The Starry Night was completed near the mental asylum of Saint-Remy, 13 months before Van Gogh's death at the age of 37 in June 1889.
Van Gogh painted furiously and The Starry Night vibrates with rockets of burning yellow while planets gyrate like cartwheels. The hills quake and heave, yet the cosmic gold fireworks that swirl against the blue sky are somehow restful.
This painting is probably the most popular of Vincent's works.
Affective disorders,alterations in mood and behavior are predominant features of senile dementia of the Binswanger's type. These mental status changes are typically found early in the course of the disease and may not accompany the neurologic findings. The changes vary in onset and severity but are present in most cases.
Types of Hyperkinetic Movements Chorea: refers to involuntary, irregular, purposeless, non-rhythmic, rapid, unsustained movements that seem to flow from one body part to another. They are unpredictable in timing, direction and distribution. Chorea involve random group of muscles.They can be partially suppressed and the patient can often camouflage some of the movements by incorporating them into semi-purposeful(quasipurposive) movements (termed ‘parakinesias’). Huntington's disease presents with chorea.
Athetosis: Here the involuntary movements are slow, writhing, continuous.
Ballismus :this constitutes large amplitude choreic movements of the proximal parts of the limbs causing flinging and flailing limb movements. Most frequently unilateral,The lesion is most likely in the contralateral subthalamic nucleus.
Athetosis, chorea, and ballism may represent a continuum of one type of hyperkinetic movement disorder and are sometimes combined (‘choreoathetosis’ or ‘chorea-ballism’).
Dystonia: refers to twisting movements, they are sustained at the peak of the movement;many a time progress to prolonged abnormal postures. Both agonist and antagonist muscles contract simultaneously to produce the twisted posture of the limb, neck or trunk. Dystonic movements repeatedly involve the same group of muscles.
Focal dystonia - a single body part is affect. Examples of focal dystonia include: blepharospasmspasmodic torticollis (cervical or neck dystonia), writer’s cramp (hand dystonia).
Segmental Dystonia: Involvement of 2 or more contiguous regions of the body .
Generalized dystonia: Involvement of the trunk, legs and other body parts.
Idiopathic torsional dystonia:Common among Ashkenazi Jews, autosomal dominant disorder (with reduced penetrance) that begins in childhood as a focal or segmental dystonia that later generalizes to the entire body. (dystonia of the eyelids), Focal dystonia can be treated by injecting the involved muscles with botulinum toxin.
Generalized dystonia can be treated by anticholinergic agents (benztropine, trihexyphenidyl), or muscle relaxants (clonazepam, baclofen).
Myoclonus: is a sudden, brief, shock-like jerk caused by a muscle contraction (positive myoclonus) or inhibition (negative myoclonus). The causes of myoclonus are quite diverse from epileptic syndromes, to drug side effects, metabolic disturbances, and CNS lesions. Unless the cause is readily identifiable, it often requires a laborious work-up.
Regardless of its etiology, mainstay symptomatic treatments are benzodiazepines (such as clonazepam) and valproic acid.
Restless legs syndrome: refers to the phenomenon of restless legs, where the patient describes an unpleasant, crawling sensation in the legs, particularly when sitting and relaxing in the evening which then disappear on walking. It is quite common, found in 10% of the general population in one study. It is mostly “idiopathic” but is found in increased frequency among parkinsonian patients and in patients with iron deficiency anemia. Sometimes, simply replacing with iron will provide relief. Otherwise, dopaminergic agents (such as dopamine agonists and levodopa) are the mainstay treatments of RLS. In refractory RLS, anti-epileptic agents (such as gabapentin), benzodiazepines and opiates can be used.
Tics: consist of abnormal movements (motor tics) or abnormal sounds (phonic tics). When both types of tics are present, and occurring under the age of 15, accompanied by obsessive compulsive features, the designation of Tourette syndrome is commonly applied. Tics frequently vary in severity over time and can have remissions and exacerbations. Motor and phonic tics can be simple or complex. Most of the time tics are repetitive. They can be suppressed temporarily but will need to be “released” at some point providing internal ‘relief’ to the patient until the next ‘urge’ is felt. Examples include: shoulder shrug, head jerk, blink, twitch of the nose, touching other people, head shaking with shoulder shrugging, kicking of the legs, obscene gesturing, grunting, throat clearing, etc. Dopamine receptor blocking agents (such as conventional antipsychotic agents), dopamine depleting agents (such as reserpine), clonazepam, and clonidine are used to symptomatically control tics.
Tremor: is an oscillatory, usually rhythmical and regular movement affecting one or more body parts, such as limbs, neck, tongue, chin or vocal cords. The rate, location, amplitude and constancy varies depending on the specific type of tremor. It is always helpful to determine whether a tremor is present at rest (resting tremor), with posture holding (postural tremor) or with action such as writing or pouring water (intention or kinetic tremor). Resting tremor, for example, while on its own is a hyperkinetic movement, is often part of a hypokinetic movement disorder: parkinsonism. When tremor occurs mostly with action or intention, the most common cause is Benign Essential Tremor—a non-progressive disorder which can either be hereditary (usually autosomal dominant) or sporadic. The tremor can sometimes be relieved by beta blockers (propranolol), primidone (an old anti-epileptic drug) or clonazepam.
When the tremor frequency is rapid and most prominent with posture holding, it can be a manifestation of “enhanced physiologic tremor”.
Remember the conditions that ‘enhance’ the silent tremor that is in all of us include: hyperthyroidism, anxiety, hypoglycemia, medications such as steroids and anti asthma agents such as terbutaline, albuterol, etc.
Almost half of all movement disorders is Parkinsonism. This is manifested by any combination of 4 cardinal features: resting tremor, bradykinesia (slowness in movement), rigidity (stiffness) and gait/postural instability. At least 2 of these features need to be present with one being resting tremor or bradykinesia before the diagnosis of parkinsonism is made.
There are several causes of parkinsonism: primary, secondary, parkinson-plus, and heredo-degenerative disorders. Primary parkinsonism (Parkinson’s disease) refers to a progressive disorder of unclear etiology and the diagnosis is often made by excluding other causes of parkinsonism. For this reason, it is also called “idiopathic” PD. It is probably the most common type of parkinsonism encountered by a neurologist.
Secondary parkinsonism refers to disorders with an identifiable cause such as drug-induced parkinsonism (from intake of dopamine receptor blocking agents such as antipsychotic and anti-emetic drugs), or parkinsonism resulting from a stroke, infection, or tumor in and area of the basal ganglia.
Parkinson-plus syndromes are also progressive neurodegenerative disorders with parkinsonism as their main but not the only feature. Examples of parkinson-plus disorders are: progressive supranuclear palsy (with early dementia, vertical gaze palsy and early, frequent falls), multiple systems atrophy (with lack of tremor, more prominent cerebellar features such as ataxia and incoordination, significant autonomic dysfunction such as urinary incontinence, erectile dysfunction or orthostatic hypotension) and cortico-basal-ganglionic degeneration or cortico-basal-degeneration (presenting with early dementia, limb dystonia and “alien limb phenomenon”—where the limb performs autonomous movements). Finally, other neurodegenerative disorders can also present with parkinsonism. The main difference between this group (compared to the parkinson-plus) of disorders is that parkinsonism is not their most prominent feature. For example, Alzheimer’s disease is primarily a neurodegenerative disorder of memory dysfunction but parkinsonism can occur at the later stages of the illness.
Movement Disorders can be defined as neurological syndromes in which there is either an excess of movement (termed “hyperkinetic movements”) or a paucity of voluntary or automatic movements (termed “hypokinetic movements”) these are unrelated to weakness or spasticity.
Hyperkinesias have also been called dyskinesias or abnormal involuntary movements. The six major categories of hyperkinetic movement disorders are: restless legs, tremor, chorea, dystonia, myoclonus and tics. However, there are other ‘minor’ or less common hyperkinetic movement disorders such as akathisia, hemifacial spasms, hyperekplexia, myokimia, myorhythmia, and stereotypy.
These hyperkinetic disorders can be, involuntary, automatic (i.e. learned motor behaviors performed without conscious effort such as the act of walking or swinging of arms during walking), voluntary (planned or self-initiated), semi-voluntary (induced by an inner sensory stimulus such as a need to scratch an itch; or an unwanted feeling or compulsion such as those seen in restless legs or akathisia).
Hypokinesia (decreased amplitude of movement) is sometimes used alternatively with bradykinesia (slowness of movement), and akinesia (loss of movement). Parkinsonism is the most common cause of hypokinetic movements but there are other less common causes of hypokinetic movements such as: cataplexy and drop attacks, catatonia, hypothyroid slowness, rigidity, and stiff muscles.
Most, but not all, movement disorders are a result of basal ganglia dysfunction—what we term as “extrapyramidal disorders”. Movement disorders can also come from injury of the cerebral cortex, cerebellum, brainstem, spinal cord, peripheral nerve, and other areas.
Dr Vasantha Muthuswamy, called the Queen of Bioethics. head of basic medical sciences at the Indian Council of Medical Research, was responsible for coordinating the ICMR’s guidelines for biomedical research, finalised in 2000. Dr Muthuswamy was a keynote speaker at Indian Journal of Medical Ethics’ National Bioethics Conference held in Mumbai in the last week of November. Excerpts from the interview:
ICMR is a research organisation and have issued guidelines: Ethical guidelines for biomedical research on human subjects, 2000. But ICMR is not a policing authority and have no legal authority to take any action against anybody. Even if the guidelines become law, there has to be someone to implement the law, and this authority may or may not be the ICMR.
But there are laws governing research in India. Under the Drugs and Cosmetics Act all trials in India should follow the ICMR guidelines of 2000. The Medical Council of India (MCI) Act, amended in 2002, states that all research in India carried out by physicians has to follow the ICMR guidelines. So there is indirect power to enforce our guidelines.
The Drugs Controller General is the regulatory authority for clinical trials. Schedule Y of the Drugs and Cosmetics Act applies to trials of new drugs, but permission must be sought from the DCGI for other trials as well, of drugs which have received approval in other countries but have to be marketed in India.
Which agencies have control over different aspects of supervision of a trial?
Every doctor is governed by the MCI Act. Any doctor doing wrong in a trial or in practice can be prosecuted. The hospital can be closed. The MCI Act is very strong, the MCI has the power to take punitive measures. Whether they are using the power or not, we cannot say.
The Drugs Controller has authority over any clinical trial for which DCGI permission has been sought and functions under the Drugs and Cosmetics Act. (Trials of recombinant or biotechnology products come under the Environmental Protection Act and the Department of Biotechnology and the Ministry of Environment have a regulatory role.)
But if someone did a trial without asking the Drugs Controller because it is an approved drug and something goes wrong then the Drug Controller will not come to know.
What do you fear?
The fear is that India is being projected as a global hub for clinical trials. Will the ethics committees of each institution be strong enough? For example, will they understand the implications of post-trial benefits? Now the pharmaceutical industry will have its strategies, like selecting 30 centres with 10 cases each to arrive at the statistically valid sample of 300, but it is invalid per centre. Will the local institutional ethics committee have the power to ask the right questions?That’s the only way of controlling research at the moment. We think that ethics committees have certain powers, you have to empower them to ask questions.
The second concern is that all these new contract research organisations are coming up to get their clinical trials done fast. Now some of them may be good, some may not be that good. Their intentions or ulterior motives may be different. And they get paid for the trials…
The Clinician Alcohol Abuse Scale and Clinician Drug Use Scale are short, reliable, and valid measures that are suitable for use by clinicians. Comorbid substance abuse occurs in up to 50% of people with schizophrenia. However, there is evidence that the use of clozapine reduces suicidality and persistent suicidal ideation in patients with schizophrenia. Evidence for this comes from an innovative randomized controlled study in which increased suicidality was the primary outcome (3-fold overall reduction in risk of suicidal behaviors).
A recent systematic review indicates that there are a number of reliable individual risk factors for schizophrenia and suicide as well as attempted suicide.Furthermore, people with schizophrenia do communicate their potential for suicide. A systematic review identified 8 strategies that were promising.
In addition, clinical practice guidelines have identified a number of evidence-based treatments related to reducing suicidality in schizophrenia.
In a Swedish 10-year longitudinal cohort study mortality was double that of the general population rate, with suicide being the leading cause of death
In a study following a Danish cohort of 9156 patients with schizophrenia admitted to the hospital for the first time, there were increasing rates of suicide in 3 successive 5-year cohorts after patients were discharged. There was a particularly high risk in the first year.
The suicide attempts by patients with schizophrenia were, on average, more medically dangerous than attempts made by patients with other diagnoses.
A recent systematic review of risk factors for schizophrenia and suicide identified 7 robust risk factors.
| Risk Factors |
| Previous depressive disorder |
| Drug misuse |
| Previous suicide attempts |
| Fear of mental disintegration |
| Agitation or motor restlessness |
| Recent loss |
| Poor treatment adherence |
Reduced risk was associated with hallucinations. This finding is consistent with a study that found that command auditory hallucinations were not more common in those who had attempted suicide. Overall, suicide was less associated with the core symptoms of psychosis and more with affective symptoms, agitation, and awareness that illness was affecting mental function. In a relatively small sample, those who had both suicide attempts and command hallucinations made more suicide attempts than those who did not. The authors hypothesized that command hallucinations were not an independent risk factor, but they increased the risk in those already predisposed to attempted suicide.
| Current presentation of suicidality |
| A. Mental disorder |
| B. History |
| C. Psychosocial situation |
| D. Individual strengths and vulnerability |
| Estimation of risk |
| Treatment plan |
The Calgary Depression Scale for Schizophrenia (CDSS) is specifically developed for schizophrenia, has been found to be reliable and valid and can be used to predict future suicidality in the context of a randomized clinical trial. It includes items that rate hopelessness and suicidality, which may have more specific predictive validity for suicidality than the total depression score.
In international survey of clinical experts in schizophrenia care identified 3 key questions that clinicians can use to screen for depression in schizophrenia:
Clinical practice guidelines suggest that there is evidence to support both antidepressant pharmacotherapy and cognitive therapy for depression in schizophrenia. There is also evidence that second-generation antipsychotics are more effective than first-generation ones in reducing the level of depression in patients with schizophrenia
Sandor Ferenczi ,Ernest Jones, Otto Rank, Sachs and Karl Abraham, Etington were the other members. The group was dissolved 20 years after its creation.
Whenever anxiety becomes overwhelming, the ego, which has to deal with reality, the id, and the superego to its fullest. has to protect itself. So it tries to block out all impulses or change them into more acceptable forms which are less anxiety provoking. These techniques are called the ego defense mechanisms.
Denial involves blocking external events from awareness. If some situation is just too much to handle, the person just refuses to experience it. Anna Freud also talks of denial in fantasy. Eg: Your’e fuming angry with your friend, but you completely reject the thought or feeling."I'm not angry with him!"
Repression, which Anna Freud also called "motivated forgetting," is just that: not being able to recall a threatening situation, person, or event. That is your unconscious chooses not to remember an event which produces anxiety and threaten the ego.
Asceticism, or the renunciation of needs. An example of this can be seen with the new age disease of anorexia. Preadolescents, when threatened by their emerging sexual desires, unconsciously try to protect themselves by denying all their desires.
Isolation (sometimes called intellectualization) involves stripping the emotion from a difficult memory or threatening impulse. A person may, in a very cavalier manner, acknowledge that they had been abused as a child, or may show a purely intellectual curiosity in their newly discovered sexual orientation. Something that should be a big deal is treated as if it were not. Many times in event of death you are able to continue with social obligations and you crumble with the knowledge of the loss later after the storm ceases. Your mad at your friend, you "think" the feeling but don't really feel it. "I guess I'm angry with him, sort of."
Displacement is the redirection of an impulse onto a substitute target. If the impulse, the desire, is okay with you, but the person you direct that desire towards is too threatening, you can displace to someone or something that can serve as a symbolic substitute. You are angry with your best friend, but you can’t hit him, you go out and kick the dog.
Turning against the self is a very special form of displacement, where the person becomes their own substitute target. It is normally used in reference to hatred, anger, and aggression, rather than more positive impulses, and it is the Freudian explanation for many of our feelings of inferiority, guilt, and depression. The idea that depression is often the result of the anger we refuse to acknowledge is accepted by many people, Freudians and non-Freudians alike.
Projection, which Anna Freud also called displacement outward, is almost the complete opposite of turning against the self. It involves the tendency to see your own unacceptable desires in other people. In other words, the desires are still there, but they're not your desires anymore. I confess that whenever I hear someone going on and on about how aggressive everybody is, or how perverted they all are, I tend to wonder if this person doesn't have an aggressive or sexual streak in themselves that they'd rather not acknowledge. You’re angry this time with you’re teacher, but you project that feeling as "That professor hates me."
Let me give you a couple of examples: A husband, a good and faithful one, finds himself terribly attracted to the charming and flirtatious lady next door. But rather than acknowledge his own, hardly abnormal, lusts, he becomes increasingly jealous of his wife, constantly worried about her faithfulness, and so on. Or a woman finds herself having vaguely sexual feelings about her girlfriends. Instead of acknowledging those feelings as quite normal, she becomes increasingly concerned with the presence of lesbians in her community.
Altruistic surrender is a form of projection that at first glance looks like its opposite: Here, the person attempts to fulfill his or her own needs vicariously, through other people.
A common example of this is the friend (we've all had one) who, while not seeking any relationship himself, is constantly pushing other people into them, and is particularly curious as to "what happened last night" and "how are things going?" The extreme example of altruistic surrender is the person who lives their whole life for and through another.
Reaction formation, which Anna Freud called "believing the opposite," is changing an unacceptable impulse into its opposite. So a child, angry at his or her mother, may become overly concerned with her and rather dramatically shower her with affection. An abused child may run to the abusing parent. Or someone who can't accept a homosexual impulse may claim to despise homosexuals. You don’t like a friend but you turn the feeling into its opposite. "I think he's really great!"
Undoing involves "magical" gestures or rituals that are meant to cancel out unpleasant thoughts or feelings after they've already occurred. Anna Freud mentions, for example, a boy who would recite the alphabet backwards whenever he had a sexual thought, or turn around and spit whenever meeting another boy who shared his passion for masturbation. Generally seen with Obsessive Compulsive Disorders. When your angry maybe a sorry may be your way to defuse the situation or even "I think I'll give that professor an apple."
Introjection, sometimes called identification, involves taking into your own personality characteristics of someone else, because doing so solves some emotional difficulty. For example, a child who is left alone frequently, may in some way try to become "mom" in order to lessen his or her fears. You can sometimes catch them telling their dolls or animals not to be afraid. And we find the older child or teenager imitating his or her favorite star, musician, or sports hero in an effort to establish an identity.
I must add here that identification is very important to Freudian theory as the mechanism by which we develop our superegos.
Identification with the aggressor is a version of introjection that focuses on the adoption, not of general or positive traits, but of negative or feared traits. If you are afraid of someone, you can partially conquer that fear by becoming more like them.
eg: Stockholm Syndrome. After a hostage crisis in Stockholm, psychologists were surprised to find that the hostages were not only not terribly angry at their captors, but often downright sympathetic. A more recent case involved a young woman named Patty Hearst, of the wealthy and influential Hearst family. She was captured by a very small group of self-proclaimed revolutionaries called the Symbionese Liberation Army. She was kept in closets, raped, and otherwise mistreated. Yet she apparently decided to join them, making little propaganda videos for them and even waving a machine gun around during a bank robbery. When she was later tried, psychologists strongly suggested she was a victim, not a criminal. She was nevertheless convicted of bank robbery and sentenced to 7 years in prison
Regression is a movement back in psychological time when one is faced with stress. When we are troubled or frightened, our behaviors often become more childish or primitive. A child may begin to suck their thumb again or wet the bed when they need to spend some time in the hospital. Where do we retreat when faced with stress? To the last time in life when we felt safe and secure, according to Freudian theory. When your angry with your buddy, you revert to an old, usually immature behavior to ventilate your feeling."Let's shoot spitballs at people!"
Rationalization : A better way of making excuses i.e. the cognitive distortion of "the facts" to make an event or an impulse less threatening.. But for many people, with sensitive egos, making excuses comes so easy that they never are truly aware of itA useful way of understanding the defenses is to see them as a combination of denial or repression with various kinds of rationalizations.
And yet Freud saw defenses as necessary. You can hardly expect a person, especially a child, to take the pain and sorrow of life full on! While some of his followers suggested that all of the defenses could be used positively, Freud himself suggested that there was one positive defense, which he called sublimation.
eg This time your’e angry, you come up with various explanations to justify the situation (while denying your feelings) "He's so critical because he's trying to help us do our best."
Anna O,21 yrs old, was Joseph Breuer's patient from 1880 through 1882., Anna spent most of her time nursing her ailing father. She developed a bad cough, then she developed some speech difficulties, then became mute, and then began speaking only in English, rather than her usual German. All these difficulties seemed to have no physical basis.
After the death of her father she started to refuse food, and developed an unusual set of problems. She lost the feeling in her hands and feet, developed some paralysis, began to have involuntary spasms, visual hallucinations and tunnel vision. Specialists could find no physical causes for these problems.
If all this weren't enough, she had fairy-tale fantasies, dramatic mood swings, and made several suicide attempts. Breuer's diagnosis was that she was suffering from what was then called hysteria (now called conversion disorder), which meant she had symptoms that appeared to be physical, but were not.
In the evenings, Anna would sink into states of what Breuer called "spontaneous hypnosis,"she could explain her day-time fantasies and other experiences, and she felt better afterwards. Anna called these episodes "chimney sweeping" and "the talking cure." Here some emotional event was recalled that gave meaning to some particular symptom. The first example came soon after she had refused to drink for a while: She recalled seeing a woman drink from a glass that a dog had just drunk from. While recalling this, she experienced strong feelings of disgust...and then had a drink of water! In other words, her symptom -- an avoidance of water -- disappeared as soon as she remembered its root event, and experienced the strong emotion that would be appropriate to that event. BREUER CALLED THIS CATHARSIS, from the Greek word for cleansing. or what Anna herself called "clouds." Breuer found that, during these trance-like states,
Breuer and Freud, 11 years later, wrote a book on hysteria. In it they explained their theory: Every hysteria is the result of a traumatic experience, one that cannot be integrated into the person's understanding of the world. The emotions appropriate to the trauma are not expressed in any direct fashion, but do not simply evaporate: They express themselves in behaviors that in a weak, vague way offer a response to the trauma. These symptoms are, in other words, meaningful. When the client can be made aware of the meanings of his or her symptoms (through hypnosis, for example) then the unexpressed emotions are released and so no longer need to express themselves as symptoms.
In this way, Anna got rid of symptom after symptom. But it must be noted that she needed Breuer to do this: Whenever she was in one of her hypnotic states, she had to feel his hands to make sure it was him before talking! And sadly, new problems continued to arise.
According to Freud, Breuer recognized that she had fallen in love with him, and that he was falling in love with her. Plus, she was telling everyone she was pregnant with his child. You might say she wanted it so badly that her mind told her body it was true, and she developed an hysterical pregnancy. Breuer, a married man in a Victorian era, abruptly ended their sessions together, and lost all interest in hysteria.
It was Freud who would later add what Breuer did not acknowledge publicly -- that secret sexual desires lay at the bottom of all these hysterical neuroses.
TO FINISH HER STORY, ANNA SPENT TIME IN A SANATORIUM. LATER, SHE BECAME A WELL-RESPECTED AND ACTIVE FIGURE -- THE FIRST SOCIAL WORKER IN GERMANY -- UNDER HER TRUE NAME, BERTHA PAPPENHEIM. She died in 1936. She will be remembered, not only for her own accomplishments, but as the inspiration for the most influential personality theory we have ever had.