richardson LC, Plescia M, & Centers for Disease Control and Prevention (CDC) (2010). Surveillance of screening-detected cancers (colon and rectum, breast, and cervix) - United States, 2004-2006. MMWR. Surveillance summaries : Morbidity and mortality weekly report. Surveillance summaries / CDC, 59 (9), 1-25 PMID: 21102407

Anxiety as a Gut Feeling: Understanding Interoception

Marcus Paulus presented the April 2011 Warren Neuroscience Frontiers in Neuroscience Lecture.  The presentation was titled: Interoception and Anxiety.

Interoception is the summation of a variety of bodily perceptions that make up the integrated sense of our own physiological state.  Perceptions included in interoception include: pain, temperature, tickle, sensual touch, stomach discomfort to due acidity, air hunger and muscle tension.  Here are my notes from Dr. Paulus' presentation and his research manuscript on this topic area.

• Anxiety proneness is a trait that can be measured and is associated with high risk of later development of an anxiety disorder
• Anxiety proneness linked to increased activation of the dorsal amygdala and the anterior insula in brain fMRI tasks such as the Emotion Face Assessment task of Hariri
• Patients with anxiety also show insular hyperactivation in anticipation of negative cues
• Benzodiazepines like Valium reduce activation of the insula as well as the amygdala in response to angry faces

• There is growing awareness the brain insular cortex plays a key role in interoception--receiving signals from the body and integrating these signals with emotional response and regulation (see a previous post summarizing the function of the insula and possible roles in clinical neuroscience disorders)
• The insula also connects to a central pathway important in anxiety involving the anterior cingulate cortex and the dorsolateral prefrontal cortex--these areas provide input to the insula for planning and acting in the face of

• Key properties of the interoception include the signals from internal organs including the lungs, heart, gastrointestinal tract and genitourinary systems
• Many of these signals provide awareness of body and help promote homeostasis
• These signals also are involved in our sense of self and the passing of time

• A new area of understanding is the important role of personal beliefs in emotional processing--personal beliefs may modulate interoception and the perception of emotional cues
• A belief that a situation or cue is more dangerous than it really is, i.e. I will embarrass myself at the party, can modulate how emotion is processed, and can amplify a anxious response to the situation

Future research in the area of interoception and anxiety will target:

• Genetic influences on interoception
• How cognitive interventions may influence dysfunctional beliefs related to anxiety
• How interoception may help with more biological classification of types of anxiety
• Can people be trained to up or down regulate the insular cortex to reduce anxiety?
• How treatments for anxiety effect the elements of interoception

Brain Tutor iPad Screenshot of Insular Cortex in Green Courtesy of Author

Paulus MP, & Stein MB (2010). Interoception in anxiety and depression. Brain structure & function, 214 (5-6), 451-63 PMID: 20490545