SCIENTIFIC COLLEGE DROPOUTS AND THE RISK
FOR PSYCHOTIC OUTCOME: FOUR MALE CASES
Renato
COCCHI, neurologist and medical psychologist
Summary
Scientific high
schools and college dropout students with particular skills for mathematics
were asserted to be at risk for a psychotic outcome (Cocchi R.: Ital. J.
Intellect. Impair. 1994, 7: 29-38). This paper presents case histories of four
university students seen within two years in a psychiatric unit.
All four were males,
21-34 years old, who ended with success a senior high school of scientific
type. All of them had shown special skills for mathematics and entered
scientific faculties (Economics and Commerce, and Engineering).
Every one suffered
from a psychiatric illness. That was a schizophrenic psychosis in two, a
depression with psychotic features in third one, and alcohol and drug
dependence with psychotic traits in the last one. As for studying, the two
older are definitively dropouts, while the remaining ones appear to have only
break into their university careers.
Of them, the younger,
who had inpatient drug treatment for his first psychotic episode, has started
again studying also for university exams. The severe alcohol and drug
dependence of the second one, who refused treatment, prevents to foresee a
favourable exit.
Although rare, the
risk of a psychotic outcome, in scientific high schools or colleges dropouts,
needs a careful survey. If it had gone off, personal, family and society
emotional and economical costs should have an awful raise.
Key words: Dropouts, college students, mathematics skills,
psychosis.
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In my previous paper, I stated some
dropout students of scientific high schools or colleges as at risk of a
psychotic outcome (Cocchi, 1994). I cannot account for the incidence of this
fate, but I think it surely different from what happens to dropouts of high
schools or colleges of Arts.
I shall present here four cases I have
checked by myself in a neuropsychiatric hospital during last two years.
Casuistry
Case 1: Male, 24 years old, a university
student in Economics and Commerce. His father asked for consultation and help for
alcohol and drug detoxification. After some years and good marks in exams, he
became unable to concentrate. Lot of intrusive thoughts kept him from memory
storing what he was reading, with the need to read many times the same
paragraph.
Forthcoming anxiety and depression led
him to increase drinking alcoholics, mainly beer on which he had indulged since
his seventeenth year. Moreover, he used cannabis, and non medical doses of
flunitrazepam. During the visit he was clearly unable to pay continuous attention
to what I asked about.
Some psychotic traits such as nihilistic
delusion, incoherence with inappropriate affect, and social deterioration came
out. After many words, and having protested his interest in ending the
university, he agreed to soon enter our clinic.
The father could not give any information
about fetal life and delivery of the son, but he did not recall anything
unsound. The subject did a high school for Accounting and Commerce where he
showed better ability in mathematics. He explained he used alcohol to
counteract anxiety, cannabis to feel better and flunitrazepam to relieve severe
sleep troubles. Cigarette smoking was also more then usual. About his sexual
life he said a lack of interest.
We treated him with diazepam,
methadoxine, pyridoxine and ascorbic acid all into saline infusion; with
silimarine, promazine, delorazepam and gammahydroxybutirate by the oral via. He
slept all night and the day after he did not show any problem and somatic
symptoms of withdrawal, but he began to say he could not stay longer.
When his father came back to visit him in
third day morning, he asked his discharge and did get off against medical
advice. "Psychological" symptoms did get the upper hand on him.
I think that he had used alcohol,
cannabis and flunitrazepam to prevent himself from a psychotic outcome, and
that now he feared to loose the control of his mind. Of course such mechanisms
could have acted at a nonrational level.
Case 2: Male, 21 years old, a university
student in Economics and Commerce. He comes from a broken family and currently
lives with his mother. This one asked to consult me, because her son showed
symptoms of "great nervousness." Born in time after a drug induced
delivery, he caught severe diarrheas in the first year of live. After a
technical high school where he showed special skills for mathematics, he
entered the university.
Since the end of his first year
university, he felt even more intrusive thinking and found himself unable to
study because of lack of concentration. However, he could not carry out any
exam.
This impaired state of his mind forced
him to do his army service before, having the hope of freeing himself of this
trouble by a nonintellectual activity. When I first met him, he was on duty in
a military airport, nearly 80 km far from his home.
Clear psychiatric symptoms came out in
previous midwinter and were growing as the year went on. Five months later,
during the visit he paid me soon before his entry in our clinic I could detect
him as half-a-inch far from a clear psychotic state.
He was unable to control the course of
his thinking, and so he often did not pay attention to whom was talking him.
He had some persecutory ideas, auditory
hallucinations located into himself, and some impression that poeple can steal
his thoughts. Without any pain he had made self-injuries by shutting cigarettes
off in hand palms and foot soles. The mother reported his need to see him in
the mirror, and that he had some aggression against herself and his girlfriend,
a fact he confirmed.
Some days his face had become suddenly
pale and sometimes he had needed to utter outbursts of dirty words and
blasphemies. Now he has always fear to be left alone and in past he thought to
be an adopted child. Whenever he was out of army duty and had got consent, he
had come back home even during the night, driving the car at high speed.
He did not report anxiety and depression,
although I could relate some of his behaviours to them. Reduced appetite and
heavy sleep troubles were also present. The psychiatrist, who had previously
visited him, had made a diagnosis of depression, reactive type, and had
prescribed some antidepressant and hypnotic drugs without any favourable
result. Two days after this visit he entered our clinic.
His stay as inpatients lasted 33 days and
he had psychological evaluation (Raven PM38 = 51/60; MMPI: pathological scales:
F, 1.HS, HS+5K, 2.D, 3.HY, 7.PF, PT+1K, SC, SC+1K). His EEG was completely
normal. Drug therapy during first 18 days made up haloperidol, carbamazepine,
delorazepam, biperiden, acesparagine + citrulline + glycine + thiamine +
cyanocobalamine + calcium gluconate (BIOTASSINA, tm), fluphenazin decanoas, and
chlorpromazine.
Having clear depressive symptoms come
out, then we stopped chlorpromazine and BIOTASSINA, and we start antidepressant
therapy with viloxazine, nortriptyline and pyritinol. At discharge I wrote in
his clinical record this final evaluation. "Although his behaviour greatly
improved, he has poor control of impulses and reduced skill in dealing with mutual
relations. There are risks of a relapse."
During five months following discharge he
had three checkups. An initial depression went off, but he did not come back to
the university and preferred to start a course for computer repairing. His
ability in studying mostly recovered. As last drug therapy, I prescribed
glutamine, pyritinol, pyridoxine, and low doses carbamazepine, haloperidol,
viloxazine, nortriptyline and delorazepam.
Last check up (06.06.95): He ended the
course of computer repairing, but he passed also a written university exam in
mathematics and his score was the second one. No signs of psychosis, but slight
signs of depression were noted.
Case 3: Male, 24 years old, a dropout
student in Engineering. He suffered from a first psychotic episode when he was
20, and he stopped studying after two other admissions in a psychiatric unit.
Following a relapse soon after discharge from the fourth admission, his family
physician advised him on our clinic, where he entered of his own freewill.
He was taking bromperidol,
trihexyphenydil and high doses bromazepam. Until four years before this young
adult did not have any mental trouble. He has been a brilliant student of a
scientific senior high school (the Italian Liceo Scientifico) with particular
skills for mathematics and speculative philosophy. His life has had a very
regular course, with many interests, and he was always prompt to fulfill what
he thought the parents expected from him.
Beside studying piano at the School of
Music, he did regular and competitive athletics. As Engineering student he had
well acted some exams of first two years, with full marks, before he first
entered a psychiatric ward. His mental symptoms arose in springtime as ideas of
being badly influenced, and stolen of his thoughts. For this he consulted a
female soothsayer.
After about three months, in few days he
worsened, with complete lack of sleep, persecutory delusion, aggression against
his parents, impaired consciousness, illogical thinking and worsening of social
relations. After 21 days as inpatient drug treatment, he did get his discharge
as recovered, with a diagnosis of "acute psychotic trouble."
Although he was taking a drug therapy,
two years later, in February and in October he had two relapses requiring
hospital admission. Both these episodes have mood troubles and aggression
against his parents as main features.
Between them he could end all the exams
of the first two years of Engineering with very good marks. As he said, lack of
concentration and intrusive thinking came out before any relapse after a period
of hard studying. The same had come about before the first psychotic episode.
He could not get down on studying music,
and had begun to feel himself without energy as compared with his past life
before the illness. He decided to stop the university.
In October of his twenty-fourth year he
had his third relapse and his fourth admission. One month before, he had
started to be choleric, to get angry with his family, to have no rest, to stop
meeting the few friends he took up with. He shut himself up in his room. In
reply to his parents who suggest him to take the drugs prescribed, he attacked
his sister and the home furniture.
Discharged after few days of hospital, about
two weeks later he started again to get angry. For this he asked to enter our
clinic.
During 21 days of his fifth admission he
had three anger outbursts against the staff, which required a larger use of
neuroleptics. He did not accept the psychological help going on, and all the
doctors who have met him reported how it was difficult to do a plain interview.
We did not see anything abnormal in his
EEG. He asked to leave our clinic, because he attributed anxiety and easiness
to become angry to his being inpatient.
As home drug therapy, he did get
chlorpromazine, chlotiapine, bromazepan, and low doses carbamazepine,
paroxetine, amitriptyline and flunitrazepam. After his discharge I checked him
twice within three months.
No angry outburst came out, and so I
could lessen the neuroleptics doses. It seemed that he and his family had
accepted his illness as "misfortune." There was a strong refusal to
think about the university and now he was seeking a blue collar job. I noted
that depression and reduced social relations still did not give over.
Case 4: Male, 34 years old, a former
student in Engineering. After he had acted 12 exams with full marks (which
parallels nearly three years of the course, out of 5), he left the university.
When in the Liceo Scientifico - the Italian scientific senior high school - his
teachers viewed him as a very gifted student with paramount skills in
mathematics.
Since his third year of Engineering
course he noted his studying as even more difficult because lack of
concentration and memory. However, the need of a coming back to the start of
just a read paragraph made his exams rhythm becoming slower.
Although this studying fatigue he could
go on, but some anxiety and doubts about his success started to get on. In
springtime of his twenty-third year of life to study turned out to be uneasy,
because of somatic symptoms of stress like headache, nausea, vomiting and
diarrheas followed on. After some months stop studying, he could do 3 exams,
but with even more difficulty.
To avoid wasting time, he prompted
himself to do his army service in advance, so hoping that a reduced mental
activity would give him some relieve. One and a half-a-year later this service
enden, he found his troubles did not narrow down, and he decided to leave
Engineering and to enter Physics.
More difficult exams and same somatic
symptoms when he tried studying led him to depression, feelings of being
inadequate, abulia and social withdrawal. He eventually left the university and
asked for psychiatric help.
When I first saw him 8 years after, he
was taking haloperidol, biperiden, amitriptyline and bromazepam. His depression
was severe and had presented mood-congruent psychotic features. In that time he
had no job at all. In past years he did get only some three months activity
over one and half-a-year, given to him by community social welfare. He said it
was the only work he could have, because of his low energy.
After two admissions in our clinic, both
in springtime, I could manage his depression with good results. The therapy did
not change since one year and comprises low doses haloperidol, delorazepam,
amitryptiline and valpromide, all at evening. Nevertheless pessimistic
attitudes towards a future and hopes to find a stable blue collar job even of a
low profile persist.
Discussion
These four cases have many features in
common. All four were young adult males who ended with success a senior high
school of scientific type. All of them had shown special skills for mathematics
and entered scientific faculties of the university (Economics and Commerce, and
Engineering).
Every one suffered from a psychiatric
illness. That was a schizophrenic psychosis in cases 2 and 3, a depression with
psychotic features in case 4, alcohol and drug dependence with psychotic traits
in case 1. As for studying, cases 3 and 4 are definitively dropouts, but at the
moment the first two appear to have only break into their university careers.
While case 2 has again started studying
also for university exams, the severe alcohol and drug dependence of case 1
hardly allows me to think of a favourable exit.
In my opinion, this young adult actually
swings between the risk of an overdose (alcohol plus flunitrazepam) and his
going off into a frank psychosis. His refusal to stop abusing by undergoing a
medical detoxification, might be the way to maintain a kind of unsuitable
automedication (Cocchi & Tornati, 1977).
The link between mathematics skills and a
psychotic outcome seems not casual, although not a direct one. I dare here to
give only a rough suggestion, bearing in mind that this one drives at a
hypothesis to be verified, if possible. We can divide skills in mathematics
into two types of activities.
One is computation whose brain area seems
located into left half-brain; the second is a space representation of algebraic
problems, perhaps more acted in right half-brain (Grafman et al., 1982).
Now I have to remind that computation
sets up a so-called mental stress. In heart check up, a computation by
continuous subtraction of 17 from a four-digit figure is a standard technique
that alters some heart parameters ( Ludbrook & Vincent, 1974; Nyberg,
Graham & Stokes, 1977; Brod et al., 1979). The ECG recording reveals that
the subject under such a test could risk a blood tension drop off or even a
heart failure.
I remind this fact only to point up that
computation gets up to a type of stress whose non specific effects on heart are
well known. In other terms, working on mathematics may set off a stress.
Of course this stress cannot be the sole
cause for having a psychotic outcome. Three of these students out of four
clearly remember intrusive thinking and lack of concentration. They told they
cannot memorize what they were studying. Intrusive thoughts did inhibit the
forwarding of information from the short-term memory store to the long-term
memory store.
We can find this last symptom both in
neuroses and psychoses. It seems to relate to a temporary change of balance
between half-brains, at least in some areas or functions, with a reduced
thought mobility in left half-brain and relative prevalence of right half-brain
(Cocchi, 1994). About case four, I maintain that it is a mixed case because it
sounds unlike in some aspects.
He did not remember intrusive thinking
and the fall of studying went off in springtime, mainly as increasing fatigue.
Rather than lack of concentration, as his record reports, perhaps he had lack
of attention and memory (Cocchi, 1993).
When a student in senior high school he
had very good marks also in humanities, although he was exceptional in
mathematics.
The loss of their ability in studying
strongly hit these four students, and a secondary depression and reduced
self-esteem came out. At least 3 of them had depression also after acute
episodes, and cases 3 and 4 went to search low profile jobs, which drives at
persistent low self-esteem. Case 1 hides his signs of depression by the abuse
of stimulants, alcohol and drugs.
I cannot make clear why these symptoms
and states of the mind might lead to a psychotic outcome. Moreover, because we
do not know all the variables into play, and why only small part of scientific
college dropouts becomes psychotic. However, to have found four cases in two
years points to think this outcome as a non-rare event, with heavy followings.
Conclusion
When I wrote my previous paper on
dropouts from senior high schools or college students, I would have pointed to
an important event, at least in Italy. For they were average or brilliant
students in past, to leave studying leads to high emotional and economical
costs for the students, their family and the whole society.
The possibility of a suitable drug
therapy in some of these students turns out into a new approach to a problem
scarcely considered by neuro-psychiatrists. Although rare, the risk of a psychotic
outcome, in scientific high schools or colleges dropouts, needs a careful
survey. If it had gone off, personal, family and society costs should have an
awful raise.
Having put into light the possible link
between dropping out and becoming psychotic could deserve some interest in what
I believe a current no-man land.
References
Brod J., Cachovan M., Bahlmann J., Bauer
G.E., Celsen B., Sippel R., Hundeshagen H., Feldmann U., Reinhoff O.:
Haemodynamic changes during acute emotional stress in man with special
reference to the capacitance vessels. Klin. Wochenschr. 1979, 57: 555-565.
Cocchi R. Problemes of attention and
concentration leading to interruption in studying by high school and university
students: A report on 4 typical cases. It. J. Intellect. Impair. 1994; 7:
29-38.
Cocchi R. Defective hemispheric dominance
and cognitive behaviour: Speculative considerations. It. J. Intellect. Impair.
1994; 7: 19-27.
Cocchi R., Tornati A.: Psychic
dependence? A different formulation of the problem with a view to the
reorientation of therapy for chronic drug addiction. Acta Psychiat. Scand.
1977, 56: 337-346.
Grafman J., Passafiume D., Faglioni P.,
Boller F.: Calculation disturbances in adults with focal hemispheric damage.
Cortex 1982, 18: 37-50.
Lundbrook J., Vincent A.H.: The effect of
mental arithmetic on hand blood flow. AJEBAK 1974, 52: 679-686.
Nyberg G., Graham R.M., Stokes G.S.: The
effect of mental arithmetic in normotensive and hypertensive subjects, and its
modification by beta-adrenergic receptor blockade. Br. J. Clin. Pharmacol.
1977, 4: 469-474.
Printed on It. J. Intellect. Impair. 1995:, 8: 37-43.
Author’s address: dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it
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