- Email: [email protected]
Brief sleep treatment with chlorpromazine
Brief Sleep Treatment With
Chlorpromazine
By H. SPENCER BLOCH
I
N A RECENT COMMUNICATION the psychiatric management of severely disturbed soldiers in Vietnam was described.l In that setting it was necessary to treat all manner of hospitalized psychiatric casualties on a single, small, completely open ward without facilities for sequestering violent or uncontrolled patients, without somatic therapies except for medication and with limited numbers of ward staff. It thus became necessary to devise practical and effective means of managing such patients. This paper describes one technique which became such a valuable therapeutic-diagnostic-management tool that it may have practical application for crisis intervention in the civilian community, in light of the current interest of American psychiatry in early detection and efficient management of psychiatric patients with rapid return to the community. SLEEP TREATMENT Observations about the value and dangers of sleep for mental patients were recorded in antiquity2s3. Attempts to disrupt psychotic mechanisms by periods of unconsciousness using anesthetics, alcohol and opiates were made in the latter 189Os, and around 1990 McLeod introduced bromide sleep therapy for mania.4 That may have been the first use of modern-day sleep treatment. However, most authors credit Klaesi in 19225 with the concept of narcotherapy and the technique of dauerschlaf or prolonged sleep treatment. It has been in and out of vogue since that time, always more popular abroad than in the United States, but recently reviewed here* and again discussed and utilized for research6 and treatment.7 Sleep treatment for psychiatric conditions has been described both as a therapeutic modality in itself8 and as an adjunctive therapy either for potentiating therapeutic alliance (e.g., anaclitic drug therapy9 or psychotherapy’“) or as part of a more somatically-oriented regimen (e.g., “depatterning” treatment of schizophrenics11 and “hibernation” therapyI ) . Sleep therapy has probably been attempted for patients with every psychiatric diagnosis. The reported results vary so greatly that at present no concensus exists regarding the indications for sleep treatment, the types of patients who might consistently be expected to respond favorably, and even whether it is more efficacious in psychotic or neurotic illnesses. Difficulties in assessing these results and techniques are compounded for Americans by the fact that 85 per cent of the worlds literature on sleep treatment between 1950-1960 appeared in non-English publications.3 Problems inherent in evaluating translations and assessing abstracts, in differing nosological categories H. SPENCER BLOCH, M.D.: Clinical Fellow in Psychiatry, Harvard Cambridge, Mass.; present address: Judge Baker Guidance Center/The pital Medical Center, Boston, Mass. 346
Medical School, Children’s Hos-
COMPREHENSIVEPSYCHIATRY, VOL. 11, No. 4 (JULY), 1970
BRIEF SLEEP TREATMENT
347
utilized in different countries and in differing techniques make critical comparisons difficult to the point of questionable accuracy. Traditionally and in previous studies, sleep treatment has been maintained for long periods of time (3 to 30 days, usually 10 to 20)) sometimes fairly continuously, though more often for 12-20 hours daily. At least in America the inefficiency of the technique seems to have overshadowed any therapeutic efficacy and discouraged continued investigation of its value. For the prolonged narcosis necessitated meticulous, intensive and expensive nursing care and the incidence of respiratory complications (primarily broncho-pneumonia ) was formidable (as much as 41 per cent, though less since the introduction of antibiotics)13 and mortality reported as high as 5-10 per cent in foreign literature,s though l-3 per cent in a standard American source book.14 Other reported complications include withdrawal seizures at the completion of treatment, alterations in vital signs outside of the normal range (hypotension, tachycardia, fever, rapid respirations), emesis, cough, diarrhea, atelectasis, acute renal insufficiency, toxic confusional states, embolic phenomena, coma. The technique to be described in this report utilized continuous sleep for 24 to 48 hours. The abbreviated duration of therapy minimized both the necessity for prolonged, expensive nursing care, and also the incidence of respiratory complications. SLEEP TREATMENT WITH CHLORPROMAZINE In addition to the brevity of the treatment another factor of note was the use of chlorpromazine as the narcotizing agent. (Chlorpromazine will hereafter be abbreviated CPZ. ) Historically, several different agents have been employed for achieving and maintaining narcosis in sleep therapy. Since 1952 when Deschamps used CPZ in combination with antihistamines and barbiturates in the treatment of psychoses, CPZ has been used for sleep therapy, though almost invariably in relatively small doses and in conjunction with sedative-hypnotic drugs.10,12J5J6. The CPZ was thought to potentiate the narcotizing effects of the hypnotics in a safe manner and to combat anxiety in the patients.“J* CPZ has not been used alone, apparently because it is not considered to be a soporific, though it frequently produces drowsiness, especially during the first two weeks of therapy 12$lQ.At least one early CPZ study reported that drowsiness following initial doses was a good prognostic sign.?O In the technique being reported here the therapeutic attempt was to achieve a CPZ-induced sleep without using adjunctive narcotizing medications and to do so as quickly as possible after the patient had been hospitalized and introduced to the ward staff and ward procedures. CPZ was chosen because of its relative safety with regard to serious side effects, drastic allergic reactions and lethal toxicity. It was also selected because of its reorganizing effects on human psychological life (specifically psychotic conditions). It was hoped that patients who were behaviorally disorganized might respond. RATIONALE AND TECHNIQUE OF BRIEF SLEEP TREATMENT Violent, assaultive or otherwise uncontrolled, disorganized or agitated behavior was frequently the precipitant for psychiatric hospitalization in Viet-
H. SPENCER BLOCH
348
nam. Such patients were initially introduced to the ward stafE and seen by the psychiatrist who attempted to obtain history from the patient, to assess his mental status and perform a physical examination if possible. The patient was then told that he would be given medicine which would enable him to sleep for a day or even a little longer afterwhich his condition would be much improved, for we knew this treatment to be helpful. He was then administered oral or intramuscular doses of CPZ every hour until a sound narcosis was achieved and thereafter as necessary when he awoke to maintain sleep. With regard to specific dosages, treatment was initiated and maintained with oral doses of 100400 mg. of CPZ or intramuscular doses of 50-100 mg. and occasionally 200 mg. when oral medication was refused. The size of the dose was based on subjective considerations of the man’s size, the intensity of his disorganized behavior and other factors which will be discussed later. Trihexyphenidyl (artane), 2 mg. per each 400 mg. of CPZ, was administered prophylactically for extrapyramidal side effects. This approach was used regardless of the patient’s presumptive diagnostic category. That is, the patient’s behavior and not his probable diagnosis was the indication for a trial of sleep treatment. He was put to bed on the open ward, generally without a pillow. Attention was paid to his vital signs and observation made for possible allergic phenomena and signs of respiratory distress. Physical restraints were sometimes used if necessary until sleep was achieved. At times when he awoke he was taken to the latrine when necessary. Occasionally if the patient complained of great hunger upon awakening he was fed. However, as much as possible continuous CPZ-narcosis was maintained for 24 to 48 hours and never longer than 72 hours. At that point the patient was allowed to waken and then mobilized in the ward milieu program. Three representative case histories will illustrate both the technique and the uses of this treatment modality. CASE
HISTORIES
Case 1 A 19-year-old medic with four months in Vietnam was sent in directly from his unit where he was reported to have been combative and delirious. No other history was available except that he kept calling out the name of a soldier who had been killed in action. At the time of admission he was struggling wildly, calling out to everybody who came near “Please sir, let me go get Sims. I’ve got to get him. He’s been hit. Please, let me get Sims. He’ll die. I don’t like him but, I’ve got to get him.” Meaningful cornmunication with him could not be sustained. He was experiencing illusions and perhaps hallucinating as well. He continued to attempt to get up and away from the stretcher on which he was strapped, presumably to get Sims. He was put to sleep with CPZ for 24 hours and then allowed to stay awake for a few hours around mealtimes, but kept asleep for much of the second 24 hours as well. While awake he was managed as a case of combat exhaustion. During the third day of hospitalization medication was discontinued and he was allowed to stay up and do what he wished. He was functioning appropriately and well at that time. He reported having been in severe combat within days before his symptoms developed. He performed well as he always had during battle-going to and caring for the wounded under enemy fire. Sims had been blown up at that time and he had had to collect and carry Sim’s body parts in addition to ministering to several wounded men. He persisted in his duties for days thereafter, and did not sleep for 38 hours prior to his admission. This was because
BRIEF SLEEP TREATMENT
349
he had been designated to a position of greater responsibility and felt that he sh0uk-I remain awake while there was enemy activity nearby. He had lost his taste for C-rations and had lost 5-6 pounds in three days. In this setting, as his unit prepared to move in pursuit of the enemy, he felt faint and “fainted.” That was the last thing he recalled. This history, obtained from the patient, was not corroborated but presumed to be reasonably accurate. At that point, he was still a bit emotionally labile and perhaps a little con&sivelY intense in his pleas to return to duty. However, he was eating well, was rested and without evidence of incapacitating psychiatric symptomatology. Accordingly, he was returned to full duty on his third hospital day. Casual follow-up three months later revealed him to be asymptomatic, to have been promoted and made permanent senior aidman. He had continued to serve with his combat unit, refusing opportunities to rotate out of combat conditions to a hospital job.
Case 2 A 24-year-old paratrooper with a distinguished record as a combat infantry platoon sergeant was hospitalized after he tried to leave his base camp to see General Westmoreland with a message from God. Apparently he had always performed well under stress and in combat. Then, within 10 days prior to his admission, while on a 5-day rest and recuperation period in Hong Kong, he became imbued with the beauty of nature all around him, disenchanted with the war and with fighting, and he resolved to become a stand-up singer which had been his lifelong ambition. Returning on a plane from his R&R during a severe storm, he suddenly experienced ‘*God” in the form of a deep moving feeling in his stomach. From that time on his behavior became progressively more hypomanic, his mood euphoric to the point of elation and his thinking transiently delusional (being preoccupied with the idea of spreading peace and stopping the war in God’s name). This condition culminated in his stealing a jeep to visit General Westmoreland. Although he had been heavily medicated prior to his admission, his mental status revealed typical hypomanic features of euphoria, grandiosity, vehemence, thinly-veiled irritability, flight of ideas, pressured speech, inappropriate jocularity, marked hyperactivity, and delusional ideation. There was no history of drug use. Shortly after admission he was put to sleep for 24 hours with CPZ after which his hyperactive behavior subsided and his hypomanic ideation and affect abated. He was then mobilized in the ward milieu and medications were progressively tapered and discontinued within a week. He became increasingly more appropriate in thought and action, and presented no problems in ward management. He did retain his desire and intent to be transferred from the combat unit in which he had served. He felt he would not be effective as a combat soldier because his heart was no longer in it and he worried about a recurrence of symptoms in combat and the adverse effect that would have on his men. He was discharged to full duty (to his own unit) on the 10th hospital day and was seen in casual follow-up two months later. At that point he had been transferred to a non-combat though infantry-type job and was functioning without symptoms. He had, however, retained his intention of leaving his army career and becoming a professional entertainer when he completed his present enlistment.
Case 3 A 24-year-old private was admitted from the stockade because of bizarre speech and behavior. He had been serving a sentence for failure to obey an order and for assault. The stockade personnel reported that after some initial recalcitrance his deportment had been good. Although there was a possible history of marijuana usage, no clear-cut precipitants were reported to explain the onset of his symptoms which had begun a few days prior to his admission with increasing suspiciousness and progressive fearfulness. At admission he was extremely hyperactive and exhibited logorrhea, his verbal productions being in the form of a word salad. No meaningful contact could he maintained with him and he failed to comply with any questions or instructions. He did recognize the
350
H. SPENCER
BLOCH
presence of people about him, but seemed to relate only to a fellow prisoner who was admitted at the same time and who exhibited similar symptoms. This latter factor gave rise to the possibility of a Ganser-type folie a deux, but also diagnoses of toxic psychosis, stress-induced psychosis, malingering, and a malignant functional psychosis were entertamed at admission. The patient was placed on sleep therapy for 48 hours with large doses of CPZ but his narcosis was punctuated by frequent outbursts of uncontrollable screaming and agitation which required restraining in addition to very large amounts of medication to manage. Verbal productions remained disjointed, loosened and incomprehensible. Gradually his outbursts lessened and his behavior became more manageable and tractable. At that point he was able to divulge some anamnestic data, some of which remained consistent on subsequent interviews. He reported unstable peer and family relationships and difficulties with civilian authorities during his growing and pm-service life as well as prior disciplinary action in the service, though no history of overt psychiatric disorder. He was maintained on high dose phenothiazine (CPZ 1600 mg. and trifluoperazine 40 mg. p.o. daily) for the duration of his hospitalization and evacuated from the war zotie for further treatment on his ninth hospital day. COMMENT These cases illustrate several facets of brief sleep treatment with CP’Z. As a tool for management of severely disturbed patients on an open milieu ward, this technique proved particularly effective and efficient in several respects: agitated, disruptive and assaultive patients were allowed to begin to reconstitute with a minimum of embarrassment to themselves, with a minimum of physical restraining required, and with no injury to staff or other patients. Consequently, a minimum of anxiety was aroused in fellow-patients from observing violent or agitated behavior in another patient or from the efforts of corpsmen to restrain the uncontrolled one. Especially in the presence of limited numbers of personnel who had responsibility for other patients as well, the ward corpsmen’s level of anxiety about managing such patients was reduced. As a therapeutic tool the efficacy of this technique was demonstrated particularly in the first two cases. In Case 1, a combat-exhaustion syndrome (formerly known as combat neurosis ) which phenomenologically represents a stress-induced psychotic reaction with both external precipating factors (including sleep deprivation, traumatic events, and possibly poor nutrition) and internal predisposing factors (including the inability to tolerate hostility toward a fellow soldier, anxiety associated with increased responsibility, hyperconscientiousness, and strong superego pressures) the response is dramatic. However, good results have been reported for such patients using barbiturates for sleep. Since none of our patients were treated either with other narcotizing agents or with non-soporific doses of phenothiazine for comparison of efficacy no control sample is available. After experience had been gained with this technique it was utilized for certain cases in which the primary symptomatology constituted a restriction of motor behavior, affective expression and manifest cognition, rather than uncontrolled expressions of these psychological parameters. (See References 1 and 21 for case examples.) Many of these patients were treated successfully in WWII by the technique of narco-synthesis described by Grinker and Spie-
BRIEF
SLJXEP TREATMENT
351
were used to geLz2 In narco-synthesis hypnotic medications (barbiturates) promote abreaction of repressed experiences. Symptom resolution was thought to occur through more rational integration of the stressful experience accomplished by reliving the episode in a safe, controlled environment with the aid of a psychotherapist. Those authors had hoped that narcosynthesis might be equally valuable and applicable to civilian psychiatry. This did not prove to be the case.“’ The aim of brief sleep treatment with CPZ is different from that of narcosynthesis. The former capitalizes on the as yet poorly understood psychologically restitutive powers of sleep or CPZ-induced sleep rather than on abreaction. Nevertheless, it was a technique also devised for use in war conditions and may have the same fate as narcosynthesis if used in the civilian community. Our clinica impression from 114 patients treated with brief sleep treatment with CPZ was that people with acute situational and stress psychoses, manic reactions, pathological intoxications and combat exhaustion syndromes responded remarkabIy well and dramatically to this technique. The response of patients diagnosed schizophrenic is discussed in the next section. As a pragmatic diagnostic tool, the technique proved valuable in cases such as #3 where minimal historical data were available and differential diagnosis was difficult. Especially, as in Case 3, where behavioral manifestations constituted the primary symptoms and/or masked an underlying thought disorder, this technique helped to control the former and reveal the latter. In such cases the response to sleep treatment became a prime factor in establishing a diagnosis. Those who responded favorably were diagnosed as situational or stress psychoses and those whose behavior came more under their own volition but whose thought processes remained disorganized were diagnosed schizophrenic. This is a most pragmatic approach to nosology, and some of those who responded may well have been schizophrenic or schizophreniform, and were certainly phenomenologically similar. Usually it was not possible to predict in such cases those who would respond favorably, unless on the one hand there was a history of stable premorbid adjustment and severe precipitating stress and such adjunctive factors as sleep deprivation, or on the other hand, some extraordinarily bizarre delusional or hallucinatory phenomena were exhibited in the absence of possible precipitating factors. As a rule we found that the more readily narcosis couId be obtained and the more sound the slumber, the more dramatic and salutory the therapeutic outcome. If sound sleep could be obtained within one to six hours after the initial dose of medication, then the patient’s symptoms improved markedly after the course of sleep treatment. Where sleep was achieved with difficulty during the first 12 hours and maintained with difficulty, then following the 48-hour course of treatment, significant behavioral improvement could be anticipated (though maintenance doses were required), but cognitive disorders persisted and were more evident. One phenomenon of note observed in several of the schizophrenic-type cases involved very disorganized, agitated patients who responded with a seemingly complete restitution to a non-psychotic state following sleep treatment, only to relapse within a few days and remain in a psychotic or partially
352
II. SPENCER BLOCXI
reconstituted position despite repeated courses of brief sleep treatment. Relapse usually occurred as they were being readied in the ward milieu for return to duty or shortly after they had returned to duty, Our only explanation for this phenomenon is one which presumes that external stresses can precipitate psychoses, at least in predisposed individuals. Apparently anticipation of the same fears that they would again encounter at duty was sufficient to overcome the reconstituted ego defenses of these patients and they relapsed into a psychotic response to the perceived stress. COMPLICATIONS The major complications anticipated from this technique were of two types: those related to prolonged narcosis and those related to CPZ. Regarding the former, we know of only one case in which such a complication may have developed. Within 10 days following discharge, Case 2 was hospitalized briefly for pneumonia. This group of complications was probably minimized by the relative brevity of the sleep treatment, even though bronchopneumonia is thought to occur early in the course of dauerschlaf. When this modality was first instituted, 72 hours of sleep were maintained. However, our subsequent clinical impression was that the maximum therapeutic effect was achieved by 48 hours, so our technique evolved to the use of 48 hours maximum sleep time. Regarding complications related to CPZ, because small test doses were not usually given, the potential dangers of hypotension as well as allergic reactions were probably maximized. No serious or significant complications of this nature occurred among the 114 men who received this treatment. However, the fact that most of them were young, organically-healthy soldiers in good physical condition should be emphasized. Hypotension did occur, but the men were essentially kept in bed from the time treatment began except to go to the latrine (and often taken in a wheelchair), so that the danger of injury from falling was minimized. Blood pressures were monitored every four hours in sleeping patients and when less than 90 mm. systolic (which rarely happened and primarily occurred in older men), the patient was placed in a low Trendelenburg position. No cases of jaundice, abscesses at ‘injection sites, withdrawal seizures or renal failure occurred. Dyskinetic reactions were observed occasionally but always responded to intravenously-administered diphenhydramine ( Benadryl) . The occasional use of relatively large intramuscular doses of CPZ, both initially and subsequently, also warrants discussion. Doses of 50-106 mg. were administered as often as hourly when necessary. Occasionally 266 mg. were given initially. Although large doses of CPZ can be administered intramuscularly (up to 466 mg. every 4 to 6 hours according to the prescribing literature for thorazine), and doses of 109-206 mg. have been reported in the psychiatric literature, 1g~24-27 it is invariably recommended that such doses be gradually achieved over a period of days rather than being administered initially. However, no significant complications were observed in the particular group in whom such doses were used. Again, they were almost exclusively young, physically healthy, well-conditioned men.
BRIF.F SLEEP TREATMENT
353
Many reports indicate that assaultive, destructive and agitated behavior can be controlled and improved with high dose phenothiazine.12J7J8*23 However, one recent study disputed the value of “snowing” assaultive patients, that is, rendering them “powerless, under control and often asleep through the action of a neuroleptic drug attempted through rapid dose elevation of a phenothiazine with a wide margin of safety and marked somnulent effects.“28 Appleton reported such treatment ineffective for most assaultive patients. He underscored the potential dangers of high dose phenothiazine treatment (convulsions, coma) and recommended utilizing other techniques (milieu, E’CT) for obtaining control of behavior. Although we did not encounter the side effects that Appleton anticipated, nevertheless one can hardly dispute pleas for judicious use of any treatment modality, and his points are well taken. However, comparison of his study and this one bring to light important considerations both in choice of treatment procedure and factors of relevance in comparing different studies. Appleton’s results were reported from a training institution with a well-staffed, effective and experienced treatment milieu and with a multiplicity of somatic and psychotherapeutic techniques available. The cases he reported were essentially ones in which inexperienced first-year psychiatric residents were “snowing” excited, assaultive patients in what was presented as a last-ditch, desperate attempt to control them. He suggested that the “snow” phenomenon derived primarily from the residents’ fear of the patients and anxiety about controlling their behavior and that the atmosphere of fear impeded the therapeutic efforts. In that setting the relatively rapid elevation of phenothiazines proved ineffective. In the setting from which this report originated both the treatment conditions and the view of the technique were much different. Experienced psychiatrists were conducting treatment in a setting which had no other somatic therapies and limited personnel. The modality of sleep treatment was neither presented nor communicated as a fearful reaction to the patient’s assaultiveness or threats, but rather as a valuable treatment procedure which would help the patient to readily regain self-control and self-esteem. It was highly cathected by the staff as being in everyone’s best interest, viewed optimistically, accompanied by a high level of expectation that the patient would respond favorably, and augmented by intensive use of what milieu techniques were available after the course of sleep was completed. Notwithstanding the possible fact that treatment aimed at rapidly inducing sleep with CPZ may be different from treatment aimed at reaching a level of CPZ which will tranquilize a patient, the type of considerations just noted probably have important bearing both on choice and outcome of a treatment modality. The decision about what treatment modality to utilize at any time, and even what dose of psychotherapeutic medication to administer (within certain limits) is not a decision made in vacua. Rather, it depends on the available altematives, the severity of the symptoms, evaluation of the efficacy of adjunctive factors in the patient’s environment which will aid the therapeutic endeavor, and the relative danger of the various treatment alternatives and dosages. While not recommending that drug or any other treatment be conducted in a cavalier fashion, this paper is written expressly to suggest a way of recon-
354
H. SPENCER BLOCH
stituting severely disorganized people when there are a minimum of adjunctive or alternative techniques available to the treators. One last point involves the adoption of a symptom-complex rather than a disease entity or nosological category as the indication for a trial of a treatment modality. Such an approach may be one way of beginning to bridge the difficulties alluded to in the introduction when attempting to critically evaluate and compare results of a treatment technique reported from several different countries in different languages. SUMMARY
A technique utilizing brief periods of sound narcosis (24-48 hours of sleep treatment) induced by chlorpromazine is described. It proved to be an effective and efficient therapeutic-diagnostic-management tool for severely behaviorally-disturbed and uncontrolled patients in an open, crisis-oriented milieu ward in Vietnam where no other facilities for managing such patients existed. The patient’s behavioral state (assaultive, agitated, excited, disruptive manifestations) rather than a nosological diagnostic category constituted the indication for a trial of brief sleep treatment. The success of the treatment could usually be predicted from the promptness with which the patient succumbed to the soporific effects of chlorpromazine upon its initial administration and from the “soundness” of his sleep. Thus it became particularly helpful in differentially diagnosing acute or transient psychotic stress states from the more entrenched, persistent ones. The degree to which this therapeutic tool may have aborted more lasting psychotic reactions was not assessed through the use of control patients, nor was the possible efficacy of drugs other than the antipsychotic, chlorpromazine, determined. No hypothesis for the possible specific therapeutic effects of chlorpromazine-induced sleep is advanced, though some appear in the world literature.8~gJ6~2g Because the usual complications of sleep treatment have been minimized by the particular form in which it was used here and because of the potential implications of this relatively simple and safe technique for the crisis management of severely disturbed psychiatric patients in the civilian community (secondary prevention), especially for settings which have limited psychiatric treatment resources, a description of this technique and a discussion of its results have been presented. ACKNOWLEDGMENT E. D. Longaker, M.D., Associate Director of Clinical Services, Smith Kline & French Laboratories, provided a bibliography from the world literature on the use of chlorpromazine.
REFERENCES 1. Bloch, H. S.: Army clinical psychiatry in the combat zone-1967-1968. Amer. J. Psychiat. 126:289, 1969. 2. Palmer, H.: The value of continuous narcosis in the treatment of mental disorders. J. Ment. Sci. 83:636, 1937. 3. Williams, R., and Webb, W.: Sleep
Charles C Ill., Therapy. Springfield, Thomas, 1966. 4. Palmer, H. D., and Payne, A. L.: Prolonged narcosis as therapy in the psychases. Amer. J. Psychiat. 12:143, 1933. 5. Klaesi, J.: Uber die Therapeutische Anwendung des Dauemarkose mittels som-
BBIFJ? SLEEP TREATMENT
nifens bei Schizophren.
Z. Neurol.
355
Psychiat.
74557, 1922. 6. Hartmann, E.: Dauerschlaf. Arch. Gen. Psychiat. 18:99, 1968. 7. Nilsen, J. A.: Immediate treatment expedites hospital release. Hosp. Community Psychiat. 20:20, 1969. 8. Pekarek, L., and Svestkova, H.: The treatment of psychosis by the combination ataractics and antideof sleep therapy, pressants. Int. J. Neuropsychiat. 3:72, 1967. 9. Nishizono, M.: High dose treatment with psychotherapeutic drugs seen from the psychoanalytic viewpoint. Psychosomatics 5:34, 1964. 10. Franchini, C., and Ferutta, A. M.: Sleep therapy in the treatment of neuropsychasthenia ( in Italian ) . Nevrasse 5: 692, 1955. 11. Cameron, D. E., Lohrenz, J. G., and Handcock, M. B.: The depatterning treatment of schizophrenia. Compr. Psychiat. 3:65,
1962.
12. Charatan, F. B. E.: An evaluation of chlorpromazine (“largactil”) in psychiatry. J. Ment. Sci. 100:882, 1954. 13. Clapp, J., and Loomis, E.: Continuous sleep treatment: Observations on the use of prolonged deep, continuous narcosis in mental disorders. Amer. J. Psychiat. 106:821, 1950. 14. McGraw, R., and Oliver, J.: Miscellaneous therapies. In Arieta, S. (Ed.): American Handbook of Psychiatry. New York. Basic Books, 1959, pp. 1552-1582. 15. Ey, H., and Faure, H.: Sleep therapy and the use of chlorpromazine. Int. Rec. Gen. Prac. Clin. 170:1, 1957. 16. Monnerot, E. et al; Does the sleep cure adhere to psychiatric indications? Personal observation on 700 Cases (in French). Ann. Medicopsychol. ( Paris ) 115: 845, 1957. 17. Reda, G. C., and Rambelli, L.: ficial hibernation with ganglioplegics
Arti(lar-
gactil)
in
the
treatment
of
some
mental
diseases (in Italian). Neuropsichiatria 19:31, 1954. 18. Maroncelli, P.: Treatment of some psychoses with a method derived from artificial hibernation (in Italian). G. Psichiat. Neuropat. 81:223, 1953. 19. Goldman, D.: Chlorpromazine treatment of hospitalized psychotic patients. J. Clin. Ex. Psychopath. Quart. Rev. Psychiat. Neurol. 17:45, 1956. 20. Anton-Stephens, D.: Preliminary observations on the psychiatric uses of chlorpromazine (largactil). J, Ment. Sci. 100:543, 1954. 21. Bloch, H. S.: Some interesting reaction-types seen in a war zone. (unpublished ) . 22. Grinker, R. R., and Spiegel, J. P.: Men Under Stress. New York, McGrawHill, 1963. 23. Bonello, general practice.
F. J.: Chlorpromazine in Int. Rec. Med. Gen. Prac.
Clin. 169: 197, 1956. 24. Bonafede, V. (thorazine) treatment
I.: of
Chlorpromazine disturbed epi-
leptic patients. Arch. Neurol. Psychiat. 77:243, 1957. report on 25. Pollack, B.: Preliminary 500 patients treated with thorazine at Rochester State Hospital. Psychiat. Quart. 29:439, 1965. 26. Salzberger, G. J.: Combined chlorpromazine and trifluoperazine on a readmission service. Dis. Nerv. Syst. 24:1, 1963. 27. Kinross-Wright, V.: The intensive chlorpromazine
treatment
of schizophrenia.
Psychiat. Res. Rep. 1:53, 1955. 28. Appleton, W. S.: The snow phenomenon: Tranquilizing the assaultive. Psychiatry 28:88, 1965. 29. Delay, J., and Deniker, P.: Neuroleptic effects of chlorpromazine in therapeutics of neuropsychiatry. Int. Rec. Med. Gen. Prac. Clin. 168:318, 1955.
Chlorpromazine
By H. SPENCER BLOCH
I
N A RECENT COMMUNICATION the psychiatric management of severely disturbed soldiers in Vietnam was described.l In that setting it was necessary to treat all manner of hospitalized psychiatric casualties on a single, small, completely open ward without facilities for sequestering violent or uncontrolled patients, without somatic therapies except for medication and with limited numbers of ward staff. It thus became necessary to devise practical and effective means of managing such patients. This paper describes one technique which became such a valuable therapeutic-diagnostic-management tool that it may have practical application for crisis intervention in the civilian community, in light of the current interest of American psychiatry in early detection and efficient management of psychiatric patients with rapid return to the community. SLEEP TREATMENT Observations about the value and dangers of sleep for mental patients were recorded in antiquity2s3. Attempts to disrupt psychotic mechanisms by periods of unconsciousness using anesthetics, alcohol and opiates were made in the latter 189Os, and around 1990 McLeod introduced bromide sleep therapy for mania.4 That may have been the first use of modern-day sleep treatment. However, most authors credit Klaesi in 19225 with the concept of narcotherapy and the technique of dauerschlaf or prolonged sleep treatment. It has been in and out of vogue since that time, always more popular abroad than in the United States, but recently reviewed here* and again discussed and utilized for research6 and treatment.7 Sleep treatment for psychiatric conditions has been described both as a therapeutic modality in itself8 and as an adjunctive therapy either for potentiating therapeutic alliance (e.g., anaclitic drug therapy9 or psychotherapy’“) or as part of a more somatically-oriented regimen (e.g., “depatterning” treatment of schizophrenics11 and “hibernation” therapyI ) . Sleep therapy has probably been attempted for patients with every psychiatric diagnosis. The reported results vary so greatly that at present no concensus exists regarding the indications for sleep treatment, the types of patients who might consistently be expected to respond favorably, and even whether it is more efficacious in psychotic or neurotic illnesses. Difficulties in assessing these results and techniques are compounded for Americans by the fact that 85 per cent of the worlds literature on sleep treatment between 1950-1960 appeared in non-English publications.3 Problems inherent in evaluating translations and assessing abstracts, in differing nosological categories H. SPENCER BLOCH, M.D.: Clinical Fellow in Psychiatry, Harvard Cambridge, Mass.; present address: Judge Baker Guidance Center/The pital Medical Center, Boston, Mass. 346
Medical School, Children’s Hos-
COMPREHENSIVEPSYCHIATRY, VOL. 11, No. 4 (JULY), 1970
BRIEF SLEEP TREATMENT
347
utilized in different countries and in differing techniques make critical comparisons difficult to the point of questionable accuracy. Traditionally and in previous studies, sleep treatment has been maintained for long periods of time (3 to 30 days, usually 10 to 20)) sometimes fairly continuously, though more often for 12-20 hours daily. At least in America the inefficiency of the technique seems to have overshadowed any therapeutic efficacy and discouraged continued investigation of its value. For the prolonged narcosis necessitated meticulous, intensive and expensive nursing care and the incidence of respiratory complications (primarily broncho-pneumonia ) was formidable (as much as 41 per cent, though less since the introduction of antibiotics)13 and mortality reported as high as 5-10 per cent in foreign literature,s though l-3 per cent in a standard American source book.14 Other reported complications include withdrawal seizures at the completion of treatment, alterations in vital signs outside of the normal range (hypotension, tachycardia, fever, rapid respirations), emesis, cough, diarrhea, atelectasis, acute renal insufficiency, toxic confusional states, embolic phenomena, coma. The technique to be described in this report utilized continuous sleep for 24 to 48 hours. The abbreviated duration of therapy minimized both the necessity for prolonged, expensive nursing care, and also the incidence of respiratory complications. SLEEP TREATMENT WITH CHLORPROMAZINE In addition to the brevity of the treatment another factor of note was the use of chlorpromazine as the narcotizing agent. (Chlorpromazine will hereafter be abbreviated CPZ. ) Historically, several different agents have been employed for achieving and maintaining narcosis in sleep therapy. Since 1952 when Deschamps used CPZ in combination with antihistamines and barbiturates in the treatment of psychoses, CPZ has been used for sleep therapy, though almost invariably in relatively small doses and in conjunction with sedative-hypnotic drugs.10,12J5J6. The CPZ was thought to potentiate the narcotizing effects of the hypnotics in a safe manner and to combat anxiety in the patients.“J* CPZ has not been used alone, apparently because it is not considered to be a soporific, though it frequently produces drowsiness, especially during the first two weeks of therapy 12$lQ.At least one early CPZ study reported that drowsiness following initial doses was a good prognostic sign.?O In the technique being reported here the therapeutic attempt was to achieve a CPZ-induced sleep without using adjunctive narcotizing medications and to do so as quickly as possible after the patient had been hospitalized and introduced to the ward staff and ward procedures. CPZ was chosen because of its relative safety with regard to serious side effects, drastic allergic reactions and lethal toxicity. It was also selected because of its reorganizing effects on human psychological life (specifically psychotic conditions). It was hoped that patients who were behaviorally disorganized might respond. RATIONALE AND TECHNIQUE OF BRIEF SLEEP TREATMENT Violent, assaultive or otherwise uncontrolled, disorganized or agitated behavior was frequently the precipitant for psychiatric hospitalization in Viet-
H. SPENCER BLOCH
348
nam. Such patients were initially introduced to the ward stafE and seen by the psychiatrist who attempted to obtain history from the patient, to assess his mental status and perform a physical examination if possible. The patient was then told that he would be given medicine which would enable him to sleep for a day or even a little longer afterwhich his condition would be much improved, for we knew this treatment to be helpful. He was then administered oral or intramuscular doses of CPZ every hour until a sound narcosis was achieved and thereafter as necessary when he awoke to maintain sleep. With regard to specific dosages, treatment was initiated and maintained with oral doses of 100400 mg. of CPZ or intramuscular doses of 50-100 mg. and occasionally 200 mg. when oral medication was refused. The size of the dose was based on subjective considerations of the man’s size, the intensity of his disorganized behavior and other factors which will be discussed later. Trihexyphenidyl (artane), 2 mg. per each 400 mg. of CPZ, was administered prophylactically for extrapyramidal side effects. This approach was used regardless of the patient’s presumptive diagnostic category. That is, the patient’s behavior and not his probable diagnosis was the indication for a trial of sleep treatment. He was put to bed on the open ward, generally without a pillow. Attention was paid to his vital signs and observation made for possible allergic phenomena and signs of respiratory distress. Physical restraints were sometimes used if necessary until sleep was achieved. At times when he awoke he was taken to the latrine when necessary. Occasionally if the patient complained of great hunger upon awakening he was fed. However, as much as possible continuous CPZ-narcosis was maintained for 24 to 48 hours and never longer than 72 hours. At that point the patient was allowed to waken and then mobilized in the ward milieu program. Three representative case histories will illustrate both the technique and the uses of this treatment modality. CASE
HISTORIES
Case 1 A 19-year-old medic with four months in Vietnam was sent in directly from his unit where he was reported to have been combative and delirious. No other history was available except that he kept calling out the name of a soldier who had been killed in action. At the time of admission he was struggling wildly, calling out to everybody who came near “Please sir, let me go get Sims. I’ve got to get him. He’s been hit. Please, let me get Sims. He’ll die. I don’t like him but, I’ve got to get him.” Meaningful cornmunication with him could not be sustained. He was experiencing illusions and perhaps hallucinating as well. He continued to attempt to get up and away from the stretcher on which he was strapped, presumably to get Sims. He was put to sleep with CPZ for 24 hours and then allowed to stay awake for a few hours around mealtimes, but kept asleep for much of the second 24 hours as well. While awake he was managed as a case of combat exhaustion. During the third day of hospitalization medication was discontinued and he was allowed to stay up and do what he wished. He was functioning appropriately and well at that time. He reported having been in severe combat within days before his symptoms developed. He performed well as he always had during battle-going to and caring for the wounded under enemy fire. Sims had been blown up at that time and he had had to collect and carry Sim’s body parts in addition to ministering to several wounded men. He persisted in his duties for days thereafter, and did not sleep for 38 hours prior to his admission. This was because
BRIEF SLEEP TREATMENT
349
he had been designated to a position of greater responsibility and felt that he sh0uk-I remain awake while there was enemy activity nearby. He had lost his taste for C-rations and had lost 5-6 pounds in three days. In this setting, as his unit prepared to move in pursuit of the enemy, he felt faint and “fainted.” That was the last thing he recalled. This history, obtained from the patient, was not corroborated but presumed to be reasonably accurate. At that point, he was still a bit emotionally labile and perhaps a little con&sivelY intense in his pleas to return to duty. However, he was eating well, was rested and without evidence of incapacitating psychiatric symptomatology. Accordingly, he was returned to full duty on his third hospital day. Casual follow-up three months later revealed him to be asymptomatic, to have been promoted and made permanent senior aidman. He had continued to serve with his combat unit, refusing opportunities to rotate out of combat conditions to a hospital job.
Case 2 A 24-year-old paratrooper with a distinguished record as a combat infantry platoon sergeant was hospitalized after he tried to leave his base camp to see General Westmoreland with a message from God. Apparently he had always performed well under stress and in combat. Then, within 10 days prior to his admission, while on a 5-day rest and recuperation period in Hong Kong, he became imbued with the beauty of nature all around him, disenchanted with the war and with fighting, and he resolved to become a stand-up singer which had been his lifelong ambition. Returning on a plane from his R&R during a severe storm, he suddenly experienced ‘*God” in the form of a deep moving feeling in his stomach. From that time on his behavior became progressively more hypomanic, his mood euphoric to the point of elation and his thinking transiently delusional (being preoccupied with the idea of spreading peace and stopping the war in God’s name). This condition culminated in his stealing a jeep to visit General Westmoreland. Although he had been heavily medicated prior to his admission, his mental status revealed typical hypomanic features of euphoria, grandiosity, vehemence, thinly-veiled irritability, flight of ideas, pressured speech, inappropriate jocularity, marked hyperactivity, and delusional ideation. There was no history of drug use. Shortly after admission he was put to sleep for 24 hours with CPZ after which his hyperactive behavior subsided and his hypomanic ideation and affect abated. He was then mobilized in the ward milieu and medications were progressively tapered and discontinued within a week. He became increasingly more appropriate in thought and action, and presented no problems in ward management. He did retain his desire and intent to be transferred from the combat unit in which he had served. He felt he would not be effective as a combat soldier because his heart was no longer in it and he worried about a recurrence of symptoms in combat and the adverse effect that would have on his men. He was discharged to full duty (to his own unit) on the 10th hospital day and was seen in casual follow-up two months later. At that point he had been transferred to a non-combat though infantry-type job and was functioning without symptoms. He had, however, retained his intention of leaving his army career and becoming a professional entertainer when he completed his present enlistment.
Case 3 A 24-year-old private was admitted from the stockade because of bizarre speech and behavior. He had been serving a sentence for failure to obey an order and for assault. The stockade personnel reported that after some initial recalcitrance his deportment had been good. Although there was a possible history of marijuana usage, no clear-cut precipitants were reported to explain the onset of his symptoms which had begun a few days prior to his admission with increasing suspiciousness and progressive fearfulness. At admission he was extremely hyperactive and exhibited logorrhea, his verbal productions being in the form of a word salad. No meaningful contact could he maintained with him and he failed to comply with any questions or instructions. He did recognize the
350
H. SPENCER
BLOCH
presence of people about him, but seemed to relate only to a fellow prisoner who was admitted at the same time and who exhibited similar symptoms. This latter factor gave rise to the possibility of a Ganser-type folie a deux, but also diagnoses of toxic psychosis, stress-induced psychosis, malingering, and a malignant functional psychosis were entertamed at admission. The patient was placed on sleep therapy for 48 hours with large doses of CPZ but his narcosis was punctuated by frequent outbursts of uncontrollable screaming and agitation which required restraining in addition to very large amounts of medication to manage. Verbal productions remained disjointed, loosened and incomprehensible. Gradually his outbursts lessened and his behavior became more manageable and tractable. At that point he was able to divulge some anamnestic data, some of which remained consistent on subsequent interviews. He reported unstable peer and family relationships and difficulties with civilian authorities during his growing and pm-service life as well as prior disciplinary action in the service, though no history of overt psychiatric disorder. He was maintained on high dose phenothiazine (CPZ 1600 mg. and trifluoperazine 40 mg. p.o. daily) for the duration of his hospitalization and evacuated from the war zotie for further treatment on his ninth hospital day. COMMENT These cases illustrate several facets of brief sleep treatment with CP’Z. As a tool for management of severely disturbed patients on an open milieu ward, this technique proved particularly effective and efficient in several respects: agitated, disruptive and assaultive patients were allowed to begin to reconstitute with a minimum of embarrassment to themselves, with a minimum of physical restraining required, and with no injury to staff or other patients. Consequently, a minimum of anxiety was aroused in fellow-patients from observing violent or agitated behavior in another patient or from the efforts of corpsmen to restrain the uncontrolled one. Especially in the presence of limited numbers of personnel who had responsibility for other patients as well, the ward corpsmen’s level of anxiety about managing such patients was reduced. As a therapeutic tool the efficacy of this technique was demonstrated particularly in the first two cases. In Case 1, a combat-exhaustion syndrome (formerly known as combat neurosis ) which phenomenologically represents a stress-induced psychotic reaction with both external precipating factors (including sleep deprivation, traumatic events, and possibly poor nutrition) and internal predisposing factors (including the inability to tolerate hostility toward a fellow soldier, anxiety associated with increased responsibility, hyperconscientiousness, and strong superego pressures) the response is dramatic. However, good results have been reported for such patients using barbiturates for sleep. Since none of our patients were treated either with other narcotizing agents or with non-soporific doses of phenothiazine for comparison of efficacy no control sample is available. After experience had been gained with this technique it was utilized for certain cases in which the primary symptomatology constituted a restriction of motor behavior, affective expression and manifest cognition, rather than uncontrolled expressions of these psychological parameters. (See References 1 and 21 for case examples.) Many of these patients were treated successfully in WWII by the technique of narco-synthesis described by Grinker and Spie-
BRIEF
SLJXEP TREATMENT
351
were used to geLz2 In narco-synthesis hypnotic medications (barbiturates) promote abreaction of repressed experiences. Symptom resolution was thought to occur through more rational integration of the stressful experience accomplished by reliving the episode in a safe, controlled environment with the aid of a psychotherapist. Those authors had hoped that narcosynthesis might be equally valuable and applicable to civilian psychiatry. This did not prove to be the case.“’ The aim of brief sleep treatment with CPZ is different from that of narcosynthesis. The former capitalizes on the as yet poorly understood psychologically restitutive powers of sleep or CPZ-induced sleep rather than on abreaction. Nevertheless, it was a technique also devised for use in war conditions and may have the same fate as narcosynthesis if used in the civilian community. Our clinica impression from 114 patients treated with brief sleep treatment with CPZ was that people with acute situational and stress psychoses, manic reactions, pathological intoxications and combat exhaustion syndromes responded remarkabIy well and dramatically to this technique. The response of patients diagnosed schizophrenic is discussed in the next section. As a pragmatic diagnostic tool, the technique proved valuable in cases such as #3 where minimal historical data were available and differential diagnosis was difficult. Especially, as in Case 3, where behavioral manifestations constituted the primary symptoms and/or masked an underlying thought disorder, this technique helped to control the former and reveal the latter. In such cases the response to sleep treatment became a prime factor in establishing a diagnosis. Those who responded favorably were diagnosed as situational or stress psychoses and those whose behavior came more under their own volition but whose thought processes remained disorganized were diagnosed schizophrenic. This is a most pragmatic approach to nosology, and some of those who responded may well have been schizophrenic or schizophreniform, and were certainly phenomenologically similar. Usually it was not possible to predict in such cases those who would respond favorably, unless on the one hand there was a history of stable premorbid adjustment and severe precipitating stress and such adjunctive factors as sleep deprivation, or on the other hand, some extraordinarily bizarre delusional or hallucinatory phenomena were exhibited in the absence of possible precipitating factors. As a rule we found that the more readily narcosis couId be obtained and the more sound the slumber, the more dramatic and salutory the therapeutic outcome. If sound sleep could be obtained within one to six hours after the initial dose of medication, then the patient’s symptoms improved markedly after the course of sleep treatment. Where sleep was achieved with difficulty during the first 12 hours and maintained with difficulty, then following the 48-hour course of treatment, significant behavioral improvement could be anticipated (though maintenance doses were required), but cognitive disorders persisted and were more evident. One phenomenon of note observed in several of the schizophrenic-type cases involved very disorganized, agitated patients who responded with a seemingly complete restitution to a non-psychotic state following sleep treatment, only to relapse within a few days and remain in a psychotic or partially
352
II. SPENCER BLOCXI
reconstituted position despite repeated courses of brief sleep treatment. Relapse usually occurred as they were being readied in the ward milieu for return to duty or shortly after they had returned to duty, Our only explanation for this phenomenon is one which presumes that external stresses can precipitate psychoses, at least in predisposed individuals. Apparently anticipation of the same fears that they would again encounter at duty was sufficient to overcome the reconstituted ego defenses of these patients and they relapsed into a psychotic response to the perceived stress. COMPLICATIONS The major complications anticipated from this technique were of two types: those related to prolonged narcosis and those related to CPZ. Regarding the former, we know of only one case in which such a complication may have developed. Within 10 days following discharge, Case 2 was hospitalized briefly for pneumonia. This group of complications was probably minimized by the relative brevity of the sleep treatment, even though bronchopneumonia is thought to occur early in the course of dauerschlaf. When this modality was first instituted, 72 hours of sleep were maintained. However, our subsequent clinical impression was that the maximum therapeutic effect was achieved by 48 hours, so our technique evolved to the use of 48 hours maximum sleep time. Regarding complications related to CPZ, because small test doses were not usually given, the potential dangers of hypotension as well as allergic reactions were probably maximized. No serious or significant complications of this nature occurred among the 114 men who received this treatment. However, the fact that most of them were young, organically-healthy soldiers in good physical condition should be emphasized. Hypotension did occur, but the men were essentially kept in bed from the time treatment began except to go to the latrine (and often taken in a wheelchair), so that the danger of injury from falling was minimized. Blood pressures were monitored every four hours in sleeping patients and when less than 90 mm. systolic (which rarely happened and primarily occurred in older men), the patient was placed in a low Trendelenburg position. No cases of jaundice, abscesses at ‘injection sites, withdrawal seizures or renal failure occurred. Dyskinetic reactions were observed occasionally but always responded to intravenously-administered diphenhydramine ( Benadryl) . The occasional use of relatively large intramuscular doses of CPZ, both initially and subsequently, also warrants discussion. Doses of 50-106 mg. were administered as often as hourly when necessary. Occasionally 266 mg. were given initially. Although large doses of CPZ can be administered intramuscularly (up to 466 mg. every 4 to 6 hours according to the prescribing literature for thorazine), and doses of 109-206 mg. have been reported in the psychiatric literature, 1g~24-27 it is invariably recommended that such doses be gradually achieved over a period of days rather than being administered initially. However, no significant complications were observed in the particular group in whom such doses were used. Again, they were almost exclusively young, physically healthy, well-conditioned men.
BRIF.F SLEEP TREATMENT
353
Many reports indicate that assaultive, destructive and agitated behavior can be controlled and improved with high dose phenothiazine.12J7J8*23 However, one recent study disputed the value of “snowing” assaultive patients, that is, rendering them “powerless, under control and often asleep through the action of a neuroleptic drug attempted through rapid dose elevation of a phenothiazine with a wide margin of safety and marked somnulent effects.“28 Appleton reported such treatment ineffective for most assaultive patients. He underscored the potential dangers of high dose phenothiazine treatment (convulsions, coma) and recommended utilizing other techniques (milieu, E’CT) for obtaining control of behavior. Although we did not encounter the side effects that Appleton anticipated, nevertheless one can hardly dispute pleas for judicious use of any treatment modality, and his points are well taken. However, comparison of his study and this one bring to light important considerations both in choice of treatment procedure and factors of relevance in comparing different studies. Appleton’s results were reported from a training institution with a well-staffed, effective and experienced treatment milieu and with a multiplicity of somatic and psychotherapeutic techniques available. The cases he reported were essentially ones in which inexperienced first-year psychiatric residents were “snowing” excited, assaultive patients in what was presented as a last-ditch, desperate attempt to control them. He suggested that the “snow” phenomenon derived primarily from the residents’ fear of the patients and anxiety about controlling their behavior and that the atmosphere of fear impeded the therapeutic efforts. In that setting the relatively rapid elevation of phenothiazines proved ineffective. In the setting from which this report originated both the treatment conditions and the view of the technique were much different. Experienced psychiatrists were conducting treatment in a setting which had no other somatic therapies and limited personnel. The modality of sleep treatment was neither presented nor communicated as a fearful reaction to the patient’s assaultiveness or threats, but rather as a valuable treatment procedure which would help the patient to readily regain self-control and self-esteem. It was highly cathected by the staff as being in everyone’s best interest, viewed optimistically, accompanied by a high level of expectation that the patient would respond favorably, and augmented by intensive use of what milieu techniques were available after the course of sleep was completed. Notwithstanding the possible fact that treatment aimed at rapidly inducing sleep with CPZ may be different from treatment aimed at reaching a level of CPZ which will tranquilize a patient, the type of considerations just noted probably have important bearing both on choice and outcome of a treatment modality. The decision about what treatment modality to utilize at any time, and even what dose of psychotherapeutic medication to administer (within certain limits) is not a decision made in vacua. Rather, it depends on the available altematives, the severity of the symptoms, evaluation of the efficacy of adjunctive factors in the patient’s environment which will aid the therapeutic endeavor, and the relative danger of the various treatment alternatives and dosages. While not recommending that drug or any other treatment be conducted in a cavalier fashion, this paper is written expressly to suggest a way of recon-
354
H. SPENCER BLOCH
stituting severely disorganized people when there are a minimum of adjunctive or alternative techniques available to the treators. One last point involves the adoption of a symptom-complex rather than a disease entity or nosological category as the indication for a trial of a treatment modality. Such an approach may be one way of beginning to bridge the difficulties alluded to in the introduction when attempting to critically evaluate and compare results of a treatment technique reported from several different countries in different languages. SUMMARY
A technique utilizing brief periods of sound narcosis (24-48 hours of sleep treatment) induced by chlorpromazine is described. It proved to be an effective and efficient therapeutic-diagnostic-management tool for severely behaviorally-disturbed and uncontrolled patients in an open, crisis-oriented milieu ward in Vietnam where no other facilities for managing such patients existed. The patient’s behavioral state (assaultive, agitated, excited, disruptive manifestations) rather than a nosological diagnostic category constituted the indication for a trial of brief sleep treatment. The success of the treatment could usually be predicted from the promptness with which the patient succumbed to the soporific effects of chlorpromazine upon its initial administration and from the “soundness” of his sleep. Thus it became particularly helpful in differentially diagnosing acute or transient psychotic stress states from the more entrenched, persistent ones. The degree to which this therapeutic tool may have aborted more lasting psychotic reactions was not assessed through the use of control patients, nor was the possible efficacy of drugs other than the antipsychotic, chlorpromazine, determined. No hypothesis for the possible specific therapeutic effects of chlorpromazine-induced sleep is advanced, though some appear in the world literature.8~gJ6~2g Because the usual complications of sleep treatment have been minimized by the particular form in which it was used here and because of the potential implications of this relatively simple and safe technique for the crisis management of severely disturbed psychiatric patients in the civilian community (secondary prevention), especially for settings which have limited psychiatric treatment resources, a description of this technique and a discussion of its results have been presented. ACKNOWLEDGMENT E. D. Longaker, M.D., Associate Director of Clinical Services, Smith Kline & French Laboratories, provided a bibliography from the world literature on the use of chlorpromazine.
REFERENCES 1. Bloch, H. S.: Army clinical psychiatry in the combat zone-1967-1968. Amer. J. Psychiat. 126:289, 1969. 2. Palmer, H.: The value of continuous narcosis in the treatment of mental disorders. J. Ment. Sci. 83:636, 1937. 3. Williams, R., and Webb, W.: Sleep
Charles C Ill., Therapy. Springfield, Thomas, 1966. 4. Palmer, H. D., and Payne, A. L.: Prolonged narcosis as therapy in the psychases. Amer. J. Psychiat. 12:143, 1933. 5. Klaesi, J.: Uber die Therapeutische Anwendung des Dauemarkose mittels som-
BBIFJ? SLEEP TREATMENT
nifens bei Schizophren.
Z. Neurol.
355
Psychiat.
74557, 1922. 6. Hartmann, E.: Dauerschlaf. Arch. Gen. Psychiat. 18:99, 1968. 7. Nilsen, J. A.: Immediate treatment expedites hospital release. Hosp. Community Psychiat. 20:20, 1969. 8. Pekarek, L., and Svestkova, H.: The treatment of psychosis by the combination ataractics and antideof sleep therapy, pressants. Int. J. Neuropsychiat. 3:72, 1967. 9. Nishizono, M.: High dose treatment with psychotherapeutic drugs seen from the psychoanalytic viewpoint. Psychosomatics 5:34, 1964. 10. Franchini, C., and Ferutta, A. M.: Sleep therapy in the treatment of neuropsychasthenia ( in Italian ) . Nevrasse 5: 692, 1955. 11. Cameron, D. E., Lohrenz, J. G., and Handcock, M. B.: The depatterning treatment of schizophrenia. Compr. Psychiat. 3:65,
1962.
12. Charatan, F. B. E.: An evaluation of chlorpromazine (“largactil”) in psychiatry. J. Ment. Sci. 100:882, 1954. 13. Clapp, J., and Loomis, E.: Continuous sleep treatment: Observations on the use of prolonged deep, continuous narcosis in mental disorders. Amer. J. Psychiat. 106:821, 1950. 14. McGraw, R., and Oliver, J.: Miscellaneous therapies. In Arieta, S. (Ed.): American Handbook of Psychiatry. New York. Basic Books, 1959, pp. 1552-1582. 15. Ey, H., and Faure, H.: Sleep therapy and the use of chlorpromazine. Int. Rec. Gen. Prac. Clin. 170:1, 1957. 16. Monnerot, E. et al; Does the sleep cure adhere to psychiatric indications? Personal observation on 700 Cases (in French). Ann. Medicopsychol. ( Paris ) 115: 845, 1957. 17. Reda, G. C., and Rambelli, L.: ficial hibernation with ganglioplegics
Arti(lar-
gactil)
in
the
treatment
of
some
mental
diseases (in Italian). Neuropsichiatria 19:31, 1954. 18. Maroncelli, P.: Treatment of some psychoses with a method derived from artificial hibernation (in Italian). G. Psichiat. Neuropat. 81:223, 1953. 19. Goldman, D.: Chlorpromazine treatment of hospitalized psychotic patients. J. Clin. Ex. Psychopath. Quart. Rev. Psychiat. Neurol. 17:45, 1956. 20. Anton-Stephens, D.: Preliminary observations on the psychiatric uses of chlorpromazine (largactil). J, Ment. Sci. 100:543, 1954. 21. Bloch, H. S.: Some interesting reaction-types seen in a war zone. (unpublished ) . 22. Grinker, R. R., and Spiegel, J. P.: Men Under Stress. New York, McGrawHill, 1963. 23. Bonello, general practice.
F. J.: Chlorpromazine in Int. Rec. Med. Gen. Prac.
Clin. 169: 197, 1956. 24. Bonafede, V. (thorazine) treatment
I.: of
Chlorpromazine disturbed epi-
leptic patients. Arch. Neurol. Psychiat. 77:243, 1957. report on 25. Pollack, B.: Preliminary 500 patients treated with thorazine at Rochester State Hospital. Psychiat. Quart. 29:439, 1965. 26. Salzberger, G. J.: Combined chlorpromazine and trifluoperazine on a readmission service. Dis. Nerv. Syst. 24:1, 1963. 27. Kinross-Wright, V.: The intensive chlorpromazine
treatment
of schizophrenia.
Psychiat. Res. Rep. 1:53, 1955. 28. Appleton, W. S.: The snow phenomenon: Tranquilizing the assaultive. Psychiatry 28:88, 1965. 29. Delay, J., and Deniker, P.: Neuroleptic effects of chlorpromazine in therapeutics of neuropsychiatry. Int. Rec. Med. Gen. Prac. Clin. 168:318, 1955.