Biology and consciousness

LETTERS Do medications reduce cerebral blood flow in COPD patients? Sir: In their comprehensive review of the literature, Greenberg, Ryan, and Bourlier (Psychosomatics 26:29-33, 1985) thoroughly describe the psychological and behavioral difficulties seen in patients with chronic pulmonary disease (COPO). The clinical improvement of patients receiving supplemental oxygen in the Nocturnal Oxygen Therapy Trials'" suggests that the patients' cerebral oxygen delivery may have been compromised as a consequence of their disease. While the patients in these studies received bronchodilating drugs, apparently no attempt was made to evaluate the possibility that decreased cerebral blood perfusion secondary to these medications might have contributed to the functional deficits observed. This omission is particularly striking in light of published findings that aminophylline, one of the most frequently administered bronchodilators, has led to reduced regional cerebral blood flow (rCBF) in patients with cerebrovascular disease'" and that neuropsychological performance in young asthmatic patients has been affected adversely by the administration of corticosteroids or aminophylline. '.. One double-blind investigation 7 found that aminophylline was associated with greater deficits on standard neuropsychological tests as well as on parental ratings of mood and behavior than was an alternative bronchodilating drug. Nonetheless, the literature contains no documentation that aminophylline can result in rCBF changes in adult patients suffering from COPO.

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We assessed the effect of aminophylline (the ethylenediamine salt of theophylline) on rCBF in five patients with moderate to severe COPO confirmed by history, examination, and pulmonary function studies. We determined rCBF with the xenon-133 washout technique, modified from Obrist et al," using intravenously administered xenon-133. Patients discontinued all theophylline-containing preparations at least four days prior to the study. Following determination of baseline rCBF, each patient received a standard intravenous loading dose of aminophylline of 6 mg/kg within a 30minute infusion period and was switched to a maintenance infusion of 0.5 mg/kg/hr. A second rCBF determination was obtained at the conclusion of the loading infusion and a third during the maintenance period (two hours later in four patients; 24 hours later in the fifth patient). Therapeutic blood levels of the drug had been reached at the time of the second and third rCBF assessments (mean theophylline levels of 13.1 g/mL in both acute and maintenance phases). The rCBF, calculated as mL blood/loo g gray matter/minute, decreased an average of 25.9% from baseline to post-loading and 22.4% from baseline to maintenance. All decreases were highly significant statistically. This evidence of a substantial drop in rCBF following administration of aminophylline raises the possibility that at least a portion ofthe functional and neuropsychological impairment reported in patients with COPO may be attributed to their therapeutic regimen. If this is true, patients with reduced rCBF as a consequence of underlying cerebrovascular disease or polycythemia may be at increased risk

of cerebral ischemia if treated with aminophylline preparations at current standard dosages. It is possible that changing therapeutic regimens to alternative bronchodilating agents that do not produce such profound decreases in cerebral perfusion would result in improvements in patients' functional status without requiring additional treatment with supplemental oxygen. Larry D. Young. Ph.D. David Bowton, M.D. Peter Alford. M.D. Byron McLees. M.D. Wake Forest University

REFERENCES 1. Nocturnal Oxygen Therapy Trial Group: Con· tinuous or nocturnal oxygen therapy in hy· poxemic chronic obstructive lung disease. Ann Intern Med 93391-398. 1980. 2 Heaton RD, Grant I, McSweeny AJ, et al: Psy· chological effects of continuous and noctur· nal oxygen therapy in hypoxemic chronic obstructive pulmonary disease. Arch Intern Med1243:1941·1947,1983. 3. Gottstein U, Held K, Sebening H. et al: Is decrease of cerebral blood flow after intravenous injections of theophylline due to direct vasoconstrictive action of the drug? Eur Neuro/6:153-157,1971-72. 4. Gottstein U, Paulson OP: The effects of intracarotid aminophylline infusion on the cerebral circulation Stroke 3:560-565. 1971. 5. Dunleavy RA: Neuropsychological correlates of asthma: Effects of hypoxia or drugs? J Consult Clin Psycho/49:137, 1981. 6. Suess WM, Chai H: Neuropsychological cor· relates of asthma: Brain damage or drug effects? J Consult Clin Psychol 49:135·136, 1981. 7. Furukawa CT, Shapiro GG, DuHamel T. et al: Learning and behavior problems associated with theophyltine therapy. Lancet 1:621, 1984 8. Obrist W, Thompson HK. Wang HS, et al: Regional cerabral blood flow estimated by ''''xe_ non inhalation. Stroke 6:245-246, 1975.

Biology and consciousness Sir: In his editorial, "Biologic psychiatry and the psychosomatic approach" (Psychosomatics 26:478, 1985), Or. Judd Marmor warns of the PSYCHOSOMATICS

LETTERS reductionistic dangers in 'relying too heavily on a predominantly biologic approach' to patients, in which subjective experience is minimized. By thus placing biology at conceptual odds with subjectivity, Dr. Marmor himself participates in reductionistic thinking. To differentiate biology from subjectivity is to enact the Cartesian notion of mind-body dualism that insidiously persists in psychiatry. Mind and body are not predicated of different essences that somehow interact with each other. Rather, psyche and soma reflect different organizational levels of biology. The field of consciousness is no less biological than is a cell in the frontal granular cortex. A conscious field is, however, organizationally more complex, and transcendent in that it is not reducible to its enfolded sub-organizations (which include cells in the frontal cortex). Psychiatry is inevitably biological. It need not turn away from itself to embrace consciousness. Thomas D. Geracioti. M.D. University o/California San Francisco The author replies:

It seems to me that Dr. Geracioti is confusing an important theoretical issue with a clinical one. I am, of course, in complete agreement with his statement about the essential unity of mind and body. What I was referring to in my editorial, however, was the question of how one deals clinically with this unity, and I suggested that a bio-psycho-social treatment appreach is the most effective way of coping with most psychosomatic pathology. I was not in any way implying that we ought to turn away from APRIL 1986· VOL 27 • NO 4

the valuable understanding that new research in biology is giving us; rather, I was calling attention to the fact that psychosocial factors inevitably become reflected at biological levels, and must not therefore be ignored in any program of comprehensive treatment. Such a clinical approach is in complete harmony with the theoretical model of mind-body duality and, indeed, is derived from it. Judd Marmor. M.D. Los Angeles

Consultee confusion Sir: We read the recent article by Golinger and associates, "Clarity of request for psychiatric consultation: Its relationship to psychiatric diagnosis" (Psychosomatics 26:649-653, 1985), with great interest, especially since we provide freq.Jent psychiatric consultation to the large medical, surgical, and emergency services in our hospital. Their finding that major mental illness was diagnosed almost twice as often when the request for consultation was unclear versus when the request was clear is consistent with our experience that difficult patients contribute to miscommunication between members of the treatment team and that requests for consultation may signal distress or confusion on the part of the consultee. I Anxiety certainly contributes to the unclarity, as the authors suggest, although we frequently find that simple lack ofknowledge and inexperience with major mental illness also commonly contribute to consultees• inability to articulate clearly their observations and requests. Faced with serious psychopathology, nonpsychiatric clinicians may quickly react by thinking "psych

consult" and then stop pursuing assessment and treatment on their own. We agree with Golinger and associates that an unclear request should prompt the consultant to look for serious psychiatric disorder, and we hasten to add that the consultant should also address and attempt to assuage the consultee's anxiety. This can often be done through an educational approach. Teaching the consultee about the patient's psychiatric illness helps relieve anxiety by restoring a sense of competence and control, and may pay the bonus of making him or her a better consultee in the future. Michael F. Hoyt. Ph.D. Frederick C. Bittiko/er. M.D. Norman W. Weinstein. M.D. Kaiser-Permanente Medical Center Hayward. Calif.

REFERENCE 1. Hoyl MF, Opsvig P, Weinstein NW: Conjoint patient-staff interview in hospital case management 1m J Psychiatry Med 11 :83-87, 1981

Scan orientation corrected Sir: The article' 'CT scanning in psychiatric inpatients: Clinical yield," by Beresford and associates (Psychosomatics 27: 105-112, 1986), is excellently illustrated by CT scan images of the brain. However, the orientation of the photographs as described in the caption appears incorrect. Theodore Pearlman. M.D. Houston

Dr. Pearlman is correct. The caption should have read: "The figures should be viewed as if you were looking up from beneath the chin." We apologize for this error. The Editors