Nervous breakdown’ means a disruptive, psychological disturbance
ON a trans-Atlantic flight from Canada to Britain last week, passengers were taken aback to see their co-pilot dragged from the cockpit shouting, crying and asking for God, and handcuffed to a seat in economy class. According to reports of the incident ( The Australian , 1/02), the aircraft had to be diverted to Shannon Airport in Ireland, where on arrival he was taken to a psychiatric hospital suffering from a nervous breakdown.
Nervous breakdown, like heart attack, is a commonly used term for which there is no precise medical equivalent. It is generally taken as meaning an episode of acute psychological disturbance severe enough to disrupt a person’s normal life and possibly put them, like the pilot, in hospital.
Not infrequently people refer to severe episodes of anxiety, particularly panic attacks, as being nervous breakdowns, but more commonly the term is referring to a psychotic episode, as it seems to be here. Psychosis is not itself a diagnosis, but describes an abnormal mental state characterised by distortion of, or loss or contact with, reality. Hallucinations, delusions and disorganised thinking, speech and behaviour are the hallmarks of a psychotic state.
These so-called positive symptoms are often very florid and attract attention, but people also experience negative symptoms in the form of poverty of thought and speech, restricted emotional range and loss of interest and pleasure in usual activities. It is an entirely clinical diagnosis — there are no scans or blood tests that identify psychosis.
While acute psychotic symptoms are sometimes dramatic, establishing whether someone’s unusual belief constitutes a delusion is not always straightforward. An atheist, for instance, might regard all religious belief as delusory, but so long as the belief was of a type commonly held in the believer’s culture it could never be called a symptom of psychosis.
A number of medical conditions and prescription drugs can cause psychotic episodes, but the majority are associated with psychiatric disorders or non-prescription drugs, particularly cannabis, amphetaminelike drugs and alcohol. Among common psychiatric conditions, people with depression and bipolar disorder can sometimes experience mood-congruent psychotic episodes, but psychosis is the defining characteristic of schizophrenia.
Schizophrenia is a relatively common illness, affecting about 1 per cent of the population. Equally frequent in men and women, it tends to develop earlier in men — typically between the ages of 15 and 25. The cause is still uncertain, though both genetic factors and obstetric problems causing a lack of oxygen to the brain at birth are strongly implicated. Like most psychiatric conditions, it is probably a case of environmental stresses (including drugs) triggering the illness in a susceptible individual.
Schizophrenia is associated with abnormal brain biochemistry, particularly the neurotransmitter dopamine, but also serotonin and glutamate. Antipsychotic medications work predominantly by blocking excessive dopamine activity. These neurotransmitters are spread widely throughout the brain, and imaging studies show altered functioning in a variety of areas including the prefrontal cortex, temporal lobe, basal ganglia and hippocampus.
Most people do not go straight into florid psychosis, but experience what is called a ‘‘ prodrome’’, when they may have declining social function and seem increasingly odd, withdrawn and preoccupied.
While distinguishing between the healthy eccentric and the prodromal schizophrenic can be difficult, early detection and treatment is associated with improved outcomes. In contrast, people with prolonged untreated first-episode psychosis have a worse prognosis.
For most people schizophrenia is a recurring condition, though treatment can prevent relapses and allow people to maintain a high level of social functioning.
If schizophrenia is the cause of the copilot’s psychosis, it is unlikely it could have been going on undetected for long, and so his prognosis should be good.
Depression, however, though not part of schizophrenia, commonly co-exists and is something to which he will be vulnerable on recovery from his nervous breakdown. Simon Cowap is a GP in Newtown, Sydney