ECT Studies

Go straight to the journals and read more about ECT and its effects, as well as the issue of informed consent for electroconvulsive therapy. One of the biggest criticisms about contemporary ECT research is that the leading researchers are those who make their living from ECT - writing papers, books, and yes, owning the companies that manufacture not only the machinery, but the accessories (mouth guards, and so on).

The leading names in the ECT industry, to aid your reading, plus the companies they are affiliated with:

Max Fink (Somatics; Max is considered the grandfather of American ECT, and thinks it's perfectly okay to give the treatments to toddlers!)
Richard Abrams (Somatics, plus writes the bible on ECT)
Charles Kellner (Somatics, Mecta)
Harold Sackeim (Mecta)

ECT Statistics

If you're confused by the studies, read the statistics. You can read the original numbers as collected and make your own conclusions. Unfortunately, only a few states collect data on ECT. ECT activists are demanding that a federal law be enacted to make data collection mandatory. As it stands, even the statement you hear constantly, that "100,000 to 200,000 persons each year undergo ECT" is simply a guesstimate. Nobody really knows, because data collection is not done.

If you would like to see mandatory recordkeeping concerning ECT, write your congress person and write to the FDA. Vermont just passed a new law that will require recordkeeping...so we're making progress!

Official Statements

Here you will find official statements from a variety of organizations and agencies. These statements represent "official" views on electroconvulsive therapy. You will also be able to read about the politics surrounding the issuance of some of these statements - some of these are highly controversial.

Others

Learn more about CTIP, The Committee for Truth In Psychiatry, the world's largest shock survivor organization. You can join online for free!

next: ECT, The Thymatron and Dr. Richard Abrams
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

Welcome to SHOCKED! ECT

This site is a comprehensive collection of information about ECT, electroconvulsive therapy (aka electroshock, shock therapy).

I started this website in 1995, after having had ECT myself. I had many questions that were not answered by my health care providers, and I have found that too often, patients are not given adequate information. This website is an attempt to bridge that information gap and to help you make a more informed decision.

I am not affiliated with the Church of Scientology, nor am I anti-psychiatry. Individuals with vested interests in the ECT industry continually make these claims, in attempts to divert attention from the real issues. I have repeatedly battled attempts to shut this website down, threats of lawsuits, hacking attempts, and more.

It is my goal to continue to battle all attempts to shut down Shocked! ECT and to work towards reform in the industry, more complete ECT research, as well as battle the use of forced ECT against patients who do not want to have ECT.

I hope that Shocked! ECT will provide you with enough information and support so that you may make a more informed decision about having electroconvulsive therapy. The choice to have electroshock is a personal one that should be yours, and should be based on a variety of sources and points of view about ECT.

Contents:

• Why I Created The Shocked! ECT Website
• Does Electroconvulsive Therapy Prevent Suicide?
• ECT and Non-Memory Cognition
• Effects of Stimulus Intensity and Electrode Placement
• Electroconvulsive Therapy Background Paper
• How Shock Therapy Works
• More Children Undergo Shock Therapy
• Patient Satisfaction With Electroconvulsive Therapy
• Shock Therapy Cuts Hospital Costs
• Shock Therapy: Positive and Negative Charges
• Shock Treatment!
• Shock Treatment Survivor Continues To Speak Out
• Speak Out Against Shock (ECT)
• Adverse Psychological Effects of ECT
• Bilateral and Unilateral ECT: Effects on Verbal and Nonverbal Memory
• Can ECT Permanently Harm the Brain?
• CHAPTER 13: Management of Patient's Post-ECT Course
• Chapter 2: 2.1. - Indications for Use of ECT
• Chapter 5. Adverse Effects
• Chapter 6. Pre-ECT Evaluation
• Chapter 8: Consent for ECT
• Continuation Pharmacotherapy in the Prevention of Relapse Following Electroconvulsive Therapy
• Debate Rages Over Safety of ECT, or Shock Therapy, Used on Elderly
• ECT and Brain Damage
• ECT and Informed Consent
• ECT Stimulus Intensity, Seizure Threshold and Seizure Duration
• ECT Studies, Statistics, Reports
• EEG Monitoring in ECT: A Guide to Treatment Efficacy
• Electroconvulsive Therapy During Pregnancy
• Electroconvulsive Therapy (ECT)
• Electroconvulsive Therapy for Schizophrenia
• Electroshock As Head Injury
• Forced ECT
• Online Audio and Videos on ECT, Electroconvulsive Therapy
• Participate In An ECT Evaluation
• Patients Often Aren't Informed of Danger of ECT
• Psychopathology of Frontal Lobe Syndromes
• Recommendations for Electroconvulsive Therapy (ECT) Consumer Guide
• Shock Treatment Victim Supports ECT Lawsuit
• What Is SAMe?

next: Why I Created The Shocked! ECT Website
~ depression library articles
~ all articles on depression

Does ECT cause brain damage?

Dr. John Breeding gives testimony to the New York State Assembly hearings on electroshock, May 2001. Dr. Breeding says ECT *always* causes brain damage.

Writing in Nature, Dr. Peter Sterling says: ECT damage is easy to find if you look for it, and says that ECT practitioners don't find any memory loss because they don't test for it.

What do they really think?
In public, psychiatrists say that ECT is safe. But what do they say to each other?

What does ECT do to the brain?
An in-depth look at what the brain goes through during ECT.

Do neurologists know something the rest of us haven't yet figured out?

Does ECT cause brain damage?
This MD says yes, in an article on ECT and EEGs.

Can ECT permanently harm the brain? This article says it has, and can, cause permanent brain pathology.

Dr. John Friedberg, writing in the American Journal of Psychiatry, takes an in-depth look at the effects of ECT on the brain and questions, "Do we really want to offer brain damage to our patients?"

A lengthy chronology on epilepsy and ECT, something denied by the ECT industry. Yet there are many documented cases of ECT-induced epilepsy.

Psychopathology of Frontal Lobe Syndrome
This article from Seminars in Neurology details frontal lobe syndrome, which many neurologists believe is one of the side effects of ECT. The researcher explains how this injury is often difficult to measure clinically, but how damaging the results are to the person who has it.

Neuroscientist testimony on ECT brain effects
From Dr. Peter Sterling, a neuroscientist at the University of Pennsylvania School of Medicine, this remarkable testimony and review of the available studies on the effects of electroconvulsive therapy on the human brain. Analyzing years of data, including private communications with one of the leading researchers of our time on memory loss from ECT (Janis), Sterling strongly concludes that ECT does, in fact, cause organic brain damage, similar to that seen from the results of trauma or toxicity in the brain.

Neuropsychological assesment
This journal article from Dr. Alan E. Brooker, clinical neuropsychologist with the USAF, details the complexities of evaluating the function of the brain. What this shows is how extensive the measurements are when truly understanding how one's brain is working on a day-to-day basis.

ECT as head injury?
In a report for the National Head Injury Foundation, the case is made that ECT works by inducing the effects of head injury. This well-researched report highlights the work of many neurologists and psychiatrists who believe this is the mechanism of action of ECT, as well as case reports of patients. Included are some great tips on recovery.

Electroshock: Scientific, ethical and political issues
From Dr. Peter Breggin, this comprehensive article explains how ECT works as head trauma, and goes into the scientific, ethical and political ramifications of the controversial treatment. A Must Read!

Dr. Charles Kellner (Hall of Shame winner) says "There are now important carefully controlled studies with MRI brain scans before and after ECT showing conclusively that there is absolutely no structural brain damage." Here are those "carefully controlled studies." Judge for yourself. Are these proof of "absolutely" no brain damage?View the video

Quite a bit more on the issue of brain damage in the news section.

A new article about how ECT induces PTSD and what can be done to aid recovery, from David Armstrong. I strongly believe this is an effect of ECT that is almost always overlooked, so this is an important article to read! (PDF format - can get a free reader at Adobe.com if you don't already have it)

next: ECT and Informed Consent
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

The Committee for Truth in Psychiatry, or CTIP, is a national organization of over 500 former electric shock patients. None of us was truthfully informed about the nature or consequences of this treatment before consenting to it, and we have pooled our experience-gained knowledge to provide truthful information about it for future psychiatric patients.

Over the years, many individual recipients of "electroconvulsive therapy" (ECT) (shock treatment) have related their personal experiences, verbally or in writing, emphasizing whatever aspects were most important in each one's special circumstances. What the CTIP has done as a group is to highlight and emphasize the common demoninators in the shock experience. Accordingly, though our members differ widely in the details of their own stories, including how they got into ECT and how much good or (more often) harm it did them, we can agree on the most certain effects of ECT and that future patients should be informed of them before they give their consent to it.

Following are the most important points we make:

• If a person is in a state of physical suffering of nervous origin, ECT will almost certainly relieve it temporarily. ECT relaxes the nervous system and the relaxing effect lasts from a couple of days to a couple of months. Sometimes people stay well after the relaxing effect has worn off, but, typically, they quickly relapse.

• Regardless of any beneficial effect, there is always a permanently deleterious effect on memory. This consists of erasure of a good deal of pre-shock memory and dimming of more, and it frequently includes also a permanent reduction in retentiveness for post-shock experience and learning.

• These two effects in combination---the temporary feeling of well-being and the permanent harm to memory---imply that ECT "works" by damaging the brain. These are the classic symptoms of acute brain injury by any means---strokes, asphyxiation, concussion, carbon monoxide poisoning, etc. In all these events, the patient feels very well for a while but can't remember. If further evidence were needed of the principle at work in ECT's beneficial effect, it could be noted that the memory loss from ECT has always the distinctive pattern of brain damage forgetting (recent memories hardest hit) and that ECT is sometimes followed by other brain damage phenomena (examples common among our members are impairment of sense of direction and a touch of aphasia, or difficulty saying the words you meant to say).

As a vehicle for communicating these few salient points about ECT to future patients, we have incorporated them (along with other information) in a model ECT informed consent statement which we should like to see sponsored by the FDA or some governmental body. All CTIP members have endorsed the statement.

Origin, History, Format and Future

Our Committee was formed in l984, with 17 founding members, to participate in the Food and Drug Administration's regulatory proceedings concerning ECT.

FDA had classified the ECT device or shock machine in the highest risk class of medical devices, Class III, which classification earmarked ECT for a safety investigation; and the American Psychiatric Association (APA) had subsequently petitioned FDA to reclassify the device to Class II, which action would constitute recognizing ECT as a safe treatment without an investigation. The FDA was preparing to grant the APA's petition when the CTIP came in to oppose reclassification and to press for an investigation. We were confident that an impartial scientific investigation would confirm in physical terms what is apparent from ECT's emotional and memory effects: that it is inherently brain damaging.

Throughout the rest of the 1980s, the CTIP both enlarged its shock patient membership and also became the central contact for other individuals and organizations who urged an FDA investigation of shock treatment, including all fifty of the state Protection and Advocacy agencies.

Expansion of the CTIP was based on its informed consent statement. Any former shock patient who endorses it is a member. Membership imposes no duties or dues, but every endorsement stregthens the patient voice. And since we were bound together by agreement on the fundamental of the shock experience, we could operate without elected officers. Any member who chose to be active could speak, write, or deal with the FDA in the name of all.

With only such an informal kind of organization, we managed for six years to forestall action toward reclassification. Ultimately, however, the FDA bent to the stronger pressure from the psychiatrists and published in the Federal Register of September 5, 1990 a "proposal to reclassify" the ECT device to Class II. Since then, the classification (and investigation) have been "on hold", with no reclassification or investigation having yet taken place.

Regardless of when or in what direction the FDA may move, the CTIP is continuing to work for truthfully informed consent. The problem we alone address is that patients throughout the country are routinely misinformed and misled as to the results to be expected from shock treatment. At the same time, regulatory actions concerning ECT are under way in various state and local governments, instigated in some cases by ex-patients and in some cases by the electroshock industry. In any of these arenas, the opportunity exists for CTIP members to step forward and push for a requirement for truthful information, for they speak with the authority and credibility of a concerted voice of experience---a voice which grows stronger with the addition of each new member.

If you have had ECT, and if you would like to help protect future patients from consent by deception, we hope you will add the weight of your endorsement to our proposed ECT informed consent statement. Both electronic and snail-mail versions of the statement and membership form are available. If you have questions, please call or write the CTIP Director, Linda Andre, at PO Box 1214, New York, NY 10003, phone 212 NO-JOLTS.

Join CTIP online now!

Notice: Just to straighten out people who are confused: CTIP is NOT ect.org, and ect.org is not CTIP. They are two totally separate organizations. I am Juli Lawrence, and I run ect.org myself. There is no corporate sponsor and no men in black helicopters running things behind the scene (Dmitri is the black godwizard behind the curtain). Same deal with CTIP, except that it's run by Linda Andre and founded by the late Marylin Rice. I, Juli Lawrence, am a member of CTIP and offer this online information about it (plus the join form) as a service to electroshock survivors who wish to join. I consider Linda Andre a very dear friend of mine. I just wanted to clarify that this is not the official website of CTIP because a lot of people confuse this point.

next: Does Electroconvulsive Therapy Prevent Suicide?
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

Welcome to Shocked! ECT. Even though I sometimes take a lighthearted approach to the issue of electroconvulsive therapy (ECT), I consider it a serious issue, often shrouded in misinformation.

You will find information that is pro and con on the topic of ECT. I leave it to you to weed through the materials and choose for yourself. I hope that you find this information useful, and if you are considering ECT, you will have made an informed choice. As an ECT survivor, I wish you the best, and a full recovery from the beast known as mental illness.

I created Shocked! ECT in 1995 after having had ECT myself the year before and having a very bad result. It started simply, a way of sharing information with others who were searching for answers. It's grown into an extensive website with what I hope is comprehensive information that will offer support and provide some of the answers to many of your questions.

I receive a lot of email every day, from persons considering ECT, loved ones, and persons who have had ECT and don't understand what happened. They were given promises, and those promises were broken. Yet it never fails to astound me when I receive email full of the lies the industry continues to tell. I absolutely swear that out in the field, in modern day civilization, psychiatrists are telling their patients that ECT is the miracle cure, it will cure your mental illness, your migraines, and even Alzheimer's Disease. (That was even testified as fact in a court of law, and swallowed by a US judge, who then ordered forced ECT on a woman in her 80s.)

I am called many things by the ECT industry and proponents - a Scientologist, a nut case, anti-psychiatry zealot.

I am none of the above. I am a woman who was severely depressed (re-diagnosed as bipolar disorder during the ECT treatments) and had ECT in 1994. The ECT, according to my mother, lifted me from a depression into a brief silliness (the euphoric high that typically follows ECT), quickly followed by an even worse depression than before. And it left me with severe memory loss, and I believe some cognitive damage.

I'm interested in the people who say "But you're so articulate now, how could it have possibly been destructive?" My answer: You do not know me. You do not know what I was like before I had the ECT, and you do not know what I am like now. Do not pretend that you know what I feel, what I think or who I am. A few words on a website does not give you a picture of me, other than the picture I *choose* to present in public. Most people who know me, other than those EXTREMELY close to me never even knew I was depressed. I have a public face, and a private face, and the two are very different. I work very hard at maintaining the public face, and I have worked hard to recover from a very low point. I have never said I was brain dead, simply that there was damage.

It took me a year to emerge from the fog that resulted from the ECT. And it's taken six years to recover to the point that I am able to fully articulate what has happened. I have spent the last years reading the research, including the studies that ECT experts use to promote the treatment. Day by day, I grow more convinced that ECT is not an effective treatment, and that it does little more than provide a brief respite from depression, followed by despair and hopelessness.....and potential damage to the brain.

This website is not an attempt to dissuade anyone from having ECT. If you have chosen to have the treatment, I support your decision and wish you well. If you've come looking for information, I sincerely hope that you will find genuine sources of information presenting all sides of ECT, not just the public face that the industry presents. However, you will find plenty of pro-ECT information here, because I think it's important to look at this from every angle.

Yes, there are anecdotal stories that ECT is a miracle cure. And those are trotted out continually when proponents of the treatment try to deflect any negative information. Yet, when former patients come to the forefront to discuss their bad experiences, the proponents say their concerns aren't valid, that anecdotal information isn't worthy of recognition. Well, folks, you can't have it both ways. I believe that if you're going to listen to anecdotal information, you must listen to both sides, not just the "ECT saved my life" viewpoint. On the other hand, I do believe it's important to hear the happy endings as well. They are important. All of the voices of ECT are important, and should be heard...including mine.

I have been threatened and I have been harassed because of my views. I have had emails from fanatics that included viruses; pictures of mutilated animals with threats that I'm next; name calling (Scientologist, as well as words that are offensive to women); gifs saying f*** you wh***; and "orders" telling me to stop what I'm doing. People are now on notice that, from this point on, all emails like these will be publicly posted. You will see various threats of lawsuits posted around the site, and I will post all emails containing legal and any other kind of threat.

I will not submit to the powers that be, and I will be heard. I am continually called a Scientologist, and it makes me angry. I don't believe that my religious beliefs are anyone's business but my own, but for the record....I was raised a good Presbyterian and if I went to church today, that is the church I would choose.

I do have some goals regarding ECT and those include:

1. Regulation. As it stands, this treatment is not regulated. Devices are not tested until they are used in practice. And as we've seen with the recent MECTA lawsuit, consequences can be disastrous. Moreover, there's been no recall of this machine. How many of these machines are out there still being used?

I want statistics kept in every state. Currently, only four states - California, Massachusetts, Colorado, and Texas - maintain any sort of record keeping. Groups like NAMI and the APA oppose this, saying it adds a layer of red tape. Bullshit! It gives data to researchers on the number of patients receiving ECT, complication rates, and demographics. We don't even know the number of patients having ECT...any figures are estimates only.

Even very strongly pro-ECT doctors are recognizing that ECT treatment is a free-for-all. With some regulation, perhaps there would be standards, rules, and accountability instead of what is now nothing more than haphazardness.

2. Informed consent. Patients have the right to know the full risks, not a watered-down version that the kinder, gentler ECT of today is without any risk. In public, doctors say memory loss from ECT and cognitive damage doesn't occur. In private, it's accepted as fact, and studies are done to find drugs to lessen this. The truth beforehand, IMO, would result in better outcomes for patients. They would know *before* ECT that they might have substantial, permanent memory loss, and would be able to make a valid choice that such loss outweighed continuing depression. And they should be told it is not 100 percent effective, nor do the effects last in most cases. They should be made aware of maintenance ECT *before* they undergo a series, not when their treatments have failed.

3. An end to forced ECT. This is not a treatment that should be given without consent. Enough said.

4. More research into the lasting effects of ECT. ECT proponents claim that studies showing brain damage and permanent negative effects are out of date. But they are the only studies that exist. Let's do more research into this - the funding is there. Promises are not being kept.

I certainly don't want to believe that the very people we entrust with our health would deliberately harm us. But in the last years of intense research, in talking with thousands of ECT patients, I do believe that we, the public and consumers, are not being told the full truth. Whether that's out of a misguided, paternalistic attempt to do what's "best" for the mentally ill, who don't know any better, or whether it's financial, I can't say for sure. I suspect it's a combination of the two.

I think the doctors on the front line, for the most part, are sincere in their belief that they are helping us. And certainly in some cases, patients have credited ECT with saving their lives. Their views are every bit as important as those people who say ECT has ruined theirs.

Quite often, people charge that I'm just an anti-psychiatry zealot, someone out to deny lifesaving treatment to those in need. I am neither anti-psychiatry, (I still see a psychiatrist every other week) nor am I out to ban electroconvulsive therapy. I do want it regulated, and I want my end of the spectrum, someone who has been harmed by ECT, recognized.

I had ECT in July 1994 and this is my experience. I am one of many.

Honestly, I don't remember most of what I'm going to tell you. It's based on stories from family and friends, and from writings in my journal.

I was suffering a severe depression, and my psychiatrist, like so many others, felt the antidepressant medications weren't working. He had been pushing for ECT for months, but I resisted. He told me the "new and improved" ECT was nothing like the ECT of the past. They now used unilateral instead of bilateral, and a lot less power. He engaged my family in the fight, and they joined him in encouraging this treatment.

Finally, according to my journal, my psychiatrist gave me an ultimatum. Have the ECT or get lost. This wasn't force, but it certainly was coercion. My feelings were so clear, as evidenced in my journal:

I feel like I'm going to die. The blackness surrounds me and there's no way out. Today I asked Dr. E if I could try a couple of drugs I'd heard about from Dr. Goldberg, but he yelled at me. Said he didn't care how the hell they did it at Columbia. This is how we do it here. And he told me I had to have ECT, or he wanted me out as his patient. I don't have a choice anymore. No other doctor will take me. I'm such a bad patient. Hard to treat. No one wants that. They want a patient who will cheerfully take her Prozac and get better. I fail, even at depression. So I guess I'll have the fucking ECT. Nothing left to try. It worries me, but at least it will work, and get rid of this black cloud that is swallowing me whole. Let's electrocute that part of me, sentence it to death, and let my old self reemerge. Dr. E finally wins this round.

And so I was given a series of bilateral ECT treatments. Apparently they talk a good talk about unilateral, but in reality it's not used that much. In my dealings with so many ECT patients, I've only run into one person who actually had unilateral. And it didn't help his depression at all.

Frankly, I don't remember a thing. I was in the hospital for the entire time. Each day, according to accounts from others, I had a bad headache.

For one day, I refused to speak any English, my native language. I spoke only Russian, and they think I was cussing out the doctor, due to the intensity of my voice and body language.

I tried to fix my mother up with a man (patient) whose pants kept falling off. Then I gave him a pair of my sweatpants. My mother was not amused, although the rest of my family thinks it's hilarious.

My aunt brought me some kitchen towels and placemats with kittens on them. I thought they were cute and thanked her. This is now a joke, although it's more tragic than funny, IMO. Each day, I would see the items and say, "Oh, aren't those cute. Where did they come from?" My mother or aunt would tell me my aunt brought them. That was a daily event, and continued for weeks after I was home. For weeks, I would ask, "Oh, aren't those cute. Where did they come from?" when I saw them on the table.

The worst of all is that I apparently gave my phone number to several patients. One was a drug dealer, and he called me several times, saying I had given him my number in hospital, trying to set up drug deals...that I wanted to buy crack. I've never used crack in my life. I admit that I occasionally indulge in a toke or two of pot, but I certainly would never attempt to buy it from someone I didn't know.

I would get calls from men, saying I had consented to go on dates with them, and got one from a fellow who said I told him he could move in with me. I have no idea who these people were, except that I'd given my number to them in the hospital. (My number was unlisted.) From the conversations, I don't think I ever met any of them outside the hospital. I sure hope not.

Those calls continued until the day I moved to a new town. I've since heard from several ECT patients who have done similar things.

The spring before ECT, I had taken (apparently) a few trips to New York City, to see my then-boyfriend. He and I are still friends and talk by phone occasionally. I have absolutely no memory of those trips, although from the smiles on my face in pictures, I apparently had a wonderful time. The only proof I have of those trips is plane ticket stubs, photos and conversations with the gentleman. He and I have talked many times, and I have to fake it, pretending I remember what he's talking about. (He didn't know I had ECT...he was - very smartly - against it.)

Recently, I talked to him, and he asked me about something I'd apparently purchased on one of my NY trips . To this minute, I'm confused about it. I can't find the item, and have no memory of ever having it. I still have some boxes at my aunt's house, so perhaps it's there. But it's so bothersome to know that I have no memory of ever having bought or owned it.

I've lost about two years of my life from memory loss...approx. a year and a half before the ECT, and about 8 months following. It's just gone. The ECT industry says that I'm mistaken. Some say I'm a Scientologist, as if my religious belief would cause me to misunderstand what happened to me. I am offended by that, and I am offended that I continually have to publicly proclaim what my religious beliefs are.

The memory loss is heartbreaking because I should have some wonderful memories of my NY trips. And I'm sure there are many other good times in there. But I don't remember them.

What hurts the most is the scorn I receive from the ECT industry, from the doctors who make their living by this, from NAMI, and from the APA. They simply dismiss my complaints, as they deny the memory loss of so many others. It's bad enough to have the loss, but then to be told I'm lying, or over exaggerating, or misunderstanding - it's horrible. They just say it didn't happen.

Or that I'm a Scientologist.

But it did happen. I live it every day. And I'm a Presbyterian.

(I have removed another story concerning my ECT at the request of those involved.)

Let me again be very clear. I am pro-choice on all things, and that extends to ECT. I absolutely support the right of anyone who chooses ECT...or chooses something else.

Had I been told honestly that I might lose a portion of my memory, and that I might suffer permanent cognitive damage, I would not be angry as I am today. It would not have been so devastating to me. I would have made a more informed decision.

Juli Lawrence
ECT survivor

next: British Expert Warns Against Shock Therapy for Children
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

Anxiety disorders research going on at the National Institute of Mental Health (NIMH).

More than 19 million adult Americans ages 18 to 54 have anxiety disorders. The National Institute of Mental Health (NIMH) supports research into the causes, diagnosis, prevention, and treatment of anxiety disorders and mental illnesses. This research is conducted both in the Institute's intramural laboratories and in biomedical research institutions across the country. Studies examine the genetic and environmental risks for major anxiety disorders, their course, both alone and when they co-occur with other illnesses such as heart disease or depression, and their treatment. Scientists seek to discover the basis of anxiety disorders in the brain and their effects on the fu and other nctioning of the brain and other organs. The ultimate goal is to be able to cure, and perhaps even to prevent, anxiety disorders.

Types of Anxiety Disorders

The term anxiety disorders encompasses several clinical conditions:

• panic disorder, in which feelings of extreme fear and dread strike unexpectedly and repeatedly for no apparent reason, accompanied by intense physical symptoms
• obsessive-compulsive disorder (OCD), characterized by intrusive, unwanted, repetitive thoughts and rituals performed out of a feeling of urgent need
• post-traumatic stress disorder (PTSD), a reaction to a terrifying event that keeps returning in the form of frightening, intrusive memories and brings on hypervigilance and deadening of normal emotions
• phobias, including specific phobia a fear of an object or situation and social phobia a fear of extreme embarrassment
• generalized anxiety disorder (GAD), exaggerated worry and tension over everyday events and decisions

Research Progress

NIMH research has led to advances in understanding the causes of these disorders and how to treat them. Today, the majority of people with panic disorder and OCD improve significantly within weeks or months of getting proper treatment. The same is true for people with phobias. And many people with PTSD and generalized anxiety disorder also make substantial improvement with treatment.

As the search continues for better treatments, NIMH is harnessing the most sophisticated scientific tools available to determine the causes of anxiety disorders. Like heart disease and diabetes, these brain disorders are complex and probably result from the interplay of genetic, behavioral,developmental, and other factors. Scientists in a number of disciplines are trying to identify risk factors that make certain people prone to these conditions.

Studies of the Brain and Anxiety Disorders

Studies in animals and humans have focused on pinpointing the specific brain areas and circuits involved in anxiety and fear, which underlie anxiety disorders. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response that occurs without the need for conscious thought. It has been found that the body's fear response is coordinated by a small structure deep inside the brain, called the amygdala.

Neuroscientists have shown that when confronted with danger, the body's senses launch two sets of signals to different parts of the brain. One set of signals, which takes a more roundabout route, relays information to the cerebral cortex, the cognitive part of the brain that explains in detail the threatening object or situation such as a big black car heading for you as you cross the street. The other set of signals shoots straight to the amygdala, which sets the fear response in motion, readying the body for quick action before the cognitive part of the brain comprehends just what is wrong. The heart starts to pound and diverts blood from the digestive system to the muscles for quick action. Stress hormones and glucose flood the blood stream to provide the energy to fight or flee. The immune system and the pain response are suppressed to prevent swelling and discomfort, which could interfere with a quick escape. And, as a preventive measure for similar confrontations in the future, the learned fear response is etched on the amygdala.

How Does this Learned Fear Response Turn into an Anxiety Disorder?

One or more fearful experiences can prime a person to respond excessively to situations where most people would experience no fear such as in the supermarket or only moderate nervousnesss such as giving a speech. In anxiety disorders, the deeply etched memory can result in hypervigilance, making it hard to focus on other things, and leading to feelings of anxiety in many situations. In people who have survived overwhelming trauma and developed PTSD, for example, even mild reminders of the trauma may initiate the fear response. People with specific or social phobia often completely avoid their feared situation. In panic disorder the chronic worry about having another attack may lead to stress-related conditions such as heart problems and irritable bowel syndrome. In people with generalized anxiety disorder, the chronic anxiety may prevent them from focusing on even the simplest tasks. The amygdala, although relatively small, is a very complicated structure, and recent research with animals suggests that different anxiety disorders may be associated with activation in different parts of the amygdala.

Brain Findings Point the Way to New Approaches

The amygdala findings may have important implications for treating people who suffer from anxiety disorders. If, as studies suggest, the memories stored in the amygdala are relatively indelible, one aim of research is to develop therapies for anxiety disorders that increase cognitive control over the amygdala so that the "act now, think later" response can be interrupted.

Clinical Trials of New Treatments

Anxiety disorder treatment studies have been designed so that pharmacological and cognitive or behavioral therapies can be tested head-to-head. In one clinical trial, two separate centers are examining how well drug and behavioral therapies work separately and together in the treatment of OCD. Data collected from this study should help scientists determine if one of the treatments works better than the other in decreasing obsessions and compulsions.

In addition, the direct comparison of the combined treatment with the medication will provide much needed information on whether the high relapse rate associated with stopping the drug can be reduced. The comparison should also help determine if the medication can enhance compliance with the behavioral treatment.

Many of the current medications for anxiety disorders affect the neurotransmitter serotonin. New treatment approaches are examining drugs that affect other neurotransmitters and brain chemicals such as GABA, gamma-aminobutyric acid, and Substance P. A new research tool, magnetic resonance spectroscopy will help scientists measure brain levels of GABA and other substances.

Researchers are also looking at combinations of medications that may have a synergistic effect in panic disorder, for example, studies are underway to determine if an antidepressant medication that affects serotonin works better when used with the new antianxiety drug buspirone.

The Role of Cognitive Factors

Cognitive factors play a significant role in the onset of anxiety disorders. People at risk for these disorders tend to be overly responsive to potentially threatening stimuli. Studies are underway to look at how people with anxiety disorders process information. The goal is to see which cognitive capabilities are affected by anxiety and which are free to handle other information. Data collected from the studies should help researchers determine more about the brain pathology associated with anxiety disorders.

Early Life Stress May Play a Role

In animals, NIMH-funded researchers are studying how stress, especially when it occurs in early life, affects how adverse events are handled later in life. Rat pups who are subjected to the stress of being separated from their mothers for several minutes early in life have, months later, a much greater startle reaction to a stressful event than pups who were never separated. This line of research may help scientists learn how genes and experience affect who is vulnerable and who is resistant to anxiety disorders.

Anxiety Disorders and Hormones

Another area of research has led to the discovery that anxiety disorders are associated with abnormal levels of certain hormones. People with PTSD, for example, tend to be low on the stress hormone cortisol, but have an overabundance of epinephrine and norepinephrine, which could be why they continue to feel anxious after the trauma. In addition, they tend to have higher-than-usual levels of corticotropin releasing factor (CRF), which switches on the stress response and may explain why people with PTSD startle so easily. Scientists are researching ways to correct hormonal imbalances and bring symptoms under control.

The Importance of Imaging Tools

Scientists may be closer than ever before to creating therapies that are specifically targeted. NIMH studies use imaging tools to allow researchers to peer into the living brain and watch the amygdala, the cortex, and other areas of the brain at work. They can identify abnormal activity when a person has an anxiety disorder and determine if medication or cognitive and behavioral therapies help to correct it.

Recent studies of the brain using magnetic resonance imaging showed that people with OCD had significantly less white matter than did control subjects, suggesting a widely distributed brain abnormality in OCD.

Imaging studies are also looking at how brain structure may be related to PTSD. A part of the brain involved in emotion, called the hippocampus, tends to be smaller in some people with PTSD. NIMH-funded researchers are trying to decipher whether that is a result of extreme stress responses related to the trauma or whether people who already have a smaller hippocampus are more prone to PTSD.

NIMH Anxiety Research and Genetics

Research evidence points to genetics as a factor in the origin of anxiety disorders. Scientists have recently discovered a gene that influences fearfulness in mice. And NIMH-supported studies of twins have found that genes play a role in panic disorder and social phobia. Although genes help determine whether someone will develop an anxiety disorder, heredity alone can't explain what goes awry. Experience also plays a part. In PTSD, for example, the trauma is the experience that triggers the anxiety disorder; genetic factors may help explain why only certain individuals exposed to similartraumatic events develop full-blown PTSD. Researchers are honing in on the degree of influence that genetics and experience exert in each of the anxiety disorders information they hope will yield clues to prevention and treatment.

Some Cases of OCD Linked to Earlier Infection

NIMH studies of obsessive-compulsive disorder in young people have shown that the experience of having a streptococcal bacterial infection may lead to the development of crippling obsessions and compulsions. It appears that a genetic vulnerability, coupled with rheumatic fever, is associated with some cases of OCD. Preliminary evidence indicates that special treatment for the infection improves or cures the OCD.

The Broad NIMH Research Program

In addition to studying anxiety disorders, NIMH supports and conducts a broad based, multidisciplinary program of scientific inquiry aimed at improving the diagnosis, prevention, and treatment of other mental disorders. These conditions include bipolar disorder, clinical depression, and schizophrenia.

Increasingly, the public as well as health care professionals are recognizing these disorders as real and treatable medical illnesses of the brain. Still, more research is needed to examine in greater depth the relationships among genetic, behavioral, developmental, social and other factors to find the causes of these illnesses. NIMH is meeting this need through a series of research initiatives:

• NIMH Human Genetics Initiative
  This project has compiled the world's largest registry of families affected by schizophrenia, bipolar disorder, and Alzheimer's disease. Scientists are able to examine the genetic material of these family members with the aim of pinpointing genes involved in the diseases.
• Human Brain Project
  This multi-agency effort is using state-of-the-art computer science technologies to organize the immense amount of data being generated through neuroscience and related disciplines, and to make this information readily accessible for simultaneous study by interested researchers.
• Prevention Research Initiative
  Prevention efforts seek to understand the development and expression of mental illness throughout life so that appropriate interventions can be found and applied at multiple points during the course of illness. Recent advances in biomedical, behavioral, and cognitive sciences have led NIMH to formulate a new plan that marries these sciences to prevention efforts.

While the definition of prevention will broaden, the aims of research will become more precise and targeted.

Source: NIMH, Dec. 2000

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Researchers discover that heavy smoking during adolescence leads to anxiety disorders in young adults.

Scientists supported by the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) have documented that chronic cigarette smoking during adolescence may increase the likelihood that these teens will develop a variety of anxiety disorders in early adulthood. These disorders include generalized anxiety disorder, panic disorder and agoraphobia, the fear of open spaces.

Researchers from Columbia University and the New York State Psychiatric Institute report their findings in the November 8 edition of the Journal of the American Medical Association (JAMA).

Scientists have known of strong connections between panic disorder and breathing problems in adults. Given this association, the research team hypothesized that smoking might also relate to risk for panic disorder in children and adolescents through an effect on respiration.
"Numerous studies have shown that smoking causes a number of diseases, " says NIDA Director Dr. Alan I. Leshner. "This study is important because it highlights how cigarette smoking may rapidly and negatively affect a teen's emotional health-perhaps even before any of the widely known physical effects such as cancer may occur."

"These new data provide further evidence of commonalities between processes associated with anxiety in children and adults," says Dr. Daniel Pine, Chief of NIMH's Section on Developmental and Affective Neuroscience.

The researchers interviewed 688 youths and their mothers from 1985 to1986 and from 1991 to 1993. They found that a startling 31 percent of those adolescents who smoked 20 or more cigarettes per day had anxiety disorders during early adulthood. Among those who smoked every day and had an anxiety disorder during adolescence, 42 percent began smoking prior to being diagnosed with an anxiety disorder and only 19 percent were diagnosed with anxiety disorders before they reported daily smoking.

The research team used a community-based sample that has served as the foundation of a longitudinal study that has been ongoing for the last 25 years. They were able to exclude a wide range of other factors that might determine whether or not a smoking adolescent or young adult develops anxiety disorders, including age, gender, childhood temperament, parental smoking, parental education, parental psychopathology, and the presence of alcohol and drug use, anxiety, and depression during adolescence.

Source: NIMH, Nov. 2000

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The Difficult Boss

At one time I had a boss named Tom who operated his business on a continuous stream of crisis management. His modus operandi was stress and panic. He was quick to criticize, rare to praise, and was always on the look out for who to blame.

"Transform an apparent disadvantage into an opportunity."

I wasn't enjoying the working there, it was not a fun place to be. I found myself being more stressed and spending more and more precious time and energy involved in gripe sessions with the other employees. It's like we were all comparing notes to makes sure we weren't insane.

After a few months on the job, I realized I was complaining about him almost daily to my husband. It seemed like every time I'd discuss work, it would begin with "guess what he did today!" At some point I asked myself, how can this situation be an opportunity? What possible good could come of this?

Then it hit me. This man pushed my buttons! Here I was talking about how no one can make you feel anything without your permission, yet I was thinking and speaking as if my boss was making me feel stressed, unappreciated and unhappy.

Ah ha! What an opportunity! This was an opportunity for me to really walk my talk. It was a change for me to identify and remove the buttons my boss was pushing. It was not only an opportunity to prove to myself it could be done, but if successful, I would be creating a better work environment for myself.

There was no way I would ever be able to change him or his behavior. It simply was not possible. If the situation, or my response to the situation to be more accurate, was to change, I would have to change myself.

The first thing I did was identify and describe the buttons (beliefs) he was pushing. What were the situations where I felt the most stressed? When did I feel the most unappreciated? When was I most unhappy at work?

continue story below

Using the Option Method, I was able to identify three core beliefs that were operating and contributing to my dismay. Those were....

If a boss approaches you with stress in their voice, and asks if you have something completed yet, that means that you're someone who can not be trusted to complete jobs on your own. And that translates into you being incompetent.

If you don't receive appreciation for your work (i.e.: no at-a-boys, good job, nice work, type comments) that means you're not doing a good job.

If a boss is stressed out, you too have to become stressed out to show him or her you care as much as he or she does.

I was able to re-examine those beliefs for accuracy and find out if they were really true.

1. To address the first belief, I needed some standard of measurement to determine if I was a good worker. So I asked myself, am I a trustworthy and competent worker? After a lot of soul searching, the answer came out to be Yes. Yes, I am skilled in what I do, I put out quality work quickly, and I meet deadlines. I also identified certain activities I procrastinated doing because I didn't enjoy doing them. I vowed to change those. But on the whole, I'm a responsible, trustworthy and competent worker.

So with this in mind, what did it mean when Tom became stressed and questioned my work? I determined that this was his way of dealing with responsibility and it had nothing to do with me and my work. He acted this way with everyone. His approach had everything to do with him, and nothing to do with me.

2. What about not receiving any praise? Did that necessarily mean I wasn't doing a good job? Again, I determined that someone could be doing good work and receive no acknowledgment for it. I concluded that if I wanted any praise, I was going to have to give it to myself.

3. Was it possible to care about your work and NOT be stressed out about it? Yes, that was not only possible, but doable. One could care yet not make themselves miserable when there were snags or difficulties. I did care but I didn't want to feel stress.

After going through this process of examining my beliefs, I realized that there was still some lingering doubts and fears. I was changing my beliefs which would change my responses and how I felt, but what about Tom? I wasn't changing him. He might interpret my not being stressed as a sign that I don't care about my work. What if he thinks all those things and fires me?!?

Did getting fired mean my work was bad? No. I had already established the value of my work. I was afraid I wouldn't be able to find another job I liked as much or got paid as well. I concluded that that belief was not true. I COULD find another job that paid as much. And, if I was fired for not being stressed, that was actually a GOOD thing, cause I didn't want a job where I had to be stressed out to demonstrate my caring.

So with all these newly revised beliefs and fresh perspectives, I was actually eager to go to work and face Tom. It became a challenge I was excited about facing. So far, it had only been conceptual. Would I be able to pull it off when faced with reality?

By George, it worked! After a month or so, I completely changed my experience at the job. I won't kid you, it wasn't instantaneous. There were times I would react out of habit. But for the most part, my work environment changed enormously. I was no longer riddled with self doubt about my work, or stressed.

And there were some surprising manifestations to my new beliefs that I hadn't anticipated. Since his words and actions no longer meant anything about me, I was able to see him more clearly. I no longer felt disdain but compassion for him. He was so hard on myself, putting himself through so much angst. It wasn't pity, but more like a new connection with him because I could relate. He was doing the best he could. We ended up developing a friendship.

My co-workers noticed the difference as well. We use to joke around about "who's turn is it today?" meaning, who was going to be the one he picked on that day. Now they made comments like "he doesn't pick on you as much." I also think I was able to help them see that his comments said nothing about them, but more about his "style" of working and management.

What an opportunity this apparent disadvantage turned out to be.

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Social phobia, a paralyzing fear of social situations, may be brought on by a combination of genetics and child-rearing methods.

Teenagers are notorious for blaming all their problems on their parents. Sometimes they may be right, but just as often they may be wrong. But if your teen has a social phobia, he or she may have hit paydirt in the blame department.

According to a group of American and German researchers, social phobia -- a paralyzing fear of social situations -- may be brought on by a combination of genetics and child-rearing methods. The researchers found that children overprotected or rejected by parents who suffer from depression or anxiety are more likely than other kids to develop the mental disorder, though not necessarily destined to develop it.

"We've studied parental mental illness and parenting style as potential risk factors for adolescents developing social phobia, and we found that both contribute to the risk," says study author Roselind Lieb, PhD. She is with the department of clinical psychology and epidemiology at the Max Planck Institute of Psychiatry in Munich, Germany. Her study appears in the September issue of the Archives of General Psychiatry.

The researchers conducted two sessions of extensive interviews 20 months apart with more than 1,000 teen-age subjects. The participants were 14 to 17 years old, mostly middle class, attending school, and living with their parents at the time of the first interview session. One parent of each child -- the mother, unless she had died or could not be located -- also underwent similar, independent interviews.

They used several questionnaires to assess parenting style (rejection, emotional warmth, overprotection), and how well the family was functioning (problem solving, communication, behavioral control), and they diagnosed the parents and children using internationally accepted psychiatric criteria.

Lieb's team found no link at all between family functioning and teenage social phobia. They did find, however, that teenagers with parents who had social phobia, depression, or other anxiety disorders or who abused alcohol, as well as those with parents who were overprotective or rejected them, were at a significantly increased risk of developing social phobia.

When asked why and how these parental factors might be leading to social phobia in the teenagers, Lieb says that "the design of the study doesn't let us determine cause." Both parental history of mental illness and child-rearing traits are playing important roles in the equation, she says, "but we do not know how they interact."

She will, however, hazard a guess. "It's possible that it's a genetic mechanism, and it's also possible that it's behavioral modeling, [that is] children learn how to act in social situations by watching their parents." Because anxious parents might not encourage social activities in their children, the children never learn how to behave in such situations. "Finally, we can imagine complicated interactions between genetic and environmental factors," she says, although the nature of that interaction remains unclear.

But according to Debra A. Hope, PhD, who reviewed the study, Lieb's team has "overreached their conclusions a little bit." For one thing, she says, the parental interview responses were inconsistent with those of the teenagers. So what the study tells us "is that adolescent perception of parenting style is related to social anxiety." This may be important, but "it is very different from saying that the actual parenting style is to blame," she says.

"Another really important point is that this study was not about parenting," says Hope, "it's about mothers. They interviewed very few fathers, which is a poor design." Hope is a professor and director of the Anxiety Disorders Clinic at University of Nebraska in Lincoln.

Still, Hope adds that the data has a hopeful message for concerned parents. "It's important for the public to know that social phobia has both family environment and genetic components. Not all anxious parents have anxious kids, and not all anxious kids have anxious parents. It does run in families, but that's not the whole picture by any means. Parents with anxiety disorders shouldn't be excessively worried about passing it on to their kids. "

Lieb says that future work will "look deeper into parts of the puzzle in very early childhood that might lead to developing social phobia in adolescence."

Sources:

• Archives of General Psychiatry, Sept. 2000.
• Debra A. Hope, PhD, professor and director of the Anxiety Disorders Clinic at University of Nebraska.

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Two potentially fatal side-effects of antipsychotic medications - NMS and Serotonin Syndrome. Could you recognize these psychiatric emergencies?

Virtually all antipsychotic drugs-and even some dopamine-blocking agents and antidepressants-carry the risk of a potentially fatal reaction. Your ability to recognize the symptoms and intervene quickly can save a patient's life. Two days after being admitted to the psychiatric ICU for an exacerbation of paranoid schizophrenia, 35-year-old Scott Thorp was still not improving. Not only did he continue to suffer psychotic symptoms, but he complained of feeling "extremely uneasy" and "jittery inside." Because Mr. Thorp was being treated with the high-potency antipsychotic drug haloperidol (Haldol), the staff conducted a routine assessment for extrapyramidal symptoms (EPS) and recognized his restless movements as akathisia-a common adverse effect of such medications-rather than illness-related agitation. The akathisia subsided after four doses of the anticholinergic agent benztropine mesylate (Cogentin) were administered over two days.

But on day 3, Mr. Thorp's condition worsened. He developed lead-pipe muscular rigidity with resistance of the upper extremities. His BP fluctuated wildly, and he was mildly tachycardic, with a pulse rate of 108/114. His nurse also noted tremulousness and, to her surprise, urinary incontinence.At shift change, his temperature was 101.4° F (38.5° C), he was confused, lethargic, and noticeably diaphoretic. The nurse looked again at the elevated temperature and began to suspect an adverse reaction to haloperidol-and she was right. Mr. Thorp had developed neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening side effect of antipsychotic medications.1 Besides elevated temperature, Mr. Thorp had other signsautonomic dysfunction (which includes hypertension, tachycardia, urinary incontinence, and diaphoresis) and muscular rigidity-that are "red flags" for NMS. The nurse immediately contacted the attending psychiatrist, who ordered that haloperidol be discontinued and Mr. Thorp be transferred to the medical ICU.

There, lab results confirmed a diagnosis of NMS. They showed increased levels of lactic dehydrogenase (LDH), serum creatine phosphokinase (CPK), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). Mr. Thorp's WBC count was also elevated-another lab finding that confirms NMS, in which WBC levels as high as 40,000/mm3 have been reported.2 Mr. Thorp's labs also revealed that he had become dehydrated and was hyperkalemic. His urinalysis revealed proteinuria and myoglobinuria, two signals of muscle deterioration and early indicators of renal insufficiency.

Recognizing the signs of NMS

NMS is an extreme medical emergency. Although it occurs in no more than 1% of patients who take antipsychotic medications,1 NMS develops rapidly, and death occurs in about 10% of cases, largely because of the consequences of severe rigidity and dehydration, including acute renal failure, respiratory distress, and deep vein thrombosis.2,3 NMS is believed to be caused by an acute reduction in dopamine activity as a result of drug-induced dopamine blockade. It was first described in 1960 during early studies of haloperidol, but it can occur with virtually any antipsychotic medication. Although NMS was not originally thought to occur with newer "atypical" antipsychotics such as clozapine (Clozaril) and risperidone (Risperdal), the syndrome has been associated with both those agents as well as with lithium carbonate (Eskalith, Lithane, Lithobid) and with dopamine-blocking antiemetics such as metoclopramide (Reglan) and prochlorperazine (Compazine).1,2 NMS or NMS-like side effects may also occur with some antidepressants, such as monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants.2-4 Signs of NMS usually appear within two weeks after therapy is begun or the dosage of the medication is increased. Hyperthermia, severe muscular rigidity, autonomic instability, and changing levels of consciousness are the four major hallmarks.1,2 Temperatures of 101° F (38.3° C) to 103° F (39.4° C) are not uncommon, and, in some cases, rise as high as 108° F (42.2° C).3 The leadpipe rigidity of the upper extremities Mr. Thorp exhibited is the most common form of muscle rigidity, but the ratcheting movement of the joints known as cogwheeling is also seen; in addition, the muscular rigidity can affect the neck and chest, leading to respiratory distress. As seen with Mr. Thorp, rapid physical decline occurs over the course of two to three days. NMS may be difficult to recognize. It can occur along with a cluster of other extrapyramidal symptoms and has been associated with dystonia and parkinsonism. Many times akinesia, a generalized slowing of movement, with fatigue, blunted affect, and emotional unresponsiveness, is present rather than akathisia. Akinesia can easily be mistaken for the vegetative symptoms of a major depressive disorder. In addition, several disorders have symptoms similar to those of NMS, including catatonia, degenerative diseases of the brain, heat stroke, infections, and malignant hyperthermia.

The rise in temperature caused by NMS could be mistaken for a sign of pneumonia or urinary tract infection. But symptoms of confusion, disorientation, muscle rigidity, and rapid change in temperature for no physiological reason should always trigger an evaluation of a patient's medications. Tachycardia, for example, can be a side effect of drugs like clozapine and chlorpromazine hydrochloride (Thorazine). Furthermore, high temperature, confusion, and disorientation are not usually seen with psychosis. Which patients are more likely to develop NMS? The syndrome occurs twice as often in men as in women, and patients who have had prior NMS episodes have a higher risk of recurrence.2 Certain medications, alone or in combination, and how they are administered increase the risk of NMS: rapid titration or high-dose administration of a neuroleptic, IM medications that form a deposit and are released over time (called a depot injection), use of high-potency neuroleptics like haloperidol and fluphenazine hydrochloride (Prolixin), lithium alone or in combination with an antipsychotic, and the combination of two or more neuroleptics. Exhaustion and dehydration put patients who are taking neuroleptics at higher risk of NMS, as do akinesia and organic brain disease. The syndrome also occurs more frequently in hot geographic regions.

Providing treatment and supportive care

Given its life-threatening complications, NMS calls for early recognition and immediate intervention. A psychiatrist or neurologist with expertise in NMS should be consulted at the first signs of this syndrome. The most critical intervention is to discontinue neuroleptic therapy. If the patient had received a long-acting depot injection, however, it may take as long as a month to bring symptoms under control. Medications that are most frequently used to treat the syndrome are bromocriptine mesylate (Parlodel), an antiparkinsonian dopaminergic drug; and dantrolene sodium (Dantrium), a muscle relaxant. As seen in Mr. Thorp's case, anticholinergics such as benztropine, while effective in the treatment of extrapyramidal symptoms, are not helpful in treating NMS. As medications are administered, be alert to potential toxicity or adverse effects. With dantrolene, there is an increased risk of liver toxicity as well as phlebitis at the IV site. You will also need to provide supportive care to control and reduce fever, treat secondary infections, and regulate vital signs and cardiac, respiratory, and renal function. Renal failure is treated with hemodialysis, as necessary. Since the patient may well become confused, determine whether additional safety measures are needed. Sedatives may also be called for. A change of position and decreased environmental stimulation may make the patient more comfortable. Understandably, NMS is painful and frightening for the patient and emotionally upsetting to the family. Make time to explain what has happened and why, and what the treatments are designed to do. With the measures described, NMS usually resolves in one or two weeks. The patient's level of consciousness should improve, and delirium and confusion should decrease. However, the patient's episode of psychosis may continue until after an antipsychotic medication can be reintroduced. You'll want to do frequent mental status assessments, monitor I & O, and evaluate lab results. Once the NMS symptoms are under control (and, ideally, not until two weeks after they've resolved), alternative antipsychotic medications should be explored. In some cases, it may be necessary to gradually reintroduce the original antipsychotic, a process called "rechallenge." Rechallenge should always begin with the lowest dose possible and then proceed with gradual upward titration. Because of the high risk that NMS will recur, however, monitor the patient closely for extrapyramidal symptoms and other side effects.

A new syndrome looks like NMS

Serotonin syndrome is another potentially fatal drug reaction that resembles NMS in its presentation. Until recently, it was described as NMS without the involvement of neuroleptics. Drug history is the most important factor for distinguishing between the two.(3) Whereas NMS results from the depletion of the neurotransmitter dopamine, serotonin syndrome results from excess levels of serotonin. Typically, the excess results from the combination of a serotonin-enhancing drug with an MAOI. For example, the syndrome could develop if a depressed patient on an MAOI is switched to a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac) without allowing a sufficient "washout" period for the MAOI to be eliminated from the body. Symptoms include hyperthermia as well as mental changes, muscle rigidity or exaggerated reflexes, autonomic instability, and seizures or pseudoseizures. Comprehensive assessment and early recognition of NMS and serotonin syndrome are critical to a positive outcome. The nurse who was quick to recognize Mr. Thorp's symptoms, for example, could literally have saved his life.

REFERENCES

1. Varcarolis, E. M. (1998). Schizophrenic disorders. In E. M. Varcarolis
(Ed.), Foundations of psychiatric mental health nursing (3rd ed.), (pp. 650 651). Philadelphia: W. B. Saunders.
2. Pelonero, A. L., & Levenson, J. L. (1998). Neuroleptic malignant syndrome: A review. Psychiatric Services, 49(9), 1163.
3. Keltner, N. L. (1997). Catastrophic consequences secondary to psychotropic drugs, Part 1. Journal of Psychosocial Nursing, 35(5), 41.
4. "Clinical reviews: Neuroleptic malignant syndrome." MICROMEDEX Healthcare Series, 105. CD-ROM. Englewood, CO: MICROMEDEX Inc. Copyright 1999.

NMS at a glance

Sources:

1. Varcarolis, E. M. (1998). Schizophrenic disorders. In E. M. Varcarolis (Ed.), Foundations of psychiatric mental health nursing (3rd ed.), (pp. 650 651). Philadelphia: W. B. Saunders.

2. Pelonero, A. L., & Levenson, J. L. (1998). Neuroleptic malignant syndrome: A review. Psychiatric Services, 49(9), 1163.

3. Keltner, N. L. (1997). Catastrophic consequences secondary to psychotropic drugs, Part 1. Journal of Psychosocial Nursing, 35(5), 41.

Differentiating NMS from other medical disorders with similar signs

Sources:

1. Pelonero, A. L., & Levenson, J. L. (1998). Neuroleptic malignant syndrome: A review. Psychiatric Services, 49(9), 1163.

2. Keltner, N. L. (1997). Catastrophic consequences secondary to psychotropic drugs, Part 1. Journal of Psychosocial Nursing, 35(5), 41.

About the author: CATHY WEITZEL, an RN certified in psychiatric and mental health nursing, is a staff nurse at the Psychiatric Adult Partial Hospital, St. Joseph's Campus, Via Christi Regional Medical Center, Wichita, Kan.

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