Thursday, 25 January 2007

Fat and Bipolar... Huzzah

Prevalence and Consequences of Metabolic Syndrome in Bipolar Disorder

By Dale A. D'Mello, MD, Supriya Narang, MD, and Gina Agredano, MD

Psychiatric Times, January 2007, Vol. XXIV, No. 1

Patients with bipolar disorder suffer a disproportionate burden of cardiovascular illness compared with others in the general population.1,2 While the pathogenesis of this excess morbidity is undetermined, biologic, behavioral, and sociodemographic factors have been implicated.3 Bipolar disorder is commonly associated with disrupted circadian rhythms,4 insomnia,5 breathing-related sleep disorders,6 immune function disorders,7 and hyperactivity of the sympathetic adrenal medullary8 or hypothalamic-pituitary- adrenal axes.9 All of these seemingly disparate phenomena are now known to have dire metabolic consequences.3 For instance, sustained hypercortisolemia is associated with visceral obesity and subsequent insulin resistance.10 Not surprisingly, several previous studies have established that the prevalence of metabolic disorders is alarmingly high among patients with bipolar disorder (Table 1).11-16 Furthermore, medications that are commonly used in the management of bipolar disorder are now known to contribute to weight gain, dyslipidemia, and diabetes.2

We recently conducted a study to examine the prevalence and clinical correlates of metabolic disorders in a cohort of hospitalized patients with bipolar disorder.

We recruited 41 patients with bipolar disorder, who were consecutively admitted to the psychiatric unit of a general hospital in central Michigan in a manic or mixed state during calendar years 2004 and 2005. All of the patients received the customary physical examination, laboratory tests, and comprehensive psychiatric evaluations. Following informed consent, we retrieved demographic and clinical information. Demographic data included age, sex, and ethnicity. Clinical information included height, weight, body mass index (BMI), blood pressure, fasting plasma glucose levels, and a serum lipid panel. Other clinical information included the psychiatric diagnosis, the list of discharge medications, the age of onset, and duration of psychiatric illness. We used the Young Mania Rating Scale (YMRS) scores, hospital length of stay (LOS), and number of days hospitalized in the preceding 5 years as measures of illness severity.

We used the modified National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) diagnostic criteria to establish the diagnosis of metabolic syndrome (Table 2).17 We used a BMI value of 25 or greater as an inclusion criterion rather than the customary waist circumference value of greater than 40 inches in men and greater than 35 inches in women. Patients who met 3 or more of the diagnostic criteria were considered to have metabolic syndrome. The data were entered into a statistical software program (SYSTAT Version 11) for analysis. The mean values for age, BMI, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, serum triglycerides, fasting plasma glucose, LOS, and YMRS scores were computed. The patients were then grouped according to the presence of obesity, hypertension, dyslipidemia, diabetes or prediabetes, or metabolic syndrome.

The prevalence of metabolic syndrome was calculated for the entire cohort of patients and in both sex sub- groups. Finally, each component of metabolic syndrome was correlated with the severity of illness assessed by the LOS and the admission YMRS score.

There were 41 patients in the study: 17 men and 24 women. The mean age of the sample was 41 (SD = 11) years. The mean LOS was 16 (SD = 10) days. The mean YMRS score was 36 (SD = 9). The mean BMI was 31 (SD = 8).

Fifty-six percent of the sample met modified NCEP-ATP III criteria for metabolic syndrome, 41% were obese, 71% had dyslipidemia, 62% were hypertensive, and 48% were diabetic or prediabetic (Figure 1). The mean LOS and YMRS scores were numerically higher in patients with obesity, dyslipidemia, diabetes or prediabetes, and metabolic syndrome than in individuals without these metabolic disorders (Figure 2 and Figure 3). However, perhaps because of the small sample size, the differences in values did not achieve statistical significance. At the time of discharge, the patients were typically maintained on combinations of mood stabilizers and antipsychotic medication, but the cross-sectional nature of this study precluded making a valid correlation between psychotropic compounds and metabolic effects.

In the present study, the prevalence of metabolic syndrome in patients hospitalized with bipolar disorder (56%) was dramatically higher than the prevalence observed in community samples (25%).18 The magnitude of comorbid metabolic disorders correlated positively with the severity of the mood disorder.

This suggests that patients with more severe mood disorders may be more susceptible to metabolic conditions such as visceral obesity, hypertension, dyslipidemia, and diabetes. Future studies using larger patient populations are needed to confirm this finding.

If metabolic disorders such as obesity, diabetes, dyslipidemia, and hypertension are in fact common complications of mood disorders, as they appear to be, then perhaps early and effective interventions in bipolar disorder may prevent the development of these metabolic consequences.2 Primary preventive measures such as regular physical exercise and dietary counseling should be routinely incorporated into the long-term treatment plan for patients.2

Medications used in the treatment of bipolar disorder are commonly associated with weight gain.19-21 Antipsychotic drugs have been implicated in new-onset diabetes and in dyslipidemia.22,23 In addition, divalproex sodium is associated with polycystic ovarian syndrome.24 Current treatment guidelines require that psychiatrists routinely screen for the presence of obesity, dyslipidemia, hypertension, and dysglycemia.22 Considering the emerging recognition of the true enormity of the metabolic consequences of bipolar disorder, drugs with an advantageous metabolic profile should be considered as first-line therapy in the long-term management of this condition.

Tuesday, 23 January 2007

Ancient Philosophy Essay

What, if anything, has knowledge got to do with bravery? Answer with reference to both Plato’s Laches and Aristotle’s Nichomachean Ethics.

Plato’s Laches and Aristotle’s Nichomachean Ethics are both works concerned with the nature of courage. These texts, then, are ideal to refer to when examining this question, but they could be said not to explore it fully as little or no attempt is made to explore the nature of knowledge. Guthrie writes that knowledge, as the ancient Greeks conceived it, “embraced and transcended all partial ends and individual arts such as those aiming at health, physical safety, wealth, political power,”[1] to a deeper knowledge of philosophy and the human condition. In the Laches, Socrates demonstrates an awareness of different types of knowledge when he ironically suggests that the knowledge inspiring bravery, to which Nicias refers, could be cleverness at playing the flute or the lyre.[2] Socrates believed that “what is called the acquisition of knowledge is no more than the explication of what was implicit, the actualization of knowledge that was potentially ours already,” and so his aim was “not to teach people what they did not know, but to make them aware of what they knew already.”[3] This would be true, it seems, because much of the sort of knowledge would inevitably be self-knowledge. Although the Laches and the Nichomachean Ethics do not speak explicitly about the nature of knowledge, they do consider it, at length, in relation to courage.

In considering the question with reference to these texts, it would be helpful first to look briefly at the texts themselves in their entirety. The Laches is one of Plato’s early dialogues, written in defence of Socrates, who had previously been executed on political charges. It could be seen as paradoxical that Plato wrote to defend a philosopher who never wrote anything down, but instead carried out conversations with people.[4] The Laches is both a dramatic dialogue and a philosophical work, in which “the interlocutor is gradually led to question some of the principles on which he leads his life.”[5]

It begins with Lysimachus and Melesias, both less successful sons of famous fathers, seeking advice about the education of their sons. They ask Nicias and Laches, two well-known generals of the time, to help. Laches introduces Socrates to the discussion as something of an expert on education, and he invites Nicias to give his views. Nicias promotes military training, which Laches then opposes. This leads to Socrates’ assertion that “if we know that we can improve something by adding something else to it, and we can moreover, cause the one to be added to the other, clearly we know what we’re adding,”[6] meaning, likewise, to know how to add bravery to Lysimachus’ and Melesias’ sons, it is necessary to be able to first define bravery. Irwin questions this,[7] saying that it is surely sufficient to recognise the quality: the colours blue and red, for example, are known by recognition but very difficult to define. He suggests that the nature of bravery in Socrates’ culture was not as universally agreed as it is today and points to the Corcyreans in civil war, whose concept of bravery was very different to ours: “It seems that bravery required unscrupulous determination to ignore any sanction of law or morality to advance one’s own cause, and that justice, as normally conceived, would be mere cowardice.”[8]

The Laches continues with Laches’ first attempt at defining bravery. He says, “If a man is prepared to stand in the ranks, face up to the enemy and not run away, you can be sure that he’s brave.”[9] This is insufficient for Socrates, however, firstly because it is possible to run away and be brave, if that is the wise thing to do, and secondly because he wants a definition that applies not only to war but to all areas of life. As Irwin writes, “Socrates wants a definition that gives a single account of… bravery that applies to all and only brave people and actions” and desires to “provide a ‘standard’ or ‘pattern’ by reference to which we can judge whether someone’s actions display the virtue or not.”[10] Laches then says that bravery is endurance, which raises further questions about whether endurance accompanied by wisdom or foolishness is brave. Nicias then gives his definition of bravery: the knowledge of what is fearful and what is encouraging. Socrates goes on to point out that this would mean that animals and children cannot be brave, as they cannot possess that knowledge. Nicias accepts this, and then Socrates further asserts that Nicias’ definition of bravery as the knowledge of future good and evil must be the knowledge of good and evil generally as “it’s one and the same kind of knowledge that understands future, present and past.”[11] This, Socrates claims, is the definition of all virtue rather than just bravery as “only one of the parts of goodness.”[12] The dialogue finishes with the characters’ coming to the conclusion that they don’t really know what bravery is and have a lot to learn.

Aristotle’s Nichomachean Ethics is a very different text, both in its didactic prose style and its content. Aristotle was both influenced by and reacting against Plato.[13] He saw a brave person as being one who “faces and who fears the right things and from the right motive, in the right way and at the right time, and who feels confidence under the corresponding conditions,”[14] which is similar to Nicias’ notion of knowing what is fearful and what is encouraging. Aristotle also stresses the importance of courage as being “noble,” the Greek word “kalon” also meaning “fine” or “beautiful,”[15] with courageous acts being done for their own sake. He believed that motive was essential: “it is for a noble end that the brave man endures and acts as courage directs.”[16] He then describes courage as a “mean,” a middle ground, between excessive fearlessness and excessive timidity.

Aristotle goes on further to give five examples of “courage improperly so called”[17] which demonstrate what true courage is. These examples are: the soldier who acts in a courageous manner but whose motivation is to avoid military punishment or to acquire military glory; the soldier whose experience gives him an advantage and makes him appear brave; someone who acts fearlessly out of passion; someone who is confident in danger because he thinks he is the strongest and therefore not in any real danger; and someone who is unaware of any danger at all. Aristotle then goes on to say that although “courage involves pain, and is justly praised; for it is harder to face what is painful than to abstain from what is pleasant,”[18] that is overridden by the pleasure of doing the right thing. Aristotle believed that virtue and happiness are inextricably linked; for this reason, “the more [a man] is possessed of virtue in its entirety, the more he will be pained at the thought of death,”[19] and so Aristotle concludes that perhaps brave men do not make such good soldiers as those who are willing to “sell their life for trifling gains.”[20]

Having looked briefly at the texts to which we are referring in considering this question, it would be appropriate now to examine in more detail those parts which are more directly relevant to the relationship between bravery and knowledge. Part of the Laches can be said to suggest that, in fact, bravery has nothing to do with knowledge, chiefly the assertions of Laches himself: firstly that bravery is simply not running away in battle and secondly that bravery is endurance. It is tempting to dismiss the first suggestion as foolish but, as Guthrie writes: “A sailor or mountaineer, faced unexpectedly with the same question, would probably answer similarly in terms of the hazards of his own occupation… this is not an answer which covers all the ordinary and typical uses of the word, nor indeed does Laches believe that .courage is limited in this way,”[21] and he “agrees at once” when Socrates points out that other aspects of life that can be faced with courage.[22] It merely “did not occur to him” to use the word in circumstances other than his own.[23] When Laches gives his second definition, Socrates brings in the question of knowledge, asking Laches if he thinks people who undertake an activity without an expert’s knowledge of it are braver than the expert. Laches agrees that they are, and Socrates reminds him that they had previously decided that “without knowledge endurance and daring are disgraceful and damaging,”[24] thus he’s contradicting himself. Perhaps this difficulty could have been resolved if they had considered the possibility that courage and foolishness can co-exist: for example, to jump into a lake to save someone from drowning is especially courageous if one doesn’t know how to swim, in that it is especially selfless, but it is still foolish because one would be unlikely to succeed and might drown oneself. Socrates, however, believed that virtue is always beneficial and rashness is always harmful,[25] even if well-intentioned, so he probably would not have accepted that example to be one of bravery. Nevertheless, it is because of this paradox that Laches’ definitions of courage are important to the question of the relationship between courage and knowledge. They are not, as Lane writes that many scholars have suggested, “simply a device to prepare the reader for the more sophisticated account of bravery given by Nicias.”[26]

However, Nicias’ definition of bravery does seem to be closer to what we know of Socrates’ views: Guthrie claims that Socrates believed that knowledge is what distinguishes courage from confidence or daring.[27] Nicias asserts that not only are courage and knowledge closely related, but virtue is knowledge: more specifically, the knowledge of what is fearful and encouraging, which enables us to know what would be the wisest way to react to any given situation. This fits perfectly with Socrates’ earlier assertion that in some wartime situations, it is actually braver to flee, but still Nicias’ definition could be seen as confusing courage with wisdom.

Another major difficulty with defining bravery as the knowledge of what is fearful and what is encouraging is that, seeing as good and evil are the same in all time frames, it must also be the knowledge of good and evil generally. This, Socrates claims, is virtue itself, rather than courage, which is only a part of virtue. Guthrie writes that Socrates endeavoured “to show that all the virtues coalesce in being knowledge” because “it is the presence of knowledge which ensures that the so-called virtuous activity will be good and beneficial.”[28] Again, knowledge of good and evil is what we would typically call wisdom rather than virtue, but Socrates believed that nobody does wrong except out of ignorance, or as Nicias puts it: “we’re each good in so far as we’re clever, but in so far as we’re ignorant, we’re bad.”[29]

Aristotle’s views on the relationship between courage and knowledge differed radically from this. He refers to Socrates while explaining his second example of non-courage, saying: “Experience with regard to particular facts is also thought to be courage; this is indeed the reason why Socrates thought courage was knowledge.”[30] We cannot know if this misinterpretation of the views expressed in the Laches is deliberate, or if Aristotle had forgotten what he had read.[31] If it is a deliberate misunderstanding, this raises the question of why Aristotle would chose to do that. Perhaps he wished to make Socrates look foolish as part of his reacting against Plato.

Although it may seem that Aristotle saw courage and knowledge as wholly unrelated, on closer examination of the Nichomachean Ethics, we see that that is not the case. Firstly, Aristotle asserts that the brave man endures pain whilst looking towards a pleasurable end: “the end which courage sets before itself would seem to be pleasant, but to be concealed by the attending circumstances.”[32] Therefore the brave man must have knowledge of that end, in order to look past immediate circumstances towards it. As Guthrie writes, people face danger “in the knowledge that what may happen to them is not an evil at all, if it is more beneficial than cowardice to the real self, the psyche.”[33] Aristotle also defines courage as moderation between excessive fear and excessive confidence, or, as Irwin puts it: “A brave person is not distracted from pursuit of his rational plans by excessive fears; nor, however, is he so recklessly over-confident that he fears nothing.”[34] Essentially, then, courage is knowing how much to fear, and what to fear, which is a disguised form of Nicias’ definition: knowing what is fearful and what is encouraging. Therefore, the views expressed in Aristotle’s and Plato’s works are not nearly as dissimilar as first appears.

The Laches and the Nichomachean Ethics do differ greatly in terms of a conclusion, however. Aristotle maintains a tone of certainty throughout, while Plato, by creating a series of questions and providing disagreement between characters, leaves everything much more open to debate, and this remains the case at the end. The ending to the Laches is so inconclusive, in fact, that all definitions of courage are disregarded: the characters decide that they simply don’t know and need to go back to school. Irwin argues that “Socrates believed all along that he did not know.”[35] It may not necessarily be the case, however, that Socrates believed that he did not know, as that could have been part of his self-effacing manner, just as he claims to be asking questions for his own benefit rather than teaching: “since I’m younger than these gentlemen and rather inexperienced in the field, I should listen to what they have to say first and learn from them.”[36] The Laches’ inconclusive ending leaves the reader to come to his or her conclusion, as it is necessary for the individual to do on all philosophical and moral matters, though we can be guided by reading the teachings of philosophers like Aristotle.


Aristotle, Ethics III.6-10 – from handout
Guthrie W. K. C. (1975) A History of Greek Philosophy: Volumes III and IV, Cambridge: Cambridge University Press
Irwin, T. (1989) Classical Thought, Oxford: Oxford University Press
Plato, Laches (tr. Iain Lane) in Plato: Early Socratic Dialogues (ed. Trevor J. Saunders), (2005) London: Penguin Classics

[1] Guthrie 1975: III, 459
[2] Plato, Laches 194e
[3] Guthrie 1975: IV, 245
[4] Anne Sheppard, lecture, 23rd November 2006
[5] Irwin 1989: 72
[6] Plato, Laches 189e
[7] Irwin p73
[8] Ibid.
[9] Plato, Laches 190e
[10] Irwin 1989: 72
[11] Plato, Laches 199a
[12] Plato, Laches 199e
[13] Anne Sheppard, lecture, 14th December 2006
[14] Aristotle, Nichomachean Ethics III.7
[15] Anne Sheppard, lecture, 14th December 2006
[16] Aristotle, Nichomachean Ethics III.7
[17] Aristotle, Nichomachean Ethics III.8
[18] Aristotle, Nichomachean Ethics III.9
[19] Ibid.
[20] Ibid.
[21] Guthrie 1975: IV, 244
[22] Guthrie 1975: IV, 245
[23] Ibid.
[24] Plato, Laches 193d
[25] Guthrie 1975: IV, 228
[26] Lane 2005: 73
[27] Guthrie 1975: IV, 228
[28] Ibid.
[29] Plato, Laches 194d
[30] Aristotle, Nichomachean Ethics III.8
[31] Anne Sheppard, lecture, 14th December 2006
[32] Aristotle, Nichomachean Ethics III.9
[33] Guthrie 1975: III, 453
[34] Irwin 1989: 137
[35] Irwin 1989: 72
[36] Plato, Laches 181d

Friday, 12 January 2007


I'm going back to uni on Sunday. I don't want to go! Leaving all my family and friends to be surrounded by people who are, at worst, hostile and, at best, indifferent is... well, not great, really. I know that I'm privileged to be at university in the first place, and it's not really as bad as all that, but I'm still sad. It feels like exile. It's had me thinking a lot about Ovid and his exile in Tomis. I did my GCSE Latin coursework on the life and work of Ovid and Virgil and that was when I got my passion my Classical literature. Ovid, in particular, is great, and so versatile: the wicked wit of the Ars Amatoria and the imaginative force of the Metamorphoses. What I've been reading lately, though, are his Tristia and Ex Ponto (you can read them online here) which he wrote in exile. For some reason, it's comforting, when you're miserable, to read your own miserable sentiments put much better than you could put them. As Sylvia Plath said, "Don't talk to me about the world needing cheerful stuff! What the person out of Belson - physical or psychological - wants is nobody saying the birdies still go tweet-tweet, but the full knowledge that somebody else has been there and knows the worst, just what it is like."

Ovid can be a bit of a bore in some of these letters, like when he describes all his various ailments in detail to his friend Flaccus, and he does whinge. This, however, to Rufinus, from Ex Ponto Book I.III, I find very moving:

"When your advice has strengthened my low spirits,
when I’ve adopted your mind’s defences,
then love of my country, stronger than all reason,
undoes the work your letters have achieved.
Whether you wish to call it love or unmanly tenderness,
I confess my strength of mind is weakened by misery.
No one doubts Ulysses’ worldly wisdom, but even he prayed
that he might see the smoke of his ancestral hearth again.
Our native soil draws all of us, by I know not
what sweetness, and never allows us to forget.
Where’s better than Rome? Where’s worse than cold Scythia?
Yet the homesick barbarian will still flee the City.
Though Pandion’s daughter is fine, shut in her cage,
she yearns to return to her woodlands.
Bulls seek the pastures they know, and lions –
despite their wild natures – seek their lairs.
Yet you hope, by your palliatives, to remove
the pangs of exile from my mind.
Ensure that you and yours are not so dear to me,
then it will be that much less painful to miss you.
And, I suppose, though I’m distant from my native land
I’ve still managed to end among human society."

Tuesday, 9 January 2007

Graveyard Love

"What's in a name? That which we call a rose
By any other word would smell as sweet."
~ Romeo and Juliet (II, ii, 1-2)

As I survey my ever-expanding blogroll (partly due to this thread I started over at PFFA), I can't helping wondering at the vast array of names people have for themselves and their blogs. How exactly does this chap resemble a large aquatic mammal? And, likewise, I know for a fact that this chap is not a whale at all, because I've seen him and he wasn't large or wet or blubbery enough. Likewise I doubt that this chap is really a garden ornament.

Over the years I've had more online aliases than I can count on my fingers and toes, pretty much one for every website, and I still change it regularly on MSN and My MySpace as circumstances and/or mood dictate. Thinking back... I started on my first Hotmail account as Flutterbunny, an unfortunate pet name my mother had given me. Mummy's nicknames became something of a tradition: Dolly Daydream, Dolloppy Daydreamer, Flossie, which is the favourite at home at the moment and my current MySpace name. At twelve I became Joyful Girl Zero, from this poem (yes, yes, I cringe). That one stuck, as did some friends' nicknames: Laulia, The Bardic Princess. All those at PFFA know me as Empty Chairs, which I conveniently pinched off someone else. I've also, over the years, been Sleepless, Ellen of the Ways, Whalesong, An Angry Girl, Graveyard Girl, Persephone, Electra, January Girl, Raggedy Ann, Child Owlet, Ruby Tuesday, Little Lights, Emma Miranda, Lament, Cornflake Girl, Hummingbird and Cooksferry Queen.

The Library Princess, however, is actually a first. It, of course, fits in with my intention for this to be primarily a literary blog. It also hearkens back to the days in Year 11 when, as something of a social outcast, I spent every break time alone in the library, either reading poetry (if it was a good day) or crying (if it was a bad day). I became very well acquainted with Emily Bronte and Christina Rossetti. In sixth form, I became happier and healthier, made friends and stopped hanging out in the library. But since coming to uni, I've found that, once again, I'm something of a loner and I'm, once again, The Library Princess. We have the most gorgeous library, though in its grandeur it lacks the cosiness, and, alas, no solitude either.

Another favourite "haunt" of mine is graveyards. (God, I'm witty.) In Year 11, I spent my days in the library and my evenings in the graveyard on Southampton Common. Similarly, I always used to stop at the churchyard on my way home from junior school and, in sixth form, on bad days, I went to the one just down the road. I know this qualifies me as deeply odd. Somehow in the depths of a depression I feel closer to the dead than the living. And it's a little like human contact without the difficulties of social interaction.

You can see, then, why I fell in love with this blog, devoted entirely to photographs of graveyards. I've always loved taking photos, partly because I'm convinced I'd be a passable artist, if only I could draw. I'm going to splash out on a digita camera - something I've been wanting to do for years - and start doing photography properly. Just as soon as my student loan comes through. There's this wonderful cemetery near my uni, which I pass every day on the bus, and I always see the arch of the winter trees and long for a camera. I've held back from exploring the cemetery 'til I get it. And then I can remember my first taste of that delicious solitude and scenery. There's woods nearby too. I love woods just as much as graveyards! Cookie inspires me with her photos, as does Elle. Watch this space!

Wednesday, 3 January 2007

Things I Learnt During My First Term at University

  1. Syllabub is evil, despite its deliciously creamy taste - and I am not impervious to hangovers.
  2. When a man asks you back to his place to play Monopoly, it's not Monopoly he has in mind.
  3. Wherever you go, there will be good, kind people. The trick is finding them.
  4. Limes are the manly fruit.
  5. Men are just as fickle as women. I myself can be a bit fickle on occasion.
  6. We rely on others for our sanity as much as ourselves.
  7. I can sing.
  8. Guys are great company.
  9. Academics are bonkers, most of them. Is strangeness on the exam?
  10. Being blind drunk need not prevent you from writing a decent essay - indeed it may help.