Treatment of negative schizophrenic symptoms with antidepressants

Due to similarity and association of depression with negative symptoms of schizophrenia, many doctors prescribe anti-depressants to patients with negative schizophrenic symptoms. 

According to meta-analysis published in British Journal of Psychiatry (Efficacy of anti-depressants in treating the negative symptoms of chronic schizophrenia: Meta-analysis by Surendra p. Singh, Vidhi Sinh, Nilamadhab Kar and Kelvin Chan) there is a good reason to believe that above practice has good evidence base.

 

Above meta-analysis went through 22 randomized placebo controlled clinical trials. It found that there is a statistically significant symptom relief when anti-depressants were co - prescribed with antipsychotics for negative schizophrenic symptoms. 

What are the common negative schizophrenic symptoms?

• Social withdrawal

• Underactivity

• Lack of speech

• Slowness

• Depression

• Lack of drive

• Apathy

Above symptoms are the most common symptoms seen in negative schizophrenia. They are very difficult to treat. Co prescribing Antidepressants are found to be effective in treating negative schizophrenia.  

Individual antidepressants that are found to be effective in treating negative symptoms

It seems Ritanserin and Trazadone is more effective in treating negative schizophrenic symptoms. Ritanserin > Trazadone > Fluoxetine

Ritanserin is the generic name of Tisterton. Trazadone is generic name of Desyrel. Fluoxetine is the generic of Prozac. Fluoxetine had minimal effects in treating negative schizophrenia. 

Limitations of above meta-analysis

• Numbers of trials are relatively small. 

• Number of trials are not adequate in interpreting individual anti-depressant effects.

• Three studies with very large effect size shift whole study to that direction

• No RCTs available for tricyclics, venlafaxine, and mono amine oxidase inhibitors. 

Sources

1. Efficacy of anti-depressants in treating the negative symptoms of chronic schizophrenia: Meta-analysis by Surendra p. Singh, Vidhi Sinh, Nilamadhab Kar and Kelvin Chan

Complications of Newer Antipsychotic drugs

Newer anti-psychotics gave hope for the psychiatry patients due to their low side effects profile. Commonly used newer antipsychotic drugs are Zyprexa, Clozaril, Risperdal and Abilify. They cause fewer extra-pyramidal side effects compared to older typical anti-psychotics. In addition, serious complications such as neuroleptic malignant syndrome and tardive dyskinesia are rare in newer anti psychotics (compared to older anti psychotics).

But recent evidence suggest that newer anti psychotics have different very dangerous complications. Newer atypical anti psychotics are known to cause serious blood lipid elevation in certain patients. It can complicate ischemic heart disease treatment in such patients. In addition, atypical/newer anti psychotics increase body weight. Common drugs that are responsible for body weight increase are Zyprexa, Clozaril and Seroquel. Risperdal and Abilify cause less weight gain. In fact Abilify seems to cause weight reduction in certain individuals.

Newer atypical antipsychotics such as Zyprexa, Clozaril and Risperdal (less) can also cause diabetes mellitus by way of increasing blood glucose level.

Therefore, long term overall benefit of newer anti psychotics remain questionable.

Can depression cause heart problems

According to a recent study published in Psychophysiology ( Volume 48, Issue 11, pages 1605–1610, November 2011) there seems to be  a statistically significant relationship between DSM IV Major depressive disorder and cardiovascular recovery after exercise.

There were numerous studies done to determine relationship between heart problems and depression. According to (Barth, Schumacher, & Herrmann-Lingen, 2004; Carney et al., 2008; Lavoie & Fleet, 2000; Lesperance, Frasure-Smith, Talajic, & Bourassa, 2002; Rozanski, Blumenthal, & Kaplan, 1999; Rutledge et al., 2006) Major depressive disorder is associated with heart problems. In fact, heart diseases can be caused by Major depression  as well as existing heart problems can be aggravated by major depressive disorder.

During vigorous exercises our heart rate increases exponentially. But immediately after physical exercise, heart rate becomes normal within a short period of time. But people with a dysfunctional autonomic nervous system have delayed heart rate recovery after exercise. This delayed recovery is linked to heart diseases by several studies (Cole, Blackstone, Pashkow, Snader, & Lauer, 1999; Jouven et al., 2005; Mora et al., 2003; Nishime, Cole, Blackstone, Pashkow, & Lauer, 2000).

According to the above “The effect of major depression on post exercise cardiovascular recovery” study researcher’s found a statistically significant delay in recovery of heart rate following exercise by way of stress testing (treadmill). Therefore, there can be a autonomic nervous system dysfunction in Major depressive disorder. 

In addition to the biological vulnerability for heart disease, people with major depression have many life style issues that is detrimental to the heart such as lack of exercises and bad food habits.

Depression increases risk of heart disease

Most people with depression do not care about the healthy food choices, because of lack of energy and motivation. In addition, they do not do regular exercises again due to lack of energy. In addition, depressed people with diabetes or ischemic heart disease tend to miss their pills.

Diabetic patients with depression tend to forget monitoring their health and take medications

Depressed people tend to ignore healthy food choices

Depressed people tend to do less exercise

Conclusion

Major depression is associated with significant heart problems. It is due to both life style issues such as lack of exercises seen in major depression as well due to biochemical and physiological abnormalities seen in depression.

Therefore, it is very important to treat depression in people with cardiovascular risk. 

Sources

The effect of major depression on post exercise cardiovascular recovery

What is Cytop (citalopram) depression medication prescribed for?

Cytop is a medication is SSRI drug class.SSRI stands for Selective serotonin reuptake inhibitors. Its generic name is citalopram. It is prescribed for clinical depression, Premenstrual dysphoric disorder (PMDD), Panic disorder, generalized anxiety disorder, Post traumatic stress disorder, Social anxiety disorder and obsessive compulsive disorder.

However, Citalopram is a racimic mixture of R and S enantiomer . S - enantiomer is the most effective active component. Escitalopram is the pure form of S - Citalopram and it is more effective in treating depression. But the clinical evidence is not so convincing.

Treatment most often reduces or even eliminates symptoms, but not a cure since symptoms can recur after medicine stopped. Once symptoms are gone, this medication should be continued for 1 year for the first episode of depression. For second and subsequent episodes of depression, treatment may need to be indefinite.  Use in anxiety disorders may also need to be indefinite ( Panic disorder, generalized anxiety disorder, Post traumatic stress disorder, Social anxiety disorder ).

Usual dosage is 20–60 mg/day. This drug usually is prescribed in the morning to avoid insomnia or sleep disturbances.

READ MORE

1. What is Citalopram or Cytop is prescribed for?

2. What are the side effects Cytop or Citalopram?


Sources



British National Formulary 59th edition

Relationship of Alcohol and mania (Bipolar disorder)

Mania is a one end of bipolar affective disorder (It is characterized by shifts between mania and depression.). Mania is characterized by elevated mood, increased energy, increased spending, increased talkativeness and increased pressure of thoughts. In the severe form it can cause grandiose delusions and  auditory hallucinations.

Alcoholism and mania (Bipolar disorder) can co exist, because of the possibility of sharing common genes.

In addition, alcoholism can complicate preexisting bipolar mania. Abuse of alcohol can make the condition, difficult to treat. In addition, patients with mania is known to have social and emotional disinhibition. This make it hard to stop alcohol in a patient with bipolar disorder.

Alcohol is also known to cause or precipitate bipolar affective disorder. Therefore, alcoholism and bipolar disorder creates a viscous cycle that lower the prognosis of both conditions (Alcoholism and Bipolar disorder).

A person with both problems need to take drugs to control his/her bipolar disorder and take steps to stop alcoholism at the same time. Theses patients need lot of help from his/her family and the healthcare provider.

Health risks of stress and tips for dealing with it

Stress is defined as the human body's response to a change. Even though it is good in short term, it can cause harm to your body in long term. Stress can increase certain hormonal levels in the body. This can cause certain changes in long term which can cause heart attacks, stroke and various other problems.
Importance of stress in our current society
Even though our society increased its sophistication, our body's mechanisms are lagging behind in the Stone Age.

Our body has two main roles. They are rest and face threats (fight/flight). During rest, our body increases digestion of food, stores energy and do general housekeeping jobs. But in a threat it increases energy expenditure, increases metabolism and prepare our body to fight or run. 

In the stone stage, threats are not persistent. Once the caveman saves itself from a predator he can relax. But in the current society our body identifies normal day to day stressors as threat to its survival and switch to fight/flight mode. The difference is that our day to day stressors never end like in the Stone Age. 

In addition, our day to day stressors do not need a flight/fight response (anxiety). They need a calm mind to sort the things out. 

Our body is not prepared to maintain a fight/flight mode forever. Maintaining in that mode for longer duration would result in various diseases such as heart diseases and diabetes mellitus.

This maladaptation of physiology in current society makes stress one of the main causes of disease.

How stress increase the health risks

Stress increases adrenaline, noradrenaline and cortisol levels in the body. These hormones increase blood lipid and sugar levels. When the stress is persistent for long time, above risk factors can cause ischemic heart disease and precipitate diabetes mellitus. In addition, Stress hormones increase heart rate and power of the heart contractions. These actions could cause wear and tear of heart muscles. It could lead to heart failure and heart muscle dysfunction (cardiomyopathy). 

Stressed out heart

In addition, elevated levels of stress hormones for longer duration can cause hypertension. This could further increase the heart dysfunction.

Addition to above methods stress could lead to unhealthy coping strategies such as increased smoking, increased alcohol intake and unhealthy dietary habits (taking fast foods, salty foods).





Tips for dealing with stress

• Don't worry about things you can't control, such as the weather.
• Solve the little day to day problems. This can help you gain a feeling of control.
• Prepare to the best of your ability for events you know may be stressful, such as a job interview.
• Try to look at change as a positive challenge, not as a threat.
• Work to resolve conflicts with other people.
• Talk with a trusted friend, family member or counselor.
• Set realistic goals at home and at work. Avoid overscheduling.
• Exercise on a regular basis.
• Eat regular, well-balanced meals and get enough sleep.
• Meditate.
• Participate in something you don't find stressful, such as sports, social events or hobbies.

Long term stress affects our health badly. It can cause increase heart diseases and hypertension. However, you could control your stress levels by way of good coping strategies, meditation and exercises. 

Further reading


Stress - NIH article
Stress: How to Cope Better With Life's Challenges

Usage and side effects of Venlafaxine (Venlift, Venlamax, Vexor, Venla, Venjoy, Venfax, Vendep, Sentosa, Flavix and Dallium)

Venlafaxine is a medication prescribed for major depression and anxiety disorders. In addition, it is prescribed for chronic pain syndromes such as neuropathic pain and fibromyalgia. Commonest Indian brand names are Venlift, Venlamax, Vexor, Venla, Venjoy, Venfax, Vendep, Sentosa, Flavix and Dallium. In US it is sold as Effexor.

Its commonest side effects are dry mouth, reduced sleep and constipation. Venlafaxine XR is the extended release preparation of the Venlafaxine. Therefore, Patients usually get minimal side effects with Venlafaxine XR compared to Venlafaxine.

How Venlafaxine works?

Venlafaxine works by increasing natural neurotransmitters serotonin and noradrenalin inside certain brain areas. However, side effects are due to increased noradrenalin and serotonin levels in unwanted areas of the brain.

What are the common side effects Venlafaxine ?

Constipation, nausea, loss of appetite, diarrhea, gastritis, vomiting, and abdominal pain are most common side effects. Patients can get increased blood pressure as a side effect.  Sometimes palpitations (feeling one’s own heart beat associated with distress) can occur.

Dizziness, dry mouth, insomnia, nervousness, and headache are other common side effects. In addition, patients can complain abnormal dreams. Short term anxiety and agitation is also common.

Sexual dysfunction is another problematic side effect that can leads to poor drug compliance. Women in reproductive age, taking Venlafaxine may complain menstrual irregularities. Muscle pain and joint pain can occur with some patients. Some patients can have pupillary dilatation in their eyes. This can leads to angle closure glaucoma. However compared to other anti-depressants (SSRIs) sexual side effects such as erectile impotence and lack of desire are uncommon.

Venlafaxine (Effexor) capsules

What are the conditions the doctor should know before prescribing Venlafaxine ?

Doctors usually do not prescribe Venlafaxine , when the patient has serious cardiac rhythm abnormalities, uncontrolled hypertension, severe liver diseases, severe renal impairment and pregnancy. Before starting the drug doctor will check your blood pressure, take an electrocardiogram, and check whether you are pregnant (doctor may ask whether you missed a period).

Doctors will prescribe cautiously, when the patient has certain heart diseases. Blood pressure monitoring is essential in heart diseases. In addition the doctor must know whether the patient has epilepsy. If the patient has a bleeding disorder, the doctor should know that as well. Venlafaxine is present in breast milk, so nursing mothers should consult their doctor before taking this drug.

What are rare side effects of Venlafaxine ?

Taste abnormalities, hallucinations, urinary retention, bleeding disorders, hair loss, and hypersensitivity reactions like hives, angioedema, and photo sensitivity can occur with certain patients.

What you should know before taking this drug?

Patients should not drive or operate machinery while on the drug, until they know how this drug will affect them. In addition, Venlafaxine should not be stopped abruptly. If it is stopped suddenly then the patient may get withdrawal symptoms such as gastro intestinal disturbance, headache, tremors, sleep disturbances, and sweating.

Originally published in 

http://mentalhealthdoc.blogspot.com 

Causes, symptoms and treatment of Confabulation?

Image via Wikipedia

Confabulation is falsification of memory in clear consciousness in association with an organically derived amnesia. It is a falsely retrieved memory, often containing false details within its own context.

In addition confabulations are not intentionally produced. person does not know about the existence of memory deficit. Some people may act on them, confirming the belief in the false memory.

There are two type


1. Embarrassment confabulation : – This form is momentary in nature. The person tries to cover up memory gap by an ad hoc confabulated excuses.

2. Fantastic confabulation : – The patient spontaneously describes adventurous experiences of a fantastic nature.

Confabulating patients are often suggestible. That means a mere suggestion can induce a lie. For an example, if we suggest to him that he was there at a cafe during this morning (which does not happened) then he will describe the experience as " Yes i took my breakfast and it was fine".

Confabulation usually occur in Amnesic syndrome seen among alcoholic dependent patients. It is called Korsakoff's psychosis. It usually results due to thiamine deficiency that is associated with long term alcohol abuse. In addition, it can be seen among people with neurological disorders in the brain.

Treatment of Confabulation


It is usually treated with Thiamine replacement. However, established confabulation cannot be treated effectively. Only the progression can be stopped. It can be stopped by taking regular thiamine supplementation and complete abstinence of alcohol.

Summary 

It is a primarily a memory disorder and the patients is unaware of the memory deficit. This leads to filling of memory gaps by a subconscious process that leads to believing a false memory as true. Patient genuinely believe that the false memory is true.

Further reading


Wishful reality distortions in confabulation: a case report.

Originally published in 

http://mentalhealthdoc.blogspot.com/

Side effects of Vistagra

Vistagra is a medication prescribed for male erectile dysfunction. Its popular brand name is Viagra and its generic name is Sildenafil Citrate.

It is manufactured in India by Cadilla Pharmaceuticals. Therefore, side effects are almost similar between these two preparations.

Vistagra causes erection after adequate sexual stimulation. It does not causes erection when the person does not have adequate sexual stimulation. It is also not effective when the sexual problems are due to serious psychological, relationship problems or serious medical problems such as vascular disease of the genitalia.

Common Side effects of Vistagra 

1. Low blood pressure: Sudden lowering of blood pressure can cause strokes, heart attacks and blindness.
2. Seizures or fits
3. Priaprism or continuous erection of penis can result in penile fracture.
4. Nausea, Vomiting and heartburn
5. Nasal bleeding

Since Vistagra can precipitate low blood pressure it is not recommended in people with heart diseases such as recent myocardial infarction or heart attacks, heart failure and heart rhythm abnormalities. In addition, it is not recommended in people with epilepsy. In addition, if you had a episode of priaprism  then it is not recommended.

Vistagra is a medication prescribed for male erectile dysfunction. Vistagra does this by inhibiting an enzyme called PGE5 or phosphodiesterase 5. By way of this inhibition it increases the Nitrous oxide level inside the penile vascular smooth muscles. This causes relaxation of vascular smooth muscles and penile erection. But this all happens when there is a proper emotional background. Therefore, Vistagra cannot erect a penis alone without sexual feelings.

Causes, symptoms and treatment of Extrapyramidal side effects of antipsychotics

Extrapyramidal side effects are type of drug reaction that occurs due to interactions with the extrapyramidal system in our body. There are two broad categories of motor neural pathways in our body.

One is pyramidal system (Tracts originating from motor cortex and innervating skeletal muscles) and other is Extrapyramidal system (Pathways other than pyramidal system which affects motor movements).

Most antipsychotic drugs affect this extrapyramidal system due to their dopamine blocking properties. Therefore, they cause extrapyramidal side effects. Older or typical antipsychotics are notorious for this sideeffect. However, newer atypical antipsychotics can also cause them. In addition, extrapyramidal symptoms can be seen in patients with Parkinson’s diseases and Huntington’s chorea.

Extrapramidal system

Pyramidal system

What are the symptoms of extrapyramidal side effects?

There are four discreet categories of extrapyramidal side effects.

Acute dystonia occur within minutes to hours of antipsychotic medications. They include abnormal and painful movements of the neck, tongue, and body.

Usual treatment is taking anticholinergic drugs such as Benzhexol or Intra muscular benztropine. In addition, taking Intra muscular Phenergon can also alleviate these symptoms.

Akathisia is abnormal sensation of difficult in keeping the legs in one place. It is a very distressing side effect that occurs usually days to weeks after taking antipsychotic drugs.

It is treated with reduction of antipsychotic dose, beta blocker medications such as Propranolol, or diphenhydramine. Usually doctors follow a protocol in treating drug induced akathisia.

Drug induced Parkinsonism present similar to Parkinson’s disease. It includes muscle stiffness, pill rolling tremor and reduced movements (Bradykinesia). It usually occurs months after start of antipsychotic drug treatment.

It is treated with anti-cholinergic drugs mentioned such as Benzhexol.  

Tardive dyskinesia is the side effect that is most difficult to treat. It occurs usually years after treating with antipsychotic drugs. It is characterized by irregular movements of the tongue and face. It usually occurs in older women who are treated with antipsychotic drugs. It is treated usually experts and prognosis is usually poor. Following video shows tardive dyskinesia. 

First posted in

http://mentalhealthdoc.blogspot.com/

Relationship between violent behavior and mental illnesses

Most people who do not know about mental illnesses think mentally ill patients can become easily violent. But the truth is little different. Most people with mental illnesses are not violent. According to the MacArthur Violence Risk Assessment Study, “the prevalence of violence among those with a major mental disorder who did not abuse substances was indistinguishable from their non-substance abusing neighborhood controls (normal people)”.

In addition, schizophrenia shows lowest incidence of violence. Bipolar affective disorder and major depression patients are more violent than schizophrenic patients. Patients with substance abuse issues are the most violent.

Who are at risk?
According to the above study and the personal experience of this author, close relatives of the mentally ill are at most risk. Risk to general public is much less than expected. In fact incidence of violence is almost similar to non-mentally ill people.

What are the predictions of violence in mentally ill?

One of the best predictor is past violence. Past unprovoked violence carries the greatest risk. In addition, substance abuse issues increase the violence of mentally ill patients. Other factors that are thought to increase violence are command hallucinations, and severe prosecutory delusions. In addition, people with severe depression may harm their dependents. E.g. severely depressed mother may kill her young children just to save them from her imagined misery.

How to control violence in a mentally ill?

Even the risk of violence is low, they do occur and most people who deal with mentally ill patients need to know how to tackle them.
 

1. Talking to the patient calmly will alleviate most of the violence. Most people with mental illnesses become violent because they do not get their basic needs. In fact for some of the reasons even the most normal sane people could get violent. For an example, one of the patients who really got violent and try to break the door of the seclusion room became so because he could not contact his mother. Contacting his mother stopped his violence completely.

2. Even most patients can be calmed down by talking, some do need drugs. First option is oral antipsychotics with sedating properties such as Olanzapine.

3. Third option is intramuscular sedative drugs such as Olanzapine, Haloperidol and Midazolam. These drugs will quickly calm down a patient but they can cause side effects such as abnormal movements and respiratory depression (Midazolam).

In extreme rare cases patients need to be physically restrained. Usually it is to allow an intramuscular injection. When the patient is sedated physical restrain should be removed.

Sources

Violence and mental illness: an overview
Violence and Mental Illness — How Strong is the Link?

Link of this post
Relationship between violent behavior and mental illnesses

Mental health problems associated with obesity

Obesity is an epidemic in developed countries. In 2004, around quarter of the population were obese in UK (Psychiatry, Volume 8, Issue 6, June 2009). This epidemic would results in huge increase in type 2 diabetes, heart disease, hypertension, sleep apnea, hyperlipidaemia, increased incidence of cancer, and joint problems.

However, mental health effects of obesity are not discussed readily most of the time. But there are many mental health issues that can be directly caused by obesity. It is generally related to increased BMI or body mass index (OBESITY SURGERY, Volume 14, Number 5, 579-588).

In obese (BMI >25 kg/m²) category, Life time prevalence of anxiety and mood disorders are 25% higher than the general population. Interestingly substance misuse is lower in this category. Doctors believe it is due to the changes in brain reward system, where obese people get satisfaction from food rather than drugs of abuse (Alcohol and Opiates).

People who seek surgery for weight loss have a very high risk of developing above psychiatric disorders. In addition, there is an increased risk of psychological problems seen among women compared to men with obesity.

Obese people tend to have impulsivity, less self-control, and obsessive perfectionist traits. This would lead them to develop psychological problems but the association is not very clear.

In addition, most studies found that psychological problems tend to improve once the weight is controlled.

Summary

According to evidence certain mental health issues can cause obesity. In addition, certain other biological problems in our brain can cause both mental health problems and obesity. In addition, obesity per se can cause mental health problems. So both conditions are interdependent to some degree.

In addition, it is surprising that people with obesity have less substance use issues (Such as alcohol, cannabis and opioids).

Sources

Elsevier, Psychiatry, Volume 8, Issue 6, June 2009, Pages 198-202

Effects of lithum on developing fetus

Lithium is a drug that is used in Bipolar affective disorder and resistant depression. However, it is a rather toxic molecule to the human body. But it is safe within certain dose range.

There are several documented cases of birth defects caused by Lithium in humans. They include Epstein anomaly. It is a heart anomaly that can become a severe problem in later life.

In addition, high doses of lithium can cause several abnormalities in the rat fetus. They include high incidence of cleft palate, growth retardation, brain liquification and pulpy brain, hepatomegaly and digital abnormalities. However, incidence in humans are not available because of the obvious reasons.

But stopping lithium during pregnancy can cause severe relapse of bipolar disorder. Which can result in more damages to the fetus and the mother. So doctors weigh risks and benefits of continuing lithium during pregnancy. Sometimes your doctor may decide to continue lithium with the aforementioned risks. In addition, there are very few safer bipolar maintenance therapy options available to the doctors. Some doctors may change the drug regimen to anti-psychotic medications with mood stabilizing properties such as seroquel/zyprexa.

Sources

Teratogenic effects of lithium and ethanol in the developing fetus.

Best drugs for insomnia after giving up alcohol

According to a systematic review (Pharmacological Treatment of Insomnia in Alcohol Recovery: A Systematic Review) published in Alcohol and Alcoholism journal, there are several drugs that can be used for insomnia or lack of sleep seen in patients who gave up alcohol. In most patients, these sleep problems can go on for months.

Usually chronic alcohol dependence patients need to be detoxified before stopping alcohol. It is because alcohol changes the person's brain chemistry and sudden alcohol withdrawal can cause severe reaction that can even kill the person. Therefore, doctors give certain drugs to allow the brain to adjust to sudden withdrawal of alcohol. 

However, after taking off these detox drugs (Usually Librium) some patients complain insomnia for a prolonged period and it can cause treatment failure (Returning to take alcohol).

The treatment of insomnia in alcoholic patients has been poorly studied by doctors. In addition, treating sleep problems in alcohol recovery phase is complicated by the fact that some of the most commonly used medications to treat sleep disturbance are thought to have a high abuse potential e.g Ambien, Benzodiazepines (Vallium).

Above study has identified some drugs that can be used for this condition. They are

1. Trazadone (Desyrel)

2. Gabapentine (Neurontin)

3. Lormetazepam (Noctamid)

However, contrary to popular belief Ambien and other Z drugs are not effective in this condition.

Sources

Alcohol and Alcoholism Volume46, Issue5

Effects of antipsychotic medications on dementia – Analysis of CATIE-AD study

Dementia is known to cause memory impairment, personality change, problems in judgments, and intellectual impairment. These changes taken together are called impairments in cognitive capacity.

Doctors usually prescribe antipsychotic medications for dementia, especially to calm down acutely disturbed patients. In addition, some patients are given regular dose of antipsychotics as a maintenance therapy to improve sleep and agitation. Most common antipsychotics prescribed are Risperidone (Risperdal®), Quetiapine (Seroquel ®), and Olanzapine (Zyprexa®).

However, there is a recent debate among doctors regarding the long term outcome of this practice. One of the reasons is the blood lipid abnormalities seen in patients who are prescribed atypical antipsychotics such as Risperidone (Risperdal®), Quetiapine (Seroquel ®), and Olanzapine (Zyprexa®). This could lead to heart problems such as heart attacks. In addition, these problems could increase the memory impairment seen in Alzheimer's disease due to blockage of vessels in the brain.

Now doctors have concluded several studies on this regard. One of such is the “Clinical Antipsychotic Trials of Intervention Effectiveness–Alzheimer's Disease study (CATIE-AD)” study. As the name suggest it looked into the relationship between prescription of antipsychotic medications and Alzheimer’s dementia. This study mainly looked at memory impairment and other cognitive impairments seen in dementia patients who are prescribed antipsychotics.

How the CATIE-AD study is conducted?


This study carried out in more than 400 patients. Most of them are community dwelling moderate to severe dementia patients. These patients were randomly allocated to different treatment groups and they were prescribed Risperidone, Quetiapine and Olanzapine. In addition, patients were given different medications in different times similar to crossover design. This study was carried out around three years.

Results of the study


This study reported a statistically significant cognitive impairment associated with antipsychotic medications. That means people who were prescribed antipsychotics showed greater memory impairment than the people who were not prescribed them.

Background


Many other studies that were performed around the time showed conflicting results.

Conclusions
This study is not a very large study and the cross over design can have many problems that would change the outcome. However, it will certainly put more weight on the argument that antipsychotics cause cognitive impairment. But other options available for agitation and psychosis seen in dementia patients such as benzodiazepines may also cause cognitive impairment. Therefore, in practice it is difficult to stop prescribing antipsychotics for patients with dementia.

Sources
Consequences of Antipsychotic Medications for the Dementia Patient - Am J Psychiatry 168:767-769, August 2011

What is the psychology behind rioting

England has seen the worst of riots in recent times. Here normal ordinary law abiding citizens are turned into robbers, looters and starts to wanderlize property. In fact, there is a psychological phenomena behind it and it is called de-individuation.

According to psychologists, Three psychological concepts operate in rioting. First one is the broad concept of Fundamental attribution error. Second one is Deindividuation and it comes under fundamental attribution error. Third one derived from psychoanalytic theory and here natural aggressive drives are let loose by the context of riot.

What is Deindividuation ?

Deindividuation is a social psychological phenomena seen in certain situations. It is especially seen in mobs. Here an anonymous member of a mob will act differently than as an individual.

"In Deindividuation people’s salience of the personal identities are reduced and they acquire the identity of the group or mob. In addition, in deindividuation, there is a reduction in the sense of public accountability. These factors cause the individual to act aggressive or show unusual behavior. Two key characteristics are the group size and anonymity of the individual."

 In simple terms during a riot people tend to remove previous personal value system and merge into the value system of the mob. In addition, there is a diffusion of responsibility among the individuals. These effects are directly proportionate to the number of people in the riot and the individuals anonymity in the situation. Anonymity can be enhanced by wearing masks.

In addition, some psychologists believe riots give a perfect place to explore humans hidden motives such as aggression.

In English riots Clive Coleman of the BBC News legal team said,

"A significant number of those charged were said in court to be of previously good character and had simply been drawn in to the offending."

Normal people turned into robbers
 Courtesy - BBC

Above statement explains the power of situations in shaping our behaviors. But the England's prime minister said,

 "You will feel the full force of the law. And if you are old enough to commit these crimes, you are old enough to face the punishment." - English Prime minister

What is fundamental attribution error?

This concept of de individuation is under the another broader social psychological principle called Fundamental Attribution error.

Fundamental attribution error is "The human tendency to overestimate constitutional factors and underestimate the power of situations in shaping our behavior." For an example we may believe a person whom we know little about is not good person when he does not smile at us. 

But we ignore the fact that he may had a quarrel with his wife when we saw him or he may had an bitter argument with his boss just before we met him. We simply attaches that behavior to his character, not to the situation.

Rioting is another good example of fundamental attribution error. Examples of power of situations in shaping human behavior are numerous.  Most striking example would be the horrors we saw in Nazi Germany, where normal law abiding citizens became cold blooded killers. In fact, most of the psychological research were conducted immediately after the World War 2 to explain these evil tendencies inside us (e.g. Stanford prison experiment, Milgrams experiments on obedience).

Sources

Atkinson and Hilgard - Introduction to psychology 14e
BBC report on UK Rioting
BBC article on  UK riots: What turns people into looters

What are the common schizophrenia symptoms?

Schizophrenia is a serious psychiatric disorder. It is characterized by delusions and hallucinations. Most of the patients can have a near normal life (25% complete cure, 50% some disability, 25% do not recover) despite having the illness, if adhered to the medical advice.

Frank delusions and hallucinations are categorized as positive symptoms of schizophrenia. Most common delusions are delusions of control, delusion of perception and thought broadcasting. Most common hallucinations are thought echo, third person auditory hallucinations and hallucinations hearing as a running commentary.

In addition, some patients can have negative symptoms such as apathy, social withdrawal, amotivation and lack of drive. These symptoms usually occur in patients with chronic schizophrenia. They are quite difficult to treat.

Read more

Diagnosing and treating ADHD in children

Childhood ADHD or attention deficit hyperactive disorder is one of the commonest causes of childhood learning disability. Therefore, early diagnosis and treatment is essential for better outcome.

Parents need to identify some of the salient features, therefore they can refer the child to a proper channel.

How to diagnose ADHD?

To get a accurate diagnosis, the doctor need to have good experience in child psychiatry. However, some symptoms point towards ADHD. In addition, most of the children in the age of 4 –5 are quite active and therefore diagnosis can be missed.

1. Short attention span. Most children with ADHD cannot concentrate on one task for more than 5 –10 minutes. They will shift their attention from one topic to another in very quick succession.  e.g.  after 2 –3 minutes of drawing a picture, they may start to ride a bicycle, after 4 –5 minutes they may again play with clay. However, most children in ages of 4 – 5 normal attention span is around 15 - 20 mins.

2. Doing dangerous things to themselves can be a another diagnostic factor. Children around 3 – 5 years generally know what is dangerous and what is not. However, ADHD children in that age may try to harm themselves by recklessness. They may climb trees without thinking about their safety or try to jump here and there in road. 

How ADHD affects childs life?

How to treat it?

Children with confirmed diagnosis can be effectively treated with medications. In addition, they need special schools and specially trained teachers. Most children with ADHD can become normal after proper treatment.

What are the medications used in ADHD?

1. Different types of medication used in ADHD

Side effects of drugs used for ADHD
1. Side effects of Ritalin
2. Side effects of Concerta
3. Side effects of Vyvanse

How to change human behavior through Cognitive dissonance theory?

Cognitive dissonance theory is a prominent social influence theory that was developed by Leon Festinger. It is used in behavioral modification such as in preventing alcohol abuse.

According to this theory, there is a drive towards cognitive consistency in humans. These cognitives are attitudes, behavior, and facts. When there is a inconsistency between two cognitions, the person experiences an internal discomfort. This makes the individual to remove that discrepancy and bring the cognitions into harmony.

For an example, we can ask a person who is abusing alcohol to join an anti alcohol public campaign. We can motivate him to do this by saying that it is not such a big deal and you can make new friends. In addition, if he is not willing to stop alcohol then we can say that he can continue drinking in other times and the participation is just a another event.

However, active participation in an anti alcohol campaign creates a cognitive dissonance in a person who abuse alcohol and it causes discomfort.

Image via Wikipedia

Most people will remove that discomfort by changing their attitude against alcohol. which will ultimately result in stopping the alcohol taking behavior. It is because changing the line of action that is already undertaken create more discomfort and it introduces the idea that the initial judgment to participate in the event is wrong. It is usually against one’s generally favorable view of oneself.

Actually anti alcohol campaigns are not much of a help to general public. However, they are effective in controlling alcohol intake in the people who actively participating in such programs.

Interactions of alcohol with antidepressants (Elavil, Prozac)

Alcohol is a complex psycho pharmacological agent. It has many actions on the central nervous system. Main actions are GABA stimulation and Glutamate inhibition. GABA is a naturally occurring neurotransmitter. In addition, Alcohol acts on brains opiod  receptors and causes euphoria.Alcohol also has selective serotonin reuptake inhibition properties (action of prozac).

All these actions results in significant interactions between other psychopharmacological medications such as antidepressants.

Interactions with TCA (Elavil, Amitryptalline)

 Alcohol causes reduction in REM (Rapid eye movement) sleep. It is one reason for the hangover seen in the following day. In addition, it worsens sleep disorders. Antidepressants such as TCAs also causes disturbances in REM sleep. REM sleep is believed to be important for our mental health. Taking Elavil and alcohol will result in greater sleep disturbance and can increase the hangover.

In addition, both agents causes drowsiness. Therefore it can increase the day time drowsiness as well. Both agents cause impairment skilled tasks, therefore operating machinery or driving motor vehicles would be very dangerous if you take Alcohol in combination with Elavil.

If somebody who used to take alcohol would find that they will get problems of alcohol for a small amount, when they combine Elavil or any other TCA class antidepressant with alcohol.

Interactions with SSRIs
 Even though, Prozac cause no sedation, it can happen if you take alcohol and prozac together. Prozac will increase the sedative properties of alcohol.

Summary
You should be very cautious when taking both alcohol and antidepressants. It is better not to drive or operate machinery when you take alcohol (even amount of alcohol that can be previously taken safely) with an anti depressant.

Sources
British National formulary 


Further reading
http://www.mayoclinic.com/health/antidepressants-and-alcohol/AN01653

Pathological Alcohol intoxication (mania a potu)

This is a type of abnormal state associated with alcoholism. Pathological alcohol intoxication is an extraordinary severe response to alcohol, especially to small amounts marked by apparently senseless violent behavior, usually followed by exhaustion, sleep and amnesia for the episode.
















However it is a rare phenomenon. In addition it is important to note that it is used by criminals to form a legal defense against their criminal activities. e.g. I killed that person because I took quarter of glass beer and I am having pathological intoxication. But most experts can differentiate real pathological intoxication from a fake one.

But some doctors think that there is no entity called pathological intoxication and there is no evidence based data to back it up.

In addition, this condition is not associated with bipolar mania (as the name suggests). You can read my blog post on relationship between alcohol and bipolar mania here

How Pathological intoxication differs from usual intoxication?

In usual alcohol intoxication person usually takes significant amount of alcohol. In addition he/she has physical features of alcohol intoxication such as slow reaction time and impaired coordination. Here behavior can become violent, but sometimes not.

In pathological state, behavior is always violent. After the violent episode the person complain lack of memory of the behavior. Usually in pathological intoxication behavior is more organized than the common alcohol intoxication. In addition in pathological intoxication, the person is not addicted to the alcohol. He/she usually takes alcohol occasionally and gets a severe reaction to it, then stops taking alcohol for a while.

How to differentiate pathological intoxication from delirium tremens

It should be distinguished from delirium tremens which is associated with alcohol withdrawal. Delirium tremens is a state that follows after a reduction in amount of alcohol taken by an alcohol dependent person. Person who abuses alcohol for some time may take less than the usual amount of alcohol and then he/she may go into develop delirium tremens. 

Here person sees abnormal things and hears voices/sounds that are not real. In addition in delirium the person can becomes violent, but usually due to the wrong interpretation of surroundings and people. Organized criminal activity is extremely rare in delirium tremens and if not treated it can become life threatening. However pathological intoxication is never a life threatening condition.

Relationship to the Movie : Final analysis

The movie "Final Analysis" directed by Phil Joanou and acted by Richard gere, Kim bassinger and Uma Thurman depicts pathological alcohol intoxication. In fact, it is quite accurate in terms of scientific perspective. Here you can see a trailer of this 1992 movie. 

Summary

Pathological intoxication is a rare abnormally violent response to minute amounts of alcohol. Pathological intoxication per se is not life threatening. It can be differentiated from the common alcohol intoxication. In addition it can used in legal defense.   

Further reading on alcohol related issues

Why is alcohol so addictive ?

A case history of Pathological alcohol intoxication - PsycNET - American psychological association

Pathological intoxication, Is there such an entity (Pubmed abstract)

Librium for alcohol withdrawal

Uses and side effects of Nodict tablets : A medication prescribed for alcohol relapse prevention.

Sources

Symptoms of mind by Andrew Sims

What is Delusion of Love (Erotomania) ?

Love and being loved are common human emotions. Delusional variety of this emotion is called delusion of love, Erotomania or de Clérambault's syndrome. It is quite different from nymphomania or satyriasis, which are disorders of excessive sexual activity. Erotomania is much commoner in women.

What is delusion of love?
Here, typically a woman believes a man who is in higher social status and older, is in love with her. Although the person has done nothing to deserve her attention and he may even be unaware of her existence. Often reasons given by her for being in love is illogical. For an example a women who is saying that her school headmaster is in love with her may say that it is because he enters into the lecture hall in the direction she was seated at.



In addition, sometimes this delusion can have a persecutory tinge. For an example, the deluded person may say that the love letters send by her school headmaster were stolen by her friends.
Most of the time the man is a well known public figure, singer or patients employer. Sometimes patient may even believe that he (victim) is the father of her children.

Who gets it?
Usually it is seen in delusional disorders. Here the patient does not have any other delusions and her life is revolved around a delusion. But it is common in other psychiatric disorders like schizophrenia and Bipolar disorder.
In popular culture
It is said that, Michael Jackson’s popular song Billie Jean is based on an incident where delusion of love is involved. Lyrics of Billie jean.

Sources
1. Symptoms of mind by Andrew sims
2. Wikipedia Billie jean page

The side effects of Ridal

Ridal is an atypical antipsychotic drug prescribed for schizophrenia, other psychoses and bipolar mania. It is a commonly used brand of Risperidone in New zealand.

Ridal is brand of risperidone

Uses of Ridal 

This medication is primarily used for schizophrenia and bipolar disorder. In addition, it is used to manage behavioural problems associated with dementia. It is also used for severe behavioural problems associated with childhood mental health disorders.

How Ridal works?

Since this drug is an atypical antipsychotic, side effects are less than the typical antipsychotics such as largactil. It is because older typical antipsychotics usually block only the dopamine receptors and this causes more side effects. Ridal blocks both dopamine and serotonin receptors. It seems that the additional serotonin block counteracts the dopamine side effects.

What are the common side effects of Ridal?

Drowsiness is the commonest side effect. Gastrointestinal disturbances like nausea and vomiting are also common. In addition, some patients may get abnormal movements with this medication and akathesia (inability to keep the feet in one place) is another troublesome side effect that can occur with Ridal. Drug induced Parkinson’s disease is another side effect.

Headache is another common side effect. Some patients can get blurred vision. In addition, women may complain abnormal milk production from their breasts. Sometimes this medication can cause sexual dysfunction (impotence) in both men and women.

Ridal is similar to Sizodon a brand of risperidone manufactured in India. So you can find more information there.