Definition

Carbamazepine is an anticonvulsant that is structurally related to tricyclic antidepressants such as amitriptyline and imipramine. In the United States, carbamazepine is sold under the trade names Tegretol and Carbatrol.

Purpose

Carbamazepine is effective in the treatment of psychomotor and grand mal seizures and a type of facial pain called trigeminal neuralgia and, in combination with other drugs, for psychiatric disorders such as mania and extreme aggression. Carbamazepine is also occasionally used to control pain in persons with cancer.

Description

Carbamazepine was first marketed as an anti-seizure medication and as a first-line treatment for trigeminal neuralgia. Because it was later noted to be effective in patients with certain psychiatric disorders, psychiatrists began combining it with other drugs such as lithium and major tranquilizers in severe cases of bipolar disease and aggressive behavior that could not be managed with single-drug therapy.

Carbamazepine is available in 100-mg chewable tablets, 200-mg capsules and a suspension at 100 mg per 5 ml of liquid.

Recommended dosage

When used to treat seizure disorders or psychiatric disease, the recommended initial dosage of carbamazepine is 200 mg two times each day. If needed, the daily dosage may be increased by 200 mg once each week. Total daily dosages should not exceed 1,000 mg in children between the ages of 12 and 15 years. Total daily dosages for adults should not exceed 1,200 mg. Carbamazepine should be taken with meals.

Precautions

Carbamazepine should be used with caution in persons who also experience other types of seizure disorders such as atypical absence seizures. Among such individuals, carbamazepine usage has been associated with an increased risk of initiating, rather than controlling, generalized convulsions.

Carbamazepine should never be discontinued abruptly unless another treatment for seizures is initiated at the same time. If this does not happen, acute withdrawal of carbamazepine may result in seizures.

Patients should be alert for signs and symptoms of bone marrow toxicity such as fever, sore throat, infection, mouth sores, easy bruising, or bleeding which occurs just under the skin.

Because carbamazepine may affect mental alertness, especially early in therapy, patients receiving this drug should not operate dangerous machinery or drive a car until they understand how the drug will affect them.

Side effects

The most commonly reported adverse reactions to carbamazepine include dizziness, drowsiness, unsteadiness, nausea and vomiting. These are more common when therapy is just beginning.

Carbamazepine has been reported to cause aplastic anemia. This is a form of anemia that is generally does not respond to treatment. The bone marrow of persons with aplastic anemia does not produce adequate amounts of red blood cells, white blood cells, and platelets. Blood counts should be monitored for individuals using this drug. Some people with previously diagnosed depression of the bone marrow should not take carbamazepine.

Carbamazepine may cause birth defects and should be avoided by women who are pregnant. An effective contraceptive method should be used while taking carbamazepine. It is important to note that this medication may decrease the effectiveness of oral contraceptives.

The drug can cross into breast milk and should be avoided by women who are breast-feeding.

Carbamazepine may also cause a skin rash or sensitivity to the sun.

Interactions

Blood levels of carbamazepine may be reduced when it is used in combination with other drugs such as phenobarbitol, phenytoin or primidone. This means that inadequate amounts of carbamazepine are available to the body, limiting the ability of the drug to control seizure activity or treat psychiatric disease. Carbamazepine also causes reductions in the blood levels of the following drugs when they are used simultaneously: phenytoin, warfarin, doxycycline, haloperidol, valproic acid, and theophylline.

The simultaneous administration of carbamazepine with erythromycin, cimetidine, propoxyohene, isoniacid, fluoxetine and calcium channel blockers such as nifedipine or verapamil may increase the blood level of carbamazepine to a toxic range.

The simultaneous use of carbamazepine and oral contraceptives may increase the possibility that the oral contraceptive won’t be effective in preventing pregnancy. Some physicians recommend that a different method of contraception be used while carbamazepine is being used.

People taking carbamazepine should not drink grapefruit juice. Grapefruit juice slows the breakdown of carbamazepine, increasing the concentration of carbamazepine in the bloodstream.

Due to the potential of many interactions with other drugs, individuals should consult with a physician or pharmacist prior to starting any new medications either bought over the counter or initiated by another physician.

Definition

Cannabis, more commonly called marijuana, refers to the several varieties of Cannabis sativa, or Indian hemp plant, that contains the psychoactive drug delta-9-tetrahydrocannabinol (THC). Cannabis-related disorders refer to problems associated with the use of substances derived from this plant.

Description

Cannabis—in the form of marijuana, hashish (a dried resinous material that seeps from cannabis leaves and is more potent than marijuana), or other cannabinoids—is considered the most commonly used illegal substance in the world. Its effects have been known for thousands of years, and were described as early as the fifth century B.C., when the Greek historian Herodotus told of a tribe of nomads who, after inhaling the smoke of roasted hemp seeds, emerged from their tent excited and shouting for joy.

Cannabis is the abbreviation for the Latin name for the hemp plant—Cannabis sativa. All parts of the plant contain psychoactive substances, with THC making up the highest percentage. The most potent parts are the flowering tops and the dried, blackish-brown residue that comes from the leaves known as hashish, or “hash.”

There are more than 200 slang terms for marijuana, including “pot,” “herb,” “weed,” “Mary Jane,” “grass,” “tea,” and “ganja.” It is usually chopped and/or shredded and rolled into a cigarette, or “joint,” or placed in a pipe (sometimes called a “bong”) and smoked. An alternative method of using marijuana involves adding it to foods and eating it, such as baking it into brownies. It can also be brewed as a tea. Marijuana has appeared in the form of “blunts”—cigarettes emptied of their tobacco content and filled with a combination of marijuana and another drug such as crack cocaine.

Between 1840 and 1900, European and American medical journals published numerous articles on the therapeutic uses of marijuana. It was recommended as an appetite stimulant, muscle relaxant, painkiller, sedative, and anticonvulsant. As late as 1913, Sir William Osler recommended it highly for treatment of migraine. Public opinion changed, however, in the early 1900s, as alternative medications such as aspirin, opiates, and barbiturates became available. In 1937, the United States passed the Marijuana Tax Act, which made the drug essentially impossible to obtain for medical purposes.

By the year 2000, the debate over the use of marijuana as a medicine continued. THC is known to successfully treat nausea caused by cancer treatment drugs, stimulate the appetites of persons diagnosed with acquired immune deficiency syndrome (AIDS), and possibly assist in the treatment of glaucoma. Its use as a medicinal agent is still, however, highly controversial. Even although the states of Arizona and California passed laws in 1996 making it legal for physicians to prescribe marijuana in the form of cigarettes for treatment of the diseases listed above, governmental agencies continue to oppose strongly its use as a medicine, and doctors who do prescribe it may find their licenses at risk.

Cannabis-related disorders reflect the problematic use of cannabis products to varying degrees. These dis orders include:

• • Cannabis dependence: The compulsive need to use the drug, coupled with problems associated with chronic drug use.
• • Cannabis abuse: Periodic use that may cause legal problems, problems at work, home, or school, or danger when driving.
• • Cannabis intoxication: The direct effects of acute cannabis use and reactions that accompany it such as feeling “high,” euphoria, sleepiness, lethargy, impairment in short-term memory, stimulated appetite, impaired judgment, distorted sensory perceptions, impaired motor performance, and other symptoms.

Causes and symptoms

Causes

Cannabis-related disorders share many of the same root causes with other addictive substances. The initial desire for a “high,” combined with the widely held perception that cannabis use is not dangerous, often leads to experimentation in the teen years.

Recent research challenges the notion that cannabis use is not physically addictive. According to the National Institute of Drug Abuse (NIDA), daily cannabis users experience withdrawal symptoms including irritability, stomach pain, aggression, and anxiety. Many frequent cannabis users are believed to continue using in order to avoid these unpleasant symptoms. Long-term use may lead to changes in the brain similar to those seen with long-term use of other addictive substances. It is believed that the greater availability, higher potency, and lower price for cannabis in recent years all contribute to the increase in cannabis-related disorders.

Beginning in the 1990s, researchers began to discover that cannabis-like compounds are naturally produced in various parts of the human body. These compounds, called “endocannabinoids,” appear to suppress inflammation and other responses of the immune system. One of these endocannabinoids— anandamide—appears to help regulate the early stages of pregnancy.

Symptoms

CANNABIS DEPENDENCE AND ABUSE. The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-IV-TR. This manual states that the central features of cannabis dependence are compulsive use, tolerance of its effects, and withdrawal symptoms. Use may interfere with family, school, and work, and may cause legal problems.

Regular cannabis smokers may show many of the same respiratory symptoms as tobacco smokers. These include daily cough and phlegm, chronic bronchitis, and more frequent chest colds. Continued use can lead to abnormal functioning of the lung tissue, which may be injured or destroyed by the cannabis smoke.

Recent research indicates that smoking marijuana has the potential to cause severe increases in heart rate and blood pressure, particularly if combined with cocaine use. Even with marijuana use alone, however, the heart rate of subjects increased an average of 29 beats per minute when smoking marijuana.

A study of heavy marijuana users has shown that critical skills related to attention, memory, and learning can be impaired, even after use is discontinued for at least 24 hours. Heavy users, compared to light users, made more errors on tasks and had more difficulty sustaining attention and shifting attention when required. They also had more difficulty in registering, processing, and using information. These findings suggest that the greater impairment in mental functioning among heavy users is most likely due to an alteration of brain activity directly produced by the marijuana use.

Recent studies have found that babies born to mothers who used marijuana during pregnancy were smaller than those born to nonusing mothers. Smaller babies are more likely to develop health problems. Additionally, nursing mothers who use marijuana pass some of the THC to the baby in their breast milk. Research shows that use of marijuana during the first month of breastfeeding can impair an infant’s motor development.

Cannabis abuse is characterized by less frequent use and less severe problems. However, as with cannabis dependence, abuse can interfere with performance at school or work, cause legal problems, and interfere with motor activities such as driving or operating machinery.

CANNABIS INTOXICATION. Cannabis intoxication refers to the occurrence of problematic behaviors or psychological changes that develop during, or shortly after, cannabis use. Intoxication usually starts with a “high” feeling followed by euphoria, inappropriate laughter, and feelings of grandiosity. Other symptoms include sedation, lethargy, impaired short-term memory, difficulty with motor tasks, impaired judgment, distorted sensory perceptions, and the feeling that time is passing unusually slowly. Sometimes severe anxiety, feelings of depression, or social withdrawal may occur. Along with these symptoms, common signs of cannabis intoxication include reddening of the membranes around the eyes, increased appetite, dry mouth, and increased heart rate.

Demographics

The NIDA conducts an annual nationwide study of twelfth-, tenth-, and eighth-grade students and young adults. This study is known as the Monitoring the Future Study, or MTF. Results show that after a decade of decreased use in the 1980s, marijuana use among students began to rise in the early 1990s. Data show that, between 1998 and 1999, marijuana use continued to increase among twelfth and tenth graders. For twelfth graders, the lifetime rate (use of marijuana at least one or more times) is higher than for any year since 1987. However, these rates remain well below those seen in the late 1970s and early 1980s. Daily marijuana use among students in all three grades also showed a slight increase.

Another method by which the government measures marijuana use is the Community Epidemiology Work Group, or CEWG. This method examines rates of emergency room admissions related to marijuana use in 20 major metropolitan areas. In 1998, use of marijuana showed an upward trend in most of the areas monitored, with the largest increases occurring in Dallas, Boston, Denver, San Diego, and Atlanta. The highest percentage increase in emergency room visits related to marijuana was among 12- to 17-year-olds.

Treatment data for marijuana abuse increased in six of the metropolitan areas surveyed but remained stable elsewhere. Marijuana treatment admissions were highest in Denver, Miami, New Orleans, and Minneapolis/St. Paul. Half of the admissions in Minneapolis/St. Paul were under the age of 18 years.

Marijuana remains the most commonly used illicit drug in the United States. As with most other illicit drugs, cannabis use disorders appear more often in males and is most common among people between the ages of 18 and 30 years.

An estimated 2.1 million people started using marijuana in 1998. According to data from a study released in the late 1990s called the National Household Survey on Drug Abuse, or NHSDA, more than 72 million Americans ages 12 years and older (33%) tried marijuana at least once during their lifetime, while almost 18.7 million (8.6%) used marijuana in the previous year. The reader can compare these figures to the figures from 1985, when 56.5 million Americans (29.4%) had tried marijuana at least once in their life, and 26.1 million (13.6%) had used marijuana within the past year.

Diagnosis

Diagnosis of cannabis-related disorders is made in a number of ways. Intoxication is easiest to diagnose because of clinically observable signs, including reddened eye membranes, increased appetite, dry mouth, and increased heart rate. It is also diagnosed by the presence of problematic behavioral or psychological changes such as impaired motor coordination, judgment, anxiety, euphoria, and social withdrawal. Occasionally, panic attacks may occur, and there may be impairment of short-term memory. Lowered immune system resistance, lowered testosterone levels in males, and chromosomal damage may also occur. Psychologically, chronic use of marijuana has been associated with a loss of ambition known as the “amotivational syndrome.”

Cannabis use is often paired with the use of other addictive substances, especially nicotine, alcohol, and cocaine. Marijuana may be mixed and smoked with opiates, phencyclidine (”PCP” or “angel dust”), or hallucinogenic drugs. Individuals who regularly use cannabis often report physical and mental lethargy and an inability to experience pleasure when not intoxicated (known as “anhedonia”). If taken in sufficiently high dosages, cannabinoids have psychoactive effects similar to hallucinogens such as lysergic acid diethylamide (LSD), and individuals using high doses may experience adverse effects that resemble hallucinogen-induced “bad trips.” Paranoid ideation is another possible effect of heavy use, and, occasionally, hallucinations and delusions occur. Highly intoxicated individuals may feel as if they are out-side their body (”depersonalization”) or as if what they are experiencing isn’t real (”derealization”). Fatal traffic accidents are more common among individuals testing positive for cannabis use.

Urine tests can usually identify metabolites of cannabinoids. Because cannabinoids are fat soluble, they remain in the body for extended periods. Individuals who have used cannabis may show positive urine tests for as long as two to four weeks after using.

Examination of the nasopharynx and bronchial lining may also show clinical changes due to cannabis use. Marijuana smoke is known to contain even larger amounts of carcinogens than tobacco smoke. Sometimes cannabis use is associated with weight gain.

Treatments

Treatment options for individuals with cannabis-related disorders are identical to those available for people with alcohol and other substance abuse disorders. The goal of treatment is abstinence. Treatment approaches range from in-patient hospitalization, drug and alcohol rehabilitation facilities, and various outpatient programs. Twelve-step programs such as Narcotics Anonymous are also treatment options. For heavy users suffering from withdrawal symptoms, treatment with anti-anxiety and/or antidepressant medication may assist in the treatment process.

Prognosis

According to the DSM-IV-TR, cannabis dependence and abuse tend to develop over a period of time. It may, however, develop more rapidly among young people with other emotional problems. Most people who become dependent begin using regularly. Gradually, over time, both frequency and amount increase. With chronic use, there can sometimes be a decrease in or loss of the pleasurable effects of the substance, along with increased feelings of anxiety and/or depression. As with alcohol and nicotine, cannabis use tends to begin early in the course of substance abuse and many people later go on to develop dependence on other illicit substances. Because of this, cannabis has been referred to as a “gateway” drug, although this view remains highly controversial. There is much that remains unknown about the social, psychological, and neurochemical basis of drug use progression, and it is unclear whether marijuana use actually causes individuals to go on to use other illicit substances.

One long-term effect of chronic use has been termed the “amotivational syndrome.” This refers to the observation that many heavy, chronic users seem unambitious in relation to school and/or career.

Prevention

Many drug education programs focus strongly on discouraging marijuana experimentation among young teenagers. Recent research reported by the NIDA indicates that high-sensation-seekers—that is, individuals who seek out new, emotionally intense experiences and are willing to take risks to obtain these experiences— are at greater risk for using marijuana and other drugs, and for using them at an earlier age. As a result, the NIDA developed a series of public service announcements (PSAs) for national television. These PSAs were dramatic and attention getting, and were aired during programs that would appeal to high sensation-seekers, such as action-oriented television shows. These PSAs were aired in a limited television area and the results monitored. Marijuana use declined substantially among teens during the PSA campaigns, and long-term effects were shown for several months afterwards. In one county, marijuana use decreased by 38%, and in another, by 26.7%.

Definition

Caffeine is a white, bitter crystalline alkaloid derived from coffee or tea. It belongs to a class of compounds called xanthines, its chemical formula being 1,3,7-trimethylxanthine. Caffeine is classified together with cocaine and amphetamines as an analeptic, or central nervous system stimulant. Coffee is the most abundant source of caffeine, although caffeine is also found in tea, cocoa, and cola beverages as well as in over-the-counter and prescription medications for pain relief.

In the clinician’s handbook for diagnosing mental disorders (the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM-IV-TR), caffeine-related disorders are classified under the rubric of substance-related disorders. DSM-IV-TRspecifies four caffeine-related disorders: caffeine intoxication, caffeine-induced anxiety disorder, caffeine-induced sleep disorder, and caffeinerelated disorder not otherwise specified. A fifth, caffeine withdrawal, is listed under the heading of “Criteria Sets and Axes Provided for Further Study.”

Caffeine-related disorders are often unrecognized for a number of reasons:

• Caffeine has a “low profile” as a drug of abuse. Consumption of drinks containing caffeine is unregulated by law and is nearly universal in the United States; one well-known textbook of pharmacology refers to caffeine as “the most widely used psychoactive drug in the world.” In many countries, coffee is a social lubricant as well as a stimulant; the “coffee break” is a common office ritual, and many people find it difficult to imagine eating a meal in a fine restaurant without having coffee at some point during the meal. It is estimated that 10–12 billion pounds of coffee are consumed worldwide each year.
• People often underestimate the amount of caffeine they consume on a daily basis because they think of caffeine only in connection with coffee as a beverage. Tea, cocoa, and some types of soft drink, including root beer and orange soda as well as cola beverages, also contain significant amounts of caffeine. In one British case study, a teenager who was hospitalized with muscle weakness, nausea, vomiting, diarrhea, and weight loss was found to suffer from caffeine intoxication caused by drinking 8 liters (about 2 gallons) of cola on a daily basis for the previous two years. She had been consuming over a gram of caffeine per day. Chocolate bars and coffee-flavored yogurt or ice cream are additional sources of measurable amounts of caffeine.
• Caffeine has some legitimate medical uses in athletic training and in the relief of tension-type headaches. It is available in over-the-counter (OTC) preparations containing aspirin or acetaminophen for pain relief as well as in such OTC stimulants as NoDoz and Vivarin.
• Caffeine is less likely to produce the same degree of physical or psychological dependence as other drugs of abuse. Few coffee or tea drinkers report loss of control over caffeine intake, or significant difficulty in reducing or stopping consumption of beverages and food items containing caffeine.
• The symptoms of caffeine intoxication are easy to confuse with those of an anxiety disorder.

The DSM-TR-IVstates that it is unclear as of 2000 whether the tolerance, withdrawal symptoms, and “some aspects of dependence on caffeine” seen in some people who drink large amounts of coffee “are associated with clinically significant impairment that meets the criteria for Substance Abuse or Substance Dependence.” On the other hand, a research team at Johns Hopkins regards caffeine as a model drug for understanding substance abuse and dependence. The team maintains that 9%–30% of caffeine consumers in the United States may be caffeine-dependent according to DSMcriteria for substance dependency.

Description

Pharmacological aspects of caffeine

An outline of the effects of caffeine on the central nervous system (CNS) and other organ systems of the body may be helpful in understanding its potential for physical dependence. When a person drinks a beverage containing caffeine (or eats coffee-flavored ice cream), the caffeine is absorbed from the digestive tract without being broken down. It is rapidly distributed throughout the tissues of the body by means of the bloodstream. If a pregnant woman drinks a cup of coffee or tea, the caffeine in the drink will cross the placental barrier and enter the baby’s bloodstream.

When the caffeine reaches the brain, it increases the secretion of norepinephrine, a neurotransmitter that is associated with the so-called fight or flight stress response. The rise in norepinephrine levels and the increased activity of the neurons, or nerve cells, in many other areas of the brain helps to explain why the symptoms of caffeine intoxication resemble the symptoms of a panic attack.

The effects of caffeine are thought to occur as a result of competitive antagonism at adenosine receptors. Adenosine is a water-soluble compound of adenine and ribose; it functions to modulate the activities of nerve cells and produces a mild sedative effect when it activates certain types of adenosine receptors. Caffeine competes with adenosine to bind at these receptors and counteracts the sedative effects of the adenosine. If the person stops drinking coffee, the adenosine has no competition for activating its usual receptors and may produce a sedative effect that is experienced as fatigue or drowsiness.

Caffeine content of food items and OTC preparations

The caffeine content of various food items and medications is as follows:

• Brewed coffee, 8-oz cup: 135–150 mg
• Instant coffee, 8-oz cup: 95 mg
• Powdered cappuccino beverage, 8-oz cup: 45–60 mg
• Tea brewed from leaves or bag, 8-oz cup: 50 mg
• Iced tea from mix, 8-oz glass: 25–45 mg
• Snapple iced tea, 8-oz glass: 21 mg
• Mountain Dew, 8-oz glass: 38 mg
• Dr. Pepper, 8-oz. glass: 28 mg
• Diet cola, 8-oz glass: 31 mg
• Root beer, 8-oz glass: 16 mg
• Coffee ice cream, 8-oz serving: 60–85 mg
• Coffee yogurt, 8-oz serving: 45 mg.
• Dark chocolate candy bar, 1.5 oz: 31 mg
• NoDoz, regular strength, 1 tablet: 100 mg
• NoDoz, maximum strength, 1 tablet: 200 mg
• Excedrin, 2 tablets: 130 mg

Caffeine can produce a range of physical symptoms following ingestion of as little as 100 mg, although amounts of 250 mg or higher are usually needed to produce symptoms that meet the criteria of caffeine intoxication.

Caffeine intoxication

To meet DSM-IV-TRcriteria for caffeine intoxication, a person must develop five or more of the twelve symptoms listed below; the symptoms must cause significant distress or impair the person’s social or occupational functioning; and the symptoms must not be caused by a medical disorder or better accounted for by an anxiety disorder or other mental disorder.

Because people develop tolerance to caffeine fairly quickly with habitual use, caffeine intoxication is most likely to occur in those who consume caffeine infrequently or who have recently increased their intake significantly.

Caffeine-induced anxiety and sleep disorders

DSM-IV-TRcriteria for caffeine-induced anxiety and sleep disorders specify that the symptoms of anxiety and insomnia respectively must be more severe than the symptoms associated with caffeine intoxication. In addition, the anxiety or insomnia must be severe enough to require separate clinical attention.

Causes and symptoms

Causes

The immediate cause of caffeine intoxication and other caffeine-related disorders is consumption of an amount of caffeine sufficient to produce the symptoms specified by DSM-IV-TRas criteria for the disorder. The precise amount of caffeine necessary to produce symptoms varies from person to person depending on body size and degree of tolerance to caffeine. Tolerance of the stimulating effects of caffeine builds up rapidly in humans; mild withdrawal symptoms have been reported in persons who were drinking as little as one to two cups of coffee per day.

Some people may find it easier than others to consume large doses of caffeine because they are insensitive to its taste. Caffeine tastes bitter to most adults, which may serve to limit their consumption of coffee and other caffeinated beverages. Slightly more than 30% of the American population, however, has an inherited inability to taste caffeine.

Symptoms

The symptoms of caffeine intoxication include:

• restlessness
• nervousness
• excitement
• insomnia
• flushed face
• diuresis (increased urinary output)
• gastrointestinal disturbance
• muscle twitching
• talking or thinking in a rambling manner
• tachycardia (speeded-up heartbeat) or disturbances of heart rhythm
• periods of inexhaustibility
• psychomotor agitation

People have reported ringing in the ears or seeing flashes of light at doses of caffeine above 250 mg. Profuse sweating and diarrhea have also been reported. Doses of caffeine higher than 10 g may produce respiratory failure, seizures, and eventually death.

Side effects and complications

High short-term consumption of caffeine can produce or worsen gastrointestinal problems, occasionally leading to peptic ulcers or hematemesis (vomiting blood).

In addition to the symptoms produced by high short-term doses, long-term consumption of caffeine has been associated with fertility problems and with bone loss in women leading to osteoporosis in old age. Some studies have found that pregnant women who consume more than 150 mg per day of caffeine have an increased risk of miscarriage and low birth weight babies, but the findings are complicated by the fact that most women who drink large amounts of coffee during pregnancy are also heavy smokers. Some researchers believe that long-term consumption of caffeine is implicated in cardiovascular diseases, but acknowledge that further research is required.

On the other hand, moderate doses of caffeine improve athletic performance as well as alertness. Caffeine in small doses can relieve tension headaches, and one study found that a combination of ibuprofen and caffeine was more effective in relieving tension headaches than either ibuprofen alone or a placebo. Coffee consumption also appears to lower the risk of alcoholic and nonalcoholic cirrhosis of the liver.

Drug interactions

Caffeine is often combined with aspirin or acetaminophen in over-the-counter and prescription analgesics (pain relievers). It can also be combined with ibuprofen. On the other hand, certain groups of drugs should not be combined with caffeine or taken with beverages containing caffeine. Oral contraceptives, cimetidine (Tagamet), mexiletine (Mexitil), and disulfiram (Antabuse) interfere with the breakdown of caffeine in the body. Caffeine interferes with the body’s absorption of iron, and with drugs that regulate heart rhythm, including quinidine and propranolol(Inderal). Caffeine may produce serious side effects when taken together with monoamine oxidase inhibitors or with certain decongestant medications.

Combinations of ephedra and caffeine have been used in weight-loss programs because they produce greater weight loss than can be achieved by caloric restriction alone. Major studies were underway as of 2001 at Harvard and Vanderbilt to determine the safety of these regimens.

Practitioners of homeopathy have traditionally advised patients not to drink beverages containing caffeine in the belief that caffeine “antidotes” homeopathic remedies. Contemporary homeopaths disagree on the antidoting effects of caffeine, observing that homeopathy is used widely and effectively in Europe and that Europeans tend to drink strong espresso coffee more frequently than Americans.

Demographics

The general population of the United States has a high level of caffeine consumption, with an average intake of 200 mg per day. About 85% of the population uses caffeine in any given year. Among adults in the United States, about 30% consume 500 mg or more each day. These figures are lower, however, than the figures for Sweden, the United Kingdom, and other parts of Europe, where the average daily consumption of caffeine is 400 mg or higher. In developing countries, the average consumption of caffeine is much lower— about 50 mg per day.

In the United States, levels of caffeine consumption among all races and ethnic groups are related to age, with usage beginning in the late teens and rising until the early 30s. Caffeine consumption tapers off in adults over 40 and decreases in adults over 65. Caffeine intake is higher among males than among females in North America.

The prevalence of caffeine-related disorders in the United States is not known as of 2002.

Diagnosis

Diagnosis of a caffeine-related disorder is usually based on the patient’s recent history, a physical examination, or laboratory analysis of body fluids. In addition to medical evidence, the examiner will rule out other mental disorders, particularly manic episodes, generalized anxiety disorder, panic disorder, amphetamine intoxication, or withdrawal from sedatives, tranquilizers, sleep medications, or nicotine. All of these disorders or syndromes may produce symptoms resembling those of caffeine intoxication. In most cases, the temporal relationship of the symptoms to high levels of caffeine intake establishes the diagnosis.

In some cases, the examiner may consider the possibility of depression during the differential diagnosis, as many people with depression and eating disorders self-medicate with caffeine.

Treatments

Treatment of caffeine-related disorders involves lowering consumption levels or abstaining from beverages containing caffeine. Some people experience mild withdrawal symptoms that include headaches, irritability, and occasionally nausea, but these usually resolve quickly.

Caffeine consumption has the advantage of having relatively weak (compared to alcohol or cigarettes) social reinforcement, in the sense that one can easily choose a noncaffeinated or decaffeinated beverage in a restaurant or at a party without attracting comment. Thus physical dependence on caffeine is less complicated by the social factors that reinforce nicotine and other drug habits.

Prognosis

With the exception of acute episodes of caffeinism, people recover from caffeine intoxication without great difficulty.

Prevention

Prevention of caffeine-related disorders requires awareness of the caffeine content of caffeinated beverages, OTC drugs, and other sources of caffeine; monitoring one’s daily intake; and substituting decaffeinated coffee, tea, or soft drinks for the caffeinated versions of these beverages.

Definition

Buspirone is an anti-anxiety (anxiolytic) drug sold in the United States under the brand name of BuSpar. It is also available under its generic name.

Purpose

Buspirone is used for the treatment of generalized anxiety disorders and for short term relief of symptoms of anxiety.

Description

Buspirone’s mechanism of action is unclear but probably involves actions on such central nervous system chemicals as dopamine, serotonin, acetylcholine, and norepinephrine. These chemicals are called neurotransmitters and are involved in the transmission of nervous impulses from cell to cell. Mental well-being is partially dependent on maintaining a balance among different neurotransmitters.

Buspirone’s actions are different from a common class of sedatives called benzodiazepines. The primary action of benzodiazepines is to reduce anxiety, relax skeletal muscles, and induce sleep. The earliest drugs in this class were chlordiazepoxide (Librium) and diazepam (Valium). Buspirone also acts through a different mechanism than barbiturates such as phenobarbital. Unlike benzodiazepines, buspirone has no anticonvulsant or muscle-relaxant properties, and unlike benzodiazepines or barbiturates, it does not have strong sedative properties. If insomnia is a component of the patient’s anxiety disorder, a sedative/hypnotic drug may be taken along with buspirone at bedtime. Buspirone also diminishes anger and hostility for most people. Unlike benzodiazepines, which may aggravate anger and hostility in some patients, (especially older patients), buspirone may help patients with anxiety who also have a history of aggression.

The benefits of buspirone take a long time to become evident. Unlike benzodiazepines, where onset of action and time to maximum benefit are short, patients must take buspirone for three to four weeks before feeling the maximum benefit of the drug. In some cases, four to six weeks of treatment may be required. Patients should be aware of this and continue to take the drug as prescribed even if they think they are not seeing any improvement.

Buspirone is available in 5-, 10-, 15-, and 30-mg tablets.

Recommended dosage

The usual starting dose of buspirone is 10 to 15 mg per day. This total amount is divided into two or three doses during the day. For example, a dose of 5 mg may be given two or three times per day to make a total dose of 10 to 15 mg per day. The dose may be increased in increments of 5 mg daily every two to four days. Most patients will respond to a dose of 15 to 30 mg daily. Patients should not take a total dose of more than 60 mg daily. When patients are receiving certain other drugs (see below) in addition to buspirone, starting doses of buspirone may need to be lowered (for example, 2.5 mg twice daily), and any dosage increases should be done with caution and under close physician supervision. Dosages may need to be reduced in patients with kidney or liver problems.

Precautions

Buspirone is less sedating (causes less drowsiness and mental sluggishness) than other anti-anxiety drugs. However, some patients may still experience drowsiness and mental impairment. Because it is impossible to predict which patients may experience sedation with buspirone, those starting this drug should not drive or operate dangerous machinery until they know how the drug will affect them.

Patients who have been taking benzodiazepines for a long time should be gradually withdrawn from them while they are being switched over to buspirone. They should also be observed for symptoms of benzodiazepine withdrawal.

Patients with kidney damage should take buspirone with caution in close consultation with their physician. They may require a lower dosage of buspirone to prevent buildup of the drug in the body. Patients with severe kidney disease should not take buspirone. Patients with liver damage should likewise be monitored for a buildup of buspirone and have their doses lowered if necessary.

Side effects

The most common side effects associated with buspirone involve the nervous system. Ten percent of patients may experience dizziness, drowsiness, and headache, and another 5% may experience fatigue, nervousness, insomnia, and light-headedness. Patients may also experience excitement, depression, anger, hostility, confusion, nightmares, or other sleep disorders, lack of coordination, tremor, and numbness of the extremities. Although buspirone is considered non-sedating, some patients will experience drowsiness and lack of mental alertness at higher doses and especially early in therapy. In most patients, these side effects decrease with time.

The following side effects have also been associated with buspirone:

• • nausea (up to 8% of patients)
• • dry mouth, abdominal distress, gastric distress, and diarrhea, constipation (up to 5% of patients)
• • rapid heart rate and palpitations (up to 2% of patients)
• • blurred vision (up to 2% of patients)
• • increased or decreased appetite
• • flatulence
• • non-specific chest pain
• • rash
• • irregular menstrual periods and/or breakthrough bleeding

Interactions

Dangerously high blood pressure has resulted from the combination of buspirone, and members of another class of antidepressants known as monoamine oxidase (MAO) inhibitors. Because of this, buspirone should never be taken in combination with MAO inhibitors. Patient taking any MAO inhibitors, for example Nardil (phenelzine sulfate) or Parmate (tranylcypromine sulfate), should stop the MAO inhibitor then wait at least 10 days before starting buspirone. The same holds true when discontinuing buspirone and starting an MAO inhibitor.

Certain drugs may inhibit the enzyme system in the liver that breaks down buspirone. Examples of drugs that might inhibit this system are erythromycin, a broad-spectrum antibiotic, itraconazole, an oral antifungal agent, and nefazodone, an antidepressant. When these drugs are combined with buspirone, buspirone concentrations may increase to the point of toxicity (poisoning). These combinations should either be avoided or doses of buspirone decreased to compensate for this interaction.

Definition

Bupropion is an antidepressant drug used to elevate mood and promote recovery of a normal range of emotions in patients with depressive disorders. In addition, bupropion is used to as an aid in smoking cessation treatment. In the United States, bupropion is sold as an antidepressant under the brand name Wellbutrin. As a smoking cessation treatment, the drug is marketed under the brand name Zyban.

Purpose

Bupropion is principally known as an antidepressant drug used to promote recovery of depressed patients. It also has therapeutic uses in smoking cessation treatment, panic disorder, and attention-deficit/hyperactivity disorder (ADHD).

Description

Bupropion is a non-tricyclic antidepressant drug. Tricyclic antidepressants, which have a three-ring chemical structure, may cause troublesome side effects, including sedation, dizziness, faintness, and weight gain. Until the 1980s, such drugs were the mainstay of the pharmacological treatment of depression. Bupropion was one of the first antidepressants with a significantly different chemical structure to be developed by pharmaceutical researchers seeking drugs effective in treating depression but without the unwanted actions of the tricyclic antidepressants.

The exact way that bupropion works in the brain is not understood. Its mechanism of action appears to be different from that of most other antidepressant drugs, although bupropion does act on some of the same neurotransmitters and neurotransmission pathways. Neurotransmitters are naturally occurring chemicals that regulate the transmission of nerve impulses from one cell to another. Mental well-being is partially dependent on maintaining the proper balance among the various neurotransmitters in the brain. Bupropion may restore normal emotional feelings by counteracting abnormalities of neurotransmission that occur in depressive disorders.

In contrast to the drowsiness frequently caused by other antidepressants, bupropion is a mild stimulant. Bupropion is also less likely to cause weight gain and adverse effects on blood pressure and the heart. However, it is more likely to trigger epileptic seizures.

Recommended dosage

The usual adult dose of bupropion (Wellbutrin) is 100 mg, taken three times per day, with at least six hours between doses. The extended release form of the drug (Wellbutrin SR) is taken as 150 mg twice a day with at least eight hours between doses. For smoking cessation, bupropion (Zyban) is taken as 150-mg extended release tablets twice a day, with at least eight hours between doses. Bupropion treatment should be started at a lower dose, then gradually increased to a therapeutic dosage, as directed by the physician. Generally, the total dosage should not exceed 300 mg per day, except as directed by the physician.

The therapeutic effects of bupropion, like other antidepressants, appear slowly. Maximum benefit is often not evident for several weeks after starting the drug. People taking bupropion should be aware of this and continue taking the drug as directed even if they do not see immediate improvement in mood.

Since higher doses of bupropion increase the risk of seizures, no more than 150 mg should be given at any one time, and the total daily dosage should not be increased by more than 100 mg every three days. Increasing the dosage gradually also minimizes agitation, restlessness, and insomnia that may occur.

Healthy elderly patients do not appear to be more sensitive to side effects of bupropion than younger adults and do not require reduced doses. Certain medical conditions, especially liver and kidney disease, may necessitate dose reduction. Although bupropion has been taken by children and adolescents under age 18, it has not been systematically studied in these age groups.

Precautions

Bupropion is more likely to trigger epileptic seizures than other antidepressants. The drug should not be given to patients who have a history of epilepsy, take other medication to help control seizures, or have some other condition associated with seizures, such as head trauma or alcoholism. Nevertheless, in fewer than 1% of healthy people taking bupropion at the recommended dose have seizures. The possibility of seizures is increased at higher doses and following a sudden increase in dose. Patients should minimize alcohol intake while taking bupropion, since alcohol consumption increases the chance of seizures.

Because of the possibility of overdose, potentially suicidal patients should be given only small quantities of the drug at one time. Increases in blood pressure have occurred in patients taking bupropion along with nicotine treatment for smoking cessation. Monitoring blood pressure is recommended in such cases. Excessive stimulation, agitation, insomnia, and anxiety have been troublesome side effects for some patients, especially when treatment is first begun or when the dose is increased. Such adverse effects may be less intense and less frequent when the dose is increased gradually.

It has not been determined whether bupropion is safe to take during pregnancy. Pregnant women should take bupropion only if necessary. The drug is secreted in breast milk. Women taking bupropion should consult their physicians about breast-feeding.

Side effects

Bupropion is a mild stimulant and may cause insomnia, agitation, confusion, restlessness, and anxiety. These effects may be more pronounced at the beginning of therapy and after dose increases. Headache, dizziness, and tremor may occur. Despite stimulating effects, bupropion may also cause sedation.

Weight loss is more common with bupropion than weight gain, but both have been reported. Excessive sweating, dry mouth, sore throat, nausea, vomiting, decreased appetite, constipation, blurred vision, and rapid heart rate may occur.

Interactions

Bupropion should not be administered along with other medications that lower the seizure threshold, such as steroids and the asthma medication theophylline. Many psychiatric medications also lower the seizure threshold. Monoamine oxidase inhibitors (MAOs), another type of antidepressant medication, should not be taken with bupropion. Adverse effects may increase in patients taking levodopa and other medications for Parkison’s disease along with bupropion. Patients should inform their doctors about all other medications they are taking before starting this drug.

Nicotine patch therapy may be administered concurrently with bupropion in smoking cessation treatment. If this is done, blood pressure must be monitored, since increased blood pressure has been reported with this combination of medications.

Certain drugs, especially those eliminated by the liver, may interfere with the elimination of bupropion from the body, causing higher blood levels and increased side effects. Conversely, bupropion may retard the elimination of other medicines, including many antidepressants, antipsychotic drugs, and heart medications, resulting in higher blood levels and potentially increased side effects.

Definition

Brief psychotic disorder is a short-term, time-limited disorder. An individual with brief psychotic disorder has experienced at least one of the major symptoms of psychosis for less than one month. Hallucinations, delusions, strange bodily movements or lack of movements (catatonic behavior), peculiar speech and bizarre or markedly inappropriate behavior are all classic psychotic symptoms that may occur in brief psychotic disorder.

The cause of the symptoms helps to determine whether or not the sufferer is described as having brief psychotic disorder. If the psychotic symptoms appear as a result of a physical disease, a reaction to medication, or intoxication with drugs or alcohol, then the unusual behaviors are not classified as brief psychotic disorder. If hallucinations, delusions, or other psychotic symptoms occur at the same time that an individual is experiencing major clinical depression or bipolar (manic-depressive) disorder, then the brief psychotic disorder diagnosis is not given. The decision rules that allow the clinician to identify this cluster of symptoms as brief psychotic disorder are outlined in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision, produced by the American Psychiatric Association. This manual is referred to by most mental health professionals as DSM-IV-TR.

Description

Positive symptoms

The person experiencing brief psychotic disorder always has one or more “positive” psychotic symptoms. The psychotic symptoms are not “positive” in the everyday sense of something being good or useful. Positive in this context is used with the medical meaning: a factor is present that is not normally expected, or a normal type of behavior is experienced in its most extreme form. Positive symptoms of psychosis include hallucinations, delusions, strange bodily movements or lack of movements (catatonic behavior), peculiar speech and bizarre or primitive behavior.

HALLUCINATIONS. Hallucinations involve experiencing sensations that have no corresponding objective reality. Hallucinations can occur in various forms that parallel the human senses. Visual hallucinations involve the sense of sight, or “seeing things.” Auditory hallucinations generally involve hearing voices, and are the most common of the hallucinations. Sometimes, a hallucination can include both voices and some visual experience; mental health professionals describe this as an “auditory-visual hallucination.” Smelling non-existent smells or feeling things on or under one’s skin that do not actually exist are forms of somatic hallucinations. Somatic comes from soma, the Greek word for body; thus, somatic hallucinations are bodily hallucinations.

DELUSIONS. Delusions are also a classic psychotic feature. Delusions are strongly held irrational and unrealistic beliefs that are extremely difficult to change, even when the person is exposed to evidence that contradicts the delusion. The layperson typically thinks of delusions as being “paranoid,” or “persecutory” wherein the delusional person is excessively suspicious and continually feels at the mercy of conspirators who are “out to get” him or her. However, delusions can also be unjustified beliefs that are grandiose, involve elaborate love fantasies (”erotomanic” delusions), or extreme and irrational jealousy. Grandiose delusions are persistent irrational beliefs that somehow exaggerate the person’s importance, such as believing oneself to be a famous person, or having an enviable position such as being the Prime Minister or President. Often grandiose delusions take on religious overtones; for instance, a person might become convinced that she is the Virgin Mary. Furthermore, delusions can be somatic. Somatic delusions are erroneous but strongly held beliefs about the characteristics or functioning of one’s body; an example is a mental health consumer who refuses to eat because of a conviction that the throat muscles are completely paralyzed and that only liquids can be swallowed, when there is no actual physical reason to be unable to swallow.

OTHER PSYCHOTIC SYMPTOMS. Other psychotic symptoms that may occur in brief psychotic disorder are strange bodily movements or lack of movements (catatonic behavior), peculiar speech, and bizarre or child-like behavior. Catatonic behavior or catatonia involves both possible extremes related to movement. Catalepsy is the motionless aspect of catatonia—a person with catalepsy may remain fixed in the same position for hours on end. Rapid or persistently repeated movements, frequent grimacing and strange facial expressions, and unusual gestures are the opposite end of the catatonia phenomenon. Peculiar speech is also seen in some cases of brief psychotic disorder. Speech distortions can involve words mixed together in no coherent order, responses that are irrelevant and strange in the context of the conversation in which they occur, or echolalia, the repetition of another person’s exact spoken words, repeated either immediately after the speaker or after a delay of minutes to hours. Bizarre behavior can range from child-like behaviors such as skipping, singing, or hopping in inappropriate circumstances to unusual practices such as hoarding food or covering one’s head and clothing with aluminum foil wrappings.

Of course, not all of these psychotic symptoms will be observed simultaneously in the person with brief psychotic disorder. Any constellation of these positive psychotic symptoms that occurs for one entire day up to one month is considered to be brief psychotic disorder, unless there is some other syndrome or biological cause that caused the symptoms to appear.

Causes and symptoms

Causes

Brief psychotic disorder is not a simple or consistent disorder with a single cause. Because many phenomena can prompt a short-term experience of psychotic symptoms, there are several ways of viewing the causes of the disorder.

AN EARLY PHASE OF SCHIZOPHRENIA. Because of the similarities between brief psychotic disorder, schizophreniform disorder and schizophrenia, many clinicians have come to think of brief psychotic disorder as being the precursor to a lengthier psychotic disorder. Although this can only be identified retrospectively, brief psychotic disorder is often the diagnosis that was originally used when an individual (who later develops schizophrenia) experiences a first “psychotic break” from more typical functioning.

A STRESS RESPONSE. At times, under severe stress, temporary psychotic reactions may appear. The source of stress can be from typical events encountered by many people in the course of a lifetime, such as being widowed or divorced. The severe stress may be more unusual, such as being in combat, enduring a natural disaster, or being taken hostage. The person generally returns to a normal method of functioning when the stress decreases or more support is available, or better coping skills are learned.

POSTPARTUM PSYCHOSIS. In some susceptible women, dramatic hormonal changes in childbirth and shortly afterward can result in a form of brief psychotic disorder often referred to as postpartum psychosis. Unfortunately, postpartum conditions are often misidentified and improperly treated. In many cases of a mother killing her infant or committing suicide, postpartum psychosis is involved.

DEFENSE MECHANISM IN PERSONALITY DISORDER. Persons with personality disorders appear to be more susceptible to developing brief psychotic reactions in response to stress. Individuals with personality disorders have not developed effective adult mechanisms for coping with life. When life becomes more demanding and difficult than can be tolerated, the person may lapse into a brief psychotic state.

CULTURALLY DEFINED DISORDER. Culture is a very important factor in understanding mental health and psychological disturbance, and brief psychotic disorder is an excellent example. The types of behavior that occur during brief psychotic disorder are very much shaped by the expectations and traditions of the individual’s culture. Many cultures have some form of mental disorder that would meet criteria for brief psychotic disorder the features of which are unique to that culture, wherein most sufferers have similar behaviors that are attributed to causes that are localized to that community. The DSMIV-TR calls disorders unique to certain societies or groups “culture-bound.” An example of a culture-bound syndrome is koro, a syndrome observed in Japan and some other areas of Asia but not elsewhere. Koro is an obsession to the point of delusion with the possibility that the genitals will retract or shrink into the body and cause death.

Conversely, while culture shapes the form a psychotic reaction may take, culture also determines what is not to be considered psychotic. Behaviors that in one culture would be thought of as bizarre or psychotic, may be acceptable in another. For example, some cultural groups and religions view “speaking in tongues” as a valuable expression of the gifts of God, whereas viewed out of context, the unrecognizable speech patterns might be viewed as psychotic. If the behaviors shown are culturally acceptable in the person’s society or religion, and happen in an approved setting such as a religious service, then brief psychotic disorder would not be diagnosed.

Symptoms

DSM-IV-TR provides three major criteria for brief psychotic disorder:

• • At least one positive symptom of psychosis, from the following symptoms: delusions; hallucinations; disorganized speech which is strange, peculiar, difficult to comprehend; disorganized (bizarre or child-like) behavior; or catatonic behavior.
• • Limited duration. The psychotic symptoms have occurred for at least one day but less than one month. There is an eventual return to normal level of functioning.
• • The symptoms are not biologically influenced or attributable to another disorder. In other words, the symptoms cannot be occurring as part of a mood disorder, schizoaffective disorder, or schizophrenia, and they cannot be due to intoxication with drugs or alcohol. Further, the symptoms cannot be an adverse reaction to a medication, and they cannot be caused by a physical injury or medical illness.

Demographics

The actual rate of brief psychotic disorder is unknown, although it appears to be fairly rare in the United States and other developed countries. While psychotic reactions that occur and subside in under a month are more common in non-industrialized nations, the mental disorders wherein psychotic symptoms last longer than one month are more prevalent in developed countries. The disorder appears to be more common in adolescents and young adults than in those of middle age or older.

Diagnosis

Using the DSM-IV-TR criteria previously listed makes identification of the disorder relatively clear-cut. However, an unusual aspect to this diagnosis is the emphasis on the length of time that symptoms have been evident. Most mental health disorder diagnoses do not include the duration of the symptoms as part of their definitions. However, the length of time the person has had psychotic symptoms is one of the major distinctions among three different psychotic disorders. Brief psychotic disorder involves the shortest duration of suffering psychotic symptoms: one day to one month. Schizophreniform disorder also involves the individual showing signs of psychosis, but for a longer period (one month or more, but less than six months). Schizophrenia is diagnosed in individuals who have evidenced psychotic symptoms that are not associated with physical disease, mood disorder or intoxication, for six months or longer. Another complicating factor in making the diagnosis is the context in which the “psychotic symptoms” are experienced. If the psychotic-like behaviors evidenced are acceptable in the person’s culture or religion and these behaviors happen in a traditionally expected context such as a religious service or meditation, then brief psychotic disorder would not be diagnosed.

The disorder is usually diagnosed by obtaining information in interview from the client and possibly from immediate family. Also, the diagnostician would be likely to perform a semi-structured interview called a mental status examination, which examines the person’s ability to concentrate, to remember, to realistically understand the situation, and to think logically.

Treatments

Antipsychotic medications are very effective in ending a brief psychotic episode. A number of different antipsychotics are used for the purpose of terminating acute psychotic episodes. Haloperidol (Haldol) is most commonly used if the psychotic symptoms are accompanied by agitation. Agitation is a state of frantic activity that is often accompanied by anger or fearfulness; when in an agitated state, the client is more likely to cause harm to self or others. In agitated psychotic states, the haloperidol is often given as an injection, accompanied by other medications that decrease anxiety (lorazepam, also known as Ativan) and slow behavior (diphenhydramine, also known as Benadryl). If the client is not agitated, usually a newer-generation antipsychotic is used, given daily as tablets, capsules or liquid, for a lengthier period of time. The novel antipsychotic that would be used is likely to be one of the following: olanzapine (Zyprexa), quetiapine (Seroquel), or risperidone (Risperdal). Hormones may also be prescribed for postpartum psychosis. Supportive therapy may also prove helpful in some situations, in decreasing the client’s anxiety and educating the client about the psychiatric illness. In culture-bound syndromes, the most effective treatment is often the one that is societally expected; for example, bathing in a river viewed as sacred might be a usual method of curing the psychotic-like state, in a particular culture.

Prognosis

The prognosis is fairly positive in brief psychotic disorder because by its own definition, a return to normal functioning is expected. If there is a major life event as a stress or an unusual traumatic experience that initiated the episode, chances are very good that there will be no recurrence. If there is not a particular triggering event or if the episode occurred in an individual with a personality disorder, the likelihood of recurrence is higher. If an episode is a recurrence without a specific triggering event, then the beginnings of the development of schizophrenia or bipolar disorder may be at hand, in which case the prognosis is poor. In the individual with personality disorder, the pattern may recur in response to stress, so that there are intermittent experiences of brief psychotic disorder over the course of a lifetime.

Prevention

In women who have experienced brief postpartum psychosis, one prevention option is to forgo having additional children. If a postpartum psychosis has occurred in the past, in subsequent pregnancies the physician may be proactive in prescribing an antipsychotic medication regimen to be taken in the postpartum period in order to prevent psychotic symptoms from recurring. Severe stressors can be a trigger for brief psychotic disorder in many cases. Therefore, in response to identifiable extreme stressors, such as natural disasters or terrorist attacks, strong social support and immediate post-crisis counseling could possibly prevent the development of brief psychotic disorder in susceptible persons.

Definition

Breathing-related sleep disorder is marked by sleep disruption caused by abnormal breathing during sleep. The most common complaint of individuals with breathing-related sleep disorder is excessive daytime sleepiness, brought on by frequent interruptions of nocturnal, or nighttime, sleep. A less frequent complaint is insomnia or inability to sleep.

Mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders also known as the DSM to diagnose mental disorders. In the 2000 edition of this manual (the fourth edition, text revision, also known as DSM-IV-TR) breathing-related sleep disorder is listed as one of several different primary sleep disorders. Within the category of primary sleep disorders, it is classified as one of the dyssomnias, which are characterized by irregularities in the quality, timing, and amount of sleep.

The DSM-IV-TR lists three types of breathing-related sleep disorder: obstructive sleep apnea syndrome (the most common type); central sleep apnea syndrome; and central alveolar hypoventilation syndrome.

Description

The most common feature of any breathing-related sleep disorder is interruption of the person’s sleep leading to excessive daytime sleepiness. When the regular nighttime sleep of individuals is frequently interrupted, sleepiness at other times of the day is the usual result. People with breathing-related sleep disorder often find that they feel sleepy during such relaxing activities as reading or watching a movie. With extreme cases, the person may feel so sleepy that he or she falls asleep during activities that require alertness, such as talking, walking, or driving.

Other people with breathing-related sleep disorder report having insomnia, or the inability to sleep. Patients also find that their sleep does not refresh them; they may awaken frequently during sleep, or have difficulty breathing while sleeping or lying down.

The two sleep apnea syndromes that are listed as subtypes of breathing-related sleep disorder are characterized by episodes of airway blockage or stopping of breathing during sleep. Sleep apnea is potentially deadly. The other type of breathing-related sleep disorder, central alveolar hypoventilation syndrome, is distinguished from the other two subtypes by the fact that the reduced oxygen content of the blood is caused by shallow breathing. The alveoli, which are the tiny air sacs in the lung tissue, are not able to oxygenate the blood efficiently because the person is not breathing deeply enough. Shallow breathing often occurs when people are awake and is common in severely overweight individuals.

Causes and symptoms

Causes

Many persons with the obstructive sleep apnea syndrome subtype of breathing-related sleep disorder are overweight. The symptoms often grow worse as the person’s weight increases. Persons who have obstructive sleep apnea and are not overweight often have breathing passages that are narrowed by swollen tonsils, abnormally large adenoids, or other abnormalities of the various structures of the mouth and throat.

Central sleep apnea syndrome is often associated with cardiac or neurological conditions affecting airflow regulation. It is a disorder that occurs most frequently in elderly patients.

Patients diagnosed with central alveolar hypoventilation syndrome experience a breathing impairment related to abnormally low arterial oxygen levels.

Symptoms

Obstructive sleep apnea syndrome, which is the most common type of breathing-related sleep disorder, is marked by frequent episodes of upper-airway obstruction during sleep. Patients with this syndrome alternate between loud snores or gasps and silent periods that usually last for 20–30 seconds. The snoring is caused by the partial blockage of the airway. The silent periods are caused by complete obstruction of the airway, which makes the patient’s breathing stop.

Obstructive sleep apnea syndrome is also common in children with enlarged tonsils. The symptoms of any breathing-related sleep disorder in children are often subtle and more difficult to diagnose. Children under five are more likely to demonstrate such nighttime symptoms as apnea and breathing difficulties. Children over five are more likely to demonstrate such daytime symptoms as sleepiness and attention difficulties.

Persons with central sleep apnea syndrome experience periods when the oxygenation of blood in the lungs temporarily stops during sleep; but they do not suffer airway obstruction. Although these patients may snore, their snoring is usually mild and not a major complaint.

Central alveolar hypoventilation syndrome is characterized by excessive sleepiness and insomnia.

Demographics

The majority of patients with the obstructive sleep apnea type of breathing-related sleep disorder are overweight, middle-aged males. Adult males are two to four times as likely as adult females to experience obstructive sleep apnea syndrome. Among children the male: female ratio is 1:1.

Central sleep apnea syndrome is most common in the elderly.

Diagnosis

A diagnosis of breathing-related sleep disorder usually requires a thorough physical examination of the patient. The patient may be referred to an otorhinolaryngologist (a doctor who specializes in disorders of the ear, nose, and throat) for a detailed evaluation of the upper respiratory tract. The physical examination is followed by observation of the patient in a sleep clinic or laboratory. Breathing patterns, including episodes of snoring and apnea, are evaluated when the patient is connected to a device called a polysomnogram. The polysomnogram uses a set of electrodes to measure several different body functions associated with sleep, including heart rate, eye movements, brain waves, muscle activity, breathing, changes in blood oxygen concentration, and body position. Interviews are also conducted with the patient and his or her partner.

To meet criteria for the diagnosis of breathing-related sleep disorder, the patient must experience interruptions of sleep leading to insomnia or excessive sleepiness that have been determined to result from one of the following sleep-related breathing conditions: obstructive sleep apnea syndrome; central sleep apnea syndrome; or central alveolar hypoventilation syndrome.

The disturbance in sleep must also not be better accounted for by another mental disorder or by a general medical condition not related to breathing.

The disturbance in sleep must not be due to the direct effects on the body of a prescription medication or drug of abuse.

Treatments

Weight loss is a key to effective treatment of overweight people with breathing-related sleep disorder. It is often considered the first step in treating any disorder involving sleep apnea. Increased exercise and reduced-calorie diets are the most important components of an effective weight loss regimen.

Nasal continuous positive airway pressure therapy, also known as nasal CPAP therapy, is a popular form of treatment for the obstructive sleep apnea subtype of breathing-related sleep disorder. Nasal CPAP therapy, which has been in use since 1981, involves the use of a high-pressure blower that delivers continuous air flow to a mask worn by the patient during sleep. The airflow from the nasal CPAP blower is often very effective in reducing or eliminating sleep apnea episodes. Nasal CPAP treatment is, however, inconvenient and somewhat noisy for anyone who must share a bedroom with the patient. Patients do not always comply with this form of treatment; one study indicated that about 25% of patients who are treated with nasal CPAP therapy stop using it within a year.

Medications for patients with the sleep apnea subtype of breathing-related sleep disorder are most commonly such respiratory stimulants as medroxyprogesterone acetate (Depo-Provera) and acetazolamide (Diamox). Protriptyline (Vivactil), which is a tricyclic antidepressant, is also used for some patients.

Surgery to relieve airway obstruction is increasingly preferred by many patients. If the airway obstruction is related to anatomical structures that are narrowing the airway, surgical reshaping of the soft palate and uvula (a small, conical-shaped piece of tissue attached to the middle of the soft palate) may be performed. Another surgical procedure that is sometimes done in very obese patients with obstructive sleep apnea is a tracheostomy, or an artificial opening made in the windpipe. This operation has a number of unpleasant side effects, however, and so is usually reserved for patients whose breathing related disorder is life-threatening.

Patients with sleep apnea are advised to abstain from alcohol and sedative medications, which are often given to patients who display any type of sleeping irregularities. Alcohol and sedatives often increase the likelihood of upper airway problems during sleep.

Prognosis

Breathing-related sleep disorder often has a gradual long-term progression and a chronic course. For this reason, many people have the disorder for years before seeking treatment. For many, symptoms worsen during middle age, causing people to seek treatment at that point.

Successful treatment of other conditions, such as obesity, cardiac or neurological conditions in the elderly, or enlarged tonsils in children often aids in the treatment of breathing-related sleep disorder. Weight loss often leads to spontaneous resolution of the disorder.

Prevention

Because overweight people are more likely to develop the more common obstructive sleep apnea type of breathing-related sleep disorder, a good preventive measure is effective weight management. Good general health and treatment of related physiological conditions are also effective in preventing the disorder.

Definition

The brain is the part of the central nervous system located in the skull. It controls the mental processes and physical actions of a human being.

Description

The brain, along with the spinal cord and network of nerves, controls information flow throughout the body, voluntary actions such as walking, reading, and talking, and involuntary reactions such as breathing and digestion.

The human brain is a soft, shiny, grayish-white, mushroom-shaped structure. The brain of an average adult weighs about 3 lb (1.4 kg). At birth, the average infant’s brain weighs 13.7 oz (390 g); by age 15, it has nearly reached full adult size. The brain is protected by the skull and a three-layered membrane called the meninges. The brain’s surface is covered with many bright red arteries and bluish veins that penetrate inward. Glucose, oxygen, and certain ions pass easily across the blood-brain barrier into the brain, although other substances, such as antibiotics, do not.

The four principal sections of the human brain are: the brain stem, the diencephalon, the cerebrum (divided into two large paired cerebral hemispheres), and the cerebellum.

The brain stem

The brain stem connects the brain with the spinal cord. Every message transmitted between the brain and spinal cord passes through the medulla oblongata—a part of the brain stem—via nerve fibers. The fibers on the right side of the medulla cross to the left and those on the left cross to the right. As a result, each side of the brain controls the opposite side of the body. The medulla regulates the heartbeat, breathing rate, and blood-vessel diameters; it also helps coordinate swallowing, vomiting, hiccuping, coughing, and sneezing.

Another brain stem component, the pons (meaning “bridge”), conducts messages between the spinal cord and the rest of the brain, and between the different parts of the brain. The midbrain conveys impulses between the cerebral cortex, pons, and spinal cord, and also contains visual and audio reflex centers involving the movement of the eyeballs and head.

Twelve pairs of cranial nerves originate in the underside of the brain, mostly from the brain stem. They leave the skull through openings and extend as peripheral nerves to their destinations. Among these cranial nerves are the olfactory nerves that bring messages about smell and the optic nerves that conduct visual information.

The diencephalon

The diencephalon lies above the brain stem and embodies the thalamus and hypothalamus. The thalamus is an important relay station for sensory information, interpreting sound, smell, taste, pain, pressure, temperature, and touch; it also regulates some emotions and memory. The hypothalamus controls a number of body functions, such as heartbeat and digestion, and helps regulate the endocrine system (hormonal system) and normal body temperature. The hypothalamus signals hunger and thirst, and also helps regulate sleep, anger, and aggression.

The cerebrum

Constituting nearly 90% of the brain’s weight, the cerebrum is divided into specific areas that interpret sensory impulses. For example, spoken and written languages are transmitted to a part of the cerebrum called Wernicke’s area where meaning is constructed. Motor areas control muscle movements. Broca’s area translates thoughts into speech, and coordinates the muscles needed for speaking. Impulses from other motor areas direct hand muscles for writing and eye muscles for physical movement necessary for reading. The cerebrum is divided into left and right hemispheres. A deep fissure separates the two, with the corpus callosum, a large bundle of fibers, connecting them.

By studying patients whose corpora callosa had been destroyed, scientists realized that differences existed between the left and right sides of the cerebral cortex. The left side of the brain functions mainly in speech, logic, writing, and arithmetic. The right side, on the other hand, is more concerned with imagination, art, symbols, and spatial relations. In general, the left half of the brain controls the right side of the body, and vice versa. For most right-handed people (and many left-handed people as well), the left half of the brain is dominant.

The cerebrum’s outer layer, the cerebral cortex, is composed of gray matter, which is made up of nerve cell bodies. About 0.08 in (2 mm) thick with a surface area about 5 sq ft (0.5 sq m), it’s nearly half the size of an office desk. White matter, composed of nerve fibers covered with myelin sheaths, lies beneath the gray matter. During embryonic development, the gray matter grows faster than the white and folds in on itself, giving the brain its characteristic wrinkles, called convolutions, or gyri; the grooves between them are known as sulci.

The cerebellum

The cerebellum is located below the cerebrum and behind the brain stem. It is butterfly-shaped, with the “wings” known as the cerebellar hemispheres; the two halves are connected by the vermis. The cerebellum coordinates many neuromuscular functions, such as balance and coordination. Disorders related to damage of the cerebellum often result in ataxia (problems with coordination), dysarthria (unclear speech resulting from problems controlling the muscles used in speaking), and nystagmus (uncontrollable jerking of the eyeballs). A brain tumor that is relatively common in children known as medulloblastoma grows in the cerebellum.

Studying the brain

Neurons carry information through the nervous system in the form of brief electrical impulses called action potentials. When an impulse reaches the end of an axon, neurotransmitters are released at junctions called synapses. The neurotransmitters are chemicals that bind to receptors on the receiving neurons, triggering the continuation of the impulse. Fifty different neurotransmitters have been discovered since the first was identified in 1920. By studying the chemical effects of neurotransmitters in the brain, scientists have developed treatments for mental disorders and are learning more about how drugs affect the brain.

Scientists once believed that brain cells do not regenerate, thereby making brain injuries and brain diseases untreatable. Since the late 1990s, however, researchers have been testing treatment for such patients with neuron transplants, which introduce nerve tissue into the brain, with promising results. They have also been investigating substances such as nerve growth factor (NGF), which may someday help regenerate nerve tissue.

Computerized brain imaging

Technology provides useful tools for researching the brain and helping patients with brain disorders. An electroencephalogram (EEG) records brain waves, which are produced by electrical activity in the brain. It is obtained by positioning electrodes on the head and amplifying the waves with an electroencephalograph. EEGs are valuable in diagnosing brain diseases such as epilepsy and tumors.

Scientists use three other techniques to study and understand the brain and diagnose disorders:

MAGNETIC RESONANCE IMAGING (MRI). Using a magnetic field to display the living brain at various depths, MRI can produce very clear and detailed pictures of brain structures. These images, which often appear as cross-sectional slices, are obtained by altering the main magnetic field of a specific brain area. MRI is particularly valuable in diagnosing damage to soft tissues, such as areas affected by head trauma or stroke. This is crucial when early diagnosis improves the chances of successful treatment. MRI also reveals tumors and other types of brain lesions.

POSITRON EMISSION TOMOGRAPHY (PET). During this test, a technician injects the patient with a small amount of a substance, such as glucose, that is marked with a radioactive tag. By tracking the radioactive substance as it travels to the brain, physicians can see almost immediately where glucose is consumed in the brain. This indicates brain activity, an important factor in diagnosing epilepsy, Alzheimer’s, or Parkinson’s. PET is also valuable in locating tumors and brain areas that have been affected by a stroke or blood clot.

MAGNETOENCEPHALOGRAPHY (MEG). Magnetoencephalography measures the electromagnetic fields created between neurons as electrochemical information is passed along. Of all brain-scanning methods, MEG provides the most accurate indicator of nerve cell activity, which can be measured in milliseconds. By combining an MRI with MEG, clinicians can get a noninvasive look at the brain that is especially useful in diagnosing epilepsy or migraines, for example. MEG also helps identify specific brain areas involved with different tasks. Any movement by the patient—wiggling the toes, for example—appears on the computer screen immediately as concentric colored rings. This pinpoints brain signals even before the toes are actually wiggled. Researchers foresee that these techniques could someday help paralysis victims move by supplying information on how to stimulate their muscles or indicating the signals needed to control an artificial limb.

Definition

Bodywork therapies is a general term that refers to a group of body-based approaches to treatment that emphasize manipulation and realignment of the body’s structure in order to improve its function as well as the client’s mental outlook. These therapies typically combine a relatively passive phase, in which the client receives deep-tissue bodywork or postural correction from an experienced instructor or practitioner, and a more active period of movement education, in which the client practices sitting, standing, and moving about with better alignment of the body and greater ease of motion.

Bodywork should not be equated with massage simply speaking. Massage therapy is one form of bodywork, but in massage therapy, the practitioner uses oil or lotion to reduce the friction between his or her hands and the client’s skin. In most forms of body work, little if any lubrication is used, as the goal of this type of hands-on treatment is to warm, relax and stretch the fascia (a band or sheath of connective tissue that covers, supports, or connects the muscles and the internal organs) and underlying layers of tissue.

Purpose

The purpose of bodywork therapy is the correction of problems in the client’s overall posture, connective tissue, and/or musculature in order to bring about greater ease of movement, less discomfort, and a higher level of energy in daily activity. Some forms of bodywork have as a secondary purpose the healing or prevention of repetitive stress injuries, particularly for people whose occupations require intensive use of specific parts of the body (such as dancers, musicians, professional athletes, opera singers, etc.) Bodywork may also heal or prevent specific musculoskeletal problems, such as lower back pain or neck pain.

Bodywork therapies are holistic in that they stress increased self-awareness and intelligent use of one’s body as one of the goals of treatment. Some of these therapies use verbal discussion, visualization or guided imagery along with movement education to help clients break old patterns of moving and feeling. Although most bodywork therapists do not address mental disorders directly in their work with clients, they are often knowledgeable about the applications of bodywork to such specific emotions as depession, anger, or fear.

Although some bodywork therapies, such as Rolfing or Hellerwork, offer programs structured around a specific number or sequence of lessons, all therapies of this type emphasize individualized treatment and respect for the uniqueness of each individual’s body. Bodywork instructors or practitioners typically work with clients on a one-to-one basis, as distinct from a group or classroom approach.

Precautions

Persons who are seriously ill, acutely feverish, or suffering from a contagious infection should wait until they have recovered before beginning a course of bodywork. As a rule, types of bodywork that involve intensive manipulation or stretching of the deeper layers of body tissue are not suitable for persons who have undergone recent surgery or have recently suffered severe injury. In the case of Tragerwork, shiatsu, and trigger point therapy, clients should inform the therapist of any open wounds, bruises, or fractures so that the affected part of the body can be avoided during treatment. Craniosacral therapy, the Feldenkrais method, and the Alexander technique involve gentle touch and do not require any special precautions.

Persons who are recovering from abuse or receiving treatment for any post-traumatic syndrome or dissociative disorder should consult their therapist before undertaking bodywork. Although bodywork is frequently recommended as an adjunctive treatment for these disorders, it can also trigger flashbacks if the bodywork therapist touches a part of the patient’s body associated with the abuse or trauma. Many bodywork therapists, however, are well informed about post-traumatic symptoms and disorders, and able to adjust their treatments accordingly.

Description

The following are brief descriptions of some of the more popular bodywork therapies.

Alexander technique

The Alexander technique was developed by an Australian actor named F. Matthias Alexander (1869-1955), who had voice problems that were not helped by any available medical treatments. Alexander decided to set up a number of mirrors so that he could watch himself during a performance from different angles. He found that he was holding his head and neck too far forward, and that these unconscious patterns were the source of the tension in his body that was harming his voice. He then developed a method for teaching others to observe the patterns of tension and stress in their posture and movement, and to correct these patterns with a combination of hands-on guidance and visualization exercises. As of 2002, the Alexander technique is included in the curricula of the Juilliard School of Music and many other drama and music schools around the world, because performing artists are particularly vulnerable to repetitive stress injuries if they hold or move their bodies incorrectly.

In an Alexander technique session, the client works one-on-one with an instructor who uses verbal explanations as well as guided movement. The sessions are usually referred to as “explorations” and last about 30 minutes. Although most clients see positive changes after only two or three sessions, teachers of the technique recommend a course of 20–30 sessions so that new movement skills can be learned and changes maintained.

Rolfing

Rolfing, which is also called Rolf therapy or structural integration, is a holistic system of bodywork that uses deep manipulation of the body’s soft tissue to realign and balance the body’s myofascial (muscular and connective tissue) structure. It was developed by Ida Rolf (1896-1979), a biochemist who became interested in the structure of the human body after an accident damaged her health. She studied with an osteopath as well as with practitioners of other forms of alternative medicine, and developed her own technique of body movement that she called structural integration. Rolfing is an approach that seeks to counteract the effects of gravity, which tends to pull the body out of alignment over time and cause the connective tissues to stiffen and contract.

Rolfing treatment begins with the so-called “Basic Ten,” a series of ten sessions each lasting 60–90 minutes, spaced a week or longer apart. After a period of integration, the client may undertake advanced treatment sessions. “Tune-up” sessions are recommended every six months. In Rolfing sessions, the practitioner uses his or her fingers, hands, knuckles, or elbows to rework the connective tissue over the client’s entire body. The deep tissues are worked until they become pliable, which allows the muscles to lengthen and return to their proper alignment. Rolfing treatments are done on a massage table, with the client wearing only undergarments.

Hellerwork

Hellerwork is a bodywork therapy developed by Joseph Heller, a former NASA engineer who became a certified Rolfer in 1972 and started his own version of structural integration, called Hellerwork, in 1979. Heller describes his program as “a powerful system of somatic education and structural bodywork” based on a series of eleven sessions. Hellerwork is somewhat similar to Rolfing in that it begins with manipulation of the deep tissues of the body. Heller, however, decided that physical realignment of the body by itself is insufficient, so he extended his system to include movement education and “self-awareness facilitated through dialogue.”

The bodywork aspect of Hellerwork is intended to release the tension that exists in the fascia, which is the sheath or layer of connective tissue that covers, supports, or connects the muscles and internal organs of the body. Fascia is flexible and moist in its normal state, but the effects of gravity and ongoing physical stresses lead to misalignments that cause the fascia to become stiff and rigid. The first hour of a Hellerwork session is devoted to deep connective tissue bodywork in which the Hellerwork practitioner uses his or her hands to release tension in the client’s fascia. The bodywork is followed by movement education, which includes the use of video feedback to help clients learn movement patterns that will help to keep their bodies in proper alignment. The third component of Hellerwork is verbal dialogue, which is intended to help clients become more aware of the relationships between their emotions and attitudes and their body.

Tragerwork

Trager psychophysical integration, which is often called simply Tragerwork, was developed by Milton Trager (1908-1977), a man who was born with a spinal deformity and earned a medical degree in his middle age after working out an approach to healing chronic pain. Tragerwork is based on the theory that many illnesses are caused by tension patterns that are held in the unconscious mind as much as in the tissues of the body; clients are advised to think of Tragerwork sessions as “learning experiences” rather than “treatments.” Tragerwork sessions are divided into bodywork, which is referred to as tablework, and an exercise period. Trager practitioners use their hands during tablework to perform a variety of gentle motions—rocking, shaking, vibrating, and gentle stretching—intended to help the client release their patterns of tension by experiencing how it feels to move freely and effortlessly on one’s own. Following the tablework, clients are taught how to perform simple dance-like exercises called Mentastics, for practice at home. Tragerwork sessions take between 60–90 minutes, while clients are advised to spent 10–15 minutes three times a day doing the Mentastics exercises.

Feldenkrais method

The Feldenkrais method, like Hellerwork, refers to its approach as “somatic education.” Developed by Moshe Feldenkrais (1904-1984), a scientist and engineer who was also a judo instructor, the Feldenkrais method consists of two major applications— Awareness Through Movement (ATM) lessons, a set of verbally directed exercise lessons intended to engage the client’s intelligence as well as physical perception; and Functional Integration (FI), in which a Feldenkrais practitioner works with the client one-on-one, guiding him or her through a series of movements that alter habitual patterns and convey new learning directly to the neuromuscular system. Functional Integration is done with the client fully clothed, lying or sitting on a low padded table.

Perhaps the most distinctive feature of the Feldenkrais method is its emphasis on new patterns of thinking, attention, cognition, and imagination as byproducts of new patterns of physical movement. It is the most intellectually oriented of the various bodywork therapies, and has been described by one observer as “an unusual melding of motor development, biomechanics, psychology, and martial arts.” The Feldenkrais method is the form of bodywork that has been most extensively studied by mainstream medical researchers.

Trigger point therapy

Trigger point therapy, which is sometimes called myotherapy, is a treatment for pain relief in the musculoskeletal system based on the application of pressure to trigger points in the client’s body. Trigger points are defined as hypersensitive spots or areas in the muscles that cause pain when subjected to stress, whether the stress is an occupational injury, a disease, or emotional stress. Trigger points are not necessarily in the same location where the client feels pain.

Myotherapy is a two-step process. In the first step, the therapist locates the client’s trigger points and applies pressure to them. This step relieves pain and also relaxes the muscles associated with it. In the second part of the therapy session, the client learns a series of exercises that progressively stretch the muscles that have been relaxed by the therapist’s pressure. Most clients need fewer than 10 sessions to benefit from myotherapy. One distinctive feature of trigger point therapy is that clients are asked to bring a relative or trusted friend to learn the pressure technique and the client’s personal trigger points. This “buddy system” helps the client to maintain the benefits of the therapy in the event of a relapse.

Shiatsu

Shiatsu is the oldest form of bodywork therapy, having been practiced for centuries in Japan as part of traditional medical practice. As of 2002, it is also the type of bodywork most commonly requested by clients in Western countries as well as in East Asia. The word shiatsu itself is a combination of two Japanese words that mean “pressure” and “finger.” Shiatsu resembles acupuncture in its use of the basic concepts of ki, the vital energy that flows throughout the body, and the meridians, or 12 major pathways that channel ki to the various organs of the body. In Asian terms, shiatsu works by unblocking and rebalancing the distribution of ki in the body. In the categories of Western medicine, shiatsu may stimulate the release of endorphins, which are chemical compounds that block the receptors in the brain that perceive pain.

A shiatsu treatment begins with the practitioner’s assessment of the client’s basic state of health, including posture, vocal tone, complexion color, and condition of hair. This evaluation is used together with ongoing information about the client’s energy level gained through the actual bodywork. The shiatsu practitioner works with the client lying fully clothed on a futon. The practitioner seeks out the meridians in the client’s body through finger pressure, and stimulates points along the meridians known as tsubos. The tsubos are centers of high energy where the ki tends to collect. Pressure on the tsubos results in a release of energy that rebalances the energy level throughout the body.

Craniosacral therapy

Craniosacral therapy, or CST, is a form of treatment that originated with William Sutherland, an American osteopath of the 1930s who theorized that the manipulative techniques that osteopaths were taught could be applied to the skull. Sutherland knew from his medical training that the skull is not a single piece of bone, but consists of several bones that meet at seams; and that the cerebrospinal fluid that bathes the brain and spinal cord has a natural rise-and-fall rhythm. Sutherland experimented with gentle manipulation of the skull in order to correct imbalances in the distribution of the cerebrospinal fluid. Contemporary craniosacral therapists practice manipulation not only of the skull, but of the meningeal membranes that cover the brain and the spinal cord, and sometimes of the facial bones. Many practitioners of CST are also osteopaths, or DOs.

In CST, the patient lies on a massage table while the therapist gently palpates, or presses, the skull and spine. If the practitioner is also an osteopath, he or she will take a complete medical history as well. The therapist also “listens” to the cranial rhythmic impulse, or rhythmic pulsation of the cerebrospinal fluid, with his or her hands. Interruptions of the normal flow by abnormalities caused by tension or by injuries are diagnostic clues to the practitioner. Once he or she has identified the cause of the abnormal rhythm, the skull and spinal column are gently manipulated to restore the natural rhythm of the cranial impulse. Craniosacral therapy appears to be particularly useful in treating physical disorders of the head, including migraine headaches, ringing in the ears, sinus problems, and injuries of the head, neck, and spine. In addition, patients rarely require extended periods of CST treatments.

Preparation

Bodywork usually requires little preparation on the client’s or patient’s part, except for partial undressing for Rolfing, trigger point therapy, and Hellerwork.

Aftercare

Aftercare for shiatsu, trigger point therapy, and craniosacral therapy involves a brief period of rest after the treatment.

Some bodywork approaches involve various types of long-term aftercare. Rolfing clients return for advanced treatments or tune-ups after a period of integrating the changes in their bodies resulting frm the Basic Ten sessions. Tragerwork clients are taught Mentastics exercises to be done at home. The Alexander technique and the Feldenkrais approach assume that clients will continue to practice their movement and postural changes for the rest of their lives. Trigger point therapy clients are asked to involve friends or relatives who can help them maintain the benefits of the therapy after the treatment sessions are over.

Risks

The deep tissue massage and manipulation in Rolfing and Hellerwork are uncomfortable for many people, particularly the first few sessions. There are, however, no serious risks of physical injury from any form of bodywork that is administered by a trained practitioner of the specific treatment. As mentioned, however, bodywork therapies that involve intensive manipulation or stretching of the deeper layers of body tissue are not suitable for persons who have undergone recent surgery or have recently suffered severe injury.

Normal results

Normal results from bodywork include deep relaxation, improved posture, greater ease and spontaneity of movement, greater range of motion for certain joints, greater understanding of the structures and functions of the body and their relationship to emotions, and release of negative emotions.

Many persons also report healing or improvement of specific conditions, including migraine headaches, repetitive stress injuries, osteoarthritis, insomnia, sprains and bruises, sports injuries, stress-related illnesses, sciatica, postpregnancy problems, menstrual cramps, temporomandibular joint disorders, lower back pain, whiplash injuries, disorders of the immune system, asthma, depression, digestive problems, chronic fatigue, and painful scar tissue. The Alexander technique has been reported to ease the process of childbirth by improving the mother’s postural alignment prior to delivery.

Some studies of the Feldenkrais method have found that its positive effects on subjects’ self-esteem, mood, and anxiety sympoms are more significant than its effects on body function.

Abnormal results

Abnormal results from bodywork therapies would include serious physical injury or trauma-based psychological reactions.; Acupuncture; Energy therapies

Definition

Body dysmorphic disorder (BDD) is defined by the DSM-IV-TR(a handbook for mental health professionals) as a condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body. The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient’s social, occupational, or educational functioning. The most common cause of this decline is the time lost in obsessing about the “defect.” The DSM-IV-TRassigns BDD to the larger category of somatoform disorders, which are disorders characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.

Although cases of BDD have been reported in the psychiatric literature from a number of different countries for over a century, the disorder was first defined as a formal diagnostic category by the DSM-III-Rin 1987. The word dysmorphiccomes from two Greek words, dysthat means “bad,” or “ugly;” and, morphos,that means “shape,” or “form.” BDD was previously known as dysmorphophobia.

Description

BDD is characterized by an unusually exaggerated degree of worry or concern about a specific part of the face or body, rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa, to the extent that patients with these disorders are preoccupied with their overall weight and body shape. For example, an adolescent who thinks that her breasts are too large and wants to have plastic surgery to reduce their size but is otherwise unconcerned about her weight and is eating normally would be diagnosed with BDD, not anorexia or bulimia. As many as 50% of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects.

Since the publication of DSM-IVin 1994, some psychiatrists have suggested that a subtype of BDD exists, which they term muscle dysmorphia. Muscle dysmorphia is marked by excessive concern with one’s muscularity and/or fitness. Persons with muscle dysmorphia spend unusual amounts of time working out in gyms or exercising rather than dieting obsessively or looking into plastic surgery. Although gender stereotypes would suggest that women are more likely to develop BDD while men are more vulnerable to developing muscle dysmorphia, surveys indicate that both disorders have approximately equal gender ratios. DSM-IV-TRhas additional references regarding body build and excessive weight lifting to DSM-IV’s description of BDD to accommodate muscle dysmorphia.

BDD and muscle dysmorphia can both be described as disorders resulting from the patient’s distorted body image. Body image refers to the mental picture individuala have of their outward appearance, including size, shape, and form. It has two major components: how the people perceive their physical appearance, and how they feel about their body. Significant distortions in self-perception can lead to intense dissatisfaction with one’s body and dysfunctional behaviors aimed at improving one’s appearance. Some patients with BDD are aware that their concerns are excessive; others do not have this degree of insight. About 50% of patients diagnosed with BDD also meet the criteria for a delusional disorder, which is characterized by beliefs that are not based in reality.

The usual age of onset of BDD is late childhood or early adolescence; the average age of patients diagnosed with the disorder is 17. Ironically, even though BDD begins in childhood or adolescence, most research and treatment studies to date have been done on adults aged 35 and older.

BDD has a high rate of comorbidity, which means that people diagnosed with the disorder are highly likely to have been diagnosed with another psychiatric disorder— most commonly major depression, social phobia, or obsessive-compulsive disorder(OCD).

Causes and symptoms

Causes

The causes of BDD fall into two major categories, neurobiological and psychosocial.

NEUROBIOLOGICAL CAUSES. Research indicates that patients diagnosed with BDD have serotonin levels that are lower than normal. Serotonin is a neurotransmitter— a chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells. Low serotonin levels are associated with depression and other mood disorders.

PSYCHOSOCIAL CAUSES. Another important factor in the development of BDD is the influence of the mass media in developed countries, particularly the role of advertising in spreading images of physically “perfect” men and women. Impressionable children and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.

A young person’s family of origin also has a powerful influence on his or her vulnerability to BDD. Children whose parents are themselves obsessed with appearance, dieting, and/or bodybuilding; or who are highly critical of their children’s looks, are at greater risk of developing BDD.

An additional factor in some young people is a history of childhood trauma or abuse. Buried feelings about the abuse or traumatic incident emerge in the form of obsession about a part of the face or body. This “reassignment” of emotions from the unacknowledged true cause to another issue is called displacement. For example, an adolescent who frequently felt overwhelmed in childhood by physically abusive parents may develop a preoccupation at the high school level with muscular strength and power.

Symptoms

The central symptom of BDD is excessive concern with a specific facial feature or body part. Research done in the United Kingdom and the United States indicates that the features most likely to be the focus of the patient’s attention are (in order of frequency) complexion flaws (acne, blemishes, scars, wrinkles); hair (on the head or the body, too much or too little); and facial features (size, shape, or lack of symmetry). The patient’s concerns may, however, involve other body parts, and may shift over time from one feature to another.

Other symptoms of body dysmorphic disorder include:

• Ritualistic behavior. Ritualistic behavior refers to actions that the patient performs to manage anxiety and that take up excessive amounts of his or her time. Patients are typically upset if someone or something interferes with or interrupts their ritual. In the context of BDD, ritualistic behaviors may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, etc.
• Camouflaging the “problem” feature or body part with makeup, hats, or clothing. Camouflaging appears to be the single most common symptom among patients with BDD; it is reported by 94%.
• Abnormal behavior around mirrors, car bumpers, large windows, or similar reflecting surfaces. A majority of patients diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A minority, however, react in the opposite fashion and avoid mirrors whenever possible.
• Frequent requests for reassurance from others about their appearance.
• Frequently comparing one’s appearance to others.
• Avoiding activities outside the home, including school and social events.

The loss of functioning resulting from BDD can have serious consequences for the patient’s future. Adolescents with BDD often cut school and may be reluctant to participate in sports, join church- or civic-sponsored youth groups, or hold part-time or summer jobs. Adults with muscle dysmorphia have been known to turn down job promotions in order to have more time to work out in their gym or fitness center. Economic consequences of BDD also include overspending on cosmetics, clothing, or plastic surgery.

Demographics

As was mentioned earlier, BDD is primarily a disorder of young people. Its true incidence in the general population is unknown; however, it has been diagnosed in 1.9% of nonclinical patients and 12% of psychiatric outpatients. The DSM-IV-TRgives a range of 5%–40% for patients in clinical mental health settings diagnosed with anxiety or depressive disorders to be diagnosed with BDD. One community study published in 2001 found that 0.7% of women between the ages of 36 and 44 met the criteria for BDD. The disorder appears to be equally common in men and women.

As a result of gaps in research, little is known as of 2002 about the lifetime course of BDD or its prevalence in different ethnic or racial groups. The majority of patients in research studies to date have been Caucasians, but it is not clear whether this reflects racial patterns in the wider society or whether it represents referral bias, in that most study subjects are patients in private psychiatric hospitals. Anecdotal evidence, however, indicates that Asian Americans and African Americans with BDD are more likely to obsess about facial features or skin color that conflict with appearance ideals that dominate the mass media and have been derived from Caucasian people. Information through research done on the history of the American cosmetics industry reveals the startling statistic that African Americans spend three to five times as much money on personal care products as Caucasian Americans. In add