Editorial board Editor in Chief Farouk Lotaief Chairman of the Board Ahmed Okasha Honorary Editor Mahmoud S. Abdelgawad Moustafa Kamel Mounir Fawzi Assistant to Editor in Chief Tarek Asaad Tarek Okasha Yasser A. Elsayed Associate Editor Mohamed Ghanem International Advisory Board: Tarek Abdel-Gawad (Egypt) Ahmed Abdel-Latief (Egypt) Abdullah Abdelrahman (Sudan) Mohamed Abouzied (Egypt) Tsuyoshi Akiyama (Japan) Abdel Moniem Ashour (Egypt) Zienab Bishry (Egypt) Haroon R. Chaudhry (Pakistan) Safia Effat (Egypt) Abdou El-Dod (Egypt) Mohamed El-Fiky (Egypt) Tarek El-Habib (Saudi Arabia) Suzan El-Kholi (Egypt) Tarek El-Maadawy (Bahrain) Naglaa El-Mahalawy (Egypt) Gihan El-Nahas (Egypt) Ali El-Roey (Libya) Heba Essawy (Egypt) Wolfgang Gabel (Germany) Hamid Ghodse (UK) Oye Gureje (Nigeria) Amany Haroon (Egypt) Helen Herrman (Australia) Afzal Javed (UK) Eli Karam (Lebanon) Siegfried Kasper (Austria) Levent Kuey (Turkey) Juan Lopez-Ibor (Spain) Felice Lee Mac (China) Mario Maj (Italy) Mona Mansour (Egypt) Jari Mari (Brazil) Driss Moussaoui (Morocco) Nahla Nagy (Egypt) Abdel Naser Omar (Egypt) Ossama Osman (UAE) Hisham Ramy (Egypt) Richard Rawson (USA) Pedro Ruiz (USA) Ahmed Saad (Egypt) Victor Samy (Egypt) Waleed Sarhan (Jordan) Norman Sartorius (Switzerland) Maha Sayed (Egypt) Christopher Sazbo (China) Adel El Sheshaie (Egypt) Constantine Soldatos (Greece) Alaa Soliman (Egypt) Costas Stefanis (Greece) Peter Tyrer (UK) Editorial Manager: Aida Sief El Dawla Ghada El Kholy Hisham Sadek Scientific Editorial Manger: Dina Ibrahim Hussien Elkholy Menan Rabie General Secretary: Neveen Farouk For subscriptions to the printed journal, please contact: Neveen Farouk, General Secretary, MECPsych official journal of Okasha Institute of Psychiatry, Faculty of Medicine, Ain Shams University. Tel. & Fax. 02 26824738; Mobile: 0106609575. Advertisements, statements or opinions expressed in Middle East Current Psychiatry reflect the views of the advertiser or author(s) and are not the opinion of Lippincott Williams & Wilkins or the Editorial Board unless so stated. Readers are advised that new methods and techniques described involving drug usage should be followed only in conjunction with drug manufacturer’s own published literature. MIDDLE EAST CURRENT PSYCHIATRY Vol 18 No 4 October 2011
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Amany Haroon (Egypt)Helen Herrman (Australia)Afzal Javed (UK)Eli Karam (Lebanon)Siegfried Kasper (Austria)Levent Kuey (Turkey)Juan Lopez-Ibor (Spain)Felice Lee Mac (China)Mario Maj (Italy)Mona Mansour (Egypt)Jari Mari (Brazil)Driss Moussaoui (Morocco)Nahla Nagy (Egypt)Abdel Naser Omar (Egypt)Ossama Osman (UAE)Hisham Ramy (Egypt)Richard Rawson (USA)Pedro Ruiz (USA)Ahmed Saad (Egypt)Victor Samy (Egypt)Waleed Sarhan (Jordan)Norman Sartorius (Switzerland)Maha Sayed (Egypt)Christopher Sazbo (China)Adel El Sheshaie (Egypt)Constantine Soldatos (Greece)Alaa Soliman (Egypt)Costas Stefanis (Greece)Peter Tyrer (UK)
Editorial Manager:
Aida Sief El DawlaGhada El KholyHisham Sadek
Scientific Editorial Manger:
Dina IbrahimHussien ElkholyMenan Rabie
General Secretary:
Neveen Farouk
For subscriptions to the printed journal, please contact: Neveen Farouk, General Secretary, MECPsych official journal of OkashaInstitute of Psychiatry, Faculty of Medicine, Ain Shams University. Tel. & Fax. 02 26824738; Mobile: 0106609575.
Advertisements, statements or opinions expressed in Middle East Current Psychiatry reflect the views of the advertiser or author(s)and are not the opinion of Lippincott Williams & Wilkins or the Editorial Board unless so stated. Readers are advised that newmethods and techniques described involving drug usage should be followed only in conjunction with drug manufacturer’s ownpublished literature.
MIDDLE EAST CURRENT PSYCHIATRY
Vol 18 No 4 October 2011
Table of contents
Editorial
185 COPE membership for MECPsych: a message behind the news
Mounir Fawzi
Review article
190 The dilemma in the concept and the management of bipolar disorder
Ahmed Okasha
Original articles
195 Diagnosis of Alzheimer’s disease: possible role of functional imaging technique
Mohamed Ezzat El-Hadidy and Salwa Mohamed Etiaba
203 Cognitive functions after hemorrhagic stroke: follow-up study
Hala Ahmed El-Boraie, Mohamed Abd El-Salam Mohamed, Mostafa Amr and Salwa Tobar
211 Characteristics of substance dependence in adolescents with and without a history of trauma
Hosam El-Sawy and Mohamed Abd Elhay
217 Duration of untreated psychosis in two Arab samples from Egypt and Saudi Arabia: Clinical and sociocultural correlates
Mohab M. Fawzi, Hany M. El-Amin and Mounir H. Fawzi
226 Shyness and sociability in a sample of Egyptian patients with schizophrenia and its relation to resting frontal EEG
Hoda Abdou Hussein, Heba Fathy, Sherine Mohamed Abdel Mawla, Fadia Zyada and Reem A. El Hadidy
231 Prevalence and risk factors of unexplained somatic symptoms in school-aged children of Sharkia Governorate
Nagy M. Fawzy, Haitham M. Hashim and Hadeel M.A. Rahman
237 Psychological manifestations in adolescents with thalassemia
Hani Hamed, Osama Ezzat and Tamer Hifnawy
245 Central auditory processing in attention deficit hyperactivity disorder: an Egyptian Study
Saffeya Effat, Somaya Tawfik, Hanan Hussein, Hanan Azzam and Safaa El Eraky
MIDDLE EAST CURRENT PSYCHIATRY
Vol 18 No 4 October 2011
Instructions for Authors
Note: These instructions comply with those formulated by the International Committee of Medical Journal Editors (ICMJE). Forfurther details, authors should consult the following article: International Committee of Medical Journal Editors. ‘‘UniformRequirements for Manuscripts Submitted to Biomedical Journals’’ New Engl J Med 1997, 336:309–315. The complete documentappears at www.icmje.org.
Scope
Middle East Current Psychiatry (MECPsych) is one of the Middle East’s leading psychiatric journals. It covers all branches of thesubject, with particular emphasis on the clinical aspects of each topic. MECPsych is committed to keeping the field of psychiatry inthe Middle East updated and relevant by publishing the latest advances in the diagnosis and treatment of mental illness. MECPsychpublishes high-quality, scientific articles in English, representing clinical and experimental work in psychiatry. The journal acts as aninternational forum for the dissemination of information advancing the science and practice of psychiatry, MECPsych encouragesarticles in compliance with the Madrid and Helsinki Declarations.
Original articles are welcomed, especially those that bring new knowledge or extend the present understanding of mental disorders.Equal priority is given to review articles. All manuscripts published have been assessed by at least two experienced internationalreferees.
The ultimate responsibility for any decision lies with the Editor-in-Chief, to whom any appeals against rejection should be addressed.
Covering letter
A cover letter should accompany your submission. A standard letter is available on the journal’s submission sitewww.editorialmanager.com/mecpsych, or you can submit your own version. Please use the letter to explain why your manuscriptshould be published in the journal and to elaborate on any issues relating to our editorial policies detailed in these instructions.
Redundant or duplicate publication
We ask you to confirm that your paper has not been published in its current form or a substantially similar form (in print orelectronically, including on a web site), that it has not been accepted for publication elsewhere, and that it is not under considerationby another publication. The ICMJE has provided details of what is and what is not duplicate or redundant publication. If you are indoubt (particularly in the case of material that you have posted on a web site), we ask you to proceed with your submission but toinclude a copy of the relevant previously published work or work under consideration by other journals. In your covering letter to theeditors, draw attention to any published work that concerns the same patients or subjects as the present paper.
Conflicts of interest
MECPsych requires authors to state all possible conflicts of interest, including financial and other relationships on a separate line inthe Acknowledgements section of the paper. If you are sure that there is no conflict of interest, please state so. The ICMJE providesfurther information on conflicts of interest. Remember that sources of funding should also be acknowledged in your paper on aseparate line (see paragraph: Acknowledgements).
Permissions to reproduce previously published material
MECPsych requires you to send us copies of permission to reproduce material (such as illustrations) from the copyright holder ofthe previously published material. Articles cannot be published without these permissions.
Patient consent forms
The protection of a patient’s right to privacy is essential. Please send copies of patients’ consent forms on which patients or othersubjects of your experiments clearly grant permission for the publication of photographs or other material that might identify them. Ifthe consent form for your research did not specifically include this, please obtain it or remove the identifying material. A statement tothe effect that such consent had been obtained should be included in the ‘Methods’ section of your paper.
Ethics committee approval
Submission of a manuscript to MECPsych implies that all authors have read and agreed to its content and that any experimentalresearch that is reported in the manuscript has been performed with the approval of an appropriate ethics committee. Researchcarried out on humans must be in compliance with the Madrid and Helsink Declarations. A statement to this effect must appear inthe Methods section, including the name of the body which gave approval. Informed consent must also be documented. Similarly, forexperiments involving animals you must state the care of animal and licensing guidelines under which the study was performed. If
MIDDLE EAST CURRENT PSYCHIATRY
Vol 18 No 4 October 2011
ethics clearance was not necessary, or if there was any deviation from these standard ethical requests, please state why it was notrequired. Please note that the editors may ask you to provide evidence of ethical approval. If you have approval from a National DrugAgency (or similar) please state this and provide details, this can be particularly useful when discussing the use of unlicensed drugs.Manuscripts may be rejected if the editorial office considers that the research has not been carried out within an ethical framework.
Authorship
We ask that all authors sign the covering letter. We ask all authors to confirm that they have read and approved the paper. Second,we ask all authors to confirm that they have met the criteria for authorship as established by the ICMJE, believe that the paperrepresents honest work, and are able to verify the validity of the results reported.
All persons designated as authors should qualify for authorship and all those who qualify should be listed. Each author should haveparticipated sufficiently in the work to take public responsibility for appropriate portions of the content. One or more authors shouldtake responsibility for the integrity of the work as a whole, from inception to published article. Authorship credit should be based onlyon 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting thearticle or revising it critically for important intellectual content; 3) final approval of the version to be published. Conditions 1, 2 and 3must all be met. Acquisition of funding, the collection of data or general supervision of the research group, by themselves, do notjustify authorship. All others who contributed to the work who are not authors should be named in the Acknowledgements section.
Copyright assignment
Papers are accepted for publication on the understanding that exclusive copyright in the paper is assigned to the Publisher. Authorsare asked to sign a copyright assignment form at the revision stage and to submit it with their revised manuscript. Without thesigned copyright form, the manuscript cannot be published. Authors may use material from their paper in other works published bythem.
Submissions
Manuscripts must be submitted by one of the authors and should not be submitted by anyone on their behalf. The submitting authortakes responsibility for the article during submission and peer review. All manuscripts and materials must be submitted through theweb-based tracking system at www.editorialmanager.com/mecpsych. A covering letter should be included in the submission as a’supporting document’. The site contains instructions and advice on how to use the system. Authors should NOT in addition thenpost a hard copy submission to the editorial office, unless you are supplying artwork, letters or files that cannot be submittedelectronically, or have been instructed to do so by the editorial office. Include the following where appropriate: subject consentforms; transfer of copyright form; permission to reproduce previously published material.
The manuscript should include the following sections, each starting on a separate page: Title Page, Abstract and Keywords, Text,Conflict of interests, Acknowledgements, References, Tables and Figures, captions, Statistics, and Arabic summary. Two letterabbreviations should be avoided. Longer abbreviations should be defined on their first appearance in the text; those not accepted byinternational bodies should be avoided.
Manuscript
Title Page
The Title Page should carry the full title of the paper (be specific, clear and limit to two lines with no abbreviations) and a short title tobe used as a ‘running head’ (and which should be so identified). Please, include the study design in the title; for instance,‘‘randomized trial’’, or ‘‘systematic review’’. The first name, middle initial and last name of each author and their affiliations shouldappear. Academic degrees should not be stated. If the work is to be attributed to a department or institution, its full name should beincluded. The name and address of the corresponding author and the name and address of the author to whom requests for reprintsshould be made should also appear on the Title Page.
Structured Abstract
The second page should carry an abstract, which will be printed at the beginning of the paper and should not be more than 250words. The abstract should state the background or objective, methods, results, and conclusions, with an emphasis on the newaspects of the study. The abstract should be usable as it stands by abstracting journals. Because of this it should contain somenumerical data (if appropriate), not just statistical statements, and it should not contain abbreviations or references.
Key Words
The abstract should be followed by a list of 3–10 key words or short phrases which will assist the cross-indexing of the article.When possible, the terms used should be from the Medical Subject Headings list of the National Library of Medicine.
Text
The remainder of the text should be divided into sections headed Introduction, Materials and Methods (including ethical andstatistical information), Results, and Discussion (including a conclusion). Other descriptive headings and sub-headings may be usedif appropriate. Contents of the study should be presented as clearly and as concisely as possible.
Conflicts of Interest
You must make reference to any conflicts of interest related to this study. If there are no conflicts of interest, please state: none.
Acknowledgements
The acknowledgements section should contain three distinct statements:
1. Assistance with the study. Acknowledgements should be made only to those who have made a substantial contribution to thestudy. Authors are responsible for obtaining written permission from people acknowledged by name in case readers infer theirendorsement of data and conclusions.
2. Financial support and sponsorship. You must make reference to any funding bodies, or sponsorship of any type. If there are nofinancial support or sponsorship, please state: none.
For example:
Acknowledgements
We would like to thank Dr John A. Smith for his assistance with the study.
This work was supported by the Department of Anaesthesiology, London Hospital, London, UK.
References
Number references consecutively in the order in which they are first mentioned in the text. Identify references in the text, tables andlegends using numerals. References cited only in tables or in legends to figures should be numbered in accordance with thesequence established by the first identification in the text of the particular table or illustration.
Use the Vancouver reference system as adopted by the U.S. National Library of Medicine ensuring that all journal titles conform toIndex Medicus approved abbreviations.
Avoid citing abstracts unless from a MEDLINE or EMBASE indexed journal. Unpublished observations and personalcommunications should not be used as references, although references to written (not verbal) communications may be inserted(in parentheses) in the text. Manuscripts that have been accepted but not yet published (e.g. Epub ahead of print) should beincluded in the list, followed by (in press). Information from manuscripts not yet accepted may be cited only in the text as(unpublished observations). Authors should verify references against the original documents before submitting the article.
Electronic or online references should be cited in the reference list only if the material referenced is a specific article (e.g. a paperpublished in a web-based journal); see below for correct style. Less specific references (e.g. the web pages of societies,organisations and university departments) should not appear in the references, instead the URL should be cited in full in the text.
Authors must confirm that the details of these references are accurate and complete. In the full list of references give the names andinitials of all authors. If there are more than six, cite only the first three names followed by et al. The authors’ names are followed bythe title of the article: the title of the journal (italics) abbreviated according to the style of Index Medicus: the year of publication: thevolume number (in bold): the first and last page numbers in full followed by a full stop. Titles of books should be followed by the townand country of publication, the publisher, the year and inclusive page numbers. See the following examples:
Journal articlesPollard BJ, Bryan A, Bennett D et al. Recovery after oral surgery with halothane, enflurane, isoflurane or propofol anaesthesia. Br JAnaesth 1994; 72: 559–566.
BooksKorttila K. Recovery period and discharge. In: White P, ed. Outpatient Anaesthesia. New York, USA: Churchill Livingstone Inc, 1990:369–395.
Chapter in a book:Pessayre D, Feldmann G, Haouzi D, Fau D, Moreau A, Neumann M. Hepatocyte apoptosis triggered by natural substances(cytokines, other endogenous molecules and foreign toxins). In Cameron RG, Feuer G (editors): Apoptosis and its Modulation byDrugs. Handbook of Experimental Pharmacology. Berlin: Springer-Verlag; 2000, pp. 59–108.
Electronic articles:Margolis PA, Stevens R, Bordley WC, Stuart J. From concept to application: the impact of a community-wide intervention to improvethe delivery of preventive services to children. Pediatrics [online serial] 2001; 108:e42.
http://www.pediatrics.org/cgi/content/full/108/3/e42. [Accessed 20 September 2001].
Tables
References to tables should be made in order of appearance in the text and should be in numerals in parentheses, e.g. (Table 1).Each table should be typed on a separate sheet. Tables should not be submitted as photographs. Each table should have a brief titleas a heading. Vertical rules should not be used. Place explanatory matter in footnotes, not in the heading. Authors are discouragedfrom using abbreviations in tables. If abbreviations are necessary then please explain them in the table’s footnotes. Identify statisticalmeasures of variations, such as standard deviation (SD) and standard error of the mean (SEM).
Be sure that each table is cited in the text. If you use data from another published or unpublished source, obtain permission andacknowledge the source fully.
Statistics
Statitstical methods should be specified explicitly and referenced if they are non-standard. Estimates presented should beaccompanied by indicies of precision (e.g. means accompanied by confidence intervals).
Arabic summary
A short Arabic summary is required at the end of the manuscript in a seperate section.
Units of measurement
Scientific measurements should be given in SI units. Blood pressure, however, may be expressed in mmHg and haemoglobin asg dL
-1.
Abbreviations and symbols
Authors are discouraged from using abbreviations. If an abbreviation is necessary please use only standard abbreviations. Avoidabbreviations in the title and abstract. The full term for which an abbreviation stands should precede its first use in the text unless it isa standard unit of measurement.
MIDDLE EAST CURRENT PSYCHIATRY
Official Journal of the Okasha Institute of Psychiatry, Ain Shams University
WHO Collaborative Center for Trainin and Research
Aims and Scope
MECPsych is one of the Middle East’s leading psychiatric journals. It covers all branches of the subject, with particular emphasis onthe clinical aspects of each topic. MECPsych is committed to keeping the field of psychiatry in the Middle East updated and relevantby publishing the latest advances in the diagnosis and treatment of mental illness. MECPsych publishes high-quality, scientificarticles in English, representing clinical and experimental work in psychiatry. The journal acts as an international forum for thedissemination of information advancing the science and practice of psychiatry MECPsych encourages articles in compliance with theMadrid and Helsinki Declarations.
Original articles are welcomed, especially those that bring new knowledge or extend the present understanding of mental disorders.Equal priority is given to review articles. All manuscripts published have been assessed at least by two experienced internationalreferees.
MIDDLE EAST CURRENT PSYCHIATRY
Vol 18 No 4 October 2011
COPE membership for MECPsych: a message behind the newsMounir Fawzi
Department of Psychiatry, Faculty of Medicine,Zagazig University, Zagazig, Egypt
Correspondence to Mounir Fawzi, FRCPsych,Professor of Psychiatry, Department of Psychiatry,Faculty of Medicine, Zagazig University, Zagazig, EgyptTel:/fax: + 002055 2304560;e-mail: [email protected]
Middle East Curr Psychiatry 18:185–189& 2011 Okasha Institute of Psychiatry, Ain Shams University2090-5408
Good news! In June 2011, along with all Lippincott/
Williams & Wilkins journals, Middle East Current
Psychiatry (MECPsych) became a new member of the
Committee on Publication Ethics (COPE). Thus, I was
spurred to write this Editorial with a number of aims. I
wanted first to congratulate the Editor-in-Chief and all
staff members of the MECPsych on this membership. I
also wanted to briefly introduce COPE to our interested
readers and to try to construe the message behind the
news. Moreover, I saw this as an opportunity to draw the
attention of readers and contributors to some of the main
processes of research ethics that aim to ensure transpar-
ency and integrity of the scientific process that all COPE
members including the most recent one, the MECPsych,
are very concerned about and to finally discuss in brief
the impact of cultural factors on the practice of these
ethics.
It is no wonder that our editorial team should feel proud
because MECPsych is the first in the history of
psychiatric journals in Egypt to obtain the COPE
membership. However, my congratulations should be
extended to all Egyptian psychiatric academics and
clinicians who can see that out of all scientific publica-
tions in the Middle East region, there is at least one
psychiatric journal from Egypt that has earned the
membership of COPE. My wish, however, is to see as
many more as possible, if not all the journals of Egypt and
the Middle East becoming members of highly reputable
organizations concerned with publishing Ethics such
as COPE.
COPE was inaugurated in 1997 as a small self-help group
of medical journal editors in the UK providing a forum for
editors to share problems around difficult ethical cases. It
also took on the role of a pressure group to force the
government to place research misconduct on the national
agenda, and in this, it has been successful (http://www.publicationethics.org/). COPE has continued to flour-
ish. By 2000, COPE had over 90 members. Currently, it
includes more than 6000 members worldwide from all
academic fields. All COPE members are expected to
follow the Code of Conduct for Journal Editors. COPE
takes on the responsibility of investigating complaints
that a member has not followed the Code.
Well, as far as I can see, there is a clear message behind
the news that MECPsych has become a member of
COPE. The message is that articles in this Journal can be
considered trustworthy, that MECPsych is aiming for the
highest ethical standards, striving to follow COPE’s Code
of Conduct, and will take suitable action in cases of
possible scientific misconduct. This is vital because
basically, academic publishing has to be dependent on
trust. Editors trust peer reviewers to provide fair
assessments, authors trust editors to select appropriate
peer reviewers, and readers place their trust in the peer-
review process [1]. Scientists are generally perceived as
well-intentioned seekers of truth and as producers of
knowledge vital to the health and welfare of society, while
fraudsters are seen as just a ‘few bad apples’ [2], and the
public is reassured that fraudulent scientists are ulti-
mately caught and punished. Nevertheless, dark clouds of
distrust and concern are hanging over research. Highly
publicized instances of scientific fraud have led to
increased scrutiny of research ethics. Although this
scrutiny has extended across all branches of medicine, it
has been most extensive on psychiatric research. Perhaps
this is because mental illness is less well understood by
scientists and the general public or perhaps individuals
with mental illness are viewed as more susceptible to
exploitation. In addition, some ethical issues relevant to
psychiatric research have arisen primarily from the risks
posed by some research methodologies. Ethical questions
concerning the recent rapid progress in the acquisition
and application of knowledge and technologies stemming
from the sciences of the mind have led to the
development of a novel eld called ‘neuroethics.’ Ob-
viously, biologically informed psychiatry falls within the
purview of neuroethics. So too does the prescription of
antidepressants, antipsychotics, and other psychopharma-
ceuticals [3]. Some distinction has been attempted
between ethics of neuroscience and neuroscience of
ethics. The ethics of neuroscience deal with ethical
problems arising from advances in neuroimaging and
other new forms of interventions into the brain, whereas
the neuroscience of ethics investigates the neural
mechanisms that may possibly underlie moral concepts
and practices [4]. In any case, sensitivity is required in
the design of psychiatric research [5]. To safeguard the
adoption of ethical principles in research, various forms of
Editorial 185
2090-5408 & 2011 Okasha Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000403778.57074.30
national commissions, institutional review boards, re-
search ethics committees, and hospital ethics committees
have been developed. A number of international organi-
zations, such as the World Association of Medical Editors,
the International Committee of Medical Journal Editors
(ICMJE), and of course, COPE have also been estab-
lished. They all cater to one and the same goal: to bring
together different opinions, expectations, forms of
expertise, social interests, and to practice the art of
deliberation and confrontation in a tolerant and demo-
cratic spirit [6]. COPE has issued a number of important
publications. These include a series of ‘owcharts’ to
evaluate and respond to the most common questions of
misconduct, ‘Code of Conduct for Journal Editors,’ to
provide a set of minimum standards to which all COPE
members are expected to adhere, and ‘Best Practice
Guidelines,’ which is an extension of the Code as a gold
standard to which to aspire. The two guidelines were
revised in 2011 and combined into a single document but
in which the mandatory Code of Conduct and the more
aspirational Best Practice Guidelines remained distin-
guishable. Obviously, I cannot go into the details of these
publications here. They can be freely obtained from the
COPE’s website (http://www.publicationethics.org/). This
editorial, however, represents an opportunity to draw
the attention of readers and contributors to some basic
processes of research ethics that aim to ensure transpar-
ency and honesty of the scientific process.
TransparencySources of funding for research or publication should be
totally disclosed.
Conflicts of interest
Editors, authors, and peer reviewers have a responsibility
to disclose interests that might appear to affect their
ability to present or review data objectively. These
include relevant financial, personal, political, intellectual,
or religious interests. Readers will benefit from transpar-
ency, including knowing authors’ and contributors’
affiliations and interests. Editors should strive to maintain
transparent policies and procedures regarding authorship
and disclosure of conflicts of interest.
Informed consent
As the use of human beings as a means to the ends of
others without their knowledge and freely granted per-
mission constitutes exploitation and is therefore unethi-
cal, informed consent is fundamental. People may submit
themselves to possible risk or inconvenience or forego the
certainty of specific treatments to participate in a study
as an expression of their personal autonomy, individual
rights, and humanitarian interest. However, this is only
ethical if the research participants have been fully
informed about the study and have signed the consent
form to enter into the study voluntarily. Thus, informed
consent is not a signed consent [7]. A signed consent is a
documentary evidence of the consent process. To confuse
them with each other may be a violation of the ethical
intent of informed consent, which is an educational
process to generate discussion, in an atmosphere of trust
and respect, between researchers and prospective parti-
cipants to ensure that the decision to participate is made
voluntarily and knowingly. Voluntariness implies that the
consent is obtained willingly without using force, threats,
or coercion. The concept of knowledge means that the
prospective participant is allowed to enquire about the
needed details of the study and is given all of the relevant
information, which must be complete and understand-
able, to make a decision on whether or not to participate.
It is important to note that failure to disclose material
facts when obtaining a patient’s consent for research is
fraud. Consent needs to be in writing. If verbal consent is
used, one has to provide the rationale for doing so, for
example, patient illiteracy or visual impairment, but still,
in this case, a short form must be signed or fingerprinted
by the patient and cosigned by an independent witness to
what was said. Some researchers have advocated the
documentation of the process of informed consent by
audiorecording, videorecording, and photography when
patients cannot read [8]. If the participant is not able to
provide consent, as in some patients with psychiatric
disorders, it should then be obtained from the partici-
pant’s legally acceptable representative, for example,
parent, guardian, or designated other, before involvement
in any research-related activity. However, research has not
supported the assumption that all psychiatric patients by
virtue of their illness are not competent enough to
understand the issues and to provide informed consent.
Indeed, many of these patients are able to provide
informed consent.
Research honestyResearch honesty or integrity is the maintenance of
truthfulness and proper crediting of research sources. It
encompasses a wide range of topics relating to the ethical
conduct of research involving humans and animals.
Animal welfare concerns
It is essential that researchers do everything possible to
promote and ensure the humane care and treatment of
animals used in research. Animals to be used in the
laboratory must be acquired lawfully, properly fed and
sheltered and, under no circumstances, subjected to
unnecessary pain or discomfort.
Human use concerns
The origin of advancing scientific knowledge through
human experimentation using vulnerable groups can be
traced back to ancient history, when Herophilus per-
formed vivisections on prisoners. In recent times, the
principles of conducting human research were first deve-
loped as the ‘Nuremberg code’ in 1947 to try 23 Nazi
physicians and officials as war criminals for conducting
‘studies’ of prisoners. The three basic principles of the
and provide care and reinsertion for patients [13].
AuthorshipThe list of authors should accurately reflect who carried
out the study. However, authorship relates more to the
intellectual rather than to the practical implementation
of the project. According to the ICMJE (http://www.icmje.org), authorship requires the fulfillment of three condi-
tions: (a) substantial contributions to conception and
design, or acquisition of data, or analysis and interpreta-
tion of data; (b) drafting the article or revising it critically
for important intellectual content; and (c) final approval
of the version to be published. All three conditions should
be fulfilled for assigning authorship. Although the ICMJE
criteria are clear, many authors are unaware of them or
prefer to use their own ad-hoc criteria for deciding
authorship [14]. Two forms of ethical problems concern-
ing authorship have been frequently recognized: (a) Gift
(guest or honorary) authorship, that is, inclusion of
authors who did not contribute substantially to the study,
for example, those who provide technical help only,
writing assistance, or the head of the department who
provides only general support. These people are relegated
to the acknowledgments section. Another form of gift
authorship occurs between colleagues and collaborators.
In this case, a name of a colleague is unjustifiably added
to the manuscript in the expectation that the favor will be
returned. In this way, both authors unethically increase
the number of their publications. (b) Ghost authorship,
that is, exclusion of authors who did contribute sig-
nificantly to the study. This usually involves people,
such as postgraduate students, who are too junior to
protest.
Listing individuals’ contributions to the research and
publication process provides greater transparency than
the traditional listing of authors and may discourage
inappropriate authorship practices such as ‘ghost’ authors
and gift authors. A declaration should be made that all
authors meet the journal’s criteria for authorship and that
nobody who meets these criteria has been excluded from
the list. Authors should also declare that they have
acknowledged all significant contributions made to their
publication by individuals who did not meet the journal’s
criteria for authorship. If an authorship dispute or
discrepancy comes to light before publication (for
example, changes to the list of authors are proposed
after submission), editors should take care to explain the
journal’s authorship policy to the corresponding author
and to establish that all authors agree to the change
before proceeding with publication. If an authorship
dispute emerges after publication (for example, some-
body contacts the editor claiming they should have been
an author of a published paper or requesting that their
name be withdrawn from a paper), the editor should
contact the corresponding author and, where possible, the
other authors to establish the veracity of the case. If
authorship policies have been clearly set out and an
explicit authorship declaration(s) has been received
(stating that all authors meet the agreed criteria and
that nobody deserving authorship has been excluded),
then genuine errors are unlikely; however, editors should
consider publishing a correction in the case of such errors.
Has the work been published before?Duplicate publication
This is the publication of an article that is identical or
overlaps substantially with an article already published
elsewhere, with or without acknowledgment. Duplicate
publication is considered misconduct because, aside from
the obvious attempt to inflate one’s own publication
record, duplication (and redundant) publication has the
potential to skew the evidence base (if the same data
were counted more than once, the outcomes of meta-
analysis used to establish the best practice would be
invalid). Guidelines on good publication practice state
that the authors can only submit their manuscript to a
single journal at a time. However, there are some
exceptions to the rule, for example, publication of results
in an abstract form (and as a poster or oral communica-
tion) at a congress. Once a manuscript has been publi-
shed, data should not then be submitted to a congress.
Authors may resubmit the same or a revised version to
another journal only if the first journal makes the decision
not to publish it or it is withdrawn by the author.
Other research misconductsThe most important other forms of research misconduct
include the trio ‘FF&P’: fabrification, falsification, and
plagiarism.
(1) Fabrication: Fabrication of data refers to the invention
or the making up of fictitious data, that is, data are
made up or ‘cooked’ and then presented as research
findings;
(2) Falsification: Falsification is the changing of data or
exclusion of critical data to produce a desired
outcome or to avoid a complicating or an inexplicable
result;
COPE membership for MECPsych Fawzi 187
(3) Plagiarism (from the Latin word plagiarius, meaning
the theft of words as well as slaves): Plagiarism is the
use of someone else’s words, ideas, or results without
appropriate attribution. It is a form of academic
dishonesty and can be a criminal offense.
However, not all research misconduct allegations are true.
A surprising number of plagiarism allegations turn out to
be misunderstandings of exactly what constitutes plagiar-
ism or proper citation procedure. On the basis of
contemporary guidelines, I further discussed research
misconduct elsewhere [15]. It is true that there are
certain universal concepts, but it should be noted that
the standards or the requirements of publishing, as other
human endeavors, undergo a natural evolution, and
standards acceptable even 10–20 years ago are no longer
acceptable [16]. Moreover, these guidelines are western-
oriented and although the problem of ensuring ethical
practices in research on humans appears to be universal,
the influence of traditional and hierarchical social norms
of physician–patient relationships, in the developing
world, adds yet another dimension to the difficulties in
ensuring that research is conducted in an ethical manner.
Some observers in the Western world noted that many of
those found guilty of scientific misconduct were from
foreign cultures. Applying theories from sociological
criminology, Davis [17] posited that the culture brought
to the West by some researchers may be at odds with the
norms of academic science and may emphasize ends more
than means. Nonetheless, in the developing world, the
influence of traditional and hierarchical social norms of
physician–patient relationships adds yet another dimen-
sion to the difficulties in ensuring that research is
conducted in an ethical manner [18].
In some cultures, it is still customary for physicians to
withhold certain information from patients. Clinicians
may provide diagnoses (as well as prognoses) of some
serious conditions to family members, but not to the
patients. As a result, the patient’s consent to certain
procedures, if sought, may not be fully informed. Hence,
valid informed consent (for either treatment or research
participation) can be difficult. In some cultural contexts,
the appropriateness of requiring information to be
disclosed about the use of a placebo and the randomiza-
tion of participants may also be queried. Some have
recommended, therefore, that researchers should develop
culturally appropriate ways to disclose information that is
necessary for adherence to the ethical standard of
informed consent, with particular attention to disclosures
relating to diagnosis and risk, research design, and
possible posttrial benefits. Researchers have to explain
to the Ethics Review Committee(s) their plan for
disclosing such information to participants [19]. More-
over, in some cultures where people may not understand
or accept scientific explanations of health and disease,
the challenge of obtaining informed consent can be
daunting. Yet, researchers can devise innovative methods
to surmount these obstacles and to ensure that potential
participants do, in fact, comprehend the information
contained in the consent process. In some countries,
community education is performed before obtaining
individual consent.
We should also bear in mind that in the Eastern
Mediterranean Region, the foundations of ethical princi-
ples can be found within the three major religions of
Judaism, Christianity, and Islam. In Egypt, the numerous
ethical issues that are emerging as result of the
technological advances tend to be addressed in accor-
dance with Islamic principles [20]. Acknowledging the
role of culture in the adherence to research ethics,
however, underscores the importance of education and
training of both researchers and administrators in the
responsible conduct of research and cultural diver-
sity [17].
Culture also has an impact on the definitions of scientific
misconduct, which differ from country to country and
from one institution or government agency to an-
other [21]. However, the increasing globalization of
scientific research calls for an international agreement
on the definition of scientific misconduct. Universal
spiritual and moral principles on which ethical standards
are generally based indicate that it is possible to reach
international agreement on the ethical principles under-
lying good scientific practice without creating unneces-
sary obstacles to research. This is very much needed for
research, especially in developing countries. Ethical stan-
dards promote high-quality research. It is crucial, there-
fore, to draw attention to and follow such standards [16].
To conclude, I think one can see that getting a
membership of COPE is a message signifying that this
Journal will be taking part in the development of local
and international research ethical standards. So, once
more, congratulations!!
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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COPE membership for MECPsych Fawzi 189
The dilemma in the concept and the management of
bipolar disorderAhmed Okasha
WHO Collaborating Center for Research and Trainingin Mental Health, Okasha Institute of Psychiatry,Ain Shams University, Cairo, Egypt
Correspondence to Ahmed Okasha, MD, PhD, FRCP,FRC, Psych, FACP (Hon) Director, WHO CollaboratingCenter for Research and Training in Mental HealthOkasha Institute of Psychiatry, Ain Shams University,Cairo, EgyptTel: +202 29200900/1/2/3/4;fax: +202 29200907/8;e-mail: [email protected];
relationships with friends–37% expressing own opi-
nion [29].
A survey of European psychiatrists indicated that over
60% of patients with bipolar disorder had to undergo at
least two changes of therapy before stabilization. The
average number of therapy changes before patients were
stabilized was 2.4 [31].
A few developments have led to renewed interest in
psychotherapies for bipolar disorder, especially the lack of
effectiveness of long-term pharmacotherapy under ordin-
ary clinical conditions and the significant role of patients’
poor adherence in reducing the effectiveness of pharma-
cotherapy; however, there is evidence that life stressors
and social support can have an influence on the course of
the disorder and that social, family and occupational
dysfunction is very frequent in patients with bipolar
disorder. Psychotherapeutic techniques that can be used
systematically in patients with bipolar disorder include
cognitive-behavioural techniques, interpersonal and social
rhythm therapies, psychoeducational techniques and
family and couple interventions. The common psy-
chotherapeutic techniques of proven efficacy in bipolar
disorder include providing information on the disorder,
focusing on triggers of episodes, seeing the individual as
part of a group and formulating a patient-specific action
plan [6].
Need for new and effective treatments inbipolar disorderThere is a recognized need for new and effective
treatments in bipolar disorder maintenance. The episodic
and chronic nature of bipolar disorder requires long-term
treatment in all patients, and yet, there is an unmet need
for well tolerated and clinically effective maintenance
therapy with enhanced patient adherence. A substantial
number of patients with bipolar disorder do not respond,
have relapses or cannot tolerate the side effects of
common treatments for bipolar disorder. Treatment
guidelines for bipolar disorder recommend a wide range
of treatments, with no obvious trend in recommendations
across guidelines. This suggests that there is an unmet
need for treatment that is effective across all phases of
bipolar disorder (Tables 2 and 3) [33–37].
Table 2 Food and Drug Administration approved treatments
for bipolar disorder
Phases of bipolar disorders Mania Depression
Acute treatment Lithium (Lithium)a
Valproate (Lamotrigine)a
(carbamazepine)a Olanzapine/fluoxetineOlanzapine (SSRIs)a, c
RisperidoneQuetiapine Quetiapine
Maintenance treatment Lithiumc
Lamotrigined
Quetiapine
aOff label for this indication.bNot recommended as monotherapy (can induce mania and rapidcycling).cPredominantly effective against mania.dPredominantly effective against depression.
Table 3 Food and Drug Administration approved treatments/bipolar disorder
Maintenance Depression
Mania Mixed Mania Depression Bipolar disorder I Bipolar disorder II
Mood stabilizerLithium + – + – – –Divalproex DR + – – – – –Divalproex ER + + – – – –Carbamazepine ER + + – – – –
Physicians’ Desk Reference 2009 [32].+ , approved by Food and Drug administration;– , not approved by Food and Drug administration;DR, Delayed release;ER, Extended release.
The dilemma in the concept and the management of bipolar disorder Okasha 193
SummaryBipolar disorder is a lifelong illness and is associated with a
substantial health, social and economic burden. An
accurate diagnosis of bipolar disorder is essential to initiate
effective treatment and prevent relapse. Evidence sup-
ports a range of treatments for the improvement of manic
and depressive symptoms in bipolar disorder. The ideal
treatment would achieve mood stabilization by effectively
treating mania and depression and preventing relapse
among patients with bipolar disorders I and II and rapid
cyclers. The most successful treatment strategy would
involve a holistic approach that is tailored to the individual
patient inclusive of the following aspects: physical
(symptom control), emotional (become calmer, feel good
about themselves), mental (able to think clearly, make
sense of life and regain control) and social (return to work,
reengage in social activities and family).
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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10 Tohen M, Jacobs TG, Grundy SL, McElroy SL, Banov MC, Janicak PG, et al.Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo -controlled study. The Olanzipine HGGW Study Group. Arch Gen Psychiatry2000; 57:841–849.
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194 Middle East Current Psychiatry
Diagnosis of Alzheimer’s disease: possible role of functional
imaging techniqueMohamed Ezzat El-Hadidya and Salwa Mohamed Etiabab
aDepartments of Psychiatry andbDiagnostic Radiology, Faculty of Medicine,Mansoura University, Mansoura, Egypt
Correspondence to Mohamed Ezzat El-Hadidy, MD,Associate Professor of Psychiatry, Department ofPsychiatry, Mansoura University Hospitals, Facultyof Medicine, Mansoura University, Mansoura,Egypt, Mansoura 35111, EgyptTel: + 010 2243352;e-mail: [email protected]
Received 15 March 2011Accepted 4 May 2011
Middle East Current Psychiatry
2011, 18:195–202
Background
The combination of clinical diagnosis of Alzheimer’s disease (AD) with
diffusion-weighted imaging (DWI) may improve the diagnostic accuracy of AD.
Objectives
This study primarily aims to determine the relationship between the measures of DWI
and clinically diagnosed AD and its severity.
Participants and methods
The sample evaluated comprised three groups: 14 patients with AD, nine patients with
minimal cognitive impairment of amnesic type (a-MCI), and 11 healthy controls. They
were recruited from 2008 to 2009. The diagnosis of AD was made according to the
Diagnostic and Statistical Manual of Mental Disorders fourth edition text revision and
that of a-MCI was made according to Mayo Clinic’s criteria. Dysfunctional severities
were assessed using the Mini-Mental State Examination and Alzheimer’s disease
Assessment Scale. The magnetic resonance DWI technique was used to estimate the
diffusivity of water through different cerebral regions as the assumed imaging marker.
Results
DWI measures of AD in different cerebral regions were found to be higher but not
significantly different from that of the control group. Apparent diffusion coefficient
means of the a-MCI group were closer to and not significantly different from that of the
AD group. In addition, there was no significant relation between the diffusivity
measures in such regions and the total scores of assessments for the
dysfunctional severities.
Conclusion
The only trend toward increased diffusivity was shown with conventional DWI but no
statistically conclusive results were obtained either for gray or for white matter among
diagnosis of AD [14]. However, higher baseline hippo-
campal diffusivity was associated with a greater hazard of
progression to AD in a-MCI [24]. Hence, it was argued
that DWI may help identify patients with a-MCI who will
progress to AD as efficiently as or better than structural
MRI measures of hippocampal atrophy.
Limitations
The sample size was small as it was difficult to recruit
pure concordantly diagnosed AD and a-MCI cases. The
wide age range (50–80 age years) may result in
differences between individuals in different stages of
age-related brain involution changes.
ConclusionConventional DWI only showed a trend toward increased
diffusivity, with no statistically significant results ob-
tained for either gray or white matter. This may reach
significance with large-scale research projects. In addi-
tion, the use of more sophisticated diffusion techniques
may yield more precise results. In the dementia and
predementia stages, microstructural diffusion changes in
certain regions occur on both sides. These can contribute
toward the diagnostic accuracy of AD and the prede-
mentia stage but may not help in the assessment of
cognitive or behavioral dysfunctional severity.
AcknowledgementsThe authors thank faculty members at the Psychiatric and DiagnosticRadiological Departments of the Mansoura University Hospitals. Theresearchers work at El-Mansoura Faculty of Medicine, a Government-funded institute that serves as a primary educational and researchfacility for the east Delta areas. The current research has nospecial fund.
Conflicts of interestThere is no conflict of interest to declare.
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21 Yoshiura T, Noguchi T, Koga H, Ohyagi Y, Hiwatashi A, Togao O, et al.Cortical damage in Alzheimer’s disease. Estimation in medial and lateralaspects of the cerebrum using an improved mapping method based ondiffusion-weighted magnetic resonance imaging. Acad Radiol 2008;15:193–200.
22 Canu E, McLaren DG, Fitzgerald ME, Bendlin BB, Zoccatelli G, AlessandriniF, et al. Microstructural diffusion changes are independent of macrostructuralvolume loss in moderate to severe Alzheimer’s disease. J Alzheimer’s Dis2010; 19:963–976.
23 Fayed N, Davila J, Oliveros A Jr, Medrano J, Castillo J. Correlation of findingsin advanced MR techniques with global severity scales in patients with somegrade of cognitive impairment. Neurol Res 2010; 32:157–165.
24 Kantarci K, Petersen RC, Boeve BF, Knopman DS, Weigand SD, O’BrienPC, et al. DWI predicts future progression to Alzheimer disease in amnesticmild cognitive impairment. Neurology 2005; 64:902–904.
Diagnosis of Alzheimer’s disease El-Hadidy and Etiaba 201
202 Middle East Current Psychiatry
Cognitive functions after hemorrhagic stroke: follow-up studyHala Ahmed El-Boraiea, Mohamed Abd El-Salam Mohamedb, Mostafa Amra
and Salwa Tobara
aDepartments of Psychiatry andbNeurology, Mansoura University, Mansoura, Egypt
Correspondence to Hala Ahmed El-Boraie,Department of Psychiatry, Mansoura University,Mansoura, EgyptTel: + 123103929l; fax: + 2050 2248487;e-mail: [email protected]
Received 5 March 2011Accepted 7 April 2011
Middle East Current Psychiatry
2011, 18:203–210
Objectives
There are scarce data on long-term cognitive outcomes after first-ever hemorrhagic
stroke.
Aim
This study was carried out to determine the frequency of cognitive impairment,
no dementia after an intracerebral hemorrhagic stroke and to study their evolution
toward dementia (transitions in cognitive state) during a 2-year follow-up.
Methods
Thirty-five patients with first-ever hemorrhagic strokes and in an age-matched and sex-
matched comparison group (nonstroke, n = 20) were followed up for 2 years by three
serial assessments. Stroke patients at 3, 12, 24 months after discharge were
evaluated together with nonstrokes, by an extensive neuropsychological battery and
clinical psychiatric interview based on Diagnostic and Statistical Manual of Mental
Disease, 4th edition TR criteria. Rates of cognitive change were compared using
repeated-measures analyses. Factors associated with incident dementia and cognitive
impairment, no dementia at 2 years were determined by multinomial logistic regression.
Results
The majority of patients (71.4%) were cognitively stable. Fewer cases improved
(11.5%) and 71.1% of the stroke cases worsened at the end of the 24-month
follow-up. There was impaired cognitive function in nearly all cognitive domains of
stroke cases compared with nonstroke cases. Overall, stroke cases showed a
statistically significant decline in mini-mental state examination (MMSE), spatial ability,
and in the executive function domain; however, there was no improvement in attention
nonverbal memory domains. Age at stroke onset was independently associated with
cognitive impairment at the 2-year follow-up P = 0.03.
Conclusion
Cognitive evolution 2 years after hemorrhagic stroke is different among patients, but a
substantial number of patients remain stable. Additional studies are required to reliably
identify individuals at risk for cognitive decline for whom pharmacologic or other
therapeutic interventions would be more suitable and who will probably spontaneously
improve. Classification of stroke by etiology may be more useful to determine patients
at a higher risk of stroke and for its prevention.
Executive functionTrail making A 254.55 ± 93.9 – 2.139 0.040 256.7 ± 94.9 – 2.13 0.04Trail making B 631.87 ± 25.3 – 1.823 0.077 643.9 ± 25.7 – 2.19 0.03Word association 3.74 ± 3.57 0.367 0.716 3.71 ± 3.44 0.260 0.79
BG, Bender–Gestalt test; MMSE, mini-mental state examination; SD, standard deviation.aComparison of the first year with 3 months (baseline).bComparison of the second year with 3 months (baseline).
206 Middle East Current Psychiatry
of CIND was diagnosed in three cases of stroke group
(CDR = 0.5) and one case of the nonstroke group
between the first-year and the second-year follow-up
interviews. Dementia was diagnosed in five stroke cases
and one nonstroke case. Of these, four stroke cases had
developed a new incidence of dementia (two cases
CDR = 1, one case CDR = 2, one case CDR = 3)
between the first-year and the second-year follow-up
interviews, whereas the other two cases developed
dementia (CDR = 1) at the 2-year follow-up. However,
by the end of the follow-up, the majority of the patients
(25, 70.1%) and (17, 85%) controls were cognitively
stable. Fewer stroke cases than nonstroke cases showed
an improvement from being cognitively impaired at
baseline to being unimpaired at 2 years [19.4% (4/21)
and 25% (1/4), respectively]. Also, 42.8% (6/14) of stroke
cases worsened from being cognitively unimpaired at
baseline to being impaired at 2 years versus 12.5% (2/16)
of nonstroke cases. Table 4 shows that there is impaired
cognitive function in nearly all domains with a significant
difference between stroke and nonstroke groups. Overall
stroke cases declined the most in MMSE, spatial ability,
and in executive function between baseline and the first
and the second year of follow-up with a statistically
significant difference and to a lesser extent in other
domains with no statistically significant difference. There
was also a lack of improvement in attention and nonverbal
memory (Table 5). Nonstroke cases, in contrast, showed
stable performance in all cognitive domains (Table 6).
Table 7 shows that sex was a significant predictor of
executive dysfunction when a multivariate regression
analysis was carried out for significant factors in univariate
analysis. Also, in multivariable analysis, only the age at
stroke onset was independently associated with cognitive
impairment at the second year of follow-up (Table 8).
DiscussionIn the early phase of stroke, a cognitive disorder is usually
related to the direct local effects of the lesion, indicating
that the afflicted brain area is an essential component in
a network subserving that specific cognitive function.
In case of ischemic stroke, these local effects are related
to the core area of the infarct and the ischemic zone
surrounding the infarct, whereas an intracerebral hemor-
rhage usually causes symptoms by exerting pressure on
the surrounding brain tissue. Indirect effects may also
play a role in causing cognitive impairment, such as (a)
‘diaschisis’, in which the lesion cuts off neural input to a
remote area of the brain, causing a dysfunction of that
remote area [8], (b) ‘hypoperfusion’, in which neural
dysfunction is caused by a decreased cerebral blood flow
in case of occlusion of one or more cerebropetal arteries
[26], or (c) neuronal metabolic abnormalities throughout
the entire brain beyond the effects of the stroke lesion
[27]. In patients with stroke, CIND is associated with
disability and a rate of progression to dementia, but its
operational definition is not straightforward.
Table 6 Cognitive change from baseline to the first-year and the second-year follow-up of the nonstroke group
First year Second year
Cognitive ability Mean ± SD t-test Significance Mean ± SD t-test Significance
studies are required to reliably identify individuals at risk
of cognitive decline for whom pharmacologic or other
therapeutic interventions would be more suitable and those
who will probably show spontaneous improvement. The
determinants of progression of cognitive impairment are
still poorly known. In our sample, age at stroke onset was
found to be a determinant of progression of cognitive
impairment. It was also found in this study that sex can be
considered as a predicting factor for executive dysfunction.
Further Egyptian studies are essential with a larger sample
size. Classification of stroke by etiology may be more useful
for explaining the excess risk of stroke and the scope for its
prevention.
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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3 Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S,et al. Guidelines for the primary prevention of stroke. A guideline forhealthcare professionals from the American Heart Association/AmericanStroke Association. Stroke 2011; 42 (Suppl 1):s40–s43.
4 Del Ser T, Barba R, Morin MM, Domingo J, Cemillan C, Pondal M, et al.Evolution of cognitive impairment after stroke and risk factors for delayedprogression. Stroke 2005; 36:2670–2675.
5 Hacke W, Donnan G, Fieschi C, Kaste M, Von Kummer R, Broderick JP, et al.Association of outcome with early stroke treatment: pooled analysis ofATLANTIS, ECASS and NINDS rt-PA stroke trials. Lancet 2004; 363:768–774.
6 Stone J, Townend E, Kwan J, Haga K, Dennis MS, Sharpe M. Personalitychange after stroke: some preliminary observations. J Neurol NeurosurgPsychiatry 2004; 75:1708–1713.
7 Bogousslavsky J. William Feinberg lecture 2002: emotions, mood and be-havior after stroke. Stroke 2003; 34:1046–1050.
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10 Roman GC. Facts, myths and controversies in vascular dementia. J NeurolSci 2004; 226:49–52.
11 Bowler JV, Hachinski V. Vascular cognitive impairment: a new approach tovascular dementia. Baillieres Clin Neurol 1995; 4:357–376.
12 Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mildcognitive impairment: clinical characterization and outcome. Arch Neurol1999; 56:303–308.
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Cognitive functions after hemorrhagic stroke El-Boraie et al. 209
210 Middle East Current Psychiatry
Characteristics of substance dependence in adolescents with
and without a history of traumaHosam El-Sawy and Mohamed Abd Elhay
Department of Neuropsychiatry, Faculty of Medicine,Tanta University, Egypt
Correspondence to Hosam El-Sawy, AssistantProfessor of Neuropsychiatry, Faculty of Medicine,Tanta University, EgyptTel: + 20127904167;e-mail: [email protected]
Received 1 January 2011Accepted 13 March 2011
Middle East Current Psychiatry
2011, 18:211–216
Background
Numerous studies have documented a strong correlation between trauma exposure
and substance abuse in young people. The link between trauma and substance abuse
is even more striking among adolescents with posttraumatic stress disorder (PTSD).
Aim of the study
The aim of this study was to address the characteristics of substance dependence and
comorbid psychiatric disorders in adolescents with and without a history of trauma
(physical or sexual) and in a subgroup that had posttraumatic stress disorder.
Methodology
A total of 78 adolescents aged between 12 and 17 years who attended the drug
dependence clinic at the Neuropsychiatry center, Tanta University, were classified
according to the Childhood Trauma Questionnaire into 29 without a history of trauma,
15 with PTSD, and 34 with a history of trauma without PTSD. All groups were
assessed as regards onset of drug use, number of substances used, motives for use,
attempts for abstinence, and comorbid psychiatric disorders using The MINI
International Neuropsychiatric Interview.
Results
It was found that adolescents exposed to trauma had early onset of drug abuse and
were more likely to use tramadol, followed by cannabis and benzodiazepines. They
have a tendency to polysubstance abuse compared with others. The primary reasons
for drug abuse in trauma patients were coping with stress and enhancement of
self-esteem, whereas it was social pressure in others and they made less attempts
at abstinence. Anxiety disorders and psychotic disorders were more common in the
PTSD group.
Conclusion
Adolescent substance abuse is common among children with sexual or physical
trauma and needs careful attention to minimize comorbid psychiatric disorders.
Keywords:
adolescents, physical and sexual trauma, substance dependence, posttraumatic stress
disorder
Middle East Curr Psychiatry 18:211–216& 2011 Okasha Institute of Psychiatry, Ain Shams University2090-5408
IntroductionNumerous studies have documented a strong correlation
between trauma exposure and substance abuse in young
people. A recent survey of adolescents revealed that
teens who had experienced physical or sexual abuse/
assault were three times more likely to report past or
current substance abuse than those without a history of
trauma [1]. Surveys of adolescents receiving treatment
for substance abuse have shown that more than 70% had
a history of trauma exposure [2,3]. The link between
trauma and substance abuse is even more striking among
adolescents with posttraumatic stress disorder (PTSD).
Studies indicated that up to 59% of young people with
PTSD subsequently develop problems related to sub-
stance abuse [3–6].
Many researchers and providers point to the self-
medication hypothesis to explain the connection between
trauma exposure and substance abuse, suggesting that
youth resort to psychoactive drugs and alcohol in an
attempt to cope with traumatic stress or reminders of loss.
Although there is a lot of evidence to support this pathway,
studies evaluating the frequency of substance abuse after
trauma exposure have reported rates as high as 76% [6–9].
It is also true that substance abuse can increase an
adolescent’s risk of trauma exposure and of experiencing
traumatic stress symptoms.
Successful treatment of adolescents with co-occurring
traumatic stress and substance abuse therefore requires
interventions that address the challenges of both dis-
orders. Failure to provide such comprehensive treatments
may significantly impair these teenagers’ likelihood of
long-term recovery. In the absence of coping strategies to
manage distress associated with trauma, adolescents with
co-occurring disorders are more likely to relapse and
revert to maladaptive coping strategies than are teenagers
Original article 211
2090-5408 & 2011 Okasha Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000403816.99317.90
with substance abuse alone [10]. There are very few
studies in Egypt that have investigated the characteristics
of substance dependence in adolescents with a history of
trauma [11]. The aim of this study was to address the
characteristics of substance dependence and comorbid
psychiatric disorders in adolescents with and without a
history of trauma (physical or sexual) and in a subgroup
that had PTSD.
MethodologyThe study included all adolescent substance dependants
whose ages ranged between 12 and 17 years and who were
being treated at the Drug dependence Outpatient Clinic
of Psychiatry, Neurology and Neurosurgery Center, Tanta
University, from October 2009 to November 2010. They
were diagnosed according to Diagnostic and StatisticalManual of Mental Disorders Fourth Edition [12] diagnostic
criteria for drug dependence and administered a Child-
hood Trauma Questionnaire (CTQ). The Childhood
Trauma Questionnaire is a 28-item self-report retro-
spective inventory that measures childhood or adolescent
abuse and neglect. It is straightforward and easy to use.
The CTQ can be administered individually or to a group.
The examinee responds to 28 simple questions on a 5-
point scale ranging from Never True to Very Often True.
The central constructs underlying the questionnaire are
emotional, physical neglect and abuse, and sexual abuse.
Other traumatic events that may occur during childhood,
such as the death of a parent or a major illness, are not
assessed. The items are written at a sixth grade reading
level, and reading level and intellectual functioning
should be assessed before administering the scale (by
Wechsler Adult Intelligence Test by Mleka 2000) [13,14].
The measure also includes a three-item Minimization/
Denial scale indicating the potential underreporting of
maltreatment. Participants respond to each item in the
context of ‘when you were growing up’ and answer
according to a 5-point Likert scale ranging from ‘never’ =
1 to ‘very often’ = 5, producing scores of 5–25 for each
trauma subscale. The three items comprising the
Minimization/Denial scale are dichotomized (‘never’ = 0,
all other responses = 1) and summed; a total of one [1] or
greater suggests the possible underreporting of maltreat-
ment (false negatives). Participants were divided into
three groups: group I comprised adolescents with
substance dependence without a history of trauma; group
II comprised adolescents with a history of trauma with
PTSD (current or past); and group III comprised
adolescents with a history of trauma without posttrau-
matic stress disorder. All participants were assessed with
regard to onset of drug use, number of substances used,
motives for use, attempts at abstinence, and comorbid
psychiatric disorders using The MINI International
Neuropsychiatric Interview. This interview was trans-
lated and validated into Arabic by Ghanem et al. [15,16].
Written consent was taken from all patients and controls
after they were informed of all the steps and aims of
the study.
Statistical analysis
The collected data were organized and statistically
analyzed using the 15 Minitabe software [17] statistical
computer package. Mean and standard deviations were
used for presentations of quantitative data. The differ-
ences with regard to psychiatric disorders were analyzed
using a multivariate analysis of variance. The Student
t-test was used for comparison between two means. The
w2 test and the Fischer exact test were used for comparison
between the studied groups. A 5% level of significance
was adopted for interpretations of tests of significance.
ResultsDuring the study period, 78 adolescents with substance
dependence whose ages ranged between 12 and 17 years
were interviewed. Of them, 29 (37%) reported no trauma
(physical or sexual) during childhood and were termed
group I; 49 (63%) reported trauma (physical, sexual, or
both) and were further divided into group II (15 patients,
19%; those who developed PTSD) and group III (34
patients, 44%; those without PTSD). There was no
significant statistical difference among the studied groups
as regards age or sex (P 40.05), although there were
more female patients in trauma groups II and III (33;
32%) than in group I (18%). Early onset of substance
dependence was significantly more in groups II and III
than in group I, but there was no significant difference
between groups II and III. The CTQ showed signifi-
cantly higher scores in the physical trauma subscale in
patients with PTSD (Po0.05), but no significant
differences were found between the two groups on the
sexual trauma subscale (P40.05) (Table 1).
Characteristics of substance used in the studied groups
It was found that all patients had a tendency to
polysubstance abuse. In group I, 41% used more than
two drugs in comparison with 53% in group II and 50% in
group III. The difference was not statistically significant
(P40.05). In addition, 44% in group I, 40% in group II,
and 41% in group III used two drugs. Only a minority
used only one drug in the three groups (15% in group I,
7% in group II, and 9% in group III). The difference was
not significant (P40.05) (Table 2).
Tramadol was the most commonly used drug by groups II
and III (93 and 94%, respectively), followed by cannabis
(93 and79%, respectively), opiates (60 and 47%, respec-
tively), and benzodiazepines (13 and 20%, respectively).
Cannabis was the most commonly used drug by group I
(82%), followed by Tramadol (65%), opiates (41%), and
benzodiazepines (17%). Other substances include antic-
holinergics, inhalants, and barbiturates and were used by
37% of group I, 33% of group II, and 44% of group III.
The difference was not statistically significant (P40.05)
(Table 2). Nicotine was excluded as it was used by all
patients.
Social pressure was the most important motive for
substance use in group I (44%), which was statistically
significant compared with groups II and III (7 and 6%,
212 Middle East Current Psychiatry
respectively). Curiosity also was the motive for 28% in
group I, which was not significant in relation to 20 and
11% in groups II and III, respectively. In contrast, coping
with stress was the most important motive for substance
use in patients with PTSD (93%) and in trauma patients
without PTSD (79%), followed by enhancement of self-
esteem (53% in group II and 30% in group III). The
difference between both groups of trauma patients was
statistically significant (Po0.05) (Table 2).
Patients without trauma (group I) showed more sig-
nificant attempts at abstinence than those who had
undergone trauma (Po0.05) (Table 2).
Anxiety disorders (other than PTSD) comprised the most
common comorbidity among group II (67%) patients in
comparison with group III (41%) and group I (20%)
(Po0.05). Psychotic disorders as comorbid disorders
were found in a small percentage in the three groups
Table 1 Demographic data of the patients
VariableGroup I patients without
trauma N = 29Group II patients with trauma
(with PTSD) N = 15Group III traumatic patients
(without PTSD) N = 34
Age:(Years)Range 12–17 12-17 12–17 F = 0.17
P = 0.846Mean 14.51 14.20 14.38SD ± 1.76 1.74 1.70
SexMales 24 (82%) 10 (67%) 23 (68%) X = 2.204Females 5 (18%) 5 (33%) 11 (32%) P = 0.332
Duration of substance use: (months) F = 8.74P = 0.00a
Range 12–48 12–60 12–59 T1 = – 3.12P = 0.005a
Mean 25.03 38.80 37.32 T2 = – 3.93P = 0.000a
SD ± 11.32 15.02 13.53 T3 = 0.33P = 0.747
CTQ physical scores: T = 4.43P = 0.000aRange 10–17 6–14
Mean 12.67 9.79SD ± 2.16 1.93
CTQ sexual scores:Range 5–16 5–18 T = 1.52
P = 0.140Mean 9.93 11.35SD ± 2.89 3.29
CTQ, Childhood Trauma Questionnaire; PTSD, posttraumatic stress disorder; SD, standard deviation.aSignificant T1 (Group I vs. II). T2 (Group I vs. III). T3 (Group II vs. III).
Table 2 Characteristics of drug dependence in the studied patients
VariableGroup I patients without
trauma N = 29Group II patients with trauma
(with PTSD) N = 15Group III traumatic patients
(without PTSD) N = 34
Number of drug usedMore than two 12 (41%) 8 (53%) 17 (50%) P = 0.900Only two 13 (44%) 6 (40%) 14 (41%)Only one drug 4 (15%) 1 (7%) 3 (9%)
Type of drugTramadol 19 (65%) 14 (93%) 32 (94%) P = 0.005a
Cannabis 24 (82%) 14 (93%) 27 (79%) P = 0.481Opiates 12 (41%) 9 (60%) 16 (47%) P = 0.502Benzodiazepines 5 (17%) 2 (13%) 7 (20%) P = 0.824Others 11 (37%) 5 (33%) 15 (44%) P = 0.752
Motives for useSocial pressure 13 (44%) 1 (7%) 2 (6%) P = 0.000a
Curiosity 8 (28%) 3 (20%) 4 (11%) P = 0.282Enhancement of self-esteem 2 (7%) 8 (53%) 10 (30%) P = 0.003a
Coping with stress 1 (3%) 14 (93%) 27 (79%) P = 0.000a
Others 5 (18%) 2 (13%) 4 (11%) P = 0.820Attempts at abstinence
Yes 12 (41%) 3 (20%) 5 (14%) P = 0.046a
No 17 (95%) 12 (80%) 29 (86%)Comorbid psychiatric disorders
Depressive disorders 8 (28%) 7 (47%) 15 (44%) P = 0.311Anxiety disorders (other than PTSD0 6 (20%) 10 (67%) 14 (41%) P = 0.011a
tempts were also found in adolescents with co-occurring
substance use disorders and mood disorders [34]. Anxiety
disorders, especially panic and social phobia, are common
in adolescent substance abusers associated with a history
of trauma [35]. Adolescents with PTSD are very common
and have higher comorbid mental health and used more
drugs in their life time [36]. A high prevalence of
cannabis use among those patients explains the estab-
lished psychotic disorders observed [36].
Limitation of the study
The Questionnaire for trauma, although commonly used
in many cultures, was not standardized to the Egyptian
culture.
ConclusionEarly physical or sexual trauma has considerable impact
on adolescents’ drug dependence and needs careful
investigation to address their coping abilities and evaluate
effective strategies for their treatment.
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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Characteristics of substance dependence in adolescents El-Sawy and Abd Elhay 215
216 Middle East Current Psychiatry
Duration of untreated psychosis in two Arab samples from
Egypt and Saudi Arabia: Clinical and sociocultural correlatesMohab M. Fawzia, Hany M. El-Aminb and Mounir H. Fawzia
aDepartment of Psychiatry, Faculty of Medicine,Zagazig University, Zagazig, Egypt andbConsultant Psychiatrist, Erfan Psychiatric Hospital,Jeddah, Saudi Arabia
Correspondence to Mohab M. Fawzi, Faculty ofMedicine, Zagazig University, Zagazig, EgyptTel: + 161366617; fax: +20552338972;e-mail: [email protected]
Received 11 April 2011Accepted 6 June 2011
Middle East Current Psychiatry
2011, 18:217–225
Background
The duration of untreated psychosis (DUP) varies considerably across different cultures
and settings. However, cross-cultural studies have mostly been either comparisons
between developed and developing countries or comparisons between different ethnic
groups in unicultural investigations. Studies comparing more socioculturally related
countries, such as Arab countries, are required. To the best of our knowledge, no
previous studies have compared DUP between Egypt and Saudi Arabia.
Aims
The aims of the study are to determine DUP in two samples of patients with first-
episode psychosis from Egypt and Saudi Arabia; to explore the sociodemographic,
clinical, and help-seeking characteristics that are associated with DUP in these two
groups; to distinguish which of these sociodemographic, clinical and help-seeking
correlates the DUP are shared by Egyptian and Saudi Arabian patient groups and
which are more culture specific; and to test the hypothesis that severity of illness
predicts the length of DUP.
Methods
A total of 96 (50 from Egypt and 46 from Saudi Arabia) consecutive attendees at two
outpatient clinics with first-episode psychosis were assessed by semistructured
interviews. In addition to the determination of DUP and help-seeking contacts, patients
were assessed by the Positive and Negative Syndrome Scale.
Results
The mean DUP was 3.2 and 3.1 years for the Egyptian and Saudi Arabian patient
groups, respectively. There were no significant differences between the two groups
with regard to most of the variables studied. Variables that significantly correlated with
DUP were entered into multiple regression analyses. The final model, which accounted
for 56.9% of the variance in DUP, included only two variables: ‘first contact’ and ‘mode
of onset’.
Conclusion
In the two countries, patients with first-episode psychosis were found to have long
DUP. First contact with a traditional (faith) healer and insidious mode of onset of
psychosis were the two significant predictors of long DUP. Although severity of
negative symptoms, as indicated by Positive and Negative Syndrome Scale negative
subscale scores, was correlated with DUP, it could not be retained in the final
regression model as a significant predictor. Our hypothesis that severity of illness
predicts long DUP had to be rejected. Factors found to influence DUP should be taken
into account in early intervention initiatives.
Keywords:
duration of untreated psychosis, Egypt, first-episode psychosis, help-seeking, Positive
and Negative Syndrome Scale, Saudi Arabia, traditional (faith) healer
Middle East Curr Psychiatry 18:217–225& 2011 Okasha Institute of Psychiatry, Ain Shams University2090-5408
Introduction
The duration of untreated psychosis (DUP), which
represents the delay in initiation of treatment, is a
concept of paramount importance in schizophrenia
research, at least from the point of view of secondary
prevention. Its importance began to be appreciated in the
mid 1980s when the Northwick Park Study of first-
episode schizophrenia found that the most important
determinant of relapse was the duration of illness before
starting antipsychotics [1]. Interest in the topic has
increased even more in recent years, with a growing sense
of optimism derived from the understanding that
attention to the early phases of illness could result in a
substantial reduction in morbidity and lead to a better
quality of life. Moreover, although there is some
controversy about whether long DUP is associated with
poor outcome, the weight of evidence supports an
association that, although not strong, is persistent; for
example, [2–5]. Thus, in a systematic review of literature,
Original article 217
2090-5408 & 2011 Okasha Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000403822.37436.43
Marshall et al. [6] concluded that there is convincing
evidence of an association, albeit small to moderate,
between DUP and outcome. Similarly, literature review in
low and middleincome countries by Farooq et al. [7]
showed that the lack of treatment for psychotic illness
early in its course is associated with poor outcomes,
irrespective of the income or cultural status of the
setting. Long DUP was frequently reported to be
associated with increased mortality and poor prog-
nosis [8,9]. The relationship between DUP and 1-year
outcome, as demonstrated by two large studies from
UK [10] and Australia [11], is curvilinear, with greater
improvement in outcome if DUP is reduced from 6 to 3
weeks compared with reduction from 6 to 3 months. In
other words, the maximum benefit of early intervention
services will be obtained only by shifting patients to the
shortest part of the DUP range.
However, the mechanism by which long DUP might lead
to poor outcome is still uncertain. It has been postulated
that a long DUP might lead to neurotoxic processes,
manifested as persistent morbidity, treatment resistance,
and symptom worsening [12], and that there is a critical
period, postulated to be up to 5 years from the onset of
psychosis, for intervention before psychosis can be
established [13,14]. Biological mechanisms involving
dopaminergic and glutamatergic processes have also been
suggested to explain how prolonged active psychosis will
result in treatment refractoriness. Recently, neuroimaging
studies have demonstrated reductions in hippocampus
volume [15] and temporal gray matter [16] in patients
with long DUP. These findings could reflect a progressive
pathological process that is active before treatment. In
contrast, these abnormalities could be associated with a
more insidious onset of illness and a later presentation to
services. Thus, possible explanatory mechanisms would
also include psychosocial processes, with prolonged
our results, not only for the Egyptian patient group but
also for the Saudi Arabian patient group, are in accordance
with this conclusion. They also draw attention to the
failure of other agencies in directing patients to seek
help. Continued public education about psychosis, there-
by improving the knowledge of potential patients, their
222 Middle East Current Psychiatry
relatives, and other people or organizations involved,
would be an important component in an overall strategy
to achieve early detection of psychosis and shorten DUP.
Our study, however, has a number of limitations. First,
patients as described above were taken from different
population areas. Egyptian patients came from urban and
rural areas of one governorate (Sharkia), whereas Saudi
Arabian patients were from the metropolitan area of
Jeddah city and from some of its surrounding nonme-
tropolitan areas. Second, patients recruited were from
those presenting to private psychiatric service only,
making it an false representation of Egyptian or Saudi
Arabian samples. Third, the sample size was modest, and
further study comprising a larger group of patients would
be worthy. Fourth, although a systematic approach with
the use of standardized instruments and a semistructured
interview was adopted, the DUP and pathway data are
based on patients’ descriptions and are subject to recall
bias. To enhance validity, all data were confirmed by at
least one family member who was present during the
interview. Moreover, some patient-related factors such as
lack of insight, poor social adjustment, or other psycho-
pathologies that might contribute to treatment delays
were not controlled for.
ConclusionThe limitations noted above signify that conclusions
should be viewed with some caution.
Patients with first-episode psychosis in both Egypt and
Saudi Arabia have a long DUP, which should be of major
clinical concern. In the two study sites, we found that
first contact with a traditional (faith) healer and insidious
mode of onset of psychosis were the two significant
predictors of long DUP. Although severity of negative
symptoms, as indicated by PANSS negative subscale
scores, was correlated with DUP, it could not be retained
in the final regression model as a significant predictor of
DUP. Therefore, our hypothesis that severity of illness at
presentation would strongly predict long DUP had to be
rejected. Factors found to influence DUP should be taken
into account in early intervention initiatives.
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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224 Middle East Current Psychiatry
Duration of untreated psychosis Fawzi et al. 225
Shyness and sociability in a sample of Egyptian patients
with schizophrenia and its relation to resting frontal EEGHoda Abdou Husseina, Heba Fathya, Sherine Mohamed Abdel Mawlaa,Fadia Zyadaa and Reem A. El Hadidyb
Departments of aPsychiatry and bNeurophysiology,Faculty of Medicine, Cairo University, Giza, Egypt
Correspondence to Heba Fathy, Department ofPsychiatry, Faculty of Medicine, Giza, EgyptTel: + 101404826;e-mail: [email protected]
Received 22 February 2011Accepted 1 March 2011
Middle East Current Psychiatry
2011, 18:226–230
Introduction
One of the most disabling features and consequences of schizophrenia is the marked
impairment of social skills.
Aim of the study
The aim of this study is to determine the relationship between premorbid shyness
and negative symptoms and resting frontal quantitative EEG alpha activity in patients
with schizophrenia.
Methodology
Forty patients with schizophrenia were selected successively in a cross-sectional
study. The patients were assessed using The Structured Clinical Interview for
Diagnostic and Statistical Manual of Mental Disease Axis of Disorders, Positive and
Negative Syndrome Scale, The Revised Cheek and Buss Shyness, and Sociability
Scale. Quantitative EEG was carried out and assessed for frontal alpha asymmetry.
Results
Ninety-seven percent of the patients showed asymmetrical frontal alpha EEG activity
and 85% showed right resting frontal alpha EEG asymmetry. Patients with right frontal
asymmetry showed higher PANSS-negative and shyness scores than those with
left asymmetry.
Conclusion
The negative symptoms of schizophrenia and premorbid shyness could be related to
PANSS, Positive and Negative Syndrome Scale; SD, standarddeviation.
228 Middle East Current Psychiatry
were selected for high and low self-ratings of shyness and
sociability. They found that LOSHY/HISOCIABLE parti-
cipants displayed greater relative right parietal activation
and LOSHY/LOSOCIABLE participants displayed great-
er relative left parietal activation [26]. Also, the results
of Jetha et al. [13] disagree with our results; they did not
find a relation between parietal asymmetry and the
negative symptoms scale.
Limitations
(1) The relatively small sample size limits generaliza-
tions to a broader population of individuals with
schizophrenia. Future studies should attempt to
replicate the present findings with a larger sample
of adults with schizophrenia.
(2) The second limitation concerns the reliance on self-
report measures in general for patients with schizo-
phrenia, which may have potential for distortion
depending on the degree of psychotic symptoms.
However, we confirmed this information from the
participants.
(3) In addition, Beaton et al. [27] highlight the importance
of considering concurrent emotional states of partici-
pants when examining psychophysiological correlates of
personality. But in this study we did not measure the
emotional state of the participants.
(4) Although The Revised Shyness and Sociability Scale
was translated and back translated by two different
blind researchers, the methodological standardization
of the applied test is still ongoing.
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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13 Jetha MK, Schmidt LA, Goldberg JO. Resting frontal EEG asymmetry andshyness and sociability in schizophrenia: a pilot study of community-basedoutpatients. Int J Neurosci 2009; 119:847–856.
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19 Davidson RJ, Tomarken AJ. Laterality and emotion: an electrophysiologicalapproach. In: Boller F, Grafman J, editors. Handbook of neuropsychology.Amsterdam: Elsevier; 1989. pp. 419–441.
20 Cuesta MJ, Peralta V, Caro F. Premorbid personality in psychoses. SchizophrBull 1999; 25:801–811.
21 Schmidt LA, Cote KA, Santesso DL, Milner CE. Frontal electro-encephalogram alpha asymmetry during sleep: stability and its relation toaffective style. Emotion 2003; 3:401–407.
22 Davidson RJ, Goldsmith HH, Scherer K. Handbook of affective science.New York: Oxford University Press; 2003.
23 Gruzelier JH. Functional neuropsychophysiological asymmetry in schizo-phrenia: a review and reorientation. Schizophr Bull 1999; 25:91–120.
24 Sutton SK, Davidson RJ. Prefrontal brain asymmetry: a biological substrateof the behavioral approach and inhibition systems. Psychol Sci1997; 8:204–210.
25 Coan JA, Allen JJ. Frontal EEG asymmetry and the behavioral activation andinhibition systems. Psychophysiology 2003; 40:106–114.
26 Schmidt LA, Fox NA. Patterns of cortical electrophysiology and autonomicactivity in adults’ shyness and sociability. Biol Psychol 1994; 38:183–198.
27 Beaton EA, Schmidt LA, Ashbaugh AR, Santesso DL, Antony MM,McCabe RE. Resting and reactive frontal brain electrical activity (EEG)among a non-clinical sample of socially anxious adults: does concurrentdepressive mood matter? Neuropsychiatr Dis Treat 2008; 187–192.
Shyness in schizophrenia Hussein et al. 229
230 Middle East Current Psychiatry
Prevalence and risk factors of unexplained somatic symptoms
in school-aged children of Sharkia GovernorateNagy M. Fawzya, Haitham M. Hashima and Hadeel M.A. Rahmanb
aDepartments of Psychiatry andbPediatrics, Faculty of Medicine, Zagazig University,Zagazig, Egypt
Correspondence to Nagy M. Fawzy, AssistantProfessor of psychiatry, Department of Psychiatry,Faculty of Medicine, Zagazig University, Zagazig, EgyptTel: +0106895396;e-mail: [email protected]
Received 16 March 2011Accepted 19 May 2011
Middle East Current Psychiatry
2011, 18:231–236
Background
Somatization in children consists of the persistent experience and complaints of
somatic distress that cannot be fully explained by a medical diagnosis. The aim of
this study was to determine the prevalence and risk factors of unexplained somatic
symptoms and their relation to emotional symptoms in school-aged children.
Participants and methods
The sample included 294 children recruited from four primary schools of Sharkia
Governorate. All the children were between 6 and 12 years of age, were from both
sexes, and had no social limitation. All participants were subjected to psychiatric
assessment for somatic symptoms by the Children’s Somatization Inventory. They were
also assessed for depression by the Child Depression Inventory and for anxiety by the
Revised Children’s Manifest Anxiety Scale.
Results
The prevalence rate of somatic symptoms was 13%, that of depression was 9%,
and that of anxiety was 21%. Somatic symptoms were correlated with emotional
symptoms.
Conclusion
This study concluded that there was a high rate of somatic and emotional symptoms
in school children that were interrelated with sociodemographic characteristics.
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20 Litcher L, Bromet E, Carlson G, Gilbert T, Panina N, Golovakha E, et al.Ukrainian application of the children’s somatization inventory: psychometricproperties and associations with internalizing symptoms. J Abnorm ChildPsychol 2001; 29:165–175.
21 Meesters C, Muris P, Ghys A, Reumerman T, Rooijmans M. The children’ssomatization inventory: further evidence for its reliability and validity in apediatric and a community sample of Dutch children and adolescents.J Pediatr Psychol 2003; 28:413–422.
22 Kovacs M. The children’s depression, inventory (CDI). Psychopharmacol Bull1985; 21:995–998.
23 Gharib A. Arabic version of CDI. Cairo: El Nahda El Masrya; 1985.
24 Reynolds CR. Concurrent validity of ‘‘what i think and feel:’’the revisedchildren’s manifest anxiety scale. J Consult Clin Psychol 1980; 48:774–775.
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27 Rask CU, Olasen EM, Elberling H, Christensen MF, Ornbol E, Fink P.Functional somatic symptoms and associated impairment in 5–7-year-oldchildren: the copenhagen child cohort 2000. Eur J Epidemiol 2009;24:625–634.
28 Shapiro CM. Alexithymia-a useful concept for all psychiatrists? J PsychosomRes 1996; 41:503–504.
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30 Susman EJ, Reiter EO, Ford C, Dorn LD. Work group I: developing modelsof healthy adolescent physical development. J Adolesc Health 2002;31 (6 Suppl171–174.
31 Rhee H. Relationships between physical symptoms and pubertal develop-ment. J Pediatr Health Care 2005; 19:95–103.
32 Fearon P, Hotopf M. Relation between headache in childhood and physicaland psychiatric symptoms in adulthood: National Birth Cohort study. BMJ2001; 322:1145.
33 Brown RJ, Schrag A, Trimble MR. Dissociation, childhood interpersonaltrauma and family functioning in patients with somatization disorder. Am JPsychiatry 2005; 162:899–905.
34 Muris P, Meesters C. Children’s somatization symptoms: correlations withtrait anxiety, anxiety sensitivity and learning experiences. Psychol Reports2004; 94:1269–1275.
35 Toft T, Fink P, Oernboel E, Christensen K, Frostholm L, Olesen F. Mentaldisorders in primary care: prevalence and co-morbidity among disorders:results from the Functional Illness in Primary Care (FIP) study. Psychol Med2005; 35:1175–1184.
36 Karvonen JT. Somatization in young adults. The Northern Finland 1966 BirthCohort Study. Acta Univ Oul 2007.
37 Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints andpsychopathology in children and adolescents: stomach aches, muscu-loskeletal pains, and headaches. J Am Acad Child Adolesc Psychiatry 1999;38:852–860.
38 Beck JE. A developmental perspective on functional somatic symptoms.J Pediatr Psychol 2008; 33:547–562.
39 Vila M, Kramer T, Hickey N, Dattani M, Jefferis H, Singh M. Assessment ofsomatic symptoms in British secondary school children using the children’ssomatization inventory (CSI). J Pediatr Psychol 2009; 34:989–998.
40 McCauley E, Carlson GA, Calderon R. The role of somatic complaints in thediagnosis of depression in children and adolescents. J Am Acad ChildAdolesc Psychiatry 1991; 30:631–635.
41 Gunnar MR, Bruce J, Hickman SE. Salivary cortisol response to stress inchildren. Adv Psychosom Med 2001; 22:52–60.
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43 Dorn LD, Campo JC, Thato S, Dahl RE, Lewin D, Chandra R, et al. Psy-chological comorbidity and stress reactivity in children and adolescents withrecurrent abdominal pain and anxiety disorders. J Am Acad Child AdolescPsychiatry 2003; 42:66–75.
Prevalence and risk factors Fawzy et al. 235
236 Middle East Current Psychiatry
Psychological manifestations in adolescents with thalassemiaHani Hameda, Osama Ezzatb and Tamer Hifnawyc
Departments of aPsychiatry, bPediatrics andcPublic Health and Community, Beni-Sueif University,Beni-Sueif, Egypt
Table 4 Family history of psychiatric illness distribution in
both groups
Patients Controls
Psychiatric illness Number (%) Number (%) P
Negative family history 27 (90) 28 (93.4) 0.503Family history of mood disorder 2 (6.7) 1 (3.3)Family history of psychotic disorder 0 (0.0) 1 (3.3)Family history of mental retardation 1 (3.3) 0 (0.0)Total 30 (100) 30 (100)
Psychological manifestations in adolescents Hamed et al. 239
Psychometric data
Patient Health Questionnaire-9
The PHQ-9 distribution in both groups is shown
in Table 5
Hospital Anxiety Depression Scale
The HADS distribution in both groups is shown
in Table 6.
Middlesex Hospital Questionnaire
The Middlesex Hospital Questionnaire distribution in
both groups is shown in Table 7.
McGill Quality of Life Questionnaire
The McGill Quality of Life Questionnaire distribution in
both groups is shown in Table 8.
Correlation studies
The correlation between the HADS and the Middlesex
Hospital Questionnaire is shown in Table 9.
The correlation between the Middlesex Hospital Ques-
tionnaire (depression) and the McGill Quality of Life
Questionnaire, general and physical subscale is shown
in Table 10.
DiscussionThere was no statistically significant difference between
the two groups with regard to age (P = 1.18) (Table 1).
Participants from both groups were selected from the
Pediatrics Outpatient Clinic.
There was no statistically significant difference between
the two groups with regard to sex (P = 0.194) (Table 2).
The majority of the patient group were men (53.3%).
This was consistent with the results of Sabry and
Salama [21], who found that 54% of patients with
thalassemia in their study in Egypt were men.
There was a statistically significant difference between
the two groups with regard to the educational level
(P = 0.047). Twenty percent of the individuals in the
patient group were illiterate, whereas only 6.7% of
adolescents in the control group were illiterate (Table 3).
This was in line with the study of Sabry and Salama [21];
a statistically significant difference was found in the
levels of education between the patient group and the
control group: 55% of cases did not attend school
compared with 12% of the control group. This could be
explained by the physical weakness caused by their
chronic illness, and frequent blood transfusion. Another
explanation for the lack of school attendance could be an
overprotective parenting style among Egyptian families
which is prevalent during the illness of their children.
Ratip et al. [22] found that, in the United Kingdom,
among 27 patients with thalassemia, 90% had to take time
off from school because of their medical condition. In
addition, thalassemia affected the scholastic performance
of 70% of Indian adolescents adversely [22].
There was no statistically significant difference between
both groups with regard to a family history of psychiatric
illness (P = 0.503). The majority of adolescents in both the
groups had a negative family history of psychiatric illness
(90% of the patient group, 93.4% of the control group)
(Table 4). This was similar to the study of Mazzone et al. [3],
who found a statistically significant difference between
a group of adolescents with thalassemia (28 patients) and
Table 5 Patient Health Questionnaire-9 distribution in
Table 8 McGill Quality of Life Questionnaire distribution in both groups
Patients Controls
Mean ± SD Mean ± SD P
McGill Quality of Life Questionnaire total 83.57 ± 11.60 128.7 ± 1.93 o0.001McGill Quality of Life Questionnaire general 3.70 ± 0.92 9.90 ± 0.31 o0.001McGill Quality of Life Questionnaire physical 31.60 ± 2.75 3.33 ± 3.33 o0.001McGill Quality of Life Questionnaire emotional 48.60 ± 13.05 115.5 ± 3.99 o0.001
SD, standard deviation.
240 Middle East Current Psychiatry
the control group (28 normal participantss) with regard to a
family history of psychological illness.
There was a statistically significant difference between
the two groups with regard to PHQ-9 (Po0.001). All
adolescents in the patients group were depressed (13.3%
had mild depression, 53.4% had moderate depression, and
33.3% had moderate-to-severe depression). In contrast,
only 6.7% of the participants in the control group had
mild depression (Table 5). This was in line with the study
of Sabry and Salama [21], who found that patients with
thalassemia have three times higher likelihood of having
depression. No patient with thalassemia was found to be
free of depressive symptoms compared with 70% of the
controls. Dysphoric moods and low selfesteem were
reported by the majority of children with thalassemia [23].
Woo et al. [24] reported that two-third of the patients
were worried about pain, death, and the unknown in a
sample of 22 children with thalassemia. This conclusion
was also supported by Khurana et al. [23], who reported
that chronic illnesses such as thalassemia give rise to
feelings of being different and inferior, with a consequent
loss of selfesteem and increased dependence. Facial
characteristics in thalassemia occur as a consequence of
the expansion of bones, particularly the skull and the jaw
bones. Anemia and iron overload in these patients often
lead to short stature and delayed puberty. Delayed
puberty is associated with other endocrine disturbances,
which can cause depression. They are likely to have
reduced self-esteem, feelings of difference, poor self-
image, being dependent, and anxiety over issues such as
pain and death. Huurre and Aro [25] observed that
patients with chronic illness limiting their daily life
experience more depression than those with illnesses that
do not limit daily life.
There was a statistically significant difference between
the two groups with regard to the HADS (Po0.001).
Adolescents with thalassemia showed significantly higher
levels of anxiety and depression than the control group
(mean = 8.63 ± 1.65, 10.07 ± 2.12 and mean = 0.30 ±
symptoms, depressive symptoms, and hysteria. QoL was
highly affected among adolescents with thalassemia. A
higher degree of depression is associated with lower levels
of QoL among adolescents with thalassemia.
Limitations
The small-sized sample in this study can be considered as
one of the limitations of this study. A large-sized sample
may be needed to assess other possible psychological
profiles of adolescents with thalassemia. In addition,
follow-up studies may be valuable in the assessment of
the course and prognosis of depression and anxiety among
adolescents with thalassemia.
AcknowledgementsConflicts of interestThere is no conflict of interest to declare.
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Psychological manifestations in adolescents Hamed et al. 243
244 Middle East Current Psychiatry
Central auditory processing in attention deficit hyperactivity
aDepartments of Psychiatry,bAudiology Department, Faculty of Medicine,Ain Shams University, Cairo andcHospital of Mental Health, Abbasseya, Egypt
Correspondence to Hanan Hussein, AssistantProfessor of Psychiatry, Department of Psychiatry,Faculty of Medicine, Ain Shams University, Cairo, EgyptFax: + 20122193402;e-mail: [email protected]
Received 27 February 2011Accepted 4 March 2011
Middle East Current Psychiatry
2011, 18:245–252
Introduction
Attention deficit hyperactivity disorder (ADHD) and central auditory processing disorder
(C)APD are two neurodevelopmental disorders that usually result in poor scholastic
performance. Both disorders share common symptoms such as poor attention
particularly in noisy situations. Several studies suggested that they are the same disorder.
Aim
This study aimed to explore the relationship between ADHD and (C)APD.
Participants and methods
A group of 20 children with ADHD were assessed psychologically using Wechsler
Intelligence Scale for Children and Conner’s Parent Rating Scale. Then, central
auditory function was assessed subjectively using the Scale of Auditory Behavior
(SAB) and objectively using the central auditory processing test battery.
Results
It was found that 55% (n = 11) of children showed abnormality in one or more of the
(C)APD test results. SAB scores and Conner’s scores did not vary significantly
between both the groups. In contrast, Intelligence Quotient Scores were significantly
lower in patients with ADHD than in patients with (C)APD. The results showed that
pitch pattern sequences, pitch pattern discrimination (PPD), and gap in noise were
significantly abnormal in patients with ADHD with affected (C)APD, indicating that the
most affected central ability in (C)APD ADHD is auditory temporal processing, namely,
‘temporal ordering and sequencing as well as temporal resolution’. In addition,
inattention and cognitive problems in Conner’s Parent Rating Scale-Long version
were statistically significantly associated with (C)APD.
Conclusion
It was concluded that high comorbidity exists between (C)APD and ADHD, with the
most affected ability being temporal auditory processing. Inattention and cognitive
problems were the only clinical variables correlated to the presence of (C)APD.
Middle East Curr Psychiatry 18:245–252& 2011 Okasha Institute of Psychiatry, Ain Shams University2090-5408
IntroductionAttention deficit hyperactivity disorder (ADHD) is a
neurodevelopmental disorder characterized by age-inap-
propriate poor attention span as well as features of
hyperactivity and impulsivity or both [1]. It is the most
common neurobehavioral disorder presenting for treatment
in childhood. ADHD is often chronic, with prominent
symptoms, and impairment spanning into adulthood. It is
often associated with cooccurring anxiety, mood, and
disruptive disorders, as well as substance abuse [2].
A pathophysiological explanation for ADHD symptoma-
tology relates to deficits in prefrontal cortex-mediated
executive brain function, also known as response inhibi-
tion [3]. Neuroimaging is allowing researchers to further
study the ways in which medications affect neurophysiol-
ogy, providing more precise insights into ADHD and its
etiology, diagnosis, and treatment [4]. Neuropsychologi-
cal studies have implicated the frontal cortical regions
of the brain and the circuits linking them to the basal
ganglia as critical to executive function, attention, and
the ability to exercise inhibition [5].
There may be a greater likelihood for the causal pathway to
be from hyperactivity-inattention symptoms to scholastic
deficits. This is consistent with findings showing that
inattention symptoms contribute to later reading difficul-
ties [6]. It was found that the severity of ADHD affects
academic performance in school, with psychiatric morbid-
ity [7]. Children with ADHD are up to five times more
likely to require special needs education than children
without ADHD [8,9]
Central auditory processing disorder [(C)APD] is defined
as a hearing disorder resulting from impaired brain
Original article 245
2090-5408 & 2011 Okasha Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000405285.63178.ef
function and characterized by poor discrimination,
separation, grouping, localization, or ordering of sounds.
It is a common cause of poor scholastic performance as it
is reported to contribute significantly to academic and
behavioral dysfunctions among school-aged children [10].
In USA, (C)APD is included in the ‘specific learning
disability’ category under the Individuals with Disabil-
ities Education Act. It is defined under Individuals with
Disabilities Education Act as a disability that causes
problems in comprehending the social and interpersonal
content of language [11].
Since the introduction of (C)APD, there has been a debate
about its relation to ADHD. Although the comorbidity of
(C)APD with ADHD has been well documented [12],
some researchers argued that (C)APD and ADHD may be
overlapping but independent disorders [13], whereas other
investigators argued that there are similarities between
both disorders. There is a similarity between ADHD and
(C)APD in symptomatology as well as in psychoeduca-
tional and behavioral sequelae [14]. Research findings
concluded that a diagnosis of ADHD places the child at
risk (50–80%) for (C)APD [15]. Chermak and Museik
suggested that understanding the relationship between
the attention deficits of ADHD and (C)APD hinges on the
interaction between perception and higher-level cognitive
processing [16]. Although several studies were conducted
to evaluate (C)APD in ADHD, debate still exists on the
relation of both disorders [14,17,18]. Accordingly, this
study was conducted to explore the relationship between
ADHD and (C)APD.
HypothesisADHD and (C)APD are different but overlapping
disorders with high comorbidity. The comorbid cases
show particular clinical and electrophysiological profi-
les.The aims of this study were (a) to detect the profile
of central auditory processing among ADHD patients and
(b) to study the behavioral and psychophysical correlates
of comorbid ADHD and (C)APD.
Participants and methodsA convenient sample of 20 children aged 6–12 years
fulfilling the diagnosis of ADHD according to the Diagnosticand Statistical Manual of Mental Disorders-Fourth Edition
(DSM-IV) criteria [19] who were not under medication
were recruited from the outpatient clinic of the Institute
of Psychiatry, Ain Shams University (Cairo, Egypt). The
inclusion criterion was Intelligence Quotient of 85 or more
on the Wechsler Intelligence Test for Children, Arabic
version [20]; written consent was obtained from one
parent to involve his or her child in the study. Children
with any other neurological problems, sensory deficit, or
receiving psychotropic drugs or auditory training were
excluded. Each child was evaluated in two sessions.
During the first session, a proper case history and
examination using the child psychiatry clinical sheet of
the Institute of Psychiatry, Ain Shams University, was
applied to diagnose ADHD and exclude patients on
treatment or with comorbidity. Confirmation of the
diagnosis according to the criteria was carried out using
the DSM-IV [19]. Comorbidity was excluded using the
Mini International Neuropsychiatric Interview for chil-
dren, Kid-Arabic version [21], which is a short structured
diagnostic interview based on DSM-IV criteria. General
intelligence was assessed by a professional clinical
psychologist using the Wechsler Intelligence Scale for
Children-Arabic version [20]. The severity of ADHD was
assessed using Conner’s Parent Rating Scale-revised-
Long version (CPRS-L) [22]. It scores the parents’ report
of their child’s behavior during the past month on a 4-
point response scoring. It has an excellent specificity for
ADHD dimensions (Short-Band Questionnaire).
During the second session, an audiological assessment
was made. It included a case history and otological
examination, followed by a basic audiologic evalua-
tion that included pure-tone audiometry (air conduc-
tion testing) and speech audiometry that consisted of
speech reception threshold using Arabic bisyllabic
words [23], and a speech discrimination test using Arabic
Phonetically Balanced Kindergarten words [23]. Immit-
tanemetry was carried out to assess middle ear function.
Patients with abnormal test results were excluded.
Patients were then screened for (C)APD using the Arabic
version of the SAB Questionnaire [24]. It is a 12-item
questionnaire with an average time of administration of
5 min. It scores the parents’ report of their child’s
auditory behavior on a 5-point response. It is used for
the screening of (C)APD. The scale was translated from
the English form developed by Schow et al. [24].
A series of psychophysical central auditory tests were
then carried out for the selected patients including the
following:
(1) Arabic low-pass-filtered (LPF) test [25]: Assessing
auditory closure ability;
(2) Arabic speech intelligibility-in-noise (SPIN) test
[25]: Assessing selective auditory attention;
(3) Arabic dichotic digit test [26]: Assessing binaural
integration;
(4) Arabic-gap in noise (GIN) test [27]: Assessing
temporal resolution;
(5) Pitch pattern sequences (PPS)(PPD) test [28]:
Assessing temporal ordering and sequencing;
(6) All tests were scored as percent correct for ears, except
the GIN test, which was scored by measuring the Gin
threshold in milliseconds (the shortest gap duration
for which at least four of six responses are correct [29].
Statistical methodsThe data collected were statistically analyzed using
Statistical Package for Social Sciences program software
version 17.0. (Chicago, Illinois, USA). Descriptive
statistics were obtained for numerical parametric data as
means, standard deviation, minimum and maximum of the
246 Middle East Current Psychiatry
range, and 95% confidence interval, whereas for categorical
data, it was expressed as number and percentage.
Inferential analyses were carried out for quantitative
variables using an independent t-test in case of two
independent groups with parametric data. Qualitative data
were obtained using Fisher’s exact test. Correlations were
assessed using the Pearson’s correlation for numerical
parametric data. The level of significance was set at a
P value of less than 0.05, and nonsignificant otherwise.
ResultsDescriptive statistics
Twenty children with ADHD were included in this study,
six children (30%) had ADHD-I (inattentive type) and
14 children (70%) had ADHD-C (combined type). There
were six (30%) females and 14 (70%) males. Their mean
age was 8.65 years [standard deviation (SD) = ± 1.18)],
ranging from 7 to 11 years. The mean verbal intelligence
quotient was 101.0 (SD = + 11.4), the mean performance
intelligence quotient was 102.9 (SD = + 10.9), and the
mean total intelligence quotient was 101.5 (SD = + 10.4).
The mean scores on (CPRS-L) are presented in Fig. 1.
The mean score on the SAB is 31.8 (SD = ± 5.2), ranging
from 23 to 41, and 95% confidence interval was 29.3–34.2.
The diagnosis of (C)APD among patients with ADHD
was made on the basis of abnormal scores even in one test
according to age-specific norms. Among the entire study
sample of ADHD patients, 45% (n = 9) showed normal
(C)APD test scores, whereas 55% (n = 11) showed
abnormality in one or more of the (C)APD test results.
Among inattentive-type ADHD, two cases (33.3%) were
non-(C)APD and four cases (66.6%) were (C)APD,
whereas among combined-type ADHD, seven cases
(50%) were non-(C)APD and seven cases (50%) were
(C)APD, w2 = 0.6, P = 0.5.
The (C)APD pattern was as follows: 55% showed abnormal
scores on PPS, 30% on PPD, 15% on DD, and 40% on GIN
tests. None of the patients with ADHD showed abnorm-
ality in LPF and SPIN. The results are shown in Fig. 2.
Relation between patients with ADHD with (C)APD and
patients with ADHD without (C)APD
Demographic variables
Patients with ADHD with (C)APD did not differ
significantly from patients with ADHD without
(C)APD in terms of age [ADHD with (C)APD, mean
age: 8.5 years, SD = ± 1.4 vs. ADHD without (C)APD,
mean age: 8.9 years, SD = ± 0.9, t = 0.81, P = 0.42].
Similarly, sex was not statistically associated with either
diagnosis. In the ADHD with (C)APD group, three
(27%) were females and eight (72.7%) were males; in the
ADHD without (C)APD group, three (33.3%) were
females and six (66.6%) were males.
Behavioral variables
Patients with ADHD with (C)APD did not differ
significantly from patients with ADHD without
(C)APD with regard to their auditory behavior using
(SAB) [ADHD with (C)APD mean SAB score: 30 ± 5.1
SD vs. ADHD without (C)APD mean age: 34 ± 4.8 SD,
t = 1.8, P = 0.089). Similarly, there was no statistically
significant difference between patient scores on CPRS
among patients with ADHD with or without (C)APD,
except for the cognitive problem subscale, which was
significantly lower in patients with (C)APD [ADHD
without C(APD) mean cognitive probability score:
74.4 ± 5.6 SD vs. ADHD with C(APD) mean cognitive
score: 81.6 ± 8.2 SD, t = 2.216, P = 0.4]. In addition, the
inattention subscale scores tended to be significantly
lower in patients without (C)APD [ADHD without
(C)APD inattention score: 75 ± 6.7 SD vs. ADHD with
(C)APD mean inattentive score: 81.4 ± 7.7 SD, t = 1.94,
P = 0.06]. The results are shown in Fig. 3.
Psychometric variables
However, VIQ and TIQ were statistically significantly higher
in patients without (C)APD ADHD compared with patients
with (C)APD ADHD . The results are shown in Table 1.
Audiometric variables
Different CAP subsets were tested for a statistically
significant association with the presence or absence of
Fig. 1.
Mean scores of Conner’s Parent Rating Scale.
Fig. 2.
Percentage of patients with attention deficit hyperactivity disordershowing normal or abnormal central auditory processing disorder testresults. DD, dichotic digit; GIN, gap in noise; LPF, low-pass-filtered;PPS, pitch pattern sequences; PPD, pitch pattern discrimination; SPIN,speech intelligibility-in-noise.
Central auditory processing in attention deficit hyperactivity disorder Effat et al. 247
(C)APD among patients with ADHD in an attempt to
find a specific marker among them for the presence of
(C)APD or to at least detect the specific differentiating
pattern of CAP between ADHD and (C)APD.
The results showed that PPS, PPD, and GIN were
significantly atypical in patients with ADHD with
(C)APD, indicating that the most affected central ability
in (C)APD ADHD is auditory temporal processing
namely ‘temporal ordering and sequencing as well as
temporal resolution’, which are not affected in ADHD
alone (Table 2).
Both groups were then compared in terms of their
(C)APD test battery results using an independent-
sample t test and a highly statistically significant
difference was found between them with regard to two
of the six tests conducted, namely, temporal ordering and
sequencing, being lower in the (C)APD group. Moreover,
a statistically significant difference was found on the
dichotic test and the GIN test, reflecting poor perfor-
mance in the (C)APD group on these two tests as shown
in Table 3.
DiscussionThis study was carried out to determine the rate of
comorbidity between ADHD and (C)APD among
patients in a clinical setting in our community, which
was found to be 55%. No statistically significant
association existed between the clinical subtype of
ADHD and the occurrence of (C)APD. The (C)APD
pattern was as follows: 55% showed abnormal scores on
PPS, 30% on PPD, 15% on DD, and 40% on GIN tests.
None of the patients with ADHD showed abnormalities
in LPF and SPIN. The results are shown in Fig. 2. This is
consistent with the result obtained by Tillery et al. [15],
who found that a diagnosis of ADHD places the child at
risk (50–80%) for (C)APD. In addition, Riccio et al. [30]
found that in 30 children diagnosed with (C)APD, 50%
would also fulfill the criteria of ADHD on the basis of a
formal diagnosis.
In terms of the sociodemographic characteristics of cases
with overlap between ADHD and (C)APD, there is no
statistically significant difference between patients with
(C)APD and patients without (C)APD as regards age.
This might be explained by the fact that both ADHD and
(C)APD are neurodevelopmental disorders. Hence, they
will go hand in hand with regard to age of presentation.
Furthermore, patients are selected according to a limited
age range (6–12 years). Similarly, there was no statistically
significant difference between both groups with regard to
sex. This could be attributed to the higher number of
males (high male-to-female ratio) in this study, which
might implicate the findings. This result should be
interpreted with caution as the sample studied was too
small to detect a difference.
The aim of this study was to detect symptom patterns in
ADHD both with and without (C)APD. On comparing
patients without (C)APD and patients with (C)APD
ADHD with regard to the four subscales of (CPRS-L)
(Fig. 3), we found that the Cognitive Problem Subscale
Score was significantly higher in patients with (C)APD.
Fig. 3.
Comparison between noncentral auditory processing disorder[(C)APD] and (C)APD attention deficit hyperactivity disorder cases inConner’s scores.
Table 1 Comparison between non-(C)APD and (C)APD ADHD
ADHD, attention deficit hyperactivity disorder; (C)APD, central auditoryprocessing disorder; CI, confidence interval; IQ, Intelligence Quotient;SD, standard deviation.*P value is Sf statistically significant.
Table 2 Association between (C)APD tests and the presence of
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