© 2008 The Royal College of Psychiatrists
COLUMNS |
From the Editor's desk
Drunk and incapable in charge of psyche
I have never been drunk. This may seem like a boast but it reflects an inner fear. When I was an undergraduate our class did an experiment in pharmacology in which the participants had to perform simple calculations while breathing increasing concentrations of nitrous oxide. As predicted, with more nitrous oxide depressing the nervous system the performance gradually approached total incompetence, but not before I had experienced a great personal feeling of panic at my faculties slowly disintegrating, accompanied by experiences that were probably hypnogogic hallucinations in which our Lancastrian teacher's voice stridently rose in volume and his normally humorous comments were perceived as a personal threat rattling every part of my crumbling psyche. `So this is what it is to be drunk and incapable', I thought, `a temporary descent into incoherent madness', and so ended any flirtations with substance misuse for good. This issue suggests my reaction was probably a prudent one. It gives a possible explanation of the curious experiences I had at the time (Hoffmann et al, pp. 424–425) as well as some of the dangers. Gupta & Warner's prediction (pp. 351–353) of increasing alcohol-related dementia does not seem unduly alarmist on the basis of the data available, and our increasing awareness of the more subtle forms of cognitive impairment shows that these are constant companions in many illnesses. Dickinson (pp. 354–356) shows clearly that our ability to code is a core feature in many psychoses but general cognitive impairment is also common and seems to be a stable marker1 even when patients are apparently well.
The possibility that temporary or longer-term disruption to our cognitive function may make us more liable to schizophrenia and dementia is not an idle hypothesis. Cannabis not only appears to be a clear risk factor for psychosis2 but also brings forward its presentation in those who are susceptible3 and the review by Zammit et al (pp. 357–363) shows that it clearly provokes more frequent relapse, although the authors are careful not to conclude that it makes the cognitive and clinical outcome worse as the evidence is not yet available. We also need more information on cognitive functioning in outcome studies in other countries, where schizophrenia appears to respond better to treatment and have a better outcome in general;4,5 is this related to cognitive performance? Morgan et al (pp. 364–372), in their elegant paper, look at the problem from the other side, from the population that is already cognitively disabled through intellectual impairment, and by so doing give a much better appreciation of the extent of Kraepelin's Pfropfschizophrenie.6 Their prevalence figures of schizophrenia of up to 5% in those with intellectual disability is higher than other studies but the methodology is rigorous and the results convincing. So it appears that we should be paying more attention to improving the mentalising and cognitive performances in our patients with schizophrenia7,8 but if we are to do this successfully, we must follow the advice of Goss et al (pp. 416–421) and improve our patient involvement skills, perhaps adding `thinking better' to the ones of treatment satisfaction and need for care that patients commonly convey.9
It still does not quite explain why my pharmacology teacher's comments about my poor mathematical and spelling performance in the nitrous oxide experiment were perceived as so psychotically threatening. `Ee,' he said, `can't yer spell now? Yer've got to spell right if yer going to be a proper doctor, `cos if yer spell "tinnitus" and "formication" wrong yer'll get into reel trouble'. Why did this scare me so? Am I still at high risk for psychosis?10
Andrej Maru
i
The British Journal of Psychiatry is not normally celebrated for
its international outlook, but in the past ten years it has turned its face
outward at least a little way. It is sad for me to report that the person who
played a major part in initiating this change, Professor Andrej
Marui, is no longer with us. He died in June this year at the
early age of 43 and his loss will be felt tremendously by those who had the
benefit of encountering his quicksilver intellect, personal charm and immense
energy. He was invited by Greg Wilkinson, former Editor of the
Journal, to edit a new section, `Psychiatry Around the World',
published during 2003 and 2004. He was a key figure in suicide studies,
particularly in an international context, and will be missed in this growing
area of research and as a major force in Slovenian psychiatry. Our tribute to
Andrej is only one of
many11 but it is
important to us and in mourning his loss we need to trumpet the many
achievements of his tragically short life.
REFERENCES
-
1
- Goswami U, Sharma A, Khastigir U, Ferrier IN, Young AH, Gallagher
P, Thompson JM, Moore PB. Neuropsychological dysfunction, soft neurological
signs and social disability in euthymic patients with bipolar disorder.
Br J Psychiatry 2006;
188: 366
-73.
[Abstract/Free Full Text] 2 - Moore TH, Zammit S, Lingford-Hughes A, Barnes TR, Jones PB, Burke M, Lewis G. Cannabis use predicts future psychotic or affective mental health outcomes: a systematic review. Lancet 2007; 370: 319 -28.[CrossRef][Medline] 3
- Barnes TRE, Mutsatsa SH, Hutton SB, Watt HC, Joyce EM. Comorbid
substance use and age at onset of schizophrenia. Br J
Psychiatry 2006; 188: 237
-42.
[Abstract/Free Full Text] 4 - Crumlish N, Samalani P, Sefasi A, Kinsella A, O'Callaghan E,
Chilale H. Insight, psychopathology and global functioning in schizophrenia in
urban Malawi. Br J Psychiatry 2007;
191: 262-3.
[Abstract/Free Full Text] 5 - Isaac M, Chand P, Murthy P. Schizophrenia outcome measures in the
wider international community. Br J Psychiatry 2007; 191 (suppl. 50): s71
-7.
[Abstract/Free Full Text] 6 - Doody GA, Johnstone EC, Sanderson TL, Owens DG, Muir WJ.
`Pfropfschizophrenie' revisited. Schizophrenia in people with mild learning
disability. Br J Psychiatry 1998;
173: 145
-53.
[Abstract/Free Full Text] 7 - Wykes T, Reeder C, Landau S, Everitt B, Knapp M, Patel A, Romeo R.
Cognitive remediation therapy in schizophrenia: randomised controlled trial.
Br J Psychiatry 2007;
190: 421-7.
[Abstract/Free Full Text] 8 - Sprong M, Schothorst P, Vos E, Hox J, Van Engeland H. Theory of
mind in schizophrenia: meta-analysis. Br J Psychiatry 2007; 191: 5
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[Abstract/Free Full Text] 9 - McCabe R, Saidi M, Priebe S. Patient-reported outcomes in
schizophrenia. Br J Psychiatry 2007;
191 (suppl. 50): s21
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[Abstract/Free Full Text] 10 - Valmaggia LR, Freeman D, Green C, Garety P, Swapp D, Antley A,
Prescott C, Fowler D, Kuipers E, Bebbington P, Slater M, Broome M, McGuire PK.
Virtual reality and paranoid ideations in people with an `at-risk mental
state' for psychosis. Br J Psychiatry 2007; 191 (suppl. 51): s63
-8.
[Abstract/Free Full Text] 11 - Dernovek MZ, Tavèar R, Kozel D. In memoriam: Andrej
Marui. Psychiatrica Danubina 2008; 20: 252
-5.
Related articles in BJP:
- Alcohol-related dementia: a 21st-century silent epidemic?
- Susham Gupta and James Warner
BJP 2008 193: 351-353.[Abstract] [Full Text] - Digit symbol coding and general cognitive ability in schizophrenia: worth another look?
- Dwight Dickinson
BJP 2008 193: 354-356.[Abstract] [Full Text] - Effects of cannabis use on outcomes of psychotic disorders: systematic review
- Stanley Zammit, Theresa H. M. Moore, Anne Lingford-Hughes, Thomas R. E. Barnes, Peter B. Jones, Margaret Burke, and Glyn Lewis
BJP 2008 193: 357-363.[Abstract] [Full Text] - Intellectual disability co-occurring with schizophrenia and other psychiatric illness: population-based study
- Vera A. Morgan, Helen Leonard, Jenny Bourke, and Assen Jablensky
BJP 2008 193: 364-372.[Abstract] [Full Text] - Involving patients in decisions during psychiatric consultations
- Claudia Goss, Francesca Moretti, Maria Angela Mazzi, Lidia Del Piccolo, Michela Rimondini, and Christa Zimmermann
BJP 2008 193: 416-421.[Abstract] [Full Text] - Time course of regional brain activation associated with onset of auditory/verbal hallucinations
- Ralph E. Hoffman, Adam W. Anderson, Maxine Varanko, John C. Gore, and Michelle Hampson
BJP 2008 193: 424-425.[Abstract] [Full Text]
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