DISSOCIATIVE DISORDER

• DEFINITION:
  

We all get lost in a good book or movie. But someone with dissociative disorder escapes reality in ways that are involuntary and unhealthy. The symptoms of dissociative disorders — ranging from amnesia to alternate identities — usually develop as a reaction to trauma and help keep difficult memories at bay.

Treatment for dissociative disorders may include psychotherapy, hypnosis and medication. Although treating dissociative disorders can be difficult, many people with dissociative disorders are able to learn new ways of coping and lead healthy, productive lives.

• SYMPTOM
  

There are four major dissociative disorders:

• Dissociative amnesia
• Dissociative identity disorder
• Dissociative fugue
• Depersonalization disorder

Signs and symptoms common to all types of dissociative disorders include:

• Memory loss (amnesia) of certain time periods, events and people
• Mental health problems, including depression and anxiety
• A sense of being detached from yourself (depersonalization)
• A perception of the people and things around you as distorted and unreal (derealization)
• A blurred sense of identity

Dissociative disorder symptoms (depending on the type of disorder) may include:

• Dissociative amnesia. Memory loss that's more extensive than normal forgetfulness and can't be explained by a physical or neurological condition is the main symptom of this condition. Sudden-onset amnesia following a traumatic event, such as a car accident, is rare. More commonly, conscious recall of traumatic periods, events or people in your life — especially from childhood — is simply absent from your memory.
• Dissociative identity disorder. This condition, formerly known as multiple personality disorder, is characterized by "switching" to alternate identities when you're under stress. In dissociative identity disorder, you may feel the presence of one or more other people talking or living inside your head. Each of these identities may have name, personal history and characteristics, including marked differences in manner, voice, gender and even such physical qualities as the need for corrective eyewear. There often is considerable variation in each alternate personality's familiarity with the others. People with dissociative identity disorder typically also have dissociative amnesia.
• Dissociative fugue. People with this condition dissociate by putting real distance between themselves and their identity. For example, you may abruptly leave home or work and travel away, forgetting who you are and possibly adopting a new identity in a new location. People experiencing dissociative fugue may be very capable of blending in wherever they end up. A fugue episode may last only a few hours or, rarely, as long as many months. Dissociative fugue typically ends as abruptly as it begins. When it lifts, you may feel intensely disoriented, depressed and angry, with no recollection of what happened during the fugue or how you arrived in such unfamiliar circumstances.
• Depersonalization disorder. This disorder is characterized by a sudden sense of being outside yourself, observing your actions from a distance as though watching a movie. It may be accompanied by a perceived distortion of the size and shape of your body or of other people and objects around you. Time may seem to slow down, and the world may seem unreal. Symptoms may last only a few moments or may come and go over many years.

When to see a doctor
If you or someone you love has significant, unexplained memory loss or experiences a dramatic change in behavior when under stress, talk to a doctor. A chronic sense that your identity or the world around you is blurry or unreal also may be caused by a dissociative disorder. Effective treatment is available for these conditions. Seek medical help.

If you or your child experiences abuse or another traumatic situation, talk to a doctor as soon as possible. Early intervention and counseling may help prevent the formation of dissociative disorders.

• CAUSES
  

Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable.

Personal identity is still forming during childhood, so a child is more able than is an adult to step outside herself or himself and observe trauma as though it's happening to a different person. A child who learns to dissociate in order to endure an extended period of his or her youth may use this coping mechanism in response to stressful situations throughout life.

Rarely, adults may develop dissociative disorders in response to severe trauma.

People who experience chronic physical, sexual or emotional abuse during childhood are at greatest risk of developing dissociative disorders. Children and adults who experience other traumatic events, including war, natural disasters, kidnapping, torture and invasive medical procedures, also may develop these conditions.

• COMPLICATION
  

People with a dissociative disorder are at increased risk of complications that include:

• Self-mutilation
• Suicide attempts
• Sexual dysfunction, including sexual addiction or avoidance
• Alcoholism and substance abuse
• Depression
• Sleep disorders, including nightmares, insomnia and sleepwalking
• Anxiety disorders
• Eating disorders
• Severe headaches

Dissociative disorders are also associated with significant difficulties in relationships and at work. People with these conditions often aren't able to cope well with emotional or professional stress, and their dissociative reactions — from tuning out to disappearing — may worry loved ones and cause colleagues to view them as unreliable.

• DIAGNOSIS
  

Doctors diagnose dissociative disorders based on a review of your symptoms and your personal history. As part of your evaluation, your doctor may perform tests to rule out physical conditions — including head injuries, certain brain diseases, sleep deprivation and intoxication — that can cause symptoms such as memory loss and a sense of unreality. If your doctor rules out physical causes, he or she will likely refer you to a mental health for an in-depth interview.

To help diagnose dissociative identity disorder, some doctors use medication or hypnosis. These may help your doctor identify alternate personalities or may help you describe repressed memories that played a role in the development of dissociative patterns.

To be diagnosed with a dissociative identity disorder, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DMS), published by the American Psychiatric Association.

Criteria for dissociative amnesia to be diagnosed include:

• You have had one or more episodes in which you couldn't remember important personal information, usually something traumatic or stressful. This memory loss is too extensive to be explained by ordinary forgetfulness.
• Your episodes of memory loss do not occur only during the course of another disorder, such as dissociative identity disorder, dissociative fugue, posttraumatic stress disorder, acute stress disorder, or somatization disorder (a condition in which affected people have many recurring physical symptoms that cannot be fully explained by a physical disorder). Your symptoms also are not explained by the direct effects of a substance, such as a prescription medication or recreational drug, or by a neurological or other general medical condition, such as amnesia related to head trauma.
• Your symptoms cause you significant stress or problems in your relationships, work or other important areas of your life.

Criteria for dissociative identity disorder to be diagnosed include:

• You display the presence of two or more distinct identities or personalities, each with its own relatively stable pattern of perceiving, relating to, and thinking about yourself and the world.
• At least two of these identities or personality states recurrently take control of your behavior.
• You can't recall important personal information that is too extensive to be explained by ordinary forgetfulness.
• Your symptoms are not due to the direct effects of a substance, such as alcohol, or a general medical condition, such as complex partial seizures. In children, symptoms are not due to imaginary playmates or other fantasy play.

Criteria for dissociative fugue to be diagnosed include:

• You experience sudden, unexpected travel away from your home or place of work, and can't remember your past.
• During fugue episodes, you are confused about your personal identity or you assume a partially or completely new identity.
• Your episodes of fugue do not occur only during the course of dissociative identity disorder. Your symptoms also are not explained by the direct effects of a substance, such as a prescription medication or recreational drug, or a general medical condition, such as temporal lobe epilepsy.
• Your symptoms cause you significant stress or problems in your relationships, work or other important areas of your life

Criteria for depersonalization disorder to be diagnosed include:

• You have persistent or recurrent experiences of feeling detached from yourself, as if you are an outside observer of your mental processes or your body — you feel as though you are in a dream.
• While you are experiencing an episode of depersonalization, you are aware that your feeling of being outside yourself isn't reality.
• Your symptoms cause you significant stress or problems in your relationships, work or other important areas of your life.
• Your depersonalization symptoms do not occur only during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder. Your symptoms also are not explained by the direct effects of a substance, such as a prescription medication or recreational drug, or a general medical condition, such as temporal lobe epilepsy.

• TREATMENT
  

Psychotherapy is the primary treatment for dissociative disorders. This form of therapy, also known as talk therapy, counseling or psychosocial therapy, involves talking about your disorder and related issues with a mental health provider. Your therapist will work to help you understand the cause of your condition and to form new ways of coping with stressful circumstances.

Psychotherapy for dissociative disorders often involves techniques, such as hypnosis, that help you remember and work through the trauma that triggered your dissociative symptoms. The course of your psychotherapy may be long and painful, but this treatment approach often is very effective in treating dissociative disorders.

Other dissociative disorder treatment may include:

• Creative art therapy. This type of therapy uses the creative process to help people who might have difficulty expressing their thoughts and feelings. Creative arts can help you increase self-awareness, cope with symptoms and traumatic experiences, and foster positive changes. Creative art therapy includes art, dance and movement, drama, music, and poetry.
• Cognitive therapy. This type of talk therapy helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. It's based on the idea that your own thoughts — not other people or situations — determine how you behave. Even if an unwanted situation has not changed, you can change the way you think and behave in a positive way.
• Medication. Although there are no medications that specifically treat dissociative disorders, your doctor may prescribe antidepressants, anti-anxiety medications or tranquilizers to help control the mental health symptoms associated with dissociative disorders.

HUNTER SYNDROME

• DEFINITION

Hunter syndrome is a rare genetic disorder that occurs when an enzyme your body needs is either missing or malfunctioning.

Because the body doesn't have adequate supplies of the enzyme to break down certain complex molecules, the molecules build up in harmful amounts in certain cells and tissues. The buildup that occurs in Hunter syndrome eventually causes permanent, progressive damage affecting appearance, mental development, organ function and physical abilities.

Hunter syndrome appears in children as young as age 2. It nearly always occurs in males, although it may occur in females.

Treatment of Hunter syndrome mostly involves management of your symptoms and complications. Enzyme replacement therapy and other emerging therapies may offer more help in the future.

• SYMPTOMS

Hunter syndrome is one type of a group of inherited metabolic disorders called mucopolysaccharidosis (MPS), and Hunter syndrome is referred to as MPS II. There are two subtypes of Hunter syndrome, MPS IIA and MPS IIB. Symptoms vary according to subtype.

Type MPS IIA (early onset)
Early-onset Hunter syndrome (MPS IIA) is the more severe of the two types and usually appears around age 2 and up to age 4. This form of the disorder may result in profound mental retardation by late childhood. Children with this form of the syndrome usually don't survive beyond their teens.

Signs and symptoms of MPS IIA include:

• A decline in development, which usually appears between ages 1 1/2 and 3, followed by a progressive loss of skills
• Coarse facial features, including thickening of the lips, tongue and nostrils
• Abnormal bone size or shape and other skeletal irregularities
• Enlarged internal organs, such as the liver and spleen, resulting in a distended abdomen
• Respiratory difficulties including sleep apnea, a condition in which breathing intermittently stops during sleep
• Cardiovascular disorders, such as progressive thickening of heart valves, high blood pressure (hypertension) and obstruction of blood vessels
• Vision loss or impairment from degeneration of cells that capture light and buildup of cellular debris in the brain causing pressure on the optic nerve and eye
• Skin lesions on the back and upper arms
• Progressive loss of hearing
• Aggressive behavior
• Stunted growth
• Joint stiffness
• Diarrhea

Type MPS IIB (late onset)
Late-onset Hunter syndrome (MPS IIB) is milder and causes less severe symptoms that appear much later. This form is usually diagnosed after age 10, and may not be detected until adulthood. Intellectual and social development usually is nearly normal, but the condition may affect verbal and reading skills. People with this type of Hunter syndrome can live into their 50s.

Signs and symptoms of MPS IIB include:

• Abnormal bone size or shape and other skeletal irregularities, but less severe than in MPS IIA
• Somewhat stunted growth
• Poor peripheral vision
• Joint stiffness
• Hearing loss
• Diarrhea
• Sleep apnea

When to see a doctor
Hunter syndrome isn't a common disorder, but if you notice changes in your child's facial appearance, a loss of previously acquired skills, or other signs or symptoms listed above, talk to your child's primary care doctor. He or she can perform an evaluation and help you decide if you need to see a specialist or seek out further testing.

• CAUSES

As with all types of MPS, Hunter syndrome is caused when a person lacks a specific enzyme his or her body needs to break down glycosaminoglycans — molecules formed from long chains of complex carbohydrates.

In unaffected people, these enzymes are found in cell components called lysosomes. Lysosomes break down the complex carbohydrates into nutrients, such as proteins and simpler molecules so that your body can use them at the cellular level. These nutrients help your body build bone, cartilage, tendons, corneas, skin and connective tissue, and are also found in the fluid that lubricates your joints. MPS disorders are also referred to as lysosomal storage disorders.

The lysosomes use enzymes to break down glycosaminoglycans, as part of the body's normal recycling and renewal process. In a person with Hunter syndrome or other form of MPS, these enzymes either are missing or don't work correctly.

These breaking-down tasks involve 11 different enzymes, and the particular enzyme that is missing or malfunctioning largely determines the type of MPS disorder. As a result of these enzyme malfunctions, undigested glycosaminoglycans collect in the cells, blood and connective tissues, causing permanent and progressive damage. In the case of Hunter syndrome, the missing or malfunctioning enzyme is called iduronate-2-sulfatase.

• RISK FACTORS

The risk of an unborn child acquiring Hunter syndrome is determined by the genetics of the child's mother.

Hunter syndrome is an X-linked recessive disease. This means that women carry the disease and pass it on — most often to their sons — but the mothers aren't affected by the disease themselves. Hunter syndrome is the only type of MPS that can be passed on by a defective gene in the mother alone. In all other types of MPS, the child inherits the syndrome because the same defective gene has been passed on by both parents.

In an X-linked recessive disorder, the mutated gene is located on the X chromosome. In this case, the mother is a carrier, which means she has one mutated gene and one normal gene for the condition.

Girls are less at risk of inheriting this disease because they have two X chromosomes. If one of the X chromosomes is defective, their normal X chromosome can provide a functioning gene. If the X chromosome of a boy is defective, however, there isn't another normal chromosome to compensate for the problem.

A man with an X-linked recessive disorder will pass his normal Y gene to his sons, and none will be affected. He will pass his mutated X gene to his daughters, and they will be carriers. These chances are the same in each pregnancy.

If you have a child with Hunter syndrome or other MPS syndrome, talk to your doctor or a genetic counselor before planning to have more children. If you're a sister or aunt of a person with Hunter syndrome, you may also be a carrier. There are tests for genetic carriers, so you may wish to seek genetic counseling before having children.

• TESTS & DIAGNOSIS

Confirmation of a diagnosis of Hunter syndrome requires tests performed on blood, urine or tissue samples. Your doctor will look for excess glycosaminoglycans in your child's urine or a deficiency of enzymes in your child's body fluids or cells.

Sometimes secondary health issues can lead to a diagnosis of Hunter syndrome. For example, if your child has recurrent pneumonia, a chest X-ray may show irregularly shaped vertebrae and ribs, a common sign of this syndrome. This finding could lead to further testing and an earlier diagnosis of the disease. However, because the disorder progresses slowly and its signs and symptoms overlap with a number of other disorders, definitive diagnosis may take some time.

Prenatal testing
Prenatal testing of the fluid that surrounds the baby (amniocentesis) or taking a tissue sample from the placenta (chorionic villus sampling) can verify if your child carries a copy of the defective gene or is affected with the disorder.

• TREATMENTS

Because there's no cure for Hunter syndrome, treatment focuses on managing signs, symptoms and complications to provide some relief for your child as the disease progresses. Treatment may involve the following:

• Relief for respiratory complications. Removal of tonsils and adenoids can open up your child's airway and relieve sleep apnea. But as the disease progresses, tissues continue to thicken and these problems can come back. Some types of breathing devices can help with upper airway obstructions and sleep apnea. Keeping your child's airway open can also avoid low blood oxygen levels (hypoxemia).
• Addressing heart complications. Your child's doctor will want to watch closely for cardiovascular complications, such as high blood pressure, heart murmur and leaky heart valves. If your child has severe cardiovascular problems, your doctor may recommend surgery to replace heart valves.

• Treatment for skeletal and connective tissue problems. Most children with Hunter syndrome don't heal well and often have complications from surgery. That limits options for addressing skeletal and connective tissue complications. For example, surgery to stabilize the spine using internal hardware is difficult when bones are fragile.

  Your child's joint flexibility can be improved with physical therapy, which helps address stiffness and maintain function. However, physical therapy can't prevent the progressive decline of mobility. Your child may eventually need to use a wheelchair because of pain and limited stamina.

  Surgery can repair hernias, but because of weakness in connective tissues, results usually aren't ideal. The procedure often needs to be repeated. One option is to manage your child's hernias with supportive trusses rather than surgery because of the risks of anesthesia and surgery.

• Managing neurological complications. Problems associated with the buildup of fluid and tissue around the brain and spinal cord are difficult to address because of the inherent risks in treating these parts of the body. Your child's doctor may recommend surgery to drain excess fluids or remove built-up tissue.

  If your child has seizures, your doctor may prescribe anticonvulsant medications.

• Managing behavioral problems. If your child develops abnormal behavior as a result of Hunter syndrome, providing a safe home environment is one of the most important ways you can manage this challenge. Treating behavior problems with medications has had limited success because most medications have negative effects on other manifestations of the disease.
• Addressing sleep issues. The sleep patterns of a child with Hunter syndrome become more and more disorganized, causing some children to be active around the clock. Medications including sedatives and especially melatonin can improve sleep. Keeping a strict bedtime schedule and making sure your child sleeps in a well-darkened room also can help. In addition, creating a safe environment in your child's bedroom — putting the mattress on the floor, padding the walls, removing all hard furniture, placing only soft, safe toys in the room — may help you rest easier if you know your child has less opportunity for injury.

Treatments in development
Although there's no cure for Hunter or other MPS syndromes, some treatments that are in their early stages have had some success in altering the natural course of the disease to slow its progress and lessen its severity.

These emerging treatments include:

• Bone marrow transplantation. If a healthy donor is found that matches your child's blood and tissue type, bone marrow transplantation can be used to treat some symptoms in milder forms of Hunter syndrome. Bone marrow is taken from the hip of the donor and transplanted to your child by injecting it into his or her veins (intravenously). This treatment can help ease the problems of breathing; mobility; and heart, liver and spleen function. It can also help prevent your child's mental regression. This treatment won't help with bone or vision problems.
• Cord blood transplantation. This treatment uses umbilical cord blood from an unrelated donor that's collected at the time of the donor's birth. The cord blood is transplanted intravenously. This treatment is designed to help your child's bone marrow and enzyme activity recover. It can also reduce the effects of the disease on facial and skin features, joint mobility, hearing, and enlargement of the liver and spleen.
• Enzyme therapy. This treatment uses man-made or genetically engineered enzymes, which are injected directly into your child's bloodstream to replace your child's missing or defective enzymes and ease the disease symptoms. The Food and Drug Administration gave its approval in July 2006 for the first human enzyme replacement therapy for Hunter syndrome. People involved in tests of the drug idursulfase (Elaprase) showed improvement in their ability to walk after a year of weekly treatments. The infusion has produced severe allergic reactions in some people, so your doctor will monitor your child closely if this treatment is chosen.

These therapies show promise, but they don't provide a cure. More research is needed.

BRAIN TUMOUR

DEFINATION

A brain tumor is a mass or growth of abnormal cells in your brain. Many different types of brain tumors exist. Some brain tumors are noncancerous (benign), and some brain tumors are cancerous (malignant). Brain tumors can begin in your brain (primary brain tumors), or cancer can begin in other parts of your body and spread to your brain (secondary, or metastatic brain tumors).

The number of brain tumors diagnosed each year is increasing. There's evidence the increase has been occurring for decades. But it's not clear why.

• CAUSES
  

Brain tumors that begin in the brain
Primary brain tumors originate in the brain or close to it, such as in the brain-covering membranes (meninges), cranial nerves, pituitary gland or pineal gland. Primary brain tumors begin when normal cells acquire errors (mutations) in their DNA. These mutations allow cells to grow and divide at increased rates and to continue living when healthy cells would die. The result is a mass of abnormal cells, which forms a tumor.

Primary brain tumors are much less common than are secondary brain tumors, in which cancer begins elsewhere and spreads to the brain. Many different types of primary brain tumors exist. Each gets its name from the type of cells involved. Examples include:

• Acoustic neuroma (schwannoma)
• Astrocytoma, also known as glioma, which includes anaplastic astrocytoma and glioblastoma
• Ependymoma
• Ependymoblastoma
• Medulloblastoma
• Meningioma
• Neuroblastoma
• Oligodendroglioma
• Pineoblastoma

Cancer that begins elsewhere and spreads to the brain
Secondary (metastatic) brain tumors are tumors that result from cancer that starts elsewhere in your body and then spreads (metastasizes) to your brain. In some cases you may have a history of cancer when a brain tumor is discovered. In other cases, a brain tumor is the first sign of cancer that began elsewhere in your body.

Secondary brain tumors are far more common than are primary brain tumors. Any cancer can spread to the brain, but the most common ones include:

• Breast cancer
• Colon cancer
• Kidney cancer
• Lung cancer
• Melanoma
• Neuroblastoma
• Sarcoma

• RISK FACTOR
  

Though doctors aren't sure what causes the genetic mutations that can lead to primary brain tumors, they've identified factors that may increase your risk of a brain tumor. Risk factors include:

• Your race. Brain tumors occur more frequently in whites than they do in others. One exception is meningioma, which occurs most frequently in blacks.
• Your age. Your risk of a brain tumor increases as you age. The majority of brain tumors occur in people 45 and older. However, a brain tumor can occur at any age. And certain types of brain tumors, such as medulloblastomas, occur almost exclusively in children.
• Exposure to radiation. People who have been exposed to a type of radiation called ionizing radiation have an increased risk of brain tumor. Examples of ionizing radiation include radiation therapy used to treat cancer and radiation exposure caused by atomic bombs. More-common forms of radiation, such as electromagnetic fields from power lines and radiofrequency radiation from cell phones and microwave ovens, have not been conclusively linked to brain tumors.
• Chemical exposure on the job. People working in certain industries have an increased risk of brain tumors, possibly because of the chemicals they're exposed to on the job. Studies don't always agree, but there is some evidence of an increased risk of brain tumor in certain industries, including agricultural, electrical, health care and oil refineries.
• Family history of brain tumors. A small portion of brain tumors occur in people with a family history of brain tumors or a family history of genetic syndromes that increase the risk of brain tumors.

• DIAGNOSIS
  

If it's suspected that you have a brain tumor, your doctor may recommend a number of tests and procedures, including:

• A neurological exam. A neurological exam may include, among other things, checking your vision, hearing, balance, coordination and reflexes. Difficulty in one or more areas may provide clues about the part of your brain that could be affected by a brain tumor.
• Imaging tests. Magnetic resonance imaging (MRI) is commonly used to help diagnose brain tumors. MRI uses magnetic fields and radio waves to generate images of the brain. In some cases a dye may be injected through a vein in your arm before your MRI. A number of specialized MRI scans may help your doctor in evaluation and treatment planning, including functional MRI, perfusion MRI and magnetic resonance spectroscopy.
• Tests to find cancer in other parts of your body. If it's suspected that your brain tumor may be a result of cancer that has spread from another area of your body, your doctor may recommend tests and procedures to determine where the cancer originated. One example might be a chest X-ray to look for signs of lung cancer.

• Collecting and testing a sample of abnormal tissue (biopsy). A biopsy can be performed as part of an operation to remove the brain tumor, or a biopsy can be performed using a needle. A stereotactic needle biopsy may be done for brain tumors in hard to reach areas or very sensitive areas within your brain that might be damaged by a more extensive operation. Your neurosurgeon drills a small hole, called a burr hole, into your skull. A narrow, thin needle is then inserted through the hole. Tissue is removed using the needle, which is frequently guided by computerized tomography (CT) or MRI scanning.

  The biopsy sample is then viewed under a microscope to determine if it is cancerous or benign. This information is helpful in guiding treatment.

• TREATMENT
  

Treatment for a brain tumor depends on the type, size and location of the tumor, as well as your overall health and your preferences. Your doctor can tailor treatment to fit your particular situation.

Surgery
If the brain tumor is located in a place that makes it accessible for an operation, your surgeon will work to remove as much of your brain tumor as possible. In some cases, tumors are small and easy to separate from surrounding brain tissue, which makes complete surgical removal possible. In other cases, tumors are located near sensitive areas in your brain, making surgery risky. In these situations your doctor may try to remove as much of the tumor as is safe. Even removing a portion of the brain tumor may help reduce signs and symptoms you experience. In some cases only a small biopsy is taken to confirm the diagnosis.

Surgery to remove a brain tumor carries risks, such as infection and bleeding. Other risks may depend on the part of your brain where your tumor is located. For instance, surgery on a tumor near nerves that connect to your eyes may carry a risk of vision loss.

Radiation therapy
Radiation therapy uses beams of high-energy particles, such as X-rays, to kill tumor cells. Radiation therapy can come from a machine outside your body (external beam radiation), or, in very rare cases, radiation can be placed inside your body close to your brain tumor (brachytherapy).

External beam radiation can focus just on the area of your brain where the tumor is located, or it can be applied to your entire brain (whole brain radiation). Whole brain radiation is sometimes used after surgery to kill tumor cells that might have been left behind. Whole brain radiation may also be an option if you have several brain tumors that can't be removed through surgery. Whole brain radiation is often used in situations where cancer has metastasized to the brain.

Side effects of radiation therapy will depend on the type and dose of radiation you receive. In general it can cause fatigue, headaches and scalp irritation.

Radiosurgery
Stereotactic radiosurgery is not a form of surgery in the traditional sense. Instead, radiosurgery uses multiple beams of radiation to give a highly focused form of radiation treatment to kill the tumor cells in a very small area. Each beam of radiation isn't particularly powerful, but the point where all the beams meet — at the brain tumor — receives a very large dose of radiation to kill the tumor cells.

Radiosurgery may be an option if your brain tumor can't be removed with traditional surgery. Radiosurgery is typically done in one treatment, and in most cases you can go home the same day. Side effects may include fatigue, headache and nausea.

Chemotherapy
Chemotherapy uses drugs to kill tumor cells. Chemotherapy drugs can be taken orally or injected into a vein (intravenously) so that they travel throughout your body. Chemotherapy drugs can also be administered into your spinal column, so treatment affects only your central nervous system.

Another type of chemotherapy can be placed during surgery. When removing all or part of the brain tumor, your surgeon may place one or more disk-shaped wafers in the void left by the tumor. These wafers slowly release a chemotherapy drug over the next several days.

Chemotherapy side effects depend on the type and dose of drugs you receive. Systemic chemotherapy can cause nausea, vomiting and hair loss.

Targeted drug therapy
Targeted drug treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die. Many targeted drug therapies are very new and still undergoing careful study in clinical trials.

One targeted drug therapy used to treat brain tumors is bevacizumab (Avastin). This drug, given through a vein (intravenously), stops the formation of new blood vessels, cutting off blood supply to a tumor and killing the tumor cells.

Clinical trials
Clinical trials are studies of the latest treatments, such as new drugs or new ways of using existing drugs and new surgical techniques. A clinical trial may offer you a chance at the latest treatment advances. But clinical trials can't guarantee a cure. And, in some cases, side effects of new treatments may not be fully known.

Talk to your doctor about clinical trials. Together you can discuss the benefits and risks and decide if a trial is appropriate for you.

Rehabilitation after treatment
Because brain tumors can develop in parts of the brain that control motor skills, speech, vision and thinking, rehabilitation may be a necessary part of recovery. The brain can sometimes heal itself after trauma from or treatment of a brain tumor — but this can take time and patience.

• Cognitive rehabilitation can help you cope with or regain lost cognitive abilities.
• Physical therapy can help you regain lost motor skills or muscle strength.
• Vocational therapy can help you get back to work after a brain tumor or other illness.
• Specialists in speech difficulties (speech pathologists) are just one of many types of therapists who can help you recover.

School-age children with brain tumors may especially benefit from tutoring as a part of their overall treatment plan. A brain tumor can cause changes in the brain that affect thinking and learning. The earlier these problems are identified, the earlier they can be addressed with strategies that provide the most benefits to the child

TONSILITIS

What is Tonsillitis?

Tonsillitis (ton-sil-lie-tiss) is an inflammation of the tonsils caused by an infection. In tonsillitis, the tonsils are enlarged, red, and often coated (either partly or entirely) by a substance that is yellow, gray, or white. Tonsillitis usually occurs as part of a pharyngitis (throat infection). Tonsillitis usually begins with sudden sore throat and painful swallowing.

Sometimes, tonsillitis reoccurs, and may cause difficulty breathing. If this occurs, your doctor may recommend taking them out. This procedure of removing tonsils from the throat is called a tonsillectomy.

What are Tonsils?

The tonsils are fleshy clusters of tissue that lie in bands on both sides of the back of the throat, above and behind the tongue. The tonsils' major function is to catch incoming germs before the germs cause infections in the throat, mouth, or sinuses. Tonsils contain infection-fighting cells and antibodies that stop the spread of the germs further into the body.

If the tonsils are taken out, the individual will not suffer from more infections than they did when they had their tonsils. There are other tissues in the body that will produce antibodies to fight infection.

What are the symptoms of Tonsillitis?

Each person with tonsillitis may not experience all of the symptoms. Some of the major symptoms of tonsillitis are:

• fever
• redder-than-normal tonsils
• chills
• a yellow or white coating on the tonsils
• a funny-sounding voice
• swollen glands in the neck
• bad breath

How is Tonsillitis diagnosed?

Tonsillitis can be diagnosed by performing a rapid strep test, also called a throat culture. To perform the throat culture, the doctor will use a long cotton swab to swipe off some of the stuff on the surface of the back of your throat. The doctor will then test the "stuff" on the cotton swab. This test will determine whether you have tonsillitis and whether it is caused by a bacteria or a virus.

Is Tonsillitis Contagious?

Yes. Tonsillitis usually spreads from person to person by contact with the throat or nasal fluids of someone who is already infected.

How Is Tonsillitis Treated?

Treatment for tonsillitis depends on whether it was caused by a virus or bacteria. If the tonsillitis was caused by strep bacteria (streptococci), the doctor will prescribe antibiotics. If the tonsillitis was caused by a virus, your body will fight off the infection on its own.

How long does Tonsillitis Last?

If tonsillitis is caused by bacteria, with antibiotic treatment, the illness is usually cured within 1 week. However, it may take several weeks for the tonsils and swollen glands to return to normal size.

When tonsillitis is caused by viruses, the length of illness depends on which virus is involved. Usually, people are almost completely recovered within 1 week.

ALZHEIMER'S DISEASE

• DEFINITION

Alzheimer's disease is the most common cause of dementia — the loss of intellectual and social abilities severe enough to interfere with daily functioning. In Alzheimer's disease, healthy brain tissue degenerates, causing a steady decline in memory and mental abilities.

Alzheimer's disease is not a part of normal aging, but the risk of the disorder increases with age. About 5 percent of people between the ages of 65 and 74 have Alzheimer's disease, while nearly half the people over the age of 85 have Alzheimer's.

Although there's no cure, treatments may improve the quality of life for people with Alzheimer's disease. Those with Alzheimer's — as well as those who care for them — need support and affection from friends and family to cope.

• SYMPTOM'S

Alzheimer's disease may start with slight memory loss and confusion, but it eventually leads to irreversible mental impairment that destroys a person's ability to remember, reason, learn and imagine.

Memory loss
Everyone has occasional lapses in memory. It's normal to forget where you put your car keys or to blank on the names of people whom you rarely see. But the memory problems associated with Alzheimer's disease persist and worsen. People with Alzheimer's may:

• Repeat things
• Often forget conversations or appointments
• Routinely misplace things, often putting them in illogical locations
• Eventually forget the names of family members and everyday objects

Problems with abstract thinking
People with Alzheimer's may initially have trouble balancing their checkbook, a problem that progresses to trouble recognizing and dealing with numbers.

Difficulty finding the right word
It may be a challenge for those with Alzheimer's to find the right words to express thoughts or even follow conversations. Eventually, reading and writing also are affected.

Disorientation
People with Alzheimer's disease often lose their sense of time and dates, and may find themselves lost in familiar surroundings.

Loss of judgment
Solving everyday problems, such as knowing what to do if food on the stove is burning, becomes increasingly difficult, eventually impossible. Alzheimer's is characterized by greater difficulty in doing things that require planning, decision making and judgment.

Difficulty performing familiar tasks
Once-routine tasks that require sequential steps, such as cooking, become a struggle as the disease progresses. Eventually, people with advanced Alzheimer's may forget how to do even the most basic things.

Personality changes
People with Alzheimer's may exhibit:

• Mood swings
• Distrust in others
• Increased stubbornness
• Social withdrawal
• Depression
• Anxiety
• Aggressiveness

• CAUSES
  

No one factor appears to cause Alzheimer's disease. Instead, scientists believe that it may take a combination of genetic, lifestyle and environmental factors to trigger the onset of symptoms. While the causes of Alzheimer's are poorly understood, its effect on brain tissue is clear. Alzheimer's disease damages and kills brain cells.

Two types of brain cell (neuron) damage are common in people who have Alzheimer's:

• Plaques. Clumps of a normally harmless protein called beta-amyloid may interfere with communication between brain cells. Although the ultimate cause of neuron death in Alzheimer's isn't known, mounting evidence suggests that the abnormal processing of beta-amyloid protein may be the culprit.
• Tangles. The internal support structure for brain cells depends on the normal functioning of a protein called tau. In people with Alzheimer's, threads of tau protein undergo alterations that cause them to become twisted. Many researchers believe this may seriously damage neurons, causing them to die.

• RISK FACTOR'S

Age
Alzheimer's usually affects people older than 65, but can, rarely, affect those younger than 40. Less than 5 percent of people between 65 and 74 have Alzheimer's. For people 85 and older, that number jumps to nearly 50 percent.

Heredity
Your risk of developing Alzheimer's appears to be slightly higher if a first-degree relative — parent, sister or brother — has the disease. Although the genetic mechanisms of Alzheimer's among families remain largely unexplained, researchers have identified several genetic mutations that greatly increase risk in some families.

Sex
Women are more likely than men are to develop the disease, in part because they live longer.

Mild cognitive impairment
People who have mild cognitive impairment have memory problems that are worse than what might be expected for people of their age, yet not bad enough to be classified as dementia. Many of those who have this condition go on to develop Alzheimer's disease.

Lifestyle
The same factors that put you at risk of heart disease may also increase the likelihood that you'll develop Alzheimer's disease. Examples include:

• High blood pressure
• High cholesterol
• Poorly controlled diabetes

And keeping your body fit isn't your only concern — you've got to exercise your mind as well. Some studies have suggested that remaining mentally active throughout your life, especially in your later years, reduces the risk of Alzheimer's disease.

Education levels
Studies have found an association between less education and the risk of Alzheimer's. But the precise reason why this occurs is unknown. Some researchers theorize that the more you use your brain, the more synapses you create, which provides a greater reserve as you age. But it may simply be harder to detect Alzheimer's in people who exercise their minds frequently or who have more education.

• TESTS AND DIAGNOSIS

Doctors can accurately diagnose 90 percent of Alzheimer's cases. Alzheimer's disease can be diagnosed with complete accuracy only after death, when microscopic examination of the brain reveals plaques and tangles.

To help distinguish Alzheimer's disease from other causes of memory loss, doctors typically rely on the following types of tests.

Lab tests
Blood tests may be done to help doctors rule out other potential causes of the dementia, such as thyroid disorders or vitamin deficiencies.

Neuropsychological testing
Sometimes doctors undertake a more extensive assessment of thinking and memory skills. This type of testing, which can take several hours to complete, is especially helpful in trying to detect Alzheimer's and other dementias at an early stage.

Brain scans
By looking at images of the brain, doctors may be able to pinpoint any visible abnormalities — such as clots, bleeding or tumors — that may be causing signs and symptoms. Positron emission tomography (PET) can reveal areas of the brain that may be less active and the density of amyloid plaques.

• Magnetic resonance imaging (MRI). An MRI machine uses radio waves and a strong magnetic field to produce detailed images of your brain. You lie on a narrow table that slides into the tube-shaped MRI machine, which makes loud banging noises during scans. The entire procedure can take an hour or more. MRIs are painless, but some people feel claustrophobic in the machine.
• Computerized tomography (CT). For a CT scan, you lie on a narrow table that slides into a small chamber. X-rays pass through your body from various angles, and a computer uses this information to create cross-sectional images, or slices, of your brain. The test is painless and takes about 20 minutes.
• Positron emission tomography (PET). During a PET scan, you'll be injected with a low-level radioactive material, which binds to chemicals that travel to the brain. You lie on a table while an overhead scanner tracks the radioactive material. This helps show which parts of your brain aren't functioning properly. The test is painless and can be particularly useful in distinguishing between different types of dementia.

• TREATMENT'S

Currently, there's no cure for Alzheimer's disease. Doctors sometimes prescribe drugs to improve signs and symptoms that often accompany Alzheimer's, including sleeplessness, wandering, anxiety, agitation and depression. But only two varieties of medications have been proved to slow the cognitive decline associated with Alzheimer's.

Cholinesterase inhibitors
This group of medications — which includes donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne) — works by improving the levels of neurotransmitters in the brain. But cholinesterase inhibitors don't work for everyone. As many as half the people who take these drugs show no improvement. Other people may choose to stop taking the drugs because of the side effects, which include diarrhea, nausea and vomiting.

Memantine (Namenda)
The first drug approved to treat moderate to severe stages of Alzheimer's, memantine protects brain cells from damage caused by the chemical messenger glutamate. It sometimes is used in combination with a cholinesterase inhibitor. Memantine's most common side effect is dizziness, although it also appears to increase agitation and delusional behavior in some people.

• COMPLICATION'S

In advanced Alzheimer's disease, people may lose all ability to care for themselves. This can make them more prone to additional health problems such as:

• Pneumonia. Difficulty swallowing food and liquids may cause people with Alzheimer's to inhale (aspirate) some of what they eat and drink into their airways and lungs, which can lead to pneumonia.
• Infections. Urinary incontinence may require the placement of a urinary catheter, which increases the risk of urinary tract infections. Untreated urinary tract infections can lead to more-serious, life-threatening infections.
• Injuries from falls. People with Alzheimer's may become disoriented, increasing their risk of falls. Falls can lead to fractures. In addition, falls are a common cause of serious head injuries, such as bleeding in the brain.

PARKINSON'S DISEASE

• DEFINITION

Parkinson's disease develops gradually, often starting with a barely noticeable tremor in just one hand. But while tremor may be the most well-known sign of Parkinson's disease, the disorder also commonly causes a slowing or freezing of movement.

Friends and family may notice that your face shows little or no expression and your arms don't swing when you walk. Speech often becomes soft and mumbling. Parkinson's symptoms tend to worsen as the disease progresses.

While there is no cure for Parkinson's disease, many different types of medicines can treat its symptoms. In some cases, your doctor may suggest surgery.

• CAUSES

Many symptoms of Parkinson's disease result from the lack of a chemical messenger, called dopamine, in the brain. This occurs when the specific brain cells that produce dopamine die or become impaired. But researchers still aren't certain about what sets this chain of events in motion. Some theorize that genetic mutations or environmental toxins may play a role in Parkinson's disease.

• RISK FACTOR'S

Risk factors for Parkinson's disease include:

• Age. Young adults very rarely experience Parkinson's disease. It ordinarily begins in middle or late life, and the risk continues to increase with age.
• Heredity. Having one or more close relatives with Parkinson's increases the chances that you'll also develop the disease, although your risk is still less than 5 percent. Recent evidence suggests a crucial role for small contributions from many different genes that program brain architecture.
• Sex. Men are more likely to develop Parkinson's disease than women are.
• Exposure to toxins. Ongoing exposure to herbicides and pesticides puts you at slightly increased risk of Parkinson's.

• SYMPTOMS

The symptoms of Parkinson's disease vary from person to person. Early signs may be subtle and can go unnoticed for months or years. Symptoms typically begin on one side of the body and usually remain worse on that side. Parkinson's signs and symptoms may include:

• Tremor. The characteristic shaking associated with Parkinson's disease often begins in a hand. A back-and-forth rubbing of your thumb and forefinger, known as pill-rolling, is common. However, many people with Parkinson's disease do not experience substantial tremor.
• Slowed motion (bradykinesia). Over time, Parkinson's disease may reduce your ability to initiate voluntary movement. This may make even the simplest tasks difficult and time-consuming. When you walk, your steps may become short and shuffling. Or your feet may freeze to the floor, making it hard to take the first step.
• Rigid muscles. Muscle stiffness often occurs in your limbs and neck. Sometimes the stiffness can be so severe that it limits the range of your movements and causes pain.
• Impaired posture and balance. Your posture may become stooped as a result of Parkinson's disease. Imbalance also is common, although this is usually mild until the later stages of the disease.
• Loss of automatic movements. Blinking, smiling and swinging your arms when you walk are all unconscious acts that are a normal part of being human. In Parkinson's disease, these acts tend to be diminished and even lost. Some people may develop a fixed staring expression and unblinking eyes. Others may no longer gesture or seem animated when they speak.
• Speech changes. Many people with Parkinson's disease have problems with speech. You may speak more softly, rapidly or in a monotone, sometimes slurring or repeating words, or hesitating before speaking.
• Dementia. In the later stages of Parkinson's disease, some people develop problems with memory and mental clarity. Alzheimer's drugs appear to alleviate some of these symptoms to a mild degree.

• TEST'S & DIAGNOSIS

No definitive tests exist for Parkinson's disease, so it can be difficult to diagnose, especially in the early stages. And parkinsonism — the symptoms of Parkinson's disease — can be caused by many other types of problems. Examples include:

• Other neurological disorders. Essential tremor, dementia with Lewy bodies, multiple system atrophy and progressive supranuclear palsy each feature some symptoms common to Parkinson's disease.
• Drugs. Antipsychotic medications — such as chlorpromazine (Thorazine) and haloperidol (Haldol) — block dopamine, as do anti-nausea drugs like prochlorperazine (Compazine) or metoclopramide (Reglan). If you take any of these drugs, you may develop parkinsonism, although it is reversible when the drug is stopped.
• Toxins. Exposure to carbon monoxide, cyanide or certain other toxins can produce symptoms similar to Parkinson's disease.
• Head trauma. Both solitary head injuries and the repetitive variety of head trauma common in boxing have been linked to parkinsonism, although risks are small.
• Structural problems. Strokes or fluid buildup in the brain (hydrocephalus) may occasionally mimic Parkinson's disease.

A diagnosis of Parkinson's disease is based on your medical history and a neurological examination. As part of your medical history, your doctor will want to know about any medications you take and whether you have a family history of Parkinson's. The neurological examination includes an evaluation of your walking and coordination, as well as some simple hand tasks.

A diagnosis of Parkinson's is most likely if you have:

• At least two of the three cardinal Parkinson's symptoms — tremor, slowing of motion and muscle rigidity
• Onset of symptoms on only one side of the body
• Tremor more pronounced at rest, for example, when your hands are resting in your lap
• Strong response to levodopa, a Parkinson's drug

• TREATMENT'S

Your initial response to Parkinson's treatment can be dramatic. Over time, however, the benefits of drugs frequently diminish or become less consistent, although symptoms can usually still be fairly well controlled. Your doctor may recommend lifestyle changes, such as physical therapy, a healthy diet and exercise, in addition to medications. In some cases, surgery may be helpful.

Medications
Medications can help manage problems with walking, movement and tremor by increasing the brain's supply of dopamine. Taking dopamine itself is not helpful, because it is unable to enter your brain.

• Levodopa. The most effective Parkinson's drug is levodopa, which is a natural substance that we all have in our body. When taken by mouth in pill form, it passes into the brain and is converted to dopamine. Levodopa is combined with carbidopa to create the combination drug Sinemet. The carbidopa protects levodopa from premature conversion to dopamine outside the brain; in doing that, it also prevents nausea. In Europe, levodopa is combined with a similar substance, benserazide, and is marketed as Madopar.

  As the disease progresses, the benefit from levodopa may become less stable, with a tendency to wax and wane ("wearing off"). This then requires medication adjustments. Levodopa side effects include confusion, delusions and hallucinations, as well as involuntary movements called dyskinesia. These resolve with dose reduction, but sometimes at the expense of reduced parkinsonism control.

• Dopamine agonists. Unlike levodopa, these drugs aren't changed into dopamine. Instead, they mimic the effects of dopamine in the brain and cause neurons to react as though dopamine is present. They are not nearly as effective in treating the symptoms of Parkinson's disease. However, they last longer and are often used to smooth the sometimes off-and-on effect of levodopa.

  This class includes pill forms of dopamine agonists, pramipexole (Mirapex) and ropinirole (Requip), as well as a patch form, rotigotine (Neupro). Pergolide (Permax) has been withdrawn from the market because of its association with heart valve problems. A short-acting injectable dopamine agonist, apomorphine (Apokyn), is used for quick relief.

  The side effects of dopamine agonists include those of carbidopa-levodopa, although they're less likely to cause involuntary movements. However, they are substantially more likely to cause hallucinations, sleepiness or swelling. These medications may also increase your risk of compulsive behaviors such as hypersexuality, compulsive gambling and compulsive overeating. If you are taking these medications and start behaving in a way that's out of character for you, talk to your doctor.

• MAO B inhibitors. These types of drugs, including selegiline (Eldepryl) and rasagiline (Azilect), help prevent the breakdown of both naturally occurring dopamine and dopamine formed from levodopa. They do this by inhibiting the activity of the enzyme monoamine oxidase B (MAO B) — the enzyme that metabolizes dopamine in the brain. Side effects are rare but can include serious interactions with other medications, including drugs to treat depression and certain narcotics.
• Catechol O-methyltransferase (COMT) inhibitors. These drugs prolong the effect of carbidopa-levodopa therapy by blocking an enzyme that breaks down levodopa. Tolcapone (Tasmar) has been linked to liver damage and liver failure, so it's normally used only in people who aren't responding to other therapies. Entacapone (Comtan) doesn't cause liver problems and is now combined with carbidopa and levodopa in a medication called Stalevo.
• Anticholinergics. These drugs have been used for many years to help control the tremor associated with Parkinson's disease. A number of anticholinergic drugs, such as trihexyphenidyl and benztropine (Cogentin), are available. However, their modest benefits may be offset by side effects such as confusion and hallucinations, particularly in people over the age of 70. Other side effects include dry mouth, nausea, urine retention — especially in men with an enlarged prostate — and severe constipation.
• Antivirals. Doctors may prescribe amantadine (Symmetrel) alone to provide short-term relief of mild, early-stage Parkinson's disease. It also may be added to carbidopa-levodopa therapy for people in the later stages of Parkinson's disease, especially if they have problems with involuntary movements (dyskinesia) induced by carbidopa-levodopa. Side effects include swollen ankles and a purple mottling of the skin.

Physical therapy
Exercise is important for general health, but especially for maintaining function in Parkinson's disease. Physical therapy may be advisable and can help improve mobility, range of motion and muscle tone. Although specific exercises can't stop the progress of the disease, improving muscle strength can help you feel more confident and capable. A physical therapist can also work with you to improve your gait and balance. A speech therapist or speech pathologist can improve problems with speaking and swallowing.

Surgery
Deep brain stimulation is the most common surgical procedure to treat Parkinson's disease. It involves implanting an electrode deep within the parts of your brain that control movement. The amount of stimulation delivered by the electrode is controlled by a pacemaker-like device placed under the skin in your upper chest. A wire that travels under your skin connects the device, called a pulse generator, to the electrode.

Deep brain stimulation is most often used for people who have advanced Parkinson's disease who have unstable medication (levodopa) responses. It can stabilize medication fluctuations and reduce or eliminate involuntary movements (dyskinesias). Tremor is especially responsive to this therapy. Deep brain stimulation doesn't help dementia and may make that worse.

Like any other brain surgery, this procedure has risks — such as brain hemorrhage or stroke-like problems. Infection also may occur, requiring parts of the device to be replaced. In addition, the unit's battery beneath the skin of the chest wall must be surgically replaced every few years. Deep brain stimulation isn't beneficial for people who don't respond to carbidopa-levodopa.

PSYCOSIS

• 
  WHAT IS PSYCOSIS?
  

The word "psychosis" is used to describe conditions that affect the mind, in which there has been some loss of contact with reality. The terms "early psychosis" or "first episode psychosis" mean that an individual is experiencing psychosis for the first time. Hallucinations, delusions (false beliefs), paranoia and disorganized thoughts and speech are symptoms of psychosis. These symptoms can seem so real that often the person does not realize that they are experiencing psychosis. Psychosis also affects feelings and behaviour.

Psychotic episodes are periods of time when symptoms of psychosis are strong and interfere with regular life. Although the lengths of these episodes vary from person to person and may only last a few hours or days, psychosis is most likely to continue for weeks, months or even years unless the person is given proper treatment.

The experience of psychosis varies greatly from person to person and individuals experiencing psychosis may have very different symptoms.

• Who gets psychosis?

Approximately 3% of people will experience a psychotic episode at some stage in their life, although a first episode usually occurs in adolescence or early adult life. Psychosis occurs across all cultures and levels of socioeconomic status and affects males and females equally.

Being able to treat psychosis early is very important, since it usually starts during a very critical stage of a young person's life. Adolescents and young adults are just starting to develop their own identity, form lasting relationships, and make serious plans for their careers and future. A successful recovery leads to a healthy, productive future.

• Phases of a psychotic episode

There are three phases to psychosis; however, not all people having a psychotic episode will experience clear symptoms of all three phases. Each person's experience will differ.

The first phase is called the Prodromal Phase.

This is the period before the psychosis becomes more obvious. There are often changes in feelings, thoughts, perceptions and behaviours. Prodromal symptoms vary from person to person and some people may not experience a prodrome. The duration of this phase is quite variable, although it usually spans several months.

The second phase is the Acute Phase.

This is the stage when the typical psychotic symptoms emerge. It is also the stage that is easiest to recognize and diagnose. Therefore the acute phase is when most people begin receiving treatment.

The third phase is Recovery.

Some of the symptoms that are apparent in the Acute Phase may linger in Recovery. With appropriate treatments, the great majority of people successfully recover from their first episode of psychosis.

• Signs and Symptoms

Early Signs (Prodromal Phase)

Prior to the onset of acute psychosis people may have symptoms that are characterized as Prodromal symptoms. Some of the more common Prodromal symptoms include:

• social withdrawal
  
• reduced concentration, attention
  
• depressed mood
  
• sleep disturbance
  
• anxiety
  
• suspiciousness
  
• skipping school or work
  
• irritability

These symptoms are very general and could be signs of many different things, including normal adolescent behaviour. It is always important to be on the alert for such changes in thoughts, feelings, perceptions and behaviour especially when they are continuous over a period of time. The earlier the treatment starts, the greater the chance of a successful recovery.

Definite Psychotic Symptoms

It is in the Acute Phase that typical psychotic symptoms emerge. These are the symptoms that are hard to miss. They are intense, active and continuous. They interfere with normal life functioning. These symptoms are frequently separated into "positive" and "negative" categories.

Positive symptoms are referred to as "positive" because they are viewed as an excess or distortion of the person's normal functioning.

Some of the positive symptoms include:

Delusions (Fixed false beliefs)

Such as:

• being followed or monitored
  
• being plotted against
  
• having special abilities or "powers"
  
• certain songs or comments are specifically directed toward oneself or communicating a hidden message
  
• being controlled by forces or other individuals
  
• having one's thoughts broadcast so others can hear them

Hallucinations
Hallucinations involve seeing, hearing, feeling, smelling or tasting something that is not actually there. The most common type of hallucination involves hearing things - such as voices or particular sounds. These hallucinations can be so real that the individual may not realize that what they are hearing is false. It is often the odd behaviour that happens as a result of the hallucinations that gets recognized as a problem.

Disorganized Speech or Behaviour
The speech of individuals with psychosis may be disorganized in such a way that the person moves quickly from one topic to the next, or to the point where the person's speech may not be understandable.

The behaviour of individuals with psychosis also may be disorganized. The person may have difficulties performing activities of daily living (e.g., cooking, self-care) or display inappropriate behaviours or responses (e.g., laughing while describing a personal tragedy).

Negative symptoms reflect a decrease in, or loss of, normal functions. These symptoms are often less evident than positive symptoms and require careful assessment.

Some examples of negative symptoms include:

• little display of emotions
  
• not speaking very much
  
• difficulties in thinking or coming up with ideas
  
• decreased ability to initiate tasks
  
• lowered levels of motivation or drive

It is also common for other symptoms or problems to occur along with the psychotic symptoms.

Some examples of other problems include:

• depression
  
• anxiety
  
• suicidal thoughts or behaviours
  
• substance abuse
  
• difficulties functioning
  
• sleep disturbance
  

Recovery Stage

In the recovery stage, the acute symptoms mentioned above will lessen and start to fade; however, some symptoms may linger. Even after the psychosis has responded to treatment, problems such as depression, anxiety, decreased self esteem, social problems and difficulties with work or school may occur.

• What causes psychosis?

Biology

Neurotransmitters. There is strong evidence that some psychoses involve a dysfunction in neurotransmitters in the brain. Neurotransmitters are the "chemical messengers" of the brain. They transmit impulses throughout the brain and the central nervous system. Of particular importance is the neurotransmitter dopamine. Most antipsychotic drugs that control the positive symptoms of psychosis also block the transmission of dopamine.

Genetics. Individuals whose close relatives experience psychosis are themselves at increased risk. For example, the risk of developing psychosis associated with schizophrenia in the general population is approximately 1%, yet the children and siblings of those with schizophrenia have respective lifetime risks of 13% and 9%.

Brain Changes. Changes have been found in the brains of some individuals with schizophrenia, which appear to have been present since birth or early childhood. Possible causes of the changes include: genetic transmission, abnormal neurodevelopment and pregnancy or birth complications (e.g. exposure of mother to a virus during the second trimester of pregnancy).

Stress

Some psychoses appear to occur primarily in response to stress. In most cases, it is believed that a vulnerability to psychosis combined with stress will lead to psychosis.

Drugs

Psychosis can be induced by drugs or can be drug assisted. For example, it appears that amphetamines can cause a psychotic episode, while other drugs, including marijuana, can increase a person's natural vulnerability to psychosis resulting in a psychotic episode.

Vulnerability and Stress

Stresses can be such things as significant life events (e.g. death of a loved one, moving to a new city, etc.), abuse of alcohol and drugs or stressful living conditions (e.g. high levels of family conflict or financial problems).

The degree of vulnerability varies from person to person. Likewise, the amount of stress that may trigger psychosis likely differs for each individual. For example, a person with a low vulnerability might withstand a large amount of stress without experiencing psychosis, whereas, a person with a high vulnerability might only withstand a minimal amount of stress without experiencing psychosis.

• Is a psychotic person dangerous?

Although some individuals with psychosis may experience mood swings and increased feelings of agitation, they are more likely to present emotional dampening and social withdrawal. While strong delusions and hallucinations may cause a person to react unpredictably or even aggressively, individuals with psychosis are rarely violent and, in fact, they are at much greater risk of causing harm to thems

• TREATMENTS

Treating psychosis involves education, medication, close monitoring of symptoms, stress management and creating a strong, supportive environment.

These treatments all help to speed up the recovery process and promote good quality of life for both the person and the family.

Education

Becoming educated about psychosis is an important part of treatment because it allows the person and family to understand the experience of psychosis and what to expect with the treatments that are recommended.

Medication

Medication is an important part of the treatment of psychosis. It relieves symptoms of psychosis and is critical in preventing relapse. There are many different medications available to treat psychosis. These medications are called antipsychotics (or sometimes neuroleptics).

The antipsychotic medications are usually divided into two categories:

1. Typical antipsychotics which include haloperidol, loxapine and many others
   
2. Atypical antipsychotics which include risperidone, olanzapine, quetiapine, ziprasidone and clozapine

There are also other medications that are sometimes used along with antipsychotics, depending on the symptoms. For example, antidepressants or mood stabilizers may be used for problems with mood.

Handling side-effects

Antipsychotics differ in terms of side effects. Many side effects diminish over time and some people do not experience any side effects. Atypical antipsychotics are usually tried first, as they have fewer side effects.

Some common side effects of the atypical antipsychotics include tiredness, dry mouth, blurred vision and weight gain.

Mental health professionals need to closely monitor for side effects, and if bothersome side effects develop, they may recommend a lower dose, or add a medication to reduce them, or try an alternative medication. Mental health professionals may also work with a person by helping cope better (eg. chewing gum for dry mouth; walking more to avoid weight gain).

Stress management and coping skills

Stress can worsen a person's symptoms and ability to function. Managing stress starts with learning to recognize stress. Stress symptoms include many mental, social and physical changes. Common symptoms of stress include feelings of exhaustion and fatigue, irritability or anxiety, changes in appetite or sleep patterns, headaches and/or muscle tension in the back and neck. Increased use of alcohol and/or drugs may also be a sign of poor coping. Each person's response to stress is unique.

By anticipating stress, a person can prepare for it and work out how to control it when it happens. Some ways to reduce stress include:

• Relaxation
  
• Realistic thinking
  
• Time management and organization
  
• Reducing responsibilities and obligations

Other strategies include regular exercise, eating and sleeping well and goal-setting. Different stress strategies work better for some people than others. Therefore, trying out a number will help to figure out what works best.

Support groups

Having the support of groups can be very beneficial. Groups provide a safe environment to meet with others who have been through similar experiences. Groups offer education about psychosis through videos, presentations, written material and discussion. They are also a great way to learn and be positive about recovery.

What about counselling/therapy?

Having someone to talk to is an important part of treatment. The exact method may vary to suit the individual and the phase of the psychotic episode. A person with acute psychotic symptoms may simply want to know there is someone who can understand their experience and provide reassurance that they will recover. As the recovery phase progresses, people may ask "why me" and want to learn practical ways to prevent further episodes, such as stress management and early recognition of warning signs. Counselling or therapy can take place on an individual basis or in groups.

Relapse prevention

Many of the treatments offered are important to help prevent a reoccurrence of psychosis (called a "relapse"). Taking medication as prescribed, education and learning how to manage stress will all help prevent relapse.

In addition, becoming educated about the early warning signs of relapse and developing a plan of action if these occur, can help thwart or reduce the severity of relapse.