Ner­vous break­down’ means a dis­rup­tive, psy­cho­log­i­cal dis­tur­bance

The Weekend Australian - Travel - - Health - SI­MON COWAP

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

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