Biomedical subjects
Publications and source records attributed to Harold Merskey.
An ideal taxonomy should be comprehensive and its categories should be mutually exclusive. Every item should have a particular place either on its own or with other items that resemble it. This is rarely, if ever, achievable in practice in medicine. The reasons for this are explained. The taxonomy developed by the Task Force on Taxonomy of the International Association for the Study of Pain is described as well as the basis for it.
Evidence acquired through research is increasingly being used to manage medical problems, and, where applicable, to decide on which medically related conditions warrant compensation for disability. Consensus-based guidelines are supposedly prepared by learned individuals, making use of the best evidence and their experiences to provide group wisdom for practicing clinicians. Because bias is always a problem, research strives to minimize bias through scrupulous methodology, while consensus panels work carefully through the constitution of the group and disclosure of conflicts of interest by participants. Where research is not funded at arm's length by the external funding agency the potential for bias is enormous, especially when substantial funds are at stake, depending on the outcome of the study. In order that future research and consensus group recommendations may result in better care and a fairer compensation system, substantial efforts to minimize bias will be required.
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OBJECTIVE: To compare the clinical and pathological features of Alzheimer's disease (AD) patients with and without associated cerebral infarcts (CI). METHODS: The consecutive records of 57 prospectively studied demented patients fulfilling the CERAD criteria for the pathological diagnosis of AD were reviewed. Cases with cortical Lewy bodies were excluded. CI were found in 22 cases (39%) (AD+CI group): large infarcts (5), lacunes (13) and/or hippocampal sclerosis (4), and were absent in 35 cases (AD group). Microscopic infarcts, cribiform change, amyloid angiopathy, and white matter rarefaction were not considered in this classification, but were quantified. Cortical atrophy, neurofibrillary tangle and senile plaque (diffuse and neuritic) load were also measured. Pathological evaluation was independent of clinical information. Clinical and pathological data were compared between both groups. RESULTS: AD+CI cases were significantly older, more commonly female, less educated, and more often had blue collar occupations, sleep disturbances, frontal release signs, and EEG spikes than AD cases. Other differences found (acute/subacute onset, behavioral disturbances, and leukoaraiosis on CT scan) disappeared after controlling for age. The frequency of known vascular risk factors and focal motor and sensory signs did not differ between the groups, which showed remarkable clinical similarity overall. The only significant differences on pathological exam were hippocampal microinfarcts and white matter lesions, although there was a trend for lower neurodegenerative lesion load in the AD+CI group. The ischemic lesions were located in temporal lobe in 50% of AD+CI patients; these cases had a significantly lower neocortical neurodegenerative lesion load than those with CI in other sites. CONCLUSIONS: The presence of CI in AD increases significantly with age, but has scarce influence on the clinical features, and cannot be predicted from common vascular risk factors. In spite of a trend, there are no major differences in neurodegenerative lesion load between AD and AD+CI groups, except when CI are located in the temporal lobe (including hippocampus), suggesting that this location may be important in the physiopathology of mixed vascular and AD dementia.
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OBJECTIVE: To examine the concept of dissociative identity disorder (DID). METHOD: We reviewed the literature. RESULTS: The literature shows that 1) there is no proof for the claim that DID results from childhood trauma; 2) the condition cannot be reliably diagnosed; 3) contrary to theory, DID cases in children are almost never reported; and 4) consistent evidence of blatant iatrogenesis appears in the practices of some of the disorder's proponents. CONCLUSIONS: DID is best understood as a culture-bound and often iatrogenic condition.
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In this second part of our review, we continue to explore the illogical nature of the arguments offered to support the concept of dissociative identity disorder (DID). We also examine the harm done to patients by DID proponents' diagnostic and treatment methods. It is shown that these practices reify the alters and thereby iatrogenically encourage patients to behave as if they have multiple selves. We next examine the factors that make impossible a reliable diagnosis of DID--for example, the unsatisfactory, vague, and elastic definition of "alter personality." Because the diagnosis is unreliable, we believe that US and Canadian courts cannot responsibly accept testimony in favour of DID. Finally, we conclude with a guess about the condition's status over the next 10 years.
111 schizophrenic patients diagnosed in accordance with DSM-III were rated on Landmark's symptom checklist, on demographic variables, and on variables descriptive of the course of illness. Of the 111 patients, 108 (97.3%) showed poor insight into their illness at some time in the past and 65 (58.6%) at the time of assessment. Those presently showing poor insight were significantly (Pearson rs, p< .01, 2-tailed) more frequently rated as currently displaying poor judgement also in other matters (r =.50), as showing social withdrawal (r=.42) and poor rapport (r=.33), and as being preoccupied with their delusions or hallucinations (r=.31) and as being unreliable informants (r=.41). They usually had lower education (r=.33), their income in the last taxation year was lower (r = .47), and their work functioning was less adequate (r = .30).
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There have been a number of attempts, particularly in the last five decades to understand the origins of pain in terms of psychological or psychosomatic patterns. These include psychoanalytic explanations relying on hysterical mechanisms, and psychophysiological proposals. The occurrence of pain in the course of psychiatric illness and its remission after the illness, has long been known and is not a controversial issue. However, the reported explanations of pain without overt and obvious prior psychiatric illness have largely failed to convince a significant portion of the professional establishment. These explanations have very often coincided with the interests of insurance companies, whether those insurance companies were providing medical benefits, disability insurance or workers' or accident compensation. Critical examination of the evidence generated by insurance company related research indicates profound weaknesses in it.
Increased interest in types of dementia has developed as more cases are identified in aging populations. Here we compare the rates of cognitive decline over time in three groups with dementia from the University of Western Ontario Dementia Study: Alzheimer's disease (AD), dementia with Lewy bodies and a group with both AD and Lewy bodies. All diagnoses were verified by autopsy using standard diagnostic methods. Cognitive impairment was measured with the Extended Scale for Dementia (ESD). Members of each group with dementia were age and sex matched with individuals without dementia as controls. The 15 cases of AD, 7 cases with Lewy bodies and 8 cases with both conditions were all free of significant vascular disease. Linear regression was used to determine the rate of changes in ESD scores over time in months. All three control groups showed no change in cognitive status over time. As expected, all groups with dementia showed progressive cognitive impairment. Analysis of the slope parameter showed that all groups deteriorated at the same rate of approximately 2 ESD points per month. Quadratic models fit better than simple linear models in all groups. Results suggest that the final rate of cognitive decline in dementia may not necessarily reflect the underlying cause.
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