Mary V. Seeman, MDCM, DSc

Slideshows

The body image disturbance at the heart of anorexia nervosa is a false perception akin to the perceptual disorders found in schizophrenia.

When Eating Disorders and Psychosis Co-Exist: 6 Take Home Points

Patients who are at risk need to be assessed, monitored, and seen often. Their grief needs to be acknowledged, whether or not the object of grief was known to them.

Dr Seeman is Professor Emerita, Department of Psychiatry, Institute of Medical Science, Toronto, Canada. She reports no conflicts of interest concerning the subject matter of this article.

On August 5, 1962, Marilyn Monroe was found dead of an overdose of barbiturates. I was a second-year psychiatry resident in New York City at the time, and I remember exactly where I was when I heard of her death. The sad news shook the staff and dazed the patients in our all women’s hospital ward. The ripple effect of Marilyn Monroe’s death can still be felt today simply by counting the number of books and films dedicated to the stories of Marilyn’s deprived childhood, her astonishing Hollywood career, and the fame and glamour of the men in her orbit, not to mention the psychiatric theories about her mental illness and the many conspiracy theories that continue to surround her death.

The female patients for whom I was responsible were particularly devastated by the news of her death because they identified with her in so many ways. Many had experienced similar childhoods in foster care, had aspired to be film stars, and had suffered through difficult relationships.

As it was summer when this happened, the head of our ward was on vacation in Europe. This left me temporarily in psychiatric charge.

Once I realized how deeply Marilyn Monroe’s death had affected my patients, I knew that some form of intervention was urgently needed. I immediately invited patients to join a support group that I would lead. I had led groups before-these were fairly routine on our ward. I knew how to be emotionally supportive and how to listen. I was confident that I was good at bringing people out. I had all the brash self-assurance of the very naÃ¯ve.

Our group of eight got off to a good start. We cried and shared our feelings. The women talked about their suicidal urges. “Her life was so great compared to mine,” one woman said. Everyone agreed, as she added, “She was rich; she was beautiful; she was talented. Look at all the men who loved her!”

“This group is a catharsis,” I proudly pronounced to my fellow residents.

But this is what happened next. Three of the women in the group attempted suicide, one very seriously. Fortunately, all three survived. The head nurse, frightened by what had happened, contacted the head of our ward in Europe. He immediately cut his vacation short and returned to New York. The first thing he did was to end the group. Then, he gave me the worst dressing down of my life. I thought it was the end of my residency, but he allowed me to stay. What came to an end was my early confidence in myself as a therapist. Since then, there has always been a seed of doubt when I see a patient. I now ask myself, “By stirring the pot, am I perhaps doing more harm than good?”

It was not as if I hadn’t read up on suicide. I had read Ãmile Durkheim’s work in my first year. In the French sociologist’s 1887 study on 

, he had in fact underplayed the effect of imitation as a critical factor in suicide.

 Durkheim believed it was useless, for instance, to prohibit newspapers from publishing suicide stories. But he was wrong. Human beings are very easily influenced. What my Marilyn Monroe group had done was to bring together eight vulnerable women who, with the complicity of their group leader, had laid fertile ground for intense behavioral contagion.

 Out of a mix of would-be Marilyn Monroes, raw emotions, media prodding, and myself as a greenhorn therapist, the belief had emerged that suicide was the answer to distress.

 after the widespread emotional reaction to the 18th century novel 

 The story is about an unhappy lover who ends his life with a pistol. At publication, the book precipitated a massive wave of imitative suicides throughout Germany and much of Europe. This response was not unlike what took place the month after Marilyn Monroe’s death when there was a 10% increase in suicides in the US.

More recently, there has again been much discussion about the potentially 

 effect of celebrity suicide. According to one 

, the suicide of film stars is especially dangerous because there are many facets of the person’s real life that are widely known because of extensive media coverage and that consequently serve as springboards for identification.

 In addition, people identify with various aspects of the characters a film star has portrayed. Marilyn Monroe is a case in point. The obsession with her suicide continues to this day, almost 60 years after her death.

The sources of copycat suicides go beyond identification. By using new technology to analyze the emotional tone after celebrity suicide tweets, recent studies conclude that the unexpectedness of the suicide 

 A surprising, unexpected suicide seems to shake people out of their habitual routine into serious reconsideration of their reasons for living and, at times, into impulsive action.

Are there lessons here for clinicians? I think there are. In the wake of a celebrity suicide, it is wisest to express neither shock nor surprise to one’s patients. Patients who are at risk need to be assessed, monitored, and seen often. Their grief needs to be acknowledged. They also need assurances that you understand, are available, and that there are ways, admittedly difficult, by which one can overcome adverse circumstances and survive anguish. Persuading someone that viable alternatives to suicide exist has been called the 

. In the plot, Papageno decides to hang himself because he is convinced that he has forever lost his one true love, Papagena. Three child spirits prevent his death, however, by showing him how he can summon her back.

My own experience suggests that overzealous intervention is not a good idea and that it is best to check with elders in the field who are more experienced before leaping into unknown therapeutic territory. Sensitive topics such as thoughts of suicide need private one-on-one discussion, not group therapy. Membership in a group transforms a person and the results of such transformations can be difficult to foresee.

Originally posted on 9/10/19 and has since been updated.

2.  Wheeler L. Toward a theory of behavioral contagion. 

3.  Haw C, Hawton K, Niedzwiedz C, Platt S. Suicide clusters: a review of risk factors and mechanisms. 

4.  Niedzwiedz C, Haw C, Hawton K. Platt S. 

The definition and epidemiology of clusters of suicidal behavior: a systematic review

The influence of suggestion on suicide: substantive and theoretical implications of the Werther effect

The Marilyn Monroe group and the Werther effect

7. Stack S. Celebrities and suicide: a taxonomy and analysis, 1948-1983. 

8. Fahey RA, Matsubayashi T, Ueda M. Tracking the Werther effect on social media: emotional responses to prominent suicide deaths on twitter and subsequent increases in suicide. 

9. Ueda M, Mori K, Matsubayashi T, Sawada Y. Tweeting celebrity suicides: users’ reaction to prominent suicide deaths on Twitter and subsequent increases in actual suicides. 

Articles

Durkheim believed it was useless to prohibit newspapers from publishing stories of the ultimate act of self-harm. But he was wrong.

Celebrity Suicide

Psychiatrists should advocate for their patients to ensure prompt and state-of-the-art care when they are ill.

Risks for which of the following are increased in women because they take antipsychotics?

Maintenance of physical health is very important in schizophrenia because mortality rates are 

Psychiatrists need to ensure that their patients stay in regular contact with a general practitioner and that men and women are screened for disorders relevant to their sex (ie, cervical smears, breast examinations and mammograms, prostate and colon cancer screening), that they are adequately immunized against infectious agents, and regularly checked for the sequelae of chronic intake of antipsychotic medication (ie, obesity, diabetes, hypertension, osteoporosis, cardiovascular disease).

For more on the risks of antipsychotic treatment in women, see 

Clinical Implications of Gender Differences in Schizophrenia

*B is equivocal, might or might not be true.

Poll

In some cases, treatment with antipsychotics can pose risks in women. Take the quiz and learn more.

Mini Quiz: Antipsychotics in Women

I did most of my psychiatric residency in the early 1960s on an all-women’s ward in New York City dedicated to research in schizophrenia. There were 30 beds and each patient stayed in the hospital for a long time, so I got to know the women well. I would describe them collectively as well-groomed, chatty, friendly, moody, and smart. It was consequently a shock when in 1975 in Toronto, Canada, I was put in charge of a schizophrenia outpatient clinic and discovered that the patients were mostly young men who were, by contrast to the women I had known, emotionally distant, apathetic, disheveled, and angry. Had my perception of people changed over the years, or, I wondered, does schizophrenia affect men and women differently?

I wondered why there were so many more men than women in my new clinic. Part of the answer was because the incidence of schizophrenia is higher in men than in women, especially in young adulthood. Nevertheless, the prevalence appears to be similar, perhaps because more men than women with schizophrenia succumb to suicide and accidental death. The men in my clinic were mostly young adults, whereas the women in the clinic tended toward middle age. This forcibly brought home the point that men develop schizophrenia earlier in life than women by several years.

The relative dearth of women in the clinic was also attributable to the fact that the women were too busy to attend. They were working, socializing, having babies, and living full lives to which the men could only aspire to.

The relatively few women who were eager to attend clinic activities felt outnumbered. As a result, I started a women-only therapy group. The members of this group were very friendly with each other; gossiping about clothes and diets. They went out for coffee after group together. In other words, they showed little flattening of affect, few negative symptoms, few evident cognitive defects, although they harbored many delusions and reported a variety of hallucinations.

Because the women’s group was going well, I invited the men to form their own group. By the end of a year of weekly group meetings, none of the eight men who had agreed to join knew the name of any other group member. They didn’t interact. All remarks in the group (mainly about sports, a little about cars) were addressed to me. There was evident poverty of speech, apathy, and many relatively blank facial expressions. There was also a manifest lack of grooming and basic hygiene in this group.

In 1985, I left the clinic to work at another hospital. I had learned that women with schizophrenia respond well to treatment. I had also noticed that they rarely had to be rehospitalized. Many of the women worked outside the home. Many stayed in committed intimate relationships and forged strong therapeutic alliances with their care providers. At the same time, I had unfortunately witnessed many male suicides; many men who abused alcohol and many who required extremely high dosages of antipsychotics. Most of the men did not work and continued to be dependent on aging parents.

Eight years later, I returned to the clinic, where I was in for an unexpected shock. The forlorn, listless men I had said goodbye to welcomed me back warmly and told me jokes! In some cases, their parents had died, so they now lived in group homes and were managing surprisingly well. They seemed content, even purposeful. They spent socially productive time in the hospital cafeteria, chatting and laughing with their buddies. On the other hand, the once high-achieving women had lost their jobs, were cycling in and out of the hospital, and were no longer responsive to their medications.

I am generalizing, of course, and there was much overlap between the men and the women, but the pattern was very clear. The men were doing better while the women were doing worse.

Explanations for sex differences in schizophrenia

One explanation for these observations about sex differences in this disease rests on the many and varied neuroprotective actions of estrogens.

 The hypothesis is that female hormones delay the onset of schizophrenia, allowing women to finish their schooling and to acquire substantial interpersonal skills before illness puts a stop to further socialization. Estrogens help the antidopaminergic action of antipsychotics so that dosages can stay relatively low in women, preventing adverse effects and, thus, permitting steady employment and the development of personal relationships. At menopause, however, these advantages are lost.

Further evidence confirmatory of the estrogen hypothesis are premenstrual (low estrogen) exacerbation of psychotic symptoms in women, postpartum exacerbations, and the significant improvement brought about when estrogens or selective estrogen receptor modulators (SERMS) are added to the medication regimen.

The estrogen hypothesis is not wholly satisfactory, however. Ovaries are not functional in fetal life, so much of the estrogen found in human fetal brain comes from the testosterone derived from testes in boys. Thus, the brains of girl fetuses are exposed to relatively less estrogen. Because fetal life is when schizophrenia allegedly starts, why are male brains not more (rather than less) protected than female brains at the outset?

Perhaps the early female advantage lies not only in hormones but also in the double X chromosome, in sexually dimorphic microglia, in epigenetic effects on schizophrenia genes, on structural differences in male and female brains, and in gene – environment interactions.

 Primary prevention rests in the hands of women and their clinicians. With knowledge and guidance, affected women can minimize the risk of schizophrenia in offspring by choosing male partners without a history of psychosis, who are younger than age 40 (but not too young either), and who live in their country of origin. They can time conception to avoid birth in late winter or early spring. Most importantly, they can be very assiduous in attending prenatal appointments, taking prescribed immunizations and vitamin/mineral supplements, paying attention to diet, avoiding alcohol and drugs of abuse, keeping antipsychotic doses low, managing their stress levels, avoiding infections whenever possible, and not tolerating any form of domestic abuse.

Clinicians need to ensure that pregnant women with schizophrenia are monitored frequently and have adequate incomes, safe housing, and sufficient social support. Children of both male and female parents with schizophrenia require careful monitoring and support throughout childhood and adolescence to prevent the development of psychosis or to catch and sidetrack psychotic symptoms, should they develop.

Finally, contraceptive guidance and genetic counseling are also important aspects of prevention.

 Diagnostic strategies differ in men and women. In men, it can be difficult to distinguish the beginning of schizophrenia from substance-induced psychosis. In women, because affect is preserved, schizophrenia is not easily distinguishable from affective psychosis. Also, in women, differential diagnoses such as anorexia-induced psychosis, steroid psychosis, thyroid disease-associated psychosis, and psychosis secondary to autoimmune disorder and its treatment need to be actively considered.

 Maintenance of physical health is very important in schizophrenia because mortality rates are high.

 Psychiatrists need to ensure that their patients stay in regular contact with a general practitioner and that men and women are screened for disorders relevant to their sex (ie, cervical smears, breast examinations and mammograms, prostate and colon cancer screening), that they are adequately immunized against infectious agents, and regularly checked for the sequelae of chronic intake of antipsychotic medication (ie, obesity, diabetes, hypertension, osteoporosis, cardiovascular disease). Psychiatrists should advocate for their patients to ensure prompt and state-of-the-art care when they are ill.

 Antipsychotics have sexual adverse effects that need to be asked about and addressed. Intimate relationships and contraceptive methods require attention. Women with schizophrenia usually have questions about changes in their menstrual periods and many experience premenstrual exacerbations of symptoms.

 Because of antipsychotic adverse effects, some women may believe that they are pregnant when they are not, whereas women who want to be mothers may find it difficult to conceive. Some pregnant women may deny their pregnancy; others may seek abortions. Pregnant women should be seen often, their medication dosages adjusted carefully, and their domestic situation addressed with referrals not only to obstetrics but also to affordable housing, income support, and substance abuse programs as necessary. Family meetings usually become necessary at this time to garner as much support as possible for the mother-to-be.

The postpartum period is a time of risk for women with schizophrenia. Home visits are important, with monitoring required for both mother and baby. Parenting support is critical and help from a child welfare agency may be necessary. The question of breast-feeding needs to be addressed, with most guidelines recommending no breast feeding because of unresolved safety concerns about psychotropic medications. If a medication is taken immediately after breastfeeding and just before the infant’s longest sleep period, however, and the infant’s serum drug level is monitored, there are definite advantages to breastfeeding for both infant and mother. Consultation with a lactation expert is helpful. It is critical that mothers not stop their medications during this vulnerable time.

The menopausal transition is an important one for all women. Most women experience symptoms of menopause that need to be anticipated and effectively treated. The personal meaning of menopause needs to be explored with women who have schizophrenia. Unfortunately, psychotic symptoms may worsen during this time and antipsychotic dosages may have to be adjusted.

 Safety issues are of utmost importance in the treatment of schizophrenia. Patients with severe mental illness need to be protected from their own sometimes very unhealthy lifestyles and from suicidal urges. A suicide in a treatment setting can lead to chain events in a vulnerable population. Treatment with antipsychotics can also pose risks in situations in which being fully alert matters (ie, driving, operating heavy machinery, looking after young children).

Women, more than men, must be protected from exploitation and violence inflicted by others, whether intimate others, co-patients on hospital wards, or strangers. Both men and women need protection from stigmatizing attitudes, in particular on the part of childcare workers (women), police, and the justice system (men) as well as medical professionals (men and women).

There are also understandable safety concerns about individuals with schizophrenia acting on dangerous delusional beliefs and command hallucinations, especially when inebriated. Family members are most at risk.

 Standard antipsychotic treatment frequently requires modification in women. Women respond to lower dosages and, because they are usually on many more different medications than men and have a more active immune system, they experience more adverse effects.

 Dosages may need to be adjusted over the menstrual month, during pregnancy, the postpartum, and the menopausal transition. In older age, dosages should be kept low in both women and men.

Several other clinical interventions useful to individuals with schizophrenia, such as exercise programs, substance abuse programs, employment programs, and weight-loss programs also benefit from sex-specific modifications.

In an ideal world, each patient is treated individually because no two persons are identical, but that may be impossible for now. Differentiating between men and women is a first step.

• Escott-Price V, Smith DJ, Kendall K, et al. Polygenic risk for schizophrenia and season of birth within the UK. 

• Hung YN, Yang SY, Kuo CJ, Lin SK. Diagnostic consistency and interchangeability of schizophrenic disorders and bipolar disorders: a 7-year follow-up study. 

• Lu Y, Pouget JG, Andreassen OA, et al. Genetic risk scores and family history as predictors of schizophrenia in Nordic registers. 

• Riecher-RÃ¶ssler A, Butler S, Kulkarni J. Sex and gender differences in schizophrenic psychoses: a critical review. 

• Terres NM. Resources for psychiatric clinicians working with breastfeeding mothers. 

Dr Seeman is Professor Emerita, Department of Psychiatry, Institute of Medical Science, University of Toronto, Ontario, Canada. Dr Seeman reports no conflicts of interest concerning the subject matter of this article.

 Arevalo MA, Azcoitia I, Garcia-Segura LM. The neuroprotective actions of oestradiol and oestrogen receptors. 

 Seeman MV. Menstrual exacerbation of schizophrenia symptoms. 

 Vigod SN, Rochon TG, Fung K, et al. Factors associated with postpartum psychiatric admission in a population-based cohort of women with schizophrenia. 

 Kulkarni J, Gavrilidis E, Wang W, et al. Estradiol for treatment-resistant schizophrenia: a large-scale randomized-controlled trial in women of child-bearing age. 

 Zhu XM, Zheng W, Li XH, et al. Adjunctive raloxifene for postmenopausal women with schizophrenia: a meta-analysis of randomized, double-blind, placebo-controlled trials. 

 Reininghaus U, Dutta R, Dazzan P, et al. Mortality in schizophrenia and other psychoses: a 10-year follow-up of the AESOP first-episode cohort. 

 Zhu Y, Li C, Huhn M, et al. How well do patients with a first episode of schizophrenia respond to antipsychotics: a systematic review and meta-analysis. 

 Seeman MV. Schizophrenia: women bear a disproportionate toll of antipsychotic side effects. 

A deep dive into how schizophrenia affects men versus women.

Consider these travel tips to help alleviate your patients’ fears that, if left unchecked, can trigger full-blown psychosis.

Travel Destination Syndromes and Schizophrenia

Major life events, such as travel to unfamiliar places, can lead to an increase in general arousal and the exacerbation of psychotic symptoms in schizophrenia. Although most patients with schizophrenia cannot afford long-distance travel, some lead a quasi-permanent itinerant lifestyle, and many are able to take holiday trips with family.

Thanks to a generous donation a decade ago (called Cathy’s Fund after a former clinic member who had been a successful single parent despite serious long-standing psychotic illness), the Women’s Clinic for Psychosis in Toronto was able to sponsor travel abroad for some of its members.

The mission of the fund was to keep families together by helping women with schizophrenia reconnect with family members who lived far away, helping mothers reunite with estranged children, helping women visit and bond with distant friends and relatives, and allowing women to enjoy otherwise unaffordable holiday trips with relatives or close friends.

Psychotic decompensation can occur during travel in persons with or without a psychiatric history.

 Air travel, in particular, is implicated. According to the World Health Organization, mental illness constitutes 1 of the 3 main health crises encountered in air travel; the other 2 are physical injury and cardiac events.

Phobias such as fear of flying, enclosed spaces, crowds, or strangers can be triggered by travel.

About 20% of travel incidents are described as acute psychotic episodes-individuals with a history of a psychiatric disorder are the most susceptible.

 For a patient with long-standing mental illness, travel may mean distance for the first time from trusted care providers and health resources.

The longer the travel, the higher the risk appears to be. Older age and cognitive compromise increase the risk. Use of alcohol and drugs constitutes a well-recognized risk factor for a psychotic reaction during travel. In addition, factors such as physical discomfort, forced immobility, motion sickness, and dehydration may all facilitate the emergence of psychiatric symptoms. Psychotic symptoms may also result from the adverse effects of drugs required for travel, such as mefloquine for malarial prophylaxis.

Special risks for patients with schizophrenia

Patients with preexisting schizophrenia face added risks, especially if their motive for travel is suspect (eg, a response to hallucinatory commands, a flight from supposed enemies). For a person with schizophrenia, even when the motive is realistic, uncertainty and bewilderment are easily induced by the unfamiliarity of an airport, a crowd, a foreign language, or the general excitement and arousal associated with travel. Arousal and fear can progress to full-blown delusion in predisposed persons.

Travel can also mean separation from a special person, from one’s home, country, and culture. For a patient with long-standing mental illness, travel may mean distance for the first time from trusted care providers and health resources. Separation from attachment figures is known to be intensely anxiety-provoking for patients with preexisting psychosis.

Even inanimate objects and familiar routines may be difficult to leave behind. The loss of a familiar environment can be as distressing as the loss of a person, leading to homesickness, nostalgia, and a profound sense of diminished belonging. The loss of one’s habitual social or occupational role during travel can also lead to a feeling of rootlessness and lost identity, even though the lost social role may be the stigmatized role of a psychiatric service user.

Alcohol and drugs, physical discomfort, motion sickness, sleep loss, dehydration, and prophylactic medications are all recognized for their ability to trigger psychosis even in individuals with no prior psychiatric history; their influence is that much more potent in people contending with psychotic illness. On arrival at one’s destination, jet lag and the demands of acculturation become the major stressors.

Trying to fit in to a new environment where norms, values, and social customs are unfamiliar can result in a form of acculturative stress that might heighten the risk for psychosis. Circadian rhythm disruption-such as changes in ambient light, desynchronization of mealtimes and medication routines, and especially sleep deprivation-can be destabilizing for anyone, but especially so for people with schizophrenia, who may be genetically vulnerable to disruptions of circadian rhythms.

The Women’s Clinic for Psychosis was able to prevent travel complications in clinic patients by careful pre-travel screening and coaching.

 One clinic patient who was awarded a Cathy’s Fund scholarship had a police record because she had been brought to the hospital by police for psychiatric assessment at one point in the past. Staff needed to erase the police record or her access to the country of her destination would have been blocked.

Our patients were all advised to travel with prescriptions and doctors’ letters that explained their need for medications. We made sure they had medical insurance to cover the cost of hospital treatment in a foreign country, as well as potential emergency repatriation, should these prove necessary. We liaised with care providers at the destination site to facilitate easy access to psychiatric care.

For individuals who receive depot antipsychotic injections, we timed the injections to fit the patients’ travel plans and arranged for blood tests at the destination site to monitor patients on clozapine or lithium. We made sure to dispense sufficient medication to cover the time away. We suggested literature about the destination country and about the problems of and solutions to jet lag or seasickness. We rehearsed responses to potential travel stressors and practiced relaxation and breathing exercises with our patients before their trips. We cautioned against alcohol and caffeine overuse.

What should clinicians do when patients with preexisting psychosis express an interest in lengthy travel?

What should you do when patients with preexisting psychosis express an interest in lengthy travel? Unless patients are acutely psychotic and potentially dangerous to themselves or others and they have the funds to pay for at least a one-way ticket, they cannot be prevented from traveling-no matter how ill-advised you may think the trip is. Measures to prevent serious consequences, however, need to be put in place.

Checking into finances is a good starting point. It is vital that the patient have the funds to cover not only the roundtrip costs of travel but also the stay away from home plus unexpected expenses. Many patients with psychosis live on monthly disability payments that are sent to their home address. Before leaving on a lengthy trip, they must make arrangements for their check to be forwarded.

If the patient intends to travel with a family member or friend, it is useful that all meet together to discuss travel plans. Should the patient be traveling alone, extra safeguards are needed, especially if family members are not fully aware of the plans.

The range of ways that travel can affect a person’s mental heath needs to be fully addressed by discussing its effects not only on finances but also on sleep, stress levels, personal and professional relationships, medication schedules, feelings of belonging, and identity. The patient needs to be helped to prepare a travel medical portfolio, which might include contact information for people who are to be notified in case of emergency; care providers at home; and physicians, hospitals, and pharmacies that can be accessed as needed. The address and telephone number of the home consulate are useful as well.

Physicians need to prepare patients for the possibility of loneliness, homesickness, and culture shock.

The patient’s physician should also prepare a letter to be included in the portfolio that specifies all pre-travel inoculations, a list of allergies, all current medications with their doses and schedules, and all required blood tests. The names of medications differ in different countries; the name used in the country of destination should be used. The portfolio also needs to contain medical insurance information, recent exposure to infection if applicable, and the possibility of pregnancy, should that be a concern. The physician may want to include a letter stating that the patient is fit to travel.

Depending on the situation, the patient may also be advised to carry a medical kit that contains a sufficient amount of daily medications in the original containers, a thermometer, sunscreen, insect repellent, antiseptic wipes, condoms, antacids, and laxatives. A medical bracelet may be useful.

The effects of time change on sleep, meal times, and medication schedules all need to be discussed with the patient. Temperature changes and dehydration need to be warned against as they may lead to drug toxicity. Because some persons with psychotic illness habitually use illicit substances, physicians need to warn them about the laws of the countries they are visiting, since some have very severe penalties for drug possession.

Physicians need to prepare patients for the possibility of loneliness, homesickness, and culture shock when traveling. Reading up on the new country’s language, traditions, laws, and ways of life helps. Preparation will not prevent the occurrence of these very natural reactions to travel, but patients will be able to recognize them for what they are and be better able to adapt.

Part of the preparation may be ensuring that the patient has the means and the know-how to phone home from wherever he or she is and stay in touch with attachment figures. Practical issues, such as making sure passports are valid and visas and vaccinations are obtained when necessary, advice on what to pack and on compatible electronic equipment, and information about the new country’s currency and accessible locations for money exchange, are also within the physician’s purview.

Because of terrorism alerts, it is important to advise patients on what to wear or not to wear, and what to refrain from saying at airports or on board airplanes. Patients who do not pay attention to hygiene or grooming may be singled out as potential security threats. The process of security checks on airplanes and long lines and delays at airports need to be carefully explained to patients who are not used to them because they invariably cause stress and can arouse paranoia.

Patients also need to be told what they cannot bring onto airplanes and advised on the process of boarding passes and check-ins. The more information they have on what they may encounter, the less strange and destabilizing travel will be.

Dr. Seeman is Professor Emerita, Department of Psychiatry, Institute of Medical Science, Toronto, Canada. She reports no conflicts of interest concerning the subject matter of this article.

 Flinn DE. Transient psychotic reactions during travel. 

 World Health Organization (WHO) International Travel and Health. Psychological health. General considerations, 2014. 

http://www.who.int/ith/other_health_risks/psychological_health/en/

 McIntosh IB, Swanson V, Power KG, et al. Anxiety and health problems related to air travel. 

 Felkai P, Kurimay T. The most vulnerable travelers: patients with mental disorders. 

 Vermersch C, Geoffroy PA, Fovet T, et al. Travel and psychotic disorders: clinical aspects and practical recommendations [in French]. 

 Burnham DL. Separation anxiety: a factor in the object relations of schizophrenic patients. 

 Johansson AS, Owe-Larsson B, Hetta J, Lundkvist GB. Altered circadian clock gene expression in patients with schizophrenia. 

 Wulff K, Dijk DJ, Middleton B, et al. Sleep and circadian rhythm disruption in schizophrenia. 

 Roupa Z, Zikos D, Vasilopoulos A, Diomidous M. Common health risks, required precautions of travelers and their customs towards the use of travel medicine services. 

 Tafuri S, Guerra R, Gallone MS, et al. Effectiveness of pre-travel consultation in the prevention of travel-related diseases: a retrospective cohort study. 

What should you do when patients with preexisting psychosis express an interest in lengthy travel?

Travel With Serious Mental Illness

While treating women with psychotic illness, I noticed that many of my patients, in addition to their psychosis, had eating disorders (anorexia and binge eating) and I wondered whether my prescription of antipsychotic drugs was responsible. I knew that these drugs led to increased appetite and weight gain, which could provoke a counter reaction, ie, a drive to be thin.

The neuroscientist and author Erin Hawkes-who was treated for schizophrenia with olanzapine-writes about how her bulimia subsequently intensified:

I was put on olanzapine. Terrible mistake: I was, within two months, 137 pounds of (in my opinion) fat. My purging went wild. . . . Olanzapine gave me a ravenous appetite. . . . Thus, purging became all-important.

She is not the only person to have made the connection between antipsychotic medication and increased eating disorder symptoms. Olanzapine and clozapine in particular have been implicated in medication- induced bingeing secondary to antipsychotic drug intake.

On the other hand, a 2013 meta-analysis of 8 randomized trials involving olanzapine, risperidone, or amisulpride in eating disorders concluded that, when compared with placebo, these agents did not cause significant body dissatisfaction, nor did they curtail eating.

 Note, however, that the participants in these trials had an eating disorder and were not being treated primarily for psychosis. The doses in the 8 trials were relatively low (eg, 4.2 to 10 mg of olanzapine)-substantially lower than they would have been had the target been psychotic symptoms. Moreover, only 2 of the 8 trials controlled for medication adherence-a particularly significant issue for patients with an eating disorder, who would be strongly tempted to stop treatment if it made them gain weight.

Antipsychotics are sometimes used off label for eating disorders. The reason is because clinicians find it difficult to distinguish the firm belief that one is fat (when that is clearly not the case) from a delusion. The body image disturbance at the heart of anorexia nervosa is a false perception akin to the perceptual disorders found in schizophrenia. Additional psychotic features associated with eating disorders-usually transient-have been attributed to the effects of starvation and electrolyte imbalance.

 report the case of a 37-year-old woman with anorexia who, for 4 years, had acute paranoid-hallucinatory psychosis at the tail end of fasting episodes (when she was most starved). Psychotic symptoms were not in evidence either before or after the fasting periods; this suggests a cause-and-effect relationship between starvation and psychotic decompensation. The authors hypothesize that starvation led to acute hyperactivity of the dopaminergic system, giving rise to a subsequent transient psychosis.

However, despite several potential explanations for the co-occurrence of the conditions, it is possible that eating disorders and psychotic disorders are different phenotypic expressions of a similar genetic predisposition (

Categorical overlap between eating disorders and psychosis

It is customary for psychiatry to categorize different types of psychiatric illnesses as qualitatively distinct from one another. An early study that used this categorical approach looked at the likelihood of a change in diagnosis over time in persons initially admitted to the hospital with an eating disorder.

 The investigators found that of more than 1000 patients admitted to Danish psychiatric institutions from 1968 to 1986, one-fifth were subsequently readmitted; of those, 6% received a diagnosis of psychosis at the second hospitalization. A later review concluded that a concurrent diagnosis of schizophrenia and anorexia nervosa was rare.

 found no cases of comorbid schizophrenia in more than 100 female patients with DSM-IV eating disorders.

The co-occurrence of the 2 types of disorder may be more prevalent in men. In a study of male veterans with an eating disorder, 28% had a diagnosis of schizophrenia or other psychosis.

 The incidence of psychosis was more than 3 times that of male veterans who did not have an eating disorder, and also more than 3 times that of female veterans with an eating disorder. One potential explanation for these results is differential gender expectation on the part of the diagnostic team. Clinicians tend to be less familiar with eating disorders in males. When they encounter cognitive distortions and food phobias in males, they think of psychotic illness first, while in females they think primarily of eating disorders.

Overall, there seems to be little evidence for the commonly advanced speculation that psychotic illness such as schizophrenia can occur in up to 10% of patients with eating disorders. The incidence of psychotic illness in patients with an eating disorder appears to be approximately that of the population at large, although individual psychotic symptoms-such as occasional paranoid ideation (feeling that others are to blame for troubling events) and alienation (never feeling close to another person)-may be more frequent.

In a study of eating disorders in a population with previously diagnosed psychosis, GÃ¶testam and colleagues

 found that among 19,000 inpatient Norwegian males with schizophrenia, almost 2% had a diagnosed eating disorder. This is considered a high figure for anorexia nervosa in men but may or may not be a high figure for all eating disorders. Study results differ depending on the sociocultural background of the sample and on whether it consists of service users or community members (there is less of a male to female rate difference in the latter).

Whatever the case, there seems to be a greater overlap between eating disorders and psychotic disorders in males than in females. This overlap seems more evident in care settings for patients with psychosis than in those for patients with eating disorders, which throws suspicion on the role of antipsychotic medication.

Dimensional overlap between eating disorders and psychosis

In contrast to a categorical model of psychiatric disease, a dimensional model acknowledges that psychiatric disorders are inherently heterogeneous and overlapping. This method of classifying psychiatric disorders is becoming more popular because syndromal overlap is more the rule than the exception in the clinic.

Eating disorders and psychotic disorders are both characterized by distorted thoughts, overvalued ideas, depersonalization and derealization phenomena, and delusions. Moreover, auditory hallucinations, considered to be the hallmark of psychosis, can also occur in anorexia nervosa. A basic mistrust of others-a trait that often leads to social isolation, poor therapeutic alliance, and poor treatment adherence-is common to both eating disorders and psychotic disorders. The ability to put oneself in the mindset of the other person (theory of mind) is deficient in both disorders, as are difficulties in shifting sets or being able to pass quickly from one mode of thinking to another.

Genetic overlap between  eating disorders and  psychosis

A genetic basis exists for most disorders and this, too, can overlap among diagnostic categories. Data from the National Survey of American Life show an association between having a first-degree relative with schizophrenia and the lifetime risk of bulimia, among other disorders.

 found that dopamine receptor D2 polymorphisms were significantly associated with anorexia nervosa. Data from genome-wide association studies in schizophrenia show the same associations.

 Both disorders have been linked to altered dopamine activity: expressed mainly by hyperactivity in anorexia nervosa and by delusions and hallucinations in psychotic illness.

Comorbidity between eating disorders and psychotic illness is seen more commonly in care services for psychotic disorders than in treatment programs for eating disorders, despite the fact that the self-starvation associated with some types of eating disorder can often result in psychotic symptoms. It is possible, therefore, that the treatment of psychosis (ie, with antipsychotic medication) may, in part, be responsible. The 

 presents recommendations intended to minimize the risk of triggering eating disorders when treating patients who present with a psychotic illness.

Antipsychotic doses should be kept as low as possible. Remember that positive symptoms of psychosis, which are targeted by antipsychotic medications, need not always be totally eliminated for patients to enjoy a good quality of life. The treatment target should be function, not symptoms. Attempts to eliminate all psychotic symptoms can induce anorexia nervosa, which is in many ways more dangerous than the original problem, with higher mortality than any other psychiatric disorder.

Dr Seeman is Professor Emerita in the department of psychiatry at the University of Toronto, King’s College Circle, Toronto, Ontario, Canada. She reports no conflicts of interest concerning the subject matter of this article.

 Hawkes E. How schizophrenia gave me an eating disorder; 2014. 

http://www.huffingtonpost.ca/erin-hawkes/schizophrenia-eating-disorder_b_3022802.html

 Gebhardt S, Haberhausen M, Krieg JC, et al. Clozapine/olanzapine-induced recurrence or deterioration of binge eating-related eating disorders. 

 Kluge M, Schuld A, Himmerich H, et al. Clozapine and olanzapine are associated with food craving and binge eating: results from a randomized double-blind study. 

 Lebow J, Sim LA, Erwin PJ, Murad MH. The effect of atypical antipsychotic medications in individuals with anorexia nervosa: a systematic review and meta-analysis. 

 Mavrogiorgou P, Juckel G, Bauer M. Recurrence of paranoid hallucinatory psychoses after beginning a fasting period in a patient with anorexia nervosa. 

 MÃ¸ller-Madsen SM, Nystrup J. Anorexia nervosa in Denmark-changes in diagnosis. 

 Steinhausen H-C. The outcome of anorexia nervosa in the 20th century. 

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 Striegel-Moore RH, Garvin V, Dohm FA, Rosenheck RA. Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans. 

 GÃ¶testam KG, Eriksen L, Hagen H. An epidemiological study of eating disorders in Norwegian psychiatric institutions. 

 Faravelli C, Ravaldi C, Truglia E, et al. Clinical epidemiology of eating disorders: results from the Sesto Fiorentino study. 

 Hudson JL, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. 

 DeVylder JE, Lukens EP. Family history of schizophrenia as a risk factor for axis I psychiatric conditions. 

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What is the clinical response to the occasional presence of psychotic symptoms among patients with eating disorders?

Eating Disorders and Psychosis

Most psychiatric illnesses, indeed most illnesses, are affected by the patient’s gender. Being male, female, or transgender exerts effects not only on anatomy and reproductive behaviors but also on immune mechanisms, pain perception, diet, occupation, social behaviors, and risk exposures.

A good example of sexual dimorphism is obesity. Obesity is patterned differently in men than in women, presumably because it was initially advantageous for men, as hunters, to be able to rely on a rapid source of energy when pursuing their quarry. Visceral fat (the male pattern) is rapidly mobilized and metabolized in the liver. For women, it was more efficient to store fat in hips and buttocks for access, when needed, during pregnancy and lactation. What was once important to survival has become an albatross to both sexes-for men, it contributes to cardiovascular risk; for women, it contributes to the difficulty of dieting.

Another interesting evolutionary lesson comes from the observation known as Bateman’s principle. In many species, including humans, females produce a limited number of eggs (once a month during the reproductive years) and males have to compete with other males to successfully fertilize those eggs. It has been suggested that this sex difference has led to increased immune response in females (to protect the egg) and decreased immune response in males (who devote energy to the production of secondary sex characteristics-muscle power, aggression, competitiveness-at the expense of immune function.

The article by Paul M. Elizondo III, DO, Willy Wilkinson, MPH, and Christopher Daley, MD, on 

, throws into question the wisdom of discussing separate sexes and sex-specific evolutionary strategies. Indeed, being a man in the anatomical body and hormonal milieu and chromosomal structure of a woman, and vice versa, tends to completely shift one’s frame of reference and make one question one’s most fundamental beliefs in scientific principles and societal norms. This is a good thing, because all theory is limiting. It is to be hoped that new insights will come from the blurring of boundaries and the shifting of frames. In the meantime, much can still be learned from looking at traditional gender differences in psychiatric illness.

In Part 2 in the October issue, the article by E. Mark Mahone, PhD, on 

neuropsychiatric differences between boys and girls with ADHD

 will discuss the clinical sex differences in this disorder. Boys show impulsivity, aggression, and high energy. These sex traits, which served to establish social dominance among males early in the evolution of our species and aided the cause of sexual selection, are now a handicap and require therapeutic intervention. It is interesting to see how sex ratios for the ADHD cluster of symptoms are changing as variation and selection continue to exert their influence over succeeding generations.

Being male, female, or transgender exerts effects not only on anatomy and reproductive behaviors but also on immune mechanisms, pain perception, diet, occupation, social behaviors, and risk exposures.

Author | Mary V. Seeman, MDCM, DSc

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