Case report: Anorexia nervosa and unspecified restricting-type eating disorder in Jewish ultra-orthodox religious males, leading to severe physical and psychological morbidity.

Background: Young Jewish Ultra-Orthodox women usually show less disturbances in body image and eating in comparison to less religious communities. By contrast, problems with eating are highly unknown and unrecognized in Jewish Ultra-Orthodox males. Aim: To investigate whether in Ultra-Orthodox males, restricting-type AN (AN-R) with highly obsessional physical activity and unspecified restricting eating disorder (ED) in the context of obsessive-compulsive disorder (OCD) would lead to severe physical and emotional morbidity. Results: The study included two groups: the first, 3 adolescents with AN-R developing severely increased ritualized obsessional physical activity in addition to restricting eating, requiring inpatient treatment because of severe bradycardia. These youngsters ignored the severity of their obsessional physical activity, continuing with it in hospital despite their grave medical condition. One student began extensive training for triathlon, whereas another student, upon remitting from AN, developed severe muscle dysmorphia. These findings suggest that young Ultra-Orthodox males with AN may develop obsessional physical activity to increase their muscle mass rather than to lose weight Another four Jewish Ultra-Orthodox males developed malnutrition in the context of severe OCD, with no evidence of dieting or body-image disturbances. These individuals developed highly obsessional adherence to different Jewish religious rules, including prolonged praying, asceticism, and overvalued strict adherence to Jewish Kashrut rules of eating, leading in all cases to severe food restriction. They were highly unaware of their severe weight loss and required hospitalization because of severe physical disturbances associated with malnutrition. Moreover, most did not cooperate with their treatment, and their ED-related obsessionality was mostly resistant to psychopharmacotherapy. Conclusion: Owing to their highly ritualistic rigid way of life, combined with the need for excellency in studying, Jewish Ultra-Orthodox adolescent males with AN might be at a specific risk of developing severe physical disturbances if their illness is associated with highly perfectionistic obsessional physical activity. Second, Jewish Ultra-Orthodox religious males with OCD might be at a specific risk for severe undernutrition, as their rigid relentless observance of Jewish everyday laws might highly interfere with their eating.

Dissociation and Suicidality in Eating Disorders: The Mediating Function of Body Image Disturbances, and the Moderating Role of Depression and Anxiety.

In patients with eating disorders (EDs), elevated dissociation may increase the risk of suicide. Bodily related disturbances, depression, and anxiety may intervene in the association between dissociation and suicidality. In this study we aimed to examine the influence of bodily related disturbances, depression, anxiety, severity of ED symptoms, body mass index (BMI), and type and duration of the ED on the relationship between elevated dissociation and elevated suicidality. The study included 172 inpatients: 65 with anorexia nervosa restricting type, 60 with anorexia nervosa binge/purge type, and 37 with bulimia nervosa. Participants were assessed using self-rating questionnaires for dissociation, suicidality, bodily related parameters, and severity of ED symptomatology, depression, and anxiety. We found that dissociation and suicidality were directly associated. In addition, depression and anxiety moderated the mediating role of body image parameters in the association between increased dissociation and increased suicidality. Thus, only in inpatients with high depression and anxiety, i.e., above the median range, body image disturbances were found to mediate the association between dissociation and suicidality. ED-related parameters did not moderate these relationships. Our study demonstrates that in inpatients with EDs, increased dissociation may be significantly associated with increased suicidality, both directly and via the intervening influence of body image, depression, and anxiety.

Traumatic Bereavements: Rebalancing the Relationship to the Deceased and the Death Story Using the Two-Track Model of Bereavement.

Bereavements that occur under external traumatic circumstances increase the risk for dysfunction, trauma symptomatology, as well as disordered and prolonged grief. While the majority of individuals who have experienced traumatic bereavements do not meet formal criteria for posttraumatic stress disorder (PTSD), persistent complex bereavement disorder (PCBD), or prolonged grief disorder (PGD), the degree of distress and dysfunction for these bereaved can be quite significant. The assessment and intervention paradigms in use with traumatic bereavements often prioritize the trauma and bypass the centrality of the interpersonal loss. By using a bifocal approach in conceptualizing bereavement, the Two-Track Model of Bereavement (TTMB) rebalances the approach to the class of traumatic bereavements. Track I examines biopsychosocial functioning and symptoms of trauma, and track II focuses on the nature of the ongoing relationship with the deceased and the death story that may also have elements of traumatic response. The model and its application serve to identify both adaptive and maladaptive responses to loss along both axes to optimally focus interventions where needed. The story of the death, the psychological relationship with the deceased, and the presence of biopsychosocial difficulties each have a part to play in assessment and intervention. A case study of assessment and intervention following traumatic bereavement due to suicide illustrates how attention to each of these factors in the TTMB can facilitate change. Ultimately, the relational bond with the deceased is a major vector in grief and mourning. Assessment and intervention with traumatic bereavements require attention to dysfunction and symptoms of trauma as well as to the death story and the state of the relationship to the deceased.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders.

BACKGROUND: Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs. METHODS: Four cases from different treatment centers in Israel were analyzed. RESULTS: All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34. DISCUSSION: All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Treating ultra-orthodox adolescents with eating disorders in Israel: Culturally-sensitive interventions, difficulties, and dilemmas.

Young ultra-Orthodox women in Israel have been faced in recent years with a greater risk of developing disordered eating, as they are more exposed to Westernized norms of the thin-body ideal, self-realization, and personal choice. Most are treated by mainstream Israeli psychotherapists who likely have different value systems and different perspectives on the nature of the illness, aims of treatment, and recovery. Ultra-Orthodox psychotherapists may well experience a conflict between a need to be loyal to their patients and a concomitant need to honor the values of patients' families and the community from which they come. The current article presents a theoretical background and four case studies highlighting the complexities and controversies inherent in the treatment of these women. We conclude that both ultra-Orthodox and mainstream secular psychotherapists must be knowledgeable in regard to both Judaism and psychology, and be flexible, creative, and emphatic to all parties, to arrive at a compromised definition of recovery that can be accepted by the patient, her family, and her community.

Creativity and mood disorders: The enigmatic case of Isaak Il'ich Levitan (1860-1900).

Isaak Levitan (1860-1900) was one of Russia's most influential landscape artists. He lived a very short life, only 40 years, but left more than 1000 paintings. He suffered from mood fluctuations, and died as a result of serious heart disease. After an introduction related to the issue of creativity and mental disorders, a short biography of Levitan's life is outlined, followed by some examples of his mood and behavior. A section on the mood's reflection in Levitan's professional work is followed by a description of his romantic loves and disappointments and his relationship with his contemporary Russian, the writer Anton Chekhov.

Pavel Ivanovich Karpov (1873-1932?)--the Russian Prinzhorn: art of the insane in Russia.

The complicated relationship between the discipline of mental health and the arts has barely been studied systematically. Mental hospitals, shelters and prisons--institutions that accommodate the mentally ill--sometimes promote but often discourage and disrupt the patients' artistic creativity and the images created. In psychiatric circles, the recognition of patient art was a long, slow and frustrating process. Among the Western psychiatrists who studied the creative activity of the mentally ill, researchers usually mention such names as C. Lombroso, M. Shearing, V. Morgentaller, H. Prinzhorn and others, but rarely refer to their Russian colleagues and contemporaries. Pavel Ivanovich Karpov (1873-1932?), a Russian psychiatrist, was one of the most extensive researchers in the field of the art of the insane, but unfortunately his name is little known among modern psychiatrists. For his clinical and scientific contributions, he deserves to be remembered in the history of psychiatry.

Alexander Nikolaevich Scriabin (1872-1915): Enlightenment or illness?

The similarity between psychotic symptoms and aspects of mystical experiences is well known. It has long been recognized that there are similarities between mystical and spiritual and psychotic experiences. The content of an experience alone usually does not determine whether an individual is psychotic. The Russian composer Scriabin (1872-1915) was among the most famous artists of his time. Scriabin infused his music with mysticism, evolving a modernistic idiom through which he created a musical counterpart to the Symbolist literature of that period. In this paper, we discuss the question that arises from perusing Scriabin's life is whether the composer was a mystic genius or whether he suffered from affective psychopathology with psychotic features.

[FUNCTIONAL SOMATIC SYNDROMES AMONG ETHIOPIAN IMMIGRANTS IN ISRAEL].

INTRODUCTION: The psychiatric classifications of disease (DSMIV; ICD-10) relate to a family of high incidence somatoform disorders whose use isn't uniform and cannot be measured. DSM-5 presents the term "cultural conceptualization of distress", which attempts to describe the cultural construct and its influences on mental distress and symptom presentation. Somatization among immigrants poses a diagnostic, treatment and research challenge due to cultural differences such as wrong understanding of their symptoms that may lead to misdiagnosis and to prescribing wrong and possibly harmful treatment and unnecessary hospitalization. This challenge is greater when encountering Ethiopian new immigrants due to the significant doctor-patient cultural gaps on one hand, and the community's heterogeneity, on the other. The Integrative Culture Sensitive Assessment and Treatment Model helps structure the diagnostic and treatment processes appropriately. METHODS: Two culture-related functional somatic disorders are presented, alongside with their diagnosis and treatment: The "Ken-Ken" syndrome (worms in the ear) - where the patient complains worms have entered her ear and head influencing her daily functioning, and the "prolonged pregnancy" syndrome, where the menopausal woman believes she is pregnant for many years and that the fetus "has turned into bone". DISCUSSION: This article presents the somatization mechanism via two culture-related case studies of Ethiopian new immigrants to Israel suffering from emotional distress via culturally different symptomatology. It further presents an integrated cultural oriented treatment approach as a way to reduce overuse of primary and secondary medical services.

Poet and profligate: the secrets of Aleksandr Sergeyevich Pushkin's (1799-1837) personality and maladies.

Aleksandr Sergeyevich Pushkin (1799-1837) was one of the great figures of Russian poetry and literature. There are numerous publications about his life, adventures and creative work. However, little has been written about his character, mental state and the condition of his wound during his fatal duel. Furthermore, his sexual illnesses and their nature were discussed even less. This paper attempts to lift the veil from this mystery.

Dissociation: adjustment or distress? Dissociative phenomena, absorption and quality of life among Israeli women who practice channeling compared to women with similar traumatic history.

This study aimed to explore the relationship between traumatic history, dissociative phenomena, absorption and quality of life among a population of channelers, in comparison with a population of non-channelers with similar traumatic history. The study sample included 150 women. The measures included Traumatic Experiences Scale, Dissociative Experience Scale, Absorption Scale, Brief Symptom Inventory and Quality of Life (QOL) Assessment. Channelers presented significantly higher levels of dissociation, absorption and psychological health compared to the other group. Dissociation and absorption were trauma-related only among the comparison group. Hence, dissociation has different qualities among different people, and spiritual practice contributes to QOL.

Dissociative symptoms as a consequence of traumatic experiences: the long-term effects of childhood sexual abuse.

BACKGROUND: The purpose of this study was to assess the prevalence of dissociative symptoms and post-traumatic experiences in an ambulatory setting. METHOD: The study was conducted in the ambulatory outpatient clinic of the Beersheva Mental Health Center. Over a period of six months new patients over 18 years of age were asked to participate in this survey. Patients completed questionnaires including the Dissociative experience Scale, trauma History Questionnaire, impact of event Scale, and Post-traumatic Diagnostic Scale. RESULTS: A total of 505 patients were enrolled in the study, and 456 completed questionnaires were analyzed. of these, 442 (97%) participants reported at least one traumatic event during their lifetime. the traumatic events were experienced as meaningful and severe at the time of occurrence. the effects of sexual and childhood emotional abuse remained very intense throughout the victim's life and were viewed as powerful, significant experiences. on the other hand, traumatic experiences such as natural disasters and battle trauma were associated with longterm effects of relatively low intensity. CONCLUSIONS: The presence of undiagnosed posttraumatic stress disorder (PtSD) among patients in outpatient mental health clinics suggests that screening and diagnostic procedures for this condition be more carefully defined. our most important finding is the large impact of childhood trauma, especially sexual abuse, on later life. thus the prevention, early detection and treatment of child abuse in preventing long term psychopathology must be emphasized.

Challenges and conflicts in the delivery of mental health services to ultra-orthodox Jews.

Ultra-orthodox Jews are a religious group that lives apart, valuing its separateness and ascribing sanctity to its life style. Community members are reticent to seek help from mental health services, especially if provided by professionals from outside the community. Therapeutic interventions should be explained in terms meaningful to the patient's explanatory model. Community members may face stigmatic attitudes of service providers. Situations are presented of the challenges and conflicts that confront ultra-orthodox Jews and mental health service providers concerning seeking help, understanding idioms of distress, providing appropriate rehabilitation services and negotiating arranged matches for marriage (shidduchim).

Food insecurity among psychiatric patients and welfare clients in Israel.

BACKGROUND: Twenty-two percent of households in Israel experience food insecurity, and it is especially widespread in socio-economically distressed strata. Although their low socio-economic status renders psychiatric patients at risk for food insecurity, this issue has thus far been ignored in both practice and research. OBJECTIVE: To explore food insecurity among psychiatric patients in comparison with welfare-services clients in order to raise awareness of food insecurity in this population. METHOD: 114 respondents were recruited from among patients admitted to the emergency room and hospitalized in a mental health center in Beer Sheva; 555 respondents were recruited from among low-income clients of welfare service agencies in the Beer Sheva area. All respondents were surveyed with a self-report questionnaire and with the Food Security Core Survey Module (FSCSM). RESULTS: Forty percent of psychiatric patients and 59% of welfare-services clients reported food insecurity. The use of formal and informal support systems was lower among food-insecure psychiatric patients than among food-insecure welfare clients. CONCLUSIONS: Psychiatric patients appear to be a risk population for food insecurity; therefore planned interventions and specific food programs are called for.

Arranged matches and mental illness: therapists' dilemmas.

Traditional societies place especial value on marriage and having children, and marriages are often arranged. A series of situations and dilemmas associated with arranged matches and their consequences are described in the course of mental health work with ultra-orthodox Jewish people with severe mental illness. Issues of confidentiality may arise with parents and matchmakers; on the other hand, respectful cooperation with religious authorities, counselors in the community, and family members is important. Information on genetic counseling, contraception, medication during pregnancy, and breastfeeding are considered and interact with communal structures and practices. There is a need for close support and evaluation during the process of marriage, childbearing, and parenthood.

Victor Kandinsky (1849-89): pioneer of modern Russian forensic psychiatry.

The paper describes Victor Kandinsky's professional achievements within nineteenth-century Russian forensic psychiatry. A thorough review of nineteenth-century Russian psychiatry is presented, followed by a short biographical account of Kandinsky's personal life. Within the backdrop of Russian forensic psychiatry toward the end of nineteenth century, Kandinsky's pioneer innovations in psychopathology and classification as well as his contributions to Russian forensic psychiatry are reviewed. These are exemplified by two of his forensic case studies relating to forensic responsibility and malingering, which are included in his famous book 'On Irresponsibility'.