Brought to you by http://www.schizophrenia.com
Issue #10, September 16, 1996
A Summary of Schizophrenia News and Events
Note: Feel free to forward this newsletter to others
To Subscribe or Unsubscribe send a note to individuals
at the following email address: firstname.lastname@example.org
1. Letters to the Editor
2. Web sites of Note:
The BC Schizophrenia Society
3. NEW BILL BEFORE US CONGRESS - SUPPORT WITH A PHONE CALL..
4. HOW TO TELL IF SOMEONE DIAGNOSED WITH AN NBD, HAS ANOTHER MEDICAL DISORDER
5. Recent Schizophrenia Research Summary
Letters to the Editor:
I've just come from my meeting of O. F. O. S. ( Ontario Friends of
Schizophrenics) and we we're talking about all the t. v. shows we've missed on
schizophrenia because we didn't know they were on. The "Shirley" show had a
show on mental illness and Pamela Wallen had a show specifically on
schizophrenia. Most of us didn't see them. Becuse of your newsletter we did see Barbara Walters
interviewing Margot Kidder. Thank you very much for that.
My question is "Is there any way we could know in advance of programs about this disease"?
Actually I don't even watch TV - so I'm not the best person to ask this question - however the only way I see for us all to have advance warning on shows such as these if someone who does notice them in the newspaper or wherever, forwards the information to me so that I can publish them. I encourage everyone to send me information that may be of value to others involved with schizophrenia.
Web Address: http://mindlink.net/bcss
The BC Schizophrenia Society
(British Columbia, Canada)
A great sample of a web site from a local schizophrenia organization. I'm hoping that other organizations around the world will also create sites like this. Free space on the www.schizophrenia.com web site is available to any organization that so needs it.
Web Address: http://www.vaxxine.com/schizophrenia
The Canadian quarterly magazine Schizophrenia Digest has just gotten its own home page. I encourage you to check it out, and also to subscribe to the magazine. Its a great source of information on Schizophrenia put out by a team led by William (Bill) MacPhee - a person recovering from schizophrenia (Congratulations Bill!) It includes the feature story from this issue about Positron Emission Tomography PET and photos and graphics are suppose to be coming in near future.
DR. RON DIAMOND
This is a special issue of The AMI/FAMI Reporter (in four parts) to help
individuals determine if what is presenting as schizophrenia, depression, or
anxiety disorder is really caused by some other physical illness. It will
also help you evaluate whether someone correctly diagnosed as having an NBD
also has an underlying undiagnosed medical illness.
It is based entirely on information in a paper by Dr. Ron Diamond, who was
kind enough to let us use it. This paper was edited for families by D.J.
Jaffe. This information should not substitute for a consultation with your
doctor. We thank Dr. Diamond and you for your support of AMI/FAMI which
makes this special insert possible.
SECTION 1: WHAT TO LOOK FOR IF YOU EXPECT SOMEONE WITH AN NBD HAS AN UNDERLYING MEDICAL ILLNESS
SECTION 2: MEDICAL CONDITIONS THAT CAN MIMIC SCHIZOPHRENIA/PSYCHOSIS
SECTION 3: MEDICAL CONDITIONS THAT CAN MIMIC DEPRESSION
LOOK FOR SOMETHING SPECIFIC
RATHER THAN GROPE RANDOMLY.
On pages 4, 5,and 6 you will find a list of diagnosis which could be mimicing
schizophrenia, depression, and anxiety respectively. What follows below is
how a lay person can look for signs of the medical disorders that may mimic
psychiatric disorders, record them, and bring them to doctors attention if
found. The following observations are often possible for a consumer to
determine, or can be done by a family member (even on a completely
uncooperative person). They should be done to help determine if what is being
diagnosed as 'psychosis', is actually another organic disorder masquerading
The following factors make medical illness more likely:
a person over 40 with no previous psychiatric history
no history of similar symptoms
coexistence of chronic disease
history of head injury
change in headache pattern
a patient who gets worse when given antipsychotic or anxiolytic medications
visual disturbances, either double vision or partial visual loss
speech deficits, either dysarthrias (problems with the mechanical production
of speech sounds) or aphasias (difficulty with word comprehension or word
abnormal autonomic signs (blood pressure, pulse, temperature)
disorientation and/or memory impairment
fluctuating or impaired level of consciousness
abnormal body movements
hallucinations that are visual and vivid in color and change rapidly
olfactory (smell) hallucinations
illusions (misinterpretations of stimuli)
blood or pus in the urine,
high blood pressure
Symptoms of chest pain while at rest,
headaches associated with vomiting
loss of control of urine or stool
You should ask about each of these and try to determine if they are present.
Take specific notes to bring to the doctor.
Look for the following information if you are looking for an underlying
General appearance: How does the person look? How are they dressed? Do they
appear ill? Is the face symmetrical or asymetrical? Then go to more specific
Skin: Is it very dry or abnormally colored? Extremely pale skin or lips may
suggest anemia. A yellow skin may indicate jaundice and liver disease. Dry
skin and hair may be a sign of hypothyroidism. Look for such things as
dehydration, nutritional status, rashes, edema, petechiae
Eyes: Are they focused? Are the pupils equal? Are they aligned with each
other? Do they move together? Differences in pupil size may indicate brain
masses such as tumors. Wildly dilated pupils may indicate a variety of drugs
including hallucinogens, stimulants, and anticholinergics. Constricted pupils
may indicate opiates. Bulging eyes can be a sign of hyperthyroidism. See if
eyes move equally and fully in all directions. Check for vertical and
horizontal nystagmus: refers to rapid movements of jerking of the eyes, and
can be either up and down (vertical) or back and forth (horizontal). It is
most easily seen if individual is asked to look up or over to the side as far
as possible. Nystagmus is frequently present with drug intoxications, and
vertical nystagmus is never a normal finding in functional psychosis.
Observe body movement to rule out weakness, clumsiness, ataxia, facial
asymmetry, asymmetry of movements, choreiform movements ("worm-like" or other
involuntary movements, usually occurring less than 2 times/second), tremors.
Is there any gait disturbance (a very common finding in a wide range of
medical conditions)? Is there any disturbance in the way they move, hold
themselves,position their body or touch their nose?
Observe neurological abnormalities. Is there motor stereotypy (repetitive
stereotyped movements). Look for aphasias (difficulties with speech). These
can be broken down into word finding difficulties (nominal aphasias);
difficulty understanding speech (receptive aphasias) or difficulty producing
speech (expressive aphasia). Does the person slur words or have excessive
difficulty finding the right words?
Do they have any of the following difficulties:
agnosias (recognition of complex shapes)
apraxias (execution of proper manipulation of objects) perseveration
(inability to switch tasks or mental sets)
Take blood pressure, Is it high or low? Take it preferably lying and
standing (or you can ask the person about any recent blood pressure checks,
or ask them to get their blood pressure taken at one of the blood pressure
machines that seem to be in every bank and drugstore)
Take pulse for evaluation of rate and arrythmias (irregularities of heart
Bring any of these symptoms to your doctors attention and require him/her to
In addition to specific observances, bring your doctor a comprehensive
overview of the individuals medical history to help determine what may be
causing these symptoms.
In order to decide if a physical disorder exists, and whether or not it could
be affecting the psychiatric disorder, the psychiatrist and doctor must have
comprehensive information. They should get it themselves, but may not have
had time. They may only see a person for 15 minutes, once a month, including
paperwork. Records may have been lost. So you may have to do some for them.
Make sure you bring to the doctor in a useful form all of the following.
Fill in gaps in your information so that important areas are not missed. Use
this as a 'crib sheet' to ask the right questions and make sure your doctor
is following the right leads.
1. Describe the Symptoms- How did they begin? How long has s/he had them?
What has the progression of symptoms been like? Include a careful review of
other "extraneous" symptoms the patient may have-starting at the top with
questions about headache and dizziness and ending at the bottom with
questions about leg sores and trouble walking. This "review of systems" is an
extremely important part of a medical assessment.
2. Describe the History A history of similar problems in the past; past
medical problems including all medical hospitalizations and surgeries; Family
history, both medical and psychiatric. Specifically ask about a history of
epilepsy, emphysema, asthma, diabetes, or thyroid disease and bring these to
the doctors attention.
3. Describe medical status- List all current medical illnesses; all current
medications (Ask specific questions about vitamins, birth control, over the
counter meds, past medical problems, past surgeries, past medical
hospitalizations ; any head injury, coma, periods of unconsciousness,
seizures; the name of person's physician--date of last contact--for what
4. Describe current habits The doctor should have honest info about drug
use, starting with questions about tobacco, caffeine and alcohol and
proceeding on to questions about other drugs x exercise and activity
patterns, sleep patterns.
5. List Medicines: ask about all drugs that a patient is taking, licit and
illicit, prescribed and over the counter. Ask about all illnesses that a
patient has had asthmatics take combinations of sympathomimetics and xanthines
patients with allergies may take ephedrine
patients with diabetes may be hypoglycemic from their insulin
thyroid preparations may be prescribed for thyroid illness, following
thyroid surgery (from years ago), or even for weight loss
The goal is not to come up with a specific diagnosis. The goal is to organize
the data that you collect about the person so that you can decide what to do
next, how worried you need to be, and when and how and what to say to your
consulting physician if you decide further medical assessment is necessary.
Here are some of the specific things you want your doctor to do.
The following tests are the most useful screen for picking up physical
disease in psychiatric patients (Sox et. al. (1989), so your doctor should do
T4 (thyroid test, now replaced with a more modern test called sTSH),
CBC (complete blood count),
SGOT (liver function test),
Laboratory and other diagnostic tests should be used to pursue specific parts
of the differential diagnosis list (pages 4, 5, and 6). Diagnostic tests are
much more likely to give useful results when you and the doctor are clear
what question you have in mind and what specific test is needed to answer
that specific question. For example an EEG detects abnormal brain function
while CAT scan detects abnormal anatomy.
If you think a "drug screen" is needed to find out if the person has
recently used an illicit drug, find out if the doctor's laboratory can
measure the drug or drugs that you expect this person might be using, and
whether blood or urine tests are better depending on the particular drug and
time since ingestion. Most labs can test for the presence of cocaine, but LSD
is used in much smaller amounts and may not be detectable even if recently
used. This kind of question can be answered by a call to the chemistry lab of
the local hospital, but such a call requires that you step out of your
typical "non-medical" role and interact with a strange and often forbidding
medical system that probably won't welcome you.
At different times with different doctors and different clinical situations
this will mean different things. It always means making the consultation
request as clear as possible. What kind of answer do you want back from the
doctor? What are you most worried about? What information do you already
have? You might think that your job is just to get someone to see the doctor,
and the rest of the job is up to the doctor. This is true-and not true. The
doctor will typically spend less than 15 minutes with the patient to collect
a history, do the physical, order the tests and write a note in the chart.
If the client is less than articulate, important information is likely to
get lost. This is a particular problem with older clients, those who are hard
of hearing or who have other communication problems, or those who are less
organized or less clear in their thinking. It is also a problem when the
symptoms you want evaluated are vague, or your concerns leading to the
referral do not relate to a particular "medical" symptom. Your job must
include organizing the information that you have collected and transmitting
it to the doctor in such a way as to do you or your loved one the most good.
Telling the person to see his local doctor, or phoning the local internist
with a request to "Please do a physical exam on this client." is much less
likely to lead to a reasonable consultation result than a request, "This
client has a depression that seems very atypical. Could you please see if
there could be a medical illness involved?" Or even better yet, "This patient
is complaining of depression with decreased energy level, but he is also
complaining of increased weight, cold intolerance, decreased libido and
extremely dry skin. He was treated for hyperthyroidism 15 years ago. Could
you see if any thyroid problems or any other medical problems might be
potentiating his depression?"
Most of the time you will not be able to frame a consult request with as
much detail as this last example-but in all cases the more the better. Often,
the referral to the physician is based on a pattern suggesting a higher
probability of medical illness, rather than any particular symptom suggesting
a particular illness. For example, anyone who initially develops psychiatric
symptoms over the age of 40 should have a medical workup. If this is the
reason you are referring the client, then the physician needs to have that
Finally, there are differences of communication styles between you and
physicians. You are likely to want to give the physician a complete
description of the patient and the problem in a phone discussion that may go
on for many minutes. The physician is likely to be in the middle of office
hours, with a clinic full of patients waiting to be seen. A brief, succinct
and very focused description and problem statement with a focused
consultation request is likely to be better received by a physician than the
more complete communication often expected between psychotherapists.
by Dr. Ron Diamond
Hypoglycemia (low blood sugar): symptoms can include delirium or coma,
palpitations, sweating, anxiety, tremor, vomiting. If in doubt, give candy
or orange juice sweetened with sugar. In an emergency room, give 50 cc. of
50% dextrose for both treatment and diagnosis.
Diabetic Ketosis or non-ketotic hyperosmolarity (blood sugar so high that it
upsets body chemistry): delirium with history of diabetes, increased
breathing, sweet smell of acetone on breath (can be mistaken for smell of
alcohol), dehydration, decreased blood pressure.
Wernickes-Korsakoff's syndrome: acute thiamine (vitamin B6) deficiency so
severe that it can cause rapid brain damage. Usually found in alcoholics.
Symptoms include nystagmus (rapid small jerking movements of eyes),
cerebellar ataxia (person moves as if drunk), evidence of peripheral
neuropathy, ocular palsies (inability to move both eyes together in all
directions) If in any doubt, give thiamine l00 mg. IM. This is not diagnostic
but will prevent any further brain damage.
DT's (delirium tremens): drug withdrawal from alcohol or other sedative
hypnotics. Frequently missed and can be medically very serious. Symptoms
include elevated autonomic signs, agitation, visual and tactile
hallucinations and history of alcohol abuse. Onset is usually three to four
days after reduction or discontinuation of alcohol.
Hypoxia (low blood oxygen): from pneumonia, heart attack, COPD (chronic
obstructive pulmonary disease), arrythmias (abnormal heart rhythm), etc.
Meningitis (infection of the covering of the brain): be alert for stiff neck
Subarachnoid hemorrhage (rapid arterial bleeding into the brain): stiff
neck, fluctuating consciousness and headache. If there is a fluctuating
consciousness along with stiff neck and headache, a spinal tap for diagnosis
needs to be done immediately.
Subdural hematoma (bleeding from veins under the outside covering of the
brain, which compresses the brain over hours to weeks or even longer):
symptoms are variable but frequently (not invariably) there is a history of
Anticholinergic (atropine) poisoning: from overdose of tricyclics or
over-the-counter drugs, or from organophosphate insecticides. Classic
symptoms include: Flushing "red as a beet" x Mouth dry "dry as a bone"
Dilated pupils "blind as a bat" Delirious "mad as a hatter" These patients
will also have increased pulse and sometimes elevated blood pressure. Most
fatalities are from cardiac arrythmias, although seizures are not uncommon.
Progressive neurological diseases
Multiple sclerosis: no typical signs or symptoms. It may begin very suddenly
and affect any part of the neurological system. Early in its course,
diagnosis may be extremely difficult.
Huntington's chorea: hereditary illness that includes movement disorder but
can present with psychosis initially.
Alzheimer's disease and Pick's disease: progressive diseases that cause
dementia, but can initially present in a wide variety of ways. Alzheimer
causes diffuse dementia, while Pick's primarily affects the frontal lobes of
Central nervous system infections
Encephalitis (viral infection of the brain-usually Herpes Simplex): usually
presents with fever and seizures, but various mental symptoms including
catatonia or psychosis may present before any clear cut neurological
symptoms. Usually has a fluctuating mental status.
Neurosyphilis (syphilis of the central nervous system).
HIV infections: HIV encepalopathy commonly includes apathy, decreased
spontaneity and depression and may present before any other signs of AIDs are
AIDS can also first present as delirium with paranoia and other prominant
Space occupying lesions within the skull Brain tumors, Bleeding within
skull, Brain abcesses
Accumulation of toxins from severe liver or kidney disease.
Disturbances in electrolytes, either too low a serum level of sodium or too
high a serum level of calcium.
Acute intermittent porphyria (disease of porphyrin metabolism): very rare,
but may present as classical psychosis.
Myxedema (underactive thyroid gland-hypothyroidism)
Cushing's syndrome (too much cortisol caused by overactive adrenal gland or
overactive pituitary gland) Hypoglycemia, either from insulin secreting
tumor or administration of insulin
Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome;
Pellegra (nicotinic acid defeciency) and other B complex deficiencies;
Temporal lobe epilepsy (or partial complex seizure disorder)
Drugs-licit and illicit
Dr. RON DIAMOND
There are many different physical disorders that may lead a doctor to
misdiagnose someone as having depression or bi-polar disorder. Following is
a list of disorders that may mimic depressive disorders.
Post viral depressive syndromes: especially influenza, infectious
mononucleosis, viral hepatitis, viral pneumonia, and viral encephalitis
Cancer Cancer of the pancreas commonly presents as depression. Lung Cancer,
especially oat cell carcinoma.
Brain tumors, either primary tumors or metastastic, may present with
Cardiopulmonary disease with hypoxia (decreased oxygen in the blood): acute
hypoxia often leads to symptoms resembling anxiety or panic. Chronic hypoxia
may present with lassitude, apathy, psychomotor retardation and other
symptoms confused with depression.
Sleep apnea: should be suspected in a patient with sleep disturbance and day
Endorcrine System Disorders
may mimic depression
Hypothyroidism (underactive thyroid): causes a general slowing of all body
functions. Patient complains of fatigue, weight gain, constipation, and, when
asked, will describe cold intolerance, dry skin and hair, and hoarseness or
deepening of the voice. Often very insidious but easily diagnosed and treated
Hyperthyroidism or thyrotoxicosis (overactive thyroid): usually associated
with anxiety but may present as depression, especially in the elderly who may
have few classical signs of thyroid disease.
Adrenal hypofunction (Addison's Disease): often presents with weakness and
fatigue, along with low blood pressure and hyponatremia (low serum sodium)
and hyperkalemia(increased serum potassium).
Adrenal hyperfunction (Cushing's Disease): from either steroid medication,
pituitary, adrenal or other ACTH secreting tumors. Various affective
disturbances, either depression or mania, are common. Syndrome is marked by
truncal obesity, hypertension, puffy face, and hirsutism.
Hyperparathyroidism: usually from small tumors of the parathyroid glands.
Early symptoms develop insidiously and can include lassitude, anorexia,
weakness, constipation and depressed mood. The classic symptoms of bone pain
and renal colic often develop only years later.
Post-partum, post menopausal, and premenstrual syndromes.
Collagen-Vascular Diseases This is a strange set of different diseases where
the person essentially becomes allergic to parts of their own body. It can
effect all parts of the body and can, at times, cause death.
Systemic lupus erythematosus (SLE) is most often seen in women 13-40 years
old. It often presents initially with nonspecific symptoms such as fatigue,
malaise, anorexia and weight loss, all of which can lead to the diagnosis of
Brain tumors and masses inside of the skull such as subdural hematomas
(bleeding under the dural sack that surrounds the brain). Masses, especially
in the frontal and temporal areas, can grow for years and cause psychiatric
symptoms before any focal neurological abnormality is apparent.
Complex partial seizures: ictal-repetitive behaviors during the seizure,
interictal-personality changes between seizures, increased lability of
emotions, quick to anger, increased preoccupation with religion, hypergraphia
Medications can cause
Antihypertensive medications (drugs used to control high blood pressure):
reserpine and alpha-methyldopa are probably the worst, but propranolol has
been implicated and all antihypertensives are suspect.
Digitalis preparations, along with a variety of other cardiac medications.
Cimetidine: used for gastric ulcer disease
Indomethacin and other non-steroidal anti-inflammatory medications.
Disulfuram (Antabuse): usually described by patients as more a sense of
fatigue than true depression
Antipsychotic medications: can cause an akinesia or inhibition of spontaneity
that can both feel and look like a true depression
Anxiolytics: all sedative hypnotics from the barbiturates to the
benzodiazepines have been implicated both in causing depression and making it
worse in susceptible individuals
Steroids, including prednisone and cortisone
Drugs of abuse can cause depressive symptoms
Alcohol: very commonly a cause of depression, as well as a reaction to
This list is taken from a paper by Dr. Ronald Diamond and should not
substitute for consultation with a doctor. It is provided as a public
service of AMI/FAMI in NYC. For more information, contact AMI/FAMI at 432
Park Ave. South, New York, NY 10016. Call (212) 684-3264
Note: I don't have access to any of these periodicals - If someone can identify sources for them on the Internet please let me know. Otherwise your local college library is probably your best bet.
R2123.Electroconvulsive therapy: a review on indications,
methods, risks and medication. Stevens A, Fischer A, Bartels M,
Buchkremer G. 1996;11. pp.165-174.
2124. Functional hemisphere imbalance in patients with paranoid
or disorganized schizophrenia. Spivak B, Karny N, Katz G, et al.
2125. Psychogenic paranoid psychosis: an empirical study.
Vicente N, Ochoa E, Rios B. 1996;11. pp.180-184.
2126. A psychometric evaluation of dementia rating scales.
Korner A, Lauritzen L, Bech P. 1996;11. pp.185-191.
2127. Burden on the families of patients with obsessive-compulsive
disorder: a pilot study. Magliano L, Tosini P, Guarneri M, Marasco C,
Catapano F. 1996;11. pp.192-197.
2128. Internal validation of a French version of the Dutch Eating
Behaviour Questionnaire. Lluch A, Kahn JP, Stricker-Krongrad A,
Ziegler O, Drouin P, Mejean L. 1996;11. pp.198-203.
2129. The efficacy of a dose-escalated application of transdermal
nicotine plus sulpiride in Tourette's syndrome. Dursun SM, Reveley MA.
2130. Obsessive-compulsive symptoms in panic disorder: the association
with major depression. Agargun MY, Kara H, Alpkan L, Ucisik M. 1996;11.
2131. Suicidality in patients with panic disorder: the association with
comorbidity. Agargun MY, Kara H. 1996;11. pp.209-211.
2132. Tricyclics and malignant syndrome. Abbar M, Carlander B,
Castelnau D. 1996;11. pp.212-213.
The British Journal of Psychiatry
2133. The Mental Health Residential Care Study: Classification of
Facilities and Description of Residents. Lelliott P, Audini B, Knapp M,
Chisholm D. 1996;169. pp.139-147.
2134. The Neural Correlates of Inner Speech and Auditory Verbal
Imagery in Schizophrenia: Relationship to Auditory Verbal Hallucinations.
McGuire PK, Silbersweig DA, Wright I, Murray RM, Frackowiak RSJ,
Frith CD. 1996;169. pp.148-159.
2135. Life Events and Primary Affective Disorders. A One Year
Prospective Study. Pardoen D, Bauwens F, Dramaix M, et al. 1996;169.
2136. The Bereavement Response: A Cluster Analysis. Middleton W,
Burnett P, Raphael B, Martinek N. 1996;169. pp.167-171.
2137. The Entry of Mentally Disordered People to the Criminal Justice
System. Robertson G, Pearson R, Gibb R. 1996;169. pp.172-180.
2138. Individual Behavioural-Cognitive Therapy v. Marital Therapy
for Depression in Maritally Distressed Couples. Emanuels-Zuurveen L,
Emmelkamp PMG. 1996;169. pp.181-188.
2139. A Controlled Trial of Cognitive-Behavioural Treatment of
Hypochondriasis. Warwick HMC, Clark DM, Cobb AM, Salkovskis PM.
2140. Body Dysmorphic Disorder. A Survey of Fifty Cases. Veale D,
Boocock A, Gournay K, et al. 1996;169. pp.196-201.
2141. Deliberate Self-Poisoning and Self-Injury in Children and Adolescents
Under 16 Years of Age in Oxford, 1976-1993. Hawton K, Fagg J, Simkin S.
2142. Symptoms of the Schizophrenic Negative Syndrome. Peralta V,
Cuesta MJ. 1996;169. pp.209-212.
2143. Age at Onset in Schizophrenia and Risk of Illness in Relatives.
Results from the Roscommon Family Study. Kendler KS, Karkowski-Shuman
L, Walsh D. 1996;169. pp.213-218.
2144. Prevalence and Cluster Typology of Maladaptive Behaviours in a
Geographically Defined Population of Adults with Learning Disabilities.
Smith S, Branford D, Collacott RA, Cooper S-A, McGrother C. 1996;169.
2145. Cumulative Incidence and Prevalence of Childhood Autism in
Children in Japan. Honda H, Shimizu Y, Misumi K, Niimi M, Ohashi Y.
2146. Physical and Psychiatric Comorbidity in General Practice. Kisely
SR, Goldberg DP. 1996;169. pp.236-242.
2147. A Genetic Linkage Study of the D2 Dopamine Receptor Locus in
Heavy Drinking and Alcoholism. Cook CCH, Palsson G, Turner A, et al.
British Medical Journal
2148. St John's wort for depression-an overview and meta-analysis of
randomised clinical trials. Linde K, Ramirez G, Mulrow CD, Pauls A,
Weidenhammer W, Melchart D. 1996;313. pp.253-258.
2149. Road traffic noise and psychiatric disorder: prospective findings
from the Caerphilly study. Stansfeld S, Gallacher J, Babisch W, Shipley
M. 1996;313. pp.266-267.