Psychiatry Grand Rounds from the UCLA Semel Institute

Bipolar disorder is centrally characterized by periodic significant variations in mood, ranging for example from the depths of depression to the highs of euphoric mania. The triggering of an episode is thought to reflect a combination of biological factors in the brain of the individual, and environmental factors, such as stresses related to family, friends, work, and school. The arrow points both ways, however, and the impact of bipolar disorder on the family, friends, and colleagues of a person with that illness can be very marked as well. Medications are a core element of treatment for this disorder, but considerable attention has also been focused on how involvement of the family can lead to an improved course of illness. Family focused therapy has been studied in adults with bipolar disorder as well as in children and adolescents. It may be able not only to improve the function and symptoms of patients but also potentially to prevent the onset of the illness in at-risk children. In this Grand Rounds presentation, Dr. David Miklowitz will update us on the work he and others have done in this area. He is a Professor of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA, Director of the Integrative Study Center in Mood Disorders at the Semel Institute, and Director of the new Child and Adolescent Mood Disorders Program (CHAMP).

Issues of gender and gender identity have clinical aspects but are embedded in a context marked by social, political, economic, religious, and cultural aspects as well. As the Diagnostic and Statistical Manual of Mental Disorders, the DSM, approaches its fifth revision, questions remain as to how transgenderism will be addressed. Transgender refers to the situation of a mismatch between person's sex, the identification as male or female by others, based upon physical and genetic sex, and one's "gender identity" the self-identification as woman, man, or neither. The past few decades have been marked by increasing visibility of transgender individuals in society. People frustrated by gender-related life experiences may seek mental health care, so practitioners must be knowledgeable about transgenderism, its phenomenology and clinical aspects, and some of the controversies surrounding it. Some of the early influential work in this area was conducted in past decades at the UCLA Neuropsychiatric Institute. This Grand Rounds presentation will update us on more recent work in this area. Our speaker is Dr. Vernon Rosario, Assistant Clinical Professor of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA.

Though some observers have asserted we are now living in "post racial America," there is considerable evidence that perceptions of race and ethnicity continue to exert effects on behavioral patterns. Stereotypes, fears of being labeled "racist," and other factors may impact how people of different races interact, even when people do not endorse overtly racist beliefs and perspectives. Issues with bias may be especially problematic in circumstances where there is less time to fully understand people as individuals, such as in an emergency room setting or in a police SWAT team operation. In this Grand Rounds presentation, we will be updated on recent work in this area by Dr. Phillip Atiba Goff, Assistant Professor of Psychology at the University of California, Los Angeles. He is also co-Founder and Executive Director of Research for the Consortium for Police Leadership and Equity.

The experience of stress is a common one, yet the impact of stressful life events on mind, brain, and body are still incompletely understood. The concept of allostatic load has been advanced by researchers including McEwen, and refers to the physiological costs of chronic exposure to the neuroendocrine stress response. While this response is essential for managing acute threats, frequent activation of the body's stress response can damage the body in the long run. Much of the work in this area has focused on the impact on cardiovascular or endocrine systems, but what of adverse impact on the brain itself? Recent studies of the impact of stress on specific brain structures and the relationship to indices of allostatic load have been conducted by Dr. Dorie Glover, our Grand Rounds speaker. Dr. Glover is an Assistant Professor of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine and the Semel Institute for Neuroscience and Human Behavior at UCLA.

When one considers brain development over the lifecycle, the early phases of life are marked by the generation of brain structures and modifying how they are connected through neuroplastic changes. Some of these processes generally are thought to plateau once one reaches maturity in adulthood. Much later in life, degeneration of neural structures has been linked to many common neuropsychiatric disorders, including Alzheimer's disease, fronto-temporal dementia, Parkinson's disease, and others. Along with loss of neural tissue comes loss of function, manifest as motor, cognitive, or affective symptoms. New work provides provocative evidence that it may be possible to increase the size and function of brain structures even in fully-developed adults. Although many pharmacologic interventions are also under examination, some behavioral approaches that have been studied rely on regular repeated activity, such as meditation or focused learning tasks. With functional and structural neuroimaging methods, it is possible not only to measure change in performance on tests, but also changes in volume and activity of the fundamental brain structures that support these activities. In this Grand Rounds presentation, we will be updated on recent work in this area by Dr. Eileen Luders, from the Laboratory of Neuro Imaging in the Department of Neurology at the David Geffen School of Medicine at UCLA.

Traumatic brain injury, or TBI, is associated with considerable risk for long term neurological and psychiatric disability. TBI has gained considerable public attention recently, in part because of the large number of veterans returning from Iraq and Afghanistan who have sustained traumatic brain injury, potentially along with post traumatic stress disorder. The neurological, psychiatric, and functional consequences of these injuries are becoming better characterized along with greater neurobiological insights into the early cellular and tissue-level events. A greater elucidation of the neurobiology of TBI can help us both to understand the pathophysiologic connections between injury and clinical outcome, and to develop new interventions that focus on the cascade of events tied to the increased in cellular energetic demands when brain tissue is injured in this way. In this Grand Rounds presentation, we will be updated on recent work in this area by Dr. David Hovda, Director of the UCLA Brain Injury Research Center. Dr Hovda is Professor and Vice Chairman of Research and Academic Affairs in the Department of Neurosurgery at the David Geffen School of Medicine at UCLA.

Much attention has been directed in recent years to the practice of evidence-based medicine, where the central tenet is that there should be scientifically-sound research to support the procedures we employ in patient care. In some areas, there is a solid precedent, such as studying medications by using evidence from placebo-controlled trials or using comparisons with sham treatments for medical and surgical procedures. Such studies in psychotherapy have been, at times, more challenging to conduct, given the way that practitioners customize the material discussed in each session to the individual patient's circumstances, and the difficulties of establishing how a control or sham psychotherapy session should be constructed. Despite these sorts of challenges, it has been possible to conduct high quality research into a number of types of psychotherapy, and a particular type of psychotherapy that has been examined with rigor is Intensive Short-Term Dynamic Psychotherapy or ISTDP. With roots in classic psychoanalysis but also in attachment theory and other aspects of psychology, the development of ISTDP by Davanloo and others has led to a set of practices that include a series of emotionally-intense sessions which overcome resistance, which trace the origins of current emotions to their antecedents in the past, and which lead to the construction of a clearer narrative of self-understanding that is not solely cognitive but goes to the emotional core. In this Grand Rounds presentation, Dr. Allan Abbass will update us on research into ISTDP. Dr. Abbass is Founding Director of the Centre for Emotions and Health and Director of Education for the Department of Psychiatry at Dalhousie University in Halifax, Nova Scotia, Canada.

Successful social communication is vital to human life, and a major factor in establishing connections with other people is understanding their emotions. In healthy human interactions, empathy is a critical factor for social organizations, all the way from dyadic couples to family units to societies as a whole. In disorders such as autism, there appear to be impairments in understanding the emotions of others. The neurobiological underpinnings of empathy have recently been tied to the mirror neuron system in the brain. In this Grand Rounds presentation, Dr. Marco Iacoboni will update us on research into mirror neurons and empathy, and the implications of dysfunction of this system for mental health. Dr. Iacoboni is Director of the Transcranial Magnetic Stimulation Lab in the Ahmanson-Lovelace Brain Mapping Center at UCLA, and is a Professor of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA

As our national dialog about healthcare continues at a fever pitch, the role of the environment is a factor of potentially considerable importance that has escaped much attention. While a common-sense perspective lets us appreciate the benefits of clean air and water, much of the environment in which we live and work is the so-called “built environment” -- cities, highways, public buildings, or private homes, for example. How communities are constructed, how the spaces of our daily lives are organized, how easy or difficult it is for our children to find safe places to play -- all these factors may also exert subtle or not-so-subtle effects on our physical and mental health and well-being. To update us on research in this area, to discuss the way policy decisions in this area may impact the health of our patients, and to outline ways in which we, as healthcare providers, can fulfill our professional responsibilities by becoming part of the process, we are pleased to welcome Dr. Richard Jackson. A pediatrician and public health leader, Dr. Jackson is Professor and Chair of Environmental Health Sciences at the UCLA School of Public Health.

Depression in older adults is a common clinical problem. Some patients may have a recurrent episode in a depressive disorder that began earlier in life, while others may experience the onset of a major depressive episode for the first time in their life. Social and psychological factors have been often considered as reasons for late life depression, along with medical factors such as vascular disease. New data raise important questions about genetic factors as well. In contrast to studies of so-called "vulnerability genes" that lead more-or-less directly to illnesses that begin in the first two or three decades of life, new studies have considered genetic factors that may modify other risk factors in later life that may in turn lead less directly to depression. Genetic factors that may influence other aspects of physical health or that may skew social interactions are among the targets in this expanded paradigm. To update us on these developments and describe how they may come to impact clinical care, we are pleased to welcome Dr. Warren Taylor in his visit to UCLA. Dr. Taylor is an associate professor in the Associate Professor of Psychiatry and Behavioral Sciences at Duke University Medical Center in Durham, NC.

For decades the phenomenologic importance of early childhood experiences in shaping lifelong patterns of behavior and mental health has been recognized. Many different theories have been invoked to explain this relationship. Deprivation of infant-maternal bonding and other adverse experiences in early life may contribute to lasting brain structural and functional alterations that have enduring behavioral consequences. Some of these changes may be probed by evaluating brain activation during tasks of identifying and understanding the emotional state of others communicated by their facial expressions. To update us on developments in this important research area is UCLA's own Dr. Nim Tottenham. Dr. Tottenham is an assistant professor in the UCLA Department of Psychology, where she leads the Developmental Affective Neuroscience Laboratory.

Unlike some organ systems, the development of the human brain is not complete at the time of birth, but continues for decades afterwards. Nonetheless, exposure to certain compounds during gestation can alter the growth trajectory for the developing central nervous system for an individual's lifetime. Fetal alcohol syndrome has been associated with clinical features and neurobehavioral issues for many years, but new data demonstrate how prenatal exposure to alcohol alters the trajectory of brain growth throughout childhood and adolescence. Findings from prenatal exposure to crystal meth also show long-lasting effects. Dr. Elizabeth Sowell will discuss these new insights from neuroimaging and behavioral studies in this Grand Rounds presentation. Dr. Sowell is an Associate Professor of Neurology at the David Geffen School of Medicine at UCLA and leads the Developmental Cognitive Neuroimaging Group at the UCLA Laboratory of Neuroimaging.

The substance users who use the most drugs and create the highest social costs frequently are also criminally active as drug dealers themselves and as property and violent offenders. The criminal justice system and mental health care system intersect in the management these individuals. Different jurisdictions have tried different approaches, with variable outcomes. An innovative approach has been pioneered in Hawaii, named Hawaii's Opportunity Probation with Enforcement program or H.O.P.E. H.O.P.E. aims to reduce drug use and crime among drug-using offenders by laying out clear expectations for drug-free behavior and backing up those expectations with tight monitoring linked to swift and certain consequences. Those who test positive are subject to immediate, brief incarceration. In contrast, typical community-based corrections, including most drug-diversion programs and California's Proposition 36, have little provision for monitoring for drug use. Furthermore, when drug use is detected, the responses are unpredictable and often are long delayed. Today's presentation will update us on perspectives and experiences in California and elsewhere in this difficult societal issue. Each year, the Department of Psychiatry honors the career of Dr. Thomas Ungerleider and this year's Ungerleider Lecturer will be Professor Mark Kleiman. Dr. Kleiman is a Professor of Policy Studies at the School of Public Policy and Social Research here at UCLA.

Most of modern medical research and teaching focuses on illness - making a diagnosis, understanding pathophysiology and etiology, and developing therapeutics to correct a problem. A complementary perspective can be found in the field of "positive psychology," which considers the characteristics of what might be termed positive, healthy, or desirable states: happiness, contentment, well-being, joy, gratitude, inspiration, love, and kindness, for example. Studies from positive psychology can balance research into deficit states, and may have implications for the treatment of psychiatric illness as well as a richer understanding of the phenomenology and pathophysiology. An expert in bringing this area of psychological study to application in psychiatry is Dr. George E. Vaillant. Dr. Vaillant is Co-Director for the program on the Study of Adult Development in the Department of Psychiatry at Brigham and Women's Hospital in Boston, and is a Professor of Psychiatry at Harvard Medical School.

Considerable research effort has been undertaken to realize the central promise of Personalized Medicine, namely, "the right treatment for the right person at the right time." The role of genetic factors in influencing the bioavailability of psychiatric medications has been a key part of this work. In particular, the role of hepatic enzymes in influencing the serum concentration of psychotropic medications has received much attention. Elements of the liver's cytochrome P450 enzyme system have been identified and specific genetic variants have been associated with greater or lesser enzymatic activity. A number of institutes have pursued the idea of genotyping individual patients to provide guidance about which medications are most likely to cause adverse events and thus might be avoided. Much of the leading work in this area has taken place at the Mayo Clinic, where genotyping is now offered as a clinical service. Today's presentation will update us on this intriguing work. Each year, the Department of Psychiatry honors the memory of Dr. Gertrude Rogers Greenblatt, and this year's Rogers Greenblatt Memorial Lecturer will be Dr. David Mrazek. Dr. Mrazek is a Professor of Psychiatry, Psychology, and Pediatrics at the Mayo Clinic School of Medicine in Rochester, MN, where he is also Director of the S.C. Johnson Genomics of Addictions Program.