Mental disorders caused by a medical condition 9781422289891, 1422289893

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Jeff’s family and friends described him as “good-looking,” “fun-loving,” “quick-witted,” and “talented.” He was kind, friendly, ambitious, and always succeeded at every task he undertook. No one was surprised when Jeff was selected to represent his school in an international exchange program. But when Jeff returned to Ridgemont High a year later, everyone was shocked at his change in behavior. Why was Jeff so angry and out of control? Could it have something to do with his health? Many medical conditions have serious psychological components and effects. Sometimes, a medical condition in the body can lead to medical disorders of the mind. These are called mental disorders due to a medical condition. Adolescents are among those who suffer from medical conditions, and they are not immune to the accompanying psychological issues that may be involved. But mental disorders caused by medical conditions bring additional challenges to adolescents. Everyday care, management, regulating medication, and the emotional ramifications of medical conditions can be difficult for anyone. Attempting to balance these challenges while maintaining schoolwork, jobs, and extra-curricular activities can add to the stress for young people. In this book, you will learn about some medical disorders, the psychological complications that can result, and the treatments available to fight them. Along the way, you will explore the advances in drug treatment for psychological disorders, how such drugs work, and the risks and side effects associated with these treatments. Numerous case studies and stories of young people like Jeff who are coping with mental disorders caused by medical conditions illustrate the realities of these illnesses, while a chapter on alternative treatment adds information about additional treatment options.

BE SURE TO READ OTHER BOOKS IN THIS SERIES

EAN

ISBN 978-1-4222-2828-9

9 781422 228289

90000

Mental Disorders Due to a Medical Condition

The State of Mental Illness and Its Therapy Adjustment Disorders Anxiety Disorders Cognitive Disorders Childhood & Adolescent Disorders Dissociative Disorders Eating Disorders Impulse-Control Disorders Mental Disorders Due to a Medical Condition Mood Disorders Obsessive-Compulsive Disorder Personality Disorders Postpartum Disorders Premenstrual Disorders Psychosomatic Disorders Schizophrenia Sexual Disorders Sleep Disorders Substance-Related Disorders The FDA & Psychiatric Drugs: How a Drug Is Approved

The State of Mental Illness and Its Therapy

Mental Disorders Due to a Medical Condition

joyce libal

Mason Crest

Mason Crest 450 Parkway Drive, Suite D Broomall, PA 19008 www.masoncrest.com Copyright © 2014 by Mason Crest, an imprint of National Highlights, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, taping or any information storage and retrieval system, without permission from the publisher. Printed in the Hashemite Kingdom of Jordan. First printing 987654321 Series ISBN: 978-1-4222-2819-7 ISBN: 978-1-4222-2828-9 ebook ISBN: 978-1-4222-8989-1 The Library of Congress has cataloged the hardcopy format(s) as follows: Library of Congress Cataloging-in-Publication Data Libal, Joyce. [Drug therapy for mental disorders caused by a medical condition] Mental disorders caused by a medical condition / Joyce Libal. pages cm. – (The state of mental illness and its therapy) Audience: Age 12. Audience: Grade 7 to 8. Revision of: Drug therapy for mental disorders caused by a medical condition. 2004. Includes bibliographical references and index. ISBN 978-1-4222-2828-9 (hardcover) – ISBN 978-1-4222-2819-7 (series) – ISBN 978-1-4222-8989-1 (ebook) 1. Psychological manifestations of general diseases–Chemotherapy–Juvenile literature. I. Title. RC455.4.B5.L53 2014 616.89’18–dc23 2013008258 Produced by Vestal Creative Services. www.vestalcreative.com This book is meant to educate and should not be used as an alternative to appropriate medical care. Its creators have made every effort to ensure that the information presented is accurate—but it is not intended to substitute for the help and services of trained professionals. Picture Credits: Artville: pp. 14, 64, 66, 68, 69, 82, 85, 108, 110, 112, 116. Benjamin Stewart: pp. 24, 36, 37, 102. Comstock: pp. 42, 45, 46, 78, 96, 103. Corbis: pp. 18, 22, 29, 38, 40, 70, 114, 120. Digivision: p. 33. Image Source: p. 49. Lightpoet | Dreamstime.com : p. 51. PhotoAlto: pp. 41, 63. PhotoDisc: pp. 20, 21, 26, 27, 30, 58, 61, 65, 84, 98, 99, 100, 104, 106. Quigman’s: pp. 12, 16, 17. Roman Blagovirny: pp. 91, 93, 94. Stockbyte: pp. 10, 113. The individuals in these images are models, and the images are for illustrative purposes only. To the best knowledge of the publisher, all other images are in the public domain. If any image has been inadvertantly uncredited or miscredited, please notify Vestal Creative Services, Vestal, New York 13850, so that rectification can be made for future printings.

Contents Introduction

7

Foreword

9

1. Defining the Disorders

11

2. How the Brain Works

25

3. The History of Drug Treatment and How Some Drugs Work

39

4. More Treatment Descriptions

59

5. Case Studies

79

6. Risks and Side Effects

97

7. Alternative and Supplementary Treatments

107

Further Reading

124

For More Information

125

Index

127

About the Author & Consultants

128

Introduction

T

by Mary Ann McDonnell

eenagers have reason to be interested in psychiatric disorders and their treatment. Friends, family members, and even teens themselves may experience one of these disorders. Using scenarios adolescents will understand, this series explains various psychiatric disorders and the drugs that treat them. Diagnosis and treatment of psychiatric disorders in children between six and eighteen years old are well studied and documented in the scientific journals. A paper appearing in the Journal of the American Academy of Child and Adolescent Psychiatry in 2010 estimated that 49.5 percent of all adolescents aged 13 to 18 were affected by at least one psychiatric disorder. Various other studies have reported similar findings. Needless to say, many children and adolescents are suffering from psychiatric disorders and are in need of treatment. Many children have more than one psychiatric disorder, which complicates their diagnoses and treatment plans. Psychiatric disorders often occur together. For instance, a person with a sleep disorder may also be depressed; a teenager with attention-deficit/hyperactivity disorder (ADHD) may also have a substance-use disorder. In psychiatry, we call this comorbidity. Much research addressing this issue has led to improved diagnosis and treatment. The most common child and adolescent psychiatric disorders are anxiety disorders, depressive disorders, and ADHD. Sleep disorders, sexual disorders, eating disorders, substance-abuse disorders, and psychotic disorders are also quite common. This series has volumes that address each of these disorders. Major depressive disorders have been the most commonly diagnosed mood disorders for children and adolescents. Researchers don’t agree as to how common mania and bipolar disorder are in children. Some experts believe that manic episodes in children and

7

adolescents are underdiagnosed. Many times, a mood disturbance may co-occur with another psychiatric disorder. For instance, children with ADHD may also be depressed. ADHD is just one psychiatric disorder that is a major health concern for children, adolescents, and adults. Studies of ADHD have reported prevalence rates among children that range from two to 12 percent. Failure to understand or seek treatment for psychiatric disorders puts children and young adults at risk of developing substance-use disorders. For example, recent research indicates that those with ADHD who were treated with medication were 85 percent less likely to develop a substance-use disorder. Results like these emphasize the importance of timely diagnosis and treatment. Early diagnosis and treatment may prevent these children from developing further psychological problems. Books like those in this series provide important information, a vital first step toward increased awareness of psychological disorders; knowledge and understanding can shed light on even the most difficult subject. These books should never, however, be viewed as a substitute for professional consultation. Psychiatric testing and an evaluation by a licensed professional are recommended to determine the needs of the child or adolescent and to establish an appropriate treatment plan.

8

FOREWORD by Donald Esherick

W

e live in a society filled with technology—from computers surfing the Internet to automobiles operating on gas and batteries. In the midst of this advanced society, diseases, illnesses, and medical conditions are treated and often cured with the administration of drugs, many of which were unknown thirty years ago. In the United States, we are fortunate to have an agency, the Food and Drug Administration (FDA), which monitors the development of new drugs and then determines whether the new drugs are safe and effective for use in human beings. When a new drug is developed, a pharmaceutical company usually intends that drug to treat a single disease or family of diseases. The FDA reviews the company’s research to determine if the drug is safe for use in the population at large and if it effectively treats the targeted illnesses. When the FDA finds that the drug is safe and effective, it approves the drug for treating that specific disease or condition. This is called the labeled indication. During the routine use of the drug, the pharmaceutical company and physicians often observe that a drug treats other medical conditions besides what is indicated in the labeling. While the labeling will not include the treatment of the particular condition, a physician can still prescribe the drug to a patient with this disease. This is known as an unlabeled or off-label indication. This series contains information about both the labeled and off-label indications of psychiatric drugs. I have reviewed the books in this series from the perspective of the pharmaceutical industry and the FDA, specifically focusing on the labeled indications, uses, and known side effects of these drugs. Further information can be found on the FDA’s website (www.FDA. gov).

9

Marital can cause problems entire family. ChilA persontension can have many things going for for the him—and then a medidren may havecomes difficulty adjusting to theeverything. constant stress. cal condition along and changes

Chapter One Defining the Disorders

N

o one was surprised when Jeff Turner was selected to represent his school district in an international exchange program. Jeff’s family and friends described him as “good-looking,” “funloving,” “quick-witted,” and “talented.” He was kind, friendly, ambitious, and succeeded at every task he undertook. In the yearbook, he was described by his friends as having the “best personality” of anyone in their class. Everyone was certain that Jeff’s future would be rosy. Colleges sent him information every day, and he was applying for prestigious scholarships. Everything about life felt like it was on track and going his way. So when negative feelings began to descend on him several weeks later, Jeff was confused . . . and scared.

At first Jeff thought his sudden unhappiness and anger were the effects of exhaustion. After all, his life was pretty busy lately. He tried to think back to times in his life when he had felt such negative emotions, but nothing seemed to come close to what he was feeling now. The worst thing he could remember was when, during sophomore year, he had asked Sally Hennessey to the homecoming dance only to discover that she had already agreed to go with Bill Hurley. Jeff ended up going to the dance alone. That hadn’t felt the greatest, but it was nothing compared to the intense disappointment, dread, anger, confusion, and fear that now enveloped him.

A physical illness can make anyone feel like snarling!

12 •

Mental Disorders Due to a Medical Condition

With each passing day, Jeff’s attitude worsened and his foreboding grew. Jeff used to wake with a feeling of vitality and enthusiasm, but now he woke physically exhausted, mentally drained, and emotionally tense. One morning, the alarm clock sounded, and Jeff reacted with extraordinary violence, striking the alarm clock hard, and then flinging it at the wall. Jeff stared blankly at the now silent clock, then rolled onto his side and tried to fall back asleep. Fifteen minutes later, Jeff’s mother knocked on the door. “Jeff, honey, are you okay? You’re going to be late for school.” Jeff covered his head with a pillow as he tried to block out her voice. Sometimes I hate the sound of her voice, Jeff thought. As soon as the words slithered across his brain, Jeff felt embarrassed. “What’s wrong with me?” he whispered. “I’m up,” he called, but the bitterness with which he said it made Jeff’s voice sound foreign even to his own ears. Jeff dragged himself from bed and headed down the hall toward the bathroom. The door was closed and he rapped loudly. “Who’s in here?” “I’ll only be a minute,” his sister replied. “Hurry up, Meredith. You’re always in the bathroom when somebody else needs it.” “I am not,” she replied. “What’s wrong with you? Did you get up on the wrong side of the bed or something?” “Shut up and get out of the bathroom,” shot out of Jeff’s mouth as he kicked the bathroom door. “Jeff,” came his mother’s voice from the kitchen. “It’s not your sister’s fault that you got up late. Take it easy. She’ll be out in a moment.” Jeff’s sour mood lasted as he climbed on the bus and ignored the driver’s greeting. Lately Jeff had taken to sitting alone on the bus and putting his leg up on the seat to discourage anyone from joining him. When the bus came to another abrupt halt, Tom Delaney hopped on board. A cheerful smile lit his face as he stopped by Jeff’s seat and nudged Jeff’s foot with his knee. “Hey buddy, you won’t believe what happened last night.”

Defining the Disorders

• 13

Jeff’s leg refused to move. “I’m not interested,” he grunted. “Fine,” came Tom’s response as he took a seat with Bill Hurley. “Do you believe that? What’s gotten into him?” “Beats me,” Bill responded. “You know, I heard about a guy who went to some African country one time, and while he was there, somehow a worm crawled into his brain. They had to operate to get it out or inject drugs to kill it or something. Maybe that’s it. Maybe old Jeff has a worm in his brain, and it’s making him mean.” The corners of Bill’s mouth curled up in a sneer. “You’re crazy, Bill,” Tom responded. “Jeff didn’t go to Africa, and he doesn’t have a worm in his brain, but there sure is something wrong.”

When a person is unable to control his emotions, sometimes a medical condition is the cause.

14 •

Mental Disorders Due to a Medical Condition

The discussion taking place in the teacher’s lounge had much in common with the conversation on the bus that morning. Jeff had been having trouble concentrating in his classes, and everyone had noticed his new abrupt manner. “Jeff’s just not his old self.” “What could be wrong?” “Do you think someone should talk to him?” “I wonder how he’s doing at home.” “He really acted out in class yesterday. I was shocked. That’s just not Jeff. I’ve been thinking of giving his parents a call.” Meanwhile, Jeff didn’t enjoy a single minute of his day. In fact, he never enjoyed any days any more. He felt like he was under a microscope—like everyone was looking at him and talking about him. A momentary sense of relief washed over him as the final bell sounded, but then he realized that he had to go to football practice. The thought of football practice filled him with dread. When would the horror of this day end? He was sure he overheard Bill Hurley saying his name as he entered the locker room, but everyone became quiet as he opened his locker and changed clothes. Jeff’s feet felt heavy as he walked over to the coach and players standing in the center of the field. Thoughts crowded into his head as the coach ordered them to take a lap around the field. Everyone’s talking about me. Do they think I don’t notice? Do they have to be so obvious about it? I’m not stupid. The coach decided they should play a little offense versus defense. Jeff was on offense and Bill was a defensive player. As Jeff looked across at him, Bill smiled and Jeff thought, I’d like to wipe that phony smile off your face forever. The quarterback called the play, and Jeff stepped back to take the ball. As he began to move forward, Bill’s body met him with a smack, and they both fell to the ground. There was nothing unusual about the play, but what happened next took the entire team by surprise. Bill got up first and put his hand out to help Jeff up. Jeff took Bill’s hand, got up, but then instead of letting go, Jeff gave a violent jerk. As Bill fell forward, Jeff

Defining the Disorders

• 15

Jeff didn’t feel like himself! grabbed his shoulders and shoved hard. Bill was unprepared for the assault, and he fell back like a stone. Shouting insults, Jeff landed full force on him. Jeff’s teammates rushed over, pulled him off Bill, and tried to calm him down. “Jeff,” the coach shouted above the ruckus. “What’s wrong with you? This is uncalled for. You’re done for the day, maybe longer. Get off the field.” Jeff yanked off his helmet and threw it to the ground. Then he turned on his heel and stomped off. The coach decided to call Jeff’s father. By the time Jeff got home, his parents were already aware of what had happened and were waiting for the explanation that he didn’t have for them. Jeff didn’t know why he had done what he did. All he knew was that he was miserable. Now, as if he didn’t feel bad enough already, he had a terrible headache.

16 •

Mental Disorders Due to a Medical Condition

“Bill’s an idiot,” he muttered to his parents. “People should thank me for trying to knock some sense into him. I don’t want to talk about it.” He stumbled to his room. A tear trickled down Jeff’s mother’s cheek. “I’m scared,” she confessed to her husband. “Something’s wrong. What should we do?” “I’m not sure.” Jeff’s father shook his head. “This just isn’t Jeff. I’m really worried, too. I’m going to make an appointment with the school psychologist in the morning. Jeff’s behavior isn’t normal, and we’ve got to help him.” Jeff couldn’t understand why he was filled with anger. He hadn’t been well physically either lately, but now he began to feel really sick. When his mother heard him vomiting in the bathroom the next morning, she made an immediate call to their general practitioner.

A doctor may not have all the answers, but he is a good place to start when a person is not feeling like himself.

Defining the Disorders

• 17

MRIs allow medical practitioners to look inside the brain.

neurologist:

A physician who specializes in treating injuries and diseases of the nervous system.

MRI: Magnetic reso-

nance imaging—a medical test that produces films showing the interior of the body.

18 •

Two hours later, she and her husband were sitting in the waiting room while the doctor examined their son. The doctor had known Jeff for several years and had the same high opinion of him as everyone else. After hearing Jeff describe his aggressive feelings and physical symptoms (he was now noticing a growing weakness in one leg and foot), the doctor called a neurologist.

Mental Disorders Due to a Medical Condition

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) lists three criteria for a mental disorder due to a general medical condition: 1. The medical history, physical examination, or laboratory findings indicate that the psychiatric disturbance is the direct physiological consequence of a medical condition. 2. The psychiatric disturbance cannot be better accounted for by another mental disorder. 3. The psychiatric disturbance does not occur exclusively during delirium.

Jeff’s mother and father couldn’t believe how quickly things were happening. They knew it must be unusual to get an appointment with a neurologist on the same day that you visit the general practitioner and more unusual yet for the neurologist to order an MRI on the same afternoon as a patient’s first visit. But that’s what happened to Jeff. And a few days later, before they knew what hit them, the neurologist was explaining that the change in Jeff’s personality had a biological cause. Jeff’s parents held hands and Jeff’s dad put his arm around Jeff’s shoulders as the doctor informed them that Jeff had a brain tumor. As the tumor became larger, it had begun to exert pressure on parts of the brain. The doctor pointed to the growing mass and explained that it was the reason for Jeff’s change in behavior. Jeff is experiencing personality changes and emotional distress so severe that he needs medical intervention. Many things in our lives can cause emotional distress, and it’s perfectly normal for people to occasionally have negative feelings

Defining the Disorders

• 19

psychiatric disorder: A mental, emotional, or behavioral abnormality.

physiological:

Having to do with the body’s activities or processes.

metabolic: The pro-

cess by which energy is created in the body through chemical changes in cells.

endocrine:

Relating to hormones and/or hormone-secreting glands.

hematological: Hav-

ing to do with blood and blood-forming organs.

genitourinary:

Having to do with genital and urinary functions and organs.

musculoskeletal:

Relating to the muscles and skeleton.

20 •

without clearly understanding the reason for their emotions. Sometimes, however, such feelings can be part of a larger condition known as a psychiatric disorder. We usually think of psychiatric disorders, such as anxiety, depression, and personality disorders, as having psychological causes, but sometimes such mental disorders are caused by physical changes in the body. In the medical field, this type of disorder is called a mental disorder due to a general medical condition. This is what Jeff is experiencing. He is experiencing unnatural aggression as part of a personality disorder triggered by the physical affects of a brain tumor. Mental disorders that result from a medical condition are not caused by depression, anxiety, or any other psychological factors. The most recent volume of the American Psychiatric Association’s diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), explains that these mental disorders are “the direct physiological consequence of a general medical condition.” Many different medical conditions can cause mental disorders including:

Mental Disorders Due to a Medical Condition

• diseases of the nervous system, circulatory system, and respiratory system • tumors • many forms of cancer • nutritional, metabolic, endocrine, hematological, and genitourinary system diseases • diseases of the digestive system • diseases of the eyes, ears, nose, and throat • diseases of the musculoskeletal system and connective tissue • diseases of the skin • diseases of pregnancy, childbirth, and puerperium • infectious diseases • congenital malformations, deformations, and chromosomal abnormalities

puerperium:

The period between childbirth and the return of the uterus to its prepregnancy size.

congenital malformations: A nonhereditary

abnormality that occurs before birth.

HIV:

Human Immunodeficiency Virus—the retrovirus that attacks and disables the immune system causing AIDS (acquired immunodeficiency syndrome).

autoimmune:

Relating to autoantibodies that attack molecules, cells, or tissues of the organism producing them.

Jeff experienced a change in personality, but not all medical conditions that can be responsible for mental disorders do cause personality changes. Changes in personality that are caused by a medical condition are generally attributed to neurological diseases or injuries, infectious diseases (such as HIV), autoimmune diseases (such as lupus) that involve the central nervous system, and some

Defining the Disorders

• 21

A doctor or advanced practice nurse can help patients determine if their psychiatric difficulties are being caused by a medical problem.

22 •

Mental Disorders Due to a Medical Condition

endocrine conditions (hypothyroidism, for example). Personality disorders are only one type of mental disorder that can be caused by medical conditions. Other types include: • catatonic disorder • delirium • dementia • amnesia • psychotic disorder • anxiety disorder • sexual dysfunction • sleep disorder • mood disorder Jeff’s tumor caused personality changes, but depending on their exact location in the brain, tumors can cause any of the mental disorders listed here. The important thing to remember about mental disorders caused by a medical condition is that they are not purely psychological. They are one of the physiological consequences of the person’s medical problem.

hypothyroidism:

A medical condition in which the thyroid gland is underactive.

catatonic disorder: A

condition characterized by a loss of voluntary movement.

delirium: A condition

that can include uncontrolled excitement, uncontrolled speech, confusion, and hallucinations.

dementia:

A condition that includes confusion and deterioration of thought processes.

psychotic disorder: A

condition in which the individual loses contact with reality.

Defining the Disorders

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The human brain is a complicated organ with many parts. When some part of the rest of the body is not functioning correctly, the brain is sometimes affected as well.

Chapter Two How the Brain Works

T

o understand and effectively treat mental disorders due to a general medical condition, scientists need to understand how the brain works and how the brain interacts with the rest of the body. Sometimes people compare the brain to a computer that is running the entire body. Weighing in at about three pounds and only about the size of a large grapefruit, the brain is infinitely more complicated than any computer that has ever been invented. For centuries, human beings have been speculating about the brain and trying to comprehend all its complicated mechanisms and circuitry. Hippocrates was certainly correct back in 430 bce when he

hypothesized: Stated

a theory to provide a possible explanation for something.

postulated: To assert

in a manner that implies truth.

anatomist: Someone who studies the makeup of the body and is skilled in dissection.

hypothesized that the brain is the place where thoughts originate. Aristotle made quite a mistake a hundred years later, however, when he postulated his theory that the brain was designed to cool the blood. Aristotle’s idea held favor for nearly two thousand years, despite the fact that a Greek anatomist had questioned the theory shortly after Aristotle articulated it. The anatomist, named Herophilus, suggested instead that intelligence was housed in the brain. Unfortunately, he was ignored. Real understanding of the functions of the brain did not begin until the middle of the seventeenth century, and study concerning the brain continues to this day.

The spinal cord, part of the central nervous system, is protected by the spine.

26 •

Mental Disorders Due to a Medical Condition

The central nervous system is formed while an embryo is still inside its mother’s body. Isaac Asimov, a well-known twentieth-century scientist and author, said that the bone structure of the human body provided early clues regarding the importance of the brain. The brain is encased in a protective skull. The spinal cord is also protected by bone. You’ll notice that no other part of your body is so protected. Together, the brain and spinal cord make up the central nervous system. In addition to bone, the brain and spinal cord are protected by the meninges (which is composed of three thin membranes) and cerebrospinal fluid (which is found between each of the layers of the meninges). Housed within these protective layers is the most complex, mysterious, and least understood part of the human body. The complicated circuitry in the human brain begins to form before a person is born. When a human being is still a tiny embryo in the mother’s womb, some of the embryo’s cells begin multiplying, dividing, and forming a neural tube. The upper end of the tube soon

How the Brain Works

• 27

neuroscientists:

grows larger and a cavity forms within it. This part of the neural tube eventually People who study develops and houses the brain, and the the nervous remainder of the neural tube develops system. into a spinal cord. hemispheres: The The cerebrospinal fluid that surhalves of a threerounds the brain also begins developing dimensional circle before birth. When describing what the human brain looks like, many people (such as the brain) have compared its wrinkled surface to a that has been dividshelled walnut. The fact that the brain ed in two. is wrinkled means it has more surface area than if it were smooth. The ridges of this wrinkled surface are called gyri and the valleys are called sulci. As the brain forms, it begins to split into several interconnected parts. The basic parts can be divided into the forebrain, midbrain, and hindbrain. Even though neuroscientists have been studying the brain intensively for decades, much about what the various parts of the brain do and how they interconnect and communicate with each other remains unknown. However, there have been many advances in the field of neuroscience during the past decades, and scientists can now speak with a fair amount of certainty about many general aspects of the brain. The forebrain has two hemispheres. The left hemisphere and a right hemisphere are divided by a deep groove called the cerebral fissure. Though separated by the cerebral fissure, the two hemispheres remain connected through a group of nerves called the cor-

If you could open up the wrinkled cortex of a human brain and lay it flat, it would cover approximately 11⁄2 square feet.

28 •

Mental Disorders Due to a Medical Condition

The brain looks a little like a walnut.

How the Brain Works

• 29

pus callosum. The corpus callosum allows information to be transmitted from one hemisphere to the other. At first glance, you might assume that the hemispheres are mirror images of each other, but in fact, each hemisphere has been assigned different duties. Interestingly, the left hemisphere controls the right neurons: Cells that side of the body, and the right hemiconduct impulses in sphere takes charge of the left side of the central nervous the body. system. Taken together, the right and left hemispheres compose the cerebrum, which is the largest area of the brain. The wrinkled outer covering of the cerebrum is called the cortex. More than 70 percent of the neurons of the central nervous system are located here. The cerebrum is like the central processing unit in your brain “computer.” It accepts input coming from all parts of the body and

MRIs show various details of the brain’s structure.

30 •

Mental Disorders Due to a Medical Condition

Brain Questions 1. How much cerebrospinal fluid does the brain produce each day? 2. What eventually happens to all of the cerebrospinal fluid that is produced? Answers 1. One pint 2. It is absorbed by the body.

directs thought, movement, and various other processes like learning and reasoning. Emotions and memory are also located here. Each hemisphere is further divided into four lobes. The frontal lobes are closest to the front of your head, followed by temporal lobes above the ear on each side of your head, parietal lobes just behind the top of your head and reaching from about one ear to the other (behind the fontal lobes and above the temporal lobes), and occipital lobes at the back of your head. The frontal lobes control a person’s personality. Thinking and memory are also centered here, along with some aspects of speech and movement. Speech does not originate exclusively from the frontal lobes. It is also under the direction of the temporal lobes, as are hearing, language, and more aspects of memory. An awareness of time and depth perception are also found here. It is believed that the temporal lobes process information from various senses and that this in turn makes possible complex thoughts and actions. As we think about the functions of these different lobes, we begin to see how complicated the interactions of the different parts of the brain are. We must remember that scientists are still learning about the brain and do not fully understand all of its functions.

How the Brain Works

• 31

Symptoms of a tumor or brain injury located in the cerebrum might include:

Many structures are located inside of the brain. The limbic system is found deep in the cePersonality change rebrum and below the Forgetfulness temporal lobes. This part of the brain is called the Speech problems visceral core. Excitement, Vision problems social behavior, aggresHeadache sion, and recent memory Seizure are all found here. This Weakness or paralysis of deep area of the brain is arms or legs also part of the cerebral hemispheres, so there are actually two of each brain structure found in the limbic system, one on each side of the brain. The diencephalon, composed of the pineal gland, thalamus, and hypothalamus, is also located within the visceral core brain, although this area is not considered to be part of the limbic system. With the exception of smell, all sensory information travels through the thalamus en route to the forebrain. For this reason, people sometimes compare the thalamus to a transportation terminal. For example, one area of the thalamus relays information from the ears to the proper area of the cerebrum, and another area transports visual signals coming from the retina. The hypothalamus (hypo means under, so this organ is found under the thalamus) is in control of the pituitary gland. The pituitary gland hangs beneath the hypothalamus and is the “command center” for the endocrine system. Various hormones are manufactured and utilized here. The hypothalamus has other duties, such as the management of blood pressure, body temperature, muscle contractions, hunger, and digestion. It also plays a role in emotions. More mystery surrounds the pineal gland, but it is known to play a role in biological cycles, including reproduction. Taste, temperature, touch, and pain are processed in the parietal lobes. Your ability to do arithmetic is determined by the

32 •

Mental Disorders Due to a Medical Condition

We are able to daydream about happy memories because of the frontal lobes of our brains.

How the Brain Works

• 33

parietal lobes as well, and they are also involved with language. Some aspects of hearing, memory, movement, and vision take place here too, but the visual center of the brain is located in the occipital lobes. The occipital lobes receive information from the eyes through the optic nerves and then sends it on to the temporal lobes for further processing. Sitting above the spinal cord, at the back of the brain (in the hindbrain), is the posterior fossa, or infratentorium. The posterior fossa is composed of three parts: brain stem, cerebellum (sometimes referred to as the little brain), and fourth ventricle (a compartment filled with spinal fluid that is located between the cerebellum and brainstem). The brain stem is the source of twelve cranial nerves, which control neck and shoulder movement along with other activities described under the various brain stem parts. Some people have compared the brain stem to a highway, because messages going be-

Our brains function because of messages being sent between neurons.

34 •

Mental Disorders Due to a Medical Condition

Many Latin and Greek words were

tween the brain and the used to name parts of the brain. Here remainder of the huare their literal definitions. man body pass through it. The brain stem is dicortex = bark vided into three parts: hippocampus = sea horse medulla, pons, and the amygdala = almond midbrain. The medulla pons = bridge is in charge of blood thalamus = chamber pressure, heart rate, swallowing, and breathing. The pons provides the link between the cerebrum and the cerebellum. It is in charge of facial and eye movement and plays a role in sleeping and waking. The midbrain is also involved in sleeping and waking. Additionally, it processes hearing and vision. Also located within the brain stem is the reticular activating system. This important group of cells keeps the brain “awake” even when the person is sleeping. The cerebrum makes some people think of a little brain because its wrinkles and lobes make it look like a small ­version of the cerebellum. The cerebrum helps control movement, posture, and equilibrium. It processes the information coming from muscles, tendons, and joints. “Controlling” movement does not mean simply to propel and activate the body; it also means to restrain equilibrium: Balance. movement, which is equally important. For example, imagine what would happen if your arm decided to flop around independent of your control. This kind of activity can happen to people with certain diseases that interfere with this area of the brain. The brain runs the entire body. It is filled with cells and chemicals that are engaged in countless and constant interactions. The brain and the body are in direct communication through neurotransmitters.

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A neurotransmitter is a chemical compound that is released from the end of a nerve (neuron) in the brain. From there it passes across a gap, called a synapse, and then activates the receiving end (called the dendrite) of another nerve. The receiving nerve then sends (transmits) a neurotransmitter to the next nerve, and this process is repeated. Receptors are small areas on each dendrite. These receptors are sensitive to the neurotransmitter that has been released by the sending nerve. The brain sends impulses to the different parts of the body through the spinal cord. The brain receives oxygen and nourishment from the body. The nerves that branch off from the spinal cord and extend throughout the body are part of the peripheral nervous system. In some cases when a disease or injury disrupts an element of these interrelated systems in a way that affects the brain, a mental disorder may occur. Many conditions, both psychological and physical, can interrupt the normal flow of information within the brain and between the brain and body. When the proper functioning of the brain and central nervous

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system is compromised, mental and physical disorders can result. When a person is diagnosed with a mental disorder due to a general medical condition, it means that the medical condition is causing interference with the usual functions that take place in one or more locations in the central nervous system. It is not usually possible to correctly diagnose a medical condition based strictly on the symptoms of a mental disorder. Some mental disorders can be caused by any one of several different medical conditions. For example, temporal lobe lesions, diabetes, hypothyroidism, and multiple sclerosis can all cause sexual dysfunction. Many other factors, including purely psychological factors, could also account for sexual dysfunction. Therefore, a physician cannot diagnose a specific disease simply by knowing that a patient ­suffers from this mental disorder. Most often, a comprehensive medical exam and laboratory tests have lesions: Abnormal to be performed in order to make the changes in the struccorrect diagnosis. Jeff and his parents ture of an organ or were lucky to receive a diagnosis so part due to disease or quickly. Some medical conditions ininjury. volve complicated sets of symptoms. In those cases, it can take weeks, months, multiple sclerosis: A or in rare situations even years to obprogressive disease tain an accurate diagnosis. characterized by

patches of hardened tissue in the brain or spinal cord and associated with complete or partial paralysis and muscle tremor.

comprehensive: In-

cluding everything or almost everything.

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When a personality disorder is caused by a brain tumor, surgery is often part of the answer.

Chapter Three The History of Drug Treatment and How Some Drugs Work

J

eff and his parents listened carefully as the neurosurgeon explained that the course of treatment for Jeff would involve surgical removal of his brain tumor. The doctor believed that once the tumor was removed, Jeff would regain complete use of his leg, and his personality would return to normal. The Turners sat in stunned silence as the doctor telephoned the receptionist, explained the situation, and asked her to schedule surgery as soon as possible. Jeff’s parents wrapped their arms reassur-

ingly about Jeff’s slumped shoulders. Anxiety and fear gnawed at their hearts, but they cloaked their emotions in an outward appearance of confidence. Jeff almost felt relieved to know that there was a log­ical explanation for his personality change. But this knowledge was small comfort. No matter how hard he tried, he couldn’t shake the uncontrollable anger and frustration from his mind. And now a new fear was mixed with these emotions—the fear of surgery. The doctor seemed confident about the operation, but Jeff didn’t feel so sure. All he could think about was the image of someone cutting into his brain. What if they made a mistake? What if they cut the wrong thing? Maybe he’d end up worse off than he was now . . . maybe he’d even die. But Jeff wanted to be normal again more than he wanted anything else in the world, so just four days after learning that he had a brain tumor, Jeff was in an operating room preparing for the doctors to cut into his brain.

Doctors can evaluate brain tumors with MRIs.

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Surgery may not provide all the answers to a psychiatric condition that was initially caused by a tumor. When Jeff’s friends and teachers heard about his brain tumor, they felt terrible. Everyone suddenly understood why Jeff had been acting so strangely, and they wanted to show their support. Bill Hurley couldn’t wait for Jeff to get out of the hospital so that he could begin mending their friendship. When Jeff arrived home from the hospital, a beautiful banner graced the front door with the words “Welcome Home, Jeff.” His friends and family were all there, and for the first time in months, Jeff felt hopeful that life might return to normal again. Jeff’s newfound hope was short lived. Several weeks after surgery, Jeff was still experiencing feelings of anger and frustration. He felt devastated. If brain surgery couldn’t make him normal again, what could? Jeff didn’t want to be angry, but he couldn’t help it. Before he knew what was happening, he was exploding at someone over the smallest thing. Then he felt terrible and wanted to take it all back, but he couldn’t. Not knowing how to deal with his emotions, Jeff began spending most of his time alone. He no longer went to football practice, and he skipped school as much as possible. He wanted to lock himself away from the world.

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Luckily, his friends wouldn’t let him. If Jeff skipped school, Bill was sure to be at his door that evening trying to cheer up Jeff. Jeff’s parents were determined as well. They were committed to finding the best medical care for Jeff and were sure that there must be additional ways to help him. Jeff’s doctor assured them that even though the tumor had been removed, there were still options for treating his remaining mental disorder. The doctor suggested psychiatric medication as a possibility. Just as Jeff had been nervous about surgery, he was suspicious of taking drugs that would affect his brain. Nevertheless, Jeff wanted to get better, and he knew that this might be the only way. His doctor decided that a drug called lithium would be most beneficial in helping to control Jeff’s anger and explosive episodes. He explained to Jeff that the dosage of powerful drugs like lithium must be monitored closely. Jeff was placed on an average beginning dose, and his behavior was monitored to determine whether or not the amount would have to be increased.

Psychiatric drugs affect brain functions.

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The History of the Drugs

Throughout recorded history, substances from plants, animals, and minerals have been used to help the symptoms of disease. It was probably while experimenting with plants to locate sources of food that the first substances with the power to alleviate symptoms of various illnesses were discovered. Once discovered, people most likely repeated their use of these early herbal medicines and shared them with others. Early remedies such as these have played an important role in the evolution of medicine today. Despite the long history of using substances to treat disease, it wasn’t until the middle of the twentieth century that psychiatric drugs began to play a significant role in the treatment of mental disorders. That’s when researchers began to create substances that are so specific as to affect only certain areas or even specific transmitters in the brain. This ability to target specific parts of the brain has made pharmacological treatments more effective. People can suffer mental disorders for many reasons, including substance abuse, emotional trauma, chemical imbalances, and as complications of medical conditions. Understanding the origins of an individual’s pharmacological: Havmental disorder is an important step ing to do with the toward treatment. Once doctors underscience of drugs, espestand the causes of an illness, they can cially medical drugs. design a treatment program that will best suit the patient’s needs. alleviated: Made less In the case of mental disorders due severe; eased. to general medical conditions, the usual course of action is to treat the underlying physical condition. Hopefully, once the primary medical condition is resolved, the mental disorder will also be alleviated. Sometimes, however, a person’s psychological symptoms may be so severe or life-changing that they require immediate treatment. In such cases,

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it might be necessary to treat the mental disorder with psychological counseling and psychotropic pharmaceuticals while also treating the medical condition. In rare cases, the patient may continue experiencing the troublesome psychological symptoms even after the underlying medical condition has been treated. In these situations, psychological counselpsychotropic ing and drug treatment may become a pharmaceuticals: necessary part of restoring and maintaining good health. Drugs that affect the In Jeff’s story, we see an example mind. of how psychiatric drugs may be used residual: Something in the treatment of a mental disorder that remains when due to a general medical condition. Desomething else is pending on the nature of a tumor and removed. its location in the body, surgeons may not always be able to remove it entirely. Other times, a ­tumor may have already caused some irreparable damage before it is removed. Even though surgery has been performed, in cases like these the patient may not recover fully from the tumor’s effects. In Jeff’s case, when surgery did not completely resolve his mental disorder, medications were used to treat his residual symptoms. Lithium, the drug Jeff’s doctor prescribed, would not be an appropriate treatment for all people experiencing mental disorders. Today, there are many different psychiatric drugs available to treat mental conditions. Which particular psychiatric drug a doctor may prescribe depends on many factors, including the nature of the patient’s psychiatric symptoms, her underlying medical condition, and other medications that she may be taking. Because there are many medical conditions that can cause mental disorders, treatment options are extremely varied. Furthermore, even within one medical condition, there are often many options for

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Researchers seek new treatments for both medical and psychiatric conditions.

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Medication is often used to treat the leftover symptoms after a medical intervention like surgery.

chemotherapy:

Drug therapy that is toxic to specific cells.

radiation:

Therapy to destroy tumors by exposure to highenergy X-rays.

treatment. For example, for some tumors, chemotherapy may offer a better treatment option than surgery. Many different kinds of drugs can be used to destroy tumors. If the tumor is cancerous, it can be treated with drugs that interfere with the cancer cell’s ability to reproduce itself. Others make it difficult for cancer cells to grow. Still other drugs starve cancer cells by depriving them of nutrients. Radiation is another treatment option for some tumors.

Carol’s Story

“Systemic lupus erythematosus is a complicated name for a complicated disease,” the doctor explained to his patient. Carol felt like she was in a dream. The doctor’s voice seemed to be traveling to her ears from some great distance. She had been

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Lithium acts as a mood stabilizer in the brain; this means it helps to keep emotions and reactions from becoming too extreme. Although scientists know that this chemical changes the transport of sodium in muscle and nerve cells, they do not know exactly how or why the individual’s behavior is affected.

feeling sick for so long, and she was tired of not knowing what was wrong. But now that she had a diagnosis, she didn’t know what to think. Carol recognized the name “lupus,” but she wasn’t sure what lupus was. One thing she did know was that it wasn’t good. Carol couldn’t remember exactly when the symptoms started. A year ago she had been the picture of perfect health. Then, late in the winter, Carol came down with a sore throat that seemed to last forever. She ignored it at first, but when it refused to leave, she made an appointment with her doctor. He found that she had a low-grade fever (less than 100°), which wasn’t very worrisome. Carol also complained of pain in her joints and general fatigue. The doctor told her that she must have picked up some kind of a virus. She was sent on her way with a prescription for cold medicine and the suggestion that she rest and take an analgesic (pain reliever) as necessary. The symptoms did go away, eventually, but then they returned and refused to leave. A month or so ago she had begun a nightly ritual that always left her in tears. Each evening she would step into the shower. The warm water felt good against her cold and aching body. She stood watching the water run down her hands and fingers that just never seemed to get warm enough anymore. She poured a small amount of shampoo into her palm. Then, ever so gently, she moved the creamy mass through her hair, tipped her head back, and felt the soft bubbles washing away as they cascaded down her back. Then lifting her head, she opened her eyes, took a deep breath, and courageously looked down at the shower floor. Strands of long dark hair spiraled in the pool beneath her feet.

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How does lupus affect the body? When a person has an autoimmune disease, his immune system malfunctions. In lupus, the immune system, which normally protects the individual against disease, gets confused and begins instead to attack organs and tissues essential to the health of the body. Typically with lupus, symptoms are intermittent. In other words, a person will be sick for a while and then recover only to become sick again. Symptoms can vary widely depending on the systems of the body that are being attacked.

She could no longer ignore the fact that her hair was falling out. Her eyes filled with tears each time she faced this—and she noticed that the tears, ironically, made her dry, sore eyes feel better. That made her cry even harder. Meanwhile, Carol’s husband, Jared, was worried about her. He had watched the deterioration in her health, and now he noticed a red rash had spread across her face. Lately, he took care of the house and the children by himself. Carol just didn’t have energy for much of anything anymore. When Carol returned from the doctor’s office with her diagnosis, Jared immediately got on the Internet and began researching lupus. By the end of the evening, he and Carol knew that lupus was an autoimmune disease that had received its name in the 1850s. It wasn’t until the late 1940s that the first significant treatment (the drug cortisone acet) was developed, however, and much about the disease is still being discovered. Knowing that the disease was still little understood and had no cure made them nervous, but other information gave them more hope. They read that despite the lack of cure, the disease is often manageable through drug treatment, and that drug treatment is usually not continuous. When Carol and Jared stepped into the doctor’s office again the following week, they were well prepared to discuss a course of action.

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Physical pain can contribute to emotional difficulties.

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Today, most people with lupus live long and productive lives. However, a mental disorder called lupus psychosis can become a condition of the disease. Luckily, the occurrence of this disorder is rare, but it can arise if chemical changes take place in the brain as the result of antigens attacking that part of the body. If a person does have lupus of the brain and lupus psychosis results, this would be a mental disorder due to a general medical condition. In such a case, the patient will need to take medication to control behavior resulting from the psychosis. A person experiencing psychotic symptoms might be placed on a psychiatric medication known as an antipsychotic. There are many different antipsychotic drugs, but some common examples are Haldol, Risperdal, and Thorazine. Even in the twenty-first century, we do not know all the details about how every antipsychotic medication works. antigens: Proteins or Risperdal, for example, is believed to afcarbohydrate subfect an individual’s behavior because it stances that are able acts as an antagonist, interfering with to stimulate an imthe dopamine and the serotonin actions mune response. in the brain. Both dopamine and serotonin are nerotransmitters that are esantagonist: A chemisential to the normal functioning of the cal that interferes central nervous system. Serotonin afwith the physiology fects mood. of another chemical. Remember, the brain communicates with the body by sending messages throughout the nervous system by way of neurons. Each message moves from neuron to neuron. No connection lies between one neuron and another; in fact, between each neuron is a small gap called a synapse. Messages move across the gaps by way of chemicals called transmitters. Each cell that receives a transmitter has thousands of receptors ready to catch it. These receptors are chemical specific. For example,

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When a patient researches her medical condition—in books or online—it helps her understand her symptoms and gives her a greater sense of control.

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Brand Names vs. Generic Names Talking about psychiatric drugs can be confusing, because every drug has at least two names: its “generic name” and the “brand name” that the pharmaceutical company uses to market the drug. Generic names come from the drugs’ chemical structures, while brand names are used by drug companies in order to inspire public recognition and loyalty for their products. Here are the brand names and generic names for some common psychiatric drugs used to treat anxiety disorders: Celexa® citalopram Depakote® valproate Effexor® venlafaxine Elavil® amitriptyline Halcion® triazolam Haldol® haloperidol Klonopin® clonazepam Librium® chlordiazepoxide Luvox® fluvoxamine Nardil® phenelzine Parnate® tranylcypromine Paxil® paroxetine Prozac® fluoxetine Remeron® mirtazapine Restoril® temazepam Risperdal® risperidone Serax® oxazepam Serzone® nefazodone Thorazine® chlorpromazine Valium® diazepam Xanax® alprazolam Zoloft® sertraline hydrochloride

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serotonin transmitters can only be received by serotonin receptors just as norepinephrine transmitters are received by norepinephrine receptors. Once their job of relaying the message is accomplished, transmitters are partially broken down and sent as waste to the kidneys. The remaining neurons are reabsorbed back into the nerve by a process called reuptake. By forcing the transmitter to remain in the synapse longer, the brain has more of this chemical at its disposal as it sends messages. Some psychiatric medications affect changes in an individual’s mood and behavior by manipulating the chemical transmitters in the brain. Some of what we now know about schizophrenia: A serihow the brain works and about how ous and debilitating pharmaceuticals act upon the brain psychological condihas been discovered through diligent tion in which an indiresearch. Other important information has been realized by accident. For exvidual becomes conample, in the 1950s, several patients fused about with schizophrenia were given an anreality. tihistamine called chlorpromazine. Antihistamines are typically used to treat allergic reactions, but when someone takes this particular drug, the levels of dopamine in the brain are lowered. The unexpected effect on the patients was to calm them. Knowing this, researchers began to develop more drugs that would have this effect. They also began to develop drugs that would raise the level of dopamine in the brain, thus having the opposite effect—the effect of stimulating the patients or “waking them up.” In the 1960s, a drug called L-dopa was developed. Neurologist Dr. Oliver Sacks learned about this drug and became one of the first neurologists to test it in the treatment of Parkinson’s disease. His experience was described in his book Awakenings and later in a movie of the same name.

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History of One Type of Antianxiety Medication Discovered in the 1950s, benzodiazepines have been available since the 1960s with the introduction of librium. But the story of their origin is really much older than that. The research that led to their development was based on the 1864 discovery of barbituric acid by Adolph von Baeyer, a German chemist. Research involving barbiturates led to the development of benzodiazepines, which now include a dozen drugs such as Valium, Halcion, and triazolam, along with Librium, Serax, Klonopin, Restoril, and Xanax. But the first of these antianxiety medications to be discovered was Librium, and it was discovered quite by accident in 1955 at the Hoffman-LaRoche pharmaceutical company. A chemist named Leo Sternbach was the first to synthesize Librium, but initially he did not realize how it could be used or what the effects of use would be. In fact, the substance was set aside and essentially forgotten about for two years while other projects were worked on. At that point, the forgotten chemical was rediscovered while cleaning the facilities, and new testing was begun on the substance. The drug’s tranquilizing quality was discovered when it was tested on animals in the laboratory. It was also noted that the chemical caused muscle relaxation. After considerable more testing, this chemical, chlordiazepoxide hydrochloride, was made available as Librium. It was while studying Librium that more benzodiazepines were synthesized. Some of these substances are more addictive than others, however. Diazepam (Valium) was the second benzodiazepine to go on the market, and it is considerably more potent than Librium.

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Behaviors like the ones Dr. Sacks’s patients experienced can be symptoms of a psychotic disorder. In the case of Dr. Sacks’s patients, however, psychotic symptoms were caused by the medication being administered to them. The DSM-IV-TR makes a distinction between mental disorders caused by medications and other substances and mental disorders due to a general medical condition. In Dr. Sacks’s patients, therefore, the original catatonia would be classified as a mental disorder due to a medical condition, but psychotic symptoms that resulted from the medication would receive a different diagnosis—substance-induced disorder.

Dr. Sacks’s patients all suffered from a mental disorder due to a general medical condition. They had been victims of a mysterious “sleeping sickness,” which may have first appeared in London in the seventeenth century. In 1916, encephalitis lethargica, thought to be the same disease, surfaced in Italy and quickly spread across the globe. It continued for about ten years and then disappeared. Dr. Sacks’s patients had been victims of this disease and had later developed Parkinson’s disease, presumably as a result of their original infection. Parkinson’s disease can have several different symptoms over many years; by the late 1960s, the most striking symptom of these particular individuals was catatonia. For the most part, they were mute and motionless. This is an example of a mental disorder (catatonia) caused by medical conditions (encephalitis lethargica and Parkinson’s disease). After Dr. Sacks’s L-dopa treatment, his patients first experienced a seemingly miraculous return to life. Individuals who hadn’t said a word in years began to speak normally. People who had been frozen in time could walk and run. Unfortunately, this initial recovery was soon followed by a crisis of dramatic proportions. Patients began to

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Drug Approval in Canada Whereas the United States has the Food and Drug Administration (FDA) for the approval and regulation of drugs and medical devices, Canada has a similar organization called TPD or Therapeutic Product Directorate. The TPD is a division of Health Canada, the Canadian government department of health. The Therapeutic Product Directorate regulates drugs, medical devices, disinfectants, and sanitizers with disinfectant claims. Some of the things that the TPD monitors are quality, effectiveness, and safety. Just as the FDA must approve new drugs in the United States, the TPD must approve new drugs in Canada before those drugs can enter the market.

react very unpredictably—even violently—to the medication. Hallucinations, delusions, delirium, and uncontrollable rage were among the behaviors they exhibited. For these patients, the side effects of L-dopa became so severe that they had to discontinue use of the drug. Sadly, when they were no longer on this psychiatric medication, they returned to their catatonic states. Negative side effects are an important concern when researching and developing psychiatric medications. When serious side effects occur, researchers normally continue their search for a more specific or appropriate drug by creating similar chemical compounds that will, hopefully, have the same positive effects with fewer negative consequences. This type of research is called homology, because the researchers use the fundamental structure of the original chemical but try to change some part of the formula. Because this is the easiest route toward drug development, much research starts here. New drugs may also be developed using analogy. In this case researchers look for other substances that will function similarly.

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Determining exactly how a new drug works and all the possible effects a drug can have is a difficult and painstaking process. That’s why drugs usually spend years in clinical trials before being approved for widespread use. Clinical trials are ofclinical trials: Conten conducted by universities or matrolled medical testing jor hospitals, and only patients who of the use, effectivemeet specified criteria are invited to participate. This is because everything ness, and safety of a about the clinical trial will be closely pharmaceutical that controlled and monitored in order to takes place on a select understand the results accurately. The group of human beings participating doctors want to know before the drug is apexactly what works and what doesn’t proved for widespread work concerning the drug being tested. use. They may also discover outcomes that were not expected, as Dr. Sacks did with L-dopa. New drugs are constantly being tested and many are added annually to the arsenal of pharmaceuticals available to physicians for treatment. By the time a drug is approved by the Food and Drug Administration (FDA) it has usually undergone many years of testing.

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Psychiatric drugs come in a variety of shapes, colors, and sizes.

Chapter Four More Treatment Descriptions

B

ecause Jeff was eighteen years old and his body was the size of an average adult man, Jeff’s doctor determined that he could safely take lithium. (Data regarding the safety of psychiatric medications in the treatment of children does not always exist. For example, information is not available regarding the effectiveness or safety of lithium for children under the age of twelve.) The doctor decided to prescribe the drug in a controlled-release tablet form so that the medication would be gradually and continuously released in his body. These tablets come in a 450-milligram dosage, and Jeff was instructed to take one of them every twelve hours. Like other patients who take lithium, Jeff needed to have a test to determine his kidney function before starting on the medication. He

would then have to have a periodic urinalysis, and possibly other tests, to be certain that kidney function remained normal. Jeff’s doctor also cautioned him that individuals taking lithium must make certain they are drinking enough liquids daily and be careful to eat a normal diet (including salt). Jeff needed to be particularly mindful of ingesting enough water and salt while engaging in sports that cause sweating. Despite some drowsiness as a result of the medication, three weeks after his treatment began Jeff’s family thought that they were noticing a positive difference in his emotions. Carol did in fact develop lupus psychosis, so treatment for psychosis became necessary. People who receive medication for psychosis need to be carefully monitored by their doctor. In the case of Risperdal, the drug can be administered in tablet form or in an oral solution. Haldol, however, is administered by injection, but it is also available in pill form. urinalysis: A medical Thorazine can be administered as a tabtest made on a urine let, syrup, injection, or suppository. sample. There are many different antipsychotic medications and many means of delivering them to the body. The duration of treatment with specific antipsychotic medications also varies. For example, the effectiveness of long-term use of Risperdal and many other drugs has not been fully determined. Therefore, a medical practitioner who decides her patient should take one of these medications will reevaluate her patient’s condition every six months to see if he no longer needs the medication. Today many physical injuries can be repaired and diseases can be cured. However, some medical conditions still require long-term management. Proper treatment of these illnesses can help avoid mental disorders that might otherwise be associated with them.

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People who are taking lithium will need regular urine tests to monitor their kidney function.

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Bethany’s Story

Bethany was a bright and ambitious high school sophomore when her family moved across the country. Leaving friends behind and starting over at a new school was difficult, but Bethany had an additional challenge. While she was still in elementary school, she had been diagnosed with diabetes—Type I insulin-dependent diainsulin: A hormone betes mellitus. that is essential Like many people with this disease, for the proper meBeth­any’s condition began with very tabolism of carbohyfew symptoms. She had not been feeldrates. ing well for quite a while, but she was able to keep up with her schoolwork pancreas: A gland and other activities; her feeling of bethat is responsible ing under the weather just slowed her for the secretion of down at times. Bethany’s mother could insulin. tell that something was wrong, however, and routine medical tests provided chronic: Marked by an explanation. Bethany’s parents were long duration or fresurprised to discover that their daughquent recurrence. ter had diabetes. Type I diabetes, formerly called juvenile-onset diabetes because it most often occurs in children and adolescents, usually begins quite suddenly as it did in Bethany’s case. The pancreas of a person with Type I diabetes produces too little or no insulin. For these persons, insulin must be taken every day for the rest of their lives. Bethany’s parents didn’t want to frighten her, but they both realized they were dealing with a serious chronic disease that would require diligent management in order for Bethany to live a long and healthy life. With the knowledge available today that allows us to monitor and treat various systems of the body, controlling diabetes

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can help avoid or reduce complications from the condition. At first, Bethany’s parents took charge of the disease. Her mother monitored Bethany’s glucose level and gave her needed insulin injections. As Bethany got older, she assumed these responsibilities herself. Lately, however, Bethany was growing really tired of the need to always be alert to her condition. She had so much to be concerned about, especially now that she was trying to fit in at a new school and with a new group of friends. The nurse at the new school had been informed of Bethany’s diabetes, but Bethany refused to let her mother tell anyone else. “Why don’t you just hang a big sign that says ‘diabetic’ around my neck?” she asked her mother after hearing her explain the situation to a neighbor. “Why, Bethany, I’m sorry. It’s nothing to be ashamed of. I didn’t realize that it bothered you if people were aware of it,” her mother responded. “It’s not that I’m ashamed of it. I just don’t see why everybody has to know my personal business,” Bethany explained.

A medical condition can add to the stress of adolescence.

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No one likes to feel “weird” or left out. “But what if something were to happen? What if you needed help?” “It’s my life, and I want it kept private. I can take care of my diabetes, and nothing’s going to happen. It’s hard enough to make new friends. Don’t make it even harder!” Bethany’s mother reluctantly agreed. So hardly anyone was aware of Bethany’s medical condition in this new neighborhood and school. Bethany had noticed in the past that knowing she had diabetes occasionally made people reluctant to include her in special activities. If it wasn’t the kids, sometimes it was the parents who would get nervous about inviting her to take part in an overnight trip or who worried about her overexerting herself during some athletic activity. Bethany wanted to start over with a clean slate. As the days went by, Bethany became more at ease with the friends she was making, but she didn’t change her mind about keeping diabetes a secret. She didn’t want to jinx anything, and her annoyance at the need to deal with the disease continued to grow.

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A person with diabetes may have to give herself regular injections of insulin.

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Dealing with disease was making Bethany feel exhausted and different from everyone else. She didn’t like that, and she began to be less diligent about her health care. She had been late with her insulin shots on several occasions. On Tuesday night, Sue, a new friend from school, invited her to an away game in the city. A group of girls were going to make a weekend trip out of it; Sue’s parents were providing transportation and supervision. “Thanks for inviting me. It sounds like it’s going to be great! I’ll just have to let my mom and dad know.” But Bethany’s parents were less enthusiastic. Naturally her mother wanted to speak with Sue’s mother about Bethany’s health situation, but Bethany had a fit. “No! They’ll change their minds about wanting me to go along if they think there’s something the matter with me. Stop worrying and let me live my life.”

A person with diabetes needs to limit how much cake and other desserts she eats.

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Two young men from Canada, one a surgeon named Frederick Banting and the other a medical student named Charles Best, began diabetes research during the summer of 1921. Working with dogs, they were able to create a state of diabetes and then try to regulate the blood sugar by injecting a pancreatic hormone into the body. Finally, one of the dogs was successfully treated, and in less than six months the first human patient was injected with insulin. Leonard Thompson was a very sick fourteen-yearold young man when he received that first shot on January 11, 1922. He was so ill at the time that they were not sure he would survive. After the injection, however, Leonard’s blood sugar dropped. Only twelve days after his first insulin injection, Leonard began daily doses. His improvement was dramatic, and he was soon living a normal life. Soon others joined the research. One man was Professor Macleod, who helped to make insulin more active with fewer side effects.

Unaware of Bethany’s growing negligence regarding the monitoring and treatment of her diabetes, her parents reluctantly agreed to let her go away for the weekend. Her growing excitement about the upcoming trip made Bethany even more forgetful about her daily health maintenance. To make matters worse, a flu-like illness was working its way through the school, and Bethany was afraid she had gotten it. Her body began to feel sore. She rubbed her arms first and then her neck; soon a pounding headache settled in her temples. Maybe she was just making herself sick because she was worried about getting sick, she thought. She was annoyed with herself for worrying so much and decided to just relax. Bethany packed her suitcase on Wednesday, and when Friday came, she forgot to put her insulin in the bag. She didn’t remember

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it until they were miles from home, and then she was afraid to mention it. Realizing that she had taken her insulin off schedule many times lately, she assured herself that she could go without it until she got back home. By the time the travelers arrived in the city, Bethany was growing weary, but being with friends was helping to keep her spirits up. She wasn’t feeling so great, yet there was no way she was going to stick to her normal diet tonight. She was determined to have a good time, and there were so many great things to try at the restaurant where they ate dinner. Everyone was sampling each other’s selections. Bethany was sure that just a little bit of this and that wouldn’t cause any real problems. She had been so thirsty in the car; it was good to have the waiter constantly filling the water glasses.

Diabetes can increase a person’s thirst.

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When a person has diabetes, careful monitoring of sugar intake is an essential part of good health.

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Diabetic ketoacidosis is a serious condition that may require a trip to the emergency room That night Bethany had to get up several times to use the bathroom, but she attributed it to all the water she had been drinking. She couldn’t seem to get enough to drink. In the morning, she didn’t feel well at all, but she wasn’t going to risk spoiling everyone else’s weekend by mentioning it. Trying to ignore the growing pain in her abdomen, she got dressed and decided to force down some breakfast. Later, she regretted that decision. During the first quarter of the game she needed to excuse herself because her breakfast refused to stay where she had put it. Vomiting didn’t improve the way she was feeling at all. When she returned to her seat, the players on the field looked blurry, and she couldn’t follow the game. Bethany didn’t remember what happened next. She woke up in the hospital emergency room. Diabetic ketoacidosis was the medical term used to explain her condition. Only three

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Diabetes Law Passed in North Carolina In September 2002, a new law was passed that many see as a significant advance in health care for children with diabetes. Those children suffering with Type I diabetes are now allowed to check their own blood sugar level in class, which could prevent serious health crises for these kids. By helping to eliminate emergencies, children and adolescents with diabetes may be able to remain healthier in general. Adapted from the Juvenile Diabetes Research Foundation International.

to eight people per one thousand with diabetes have an incident like this each year; it usually results if the person fails to take her insulin or if she is ill and doesn’t realize that she needs increased insulin because of that. A dangerous catatonic state can result. This state can be considered a mental disorder, and in the case of a person with diabetes, it is caused by a medical condition. Bethany had never realized that the result of neglecting her health care could be so serious, and she vowed to never be careless about it again. Naturally, all of her new friends quickly became aware of her medical condition after this incident, but they were very supportive. Bethany was sorry that she hadn’t trusted them with the truth sooner. For some chronic medical conditions, such as diabetes, continuous management of the illness constitutes treatment and also prevents the development of associated mental disorders. Proper education of the patient is critical to be certain that he understands the importance of maintaining his health. Not doing so can result in

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serious medical consequences including the occurrence of associated mental disorders. Many negative medical situations can be quickly reversed once a diagnosis is made. In most cases, treating the etiologically: A cause disease will also cure any associated or reason for an illmental disorders. In cases like these, it may be necessary to treat the mediness. cal condition with drugs, but treatment lethargic: Feeling specifically targeted to the mental disunusually drowsy, order, such as that with psychotropic tired, sluggish. drugs, may be unnecessary. Mood disorder is one of the classifications of a mental disorder due to a general medical condition. However, the DSM-IV-TR carefully specifies that in order to be correctly diagnosed as being caused by a medical condition, “the clinician must establish that the mood disturbance is etiologically related to the general medical condition through a physiological mechanism.”

Bob’s Story lethargic

Bob had always been a boy, so no one was surprised when he grew to be an overweight teenager. It seemed to Bob like everyone in Minnesota played hockey, but he’d rather watch it on television. He did learn to skate, to swim, and to ride a bike, but he never felt much like doing any of it. Bob’s bike usually stood in the garage gathering dust, right next to the skates that never seemed to move off the peg in the wall. Bob was an easygoing guy and he had plenty of friends. They’d invite him over to watch a game, go to the movies, or have pizza, but they had long ago stopped issuing invitations to participate in anything that involved physical movement. Bob had a reputation for being a nice guy who was lazy.

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Checking the glucose level, which is the way diabetes is monitored, refers to testing the concentration of sugar in the blood. The food taken into the body and the functioning of the liver are the two ways glucose gets into the bloodstream. We all have sugar in our blood, and the brain needs this sugar, or glucose, to function. It provides energy for cells in the muscles and tissues of the body. As the sugar or insulin level rises in the blood, the liver stores the extra sugar in case you need it later. In this way, the blood sugar level remains at a safe level. For someone with diabetes, however, the sugar level is too high. This is called hyperglycemia. When a person has diabetes, glucose remains in the bloodstream where it gets higher and higher.

Although Bob hid his feelings, under the surface he was filled with conflicting emotions. He felt abandoned by friends when he knew they were off doing something and he hadn’t been invited; yet he realized that he didn’t want to participate, so he never did anything to change the situation. Things weren’t too great for Bob at school either. He had trouble concentrating, and he hated having to do homework. Consequently, he studied as little as possible, and his grades were below average. He felt like he was a spectator at school more than a participant. In fact, he felt that way about his whole life. He could watch everyone in the real world be happy and enjoy life, but he couldn’t quite be a part of it. Naturally Bob’s poor grades and laziness disappointed his parents, and their disappointment made Bob feel even worse about himself. He managed to plaster a smile across his face much of the time, but inside he felt like he could cry. Real happiness was rare for him, and when it did come along, the emotion was so foreign to Bob that it felt unreal.

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How to Help a Person with Diabetes • Do not try to control a person’s behavior or the way she take cares of herself. • Acknowledge the person’s diabetes. It does exist and it’s okay. • Do not tempt a person who has diabetes with forbidden food. • Support the person when she is tempted by forbidden food. Do not ignore continued indiscretions but realize that occasionally forbidden foods will be eaten. With your help, that may not be often. • Respect the privacy of the person. Keep talk of diabetes where the person wants it. If she does not like talking about it in public, then don’t. If conversation helps to air things out with others, then join in. • Be especially supportive when the stress of the disease seems to be high. • Be patient when the person’s blood sugar level is low. She may not act the same way that she normally would. • Be helpful, especially in public situations. • Be considerate. Try to be open with each other about the difficult topics concerning the disease, such as how to handle used syringes or how the person with diabetes feels when you are eating forbidden food in front of her. • Remember to laugh—with the other person, not at her! Adapted from The Johns Hopkins Guide to Diabetes.

Bob tried to join in activities during gym class. He had learned long ago that anyone who didn’t participate there could really be ostracized, and he certainly didn’t want that. The guys might

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not invite him to participate in every activity, but at least he was their friend. He didn’t want that to change. So he made it a habit to muster every ounce of energy to get through gym class. He was grateful that the class came at the end of the day, ostracized: Excluded because when it was over, he always from a group. went straight home and took a nap. The new gym teacher couldn’t help but nomigraine: Recurring tice how tired Bob looked, his labored headaches that are exbreathing, and the fact that he periodiceptionally severe and cally asked for a time out so he could often include nausea and rest. This concerned the teacher, but he sometimes vomiting. attributed it to the fact that Bob was an overweight kid who wasn’t used to exdebilitated: Weakened. ercise. Just when it seemed to Bob like he was at the all-time low of his unexciting life, he started to suffer from occasional migraine headaches. They left him feeling completely debilitated. During these episodes, Bob couldn’t stand to be in the light. He’d lie in his darkened bedroom with one cold, wet cloth across his forehead and another behind his neck. While he endured this new routine, he began to have momentary thoughts about whether or not life was worth living. That really scared Bob, and the next day he went to see the school nurse. When Bob told Mrs. Smith about the headaches and about how depressed he was, she made an appointment for him with the school psychologist—but she also gave him a thermometer and suggested he take his temperature the next two mornings before getting out of bed. When he awoke the next morning, Bob remembered Mrs. Smith’s instructions. While still in bed, he tucked the thermometer in his armpit and remained resting for ten minutes. Then he recorded the temperature on a piece of paper. This is called the Barnes Basal Temperature Test. The next morning he repeated the process and

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Off-Label Prescriptions The FDA bases its approval on specific research results. Sometimes, a particular use for a drug may have been thoroughly researched by many studies, while other uses lack the same amount of research. In that case, the drug label will only include the uses that have met the FDA’s stringent research requirements. Physicians, however, may continue to prescribe that drug for other “off-label” uses.

reported the results to Mrs. Smith. “Bob,” she said, “I think you may have an underactive thyroid. That could account for the way you’re feeling. I’m going to telephone your parents and suggest they take you in for a good checkup.” Dr. Lithgow ordered more tests, and Mrs. Smith’s suspicions were confirmed. Bob was diagnosed with hypothyroidism. Dr. Lithgow prescribed some pills, and Bob’s mood improved. The thyroid is a hormone-producing gland that lies at the base of the neck. Bob had to take medication daily to supplement the amount of hormone being produced by his thyroid, but it was not necessary for him to take any psychiatric medication. Several months later, Bob awoke to warm sunshine streaming through the window and across his face. He dressed quickly and said, “No time for breakfast, I’ll be back soon,” as he breezed past his mother in the kitchen. Her son’s newly lean body and quick step were still unfamiliar, but they made Bob’s mother smile. The garage door creaked open, and Bob lifted the bike helmet off the handlebars and placed it on his head. He hopped on the ten-speed and was down the driveway, off on his daily morning ride. He couldn’t help but smile.

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Everyone feels sad occasionally, but sometimes sadness turns into depression, which can get in the way of a person’s ability to live his life. It is important to determine the cause of depression. When the depression is caused by a medical condition, psychotherapy: Psychoas in Bob’s case, it is usually alleviated logical counseling and by treatment that corrects the meditreatment of a mental cal problem. There are times, however, when treatment of depression requires or emotional disorder. psychotherapy or medication with mood-altering psychotropic drugs. Each medical condition requires a course of treatment specific to the particular disease or injury and the individual’s circumstances. Surgery; radiation; organ, stem cell and bone marrow transplants; physical therapy; and drug therapy are among the types of treatment required for various medical conditions.

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Each person who has a psychiatric disorder caused by a medical condition will require different treatment.

Chapter Five Case Studies

N

o two mental disorders caused by a medical condition will be exactly alike. A wide range of variables affects these disorders. Depending on the specifics of each diagnosis, treatment targeted specifically to the mental disorder may or may not be necessary. When psychiatric treatment is necessary, it may or may not require psychiatric drugs—and the duration of treatment can be temporary or lifelong. Each person’s story will be different.

Jennifer’s Story

(a condition requiring temporary treatment)

The news traveled quickly when Jen and Peter’s mother died in a car accident. The children’s father had been out of the picture for years (Peter didn’t even remember him), and they had no nearby relatives. Jennifer and Peter were shocked, therefore, when their father turned up on their doorstep to attend their mother’s burial service—but they were also relieved. Someone would take care of them after all. Their relief was short lived, however. Jennifer soon realized that her father had no income. She strongly suspected the reason for his sudden concern in his children’s lives had much to do with their Social Security checks, which began arriving after their mother’s death. Another thing that became apparent rather quickly was that their father had a drinking problem. A predictable pattern began to develop with the arrival of the first checks. Their father would be gone when they returned from school. He would obviously cash their checks and spend the day drinking. Most of the time he wouldn’t return home until the next day. The amount of food he brought home was pitiful. Luckily, he would always include rice in his grocery shopping. One thing about rice—it can fill an empty stomach. Jennifer was so depressed over her mother’s death and the deteriorating situation at home that she hardly ever felt like eating anyway, but it really bothered her that Peter was hungry all the time. Peter was brave, but he was only six years old, and sometimes he cried because he was hungry. Jennifer was confused about what to do. She knew that she should tell someone at school what was going on, but she was afraid that she and Peter would be put in foster care, and she was worried about the possibility that they would be separated. She thought there might be nice people who would

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Each class of psychiatric medication has several options available for treatment. For example, some of the available antidepressants include the following: • Amoxipine tablets • Celexa • Effexor • Elavil • Nardil • Parnate

• Paxil • Prozac • Remeron • Wellbutrin • Zoloft

These antidepressants do not all work in the same way. If a particular medication is not effective for an individual, or if a person is not able to take a specific medication because they experience a negative side effect, one of the other medications will probably work better for them.

take in Peter, but who would want a teenager like her? All they had now was each other. She loved Peter. How could she go on if he was taken away from her? Luckily, there was a school lunch program. Jen started saving most of her lunch at school and bringing it home for Peter. At first she felt hungry all the time, but after a while she didn’t mind. It made her feel proud to be so in control that she could go without eating. And anyway, there would be rice when she got home; that was enough for her. This new routine lasted for several months—and Jennifer lost weight continuously. When she looked in the mirror, she felt even more powerful. She knew she was too thin, but her thinness was a symbol of her strength and her love for Peter, who was doing much

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Diet plays an important role in both physical and mental conditions. better since she started giving him her lunch. She now took a container to school every day. So no one would notice that she didn’t eat more than a mouthful, she’d push the food around on her plate while engaging everyone in conversation. As the bell rang ending the lunch period, she’d say something about how she didn’t want good food to go to waste, put the food into a container, and be happy that Peter would be able to eat it later that evening. Often she could scrounge an extra piece of fruit or a cookie from friends. These she would save up to get Peter through the weekend. Their father was seldom home in the evenings or on weekends, and Jennifer and Peter had come to like it that way. Innocent little Peter never realized that the food showing up each night came from Jennifer’s school lunch. Each evening Jen would remind Peter that rice was really her favorite food, and she’d eat a little of that while Peter had a salad, a hamburger, or whatever had been on the high school lunch menu that day.

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Jennifer had conquered hunger, but fatigue was a bigger monster. It began to settle down upon her, and she couldn’t shake it off. She also began having trouble with her homework. She was agitated, and sometimes she snapped at Peter. Of course she regretted it later, but she couldn’t always control her irritability. It became increasingly difficult to concentrate. She could read storybooks to Peter, but she couldn’t seem to comprehend her math, science, and En­glish assignments. She’d read and reread the same paragraph a half dozen times, yet each reading felt like she was seeing the words for the first time. She just couldn’t follow the logic. Some homework assignments were forgotten entirely. Jennifer was being truthful when she told her teacher that she didn’t remember being told to do a specific assignment. There were lots of things she didn’t remember lately. And then one day, Jennifer didn’t even make it to school. She had been trying to ignore the pain in her abdomen for several days, but that night she began to feel really ill. As luck would have it, her father was home that evening, and he was sober. He was shocked when he saw how much weight Jennifer had lost. “What’s happened to you?” he asked. “I’ve lost some weight. It’s no big deal. Anyway, what’s it to you? It’s not like you care or anything.” Jennifer’s words stung both of them. Her father watched her remove the lunch container from her purse. “What’s that?” “It’s Peter’s dinner, if you’d like to know. How do you think we live around here?” “Oh, I get it. You feed Peter your lunch. That’s why you look like death warmed over.” Peter was listening in the hallway. The tone of their voices upset him, and he began to cry. He rushed into the kitchen and grabbed her leg. “Jen, please eat. I don’t want you to die,” he sobbed. Jen stooped down to comfort Peter but then had trouble getting back up. Her stomach hurt, and her legs felt like they were going to give way beneath her. She grabbed the counter to steady herself and pull herself back to a standing position. As her father watched, he became truly frightened. He insisted on taking her to the emergency room.

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When they arrived at the hospital, a worker volunteered to entertain Peter while Jennifer was examined and someone spoke to their father. Soon, Peter opened up to the worker about the entire situation. The volunteer shared all of the details with the doctor who had just finished a preliminary examination of Jennifer. “That pretty much confirms my suspicions,” the doctor announced, although she ordered a few tests to confirm her diagnosis. She then called social services to ask for help for both Jennifer and Peter. Jennifer had a fever when she arrived at the hospital. The last few days she had suffered first from constipation and then from diarrhea. Dr. Pines explained to Jennifer and her father that she would like Jennifer to stay in the hospital at least overnight but probably a little longer; she would also speak with a psychologist in the morning. Dr. Pines wanted to determine if Jennifer’s anorexia was the sole result of her desire to keep her brother well fed and healthy or if there might be more underlying psychological causes involved.

Nutrition labels on food packages can help us evaluate whether we are meeting our nutritional requirements each day.

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A medical practitioner may prescribe vitamins as part of the treatment for a medical condition causing a mental disorder.

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There are many psychiatric medications available for the treatment of various mental disorders. • • • • • •

antianxiety medications antimanic medications antipsychotic medications sedatives stimulants antidepressants

Dr. Pines was waiting for test results to confirm her preliminary diagnosis, but she strongly felt that Jennifer was suffering from a vitamin deficiency, most specifically vitamin B1, thiamine. Dr. Pines ordered immediate supplements of 10 milligrams per day first thing in the morning and ten more milligrams in the afternoon for two weeks. She also told Jennifer that she would need to take a multi­ vitamin and to eat several nutritious meals each day. A nutritionist would be visiting Jennifer the next day to talk about that, and a psychologist would be visiting to discuss anorexia. Finally, she assured Jennifer and Peter that everything was going to be okay and gently informed them that she had spoken with a caseworker from social services. He had already arrived and needed to speak with all of them immediately. Fatigue, poor memory, irritation, abdominal pain, sleep disturbances, anorexia, a burning feeling in the feet, and muscle cramps in the calves of the legs are among the symptoms of thiamine deficiency. Thiamine is important to the metabolism of carbohydrates and also affects glucose in the body. A deficiency of this nutrient can have a negative effect on the neurological, cardiovascular, and gastrointestinal systems. When thiamine deficiency goes unchecked, amnesia, a potentially serious mental disorder, can result. In this case, the amnesia is a mental disorder caused by a general medical

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condition. Jennifer had begun to forget things, but she was lucky to have her thiamine deficiency correctly diagnosed in time to avoid more serious consequences. Sometimes it is relatively simple to correct a medical problem and any related mental disorders. Jennifer’s memory will probably be fine once her diet improves and her thiamine deficiency has been corrected. Other situations may require longer treatment to overcome a mental disorder. The psychologist who visits Jennifer may decide that additional treatment with counseling and psychotropic medication is necessary to overcome the depression and anorexia Jennifer is experiencing. In this case, however, the depression and anorexia are not caused by the medical condition (Jennifer’s thiamine deficiency). Jennifer was depressed because her mother died and because she and her brother were living under intolerable conditions. While anorexia can be a symptom of thiamine deficiency, it is not caused by the thiamine deficiency. Instead, the thiamine deficiency is one of the results of the anorexia.

Rachel’s Story

(a condition requiring long-term— possibly lifelong—treatment)

Until the age of thirteen, Rachel led a perfectly normal childhood. She loved to sing, dance, and play the piano. Reading was another pastime she enjoyed, and Anne of Green Gables was her favorite book. In fact, Rachel adored all of the books in this series. She had a vivid imagination and thought about Anne’s life often as she did chores around the house and yard. When her father announced that the family would be taking a trip to Prince Edward Island the next summer, Rachel was overjoyed. That was the summer Rachel’s carefree life began to change. The trip to Prince Edward Island was wonderful, but the first evening on the island Rachel’s parents noticed a curious behavior while Rachel

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When a person has a mental condition that is causing a mental disorder, he may have difficulty keeping track of the days of the week. As a result, he may miss appointments and find himself in trouble at work or school.

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How do Depakote and Dilantin work? As with many medications, the exact reason these drugs eliminate seizures is not understood completely. Depakote may be effective in some people because it causes an increase in a chemical in the brain called gamma-aminobutyric acid (GABA). Dilantin appears to prevent seizures by affecting the area of the brain’s cortex that is involved with motor activity. It is thought that it does this by stimulating neurons to release sodium. According to the Physician’s Desk Reference, phenytonin sodium, the active ingredient in Dilantin, also reduces the maximal activity of brain stem centers responsible for grand mal seizures.

was sleeping. The family shared a hotel room, and her parents were startled late that night by a series of unusual moans coming from Rachel’s bed. “Ted, did you hear that?” Rachel’s mother whispered. “Rachel must be dreaming,” her husband replied sleepily. “There she goes again. Maybe she’s having a nightmare. Do you think we should wake her?” “No, she’ll be okay. Let her sleep.” The moaning stopped and Rachel’s parents fell back asleep, but the pattern was repeated again the next night, and the next. Rachel didn’t appear to be disturbed during these episodes, however, and she had no memory of them the next day, so her parents decided that Rachel’s “dreams” must not be a sign of anything serious. When the vacation was over and the family returned home, Rachel moved back to the privacy of her own bedroom, and no more was noticed regarding her pattern of sleep. A year later, Rachel was becoming involved in an increasing number of activities. There was always homework to do, but now she

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was also active in after-school sports, she had become a member of French club and art club, and there were committees that she wanted to join. Rachel began to feel tired during the day, but she attributed this to the fact that she simply went to bed later. One frightening morning, Rachel woke to the taste of blood in her mouth. She opened her eyes in a state of confusion. Ever so slowly, thoughts began to float back into her head. What day is this? Is it a school day? I need to get dressed. The house was silent, and Rachel wandered into the kitchen where a note lay on the table. At first glance the pen marks looked like a jumble of meaningless lines, but as Rachel stared at the paper, the lines began to come together and form words. “Rachel, We went to the grocery store. We didn’t want to wake you. See you later. Don’t forget about Mrs. Becker. Love, Mom.” So, it must not be a school day, Rachel realized. No, of course not. It’s Saturday, and I’m supposed to go to Mrs. Becker’s house this morning to pick apples. Rachel changed and grabbed a basket as she headed out the door and down the street. Mrs. Becker lived at the end of the block, and several gnarled old apple trees grew in her backyard. Each year Rachel picked apples for Mrs. Becker to make sauce and pies, and in return, Mrs. Becker allowed Rachel to bring apples to her mother. Mrs. Becker and Rachel thoroughly enjoyed their morning. Rachel was the best tree climber on the block. Mrs. Becker pointed with her cane to the best apples, and Rachel dutifully climbed and plucked as directed. Their baskets were soon full, and Rachel headed home, her bloody mouth a distant memory. Feeling even more exhausted than usual, Rachel went to bed early that evening. Violent pounding awakened her parents in the wee hours of the morning. Earthquake, was the first thought that popped into Rachel’s father’s mind as his eyes opened with a start. But this wasn’t any earthquake. It sounded like Rachel was pounding on the wall between their bedrooms. Rachel’s parents dashed to Rachel’s room. What they saw when they opened the door frightened them more than anything either of them had ever experienced before; Rachel was in the midst of a grand mal seizure.

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During an epileptic seizure, electrical impulses in the brain can cause the body to move in a violent dance of jerks and shakes.

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The bed bounced as Rachel twitched violently, eyes rolled back and blood trickling from the side of her mouth. Her mother shrieked in terror. “Don’t panic,” her father told her mother. “I think it’s almost over. Go get a wet cloth.” Rachel looked as calm as a baby in her father’s arms when her mother returned. She dabbed at the blood on Rachel’s face. “Is she okay? Should I call the emergency room?” Rachel regained consciousness as her father responded to her mother, but all language seemed to have left her head. She didn’t know what had happened and she couldn’t speak, so Rachel closed her eyes again and slept. When she opened her eyes a second time, she was in the hospital and a new chapter of her life—one filled with doctors and medical tests—had begun. She went home later that day, but blood tests, urine tests, EEGs, MRIs, and even a sleep study now filled her life. After weeks of testing and waiting, Rachel and her parents had finally been provided with an explanation for her sleep disturbances —epilepsy. Rachel was told that her seizures were triggered by brain waves during a particular phase of sleep. Rachel would have to immediately begin taking medication to prevent the seizures. A few days later, Mrs. Becker stroked the soft head that lay weeping in her lap. “You go ahead and cry, Rachel. But when you’re through, remember that we’re all going to be here to help you. You’re a strong girl, and you’re going to be okay. You’re going to take your medicine every day, and life is going to go on. The sun is still going to shine on you, and your life is going to be filled with blessings.” Rachel was feeling tired each day because she had a sleep disorder caused by a medical condition. Whether seizures happen during the day or at night, they must be brought under control. In Rachel’s case, removing seizure activity had the added benefit of curing the associated mental disorder (her sleep disorder). Many antiepileptic drugs are available, and it is up to the physician to determine which one is best in each person’s situation. Peo-

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An MRI can show structural abnormalities in the brain that may cause epilepsy or other medical conditions. ple often respond to medications in different ways, so what works for one individual may not be ­effective for another. A medication called Depakote was prescribed first for Rachel, but when it failed to stop her seizures completely Rachel was placed on the drug Dilantin. These are powerful medications, and Rachel could not just stop taking one and begin taking the other. She had to be gradually weaned off Depakote while she began taking Dilantin. She would need to take this medication twice each day indefinitely—possibly for the rest of her life. Both Depakote and Dilantin can have negative effects on the liver; therefore, individuals taking either of these drugs must have periodic liver-function analyses (blood tests) to be certain that they

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Some dogs can predict when a person is going to have an epileptic seizure. These dogs are good companions for people with epilepsy. Dogs and other pets also provide therapeutic comfort to many people with psychological disorders.

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can continue taking the medication safely. In addition to the positive effects that medications bring people, they can also have side effects. Understanding this treatment issue is an essential part of learning about psychiatric disorders.

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Some psychiatric drugs are given as injections.

Chapter Six Risks and Side Effects

W

hen removal of his brain tumor did not completely alleviate Jeff’s mental symptoms, the doctor felt that he could safely treat Jeff with lithium. Jeff was not suffering from cardiovascular or kidney disease, he was not dehydrated, he did not have sodium depletion, and he was not taking any diuretics. If any one of these conditions had been present, it would have meant that the doctor should look for another medication for Jeff, as the presence of these symptoms would

dehydrated: Lacking

water and other fluids in the body.

diuretics: Drugs that

increase the frequency of urination.

When taking a psychiatric medication, it is important to report any side effects to your medical practitioner. have increased the possibility of lithium toxicity. Lithium is also contrainto which something is dicated in pregnancy (especially during the first trimester) since studies have poisonous. shown an increase in cardiac and other contraindicated: Not abnormalities in babies born to mothindicated, should not ers taking this medication. If Jeff had be used under some been a female, the doctor would have circumstances. made certain that the patient was not pregnant before prescribing lithium. Jeff’s doctor explained that nausea might occur during the first days of treatment, but should subside in a short time. He also explained that Jeff could experience minor side effects like mild thirst and hand tremors. Jeff was cautioned to alert the doctor if any more serious

toxicity: The degree

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symptoms such as blurred vision, slurred speech, clonic movements of the arms or legs, hallucinations, poor memory, or excessive urination occurred or if the more minor expected symptoms persisted beyond a few days. The doctor also discussed all of this with Jeff’s parents, so that they could be on the alert for negative symptoms. Ongoing use of lithium has been associated with the onset of a form of diabetes, so tests are conducted before therapy begins and routine urinalyses are performed for the duration of therapy to be certain the kidneys are functioning properly. Patients are warned to discontinue use of lithium if certain symptoms develop, as these can be signs of lithium toxicity. These signs include: muscular weakness or an inability to properly coordinate muscular movements, tremors, diarrhea, vomiting, and drowsiness. Individuals who take lithium should also be cautious about operating motor vehicles and other mechanical equipment, as mental and physical abilities could

Dose sizes make a big difference when a person is taking a psychiatric drug.

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Physicians and researchers carefully monitor treatment outcomes.

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Common side effects of some antipsychotic medications include: • • • • • • • • •

dizziness nausea anxiety constipation rash indigestion inflammation in the nose rapid heartbeat drowsiness

be impaired. Side effects should be reported immediately to the patient’s medical practitioner, and blood tests should be performed periodically. Sometimes scientists discover that a chemical produces positive results when used in the treatment of a specific disease, but they are not certain how the chemical is working in the brain or body or exactly why the positive result is occurring. Even with these unknowns, the benefit can be so great as to allow standard use of the drug in treatment. Managing the different facets of either short-term or long-term disease and any resulting mental disorders through drug therapy is a serious undertaking. Brain and body chemistry are altered by various medications, and there are risks to every treatment. Physicians and scientists keep a careful record of any negative outcomes that occur as a result of the use of medications. Adverse side effects can vary greatly from one person to another. Most of the time, they will not occur at all; sometimes they will be minimal; but occasionally side effects can be severe and even dangerous. Sometimes physicians can determine that a particular patient is at risk for serious side effects based on that person’s medical history, but

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other times doctors have no way of knowing ahead of time who may experience a dangerous side effect. Some negative side effects are possible with most medications. When a physician prescribes a drug, she usually looks up that medication in a book called the Physician’s Desk Reference (PDR). This book lists the dosage level recommended for each drug on the market today, explains what is known about how the drug works in the body, tells the physician what the drug is usually administered for, and gives an account of the risks and side effects that have been noted for that medication. In this way, the doctor is completely informed about the medication she is about to administer to her patient. Often the PDR will have listings for several medications that can be used to accomplish the same purpose. In this case, the doctor can read all of the information and make an informed choice as to which medication is likely to have the best outcome with the least number of negative side effects for a particular patient. Some medications for mental disorders act on the synapses of the brain by releasing neurotransmitters, as in the case of some stimulants. Other medications block the reuptake of neurotransmit-

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When taking any medication, never take additional drugs without first discussing it with your medical practitioner or pharmacist. Different drugs can interact with each other in harmful ways. ters, thus allowing the neurotransmitters to remain in the synapse for a longer period of time. This is how some antidepressants work. The complexities of the brain make this more technical than it may sound. When medicating an individual for a mental disorder while also medicating them for a medical condition, the physician must determine how various drugs will interact when taken together. Some antidepressants can cause serious side effects when combined with other medications. For example, alcohol must be avoided when taking many psychiatric medications in order to avoid an adverse reaction. Some of the drugs themselves can be habit forming; this is one more reason why the patient must be very careful to follow the physician’s instructions regarding use. Certain medications are not appropriate for long-term use because they can be addictive. Other medications can become ineffective if they are used for an extended period of time, because an individual can develop tolerance to them. If this happens, an individual’s symptoms may recur and different medication will have to be administered.

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Mixing alcohol and psychiatric drugs can be dangerous.

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Another consideration when prescribing antidepressants and certain other pharmaceuticals is the possible development of withdrawal symptoms when treatment is ­discontinued. A discontinuation syndrome is associated with terminating the use of some medications. When withdrawal symptoms occur, patients can experience distressing effects, including dizziness, stomach problems, sleep disturbances, nightmares, anxiety, irritability, numbness, or other unpleasant sensations. Most individuals who are coming off an antidepressant should gradually decrease their dose in order to withdraw use without negative symptoms. No one should stop taking a psychiatric medication without first consulting with her medical practitioner. Side effects are very real dangers that must be managed appropriately when taking any drug. In most cases, however, the benefits of drug therapy for psychiatric disorders (like those caused by a medical condition) outweigh the risks. Complete and ongoing communication between doctor and patient is the best way to avoid dangerous side effects.

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Asthma is a chronic medical condition that can be controlled but not cured.

Chapter Seven Alternative and Supplementary Treatments

R

yan was on the wrestling team, and every day before school he spent time lifting weights. Between practices, meets, weightlifting, and school studies, he was very busy. In October, he began to feel a tightness in his chest—but he assumed that it was probably caused by a pulled muscle from weightlifting, so he ignored it. One day he and his dad helped his grandparents move. While Ryan was cleaning out his grandparents’ old stone basement, which was very damp, his throat started to feel scratchy. Soon he began sneezing and sniffling. Suddenly he was wheezing and coughing, and he had difficulty catching his breath. The symptoms became worse as the day progressed, and finally he and his father decided to go to the emergency room. The physician on duty gave Ryan a shot of epi-

Some forms of asthma are caused by allergies.

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The word asthma comes from the Greek word panos, which means to pant or breathe heavily.

nephrine (which is often used for the emergency treatment of allergic reactions) and some oral drugs; she explained that Ryan was suffering from an asthma attack. The symptoms cleared up quickly, but for Ryan the diagnosis of asthma seemed like the end of the world. Asthma is a chronic disease that includes inflammation of the passages that carry air to the lungs. Each breath may include a cough, then wheezing and shortness of breath as the person tries to get enough air to fill his lungs. When these symptoms persist, each breath may feel labored and tight. The inflammation of the lungs usually occurs because of sensitivity to irritants. As this happens, the body responds by tightening the airways and filling them with mucus, making it difficult to get a breath. Although it is chronic, asthma is not usually continuous. Instead, most sufferers experience attacks that can be severe or gradual, and they may happen almost without warning. Ryan was very involved in sports, panic attack: A period and he worried about how asthma was going to affect that. His first asthma of intense fear or disepisode was followed by three more comfort. within just a few months. The doctor kept reassuring Ryan that he would be fine, yet Ryan couldn’t seem to get his asthma under control. He became very fearful of having an attack. Eventually, the anxiety became so bad that he had a full-blown panic attack. Soon Ryan stopped going to the gym; he worried that weightlifting or wrestling might cause another attack of overwhelming panic. He became depressed over the changes in his life, and his parents noticed he was becoming withdrawn. Ryan’s parents decided to take him to a doctor who specialized in the treatment of asthma in children and adolescents. The doctor

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performed a complete physical exam and tested Ryan’s lung function. Ryan was disappointed to learn that he would have this condition for the rest of his life—but the physician assured Ryan that he could lead a normal life and gave him a book with stories of many athletes who achieved success in everyday sports, on major league teams, and in the Olympics . . . even though they had asthma. The doctor also taught Ryan and his parents how to look for asthma triggers. During his asthma attacks, Ryan experienced severe anxiety and panic attacks, and Ryan’s doctor diagnosed this anxiety as a mental disorder due to a general medical condition. The doctor talked with Ryan about how the anxiety and panic he experienced during attacks affected his brain and body and made the asthma attacks even worse. Then she explained that the brain’s chemicals could be altered with medication and sound psychological treatment. She showed Ryan how to use his inhaler properly so that medication would be delivered to his body quickly when needed. In addition, she prescribed an antianxiety medication and referred Ryan to a counselor, who also happened to be an amateur athlete. The doc-

A rescue inhaler can help control asthma’s physical symptoms, but the emotional symptoms may remain.

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Rhodiola Rosea Extracts of the plant Rhodiola rosea have only recently appeared in the North American herbal market. However, people as far back as the Vikings have been taking the herb (usually in the form of tea) for its perceived physical and mental benefits. In Russia, soldiers attempting to reduce stress and boost their energy drank tea made from the root of Rhodiola rosea. Today, numerous studies are being conducted on this herb, its possible benefits, and its possible side effects. Researchers now believe that its benefits may be the result of a number of chemical reactions including reduction of the stress hormone cortisol, an increase in hormones that positively affect mood, and a surge in the molecule adenosine triphosphate, which cells use for energy.

tor assured Ryan that with proper regulation of his asthma drugs, a short time on the antianxiety medication, and some counseling, he would be fine. Like many chronic diseases, asthma can be frightening. It can also be embarrassing for the person who is forced to leave areas that are smoke-filled, needs to stay away from friends’ homes because they have pets, and is sometimes seen using an inhaler. During an asthma attack that causes difficulty breathing, an individual can suffer real panic. Fortunately, most physicians are aware of the difficulties caused by various chronic illnesses. They are able to treat them effectively with a variety of modern medications. The most important medications needed to treat asthma are antiinflammatories, which work by reducing the swelling in the lining of the airways and by curtailing the amount of mucus that is being produced. They are a preventative medication in that they help to

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Exercise plays an important role in good health. keep the person from having an attack, so they must be used even if the patient feels well. Bronchodilators relax the muscles that cause tightening of the airways during an asthma attack. These are used only as needed. For those suffering with asthma or other serious illnesses, alternative treatments may be used along with a medication program. Support groups, for example, can provide both psychological and medical help to a person suffering from a mental disorder caused by a medical condition. Teenagers often enjoy these groups because it is a chance for them to make friends with others who are experiencing the same situations they are. The group allows teens to share fears and worries. Together they can work to discover solutions to the problems they face. When a teenager is able to see another person his age learning how to correctly use her inhaler or successfully learn how to keep asthma under control without bringing attention to herself, he may begin to feel more comfortable with his own medical situation.

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Teens can benefit from talking over medical and emotional problems with people their own age.

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Yoga includes breathing exercises that can be an effective treatment for asthma.

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Techniques that include meditation, breathing exercises, and progressive diaphragm: The partirelaxation can provide the means to tion separating the remain calm even when facing the anxchest and the abdomiiety of a chronic illness. Breathing exnal cavity. ercises, while an important relaxation tool for almost anyone, are especially helpful for people with asthma. Generally these exercises involve abdominal breathing that is slower and deeper than normal and result in improved lung function. More oxygen gets to the body and brain, and the diaphragm is strengthened. Many people in the world today deal with some form of generalized anxiety at least on an occasional basis—so it’s no wonder that those who deal with chronic disease may also suffer from anxiety. However, the DSM-IV-TR lists a specific set of requirements for anxiety to be diagnosed as a mental disorder due to a general medical condition. According to the DSM-IV-TR: The essential feature of Anxiety Disorder Due to a General Medical Condition is clinically significant anxiety that is judged to be due to the direct physiological effects of a general medical condition. . . . There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. Although many people may be sad and upset and suffer from anxiety because they have been diagnosed with a serious medical condition, most of these cases of anxiety would not meet the qualifications above, and therefore would not be classified as a mental disorder due to a general medical condition. Asthma was originally thought to be an illness that affected nervous or excitable people. Although asthma is not actually caused by emotions, a close relationship often exists between emotions and

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precipitate: To come

asthmatic attacks. Strong negative emotions may precipitate an attack of asthma, and nervous pressure and anxiety make asthma episodes worse. Powerful hyperventilating: emotions can lead to changes in breathing, and emotional stress can increase Breathing in a manheart rates and disrupt normal breathner that is unconing patterns. Hyperventilating can cause trolled and abnorbronchial tubes to constrict, triggering mally fast and deep. the symptoms of asthma—or someone bronchial: Havexperiencing an asthma attack may feel ing to do with the exceedingly anxious and panic during organs and tissues the attack. School-age individuals with that carry air to the asthma may often miss school and be lungs. prevented from participating in physical activities. As a result, they may feel left out and lonely. Factors like these can lead to a vicious cycle of symptoms—the emotional feeding into the physical and the physical feeding into the emotional. With a cycle like this, it is often difficult to determine whether emotional or physical factors came first.

before and cause something to happen.

Getting upset emotionally can bring on an asthma attack.

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Asthma and E.T.—Can emotion affect disease? A research study reported in the Journal of the American Academy of Child and Adolescent Psychiatry indicates that sadness and other negative emotions may increase the likelihood that children with asthma will have an attack, while happy emotions may ward off attacks. The study monitored twenty-four children with asthma while they watched the movie E.T. The researchers chose this movie because it contains themes of concern to many children (such as family stress and divorce) as well as themes of particular concern to children with chronic diseases (such as illness and death). The study found that emotions apparently affect involuntary responses in the cardiopulmonary system. On the one hand, the children’s heart rate and oxygen saturation (an indication of how much oxygen they were getting) were least stable during the scene when E.T. “dies.” This caused researchers to believe that sad emotions may lead to increased involuntary nervous system activity and changes in oxygen supply similar to those seen during an asthma attack. On the other hand, heart rate and oxygen saturation were more stable during the scene when E.T. revives. The link between emotions and asthma is not simple, but studies like this one suggest that sad feelings may make children more vulnerable to asthma attacks.

A sense of control is important whenever a person suffers from a chronic illness like asthma. Ongoing illness is bound to affect emotional health. Taking care of emotional symptoms is as important as taking care of physical ones. Asthma cannot be controlled by sheer willpower, but learning to understand and manage symptoms gives

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Tips from Teens Who Have Asthma to Others with the Same Condition 1. Take your medicine regularly. Asthma medication that is made to keep you from having attacks must be taken every day, even when you feel fine. If you have an attack, keep taking the medicine so that it has time to work on the symptoms. 2. Take the correct amount of medicine. Do not change your dose of medication unless your doctor tells you to. 3. Keep your inhaler with you, and use it when necessary. Ask your doctor to show you exactly how to use your inhaler so that it works best for you. Take the inhaler everywhere you go. Be sure to check regularly to make sure it still contains medicine. 4. Tell your friends, teachers, and any people you work with that you have asthma. The people you spend time with need to know you have asthma. They will be better able to help you if you have an attack, which might save you from an emergency room visit and keep them from being frightened about what is happening to you during the attack. 5. Don’t miss out on physical fun. A number of professional athletes have asthma. You can participate in a sport if you want to. You may have to adjust the way you play a constantmotion sport like soccer. Activities that take place in warm, humid air (like swimming) can be good for people who have asthma. Baseball may work for you because it will allow you to rest between innings. Be creative and work with your doctor.

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Tips from Teens Who Have Asthma to Others with the Same Condition 6. Figure out what triggers your asthma attacks. Be a detective. Try to figure out what causes you to have an attack. It might not be the same as for your friend who also has asthma. Look for things like cigarette smoke, pet dander, or dust. Then try to eliminate those triggers from your environment. 7. Learn how you feel when an attack is coming on. And get the help you need right away. Learn how to predict an attack. Are you tired, does your chest feel tight, or do you feel out of breath? Don’t try to make it without help. You may want to check with your doctor about using a peak-flow meter. It could help you to know if an attack is coming on. Adapted from the American Lung Association.

a greater sense of control. Both children and adults will feel less frightened and frustrated if they know what they can do to prevent asthmatic episodes and to better manage them when they do occur. Asthma can be triggered without advance notice, but it does not permanently damage the lungs if treated properly, and it can be kept under control with a specific treatment plan. As each person understands what triggers or causes her attacks, she will be better able to regulate this inflammation. Medication plays an important role in the treatment of asthma, but learning to control emotions may reduce asthma symptoms as well. Some antidepressants coun-

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Yoga and other exercise forms teach relaxation techniques that promote emotional and physical health. teract airway constriction, thereby combating both asthma and depression. Alternative treatment for many chronic conditions might best begin with a kind of self-help program where the patient monitors her own behavior and learns new techniques to better deal with stress, develops healthy eating habits, and incorporates an appropriate exercise program into her daily routine. Even if a person is in good health, she will feel better when she eats a healthy diet. A healthy balance of food that includes few refined sugars, more fruits and vegetables, fewer processed foods, no caffeine, and a balance of proteins, carbohydrates, and fats will increase energy. Adding vitamins or food supplements is usually a good idea, but it is always best to get as many vitamins and minerals as possible from fresh food. Exercise also works to keep the body in shape and to

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Homeopathic Medicine Homeopathy is a form of alternative medicine that looks at disease and disorders from a very different perspective from conventional medicine. It looks at a person’s entire physical and mental being, rather than dividing a patient into various symptoms and disorders. Homeopathic medicine uses tiny doses to stimulate the body’s ability to heal itself. In some cases, these doses may be administered only once every few months or years. According to Judyth Reichenberg-Ullman and Robert Ullman, authors of several books on homeopathy, this alternative form of medicine offers safe, natural alternatives that can supplement or replace conventional pharmaceutical treatment. Because homeopathy treats the whole person—body, mind, and emotions—the same homeopathic medication may address both physical and psychiatric symptoms at once. Homeopathic treatments should be used only after consulting with a licensed practitioner.

release the brain’s powerful endorphins, which help to eliminate or decrease pain. Relaxation techniques can work in the same way. Through different methods such as meditation, progressive body relaxation, and yoga, individuals are able to reduce stress levels. Progressive relaxation works by teaching the paendorphins: A group tient to systematically tighten and then of proteins that have relax the entire body one set of muscles an analgesic quality at a time. Meditation works to relax the in the body. mind and body, thus improving general health, often even lowering blood pressure. When a person meditates regularly,

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it can become progressively easier to remain calm in stressful situations. This can be especially helpful to an individual with asthma. Relaxation and meditation would probably also help someone like Jeff, whom we met in the first chapter of this book. After Jeff began taking lithium, he did notice improvement in his mood. But while Jeff no longer felt angry all the time, he still didn’t feel “normal.” Because he had been through so much, Jeff’s parents felt that he could benefit from seeing a counselor. The counselor helped Jeff learn techniques to identify and deal with his emotions. Now, when he did feel anger coming on, he could sometimes recognize and control it through relaxation and meditation techniques before it got out of hand. Soon he was thinking less about his medical condition and more about living his life again. Sometimes “natural” remedies can provide relief to people suffering from a mental disorder caused by a medical condition. However, care must be taken with any drugs, including over-the-counter medications and products that are marketed as natural. These include herbal treatments, such as SAM-e and Saint-John’s-wort, which some people use to try to alleviate depression. Herbs do not fall under the same kind of testing and governmental controls as prescription and over-the-counter pharmaceuticals. Individuals will experience varying results with alternative treatments, but trying several different options may lead to the right combination of methods that help in each particular situation. The best way to successfully combat illness is always to seek medical advice from a professional. The medical field, both physical and psychological, is constantly changing. What is a problem today may have a solution tomorrow. For those suffering from both a physical and a mental disorder, the pain and anguish over what to deal with first may only be resolved by consulting a competent and caring physician. Many different medications are available to treat most disorders, and often people do not get relief with the first prescription they try. A variety of solutions may work alone or in combination with each other to achieve successful alleviation of disease, injury, and any associated mental disorder due to a general medical condition. Modern drug treatments offer real hope.

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Keep Stress and Anxiety in Control • Try to recognize the stressors in your life. These may not be the same as your friend’s or even any other family member. But it is important to identify them so that they can be reduced or eliminated. • Learn relaxation techniques like meditation, prayer, and progressive muscle relaxation. You might even get help from someone who knows hypnosis. • Get enough sleep. Being rested can make a great difference for any disorder. If sleeping is a problem, be sure to discuss it with your doctor. • Exercise regularly. Exercise releases chemicals in the brain that make a person feel calmer and more relaxed. It also improves general health and psychological well-being. • Make a list of everything that worries you. When you see your worries written on paper they may not look as scary. If they do still bother you, you might be able to find solutions more readily by seeing the problems written out. Finally, try to convince yourself to look at this list once a day and worry about it only at that time; the rest of the time you may become worry-free. If you think of one of the worries later, remind yourself that it’s not time to worry. Later, when you look at the list again, you can worry about it. The goal is to restrict worry time to only when you are looking at the list. Adapted from the Northern County Psychiatric Associates at www.ncpamd.com/dmdepression.htm

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Further Reading Collazo-Clavell, Maria (Ed.). Mayo Clinic on Managing Diabetes. Rochester, Minn.: Mayo Foundation for Medical Education and Research, 2006 . Edelman, Norman H. American Lung Association Family Guide to Asthma and Allergies. New York: Skyhorse Publishing, 2013. Gorman, Jack M. The Essential Guide to Psychiatric Drugs. New York: St. Martin’s Griffin, 2007. Lahita, Robert G. Lupus Q and A. New York: Avery Publishing Group, 2004. Langer, Stephen E., and James F. Scheer. Solved: The Riddle of Illness. Springfield, Ill.: Keats Publishing, 2006. Ehde, Dawn, Robert Fraser, Kurt Johnson, and George Kraft. The MS Workbook: Living Fully with Multiple Sclerosis. Oakland, Calif.: New Harbinger Publications, 2006. Sacks, Oliver. Awakenings. New York: Vintage Books, 2006. Saudek, Christopher D., Frederick L. Brancati, and Rita Rastogi Kalyani. Johns Hopkins Poc-It Center Diabetes Guide 2012. Burlington, Mass.: Jones and Bartlett Learning, 2012 Shiminski-Maher, Tania, Patsy Cullen, and Maria Sansalone. Childhood Brain & Spinal Cord Tumors. San Diego, Calif.: O’Reilly & Associates, 2002.

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For More Information American Academy of Child and Adolescent Psychiatry www.aacap.org American Diabetes Association www.diabetes.org The American Lung Association/Asthma www.lungusa.org/asthma Asthma and Allergy Foundation of America www.aafa.org Canadian Diabetes Association www.diabetes.ca The Food and Drug Administration www.fda.gov InsulinIndependance www.insulinindependance.org Juvenile Diabetes Research Foundation International www.jdrf.org Living Well With Asthma—The Asthma Society of Canada www.asthma.ca/adults National Heart, Lung, and Blood Institute Information Center: National Institutes of Health www.nhlbi.nih.gov

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Neuroscience for Kids faculty.washington.edu/chudler/neurok.html

Publisher’s Note: The websites listed on these pages were active at the time of publication. The publisher is not responsible for websites that have changed their address or discontinued operation since the date of publication. The publisher will review and update the websites upon each reprint.

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alprazolam (Xanax) 52, 54 amitriptyline (Elavil) 52, 81 Amoxipine 81 asthma 106, 108–112, 114–119, 121

Index

barbiturates 54 benzodiazepines 54 brain tumor 19–20, 38–41, 97 central nervous system (CNS) 21, 26–27, 30, 37, 50 chlordiazepoxide (Librium) 52, 54 chlorpromazine (Thorazine) 50, 52–53, 60 citalopram (Celexa) 52, 81 clonazepam (Klonopin) 52, 54 diabetes 37, 62–69, 71, 73–74, 99 Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) 19–20, 55, 72, 115 diazepam (Valium) 52, 54 epilepsy 92–94 fluoxetine (Prozac) 52, 81 fluvoxamine (Luvox) 52 gamma-aminobutyric acid (GABA) 89 haloperidol (Haldol) 50, 52, 60 homeopathic medicine 121 Journal of the American Academy of Child and Adolescent Psychiatry 7, 117 L-dopa 53, 55–57 lithium 42, 44, 47, 59–61, 97–99, 121 lupus 21, 46–48, 50, 60

mirtazapine (Remeron) 52, 81 nefazodone (Serzone) 52 neurons 30, 36, 50, 53, 89 neurotransmitters 36, 102–103 oxazepam (Serax) 52, 54 panic attack 109 paroxetine (Paxil) 52, 81 phenelzine (Nardil) 52, 81 phenytonin sodium (Dilantin) 89, 93 Physician’s Desk Reference (PDR) 89, 102 psychotherapy 77 Rhodiola rosea 111 risperidone (Risperdal) 50, 52, 60 Sacks, Oliver 53 Saint-John’s-wort 122 SAM-e 122 serotonin 50, 53 sertraline hydrochloride (Zoloft) 52, 81 support groups 112 temazepam (Restoril) 52, 54 Therapeutic Product Directorate (TPD) 56 thiamine deficiency 86–87 tranylcypromine (Parnate) 52, 81 triazolam (Halcion) 52, 54 U.S. Food and Drug Administration (FDA) 9, 56–57, 76 valproate (Depakote) 52, 89, 93 venlafaxine (Effexor) 52, 81 Wellbutrin 81

magnetic resonance imaging (MRI) 18–19, 93

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About the Author & Consultants Joyce Libal is a graduate of the University of Wisconsin. She lives in northeastern Pennsylvania where she works as a magazine editor and freelance writer. She has also written books for other Mason Crest series, including Careers with Character and North American Folklore. Mary Ann McDonnell, Ph.D., R.N., is the owner of South Shore Psychiatric Services, where she provides psychiatric services to children and adolescents. She has worked as a psychiatric nurse at Franciscan Hospital for Children and has been a clinical instructor for Northeastern University and Boston College advanced-practice nursing students. She was also the director of clinical trials in the pediatric psychopharmacology research unit at Massachusetts General Hospital. Her areas of expertise are bipolar disorder in children and adolescents, ADHD, and depression. Donald Esherick has worked in regulatory affairs at Rhone-Poulenc Rorer, Wyeth Pharmaceuticals, Pfizer, and Pharmalink Consulting. He specializes in the chemistry section (manufacture and testing) of investigational and marketed drugs.

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