Heatstroke and Psychiatric Patients
Heatstroke and Psychiatric Patients
Jerome Murdough was a 56-year-old former Marine who was receiving antipsychotic and antiseizure medication. He was found dead in his Rikers Island jail cell. When his lifeless body was discovered, his cell was found to be at least 100°F. The initial autopsy performed on Mr Murdough was inconclusive, but evidence strongly suggested that his death was likely due to severe dehydration and heatstroke. Mr Murdough had not been convicted of a crime—rather, he had been arrested on a misdemeanor trespassing charge (for sleeping in a stairwell of a public housing building).
Because he was unable to post bail, Mr Murdough was sent to Rikers Island. On February 14, 2014, he was locked in his cell at around 10:30 pm; approximately 6 hours later, he was dead. His mother reported that her son had suffered from chronic serious mental illness.1
Heatstroke is a severe, life-threatening illness that occurs with regularity during the summer months, particularly among psychiatric patients. Psychiatric patients in jails and prisons face a difficult challenge in that they may not have the freedom to change their environment to avoid heatstroke.
Thermoregulation and heatstroke
Body temperature is regulated by balancing heat production and heat loss. Heat production is a principal by-product of metabolism. The rate of heat loss is determined by how rapidly heat can be conducted from the body core to the skin, and how rapidly heat from the skin can be transferred to the surroundings.
When body temperature rises to 105°F, heatstroke becomes likely. Heatstroke is characterized by a core temperature of more than 104°F and CNS abnormalities (delirium, seizures, coma), which lead to multiorgan dysfunction, sepsis, and tissue destruction. Symptoms heralding the onset of heatstroke include dizziness and abdominal distress that may be followed by vomiting, confusion, and loss of consciousness. Even a few minutes with a high body temperature can be fatal because of damage to body tissues and end-organs, especially the brain (Table 1).
Heatstroke is either “classic” or “exertional.” When it results from exposure to high environmental heat, it is passive, or classic. Heatstroke primarily from strenuous work is exertional. Preexisting conditions, such as mental illness, alcoholism, and drug use (especially anticholinergics), may interfere with the physiological ability to adjust to heat stress, thus increasing the risk of passive heatstroke.
Thermoregulation and medications
Anticholinergic medications can interfere with thermoregulation by inhibiting parasympathetic pathways. This results in an inhibition of sweating and leads to decreased ability to eliminate heat. The antidopaminergic activity of an antipsychotic can increase the set point of the body’s temperature regulation. Antipsychotics may also reduce behaviors that regulate temperature, such as increasing water intake or removing extra clothing.2
Phenothiazines, such as chlorpromazine, thioridazine, fluphenazine, and perphenazine, have anticholinergic and central thermo-regulatory effects. Phenothiazines inhibit afferent neuronal input to the hypothalamus, which decreases the hypothalamus’s compensatory response of increasing cutaneous blood flow to assist in heat dissipation. Other commonly used psychiatric medications that have been shown to disturb thermoregulation include atypical antipsychotics, serotonergic agonists, and β-blockers.3 Some psychiatric medications may increase the risk of dehydration by reducing thirst. Such medications include SSRIs, clonidine, carbamazepine, and valproic acid.