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From the Townsend Letter
December 2013

briefed by Jule Klotter
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Acupuncture and PTSD
Clinical and animal studies indicate that acupuncture is a helpful adjuvant therapy for several mental conditions, including anxiety and depression; but evidence for its value in treating PTSD is still meager, according to a Korean review article led by Young-Dae Kim. The Korean researchers used four randomized controlled trials and two uncontrolled clinical trials. Five studies involved earthquake victims in China. The sixth, which the reviewers assessed as having the highest quality, was a randomized controlled US pilot study.

The US study, led by Michael Hollifield, MD, at the University of Louisville's School of Medicine (Kentucky), involved 84 patients with a PTSD diagnosis and a Posttraumatic Symptom Scale-Self Report (PSS-SR) score of  ≥16 (upper moderate range; above 20 is severe). Seventy of the 84 (83%) were dealing with traumatic events that had occurred before age 17; 28 of them (33%) experienced at least five years of abuse as children. Patients were randomly assigned to one of three groups: acupuncture, cognitive behavioral therapy, or a wait list that acted as a control. Trauma-focused cognitive behavioral therapy (CBT) is one of the main treatments for the nervousness and avoidance behavior that comes with reexperiencing past traumas. Patients in the acupuncture and CBT groups received 2 hours of standardized therapy per week plus at least 15 minutes/day of home-based therapy. Home-based therapy for the acupuncture group consisted of massaging Vaccaria seeds taped to acupuncture points in the ear.

Mean PSS-SR score for the acupuncture group dropped from 31.2 at baseline to 14.3 at treatment's end, which was comparable to the CBT group (32.0 at baseline to 17.5 at treatment's end). The wait-list control group showed no significant change. "By the end of treatment 68% (13 of 19 people) in the acupuncture group, 43% (9 of 21 people) in the CBT group, and 19% (4 of 21 people) in the WLC group had PSS-SR scores below the entry criterion level of  ≥16," say the authors. At the three-month follow-up, 68% of the acupuncture group remained below a PSS-SR score of 16. The percentage of CBT patients below 16 had increased from 43% to 62% (13 of 21).

A 2012 case study, written by licensed acupuncturist Greg Golden, describes the use of auricular acupuncture to treat combat-related PTSD in a 60-year-old Vietnam veteran. Golden used the NADA protocol, which inserts acupuncture needles into five specific points on the ears: Sympathetic, Shen Men, Kidney, Liver, and Lung. The NADA protocol is used as an adjuvant treatment for detoxification programs. Its reported effects include "improved retention in drug treatment programs; more optimistic attitudes about detoxification and recovery; reductions in cravings and anxiety; fewer episodes of sleep disturbance; and reduced need for pharmaceuticals," according to Acupuncture Today.

Golden's patient reported 11 PTSD-related symptoms: chronic fatigue/lack of energy, chronic pelvic pain, depression/grief, general anxiety, headaches, insomnia, irritability/anger issues, nightmares, panic attacks, skin rashes, and stomach/intestinal problems. The patient received 7 consecutive weekly treatments, beginning November 11, 2010, and an additional 11 treatments as needed through his final treatment on May 12, 2011. During a follow-up phone consult about seven months after the last treatment, the patient reported complete resolution of 5 of the initial 11 symptoms (fatigue, anxiety, insomnia, panic attacks, and skin problems) and noticeable improvement in another 4 symptoms (depression, headaches, anger issues, nightmares). The chronic pelvic pain and stomach/intestinal problems did not respond to acupuncture. Walter Reed Veterans Administration Hospital (Washington, DC) offers the NADA protocol to veterans, their families, and their caregivers at no charge, according to Golden.

Golden G. The lasting effects of using auricular acupuncture to treat combat-related PTSD: a case study. American Acupuncturist. Summer 2012. Available at Alt-HealthWatch database. Accessed September 7, 2013.

Hollifield M, Sinclair-Lian, N, Warner TD, Hammerschlag R. Acupuncture for Posttraumatic Stress Disorder. J Nerv Ment Dis. June 2007:195(6):504–513. Available at
. Accessed September 13, 2013.

Kim YD, Heo I, Shin BC, Crawford C, Kang HW, Lim JH. Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials. Evid Based Complement Altern Med. 2013. Available at Accessed September 13, 2013.

The NADA Protocol [Web page]. Acupuncture Today. Accessed September 13, 2013.

ADHD Overdiagnosis in Boys
Boys are more likely to be treated for attention deficit/hyperactivity disorder (ADHD) than girls. Multiple ADHD clinical samples have a male-to-female ratio between 5:1 and 9:1, according to Katrin Bruchmüller et al.The rationale for this wide disparity has been that girls are being underdiagnosed. Girls with ADHD tend to be inattentive, rather than impulsive and disruptive, so they are easily overlooked. However, two recent studies present evidence that boys are being overdiagnosed.

Swiss researcher Katrin Bruchmüller and German colleagues Jürgen Margraf and Silvia Schneider investigated the role of bias in ADHD diagnosis. They hypothesized that some therapists rely on their perception of ADHD rather than following the specific Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) and/or International Classification of Diseases (10th rev.; ICD-10) diagnosis criteria. To test their hypothesis, Bruchmüller and colleagues constructed and pretested four different case vignettes based on DSM-IV and ICD-10, which have identical criteria. The first vignette clearly met DSM-IV and ICD-10 criteria for an ADHD (combined type) diagnosis. The second vignette matched the first except that it noted a failure to met criterion b (onset before age 7) and c (impairment in two or more settings). In addition to lacking criteria b and c, Vignette three reported fewer than the required six symptoms of inattention and six symptoms of hyperactivity/impulsivity. The fourth vignette met the diagnostic criteria for generalized anxiety disorder, which has some of the same symptoms as ADHD. "To test whether the gender of the youth influenced the therapists' diagnostic decision, we formulated all four vignettes in boy and girl versions," say the authors. "The boy was named Leon and the girl was named Lea. All other information in the vignettes was identical."

Each of the eight vignettes, along with a cover letter and questionnaire, was sent to 125 German therapists who specialized in children and adolescents. One reminder letter was mailed to therapists who did not respond within six weeks. A total of 473 therapists out of 1000 responded. (The authors were aiming for a 40% response rate: 400.)

After excluding the therapists who refused to make a diagnosis without more information, the authors found that 8 out of 98 (8.2%) therapists who received Vignette 1 gave a diagnosis other than ADHD (false negative diagnoses). In contrast, 57 of 285 (20%) of the non-ADHD vignettes (Vignettes 2–4) received an ADHD diagnosis (false positive diagnoses). When they analyzed false negative and false positive diagnoses for girls separately, the authors found "no significant difference between the proportion of false positive (11.3%) and false negative (7.5%) diagnoses." In comparison, 21.8% of the boy Vignettes 2–4 were falsely diagnosed with ADHD. Only 6.6% of boys with the ADHD Vignette 1 were given a false negative diagnosis. The significantly higher rate of false positive diagnoses compared with false negatives indicates an overdiagnosis of ADHD in boys. Overdiagnosis means unnecessary treatment.

A 2012 Canadian study, led by Richard L. Morrow, focused on another factor that contributes to ADHD overdiagnosis: the relative age of children. The researchers looked at the health records of 937,943 schoolchildren, age 6 to 12 years, living in British Columbia. A December 31 birth date is the cut-off for entry into kindergarten or first grade. Consequently, children born in December can be several months younger than their classmates. Morrow and colleagues found that " … boys born in December were 41% more likely, and girls 77% more likely, to have a prescription for a medication to treat ADHD than their peers born in January." The study, like two earlier US studies, indicates that being among the youngest and least mature children in a classroom increases their risk of being diagnosed with ADHD and receiving treatment. "Inappropriate diagnosis of ADHD in a child born late in the year might lead parents and teachers to treat the child differently or adversely change the child's self-perceptions," they write. In addition, ADHD medications can adversely affect sleep, appetite, growth, and cardiovascular health. "Our analyses add weight to concerns about the medicalization of the normal range of childhood behaviours," say Morrow and colleagues, "particularly for boys."

Bruchmüller K, Margraf J, Schneider S. Is ADHD diagnosed in accord with diagnostic criteria? overdiagnosis and influence of client gender on diagnosis. J Consult Clin Psychol. 2012:80(1);128–138. Available at Accessed September 13, 2013.

Morrow RL, Garland EJ, Wright JM, Maclure M, Taylor S, Dormuth CR. Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children (early release version). CMAJ. March 5, 2012. Available at
. Accessed September 13, 2013.

Cherries for Gout
Eating cherries decreases the risk of recurrent gout attacks, according to a 2012 study. Gout (painful inflammation that usually affects the big toe, midfoot, or ankle) is caused by monosodium urate crystals. The crystals form when serum urate levels exceed saturation concentrations (6.8 mg/dL or 0.41 mmol/L). If urate levels remain too high, acute gout flares become more frequent and joint damage can result. Icing the painful joint and NSAIDs are the usual treatment for acute gout flares. Xanthine oxidase inhibitors, such as allopurinol, are usually prescribed for people who have more than one gout attack per year or who display joint damage. These drugs lower serum urate levels. Foods that worsen gout include high-purine foods such as organ meats and seafood; alcohol (especially beer); and fructose-containing beverages, according to researcher Nicola Dalbeth. Vitamin C and cherries decrease the risk of recurrent gout; both decrease serum urate, according to Gelber and Solomon.

Researchers at Boston University initiated an ongoing case-crossover study to investigate risk factors for recurrent gout attacks in February 2003. Yuqing Zhang, DSc, and colleagues used data from this study to assess the effect of cherry intake. They followed, via the Internet, 633 people with a physician diagnosis of gout for one year. Participants reported date and symptoms of gout attacks, their use of medications, exposures to risk factors, and daily servings of cherries and cherry extract during the 2-day period before an attack and gave the same information during control periods. A single serving consists of one-half cup, about 10 to 12 cherries.

Eating about three servings of cherries within a two-day period was associated with a 35% decreased risk of having a gout attack. Eating more than three servings was not as beneficial. Participants who consumed cherry extract alone had a 45% lower gout attack risk compared with periods when they did not consume cherry extract. "The effect of cherry intake on the risk of recurrent gout attacks tended to be stronger when cherries or cherry extract were consumed during periods of higher purine intake or alcohol abstention, and when diuretics or NSAIDs were not used," say the researchers. In addition, cherries appear to have a synergistic effect with allopurinol; participants who took allopurinol and ate cherries had a 75% lower gout attack risk compared with periods when they took neither. It will be interesting to see if these benefits can be produced in an intervention study.

Dalbeth N. Management of gout: from lifestyle to pharmacotherapy. Rheumatol Pract News. November 2012;4–8. Available at Accessed September 25, 2013.

Gelber AC, Solomon DH. If life serves up a bowl of cherries, and gout attacks are "the pits": implications for therapy. Arthritis Rheum. December 2012:64(12);3827–3830.

Zhang Y, Neogi T, Chen, C, Chaisson C, Hunter DJ, Choi HK. Cherry Consumption and Decreased Risk of Recurrent Gout Attacks. Arthritis Rheum. December 2012;64(12):4004–4011.

Confidence, Risk, and Testosterone
Financial traders' testosterone and cortisol levels affect confidence and risk preferences, according to research led by neuroscientist John M. Coates. With permission of a London trading floor, Coates and J. Herbert enlisted 17 male traders, ages 18 to 38 (mean 27.6 years). For eight consecutive business days, participants gave a saliva sample to check hormone levels and recorded their profit and loss (P&L) each morning at 11 a.m. and again at 4 p.m. (before and after most of the day's trading). At day's end, they also completed a questionnaire to monitor food, drinks, medications, or personal news received during the day that might affect endocrine response. If a morning testosterone level was higher than the trader's median level, the trader increased his profit by day's end. Coates and Herbert also found that a trader's cortisol levels rose with market volatility and with variations in his trading results; cortisol rose " … in some cases by as much as 500 per cent," according to a 2010 review article.

In the 2010 review article, Coates, Mark Gurnell, and Zoltan Sarnyai connected medical research on steroid hormones to financial traders' behaviors. The steroid hormones – cortisol, testosterone, and estradiol – regulate brain neural function in areas that relate to economic decision-making (e.g., prefrontal cortex and hippocampus) and to emotional response (e.g., amygdala). Testosterone (produced primarily in the testes but also by the adrenal cortex and ovaries) increases vigilance, visual-motor skills, search persistence, and confidence. Animal and human studies indicate that testosterone relates to competition and risk-taking. All of these qualities are useful in financial trading.

Successful outcomes during competitions increase testosterone levels. Numerous animal and human studies have found that testosterone surges before a competition (athletic or not). Winners experience a further increase in testosterone, while the hormone drops significantly in losers. These levels can persist for weeks. With higher testosterone come the benefits of confidence, vigilance, increased visual-motor skills, and so on – qualities that give competitors an advantage. But too much testosterone can also produce detrimental risk-taking, impulsivity, and sensation seeking. The boom can go bust as financial traders take irrational risks.

Cortisol, a stress biomarker, climbs when people and animals face uncertainty. Coates et al. explain that lab animals subjected to electric shocks can maintain normal cortisol levels if the shocks occur at regular intervals and are preceded by a warning sound, but their cortisol levels rise as the shocks become increasingly haphazard. A moderate amount of cortisol improves performance. However, "extended periods of uncertainty and uncontrollable stress can promote a condition known as 'learned helplessness', in which persons, and animals, lose all belief in their ability to control or influence their environment," say the authors. In contrast to high testosterone that produces irrational risk-taking, high cortisol provokes an unwillingness to take any risks.

"Market stability is served by opinion diversity," say Coates et al., "so it may be served as well by having more [hormonal] balance in the banks between young and old, men and women. One does not need to argue that one group is better than others for this policy to work; merely different."

Coates JM, Gurnell M, Sarnyai Z. From molecule to market: steroid hormones and financial risk-taking. Phil Trans R Soc B. (2010); 365:331–343. Available at Accessed September 13, 2013.

Coates JM, Herbert J. Endogenous steroids and financial risk taking on a London trading floor. PNAS. April 22, 2008; 105(16):6167–6172. Available at Accessed September 13, 2013.

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