Author Archives: rajani

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Hypothalmic Hamartoma – A Rare Cause of Central Precocious Puberty

DOI: 10.31038/JCRM.2022553

Abstract

Hypothalamic hamartoma is a well-known neurological rare cause of central precocious puberty and gelastic seizures and may be asymptomatic for long period. It is rare and non-progressive tumor like congenital malformation. Precocious puberty defined as children attained the puberty before age of 8 years in girls and 9 years in boys. We present such a case of precocious puberty due to hypothalamic hamartoma in 5 year old boy and its radiological imaging findings.

Keywords

Hamartoma, hypothalamic, precocious, puberty, central cause

Introduction

Hypothalamic hamartoma is a rare non progressive tumor like well-organized congenital malformation of tuber cinereum in the floor of third ventricle [1-4]. It causes the classical spectrum or trait of gelastic seizures, precocious puberty and developmental delay or behavioral disorder [1,3]. It is most usual neurological cause of central precocious puberty.2 This condition may be asymptomatic for long period, or may present with clinical appearance and symptoms of precocious puberty and complex partial seizures refectory to anticonvulsant drugs [1,2]. One third of patients with hypothalamic hamartoma can be present with precocious puberty and it is defined as children attained the puberty before age of 8 years in girls and 9 years in boys [1,4,5]. Furthermore precocious puberty is divided into gonadotropin releasing hormone (GnRH)-dependent/central and gonadotropin releasing hormone (GnRH)-independent / peripheral precocious puberty [4]. Contrast enhanced MRI is investigation of choice and play important role in diagnosis of hypothalamic hamartoma [2,3] It appears as well-defined non enhancing lesion in floor of third ventricle showing similar signal intensity to the grey matter of brain parenchyma [3,4,6]. Gold standard treatment option for isolated central precocious puberty due to hypothalamic hamartoma is long acting analogs agonists of GnRH (GnHas) with good efficacy and safety [4,7].

Case Report

5 Years old boy came in paediatric outpatient department of Liaquat National Hospital with complain of faster growth of child than expected according to his father. On further questioning child has also history of epileptic laughter (gelastic seizures) 1-2 times, 2-3 months back for which he has taken antiepileptic drugs from local doctor in periphery of Afghanistan.

On local examination there were axillary and pubic hair and enlargement of penis measured about 4-5 cm in length. This was classified as TANNER stage (sexual maturity rating) 04 (Figure 1). Neurological examination was normal with Glasgow coma scale (GCS) of 15/15. Electroencephalogram (EEG) was recommended to see the cause of previous history of epileptic seizures was negative. His baseline laboratory investigations turned out to be within normal limits. On the basis of clinical and examination diagnosis of precocious puberty was made. His endocrinology related laboratory investigations were deranged. Follicle Stimulating Hormone (FSH) 4.11 (N= 1.9 mIU/ml), Luteinizing Hormone (LH) 9.82 (N1.3 mIU/ml) Testosterone 1500 ng/dL and Testosterone/Estradiol T/E2 ratio 45 pg/ml. All these investigations are raised and not normally corresponding to the patient’s age. Thyroid Function Tests (TFT) were within the normal limit.

fig 1

Figure 1: Enlarged penis and appearance of pubic hair not corresponding to the patient’s actual age

He underwent the contrast enhanced MRI brain which showed abnormal signal intensity mass arising from the tuber cinereum in the region of hypothalamus. It appeared iso-intense to grey matter on T1 and T2 weighted images and showed no post contrast enhancement. It measured about 0.9 x 1.1 cm. The lesion was very small in size and has no mass effect or compression over the adjacent brain parenchyma. This was diagnosed as hypothalamic hamartoma. (Figures 2 and 3). Patient also underwent the X-ray right hand and elbow according to the radiological protocol to see the exact age of patient which showed 15 years reported by the experienced radiologist (Figure 4). During hospital stay course patient was asymptomatic and discharged on long acting analogs agonists of GnRH (GnHas). Follow-up was recommended in outpatient department of endocrinology.

fig 2

Figure 2: A Axial T2 weighted image and B sagittal T2 weighted image show abnormal signal intensity mass arising from the tuber cinereum in the region of hypothalamus. It appears iso-intense to the brain parenchyma (black arrow head)

fig 3

Figure 3: A sagittal plain T1 weighted image and B sagittal contrast enhanced T1 weighted image show abnormal signal intensity mass arising from the tuber cinereum in the region of hypothalamus. It appears iso-intense to brain parenchyma and show no post contrast enhancement (White arrow head)

fig 4

Figure 4: A anterior-posterior elbow, B lateral elbow and C anterior-posterior wrist X-rays show bone age of 15 years

Discussion

Previously Hypothalamic hamartoma used to be an uncommon finding and was estimated to occur in one person per one million population,1 however with timely advancement in the field of Radiology and better clinical recognition, the early diagnosis has now become possible and its incidence has significantly decreased [1,2].

Most patients usually present in the first or second decade of life [1-3]. Precocious puberty is the most common presentation, however larger hamartomas are less likely to produce precocious puberty [2,3]. Other clinical presentations include developmental delay, attention deficit or hyperactivity disorder and anxiety [1-4]. A very specific feature of hypothalamic hamartoma is Gelastic seizure [1-3]. In our case, hamartoma measured up to 1cm on MRI brain (Figure 2) and patient was presented with complaints of both precocious puberty and laughing fits (Gelastic seizures).

On MRI, hypothalamic hamartomas produce soft tissue intensity masses which are isointense to grey matter on T1WI and hyperintense on T2WI [2,3]. They are homogeneous and sharply marginated by the surrounding CSF with no post contrast enhancement [2,3,6]. Calcification is rare and hemorrhage is not described in these lesions [2,3]. This classical appearance of soft tissue intensity mass in the region of hypothalamus was also observed in our patient (Figure 2).

Patients with central precocious puberty are usually managed conservatively [2], for progressive central precocious puberty, treatment with a depot GnRH agonist is suggested and is generally continued for 11 years [2-4]. However, surgery including resection or disconnection through craniotomy or trans-spheroidal approach can be helpful in cases of poorly controlled epilepsy [2-6], to our patient, we advised long acting analogs agonists of GnRH (GnHas) with a follow up in OPD.

Conclusion

Hypothalamic hamartomas are rare congenital malformation seen in floor of third ventricle. Precocious puberty is most usual presenting feature. MRI brain play important role in diagnosis of these lesions. Radiologist should aware of imaging findings of hypothalamic hamartoma and should examine the hypothalamic region properly in suspected cases as they can be easily missed due to small size. Bone age can be assessed by using the wrist X-ray and we can also observe the slowing of bone growth after treatment by X-ray wrist recommendation in every 6th month.

References

  1. Qasim BA, Mohammed AA (2020) Hamartoma of hypothalamus presented as precocious puberty and epilepsy in a 10-year-old girl. International Journal of Surgery Case Reports 77: 170-173. [crossref]
  2. Mahmood R, Al Taei TH, Samah Al Obaidi MD (2019) Hamartoma of the Hypothalamus. Bahrain Medical Bulletin 41.
  3. Kalekar T (2015) Hypothalamic Hamartomas: Two Cases. Open Journal of Medical Imaging 5: 20.
  4. Sharma P, Acharya N, Guleria TC (2020) Hypothalamic hamartoma presenting as central precocious puberty: a rare case report. International Journal of Contemporary Pediatrics 7: 1634.
  5. Mahajan ZA, Mehta SR (2020) Central precocious puberty: A case report. Medical Journal of Dr. DY Patil Vidyapeeth 13: 413.
  6. Boyko OB, Curnes JT, Oakes WJ, Burger PC (1991) Hamartomas of the tuber cinereum: CT, MR, and pathologic findings. American Journal of Neuroradiology 12: 309-314. [crossref]
  7. Eugster EA (2019) Treatment of central precocious puberty. Journal of the Endocrine Society 3: 965-972. [crossref]
fig 5

Arizona Reopening Phase 3 and COVID-19: After 18 Months

DOI: 10.31038/JCRM.2022544

Abstract

There had been three Arizona COVID-19 Reopening Phases. On March 5, 2021, Arizona’s Reopening Phase 3 began. The state is the sixth largest in size of the United States 50 states and about the same size as Italy. There were four case surges — in the summer and fall 2021 with Delta variant, and the winter 2021-22 and summer 2022 with Omicron variants. This 18 months longitudinal study examined changes in the number of new COVID-19 cases, hospitalized cases, deaths, and vaccinations. There was an increase of more than 1.4 million cases during the study period. The data source used was from the Arizona Department of Health Services COVID-19 dashboard database. Even with the case surges, the new normal was low number of severe cases, manageable hospitalization numbers, and low number of deaths.

Keywords

COVID-19, Arizona returning to normal, Longitudinal study, Arizona and COVID-19

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is also known as COVID-19 (coronavirus). It is a respiratory disease (attacks primarily the lungs) that spreads by person to person through respiratory droplets (coughs, sneezes, and talks) and contaminated surfaces or objects. Since the virus first appears in Wuhan, China in December 2019, there has been more than 600 million cases in the world. On September 7, 2022, Johns Hopkins University [1] reports that there are 606,889,445 total COVID-19 cases and 6,507,958 deaths associated with the virus in the world. The United States has the highest total cases (95,020,855) and deaths (1,048,989) in the world [1].

A three prolong attack is used against the virus by encouraging the public to practice preventive health behaviors that reduces the risks of getting respiratory infections (e.g., coronavirus, flu, and cold), and using vaccines and therapeutics. The preventive health behaviors include, but not limited to, practicing physical and social distancing, washing hands frequently and thoroughly, and wearing face masks. Johns Hopkins reports that more than 12.18 billion vaccine doses have been administered in the world and the U.S. has administered more than 605 million vaccine doses (September 7, 2022) [1].

There has been three Arizona Reopening Phases. During Arizona’s Reopening Phase 2 winter surge in 2020, ABC and NBC News report that the state has the highest new cases per capital in the world [2,3]. On September 7, Arizona is ranked 12th in total COVID-19 cases (2,258,040) and 11th in total deaths (31,162) of the 50 U.S. states [1]. Arizona is the sixth largest in size (113,990 square miles / 295,233 square kilometers) of the U.S. 50 states and is about the same size as Italy (301,340 square kilometer) [4,5]. The state population estimate is 7,276,316 on July 1, 2021 [6].

A partnership between the U.S. federal government and each of the 50 states is required to address the COVID-19 pandemic [7,8]. The federal government provides the national guidance primarily through the Centers for Disease Control and Prevention (CDC) and needed logistical support (e.g., provide federal supplemental funding, needed medical personnel and resources, and other needed assistance). The states decide on what actions to take and when to carry out those actions; the state COVID-19 restrictions; when to carry out each reopening phase; and the state vaccination plan.

On March 5, 2021, Arizona Governor Douglas Ducey begin Reopening Phase 3 (final reopening phase) after the state had administered more than two million vaccine doses and several weeks of declining cases [9,10]. This eases more of the COVID-19 restrictions. As more people become vaccinated and those infected recovered and have immunity against the virus; the numbers of cases, hospitalizations, and deaths will be low; COVID-19 will be manageable; and the state returns to normal.

The remainder of the paper examines Arizona Reopening Phase 3 (March 5, 2021 to September 7, 2022) looking at changes in the number of new COVID-19 cases, hospitalizations, and deaths.

Methods

This was an 18-months longitudinal study. The Arizona Department of Health Services (the state health department) COVID-19 dashboard database was the data source used. The study examined the changes in the numbers of new COVID-19 cases, hospitalized cases, deaths, and vaccines administered.

There were several data limitations. The COVID-19 case numbers represented the numbers of positive tests reported. When more than one test given to the same person (e.g., during hospitalization, at work, and mandatory testing), there were individual case duplications. Aggressive testing resulted in increases in false positive and false negative testing results. The case numbers did not include positive home testing results.

Delays in the data submitted to the state health department affected the timeliness of data reported and caused fluctuations in the number of cases, hospitalizations, deaths, and vaccinations. The state health department continued to adjust the reported numbers that may take more than a month to correct the numbers. The deaths associated with the coronavirus may cause by more than one serious underlying medical conditions, and the virus may not be the primary cause of death.

Results

A case could be mild (no symptoms), moderate (sick, but can recover at home), and severe (require hospitalization and/or result in death). There were four case surges during the Reopening Phase 3: 2 summers, 1 fall, and 1 winter. The 2022 cases (882,671) had already exceeded the 2021 total case numbers (838,836). Figure 1 shows the Arizona weekly COVID-19 cases during January 1, 2020 to September 10, 2022.

fig 1

Figure 1: Arizona Weekly COVID-19 Cases: January 1, 2020 to September 10, 2022.
Source: Arizona Department of Health Services Arizona COVID-19 weekly Cases Graph*2022 cases as of September 14.

At the end of the 18 months of Arizona Reopening Phase (began March, 5, 2021), there were 1,432,921 COVID-19 cases, 59,091 case hospitalizations, and 14,839 deaths associated with the virus in Arizona (Table 1). There were higher percentages of hospitalizations, and deaths in the first 6 months of the first year than the following two 6-month periods.

Table 1: Arizona Reopening Phase 3 Total Numbers of COVID-19 Cases, Hospitalizations, and Deaths: March 7, 2021 to September 7, 2022

table 1

Source: Arizona Department of Health Services COVID-19 Dashboard.
Arizona 2021 population estimate is 7,276,316, July 1, 2021 – U.S. Census.

Table 2 tracks the weekly total and weekly numbers of COVID-19 cases, hospitalized cases, and deaths during the past 6 months (March 9 through September 7, 2022). The largest weekly numbers of cases (20,198) occurred on July 6, while hospitalizations (1,955) occurred on March 9. The largest weekly number of deaths was on March 16 (457).

Table 2: Arizona Total and Weekly Numbers of COVID-19 Cases, Hospitalizations, and Deaths

table 2

Source: Arizona Department of Health Services COVID-19 Dashboard.
Arizona 2021 population estimate is 7,285,370, July 1, 2021 – Arizona OEO.

Figures 2-4 compare the numbers of COVID-19 cases, hospitalized cases, and deaths by age groups for the three 6-month periods. A case could be mild, moderate, and severe. Most people recovered and did not require hospitalization. There was an increase of 1,432,921 cases during the 18 months. The 20-44 years age group had the largest number of cases (Figure 2). There were more females (52.8%) than males (47.2%) who got the virus on September 7, 2022.

fig 2

Figure 2: Arizona Reopening Phase 3 COVID-19 Cases by Age Groups for Three 6-Month Periods.
Source: Arizona Department of Health Services COVID-19 Cases by Age Groups Statistics.

The percentages of total hospitalized cases (severe cases) decreased from 7 percent on March 6, 2021 to 5 percent on September 7, 2022. The case hospitalizations had increased by 59,091 during the study period. Seniors had the highest percent of the total hospitalizations (43.7% on September 7) and those under 20 years of age had the lowest percent (4.5%). Eighteen percent (18.1%) of seniors diagnosed with COVID-19 hospitalized, while 1.1 percent of those under 20 years of age hospitalized. There were more males (52.2%) than females (47.8%) hospitalized. Figure 3 shows the hospitalization numbers for each age group with the virus for the three 6-month periods.

The numbers of deaths had increased by 14,839 during the 18 months. The rates of fatalities per 100,000 population increased 227.05 to 433.50. As expected, seniors had the highest percent of total deaths (71.3% on September 7) and those under 20 years of age had the lowest percent (0.2) Eight percent (7.9%) of the seniors diagnosed with COVID-19 died, while 0.01 percent of those under 20 years of age died. There were more males (59%) than females (41%) who died. Figure 4 shows the numbers of deaths for each age group with the virus for the three 6-month periods.

The first U.S. COVID-19 vaccine, Pfizer/BioNTech Comirnaty, approved for emergency use authorization on December 11, 2020. In late December, Arizona began to administer vaccines. During Reopening Phase 3 (March 5, 2021 to September 7, 2022), there were 10,451,502 vaccine doses administered, and 3,813,974 fully vaccinated against the virus. Figure 5 shows the numbers of COVID-19 vaccines that were given in Arizona (persons fully vaccinated, persons receiving at least one dose, and total doses given) during the 18 months.

Initially, there were three vaccines available (Pfizer/BioNTech Comirnaty, Moderna Spikevax, and Johnson&Johnson Jcovden). Novavax Nuvaxivud became the fourth vaccine available in July 2022. The vaccines provided different levels of protection against COVID-19 and its variants. Those 65 years and older had the highest vaccination percentage, while those under 20 years of age had the lowest (Figure 6). It was expected the vaccination rates for this age group will increase with the approval of younger children vaccines use.

fig 3

Figure 3: Arizona Reopening Phase 3 Hospitalized COVID-19 Cases by Age Groups for Three 6-Month Periods.
Source: Arizona Department of Health Services Hospitalized COVID-19 Cases by Age Groups Statistics.

fig 4

Figure 4: Arizona Reopening Phase 3 COVID-19 Deaths by Age Groups for Three 6-Month Periods.
Source: Arizona Department of Health Services COVID-19 Deaths by Age Groups Statistics.

fig 5

Figure 5: Arizona Reopening Phase 3 COVID-19 Vaccination Numbers: March 5, 2021 to September 7, 2022.
Source: Arizona Department of Health Services COVID-19 Vaccination Statistics.

fig 6

Figure 6: Arizona COVID-19 Vaccination Percentages (at least one dose) by Age Groups on September 7, 2022.
Source: Arizona Department of Health Services COVID-19 Vaccinations by Age Group Statistics.

Discussion

The Arizona Governor began Reopening Phase 3 (final phase of reopening) after the state had administered more than two million vaccine doses and several weeks of declining cases on March 5, 2021 [9,10]. The state continued its efforts to vaccinate its population. The number of vaccine dosages administered had increase from 2,016,512 on March 5, 2021 to 12,468,014 on September 7, 2022. Sixty-two percent (4,525,048) of the state population were fully vaccinated. The largest numbers of fully vaccinated persons occurred in the week of April 17 to 23, 2021 (249,755) [9,10]. The pace of vaccination began to slow down in June.

Arizona case numbers had decreased in the spring and early summer 2021. At the end of June, the Arizona State Legislature and Governor had rescinded many of the state COVID-19 restrictions. The state used a three-pronged attack against the virus: (1) encourage preventive health behaviors, (2) increase vaccination numbers, and (3) use therapeutics. During the month of July, the highly contagious Delta variant appeared in the state and began the summer surge. Even with the increase vaccination efforts and other actions, they were not enough to stop the Delta variant. This resulted in the fall surge.

In December, the more contagious Omicron variant appeared in the state and began to surge. The Omicron variant surge in January 2022, and the cases remained high into early March. For more than two months in the spring, the cases were low. The state cases rose at the end May as the Omicron variants moved westward in the U.S. and began the summer surge. By late August, the cases declined.

It has been more than 32 months since the first COVID-19 cases appeared in Arizona on January 22, 2020; the state has not returned to pre-pandemic normal of zero cases and no face mask wearing. Most health facilities require both medical staff and patients wear masks. Many businesses require their staff wear masks and masking wearing is optional for customers, and they still have their virus protective glass/plastic barriers. There are signs of the public experiencing COVID fatigue (e.g., significant numbers did not wear masks during summer 2022 case surge and did not pay attention to the daily/weekly number of case increases).

Many still have anxiety/depression/stress associated with the virus. The causes for the mental anguish are the uncertainty of the virus, constant emergent of new variants, vaccine limitations, the lack control of the situation, and no end to the virus. There are persons who have not adapt to the new normal and have limited their interactions with people.

Overtime, the vaccines are not as effective against the later variants (Delta and Omicron) and Omicron subvariants as the original Alpha – breakthrough infections and wane over time. Even though the vaccines and their boosters reduce the risks in getting a severe case, one can still can get the virus. There has been very little increase in the vaccination rate in the last six months — the number of fully vaccinated percent increased only by 2.9 percent.

The Food and Drug Administration has approved both Pfizer and Moderna new bivalent COVID-19 vaccines that are effective against both the original virus and Omicron BA.4 and BA.5 variants on August 31, 2022. With the new vaccines, it is expected the vaccination rates will rise; the population immunity level will be high enough to keep the winter case surge lower than last year; and the state will move the closer to returning back pre-pandemic normal.

Conclusion

The vaccines, most of the Omicron variant cases are mild or moderate, and therapeutics have kept the number of hospitalizations and deaths low. Even with the occasion case surges, the state new normal are low number of severe cases, manageable hospitalization numbers, and low number of deaths.

References

  1. Johns Hopkins University Coronavirus Resource Center, https://coronavirus.jhu.edu/.
  2. Deliso, Meredith. “Arizona ‘hottest hot spot’ for COVID-19 as health officials warn of hospital strain: The state has the highest infections per capita globally, based on JHU data, ABC News, January 7, 2021, https://abcnews.go.com/US/arizona-hottest-hot-spot-covid-19-health-officials/story?id=75062175.
  3. Chow, Denise and Joe Murphy. These three states have the worst Covid infection rates of anywhere in the world: Arizona currently has the highest per capita rate of new Covid-19 infections, with 785 cases per 100,000 people over the past seven days, followed closely by California and Rhode Island, NBC News, January 5, 2021 and updated on January 7, 2021, https://www.nbcnews.com/science/science-news/these-three-states-have-worst-covid-infection-rates-anywhere-world-n1252861.
  4. Britannica, Arizona state, United States, https://www.britannica.com/place/Arizona-state.
  5. My Life Elsewhere, Arizona is around the same size as Italy, https://www.mylifeelsewhere.com/country-size-comparison/arizona-usa/italy.
  6. United States Census Bureau, Quick Facts, https://www.census.gov/quickfacts/AZ.
  7. Eng H (2020) Arizona and COVID-19. Medical and Clinical Research 5: 175-178.
  8. Eng H (2021) Arizona Reopening Phase 2: Rise and Fall of COVID-19 Cases. Medical and Clinical Research 6: 114-118.
  9. Eng H (2021) Arizona Reopening Phase 3 and COVID-19: Returning to Normal. Medical and Clinical Research 6: 687-669.
  10. Eng H (2022) Arizona Reopening Phase 3 and COVID-19: One Year Later. Journal of Clinical Research and Medicine 5: 1-7.

Anxiety, Stress, Depression among School Going Adolescents in Bareilly City: A Cross Sectional Study

DOI: 10.31038/PSC.2022221

Abstract

Context: Depressive disorders often start at a young age. There is a need for early identification of depression, anxiety, and stress (DAS) and prevention. The present study was undertaken to find the magnitude of DAS among adolescents.

Aims: To find the mental health status of school going adolescents in Chandigarh. The objectives were (i) to study the prevalence of DAS among school going adolescents and (ii) to study the correlates of DAS. Settings and Design: A Cross‑sectional survey of students of four classes from 9th to 12th studying in government schools.

Subjects and Methods: Ten government schools in Bareilly City were randomly selected through lottery method. In each school, for each of the four classes, a section was randomly selected again by the lottery method. Forty students were selected from each school reaching sample size of 470. DAS scale 21 questionnaires were used.

Statistical Analysis Used: The data entry was done in MS Office Excel 2007. The analysis was done in the form of frequency tables, charts cross tables. For statistical significance, Chi‑square test and correlation was found between various factors.

Results: The prevalence of DAS was 65.53%, 80.85%, and 47.02%, respectively. Overall, comorbidity between depression and anxiety was 57.65%. Extremely severe depression was very less (3%). The prevalence of DAS was higher in females. For depression and anxiety, the peak age was 18 years. Conclusions: The prevalence of DAS was high among school going adolescents in Bareilly City. There is a need for early and effective identification of DAS that can prevent many psychiatric disorders at their nascent stage.

Keywords

Adolescent, Depression, Anxiety, Stress, Bareilly City

Introduction

Mental illnesses account for a significant share of the disease burden in all civilizations. Depression, anxiety, and stress are among the most common causes of illness and disability in children. Teenagers are predisposed to a range of mental health difficulties due to the physical, psychological, and behavioral variations during this time. Poor academic performance, lack of communication with friends and family members, substance misuse, feelings of abandonment, homicidal thoughts, and suicide ideation are all signs of these three diseases [1,2].

For at least two weeks, depression is defined by persistent unhappiness and a loss of interest in activities that you generally love, as well as incapacity to function in everyday life. Anxiety is a sensation of tension accompanied by concerned thoughts and bodily changes such as elevated blood pressure. Anxiety disorders are characterized by recurrent intrusive thoughts or concerns.

Nearly 20% of children suffer from a diagnosable mental illness. In addition, numerous mental health illnesses emerge during adolescence. Before reaching adulthood, between 20-30% of children will experience at least one significant depressive episode. For a quarter of people, mood disorders such as depression first appear throughout adolescence. Anxiety disorders and impulse control disorders (such as conduct disorder or attention deficit/hyperactivity disorder) affect 50-75 percent of adolescents during their adolescence. As children enter puberty, existing mental health issues become more complex and acute. Adolescents with untreated mental health issues are more likely to perform poorly in school, drop out, have strained family connections, abuse substances, and engage in risky sexual practices [3].

Being away from home, grade, stream of study, academic performance and examination-related concerns, and cyber bullying have all been connected to depression in previous studies. According to earlier studies, sex, grade level of pupils, and kind of school (public or private), family type, not living with parents, educational level of parents, and high academic stress were all factors of anxiety.

Globally, depression is one of the leading causes of illness and disability. Even in developed nation’s depression is a known health burden among children, adolescents, and adults. One in four children in the age group of 13-15 years in India suffers from depression, which affects 86 million people in the South-East Asia region, the World Health Organization. In adolescents, major depression is projected to rank second-most cause of human illness by the year 2020 [4,5].

To battle the burden of juvenile mental health concerns, researchers must investigate the extent and risk factors of symptoms of depression, anxiety, and stress. Nevertheless, anxiety and depression in early teens commonly go undetected and untreated, particularly in developing countries like India, due to limited access to psychological and psychiatric care as well as the enormous societal stigma regarding mental health concerns. Keeping these points in mind, an attempt will be made to assess the depression, anxiety and stress among school students in Bareilly City, Uttar Pradesh.

Materials and Methods

The A cross sectional research was carried out among school students in Bareilly city from February 2022 – April 2022. The study was approved by the Institutional Review Board, Institute of Dental Sciences, Bareilly. Prior beginning the research, the production lines head provided written approval for it to be carried out there. Sample size has been scientifically estimated using G Power V 3.1 Software which yielded a minimum sample size of 470 School students. School students who were aged 10-19 years and whose parents will give consent to allow their children to participate were included in the study. School going children whose parents are not willing to give consent and who are likely to take transfer during the study period and those who did not want to take part in this research were eliminated. Multistage sampling technique was used for all the study units until the required sample size is attained.

The complete information about the study will be informed to the participants as mentioned in the participant information sheet. Signed informed consent form will be obtained from all the participating subjects after explaining the complete procedure in their vernacular language. A pre-designed semi-structured, self-administered questionnaire was used to assess socio-demographic profile like age, gender, religion etc. and associated factors like pressure to perform, relations with parents etc. Depression anxiety stress scale (DASS)-21 was used to detect depression, anxiety and stress.

Statistical Analysis

Data was entered on Microsoft excel software and statistical analysis was done using a licensed version of SPSS 21. Descriptive analysis was done by calculating proportions, means and standard deviation.

Results

Out of 470 students, the maximum number of students participating in study was from 9th class (28.72%), and minimum number of students was from 12th class (22.76%). There were 257 male (54.68%) and 213 female (45.31%) participants in the study. The maximum number of students were from the age group of 16 years, i.e., 180 (38.29%) and minimum from the age group of 19 years, i.e., 3 (0.63%) students. Table 1 shows gender‑wise distribution of participants having DAS. Table 2 shows that overall comorbidity between all three disorders, i.e., DAS was 36.1%. Distribution of participant and 12th class having the DAS is shown in Table 3. On comparison of DAS among participants of 9th, 10th, 11th, 12th classes, it can be seen that depression was higher in 12th class, anxiety was higher in 10th class, and stress was higher in 9th class. While comparing DAS among participant of nonboard (9th + 11th) and board classes (10th + 12th), it was found that it was higher in board classes than in nonboard classes. It was found that all types of depression (75.59%) and stress (53.52%) were higher in board classes than of nonboard classes (57.2% and 41.63%,respectively).Among students of classes 11th and 12th, according to their stream, it was found that depression and anxiety were maximum in medical students (78.57%), and stress was more in commerce students (48.89%). It was found that extremely severe depression was highest among medical students (03.57%); mild depression was also more in them (28.57%). Moderate depression was more in arts students (43.42%). Extremely severe (17.10%) and moderate anxiety (27.63%) were higher in arts students. Mild anxiety was higher in medical students (42.86%). Severe anxiety was higher in commerce students (16.67%). Extremely severe stress was present only in commerce students (01.11%); severe stress was higher in nonmedical students (60.71%). Mild stress was higher in arts students (35.53%).

Table 1: Gender wise distribution of participants having depression, anxiety, and stress (n=470)

Gender

Number of students

Prevalence of DAS (%)

Males

257

85 (33.07)

Females

213

85 (39.9)

DAS: Depression, anxiety and stress

Table 2: Comorbidity between different disorders (n=470)

Comorbidity

n (%)

Overall

170 (36.17)

Depression and anxiety

271 (57.65)

Depression and stress

144 (40)

Stress and anxiety

200 (50)

Table 3: Distribution of participants of 9th, 10th, 11th and 12th class having the depression, anxiety, and stress (n=470)

Students of class

DAS Normal (%) Mild (%) Moderate (%) Severe (%)

Extremely severe (%)

Class 9th (n=135) Depression

55 (40.74)

21 (15.56) 40 (29.63) 14 (10.37)

5 (3.7)

  Anxiety

37 (27.41)

31 (22.96) 52 (38.52) 14 (10.37)

1 (0.74)

  Stress

32 (23.7)

37 (27.41) 51 (37.78) 9 (06.67)

6 (4.44)

Class 10th (n=106) Depression

28 (26.42)

27 (25.47) 32 (30.19) 14 (13.21)

5 (4.72)

  Anxiety

18 (16.96)

21 (19.81) 39 (36.79) 15 (14.15)

13 (12.26)

  Stress

50 (47.17)

30 (28.30) 10 (09.43) 15 (14.15)

1 (0.94)

Class 11th (n=122) Depression

55 (45.08)

20 (16.39) 34 (27.87) 12 (09.84)

1 (0.82)

  Anxiety

27 (22.13)

36 (29.51) 26 (21.31) 21 (17.21)

12 (09.84)

  Stress

72 (59.02)

29 (23.77) 11 (09.02) 9 (07.38)

1 (0.82)

Class 12th (n=107) Depression

25 (23.30)

23 (21.36) 43 (40.78) 12 (11.65)

4 (02.91)

  Anxiety

21 (19.42)

29 (27.18) 25 (23.30) 12 (11.65)

20 (18.45)

  Stress

49 (45.63)

40 (37.86) 6 (05.83) 12 (10.68)

0

DAS: Depression, anxiety and stress            

Self-satisfaction with academic performances in participants with DAS was 67.08%, 86.07%, and 40.5%, respectively whereas the parent’s satisfaction with academic performances of their wards with DAS was 66.86%, 80.47%, and 43.19%, respectively. Poor socioeconomic conditions and father’s occupation (nonworking) were directly related with higher level of DAS. With increase in the education level of parents, level of DAS in their children decreased. As the parents love decreased, level of depression and stress in the participants increased. DAS was found to be more among students whose mothers were not alive. The level of anxiety was found higher in the participants belonging to the joint families. Students staying away from home in hostels and paying guest accommodations had higher levels of depression and stress. It was found that the prevalence of depression and stress was more in students who were bullied by batch mates. It was also found that the prevalence of DAS was more in students who felt overburdened with test schedules. The level of stress was higher among the participants who were not self‑satisfied with their academic performance and whose parents were not satisfied. Participants, who took alcohol and smoked, showed higher prevalence of DAS.

Discussion

In our study, we found that the prevalence of DAS was more in students who feel overburdened with test schedules. The level of stress was higher among the participants who were not self‑satisfied with their academic performance and whose parents not satisfied. Similar results have been reported by other studies, namely, Kaur and Sharma, Moreira and Furegato, Liu and Lu and Gray-Stanley et al. [6-12].

A study done by Deb et al. revealed that 63.5% of the higher secondary students in Kolkata experience academic stress, and the parental pressure for better academic performance was found to be mostly responsible for academic stress as reported by 66.0% of the students. It was found that the prevalence of DAS was higher in females than in males. The study by Kaur and Sharma in Chandigarh also found that girls were more academically frustrated than the boys. The study conducted in Bengaluru by Sharma and Kirmani found that girls had higher scores on beck depression inventory than boys. A comprehensive review of almost all general population studies conducted to date in the United [13,14].

States of America, Puerto Rico, Canada, France, Iceland, Taiwan, Korea, Germany, and Hong Kong reported that young women predominated over men in lifetime prevalence rates of major depression. In India, similar findings were obtained by Verma et al. Academic stress is a type of stress that arises due to academic factors such as heavy school schedule, unrealistic expectation and demands of parents and teachers, low academic performance, poor study habits, and not having enough time to deal with school’s multiple priorities. Academic stress is recognized as a risk factor for depression and suicidal behavior. The experience of school-related stress such as poor academic performance, negative feedback from parents and teachers about school work; daily hassles in the school environment, stressful life events, and negative affect states during school work were all leads to increase in depression. Poor academic grades generally predict high educational stress; the discrepancy between expected and actual grades may play a more important role in the development of psychological distress and other mental health problems [15-20].

In our study, DAS increases as the intake of alcohol increases. Higher DAS was found among those who drink alcohol and those who were occasional smokers. Severe depression and extremely severe stress were more in males as compared to females. A study done in Chennai in 1986 revealed that 23.25% had contemplated suicide earlier and that 91.9% of them were aged 30 years or less. A strong association of suicidal tendency with alcohol was reported in 10.42% of the sample. The suicide rate was more in males as compared to females. It might be due to the reason that males are not emotionally very strong as compared to females and shared less of their problems as compared to female.

The prevalence of DAS increases as the parents love decreases, lack of parental affection takes toil on mental peace of children. In a review done by Zgambo, et al. in 2012, it was seen that children and adolescents who live without parents exhibit higher levels of depressive symptoms than those who live with parents around them. Depression is decreased by higher levels of parental care and lower levels of parental indifference. Greenberger et al. stipulate that strong positive family relationships lessen the symptoms of depression. Many other factors, such as loss of loved ones, conflicts with parents, teachers, and peers, and significant physical diseases may have important effects on adolescent suicidality.In our study, as the level of parent’s education increases, the level of prevalence DAS among adolescents decreases. There is a direct relation between the parents’ mental health and their children’s health.

A cross-sectional study by Olfson et al. in 2003, on parental depression and child mental health reported that children of parents with depression were approximately twice as likely as children of parents without depression to have a variety of mental health problem. The prevalence of depression and stress was more among the participants who were bullied by their batch mates or seniors. According to the study conducted by Khawaja et al. in 2015 in Pakistan showed that physical abuse (P = 0.05), verbal abuse (P = 0.003), injury (P = 0.02), and bullying (P < 0.001) were significantly associated with psychological stress.

As the age increases, the prevalence of DAS was also found to be increasing. The peak of the prevalence of depression was in the 18th year of age. Tepper et al. argue that depressive symptoms do not differ between boys and girls but intensify with age. This trend of increasing DAS may be due to different social and developmental challenges faced by teens. In our study, depression and stress were prevalent in participants who belong to poor families. Direct and indirect effects of relative poverty had bad effect on the development of emotional, behavior, and psychiatric problems. Poverty has multidimensional phenomenon, encompassing inability to satisfy basic needs, lack of control over resources, lack of education and poor health [21-28].

Conclusion

According to study, the overall prevalence of DAS among school going adolescents in Chandigarh was high. DAS in this population have been shown to be associated with increased risk of suicidal behavior, homicidal ideation, tobacco use, and other substance use. The burden of mental disorder is great as they are prevalent in all societies. They create a substantial burden for affected individuals and their families and produce significant economic and social hardships that affect society as a whole.

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What is the Status of Female Adolescent Depression in India and How is it Affecting the Modern Society

DOI: 10.31038/ASMHS.2022662

 

Adolescence is marked by dramatic developmental changes in physical, cognitive, and social-emotional capacities [1]. However, this is also a period which is beset by a number of challenges. For instance, engagement risk behaviours are more common among adolescents. Engagement in risk behaviours may pose a significant threat to health if involvement spans multiple behaviours. The asset model suggests that contextual aspects of young people’s lives, such as factors related to family, school and community, serve as a protective function against health risk behaviours [2]. Even though most adolescents are able to cope with such dramatic changes a large number of them encounter problems and difficulties caused by such changes. If they are unable to cope with stress caused by these changes, they may develop mental health problems, especially depression [3].

Moreover, abnormalities of social adjustment are detectable in childhood in some people who develop psychotic illness. Sex and the rate of development of different components of the capacity for social interaction are important determinants of the risk of psychosis and other psychiatric disorders in adulthood [4].

While the link between positive ageing and the perception of loneliness has been well-established [5], it is also well-known that psychological distress during adolescent period of the life span is common experience that may be due to the innumerable changes adolescents face [6]. As early as age 11, young adolescents begin to form their self-concept and must cope with increasing expectations from parents, peers, school, and society [7]. The intersection of these experiences, couple with other environmental stressors, can result in elevated distress, such as anxiety and depression [8]. These stressors are sometimes manifested in academic performance, such as reading abilities [9].

A study [10] defines depression in cognitive terms. It is based on the underlying theoretical assumption that the affection and behaviour of an individual are determined in great measure by the way an individual structures the world. His cognitions are based on attitudes and assumptions developed from previous experiences. The cognitive model states that there are specific concepts to explain the psychological substrata of depression: cognitive triad, schemas, and cognitive errors.

The cognitive triad consists of three main cognitive patterns: (a) patients view themselves negatively; (b) they interrupt their experiences negatively; and, (c) they have a negative view of the future. The second component of the cognitive model is the structural organisation of thought which Beck called schema. Schemas are relatively stable cognitive patterns that constitute model. [10] argue that a schematic interpretation always mediates between experience and emotional responses. A person’s negative and distorted cognition in a concrete situation are considered errors in the processing of the information, which are also called “automatic thoughts”. [11] offers a complementary perspective by proposing that adverse interactions with primary caregivers lead children to form negative internal working models of themselves and others. These insecurely attached individuals are likely to believe that they are unworthy of care and that others are unavailable and unpredictable.

[12] argued that cognitive distortion, that is the tendency to construe or distort the significance of events in a way that is consistent with a negative view of the self, the environment, and the future, all play a central role in the development and maintenance of depression. In one study it has been argued that depressive symptoms were differentially related to eating concerns and depressive symptoms may give clues as to which aspects of shame are important in each of the two types of pathology [13]. This emphasise the notion that cognitive distortions are likely to lead to depression in adolescents and the chances are further maximised if they have faulty relationships with their parents.

Adolescence is a period when fitting and connecting with others are highly valued; thus, interpersonal conflicts in close relationships can lead to even greater anxiety and depression levels [14]. Vast amounts of literature highlight adolescents’ need for a sense of belongingness and the importance it plays in their daily relationship. As per the hierarchy attachment model, adolescent–mother attachment outweighed adolescent–father attachment to some extent in predicting adolescents’ perceived social interrelationship measures. As per the integration attachment model, significant differences emerged on most social interrelationship measures between the 4 distinct subgroups: secure attachment to both parents, neither, only father, only mother [15]. Adolescence is a time of change, growth and all too often, struggle. It is a period where an individual could potentially have a notable experience of self-compassion [16].

[17] found that depressed youths were subject to harsher and less consistent parenting, as reported by both the child and the parent, compared to youths who were not depressed. Using data collected as part of the National Longitudinal Survey of Youth, it has been revealed that mother’s use of physical punishment predicted children’s depressive symptoms [18]. Also, Domestic violence negatively impacted children’s behaviour with their mothers in interactions but did not influence maternal report of problem behaviours, suggesting that the impact of domestic violence begins very early and in the realm of relationships rather than in mental health [19].

While prior work has theorised that certain populations may be at increased psychological vulnerability from intimate partner violence (IPV), recent findings indicate that both perpetration and victimisation are associated with increases in depressive symptoms for both men and women, and irrespective of whether IPV exposure occurred in adolescence or young adulthood. Cumulative exposure to IPV does not appear to increase depressive symptoms beyond the effect observed for the most recent IPV exposure, but physical maltreatment by a parent does appear to diminish the association between IPV perpetration and depressive symptoms for a small subset of the sample [20].

Interaction between parents and children are determining the quality of parent-child relationship. Negative interactions in a family can lead to blame game. Adolescents may blame their aggressive and depressive behaviours on their parents’ rejecting attitudes, and parents may excuse their rejecting attitudes on their children’s behaviours. But instead of blame, perhaps it is more a question of dysfunctional interactions that are self-perpetuating, negativity begetting negativity as it were.

Few studies have examined both maternal and paternal parenting practices in the prediction of child outcomes despite evidence that underscores the salience of fathers throughout their children’s development. This study examined the role of the quality of mother–child and father–child relationships in buffering the influence of ineffective parenting practices on subsequent adolescent aggression. Measures of parental psychological control, the quality of the parent–child relationship, and youth aggressive behavior were completed by 163 (49% female) mostly White and Asian adolescents and their parents during the eighth and ninth grades. Paternal psychological control predicted aggression when adolescents perceived low-quality relationships with their mothers. Similarly, maternal psychological control predicted aggression when adolescents perceived low-quality relationships with their fathers. Maternal psychological control was also associated with lower levels of aggression among adolescent males who reported a high-quality relationship with their father. These findings indicate that, when one parent exerts psychological control, the low-quality relationship the adolescent shares with the opposite gender parent increases risk for adolescent aggression. The findings also suggest that, as mothers exert psychological control, the high-quality parent–child relationship a son shares with his father decreases risk for adolescent aggression [21].

The Revelence of the Study

The study sought to identify the role of cognitive distortion and parental bonding in depressive symptoms among Fe male adolescents in rural India. The study also aims to ascertain the extent to which parent-child relationship, specifically father care and mother care; and, father overprotection and mother overprotection differ in the way they contribute to depressive symptoms of adolescents [22].

Materials and Methods

A total of 150Fe male adolescents aged 18-19 were drawn through random sampling. The educational institution was randomly selected from a list of higher educational institutions in India. The subject chosen for the study were also randomly selected from a class of 40-50 students.

All tests were administered in the group of 20-30 students. Stepwise multiple regression analysis was carried out to ascertain the contribution of cognitive distortion (self-criticism, self-blame, helplessness, hopelessness and preoccupation with danger); parent-child relationship (mother care, mother overprotection, father care, father overprotection) towards depressive symptoms.

Survey Instrument

Reynolds Adolescent Depression Scale (RADS-2) was developed by [23] to measure the severity of depressive symptoms in adolescents in clinical settings. The RADS-2 is a brief, 30-item self-report measure that includes subscales which evaluate the current level of an adolescent’s depressive symptoms along four basic dimensions of depression: (1) dysphoric mood; (2) anhedonia; (3) negative self-evaluation; and, (4) somatic complaints. In addition to the four subscale scores, the RADS-2 yields a depression total score that represents the overall severity of depressive symptoms. The reliability and validity of the test is well-established with internal consistency of 0.86, test-retest of 0.80, and validity criterion of 0.83.

Cognitive Distortion Scales (CDS) was developed by [23]. It measures distorted or negative cognitions and consists of 40 items. Each symptom item is rated according to its frequency of occurrence over the preceding month; using a five-point scale range from never to very often. The five subscales are self-criticism, self-blame, helplessness, hopelessness, and preoccupation with danger. The score on each dimension can be added to 9, which is the total score. The reliability and validity of the test is well-established, with reliability of 0.89 and validity of 0.94.

Parental Bonding Instrument (PBI) was developed by [24]. PBI is a 25-item instrument designed to assess the children’s perception to parent-child relationship in terms of parental behaviours and attitudes. The authors identified two variables that are important in developing parent-child bonding: (1) care and, (2) overprotection. Out of 25 items, 12 items measure children’s perception of their parents as caring with the opposite end of the spectrum being indifference or rejection, the remaining 13 items assess children’s overprotectiveness with the extreme opposite  being encouragement and independence. The care subscale allows maximum of 36 and overprotection a score of 39. The scale yields information on four dimensions, namely: mother care, father care, mother overprotection, and father overprotection. The participants’ responses are scored on a four-point scale ranging from “very likely” to “very unlikely”. Some of the items are reverse scored. The PBI demonstrated high internal consistency with split-half reliability coefficients of 0.88 for care and 0.74 for overprotection. The instrument shows good concurrent validity and correlated significantly well with independently rated judgement of parental care and overprotection.

Analysis

Stepwise multiple regression analysis was carried out to identify the level of variance in dependent variable that could be accounted by the different variables (cognitive distortion dimensions and parent-child relationship dimensions) and the impact of each dependent variable. Total depression scores generated from RADS-2 were taken as the criterion.

Interpretation and Discussion

As can be gleaned from Table 1, the highest positively contributing dimension is self-criticism (β=0.60) which was followed by helplessness (β=0.34), preoccupation with danger (β=0.22), self-blame (0.14), and father overprotection (β=0.10). Whereas, father care dimension of parent-child relationship was contributing negatively towards adolescent depression (β=0.10).

Table 1: Stepwise Multiple Regression Analysis for Adolescent Depression

 

R

R2

R2 Δ

P

β

P

Self-criticism

0.60

0.36

0.36

0

0.60

<0.01

Helplessness

0.67

0.44

0.08

0

0.34

<0.01

Preoccupation with danger

0.68

0.47

0.03

0

0.22

<0.01

Father overprotection

0.69

0.48

0.01

0

0.10

<0.01

Father care

0.70

0.49

0.01

0

0.10

<0.01

Self-blame

0.71

0.50

0.01

0

0.14

<0.01

Table 1 further suggests that various cognitive distortion dimensions are also contributing towards depression in adolescents. It has been reported that self-reported exposure to stressful life events was associated longitudinally with increased engagement in rumination. In addition, rumination mediated the longitudinal relationship between self-reported stressors and symptoms of anxiety in both samples and the relationship between self-reported life events and symptoms of depression in the adult sample. Identifying the psychological and neurobiological mechanisms that explain a greater propensity for rumination following stressors remains an important goal for future research. This study provides novel evidence for the role of stressful life events in shaping characteristic responses to distress, specifically engagement in rumination, highlighting potentially useful targets for interventions aimed at preventing the onset of depression and anxiety [25].

According to Blatt and others (e.g., A. T. Beck), self-definition, or one’s sense of self and one’s sense of relatedness to others represent core lifespan developmental tasks. This study examined the role of events pertaining to self-definition or relatedness in the development of personality traits from each domain (self-criticism and dependency), and their relationship to the development of depressive and anxiety symptoms. Two hundred seventy-six early adolescents completed a measure of self-criticism and dependency at baseline and again 24 months later, along with measures of depressive and anxiety symptoms. Every three months, participants completed a measure of life events, which were coded as self-definitional or relatedness oriented (80% rater agreement, kappa = .70). Structural equation models showed that self-definitional events predicted increases in self-criticism, which in turn predicted increases in depressive symptoms, whereas relatedness events predicted increases in dependency, although dependency was unrelated to change in symptoms [26].

One study [27] has suggested that early intervention with mother–child dyads during this developmental period may promote more adaptive attachment behaviours that could subsequently change the developmental trajectory of these “at-risk” children. Moreover, a special focus might be on improving mother–child interactions, as we know now that disorganised children are likely to have interactions that are characterised by role reversal. In addition, these findings point to the need to work with mothers to help them with their roles as parents to prevent caregiving helplessness, which we know now, along with role reversal, plays an important role in explaining the association between disorganised/controlling attachments and externalising problems in adolescence. These findings will be important for future prevention and intervention efforts.

Conclusion

Preoccupation with danger (β=0.22) as dimension of cognitive distortion is contributing positively towards adolescent depression. Self-blame (β=0.71) as dimension of cognitive distortion is contributing positively towards adolescent depression. It seems that adolescents give up against the problem and they have no way of dealing with the depression. Depressed adolescents appear to have predominantly cognitive symptoms with negative thought processes such as feelings of self-blame, self-hate, punishment, dissatisfaction and failure. Moreover, because of the digital age, adolescent are facing more stressors. For instance, smartphone ownership was related to more electronic media use in bed before sleep, particularly calling/sending messages and spending time online compared to adolescents with a conventional mobile phone. Smartphone ownership was also related to later bedtimes while it was unrelated to sleep disturbance and symptoms of depression. Sleep disturbance partially mediated the relationship between electronic media use in bed before sleep and symptoms of depression. Electronic media use was negatively related with sleep duration and positively with sleep difficulties, which in turn were related to depressive symptoms. Sleep difficulties were the more important mediator than sleep duration. The results of this study suggest that adolescents might benefit from education regarding sleep hygiene and the risks of electronic media use at night [28].

Previous works show that eliminating these distortions and negative thoughts is said to improve mood and discourage maladies such as depression and chronic anxiety. The process of learning to refute these distortions is knows and “cognitive restructuring”.

Father overprotection (β=0.10) is positively contributing to depression among male adolescents. According to theoretical views, parental overprotection may lead to anxiety by increasing beliefs in dangerousness of the situation and the lack of ability to avoid the danger [29].

Descriptions of parental authority and of the formation of a secure parent-child bond have remained unconnected in conceptualisations about parenting and child development. The parental anchoring function is here presented as an integrative metaphor for the two fields. Parents who fulfil an anchoring function offer a secure relational frame for the child, while also manifesting a stabilising and legitimate kind of authority. The anchoring function enriches the two fields by: (1) adding a dimension of authority to the acknowledged functions of the safe haven and the secure base that are seen as core to a secure parent-child bond, and (2) adding considerations about the parent-child bond to Baumrind’s classical description of authoritative parenting [30-33].

Finding

The main finding suggests that out of cognitive distortion and parent-child relationship dimensions, self-criticism, hopelessness, preoccupation with danger, father overprotection and self-blame are contributing positively towards adolescent depression. Father care is negatively contributing to adolescent depression scores.

Father care plays an important role in the depression among male adolescents. It is clear that parent-child relationship and inaccurate thoughts and ideas are important determinants of depressive symptoms among adolescents. Adolescence is a challenging phase of life. However, healthy parent-child relationship can cushion the effects of ruthless biopsychosocial changes of this period.  Adolescents need to be educated as to how to make healthy appraisals of events and occurrences within and around them and a healthy parent-child relationship can ensure better psychological health in adolescents.

Limitations and Future Directions

Although the current investigation provides useful insight for understanding depression which has important implications for dealing positively with the issue of adolescent depression but the study is not free from limitation. The study was only limited to with Fe male adolescents ageing 18-19. Hence, the findings should not be generalised. Moreover, the sample was selected from all the major city of India City which limits the scope for the generalisation of the findings. The focus of the investigation was on studying the relative contribution of subscales of cognitive distortion (self-criticism, self-blame, helplessness, and preoccurance and preoccupation with danger) and the dimensions of parent-child relationship (mother care, mother overprotection, father care, and father overprotection). However, there are many other variables that might contribute towards adolescent depression which might be studies in the future. This finding calls for the improvement of access to adolescent mental health services in rural India.

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Treatment of Methamphetamine Withdrawal with Methylphenidate and Modafinil

DOI: 10.31038/PSYJ.2022443

Abstract

Background: Methamphetamine is globally abused. Like other addictions, methamphetamine abuse is a chronic relapsing disorder requiring for effective treatment and medications to promote the prevention of relapse. Methamphetamine use is accompanied with a state of well-being and also with increased wakefulness, physical activity, concentration and energy. Prolong use results to weight loss, aggression, memory deficits, poor impulse control, low concentration, severe dependency, unstable mood, hallucinations and delusions.

Conclusions: Some studies support the efficacy and safety of methylphenidate and modafinil in the treatment of methamphetamine withdrawal symptoms.

Keywords

Methylphenidate; Modafinil; Methamphetamine withdrawal

Introduction

In the industrialized and modern world, mainly developed countries, the rate of physical and mental diseases is going up therefore, policy makers, health decision makers and research workers have been paying out more consideration, care, concern, and currency to the treatment and direction [1-10] epidemiology, etiology, rate and prevention of mental disorders [11-31].

The most common cause of substance use disorders is psychiatric disease. A significant number of people self-medicate to decrease or improve their mental disorders such as irritability, anxiety, agitation, depression, mania, aggression, exhaustion, insomnia, impotency, and pain. Considering increasing level of mental problems globally, substance use disorders and substance related diseases, especially and mainly stimulants induced disorders have been considered as progressing dilemma [32-71]. At present, outpatient and inpatient referrals of psychiatric problems resulted from substance use and abuse are going up [72-110].

Use of methamphetamine produces a state of well-being accompanied with enhanced energy, wakefulness, and physical activity [1,111]. Repeatedly and extended use results to driven drug abuse, reduced weight, increased aggression, violence, memory deficits, poor impulse control, low concentration, prolonged health consequences, severe dependency, unstable mood and affect, delusions and hallucinations [112,113]. Methamphetamine is universally abused. In the United States, 18 million people over age 12 have experienced methamphetamine in their lives [112]. Similar to other addictions, methamphetamine abuse is a chronic relapsing disorder requiring for effective medications to promote the prevention of relapse.In Iran, in the past years, methamphetamine was illegally smuggled in from other countries mainly the West, but at the present time it is illegally synthesized and provided here in ‘underground’ laboratories. We should mention that the methamphetamine illegally synthesized in Iran is much more powerful and harmful and also is frequently associated with psychosis [114,115].

Following use of methamphetamine, cocaine  andalcohol, dopamine discharged into the nucleus accumbens and prefrontal cortex strengthen alcohol, cocaine, and methamphetamine seeking behaviors [116-120].

Presently there is not any approved medication for the treatment of methamphetamine withdrawal symptoms. Although administration of methylphenidate and modafinil is for the treatment of ADHD and narcolepsy [1] however, we are prescribing them for the management and treatment of severe methamphetamine withdrawal craving; because we theorize that (our rationale) biochemistry involved in the use of modafinil, methamphetamine and methylphenidate is more or less the same (all of them raise the level of dopamine [114-123]. We suggest more research studies and clinical trials that demonstrates data collected from comparing of modafinil and methylphenidate in the treatment or reduction of methamphetamine withdrawal symptoms.

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Three Losses: A Mind Genomics Exploration of Messages Which Drive Anxiety

DOI: 10.31038/ASMHS.2022661

Abstract

Three studies explored how systematically designed combinations of messages drive the subjective estimation of anxiety. The topics were loss of assets, loss of income, and loss of health, respectively. Respondents evaluated unique sets of 60 vignettes comprising 2-4 messages from a pre-selected set of 36 messages. Deconstruction of the ratings using ordinary least-squares regression revealed the basic anxiety-provoking potential of the loss (additive constant from the model), as well as the part-worth additional contribution of the particular element (the 36 coefficients). The data matrix was enriched by breaking out the respondents in each study into geo-demographic groups, into groups defined by when they experienced the anxiety. The creation of equations for the key subgroups revealed both differences in basic anxiety from size of the additive constant, as well as differences in the power of specific messages to drive anxiety. The approach using Mind Genomics coupled with a detailed self-profiling questionnaire, provides a new way to create an experimentation-oriented method to understand the mind and anxiety, a method which is fast, inexpensive, iterative, and generates scalable databases.

Introduction

We live in an uncertain world, one filled with dangers, resulting in bad things happening to good people [1] causing anxiety, and eventuating into a source of poetry, prose [2], not to mention words spoken to family, friends, and professional helpers in the field of mental health.

One need only go to Google® or some other source, to get a sense of the pervasiveness of anxiety. Table 1 shows the number of ‘hits’ in Google Scholar®, for the years 1980, 1985, 1990, etc., up to 2020. The topics are anxiety, anxiety about losing one’s assets, anxiety about losing one’s income, and anxiety about losing one’s health, the three major topics dealt with in this paper. Table 1 reveals clear the increase in ‘hits’, show the pervasive interest in anxiety. A reading of this literature will reveal the various aspects, viz., externalities driving anxiety, personal proclivities, and the like. There are numerous references to the physiological correlates of anxiety and situational correlates, along with expected discussions and analyses of personal predilections towards anxiety [3].

Table 1: Number of ‘hits’ in the academic literature pertaining to loss and other personal issues of the topic. Data from Google Scholar®

table 1

Understanding Anxiety from the Vantage Point of Mind Genomics

People are fascinated by the life stories of other people A great deal is known about the everyday, perhaps not always from science, but certainly from inter-personal interactions, as well as from published material. If personal experience is not sufficient, we have at our disposal the whole gamut of literature, the diverse ways of describing daily life, presented in an artistic manner to delight as well as to report. With this introduction, then, to the world of anxiety, what can experimentation contribute that has not been contributed in a far more elegant way by the literature, not to mention the analysis of countless sessions, whether with professionals, or far more frequently, with friends?

Conventional research methods give a sense of the nature of the experience (viz., in-depth interviews and focus groups), the distribution of different variations of th experience (viz., polls and quick surveys), as well as the nature of the world surrounding the experience (viz., behavioral studies, anthropological and sociological studies). Absent, however, is a delineation of the experience in a way which combines qualitative approaches to dive deeply into the topic, and quantitative approaches which provides data that can be used to create a database, and from there extract new insights into the topic.

Mind Genomics is an emerging branch of experimental psychology, with roots in psychophysics, in statistics, and in consumer research. The objective of Mind Genomics is to understand the way we respond to the topics of our daily lives, through systematic experiments about responses to descriptions of the ‘ordinary’ [4]. Mind Genomics quantifies how we respond to the general topics, issues, and specific actions of the everyday. For example, the topic of this paper is anxiety, specifically the anxiety emerging from the possible loss of assets, or income, or health, respectively, all three topics important to people. How can we explore the way people think about the anxiety emerging from the disruption of daily life, specifically disruption one of the three areas, assets, income, or health, respectively. How do we respond? Can we quantify our feelings? Are there different patterns of response?

Mind Genomics grew out of the interest in the way people think. Over the 40 years that Mind Genomics developed, the author was active in the world of psychophysics and perception, the study of how we perceive the outside world. It became increasingly obvious that scientists studying various aspects of ordinary behavior were attempting to bring disciplined evaluation from science into the world of the everyday. Missing, however, was an integrated approach, one that could be applied across many different areas, easy to do, and with the potential to easily, and affordably create a large, searchable database which could tell us about the way people think. The focus of Mind Genomics was not to put individuals into unusual situations and observe reactions to the unusual, but rather study reactions to the far more frequent ‘usual,’ the warp and woof of life usually ignored because it is always in view.

Explicating the Approach by Investigating Three Sources of Anxiety Emerging from ‘Loss’

This paper grew out a set of studies called Deal With It!, designed and executed 20 years ago, in 2002. The studies focused on actual issues driving everyday anxiety. The objective was to understand the relation between descriptions of anxiety-provoking situations, and the stated feeling of anxiety experienced by the respondent, who read the descriptions.

The actual process follows these steps:

Step 1: Select the Topics

The actual Deal with It! study comprised an investigation of 15 different topic areas. The respondent was invited to participate by an email invitation. Pressing the embedded link led to the ‘wall’ of studies shown in Figure 1. The respondent selected the study, and participated in the study. This choice of studies allowed the respondent to select a topic of interest. All 15 studies shown in Figure 1 were run. This paper presents and discusses only the results from three of the 15 studies (loss of assets; loss of income; loss of health, respectively).

fig 1

Figure 1: The Wall showing the 15 ‘Deal With It!’ studies. The respondent chose the study in which to participate.

Step 2: Create the Elements according to a Specific Plan

Mind Genomics works by the approach in experimental psychology known as S-R, stimulus-response. The stimuli are messages (elements), messages that will be later combined in a specified manner described below. It is important to select a representative set of these messages, covering various aspects of the topic. One of the benefits of Mind Genomics is the ability to do small initial experiments to identify promising messages. These preparatory efforts are not discussed here.

The basic structure of elements in a Mind Genomics study comprises a set of questions (categories of ideas), and for each set of questions a limited set of answers. Thus, for the Deal With It! studies presented here the underlying structure comprised the topic (viz., nature of loss), then four questions, and then nine answers for each question. Table 2 shows the underlying structure.

Table 2: Structure underlying the creation of the elements

table 2

It is important to keep in mind that the set of answers should be chosen so that a combination of answers (our elements) generates the rough outline of a ‘story’ when the elements are combined into vignettes, viz., combinations comprising 2-4 elements. Each vignette can comprise at most one answer from each question, or may be absent answers from one or two questions, as dictated by the design.

There are three requirements for the elements listed in Table 2:

  1. The questions should be answered by declarative phrases. These phrases should be as short as possible.
  2. The declarative phrases should paint ‘word’ pictures, even though they are phrases, and not complete sentences. Word pictures are important because they convey idea quickly.
  3. The four sets of answers comprise the same number of answers in each set. This property makes it possible and straightforward to create experimental designs, templates for the vignettes.
  4. The actual elements appear in Table 3. Table 3 shows the full text of the different elements and, to the right side, the abbreviated text for the element which appears in the data tables The top part of Table 3 shows the 13 elements common to all three studies. These elements describe one’s feelings, and general actions from the outside. The bottom part of Table 3 shows the unique elements from each of the three studies. In the interest of brevity and readability the data tables present the abbreviated text.

Table 3: Elements in the three studies

table 3

table 3(2)

table 3(3)

Step 3: Combine the Elements into Unique Sets of 60 Combinations (Vignettes)

Mind Genomics moves away from the traditional and hallowed approach of isolating a variable, and studying that variable thoroughly. The rationale for moving away from the traditional ‘isolate and study’ comes from two realizations.

  1. The reality of our everyday experience is that the experience comprises mixtures of stimuli, not single stimulus in solitude. We could be instructed to pay attention to one stimulus in the mix, and disregard other stimulus, but our mind and our behavior appears to be wired to deal with compound stimuli, with mixtures. The focus on one single aspect is artificial. That focus may work with conventional science, but humans live in a world where they respond most naturally to ever-changing mixtures of stimuli, and NOT to pure stimuli. Pure stimuli are artificial, and the results may fail to mirror what happens in everyday life when stimuli must ‘fight each other’ to gain attention.
  2. When people judge aspects of their everyday life, they typically use a common scale for the different combinations of the same type of stimuli that they encounter. For example, when a person deals with traveling on a road, most roads of the same type are subject to the same judgment criteria. This makes the person’s job easy, and routine, allowing the person to focus on other issues of the moment. However, were each aspect of the travel on the road to be separately evaluated, such as weather, pavement, trees, time of year, etc., it may well turn out that the respondent uses different criteria to judge each aspect, making it impossible to truly compare travel on one street to travel on the other. The plethora of details, abstracted and evaluated one at a time, makes it likely that the respondent will change the criterion for evaluation for each aspect, to make the criterion fit the topic. The researcher might well think that the respondent is using the same criterion for all judgments whereas in actuality the respondent is dynamically changing the criterion to be appropriate for each isolated aspect. There is no way the researcher could know that unless the respondent were to volunteer, but the respondent might not yet know just what criterion had been used for each of the judgments.

Given the foregoing issue, Mind Genomics studies work in a manner more similar to nature, albeit in manner which is carefully choreographed. The test stimuli no longer are single ideas such as those in Table 2. Rather, the test stimuli become combinations of messages which tell a story, or at least have the surface appearance of something which might actually exist. Her is an example for ‘loss of health.’

Diagnosis of uncontrollable disease…

You never expected it to happen to you or someone close to you…

At a turning point in your life…

You trust your God will help you get through this

The respondent does not rate each of the four phrases (elements), but rather reads the combinations, and assigns a single rating to the combination. Although the messages are compounded into one vignette, the respondent usually has no problem assigning a single rating to the combination. The respondent may not consciously know the criteria used to assign the rating, and may feel that she or he guessed, but subsequent analyses show that the respondent’s ratings generate an interpretable pattern, and the pattern points to consistent criteria for judgment.

The actual combinations follow a prescribed grouping, called an experimental design. The experimental designs for Mind Genomics were created with the property that each of 60 vignettes comprised 2-4 elements, that a vignette could be absent elements from one or two questions but not from three questions, and that the 36 elements were statistically independent of each other. A vignette could have at most one element (answer) from any question, ensuring that a vignette would never present to the respondent pairs of elements which contradicted each other.

The final and most important feature was that the experimental design could be permuted [5]. Permutation means that the basic design could be changed, by having the elements vary; for one permutation an element could be assigned to code A1, whereas for another permutation the same element could be assigned to code A3. The permutation allowed the creation of hundreds of alternative designs, all similar mathematically, but with the elements having different codes. The elements remained within their groups, viz., an element in Question A always remained in that group, but its code changed. The permutation generated several hundred equivalent designs. The permutation made it unlikely that two respondents would ever evaluate the same combination of elements. Finally, the permutation allowed the researcher to explore a wide range of combinations, rather than having to ‘know’ the most promising area to assess. It is this ability to assess a wide range of combinations which makes the Mind Genomics processes a tool to explore in the absence of any knowledge whatsoever.

The design was structured so that the set of 60 ratings assigned to the 60 vignettes in that design (one respondent) could be analyzed by OLS (ordinary least-squares) regression.

For each vignette, the respondent was instructed to read the vignette as a complete entity, and rate the combination, using an anchored scale, as shown in Figure 2.

fig 2

Figure 2: The instruction page

Step 4: Create a Detailed Self-profiling Questionnaire

A hallmark of the It! studies was the extensive questionnaire, requiring information from the respondent about WHO the respondent is, WHAT the respondent believes/does, and WHEN the actual participation in the study occurred. Keep in mind that the It! studies were run in the early days of Mind Genomics, around 2000-2004, when the respondents were far more willing to participate in longer studies executed on the Internet. Thus, at that time, there was no issue with adding a few more minutes to the Internet-based interview in order to accommodate the extensive self-profiling questionnaire (Table 4).

Table 4: The self-profiling questionnaire

table 4

Step 5: Run the Studies

The studies were placed on a protected server in the United States, owned by Moskowitz Jacobs, Inc. Respondents in the panel owned by Open Venue, Ltd. Of Toronto, Canada, were invited to participate. These panelists had previously signed up to participate in on-line studies. All respondents lived in the United States, even though the panel provider, Open Venue, was Canadian. Throughout the past two decades, as internet-based research has proliferated, it has become increasingly easy to work with a panel provider in one country, who could source respondents in another country, while the researcher lived in a third country.

Analysis-Transforming Ratings, Creating Individual-level Models, Creating Summary Tables

The data from these studies generate a ‘wall of numbers.’ The easiest way to discover patterns is through a straightforward, four step analysis, which reduces the number of data points to those which are strong. It is a great deal easier to discern patterns with 1-5 strong performing elements (all others not shown) than it is to discern patterns with a number-dense array of 36 data points.

The analysis follows these steps:

  1. At the level of the individual respondent transform the original assigned 9-point rating into a new binary value. Ratings of 1-6 (can deal with it) are transformed to 0. Ratings of 7-9 (cannot deal with it) are transformed to 100. A vanishingly small random number is added to each transformed value, whether the transformation creates a 0 or a 100, respectively. The rationale for transforming the ratings into two numbers comes from the world of consumer research and polling, wherein it is not sufficient to report mean ratings from an anchored Likert Scale, like our 9-point scale, but also necessary to make practical, important decisions using the data. Managers often express discomfort when they work with Likert sales, mainly because they cannot straightforwardly interpret the scales and the statistics. A binary scale moves the result to a yes/no, an all-or-none, something that the managers finds more palatable to help drive action.
  2. At the level of the individual respondent, use the 60 ‘cases’, viz., data from the 60 vignettes (experimental design and transformed rating) to create an equation or a model representing the linear relation between the presence/absence of the 36 elements and the binary value of the transformed rating. The equation is expressed as: Binary Rating = k0 +k1(A1) + k2(A2)…k36(D9)
  3. The foregoing equation expresses the relation between the independent elements, which either appear in a vignette (coded as 1 in the regression analysis), or is absent from the vignette (coded as 0 for the regression analysis).
  4. The additive constant is the estimated proportion or probability of getting a value ‘100’ (viz., original rating of 7-9), in the absence of elements. Of course, by design all vignettes comprise a minimum of two and a maximum of four elements so there cannot be any vignettes without any elements. Nonetheless, the OLS (ordinary least squares) regression estimates the value of k0 for each respondent. We interpret the additive constant as a baseline for anxiety.
  5. The OLS regression now returns with data for each individual respondent. Whereas before we began with raw data comprising 60 rows for each respondent, the OLS regression returns with data comprising one row for each respondent, both a 60-fold reduction, and the source of insights as shown below. We now move to the second stage of analysis, working only with the output of the OLS regression, done at the level of each respondent.
  6. The new data, viz., second data matrix, comprises one row for each respondent. The row contains the study identification, the unique identification number for the respondent, the information about the respondent from the self-profiling questions (see Table 3). Following this information about the study and the respondent are 37 columns, the additive constant and the 36 columns, one column reserved for the coefficient of each element.
  7. We are now ready to create the third data matrix, which will be much simpler. Steps ‘E’ and ‘F’ reduced the data to a manageable format. One last step remains to make the data even easier to understand. We know from statistical analyses that for a coefficient to be ‘statistically significant’ (viz., the coefficient be different from 0), the magnitude of the coefficient for these designs must be approximately 7-9 or higher. Thus can recode each of the 36 coefficients for each respondent. When the original coefficient for a respondent is +10 or higher for an element the element we replace the coefficient by the number ‘100’. When the coefficient is less than 10 for the element (including negative numbers), we replace the coefficient by the number ‘0.’ In this way each respondent generates a series of 36 0’s or 100’s, showing which elements drive anxiety (viz., cannot deal with it.).
  8. Recall that the respondent completed the self-profiling questionnaire. It is straightforward now to sort the set of transformed profiles into groups, based upon the specific question in the-self profiling questionnaire. In turn, the data being sorted comprises the now-transformed profile of 36 coefficients, which are either 100 (original coefficient for the element being 10 or higher), or 0 (original coefficient for the element being lower than 10). Step G above explicated the transformation.
  9. The analysis can now move more quickly, using matrices comprising 0’s and 100’s, instead of a matrix of coefficients as estimated for each respondent (F, above). The final step creates averages for each of the 36 elements, for all respondents from a specified subgroup of individuals. The interpretation of the averages is straightforward. The average transformed coefficient for an element from a specified group of respondents is defined as the proportion of respondents in that group who felt that they just ‘cannot handle’ the anxiety (or other internal feeling), when they read the particular element embedded in a vignette.
  10. Recall that the additive constant can be interpreted as a ‘baseline’ level of anxiety, albeit a derived baseline, emerging from the OLS regression Thus, the average additive constant within a subgroup of respondents can be defined as the likely baseline of anxiety (viz. ‘I cannot deal with it’) for the topic itself for this particular group of respondents.
  11. Finally, the tables for the strong performing elements are deliberately shortened. For the total panel, only those elements are shown which generate an average of 51 or higher (viz., 51% or more of the respondents in the defined group ‘cannot handle it.’) For the key subgroups defined by the self-profiling classification we make the criterion more stringent, with a value of 55 or higher required to appear in the table. This stringent criterion eliminates most of the elements, allowing patterns to emerge more easily.

Total Panel

It is clear from Table 5 that only a few elements perform strongly for the total panel. The strongest performing element, viz. the most anxiety provoking, is ‘You lose your home’ (loss of assets), with a mean of 70% expressing strong anxiety. The only other strong element occurs, ‘You believe your company will help you get through this’ (loss of health), with a mean of 60% expressing strong anxiety. We will see the ongoing recurrence of these two elements as strong drivers of anxiety.

Table 5: Strong performing (viz., anxiety-provoking) elements from the total panel. The coefficients are the percent of respondents in the total panel whose coefficient is 51 or higher.

table 5

When looking at the strong performing elements, it is important to keep in mind that there is no way that the respondents could have ‘gamed the system.’ The respondent evaluated 60 vignettes, each vignette comprising 2-4 elements. Exit interviews with respondents doing these types of studies have, year after year, revealed that most people think they are guessing. Clearly they are not. They are simply responding at a so-called ‘gut level.’ And, the results are no surprise, although it is disconcerting to see the lack of trust of people in business. Yet,the headlines at the time of this writing (summer, 2022) talking about the ‘great resignation’ and the ‘silent resignation.’ People do not trust their employers to help them.

Time of Day When Respondent Participated in the Study

  1. The first question in the self-profiling questionnaire required the respondent to record the time of day. Table 6 shows that there are time-anxiety relationships, mostly in terms of the additive constant (Add Con). When considered as a baseline level of anxiety, the additive constant is lowest in the afternoon (12 PM-6 PM), and much higher in the evening (6 PM-10 PM). Worries about income are highest in the morning, worries about assets and health are lowest in the morning.
  2. In terms of the specific elements, the pattern is difficult to discern, except for one’s worry of the loss of one’s home, which is very frequent at all times of the day, but most frequent when the respondent participates in the late evening and during the morning.

Table 6: Strong performing (viz., anxiety-provoking) elements from respondents participating in the study at four defined time periods of the day. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 6

Immediacy of the Loss

  1. In the self-profiling questionnaire the respondent was instructed to select whether or not the respondent felt that the anxiety-provoking situation was happening or is possibly happening, versus not happening. The response ‘happening yes/maybe’ show different patterns than ‘happening/no.’ The additive constant showing the base level of anxiety for the topic is higher for those reporting ‘happening’ than for those reporting ‘not happening,’ but only for losing assets and for losing income. That is, the basic level of anxiety for monetary loss is higher when it is actually happening. In contrast, the thought of losing one’s health, whether happening or not, shows the same level of anxiety (Table 7).
  2. As one would expect, the specific elements driving strong anxiety responses (viz., ‘can’t deal with it’) differ by type of loss. The strong anxiety is the thought of losing one’s home. That is, 70% of the respondents report strong anxiety, viz., 70% of the respondents show coefficients for this element of +10 or higher.
  3. Finally, the thought of external sources of aid is also anxiety producing, not for losing assets but for losing income (relying on insurance aid causes anxiety), and losing health (relying on charities or on one’s company causes anxiety).

Table 7: Strong performing (viz., anxiety-provoking) elements from respondents who are experiencing the issue vs. respondents who are not experiencing the issue. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 7

Frequency of Occurrence of the Specific Anxiety

  1. Our analysis focuses only on those who report experiencing the anxiety daily.
  2. Lose assets-shows a moderate additive constant. The element which drives anxiety is losing one’s home.
  3. Lose income-a higher additive constant of 47, but no strong performing elements.
  4. Lose health-a moderate additive constant of 41, but three strong performing elements based on ‘outside help’ (company, charities, local hospital), and one strong performing element based on the sickness (lose control of bodily functions) (Table 8).

Table 8: Strong performing (viz., anxiety-provoking) elements from respondents who experience the issue daily or frequently, respectively. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 8

Geo-demographics of the Respondents

  1. Females show a higher additive constant than do males (viz., greater proclivity for anxiety) for loss of assets and loss of income, respectively. In contrast, males show a higher additive constant for loss of health.
  2. Younger respondents show a higher additive constant for loss of assets and loss of income, respectively. In contrast, older respondents show a slightly higher additive constant for loss of health.
  3. Higher-income respondents show a higher additive constant for loss of assets and loss of income, respectively. Lower income respondents show higher additive constant for loss of health.
  4. Respondents frequently find help distressing when that help is presented as coming from third parties (charities, insurance, one’s company, etc.) Respondents age 60+ find the help of one’s company quite distressing, both in the case of losing one’s assets (82% find the mention of company to drive anxiety), and in the case of losing one’s health (70% find the mention of company to drive anxiety) (Table 9).

Table 9: Strong performing (viz., anxiety-provoking) elements from respondents self-defined in terms of gender, age, and income, respectively. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 9

Location of the Anxiety Occurrence

As part of the self-profiling classification, the respondent was instructed to select the one or two locations where the experience of anxiety occurs. The actual question was phrased as: Q8:Where do you generally think about this Situation? (Check 2)

  1. Table 10 suggests that the basic level of anxiety differs by type of loss and by location. There is no clear pattern, other than loss of assets and loss of income are both high in various places, whereas loss of health is far lower, other than at work (viz., additive constant of 39 for work versus 29 or lower elsewhere).
  2. Table 10 shows notable differences in the ability to elements to drive anxiety, as well as differences in basic anxiety experienced, with different additive constants for the same location across three sources of anxiety. Recall that the additive constant is a measure of the basic proclivity of the respondent to experience anxiety when the loss or situation is stated in the vignette. For example, when the respondent is at work, the most severe anxiety is occasioned by the thought of losing one’s assets (additive constant = 55). When the respondent is at work, the thought of losing income is less anxiety provoking (additive constant = 44). Finally, when the respondent is at work the thoughts about losing health is the least anxiety-provoking (additive constant = 39).
  3. It is anxiety about the loss of one’s health which emerges in many different places, and triggered by the greatest number of elements. For losing assets and losing income anxiety is triggered by two or three elements, respectively. For losing health anxiety is triggered by six elements.
  4. The complexity emerging from Table 10 may require the reader to scan the table, so that the reader’s focus can allow the relevant patterns to emerge.

Table 10: Strong performing (viz., anxiety-provoking) elements from respondents self-defined in terms Where the anxiety is experienced. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 10

Emotions Experienced after Participating in the Study

Question 6 in the self-profiling questionnaire instructed the respondent to introspect about her or his global feeling after having evaluated the 60 different vignettes. The respondent was allowed to check all that apply. Table 11 shows the number selecting each emotion, the additive constant for their proclivity to experience anxiety, and the elements most able to drive anxiety for the particular subgroup of respondents. As was the case for many of the other tables (except self-profiling geo-demographics shown in Table 9), each section of the table is sorted in descending order by additive constant.

Table 11: Strong performing (viz., anxiety-provoking) elements from respondents self-defined in terms of how the respondent feels after evaluating the 60 vignettes. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 11

The first observation is that the rank order of additive constants makes sense, at least at the most general level. Those who check off ‘angry’ or ‘depressed’ show the highest additive constant. Those who check off optimistic and relaxed show the lowest additive constant. There are no surprises here, other than that the data appear to show consistency across different measures, in a way that would be hard to ‘game.’

The second pattern is the nature of the elements which drive anxiety.

  1. For losing assets the elements driving anxiety are help from charities, from company, and from insurance, respectively. These elements ‘jump’ out from individuals/emotions showing low additive constants. That is these elements disturb people who are otherwise not prone to feeling anxiety, reflected in the low additive constants.
  2. For losing income the emergent pattern differs. The strong drivers of anxiety are expectation of help from insurance, and expectation of help from the government. These elements drive anxiety, no matter what the respondent feels.
  3. For losing health anxiety is strongest when the messages are help from charities, from the company, and from supplemental insurance, no matter what the emotion felt, and no matter how high the additive constant (basic proclivity to anxiety).

The Person’s Self-chose ‘Relevant Responses’ to the Situation

Questions 16-30 in the self-profiling questionnaire instructed the respondent to check the activities that the respondent thought to be relevant for the particular anxiety-provoking situation which was the topic of the study. The question was phrased as: In the next few screens we will talk about various activities. For each activity please indicate how relevant it is to your situation. The phrasing did not direct the respondent to say what the respondent was actually doing, but rather what was thought to be relevant.

Table 12 shows that respondent differentiate among the relevant or appropriate responses to loss, at least based upon the additive constant. If we assume that the higher the additive constant represents the proclivity to anxiety for the specific loss, then the three losses engender different behaviors patterns of anxiety associated with the behaviors that the respondents feel to be ‘relevant’ in the wake of the loss.

  1. For loss of assets, the effort to deal with anger generates the highest additive constant (41), i.e., the highest proclivity to anxiety. Exercise generates the lowest additive constant (24).
  2. For loss of income, ‘talking’ generates the highest additive constant (52) whereas exercise generates the lowest additive constant (34).
  3. For loss of health, ‘talking’ again generates the highest additive constant (39) whereas exercise generates the lowest additive constant (14)
  4. There are different elements which drive anxiety. For losing assets it is clearly losing one’s home. For losing income it is clearly the mention of help from insurance, as well as losing one’s job because of one’s own mistakes. For losing health, it is loss of bodily functions as well as the dependence upon charity.

Table 12: Strong performing (viz., anxiety-provoking) elements from respondents self-defined in terms of what the respondent feels to be the relevant action to be taken given that loss occurs. The coefficients are the percent of respondents in the total panel whose coefficient is 55 or higher.

table 12

Discussion and Conclusions

An inspection of today’s scientific methods suggest that a great deal of the focus is placed on either filling ‘holes’ in the literature, or creating limited-scope hypotheses about a topic [6]. The ascendance of the hypothetico-deductive system, coupled with the increasing focus on inferential statistics to support hypotheses, mean that the studies become increasingly more focused, far more narrow. As a consequence, the scientific community has learned to deconstruct a topic such as responses to everyday anxiety provokers into small pieces, viz., testable hypotheses. An example might be that the most severe anxiety producer is the expected loss of one’s home, a statement that can be assessed by having the respondent rate the different losses in terms of severity. This is an attractive finding, one that can be tested, and which gives a ‘sense’ of how people think about anxiety. The finding is certainly better than simply saying that there are a number of anxiety producers, such as loss of home, loss of health, loss of income, and so forth.

When the researcher moves beyond the simple aspects, the one-at-a-time thinking, the traditional way of doing so have been to use qualitative methods, discussion, and observation (e.g., [7]). The researcher can get a sense of the nature of the way people cope with anxiety producing situations, e.g., by using one-on-one depth interviews with one or two people to discuss their feelings about the anxiety issue. Or, as if often the case, the researcher can use group discussions, where a group of individuals guided by a trained professional discusses a topic.

The contribution of Mind Genomics to the knowledge of anxiety is to move the approach to experimentation and collection of ancillary information about the respondent. Mind Genomics can determine whether defined subgroups of individuals show identifiable, interpretable patterns of responses to test stimuli. These groups are those emerging from using the self-profiling classification (Table 3) as a system for creating these subgroups. The results can be new insights into the mind of the person, responses generates to systematically controlled and varied verbal stimuli (viz., the elements in the vignettes).

The Role of the Additive Constant

As noted in the methods section, the additive constant is the ‘adjustment factor’ incorporated into the regression to correct for the fact that the regression model may not actually go through the origin. In terms of the underlying mathematics, the additive constant is the estimated value of the dependent variable when all of the independent variables are 0. In Mind Genomics terms, the additive constant is the estimated value of the binary rating (viz., 7-9, ‘cannot deal with it’, i.e., makes me anxious) when there are no elements present. We choose to call it the predisposition to express anxiety.

The additive constant emerges from the pattern of responses to the 60 different vignettes. Thus, it is virtually impossible to ‘game’ the Mind Genomics experiment, in order to provide a desired, pre-defined additive constant. Furthermore when we look at the change in the additive constant across different situations different emotions, and so forth, we find that for the most part the rank order of the additive constants makes intuitive sense. For example, those who have just participated in the experiment and are feeling happy or optimistic show a lower additive constant than those who have just participated in the same experiment, albeit with different combinations of elements. Thus the additive constant can be analyzed in and of itself as a basic metric of predisposition to anxiety.

The Role of the ‘Transformed Coefficients’

As noted in the analytic section, the data from each respondent were used to create an individual-level equation relating the presence/absence of the elements to the likelihood of having an anxiety-driven response (viz., 7-9, cannot deal with it). The individual coefficients were transformed so that all coefficients of 10 or higher (viz. element ‘drives’ anxiety response) were transformed to one number, the value ‘100.’ All remaining coefficients under the value 10 (whether positive, zero, or negative) were transformed to 0 (viz., element does not ‘drive’ a strong anxiety response for that individual). This transformation of the coefficient enables the researcher to average the transformed values. The average represents the proportion of respondents in the group who feel that the element is felt to ‘drive’ anxiety. For our analysis, the story emerges when we look only at those elements driving a majority of the respondents to respond that ‘I can’t deal with it’ (viz. coefficient of 10 or higher).

When we look across the elements and groups, we begin to get a sense of what elements are thought by respondents to drive anxiety. Most surprising is the exceptionally negative response to elements talk about the ‘help’ proffered by groups, including charities, government, and one owns company, respectively This disbelief in organized help and corporate help is worth further investigation because the disbelief seems cynical in the face of the oft-proclaimed desire of groups be of help ‘when the situation arises.’ One hears organization proclaiming their aid, actual and emotional, in times of need. The disbelief by respondents could be considered to be an artifact, casting doubt on the entire effort because the disbelief goes head to head with the organization messages. Yet, the disbelief is credible. The experimental design makes it again impossible to ‘game the system,’ and so the disbelief, the cynicism must be respected and investigated.

Contributions of Mind Genomics to Our Knowledge of People

The published academic literature deals with many types of losses that people sustain, and the response to them. The majority of these studies focus on specific issues, such as loss of jobs and failure to pay mortgage, but most frequently on the loss of health and what it entails [8-12]. These studies focus narrowly on the topic, looking at the issue in depth. By their very nature, the studies are narrow and limited, rather than being holistic. In contrast, Mind Genomics presents a ‘deep dive’ into the problem, albeit one mediated by the S-R (stimulus-response) method from experimental science. Mind Genomics provides an easy-to-develop scalable database, useful to measure the subjective degree of anxiety, as well as identify the possible triggers, executed in a way where the ‘experiment’ is less threatening because of its superficial similarity to the now common Internet-based survey.

Acknowledgment

The author would like to acknowledge the efforts of the late Hollis Ashman of the Understanding and Insight Group, Inc., for her efforts in putting together the 15 It! studies, under the auspices of It! Ventures, LLC. It was through Hollis’ efforts that the studies were designed, executed, and initially reported during the years 2003 to 2006.

References

  1. Kushner HS (2007) When Bad Things Happen to Good People. Anchor.
  2. Bloom H (1997) The Anxiety of Influence: A Theory of Poetry. Oxford University Press, USA.
  3. Ketonen EE, Visajaani S, Lonka K, Salmela-Aro K (2022) Can you feel the excitement? Physiological correlates of students’ self-reported emotions. British Journal of Educational Psychology 12534. [crossref]
  4. Moskowitz HR (2012) ‘Mind Genomics’: The experimental, inductive science of the ordinary, & its application to aspects of food & feeding. Physiology & Behavior 107: 606-613. [crossref]
  5. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127-145.
  6. Kell DB, Oliver SG (2004) Here is the evidence, now what is the hypothesis? The complementary roles of inductive & hypothesis-driven science in the post-genomic era. Bioessays 26: 99-105. [crossref]
  7. Traina G, Feiring E (2020) ‘There is no such thing as getting sick justly or unjustly’–a qualitative study of clinicians’ beliefs on the relevance of personal responsibility as a basis for health prioritisation. BMC Health Services Research 20: 497. [crossref]
  8. Abumrad NN, Frexes-Steed M (1990) What getting sick means. Journal of Parenteral and Enteral Nutrition 14: 157S-163S. [crossref]
  9. Budetti J, Schoen C, Simantov E, Shikles J (2000) Risks for midlife Americans: Getting sick, becoming disabled, or losing a job and health coverage. New York: The Commonwealth Fund.
  10. Clarke DM (2007) Growing old and getting sick: maintaining a positive spirit at the end of life. Australian Journal of Rural Health 15: 148-154. [crossref]
  11. Dy S, Lynn J (2007) Getting services right for those sick enough to die. British Medical Journal 334: 511-513.
  12. Houle JN, Keene DE (2015) Getting sick and falling behind: health and the risk of mortgage default and home foreclosure. Journal of Epidemiology & Community Health 69: 382-387. [crossref]
fig 1

The Mind of the West European Coffee Drinker Revealed through Mind Genomics

DOI: 10.31038/NRFSJ.2022522

Abstract

Respondents from three countries (France, Germany, and UK) each evaluated unique sets of 60 vignettes about coffee, created by combining elements (messages) according to an underlying experimental design. Respondents rated each vignette on an anchored 9-point scale of craving (1=do not crave. 9=crave extremely). The ratings were deconstructed into individual level models, showing the contribution of each message to craveability. By incorporating an extensive self-profiling classification questionnaire, the research paradigm, Mind Genomics, revealed the nature of how respondents think about coffee, showing the contribution of the message itself, as well as the country, and the nature of what the respondent does in terms of coffee behavior. The paradigm presents the potential for a deep understanding of the mind of the ordinary person, doing ordinary tasks, e.g., those involved with coffee, and allows the affordable and easy creation of large-scale databases of human behavior and decision making.

Introduction

As this paper is being written the world of coffee is actively evolving. From a drink in a modern day ‘coffee house’ enjoyed in leisure, coffee has become what might well be the most popular beverage in the world, emblematic of different social norms around the world, and today a source of involvement in societal-moral issues. Coffee has evolved into a drink that people enjoy together in coffee houses, chatting, reading paper, starting their morning with a quick cup, or passing the day leisurely [1,2]. Moving further, coffee ready to drink comes in a variety of ‘forms’, whether traditional ‘black’, doctored up with all sorts of other ingredients [3,4]. Coffee has emblemized social change. During the past decades consumers have fallen in love with Italian espresso coffee, so much so that that one can feel an Italiphila (love of things Italian) pervading the word through the world-wide reception of espresso [5-7].

This most popular drink has, in turn, evolved into a topic of social concern. In, study after study the academic literature has started to focus on social issues, such as the environment as well as ‘fair trade’ for the farmers who grow the coffee beans [8-11]. The sheer popularity of coffee in daily life and the social significance of fair trade to pay the farmer the real value of the coffee make the topic irresistible to academics. Google® has 62,400 hits for the topic ‘coffee and fair trade’, Google Scholar® has about 8x as many, 481,000 hits for coffee and fair trade!

Despite the importance of coffee, there are relatively a handful of academic papers on the topic of coffee itself. Some of these are studies the sensory properties of coffee, and the different pattern of preferences for these sensory properties. For example, Geel et al. (2005) reported that four patterns of the acceptance emerging from the response to 11 coffees: “Based on consumer preferences, four consumer groups were identified, “pure coffee lovers” (23%), “coffee blend drinkers” (30%), “general coffee drinkers” (37%) and “not serious coffee drinkers” (10%). The “pure coffee lovers” prefer the more astringent, bitter, roasted, nutty and full-bodied flavour of the pure coffee samples. The less intense coffee flavour character, but higher sweetness and root flavour, typical of chicory blended instant coffee, were attributes that were preferred by the “coffee blend lovers”. The “general coffee drinkers” seem to consume coffee out of habit and are less concerned about the specific sensory properties of the coffee [12].”

The academic literature is equally sparse when it comes to what to communicate about coffee in order to entice prospective buyers. From the author’s own experience, the companies selling coffee do extensive research, from basic attitudes and usage studies (A&U) dealing with coffee as part of life, and then concept tests to find out the acceptance of new ideas, and finally advertising evaluation to find out ‘what works’.

One might think that the knowledge is extensive in corporations about the aspects of coffee, specifically the most persuasive messaging. The author’s experience, however, over the past 46 years since 1976 would suggest just the opposite. There seems to be no systematic study about coffee messaging that the author has ever encountered in the public literature, nor has the author encountered evidence of this systematic approach in private consulting. There are tests of individual messages, but no large scale, systematic tests of the mind of the coffee consumer regarding the language of coffee. When directly confronted with the request ‘show me the book of messages which work with consumers’ no one, either in academia or in business has been ever able to provide the request ‘book’ or at least ‘database.’

Getting into the Mind of the Coffee Consumer through Mind Genomics

Given the importance of coffee, there is an extraordinarily amount known about the consumer attitudes towards coffee and the consumption patterns of the actual product, most of the information residing in the file cabinets and stored and archived ‘banker’s boxes’ of study results owned by corporations usually residing in dead storage. Indeed, the author’s own experience with Maxwell House Division of General Foods Corporation in the mid 1980’s suggested that for General Foods Corporation alone, the consumer research budget was in the millions of dollars, with hundreds of reports issued by the market research department as well as by the sensory evaluation department. What new, if anything, can consumer-focused scientific research add with to what has been developed with the large corporate budgets? Can we learn new things about the way people think about coffee?

Despite the richness of information, from the public domain (popular press, from companies, and from presumably more objective science there still is a lot to be discovered, which is where the emerging science of Mind Genomics enters. Mind Genomics was developed from a different world view, that of looking at how people make decisions when confronted with compound stimuli, mixtures of messages, the more typical situation in nature. Mind Genomics traces its heritage to conjoint measurement [13] and to experimental design [14].

Mind Genomics paints word pictures of products (and intangibles, such as service), these word pictures created from defined combinations of simple phrases that a person would encounter during everyday experience. The combinations are called ‘vignettes.’ Using statistical methods such as OLS (ordinary least-squares) regression to deconstruct the response to the mixture into the driving power of the components, viz., elements. Mind Genomics studies ends up being far deeper, and often far more ‘actionable’ for science and business purposes than information and ‘insights’ emerging from conventional qualitative, quantitative, and behavioral studies [15,16].

The foregoing approach of mix/evaluate/deconstruct is quite different from that used in conventional research, where the respondent is presented with one idea or question after another, forced to focus on an array of topics which keep changing. In such a system, viz. the typical questionnaire, the respondent must keep changing her or his frame of reference, first thinking for example about the occasion, and then about the product, and then about feelings, etc.

It! Studies – the Lure of Mind Genomics Databases across Products and Across Countries

After successful research with Mind Genomics in the world of foods, the McCormick & Company approached the author and colleague Jacqueline Beckley of the Understanding and Insight Group, Inc. to extend the scope of Mind Genomics studies that they had already run. Rather than applying Mind Genomics to one topic of food, the research sponsor at McCormick, Director Dr. Hamed Faridi, wanted to look at a whole set of foods, the elements appropriate for that food, but with common elements dealing with emotion benefits. This effort become the 2001 Crave It! study, a study of 30 foods then repeated with teens, rather than with adults [17]. The study was massive by any consideration, with each study comprising more than 100 respondents, and exactly 36 elements, combined into unique sets of 60 vignettes for each respondent. The results were analyzed ‘globally’ to identify recurring themes among people. The data suggested that across all the 30 studies, three patterns continued to emerge: Elaborates, Imaginers, and Classics. These groups, so-called ‘mindsets’ clearly differed in terms of the particular elements which appealed to them. The Elaborates focuses on the food, the Imaginers on the situation, and the Traditionals on the typical factors involved with the food, such as enjoyment, price, etc.

About a year later, the same idea was supported by the Firmenich Corporation, this time looking at foods in three western European countries, France, Germany and the UK, respectively. The structure was the same, and at that time the focus was on the re-emergence of the three now ‘canonical’ groups of respondents, again based upon the pattern of their coefficients when the data from each country and each food were more deeply analyzed [18]. Nothing of the sort had been done before. The notion was conceived of and developed by Pieter Aarts of Belgium, Klaus Paulus of Germany, and the It! Ventures LLC in the US (Jacqueline Beckley and Howard Moskowitz). The studies, sponsored by Firmenich in Switzerland, were designed to understand how people respond to different ideas and descriptions of food, not so much using the traditional attitude and usage sales, but rather using the new method of experimentation offered by Mind Genomics.

The Eurocrave Studies on Coffee

The three studies reported here come from the early days of Mind Genomics, when getting respondents showed that respondents could participate with little difficult, as long as they were somewhat motivated. During the early years of this century the novelty of the Internet was such that people were intrigued. The respondents were sent invitations, and offered a chance to participate in a sweepstakes for money. This sufficed to bring in thousands of respondents, these thousands choosing to participate in a study that interested them.

The actual Mind Genomics study, positioned as a ‘survey’, was actually an experiment. The word ‘experiment’ is negatively tinged, but the word survey and the word opinion is not. The Mind Genomics approach begins with a topic, requires a set of four questions, and nine answers to each question. The questions tell a story, or provide distinct types of information. These early studies, of which Crave It! and Eurocrave! are examples, show the early focus on acquiring as much information as possible about a topic?

The ingoing notion of Mind Genomics was and remains the idea that we can learn a lot by presenting a person with combinations of messages, and instruct the respondent to rate the combination. Rather than polishing the combination so the combination becomes a dense paragraph, albeit a well-written one, the Mind Genomics experiments virtually ‘throws’ the ideas at the respondent, instructing the respond to react to the combination. The approach is a bit off-putting at first, because respondents are far more accustomed to well written, dense paragraphs. An analogy is the difference between a compote comprising many fruits versus a thrown-together fruit salad.

The structure required four questions, each with nine answers. The objective of the experimental design was to ensure that the elements would be put together in such a way that each vignette would have at most one answer from two, three, or four questions. The actual design, four questions by nine answers per question, is a template, required for ‘bookkeeping’, so that a vignette would never have two answers from a single question, answers that might contradict each other.

Table 1 shows the raw materials, the elements, from the three studies, one in the UK, one in France, and one in Germany. The elements are in the native language. As much as possible the elements were the same across countries, but that equivalence of elements was not possible in the case of brands or stores present in one country but not in the other. Table 1 shows that the same idea might be expressed in slightly different ways by country. Thus, one should look at the elements as specific instantiations of more general ideas, instantiations which may differ across countries. This caveat means that the data should not be rigorously compared across countries, simply because the execution of the same idea in one country might be quite different from the execution of the same idea in another country.

Table 1: Elements for the three-country Eurocrave study on coffee

TABLE 1

One of the hallmarks of Mind Genomics is the use of language that is best characterized as ‘colloquial.’ That is, the elements themselves are phrased in the way a person of the country might talk. In the actual Mind Genomics experiment this effort to be simple and colloquial will end up playing an important role. The language itself will allow the respondent to ‘graze’ through the text, rather than force the respondent to think about the answer. That is, the simple declarative format will simplify the respondents task, with the respondent simply looking at easy-to-understand sets of phrases.

Running the Mind Genomics Experiment

In conventional studies, specifically surveys, the study is set up so that the respondent must focus on a single question, answer it, and then move on to the next. The effort is made to minimize respondent bias although it is in the nature of respondents to want to please the researcher, and to give the correct answer Whether the respondent can actually come up with the ‘correct answer’ is not important. What is important is the pervasive subconscious nature to be right or at least to be consistent. Such biases abound in survey research. Researchers attempt to counteract these biases by such strategies as rotating the order questions in order to reduce effects due to test order, and disguise the nature of the topic so that that the respondent cannot really guess about the goal of the question.

The Mind Genomics approach to the interview is described as a survey to people, but as stated above, the reality is that Mind Genomics constitutes really a well -controlled experiment. The experimenter presents test stimuli (viz., combinations of messages, the aforementioned elements shown in Table 1), obtains a response (a rating of the vignette by the respondent), repeats the task, collects the data, and then relates the presence/absence of the elements to the ratings. The respondent simply rates the combination, almost it would appear from exit interview, assigning the ratings in what is report as a guessing, or in a state of indifference because the task seems daunting.

The respondent in the Mind Genomics experiments does not evaluate one phrase at a time, viz., rate 36 phrases. Rather, the respondent in a study is exposed to 60 different combinations of these elements, each combination comprising 2-4 elements, no more than one element or answer from a question. The respondent is simply instructed to the read the vignette (combination of elements) as one idea, and rate the combination on a nine-point scale. The scale is simple, anchored at both ends:

Using this 9-point scale, please show how you feel about the COFFEE as described:

1 = Do not crave it at all … 9= Definitely crave it

Most people participating in the study, or even just inspecting the set of 60 vignettes, the combinations of elements, feel that the elements have been thrown together randomly. Nothing could be further from the truth. The underlying structure for the 60 combinations is dictated precisely by an experimental design, a blueprint, which defines the specific elements present in each combination.

The experimental design provides these convenient features and benefits:

  1. Each vignette comprises a specific set of elements. The minimum number of elements is two, the maximum number is four. By design, many of the vignettes are incomplete. Each element appears equally often, five times in 60 vignettes, and absent 55 times from the 60 vignettes. Doing the arithmetic shows that each of the four questions contributes 45 elements to the 60 vignettes and is absent from the remaining 15 of the 60 vignettes.
  2. No vignette comprises more than one element (answer) from a specific question. The underlying rationale is that no vignette can carry mutually contradictory information of the same type (e.g., no vignette can comprise two brands).
  3. Each respondent tests a unique set of 60 vignettes, different from the 60 vignettes tested by any other respondent. This approach, permuted designs, was patented by author Moskowitz and colleague Alex Gofman [19].
  4. The happy outcome of the structure is that one can create an equation relating the presence/absence of the 36 elements to the rating (or a transform of the rating), at the level of a single respondent, or at the level of a group of respondents. This ‘within subjects’ feature allows clustering algorithms to identify groups of respondents with similar patterns of coefficients, viz., ‘mind-sets’ in the language of Mind Genomics [20].

The studies for Eurocrave were set up in the United States. Local field services in the three countries invited respondents to participate by internet survey. The respondent was invited to participate by the local field service in the country, a field service with a specialty in recruiting panelists for web-based, viz. online, studies.

It is important to keep in mind that even as far back as 2002, two decades ago, it was virtually impossible to source a sufficient number of respondents from one’s friends and colleagues. The notion that people want to participate in research interviews, whether with live interviewers or on the web, is simple unreasonable, then, and increasingly so. One cannot expect people to offer their time for free. It is important to compensate them, and even more important to work with companies specializing in providing people to participate in consumer research studies. The criticism that these may become ‘professional respondents’ is far less cogent than the almost certain fact that depending upon the goodwill of random people, even students in a class, will probably end up with fewer respondents than needed.

Each of the three countries had a pre-created ‘wall’ listing the different foods being covered in the Eurocrave project. Figure 1 shows the wall for the German study. The wall was designed with three properties in mind.

fig 1

Figure 1: The wall for the Eurocrave study (Germany)

  • The studies (really names of the foods) appeared in random order, to minimize the selection of studies in one position, e.g., the top right.
  • When a study had 120 respondents who successfully completed the study, the study temporarily ‘disappeared’ from the wall, so it could not be chosen. The respondent had to choose from among the less popular studies.
  • The happy consequence of this strategy was that respondents only participated in a study, which interested them.

The respondent was led to the correct study, read the introduction informing the respondent of the topic and the length of time (15 minute), and then presented the respondent with the vignettes, one after another. As soon as the respondent pressed the rating key the vignette disappeared, and the next vignette appeared in its place. There was no opportunity to change the rating once it was assigned. Afterwards, the respondent completed a self-profiling questionnaire dealing with different aspects of who the respondent IS, what the respondent THINKS regarding coffee, as well as the time of day that the respondent was completing the study.

Strategy for Analysis and for Presentation of Results

Most users of data do not feel comfortable with Likert scales, like the scale for craveability. They do not know what the scale means, even though respondents seem to have no trouble using the scale, AND the scale allows for valid statistical analysis.

Many researchers feel that they learn more when they can divide the scale into two parts, viz. NO and YES, respectively. It is easier for managers to understand NO vs YES. To make the research easier to understand, the data were divided into two points, ratings 1-6 transformed to 0, ratings 7-9 transformed to 100. This division was arbitrary but made intuitive sense. After the foregoing transformation, a vanishingly small random number was added to each transformed value, so that the ratings were slightly different from 0 or 100, and slightly different from each other when they had been transformed. This addition of the small random number enabled the dependent variable for each respondent to show some variation across vignettes, even when the respondent confined her or his ratings to the lower part of the scale (1-6, always transformed to 0) or to the upper part of the scale (7-9 always transformed to 100). The variation ensured the data be further processed at the level of the individual respondent.

The individual data were analyzed by OLS (ordinary least-squares) regression, which estimated the additive constant (k0) and the 36 coefficients (k1-k36), one coefficient for elements A1-D9, respectively. The regression equation is expressed as: Transformed Rating = k0 + k1(A1) + k2(A2) …. K36(D9).

The regression equation summarizes the data for a respondent or group of respondents. The additive constant, k0, can be interpreted ais the estimated proportion of respondents who would rate a vignette 7, 8 or 9, respectively, in the absence of elements. Of course, the underlying experimental design ensures that no vignette will comprise fewer than two elements, so the additive constant is a purely estimated parameter. The additive constant plays a role, becoming a baseline value of the likelihood of respondent assigning a positive rating of 7, 8 or 9. High additive constants (e.g., 50 or more) mean that the respondent has a predilection for up-rating vignettes. In this ‘happy’ situation, a vignette simply has to feature elements which are slightly positive, and avoid elements which are negative. Low additive constants (e.g., lower than 30, for example) mean that for a vignette to get a high rating of 7, 8 or 9, respectively, the elements ought to be strong performers because the predilection of the respondent is to use the lower part of the scale.

The analysis of the ratings by OLS regression produces a large data set, namely 37 numbers for each respondent. The 37 numbers per respondent is far smaller than the matrix required to code the raw data for the respondent. The original data for each respondent constituted requires 60 rows of numbers, beginning with information about who the respondent is, what the respondent does, et., continuing then into 36 columns (one column for each element), then the rating, and then the transformed rating. This matrix contains one row per vignette per respondent. Across all 60 rows for a single respondent the information about the respondent remains the same, but the data fields corresponding to the structure of the vignette (which element appear, which do not appear), and the rating, change from vignette to vignette.

The Mind Genomics exercise produces a great deal of data, specifically 37 numbers per subgroup of respondents. It is impractical and counterproductive to report the data from each element across all of the relevant subgroups (viz. total panel and key self-defined subgroups, as well as emergent mind-sets). The amount of data for one subgroup overwhelms. Multiply that amount of information by the number of subgroups relevant to an analysis, and one can easily end up with 100+ cells of data. Looking for a pattern across 100 cells is data is simply too difficult.

One of the ways to cut down on the amount of data, and allow important data through, is to eliminate any coefficient less than a certain value for any of the 36 elements. The standard error of the coefficient is 4-5 for these studies, so a coefficient of 8 or 9 is likely to be significant, and more important, likely to signify something relevant about the topic. Thus, a coefficient of 10 or higher can be considered important. Other coefficients, viz., those below 10, need not be shown, and thus allowing the patterns to emerge. For this paper we will only look at coefficients of +10 or higher. As we begin the analysis of the data, it will quickly become apparent that most of the elements do not have strong performing coefficients, simplifying our search for patterns. Furthermore, each data table will show highlighted elements, viz., elements which score well (coefficient of 10 or higher) for at least three subgroups. These are ‘strong performers,’ viz., ‘strong performing elements.

Results

Who the Person Is – Total and Gender

We begin the analysis with the total panel and with males and females (Table 2). The first analysis looks at the additive constant. Recall that the additive constant is a baseline, or at least can be interpreted as a baseline. Looking at Table 2, we see that the additive constants differ by country. Those for the UK and France are 41, moderate, but the elements show low coefficients. The additive constant for Germany is low, 30, but more elements are strong performers.

Table 2: Strong performing elements for total panel and for gender

table 2

From study after study one of four patterns emerge, to describe the value of the additive constant and the value of the coefficients:

  • Low additive constant, low values for the coefficients – an unpopular idea. A good example is credit cards. The values of the additive constant are usually 0 or even negative up to about 20.
  • Moderate additive constant, low values for the coefficients. The value for the additive constant is 20-50. Here the basic idea is neutral, buoyed up by some good ideas if any.
  • Moderate additive constant, high values for many coefficients. The value for the additive constant is again 20-50-. Here the basic idea is neutral Here the respondent is discriminating among the elements, with some elements really being winners.
  • High additive constant, low values for many coefficients. The value for the additive constant is 50 or higher. Here the basic idea is very good, and the respondent does not really find elements to strongly augment the already-high basic response to the vignette.

The second analysis looks at the strong performing elements. Surprisingly, the three countries exhibit few strong performing elements, at least for total sample and gender. Respondents in each country show only one strong performing element each across all three groups (total, two genders). The elements are different, but all from Question or Group A, dealing with the description of the product itself. This finding surprises because of the absence of strong-performing elements, but is in line with other studies from Mind Genomics which point to the importance of an appetizing description of the product as a driver of strong performance.

UK: AE2 Fresh coffee, made from 100% Colombian coffee beans

France: AF8 Expresso: saveur intense en une gorgée

Germany: AG1 Kaffee: frisch gemahlen und aufgebrueht

Who the People Are – Age

The self-profiling classification allowed the respondent to report their age. Table 3 shows age does not play an important role. The additive constants show a mixed pattern, increasing with age in the UK, decreasing with age in France (except for a very low additive constant for those 18-25), and not clear in Germany, which presented only two ages.

Table 3: Strong performing ‘coffee elements’ for three countries, by age

table 3

The strong elements in country are different, but again it is important to note that the strongest elements come from the first group of elements, the first question, about the product.

UK: AE2 Fresh coffee, made from 100% Colombian coffee beans

France: AF8 Expresso: saveur intense en une gorgée

When the Respondent Participated – Time of Day

One of the foci of the It! studies, such as our coffee study, was the question regarding differences in the additive constant and in the coefficients. Table 4 shows the relevant data.
These patterns emerge:

  1. The additive constants are almost all quite low. It is the elements which must do the work.
  2. The additive constants increase from morning to night, suggesting a more positive ‘basic response’ to the message at night. The pattern is not perfect, however, but is worth noting because there may be an increasing sensibility about the quality of the coffee as the day progresses, with the quality of the coffee less important than the ability to ‘wake one up’, expected to be the case in the morning hours.
  3. The only time which does not feature many very strong performing elements is 6pm to 9pm.
  4. UK respondents do not show strong performing elements emerging in the three hour period of 9PM to 12 Midnight, whereas in contrast, French and German respondents do.
  5. The strong performing elements are:

Table 4: Strong performing ‘coffee elements’ for three countries, by daypart (three hour segments)

table 4

UK: AE2 Fresh coffee, made from 100% Colombian coffee beans

France: AF8 Expresso: saveur intense en une gorgée

DF3 De la marque Carte Noir

Germany: AG6 Cappucino: herzhaft, schaumig und weich

AG1 Kaffee: frisch gemahlen und aufgebrueht

AG5 Kaffee und Milch zum perfekten Milchkaffee gemischt

How the Respondent Felt – Self-Reported Thirst

As part of the self-profiling questionnaire the respondent selected the level of thirst experienced. Once again across the three countries on a few elements perform well for different levels of perceived thirst (Table 5)

Table 5: Strong performing ‘coffee elements’ for three countries, by self-reported degree of thirst

table 5

There are two patterns here worth noting:

  1. The additive constant is much higher when the respondent reports a high degree of thirst
  2. All strong performing elements showing up in three or more states of thirst come from Question A, dealing with product.

UK: AE2 Fresh coffee, made from 100% Colombian coffee beans

France: AF8 Expresso: saveur intense en une gorgée

Germany: AG6 Cappucino: herzhaft, schaumig und weich

AG1 Kaffee: frisch gemahlen und aufgebrueht

Coffee Behavior – Frequency of Coffee Consumption

Table 6 shows that the vast majority of respondents participating in this study were frequent coffee drinkers. One of the more interesting things emerging from Table 6 is that those who drink coffee less frequently, viz., once a day, find more evocative elements of interest.

Table 6: Strong performing ‘coffee elements’ for three countries, by self-reported frequency of drinking coffee

table 6

UK: AE2 Fresh coffee, made from 100% Colombian coffee beans

France: AF8 Expresso: saveur intense en une gorgée

Germany: AG6 Cappucino: herzhaft, schaumig und weich

Coffee Behavior – Day-part of Coffee Consumption

Depending upon one’s culture, coffee can be consumed any time during the day or night. It is only a matter of cultural norms and one’s predilections. Table 7 shows that the most frequent day-part differs by country. Looking at the frequency of 30 respondents or more we find the following:

Table 7: Strong performing ‘coffee elements’ for three countries, by self-reported time of day when coffee is consumed

table 7

UK – breakfast most, and then evening and finally mid-morning parts. Highest additive constant in the mid-afternoon, lowest in the evening.

AE2 – Fresh coffee, made from 100% Colombian coffee beans

France – breakfast most, then mid-afternoon, and finally mid-morning. French respondents do not say that they drink coffee in the afternoon. The same size additive constant for breakfast, mid-morning, and mid-afternoon, respectively.

Germany – breakfast most, then mid-afternoon, then mid-morning. The same additive constant across all times (from breakfast to just before dinner)

AG1 – Kaffee: frisch gemahlen und aufgebrueht

AG6 – Cappucino: herzhaft, schaumig und weich

The ‘bottom line’ is that there are dramatic differences across countries, and even differences in the performance of elements in a single country across dayparts. The patterns are difficult to summarize.

Coffee Behavior – Where Coffee is Purchased or Consumed

In the self-profiling questionnaire the respondents checked off the places where they purchase or consumed coffee. Table 8 shows the distribution of the responses across five venues. The venues are not equally represented across the three countries, however, primarily due to low base sizes of respondents.

Table 8: Strong performing ‘coffee elements’ for three countries, by self-reported venue of purchase or consumption

table 8

UK – Not in a department store nor in a local restaurant known in one’s area. The UK respondents purchase their coffee in a supermarket or food store. It may well be that the respondents don’t think of drinking coffee after a meal in a local restaurant as a real ‘coffee occasion’.

France – The French respondents purchase their coffee in a supermarket, and do think about coffee consumed in a local restaurant, but again without the strong focus of that as being a real ‘coffee occasion.’ (The base size is only 19 respondents). The French respondents consider coffee at a department store as a real coffee occasion.

Germany – The German respondents think of all venues (food store, department store, supermarket, coffee shop) as coffee occasions, but do not think of local restaurants and coffee as coffee occasions. German respondents show the greatest number of strong-performing elements associated with venue.

Coffee Attitudes – Features Selected as Important

The self-profiling classification questionnaire contained a question about what features of coffee the respondent felt to be important. The respondent could select up to three features. These features comprise, respectively, sensory aspects (appearance, aroma, taste), emotional aspects (memories, associations, brand), package features (packaging), and consumption features (portion size, social situation, mood).

Table 9 shows the patterns. As one would expect, aroma and taste, the sensory impressions, are chosen most frequently. The remaining features are distributed in different ways by country and show different patterns. In the interest of simplicity, we focus only on groups comprising 30 respondents or more.

Table 9: Strong performing ‘coffee elements’ for three countries, by self-reported selection of ‘what is important’

table 9

UK – Brand and mood are chosen most frequently.

Those choosing brand show a higher additive constant (50), but few strong performing elements. No brand elements are chosen!

Those choosing mood show a lower additive constant (31) and only two strong performing elements

France – Only brand chosen frequently, with an additive constant of 47.

One brand element chosen, Carte Noire, but with a low coefficient, 8.

Germany – brand and mood chosen most frequently after aroma and taste.

Brand has an additive constant of 33, with the only brand performing well being Tschibo (coefficient of 9)

Mood has an additive constant of 47 but no mood or emotional elements score well!

Once again the data suggest a disconnect between what respondents say may be important and the strength of their reactions. When actually presented with that information in an element which paints a word picture, an element which instantiates the general idea, the element may not perform well.

Emergent Mind-Sets – Similar Patterns of Coefficients

A hallmark of Mind Genomics is the effort to uncover basic groups of individuals, with these groups showing similar patterns of behavior or responses to test stimuli. These test stimuli are granular in nature, such as our study of responses to coffee. The focus on granularity, on the rich specifics contained within the granularity means that these emergent basic groups, so-called mind-sets, represent the way people think about the particular topic, at the particular time. Mind Genomics does not try to create general groups of people, although these groups may emerge, such as the division of people into Elaborates, Imaginers, and Traditionals, names given to the three mind-sets emerging many times in the early work on foods [18].

The creation of these ‘mind-sets’ is done in a purely statistical fashion. The steps to create the mind-sets are listed below, and follow the well-accepted approach in statistics known as ‘clustering’ [20]:

  1. For a given dataset, create the individual-level models, expressed as: Transformed Rating = k0 + k1(A1) + k2(A2) …. K36(D9).
  2. Work only with the 36 coefficients, discard the additive constant k0.
  3. Compute the ‘distance’ between pairs of respondents using the expression: (1-Pearson Correlation, although expressed as 1-R).
  4. The Pearson Correlation measures the strength of a linear relation between two sets of measures (viz., the linear relation between the 36 pairs of coefficients for two respondents).
  5. The clustering program (k-means) puts the objects (viz., the respondents) into groups, based strictly on mathematical criteria, namely that the distance be large between the centroids (averages) of the groups (clusters) should be large, and the distances be small between the pairs of respondents.
  6. The analysis created both two clusters and three clusters.
  7. It is the researcher’s job to determine the underlying pattern, if any, for each country, for each mind-set. The criteria are to choose the smallest number of clusters (parsimony), as well ensure that the mind-sets tell a story (interpretability).
  8. There is no need to have the mind-sets for the three countries be the same
  9. Three clusters (mind-sets) emerged for the UK and for France, two clusters emerged for Germany.

Table 10 presents the strong performing elements by country and mind-set within country:

Table 10: Strong performing ‘coffee elements’ for three countries, by mind-sets for each country

table 10

UK: One large mind-set (UK-MS2) and two smaller mind-sets (UK-MS1 and UK-MS3).

The three mind-sets show approximately the same magnitude of the additive constant (43-50)

Only one of these mind-sets shows strong performing elements, UK-MS1.

Mind-Set UK-MS3 shows only one strong performing element, AE2 Fresh coffee, made from 100% Colombian coffee beans.

France: Two large mind-sets (FR-MS1, FR-MS3) and one small mind-set (FR-MS2).

The additive constants and the strong performing elements are different.

FR-MS1 shows the highest additive constant (72), and react most strongly to descriptions of emotional experience.

FR-MS2, the smallest mind-set, shows strong responses to the elements. The base size of 11 respondents in FR-MS2 may be too low to assume FR-S2 is a ‘real’ mind-set. It may simply be the result of forcing the clustering to come up with three mind-sets.

FR-MS3 responds strongly to statements about product and features (Question A)

Germany: Only two mind-sets emerged for Germany, with the third mind-set having very respondents, and thus not shown.

All elements for Germany come from product and features (Question A).

In most Mind Genomics studies the search for mind-sets generates strongly defined, exceptionally different groups. Surprisingly, this does not seem to be the case for coffee, despite the hundreds of millions of dollars spend on advertising. It may well turn out that there is simply not enough differences among coffees to create sharply different mind-sets, based simply on description. That is, ‘coffee may just be coffee.’ There are not enough intrinsic features in coffee to drive radically different mind-sets, despite the popularity of coffee, or perhaps the underlying reason for that popularity!

Discussion

Improving Research by Reducing Bias

The approach presented here with coffee emerges with some clear patterns, the clearest of which is that the strongest performing elements in these Mind Genomics studies come from the question about product description. Although the respondents are presented by systematically varied vignettes, combinations of messages, and cannot possible ‘game’ the system, they act in a consistent manner. It is impossible to know the ‘correct’ answer when presented with a rapidly changing set of 60 vignettes. The demands on the respondent are very strong, and militate against overthinking. Yet again and again what emerges are the same types of messages. No matter how we attempt to provide additional types of information the pattern re-emerges. Only a few messages are strong.

It is important to reiterate the fact that the design in this study prevents bias. With the continuing presentation of vignettes, most respondents simply ‘turn off,’ responding automatically. The data do not suggest that the respondent down-rates the vignettes out of irritation. Yet, in many ‘exit interview’ respondents have said, by way of complaint that they felt they were guessing, that they were unable to discern a pattern which would lead to the ‘correct answer. Respondents do try to guess in these situations. The fact that they cannot discern the pattern simply means that they must react at an intuitive level, or react randomly. Yet, if respondent were to react randomly, then we would see many more elements from Questions B, C and D emerging as strong performers. They do not. The respondents do respond in a truthful manner, even if the respondents do not think so. The result may be the accuracy emerging by of averaging well-meaning ‘guesses’, with the result being the ‘correct answer’ as Surowiecki discusses in his work on the Wisdom of the Masses [21].

To summarize the differences then, the conventional questionnaire instructs the respondents to think about different aspects of the product and situation, in our case here ‘coffee.’ The respondent may be asked dozens of questions. The pattern of responses gives us an idea of how the respondent feels about coffee. The respondent may subconsciously change the responses to questions to be perceived as consistent. Indeed, the emphasis is often on answering consistently, digging into one’s own thinking to answer the question as best as possible. The interview can be perceived as a test, and there is always the worry about ‘interviewer bias,’ a concern with a history of at least three quarters of a century [22-24]. In contrast, the Mind Genomics approach creates an experiment, comprising known combinations of messages, presents these combinations, acquires the response, and estimates the driving power of each element.

A New Type of Insight

Traditional research in the world of psychology and consumer behavior has focused on attitudes towards product or services, looking at the way different ‘types’ of people respondent, or looking at how some antecedent experimental manipulation affects the response. From these data, whether through discussion, observation, or experimentation, the researcher is able to fill one more ‘hole in the literature,’ one more gap in the web of knowledge. It is through the accretion of these pieces of information, individual moments of insights, and the integrative ability of analysts with a wide scope and imagination, that the ‘story’ builds, and understanding increases.

The approach presented here, while incomplete by necessity, provides a grander, more holistic view of the topic. The study here on coffee is not only on one particular problem, one recurrent issue, but is rather an attempt to create a new type of database, multi-dimensional in nature. On the one hand we have the topic, coffee, which has been well explored on different, scientifically relevant dimensions. On the other hand, we have a product consumed around the world, which, when examined closely, lacks a deep reservoir of integrated information about the nature of people and coffee. We don’t know what messages attract people. We know that people differ, but we don’t know how they differ. Nor do we have any real idea of the co-variation of factors, such as the responsivity of individuals to coffee messages, these individuals classified by who they are, when they participate, what they hold to be important, and so forth.

The Mind Genomics paradigm creates this type of information, doing so easily and quickly. Rather than plugging ‘holes’ in the literature, closing gaps, and growing science one finding at a time, Mind Genomics becomes a holistic knowledge-development tool, creating information that is both novel and in fact occasionally fascinating.

Creating Large Databases

As emphasized throughout this paper, Mind Genomics is actually a well-constructed experiment with defied independent variables and responses. The outcome of the experiment is a database. This set of three studies shows how one can construct the database for three countries, for one product, working with respondents from each country. The studies are rapid, taking days, and cost-efficient, with estimates today as of this writing being $4-$6 per respondent for a smaller version of Mind Genomics (16 elements), with easier to find respondent. Thus, in terms of economics, the per country cost of a Mind Genomics study with 16 elements, rather than 36, is less than $1,000, low by today’s standards. Indeed, the potential exist for the enterprising consumer researcher or marketer to spend less than $100,000 to create a world-wide database of a particular product, at a particular point in time. We can only speculate about the vast increase in knowledge this database will bring, across cultures, across time, and across different mind-sets within a culture. The dream of the It! Studies, developed around the year 2000, is now immediately doable by virtually anyone (see www.BimiLeap.com and www.PVI360.com)

Acknowledgments

The author gratefully acknowledges the foundational work for Eurocrave, sponsored by Firmenich in Switzerland, with the guidance and help of Pieter Aarts of ScentTaste (Belgium), and Klaus Paulus (Germany). The late Hollis Ashman of the Understanding and Insight Group in the USA did much of the design work prior to the study, and analytics after the study.

References

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BMI and Physical Activity in College Students Assessed Using the International Physical Activity Questionnaire (IPAQ)

DOI: 10.31038/NRFSJ.2022521

Abstract

A volunteer sample of 100 first-year college students were recruited to examine their body fat percentage levels and to investigate the association between their body fat and their levels of physical activity. Body fat percentage scores were regressed stepwise on college students’ vigorous physical activity, moderate physical activity, walking, and gender. The results of the regression indicated that the model explained 35.0% of the variance, and two factors such as vigorous PA and gender were significant predictors of first-year college students’ body fat percentage, F(1.78)=56.00, p<0.001. The rest of the variables entered were the moderate PA and walking, and these were not significant factors.

Keywords

BMI, Physical Activity, IPAQ

Introduction

More than 70% of U.S. adults and 30% of college students were classified as either overweight or obese, and it is reported that 18.4% of adolescents were classified as obese [1-6]. Although the etiology of obesity is multifactorial, insurmountable evidence supports the premise that obesity is highly correlated with physical inactivity [7,8]. Of the various factors leading to obesity in college students, physical activity levels have been consistently reported to be a significant factor in maintaining normal body weight and lowering the risks of developing chronic conditions, including type II diabetes, heart diseases, hyperlipidemia, and hypertension [9,10]. To prevent young adults from developing chronic diseases, the American Health Association (AHA) recommends individuals get at least 150 minutes per week of moderate-intensity aerobic physical activity [11,12]. Despite this recommendation, only half of the adults aged 18 and over met the 2008 federal physical activity guidelines from 2016 to 2018 [13]. In a meta-analysis conducted by Keating and his colleagues (2005) on the college students’ physical activity levels, they found that half of the college student population did not meet the AHA’s recommended physical activity [14]. It is noteworthy that according to an observational study by Clemente et al. (2015), male students walked more steps and spent more time in a moderate and vigorous activity than female students [15-17].

Examining the levels of physical activity requires a thorough process of measuring all types of physical activities and calculating the energy expenditure associated with each type and level of physical activity. International Physical Activity Questionnaire (IPAQ) is designed to measure individuals’ level of physical activity and its metabolic equivalents (METs), allowing researchers to examine the relationship between these factors [18]. Liu and his colleagues’ study conducted in 2015 demonstrated that physical activity levels were a mediating factor in the subjects’ body mass index measured by the IPAQ forms. They also found that lower BMI scores were positively correlated with moderate and vigorous physical activity, while higher BMI scores were positively correlated with insufficient physical activity [19]. A cross-sectional study of a volunteer sample of 738 college students conducted by Huang and his colleagues that examined the collective effects of dietary intake and physical activity on college students’ BMI found a correlation between physical activity and BMI in late adolescents and early adults, supporting the hypothesis that physical activity was a significant predictor of BMI [20].

The BMI has been widely used in research and clinical practice in the last 30 years when reporting adults’ obesity in predicting their health risks for chronic diseases. However, Coral and his colleagues pointed out the limitations of the BMI measure in a cross-sectional study of 13, 601 subjects from the National Health and Nutrition Examination Survey (NHANES): the diagnostic accuracy of BMI in measuring adiposity is limited because the BMI does not account for variations in body composition (i.e., the relative proportion of total fat versus skeletal muscle mass) [21-23]. Therefore, it is a concern when research is aimed at predicting college students’ future health risks based on the BMI measure because some college students who are either athletes or are extremely muscular were misclassified as obese. To address this concern, the National Heart, Lung, and Blood Institute recommends using not only BMI but other anthropometric measures that are a good indication of individuals’ health risks, including body fat percentage, waist circumference, and waist-hip ratio. In the past decades, numerous studies have steadily reported the danger of college students’ weight gain based on their BMI. However, only a small portion of the research measures college students’ obesity using BMI and anthropometric measures to predict their future health risks [24-27]. Despite a multitude of studies reporting first-year college students’ weight gain, the majority of the findings of such studies did not measure the first-year college students’ baseline anthopometric information [28]. Thus, this study aimed to measure in-coming first-year college students’ baseline obesity before their exposure to the college lifestyle and investigate the association between young adults’ body fat percentage levels and their physical activity levels.

Methodology

Subjects

A volunteer sample of 100 college freshmen was recruited from a total of 900 incoming freshmen in Fall 2015. Recruitment strategy was conducted through trained undergraduate student volunteers. These volunteers were visiting the foyers of college resident dormitories to distribute flyers to freshman students on the opportunity to participate in this study.

Procedures

Before participating in this research researchers handed out informed consent forms to explain the purpose of the research and any potential harms and benefits and discomforts that were associated with participating this research in order to prevent any potential harms or coercion of student participants. After that, participants were asked to complete a survey that asks questions about their eating behaviors and physical activity. The questions are general and do not imply that they are in any inappropriate behavior. The survey takes about 25 minutes to complete. After survey completion, participants’ height, weight, waist circumference, tricep skinfold and calf skinfold were measured.

Measures

International Physical Activity (IPAQ) short form was used to measure college students’ physical activity levels, and anthropometric (physical measures) were be taken for height, weight, waist circumference, tricep skinfold and calf skinfold using standardized protocols from National Institute of Health (NIH).

Results

Demographic Information

Of the 100 first-year college students in the study, 57% (n=57) were males and 43% (n=43) were females. The mean age was 18.53 (SD=1.20) for males and 18.26 (SD=0.51) for females, where the youngest students were 18 year old and the eldest were 25 years old. Table 1 depicts the participants’ anthropometric data, including weight in kilogram, and height, waist, and hip in centimeters.

Table 1: Participants’ Anthropometric Information

Weight (kg)

Mean (SD)

Height (cm)

Mean (SD)

Waist

Mean (SD)

Hip

Mean (SD)

Body Fat

Mean (SD)

Male

72.80 (13.24)

174.02(9.96)

80.32(9.72)

98.77(7.75)

14.04(6.45)

Female

64.06(16.77)

161.62(7.42)

79.06(13.55)

99.78(10.78)

25.21(9.11)

Body Fat Percent Distributions by Gender

As illustrated in Table 2, the study subjects (n=100) were classified as essential fat (n=7), athletes (n=35), fitness (n=18), acceptable (n=26), and obese (n=14) based on the American Council on Exercise (ACE)’s fat norms for men and women. The majority of male students (n=39, 90.7%) and female student (n=47, 82.5%) were found to be within the normal body fat percentages. Concerning the first-year students’ obesity, obesity rates of females were almost twice higher than that of males: 9.3% of male and 17.5% of female students, respectively.

Table 2: ACE’s Body Fat Percentage Distributions by Gender

American Council on Exercise (ACE)’s Fat Norms for Men and Women

Essential Fat

Athletes

Fitness

Acceptable

Obese

Men

(2-5%)

(6-13%)

(14-17%)

(18-24%)

(>25%)

Women

(10-13%)

(14-20%)

(21-24%)

(25-31%)

(>32%)

This Study
Men

7.0% (n=3)

58.1% (n=25)

11.6% (n=5)

14.0% (n=6)

9.3% (n=4)

Women

7.0% (n=4)

17.5% (n=10)

22.8% (n=13)

35.1% (n=20)

17.5% (n=10)

The statistical analysis verified a significant difference in the mean body fat percentage of male students compared to that of female students (Welch’s two-sample t-test: t=-7.309 with df=98, p<0.05). The mean body fat percentages of the male students were 14.04% (SD=6.45), and those of the female students were reported to be 25.21% (SD=9.11).

Levels of Physical Activity by Gender

As seen in Table 3, descriptive data analyses on college students’ levels of physical activity showed that male students engaged in more days of physical activities per week compared to female students.

Table 3: Mean Days of Physical Activities (PA) per Week

   

Male

   

Female

   
Days of PA  
Per Week

n

Mean

SD

n

Mean

SD

P-value

Vigorous PA

43

3.19

2.42

57

1.33

1.84

0.00*

43

4.16

2.51

57

3.00

2.19

0.09

43

5.33

2.33

57

4.91

2.22

0.77

(Note: Physical Activity (PA), * Statistically significant at 0.05)

Of the three levels of physical activity, the most common type of physical activity was walking in both male and female students: 5.33 days for males and 4.91 days per week for females. It is noteworthy that there was a statistically significant difference in first-year students’ mean days of vigorous physical activity per week. Specifically, the mean days of vigorous physical activity per week for male students was almost three times higher than those of the first-year female students: t=7.619 (df=98), p<0.05.

Predictors of Obesity by Levels of Physical Activity and Gender

The main purpose of this study was to assess the association of body fat percentage scores with college students’ vigorous physical activity, moderate physical activity, walking, and gender in the context of stepwise regression. Before each of the possible predictor entered into the regression equation one at a time, the main assumptions of the multiple regression models were examined. The normal Q-Q plots were used to check the normality of the data, which appears to be normally distributed. The multicollinearity test showed all the factor’s VIF scores were less than four, which implies that the predictors were not highly correlated with each other. The results of the regression in Table 4 indicated that the full model explained 35% of the variance in body fat percentages, and vigorous PA and gender were two significant predictors of first-year college students’ body fat percentage: F(1.78)=56.00, p<0.001. The rest of the variables entered were the moderate PA and walking, and these were insignificant factors.

Table 4: Regression results of body fat percentages dependent on vigorous PA, moderate PA, waking, and gender

Step

Variables

R2

AdR2

R2 Change

p-value

1

Vigorous PA

0.06

0.51

0.60

0.01*

2

Moderate PA

0.07

0.05

0.01

0.19

3

Walking

0.10

0.07

0.02

0.08

4

Walking

0.35

0.33

0.25

0.00

*Statistically significant at 0.05

Discussion/Limitations

The incoming first-year college students’ body fat levels were measured by the average thickness of subcutaneous fat in their two body regions, including calf and triceps. Surprisingly, the average body fat percentages of the participants were found to be lower than the national obesity rate of young adults. However, it is noteworthy that the first-year female students’ body fat percentage was reported to be almost twice higher than that of male students.

The mean days of different types of physical activity per week were compared between the male and female students to see if there were any gender differences of body fat levels, and the vigorous physical activity was shown to be an important factor among the three types of physical activities: vigorous physical activity, moderate physical activity, and walking. When three types of the physical activity levels were entered into the stepwise regression along with the gender factor, vigorous level of physical activity and gender were the significant factors in explaining the levels of the first-year college students’ body fat percentages. In addition, when the vigorous physical activity level was entered in the model, it accounted for six percent of the variance, and this indicates that first-year students who were engaging in the vigorous level of physical activity were less likely to be obese.

There were some limitations of this study that might influence the result. One of the weaknesses of this study might be the fact that the first-year college students’ levels of physical activity were measured by an instrument that heavily relies on participants’ recall and self-report in nature. Although the IPAQ-SF’s validity and reliability were well-documented in several studies, one of the common drawbacks of the IPAQ-SF was that it tends to overestimate physical activity levels.

While first-year college students’ body fat percentage levels were found to be lower than the national average young adults’, the timing of the body fat measurement could be an important factor leading to a lower body fat percentage of the subjects. The first-year students’ body fat was measured during the freshman orientation period rather than few months into their academic semester where they could be exposed to different college lifestyle related factors, including types of food choices, levels of stress, academic demands. Lastly, anthropometric data such as body weight, height, and waist and hip circumference were collected from the first-year college students; therefore, there is a potential sample bias that participants who were reluctant to disclose their anthropometric data could have been excluded from this study.

Conclusion

Obesity rates of first-year female students were to be almost twice higher than those of male students. Such gender gap could be explained by the type of physical activity performed, where male students were more often doing the vigorous level of physical activity than the female students.

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fig 1

Review on the Skeletal Effects of Rapid Palatal Expansion in Late Mixed Dentition

DOI: 10.31038/JDMR.2022524

Abstract

Introduction: Rapid palatal expansion is utilized in Orthodontics to treat maxillary transverse deficiencies. Such deficiencies can cause functional defects, misalignments, and mandibular shifts that can impact one’s function, comfort, and quality of life. This review aimed to synthesize the clinical findings of rapid palatal expanders.

Methods: A literature search of skeletal effects of maxillary rapid palatal expansion was performed using PubMed and Google Scholar. Inclusion criteria consisted of studies that measured changes in maxillary width over at least one year of expansion and retention or radiographic confirmation of skeletal expansion with a sample size of over 15 subjects. Exclusion criteria were subjects with developmental defects, such as cleft palate, or any type of surgical assisted rapid palatal expansion. A total of 12 articles were found from January 1990 to April 2022 and included in this review.

Results: All 12 articles reported that rapid palatal expansion notably increases the maxillary skeletal transversal dimension. Across all studies, the amount of intercanine expansion from rapid palatal expansion ranged from 2.5 to 4.0 mm, and the amount of intermolar expansion ranged from 3.9 to 6.5 mm. The studies also showed a significant expansion of nasal cavity (airway), various facial sutures being affected, occurrence of buccal tipping of all maxillary teeth, mandibular spacing being gained, and that relapse, although present, had an insignificant effect on the long-term retention of expansion.

Conclusion: Rapid palatal expanders are effective in producing both immediate and long-term transverse expansion in subjects in late mixed dentition.

Keywords

Rapid palatal expansion, Mixed dentition, Orthodontics, Tooth-borne, Maxillary expansion, Midpalatal suture, Computed tomography analysis, Retention, Skeletal changes

Introduction

Rapid palatal expansion (RPE) is utilized in Orthodontic treatment to correct maxillary transverse deficiencies. Patients with maxillary transverse deficiencies may present with functional problems such cross bites, misaligned teeth due to lack of arch coordination, and even mandibular shifts that can develop into future skeletal asymmetry [1]. RPE treatment has long been advocated to solve maxillary constriction. There is a wide variety of maxillary palatal expansion appliances in use today, all with similar effectiveness [2].

The American Association of Orthodontics states that the most critical factor for RPE success is timing and thus routine orthodontic screenings in children are highly recommended to diagnose and treat problems such as cross bites [3]. RPE is most effective in children and young adolescents because their palatal and maxillary sutures are still malleable, as they have not yet completely fused. Transverse expansion of the maxilla is accomplished by banding an expander appliance on the patient’s upper dentition; the appliance has an inbuilt jackscrew that is turned to provide leveraged force that pushes the appliance apart, which then provides force that widens the skeletal base of the palate. Most of the force is applied to split the midpalatal suture; however, the pterygopalatine, inter maxillary, intranasal, maxillonasal, front maxillary, and frontonasal sutures are also affected [4]. Early indicators of maxillary expansion success is evident by the formation of a diastema between the front teeth and an increased intermural width. When these sutures are completely fused, usually by early adulthood, they require more invasive methods of separation such as surgical or manipulate induced separation of the sutures.

It is critical to note that maxillary expansion is one of the most difficult procedures to achieve and maintain, due to the body’s tendency for relapse from disruption of the neuromuscular equilibrium including factors such as (but not limited to): teeth tipping back, incomplete alveolar bone remodelling (necrosis or fenestrations), and periodontal fiber inelasticity. Multiple studies have found that rapid palatal expanders have relapse rates of up to 60% [5,6]. Additionally, because the force is distributed between the maxilla and the teeth, this expansion is a combination of both dental tipping and skeletal expansion, even though purely skeletal expansion is what is desired as the expansion from the dental tipping relapses quickly (within one year) as the teeth upright over time due to equilibrating intraoral pressures [1].

While there are many individual studies that present the results of RPE, the aim of this study is to present a more focused review. Many earlier studies presented the immediate effects of RPE but did not account for the fact that maxillary expansion often partially relapses after treatment, thus overestimating expansion. Studies included in this review had either: 1) skeletal effects of expansion verified through radiographic analysis (such as confirming sutural bone deposition or transverse maxillary bone deposition) or 2) sufficient elapsed time (1 year) for the bone to remodel and teeth to be stable in their new expansive positions. This study also distinguishes between anterior and posterior maxillary expansion and presents intercanine and intermural distance in order to present quantifiable data. The data provided in this study can be useful for clinicians to predict the changes in intercanine and intermural distances to help clinician’s treatment plan more effectively.

Methods

This study consisted of a literature review in which the sources were all obtained from a search through published papers in PubMed and Google Scholar. Search terms included RPE; rapid palatal expansion; retention; radiographic analysis; tooth-borne; maxillary expansion; midpalatal suture; mixed dentition; computed tomography analysis; retention; skeletal changes.

Inclusion and Exclusion Criteria

Inclusion criteria consisted of only English language articles from January 1990 to April 2022 that included sufficient elapsed time (>1 year follow up) or radiographic confirmation of skeletal expansion. Only studies with a sample size greater than 15 subjects were considered.

Exclusion criteria consisted of studies involving patients with developmental defects such as cleft lip or palate or developmental disorders and those with miniscrew-assisted rapid palatal expansion and surgically assisted rapid palatal expansion.

Study Selection

A total of 501 articles were found from Pubmed (n=220) and Google Scholar (n=281). After removing duplicates and screening by inclusion/exclusion criteria, a total of 12 articles met the selection criteria (Figure 1).

fig 1

Figure 1: Literature search flow chart

Results

Across all twelve studies, the range of intercanine expansion was 2.5-4.0 mm; the range of intermural expansion was 3.9-6.5 mm (Table 1). The control for intercanine expansion ranged from 0.05 to 3.0 mm, and for intermural expansion, the control ranged from 0.02 to 0.8 mm. When broken down by using radiographic versus cast analysis: Half of the 12 studies analysed RPE radiographically and found intercanine expansion ranged from 2.5 mm to 3.5 mm whereas the controls ranged from 0.25 mm to 0.30 mm expansion. Intermural expansion ranged from 4.5 to 6.0 mm whereas control ranged from 0.02 mm-0.80 mm. The other 6 studies analysing the casts of RPE patients found that RPE intercanine expansion ranged from 2.9 to 4.0 mm whereas the control ranged from 0.05 mm to 0.30 mm. Intermural expansion ranged from 4.4 to 6.1 mm, and control ranged 0.55 mm to 0.61 mm. One meta-analysis analysing 18 studies revealed an overall average gain in intercanine dimension of 2.91 mm and intermural expansion of 4.38 mm. Together, these studies support existing literature that rapid palatal expanders are effective in promoting transverse expansion.

Table 1: Summary of Findings – Changes in Intercanine & Intermolar Widths, Experimental vs. Control

(Article Number) Author Last Name

Average Age, (Sample Size) Experimental-Intercanine Expansion Experimental-Intermolar Expansion Control-Intercanine Width Control-Intermolar Width
(1) Mehtaa [7]

13.9 ± 1.14 (21)

N/A 6.1 N/A .02
(2) Kavand [8]

14.4 ± 1.3 (18)

N/A

4.5 N/A N/A
(3) da Silva [9]

8.0 (32)

3.05 ± 1 5.05 ± 1.0 0.04 0.55
(4) Reed [10] 13.3 (55) N/A 5.4 ± 2.1 N/A N/A
(5) Bazargani [11] 9.3 (26) 2.5 4.75 ± 1 0.25 0.80
(6) Celenk-Koka [12] 13.8 ± 1.4 (20) N/A 4.2 ± 1.7 N/A N/A
(7) McNamara [13] 12.2 ± 1.3 (112) 3.9 ± 2.7 4.4 ± 1.8 0.30 0.60
(8) Fenderson [14] 11.7 ± 1.7 (41) 3.9 ± 5.8 6.1 ± 2.3 N/A N/A
(9) Geran [15] 8.8 (51) 4.0 4.3 0.21 0.70
(10) O’Grady [16] 9.0 (27) 4.0 3.9 0.30 0.55
(11) Moussa [17] 13.7 (165) 2.5 5.5 0.05 0.60
(12) Adkins [18] 14.0 (21) 2.9 ± 1.4 6.5 ± 1.2 N/A N/A

Anatomically, the studies found that patients undergoing RPE underwent a significant increase in maxillary width, nasal cavity, and nasopharynx volume as well due to midpalatal suture expansion [1,2,4,8,9,10]. Most of the patient groups demonstrated a triangular-shaped sutural opening that was wider anteriorly, and that the arch development in the maxilla resulted in a complimentary 2.5 mm average space gain in the mandibular arch perimeter as well [1,3,4]. In terms of the dent alveolar changes, the studies found that RPE resulted in slight palatal movement of maxillary incisors, mild buccal crown tipping of all the maxillary dentition, with up righting of the mandibular dentition as a result of the curve of Wilson being levelled over time [2,6,7,9,10].

Discussion

Rapid palatal expanders have been used to increase the maxillary transverse dimension. While there are many individual studies examining the effect of rapid palatal expanders, this literature review presents quantifiable clinical results of expansion verified through stable retention. The existing reviews in the literature focused on RPE’s effects on other anatomical structures or analysed surgically assisted rapid palatal expansion. This review adds to the literature by synthesizing non-surgical RPE clinical finding.

The average age of patients across the studies ranged from 8.0 to 14.4 years old and had either mixed dentition or permanent dentition. Rapid palatal expanders have long been recommended for children and young adolescents before the palatal and maxillary sutures have fused. Because skeletal changes are less significant when matured due to increased rigidity [19], timing of treatment is important. Notably, our results showed that patients in early permanent dentition had more intermural width expansion. Sari et al compared rapid maxillary expansion in mixed dentition (average age 9.2 years) and early permanent dentition (average age 12.7 years) and found that intercanine and intermural widths increased and remained stable in both the mixed dentition and permanent dentition groups [20]. However, subjects in mixed dentition showed a greater tipping of the anchorage teeth and less increases in the ANB angle [20], suggesting that it might be better to delay RPE treatment until early permanent dentition. Another study evaluated the effects of RPE according to cervical vertebrae maturity, with the group treated before the pubertal peak (average age 11 years) showing significantly greater maxillary skeletal and intermural width compared to those treated after (average age 13.6 years) [21]. Based on our review, it appears that treatment with rapid palatal expanders is effective in both mixed and early permanent dentition with an emphasis to treat patients before palatal sutures fuse.

Furthermore, our study evaluated articles that had radiographic evidence of expansion or sufficient elapsed time for remodelling to be stable (>1 year). The results showed a retained increase in intercanine and intermural width. Many studies suggest a significant relapse in maxillary expansion following RPE with one study finding no significant difference in relapse rate between mixed or permanent dentition [22]. Contrarily, other studies have found good stability for intercanine and intermural widths following treatment [17,23], consistent with our findings. However, long-term stability of rapid palatal expansion still seems to be questionable with mixed results across studies. The short-term results are consistent [24], showing significant palatal and/or dental expansion. Nevertheless, orthodontists may experience some long-term relapse in intercanine and intermural expansion everyday practice due to natural neuromuscular equilibrium forces. Orthodontists can utilize the findings of this study to better accurately predict the amount of intercanine and intermural expansion that can be utilized to align the teeth. For this reason, long-term follow-up of children treated with RPE is important.

Limitations

One limitation of this review is that not all articles included control values for intercanine and intermural widths. Except for two studies, each study had uniquely different presentations of their findings. For example, some studies looked into sutural expansion, arch length (in addition to width), tipping of teeth, nasal/oropharyngeal cavity changes, and bone density/deposition to name a few. Additionally, variation in operator technique, RPE design, patient compliance, slight age variations, and physiologic differences are just a few of the factors that add to the complexity of synthesizing various studies.

Conclusion

Rapid palatal expanders are effective in promoting transverse expansion in subjects in late mixed dentition. When timed appropriately, RPE can be utilized to successfully promote maxillary expansion. A future review could focus on a more thorough, dual approach: combining long-term follow-up along with cone beam computed tomography measurements of skeletal expansion. Future review could also compare expansion in pure primary dentition vs early adolescent (mixed) dentition.

References

  1. Proffit WR, Fields HW, Sarver DM (2007) Contemporary Orthodontics St Louis: Mosby 689-693.
  2. Agarwal A and Mathur R (2010) Maxillary expansion. Int J Clin Pediatr Dent 3(3):139-146. [crossref]
  3. Baccetti T, Franchi L, Cameron CG, et al. (2001) Treatment timing for rapid maxillary expansion. Angle Orthod, 71(5), 343-350. [crossref]
  4. Ghoneima A, Ezzat AF, James H, et al. (2011) Effects of rapid maxillary expansion on the cranial and circummaxillary sutures. Am J Orthod Dentofacial Orthop 140(4): 510-519. [crossref]
  5. Bishara Samir E and Staley RN (1987) Maxillary expansion: clinical implications. Am J Orthod Dentofacial Orthop, 91(1): 3-14. [crossref]
  6. Velazquez P, Benito E, and Bravo LA (1996) Rapid maxillary expansion: A study of the long-term effects. Am J Orthod Dentofacial Orthop 109(4): 361-367. [crossref]
  7. Shivam M, Wanga D, Chia-Ling K, et al. (2021) Long-term effects of mini-screw-assisted rapid palatal expansion on airway: A three-dimensional cone-beam computed tomography study. Angle Orthod 91(2): 195-205. [crossref]
  8. Golnaz K, Lagravère M, Kula K, et al. (2019) Retrospective CBCT analysis of airway volume changes after bone-borne vs. tooth-borne rapid maxillary expansion. Angle Orthod 89(4): 566-574. [crossref]
  9. Silva Filho OG, Prado Montes LA, and Torelly LF (1995) Rapid maxillary expansion in the deciduous and mixed dentition evaluated through posteroanterior cephalometric analysis. Am J Orthod Dentofacial Orthop 107(3): 268-275. [crossref]
  10. Reed N, Ghosh J and Nanda RS (1999) Comparison of treatment outcomes with banded and bonded RPE appliances. Am J Orthod Dentofacial Orthop 116(1): 31-40. [crossref]
  11. Bazargani F, Feldmann I, Bondemark L (2013) Three-dimensional analysis of effects of rapid maxillary expansion on facial sutures and bones: a systematic review. Angle Orthod 83(6): 1074-1082. [crossref]
  12. Celenk-Koca T, Erdinc AE, Hazar S, et al. (2018) Evaluation of miniscrew-supported rapid maxillary expansion in adolescents: a prospective randomized clinical trial. Angle Orthod 88 (6): 702-709. [crossref]
  13. McNamara JA, Baccetti T, Franchi L, et al. (2003) Rapid maxillary expansion followed by fixed appliances: a long-term evaluation of changes in arch dimensions. Angle Orthod 73(4): 344-353. [crossref]
  14. Fenderson FA, McNamara JA, Baccetti T, et al. (2004) A long-term study on the expansion effects of the cervical-pull facebow with and without rapid maxillary expansion. Angle Orthod 74(4): 439-449. [crossref]
  15. Geran RG, McNamara JA, Baccetti T, et al. (2006) A prospective long-term study on the effects of rapid maxillary expansion in the early mixed dentition. Am J Orthod Dentofacial Orthop 129(5): 631-640. [crossref]
  16. O’Grady PW, McNamara JA, Baccetti T, et al. (2006) A long-term evaluation of the mandibular Schwarz appliance and the acrylic splint expander in early mixed dentition patients. Am J Orthod Dentofacial Orthop 130(2): 202-213. [crossref]
  17. Moussa R, O’Reilly MT and Close JM (1995) Long-term stability of rapid palatal expander treatment and edgewise mechanotherapy. Am J Orthod Dentofacial Orthop 108(5): 478-488. [crossref]
  18. Adkins MD, Nanda RS, Currier GF (1990) Arch perimeter changes on rapid palatal expansion. Am J Orthod Dentofacial Orthop 97(3): 194-199. [crossref]
  19. Wertz RA (1970) Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Orthod 58(1): 41-66. [crossref]
  20. Sari Z, Uysal T, Usumez S, et al. (2003) Rapid maxillary expansion. Is it better in the mixed or in the permanent dentition? Angle Orthod 73(6): 654-661 [crossref]
  21. Baccetti T, Franchi L, Cameron CG, et al. (2001) Treatment timing for rapid maxillary expansion. Angle Orthod 71(5): 343-350. [crossref]
  22. Mohan CN, Araujo EA, Oliver DR, et al. (2016) Long-term stability of rapid palatal expansion in the mixed dentition vs. the permanent dentition. Am J Orthod Dentofacial Orthop 149(6): 856-862. [crossref]
  23. Mew J (1983) Relapse following maxillary expansion: a study of twenty-five consecutive cases. Am J Orthod 83(1): 56-61. [crossref]
  24. Ciambotti C, Ngan P, Durkee M, et al. (2001) A comparison of dental and dentoalveolar changes between rapid palatal expansion and nickel-titanium palatal expansion appliances. Am J Orthod Dentofacial Orthop 119(1): 11-20. [crossref]
fig 1

Neurosarcoidosis: What are the Evocative Signs on Magnetic Resonance Imaging (MRI)

DOI: 10.31038/JNNC.2022513

Clinical Image

Neurosarcoidosis is known as the involvement of the central nervous system in sarcoidosis, usually affects patients between 30 and 40 years of age, more predominantly in women. It can affect different organs such as the lung, lymph nodes, eyes, joints and more rarely (5% of cases) the central nervous system, which manifested with a clinical and radiological polymorphism that makes the diagnosis more difficult. Clinical symptomatology is very variable, rarely isolated without systemic sarcoidosis involvement, and in some cases the diagnosis is made only based on imaging data; if signs are present, they would be related to the type of intracranial involvement (leptomeningeal, pachymeningeal, parenchymal, pituitary stalk, etc.): headaches (hydrocephalus), endocrine signs of hypothalamic or pituitary involvement: diabetes insipidus, optic nerve involvement, facial nerve palsy, general signs: Tiredness, joint pain [1].

The diagnosis is difficult and relies on the Association of clinical and paraclinical arguments. The main ones are magnetic resonance imaging, cerebrospinal fluid study, intradermal tuberculin reaction, phosphocalcic and angiotensin-converting enzyme evaluation. MRI identified lesions present an iso or hyperintense signal in T1 signal, variable signal in T2, hypo signal diffusion with high ADC, are intensely and homogeneously enhanced after injection, and may involve a single or several compartments [2].

Pachymeninge

Thickening of the pachymeninges, which is most often in hyposignal, T2 enhances homogeneously.

fig 1

Figure 1: Brain MRI in a 56-year-old woman, partial left convulsive seizure for 3 months, shows an extra axial mass of the right frontal convexity in heterogeneous signal T2 (red arrow) with subcortical oedema (blue star) in Axial T2 and Flair (a, b). Without restriction on diffusion. In SWI (c) shows a leptomeningeal hemosiderosis, homogeneously enhanced in T1 contrast enhanced (d). This mass infiltrates the cortical sulci, with enhancement of the pachymeninges and leptomeninges (e, f).

Leptomeninges

The key sequence is contrast-weighted T1, shows focal or general leptomeningeal enhancement, node or smooth, about the basal aspects of the brain and the polygon of Willis ; sometimes it goes along the spaces of the Wirshow Robbin, as it may mimic parenchymal lesions.

Parenchyma

Parenchymal involvement is the most common and diverse, appearing as intraparenchymal masses or nodules, periventricular white matter involvement, or extension of leptomeningeal lesions through perivascular spaces.

Hypothalamic and Pituitary

Frequently associated with more extensive leptomeningeal involvement, as it can be isolated, it is observed in some cases only in the infundibulum.

Cranial Nerve

All cranial nerves can be affected, either in isolation or as part of a diffuse leptomeningeal injury. The two nerves that are most sought after are the facial nerve, which is often symptomatic, and the optic nerve [3].

The most important differential diagnoses of neurosarcoidosis are meningioma, dural metastasis, idiopathic hypertrophic cranial pachymeningitis, tuberculous, metastasis, lymphoma, multiple sclerosis, ADEM, primary brain tumors. Treatment based on corticosteroids is recommended as first-line therapy in patients with neurosarcoidosis, although immunosuppressive drugs are usually added due to the chronic course of this condition and to limit the side effects of steroids. With high rate of relapses.

References

  1. Shah R, Roberson GH, Curé JK (2009) Correlation of MR imaging findings and clinical manifestations in neurosarcoidosis. AJNR Am J Neuroradiol 30: 953-961. [crossref]
  2. Smith JK, Matheus MG, Castillo M (2004) Imaging manifestations of neurosarcoidosis. AJR Am J Roentgenol 182: 289-295. [crossref]
  3. Mahi M, Semlali S, En-Nouali H, Karouache A, Satte A, et al. (2007) Imagerie de la neurosarcoïdose. Feuillets de Radiologie 47: 357-362.