cardiovascular benefits of multifactorial intervention in diabetes (Figure 5.6).

One-hundred and sixty type 2 patients with microalbuminuria were randomised to receive conventional treatment in accordance to national Danish guidelines or to an intensive treatment arm. This involved stepwise implementation of behaviour modification and pharmacological treatment that targeted hyperglycaemia, hypertension, dyslipidaemia, microalbuminuria and secondary prevention of cardiovascular disease with aspirin. At the end of the 7.8 year study period there were significant reductions in HbA1c%, systolic and diastolic blood pressure, serum cholesterol and triglycerides, and urine albumin excretion in the treatment group. Patients receiving intensive treatment had a significantly lower risk of cardiovascular disease by about 50%. At the end of the treatment period all the patients were offered intensive treatment and were further followed up for an additional 5.5 years. Despite convergence of most of the risk factors between the groups there was an additional 20% benefit in CVD-related deaths in the original intensive treatment group. This suggests that treatment of multiple risk factors should be started early. The Alphabet Strategy is an ABC of reducing diabetes complications published in 2002 and is summarised in Boxes 5.4 and 5.5. for

many days even after a short

binge. The chemical disruption lasts longer than the binge that caused them. Why are moods and memories affected by alcohol? The parts of the brain involved in memory and mood (the hippocampal formation and the frontal cortex) are about the size of your fist, and the parts that control movement and coordination (the motor cortex) are about the size of your index finger. The memory and mood parts are not only larger but also much more complex, and they need to work together in a much more complicated way. If the motor cortex cant work properly for almost a day after a small amount of alcohol, theres not much chance that the emotional areas are going to work well. Drug use is another suicide risk factor. The suicides of many famous people are often accompanied by stories of drug and alcohol abuse or prescription drug misuse. There is often connection between a glamorous lifestyle and substance use, but if examined carefully, these lives are also full of heartbreak and personal tragedy. Drug addictions are difficult to heal, even with help. The notes that suicidal celebrities leave behind, talking about their loneliness, isolation, and lost ability to enjoy life, always baffle their fans. It just doesnt make sense to us. How could they be missing out when they have so much?
Suicide and Treatm ent

Research studies and the experiences of patients who have survived

a suicide attempt show improvements with treatment. Abe can be expected to benefit from talk therapy, in which he would meet with a trained therapist to understand why his relationship with his ex-girlfriend led him to experience such self-destructive feelings, as well as to recognize and minimize the factors that increase his risk. A mild medication might be considered under the supervision of a specialist.on.
More recently, however, the focus has shifted, and CS is now considered by many clinicians to be a disorder of the central nervous system. It is estimated that between 21% and 40% of CS cases stem from physiological disorders including dementia, head trauma, epilepsy, and cerebrovascular disease. Neuroimaging data suggest a link between CS and abnormalities of the right hemisphere of the brain. In fact, the literature supports the conclusion that CS can be a symptom of virtually any central nervous system disorder. CS has been observed in association with various systemic illnesses including vitamin B-12 deficiency, chicken encephalitis, and diseases of the thyroid, parathyroid, and liver. CS has also been found associated with the use of various drugs, including morphine and diazepam (Valium). CS has been observed following transient physiological disturbances such as pneumocystis pneumonia in an HIV-positive patient, migraine headache, overdose of a bronchial dilator containing adrenaline and adropinemethonitrate, and interictal psychosis of epilepsy.

Diagnosis
Most clinicians regard CS as a symptom associated with numerous underlying causes rather than a syndrome in the classical sense of the term. Diagnosis should be based on psychological and personality testing as well as neuroradiological testing to determine the underlying cause rather than relying purely on behavioral descriptions. CS can occur at any time during a psychosis and is not currently considered to be an essential element of any psychological disorder. It is impossible to predict the occurrence of CS based on the course of the overall psychopathology.

Treatments
CS is typically treated with a combination of antipsychotic medication and supportive psychological therapy in which stronger areas of mental and behavioral processes are used to overcome weaker areas of functioning. Patients presenting with CS stemming from psychosis have been found to improve on pimozide even when nonresponsive to haloperidol. CS stemming from physiological causes is best treated by treating the underlying disorder.

Prognosis
The symptoms of CS have been found in most, but

not all, cases to clear shortly after the remission of the psychosis. In the case of depression, however, the symptoms of CS persist longer than those of other syndromes of doubles (syndrome of Fregoli, syndrome of intermetamorphosis, syndrome of subjective doubles). The symptoms of CS invariably recur when there is a relapse of the basic psychotic condition with which they were associated.

Prevention
CS is an uncommon occurrence associated with a range of disorders both psychological and physiological in nature. Prevention of CS is actually a question of preventing the underlying disorder resulting in CS. There are no investigations under way concerning the prevention of CS. Resources
BOOKS

Fewtrell, David, and Kieron OConnor. Capgras syndrome and delusions of misidentification. in Clinical Phenomenology and Cognitive Psychology. New York: Routledge, 1995.
PERIODICALS

Doran, John M. The Capgras Syndrome: Neurological/ Neuropsychological Perspectives. Neurolpsychology 4, no. 1(January 1990): 29-42.

Ruth A. Wienclaw, Ph.D.

Carbamazepine
Definition
Carbamazepine is an anticonvulsant that is structurally related to tricyclic antidepressants such as amitriptyline and imipramine. In the United States,

KEY TERMS
Central nervous systemThe brain and spinal cord. DelusionA false idea held despite all evidence to the contrary. DementiaDeterioration of intellect, reasoning ability, memory, and will resulting from organic brain disease. InterictalOccurring between seizures. PsychosisA mental illness that markedly interferes with the patients ability to deal with the demands of everyday life. Psychosis is characterized by loss of contact with reality, often accompanied by delusions and hallucinations.
204 GALE ENCYCLOPEDIA OF MENTAL HEALTH, SECOND EDITION

Carbamazepinephenytoin (Dilantin).

Barbiturates should not be combined with alcohol because the combination produces additive depressant effects in the central nervous system. Barbiturates may lower the amount of absorption of the vitamins D and K.

Resources BOOKS Consumer Reports Staff. Consumer Reports Complete Drug Reference. 2002 ed. Denver: Micromedex Thomson Healthcare, 2001. Ellsworth, Allan J., and others. Mosbys Medical DrugAbuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems of abuse survivors.Autoantibodies in type 1 diabetes Islet cell autoantibodies are present at diagnosis but will gradually decline and disappear in ensuing years. This means that if there is diagnostic uncertainty, islet cell antibodies can be checked early during presentation. Specific tests have been devised recently

including anti-GAD (glutamate decarboxylase) antibodies and also anti-IAP (inhibitor of apoptosis protein) antibodies. The presence of both together is associated with a significantly higher risk of developing type 1 diabetes. The use of these tests in clinical practice is restricted to situations where there is doubt about the diagnosis of the type of diabetes and to distinguish from type 2 diabetes. Clinically, the implication is that if the tests are negative the patient might then not require insulin. Attempts to prevent type 1 diabetes in these susceptible individuals has thus far not proved successful. Type 2 diabetes Type 2 diabetes is a complex heterogeneous condition and recent genetic studies have revealed numerous sub-types. Children presenting with mild hyperglycaemia present diagnostic problems as they may have latent slowly progressing type 1 diabetes. These children may then progress to requiring insulin. On the other hand, with increasing prevalence of obesity more children are now presenting with type 2 diabetes, particularly from ethnic minorities. In the USA, in some areas, up to 50% of children with diabetes are now presenting with the type 2 form. Latent autoimmune diabetes in adults (LADA) is thought to comprise about 5% of all patients with type 2 diabetes. These people have autoantibodies usually seen in type 1 diabetes, but their clinical presentation is like someone with type 2 diabetes. This is a group that may present an excellent opportunity for subsequent

prevention of diabetes if an effective intervention can be developed to prevent further beta cell destruction. Monogenic diabetes (previously referred to as maturity onset diabetes in the young, MODY) Monogenic diabetes is the term used for a collection of conditions that cause diabetes now shown to result from single gene defects. One feature of these conditions is that they show autosomal dominant inheritance patterns where the disease appears to be vertically transmitted (e.g. through several generations). It is also diagnosed before the age of 25 years, but, unlike type 1 diabetes patients, monogenic diabetes patients do not often require insulin for at least 5 years after diagnosis. Genetic testing in these cases can confirm the particular sub-type of diabetes. This can have significant clinical implications. Patients with HNF1a (hepatocyte nuclear factor 1a) mutations, for example, exhibit exquisite sensitivity to sulphonylureas and can be successfully treated with tablets. Knowledge of the mutation, therefore, can help in the management of this disorder, even in children who would otherwise have been put onto insulin. This is also one form of type 2 diabetes where we would use a sulphonylurea in preference to metformin when initiating therapy. Patients with HNF1 have renal cysts. Patients with glucokinase mutations are less common but the diagnosis is significant for the individual and their families. Such patients are much less likely to develop complications of diabetes because they

mainly have mild fasting hyperglycaemia without significant post meal hyperglycaemia. Maternally inherited diabetes with deafness (MIDD) This is a form of diabetes due to mutations in mitochondria, most commonly related to 3243A > G mitochondrial DNA mutation. Mitochondria in an individual are inherited from the mother rather than from the father, therefore one clue would be evidence of strong maternal transmission of diabetes, particularly when this is associated with a sensorineural deafness. Some patients may also have peripheral vision problems, particularly night blindness. These patientsAbuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education,

workplace absenteeism, and long-term health problems of abuse survivors. Types of abuse Physical often require insulin. Infusion strategy
Initially reduce total daily insulin dose by 30%. Give half the daily insulin dose as the constant basal pump
rate (usually around 1 unit/hour). Give half the daily insulin dose divided between the three main meals, giving the insulin boost immediately before the meal. The patient is taught to count carbohydrate portions (see page 12) and thereafter will give the bolus doses in direct relation to the amount of carbohydrate consumed (for example, 1 unit for every 10 g of carbohydrate). During the first few days adjustments need to be made as follows: basal rate determined by assessment of fasting and 3 am blood glucose readings preprandial boosts are adjusted by assessment of postprandial blood glucose readings. Note: Specific instructions are given for exercise, and basal rates should be reduced during and after exercise.

Dose adjustment for normal eating (DAFNE)

A more liberal dietary pattern for Type 1 diabetic patients has become possible by using the DAFNE approach, ideal for some people who thus regain considerable freedom while at the same time maintaining good control. It is based on: a 5-day structured, group education programme delivered by quality assured diabetes educators the educational approach is based on adult educational principles to facilitate new learning two injections of medium acting insulin each day (see page 21) injections of short acting insulin every time meals are taken testing blood glucose before each injection. This programme enables people to eat more or less what they like when they like, and not to eat if they do not wish to do so. It depends on a quantitative understanding of the carbohydrate values of individual foods, and calculating by trial and error the correct amount of soluble insulin needed for a specified quantity of carbohydrate, developing an insulin/carbohydrate ratio for each individual patient. DAFNE has been used in continental Europe for many years: the- tongue covered with fur. Bell, (white and clammy,

which can be pulled off in strings), Phos. (black crusts). - tongue c. with mucus. Bell, (brown), Carbo. veg. (yellow-brown), Kali bi. (ropy), Merc, sol., Nitr.- ac. (tough, ropy, with ulcers), Phos. ac. (clammy, tough). Puls, (tenacious), Psorin,(whitish-yellow), Rhus. tox. (brown), Sil.(brownish).

- tongue c. with ulcers. Caps, (flat, sensitive, spreading), Kali bi. (small, painful), Natr. mur. (also vesicles). - tongue c. with vesicles, Ars. (painful, burning), Apis* (stinging), Canth. (at base). Hell., Natr. mur. (smarting and burning when touched by food), Spong., Zinc. Cracked. Ailanth., Apis, Arum., Bapt., Bar., Bell., Benz. ac, Bry., Calc. fl., Cham., China, Cic, Cur., Hyos., Kali bi, I^yc, Magn. mur., Nux-vom., Phos., Phos. ac, Plb., Podo., Puls., Ran.sc, Rhus tox., Sacch., Spig., Sulph., Ver. alb. - edges, Nux vom. (rest black or red). - middle, across the, Cobalt. - tip, Lach. - tongue dry, parched and cracked, Ailanth. - tongue dry, parched and cracked in typhus, Bapt. - chronic inflammation of tongue; c, swollen and bleeding, Podo. - tongue swollen, dry, c, sore, ulcerated, covered with vesicles. Apis - tongue, painful and burning. Arum. - tongue yellow along center, first white with reddish papillae; followed by yellow-brown coating in center, edges dark red and shining; dry brown down center (Plb.); c, sore, ulcerated, Bapt., (Apis, Ars., Rhus tox). - smarting, burning pain in tip of tongue, sore and c. Bar. carb. - tongue rough, c, and often of a dark- brown color, Bry. - tongue dry, smooth, red, c. (in dysentery). Kali bi. - tongue dry, red, brown, c, and tremulous, Hyos. - tongue dry, red, c, black stiff, Lach., Rhus tox. - tongue coated yellow, burning with blisters, c, Spig. - tongue smooth, red and c, dry and red, coated - thick whitish-yellow, ulcerated. Kali bi. - mouth very sore, parched and dry, mucous membrane c. and bleeding, tongue swollen and covered - with blisters on each side, Lach. - dry, black or c. tongue, Lj^c. (Ars., Lach., Phos., Rhus tox. ) - tongue cold, dry, blackish, c, red and swollen, Ver. alb. - brown, parched, c. tongue, Sulph. - tongue c. or coated yellow, with red tip and edges, Ver. alb. - and burning, Arum tr.. Bell., Bry., Ran. sc., Sulph., Ver. alb. - black and dry, stiff as a board, Ars. - on edges, black or dark red, Nux. vom. - and dry (tip). Kali bi., Lach., Rhus tox., Sulph. Crack deep,