Magazine article Clinical Psychiatry News

Letters

Magazine article Clinical Psychiatry News

Letters

Article excerpt

CBT Works for Schizophrenia

I appreciated the article on Dr. Peter Weiden's cognitive-behavioral-oriented therapy for patients with schizophrenia ("Time to Take Another Look at CBT for Schizophrenia," November 2002, p. 1).

As a practicing psychiatrist, I have come to the conclusion that development of a therapeutic alliance and specific attention to ongoing evaluation of delusions and perceptual distortions in the context of interpersonal and environmental stress really work.

Not only is the patient able to see psychotic phenomena as symptoms and participate with the psychiatrist as an observer, but the patient can compartmentalize psychotic phenomena by relating this to environmental stress or fatigue. Moreover, the therapeutic affiance allows an ongoing discourse about early signs of relapse and regression strategies to avoid "toxic" situations.

I agree totally with Dr. Weiden's appeal to increase psychotherapy access for patients with schizophrenia and his emphasis on the need to strategize with patients about reducing symptoms, cope with symptoms, and understand symptoms in a context. This is so important to improve adherence and compliance with psychotropic medications. Regrettably, the current norm in American psychiatry for psychiatric treatment of schizophrenia too often involves infrequent medication checks and perfunctory prescriptions.

I hope that the National Alliance for the Mentally Ill and the American Psychiatric Association will forcefully promote improved doctor-patient relationships and the use of Dr. Weiden's brand of psychotherapy for the treatment of schizophrenia.

Lee Beecher, M.D.

St. Louis Park, Minn.

Dreaming of Schizophrenia

I greatly enjoyed the report on Dr. Matcheri Keshavan's excellent work ("Sleep Pattern Abnormalities Shed Light on Schizophrenia," November 2002, p 14).

Although the theory could explain wonderfully well why dreams were bizarre, it never did explain why some dreams were exquisitely constructed. Above all, it never explained the intensity of emotions in the dreams and their frequent incongruence with the subject matter. It was amazing how psychiatrists en masse abandoned the wish-fulfillment theory in favor of chaos theory losing the most valuable tool they had to understand what was going on in the patient's mind beyond what he could volunteer.

It is gratifying to note that the riddle of affects in dreams is finally getting proper attention. For too long we were caught in the quagmire of activation-synthesis hypothesis, which taught us that dreams were nothing but cortical froth generated by chaotic signals coming from subcortical pons.

For the psychoanalyst, Dr. Keshavan's findings make complete sense. Schizophrenics, suffering from greater repression and inhibitions, should show greater withdrawal from the world, less novelty seeking, and therefore greater pruning of their synaptic connections during adolescence and consequently less delta sleep. Normals, who are more tuned to what is happening around them, for expediency will show greater suppression of affect during the day abreacting them during sleep in dreams.

Schizophrenics, less responsive to their immediate surroundings and living mostly in their ontogenic and phylogenetic past, may show less suppression of their limbic activity during wakefulness. Sleep perhaps allows downtime for the limbic system and an opportunity for the prefrontal cortex to do what it could not do during wakefulness.

There appears to be a reciprocal relation between the frontal cortex and the limbic system. When one is revved up the other goes into suppression. As Freud, and before him Spinoza, pointed out, when our emotions are aroused our thinking becomes primitive and runs through fewer circuits before emerging as action.

I noted wryly that Dr. Keshavan is still trying to understand how his data fit in with dream's great role as an archiver of memory. …

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