Drugs bizarre behavior

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by Margie Patlak        "The visions are extremely vivid. Paving stones transform into demonic
                   faces, shattering in front of my petrified eyes.WhenI am in contact with
                   people, they can becomegrotesquely deformed, their skin peeling away to re-
                    veal decomposinginner musclesand organs. Buildings and rooms spin and
                    weave and their walls close in as I look on, paralyzed by fean ... The voices
                    either ramble in alien tongues or scream orders to carry out violent acts.
                    They also persecute me by way of unwavering commentary and ridicule to
                    deceive,derange, and force me into a world of crippling paranoia."
                    --{.obert Bayley, a schizophreniasufferer, rn SchizophreniaBulletin, No. 4,

                                                                                         1997/ 23
                                                              FDAConsumer September{ctober
                                                sity of California in Los Angeles.            uting to this hamPered    logic is an
1996, publishedby the National Institute
                                                   Becausethe drugs that effectivelY          inability to sort out relevant from pe-
of Mental Health (NIMH).
                                                treat schizophrenia affect the functioning    ripheral information in a situation'
  More than 300.000adults in this
                                                of the chemicalmessengers the brain
                                                                             in                  Another frequent symptom of schizo-
country are like Bayley, unableto distin-
                                                known as neurotransmitters,   some ex-        phreniais deadened     emotional expres-
guish their imaginationsfrom reality'
                                                pertshypothesize  that the disorderstems      sion, indicatedby a monotonoustone of
Thesepeople have schizoPhrenia,   a

       More than 3OO,OOO   adults in this Gountryare unable to
       distin$uish their ima$inations from reality'

                                                                       balanceof these        voice and flat facial expressions."Her
mental illness whose hallmarksare vi-           from an inappropriate
                                                messengers brain cells.
                                                             in                               face was a solemn mask, and she could
sual and auditory hallucinations'Fortu-
                                                   In some patients,schizophrenia per-
                                                                                  is          neither give nor receive affection,"
nately the living hell Bayley describes
                                                sistent,while othershave  remissionsand       wrote Evelyn Smith of her schizo-
can often be alleviatedwith a number of
                                                exacerbations.  Full recoveryrarely oc-       phrenic daughter in Schizophrenia Bul-
antipsychoticdrugs, including the rela-
                                                curs. Suicide ratesamong paranoid             letin, No. 4, t991.
tively new drugs clozapine(Clozaril)
                                                schizophrenics be as high as 10 per-
                                                                can                               Schizophrenics  also may show inap-
and risperidone(Risperdal),which don't
                                                cent, accordingto studYbY Thomas              propriateemotions-a laugh in re-
seemto have some of the limiting side
                                                McGlashan,M.D., of the Yale Psychiat-         sponseto a tragic situation,for ex-
effectsof more traditional drugs,as well
                                                ric Institute,publishedin the February        ample. Some schizophrenics     exhibit
as the newcomerknown as olanzapine                                                                                                 ac-
                                                 1997American Journal of Psychiatry.          bizarrebehavior,such as excessive
(Zyprexa),which came on the market in
                                                                                              tivity that is apparentlypurposeless  and
the fall of 1996.The Food and Drug Ad-
                                                Voices No One Else Can Hear                   not influencedby what is haPPening
ministration is responsible ensuring
                                                   Schizophrenia one of the most com-
                                                                  is                          aroundthem. In contrast,some
the   safety and effectiveness the drugs
                                                plex, puzzling and disablingof the major      schizophrenics   may lapseinto a cata-
used   to treat schizophrenia.
                                                mental illnesses.People who suffer from       tonic stat€in which they are immobile
    About one out of a hundredPeoPlein
                                         dur-   this condition can have a number of dif-       and unresponsive.
this country developsschizophrenia                                                                                                   a
                                                ferent symptoms,the most prominentbe-             To be diagnosedas schizoPhrenic,
 ing  his or her lifetime, accordingto
                                                ing hallucinations,  delusions,disordered      patient needsto have two or more of
 NIMH. Usually, it first surfacesin the
                                                thinking and behavior,and abnormalex-          any of thesesymPtomsduring a one-
 teensor 20s in men and in the 20s or
                                                pressionof emotions.Hearing voices             month period. However,some sYmP-
 early 30s for women. Schizophrenia
                                                that other peopledon't is the most com-        toms are more characteristic schizo-
 rarely developsin children, and many
                                                mon type of hallucinationin schizophre-        phreniaand aid in more definitive
 schizophrenics     appeared perfectly nor-
                                                nia. Such voices may describethe               diagnosis.For example, it is rare for
 mal   during childhood.
                                                patient'sactivities,carry on a conversa-       people with other disordersto hear a
    Although research    has turned up some
                                                tion, warn of impendingdangers, tell
                                                                                   or          voice commentingon their behavior
 intriguing   clues, the puzzle of what
                                                the personwhat to do.                          or to hear two or more voices con-
 causes   schizophrenia   has yet to be
                                                   Another common symPtomof schizo-            versing with each other.Also key to
 solved.   Some people may inherit suscep-
                                                phreniais delusionsof persecution     or       the diagnosisof schizophrenia, a  is
 tibility to the condition.A personwith a
                                                grandeur. cited in an
                                                           As             issueof Schizo'      significantly hamperedability to work
 parentor sibling who is schizophrenic
                                                phrenia Bulletin, one schizophrenic,   who     or socializefor at least six months.
 has about a 10 percentrisk of develop-
                                                was a computer programmer,     imagined            Before providing a firm diagnosis
  ing the condition, and half of all identi-
                                                that the end of the world was coming           of schizophrenia,   doctors need to rule
 cal twins of schizophrenics    also suc-
                                                 and he determinedwhich of his col-            out drugs as the cause.A number of
  cumb   to the mental illness.
                                                 leagues  would survive in the afterlife by     illegal drugs, such as PCP (phencycli-
     Anatomy studiessuggestthe condition
                                                 the keys he punchedon the computer'           dine hydrochloride),or chronic use of
  is not causedby damageto the brain, but
                                                 Another patient,cited in an NIMH bro-          high dosesof amphetamines cause
  rather due to faulty brain development.
                                                 chure,thought a neighborwas control-           someof the disorder'ssymPtoms.
  Studiesshow that exposureto viral in-
  fections during the secondtrimester            ling his behaviorwith magneticwaves.
                                                    Schizophrenics  often are not able         Treatment Revolutionized
  and birth complications can boost the
                                         be-     completea line of thought' Their              By Antipsychotics
  risk of developingschizophrenia,
                                                 thoughtscome and go so rapidly it is not        A dismal outlook for schizophrenia
  causethe    normal development the  of
                                                 possibleto "catch them." Fragmented           was dramaticallYchangedin the
  brain may be altered,accordingto
                                                 thinking and conversingresults.Contrib-       1950swith the develoPment the
  StephenMarder, M.D., of the Univer-

                     1997/ FDAConsumer
 24 / September€clober
first antipsychoticdrug, chlorprom-          studiesshow thesedrugs don't work in a      prone to seizures,  and about I to 2 per-
azine (Thorazine).Since then, more                                 of
                                             little over one-quarter schizophrenics      cent developa paucity of infection-fight-
than a dozen other similar-acting            who do take them, accordingto Lisa          ing white blood cells.This condition,
antipsychoticmedicationshave been            Dixon, M.D., of the Universityof Mary-      known as agranulocytosis, be fatal if
developed,including haloperidol              land in Baltimore. However,three drugs      not diagnosedand treatedimmediately.
(Haldol), thioridazine(Mellaril),            havecome on the market during this de-      If detectedand promptly treated,how-
loxapine (Loxatane),and molindone            cade that countersome of theseprob-         ever,this condition is completely revers-
(Moban). These drugs work by block-          lems.                                       ible. To detectagranulocytosis, patients
ing binding sitesof the neurotransmitter                                                 who takeclozapine    must haveweekly
dopamine.They are equally effectiveat        New Drugs                                   blood tests.
stemmingthe delusions   and hallucina-         Clozapine,which can only be usedto           Unlike the older antipsychotics,studies
tions and bizarre behaviorand speech         treat patieirtswho do not respondto         suggest  clozapine,risperidone and
experienced schizophrenics,    accord-       other antipsychoticmedications,can ef-      olanzapinework by affecting the action of
ing to NIMH. What effectstheseolder          fectively treat about one-thirdto one-      the neurotransmitter           as
                                                                                                              serotonin, well as
antipsychoticmedicationshave on other        half of thosenon-responders,   according    dopamine.   Somestudies  suggest that in
symptomsof schizophrenia,   such as flat-    to UCLAs Marder.                            additionto effectively stemmingthe hallu-

      Although research has turned up some intriguing clues, the
      puzzle of what causes schizophreniahas yet to be solved.

 tenedemotionsand apathy, not as well
                              is                Although it can make patientsmore        cinationsand bizarrebehavior   of
 documented.   They also foster significant prone to seizures, clozapineappears   to     schizophrenics,thesenewerantipsychotic
 side effectsthat can limit their use.       causelesscramping,tremor, muscle            drugscan alsohelp counterwhat are
   When patientsfirst start taking these     stiffness,and restlessnessthan someof       known as "negativesymptoms,"such as
 antipsychotic drugs,they may be                                      and
                                             the older antipsychotics, it hasbeen the socialwithdrawal,apathy,          and paucity
 troubled by such side effectsas drowsi-                that
                                             suggested clozapine      may be less        of emotions expressed these
                                                                                                               by        patients.
 ness,restlessness, cramps,muscle            likely to produceTD, althoughthe evi-       But asThomaslaughren, M.D., of FDAs
 spasms,  dizziness,stiffnessof the limbs,   denceon the latteris not yet definitive.    divisionof neuropharmacological    drugs,
 tremors, dry mouth, impotence,    men-      However,it can make patientsmore                           the
                                                                                         notes,because effect of older anti-
strual irregularities,or blurring of vi-
sion. Most of thesecan be correctedby
lowering the dosageor can be controlled
by other medications.                                                                                        I
   More problematicwith the long-term
use of older antipsychoticdrugs is the
developmentof a disorderknown as tar-
dive dyskinesia(TD), a disorderthat
causesinvoluntary movements.Patients
with TD may frequently grimace,frown,                                                                          z.a' ..:
smirk, or experiencefacial tics. They
may also flick or jerk their trunk, pelvis,
arms, or legs.The risk of developingTD
increases  with the length of drug treat-
ment and occurs in more than one-quar-
ter of patientswho havebeen receiving
antipsychoticdrugs for more than five
years.In some patients,symptomsof
TD may be reversed reducedby alter-
ing the dosageof antipsychoticmedica-
tion or by treatingthem with a different
   Becauseof the side effects,many pa-      One of VincentVanGogh'smostfamouspaintings is "The Starry Night,'
tientsdo not comply with takingolder        above.  Many medicalscholarsbelieve     that one sourceotVan Gogh's
antipsychotic  medications. addition,
                             In             psychiatricproblemsmay havebeenschizophrenia.

                                                                                        FDA Consumer/ September-October
                                                                                                                      1997 / 25
psychoticmedicationson thesesymp-            and2Opercentof schizophrenic      patients    many patientsfind the addition of indi-
toms has not beenwell characterized,   it    experience  a relapsein any one year de-      vidual, family or group psychotherapy
is not clear whether the newer drugs         spite continuedmedication,accordingto         to be helpful. According to Jack Scott,
have an advantage   over the older ones in   John Kane, M.D., of the Albert Einstein       M.D., of the MarylandPsychiatric
relieving them. "There's not sufficient      Collegeof Medicine in the Bronx.              Research   Center in Baltimore, recent
evidenceto concludethat risperidoneor          Although there are injectableforms of       studiesindicatethat supportivereality-
olanzapineare superiorto older               antipsychotics,  patientsusually take         orientedtherapyaimed at developing
antipsychotics  regardingnegativesymp-       thesedrugs orally. There is insufficient      practical interpersonal skills is generally
toms," he said.                              evidenceto know whether they are asso-        of more benefit to schizophrenics    than
   He addedthat studieswith both             ciatedwith birth defects.Because   these      more probing psychoanalyticor insight-
risperidoneand olanzapinesuggestthat         drugs can be   passed a baby via breast
                                                                   to                      orientedpsychotherapy.    Rehabilitation
                                             milk, schizophrenic   mothersare usually      programsthat emphasize     job counseling
they are no more likely than placeboto
causemuscle stiffness,cramps,restless-       discouraged   from breast-feeding.            and training, problem-solvingand
ness,and tremors,especiallY the at                                                         money management      skills, use of public
lower recommended     doses.However,         Other Theatments                              transportation, and social skills training
there are not sufficient data to conclude       Because  some patientsreceiveonly          are often essential.
definitively that either of thesenewer       partial relief of their symptomsfrom an-         Although there currently is no cure
drugs is superiorto the older antipsy-       tipsychoticmedications,doctorsmay             for schizophrenia, presentarray of
chotic drugs in regardsto theseimmedi-       prescribeadditionalmedications.Stud-          drugs availableoften can effectively
ate side effectsor the more chronic de-      ies suggest additionof anti-anxiety
                                                          the                              control many of the disorder'ssymp-
velopmentof TD. There are a numberof         medicationssuch as lorazepam(Ativen) or       toms and enablepatientsto lead more
side effects associated  with both the       alprazolam   (Xanax)helpsabouthalf of         satisfactorylives.A review of the life
older and newer drugs, including sleepi-     schizophrenics,   accordingto James           historiesof almost 2,000 patientsdiag-

         Schizophreniais one of the most complex, p.raalin$and
         disabling of the mqior mental illnesses.

ness,weight gain, and sexualproblems.        Thompson,   M.D., of the Universityof         nosedwith schizophrenia     suggests that
   To minimize side effects,psychiatrists    Maryland in Baltimore. He noted that a        one-quarter   achievefull remission,half
usually treat schizophrenics   with the      smaller percentage patientsalso appear
                                                                of                         recoverat leastpartially, and one-quar-
lowest doseof an antipsychoticdrug that      to receivesomebenefit from lithium and        ter require long-term care, accordingto
diminishessymptomsduring an episode          carbamazepine,  which are also usedto         NIMH. It is unknownwhetherbetterre-
of worseningsymptoms.After that epi-         treatmanicdepression.   Somestudies  cited    sults might be garneredwith the newer
sodesubsides, doctor usually will
                the                          by Thompsonalso    suggestthat antidepres-    antipsychoticdrugs now on the market.
taper the dosageslowly to the lowest         sants suchas fluvoxamine  may help di-          With appropriatetreatment,many
possiblelevel to keep symptomsat bay.        minish the depression, emotional  blunting,   schizophrenics  havebeenableto turn
In a few circumstances,    especiallywhen    and inabilityto speak someschizophrenic       their imaginaryhells into lesstenifying
symptomsare mild and patientsare par-        patients experience.However,  sinceno         and more fertile grounds.Bayley, for
ticularly resistantto taking medication,     pharmaceutical  companies havesought          example, transformed
                                                                                                      has             many of his bi-
treatment  may be discontinued.              FDA approvalfor antipsychoticclaims for       zarrevisionsinto oil paintingsand musi-
   Severalstudiesindicatethat                thesedrugs,FDA has not evaluated    what-     cal compositions. notesthat much can
schizophrenics   who are not receiving       everdatasupportsuchclaims    and,conse-       be gainedby "tappinginto a mind experi-
maintenance   treatmentwith an antipsy-      quently,has not approvedtheir usefor          encing the truly extraordinary."He also
chotic drug following an acuteepisode        schizophrenics.                               advocates   greatercomPassion  for
are at much greaterrisk of experiencing         Shockingpatientswith electricity,called    schizophrenics. is often forgotten that
a relapse,accordingto Dixon. Conse-          electroconvulsive therapy,one of the earli-   there is a personbehind the condition,
quently,many schizophrenic      patients                                     is
                                             est treatments schizophrenia, rarely
                                                            of                             with a fundamentalneedto be under-
continue taking antipsychoticmedica-         usedtoday because benefits
                                                                 the         havenot       stood,"he wrote. I
tion for the rest of their lives. Some may   beendefinitively shown.
be able to take very low dosesexcept            Once antipsychoticmedicationshave          Margie Patlak is a writer in Elkins Parh
when symptomsare severe.       Between 15    helpedstem schizophrenia's    symptoms,       Pa.

                     1997/ FDAConsumer
 26 / September€ctober

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