- Email: [email protected]
The relevance of somatic treatments in psychoses
361
Correspondence / Medical Hypotheses 72 (2009) 359–371
The relevance of somatic treatments in psychoses Electroconvulsive therapy (ECT) and other somatic therapies are effective in schizophrenia and affective psychoses [1,2] but do not maintain their effectiveness over sustained periods of time [1]. It is also observed that recovery from delirium is often associated with improvement in psychosis [3]. On the other hand, recovery from neurological insults often follows the pattern of ontogeny [4]. From the above observations, it can be hypothesised that psychoses and affective psychoses can be thought of as disorders of development of the central nervous system rather than aberrant conditions removed from developmental processes. This is supported by the fact that somatic treatments and delirium that cause a widespread upheaval in the brain processes are effective in such conditions and that most patients relapse after such treatments in absence of psychotropic medication. This is indicative of the fact that brain processes in certain individuals may find homeostasis and seeming stability only in a psychotic state, and that relapse after somatic treatments is actually a ‘recovery’ much like functions after stroke are recovered only gradually. This supposition can lead to the following corollaries. Firstly, schizophrenia may be an inevitable by-product of evolutionary processes in certain predisposed individuals [5]. Secondly, treatments of psychoses are unlikely to reach a state where an acute management would suffice and treatments would necessarily be prolonged. Thirdly, there is likely to be common, wide-spread and crude similarities between seemingly disparate treatments such as ECT, insulin coma and malaria therapy and delirium; and research into this would probably enable us to devise newer, more effective
and less invasive treatments for psychoses and affective psychoses. Fourthly, the effectiveness of these treatments underlines an urgent need to examine the question of Kraepelinian dichotomy. It needs to be stressed that being a developmental process does not make schizophrenia or an affective psychoses any less of a disorder, and these need to be recognised and aggressively treated. References [1] Greenhalgh J, Knight C, Hind D, Beverley C, Walters S. Clinical and costeffectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies. Health Technol Assess 2005;9:1–156. iii–iv. [2] Rudolf G. Experimental treatments of schizophrenia. J Ment Sci 1931;77:767–91. [3] Malur C, Fink M, Francis A. Can delirium relieve psychosis? Compr Psychiatry 2000;41:450–3. [4] Cramer S, Chopp M. Recovery recapitulates ontogeny. Trends Neurosci 2000;23:265–71. [5] Randall P. Schizophrenia as a consequence of brain evolution. Schizophr Re. 1998;30:143–8.
Shubh M. Singh Department of Psychiatry, Gian Sagar Medical College and Hospital, Banur 140601, Punjab, India Tel.: +91 9417249900 E-mail address: [email protected]
doi:10.1016/j.mehy.2008.11.007
The possible process of neovascularization in degeneration intervertebral disc The nucleus pulposus is an avascular tissue in the human body, residing in a physiological ischemic environment. However, in degeneration intervertebral disc the formation of small blood vessels was observed using histological examination and imaging techniques [1,2]. The adult intervertebral disc is nourished only through diffusion from upper and lower end-plate of the cartilage that is in their vicinity. With aging and degeneration, the cartilaginous end-plates undergoes ossification gradually, and is replaced by true bone. Importantly, the nutrient exchange between the vertebrate and the nucleus pulposus is possibly hindered by the new bone tissue [3]. So the nucleus pulposus environment begins to change from physiological ischemia to pathological ischemia. Protective reactions for cell survival are invoked in response to the ischemic diverse stimulation, which results in the remarkable increase of chemocytokines such as HIF-1, VEGF, and metalloproteinase. Then they play their role in the formation of capillary vessels [4,5]. The regulation of neovascularization by these chemocytokines is an important component of self-adjustment mechanisms that link vascular nutritional supply to metabolic demand. The neovascularization of degeneration intervertebral discs explain why the symptoms of sciatic pain often experienced in herniated discs gradually improve in some patients even without the surgical removal of a herniated intervertebral disc [6]. On the other hand, some studies have shown also that neovascularization of
degenerated discs is related to generation of potentially adverse nerves and the appearence of discogenic low back pain [7]. Certainly, more studies are required to confirm these ideas. Acknowledgements This work was supported by Liaoning Province Science and Technology Program (No. 2006408002-4). References [1] Yasuma T, Arai K, Yamauchi Y. The histology of lumbar intervertebral disc herniation. The significance of small blood vessels in the extruded tissue. Spine 1993;18(13):1761–5. [2] Taneichi H, Abumi K, Kaneda K, Terae S. Significance of Gd-DTPA-enhanced magnetic resonance imaging for lumbar disc herniation: the relationship between nerve root enhancement and clinical manifestations. J Spinal Disord 1994;7(2):153–60. [3] Roberts S, McCall IW, Menage J, Haddaway MJ, Eisenstein SM. Does the thickness of the vertebral subchondral bone reflect the composition of the intervertebral disc? Eur Spine J 1997;6(6):385–9. [4] Hickey MM, Simon MC. Regulation of angiogenesis by hypoxia and hypoxiainducible factors. Curr Top Dev Biol 2006;76:217–57. [5] Haro H, Kato T, Komori H, Osada M, Shinomiya K. Vascular endothelial growth factor (VEGF)-induced angiogenesis in herniated disc resorption. J Orthop Res 2002;20(3):409–15. [6] Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 1990;15(7):683–6.
Correspondence / Medical Hypotheses 72 (2009) 359–371
The relevance of somatic treatments in psychoses Electroconvulsive therapy (ECT) and other somatic therapies are effective in schizophrenia and affective psychoses [1,2] but do not maintain their effectiveness over sustained periods of time [1]. It is also observed that recovery from delirium is often associated with improvement in psychosis [3]. On the other hand, recovery from neurological insults often follows the pattern of ontogeny [4]. From the above observations, it can be hypothesised that psychoses and affective psychoses can be thought of as disorders of development of the central nervous system rather than aberrant conditions removed from developmental processes. This is supported by the fact that somatic treatments and delirium that cause a widespread upheaval in the brain processes are effective in such conditions and that most patients relapse after such treatments in absence of psychotropic medication. This is indicative of the fact that brain processes in certain individuals may find homeostasis and seeming stability only in a psychotic state, and that relapse after somatic treatments is actually a ‘recovery’ much like functions after stroke are recovered only gradually. This supposition can lead to the following corollaries. Firstly, schizophrenia may be an inevitable by-product of evolutionary processes in certain predisposed individuals [5]. Secondly, treatments of psychoses are unlikely to reach a state where an acute management would suffice and treatments would necessarily be prolonged. Thirdly, there is likely to be common, wide-spread and crude similarities between seemingly disparate treatments such as ECT, insulin coma and malaria therapy and delirium; and research into this would probably enable us to devise newer, more effective
and less invasive treatments for psychoses and affective psychoses. Fourthly, the effectiveness of these treatments underlines an urgent need to examine the question of Kraepelinian dichotomy. It needs to be stressed that being a developmental process does not make schizophrenia or an affective psychoses any less of a disorder, and these need to be recognised and aggressively treated. References [1] Greenhalgh J, Knight C, Hind D, Beverley C, Walters S. Clinical and costeffectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies. Health Technol Assess 2005;9:1–156. iii–iv. [2] Rudolf G. Experimental treatments of schizophrenia. J Ment Sci 1931;77:767–91. [3] Malur C, Fink M, Francis A. Can delirium relieve psychosis? Compr Psychiatry 2000;41:450–3. [4] Cramer S, Chopp M. Recovery recapitulates ontogeny. Trends Neurosci 2000;23:265–71. [5] Randall P. Schizophrenia as a consequence of brain evolution. Schizophr Re. 1998;30:143–8.
Shubh M. Singh Department of Psychiatry, Gian Sagar Medical College and Hospital, Banur 140601, Punjab, India Tel.: +91 9417249900 E-mail address: [email protected]
doi:10.1016/j.mehy.2008.11.007
The possible process of neovascularization in degeneration intervertebral disc The nucleus pulposus is an avascular tissue in the human body, residing in a physiological ischemic environment. However, in degeneration intervertebral disc the formation of small blood vessels was observed using histological examination and imaging techniques [1,2]. The adult intervertebral disc is nourished only through diffusion from upper and lower end-plate of the cartilage that is in their vicinity. With aging and degeneration, the cartilaginous end-plates undergoes ossification gradually, and is replaced by true bone. Importantly, the nutrient exchange between the vertebrate and the nucleus pulposus is possibly hindered by the new bone tissue [3]. So the nucleus pulposus environment begins to change from physiological ischemia to pathological ischemia. Protective reactions for cell survival are invoked in response to the ischemic diverse stimulation, which results in the remarkable increase of chemocytokines such as HIF-1, VEGF, and metalloproteinase. Then they play their role in the formation of capillary vessels [4,5]. The regulation of neovascularization by these chemocytokines is an important component of self-adjustment mechanisms that link vascular nutritional supply to metabolic demand. The neovascularization of degeneration intervertebral discs explain why the symptoms of sciatic pain often experienced in herniated discs gradually improve in some patients even without the surgical removal of a herniated intervertebral disc [6]. On the other hand, some studies have shown also that neovascularization of
degenerated discs is related to generation of potentially adverse nerves and the appearence of discogenic low back pain [7]. Certainly, more studies are required to confirm these ideas. Acknowledgements This work was supported by Liaoning Province Science and Technology Program (No. 2006408002-4). References [1] Yasuma T, Arai K, Yamauchi Y. The histology of lumbar intervertebral disc herniation. The significance of small blood vessels in the extruded tissue. Spine 1993;18(13):1761–5. [2] Taneichi H, Abumi K, Kaneda K, Terae S. Significance of Gd-DTPA-enhanced magnetic resonance imaging for lumbar disc herniation: the relationship between nerve root enhancement and clinical manifestations. J Spinal Disord 1994;7(2):153–60. [3] Roberts S, McCall IW, Menage J, Haddaway MJ, Eisenstein SM. Does the thickness of the vertebral subchondral bone reflect the composition of the intervertebral disc? Eur Spine J 1997;6(6):385–9. [4] Hickey MM, Simon MC. Regulation of angiogenesis by hypoxia and hypoxiainducible factors. Curr Top Dev Biol 2006;76:217–57. [5] Haro H, Kato T, Komori H, Osada M, Shinomiya K. Vascular endothelial growth factor (VEGF)-induced angiogenesis in herniated disc resorption. J Orthop Res 2002;20(3):409–15. [6] Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 1990;15(7):683–6.