a form of *formal thought disorder, common in psychosis, in which connections between sentences or parts of sentences are without a coherent train of thought.
Causes There is an inherited element: parents, children or siblings of schizophrenic sufferers have a one in ten chance of developing the disorder; a twin has a 50 per cent chance if the other twin has schizophrenia. Some BRAIN disorders such as temporal lobe EPILEPSY, tumours and ENCEPHALITIS seem to be linked with schizophrenia. Certain drugs – for example, AMPHETAMINES – can precipitate schizophrenia and DOPAMINE-blocking drugs often relieve schizophrenic symptoms. Stress may worsen schizophrenia and recreational drugs may trigger an attack.
Symptoms These usually develop gradually until the individual’s behaviour becomes so distrubing or debilitating that work, relationships and basic activities such as eating and sleeping are interrupted. The patient may have disturbed perception with auditory HALLUCINATIONS, illogical thought-processes and DELUSIONS; low-key emotions (‘?at affect’); a sense of being invaded or controlled by outside forces; a lack of INSIGHT and inability to acknowledge reality; lethargy and/or agitation; a disrespect for personal appearance and hygiene; and a tendency to act strangely. Violence is rare although some sufferers commit violent acts which they believe their ‘inner voices’ have commanded.
Relatives and friends may try to cope with the affected person at home, but as severe episodes may last several months and require regular administration of powerful drugs – patients are not always good at taking their medication
– hospital admission may be necessary.
Treatment So far there is no cure for schizophrenia. Since the 1950s, however, a group of drugs called antipsychotics – also described as NEUROLEPTICS or major tranquillisers – have relieved ?orid symptoms such as thought disorder, hallucinations and delusions as well as preventing relapses, thus allowing many people to leave psychiatric hospitals and live more independently outside. Only some of these drugs have a tranquillising e?ect, but their sedative properties can calm patients with an acute attack. CHLORPROMAZINE is one such drug and is commonly used when treatment starts or to deal with an emergency. Halperidol, tri?uoperazine and pimozide are other drugs in the group; these have less sedative effects so are useful in treating those whose prominent symptoms are apathy and lethargy.
The antipsychotics’ mode of action is by blocking the activity of DOPAMINE, the chemical messenger in the brain that is faulty in schizophrenia. The drugs quicken the onset and prolong the remission of the disorder, and it is very important that patients take them inde?nitely. This is easier to ensure when a patient is in hospital or in a stable domestic environment.
CLOZAPINE – a newer, atypical antipsychotic drug – is used for treating schizophrenic patients unresponsive to, or intolerant of, conventional antipsychotics. It may cause AGRANULOCYTOSIS and use is con?ned to patients registered with the Clorazil (the drug’s registered name) Patient Monitoring Service. Amisulpride, olanzapine, quetiapine, risperidone, sertindole and zotepine are other antipsychotic drugs described as ‘atypical’ by the British National Formulary; they may be better tolerated than other antipsychotics, and their varying properties mean that they can be targeted at patients with a particular grouping of symptoms. They should, however, be used with caution.
The welcome long-term shift of mentally ill patients from large hospitals to community care (often in small units) has, because of a lack of resources, led to some schizophrenic patients not being properly supervised with the result that they fail to take their medication regularly. This leads to a recurrence of symptoms and there have been occasional episodes of such patients in community care becoming a danger to themselves and to the public.
The antipsychotic drugs are powerful agents and have a range of potentially troubling side-effects. These include blurred vision, constipation, dizziness, dry mouth, limb restlessness, shaking, sti?ness, weight gain, and in the long term, TARDIVE DYSKINESIA (abnormal movements and walking) which affects about 20 per cent of those under treatment. Some drugs can be given by long-term depot injection: these include compounds of ?upenthixol, zuclopenthixol and haloperidol.
Prognosis About 25 per cent of sufferers recover fully from their ?rst attack. Another 25 per cent are disabled by chronic schizophrenia, never recover and are unable to live independently. The remainder are between these extremes. There is a high risk of suicide.... schizophrenia
Alcohol depresses the central nervous system and disturbs both mental and physical functioning. Even small doses of alcohol will slow a person’s re?exes and concentration; potentially dangerous effects when, for example, driving or operating machinery. Drunkenness causes slurred speech, muddled thinking, amnesia (memory loss), drowsiness, erectile IMPOTENCE, poor coordination and dulled reactions – thereby making driving or operating machinery especially dangerous. Disinhibition may lead to extreme euphoria, irritability, misery or aggression, depending on the underlying mood at the start of drinking. Severe intoxication may lead to COMA and respiratory failure.
Persistent alcohol misuse leads to physical, mental, social and occupational problems, as well as to a risk of DEPENDENCE (see also ALCOHOL DEPENDENCE). Misuse may follow several patterns: regular but controlled heavy intake, ‘binge’ drinking, and dependence (alcoholism). The ?rst pattern usually leads to mainly physical problems such as gastritis, peptic ulcer, liver disease, heart disease and impotence. The second is most common among young men and usually leads to mainly social and occupational problems – getting into ?ghts, jeopardising personal relationships, overspending on alcohol at weekends, and missing days o? work because of hangovers. The third pattern – alcohol dependence – is the most serious, and can severely disrupt health and social stability.
Many researchers consider alcohol dependence to be an illness that runs in families, with a genetic component which is probably passed on as a vulnerable personality. But it is hard to disentangle genetic, environmental and social factors in such families. In the UK there are estimated to be around a million people suffering from alcohol dependence and a similar number who have di?culty controlling their consumption (together about 1:30 of the population).
Alcohol causes tolerance and both physical and psychological dependence (see DEPENDENCE for de?nitions). Dependent drinkers classically drink early in the morning to relieve overnight withdrawal symptoms. These symptoms include anxiety, restlessness, nausea and vomiting, and tremor. Sudden withdrawal from regular heavy drinking can lead to life-threatening delirium tremens (DTs), with severe tremor, hallucinations (often visual – seeing spiders and monsters, rather than the pink elephants of romantic myth), and CONVULSIONS. This must be treated urgently with sedative drugs, preferably by intravenous drip. Similar symptoms, plus severe INCOORDINATION and double-vision, can occur in WERNICKE’S ENCEPHALOPATHY, a serious neurological condition due to lack of the B vitamin thiamine (whose absorption from the stomach is markedly reduced by alcohol). If not treated urgently with injections of thiamine and other vitamins, this can lead to an irreversible form of brain damage called Korsako?’s psychosis, with severe amnesia. Finally, prolonged alcohol misuse can cause a form of dementia.
In addition to these severe neurological disorders, the wide range of life-threatening problems caused by heavy drinking includes HEPATITIS, liver CIRRHOSIS, pancreatitis (see PANCREAS, DISEASES OF), gastrointestinal haemorrhage, suicide and FETAL ALCOHOL SYNDROME; pregnant women should not drink alcohol as this syndrome may occur with more than a glass of wine or half-pint of beer a day. The social effects of alcohol misuse – such as marital breakdown, family violence and severe debt – can be equally devastating.
Treatment of alcohol-related problems is only moderately successful. First, many of the physical problems are treated in the short term by doctors who fail to spot, or never ask about, heavy drinking. Second, attempts at treating alcohol dependence by detoxi?cation or ‘drying out’ (substituting a tranquillising drug for alcohol and withdrawing it gradually over about a week) are not always followed-up by adequate support at home, so that drinking starts again. Home support by community alcohol teams comprising doctors, nurses, social workers and, when appropriate, probation o?cers is a recent development that may have better results. Many drinkers ?nd the voluntary organisation Alcoholics Anonymous (AA) and its related groups for relatives (Al-Anon) and teenagers (Alateen) helpful because total abstinence from alcohol is encouraged by intensive psychological and social support from fellow ex-drinkers.
Useful contacts are: Alcoholics Anonymous; Al-Anon Family Groups UK and Eire (including Alateen); Alcohol Concern; Alcohol Focus Scotland; and Alcohol and Substance Misuse.
1 standard drink =1 unit
=••• pint of beer
=1 measure of spirits
=1 glass of sherry or vermouth
=1 glass of wine
Limits within which alcohol is believed not to cause long-term health risks:... alcohol
Nutritional Profile Energy value (calories per serving): Moderate Protein: Moderate Fat: Low to moderate Saturated fat: Low to high Cholesterol: Low to high Carbohydrates: High Fiber: Moderate to high Sodium: Moderate to high Major vitamin contribution: B vitamins Major mineral contribution: Calcium, iron, potassium
About the Nutrients in This Food All commercially made yeast breads are approximately equal in nutri- tional value. Enriched white bread contains virtually the same amounts of proteins, fats, and carbohydrates as whole wheat bread, although it may contain only half the dietary fiber (see flour). Bread is a high-carbohydrate food with lots of starch. The exact amount of fiber, fat, and cholesterol in the loaf varies with the recipe. Bread’s proteins, from grain, are low in the essential amino acid lysine. The most important carbohydrate in bread is starch; all breads contain some sugar. Depending on the recipe, the fats may be highly saturated (butter or hydrogenated vegetable fats) or primarily unsaturated (vegetable fat). All bread is a good source of B vitamins (thiamin, riboflavin, niacin), and in 1998, the Food and Drug Administration ordered food manufactur- ers to add folates—which protect against birth defects of the spinal cord and against heart disease—to flour, rice, and other grain products. One year later, data from the Framingham Heart Study, which has followed heart health among residents of a Boston suburb for nearly half a cen- tury, showed a dramatic increase in blood levels of folic acid. Before the fortification of foods, 22 percent of the study participants had a folic acid deficiency; after, the number fell to 2 percent. Bread is a moderately good source of calcium, magnesium, and phos- phorus. (Breads made with milk contain more calcium than breads made without milk.) Although bread is made from grains and grains contain phytic acid, a natural antinutrient that binds calcium ions into insoluble, indigestible compounds, the phytic acid is inactivated by enzyme action during leavening. Bread does not bind calcium. All commercially made breads are moderately high in sodium; some contain more sugar than others. Grains are not usually considered a good source of iodine, but commer- cially made breads often pick up iodine from the iodophors and iodates used to clean the plants and machines in which they are made. Homemade breads share the basic nutritional characteristics of commercially made breads, but you can vary the recipe to suit your own taste, lowering the salt, sugar, or fat and raising the fiber content, as you prefer.
The Most Nutritious Way to Serve This Food As sandwiches, with cheese, milk, eggs, meat, fish, or poultry. These foods supply the essen- tial amino acid lysine to “complete” the proteins in grains. With beans or peas. The proteins in grains are deficient in the essential amino acids lysine and isoleucine and rich in the essential amino acids tryptophan, methionine, and cystine. The proteins in legumes (beans and peas) are exactly the opposite.
Diets That May Restrict or Exclude This Food Gluten-free diet (excludes breads made with wheat, oats, rye, buckwheat and barley flour) Lactose-free diet Low-fiber diet (excludes coarse whole-grain breads) Low-sodium diet
Buying This Food Look for: Fresh bread. Check the date on closed packages of commercial bread.
Storing This Food Store bread at room temperature, in a tightly closed plastic bag (the best protection) or in a breadbox. How long bread stays fresh depends to a great extent on how much fat it contains. Bread made with some butter or other fat will keep for about three days at room tempera- ture. Bread made without fat (Italian bread, French bread) will dry out in just a few hours; for longer storage, wrap it in foil, put it inside a plastic bag, and freeze it. When you are ready to serve the French or Italian bread, you can remove it from the plastic bag and put the foil- wrapped loaf directly into the oven. Throw away moldy bread. The molds that grow on bread may produce carcinogenic toxins. Do not store fresh bread in the refrigerator; bread stales most quickly at temperatures just above freezing. The one exception: In warm, humid weather, refrigerating bread slows the growth of molds.
When You Are Ready to Serve This Food Use a serrated knife to cut bread easily.
What Happens When You Cook This Food Toasting is a chemical process that caramelizes sugars and amino acids (proteins) on the surface of the bread, turning the bread a golden brown. This chemical reaction, known both as the browning reaction and the Maillard reaction (after the French chemist who first identified it), alters the structure of the surface sugars, starches, and amino acids. The sugars become indigestible food fiber; the amino acids break into smaller fragments that are no longer nutritionally useful. Thus toast has more fiber and less protein than plain bread. How- ever, the role of heat-generated fibers in the human diet is poorly understood. Some experts consider them inert and harmless; others believe they may be hazardous.
How Other Kinds of Processing Affect This Food Freezing. Frozen bread releases moisture that collects inside the paper, foil, or plastic bag in which it is wrapped. If you unwrap the bread before defrosting it, the moisture will be lost and the bread will be dry. Always defrost bread in its wrappings so that it can reabsorb the moisture that keeps it tasting fresh. Drying. Since molds require moisture, the less moisture a food contains, the less likely it is support mold growth. That is why bread crumbs and Melba toast, which are relatively mois- ture-free, keep better than fresh bread. Both can be ground fine and used as a toasty-flavored thickener in place of flour or cornstarch.
Medical Uses and/or Benefits A lower risk of some kinds of cancer. In 1998, scientists at Wayne State University in Detroit conducted a meta-analysis of data from more than 30 well-designed animal studies mea- suring the anti-cancer effects of wheat bran, the part of grain with highest amount of the insoluble dietary fibers cellulose and lignin. They found a 32 percent reduction in the risk of colon cancer among animals fed wheat bran; now they plan to conduct a similar meta- analysis of human studies. Breads made with whole grain wheat are a good source of wheat bran. NOTE : The amount of fiber per serving listed on a food package label shows the total amount of fiber (insoluble and soluble). Early in 1999, however, new data from the long-running Nurses Health Study at Brigham Women’s Hospital/Harvard University School of Public Health showed that women who ate a high-fiber diet had a risk of colon cancer similar to that of women who ate a low fiber diet. Because this study contradicts literally hundreds of others conducted over the past 30 years, researchers are awaiting confirming evidence before changing dietary recommendations. Calming effect. Mood is affected by naturally occurring chemicals called neurotransmitters that facilitate transmission of impulses between brain cells. The amino acid tryptophan amino acid is the most important constituent of serotonin, a “calming” neurotransmitter. Foods such as bread, which are high in complex carbohydrates, help move tryptophan into your brain, increasing the availability of serotonin.
Adverse Effects Associated with This Food Allergic reactions and/or gastric distress. Bread contains several ingredients that may trigger allergic reactions, aggravate digestive problems, or upset a specific diet, among them gluten (prohibited on gluten-free diets); milk (prohibited on a lactose- and galactose-free diet or for people who are sensitive to milk proteins); sugar (prohibited on a sucrose-free diet); salt (controlled on a sodium-restricted diet); and fats (restricted or prohibited on a controlled-fat, low-cholesterol diet).... bread
The outer coat consists of the sclera and the cornea; their junction is called the limbus. SCLERA This is white, opaque, and constitutes the posterior ?ve-sixths of the outer coat. It is made of dense ?brous tissue. The sclera is visible anteriorly, between the eyelids, as the ‘white of the eye’. Posteriorly and anteriorly it is covered by Tenons capsule, which in turn is covered by transparent conjunctiva. There is a hole in the sclera through which nerve ?bres from the retina leave the eye in the optic nerve. Other smaller nerve ?bres and blood vessels also pass through the sclera at di?erent points. CORNEA This constitutes the transparent, colourless anterior one-sixth of the eye. It is transparent in order to allow light into the eye and is more steeply curved than the sclera. Viewed from in front, the cornea is roughly circular. Most of the focusing power of the eye is provided by the cornea (the lens acts as the ‘?ne adjustment’). It has an outer epithelium, a central stroma and an inner endothelium. The cornea is supplied with very ?ne nerve ?bres which make it exquisitely sensitive to pain. The central cornea has no blood supply – it relies mainly on aqueous humour for nutrition. Blood vessels and large nerve ?bres in the cornea would prevent light from entering the eye. LIMBUS is the junction between cornea and sclera. It contains the trabecular meshwork, a sieve-like structure through which aqueous humour leaves the eye.
The middle coat (uveal tract) consists of the choroid, ciliary body and iris. CHOROID A highly vascular sheet of tissue lining the posterior two-thirds of the sclera. The network of vessels provides the blood supply for the outer half of the retina. The blood supply of the choroid is derived from numerous ciliary vessels which pierce the sclera in front and behind. CILIARY BODY A ring of tissue extending 6 mm back from the anterior limitation of the sclera. The various muscles of the ciliary body by their contractions and relaxations are responsible for changing the shape of the lens during ACCOMMODATION. The ciliary body is lined by cells that secrete aqueous humour. Posteriorly, the ciliary body is continuous with the choroid; anteriorly it is continuous with the iris. IRIS A ?attened muscular diaphragm that is attached at its periphery to the ciliary body, and has a round central opening – the pupil. By contraction and relaxation of the muscles of the iris, the pupil can be dilated or constricted (dilated in the dark or when aroused; constricted in bright light and for close work). The iris forms a partial division between the anterior chamber and the posterior chamber of the eye. It lies in front of the lens and forms the back wall of the anterior chamber. The iris is visible from in front, through the transparent cornea, as the ‘coloured part of the eye’. The amount and distribution of iris pigment determine the colour of the iris. The pupil is merely a hole in the centre of the iris and appears black.
The inner layer The retina is a multilayered tissue (ten layers in all) which extends from the edges of the optic nerve to line the inner surface of the choroid up to the junction of ciliary body and choroid. Here the true retina ends at the ora serrata. The retina contains light-sensitive cells of two types: (i) cones – cells that operate at high and medium levels of illumination; they subserve ?ne discrimination of vision and colour vision; (ii) rods – cells that function best at low light intensity and subserve black-and-white vision.
The retina contains about 6 million cones and about 100 million rods. Information from them is conveyed by the nerve ?bres which are in the inner part of the retina, and leave the eye in the optic nerve. There are no photoreceptors at the optic disc (the point where the optic nerve leaves the eye) and therefore there is no light perception from this small area. The optic disc thus produces a physiological blind spot in the visual ?eld.
The retina can be subdivided into several areas: PERIPHERAL RETINA contains mainly rods and a few scattered cones. Visual acuity from this area is fairly coarse. MACULA LUTEA So-called because histologically it looks like a yellow spot. It occupies an area 4·5 mm in diameter lateral to the optic disc. This area of specialised retina can produce a high level of visual acuity. Cones are abundant here but there are few rods. FOVEA CENTRALIS A small central depression at the centre of the macula. Here the cones are tightly packed; rods are absent. It is responsible for the highest levels of visual acuity.
The chambers of the eye There are three: the anterior and posterior chambers, and the vitreous cavity. ANTERIOR CHAMBER Limited in front by the inner surface of the cornea, behind by the iris and pupil. It contains a transparent clear watery ?uid, the aqueous humour. This is constantly being produced by cells of the ciliary body and constantly drained away through the trabecular meshwork. The trabecular meshwork lies in the angle between the iris and inner surface of the cornea. POSTERIOR CHAMBER A narrow space between the iris and pupil in front and the lens behind. It too contains aqueous humour in transit from the ciliary epithelium to the anterior chamber, via the pupil. VITREOUS CAVITY The largest cavity of the eye. In front it is bounded by the lens and behind by the retina. It contains vitreous humour.
Lens Transparent, elastic and biconvex in cross-section, it lies behind the iris and in front of the vitreous cavity. Viewed from the front it is roughly circular and about 10 mm in diameter. The diameter and thickness of the lens vary with its accommodative state. The lens consists of: CAPSULE A thin transparent membrane surrounding the cortex and nucleus. CORTEX This comprises newly made lens ?bres that are relatively soft. It separates the capsule on the outside from the nucleus at the centre of the lens. NUCLEUS The dense central area of old lens ?bres that have become compacted by new lens ?bres laid down over them. ZONULE Numerous radially arranged ?bres attached between the ciliary body and the lens around its circumference. Tension in these zonular ?bres can be adjusted by the muscles of the ciliary body, thus changing the shape of the lens and altering its power of accommodation. VITREOUS HUMOUR A transparent jelly-like structure made up of a network of collagen ?bres suspended in a viscid ?uid. Its shape conforms to that of the vitreous cavity within which it is contained: that is, it is spherical except for a shallow concave depression on its anterior surface. The lens lies in this depression.
Eyelids These are multilayered curtains of tissue whose functions include spreading of the tear ?lm over the front of the eye to prevent desiccation; protection from injury or external irritation; and to some extent the control of light entering the eye. Each eye has an upper and lower lid which form an elliptical opening (the palpebral ?ssure) when the eyes are open. The lids meet at the medial canthus and lateral canthus respectively. The inner medial canthus is ?xed; the lateral canthus more mobile. An epicanthus is a fold of skin which covers the medial canthus in oriental races.
Each lid consists of several layers. From front to back they are: very thin skin; a sheet of muscle (orbicularis oculi, whose ?bres are concentric around the palpebral ?ssure and which produce closure of the eyelids); the orbital septum (modi?ed near the lid margin to form the tarsal plates); and ?nally, lining the back surface of the lid, the conjunctiva (known here as tarsal conjunctiva). At the free margin of each lid are the eyelashes, the openings of tear glands which lie within the lid, and the lacrimal punctum. Toward the medial edge of each lid is an elevation known as the papilla: the lacrimal punctum opens into this papilla. The punctum forms the open end of the cannaliculus, part of the tear-drainage mechanism.
Orbit The bony cavity within which the eye is held. The orbits lie one on either side of the nose, on the front of the skull. They a?ord considerable protection for the eye. Each is roughly pyramidal in shape, with the apex pointing backwards and the base forming the open anterior part of the orbit. The bone of the anterior orbital margin is thickened to protect the eye from injury. There are various openings into the posterior part of the orbit – namely the optic canal, which allows the optic nerve to leave the orbit en route for the brain, and the superior orbital and inferior orbital ?ssures, which allow passage of nerves and blood vessels to and from the orbit. The most important structures holding the eye within the orbit are the extra-ocular muscles, a suspensory ligament of connective tissue that forms a hammock on which the eye rests and which is slung between the medial and lateral walls of the orbit. Finally, the orbital septum, a sheet of connective tissue extending from the anterior margin of the orbit into the lids, helps keep the eye in place. A pad of fat ?lls in the orbit behind the eye and acts as a cushion for the eye.
Conjunctiva A transparent mucous membrane that extends from the limbus over the anterior sclera or ‘white of the eye’. This is the bulbar conjunctiva. The conjunctiva does not cover the cornea. Conjunctiva passes from the eye on to the inner surface of the eyelid at the fornices and is continuous with the tarsal conjunctiva. The semilunar fold is the vertical crescent of conjunctiva at the medial aspect of the palpebral ?ssure. The caruncle is a piece of modi?ed skin just within the inner canthus.
Eye muscles The extra-ocular muscles. There are six in all, the four rectus muscles (superior, inferior, medial and lateral rectus muscles) and two oblique muscles (superior and inferior oblique muscles). The muscles are attached at various points between the bony orbit and the eyeball. By their combined action they move the eye in horizontal and vertical gaze. They also produce torsional movement of the eye (i.e. clockwise or anticlockwise movements when viewed from the front).
Lacrimal apparatus There are two components: a tear-production system, namely the lacrimal gland and accessory lacrimal glands; and a drainage system.
Tears keep the front of the eye moist; they also contain nutrients and various components to protect the eye from infection. Crying results from excess tear production. The drainage system cannot cope with the excess and therefore tears over?ow on to the face. Newborn babies do not produce tears for the ?rst three months of life. LACRIMAL GLAND Located below a small depression in the bony roof of the orbit. Numerous tear ducts open from it into predominantly the upper lid. Accessory lacrimal glands are found in the conjunctiva and within the eyelids: the former open directly on to the surface of the conjunctiva; the latter on to the eyelid margin. LACRIMAL DRAINAGE SYSTEM This consists of: PUNCTUM An elevated opening toward the medial aspect of each lid. Each punctum opens into a canaliculus. CANALICULUS A ?ne tube-like structure run-ning within the lid, parallel to the lid margin. The canaliculi from upper and lower lid join to form a common canaliculus which opens into the lacrimal sac. LACRIMAL SAC A small sac on the side of the nose which opens into the nasolacrimal duct. During blinking, the sac sucks tears into itself from the canaliculus. Tears then drain by gravity down the nasolacrimal duct. NASOLACRIMAL DUCT A tubular structure which runs down through the wall of the nose and opens into the nasal cavity.
Visual pathway Light stimulates the rods and cones of the retina. Electrochemical messages are then passed to nerve ?bres in the retina and then via the optic nerve to the optic chiasm. Here information from the temporal (outer) half of each retina continues to the same side of the brain. Information from the nasal (inner) half of each retina crosses to the other side within the optic chiasm. The rearranged nerve ?bres then pass through the optic tract to the lateral geniculate body, then the optic radiation to reach the visual cortex in the occipital lobe of the brain.... eye
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
Structure Each tooth is composed of enamel, dentine, cement, pulp and periodontal membrane. ENAMEL is the almost translucent material which covers the crown of a tooth. It is the most highly calci?ed material in the body, 96–97 per cent being composed of calci?ed salts. It is arranged from millions of long, six-sided prisms set on end on the dentine (see below), and is thickest over the biting surface of the tooth. With increasing age or the ingestion of abrasive foods the teeth may be worn away on the surface, so that the dentine becomes visible. The outer sides of some teeth may be worn away by bad tooth-brushing technique. DENTINE is a dense yellowish-white material from which the bulk and the basic shape of a tooth are formed. It is like ivory and is harder than bone but softer than enamel. The crown of the tooth is covered by the hard protective enamel and the root is covered by a bone-like substance called cement. Decay can erode dentine faster than enamel (see TEETH, DISORDERS OF – Caries of the teeth). CEMENT or cementum is a thin bone-like material which covers the roots of teeth and helps hold them in the bone. Fibres of the periodontal membrane (see below) are embedded in the cement and the bone. When the gums recede, part of the cement may be exposed and the cells die. Once this has happened, the periodontal membrane can no longer be attached to the tooth and, if su?cient cement is destroyed, the tooth-support will be so weakened that the tooth will become loose. PULP This is the inner core of the tooth and is
composed of a highly vascular, delicate ?brous tissue with many ?ne nerve-?bres. The pulp is very sensitive to temperature variation and to touch. If the pulp becomes exposed it will become infected and usually cannot overcome this. Root-canal treatment or extraction of the tooth may be necessary. PERIODONTAL MEMBRANE This is a layer of ?brous tissue arranged in groups of ?bres which surround and support the root of a tooth in a bone socket. The ?bres are interspersed with blood vessels and nerves. Loss of the membrane leads to loss of the tooth. The membrane can release and re-attach the ?bres to allow the tooth to move when it erupts, or (to correct dental deformities) is being moved by orthodontic springs.
Arrangement and form Teeth are present in most mammals and nearly all have two sets: a temporary or milk set, followed by a permanent or adult set. In some animals, like the toothed whale, all the teeth are similar; but in humans there are four di?erent shapes: incisors, canines (eye-teeth), premolars (bicuspids), and molars. The incisors are chisel-shaped and the canine is pointed. Premolars have two cusps on the crown (one medial to the other) and molars have at least four cusps. They are arranged together in an arch in each jaw and the
cusps of opposing teeth interdigitate. Some herbivores have no upper anterior teeth but use a pad of gum instead. As each arch is symmetrical, the teeth in an upper and lower quadrant can be used to identify the animal. In humans, the quadrants are the same: in other words, in the child there are two incisors, one canine and two molars (total teeth 20); in the adult there are two incisors, one canine, two premolars and three molars (total 32). This mixture of tooth-form suggests that humans are omnivorous. Anatomically the crown of the tooth has mesial and distal surfaces which touch the tooth next to it. The mesial surface is the one nearer to the centre line and the distal is the further away. The biting surface is called the incisal edge for the anterior teeth and the occlusal surface for the posteriors.
Development The ?rst stage in the formation of the teeth is the appearance of a down-growth of EPITHELIUM into the underlying mesoderm. This is the dental lamina, and from it ten smaller swellings in each jaw appear. These become bell-shaped and enclose a part of the mesoderm, the cells of which become specialised and are called the dental papillae. The epithelial cells produce enamel and the dental papilla forms the dentine, cement and pulp. At a ?xed time the teeth start to erupt and a root is formed. Before the deciduous teeth erupt, the permanent teeth form, medial to them. In due course the deciduous roots resorb and the permanent teeth are then able to push the crowns out and erupt themselves. If this process is disturbed, the permanent teeth may be displaced and appear in an abnormal position or be impacted.
Eruption of teeth is in a de?nite order and at a ?xed time, although there may be a few months’ leeway in either direction which is of no signi?cance. Excessive delay is found in some congenital disorders such as CRETINISM. It may also be associated with local abnormalities of the jaws such as cysts, malformed teeth and supernumerary teeth.
The usual order of eruption of deciduous teeth is:
Middle incisors 6–8 months Lateral incisors 8–10 months First molars 12–16 months Canines (eye-teeth) 16–20 months Second molars 20–30 months
The usual order of eruption of permanent teeth is:
First molars 6–7 years Middle incisors 6–8 years Lateral incisors 7–9 years Canines 9–12 years First and second premolars 10–12 years Second molars 11–13 years Third molars (wisdom teeth) 17–21 years
The permanent teeth of the upper (top) and lower (bottom) jaws.
Teeth, Disorders of
Teething, or the process of eruption of the teeth in infants, may be accompanied by irritability, salivation and loss of sleep. The child will tend to rub or touch the painful area. Relief may be obtained in the child by allowing it to chew on a hard object such as a toy or rusk. Mild ANALGESICS may be given if the child is restless and wakens in the night. A serious pitfall is to assume that an infant’s symptoms of ill-health are due to teething, as the cause may be more serious. Fever and ?ts (see SEIZURE) are not due to teething.
Toothache is the pain felt when there is in?ammation of the pulp or periodontal membrane of a tooth (see TEETH – Structure). It can vary in intensity and may be recurring. The commonest cause is caries (see below) when the cavity is close to the pulp. Once the pulp has become infected, this is likely to spread from the apex of the tooth into the bone to form an abscess (gumboil – see below). A lesser but more long-lasting pain is felt when the dentine is unprotected. This can occur when the enamel is lost due to decay or trauma or because the gums have receded. This pain is often associated with temperature-change or sweet foods. Expert dental advice should be sought early, before the decay is extensive. If a large cavity is accessible, temporary relief may be obtained by inserting a small piece of cotton wool soaked, for example, in oil of cloves.
Alveolar abscess, dental abscess or gumboil This is an ABSCESS caused by an infected tooth. It may be present as a large swelling or cause trismus (inability to open the mouth). Treatment is drainage of the PUS, extraction of the tooth and/or ANTIBIOTICS.
Caries of the teeth or dental decay is very common in the more a?uent countries and is most common in children and young adults. Increasing awareness of the causes has resulted in a considerable improvement in dental health, particularly in recent years; this has coincided with a rise in general health. Now more than half of ?ve-year-old children are caries-free and of the others, 10 per cent have half of the remaining carious cavities. Since the start of the National Health Service, the emphasis has been on preventive dentistry, and now edentulous patients are mainly found among the elderly who had their teeth removed before 1948.
The cause of caries is probably acid produced by oral bacteria from dietary carbohydrates, particularly re?ned sugar, and this dissolves part of the enamel; the dentine is eroded more quickly as it is softer (see TEETH – Structure). The exposed smooth surfaces are usually protected as they are easily cleaned during normal eating and by brushing. Irregular and overcrowded teeth are more at risk from decay as they are di?cult to clean. Primitive people who chew coarse foods rarely get caries. Fluoride in the drinking water at about one part per million is associated with a reduction in the caries rate.
Prolonged severe disease in infancy is associated with poor calci?cation of the teeth, making them more vulnerable to decay. As the teeth are formed and partly calci?ed by the time of birth, the diet and health of the mother are also important to the teeth of the child. Pregnant mothers and children should have a good balanced diet with su?cient calcium and vitamin
D. A ?brous diet will also aid cleansing of the teeth and stimulate the circulation in the teeth and jaws. The caries rate can be reduced by regular brushing with a ?uoride toothpaste two or three times per day and certainly before going to sleep. The provision of sweet or sugary juices in an infant’s bottle should be avoided.
Irregularity of the permanent teeth may be due to an abnormality in the growth of the jaws or to the early or late loss of the deciduous set (see TEETH – Development). Most frequently it is due to an imbalance in the size of the teeth and the length of the jaws. Some improvement may take place with age, but many will require the help of an orthodontist (specialist dentist) who can correct many malocclusions by removing a few teeth to allow the others to be moved into a good position by means of springs and elastics on various appliances which are worn in the mouth.
Loosening of the teeth may be due to an accident or in?ammation of the GUM. Teeth loosened by trauma may be replaced and splinted in the socket, even if knocked right out. If the loosening is due to periodontal disease, the prognosis is less favourable.
Discoloration of the teeth may be intrinsic or extrinsic: in other words, the stain may be in the calci?ed structure or stuck on to it. Intrinsic staining may be due to JAUNDICE or the antibiotic tetracycline. Extrinsic stain may be due to tea, co?ee, tobacco, pan (a mixture of chuna and betel nuts wrapped in a leaf), iron-containing medicines or excess ?uoride.
Gingivitis or in?ammation of the gum may occur as an acute or chronic condition. In the acute form it is often part of a general infection of the mouth, and principally occurs in children or young adults – resolving after 10–14 days. The chronic form occurs later in life and tends to be progressive. Various microorganisms may be found on the lesions, including anaerobes. Antiseptic mouthwashes may help, and once the painful stage is past, the gums should be thoroughly cleaned and any calculus removed. In severe conditions an antibiotic may be required.
Periodontal disease is the spread of gingivitis (see above) to involve the periodontal membrane of the tooth; in its ?orid form it used to be called pyorrhoea. In this, the membrane becomes damaged by the in?ammatory process and a space or pocket is formed into which a probe can be easily passed. As the pocket becomes more extensive, the tooth loosens. The loss of the periodontal membrane also leads to the loss of supporting bone. Chronic in?ammation soon occurs and is di?cult to eradicate. Pain is not a feature of the disease but there is often an unpleasant odour (halitosis). The gums bleed easily and there may be DYSPEPSIA. Treatment is largely aimed at stabilising the condition rather than curing it.
Dental abscess is an infection that arises in or around a tooth and spreads to involve the bone. It may occur many years after a blow has killed the pulp of the tooth, or more quickly after caries has reached the pulp. At ?rst the pain may be mild and intermittent but eventually it will become severe and a swelling will develop in the gum over the apex of the tooth. A radiograph of the tooth will show a round clear area at the apex of the tooth. Treatment may be by painting the gum with a mild counter-irritant such as a tincture of aconite and iodine in the early stages, but later root-canal therapy or apicectomy may be required. If a swelling is present, it may need to be drained or the o?ending teeth extracted and antibiotics given.
Injuries to teeth are common. The more minor injuries include crazing and the loss of small chips of enamel, and the major ones include a broken root and avulsion of the entire tooth. A specialist dental opinion should be sought as soon as possible. A tooth that has been knocked out can be re-implanted if it is clean and replaced within a few hours. It will then require splinting in place for 4–6 weeks.
Prevention of dental disease As with other disorders, prevention is better than cure. Children should be taught at an early age to keep their teeth and gums clean and to avoid re?ned sugars between meals. It is better to ?nish a meal with a drink of water rather than a sweetened drink. Fluoride in some of its forms is useful in the reduction of dental caries; in some parts of the UK natural water contains ?uoride, and in some areas where ?uoride content is low, arti?cial ?uoridation of the water supply is carried out. Overcrowding of the teeth, obvious maldevelopment of the jaw and persistent thumbsucking into the teens are all indications for seeking the advice of an orthodontist. Generally, adults have less trouble with decay but more with periodontal disease and, as its onset is insidious, regular dental inspections are desirable.... teeth
Clinical psychologists are involved in health care in the following ways: (1) Assessment of thoughts, emotions and behaviour using standardised methods. (2) Treatment based on theoretical models and scienti?c evidence about behaviour change. Behaviour change is considered when it contributes to physical, psychological or social functioning. (3) Consultation with other health-care professionals about problems concerning emotions, thinking and behaviour. (4) Research on a wide variety of topics including the relationship between stress, psychological functioning and disease; the aetiology of problem behaviours; methods and theories of behaviour change. (5) Teaching other professionals about normal and dysfunctional behaviour, emotions and functioning.
Clinical psychologists may specialise in work in particular branches of patient care, including surgery, psychiatry, geriatrics, paediatrics, mental handicap, obstetrics and gynaecology, cardiology, neurology, general practice and physical rehabilitation. Whilst the focus of their work is frequently the patient, at times it may encompass the behaviour of the health-care professionals.... clinical psychology
Research has shown that cognitive therapy is very e?ective in depression and that it can also help in anxiety, OBSESSIVE COMPULSIVE DISORDER, and EATING DISORDERS such as anorexia and bulimia nervosa. This therapy is also proving useful in helping people cope with HALLUCINATIONS and other symptoms of SCHIZOPHRENIA.... cognitive behaviour therapy
Habitat: Cultivated in gardens.
English: Forking Larkspur, Larkspur, Lark's Claw, Knight's Spur.Action: Parasiticide. A tincture is used to destroy lice in hair.
The toxicity of the seeds is due to diterpene alkaloids (delcosine, delso- line, consolidine). Delsonine and an- thranoyllycoctonine are amorphous alkaloids.The alkaloids lead to bradycardia, lowering of blood pressure, and cardiac arrest. Also, they have a central paralyzing and curare-like effect on the respiratory system. (German Commission E.)Entire plant, including roots and seeds, is used topically. Not to be used on abraded skin.Seeds contain 1.01-1.06% alkaloids and 28.7% of a fixed oil. A digly- coside pigment, delphonin and kaem- pferol have been isolated from the flowers.... delphinium consolidaIt is worn for cosmetic reasons.
Some movement of the artificial eye may be achieved by attaching the muscles that normally move the eye to the remaining conjunctival membrane (see conjunctiva) or to a plastic implant in the eye socket.... eye, artificial
the body. Visceral larva migrans (toxocariasis) is caused by a type of worm that normally parasitizes dogs. Cutaneous larva migrans (creeping eruption) is caused by a form of hookworm infestation; the larvae penetrate the skin and move around, leaving intensely itchy red lines sometimes accompanied by blistering. Both types of larva migrans can be treated with anthelmintic drugs.... larva migrans
The University of Exeter Centre for Complementary Health Studies report, published in 2000, estimated that there are probably more than 60,000 practitioners of complementary and alternative medicine in the UK. In addition there are about 9,300 therapist members of organisations representing practitioners who have statutory quali?cations, including doctors, nurses (see NURSING), midwives, osteopaths and physiotherapists; chiropractors became fully regulated by statute in June 2001. There are likely to be many thousands more health sta? with an active interest or involvement in the practice of complementary medicine – for example, the 10,000 members of the Royal College of Nursing’s Complementary Therapy Forum. It is possible that up to 20,000 statutory health professionals regularly practise some form of complementary medicine including half of all general practices providing access to CAMs – most commonly manipulation therapies. The report from the Centre at Exeter University estimates that up to 5 million patients consulted a practitioner specialising in complementary and alternative medicine in 1999. Surveys of users of complementary and alternative practitioners show a relatively high satisfaction rating and it is likely that many patients will go on to use such therapists over an extended period. The Exeter Centre estimates that, with the increments of the last two years, up to 15–20 million people, possibly 33 per cent of the population of the country, have now sought such treatment.
The 1998 meeting of the British Medical Association (BMA) agreed to ‘investigate the scienti?c basis and e?cacy of acupuncture and the quality of training and standards of con?dence in its practitioners’. In the resulting report (July 2000) the BMA recommended that guidelines on CAM use for general practitioners, complementary medicine practitioners and patients were urgently needed, and that the Department of Health should select key CAM therapies, including acupuncture, for appraisal by the National Institute for Clinical Medicine (NICE). The BMA also reiterated its earlier recommendation that the main CAM therapies, including acupuncture, should be included in familiarisation courses on CAM provided within medical schools, and that accredited postgraduate education should be provided to inform GPs and other clinicians about the possible bene?ts of CAM for patients.... complementary and alternative medicine (cam)
Genetic screening is proving to be a controversial subject. Arguments are developing over whether the results of such screenings should be made available to employers and insurance companies – a move that could have adverse consequences for some individuals with potentially harmful genetic make-ups. (See GENES; GENETIC DISORDERS.)... genetic screening
Malocclusion usually develops during childhood. It is inherited, or is caused by thumb-sucking or a mismatch betweenthe teeth and jaws – for example, the combination of large teeth and a small mouth (see overcrowding, dental).
Orthodontic appliances (braces) may be used to move teeth into the proper position, and if there is dental overcrowding, some teeth may be extracted. Orthognathic surgery is used to treat severe recession or protrusion of the lower jaw. Treatment is best carried out in childhood or adolescence.... malocclusion
Manipulation may be used to treat deformity and stiffness caused by bone and joint disorders, to realign bones in a displaced fracture, to reposition a joint after a dislocation, or to stretch a contracture.
Occasionally, manipulation is used to help treat frozen shoulder.... manipulation
A severe blow to the face may fracture the orbit, but the eyeball is often undamaged as it can move back into the socket.
Fractures often heal without treatment, but some cause deformity and require corrective surgery.
Rarely, bacterial infection spreads from a sinus or the face to cause orbital cellulitis.... orbit
It is used to investigate male infertility and is also done some weeks after vasectomy to ensure that the semen no longer contains sperm.... seminal fluid analysis
In the United Kingdom, the 1993 Education Act refers to ‘learning diffculties’: generalised (severe or moderate), or speci?c (e.g. DYSLEXIA, dyspraxia [or APRAXIA], language disorder). The 1991 Social Security (Disability Living Allowance) Regulations use the term ‘severely mentally impaired’ if a person suffers from a state of arrested development or incomplete physical development of the brain which results in severe impairment of intelligence and social functioning. This is distinct from the consequences of DEMENTIA. Though ‘mental handicap’ is widely used, ‘learning disability’ is preferred by the Department of Health.
There is a distinction between impairment (a biological de?cit), disability (the functional consequence) and handicap (the social consequence).
People with profound learning disability are usually unable to communicate adequately and may be seriously movement-impaired. They are totally dependent on others for care and mobility. Those with moderate disability may achieve basic functional literacy (recognition of name, common signs) and numeracy (some understanding of money) but most have a life-long dependency for aspects of self-care (some fastenings for clothes, preparation of meals, menstrual hygiene, shaving) and need supervision for outdoor mobility.
Children with moderate learning disability develop at between half and three-quarters of the normal rate, and reach the standard of an average child of 8–11 years. They become independent for self-care and public transport unless they have associated disabilities. Most are capable of supervised or sheltered employment. Living independently and raising a family may be possible.
Occurrence Profound learning disability affects about 1 in 1,000; severe learning disability 3 in 1,000; and moderate learning disability requiring special service, 1 per cent. With improved health care, survival of people with profound or severe learning disability is increasing.
Causation Many children with profound or severe learning disability have a diagnosable biological brain disorder. Forty per cent have a chromosome disorder – see CHROMOSOMES (three quarters of whom have DOWN’S (DOWN) SYNDROME); a further 15 per cent have other genetic causes, brain malformations or recognisable syndromes. About 10 per cent suffered brain damage during pregnancy (e.g. from CYTOMEGALOVIRUS (CMV) infection) or from lack of oxygen during labour or delivery. A similar proportion suffer postnatal brain damage from head injury – accidental or otherwise – near-miss cot death or drowning, cardiac arrest, brain infection (ENCEPHALITIS or MENINGITIS), or in association with severe seizure disorders.
Explanations for moderate learning disability include Fragile X or other chromosome abnormalities in a tenth, neuro?bromatosis (see VON RECKLINGHAUSEN’S DISEASE), fetal alcohol syndrome and other causes of intra-uterine growth retardation. Genetic counselling should be considered for children with learning disability. Prenatal diagnosis is sometimes possible. In many children, especially those with mild or moderate disability, no known cause may be found.
Medical complications EPILEPSY affects 1 in 20 with moderate, 1 in 3 with severe and 2 in 3 with profound learning disability, although only 1 in 50 with Down’s syndrome is affected. One in 5 with severe or profound learning disability has CEREBRAL PALSY.
Psychological and psychiatric needs Over half of those with profound or severe – and many with moderate – learning disability show psychiatric or behavioural problems, especially in early years or adolescence. Symptoms may be atypical and hard to assess. Psychiatric disorders include autistic behaviour (see AUTISM) and SCHIZOPHRENIA. Emotional problems include anxiety, dependence and depression. Behavioural problems include tantrums, hyperactivity, self-injury, passivity, masturbation in public, and resistance to being shaved or helped with menstrual hygiene. There is greater vulnerability to abuse with its behavioural consequences.
Respite and care needs Respite care is arranged with link families for children or sta?ed family homes for adults where possible. Responsibility for care lies with social services departments which can advise also about bene?ts.
Education Special educational needs should be met in the least restrictive environment available to allow access to the national curriculum with appropriate modi?cation and support. For older children with learning disability, and for young children with severe or profound learning disability, this may be in a special day or boarding school. Other children can be provided for in mainstream schools with extra classroom support. The 1993 Education Act lays down stages of assessment and support up to a written statement of special educational needs with annual reviews.
Pupils with learning disability are entitled to remain at school until the age of 19, and most with severe or profound learning disability do so. Usually those with moderate learning disability move to further education after the age of 16.
Advice is available from the Mental Health Foundation, the British Institute of Learning Disabilities, MENCAP (Royal Society for Mentally Handicapped Children and Adults), and ENABLE (Scottish Society for the Mentally Handicapped).... learning disability
Two types of sperm cells are produced: one contains 22 autosomes and a Y sex chromosome (see SEX CHROMOSOMES); the other, 22 autosomes and an X sex chromosome. All the ova, however, produced by normal meiosis have 22 autosomes and an X sex chromosome.
Two divisions of the NUCLEUS occur (see also CELLS) and only one division of the chromosomes, so that the number of chromosomes in the ova and sperms is half that of the somatic cells. Each chromosome pair divides so that the gametes receive only one member of each pair. The number of chromosomes is restored to full complement at fertilisation so that the zygote has a complete set, each chromosome from the nucleus of the sperm pairing up with its corresponding partner from the ovum.
The ?rst stage of meiosis involves the pairing of homologous chromosomes which join together and synapse lengthwise. The chromosomes then become doubled by splitting along their length and the chromatids so formed are held together by centromeres. As the homologous chromosomes – one of which has come from the mother, and the other from the father – are lying together, genetic interchange can take place between the chromatids and in this way new combinations of GENES arise. All four chromatids are closely interwoven and recombination may take place between any maternal or any paternal chromatids. This process is known as crossing over or recombination. After this period of interchange, homologous chromosomes move apart, one to each pole of the nucleus. The cell then divides and the nucleus of each new cell now contains 23 and not 46 chromosomes. The second meiotic division then occurs, the centromeres divide and the chromatids move apart to opposite poles of the nucleus so there are still 23 chromosomes in each of the daughter nuclei so formed. The cell divides again so that there are four gametes, each containing a half number (haploid) set of chromosomes. However, owing to the recombination or crossing over, the genetic material is not identical with either parent or with other spermatozoa.... meiosis
For a diagnosis of PVS to be made, the state should have continued for more than a prede?ned period, usually one month. Half of patients die within 2–6 months, but some can survive for longer with arti?cial feeding. To assess a person’s level of consciousness, a numerical marking system rated according to various functions – eye opening, motor and verbal responses – has been established called the GLASGOW COMA SCALE.
The ETHICS of keeping patients alive with arti?cial support are controversial. In the UK, a legal ruling is usually needed for arti?cial support to be withdrawn after a diagnosis of PVS has been made. The chances of regaining consciousness after one year are slim and, even if patients do recover, they are usually left with severe neurological disability.
PVS must be distinguished from conditions which appear similar. These include the ‘LOCKED-IN SYNDROME’ which is the result of damage to the brain stem (see BRAIN). Patients with this syndrome are conscious but unable to speak or move except for certain eye movements and blinking. The psychiatric state of CATATONIA is another condition in which the patient retains consciousness and will usually recover.... persistent vegetative state (pvs)
Those in the row nearest the hand are the trapezium, trapezoid, capitate and hamate. These latter articulate with the metacarpal bones in the hand and are closely bound to one another by short, strong ligaments; and the wrist-joint is the union of the composite mass thus formed with the RADIUS and ULNA in the forearm. The wrist and the radius and ulna are united by strong outer and inner lateral ligaments, and by weaker ligaments before and behind, whilst the powerful tendons passing to the hand and ?ngers strengthen the wrist.
The joint can move in all directions, and its shape and many ligaments mean that it rarely dislocates – although stretching or tearing of some of these ligaments is a common accident, constituting a sprain. (See JOINTS, DISEASES OF.) In?ammation of the tendon-sheaths may occur as a result of injury or repetitive movement (see UPPER LIMB DISORDERS). A fairly common condition is the presence of a GANGLION, in which an elastic swelling full of ?uid develops on the back or front of the wrist in connection with the sheaths of the tendons. (See also HAND.)... wrist
The medulla, or core of the gland, secretes adrenalin and noradrenalin, known as the ‘fight or flight’ hormones that move the body into top gear to meet an emergency. Mental or physical stress may cause it to swing into action; increasing the heart beat, elevating blood pressure and releasing glycogen from the liver.
The cortex secretes a hormone – aldosterone (the salt and water hormone) which regulates water retention in the body. Also, the cortex secretes cortisone which raises the level of sugar in the blood . . . insulin reduces it. Also secreted are the adrenal sex hormones that complement the gonads.
Re-vitalisers for exhausted or hypoactive adrenals: Borage, Cayenne, Ginger root, Ginseng, Gotu Kola, Hawthorn, Liquorice, Mullein, Parsley root, Sarsaparilla, Wild Yam. ... adrenal glands
Diagnosis: dementia requires six months mental impairment, whereas acute confusional states may develop in a few days. Distinguish from Alzheimer’s disease.
Causes: Oxygen deficiency in the tissues (Vitamin E). Toxaemia (eliminatives). Delirium (nerve relaxants). Infections (Echinacea). Metabolism (Dandelion). Drugs (Ginseng). Hypothermia (Cayenne). Nutritional (Slippery Elm, thiamine).
Tea. Combine herbs, equal parts: Agrimony, Skullcap, Balm. 2 teaspoons to each cup boiling water; infuse 5-15 minutes. 1 cup freely.
Ginkgo: Favourable results reported.
Vitamins. B-complex. B12. Thiamine. E (1000iu daily). Minerals. Dolomite. Zinc. ... confusional state
Basically, the therapy consists of a vegetarian diet with meals of vegetables, fruits and whole grains, fresh or freshly prepared. Drinking water is replaced by hourly, fresh, raw juices of vegetables and fruits. Refined, altered, denatured or enhanced foodstuffs are forbidden. The diet is sodium, chloride, fat and protein restricted. Supplemental potassium, iodine, thyroid and crude liver extract comprise the medical armamentarium. A repeatable choleretic, enemas of a solution of boiled coffee, is administered to lower serum toxin levels. Coffee is a potent enhancer of the carcinogen detoxifying enzyme system, glutathione S-translerase (Wattenburg). The Gerson cancer therapy reduces accumulated tissue sodium and chloride, promoting diuresis. Gerson Therapy Center: Hospital de Baja California, at La Gloria, Mexico
Diet. Lunch and dinner contain ample cooked food, mainly to act as a ‘blotter’ to the daily intake of 5.25 pints fresh raw fruit juices that are the backbone of the therapy. Ingredients of the juices include 41bs raw organic carrots a day, with no harm to the liver. (JAM, May 1991, p5. Beata Bishop on her recovery from metastasised malignant melanoma)
The Gerson therapy is based on the ‘holistic’ philosophy which states that cancer represents a clinical manifestation of an underlying toxic condition. Such condition should receive primary treatment that is lifestyle orientated. The theme is: detoxification through internal cleansing. The diet and supplements are re-inforced by ‘positive thinking’ and supported by meditation and emotional balance. ... gerson cancer therapy
Mitral disease leads to heart failure either by a narrowing of the orifice (stenosis) or a regurgitation blocks the passage of blood from the left atrium (auricle) to the left ventricle. The left atrium enlarges (hypertrophies) in an effort to counter the impediment. Real compensation – increased thrust of the blood – is provided by the right ventricle. In order to overcome a mitral impediment the right ventricle has to enlarge.
Sooner or later the right ventricle cannot enlarge any further and general heart failure sets in. Though caused primarily by a lesion of the mitral valve, it may be secondary to left ventricular failure (LVF), thyroid disorder (thyrotoxicosis), pericarditis, congenital heart disease, or any disease which weakens ventricular muscle.
Venous congestion and back pressure of RVF leads to congestion and accumulation of fluid in the lungs, cough and spitting of blood, painful swelling of the liver, nausea, loss of appetite and severe wasting.
Where the right ventricle fails to move the blood forward as it arrives from the systemic circulation, generalised dropsy sets in. Congestion of the kidneys leads to reduced urinary excretion and presence of albumin in the urine.
The picture is well known to the cardiac practitioner: blueness of the skin, congestion of the brain circulation with sleeplessness and delirium. Soon the tension of water-logged tissues results in pain and extreme anxiety. Feet are swollen and ankles pit on pressure; chest cavities fill with fluid and the abdomen swells (ascites).
Alternatives. Cardio-tonics would be given to strengthen the ventricle and diuretics to correct fluid retention: Lily of the Valley, Hawthorn, Motherwort, Broom. BHP (1983).
Due to rheumatic fever: Hawthorn.
High Blood Pressure: Mistletoe.
Effort Syndrome: Motherwort.
Tinctures. Combine, Lily of the Valley 2; Hawthorn 2; Motherwort 3. Dose: 1 teaspoon thrice daily after meals.
Diet. Low salt, low fat, high fibre. Restricted fluids, vegetarian protein foods, yoghurt. See also: DIET – HEART AND CIRCULATION.
Supplements. Potassium (bananas), Vitamin B6.
General. Stop smoking. Correction of overweight. Complete bed-rest with legs raised above level of the abdomen and patient propped-up to relieve difficult breathing. ... heart – right ventricular failure (rvf)
He said: “Ill health is a disharmony between man and his environment” and “Let medicine be your food, and food your medicine”. The long list of herbs used in his practice are still popular among herbalists today. He taught that diseases were disturbances in the balance of the four humours. For centuries he was regarded as a model for doctors and it is claimed he ‘gave medicine a soul’. ... hippocrates
Alternatives. All types of irritation, including itching of anus and vulva.
Teas. Chaparral, Chickweed, Figwort, Dandelion, Boneset, Marigold, Nettles, Red Clover.
Tea formula. Equal parts: Figwort, Meadowsweet, Juniper berries. 1 heaped teaspoon to each cup boiling water; infuse 15 minutes; 1 cup thrice daily.
Tea (cold). Barberry bark: one heaped teaspoon to each cup cold water steeped overnight. Dose: 1 cup thrice during the following day.
Tablets/capsules. Blue Flag, Dandelion, Echinacea, Devil’s Claw, Poke root, Seaweed and Sarsaparilla, Wild Yam.
Formula. Echinacea 2; Dandelion 2; Poke root half. Dose – Powders: 500mg (two 00 capsules or one- third teaspoon). Liquid Extracts: one 5ml teaspoon. Tinctures: two 5ml teaspoons).
Practitioner. Tinctures BHP (1983). Barberry (Berberis vulgaris) 2; Kava Kava 1; Figwort 1. Dose: 1-2 teaspoons in water thrice daily for severe anal or vulval attack.
Topical. Wipe affected area with: (a) Witch Hazel water. (b) Witch Hazel water plus 2-3 drops Tincture Goldenseal (severe, anus or vulva). (c) Cider vinegar. (d) Jojoba oil. (e) Aloe Vera (anus and vulva). (f) Well diluted essential oils of Aromatherapy: Lavender, Aniseed. (g) 2-3 drops Australian Tea Tree oil to 100ml water. (h) Zinc and Castor oil cream. (i) Bathe with strong infusion Tansy (anus).
Evening Primrose oil capsules. Contain gamolenic acid which has a significant effect on relieving itching by its antihistamine action.
Diet. Gluten-free.
Vitamins. A. B-complex. B3. B6. B12. D. F.
Minerals. Zinc.
Note: Constantine Hering MD, physician, sums up the law of cure: “The direction of disease is inwards and upwards. The direction of cure is downwards and outwards. Symptoms that move deeper into the body and from the surface towards the head are considered dangerous. Any skin eruption, or itching, or nervous symptoms moving from the head towards the feet would be regarded as favourable.
“Itch is an effort of the central nervous system to move a deeper disturbance towards the skin where the irritation may be distressing but where it is least damaging.”
Perhaps the most common cause of chronic itching in the 1990s is Candida. ... itching
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