Current Psychiatry

Current Psychiatry
Ain Shams University

Vol. 13 No 1 March 2006
Burnout Syndrome among Saudi Medical Residents: A Controlled Study

Motives for Substance Use Disorders: A Trans-cultural Study
Burnout Syndrome among Resident Physician in Suez Canal University
Hospital
Amphetamine Related Symptoms: Descriptive Analysis and Reasoning
Sleep Profile in Children with Pervasive Developmental Disorders
Acute Phase Reactants (Proteins) in Schizophrenia
Emotional Disturbances and Quality of Life in Type-1 Diabetic Children
and Adolescents: Relation to Glycemic Control and Microvascular
Complications
Diagnostic Value of Regional Cerebral Blood Flow Changes on Spect and
Hippocampal Atrophy on MRI in Diagnosis of Alzheimer's disease and
Vascular Dementia
The Practice of Electroconvulsive Therapy (ECT) in a Sample of
Egyptian Patients
Assessment of Neurochemical Alterations that Occur in Bipolar Patients
Following Medication Using Proton Magnetic Resonance Spectroscopy.
Bipolar Mood Disorder among Children of Attention Deficit
Hyperactivity Disorder
Official Journal of the Institute of

Psychiatry Volume 13 No 1 March 2006
ISSN 002-2144
Vol. 13 No.1 March 2006 Current Psychiatry
Burnout Syndrome among Saudi Medical Residents: A Controlled

Study
Rahemi J., Saadani M., Kinsara A.
Abstract:
To investigate resident burnout among different medical specialties. Method: Maslach
Burnout Inventory forms had been fulfilled by 71 residents from eight different medical
specialties. All residents were from Saudi Board Program. Results: A greater percentage of
senior residents (34%) were doing recreational activities than junior residents (28%). Eighty
percent of residents were not satisfied with the number of working hours. There was no
significant difference between junior and senior residents regarding to the number of calls per
week. There was no significant difference between junior and senior residents regarding to the
three mean values of the subscales of MBI (t-values = -0.8, -0.9, -1.5 and significance = 0.5,
0.4, 0.1). Medical residents had a significant lower mean values regarding to accomplishment
subscale (35±10) than the other 4 main sections of residents (f = 2.2, p = 0.04). Surgical
residents got significantly higher mean scores in two items of MBI than medical residents.
These two items are sense of fatigue and dealing with their patients as objects. The test which
had been used was t-test (t = 2.4 and 3.5) respectively, significances were 0.02 and 0.001
Conclusions: Junior Medical residents are the least who suffer from burnout, followed by
senior medical residents. Obstetrics, Gynecology and Surgical residents are the most sufferer
from burnout symptoms among all specialties included in this study. Numbers of working
hours, number of on calls per week, and residents who live away from their places of work
are issues need to be discussed with the decision makers.
Introduction:
decreased job performance (Lemkau J, et al
Maslach defined burnout syndrome as a
loss of interest and care for users and 1994) (i.e., increased medical errors), low
career satisfaction, and a decrease in
consequently the development of a
relationship characterized by detachment empathic concern, including feeling less
and coldness within an environmental humanistic (Nyssen AS, et al 2003). Using
the Maslach Burnout Inventory (MBI)
model including situational factors like
social and environmental context and the (Maslach C, et al 1996), a validated and
reliable tool, one survey of an internal
nature of the job (Maslach C, et al 2001).
Maslach distinguishing three components of medicine residency program found that
76% of the respondents met criteria for
burnout: emotional depletion, indifferent
attitudes to colleagues and users, and burnout (Iacovides A, et al 2003). Two
years after New York State implemented
negative self-evaluation of job performance
(Thomas NK, 2004). revisions to the state health code (section
405), which required reduction in on-call
The 80 hours-per-week limits implemented work and increased supervision, residents
nationally on residents' work have been reported diminished fatigue and better
sought, in part, as a response to resident patient care (Geurts S, et al 1999). Home-
burnout, which has been linked to related Stressors for residents may also play
1
a vital role in work-related fatigue (Levey MBI was used as a measure to assess the
RE, 2001). quantity of burnout among all residents
Burnout differs from depression, in that it is (who are under the supervision of Saudi
Board Program) and working at KAMC.
confined to the workplace. However, if
generalization to the home environment Given the stress that accompanies this kind
of uncertain job situation when hospitals are
occurs, burnout may progress to clinical
depression, although such a temporal undergoing restructuring, nurses are
particularly prone to developing
relationship is not well established(Levine
RE, et al 2003, Veasey S, et al 2002, psychological burnout. Maslach burnout
Inventory consists of three different
Beckman JA & Fang JC, 2002 ).
aspects: emotional exhaustion,
Based on these results, we undertook depersonalization, and reduced personal
checking a sample of residents to measure accomplishment. Emotional exhaustion is
their burnout and explore the association defined as feelings of being emotionally
with specialty, the effects of recreational overextended and drained by others.
activities, their frequencies, satisfaction Depersonalization is a callous response
with working hours, number of calls per toward people who are the recipients of
week, the distance of residents one's services. Lack of personal
Housing from the working place, stager in accomplishment is a decline in one's
training e.g. junior or senior, and which feelings of competence and successful
specialties are more vulnerable to burnout achievement in one's work with people.
syndrome?. Burnout is considered a special type of
prolonged exposure to occupational stress
Subjects and methods: and results from interpersonal demands at
Subjects of this study are all residents work (Maslach C, et al 1996)
working at King Abdul-Aziz Medical City MBI consists of 22 statements representing
(KAMC) during March 2005. Confounding 3 main components:
variables were assessed among all residents
e.g. age, sex, marital status, recreational A-Emotional exhaustion are represented by
activities, their frequencies, distance of statements. Their numbers are:
their living away from KAMC, number of 4,5,7,9,10,11,12,15,17,18,19,21,22
on calls & working hours. B-Depersonalization are represented by
There were 71 residents, who were statements. Their numbers are:
distributed as the following: 1,2,3,4,6,7,8,9,12,13,14,16,17,18,19,20,21
Three residents from ENT, Two residents C-Accomplishment are represented by

from ophthalmology, One resident from statements. Their numbers are
ER, Ten residents from General Surgery, :1,2,3,5,6,8,10,11,13,14,15,16,20,22
Ten residents from Obstetrics and Statistical Analysis:
Gynecology, Nine residents from
Radiology, Seventeen residents from All analyses were conducted with SPSS
software. Means, standard deviations (SD)
pediatrics, Nineteen residents from
Medicine and Qui square are reported. Comparisons
between two quantitative means’
2
differences were assessed using the two- helped the other residents in fulfilling the
sample t- test and between more than two forms of MBI. The forms of MBI included
means were assessed using f-test some other data like: age, sex, marital
(ANOVA). Significance was set post-hoc at status, doing recreational activities, and the
0.05 (SPSS version 10.1, 2001). frequency of doing these activities, the
satisfaction with the number of working
Results:
hours, the distance of housing from the
MBI forms were distributed among 79 Arab hospital, and the number of calls per week.
Board program residents at King Abdul-
There was no significant difference
Aziz Medical City. Seventy one of them
completed the answers of MBI forms, while between junior and senior residents as
regards to gender (x2 = 0.13 and
8 residents were too busy to fulfill these
significance is = 0.8) (Table 1).
forms. The 2nd, 3 rd, and 4 th authors, who
were well oriented by the items of MBI,
Table (1):: Sex distribution among junior and senior residents
Male % Female % Total % X2 Significance

Junior 24 33.8% 15 21.1% 39 54.9% 0.13 0.8
Residents
Senior 21 29.6% 11 15.5% 32 45.1%
Residents
Total 45 63.4% 26 36.6% 71 100
Level of significance at p < 0.05

Most of the residents in our study were married. There were 17 single junior residents, 9
single senior residents, and one divorced resident. The difference between junior and senior
residents regarding to marital status is statistically not significant (x2 = 2.8 and significance is
0.2) (Table 2).
Table (2): Marital status of junior and senior residents
Single Married Divorced Total X2 Significance

Junior residents 17 22 0 39 2.8 0.2
Senior residents 9 22 1 32
Total 26 44 1 71

A greater percentage of senior residents (34%) was doing recreational activities than junior
residents (28%). The difference between senior and junior residents was statistically
significant (x2 = 4.2 and significance is 0.04) (Table 3)
3
Table (3):Doing recreational activities among junior and senior residents
Doing % Not doing % Tota % X2 Significance

Recreational Recreational l
activities activities
Junior 20 28.2% 19 26.8 39 55% 4.2 0.04*
Residen %
ts
Senior 24 33.8% 8 11.2 32 45%
%
Residen
ts
Total 44 62% 27 38% 71 100%
*Level of significance at p < 0.05

Eighty percent of residents were not satisfied with the number of working hours, but the
difference between junior and senior residents regarding to satisfaction with the number of
working hours was statistically not significant (x2 = 0.6 and significance = 0.6) ( Table 4 ).
Table (4): Satisfaction with working hours among junior and senior residents
Satisfied % Not % Total % X2 Significance
with satisfied
working with
hours working
hours
Junior 30 42.3% 9 12.7% 39 55% 0.6 0.6
Residents
Senior 27 38% 5 7% 32 45%
Residents
Total 57 80.3% 14 19.7% 71 100

Thirty seven residents were not satisfied with the number of calls per week, while 34 residents
were not satisfied. There was no significant difference between junior and senior residents
regarding to the number of calls per week (Table 5).
4
Table (5): Satisfaction with number of calls per week among junior and senior residents
Not % satisfied with % Total % X2 Significance
satisfied
No. of calls
with per week
No. of calls
per week
Junior 24 33.8% 15 21.2% 39 55%
Residents
Senior 13 18.2% 19 26.8% 32 45% 3.1 0.1
Residents
Total 37 52% 34 58% 71 100%

It is expected to find a significant difference between the age of senior and junior residents. In
this study there was a significant elder mean age among senior residents than junior residents
(Table 6).
There was no significant difference between junior and senior residents regarding to the three
mean values of the components of MBI (t-value = -0.8, -0.9, -1.5 and significance = 0.5, 0.4,
0.1) (Table 6).
Table (6): Comparison between junior and senior residents
As regards to the mean values of age and the 3 components of Maslach Burnout Inventory:
Mean values Junior residents Senior residents t-value Significance

(No=39) (No=32)
Age (years) 26.6±1.5 28.9±1.8 - 5.8 0.000001*
Emotional Exhaustion 43.5±8 44.9±8 -0.8 0.5
Depersonalization 63.7±11.8 66.4±12.6 -0.9 0.4
Accomplishment 40.1±15.9 46±17.2 -1.5 0.1

Both junior and senior residents got high mean scores’ values (27 or over), as regards to
emotional exhaustion subscale (Figure 1), but the difference between the mean scores values
was statistically not significant. In addition to this, they got also high mean scores’ values
(above 14), regarding to depersonalization subscale (Figure 2). On the
Contrary, they had poor social interaction “accomplishment subscale” (Figure 3).
5
Junior &senior residents as regards to
Mean values of emotional exhaustion

mean values of emotional exhaustion
45.0
44.5
44.0
43.5
43.0
1.00 2.00
Residents' grades
Junior residents=1, Senior residents=2
High=27 or over, Mod=16-26, Low=0-16

Figure (1)
Junior &senior residents as regards to

mean values of depersonalization
67.0
Means of depersonalization
66.5
66.0
65.5
65.0
64.5
64.0
63.5
63.0
1.00 2.00
Residents' grades
Junior resid=1,Senior resid=2
High=14or over, Mod=9-13, Low=0-8
Figure(2)
6
Junior &senior residents as regards to mean

values of accomplishment
47
46
45
Mean accomplishmet
44
43
42
41
40
39
1.00 2.00
Residents' grades
Med residents=1, Surg residents=2
High=0-30, Moderate=31-36, Low=37 or over
Figure(3)
In this study, we found that these 71 residents could be classified into five main sections: 16
residents from surgery department, 10 residents from gynecology and obstetrics department, 9
residents from radiology department, 17 residents from pediatrics, and 19 residents from
medical department. The difference between the mean ages of residents among the above
mentioned five main sections was statistically not significant (ANOVA test was used, f = 1.2,
p = 0.3). Medical residents had a significant lower mean values regarding to accomplishment
subscale (35±10) than the other 4 main sections of residents ( f = 2.2, p = 0.04 ) (Table 7). On
the contrary, there were no significant differences between the five main sections as regards to
emotional expression and depersonalization subscales (f = 1.7 and 1.5, p = 0.2 and 0.3) (Table
7).
Table (7): Comparison between 5 residents’ sections as regards to the mean values of the 3
components of Maslach Burnout Inventory
Surg. Gyne. Radiol. Pedia. Med. f- Signifi-

Resid. Resid. Resid. Resid. Resid. test cance
(No=16) (No=10 ) (No=9 ) (No=17 ) (No=19 )

Age 29.6±2.5 28.1±1.4 29.9±2.4 27.7±1.3 28.6±2.2 1.2 0.3
Emotional 48.7±7.8 43.3±7.7 44.7±6.5 42.5±8 41.88 1.7 0.1
Exhaustion
Depersonalization 68±15 68.5±11.3 66.5±9.4 64.7±11.8 60.1±10.8 1.5 0.2
Accomplishment 46.8±17.8 50.8±18.2 39.8±19.3 44.4±17.2 35±10 2.2 0.04*
7

The five main sections of residents had high mean scores regarding to emotional exhaustion (
27 or over) and depersonalization ( 14 or over) subscales of MBI (Figures 4 and 5). On the
contrary, the five main sections of residents had low mean scores (37 or over) regarding to
social interactions (accomplishment) (Figure 6). The mean values in figures 4,5,6 can show us
that most of the residents in this study, were suffering from burnout syndrome.
The main 5 residents' sections &

their mean values' of emotional exhaustion
Surg=1, Gyne=2, Radiol=3, Paed=4, Med=5
Mean emotional exhaustion
50
48
46
44
42
40
1.00 2.00 3.00 4.00 5.00
Main five sections

High=27 or over, Moderate=17-26,
Low= 0-1 6
Figure(4)
The 5 main residents' sections in comparison

with the mean values of depersonalization
Mean depersonalization
70
68
66
64
62
60
58
1.00 2.00 3.00 4.00 5.00
Main five sections

High=14 or over, Moderate=9-13
Low= 0-8
8
Figure(5)
The main 5 residents' sections &

their mean values of accomplishment
Mean Accomplishment score

60
50
40
30
1.00 2.0 0 3.0 0 4.00 5.00
Main five residents' sections

High =0-30, Moderate=31-36
Low=37 or over
Figure(6)
Surgical residents got significantly higher mean scores in two items of MBI than medical
residents. These two items are sense of fatigue and dealing with their patients as objects. The
test which had been used, was t-test (t = 2.4 and 3.5) respectively, significances were 0.02 and
0.001 (Table 8)
Table (8): Significant differences between medical and surgical residents regarding to
the items of Maslach Burnout Inventory:
Item of MBI Medical Residents Surgical Residents t-test Signific

(No = 36) (No = 35) ance
Sense of fatigue 3.5±2 4.6±1.7 -2.4 0.02*

Dealing with 0.7±1.2 2.1±2 -3.5 0.001*
patients as objects

Discussion:
To our knowledge, the first study University and in South Carolina in 2004
(Balon R, et al 2004). The lack of findings
comparing burnout among residents across
medical specialties was at Wayne State of statistically significant differences in
9
burnout rates among specialties may be due residents and staff. On the contrary, in the
to low and perhaps differential response above mentioned American studies, they
rates. It is plausible that those residents who found that junior residents had higher rate
felt burned out were more or less likely to of burnout, which may indicate that they are
respond, even to three mailings. The a vulnerable group. Special attention by
findings of comparable burnout rates program directors may be needed to reduce
among family medicine residents at Wayne this high rate of burnout.
State University and in South Carolina(
In the present study, we found that surgical
Michels PJ, et al 2003) and internal residents had significantly higher mean
medicine residents at Wayne State
score value regarding sense of fatigue than
University and the University of medical residents. To explain this, we think
Washington (Shanafelt TD et al, 2002) lead surgical residents have to practice many
us to believe, although with caution, that
clinical surgical skills, in addition to
the results might be generalized to settings studying theoretical medical and surgical
outside of Wayne State University,
curriculum. All of us know that, a good
particularly in Western communities. The surgeon is a good decision taker and maker,
first study is limited by the low response
which add more responsibility to surgical
rate and small numbers of residents in some residents. All these responsibilities need
specialties, which may have affected the
extra times and efforts to be achieved. That
findings. In a survey of medical students' is why surgical residents are more fatigued
attitudes and concerns regarding possible
and overwhelmed than medical residents.
repercussions of completing a depression
Fatigue is a common complaint in the
survey, only 48% finished the survey (40% general and working population, with a
of those completed the depression inventory
reported prevalence varying from 7% to
with 10% admitting to recording dishonest 45%. Fatigue can best be understood as a
answers and 19% admitting to concerns
continuum, ranging from mild complaints
about the research(Levine RE, et al 2003). frequently seen in the community on the
These results are in accord with verbal
one hand to severe, disabling fatigue, such
feedback from residents to the first author as chronic fatigue syndrome on the other.'
(Balon R, et al 2004), expressing concerns
When fatigue among employees becomes
of confidentiality and potential negative severe and persistent, it may lead to long
consequences of self-reporting. term sick leave and work disability.
In our study, nearly all the residents of the Conceptually linked with fatigue and
Saudi Board Program at King Abdul-Aziz absenteeism is the phenomenon of burnout.
Medical City were welcoming to participate In general, burnout can be described as a
in this study, as its results will be persistent, negative, work related state of
represented in front of some authority mind characterized by work related
figures of the Saudi Board Program on the emotional exhaustion and accompanied by
Residents’ Day. In the present study, there distress, (perceived) reduced effectiveness,
were no significant differences between decreased motivation, and dysfunctional
senior and junior residents as regards to the attitudes and behaviors at work. Burnout
mean values of the three components of symptoms are mostly psychological and
MBI ( Table 6 ). This can be explained by burnt out workers often causally attribute
the support which might be given by senior their complaints to problems at work,
10
blaming their jobs for their condition. A burnout (Bennett, 199l). Moreover, only a
conservative estimate of the prevalence of weak significant correlation between the
"clinical" burnout is 4.2% in the working length of work with HIV-infected patients
population.' Like persistent fatigue, burnout and the 'Depersonalization' scale was found.
can lead to long term sick leave. However, Instead three predictive variables: 'Peer
it is important to realize that persistently relationship'. 'Social reward, 'Grief & Loss’
fatigued workers are not burnout by correlated significantly with the three MBI
definition, and that burnt out workers might components scales. As expected, 'Peer
not experience fatigue as a major relationship' and 'Social reward' were
complaint. protective (negative correlation) against
In that sense, it is of great importance to burnout in the 'Emotional exhaustion' and
identify the determinants of recovery in 'Depersonalization' MBI subscales. 'Grief &
loss', on the contrary, had positive
fatigued employees: if causal attributions
can determine the course and outcome of correlations with burnout in the 'Emotional
exhaustion' and 'Depersonalization'
fatigue complaints in employees, it might
be an indication that early prevention of subscales and a negative correlation with
burnout in the 'Personal achievement or
chronic fatigue lies partly in alterations of
the labeling of fatigue complaints, for accomplishment' MBI subscale. As
described in the results, the length of work
example with the use of cognitive
behavioral techniques (Huibers et al, 2003). variable is a predictor of clinical burnout
levels on the 'Emotional exhaustion' and
In our study, there were no significant 'Depersonalization' subscales and not,
differences between sex, marital status, obviously, on the ‘Personal achievement or
numbers of working hours and numbers of accomplishment’ subscale.
on calls per week as regards to junior and
Future studies on burnout syndrome among
senior residents. Multiple studies shows no
significant associations between variables medical residents should find out the role of
the personal characteristics of residents, the
such as sex, marital status, location of
housing, age and the three MBI style of their relationship with patients and
the individual perception of stress and of
"components' subscales (Elnagar et al,
2001, Leiter and Harvie 1996). These work stressors as etiological factors in
occurrence of burnout syndrome.
findings differ from other studies, which
found negative correlations between age, We have to mention that there are some
years of experience and burnout (Maslach studies about burnout syndrome among
& Jackson, 1981; Meadow, 1981; Randall certain residents’ specialties like anesthesia
& Scott, 1988). In a study on correlations (Nyssen AS, et al 2003), intensive care,
between age and acquired work experience gynecology & obstetrics, orthopedics,
and burnout, in a sample of nurses working internal medicine (Geurts S, et al 1999)
in an AIDS care unit versus a sample of (Shanafelt TD, et al 2002) family medicine
nurses working in an oncology unit, it was (Lemkau J, et al 1994) and psychiatry. The
found that older age was a protective factor results of one of the above mentioned
towards the development of burnout. On the studies (Nyssen et al, 2003) showed that
contrary, acquired work experience was not 40.4% of the anesthetists were suffering
a protective factor in the development of from high emotional exhaustion; the highest
11
rate was in young residents under 30 years -Number of working hours, on calls per
of age. These results are particularly week, & residents who live away from their
alarming. Moreover, first-year residents did places of work, all are issues need to be
not feel as empowered as the others. discussed with the decision makers.
Surprisingly, fourth-year anesthetists also
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13
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14
Vol. 13 No.1 March 2006 15
Current Psychiatry
Motives for Substance Use Disorders: A Trans-cultural Study

Ismail K., Molokhia T., and Saadani M.
Abstract:
The causes of substances abuse may be of greater importance in different culture. The aim of
this study was to compare between Egyptian and Saudi cultures regarding to the causes and
the socio-demographic data in substance abusers of these two countries. Thirty two abusers
from Mecca and Jeddah, Saudi Arabia, were chosen randomly, their mean age was 33.6±13.6
years old. Another 32 abusers from Alexandria, Egypt were also chosen randomly. Their
mean age was 25.3±6.4 years. There were 9 females as benzodiazepine abusers in the Saudi
sample, substance abuse causes questionnaire was applied on every abuser participated in this
study. More than one third of abusers were students. Mean values of cognitive, emotional,
somatic causes and total scores of the scale were not significantly different between Egyptian
and Saudi samples, t-test were 0.1, 1.6, 1.1 and 1.2 respectively while p = 0.9, 0.1,0.3 and 0.3
relatively. The Egyptian abusers showed a significant abuse of opioids (X224.5, p = 0.00001),
while the Saudi abusers abused benzodiazepines and stimulants significantly more than the
Egyptian abusers (X2 = 28 and 9 respectively and p = 0.000001 and 0.005 relatively). The
drivers or causes of substance abuse are similar in Egypt and Saudi Arabia, Egyptian abusers
abuse opioids more than the Saudi abusers while Saudi abusers abuse benzodiazepine and
stimulants more than Egyptian abusers.
Introduction:
The reasons for the initiation of substance 2001, Cardinal RN et al., 2002, Dickinson
A and Balleine B, 1994). The impact of
use disorders may be of greater importance
at different ages and in different cultures new drugs and new technologies in
different culture is considered. Around
(Oyepeso A, 1994). For example, the
consumption of sedatives and 1980, the discovery that heroin could be
benzodiazepines by older people may begin inhaled and sublimated off the surface of
heated tin foil undoubtedly contributed to
as self mediation. Drugs may be taken to
overcome fatigue or to enhance the appetite the explosion of heroin abuse at that time in
Britain (Strang & Gossop 1993). During the
and sexual performance. Drugs may be
taken for religious purposes purposes as an 1980s the North West Frontier of Pakistan
has been one of the major producer regions
aid to mediation or to induce mystical states
(Robinson TE & Berridge KC, 2003). for black market heroin for export around
the world and despite a long history of
Some authors classified the causes of culturally bound smoking of the opium
substance abuse into: causes in substance poppy, the refined product (heroin) is
itself, individual personality and society. decimating the young male population with
Other authors divided the motives for current estimates that there are in excess of
substance abuse into social, psychological one million young men who have recently
and environmental factors. Some become addict to heroin in Pakistan
psychologist divides the causes of (Gossop M, 1989, Abdel-Gawad TMS and
substance abuse into cognitive, emotional Osman MI, 1996).
and somatic causes (Combag HS et al.,
15
Vol. 13 No.1 March 2006 16
Current Psychiatry
The cathinoids which are alkaloids derived Methods:

from khat, that is native to East Africa and
Thirty two substance abusers were chosen
the Western south part o the Arabian randomly from the psychiatric patients who
Peninsula, where it grows as evergreen
attended the out patient psychiatric clinics
shrub or small tree. The primary active in three governmental hospital of Mecca
psychoactive ingredients in that are
and Jeddah (Saudi Arabia).
cathinone and cathine, two central nervous
system stimulants. A systemic analog of The researchers chose every third substance
cathinone and metcathinone appeared in the abuser patients during the period from the
USA for the first time in 1991. In Egypt 1 st of January to the end of June, 2003. Fifty
cannabinoids have always been more three Saudi substance abusers refused to
widely abused than opioids. Also the wide- participate in this study. Another 32
spread availability of bango and its cheap substance abusers were randomly chosen
price made helped in the persistence of from two private psychiatric hospitals in
cannabinoids as the most widely abused Alexandria, Egypt.
illicit drug in Egypt till now. A study done They were chosen from the in-patients
to determine why do people abuse drugs in randomly (every third admitted patient)
certain categories of drug-abuser found that during the same above mentioned periods
among high school and university male of time. Sixty one substance abusers
students the main causes for cannabis abuse refused to participate in this study from
were having fun and sharing in a social Egyptian substance abusers.
events as well as sharing peers, while the
use of other psychoactive drugs (stimulants A questionnaire about causes of substance
and benzodiazepines) was mainly for the abuse was applied on every substance
relief of physical problems and fatigue abuser, who participated in this study
followed by the desire to study particularly (Askar A, 1989). An informed consent was
at the time of exams. However, regarding taken from every substance abuser, who
laborers it was found that they abused participated in this study. The questionnaire
cannabis for the same causes as students. is consisted of 33 items, which cover the
On the other hand, they used psychoactive different causes or motives for substance
substances for the relief of physical abuse. The author of this questionnaire
problems and fatigue as well as for getting mentioned 3 types of causes for substance
rid of psychological and social problems abuse: Cognitive emotional and somatic
(Saueif et al, 1988). causes. The reliability of this questionnaire
was 0.57 using Sperman and Brown test
The aim of this study was to compare and its validity was 0.25 (using kappa).
between two samples of substance abusers This questionnaire is subjective which can
one sample was from Alexandria, Egypt be applied individually or in groups. In
and the other one was from Mecca and cases of illiterate patients the researcher,
Jeddah, Saudi Arabia – as regards to socio- could read the items and check correct in
cultural demographic data and the causes of front of chosen items consisted of the
substance abuse either emotional, cognitive illiterate individual. The time needed to
or somatic and sexual causes. complete this questionnaire is ranged from
8-12 minutes.
16
Vol. 13 No.1 March 2006 17
Current Psychiatry
Socio-demographic data and the time of while Chi-square was used to compare
substance abuse were collected from all between qualitative means.
substance abusers who participated in this
Results:
study.
The mean age of the Egyptian sample of
All substance abusers who participated in
substance abusers was 25.3±6.4 years old
this study were fulfilling the criteria of while the mean age of the Saudi sample
diagnostic and statistical Manual of Mental
was 33.6±13.6 years old. The difference
disorders number IV-TR. (American between these 2 means was statistically
psychiatric Association 2000). All
significant (t-test = 3.1 and p = 0.003). The
substance abusers who participated in this 95.0% confidence interval of the difference
study had no psychotic disorders and no
was 3-13.6 years. The mean duration of
physical illnesses like diabetes mellitus
substance abuse among the Egyptian
ischemic heart disease, cancer, … etc. abusers was 4.2±3.4 years, while that for
Statistical analysis: the Saudi abusers was 4.6±2.7 years. The
difference between these two means was
The program of SPSS + PC was used to
analysis the data. T-test was used to statistically not significant (t-test = 0.5 and
p = 0.6). The 95% C.I. was ranging from –
compare between two quantitative means
1.2 to 1.9 years (Table 1).
Table (1): Comparison of mean age and mean duration of substance abuse between
Egyptian and Saudi samples
Mean Egyptian Saudi 95%
sample sample t- test Significance confidence
Variables interval
Mean r SD Mean r SD
Age (years) 25.3r6.4 33.6r13.6 3.1 0.003* 3-13.6
Duration of 4.2r3.5 4.6r2.7 0.50 0.60 -1.2-1.9
substance of
substance abuse
(years)
Level of significance is at p < 0.05

There were 9 females out of 32 substance abusers in the Saudi Sample while there was no
female in the Egyptian sample. All these females were house wives and benzodiazepines and
Saudi substance abusers as regards to gender was statistically significant (X2=10 while p =
0.001). (Table 2).
17
Vol. 13 No.1 March 2006 18
Current Psychiatry
Table (2): Sex distribution between Egyptian and Saudi samples of abusers:
Nationality Egyptian Saudi abusers X2 Significance
abusers
Sex
Female 0 9
Male 32 23 10 0.001*
Total 32 32

In the present study, there were 23 students, 10 semiprofessionals, 8 professionals, 6 laborer
workers, 5 soldiers and 3 not working. The difference between Egyptian and Saudi substance
regarding to occupations was statistically significant (X2 = 29.6 & p = 0.00001) (Table 3).
Table (3): Comparison of occupations between an Egyptian and Saudi substance
abusers’ samples.
Egyptian Saudi sample Total X2 Significant
samples
No = 32
No= 32
Professional 8 0 8
Semi-professional 6 4 10
Soliders 0 5 5
House-wives 0 9 9 29.6 0.00001*
Students 16 7 23
Laborer workers 2 4 6
Not-working 0 3 3
Total 32 32 64

Forty two substance abusers out of 64 were single, while only 17 abusers were married, 3
were divorced and 2 were widowed. The difference between Egyptian and Saudi abusers
regarding to marital status was statistically not significant (X2 = 7.6 while p 0.06) (Table 4).
18
Vol. 13 No.1 March 2006 19
Current Psychiatry
Table (4): Comparison of marital status between an Egyptian and Saudi substance
abusers’ samples.
Egyptian Saudi Total X2 Significance

samples sample
No= 32 No = 32
Single 26 16 42
Married 5 12 17
7.6 0.06
Divorced 1 2 3
Widowed 0 2 2
Total 32 32 64
Mean values of cognitive emotional, somatic causes and total scores of substance
abuser causes questionnaire were not significantly different between Egyptian and Saudi
samples, t-test were 0.1, 1.6, 1.1 and 1.2 respectively, p = 0.9, 0.1, 0.3 and 0.3 relatively. The
mean values of total scores of the questionnaire for Egyptian and Saudi samples were 8.5 ±6.2
and 10±3.6 relatively, the 95% confidence for the difference was 01.1 to 4. (Table 5).
Table (5): Comparison of cognitive emotional somatic and total mean scores-constitutes
of substance abuse causes questionnaire-between an Egyptian and Saudi samples
Egyptian Saudi
sample sample 95%
t- test Significance confidence
No = 32 No = 32 interval
Mean r SD Mean r SD
Cognitive causes 3.1r 2.9 3.1r2.1 0.1 0.9 -1.2-1.3
Emotional causes 3.2r2.0 3.9r1.5 1.6 0.1 -0.2-1.6
Somatic causes 2.2r3.2 2.9r1.6 1.1 0.3 -0.6-2
Total 8.5r6.2 10r3.6 1.2 0.3 -1.1-4

The Egyptian sample showed a significant abuse of opioids than Saudi sample (X2 =
24.5, p = 0.00001). Twenty one Egyptian abusers out of 32 substance abusers were abusing
different types of opioids in the form of heroin, opium, codeine and pethidine. Only two of
the Saudi sample were abusing opioids. Eight Egyptian abusers were abusing cannabinoids in
the form of cannabis and Bango while 3 Saudi abusers were abusing cannabis. The difference
19
Vol. 13 No.1 March 2006 20
Current Psychiatry
between Egyptian and Saudi samples was not statistically significant regarding to
cannabinoids abuse (X2 = 2.7 and p = 0.09). Three Egyptian abusers were abusing alcohol
while 4 Saudi patient were abusing it. The difference as regards to alcohol abuse between 2
samples was statistically not significant (X2 = 0.2 and p = 0.7). Twenty one Saudi were
abusing benzodiazepines while only 2 Egyptians were abusing them. The difference between
Egyptian and Saudi samples regarding to benzodiazepines abuse was statistically significant
(X2 = 28.0 and p = 0.000001). Nine females were abusing benzodiazepines from the Saudi
sample. Twelve Saudi patients were abusing stimulants mainly in the form of amphetamines
(Pemoline magnesium). They call it “white”. Two Egyptians were abusing “Maxitone forte”
which contains amphetamines. There was a statistically significant difference between
Egyptian and Saudi samples regarding to amphetamine abuse (X2 = 9.0, p = 0.005) (Table 6).
Table (6): Comparison of occupations between an Egyptian and Saudi substance

abusers’ samples.
Individuals Egyptian samples Saudi sample

Abusers Not- Abusers Not- Total X2 Significant
Substance abusers abusers
Opioids 21 11 2 30 64 24.5 0.00001*

Cannabinoids 8 24 3 29 64 2.7 0.09
Alcohol 3 29 4 28 64 0.2 0.70
Benzodiazepines 2 30 21 11 64 28 0.000001*
Stimulants 2 30 12 20 64 9 0.005*
Discussion:
above mentioned reasons, we could not
Many studies have shown that there is
indeed an increased incidence of exclude neurotic and personality disorders
co-morbid with substance abusers who
personality disorder among substance
abusers for example application of MMPI participated in this study (Graig RJ, 1982).
to opiate abusers showed that they scared A problem which faced us in the present
higher than expected for psychopathic study was that, we selected sub-groups of
deviance (Cami J et al 1991). However, substance abuse subjects from
when Eysenck personality inventory was governmental and private hospitals. These
applied to opiate abusers, they scored abusers are probably unrepresentative of the
higher on neuroticism than normal (but drug dependent population as a whole
lower than neurotic or alcoholic patients). (Iqbal N, 2001). Moreover, the sample of
Moreover, it was found that 73-90% of substance abusers from Saudi Arabia did
opiate addicts were diagnosed as having not include abusers from specialized
some sort of personality disorders. For the hospitals for addiction i.e. (Al-Amal
20
Vol. 13 No.1 March 2006 21
Current Psychiatry
Hospitals). Not only this, but also a mainly as sleeping pills. Tolerance to them
relatively small number of substance occurred with running the time. A previous
abusers in both Egyptian and Saudi samples study in Jeddah, showed the presence of
should be considered. heroin dependence complications among 3
A replication of this study by using larger females (Othman A and Shawoosh M,
2003).
samples may be needed in the future to
understand, assess the problem of substance This is consideration an iatrogenic
abuse in these 2 different cultures in a better benzodiazepines abuse, which is common
way, and to prepare suitable programs in developed countries like France and
which will help in combating the dangerous USA. The weather in Mecca is very hot
problem of substance abuse. nearly during the whole year, overcrowded;
noisy and shopping is continuous for 24
One of the outstanding findings in this
study is the significantly higher mean age hours around Al-Harm -due to Hajj and
Omrah. Because of all the previously
of Saudi substance abusers. This may be the
effect of extended families which are mentioned reasons, insomnia is common
and drive to abuse sedatives and hypnotics
common in Saudi communities. The grand
parents and parents are controlling the (Mohit A, 2001). According to Roth,
approximately “70%” of the prescriptions
young adult and this may be one
explanation of this phenomenon. Another for benzodiazepines and sedatives are
written for women Moreover, women are
explanation is that a good number of Saudi
abuses stimulants, which are expected to be twice as likely as men to be addicted to
abused in an elder age where the sleep is prescription drugs in combination with
alcohol” (Roth, 1991). Alcohol is
induced by benzodiazepines at night and
stimulants are used to increase activities prohibited in Islamic religion, that is whey
a few number of abusers, abused. Alcohol
and prevent sleeping and keeping awake
during wedding nights and driving for a in both Egypt and Saudi Arabia.
long distance for some abusers (Amir T, A large number of abusers in the present
2001). Some of them abuse stimulants to study were students (more than one third of
increase their sexual drives (AL-Nahedh N, the whole samples). In any community
1999). In the Egyptian sample, the absence students are the real future of its. So, this
of extended family, the absence of the role study gives us an alarm against the
of grand parents and even the weak control dangerousness of substance abuse in our
of parents in some nuclear families may be developing countries.
behind the younger mean age of substance The drives, the causes or the motives for
abuse among the Egyptian abusers
substance abuse were similar in Egyptian
(Anthony JC et al, 1995). and Saudi communities. For this reason, the
Another strange finding in this study is the programs and the planning for future
significantly higher number of female in prevention and management of this hot and
Saudi sample. This may be due to the bias dangerous topic can be shared between the
in selecting the samples as we mentioned responsible governments and authority
above. Another explanation is that all 9 figures in both Egypt and Saudi Arabia.
substance abusers’ Saudi females were
benzodiazepines’ users. They use them
21
Vol. 13 No.1 March 2006 22
Current Psychiatry
Opioid abuse is more significantly common drug abuse liability. British Journal of
among the Egyptian sample than the Saudi Addication ; 86: 1525-52.
one. This might be due to the selection of
Cardinal RN, Parkinson JA, Hall J,
Saudi sample from governmental general
Everitt BJ.( 2002) Emotion and motivation:
hospitals and not from specialized hospitals the role of the amygdale, ventral striatum,
in substance abuse like (Al Amal Hospitals)
and prefrontal cortex. Neuroscience
where, opioids abusers especially heroin are Behavior Review; 26: 321-52.
admitted there for detoxification. This again
reminds us that in future studies we have to Combag HS, Badiani A, Chan J,
take larger samples to represent abusers Dell’Orco J, Dineen SP, Robinson TE.
from different cities and different types of (2001): The ability of environmental
hospitals, schools, universities, institutes, context to facilitate psychomotor
factories and even prisons. sensitization to amphetamine can be
dissociated from its effect on acute drug
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Cossop M.(1989): The detoxification of
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Dickinson A, Balleine B, (1994)
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Behaviour and Personality;29: 519-30. Medicine 21: 196-200.
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TJ.(1995): Parent monitoring and the Eastern Mediterranean Region of the World
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Egyptian Anglo Bookshop; behavioural problem. Ann Saudi Med; 419-
21.
Cami J, Bigelow GE, Griffiths RR,
Dummond DC. (1991): Clnical testing of
22
Vol. 13 No.1 March 2006 23
Current Psychiatry
Oyefeso A. (1995): ;Sociocltural aspects of Authors:

substance use and misuse. Current opinion Ismail K.,
in psychiatry 7: 273-277. Consultant psychiatrist, Mecca
Robinson TE (2003): and Berridge KC.
Addiction: brain mechanism and behaviour. Molokhia T
Lecturer of Psychiatry,
Annual Revies psychology; 54: 25-53.
Alexandria University
Roth P.( 1991) The Model program Guide.
Alcohol and drugs are women’s issues Saadani M.
Volume I & II Metuchen: NJ: The scare Assistant Professor of Psychiatry,
crow Press, ix. Alexandria University
Soueif MI, Ynis GS, Moneim HA, Taha
HS, Sree DA, and Bdr K. (1988): The use Address of correspondence:
of psychoactive substances among Egyptian Saadani M.
males working in the manufacturing King Abdul-Aziz Medical City
industries. Drug Alcohol dependence; 21: Psychiatry Section
217-29. MC1, Building 36, Flat 12
PO Box:9515
Strang J & Gossop M. (1993): Drug use Jeddah, 21423
problems and drug addiction: social Saudi Arabia
influences and social responses. In: Bhugra Fax: 026247444
D & leff J (eds). Principles of social E-mail:[email protected]
psychiatry. Oxford: Blackwell Scientific
publications,: 37-42.
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23
Burnout Syndrome among Resident Physician in Suez Canal

University Hospital
Yousef I. M., Hosny A. O., Elsayed O.I. and Ali. E. G
Abstract
Background: Burnout is a syndrome of emotional exhaustion, depersonalization and a sense
of low personal accomplishment. Little is known about burnout or its demographic
perspectives in Egyptian residents. Objective: To determine the prevalence of burnout among
residents and explore its demographic perspectives. Design: Cross-sectional study using an
anonymous handled survey. Setting: University-based residency program in Suez Canal
University Hospital. Participants: 84 residents. Measurements: Burnout was measured by the
Maslach Burnout Inventory and was defined as scores in the high range for medical
professionals on 2 or more of the subscales. An inventory developed for this study assessed
self-reported sources of stress in job setting and involvement with people. Results: Of 84
(72.4%) responding residents, 53 (63.1%) met the criteria for burnout. None of the burnout
dimensions was significantly associated with sex. Only lack of personal accomplishment was
significantly associated with marital status and number of work-hours per week (p value <
0.05). Burnout domains were significantly associated with sources of stress. Conclusion:
Burnout was common among resident physicians and mainly related job setting and
involvement with people.
Introduction
The word “burnout” means to be depleted. job-related affective well being (Schaufeli
& Buunk, 1999). Burnout, a widely studied
It is associated with the worker’s physical
and psychological exhaustion when he syndrome, has been defined by Barnett et al
(1999) as comprising three factorially
wears his resources out trying to cope with
the difficulties of his everyday working distinct symptoms: emotional exhaustion,
decreased sense of professional efficacy,
activity. The word burnout refers to the
“bad mood, the daily irritation, the and cynicism. According to Maslach et al
prostration, the feeling of emptiness, the (2001), burnout is a syndrome defined by
the 3 principal components of emotional
disillusion, and the powerlessness many
workers feel, particularly those in the exhaustion, depersonalization, and
diminished feelings of personal
helping professions (Unknown, 2002).
Within the job stress-illness literature, the accomplishment. Earlier studies on
physicians have reported a burnout rate of
study of burnout has started since 1964
(Snibbe et al, 1989). Since Freudenberger 30% to 40% (Henderson, 1984). Some
particular subgroups, such as infectious
(1974) used the term burnout, it has mainly
been used to describe a state of physical and disease physicians, have been subsequently
found to have burnout rates as high as
emotional exhaustion whose characteristics
43.5% (Deckard et al, 1992). A study by
have been mostly applied to human services
professionals, within which health staff is Fields et al (1995) reported that 36% of
physicians in pediatric critical care were
included. Burnout can be described as a
specific type of job stress, which influences classified as at risk for burnout, and 14%
24
were burned out. The evidence, albeit from experience, but also to various
small and generally localized samples, organisational outcomes. Burnout has been
suggests that the components of burnout associated with reduced organisational
may be common among practicing efficiency and work related problems such
physicians, with 46% to 80% reporting as employee turnover, low morale, poor
moderate to high levels of emotional quality of care, lowered productivity,
exhaustion, 22% to 93% reporting moderate absenteeism and interpersonal problems
to high levels of depersonalization, and (Rosse et al, 1991; Levert et al, 2000).
16% to 79% reporting low to moderate The study of burnout, therefore, becomes
levels of personal achievement (Lloyd et al,
crucial for identifying the dimensions of the
1994). Studies of medical residents have problem among Egyptian residents, to
yielded similar results (McCue and Sachs, improve their quality of life and optimising
1991). In a survey of 119 academic
the care they aught to give to their patients.
obstetrics and gynecology department
chairs in the United States and Puerto Rico Aim of the work This study aim to identify
(response rate, 91%), Gabbe et al (2002) the burnout syndrome among the resident
found that 56% of respondents physicians in Suez Canal University
demonstrated high levels of emotional Hospital. Specifically, the study will
exhaustion, 36% had high levels of determine; the prevalence of burnout
depersonalization, and 21% reported low syndrome among the residents, sources of
levels of personal accomplishment. Mirvis stress and the Effects of gender
et al (1999) reported an increase in the susceptibility among them
prevalence of high levels of burnout (from Subjects and Methods
25.3% in 1989 to 38.1% in 1997) in a
cohort of 83 administrators of the A descriptive cross sectional study was held
Department of Veterans Affairs medical targeting resident physicians at Suez Canal
centers. The specific consequences of university hospital in Ismailia.
physician burnout are less well known. Sampling and sample size:
Mirvis et al (1999) identified loss of job
satisfaction as both a primary consequence ** Sample type: simple random sample.
of burnout and a contributor to its further ** Sample size: The sample size was
progression. Similarly, Grunfeld et al determined using the following equation:
(2000) reported that emotionally exhausted
S = [Z .⁄2 ⁄ û] 2 * P (1-P) (Dobson,
Canadian oncologists were more likely to
1984)
consider changing jobs or reducing work
hours. Burned-out residents were also Where: -
significantly more likely to indicate that Z .⁄2 (confidence level) = 1.96
they had been responsible for 1 suboptimal
patient care practice at least weekly or û (width of confidence interval) = 0.05
monthly compared with non–burned-out P (prevalence) = 30% (Henderson, 1984)
residents (Shanafelt et al, 2002). Research
over the last three decades has shown that S (sample size) = 323
the consequences of burnout are not just As the population is known and is small
limited to the individual’s subjective (there are 180 resident physicians in
25
University Hospital of Suez Canal the SOURCES OF STRESS and the MBI
University according to the hospital files), was counterbalanced to minimize any
finite population correction was calculated potential order effect.
as follows:
After the end of the one-week period; the
N = S ⁄ [1 + (S - 1) / N] (Israel, physician was considered as “non –
1992) respondent” if the questionnaire was not
returned.
Where: -
N (finite population size) = 180 Scoring and interpretation of results:
1- Maslach Burnout Inventory (MBI):
N (adjusted sample size) = 116
(1996)
The following inclusion criteria were
applied: The MBI is designed to assess the
three aspects of burnout syndrome:
Physicians who have not got their emotional exhaustion (EE) (statements No.
Master Degree yet. 1, 2, 3, 6, 8, 13, 14, 16, and 20),
Residents who have been working depersonalization (DP) (statements No. 5,
for one year or more. 10, 11, 15, and 22), and lack of personal
accomplishment (PA) (statements No. 4, 7,
Residents who have regular 9, 12, 17, 18, 19, and 21). A separate
attendance and shifting schedules. subscale measures each aspect.
Measurement instruments: Burnout is conceptualized as a continuous
To achieve the objectives of this variable, ranging from low to average to
study, a questionnaire was used; high degrees of experienced feeling.
formed of three parts: A high degree of burnout is reflected in
1- Socio-demographic data: age; sex; high scores on EE and DP subscales and in
marital status and average number of low scores on PA subscale.
working-hours per week. An average degree of burnout is reflected in
2- Part adopting the Arabic Translation average scores on the three subscales.
(Appendix B) of Maslach Burnout
Inventory (MBI) (1996) specially tailored A low degree of burnout is reflected in low
to apply to physician. (Appendix C), scores on EE and DP subscales and in high
3- Part including an inventory of the scores on PA subscale.
sources of stress for the resident physicians. At present, scores are considered high if
(Appendix D) they are in the upper third of the normative
Procedure: distribution, average if they are in the
middle third, and low if the are in the lower
Questionnaire was tested for applicability third. The numerical cut-off points are
and practicability in a pilot study, and any shown in the following table: (MBI
inconsistencies were removed. Manual, 1996)
Each physician was handled a 3-part
questionnaire and given a one-week period
to complete it. The order of presentation of
26
Range of Experienced Burnout

MBI Subscales Low Average High
(Lower third) (Middle third) (Upper third)
EE 16 17-26 27
DP 6 7-12 13
PA 39 38-32 31
(N.B. PA is measured in the opposite direction to EE and DP)

The MBI scores for a group of respondents may be treated as aggregate data. Means (M) and
standard deviations (SD) for each subscale are computed for the entire group and can be
compared to the normative data in the following table:
MBI Subscales
EE DP PA
M 20.99 8.73 34.58
SD 10.75 5.89 7.11
(MBI Manual, 1996)

A participant was considered to meet the study criteria for burnout if he or she got a “high”
score on at least 2 of the three dimensions of MBI.
2- Sources of Stress (SS):
The Sources of Stress questionnaire is designed to assess the two main sources of stress: job
setting (JS) (statements No. 1, 7, 8, 9, 11, 12, 15, 16, 17, 19, 20, 21, 22, 23 and 24) and
involvement with people (IP) (statements No. 2, 3, 4, 5, 6, 10, 13, 14, and 18). A separate
subscale measures each aspect.
Sources of Stress are conceptualized as a continuous variable, ranging from low to moderate
to high degrees of experienced feeling.
x A high-degree source of stress is reflected in high scores on JS and IP subscales.
x An average-degree source of stress is reflected in averages scores on the two
subscales.
x A low-degree source of stress is reflected in low scores on JS and IP subscales.
At the present study, scores were considered high, average, and low according to the
following empiric numerical cut-off points as shown in the following table:
27
Range of Experienced Stress

SS Subscales Low Average High
JS 25 26-50 51
IP 15 16-30 31
The SS scores for a group of respondents may be treated as aggregate data. Means (M) and
standard deviations (SD) for each subscale are computed for the entire group.
resident physicians along with those
Statistical analysis:
previously reported by Maslach, Jackson
Responses from physicians will be and Leiter (1996) from normative data of
statistically analyzed by use of latest medical practitioners. As shown in Table 2,
version of SPSS available. Significance the mean burnout sub-scale scores of
tests (Chi square) will be applied and emotional exhaustion (32.74) and
significance will be determined when depersonalization (14) are much higher than
p<0.05. For presentation purpose, only the the normative data from other medical
significant or the more prevalent options of practitioner populations.
the findings will be presented.
However, the mean sub-scale score on the
Results: dimension of personal accomplishment
Out of the 116 residents handled the (35.03) is almost equal to those of the other
questionnaire; 84 returned it within the time populations, indicating that, on average, the
limit of one week, giving a response rate of resident physicians in the present sample
72.4%. are still experiencing the sense of
accomplishment to a more or less similar
Respondents: degree as the comparison groups.
The socio-demographic characteristics of Mean score for emotional exhaustion is in
the respondents (Table 1) were such that the “high” range ( 27), and the same for
most were males (76.2%) and single depersonalization ( 13). For personal
(63.1%). The mean of working hours per accomplishment, the mean score is in the
week of the group was 83.6 work- “average” burnout range (38-32) (Table 3).
hours/week (SD 35.5).
In terms of the personal impact of work-
Burnout related stress, work-induced “high”
Presently, normative data of the MBI emotional exhaustion was identified in 75%
burnout dimensions of emotional of resident physicians, depersonalization in
exhaustion, depersonalization and personal 60.7%, and lack of personal
accomplishment exist for medical accomplishment in 27.4% (Table 3).
practitioners. Table 2 provides the mean More than 25% of the respondents scored
and standard deviation of all of the three “high” on only one dimension of Maslach
dimensions of burnout for this population of Burnout Inventory (MBI), 50% scored
28
“high” on any two of the dimensions of Meanwhile, experiencing work-related

MBI, and 13.1% scored “high” on the 3 stress associated with job setting and
dimensions altogether. So, 63.1% of involvement with people is also
participants met study criteria for burnout (a independent of sex.
“high” score on at least 2 of the three Table (6) shows that female residents are
dimensions of MBI).
relatively more at the “high” range of job
Table 4 provides the mean and standard setting- induced stress (55 %) than their
deviation for each of the 2 dimensions of male colleagues (39.1 %). Also, female
sources of stress (SS) studied for this residents are relatively more at the “high”
sample of residents. Unfortunately, no range of involvement with people - induced
normative data are currently available; stress (45 %) than their male colleagues
therefore, it is not possible to make direct (29.7 %). But in either case, the difference
comparisons of scores obtained from the between both sexes is statistically
population in this study with a insignificant.
representative norm group.
Other socio-demographic perspectives:
However, the mean scores for job setting Work-induced emotional exhaustion and
(48.85) and involvement with people
depersonalization are independent of
(26.73) as sources of stress are in the marital status (Table 7). However, lack of
“average” range for both dimensions (table
personal accomplishment proved to be
5). significantly associated with marital status.
Table 5 also shows that all the responding This table shows that married residents are
physicians are either averagely or highly more at the “high” range of emotional
stressed by their job settings.
exhaustion (83.9%) than their single
Gender perspectives: colleagues (69.8%). Also, shows that
Work-induced emotional exhaustion (EE), married residents are more at the “high”
range of depersonalization (67.8%) than
depersonalization (DP), and lack of
personal accomplishment (PA) are their single counterparts (56.6%). But the
difference between the two groups was
independent of sex (Tables 6).
statistically insignificant.
The table shows that 75 % of the males and
75% of the females participating in this However, a significant relationship between
marital status and lack of personal
study score “high” on emotional
accomplishment is shown in this table.
exhaustion, so they are equally expressed in
the “high” range of this dimension of MBI. Single participants are more at the “high”
range (28.3%) than their married colleagues
Lack of personal accomplishment, as well,
seems to be almost evenly distributed (25.8%). However, while 43.4% of the
single residents in the study sample being in
among male and female resident physicians.
the “low” range for lack of personal
However, it is shown that male residents are accomplishment, only 19.4% of the married
relatively more depersonalized by the effect are in the “low” range.
of work (62.5%) than their female
counterparts (55%). However, the At the same time, experiencing work-
related stress associated with job setting and
difference is statistically insignificant.
29
involvement with people is independent of “high” range than residents with more than
marital status. 100 work-hours per week (20%).
Table (7) shows that single (43.4%) and At the same time, residents with more than
married (41.9%) participants experience 100 work-hours per week are more at the
“high” job setting-induced stress almost “low” range of lack of personal
equally. Also, shows that single (33.9%) accomplishment (50%) than those with 50-
and married (32.3%) participants are in the 100 work-hours per week (30.9%), who are;
“high” range of involvement with people- in turn, more at the “low” range than
induced stress almost equally. residents working less than 50 hours a week
Work-induced emotional exhaustion and (27.3%).
depersonalization are independent of the Meanwhile, experiencing work-related
number of work-hours per week (Table 8). stress associated with job setting and
However, lack of personal accomplishment involvement with people is independent of
proved to be significantly associated with work-hours per week.
this socio-demographic factor.
Table (8) shows that residents with more
This table shows that residents with more than 100 work-hours per week are more at
than 100 work-hours per week are more at the “high” range of job setting-induced
the “high” range of emotional exhaustion stress (60%) than those with 50-100 work-
(90%) than those with 50-100 work-hours hours per week (42.9%), who are; in turn,
per week (76.2%), who are; in turn, more at more at the “high” range than residents
the “high” range than residents working less working less than 50 hours a week (27.3%).
than 50 hours a week (59.1%). The As regard to involvement with people, the
difference between the three groups is
residents with 50-100 work-hours per week
statistically insignificant. are more at the “high” range of involvement
The table also shows that residents with 50- with people-induced stress (38.1%) than
100 work-hours per week are more at the those with more than 100 work-hours per
“high” range of depersonalization (73.8%) week (30%), who are; in turn, more at the
than residents with more than 100 work- “high” range than residents working less
hours per week (50%), who are; in turn, than 50 hours a week (27.3%).
more at the “high” range than those
Sources of stress and burnout:
working less than 50 hours a week (45.4%).
The difference between the three groups is The different aspects of job setting have an
statistically insignificant also. upper hand over involvement with people
as a source of stress among the resident
A significant relationship between lack of
physicians (Tables 9-10).
personal accomplishment and the number
of working-hours per week is proven in this Low income and the imbalance between the
table. Residents working less than 50 hours effort and reward, together with the
a week are more at the “high” range of lack perception of the administration as being
of personal accomplishment (36.4%) than “poor” are the leading job setting stress-
those with 50-100 work-hours per week inducers of stress among the participants
(26.2%) who are; in turn, more at the (Table 9).
30
A sense of helplessness toward the terminal However, 31.2 % scoring “average” on the
patient and the mismatch of expectations job setting-induced stress are in the “high”
between the patient (and his relatives) and range for lack of personal accomplishment.
physician are the major aspects of This difference, however, has shown to be
involvement with people that induce stress insignificant.
among the participants (Table 10).
Work-induced emotional exhaustion,
The relationship between dimensions of depersonalization, and lack of personal
burnout and sources of stress was strong accomplishment prove to be dependent on
and proven to be statistically significant involvement with people-induced stress
(Table 11). (Tables 11).
Work-induced emotional exhaustion (EE) The table proves a significant relationship
proved to be significantly associated with between involvement with people-induced
job setting-induced stress experienced by stress (IP) and emotional exhaustion (EE).
participants (JS). However, Most of the participants scoring “high” on
depersonalization (DP) and lack of personal IP are in the “high” range for EE (89.3%).
accomplishment (PA) are independent of On the other hand, one-half of the
this job setting-induced stress. participants in the “low” range for IP are in
Table (11) shows a significant relationship the “low” range for EE (50%).
between job setting-induced stress and This table proves a significant relationship
emotional exhaustion, with all participants between involvement with people-induced
“highly” stressed by their job setting being stress (IP) and work-induced
at the “high” range of emotional exhaustion depersonalization (DP). Most of the
(100%). participants scoring “high” on IP are in the
However, this table shows that not “high” range for DP (82.1%). As well, most
of the participants in the “low” range for IP
only 75% of the study sample scoring
“high” on the job setting-induced stress is are in the “low” range for DP (60%).
being in the “high” range for Also, a significant relationship between
depersonalization, but also 50% of those involvement with people-induced stress (IP)
scoring “average” on the same dimension of and lack of personal accomplishment (PA)
sources of stress are in the “high” range for appears in this table. However, while 53.6%
depersonalization. However, no statistical of the study sample in the “high” range of
significant relationship has been found. IP being in the “average” range of PA, only
39.3 % are in the “high” range for PA. On
Also shown, about 22.2% of the study
sample scoring “high” on the job setting- the other hand, most of the participants in
the “low” range for IP are in the “low”
induced stress is being in the “high” range
for lack of personal accomplishment. range for PA (90%).
31
Table (1)
Number (Percentage)
Item Category
N=84
Male 64 (76.2)
Gender
Female 20 (23.8)
Single 53 (63.1)
Marital Status
Married 31 (36.9)
< 50 22 (26.2)
Work-Hour/Week 50-100 42 (50)
> 100 20 (23.8)
Table 2- Maslach Burnout Inventory subscale scores [mean ± SD] for the Participating
residents:
Normative Data
Subscales Participating Physicians Of Medical
Practitioners
Emotional exhaustion (EE) 32.74 ± 10.49 22.19 ± 9.53
Depersonalization (DP) 14 ± 6.99 7.12 ± 5.22
Personal Accomplishment (PA) 35.03 ± 7.38 36.53 ± 7.34
Table 3- Number (Percentage) of Resident Physicians Scoring Low, Average and High
on the MBI Subscales:
Subscale Low Average High

Emotional exhaustion (EE) 16 17-26 27
Residents 6 (7.1) 15 (17.9) 63 (75)
Depersonalization (DP) 6 7-12 13
Residents 15 (17.9) 18 (21.4) 51 (60.7)
Personal Accomplishment (PA•) 39 38-32 31
Residents 29 (34.5) 32 (38.1) 23 (27.4)
•
: PA is scored in opposite direction from EE and DP. Subjects scoring in the low category
have high feelings of PA while those scoring in the high category have low feelings of PA
32
Table 4- Sources of Stress subscale scores [mean ± SD] for the participating residents:
Subscale Participants
Job Setting (JS) 48.85 ± 10.51
Involvement with People (IP) 26.73 ± 8.39
Table 5- Number (Percentage) of Resident Physicians Scoring Low, Average and High
on the SS Subscales:
Subscale Low Average High

Job Setting (JS) 25 26-50 51
Residents 0 (0) 48 (57.1) 36 (42.9)
Involvement with People (IP) 15 16-30 31
Residents 10 (11.9) 46 (54.8) 28 (33.3)
Table (6) Gender perspectives associated with burnout and sources of stress:
MaleN = 64 FemaleN = 20 P value
No. % No. %
Relation between gender and EE
LOW 5 7.8 1 5
AVERAGE 11 17.2 4 20 P > 0.05
HIGH 48 75 15 75
Relation between gender and DP
LOW 11 17.2 4 20
AVERAGE 13 20.3 5 25 P > 0.05
HIGH 40 62.5 11 55
Relation between gender and PA
LOW 23 35.9 6 30
AVERAGE 23 35.9 9 45 P > 0.05
HIGH 18 28.2 5 25
Relation between gender and JS
LOW 0 0 0 0
AVERAGE 39 60.9 9 45 P > 0.05
HIGH 25 39.1 11 55
Relation between gender and IP
LOW 10 15.6 0 0
AVERAGE 35 54.7 11 55 P > 0.05
HIGH 19 29.7 9 45
33
Table (7) Relationship between marital status and dimensions of burnout and sources of
stress:
Single N = 53 Married N = 31
P value
No. % No. %
Relation between marital status and EE
LOW 5 9.4 1 3.2
AVERAGE 11 20.8 4 12.9 P > 0.05
HIGH 37 69.8 26 83.9
Relation between marital status and DP
LOW 10 18.8 5 16.1
AVERAGE 13 24.5 5 16.1 P > 0.05
HIGH 30 56.6 21 67.8
Relation between marital status and PA
LOW 23 43.4 6 19.4
AVERAGE 15 28.3 17 54.8 P < 0.05
HIGH 15 28.3 8 25.8
Relation between marital status and JS
LOW 0 0 0 0
AVERAGE 30 56.6 18 58.1 P > 0.05
HIGH 23 43.4 13 41.9
Relation between marital status and IP
LOW 8 15.2 2 6.4
AVERAGE 27 50.9 19 61.3 P > 0.05
HIGH 18 33.9 10 32.3
Table (8) Relationship between work-hours/week and the dimensions of burnout and
sources of stress:
< 50 50 – 100 > 50
N = 22 N = 42 N = 20 P value
No. % No. % No. %
Relation between work-hours/week and EE
LOW 4 18.2 1 2.4 1 5
AVERAGE 5 22.7 9 21.4 1 5 P > 0.05
HIGH 13 59.1 32 76.2 18 90
Relation between work-hours/week and DP
LOW 6 27.3 6 14.3 3 15
AVERAGE 6 27.3 5 11.9 7 35 P > 0.05
HIGH 10 45.4 31 73.8 10 50
34
Table (8): continue:

< 50 50 – 100 > 50
N = 22 N = 42 N = 20 P value
No. % No. % No. %
Relation between work-hours/week and PA
LOW 6 27.3 13 30.9 10 50
AVERAGE 8 36.4 18 42.9 6 30 P < 0.05
HIGH 8 36.4 11 26.2 4 20
Relation between work-hours/week and JS
LOW 0 0 0 0 0 0
AVERAGE 16 72.7 24 57.1 8 40 P > 0.05
HIGH 6 27.3 18 42.9 12 60
Relation between work-hours/week and IP
LOW 4 18.2 5 11.9 1 5
AVERAGE 12 54.5 21 50 13 65 P > 0.05
HIGH 6 27.3 16 38.1 6 30
Table 9- Aspects of Job setting experienced by Participants causing extreme stress:
Aspect No. %
Gaining less money for doing more 66 78.6
A sense of poor organization and loss of contact with
64 76.2
administration
Negative feedback predominates, while positive feedback is
57 67.9
minimal
No time to follow up-to-date medical literature 56 66.7
Long working hours with no enough breaks for rest 48 57.1
Table 10- Aspects of Involvement with People experienced by Participants causing

extreme stress:
Aspect No. %
Inability to induce a change or improvement with terminal cases 48 57.1
Mismatch of expectations between patient and physician 42 50
Inability to empathize with certain patients (esp. the recommended 41 48.8
ones)
Lack of positive feedback about patient’s improvement after 38 45.2
discharge
Lack of appreciation and a lot of blame from patients and their 36 42.9
families
35
Table (11) Relationship between burnout and sources of stress:

JS Low N=0 Average N=48 High N=36
EE No. % No. % No. %
Low 0 0 6 12.5 0 0
Average 0 0 15 31.3 0 0
High 0 0 27 56.2 36 100
P value < 0.05
DP No. % No. % No. %
Low 0 0 10 20.8 5 13.9
Average 0 0 14 29.2 4 11.1
High 0 0 24 50 27 75
P value > 0.05
PA No. % No. % No. %
Low 0 0 19 39.5 10 27.8
Average 0 0 14 29.2 18 50
High 0 0 15 31.3 8 22.2
P value > 0.05
IP Low N=10 Average N=46 High N=28
EE
No. % No. % No. %
Low 5 50 1 2.2 0 0
Average 2 20 10 21.7 3 10.7
High 3 30 35 76.1 25 89.3
P value < 0.05
IP
DP Low N=10 Average N=46 High N=28
No. % No. % No. %
Low 6 60 8 17.4 1 3.6
Average 4 40 10 21.7 4 14.3
High 0 0 28 60.9 23 82.1
P value < 0.05
IP Low N=10 Average N=46 High N=28
PA
No. % No. % No. %
Low 9 90 18 39.2 2 7.1
Average 0 0 17 36.9 15 53.6
High 1 10 11 23.9 11 39.3
P value < 0.05
36
Discussion:
Burnout seems to be prevalent and severe Rates of emotional exhaustion and
among residents of the study sample. The depersonalization rise significantly during
reasons for such high levels of burnout the residency years (Willcock et al, 2004).
among new medical graduates are likely to If the non-respondents in this study were
be complex, and to reflect both the taken into consideration (32 physicians), the
environment in which young doctors work prevalence may have ranged from 46% (if
and personal characteristics of the doctors all were not burnt out) to 73.6% (if all
themselves (Firth-Cozens, 1987), and were). Shanafelt et al (2002) found that
cannot be attributed to single issues such as burnout was very common among residents
working hours (Firth-Cozens & Moss, in all 3 years of residency training: More
1998). than 75% of respondents in his study met
More than 63% of the study sample suffers the criteria for burnout. If it means
anything, it is the burden of residency on
from burnout using the criteria of scoring
”high” in at least two of the three the young physicians.
dimensions of burnout; with considerably In terms of personal impact of work-related
high mean scores for emotional exhaustion, stress, work-induced emotional exhaustion
depersonalization and lack of personal was identified in 75% 0f participant
accomplishment. This is especially residents, depersonalization in 60.7%, and
dangerous as the presence of any lack of personal accomplishment in 27.4%;
combination of the features of burnout leads figures that are remarkably higher than
to decreased effectiveness at work (Maslach what Velamoor et al (2000) found in the
et al, 1996). Not only that, but also resident study carried out on a sample including
burnout could contribute to the senior as well as junior physicians (32.4%,
dehumanizing effects of medical 10.3%, 13.1% respectively).
education—especially for medical students,
However, burnout; as shown from this
and for other residents as well. study is neither a reflection of the
Socialization of medical students has been physician’s socio-demographic
described as a “hidden curriculum” in characteristics, nor a matter of prolonged
which students acquire attitudes and habits hours of working. There were no significant
from other physicians, (Hafferty & Franks, differences between perceived stress levels
1994). The high rate of burnout among in the males and females on direct
residents, who spend far more time with comparison, which is similar to what
medical students (Barnett et al, 1999) and Rathod et al (2000) found in their study of
each other than with faculty physicians, burnout. It is suggested that women have
raises the possibility that resident burnout lower job expectations than men, are
influences what medical students and junior socialized not to express discontent, and
residents interpret as appropriate value different characteristics in a career
professional behavior. Burnout could than do men (Phelan, 1994); characteristics
contribute to increases in cynicism and that might recommend women to be less
decreases in compassion that have been stressed by their job settings and
observed over the course of postgraduate interactions with people. However, in the
training (Colford & McPhee, 1989). current study sample, women are found
37
more at the “high” ranges of work-induced during their residency, namely; their
stress, an observation that may reflect seniors’ appreciation. Although residents
cultural discrepancies between women from complain about the long working hours they
the two studies. have to admit to, they consider the number
Work-induced emotional exhaustion, of working hours as the main evaluative
tool for their accomplishment. This is not
depersonalization, and lack of personal
accomplishment were independent of the all good though, because it is the quality;
not the quantity, that matters in medical
socio-demographic factors of sex or marital
status; something repeatedly proved by practice.
Velamoor and his colleagues (2000). A On the other hand, burnout is more a matter
survey conducted in the Netherlands of what the resident has to deal with in his
surveying 1426 physicians in primary care or her workplace; namely the job setting
and specialties (response rate, 63%; 18% and involvement with people. As it might
women), the authors found no significant appear in the current study, work-induced
sex difference in burnout rates in Dutch burnout proved to be dependent on work-
physicians (Linzer et al, 2002). The power induced stress. In 2001, Richard Smith
of physicians, defined as a combination of asked "Why are doctors so unhappy?" and
clinical freedom, autonomy, authority, concluded that "The most obvious cause of
influence, and participation in decision- doctors' unhappiness is that they feel
making, has been decreasing both among overworked and under-supported" (Smith,
male and female physicians (Friedman, 2001). As well, professional unhappiness
1995; Forsberg et al, 2001). The findings of among physicians, with increasing stress
no significant differences on any of the and decreased well-being, might partly be
socio-demographic factors for the personal due to worsening working conditions (von
impact of work-related stress suggest equal Vultée et al, 2004).
vulnerability to emotional exhaustion, However, some aspects are more stressful
depersonalization, and lack of personal
than others. Poor financial gain, poor
achievement. contact with administration and negative
Only “lack of personal accomplishment” feedback from seniors are especially
proved to be influenced by socio- stressful job settings, while a sense of
demographic factors. Single participants helplessness toward terminal cases ranked
seem to be more into their job and more first in the stressful aspects of involvement
extreme in their attitude toward their with people. This is at the time when it is
accomplishment than their married known that: as a buffer against work-related
colleagues, who may have other sources for stress, the support, which junior staffs
a sense of accomplishment that their single perceive from consultants, may be crucial
counterparts do not have. Also, residents (Firth-Cozens, 1987).
appear to get their sense of personal Mismatch between the expectations of the
accomplishment from the number of hours
patient and physician is another aspect of
they work- the more the hours the more the involvement with people-induced stress.
accomplishment. Such an attitude can
This is especially true as the process of
reflect the way in which residents are being
burnout “exhausts one’s physical and
evaluated and the major aim they seek mental resources by excessively striving to
38
reach some unrealistic expectation imposed protect the anonymity of all residents
by oneself or by the values of society” (regardless of participation); we obtained
(Wessels et al, 1989). only limited demographic information from
respondents.
Other common themes that are worthy of
consideration seem to emerge from the The outcome measures for work-induced
findings on appraisals of work-related stress stress were based on self-report, and it is
among medical faculty include: non-clinical not possible to know the extent to which
functions (excessive paperwork), dealing these self-reports accurately reflect the
with difficult patients, and dealing with degree of stress caused by the different
relatives of patients (Velamoor et al, 2000). aspects of job setting and involvement with
In another study, the areas most frequently people assessed in the survey. Criterion
rated as stressful were: out of hours duties, validity and reproducibility of the questions
dealing with difficult and hostile relatives have not been studied. In addition, biased
of patients, working long hours, arranging reporting of work-induced stress could
admissions, paperwork, demands of job explain the observed relationship between
interfering with personal life, and burnout and stress experienced due to job
responsibility of suicidal and homicidal setting and involvement with people. For
patients on increasing workload and bed example, residents who met criteria for
scarcities (Rathod et al, 2000). burnout could have over-reported work-
induced stress they experience.
It has been stated “The attitude of the
medical profession to the health of its Alternatively, residents who were not
members has always been one of disinterest burned out might have been more
susceptible to social desirability bias;
which is transiently discarded when disaster
overtakes one of its members (’Hagan & therefore, these residents could have under-
reported their work-induced stress.
Richards, 1998).
Although the author believes the results
It is incumbent on the individuals and
healthcare systems that employ and regarding the association between burnout
and work-induced stress should be viewed
supervise the new generation of medical
practitioners that these young doctors are cautiously and should be used primarily to
generate hypotheses for future research, the
given the same care and support that people
expects them to provide to their patients author doubts that these findings solely
(Willcock et al, 2004). reflect biased reporting. Finally, this study
is limited by its cross-sectional design.
The current study had several important Future longitudinal studies are required to
limitations. Although the response rate was evaluate the possibility of a causal
high, response bias remains a possibility, relationship between work-induced stress
and the prevalence of burnout in this and burnout.
residency program could range from 45%,
The generalizability of the results in this
if all 32 non-respondents were not burned
out, to 73.7%, if all non-respondents were sample of residents from a single university
hospital is unknown. However, the author
burned out.
doubts that the results reflect unique
It was not possible to compare respondents characteristics of the residency program or
with non-respondents because, to fully residents studied, as residents in this
39
hospital work in inpatient and outpatient stresses of residency training. JAMA;

settings that are typical for Egyptian 261:889-93.
university-based training programs in
Deckard G, Hicks L and Hamory B.
different specialties. For this reasons, it
(1992): The occurrence and distribution of
seems unlikely that these findings are burnout among infectious disease
unique to the hospital that was studied.
physicians. J Infect Dis; 165:224–8.
Recommendations:
Fields AI, Guerdon TT, Brasseux CO,
Annual self-assessment of the level of Getson PR, Thompson AE and Orlowski
burnout and work-induced stress, using JP. (1995): Physician burnout in pediatric
validated measuring tools (e.g. MBI), to critical care medicine. Critical Care Med;
follow-up the level of burnout among the 23:1425–9.
residents.
Establishing a mechanism for providing Firth-Cozens J. (1987): Emotional distress
psychiatric counseling for physicians in junior house officers. BMJ; 295:533-536.
identified as “burned out” through the Firth-Cozens J and Moss F. (1998): Hours,
Psychiatry Department. sleep, teamwork and stress. BMJ;
Organizing regular meetings between 317:1335-1336.
residents on one side and administration Forsberg E, Axelsson R and Arnetz BB.
members and patients’ relatives on the other (2001): Financial incentives in health care.
side to simplify and clarify various The impact of performance-based
controversies and to communicate openly. reimbursement. Health Policy; 58:243–262.
Strict regulations considering the number of Freudenberger HJ. (1974): Staff burnout.
hours the resident has to work per week, Journal of Social Issues, 30, 159-165.
which – if violated- give the resident the
Friedman E. (1995): The power of
right to get more “off” hours.
physicians: autonomy and balance in a
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essential social skills they may need in
Gabbe SG, Melville J, Mandel L and
dealing with different personalities
Walker E. (2002): Burnout in chairs of
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residents gain from their work in respect to Gynecol; 186:601-612.
the duties they have to attain.
Grunfeld E, Whelan TJ, Zitzelsberger L,
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41
Authors: Lecturer of Psychiatry

Faculty of Medicine
Yousef I. M
Prof. of Psychiatry Suez Canal University
Faculty of Medicine Address of Correspondence:
Suez Canal University
Elsayed O.I.
Hosny A. O. Lecturer of Psychiatry
Assistance Prof. of Psychiatry Faculty of Medicine
Faculty of Medicine Suez Canal University
Suez Canal University
Elsayed O.I.
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43
Amphetamine Related Symptoms: Descriptive Analysis and

Reasoning
Abdel Razek Y, Refaat, G., Abdel Razek G , Rashad, M , Al-Zahrany M. and Al-Johi. M.
Abstract
At the last few years a lot of data in the gulf region reported that amphetamine psychosis
became more common and more prolongedThis study was done to: 1) assess clinical features
related to amphetamine withdrawal, 2) assess if there are changes in these features in
comparison to other previous studies or not, 3) study the relation between amphetamine and
chronicity of psychotic symptoms, 4) Find a reason for such suspected changes if present. A
total of 150 male amphetamine dependent inpatient were selected according to ICD-10
research diagnostic criteria. Patients were subjected to the following procedures: 1) Oral
informed consent. 2) Full psychiatric interview. 3) Urine test for common addictive
substances on admission 4) Symptoms checklist which have been designed by the authors to
assess Clinical features associated with amphetamine 5) Symptom Checklist–90—Revised
(Derogates 1994). Generally the present study shows that the psychotic symptoms were very
common with Amphetamine dependent patients and the severity of all symptoms decreased
significantly during the different phases of treatment. Delusions and hallucinations were very
common during 2 nd week (54% and 51% respectively) and persisted for more than 8 weeks in
24% and 10% of patients respectively. 1999 and Koyama et al 1991 but still the duration of
psychosis is much longer. There is increased risk of psychosis with use of amphetamine and a
lot of reasons may play role as starting abuse at early age, sensitization process that may lead
to chronic psychosis, and adulterating substances like ephedrine that may be dangerous and
can lead to permanent damage of brain serotonin nerve endings.
Introduction
Drug dependence is a chronic problem in neurons that project from the ventral
tegmental area to the cerebral cortex and
all countries of the world. The prevalence
of Drug abuse and addiction continue to be the limbic areas. That pathway has been
among the largest and most challenging termed the rewarding pathway and its
activation is probably the major addicting
health, economical, ethical and social
problems facing society. mechanism for the amphetamines.
Amphetamine induced psychosis has been
Many studies raised great concern about the extensively studied because of its close
prevalence of amphetamine dependence and resemblance to paranoid schizophrenia.
its associated problems especially psychosis Several studies have also found that,
(Farrel et al 2002, Dalamu et al, 1999, although the positive symptoms of
Muray, 1998 and Koyama et al, 1991). schizophrenia and amphetamine induced
The classic amphetamines have their psychosis are similar, the affective
primary effects by causing the release of flattening of schizophrenia and also alogia
catecholamine particularly dopamine from are generally absent in amphetamine
presynaptic terminals. The effects are induced psychotic disorder. Clinically,
particularly potent for the dopaminergic however, acute amphetamine induced
44
psychotic disorder can be indistinguishable chronicity of psychotic symptoms. 4) Find a

from schizophrenia and only the resolution reason for such suspected changes if
of the symptoms in a few days or a positive present.
finding in a urine drug screening test
Methods
eventually reveals the correct diagnosis.
This study was done in Al-Amal Complex
Some evidence indicates that the long term for mental health which is located in Al-
use of amphetamines is associated with an
Dammam, Kingdom of Saudia Arabia
increased vulnerability to the development (KSA). It is a 500 bed hospital, 200 for
of psychosis under a number of
addiction, 150 bed for half way house for
circumstances including alcohol abstinent patients and 150 bed for
intoxication and stress. Previous studies
psychiatric patients. The complex serves all
reported that psychotic symptoms only
the Eastern and Northern provinces of KSA
develop after prolonged use and typically at in addition to nearby other gulf countries
high doses and usually only hours in length
like Bahrain, Kuwait, Doha, etc. yearly the
and maximum for few days (Kaplan and Addiction treatment in patient units in this
Sadock, 2000). However at the last few
complex dealt with more than 2000 case. At
years a lot of data in the gulf region the last three years patients dependent on
reported that amphetamine psychosis
amphetamine only constitute more than
became more common and more prolonged. 50% of patients dependent on one substance
Patients admitted to Al-Amal complex are (Al-Amal complex annual report 2005)
subjected to a preset program as patients are
A total of 150 male amphetamine
received in a detox unit for few days till
dependent inpatient at Al Amal Mental
they recover from physical withdrawal Health complex were selected according to
symptoms and/or psychotic symptoms then
ICD-10 research diagnostic criteria (during
patients are transferred to rehabilitation a period of 8 months. Cases who reported
units to receive other modalities of
any significant history of other substances
therapies. In the last few years it was use within past two years or who had a
noticed that the mean duration of stay in
previous history of a major psychiatric
detox units was increasing. Also, cases of disorder not related to amphetamine were
amphetamine dependence increased
excluded. After start of the study 19 cases
gradually along these years (annual Report were excluded after getting data from their
2005, Alamal complex). These observations informants about history of previous
has led the authors to investigate symptoms
depression, schizophrenia, mania and use of
related to amphetamine especially psychotic other substances.
features.
All patients subjected to the following
Aim procedures: 1) Oral informed consent to
This study was done to: 1) Assess clinical take part in the study. 2) Complete
features related to amphetamine psychiatric interview. 3) Urine test for
withdrawal. 2) Assess if there are changes common addictive substances on admission
in these features in comparison to other to confirm the diagnosis of amphetamine
previous studies or not. 3) Study the use without any other substances. 4)
relation between amphetamine and Symptoms checklist which have been
45
designed by the authors to assess Clinical Only data of 131 patients were subjected to
features associated with amphetamine. It the statistical analysis. The symptoms
was applied daily from the first day of checklists results were collected and
admission till the second week then weekly statistically analyzed utilizing mean,
till discharge. 5) Symptom Checklist–90— standard deviation, and frequencies,
Revised (SCL-90-R) (Derogates 1994) discriminate function analysis, to compare
which is a quick screening instrument, to the daily differences. All collected data
measure the status of psychopathology, and were Statistical analyzed using SPSS
as a quantification of current version 12 (2003). All given percentages
psychopathology along nine symptom are approximated numbers done by the
constructs: Somatization, Obsessive- computer.
Compulsive, Interpersonal Sensitivity,
Results
Depression , Anxiety, Hostility, Phobic-
Anxiety Paranoid Ideation , and The Mean age of the patients included in
Psychoticism. It is a self-administrated the sample was 26.24 SD+ 5.4. Regarding
questionnaire. Instructions direct the demographic data of this sample, 76 %
respondents to report how much discomfort were currently single, 14 % were married,
each item caused them during the previous and 8% divorced, 2% widows. Regarding
weeks. Items are numbered rejoinders to the Educational level 51% were graduated from
opening stem “How much were you Middle school, 22% Primary school ,11%
distressed by . . . ?” Respondents mark one Secondary school, 6% illiterate and 4 %
numbered circle for each item on a Liker t- can read and write, while there were 6%
type scale of 0 = not at all, 1 = a little bit, 2 University graduates. In regard of the Place
= moderately, 3 = quite a bitì and 4 = of residence, 78% were from eastern
extremely. SCL-90 6) Each patient was province, 7% from western province, 5%
asked specifically during the interview from south and 4% from north province and
about, starting age of abuse of 6% from other nearby Gulf countries. The
amphetamine, duration of abuse, dose, results of urine toxicology showed that 42%
number of previous hospitalizations and had negative results, where 58% had
past history of psychosis related to use of positive results on admission .the samples
amphetamine. 7) In addition to the were collected on the second day of
procedures done for patients, 7 different admission. Regarding the family history of
types of amphetamine tablets available in substance use, the majority of that sample
the market were collected through narcotic 82% had negative results and 18% had
prevention department and the content of positive results. Although no personality
such types were analyzed through the tests were administred on our patients, the
central toxicology laboratory in Dammam results of clinical evaluation revealed that
central Hospital by expert professor of 22 % were diagnosed as having personality
chemistry and toxicology. disorder.
46
Tables 1: the common symptoms of the Amphetamine patients in the first and 2 nd weeks
Symptoms Frequency( first Frequency( second

week ) week )
Objective symptoms Normal high Normal high
( Physical )
Blood pressure %96 %4 %98 %2
Sweating %64 %36 %20 %80
Tachycardia %84 %16 %90 %10
Vomiting %90 %10 %100 %0
Diarrhea %94 %6 %100 %0
Sneezing %88 %12 %100 %0
Sleep disorder %42 %58 %42 %31
Dilated pupils %90 %10 %100 %0
Tremors %82 %18 %100 %0
Back pain %90 %10 %100 %0
Running nose %86 %14 %100 %0
Fever %96 %4 %100 %0
Subjective symptoms
(Psychological )
Headache %76 %24 %98 %2
Delusions %72 %28 %46 %54
Hallucinations 39% 61% 49% 51%
Chest tightness %89 %12 %98 %2
Anxiety %56 %44 %57 %43
Abdominal pain %98 %2 %100 %0
Restless %66 %34 71% 29%
Depressed mood %54 %46 %62 %38
Irritability %58 %42 %88 %12
Abnormal behavior %68 %32 %12 %88
47
Tables 2: the common symptoms of the Amphetamine patients in the 3 rd and 4 th weeks
Symptoms Frequency( 3rd Frequency( 4th

week ) week )
Objective symptoms Normal high Normal high
( Physical )
Blood pressure %97 %3 %99 %1
Sweating %81 %19 %88 %12
Tachycardia %92 %8 %94 %6
Vomiting %100 %0 %100 %0
Diarrhea %99 %1 %100 %0
Sneezing %99 %1 %100 %0
Sleep disorder %73 %27 %77 %23
Dilated pupils %100 %0 %100 %0
Tremors %100 %0 %100 %0
Back pain %99 %1 %100 %0
Running nose %98 %2 %100 %0
Fever %100 %0 %100 %0
Subjective symptoms
(Psychological )
Headache %97 %3 %96 %4
Delusions %55 %45 %61 %39
Hallucinations 68% 32% 79% 21%
Chest tightness %95 %5 %97 %3
Anxiety %51 %49 %71 %29
Restless 79% %21 %76 %24
Depressed mood %65 %35 %77 %23
Irritability %90 %10 %96 %4
Abnormal behavior %68 %32 %69 %21
48
Generally the present study shows that and decreased gradually during the
following weeks.
physical symptoms were mild and un
common with Amphetamine withdrawal 84% of cases reported a previous history of
and the severity of symptoms decreased psychotic symptoms associated with use of
significantly within short time. The physical amphetamine. 34% of the sample reported
withdrawal symptoms generally peak in 2 that they had used amphetamine on over
to 4 days and are resolved in most of cases 100 separate occasions. Those frequent
within first week. The most common users were at greater risk of psychosis than
physical withdrawal symptoms were those who had used less extensively. For
excessive sleep and sweating while the those who had used amphetamine on over
most serious physical withdrawal symptom 100 occasions, the risk of delusions was
was tachycardia (16% in first week). more than double that of other users
The most common psychological (OR=2.37, P < 0.01).
withdrawal symptoms were delusions, Starting use of amphetamine before the age
hallucinations, depressed mood and anxiety of 18 years also doubled the risk of
symptoms. The most serious psychological developing delusions odd ratio = 2.73,
withdrawal symptom was depression that P<0.05. Early amphetamine use before age
can be severe after sustained use of high of 18 years has been also, associated also
doses and can be associated with suicidal with multiple hospitalizations.
ideation or behavior. Psychological Also, there was positive correlation
withdrawal symptoms started during the between presence of delusions and history
first week and in some cases persisted for
of previous psychosis, number of previous
more than 8 weeks. Percentage of cases had hospitalizations, duration of stay n the
delusions increased during the second week
hospital and daily dose of amphetamine.
Tables 3: the mean Score on SCL-90 R of the Amphetamine patients.
Scale Items Mean SD

Somatization .43 .32
Obsessive-compulsive .97 .81
Interpersonal Sensitivity 1.69 .33
Depression 1.23 .67
Anxiety 1.12 .39
Hostility 1.20 .42
Phobic- anxiety .80 .22
Paranoid ideation 1.48 .47
Psychoticism 1.01 .32
49
policy of Al-Amal mental complex, which

The results showed that there were high
does not permit admission below this age.
scores of Interpersonal Sensitivity, hostility
due to suspiciousness, delusion of Regarding the educational level of our
sample, only 6% was university graduated,
persecutions, Paranoid ideation, and
Psychoticism. In the other side, the which could be explained on basis of level
of education and more maturity. The
depression was also higher than average
level. Middle school graduated represented the
highest percentage of the sample because at
Duration of hospitalization was 4-5 weeks this level of education they sought to work
in 21% of cases, 5-6 weeks in 34%, 6-8 in governmental places, and some of them
weeks in 30%, and 15% more than 8 weeks. are referred from their work for assessment
At discharge 24% of patients still have and management. Regarding marital status
delusions and 10% still have hallucinations. the results showed that 86% the sample
Analysis of the amphetamine tablets were singles probably due to social stigma
revealed that each tablet contain different of addiction, and unemployment.
amounts from different substances even if it As regards to the physical withdrawal
is from the same type (same the shape and symptoms, all results were concordant with
color). Some of the tablets analyzed have results of previous studies (Dalamu et al
no amphetamine at all. Ephedrine and 1999 and Koyama et al 1991) which
pseudoephedrine were common finding in denoted that most of physical symptoms
most of tablets analyzed. Other substances disappeared during the first week and that
like caffeine, theophylline, the most resistant objective symptoms are
diphenhydramine, methyle salicylates, sleep disorders and sweating (Iwanami, et
quinine and ascorbic acid were also found. al 1994) . Sleep disorders are explained by
Discussion the powerful effect of the amphetamine as a
stimulant on reticular activating system
Previous studies denoted that typically while the prolonged sweating is explained
symptoms of amphetamine psychosis remit by the tendency of autonomic disturbance
within a week, but in a small proportion of to persist more and to adapt more slowly
patients, psychosis may last for more than a than other body systems (Kaplan and
month (Kaplan and Sadock, 2000; Koyama Sadock, 2000).
et al , 1991; and Kandel and Davis 1996).
Some amphetamine users may develop Patients were examined daily by symptom
persistent psychosis and those who recover checklist and to avoid biased judgment
remain at high risk of reexperiencing from patients and clinician themselves
psychosis even if they don’t use application of SCL-90 R was done weekly.
amphetamines again (Hyman and Nesteler, High scores of Interpersonal Sensitivity,
1996; and Farrel et al 2000) hostility, delusion of persecutions, Paranoid
ideation, depression and psychoticism
Although Amphetamine dependent patients confirmed the clinical assessment done and
are usually of a younger age (Battaglia and gave an objective score. Delusions and
Napier, 1998), the results showed that there hallucinations were more common in the
are no cases below 18 years (Mean age of second week than in the first week as
26.24 SD+ 5.4), Because of the admission patients are more distressed by physical
50
symptoms and increased sleep during first literature that this substance can lead to
week and when they start to communicate permanent damage of brain serotonin nerve
these psychotic features started to appear endings that have a major role in psychosis
more prominently. and depression (Ellenhorn, et al, 1990).
Persistent mood symptoms like depressed The second major cause for persistence of
psychotic symptoms was the kindling
mood for more than 4 weeks in 23% of
cases is concordant with other studies process (Kaplan and Sadok, 2000) as
denoted by The positive correlation
(Koyama et al 1991 and Murray 1998) as
amphetamine is powerful stimulant for between early use of amphetamine before
age 18 years, duration of use of
dopamine and its ingestion for long periods
will be followed by dysregulation of amphetamine, dose, number of
dopamine receptors and readjustment of hospitalizations. Where as dopamine
neurotransmission is increased in response
these receptors after withdrawal will take
time because it is a structural brain change to a single dose of amphetamine and this
would suggest that repeated increases in
(Farrel et al 1998).
dopamine release may produce secondary
Persistent delusions, hallucinations, and changes that are more directly responsible
abnormal behaviors for 4 weeks in 39%, for the persistence of psychosis (Cherland
31% and 29% of cases respectively and Fitzpatrick, 1999 and Farrel et al
confirmed the clinical observation noticed 1998).
empirically. Previous studies about duration
of psychotic symptoms denoted that only Another possible interpretation of
15% of patients persisted to be psychotic at persistence of psychotic features with
amphetamine is that individual with
the 4 th week (Brabbins and Poole, 1996,
predisposition to psychosis are more likely
Brady et al, 1991, and Satu et al, 1990).
to use drugs and drugs work as precipitating
The argument that the subjects found in this
study are not suffering from psychosis but factor not an inducing factor. But this
interpretation can be minimizd by the fact
simply manifesting the toxic effects of
amphetamine has been examined and that drug induced psychosis is not common
with other substance like opiates or
excluded because toxic effects by definition
in ICD-10 research diagnostic criteria don’t benzodiazepines as with amphetamine
exceed 48 hours. ICD-10 Classifications (Peroutka , 1988 and Murray 1998)
permitted for psychosis to appear within Reports from narcotic prevention
two weeks from taking the substance and to department revealed that most of
last at least more than 48 hours and at most amphetamine was imported from outside
6 months (WHO, 1992) but there is idea the country in the past but at the last few
about the commonest duration of psychosis years there is local synthetic amphetamine
as classifications addressed other issues like and this interpretate the different structure
medicolegal aspects of different types of amphetamines and
interpret adulteration with many things like
This persistence of psychotic symptoms can
be attributed to the change in structure of salicylic acid , antihistaminincs, quinine
and the most dangerous was ephedrine.
amphetamine tablets as analysis of tablets
revealed wide use of ephedrine as an
additive and it is well known in the
51
Conclusion and behavior: A conference report. Drug

Alcohol Dependence 52:41
It is misleading and dangerous, to our youth
in particular, to label Amphetamine as “soft Beck, A et al (1993): Cognitive Therapy of
drug” and to be socially accepted. In fact Substance Abuse, The Guilford Press,
the serious adverse effects of Amphetamine U.S.A.
let it as one of the worst substances in our
Brabbins, C. & Poole, R. (1996)
countries.
Psychiatrists’ knowledge of drug induced
Policy implications psychosis. Psychiatric Bulletin, 20, 410 -
Severe dependence on amphetamine was 412.
associated with higher risk of psychosis so Brady, K. T., Lydiard, R. B., Malcolm, R.,
services should be directed more toward et al (1991) Cocaine induced psychosis.
this type of addiction especially that current Journal of Clinical Psychiatry, 52, 509 -
services are more directed toward 512.
substances like heroin.
Cherland, E. & Fitzpatrick, R. (1999)
Opening of special units for drug induced Psychotic side effects of psychostimulants:
psychosis will be beneficial because those a five year review. Canadian Journal of
cases block detox units and will disturb Psychiatry, 44, 811 -813.
rehabilitation units. This research help to
Dalmau, A., Bergman, B. & Brismar, B.
stress that the plan of narcotics prevention
(1999) Psychotic disorders among in-
should be adapted and modified to restrict patients with abuse of cannabis,
local synthesis of these substances.
amphetamines and opiates. Do
Clinical implications dopaminergic stimulants facilitate
psychiatric illness? European Psychiatry,
This work reflects the importance of
clinical observation to monitor changes in 14, 366 -371.
the presentation of patients. Also it reflects Derogatis LR: SCL-90-R, (1994) Brief
the importance of integrating clinical Symptom Inventory, and matching clinical
observation with chemical assessment of rating scales, in Psychological Testing,
the available illicit drugs Treatment Planning, and Outcome
Following recovery persons who have Assessment. Edited by Maruish, M. New
York, Erlbaum,
experienced an amphetamine-induced
psychosis seem to be sensitized and will Ellenhorn, Matthew J./ Schonwald, Seth
experience acute paranoid psychosis on (Edt)/ Ordog, Gary (Edt)/ Wasserberger,
reexposure to small doses of amphetamines. Jonathan (Edt) (1990) Ellenhorn's Medical
Toxicology2 nd edtion – pa ge number1473,
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440.
53
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54
Sleep Profile in Children with Pervasive Developmental Disorders

Gaber A., Abo Elela E., Abo El-Naga Y. and Asaad T.
Abstract
Sleep disturbances are regarded as a common clinical feature in autism and other Pervasive
Developmental Disorders (PDD) that forms a great source of stress for families. Studies have
shown that children with PDD exhibited qualitatively and quantitatively different sleep
patterns to non autistic control children. This study aimed at describing sleep patterns in a
sample of Egyptian children with pervasive developmental disorders. The study included 15
children with a pervasive developmental disorder according to DSM-IV criteria, randomly
chosen from the child psychiatry out patient clinic, at the Institute of Psychiatry, Ain Shams
University between the months of January and August, 2004. An age and sex matched control
group, formed of 10 healthy age and sex matched children from the information bank of the
sleep laboratory were obtained. All cases were clinically assessed and the severity of the PDD
was further evaluated by the Childhood Autism Rating Scale (CARS). Subjective sleep
assessment was obtained through the Arabic version of Children’s Sleep Habits Questionnaire
(CSHQ). Sleep was also objectively assessed by a polysomnogram performed at the sleep lab
of the institute of psychiatry, Ain shams University. The children were classified as mildly
autistic or moderately autistic by the CARS. Epilepsy was reported in 46.7% of the patients.
Normal sleep latency was reported in 60% of the patients while 26.7% reported a moderate
increase in sleep latency. The children’s sleep habits questionnaire (CSHQ) showed that sleep
duration was adequate in 93.3% of patients. Sleep related anxiety was seen in 53.3% of
patients and night awakening in 40% of patients. Nocturnal enuresis was seen in 20% of
patients (3 patients) and increased movements during sleep in 26.7% (4 patients). Sleep
bruxism was seen in 20% of patients (3 patients), while sleep disordered breathing occurred in
one patient. As compared to age and sex matched control, the polysomnogram has shown a
significant decrease in sleep efficiency, prolongation of stage 1 and 2 NREM sleep and
shortened REM sleep in patients with PDD. The arousal index and number of awakenings
were significantly higher in children with PDD than in the control group. The Periodic Leg
Movements during Sleep index was also significantly higher in the patient than the control
group. The results of our study confirm the presence of sleep disturbances in children with
PDD in the form of decreased sleep efficiency and change of sleep
Introduction:
The pervasive developmental disorders disintegrative disorder, Rett syndrome and
PDD not otherwise specified (Kaplan and
(PDD) are a group of disorders in which the
main features are delay and deviance in the Sadock, 1998). The differentiation between
these disorders is mainly behavioral with no
development of social skills, language and
structural, biochemical or etiological factor
communication, and limited and
stereotyped repertoire of behavior and identified as specific to any PDD subtype
(Willemson-Swinkels and Buitelaar, 2002).
interests. Autism is the prototype of these
disorders but the group also includes The exact causes underlying these disorders
are not fully understood but it is believed to
Asperger syndrome, childhood
55
be heterogeneous, with interactions sensory perception with increased

between genetic and environmental factors. sensitivity to minor environmental changes
A variety of disorders were associated with and increased levels of anxiety (Richdale
autism including viral infections, inborn and Prior, 1995; Patzold et al., 1998). Sleep
errors of metabolism, structural lesions of disturbances may also reflect functional
the brain, congenital or early neonatal alterations in the neurological structures
infections, suboptimal obstetric conditions, responsible for regulation of the sleep–
disturbed absorption from the wake cycle, and may reflect abnormalities
gastrointestinal tract, altered immunological in brain maturation and neurotransmitter
reactions and endocrinal disturbances. All systems (Richdale, 1999).
these factors are believed to act through a Sleep problems have been correlated with
final common pathway to affect increased personal and family distress and
development of the brain at a critical period
is believed to adversely affect daytime
resulting in the behavioral syndrome that behavior (Patzold et al., 1998) including
we call autism (Gilberg and Coleman
increased rates of over activity, disruptive
2000). behavior, communication difficulties and
Sleep disturbances are regarded as a stereotyped behavior (Patzold et al., 1998;
common clinical feature in autism and other Schreck et al., 2004). Only a few studies
PDD that forms a great source of stress for have investigated sleep disorders in
families (Herring et al., 1999). Studies have children with autism and most of these were
shown that children with PDD exhibited based on parental reports through sleep
qualitatively and quantitatively different diaries or sleep questionnaires. The issue of
sleep patterns to non autistic control the objectivity of parental reports was put
children (Patzold et al., 1998). Villalba and forth as a potential weakness in various
co-workers (2002) classified disorders of studies. The difficulty inherent in studying
sleep in infantile autism into three types: autistic children who are intolerant to
changes in routine or environment is a
A) Functional alterations in sleep; with
early waking and difficulties in going to likely reason for the paucity of nocturnal
polysomnographic studies, even in
sleep being the disorders most frequently
seen. symptomatic children with an obvious sleep
disturbance (Thermulai et al., 2002).
B) Immaturity of sleep: showing a disturbed
polysomnographic recording and negative This study aimed at describing sleep
patterns in a sample of Egyptian children
correlations with the level of development.
with pervasive developmental disorders.
C) Paroxysmal alterations: with Children were assessed by means of a
epileptiform discharges being the clinical history and Childhood Autism
commonest, without necessarily occurring Rating Scale (CARS) to diagnose their
with seizures. pervasive developmental disorder and
The exact causes of these sleep disturbances detect its severity. Children Sleep Habits
is not fully understood. A variety of factors Questionnaire was used to assess sleep
are believed to play a role including subjectively.
difficulties to regulate sleep and wake
cycles according to social clues, altered
56
Subjects and methods (Schopler et al., 1993). It is brief,

convenient and suitable for use for any
Study sample: child above the age of two. As most of our
This study was conducted on 15 Egyptian patients were nonverbal, and even in those
children, randomly chosen from those with some language, verbal communication
attending the child psychiatry out patient was not possible due to lack of cooperation,
clinic, at the Institute of Psychiatry, Ain non verbal IQ measurements were obtained
Shams University between the months of by trained psychologists.
January and August, 2004. Children were Subjective sleep assessment was obtained
diagnosed through clinical history taking through the Arabic version of Children’s
according to DSM-IV criteria to have a Sleep Habits Questionnaire (CSHQ) (Asaad
pervasive developmental disorder. Children and Kahla, 2001). This is 33 items
below the age of 2 and above the age of 12 questionnaire that scores sleep habits of
were excluded. All children meeting the school children as reported by the parents
diagnostic criteria whose parents agreed to during the past week on a 3 point response
participate in the study were included. scale (often, sometimes, rarely).
A control group, formed of 10 healthy age The CSHQ yields both a total score and
and sex matched children from the eight subscale scores, reflecting the key
information bank of the sleep laboratory sleep domains that encompass the major
were obtained. The control group was medical and behavioral sleep disorders in
matched to the patients’ sex and age. this age group.
Evaluation: Sleep was also objectively assessed by a
A detailed clinical history was obtained polysomnogram performed at the sleep lab
from each child including family history, of the institute of psychiatry, Ainshams
history of perinatal complications, presence University. The child’s mother attended the
of a developmental delay and epilepsy. The study to comfort the child and put him/her
age of onset of the pervasive developmental to sleep. The study was also attended by a
disorders, the clinical features and any technician who assured that the electrodes
associated behavioral disturbances were were properly attached all through the study
noted. History of an associated medical or and readjusted them when needed. All
neurological condition in the patient or his medications, except antiepileptics in some
family was also included. patients were stopped before the study.
The severity of the PDD was further Statistics:
evaluated by the Childhood Autism Rating The data was collected and analyzed with
Scale (Schopler et al., 1993). Evaluation the aid of the program Statistical Package
included both an interview with the parent for Social Sciences (SPSS). Quantitative
(usually the mother and occasionally both data were described using range, mean and
parents) and observation of the child. standard deviation. Comparison between
CARS is a popular tool for screening the groups was done using Chi square test
autistic children. It was shown to correctly with Yate’s correction.
identify up to 98% of autistic subjects and
69% of the possibly autistic as autistic
57
Results: one patient. Of these, only 5 had an

available EEG. The abnormalities detected
The sample included 5 females and 10
males. Their age ranged from 2 to 11 years included bilateral temporal foci in one
patient, frontal focus in one patient,
with a mean age of 5.3 and a standard
deviation (SD) of 2.16. Thirteen were generalized epileptic activity in one patient
and no abnormality in two patients.
diagnosed as autistic disorder, one as Rett
syndrome and one as childhood Epilepsy was controlled in all patients with
no fits occurring in the last month prior to
disintegrative disorder.
the study.
Family and Past History:
Behavioral Disturbances:
None of the children in this study showed a
family history of autism. Perinatal In 7 patients (46.7%) the parents reported
complications were reported in 7 patients that the behavioral abnormality dated since
birth. Onset was before the age of two in
(46.7%) and these included Caesarian
section (2 patients), breech presentation (1 66% and was before the age of three for all
the patients in our study. Hyperactivity was
patient), history of neonatal ICU admission
(2 patients), delayed cry (2 patients), low reported in 8 patients (53.3%), aggression
in 3 patients (20%), and self injurious
birth weight (2 patients), neonatal cyanosis
(2 patients), and maternal gestational behavior in 6 patients (40%) in the form of
head banging or hand biting, but more
diabetes mellitus in one patient.
severe forms of self injury were not found.
The developmental history of these children The main clinical features of the cases are
showed normal developmental milestones outlined in Table 1.
till the onset of the behavioral disturbance
in six of the patients (40%). In the rest IQ:
(60%), developmental delay in at least one The IQ of patients in this study ranged from
area of development (motor, mental, social 24 to 75 with a mean of 46.2 and SD of
or language milestones) was reported. 14.7. Only one patient had an IQ above 70
The medical history of the children revealed while all other patients were mentally
subnormal. There was no significant
one case of Fragile X syndrome, one case
of infantile spasms (West syndrome), and correlation between perinatal complications
and severity of intellectual disability or
one child with history of ambiguous
genitalia and dysmorphic features in the incidence of epilepsy. At the same time
form of hypertolerism and low set ears. The there was no significant correlation between
incidence of epilepsy and perinatal
chromosomal count of this child was
normal. complications.
Epilepsy and Autism: Results of CARS:
Epilepsy was reported in 7 (46.7%) patients Childhood Autism Rating Scale (CARS)
was used to assess the severity of pervasive
in this study. Types of seizures included
generalized tonic clonic seizures in one developmental disorder in the children. The
severity of the condition showed no
patient, adversive fits in two patients,
infantile spasms in one patient, generalized significant correlation to gender. Ratings
for the various CARS subscales (table 2).
tonic seizures in one patient and absence in
58
Results of CSHQ: Results of Polysomnography:

The children’s sleep habits questionnaire As compared to age and sex matched
(CSHQ) showed that sleep duration was control, the polysomnogram has shown a
adequate in 93.3% of patients. Sleep related significant decrease in sleep efficiency,
anxiety was seen in 53.3% of patients and prolongation of stage 1 and 2 NREM sleep
night awakening in 40% of patients. and shortened REM sleep in patients with
Nocturnal enuresis was seen in 20% of PDD. The arousal index and number of
patients (3 patients) and increased awakenings were significantly higher in
movements during sleep in 26.7% (4 children with PDD than in the control
patients). Sleep bruxism was seen in 20% group. The PLMS index was also
of patients (3 patients), while sleep significantly higher in the patient than the
disordered breathing occurred in one patient control group. Three of the patients with a
(table 3). periodic leg movement during sleep index
(PLMS I) above one were reported by the
Parents reported that no or mild bed time
resistance was seen in 60% of patients parents to be hyperactive during the day
while three of the patients with a PLMS
while bed time resistance was moderate in
26.7% of cases and severe in 13.3% of index above one were reported by the
parents to have increased movement during
cases. Sleep latency was mildly affected in
73% of cases and moderately prolonged in sleep (table 5, figures 1 and 2).
6.,7% of cases. Severely increased sleep The results of our study showed a highly
latency was seen in 20% of patients. significant decrease in sleep efficiency and
Moderate day time sleepiness was seen in increase in arousal index in patients with
6.7% of patients while mild or no daytime moderate PDD than those with mild PDD.
sleepiness was seen in the rest of patients This is shown in table 6. However, no
(tables 4). correlation was found between IQ and
either of these sleep parameters. Also there
There were no significant correlations
between sleep anxiety or night awakening was no correlation between number of
awakening, stage 1, stage 2 or REM
and severity of PDD.
percentage with either the IQ and the
severity of PDD.
Table 1: The main clinical features of the patients
Present
Absent
No % No %
Epilepsy 7 46.7 8 53.3
Hyperactivity 8 53.3 7 46.7
Perinatal complications 7 46.7 8 53.3
Normal early development 6 40 9 60
Aggression 3 20 12 80
Self injury 6 40 9 60
59
Table 2: Occurrence of various symptoms in the patients as detected by CARS

Absent% Mild % Moderate% Severe%
Relating to people 13 46 33.3 6.7
Imitation 20 40 26.7 13.3
Emotional response 20 46.7 33.3 0
Body use 33.3 13.3 46.7 6.7
Object use 0 60 33.3 6.7
Adaptation to change 53.3 40 6.7 0
Visual response 20 46.7 33.3 0
Listening response 20 66.7 13.3 0
Touch, smell and taste 46.7 46.7 6.7 0
Fear or nervousness 26.7 40 26.7 6.7
Verbal communication 0 13.3 33.3 53.3
Nonverbal Communication 6.7 26.7 60 6.7
Level of activity 6.7 33.3 53.3 6.7
Intellectual response 6.7 26.7 53.3 6.7
General impression 0 53.3 40 6.7
Total score 0 60 40 0
This table shows the percentage of patients showing mild, moderate and severe symptoms in
each of the items of the childhood autism rating scale (CARS).
Table 3: The occurrence of sleep disturbances in patients as detected by CSHQ
Present Absent
No % No %
Adequate sleep duration 14 93.3 1 6.7
Sleep anxiety 8 53.3 7 46.7
Night awakening 6 40 9 60
Breathing disorders 1 6.7 14 93.3
Nocturnal enuresis 3 20 9 80
Increased movements 4 26.7 11 66.3
Sleep bruxism 3 20 12 80
60
Table 4: The severities of some sleep parameters in the patients as detected by CSHQ
Mild % Moderate % Severe %

Bed time resistance 60 26.7 13.3
Sleep latency 73.3 6.7 20
Day time sleepiness 93.3 6.7 0
Table 5: Polysomnography findings in patient and control groups
Cases Control
Sleep parameter t P Significance
Mean SD Mean SD
Sleep efficiency. % 85.83 4.93 92.66 2.17 4.09 <0.01 HS
Stage 1 % 2.91 0.58 2.03 0.23 4.50 <0.01 HS
Stage 2 % 52.24 1.07 51.20 0.83 2.59 <0.05 S
Stage 3 % 11.36 0.86 11.31 0.34 0.17 > 0.05 NS
Stage 4 % 11.80 0.73 11.96 0.40 0.62 > 0.05 NS
SWS % 22.96 1.23 22.88 0.51 0.19 > 0.05 NS
REM % 21.94 1.15 23.89 1.22 4.01 <0.01 HS
SWSL 27.86 2.97 29.20 1.22 1033 > 0.05 NS
REML 66.46 5.13 67.10 4.01 0.32 > 0.05 NS
REM D 17.48 0.79 17.90 0.44 1.48 > 0.05 NS
Arousal I 0.86 0.39 0.47 0.25 2.73 <0.01 HS
Number of awakenings 1.60 1.12 0.10 .316 4.09 < 0.01 HS
Apnea index 8.66 0.22 0.00 0.00 1.21 > 0.05 NS
Obstructive apnea 6.66 0.17 0.00 0.00 1.16 > 0.05 NS
Mixed apnea 1.33 5.16 0.00 0.00 0.81 > 0.05 NS
Apnea hypoxia index 5.33 0.20 0.00 0.00 0.81 > 0.05 NS
PLMS I 0.92 0.48 0.41 0.24 3.05 <0.05 S
This table compares the various sleep parameters detected by polysomnography in the patient
and control groups. REM= rapid eye movement; SWS= slow wave sleep; REML= rapid eye
movement latency. SWSL= slow wave sleep latency; REMD= rapid eye movement density
;arousal I = arousal Index. PLMS I= periodic leg movement during sleep index. P>0.05=
non significant; P<0.05= significant; P<0.01= highly significant
61
Figure 1: Comparison between various sleep stages in patients and controls
60
50
40
30
20
10
0
Stage 1 % Stage 2 % Stage 3 % Stage 4 % SWS % REM %
cases control
This figure shows the difference between percentages of different sleep stages in cases and
controls. Stages 1 and 2 of NREM sleep are significantly longer while REM sleep is
significantly shorter in cases than in control; SWS=slow wave sleep; REM= Rapid eye
movements
Figure 2 : Comparison between various polysomnographic parameters in patients and
control
PLMS I
Number of awakenings
Arousal I
REM D
REML
SWSL
Sleep efficiency. %
cases control
This figure shows the difference between different polysomnographic parameters in case and
control groups. A significant difference is seen in PLMS index, number of awakening, arousal
index and sleep efficiency; PLMS=periodic leg movements during sleep; REM D= Rapid eye
movements density, REML= rapid eye movements latency; SWSL= slow wave sleep latency.
62
Table 6: Polysomnographic findings in patients with mild and moderate autism

Mild Moderate
T P Significance
Mean SD Mean SD
Sleep Efficiency % 87.22 3.78 87.22 5.4 2.00 <0.05 S
Stage 1 % 2.72 0.45 2.72 0.67 1.63 > 0.05 NS
Stage 2 % 52.21 0.56 52.21 1.64 0.15 > 0.05 NS
REM % 22.10 1.21 22.10 1.12 0.61 > 0.05 NS
PLMS Index 0.9 0.54 0.9 0.43 0.18 > 0.05 NS
Arousal index 0.7 0.26 0.7 0.45 2.15 <0.05 S
Number of
1.33 1.11 1.33 1.09 1.14 > 0.05 NS
awakenings
This table compares the various sleep parameters detected by polysomnography in patients
with mild and moderate autism. A significant difference is seen in sleep efficiency and arousal
index. REM= rapid eye movement; PLMS I= periodic leg movement during sleep index.
P>0.05= non significant; P<0.05= significant
Discussion
The pervasive developmental disorders Tani et al., 2004) and no studies included
(PDD) are characterized by delay and children with childhood disintegrative
deviance in the development of social disorder or PDD-NOS. Rett syndrome was
skills, language and communication, and a more extensively studied (Segawa and
restricted behavioral repertoire (Sadock and Nomura, 1990, Espinar-Sierra et al., 1990,
Sadock, 2004). Children with PDD show a Fujino and Hashimoto 1990; Segawa and
number of associated behavioral Nomura, 1992; Marcus et al., 1994;
disturbances including sleep disturbances Kohyama et al., 2001).
that are quantitavely and qualitatively Our study aimed at describing sleep
different from those exhibited by normal
patterns in a sample of Egyptian children
children and those with other psychiatric with pervasive developmental disorders.
disorders (Patzold et al., 1998).
Children were assessed by means of a
Despite the high prevalence of sleep clinical history and CARS to diagnose their
disturbances in children with PDD, only a PDD and detect its severity. Children Sleep
few polysomnographic studies in autistic Habits Questionnaire was used to assess
children are available in the literature sleep subjectively. The parents are
(Tanguay, 1976; Thermulai et al., 2002; instructed to answer the questionnaire based
Sun et al., 2003) and the number of subjects on the child’s sleep habits in the last week.
in each of these studies is small (8 to 17 This allows evaluation of the child’s sleep
patients). An even smaller number of habits at home over a relatively long period
studies included polysomnography in of time which could not be assessed by the
Asperger syndrome (Godbout et al., 2000; polysomnogram alone. It is also useful for
63
evaluating events that do not occur every features could be detected.

day as nocturnal enuresis and other
Mental sub-normality is a common
parasomnias. This was followed by associated feature in PDD that has been
objective sleep assessment by
previously associated with disturbances in
polysomnography. This allowed studying sleep. Polysomnographic studies showed a
sleep architecture and verifying the data
reduction of REM sleep percentage, a
obtained by the questionnaire. prolonged latency of the first REM period,
Fifteen children (10 males and 5 females) a reduction of the number of REM cycles
were chosen randomly from the Child and the presence of undifferentiated sleep in
psychiatry out patient clinic of the institute mentally subnormal children. The lack of
of psychiatry, Ain Shams University high functioning autism in our sample, with
Hospital. The male to female ratio in our only one child with an IQ above 70, and the
sample is consistent with various small sample size made it impossible to
epidemiological studies showing a higher isolate the effect of mental retardation on
prevalence of autism in males (Fombonne, the results of our study.
1998). The relatively young mean age of
Epilepsy, a common co-morbid condition in
the patients (5.3 SD2.16) is well suited to patients with PDD, may also affect sleep
the aim of this study as sleep problems are
pattern. In this study, 43.3% of children
reported to be more common in younger were reported to have epilepsy. Although
children (Patzold et al., 1998). Of the
chronic epilepsy was previously reported to
children in this study 13 were diagnosed as cause disturbances in sleep architecture
autistic disorder, one met the criteria for (Shouse, 1994), most of the effect was
childhood disintegrative disorder and one
attributed to seizures occurring on the night
was diagnosed as Rett syndrome. of the study. There is no generalized
Two of the children in our study had a agreement considering the influence of
known associated medical condition. One seizures taking place prior to the night of
of the children had Fragile X syndrome and the study on the sleep pattern (Lopez
the other West syndrome. Another child Gomez et al., 2004). Most of our patients
had dysmorphic features and ambiguous are well controlled and none of them had
genitalia which are highly suggestive of a any seizure in the month before the study,
chromosomal abnormality. Chromosomal thus the effect of epilepsy on sleep
count was normal in this child but a more architecture is expected to be minimal. Five
detailed study for structural chromosomal of our patients were on antiepileptic
abnormalities was not available and these medication on the time of the study
can not be excluded. These findings reflect including valproate and carbamazepine, and
the heterogeneous nature of autism and are ACTH injections. Carbamazepine was
to be expected in any clinical sample. Both previously shown to decrease REM sleep as
fragile X and West syndrome were well as the frequency and duration of
previously associated with sleep periods of wakefulness while sodium
abnormalities. For both our patients, valproate increases deep sleep in children
different sleep parameters were within one (Nicholoson, 1994). Most available studies
standard deviation from that obtained for on the effects of antiepileptic medications
the PDD group as a whole, and no specific on sleep were carried on epileptic patients
64
and it is not clear whither the effects of Sleep related anxiety was reported in 53%
these drugs are due to a primary effect on of patients in our study and this showed no
sleep architecture or to suppression of correlation with severity of autism. Anxiety
epileptic activity. All other drugs taken by is a prominent feature in many children
the patients were stopped at the night of with autism and may contribute to sleep
performing polysomnogram. However, the problems (Richdale, 1999). The role of
chronic effects of medication or effects of anxiety was believed be more in older
withdrawal of medications on sleep can not children and those with a higher IQ
be eliminated. (Richdale and Prior, 1995) and in patients
with Asperger syndrome (Tani et al., 2004).
Children in our study were classified as
mildly autistic or moderately autistic by the The result of our study indicates a high
CARS. The lack of severely affected level of anxiety even in younger children
with low IQ.
patients is probably due to the small sample
size. The most commonly encountered Seven (43.3%) of the children in our study
symptom was disturbance in verbal were reported to have a paroxysmal event
communication (severely affected in 53.3% during sleep by the parents. This is
and moderately affected in 33.3%). This consistent with a large study conducted by
could be explained by the fact that delayed Yu and Miles on 163 patients with autism
language development is the most common in which parasomnias occurred in 77.3% of
presenting feature of autism (Campbell and patients (Yu and Miles, 2002). In our study
Shay, 1995) and the most alarming to the three cases of sleep bruxism (20%), three
parents. cases of nocturnal enuresis (20%), and four
cases (26.7%) of increased movements
In previous studies parents reported a
variety of sleep disturbances in autistic during sleep were reported by the parents.
The polysomnogram showed a significant
children, with disorders in initiation and
maintenance of sleep being the most increase in PLMS index in patients with
PDD compared to control.
common. These manifested as extreme
sleep latencies, shortened sleep times and Bruxism, or the intermittent grinding or
frequent awakening (Thermulai et al., clenching of teeth during sleep is a common
2002). However, most of the patients (60%) phenomenon. Yu and Miles found bruxism
in our study were reported to have within in 24.5% of patients with autism (Yu and
normal sleep latencies by their parents and Miles, 2002) which is consistent with the
26.7% reported a moderate increase in sleep results of our study. The exact etiology of
latency. The parents also reported that bruxism is not known, however,
93.3% had adequate sleep hours although pharmacologic evidence suggests that the
40% of the children woke up at least once central dopaminergic system may be
during the night. It is not clear whither the involved in the pathophysiology of sleep
differences between the results of our study bruxism. Recent studies indicate that
and previous reports reflect a true difference bruxism may represent a mild manifestation
in the pattern of symptoms, a cultural of REM sleep behavior disorder (RBD).
difference in sleep habits or a difference in This is particularly interesting in the light of
parental report and reaction to their the recent detection of RBD, another
children’s behavior. dopamine dependent disorder, in five
65
children with autism and insomnia 1994). Abnormalities in dopamine turnover

(Thermulai, 2002). have been detected in patients with PDD
Periodic limb movements are defined as (Takahashi et al., 2001). A
hyperdopaminergic function of the CNS
involuntary repetitive movements that occur
primarily during stage 1 and 2 sleep. Our might explain the hyperactivity and
stereotyped behavior in autism and the
study has shown a significantly higher
PLMS index in children with PDD than the response to dopamine receptor antagonists
as haloperidol (Kaplan and Sadock, 1998).
control group. However, it was not elevated
enough to diagnose PLMS in any of these On the other hand, PET studies have
demonstrated low medial prefrontal
children. Previous studies have also shown
an increased incidence of PLMS in children dopaminergic activity in some patients with
with autism (Thermulai, 2002, Schreck, autism (Herring et al., 1999).
2004). PLMS was previously associated Nocturnal enuresis was found in three
with ADHD and Sun et al reported PLMS (20%) of the children in our study. High
in a child with autism and comorbid ADHD frequencies of nocturnal enuresis were
(Koherman and Carney, 2000; Sun et al., previously reported in children with PDD
2003). Of the seven children with an (Yu and Miles, 2002; Sun et al., 2003). The
elevated PLMS index in our study, three higher frequency of nocturnal enuresis in
were reported by the parents to have children with PDD can thus be explained as
increased movements during sleep, but no part of the general delay of development in
statistically significant association was these children. The findings in our study are
found between increased daytime activity consistent with this explanation as the three
and PLMS index. enuretic children showed delayed
Although these problems appear as separate developmental milestones.
items, sleep bruxism, PLMS and RBD are Our study has shown a highly significant
all related to disturbed motor control during decrease in sleep efficiency and increase in
sleep. This raises the probability of a night awakening in patients with PDD than
specific type of sleep related impairments in in the control group. This is in agreement
CNS motor areas for children with autism with most of the previous studies on autism
and mental retardation (Schreck and (Wiggs and Stores, 2004). Our study also
Mulick, 2000). Other features that may showed a highly significant decrease in
reflect abnormal motor control during sleep sleep efficiency and increase in arousal
were previously reported in children with index in patients with moderate autism than
autism, including increased dispersed rapid those with mild autism, but no correlation
eye movements occurring out of bursts of with IQ. The correlation between these
rapid eye movements, an increased amount parameters and the severity of autism may
of muscle twitches as well as presence of reflect either a true worsening of the sleep
rapid eye movements during stages 1 and 2 efficiency with more severe autism, or an
of NREM sleep (Diomedi et al., 1999). increased sensitivity of more severely
Bruxism may be related to hyper function autistic children to the changes in
environment.
of dopamine, while PLMS may be related
to hypofunction of dopaminergic Sleep architecture showed prolonged stage
neurotransmission (Montplaisir et al., 1 and 2 NREM sleep percentages and
66
decreased REM sleep percentage as of autism. In addition sleep problems have

compared to control. Changes in sleep been consistently shown to negatively
architecture were previously reported in influence learning rate and cognitive
children with autism, but there are some performance in typically developing
controversies in the results of different children and adults. Eliminating sleep
studies.15,16 Sun et al found a decreased problems, whatever their cause may aid
REM percentage which is in agreement these children achieve their full potential.
with the results of our study.18 Unlike
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Address of Correspondence: Neuropsychiatry Department

Faculty of Medicine
Gaber A.
Lecturer of Neurology Ain Shams University
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70
Acute Phase Reactants (Proteins) in Schizophrenia

Okasha, T., Elgamel, O. and Ashry, H.
Abstract
A great number of studies show biological alterations in patients with schizophrenia, but
many of these data are conflicting. Schizophrenia is a vastly heterogeneous disorder, most
likely not caused by one etiological factor, but rather due to a complex network of different,
interacting pathogenic influences. There are changes occurring in the immune system as well
as the acute phase reactants. This study was carried out on 25 patients diagnosed as non
paranoid schizophrenia and 10 controls. The results showed that there is no difference in the
scores of the patients and controls. These results show that the process of schizophrenia is
more on an immunological level than on an inflammatory level. Further in depth studies on
these changes in recommended.
Introduction
Acute-phase reactants (proteins) are a class referred to as a negative acute phase protein
(Pepys and Hirschfield, 2003).
of plasma proteins whose plasma
concentrations increase (positive acute Measurement of acute phase proteins is a
phase proteins) or decrease (negative acute useful marker of inflammation.
phase proteins) in response to 1) CRP is a member of the class of acute
inflammation. This response is called the
phase reactants as its levels rise
acute-phase reaction. The levels of these dramatically during inflammatory processes
proteins alter in response to tissue injury,
occurring in the body. It is thought to assist
inflammation, malignancy and in complement binding to foreign and
psychological conditions.
damaged cells and affect the humoral
Local inflammatory cells (neutrophil response to disease. It is also believed to
granulocytes and macrophages) secrete a play an important role in innate immunity,
number of cytokines into the bloodstream, as an early defense system against
most notable of which are the interleukins infections. C-reactive protein is a test of
IL-1, IL-6 and IL-8, and TNF-alpha. value. Marked rises in CRP reflect the
presence and intensity of inflammation.
The liver responds by producing a large
number of acute-phase reactants, most ESR provides a non-specific screening test
notable of which are: C-reactive protein for the presence of an acute phase reaction.
(CRP), mannose-binding protein, alpha 1-
Although the ESR and CRP may be
antitrypsin, alpha 1-antichymotrypsin, alpha valuable indicators of an acute phase
2-macroglobulin, some coagulation factors
response, normal results do not exclude
(Fibrinogen, prothrombin, factor VIII, von active disease.
Willebrand factor, plasminogen),
complement factors, ferritin, serum amyloid 2 Mannose-binding proteins is a soluble
P component, serum albumin factor in the human body that binds
concentrations fall in acute disease states. mannose residues to pathogens. It is part of
For this reason albumin is sometimes the immune system's defenses against
71
bacteria. It is produced in the liver as a component (AP). AP is thought to be an

response to infection, and is part of many important contributor to the pathogenesis of
other factors termed acute phase proteins. a related group of diseases called the
Mannose-binding protein may also be amyloidoses. (Retrieved from
referred to as mannan binding lectin. http://en.wikipedia.org/wiki).
3 Alpha 1-antitrypsin or .1-antitrypsin A great number of studies show biological
(A1AT) is a serine protease inhibitor alterations in patients with schizophrenia,
(serpin). It protects tissue from enzymes but many of these data are conflicting.
from inflammatory cells, especially Schizophrenia is a vastly heterogeneous
elastase, and is present in human blood at disorder, most likely not caused by one
1.5 - 3.5 gram/liter. A1AT is a 52 kDa etiological factor, but rather due to a
serine protease inhibitor, and in medicine it complex network of different, interacting
is considered the most prominent one, given pathogenic influences. Variable clinical
the fact that the words .1 antitrypsin and pictures may reflect different etiological
protease inhibitor (Pi) are often used factors. In a comprehensive theory of the
interchangeably. origin of schizophrenic disorders, genetic
4 Alpha 1-antichymotrypsin is a alpha and environmental influences cause
changes in neuronal development which
globulin glycoprotein and serpin
result in functional alterations of different
5 Alpha-2 macroglobulin is a large plasma neurotransmitter systems. Immunological
protein found in the blood. It is produced by research in schizophrenia was initially
the liver, and is a major component of the based on the "infection hypothesis" which
alpha-2 band in protein electrophoresis. was triggered by observing schizophrenia-
6 Fibrin is a protein involved in the clotting like psychoses after influenza pandemic.
of blood. Fibrin is made from its zymogen Numerous immunological studies focusing
fibrinogen, a soluble plasma glycoprotein on antibodies against specific viruses,
that is synthesized by the liver. unspecific antibodies and different other
immune-phenomena were carried out in
7 The complement system is a biochemical schizophrenia patients. Although the
cascade of the immune system that helps variability of the results from these studies
clear pathogens from an organism. It is is strikingly high, subgroups of patients
derived from many small plasma proteins with schizophrenia show an activated
that work together to form the primary end inflammatory response system with
result of cytolysis by disrupting the target increased levels of proinflammatory
cell’s plasma membrane.The actions of the cytokines and acute phase proteins.
complement system affects both innate Furthermore, some investigations find
immunity and acquired immunity. changing activities in the T-cell system
Activation of this system leads to cytolysis, with a shift of TH-1 to an increased TH-2
chemotaxis, oposonization, immune activity. Endocrinological factors which
clearance, and inflammation, as well as the may play a relevant role in the
marking of pathogens for phagocytosis. etiopathogenesis of schizophrenia include
8 Serum Amyloid P component (SAP) is sex hormones and all changes caused by
the identical serum form of Amyloid P stress or other influences which are directly
related to the HPA-axis. Alterations of the
72
immune and the endocrinological systems studies show that these forms of
might be caused by environmental factors schizophrenia are richer in structural brain
like infections or exogenous stress. Due to changes as well as brain imaging changes
the intensive interaction between the central and genetic findings which will lead them
nervous system, the immune system and to have more immunological and
different hormones the "development of a inflammatory changes, while the paranoid
pathology" like schizophrenia can be seen form is more environmentally determined.
in an integrative but multifactorial fashion.
All laboratory tests were done within 48
The clinical manifestation, the severity and hours of admission after being diagnosed
the course of the disease might then be
and before starting treatment.
modulated by genetic vulnerability, the
time of the "primary insult" -- which could All patients were not taking any medication
be an infection or psychological stress -- for at least 6 weeks and did not receive any
and its neuronal localization and intensity. ECT sessions at least 6 months prior to
Different compensatory and joining the study.
decompensatory mechanisms in later life Informed consent was taken from patients
very likely play a crucial role for the further or their families to join the study.
course of the disorder (Sperner, 2005)
The entire patient group had no co-morbid
In this study we tried to evaluate the levels medical illness, or co-morbid axis 1
acute phase proteins in a sample of psychiatric diagnosis, or substance use
Egyptian patients suffering from disorder.
schizophrenia.
A control group selected from the
Subjects and Method employees of the institute of psychiatry
This study was carried out at the Institute of were matched to age, sex and educational
Psychiatry, Ain Shams University Hospitals level of the patient group and had no
over a period of 5 months. The study medical illness, or psychiatric morbidity
included 25 patients (18 males and 7 assessed by the general health questionnaire
females), as well as 10 controls (4 females (GHQ) (Goldberg, 1988) in its Arabic
and 6 males). The inclusion criteria for the version (Okasha, 1988). The entire control
patients were: group gave their consent to participate in
study.
Inpatients at the Institute of Psychiatry Ain
Shams University Hospitals. ESR, C reactive protein, Alpha 1
antitrypsin, Fibrinogen and Complemet 3
Ages between 21 and 41 years were evaluated for all patients and controls,
Both males and females patients were however, Haptoglobin, Alpha 1
included antichymotrypsin and Ceruloplasmin from
Patients were diagnosed as suffering from the acute phase reactants were not assessed
due to unavailability of the kits at the time
non-paranoid schizophrenia according to
the ICD-10 Research and Diagnostic of the study.
Criteria (1993) using the ICD-10 symptom All laboratory investigations were carried
checklist (1994). Non-paranoid out at the Institute of Psychiatry laboratory,
schizophrenia was chosen as most of the
73
where ESR was measured in mm/hr at 20 Regarding the ESR levels the mean level in
degrees + or – 3 degrees. the patient group was 14.84 (±11.14), while
C3 and AAT were estimated by Radial that of the control group was 13.30
(±11.68) with no significant difference.
immuno diffusion (RID) plates
(manufactured by Biocientifica S.A.) Comparing the results of both groups as
Serum samples were collected and stored at regard the acute phase reactants, we found
– 20 oC using Berne Method (1974). that the C reactive protein was negative in
C- reactive protein was detected by Latex 24 patients out of the 25 and was also
negative in the control with no significant
Seralogy Test (Avitex) from omega
diagnostics LTD when latex suspension difference.
coated with antibodies to human CRP is The fibrinogen mean level result was 2.88
mixed with serum, clear agglutination is g/l (±1.60) in the patient group and 2.64 g/l
seen within 2 minutes (Ward, 1975). (±0.89) in the control group with no
Erythrocyte sedimentation rate was done significant differences between both
groups.
using the Westergren method.
There was also no significant difference
Fibrinogen was assayed by Multifibrin U
test (Dadebehring) using fibrintimer. between both groups regarding the mean
level of C3, which was 144.80 mg/dl
Results (±30.33) in the patient group and 145.10
In this study the mean age for the patient mg/dl (±52.12) in the control group.
group was 27.56 (±4.37), while that for the Similarly, no significant differences were
control group was 27.30 (±4.40). Out of the found between both groups regarding the
25 patients 18 were males (72%) and 7 mean level of Alpha 1-antitrypsin (A1AT),
were females (28%), while in the control which was 173.96 mg/dl (±33.43) in the
group, out of the 10 controls 6 males (60%) patient group and 173.10 mg/dl (±44.25) in
and 4 females (40%) (Figures (1) and (2) the control group (Table (1) and Figure (3)).
respectively).
Figure (1)
Distribution by Gender
F, 7, 28%
M, 18, 72%
74
Figure (2)
Control Distribution by Gender
F, 4, 40%
M, 6, 60%
Table (1) shows the comparison of the different mean levels of acute phase reactants
(ESR, fibrinogen, C3 and A1AT) between both the patient and the control groups.
Item Patient group Control group

ESR 14.84 (±11.14) 13.30 (±11.68)
Fibrinogen (g/l) 2.88 (±1.60) 2.64 (±0.89)
C3 (mg/dl) 144.80 (±30.33) 145.10 (±52.12)
A1AT (mg/dl) 173.96 (±33.43) 173.10 (±44.25)
Figure (3) shows the differences in mean levels of age, ESR, fibrinogen, C3 and A1AT in
both the patient group and the control group with no significant difference between both
groups.
Figure (3)
Patient vs Control Means

173.96
173.10
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(mg/dl)
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75
Discussion
difference in patient sample where they
A working model to understand
schizophrenia would help understanding the included all subtypes of schizophrenia,
while in our study non-paranoid
process of the disorder. It is suggested that
DNA, gene expression, viruses, toxins, schizophrenia was chosen as most of the
studies show that these forms of
nutrition, birth injury and psychological
experiences all play are role in the aetiology schizophrenia are richer in structural brain
changes as well as brain imaging changes
of schizophrenia. These aetioligical factors
lead to the pathophysiology of the disorder and genetic findings which will lead them
to have more immunological and
mainly affecting the brain development
which includes neuron formation, inflammatory changes, while in comparison
migration, pruning, and apoptosis. This will the paranoid form of schizophrenia is more
environmentally determined.
in turn lead to affection of the neural
connectivity and communication causing An acute phase protein (AP) response has
impairment in the fundamental cognitive been reported in major depression. In order
process (thinking) causing impairment in to examine whether an AP response occurs
the second order cognitive processes which in other psychiatric disorders, such as
include attention, memory and language. schizophrenia and mania, Maes etal. (1997)
All this will lead to the appearance of the measured plasma acute phase proteins such
symptoms of schizophrenia. This working as haptoglobin (Hp), immunoglobulin G
model helps us take into account all the (IgG), IgM, fibrinogen (Fb), complement
different factors that may be involved in the component 3 (C3C), C4, alpha 1-antitrypsin
schizophrenia process (Okasha, 2006). (alpha 1 AT), alpha 1-acid-glycoprotein
There is a growing body of opinions (alpha 1S) and hemopexin (Hpx), in 27
schizophrenic, 23 manic, 29 major
affirming schizophrenia is a spectrum
disease covering several conditions of depressed and 21 normal subjects.
Schizophrenic patients had significantly
different aetiology. Various studies have
recently shown immunological changes in higher plasma Hp, Fb, C3C, C4, alpha 1S
and Hpx than normal controls. Manic
schizophrenia, and an immune pathogenetic
hypothesis has gained acceptance. In a subjects showed significantly higher plasma
Hp, Fb, alpha 1S and Hpx than normal
study carried out by Mazzarello etal.
volunteers. Depressed subjects had
(2004), they analyzed with a relatively wide
approach the immunological dysfunction in significantly higher plasma Hp, Fb, C3C,
C4 and alpha 1S than normal controls.
schizophrenia, focusing in particular on
lymphocytes morphology and subset Overall, the above disorders in AP reactants
were more pronounced in schizophrenic
distribution. They performed in peripheral
blood samples of 24 schizophrenic patients, than in depressed subjects. No significant
differences in the above AP reactants could
assessment of acute phase proteins and
immunological variables and found an be found between normal volunteers, and
schizophrenic, manic or depressed patients
increased serum CRP concentration
(mg/ml), which is different from the results who underwent chronic treatment with
of our study since the timing of sampling psychotropic drugs. The results suggest that
not only major depression but also
was different in both studies. Also, the
schizophrenia and mania are accompanied
76
by an AP response, and that the latter may measured by rocket immunoelectrophoresis

be suppressed by (sub) chronic treatment in agarose gel. Increased levels of serum
with psychotropic drugs. alpha 1-antitrypsin, alpha 2-macroglobulin,
haptoglobin, ceruloplasmin, and thyroxine-
Chiu and his colleagues (1999) studied a
common polymorphism in the alpha1- binding globulin were observed in both
series of patients when compared to their
antichymotrypsin (ACT) gene which is
associated with Alzheimer's disease. ACT respective controls. Albumin, transferrin
and retinol-binding protein levels were
is also a trophic factor in the hippocampal
neurons. In order to examine if the ACT reduced in patients in both series.
Hemopexin levels were increased only in
gene plays a role in the pathogenesis of
schizophrenic disorders, patients (n = 175) the acutely ill patients while complement
and control subjects (n = 114) were C3 was decreased in the chronically ill
patients. No changes were observed in the
genotyped for ACT. The results
demonstrated no association between Gc-globulin levels of all groups of patients.
With the exception of complement C3, the
schizophrenia and cognitive deficit in
schizophrenia and ACT polymorphism. The changes observed in the levels of these
serum proteins were appropriate for that of
data suggest that the ACT gene is not of
major importance for the genesis of an acute phase response. Differences from
our study are due to the different laboratory
schizophrenia. In our study we were not
able to study the antichymotrypsin since the methods used and the sample was carried
out on Egyptian patients who have a
laboratory kits were unavailable but from
different ethnic background and may show
the negative results we reached in the other
acute phase proteins we can say that the a different response to environmental
stressors.
results would have been similar for
antichymotrypsin. We can conclude from this study that the
In a study carried out by Wong et al. (1996) acute phase proteins are not the main
changes taking place in patients with
measuring the changes in the concentration
of some serum acute phase proteins (alpha schizophrenia as there is no acute
inflammatory response, but rather an earlier
1-antitrypsin, alpha 2-macroglobulin,
complement C3, haptoglobin, and more subtle immunological change
which does not directly affect the acute
ceruloplasmin, transferrin, albumin and
phase proteins or elevate them to a level
hemopexin, thyroxine-binding globulin,
retinol-binding globulin, plasminogen and which can be considered as an acute
inflammatory response. The differences in
Gc-globulin) are reported in two separate
series of Chinese, male schizophrenic the results obtained from different studies
suggests that there is a deficiency in the
patients and healthy controls. In the first
series, 41 healthy blood donors and 98 process of investigating the acute proteins,
also there has been a dramatic shift to
schizophrenic patients in different stages of
the disease were investigated. The second studying the different genes involved in
schizophrenia and their polymorphism.
series consists of a random sample of 50
acutely ill schizophrenic patients and a Limitations of the study
second group of healthy subjects. The
The limitation of this study rests in three
concentrations of these serum proteins were main domains, first the number of patients
77
was limited in order to generalize these Mazzarello, V., Cecchini, A., Fenu, G.,
findings on all patients, secondly the Rassu, M., Dessy, LA., Lorettu, L. and
patients should be in acute relapse of Montella, A. (2004): Lymphocytes in
schizophrenia when being assessed, and schizophrenic patients under therapy:
thirdly a wider evaluation of the acute serological, morphological and cell subset
phase proteins and immune system changes findings. Ital J Anatomy Embryol. Jul-Sep;
should be carried out in future studies. 109(3) pp 177-188
References Okasha, A., Kamel, M., Fares, R. and
Abdel Hakiem, R. (1988): An
Berne, G.H. (1974): Clin. Chem. 200, 61-
89 epidemiological study of depressive
symptoms in rural and urban population in
Chiu, HJ., Hong, CJ., Chen, JY., Wang, Egypt. Egypt. Journal of Psychiatry.
YC., Lin, CY., Bai, YM., Song, HL., Lai,
Okasha, A. (2004): Plenary lecture at the
HC. And Tsai, SJ. (1999): Alpha-1-
antichymotrypsin polymorphism in WPA international congress, Florence,
Italy.
schizophrenia: frequency, age at onset and
cognitive function. Neuropsychobiology Pepys MB and Hirschfield GM. J Clin
40(2) pp71-74 Invest (2003): 111(12): 1805-12 Retrieved
from “http://en.wikipedia.org/wiki”
Goldberg, D. and Williams, P. (1988): A
Users Guide to the General Health Sperner, B. (2005): Biological hypotheses
Questionaire. Windor, Berkshire: NFER - of schizophrenia: possible influences of
Nelson. immunology and endocrinology. Fortschr
Neurol Psychiatr Nov;73 Suppl 1 pp 38-43
ICD - 10 Classification of Mental and
Behavioural Disorders. Diagnostic Ward A.N. and Cooper E.M. (1975)
Criteria for Research (1993): WHO clinical chem. Acta 81,75
Geneva.
Wong, CT., Tsoi, WF. and Saha, N.
ICD - 10 Symptom Chechlist of Mental (1996): Acute phase proteins in male
Disorders (1994): WHO Geneva. Chinese schizophrenic patients in
Singapore. Schizophr Res. Nov 15; 22(2):
Janca, A., Ustrin, B., Isaac,M., Van
pp 165-171
Drimmelen, J. and Dittman, V. (1994):
ICD – 10 Symptom Checklist for Mental Authors
Disorders. Division of Mental Health
Okasha T.
World Health Organization - Geneva -
Assistant Professor of Psychiatry,
Version, 1.1 Institute of Psychiatry,
Maes, M., Delange, J., Ranjan, R., Ain Shams University
Meltzer, HY., Desnyder, R., Cooremans,
Elgamel O.
W. And Scharpe, S. (1997): Acute Phase Consultant Clinical Pathology,
Protiens in schizophrenia, mania and major
Institute of Psychiatry,
depression: modulation by psychotropic Ain Shams University.
drugs. Psychiatry Res. Jan 15; 66(1): 1-11
78
Address of Correspondence:
Ashry H.
Specialist Clinical Pathology, Dr. Tarek A. Okasha
3,Shawarby Street, Kasr El Nil, Cairo,
Ain Shams University. Egypt.
E-mail: [email protected]
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79
Emotional Disturbances and Quality of Life in Type-1 Diabetic

Children and Adolescents: Relation to Glycemic Control and
Microvascular Complications
El Laboudy M. and Ramy H.
Abstract
Emotional disturbances, specifically depression and anxiety, constitute a major health
problem in type -1 diabetic children and adolescents with marked effect on the quality of life,
metabolic control and response to treatment among them. The study aims to study the
frequency and severity of depressive and anxiety symptoms and their impact on quality of life
in children and adolescent with type-1 diabetes mellitus (DM). The relation of these
symptoms to glycemic control and diabetic microvascular complications will be also studied.
The present study was conducted on 94 patients with type-1 DM (48 males and 46 females)
with a mean age of 12.5 ± 3.8 years attending the Pediatric Diabetes Clinic, Children's
Hospital, Ain Shams University. The patients were classified according to the degree of
glycemic control (as reflected by glycated hemoglobin: HbA1C levels) into: well-controlled
group (HbA1C: 6-7.5%), fairly-controlled group (HbA1C: > 7.5-8.5%) and poorly-controlled
group (HbA1C: > 8.5 %). In addition to full history taking and thorough clinical examination,
all patients were assessed using the Pediatric Quality of Life Inventory (Peds QL Generic
Core scale) and the Pediatric Quality of Life Diabetes Module scale. Emotional disturbances
were assessed using Children’s Manifest Anxiety (CMA) scale and Children Depression
Inventory (CDI). The poorly controlled group of diabetic patients experienced the worst
quality of life and had significantly higher anxiety and depressive symptoms in comparison to
the other groups with a positive correlation to disease duration, diabetic microvascular
complications and frequency of hospital admission. The well-controlled group with tight
glycemic control receiving intensive insulin therapy and kept on frequent home monitoring of
blood glucose experienced higher worry and anxiety module scores than the fairly-controlled
patients with a subsequent negative impact on the quality of life. The results of the present
study indicate the importance of adequate metabolic control of DM and proper care of
diabetic microvascular complications for the improvement of psychological well-being and
quality of life in diabetic children and adolescents. They also point to the benefits of using an
intermediate regime of glycemic control rather than the very tight regime. Regular psychiatric
evaluation and psychosocial support of diabetic patients and their parents should be
considered and encouraged as an integral part of diabetes care.
Introduction
complications (Sperling 1997, Johnson
Type -1 diabetes mellitus (DM) is the most
frequent endocrine– metabolic disorder of and Perwein, 2001) The prevalence of
type-1 DM among Egyptian school –age
children and adolescents with important
consequences on physical, emotional and children was estimated to be between
1.09/1000 to 2/1000 (Ghali et al 1985, Ali
social development due to the disease
process, treatment schedule and et al 1986, Ghali et al 1990, and Salem et
al 1990). The deleterious impact of type-1
80
DM on functional health should not be 2001, Hahl et al 2002, and Cameron

underestimated since poor functional health 2003).
in children and adolescents with type -1 Consequently, the present study was
DM invariably leads to negative clinical
designed to evaluate the emotional status
and behavioral outcomes (American and health–related quality of life in children
Diabetes Association, 2004) and adolescents with type -1 DM, and to
The prevalence of emotional disturbances provide psychological support for these
(depression and anxiety) is much higher in patients and their families accordingly.
diabetic patients than the general population
Patients and Methods
with a marked impact on the control of
diabetes and quality of life among these This randomized study was conducted on
patients (Sadock and Sadock, 2003) 94 patients with type-1 DM (48 boys and 46
Traditional outcome measures (morbidity girls), aged 6-18 years with mean age of
and mortality) had been found to be of 12.5 ± 3.8 years. They were attending the
limited value when assessing the effect of Pediatric Diabetes Clinic, Children's
chronic disease like diabetes on physical or Hospital, Ain Shams University during the
psychological status of children and their period between January 1 st, 2004 till
families, while measures of quality of life December 31 st, 2005. The disease duration
(QoL) may provide a comprehensive ranged from 6 months to 15 years with a
account of such effect (Anderson et mean disease duration of 8.6 ± 5.2 years.
al,2003). The patients were classified into two groups
according to disease duration:
Health-related quality of life (HRQoL)
refers to the physical, psychological and Group (A): included 48 patients with
social domains of health that are influenced disease duration less than 5 years. This
by a person's experience, beliefs, group composed of 28 boys and 20 girls
expectations and perceptions (Varni et al with a mean age of 8.4 ± 2.5 years.
1999, Fayers and Machi,2000).The Group (B): included 46 patients with
HRQoL in children and adolescents with disease duration equal to, or more than 5
type-1 DM could be influenced by many years. This group composed of 20 boys and
factors including the disease process, lack 26 girls with a mean age of 14.2 ± 4.8
of glycemic control, physical years.
complications, frequent hospital admission,
complexity of treatment regimens and The patients were further classified
psychosocial compromise (Brown et al according to the degree of glycemic control
2002 and Varni et al 2003). Emotional as reflected by the mean glycosylated
distress with anxiety and/or depression in hemoglobin (HbA1C) levels into:
type -1 DM may arise from the lack of Group I: included 24 patients with good
knowledge about disease itself, the fear and glycemic control (mean HbA1C was 6.0 –
worry of patients and their parents, the strict 7.5% during the period of the study). This
dietetic programs, the frequent home group comprised 14 boys and 10 girls a
monitoring of blood glucose, and the mean age of 10.2 ± 4.6 years.
intensive insulin therapy aiming for tight
glycemic control (Hanna and Gutherie
81
Group II: included 32 patients with fair Diagnostic Group was used for
glycemic control (mean HbA1C was > 7.5 – determination of HbA1C every 12 weeks.
8.5%). This group comprised 14 boys and Glycemic control in relation to HbA1C was
18 girls with a mean age of 11.9 ± 3.5 considered to be optimal (good) if HbA1C
years. is 6-7.5% suboptimal (fair) if HbA1C is
>7.5-8.5% and high risk (poor) if HbA1C >
Group III: included 38 patients with poor
glycemic control (mean HbA1C was above 8.5% of adult Hb (ISPAD, 2000).
8.5 %). This group included 20 boys and 18 Quantitative determination of urinary
girls with a mean age of 13.2 ± 3.8 years. albumin excretion rate (Test of
Patients who had, in addition to DM, Microalbuminuria): Timed-overnight urine
sample was collected by the patient in a
another chronic disease which may affect
plain container and taken to the hospital at
the quality of life as rheumatic heart
disease, bronchial asthma or chronic blood the morning. Part of the fresh sample was
examined to exclude urinary tract infection
disease were excluded.
and overt proteinuria. Urinary albumin
All patients were subjected to: excretion (UAE) was assessed using the
Comprehensive history taking with quantitative immune turbidimetric assay,
particular emphasis on the age, duration of and the test was repeated on three occasions
illness, dose and regimen of insulin therapy, one-month apart. Microalbuminuria (as an
frequency of hospital admission, number of indicator of diabetic nephropathy) was
hypoglycemic attacks or diabetic defined as when two out of three samples
ketoacidosis (DKA) during the last year, showed an albumin excretion of 30-
and socioeconomic history (number of 300ug/mg creatinine (ISPAD, 2000).
family members, job of the parents, degree Fundus examination was routinely done
of education, housing condition, income every 6 months to exclude diabetic
and resources). retinopathy for all patients. Patients with
Thorough physical and neurological suspected retinopathy were subjected to
examination including weight, height, body fundus photography to confirm diagnosis.
mass index (BMI), sites of insulin injection, Quality of Life Assessment:
chest, cardiac and abdominal examination.
Assessment of health-related quality of life
Full neurological assessment to exclude
peripheral neuropathy was also included. (HRQoL) was performed using the
Pediatric Quality of Life Inventory
Laboratory investigations: to assess the Version 4.0 (Peds QL Generic Core Scale).
degree glycemic control and diabetic It is a brief standardized assessment
complications: instrument developed by Varni et al., 1999.
Glycosylated hemoglobin (HbA1C): The Peds QL Generic Core scale
Determination of the mean HbA1C was systematically assesses patient's and
measured as a reflection of long –term parents' perception of HRQoL in pediatric
glycemic control over the preceding 10-12 patients with chronic health condition. It
weeks. High performance liquid includes a physical summary scale (items
chromatography (HPLC) using Globin assessing the child's functional status in
Chain Analyser supplied by Bio-Rad activities of daily living) and psychosocial
82
summary scale (sum of emotional, social On the other hand the Children Depression
and school scales). Emotional scale assesses Inventory (CDI) was designed by Abdel
the child's emotional distress; social scale Fatah(1989). It is an Arabic version
assesses interpersonal functioning in peer developed from the children's manifest
relations, while school scale assesses depression scale by Maria Kovacas, which
problems with cognitive performance and was adapted from the well-known adult
school attendance. The sum of the physical scale (The Beck Depression Inventory). The
summary scale and the psychosocial CDI is a 27 item –self report measure of
summary scale is the total score. mood symptoms in children.
The Pediatric Quality of Life Inventory Statistical Methods:
Diabetes Module Version 3.0 (Peds QL Analysis of data was done by IBM
Diabetes Diabetes Module) contains 4
computer using SPSS (Statistical Program
modules: diabetes mellitus symptoms for Social Science) for chi-square test,
module, treatment anxiety module, worries
unpaired t-test, correlation coefficient test
module and communication module and multi-variant analysis (linear
according to Varni et al., 2003. The sum of
regression). P value>0.05 was non-
the four scales in the Peds QL Generic Core significant, *P<0.05 was significant, and
scale constitutes the total score. Each items
**P<0.01 was highly significant.
has scores ranging from 0-4 (0 = It is never
a problem, 1 = It is almost never a problem, Results
2 = It is sometimes a problem, 3 = It is Table (1): Presents the main clinical and
often a problem, and 4 = It is almost always laboratory data of the studied patients and
a problem). The higher the score, the poorer frequency of long-term diabetic
quality of life. Both inventories were complications. Diabetic retinopathy and
translated into Arabic with blind back neuropathy were diagnosed only in long-
translation to English and the Arabic standing (group B) patients, while none of
version was used. recently diagnosed patients experienced any
Assessment of Emotional Status: of these complications. The mean
glycosylated hemoglobin (HbA1C) was
Emotional disturbances, specifically anxiety
significantly elevated in group (B) patients
and depression, were assessed using denoting poor glycemic control among the
Children's Manifest Anxiety (CMA) scale
long standing diabetic patients. The test for
and Children Depression Inventory (CDI)
microalbuminuria was repeatedly positive
for children above the age of 7 years. The in 26% of group (B) patients compared to
CMA scale was designed by Abdel Hamid
only 4.16% in group (A) indicating a
and El-Nail, 1991 as an Arabic version significantly higher incidence of early
derived from the children's manifest anxiety
nephropathy in long –standing diabetic
scale. This is a child self report measure patients.
that assesses symptoms of anxiety
consisting of 36 statements with a total Table (2) shows than 10 out of 14 patients
score of 0-36. The cut-off point of the scale with diabetic nephropathy (71.4%), as
is 18, where above 18, the child is diagnosed by persistent microalbuminuria,
considered to have high anxiety state. were included among the poorly controlled
group (HbA1C > 8.5%), and five of patients
83
with diabetic neuropathy and retinopathy Diabetic Module. The highest mean of
(62.5% and 71.4% respectively) diabetes symptoms module (worst quality
experienced poor diabetic control denoting of life) was noticed among group III
a significant increase of diabetic (poorly-controlled) diabetic patients, while
microvascular complications in group III the treatment anxiety module was markedly
(poorly controlled) diabetic patients. elevated in group I patients with strict
Table (3) shows a comparison between the glycemic control. There was also a highly
significant difference between the studied
three studied groups (according to the
degree of glycemic control) regarding the groups regarding the worry module scores
with the lowest mean (best quality of life)
scores of Peds QL Generic Core scale. It
shows a significantly higher physical in group II patients, and the highest mean
summary scale and emotional scale among (worst quality of life) in group III (poorly-
controlled) diabetic patients.
group III patients (poorly-controlled)
diabetic children denoting the worst quality Table (6) shows that depression and anxiety
of life, while the lowest mean score (best were common in our sample. As regards
quality of life) was noticed in group II of depression, the CDI showed a higher
them. The school performance scale was frequency of depression 31.6% in group III
markedly increased (denoting a poor school compared to 18.2% and 3.6% among
performance) in group III followed by groups I and II respectively, and the
group I of patients. There was also a difference was statistically significant.
statistically highly significant difference When the three studied groups were
between the studied groups regarding the compared as regards the mean scores of
psychosocial summary scale with the CDI, it was found that group III (the
lowest mean (best quality of life) noticed in poorly-controlled) diabetic children had the
group II (fairly-controlled) diabetic highest scores of depression with a
patients. The total score was significantly statistically significant difference from
elevated with a poor overall quality of life group II patients who had the lowest scores.
in group III (poorly-controlled) diabetic The results regarding the presence of
patients. anxiety using the CMA revealed also a
Table (4) shows that patients with poor highly significant statistical difference
between the three studied groups with a
glycemic control and diabetic
significantly higher frequency of anxiety
microvascular complications, particularly
those with longer disease duration, had the (CMA scale > 18) in group III patients
(73.3%) followed by group I (33.3%) and
worst quality of life.
lastly group II patients (21.8%).
Table (5) shows a comparison between the
three studied groups regarding the Peds QL
84
Table (1): Clinical and laboratory data of the studied patients
Parameter Group (A) Group (B) “p” value Significance

(DM < 5 years) (DM > 5 years)
Number 48 46 P > 0.05 Non – significant
Sex (M/F) 28/20 (1.4:1) 20/26 (0.77:1)
Age (years), 8.4 ± 2.5 14.2 ± 4.8 (t : 4.8) Highly significant
Mean ± SD P < 0.001
Disease duration 2.3 ± 1.2 8.5 ± 3.8 (t: 8.0) Highly significant
(years)
P < 0.001
Mean ± SD
Mean blood glucose 180 ± 45.9 201 ± 55.4 t (0.66) Non – significant
Mean ± SD (mg/dl) P > 0.05
HbA1C (%) 8.04 ± 0.96 11.17 ± 3.74 t (2.1) Significant
Mean ± SD P < 0.05
S. creatinine 0.7 ± 0.21 0.9 ± 0.32 t ( 1.1) Non – significant
Mean ± SD (mg/dl) P > 0.05
Creatinine clearance 61.36 ± 13.57 40.2 ± 10.61 t ( 4.6) Significant
2
(ml/min/1.73m ) P < 0.01
mean ± SD
Microalbuminuria 2/48 (4.16%) 12/46 (26.08%) t (8.0) Highly significant
(Qualitative) P < 0.001
+ ve test, (%)
Diabetic retinopathy 0/48 (0.0%) 7/46 (15.2%)
(number, %)
Diabetic neuropathy 0/48 (0.0%) 8/46 (17.4%)
(number, %)
85
Table (2): Correlation study between glycemic control (according to HbA1C) and diabetic
microvascular complications
Degree of Glycemic Control
Diabetic Good (I) Fair (II) Poor (III)
Complication Group no. = 24 no = 32 no = 38 ‘p’ value Significance
No. (%) No. (%) No. (%)
Nephropathy - ve 23 (95.8) 29 (90.6) 28 (73.7) Highly
+ ve 1 (4.2) 3 (9.4) 10 (26.3) P< significant
0.001
Retinopathy - ve 23 (95.8) 31 (96.88) 33 (86.84) Highly
+ve 1 (4.2) 1 (3.12) 5 (13.16) P< significant
0.001
Neuropathy - ve 23 (95.8) 30 (93.75) 33 (86.84) Highly
+ ve 1 (4.2) 2 (6.25) 5 (13.16) P< significant
0.001
Table (3) Comparison between the three studied groups as regards the mean scores of Peds
QL Generic Core scale version 4.0 (Child Report)
Scale Mean ± SD F P value Significance
Physical summary scale
Group I (good control) 9.3 ± 4.3 6.1 0.003** Highly significant
Group II (fair control) 6.5 ± 4.3 (group II vs. group III)
Group III (poor control) 10.5 ± 5.4
Emotional scale
Group I (good control) 7.7 ± 5.0 8.0 0.01* Highly significant
Group II (fair control) 4.1 ± 3.1 0.001** (group I vs. group II)
Group III (poor control) 8.6 ± 4.7 (group II vs. group III)
Social scale
Group I (good control) 7.0 ± 4.7 Non significant
Group II (fair control) 4.5 ± 4.1 2.3 0.1
School performance scale
Group I (good control) 6.5 ± 2.3 Highly significant
Group II (fair control) 5.9 ± 3.8 8.4 0.001** (group I vs. group III)
Group III (poor control) 10.4 ± 3.9 (group II vs. group III)
86
Table (3) continued:

Scale Mean ± SD F P value Significance
Psychosocial summary scale
Group II (fair control) 15.4 ± 8.8 7.5 0.001** (group II vs. group III)
Total Score
Group II (fair control) 36.4 ± 12.6 8.3 0.001** (group II vs. group III)
Group I: Good control (HbA1C: 6-7.5%), Group II: Fair control (HbA1C:> 7.5- 8.5%),
Group III: Poor control (HbA1C > 8.5%)
*P< 0.05: Significant, ** P< 0.01: Highly significant P> 0.05: non significant
Table (4): Correlation study between the total scores of Peds QL Generic Core scale and
disease duration, diabetic microvascular complications and glycemic control
Parameter Number Total Peds QL ‘p’ value Significance
(%) Score mean ± SD
Sex Male 48 (51 %) 38.6 ± 22.4 > 0.05 Non- significant
Female 46 (49%) 44.8 ± 26.2
Disease Duration
< 5 years 48 (51%) 24.8 ± 19.2 < 0.001 Highly significant
> 5 years 46 (49%) 62.4 ± 38.6
Glycemic control
Good ( group I) 24 52.5 ±
(25.5%) 14.8 Highly significant
Fair (group II) 32 36.4 ± 12.6 < 0.001 (Group II vs. III)
(34.0%)
Poor (group III) 38 60.7 ± 28.8
(40.5%)
Nephropathy
- ve 80 36.4 ± 18.5 < 0.001 Highly significant
(14.9%)
+ ve 14 72.8 ± 26.3
(85.1%)
Retinopathy
(92.55%)
+ ve 7 81.6 ± 22.8
(7.45%)
Neuropathy
(91.5%)
+ ve 8 82.8 ± 28.9
(8.5%)
87
Table (5): Comparison between the three studied groups as regards the Peds QL Diabetes Module
Module Scale Mean ± F P value Significance

SD
Diabetes symptoms module
Group I (good control) 17.5 ± 9.2 3.8 0.02* Significant
Group II (fair control) 16.6 ± 7.2 (Group II vs. Group III)
Treatment anxiety module
Group II (fair control) 4.7 ± 3.1 5.8 0.01** (Group I vs. Group II)
Worry module
Group II (fair control) 4.0 ± 3.7 6.5 0.002** (Group I vs. Group II)
Group III (poor control) 8.9 ± 3.7 (Group II vs. Group III)
Communications module
Group I (good control) 6.5 ± 3.3
Group II (fair control) 5.7 ± 3.5 1.6 0.2 Non - significant
Table (6): The Child Depression Inventory (CDI) scores and Children Manifest Anxiety
(CMA) in the studied groups
Children Depression Inventory (CDI) scores
Group Mean ± SD F P value Significance
Group I (good control) 9.0 ± 5.3
Group II (fair control) 8.4 ± 4.2 3.8 0.04* Significant (Group II vs.
Group III (poor control) 12.2 ± 6.9 III)
Child Manifest Anxiety (CMA) scale
Group Anxiety No anxiety
(+ ve > 18) (-ve < 18) X2 P value
No. % No. %
Group I 8 33.3% 16 66.7% 0.001**
(good control) 14.3 Highly significant
Group II 7 21.8 % 25 78.2% (Group I vs. III)
(fair control) (Group II. vs III)
Group III 28 73.7% 10 26.3%
(poor control)
88
Discussion:
symptoms module followed by the well
In this study, we attempted to assess health-
related quality of life (HRQoL) and controlled group.
emotional disturbances in children and In agreement with these Findings, Wikby et
adolescents with type -1 diabetes mellitus al, 1993, Wikbald et al., 1996 Cameron et
(DM). The relation of HRQoL and al., 2003 and Wagner, 2004 found that
emotional disturbances to glycemic control patients with poorly controlled DM had
and microvascular diabetic complications their physical and mental health lower than
was also studied. Patients of the present patients with good metabolic control. They
study were divided according to the degree added that patients with acceptable
of glycemic control (as reflected by HbA1C glycemic control without tight or strict
levels) into well controlled (group I), fairly dietetic restrictions experienced the best
controlled (group II) and poorly controlled quality of life and least emotional
(group III) patients. Two scoring systems disturbances, a similar result to that of the
(the Peds QL Generic Core Scale and Peds present study. The poor quality of life and
QL Diabetes Module) were used as a more emotional disturbances in patients
comparative measure of quality of life with poor glycemic control could be
among the three studied groups. The attributed to more frequent hospital
frequency and severity of anxiety and admissions, shifting to more intensive
depressive symptoms were also studied and insulin regimens as an attempt to correct
analysed using Children's Manifest Anxiety underlying metabolic derangement, and the
(CMA) Scale and Children Depression higher frequency of microvascular
Inventory (CDI) respectively. complications (nephropathy, retinopathy
The results of the Peds QL Generic Core and neuropathy) in patients with poorly
controlled diabetes. In a recent study done
Scale revealed that the poorly controlled
(group III) patients had the highest total by Salem et al, 2003 describing the impact
of glycemic control on the quality of life in
score and thus, they experienced the worst
quality of life, while the fairly controlled diabetic children and adolescents, they also
found that the poorly controlled group
(group II) patients experienced the best
quality of life, followed by the well experienced the worst quality of life, while
the fairly controlled group had the best
controlled (group I) patients. Analysis of
scores.
the subitems of the scale (physical,
emotional, school performance and The finding that patients with well-
psychosocial summary scale) revealed controlled DM in the present study rated
similar significant higher scales in group III their quality of life poorer than the fairly
patients denoting marked impairment of controlled group with more emotional
quality of life through its all domains. disturbances could be attributed to the use
Similarly, the results of the Peds QL of more intensive insulin therapy with
Diabetes Module showed significantly marked dietary restrictions which
higher scores (the worst quality of life) in diminishes the possibility to act
the poorly controlled patients particularly spontaneously. The frequent home testing
for the worry module and diabetes for blood glucose and the repeated
occurrence of hypoglycemic episodes with
89
intensive therapy will make the patient feels Diabetes Module discussed before. The
helpless and in need of others to deal with higher frequency of depression and anxiety
these events (Cameron et al.,2003 Hahl et in poorly controlled patients would not only
al., 20002 and, Salem et al 2003). add to their poor quality of life, but could
Longer disease duration and presence of make the control of diabetes more
problematic as stated by Andersson et al.,
diabetic microvascular complications
showed a negative impact on the quality of 2003. Depression and anxiety may lead to
the activation of hypothalamic- pituitary-
life of the studied patients (affecting both
Peds QL Generic Core Scale and Peds QL adrenal axis leading to more hyperglycemia
and resistance to treatment secondary to the
Diabetes Module) with more frequent
emotional disturbances regarding both effect of increasing levels of adrenal
anxiety and depression scales in patients glucocorticoids which may end in refusal of
treatment or non-compliance to therapy.
with long-term diabetic microvascular
complications (nephropathy, retinopathy Laffel et al., 2003 added that the concern
about long-term complications, coping with
and neuropathy). This comes in agreement
with Hahl et al., 2002 who studied the acute complications, and the burden of
treatment regimen combine together to
quality of life in diabetic Finnish children
and adolescents, and its relations to age, affect virtually all psychological domains of
life in type -1 diabetic patients.
sex, disease duration, glycemic control and
long-term microvascular complications. The findings of this study indicate the
They described a negative influence of importance of proper glycemic control in
increasing age and disease duration on the diabetic children and adolescents in order to
quality of life. Moreover, they reported that allow them to have the best quality of life
patients with long-term diabetic with early detection of diabetic micro-
complication experienced the worst quality vascular complications which may
of life effecting all its domains (physical, inversely affect the quality of life. This
emotional, social, and school performance could be done through a balanced approach
scales), a similar finding to that of the aiming for acceptable intermediate control
present study. Another study done by so that, the intensive treatment, strict
Cameron et al., 2003 proved that the regime and the dietary restrictions would
psychological indices and the general well not affect the quality of life. Moreover, the
being were worse with increasing age and present study highlights the importance of
longer disease duration, specifically in the detecting psychological and emotional
prepuberal and pubertal children and disturbances in diabetic children and
adolescents. adolescents with early intervention so as to
avoid their impact on the control of diabetes
Regarding depression and anxiety scales,
the present study showed that the poorly and subsequently, a better quality of life
will be achieved.
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93
Diagnostic Value of Regional Cerebral Blood Flow Changes on

SPECT and Hippocampal Atrophy on MRI in Diagnosis of
Alzheimer's Disease and Vascular Dementia
Farouk S., Abdalla R. Hussein M and Fikry M.
Abstract:
This study was performed to evaluate the role of regional cerebral blood flow changes on
99m
Tc-HMPAO brain SPECT and hippocampal atrophy on MRI in diagnosis of Alzheimer's
disease and vascular dementia. The study was performed at radiology department and
Institute of Psychiatry, Faculty of Medicine, Ain Shams University and a private radiology
center, at the period from December 2004 to November 2005. Ten patients with clinical
diagnosis of Alzheimer’s disease 10 patients with vascular dementia and 5 aged matched
healthy control were included in the study. All subjects underwent MRI assessment of
hippocampus and brain perfusion SPECT. Mean normal hippocampal volume was
(1806.5mm 3 ± 197), mean volume at cases of AD was (1408mm3 ± 143.5) and mean volume
at cases of VaD was (1540mm3 ± 74.9). Hippocampal atrophy was recorded in 80% of AD
patients and 90% of VaD patients. SPECT study revealed predominant parieto-temporal
hypoperfusion in AD patients, while heterogenous tracer uptake with foci of hypoperfusion
allover the brain and frontal involvement was elicited in cases of VaD. Decrease hippocampal
volume can be used as a marker of dementia without specification to its cause. However
SPECT is more specific. Combined both modalities is an adjunct to cognitive and clinical
examination in diagnosis and assessment of disease progression.
Introduction:
Alzheimer's disease (AD) and vascular moderate stages of the disease to delay its
progression (Kantarci & Jack 2003).
dementia (VaD) are the two major diseases
that cause dementia and early diagnosis and In absence of a robust biological marker,
intervention are essential for effective the diagnosis relies largely on clinical
treatment (Yoshikawa, et al. 2003). By the features and requires a thorough
time AD or even mild cognitive impairment neurological and neuropathological
(MCI) are clinically detectable, an evaluation (Varma, et al 2002).
important neuronal loss has already taken Clinical diagnosis of AD in a living person
place (Masdeu, et al. 2005). Although no is labeled either possible or probable.
currently available treatment has been
Definitive diagnosis of AD requires tissue
proven to stabilize or reverse the examination, through biopsy or autopsy of
neurodegenerative process, and no available
the brain (Kantarci & Jack 2003). From the
preventive treatment, several putative epidemiological point of view, it has
disease modifying agents are now in
become increasingly clear that the
development with early clinical trials. prevalence of VaD is heavily dependent
Primary targets of such interventions are
upon the diagnostic criteria used and that,
people who are at risk or who are at mild to accordingly, a low level of agreement exists
among different authors on how to diagnose
94
VaD (Verhey. et al. 1996, Wetterling, et al. atrophy of entorhinal cortex (ERC) have
1996 & Chui et al 2000). In these studies been reported to be larger than that of
the highest prevalence values have been hippocampus. However, technical issues
obtained adopting the Hachinski ischemia and sometimes ambiguous landmarks to
scale (Hachinski et al. 1975) or the DSM- define structural boundaries make ERC
IV diagnostic criteria and the lowest values measurement less reliable than that of
have been obtained with the NINDS- hippocampus (Du et al. 2004). Overall
AIREN diagnostic criteria for VaD. brain volume loss, although not specific,
(Roman et al 1993). In the same studies, has also been reported as a hallmark of AD
the level of agreement (k coefficient) in showing correlation with disease severity
making diagnosis of VaD has been (Chan et al. 2003). The intimate correlation
consistently low (ranging between 25% and between pathologic involvement and
60%), whereas a much higher agreement hippocampal atrophy is encouraging for the
(80% - 90%) has been obtained in making a use of hippocampal volumetery, using MRI,
diagnosis of Alzheimer’s disease (AD) as an imaging marker and a diagnostic
(Gainotti 2004). criterion of the disease (Knopman et al.
2001 & Kubota et al. 2005). Also Gainotti
The disagreement between clinical and
pathological diagnosis provides the and coworkers 2004, investigated the role
of hippocampal atrophy in assessing the
motivation to develop neuroimaging
markers that can accurately identify the severity of dementia in patient with
vascular disease.
different types of dementia pathology
(Masdeu, et al. 2005). Previous workers have suggested that a
combination of both functional and
The traditional use of structural
neuroimaging to differentiate potentially anatomic imaging studies may offer better
sensitivity and specificity for the diagnosis
reversible or modifiable causes of dementia
such as brain tumors, subdural heamatoma, of AD (Varma et al 2002). SPECT and
PET are widely investigated functional
normal pressure hydrocephalus, and
neurodegenerative diseases with focal neuroimaging techniques which evaluate
global and regional disturbances of blood
atrophy, from AD is widely accepted
(Knopman et al. 2001). Structural flow and metabolism, and helps improving
our understanding of pathophysiology of
neuroimaging can also identify anatomic
dementing illnesses (Lee et al. 2003). As
changes that occur from the pathologic
involvement in AD. Neurofibrillary perfusion SPECT is less expensive and
more available than FDG PET, the study we
pathology, which correlates with neuron
loss and cognitive decline in patients with present here examines the diagnostic utility
of abnormalities of cerebral blood flow
AD, initially involves the primary sensory
cortices. The macroscopic result is atrophy. (CBF) as demonstrated by 99mTc-HMPAO
and hippocampal atrophy demonstrated by
For this reason, the search for anatomic
imaging markers of AD has targeted the MRI as diagnostic indicators of dementia in
patients with AD and VaD.
anteromedial temporal lobe, particularly the
hippocampus and entorhinal cortex which Patients and Methods:
are involved earliest and most severely in
This study was conducted at radiology
AD (Kantarci & Jack 2003). Rate of department and Institute of Psychiatry,
95
Faculty of medicine Ain Shams University obtained to determine the long axis of the
and a private radiology center, at the period hippocampus (fig 1). Coronal sections
from December 2004 to November 2005. were obtained perpendicular to the long
Twenty patients were included in the study, axis of the hippocampus with slice
as shown in table (1) 10 patients (4 males thickness = 3mm and 1 mm space. On the
and 6 females) fulfilled the criteria AD and work station, we used an oval shape region
10 patients (3 males and 7 females) fulfilled of interest (ROI), placed around the outline
the criteria for VaD according to ICD-10 of the hippocampus in each coronal section
respectively. The mean age of the patient (fig2), with intent to achieve maximum
with AD was 62.8±7.34 with a mean coverage and to get surface area for each
duration of illness 2.95±4.81 while the slice. Then by soft ware assessment the
mean age of patient with VaD was volume is automatically calculated for each
64.5±6.21 and mean duration with illness hippocampus. By summation of the Rt. And
3.6±5.57. All patients were diagnosed Lt. Hippocampus volumes and dividing by
clinically using the ICD-10 symptoms 2 we got the mean hippocampal volume for
checklist after a complete neuropsychiatric each participant.
examination. Moreover patients with VaD
SPECT Scanning:
were subjected to Hachinski ischemic scale
to verify the diagnosis as well as Brain SPECT was done using 99mTc-
99m
assessment of the previous radiological HMPAO (technetium labeled
findings of the CT or MRI hexamethyl propylene amine oxime) in a
dose of 20mCi injected intravenous. Patient
Also 5 aged matched healthy control were data were acquired and reconstructed using
involved in the study; they had no history of
a FUFA-SMV-DSTXLi digital gamma
neurological or psychiatric disorders or camera machine. Energy window 10%
major medical illness, with normal
centered over the 140 kev peak. Imaging
neuropsychiatric examination. All patients time is 20 minutes after injection.
or the relatives and control group gave their
Acquisition protocol is 30 minutes using an
consent prior to the study. annular SPECT system, 360 degrees, 120
Patients were excluded from the study when images, 15 sec/image, matrix size128x128
other neurological and non neurological 1 byte per pixel. Patient was supine, with
disorders were detected. All patients and the head slightly elevated and eyes closed.
control group were right handed. Patient's head should be as close as possible
to the camera and strapped tightly with a
Brain perfusion SPECT and MRI
evaluation of the hippocampus volume non attenuating object (rubber) to avoid
head motion. Axial, sagittal and coronal
were performed in all subjects.
projections were obtained.
MRI scanning:
Analysis of the data obtained from SPECT
We used Philips Intra 1.5T MRI scanner and MRI studies were done with 3 expert
with a head coil and patient in supine radiologists and correlations with clinical
position. The method of calculating the condition were done.
hippocampus volume was used after
Bremner et al, 1995 An initial sagittal T1
localizing sequence (TR=572, TE= 15) was
96
Results: All cases of AD and VaD showed

heterogenous tracer uptake with areas of
MRI findings:
hypoperfusion (table 3). Prominent parieto-
The mean normal volume of the temporal decrease tracer uptake was seen in
hippocampus was (1806.5 mm3 ± 197); 8 cases of clinically diagnosed AD (fig 3).
however the mean volume recorded in While heterogenous hypoperfusion allover
patients with AD was (1408mm3±143.5) the brain was seen in two cases, one of
and in patients with VaD was (1540mm3 ± which had normal hippocampal volume in
74.9). Two cases of AD showed normal MRI (1786.3mm3) (fig 4). Radiological
hippocampal volume (mean 1796.2mm3) findings were more consistent with VaD.
and they also had mild cognitive
Heterogenous areas of decrease tracer
impairment and short duration of the
uptake were seen in 9 cases of VaD with
disease (mean 1.25years). Sever
hippocampal volume loss was detected in 4 small foci of hypoperfusion allover brain
lobes involving the frontal lob one (fig 5).
patients with the mean volume of
hippocampus was (1064 mm3 ± 44.6). However one case showed predominant
parieto-temporal hypoperfusion (fig 6) and
Three patients of VaD showed marked
decrease in hippocampal volume with mean MRI findings revealed marked decrease
hippocampal volume (1045.8mm3).
volume (1256mm3± 22.5). While one
patient showed normal hippocampal Radiological findings were more suggestive
of AD
volume (1708 mm3). (Table 2).
Two of the control subjects (none
SPECT findings:
dementing) showed areas of hypoperfusion
at parietal lobes. (fig 7).
Table (1):Characteristic of the Sample:
Mean age in years Sex Mean duration of

Group the disease in
± SD Male Female years ± SD
AD 62.8±7.34 4 6 2.95±4.84
VaD 64.5±6.21 3 7 3.6±5.57
Control 62.2±7.67 3 2 -
Table (2): Mean hippocampal volume recorded at included subjects:
AD VaD Normal
Mean hippocamal volume
1408±143.5 1540±74.9 1806.5±197
in mm3± SD
97
Table (3): SPECT and MRI findings in correlation with clinical diagnosis:
AD VaD Control
Findings
N=10 N=10 N=5
Brain SPECT
Heterogenous hypoperfusion
2 9 0
± frontal involvement
Parietal / temporal
8 1 2
hypoperfusion\
Normal perfusion 0 0 3
Hippocampal volume
Decrease 8 9 0
Normal 2 1 5
Fig(1): T1 sagittal localizing MRI shows Fig(2): coronal T1 MRI shows an oval
long axis of the hippocampus the region of interest outlining
hippocampal body
A P C
Fig(3): Brain SPECT of AD patient (A: Sagittal, B: Axial and C: Coronal) shows
predominant parieto-temporal hypo-perfusion.
98
B
A
Fig (4): Brain SPECT (A: Sagittal and B: Axial) shows heterogenous tracer uptake allover
the brain(arrows) in a case clinically diagnosed as AD, MRI of this case shows normal
hippocampal volume
Fig(5): Brain SPECT (axial) in a patient with VaD shows hypo-perfusion of the frontal
lobes.
Fig(6): Brain SPECT (coronal)of a clinically diagnosed VaD patient shows areas of hypo-
perfusion at tempero-parietal lobe.
B
A
Fig(7): Brain SPECT (A:axial and B:sagittal) of a normal individual shows areas of
hypo-perfusion at parietal lobes.
99
Discussion:
When elderly patient presents with MRI commonly demonstrates three types of
cognitive impairment, the clinical abnormalities in patients with dementing
distinctions to be made are: first between disease. First lacunar infarctions that
ages related decline and dementia, second provide evidence of cerebrovascular disease
(if dementia is established) between and are common in VaD than other types of
different etiologic types. dementia. Secondly, areas of high signal on
Alzheimer's disease (AD) is the most T2 weighted MRI, are commonly seen in
patients with dementia. The third
common cause of dementia and accurate
diagnosis is important for effective abnormality seen on MRI is accelerated
atrophy compared with normal elderly
treatment. While clinical criteria for the
individuals. More over, the distribution and
diagnosis of AD have been substantially
important, they are still imperfect, and rate of atrophy differ depending on the
disease process (Varma et al 2002). Zarow
imaging findings change the clinical
diagnosis and management in some cases et al, 2005 stated that although brain
atrophy per se is not specific to dementia of
(Roman et al. 1993).
Alzheimer's type, there is strong evidence
Risk groups for AD are composed of suggesting that rate of atrophy of certain
individuals identified either through clinical brain structures are correlated with AD
examination or family history and genetic severity. In particular, atrophy of
testing. They are the primary targets of hippocampus occurs early in the
treatment trials aimed to prevent or delay development of the disease and has been
the neurodegenerative process. Thus reported to correlate with deficits in
biomarkers that can distinguish individuals memory function. Also other workers have
at risk are required to use these found that measurement of hippocampal
interventions before neurodegenerative volume or cross sectional area can
disease advances and irreversible damage distinguish patients with AD from normal
occurs (Kantarci and Jack 2003). individuals and from patients with other
Functional imaging using photon emission neurodegenerative diseases with specificity
tomography (PET) scanning has shown of over 95% (O'Brien et al. 1997).
reduction in cerebral metabolism and blood The aim of this study is to evaluate the role
flow in AD, predominantly in posterior of regional atrophy on MRI (represented by
parietal and temporal region but the method hippocampal volume) and cerebral blood
is too costly for routine clinical use. The flow changes on SPECT in differentiation
regional uptake of 99mT-HMPAO into the between the two most common causes of
brain as measured by single photon dementia, that are AD and VaD. We
emission computerized tomography provided data on how useful individual
(SPECT) provides a quantitative imaging findings are (in isolation and in
representation of regional cerebral blood combination), and serve as a guide to the
flow and requires a rotating Gamma camera optimal use of neuroimaging in the clinical
of the type found in most nuclear medicine diagnosis of dementia.
departments and relatively inexpensive
The results of our study revealed that
(Mckeith et al. 1993).
hippocampal atrophy is detected in 80% of
100
AD and 90% of VaD. This is consistent heterogenous hypoperfusion with scattered

with (Hanyu et al. 1999) who reported that areas of decrease tracer uptake seen at
hippocampal atrophy is not specific marker frontal, parietal and occipital regions, only
for AD and appears to be a common one case shows parietotemporal
phenomenon in dementia syndrome. More hypoperfusion and radiological diagnosis
over Gianotti et al 2004 reported that was in favor of AD. Involvement of frontal
hippocampal atropy is a better predictor of cortex was absent in all cases of AD.
dementia than the number of the vascular
Our study is consistent with (ElFakhri et
lesion in patients with multiple subcortical al., 2003) and previous reports that
infarcts. Similar results with Henon et al
confirmed the presence of perfusion
1998 & Fein et al 2000 who found that in abnormalities in patients with established
patients with subcortical ischemic vascular AD. The most consistent finding in these
lesion, dementia correlates best with
studies was decrease perfusion in the
hippocampal and cortical atrophy than with tempro-parietal cortex. Another study done
any measure of lacunae. However; Du et al
by (Varma et al., 1997) using 99mTc-
2002 fount that the entrohinal cortex and HMPAO, confirmed the presence of
hippocampus are less affected by vascular
bilateral posterior cortical blood flow
dementia that AD. The limited number of abnormality in cases of AD but they did
our patients in this sample may be the cause
not find a pattern of reduced cerebral blood
of this disagreement. flow in SPECT of value in the diagnosis of
Therefore the controversial results of the VaD.
hippocampal atrophy lead the investigators Also Yoshikawa et al., 2003 using 99mTc-
to use the entrohinal (ERH) cortex in
HMPAO with 3D fractal analysis
addition as a way to differentiate between (statistical imaging processing on
different types of dementia however it was
reconstructed data). They divided the whole
found that (ERH) volume loss is also brain into anterior and posterior regions in
present in Alzheimer's disease and fronto-
patients with AD and VaD, fractal
temporal dementia. However Masdeu et al dimension was calculated for each region.
2005 reported that the annual rate of
The results were: posterior predominant
volume change has a greater sensitivity and heterogeneity of cerebral blood flow in the
specificity than one time measurement.
AD group and anterior predominant
In our study brain SPECT examination, heterogeneity in VaD group.
heterogenous cerebral blood hypo-perfusion
Masdeu, et al. 2005 concluded that a
was revealed in all cases of AD and VaD in positive SPECT increases the probability of
comparison to normal group. However the
diagnosis of AD to 92%, while a negative
distribution of tracer uptake was different SPECT lowers this figure to 70%. While
between AD and VaD patients. In 80% of
Julin, 1997 have suggested that a
AD cases there was a variable degree of combination of MRI and SPECT findings
decrease perfusion mainly at posterior
can provide excellent discrimination
cortex, involving the temporal and parietal reaching 100% between AD and normal
regions. No specific pattern of defective
control. We can add that according to our
cerebral blood perfusion was seen at cases
results combined MRI and SPECT can help
of VaD. The most predominant pattern was
101
in better differentiation between AD and involvement was more predominant in

VaD. VaD. Combined MRI and brain SPECT
Recent radiological techniques has been provides better diagnosis and differentiation
of both diseases.
used trying to differentiate between AD and
VaD. Masdeu, et al. 2005 comparing PET We advise to extend the scale of this study
and SPECT found that PET is slightly more in the future to involve a larger sample
sensitive and specific than SPECT for the volume and to study the reliability of these
diagnosis of mild AD, but it is clearly better modalities in prediction of patients at risk to
for the differential diagnosis of vascular develop dementia.
dementia. Moreover, among several regions
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105:261-269. Assistant Prof Radiology
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dementia. Neuroepidemiology; 15: 166-172 Lecturer of psychiatry
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1347 [email protected]
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104
The Practice of Electroconvulsive Therapy (ECT) in a Sample of

Egyptian Patients
Okasha T.
Abstract
Since its inception in 1938, ECT has proved effective and even life saving in certain
psychiatric conditions when other treatments have been of little or no benefit. ECT is the only
treatment in psychiatry that has withstood the test of time for nearly 70 years. ECT in Egypt is
used in patients suffering from depression, mania, schizophrenia and catatonia which are
slightly different from the literature where ECT is mainly used for depression; however,
recently an abundance of literature has proved that ECT is as effective in mania as it is
effective in depression. This study was carried out on 544 patients admitted to the Psychiatric
Health Resort in New Cairo over a period of one year. From the 399 patients receiving ECT
273 (68%) were male and 126 (32%) were females. The 399 patients in this study received a
total of 2866 ECT sessions. From these 2866 ECT sessions, 2734 sessions (95%) were given
bilaterally and 132 sessions (5%) were given unilaterally. All psychiatrists should be
acquainted with ECT and be able to present the treatment to the patient and the patient’s
relatives in a knowledgeable and scientific manner, in order to reduce the stigma and transmit
the fact that it is no longer “shock” or “convulsive” treatment. Emphasis also should be that it
is not a last resort treatment, but rather a first line therapy when indicated. An urgent goal of
mental health care should be to provide access to ECT and eliminate the severe impediments
to its use, so long as it can defend evidence based superiority over other treatments.
Introduction
This year the world celebrates 67 years of in other psychiatric disorders mainly severe
depression.
electro-convulsive therapy (ECT). There
has been no other line of treatment in The stigma of ECT is one of the main
medicine that withstood the test of time for issues that need to be addressed worldwide,
nearly six decades like ECT. The ECT is a technically advanced and effective
controversy over ECT is what enabled it to treatment that is often misunderstood and
prove itself and helped it in its development maligned by the lay public and by
to our present day as when a thing ceases to psychiatrists as well. From 1938 to the
be a subject of controversy; it ceases to be a 1950's an extensive use of ECT was seen.
subject of interest. During that period of time, ECT was the
Since its inception ECT has proved major treatment, if not frequently the only
biological treatment available for mental
effective and even life saving in certain
psychiatric conditions when other illness (Fink, 1992).
treatments have been of little or no benefit. From the 1950's through the 1970's with
the advent of psychotropic medications
ECT was initially used to treat psychotic
(including the development of neuroleptics
patients in whom schizophrenia was
diagnosed. However, practitioners quickly and of tricyclic antidepressants), a decline
in the use of ECT was seen. In the 1970's,
began to discover that ECT was also useful
105
concern developed regarding the side as portrayed by the mass media do not
effects of psychotropic medications, occur with modern ECT methods. "Seizure"
including the cardiovascular effects of the is used in its' technical sense to refer to the
tricyclic antidepressants and the potential patterned electrical response produced by
for tardive dyskinesia with neuroleptics. an electrical stimulus on an EEG level.
This concern resulted in a resurgence of
Lack of awareness of the natural history of
interest in ECT and led to many studies and disorders treated by ECT in the Egyptian
reports evaluating the effectiveness of this
population make nearly 70% of families of
modality. patients believe that ECT is addictive and
At the same time, the myths, once they receive ECT they will continue to
misinformation, and public outcry relapse and never get better unless they
continued. Senator Eagleton lost his vice receive another course of ECT (Okasha,
presidential bid when he revealed that he 2006).
had received ECT. In the film "One Flew
The treatment itself should be given a new
over the Cuckoo's Nest", Jack Nicholson name that describes what is done in neutral,
portrayed a patient receiving ECT for the
"unloaded" language. Words like "Shock",
wrong purpose (coercion) and in the wrong "Seizure" and "Convulsive" should be
fashion (without anaesthesia or muscle
eliminated. Several proposed terms as
relaxant). While public concern continues "cerebroversion", analogous with
as a result of negative media portrayal,
"cardioversion", or "Central Stimulation" or
progress in ECT has continued with "Central Stimulation with Patterned
significant medical advancements (Hay, Response” (CSPR), in Egypt a proposal by
1992). Currently, there is a surge in ECT
Okasha (1988) suggested the use of "Brain
research and publications which has helped Synchronization Therapy" (BST) or
ECT to enter the biological age of
"Rhythm Restoration Therapy" suggested
psychiatry. A journal now is available only by Rakhawy (1982) all would be effective
for research in ECT and allied sciences on a
in correcting the semantic description of
quarterly basis. ECT.
The semantic issue becomes paramount. It Previous refusal and stigma have changed
is very inappropriate to call such treatment
and decreased after the introduction of these
"Shock therapy". Fink (1979 and Ottosson new names to some university hospitals in
2004) has pointed out that "Shock" has a Egypt, and families were more accepting of
specific meaning: it is the perception of the
this treatment after they previously said that
passage of an electric current. This our patient can be admitted to hospital, but
produces pain and discomfort. The word
do not give him electric treatment.
"Shock" denotes perceptions that do not
occur under anaesthesia. This would be The aim of this work is to review the
analogous to labelling surgery "pain practice of ECT in a selective Egyptian
therapy". sample of inpatients and assess the
mortality, complications and outcome of
This outdated use of language leads to
patients.
negative attitudes and prejudice. The words
"convulsion" and "seizure" both have
special meanings to the public. Convulsions
106
Subject and Method seizures fulfilled the criteria for an effective

seizure.
The study was carried out as a retrospective
descriptive study. Studying the files and The criteria for an effective monitored
retrieving the data of 544 patients admitted seizure are:
to the Psychiatric Health Resort in New
- A post-ictal suppression index above 70 %
Cairo over a period of one year. The (Weiner, 1991).
psychiatric health resort is a private
psychiatric hospital with both inpatient and - A seizure concordance index above 50 %
out patient facilities. (Swartz and Larson, 1986).
Any patient receiving ECT was viewed - A seizure energy index above 550 units
regarding their sex, diagnosis and method (Abrams, 1992).
of receiving ECT. All patients were Results
included and the only exclusion criterion
was not receiving ECT. All diagnoses were Out of the 544 patients admitted to the
made according to the ICD-10 Research Psychiatric Health Resort over a period of
and Diagnostic Criteria (1993) using the one year, 399 patients received ECT. The
ICD-10 symptom checklist (1994). oldest patient receiving ECT was 83 years
old and the youngest was 18 years old. The
An informed consent was taken from all the distribution of patient’ age can be seen in
patients or their relatives to be included in Table (1). This table should act as an eye-
this study. opener that elderly people who respond to
Patients receiving ECT were investigated ECT better than pharmacotherapy are
routinely by complete blood count (CBC), deprived of this treatment due to the
erythrocyte sedimentation rate (ESR), reluctance of the attending psychiatrists to
fasting blood sugar (FBS), liver and kidney prescribe it form fear of stigma. More
functions and ECG. Patients were fasting education is needed to correct these wrong
for a period of at least 6 hours before perception both for psychiatrists, patients
receiving the treatment. ECT was given and their families.
three times weekly, bilaterally using the From the 399 patients receiving ECT 273
bitemporal electrode placement and (68%) were male and 126 (32%) were
unilaterally using d’Elia (1970) position. females as shown in figure (1).
Patients were given thiopental sodium and The patients were diagnosed according to
atropine by the IV route followed by the ICD10 research and diagnostic criteria
succinyl choline and oxygenation. A using the ICD 10 symptom checklist. The
Thymatron DG apparatus was used setting diagnoses of the patients were as shown in
the energy dial according to age giving a figure (2). 166 patients (42%) were
charge of 100.8 - 277.2 millicolombs, a suffering from schizophrenia, 105 patients
current of 0.9 ampere, a frequency of 30 - (27%) were suffering from bipolar disorder
50 HZ, a pulse width of 1.0 msec and a (mania), 63 patients (16%) were suffering
duration of stimulus of 1.87 - 2.20 seconds. from depression and 60 patients (15%) were
The seizure was monitored by one channel suffering from other diagnoses.
of EEG and one channel of EMG. All
107
The other diagnoses for the 60 patients who suffered from co-morbid depression.
included 13 patients with obsessive From the 132 patients receiving unilateral
compulsive disorder, 32 patients with ECT 101 patients (77%) were above the age
mental and behavioural disorder secondary of 50 years and 31 patients (23%) were
to substance abuse, 1 patient with between the ages of 20 and 49 years.
generalised anxiety disorder, 11 patients
Unilateral ECT was given to the patients for
with personality disorder, 1 patient with 3 reasons; firstly, some patients had exams
panic disorder and 2 patients with
and the need to decrease the cognitive
somatization disorder (figure 3). deficit especially to recent memory was
All patients with the label other diagnoses necessary, secondly some patients ran their
had co-morbid depression except for 8 own businesses and needed be supervising
patients from mental and behavioural their work while hospitalized and thirdly
disorder secondary to substance abuse some patients from the older age bracket
group who had substance induced were suffering from early cognitive decline.
psychosis. Out of the 2866 ECT sessions, as reported
The 399 patients in this study received a in the patient files, there were no
total of 2866 ECT sessions. From these mortalities, fractures or dislocations,
2866 ECT sessions as shown in figure (4), specific complications whether
2734 sessions (95%) were given bilaterally cardiovascular or respiratory, or acute
using the bitemporal electrode placement confusion states after the ECT sessions.
position and 132 sessions (5%) were given
Upon discharge patients with depression
unilaterally on the non dominant
showed an 80% improvement from
hemisphere using the d’Elia position (2.5 admission, 85% improvement from
cms from the vertex of the head).
admission in bipolar patients, 70%
The patients receiving unilateral ECT had improvement from admission in patients
different diagnoses according to the ICD 10 with schizophrenia and 60% improvement
as shown in figure (5). 10 patients (39%) in the category of patients diagnosed as
were diagnosed with severe depression, 7 other diagnoses. This improvement was
patients (27%) were diagnosed with bipolar evaluated comparing the on admission and
disorder (mania), 5 patients (19%) were on discharge Clinical Global Impression
diagnosed with schizophrenia and 4 patients Scale (Severity).
(15%) were diagnosed as other diagnoses
Table (1). Distribution of patients by age
Age Number of Patients
Below 20 17
21 - 30 129
31 – 40 111
41 – 50 71
51 – 60 33
61 – 70 22
Above 70 16
108
Figure (1)
Gender Distribution
Females, 126,
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32% xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Males, 273,
68%
Figure (2)
Diagnosis of Patients
Others, 60, 15%

Depression, 63, Schizophrenia,
16% 166, 42%
Bioplar
disorder, 105,
27%
109
Figure (3)
Other Diagnoses
35
32
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0
s
dis
e
de
er
di
rd
D
rd
or
so
d
OC
ty
iso
te
dis
xie
di
la
cd
m
an
ty
re
or
ali
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of
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on
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at
ta
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ali
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bs
Pe
nr
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Su
Ge
Figure (4)
Bilateral vs. Unilateral
Unilateral, 132, 5%
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Bilateral, 2734, 95%
110
Figure (5)
Unilateral ECT by Diagnosis
Schizophrenia,
Others, 4, 15% 5, 19%
Bioplar
Depression, disorder, 7,
10, 39% 27%
Discussion
In this study, is to review the practice of consistent with the culture in Egypt and
most developing countries where families
ECT in a selective Egyptian sample of
inpatients and assess the mortality, prefer not to admit female patients for fear
complications and outcome of patients. of stigma or because it might jeopardise
their chances of getting married.
Some countries like the United States and
Many treatment algorithms developed over
countries in Europe are reluctant to use
ECT despite the evidence of the efficacy of the years stated that ECT was used as last
resort treatment for patients who were not
this treatment. ECT was used in patients
suffering from depression, mania and responding to pharmacotherapy or
psychotherapy. Recently all these
schizophrenia which are slightly different
from the literature where ECT is mainly algorithms state the efficacy of ECT and the
importance of using it patients to reach
used for depression as reported by the
faster response and allow our patients to
Royal College of Psychiatrists (1995).
However, recently an abundance of have a better quality of life.
literature has proved that ECT is as Egypt and most developing countries have
effective in mania as it is effective in many economic and financial problems
depression (American Psychiatric which necessitate finding a treatment which
Association (2002). The American has a rapid onset of action, shorter duration
Psychiatric Association task force on ECT of stay in hospital, leads to the use of lower
(2001), reported that ECT was underused doses of pharmacotherapy and is cheap
and that there are many indications for ECT compared to the newer generations of
other than mood disorders and antipsychotics and antidepressants. ECT is
schizophrenia. one of the main answers.
Out of the 399 patients 273 were male 126 In a study conducted in Egypt by Okasha
female, the lower rate of female patients is and Ramy (2006) to review the economical
111
aspects of using ECT in mania, carried out Developing countries should not follow the
on 60 patients in both a university hospital steps of developed countries when it comes
and a private psychiatric hospital, it was to algorithms in treatments, but should
found that patients receiving ECT for the create their own guidelines for treatment
treatment of mania compared to patients not which in more reality based according to
receiving ECT had a shorter hospital stay at their needs and economical situation. It
19 days versus 38 days and the cost of should be the first line treatment for severe
hospitalization was 4845 EGP (850 USD) depression (psychotic depression), acute
compared to 8464 EGP (1485 USD) in the mania and excited or agitated
non ECT group. The cost of treatment as schizophrenia.
well as the duration of stay in hospital are All psychiatrists should be acquainted with
critical factors in psychiatric health care in the state of art in giving ECT and be able to
Egypt, where the turn over is high in
present the treatment to the patient and the
hospitals in order to accommodate patients patient’s relatives in a knowledgeable and
in need for hospitalization and at the same
scientific manner, in order to reduce the
time decreasing the cost of hospitalization, stigma and transmit the fact that it is no
which is essential due to budget constraints,
longer “shock” or “convulsive” treatment.
noting that unfortunately, the majority of Emphasis on the fact that it should not be
patients pay for these services out of their
the last resort treatment as stated in some
pockets in Egypt. treatment algorithms, but rather a first line
Similarly the use of ECT in patients with therapy when indicated.
co-morbid severe depression with other axis According to the World Psychiatric
I diagnoses such as OCD, panic and
Association ethical guidelines known as the
substance abuse was effective in the “Madrid Declaration”, any psychiatrist who
alleviation of depression and improving the
is not abreast of knowledge and with holds
symptoms of the primary diagnosis with treatment from a patient is unethical
pharmacotherapy, this does not mean that
(Okasha etal., 2000). That is to say
ECT should be used as a first line treatment withholding an effective treatment like ECT
for these disorders.
from a patient can be considered as
From the 2866 ECT sessions there were no unethical.
mortalities which are in agreement with the Based on the evidence derived from
literature which states that the mortality rate randomized controlled trials and extensive
with ECT is 1/10000 ECT sessions (Royal
clinical experience for nearly 70 years, ECT
College of Psychiatrists, 1995). There were is, presently, the most effective treatment
also no cardiovascular or respiratory
for certain psychiatric disorders. In
complications or acute confusion states consideration of what can be achieved, the
which are common with the use of non-
most transient memory disturbance is a
modified ECT (Beyer etal., 1998). moderate price. The benefit to risk ratio of
The group of patients receiving unilateral ECT is usually favourable.
ECT was in an attempt to decrease the
Principles of biomedical ethics, endorsed
cognitive deficit that patients may suffer four principles of ethics. Without ranking
with bilateral ECT mainly as recent their importance, the principles are
memory affection.
112
beneficence (doing good), nonmaleficence Beauchamp, T.L., & Childress, J.F (2001):
(not doing harm), autonomy (respect for the Principles of biomedical ethics (5 th Ed).
individual) and justice (being fair) Oxford. Oxford University Press
(Beauchamp and Childress, 2001). Ottosson
Beyer, J., Weiner, R. and Glenn, M. (eds.)
and Fink (2004) state that in most cases the (1998): Electroconvulsive therapy, a
use of ECT is in agreement with the
programmed text. American Psychiatric
principles of beneficence, nonmaleficence, Press, Inc
and respect for autonomy. Sadly, the
principle of justice is far from satisfied. D’Elia, G. (1970): Unilateral
electroconvulsive therapy. Acta Psychiatr.
An urgent goal of mental health care should Scand. (Supp 1.215), 5 – 98
be to provide access to ECT and eliminate
the severe impediments to its use, so long Fink, M.: Convulsive Therapy (1979):
as it can defend evidence based superiority Theory and Practice. Raven Press
over other treatments. Fink, P.J. and Tasman, A. (1992): Stigma
Limitations of the study and Mental illness. American Psychiatric
Press. Inc.
The study was carried out in a selective
group of patients who required admission in Hay, D.P: The stigma of Electroconvulsive
a private hospital which is not Therapy (1992): A workshop: Introduction.
representative of the whole Egyptian patient Quoted from Stigma and Mental Illness
sample; future studies should also include Fink, P.J. and Tasman, A. (Eds.) American
university and state hospitals. In depth Psychiatric Press Inc.
study of prognosis of different patient ICD - 10 Classification of Mental and
diagnoses should be carried out in future Behavioural Disorders. Diagnostic
studies as well as studies on ECT given on Criteria for Research (1993): WHO
out patient basis. Geneva.
References ICD - 10 Symptom Checklist of Mental
Abrams, R. (1992) (Ed.): Electroconvulsive Disorders (1994): WHO Geneva.
Therapy. 2 edition. Oxford University Janca, A., Ustrin, B., Isaac,M., Van
Press. New York. Drimmelen, J. and Dittman, V. (1994):
American Psychiatric Association (2001): ICD – 10 Symptom Checklist for Mental
The Practice of Electroconvulsive Therapy: Disorders. Division of Mental Health World
Recommendations for treatment, Training Health Organization - Geneva - Version,
and Privileging- A taskforce report, 2nd ed. 1.1
American Psychiatric Press, Washington Okasha, A. (2006): Plenary lecture
DC presented at the WPA International
American Psychiatric Association (2002): Congress, Istanbul, Turkey.
Practice guideline for the treatment of Okasha, A. (1988): Okasha's Clinical
patients with bipolar disorder (revision). Psychiatry. Anglo Egyptian Bookshop,
Am J Psychiatr 159 (Suppl 4), pp.1-50 Cairo.
113
Okasha, A., Arboleda-Florez, J. and and bilateral ECT. Am. J. Psychiatry 143:
Sartorius, N. (2000): Ethics Culture and 1040 – 1041
Psychiatry International Perspectives. Weiner, RD. (1991): The monitoring and
American Psychiatric Press.
management of electrically induced
Okasha, T. and Ramy, H. (2006): Using seizures. Psychiatr. Clin. North America 14:
Electro-convulsive Therapy (ECT) in the 845 – 869
Treatment of Mania: Economical Aspects
Author
(in press).
Okasha T.
Ottosson, JO. and Fink, M. (eds.) (2004): Assistant Professor of Psychiatry,
Ethics in Electroconvulsive Therapy.
Brunner-Routledge, Taylor & Francis Ain Shams University
Group.
Address of Correspondence:
Rakhawy, Y.T.: Electroconvulsive Therapy
(1982): A Synchronizing Remedy. Egypt. J. Okasha T
Psychiatry, 5, 17-21. 3, Shawarby Street, Kasr El Nil, Cairo,
Royal College of Psychiatrists (1995): The Egypt.
ECT handbook. The second report of the E-mail: [email protected]
Royal College of Psychiatrists’ Special
Committee on ECT.
Swartz, CM. and Larson, G. (1986):
Generalization of the effects of unilateral
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114
Assessment of Neurochemical Alterations that Occur in Bipolar

Patients Following Medication Using Proton Magnetic Resonance
Spectroscopy.
Fikry M, Hussein M.
Abstract :
Several studies demonstrated the neurochmeical alterations in bipolar patients using proton
magnetic resonance spectroscopy (MRS). Few studies compared between the changes that
occur before treatment and that which occur after the patient achieved complete remission.
Patients with bipolar disorder having manic episode were hypothesized to demonstrate
metabolic abnormalities with in the anterior cingulate and that these abnormalities are altered
with medication. Twenty patients with bipolar disorder (age 20-53 years, mean 29.5 ± 7.61)
with a mean duration of (32.65 ± 12.93) to achieve complete remission were evaluated with
proton MRS. The metabolic concentration of the anterior cingulate were calculated using a
single voxel. The results of this study revealed that there is a significant decrease in the level
of myo-inositol following treatment. In addition there is a trend towards increase in the level
of N-acetyl aspartate following medication. However there was no significant difference in
the level of choline and creatine. The results of this study suggest that there is abnormalities in
the phosphoinositid cycle as evident by the significant changes that occur in the myo-inositol
level. Changes that occur in N-acetyl aspartate level suggest that there is neuronal dysfunction
in bipolar patients and that it may need more time to be more evident.
Introduction
Bipolar disorder is a common, life long histopathologic reports demonstrating
marked reduction in density and size of
illness that typically begins in late
adolescence. The illness is implicated in cortical neurons and glial cells (Rajkowska,
1997; Ongur et al, 1998).
functional impairment and represents an
important risk factor for suicide (Oquendo One strategy used to gain insight into the
and Mann, 2001). However, the underlying pathophysiology of a
neurochemistry and pathogenesis of bipolar disease/illness is to identify the
disorder remain poorly understood. mechanism(s) of action of medications
Evidence implicating abnormal frontal which reduce symptom severity in the
circuitry in the pathophysiology of mood majority of patients afflicted with the
disorders is known (Soares and Mann, disease/illness. There is mounting evidence
1997). Morphometric measures of frontal suggesting that the phosphoinositide –
(prefrontal and orbitofrontal) structures protein kinase C (PI-PKC) signal
have demonstrated a trend for decreased transduction pathway is a common target of
volume particularly in gray matter (Lim et chronic mood stabilizer, atypical
al, 1999; Sax et al, 1999). Cerebral blood antipsychotic and antidepressant drugs
flow and metabolism investigations suggest (Calker and Belmarker, 2000).
frontal hypometabolism in patients with
Moreover, until very recently Lithium was
mood disorders (Drevets et al. 1997). the mainstay of long term treatment for
Consistent with these findings are
115
patients with bipolar disorder (Geddes et al, been discovered as a major second
2004). Lithium is an uncompetitive messenger system (Berridge and Irvine,
antagonist of inositol monophosphatase 1989). Receptor stimulation by
thus resulting in increased concentrations of neurotransmitters activates phospholipase C
the inositol monophosphates (Berridge and enzyme in a number of membrane receptor
Irvine, 1989), and a corresponding decrease signaling pathways. Phospholipase C
in myo-inositol concentration based upon triggers the break-down of
these findings it was hypothesized that the phosphatidylinositol-bis-phosphate (PIP2)
clinical utility of lithium in bipolar disorder to inositol 1,4,5 triphosphate (IP3), which
may be due to these actions on the PI cycle releases calcium from internal stores. A
(Berridge et al, 1989). series of phosphatases remove the
Phosphotidylinositol (PI) is a major phosphate groups from IP3 sequentially,
releasing free inositol (Frey et al, 1998).
component of neuronal cell membranes.
The phosphoinositide cycle (Fig 1) has
occur in psychiatric disorders such as

Magnetic resonance spectroscopy (MRS) is
a non-invasive computerized imaging schizophrenia, dementia and affective
disorders (Malhi et al, 2002). Recently it
technique that relies on the same nuclear
magnetic resonance (NMR) principles that has been used to identify the neurochemical
effects and predictors of response to
form the basis of magnetic resonance
imaging (MRI) and functional MRI (fMRI). medication commonly used to treat bipolar
disorder (DelBello et al, 2006).
It is used in both clinical and research
settings to study brain chemistry, as it Over the past decade a growing number of
enables the relative quantification of certain magnetic resonance spectroscopic studies
compounds and their constituents in investigating the neurochemical basis of
specific brain regions (Chakos et al, 1998). bipolar disorder have been accumulated.
In psychiatry, MRS is increasingly used to However, there have been mixed results
research the neurochemical changes that from these studies preventing a conclusion
116
on the direction of the alterations expected (MRI), a diagnosis of mental retardation

on individual neurochemcials (Brambilla et were excluded from the study.
al, 2005a). The institutional review boards of research
With these considerations in mind, the aim of Ain Shams University Institute of
of this study was to identify the Psychiatry approved the study protocol. All
neurochemical effects of treatment in participants provided an informed consent
bipolar patients presenting with manic with after complete description of the study
psychotic features in the anterior cingulate. protocol was provided to them.
We hypothesized elevated myo-inositol
Procedures:
(MI) would reflect impaired
phosphoinositide metabolism and decreased Manic symptoms were assessed using the
N acetyl aspartate (NAA), choline (Cho)and Young Mania Rating Scale Score (YMRS)
Creatine (Cr) of the prefrontal cortex would (Young et al, 1978). The mean score before
reflect impairments in neural function and starting any medication was 47.65 ± 6.1.
that these metabolites are altered with The patient before scanning did not receive
medications. any medication except for Midazolam
intravenous between 15 to 20 mg to sedate
Methodology : the patients during scanning as any slight
Subjects: movement affect the scanning. Medications
Patients hospitalized with bipolar disorder to which the patient responded include
mood stabilizer, antipsychotic and ECT are
receiving the diagnosis manic with
psychotic features were recruited from summarized in table 3. The medication was
consecutive admissions to the inpatient adjusted according to the protocol of each
unit and patients’ past history of medication
psychiatric units at the Institute of
Psychiatry Ain Shams University Faculty of to which they responded. The mean
duration to which the patients achieved
Medicine. Twenty patients were between 20
ad 53 years with a mean age (29.5 ± 7.61). complete remission was 32.65 ± 12.93 to
which the mean score of YMRS was 4.8 ±
Twelve patients were male (60%) and 8 2.04.
patients were female (40%). The diagnosis
were made according to ICD10 using the Magnetic resonance imaging and
ICD10 symptoms check list. The mean spectroscopy:
duration of the illness was 7.15 ± 5.33, with Structural imaging and spectroscopy were
a mean age of onset 22.35 ± 6.6 and a mean performed using a 1.5 T Philips Intera
number of episode 5.2 ± 3.49. Ten patients scanner and a quadrate proton head coil.
(50%) had a positive family history of Following sagital image localization, a 3D
mood disorder as out lined in table 1 and 2. coronal volume scan (SPGR; 124/60 slices;
matrix: 256 x 192; 1 NEX; Flip angle = 45;
Patients with history of ICD10 substance
dependence excluding tobacco, any major SLT = 1.5/3mm; TE = 5 ms; TR = 35 ms)
was acquired for image segmentation and
medical or neurological disorder, a history
of head trauma, any contraindication to T2 weighted axial images were used for
spectral localization.
receiving a magnetic resonance imaging
117
Water suppressed localized spectra were Data were processed and pertinent
acquired using a 16 x 16 MRS I grid [ field metabolic ratios were obtained via intensity
of view : 16 x 16 cm; voxel size : 1 x 1 x 2 values generated by the machine. The
cm; in plan (axial) thickness : 2 cm] and the spectral peak areas for Myo-inositol (MI),
PRESS pulse sequence (echo time = 6000 N-acetyl aspartate (NAA), choline (Cho)
ms; repetition time = 31 ms and 144 ms). A and creatine (Cr) were expressed as peak
single voxel was centered on the anterior intensity curves in both short Fig (2,4) and
cingulate cortex and midline with sufficient long sequences (Fig 3,5).
tissue surrounding it being no closer than 1
cm from the skull.
Table (1): Descriptive analysis of the sample
Minimum Maximum Mean ± Sd

Age 20 53 29.5 ± 7.61
Age of onset 16 43 22.35 ± 6.6
No. of episode 2 13 5.2 ± 3.49
Duration of illness 1 21 7.15 ±5.33
YMRS before treatment 30 54 47.65 ± 6.1
YMRS after treatment 2 8 4.8 ± 2.04
Time to B.L 15 55 32.65 ± 12.93
Table 2: Gender and Family history
Sex Male 12 60%
Female 8 40%
Family history Positive 10 50%
negative 10 50%
118
Age Sex Age of No. of Family Duration of YMRS YMRS Time to Medications
Patient onset episode history illness before after return to
treatment treatment baseline
1 30 M 17 12 Negative 13 52 6 55 Carbamazpine, Risperdone, ECT
2 23 F 21 2 Positive 2 50 7 35 Lithium, Haloperidol, ECT
3 30 M 25 5 Negative 5 52 4 34 Carbamazpine, Haloperidol, ECT
4 28 M 20 6 Positive 8 50 6 40 Lithium, Trifluperazine, ECT
5 25 M 20 5 Positive 5 54 8 28 Lithium, Olanzapine ECT
6 26 F 20 6 Negative 6 39 2 20 Carbamazpine, Haloperidol ECT
7 30 F 28 3 Negative 2 40 2 19 Lithium, Risperdone, ECT
8 20 M 16 4 Positive 4 49 8 53 Divaloprate. Clozapine ECT
9 28 F 16 12 Negative 12 50 4 25 Carbamazpine, Triflueperazine ECT
11 28 M 22 2 Negative 6 50 5 28 Lithium, Divaloprate, Aripiprazole ECT
12 26 F 16 4 Positive 10 43 5 20 Lithium, Risperdone, ECT
13 28 M 27 2 Positive 1 52 7 52 Lithium,Carbamazepine Risperdone, ECT
14 53 F 43 5 Negative 10 30 4 15 Carbamazpine,Chloropromazine
15 35 M 28 2 Negative 7 50 4 33 Lithium, Haloperidol, ECT
18 26 M 20 5 Positive 6 53 4 35 Lithium, Clozapine ECT
19 24 M 22 2 Positive 2 45 5 25 Lithium,Risperdone, ECT
Statistics: Statistical analysis was done = 2.9, P<0.01), in the post medicated
patients. However, although the increase in
using the Statistical Package for Social
Sciences (SPSS) version 10. Wilcoxon N-acetyl aspartate is non significant, there
is a trend towards increase of NAA in most
Signed Ranks test was used to detect the
difference between metabolites before and patients (Z=0.3, P>0.05). Moreover there is
no statistical difference in Choline (Z=0.73,
after medications
P>0.05). and creatine level (Z = 0.21,
Results: P>0.05). in patients following medication
The result of our study reveal that there is (table 4).
significant decrease in myoinositol level (Z
Figure 2: Premedication short
Figure (3): Pre-medication long
120
Figure 4: Post medication short Figure 5: Post medication long
Table (4): Comparison between metabolites pre and post medication
Pre medications Post medications Z value Sign.

Min Ma Mean Min Max Mean
x
MI 53 515 162.6±125.9 36 150 75.7±29.6 2.9 <0.01
NAA 63 232 130±54.5 68 302 170±70.1 0.3 >0.05*
Cho 24 175 68.5±44.9 34 190 87.8±56.4 0.73 >0.05
Cr 8 224 99.4±56.1 20 176 98.5±48.9 0.21 >0.05
*although the p value of NAA is not significant, yet there is a trend towards increase.
Discussion:
Magnetic resonance spectroscopy (MRS) is Anterior cingulate was chosen in this study
a non-invasive approach that allows in vivo since the prefrontal cortex has been linked
investigation of brain chemistry. The most to the regulation of the expression of
commonly used spectroscopic approach is emotional state. (Sax et al, 1999). Within
proton MRS (1 HMRS) which can detect the prefrontal cortex the anterior cingulate
myo-inositol (MI) N-acetyl aspartate has extensive connections with other brain
(NAA), choline containing compounds areas involved in emotional processing
(Cho) and creatine (Cr) which is composed (Bush et al, 2002), such as amygdale,
of phosphocreatinine and creatinine which insula, thalamus and preiaqueductal gray
are high energy phosophate metabolites matter, and orbital cortex (Lane et al, 1998;
(Brambilla et al, 2004). Barbas, 2000). Therefore it has been
implicated in the pathophysiology of
121
bipolar disorder because it participates in be a marker of neuronal integrity, viability

modulating decision making, planning and and activity (Urenjak et al, 1993). Our
mood regulation (Drevets et al, 1998, Vogt results reported a trend towards an increase
et al, 2003). in NAA concentration following
medications. This is in agreement with
Myo-inositol (MI):
Moore et al 2000 who reported an increase
Myo-inositol plays a crucial role in the in NAA concentration with in the frontal
transduction of signals in the brain acting as lobe following 4 weeks of lithium therapy
a second messenger and being the key in adult patient. Consistent with these
intermediate of the phosphinositol pathway finding DelBello et al 2006 who reported
and the substrate for recycling of inositol olanzapine remitters patients exhibited a
phospholipid (Stanley, 2002) greater increase in medial ventral prefrontal
The results of our study indicate that there NAA level compared with non-remitter.
is significant reduction of the myo-inoistol Also Cecil et al 2003 reported 8% lower
level following complete remission. This is for NAA level in children with a mood
in agreement with previous reports disorder with in the cerebellar vermis
Davanzo and colleagues 2001, who found compared with healthy children.
increased myo-inositol level in the anterior Furthermore increased bilateral thalamic
cingulate cortex of children with bipolar NAA levels have been shown in euthymic
disorder during the manic phase and male patients with bipolar 1 disorder
subsequent decease following 7 days of compared with healthy control (Deicken et
lithium intake. Also Cecil et al, 2003, al, 2001). Brambilla et al 2005a concluded
reported 16% elevation in the myo-inositol that this increase in NAA level may reflect
concentration in the frontal cortex in bipolar neuronal hypertrophy, reduced glial density
patients in the manic phase. Moreover other or abnormal synaptic or dendritic pruning.
studies investigating the euthymic state The result of our study though revealed
found no difference in the level myo- only a trend towards increase in NAA level
inositol between patient and healthy control yet it is preliminary and needs replication
(Winsberg et al, 2000; Silverstone et al with assessment of the effect of medication
2002; chang et al, 2003). The results of our on the long term basis and its effect on the
study support the hypothesis of previous structure changes that occur due to
studies that in bipolar patients who are medications.
acutely ill, there is abnormal PI cycle Choline (Cho):
activity. In euthymic patients any
abnormalities in PI cycle functioning are Choline (Cho) resonance is predominantly
composed of phosphorylcholine (PC) and
normalized possibly secondary to the effect
of medications. glycerophosphoryl choline. Therefore, the
Cho Peak is considered as a potential
N-acetyl aspartate (NAA) : biomarker for the status of membrane
N-acetyl aspartate is the second abundant phospholipids metabolism (Moore and
aminoacid after glutamate, in the human Galleway 2002). The results of our study
brain and is the most prominent peak in the find no significant difference between
proton spectrum after water. NAA is found choline level before and after medication.
only in the mature neurons and is thought to This is consistent with other studies where
122
subjects were mostly on lithium which reported no significant difference between

couldnot detect any significant difference in euthymic bipolar patients and normal
choline levels between patients and controls cortrol in the basal ganglia, frontal cortex
in different brain regions (Stoll et al, 1992; and dorsolateral prefrontal cortex.
Bruhn et al, 1993; Kato et al, 1994; ohara Moreover studies investigated the
et al, 1998; Amaral et al, 2002; Brambilla, depressive phase Friedman et al 2004 and
2005b). However other studies reported Dager et al 2004 reported the same result in
increased choline in the basal ganglia of cingulate, thalamus, parietal and occipital
euthymic bipolar patients compared with lobe. Therefore it seems that the level of
healthy subjects, a findings not attributable creatine is relatively constant through out
to lithium since most of the subjects on the phases of the illness.
these studies were not taking lithium
Limitation of the study:
(Sharma et al, 1992; Lafer et al, 1994;
Kato et al, 1996; Hamakawa et al, 1998). It should be pointed out that the present
Another study by Moore et al 2000 study has a number of limitations. We only
reported increase choline in the right investigated metabolism in the anterior
cingulate cortex compared with control cingulate cortex using a single voxel
subjects. From the previous studies technique with inability to compare
Bramella et al 2005a concluded that between the right and left cingulate as this
elevated choline levels in bipolar disorder if would need more time with equivalent
present may be specific for basal ganglia increase in sedation doses. Also the small
and may be independent of lithium number of the subjects with heterogeneity
treatment suggesting alterations in regarding the duration of the illness, family
membrane metabolism. history and medication used.
Creatine (Cr) In conclusion we have noted alterations in
the myo-inositol level and N-acetyl
Creatine peak reflects the presence of both
aspartate in the anterior cingulate before
creatine and phosphocreatine. The and after treatment. However, the results of
equilibrium between creatine and
this study is very preliminary and need
phosphocreatine is determined by the further replication taking in consideration
cellular demand for high energy phosphate
larger samples, other phases of the illness
stored as creatine phosphate (Moore and as depressive and mixed phases, first
Galloway, 2002). The results of our study episode patients with longitudinal studies,
revealed that there is no statistical
using same treatment and further detailed
difference between creatine level before analysis of the aminoacid moieties
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126

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127
Bipolar Mood Disorder Among Children of Attention Deficit

Hyperactivity Disorder
Yousef I., Tantawy A., Elsayed O., AbdAlmoez K., Bishry Z., Haggag W., Zakaria A.,
Abstract
Bipolar mood disorder is one of the most difficult disorders to recognize in children because it
does not fit precisely the adult criteria. Since there is overlap regarding major symptoms
between Bipolar Mood disorder and Attention Deficit Hyperactivity disorder in children, we
hypotheses that Attention Deficit Hyperactivity disorder is over diagnosed and Bipolar Mood
disorder is under diagnosed. One hundred and twenty children have the diagnosis of Attention
Deficit Hyperactivity disorder were reevaluated for Bipolar Mood disorder using DSM-IV-
TR., Conner's Rating Scale, Achenbach's Child Behavior Checklist, Clinical Administered
Rating Scale for Mania and Parent Version of the Young Mania Rating Scale. Out of 120
Attention Deficit Hyperactivity disorder Children, 45 children (37.5%) were re-diagnosed and
met the criteria of Bipolar Mood disorder. There were statistical significant difference
between the two groups regarding gender, type of school, family history of Bipolar Mood
disorder and social and sport participation. We concluded that Bipolar Mood disorder can be
misdiagnosed in children as Attention Deficit Hyperactivity disorder so these children will not
receive their proper management and be socially impaired with high level of behavioral
difficulties, school failure and poor academic performance.
Introduction
Although bipolar mood disorder (BPD), is chronic and carry high risks of substance
abuse and suicide. BPD is often recognized
probably the most prevalent psychotic
disorder in adults, it has been relatively in adolescents, but the syndrome or its
antecedents are almost certainly under
neglected in children and adolescents over
the past century (Anthony and Scott, 2000). recognized and under treated in children
(Weller, et al., 2001; Adler, et al., 2005;
The literatures on early onset BPD that
estimated prevalence, particularly before Faraone, et al., 2005; Kowatch, et al., 2005;
puberty, is limited by historical biases Udal and Groholt, 2006). Controlled studies
of short and long term treatment, course,
against pediatric mood disorders and by
formidable diagnostic complexity and co and outcome regarding BPD remain
strikingly limited, and the syndrome
morbidity (Weinberg and Brumback, 1976).
Although clinical features of pediatric and urgently requires increased clinical and
scientific interest. The relationship between
adult BPD have similarities, pediatric cases
probably cannot be defined solely by BPD and attention-deficit hyperactivity
disorder (ADHD) in children has been one
features characteristic of adult cases. Onset
was before age 20 years in at least 25% of of the most hotly debated topics in recent
child psychiatry (Giedd, 2003). At the heart
reported BPD cases, with some increase in
of matter, there is a large numbers of
this incidence over the past century
(Carlson, 1999). Pediatric BPD episodes children with bipolar disorder are being
unrecognized or misdiagnosed (Pliszka,
frequently include irritability, dysphoria, or
psychotic symptoms; they are commonly 2001). It was reported that the most
129
diagnostic clinical dilemmas seem to arise hyperactivity which are seen in the ADHD
in child psychiatry from overlapping patients (Wozniak, et al., 2003).
symptomatology between BPD and ADHD Conversely, twenty two percent of those
(Sachs, et al., 2003). Prominent children diagnosed with ADHD fit the
hyperactivity and impaired concentration in criteria for BPD (Butler, et al., 2000). It is
ADHD make a problem in differential extremely important to identify children
diagnosis with early BPD, and the two are with dual diagnosis (BPD and ADHD) in
strongly related. Since these disorders share order to receive proper management and get
features, misdiagnosis may occur, probably better quality of life. We have to test the
more often in children than in adolescents hypothesis that ADHD may be a childhood
(Biederman, et al., 2002). A recent study version of BPD among some children and
helps to clarify this relationship: 91% of to study the impact of BPD among children
children evaluated with current or previous on their social competencies, behavioral,
mania also met criteria for ADHD, while and academic performance.
only 19% with a diagnosis of ADHD also
Subjects and Methods
met DSM-VI-TR criteria for current or
previous mania. Similar diagnostic criteria Subjects:
persisted even after elimination of A cross sectional comparative study was
obviously similar symptoms found in both carried out over one year period on children
disorders, such as hyperactivity, attending the Neuropsychiatry Outpatient
talkativeness, and distractibility (Wozniak, Clinic in Suez Canal University Hospital.
et al., 2003; Adler, et al., 2005; Faraone, et One hundred and twenty children coming
al., 2005; Kowatch, et al., 2005; Udal and for follow up of their ADHD, diagnosed
Groholt, 2006). Hyperactivity, impulsivity, according to DSM-IV-TR criteria without
and inattention are seen in children with co morbid psychiatric disorder, were
ADHD and BPD, but these two disorders included in our study. Our group study had
are radically different in terms of the impact fulfill the following including criteria:
that they have on a child's life. Determining children aged 6-12 years old, the child must
causes of child behavioral problems is be accompanied by at least one of his or her
extremely important. ADHD is far less parents and consent was obtained from one
severe regarding impairment than BPD. of the parents. Children with epilepsy, other
The most important problems for an ADHD apparent neurological manifestations or any
child are how to slow down, focus, and sign or symptom suggestive of physical
organize his life. The most important disorder were excluded from the study.
problem for a child with BPD is how to
manage his mood shift from potentially Sampling strategy:
destructive hypomania, to a depression, so Woolston and Mayes (2001) study the rates
dark that it can be paralyzing or suicidal of bipolar disorder in a group of ADHD in
(Akiskal, 2000). It may be difficult to child Neuropsychiatry Outpatient they
distinguish bipolar disorder from ADHD. found that 23%children how diagnosed as
Ninety eight percent of children with the ADHD were re-diagnosed and met the
diagnosis of BPD also qualify for the criteria for BPD. Z X p (1- p)
diagnosis of ADHD because of the presence
of inattention, impulsivity, and
130
The sample size was 120 children according have suggesting raising the cut off score for
to the following equation: N = -D2 behavioral problems up to 19 points.
Methods: II- Achenbach's Child Behavior
Children in our study were examined and Checklist (CBCL) (1982)
subjected to: fully detailed psychiatric sheet The Child Behavior Checklist (CBCL) was
designed in our psychiatry department, developed by Achenbach, (1979) and
using DSM-IV-TR diagnostic criteria. The modified by Achenbach and Edel-brock,
interview with one or both parents, the (1983). It was designed to provide mental
evaluation included observation of the child health professionals with a reliable means
behavior, the child parent interaction and of assessing the behavior problems and
the separation process. Parents were asked social competencies of children referred for
to fill the questionnaires independently. treatment. More recently direct observation
Those who can not read were helped by the Achenbach, (1988), revised the method of
interviewers. scoring of the parent CBCL and extended
the range of scores on each behavior
Methodological Tools :
problem scales. In epidemiological studies
I- Conner's Rating Scale it is used as a screening instrument for case
It is one of the most widely used scales in identification (Bird, et al., 1987). Another
rating behavior. A total score is derived version was done by Achenbach and Edel-
from the scale and the cut off score of 15 brock, (1991), it is one of the most
has been established as the point that extensively used parent report
confirms the presence of ADHD since it is questionnaires that assess social
very much above the scores received by competencies and behavioral problems
normal children (Conner, 1969). Conner's among children aged 4 to18 years old
scale appears to distinguish with good and (Achenbach and Edel-brock, 1983; 1991).
accepted precision between normal and The CBCL is designed to obtain
hyperactive disturbed children. In order to standardized parents report of children's
facilitate the practical use of this scale it problems and competency. It is for ages 4
was translated to Arabic language and was to 18 and can be completed in 15 to 17
given to referees to comment on the minutes. Rigorous cross-cultural
adequacy and fluidity of the items comparisons of CBCL data have been
compared to the original version (El- reported on children from USA, Holland,
Defrawi, et al., 1992). In Egypt, Conner’s Thailand, Australia and French (Achenbach
ADHD scale, when applied to children and Edel-brock, 1987; Verhulst, et al.,
diagnosed as having ADHD, appeared to be 1995; Offord, 1995). According to
very effectively differentiating them from Achenbach and Edel-brock, (1991),
children with no psychiatric complaints. maternal reports were compared with initial
However, the score of 15 is low especially teacher reports and the means of both were
for young children (6-8 years) and in spite used to contrast differences between boys
of statistical distinction between normal and girls. The CBCL is designed to be self-
children and children referred for ADHD, it administered by parents who have at least
may lead to identification of false positive fifth grade reading skills, but it can also be
for this reason, EI Defrawi, et al., (1992) administered by an interviewer. Arabic
131
version of CBCL was done by El Defrawi, the severity of a manic state for either
et al., (1991), the instrument was initially clinical or research purposes. Because it is
translated into Arabic for use with Egyptian compatible with DSM-IV criteria, it may be
parents; the translation was reviewed by used to evaluate the presence of manic
child psychiatrists and clinical symptoms in order to facilitate diagnostic
psychologists who are fully bilingual. After assessment. Psychotic symptoms also may
being modified in the course of this review, be assessed with the CARS-M. For studies
the instrument was back translated by a investigating patient responses to clinical
professional translator from the university, treatment, the CARS-M can provide a
the bilingual mental health professionals reliable measure of efficacy. This rating
reviewed the back translation to ensure that scale help parents and teachers recognize
the connotations of the original CBCL mania in children and adolescents (Alessia,
items were accurately captured and et al., 2002). The CARS-M contains 2
vernacular expressions were added where subscales, each of which is scored
necessary to facilitate understanding. separately. To derive the mania subscale
Achenbach's child behavior checklist, score, items 1 through 10 are summed. To
contains 113 items for which a parent and/ gauge severity level, the following cut off
or teacher uses a three-point scale to rate points is recommended: 0-7 none or
each behavior. According to the parent questionable mania; 8-15 mild; 16-25
report: moderate; and 26 or greater indicates severe
symptomatology. The second subscale,
A) Internalizing factors are anxious,
which measures psychotic symptoms/
schizoid, depressed, uncommunicative,
obsessive compulsive, somatic complaint disorganization, is derived by summing
items 11 through 15. Both subscale scores
and social withdrawal. B) Externalizing
factors are hyperactive, aggressive and may be totaled to yield a global measure of
mania with psychotic features. However,
delinquent. Since the norms for the CBCL
are based on no clinical (normal) samples, the total score should not be used to
measure severity of mania, but rather, only
the CBCL may be used to determine
whether a child exhibits unusual or subscale 1 scores (items 1 to 10). The two
subscales allow for the independent
excessive behaviors relative to normal
children. assessment of manic versus psychotic
symptoms, which may respond differently
III- Clinician-Administered Rating Scale to treatment (Campbell, et al., 2002). It was
for Mania (CARS-M): translated by the researchers and was
The CARS-M is a 15-item clinician- revised by three experts in the filed to take
administered scale designed to assess the their consent to use it as a clinical tool.
severity of both manic and psychotic IV- Parent Version of the Young Mania
symptomatology in children. Most items Rating Scale (P-YMRS)
are scored from 0 (absent) to 5 (symptom
The P-YMRS consists of eleven questions
present to severe degree), based on
increasing severity. One item is scored from that parents are asked about their child's
present state. The original rating scale
0 to 4. The CARS-M takes approximately
(Young Mania Rating Scale) was developed
15-30 minutes to administer (Pavuluri,
2002). The CARS-M may be used to assess to assess severity of symptoms in adults
132
hospitalized for mania (Young, et al., Statistical Analysis:

1978). It has been revised in an effort to
Descriptive statistics such as number of
help clinicians such as pediatricians patients, percentages and means were used
determine when children should be referred
to describe the study population. For
for further evaluation by a mental health Comparative statistics, we used student t-
professional (such as a child psychiatrist),
test to compare means and chi square test to
and also to help assess whether a child's compare percentages. Data were collected,
symptoms are responding to treatment
entered into personal computer and
(Poolsup, et al., 1999). The scale is analyzed using EPI-Info version 6.04
intended to diagnose BPD in children. This
software (CDC, 2001) and SPSS V.13
version has been tested in a pediatric software (SPSS, 2002). Statistical
research clinic with a high number of significance was set at 5% level (p0.05).
children with bipolar disorder (Barbar, et
al., 2002). The child's total score is Results:
determined by adding up the highest Out of 120 Attention Deficit Hyperactivity
number circled on each question. Scores disorder Children, 45 children (37.5%)
may range from 0-60. Extremely high were re-diagnosed and met the criteria of
scores on the P-YMRS increase the risk of Bipolar Mood disorder (Table, 1). There
having BPD by a factor of 9, roughly the were statistical significant difference
same increase as having a biological parent between BPD group and ADHD group
with bipolar disorder. Low scores decrease regarding gender, type of school, family
the odds by a factor of ten. Scores in the history of BPD but no significant difference
middle don't change the odds much (Barbar, regarding age, residence and socioeconomic
et al., 2002). The average scores in children status (Tables, 2; 3). BPD group has
studied were approximately 25 for mania (a statistically significant higher scores
syndrome found in patients with BPDI), (Mean= 36.89±10.59) than ADHD group
and 20 for hypomania (a syndrome found in (Mean= 9.17±2.00), regarding YMRS-
patients with BPD2, BPD-NOS, and Parent Version as shown in table (4). BPD
Cyclothymia). Anything above 13 indicated group has statistically significant higher
a potential case of mania or hypomania for scores (moderate to severe degrees) than
the group that was studied, while anything ADHD group (normal to mild degrees),
above 21 was a probable case. In situations regarding CARS-M as reported by parent
where the odds of BPD diagnosis are high (Table, 5). ADHD group has statistically
to begin with (e.g., a child with mood significant higher scores (mean=
symptoms with 2 parents having bipolar 27.76±12.00) than BPD group (mean=
disorder), the P-YMRS can be extremely 18.78±4.59), regarding Conner’s Rating
helpful. But for most groups of people, the Scale parent form (Table, 6). BPD group
base rate of BPD is unknown but low. has statistically significant higher scores
Then, the most that a high score can do is than ADHD group in sport participation
raising a red flag (similar to having a family (Table, 7), but not in joining sport club
history of BPD) (Kaufman, et al., 2001). It (Tables, 8), according to CBCL. There were
was translated by the researchers and was statistical significant difference between
revised by three experts in the filed to take BPD group and ADHD group regarding
their consent to use it as a clinical tool. social and hobbies, academic performance
133
and externalizing or internalizing problems frequent involvement in social activities,

(Tables, 9-14). Finally, we put predictors of participation in house chores, arithmetic
BPD in children as family history of BPD, skills, school failure, YMRS-Parent
disturbances in relationship with parents Version score, CARS-M score and
and siblings, good number of friends, Conner’s score (Table, 15).
Table (1): Re-diagnosis of ADHD children as BPD.
Children with BPD Children with ADHD Total

No % No %
45 37.5 75 62.5 120
Table (2): Demographic Variables of Both BPD and ADHD Groups.
Demographic BPD Group ADHD Group

Variables N=45 N=75 P Value
N % N %
Age (Years) 6-8 13 28.9 23 30.7 0.321
8-10 19 42.2 39 52
10-12 13 28.9 13 17.3
Sex Males 26 57.8 49 65.3
Females 19 42.2 26 34.7 0.040*
Residence Urban 33 73.3 45 60 0.134
Rural 12 26.7 30 40
School Type Private 12 26.7 9 12 0.048*
Government 32 71.1 61 81.3
No school 1 2.2 5 6.7
Socioeconomic Low 15 33.3 33 44 0.246
Middle\High 30 66.7 42 56
*Statistically significant
134
Table (3) BPD group and ADHD group on Family history.

Family History BPD group ADHD group P Value
N=45 N=75
N % N %
BPD 23 51.1 7 9.3
ADHA 0 0 3 4
Other psychiatric 3 6.7 5 6.7
disorder 0.001*
No family history 19 42.2 60 79
psychiatric disorder
Table (4): BPD group and ADHD group according to Young (YMRS-Parent Version).
Psychiatric
diagnosis Number Mean S.D P value
BPD 45 36.89 10.59 0.001*
ADHD 75 9.17 2.00
Table (5): BPD group and ADHD group according to (CARS-M) as reported by parents.
CARS-M BPD group ADHD group P value
N=45 N=75
N % N %
Non 0 0 52 69.3
Mild 6 13.3 23 30.7 0.001*
Moderate 33 73.3 0 0
Sever 6 13.3 0 0
Table (6): BPD group and ADHD group according to Conner’s Rating Scale parent
form.
Psychiatric
diagnosis Number Mean S.D P value
BPD 45 18.78 4.59 0.001*
ADHD 75 27.76 12.00
135
Table (7): BPD group and ADHD group on Sport Practice according to the CBCL.
Sport Practice BPD group ADHD group P Value
N=45 N=75
N % N %
Actual sport practice N= 45 N=75
Participating 17 37.8 17 22.7
Not participating 28 62.2 58 77.3 0.044*
Time spent in sport activity N=17 N=17
Don’t know 0 0 4 5.3

Less than average 4 8.9 11 14.7
Average 11 24.4 2 2.7 0.001*
More than average 2 4.4 0 0
Degree of skillfulness in N=17 N=17 0.001*
sport activity
Don’t Know 0 0 4 5.3
Average 6 13.3 0 0
More than average 0 0 0 0
Table (8): BPD group and ADHD group in joining sport club according to CBCL.
Joining club BPD group ADHD group P Value

N=45 N=75
N % N %
Joining 9 20 14 18.7 0.858
Not joining 36 80 61 97
Table (9): BPD group and ADHD group in Hobbies according to CBCL.
Hobbies BPD group ADHD group P Value

N=45 N=75
N % N %
Yes 19 42.2 19 25.3
No 26 57.8 56 74.7 0.045*
136
Table (10): BPD group and ADHD group participation in house chores according to
CBCL.
Participation in house BPD group (N=45) ADHD group (N=75) P Value

chores
N % N %
Participating 30 66.7 25 33.3
Don’t participating 15 33.3 50 66.7 0.001*
Table (11): Social Competence between BPD group and ADHD group according to
CBCL.
Social competence BPD group (N=45) ADHD group (N=75) P Value
N % N %
Relation with parents
Worse 20 44.4 45 60
About the same 20 44.4 20 26.7 0.001*
Better 5 11.2 10 13.3
Relation with siblings
Worse 16 35.6 38 50.7
About the same 19 42.2 33 44.0
Better 10 2.2 4 5.3 0.001*
Table (12): Social activities in BPD group and ADHD group according to CBCL.
Social activity BPD group (N=45) ADHD group (N=75) P Value
N % N %
Number of friends
No friend 0 0 24 32
One friend 5 11.1 39 52 0.001*
Two or three friends 11 24.4 11 14.7
Four friends or more 29 64.5 1 1.3
Social involvement with friends 0.001*
Less than one time 2 4.4 58 77.3
One or two times 6 13.4 16 21.4
Three or more times 37 82.2 1 1.3
137
Table (13): BPD group and ADHD group in school performance according to CBCL.
School performance BPD group (N=44) ADHD group (N=70) P Value

N % N %
School failure 24 54.5 41 58.6
No School failure 20 45.5 29 41.4 0.535
N.B: 6 children were drops out from school (one child from the BPD group and 5 children
from the ADHD group).
Table (14): BPD group and ADHD group on academic performance according to CBCL.
Academic subjects BPD group (N=44) ADHD group (N=70) P Value
N % N %
Performance in Arabic subject
Failure 8 18.2 37 52.9
Less than average 12 27.2 27 38.6 0.001*
Average 16 36.4 6 8.5
More than average 8 18.2 0 0
Performance in Arabic
spelling
Failure 7 16 42 60
Less than average 18 41 28 40 0.001*
Average 11 25 0 0
Performance in Arabic reading
Failure 8 18 42 60
Less than average 20 45.5 28 40
Average 7 16 0 0
More than average 9 20.5 0 0 0.001*
Difficulty in arithmetic
Failure 34 77.3 45 64.3
Average 1 2.2 6 8.5 0.877
N.B: 6 children were drops out from school (one child from the BPD group and 5 children
from the ADHD group).
138
Table (15): Multiple regression analysis for the predictors of BPD in children.
Parameters Odds ratio 95% Confidence P value
Interval
Lower Upper
1. Age 0.98 0.14 1.12 0.322
2. Sex 0.69 0.26 0.95 0.408
3. Residence 2.20 0.31 2.51 0.138
4. School 0.31 0.26 0.57 0.575
5. Family history 40.60 0.66 41.26 < 0.0001**
6. Sport particiption 3.43 0.34 3.77 0.064
7. Joining club 0.03 0.16 0.19 0.857
8. Hobbies 3.71 0.35 4.06 0.054
9. House chores 9.35 0.19 13.10 < 0.001**
10. Relation with siblings 33.70 0.65 34.35 < 0.001**
11. Relation with parents 38.47 0.61 39.08 < 0.001**
12. Number of friend 69.04 1.42 70.46 < 0.001**
13. Social activity 84.93 1.35 86.28 < 0.001**
14. School faliure 13.75 0.21 13.96 < 0.001**
15. Airthmetc skill 33.69 0.68 34.37 < 0.001**
16. Conners scale 19.94 5.34 25.28 < 0.001**
17. Cbcl scale 10.2 2.26 2.10 0.075
18. Cars for mania 100.95 11.70 112.65 < 0.001**
19. Ymr scale- parent version 96.59 24.50 121.09 < 0.001**
** Statistical significant at the 0.01 levels.

Discussion
symptoms of ADHD that precede the onset
The present study was designed to test the
hypothesis that ADHD is a childhood of BPD represent a pre-pubertal expression
of illness antecedent to the development of
version of BPD in some children and to
study the impact of BPD in children on a full mood episode, that ADHD may be an
“age specific manifestation of BPD. The
their social competencies, behavioral, and
academic performance. It was found that 45 predictive significance of early ADHD
(37.5%) children out of 120 children symptoms for the ultimate development of
BPD is debatable. Some investigators have
diagnosed as ADHD were re-diagnosed and
met the criteria for BPD. Our result was proposed that ADHD may represent an age-
specific manifestation of BPD, while others
supported by other studies that found
similar rates of BPD in hospitalized argue that the two disorders are separate and
co morbid, with perhaps one (ADHD)
children with ADHD (Butler, et al., 2000;
Faraone, et al., 2000; Geller, et al., 2002). increasing the risk of development of the
other (BPD) (Biederman, 1999). Other
Testable hypotheses might explain the high
rates of incorrect diagnosis of ADHD Co possibility—that children with ADHD who
go on to manifest mania-like symptoms
morbidity is a chance phenomenon and
139
have "bad" ADHD or a new diagnostic assumption that the disorder is genetically
entity altogether—has also been proposed determined with polygenetic inheritance. It
(Jensen, 2005). is assumed that the females have a higher
threshold of phenotypic expression than
Demographic variables of both bipolar
and ADHD groups: There was no males (Mubarak and Shamah, 1999). Our
result was inconsistent with previous
significant difference between children with
BPD and those with ADHD as regard to reports that BPD was equally distributed in
between both sexes (Keck, et al., 2001).
age. But the distributions of psychiatric
disordered children were present more at As regard to residence, there was no
age 8-10 years, which was found to be significant difference between BPD group
consistent with other previous studies and ADHD group as regards residence, this
(Khashaba, et al., 1997; Szatamri, et al., result may be due to the nature of Ismailia
1997; El-Batrawy, et al., 2004). Our result area which content rural, semi rural and
could be explained on the assumption that urban and there is no big difference
in our culture there is a strong tendency to between different areas. Our results are
delay referral of the child to clinics and inconsistent with Okasha, 1988 and El-
hope that child will grow out of it. Akabawy, et al., 1982, who pointed that
Moreover our culture is more tolerable to psychiatric symptoms and disorders are
children with disturbed behavior than many more common in rural Egypt than urban
other cultures. In contrast to our finding Egypt.
some researchers in well designed As regard to the type of school: there was
prospective studies gave the light that significant difference between children with
bipolar disorder showed three peaks of
BPD and children with ADHD according to
onset; first from 15 to 19 years, followed by the type of school, but we found the
the age range from 20 to 24 years and
distribution of children with BPD according
another peak is the age above 65 years, with to the type of school was in private school
a mean age of onset of 18 years (Goodwin
12 (26.7%) and government 32 (71.1%),
and Jamison, 1990; Keck, et al., 2001). The compared to 9 (12%) and 61 (81.3%)
cause of this stratified nature of age of onset
respectively in ADHD children. This result
is still under work but many hypotheses had can be explained by the low to moderate
been given as over secretion of cortisol,
socioeconomic resources of Ismailia area.
super fast biologic clock located in the
In consistent to this result, Farrag et al.,
suprachiasmatic nucleus or excessive influx (2002), study the relationship between BPD
of calcium into brain cells which assumed
and ADHD and type of the school in
to be preprogrammed (Simon, 2003). Assiut, they found that pupils in national
As regard to sex: there was significant schools had significantly more psychiatric
difference between children with BPD and disorders (BPD and ADHD) than those in
those with ADHD disorder which was private school. These results could be
consistent with the results of previous related to the selection criteria for
studies (El-Defrawi, et al., 1995; Szatmari, admission in private schools, students
et al., 1996; Simon, 2003). Reasons for this usually come from higher social classes. In-
gender discrepancy remain obscure; addition, most private schools had
however, it could be explained by the environmental advantages, less
140
overcrowded classrooms and relatively high from other mental health conditions in
quality teachers. children especially ADHD (Fristad, et al.,
Regarding the family history: We found 1999; Bowring and Kovacs, 2002; Weller,
et al., 2003). Our result showed that there
that positive family history of BPD was
reported in 51.9% in BPD children was significant difference between BPD
children and ADHD groups regarding to
compared to 9.31% in ADHD children.
This finding is similar to previous studies Young Mania Rating Scale Parent Version
(YMRS- Parent Version) that was in
that reported that biological especially
genetic factors are one of the most agreement with Fristad, et al., (2002), who
found that YMRS- Parent Version scores
important risk factors of BPD in children.
Some of this studies tried to find a relation were significantly higher in manic versus
between BPD and specific genetic loci, ADHD children. Also, YMRS is not only
useful in differentiating mania from ADHD
where certain loci of different
chromosomes where found to have a link but also in determining the severity of
mania in pre-pubertal children (Poolsup, et
with BPD as chromosomes X, 5, 11, 12, 13
and 18 (Pollock, et al., 2003; Simon, 2003). al., 2001; Weller, et al., 2003).
In this study there is no significant Regarding results of Clinical
difference between children with BPD and Administered Rating Scale for Mania: It
those with ADHD regarding the family was found that there was significant
history of ADHA, we found the that there is difference between BPD group and ADHD
no children with BPD had a family history group in Clinical Administered Rating
of ADHD, and those with ADHD had a Scale for Mania (CARS-M) as reported by
family history of ADHD 3 (4%). This parents as expected. Geller, et al., (2001),
finding is consistent with the results of El- found that the (CARS-M) detected 88% of
Batrawy, et.al. (2004), who found no the children with BPD. Alicia, et.al. (2004),
significant difference between children with reported that Clinical Administered Rating
BPD and those with ADHD regarding the Scale (CARS-M) was more specific to
presence of family history of hyperactivity some manic presentations. Our study
or misconduct behavior. But our result was provided additional evidence of the validity
inconsistent with results of other studies of the (CARS-M) for screening children for
where the authors found that early onset BPD. So, our study provided additional
type of BPD was commonly preceded by a evidence of the validity of the (CARS-M)
family history of ADHD (Sachs, et al., for screening children for BPD.
2000; Spencer, et al., 2002; Weckerly,
Regarding results of Conners’ Rating
2002). This contradiction could be Scale: There was significant difference
explained by cultural and educational level
between BPD children and ADHD group
of parents in our sample and the degree of regarding Conners’ Rating Scale which was
their orientation to their children symptoms,
consistent with the results of El-Batrawy, et
which may give us a false negative or may al., (2004), but inconsistent with the results
be bias in our sample.
of Fristad, et al., (2001) and Thomas, et al.,
Regarding results of Young Mania (2004), who found that scores on
Rating Scale Parent Version: It is often hyperactivity rating scales did not differ
clinically difficult to differentiate BPD between the two groups. There are several
141
mechanisms that could account for these sustaining attention and while waiting in
discrepancies between our result and those line, he will frequently kick or push the
two studies. In general these two studies child next to him, always looking to move
use Conners’ Rating Scale for teachers and on to something new, action before thought.
parents so different informants identify In contrast to our findings, DePauw, et al,
different children as problematic; this is (2000), reported that there was no
may be due to informant variance or significant difference between children with
instrument variance and sampling variance. BPD and ADHD in sport participation.
On the other hand, differences in rate may They explained their finding that families
stem from differences in the way each of children with BPD and ADHD always
informants views the child, for instances, aware about precautions need to be taken to
parent may deny the problem that are in fact ensure safety for the children. These
present in the child perhaps out of a desire precautions would include the environment
to see the child as healthy or normal, (field, court, etc.,), equipment, and
alternatively the parent may recognize the knowledge of the rules. Our results revealed
child's difficulty but attribute minimal insignificant difference between children
negative consequence to it. Lastly different with BPD and children with ADHD in
informants have different levels of exposure joining sport club. That could be explained
to the symptoms of problem behavior. In 6- by joining sport club controlled by several
12 years, the teacher's had direct factors, like social class of the family. In
information about the child performance in Ismailia community most of the families
this context where as the parent must rely have low to moderate socioeconomic
on proxy information from the child and resources, furthermore, the number of the
teacher, presumably parents may often lack sport club in Ismailia is few. In addition,
exposure to a comparison group and thus there are no much differences between rural
may fail to recognize that the child behavior and urban areas. Also, most of the families
is abnormal. are not interested in joining clubs due to
their children disorders.
Regarding sport practice: Our results
showed that BPD children were Regarding hobbies: It was shown that
significantly participated, spent time and there was significant difference between
skilled in sport practice compared with BPD group and ADHD group in the
ADHD children. This finding was presence of hobbies. This could be
supported by Tillman, et al., (2001), who explained by inattention, poor
reported that children with BPD concentration, and abrupt shifts in activity,
participated more in sport activity as a part lack of organization in ADHD children.
from their disorder, (increase activity and This result is in agreement of Papolos and
increase in intensity in goal-directed Papolos, (2002), and Krasa and Tolbert,
activities related to social behavior). Also, (2003).
Ward and Purvis, (2001), found that BPD
Regarding participation in house chores:
child participated in sport more than child
It was found that there was insignificant
with ADHD, because child with ADHD has difference between BPD children and
difficulty in following rules, has a short ADHD children. That was inconsistent with
attention span, often fails to give close
the results of EL-Defrawi, et al., (1997),
attention to details and difficulty in
142
who found that child with psychiatric children with ADHD had a worse
disorder do not share their family in house relationship with their siblings. Also,
chores, because limitation in the child Lewine and his coworkers 2002 found that
performance makes the child more ADHD children show poor social
dependent on the parents. Our results can be adjustment, than BPD children. On the
explained that in our study we have 45 other hand, we found that BPD children had
female and in our culture the family was also a worse relationship with their siblings.
always aware about training girls on the Our findings was supported by Aziz,
housework to prepare girls to be a (2002), who found that 25% of the BPD
housewife. children had a bad relationship between
Regarding social relationship: BPD group their siblings especially during episode of
was significantly more socially comptent the disorder, and 75% of the BPD children
show a good relation with their siblings or
than ADHD group. A lesser, but still
significant, difference was observed the same relation after or before the
episode. This relationship can be explained
between BPD children and ADHD children
in relationship with their parents. Our result on the base that these emotional and social
difficulties in both groups and the illness
was supported by the results of Seif-El-Din,
et. el., (2001), who found that the leads to poor self image, decrease self
esteem, decrease self confidence, social
relationship with parents getting worse in
about 63% of ADHD children and also, embarrassment and social restriction.
with the results of. Aziz (2002), who found Regarding social activities: BPD children
that 35% of the BPD children had a bad were more sociable than children with
relationship between their parents ADHD, as they had significant more
especially mothers especially during number of friends, Also there were more
episode of the disorder, and 65% of the socially involved with their friends within
BPD children show a good relation with the last 6 months. Our results was
their parents or the same relation after or supported by Akiskal and his coworkers
before the episode. Furthermore, our result 2000, who found that these children with
agreed with Hans, (2002), who reported early onset BPD had relatively good peer
that the degree of social functional relationships. DeLong and Aldershof,
deterioration among BPD children is not as (2000), reported that one-third (33.3%)
severe as that seen in ADHD children. This were noted to posses leadership qualities;
can be explained by the nature of the 68% of these children with early onset BPD
disorder; the disruptive behavior, were involved in a variety of extra-
moodiness, difficulty sleeping at night, curricular activities and were seen by their
impulsiveness, overactivity and inability to teachers as making a positive contribution
concentrate. All these have been associated to their social life. This could be explained
with great familial loading (El-Batrawy, et by the nature of the disorder which makes
al., 2004). Also, the table showed that the the child shows increase in goal-directed
relationship with siblings of the ADHD activity especially in school and excessive
children was statistically significant worse involvement in pleasurable activities. A
than BPD children. This result was markedly different peer relationship profile
consistent with the results of Abdel-Gadir, was shown in children with ADHD where
et.al., (2001), who found that (45%) of two thirds of the chidren with ADHD were
143
described as having significant poor peer visuospatial representation (Jamison, 2002).

relationship and diminished extracurricular Functional imaging studies have
activities (El-Batrawy, et al., 2004). demonstrated that mathematical reasoning
involves a distributed network, including
Regarding school performance: Our
results revealed that poor school the lateral and ventral lateral prefrontal
cortex and the posterior parietal lobe, as
performance was found in both BPD group
and ADHD group without significant well as subcortical regions such as the
caudate nucleus and cerebellum. Also,
difference that could be attributed primary
to adjustment problems, the effects of Specific deficits in mathematic were
correlated with abnormalities in brain
multiple hospitalization and difficulties
with peers (Salzman and Salzman, 2000). structure. For example, mathematics deficits
Also, cognitive deficits associated with in children with velocardiofacial syndrome
have been related to structural abnormalities
BPD cause academic difficulties (Katcher,
et al., 1999; Riley, et al., 2001). in the parietal lobe region (Menon, et al.,
2002). In the present study it was found that
Additionally, the disorder itself may
impede both cognitive and social ADHD children showed a higher rate of
failure in Arabic reading than BPD children
functioning, leading to decreased academic
ability. It is possible to hypothesize that that is supported by Rutter et al., (2001),
who reported that student with reading
disturbance in frontal lobe and/ or right
hemisphere functioning in BPD children disorder had an elevated rate of
hyperactivity and inattention. Generally, we
may, at least in part, be responsible for this
found that both BPD and ADHD children
finding (Burder, et al., 2002). As regard,
ADHD group, our finding was supported by reported less than average level in academic
performance this may be due to their
Biederman, et al., (2002), who found that
the frequency of learning disabilities in illness. There is evidence from a number of
studies which suggest that children with
ADHD ranged from 25% to 45%. Poor
academic performance in ADHD could be psychiatric disorder are underachiever and
do more poorly in academically than do
regard as secondary to impairments of
attention and behavior control. In addition, their healthy peers. Also, this can be
explained by that children with psychiatric
Sliver, et al., (2000), found that academic
learning may also be impaired in children illness miss days of school because of acute
who have not developed. In the current exacerbation of their conditions, out patient
health care related appointment, or
study, BPD group showed a higher rate of
arithmetic failure than ADHD group, that is hospitalization.
consistent with the results of other previous Regarding results of Child Behavior
studies that reported specific academic Checklist: We found that there was
difficulties in children with early onset significant difference between BPD group
BPD specially problems in mathematics and ADHD group in Internalizing and
(Jamison, 2002; Menon, et al., 2002). Externalizing problems as reported by
Arithmetic deficits could be due to parents. This result was consistent with the
underlying deficiencies in a number of results of Dienes, et al., (2002), who found
cognitive processes, including retrieval of that children with BPD received elevated
arithmetic facts from semantic memory, scores on the CBCL scales in comparison
execution of arithmetical procedures, or with non-clinical populations. In addition,
144
the BPD group differed from the ADHD misdiagnosed with ADHD because both
group only on the aggressive behaviors, BPD and ADHD share symptom
withdrawn and anxious/ depressed characteristics of inattention, behavioral
subscales of the CBCL. Hazell and Lewin, and emotional problems, impulsivity and
(2000), reported that BPD children may be even hyperactivity. Children with BPD
distinguished from those with ADHD by have impairment in their social
the internalizing and externalizing competencies, and have high level of
symptoms in CBCL. Our results are behavioral difficulties. They also have
inconsistent with the results of Chang, et learning difficulties; hence they are prone to
al., (2000), who found no significant school failure and poor academic
difference between BPD children and performance. We are in agreement with
ADHD in CBCL. many recent studies (Adler, et al., 2005;
Faraone, et al., 2005; Kowatch, et al., 2005;
Regarding predictors of bipolar disorder
in children: Multiple regression analysis Udal and Groholt, 2006), to conclude that
Child BPD severely impairs a child
revealed that the CARS for Mania was the
most predictor tool for BPD in children developmental and emotional growth. It is
frequently misdiagnosed, resulting in
than the YMR Scale-Parent Version,
Conner Scale or CBCL. This result is inadequate management that worsening of
the disorder. BPD is not often recognized in
consistent with the results of Alessia, et al.,
(2002), who found that the CARS for children and the child reports a long history
of related psychopathology misdiagnosed
Mania is a good tool to use in discriminate
as ADHD. Therefore the first and most
between ADHD and BPD. However,
Pavuluri, (2002), explained that why the important step in treating these children is
accurately recognizing the disorder.
CARS for Mania is a good predictor for
BPD. First: CARS is a shorter instrument References:
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150
Authors: Abd Amoez K.

Yousef I. Lecturer of psychiatry
Professor of psychiatry Faculty of medicine
Faculty of medicine Sues Canal University
Sues Canal University
Bishry Z.
Tantawy A Professor of psychiatry
Associate professor of psychiatry Faculty of medicine
Faculty of medicine
Sues Canal University Haggag W.
Professor of psychiatry
Elsayed O.
Faculty of medicine
Lecturer of psychiatry Sues Canal University
Faculty of medicine
Sues Canal University Zakaria A.
Assistant lecturer of psychiatry
Faculty of medicine
Sues Canal University
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Ain Shams University

Burnout Syndrome among Saudi Medical Residents: A Controlled Study

Official Journal of the Institute of

Burnout Syndrome among Saudi Medical Residents: A Controlled

Three residents from ENT, Two residents C-Accomplishment are represented by

Male % Female % Total % X2 Significance

Level of significance at p < 0.05

Single Married Divorced Total X2 Significance

Level of significance at p < 0.0

Table (3):Doing recreational activities among junior and senior residents

Doing % Not doing % Tota % X2 Significance

*Level of significance at p < 0.05

Level of significance at p < 0.05

Level of significance at p < 0.05

Mean values Junior residents Senior residents t-value Significance

*Level of significance at p < 0.05

Junior &senior residents as regards to

Mean values of emotional exhaustion

High=27 or over, Mod=16-26, Low=0-16

Junior &senior residents as regards to

High=14or over, Mod=9-13, Low=0-8

Junior &senior residents as regards to mean

High=0-30, Moderate=31-36, Low=37 or over

Surg. Gyne. Radiol. Pedia. Med. f- Signifi-

(No=16) (No=10 ) (No=9 ) (No=17 ) (No=19 )

*Level of significance at p < 0.05

The main 5 residents' sections &

Main five sections

The 5 main residents' sections in comparison

Main five sections

The main 5 residents' sections &

Surg=1, Gyne=2, Radiol=3, Paed=4, Med=5

Main five residents' sections

Item of MBI Medical Residents Surgical Residents t-test Signific

Sense of fatigue 3.5±2 4.6±1.7 -2.4 0.02*

*Level of significance at p < 0.05

Motives for Substance Use Disorders: A Trans-cultural Study

The cathinoids which are alkaloids derived Methods:

Level of significance is at p < 0.05

Level of significance is at p < 0.05

Level of significance is at p < 0.05

Egyptian Saudi Total X2 Significance

Level of significance is at p < 0.05

Level of significance is at p < 0.05

Table (6): Comparison of occupations between an Egyptian and Saudi substance

Individuals Egyptian samples Saudi sample

Opioids 21 11 2 30 64 24.5 0.00001*

Oyefeso A. (1995): ;Sociocltural aspects of Authors:

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Burnout Syndrome among Resident Physician in Suez Canal

Range of Experienced Burnout

(N.B. PA is measured in the opposite direction to EE and DP)

(MBI Manual, 1996)

Range of Experienced Stress

“high” on any two of the dimensions of Meanwhile, experiencing work-related

Subscale Low Average High

Subscale Low Average High

Table (8): continue:

Table 10- Aspects of Involvement with People experienced by Participants causing

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