by the pines

Definition

People with paranoid personality disorder (PPD) have long-term, widespread and unwarranted suspicions that other people are hostile, threatening or demeaning. These beliefs are steadfastly maintained in the absence of any real supporting evidence. The disorder, whose name comes from the Greek word for “madness,” is one of ten personality disorders described in the 2000 edition of the Diagnostic and Statistical Manual of Mental Disorders,(the fourth edition, text revision or DSM-IVTR), the standard guidebook used by mental health professionals to diagnose mental disorders.

Despite the pervasive suspicions they have of others, patients with PPD are not delusional (except in rare, brief instances brought on by stress). Most of the time, they are in touch with reality, except for their misinterpretation of others’ motives and intentions. PPD patients are not psychotic but their conviction that others are trying to “get them” or humiliate them in some way often leads to hostility and social isolation.

Description

People with PPD do not trust other people. In fact, the central characteristic of people with PPD is a high degree of mistrustfulness and suspicion when interacting with others. Even friendly gestures are often interpreted as being manipulative or malevolent. Whether the patterns of distrust and suspicion begin in childhood or in early adulthood, they quickly come to dominate the lives of those suffering from PPD. Such people are unable or afraid to form close relationships with others.

They suspect strangers, and even people they know, of planning to harm or exploit them when there is no good evidence to support this belief. As a result of their constant concern about the lack of trustworthiness of others, patients with this disorder often have few intimate friends or close human contacts. They do not fit in and they do not make good “team players.” Interactions with others are characterized by wariness and not infrequently by hostility. If they marry or become otherwise attached to someone, the relationship is often characterized by pathological jealousy and attempts to control their partner. They often assume their sexual partner is “cheating” on them.

People suffering from PPD are very difficult to deal with. They never seem to let down their defenses. They are always looking for and finding evidence that others are against them. Their fear, and the threats they perceive in the innocent statements and actions of others, often contributes to frequent complaining or unfriendly withdrawal or aloofness. They can be confrontational, aggressive and disputatious. It is not unusual for them to sue people they feel have wronged them. In addition, patients with this disorder are known for their tendency to become violent.

Despite all the unpleasant aspects of a paranoid lifestyle, however, it is still not sufficient to drive many people with PPD to seek therapy. They do not usually walk into a therapist’s office on their own. They distrust mental health care providers just as they distrust nearly everyone else. If a life crisis, a family member or the judicial system succeeds in getting a patient with PPD to seek help, therapy is often a challenge. Individual counseling seems to work best but it requires a great deal of patience and skill on the part of the therapist. It is not unusual for patients to leave therapy when they perceive some malicious intent on the therapist’s part. If the patient can be persuaded to cooperate— something that is not easy to achieve— low-dose medications are recommended for treating such specific problems as anxiety, but only for limited periods of time.

If a mental health care provider is able to gain the trust of a patient with PPD, it may be possible to help the patient deal with the threats that they perceive. The disorder, however, usually lasts a lifetime.

Causes and symptoms

Causes

No one knows what causes paranoid personality disorder, although there are hints that familial factors may influence the development of the disorder in some cases. There seem to be more cases of PPD in families that have one or more members who suffer from such psychotic disorders as schizophrenia or delusional disorder.

Other possible interpersonal causes have been proposed. For example, some therapists believe that the behavior that characterizes PPD might be learned. They suggest that such behavior might be traced back to childhood experiences. According to this view, children who are exposed to adult anger and rage with no way to predict the outbursts and no way to escape or control them develop paranoid ways of thinking in an effort to cope with the stress. PPD would emerge when this type of thinking becomes part of the individual’s personality as adulthood approaches.

Studies of identical (or monozygotic) and fraternal (or dizygotic) twins suggest that genetic factors may also play an important role in causing the disorder. Twin studies indicate that genes contribute to the development of childhood personality disorders, including PPD. Furthermore, estimates of the degree of genetic contribution to the development of childhood personality disorders are similar to estimates of the genetic contribution to adult versions of the disorders.

Symptoms

A core symptom of PPD is a generalized distrust of other people. Comments and actions that healthy people would not notice come across as full of insults and threats to someone with the disorder. Yet, generally, patients with PPD remain in touch with reality; they don’t have any of the hallucinations or delusions seen in patients with psychoses. Nevertheless, their suspicions that others are intent on harming or exploiting them are so pervasive and intense that people with PPD often become very isolated. They avoid normal social interactions. And because they feel so insecure in what is a very threatening world for them, patients with PPD are capable of becoming violent. Innocuous comments, harmless jokes and other day-to-day communications are often perceived as insults.

Paranoid suspicions carry over into all realms of life. Those burdened with PPD are frequently convinced that their sexual partners are unfaithful. They may misinterpret compliments offered by employers or coworkers as hidden criticisms or attempts to get them to work harder. Complimenting a person with PPD on their clothing or car, for example, could easily be taken as an attack on their materialism or selfishness.

Because they persistently question the motivations and trustworthiness of others, patients with PPD are not inclined to share intimacies. They fear such information might be used against them. As a result, they become hostile and unfriendly, argumentative or aloof. Their unpleasantness often draws negative responses from those around them. These rebuffs become “proof” in the patient’s mind that others are, indeed, hostile to them. They have little insight into the effects of their attitude and behavior on their generally unsuccessful interactions with others. Asked if they might be responsible for negative interactions that fill their lives, people with PPD are likely to place all the blame on others.

A brief summary of the typical symptoms of PPD includes:

• suspiciousness and distrust of others
• questioning hidden motives in others
• feelings of certainty, without justification or proof, that others are intent on harming or exploiting them
• social isolation
• aggressiveness and hostility
• little or no sense of humor

Demographics

As of 2002, it has not been possible to determine the number of people with PPD with any accuracy. This lack of data might be expected for a disorder that is characterized by extreme suspiciousness. Such patients in many cases avoid voluntary contact with such people as mental health workers who have a certain amount of power over them. There are, nonetheless, some estimates of the prevalence of PPD. According to the DSM-IV-TR, between 0.5% and 2.5% of the general population of the United States may have PPD, while 2%–10% of outpatients receiving psychiatric care may be affected. A significant percentage of institutionalized psychiatric patients, between 10% and 30%, might have symptoms that qualify for a diagnosis of PPD. Finally, the disorder appears to be more common in men than in women.

There are indications in the scientific literature that relatives of patients with chronic schizophrenia may have a greater chance of developing PPD than people in the general population. Also, the incidence of the disorder may be higher among relatives of patients suffering from another psychotic disorder known as delusional disorder of the persecutory type.

Diagnosis

There are no laboratory tests or imaging studies as of 2002 that can be used to confirm a diagnosis of PPD. The diagnosis is usually made on the basis of the doctor’s interview with the patient, although the doctor may also give the patient a diagnostic questionnaire. In addition, input from people who know the patient may be requested.

Diagnostic criteria

Mental health care providers look for at least five distinguishing symptoms in patients who they think might suffer from PPD. The first is a pattern of suspiciousness about, and distrust of, other people when there is no good reason for either. This pattern should be present from at least the time of the patient’s early adulthood.

In addition to this symptom that is required in order to make the PPD diagnosis, the patient should have at least four of the following seven symptoms as listed in the DSM-IV-TR:

• The unfounded suspicion that people want to deceive, exploit or harm the patient.
• The pervasive belief that others are not worthy of trust or that they are not inclined to or capable of offering loyalty.
• A fear that others will use information against the patient with the intention of harming him or her. This fear is demonstrated by a reluctance to share even harmless personal information with others.
• The interpretation of others’ innocent remarks as insulting or demeaning; or the interpretation of neutral events as presenting or conveying a threat.
• A strong tendency not to forgive real or imagined slights and insults. People with PPD nurture grudges for a long time.
• An angry and aggressive response in reply to imagined attacks by others. The counterattack for a perceived insult is often rapid.
• Suspicions, in the absence of any real evidence, that a spouse or sexual partner is not sexually faithful, resulting in such repeated questions as “Where have you been?” “Whom did you see?” etc., and other types of jealous behavior.

Differential diagnosis

Psychiatrists and clinical psychologists should be careful not to confuse PPD with other mental disorders or behaviors that have some symptoms in common with the paranoid personality. For example, it is important to make sure that the patient is not a long-term user of amphetamine or cocaine. Chronic abuse of these stimulants can produce paranoid behavior. Also, some prescription medications might produce paranoia as a side effect; so it is important to find out what drugs, if any, the patient is taking.

There are other conditions that, if present, would mean a patient with paranoid traits does not have PPD. For example, if the patient has symptoms of schizophrenia, hallucinations or a formal thought disorder, a diagnosis of PPD can’t be made. The same is true of delusions, which are not a feature of PPD.

Also, the suspiciousness and other characteristic features of PPD must have been present in the patient for a long time, at least since early adulthood. If the symptoms appeared more recently than that, a person can’t be given a diagnosis of this disorder.

There are at least a dozen disorders or other mental health conditions listed in the DSM-IV-TRthat could be confused with PPD after a superficial interview because they share similar or identical symptoms with PPD. It is important, therefore, to eliminate the following entities before settling on a diagnosis of PPD: paranoid schizophrenia; schizotypal personality disorder; schizoid personality disorder; persecutory delusional disorder; mood disorder with psychotic features; symptoms and/or personality changes produced by disease, medical conditions, medication or drugs of abuse; paranoia linked to the development of physical handicaps; and borderline, histrionic, avoidant, antisocial or narcissistic personality disorders.

In some individuals, symptoms of PPD may precede the development of schizophrenia. Should a patient who as been correctly diagnosed with PPD later develop schizophrenia, the DSM-IV-TRsuggests that the diagnosis on the patient’s medical record be changed from “Paranoid Personality Disorder” to “Paranoid Personality Disorder (Premorbid).”

Treatments

Because they are suspicious and untrusting, patients with PPD are not likely to seek therapy on their own. A particularly disturbing development or life crisis may prompt them to get help. More often, however, the legal system or the patient’s relatives order or encourage him or her to seek professional treatment. But even after a patient finally agrees or is forced to seek treatment, the nature of the disorder poses very serious challenges to therapists.

Psychotherapy

The primary approach to treatment for such personality disorders as PPD is psychotherapy. The problem is that patients with PPD do not readily offer therapists the trust that is needed for successful treatment. As a result, it has been difficult to gather data that would indicate what kind of psychotherapy would work best. Therapists face the challenge of developing rapport with someone who is, by the nature of his personality disorder, distrustful and suspicious; someone who often sees malicious intent in the innocuous actions and statements of others. The patient may actively resist or refuse to cooperate with others who are trying to help.

Mental health workers treating patients with PPD must guard against any show of hostility on their part in response to hostility from the patient, which is a common occurrence in people with this disorder. Instead, clinicians are advised to develop trust by persistently demonstrating a nonjudgmental attitude and a professional desire to assist the patient.

It is usually up to the therapist alone to overcome a patient’s resistance. Group therapy that includes family members or other psychiatric patients, not surprisingly, isn’t useful in the treatment of PPD due to the mistrust people with PPD feel towards others. This characteristic also explains why there are no significant self-help groups dedicated to recovery from this disorder. It has been suggested, however, that some people with PPD might join cults or extremist groups whose members might share their suspicions.

To gain the trust of PPD patients, therapists must be careful to hide as little as possible from their patients. This transparency should include note taking; details of administrative tasks concerning the patient; correspondence; and medications. Any indication of what the patient would consider “deception” or covert operation can, and often does, lead the patient to drop out of treatment. Patients with paranoid tendencies often don’t have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.

With some patients, the most attainable goal may be to help them to learn to analyze their problems in dealing with other people. This approach amounts to supportive therapy and is preferable to psychotherapeutic approaches that attempt to analyze the patient’s motivations and possible sources of paranoid traits. Asking about a patient’s past can undermine the treatment of PPD patients. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.

With time and a skilled therapist, the patient with PPD who remains in therapy may develop a measure of trust. But as the patient reveals more of his paranoid thoughts, the clinician will continue to face the difficult task of balancing the need for objectivity about the paranoid ideas and the maintenance of a good rapport with the patient. The therapist thus walks a tightrope with this type of patient. If the therapist is not straightforward enough, the patient may feel deceived. If the therapist challenges paranoid thoughts too directly, the patient will be threatened and probably drop out of treatment.

Medications

While individual supportive psychotherapy is the treatment of choice for PPD, medications are sometimes used on a limited basis to treat related symptoms. If, for example, the patient is very anxious, anti-anxiety drugs may be prescribed. In addition, during periods of extreme agitation and high stress that produce delusional states, the patient may be given low doses of antipsychotic medications.

Some clinicians have suggested that low doses of neuroleptics should be used in this group of patients; however, medications are not normally part of long-term treatment for PPD. One reason is that no medication has been proven to relieve effectively the long-term symptoms of the disorder, although the selective serotonin reuptake inhibitors such as fluoxetine(Prozac) have been reported to make patients less angry, irritable and suspicious. Antidepressants may even make symptoms worse. A second reason is that people with PPD are suspicious of medications. They fear that others might try to control them through the use of drugs. It can therefore be very difficult to persuade them to take medications unless the potential for relief from another threat, such as extreme anxiety, makes the medications seem relatively appealing. The best use of medication may be for specific complaints, when the patient trusts the therapist enough to ask for relief from particular symptoms.

Prognosis

Paranoid personality disorder is often a chronic, lifelong condition; the long-term prognosis is usually not encouraging. Feelings of paranoia, however, can be controlled to a degree with successful therapy. Unfortunately, many patients suffer the major symptoms of the disorder throughout their lives.

Prevention

With little or no understanding of the cause of PPD, it is not possible to prevent the disorder.

Definition

Paranoia is a symptom in which an individual feels as if the world is “out to get” him or her. When people are paranoid, they feel as if others are always talking about them behind their backs. Paranoia causes intense feelings of distrust, and can sometimes lead to overt or covert hostility.

Description

An individual suffering from paranoia feels suspicious, and has a sense that other people want to do him or her harm. As a result, the paranoid individual changes his or her actions in response to a world that is perceived as personally threatening. Objective observers may be quite clear on the fact that no one’s words or actions are actually threatening the paranoid individual. The hallmark of paranoia is a feeling of intense distrust and suspiciousness that is not in response to input from anybody or anything in the paranoid individual’s environment.

Other symptoms of paranoia may include

• Self-referential thinking: The sense that other people in the world (even complete strangers on the street) are always talking about the paranoid individual.
• Thought broadcasting: The sense that other people can read the paranoid individual’s mind.
• Magical thinking: The sense that the paranoid individual can use his or her thoughts to influence other people’s thoughts and actions.
• Thought withdrawal: The sense that people are stealing the paranoid individual’s thoughts.
• Thought insertion: The sense that people are putting thoughts into the paranoid individual’s mind.
• Ideas of reference: The sense that the television and/or radio are specifically addressing the paranoid individual.

Demographics

Paranoia is a very human feeling. Nearly everyone has experienced it at some or another time, to varying degrees. Paranoia exists on a continuum, ranging from a feeling of distrust due to an occasional misinterpretation of cues that can be appropriately dealt with and reinterpreted, to an overarching pattern of actual paranoia that affects every interpersonal interaction.

Some research studies have suggested that 6% of all women and 13% of all men have some chronic level of mistrust towards the motivations of others towards them. Only about 0.5% to 0.25% of men and women can actually be diagnosed with paranoid personality disorder, however. It remains interesting to researchers that men are more prone to paranoid traits and mental disorders with paranoid features than are women.

Causes of paranoia

Researchers do not understand fully what chemical or physical changes in the brain cause paranoia. Paranoia is a prominent symptom that occurs in a variety of different mental disorders, as well as a symptom of certain physical diseases. Furthermore, use of certain drugs or chemicals may cause symptoms of paranoia in an otherwise normal individual.

Paranoia is often manifested as part of the symptom complex of schizophrenia. In fact, one of the subtypes of schizophrenia is termed “paranoid schizophrenia,” which actually refers to a type of schizophrenia in which the individual is particularly preoccupied with delusions in which the world seems to be pitted against him or her. As with other forms of schizophrenia, sufferers often lack contact with reality, and display hallucinations, flat or emotionless affect, and disorganized thinking and behavior.

Paranoid personality disorder is diagnosed when an individual does not have other symptoms of schizophrenia, but a personality that is driven by chronic manifestations of paranoia. These individuals are mistrustful, suspicious, and convinced that the world is out to get them.

In order for an individual to be diagnosed with paranoid personality disorder, he or she must display at least four of the following traits:

• chronically suspicious that people are lying or cheating him or her in some way
• frequently preoccupied with whether people are loyal or trustworthy
• cannot confide in others for fear of being betrayed
• misinterprets benign comments or events as being personally threatening
• harbors long-term grudges against others who are perceived as having been threatening or insulting in some way
• sees others’ actions and/or words attacking him or her in some way, and therefore goes on the counterattack
• repeatedly assumes that partner or spouse is unfaithful

Paranoia can also occur as a symptom of other neurological diseases. Individuals suffering from the aftereffects of strokes, brain injuries, various types of dementia(including Alzheimer’s disease), Huntington’s disease, and Parkinson’s disease may manifest paranoia as part of their symptom complex. The paranoia may decrease in intensity when the underlying disease is effectively treated, although since many of these diseases are progressive, the paranoia may worsen over time along with the progression of the disease’s other symptoms.

A number of different medications and drugs can cause paranoia. These include corticosteroid medications, H-2 blockers (cimetidine, ranitidine, famotidine), some muscle relaxants (Baclofen), antiviral/anti-Parkinson drugs (amantadine), some amphetamines(including methylphenidate, or Ritalin), anti-HIV medications, anti-depressants (Nardil). Abused drugs that can prompt paranoia include alcohol, cocaine, marijuana, ecstasy (MDMA), amphetamines (including Ritalin), LSD, and PCP (angel dust). Withdrawal from addictive drugs may also cause symptoms of paranoia.

Treatments

It can be quite challenging to get an individual who is suffering from paranoia to accept treatment. Their paranoid condition makes them distrustful of people’s motivations towards them, so that even a medical doctor appears to be a suspicious party. Medications that may be offered are usually looked at with great distrust, and efforts at psychotherapy are considered “mind control” by a profoundly paranoid individual.

The first step to be taken when someone is suffering from paranoia is that of determining whether an easily reversible situation (such as an adverse reaction to a medication) might be causing the paranoia. If so, discontinuing the drug (either immediately or by gradually weaning the dose) might end the symptoms of paranoia.

Patients who have other diseases, such as Alzheimer’s disease or other forms of dementia, Huntington’s disease, or Parkinson’s disease may notice that their paranoid symptoms improve when their general medical condition is treated. The circumstance that can occur as their underlying disease progresses, is that the paranoia may return or worsen over time.

People who are suffering from diagnosable mental conditions such as schizophrenia or paranoid personality disorder may benefit from the use of typical antipsychotic medications, such as chlorpromazine or haloperidol, or from the newer, atypical antipsychotic medications, such as clozapine, olanzapine, or risperidone.

Cognitive-behavioral therapy(CBT) or other forms of psychotherapy may be helpful for certain people who have paranoia. CBT attempts to make a person more aware of his or her actions and motivations, and tries to help the individual learn to more accurately interpret cues around him or her, in an effort to help the individual change dysfunctional behaviors. Difficulty can enter into a therapeutic relationship with a paranoid individual, due to the level of mistrust and suspicion that is likely to interfere with their ability to participate in this form of treatment.

Support groups can be helpful for some paranoid individuals—particularly helpful in assisting family members and friends who must learn to live with, and care for paranoid individuals.

Prognosis

It is difficult to predict the prognosis of an individual who has paranoia. If there is an underlying mental illness, such as schizophrenia or paranoid personality disorder, then the paranoia is likely to be a lifelong condition. It may improve with some treatments (remission), only to become exacerbated under other more stressful conditions, or with changes in medication.

Individuals who have symptoms of paranoia as part of another medical condition may also have a waxing-and-waning-course.

When paranoia is caused by the use of a particular drug or medication, it is possible that discontinuing that substance may completely reverse the symptoms of paranoia.

Definition

Panic disorder is a condition in which the person with the disorder suffers recurrent panic attacks. Panic attacks are sudden attacks that are not caused by a substance (like caffeine), medication, or by a medical condition (like high blood pressure), and during the attack, the sufferer may experience sensations such as accelerated or irregular heartbeats, shortness of breath, dizziness, or a fear of losing control or “going crazy.” The sudden attack builds quickly (usually within 10 minutes) and is almost paralyzing in its severity. When a diagnosis of panic disorder is given, the disorder can be considered one of two different types—panic disorder with or without agoraphobia.

The handbook for mental health professionals (called the Diagnostic and Statistical Manual of Mental Disorders, or theDSM-IV-TR) classifies both types of panic disorder as anxiety disorders.

Panic disorder without agoraphobia

Panic disorder without agoraphobia is defined by the DSM-IV-TRas a disorder in which patients are plagued by panic attacks that occur repeatedly and without warning. After these attacks, the affected individual worries for one month or more about having more embarrassing attacks, and may change his or her behavior with regard to these attacks. For example, a patient may fear that he or she has a cardiac condition, and may quit a job or quit exercising because of the fear. Patients may also worry that they are going to lose control or appear insane to other people. Panic disorder without agoraphobia has a less severe set of symptoms than panic disorder with agoraphobia. Patients without agoraphobia do not become housebound—they suffer panic attacks but do not have significant interference in their level of function and are still able to accomplish their daily activities.

Panic disorder with agoraphobia

People who suffer from this kind of panic disorder may experience their agoraphobia in one of two ways. They may experience sudden, unexpected panic attacks that cause them to fear being in a place where help might not be available; or, they may experience sudden panic attacks in specific, known situations, and fear those situations or places that may trigger attacks. In either case, the fear of further panic attacks restricts the affected person’s activities. For example, people whose attacks are triggered by being in crowds may avoid shopping malls for fear that they will be in a crowd and have a panic attack. Or, a person may experience sudden, debilitating panic attacks without a particular trigger, and, as a result, he or she is afraid to go to a supermarket (or similar place) for fear that a panic attack could occur while there and no one could help.

Description

Panic disorder can be very difficult to distinguish from other mental illnesses such as major depression, other anxiety disorders, or medical conditions such as heart attacks. Panic attacks differ from general anxiety in that they are episodes that last for discrete periods of time and the symptoms that people suffer are more intense. Panic attacks have three types: unexpected, situationally bound, and situationally predisposed. The unexpected attacks occur without warning and without a trigger. The situationally bound attacks happen repeatedly when the person is performing some activity, about to do that activity, or even when the person thinks about doing that activity. For example, a person whose panic attacks are triggered by being in crowds can have an attack just by thinking about going to a shopping mall. Situationally predisposed attacks are similar to the situationally bound attacks, except that they do not always occur when the trigger stimulus is encountered. For example, someone who experiences panic attacks while in crowds may sometimes be in crowds and not experience attacks, or may experience attacks in other, non-crowded situations, as well.

Patients who suffer from panic disorder without treatment usually have a diminished quality of life and end up spending excessive money on health care because of frequent visits to emergency rooms and to other medical doctors. However, very effective treatments for panic disorder exist.

Agoraphobia is a fear of being in a place or situation from which escape might be difficult or embarrassing, or in which help may not be available in the case of a panic attack. It is not clear why some people develop agoraphobia and other people do not. Many people may develop their agoraphobia symptoms right after their first attack, but others do not develop agoraphobia until sometimes years after their attacks began.

Causes and symptoms

Causes

BIOCHEMICAL/PHYSIOLOGICAL CAUSES. It is extremely difficult to study the brain and the underlying causes of psychiatric illness; and understanding the chemistry of the brain is the key to unlocking the mystery of panic disorder. The amygdala is the part of the brain that causes fear and the response to stress. It has been implicated as a vital part of anxiety disorders. Sodium lactate, a chemical that the body produces when muscles are fatigued, and carbon dioxide are known to induce panic attacks. These substances are thought to inhibit the release of neurotransmitters in the brain, which leads to the panic attacks. One hypothesis is that sodium lactate stimulates the amygdala and causes panic attacks. Another hypothesis is that patients with panic disorder have a hypersensitive internal suffocation alarm. This means that the patient’s brain sends the body false signals that not enough oxygen is being received, causing the affected person to increase his or her breathing rate. Panic disorder patients have attacks when their overly sensitive alarm goes off unpredictably. Yohimbine, a drug used to treat male sexual dysfunction, stimulates a part of the brain called the locus ceruleus and induces panic symptoms thus pointing to this area of the brain’s involvement in panic disorder. Brain neurotransmitters serotonin and GABA are suspected to be involved in causing the disorder, as well.

GENETICS. Genetics also plays a pivotal role in the development of panic disorder. Twin studies have demonstrated that there is a higher concordance in identical versus fraternal twins thus supporting the idea that panic disorders are inherited. Family studies have also demonstrated that panic attacks run in families. Relatives of patients with panic disorder are four to 10 times more likely to develop panic disorder. People who develop early onset of panic attacks in their mid-20s are more likely to have relatives who have panic disorder. When relatives of patients with panic disorder are exposed to high levels of carbon dioxide, they have panic attacks. Another hypothesis is that patients with panic disorder who develop agoraphobia have a more severe form of the disease. Current efforts to identify a gene for panic disorder have not been successful.

PERSONAL VARIABLES. There are several themes in the psychology of panic disorder. Research has shown that patients who develop panic disorder have difficulty with anger. They also have difficulty when their job responsibilities are increased (as in the case of a promotion), and are sensitive to loss and separation. People with this disorder often have difficulty getting along with their parents, whom they see as controlling, critical, and demanding, causing the patients to feel inadequate. Early maternal separation is thought to be an underlying cause of panic disorder.

Panic disorder patients also have a pattern of dependency in their interpersonal relationships. As children, people with panic disorder relied on parents to protect them from fear. As a result, they develop an angry dependence on their parents and fear detaching from them. They constantly feel as though they are trapped.

There is also an association between sexual abuse and patients who have panic attacks. Sixty percent of female patients with panic disorder were sexually abused as children. This explains their difficulty with developing trusting relationships.

Symptoms

PANIC ATTACK SYMPTOMS. The DSM-IV-TRlists thirteen symptoms to meet the criteria for a diagnosis of panic attack. The affected person must have four or more of these symptoms within ten minutes of the beginning of an attack in order to meet the panic attack criteria:

• bounding or pounding heartbeat or fast heart rate
• sweating
• shaking
• shortness of breath
• feeling of choking
• pains in the chest; many people they feel as though they are having a heart attack
• nausea or stomach ache
• feeling dizzy or lightheaded as if he or she is going to pass out
• feeling of being outside of one’s body or being detached from reality
• fear that he or she is out of control or crazy
• fear that he or she is going to die
• feeling of tingling or numbness
• chills or hot flashes

Symptoms of panic disorder without agoraphobia

The DSM-IV-TRcriteria for panic disorder without agoraphobia include:

• recurrent panic attacks (see above) that occur without warning for one month
• persistent worry that panic attacks will recur
• possible change in behavior because of that fear
• no agoraphobia
• not due to a medical condition or substance abuse
• not due other mental illness like specific phobia, social phobia, obsessive-compulsive disorder, separation anxiety disorder, or post-traumatic stress disorder

Symptoms of panic disorder with agoraphobia

The DSM-IV-TRcriteria for panic disorder with agoraphobia are the same as above, but agoraphobia is present. The symptoms of agoraphobia include fear of being in situations that can trigger panic attacks, and avoiding places where attacks have occurred because of the affected person’s fear that he or she will not be able to leave, or will not be able to get help. People with this condition may need to have another person accompany them when going to a place that may trigger anxiety attacks. Sometimes this fear can be so severe that the person becomes housebound. This fact is important to consider because 15% of the general population can have one spontaneous panic attack without the recurrence of symptoms.

Demographics

Factors such as race, gender and socioeconomic status are important factors in the development of panic disorder. An individual has a chance of between one and two percent of developing panic disorder with or without agoraphobia. The symptoms usually begin when the person is in his or her early to mid-twenties. Women are twice as likely as men to develop panic attacks regardless of age. The National Institute of Mental Health Epidemiologic Catchment Area Study (ECA) shows no real significant differences between the races or ethnic groups, although it appears that African American and Hispanic men between the ages of 40 and 50 have lower rates of panic disorder than white men. Panic disorder patients are at increased risk for major depression and the development of agoraphobia. According to ECA studies, an individual with panic disorder has a 33% chance of developing agoraphobia. People without panic disorder only have a 5.5% chance of developing agoraphobia. Again, women were more likely to develop agoraphobia than men. Over the course of their lifetime, African Americans were more likely to develop agoraphobia than whites or Hispanics. Agoraphobia is more prevalent among people with less education and lower economic class.

Diagnosis

Differential diagnosis

Differential diagnosis is the process of distinguishing one diagnosis from other, similar diagnoses. Panic disorder can be difficult to distinguish from other anxiety disorders such as specific phobia and social phobia. However, in general, specific phobia is cued by a specific trigger or stimulus and social phobia by specific social situations, while the panic attacks of panic disorder are completely uncued and unexpected. In certain cases, it may be difficult to distinguish between certain, situational phobias and panic disorder with agoraphobia, and the mental health professional must use the DSMand professional judgment in these cases. Panic attacks that occur during sleep and wake the person up are more characteristic of panic disorder, than are the other disorders that include panic attacks. It can be distinguished from posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and generalized anxiety disorder(GAD) again by what cues the attacks. In PTSD, thinking about the traumatic event can trigger attacks. In obsessive-compulsive disorder, worries about getting dirty can fuel an attack of anxiety. In generalized anxiety disorder, general worries or concerns can lead to the symptoms of panic. However, in panic disorder, a main component is that the affected individual fears recurrent panic attacks.

Panic attacks can often be difficult to distinguish from other physical problems such as hyperthyroidism, hyperparathyroidism, seizure disorder, and cardiac disease. If patients are middle aged or older and have other complaints, including dizziness and headaches, their attacks are more likely to be another medical problem and not panic attacks. Panic attacks can also be difficult to distinguish from drug abuse since any drug that stimulates the brain can cause the symptoms. For example, cocaine, caffeine, and amphetamines can all cause panic attacks. Therefore, a person must be free of all drugs before a diagnosis of panic disorder can be made. Many patients may attempt to self-medicate with alcohol to try to calm down. Withdrawal from alcohol can lead to worse panic symptoms. The patient may believe that he or she is reducing symptoms while actually exacerbatng their panic attacks.

Dual diagnosis

Individuals with panic disorders have a high rate of coexisting depression. Patients who have panic disorder have about a 40–80% chance of developing major depression. In most situations, the panic disorder happens first and the depression comes later. Patients are also at risk for substance abuse difficulties as a result of attempts to stop attacks. These attempts may involve the use of alcohol, illicit or unprescribed sedatives, or benzodiazepines (medications that slow down the central nervous system, having a calming effect). Patients with panic disorder are not at high risk for suicide attempts. A recent Harvard-Brown study showed that people with panic disorder with or without agoraphobia are not at risk for suicide unless they have other conditions such as depression or substance abuse.

Psychological measures and diagnostic testing

Currently there is no diagnostic test for panic disorder. Any patient who has panic attacks should receive a thorough medical examination to rule out any medical condition. Patients should have baseline blood counts and glucose should be measured. Patients with cardiac symptoms need a cardiac workup and should see their primary medical doctor. Patients who have complaints of dizziness should receive a thorough neurological evaluation. There are several psychological inventories that can help the clinician diagnose panic disorder including the BeckDepression Inventory(BDI), Beck Anxiety Inventory (BAI), Specific Fear Inventory, Clinical Anxiety Scale (CAS), and the Clinical Global Inventory (CGI).

Treatments

Psychological and social interventions

A psychotherapeutic technique that is critical to the treatment of panic disorder is cognitive-behavioral therapy(CBT). Patients are panic-free within six months in about 80–90% of cases. Some people even experience long-term effects after the treatments have been stopped. About half of the patients say that they have rare attacks even two years after treatment has ended.

New studies reveal that the approach to treating panic disorder should have three aspects: the cognitive, the physiological, and the behavioral. The cognitive techniques try to focus on changing the patient’s negative thoughts—for example, “I will die if I don’t get help.” Patient education about symptoms is also critical to the treatment of panic attacks. In one physiological approach, patients are taught breathing techniques in an effort to try to help them lower their heart rate and decrease their anxiety. Repeated exposure to physical symptoms associated with the panic disorder is also a part of treatment. The patients cause themselves to hyperventilate in effort to reproduce the panic symptoms. In behavioral approaches, the individual who experiences panic attacks also needs to be exposed to situations that he or she may have previously feared. A patient can also be taken to places associated with agoraphobia with the therapist.

Some patients may benefit from psychodynamic psychotherapy and group therapy. Psychodynamic psychotherapy explores thoughts and ideas of the person’s subconscious. It takes a longer time to achieve efficacy than cognitive-behavioral therapy, but it can be just as effective for patients with panic disorder. Group therapy is also just as helpful to some patients as CBT. Support groups can also be helpful to some patients. It can be very therapeutic and healing to the individual to discuss their problems with someone who has actually experienced the same symptoms. Patients can learn from each other’s coping styles.

Medical treatments

Panic disorder patients have a 50–80% chance of responding to treatment, which attempts to block the symptoms of panic attacks. Treating the agoraphobia symptoms is more challenging. Developing some antipanic regimens that address all symptoms is important.

The Food and Drug Administration (FDA) to treat panic disorder approves only five classes of drugs. They are:

• benzodiazepines
• Selective serotonin reuptake inhibitors (SSRIs), which cause a buildup of serotonin. This buildup is thought to cause the antidepressant effect.
• Tricylic antidepressants (TCAs).
• Monoamine oxidase inhibitors (MAOIs) and reversible MAOIs, which inhibit the breakdown of neurotransmitters in the brain, including dopamine and serotonin.
• Atypical antidepressants, including bupropion(Wellbutrin), mirtazapine(Remeron), trazodone(Desyrel), and others.

Patients should first be started on a low-dose SSRI and then the dose should be increased slowly. Patients with panic disorder are extremely sensitive to the side effects that many patients experience in the first weeks of antidepressant therapy. Patients should also have a benzodiazepine, such as clonazepam(Klonopin) or alprazolam(Xanax), in the first weeks of treatment until the antidepressant becomes therapeutic. Most people need the same dose of antidepressant as patients with major depression. About 60% of patients will have improvement in their symptoms while taking an antidepressant and a benzodiazepine. Patients with mitral valve prolapse may benefit from a beta blocker. Patients who have tried an SSRI, and after six weeks, show no improvement can be switched to another SSRI, benzodiazepine, TCA, MAOI, or venlafaxine(Effexor). An SSRI should be stopped if the patient has intolerable side effects such as loss of sexual libido, weight gain, or mild form of manic depression. When SSRIs are stopped, it is important that the dosage is gradually tapered because patients can suffer symptoms when it is abruptly withdrawn. These symptoms may include confusion, anxiety and poor sleep.

Alternative therapies

Some alternative therapies for panic disorder are hypnosis, meditation, yoga, proper nutrition, exercise, and abdominal breathing techniques that foster relaxation and visualization. Visualization is imagining oneself in the stressful situation while relaxed so that coping strategies can be discovered. The herb kava kava has been studied in trials to treat anxiety attacks and has been found to be effective in some clinical trials; but has not been studied intensely enough to determine its benefits and side effects, and has been associated liver toxicity. The National Center for Complementary and Alternative Medicine was going to conduct two research studies of kava kava but as of 2002 it has suspended the trials until the FDA has determined whether or not the herbal supplement is safe.

Prognosis

Patients with panic disorder have a poor prognosis particularly if untreated. Patients often relapse when they attempt to discontinue treatment. However, if patients are compliant and willing to stay in treatment, then the long-term prognosis is good. According to one study, eight years after treatment has been done, 30–40% of patient are doing better. Only 10–20% of patients do poorly. The patient with panic attacks has a relapsing and remitting course that can be worsened by significant stressors such as the death of the spouse or divorce. Cognitive-behavioral therapy has an 80–90% chance that the patient will benefit six months after treatment. Medications have a 50–80% efficacy. If patients are committed to staying in treatment, their prognosis is very favorable.

Prevention

Although panic disorder is not totally preventable, individuals with a strong family history of them who are susceptible to panic atacks are encouraged to be aware of the symptoms and get treatment early. Compliance with treatment is important to the recovery from panic disorder.

Definition

Panic attacks, the hallmark of panic disorder, are discrete episodes of intense anxiety. Panic attacks can also be experienced by people with specific phobia, social phobia, or by people who have used or consumed certain substances, such as cocaine.

Description

Panic attacks are intense anxiety experiences that are usually accompanied by symptoms in the affected person’s body and thinking. The panic attack can occur unexpectedly during early stages of panic disorder illness. As panic disorder progresses, panic attacks may become associated with certain situations that trigger attacks. Panic attacks triggered by a specific experience are called situational panic attacks, since a certain situation initiates the intense anxiety.

Persons affected with panic attacks usually exhibit a broad range of clinical signs and symptoms that include:

• heart palpitations (accelerated heart rate)
• shaking or trembling
• sweating
• shortness of breath or sensation of feeling smothered or choked
• feeling of tingling
• chest discomfort or pain
• nausea or abdominal distress
• feeling dizzy, light headed, unsteady or faint
• perceptions of being detached from oneself (depersonalization), or a feeling out of touch with reality (derealization)
• chills or hot flashes
• fear of dying
• fear of going crazy or losing control

A person meets the criteria for a panic attack if the symptoms start abruptly, reach a quick peak (usually within 10 minutes), and if the affected individual has at least four symptoms as listed above. In persons who have less than four symptoms during an attack, the disorder is called a limited symptom attack.

It is typical that affected persons who seek treatment usually have one to two attacks a week and in worse periods may have one daily attacks or several within a week.

As stated, panic attacks can be experienced as a result of stimulant chemical usage, such as cocaine usage. There is evidence to suggest that persons with panic attacks are sensitive to certain chemicals such as caffeine, carbon dioxide, antihistamines, and, in women, progesterone replacement. Exposure to these substances may precipitate an attack.

Definition

Pain disorder is one of several somatoform disorders described in the revised, fourth edition of the mental health professional’s handbook, the Diagnostic and Statistical Manual of Mental Disorders(known asDSM-IV-TR). The term “somatoform” means that symptoms are physical but are not entirely understood as a consequence of a general medical condition or as a direct effects of a substance, such as a drug. Pain in one or more anatomical sites is the predominant complaint and is severe enough to require medical or therapeutic intervention. Pain disorder is classified as a mental disorder because psychological factors play an important role in the onset, severity, worsening, or maintenance of pain.

Earlier names for this disorder include psychogenic pain disorder and somatoform pain disorder. There is some overlap in the meaning of these terms, but views regarding the nature of pain have been changing and they are, therefore, not equivalent diagnostic categories. Sometimes pain disorder is referred to as somatization, but this is an imprecise term and is easily confused with somatization disorder.

Description

In 1994, the International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory or emotional experience arising from real or probable tissue damage. In other words, the perception of pain is, in part, a psychological response to noxious stimuli. This definition addresses the complex nature of pain and moves away from the earlier dualistic idea that pain is either psychogenic (of mental origin) or somatogenic (of physical origin). The contemporary view characterizes pain as multidimensional; the central nervous system, emotions, cognitions (thoughts), and beliefs are simultaneously involved.

When a patient’s primary complaint is the experience of pain and when impairment at home, work, or school causes significant distress, a diagnosis of pain disorder may be warranted. The diagnosis is further differentiated by subtype; subtype is assigned depending on whether or not pain primarily is accounted for by psychological factors or in combination with a general medical condition, and whether the pain is acute (less than six months) or chronic (six months or more). The classification of pain states is important since the effectiveness of treatment depends on the aptness of the diagnosis of pain disorder and its type.

Causes and symptoms

Causes

Common sites of pain include the back (especially lower back), the head, abdomen, and chest. Causes of pain vary depending on the site; however, in pain disorder, the severity or duration of pain or the degree of associated disability is unexplained by observed medical or psychological problems.

The prevailing biopsychosocial model of mental disorders suggests that multiple causes of varying kinds may explain pain disorder, especially when the pain is chronic. There are four domains of interest:

• The underlying organic problem or medical condition, if there is one. For example, fibromyalgia (a pain syndrome involving fibromuscular tissue), skeletal damage, pathology of an internal organ, migraine headache, and peptic ulcer all have characteristic patterns of pain and a particular set of causes.
• The experience of pain. The severity, duration, and pattern of pain are important determinants of distress. Uncontrolled or inadequately managed pain is a significant stressor.
• Functional impairment and disability. Pain is exacerbated by loss of meaningful activities or social relationships. Disruption or loss may lead to isolation and resentment or anger, which further increases pain.
• Emotional distress. Depression and anxiety are the most common correlates of pain, especially when the person suffering feels that the pain is unmanageable, or that the future only holds more severe pain and more losses.

In sum, there are multiple causes of pain disorder. A therapist or team of health professionals will weigh the relative causal contributions, assign priorities for therapeutic intervention, and address the several domains in a multimodal fashion. For example, the design of a treatment plan in a pain clinic may involve a physician, psychotherapist, occupational therapist, physical therapist, anesthesiologist, psychologist, and nutritionist.

Symptoms

Symptoms vary depending on the site of pain and are treated medically. However, there are common symptoms associated with pain disorder regardless of the site:

• negative or distorted cognition, such as feeling helpless or hopeless with respect to pain and its management
• inactivity, passivity, and/or disability
• increased pain requiring clinical intervention
• insomnia and fatigue
• disrupted social relationships at home, work, or school
• depression and/or anxiety

Demographics

There is very little information regarding rates of pain disorder. A major difficulty is that the diagnostic categories for psychogenic pain disorder in DSM-III, somatoform pain disorder in DSM-III-R, and pain disorder in DSM-IVand DSM-IV-TRare not equivalent. Furthermore, many criticize the somatoform disorder group (which includes pain disorder) as being an aggregate of disorders that are not truly distinct from one another. This lack of distinctiveness suggests to some researchers that a more appropriate system of classification should be dimensional rather than categorical. In other words, if shared dimensions or characteristics of the several somatoform disorders exist, differences among disorders should be a matter of degree along the possible dimensions. The critics of the DSMcategorical approach would prefer a dimensional or multiaxial system because when classification systems are improved, the reliability and validity of measures assessing disorder improve, and better estimates of rates are possible.

Nevertheless, some researchers find the DSM-IVcategory for pain disorder useful. For example, in one study of psychiatric pain clinic outpatients, 79% met the criteria for pain disorder of the subtype where psychological factors and a general medical condition co-exist; 9% of the outpatients met the criteria for pain disorder with psychological factors and no medical condition. In another study of patients at a psychiatric clinic, 38% of the patients at admission and 18% of the outpatients reported significant pain. In comparison, 51% in a study of general medical and surgical inpatients met the criteria for pain disorder.

Currently, there are no good estimates for rates of pain disorder in the general population.

Diagnosis

Apsychiatrist or mental health professional arrives at the diagnosis of pain disorder after considering several questions. An important preliminary question is whether the pain is entirely accounted for by a general medical condition. If so, the diagnosis of pain disorder is ruled out; and if not, the psychiatrist considers whether the pain is feigned. If the psychiatrist believes the patient is pretending to be in pain, the patient is diagnosed as malingering for external rewards, such as seeking mood-altering drugs, or as having a factitious disorder that reflects the patient’s need to adopt a sick role. Neither malingering nor factitious disorder is in the somatoform group.

The psychiatrist may employ a variety of methods to assess the severity of pain and the contribution of psychological factors to the experience of pain. These include structured interviews (where the questions asked are standardized), open or unstructured interviews, numerical rating scales, visual analog scales (where the patient makes a mark along a line to indicate severity of pain, or if the patient is a child, or is illiterate, selects a face to represent the degree of pain), and instruments such as the McGill Pain Questionnaire or the West Haven-Yale Multidimensional Pain Inventory.

There are several conditions that rule out a diagnosis of pain disorder:

• Dyspareunia. (The patient’s primary complaint relates to the experience of painful sexual intercourse.)
• Somatization disorder. (The patient has a long history of pain that began prior to age 30 and involves the gastrointestinal, reproductive, and nervous systems.)
• Conversion disorder. (In addition to pain, there are other symptoms associated with motor or sensory dysfunction.)
• Mood, anxiety, or psychotic disorder. (Any one of these more fully accounts for the pain. This last exclusion rests upon a very subjective opinion. Subjectivity reduces inter-rater reliability and is one of the points raised by critics of the DSMcategory for pain disorder.)

A final consideration is whether the pain is acute or chronic.

Treatments

Depending on whether the pain is acute or chronic, management may involve one or more of the following: pharmacological treatment (medication); psychotherapy(individual or group); family, behavioral, physical, hypnosis, and/or occupational therapy. If the pain is acute, the primary goal is to relieve the pain. Customary agents are acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs); if opioid analgesics are prescribed, they often are combined with NSAIDs so that the dosage of opioids may be reduced. Psychotherapy is less important for the treatment of acute pain as compared to chronic pain disorder. In comparison, treatment of chronic pain disorder usually requires some sort of psychotherapy in combination with medication.

Antidepressants

Tricyclic antidepressants (TCAs) reduce pain, improve sleep, and strengthen the effects of opioids (such as codeine and oxycodone), as well as moderate depression. Relief of pain may occur in a few days while lessening of depression may take several weeks. Usually, TCAs for pain are prescribed at doses 33% to 50% lower than when prescribed for depression. TCAs are particularly effective for neuropathic pain, headache, facial pain, fibromyalgia, and arthritis.

Treatment of sleep dysfunction

Pain and depression diminish the restorative quality of sleep. When the cycle of pain, depression, insomnia, and fatigue is established, it tends to be self-perpetuating. Treatment may include antidepressants, relaxation training, and education regarding good sleep hygiene.

Cognitive-behavioral therapy

Many people who suffer chronic pain experience isolation, distress, frustration, and a loss of confidence regarding their ability to cope; subsequently, they may adopt a passive, helpless style of problem solving. The goal of cognitive-behavioral therapy(CBT) is to restore a sense of self-efficacy by educating patients about the pain-and-tension cycle, by teaching them how to actively manage pain and distress, and by informing them about the therapeutic effects of their medications. CBT is time-limited, structured, and goal-oriented.

Some tension-reducing techniques include progressive muscle relaxation, visual imagery, hypnosis, and biofeedback. Pain diaries are useful for describing daily patterns of pain and for helping the patient identify activities, emotions, and thoughts that alleviate or worsen pain. Diaries also are useful in evaluating the effectiveness of medication. Patients may be taught pacing techniques or scheduling strategies to restore and maintain meaningful activities.

The cognitive aspect of CBT is based on cognitive-social learning theory. The focus is on helping the patient to restructure his or her ideas about the nature of pain and the possibility of effective self-management. In particular, the patient is taught to identify and then modify negative or distorted thought patterns of helplessness and hopelessness.

Operant conditioning

The principles of operant conditioning are taught to the patient and family members so that activity and non-pain behaviors are reinforced or encouraged. The goal is to eliminate pain behaviors, such as passivity, inactivity, and over-reliance on medication.

Other Treatments

Other treatments effective in the management of pain include acupuncture, transcutaneous electrical nerve stimulation (TENS), trigger point injections, massage, nerve blocks, surgical ablation (removal of a part or pathway), meditation, exercise, yoga, music and art therapy.

Prognosis

The prognosis for total remission of symptoms is good for acute pain disorder and not as promising for chronic pain disorder. The typical pattern for chronic pain entails occasional flare-ups alternating with periods of low to moderate pain. The prognosis for remission of symptoms is better when patients are able to continue working; conversely, unemployment and the attendant isolation, resentment, and inactivity are correlates of a continuing pain disorder. Additionally, if reinforcement of pain behavior is in place (for example, financial compensation for continuing disability, an overly solicitous spouse, abuse of addictive drugs), remission is less likely.

The results of outcome studies comparing pain disorder treatments point to cognitive-behavioral therapy in conjunction with antidepressants as the most continually effective regimen. However, people in chronic pain may respond better to other treatments and it is in keeping with the goal of active self-management for the patient and health professional(s) to find an individualized mix of effective coping strategies.

Prevention

Pain disorder may be prevented by early interventioni.e., at the onset of pain or in the early stages of recurring pain. When pain becomes chronic, it is especially important to find help or learn about and implement strategies to manage the distress before inactivity and hopelessness develop. Most patients in pain first contact their primary care physician who may make a referral to a mental health professional or pain clinic. Many physicians will reassure the patient that a referral for psychological help is not stigmatizing, does not in any way minimize the experience of pain or the medical condition, and does not imply that the physician believes the pain is imaginary. On the contrary, the accepted IASP definition of pain fully recognizes that all pain is, in part, an emotional response to actual damage or to the threat of damage.

Definition

Oxazepam is a member of a family of tranquilizers known as benzodiazepines. It is sold in the United States under the brand name Serax and in Canada under the brand name Ox-Pam. Generic forms of oxazepam are also available.

Purpose

Oxazepam is prescribed to treat feelings of tension and anxiety. It is also used to calm patients who are suffering from the symptoms of alcohol withdrawal.

Description

Oxazepam is one of several drugs in the class called benzodiazepines. Oxazepam slows down certain brain functions by blocking specific chemicals that transmit messages among the nerve cells in the brain.

Recommended dosage

The typical starting dose for adults ranges from 5–15 mg per day. The dosage is sometimes increased by the doctor, but 80 mg is usually the maximum amount prescribed per day. The amount used each day is typically divided into at least two doses. Oxazepam is taken by mouth, and is available in tablets and capsules. It can be taken with food if the patient is having side effects in the digestive tract.

Oxazepam is not FDA-approved for use in children under six years. However, often in clinical practice, the medication is used with close physician supervision. The typical starting dose for children aged two to 16 years is 5 mg. The doctor may increase this dose if necessary. Typically, the dose does not exceed 40 mg per day, and is given in divided doses. Children under two years of age may receive a dose based on body weight. The doctor must determine whether the child needs the drug as well as the dosage.

Precautions

The doctor should monitor the patient at regular intervals to ensure that the medicine is not causing troublesome side effects. Monitoring the patient is particularly important if the drug is being taken over a long period of time. Patients should not stop taking oxazepam suddenly, especially if they are taking large doses. The dose should be tapered (gradually decreased), and then stopped. Suddenly discontinuing oxazepam may cause a rebound effect. In a few cases patients have reported serious withdrawal symptoms when they stopped taking oxazepam, including nausea, vomiting, muscle cramps, and unusual irritability.

Oxazepam should be given with great care to elderly patients; to people who are significantly disabled; and to people with a history of liver or kidney disease, drug abuse, or breathing problems. Pregnant women should not take oxazepam because of the risk of birth defects in the baby. Likewise, nursing mothers should not use oxazepam while they breast-feed. Oxazepam and other benzodiazepines should never be combined with alcohol or other drugs that depress (lower the activity of) the central nervous system. Oxazepam and other benzodiazepines should be prescribed and used very carefully if they are given for long-term treatment because they are habit-forming. Patients who have been diagnosed with glaucoma or serious psychological disorders should not receive oxazepam. Patients who have a history of alcohol abuse, drug abuse, brain disease, mental depression, mental illness, sleep apnea, or myasthenia gravis should tell their doctor about their condition. Similarly, a woman who becomes pregnant while she is taking the drug should tell her doctor at once.

Side effects

Rare but serious side effects associated with the use of oxazepam include: anxiety, mental depression, reduced memory, and confusion. Even more rare are disorientation, delusions, seizures, unusually low blood pressure, sleeping difficulties, muscle weakness, and changes in behavior.

Less serious but more common side effects include: difficulty talking, dizziness, clumsiness, and drowsiness. Less common but not particularly serious side effects include dry mouth, general weakness, headache, mild abdominal pain, constipation, diarrhea, nausea, and vomiting.

When the patient stops taking oxazepam, nervousness, irritability, and sleeping problems are common withdrawal side effects. Less common withdrawal side effects can include confusion, hearing problems, stomach cramps, increased sweating, mental depression, nausea, and vomiting. Rare withdrawal side effects can include seizures, hallucinations, and paranoid ideas.

Interactions

Patients should always inform every health professional that they deal with— doctors, pharmacists, nurses, dentists, and others— about every medication they take. Oxazepam, alcohol, and other medications that cause drowsiness can intensify one another’s effects. Some medications that are used to treat viral infections, fungal infections, high blood pressure, and some heart rhythm problems can increase the effects of oxazepam.

Heavy smoking decreases the effectiveness of oxazepam.

History of theories about mental illness

Mental illness in the ancient world

Over the history of the healing arts, there has been an evolution of theories regarding the root causes of mental illness. Early writings from such ancient civilizations as those of Greece, Rome, India, and Egypt focused on demonic possession as the cause. This concept eventually disappeared only to resurface again in the Middle Ages in Europe, along with inadequate treatment of the mentally ill. Demons or “foul spirits” were believed to attach themselves to individuals and make them depressed (“poor-spirited”) or “mad.” The word mad became an early synonym for psychosis. Unfortunately, the “possessed” included people with seizure disorders as well as others suffering from what are now known to be medical disorders. Few genuinely helpful treatments were available to relieve the suffering of the mentally ill.

The Hippocratic tradition

Hippocrates, a Greek physician who lived around 400 B.C. and is regarded as the source of the Hippocratic Oath taken by modern physicians, first introduced the concept of disturbed physiology (organic processes or functions) as the basis for all illnesses, mental or otherwise. Hippocrates did not describe disturbances of the nervous system as we do today, in terms of a chemical imbalance or a low level of neurotransmitters (neurotransmitters are the chemical messengers sent between brain cells). Instead, he used the notion of an imbalance of “humors.” Humors were defined as bodily fluids, and were believed to be influenced by the environment, the weather, foods, and so on, producing various imbalances in a person’s state of health. Hippocrates’ theory was an early version of the idea that physiological disturbances or body chemistry might play a role in the development of mental illness. Most importantly, perhaps, Hippocrates’ concept placed mental illness on the same footing as other medical disorders by highlighting the belief that the mentally ill are genuinely suffering, and therefore to be treated like other sick persons rather than as moral degenerates. Sadly, modern society has not fully overcome the tendency to stigmatize persons with mental disorders. Hippocrates’ more “enlightened” perspective, however, meant that someone with depression or schizophrenia could be viewed as being in a state of “dis-ease,” just like a diabetic or someone with high blood pressure.

The nineteenth century

Toward the end of the nineteenth century, several European neurologists began actively investigating the causes of mental illness. Chief among them, and destined to change forever the understanding of mental illness, was Sigmund Freud. Although psychology and psychiatry have advanced considerably since Freud (as have other fields of medicine), his explorations were revolutionary. Freud introduced the concepts of the unconscious and the ego to modern thought, and reintroduced the ancient art of dream interpretation, but from a psychological standpoint. Freud also regarded human psychological states as an energy system in which blockages in the flow of thought (repression or suppression, for example) would result in disease or illness, expressed as mental or emotional loss of balance. He introduced the notion of a “talking cure”; through the use of talk therapy alone, many patients would improve. This method of treatment is still used today, although the technique of talk therapy itself has undergone further development. Freud’s early advances in understanding the mind, however, awaited further anatomical and biochemical discoveries of the structures and functions of the human brain. As a result, early psychiatry (from two Greek words, psyche, meaning “soul” or “mind,” and iatros, meaning “physician”) split into two competing traditions, one that followed Freud in emphasizing thoughts, emotions and dreams as keys to the healing of mental disorders, and another that looked for clues to these disorders in the tissues of the brain.

In the first half of the twentieth century, psychiatry was advanced by the discovery of medications that helped to alleviate depression, mania, and psychosis. As often occurs in the history of medicine, physicians stumbled upon solutions before they understood the mechanisms that made the treatment work. Later studies began to reveal that certain patients responded to medications that increased certain neurotransmitters. Drugs that increased the levels of the neurotransmitters norepinephrine and serotonin seemed to help depressed patients. Similarly, medications that blocked the transmission of dopamine, another neurotransmitter, provided relief for patients suffering from hallucinations and paranoia. These insights have led to the present emphasis on the biochemistry of the human brain. If, however, the biochemical model becomes the only view of mental health, modern psychiatry risks becoming “mindless.” Clearly, a unified theory is needed to understand all the factors that contribute to mental disorders, and to do justice to the complexity of each human being. Understanding all the factors that lead to a disease state has much to do with an adequate treatment response.

Nature and nurture

One attempt to unify the varied theories regarding the origin of mental illness is called simply the “nature versus nurture” theory. It is really the “nature and nurture” theory, however, as it establishes the importance of two forces in the development of mental illness. For example, “nature” refers to biological factors that produce a tendency or predisposition to develop certain diseases. For instance, parents who have high blood pressure have offspring who have a higher probability of developing the same condition. If, on the other hand, these offspring learn to eat properly, exercise, and live in a relatively peaceful home, for instance, they may be able to avoid the expression of high blood pressure that runs in their family. This example illustrates the impact that a person’s environment may have on the development of physical disease. Researchers believe the same holds true for mental illnesses. For example, researchers know that patients with schizophrenia who return to a family environment in which there is a high level of expressed emotion, such as critical and angry remarks, have more frequent psychotic episodes that require hospitalization. Thus, it appears that the interaction between the biological and psychological dimensions of a person and his or her environment determines the likelihood of expressing a mental illness, or perhaps any illness whatsoever. There is, however, no accurate prediction or test that will determine whether or not a specific person will develop a certain mental illness, even if many members of his or her are positive for that disease.

Conversely, a child with minimal genetic predisposition to mental illness may develop mental illness if he or she is traumatized in any number of ways, such as being raised in a non-nurturing or a physically, mentally, or emotionally abusive household. As of 2002, scientists do not know why some people become mentally ill while others do not. Much research remains to be done; although theories abound, the precise etiology or origin of all mental illnesses remains uncertain.

Current theories about the origin of mental disorders

Biological theories

GENETICS. Genetics is at this time an important area of research for psychiatric disorders. For example, a specific gene has been associated with bipolar disorder (also known as manic-depressive disorder), but unfortunately, the °switch” that controls the expression of the disorder is still unknown. It is presently thought that many genes go into the expression or nonexpression of any human characteristic, such as a facial feature or a certain aspect of mental health. Research done on identical twins has provided strong support for a genetic component in the development of schizophrenia. For instance, the average person in the United States has a 1% chance of developing schizophrenia, while the identical twin of a person diagnosed with schizophrenia has a 50% chance, even if he or she has been reared by adoptive parents. Other researchers who are studying schizophrenia have found that during embryonic development, there are nerve cells that do not migrate to their proper position in the brain. On the other hand, none of the genetic or embryological findings can account for the rare but occasional recoveries from schizophrenia, indicating that biology alone does not determine the occurrence of mental disorders.

Dementias are also noted to run in families, but most of these disorders cannot be predicted with any certainty for the following generation. Only one disorder, Huntington’s chorea, which is really a movement disorder with a psychiatric component, appears to be determined by a single gene. Dementia of the Alzheimer’s type does seem to have familial pattern, but again, the expression of the disease in any specific individual is not predictable at this time. Scientists believe that similar statements can be made for many mental disorders that run in families, such as obsessive-compulsive disorder (OCD), depression, anxiety, and panic disorder. The roles of the environment and learning behavior in the ultimate expression of genetically predisposed individuals are, however, undisputed.

NEUROTRANSMITTER-RELATED CHEMICAL IMBALANCES. This theory regarding the origin of mental disorders has become the foundation of most psychiatric treatment today. It has legitimized psychiatry by returning it to the world of biological medicine. Diabetes may offer a helpful analogy. In diabetes, a chemical necessary to health (insulin) is missing and can be replaced, essentially restoring the patient’s health. In mental illness, the neurotransmitters in the brain may be present in insufficient amounts. These chemicals or transmitters allow communication between nerve cells; as a result, they coordinate information processing throughout the brain. As a person reads, for example, chemical levels rise and fall in response to the letters; the meaning they have; the reader’s eye movements, thoughts, reflections and associations; and to the feelings the reader may have while reading. Thus, a person’s brain chemistry is changed by everything that influences him or her, whether internally or externally. While the discovery of certain neurotransmitters and their roles in mental disorders has led in turn to the discovery of effective medications to treat these disorders, it has also resulted in the unfortunate notion that medication is the only method of treatment that is helpful.

Major neurotransmitters identified thus far include acetylcholine, dopamine, epinephrine, norepinephrine, histamine, and serotonin. Serotonin and norepinephrine are most highly implicated in depression, panic disorder and anxiety, as well as OCD. Most of the medications found effective for these disorders are drugs that increase the availability of serotonin and norepinephrine (such as selective serotonin re-uptake inhibitors, or SSRIs). In particular, depression, panic disorder, anxiety disorders, and OCD have responded strongly to medications that increase serotonin levels. On the other hand, medications that block the effects of dopamine in certain parts of the brain are effective in controlling auditory and visual hallucinations as well as paranoia in patients with psychotic disorders.

STRESS-RELATED FACTORS. Stress is something everyone in modern society seems to understand. There are two basic kinds of stress: inner stress from previous traumas or wounds that affect one’s present life; and outer stress, or the environmental issues that complicate life on a daily basis, such as work or family problems. The interplay of these two forms of stress affects brain chemistry just as it can affect physical health. Numerous studies have shown that when people are chronically stressed in life, they are vulnerable to depression, anxiety, and other disorders. Interestingly, 70% of the adults in one recent European war situation were found to have depression, which is a normal human response to relentless stress. Researchers presently think that the mechanism that triggers this depression is the depletion of certain neurotransmitters, particularly serotonin and norepinephrine, which may lead to other biochemical imbalances. For instance, most people diagnosed with schizophrenia have their first psychotic episode during such stressful situations as leaving home for college or military service.

Genetic factors may add to a person’s susceptibility to mental illness by lowering the body’s production of neurotransmitters during difficult life transitions. The same combination of circumstances might affect the development of high blood pressure, diabetes, or ulcers in some families.

MEDICAL CONDITIONS. It is important to note that bacterial and viral infections, metabolic illnesses, medications and street drugs can all affect a person’s mental status. Insults (injuries) to the brain can cause a person to be disoriented, speak incoherently, have difficulty concentrating, hallucinate, or even act out violently. When clinicians see disorientation and an abrupt change in a person’s level of alertness, they refer to the altered mental state as delirium. Delirium is considered a medical emergency because the underlying cause must be identified and treated as quickly as possible. The exact way in which infectious disease and chemical agents change human mental function is unclear, and thus may not be visible on imaging studies.

The elderly are particularly vulnerable to changes in mental status resulting from apparently minor changes in body chemistry. Fever, dehydration, electrolyte imbalances, and even aspirin or antibiotics can all have an abrupt effect on the mental status of the elderly. Older people are susceptible simply because older brain tissue is more sensitive to the slightest change in metabolism or the presence of toxins.

Certain diseases have severe effects on the brain. An example is HIV/AIDS, in which approximately 70% of patients suffering from full-blown AIDS develop dementia, depression, or delirium. Similarly, at least 50% of patients with multiple sclerosis develop depression from the effects of the disease on brain tissues—not simply as a reaction to knowing that they have MS. Any infectious disease that causes inflammation inside the skull, such as meningitis or encephalitis, will usually result in some change in mental status; fortunately, these changes are usually completely reversible.

Recently, there has been an exciting development involving infectious disease and OCD as exemplified by “PANDAS,” the acronym for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Group A Streptococcus is an autoimmune disorder thought to cause OCD symptoms (neuropsychiatric symptoms) in children with streptococcal infection of the tonsils and pharynx (more commonly known as strep throat). The OCD symptoms resolve when the infection is treated with antibiotics. The neuropsychiatric symptoms are believed to result from an autoimmune reaction, meaning that antibodies made to fight the bacteria mistakenly attack part of the brain, resulting in symptoms of OCD. The discovery of this connection between a streptococcal infection and an autoimmune reaction may have great importance for treating certain mental illnesses in the future, since links between the onset of psychiatric disorders and physical infections have been observed from time to time.

Disorders of metabolism can certainly mimic depression, anxiety and sometimes, even psychosis. Overproduction of thyroid hormone (thyrotoxicosis) can cause agitation, anxiety, mania and even psychosis; while a lack of thyroid hormone produces symptoms of depression and is routinely checked in patients with depression of recent onset. Imbalances in glucose (sugar) management can result in mood swings and should always be evaluated. Less commonly, malfunctions of the adrenal glands can profoundly affect a person’s energy level and mental activity. The role of estrogen in postmenopausal depression has been intensively studied in recent years, but the findings remain inconclusive.

NEUROPATHOLOGY. Neuropathology refers to damage to the brain tissue itself that results in mental illness. Dementias are placed in this category, since the brains of persons diagnosed with dementia exhibit microscopic changes in tissue structure when viewed under a microscope. These changes may ultimately appear on tests such as a CAT scan of the brain. Larger changes are seen with strokes, which result when the blood supply is cut off to a specific area of the brain and causes localized damage. In these instances, a person may have altered speech patterns but retain the ability to think clearly, or vice versa. The losses are somewhat predictable and specific, based on the area of the brain that was affected and the extent of oxygen starvation of the tissue in that region.

Brain tumors and accidental injuries are random in their effects, and the deficits are usually less predictable. Each case must be examined individually. As with strokes, however, the location of the injury or tumor will determine the resulting mental status changes or deficits.

Pancreatic and certain colon cancers are particularly interesting for psychiatrists. For reasons that are unknown as of 2002, these tumors are frequently accompanied by depression even though they are located in organs that are far removed from the brain. More research is needed on the relationship between mood disorders and certain illnesses; it is possible that the tumor releases compounds into the bloodstream that have depressive effects.

NUTRITIONAL FACTORS. There is no doubt that poor nutrition leads to mental imbalances. While few people in the United States are truly starving or completely depleted nutritionally, instances of mental disorders related to malnutrition still occur in this country. The B vitamins are essential for mental clarity and stability. Insufficient amounts of the B vitamins, which include thiamin, nicotinamide, pyridoxine, and B, can result in confusion, irritability, insomnia, depression, and in extreme cases, psychosis. The body does not store these vitamins, so one should monitor one’s daily intake to ensure a sufficient supply. Tryptophan is an amino acid and supplement that is a building block for serotonin, the neurotransmitter that has been found to be essential in treating depression, anxiety, panic, and OCD, among others. Tryptophan is so important nutritionally that studies have shown that its absence in the diet will result in depression even when the person is taking a prescription antidepressant to increase the availability of serotonin.

Psychological/interpersonal theories

PSYCHODYNAMIC THEORIES. Freud certainly opened the doors for humans to understand themselves in terms of psychology, or the notion that how one thinks and feels affects one’s view of the world. Freud also found that simple conversation could help some very sick people out of depressions and other mental disorders. His work essentially demonstrated that extreme inner conflicts can become a source of mental illness. These extreme internal conflicts can occur, for instance, when one loves another deeply but also feels that that person is hurting them or limiting their development in some way. If the person who is causing pain or hindering growth is a parent or other powerful figure, these intense feelings can be hidden away or repressed. Also, a lack of honesty about reality can lead to any number of illnesses. For instance, feelings of anger and powerlessness, if unrecognized, may place the person at risk for developing aggressive behaviors or depression if insights and appropriate coping skills are not gained. These psychological dis-harmonies, if ignored, can lead to dis-ease if they are sufficiently intense or associated with central relationships in the person’s life.

Freud’s view of psychological conflicts as rooted in sexual repression was questioned by Jung, a psychiatrist and protégé of Freud, who felt that people’s lives were affected by deep spiritual forces. Jung’s work centered on psychological imbalances stemming from spiritual distress. There were other theorists after Freud, such as Adler, who regarded power as the central motivating force of human personality, or Melanie Klein, who emphasized the significance of envy.

Since the Second World War, behavioral and cognitive theories have emphasized the role of learning in the development of mental disorders. Children growing up in an abusive home, for example, may be “rewarded” by not getting beaten if they learn to be quiet and internalize everything. This internalized state may be a precursor of full-blown depression in later years. Unconscious assumptions based on early experiences may spill over into other situations later in life. As another example, children may learn to be “good” for their parents or society by taking on careers they don’t like or belief systems that don’t fit them, all for approval by the perceived higher authority.

Cognitive approaches to therapy maintain that people construct their view of the world from beliefs and feelings based on deeper assumptions about their own competencies. Depression, for instance, would be seen as a spiral downward into negative “self-talk” and feelings of inadequacy. Re-examining these negative assumptions then breaks the cycle based on erroneous thinking (cognition) which is causing the depression, anxiety, or aberrant behavior. Studies have shown that three months of cognitive therapy is as effective as medication in the treatment of depression. This finding shows clearly that talk therapy does change the chemistry of the brain.

TRAUMA-RELATED FACTORS. Psychological traumas refer to events that are outside the experience of everyday life, although the exact definition of a traumatic experience may vary from person to person, country to country, and century to century. Traumas in early life, such as sexual or physical abuse, can lead to mood disorders and contribute to the development of personality disorders. Horrendous early traumas involving torture of a child, other people, or animals, may result in dissociative identity disorder, formerly called multiple personality disorder. Dissociation is a self-protective mechanism for separating conscious awareness from repeated traumas. It has sometimes been described as self-hypnosis, but most clinicians believe that it is not under the patient’s control, at least initially.

In later life, such severe traumas as war, rape, natural disasters, or any similar event, can lead to psychiatric difficulties. Post-traumatic stress disorder (PTSD) is a well-known disorder that affects war veterans. Extreme trauma causes the brain to record impressions in a way that is different from ordinary formation of memories. These disjointed impressions may re-emerge as flashbacks months or years after the traumatic experience. Chronic and repetitive trauma, exemplified by intermittent abuse or hostage situations, can lead to a chronic form of PTSD as well.

A subcategory of psychiatric disorders that occur in response to traumatic shock are termed fugue states. Fugue states are poorly understood, but can be described as conditions of total memory loss after witnessing an overwhelmingly horrible accident or atrocity. These states of memory loss can last from minutes to years.

SOCIOCULTURAL FACTORS. Some mental disorders are influenced by social values and social interactions shaped by those values. Anorexia nervosa, bulimia nervosa, and body dysmorphic disorder are the most commonly used examples of mental illnesses in this category. With the increased visibility of unnaturally slender women in modern society (as seen everywhere in advertising, television shows, movies, and celebrity fan magazines) doctors have seen a tremendous rise in the occurrence eating disorders. “You can never be too thin or too rich,” a saying attributed to the Duchess of Windsor, is a phrase that has many women, and some men, monitoring their every ounce of food intake. The core of the illness is a lack of self-esteem combined with feelings that one’s world is out of control. Some clinicians add fear of sexual maturation to this list of psychological causes of eating disorders. The common denominator is that these patients apparently believe they can control their world by controlling their food intake. Although neurotransmitter deficits have been found in patients with bulimia, whose vomiting may actually change their body chemistry, the desire to be thin is the conscious motivating force.

Modern society also values activity over rest, doing over being, thinking over feeling, resulting in many people becoming slaves to work and productivity, and having little respect for their inner life. Many cases of mild stress-related disorders run the risk of developing into full-blown generalized anxiety, panic, and depressive disorders. Mental health requires a reasonable balance between work and activity on the one hand and periods of rest and relaxation on the other.

ALCOHOL AND SUBSTANCE ABUSE. Alcohol is a central nervous system depressant. It plays a prominent role in the development of at least depression and is often involved in other mental disorders. In addition, people who abuse alcohol are at increased risk of mental disorders related to nutritional deficiencies. A lack of thiamin, a B-vitamin, can result in permanent brain damage in the form of severe dementia even at an early age. People in withdrawal from alcohol are also at risk for delirium tremens, a serious condition that can result in cardiovascular shock and death.

Street drugs are well known for their effects on young people’s mood and behavior. Permanent brain damage may result from the use of some “designer” drugs. One example is “Ecstasy,” which can cause permanent memory loss and severe depression that responds only slowly to treatment. Street drugs must always be considered as a possible factor in the sudden onset of a mental illness in a young person. Moreover, drugs may precipitate a first psychotic episode in a person with a genetic predisposition to schizophrenia. In this case, the drug is the stressor that reveals the person’s dormant susceptibility to the disorder.

Current theory and future directions

The biopsychosocial model of mental illness

All of the above factors are most succinctly summarized in terms of the biopsychosocial model of mental illness. Biological contributions, thoughts and perceptions, social pressures, and environmental stressors, the presence or absence of nurturing and consistency of love, core values, and self-worth are just a few of the things that contribute to making up the psychological uniqueness of every human being on the planet. In addition to the above, researchers are actively examining the role of spirituality in mental health and recovery. No one factor can be said to be the sole cause of mental illness; rather, disorders result from a complex set of forces that act upon each person as an individual. Finding the various elements that contributed to the onset of an illness requires considerable patience from the patient, his or her family, and health workers. Identifying all factors, if possible, provides the best road map for the healing process.

New directions

In the future, scientists will certainly modify and expand our thought-models about the mind and brain. For example, a new treatment called transcranial magnetic stimulation (TMS) is being evaluated as an alternative to electric shock therapy. TMS uses powerful magnets instead of electricity, and is delivered to specific areas of the brain. Hence, in the future scientists must integrate some of the electromagnetic aspects of nature into the mind-brain puzzle. In addition, the National Institute of Mental Health (NIMH) is researching alternative healing modalities. Prominent among them is acupuncture, which has been used to treat depression, anxiety and panic disorder. Other alternative treatments being studied include the effects of prayer, meditation, creative writing, and yoga.

Deeper exploration of the human condition is both inevitable and desirable. Perhaps researchers will find better answers by asking the question, “What makes people healthy?” instead of simply looking at what makes us sick. In the end, researchers may find proof of some of the ancient truths taught by spiritual teachers from all traditions; and that the physical changes seen with human eyes or under a microscope are really just the symptoms of and not the causes of imbalances.

Definition

Oppositional defiant disorder (ODD) is a disorder found primarily in children and adolescents. It is characterized by negative, disobedient, or defiant behavior that is worse than the normal “testing” behavior most children display from time to time. Most children go through periods of being difficult, particularly during the period from 18 months to three years, and later during adolescence. These difficult periods are part of the normal developmental process of gaining a stronger sense of individuality and separating from parents. ODD, however, is defiant behavior that lasts longer and is more severe than normal individuation behavior, but is not so extreme that it involves violation of social rules or the rights of others.

The mental health professional’s handbook, Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), classifies ODD as a disruptive behavior disorder.

Description

Children who have ODD are often disobedient. They are easily angered and may seem to be angry much of the time. Very young children with the disorder will throw temper tantrums that last for 30 minutes or longer, over seemingly trivial matters.

In addition, the child with ODD often starts arguments and will not give up. Winning the argument seems to be very important to a child with this disorder. Even if the youth knows that he or she will lose a privilege or otherwise be punished for continuing the tantrum or argument, he or she is unable to stop. Attempting to reason with such a child often backfires because the child perceives rational discussion as a continuation of the argument.

Most children with ODD, however, do not perceive themselves as being argumentative or difficult. It is usual for such children to blame all their problems on others. Such children can also be perfectionists and have a strong sense of justice regarding violations of what they consider correct behavior. They are impatient and intolerant of others. They are more likely to argue verbally with other children than to get into physical fights.

Older children or adolescents with ODD may try to provoke others by being deliberately annoying or critical. For example, a teenager may criticize an adult’s way or speaking or dressing. This oppositional behavior is usually directed at an authority figure such as a parent, coach, or teacher. Youths diagnosed with ODD, however, can also be bullies who use their language skills to taunt and abuse other children.

Causes and symptoms

Causes

ODD has been called a problem of families, not of individuals. It occurs in families in which some or all of the following factors are present:

• Limits set by parents are too harsh or too lax, or an inconsistent mix of both.
• Family life lacks clear structure; rules, limits, and discipline are uncertain or inconsistently applied.
• At least one parent models oppositional behavior in his or her own interactions with others. For example, mother or father may get into frequent disputes with neighbors, store clerks, other family members, etc., in front of the child.
• At least one parent is emotionally or physically unavailable to the child due to emotional problems of the parent (such as depression), separation or divorce, or work hours.

The defiant behavior may be an attempt by the child to feel safe or gain control. It may also represent an attempt to get attention from an unresponsive parent.

There may be a genetic factor involved in ODD; the disorder often seems to run in families. This pattern may, however, reflect behavior learned from previous generations rather than the effects of a gene or genes for the disorder.

Symptoms

According to DSM-IV-TR, a diagnosis of ODD may be given to children who meet the following criteria, provided that the behavior occurs more frequently than usual compared to children of the same age and developmental level.

A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four (or more) of the following are present. The child:

• often loses his or her temper
• frequently argues with adults
• often disregards adults’ requests or rules
• deliberately tries to provoke people
• frequently blames others for his or her mistakes or misbehavior
• is often easily irritated by others
• is often angry and resentful
• is often spiteful

In order to make the diagnosis of oppositional defiant disorder, the behavioral disturbances must cause significant impairment in the child’s social, academic or occupational functioning, and the behaviors must not occur exclusively during the course of a psychotic or mood disorder. In addition, the child must not meet criteria for conduct disorder, which is a more serious behavioral disorder. If the youth is 18 years or older, he or she must not meet criteria for antisocial personality disorder.

Demographics

Oppositional defiant disorder is thought to occur in about 6% of all children in the United States. It is more common in families of lower socioeconomic status. In one study, 8% of children from low-income families were diagnosed with ODD. The disorder is often apparent by the time a child is about six years old. Boys tend to be diagnosed with this disorder more often than girls in the preteen years, but it is equally common in males and females by adolescence.

It is estimated that about one-third of children who have attention-deficit/hyperactivity disorder(ADHD) also have ODD. Children who have ODD are also often diagnosed with anxiety or depression.

Diagnosis

Oppositional defiant disorder is diagnosed when the child’s difficult behavior lasts longer than six months. There is no standard test for diagnosing ODD. A full medical checkup may be done to make sure that there is no medical problem causing the child’s behavior. The medical examination is followed by a psychological evaluation of the child, which involves an interview with a mental health professional. The mental health professional may also interview the child’s parents and teachers. Psychological tests are sometimes given to the child to rule out other disorders.

Evaluation for ODD includes ruling out a more disruptive behavioral disorder known as conduct disorder (CD). CD is similar to ODD but also includes physical aggression toward others, such as fighting or deliberately trying to hurt another person. Children with CD also frequently break laws or violate the rights of others, for example by stealing. They tend to be more covert than children with ODD, lying and keeping some of their unacceptable behavior secret.

The diagnosis of ODD may specify its degree of severity as mild, moderate, or severe.

Treatments

Treatment of ODD focuses on both the child and on the parents. The goals of treatment include helping the child to feel protected and safe and to teach him or her appropriate behavior. Parents may need to learn how to set appropriate limits with a child and how to deal with a child who acts out. They may also need to learn how to teach and reinforce desired behavior.

Parents may also need help with problems that may be distancing them from the child. Such problems can include alcoholism or drug dependency, depression, or financial difficulties. In some cases, legal or economic assistance may be necessary. For example, a single mother may need legal help to obtain child support from the child’s father so that she won’t need to work two jobs, and can stay at home in the evenings with the child.

Behavioral therapy is usually effective in treating ODD. Behavioral therapy focuses on changing specific behaviors, not on analyzing the history of the behaviors or the very early years of the child’s life. The theory behind behavioral therapy is that a person can learn a different set of behaviors to replace those that are causing problems. As the person obtains better results from the new behavior, he or she will want to continue that behavior instead of reverting to the old one. To give an example, the child’s parents may be asked to identify behaviors that usually start an argument. They are then shown ways to stop or change those behaviors in order to prevent arguments.

Contingency management techniques may be included in behavioral therapy. The child and the parents may be helped to draw up contracts that identify unwanted behaviors and spell out consequences. For example, the child may lose a privilege or part of his or her allowance every time he or she throws a temper tantrum. These contracts can include steps or stages—for example, lowering the punishment if the child begins an argument but manages to stop arguing within a set period of time. The same contract may also specify rewards for desired behavior. For example, if the child has gone for a full week without acting out, he or she may get to choose which movie the family sees that weekend. These contracts may be shared with the child’s teachers.

The parents are encouraged to acknowledge good or nonproblematic behavior as much as possible. Attention or praise from the parent when the child is behaving well can reinforce his or her sense that the parent is aware of the child even when he or she is not acting out.

Cognitive therapy may be helpful for older children, adolescents, and parents. In cognitive therapy, the person is guided to greater awareness of problematic thoughts and feelings in certain situations. The therapist can then suggest a way of thinking about the problem that would lead to behaviors that are more likely to bring the person what they want or need. For example, a girl may be helped to see that much of her anger derives from feeling that no one cares about her, but that her angry behavior is the source of her problem because it pushes people away.

Although psychotherapy is the cornerstone of treatment for ODD, medicine may also be helpful in some cases. Children who have concurrent ADHD may need medical treatment to control their impulsivity and extend their attention span. Children who are anxious or depressed may also be helped by appropriate medications.

Prognosis

Treatment for ODD is usually a long-term commitment. It may take a year or more of treatment to see noticeable improvement. It is important for families to continue with treatment even if immediate results are not apparent.

If ODD is not treated or if treatment is abandoned, the child has a higher likelihood of developing conduct disorder. The risk of developing conduct disorder is lower in children who are only mildly defiant. It is higher in children who are more defiant and in children who also have ADHD. In adults, conduct disorder is called antisocial personality disorder, or ASD.

Children who have untreated ODD are also at risk for developing passive-aggressive behaviors as adults. Persons with passive-aggressive characteristics tend to see themselves as victims and blame others for their problems.

Prevention

Prevention of ODD begins with good parenting. If at all possible, families and the caregivers they encounter should be on the lookout for any problem that may prevent parents from giving children the structure and attention they need.

Early identification of ODD and ADHD is necessary to obtain help for the child and family as soon as possible. The earlier ODD is identified and treated, the more likely it is that the child will be able to develop healthy patterns of relating to others.

Definition

Opioids are a class of drugs that include both natural and synthetic substances. The natural opioids (referred to as opiates) include opium and morphine. Heroin, the most abused opioid, is synthesized from opium. Other synthetics (only made in laboratories) and commonly prescribed for pain, such as cough suppressants, or as anti-diarrhea agents, include codeine, oxycodone (OxyContin), meperidine (Demerol), fentanyl (Sublimaze), hydromorphone (Dilaudid), methadone, and propoxyphene (Darvon). Heroin is usually injected, either intravenously (into a vein) or subcutaneously (under the skin), but can be smoked or used intranasally (i.e., “snorted”). Other opioids are either injected or taken orally.

The manual that is used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders. The latest edition of this manual was published in 2000, and is also known as the DSM-IV-TR. DSM-IV-TRlists opioid dependence and opioid abuse as substance use disorders. In addition, the opioid-induced disorders of opioid intoxication and opioid withdrawal are listed in the substancerelated disorders section as well.

Opioid dependence

Opioid dependence, or addiction, is essentially a syndrome in which a person continues to use opioids in spite of significant problems caused by or made worse by the use of opioids. Typically individuals with opioid dependence are physically dependent on the drug as evidenced by tolerance and/or withdrawal.

Opioid abuse

Opioid abuse is less severe than opioid dependence and typically does not involve physical dependence on the drug. Opioid abuse is essentially repeated significant negative consequences of using opioids recurrently.

Opioid intoxication

When an individual uses a sufficient amount of an opioid, they will get “high” from the drug. Some people, however, have negative experiences when they use an opioid. When too much of an opioid is taken, an individual can overdose.

Opioid withdrawal

Individuals who use opioids on a regular basis, even if only for a few days, may develop a tolerance to the drug and experience physiological and psychological symptoms when they stop using the drug. The “abstinence syndrome” related to opioids is very similar to a bad case of influenza (or the “flu”).

Description

Opioid dependence

Dependence on opioids involves significant physiological and psychological changes, which make it extremely difficult for an individual to stop using the opioids. Recurrent use of opioids causes actual changes in how the brain functions. An individual who is addicted to opioids cannot simply just stop using, despite significant negative consequences related to their use. Marital difficulties, including divorce, unemployment, and drug-related legal problems are often associated with opioid dependence. People dependent on opioids often plan their day around obtaining and using opioids.

Opioid abuse

People who abuse opioids typically use them less frequently than those who are dependent on opioids. However, despite less frequent use, an individual with opioid abuse suffers negative consequences. For example, while intoxicated on opioids, an individual may get arrested for their behavior.

Opioid intoxication

An individual who uses opioids typically experiences drowsiness (“nodding off”), mood changes, a feeling of heaviness, dry mouth, itching, and slurred speech. Individuals who use heroin intravenously describe an intense euphoria (or “rush”), a floating feeling, and total indifference to pain. Symptoms of intoxication usually last several hours. Severe intoxication from an overdose of opioids is life-threatening because breathing may stop.

Opioid withdrawal

Tolerance to opioids occurs quickly. Regular users of opioids take doses that would kill someone who has never used before. After regular use, the human body adapts to the regular presence of the drug and the person only feels “normal” when they have opioids in their system. Therefore, when an opioid-dependent individual stops using opioids abruptly, he or she will experience withdrawal symptoms. Withdrawal symptoms from heroin usually begin six to eight hours after last use and peak after two days. Acute withdrawal typically lasts no more than seven to ten days, but some symptoms of withdrawal (such as craving, insomnia, anxiety, lack of interest) can last six months or longer. Although withdrawal is very uncomfortable, it is not life-threatening unless there is an underlying medical condition, such as heart disease. In addition to physical withdrawal, “psychological withdrawal” often occurs. The individual who is dependent on opioids has difficulty imagining living without the drug, since they were dependent on it to function. This is similar to how someone addicted to nicotine may feel after giving up cigarettes.

Causes and symptoms

Causes

There are no clear-cut causes of drug use other than the initial choice to use the drug. This decision to use may be highly influenced by peer group. Typically, the age of first use of heroin is about 16 years old, but this age has been dropping in recent years.

Certain social and behavioral characteristics, however, are more commonly seen among individuals who become dependent on opioids than those who do not. For instance, many heroin users come from families in which one or more family members use alcohol or drugs excessively or have mental disorders (such as antisocial personality disorder). Often heroin users have had health problems early in life, behavioral problems beginning in childhood, low self-confidence, and anti-authoritarian views.

Among opioid-dependent adolescents, a “heroin behavior syndrome” has sometimes been described. This syndrome consists of depression (often with anxiety symptoms), impulsiveness, fear of failure, low self-esteem, low frustration tolerance, limited coping skills, and relationships based primarily on mutual drug use.

Symptoms

OPIOID DEPENDENCE. The DSM-IV-TRspecifies that three or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid dependence:

• Tolerance: The individual either has to use increasingly higher amounts of the drug over time in order to achieve the same drug effect or finds that the same amount of the drug has much less of an effect over time than before.
• Withdrawal: The individual either experiences the characteristic abstinence syndrome (i.e., opioid-specific withdrawal) or the individual uses opioids or similar-acting drugs in order to avoid or relieve withdrawal symptoms.
• Loss of control: The individual either repeatedly uses more opioids than planned or uses the opioids over longer periods of time than planned.
• Inability to stop using: The individual has either unsuccessfully attempted to cut down or stop using the opioids or has a persistent desire to stop using.
• Time: The individual spends a lot of time obtaining opioids, getting money to buy opioids, using opioids, being under the influence of opioids, and recovering from the effects of opioids.
• Interference with activities: The individual either gives up or reduces the amount of time involved in recreational activities, social activities, and/or occupational activities.
• Harm to self: The individual continues to use opioids despite having either a physical or psychological problem (depression, for example) that is caused or made worse by the opioid use.

OPIOID ABUSE. The DSM-IV-TRspecifies that one or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid abuse:

• Interference with role fulfillment: The individual’s use of opioids repeatedly interferes with the ability to fulfill obligations at work, home, or school.
• Danger to self: The individual repeatedly uses opioids in situations in which it may be physically hazardous (while driving a car, for example).
• Legal problems: The individual has recurrent opioidrelated legal problems (such as arrests for possession of narcotics).
• Social problems: The individual continues to use opioids despite repeated interpersonal or relationship problems caused by or made worse by the use of opioids.

OPIOID INTOXICATION. The DSM-IV-TRspecifies that the following symptoms must be present in order to meet diagnostic criteria for opioid intoxication:

• Use: The individual recently used an opioid.
• Changes: The individual experiences significant behavioral or psychological changes during, or shortly after, use of an opioid. These changes may include euphoria initially, followed by slowed movements or agitation, impaired judgment, apathy(“don’t care attitude”), dysphoric mood (depression, for example), or impaired functioning socially or at work.
• Opioid-specific intoxication syndrome: The pupils in the eyes get smaller. In addition, drowsiness or coma, slurred speech, and/or impaired memory or attention during, or shortly after, opioid use occur.

OPIOID WITHDRAWAL. The DSM-IV-TRspecifies that the following symptoms must be present in order to meet diagnostic criteria for opioid withdrawal:

• Abstinence: Either the individual has stopped using (or has reduced the amount of) opioids, or an opioid antagonist (i.e., a drug, such as naloxone, that blocks the action of opioids) has been administered.
• Opioid-specific withdrawal syndrome: Three or more symptoms develop after abstinence. These symptoms include dysphoric (negative) mood, nausea or vomiting, muscle aches, runny nose or watery eyes, dilated pupils, goosebumps, or sweating, diarrhea, yawning, fever, and insomnia.
• Impairment or distress: The withdrawal symptoms must cause significant distress to the individual or impairment in functioning (socially, at work, or any other important area).
• Not due to other disorder: The withdrawal symptoms cannot be due to a medical condition or other mental disorder.

Demographics

There are at least 600,000 individuals with opioid dependence living in the United States. It has been estimated that almost 1% of the population has met criteria for opioid dependence or abuse at some time in their lives.

In the late 1800s and early 1900s, individuals who were dependent on opioids were primarily white and from middle socioeconomic groups. However, since the 1920s, minorities and those from lower socioeconomic groups have been overrepresented among those with opioid dependence. It appears that availability of opioids and subcultural factors are key in opioid use. Therefore, medical professionals (who have access to opioids) are at higher risk for developing opioid-related disorders.

Males are more commonly affected by opioid disorders than females—males are three to four times more likely to be dependent on opioids than females. Age also is a factor in opioid dependence. There is a tendency for rates of dependence to decrease beginning at 40 years of age. Problems associated with opioid use are usually first seen in the teens and 20s.

Diagnosis

Diagnosis of opioid-related disorders are based on patient interview and observations of symptoms, including signs of withdrawal such as dilated pupils, watery eyes, frequent yawning, and anxiety, among others.

Opioid dependence

Other mental disorders are common among individuals with opioid dependence. It has been estimated that 90% of those with opioid dependence have one or more other mental disorders. Depression (usually either major depression or substance-induced mood disorder) is the most common disorder. Opioid-dependent individuals frequently report suicidal ideation (thoughts) and insomnia. Other substance use disorders (such as alcoholism), anxiety disorders, antisocial personality disorder, post-traumatic stress disorder, and a history of conduct disorder are also fairly common.

Opioid intoxication

Intoxication on other substances, such as alcohol, sedatives, hypnotics, and anxiolytics, can resemble intoxication on opioids. Furthermore, dilated pupils can be seen in hallucinogen intoxication, amphetamine intoxication, and cocaine intoxication.

Opioid withdrawal

The restlessness and anxiety seen in opioid withdrawal is also seen in withdrawal from sedatives, hypnotics, and anxiolytics.

Treatments

Opioid dependence

Because opioid-related disorders are complex, multiple treatment approaches are often necessary. Generally, the more treatment (a combination of medication, individual therapy, and self-help groups, for example) and longer the treatment (i.e., at least three months), the better the outcomes. There are a wide variety of treatment options, both inpatient or residential and outpatient:

• Methadone maintenance treatment. Methadone is a long-acting opioid that is generally administered in an outpatient setting (a methadone maintenance clinic). The methadone prevents the individual from experiencing opioid withdrawal, reduces opioid craving, and enables the individual to have access to other services (such as individual counseling, medical services, and HIV-prevention education). A proper dose of methadone also prevents the individual from getting “high” from heroin. Methadone maintenance therapy can decrease criminal activity, decrease HIV-risk behaviors, and increase stability of employment. Low-dose methadone maintenance treatment is preferable for pregnant individuals who would otherwise use illicit opioids. A longer-acting alternative to methadone is LAAM (levo-alphacetylmethadol). Individuals receiving the proper doses of LAAM only need to take it three times per week, instead of every day as with methadone.
• Opioid antagonist treatment. An opioid antagonist is a medication that blocks the effects of opioids. Treatment with an antagonist, usually naltrexone(Trexan), typically takes place on an outpatient basis following an inpatient medical detoxification from opioids. The effects of taking any opioids are blocked by the naltrexone and prevent the individual from getting “high,” thereby discouraging individuals from seeking opioids. By itself, this treatment is suitable for individuals highly motivated to discontinue opioid use. However, antagonists can be used in addition to other treatment modalities or with individuals who have been abstinent for some time but fear a relapse.
• Opioid agonist-antagonist treatment. An opioid agonist is a drug that has a similar action to morphine. Buprenorphine (Buprenex) is an example of an opioid agonist-antagonist, which means it acts as both an agonist (having some morphine-like action) and antagonist (it blocks the effects of additional opioids). Buprenorphine has been shown to effectively reduce opioid use. It is also being studied for opioid detoxification.
• Outpatient drug-free treatment. These are outpatient treatment approaches that do not include medications. There are a number of different types of programs ranging from simple drug education to intensive outpatient programs that offer most of the services of an inpatient setting. Some programs may specialize in treating specific groups of people who are opioid-dependent (those with co-occurring mental disorders, for example).
• Residential or inpatient treatment. These include inpatient rehabilitation programs (usually seven to 30 days in length) and long-term residential programs (such as therapeutic communities). Rehabilitation programs provide an inpatient atmosphere following detoxification and usually offer individual and group counseling as well as medical services. Therapeutic communities are designed to be more than six months long and are highly structured. The primary focus is on resocializing the individual to a drug-free and crime-free lifestyle.
• Individualized drug counseling. Individual counseling is often a part of a methadone maintenance program or inpatient rehabilitation program. The primary focus is on helping the individual learn strategies to reduce or stop their opioid use and learn coping mechanisms to maintain abstinence. Twelve-step participation is encouraged and referrals for medical, psychiatric, employment, or other services are made as necessary.
• Supportive-expressive psychotherapy. This type of individual psychotherapy may be a part of a methadone maintenance program or offered alone. The focus of this type of therapy is to help individuals feel comfort able talking about themselves, work on relationship issues, and solve problems without resorting to opioids or other drugs.
• Self-help groups. Narcotics Anonymous (NA) is a twelve-step group based on the same model as Alcoholics Anonymous. This self-help group can provide social support to an individual in the process of reducing or stopping opioid use. Participation in NA is often encouraged or is a required component of other types of treatment for opioid dependence. Nar-Anon is a group for family members and friends of opioid-dependent individuals.
• Alternative therapies. Hypnosis, guided imagery, biofeedback, massage, and acupuncture have all been studied as adjunctive treatments for opioid dependence, but none have been proven to be effective.

Opioid abuse

Most of the treatments for opioid dependence would be appropriate for opioid abuse except methadone main tenance and opioid antagonist treatment.

Opioid intoxication

An opioid antagonist, naloxone (Narcan), can be administered to reverse the effects of acute intoxication or overdose on most opioids.

Opioid withdrawal

Opioid withdrawal can be treated either on an inpatient basis (detoxification) or on an outpatient basis (methadone detoxification):

• Inpatient detoxification program. Typically, this would be from three to seven days. The withdrawal can be medically managed. Clonidine may be administered to help reduce some symptoms of withdrawal.
• Outpatient methadone detoxification. Methadone would be substituted for the illicit opioid and the dose would be gradually reduced. Detoxification from methadone is easier (i.e., the symptoms are less severe) than from heroin. However, the withdrawal or abstinence syndrome also lasts longer. Clonidine may also be administered during the methadone detoxification to help reduce withdrawal symptoms.

Prognosis

Opioid dependence

Recovering from opioid dependence is a long, difficult process. Typically, multiple treatment attempts are required. Relapsing, or returning to opioids, is not uncommon even after many years of abstinence. Brief periods of abstinence are common.

Inpatient detoxification from opioids alone, without additional treatment, does not appear to have any effect on opioid use. However, other treatments have been shown to reduce opioid use, decrease illegal activity, decrease rates of HIV-infection, reduce rates of death, and increase rates of employment. Benefits are greatest for those who remain in treatment longer and participate in many different types of treatment (individual and group counseling in addition to methadone maintenance, for example).

Opioid abuse

Very little is known about the course of opioid abuse.

Prevention

The best single thing an individual can do to prevent opioid-related disorders is never to use illicit opioids such as heroin. Opioids are powerfully addicting, especially if used intravenously. The risk of becoming dependent on appropriately prescribed opioids, however, is generally low except for individuals who already have a substance use disorder.

On a larger scale, comprehensive prevention programs that utilize family, schools, communities, and the media can be effective in reducing substance abuse. The recurring theme in these programs is not to use drugs in the first place.

Definition

Olanzapine is classified as an atypical antipsychotic drug. It is available in the United States under the brand names Zyprexa and Zyprexa Zydis.

Purpose

Olanzapine is used to treat schizophrenia, to control manic episodes of bipolar disorder (manic-depressive disorder), or to treat dementia related to Alzheimer’s disease.

Description

Olanzapine is thought to modify the actions of several chemicals in the brain. Onlanzapine is chemically related to another atypical antipsychotic agent, clozapine, but differs both chemically and pharmacologically from the earlier phenothiazine antipsychotics.

Olanzapine is available as 2.5-mg, 5-mg, 7.5-mg, 10-mg, 15-mg, and 20-mg tablets that can be swallowed (Zyprexa) and 5-mg, 10-mg, 15-mg, and 20-mg tablets that disintegrate when placed under the tongue (Zyprexa Zydis). Olanzapine is broken down by the liver.

Recommended dosage

The dosage of olanzapine varies depending upon the reason for its use. When used to treat schizophrenia, 5–10 mg is the typical starting dosage. If dosage adjustments are needed, increases are made in 5-mg increments once a week. When treating schizophrenia, a total daily dosage of 10–15 mg is usually effective. When olanzapine is used to treat acute manic episodes, initial doses of olanzapine are often 10–15 mg; 20 mg per day may be needed for maximum effect. The safety of doses greater than 20 mg per day has not been determined.

Olanzapine is eliminated from the body more quickly in young people than in older (over age 60) individuals, in men than in women, and in smokers faster than in non-smokers. Dosage adjustments may be needed based upon individual patient characteristics.

Precautions

Caution should be used in patients with heart disease because the drug may cause blood pressure to fall too low resulting in dizziness, rapid heartbeats, or fainting. Olanzapine should be used carefully in people with known seizure disorders since olanzapine may alter properties of the brain making seizures occur more easily. People with liver disease should have their liver function monitored regularly while taking olanzapine. Women who are pregnant or breast-feeding should not take olanzapine. People with phenylketonuria, a disorder in which the body is unable to metabolize a protein called phenylalanine, should avoid olanzapine disintegrating tablets, because this form of the drug contains phenylalanine.

Side effects

Side effects that occur in more than 5% of patients taking olanzapine include involuntary movements, weakness, dizziness, extreme drowsiness, nonviolent objectionable behavior, constipation, weight gain, dry mouth, low blood pressure, stomach upset, increased appetite, cold-such as symptoms, or fever.

Other side effects that are possible include rash, body aches and pains, elevated liver enzymes, vision abnormalities, chest pain, or rapid heartbeats.

Olanzapine has the potential to produce a serious side effect called tardive dyskinesia. This syndrome consists of involuntary, uncoordinated movements that may appear late in therapy and not disappear even after the drug is stopped. Tardive dyskinesia involves involuntary movements of the tongue, jaw, mouth or face or other groups of skeletal muscles. The incidence of tardive dyskinesia increases with increasing age and with increasing dosage of olanzapine. Women are at greater risk than men for developing tardive dyskinesia. There is no known effective treatment for tardive dyskinesia, although gradual (but rarely complete) improvement may occur over a long period.

An occasionally reported side effect of olanzapine is neuroleptic malignant syndrome. This is a complicated and potentially fatal condition characterized by muscle rigidity, high fever, alterations in mental status, and cardiac symptoms such as irregular pulse or blood pressure, sweating, tachycardia (fast heartbeat), and arrhythmias (irregular heartbeat).

Interactions

Any drug that causes drowsiness may lead to decreased mental alertness and impaired motor skills when taken with olanzapine. Some examples include alcohol, antidepressants such as imipramine (Tofranil) or paroxetine (Paxil), antipsychotics such as thioridazine (Mellaril), and some antihistamines. Because olanzapine may lower blood pressure, it may reduce blood pressure to dangerously low levels if taken with drugs that are used to treat high blood pressure. Carbamazepine (Tegretol), a drug commonly used to treat seizures, may decrease the effectiveness of olanzapine.