Coping With Schizophrenia and Psychosis

The Schizophrenia-free Package

What are you going to find in the Schizophrenia-FreeYour New Life Begins Today e-book: Relationships and Friends: In this chapter, I share with you my way of thinking about friends and relationships. I provide my point of view about how I see this interesting issue. I also give you some tips about how to get friends, deal with friends, and treat relationships. About Schizophrenia and Getting Well: In this chapter, I describe my way of thinking about schizophrenia and other similar mental illnesses. Living on Your Own and Being Independent: In this chapter, I share my perspective about our independence as sufferers and how to live on our own and be independent. Other Sufferers' Recovery Examples: I decided to share other sufferers' stories so you won't feel alone in your illness. Finding Your Mate and Getting Married: Having a mate is one of the most important pillars in your life as a sufferer. In this chapter, you learn some of the most important basics in this matter. Preventing Future Seizures and Getting Help: This chapter shows how to reduce the chance of having future psychotic disorder seizures and, even if you experience one, how to make it as minimal as possible. Dieting and Exercising: This chapter demonstrates how to acquire easy life habits in order to survive your years to come in the healthiest manner possible. Living by Yourself and Earning Your Own Money: This chapter shows how to earn your own money and live by yourself as a result. Ways of Getting Support: There is nothing like a good support system in order to rehabilitate in the best matter possible. This chapter discusses the most basic and powerful ways of getting support. Quitting Smoking: In this chapter, you learn the basic principles of why and how to quit smoking. Learning a Profession and Finding a Job: In this chapter, you learn the most important factors for learning a profession and finding a job. Read more...

The Schizophreniafree Package Overview


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Contributors to Medical Morbidity in Schizophrenia

Although these chapters illustrate the undeniable reality of excessive medical comorbidity in patients with schizophrenia, they also reflect a resurgent interest within the psychiatric community in defining the underlying systemic and illness-specific causes for this phenomenon, as evidenced in the growing body of literature on medical illness and health behaviors among the chronically mentally ill population. Ranking high among the causes of poor physical health in schizophrenic patients are the unhealthy lifestyle practices so prevalent in this disorder. The fact that 70 -80 of patients with schizophrenia are chronic smokers has been extensively documented (Davidson et al. 2001), and studies of individuals with schizophrenia living in the community have also found a high prevalence of sedentary habits and poor dietary choices (Brown et al. 1999 Davidson et al. 2001). Comorbid substance use disorders have been shown to be common among patients with schizophrenia, and further...

Natural Causes of Death in Patients With Schizophrenia

An autopsy study from the time when phenothiazine medications were new, roughly 50 years ago, provided a view of death by natural causes (Hussar 1966). Autopsy data from 1,275 chronically hospitalized patients with schizophrenia in a Veterans Affairs (VA) hospital who died at age 40 or older found that heart disease and cancer were the most common causes of death (similar to findings in the general 40+ population of that time). Pneumonia was somewhat overrepresented as a cause of death. Undetermined causes and aspiration of food were among the top eight causes of death in the patients with schizophrenia but not in the general population. The authors speculated that phenothiazines could be responsible, although they noted that other investigators at the time found no association between the new medications and death rates. Harris and Barraclough (1998) reviewed mortality rates in cohorts of patients with various mental disorders between 1966 and 1995. Cohorts of patients with...

The Effects of Antipsychotic Medications on Weight

Antipsychotic medications have been the mainstay of treatment for schizophrenia for over half a century. A link between weight gain and treatment with chlorpromazine and other low-potency conventional anti-psychotic agents, such as thioridazine, was noted in early studies of the metabolic effects of these agents. (Bernstein 1988 Rockwell et al. 1983). A recent study by Allison et al. (1999b) based on 1989 National Health Interview Survey data revealed that a significantly greater proportion of female patients with schizophrenia had BMI distributions in the overweight and obese spectrum compared with their counterparts in the general medical population, with a trend toward greater BMI seen among male schizophrenic patients. This study is notable because the data are based on survey material collected in 1989, before the advent of the novel anti-psychotic medications. Thus, the results of that survey reflect obesity in a population of schizophrenic patients medicated with conventional...

Weight Monitoring for Schizophrenia

The effects of antipsychotic-related weight gain have both medical and psychiatric components. In particular, medication compliance is adversely affected by excessive weight gain, with weight gain being a well-known cause of treatment nonadherence (Bernstein 1988 Silverstone et al. 1988) and subsequent psychotic relapse (Rockwell et al. 1983). During the 2000 American Psychiatric Association meeting, investigators at the Columbia-St. Luke's Obesity Research Center released survey data examining this link between obesity and antipsychotic medication compliance. They found that obese patients were 13 times as likely to request discontinuation of their current antipsychotic agent because of concerns about weight gain and 3 times as likely to be noncompliant with treatment compared with nonobese individuals (Weiden et al. 2000). Patients who gain weight on antipsychotics also utilize health care resources more than patients who do not experience weight gain (Allison and Mackell 2000). The...

Risk Factors for Cardiovascular Illness and Their Prevalence in Patients With Schizophrenia

As with many chronic disorders, prevention is the key, and patients with schizophrenia possess numerous modifiable cardiovascular risk factors that may be the focus of intervention. As Osby et al. (2000) concluded, The number of excess deaths, rather than increased SMRs, may be the target for preventive programs since the aim of prevention should be to reduce this excess mortality (p. 25). The literature on cardiovascular risk factors is rapidly evolving, but a core group of modifiable risk factors have emerged as targets for treatment (Table 4-1). Individuals at risk present with a constellation of modifiable and nonmodifiable risk factors, with the latter including age, gender, family history, personal history, and genetic predisposition toward high CHD risk by various mechanisms inducing Table 4-1. Modifiable risk factors for cardiovascular disease and their prevalence in patients with schizophrenia Table 4-1. Modifiable risk factors for cardiovascular disease and their prevalence...

Specific Lipid Monitoring Recommendations for Patients With Schizophrenia

Given the fact that patients with schizophrenia typically possess multiple cardiovascular risk factors, a full lipid panel with fractionation of cholesterol should be performed annually as part of routine health monitoring for inpatients and outpatients. With higher-risk agents for hyperlipidemia (clozapine, olanzapine, quetiapine), quarterly fasting triglycerides and TC can be considered for ongoing screening instead of the more expensive lipid panel during the first year of atypical antipsychotic therapy. This monitoring frequency for higher-risk agents is necessary to detect severe hypertriglyceridemia, which presents a risk for acute pancreatitis at triglyceride levels much greater than 500 mg dL, and particularly at those above 1,000 mg dL. After 1 year the monitoring frequency for patients on dibenzodiazepine-derived compounds may be decreased to annual assessment depending on the results. Although it is sometimes difficult to obtain reliable fasting specimens on outpatients,...

Pharmacokinetic Implications of Smoking for Psychotropic Drug Use in Schizophrenia

The metabolism of antipsychotic drugs such as haloperidol, chlorpromazine, olanzapine, and clozapine (George and Vessicchio 2001 Perry et al. 1993). Accordingly, smoking cessation may be expected to lead to increases in plasma concentrations of antipsychotic drugs metabolized by the 1A2 system, a finding demonstrated in both prospective and retrospective studies using both between-subject (Perry et al. 1993, 1998 Seppala et al. 1999) and within-subject (Meyer 2001) designs. Such an increase in circulating levels would be expected to increase the likelihood of extrapyramidal reactions and other antipsychotic drug side effects. A nomogram has been developed for clozapine in an attempt to aid clinicians in adjusting clozapine doses in smoking compared with nonsmoking schizophrenic subjects (Perry et al. 1998). Although no smoking cessation study in schizophrenics to date has prospectively measured antipsychotic plasma levels before and after smoking cessation, Meyer (2001) reported on...

Effects of Nicotine and Smoking on Clinical and Cognitive Deficits Associated With Schizophrenia

There have been few direct studies of the effects of smoking or nicotine administration on clinical symptoms in patients with schizophrenia. In contrast to results from cross-sectional studies, controlled laboratory studies of smoking abstinence (Dalack et al. 1999 George et al. 2002a) and nicotine patch administration (Dalack and Meador-Woodruff 1999) have not shown significant effects on these clinical symptoms of schizophrenia. Furthermore, two recent smoking cessation trials (Addington et al. 1998 George et al. 2000a), in which all subjects used the nicotine patch, found no evidence of significant changes in psychotic symptoms with smoking abstinence in schizophrenic patients. Thus, the effects of cigarette smoking and smoking abstinence on schizophrenia symptoms are not clear. There may be some trait differences in psychotic symptoms in schizophrenic smokers versus nonsmokers (e.g., more refractory symptoms in nonsmok-ers) that could explain these findings, independent of smoking...

Rational Psychopharmacology for People With Hiv Hcv and Schizophrenia

HIV-related psychopharmacological interventions for people with preexisting schizophrenia follow similar guidelines for patients with new-onset psychosis associated with HIV infection. In advanced HIV infection, traditional neuroleptic agents have been found to produce modest but significant reductions in psychotic symptoms but have been eschewed for newer, atypical antipsychotics for the primary reason that such patients are very sensitive to extrapyramidal side effects due to viral involvement periodic liver function tests are the standard of care. Because some psychotropics may elevate liver enzymes (e.g., valproic acid, carbamazepine, nefazodone), it is important to check these at baseline, early after initiation of therapy (2-4 weeks), and every 2-3 months thereafter. Nevertheless, data from a large retrospective study in Seattle, Washington, found that among 94 HCV seropositive patients treated with valproic acid, 81.9 showed minimal or no evidence of serum transaminase...

Neurobiology Of Dopamine In Schizophrenia

Evidence Supporting Alterations of DA Systems in Schizophrenia This chapter is an update on the dopamine (DA) imbalance in schizophrenia, including the evidence for subcortical hyperstimulation of D2 receptors underlying positive symptoms and cortical hypodopaminergia-mediating cognitive disturbances and negative symptoms. After a brief review of the anatomical neurocircuitry of this transmitter system as a background, we summarize the evidence for dopaminergic alterations deriving from pharmacological, postmortem, and imaging studies. This evidence supports a prominent role for D2 antagonism in the treatment of positive symptoms of schizophrenia and strongly suggests the need for alternative approaches to address the more challenging problem of negative symptoms and cognitive disturbances.

Antipsychotic Medications

Weight gain as a side effect of antipsychotic treatment has been well documented for over 40 years (29,30) but its importance in the clinical management of chronic schizophrenia has been downplayed (31). Like antidepressants, it is also a common reason for medication non-compliance (31-33). Although numerous mechanisms have been proposed to explain such medication-induced weight gain, the mechanism(s) involved are even less clear than those for antidepressants some data sup

Demographics of Substance Use in Patients With Schizophrenia

The proportion of schizophrenia patients suffering from a comorbid drug or alcohol use disorder varies tremendously in published studies, from as low as 10 to as high as 70 (Mueser et al. 1990). The observed range is partially due to variability in the diagnostic criteria employed for schizophrenia, sample demographic characteristics (e.g., male vs. female, urban vs. rural), the types of patient populations studied (e.g., inpatient vs. outpatient), and different criteria for defining drug and alcohol disorders (e.g., DSM-III-R diagnosis, positive urine toxicology screens, rating scales) (Mueser et al. 1990). Although structured clinical interviews have been found to produce the most reliable diagnoses, these are time consuming and expensive due to the need for trained personnel, and therefore are not often used in clinical studies (Mueser et al. 1995). Surveys conducted exclusively in inpatient settings tend to produce higher rates of substance use disorders, in part because persons...

Evidence Supporting Alterations of DA Systems in Schizophrenia

The psychotogenic effect of amphetamine and other DA-enhancing drugs, such as methylphenidate and l-dopa, is a cornerstone of the classical DA hypothesis of schizophrenia. Two sets of observations are relevant to this issue. First, repeated exposure to high doses of psychostimulants in nonschizophrenic subjects might gradually induce paranoid psychosis. This well-documented observation shows that sustained increase in DA activity is psychotogenic. Second, low doses of psychostimulants that are not psychotogenic in healthy subjects might induce or worsen psychotic symptoms in patients with schizophrenia. This observation indicates that patients with schizophrenia have an increased vulnerability to the psychotogenic effects of DA-enhancing drugs. a. Amphetamine-Induced Psychosis in Nonschizophrenic Subjects. Although mentioned in 1938 (Young and Scoville, 1938), amphetamine-induced psychosis was not clearly recognized as a possible consequence of chronic amphetamine use until 1958 on...

F062 Organic delusional [schizophrenialike disorder

A disorder in which persistent or recurrent delusions dominate the clinical picture. The delusions may be accompanied by hallucinations. Some features suggestive of schizophrenia, such as bizarre hallucinations or thought disorder, may be present. Paranoid and paranoid-hallucinatory organic states Schizophrenia-like psychosis in epilepsy induced ( F11-F19 with common fourth character .5) schizophrenia ( F20.- )

Schizophrenia ICD10 F2x

Goes along with thought disturbances, delusions and affective impairment without intellectual disabilities. Symptoms include delusions, hallucinations, so-called negative symptoms (such as affective flattening, alogia or avolition), formal thought disorder, feelings of thought control from outside and behavioural changes of the person often leading to social withdrawal. Symptoms have to be present for at least one month. Often a prodromal phase can be seen in adolescents before the onset of schizophrenic symptoms. A prodromal phase can be accompanied by diminished interest, absence from work, social withdrawal and dysphoria to an extent atypical for the person affected. Several forms of schizophrenia can be differentiated including paranoid schizophrenia, hebephrenic schizophrenia, catatonic schizophrenia, schizophrenia simplex and undifferentiated schizophrenia.

Patterns of Substance Abuse Among Persons With Schizophrenia

Overall, it is clear that substance use disorders in persons diagnosed with schizophrenia occur more frequently than in the general population however, there is little evidence to suggest that persons with schizophrenia abuse substances for different reasons than the general population. Specifically, the literature demonstrates that patients with schizophrenia do not differentially choose to abuse specific drugs to ameliorate specific psychic states (e.g., anhedonia). Multiple studies also indicate that patients with schizophrenia do not preferentially abuse certain agents, nor does choice of agent correlate with extent of psychopathology rather, these individuals use those substances most available and affordable (Cantor-Graae et al. 2001 Chambers et al. 2001 Lambert et al. 1997 Mueser et al. 1992). For the most part, research has also failed to find patterns of drug choice in persons with schizophrenia that differ from groups of patients with other major mental disorders. Thus,...

F232 Acute schizophrenialike psychotic disorder

An acute psychotic disorder in which the psychotic symptoms are comparatively stable and justify a diagnosis of schizophrenia, but have lasted for less than about one month the polymorphic unstable features, as described in F23.0, are absent. If the schizophrenic symptoms persist the diagnosis should be changed to schizophrenia (F20.-). Acute (undifferentiated) schizophrenia Brief schizophreniform psychosis Oneirophrenia Schizophrenic reaction Excludes organic delusional schizophrenia-like disorder ( F06.2 ) schizophreniform disorders NOS ( F20.8 )

Serotonin and Dopamine Interactions in Rodents and Primates Implications for Psychosis and Antipsychotic Drug

Cholinergic Circuits and Signaling in the Pathophysiology of Schizophrenia II. ACh in Brain Regions Implicated in Implicated in Schizophrenia IV. Developmental and Genetic Deficits in Schizophrenia That May Brain Cholinergic Systems in VI. Evidence for Cholinergic Contributions to Schizophrenia Pathophysiology from Clinical and Schizophrenia and the a7 Nicotinic Acetylcholine Receptor the a7 Nicotinic Acetylcholine Receptor and Schizophrenia 226 III. The Prototypic a7 Nicotinic Agonist, Nicotine, and Schizophrenia 228 V. The Phase 1 Study of DMXBA in Histamine and Schizophrenia III. Changes in the Histaminergic System in V. Role of Histaminergic Neurons in Cannabinoids and Psychosis V. Cannabis and Psychosis Involvement of Neuropeptide Systems in Schizophrenia Human Studies Brain-Derived Neurotrophic Factor in Schizophrenia and Its Relation with Dopamine III. BDNF in the Serum of Patients with Patients with

F201 Hebephrenic schizophrenia

A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate, thought is disorganized, and speech is incoherent. There is a tendency to social isolation. Usually the prognosis is poor because of the rapid development of negative symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults. Disorganized schizophrenia Hebephrenia

F230 Acute polymorphic psychotic disorder without symptoms of schizophrenia

An acute psychotic disorder in which hallucinations, delusions or perceptual disturbances are obvious but markedly variable, changing from day to day or even from hour to hour. Emotional turmoil with intense transient feelings of happiness or ecstasy, or anxiety and irritability, is also frequently present. The polymorphism and instability are characteristic for the overall clinical picture and the psychotic features do not justify a diagnosis of schizophrenia (F20.-). These disorders often have an abrupt onset, developing rapidly within a few days, and they frequently show a rapid resolution of symptoms with no recurrence. If the symptoms persist the diagnosis should be changed to persistent delusional disorder (F22.-). Bouff e d lirante without symptoms of schizophrenia or unspecified Cycloid psychosis without symptoms of schizophrenia or unspecified

F202 Catatonic schizophrenia

Catatonic schizophrenia is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. The catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations.

Pharmacological Treatment of Obesity in Schizophrenia

The literature thus far suggests that some of the novel antipsychotic medications cause less weight gain than others thus it may be possible to switch patients on agents associated with the most weight gain to those with lower weight gain liability (Allison et al. 1999a Wirshing et al. 1999) however, prior to switching, it is important to recall that the most difficult symptoms to control are those of psychosis. A switch of antipsychotic medication makes sense particularly if the patient is nonresponsive to the current antipsychotic. As discussed, weight gain can be a significant cause of nonadherence with a medication regimen thus, in cases where a patient refuses to take medication due to weight gain concerns, a switch is advisable (Bernstein 1988 Silverstone et al. 1988). A switch study sponsored by Pfizer demonstrated that subjects switched from olanzapine to ziprasidone lost a statistically significant 2.2 kg on average over 6 weeks (Kingsbury et al. 2001). Moreover, recent...

Obesity in Schizophrenia

In the pre-antipsychotic era, Kraepelin noted that some patients with schizophrenia exhibited bizarre eating habits, and not uncommonly were obese. The taking of food fluctuates from complete refusal to the greatest voracity. The body weight usually falls at first often to a considerable degree. . . . L ater, on the contrary we see the weight not infrequently rise quickly in the most extraordinary way, so that the patients in a short time acquire an uncommonly well-nourished turgid appearance (Kraepelin 1919, p. 125). It is worth noting that this tendency to weight loss during more active phases of the illness has been borne out by results from a recent meta-analysis of multiple antipsychotic drug trials, which noted that placebo-treated patients on average lost weight (Allison et al. 1999a). Nevertheless, there are a number of reasons that patients with schizophrenia might be prone to obesity, including the effect of symptoms such as paranoia and negative symptoms such as apathy and...

Pharmacology of Nicotine and Tobacco Relevance to Schizophrenia

There has been an increasing understanding of the neurobiology of both schizophrenia and nicotine addiction in the past 20 years. For the purposes of this discussion, nicotine is assumed to be the active ingredient in tobacco and cigarette smoking that exerts psychopharmacological effects, though other components of tobacco smoke may also be active in this respect (Fowler et al. 1996a, 1996b). There are three possible reasons for the high comorbidity rates of nicotine addiction in schizophrenia 1) self-medication of clinical and cognitive deficits associated with schizophrenia by tobacco use, 2) abnormalities in brain reward pathways in schizophrenia that make these patients Table 5-1. Prevalence of cigarette smoking in individuals with schizophrenia vulnerable to tobacco (and other drug) use, and 3) common genetic and environmental factors that are independently associated with smoking and schizophrenia. We briefly describe next the pharmacological effects of nicotine and how such...


The course of schizophrenic disorders can be either continuous, or episodic with progressive or stable deficit, or there can be one or more episodes with complete or incomplete remission. The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedate the affective disturbance. Nor should schizophrenia be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy or other brain disease should be classified under F06.2, and those induced by psychoactive substances under F10-F19 with common fourth character .5. Excludes schizophrenia


Psychosis is a mental state in which there is gross misperception of reality. This loss of touch with reality may be evidenced by delusions (false beliefs), including paranoia, delusions of persecution or threat, or hallucinations, imagined sensory experiences. Although the patient's condition makes it impossible for him or her to cope with the ordinary demands of life, there is lack of awareness that this behavior is inappropriate. Schizophrenia is a form of chronic psychosis that may include bizarre behavior, paranoia, anxiety, delusions, withdrawal, and suicidal tendencies. The diagnosis of schizophrenia encompasses a broad category of

The Intervention Triad Prevention Treatment and Enhancement

Preventative interventions or interventions at an early state of development influencing brain development and therefore future personality traits are little discussed. However, as the example of novel antipsychotics in the prevention of schizophrenia shows, the question of preventative intervention in the brain raises many ethical considerations. The same is true for the debate on the potential use of interventions for restraint. - Antipsychotics. Classic antipsychotic medications are the phenothiazines, Butyrophenone, neuroleptics such as Haloperidol, and different derivatives. These classic conventional antipsychotic drugs have a multitude of well known effects and side effects. They are used for the treatment of schizophrenia and schizoaffective disorder, substance induced psychosis, mania, personality disorders, Tourette's syndrome and different states of aggression or self-injurious behaviour. The so-called atypical novel antipsychotics are Clozapine, Olanzapine, Quetiapine,...

Interventions 141 Prevention

In a consensus statement on prevention the World Psychiatric Association (WPA) defined three major aims of prevention (WPA December 2003). Primary prevention The identification of, and interventions with, high risk groups was recommended, for example prenatal care, healthy start to life programmes, good parenting, collaborative multi agency programmes. Secondary prevention Pre-morbid intervention in mental illness such as depression, post-traumatic stress disorder, substance abuse or psychosis was recommended. Tertiary prevention This was defined as early intervention in mental illness, for example in community-based treatment and rehabilitation programmes. The World Psychiatric Association also defined goals in educating the community about mental illness (secondary prevention) and stigma reduction (tertiary prevention). In this chapter we will focus on pre-morbid pharmacological interventions in mental illness or early intervention in mental illness, and we will take the unique...

Suicide and Other Unnatural Causes of Mortality

Reviews consistently find that suicide accounts for some of the increased mortality seen in patients with schizophrenia (Allebeck 1989 Harris and Barraclough 1998). This increased rate of death by suicide is evident in specific studies as well. In a 10-year follow-up of 1,190 patients with schizophrenia discharged from any hospital in Stockholm County in 1971 (Allebeck 1989 Allebeck and Wistedt 1986), 33 deaths out of 231 (14.3 ) were registered as suicides, for an SMR of 12.3 (95 CI 9.1-15.6). Some accidental and undetermined deaths were probably suicides, so the actual rate was probably higher. In a subsequent study of a different patient group from Stockholm County (Osby et al. 2000a), 380 of 1,849 deaths (20.6 ) were by suicide. The SMR for suicide deaths was 15.7 (95 CI 13.6-17.9) for males and 19.7 (95 CI 16.8-22.9) for females. The suicide SMR was expected to be higher because this incidence study started following patients earlier in their illness, when suicide rates are...

Nonnuisance Nonmaleficence

A last example in our plea for a stronger emphasis in safety is the use of atypical neuroleptics and the recent discussion of the appropriateness of their use in general in adults and in comparison to older drugs (Lieberman et al. 2005). Atypical neuroleptics are a new substance class of medication with potential use for children and adolescents that has been introduced to the market without any relevant studies in adolescents suffering from schizophrenia. Children and adolescents tolerate typical antipsychotics less well than adults and often react with early-onset dyskinesia. As a result, the new alternatives are widely used in the treatment of childhood schizophrenia. In a preventive study, Risperidone has even been used in adolescents to prevent schizophrenia but there is no labelling of any of these substances for the use in children or adolescents for the indication of schizophrenia due to the lack of clinical trials in this age group. Some studies, especially with Risperidone,...

Access to Health Care

One can easily conjecture that decreased access to either medical or psychiatric care could exacerbate morbidity and contribute to increased mortality in patients with schizophrenia. For instance, in reporting increasing SMRs in Stockholm County for patients admitted during more recent 5-year periods, Osby et al. (2000b) point out that a shift from inpatient to A number of reports suggest that access to medical care may be limited for patients with schizophrenia. Multiple factors could contribute to decreased access, including limitations in the communication of symptoms by patients, poor cooperation by psychotic patients, prejudice (based on fear, frustration, or anxiety) against schizophrenic patients, and insufficient attention to medical problems by mental health providers (Adler and Griffith 1991 Druss and Rosenheck 1997 Goldman 1999 Pary and Barton 1988). Dixon et al. (1999) found that less than 70 of the patients with medical problems were receiving treatment for their medical...

Therapeutic Drug Monitoring TDM

Starting in the 1850s and for the next 150 years, bromide salts were the main ingredient in most over-the-counter and patent medicine sedatives. The half-life of bromide in humans is 12 to 15 days. Toxicity from abuse progresses from delirium, delusions and hallucinations to deep sedation followed by coma. Evelyn Waugh vividly described bromide psychosis in 1957 in his autobiographical novella The Ordeal of Gilbert Pinfold (1). It has been estimated that 2 of all admissions to mental hospitals were once due to bromide psychosis (2). McDanal et al. (3) reported on six cases of bromide psychosis from over-the-counter sedatives in San Diego County, California between 1970 and 1972. By the mid-1970s bromide was removed from all over-the-counter drugs. Miles Pharmaceutical stopped selling Nervine and Emerson Drug took bromide out of Bromo Seltzer . In 1990 the incidence of bromide toxicity was very low (4). Occasional reports of toxicity from imported herbal medicines that contain bromide...

Typical Antipsychotics

Although typical antipsychotics exert their effects through a common mechanism of potent antagonism of dopamine D2 receptors, treatment with the phenothiazine class of antipsychotics such as chlorpromazine or fluphenazine was associated with significant effects on serum lipids in a manner not seen during therapy with butyrophenones such as haloperi-dol. In the decade following the widespread availability of chlorprom-azine, literature emerged documenting effects on lipids (Clark et al. 1967 Mefferd et al. 1958), but the specific effects on cholesterol fractions were not elucidated until the mid-1980s with Sasaki's data on phenothiazine-treated chronic inpatients (Sasaki et al. 1984). This study found that HDL levels were significantly lower (P< 0.001) compared with normal control subjects, while the serum triglyceride level was significantly higher (P< 0.05) in these phenothiazine-treated patients. In one subgroup of eight new patients with schizophrenia, serum HDL level decreased...

Is Repression a Mechanism

One may ask Why is repression necessary What is the inner danger that requires repression Freud believed that the unconscious is a source of danger in itself. It is the intensity of excitation itself that poses a danger to the psyche. If the unconscious erupted unchecked into consciousness, Freud (1900) asserted, the result would be psychosis. Freud also attributed childhood disgust regarding bodily functions as another motive for repression. With regard to the intensity of excitation, he analogized this internal danger to an environmental danger from which the organism takes flight through a withdrawal of cathexis. The essence of repression lies simply in turning something away, in keeping it at a distance, from the consciousness (Freud 1915a).3 As one cannot escape from one's unconscious, our only recourse, according to Freud, is a withdrawal of cathexis. Freud's explanation of repression was essentially based upon an analogy to an organism escaping from external

Clinical Recommendations and Conclusions

Increasingly, psychiatrists and mental health clinics who treat the chronically mentally ill recognize that they have become de facto primary care providers for these patients, who often have limited access to outside medical services. Integrated medical and psychiatric care appears promising in achieving important health gains for patients with schizophrenia, yet is not the reality for most mental health settings (Druss et al. 2001). A certain amount of nihilism combined with the need to immediately focus on major psychopathology often leaves chronic medical issues unaddressed by mental health practitioners (Le Fevre 2001). Moreover, patients with schizophrenia do not adequately communicate their health problems and needs (Pary and Barton 1988). Nonetheless, data reveal improved compliance with medications and health recommendations after educational intervention (Kelly et al. 1990). Therefore, one should not eschew lifestyle counseling, as the benefits seen with even modest changes...

Epidemiology and Significance of the Problem

Several epidemiological and clinical studies since the 1980s have documented the high rates of cigarette smoking in psychiatric patients, particularly those with schizophrenia-related disorders (Chong and Choo 1996 de Leon et al. 1995 Diwan et al. 1998 el-Guebaly and Hodgins 1992 George et al. 1995 Goff et al. 1992 Hughes et al. 1986 Kelly and Mc-Credie 1999 Masterson and O'Shea 1984 McEvoy and Brown 1999 Menza et al. 1991 O'Farrell et al. 1983 Ziedonis et al. 1994). This work was supported in part by grants R01-DA-13672, R01-DA-14039, and K12-DA-00167 to Dr. George from the National Institute on Drug Abuse (NIDA), and a Wodecroft Young Investigator Award to Dr. George from the National Alliance for Research on Schizophrenia and Depression (NARSAD). Although smoking rates in the general population have substantially declined from 45 in the 1960s to about 25 currently (Vocci and DeWit 1999), rates of smoking in chronic psychiatric patients, especially those with schizophrenia, continue...

Severely Depressed Individuals Lack The Capacity To Utilize Hypnosis

Pettinati, Kogan, Evans et al. (1990) compared hypnotizability on two measures, the Hypnotic Induction Profile (HIP) and the Stanford Hypnotic Suggestibility Scale C (SHSS C) for five clinical and one normal college populations. The group with a diagnosis of major depression scored higher on the SHSS C than the normal population and only marginally lower, although higher than the anorexia nervosa and schizophrenia groups, on the HIP.

Hivhcv Knowledge Among People With Severe Mental Illness and Their Providers

Mendel and Ryan's qualitative data suggest that, in practice, many mental health care providers are unsure of how many of their clients have HCV, except for a general sense that the numbers are increasing. Staff in mental health agencies were more concerned with diabetes and tuberculosis (because of the difficulty in daily self-management and the risk of contagion, respectively) than with either HCV or HIV. In addition, these qualitative data show that mental health and substance abuse treatment providers were generally unaware of the depressive side effects of interferon therapy, with only two agencies in New York City recounting specific in-service trainings that covered HCV along with other diseases. We believe that improved HCV screening followed by referral for evaluation of every HCV-positive patient, including those with schizophrenia, whose psychiatric condition is stable is now warranted.

Neuropsychiatric Manifestations

HIV infection presents a spectrum of neuropsychiatric sequelae that can pose diagnostic and treatment quandaries to clinicians. In patients with serious and persistent psychiatric illness, some of the early, subtle neuropsy-chiatric symptoms may be difficult to differentiate from preexisting symptoms of their psychiatric illness. HIV is neurotropic (O'Brien 1994), enters the CNS soon after infection (Resnick et al. 1988), and can acutely induce headache and meningeal signs as already noted. Long-term clinical sequelae of CNS infection range from subtle neurocognitive impairment to frank dementia, and their incidence increases with HIV illness progression. OIs and neoplasms that follow immunosuppression can also affect the CNS, resulting in mood disorders, psychosis, cognitive disorders, de

Contraindications Precautions And Interactions

Levodopa is used cautiously in patients with cardiovascular disease, bronchial asthma, emphysema, peptic ulcer disease, renal or hepatic disease, and psychosis. Levodopa and combination antiparkinsonism drugs (eg, carbidopa levodopa) are classified as Pregnancy Category C and are used with caution during pregnancy and lactation. Selegiline is used cautiously in patients with psychosis, dementia, or excessive tremor. When selegiline is administered with levodopa, the effectiveness of lev-odopa increases. This effect allows for a decrease in the dosage of levodopa. If selegiline is given in doses greater than 10 mg d there is an increased risk of hypertension, particularly if tyramine-containing foods (eg, beer, wine, aged cheese, yeast products, chicken livers, and pickled herring) are ingested. A potentially serious reaction Amantadine is used cautiously in patients with seizure disorders, hepatic disease, psychosis, cardiac disease, and renal disease....

Promoting an Optimal Response to Therapy

The drugs used to treat parkinsonism also may be used to treat the symptoms of parkinsonism that occur with the administration of some of the psychotherapeu-tic drugs (see Chap. 32). When used for this purpose, the antiparkinsonism drugs may exacerbate mental symptoms and precipitate a psychosis. The nurse must observe the patient's behavior at frequent intervals. If sudden behavioral changes are noted, the nurse withholds the next dose of the drug and immediately notifies the primary health care provider.

Routine laboratory examination may reveal abnormalities 1 Hematology

The diagnostic strategy for SLE involves recognition of a multisystem disease, the presence of certain serologic findings, and the absence of any other recognized disease process to explain the findings. Not all clinical and laboratory findings are of equal specificity acute pericarditis and psychosis, as well as proteinuria and leukopenia, can have many causes other than SLE. Conversely, a discoid lupus rash and high titers of anti-native DNA antibodies or anti-Smith antigen antibodies strongly support the diagnosis. The art of diagnosis rests in recognizing a constellation of findings and giving each the appropriate clinical weight. Because the presentations of SLE are many and varied, the full differential diagnosis includes most of internal medicine. B. Organ systems that may be affected by SLE include skin and mucous membranes (rash, ulceration, alopecia), joints (nondeforming, often symmetric polyarthritis and periarthritis), kidneys...

Pathogenetic Considerations

The correlation of neurological complaints and lipid storage is hampered by the presence of a combination of neuronal storage, angiopathic infarcts in nervous tissue, and deposition of glycosphingolipids in end-organs such as the sweat glands in the skin. The episodic limb pain typical of FD has been ascribed to dorsal root ganglia neuropathy, peripheral small-fiber neuropathy, involvement of substantia gelatinosa neurons, and peripheral nerve ischemia due to involvement of the vasa nervorum. Autonomic dysfunction could arise from involvement of the autonomic nervous system at either central or peripheral level, but anhidrosis could also be explained by dysfunction of sweat glands. The episodic fever may be related to lesions of the hypothalamus and to the inability to sweat. The clinical correlate of the cerebral neuronal glycosphingolipid deposition is unclear. Psychosis,personality changes, and dementia have been described in FD but are not prominent phenomena. Seizures are rare....

Dissociative Disorder Not Otherwise Specified

This category encompasses wide diversity, including cases with great similarity to dissociative identity disorder (often called ego-state disorders), derealization without depersonalization, the dissociative sequelae of coercive persuasion, dissociative trance disorder (see above), Ganser's syndrome, dissociative psychoses, some gender identity disturbances, and a mixture of dissociative symptoms of all sorts (American Psychiatric Association, 1994 Coons, 1992b). The use of hypnosis with such patients will parallel its use in patients with the conditions most akin to the symptom clusters in question. Coons' (1992b) study is a landmark contribution. Very little else has been written about the treatment of these patients, except for those forms most akin to dissociative identity disorder. The ego-state model of Watkins and Watkins (1997), which employs hypnosis to access and work with ego states, to negotiate among them, and to resolve their traumata, may be very effective with this...

Adverse Reactions

Antipsychotic drugs are used to manage acute and chronic psychoses. In addition to its antipsychotic properties, chlorpromazine (Thorazine) is used to treat uncontrollable hiccoughs. Clozapine (Clozaril) is used only in patients with schizophrenia that is unresponsive to other antipsychotic drugs. Lithium is effective in the management of bipolar (manic-depressive) illness. Some of these drugs, such as chlorpromazine (Thorazine) and prochlorperazine (Compazine), are used as antiemetics (see Chap. 34). When given in small doses, neuroleptics are effective in the control of acute agitation in the elderly. More specific uses of these drugs are given in the Summary Drug Table Antipsychotic Drugs.

Preadministration Assessment

Before starting therapy for the hospitalized patient, the nurse obtains a complete psychiatric and medical history. In the case of psychosis, patients often are unable to give a reliable history of their illness. When a psychosis is present, the nurse obtains the psychiatric history from a family member or friend. During the time the history is taken, the nurse observes the patient Physical assessments include obtaining blood pressure measurements on both arms with the patient in a sitting position, pulse, respiratory rate, and weight. The hospitalized patient may ultimately be discharged from the psychiatric setting. Some patients, such as those with mild schizophrenia, do not require inpatient care. The nurse usually sees these patients at periodic intervals in the psychiatric outpatient setting.

General Physical Health

Rates of comorbid physical illness in schizophrenic patients have been reported to occur primarily in the categories of non-insulin-dependent diabetes mellitus (NIDDM), cardiovascular disease, infectious diseases, respiratory disease, some forms of cancer, and a variety of other illnesses (Dixon et al. 1999). It has also been suggested that persons with schizophrenia may be subject to more severe forms of disorders (Jeste et al. 1996), which may be exacerbated by the side effects of antipsychotic medications (e.g., anticholinergic, cardiovascular, or metabolic effects) and by psychotic illness itself, with significant correlations found between positive symptoms and the number of medical conditions (Dixon et al. 1999 Jeste et al. 1996). Because data suggest that the diagnosis of schizophrenia across all age ranges confers greater risk for physical illness, it might be assumed that older persons with schizophrenia are more medically ill than age-matched peers. Moreover, it is...

Cardiovascular Disease

Cardiovascular diseases are among the most common disorders found among schizophrenic persons. Cardiovascular disease is reported to occur more frequently and to be responsible for increased mortality rates in schizophrenic individuals versus those in the general population (Dixon et al. 1999 Tsuang et al. 1983). The Oxford Record Linkage Study (ORLS), which used data derived from hospital activity analyses and mental health inquiry systems, included 2,314 persons with schizophrenia across all age groups, of whom one-third were age 55 or older. For these patients there was a significant increase in relative risk for atherosclerotic heart disease, but not for other forms of cardiac, hypertensive, or other circulatory diseases (Baldwin 1979). The limited data on older schizophrenic samples have been more mixed than the findings for schizophrenia in general. Sajatovic et al. (1996) studied 49 schizophrenic patients at the Cleveland Veterans Affairs Medical Center ranging in age from 65...

Saturation Assays for mGAT1 73211 GABA Transporters

Transmission was linked, directly or indirectly, to a variety of neuro-pathological and psychiatric medical conditions, e.g. epilepsy, Huntington's chorea, Parkinson, Tardive dyskinesia, schizophrenia, anxiety, depression and other behavioral disorders. The GABA transporters (GATs) that remove the neurotransmitter from the synaptic cleft after its release are very interesting targets for the development of new agents for the indications listed above 81 . Inhibitors of these transporters can extend the presence of GABA in the synaptic cleft and therefore increase the inhibitory effect of the neurotransmitter. For the GABA transporters that are a part of the superfamily of Na+ Cl -dependent transporters four subtypes are known. Among them the transporter subtype most frequently found in the brain is GAT1, an already validated target in the search for anticonvulsants 82-85 . A successful example is the agent tiagabine, an effective and selective inhibitor of GAT1 which has already been...

Subjective Health Status

Krach concluded that these patients overrated their physical health status and underreported medical symptoms, although the author provided no objective measures of physical health. Indeed, in contradistinction to Krach's conclusions, the authors of the PORT study (Dixon et al. 1999) maintained that persons with schizophrenia have the capacity for reasonable appraisal of their medical conditions that can be a useful tool to promote positive health behaviors (p. 502). This conclusion was based on the finding of a significant association between the number of medical conditions and self-rated health. In the PORT survey, lower educational level and number of comorbid medical disorders were the only variables associated with poorer self-rated physical health. Other variables, such as gender, race, age, comorbid alcohol or drug disorder, geographic location, or patient setting, were not associated with self-health ratings, although there was a trend for older subjects to perceive their...

Table 151 Characteristics of different pain types

Assessing the pain type and characteristics requires an adequate history and physical examination. In addition, any medical risk factors should be well understood. Table 15.2 gives general inclusion and exclusion criteria for intraspinal opioid therapy. The patient should have progressed to level 3 of the World Health Organization (WHO) pain ladder (Table 15.3) and should have demonstrated opiate responsivity.19 Psychological assessment has become an important part of ongoing management for chronic pain patients as well as an integral part of selection for implantable therapies. The question asked of the neuropsy-chologist or psychiatrist is whether any untreated psychosocial problems exist that might lead to a bad outcome from the therapy. The question of whether a patient is a candidate for implantable therapy is answered by the implanter, generally not by the psychologist. However, certain psychiatric diagnoses such as psychosis or conflicting motives and expectations may lead to...

What Is The Relationship Between Stress And Illicit Drug

Mental illness called psychosis.They may be too ill to recognize how ill they are and why they are ill. They may not have the mental and physical strength to cope on their own. It is therefore very important that their friends and family help them seek professional help quickly.

Substance Use Screening and Treatment

Treatment for substance use by people with schizophrenia requires an integrated approach, given the extent to which these problems interact and are interconnected (Hellerstein et al. 2001). Although the deleterious effects of comorbid substance use on relapse rates are clear, the literature on interventions offers little guidance due to the paucity of controlled studies. In a recent article Bennett et al. (2001) noted that only seven studies available in the literature through 1998 employed experimental designs, five of which examined inpatient care or intensive outpatient case management for serious mentally ill clients (primarily for homeless populations), and are not directly applicable to the treatment of the broader population of people with schizophrenia living in the community (p. 164). In the remaining two controlled studies of outpatient treatment, one found decreased substance abuse and psychiatric severity among patients who began and remained in treatment over several...

The Interpretation of Sensations

The distinction between metaphoric transfer and meta-phoric transformation of feeling can be illustrated if we turn to psychopathology. Psychopathology can be viewed as nature's experiment in which a vital component is subtracted or removed, as in a thought experiment. Not infrequently, when someone is afflicted with schizophrenia, there is a cognitive deficit in which the patient suffers from a loss of the transformative power of metaphor. The British psychoanalyst Hanna Segal gave the following account of a schizophrenic patient in a mental hospital He was once asked by his doctor why it was that since his illness he had stopped playing the violin He replied with some violence 'Why do you expect me to masturbate in public ' (1957). I can recall a similar observation regarding a patient who was severely inhibited in the use of his intellect. Unlike Hanna Segal's patient, he was not in any sense psychotic, yet he believed that the pleasure and excitement that he could obtain from...

Model of Chronic Care Enabled with Information Technology

The number of patients suffering from chronic diseases increased rapidly over the last few decades. As this group of patients consumes a considerable part of healthcare budgets in most countries, the need for consistent policies on chronic care is urgent nowadays. Chronic diseases do not resolve spontaneously and usually cannot be cured completely. As a result, patients with chronic diseases require care delivery over a prolonged period of time. Chronic conditions comprise several broad categories of diseases noncommunicable diseases like cardiovascular disease, cancer or diabetes persistent communicable diseases (AIDS) mental disorders like depression or schizophrenia and impairments of structure (blindness, musculoskeletal disorders). Chronic diseases are the major health burden in developed countries however, similar trends may also be seen in developing countries. The epidemiological data show that in the year 2000, noncommunicable conditions and mental disorders were responsible...

Alcohol and Other Substance Abuse Disorders

Substance abuse disorders complicate schizophrenia at rates that exceed those found in the general population. The Epidemiologic Catchment Area study (Regier et al. 1990) found the rate of comorbid substance abuse as 47 in schizophrenia. Alcohol accounted for 34 of this estimated rate, a figure substantially higher than that for the general population (14 ). Another recent investigation concluded that individuals with schizophrenia report rates of 16 for lifetime nonalcohol substance abuse (Duke et al. 2001). The most commonly abused substances include marijuana, stimulants, hallucinogens, opiates, and anticholinergics, and abuse was concentrated in males younger than 36 years. The suggested source of this increased vulnerability to addictive behaviors among schizophrenic patients is disturbance in the neural circuitry mediating drug desire and reinforcement. Chambers et al. (2001) argued that abnormalities in the hippocampal formation and frontal cortex (leading to disturbed dopamine...

Excitotoxicity and Neurodegeneration

The discovery of the excitotoxic effects of glutamate fuelled speculation that a similar mechanism might underlie neuronal cell death in chronic neurode-generative diseases such as Alzheimer's disease, Huntingdon's disease and amyotrophic lateral sclerosis (ALS). Several studies have examined whether the subunit composition of AMPARs is altered in these states to produce GluR with higher Ca2+ permeability. A reduction in GluR2 expression has been observed in spinal motor neurones in ALS patients, which would be consistent with an enhanced Ca2+ permeability and excitotoxicity (Virgo et al., 1996). The level of GluR2 expression is also decreased in pyramidal neurones of the parahippocampal gyrus in patients with schizophrenia (Eastwood et al., 1995). Whether these changes in GluR2 levels are the principal cause, or simply a consequence, of these disease, however, remains unknown.

Abnormal Voluntary Movements

Although voluntary movement disorders have not been as extensively studied as involuntary movement disorders, data do exist, such as those generated by Manschreck et al. (1982) in their investigation of abnormal voluntary movements in schizophrenic subjects and mood-disordered patient control subjects. The assessment included a 1-hour examination of spontaneous motor activity, examination of simple and complex motor tasks, and evaluation of medication side effects. The findings indicated that 36 of 37 schizophrenic subjects showed disturbed voluntary movements, whereas mood-disordered subjects showed less frequent and less severe disturbances. These were voluntary motor disturbances and not associated with evidence of medication effects. Indeed, antipsychotic medication had a marginally positive impact in reducing the occurrence of such movements, which did not resemble the forms of disturbance characteris tic of drug-induced motor effects. These voluntary disturbances fell into three...

David A Gorelick and Stephen J Heishman

Better scientific understanding of cannabis effects and the development of treatments for cannabis dependence require clinical studies involving cannabis administration. Cannabis can be administered by smoking a plant-derived cigarette or by oral or intravenous administration of A9-tetrahydrocannabinol (THC), the primary psychoactive chemical in cannabis. The smoked route is most commonly used outside the laboratory, but is subject to wide variation in absorbed dose. Oral synthetic THC is a legally marketed medication (dronabinol), also subject to wide pharmacokinetic variation, but offering a greater safety margin because of slower onset of action and lower potency. Intravenous THC offers precise investigator control of dose and timing. Acute adverse effects of cannabis administration include tachycardia, orthostatic hypotension, pulmonary irritation (if smoked), motor incoordination, cognitive impairment, anxiety, paranoia, and psychosis. Screening of research subjects should...

Abnormal Involuntary Movements

In recent years, there have been systematic attempts to characterize abnormal involuntary movements presumed to be intrinsic to schizophrenia. Kraepelin observed that some patients with psychosis had fixed facial expression and slow shuffling movements reminiscent of Parkinson's disease (Crow et al. 1982, 1983) and described features in dementia praecox indistinguishable from contemporary accounts of TD. Whereas Kahlbaum conceptualized catatonia as a brain disorder, Bleuler believed that all motor symptoms of schizophrenia were in some way related to the psychic factors (Arieti 1972) however, following the epidemic of influenza in the second decade of the twentieth century, which resulted in large numbers of cases of encephalitis lethargica, there was further discourse on the possibility that psychotic symptoms seen in psychiatric disorders and motor dysfunction both arose from abnormal brain function (Dretler 1935 Steck 1926 1927). When TD was initially described in the 1950s, there...

Newer Findings on Involuntary Movements

As mentioned previously, the historical (and we would argue ongoing) no-sological confusion between what is psychiatric versus neurological was evident in many of the studies reviewed (Berrios and Chen 1993 Lund et al. 1991 Rogers 1985). For example, Peralta et al. (2000) attempted to differentiate between the negative symptoms of schizophrenia and parkin-sonism. This research group in fact documented a significant correlation between the severity of negative symptoms and the severity of akinetic but not hyperkinetic parkinsonism. An important finding from their study was that 19 of neuroleptic-naive patients had a parkinsonian syndrome at admission. This number increased to 32 at discharge, after patients were treated with neuroleptic medications, despite the fact that most of the patients (39 of 49) received treatment with so-called new or second-generation anti-psychotics, which are believed to produce fewer and less prominent extrapyramidal symptoms compared with typical or...

Risk Factors and Mechanisms of Basal Ganglia Dysfunction

Studies of the prevalence and importance of basal ganglia dysfunction in schizophrenia have been compromised by medication side effects and a past perspective that considers schizophrenia separate from neurological disorders. Increasing numbers of studies of first-episode, never-medicated subjects, using rating scales that are sensitive to movement disorders, have established that basal ganglia dysfunction is surprisingly prevalent in these neuroleptic-nai've patients. Not only are abnormal involuntary movements observed, but parkinsonism is as well. The relationship of basal ganglia dysfunction to the course and prognosis of schizophrenia needs further investigation, particularly in the context of the availability of anti-psychotic drugs with significantly reduced motor side effects. Numerous investigators have examined the role of genetic factors and their relative contribution to the development of parkinsonism and dys-kinesia. A review (Wolff and O'Driscoll 1999) of high-risk...

Adverse Events From Cannabis Administration

Anxiety, Psychosis Acute cannabis administration can cause a spectrum of adverse psychological effects, ranging from hypervigilance and anxiety, to panic, agitation, paranoid thinking, and psychosis (38,40). These are rare at the doses commonly used in research studies but are more likely to occur in susceptible individuals (46,47). Although controlled studies have not been done, susceptible subjects include those with preexisting psychopathology or a history of a psychiatric illness such as schizophrenia, schizoaffective disorder, major depression, manic depression (bipolar disorder), or anxiety disorder. Screening for these conditions relies largely on subject self-report and so may not always be completely reliable. Thus, it is prudent to conduct cannabis-administration studies in a setting where appropriate psychiatric intervention is promptly available. This should include facilities for safe physical restraint of agitated subjects and administration of parenteral...

Abnormalities in Handedness

Lateralization refers to the differential activation of left and right hemispheres for motor, perceptual, cognitive, and other functions. This implies a specific dominance or specialization for different brain tasks, such as language. In psychopathology, the possible relationship of lateralization to neurological and psychological features of schizophrenia has stimulated considerable interest. One aspect of this focus has been on handedness in schizophrenia. The general finding, although not without exception, has been that there is excess left-handedness among schizophrenic subjects, suggesting altered lateralization (Boklage 1977). Because left-handedness is distributed normally in the population in the range of 7 to 10 , a higher prevalence suggests that lateralization has been modified, perhaps because of disease or CNS damage. In a related examination of this issue, Manschreck and Ames (1984) found a lack of consistency in lateralization (eye, hand, and foot preferences) in...

Failures of Normal Neurological Maturation

In work designed to unravel the nature of neurological signs and the course of early-onset schizophrenia, Karp et al. (2001) evaluated neurological functioning in 21 adolescents with schizophrenia with onset of psychosis before age 13, compared with 27 matched (in age and sex) healthy comparison subjects. They found neurological signs at high frequency among the psychopathologic subjects, at rates comparable with those reported among adult schizophrenic subjects (Ismail et al. 1998b Lane et al. 1996 Manschreck and Ames 1984). Distinguishing findings included lower IQ, sensory integration (face and hand) abnormalities, gaze imper-sistence, and corticospinal tract signs. A striking contrast was evidence of maturational loss of primitive reflexes, hypertonia, impaired coordination, and chorea with age among the healthy control subjects, a pattern not present among the childhood-onset cases. This demonstrates a failure of neurological maturation in the latter group. Other deviations from...

Imaging Techniques for Studying Neuronal Activity

The technique of functional magnetic resonance imaging (fMRI) using either relative cerebral blood volume (rCBV), blood oxygenation level dependent (BOLD) or Trbased cerebral blood flow (CBF) techniques has led to a revolution in brain mapping 1 -3 . This is largely due to the fact that the advent of a noninvasive tool with reasonable contrast to noise, spatial, and temporal resolution, allows for studies to be conducted more easily than the prior positron emission tomography (PET) studies of brain activation. Both fMRI and PET studies of brain activation are based upon the coupling between neuronal activity, metabolism, and hemodynamics (see also Chapter 11, Section 2). The possibility that fMRI may help understand the organization and flow of information in the brain has led to an explosion in the number of centers dedicated to performing the technique. In addition to the interest in fMRI by the neuroscience community, a number of clinical conditions has the potential to benefit...

Cognitive Disturbances

In the past decade the study of recovery and outcome in schizophrenia has inspired a renewed emphasis on the cognitive dimension of the disorder (Harvey 2000). The reasons are several. First, cognitive impairment is widely prevalent and affects nearly every cognitive function (Harvey and Keefe 1997). Second, it is not the result of other symptoms or drug treatment hence, it is a central component of the disorder. Third, not only is cognitive impairment present at the onset of diagnosable illness (i.e., at the appearance of psychosis), but various studies, including those of high-risk samples, indicate that it is present long before (Crow et al. 1996). Fourth, cognitive disturbance is the strongest predictor of overall outcome in schizophrenia (Harvey 1997). Fifth, cognitive impairments are largely responsible for the functional deficits that create much of the disability and indirect costs associated with schizophrenia (Harvey 2000). Finally, there are indications that the newer,...

Myocardial Infarction

Myocardial infarction has rarely been documented as a consequence of hypoglycaemia (Fisher and Frier, 1993). In a series of non-diabetic patients with schizophrenia who were treated with hypoglycaemic shock therapy in the 1930s, 12 of 90 deaths were ascribed to cardiac causes, with the majority of deaths being caused by cerebral damage. It should be emphasised that this long-abandoned form of treatment of psychiatric disease necessitated prolonged and profound hypoglycaemia.

Anatomical Basis Of Dopamineorexin Interactions

Because orexin-containing axons are found in the ventral mesencephalon, it follows that the orexin and dopamine systems may interact. The involvement of mesotelencephalic dopamine systems in such diverse functions as locomotor activity, cognition, and affect, and the alterations in these domains in neuropsychiatry disorders, suggests that orexin-dopamine interactions may prove to be a fruitful target for new approaches to schizophrenia, drug abuse, and other conditions.

Formal Thought Disorder

Some patients with schizophrenia experience a range of difficulties in language function. These difficulties often depend on speech, attention, and memory mechanisms. Among the notable problems are derailment, poverty of content of speech, and associational disturbances. Schizophrenic speech is often highly repetitive, difficult to comprehend, and at times uninformative, and it may contain neologisms, oddities of expression, and illogical features. There is no clear aphasic disturbance in schizophrenia. Formal thought disorder is the clinical term used to describe manifestations of language abnormalities in schizophrenia. Studies using clinical rating scales have found that 50 of patients with schizophrenia manifest some form of communication disorder at a moderate or greater level. The most common abnormalities are in the domains of verbal productivity (e.g., the amount of speech produced) and speech connectedness (e.g., the logic, coherence, and referential nature of speech). Much...

Studying Anatomy And Disease In Medical Images Using Shape Analysis

Shape analysis offers the possibility of improved sensitivity and specificity for detection and characterization of structural differences. A number of approaches for characterizing shape and shape changes have been developed. These methods differ in the underlying representation of shape, in the type of shapes that may be modeled, and in their capacity to differentiate shape changes. Different shape analysis methods have been proposed for a variety of clinical applications. A landmark based shape analysis has been applied to study the effect of different diseases on brain structures. For this landmark-based approach, shape is defined as the information about the landmark configuration that remains unchanged under adjustment of position, orientation or scale.1 Landmarks are manually located on the surface of the studied structures seen on magnetic resonance (MR) images. These landmarks are used to create an average shape of the studied structures, which is later compared to each...

TABLE 501 Activity of Glucocorticoids in the Body

Decreases the production of lymphocytes and eosinophils in the blood by causing atrophy of the thymus gland blocks the release of cytokines, resulting in a decreased performance of T and B monocytes in the immune response. (This action, coupled with the anti-inflammatory action, makes the corticosteroids useful in delaying organ rejection in patients with transplants.) As a protective mechanism, the corticosteroids are released during periods of stress (eg, injury or surgery). The release of epinephrine or norepinephrine by the adrenal medulla during stress has a synergistic effect along with the corticosteroids. Affects mood and possibly causes neuronal or brain excitability, causing euphoria, anxiety, depression, psychosis, and an increase in motor activity in some individuals

The Acute Model for Examining the Effects of Chronic Drug Administration

At first glance it may appear as if the acute drug challenge model has severe limitations for examining the effects of chronic drug changes. Such changes are of crucial importance for understanding receptor dynamics in situations often encountered clinically. Two important examples stand out. The first is the effects of chronic administration of antipsychotic medications in schizophrenic populations. Drugs such as haloperidol, olanzapine, or clozapine often require a period of time before attaining full efficacy. A second salient example comes from the study of chronic abusers of drugs such as cocaine or ecstasy. It is well known that abusers often experience a tolerance to the effects of these drugs, implying changes in receptor populations that modulate the pharmacology of the drug of abuse. Thus, it would appear as if the acute drug challenge may not provide an adequate model for examining receptor dynamics. However, there are many ways to construe the acute drug challenge model....

Antipsychotic Induced Hyperprolactinemia

Individuals with schizophrenia who are not taking antipsychotics do not appear to have elevated prolactin levels (Kuruvilla et al. 1992). Drugs with dopamine antagonist effects may result in prolactin elevation, and it is clear that the magnitude of hyperprolactinemia varies among the available an-tipsychotic medications, generally in proportion to the potency of D2 antagonism. Prolactin elevation is greatest during treatment with typical antipsychotics and the atypical antipsychotic risperidone (Caracci and Ananthamoorthay 1999 David et al. 2000 Kleinberg et al. 1999) the atypical antipsychotics quetiapine (Hamner et al. 1996), clozapine (Kane et al. 1981), and ziprasidone (Goff et al. 1998) are not associated with prolactin elevation. With olanzapine, transient modest elevations of prolactin occur with initial treatment, but prolactin levels appear to normalize after a few weeks and remain normal with chronic treatment (Crawford et al. 1997).

Selfinjurious behaviour

Defined by Favazza (1998) as deliberate, nonsuicidal destruction of one's own body tissue. Favazza differentiated between major self-mutilation such as eye enucleation and castration, commonly associated with psychosis and intoxication, stereotypic self-mutilation which includes such acts as head banging and self-biting most often accompanying Tourette'S syndrome and severe mental retardation and superficial moderate self-mutilation for which compulsive acts such as trichotillomania repeated urge to pull out scalp and body hair and skin picking and such episodic acts as skin cutting and burning are typical.

Natural Cure For Hydrocephalus In British Columbia

J.N., a 21-year-old woman with chronic paranoid schizophrenia, was admitted to the hospital with a diagnosis of pneumonia. She was brought to the ER by her mother, who said J.N. had been very lethargic, had a fever of 104 F, and had had muscular rigidity for 3 days. She took Haldol (haloperidol) and Cogentin (benztropine mesylate). Her mother stated that J.N.'s neuroleptic medication had been changed the week before by her psychiatrist. Her secondary diagnosis was stated as neuroleptic malignant syndrome, a rare and life-threatening disorder associated with the use of antipsychotic medications. 18. antipsychotic medications

Neurological Nonlocalizing Soft Signs

The application of newer techniques of central nervous system (CNS) investigation, such as functional neuroimaging, has generated interest in finding meaningful connections between clinical observations and the underlying neuropathology of schizophrenia. A review of the literature on neurological signs (Heinrichs and Buchanan 1988) demonstrated a higher prevalence of such signs in schizophrenia than in nonpsychiatric and psychiatric control subjects, including some degree of temporal stability, a lack of medication effect (i.e., signs appear to be a stable trait), a trend toward increased neurological soft sign prevalence in males, and a modest influence of age and socioeconomic status. The majority of studies have found abnormalities in integrative sensory function, such as bilateral extinction, left-right confusion, impaired audiovisual integration, agraphes-thesia, and astereognosis. Other areas frequently found to show difficulties include motor coordination (e.g., balance,...

Globoid Cell Leukodystrophy Krabbe Disease

Krabbe Disease Pictures

The later onset forms of GLD are clinically much more heterogeneous and progress more slowly. A subdivision into late-infantile onset (6 months to 3 years), juvenile onset (4-10 years) and adolescent-adult onset has been proposed, but the subdivision is arbitrary. In most children the onset of disease occurs before the age of 5 years adolescent-adult onset is rare. There is no significant difference in symptomatology according to the age at onset. The initial signs in the late-onset forms of GLD are quite variable spastic paraparesis, hemiparesis, cerebellar ataxia, isolated visual failure (as a result of either optic atrophy or bilateral involvement of the optic radiations), dystonia, epileptic seizures, psychosis, and mental deterioration. Of these signs, increasing difficulties in walking caused by spasticity or ataxia and isolated visual failure are the most frequent first manifestations. Irritability is not infrequently noted early in the disease. Peripheral neuropathy as an...

Linked Adrenoleukodystrophy


The adolescent (onset at 10-21 years) and adult (onset after 21 years) cerebral forms resemble the childhood cerebral form, except for the later onset. Just like the childhood from, the adolescent and adult cerebral forms have a rapidly progressive course. The disease is often misdiagnosed. It may present as a psychosis or dementing illness, or as a single focal brain lesion that can be mistaken for a tumor.

Psychiatric Disorders

Because of the recent interest in hypocretin dysfunction in neurological diseases and because of the functions of the hcrts, recent studies have evaluated whether altered hypocretin neurotransmission might be also involved in some psychiatric disorders. We will focus in the present review on depression and schizophrenia. The involvement of the hypocretins in stress and drug addiction is also today documented and we recommend to the readers to refer to the specific chapters in the book devoted to these two aspects of behavior. The hcrt system is also currently evaluated in other psychiatric disorders such as eating disorders. 8.2. Schizophrenia CSF hypocretin levels have also been studied in a psychotic disorder, schizophrenia. The hypocretins have been shown to have a neuroexcitatory effect on the midbrain dopaminergic neurons. Central administration of hypocretins increases the number of stereotypy as well as locomotor activity, an effect that is prevented by the administration of...

Schizoaffective disorders

Episodic disorders in which both affective and schizophrenic symptoms are prominent but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes. Other conditions in which affective symptoms are superimposed on a pre-existing schizophrenic illness, or co-exist or alternate with persistent delusional disorders of other kinds, are classified under F20-F29. Mood-incongruent psychotic symptoms in affective disorders do not justify a diagnosis of schizoaffective disorder.

F454 Persistent somatoform pain disorder

The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.

Table E3 Commonly used topical preparations

Periodic determinations of blood sugar, complete blood cell counts, stool guaiac tests, and blood pressure measurements should be obtained. Diabetes mellitus, hypertension, pregnancy, and psychosis are relative contraindications. In patients receiving long-term steroids, the hypothalamic-pituitary-adrenal axis is suppressed, and they require glucocorticoid supplementation when undergoing surgical procedures or other physiologic stress. Repeated administration of intraarticular injections of corticosteroid may lead to disruption of cartilage and supporting soft-tissue structures. Soft-tissue injections may cause similar effects. Long-term steroid use demands appropriate immunizations and measures to ensure protection against osteoporosis.

Metachromatic Leukodystrophy

Metachromatic Leukodystrophy Mri

The adult form usually reveals itself between 16 and 30 years. Onset of the disease at 60 years or later has also been described. Most patients experience a gradual decline in intellectual abilities. At onset the clinical picture is often dominated by emotional lability, behavioral abnormalities, or psychiatric symptoms such as delusions and hallucinations. It is not uncommon for the patient to be treated initially for schizophrenia or a psychotic depression. After several months or years progressive spastic paresis of the arms and legs develops, with increased tendon reflexes and extensor plantar reflexes. Cerebellar ataxia and such extrapyramidal features as choreiform movements and dystonia may be present. Signs of peripheral neuropathy are often absent, although flaccid tetraparesis may occur in the terminal stage. Optic atrophy and signs of bulbar dysfunction may appear. Epileptic seizures are rare. A state of severe dementia gradually develops. The patient loses contact with the...

Mechanisms by Which the Atypical Antipsychotic Agents May Cause Diabetes Mellitus

There are a number of ways in which the atypical antipsychotic medications could lead to hyperglycemia and diabetes mellitus. As discussed earlier in this chapter, decreased sensitivity (increased resistance) to insulin and decreased insulin secretion as a result of decreased beta cell function are involved in the development of type II diabetes mellitus. A few controlled studies suggest that the atypical antipsychotic medications affect insulin resistance rather than causing a primary defect in insulin secretion (Henderson et al. 2000b Selke et al. 2000). The insulin resistance seen during atypical antipsychotic treatment may be a result of increased central adiposity, or it may arise from the direct effect of the medication's action on the glucose transporter function (Haupt and Newcomer 2001). Dwyer et al. (1999) studied the effects of atypical antipsychotic agents on glucose transporter function. They suggested that a structure-function relationship exists in which similar drugs,...

Excludes posttraumatic stress disorder F431 F621 Enduring personality change after psychiatric illness

Personality change, persisting for at least two years, attributable to the traumatic experience of suffering from a severe psychiatric illness. The change cannot be explained by a previous personality disorder and should be differentiated from residual schizophrenia and other states of incomplete recovery from an antecedent mental disorder. This disorder is characterized by an excessive dependence on and a demanding attitude towards others conviction of being changed or stigmatized by the illness, leading to an inability to form and maintain close and confiding personal relationships and to social iso-lation passivity, reduced interests, and diminished involvement in leisure activities persistent complaints of being ill, which may be associated with hypochondriacal claims and illness behaviour dysphoric or labile mood, not due to the presence of a current mental disorder or antecedent mental disorder with residual affective symptoms and longstanding problems in social and occupational...

Identification of Subgroups with Nondifferential Exposure Misclassification

Bipolar psychosis Unipolar Psychosis Bipolar psychosis ICD-8 codes 296.39, 296.19, and 298.19 unipolar psychosis ICD-8 codes 296.09, 296.29, 296.89, and 296.99 reactive depression ICD-8 code 298.09, dysthymia ICD-8 codes 300.49 and 301.19. Bipolar psychosis ICD-8 codes 296.39, 296.19, and 298.19 unipolar psychosis ICD-8 codes 296.09, 296.29, 296.89, and 296.99 reactive depression ICD-8 code 298.09, dysthymia ICD-8 codes 300.49 and 301.19.

Patient Health Habits and Related Concerns

Behaviors such as abuse of drugs and alcohol, smoking, lack of exercise, and dietary indiscretion appear to contribute to mortality in the general population, and thus are likely to do so in patients with schizophrenia (Brown et al. 1999). Brown et al. (2000) noted that the SMR related to natural causes of death was significantly (P 0.05) elevated in smokers (360 x 100 , 95 CI 270-471) but not in nonsmokers (178, 95 CI 85-328). The authors reviewed apparently avoidable natural causes of death in these patients. Causes included failure to recognize medical disease by the patient or care provider (three to eight cases), missed diagnoses (three cases), poor treatment compliance (unable to quantify), treatment refusal (two cases), and inadequate social support (one case). Brown et al. (1999) directly investigated lifestyle concerns in 102 patients with schizophrenia. Patients with schizophrenia ate a diet significantly higher in fat and lower in fiber (significant for males, trend for...

Respiratory Disorders

Respiratory disease was found to be one of the most common causes of medical hospitalization (18 , compared with 22 for cardiovascular disease) in the 10-year study by Sajatovic et al. (1996) of hospital utilization by elderly veterans with bipolar disorder (n 23) and schizophrenia (n 49). Hussar (1966) examined the autopsy reports of 1,275 chronic white male schizophrenic patients with a mean age at the time of death of 63 years, collected from 29 VA hospitals, and found an increased number of deaths due to pneumonia versus the age-matched rate of the general population. Weiner and Marvit (1977) found increased morbidity from respiratory disease in their middle-aged schizophrenia population, and Dynes (1969) and Saku et al. (1995) found respiratory disease to be a leading cause of death in their schizophrenic population of all ages.

Psychiatric Disorders Involve the Limbic System

The major psychiatric disorders, including affective disorders and schizophrenia, are disabling diseases with a genetic predisposition and no known cure. The biological basis for these disorders remains obscure, particularly the role of environmental influences on individuals with a genetic predisposition to developing a disorder. Altered states of the brain's monoaminergic systems have been a major focus as possible underlying factors, based on extensive human studies in which neurochemical imbalances in catecholamines, acetylcholine, and serotonin have been observed. Another reason for focusing on the monoamin-ergic systems is that the most effective drugs used in treating psychiatric disorders are agents that alter monoamin-ergic transmission. Schizophrenia. Schizophrenia is the collective name for a group of psychotic disorders that vary greatly in symptoms among individuals. The features most commonly observed are thought disorder, inappropriate emotional response, and auditory...

The Transitional Period A More Optimistic View Of Hypnosis With Severely Disturbed Patients

A significant breakthrough in understanding the potential use of hypnosis with psychotic patients came in 1945 with the publication of Lewis Wolberg's book on the hypnoanalysis of Johan R. Johan R. had been confined on the chronic ward of a hospital with a diagnosis of hebephrenic schizophrenia when Wolberg first attempted to work with him. It took Wolberg more than a year to establish a Following Wolberg's landmark book, the work of Margaretta Bowers provided another major advance in our understanding of the clinical potential of hypnosis with psychotic patients. Bowers (Bowers, Berkowitz & Brecher, 1954) expanded the concept of the use of hypnosis for the severely disturbed patient from the unique individual case to the general class of severe mental illness. In 1954, Bowers reported on positive hypnotherapy work she had done with a series of 10 psychotic and other severely disordered patients. In later publications, she summarized hypnotic work with a series of 30 chronic,...

Malnutrition and Reproduction

Susser and Stein (36,37) studied the effects of acute food scarcity during World War II on a previously healthy and nutritionally replete population. Between October 1944 and May 1945, during the German occupation of the Netherlands, the German army restricted food supplies into certain Dutch cities, resulting in a substantial reduction in average daily energy intake to fewer than 1000 kcal. Adjacent cities, in which food supplies were not curtailed by the Germans, were not affected by the famine. Fifty percent of women who were affected by the famine developed amenorrhea. The conception rate dropped to 53 of normal (based on control cities) and correlated with the decreased caloric ration. In addition to the decrease in fertility, undernutrition resulted in an increase in perinatal mortality, congenital malformations, schizophrenia, and obesity. These observations indicate that optimal caloric intake is essential for normal fertility and prenatal growth.

Clinical Presentation

Hypercalciuria with subsequent renal calculi, glucocorticoid-induced osteopenia osteoporosis, menstrual irregularities (e.g., amenorrhea), loss of libido in both genders (hypogonadism secondary to hypercortisolism), and muscle weakness in association with proximal muscle atrophy are common features of CD CS. Avascular necrosis of the hip can be the presenting manifestation of an ACTH-secreting pituitary adenoma and requires immediate attention to save the femoral head and avoid subsequent disability (15). Cataracts (classically posterior subcapsular) and glaucoma frequently occur in patients with exogenous CS but not in those with endogenous hypercortisolism (16). Psychiatric manifestations in CD include cognitive deficits with memory loss and poor concentration, anxiety with insomnia, irritability, atypical depression, acute psychosis, and mania (17-19).

Neurosurgery for Ulcerative Colitis

Half a century ago, in the late 1950s, some neurosurgeons reported on the treatment of patients with ulcerative colitis and psychosis with a prefrontal lobotomy followed by an improvement of their abdominal symptoms 9 . As a few patients had profound psychological disturbances due to the unde-sired damage of cerebral pathways, some years later the technique was refined using a more selective elec-trocautery approach aimed at dividing part of the association fibres between the frontal cortex and the

Effects of Antipsychotics on Serum Lipids

Serum lipid levels may be influenced by multiple factors, including genetics, diet, weight gain, systemic illness (e.g., DM), and exogenous agents including alcohol and medications. An extensive list of medications from disparate drug classes exists, with each agent associated with a specific pattern of hyperlipidemia (Mantel-Teeuwisse et al. 2001). In many instances, the underlying mechanism effecting this change in lipid metabolism is unknown, as is the case with the hyperlipidemia associated with antipsy-chotic therapy. Typically, changes in serum lipids were not a focus of clinical antipsychotic trials, but the increased interest in health outcomes for patients with schizophrenia has resulted in a number of abstracts, published case series, and small studies examining the effects of antipsychot-ics, particularly atypical agents, on lipid profiles.

Diabetes and Glucose Intolerance in Schizophrenic Patients in the Preantipsychotic

Early reports dating back to the 1920s, before the use of antipsychotic agents, suggest that individuals with schizophrenia and other psychotic dis orders exhibited an elevated risk for developing glucose intolerance or diabetes mellitus (Braceland et al. 1945 Brambilla et al. 1976 Haupt and Newcomer 2001 Marinow 1971 Schwartz and Munoz 1968 Waitzkin 1966a, 1966b). Specifically, the reports indicate a pattern of insulin resistance in schizophrenic patients independent of adverse medication effects (Haupt and Newcomer 2001). These studies, however, suffer from several methodological problems there are flaws in the diagnostic criteria for schizophrenia, and they do not control for age, weight, fat distribution, ethnicity, diet, or exercise, all of which are variables now known to play a role in an individual's risk for developing glucoregulatory disturbances (Haupt and Newcomer 2001). Because no well-controlled studies exist, whether individuals with schizophrenia, when unmedicated, are...

Eye Tracking Disturbances

Some of the most consistent neurological signs have to do with ocular movements. Among those reported by Stevens (1987) are absence and avoidance of eye contact, staring, changes in blink rate (often increased) and the glabellar reflex, pupillary inequality, and inability to converge. But the best studied of the ocular movement disturbances is eye tracking. In 1908, Diefendorf and Dodge (Levy et al. 1993) reported that some persons with schizophrenia exhibit eye movement abnormalities. The movements could be photographed and were detectable on careful neurological examination. During the 1970s Holzman and colleagues (Levy et al. 1993) extended the investigation of oculomotor function in schizophrenia. Using newer techniques of measurement, these investigators found that the oculomotor abnormalities or eye tracking disturbances were of two types. One disturbance affects smooth pursuit (matching the velocity of eye movement to the velocity of a moving target so as to stabilize the...

Impact of Substance Use Disorders on Course of Illness and Outcomes

The second issue discussed by Cantor-Graae and colleagues is the degree to which history of substance abuse is associated with a more chronic clinical course of schizophrenia (p. 72). Although research on the impact of drug and alcohol use on course of illness has produced variable results, the overwhelming weight of evidence points toward substance abuse and dependence having adverse short-term and long-term affects. Overall, persons with schizophrenia who abuse drugs and or alcohol have more psychotic symptoms and psychotic relapses compared with persons with schizophrenia without substance use disorders (Negrete et al. 1986). One of the first short-term prospective studies in recent-onset schizophrenia patients (Linszen et al. 1994) found that significantly more and earlier psychotic relapses occurred in cannabis abusers. This finding was replicated in a long-term follow-up case-control study of 39 cannabis-abusing schizophrenia patients without other major drug use matched for...

Traumatic Brain Injury

Schizophrenic patients, perhaps because of clumsiness, distractibility, poor coordination, or poor judgment, are subject to various forms of traumatic insult, but there may be other connections. The impact of traumatic brain injury (TBI) on a person's functioning is, of course, related to the extent and type of injury sustained, yet TBI can mimic the features of schizophrenia, making exact diagnosis difficult. Schizophrenia following TBI could be a phenocopy of schizophrenia or the consequence of gene-environment interaction, or the association of a TBI event and schizophrenia could be spurious if those predisposed to schizophrenia have greater trauma for other reasons. Malaspina et al. (2001) investigated the relationship between traumatic brain injury and psychiatric diagnoses in a large group of subjects from families with at least two biologically related first-degree relatives with schizophrenia, schizoaffective disorder, or bipolar disorder. Rates of TBI were significantly...

Treatment Of Resistant Tb

Among other second-line agents, cycloserine is usually well tolerated, but can have substantial central nervous system (CNS) toxicity. This may be manifested as impaired mentation, psychoses, suicidal ideation, or seizures. Monitoring of serum drug levels may obviate these side effects. Peak serum levels 2 h after a dose should not exceed 25 to 35 g mL. The addition of pyridoxine (50-100 mg d) may be of some benefit (20). PAS is usually well tolerated when given in the form of Paser granules (Jacobus Pharmaceutical, Princeton, NJ). In this formulation the drug is adsorbed to methylcel-lulose beads. The drug is not well absorbed unless it is given in an acid medium such as orange juice, cranberry juice, or applesauce. Patients may be concerned about the appearance of methylcellulose beads in their stools. Ethionamide is the most poorly tolerated antibiotic, especially if it is given with aminosalicylic acid. Gastrointestinal side effects including nausea, vomiting, diarrhea, and a...

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