In the early spring of 1966, I was hospitalized and diagnosed with paranoid schizophrenia. Over the course of the following decades, I recovered sufficiently to become a psychologist and devote virtually all of my professional life to caring and advocating for others whose disabilities are similar to my own. Although accounts of my adventures with relapse and recommended coping strategies have been published elsewhere (Frese, in press; Frese, 1997; Frese, 1994; Schwartz et al., 1997), this article focuses specifically on the mental process accompanying schizophrenia, which is traditionally termed disorganized thinking or formal thought disorder.

Due to the cognitive processes that are involved in disorganized thinking, those of us with schizophrenia may exhibit a tendency toward circumstantiality, meaning that in conversations we wander from the topic at hand, but we are generally able to return to the topic after our diversionary side-trips. As this mechanism progresses, however, we increasingly become unable to return to the topic, slipping off the track, exhibiting derailment, loose associations and tangentiality. If this phenomenon further exacerbates, we may find ourselves in states of linguistic disorganization, incoherence, or in the production of "word salad." This disorganized thinking has been argued by some to be "the single most important feature of schizophrenia" (American Psychiatric Association, 2000).

My experience suggests that a model based on the thinking of the philosopher Edmund Husserl, as described by Schwartz et al. (1997) and Spitzer (1997), can be particularly helpful in rendering an increased understanding and appreciation of this process. According to these authors, the disorganized thinking of schizophrenia can be conceptualized as a cognitive process of over-inclusion, or "an expansion of the horizon of meaning" (Schwartz et al., 1997). From time to time, often as a function of stress or excitement, our neurotransmitting mechanisms become increasingly active.

During these times, we begin to conceptually broaden, or overemphasize, the connectedness of words, as well as of other sounds and sights, in a non-linear, quasi-poetic, manner. Our thinking becomes dominated by metaphors. We have a heightened awareness of similarities in the sounds of words. We become particularly aware of rhyming, alliterations and other phonological relationships among words. Words and phrases are likely to engender thoughts of music and lines from songs. We are more likely to perceive amusing relationships among words, and between words and other stimuli. In more poetic terms, our mental processes become increasingly influenced by the muses. As a part of this phenomenon, we may also begin to perceive certain mystical or spiritual aspects of everyday situations. Sometimes these experiences can be quite moving, frightening and even life-altering.

If one's mental horizons are allowed to expand too far, there will be serious consequences. If not contained, this cognitive process can become quite disabling. Fortunately, modern medicines and other forms of treatment enable increasing numbers of us to avoid the worst of these consequences. The mind's tendency to expand its horizon of meaning can be kept in check. Our sensitivity to semantic and phonological relationships does not have to become so acute that we can no longer focus on the problems of everyday life.

The DSM-IV-TR states that "less severe disorganized thinking or speech may occur during the prodromal or residual periods of schizophrenia" (American Psychiatric Association, 2000). However the DSM-IV-TR does not make it clear that, even in recovery, our thought processes tend to be colored by the same mechanisms which, when intensified, can become disabling. Even with treatment, the cognitive processes of those of us with schizophrenia continue to be affected to some degree. Even when we are in a relatively normal state, our minds often continue to be subject to perceiving relationships of which others are unaware, relationships that affect our sense of reality and truth. Because we have this tendency to "listen to a different drummer," we often experience difficulties in communicating with our more "normal" friends. Sometimes others perceive what we say and do as strange or bizarre. Even while in recovery, we may still meet one or more of the DSM-IV-TR criteria for the three schizophrenia-spectrum personality disorders-paranoid, schizoid or schizotypal.

In conclusion, there has recently begun to appear in the literature a call for reconsideration concerning the disorganized thinking aspect of schizophrenia. Recognizing this process as a function of an expanded horizon of meaning may provide an improved vehicle for a better appreciation of the phenomenological world of people with schizophrenia. Such improved understanding could be valuable in assisting those of us with this condition to more easily integrate our social and vocational efforts into the activities of the everyday world.

Dr. Frese served as director of psychology at Western Reserve Psychiatric Hospital from 1980 to 1995. He is currently coordinator of the Summit County, Ohio, Recovery Project, and is First Vice President of the National Alliance for the Mentally Ill.

Jake remembers the first time he saw the army people. High on crystal meth, he was well into his third day without sleep. Along with the boundless energy and heightened sense of alertness came the mind-bending hallucinations.

"One day I was so delusional... There were these trees on top of this overpass, and they looked like army people, dressed up with guns, marching down," the 19-year-old says between faint smiles and sips of strong coffee. "It was in the middle of the day, and I asked this truck driver, 'What's with all those army people?' He just looked at me. He was, like, 'What?' It was actually fun for me. I enjoyed the hallucinations."

But Jake started to notice that those visions kept happening even when he wasn't using meth. That's when he started getting scared.

"When the symptoms don't go away after you do it, it's no fun. That's when you know you're kinda hooped."

Jake is sitting in a hotel coffee shop in Tsawwassen on a deadly hot summer morning. He's just called local psychiatrist Bill MacEwan, asking for a refill of his antipsychotic and antidepressant medication. He'll take anything to counter the paranoia and delusions that continue to poison his thinking. Jake wasn't always so anxious. But that was years ago before he started using crystal meth.

The soft-spoken youth started using cocaine when he was 13. He switched to meth at 16, looking for something more powerful, a high that would enable him to stay up for parties that lasted days. That's one of meth's draws: you don't sleep. Then there's the hallucinatory effect. Jake would think a group of people was standing in front of him. He'd walk up to them, only to see the figures dissolve before his eyes into the bushes they really were.

Wearing a baseball cap, baggy pants, and loose shirt, Jake shifts his tired chestnut eyes away when he talks about his methamphetamine addiction. He doesn't want his name printed, although his parents and friends are well aware of the dark place he's in.

"The paranoia kicked in," Jake says. "I'd be so lonely and paranoid. It was a horrible feeling....I'd be looking out my window every five minutes to see if someone was out there. The trees I had always seen looked like people. I was so freaked out one night; I swear to God there were people out there. I hopped out my window in my boxer shorts looking for these people. I couldn't find them, so I got dressed and walked around the block looking for people in bushes. Thank God my parents caught on."

Meth is an extremely dangerous drug. It's cheap, highly addictive, easily accessible, and can be made at home, providing you have toxic chemicals like Drano and battery acid on hand. It can cause structural changes to the brain and induce psychotic symptoms that resemble those of schizophrenia: paranoia, disorganized thinking, delusions, and impaired memory. In some people, those effects will never go away, even long after they stop using.

It's also Vancouver's new demon.

The city's problem is so extreme that last November, on their own initiative, about 120 people from a vast range of professions and interests formed a group called the Methamphetamine Response Committee. It consists of psychiatrists, doctors, nurses, social workers, cops, and bureaucrats. There are representatives from high schools, custody centers, and safe homes, and users themselves. They all say meth use in town has risen dramatically over the last two years. And they're worried.

If the very existence of MARC doesn't speak to the urgency of Vancouver's problem, perhaps Steven Smith does. He's program coordinator of Dusk to Dawn, the street-youth resource center run by Family Services of Greater Vancouver. It's located in a rundown building at the back of St. Paul's Hospital and offers food, showers, and lockers for kids under 22. Teens can't use drugs in the center, but they're not turned away if they're high.

"Every single social-services agency has had to sit down in the last year and say, 'Meth has affected us. We have to talk about this,'" Smith explains in his office. "Everyone's on a fast-track learning curve. There's not a whole lot of information out there. There's no denying there's a meth epidemic, and we don't have the resources to address it. I think it caught everyone by surprise."

Meth came to prominence during the Second World War, when Japan, Germany, and the United States gave the drug to military personnel to increase endurance. Later, doctors prescribed it to treat depression, obesity, and heroin addiction. Illicit laboratories emerged in San Francisco in the 1960s, and from there it spread up and down the Pacific Coast. In the '80s came a new method of the drug's production, which led to crystal meth, a crystallized, smokable, and even more potent form of MA. Now, no city or town seems free of meth's tentacles. News stories are emerging about the drug's prevalence in places like Smoky Lake, Alberta; New York City; and the state of Hawaii.

According to the World Health Organization, methamphetamine is the most widely used illicit drug in the world after cannabis.

On local turf, there are countless youths who hang out downtown, like Jake used to, and spend as little as $5 for a high whose effects can last days. The Granville-Davie corridor is notorious for meth. It's the drug of choice for street kids: because it keeps users awake, they can guard their stuff at night; the drug also saps their desire to eat, which is convenient for those with no cash for food.

Although it may have gained popularity at raves, meth has moved well beyond that culture. This doesn't mean ravers aren't still using it--they might just not know it. Analysis by the RCMP's Vancouver-based drug-awareness program shows that almost 60 percent of ecstasy-like pills seized locally contain meth. The tablets, a random and dizzying concoction of chemicals, often contain such additional ingredients as cocaine, ephedrine, pseudoephedrine, and ketamine.

According to the Pacific Community Resources Society's 2002 "Lower Mainland Drug Use Survey", which interviewed about 2,000 youth aged 12 to 24, 19 percent had tried meth and nearly eight percent had used it within the past 30 days. The average age of first use was 14.5, and 45 percent of respondents said they could obtain the drug within 24 hours. Family Services of Greater Vancouver reported that in a six-month period in 2001, 14 to 34 youths sought detox for crystal meth. A year later, that figure jumped to 32 to 59 for the same period.

MARC members note that some adolescent girls are taking meth to lose weight, ending up not just skinny but skeletal. It's increasingly popular among the gay/bisexual/lesbian/transgendered community, and even with so-called soccer moms, some of whom take it to keep up with the demands of working and parenting. There are also stories of everyone from lawyers to software developers to longshoremen using meth.

A SYNTHETIC CENTRAL-nervous-system stimulant, meth increases the stimulation of dopamine, serotonin, and norepinephrine receptors in the brain. It can be swallowed, smoked, injected, or snorted. It provides a sense of focus and euphoria. Meth can cause hallucinations like the ones Jake described; users may also hear voices telling them to harm themselves or others or think people are following them. Coming down, users often experience an intense craving for the drug, anxiety, confusion, fatigue, headaches, and profound depression. They may be irritable, unpredictable, and suddenly violent.

"Aggression wasn't really a problem on the streets a few years ago," Smith says. "You need a whole new bag of tricks dealing with kids on crystal meth. Psychosis is one thing, but drug-induced psychosis is another."

Drug-induced psychosis is what interests Bill MacEwan. He started the Fraser Health Authority's Early Psychosis Program (www.psychosissucks.ca/) and, like so many other health professionals, has been seeing more and more kids on meth.

"I have patients who are 16 years old, in high school, who are psychotic," MacEwan says at a downtown restaurant. "They hear voices when they're partying, but those voices haven't gone away. It's very frightening, and the numbers are rapidly rising. It's not like cocaine or heroin...Methamphetamine causes symptoms that are almost exactly like [those of] schizophrenia."

What puzzles people like MacEwan is this: does crystal meth trigger psychosis in those who are already prone to mental illness (perhaps schizophrenia runs in the family), or does its use cause psychosis? It's a classic chicken-or-the-egg mystery.

A 2001 publication by the WHO, "Systematic Review of Treatment for Amphetamine-Related Disorders", found that five to 15 percent of meth users who develop a related psychosis fail to recover completely. Most users, the organization also reports, become psychotic within a week after continuous meth administration.

Making matters worse is that users who need medical help tend to fall through the cracks. "What do we do with the kid who's psychotic on the street?" asks Dr. Ian Martin, who splits his time between Vancouver Hospital, Dusk to Dawn, and Three Bridges Health Clinic. That clinic (1292 Hornby Street) is located in the heart of the Vancouver's crystal-meth central. He sees kids who snort meth, "hoop" it (insert it rectally), or "parachute" it (wrap it in a rolling paper and swallow it).

Those who have hit the bottom are often stuck there, Martin explains in a West End coffee shop. If a user in a psychotic state goes to emergency, he'll likely be sent right back out a few hours later because he's high. But most detox centers and mental-health organizations lack the resources and knowledge to handle meth-induced psychosis. In response, Martin has started giving seminars to health professionals on how to deal with users. (He also formed a crystal-meth-anonymous group, which meets every Friday at Three Bridges [604-633-4242].)

"There may be tactile hallucinations; they [users] have a sense of bugs crawling on their skin," Martin says. "They'll say, 'Look doc, it's right here,' and they're pointing to a hair on their arm, thinking it's a spider. They think they have scabies so they will pick at their skin."

Consequently, users are prone to skin infections. They're also susceptible to tooth decay. Users grind their teeth, and the drug decreases the saliva's pH level, allowing more bacteria to grow in the mouth. "I had one 21-year-old patient who had had all her teeth taken out. They were all rotten."

When the high starts to fade, the accompanying depression can be severe to the point of suicide. What also distresses Martin is that meth use significantly boosts the chances of contracting HIV, AIDS, and other sexually transmitted illnesses. The drug delays ejaculation, often leading to rougher sex as a result. (Infection spreads easily when the skin is torn.) "And if someone's high, they might not engage in safe sex," Martin says.

He notes that even though the amount of anecdotal evidence related to meth is staggering, more research is needed. But getting hard facts can be tough. It's difficult to get people with an addiction and a mental illness to take medication regularly and comply with doctors' orders. "If they get better, we never see them again. If they get a lot worse, we never see them again," Martin says.

In 2002, UCLA School of Medicine neurologist Linda Chang published "Perfusion MRI and Computerized Cognitive Test Abnormalities in Abstinent Methamphetamine Users" in Psychiatry Research Neuroimaging. The study found that ex-users were up to 30 percent slower to complete tasks requiring working memory than nonusers.

"The slower reaction times on the computerized tasks...are suggestive of subclinical Parkinsonism in individuals who abused meth," Chang's study stated.

DIFFICULTY REMEMBERING things is a consequence of meth use to which 18-year-old Vancouver resident Kasper can testify. Although he quit meth more than a year ago, he says his memory is shot. He can't recall anything he learned in school.

Wearing a studded leather jacket, a ring in his nose, and black from head to toe, the burly youth looks older than his years. When he's not at his Chinatown apartment taking care of his pet rat, Shithead, he hangs around at Dusk to Dawn. He started using meth when his mom kicked him out of the house; it was the middle of winter and his brother suggested the drug to stay warm.

"It had a crab-apple taste, like crab apples right off the trees," the amiable Kasper says at the youth center. "I liked it because of its taste. If you like it, you want to do it more and more and more. The next thing I know, I'm in Vancouver making it in my hotel."

He continued using for two or three years--he couldn't keep track of what year it was--until, after so much sleep deprivation, he hit a breaking point.

"I put an eighth of weed and a point of crystal meth on the table," he says. "I thought, 'Do I smoke this weed and get baked out of my fucking tree, or do I smoke this meth and stay up for two days and do something I think is constructive but that's just a big fucking waste of my time?' I ended up flushing the meth down the toilet and smoking myself stupid. When I see people doing meth now, I just tell them to do that.

"Getting drunk and smoking pot is a lot better than crystal meth. I've seen people make it in their bathtubs. They pour Drano, ammonia, battery acid, and all this other crap in there. You end up coughing up blood and puking blood up. I'd recommend heroin a lot more than crystal meth. And I did not enjoy heroin."

Kasper isn't exaggerating when he says crystal meth is full of crap. Mixed together, the substances can explode or give off toxic fumes that attack mucous membranes. Yet the drug isn't that hard to make. Mom-and-pop labs can be set up in high-rise apartments, storage sheds, and basements. Recipes downloaded from the Internet call for ephedrine (found in cold medication and decongestants), rubbing alcohol, methanol, lithium, and ammonia, among other ingredients. Take this excerpt from an online source:

"Dilute HCl--also called Muriatic acid--can be obtained from hardware stores, in the pool section. NaOH--also called lye--can be obtained from supermarkets in the 'drain cleaner' section....Ethyl Ether--aka Diethyl Ether--Et-O-Et--can be obtained from engine starting fluid...Desoxyephedrine--can be obtained from 'VICKS' nasal inhalers...Distilled water--it's really cheap, so you have no reason to use the nasty stuff from the tap. Do things right."

Given the prevalence of meth in Vancouver, the city is a prime spot for more research. UBC clinical psychologist Tania Lecomte is applying for funding from the Canadian Institutes of Health Research to study methamphetamine and psychosis. Her team will do magnetic-resonance-imaging scans to see if there are structural changes or neural damage in meth users' brains; it will also explore psychosocial rehabilitation.

"I worked in first-episode psychosis for a while, and I would work with clients and do diagnostic interviews," Lecomte says in a phone interview. "In a lot of cases, crystal meth is what caused them to come to the hospital. It seems to have totally changed the personality and behavior of street youth."

The Vancouver Agreement (a partnership of the federal, provincial, and local governments to foster the city's development) has funded a small study to get input from users. Theo Rosenfeld, who runs Pala Community Development, which supports harm reduction, is conducting the review. In a phone interview, he explains he has tried meth and although he never got hooked, he can see why so many kids are.

"Given the housing options, if I didn't have a place to sleep I don't know if I could be off speed," Rosenfeld says. "It feels as if life is worth living...You're not going to give that up if you've never felt that way before."

Rosenfeld says he was surprised at MARC's efficiency during that first November meeting.

"It was the most intelligent, collaborative response to a drug issue I've ever worked in, in any city I've ever been," he remarks. "Usually these meetings are full of catcalling, booing, and hissing. People are genuinely concerned."

One of the most pressing concerns is treatment. A combination of antidepressant and antipsychotic medication seems to have promising results, but other possibilities need investigation. Then there's the lack of funding, resources, and staff, thanks largely to government cutbacks.

"If you cut off your hand, you go to the hospital and they'll fix it. I'd like to see [drug] treatment work like that," Dusk to Dawn's Steven Smith says. "Youth should be able to say, 'I need help and I need it now.'...It's a really hard drug to quit. They need a lot of support and care, and it's just not there."

There are 10 beds allocated to youth detox services in Vancouver.

SINCE NOVEMBER, MARC members have formed subcommittees that meet every two months. Jennifer Vornbrock, who's heading the group's treatment-and-prevention arm, says the next step is to see what can be done with existing resources. Because those involved recognize the seriousness of Vancouver's problem, there's no room for politics or self-interest.

"This isn't the speed your parents took," says Vornbrock, the Vancouver Coastal Health Authority's manager of youth, women's, and population health. "It's 10 percent ephedrine and 90 percent ammonia. It's not a drug you want to play around with."

Back in Tsawwassen, Jake has no shortage of tales about the damage crystal meth has done to his own life. He sold a new truck for a pitiful sum to get drug money, dropped out of school in Grade 10, and has essentially lost his youth.

"When we were kids, we used to have fun," Jake says. "Now I've lost all my friends to drugs. You can't keep friends because you're antisocial and paranoid."

Perhaps the lingering delusions are the saddest part of Jake's story. Not even 20, he can't make it through a day without antipsychotics.

"They calm me down," he says. "I thought I could detox on my own. Now it's about staying clean one day at a time. It's about staying alive."

Story by: By Gail Johnson
Reprinted with permission from the Georgia Straight newspaper

Ed. Note: Paul L. Wolf, MD from the Department of Pathology and Laboratory Medicine at the University of California, San Diego, in a recently published article (Archives of Pathology and Laboratory Medicine: Vol. 129, No. 11, pp. 1457-1464. November 2005) takes us on a journey of retrograde analysis of medical conditions and self-induced medicinal ingestion that afflicted some of the most talented artists ever (Benvenuto Cellini, Michelangelo Buonarroti, Ivar Arosenius, Edvard Munch, van Gogh, and Berlioz). His conclusion: these talents could have been diagnosed and treated by today's methods, but the intervention may have dimmed or extinguished the "spark".

Below is the analysis that Dr. Wolf uses to illustrate his historical perspective.

From the Department of Pathology and Laboratory Medicine, University of California, San Diego, and the Autopsy and Hematology, Clinical Chemistry Laboratories, VA Medical Center, San Diego, Calif

Context.- Many myths, theories, and speculations exist as to the exact etiology of the diseases, drugs, and chemicals that affected the creativity and productivity of famous sculptors, classic painters, classic music composers, and authors.

Objective.- To emphasize the importance of a modern clinical chemistry laboratory and hematology coagulation laboratory in interpreting the basis for the creativity and productivity of various artists.

Design.- This investigation analyzed the lives of famous artists, including classical sculptor Benvenuto Cellini; classical sculptor and painter Michelangelo Buonarroti; classic painters Ivar Arosenius, Edvard Munch, and Vincent Van Gogh; classic music composer Louis Hector Berlioz; and English essayist Thomas De Quincey. The analysis includes their illnesses, their famous artistic works, and the modern clinical chemistry, toxicology, and hematology coagulation tests that would have been important in the diagnosis and treatment of their diseases.

Conclusions.- The associations between illness and art may be close and many because of both the actual physical limitations of the artists and their mental adaptation to disease. Although they were ill, many continued to be productive. If modern clinical chemistry, toxicology, and hematology coagulation laboratories had existed during the lifetimes of these various well-known individuals, clinical laboratories might have unraveled the mysteries of their afflictions. The illnesses these people endured probably could have been ascertained and perhaps treated. Diseases, drugs, and chemicals may have influenced their creativity and productivity.

The phrase "the inhumanity of medicine" has been used by Sir David Weatherall, Oxford's Regius Professor of Medicine, for a kind of sickness in modern technological medicine.¹ In 1919, one of his predecessors, Sir William Osler, had the remedy for that complaint. Osler suggested that the "arts" secrete materials that do for society what the thyroid does for human beings. The arts, including literature, music, painting, and sculpture, are the hormones that enhance an increased human approach to the medical profession.^2,3

Illness has affected the artistic achievement of musical composers, classical painters, creative authors, and sculptors. Illness affected their physical and mental status as well. Their inspiration may have been shaped by their human condition. The associations between illness and art may be close and many because of both the actual physical limitations of the artists and their mental adaptation to disease. Although they were ill, many continued to be productive. The afflictions these people endured probably could have been ascertained and perhaps treated with modern medical techniques.

This article analyzes the effects of drugs, chemicals, and diseases on the creativity and productivity of the famous sculptors Benvenuto Cellini and Michelangelo Buonarroti; classic painters Ivar Arosenius, Edvard Munch, Vincent van Gogh, and Michelangelo; classic music composer Louis Hector Berlioz; and author Thomas De Quincey.

BENVENUTO CELLINI

A Homicidal Attempt on Cellini Utilizing Sublimate (Mercury)

Click to enlarge Figure 1.Benvenuto Cellini's gigantic masterpiece sculpture Perseus With the Head of Medusa. This statue stands in the Loggia Dei Lanzi in Florence, Italy. Reprinted with permission from Blackwell Publishing, Ltd

Benvenuto Cellini (1500-1571) was one of the world's greatest sculptors and a connoisseur of sensuous living. He produced a gigantic masterpiece Perseus With the Head of Medusa. The casting of it was an artistic feat. Cellini was a Renaissance man in every sense. He was a goldsmith, sculptor, musician, and a swaggering figure that saw himself as Michelangelo's artistic equal.

Cellini contracted syphilis at the age of 29 years.⁴ When he was in the secondary stage of syphilis with a vesicular rash, he was advised to have mercury therapy, but refused because he had heard of the undesirable effects of mercury.⁵ He received lotion therapy, and leeches were also applied. However, the "syphilis pox" skin rash relapsed. Cellini subsequently became ill with malaria, which was common in Rome at the time. The malaria caused him to become extremely febrile and led to improvement of his symptoms following attenuation of the spirochetes by the high fever. The Romans and the Greeks believed that malaria was due to "bad air"; thus, it was called mal (bad) aria (air). They were not aware that it was caused by a parasite. The fever of malaria obviously had a transient, minimal effect on the clinical course of Cellini's syphilis. In 1539, Roy Diaz De Isla observed the minimal therapeutic value of malaria on syphilis.⁶ Four hundred years later, in 1927, the Nobel Foundation awarded a Nobel Prize to Julius Wagner Jauregg for malaria therapy of syphilis, which was ineffective, as demonstrated in Cellini's case in 1529.

article acknowledgments

Click to enlarge

Subsequently, Cellini developed tertiary syphilis, which resulted in grandiose projects due to his megalomania and which led him to initiate his sculpture of Perseus. He fell easy prey to individuals attempting to capitalize on his grandiosity, his wealth, and his influential reputation. He made a disadvantageous property purchase from clever business individuals who suspected that Cellini was in a terminal phase of syphilis. These salespeople produced a plot to murder Cellini to hasten the realization of their investments. The assassins prepared a meal in which they added mercury to a sauce. After eating the meal, Cellini quickly developed a severe hemorrhagic diarrhea. He suspected that he had been poisoned with sublimate (mercury). Fortunately for Cellini, the dose of mercury in the sauce was not large enough to cause his death, but it was sufficient to cure his syphilis. He decided not to prosecute his would-be assassins, but to honor them as his therapists. Instead of dying of syphilis, Cellini lived many more years. A modern clinical chemistry laboratory might have confirmed the presence and level of mercury by examination of Cellini's urine when he was poisoned. The modern analytic procedure for detection and quantitation of mercury includes atomic absorption spectrometry. Numerous signs and symptoms are present with mercury poisoning, including a metallic taste, stomatitis, gastroenteritis, urticaria, vesication, proteinuria, renal failure, acrodynia, peripheral neuropathy with paresthesia, ataxia, and visual and hearing loss. The half-life of mercury poisoning is 40 days. The modern treatment of mercury poisoning is the utilization of meso-2,3 dimercaptosuccinic acid.

Cellini's magnificent bronze sculpture Perseus With the Head of Medusa (Figure 1 ), stands on a pedestal that Cellini crafted. Cellini placed the mythical Mercury opposite the multibreasted Diana of Ephesus, or Venus, the goddess of love and beauty (possibly the venereal disease goddess as well) on the base of the statue of Perseus (Figure 2 ). A possible interpretation of this juxtaposition is that Cellini has demonstrated the cause and cure of his disease.

MICHELANGELO

A Brilliant Sculptor and Painter Who Projected His Own Illnesses Into His Sculpture and Paintings

Michelangelo Buonarroti (1475-1564) was born in March 1475 in Caprese, Tuscany. He lived and worked for nearly a century and worked continuously until 6 days before his death. He was considered to be a Renaissance man. He depicted a number of his mental and physical conditions in his paintings and sculpture, as did subsequent painters hundreds of years later.

Click to enlarge Figure 3. A, Michelangelo's portrait is present in Raphael's School of Athens painting. In the School of Athens, Plato (a portrait of Leonardo da Vinci) discourses with Aristotle. Located at the Stanza della Segnatura, Vatican Palace, Vatican State. Photo credit: Erich Lessing, Art Resource, New York, NY. B, Michelangelo's knees were swollen and deformed by gout, as depicted in this fresco by Raphael (1483-1520) in the Vatican. Located at the Stanza della Segnatura, Vatican Palace, Vatican State. Photo credit: Erich Lessing, Art Resource, New York, NY

Michelangelo developed various illnesses during his lifetime. Michelangelo's right knee was swollen and deformed by gout, which is depicted in a fresco by Raphael (Figure 3, A and B). This painting is present in the Vatican and was commissioned by Pope Julius II when Michelangelo was known to be on site at the Vatican completing his paintings on the ceiling of the Sistine Chapel. Michelangelo is shown with a gouty, deformed right knee.⁷ Michelangelo suffered from gout caused by elevated serum uric acid, and his stone formation may have been urate urolithiasis.

Michelangelo stated that he had kidney and urinary bladder calculi throughout his life. In 1549, he had an episode of anuria, which was followed by the passing of gravel and stone fragments. In Michelangelo's case, gout might have explained the gravel in his urine. Plumbism should be considered as a possible cause for gout. Obsessed with his work, Michelangelo would go for days on a diet of bread and wine. At that time, wine was processed in lead containers. He might also have been exposed to lead-based paints. The fruit acids of wine, chiefly tartaric contained in crocks, are excellent solvents of lead in crocks coated with lead glaze. The wine thus contained high levels of lead. Lead injures the kidneys, inhibiting the excretion of uric acid and resulting in increased serum uric acid and gout. If a modern clinical chemistry laboratory had existed during Michelangelo's lifetime, his serum uric acid might have been found to be elevated. His urine might have contained excessive uric acid with uric acid calculi, as well as excessive lead levels. A modern clinical chemistry laboratory detects and quantitates serum uric acid with the uricase procedure. Uric acid urinary calculi are associated with needlelike, nonbirefringent crystals in the urine. Thus, Michelangelo may have suffered from saturnine gout.

Michelangelo also suffered from a number of illnesses besides gout. It was also known that he suffered from depression. He exhibited the signs and symptoms of a bipolar manic-depressive illness. He painted more than 400 figures on the ceiling of the Sistine Chapel from 1508 to 1512. His paintings mirror his depression. Features of melancholy appear in the painting of Jeremiah in the Sistine Chapel. Modern medicine has confirmed that manic-depressive illness and creativity tend to run in certain families. Studies of twins provide strong evidence for the heritability of manic-depressive illness. If an identical twin has manic-depressive illness, the other twin has a 70% to 100% chance of also having the disease; if the other twin is fraternal, the chances are considerably lower (approximately 20%). A review of identical twins reared apart from birth, in which at least one of the twins had been diagnosed as manic-depressive, found that in two-thirds or more of the cases the sets were concordant for the illness. If lithium carbonate had been available in the 16th century, it might have helped Michelangelo's depression if he suffered from a bipolar illness, and a clinical chemistry laboratory could have monitored serum lithium levels.

article acknowledgments

Click to enlarge Figure 4. Michelangelo's painting Creation of Adam in the Sistine Chapel at the Vatican. A possible interpretation of this scene is that God is giving Adam either the "spark of life" or an intellect. Reprinted with permission from JAMA (1990;264:1840). Copyright 1990, American Medical Association. All rights reserved

Michelangelo dissected numerous human bodies, beginning at the age of 18 years. The dissections occurred in the monastery of Santo Spirato in Florence, where the corpses originated from various hospitals. The anatomic accuracy of his figures is due to his dissection and his observations. In the painting The Creation of Adam (Figure 4 ) in the Sistine Chapel, an irregular circular structure appears surrounding God and the angels. One interpretation of the irregular circular structure is compatible with the shape of the human brain.⁸ However, others disagree and believe the circular structure surrounding God and the angels represents the human heart. At the left of the circle there is a cleavage, possibly separating the right and left ventricles. At the top right is a tubular structure, which may represent the aorta exiting from the left ventricle. Thus, the speculation persists that if it represents a brain, it suggests that God is giving Adam an intellect or a soul. If it is a representation of a heart, God is initiating in Adam the beginning of a cardiovascular system and life, and is thereby giving Adam the "spark of life."

IVAR AROSENIUS AND EDVARD MUNCH

Click to enlarge Figure 5.Arosenius' famous painting Saint George Slaying the Dragon. This painting demonstrates that the dragon is bleeding profusely following his slaying by Saint George. Arosenius is depicting his profound bleeding tendency due to his hemophilia. (I. Arosenius, St. George and the Dragon,by Ivar Arosenius. From Sandblom P. Creativity and Disease. Revised 9th ed. 1995: Figure 72. Reprinted with permission from Marion Boyars Publishers, London, Great Britain)

Various other artists have depicted their illnesses in their works of art. Some examples include classic painters Ivar Arosenius (1878-1909) and Edvard Munch (1863-1944). Ivar Arosenius was a Swedish painter especially known for his for his paintings of fairy tales. He died of excessive hemorrhage caused by hemophilia at approximately the age of 30 years. His painting Saint George and the Dragon demonstrates a dragon that is bleeding profusely following his slaying by Saint George (Figure 5 ). The dragon bled convincingly and very profusely. A modern coagulation laboratory would have detected the genetic abnormality for hemophilia, and appropriate therapy with recombinant hemophilia factors could have been instituted. The Swedish Hemophilia Society has established an Arosenius Fund aiding hemophilia patients.

Edvard Munch may have depicted his own psychotic state of mind when he painted The Scream (The Shriek). Munch, a Norwegian painter, used intense colors in his paintings. Another possible interpretation of the event that inspired The Scream (The Shriek) is in an entry in one of Munch's numerous journals. Munch makes clear in the journal entry that The Scream (The Shriek) grew from an experience he had while walking near Oslo at sunset.

The Scream (The Shriek) may have been the direct consequence of a cataclysm half a world away from Norway, that is, the volcanic explosion on the Indonesian island of Krakatoa. The huge explosion, which occurred in August 1883, and the tsunamis it generated killed approximately 36000 people. It lofted huge amounts of dust and gases high into the atmosphere, where they remained airborne and in the next several months spread over vast parts of the globe. A report on Krakatoa's effects issued by The Royal Society of London provided "Descriptions of the Unusual Twilight Glows in Various Parts of the World, in 1883-4," including appearing in the Norwegian twilight skies. Munch, too, must have been startled, even frightened, the first time he witnessed the fiery spectacle in late 1883. Munch's sister, Laura, suffered from schizophrenia. Molecular genetic psychiatrists have searched for the genetic roots of schizophrenia.

The late Philip Holzman, PhD, professor of psychology at Harvard University and an authority on schizophrenia, was convinced that schizophrenia was broader than the psychotic phenomena and that it included many behaviors that occur in unaffected relatives of the schizophrenic patients. Modern pathology departments have established molecular genetics divisions that focus on the genetic causes of disease. In the future, these laboratories might discover a genetic root for schizophrenia.

VINCENT VAN GOGH (1853-1890)

The Chemistry of His Yellow Vision

The color yellow fascinated the Dutch postimpressionist painter, Vincent van Gogh, in the last years of his life. His house was entirely yellow. He wrote How Beautiful Yellow Is, and all of his paintings in these years were dominated by yellow. Van Gogh's preference for the color yellow may have been that he simply liked the color (Figure 6 ). However, 2 speculations exist that his yellow vision was caused by overmedication with digitalis or excessive ingestion of the liqueur absinthe. The drink contains the chemical thujone. Distilled from plants such as wormwood, thujone poisons the nervous system. The chemistry of the effect of digitalis and thujone resulting in yellow vision has been identified. It also should be noted, prior to the discussion of van Gogh's yellow vision, that many clinicians have reviewed the medical and psychiatric problems of the painter posthumously, diagnosing him with a range of disorders, including epilepsy, schizophrenia, digitalis and absinthe poisoning, manic-depressive psychosis, acute intermittent porphyria. Psychiatrist Kay R. Jamison, PhD, believes that van Gogh's symptoms, the natural course of his illness, and his family psychiatric history strongly indicate manic-depressive illness. It is also possible that he suffered from both epilepsy and manic-depressive illness.⁹ If lithium carbonate had been available in the 19th century, it might have helped Van Gogh.

article acknowledgments

The Effect of Digoxin on the Retina and the Nervous System, Resulting in Yellow Vision

Click to enlarge Figure 6.Van Gogh's painting of a Chair and Pipe. This painting emphasizes Van Gogh's preference for the color yellow. Vincent van Gogh (1853-1890). Vincent's Chair, 1888-1889. Oil on canvas. Located at the National Gallery, London, Great Britain. Photo credit: Erich Lessing, Art Resource, New York, NY

In 1785, William Withering observed that objects appeared yellow or green when foxglove was given therapeutically in large and repeated doses.¹⁰ Since 1925, various physicians, including Jackson,¹¹ Sprague,¹² and White,¹³ quoting Cushny, professor of pharmacology at the University of Edinburgh, have noted that patients overmedicated with digitalis develop yellow vision. According to Cushny, "All colors may be shaded with yellow or rings of light may be present."

It has been established that van Gogh suffered from epilepsy, for which he was treated with digitalis, as was often the case in the late 19th century.¹⁴ Barton and Castle¹⁵ stated that Parkinson recommended a trial use of digitalis in epileptics. Digitalis may have been used to relieve his epilepsy. Physicians are more likely to consider a diagnosis of digoxin toxicity if a history of xanthopsia (yellow vision) is elicited, this being the symptom best known to physicians.¹⁶

William Withering described many of the toxic effects of the cardiac glycosides in his classic treatise on foxglove in 1785: "The foxglove when given in very large and quickly repeated doses, occasions sickness, vomiting, purging, giddiness, confused vision, objects appearing green or yellow; - syncope, death." Since 1925, numerous studies have described the visual symptoms and attempted to identify the site of visual toxicity in digitalis intoxication.

The site of toxicity responsible for the visual symptoms has been debated for decades. Langdon and Mulberger¹⁷ and Carroll¹⁸ thought that the visual symptoms originated in the visual cortex. Weiss¹⁹ believed that xanthopsia was due to brainstem dysfunction. Demonstration of cellular alterations in the cerebral cortex and spinal cord of cats after administration of toxic doses of digitalis support the central dysfunction theory.

For many years, most investigators thought that the most likely site of damage in digitalis intoxication was the optic nerve. More recent investigations, however, have identified significant retinal dysfunction in digitalis toxicity and have shed some doubt on the older hypotheses.²⁰ Support for a retinal site of toxicity has been provided by studies that have shown much higher accumulations of digoxin in the retina than in other tissues, including the optic nerve and brain.²¹ Digoxin toxicity might involve inhibition of sodium-potassium-activated adenosine triphosphatase, which has been identified in high concentration in the outer segments of the rods; inhibition of the enzyme could impair photoreceptor repolarization.²² Lissner and colleagues,²³ however, found the greatest uptake of digoxin in the inner retinal layers, particularly in the ganglion cell layer, with little uptake in photoreceptors.

Another possible explanation for van Gogh's xanthopsia was his excessive ingestion of absinthe.²⁴ Van Gogh's taste for absinthe (a liqueur) may have also influenced his style of painting. The drink's effect comes from the chemical thujone.²⁵ Distilled from plants such as wormwood, thujone poisons the nervous system. Van Gogh had a pica (or hunger) for unnatural "foods," craving the entire class of fragrant but dangerous chemicals called terpenes, including thujone. As van Gogh recovered from cutting off his ear, he wrote to his brother: "I fight this insomnia with a very, very strong dose of camphor in my pillow and mattress, and if ever you can't sleep, I recommend this to you." Camphor is a terpene known to cause convulsions in animals when inhaled. Van Gogh had at least 4 such fits in his last 18 months of life.

Van Gogh's friend and fellow artist Paul Signac described an evening in 1889 when he had to restrain the painter from drinking turpentine. The solvent contains a terpene distilled from the sap of pines and firs. Van Gogh tried more than once to eat his paints, which contained terpenes as well. Signac also wrote that van Gogh, returning after spending the whole day in the torrid heat, would take his seat on the terrace of a cafe, with the absinthe and brandies following each other in quick succession. Toulouse-Lautrec drank absinthe from a hollowed walking stick. Degas immortalized absinthe in his bleary-eyed painting, Absinthe Drinker. Van Gogh nursed a disturbed mind on the aquamarine liqueur, which may have encouraged him to amputate his ear.

Absinthe is about 75% alcohol and has about twice the alcoholic volume of vodka. It is made from the wormwood plant, which is reputed to have a hallucinogenic effect, and is flavored with a blend of anise, angelica root, and other aromatics.

The chemical mechanism of α-thujone (the active component of absinthe) in neurotoxicity has been elucidated with identification of its major metabolites and their role in the poisoning process.²⁶ α-thujone has a sort of double-negative effect on the brain. It blocks a receptor known as y-aminobutyric acid-A (GABA-A), which has also been linked to a form of epilepsy. Under normal conditions, GABA-A inhibits the firing of brain cells by regulating the flux of chloride ions. By essentially blocking the blocker, thujone allows the brain cells to fire at will. α-thujone acts at the noncompetitive blocker site of the GABA-A receptor and is rapidly detoxified, thereby providing a reasonable explanation for some of the actions of absinthe other than those caused by ethanol and allowing more meaningful evaluation of risks involved in the continued use of absinthe and herbal medicines containing α-thujone. Thus, the secret of absinthe, which is considered a fuel for creative fire, has been unlocked.

article acknowledgments

There is an increasing concern about the use of thujone substances with the rise in popularity of herbal medicines. Wormwood oil, which contains thujone, is present in some herbal preparations used to treat stomach disorders and other ailments. (In fact, wormwood, a relative of daisies, got its name from its use in ancient times as a remedy for intestinal worms.) Individuals ingesting these preparations have complained of developing yellow vision.²⁷ Scientific studies of thujone are investigating the active ingredients in many herbal preparations. Absinthe is still manufactured in Spain and the Czech Republic. In modern absinthe, alcohol, which makes up three-quarters of the liqueur, may be the most toxic component. It is still illegal to buy absinthe in the United States, although it can be obtained through the Internet or when traveling overseas.

Recently, an article entitled "Poison on Line: Acute Renal Failure Caused by Oil of Wormwood Purchased Through the Internet" was published in the New England Journal of Medicine.²⁸ In this article, a 31-year-old man was found at home in an agitated, incoherent, and disoriented state by his father. Paramedics noted tonic-clonic seizures with decorticate posturing. His mental status improved after treatment with haloperidol, and he reported finding a description of the liqueur absinthe at a site on the World Wide Web entitled "What is Absinthe?" The patient obtained one of the ingredients described on the Internet, essential oil of wormwood. The oil was purchased electronically from a commercial provider of essential oils used in aromatherapy, a form of alternative medicine. Several hours before becoming ill, he drank approximately 10 mL of the essential oil, assuming it was absinthe liqueur. This patient's seizure, probably caused by essential oil of wormwood, apparently led to rhabdomyolysis and subsequent acute renal failure.

This case demonstrates the ease of obtaining substances with toxic and pharmacologic potential electronically and across state lines. Chinese medicinal herbs, some of which can cause acute renal failure, are easily procured by means of the Internet. Although absinthe liqueur is illegal in the United States, its ingredients are readily available. Absinthe is also currently a popular drink in the bars of Prague, in the Czech Republic. The essential ingredient in this ancient potion was purchased in this case by means of up-to-the-minute computer technology.

A modern clinical chemistry and genetics laboratory could possibly have determined the following in van Gogh's case: (1) serum digitalis concentration, (2) serum thujone concentration, (3) urine porphobilinogen, and (4) serum lithium levels. These tests could possibly have confirmed that van Gogh suffered from chronic digitalis intoxication or intoxication from thujone related to excessive drinking of the liqueur absinthe. Modern tests could analyze his urine for the presence of porphobilinogen, which is the diagnostic test for acute intermittent porphyria, another speculated van Gogh illness. If Van Gogh had used lithium carbonate for bipolar illness, serum lithium levels might also have been important to monitor.

LOUIS HECTOR BERLIOZ AND THOMAS DE QUINCEY

Effects of Opium on Their Creativity and Productivity

Hector Berlioz (1803-1869) was born in France. His father was a physician who taught his son to appreciate classic literature. Berlioz's family attempted to interest him in studying medicine, but after his first year of medical school in Paris, he gave up medicine and became a music student instead. Berlioz entered the Paris Conservatoire of Music in 1826. As a boy, Berlioz adored both music and literature, and he went on to compose the Symphonie Fantastique, in which the hero (a thinly disguised representation of Berlioz himself) supposedly survives a large dose of narcotic. Another interpretation of the Symphonie Fantastique is that it describes the dreams of a jilted lover (Berlioz), possibly attempting suicide by an overdose of opium. This work is a milestone marking the beginning of the Romantic era of music.²⁹ His creativity was fired in particular by a love for great literature and an unquenchable passion for the feminine ideal, and in the best of his works these elements conspired to produce music of exquisite beauty.

Click to enlarge Figure 7.Hector Berlioz conducting one of his symphonies. Located at the Historisches Museum der Stadt Wien, Vienna, Austria. Photo credit: Erich Lessing, Art Resource, New York, NY

Berlioz took opium to relieve agonizing toothaches, but there is no indication that he ever took opium to become intoxicated, as the author De Quincey did. On September 11, 1827, Berlioz attended a performance of Hamlet at the Paris Odéon, in which the actress Harriet Smithson (Berlioz later called her Ophelia and Henrietta) played the role of Ophelia. Overwhelmed by her beauty and charismatic stage presence, he fell desperately in love. The grim program of Symphonie Fantastique was born out of Berlioz's despair because of the unrequited love he had for the English Shakespearean actress Harriet Smithson.

Berlioz found a way to channel the emotional upheaval of "l'Affaire Smithson" into something he could control, that is, a "fantastic symphony" that took as its subject the experiences of a young musician in love. A detailed program Berlioz wrote prior to a performance of the Symphonie Fantastique, and which he later revised, leaves no doubt he conceived of this symphony as a romantically heightened self-portrait. Berlioz did eventually woo and win Miss Smithson, and they were married in 1833 at the British Embassy in Paris.

The program Berlioz wrote for Symphonie Fantastique reads, in part:

A young musician of morbid sensibility and ardent imagination in a paroxysm of love-sick despair has poisoned himself with opium. The drug too weak to kill plunges him into a heavy sleep accompanied by strange visions. His sensations, feelings, and memories are translated in his sick brain into musical images and ideas.

The underlying "theme" is obsessive and unfulfilled love. The symphony reflects Berlioz's hysteric nature with fits of frenzy, as revealed in his dramatic behavior (Figure 7 ).²⁹

article acknowledgments

It was obvious that Berlioz was addicted to opium, which is a yellow to dark brown, addicting narcotic drug prepared from the juice of the unripe seed capsules of the opium poppy. It contains alkaloids such as morphine, codeine, and papaverine, and is used as an intoxicant. Medically, it is used to relieve pain and produce sleep. It is a tranquilizer and has a stupefying effect. Apart from alcohol, opium was the drug most commonly relied on in the 19th century, especially by poets for stimulating creative ability and for relief from stress.

Thomas De Quincey (1785-1859) was an English essayist. He wrote a rare kind of imaginative prose that was highly ornate, full of subtle rhythms, and sensitive to the sound and arrangement of words. His prose was as much musical as literary in its style and structure, and anticipated such modern narrative techniques as stream-of-consciousness.

De Quincey authored his most famous essay, Confessions of an English Opium-Eater, in 1821. He gave us an eloquent essay both of the delights and the agonies of opium abuse. He believed that the habit of eating opium was of common practice in his day and was not considered a vice. Originally, De Quincey believed that the use of opium was not to seek pleasure, but its use was intended for his extreme facial pain, which was caused by trigeminal neuralgia.³⁰ The essay's biographical parts are important mainly as background for dreams De Quincey describes later. In these dreams, he examined (with the help of opium) the intimate workings of the memory and subconscious. It is easily understandable that De Quincey "began to use opium as an article of daily diet." He was addicted to the drug from the age of 19 until he died. The pain was not the only reason for his addiction; he also discovered the effect of opium on his spiritual life. By accident, he met a college acquaintance who recommended opium for his pain.

On a rainy Sunday in London, De Quincey visited a druggist's shop, where he asked for the tincture of opium. He arrived at his lodgings and lost not a moment in taking the quantity prescribed. In an hour, he stated:

Oh heavens! What a revulsion, what a resurrection, from its lowest depths of the inner spirit! What an apocalypse of the world within me! That my pains had vanished was now a trifle in my eyes; this negative effect was swallowed up in the immensity of these positive effects, which had opened before me, in the abyss of divine enjoyment thus suddenly revealed. Here was a panacea for all human woes; here was the secret of happiness, about which philosophers had disputed for so many ages, at once discovered; happiness might now be bought for a penny and carried in the waistcoat-pocket; portable ecstasies might be corked up in a pint-bottle.

Other famous writers and poets have used opium. Coleridge saw the palace of Kublai Khan in a trance and sang its praise "in a state of Reverie, caused by 2 grains of opium." Coleridge wrote: "For he on honeydew hath fed/ And drunk the milk of Paradise." John Keats also tried the drug and stated in his Ode to Melancholy: "My heart aches, and a drowsy numbness pains/My sense, as although of hemlock I had drunk/Or emptied some dull opiate to the drains."

If our modern clinical chemistry, toxicology, immunology, hematology-coagulation, infectious diseases, and anatomic pathology laboratories had existed during the 16th through the 19th centuries, during the lifetimes of Cellini, Michelangelo, Arosenius, Munch, Van Gogh, Berlioz, De Quincey, and other famous artists, the clinical laboratories, especially those certified by the College of American Pathologists, might have unraveled the mysteries of their afflictions.

Although the famous artists discussed in this article were ill, many continued to be productive. Diseases, drugs, and chemicals may have influenced their creativity and productivity. After the diagnoses were established, aided by anatomic and clinical pathology findings, these famous artists may have benefited from resultant treatment with modern medical techniques. Modern pathologists' clinical laboratories are important in solving today's medical disease mysteries and would have been important in solving yesteryears' medical mysteries.

Notes

Acknowledgments

I gratefully acknowledge Leikula Rebecca Carr for her excellent stenographic and editorial assistance in the preparation of this manuscript; William Buchanan, Terrence Washington, and Mary Fran Loftus, Omni-Photo Communications, Inc, for their professional photographic and technical expertise; and Patricia A. Thistlethwaite, MD, PhD for her critical review of the manuscript.

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7. Espinel CH. Michelangelo's gout in a fresco by Raphael. Lancet 1999;354:2149-2152. [PubMed Citation]

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Last updated: 12/05

Hierarchy chart for treatment of a patient with Schizoaffective Disorder.

Further Inpatient Care:

• Patients may require further inpatient care if they represent a danger to themselves or to others or they are gravely disabled.

Further Outpatient Care:

• For best results, patients require medication management and therapy.

In/Out Patient Meds:

• As an inpatient who is schizoaffective makes the transition to being an outpatient, stressing the importance of medication compliance is very crucial.
  • Patients with schizoaffective disorder often lack judgment and insight into their illness. They commonly refuse to continue the medications started in the hospital once they are discharged. This also could be due to adverse effects of the medication, such as sedation and weight gain.
  • Patients who are schizoaffective begin to feel better as a result of their medications and believe that they no longer need to take them. This leads to the discontinuation of medication and results in the patient returning to the hospital within the next several weeks or so.
  • If possible, select medications that allow once-a-day dosing or those that are long acting, such as decanoate injections, to help with patient compliance.
  • Also, discuss compliance with a family member. Always discuss all the risks, benefits, adverse effects, and alternatives of each medication with the patient and family.
  • Obtain informed consent before starting medication therapy.

Transfer:

• Medical surgical hospital, if needed
• Residential or group home, if needed

Complications:

• Noncompliance with medications is a complication of therapy.
• Expressed emotions must be reduced in all areas of a patient's life, including stress-reduction techniques employed to prevent relapse and possible rehospitalization.

Prognosis:

• Prognosis lies somewhere between that associated with schizophrenia and that associated with a mood disorder.

Patient Education:

• Patients should be educated about the following:
  • Social skills training
  • Medication compliance
  • Reducing expressed emotions
  • Cognitive rehabilitation
  • Family therapy

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Alternative therapies aid in the treatment of Schizoaffective Disorder.

While alternative therapies should never be considered a replacement for medication, these treatments can help support people with schizoaffective disorder and other mental illnesses. Dietary modifications that eliminate processed foods and emphasize whole foods, along with nutritional supplementation are alternative treatments for schizoaffective disorder that may be helpful. Acupuncture, homeopathy, and botanical medicine can support many aspects of the person's life and may help decrease the side effects of any medications prescribed.

(Visit HealthyPlace Alternative Mental Health Community for more information.)

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What can you do to make the best possible recovery from schizoaffective disorder? Read these tips from doctors and patients.

• Accept that you have a prolonged illness.
• Identify your strengths and limitations.
• Make clear, realistic goals.
• After a relapse, go slowly and gradually back to your responsibilities.
• Plan a regular, consistent, predictable daily routine.
• Make your home as quiet, calm and relaxed as you can.
• Identify and reduce stress.
• Make only one change in your life at a time.
• Work toward an active and trusting relationship with the staff involved in your care.
• Take your medicines regularly, as prescribed. Identify early signs of relapse.
• Make your own early warning list.
• Get involved with a group of people you feel comfortable with.
• Avoid street drugs. Whether or not you drink alcohol is a very personal decision you should make with your prescriber.
• Eat a well-balanced diet.
• Get enough rest.
• Get regular exercise.
• If you're not sure whether your feelings or fears are based in reality, ask someone you trust or compare your behavior with others.
• Accept that there may be setbacks from time-to-time.

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A person with Schizoaffective Disorder may display symptoms similar to other psychiatric disorders.

• Learning Problem
• Hypoactivity
• Psychotic
• Euphoric Mood
• Depressed Mood
• Somatic / Sexual Dysfunction
• Hyperactivity Guilt / Obsession
• Odd / Eccentric / Suspicious Personality
• Anxious / Fearful / Dependent Personality
• Dramatic / Erratic / Antisocial Personality

Differential Diagnosis:

Some disorders display similar or sometimes even the same symptom. The clinician, therefore, in his/her diagnostic attempt has to differentiate against the following disorders which he/she needs to rule out to establish a precise diagnosis.

• Psychotic Disorder Due to a General Medical Condition
• A delirium, or a dementia
• Substance-Induced Psychotic Disorder
• Substance-Induced Delirium
• Delusional Disorder
• Psychotic Disorder Not Otherwise Specified.

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Thoughts and concrete ideas for dealing with a loved one's diagnosis of a mental illness such as schizoaffective disorder.

If one of your family members has been diagnosed with mental illness, then you and your family, no doubt, are experiencing a number of concerns, emotions and questions about these disorders. The following information is intended to inform you about mental illness and also to provide you and your family with coping skills which will be helpful to you.

In hearing that one of your family members has a mental illness, you may have already experienced emotions such as shock, sadness, anxiety, confusion, etc. These are not uncommon emotions, given the fact that the diagnosis of mental illness has carried a lot of negative associations in our society. What is important to understand and keep in mind is that the negative stigma associated with the diagnosis of mental illness has drastically changed over the course of the last few years.

In the past in our society, most mental illness was classified as a family disorder, and families tended to be blamed by professionals rather than supported. Research and the development of new and effective psychotropic medications and treatment approaches have changed this concept, and professionals no longer place blame upon family members. Mental Illnesses are disorders of the brain (a biological condition), where environmental and sociological factors play a part in the development of the disorder.

In the past few years, we have seen major developments, progress and changes in all areas of psychiatric research which suggest that mental illness can be managed and success in recovery can be achieved. Statistically, recovery from mental illness is a reality. It does appear, however, that each person diagnosed with mental illness has a different rate of recovery, and therefore it is important for you as family members to come to accept varying degrees of recovery for your loved one. It is also important to accept your feelings and seek out help to deal with them. Remember, having feelings as mentioned above is a normal process for all family members.

For you and your other family members, it is also imperative to understand and have support. (Read Help for Bipolar Patients: Family-Focused Therapy) The diagnosis of mental illness is much like a physical diagnosis such as cancer, MS, etc. Therefore, some of the emotions that you may be experiencing are about loss and grief. There is no question that any major illness affects the whole family and changes the way everyone goes about their daily life.

To deal with loss and grief issues is not an easy matter. There are, however, two major things to remember about the grieving process. The first is to allow yourself to feel. To do this you may need supportive counseling, good friends, or you may want to consider joining a support group. Some other suggestions are shown below. The second and perhaps most important is to come to accept and let go. As Elizabeth Kubler Ross suggests, one must first go through the stages of loss in order to come to the place of acceptance. These stages revolve around the primary emotions of denial, anger, bargaining, depression, and finally acceptance.

As family members, you will need to access information and be in an environment in which professionals working with your loved one are sensitive to your needs and the grieving process associated with this illness.

The following are some suggestions for families and a few ways to cope and deal with your feelings and concerns. It is important that wherever you send your loved one for help, you get positive support and are not being blamed for your loved one's illness. Remember that you and your loved one do have a right to be informed and to make choices that work for you

Suggestions for your initial contact with professionals and organizations that can assist with your loved one's mental illness and your understanding of it:

1. Seek out a psychiatrist who seems to have an active involvement with the community resources available to families. You can ask questions such as how long has the psychiatrist worked with mental illness, what his/her knowledge is of psychotropic medication, what his/her philosophy is related to mental illness and family dynamics.

   It is important that the psychiatrist is able to refer you to qualified adjunctive professionals and programs, such as psychologists, social workers or treatment programs. Psychotropic medications can markedly improve symptoms and you can ask questions about the drugs used and their side effects, etc. If you feel comfortable with the primary psychiatrist, it makes the rest of treatment much easier to deal with. So ask questions.

2. If your psychiatrist has referred you to Community Resources such as Psychologists and/or MFCC's for supportive community or other treatment programs, check them out and ask questions about their philosophy and experience.

3. Connect with one or more of the associations in your area to gain more understanding and connect with other families experience the same concerns, feelings, etc.

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Suggestions for dealing with your emotions and feelings:

1. Accept the mental illness and its difficult consequences. This is easier said than done; however, research suggests that families who deal most successfully with a mentally ill relative are those who can find a way to accept them fully.

2. Develop realistic expectations for the mentally ill person and yourself. Do not expect to always feel happy and accept your right to have your feelings. Feelings are a normal process. Often families experience guilt and other emotions which they try to repress or pretend do not exist. This can only result in emotions and feelings building up and often other physical or emotional problems arising. Remember, adjusting to mental illness for you and your loved one takes time, patience and a supportive environment. Also, recovery is slow sometimes. So it is best to support your loved one by praising him/her for small achievements. Try not to expect too much or that your mentally ill family member will return to their previous level of functioning too quickly. Some people can return to work or school, etc., quite quickly, and others may not be able to. Comparing your situation with others can be very frustrating, and we suggest that you keep in mind that what works for someone else may not work for you or your loved one. This will help to reduce frustration.

3. Accept all the help and support you can get.

4. Develop a positive attitude and even better, keep a sense of humor.

5. Join a support group

6. Take care of yourself - seek out counseling and support.

7. Do healthy activities like hobbies, recreation, vacations, etc.

8. Eat right, exercise, and stay healthy.

9. Stay optimistic.

Experts on mental illness believe that new research discoveries are bringing deeper understanding of mental illness, which are resulting in even more effective treatments.

Continue reading for what families can do to help.

Suggestions for what families can do to help a mentally ill family member:

1. Assist your family member to find effective medical treatment. To find a psychiatrist, you may contact your own medical doctor or check with NAMI. You may also call or write the American Psychiatric Association.

2. Seek consultation regarding financial consideration for treatment. You may call your local Social Security office and check with your family member's health insurance. Often quality treatment is not pursued because of financial considerations.

3. Learn as much as you can about the mental illness with which your family member has been diagnosed.

4. Recognize warning signs of relapse.

5. Find ways to handle symptoms of schizoaffective disorder or other mental illness. Some suggestions are: Try not to argue with your loved one if they have their hallucinations or delusions (as the person believes it is real); do not make fun of or criticize them; and especially do not act alarmed. The more calm you can be, the better it is.

6. Be happy with slow progress and allow your loved one to feel O. K. with a little success.

7. If your family member is out of control or suicidal (harm to self or others), stay calm and call 911. Do not try to handle it alone.

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Diagnostic criteria for Manic Depression and Schizophrenia. Detailed list of symptoms for both Bipolar Disorder and Schizophrenia.

1. 

   (2) Criteria for Manic Episode

   • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
   • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
     1. inflated self-esteem or grandiosity
     2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
     3. more talkative than usual or pressure to keep talking
     4. flight of ideas or subjective experience that thoughts are racing
     5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
     6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
     7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
   • The symptoms do not meet criteria for a Mixed Episode
   • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
   • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

   (3) Criteria for Mixed Episode

   • The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
   • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
   • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

   (4) Criterion A of Schizophrenia

   • Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
     • delusions
     • hallucinations
     • disorganized speech (e.g., frequent derailment or incoherence)
     • grossly disorganized or catatonic behavior
     • negative symptoms, i.e., affective flattening, alogia, or avolition
   • Only one symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
2. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
3. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.
4. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

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Some believe the cause of schizoaffective disorder is associated with schizophrenia, others think it's related to mood disorders.

The cause of schizoaffective disorder remains unknown and subject to continuing speculation. Some investigators believe schizoaffective disorder is associated with schizophrenia and may be caused by a similar biological predisposition. Others disagree, stressing schizoaffective disorder's similarities to mood disorders such as depression and bipolar disorder (manic depression). They believe its more favorable course and less intense psychotic episodes, are evidence that schizoaffective disorder and mood disorders share a similar cause.

Many researchers, however, believe schizoaffective disorder may owe its existence to both disorders. These researchers believe that some people have a biologic predisposition to symptoms of schizophrenia that varies along a continuum of severity. On one end of the continuum are people who are predisposed to psychotic symptoms but never display them. On the other end of the continuum are people who are destined to develop outright schizophrenia. In the middle are those who may at some time show symptoms of schizophrenia, but require some other major trauma to set the progression of the disease into motion. It may be an early brain injury--either through a complicated delivery, prenatal exposure to the flu virus or illicit drugs; or it may be emotional, nutritional or other deprivation in early childhood. In this view, major life stresses, or a mood disorder like depression or bipolar disorder, may be sufficient to trigger the psychotic symptoms. In fact, patients with schizoaffective disorder frequently experience depressed mood or mania within days of the appearance of psychotic symptoms. Some clinicians believe that "schizomanic" patients are fundamentally different from "schizodepressed" types; the former are similar to bipolar patients, while the latter are a very heterogeneous group.

Symptoms of schizoaffective disorder vary considerably from patient to patient. Delusions, hallucinations, and evidence of disturbances in thinking--as observed in full-blown schizophrenia--may be seen. Similarly mood fluctuations such as those observed in major depression or bipolar disorder may also be seen. These symptoms tend to appear in distinct episodes that impair the individual's ability to function well in daily life. But between episodes, some patients with schizoaffective disorder remain chronically impaired while some may do quite well in day-to-day living.

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