Definition

Disulfiram is an aldehyde dehydrogenase inhibitor. It prohibits the activity of aldehyde dehydrogenase, an enzyme found in the liver. In the United States, disulfiram is sold under brand name Antabuse.

Purpose

Disulfiram is used as a conditioning treatment for alcohol dependence. When taken with alcohol, disulfiram causes many unwanted and unpleasant effects, and the fear of these is meant to condition the patient to avoid alcohol.

Description

Two Danish physicians who were investigating disulfiram for its potential benefits to destroy parasitic worms took disulfiram and became sick at a cocktail party. After a series of pharmacological and clinical studies, it was determined that disulfiram interacts with alcohol.

Disulfiram by itself is not toxic. If taken with alcohol, however, it alters certain steps in the breakdown of alcohol. When alcohol is ingested, it is converted first to a chemical called acetaldehyde. Acetaldehyde is further broken down into acetate. In order for acetaldehyde to be broken down into acetate, aldehyde dehydrogenase needs to be active. Disulfiram is an aldehyde dehydrogenase inhibitor. Since disulfiram blocks the activity of aldehyde dehydrogenase, acetaldehyde cannot be broken down and the levels of acetaldehyde become five to ten times higher than the normal levels. This causes uncomfortable effects that encourage the person to avoid alcohol.

Disulfiram comes in a 250- and 500-mg tablet.

Recommended dosage

Disulfiram therapy should be started only after the patient has abstained from alcohol for at least 12 hours. The initial dose may be as high as 500 mg taken once daily. If the medication is sedating, the dose can be administered in the evening. Ideally, though, the daily dose should be taken in the morning—the time the resolve not to drink may be strongest. The initial dosing period can last for one to two weeks.

Maintenance dose can range anywhere from 125–500 mg daily with the average dose being 250 mg daily. Disulfiram therapy should continue until full recovery. This may take months to years, depending upon patient’s response and motivation to stop using alcohol. The duration of disulfiram’s activity is 14 days after discontinuation, and patients need to avoid alcohol for this period of time.

Precautions

Before beginning therapy, patients should be carefully evaluated for their intellectual capacity to understand the goal of therapy, behavioral modification with negative reinforcement. Patients with history of psychosis, severe myocardial disease, and coronary occlusion should not take disulfiram. People with diabetes taking disulfiram are at an increased risk for complications. Severe liver failure has been associated with the use of disulfiram in patients with or without a prior history of liver problems. People with advanced or severe liver disease should not take disulfiram. Disulfiram should never be given to patients who are in a state of alcohol intoxication or without the patient’s knowledge. Those patients with history of seizures, hypothyroidism, or nephritis need to use disulfiram with caution and close monitoring.

Besides avoiding alcohol, patients should also avoid any products containing alcohol. This includes many cold syrups, tonics, and mouthwashes. Patients should not even use topical preparations that contain alcohol such as perfume and after-shave lotion.

Side effects

The most common side effect of disulfiram includes drowsiness and fatigue. Many patients experience metallic or garlic-like aftertaste, but most patients develop tolerance to this effect.

In addition, disulfiram is also associated with impotence. This is most common in doses of 500 mg daily. Disulfiram can also cause blurred vision, skin discoloration, inflammation of the skin, increased heart rate, and mental changes.

During the first three months of therapy, patients should have their liver function evaluated. Patients need to be monitored for the signs of jaundice, nausea, vomiting, abdominal pain, light stools and dark urine as these may be the signs of liver damage due to disulfiram. The signs of alcohol ingestion include flushing, headache, nausea, vomiting and abdominal pain.

Interactions

Disulfiram can make cisapride, benzodiazepines, astemizole, cyclosporine, erythromycin, and cholesterol-lowering drugs called statins more toxic. Disulfiram in combination with isoniazid, MAO inhibitors (such as phenelzide and tranylcypromine), metronidazole, omeprazole and tricyclic antidepressants may cause adverse central nervous system effects.

In addition, disulfiram may raise the concentrations of the medications theophylline and phenytoin in the body. Disulfiram may put patients on warfarin (a blood-thinning drug) at an increased risk of bleeding. Disulfiram should never be used with tranylcypromine and amprenavir oral solution.

Disulfiram may react even with small amounts of alcohol found in over-the-counter cough and cold preparations and any medication that comes in an elixir form.

Definition

Previously known as multiple personality disorder, dissociative identity disorder (DID) is a condition in which a person has more than one distinct identity or personality state. At least two of these personalities repeatedly assert themselves to control the affected person’s behavior. Each personality state has a distinct name, past, identity, and self-image.

Psychiatrists and psychologists use a handbook called the Diagnostic and Statistical Manual of Mental Disorders , fourth edition text revision or DSM-IV-TR, to diagnose mental disorders. In this handbook, DID is classified as a dissociative disorder. Other mental disorders in this category include depersonalization disorder, dissociative fugue, and dissociative amnesia. It should be noted, however, that the nature of DID and even its existence is debated by psychiatrists and psychologists.

Description

“Dissociation” describes a state in which the integrated functioning of a person’s identity, including consciousness, memory and awareness of surroundings, is disrupted or eliminated. Dissociation is a mechanism that allows the mind to separate or compartmentalize certain memories or thoughts from normal consciousness. These memories are not erased, but are buried and may resurface at a later time. Dissociation is related to hypnosis in that hypnotic trance also involves a temporarily altered state of consciousness. Dissociation occurs along a continuum or spectrum, and may be mild and part of the range of normal experience, or may be severe and pose a problem for the individual experiencing the dissociation. An example of everyday, mild dissociation is when a person is driving for a long period on the highway and takes several exits without remembering them. In severe, impairing dissociation, an individual experiences a lack of awareness of important aspects of his or her identity.

The phrase “dissociative identity disorder” replaced “multiple personality disorder” because the new name emphasizes the disruption of a person’s identity that characterizes the disorder. A person with the illness is consciously aware of one aspect of his or her personality or self while being totally unaware of, or dissociated from, other aspects of it. This is a key feature of the disorder. It only takes two distinct identities or personality states to qualify as DID but there have been cases in which 100 distinct alternate personalities, or alters, were reported. Fifty percent of DID patients harbor fewer than 11 identities.

Because the alters alternate in controlling the patient’s consciousness and behavior, the affected patient experiences long gaps in memory— gaps that far exceed typical episodes of forgetting that occur in those unaffected by DID.

Despite the presence of distinct personalities, in many cases one primary identity exists. It uses the name the patient was born with and tends to be quiet, dependent, depressed and guilt-ridden. The alters have their own names and unique traits. They are distinguished by different temperaments, likes, dislikes, manners of expression and even physical characteristics such as posture and body language. It is not unusual for patients with DID to have alters of different genders, sexual orientations, ages, or nationalities. Typically, it takes just seconds for one personality to replace another but, in rarer instances, the shift can be gradual. In either case, the emergence of one personality, and the retreat of another, is often triggered by a stressful event.

People with DID tend to have other severe disorders as well, such as depression, substance abuse, borderline personality disorder and eating disorders, among others. The degree of impairment ranges from mild to severe, and complications may include suicide attempts, self-mutilation, violence, or drug abuse.

Left untreated, DID can last a lifetime. Treatment for the disorder consists primarily of individual psychotherapy.

Causes and symptoms

Causes

The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:

• an innate ability to dissociate easily
• repeated episodes of severe physical or sexual abuse in childhood
• lack of a supportive or comforting person to counteract abusive relative(s)
• influence of other relatives with dissociative symptoms or disorders

The primary cause of DID appears to be severe and prolonged trauma experienced during childhood. This trauma can be associated with emotional, physical or sexual abuse, or some combination. One theory is that young children, faced with a routine of torture, sexual abuse or neglect, dissociate themselves from their trauma by creating separate identities or personality states. A manufactured alter may suffer while the primary identity “escapes” the unbearable experience. Dissociation, which is easy for a young child to achieve, thus becomes a useful defense. This strategy displaces the suffering onto another identity. Over time, the child, who on average is around six years old at the time of the appearance of the first alter, may create many more.

As stated, there is considerable controversy about the nature, and even the existence, of dissociative identity disorder. One cause for the skepticism is the alarming increase in reports of the disorder since the 1980s. An area of contention is the notion of suppressed memories, a crucial component in DID. Many experts in memory research say that it is nearly impossible for anyone to remember things that happened before the age three, the age when some DID patients supposedly experience abuse, but the brain’s storage, retrieval, and interpretation of childhood memories are still not fully understood. The relationship of dissociative disorders to childhood abuse has led to intense controversy and lawsuits concerning the accuracy of childhood memories. Because childhood trauma is a factor in the development of DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). In both DID and PTSD, dissociation is a prominent mechanism.

Symptoms

The major dissociative symptoms experienced by DID patients are amnesia, depersonalization, derealization, and identity disturbances.

AMNESIA. Amnesia in DID is marked by gaps in the patient’s memory for long periods of their past, and, in some cases, their entire childhood. Most DID patients have amnesia, or “lose time,” for periods when another personality is “out.” They may report finding items in their house that they can’t remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

DEPERSONALIZATION. Depersonalization is a dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of their body, or as watching a movie of themselves.

DEREALIZATION. Derealization is a dissociative symptom in which the patient perceives the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail to recognize relatives or close friends.

IDENTITY DISTURBANCES. Persons suffering from DID usually have a main personality that psychiatrists refer to as the “host.” This is generally not the person’s original personality, but is rather one developed in response to childhood trauma. It is usually this personality that seeks psychiatric help. DID patients are often frightened by their dissociative experiences, which can include losing awareness of hours or even days, meeting people who claim to know them by another name, or feeling “out of body.”

Psychiatrists refer to the phase of transition between alters as the “switch.” After a switch, people assume whole new physical postures, voices, and vocabularies. Specific circumstances or stressful situations may bring out particular identities. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Each alternate identity takes control one at a time, denying control to the others. Patients vary with regard to their alters’ awareness of one another. One alter may not acknowledge the existence of others or it may criticize other alters. At times during therapy, one alter may allow another to take control.

Demographics

Studies in North America and Europe indicate that as many as 5% of patients in psychiatric wards have undiagnosed DID. Partially hospitalized and out-patients may have an even higher incidence. For every one man diagnosed with DID, there are eight or nine women. Among children, boys and girls diagnosed with DID are pretty closely matched 1:1. No one is sure why this discrepancy between diagnosed adults and children exists.

Diagnosis

The DSM-IV-TRlists four diagnostic criteria for identifying DID and differentiating it from similar disorders:

• Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death or injury, or a serious physical threat to him- or herself or others. During exposure to the trauma, the person’s emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic than accidents, natural disasters, or “acts of God.”
• The demonstration of two or more distinct identities or personality states in an individual. Each separate identity must have its own way of thinking about, perceiving, relating to and interacting with the environment and self.
• Two of the identities assume control of the patient’s behavior, one at a time and repeatedly.
• Extended periods of forgetfulness lasting too long to be considered ordinary forgetfulness.
• Determination that the above symptoms are not due to drugs, alcohol or other substances and that they can’t be attributed to any other general medical condition. It is also necessary to rule out fantasy play or imaginary friends when considering a diagnosis of DID in a child.

Proper diagnosis of DID is complicated because some of the symptoms of DID overlap with symptoms of other mental disorders. Misdiagnoses are common and include depression, schizophrenia, borderline personality disorder, somatization disorder, and panic disorder.

Because the extreme dissociative experiences related to this disorder can be frightening, people with the disorder may go to emergency rooms or clinics because they fear they are going insane.

When a doctor is evaluating a patient for DID, he or she will first rule out physical conditions that sometimes produce amnesia, depersonalization, or derealization. These conditions include head injuries, brain disease (especially seizure disorders), side effects from medications, substance abuse or intoxication, AIDS dementia complex, or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph (EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient is malingering and/or offering fictitious complaints.

If the patient appears to be physically healthy, the doctor will next rule out psychotic disturbances, including schizophrenia. Many patients with DID are misdiagnosed as schizophrenic because they may “hear” their alters “talking” inside their heads. If the doctor suspects DID, he or she can use a screening test called the Dissociative Experiences Scale (DES). If the patient has a high score on this test, he or she can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for Dissociative Disorders (SCID-D).

Treatments

Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.

Psychotherapy

Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized training is important because the patient’s personality switches can be confusing or startling. In addition, many patients with DID have hostile or suicidal alter personalities. Most therapists who treat DID patients have rules or contracts for treatment that include such issues as the patient’s responsibility for his or her safety. Psychotherapy for DID patients typically has several stages: an initial phase for uncovering and “mapping” the patient’s alters; a phase of treating the traumatic memories and “fusing” the alters; and a phase of consolidating the patient’s newly integrated personality.

Most therapists who treat multiples, or DID patients, recommend further treatment after personality integration, on the grounds that the patient has not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help the patient’s family understand DID and the changes that occur during personality reintegration.

Many DID patients are helped by group therapy as well as individual treatment, provided that the group is limited to people with dissociative disorders. DID patients sometimes have setbacks in mixed therapy groups because other patients are bothered or frightened by their personality switches.

Medications

Some doctors will prescribe tranquilizers or antidepressants for DID patients because their alter personalities may have anxiety or mood disorders. However, other therapists who treat DID patients prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many DID patients have at least one alter who abuses drugs or alcohol, substances which are dangerous in combination with most tranquilizers.

Hypnosis

While not always necessary, hypnosis (or hypnotherapy) is a standard method of treatment for DID patients. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many DID patients exhibit, such as self-mutilation, or eating disorders like bulimia nervosa. In the later stages of treatment, the therapist may use hypnosis to “fuse” the alters as part of the patient’s personality integration process.

Prognosis

Unfortunately, no systematic studies of the long-term outcome of DID currently exist. Some therapists believe that the prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the prognosis. Patients may find they are bothered less by symptoms as they advance into middle age, with some relief beginning to appear in the late 40s. Stress or substance abuse, however, can cause a relapse of symptoms at any time.

Prevention

Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

Definition

Dissociative fugue is a rare condition in which a person suddenly, without planning or warning, travels far from home or work and leaves behind a past life. Patients show signs of amnesia and have no conscious understanding or knowledge of the reason for the flight. The condition is usually associated with severe stress or trauma. Because persons cannot remember all or part of their past, at some point they become confused about their identity and the situations in which they find themselves. In rare cases, they may take on new identities. The American Psychiatric Association (APA) classifies disassociative fugue as one of four dissociative disorders, along with dissociative amnesia, dissociative identity disorder, and depersonalization disorder.

Description

The key feature of dissociative fugue is “sudden, unexpected travel away from home or one’s customary place of daily activities, with inability to recall some or all of one’s past,” according to the APA. The travels associated with the condition can last for a few hours or as long as several months. Some individuals have traveled thousands of miles from home while in a state of dissociative fugue. (The word fuguestems from the Latin word for flight—fugere.) At first, a person experiencing the condition may appear completely normal. With time, however, confusion appears. This confusion may result from the realization that the person can not remember the past. Victims may suddenly realize that they do not belong where they find themselves.

During an episode of dissociative fugue, a person may take on a new identity, complete with a new name and even establish a new home and ties to their his/her community. More often, however, the victim realizes something is wrong not long after fleeing—in a matter of hours or days. In such cases, the victim may phone home for help, or come to the attention of police after becoming distressed at finding himself/herself unexplainably in unfamiliar surroundings.

Dissociative fugue is distinct from Dissociative Identity disorder (DID). In cases of DID, which previously was called Multiple Personality Disorder (MPD), a person loses memory of events that take place when one of several distinct identities takes control of the person. If a person with dissociative fugue assumes a new identity, it does not co-exist with other identities, as is typical of DID. Repeated instances of apparent dissociative fugue are more likely a symptom of DID, not true dissociative fugue.

Causes and symptoms

Causes

Episodes of dissociative fugue are often associated with very stressful events. Traumatic experiences such a war, or natural disasters, seem to increase the incidence of the disorder. Other, more personal types of stress might also lead to the unplanned travel and amnesia characteristic of dissociative fugue. The shocking death of a loved one or seemingly unbearable pressures at work or home, for example, might cause some people to run away for brief periods and blank out their pasts.

Symptoms

A person in the midst of a dissociative fugue episode may appear to have no psychiatric symptoms at all or to be only slightly confused. Therefore, for a time, it may be very difficult to spot someone experiencing a fugue. After a while, however, the patient shows significant signs of confusion or distress because he or she cannot remember recent events, or realizes a complete sense of identity is missing. This amnesia is a characteristic symptom of the disorder.

Demographics

Dissociative fugue is a rare disorder estimated to affect just 0.2% of the population, nearly all of them adults. More people may experience dissociative fugue, however, during or in the aftermath of serious accidents, wars, natural disasters, or other highly traumatic or stressful events.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as the DSM-IV-TRlists four criteria for diagnosing dissociative fugue:

• Unexplained and unexpected travel from a person’s usual place of living and working along with partial or complete amnesia.
• Uncertainty and confusion about one’s identity, or in rare instances, the adoption of a new identity.
• The flight and amnesia that characterize the fugue are not related exclusively to DID, nor is it the result of substance abuse or a physical illness.
• An episode must result in distress or impairment severe enough to interfere with the ability of the patient to function in social, work or home settings.

Accurate diagnosis typically must wait until the fugue is over and the person has sought help or has been brought to the attention of mental health care providers. The diagnosis can then be made using the patient’s history and reconstruction of events that occurred before, during, and after the patient’s excursion.

Treatments

Psychotherapy, sometimes involving hypnosis, is often effective in the treatment of dissociative fugue. Patients, with support from therapists, are encouraged to remember past events by learning to face and cope with the stressful experiences that precipitated the fugue. Since the cause of the fugue is usually a traumatic event, it is often necessary to treat disturbing feelings and emotions that emerge when the patient finally faces the trauma. The troubling events that drove a person to run and forget about his or her past may, when remembered, result in grief, depression, fear, anger, remorse, and other psychological states that require therapy.

Prognosis

The prognosis for dissociative fugue is often good. Not many cases last longer than a few months and many people make a quick recovery. In more serious cases, the patient may take longer to recover memories of the past.

Definition

Dissociative amnesia is classified by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as the DSM-IV-TR as one of the dissociative disorders, which are mental disorders in which the normally well-integrated functions of memory, identity, perception, or consciousness are separated (dissociated). The dissociative disorders are usually associated with trauma in the recent or distant past, or with an intense internal conflict that forces the mind to separate incompatible or unacceptable knowledge, information, or feelings. In dissociative amnesia, the continuity of the patient’s memory is disrupted. Patients with dissociative amnesia have recurrent episodes in which they forget important personal information or events, usually connected with trauma or severe stress. The information that is lost to the patient’s memory is usually too extensive to be attributed to ordinary absentmindedness or forgetfulness related to aging. Dissociative amnesia was formerly called “psychogenic amnesia.”

Amnesia is a symptom of other medical and mental disorders; however, the patterns of amnesia are different, depending on the cause of the disorder. Amnesia associated with head trauma is typically both retrograde (the patient has no memory of events shortly before the head injury) and anterograde (the patient has no memory of events after the injury). The amnesia that is associated with seizure disorders is sudden onset. Amnesia in patients suffering from delirium or dementia occurs in the context of extensive disturbances of the patient’s cognition (knowing), speech, perceptions, emotions, and behaviors. Amnesia associated with substance abuse, which is sometimes called “blackouts” typically affects only short-term memory and is irreversible. In dissociative amnesia, in contrast to these other conditions, the patient’s memory loss is almost always anterograde, which means that it is limited to the period following the traumatic event(s). In addition, patients with dissociative amnesia do not have problems learning new information.

Dissociative amnesia as a symptom occurs in patients diagnosed with dissociative fugue and dissociative identity disorder. If the patient’s episodes of dissociative amnesia occur only in the context of these disorders, a separate diagnosis of dissociative amnesia is not made.

Description

Patients with dissociative amnesia usually report a gap or series of gaps in their recollection of their life history. The gaps are usually related to episodes or abuse or equally severe trauma, although some persons with dissociative amnesia also lose recall of their own suicide attempts, episodes of self-mutilation, or violent behavior.

Five different patterns of memory loss have been reported in patients with dissociative amnesia:

• Localized. The patient cannot recall events that took place within a limited period of time (usually several hours or 1–2 days) following a traumatic event. For example, some survivors of the World Trade Center attacks do not remember how they got out of the damaged buildings or what streets they took to get away from the area.
• Selective. The patient can remember some, but not all of the events that took place during a limited period of time. For example, a veteran of D-Day (June 6, 1944) may recall some details, such as eating a meal on the run or taking prisoners, but not others (seeing a close friend hit or losing a commanding officer).
• Generalized. The person cannot recall anything in his/her entire life. Persons with generalized amnesia are usually found by the police or taken by others to a hospital emergency room.
• Continuous. The amnesia covers the entire period without interruption from a traumatic event in the past to the present.
• Systematized. The amnesia covers only certain categories of information, such as all memories related to a certain location or to a particular person.

Most patients diagnosed with dissociative amnesia have either localized or selective amnesia. Generalized amnesia is extremely rare. Patients with generalized, continuous, or systematized amnesia are usually eventually diagnosed as having a more complex dissociative disorder, such as dissociative identity disorder (DID).

Causes and symptoms

Causes

The primary cause of dissociative amnesia is stress associated with traumatic experiences that the patient has either survived or witnessed. These may include such major life stressors as serious financial problems, the death of a parent or spouse, extreme internal conflict, and guilt related to serious crimes or turmoil caused by difficulties with another person.

Susceptibility to hypnosis appears to be a predisposing factor in dissociative amnesia. As of 2002, however, no specific genes have been associated with vulnerability to dissociative amnesia.

Some personality types and character traits seem to be risk factors for dissociative disorders. A group of researchers in the United States has found that persons diagnosed with dissociative disorders have much higher scores for immature psychological defenses than normal subjects.

Symptoms

The central symptom of dissociative amnesia is loss of memory for a period or periods of time in the patient’s life. The memory loss may take a variety of different patterns, as described earlier.

Other symptoms that have been reported in patients diagnosed with dissociative amnesia include the ollowing:

• Confusion.
• Emotional distress related to the amnesia. However, not all patients with dissociative amnesia are distressed. The degree of emotional upset is usually in direct proportion to the importance of what has been forgotten, or the consequences of forgetting.
• Mild depression.

Some patients diagnosed with dissociative amnesia have problems or behaviors that include disturbed interpersonal relationships, sexual dysfunction, employment problems, aggressive behaviors, self-mutilation, or suicide attempts.

Demographics

Dissociative amnesia can appear in patients of any age past infancy. Its true prevalence is unknown. In recent years, there has been an intense controversy

among therapists regarding the increase in case reports of dissociative amnesia and the accuracy of the memories recovered. Some maintain that the greater awareness of dissociative symptoms and disorders among psychiatrists has led to the identification of cases that were previously misdiagnosed. Other therapists maintain that dissociative disorders are overdiagnosed in people who are extremely vulnerable to suggestion.

It should be noted that psychiatrists in the U.S. and Canada have significantly different opinions of dissociative disorder diagnoses. On the whole, Canadian psychiatrists, both French- and English-speaking, have serious reservations about the scientific validity and diagnostic status of dissociative amnesia and dissociative identity disorder. Only 30% of Canadian psychiatrists think that these two dissociative disorders should be included in the DSM-IV-TRwithout reservation; and only 13% think that there is strong scientific support for the validity of these diagnoses.

Diagnosis

The diagnosis of dissociative amnesia is usually a diagnosis of exclusion. The doctor will take a detailed medical history, give the patient a physical examination, and order blood and urine tests, as well as an electroencephalogram (EEG) or head x ray in order to rule out memory loss resulting from seizure disorders, substance abuse (including abuse of inhalants), head injuries, or medical conditions, such as Alzheimer’s disease or delirium associated with fever.

Some conditions, such as age-related memory impairment (AAMI), may be ruled out on the basis of the patient’s age. Malingering can usually be detected in patients who are faking amnesia because they typically exaggerate and dramatize their symptoms; they have obvious financial, legal, or personal reasons (such as draft evasion) for pretending loss of memory. In addition, patients with genuine dissociative amnesia usually score high on tests of hypnotizability. The examiner may administer the Hypnotic Induction Profile (HIP) or a similar measure that evaluates whether the patient is easily hypnotized. This enables the examiner to rule out malingering or factitious disorder.

There are several standard diagnostic questionnaires that may be given to evaluate the presence of a dissociative disorder. The Dissociative Experiences Scale, or DES, is a frequently administered self-report screener for all forms of dissociation. The Structured Clinical Interview for the DSM-IV-TRDissociative Disorders, or SCID-D, can be used to make the diagnosis of dissociative amnesia distinct from the other dissociative disorders defined by the DSM-IV-TR. The SCID-D is a semi-structured interview, which means that the examiner’s questions are open-ended and allow the patient to describe experiences of amnesia in some detail, as distinct from simple “yes” or “no” answers.

As of 2002, there are no widely used screeners or diagnostic questionnaires specifically for dissociative amnesia.

Diagnosis of dissociative amnesia in children before the age of puberty is complicated by the fact that inability to recall the first four to five years of one’s life is a normal feature of human development. As part of the differential diagnosis, a physician who is evaluating a child in this age group will rule out inattention, learning disorders, oppositional behavior, and psychosis, and seizure disorders or head trauma. To make an accurate diagnosis, several different people (i.e., teachers, therapists, social workers, the child’s primary care physician) may be asked to observe or evaluate the child.

Treatments

Treatment of dissociative amnesia usually requires two distinct periods or phases.

Psychotherapy

Psychotherapy for dissociative amnesia is supportive in its initial phase. It begins with creating an atmosphere of safety in the treatment room. Very often, patients gradually regain their memories when they feel safe with and supported by the therapist. This rapport does not mean that they necessarily recover their memories during therapy sessions; one study of 90 patients with dissociative amnesia found that most of them had their memories return while they were at home alone or with family or close friends. The patients denied that their memories were derived from a therapist’s suggestions, and a majority of them were able to find independent evidence or corroboration of their childhood abuse.

If the memories do not return spontaneously, hypnosis or sodium amytal (a drug that induces a semi-hypnotic state) may be used to help recover them.

After the patient has recalled enough of the missing past to acquire a stronger sense of self and continuity in their life history, the second phase of psychotherapy commences. During this phase, the patient deals more directly with the traumatic episode(s), and recovery from its aftereffects. Studies of the treatments for dissociative amnesia in combat veterans of World War I (1914–1918) found that recovery and cognitive integration of dissociated traumatic memories within the patient’s overall personality were more effective than treatment methods that focused solely on releasing feelings.

Medications

At present, there are no therapeutic agents that prevent amnestic episodes or that cure dissociative amnesia itself. Patients may, however, be given antidepressants or other appropriate medications for treatment of the depression, anxiety, insomnia, or other symptoms that may accompany dissociative amnesia.

Legal implications

Dissociative amnesia poses a number of complex issues for the legal profession. The disorder has been cited by plaintiffs in cases of recovered memories of abuse leading to lawsuits against the perpetrators of the abuse. Dissociative amnesia has also been cited as a defense in cases of murder of adults as well as in cases of neonatricide (murder of an infant shortly after birth). Part of the problem is the adversarial nature of courtroom procedure in the U.S., but it is generally agreed that judges and attorneys need better guidelines regarding dissociative amnesia in defendants and plaintiffs.

Prognosis

The prognosis for recovery from dissociative amnesia is generally good. The majority of patients eventually recover the missing parts of their past, either by spontaneous re-emergence of the memories or through hypnosis and similar techniques. A minority of patients, however, are never able to reconstruct their past; they develop a chronic form of dissociative amnesia. The prognosis for a specific patient depends on a combination of his or her present life circumstances; the presence of other mental disorders; and the severity of stresses or conflicts associated with the amnesia.

Prevention

Strategies for the prevention of child abuse might lower the incidence of dissociative amnesia in the general population. There are no effective preventive strategies for dissociative amnesia caused by traumatic experiences in adult life in patients without a history of childhood abuse.

Definition

The dissociative disorders are a group of mental disorders that affect consciousness and are defined as causing significant interference with the patient’s general functioning, including social relationships and employment.

Description

Dissociation is a mechanism that allows the mind to separate or compartmentalize certain memories or thoughts from normal consciousness. These split-off mental contents are not erased. They may resurface spontaneously or be triggered by objects or events in the person’s environment.

Dissociation is a process that occurs along a spectrum of severity. If someone experiences dissociation, it does not necessarily mean that that person has a dissociative disorder or other mental illness. A mild degree of dissociation occurs with some physical stressors; people who have gone without sleep for a long period of time, have had “laughing gas” for dental surgery, or have been in a minor accident often have brief dissociative experiences. Another commonplace example of dissociation is a person becoming involved in a book or movie so completely that the surroundings or the passage of time are not noticed. Another example might be driving on the highway and taking several exits without noticing or remembering. Dissociation is related to hypnosis in that hypnotic trance also involves a temporarily altered state of consciousness. Most patients with dissociative disorders are highly hypnotizable.

People in other cultures sometimes have dissociative experiences in the course of religious (in certain trance states) or other group activities. These occurrences should not be judged in terms of what is considered “normal” in the United States.

Moderate or severe forms of dissociation are caused by such traumatic experiences as childhood abuse, combat, criminal attacks, brainwashing in hostage situations, or involvement in a natural or transportation disaster. Patients with acute stress disorder, post-traumatic stress disorder (PTSD), conversion disorder, or somatization disorder may develop dissociative symptoms. Recent studies of trauma indicate that the human brain stores traumatic memories in a different way than normal memories. Traumatic memories are not processed or integrated into a person’s ongoing life in the same fashion as normal memories. Instead they are dissociated, or “split off,” and may erupt into consciousness from time to time without warning. The affected person cannot control or “edit” these memories. Over a period of time, these two sets of memories, the normal and the traumatic, may coexist as parallel sets without being combined or blended. In extreme cases, different sets of dissociated memories may cause people to develop separate personalities for these memories— a disorder known as dissociative identity disorder (formerly called multiple personality disorder).

Types of dissociative disorders

Dissociative amnesia

Dissociative amnesia is a disorder in which the distinctive feature is the patient’s inability to remember important personal information to a degree that cannot be explained by normal forgetfulness. In many cases, it is a reaction to a traumatic accident or witnessing a violent crime. Patients with dissociative amnesia may develop depersonalization or trance states as part of the disorder, but they do not experience a change in identity.

Dissociative fugue

Dissociative fugue is a disorder in which a person temporarily loses his or her sense of personal identity and travels to another location where he or she may assume a new identity. Again, this condition usually follows a major stressor or trauma. Apart from inability to recall their past or personal information, patients with dissociative fugue do not behave strangely or appear disturbed to others. Cases of dissociative fugue are more common in wartime or in communities disrupted by a natural disaster.

Depersonalization disorder

Depersonalization disorder is a disturbance in which the patient’s primary symptom is a sense of detachment from the self. Depersonalization as a symptom (not as a disorder) is quite common in college-age populations. It is often associated with sleep deprivation or “recreational” drug use. It may be accompanied by “derealization” (where objects in an environment appear altered). Patients sometimes describe depersonalization as feeling like a robot or watching themselves from the outside. Depersonalization disorder may also involve feelings of numbness or loss of emotional “aliveness.”

Dissociative identity disorder (DID)

Dissociative identity disorder (DID) is considered the most severe dissociative disorder and involves all of the major dissociative symptoms. People with this disorder have more than one personality state, and the personality state controlling the person’s behavior changes from time to time. Often, a stressor will cause the change in personality state. The various personality states have separate names, temperaments, gestures, and vocabularies. This disorder is often associated with severe physical or sexual abuse, especially abuse suffered during childhood.

Dissociative disorder not otherwise specified (DDNOS)

DDNOS is a diagnostic category ascribed to patients with dissociative symptoms that do not meet the full criteria for a specific dissociative disorder.

Rebecca J. Frey, Ph.D.

Definition

Disorder of written expression, formerly called developmental expressive writing disorder, is a learning disability in which a person’s ability to communicate in writing is substantially below the level normally expected based on the individual’s age, intelligence, life experiences, educational background, or physical impairments. This disability affects both the physical reproduction of letters and words and the organization of thoughts and ideas in written compositions.

Description

Disorder of written expression is one of the more poorly understood learning disabilities. Learning disabilities that manifest themselves only in written work were first described in the late 1960s. These early studies described three main types of written disorders:

• inability to form letters and numbers correctly, also called dysgraphia
• inability to write words spontaneously or from dictation
• inability to organize words into meaningful thoughts

There are several difficulties in studying disorder of written expression and in implementing a remedial program. Disorder of written expression usually appears in conjunction with other reading or language disabilities, making it hard to separate manifestations of the disability related only to written expression. Delays in attention, visual-motor integration, visual processing, and expressive language may also contribute to writing disorders. Also, there are no standard tests specifically designed to evaluate disorder of written expression.

Causes and symptoms

Causes

The causes of disorder of written expression are unknown. Different manifestations of the disorder may have different causes. For example, people who cannot form letters correctly on the page (dysgraphia) may have delays in hand-eye coordination and difficulties concentrating. People who are unable to write words from memory or dictation appear to have deficits in their visual memory. They cannot remember what the words look like. People who produce legible script but cannot organize their thoughts on paper may be suffering from cognitive processing problems. Because disorder of written expression is a little-studied disorder, specific causes have not yet been determined.

Symptoms

Symptoms that suggest disorder of written expression include:

• poor or illegible handwriting
• poorly formed letters or numbers
• excessive spelling errors
• excessive punctuation errors
• excessive grammar errors
• sentences that lack logical cohesion
• paragraphs and stories that are missing elements and that do not make sense or lack logical transitions
• deficient writing skills that significantly impact academic achievement or daily life.

These symptoms must be evaluated in light of the person’s age, intelligence, educational experience, and cultural or life experience. Written expression must be substantially below the level of samples produced by others of the same age, intelligence, and background. Normally, several of the symptoms are present simultaneously.

Demographics

Several studies have estimated that between 3% and 5% of students have disorder of written expression. However, it is difficult to separate this disorder from other learning disorders. Deficits in written work may be attributed to a reading, language, or attention disorders, limited educational background, or lack of fluency in the language of instruction. Disorder of written expression unassociated with any other learning disability is rare.

Diagnosis

There are no specific tests to diagnose disorder of written expression. This disorder is not normally diagnosed before age eight because of the variability with which children acquire writing skills. It is most commonly diagnosed in the fourth or fifth grade. Requests for testing usually originate with a teacher or parent who notes multiple symptoms of the disorder in a child’s writing.

Several standardized tests accurately reflect spelling abilities, but do not assess other writing skills with the same reliability. Tests that might be helpful in diagnosing disorder of written expression include the Diagnostic Evaluation of Writing Skills (DEWS), the Test of Early Written Language (TEWL) and the Test of Adolescent Language. However, assessment using standardized tests is not enough to make a diagnosis of disorder of written expression. In addition, a qualified evaluator should compare multiple samples of the student’s written work with the written work normally expected from students of comparable backgrounds. The person being evaluated may also be asked to perform tasks such as writing from dictation or copying written material as part of diagnostic testing. The American Psychiatric Association places disorder of written expression in the miscellaneous category of learning disorders not otherwise specified. It is likely to remain a poorly understood and diagnosed disability until more research findings are available.

Treatments

Little is known about how to treat disorder of written expression. Intense writing remediation may help, but no specific method or approach to remediation has proved particularly successful. Since disorder of written expression usually occurs in conjunction with other learning disabilities, treatment is often directed at those better-understood learning problems.

Prognosis

Little is known about the long-term outcome for people with disorder of written expression. However, it appears that those who have this disorder may develop low self-esteem and social problems related to their lack of academic achievement. Later in life they may be more likely to drop out of school and find employment opportunities that require writing skills closed to them.

Prevention

There are no known ways to prevent disorder of written expression.

Definition

Disease concept of chemical dependency is the concept that a disorder (such as chemical dependency) is like a disease and has a characteristic set of signs, symptoms, and natural history (clinical course, or outcome).

Description

The disease concept has long been accepted by the medical community. The concept proposes that a disease is characterized by a specific set of signs and symptoms and that the disease, if left untreated, will progress to some endpoint or outcome (clinical course). However, controversy arises when the medical community is faced with new abnormal conditions, owing mostly to the new technologies in genetic engineering. This controversy becomes especially apparent when examining psychological disorders.

In the past, psychological disorders were thought in general to be due to both psychological and social abnormalities. Although these psychosocial problems are still of utmost importance, researchers have since discovered that many psychological disorders, such as alcoholism, also have genetic causes. Recent studies have identified a genetic area (locus) where a gene is located that can transmit alcoholism from affected father to son. Mental health professionals also know from clinical experience that alcoholics demonstrate a characteristic set of specific signs and symptoms. Additionally, it is well established that the ultimate clinical course for untreated alcoholism is death. Therefore alcoholism, once thought to be a disorder of those with a weak will, or “party people” can now be characterized as a disease.

Can it be inferred that other chemical dependencies may also have biological causes? There is compelling evidence that this theory may be correct. It is interesting to note that all psychoactive mood-altering drugs (alcohol, cocaine, marijuana, heroin, etc.) act in specific sites in the brain and on a specific neurotransmitter (a chemical that delivers impulses from one nerve cell to another) called dopamine. These mood-altering substances cause dopamine depletion, inducing an abnormality in nerve cells that “hijacks” the cells into chemical dependence. In other words, the substance introduced in the body affects the dopamine in a way that makes the affected individual unable to experience everyday pleasures—the individual instead needs that substance to experience pleasure. Thus the individual’s driving force is any drug that can provide some kind of transient happiness (euphoria). In fact, the gene for alcoholism is located in the dopamine molecule. This can further suggest that chemical dependencies may have a medical (biological) cause.

The disease concept of chemical dependency is gaining worldwide acceptance, but does have some critics who argue instead that addiction must be understood as a general pattern of behavior, not as a medical problem. Advocates of the disease concept of chemical dependency model maintain that the identification of biological causes or correlations is crucially important for treatment. They argue that if clinicians can understand the intricate details concerning the mechanisms associated with drug effects, then measures to interrupt the effects can be devised. These interventions can be both medical (developing new drugs to chemical block effects of illicit drugs) and psychological.

According to the disease concept model, psychological intervention includes a vital educational component that teaches people with chemical dependency the concept of understanding addiction as disease. As a result of this understanding, affected people then view their dependency as a disease, similar to other diseases with a biological cause (heart disease, cancer, high blood pressure), and with a specific set of signs and symptoms and an outcome in the future (clinical course). Proponents of this approach believe that this understanding can help affected people to follow treatment recommendations, and can reduce shame and guilt commonly associated with chemical dependence. Alcoholics Anonymous is a prominent example of an organization that embodies the disease concept of chemical dependency.

Definition

Diphenhydramine is an antihistamine used in psychiatric medicine to treat phenothiazine drug-induced abnormal muscle movement. It is also used in general medicine to treat allergies, allergic reactions, motion sickness, insomnia, cough, and nausea. When diphenhydramine is used for allergy-related symptoms, it is sold in the United States as an over-the-counter medication Benadryl. For use in the treatment of the tremors caused by phenothiazines, diphenhydramine is prescribed in the generic form.

Purpose

Some drugs called phenothiazines are used to treat psychotic disorder such as schizophrenia. As a side effect, these drugs may cause tremors and abnormal involuntary movements of the muscles, referred to as extrapyramidal neurologic movement disorders. Diphenhydramine is used to control these symptoms. Other uses of the drug include the treatment of nausea, vomiting, and itching. Diphenhydramine is used to help limit allergic reactions to transfused blood products. It can induce sleep. It is sometimes used to treat the stiffness and tremor of Parkinson’s disease. In liquid form, it may relieve minor throat irritation.

Description

Diphenhydramine is an antihistamine that is readily distributed throughout the body. It is easily absorbed when taken by mouth. Maximal action occurs approximately one hour after swallowing the drug. The effects continue for four to six hours. Diphenhydramine acts on cells in the brain. It seems to compete with the chemical histamine for specific receptor sites on cells in the brain and central nervous system. This means that it achieves its theraputic effect by taking the place of the neurotransmitter histamine on these cells. Diphenhydramine is a useful medication for individuals with mild Parkinsonism when it is used in combination with centrally acting anticholinergic drugs.

Recommended dosage

The dosage of diphenhydramine must be adjusted according to the needs of individuals and their responses. Adults are generally given 25–50 mg orally, three to four times daily. Diphenhydramine may be administered through a vein or injected deep within a muscle. The usual dosage is 10–50 mg per injection, although some people may require 100 mg. The total daily dosage should not exceed 400 mg. People who forget to take a dose of this drug should skip the dose and take the next one at the regularly scheduled time. They should not double up subsequent doses if one is missed.

People should not take diphenhydramine if they are taking other preparations that contain antihistamines unless specifically directed to do so by a physician.

Precautions

People with peptic ulcer disease, bowel obstructions, an enlarged prostate, angle closure glaucoma, or difficulty urinating due to a blockage in the bladder should not use diphenhydramine without close physician supervision and monitoring. People with asthma, heart disease, high blood pressure, or an overactive thyroid should use this drug with caution. Before taking diphenhydramine, people with these conditions should discuss the risks and benefits of this drug with their doctor. Individuals should not take diphenhydramine for several days before an allergy test, as it will interfere with accurate results.

Elderly people are more sensitive to the sedating effects of diphenhydramine. The drug may also cause dizziness and lower blood pressure. Older people should slowly change position from sitting or lying to standing while taking this medication to prevent dizziness and fainting.

Side effects

Drowsiness commonly occurs after taking diphenhydramine. This effect may be more pronounced if alcohol or any other central nervous system depressant, such as a tranquilizer or a particular medication for pain, is also taken. People taking the drug should not drive, or operate machinery, or perform hazardous tasks requiring mental alertness until the effects of the medication have worn off. In some people, diphenhydramine also may cause dizziness, difficulties with coordination, confusion, restlessness, nervousness, difficulty sleeping, blurry or double vision, ringing in the ears, headache, or convulsions.

Stomach distress is a relatively common side effect of diphenhydramine. Some people may develop poor appetites, nausea, vomiting, diarrhea, or constipation. Individuals also may experience low blood pressure, palpitations, rapid or irregular heartbeats, frequent urination, or difficulty urinating. Urine may be retained in the bladder. Other side effects of diphenhydramine are associated with persons in age groups that are unlikely to use the drug.

Diphenhydramine may also cause hives, a rash, sensitivity to the sun, and a dry mouth and nose. Thickened lung secretions are common among older persons.

Interactions

Alcohol, pain medications, sleeping pills, tranquilizers, and antidepressants may make the drowsiness associated with diphenhydramine more severe. Diphenhydramine should not be used by persons taking hay fever medicines, sedatives, narcotics, anesthetics, barbiturates or muscle relaxants.

Definition

Special diets are designed to help individuals make changes in their usual eating habits or food selection. Some special diets involve changes in the overall diet, such as diets for people needing to gain or lose weight or eat more healthfully. Other special diets are designed to help a person limit or avoid certain foods or dietary components that could interfere with the activity of a medication. Still other special diets are designed to counter nutritional effects of certain medications.

Purpose

Special diets are used in the treatment of persons with certain mental disorders to:

• identify and correct disordered eating patterns
• prevent or correct nutritional deficiencies or excesses
• prevent interactions between foods or nutrients and medications

Special types of diets or changes in eating habits have been suggested for persons with certain mental disorders. In some disorders, such as eating disorders or substance abuse, dietary changes are an integral part of therapy. In other disorders, such as attention-deficit/hyperactivity disorder, various proposed diets have questionable therapeutic value.

Many medications for mental disorders can affect a person’s appetite or nutrition-related functions such as saliva production, ability to swallow, bowel function, and activity level. Changes in diet or food choices may be required to help prevent negative effects of medications.

Finally, interactions can occur between some medications used to treat persons with mental disorders and certain foods or nutritional components of the diet. For example, grapefruit and apple juice can interact with some specific psychotropic drugs (medications taken for psychiatric conditions) and should be avoided by individuals taking those medicines. Tyramine, a natural substance found in aged or fermented foods, can interfere with the functioning of monoamine oxidase inhibitors and must be restricted in individuals using these types of medications. A person’s pre-existing medical condition and nutritional needs should be taken into account when designing any special diet.

Special diets for specific disorders

Eating disorders

The two main types of eating disorders are anorexia nervosa and bulimia nervosa. Individuals with anorexia nervosa starve themselves, while individuals with bulimia nervosa usually have a normal or slightly above normal body weight but engage in binge eating followed by purging with laxatives, vomiting, or exercise.

Special diets for individuals with eating disorders focus on restoration of a normal body weight and control of bingeing and purging. These diets are usually carried out under the supervision of a multidisciplinary team, including a physician, psychologist, and dietitian.

The overall dietary goal for individuals with anorexia nervosa is to restore a healthy body weight. An initial goal might be to stop weight loss and improve food choices. Energy intake is then increased gradually until normal weight is restored. Because individuals with anorexia nervosa have an intense fear of gaining weight and becoming fat, quantities of foods eaten are increased very slowly so that the patient will continue treatments and therapy.

The overall dietary goal for individuals with bulimia nervosa is to gain control over eating behavior and to achieve a healthy body weight. An initial goal is to stabilize weight and eating patterns to help the individual gain control over the binge-purge cycle. Meals and snacks are eaten at regular intervals to lessen the possibility that hunger and fasting will trigger a binge. Once eating behaviors have been stabilized, energy intake can be gradually adjusted to allow the individual to reach a normal body weight healthfully.

For individuals with either anorexia nervosa and bulimia, continued follow-up and support are required even after normal weight and eating behaviors are restored, particularly since the rate of relapse is quite high. (Relapse occurs when a patient returns to the old behaviors that he or she was trying to change or eliminate.) In addition to dietary changes, psychotherapy is an essential part of the treatment of eating disorders and helps the individual deal with fears and misconceptions about body weight and eating behavior.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) accounts for a substantial portion of referrals to child mental health services. Children with ADHD are inappropriately active, easily frustrated or distracted, impulsive, and have difficulty sustaining concentration. Usual treatment of ADHD involves medication, behavioral management, and education.

Many dietary factors have been proposed as causes of ADHD, including sugar, food additives, and food allergies. In the 1970s the Feingold diet became popular for treatment of ADHD. The Feingold diet excludes artificial colorings and flavorings, natural sources of chemicals called salicylates (found in fruits), and preservatives called BHT and BHA. Although scientific evidence does not support the effectiveness of the Feingold diet, a modified Feingold diet including fruits has been shown to be nutritionally balanced and should not be harmful as long as the child continues to receive conventional ADHD treatment also.

A high intake of sugar and sugary foods has also been implicated as a cause of ADHD. Although carefully controlled studies have shown no association between sugar and ADHD, diets high in sugar should be discouraged because they are often low in other nutrients and can contribute to dental problems.

Food allergies have also been implicated as a cause of ADHD, and some groups have suggested using elimination diets to treat ADHD. Elimination diets omit foods that most commonly cause allergies in children, such as eggs, milk, peanuts, or shellfish. Although research does not support the value of elimination diets for all children with ADHD, children with specific food allergies can become irritable and restless. A child with a suspected food allergy should be evaluated by an allergist.

Stimulant medications used to treat ADHD, such as methylphenidate(Ritalin), can cause appetite loss (anorexia) and retard growth, although recent research suggests that a child’s ultimate height appears not to be affected by stimulant medications. As a precaution, children on such medicines should receive close monitoring of growth patterns, and parents should carefully observe their child’s appetite and interest in meals and snacks. Providing regular meals and snacks, even when the child is not hungry, can help to assure adequate growth.

Mood disorders

Mood disorders include both depression (unipolar disorder) and episodes of mania followed by depression (bipolar disorder). Both types of disorders can affect appetite and eating behavior.

Although some depressed individuals eat more than usual and gain weight, depression more often causes loss of appetite and weight loss. As depressed individuals lose interest in eating and social relationships, they often skip meals and ignore feelings of hunger. Unintentional weight losses of up to 15% of body mass can occur.

Treatment with antidepressant medications often reverses weight loss and restores appetite and interest in eating. If the individual has lost a significant amount of weight, he or she may need to follow a high-calorie diet to restore weight to normal levels and replaced nutritional deficiencies. High-calorie diets usually include three balanced meals from all the food groups and several smaller snacks throughout the day. A protein/calorie supplement may also be necessary for some individuals.

Depression is sometimes treated with medications called monoamine oxidase inhibitors. Individuals on these medications will need to follow a tyramine-restricted diet (see below under monoamine oxidase inhibitors).

Individuals with mania are often treated with lithium. Sodium and caffeine intake can affect lithium levels in the blood, and intake of these should not suddenly be increased or decreased. Weight gain can occur in response to some antidepressant medications and lithium.

Schizophrenia

Individuals with schizophrenia can have hallucinations, delusional thinking, and bizarre behavior. These distorted behaviors and thought processes can also be extended to delusions and hallucinations about food and diet, making people with schizophrenia at risk for poor nutrition.

Individuals with schizophrenia may believe that certain foods are poisonous or have special properties. They may think they hear voices telling them not to eat. Some may eat huge quantities of food thinking that it gives them special powers. Individuals with untreated schizophrenia may lose a significant amount of weight. Delusional beliefs and thinking about food and eating usually improve once the individual is started on medication to treat schizophrenia.

Substance abuse

Substance abuse can include abuse of alcohol, cigarettes, marijuana, cocaine, or other drugs. Individuals abusing any of these substances are at risk for nutritional problems. Many of these substances can reduce appetite, decrease absorption of nutrients into the body, and cause the individual to make poor food choices.

Special diets used for withdrawal from substance abuse are designed to correct any nutritional deficiencies that have developed, aid in the withdrawal of the substance, and prevent the individual from making unhealthful food substitutions as the addictive substance is withdrawn. For example, some individuals may compulsively overeat when they stop smoking, leading to weight gain. Others may substitute caffeine-containing beverages such as soda or coffee for an addictive drug. Such harmful substitutions should be discouraged, emphasizing well-balanced eating combined with adequate rest, stress management, and regular exercise. Small, frequent meals and snacks that are rich in vitamins and minerals from healthful foods should be provided. Fluid intake should be generous, but caffeine-containing beverages should be limited.

Individuals withdrawing from alcohol may need extra thiamin supplementation, either intravenously or through a multivitamin supplement because alcohol metabolism in the body requires extra thiamin. Individuals taking drugs to help them avoid alcohol will need to avoid foods with even small amounts of alcohol (see below).

Common withdrawal symptoms and dietary suggestions for coping with these symptoms include:

• Appetite loss: eat small, frequent meals and snacks; limit caffeine; use nutritional supplements if necessary.
• Appetite increase: eat regular meals; eat a variety of foods; limit sweets and caffeine.
• Diarrhea: eat moderate amounts of fresh fruits, vegetables, concentrated sugars, juices, and milk; increase intake of cereal fiber.
• Constipation: drink plenty of fluids; increase fiber in the diet; increase physical activity.
• Fatigue: eat regular meals; limit sweets and caffeine; drink plenty of fluid.

Dietary considerations and medications

Medications that affect body weight

Many medications used to treat mental disorders promote weight gain, including:

• anticonvulsants (divalproex)
• certain types of antidepressants (amitriptyline)
• antipsychotic medications (clozapine, olanzapine, quetiapine, and risperidone)

Dietary treatments for individuals taking these medications should focus on a balanced, low-fat diet coupled with an increase in physical activity to counter the side effects of these medications. Nutrient-rich foods such as fruits, vegetables, and whole grain products should be emphasized in the diet, whereas sweets, fats, and other foods high in energy but low in nutrients should be limited. Regular physical activity can help limit weight gain caused by these medications.

Some medications can cause loss of appetite, restlessness, and weight loss. Individuals on such medications should eat three balanced meals and several smaller snacks of protein and calorie-rich foods throughout the day. Eating on a regular schedule rather than depending on appetite can help prevent weight loss associated with loss of appetite.

Medications that affect gastrointestinal function

Many psychiatric medications can affect gastrointestinal functioning. Some drugs can cause dry mouth, difficulty swallowing, constipation, altered taste, heartburn, diarrhea, or nausea. Consuming frequent smaller meals, drinking adequate fluids, modifying texture of foods if necessary, and increasing fiber content of foods can help counter gastrointestinal effects of medications.

Monoamine oxidase inhibitors

Individuals being treated with monoamine oxidase inhibitors (MAOIs) such as tranylcypromine, phenelzine, and isocarboxazid, must carefully follow a tyramine-restricted diet. Tyramine, a nitrogen-containing substance normally present in certain foods, is usually broken down in the body by oxidases. However, in individuals taking MAOIs, tyramine is not adequately broken down and builds up in the blood, causing the blood vessels to constrict and increasing blood pressure.

Tyramine is normally found in many foods, especially protein-rich foods that have been aged or fermented, pickled, or bacterially contaminated. Cheese is especially high in tyramine. A tyramine intake of less than 5 milligrams daily is recommended. A diet that includes even just 6 milligrams of tyramine can increase blood pressure; a diet that provides 25 milligrams of tyramine can cause life-threatening increases in blood pressure.

TYRAMINE-RESTRICTED DIET. Tyramine is found in aged, fermented and spoiled food products. The tyramine content of a specific food can vary greatly depending on storage conditions, ripeness, or contamination. Reaction to tyramine-containing foods in individuals taking MAOIs can also vary greatly depending on what other foods are eaten with the tyramine-containing food, the length of time between MAOI dose and eating the food, and individual characteristics such as weight, age, etc.

Foods to avoid on a tyramine-controlled diet include:

• all aged and mature cheeses or cheese spreads, including foods made with these cheeses, such as salad dressings, casseroles, or certain breads
• any outdated or nonpasteurized dairy products
• dry fermented sausages such as summer sausage, pepperoni, salami, or pastrami
• smoked or pickled fish
• non-fresh meat or poultry
• leftover foods containing meat or poultry
• tofu and soy products
• overripe, spoiled, or fermented fruits or vegetables
• sauerkraut
• fava or broad beans
• soups containing meat extracts or cheese
• gravies containing meat extracts or nonfresh meats
• tap beer
• nonalcoholic beer
• yeast extracts
• soy sauce
• liquid powdered protein supplements

Perishable refrigerated items such as milk, meat, or fruit should be eaten within 48 hours of purchase. Any spoiled food and food stored in questionable conditions should not be eaten.

Lithium

Lithium is often used to treat individuals with mania. Lithium can cause nausea, vomiting, anorexia, diarrhea, and weight gain. Almost one-half of individuals taking lithium gain weight.

Individuals taking lithium should maintain a fairly constant intake of sodium (found in table salt and other food additives) and caffeine in their diet. If an individual restricts sodium intake, less lithium is excreted in the urine and blood lithium levels rise. If an individual increases caffeine intake, more lithium is excreted in the urine and blood levels of lithium fall.

Anticonvulsant medications

Sodium caseinate and calcium caseinate can interfere with the action and effectiveness of some anticonvulsants. Individuals taking these anticonvulsants should read labels carefully to avoid foods containing these additives.

Psychotropic medications

Some psychotropic medications, such as amitriptyline, can decrease absorption of the vitamin riboflavin from food. Good food sources of riboflavin include milk and milk products, liver, red meat, poultry, fish, and whole grain, and enriched breads and cereals. Riboflavin supplements may also be needed.

Other psychotropic drugs, such as fluvoxamine, sertraline, fesasodone, alprazolam, triazolam, midazolam, carbamazepine, and clonazepam, interact with grapefruit juice, so individuals taking these drugs must take care to avoid grapefruit juice. In some cases, apple juice must be avoided, as well. Patients should discuss potential drug interactions with their doctor or pharmacist.

Caffeine-restricted diet

Caffeine is a stimulant and can interfere with the actions of certain medications. As stated, people taking lithium and people recovering from addictions may be asked by their treatment team to monitor (and, in the case of addictions, restrict) their caffeine intake. Foods and beverages high in caffeine include:

• chocolate
• cocoa mix and powder
• chocolate ice cream, milk, and pudding
• coffee
• cola beverages
• tea

Alcohol-restricted diet

Alcohol interacts with some medications used to treat mental disorders. In the case of alcoholism recovery, the negative interaction resulting from the combination of one medication (disulfiram or Antabuse) and alcohol consumption is actually part of treatment for some people. (The medication causes an extremely unpleasant reaction to any alcohol consumed, reinforcing or rewarding the avoidance of alcohol.)

When individuals are taking medication that requires that they avoid alcohol, foods containing alcohol must be avoided as well as beverage alcohol. The following foods contain small amounts of alcohol:

• flavor extracts, such as vanilla, almond, or rum flavorings
• cooking wines
• candies or cakes prepared or filled with liqueur
• apple cider
• cider and wine vinegar
• commercial eggnog
• bernaise or bordelaise sauces
• desserts such as crepes suzette or cherries jubilee
• teriyaki sauce
• fondues