Chapter 16. Psychopathology: Biological Basis of Behavior Disorders
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By Helen Thomson High levels of inflammation as a child may predict a higher risk of manic behaviour in later life, a finding that could lead to new ways of treating conditions like bipolar disorder. Hypomania involves spells of hyperactivity and is often a symptom of mood disorders, including bipolar disorder, seasonal affective disorder and some kinds of psychosis. People experiencing hypomania may take more risks, feel more confident and become impatient with others. After spells like this, they may “crash”, needing to sleep for long periods and sometimes remembering little about the previous few days. Earlier studies suggested a link between inflammation and mood disorders, prompting Joseph Hayes at University College London and his team to see if inflammation as a child might lead to mental health problems later. Analysing data from more than 1700 people, his team identified a significant link between high levels of a chemical involved in inflammation at age 9, and experiencing aspects of hypomania at age 22. The chemical, called IL-6, is normally secreted by white blood cells to stimulate an inflammatory immune response to infection or trauma. Hayes’s team says it is unclear how inflammation in childhood could induce symptoms of hypomania but IL-6 is known to affect the brain. A study that used injections to increase IL-6 in the blood of healthy volunteers found that this caused symptoms of anxiety, and reduced performance in memory tests. © Copyright Reed Business Information Ltd.
Link ID: 22636 - Posted: 09.07.2016
By Andy Coghlan Antidepressants may be bad for your bones. People who take some selective serotonin reuptake inhibitors (SSRI) have been found to have a higher risk of fractures, but it wasn’t clear whether this was due to the drug or their depression. “It’s a puzzling question,” says Patricia Ducy at Columbia University, New York. But her team have now found that giving mice fluoxetine – the active ingredient in Prozac – for six weeks causes them to lose bone mass. The team identified a two-stage process by measuring bones, blood and gene activity. During the first three weeks, bones grew stronger as the fluoxetine impaired osteoclasts, cells that usually deplete bone tissue. But by six weeks, the higher levels of serotonin prompted by the drug disrupted the ability of the hypothalamus region of the brain to promote bone growth. “We see bone gain, but it’s not long-lasting, and is rapidly overwhelmed by the negative effects,” says Ducy. She says this two-phase pattern is also seen in people. In the short term, those who take fluoxetine are less likely to break a bone, but the risk of bone depletion and fractures rises when they have been taking the drug for a year or more. © Copyright Reed Business Information Ltd.
Link ID: 22630 - Posted: 09.06.2016
By Laurie McGinley The Food and Drug Administration, alarmed that increasing numbers of Americans are combining opioid painkillers and benzodiazepines, said Wednesday that it will require tough new warnings on the product labels that spell out the serious dangers of mixing the drugs. The agency said it will require “boxed warnings” — its strongest category — on 389 separate products and will mandate the warning on opioid-containing cough medications. The new language will list the hazards of using the medications in tandem, which include extreme sleepiness, respiratory depression, coma and even death. The agency noted that the misuse of opioids, powerful pain medications such as prescription oxycodone, hydrocodone and morphine, has “increased significantly” in the United States over the past two decades. Benzodiazepines are used to treat anxiety, insomnia and seizure disorders. Both classes of drugs depress the central nervous system and together can raise the risk of adverse outcomes. FDA officials said the number of patients prescribed both an opioid and a benzodiazepine increased by 41 percent — about 2.5 million people — between 2002 and 2014. From 2004 to 2011, the rate of emergency-department visits involving the non-medical use of both drug classes increased significantly and overdose deaths nearly tripled, the FDA said.
By Will Boggs MD NEW YORK (Reuters Health) - Most adults in the U.S. who screen positive for depression are not being treated for depression, according to results from Medical Expenditure Panel Surveys (MEPS). "With the recent increase in prescribing of antidepressant medications, many physicians might assume that undertreatment of depression is no longer a widespread problem," Dr. Mark Olfson from College of Physicians and Surgeons, Columbia University and the New York State Psychiatric Institute in New York City told Reuters Health by email. "This study makes clear, however, that most American adults who screen positive for depression receive no treatment for their symptoms." Surveys from the early 2000s show that about half of U.S. adults with a lifetime medical history of major depressive disorder had never received treatment for depression. Still, little is known about the extent to which adults with depression in the U.S. receive depression care and the extent to which such patients are matched based on their illness severity to appropriate treatments and healthcare professionals. Dr. Olfson and colleagues used data from the 2012 and 2013 MEPS to examine the prevalence and treatment of adults with screen-positive depression (a Patient Health Questionnaire-2 score of 3 or less). They also assessed whether serious psychological distress was associated with more intensive treatment. © 2016 Scientific American
Link ID: 22613 - Posted: 08.30.2016
By Nicholas Bakalar Taking antipsychotic medicines during pregnancy does not increase the risk for birth defects, a large new study has found. Antipsychotics are used to treat schizophrenia, bipolar disorder, depression and other psychiatric disorders. Previous studies of their use during pregnancy have been small and have had mixed results. This study, in JAMA Psychiatry, reviewed records of 1,341,715 pregnant women, of whom 9,258 filled prescriptions for the newer atypical antipsychotics like quetiapine (Seroquel) or aripiprazole (Abilify), and 733 for older typical antipsychotics such as haloperidol (Haldol). All prescriptions were filled in the first trimester of pregnancy. After controlling for race, number of pregnancies, smoking, alcohol use, psychiatric conditions, additional medications and other variables, there was no difference in the risk for birth defects between those who took the drugs and those who did not. One possible exception was a marginal increase in risk with one drug, risperidone (Risperdal), which the authors said will require further study. “These findings suggest that the use of antipsychotics during the first trimester does not seem to increase congenital malformation,” or birth defects, said the lead author, Krista F. Huybrechts, an assistant professor of medicine at Harvard. But, she added, “we only looked at congenital malformation, not other possible negative outcomes for women and their children.” © 2016 The New York Times Company
By Jef Akst ANDRZEJ KRAUZEAs a psychiatrist at Western University in London, Ontario, Lena Palaniyappan regularly sees patients with schizophrenia, the chronic mental disorder that drastically affects how a person thinks, feels, and behaves. The disorder can be devastating, often involving hallucinations and delusions. But one thing Palaniyappan and other mental health professionals have noticed is that, unlike those with degenerative neurological disorders such as Alzheimer’s disease, Huntington’s, or Parkinson’s, sometimes schizophrenia patients eventually start to improve. “In the clinic we do actually see patients with schizophrenia having a very relentless progress in early years,” Palaniyappan says. “But a lot of them do get better over the years, or they don’t progress as [quickly].” So far, most research has focused on the neurological decline associated with schizophrenia—typically involving a loss of brain tissue. Palaniyappan and his colleagues wondered whether there might be “something happening in the brain [that] helps them come to a state of stability.” To get at this question, he and his colleagues performed MRI scans to assess the cortical thickness of 98 schizophrenia patients at various stages of illness. Sure enough, the researchers noted that, while patients who were less than two years removed from their diagnosis had significantly thinner tissue than healthy controls, those patients who’d had the disease for longer tended to show less deviation in some brain regions, suggesting some sort of cortical amelioration (Psychol Med, doi:10.1017/S0033291716000994, 2016). “Some brain regions are regaining or normalizing while other brain regions continue to show deficits,” Palaniyappan says. © 1986-2016 The Scientist
By Jessica Hamzelou JACK NICHOLSON has a lot to answer for. One of the knock-on effects of hit 1975 movie One Flew Over the Cuckoo’s Nest was a public backlash against electroconvulsive therapy (ECT). The treatment, used since the 1930s for a wide range of mental health conditions, delivers a jolt of electricity to the brain big enough to trigger a seizure. The film’s brutal depiction of ECT and lobbying helped it fall out of favour in the 1980s and 1990s. But ECT may now be undergoing a revival, led by psychiatrists who champion it because of its success rate. “It’s the most effective treatment we have in psychiatry,” says George Kirov at Cardiff University, UK, who oversees ECT treatments in the area. A report from the UK Royal College of Psychiatrists last September showed that three-quarters of people with mental health problems felt improvement after having ECT. And psychiatrists say that a similar percentage of people who have schizophrenia that doesn’t respond to drug treatment find ECT effective. “I’ve never seen an ECT treatment that doesn’t work,” says Helen Farrell, a psychiatrist at the Beth Israel Deaconess Medical Center in Boston. “People have such a skewed view of electroconvulsive therapy. It is seen as primitive and horrific“ Mounting evidence has convinced the US Food and Drug Administration (FDA) to consider reclassifying ECT devices to make the technology more accessible for people with depression or bipolar disorder. The public will still take some convincing, however. In a 2005 survey in Switzerland, for example, 56 per cent were against ECT, while just 1 per cent said they were in favour. © Copyright Reed Business Information Ltd.
Link ID: 22571 - Posted: 08.18.2016
By MIKE SACKS You’ve seen me. I know you have. I’m the guy wearing gloves on the subway in October. Or even into April. Perhaps I’m wearing just one glove, allowing my naked hand to turn the pages of a book. No big deal. Just another one-gloved commuter, heading home. If it’s crowded, you may have noticed me doing my best to “surf,” sans contact, until the car comes to a stop, in which case I may knock into a fellow passenger. Aboveground you may have seen me acting the gentleman, opening doors for others with a special paper towel I carry in my front left pocket for just such a momentous occasion. No? How about that guy walking quickly ahead of you, the one impishly avoiding sidewalk cracks? Or perhaps you’ve noticed a stranger who turns and makes eye contact with you for seemingly no reason. You may have asked, “You got a problem?” Oh, I definitely have a problem. But it has nothing to do with you, sir or madam. (And, yes, even in my thoughts I refer to you as “sir” and “madam.”) The problem here is what multiple doctors have diagnosed as obsessive-compulsive disorder. You may refer to it by its kicky abbreviation, O.C.D. I prefer to call it Da Beast. Da Beast is a creature I have lived with since I was 11, a typical age for O.C.D. to snarl into one’s life without invitation or warning. According to the International O.C.D. Foundation, roughly one in 100 adults suffers from the disorder. Each of us has his or her own obsessive thoughts and fears to contend with. My particular beast of burden is a fear of germs and sickness. It’s a popular one, perhaps the most common. © 2016 The New York Times Company
Keyword: OCD - Obsessive Compulsive Disorder
Link ID: 22541 - Posted: 08.11.2016
Laura Sanders A busy protein known for its role in aging may also have a hand in depression, a study on mice hints. Under certain circumstances, the aging-related SIRT1 protein seems to make mice despondent, scientists report August 10 in the Journal of Neuroscience. The results are preliminary, but they might ultimately help find new depression treatments. Today’s treatments aren’t always effective, and new approaches are sorely needed. “This is one potential new avenue,” says study coauthor Deveroux Ferguson of the University of Arizona College of Medicine in Phoenix. Ferguson and colleagues subjected mice to 10 days of stressful encounters with other mice. After their demoralizing ordeal, the mice showed signs of depression, such as eschewing sugar water and giving up attempts to swim. Along with these signs of rodent despair, the mice had more SIRT1 gene activity in the nucleus accumbens, a brain area that has been linked to motivation and depression. Resveratrol, a compound found in red grapes, supercharges the SIRT1 protein, making it more efficient at its job. When Ferguson and colleagues delivered resveratrol directly to the nucleus accumbens, mice displayed more signs of depression and anxiety. When the researchers used a different compound to hinder SIRT1 activity, the mice showed the opposite effect, appearing bolder in some tests than mice that didn’t receive the compound. |© Society for Science & the Public 2000 - 2016.
By Ann Griswold, Autism shares genetic roots with obsessive-compulsive disorder (OCD) andattention deficit hyperactivity disorder (ADHD). The three conditions have features in common, such as impulsivity. New findings suggest that they also share a brain signature. The first comparison of brain architecture across these conditions has found that all are associated with disruptions in the structure of the corpus callosum. The corpus callosum is a bundle of nerve fibers that links the brain’s left and right hemispheres. The results appeared July 1 in the American Journal of Psychiatry. Clinicians may find it difficult to distinguish autism from ADHD based on symptoms alone. But if the conditions are marked by similar structural problems in the brain, the same interventions might be useful no matter what the diagnosis is, says lead researcher Stephanie Ameis, assistant professor of psychiatry at the University of Toronto. The unique aspects of each condition might arise from other brain attributes, such as differences in the connections between neurons, says Thomas Frazier, director of research at the Cleveland Clinic Foundation. “A reasonable conclusion is that autism and ADHD don’t differ dramatically in a structural way, but could differ in connectivity,” says Frazier, who was not involved in the study. Ameis’ team examined the brains of 71 children with autism, 31 with ADHD, 36 with OCD and 62 typical children using diffusion tensor imaging. This method provides a picture of the brain’s white matter, the long fibers that connect nerve cells, by measuring the diffusion of water across these fibers. © 2016 Scientific American
By BENEDICT CAREY HOLYOKE, Mass. — Some of the voices inside Caroline White’s head have been a lifelong comfort, as protective as a favorite aunt. It was the others — “you’re nothing, they’re out to get you, to kill you” — that led her down a rabbit hole of failed treatments and over a decade of hospitalizations, therapy and medications, all aimed at silencing those internal threats. At a support group here for so-called voice-hearers, however, she tried something radically different. She allowed other members of the group to address the voice, directly: What is it you want? “After I thought about it, I realized that the voice valued my safety, wanted me to be respected and better supported by others,” said Ms. White, 34, who, since that session in late 2014, has become a leader in a growing alliance of such groups, called the Hearing Voices Network, or HVN. At a time when Congress is debating measures to extend the reach of mainstream psychiatry — particularly to the severely psychotic, who often end up in prison or homeless — an alternative kind of mental health care is taking root that is very much anti-mainstream. It is largely nonmedical, focused on holistic recovery rather than symptom treatment, and increasingly accessible through an assortment of in-home services, residential centers and groups like the voices network Ms. White turned to, in which members help one another understand each voice, as a metaphor, rather than try to extinguish it. For the first time in this country, experts say, psychiatry’s critics are mounting a sustained, broadly based effort to provide people with practical options, rather than solely alleging abuses like overmedication and involuntary restraint. “The reason these programs are proliferating now is society’s shameful neglect of the severely ill, which creates a vacuum of great need,” said Dr. Allen Frances, a professor emeritus of psychiatry at Duke University. © 2016 The New York Times Company
Link ID: 22534 - Posted: 08.09.2016
Nicola Davis Scientists have discovered 17 separate genetic variations that increase the risk of a person developing depression. The findings, which came from analysing DNA data collected from more than 300,000 people, are the first genetics links to the disease found in people of European ancestry. The scientists say the research will contribute to a better understanding of the disease and could eventually lead to new treatments. They also hope it will reduce the stigma that can accompany depression. According to Nice, up to 10% of people seen by practitioners in primary care have clinical depression, with symptoms including a continuously low mood, low self-esteem, difficulties making decisions and lack of energy. Both environmental and genetic factors are thought to be behind depression, with the interaction between the two also thought to be important. But with a large number of genetic variants each thought to make a tiny contribution to the risk of developing the condition, unravelling their identity has proved challenging. While previous studies have turned up a couple of regions in the genome of Chinese women that might increase the risk of depression, the variants didn’t appear to play a role in depression for people of European ancestry. © 2016 Guardian News and Media Limited
By David Levine Almost seven percent of U.S. adults—about 15.7 million people—are diagnosed with major depression disorder, according to the National Institute of Mental Health (NIMH). The Centers for Disease Control and Prevention report that depression causes 200 million lost workdays each year at a cost to employers of between $17 billion and $44 billion. The statistics for anxiety disorders are not great either. The most common mental illnesses in the U.S., they affect 40 million adults age 18 and older, costing the economy more than $42 billion a year. In my twenties, I developed panic disorder. I failed to get better on most medications and therapy. As I reported in an article earlier this year, it took me years to find a medication that worked. Because it took me so long to be diagnosed and treated properly, I have always been interested in alternative treatments for depression and anxiety. Two years ago I attended two sessions at the World Science Festival on the use of electrical therapy to treat depression and anxiety. The first event was Spark of Genius? Awakening a Better Brain, a panel discussion moderated by ABC News Chief Health & Medical Editor Richard Besser. The panel discussed what is known about treating the brain and the ethical and legal complications of brain enhancement. (You can watch it online at the World Science Festival website.) The second panel, "Electric Medicine and the Brain" was moderated by John Rennie, former editor in chief of Scientific American His panel focused on the use of "electroceuticals," a term coined by researchers at GlaxoSmithKline to refer to all implantable devices being used to treat mental illnesses and being explored in the treatment of metabolic, cardiovascular and inflammatory disorders. © 2016 Scientific American
Link ID: 22462 - Posted: 07.20.2016
By DENISE GRADY Could pernicious anemia, a disease caused by a vitamin B12 deficiency, have explained the many strange behaviors of Mary Todd Lincoln? She was not exactly a model first lady. Historians have had a field day describing her violent temper, wild shopping sprees (she owned 300 pairs of kid gloves), depressed moods and all-consuming fears of burglars, storms and poverty. Late in life, at her son’s urging, she was committed to a mental hospital for several months. Plenty of theories, none proven, have been floated. She was bipolar. She had syphilis or that well known cause of feminine madness, menstrual trouble. She was spoiled and narcissistic. She never recovered from a road accident in which her head hit a rock. She lost her mind grieving the deaths of three of her four sons and her husband’s assassination. The latest addition to the list of possible diagnoses comes from Dr. John G. Sotos, a cardiologist, technology executive at Intel and one of the medical consultants who helped dream up the mystery diseases that afflicted patients on the television show “House.” Dr. Sotos has long been interested in difficult diagnoses, and has written a self-published book suggesting that Abraham Lincoln had a genetic syndrome that caused cancers of the thyroid and adrenal glands. In an interview, Dr. Sotos said that while he was studying President Lincoln, he came across something that intrigued him about Mrs. Lincoln: an 1852 letter mentioning that she had a sore mouth. He knew that vitamin B deficiencies could cause a sore tongue, and he began looking into her health. © 2016 The New York Times Company
Link ID: 22418 - Posted: 07.09.2016
By Nicholas Bakalar A new study has identified a bacterial blueprint for chronic fatigue syndrome, offering further evidence that it is a physical disease with biological causes and not a psychological condition. Chronic fatigue syndrome is a condition that causes extreme and lasting fatigue, preventing people from taking part in even the most routine daily activities. There are no tests to confirm the diagnosis, which has prompted speculation that it is a psychological condition rather than a physical illness. In a study published in Microbiome, researchers recruited 48 people with C.F.S. and 39 healthy controls. Then they analyzed the quantity and variety of bacteria species in their stool. They also searched for markers of inflammation in their blood. The stool samples of those with C.F.S. had significantly lower diversity of species compared with the healthy people — a finding typical of inflammatory bowel disease as well. The scientists also discovered that people with C.F.S. had higher blood levels of lipopolysaccharides, inflammatory molecules that may indicate that bacteria have moved from the gut into the bloodstream, where they can produce various symptoms of disease. Using these criteria, the researchers were able to accurately identify more than 83 percent of C.F.S. cases based on the diversity of their gut bacteria and lipopolysaccharides in their blood. Finding a biomarker for C.F.S. has been an ongoing goal for researchers who hope to one day develop a diagnostic test for the condition. Still, the senior author of the study, Maureen R. Hanson, a professor of molecular biology at Cornell, said the bacteria blueprint in the new study is not yet a method of definitively diagnosing C.F.S. The importance of the finding, she said, is that it may offer new clues as to why people have these symptoms. © 2016 The New York Times Company
Link ID: 22411 - Posted: 07.08.2016
By ERICA GOODE Irving Gottesman, a pioneer in the field of behavioral genetics whose work on the role of heredity in schizophrenia helped transform the way people thought about the origins of serious mental illness, died on June 29 at his home in Edina, Minn., a suburb of Minneapolis. He was 85. His wife, Carol, said he died while taking an afternoon nap. Although Dr. Gottesman had some health problems, she said, his death was unexpected, and several of his colleagues said they received emails from him earlier that day. Dr. Gottesman was perhaps best known for a study of schizophrenia in British twins he conducted with another researcher, James Shields, at the Maudsley Hospital in London in the 1960s. The study, which found that identical twins were more likely than fraternal twins to share a diagnosis of schizophrenia, provided strong evidence for a genetic component to the illness and challenged the notion that it was caused by bad mothering, the prevailing view at the time. But the findings also underscored the contribution of a patient’s environment: If genes alone were responsible for schizophrenia, the disorder should afflict both members of every identical pair; instead, it appeared in both twins in only about half of the identical pairs in the study. This interaction between nature and nurture, Dr. Gottesman believed, was critical to understanding human behavior, and he warned against tilting too far in one direction or the other in explaining mental illness or in accounting for differences in personality or I.Q. © 2016 The New York Times Company
Anthony Devlin/ Antidepressant use is at an all-time in high in England, where prescriptions filled for these drugs has doubled over the last decade. Figures from the Health and Social Care Information Centre show that in 2015, 61 million prescriptions were filled for antidepressant drugs, including citalopram and fluoxetine. This is up from 57.1 million in 2014, and 29.4 million back in 2005. “The reasons for this increase in antidepressant prescriptions could include a greater awareness of mental illness and more willingness to seek help,” says Gillian Connor of the charity Rethink Mental Illness. “However, with our overstretched and underfunded mental health services, too often antidepressants are the only treatment available.” UK guidelines suggest that people should be offered antidepressants as a first treatment option for moderate depression, but some critics argue that it would be better to steer people to talking therapies. In May, Andrew Green, a GP in East Riding and chairman of the British Medical Association’s Clinical and Prescribing Subcommittee, told a meeting of the UK’s All-Party Parliamentary Group for Prescribed Drug Dependence that one of the reasons doctors resort to prescribing antidepressants is because the waiting lists for talking therapies are so long. © Copyright Reed Business Information Ltd.
Link ID: 22399 - Posted: 07.06.2016
Jackie Goldstein Mental illness has been part of human society throughout recorded history, but how we care for people with mental disorders has changed radically, and not always for the better. In Colonial days, settlers lived in sparsely populated rural communities where sanctuary and community support enabled the tradition of family care brought from England. "Distracted persons" were acknowledged, but erratic behavior wasn't associated with disease. Records indicate unusual tolerance of bizarre behavior. When 18th century Pastor Joseph Moody of York, Maine, unable to face crowds, delivered sermons with a handkerchief covering his face, his behavior was tolerated for three years before he was relieved of his duties. As urban areas grew in size and number, a transient poor population with no access to family support led to almshouses, the first form of institutionalization, inspired by 18th century reforms in Europe. A Philadelphia Quaker who had visited an English retreat brought the idea to this country and in 1817 founded the Friends Asylum, a self-sufficient farm that offered a stress-free environment known as "moral treatment." Other private asylums followed, but they soon became overcrowded. By the late 19th century, this was addressed with larger state hospitals, which soon became overcrowded as well. People with mental disorders are more likely to be stigmatized owing to fear and misunderstanding when they aren't part of the community. And stigmatization can discourage those with a mental disorder from seeking or complying with treatment. © 2016 npr
Link ID: 22393 - Posted: 07.04.2016
By Tara Parker-Pope About one in eight women take an antidepressant at some time during pregnancy, reports Roni Rabin in today’s Science Times. But is it safe? Some new research shows that antidepressant use during pregnancy may be linked to certain problems in newborns. A new review of the medical literature concludes that treatment decisions for depression during pregnancy must be made on a case-by-case basis. “There’s not a one-size-fits-all answer,” said Dr. Kimberly Yonkers, a professor of psychiatry and obstetrics and gynecology at Yale School of Medicine who was the report’s lead author, and who acknowledged receiving research support from antidepressant manufacturers. “You can’t say, ‘Stop medication for all women because it’s harmful,’ and you can’t put all women on medication either.” To learn more, read the full story, “Depression Is a Dilemma for Women in Pregnancy,” and then please join the discussion below. Did you experience depression during pregnancy? Did you take medication to treat it? © 2016 The New York Times Company
Angus Chen At the center of Geel, a charming Belgian town less than an hour's drive from of Antwerp, is a church dedicated to Dymphna, a saint believed to have the power to cure mental disorders. It's a medieval church with stone arches, spires and a half-built bell tower, and it has inspired an unusual centuries-old practice: For over 700 years, residents of Geel have been accepting people with mental disorders, often very severe mental disorders, into their homes and caring for them. It isn't meant to be a treatment or therapy. The people are not called patients, but guests or boarders. They go to Geel and join households to share a life with people who can watch over them. Today, there are about 250 boarders in Geel. One of them is a Flemish man named Luc Ennekans. He's slim and has green eyes, and he's 51 years old. NPR's Lulu Miller went to Geel and met him and his host family there and reported this story for Invisibilia. Like all of the guests in the town today, Ennekans first went to a public psychiatric hospital in Geel that manages the boarder program. Ennekans saw medical professionals and received treatment and an evaluation. Then he was paired with a household. His hosts, Toni Smit and Arthur Shouten, say that living with Ennekans was rough at the start. Ennekans became deeply attached to Smit. "If it were up to Luc, he would be hugging and kissing me all day," Smit says. He showered her with such affection, bringing her flowers, little kisses, linking arms with her on walks, that it began to interfere with Smit and Shouten's marriage. "You couldn't even give each other a hug or Luc is standing behind us," Shouten says. Wrinkles like this are common, according to the couple. They've had six boarders over the years, each with a unique set of challenges. © 2016 npr