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Preliminary evidence suggests that a ketogenic diet may be effective for bipolar disorder.
Aims
To assess the impact of a ketogenic diet in bipolar disorder on clinical, metabolic and magnetic resonance spectroscopy outcomes.
Method
Euthymic individuals with bipolar disorder (N = 27) were recruited to a 6- to 8-week single-arm open pilot study of a modified ketogenic diet. Clinical, metabolic and MRS measures were assessed before and after the intervention.
Results
Of 27 recruited participants, 26 began and 20 completed the ketogenic diet. For participants completing the intervention, mean body weight fell by 4.2 kg (P < 0.001), mean body mass index fell by 1.5 kg/m2 (P < 0.001) and mean systolic blood pressure fell by 7.4 mmHg (P < 0.041). The euthymic participants had average baseline and follow-up assessments consistent with them being in the euthymic range with no statistically significant changes in Affective Lability Scale-18, Beck Depression Inventory and Young Mania Rating Scale. In participants providing reliable daily ecological momentary assessment data (n = 14), there was a positive correlation between daily ketone levels and self-rated mood (r = 0.21, P < 0.001) and energy (r = 0.19 P < 0.001), and an inverse correlation between ketone levels and both impulsivity (r = −0.30, P < 0.001) and anxiety (r = −0.19, P < 0.001). From the MRS measurements, brain glutamate plus glutamine concentration decreased by 11.6% in the anterior cingulate cortex (P = 0.025) and fell by 13.6% in the posterior cingulate cortex (P = <0.001).
Conclusions
These findings suggest that a ketogenic diet may be clinically useful in bipolar disorder, for both mental health and metabolic outcomes. Replication and randomised controlled trials are now warranted.
Strategy is a not a word not often used in connection with early medieval warfare ,which is often seen as mere feud or the gathering of loot. This was strongly reinforced by the widespread attitude that military history was a fit subject only for military academies. Only recently has it been recognised that war in this period was the subject of thought, care and calculation. Moreover, early medieval sources are relatively scarce and often pose difficulties of interpretation. And armies had no continuous institutional life of the kind we associate with the formation of strategic ideas. Nor were kings able to impose a monopoly of violence on their followers, for early medieval states were fragile and highly dependent upon the accidents of individual ability. The armies which were gathered were not unitary, but assemblages of diverse elements whose political relation to the sovereign was problematic. But although writing about strategy poses challenges, it is evident that military commanders in this period were not mere bloodthirsty brutes. An army, even a small one, represented a huge financial and political investment whose raising could only be justified by some substantial purpose. But the nature of medieval strategy was conditioned by the political structures which created it. A world where dynastic continuity and political stability were closely intertwined, and where kings were rulers of peoples rather than territories, gave birth to a very different kind of strategic outlook from our own.
Fear learning is a core component of conceptual models of how adverse experiences may influence psychopathology. Specifically, existing theories posit that childhood experiences involving childhood trauma are associated with altered fear learning processes, while experiences involving deprivation are not. Several studies have found altered fear acquisition in youth exposed to trauma, but not deprivation, although the specific patterns have varied across studies. The present study utilizes a longitudinal sample of children with variability in adversity experiences to examine associations among childhood trauma, fear learning, and psychopathology in youth.
Methods
The sample includes 170 youths aged 10–13 years (M = 11.56, s.d. = 0.47, 48.24% female). Children completed a fear conditioning task while skin conductance responses (SCR) were obtained, which included both acquisition and extinction. Childhood trauma and deprivation severity were measured using both parent and youth report. Symptoms of anxiety, externalizing problems, and post-traumatic stress disorder (PTSD) were assessed at baseline and again two-years later.
Results
Greater trauma-related experiences were associated with greater SCR to the threat cue (CS+) relative to the safety cue (CS−) in early fear acquisition, controlling for deprivation, age, and sex. Deprivation was unrelated to fear learning. Greater SCR to the threat cue during early acquisition was associated with increased PTSD symptoms over time controlling for baseline symptoms and mediated the relationship between trauma and prospective changes in PTSD symptoms.
Conclusions
Childhood trauma is associated with altered fear learning in youth, which may be one mechanism linking exposure to violence with the emergence of PTSD symptoms in adolescence.
The twenty-first volume of the Journal of Medieval Military History begins with three studies examining aspects of warfare in the Latin East: an archaeological report on the defenses of Jerusalem by Shimon Gibson and Rafael Y. Lewis; a study of how military victories and defeats (viewed through the lens of carefully shaped reporting) affected the reputation, and the flow of funds and recruits to, the Military Orders, by Nicolas Morton; and an exploration of how the Kingdom of Jerusalem quickly recovered its military strength after the disaster of Hattin by Stephen Donnachie. Turning to the other side of the Mediterranean, Donald J. Kagay analyzes how Jaime I of Aragon worked to control violence within his realms by limiting both castle construction and the use of mechanical artillery. Guilhem Pépin also addresses the limitation of violence, using new documents to show that the Black Prince's sack of Limoges in 1370 was not the unrestrained bloodbath described by Froissart. The remaining three contributions deal with aspects of open battle. Michael John Harbinson offers a large-scale study of when and why late-medieval men-at-arms chose to dismount and fight on foot instead of acting tactically as cavalry. Laurence W. Marvin reconsiders the Battle of Bouvines, concluding that it was far from being a ritualized mass duel. Finally, Michael Livingston elucidates some principles for understanding medieval battles in general, and the battle of Agincourt in particular.
Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date.
Aims
To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder.
Method
Euthymic individuals with bipolar disorder were recruited to a 6–8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198.
Results
Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6–8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication).
Conclusions
The recruitment and retention of euthymic individuals with bipolar disorder to a 6–8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.
This book provides an overarching, comprehensive analysis of the French military in the medieval period. The focus is on the armies of the French monarchy and the lands close around them, extending from the Low Countries to Provence. Central themes include recruitment and payment; military organisation; leadership, strategy, and tactics; weapons and arms; chivalry, military culture, and the rise of military professionalism.
THE KINGDOM OF France was never a coherent territorial entity, what we would call a state, but, rather, a collection of lands, rights, and claims. Additionally, as the word “claims” implies, these were often contested. The ways in which they were advanced, realized, fought over, and lost are related to the nature of French society, however, as are the armies that were a vital element in the monarchy’s development.
Since the collapse of Rome monarchs had been, essentially, the rulers of the rich and powerful who controlled the day to day life of ordinary people. The power of emperors and kings rested on their ability to build up resources, to manipulate the great through patronage, and to overawe or even threaten them with military power. The wealth of the king and his control of government gave him the means to reward. Royal offices were highly prized: to be a count was prestigious and well rewarded, and also enabled its holder to exercise power in his own interests. Kings could give their own land, and sometimes that of the Church, to favoured servants. The king could also, of course, act as a judge in disputes between the great and be the guarantor of the legitimacy of those who held power. This process left powerful lords with virtual autonomy, however, especially in the counties they controlled. Even a monarch as powerful as Charlemagne inveighed angrily against those who misused the royal power to repress lesser men in his Memorandum on Military Matters of 811. These great men drew their wealth from landed estates on which they subjugated the peasantry to the status of serfs, a process very apparent in Carolingian times and even earlier. Kings were expected to lead in war, though a wise ruler would consult so as to ensure that the great men would follow him. Successful war gained loot and gave the king’s aristocratic followers employment for their armed retinues. Monarchy had great patronage, which could be used to manipulate others. Personality mattered a great deal, though, for power was exercised in a relatively small circle of individuals and radiated out from the royal court through the spheres of influence (mouvances) of each.
I OWE THANKS to many people for the help they have given me in preparing this book. The meetings of De Re Militari, the Society for Medieval Military History, have provided enormous stimulus over many years. More particularly, I would like to thank Clifford Rogers and Kelly DeVries, my colleagues on the editorial board of the Journal of Medieval Military History, for their kindness, patience, and great learning. Professors Bernard and David Bachrach have been a rich source of ideas. My colleagues in the History Department of Swansea University, Professor Dan Power and Dr. Simon Johns, have been enormously helpful. I can only admire the scholarly learning of Professor Matthew Strickland, to whose work I owe a very great deal. Dr. Alan V. Murray has been most generous in sharing knowledge and ideas. I owe a great deal to Dominique Barthélemy, whose knowledge of medieval France is remarkable. Federico Canaccini very kindly granted me the benefit of his learning, while Peter Herde made me think again about the Battle of Tagliacozzo.
Much of this book has been written during the extraordinary restrictions imposed by Covid-19. In spite of this, my family, and especially Angela, my wife, have coped with my struggles against these circumstances. Last, but not least, I must thank Anna Henderson of Arc Humanities Press, for all her help and the occasional – albeit tactful – prods, which have kept me going.
BY THE THIRTEENTH century the French army stood out as the supreme force in western Europe. The best indication of this is that, after 1214, most of its campaigns took place outside the borders of France. The wars of Louis VIII in the 1220s established royal domination in Provence and Languedoc, areas where it had been weak. Henry III Plantagenet’s attempts to recover his family lands were poorly managed and never in any real sense threatened the Capetian realm. The wars in Guyenne and Flanders at the end of our period were, essentially, the result of French aggression and overconfidence. Edward I had shown no signs of aggression and Philip IV simply seems to have tried to take advantage of his preoccupations within Britain to eliminate his territorial position in France, probably because for a king to do homage to another was always a difficult situation. Elsewhere French armies had conquered south Italy, were active in Frankish Greece, and dominated in the crusader states and Cyprus. This remarkable efflorescence of French power had many complex causes, but it clearly attests to the remarkable success of the French way of war. How and why had that come about?
The French royal army was, in principle, no different from that of any other power of northwest Europe. Medieval armies were very close reflections of the societies that produced them. A relatively poor society dominated by a narrow elite produced a precisely parallel kind of army— in the words of Contamine, an “occasional agglomeration of small autonomous forces.” By the end of the thirteenth century the monarchy had spelled out the military obligation of the population and could raise a much more cohesive force. The outcome of Courtrai was a defeat, but despite that the planning and control exerted by an able commander is very evident. This had come about, however, solely because military service to the monarch had become accepted.
The great nobles remained vital in mobilizing troops from among the petty nobility of their families and their dominions, though increasingly they had to accept the authority of the royal officers who supervised them. The mass of foot was recruited from the cities and the urban militia, augmented by mercenaries when necessary. In addition, a general belief that in time of necessity all freemen had an obligation to serve the king was emerging. The tightening of military obligation so evident in France in the late thirteenth century had English parallels, but no other western kingdom had managed to enforce such provisions so firmly and so widely. The political evolution of the French kingdom made this possible.
LOUIS VII’S SON, Philip, who assumed power when his father became ill and was then crowned in 1179 at the age of fourteen, was a very different personality. He also inherited a radically different situation. Louis VII had blocked the expansion of the Plantagenet empire and had shown that he could interfere in all parts of that great collection of lands. Even in the far south he was a factor in maintaining the independence of Toulouse. He had checked the ambitions of Frederick Barbarossa in the east and shown himself as the protector of noble powers there. Although he had not struck any fatal blow at Henry II, he had greatly curbed his ambitions. In addition, he had done all this with an ostentatious respect for noble privilege. This was a huge step forward from the situation he had inherited, and, while he had achieved no great accretion of royal demesne, his political activities were clearly backed by considerable wealth, derived from the economic expansion of the west.
The Early Reign
Because he was only fourteen, Philip was at first subject to the regency of Philip of Flanders, who had been a close ally of his father. The count strengthened his own position at the French court by arranging for Philip to marry Elizabeth of Hainaut, daughter of Count Baldwin V of Hainaut. As dowry of his wife, the young Philip was given considerable lands around Artois, though Count Philip was to retain control of them for his lifetime, and if there was no heir of the marriage they would revert to Elizabeth’s father, Baldwin count of Hainaut. King Philip soon resented the ascendancy at his court of the Flemish count. Tension grew, and in 1181 Count Philip demanded the return of the castle of Breteuil from Raoul of Clermont, who appealed to King Philip and hostilities began. Count Philip, supported by Baldwin of Hainaut, burned Noyon and ravaged entire countrysides, until he confronted the royal army at Crépy, but there was no battle and truces were made at the approach of Christmas. It is a mark of the prestige of the French monarchy that Henry the younger, heir of Henry II, in person and with a strong following of knights, supported the French king.