Definition

Biperiden is classified as an antiparkinsonian agent. It is sold in the United States under the brand name of Akineton.

Purpose

Biperiden is used to treat a group of side effects (called parkinsonian side effects) that include tremors, difficulty walking, and slack muscle tone. These side effects may occur in patients who are taking antipsychotic medications used to treat mental disorders such as schizophrenia.

Description

Some medicines, called antipsychotic drugs, that are used to treat schizophrenia and other mental disorders can cause side effects that are similar to the symptoms of Parkinson’s disease. The patient does not have Parkinson’s disease, but he or she may experience shaking in muscles while at rest, difficulty with voluntary movements, and poor muscle tone. These symptoms are similar to the symptoms of Parkinson’s disease.

One way to eliminate these undesirable side effects is to stop taking the antipsychotic medicine. Unfortunately, the symptoms of the original mental disorder usually come back, so in most cases simply stopping the antipsychotic medication is not a reasonable option. Some drugs such as biperiden that control the symptoms of Parkinson’s disease also control the parkinsonian side effects of antipsychotic medicines.

Biperiden works by restoring the chemical balance between dopamine and acetylcholine, two neurotransmitter chemicals in the brain. Taking biperiden along with the antipsychotic medicine helps to control symptoms of the mental disorder, while reducing parkinsonian side effects. Biperiden is in the same family of drugs (commonly known as anticholinergic drugs) as benztropine, amantadine, and trihexyphenidyl.

Recommended dosage

Biperiden is available in 2-mg tablets. For the treatment of tremor, poor muscle tone, and similar parkinsonian side effects, the dose of biperiden is 2 mg orally one to three times daily. Parkinson-like side effects caused by antipsychotic drugs may come and go, so biperiden may not be needed on a regular basis. Biperiden may also be prescribed to prevent these side effects before they actually occur. This is called as prophylactic (preventative) therapy.

Precautions

Biperiden should never be used in children under age three. It should be used cautiously and with close physician supervision in older children and in the elderly. Biperiden, like all anticholinergic drugs, decreases sweating and the body’s ability to cool itself. People who are unaccustomed to being outside in hot weather should take care to stay as cool as possible and drink extra fluids. People who are chronically ill, have a central nervous system disease, or who work outside during hot weather may need to avoid taking biperiden.

People who have the following medical problems may experience increased negative side effects when taking biperiden. Anyone with these problems should discuss their condition with their physician before starting the drug:

• glaucoma, especially closed-angle glaucoma
• intestinal obstruction
• prostate enlargement
• urinary bladder obstruction

Although rare, some patients experience euphoria while taking biperiden and may abuse it for this reason. Euphoria can occur at doses only two to four times the normal daily dose. Patients with a history of drug abuse should be observed carefully for biperiden abuse.

Side effects

Although biperiden helps control the side effects of antipsychotic drugs, it can produce side effects of its own. A person taking biperiden may have some of the following side effects, which may vary in intensity:

• dry mouth
• dry skin
• blurred vision
• nausea or vomiting
• constipation
• disorientation
• drowsiness
• irritability
• increased heart rate
• urinary retention

Dry mouth, if severe to the point of causing difficulty in speaking or swallowing, may be managed by dosage reduction or temporary discontinuation of the drug. Chewing sugarless gum or sucking on sugarless candy may also help to increase the flow of saliva. Some artificial saliva products may give temporary relief.

Men with prostate enlargement may be especially prone to urinary retention. Symptoms of this problem include having difficulty starting a urine flow and more difficulty passing urine than usual. This side effect may be severe and require discontinuation of the drug. Urinary retention may require catheterization. People who think they may be experiencing any side effects from this or any other medication should tell their physicians.

Patients who take an overdose of biperiden are treated with forced vomiting, removal of stomach contents and stomach washing, activated charcoal, and respiratory support if needed. They are also given physostigmine, an antidote for anticholinergic drug poisoning.

Interactions

When drugs such as biperiden are taken with antidepressants such as amitriptyline, imipramine, trimipramine, desipramine, nortriptyline, protriptyline, amoxapine, and doxepin, as well as with many antihistamines that also have anticholinergic properties, the effects of biperiden are usually intensified.

Drugs such as biperiden decrease the speed with which food moves through the stomach and intestines. Because of this, it is possible that the absorption of some drugs may be enhanced by biperiden. Patients receiving biperiden should be observed for unusual responses to other drugs they might be taking.

Definition

Biofeedback is a technique that uses monitoring instruments to measure and feed back information about muscle tension, heart rate, sweat responses, skin temperature, or brain activity.

Terms associated with biofeedback include applied psychophysiology or behavioral physiology. It is also viewed as a mind-body therapy method used in complementary and alternative medicine. Biofeedback is an important part of understanding the relationship between physical state and thoughts, feelings, and behaviors.

Purpose

The purpose of biofeedback is to enhance an individual’s awareness of physical reactions to physical, emotional, or psychological stress, and their ability to influence their own physiological responses. The overall purpose is to develop self-regulation skills that play a role in improving health and well-being.

Biofeedback has been used as a part of a comprehensive treatment approach with a number of conditions, including chronic pain, irritable bowel syndrome (IBS), temporomandibular joint disorder (TMJ), Raynaud’s syndrome, epilepsy, attention-deficit/hyper activity disorder(ADHD), anxiety, migraine headaches, depression, traumatic brain injury, and sleep disorders. There is some support for using biofeedback in the treatment of diabetes when self-monitoring of blood glucose levels is maintained and within the context of regular physician consultation and supervision.

Biofeedback has been a useful tool in helping individuals with urinary incontinence regain bladder control by controlling the muscles used in urination. Sensors are placed in the vaginal or anal canal to help individuals learn when the muscles are properly contracted. A recent study found that this type of biofeedback treatment was safe, effective, and well liked by women patients 55 years and older.

Conditions related to stress are also treated using biofeedback, such as certain types of headaches, high blood pressure, bruxism or teeth grinding, post-traumatic stress disorder(PTSD), eating disorders, substance abuse, and some anxiety disorders. In treatment of stress-related conditions, biofeedback is often used in combination with relaxation training. Sometimes, biofeedback is used to help individuals learn how to experience deeper relaxation, such as in childbirth education programs or general stress management. This is referred to as biofeedback-assisted relaxation training. Even for individuals who can achieve relaxation through other strategies such as meditation or relaxation, biofeedback can be a valuable added technique. Biofeedback offers special advantages, such as allowing the clinician to track closely the places where an individual tenses up and helps the individual learn what thoughts and feelings are associated with the tension.

Precautions

Biofeedback depends on the motivation and active participation of an individual. Thus, it may not be suitable for individuals with low motivation who are not willing to take a highly active role in treatment, such as those suffering from depression. Also, since biofeedback focuses on initiating behavioral changes, individuals inclined to examine their past to alleviate problems and symptoms may benefit more from other treatment types, such as psychotherapy. Individuals with cognitive impairment may be unable to remain engaged in the treatment, depending on their level of functioning. Also, individuals with a pacemaker or other implanted electrical devices should inform their health care professional before entering biofeedback training, as certain types of biofeedback sensors may interfere with the devices. Patients with specific pain symptoms in which the cause is unknown should have a thorough medical examination to rule out any serious underlying disease before starting biofeedback training. Biofeedback can be used in combination with conventional therapies; however, while it can be used in combination with conventional medical treatment for illnesses such as cancer and diabetes, it should not replace those treatments.

Research on the success of biofeedback in treating certain conditions is inconclusive or needs to be validated. Some research studies use a small number of participants, which makes it difficult to generalize the results to a larger population. Also, many conditions have different subtypes with a variety of psychological, social, and physical causes. This fact, combined with research design concerns, makes it difficult to compare research studies. For example, while most studies have reported positive outcomes in the treatment of alcohol abuse and dependence, problems with methods and statistical analyses have called study results into question. Also, its effectiveness in treating opiate abuse or dependence has not been consistently shown, as with its use in treating menopausal hot flashes, and there are limitations in studies relating to its use in cancer treatment. Continued research is needed to further evaluate and improve different biofeedback techniques for various conditions.

Description

According to the Association for Applied Psychophysiology and Biofeedback, the technique was developed in the early 1970s by psychologists and physicians. These techniques continue to be used by psychologists, physicians, nurses, and other health care professionals such as physical therapists. Prior to beginning any biofeedback training, individuals may need a comprehensive psychological, educational, and/or medical assessment. Biofeedback can be used in conjunction with nonmedical treatments, such as psychotherapy, cognitive-behavioral therapy, and behavioral treatment strategies.

How biofeedback works

Biofeedback utilizes electronic sensors, or electrodes, attached to various parts of the body to detect changes in physical responses. Signals then inform the individual of these changes by means of visual or auditory signals such as a light display or a series of beeps. While the individual views or listens to feedback, he or she begins to recognize thoughts, feelings, and mental images that influence his or her physical reactions. By monitoring this mind-body connection, the individual can use the same thoughts, feelings, and mental images as cues or reminders to become more relaxed, or to change heartbeat, brain wave patterns, body temperature, and other body functions. The individual uses trial-and-error to change the signals change in the desired direction. For example, individuals trying to control their blood pressure levels may see a light flash whenever the pressure drops below a certain level. They may then try to remember what their thoughts and feelings were at the moment and deliberately maintain them to keep the blood pressure level low.

Through training, the individual learns to control the targeted physical response and, over time, is able to recognize what is required to reduce problematic symptoms. Eventually, the external biofeedback becomes unnecessary as the individual learns to perceive internal physical responses and make the desired changes. The individual then has a powerful, portable, and self-administered treatment tool to deal with problematic symptoms.

Three stages of biofeedback training

• Awareness of the problematic physical response: Individuals may complete a psychophysiological stress profile (PSP) to identify how their bodies respond to a variety of stressors and determine their ability to overcome undesired physical reactions. This involves a period of rest, stress, and recovery. For example, various sensors are attached to various parts of the body, and a baseline measurement lasting from two to four minutes records physical responses. The individual then goes through a standard set of stressors (such as rapid math calculations or running in place) each lasting from two to four minutes. This is followed by another relaxation period to determine the length of the recovery period.
• Using signals from the biofeedback equipment to control physical responses: The individual is assisted in reaching certain goals related to managing a specific physical response.
• Transferring control from biofeedback equipment or the health care professional: Individuals learn to identify triggers that alert them to implement their new-found self-regulation skills.

Types of biofeedback equipment

• Electromyograph (EMG): Sensors (or electrodes) placed on the skin on pertinent parts of the body monitor electrical activity in muscles, specifically tension. This is the most frequently used biofeedback method in the treatment of various neurologic disorders such as stroke, cerebral palsy, traumatic brain injury, and multiple sclerosis. In children and adolescents, EMG may be used to treat tension headaches, enuresis, and encopresis. In treating TMJ or bruxism, EMG sensors are placed on jaw muscles. Chronic pain is treated by monitoring muscle tension in various places on the body.
• Galvanic skin response (GSR): Sensors on the fingers monitor perspiration or sweating. This is also referred to as obtaining a skin conductance level (SCL). GSR may be used in the treatment of anxiety, fears or phobias, stress, and sleep problems.
• Temperature or thermal sensors: Sensors monitor body temperature and changes in blood flow. Changes in hand temperature, for example, can indicate relaxation when there is increased blood flow to the skin. Temperature biofeedback may be useful for treating migraine headache, Raynaud’s disorder, and anxiety disorders.
• Heart rate sensors: A pulse monitor placed on the fingertip monitors pulse rate. Increases in heart rate are associated with emotional arousal, such as being angry or fearful. Decreases in heart rate are associated with relaxation.
• Capnometry (CAP): Respiratory sensors monitor oxygen intake and carbon dioxide output. This differentiates correct breathing from problematic breathing practices. Breath control training may be used to treat panic attacks, asthma, and a variety of stress-related conditions.
• Electroencephalographs (EEG) or neurofeedback: Sensors attached to the scalp monitor brain wave activity in different parts of the brain. It may be used to treat conditions with proven or suspected impact on brain wave patterns such as seizure disorders or epilepsy, ADHD, learning disabilities, migraine headaches, traumatic brain injury, and sleep disorders.
• Biofeedback is geared toward whatever a person finds most appealing and understandable and provided in several formats such as auditory, visual, or multimedia. Audio feedback, that may take the form of changes in tone and pitch, is useful because visual attention is not necessary. Visual feedback can be provided in various forms such as bar or line graphs on a computer screen. Initially, it was thought that—over time—computer signals could become boring or visually unappealing. In response to this, Barry Bittman developed Mindscope in 1992 that displays video scenes with realistic sounds on a high-definition television set connected to a computer. Physical responses detected by the biofeedback equipment control an engaging audiovisual environment of beautiful and realistic scenes. Clarity, perspective, motion, and sounds improve as the individual deepens their relaxation. For children and adolescents, this may be described as a “video game for the body.” Visual displays for EMG biofeedback may include sports such as basketball, baseball, and golf, where the individual plays against the computer.

  The setting in which biofeedback training takes place can vary. Sometimes the clinician, client, and equipment are in the same room. Sometimes the client may sit in comfortable seating in a semi-dark, quiet room while the clinician is in another room with the equipment. In this arrangement, the clinician and client may communicate using an intercom.

  In some cases, children and adolescents may reach the desired level of control in three to five sessions. Depending on the condition, biofeedback training may require a series of sessions for several days or weeks. In general, it may take 10 or 15 sessions at the lower end to 40 or 50 sessions at the higher end.

  Preparation

  Biofeedback is most successful when individuals are motivated to learn. It is useful for people who have difficulty relaxing, even when they make efforts to do so. A receptive and open attitude is important for attaining desired responses rather than actively focusing on attaining them. It is important that individuals are willing to practice regularly at home to apply the skill to everyday life. Establishing a foundation of trust and confidence in the health care professional is an important component of biofeedback training.

  Before beginning biofeedback training, an initial consultation will be conducted to record medical history, treatment background, and biofeedback goals. The procedure will be explained to provide a clear understanding of how and why the training will be helpful. The individual may be shown the equipment and told where they will be placed and how they work.

  Before electrodes are placed on the body, the skin surface must be adequately prepared by using alcohol preparation pads to remove oils, makeup, and dead skin cells that may interfere with the biofeedback signal. An electrode paste is then applied to the sensor, or a small adhesive pad is used to adhere the sensor to the skin. Heart rate, temperature, and GSR monitors may be placed on the fingertip with a Velcro or elastic band. With CAP, the tip of a small, flexible, plastic tube is positioned in the nostril using tape. An individual may be taught several forms of biofeedback initially, then the training may be tailored to the individual’s preference.

  The biofeedback trainer must have technical skill, an understanding of basic anatomy and physiology, knowledge of various conditions, and familiarity with computer hardware and software. The American Psychological Association views biofeedback as a proficiency area, master’s and doctoral level training programs are available through a variety of sources, and certification is available through the Biofeedback Certification Institute of America.

  Aftercare

  One or two follow-up sessions may be arranged two to four months after the initial set of appointments. In this way, long-term progress can be assessed, support can be provided, and adjustments can be made, if needed.

  Risks

  There are no known side effects with properly administered biofeedback. Problems may occur if biofeedback is used to treat certain conditions where the use of biofeedback is not advised.

  Normal results

  A normal result may be indicated by achieving the desired changes in muscle tension, heart rate, sweat activity, respiration rate, temperate change, and brainwave activity. Health care professionals may use various criteria or normal values that have been developed for some biofeedback equipment. These values indicate levels that can be expected from normal physiological functioning or relaxation. Importantly, an individual learns to control their physical reactions, which may lead to feelings of empowerment and confidence.

  Abnormal results

  Unusual results may arise from a number of factors, including poor sensor or electrode contact with the skin and interference from other electrical signals or “noise.” Some equipment may react to room temperature conditions, especially when the room is very hot or very cold. Although inexpensive monitoring equipment is available, such as watches that monitor heartbeat and hand-held GSR devices, their results may not be accurate.

Description

Binge eating is a form of overeating in which a person ingests a large amount of food during a discrete period of time (within one or two hours, for example) and experiences feelings of being out of control and unable to stop eating during the episode. In practice, the duration of a binge may vary greatly from one event to the next, making it difficult to define the number of binges occurring in a given day. Binge eating often occurs in the absence of hunger and is characterized by eating very rapidly; eating alone (due to embarrassment over the amount being eaten); and having strong negative feelings, such as guilt, shame and depression, following the binge. Typically, a binge episode ends only when all the desirable binge foods have been consumed or when the person feels too full to continue eating.

While binge eating is a symptom of bulimia nervosa, it differs from this disorder in that behaviors intended to get rid of the food (fasting, excessive exercise, or using laxatives or inducing vomiting to “purge” the food from the system) are present among those with bulimia, but are generally absent among binge eaters. Binge eating may also occur in anorexia nervosa.

The clinician’s diagnostic handbook, the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revised, published in 2000) subsumes binge eating under the diagnosis of eating disorders not otherwise specified. Binge eating disorder is, however, under consideration as a separate diagnostic category, pending further study.

Symptoms and treatments

Binge eating episodes may occur in response to strong negative emotions, such as depression or anxiety, or to less defined feelings of distress or tension. The act of bingeing seems to alleviate these uncomfortable feelings temporarily and binge eaters typically describe themselves as “numb” or “spaced out” while engaged in these behaviors. Some people report that binges are related to the ingestion of certain “trigger foods,” usually carbohydrates, but regardless of the stimulus, the feeling of eating without being able to control one’s intake is a frightening experience for most people. The aftermath of a binge often includes an overwhelming sense of self-disgust, depression and anxiety.

While people who binge eat are clearly at high risk for becoming overweight, there are important differences between simple obesity and binge eating. People who binge eat are far more likely to report significant mood problems, especially depression, and to report greater dissatisfaction with their weight and shape than are comparably obese persons. They are also more likely to describe themselves as experiencing personal problems and work difficulties and to be hypersensitive to the thoughts and opinions of others. Like people with bulimia nervosa, they also have an increased likelihood of being diagnosed with major depression, substance-related disorders, and personality disorders, yet the overall rates of recovery for binge eating disorders are actually more favorable than those obtained in bulimia.

Binge eating is not common among the general public, but it is prevalent among persons attending weight loss clinics, where as many as half of the participants may fit this description. Both males and females develop binge-eating problems, but the rate of occurrence is 1.5 times greater among women. Age of onset is usually adolescence through young adulthood and the course of the disorder is often marked by a long history of on-again, off-again dieting.

As is the case with other forms of eating disorders, identification of specific causes for binge eating has been difficult. Since many people report relief from painful or uncomfortable mental states while bingeing, the behavior offers short-term emotional relief, making it likely to be repeated. Some investigators have considered genetic influences and personality variables. Still others have suggested that the “culture of thinness” in western societies contributes to the tendency toward harsh self-evaluation characterizing binge-eaters who then turn to food for solace.

At present, the most effective treatment approach to reducing the incidence of binge eating appears to be cognitive-behavioral therapy (CBT). The goal of this therapy is the development of skills for effectively coping with emotional distress rather than seeking to numb or disguise troubling feelings. This therapy focuses on helping the affected individual to decrease the binge eating behavior by recognizing the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns. Follow-up research has been very encouraging, documenting both a decrease in depressive symptoms and a corresponding likelihood of healthy weight loss as the individual achieves better control of eating behaviors.

Definition

Bibliotherapy is an adjunct to psychological treatment that incorporates appropriate books or other written materials, usually intended to be read outside of psychotherapy sessions, into the treatment regimen.

Purpose

The goal of bibliotherapy is to broaden and deepen the client’s understanding of the particular problem that requires treatment. The written materials may educate the client about the disorder itself or be used to increase the client’s acceptance of a proposed treatment. Many people find that the opportunity to read about their problem outside the therapist’s office facilitates active participation in their treatment and promotes a stronger sense of personal responsibility for recovery. In addition, many are relieved to find that others have had the same disorder or problem and have coped successfully with it or recovered from it. From the therapist’s standpoint, providing a client with specific information or assignments to be completed outside regular in-office sessions speeds the progress of therapy.

Bibliotherapy has been applied in a variety of settings to many kinds of psychological problems. Practitioners have reported successful use of bibliotherapy in treating eating disorders, anxiety and mood disorders, agoraphobia, alcohol and substance abuse, and stress-related physical disorders.

Precautions

Bibliotherapy is not likely to be useful with clients suffering from thought disorders, psychoses, limited intellectual ability, dyslexia, or active resistance to treatment. In addition, some clients may use bibliotherapy as a form of do-it-yourself treatment rather than seeking professional help.

Description

In most settings, bibliotherapy is used as an adjunct to more traditional forms of psychotherapy. Practitioners of cognitive-behavioral therapies are among the most enthusiastic supporters of bibliotherapy, particularly in the development of individualized treatment protocols, including workbooks, for specific disorders. For example, clients with eating disorders, especially bulimia nervosa, often benefit from receiving educational information appropriate to their stage of recovery, such as books or articles about cultural biases regarding weight, attractiveness, and dieting. This information helps clients better understand the rationale for their treatment and to work on new skills or behavioral changes more effectively.

Aftercare

Unlike many standard forms of psychotherapy, bibliotherapeutic approaches often include specific examples of ways to deal with relapses or setbacks. As long as the client keeps these materials, he or she has easy access to resources for getting back on track.

 

Definition

Beta blockers, also known as beta antagonists, are a class of drugs that were first developed for the treatment of certain heart conditions and hypertension. Later, beta blockers were also found to be useful in glaucoma, migraine, and some psychiatric disorders such as performance anxiety, tremors secondary to lithium, and movement disorders that are caused by some drugs used in the treatment of psychosis. In the United States, the most commonly used beta blocker used in psychiatric practice is propranolol (Inderal). Nadolol (Corgard), metoprolol (Lopressor), and atenolol (Tenormin) are also used in psychiatric practice but to a lesser degree.

Purpose

Beta blockers are proven effective in the treatment of performance anxiety, lithium-induced tremor, and neuroleptic-induced akathisia (a physical condition caused by certain antipsychotic drugs). Beta blockers have sometimes been used with benzodiazepines in treating alcohol withdrawal.

Description

Beta blockers act on that part of the central nervous system that controls mental alertness, lung function, heart rate, and blood vessels. Although there is more than one mechanism by which beta blockers work in anxiety states, the most beneficial result probably arises from the fact that beta blockers slow the heart to a normal rate and rhythm. Therefore, persons with performance anxiety do not experience the usual chest tightness and rapid heart rate that is associated with such acts as public speaking or acting.

Certain antipsychotic medications known as neuroleptics can cause an unwanted effect called akathisia, which is the inability to sit, stand still, or remain inactive. Patients are restless, and in severe cases, may pace constantly and forcefully and repeatedly stomp their feet. Beta blockers can sometimes treat this condition with a lower incidence of side effects than any other drugs used to treat this condition.

Propranolol is available in 10- to 90-mg tablets. Nadolol is available in 20-, 40-, 80-, 120-, and 160-mg tablets. Atenolol is available in 50- and 100-mg tablets. Metoprolol is available in 50- and 100-mg tablets.

Recommended dosage

For the treatment of performance anxiety, sometimes called stage fright, a single dose of propranolol ranging from 10–40 mg is given 20–30 minutes before the event causing the unwanted reactions.

For lithium-induced tremors that cannot be controlled by reducing caffeine intake or administering the dosage of lithium at bedtime, propranolol at a dose of 20–160 mg daily can be given in two or three evenly divided doses.

For akathisia caused by antipsychotic medications, propranolol can be administered at doses of 10–30 mg three times daily.

Precautions

Because of their ability to narrow airways, beta blockers, especially propranolol, should not be taken by people with asthma and chronic obstructive pulmonary disease (COPD). If there is an urgent need to use beta blockers in persons with respiratory problems, atenolol or metoprolol are the beta-blockers of choice because they are less likely to have this side effect, although even these drugs should also be used with caution. Patients with congestive heart failure or certain cardiac conduction abnormalities such as a heart block, should also receive these drugs with caution.

Beta blockers should be used with close physician monitoring in people with diabetes, since the symptoms of low blood sugar (increased heart rate, lightheadedness, and abnormal perspiration) may be not be recognized by patients.

Side effects

Beta blockers can cause undesired decreases in blood pressure and are typically not given if blood pressure is 90/60 mm Hg or less.

Beta blockers can also cause an undesired drop in heart rate. People whose resting heart rate is less than 55 beats per minute should not take beta blockers.

Occasionally, beta blockers can cause rash, weakness, nausea, vomiting, and stomach discomfort.

Interactions

Each medication in the class of beta blockers has the potential to interact with a multitude of other medications. Anyone starting beta blocker therapy should review the other medications they are taking with their physician and pharmacist for possible interactions. Patients should always inform all their health care providers, including dentists, that they are taking beta blockers.

Definition

Benztropine is classified as an antiparkinsonian agent. It is sold in the United States under the brand name Cogentin and is also available under its generic name.

Purpose

Benztropine is used to treat a group of side effects (called parkinsonian side effects) that include tremors, difficulty walking, and slack muscle tone. These side effects may occur in patients who are taking antipsychotic medications used to treat mental disorders such as schizophrenia.

Description

Some medicines, called antipsychotic drugs, that are used to treat schizophrenia and other mental disorders can cause side effects that are similar to the symptoms of Parkinson’s disease. The patient does not have Parkinson’s disease, but he or she may experience shaking in muscles while at rest, difficulty with voluntary movements, and poor muscle tone. These symptoms are similar to the symptoms of Parkinson’s disease.

One way to eliminate these undesirable side effects is to stop taking the antipsychotic medicine. Unfortunately, the symptoms of the original mental disorder usually come back, so in most cases simply stopping the antipsychotic medication is not a reasonable option. Some drugs such as benztropine that control the symptoms of Parkinson’s disease also control the parkinsonian side effects of antipsychotic medicines.

Benztropine works by restoring the chemical balance between dopamine and acetylcholine, two neurotransmitter chemicals in the brain. Taking benztropine along with the antipsychotic medicine helps to control symptoms of the mental disorder, while reducing parkinsonian side effects. Benztropine is in the same family of drugs (commonly known as anticholinergic drugs) as biperiden and trihexyphenidyl.

Recommended dosage

Benztropine is available in 0.5-, 1.0-, and 2.0-mg tablets and in an injectable form containing 2 mg of drug in each 2 mL glass container. For the treatment of tremor, poor muscle tone, and similar side effects, benztropine should be started at a dose of 1 to 2 mg orally. In cases of severe side effects, benztropine can be given as an intramuscular injection two to three times daily or as needed. Parkinson-like side effects caused by antipsychotic drugs may come and go, so benztropine may not be needed on a regular basis. Benztropine may also be prescribed to prevent these side effects before they actually occur. This is called as prophylactic (preventative) therapy.

Precautions

Benztropine should never be used in children under age three. It should be used cautiously and with close physician supervision in older children and in the elderly. Benztropine, like all anticholinergic drugs, decreases sweating and the body’s ability to cool itself. People who are unaccustomed to being outside in hot weather should take care to stay as cool as possible and drink extra fluids. People who are chronically ill, have a central nervous system disease, or who work outside during hot weather may need to avoid taking benztropine.

People who have the following medical problems may experience increased negative side effects when taking benztropine. Anyone with these problems should discuss their condition with their physician before starting the drug:

• glaucoma, especially closed-angle glaucoma
• intestinal obstruction
• prostate enlargement
• urinary bladder obstruction

Although rare, some patients experience euphoria while taking benztropine and may abuse it for this reason. Euphoria can occur at doses only two to four times the normal daily dose. Patients with a history of drug abuse should be observed carefully for benztropine abuse.

Side effects

Although benztropine helps to control the side effects of antipsychotic drugs, it can produce side effects of its own. A person taking benztropine may have some of the following reactions, which may vary in intensity:

• dry mouth
• dry skin
• blurred vision
• nausea or vomiting
• constipation
• disorientation
• drowsiness
• irritability
• increased heart rate
• urinary retention

Dry mouth, if severe to the point of causing difficulty speaking or swallowing, may be managed by reducing or temporarily discontinuing benztropine. Chewing sugarless gum or sucking on sugarless candy may also help to increase the flow of saliva. Some artificial saliva products may give temporary relief.

Men with prostate enlargement may be especially prone to urinary retention. Symptoms of this problem include having difficulty starting a urine flow and more difficulty passing urine than usual. This side effect may be severe and require discontinuation of the drug. Urinary retention may require catheterization. People who think they may be experiencing any side effects from this or any other medication should tell their physician.

Patients who take an overdose of benztropine are treated with forced vomiting, removal of stomach contents and stomach washing, activated charcoal, and respiratory support if needed. They are also given physostigmine, an antidote for anticholinergic drug poisoning.

Interactions

When drugs such as benztropine are taken with antidepressants such as amitriptyline, imipramine, trimipramine, desipramine, nortriptyline, protriptyline, amoxapine, and doxepin or with many antihistamines that also have anticholinergic properties, the effects and side effects of benztropine are usually intensified.

Drugs such as benztropine decrease the speed with which food moves through the stomach and intestines. Because of this, the absorption of other drugs being taken may be enhanced by benztropine. Patients receiving benztropine should be alert to unusual responses to other drugs they might be taking and report any changes to their physician.

Definition

The Bender Gestalt Test, or the Bender Visual Motor Gestalt Test, is a psychological assessment instrument used to evaluate visual-motor functioning and visual perception skills in both children and adults. Scores on the test are used to identify possible organic brain damage and the degree maturation of the nervous system. The Bender Gestalt was developed by psychiatrist Lauretta Bender in the late nineteenth century.

Purpose

The Bender Gestalt Test is used to evaluate visual maturity, visual motor integration skills, style of responding, reaction to frustration, ability to correct mistakes, planning and organizational skills, and motivation. Copying figures requires fine motor skills, the ability to discriminate between visual stimuli, the capacity to integrate visual skills with motor skills, and the ability to shift attention from the original design to what is being drawn.

Precautions

The Bender Gestalt Test should not be administered to an individual with severe visual impairment unless his or her vision has been adequately corrected with eyeglasses.

Additionally, the test should not be given to an examinee with a severe motor impairment, as the impairment would affect his or her ability to draw the geometric figures correctly. The test scores might thereby be distorted.

The Bender Gestalt Test has been criticized for being used to assess problems with organic factors in the brain. This criticism stems from the lack of specific signs on the Bender Gestalt Test that are definitively associated with brain injury, mental retardation, and other physiological disorders. Therefore, when making a diagnosis of brain injury, the Bender Gestalt Test should never be used in isolation. When making a diagnosis, results from the Bender Gestalt Test should be used in conjunction with other medical, developmental, educational, psychological, and neuropsychological information.

Finally, psychometric testing requires administration and evaluation by a clinically trained examiner. If a scoring system is used, the examiner should carefully evaluate its reliability and validity, as well as the normative sample being used. A normative sample is a group within a population who takes a test and represents the larger population. This group’s scores on a test are then be used to create “norms” with which the scores of test takers are compared.

Description

The Bender Gestalt Test is an individually administered pencil and paper test used to make a diagnosis of brain injury. There are nine geometric figures drawn in black. These figures are presented to the examinee one at a time; then, the examinee is asked to copy the figure on a blank sheet of paper. Examinees are allowed to erase, but cannot use any mechanical aids (such as rulers). The popularity of this test among clinicians is most likely the short amount of time it takes to administer and score. The average amount of time to complete the test is five to ten minutes.

The Bender Gestalt Test lends itself to several variations in administration. One method requires that the examinee view each card for five seconds, after which the card is removed. The examinee draws the figure from memory. Another variation involves having the examinee draw the figures by following the standard procedure. The examinee is then given a clean sheet of paper and asked to draw as many figures as he or she can recall. Last, the test is given to a group, rather than to an individual (i.e., standard administration). It should be noted that these variations were not part of the original test.

Results

A scoring system does not have to be used to interpret performance on the Bender Gestalt Test; however, there are several reliable and valid scoring systems available. Many of the available scoring systems focus on specific difficulties experienced by the test taker. These difficulties may indicate poor visual-motor abilities that include:

• Angular difficulty: This includes increasing, decreasing, distorting, or omitting an angle in a figure.
• Bizarre doodling: This involves adding peculiar components to the drawing that have no relationship to the original Bender Gestalt figure.
• Closure difficulty: This occurs when the examinee has difficulty closing open spaces on a figure, or connecting various parts of the figure. This results in a gap in the copied figure.
• Cohesion: This involves drawing a part of a figure larger or smaller than shown on the original figure and out of proportion with the rest of the figure. This error may also include drawing a figure or part of a figure significantly out of proportion with other figures that have been drawn.
• Collision: This involves crowding the designs or allowing the end of one design to overlap or touch a part of another design.
• Contamination: This occurs when a previous figure, or part of a figure, influences the examinee in adequate completion of the current figure. For example, an examinee may combine two different Bender Gestalt figures.
• Fragmentation: This involves destroying part of the figure by not completing or breaking up the figures in ways that entirely lose the original design.
• Impotence: This occurs when the examinee draws a figure inaccurately and seems to recognize the error, then, he or she makes several unsuccessful attempts to improve the drawing.
• Irregular line quality or lack of motor coordination: This involves drawing rough lines, particularly when the examinee shows a tremor motion, during the drawing of the figure.
• Line extension: This involves adding or extending a part of the copied figure that was not on the original figure.
• Omission: This involves failing to adequately connect the parts of a figure or reproducing only parts of a figure.
• Overlapping difficulty: This includes problems in drawing portions of the figures that overlap, simplifying the drawing at the point that it overlaps, sketching or redrawing the overlapping portions, or otherwise distorting the figure at the point at which it overlaps.
• Perseveration: This includes increasing, prolonging, or continuing the number of units in a figure. For example, an examinee may draw significantly more dots or circles than shown on the original figure.
• Retrogression: This involves substituting more primitive figures for the original design—for example, substituting solid lines or loops for circles, dashes for dots, dots for circles, circles for dots, or filling in circles. There must be evidence that the examinee is capable of drawing more mature figures.
• Rotation: This involves rotating a figure or part of a figure by 45° or more. This error is also scored when the examinee rotates the stimulus card that is being copied.
• Scribbling: This involves drawing primitive lines that have no relationship to the original Bender Gestalt figure.
• Simplification: This involves replacing a part of the figure with a more simplified figure. This error is not due to maturation. Drawings that are primitive in terms of maturation would be categorized under “Retrogression.”
• Superimposition of design: This involves drawing one or more of the figures on top of each other.
• Workover: This involves reinforcing, increased pressure, or overworking a line or lines in a whole or part of a figure.

Additionally, observing the examinee’s behavior while drawing the figures can provide the examiner with an informal evaluation and data that can supplement the formal evaluation of the examinee’s visual and perceptual functioning. For example, if an examinee takes a large amount of time to complete the geometric figures, it may suggest a slow, methodical approach to tasks, compulsive tendencies, or depressive symptoms. If an examinee rapidly completes the test, this could indicate an impulsive style.

Definition

Behavior modification is a treatment approach, based on the principles of operant conditioning, that replaces undesirable behaviors with more desirable ones through positive or negative reinforcement.

Purpose

Behavior modification is used to treat a variety of problems in both adults and children. Behavior modification has been successfully used to treat obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), phobias, enuresis (bed-wetting), generalized anxiety disorder, and separation anxiety disorder, among others.

Description

Behavior modification is based on the principles of operant conditioning, which were developed by American behaviorist B. F. Skinner (1904-1990). Skinner formulated the concept of operant conditioning, through which behavior could be shaped by reinforcement or lack of it. Skinner considered his concept applicable to a wide range of both human and animal behaviors and introduced operant conditioning to the general public in his 1938 book, The Behavior of Organisms.

One behavior modification technique that is widely used is positive reinforcement, which encourages certain behaviors through a system of rewards. In behavior therapy, it is common for the therapist to draw up a contract with the client establishing the terms of the reward system.

Another behavior modification technique is negative reinforcement. Negative reinforcement is a method of training that uses a negative reinforcer. A negative reinforcer is an event or behavior whose reinforcing properties are associated with its removal. For example, terminating an existing electric shock after a rat presses a bar is a negative reinforcer.

In addition to rewarding desirable behavior, behavior modification can also discourage unwanted behavior, through punishment. Punishment is the application of an aversive or unpleasant stimulus in reaction to a particular behavior. For children, this could be the removal of television privileges when they disobey their parents or teacher. The removal of reinforcement altogether is called extinction. Extinction eliminates the incentive for unwanted behavior by withholding the expected response. A widespread parenting technique based on extinction is the time-out, in which a child is separated from the group when he or she misbehaves. This technique removes the expected reward of parental attention.

Definition

The Beck Depression Inventory (BDI) is a series of questions developed to measure the intensity, severity, and depth of depression in patients with psychiatric diagnoses. Its long form is composed of 21 questions, each designed to assess a specific symptom common among people with depression. A shorter form is composed of seven questions and is designed for administration by primary care providers. Aaron T. Beck, a pioneer in cognitive therapy, first designed the BDI.

Purpose

The BDI was originally developed to detect, assess, and monitor changes in depressive symptoms among people in a mental health care setting. It is also used to detect depressive symptoms in a primary care setting. The BDI usually takes between five and ten minutes to complete as part of a psychological or medical examination.

Precautions

The BDI is designed for use by trained professionals. While it should be administered by a knowledgeable mental health professional who is trained in its use and interpretation, it is often self-administered.

Description

The BDI was developed in 1961, adapted in 1969, and copyrighted in 1979. A second version of the inventory (BDI-II) was developed to reflect revisions in the Fourth Edition Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, a handbook that mental health professionals use to diagnose mental disorders).

The long form of the BDI is composed of 21 questions or items, each with four possible responses. Each response is assigned a score ranging from zero to three, indicating the severity of the symptom. A version designed for use by primary care providers (BDI-PC) is composed of seven self-reported items, each correlating to a symptom of major depressive disorder experienced over the preceding two weeks.

Individual questions of the BDI assess mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily preoccupation, and loss of libido. Items 1 to 13 assess symptoms that are psychological in nature, while items 14 to 21 assess more physical symptoms.

Results

The sum of all BDI item scores indicates the severity of depression. The test is scored differently for the general population and for individuals who have been clinically diagnosed with depression. For the general population, a score of 21 or over represents depression. For people who have been clinically diagnosed, scores from 0 to 9 represent minimal depressive symptoms, scores of 10 to 16 indicate mild depression, scores of 17 to 29 indicate moderate depression, and scores of 30 to 63 indicate severe depression. The BDI can distinguish between different subtypes of depressive disorders, such as major depression and dysthymia (a less severe form of depression).

The BDI has been extensively tested for content validity, concurrent validity, and construct validity. The BDI has content validity (the extent to which items of a test are representative of that which is to be measured) because it was constructed from a consensus among clinicians about depressive symptoms displayed by psychiatric patients. Concurrent validity is a measure of the extent to which a test concurs with already existing standards; at least 35 studies have shown concurrent validity between the BDI and such measures of depression as the Hamilton Depression Scale and the Minnesota Multiphasic Personality Inventory-D. Following a range of biological factors, attitudes, and behaviors, tests for construct validity (the degree to which a test measures an internal construct or variable) have shown the BDI to be related to medical symptoms, anxiety, stress, loneliness, sleep patterns, alcoholism, suicidal behaviors, and adjustment among youth.

Factor analysis, a statistical method used to determine underlying relationships between variables, has also supported the validity of the BDI. The BDI can be interpreted as one syndrome (depression) composed of three factors: negative attitudes toward self, performance impairment, and somatic (bodily) disturbance.

The BDI has also been extensively tested for reliability, following established standards for psychological tests published in 1985. Internal consistency has been successfully estimated by over 25 studies in many populations. The BDI has been shown to be valid and reliable, with results corresponding to clinician ratings of depression in more than 90% of all cases.

Higher BDI scores have been shown in a few studies to be inversely related to educational attainment; the BDI, however, does not consistently correlate with sex, race, or age.

Definition

Barbiturates are a large class of drugs, consisting of many different brand name products with generic equivalents, that are used primarily for mild sedation, general anesthesia, and as a treatment for some types of epilepsy. One barbiturate, butalbital, exists only as a component of several headache preparations. The most common members of the barbiturate family are phenobarbital (Luminal)), pentobarbital (Nembutal), amobarbital (Amytal), secobarbital (Seconal), thiopental (Pentothal), methohexital (Brevital), and butalbital (component of Fiorinal and Fioricet). They exist in numerous formulations and strengths.

Purpose

Barbiturates are used to sedate patients prior to surgery as well as to produce general anesthesia, to treat some forms of epilepsy, and to treat simple and migraine headache. These drugs are highly addictive and are often abused as recreational drugs. Although still commercially available, barbiturates such as secobarbital, pentobarbital, and amobarbital are no longer routinely recommended for the treatment of insomnia because of their ability to cause dependence, tolerance, and withdrawal. These drugs also have significant side effects when taken in large doses and can cause respiratory failure and death.

Description

The therapeutic effects of barbiturates as a class of drugs are all related to their ability to sedate and, at high enough doses and with certain preparations, to induce sleep. All barbiturates also have anticonvulsant properties although phenobarbital is the preferred barbiturate to treat epilepsy because it can produce anticonvulsant effects at levels low enough not to cause extreme sedation or sleep.

Recommended dosage

The typical dose of phenobarbital for use as an anticonvulsant in adults is 50–100 mg given two to three times per day. When a series of serious seizures known as status epilepticus occurs, adults are usually first given 300–800 mg intravenously (directly into the vein) followed by 120–240 mg every 20 minutes up to a maximum of 1000–2000 mg. For sedation, adults are given 30–120 mg per day divided into two or three doses. For sedation before surgery, 100–200 mg are given in an intramuscular injection (a shot) about one hour before the surgery.

The typical dose for an anticonvulsant effect in newborns is 2 mg to 4 mg of phenobarbital per kilogram of body weight per day. In infants, this dose is 5 mg to 8 mg per kilogram of body weight per day. In children one to five years of age, the dose is 6 mg to 8 mg per kilogram of body weight per day. In children aged five to 12 years, the dose is 4 mg to 6 mg per kilogram of body weight per day. All of these doses are given in one to two divided doses per day.

In newborns with status epilepticus, phenobarbital 15 mg to 20 mg per kilogram of body weight is given in a single or divided dose. Infants and children are given 10 mg to 20 mg per kilogram of body weight in a single or divided dose. They may also receive 5 mg per kilogram of body weight every 15 to 30 minutes up to a maximum of 40 mg per kilogram body weight. For anesthesia before surgery, 1 mg to 3 mg per kilogram of body weight is given about one hour before the surgery.

The typical dose of butalbital, as a component of headache preparations such as Fiorinal or Fioricet, is 50-100 mg administered every four to six hours as needed.

Precautions

Children who are hyperactive should not receive phenobarbital or other barbiturates. Some children paradoxically become stimulated and hyperactive after receiving barbiturates.

The use of barbiturates in the elderly (over age 65) should be watched closely. Elderly patients must be carefully monitored for confusion, agitation, delirium, and excitement if they take barbiturates. Barbiturates should be avoided in elderly patients who are receiving drugs for other mental disorders such as schizophrenia or depression.

Women should not use barbiturates during pregnancy unless they are necessary to control seizures. In these cases, they should take the minimum amount to control the seizures. Barbiturate use by pregnant women has been associated with increased risk of fetal damage and bleeding during childbirth. Women who are breast-feeding should not take barbiturates because these drugs enter the breast milk and may cause serious side effects in the nursing baby.

Long-term barbiturate use should be avoided unless there is a strong medical need, as in the case of epilepsy, because of the potential for addiction, dependence, tolerance, and withdrawal. People should not drive, operate heavy equipment, or perform other hazardous activities requiring mental alertness while taking barbiturates.

Side effects

The most common side effect of barbiturate use is drowsiness. Less common side effects include agitation, confusion, breathing difficulties, abnormally low blood pressure, nausea, vomiting, constipation, lower body temperature, decreased heart rate, movement difficulty, nightmares, anxiety, nervousness, mental depression, and dizziness. Rare but reported side effects include fever, headache, anemia, allergic reactions, and liver damage.

Interactions

Patients should always tell their doctor and dentist when they are taking barbiturates. Barbiturates should generally not be taken with other drugs used to treat mental disorders.

There are a number of drugs that barbiturates should not be combined with because the barbiturates may increase the metabolism of these drugs and thus, reduce the amount of these drugs available to be of benefit. These drugs include oral corticosteroids such as predisolone, methylprednisolone, prednisone, or dexamethasone, estrogen and oral contraceptives, blood-thinning medications such as warfarin (Coumadin), the antibiotic doxycycline (Vibramycin), and anticonvulsants such as phenytoin (Dilantin).

Barbiturates should not be combined with alcohol because the combination produces additive depressant effects in the central nervous system.

Barbiturates may lower the amount of absorption of the vitamins D and K.