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Questions
of the Week
April
Through June, 1999
April 5, 1999
Q "It
seemed to me that when you were answering the question about anorexia,
you also answered a general question about bulimia. Can you tell me
about the latter?"
A Bulimia
Nervosa - involves recurrent episodes of binge eating in which the
quantity of food consumed is definitely larger than most would eat
during a similar period and under similar circumstances and there is
an apparent lack of control over the eating (the person cannot stop).
To prevent weight gain, the person will engage in self-induced
vomiting, use of laxatives and/or diuretics, enemas, fasting,
excessive exercise, etc. Bulimia is characterized not by a distortion
in body image as much as this binge eating and compensatory attempts
to avoid weight gain from the binging. For the formal diagnosis, this
must occur twice a week for three months, and the individual's
assessment of their body shape and weight influences the cycle of
eating and then compensating. The are the purging type bulimic
individuals in which the person uses the laxatives, diuretics, etc.
and the nonpurging type in which the individual fasts or excessively
exercises to compensate.
April 12, 1999
Q I go to
school with girls that engage in strange eating behavior that somewhat
looks like bulimia or somewhat looks like anorexic but does not meet
all the criteria you list for either, yet I suspect that are just
about as ill as anyone who meets those criteria. Can you see what I
mean?"
A Disorder
Not Otherwise Specified is a common reference to a combination of
unhealthy behaviors which in combination do not fit specific criteria
for a disorder but which obviously limit the social and/or
occupational functioning of the individual. For example, in the case
of eating disorders, there are individuals who meet the criteria for
Anorexia Nervosa but have regular menses, who have lost appreciable
weight but are still within average weight limits for their height,
who engage in purging activities but do so with less frequency than
necessary to meet diagnostic criteria, who engage in purging
activities after small amounts of food and/or who chew and spit out
small amounts of food. Human behavior and psychological problems are a
continuum and even when all criteria are not met, the behaviors can
still be maladaptive.
April 19, 1999
Q "I
know very little about schizophrenia. I know that the common
expression of split-personality is not accurate, but when they talk in
the newspaper or on TV about some individual being schizophrenic at
the time they committed a crime, I really do not know what they
mean.?"
A
Schizophrenic individuals have two or more of the following symptoms
for a significant period of time during a one month period. These
include delusions or false beliefs that govern their decision making,
hallucinations which are faulty sensory perceptions such as seeing,
hearing (etc) stimuli that exist only in their fantasy, disorganized
speech which is difficult to comprehend, chaotic or catatonic behavior
and/or negative symptoms such as blunting of their emotional
expression. Social and occupational functioning is severely impaired
as may be their capacity for self-care. The symptoms are not due to a
medical disorder, and the symptoms are not due primarily to a mood
disorder. Next week we shall discuss some of the subtypes of
schizophrenia of which you may have heard.
April 26, 1999
Q The
American Academy presented an overview of schizophrenia last week.
Could you tell me the various types and what makes they different from
each other.?"
A There are
chiefly five subtypes of schizophrenia:
1. Paranoid Type: preoccupation with delusions (false beliefs) or
auditory hallucinations (perception of hearing voices which can be
condemning or commanding).
2. Disorganized Type: disorganized speech, behavior and flat (blunt)
affect (emotional expression) or inappropriate (to the context)
emotional expression.
3. Catatonic Type: (can include) motoric immobility (statue like body
position), stupor or cataplexy (patient can be put into position which
they then maintain), or excessive agitation and without purpose,
mutisim and/or negativism (refusing to respond to commands), peculiar
voluntary body movements or grimacing, echolalia/echopraxia (repeating
that which is said)
4. Undifferentiated Type: none of the symptoms are sufficient to be
assigned exclusively to the first three types listed above, yet the
patient meets the criteria for schizophrenia
5. Residual Type: an absence of paranoid, disorganized or catatonic
symptoms but continuing evidence of schizophrenia by the presence of
negative symptoms and often accompanied by odd beliefs and unusual
perceptual experiences
May 3, 1999
Q The
description you gave of schizophrenia...I was not certain whether you
can cure it, it just goes away and if that influences the
diagnosis."
A There are
specifiers used after the patient has had symptoms of schizophrenia
for at least one year after the onset of active-phase symptoms. These
are described as episodice with interepisode residual symptoms when
there are significant residual symptoms even between the episodes of
schizophrenia. This can be further refined to prominent negative
symptoms if the symptoms between episodes are negative. There is a
specifier for no interepisode residual symptoms. A patient can have
continuous symptoms or sontinuous symptoms with prominent negative
symptoms. Or the patient may have a single schizophrenic episode in
partial remission and with prominewnt negative symptoms. A patient can
also have a single schizophrenic episode which is in full remission.
May 10, 1999
Q I believe
I have a better understanding of schizophrenia, but it seems to
require six months duration of symptoms for the diagnosis. Are there
people who simply recover in less than six months or who have not been
ill for six months? How are they classified?"
A
Schizophreniform Disorder is characterized by symptoms lasting at
least a month but less than six months. The symptoms are identical
(delusions, hallucinations, disorganized speech, disorganized behavior
and negative symptoms). Like schizophrenia, one must be certain that
the disorder is not due to a medical condition or drugs and that it is
not part of a schizoaffective disorder (we'll discuss next week).
Schizophreniform Disorder is often accompanied by the specifier of
having good prognostic features or without good prognostic features.
Good prognosis is characterized by absence of the previously discussed
flat/blunt emotions, having previously good social and occupational
functioning, confusion/perplexity associated with the height of the
episode, and onset of psychotic symptoms within the first four weeks
of initial symptoms. Thus, good prognosis is often associated with the
acute/suddenness of the onset.
May 17, 1999
Q You
mentioned something called schizoaffective disorder a few weeks ago.
My aunt has been diagnosed with that. Exactly what is it?"
A
Schizoaffective disorder is diagnosed when there has been an
uninterrupted period of symptoms of schizophrenia which, as noted, may
include delusions, hallucinations, disorganization of speech,
disorganized or catatonic behavior and negative symptoms such as
(affective flattening) blunted emotional expression. The patient
displays these symptoms along with mood symptoms of a major depressive
episode, a manic episode or a mixed episode and that during the period
of the illness the patient has experienced delusions or hallucinations
in the absence of these prominent mood symptoms. As with all
schizophrenic and other psychotic disorders, it is imperative to be
certain that these symptoms are not related to medication intake, drug
abuse, or a physical disorder. And in schizoaffective disorder, there
is a further subdivision of Bipolar and Depressive Types. The mood
episode of the disorder are present for a substantial period of the
active and residual periods of the illness.
May 31, 1999
Q What is
wrong with people who believe they are being followed or spied
upon...or those who feel their wives are cheating on them...or that
some celebrity is in love with them like the stalkers you read
about?"
A
Delusional Disorder involves potentially real life situations that
are, however, unreal in the life of the patient. Thus, a person may,
indeed, be poisoned, famous or followed, but this is not reality for
the patient. These patients are not odd, eccentric or bizarre as we
see in schizophrenia but instead falsely believe that important people
are in love with them (Erotomanic Type) or that they (the patients)
themselves are powerful, knowledgeable, or wealthy (Grandiose Type),
that the person is being malevolently treated (Persecutory Type), that
their sexual partner is unfaithful (Jealous Type), that they have a
physical defect or medical condition (Somatic Type) or that they have
symptoms of two or more of these subtypes (Mixed Type). Outside of
their delusional beliefs, the individual may have an overall
appearance of being functional with minimal impairment.
June 7, 1999
Q "Is
it possible, without a drug problem, for someone to have symptoms of
schizophrenia that are brief and tied to things happening in their
lives?"
A Brief
Psychotic Disorder refers to symptoms lasting at least one day, but
less than one month, and may include delusions, hallucinations,
disorganized speech and either disorganized or catatonic behavior.
This needs to be differentiatef from those who have a mood disorder
such as major depressive disorder or bipolar disorder which sometimes
presents with psychotic symptoms. A brief psychotic disorder may arise
within four weeks of childbirth or caused by marked psychological
stressors or can occur in the absence of a stressor. It is important
to validate that this is not the result of a physical condition or
substance use.
June 14, 1999
Q
"This is more a question of curiosity, but what about the cult
leaders who appear quite disturbed but manage to get others to join
them. I am thinking about those who willingly commit suicide, those
who wait on mountain tops for the end of the world, or those who
belief that they are doing the work of God or Satan? I would think
that this is more than Dependent Personality discussed some time
ago."
A In Shared
Psychotic Disorder (also called Folie a Deux) a delusion or false
belief system develops in an individual who is closely involved with
another individual who is demonstrably delusional. The second
individual's delusion is similar, if not identical, to that of the
individual with whom they are involved. They essentially share the
same delusional system. This can apply to couples, and it can apply to
groups of individuals. This must be differentiated from those who are
abusing similar psychoactive substances and/or who were, for example,
schizophrenic before entering the relationship with the delusional
individual.
June 21, 1999
Q "I
know from what has been discussed here that there are many ways in
which a person can "break from reality" and that much of
this can be based upon a combination of life stresses and their own
physical [genetic] attributes. But did I not read somewhere that some
illnesses or injuries can cause these psychotic problems?"
A Psychotic
Disorders Due to [specific general medical condition] are
characterized by hallucinations or delusions and can be the result of
metabolic, neoplastic, or structural accident of the either the
central nervous system or organ systems which impact the nervous
system. History, laboratory findings and/or physical exam are used to
determine the medical condition giving rise to the symptoms, and,
ideally, a means of addressing the medical problem.
June 28, 1999
Q "When
people take drugs that make them behave with psychotic symptoms, the
hallucinations and delusions you have been discussing, is that not a
mental disorder? Is it just considered part of the drugs and there is
no diagnosis? This is confusing to me."
A
Substance-Induced Psychotic Disorder can occur With Onset During
Intoxication by the drug or With Onset During Withdrawal from the
drug. The symptoms occur within a month of the intoxication or
withdrawal, and drug (and not a disease process) must be known to be
the cause of the symptoms. Many drugs are capable of producing
hallucinations and/or delusions when initiated or withdrawn. These
include alcohol, amphetamines, cocaine, inhalants, sedatives,
hypnotics (sleep agents), anxiolytics ("minor
tranquilizers") and numerous other compounds.
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