Neuroleptics

We report a case of conversion disorder (partial aphonia) that was successfully treated with speech therapy. During the one year duration of this illness, the patient regained transiently (minutes) her normal speech on a few occasions, independently of concomitant pharmacological interventions. One year after recovery she developed aphonia for the second time, which responded again to speech therapy, although the response rate was slower. Several mechanisms of conversion disorder are reviewed as specifically applied to this case. The possible role of pertinent shame mechanisms in the conversion pathology is discussed.

L’asile de Sainte-Gemmes-sur-Loire dans le Maine-et-Loire (49) ouvre ses portes en 1844. Il est né avec la loi de 1838 sur les aliénés qui donne naissance à un réseau d’institutions départementales spécialisées. Cette loi institue l’internement : un isolement avec obligation de soin, une mesure de police qui repose non sur la maladie mais sur la dangerosité d’un individu pour l’ordre public ou la sûreté des personnes.
Dans le contexte normatif disciplinaire du XIXe siècle, l’asile est pensé comme un « instrument de guérison » qui a pour but de redresser l’individu. L’organisation spatiale fonctionne sur la ségrégation, d’abord avec la cité par la clôture puis au sein de l’asile par une distribution/séparation des « analogues ». La vie dans l’institution est régie par un règlement strict. Victime de son succès, l’asile est rapidement surpeuplé. Dépendant essentiellement du prix de journée alloué par les collectivités locales, et dans une moindre mesure par celui payé par les familles, l’asile doit contribuer à sa survie. La surpopulation, l’inefficacité des thérapies et la sous-médicalisation nuisent au soin, aggravent l’encombrement et « chronicisent » les malades. L’ensemble alimente la stigmatisation du lieu et de ses occupants, le fantasme.
L’objet de ce livre est d’analyser comment l’institution psychiatrique de Ste-Gemmes-sur-Loire, appelée maintenant Centre de santé mentale angevin (CESAME), s’est transformée au cours du XXe siècle, et d’étudier le passage progressif du modèle asilaire vers un autre, actuellement en train de s’effacer. L’exploration commence au début du XXe siècle avec l’arrivée d’un médecin-directeur progressiste, le Dr Jacques Baruk et se termine dans les années 1970 avec la mise en place d’un nouveau dispositif : la sectorisation.

Die vorliegende Publikation ging aus dem yom Schweizerischen N ationalfonds finanzierten Nationalen Forschungsprogramm (NFP) 5l zum Thema «Integration und Ausgrenzung» hervor und befasst sich mit der Entwicklung der Zürcher Psychiatrie zwischen 1870 und 1970. Sie versteht sich in einem doppelten Sinn aIs paradigmatisch: zum einen lassen sich am Fall Zürich Überlegungen zur Entwicklung der Psychiatrie in modernen Gesellschaften generell anstellen, zum andern ermoglicht die Geschichte der «psychiatrischen Ordnung» Einblicke in gesellschaftliche Strukturen und die diskontinuierlicheDynamik des soziokulturellen Wandels. lm Foigenden wird versucht, den psychiatriegeschichtlichen Kontext, in dem die Studie entstand, zu skizzieren und einige Entwicklungen im sakularen Untersuchungszeitraum nachzuzeichnen. Ziel ist nicht eine Zusammenfassung der Resultate, sondern es wird exemplarisch auf einige Aspekte der Studie hingewiesen. Da gerade innovative Problemstellungen neue und weiterführende Fragen aufwerfen, werden abschliessend einige analytische Perspektiven benannt, mit denen sich eine wissenschaftsund kulturhistorisch sensibilisierte Psychiatriegeschichte künftig verstarkt auseinandersetzen konnte.

Вопреки распространённому убеждению, психотропные препараты - не единственное средство решения проблемы при психических расстройствах. Ярким примером может послужить история Уилла Холла, американского психолога-консультанта, которому в 26 лет диагностировали шизофрению. Он сумел побороть свое расстройство и решил посвятить жизнь борьбе за человеческие права в сфере психического здоровья. Под его авторством вышел информативный мануал о минимизации вреда для здоровья при отмене психотропных препаратов. Данное пособие послужило стимулом и основой для написания статьи.

Report about unpublished research of psychopharmacology group, Institute of Organic Synthesis, Latvian SSR Academy of Sciences, 1960-1990.
Pyridinium salt reduction, tetrahydropyridines, piperidines, piperazines, pyrophtalones, organic semiconductors, fentanyl and analogues, butyrophenones

We report a case of conversion disorder (partial aphonia) that was successfully treated with speech therapy. During the one year duration of this illness, the patient regained transiently (minutes) her normal speech on a few occasions, independently of concomitant pharmacological interventions. One year after recovery she developed aphonia for the second time, which responded again to speech therapy, although the response rate was slower. Several mechanisms of conversion disorder are reviewed as specifically applied to this case. The possible role of pertinent shame mechanisms in the conversion pathology is discussed.

This open cross-sectional questionnaire study investigated subjective oral symptoms in hospitalized psychiatric patients,
comparing those taking typical vs. atypical neuroleptic drugs. The present study included 170 hospitalized patients who
were taking psychiatric medications. We observed a significantly higher prevalence of xerostomia in the typical neuroleptic
group (66%) compared with the atypical neuroleptic group (53%, p<0.01). In our study, 28% of women and 17% of men
received professional consultations for dry mouth. Persistent oral pain lasting throughout the day was reported by 46% and
5% of patients in the typical and atypical neuroleptic groups, respectively. The oral pain was predominantly located in the
tongue and buccal mucosa; it was described as a burning sensation by patients in both medication groups. These results
emphasize the need for awareness of oral discomfort and its subsequent effects on quality of life in this challenging patient
group

The dopamine partial agonist aripiprazole is increasingly used to treat pathologies for which other antipsychotics are indicated because it displays fewer side effects, such as sedation and depression-like symptoms, than other dopamine receptor antagonists. Previously, we showed that aripiprazole may protect motivational function by preserving reinforcement-related signals used to sustain reward-maximization. However, the effect of aripiprazole on more cognitive facets of human reinforcement learning, such as learning from the forgone outcomes of alternative courses of action (i.e., counterfactual learning), is unknown. To test the influence of aripiprazole on counterfactual learning, we administered a reinforcement learning task that involves both direct learning from obtained outcomes and indirect learning from forgone outcomes to two groups of Gilles de la Tourette (GTS) patients, one consisting of patients who were completely unmedicated and the other consisting of patients who were receiving aripiprazole monotherapy, and to healthy subjects. We found that whereas learning performance improved in the presence of counterfactual feedback in both healthy controls and unmedicated GTS patients, this was not the case in aripiprazole-medicated GTS patients. Our results suggest that whereas aripiprazole preserves direct learning of action-outcome associations, it may impair more complex inferential processes, such as counterfactual learning from forgone outcomes, in GTS patients treated with this medication. Aripiprazole is a recently introduced antipsychotic medication with dopamine receptor partial agonist mechanisms 1. In schizophrenia patients, aripiprazole exhibited efficacy comparable to that of typical and atypical antip-sychotics in the treatment of positive and negative symptoms as well as in the prevention of relapse 2, 3. Its efficacy has also been demonstrated in other neurological disorders for which antipsychotics are indicated, such as Gilles de la Tourette syndrome (GTS) 4, 5. Its tolerability is often considered superior to that of typical antipsychotics, and it is associated with fewer adverse side effects, such as extrapyramidal and metabolic syndromes 6, 7. In GTS, arip-iprazole is effective for suppressing tics while displaying a less severe side effect profile than dopamine receptor antagonists with regard to motivational deficits such as sedation and depressive reactions 8. Due to this advantageous cost-benefit trade-off, aripiprazole has become a widely prescribed treatment for schizophrenia and GTS. Pharmacological studies in humans suggest that dopamine receptor antagonist-induced sedation and depres-sive states may be the consequence of blunting of reward-related signals 9, 10. For instance, reward-seeking behaviour and reward prediction errors encoded in the ventral striatum were reduced by haloperidol administration in healthy volunteers 11. In contrast, both functions were preserved in GTS patients medicated with aripiprazole 12 .

We wish to share with you our experience in treating a person with schizophrenia who developed rabbit syndrome. Rabbit syndrome, characterised by rapid, rhythmic orofacial movements, often accompanied by lip sounds (Schwartz et al, 1995) is considered one of four tardive dyskinesia (TD) variants, all of which are extrapyramidal side-effects of long-term neuroleptic treatment (Inada et al, 1991). The incidence of rabbit syndrome among TD variants is about 2.4% (Wada & Yamaguchi, 1992), with a mean prevalence of 15-20% among neuroleptic-treated patients in general (Baldessarini, 1988) and 9.9% in psychiatric hospital populations. Olanzapine is hereby suggested as a possible solution for alleviating rabbit syndrome without risking the emergence of extrapyramidal side-effects and simultaneously combating schizophrenic symptoms.

A 28-year-old single woman, suffering from schizophrenia for nine years, had been treated by depot injections of zuclopenthixol (200 mg every fortnight) and with biperiden (4 mg/day) since 1995. Her mental state deteriorated and she was hospitalised in an acute psychotic state, suffering from paranoid delusions. Signs of typical rabbit syndrome were evident.

In seeking out an appropriate treatment strategy for her psychotic state and the rabbit syndrome (which did not seem to respond to biperiden), it was decided to stop administration of zuclopenthixol and to initiate olanzapine, starting at 5 mg/day and reaching maximal dosage (10 mg/day). Within 2-3 weeks, not only had her psychotic symptoms disappeared, but improvement was also observed in her rabbit syndrome. Her Abnormal Involuntary Movement Scale (AIMS, Wojcik et al, 1980) score dropped from 14 to 8. After 25 days of hospitalisation, she was released into community care and continued to receive olanzapine (10 mg/day). Follow-up, a year later, found her to be in remission from the psychosis, with no signs of rabbit syndrome, under olanzapine treatment.

It has been postulated that the underlying mechanism of rabbit syndrome is supersensitivity of dopamine receptors, possibly due to an underlying predisposition. It has also been suggested that rabbit syndrome is a result of multiple system atrophy (Nishiyama et al, 1993). The most prominent, albeit controversial, treatment agents for rabbit syndrome are benzhexol and biperiden. We were anxious to avoid aggravation or uncovering of TD by the addition of anticholinergic agents. Olanzapine displays high affinity for type 2 serotonin (5-HT2) receptors and, although the activity ratio between 5-HT2 and type 2 dopamine (D2) receptors is slightly lower than for clozapine, it is still about twice as active at 5-HT2 than at D2 receptors. Hence, olanzapine is less likely to be associated with TD, and its application in preventing or ameliorating rabbit syndrome seemed appropriate (O'Brien & Barber, 1998).

This case demonstrates the possible usefulness of olanzapine as a mono-drug treatment strategy for dealing with rabbit syndrome triggered by typical neuroleptics and simultaneously treating psychotic symptoms.

This study was designed to validate an in vivo measurement of the functional sensitivity of basal ganglia neuronal circuits containing dopamine D 2 receptors. We hypothesized that a D 2 agonist would decrease striatopallidal neuronal activity, and hence regional cerebral blood flow (rCBF) over the axon terminals in the globus pallidus. Quantitative pallidal blood flow was measured using positron emission tomography (PET) with bolus injections of H 2 15 O and arterial sampling in six baboons before and after intravenous administration of the selective D 2 agonist U91356a. We also tested whether the response to U91356a was modified by previous acute administration of various antagonists. Another baboon had serial measurements of blood flow under identical conditions, but received no dopaminergic drugs. In all animals that received U91356a, pallidal flow decreased in a dose-related manner. Global CBF had a similar response, but the decline in pallidal flow was greater in magnitude and remained significant after accounting for the global effect. A D 2 antagonist, but not antagonists of D 1 , serotonin-2, or peripheral D 2 receptors, prevented this decrease. This work demonstrates and validates an in vivo measure of the sensitivity of D 2 -mediated basal ganglia pathways. It also supports the hypothesis that activation of the indirect striatopallidal pathway, previously demonstrated using nonselective D 2 -like agonists, can be mediated specifically by D 2 receptors. We speculate that the U91356a-PET technique may prove useful in detecting functional abnormalities of D 2mediated dopaminergic function in diseases such as parkinsonism, dystonia, Tourette syndrome, or schizophrenia.