- Email: [email protected]
The brain hallucinates and gets caught in the web
THE LANCET
The brain hallucinates and gets caught in the web Lee Friedman, Ilse R Wiechers
I n the past year, we had a remarkable glimpse of brain activity during hallucination in a patient with schizophrenia (Silbersweig; figure). In his typical hallucination, a patient saw moving, coloured scenes with rolling, disembodied heads, which were giving him instructions. 150 positron emission tomography and an image-analysis protocol, designed to image transient subjective experiences, illustrated which areas had increased regional cerebral blood flow during the hallucinations. Increased brain activity was noted in visual and auditory-associated cortices, as well as paralimbic and subcortical areas. Such studies provide clues to the pathophysiology of schizophrenia and to the neural substrate of conscious perceptual experience. Fascinating new clues to schizophrenia also emerged on the genetics/epidemiology front. Gorwood and colleagues tested the hypothesis that the age of onset of schizophrenia decreases in successive generations. This inheritance pattern, "anticipation", results from unstable trinucleotide repeat D N A sequences at the disease locus. The study took place on an island in the Indian Ocean and was based on 97 patients with schizophrenia belonging to 24 families with at least two generations of patients. In the younger generation, the age of onset was significantly less than the expected age of onset based on the data from the older generation. This evidence could accelerate the search for pathological genetic processes implicated in schizophrenia. Psychiatrists are concerned about the potential iatrogenic effects of typical antipsychotics, which are linked to tardive dyskinesia. These effects may be relieved by the findings of McCreadie and colleagues. Dyskinesia was assessed in four groups of elderly individuals including normal people, relatives of schizophrenics, nevermedicated patients with schizophrenia, and medicated patients. The prevalence of dyskinesia was similar in never-medicated and medicated patients (about 40%), and was significantly higher than that in first-degree relatives and normal controls (15%). McCreadie reported that never-medicated patients had "classic tardive dysthinesia", including chewing movements, tongue protrusion, lip smacking, and writhing. The researchers conclude that it is the illness per se that is associated with dyskinesias in elderly schizophrenic patients. However, psychiatrists may be chagrined by the work of Mojtabai and Nicholson. These researchers evaluated the inter-rater reliability of ratings of delusions and bizarre hallucinations among 50 psychiatrists selected randomly from the American Psychiatry Association Membership Directory. The inter-rater reliability estimates were quite low (K about 0-40), and call into question the adequacy of psychiatric training.
Lancet 1 9 9 6 ; 3 4 8 (suppl II): 21 Department of Psychiatry, Case Western Reserve University, Cleveland, OH 44106, USA (L Friedman PhD, I R Wiechers)
End Of Year Review
Lateral view of the left side of the brain showing areas activated during visual and auditory hallucinations With permission from Macmillan Magazines Limited, Figure provided by D A Silbersweig and E Stern.
In the USA, the restructuring of the health-delivery system, including psychiatry, has accelerated. The effort toward cost reduction continues to threaten the quality of care, and universal access remains a distant goal. In the latest salvo, the US Legislative passed a law directing insurance companies to offer comparable coverage for mental and physical illnesses. The law, which will take effect in January, 1998, was targeted toward reducing the stigma and discrimination of mental illness. One cannot discuss developments in any field in 1996 without mentioning the explosive growth of the Internet. Patients and caregivers can obtain a structured diagnostic interview for most mental disorders (www.mentalhealth. com). Psychiatrists can now get drug information (www.pslgroup. com/schizophrenia.htm) and systematic reviews of treatment strategies. For researchers who need an update on findings in schizophrenia research there is Webtrack (www.priory/com/journals/webtrack.htm). On the other hand, this headlong plunge into interactive communication is fraught with danger (Jacobsen). Are these Web sites sponsored by pharmaceutical companies, activist groups, or unqualified individuals promoting unproven treatments? Until such questions are addressed, caveat web-surfer! Key references for 1 9 9 6 G o r w o o d P, L e b o y e r M, F a l i s s a r d B, et al. A n t i c i p a t i o n in schizophrenia: new fight on a c o n t r o v e r s i a l p r o b l e m . A m J Psychiatry 1996; 153: 1173-77. Jacobsen R. F D A c o n f e r e n c e will focus on Internet drug p r o m o t i o n . The Nero York Times Cybertimes 1996, O c t o b e r 13 (www.nytimes.com/webldocsrooffcyber/week/1013.html). McCreadie RG, Tbara R, Kamath S, et al. A b n o r m a l m o v e m e n t s in never-medicated Indian patients with s c h i z o p h r e n i a . B r J Psychiatry 1996; 168: 221-26. M o j t a b a i R, Nicholson RA. I n t e r r a t e r reliability o f delusions and bizarre delusions. AmJPsyehiatry 1995; 152: 1804-06. Silbersweig DA, Stern E, F r i t h C, et ai. A f u n c t i o n a l n e u r o a n a t o m y o f hallucinations i n s c h i z o p h r e n i a . Nature 1995; 378: 176-79.
slI21
The brain hallucinates and gets caught in the web Lee Friedman, Ilse R Wiechers
I n the past year, we had a remarkable glimpse of brain activity during hallucination in a patient with schizophrenia (Silbersweig; figure). In his typical hallucination, a patient saw moving, coloured scenes with rolling, disembodied heads, which were giving him instructions. 150 positron emission tomography and an image-analysis protocol, designed to image transient subjective experiences, illustrated which areas had increased regional cerebral blood flow during the hallucinations. Increased brain activity was noted in visual and auditory-associated cortices, as well as paralimbic and subcortical areas. Such studies provide clues to the pathophysiology of schizophrenia and to the neural substrate of conscious perceptual experience. Fascinating new clues to schizophrenia also emerged on the genetics/epidemiology front. Gorwood and colleagues tested the hypothesis that the age of onset of schizophrenia decreases in successive generations. This inheritance pattern, "anticipation", results from unstable trinucleotide repeat D N A sequences at the disease locus. The study took place on an island in the Indian Ocean and was based on 97 patients with schizophrenia belonging to 24 families with at least two generations of patients. In the younger generation, the age of onset was significantly less than the expected age of onset based on the data from the older generation. This evidence could accelerate the search for pathological genetic processes implicated in schizophrenia. Psychiatrists are concerned about the potential iatrogenic effects of typical antipsychotics, which are linked to tardive dyskinesia. These effects may be relieved by the findings of McCreadie and colleagues. Dyskinesia was assessed in four groups of elderly individuals including normal people, relatives of schizophrenics, nevermedicated patients with schizophrenia, and medicated patients. The prevalence of dyskinesia was similar in never-medicated and medicated patients (about 40%), and was significantly higher than that in first-degree relatives and normal controls (15%). McCreadie reported that never-medicated patients had "classic tardive dysthinesia", including chewing movements, tongue protrusion, lip smacking, and writhing. The researchers conclude that it is the illness per se that is associated with dyskinesias in elderly schizophrenic patients. However, psychiatrists may be chagrined by the work of Mojtabai and Nicholson. These researchers evaluated the inter-rater reliability of ratings of delusions and bizarre hallucinations among 50 psychiatrists selected randomly from the American Psychiatry Association Membership Directory. The inter-rater reliability estimates were quite low (K about 0-40), and call into question the adequacy of psychiatric training.
Lancet 1 9 9 6 ; 3 4 8 (suppl II): 21 Department of Psychiatry, Case Western Reserve University, Cleveland, OH 44106, USA (L Friedman PhD, I R Wiechers)
End Of Year Review
Lateral view of the left side of the brain showing areas activated during visual and auditory hallucinations With permission from Macmillan Magazines Limited, Figure provided by D A Silbersweig and E Stern.
In the USA, the restructuring of the health-delivery system, including psychiatry, has accelerated. The effort toward cost reduction continues to threaten the quality of care, and universal access remains a distant goal. In the latest salvo, the US Legislative passed a law directing insurance companies to offer comparable coverage for mental and physical illnesses. The law, which will take effect in January, 1998, was targeted toward reducing the stigma and discrimination of mental illness. One cannot discuss developments in any field in 1996 without mentioning the explosive growth of the Internet. Patients and caregivers can obtain a structured diagnostic interview for most mental disorders (www.mentalhealth. com). Psychiatrists can now get drug information (www.pslgroup. com/schizophrenia.htm) and systematic reviews of treatment strategies. For researchers who need an update on findings in schizophrenia research there is Webtrack (www.priory/com/journals/webtrack.htm). On the other hand, this headlong plunge into interactive communication is fraught with danger (Jacobsen). Are these Web sites sponsored by pharmaceutical companies, activist groups, or unqualified individuals promoting unproven treatments? Until such questions are addressed, caveat web-surfer! Key references for 1 9 9 6 G o r w o o d P, L e b o y e r M, F a l i s s a r d B, et al. A n t i c i p a t i o n in schizophrenia: new fight on a c o n t r o v e r s i a l p r o b l e m . A m J Psychiatry 1996; 153: 1173-77. Jacobsen R. F D A c o n f e r e n c e will focus on Internet drug p r o m o t i o n . The Nero York Times Cybertimes 1996, O c t o b e r 13 (www.nytimes.com/webldocsrooffcyber/week/1013.html). McCreadie RG, Tbara R, Kamath S, et al. A b n o r m a l m o v e m e n t s in never-medicated Indian patients with s c h i z o p h r e n i a . B r J Psychiatry 1996; 168: 221-26. M o j t a b a i R, Nicholson RA. I n t e r r a t e r reliability o f delusions and bizarre delusions. AmJPsyehiatry 1995; 152: 1804-06. Silbersweig DA, Stern E, F r i t h C, et ai. A f u n c t i o n a l n e u r o a n a t o m y o f hallucinations i n s c h i z o p h r e n i a . Nature 1995; 378: 176-79.
slI21