Here is a draft I wrote about flashbacks and PD
1 L-Dopa Flashbacks in Parkinson Disease
1.1 Introduction
1.2 Flashbacks - Past Reality
Flashbacks are a vivid reliving of real but historical
events, for example Vietnam veterans and combat.
1.3 Emotional Reality
The veteran knows he is no longer in Long Tan. He
experiences the feelings. The quick reacting, emotional
"Right Brain" is still expecting danger. Part of him
doesn't know the war is over. A car backfiring or a
helicopter triggers the experience.
1.4 Hallucinations - Distortion of Reality
Hallucinations, like seeing an ocean liner cross the
highway, are a distortion of reality
1.5 Treatment
Drug treatment is difficult, especially in Parkinson Disease
where dopamine antagonists are contraindicated.
Psychological treatment is based on reality. The experience
is real, but it is a past reality. Guided visualisation is
one way of helping the "subconscious" to come home from the
war.
1.6 Method
This report is based on support group workshops and
discussion with Parkinsonians.
1.7 Report of Cases
The cases are the stories of people with PD, from their
perspective. Each case is chosen to illustrate a point, and
is based on a real experience.
1.8 Anthropology
The perspective is somewhat anthropological, as the author
has PD.
1.9 Cases
1.9.1 I Had to Take Hold of Myself
Vignette
A gentle person, she saw people standing around the foot of
her bed, talking. They wore suits. She recognised them as
people from her past. She "had to take hold of herself" to
distinguish present from past reality. She only took two
Carbidopa/L-Dopa 100mg/25mg per day. Her flashbacks
corresponded to the estimated peak L-Dopa brain levels. She
was advised to try slow release C/L to minimise peaking.
1.9.2 This case illustrates
1.9.2.1 Vivid memories
Her memories were not merely history book narratives.
Sights, sounds, tastes, smells and emotions accompany
flashbacks. The person is in danger of becoming a
participant in a vitual reality
1.9.2.2 Real memories
The men were real. Her experience superficially resembles an
hallucination.
1.9.2.3 Reality maintained
She was able to keep in touch with reality, to look at the
past and the present and to know the difference, somewhat
like knowing the difference between live tv and videotape.
This is called reality testing, and we do it all the time.
1.9.2.4 Peak dose effects.
A constant level of drug enables the brain to adjust. Levels
that rise and fall rapidly cause symptoms because the brain
cannot adjust quickly. This is why short acting
benzodiazepines such as halcion can cause strange effects.
1.9.3 Happy Memories
1.9.4 Vignette
The past for this 70 year old was full of real but happy
memories. There were no terrors because his parents had been
loving and wise. His memories of life on the farm were many
and varied. Strong men making haystacks, gardens full of
mulberries, plums, grapes, and figs. Women who made jam,
washed in coppers and fed shearers and harvest workers.
Great gentle horses pulling ploughs that turned the sod in
one long never ending strip. People who treated him with
warmth and compassion, who celebrated death even as they
grieved for those who died.
Happy Memories had a normal subconscious, which is a place
of happiness. Visiting the normal subconscious is like
visiting a happy, playful child who lives with nurturing
people in a tropical rainforest, full of amazing and
wonderful sights and sounds
1.9.5 This case illustrates
1.9.5.1 Vivid memories
These memories are the first and most permanent, and persist
when Alzheimer's disease plays havoc with later memory.
1.9.5.2 Happy memories
People with happy memories can tolerate larger doses of L-
Dopa. Loss of contact with reality is still possible.
1.9.5.3 Happy normal subconscious
Freud's view of the subconscious as the place where
repressed feelings exist is simplistic in the extreme. Freud
described only the pathology of the subconscious, a process
like mistaking lung cancer for the normal lung. His view was
further distorted because he took the adultist view that the
people he saw were unreasonably angry with their parents,
when in fact the parents had been violent towards the
children. The normal subconscious is happy, but not to be
confused with idealised memories. The normal subconscious
has resolved panful events such as the death of a loved one,
whereas idealised memories indicate amnesia for painful
events.
1.9.6 Four Leafed Clover
1.9.7 Vignette
L-Dopa caused a return to the Ireland of his childhood, with
bonnets, baby carriages, and violence, namely people hitting
each other with pieces of wood. Everything looked large, the
way it would to a child.
1.9.8 This case illustrates
1.9.8.1 Reality confirmed by content
The period clothes, the view from a child's perspective, and
the historical record of growing up in Ireland where violece
was commonplace support the diagnosis of flashbacks.
1.9.9 Kokoda Veteran
1.9.10 Vignette
Despite the reality of the present world, Kokoda was
spending much of his time fighting the Japanese in New
Guinea in World War Two. Suggestions made included stopping
bromocryptine, using a D2 blocker, talkig reality therapy,
and possibly treating the Post Traumatic Stress Syndrome.
1.10 This case illustrates
1.10.1 Post Traumatic Stress
Children exposed to stress while their personality is
forming develope Post Traumatic Stress Syndrome. Because
their personalities are still forming, they can also
develope problems like multiple personality disorder.
Kokoda has no such problems, but reliving war experience is
torment enough.
1.10.2 Failure to distinguish past from present
Reality therapy is talking about and showing and touching
real things, be they people, pets, cars, trees. The past
reality is not denied, or treated with drugs, but calmly
accepted for what it is - a painful, past reality. This is
best done right at the time of stress. Prevention is better
than cure.
1.10.3 Reality confirmed by history
External confirmation is helpful, but not always
forthcoming, and not always sought after.
1.10.4 Continued vigilance at subconscius level
Kokoda still hits the ground when cars backfire. It is as
though noone has told the subconscious person the war is
over. Therapy is aimed at telling the symbolic 'Right brain'
that the war is over.
1.10.5 Lost Child
1.10.6 Vignette
This 50 year old professional found himself in a childhood
where there was all kinds of violene - physical, verbal, and
sexual. A terrifying, depressing, crazy reality of knives,
fire torture, and rape. A reality previously experienced as
nightmares, hidden by amnesia. Rather than give up
treatment, he underwent counselling to try and live with the
traumatic past and be able to move in the present.
1.10.7 This case illustrates
1.10.7.1 Anamnesia
Sachs describes the breaking down of amnesia by L-Dopa, but
no other references are known to me.
1.10.7.2 Paucity of historical confirmation
Very little external evidence existed to support the reality
of these past experiences.
1.10.7.3 Reality confirmed by content
Some scenes were seen from a child's view, eg through the
bars of a cot.
1.10.7.4 Ease of confusion with schizophrenia
It is easy to see that the absence of external evidence
could lead to the view that Lost Child was out of touch with
reality. A label of schizophrenia easily follows.
1.10.7.5 Dilemma of dose
The dose of L-dopa is hard to stabilise. Too much causes
flashbacks, too little causes lethargy. There is a tightrope
effect.
1.10.7.6 Dilemma of Dopamine antagonists
Possible selective L-Dopa antagonists such as clozapine may
help suppress the psychiatric side effects. However, there
is commonality amongst receptors. Giving dopamine blockers
to PD sufferers goes against the grain, but there have been
favorable reports. Bone marrow depression is said to be
fatal one in 3,000 cases. There is a report of ondansetron
being used in a letter to the BMJ.
1.11 Discussion
It is important to differentiate between schizophrenia and
flashbacks, since the treatment may be very different.
Lloyd Stewart
