Labetalol

Andrew Mavor MD FRCS(Ed)

• Consultant vascular surgeon
• Leeds General Infirmary, Leeds
• Honorary senior lecturer, University of Leeds
• Examiner for RCS Edinburgh, UK

This represents a relative (not an absolute) contraindication hypertension on a cellular level generic 100 mg labetalol with visa, because if other sedative techniques pulse pressure of 50 order labetalol. Patients who are hypothyroid but are currently treated with thyroid medications blood pressure normal or high order labetalol 100 mg without prescription. Patients who are clinically hyperthyroid (signs and symptoms present) are likely to prove extremely difficult to sedate heart attack songs generic 100 mg labetalol visa. In addition hypertension question and answers order labetalol 100 mg amex, drugs such as the anticholinergics atropine and scopolamine ought not to be administered to the clinically hyperthyroid patient. It seems patently unfair for an already phobic patient to have to endure multiple unsuccessful venipuncture attempts so that we can give them a drug to help them relax. One of the objectives of this visit is to confirm the presence of superficial veins. Allergic responses and "hyperresponders" may be uncovered before the offending drug is administered. The drug package insert or Chapter 25 of this book should be reviewed for this important information. These contraindications include opioids (specifically meperidine)-asthma; and anticholinergics-glaucoma, prostatic hypertrophy. Patients receiving chronic corticosteroid therapy or patients with Addison disease may be less able physiologically to handle the stresses associated with dental care than are patients with normal adrenal cortices. Although these patients require careful management (see stress-reduction protocol, Chapter 4), deeper levels of sedation are not recommended. Anxiety As with inhalation sedation and the other sedation techniques discussed in this book, the primary indication for use of sedation is the presence of fear and anxiety. Inhalation sedation can often effectively manage the patient with a lesser degree of fear and anxiety. Diazepam, midazolam, lorazepam, and scopolamine are examples of drugs that have a greater degree of amnesia associated with their administration; meperidine and other opioids are less likely to provide an amnestic effect. This factor is the reason for my considering amnesia to be "the icing on the cake" during a sedation procedure. The patient may tolerate the procedure quite well, but at its conclusion, may not be amnesic. The primary goal-that of managing the difficult patient more easily and effectively-was accomplished. Should there also be a lack of recall of events that occurred during the procedure, so much the better. It is wiser to provide a patient comfortable dental treatment with total recall (no amnesia) at a lighter level of sedation than it is to provide comfortable dental treatment with total lack of recall at a deeper level of sedation. With loss of consciousness, lack of recall (amnesia) is virtually 100%, yet is associated with increased risk to the patient. As with all other factors relating to drug response, there is a significant degree of individual variation in the occurrence of amnesia. Some patients will be amnesic following seemingly very light levels of sedation, whereas others may demonstrate no apparent amnesia with deeper levels of sedation. Such response is consistent with normal variation in response to drug administration. Administer 3 L/min of O2 via a nasal cannula or 6 L/min via a nasal hood throughout the sedative procedure. In most cases, the seizure activity of the patient is controlled through daily administration of anticonvulsant (antiepileptic) drugs (many of which, coincidentally, are used intravenously as sedatives). Such patients will be able to tolerate almost any technique of sedation with little or no difficulty. Stress is a factor that acts to precipitate acute seizure activity; therefore use of the stress-reduction protocol is recommended. Although inhalation sedation may prove effective, the use of intravenously administered benzodiazepines, particularly midazolam or diazepam, is recommended. These drugs are effective anticonvulsants and can be administered intravenously should a protracted seizure. The use of O2 via nasal cannula or nasal hood is strongly recommended in epileptic patients because any degree of hypoxia may precipitate a seizure. The preferred route of sedation for all of these disorders is inhalation sedation with N2O-O2. Several sedation techniques possess the added benefit of diminishing the gag reflex. In most instances, the use of inhalation sedation is recommended to control a hyperactive gag reflex. Control of Secretions Occasions arise during dental treatment when it is beneficial to decrease the volume of salivary secretions. The major indication for this will be impression taking following the preparation of teeth for full coverage. A dry mouth may also prove to be beneficial during restorative dentistry and surgical procedures. Analgesia Although far from the ideal method of pain control in dentistry, intravenously administered opioid analgesics assist in obtaining clinically adequate pain control. Local anesthetics remain the ideal drugs for eliminating pain during dental treatment; however, though rare, occasions do arise where these drugs do not provide entirely adequate relief of discomfort. The use of intravenously administered drugs as the sole means of achieving pain control is ineffective in the absence of general anesthesia. A reappraisal of its pharmacological properties and therapeutic efficacy as a benzodiazepine antagonist. Diminished Gag Reflex Some dental patients have a significant problem with gagging whenever instruments or fingers are placed in the posterior part of their oral cavity. Needle maintained in the vein without a continuous infusion; patency maintained by periodic flushing 3. After ensuring that the needle tip lies within the lumen of the vein (aspiration of blood back into the syringe), the dentist or assistant removes the tourniquet, and the drug is slowly administered into the vein. Following drug administration, the needle is removed from the vein, pressure is applied to the site to stop the bleeding, and the planned treatment begins. When the needle is maintained in the vein without an infusion, the tourniquet is placed, the veins are engorged, and the tissues are prepared in the usual manner. Following successful venipuncture, the tourniquet is removed, and the syringe (without a needle attached) is connected to the needle that has been left in the vein and taped into place. After the drug is titrated to effect, the syringe is detached from the needle, and a second syringe containing a solution such as sterile water for injection is attached to the needle. The same venipuncture procedure is carried out that was described for the first two techniques. Blood is aspirated into syringe before injection to determine that needle is still within lumen of vein. Situations in which the needle needs to be maintained in the vein for only a very brief period (as in drawing of blood for laboratory analysis) Why do I believe this technique should not be used Although not a hard technique to master, venipuncture can be difficult on some occasions in even the most experienced of hands. Adherents of the needleremoval technique claim that the patient is bothered by the needle remaining in the vein and that the presence of the needle in the vein throughout the procedure reminds the patient of a hospital. However, once the needle is placed into a vein and the sedative drug titrated to effect, the patient has little, if any, awareness of its presence, whether it is in for 1 minute or several hours. In response to the belief about the hospital setting, I can only state that the presence of a needle within the vein throughout the procedure is routine in hospital practice simply because it increases safety. A valid argument in favor of the needle-removal technique is that removal of the needle from the vein makes it difficult for additional drugs to be administered following the initial titration, minimizing the chance of a drug overdose. The second technique, in which the needle remains in the vein throughout the procedure and its patency maintained by periodic flushing with some solution, is an improvement on the previous technique. The only drawback to this technique is that periodic flushing of the needle is required to prevent clotting of the lumen from occurring. During a busy dental procedure, it is not uncommon for the dentist and the assistant to become deeply engrossed in the oral cavity and to neglect to flush the needle, in which case the lumen of the needle becomes clotted with blood and a vein must be recannulated. The only drawback to this procedure is the possibility that (1) the infusate might become contaminated (an extremely unlikely occurrence) and (2) the drip rate might be too rapid, causing the bag of solution to be emptied during the procedure. The answer is that a 5% dextrose and water solution is not contraindicated in the diabetic patient. First, the concentration of dextrose (5%) is not great enough to produce significant changes in the blood sugar level of this patient. The patient arrives at the dental office with a decreased blood sugar level, perhaps not quite hypoglycemic but definitely not hyperglycemic. The addition of approximately 250 to 500 mL of 5% dextrose and water will produce a slight elevation in blood sugar level, a desirable effect at this time. Under general anesthesia, during which time the patient must be kept hydrated throughout the surgery, 1-L bags are also commonly used. Use of the 1-L bag for dental outpatient procedures is not the most highly recommended, although there is no significant reason why it could not be used. For example, during a 1-hour procedure, the typical patient may receive 250 to 500 mL of infusion fluid. It is a single-use item and must never be reused despite the fact that, in this example, approximately 500 to 750 mL of infusate remains unused. With proper management of the flow rate (as discussed in Chapter 26), a 250-mL or 500-mL bag can easily last for 3 to 4 hours. Once the seal on the bag of infusate has been opened, the fluid cannot be stored for any length of time without the possibility of contamination. It is a rigid plastic piece that must be kept sterile before its insertion into the bag of solution. The drip chamber is an enlarged, flexible, clear plastic chamber into which fluid from the bag (infusate) will drip. Although isolated air bubbles within the tubing are of little consequence (see Chapter 27), the naive patient may be quite disturbed to see any bubble of air enter into his or her body. An unfilled drip chamber or one just barely filled with solution will allow air bubbles to enter the tubing as each drop of solution falls from the bag into the drip chamber. A solution that has any coloration to it or any particulate matter floating within it should never be used. The ability to determine the precise rate of flow is of importance in these situations. The needle of the syringe containing the drug to be injected is inserted into this port, and the drug is injected into the flowing infusion. This bulb is larger than the plastic tubing and serves as a means of checking if the needle or catheter tip lies within the lumen of a vein. A second possible use of the rubber bulb is to serve as an alternative site for injection of a drug. This blood may be quite visible as it surges back into the tubing when the needle tip enters into the lumen of the vein during venipuncture, or it may be quite dilute and perhaps not visible to the eye. However, in discussions of the hypodermic needle, standard gauge numbers have come to be associated with the size of the lumen. Needles used for venipuncture generally range from 14 gauge to approximately 24 gauge. The term derives from the number of pieces of wire (in this case needles) that can be placed into a 1-mm circle. Therefore only 16 needles of 16 gauge will fit into the same space occupied by 23 needles of 23 gauge. This needle represents the basic design from which other needles in the following discussions have been modified. Since the development of the scalp vein needle and the indwelling catheter, use of the hollow metal needle for venipuncture has become limited to emergency situations in which other needles are not readily available or situations in which blood is to be drawn from a patient for laboratory analysis. Some regard the winged needle as the device of choice for venipuncture of superficial veins in patients of all ages. Several types of indwelling catheter are available, among them the catheter­overneedle unit and the catheter­insideneedle unit. Modern catheters are radiopaque so that they may easily be visualized on x-ray examination. The indwelling catheter, called the catheter­overneedle, when first designed, consisted of a metal hub to which a plastic catheter was attached. The catheter was physically connected to the separate metal hub by means of a piece of plastic. A metal needle (called the introducer because it is used to "introduce" the catheter into the vein), ranging in gauge from 14 to 23, has a very tightfitting plastic catheter placed over it. The actual technique of venipuncture using the indwelling catheter is presented in Chapter 24. The indwelling catheter is recommended for use within the operating room and in most general anesthetic procedures. In situations in which maintenance of a patent vein is essential, indwelling catheters are recommended. The reason indwelling catheters are not universally taught as the primary venipuncture needle for most ambulatory procedures is that the winged infusion set is somewhat easier for a beginner to master. With some experience using the winged infusion set, the student has little or no difficulty moving to the indwelling catheter. The wings allow the user to hold the needle more firmly, permitting greater ability to manipulate the needle and to gain greater "feel" during the procedure. In addition, following successful venipuncture, the wings may be taped down to better secure the needle within the vein. The winged needle has several synonyms: winged infusion set, Butterfly needle, and scalp vein needle.

This then provides the basis for a discussion of abnormalities of the form of thinking blood pressure medication usa labetalol 100 mg order without prescription, a particularly complex area of psychopathology pulse pressure formula labetalol 100 mg order online, as it requires the ability both to follow closely what someone is saying and also to conclude that the sequence of ideas heart attack 85 blockage order labetalol 100 mg mastercard, or the association of ideas may be awry blood pressure medication names 100 mg labetalol buy visa. With time and years the individual becomes so lazy in public life that he is not even capable of writing any more pulse pressure emt labetalol 100 mg buy online. Eugene Bleuler (1857­1939) Types of Thinking the process of thinking was divided by Fish (1967) into the following three types: · undirected fantasy (dereistic) or autistic thinking; 129 this article is concerned with disorder of thinking, and the next chapter with disorders of language. These three types have slightly different implications for psychopathology, the description and categorization of morbid processes. They can be considered as functions of thinking; that is, they are the necessary mechanisms for thinking to take place but are not themselves manifest in the phenomena. We can contrast those phenomena, which are the products of the performance of thinking, the percept or the idea, with the functions that do not become explicit. To be able to harness our imagination constructively, we require the capacity for undirected fantasy and the learned skill to structure thoughts. Fantasy also allows a person to escape from or deny reality, or alternatively to convert reality into something more tolerable and less requiring of corrective action. A 20-year-old young woman, who had a very deprived childhood and walked the city streets at night as a prostitute, listened to a vicar broadcasting on local radio. When questioned by the police one night, she gave their names as next of kin and said they really were her parents. Shy, reserved people, not suffering from mental illness, may use dereistic thinking to compensate for the disappointments of life. Fantasy, especially in some with neurotic traits, may develop from the stage of being deliberate and sporadic into an established mode; the person comes to believe the contents of his fantasy, which become subjectively real and accepted as fact. Freud, in his later writings, considered that this was so in some of the accounts he received from women of an incestuous relationship with their father during childhood (Jones, 1962). However, in his early writings he had considered that they had experienced actual sexual assault but had used unconscious mechanisms to repress this knowledge (Isräels and Schatzman, 1993; Webster, 1995). Various types of experience come into the category of acting out fantasy, such as pathologic lying (pseudologia fantastica), hysterical conversion and dissociation (somatic and psychological dissociative symptoms) and the delusion-like ideas occurring in affective psychoses. Fantasy is usually understood to be the creation of images or ideas that have no external reality. However, fantasy thinking may also reveal itself in the denial of external events. The observations for which the psychodynamic explanation of ego defence mechanisms has been described are relevant in this context. Fantasy thinking denies unpleasant reality, even though the fantasy itself may also be unpleasant. This rearranging or transformation of reality is shown by neurotic patients habitually and all people occasionally. There are at least three components of imagination: mental imagery, counterfactual thinking and symbolic representation. Mental imagery refers to the ability to create image-based mental representations of the world. Counterfactual thinking refers to the capacity to disengage from reality to think of events and experiences that have not occurred and may never occur. Symbolic representation is the use of concepts or images to represent real-world objects or entities (Roth, 2004). A facet of this type of thinking that comes from a psychoanalytic theoretical stance is the concept of maternal reverie (Bion, 1962). Wilfred Bion (1897­1979) would regard this as a necessary factor in the healthy development of the self-sensation of the baby; when maternal reverie breaks down ­ for example, in puerperal depression ­ the baby experiences this as distress. Problem-solving is defined as the set of cognitive processes that we apply to reach a goal when we must overcome obstacles to reach that goal, and reasoning is the cognitive process that we use to make inferences from knowledge and to draw conclusions. These aspects of thinking are distinct but related, so that reasoning can be involved in problem-solving (Smith and Kosslyn, 2007). Strategies for problems involve the use of heuristics, that is, rules of thumb that usually give the correct answer. Analogic reasoning involves the application of solutions to already known problems to new problems with similar characteristics. For example, if you lose the keys to your locked briefcase, you can apply the knowledge to this new problem that sharp-ended implements can be used to open padlocks. Inductive reasoning depends on the use of specific known instances to draw an inference about unknown instances. Commonly, this is formulated as generalizing from a single instance to all instances or from some members of a category known to have a given property to other instances of that category. Deductive reasoning involves an argument in which if the premises are true, the conclusion cannot be false. This is usually studied by way of syllogism: (a) all Martians are green, (b) my father is a Martian and (c) my father is green. This is the capacity for abstraction ­ the ability to theorize about the world ­ and it includes the categorization of objects or events in the world and the clarification of the concepts that determine the category or class under investigation. Superficially, these systems do not seem relevant to our understanding of the kinds of problems that are demonstrated in abnormalities of thinking but closer examination shows that they are likely to be important and relevant as they come under scrutiny in psychiatric disorders. Kahneman (2011) summarizes the evidence for the involvement of two cognitive systems in decisionmaking: System 1, which operates automatically and quickly with little or no effort and no sense of voluntary control; and System 2, which allocates attention to the effortful mental activities that demand it, including complex computations. The operations of System 2 are said to be associated with subjective experience of agency, choice and concentration. In an earlier paper, Tversky and Kahneman (1974) argued that in situations where a judgement is made under conditions of uncertainty, certain heuristics are at play and often lead to errors of judgement. These are the representativeness heuristic, the availability heuristic, and the adjustment and anchoring heuristic. Representativeness, for example, refers to how similarity to a class of objects or events, in the absence of additional information biases judgements and hence resulting in errors of judgement. Availability refers to the degree to which the probability of an event occurring is determined by the ease with which instances or occurrences can be brought to mind. It is obvious that abnormalities in the use of these heuristics probably have a role either in the development of delusions or the maintenance of abnormal beliefs. System 2 articulates judgements and makes choices, but it often endorses or rationalizes ideas and feelings that were generated by System 1. You may not know that you are optimistic about a project because something about its leader reminds you of your beloved sister, or that you dislike a person who looks vaguely like your dentist. If asked for an explanation, however, you will search your memory for presentable reasons and will certainly find some. The mass of possible associations resulting from a psychic event is called a constellation. There are an enormous number of possible associations, but thinking usually proceeds in a definite direction for various immediate and compelling reasons. This consistent flow of thinking towards its goal is ascribed to the determining tendency (Jaspers). The idea of associations is not intended to imply that one psychological event evokes another by an automatic, unintelligent, nonverbal reflex but that the thought, which may be expressed verbally or not, is a concept that results in the formation of a number of other concepts, one of which is given prominence by operation of the determining tendency. This model is conjectural but has some value in allowing description of the abnormalities of thinking and speech that occur in mental illness. In other words, the association of ideas is not random but is built on past experiences and is determined by memory functions. To develop the metaphor, thoughts are capable of acceleration and slowing, of eddies and calms, of precipitous falls, of increased volume of flow, of blockages. This analogy should not be taken too far because it is without neurophysiologic basis, but it is useful for examining certain abnormalities and is based on subjective experience. In this, there is a logical connection between each of two sequential ideas expressed. It is continuously changing because of the effect of frivolous affect and a very high degree of distractibility. The speed of forming such associations, and therefore of the pattern of thought, is grossly accelerated. Here is an example of such flight of ideas from a female patient, aged 45, with mania. Markedly different from the manic flight of ideas with pressure of speech and multiple but linked association is the confusion psychosis described by Fish (1962). In the excited form of this, incoherent pressure of speech is prominent, the context of which is out of keeping with the situation. In the inhibited state of confusion psychosis, there is poverty of speech, almost mutism. There may also be perplexity, ideas of reference, ideas of significance, illusions and hallucinations ­ auditory, visual or somatic. This is usually a cycloid psychosis in its presentation, and other features of manic-depressive psychosis may be present. The patient is likely to show little initiative and to begin neither planning nor spontaneous activity. When asked a question, he will ponder it, but as no thought comes to him, he makes no response. He has difficulty making decisions and concentrating; there is loss of clarity of thought and poor registration of those events he needs to remember. Depression, although usually associated with retardation of thought, may occur with agitation; there may be a complex situation with impaired concentration from retardation and a subjective experience of restless, anxious thoughts. Thus Sutherland (1976), a middleaged psychologist describing his own mental illness, said, I contemplated throwing myself off the cross-Channel ferry. I revisited many of the places I had once loved: the Museo Nazionale with its magnificent mosaics pillaged from Pompeii, Pompeii itself and Capri. None of them evoked a spark of interest ­ I stared listlessly and uncomprehendingly at the pictures in the museum with harrowing thoughts still racing in my mind. I could not guide the children round Pompeii, since I could not concentrate sufficiently to follow the plan. In circumstantial thinking, the slow stream of thought is not impeded by affect but by a defect of intellectual grasp, a failure of differentiation of the figure from ground. Characteristically, this occurs in patients with epilepsy, and it is seen in other organic states and in mental retardation. On being asked a question, circumstantial thought is shown by the patient in a reply that contains a great welter of unnecessary detail, obscuring and impeding the answer to the question. He even has to explain and apologize for these digressions before he can get back to moving towards the goal. However, the determining tendency remains, and he does eventually answer the question. These processes (and others) occur together to give the patient a feeling of confusion and bewilderment. He is likely to complain of feeling bemused, to be lacking in concentration and to be slightly apprehensive of he knows not what. He cannot precisely describe his altered thinking and consequent changes in speech. With derailment, the subject is unable to link the ideas and describes a change in his direction of thinking. These form links that cannot be seen as a logical progression from their constituent origins towards the goal of thought. A female patient with schizophrenia, aged 38, wrote the following: Two men are controlling the brain through telethapy [sic] or by means of ways of the spirit who open and closes the back channels of my brain releasing words and holding back the truth, by no means will I speak but will answer only to written questions by means of writing, knowing full well the channels of my brain is filtering and only half of what is the truth, also I knowing I am being read not only by a few but many very clever people but not at all acceptable they make people believe that I am some kind of miracle which I am not, I only hold the name Holyland which came to me by marrying Alfred Holyland, only by doing this do they wish to make some false stories of me coming from some special place which I have not. Thought Blocking Snapping off is the experience a patient with schizophrenia has of his chain of thought, quite unexpectedly and unintentionally, breaking off or ceasing. It is not caused by distraction by other thoughts, and, on introspecting, the patient can give no adequate explanation for it; it simply occurs. The patient describes his thoughts as being passively concentrated and compressed in his head. It becomes a headlong chase or dance of thoughts and has some of the characteristics of flight of ideas, but it also shows a schizophrenic quality of passivity, being controlled from outside. Perseveration (Chapter 5) is mentioned here as a disturbance of the flow of thinking. The patient retains a constellation of ideas long after they have ceased to be appropriate. An idea from that constellation that occurred in a previous sequence of thought is given in answer to a different question. It occurs in clear consciousness with no signs of organic disturbance of the brain. Judgement in other areas of life apart from the delusion can be preserved, and the very ingeniousness the patient uses to explain and defend his delusional belief demonstrates that his essential capacity to think logically is largely intact; only the falsely held belief, the false premise for subsequent beliefs appears disordered. For instance, not all those with delusions of persecution have any firsthand experience of being persecuted. It is an assumption about the world the patient inhabits, which he does not create by a process of logical conscious thought but from false premises. The mechanism underpinning the often spontaneous development of this false premise is yet to be understood. We can understand why the belief should be within that particular context (associated with his mother; related to interplanetary travel), but we cannot explain how the form of a primary delusion should have occurred. This is a fundamental distinction from delusion-like ideas (secondary delusions), which occur, for example, in affective psychoses. In the latter, we can see the content being progressively influenced by the changing mood state so that, eventually, the false Disturbance of Judgement A judgement is a thought that expresses a view of reality. To assess whether it is disturbed or not, one needs to measure it against objective fact. This can be difficult, perhaps requiring consultation with an expert in the same field as the patient. But the opinion that his judgement was disturbed would be confirmed if he had suddenly become convinced about his royalty when a psychiatric nurse had commented to him about the tattoos on his arm, or if he were also found to be hoarding pebbles and dead spiders in an old tobacco tin.

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The patient will quite quickly tire of the effort required to answer questions that are aimed at establishing the phenomenological status of subjective experiences blood pressure is determined by labetalol 100 mg with visa. It is important for the examiner to distinguish clearly between observations and inferences blood pressure medication make you gain weight labetalol 100 mg free shipping. The medical classification of diseases allows a cluster of symptoms to be brought under a single term that embodies the essence of a given condition hypertension with kidney disease buy labetalol uk. But there are disadvantages blood pressure medication list a-z buy cheap labetalol on line, including the unreliability of diagnostic terms as well as the risk of undue labelling and the associated stigma of a psychiatric diagnosis blood pressure medication depression labetalol 100 mg buy. It is central to the work of a professional that her first task is to carefully collect information so that she knows exactly what clinical problem confronts her within her professional competence and therefore what action would be appropriate; this is what diagnosis implies. It is true that for many common medical diseases such as diabetes, the diagnostic term refers to underlying demonstrable pathophysiology for which independent markers exist, such as blood sugar levels. In psychiatry, practically all the major disorders are still recognized at a syndromal level, that is, by the cluster of signs and symptoms that are thought to be typical of the given disease. The diagnostic term does not, as yet, refer to any well-described pathophysiology or indeed to any independent or reliable marker. This is a significant problem for the status of psychiatric diseases as bona fide medical diseases. In psychiatry, a multifactorial approach to the understanding of disorder is the rule rather than the exception. This means that a narrow diagnosis, in purely organic or purely behavioural terms, is inadequate. The diagnosis needs to be made in the context of an understanding of the biological, psychological and social antecedents, which in turn determine the biological, psychological and social management of the condition. The Psychiatric History this account is chiefly interested in the way that taking the history sheds light on the mental state. The nature and type of referral is noted and recorded, for example from a general practitioner as an urgent problem, from a solicitor for a court report and so on. A chronologic account of the present illness reveals how the patient regards the development of his symptoms as well as giving information on the actual history. It is appropriate at this point to note psychiatric symptoms of which the patient has been aware in the past but for which he has never consulted a doctor or received treatment. They may have relevance in the total picture of how the illness developed, and it is known that the majority of people with psychiatric conditions of clinical severity do not seek medical consultation, let alone come to the attention of a psychiatrist (Andrews et al. The patient feels it to be innately reasonable to describe chronologically and meticulously his previous illnesses, operations and accidents. He also will appreciate the logic of giving details of hospital and general practice treatment for mental illness and will usually give accurate information with regard to dates, duration, nature of treatment, in what hospital and whether he was an inpatient or outpatient. Treatment received from the family doctor is recalled less well; the dates are less reliable, and often the patient does not know the nature of the treatment or what it was for. History of mental illness, suicide, nature of treatment and so on is relevant for the first-degree relatives (those sharing 50% of the genetic material with the patient: parents, siblings, children) and more distant relatives. Relationships between individual members of the family are described, as are the general emotional atmosphere and social and financial problems. The occupations of different family members give information about the social context; a record of health may be relevant, as may a description of their personalities. The factual details of these stages need to be recorded, as do the way they have influenced the personality development and attitudes of the patient, how he feels about them, how he has related to other people (for example, teachers and workmates) and how all these details may be connected to the psychiatric condition. So although it is important to record the facts, the meanings and understanding that patients have of the trajectory of their life all communicate something that enriches the clinical encounter, and potentially make possible a deeper doctor­patient relationship that should be satisfying for both doctor and patient. Premorbid, Previous or Usual Personality Assessment of personality is the most complex and problematic task that a psychiatrist faces. First, the examiner asks the patient to describe in detail his relationships with other people, his interests and his activities. Second, the examiner studies the way in which the patient reacts to the examiner in the interview situation. Third, the examiner tries to help the patient describe and demonstrate what he, the patient, is like as a person; how he feels inside himself in different situations; and his interests, goals and standards. Personality assessment is not the exclusive preserve of psychiatrists or psychologists, but an important learned skill of many professionals who deal with people ­ for example, schoolteachers, lawyers and even bank managers, although their terminology is different. Personality is that part of a person, excepting his physical characteristics, that makes him individual and unique, that is, different from other people. If a clinician can attempt to predict how a patient will react in hypothetical situations, what his behaviour will be in particular circumstances, then the basis of that prediction is founded on a reasonable and relatively accurate evaluation of his personality. Indeed, no description can exhaust the rich and complex essence of any individual person. It is a truism that human beings are full of 2 Eliciting the Symptoms of Mental Illness 23 potential and continue to surprise and astonish with the capacity for change, for transformation and for moral conduct including virtues and vices, which may not be readily identifiable on first contact. Categorization into normal and abnormal personality requires a further level of abstraction. Normal, an ordinary word in everyday use, needs to be used more rigorously in this context (see Chapter 1). In medicine, the term normal is often used to denote a statistical norm, that is, what occurs in the majority of people. This comparison presupposes that the ideal notion, sometimes termed a trait, varies in a dimensional manner among people. The implication is that abnormal personality has some characteristics that are either overdeveloped or underdeveloped compared with an ideal notion, to such an extent as to significantly deviate from the mass of people. In other words, abnormalities of personality are differences of degree; the deviant traits are shared in common with others but exaggerated in expression. In the clinical interview, there are various areas of dialogue with the patient that are likely to lead to useful information for depicting the detail and colouring of his personality ­ the personality type. What sort of friendships does he form, with what sort of people, and are they close-knit or superficial, with an exclusive few or an unlimited crowd If he is interested in sport, it is useful to know if he can feel partisan and involved and also whether he is a participant or an observer. Enquiry is made of his preference and interests in films and literature: how he observes, criticizes and enjoys the material. Religion requires more than a single word designating religious affiliation in the case notes. Character traits imply a detailed adjectival list, for example, irritable, reserved, fussy and so on. It will, of course, be helpful to corroborate his description with an account from another person. Enquiry is made about his attitudes and values; his views about himself and his body; how he regards others close to him; his more general social values in religion, morality, politics and economics; how he feels events occur and can be made to occur. Drive and energy and the way these are expressed in ambition, lethargy, effectiveness and persistence are all important aspects of personality. Study of his fantasy life is made: the frequency and duration of daydreams and their content; whether these are goal-directed and realistic or dissociated from any expectation of fulfillment. Dreams and other supposed signs of unconscious psychic activity are useful, especially when the subject attempts to interpret them. We may comment on his habits of ingestion, inhalation and excretion ­ whether they are regular and to what extent he depends on this regularity. Is there an indication that there should be a more detailed history and exploration of current habits of eating, smoking, drinking alcohol and taking other drugs As the patient unfolds the facets of his personality, so the overall emphases that he puts on areas of description become illuminating in understanding him as a whole person. However, certain characteristics tend to occur together and are of clinical significance. Allocation to a particular category of personality disorder is made on the relative predominance of these different character traits. Having decided that a certain definite trait or traits are present in this individual to an abnormal extent, does the abnormality of personality cause the person himself or other people to suffer More than one abnormal type of personality may be present in any individual; they are not mutually exclusive. In formulating the psychiatric history and evaluation of mental state, comment on premorbid personality should always be made, even if it is only to state that due to the ravages of the mental illness, it is impossible to accurately assess premorbid state. The predominant traits should be described, preferably with verbatim comments of the patient to illustrate them. The interviewer should decide whether these traits are there to a significantly abnormal extent and, if so, whether this amounts to personality disorder. The mental state examination is guided by the same principles and communication skills as any other clinical interview (Box 2. It is dependent on facility with language because that is the tool with which psychiatric practice is conducted. These include the use of summary statements to summarize what the clinician has made of what the patient is saying and to provide the opportunity for the patient to correct any misapprehension on the part of the clinician. Are there things that you wanted to tell me that you have not yet had the opportunity to bring up Further practical advice on conducting the psychiatric examination is found in Leff and Isaacs (1990). As the interviewer asks each question, she should be thinking what the possible answers to that question could be from a reasonable person in this context. In everyday conversations, one is conditioned to avoid asking embarrassing questions and so, when someone makes an odd remark, the tendency is to fill in the meaning of the response to make it ordinary, sensible and avoid asking further questions in this area. One of the difficulties for the aspiring phenomenologist is to know when to pursue what the patient reveals in more detail ­ that is, when to make the incision for the psychopathological operation. It is important to be certain that both clinician and patient are using words in the same sense. He may be largely oblivious of the form of the communication as auditory and hallucinatory because he is totally absorbed with its content (an order telling him to go to Strasbourg and preach). A symptom may not be pathognomonic of a certain condition but nevertheless is predominantly found with that illness. If this is not the diagnosis, she has some difficult explaining to do to justify the use of that word. Is it really perseveration or just the repetitious use of words and phrases in a person who has intellectual disability and shows poverty of expression To avoid misunderstanding, it is best to use longer descriptions until the interviewer is sure that the symptom is truly present. Observation of the appearance and behaviour of the patient is an invaluable supplement to his selfdescription. The observations of others, and at times other than the interview, need to be taken into account. As the interview proceeds, the interviewer more definitely pursues her real intention of finding out the meaning behind the words the patient uses. His own account may be a blind to prevent other people, or even himself, from seeing how bad he really feels. Observation may reveal white lines across the knuckles of an anxious person talking about what upsets him most and which renders him impotently angry. Empathy allows the observer to employ his own capacity for emotion as a diagnostic and therapeutic tool. Training and experience are essential for knowing in which areas delving will be rewarded with useful information; how to ask questions that are comprehensible to patients of different verbal abilities and cultural backgrounds and that will result in appropriate answers; and how to avoid damaging the patient still further with welldirected but blunt questions that are likely to be perceived as brutal. Observation and empathy must always be used together in eliciting the mental state. Note also the double meaning of the word observant: it means not only noticing what is going on around oneself but also conforming with the cultural mores of the immediate society. Systematic Enquiry the appearance and behaviour of the patient are observed for the clinical medical information they carry. From his posture, gestures, facial expression and so on, he betrays his state of emotion, providing information about his personality and his attitude to the observer and to others despite his silence or contradictory verbal communication. Posture can be revealing to the acute observer, for instance, the pharaonic posture and the slow deliberate movements of head and neck of the patient with schizophrenia. If the patient is mute, observed behaviour is the only source of clinical information, but the importance of observation needs to be stressed also for those patients who do speak. Thought disorder and the interpretation of abnormalities in the use of words, syntax and association of ideas are discussed in more detail in Chapter 9. As the interviewer enquires about and forms her own assessment of mood, she has three areas for exploration: subjective and objective description of mood and evaluation of rapport. Mood can be studied for its direction (depression or elation), its consistency (stable or labile), its appropriateness, its amplitude and the degree of discrepancy between subjective description and objective observation. The doctor observes the patient and picks up available cues for mood, relating these to her experience with other patients and other people through her life, and ultimately to her knowledge of her own affective state. To do this, the doctor requires clinical experience and an objectivity in which she knows how she reacts to , and communicates with, many different sorts of people. The ideas and beliefs the patient holds and abnormalities of perception he experiences are ascertained and explored during the interview. In ordinary conversation, there is a great deal of filling in or editing to eliminate the deficiencies of communication. There is a tendency for those coming new to dialogue with the mentally ill to bring into their conversation these social niceties that are used to save embarrassment. To the patient, subjectively, a delusion is indistinguishable from any other idea she has, a hallucination is indistinguishable from any other normal perception. Skill 2 Eliciting the Symptoms of Mental Illness 27 in interviewing therefore comes very much in knowing when to look for a delusion and how to make a clear distinction between what the person describes as experience and what it reveals phenomenologically. Passivity or delusions of control, obsessions, compulsions and depersonalization may be obvious or only made plain with some difficulty. When passivity, for example, is suspected, it is generally best to follow up the clues right away and decide once and for all whether the symptom is present. Assessment of the cognitive state includes, at least briefly, testing for orientation, attention, concentration and memory.

He would often jump like a startled rabbit when he realized he was being addressed anyway blood pressure chart resting labetalol 100 mg purchase on-line, and I think that by the time he had recovered and collected himself from that excel blood pressure chart labetalol 100 mg purchase amex, the first half of my sentence had gone and all he heard was the second half blood pressure chart in europe labetalol 100 mg discount. Certainly I found that by inserting a little preliminary padding blood pressure medication and fatigue generic labetalol 100 mg buy on-line, I got a more competent response blood pressure in children buy labetalol 100 mg amex. Frith (1992) hypothesizes that the mechanism for delusions of control was also responsible for the thought or language abnormality in schizophrenia. In this scheme, it is a failure of self-monitoring that is responsible for thought or language disorder. Thus the patient is unable to edit out irrelevant or perseverating phrases, and this results in poor communication. There is also the related possibility that the fundamental problem is in planning. He showed that the performance of patients with schizophrenia was very poor compared with that of normal subjects, but they were not prone to distraction by auditory or visual external stimuli in the way that normal people were. Hebephrenic patients especially showed less distraction and also poor perception and recall of visual information. Hebephrenic patients were considered to have an inability to sweep out irrelevant extraneous information. Liddle (2001) defines the disorganization syndrome as consisting of disjointed thought, emotion and behaviour. However, the cardinal symptoms are formal thought disorder, inappropriate affect and bizarre, erratic behaviour. He concludes that disorganization is associated with slowed performance in neuropsychological tasks that demand selection between competing responses or with errors of commission in tasks that require suppression of an inappropriate response. In his view, this suggests that the disorganization found in schizophrenia derives from impairment of the neural circuits responsible for response selection and inhibition. The circuits involved are the ventrolateral frontal cortex, the left superior temporal gyrus and the adjacent inferior parietal lobule. The subjective disturbance in thinking in schizophrenia is experienced as passivity. The patient with schizophrenia experiences his thoughts as foreign or alien, not emanating from himself and not within his control. There is a breakdown in the way he thinks of the boundary between himself and the outside world, so that he can no longer accurately discriminate between the two. He may describe passivity of thought, thought withdrawal, thought insertion and/ or thought broadcasting; these are first-rank symptoms Delusions of control Delusions of control Delusions of control Delusions of alien penetration Schneider (1959) Wing et al. The patient may describe sharing his thoughts with other people or his thoughts being controlled or influenced from outside himself. These delusions of control are often associated with delusional explanations of how his thinking could be controlled, for example, with the use of electronic devices, computers or telepathy. Thought insertion is described, in which he believes that his thoughts have been placed there from outside himself. Correspondingly, he may describe his thoughts being taken away from himself against his will: thought withdrawal. This may be given as an 9 Disorder of the Thinking Process 141 explanation for thought blocking when the thoughts stop and the mind suddenly goes completely blank. Thought insertion and withdrawal are first-rank symptoms of schizophrenia; thought blocking is not because it is difficult to decide whether it is truly thought blocking, some form of retardation or other difficulty with thinking, and blocking is also subjectively similar to epileptic absences. Thought broadcasting occurs in schizophrenia when the patient describes his thoughts as leaving himself and being diffused widely out of his control. The patient knows that they are his thoughts, yet he hears them audibly while he is thinking them, or just before or after thinking them. This is, of course, a disorder of perception, an auditory hallucination (Chapter 7). Earlier in the chapter, we discussed fusion, mixing, derailment and crowding of thought, all of which occur in schizophrenia. The resultant confusion causes a loss of ability to think clearly, often described in terms of passivity. The patient may feel that his brain is replaced by cotton wool or convoluted rubber. First-Rank Symptoms of Schizophrenia First-rank symptoms of schizophrenia are discussed in this section for convenience because many of them are examples of disorder of control or possession of thoughts. According to Schneider, the presence of one or more first-rank symptoms in the absence of organic disease can be used as positive evidence for schizophrenia. These symptoms of first rank are not a comprehensive list of the clinical features of schizophrenia, for the changes in affect, volition and motor activity that may occur in the condition are not included, and many other types of delusion, hallucination and disorder of thinking also occur in schizophrenia. For a symptom to be regarded as first rank, it must have the following characteristics. There are some symptoms that occur only in schizophrenia but occur too rarely to be of practical use as first-rank symptoms. There are many features that are characteristic of schizophrenia but may also occur in other conditions, for example, unspecified auditory hallucinations, poverty of affect and overinclusive thinking. There are some symptoms that occur only in schizophrenia, but there is too much scope for argument as to whether it is, or is not, this precise symptom for it to be valued as of first rank. Some clinicians may regard a particular belief of the patient as primary delusion, whereas others do not. Although first-rank symptoms are used as a diagnostic checklist, a patient who exhibits seven of them is not more severely ill than someone who shows three. To elicit them requires considerable clinical experience; they cannot be collected quantitatively by riding past the patient on a bicycle! The whole process requires a dextrous use of the phenomenologic method as described in Chapter 1. In clinical practice, the eliciting of first-rank symptoms could best be seen as a means of deciding the degree of certainty that may be attached to the diagnosis. If first-rank symptoms are found, then, in the absence of clear organic pathology, one can reckon that the diagnosis has been confirmed. Some of the first-rank symptoms are found to be less reliable at follow-up than others as indicators of schizophrenia, for example, voices heard arguing (Mellor et al. One of the advantages of first-rank symptoms as a diagnostic tool is that, because of their emphasis on form rather than content, a person who is feigning mental illness is unlikely to produce them. They therefore have a subsidiary use as a method of distinguishing between true and simulated psychosis, for example, in prisoners. Despite the value of firstrank symptoms indicating schizophrenia when they are present, there are undoubtedly patients in whom they cannot be elicited; schizophrenia still remains, to some extent, a diagnosis of exclusion (Carpenter and Buchanan, 1994). In British usage, the symptom sometimes carries its German name, Gedankenlautwerden, or its French one, écho de pensées. The patient may hear people repeating his thoughts out loud just after he has thought them, answering his thoughts, talking about them having said them audibly or saying aloud what he is about to think so that his thoughts repeat the voices. He often becomes very upset at the gross intrusion into his privacy and concerned that he cannot maintain control of any part of himself, not even his thoughts. The volume was slightly lower than that of normal conversation and could be heard equally well with either ear. He immediately experienced whatever the voice was saying as his own thoughts, to the exclusion of all other thoughts. The patient usually features in the third person in the content of these arguing voices. The time sequence of the commentary may be such that it the only type of delusion that is regarded as of first rank is a delusional perception, that is, a normal perception delusionally interpreted and regarded as being highly significant to the patient (Chapter 8). Examples of delusional percept, and of other first-rank symptoms as follows, are cited by Mellor (1970, p. And because of this they (all the women) are all born different with their private parts back to front. These are audible thoughts, voices heard arguing and voices giving a running commentary. The patient does not know that his particular perception is unique, that other people do not share his perceptual experience. So the interviewer has the difficulty of asking questions about something of which she has no personal experience; the patient has to answer questions that, because of his situation, seem to have no point. The abnormal thing about voices commenting is that they should be experienced as perceptions and as coming from outside the self; many normal people have thoughts, recognized as their own and coming from inside themselves, commenting on their actions: A 41-year-old housewife heard a voice coming from the house across the road. The voice went on incessantly in a flat monotone describing everything she was doing, with an admixture of critical comments. The terms disorders of passivity, made experiences, delusions of control and disorders of personal activity are, in practice, synonymous and interchangeable. The event is experienced as alien by the patient in that it is not experienced by the patient as his own but inserted into the self from outside. Passivity experiences of thinking occur as thought withdrawal, thought insertion or thought broadcasting. In thought withdrawal, it is believed by the patient that his thoughts are in some way being taken out of his mind; he has some feeling of loss resulting from this process. As in thought withdrawal, there is clearly a disturbance in the selfimage, and especially in the boundary between what is self and what is not self; thoughts that have in fact arisen inside himself are considered to have been inserted into his thinking from outside. He treats my mind like a screen and flashes his thoughts onto it like you flash a picture. Everyone around has only to pass the tape through their mind and they know my thoughts. Passivity of emotion occurs when the affect that the patient experiences does not seem to him to be his own. They project upon me laughter, for no reason, and you have no idea how terrible it is to laugh and look happy and know it is not your, but their reaction. A 26-year-old engineer emptied the contents of a urine bottle over the ward dinner trolley. It was not my feeling, it came into me from the X-ray department, that was why I was sent there for implants yesterday. I sit there wanting them to move, and they are quite independent, what they do is nothing to do with me. It is not the same as haptic hallucination, but it is a delusional belief that the body is being influenced from outside the self. For example, a kinaesthetic hallucination occurred, with a passivity experience given as explanation, by a patient who felt that his hand was being drawn up to his face. Somatic passivity may also occur in association with a normal percept; these experiences are quite common in schizophrenia. A 38-year-old man had jumped from a bedroom window, injuring his right knee which was very painful. The method of ascertaining and measuring schizophrenic symptoms, among other symptoms, developed by Wing et al. The Present State Examination provides the clinician with a means of ascertaining which symptoms and syndromes are present. Koehler (1979), in a review of the way various authors describe the presence of first-rank symptoms in the English literature, considered that they were sometimes used in a very narrow and sometimes a very wide sense. He makes the distinction between alienation of thought and influence of thought and makes a plea for clear statements on the boundary criteria for firstrank symptoms and the nosologic bias attached to the phenomena. From the preceding quoted examples of Mellor, alienation is necessary ­ that is, a delusion of control and not just an experience of influence of thought. Similarly, thought broadcasting would be regarded as of first rank when the patient describes this as having occurred outside his control, irrespective of whether these thoughts are shared with others. Thus this chapter is recommending a narrow use of first-rank 9 Disorder of the Thinking Process 145 symptoms. First-rank symptoms have been employed to establish the diagnosis; they are not necessarily useful prognostically (Bland and Orn, 1980). This difference between alienation or experience of control and influence can be exemplified by the schizophrenic symptom of thought insertion. The patient experiencing passivity believes that by some concrete process, the boundaries of his self involving thinking are so invaded that his mother is actually placing thoughts inside his head (Chapter 12), so that he thinks her thoughts, or perhaps she, is thinking inside him. A reliable clinical technique for investigation of the experienced reality and unreality qualities connected with everyday life experiences in psychotic and non-psychotic persons. Changes of diagnosis in schizophrenia and first rank symptoms: an eight year follow-up. Dichotic stimulation as a method of assessing the disorder of attention of an overinclusive schizophrenic patient. Alternatively, the original script may be perfect, but the typist may be unskilled, making typing errors in the copy and thus distorting it. Finally, it is possible for an inefficient typist to add errors to an already incoherent script. Unfortunately, the psychopathologist can observe only the copy (language utterances): he cannot examine the script (the thought). In general most theorists concerned with schizophrenic language have accepted the first of the three alternatives, namely that a good typist is transcribing a deviant script. Most clinicians have taken the view that language closely mirrors thought and see the primary abnormality as the thinking disorder (Beveridge, 1985). Disordered language is then seen as merely a reflection of this underlying disturbance, with diagnosis of thought disorder only possible on the basis of what the patient says. Some of the more recent linguistic theories used for the analysis of schizophrenic speech contradict the primacy of thinking. The assumption that language directly mirrors thought can be challenged (Newby, 1995). One tradition argues that language itself structures thinking and concepts and determines how the world is understood. This view derives from the works of Edward Sapir (1884­1939) and Benjamin Whorf (1897­1941).

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