An anticonvulsant drug, chemically related to the tricyclic antidepressants.
Carbamazepine is mainly used in the long-term treatment of epilepsy.
It is also used to treat neuralgia and psychological disorders, such as mania.
Carbamazepine is mainly used in the long-term treatment of epilepsy.
It is also used to treat neuralgia and psychological disorders, such as mania.
Treatment Any obvious underlying cause should be dealt with. Neuralgia may be symptomatically relieved with ANALGESICS. Severe pain may be helped by the analgesic carbamazepine or by destroying (freezing, local alcohol injection or surgery) the affected nerve.... neuralgia
It is usually con?ned to one side. It is more common in women than in men, usually occurring over the age of 50. The attack is often precipitated by movements of the jaw, as in talking or eating, or by tactile stimuli such as a cold wind or washing the face. When the ?rst or upper division of the nerve is involved, the pain is mostly felt in the forehead and side of the head. It is usually of an intensely sharp, cutting, or burning character, either constant or with exacerbations each day while the attack continues. There is also pain in the eyelid, redness of the eye and increased ?ow of tears. When the second division of the nerve is affected, the pain is chie?y in the cheek and upper jaw. When the third division of the nerve suffers, the pain affects the lower jaw. Attacks may recur for years; and, although interfering with sleeping and eating, they rarely appear to lead to any serious results. Nevertheless, the pain may become intolerable.
Treatment The outlook in trigeminal neuralgia was radically altered by the introduction of the drug CARBAMAZEPINE, which usually relieves the pain. If the side-effects – for example, dizziness, headache, nausea or drowsiness – are unacceptable or pain not relieved, PHENYTOIN SODIUM may help. Otherwise, surgery is needed in the shape of controlled, radio-frequency heat damage to the appropriate part of the trigeminal nerve.... trigeminal neuralgia
It is a recurrent and paroxysmal disorder starting suddenly and ceasing spontaneously due to occasional sudden excessive rapid and local discharge of the nerve cells in the grey matter (cortex) of the BRAIN. Epilepsy always arises in this way from the brain, but its origin is often of microscopic size. It is diagnosed by the clinical symptoms based on the observations of witnesses. Its cause can sometimes be established by laboratory tests, and brain scanning. Fits can be the ?rst sign of a tumour, or follow a stroke, brain injury or infection, but in the large majority no underlying cause is found – so-called idiopathic epilepsy.
A single epileptic ?t is not epilepsy. Of those people who have a single seizure, a signi?cant minority (20 per cent) have no further attacks.
Major (generalised) seizures have a sudden, often unprovoked onset; the patient emits a cry, then falls to the ground, rigid, blue, and then twitching or jerking both sides of the body: the tonic-clonic convulsion. Drowsiness and confusion may last for some hours after recovering consciousness. Some experience a momentary warning (AURA): a smell, or sensation in the head or abdomen, vision, or déjà vu.
Partial seizures: focal motor (Jacksonian) begin with twitching of the angle of the mouth, the thumb, or the big toe. If the seizure discharge then spreads, the twitching or jerking spreads gradually through the limbs. Consciousness is preserved unless the seizure spreads to produce a secondary generalised ?t. In some attacks the eyes and head may turn, the arm may rise, and the body may turn, while some patients feel tingling in the limbs.
Complex partial seizures (temporal lobe epilepsy) The patient usually appears blank, vacant and may be unable to talk, or may mumble or chatter – though later they often have no memory of this period. They may be able to carry out complex tasks, taking o? gloves or clothes, and may smack their lips or rub repeatedly on one limb (automatisms). A sense of strangeness supervenes: unreality, or a feeling of having experienced it all before (déja vu). There may be a sense of panic. Strange unpleasant smells and tastes are olfactory and gustatory hallucinations. The visual hallucinations evoke complex scenes. An initial rising sense of warmth or discomfort in the stomach, or ‘speeding-up’ of thoughts are common psychomotor symptoms. All these strange symptoms are brief, disappearing within a few seconds or up to 3–4 minutes.
Minor seizures (petit mal) Attacks start in childhood. They last a few seconds. The child ceases what he or she is doing, stares, looks a little pale, and may ?utter the eyelids. The head may drop forwards. Attacks are commonly provoked by overbreathing. The child and parents may be unaware of the attacks
– ‘just daydreaming’. Major ?ts develop in one-third of subjects. By contrast with other types of epilepsy, the ELECTROENCEPHALOGRAM (EEG) is diagnostic.
Precautions Children with epilepsy should take normal school exercises and games, and can swim under supervision. Adults must avoid working at heights, with exposed dangerous machinery, and driving vehicles on public roads. Current legislation allows driving after two years of complete freedom from attacks during waking hours; those who for more than three years have had a history of attacks only while asleep may also drive.
Treatment identi?es, and avoids where possible, any factors (such as shortage of sleep or excessive ?uids) which aggravate or trigger attacks. If ?ts are very infrequent, treatment may not be recommended. However, frequent ?ts may be embarassing, may cause injury or may cause long-term brain damage so treatment is advisable. Anti-epileptic drugs are usually necessary for several years under medical supervision. Carbamazepine and sodium valproate are the most frequently prescribed. The dose is governed by the degree of control of ?ts and sometimes drug levels can be monitored by blood tests to check on dosage. Strict adherence to the drug schedule gives a reasonable chance of total suppression of ?ts, especially in younger patients whose ?ts have started recently. The table summarises anticonvulsant drugs in use. Interactions can occur between anti-epileptics and, if drug treatment is changed, the patient needs careful monitoring. In particular, abrupt withdrawal of a drug should be avoided as this may precipitate severe rebound seizures.
Indications First-choice drugs: Ethosuximide PM, JME Phenobarbitone M, P Phenytoin M, P, CP Carbamazepine M, P, CP Valproate M, PM, JME Second-line drugs: Primidone M, P, CP Clobazam M, CP Vigabatrin M, P, CP Lamotrigine M, P, CP Gabapentin M, P, CP Topirimate P
M = major generalised tonic-clonic; P = partial or focal; CP = complex partial (temporal lobe); PM = petit mal; JME = juvenile myoclonic epilepsy.
Anticonvulsant drugs
As all anticonvulsant drugs have an e?ect on the brain, it is not surprising that there may be side-effects, especially inolving alertness or behaviour. In each case careful assessment is necessary for doctor and patient to agree on the best compromise between stopping ?ts and avoiding ill-effects of medication.
Patients who have an epileptic seizure should not be restrained or have a gag or anything else placed in their mouths; nor should they be moved unless in danger of further injury. Any tight clothing around the neck should be loosened and, when the seizure has passed, the person should be placed in the recovery position to facilitate a return to consciousness (see APPENDIX 1: BASIC FIRST AID).
Patients with epilepsy and their relatives can obtain further advice and information from the British Epilepsy Association or Epilepsy Action Scotland.... epilepsy
Sodium valproate has widespread metabolic effects and may have dose-related side-effects. There has been concern over severe hepatic or pancreatic toxicity, but such adverse effects are rare. Other adverse effects include digestive upsets, drowsiness, muscle incoordination and skin rashes. Rare reports have been given of behavioural disturbances, with occasional aggression. Initiation and withdrawal of treatment should always be slow. Patients should reduce their alcohol intake; any other drugs they are taking that are metabolised by the liver should be carefully monitored.... sodium valproate
Symptoms may include extravagant spending, repeatedly starting new tasks; sleeping less; increased appetite for food, alcohol, sex, and exercise; outbursts of inappropriate anger, laughter, or sudden socializing; and delusions of grandeur. If symptoms are mild, the condition is called hypomania.
Severe mania usually needs treatment in hospital with antipsychotic drugs. Relapses may be prevented by taking lithium or carbamazepine.... mania
Psychiatrists like to categorise mental illnesses because mental signs and symptoms do occur together in clusters or syndromes, each tending to respond to certain treatments. The idea that illnesses can be diagnosed simply by recognising their symptom patterns may not seem very scienti?c in these days of high technology. For most common mental illnesses, however, this is the only method of diagnosis; whatever is going wrong in the brain is usually too poorly understood and too subtle to show up in laboratory tests or computed tomography scans of the brain. And symptom-based definitions of mental illnesses are, generally, a lot more meaningful than the vague lay term ‘nervous breakdown’, which is used to cover an attack of anything from AGORAPHOBIA to total inability to function.
There is still a lot to learn about the workings of the brain, but psychiatry has developed plenty of practical knowledge about the probable causes of mental illness, ways of relieving symptoms, and ways of aiding recovery. Most experts now believe that mental illnesses generally arise from di?erent combinations of inherited risk and psychological STRESS, sometimes with additional environmental exposure – for example, viruses, drugs or ALCOHOL.
The range of common mental illnesses includes anxiety states, PHOBIA, DEPRESSION, alcohol and drug problems, the EATING DISORDERS anorexia and bulimia nervosa, MANIC DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and a group of problems related to coping with life that psychiatrists call personality disorders.
Of these mental illnesses, dementia is the best understood. It is an irreversible and fatal form of mental deterioration (starting with forgetfulness and eventually leading to severe failure of all the brain’s functions), caused by rapid death of brain cells and consequent brain shrinkage. Schizophrenia is another serious mental illness which disrupts thought-processes, speech, emotions and perception (how the brain handles signals from the ?ve senses). Manic depression, in which prolonged ‘highs’ of extremely elevated mood and overexcitement alternate with abject misery, has similar effects on the mental processes. In both schizophrenia and manic depression the sufferer loses touch with reality, develops unshakeable but completely unrealistic ideas (delusions), and hallucinates (vividly experiences sensations that are not real, e.g. hears voices when there is nobody there). This triad of symptoms is called psychosis and it is what lay people, through fear and lack of understanding, sometimes call lunacy, madness or insanity.
The other mental illnesses mentioned above are sometimes called neuroses. But the term has become derogatory in ordinary lay language; indeed, many people assume that neuroses are mild disorders that only affect weak people who cannot ‘pull themselves together’, while psychoses are always severe. In reality, psychoses can be brief and reversible and neuroses can cause lifelong disability.
However de?ned and categorised, mental illness is a big public-health problem. In the UK, up to one in ?ve women and around one in seven men have had mental illness. About half a million people in Britain suffer from schizophrenia: it is three times commoner than cancer. And at any one time, up to a tenth of the adult population is ill with depression.
Treatment settings Most people with mental-health problems get the help they need from their own family doctor(s), without ever seeing a psychiatrist. General practictitioners in Britain treat nine out of ten recognised mental-health problems and see around 12 million adults with mental illness each year. Even for the one in ten of these patients referred to psychiatrists, general practitioners usually handle those problems that continue or recur.
Psychiatrists, psychiatric nurses, social workers, psychologists, counsellors and therapists often see patients at local doctors’ surgeries and will do home visits if necessary. Community mental-health centres – like general-practice health centres but catering solely for mental-health problems – o?er another short-cut to psychiatric help. The more traditional, and still more common, route to a psychiatrist for many people, however, is from the general practititioner to a hospital outpatient department.
Specialist psychiatric help In many ways, a visit to a psychiatrist is much like any trip to a hospital doctor – and, indeed, psychiatric clinics are often based in the outpatient departments of general hospitals. First appointments with psychiatrists can last an hour or more because the psychiatrist – and sometimes other members of the team such as nurses, doctors in training, and social workers – need to ask lots of questions and record the whole consultation in a set of con?dential case notes.
Psychiatric assessment usually includes an interview and an examination, and is sometimes backed up by a range of tests. The interview begins with the patient’s history – the personal story that explains how and, to some extent, why help is needed now. Mental-health problems almost invariably develop from a mixture of causes – emotional, social, physical and familial – and it helps psychiatrists to know what the people they see are normally like and what kind of lives they have led. These questions may seem unnecessarily intrusive, but they allow psychiatrists to understand patients’ problems and decide on the best way to help them.
The next stage in assessment is the mental-state examination. This is how psychiatrists examine minds, or at least their current state. Mental-state examination entails asking more questions and using careful observation to assess feelings, thoughts and mental symptoms, as well as the way the mind is working (for example, in terms of memory and concentration). During ?rst consultations psychiatrists usually make diagnoses and explain them. The boundary between a life problem that will clear up spontaneously and a mental illness that needs treatment is sometimes quite blurred; one consultation may be enough to put the problem in perspective and help to solve it.
Further assessment in the clinic may be needed, or some additional tests. Simple blood tests can be done in outpatient clinics but other investigations will mean referral to another department, usually on another day.
Further assessment and tests
PSYCHOLOGICAL TESTS Psychologists work in or alongside the psychiatric team, helping in both assessment and treatment. The range of psychological tests studies memory, intelligence, personality, perception and capability for abstract thinking. PHYSICAL TESTS Blood tests and brain scans may be useful to rule out a physical illness causing psychological symptoms. SOCIAL ASSESSMENT Many patients have social diffculties that can be teased out and helped by a psychiatric social worker. ‘Approved social workers’ have special training in the use of the Mental Health Act, the law that authorises compulsory admissions to psychiatric hospitals and compulsory psychiatric treatments. These social workers also know about all the mental-health services o?ered by local councils and voluntary organisations, and can refer clients to them. The role of some social workers has been widened greatly in recent years by the expansion of community care. OCCUPATIONAL THERAPY ASSESSMENT Mental-health problems causing practical disabilities – for instance, inability to work, cook or look after oneself – can be assessed and helped by occupational therapists.
Treatment The aims of psychiatric treatment are to help sufferers shake o?, or at least cope with, symptoms and to gain or regain an acceptable quality of life. A range of psychological and physical treatments is available.
COUNSELLING This is a widely used ‘talking cure’, particularly in general practice. Counsellors listen to their clients, help them to explore feelings, and help them to ?nd personal and practical solutions to their problems. Counsellors do not probe into clients’ pasts or analyse them. PSYCHOTHERAPY This is the best known ‘talking cure’. The term psychotherapy is a generalisation covering many di?erent concepts. They all started, however, with Sigmund Freud (see FREUDIAN THEORY), the father of modern psychotherapy. Freud was a doctor who discovered that, as well as the conscious thoughts that guide our feelings and actions, there are powerful psychological forces of which we are not usually aware. Applying his theories to his patients’ freely expressed thoughts, Freud was able to cure many illnesses, some of which had been presumed completely physical. This was the beginning of individual analytical psychotherapy, or PSYCHOANALYSIS. Although Freud’s principles underpin all subsequent theories about the psyche, many di?erent schools of thought have emerged and in?uenced psychotherapists (see ADLER; JUNGIAN ANALYSIS; PSYCHOTHERAPY). BEHAVIOUR THERAPY This springs from theories of human behaviour, many of which are based on studies of animals. The therapists, mostly psychologists, help people to look at problematic patterns of behaviour and thought, and to change them. Cognitive therapy is very e?ective, particularly in depression and eating disorders. PHYSICAL TREATMENTS The most widely used physical treatments in psychiatry are drugs. Tranquillising and anxiety-reducing BENZODIAZEPINES like diazepam, well known by its trade name of Valium, were prescribed widely in the 1960s and 70s because they seemed an e?ective and safe substitute for barbiturates. Benzodiazepines are, however, addictive and are now recommended only for short-term relief of anxiety that is severe, disabling, or unacceptably distressing. They are also used for short-term treatment of patients drying out from alcohol.
ANTIDEPRESSANT DRUGS like amitriptyline and ?uoxetine are given to lift depressed mood and to relieve the physical symptoms that sometimes occur in depression, such as insomnia and poor appetite. The side-effects of antidepressants are mostly relatively mild, when recommended doses are not exceeded – although one group, the monoamine oxidase inhibitors, can lead to sudden and dangerous high blood pressure if taken with certain foods.
Manic depression virtually always has to be treated with mood-stabilising drugs. Lithium carbonate is used in acute mania to lower mood and stop psychotic symptoms; it can also be used in severe depression. However lithium’s main use is to prevent relapse in manic depression. Long-term unwanted effects may include kidney and thyroid problems, and short-term problems in the nervous system and kidney may occur if the blood concentration of lithium is too high – therefore it must be monitored by regular blood tests. Carbamazepine, a treatment for EPILEPSY, has also been found to stabilise mood, and also necessitates blood tests.
Antipsychotic drugs, also called neuroleptics, and major tranquillisers are the only e?ective treatments for relieving serious mental illnesses with hallucinations and delusions. They are used mainly in schizophrenia and include the short-acting drugs chlorpromazine and clozapine as well as the long-lasting injections given once every few weeks like ?uphenazine decanoate. In the long term, however, some of the older antipsychotic drugs can cause a brain problem called TARDIVE DYSKINESIA that affects control of movement and is not always reversible. And the antipsychotic drugs’ short-term side-effects such as shaking and sti?ness sometimes have to be counteracted by other drugs called anticholinergic drugs such as procyclidine and benzhexol. Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but clozapine cannot be given as a long-lasting injection and its concentration in the body has to be monitored by regular blood tests to avoid toxicity. OTHER PHYSICAL TREATMENTS The other two physical treatments used in psychiatry are particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. In ECT, which can be life-saving for patients who have severe life-threatening depression, a small electric current is passed through the brain to induce a ?t or seizure. Before the treatment the patient is anaesthetised and given a muscle-relaxing injection that reduces the magnitude of the ?t to a slight twitching or shaking. Scientists do not really understand how ECT works, but it does, for carefully selected patients. Psychosurgery – operating on the brain to alleviate psychiatric illness or di?cult personality traits – is extremely uncommon these days. Stereo-tactic surgery, in which small cuts are made in speci?c brain ?bres under X-ray guidance, has super-seded the more generalised lobotomies of old. The Mental Health Act 1983 ensures that psychosurgery is performed only when the patient has given fully informed consent and a second medical opinion has agreed that it is necessary. For all other psychiatric treatments (except another rare treatment, hormone implantation for reducing the sex drive of sex o?enders), either consent or a second opinion is needed – not both. TREATMENT IN HOSPITAL Psychiatric wards do not look like medical or surgical wards and sta? may not wear uniforms. Patients do not need to be in their beds during the day, so the beds are in separate dormitories. The main part of most wards is a living space with a day room, an activity and television room, quiet rooms, a dining room, and a kitchen. Ward life usually has a certain routine. The day often starts with a community meeting at which patients and nurses discuss issues that affect the whole ward. Patients may go to the occupational therapy department during the day, but there may also be some therapy groups on the ward, such as relaxation training. Patients’ symptoms and problems are assessed continuously during a stay in hospital. When patients seem well enough they are allowed home for trial periods; then discharge can be arranged. Patients are usually followed up in the outpatient clinic at least once.
TREATING PATIENTS WITH ACUTE PSYCHIATRIC ILLNESS Psychiatric emergencies – patients with acute psychiatric illness – may develop from psychological, physical, or practical crises. Any of these crises may need quick professional intervention. Relatives and friends often have to get this urgent help because the sufferer is not ?t enough to do it or, if psychotic, does not recognise the need. First, they should ring the person’s general practitioner. If the general practitioner is not available and help is needed very urgently, relatives or friends should phone the local social-services department and ask for the duty social worker (on 24-hour call). In a dire emergency, the police will know what to do.
Any disturbed adult who threatens his or her own or others’ health and safety and refuses psychiatric help may be moved and detained by law. The Mental Health Act of 1983 authorises emergency assessment and treatment of any person with apparent psychiatric problems that ful?l these criteria.
Although admission to hospital may be the best solution, there are other ways that psychiatric services can respond to emergencies. In some districts there are ‘crisis intervention’ teams of psychiatrists, nurses, and social workers who can visit patients urgently at home (at a GP’s request) and, sometimes, avert unnecessary admission. And research has shown that home treatment for a range of acute psychiatric problems can be e?ective.
LONG-TERM TREATMENT AND COMMUNITY CARE Long-term treatment is often provided by GPs with support and guidance from psychiatric teams. That is ?ne for people whose problems allow them to look after themselves, and for those with plenty of support from family and friends. But some people need much more intensive long-term treatment and many need help with running their daily lives.
Since the 1950s, successive governments have closed the old psychiatric hospitals and have tried to provide as much care as possible outside hospital – in ‘the community’. Community care is e?ective as long as everyone who needs inpatient care, or residential care, can have it. But demand exceeds supply. Research has shown that some homeless people have long-term mental illnesses and have somehow lost touch with psychiatric services. Many more have developed more general long-term health problems, particularly related to alcohol, without ever getting help.
The NHS and Community Care Act 1990, in force since 1993, established a new breed of professionals called care managers to assess people whose long-term illnesses and disabilities make them unable to cope completely independently with life. Care managers are given budgets by local councils to assess people’s needs and to arrange for them tailor-made packages of care, including services like home helps and day centres. But co-ordination between health and social services has sometimes failed – and resources are limited – and the government decided in 1997 to tighten up arrangements and pool community-care budgets.
Since 1992 psychiatrists have had to ensure that people with severe mental illnesses have full programmes of care set up before discharge from hospital, to be overseen by named key workers. And since 1996 psychiatrists have used a new power called Supervised Discharge to ensure that the most vulnerable patients cannot lose touch with mental-health services. There is not, however, any law that allows compulsory treatment in the community.
There is ample evidence that community care can work and that it need not cost more than hospital care. Critics argue, however, that even one tragedy resulting from inadequate care, perhaps a suicide or even a homicide, should reverse the march to community care. And, according to the National Schizophrenia Fellowship, many of the 10–15 homicides a year carried out by people with severe mental illnesses result from inadequate community care.
Further information can be obtained from the Mental Health Act Commission, and from MIND, the National Association for Mental Health. MIND also acts as a campaigning and advice organisation on all aspects of mental health.... mental illness
Abnormalities in brain biochemistry, or in the structure and/or function of certain nerve pathways within the brain, could underlie manic–depressive illness. An inherited tendency is also an established causative factor.Severe manic–depressive illness often needs hospital treatment. Antidepressant drugs and/or ECT are used to treat depression, and antipsychotic drugs are given to control manic symptoms. Carbamazepine or lithium may be used to prevent relapse.
Group therapy, family therapy, and individual psychotherapy may be useful in treatment. Cognitive–behavioural therapy may also be helpful. With treatment, more than 80 per cent of patients improve or remain stable. Even those with severe illness may be restored to near normal health with lithium.... manic–depressive illness
Certain anticonvulsants have shown efficacy in treating bipolar disorder and chronic pain, as in postherpetic neuralgia or *peripheral neuropathy, and can be used to prevent migraine and other primary headache syndromes.... anticonvulsant
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