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MENTAL HEALTH: TREATING SCHIZOPHRENIA
Around the mid-1950s, doctors discovered drugs that control the dopamine system and lower its activity. The best known of these is chlorpromazine (trade name: Thorazine). It doesn’t cure schizophrenia, but it lessens the hallucinations and delusions. However, chlorpromazine slows the patient down, sometimes creating a slow-moving, slow-talking zombie effect. In a few patients the drug produces involuntary movements of the lip, tongue, and limbs. Usually, the movements stop if medication is reduced or stopped, but in a few patients this doesn’t help. (Some studies show that in some types of schizophrenia, lithium salts can quiet the manic or excited phases. The studies are just now defining exactly who is helped by this drug.)
These drugs are the only real treatments doctors have. In the 1920s, they tried tooth removal to treat schizophrenia; in the 1930s, injections of horse serum; in the 1940s, enemas. All failed. In the 1950s, big doses of vitamins were tried, and the megavitamin trend persists, even though the American Psychiatric Association declared in 1971 that there was no evidence from studies that vitamin therapy did any good. Dr. Morris Lipton of the University of North Carolina Medical School at Chapel Hill headed the original studies and says nothing since has changed this.
For about 40 percent of schizophrenics, the brain drugs don’t work. Dr. Friedhoff says that, although the drugs lower the dopamine levels as far as possible, the brain can’t function properly.
*12/266/5*

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DELIRIUM: OTHER CLINICAL CHARACTERISTICS OF DELIRIUM-DISTURBANCE IN THE SLEEP-WAKE CYCLE AND DISTURBANCE IN PSYCHOMOTOR ACTIVITY
DSM-JV notes that disturbances in sleep, psychomotor activity, and emotional state are common in delirium, but it does not include them among the diagnostic criteria for the disorder.
Disturbance in the Sleep-Wake Cycle-Nocturnal insomnia and daytime drowsiness are features of delirium that have been described since antiquity, and the disorder’s dreamlike quality has been commented on for hundreds of years. Because a disorganized sleep-wake cycle is such a prominent and regular part of the clinical picture in delirium, Zbigniew Lipowski believes it to be an essential feature of the syndrome. Indeed, he is willing to consider delirium “a disorder of the sleep-wake cycle characterized by the irregular appearance of the elements of sleep during wakefulness and those of the waking state during sleep”.
Disturbance in Psychomotor Activity-In addition to abnormal levels of activity (from torpor to agitation), delirious patients can exhibit abnormal forms of activity. Although these latter phenomena are often simple jerking or trembling movements, they can sometimes be complicated fragments of domestic and occupational behaviors, such as preparing a meal or assembling an object. Even recreational movements can appear in the midst of delirium, as one of my patients demonstrated: A 38-year-old man, delirious from benzodiazepine withdrawal, was observed to be sitting upright in bed, with eyes half-closed, muttering to himself. He was holding his hands like pistols and moving them in tandem from side to side and up and down as he swiveled his head. When I asked him what he was doing, he replied, “Just wait until I finish this one,” and continued the behavior for several minutes. Later, he described his experience as that of playing a video arcade game.
Abnormal forms of activity are more common in hyperactive-hyper-alert delirium and may (as in the case above) be associated with hallucinations or delusions. As delirium of either type worsens and stupor looms, patients often pick at their bedclothes or make grasping movements.
*12/172/2*

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MENTAL HEALTH: SOME COMMON TERMS
You often hear, “Oh, he’s neurotic,” when what the observer probably means is that the person is high-strung. Or someone says, “She’s just paranoid” to explain his friend’s fears about losing her job. But neurosis and paranoia are real mental disorders with identifiable symptoms. Here are some mental health terms that are commonly misused.
? Anxiety/fear. Anxiety occurs when you are paralyzed with fright but don’t know what you are afraid of. Many emotional disturbances begin with anxiety. Your fear may be specific, like a fear of snakes or mice. I know one young woman who is so terrified of mice that she cannot stand even seeing the word in print.
? Psychosis. This disorder is characterized by defective or lost contact with reality. Psychotics often “see things” and “hear voices.” Their behavior is often bizarre; they may, for example, believe that God is telling them to murder someone.
? Neurosis. This emotional disorder is caused by a conflict of which the person is unaware. For example, you want sex but also want to please your mother, who said sex was bad. This unconscious conflict produces a neurosis that could affect your sex life. You may go out of your way to avoid any sexual contact.
? Paranoia. This is a severe personality disorder in which a patient feels persecuted or has ambitions of grandeur. A paranoid person may believe that spies are out to get him or that God has picked him to lead the world. Paranoia is often a feature of schizophrenia.
? Manic-depressive syndrome. This condition is marked by mood swings between uncontrollable elation and activity, on the one hand, and withdrawal and depression, on the other.
? Schizophrenia. This group of disorders can cause delusions, hallucinations, or aggressive and antisocial behavior.
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PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: CLINICAL
ASSESSMENT-PATIENT’S PSYCHIATRIC HISTORY AND PREMORBID PERSONALITY
A personal history of psychiatric disorder can be assessed either in the review of systems or in the past medical history. Here, too, there is a smooth transition from questions about neurological symptoms to questions about psychiatric ones. In the review of systems, for example, “Do you get frequent headaches?” and “Have you been depressed or anxious?” will be regarded as parallel inquiries.
Patients sometimes report having had a “nervous breakdown.” Because the meaning of this term is so uncertain, the physician should obtain a description of symptoms at the time of the illness. Just as in the medical and surgical histories, additional informants may be needed for an accurate understanding of past diagnoses and treatments.
Premorbid personality-The goal of assessing premorbid personality is not only to learn more about the patient as an individual but also to discover traits that may shape her response to illness and her relationship to physicians and others involved in her care. A good time to evaluate the premorbid personality is following the review of systems or the past medical history: “You’ve told me a lot about your health. Now I’d like you to tell me about yourself. What kind of person would you say you are?not when you’re ill, but when you’re well?” Depending on the response, the physician may wish to inquire about traits of particular interest in the medical setting. Thus, after a patient describes herself as “a good person … a kind person … a hard worker,” the physician should ask her whether she tends to be optimistic or pessimistic; carefree or worried; trusting or suspicious; calm or irritable. Someone who knows the patient well might also be asked to characterize her, if only because we often lack the gift to see ourselves as others see us.
*4/172/2*

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Other names: Eskalith, Lithotabs

PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE:
CLINICAL ASSESSMENT-FAMILY PSYCHIATRIC HISTORY
A screening psychiatric history and mental status examination are easy to do and often provide useful information. They alert physicians to potential problems and help to explain why patients are thinking, feeling, or acting in certain ways. The areas for assessment listed below are relevant to the topics discussed in subsequent articles. I have assumed that physicians routinely inquire about the use of alcohol and illicit drugs, as well as the misuse of prescribed medications.
Family psychiatric history-A family history of psychiatric disorder is best evaluated as part of the general family history. Once the physician has established a line of questioning (e.g., “Has anyone in your family had a stroke?”), the patient is unlikely to be surprised or embarrassed when asked, “Has anyone in your family had emotional problems?” The information obtained may be important in understanding the patient’s current mental state. If, for example, her mother and sister were both treated for major depression, the physician must give additional consideration to the possibility that the patient’s dysphoric mood is the symptom of an affective disorder, rather than demoralization produced by her medical illness.
*3/172/2*

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MENTAL DISTRESS: TALKING CAN CURE
“I’m no good,” a young mother sobs. “My home life is too much for me.”
By getting this woman to talk about her feelings, her psychologist relieves her distress. He uses psychotherapy, sometimes called the “talking cure.” Clergy use a form of psychotherapy to counsel. So do social workers, doctors and teachers. Psychotherapy helps three of four persons.
Psychotherapy has many forms, all stemming from psychoanalysis, invented by Sigmund Freud in the 1890s. Dr. Freud found that hidden thoughts – the unconscious – shape behavior. And childhood experiences with our parents create unconscious thoughts. By exposing your unconscious to you, Freudians say they help you gain control over your behavior. They delve into your past to reveal the injuring events in your life. Such events include physical and sexual abuse by your parents, siblings, and other relatives. Usually, they say, by working through these events (i.e., remembering them and dealing with them now), you can feel better about yourself. Keep in mind that early childhood memories may be deeply distorted.
Dr. Carl Rogers invented a form of psychotherapy called reflection. The therapist “reflects” back to you your thoughts and feelings. You say, “I feel depressed because I have nobody to talk to.” The therapist replies, or reflects, “You feel that if you had someone to talk to you would feel better.” By examining that feeling as it is reflected back to you, you can change your thoughts and behavior.
Dr. Rogers was one of the first psychologists to subject his theory to scientific analysis. He proved that his clients were able to make personality and behavioral changes that help reduce anxiety and depression.
*3/266/5*

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PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: PREFACE AND ACKNOWLEDGMENTS
As consultation psychiatrist, I am frequently asked to evaluate patients who are delirious, demoralized, thinking of suicide, or refusing to follow medical advice. Although these patients have cognitive disturbance, emotional distress, or maladaptive behavior, the cause of the problem is often their medical illness and treatment. For that reason, many such patients can receive excellent care from their own physicians. The aim of this article is to encourage and enable that care.
I have not discussed every medical situation with psychiatric implications. In part, this is because certain problems (e.g., the treatment of alcohol abuse, the differentiation of panic disorder from myocardial infarction) are widely understood. Delirium, demoralization, suicidal thinking, and the assessment of competence to refuse medical advice are common and often vexing problems, but they remain somewhat mysterious. If I can help my colleagues in adult primary care deal with these four situations, I will be well satisfied.
I have presented several in considerable detail, not only to illustrate that multiple factors usually combine to produce the problem discussed, but also to demonstrate that the patient’s experience of illness is sometimes the most important of those factors.
*2/172/2*

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DEALING WITH THE CAUSE OF INSOMNIA: SLEEPING PILLS (A LAST RESORT)
Publicity about the side-effects of sleeping pills and tranquillizers belonging to the benzodiazepine group of drugs has made the general public wary of taking them, and doctors wary of prescribing them. When they were first produced in the 1960s they seemed to answer all sorts of problems: now we know that these drugs don’t solve any problems, and can be extremely addictive.
In addition, when taken as sleeping pills, benzodiazepines reduce the quality of your sleep. They cause suppression of REM sleep in the first part of the night, often with a rebound effect with more dreaming later in the night, which can cause early wakening. They can also leave people feeling fuzzy-minded next morning, which is particularly dangerous in the old, since it can make them confused and increases the risk of falls.
Recently some new sleeping pills have come on the market, the cyclopirolones, which don’t disturb normal sleep patterns. They haven’t been around long enough for their long-term effects to be known for certain, and it’s likely that doctors would discourage patients from taking them consistently for any length of time.
There may be a case for taking medication for a day or two under certain conditions ? after the shock of a bereavement, for instance. But no one should take sleeping pills for year after year, as has been the case in the past.
What if you are already taking them? There have been many stories about the horrors of withdrawal symptoms. That may make you scared of giving them up, even if publicity about their effects on your sleep is also causing you anxiety.
Not everyone goes through horrendous withdrawal symptoms; a less well publicized fact is that numbers of people have given up sleeping pills relatively easily. Since we all have individual body and brain chemistry, the effects of both taking and giving up benzodiazepines can vary a great deal.
Giving them up is really worth it. Once they are out of your system you will return to a normal, natural sleep pattern, and your mind will be clearer.
It’s vital to come off them slowly, by gradually tapering off the dosage over at least two or three months; the worst withdrawals happen when people give them up suddenly. Some people try reducing their intake by cutting their pills in halves or quarters, but this method is not very accurate. It’s best to consult your doctor so that he or she can prescribe gradually smaller doses. Your GP may be able to refer you to other sources of help, too, such as a relaxation class or self-help group. Some GPs are in touch with natural therapists and may be able to suggest someone reliable who can help you, through massage, aromatherapy, or hypnotherapy, for example.
Practitioners of natural therapies can be very supportive in helping you to come off sleeping pills, or dealing with the aftereffects of coming off. They are not allowed to recommend you to go against your doctor’s advice; you can of course make your own decision, but it’s best if you work in co-operation with your doctor. Some natural practitioners prefer people to give up sleeping pills before starting treatment, either because the drugs may interfere with their treatment, or because they like to know that the patient is committed to stopping.
A hypnotherapist was asked to treat a woman with agoraphobia, who had already been helped by a herbalist to wean herself off the tranquillizers and anti-depressants she had taken for eight years. On her first visit, the woman’s husband came with her because she couldn’t go out alone; on her second, she came by herself. The hypnotherapist commented: ‘She was very, very committed to her own recovery. She was going to do it! That commitment is something the therapist can’t supply’
What natural practitioners can supply is the time and the listening ear that busy GPs are rarely able to give, together with natural treatments to strengthen and detoxify the body. A naturopath and osteopath tells me that about 5 per cent of her patients are hooked on sleeping pills when they come to her. They usually come for treatment for some other problem, and after a while ask for her help in giving up the pills. She has found it possible to help them by using herbal pills as a bridge, and combining counselling with her physical treatments.
On giving up benzodiazepines, some people experience increased fatigue for a time, and some increased agitation. There can also be a period of increased dreaming. And it can happen that the suppressed anxieties for which they originally took the pills start surfacing. This is easier to cope with if you accept it as part of the healing process rather than a sign of sickness: it shows that these feelings are now on their way out. Counselling from a professional counsellor or alternative practitioner can help you through this stage.
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SCHIZOPHRENIA: CAUSES AND TREATMENT
Schizophrenia is a distressing form of mental illness that affects all levels of higher function producing severe abnormalities of mood, thought processes, perception and behaviour. Early medical theories in relation to Schizophrenia held a particularly bleak outlook for its victims. The disease was thought to follow a chronic remitting, relapsing course until eventually the schizophrenic became a vegetative, volitionless cripple. Fortunately this point of view has not stood the test of time. Many people affected by schizophrenia experience only one attack or maintain a normal personality and adjustment between what constitute infrequent episodes of disturbance.
Over 100,000 Australians suffer from schizophrenia and the cause of the condition is still unknown. Risk factors include a family history of schizophrenia, childbirth and other illnesses such as Temporal Lobe Epilepsy, Encephalitis and brain tumours.
The treatment of schizophrenia has been revolutionized by the discovery of the major tranquillizers. These antihistamines like drugs disperse the hallucinations and delusions of people with schizophrenia. They reduce the thought disorder and return the emotions to an even keel. Major changes are seen within the first six weeks of therapy on drugs such as Largactil, Melleril, Stelazine and Haloperidol. Side effects are very frequent when the major tranquillizers are used in high doses. To overcome the effects of secondary Parkinsonism, doctors often prescribe coexisting courses of Cogentin or Dissipal.
The experience of schizophrenia has a profound affect on the mental and social life of its victims. Families find problems arising out of schizophrenia particularly difficult to cope with. The disease can be all the more distressing in that it predominantly affects young adults between the ages of 15 and 25. It strikes at the most important phase of these young people’s education and early career development. Support groups such as the Schizophrenia Fellowship can be invaluable in terms of advice, assistance, insight and social networks.
*2/131/5*