5225ournal ofNeurology, Neurosurgery, and Psychiatry 1992;55:522-000

devoted by the consultant to attending the our current knowledge of schizophrenia. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.6.522 on 1 June 1992. Downloaded from MAATTERS outpatient clinic. Indeed, it would be interesting to survey Another point is the high number of whether physicians, including neurologists, ARISING patients receiving specialised investigation. would include all the conditions they diag- The main reason for this result is the highly nose and treat as cerebral diseases within the restrictive criteria for hospital admission limits laid out by Dr Kapur. Nonetheless, because of the problem of a shortage ofbeds. whether the term "dysfunction"or "disease" The great number of disorders of peripheral is preferred should not interfere with the nervous system accounts for the EMG logical process of defining more clearly what studies. might be abnormal about the brain in schizo- Hospital outpatient clinics, a neurology In conclusion, the results of this study are phrenia. In our opinion there seems little audit in South Catalonia as follows: 1) A predominant diagnostic role danger of psychological and social therapies of the neurological outpatient consultation; falling into neglect simply because we under- I read your letter about outpatient practice in 2) A small proportion of patients with seri- stand more about any underlying organic Bristol, United Kingdom.' A similar audit in ous disease; 3) An acceptable waiting time, deficits; that would be treating the dysfunc- our hospital has some common aspects but and 4) The considerable number of patients tion rather than the patient. differs greatly in others. The results are based receiving specialised investigations. on 245 new outpatient referrals to the con- M LOPEZ ALEMANY IAN HARVEY sultant neurologist in Verge de la Cinta Neurology Unit, Department ofInternal Medicine MARIA A RON Hospital (Tortosa) between 1 Hospital Verge de la Cinta, Institute ofNeurology, January and 30 43500 Tortosa, Spain Queen Square, June 1991. This is a 202 bed district general London WCIN 3BG, UK hospital in the south of Catalonia, with a 1 Wood VA, Hewer RL, Campbell MJ, Colley referral area population of 135 000 compris- JRT. Hospital outpatient clinics: an efficient specialist service? A neurology audit. J Neurol ing the counties of Montsia, Baix Ebre and Neurosurg Psychiatry 1991;54:370-1. Terra Alta. Fifty seven per cent (n = 139) of new The Neuropsychological sequelae of outpatients were referred by the different attempted hanging departments of our own hospital, mostly The Brain in schizophrenia internal medicine and traumatology, and Medalia et al ' have made a valuable con- 30% (73) by general practitioners. Four per The excellent editorial by Ron and Harvey' tribution to our understanding of the neuro- cent (11) of those attending were categorised notes that "to have forgotten that schizo- psychological consequences of attempted as "urgent" in referral letters, while 26% phrenia is a brain disease will go down as one hanging. However, their use of the terms (64) were considered "preferent", an inter- of the great aberrations of twentieth century "hypoxia" and "ischaemia" may inadvert- mediate priority cateegory, and 70% (170) medicine". However, I think it is open to ently add to the semantic confusion already "routine". Seventy per cent of total referrals question as to whether schizophrenia can be present in the literature. were attending for a diagnosis, 27% for drug considered as a brain disease in the same way Specifically, according to the authors, "In treatment or physical therapy and 3% for as established brain diseases such as vital or circumstances other than combined cardiac both reasons. The mean waiting time for the atrophic disorders of the CNS. There may be and pulmonary arrest a relatively pure hypo- "urgent" group was two days, median 0-6, more general reservations with the validity of tensive or hypoxic state may occur; perhaps SD 2-7, range 0-8; mean waiting time for the the concept of schizophrenia itself,2 but I the best examples are cardiac arrest while "preferent" group was 14 days, median 11 -6, have four specific reservations with calling intubated and ventilated during general SD 9-87, range 1-51; and mean waiting time schizophrenia a brain disease: anaesthesia (pure ischaemia) and carbon for the "routine" group was 29-6 days, 1 Unlike most brain diseases, there is as yet monoxide poisoning without circulatory col- median 29-1, SD 11-40, range 7-61. no diagnostic pre- or post-mortem biolo- lapse (pure hypoxia)."We find difficulty with The preliminary diagnoses of new out- gical or other physical marker for schizo- this model. Firstly, while hypoxia may occur patients were similar in the three groups, phrenia. without ischaemia in chronic obstructive without a significant relationship between 2 Compared with most brain diseases, there pulmonary disease or other cases oflow levels priority category and presence or absence of is no predictable pattern of deficit in of oxygen saturation, ischaemia from cardiac a definite disease at consultation. The most sensory or motor functions or in "prim- arrest, for example, cannot occur without http://jnnp.bmj.com/ common diagnoses, based on ICD classifica- itive" reflexes. rapid parallel compromise of oxygen delivery tion, were migraine or headache (17% of 3 Unlike most brain diseases, psychological to the affected tissue. The presence or total seen), disorders or peripheral nervous or psychosocial variables play a significant absence of ventilatory support is essentially system (16%), mostly entrapment neuro- part in the aetiology and stability of out- irrelevant if there is no blood flow. That is, pathy and root lesion, epilepsy (13%), vague come of many patients with schizophre- there is a state of "ischaemia with hypoxia." symptoms (12%), stroke (10%), Parkinson's nia. A term that is less clumsy is stagnant disease (6%) and syncope (5%). 4 The relationship between neurobiological hypoxia,2 which emphasises decreased oxy- Forty four per cent (107) of new out- features of patients with schizophrenia and gen availability due to decreased or arrested patients were discharged back to their referral the pattern or severity of psychiatric dis- circulation. A model of the time course of on September 26, 2021 by guest. Protected copyright. source, while only 2% (5) were admitted to turbance is much more equivocal than in stagnant hypoxia has been proposed which hospital after the consultation. Forty per cent the case of analagous relationships in brain we have found useful to our understanding of (100) received outpatient specialised inves- diseases. "watershed" lesions.' For example, while tigation, for example, 52 had a CT scan, 26 I would therefore at present feel com- total circulatory arrest produces what has an electroenceophalogram and 22 elec- fortable in calling schizophrenia a brain been called ischaemic hypoxia, the periods of tromyography. dysfunction, but I do not think there is yet lower but not zero blood pressure and blood Only one patient of the "urgent" group sufficient evidence to call it a brain disease. It flow surrounding total arrest (called oligemic was admitted to hospital after consultation, is possible that the term disease, if commonly hypoxia) demonstrate the particular vul- while the other four were of the "routine" applied to schizophrenia, may in the percep- nerability of watershed areas. It is during the group, one of them with myastenia gravis. tion of some clinicians limit the range of oligemic phases that ventilation, or the lack Some of these aspects are similar to the viable therapeuric options. of, may make a difference in lesion audit severity mentioned previously, for example, the NARINDER KAPUR since without ventilation the hypoxia pro- predominant diagnostic role of the neuro- Wessex Neurological Centre, Southampton, UK duced by circulatory slow down is that much logical consultation, the main diagnoses, the I Ron MA, Harvey I. The brain in schizophrenia. greater. Incidentally, the term "oligemic small number of people admitted to hospital J Neurol Neurolosurg Psychiatry 1990;53: hypoxia" also alerts us to reperfusion phe- after consultation and some cases of inap- 725-6. nomena. propriate 2 Boyle M. Schizophrenia: a scientific delusion. priority classification, but other Secondly, it is useful to make a distinction results are London: Routledge, 1990. very different. Our waiting time between hypoxia produced by a lower avail- seems quite acceptable for the three priority Harvey and Ron reply: ability of oxygen and that produced by the categories, and this is probably the reason of reduction of circulating haemoglobin as in the proportionately larger number of people Dr Kapur's reservations about describing carbon monoxide poisoning, if only because in each a category and the small number schizophrenia as a brain disease are doubtless encephalopathic symptoms vary between the considered "urgent". The short waiting time shared by others and seem to depend as two at least in time of onset. The is aetiologies, explained by the number of sessions much on how one defines "disease" as on term for the case of haemoglobin com-