Dr. Grossi's Blog
Disturbances of the sleep cycle are among the most common disturbances associated with psychiatric disorders. The most common sleep disturbance is insomnia but oversleeping can also be an issue. Insomnia can involve falling asleep (initial insomnia), staying asleep (middle insomnia), or early morning awakening (delayed insomnia). Usually people with this problem do not feel rested when awakened and usually experience irritability, anxiety, fatigue and reduced productivity the following day. I intend to set out the current understanding of the sleep/wake cycle in this blog.
Sleep is a regularly occurring state of unconsciousness resulting from two competing internal processes. Those processes are designated homeostatic which controls the amount of sleep and circadian which controls the timing of sleep. In the homeostatic process the longer one is awake the stronger the drive to sleep. So, as a normal day progresses the homeostatic drive increases and abates when one sleeps. If one is sleep deprived, then the homeostatic process increases to become overwhelming. The circadian process is a synchronization of many bodily processes which starts with an area called the suprachiasmatic nucleus in the hypothalamus. Signals from that nucleus influence the sleep/wake cycle, hormone release, body temperature, and other physiological systems. It is the opposition of these two systems that consolidates sleep and wakefulness into discrete periods. The opposition can be thought of as similar to a teeter totter. When weight is added to one end that end falls, when weight is added to the other end or weight is taken from the original end, then the balance shifts. So the wake promoting and sleep promoting work to inhibit one another. If wake promoting activity is higher then sleep promoting is inhibited and one is awake. I sleep promoting activity is greater, then wake promoting is inhibited and one is asleep.
The neurobiology and neurophysiology underlying these competing systems is far from clear and established. It would appear sleep promoting involves GABA, galanin, and melatonin whereas wake promoting involves orexin (hypocretin), norepinephrine, histamine, serotonin, and acetylcholine. GABA is the main inhibitory neurotransmitter in the human brain. Orexin is a peptide produced by neurons in the lateral hypothalamus and tilts the balance toward wakefulness. This discovery was made in narcoleptics who are orexin deficient. GABA is driven by the homeostatic process whereas orexin is driven by the circadian process.
Since the 1960s with the advent of the benzodiazepines the clinical treatment of sleep has focused on the sleep promoting side of the equation. The drugs thus used include all the household names. Doxepin was the first agent aimed to block wakefulness rather than promote sleep. Histamine levels increase during the night which is the likely explanation for H blockers promoting sleep maintenance. With the discovery of the orexin system and its wakefulness promoting actions, a whole new approach has opened for sleep therapeutics. Antagonists that block the orexin receptors inhibit excitatory input to arousal systems and create the conditions for sleep. Such drugs are on the horizon and should be in the marketplace soon. One such drug, Suvorexant, has demonstrated efficacy at all doses and tolerability. It should be with us in months.
This blog was stimulated by the confluence of several events at the end of May and beginning of June. I was asked by the parent of a patient about my experience as the expert witness in the 1972 Prosenjit Poddar trial which became the Tarasoff case. The rules derived from that California Supreme Court case still govern the disclosure psychiatrists and other mental health workers must make when a patient is threatening harm to someone in the community. A few days after discussing this case, a young Californian, Roger Elliot, killed six people near Santa Barbara. About two weeks later 60 Minutes had an extended piece on mass murderers. In the past I have avoided high profile topics like this in these blogs; however, I decided to make an exception in this matter because I have had some experience as an expert in certain murder defenses and there are substantial debatable public health and safety issues which need airing.
A cardinal distinction that psychiatrists draw when evaluating any patient or perpetrator is whether the individual is psychotic. This broad term is often defined as "loss of contact with reality", and typically includes hallucinations, delusions, inability to think clearly, drawing incorrect conclusions which cannot be corrected even when clear contradictory information is presented. Some recent examples include James Holmes who thought he was "The Joker" and killed twelve people at a Colorado theater; Anders Breivik thought he was the future ruler of Norway, Europe's Perfect Knight and killed seventy-seven people in Norway; and Seung-Hui Cho who thought he was Jesus Christ and said he vacationed with Vladimir Putin in North Carolina. He killed thirty-two at Virginia Tech. Psychosis can be caused by a psychiatric illness, substances, or medical illness.
About 2.7 to 3 million people in the United States population of approximately 317 million people suffer from severe mental illnesses and about one in seven commit murder. Of this number about 50% are psychotic. The remaining 50% are motivated by anger, jealousy, revenge, or attention secured by being a "copy cat." These numbers exclude war, terrorism, and gang activity.
There are a number of features that distinguish psychotic killers from non-psychotic killers. The psychotic killer usually acts alone, rarely tries to flee from the authorities, and is usually killed at the scene either by suicide or "suicide by cop." They are generally not under the influence of alcohol or drugs, are Caucasian and older than thirty, often unemployed, and usually telegraph their plans verbally, in writing, or on the internet. When looking back at their lives, they often demonstrate a fluctuating level of functioning from superior to impaired. Their actions are not usually impulsive but planned and they often know that they are behaving illegally. The individuals at greatest risk are family, friends, neighbors and mental health workers.
There are about 20 instances of psychotic mass murder in the United States each year. This rate has been stable for the last forty years. This is both a public health and safety problem. The public debate about prevention in the United States is almost exclusively focused on gun control. In my view this is too narrow a focus. I think a comprehensive strategy needs to be considered beyond guns because they are generally available and plentiful. Furthermore they are not always the instrument used in these tragedies. In addition, a significant number of psychotic perpetrators have been in contact with the mental health system but have been ineffectively treated. This shouts out loud and clear to me that the system needs reform. Such reform would perforce require a reappraisal of the balance between individual freedom and involuntary treatment or commitment. Once the public debate has taken place, community leaders should shepherd the changes into law. Follow up for patients discharged from psychiatric units needs study and improvement. Certain treatment modalities, long acting injections for certain patients, need to be discussed and guidelines for their use changed so as to increase medication compliance in very problematic patients. Finally, it strikes me as inappropriate to task the police with evaluating the mental state of individuals in the community. These evaluation when done properly require a working knowledge of psychiatric conditions, physiological responses to legal and illegal substances, and the impact of social circumstances on the individual in question. These evaluations should be performed by well-trained and experienced mental health professionals if the community interest is maximum accuracy and minimum errors.
One week ago a patient was talking to me in the office and disclosed that he was paranoid about a particular upcoming experience. He was using the word as a synonym for anxious, tense, apprehensive. This represents a colloquial slang usage of the word "paranoid." Psychiatrists use the word paranoid to mean suspicious, mistrustful. I will not be addressing a common form found in paranoid schizophrenia, because that would be mixing two confusing diagnoses, i.e., paranoid and schizophrenia. Paranoia is a way of thinking or feeling that is pervasive and whose severity varies from relatively mild to loss of reality as, for example, in delusions. The more severe, the more normal functioning is compromised.
Traits of people who are often paranoid include those who are emotionally constricted, fearful, and suspicious. Others are rigidly arrogant and more aggressively suspicious.The trait or attitude of suspiciousness involves the continual expectation of trickery and if chronic leads to a way of thinking. Rigidity refers to having something on a person's mind which causes that person to look at their experience with certain expectations and search for confirmation of those expectations. If someone tries to dissuade the individual from his original view, that person will become an object of suspicion. So, the paranoid person does not pay attention to new facts, doesn't see apparent meaning, but "looks through" the obvious and sees an aspect that confirms the original view, i.e., examination of the data takes place with prejudice so that there is confirmation of the original thought. Anything that contradicts this is dismissed as mere appearance. The paranoid individual is incapable of any other type of attention. His attention is tense, rigid, actively searching with a biased purpose and intensely concentrating.
Everyone has some expectations to help guide them in their view. We are all influenced by what we see and what we don't expect. Those people that are suggestible are easily influenced by whatever striking fact or view or opinion presents itself. People with strong views impose their anticipation on the facts. Paranoid people seek confirmation of their anticipations and these in turn allow them to disregard apparent contradictory facts. In this way the paranoid's mind becomes an instrument of bias and leads to "brilliantly perceptive mistakes", that is, the perception can be correct but the judgment wrong. They are hypersensitive and hyperalert. Anything out of the ordinary or surprising triggers their suspiciousness and heightens their extreme tension. What would appear to be obvious to most people in a given circumstance is to them mere appearance and disregarded. They need to look beyond. They listen for clues. In this was they loose the tone and color of experience and those features that modify and qualify experience or convey a sense of proportion or scale. They are over represented in fanatics. These are the cognitive mechanisms that lead to a distortion of reality or in the extreme a loss of reality.