Psychosis
Due To Cerebral-Arterial Sclerosis And Its Treatment
By
Dr. T.D Rana, DPM, Ex
Resident Psychiatrist, Warran State Hospital,
Warran, Pa, U.S.A
Paper before : 9th
Gujarat & Saurashtra Provincial Medical Conference, Navsari, 1956
During my stay in U S A, in 1953-54, I had good
opportunity to study Ch. Brain Syndrome associatedCerebral Sclerosis which amounts
to about 20% of the population in Mental Hospital. Because of the Social and
Cultural demands, most of the elderly in India suffering from such syndrome are
kept in home rather than in Mental Hospital. As the general span of life is
short in comparison to U.S. there can be such high percentage of sufferers in
India.
This paper is based on my observation on twelve cases
of psychosis due to cerebral arterial sclerosis. Though this number is too
small, rather negligible for description and discussions this attempt is just
made to create interest among the general practitioners who are likely to come
across such cases and from whose observations we are likely to collect more
data on the efficacy of the treatments. With a view to help them diagnosis. I
have described in details the pathology and the symptomatology.
PATHOLOGY: The term
arteriosclerosismay still be used in a genetic sense applied to a group of
vascular disease characterized morphologically by hardening of the vessel
wall. It does, however, place under emphasis upon the hardening aspect of the changes
that occur with age in the walls of blood vessels. It is now known that the
hardening phase is a relatively benign process which produces little, if any, interference
with flow of blood. On the other hand, the process known to the pathologist as
atherosclerosis is vastly more serious since it is characterized not so much by
hardening of the vessel wall as by the narrowing or obliteration of the lumen.
It is an occlusive disease that affects the nutrient vessel of the brain, heart
or kidney and by progressively choking off the flow of blood leads to
functional alteration and even to disability or death. When, therefore, the
term arteriosclerosis is used it should be borne in mind that the real nature
of the pathological vascular process is an atherosclerosis with its distinctive
morphological feature of stainable lipid within the atheromatous lesions.
SYMPTOMS : The memory
failure is a capricious one, the same name being recalled at one time and
forgotten at another.
1. The memory defect becomes more general and
gradually extends from recent to remote events. Sometimes the gaps in memory
are supplied by confabulations. Emotional instability is also an early
symptom; the patient's eyes readily fill with tears, and he laughs without
sufficient cause. Irritability increases, with outbursts of morbid anger, often
to the patient's distress. As the condition advances, suspicion arises which
may develop into delusions of jealousy. Periods of clouding of consciousness
are not infrequent, and in these partially disoriented states with their
poorly connected thinking, episodes of violence, e.g. against the patient's
wife, readily occur. Restlessness, both by day and night, and sleeplessness are
common. States of morbid apprehension may sometimes culminate in panic, usually
with clouding of consciousness, in which the patient believes himself about to
meet some terrible fate. The personality is fairly well preserved, but with the
increase in the mental symptoms , there is a gradual deterioration in the
patient's appearance. He becomes slovenly, allows his clothes to become stained,
and has to be reminded to wash. Insight is usually good at first, the patient
being distressed by his condition, but it gradually fades.
In the case of sclerosis of
the large cerebral vessels the first gross symptom may be an apoplectic stroke,
aphasic attack or other focal disturbance. Vertical headaches, worse in the
morning, vertigo, short periods of confusion, and fleeting loss of power in arm
or leg, or momentary aphasias or apraxia usually give warning of subsequent
more serious focal lesions. The gait is wide base, short step and spastic.
Coarse tremors may appear, and the patient may finally experience much
difficulty in feeding himself. Cardio-vascular disease in the form of cardiac
hypertrophy, coronary sclerosis or chronic valvular disease is common. Numerous
paralytic lesions appear, evidence of focal destruction of nervous tissue by
occlusion or by rupture of a vessel of considerable size. Upper motor neuron
paralyses and various aphasias and apraxia are most frequent, Paraphasia or
confusion of words may occur. Deterioration and dementia are hastened by these
focal lesions especially by those that result in serious speech disturbances.
Certain intellectual functions may be much impaired while others remain
comparatively intact. Epileptic form of attacks either Jacksonian or general,
may occur due to (some believe) temporary anemia or edema.
TREATMENT : Recently
much progress has been made in the treatment of psychotic reaction in the
aged. Previously treatment of psychotic reaction in the aged was none, for it
was believed that senile organic changes, both progressive and irreversible
were the sole causes of mental symptoms. Recent studies have shown that there
is no direct co-relation between the intensity of mental symptoms andseverity
of pathological changes.
The significance of anoxia
disease, particularly in elderly arterio-sclerosis patients is now recognized.
As brain is particularly sensitive to oxygen deficiency, anoxemia leads to
impairment of normal-brain functions. A direct relationship between the
degree of anoxemia and the extent of mental disturbances can be demonstrated
by oxygen metabolism at capillary level of function.
Many drugs like Tolozoline
(Prescoline), Steroid hormones, Dl-ampehtamine Sulfite (De- xidrine), Caffeine,
and ephedrine, various vitamins and proteins were tried by different people
with varied results. But metrozol and nicotinic acid are widely used nowadays
over the continent and so we will discuss these two drugs and an Indian Herbal
drug that I have tried in detail.
During past few years the
analeptic Metrazol has been the subject of several clinical studies of fatigue
and in the field of geriatric. Metrazol has been used in the treatment of
senile confusion, and psychosis and other depressed states in which the normal
physiologic oxygen balance is impaired and anoxemia is a primary factor to be
considered in diagnosis and treatment.
Metrazol exerts a stimulating
action on the cerebral centers and particularly on the respiratory and
vasomotor centers although all parts of the cerebral spinal axis are affected
to some degree.
On the basis of these facts
one might expect that Metrazol by stimulating the respiratory center in the
aged would improve pulmonary ventilation and indirectly the circulation and so
help to overcome the anoxia frequently present in the aged, the depressed and
the fatigued. At the same time the analeptic action of the drug and its ability
to increase nerve impulse transmission should act as a general tonic so that
the patient might well have an increased sense of wellbeing, be less depressed
and perhaps also less confused.
After the successful use of
nicotinic acid in relieving mental symptoms of pellagra, this drug soon was
applied in the treatment of a number of psychiatric syndromes, particularly
organic psychosis of varied etiology. Nicotinicacid is of value in the
treatment of organic psychosis attributed to cerebral arteriosclerosis of
senility. The rationale of this treatment is based upon the now generally
accepted hypothesis thatnicotinic acid may produce its beneficial effect in
many confusional states by means of cerebrovasodilation. Nicotinic acid is most
beneficial in confusional states and psychosis of recent onset, and that it
must be administered promptly because reversible changes in cellular function
are followed quite rapidly by irreversible structural changes. Thus, on the
basis of this study, nicotinic acid may be of more benefit in prophylaxis than
in cure.
Before the introduction of the
oral treatment of Metrazol and nicotinic acid such patients had only
symptomatic treatment. Because of the high cost and temporary effects of these
drugs.
I was interested in trying
some Indian Herbal Drugs which may help the poor population of our country. The
herbal drug selected for these studies was SILEDIN (Alarsin).
The ingredients of SILEDIN and
their therapeutic actions are discussed by Dr. Hakim in a paper read at Sixth
Gujarat & Saurashtra Provincial Medical Conference at Baroda and by Dr. S.
R. Soni in a paper read at 32nd All India Medical Conference at Jaipur. The
drug is under research as far as its pharmacological work is concerned.
DOSE: Because of the immediate actions of vasodilation of
nicotinic acid I used Pelonin (Glaxo) 2T.D.S. with SILEDIN 2T.D.S. Pelonin was
given for one month, and then it was discontinued. Then only SILEDIN was given
for a period of three months. After three months the dose was reduced to 1
T.D.S. for future period of six months, to one year. The patient belonged to
55 to 88 years age group. One patient with 210 B.P. and hemiplegia, showed improvement,
but died after one month's treatment due to fresh attack of apoplexy. Two patients
who had severe secondary cardiac failure did not show much improvement with
about11/2(One and half) months treatment and the treatment was
discontinued. Two patients showed very good improvement but discontinued the
treatment-one after one month's treatment and the other after 2 1/2month's
treatment and the follow up was not done.
Out of the remaining 7 cases
two did not show improvement. The period of abnormal symptoms observed by the
relatives was 1 ½ years and 3 years respectively. In 5 patients the duration of
the symptoms observed was from 2 to 14 months. The results achieved were excellent,
regarding the mental symptoms and physical health. As far as the explanation
for the actions of SILEDIN is concerned, till the observations of the
pharmacological research which is under progress are published, at this stage I
can only repeat what Moore and his co-workers who have worked on histamine and
nicotinic acid therapy in this particular disease have to say for the actions
of these two drugs. They have stated, "We believe intravenous his- tamine-nicotinic
acid dilation therapy actually improves the function of physiologically impaired
or non-functioning brain cells. Whether this is a result of increased cardiac
out-put, increased vasodilation of cerebral vessels, increased capillary
permeability, or an actual physiological action on the cells we do not know."
REFERENCES:
1. Noyes: Modern Clinical
Psychiatry.
2. Henderson &Gilepsy: Text Book of Psychiatry.
3. Levy : Pharmacological treatment of the aged patients. J.A.M.A. 153(4)
1260-65, 1953.
4. Chesrow& Others: Metrazol in arteriosclero associated with Senility ,
Geriatrics, 6'319-23,
1951.
5. Maurice E Linden & others: Interdisciplinary research in use of oral
Metrazol, Paper read at
Conferences of Americal Psychiatric
Association, 1954.
6. Hakim R. A.: Indigenous drug in the treatment of Mental Diseases.