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Primary Care Psychiatry
A Quick-Reference Guide
SECTION 1: BASIC PRINCIPLES
PSYCHIATRY AT THE PRIMARY LEVEL
In the past mental healthcare was burdened by a separation of psychiatric
services from general medicine. In addition, a predominantly hospitalbased system has limited access to healthcare. A primary care approach
aims to provide an integrated service that is accessible to the majority of
people and is also affordable.
An approach to assessment of mental disorders in
primary care settings
1. Exclude general medical conditions: a thorough physical
examination in patients who present with psychiatric symptoms is
mandatory.
2. Identify people with serious mental illnesses including psychoses
and severe mood disorders. These disorders are usually identifiable
without difficulty. Nevertheless, the extent of depression may not
be clear without a thorough and systematic history, mental state
examination and risk assessment. Patients with acute severe mental
illnesses usually require admission to hospital for a short period of
time or referral to a specialised mental health service. Patients who
are stable need to be managed comprehensively, including the
identification and management of common and co-morbid chronic
medical diseases.
3. Identify people with other mental disorders. Determine whether
these are likely to be self-limiting and can be managed with support
and follow-up or whether a more definitive intervention is required.
An approach to the management of mental disorders in
primary care settings
1. Manage emergency situations: a calm confident and co-ordinated
approach is required in these situations. A team approach is also
important. Policies in training and in techniques of calming and
restraint need to be established and maintained. It is important to
ensure that suitable medications are available for use in these
situations and are readily accessible.
2. Identify patients who need referral: referral systems need to be
clearly established and communicated. It is recommended that
contact be made with practitioners in the mental health service in
the relevant area. It may also be possible for them to provide
telephonic support in remote areas.
3. Provide the necessary psychiatric medication: a range of suitable
psychiatric medications are available on the primary level Essential
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Drugs List (EDL). Primary care practitioners should be familiar with
these medications, as well as indications, dosages, side-effects and
contra-indications. The majority of patients should be managed at
the primary level, but clinicians need to have a system of referral in
place for those who do not respond to treatment.
4. Provide psychosocial interventions: the apparently simple measures
of listening and understanding people’s problems can significantly
alleviate distress. Psychosocial interventions may be required and
practitioners should be familiar with resources that are available in
their areas. These may include counsellors, mental health nurses,
social workers, psychologists and occupational therapists working in
the district health service as well as non-governmental
organisations. Time invested in making links with available
resources is worthwhile in the longer term, and provides improved
and more comprehensive and sustainable care for those in need.
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SECTION 2: CLINICAL EVALUATION
INTERVIEWING AND ASSESSMENT
The most important skills required for anyone working in the field of
mental health care are those needed to interview a person who may be
suffering from a mental illness. This is because the interview not only
involves the taking of a history, but also constitutes a substantial
component of the examination and is part of the intervention.
The interview is in itself a therapeutic exercise, and is the start of a
collaborative process with the patient and potential caregivers. It should
assist in identifying problems and to embark on strategies to deal with
them.
Skills required are the ability to:
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be aware of your own emotions and behaviour
establish and maintain rapport
make continuous, careful observations
develop and test the hypotheses that may arise
adjust the interview accordingly.
The interview setting
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The consultation room should be private, have a calming
atmosphere and inspire confidence.
Disruptions should be kept to a minimum, one therefore needs to
inform other staff members when a consultation is in progress. This
will prevent any interruptions that may arise in the case of an
emergency.
In most cases a one-to-one private consultation is preferred, but
should there be any sense of danger, the presence of an additional
person to support either clinician or patient may be required. This
may also be necessary when there is a concern regarding sexual
impropriety or allegations made regarding inappropriate sexual
conduct.
The therapeutic relationship
An important initial goal in any psychiatric interview is the development of
a trusting relationship with the patient. The clinician should pay attention
to how he/she presents him/herself, taking care to demonstrate respect
and concern.
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Pay attention to the following:
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Your own appearance: This should be professional, culturally
acceptable and neither threatening nor provocative.
Courtesy: Be polite, empathic, responsive and respectful.
The initial introduction: Ensure that you introduce yourself
clearly and warmly and that you explain the nature and purpose of
the interview.
An explanation of the limitations of the interview: Explain that
you may need to interrupt or redirect the interview.
Eye contact: Maintain reasonable eye contact but at the same
time, ensure that your body language is not in any way threatening
or challenging.
Confidentiality: Address any concerns the patient may have
regarding confidentiality, but also be honest about circumstances
which may demand that confidentiality be broken.
The assessment and engaging with multiple processes
In order to successfully perform an assessment in the limited time that
may be available in the primary setting, one needs to engage with
multiple processes simultaneously.
The multiple processes include:
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developing rapport
obtaining a clear history of the presenting problem and using clinical
reasoning to decide what further details may be required
following the form of the patient’s account and identifying
pathological features
identifying areas of risk.
Certain key pieces of information needs to be obtained in every case, this
information is set out in the following sections. A balance is required
between maintaining a structured approach and allowing for a degree of
flexibility as the clinical situation requires. The following 5 points make up
the scheme for assessment at the primary care level:
Scheme for assessment at the primary care level
1.
2.
3.
4.
5.
The
The
The
The
The
history
mental state
physical examination
summary and formulation
management plan
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1. The history
When taking a history, ensure the following information is gathered.
Identifying data
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Name
Age
Sex
Marital status
Number of children/ dependents
Employment status
Level of education
Ethnic origin
First language
Religious affiliation
Current living circumstances, including family and immediate social
supports.
Note the source and means of the referral, and comment on the urgency
of the problem. Note those most involved, and likely to be affected by the
presenting problem. Some indication as to the reliability of this
information is useful, in addition to who might be available to provide
further information.
Presenting complaint and history of the complaint
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Record the presenting problem/s in detail reflecting the patient’s
own account, or the account of others identifying the problem.
Record the duration of the complaint and related symptoms,
precipitating factors and the sequence of events leading up to the
current situation, including whether the onset was sudden or
gradual.
Enquire about related symptoms from the symptom cluster of the
presenting complaint, and consider basic screening questions
related to other possible disorders.
Note any medication or other treatments that have been used to
date, and note beneficial or adverse responses.
Enquire about substance use in relation to the presenting problem.
Establish what sense the person makes of the problem, what the
causes might be, and how they expect and wish to be treated.
Medical history
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Past and current medical illness
Use of any medications
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Exclude past head injury, epilepsy, tuberculosis, syphilis, HIV,
cardiac disease, diabetes and endocrine disorders.
Drug and alcohol history
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Detailed account of all substance use
Use a non-judgemental manner that promotes the free flow of
information
Forensic history
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Current legal or criminal matters
History of past forensic issues
Family history
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Patient’s family of origin
Family history of psychiatric illness, medical illness and substance
abuse
Closest member of the family or the principal caregiver
A genogram for a quick overview of the family relationships and
dynamics.
Personal history
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Early life and development
Education
Employment
Psychosexual relationships
Religion and culture
Social circumstances.
Premorbid personality
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An account of temperament
How he or she might see themselves
How he or she relates to others
Interests, pastimes and hobbies
An evaluation of coping skills.
2. The mental state examination (MSE)
A detailed knowledge of the MSE is required in order to be able to perform
an adequate psychiatric assessment. This should begin at the time of the
first encounter with the patient, and should take place continuously
throughout the interaction.
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Appearance and behaviour
Almost every aspect of an individual’s appearance, demeanour and
behaviour can provide information which may be of value in
understanding a person and their difficulties.
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General physical condition:
o vital signs and general physical health
o general nutritional status, signs of malnutrition or neglect
o signs of substance abuse or withdrawal
o signs of past illness, surgery or trauma, especially head or
neck trauma.
Levels of alertness and arousal:
o the ability to engage and to co-operate
o any signs of irritability or increased arousal
o general level of awareness of surroundings
o level of psychomotor activation or slowing.
Dress:
o grooming and general physical appearance
o choice of clothing and appropriateness thereof
o any notable idiosyncrasies.
Demeanour and general behaviour:
o demeanour and attitude to others
o willingness to co-operate or hostility
o general attitudes to others.
Movements:
o tremors, and dystonias or abnormal movements, which may
be associated with both schizophrenia and its treatment
o tics and other complex abnormal movements, which may be
due to a neurological disorder and features associated with
catatonia, including mannerisms, stereotypes, unusual
grimacing or posturing, imitative and automatic behaviours.
Orientation and level of consciousness
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Assessment of consciousness is critical throughout
Assess orientation to place, person and most importantly, time
If there is evidence of poor orientation, consider the possibility of
delirium.
Mood and affect
Mood and affect both refer to the emotional state of the patient.
The moodis a sustained emotional state that exists for an extended
period of time and is therefore derived from an historical account, usually
given by the patient, and tends to be subjective. An objective account of
mood may also be obtained from collateral information.
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The affect is described as the feeling or tone in the interview, as
observed by the clinician. It is therefore objective by definition.
In mania, the affect may be described as:
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expansive, elevated and euphoric
irritable.
In depression, the affect may be described as:
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low, sad, flat or blunted
anxious or depressed.
In psychosis, the affect may be described as:
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perplexed, restricted or blunted
incongruent or labile.
A critical component of the assessment of mood is suicidal thinking or
intent. An explicit enquiry needs to be made and the response
documented. Failure to do so is medically negligent and may have
medico-legal consequences.
Speech
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Note abnormalities in the rate, rhythm, volume and tone of speech.
Rate and volume are usually elevated in mania and decreased in
depression.
Tone and rhythm tend to be flat or variable in schizophrenia,
depression or catatonic states.
Thought form and types of formal thought disorders
Disorders of the form of thought refers to the way in which thoughts are
structured, organised and communicated. This is assessed based on the
clinician’s observations of the patient’s speech. In assessing for psychosis,
it is critical to assess the patient for the presence of formal thought
disorder. This is characterised by disturbances in the process of thought,
these disturbances in the thought processcan be described the terms
listed below:
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Loosening of associations: Unrelated or vaguely related ideas are
expressed without any meaningful connections between them
Circumstantiality: An inability to get to the point
Tangentiality: Association between two thoughts may be apparent
but there is a subsequent drift away from the relevant subject
matter
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Neologisms: New or known words are used in an idiosyncratic
manner
Clang associations: Thoughts are associated on the basis of words
which rhyme
Incoherence: Loss of relevance and logic to the extent that the
speech is incomprehensible
Thought blocking: Sudden halt due to a loss of the train of
thought
Flight of ideas: Rapid but understandable shift from one topic to
the next, commonly associated with mania.
Content of thought and delusions
In investigating the possibility of a psychotic illness, the identification of
the delusional content of thinking is of critical importance. A delusion is
defined as a fixed, false belief that is culturally inappropriate.
Common types of delusions are discussed below.
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Delusions of grandeur: A belief that one has special abilities, or
great power or wealth, or some other exaggerated positive belief
about oneself.
Delusions of persecution: A belief that one’s life is being
interfered with by others in a harmful manner.
Delusions of reference: The belief that neutral stimuli, e.g. radio
messages or characters on television make special reference to
oneself.
Religious delusions: False beliefs of a religious nature, e.g. one is
god or a prophet. In some cases it may be critical to ensure that the
belief is indeed inappropriate for the particular religious group.
Erotomanic delusions: The belief that another person, often
someone of high public profile, is in love with one.
Delusions of misidentification: A belief that another or others,
with whom one is generally familiar, are not who they say they are
and have been replaced by impostors.
Somatic delusions: Beliefs about the body or body parts.
Nihilistic delusions: Commonly associated with depressive
psychosis, these are profoundly negative beliefs that aspects of
oneself or of the world are disappearing, rotting away, or dying.
Delusions of thought control: Commonly known as passivity
phenomena, these are the subjective experiences that some or all
of one’s thoughts, feelings or acts are foreign, and not emanating
from oneself.
Other, non-psychotic phenomena: these include ruminations and
obsessions. The latter are recurrent, unwanted thoughts that the
individual experiences as intrusive and difficult to control.
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Perceptual abnormalities
A hallucination may be defined as the perception of a single occurence
without any corresponding material event, or as a perception in the
absence of an external stimulus.
Hallucinations may be experienced in a range of modalities: auditory,
visual, gustatory (taste), olfactory (smell) and tactile (touch).
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Auditory hallucinations are most common in psychotic disorders.
Command and third person commentary-type hallucinations are
more typical of schizophrenia.
Hallucinations in other modalities, and especially when occurring in
multiple modalities, should raise a high index of suspicion of an
underlying general medical condition, particularly withdrawal
delirium, encephalopathy due to an infective agent and temporal
lobe seizures.
Cognitive function
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Basic cognitive functions include orientation, attention and
concentration, memory, intelligence, and the capacity for insight
and judgement.
With the exception of orientation, insight and judgement, the extent
of cognitive function assessment will be based on the presenting
problem and the suspected syndromal diagnosis.
Cognitive Assessment
Orientation
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Must be assessed early on in the interview to exclude delirium if
orientation is poor.
May then indicate the need for:
careful physical assessment if delirium is suspected
careful cognitive assessment in suspected dementia
specific assessment in cases of suspected intellectual disability or
catatonic states.
Attention and concentration
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Gain an impression of the ability to pay attention and distractibility
through observation.
Test by asking the patient to subtract 7 from 100 serially, or to spell
‘world’ backwards.
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Memory
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Includes a number of distinct functions that can be tested.
Registration or immediate retention can be assessed by asking the
patient to repeat up to five items named by the clinician.
Short-term memory can be tested by asking the patient to
remember the items (and in the event of attention or registration
problems, helped to do so), and requested to repeat the items a few
minutes later in the interview.
Longer-term memory can be assessed by inquiring about past
events. Confabulation or the unconscious giving of false answers in
the place of missing memory is highly suggestive of an alcohol
amnesia disorder or Korsakoff’s psychosis.
Memory is important to test where dementia is suspected but is
seldom critical as a primary level assessment.
Capacity for abstract thinking
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This refers to the ability to deal flexibly with concepts, a deficit of
which is referred to as concreteness.
Can often be inferred in the history taking, but specific tests include
the ability to explain similarities and to interpret simple, culturally
appropriate proverbs.
Tends to be disturbed in chronic schizophrenia and in intellectual
disability.
Intellectual ability
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Make a basic judgement of intellectual impairment, particularly
when aspects of the history suggest this may be the case and when
aspects of the assessment otherwise do not seem to fit together.
Question the individual’s long-term capacity for independent
functioning in the home and work environment.
Question the ability to work with money and do simple sums, and to
read and write.
Use of vocabulary and language may also be helpful indicators,
taking into account use of first or second language and educational
level.
Do not make any firm pronouncements without more formal testing.
Insight and judgement
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This is a critical assessment that informs both the risk assessment
and treatment plan.
Judgement refers to the patient’s ability to understand the likely
outcomes of his or her behaviour and to act in accordance with this
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understanding in keeping with social and legal norms. This can
usually be inferred from the history.
Insight refers to the patient’s capacity to understand that he or she
might be ill and to act in accordance with this understanding.
Question explicitly in this regard.
The mini-mental state examination (MMSE)
Parameter
Item
Points
Orientation
What is the year?
1
What is the season?
1
What is the date?
1
What is the day of the week?
1
What is the month?
1
Which country are we in?
1
Which province are we in?
1
Which town or city are we in?
1
Which building are we in?
1
Which street or floor are we on?
1
Registration
Name three objects slowly and carefully, then ask
the patient for all three items, giving one point for
each correct item named. Then repeat the items
until the patient can repeat all three.
3
Attention and
Calculation
Serial sevens: Ask the patient to subtract 7 from
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100, giving only the answer, then to subtract 7 from
that number, giving only the answer and continue to
do so 5 times in total. Or spell WORLD backwards.
Give one point for each correct answer/letter.
Recall
Ask the patient to name the three objects
mentioned in the test of registration. Give one point
for each correct answer.
3
Language
Ask the patient to identify a pencil.
1
Ask the patient to identify a watch.
1
Ask the patient to repeat the phrase ‘No ifs, ands or
but’s.’
1
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Construction
Ask the patient to follow the three-stage command:
Take a paper in your right hand, fold it in half and
put it on the floor.
3
Ask the patient to read the following and obey:
CLOSE YOUR EYES
1
Ask the patient to write a sentence.
1 for a
correct,
complete
sentence
Ask the patient to copy the following design:
The clock drawing test
The clock test provides a useful assessment of two important frontal lobe
functions, executive function and response inhibition.
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Ask the patient to draw a clock face and to fill in the numbers.
Let them know that you will then tell them what time to draw on the clock.
If they are unable to draw this on their own, you may assist.
Once the face is completed, ask them to indicate the time as “Ten past
three”, and note this command below the drawing.
The following aspects of their performance should be observed:
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drawing of the face, which tests construction
placement of the numbers, which tests construction and executive function
placement of the hands, which tests construction, executive function and
inhibition
note the patient’s ability to plan and place the numbers correctly
note the ability to inhibit the initial response to the cue “ten” such that the
minute hand is not placed at the ten but at the two (i.e. ten minutes)
International HIV dementia scale (IHDS)
In cases where the patient is known to be HIV positive, the HIV Dementia Scale is
a useful screen for HIV-associated dementia.
This is a brief screening tool that measures impairments in the three critical
domains of memory, executive functioning and motor speed. It is not a diagnostic
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instrument, and if impairments are evident, more formal neuropsychological
testing is indicated.
a) Memory-Registration
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Give four words to recall (dog, hat, bean, red)
Allow 1 second to say each
Then ask the patient all four words after you have said them
Repeat words if the patient does not recall them all immediately
Tell the patient you will ask for recall of the words again a bit later.
b) Motor speed
Have the patient tap the first two fingers of the non-dominant hand as widely and
as quickly as possible. Score as follows:
4 = 15 in 5 seconds
3 = 11‒14 in 5 seconds
2 = 7‒10 in 5 seconds
1 = 3‒6 in 5 seconds
0 = 0‒2 in 5 seconds
c) Psychomotor speed
Have the patient perform the following movements with the non-dominant hand as
quickly as possible:
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clench hand in fist and place flat on surface
put hand flat on surface with palm down
put hand perpendicular to flat surface on the side of the 5th digit.
Demonstrate and have patient perform twice for practice. Score as follows:
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4
3
2
1
0
=
=
=
=
=
4 sequences in 10 seconds
3 sequences in 10 seconds
2 sequences in 10 seconds
1 sequence in 10 seconds
unable to perform.
d) Memory-recall
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Ask the patient to recall the four words
For words not recalled, prompt with a semantic clue as follows: animal
(dog); piece of clothing (hat); vegetable (bean); colour (red)
Give 1 point for each word spontaneously recalled
Give 0.5 points for each correct answer after prompting
Maximum – 4 points
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The total international HIV dementia scale score is the sum of the scores on items
1‒3. The maximum possible score is 12 points. A patient with a score of < 10
should be evaluated further for possible dementia.
3. Physical examination
A careful physical examination is integral to the primary assessment of
any patient presenting with psychiatric symptoms.
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Remember to exclude general medical conditions.
Consider the possibility of delirium mimicking other psychiatric
conditions.
However, do not overlook co-occurring medical conditions.
Additionally, look for injury as a consequence of disturbed behaviour
and the possibility of a recent suicide attempt that might not have
been declared.
4. Summary and formulation
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Providing a brief summary of the case is a useful and important
skill, this helps to identify the most important features of the
presenting problem.
This should include the basic identifying features, a brief statement
of the presenting complaint and any important predisposing
features, a syndromal diagnosis with an assessment of the certainty
with which this is made, and an assessment of any current risk
factors.
The formulation is a more extensive account that summarises the
available information for the clinician, setting out any immediate
priorities and an action plan for further management.
The formulation provides a framework for the management plan.
5. Management plan
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A biopsychosocial framework should be used when developing a
management plan.
Details of management are discussed in later chapters.
DIAGNOSIS AND CLASSIFICATION
Diagnosis and classification in psychiatry pose a number of problems:
there are no single objectively measurable causes for the majority of
mental disorders, no confirmatory tests, few pathognomonic features, and
unclear boundaries between disorders. Partly because of these difficulties,
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current diagnostic constructs have an uncertain validity. Current systems,
principally the DSM-5 and the ICD-10, should therefore be considered as
provisional, tentative, hypothetical constructs that will in all likelihood
change in the light of emerging knowledge in the neurosciences,
linguistics, philosophy and anthropology.
The two major international classification systems in current use are the
Diagnostic and Statistical Manual of Mental Disorders (fifth edition) or
DSM-5™, published by the American Psychiatric Association (APA) in May
2013, and the ICD-10 Classification of Mental and Behavioural Disorders
(ICD-10), published by the World Health Organisation (WHO) in 1992.
ICD-10
This is a general medical classification system that has been translated
into most of the world’s commonly spoken languages. It is the official
coding system for the recording of health data in many countries around
the globe, including the United States of America, as well as locally.
The ICD-10 Multi-axial system
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Axis I: Clinical diagnoses
Axis II: Disablements
Axis III: Contextual factors.
The ICD-10 categories of mental disorders
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F0 Organic, including symptomatic, mental disorders
F1 Mental and behavioural disorders due to psychoactive
substance use
F2 Schizophrenia, schizotypal and delusional disorders
F3 Mood (affective) disorders
F4 Neurotic, stress-related and somatoform disorders
F5 Mental disorders associated with physiological dysfunction and
physical factors
F6 Abnormalities of adult personality and behaviour
F7 Mental retardation
F8 Developmental disorders
F9 Behavioural and emotional disorders with onset usually
occurring in childhood or adolescence.
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DSM-5
The DSM is the dominant diagnostic system in academic, clinical and
research settings in South Africa. The overall structure and diagnostic
groupings in the DSM-5 are:
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Neurodevelopmental disorders
Schizophrenia spectrum and other psychotic disorders
Bipolar and related disorders
Depressive disorders
Anxiety disorders
Obsessive-compulsive and related disorders
Trauma- and stressor-related disorders
Dissociative disorders
Somatic symptom and related disorders
Feeding and eating disorders
Elimination disorders
Sleep-wake disorders
Sexual dysfunctions
Gender dysphoria
Disruptive, impulse-control, and conduct disorders
Substance-related and addictive disorders
Neurocognitive disorders
Personality disorders
Paraphilic disorders
Other mental disorders
Medication-induced movement disorders and other adverse effects
of medication
Other conditions that may be a focus of clinical attention.
DSM-5™ has abandoned the multiaxial system of diagnosis. Like the ICD10, mental disorders, personality disorders, intellectual disability and the
relevant medical disorders are all coded on one diagnostic axis.
Significant psychosocial stressors and other important contextual factors
are listed in addition to the clinical diagnoses, and this replaces the
previous Axis IV. Axis V (Global Assessment of Functioning) has been
replaced by an assessment in terms of the World Health Organisation’s
Disability Assessment Schedule (WHO-DAS).
INVESTIGATING PSYCHIATRIC DISORDERS
A comprehensive clinical assessment and thorough examination remains
the foundation in the diagnosis of patients presenting with psychiatric
symptoms. Investigations are predominately used to exclude general
medical conditions and to monitor the side effects and adverse effects of
pharmacological agents.
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Investigations can be divided into the following categories:
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Haematological
Urine studies
Cerebrospinal fluid
Neuroimaging
Other
Haematological investigations
Consider the following:
Full blood count
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An elevated white cell count (WCC) may suggest an underlying
infective or inflammatory process which could co-occur with a
psychiatric illness or as the cause of a delirium mimicking
psychiatric symptoms.
Low haemoglobin levels together with changes in mean corpuscular
volumes are markers of anaemia.
Moderate to severe anaemia may present with fatigue, headaches
and lethargy, which may be mistaken for a depressive disorder.
Palpitations in severe anaemia may be mistaken for symptoms of a
panic disorder.
Unless there are specific indications, a WCC and Hb, rather than a
FBC are sufficient and cost effective as screening investigations.
Serum electrolytes
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Deranged electrolyte levels are often seen in cases of delirium and
in patients on diuretic or lithium treatment.
Hyponatraemia is seen in SIADH (Syndrome of Inappropriate Antidiuretic Hormone).
SIADH is a known side-effect of psychotropic agents such as
fluoxetine, antipsychotics and carbamazepine.
SIADH often presents with delirium and as such a psychiatric
patient on these medications may appear to be deteriorating whilst
on treatment.
Renal functions


Several psychotropic and physical medications are excreted by the
kidneys.
Establish baseline renal function and monitor regularly as impaired
renal clearance may result in toxic psychotropic medication serum
levels. This is obligatory prior to treatment with lithium.
18

Creatinine clearance or creatinine levels are the most sensitive
markers of renal clearance function.
Liver functions





Total protein is a measurement of serum albumin and globulins.
Poor nutrition due to eating disorders or chronic alcohol misuse may
be associated with diminished total protein levels.
Several psychotropic medications are protein bound and as such,
total serum concentration of the unbound or active form of
medication will be elevated in low protein states. Liver disease is
associated with elevated liver enzymes.
Elevated γ-glutamyl transpeptidase (GGT) is indicative of alcohol
liver disease or obstructive bile duct disease.
Elevation of aspartate transaminase (AST) is greater than elevation
of alanine transaminase (ALT) in alcohol liver disease whilst the
opposite is true of viral hepatitis.
Infectious diseases
Always consider the possibility of an infectious illness in a patient
presenting with psychiatric symptoms. Common infections to consider
include:


HIV/AIDS:
o commonpresentations include delirium, mania, psychosis,
apathy and dementia
o suggest a finger prick ‘rapid’ HIV test, which is the most
common screening test
o confirm with either the enzyme linked immunosorbent assay
(ELISA) or the Western blot test.
o a positive HIV result should be followed by tests to evaluate
the extent of disease burden and the extent to which the
immune system has been compromised.
o the viral load is used to estimate the HIV disease burden
whilst the T4/T8 helper cell ratio and T4 cell counts (CD4
count) are used to estimate degree of immune-compromise.
Syphilis:
o there aretwo categories of syphilis tests: treponemal (FTAABS and TPHA) and non-treponemal tests (RPR and VDRL).
Treponemal tests have better sensitivity and specificity for
syphilis than non-treponemal tests and remain positive for life
o the non-treponemal test will only be positive during recent
infection. As such the RPR or VDRL tests are often used as
screening tests. A negative screening test (RPR or VDRL)
suggests no recent infection.
19
Endocrine investigations
Several endocrine disorders may present with psychiatric symptoms or
with symptoms misinterpreted as psychiatric in origin. Psychotropic
medication may induce abnormalities in various endocrine organs.
Some examples include the following:



Thyroid disease:
o dysfunction may be associated with several psychiatric
symptoms including depression, anxiety, dementia and
psychosis
o the screening test used is the thyroid stimulating hormone
level (TSH). If this is abnormal, a repeat TSH and a T4 test
are required.
Parathyroid disease:
o this hormone regulates serum calcium and phosphate levels
o primary hyperparathyroidism may present with depression,
anxiety, cognitive slowing, and in severe cases, delirium
o it is associated with abnormal calcium and phosphate levels.
Adrenal disease:
o the two most common forms of adrenal disease are Addison’s
disease and Cushing’s syndrome
o physical symptoms include fatigue, weakness, and dizziness
o may also present with a range of psychiatric symptoms
including depression, anxiety, mania, psychosis, memory
impairments and delirium
o the dexamethasone supression test (DST) is a primarily a
research tool and is not used in routine clinical investigations.
Vitamin levels



Chronic alcohol misuse is often associated with deficiencies of
vitamin B12 and folate.
Both deficiencies can give rise to megaloblastic anaemia and may
present with delirium, dementia or psychosis.
Psychotropic medication such as valproate and carbamazepine may
also diminish folate stores elevating the risk of neural tube defects
during pregnancy.
20
Urine investigations
Consider the following:
Human chorionic gonadotropin/pregnancy test


Use psychotropic medication with caution in pregnancy, as many
carry teratogenic risks.
All women of child-bearing age should be counselled about these
potential risks and offered a pregnancy test prior to the
commencement of treatment.
Dipsticks

Used to screen for urinary tract infections, diabetes mellitus, and
diseases of the kidney and liver.
Drug screen

Amphetamines and opiates may be detected on urine drug strips up
to 72 hours post use. Cannabis may be detected up to 7 days post
use.
Cerebrospinal fluid (CSF) investigations


CSF is tested in patients suspected of having a medical condition
causing their psychiatric symptoms, for example neurosyphilis.
It is also tested in patients with a known psychiatric illness who
present with delirium, to exclude a co-occurring meningitis.
Neuroimaging




Imaging tests are divided into two broad categories: structural and
functional.
Structural imaging such as X-rays, computerised tomography (CT
scan) and magnetic resonance imaging (MRI) provide a noninvasive means to investigate the morphology of the central
nervous system. Structural imaging is used to exclude an organic
cause contributing to the patients’ psychiatric presentation.
Functional imaging includes positron emission tomography (PET),
single photon emission computed tomography (SPECT), functional
MRI (fMRI) and magnetic resonance spectroscopy (MRS).
Functional imaging provides valuable information that may support
diagnoses, yet remains largely a research tool that is not available
for routine clinical practice.
21
Computed tomography (CT)





CT scans are able to detect structural abnormalities in the cortical
and sub-cortical brain tissue.
CT scans are the preferred modality for detecting the presence of a
skull fracture, tumour, abscess, infarction or haemorrhage, both
parenchymal and subdural.
CT scans may be conducted with or without contrast. The purpose
of the contrast is to enhance the visualisation of certain pathologies
such as an abscess, a tumour or haemorrhage.
Consider a CT scan if the patient displays localising neurological
signs or a decrease in level of consciousness.
Other possible indications are first onset psychoses, especially if the
presentation is atypical, of late onset, or in the presence of delirium
or catatonia, or in treatment resistance.
Magnetic resonance imaging (MRI)


Provide better visualisation of the cerebellum, temporal lobes, deep
sub-cortical tissue and periventricular white matter.
Therefore more useful for the visualisation of vascular
abnormalities, demyelinating disorders and neurodegenerative
disorders.
Other
Tuberculosis


Diagnosis of pulmonary tuberculosis (PTB) is based on positive
findings on chest X-ray or on microscopy and culture of sputum or
pleural fluid.
A lumbar puncture is required to diagnose TB meningitis.
Investigating the metabolic syndrome
Weight gain secondary to certain antipsychotic agents is common and
should be monitored. The metabolic syndrome is a cluster of medical
problems that elevate the risk of cardiovascular and cerebrovascular
disease. This is aggravated by smoking, which is highly prevalent among
patients with severe psychiatric disorders.
The metabolic syndrome consists of 2 or more of the following factors:
1. Hypertension: systolic blood pressure ≥ 140 mmHg or diastolic
blood pressure ≥ 90 mmHg
2. Diabetes mellitus or fasting blood glucose ≥5,6 mmol/L
3. Elevated plasma triglyceride level ≥ 1,7 mmol/L
22
4. High density lipoprotein cholesterol level: < 1,03mmol/L (males)
1,29 mmol/L (females)
5. Abdominal obesity measured as waist circumference:
Males: ≥102 cm
Females: ≥88 cm.
Patients receiving treatment with high risk antipsychotic agents such as
clozapine or with existing metabolic risk factors should have their weight,
abdominal circumference, plasma lipids and plasma glucose investigated
before initiating treatment and regularly thereafter (approximately every
three to six months).
Electrocardiogram





Many psychotropic agents are associated with electrocardiogram
(ECG) changes.
Several antipsychotic agents are associated with dose-related
prolongation of the QTc interval.
The rare but fatal consequence of prolonged a QTc interval
is torsades de pointes.
There is no clear guideline for the frequency at which ECG should be
performed when using antipsychotic drugs.
It is generally recommended to do an ECG at least at baseline and
thereafter annually.
Electroencephalogram (EEG)



EEG is used to measure regional cerebral cortical electrical activity.
Most often used to eliminate a medical cause underlying a patient’s
disordered behaviour and not to diagnose a psychiatric illness.
Seizure foci may be depicted as spike waves on an EEG, and
delirium may be evident as generalised slowing in all leads.
23
SECTION 3: MANAGEMENT PROBLEMS
THE CONFUSED OR DISTURBED PATIENT
(Refer to Chapter 11 of the main text for complete information)
A common presentation in primary care is the person who seems
'confused' or whose behaviour seems 'disturbed'. Often, little or no
information is available and the patient is unable to give a clear account
of him- or herself.
A sequence of possible explanations should be considered:







Is the patient delirious?
Is the patient demented or simultaneously demented and delirious?
Is there an intellectual disability?
Could the behaviour be due to substance abuse?
Are there psychotic symptoms?
Is there a personality problem or a conduct disorder in a younger
person?
Could the confusion or disturbed behaviour be in reaction to a
stressful event or an anxiety or mood disorder?
During assessment, consider the following questions
a) Is there a fluctuating or changing level of consciousness?


Signs of an altered level of consciousness include the following:
o diminished awareness of the self and surroundings
o impaired attention
o disorientation in time and place.
An acute onset of a fluctuating level of consciousness is the
hallmark of delirium.
b) If consciousness is intact, is there evidence of cognitive impairment?


If there is evidence of cognitive impairment from birth, there is a
learning disability. Those affected are more prone to confusion or
disturbed behaviour.
If there is a history of relatively intact functioning followed by a
decline, consider dementia.
c) If there is no change in the level of consciousness, and no history of
cognitive decline, are there any psychotic features?

Remember the central feature of a psychotic disorder is a loss of
insight, with associated thinking, believing, perceiving and feeling
24

disturbances. The main groups include schizophrenia and bipolar
mood disorders.
Note that similar symptoms can occur in the context of substance
abuse and certain epilepsies.
d) If there is no change in the level of consciousness, no history of cognitive
decline, and if there are no psychotic features, is there evidence of a
pattern of disturbed behaviour dating from childhood or adolescence?


A characteristic feature of a conduct disorder is a relatively
consistent pattern of disturbed behaviour that develops during
childhood. The same applies to personality disorders that become
apparent during adolescence.
Symptoms are relatively enduring and do not respond to
pharmacological treatment.
e) If there is no change in the level of consciousness, no cognitive decline, no
psychotic symptoms and no characteristic pattern of disturbed behaviour
dating from childhood or adolescence, is the disturbed behaviour or
confusion a reaction to a stressful event?



Note that reactions can take various forms.
A central feature is a relatively abrupt change in behaviour or level
of functioning in reaction to extreme stress in a relatively stable
personality, or to everyday stresses in a vulnerable personality.
Consider the possibility of post-traumatic stress disorder (PTSD),
adjustment disorders and dissociative states.
f) If none of the above applies, that is, there is no change in the level of
consciousness, no cognitive impairment, no psychotic symptoms, no
pattern of such behaviours since childhood or adolescence, and the
behaviour is not a reaction to stress, the most common and probable
explanation is either an anxiety state or a mood disturbance.



Both depression and anxiety have physical, psychological and
cognitive features.
In depression, the central psychological characteristic is a
depressed emotion and a loss of interest and pleasure in daily
activities.
Anxiety is an emotion similar to fear, but arises spontaneously and
is not confined to dangerous situations.
25
THE AGITATED OR VIOLENT PATIENT
(Refer to Chapter 12 of the main text for full information)
Violence remains a common feature of life in southern Africa, but it does
not necessarily indicate mental illness. The relationship between mental
illness and violence is complex, but it is one of association rather than
causation.
The roots of violence in clinical settings include medical illnesses,
particularly delirium, substance abuse and psychotic or manic conditions.
Risk factors can be identified to predict and thus de-escalate violence.
Risk assessment
Risk factors are either static (age, gender, antisocial personality) or
dynamic (substance abuse, mania, psychotic experiences).




Dispositional:
o age: late adolescence, early twenties
o gender: male (although this finding may not hold true for
mental illness).
Historical:
o previous perpetration of violence
o previous exposure to violence that modelled, rewarded or
reinforced violent behaviour.
Contextual:
o stress, which, as a perception, varies among individuals
o weapon availability
o substance abuse
o victim characteristics, especially if the target population is one
or a few.
Clinical:
o co-morbid substance abuse or dependence
o psychotic thoughts (persecutory delusions) or perceptions
(command hallucinations) influencing behaviour
o the manic phase of bipolar disorders
o certain personality disorders, for example borderline
personality disorders.
Causes of acute violence in medical settings
The aetiology of violence in medical contexts is often multi-factorial.
Consider co-morbid somatic and psychiatric conditions.
26
Obtain collateral information from escorts or relatives if available as soon
as possible. Such information includes:





Non-medical: criminal behaviour of individuals or groups
Aggressive personalities: for example antisocial personality
disorders, with or without other mental illness
Substance abuse or dependence: alcohol, cannabis (dagga),
methaqualone (mandrax), methamphetamine (tik) intoxication or
withdrawal
Mental illness: acute psychotic episodes of schizophrenia, mania
or agitated depression, dementia, and, less commonly, anxiety or
severe emotional stress
Medical conditions: delirium, epilepsy (pre-ictal irritability or postictal confusion), cerebral infections, intracerebral bleeds (subdural
haematoma) and traumatic brain injury.
Management of acute agitation and violence
The most senior health workers must take control and think on their feet.
Managing the event requires three simultaneous actions, usefully labelled
'ABC’.
A. Assessment


Look for signs of the cause such as injected conjunctiva, head
wounds or features of delirium.
Continue looking for the cause during containment and complete
once the patient is settled or sedated.
B. Back-up

Gather additional staff and resources, such as security, to protect
people and property from harm.
C. Containment
This can be achieved either without drugs or by using tranquillisation if
required, and begins with non-pharmacological measures — the 5 Cs:




Be calm: do nothide your hands or turn your back. A suspicious
patient may think you are drawing a weapon
Take control, or at least appear to. This calms staff and patients
Confidently manage staff according to the prearranged plan suitable
for the setting
Contain the patient with reassurances. 'Close down the space' by
relocating to a smaller, quieter room and instructing the patient to
be seated
27

Physical or pharmacological constraint depends on the situation and
should be exercised after giving the patient the option of cooperation and either sublingual or oral medication. Increase the
number of non-threatening staff (and not weapons) to give ‘a show
of force’, which can sometimes persuade the patient it is a noncontest and, along with ongoing reassurance, restore calm.
Once non-contact measures have been exhausted, physical restraint and
tranquillisation may be required:





Be decisive.
Initiate four-point immobilisation, in which four delegated,
preferably male staff members each, in concert, take hold of a hip
or shoulder and the attached limb, and restrain the patient on a
trolley, a bed or the floor.
Make staff aware of the risk of biting or spitting.
The doctor and sister-in-charge must make sure no undue force is
being exerted, and immediately sedate the patient.
The choice of drugs administered depends on the severity of the
situation.
Pharmacological options for rapid tranquillisation include those listed
below. Note that you should check the package insert for the
correct dosage.



Benzodiazepines:
o lorazepam is the drug of choice on account of its rapid onset
of action, short half-life and favourable safety profile
o midazolam is an effective alternative
o intravenous diazepam is an option in extreme circumstances
for experienced staff with immediate access to resuscitation
equipment.
Antipsychotic agents:
o haloperidol with or without lorazepam, remains a cornerstone
of emergency management
o risperidone is a second-generation agent in both tablet and
oral solution forms
o olanzapine is sedative and may be useful, but the im
formulation should never be co-administered with
benzodiazepines, which is potentially fatal. A rapidly
disintegrating tablet is available in some settings
o intramuscular ziprasidone and aripiprazole have the
advantage of being tranquillising without being excessively
sedative, and present options where available.
A common, effective strategy during four-point immobilisation is to
inject a combination of lorazepam and haloperidol intramuscularly.
Several studies have shown this to be more effective than either
agent alone. Some authors advocate combining these agents in the
28


same syringe to reduce the number of injections, but extreme
caution should be used whenever mixing injectable agents. This can
be repeated up to twice at 30‒60 minute intervals as required.
Remember that violence has a cause or causes that need to be
elicited using rigorous clinical methods, and appropriately managed.
Give clear instructions that the sedated patient must be monitored,
including the recording of the pulse, blood pressure, respiratory
rate, and level of consciousness.
Legal issues



Section 9(l) (c) of the Mental Health Care Act allows for the
provision of treatment without consent for a 24-hour period if, 'due
to mental illness, any delay in providing care, treatment and
rehabilitation services or admission may result in the death or
irreversible harm to the health of the user, or the user inflicting
serious harm to himself or herself or others, or the user causing
serious damage to or loss of property belonging to him or her or
others'.
If treatment without consent is likely to extend beyond the initial 24
hours, arrangements need to be made for the stipulated 72-hour
assessment in terms of Section 34.
Regulations under the Act govern mechanical restraint and
seclusion, which may be appropriate in managing agitation and
violence. Mechanical restraint is permissible 'if all else fails' and
must be the 'minimum possible' required. Similarly, seclusion may
be required if the patient is likely to cause harm to others, but
never as a punishment. These interventions should be accompanied
by half-hourly observations, and a register of the details of
restraint/seclusion.
SUICIDE AND DELIBERATE SELF-HARM
(Refer to Chapter 13 of the main text for complete information)
Suicide
Suicidal behaviour is the most common psychiatric emergency and
presents in a variety of clinical settings, including primary care clinics. It
is associated with potentially devastating consequences as well as a
number of medico-legal hazards. The ability to assess and manage
suicidal behaviour appropriately is considered a core clinical competence
for all mental health professionals.
Be sure to differentiate attempted suicide from parasuicidal behaviours
and deliberate self-harm or self-mutilation.
29
Factors which increase the risk of suicide







Male gender: the male to female ratio for suicide is 3:1.
Demographic factors: the elderly, the socially isolated, and
certain professions (such as veterinary surgeons, pharmacists,
farmers and doctors).
Social factors: social deprivation, social fragmentation, poor
economic conditions and unemployment.
Familial and biological factors: a family history of suicide and
reduced activity in brain serotonin pathway.
Physical illness: chronic and severe physical illness, chronic pain,
HIV/AIDS.
Mental illness: very large increased risk for patients with mental
illness, particularly mood disorders, personality disorders,
schizophrenia and eating disorders.
Substance dependence: particularly alcohol, opioid and
prescription drug abusers.
Protective factors against suicide



Strong religious affiliation
Marriage
Coping skills, responsibility to family, fear of suicide, fear of social
disapproval and a moral objection to suicide.
Assessment of risk
The assessment should include:




an interview with the patient
a mental state examination
a physical examination
special investigations where appropriate.
The clinician should also:




gather as much information about the patient as possible from
patient, family, and previous mental health records
conduct the assessment in a tactful and sensitive manner
allow sufficient time to conduct the assessment
aim to gain the patient’s trust and establish a rapport.
During the assessment, the clinician should pay particular attention to:


the psychological and social factors that triggered the self-harm or
suicidal thoughts
previous psychiatric history and history of deliberate self-harm
30








medical history, particularly chronic painful conditions
available social supports
the patient’s current mental state (are there any symptoms of a
mental illness, and what is the current degree of suicidal intent?)
symptoms of psychosis such as persecutory delusions, delusions of
control, command hallucinations such as voices telling the individual
to kill themselves and/or others and passivity phenomena where
the individual perceives that their thoughts or actions are not under
their own control
feelings of hopelessness, helplessness, current suicidal ideation,
suicidal intent and plans
homicidal intent (a mother suffering with severe postnatal
depression may harbour thoughts about killing her baby and
herself)
circumstances relating to the suicide attempt; what occurred prior
to the act?
the patient’s intent; did the individual believe that the event would
kill them?
Note that patients may not necessarily volunteer that they have suicidal
thoughts. The clinician should thus be tactful and sensitive when
broaching this topic. Asking the patient about suicidal thoughts, plans and
intent does not imply that the clinician is putting ideas into the patient's
head.
A high degree of suicide intent is indicated if:




the act was planned and prepared, and precautions were taken not
to be found
a dangerous method was used (or the patient perceived that the
method would be lethal)
the individual did not seek help after the act
the individual left a will or suicide note.
Increased risk of suicide is also associated with the recency of the
previous attempt, more than one previous attempt, marked hopelessness,
older age, social isolation, alcohol or drug dependency and a history of
previous or current psychiatric illness, particularly depression or
schizophrenia.
Management


Evaluate the individual’s level of risk and formulate a management
plan, taking into account the factors discussed above.
Consider the availability of care and support at home or in the
community when formulating the management plan.
31









The primary requirement is to ensure the individual’s safety and to
alleviate their distress.
Admit to hospital if high risk.
If the individual refuses a voluntary admission, they may need to be
admitted as an involuntary patient under the Mental Health Care
Act.
If low risk and with good support at home or in the community,
offer treatment as an outpatient. Engage with the individual’s carers
to ensure that they are able to provide the appropriate level of
supervision, support and care that the individual requires, and that
they know where to obtain help in case of an emergency. Follow-up
visits should ideally be within the first week by a health professional
and there should be regular reviews of the individual’s suicidal risk
and mental state.
When prescribing medication, choose medications that have fewer
side effects and are less dangerous if taken in an overdose. Ideally,
the medication should be given to the patient’s carer for safe
keeping, and the carer should supervise the administration of the
medication to the patient.
Reduce the risk of further attempts by removing the means of
suicide (eg, weapons, tablets).
Treat any associated physical illnesses, mental illnesses or
substance misuse problems.
Offer coaching in problem-solving skills to help with the underlying
issues.
Instil hope in the suicidal patient and help the patient to identify
positive reasons for remaining alive.
Deliberate self-harm
Those who self-harm usually act impulsively in response to a stressful life
event or due to perceived rejection. The self-harm may be accompanied
by the use of alcohol or illicit drugs.
For some individuals the deliberate self-harm may have been a failed
suicide attempt, but only a quarter of patients who deliberately self-harm
wish to kill themselves.
Deliberate self-harm may be used as a non-verbal way of communicating
emotional distress, as a cry for help, as a way of coping with symptoms,
or used to relive tension and anxiety. Some may use self-harm to punish
others or to make them feel guilty.
Management of deliberate self-harm


Management is similar to management for a patient who is suicidal.
Take all acts of deliberate self-harm seriously.
32







The majority of cases can be managed in psychiatric outpatient
clinics or in primary care.
Attend to any medical or surgical problems.
Conduct a risk assessment.
Consider admitting high-risk patient.
Address underlying psychiatric disorders.
Investigate triggers for self-harm.
Encourage alternative to self-harm, such as exercise and seeking
support.
COPING WITH TRAUMA
(Refer to Chapter 14 in the main text for complete information)
Traumatic events are common and while many people show remarkable
resilience, there is a risk that mental health disorders may follow a
traumatic experience. Clinicians should assess for symptoms of posttraumatic stress disorder (PTSD), or anxiety and depression in anyone
presenting after a traumatic event. Clinicians should also assess for
traumatic experiences and related symptoms in patients who present with
sleep difficulties, depression, unexplained physical symptoms or
substance abuse.
Presentations


Patients are unlikely to ask for help with the psychological sequelae
of exposure to traumatic events.
Patients are more likely to request help for sleep difficulties, for
symptoms of depression, for irritability, for chronic pain or
somatisation disorders or otherwise unexplained physical
symptoms. Patients may also present with substance use disorders.
Assessment






Ask about possible traumatic events if the patient presents with
anxiety and depression, medically unexplained physical symptoms
or substance abuse.
Give specific examples of traumatic events but do not force the
patient to disclose their personal thoughts and feelings.
Establish when the event occurred as this influences treatment
choices.
Ask what happened and when, the symptoms of PTSD and possible
co-morbid disorders, together with the severity of these symptoms.
Is the patient currently safe?
Is there a supportive network?
33
Once it has been established that a traumatic event has occurred, the
more specific symptoms of PTSD need to be investigated.



Is the patient re-experiencing the event (intrusive thoughts of the
event, nightmares, flashbacks – feeling as if one is reliving the
experience, or intense psychological or physical reactions to seeing
something that reminds one of the event)?
Is the patient experiencing avoidance and numbing (efforts to avoid
thoughts, feelings, activities or other things that remind the patient
of the trauma, inability to recall parts of the trauma, loss of interest
in significant activities, feeling detached from others, difficulty
experiencing positive emotions, or a sense that she or he will not
have a normal life or lifespan).
Is the patient experiencing a heightened arousal (sleep difficulties,
irritability, difficulty concentrating, hypervigilance, or an
exaggerated startle response)?
In addition to screening for symptoms of PTSD, clinicians should also
screen for co-morbid disorders such as depression, panic disorder,
somatisation disorder, suicidality and homicidality.
Management
Many people recover with limited or no intervention. However, early
treatment (where necessary) may prevent the development of a chronic
or persisting problem. Chronic problems that present with a long delay in
help-seeking are also likely to respond to treatment. Clinicians should
explain that patients should expect to experience the symptoms for a few
weeks, but that they should seek help if these symptoms persist for more
than a month.
Do the following:







Provide information about the psychological symptoms that may
follow a traumatic event, when to seek help, and the kinds of
treatment that may be provided.
Give this information to both the patient and his or her carers.
Is there a support network?
Has the traumatic event touched the whole family?
Does the family need to be assessed?
Is the patient safe?
Is it necessary to refer to social services for help?
34
Referral and medication










Use ‘watchful waiting’ when symptoms are mild and have been
present for less than 4 weeks after the trauma.
Arrange a follow-up appointment for within 1 month and where
possible, this should be with the same clinician.
Follow-up on patients who miss appointments.
A referral to social work services for between 1 and 3 sessions may
be helpful for patients with mild symptoms who want to talk about
the incident to someone outside their usual support network.
Do not prescribe medication routinely for treating post-traumatic
symptoms, but if sleep is a serious problem, hypnotics could be
considered for short-term use.
If the patient presents with symptoms meeting criteria for an acute
stress disorder they should be referred for specialist treatment. At
this stage, brief trauma-focused cognitive-behavioural therapy may
be effective.
When patients present with depression co-morbid to PTSD, treating
the PTSD will often resolve the depression. However, if the
depression is so severe as to make treatment of the PTSD difficult,
for instance, if the patient shows an extreme lack of energy, the
depression should be treated first.
Other co-morbidities, such as suicidality, homicidality and substance
abuse take priority over the treatment of symptoms of PTSD.
Consider anti-depressant medication if adults are not willing to
engage in trauma-focused psychotherapy, or are not able to do so
because of a high likelihood of ongoing trauma
Also consider drugs where patients have not responded to traumafocused psychotherapy, or where there are features of severe comorbid depression or hyper-arousal that interfere with a patient’s
ability to benefit from psychotherapy.
SLEEPING PROBLEMS
(Refer to Chapter 16 in the main text for complete information)
Insomnia
Insomnia is the most common sleep complaint. It is defined as the
subjective report of difficulty with sleep initiation, duration, consolidation
or quality that occurs despite adequate opportunity for sleep, and which
results in some form of daytime impairment or fatigue.
35
A good practical medical definition of insomnia is as follows:









Persistent difficulty in falling asleep or maintaining sleep. This
includes:
difficulty in falling asleep
waking too early
waking too frequently
getting insufficient sleep.
Evidence of sleep-related, poor daytime functioning, regardless of
the number of hours slept each night. This can present as:
daytime drowsiness or somnolence
feeling tired and unrefreshed after a night’s sleep
feeling anxious or mildly depressed, irritable, or describing physical
symptoms, often headaches.
Any general history or examination should include enquiries about
sleeping difficulties because unless asked about, this is frequently missed.
Co-morbid disorders associated with insomnia




Insomnia presents with another psychiatric disorder or medical
disorder in more than 50% of all cases.
Co-morbid psychiatric disorders include depression, anxiety,
substance use disorders and schizophrenia.
Co-morbid medical disorders include chronic pain, hypertension,
gastrointestinal disorders, asthma and chronic obstructive airway
disorders, cardiovascular disorders, diabetes, urinary and
neurological disorders.
Co-morbid sleep disorders include obstructive sleep apnoea, restless
leg syndrome and periodic limb movement disorders.
Assessment of chronic insomnia
Establish whether or not insomnia really is present with a thorough
medical and psychiatric history, and a physical and mental state
examination.
Specific issues of inquiry should include:






onset of the problem
duration of the problem
previous episodes of insomnia
timing of sleep and wakefulness periods through a 24-hour day
pre-sleep concerns, bedtime anxieties, thoughts and preoccupations
(increased arousal)
difficulties in falling asleep
36














difficulties maintaining sleep or awakening early in the morning
if the sleep environment is conducive to sleep
if the patient is a shift worker
motor restlessness of lower limbs – indicative of restless leg
syndrome
daytime consequences of insomnia, such as fatigue and naps
effects on daytime behaviour and activity (eg, poor concentration)
general psychological well-being
history of heavy snoring or respiratory difficulties and excessive
daytime somnolence, which is indicative of sleep apnoea
nightmares, sleep-walking, nocturnal panic attacks or teeth-grinding
muscle tension, nocturia or enuresis
the use of medication (particularly hypnotics and tranquillisers)
alcohol or drug abuse
the use of caffeine or other stimulants
past or current psychiatric disorders or general medical disorders
and the treatments thereof.
Management strategies
The goals of treatment are to improve sleep quality and quantity and also
to improve insomnia-related daytime impairments.








Develop a trusting therapeutic relationship with the patient to
prevent secondary complications including:
o the misuse of hypnotic drugs and alcohol
o demoralisation and obsessional concern with the condition
itself.
Aim to consolidate sleep into one period at night
Advise the patient not to use alcohol to assist with sleep: alcohol
can initiate sleep, but later in the evening it causes sleep
fragmentation
Encourage the slow withdrawal of excessive or inappropriate or
ineffective medications
Educate the patient and the sleep partner about normal sleep
requirements, that is, an average of six to eight hours
Reinforce constructive changes in the patient’s coping mechanisms,
personal relationships and lifestyle
Treat medical causes appropriately
Initiate ‘sleep hygiene’ instructions so that the bed does not become
a place of worry and frustration.
Sleep hygiene techniques


Relax in the evening; advise whatever works for the individual.
Improve the sleep ambience by reducing noise and removing
telephones, TVs and radios from the bedroom.
37










Make the room comfortable and appropriate for sleep; preferably
cool, dark and quiet.
Establish a regular sleep schedule; attempt to establish the type of
sleep cycle by setting a time for sleep and keeping to it.
Advise adequate daytime exercise.
Encourage the patient to use the bedroom only when he or she feels
sleepy.
Reserve the bed for sleep and sex.
Air the bedroom prior to retiring.
Avoid coffee, tea and cigarettes for about two hours before retiring.
Have a warm bath or cold shower followed by a hot one.
If the patient does not fall asleep within twenty minutes, he or she
should get out of bed, go and sit somewhere else and read a book
until he or she feels sleepy, before returning to bed. If sleep is still
elusive, the patient should repeat this process. This requires
motivation from both the patient and the clinician for it to be
successful.
The patient should be advised to get up at a fixed time the next
morning and should not sleep during the day.
Relaxation training
Relaxation training has proved its value as the first specific step in the
management of insomnia. One method is to tense individual groups of
muscles and then relax them again, starting from the toes and advancing
to the face.
Cognitive behavioural therapy (CBT)
CBT seeks to identify and modify dysfunctional beliefs about sleep and to
replace them with more adaptive cognitions. There is some evidence to
suggest that CBT is superior to medication in the longer term.
Multimodal model
All the above suggestions are useful in a package, in an attempt to
change the patient’s belief and attitudes about insomnia and to modify
maladaptive behaviours that maintain insomnia.
Medication
The objective of using hypnotics (sleeping tablets) is to provide relief as
well as to change the patient’s poor sleep behaviour. It is recommended
to use the lowest possible dose, to use strategically, intermittently and for
short durations, not exceeding two to three weeks, and to discontinue
gradually and be alert for rebound insomnia following discontinuation.
38
Medication should be used together with the above non-pharmacological
strategies.
Hypnotics



Benzodiazepine receptor agonists are the most commonly prescribed
hypnotic agents in insomnia. They all bind to the benzodiazepine receptors,
although the receptor subtypes differ.
Prescribe hypnotics for short periods and with particular caution in the
psychophysiological group.
In psychiatric disorders hypnotics should be used briefly, until the more
specific agents become effective.
Other hypnotic agents, not well studied for safety and efficacy in patients with
insomnia, include the following:



Antihistamines: these are effective for a few weeks. They have potent
anti-cholinergic effects and are therefore not suitable for the elderly.
Antidepressants: these antidepressants are sedating and can be useful in
low dose ranges. May be useful for psychophysiological insomnia, as an
adjunct to non-pharmacological strategies, and in appropriate
antidepressant doses in insomnia associated with depression.
Antipsychotic medication: these are not particularly useful, except
perhaps for risperidone in the agitated dementing elderly patient with sleep
disturbances. Quetiapine in low doses is effective in the intermittent
treatment of insomnia. The possible hypnotic effects of antipsychotic
medication are in general outweighed by their possibly serious side effects.
Hypnotic agents should be withdrawn slowly from long-term users who continue to
report insomnia. They should then be evaluated in a drug-free state. Following
withdrawal, the condition is frequently no worse and may actually improve. The
risk of nightly reliance can be reduced by intermittent and strategic use, if
indicated, and by actively educating patients when treatment begins, and by
regular follow-ups.
EATING PROBLEMS
(Refer to Chapter 17 of the main text for complete information)
Eating problems occur within a variety of contexts, and therefore when
approaching a patient with such a clinical presentation, a host of
diagnostic possibilities should be borne in mind. These include a wide
range of general medical conditions, a symptom of certain psychiatric
39
conditions, for example major depression disorder, and as primary
presentations in others, for example anorexia nervosa.
Assessment
The clinician must have a sense of the range of diagnostic possibilities
with which they might be dealing. These would include:







eating disorders, for example anorexia nervosa and bulimia nervosa
mood disorders, for example major depression
bipolar disorders
anxiety disorders
psychotic disorders, for example schizophrenia
somatoform disorders, for example conversion disorder with a
motor symptom, such as difficulty in swallowing (globus
hystericus), or a body dysmorphic disorder
general medical conditions, for example peptic ulcer disease.
On taking a history, establish when the problem began. Establish if onset
is linked, for example, to a traumatic incident or a change of
circumstances. Ask the patient about:





disturbances in sleep, energy, motivation, sexual function (if
appropriate), concentration and memory
an experience of loss of interest in pleasurable activities
a sense of worthlessness or guilt for no apparent reason
social withdrawal
any disturbance in other areas of functioning, social, occupational or
academic.
Whereas such features would appear to be an attempt to establish a
diagnosis of a major depressive disorder, many of these features might
just as easily be encountered in a patient suffering from an eating
disorder. It would be reasonable to expect that, depending on the
duration of the clinical presentation, there may be either weight loss or
gain, and such information needs to be elicited together with information
related to other aspects of physical functioning.
Central to these eating disorders are inappropriate concerns related to
weight, shape and appearance. These lead to attempts to address those
concerns through dietary manipulation. In terms of the DSM-5™, the
following eating disorders are described:



anorexia nervosa
bulimia nervosa
any eating disorder not otherwise specified, for example bingeeating/obesity.
40
Anorexia nervosa





The central feature of this condition is weight loss. This is generally
achieved through reduced food intake, but a variety of other
methods may also be used
The condition is dominated by fearrelated to being or becoming
overweight, regardless of the current weight
Most sufferers have never been objectively fat
Self-perception is critical and comprises three components:
the sufferer is unable to see him or herself as they are, which is
described as a 'distorted body image'
o an inability to appreciate the seriousness of the low body
weight
o an undue influence of body weight on self-evaluation.
Anorexia nervosa is subtyped as follows:


restricting
binge-eating/purging.
Bulimia nervosa





Bulimia nervosa is characterised by recurrent episodes of bingeeating, compensatory behaviour and an undue influence of body
weight on self-evauluation.
Binge-eating is a type of eating behaviour that has specific criteria:
an objectively large amount of food, consumed in a discrete period
of time, with the sufferer experiencing a sense of loss of control.
Compensatory behaviour refers to what happens following a binge
episode: the sufferer attempts to compensate for the binge through
engaging in one or more of a number of purging behaviours, which
include self-induced vomiting, laxative or enema use, starvation and
excessive exercise.
The diagnosis of bulimia nervosa includes a frequency criterion
related to the binge-eating and compensatory behaviours, required
to occur at least twice a week for three months.
In common with anorexia nervosa, self-evaluation is unduly
influenced by weight and shape.
Bulimia nervosa is subtyped, as follows:


purging
non-purging.
41
Unspecified eating disorders
This category refers to those patients who have an eating disorder, but
who do not fulfil the diagnostic criteria for either anorexia nervosa or
bulimia nervosa. It represents the majority of those who suffer from
eating disorders.
Obesity





Obesity is broadly defined as a body weight exceeding body weight
norms by 20%, or a BMI > 30.
Obesity may develop at any age, but often develops in young
adulthood and persists throughout life.
Women show a higher incidence of obesity than men.
Obese people are at high risk of multiple health problems.
Long-term solutions need to include effective prevention directed at
the population level.
Treatment of eating disorders
Eating disorders, as for other psychiatric conditions, require a
biopsychosocial approach for effective treatment.
Biological component






Exclude any medical causes of weight loss with a thorough physical
assessment.
There is no definitive pharmacological treatment for eating
disorders.
There is some evidence of the benefit for some sufferers of the use
of certain antidepressant medications, in particular the serotonin reuptake inhibitors (SSRIs), at high doses.
Highly anxious anorexic or bulimic patients may benefit from the
use of anxiolytics, for example low dose lorazepam before meals.
The central focus is to restore appropriate eating and weight
restoration in anorexia and the stabilisation of eating patterns
among those with bulimia.
The treatment setting, either as an in-patient or as an outpatient,
will be determined by the severity of the clinical picture as well as
factors such as past history, level of functioning and support
systems.
Psychological component


Limited insight and resistance are major obstacles to effective
intervention.
The majority of suffers can be managed successfully as outpatients.
42



Many sufferers do not present themselves for treatment.
Cognitive-behavioural therapy (CBT) and interpersonal
psychotherapy have been associated with the best outcomes,
although the evidence is not strong.
Give attention to the needs of the family and other carers.
Social component
Some aspects of the social and cultural context of the problem may lie
beyond the scope of the therapist, but attention needs to be paid to the
prevailing value system, in particular the belief that being thin is a
significant determinant of social acceptance.
Management of obesity




Management is complex.
Weight reduction is achieved by reducing the kilojoule intake to
below the kilojoule output.
The main components of treatment include diet, exercise,
behavioural and educational interventions.
Identify and manage aggravating factors, including side effects of
prescribed medication.
PROBLEMS ASSOCIATED WITH SEXUALITY
(Refer to Chapter 18 of the main text for complete information)
Sexuality is an important and integral aspect of the human experience.
The healthy expression of this sexuality forms a fundamental part of
overall physical and psychological health.
Understanding and promoting sexual rights, including consent and choice
around sexual expression, as well as respect for individual men and
women, is essential for safe communities. Negative attitudes or false
ideas around sexuality can produce very harmful consequences, including
rape, child abuse and other forms of violence.
Sexual problems and disorders
In the DSM-5™, sexual problems have been separated into three different
sections, namely, sexual dysfunctions, gender dysphoria and paraphilic
disorders.
43
Sexual dysfunctions
These problems relate directly to the inability to perform and to enjoy the
physical act of sex, often including a disturbance in the sexual response
cycle or pain associated with sexual activity.
Sexual dysfunctions are divided into the following subtypes:



Lifelong vs acquired, depending on whether the dysfunction has
been present since onset of sexual activity or preceded by a period
of normal functioning.
Generalised vs situational, depending on whether it occurs in all or
is limited to certain types of stimulation, situations or partners.
Psychological factors vs combined factors, depending on whether
only psychological factors are involved or whether there are
underlying medical or substance (including medication) use that
cause the dysfunction, in addition to psychological factors that
exacerbate the dysfunction in some way.
The specific sexual dysfunctions described in DSM-5 are detailed below:

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Male hypoactive sexual desire disorder
Erectile disorder
Premature (early) ejaculation
Delayed ejaculation
Female sexual interest/arousal disorder
Genito-pelvic pain/penetration disorder
Female orgasmic disorder
Substance/medication-induced sexual dysfunction
Other specified sexual dysfunction
Unspecified sexual dysfunction.
Sexual dysfunction may also be secondary to other medical and
psychiatric conditions. Psychiatric conditions that commonly cause various
sexual dysfunction include depression, schizophrenia and anxiety
disorders. However, sexual dysfunction is most commonly related to an
underlying physical illness or substances use.
The following is a short list of common medical conditions that can cause
sexual dysfunction:




Trauma, including surgical procedures and spinal cord injuries.
Mechanical problems, such as an enlarged prostate gland or urinary
retention of other causes.
Vascular problems, especially microvascular disease as seen in
diabetes.
Neurological problems, such as multiple sclerosis.
44



Endocrine disorders, including thyroid, pituitary, adrenal or gonadal
dysfunction.
Genetic disorders, eg, Klinefelter’s (47XXY), Turner’s (45X),
congenital adrenal hyperplasia.
Poor vaginal lubrication due to the hormonal changes of
menopause, pregnancy or breast-feeding.
Sexual dysfunction is a common medication side effect and plays a major
role in non-adherence to treatment regimens. Patients are unlikely to
volunteer this information, again emphasising the importance of medical
practitioners asking about these problems, especially if prescribing
medication can cause such side effects.
Common medications causing sexual dysfunction

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

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
Most psychotropic agents, especially SSRIs/SNRIs and
antipsychotics
Some antidepressants (most notably trazadone) and many
antipsychotics have also been associated with priapism
Benzodiazepines may help reduce anxiety associated with sexual
performance but may cause sexual dysfunction.
Alcohol, particularly if used in excess
Antihypertensives
Antihistamines
Recreational drugs: commonly alcohol and nicotine
Methamphetamine and other stimulants may in the short term
cause improved sexual pleasure and function during the
intoxication phase, but sexual dysfunction usually occurs with longterm use.
Gender dysphoria
Gender dysphoria, more commonly called transexualism or
transgenderism, describes the condition where one feels a discrepancy
between one’s biological sex and one’s psychological gender. It is
important that clinicians assist these patients to access appropriate
transgender specific care. The process of starting hormonal treatment and
choices around reconstructive surgery are complex and best managed by
a multi-disciplinary team.
Paraphilic disorders
These disorders describe the circumstance when an individual can only be
sexually aroused, stimulated and satisfied by unconventional stimuli.
Patients generally present only if they feel distressed by an inability to
form meaningful relationships with other adults.
45
Assessment
Patients often present with non-sexual or non-specific symptoms, as they
may feel too inhibited or self-conscious to discuss sexual difficulties. Be
alert to the possibility of a sexual problem.
Elicit a sexual history in a calm, professional and direct manner to
establish:







how long the problem has been present and if there was previously
normal functioning
any preceding incidents or life events or changes in circumstances
whether the problem occurs only with particular partner(s) or in
specific situation(s)
whether the patient also experiences the problem while
masturbating
if male, whether he has early-morning erections; if female, the full
gynaecological history
full medical, psychiatric, surgical and family history, as well as
medications used
history of substance use.
Referral to specialist levels of care
Refer in the following circumstances:







severe sexual disorders, eg, paraphilias, requiring intervention by
trained professionals
all cases of gender dysphoria for an initial assessment and
management plan
severe psychiatric illness requiring specialist treatment
complex problems requiring intensive couple therapy
prescribed specialist medications causing, or contributing to the
problem
if a medical condition is suspected – for further investigation
male erectile problems requiring biological treatment.
PROBLEMS ASSOCIATED WITH THE FEMALE
REPRODUCTIVE CYCLE
(Refer to Chapter 19 of the main text for complete information)
There are gender differences in the prevalence, expression and course of
many psychiatric disorders. These differences are due to both
psychosocial and physiological factors.
46
Some of the psychosocial factors that contribute to higher rates of
depressive and anxiety disorders in women include the fact that they are
more vulnerable to sexual and domestic violence, and that they still do
not share equal rights with men in most countries.
Biological differences exist in brain anatomy, and the different male and
female reproductive hormones produce psychoactive effects. Oestrogen’s
anti-dopaminergic and serotonin-enhancing effects, and the modulation of
γ-aminobutyric acid (GABA) receptors by metabolites of progesterone,
may play a role in psychiatric disorders in women.
Several transitional life events in the lives of women are marked either by
the onset of or changes in, the menstrual cycle. An understanding of the
relationship between psychiatric disorders and menstrual characteristics is
important in the assessment and care of women.
Menarche




Menarche is the first menstrual cycle, or first menstrual bleeding, in
females.
Average age of onset is 12 years, but it can range from 8 to 16
years of age.
No specific psychiatric disorders associated with menarche, however
the prevalence of depression and anxiety in females increases at
this time.
Early maturing girls have been shown to be at an increased risk for
depressive symptoms in adolescence.
Premenstrual dysphoric disorder




A subgroup of women will experience clinically meaningful mood
changes in the week or two prior to onset of menstrual flow.
Premenstrual dysphoric disorder (PMDD) is considered a mood
disorder in the DSM-5™, and is the more severe variant of the
premenstrual syndrome (PMS).
PMDD is characterised by the presence of physical, emotional and
behavioural symptoms that occur repetitively in the second half of
the menstrual cycle and often also in the first few days of menses.
PMDD can be differentiated from PMS by the presence of at least
one affective symptom such as anger, irritability or internal tension.
Diagnosis of PMS or PMDD


Symptoms should be severe enough to interfere with some aspects
of the woman's life.
Owing to the poor reliability of retrospective reports, the diagnosis
is made prospectively over two menstrual cycles.
47
Management









Ask the affected woman to keep a daily diary of all symptoms for 2–
3 months to evaluate the timing and characteristics of her
symptoms.
Changes to diet and forms of aerobic exercise may often decrease
the premenstrual symptoms.
Caffeine and alcohol intake should be decreased to reduce anxiety
and irritability and salt intake decreased to minimise water
retention.
Nutritional supplements including Vitamin B6 and calcium carbonate
may be helpful.
Pharmacotherapy can be considered if symptoms are severe or do
not respond to lifestyle changes after 2 months.
When physical symptoms predominate, spironolactone given daily
during the luteal phase is effective for reduction of bloating and
breast tenderness.
Oral contraceptives or injectable progestin depot will decrease
breast pain and cramping.
A combined oral contraceptive containing the progestin,
drospirenone with a 4-day pill-free interval has been approved for
the treatment of PMDD.
When mood disorders predominate, SSRIs are an effective and safe
first-line therapy.
Pregnancy
There are many physical and psychological changes that may impact on a
woman’s mental health during this period. Depression can emerge
gradually and many symptoms such as fatigue, mood problems,
insomnia, appetite changes and pain are all common in pregnancy, and
their role as symptoms of depression may easily be overlooked. It is
important to identify depression early because, without treatment, it can
lead to postnatal and persisting depression. Anxiety is common during
pregnancy and may be particularly pronounced when there is co-morbid
depression.
The effects of untreated illness on the foetus are important, and antenatal
depression has been associated with intrauterine growth problems and
low birth weight. Anxiety during the last trimester in particular may be
associated with learning and attention difficulties. The mentally ill mother
may have a chaotic lifestyle and may be unable to care for herself. She
may not attend antenatal visits, and problems could go undetected. She
might use harmful substances such as alcohol and cigarettes. These
factors can impact on the physical health and emotional well-being of the
infant.
48
Management




Treatment ranges from simple measures such as increasing the
level of self-care to medication in the case of severe depression.
Treatment of depression in the antenatal period is complicated by
concerns for the safety of the foetus because all psychotropic
medications, including antidepressants, cross the placenta.
Avoid paroxetine in early pregnancy as there seems to be an
association in several studies with cardiac defects.
If medication is indicated, discuss the risks and benefits with the
mother and family to enable an informed decision-making process.
General strategies








Take a thorough history to guide risk-benefit analysis.
Offer psychotherapy and other support.
Meet with the patient and social supports (partner, mother, aunt,
etc.) to review risks and benefits if the patient approves.
Keep a close collaboration with the obstetrician and paediatrician if
available.
Identify triggers for the decision to initiate or change the
antidepressant dosage in advance (sleep disruption, suicidal
ideation), and have a plan in place.
Encourage a healthy lifestyle (exercise, sleep, reduce stress,
increase supports).
Discuss risks and benefits of different treatments at different time
points throughout the pregnancy.
Review the known and the unknown, including the limitations of
published studies.
Postnatal blues





Between 50% and 70% of all recently delivered women will have
this experience within ten days of delivery and it is almost
considered a normal reaction to childbirth.
Onset is commonly between days 3–5, and the episode usually lasts
for 48–72 hours.
Typical symptoms include a labile mood with tearfulness, irritability,
anxiety, sleeplessness, forgetfulness and confusion.
Headaches and a wide range of vague physical complaints are also
common.
If symptoms persist for more than a week then the diagnosis of
postnatal depression should be considered.
49
Postnatal depression (PND/PPD)



This is the most frequent of the serious psychiatric problems
following childbirth.
Approximately 11–24% of mothers will develop a significant
depressive illness in the year after childbirth.
Of those mothers with severe postpartum depression, at least half
remain depressed for more than a year and many do not receive
adequate or sustained psychiatric treatment.
Diagnosis





Symptoms of PND are the same as those for clinical depression and
must be present for more than two weeks.
Fatigue is common and waking unrelated to feeds is more common
in those who are developing PND than in control groups. This may
be an early warning sign.
Sometimes they may have intrusive thoughts about wanting to
harm the child or they may ruminate on not being a “good enough”
mother.
Self- esteem and self -confidence may be low with a tendency to
avoid other mothers as they are perceived as being more
accomplished.
Libido may be low and absent sexual relations can place further
strain on a couple attempting to adjust to a major life event.
Management




Treatment may include counselling alone, antidepressant
medication or a combination of both.
Psychoeducation and an explanation that postnatal depression is
relatively common and that the sufferer is not ‘unmotherly’ can help
to reassure the woman.
Antidepressants are not contraindicated in breast feeding and
should be considered if depression and anxiety persist or are
severe. While all of the SSRI’s are detectable in breast milk, the
levels are very low and seem not to have long-term effects on the
infant. Either sertraline or paroxetine (the shape of the molecule
minimises passage into breast milk) would be the first choice if
treatment with another agent has not already been initiated during
pregnancy.
If there is active suicidal ideation, poor response to initial treatment
or if delusions begin to develop about the baby, admission to
hospital is indicated. Electroconvulsive therapy remains a useful
treatment option for very severe cases. Response is usually rapid
and there is no contraindication to breastfeeding.
50
Postpartum psychosis
This is the most serious of the postpartum psychiatric disorders. It is
relatively rare, affecting approximately 0,1% of new mothers. In its
extreme forms it can endanger the lives of both mother and child, with
5% of affected mothers committing suicide, and 4% committing
infanticide. Postpartum psychosis is often associated with an underlying
bipolar disorder.
Diagnosis




Onset is acute and usually occurs within the first four weeks
following childbirth.
Symptoms include delusions, hallucinations and bizarre behaviours.
Those affected are restless, irritable, and often have mood
instability.
Symptoms can put the child at risk of being harmed, for example if
voices tell the mother to kill the child.
Intensifying unease and intractable insomnia in the first few days
post-delivery are warning signs.
Management


This is considered a medical emergency and the mother should be
hospitalised until there are clear signs of recovery. If the mother is
breast feeding, feeds should occur when blood levels of the drug are
low or expressed milk given in between. Doses should be as low as
possible for treatment to be effective.
Electroconvulsive therapy is a safe and often very effective
therapeutic option, without the side effects and challenges of
medication crossing into the breast milk.
Summary of management






Exclude a general medical condition.
Antipsychotic medication and/or consider referral for
electroconvulsive therapy in severe cases.
Maintain bonding with the baby.
Counsel and support the spouse.
Address psychosocial stressors.
Discuss contraception and decisions regarding future pregnancies.
Menopause
The term menopause is used to indicate the final cessation of
menstruation, either as a result of the normal aging process or as a result
51
of surgical removal of both ovaries. The average age of menopause in
Western societies is 50 years.
Menopausal symptoms include:




vasomotor symptoms, including hot flashes and night sweats
vaginal dryness and atrophy with or without dyspareunia
osteoporosis
possible decreased sexual desire.
There is no objective evidence that cessation of menstruation and ovarian
function is associated with severe emotional disturbance or personality
changes. Therefore, depression and anxiety that may occur is probably
attributed more to the other major life changes that are associated with
the time, such as children leaving home.
Psychological distress should be managed with support and counselling.
Treatment for anxiety and depression should be managed as at any other
time in a woman’s life. Hormone replacement therapy (HRT) should be
considered if the physical symptoms cause significant distress or in the
event of early or surgical menopause. HRT should be initiated in
consultation with a gynaecologist.
THE ABUSED CHILD
(Refer to Chapter 20 of the main text for complete information)
Child abuse is a major public health problem worldwide and is a serious
problem in South Africa. Broad definitions of child abuse include neglect,
physical, sexual and psychological abuse. These have severe adverse
developmental, physical and psychological effects that often persist into
adulthood. Perpetrators may be strangers but are most commonly family
members, non-related caregivers or neighbours.
Assessment



Conduct at least one interview with the child, preferably in the
company of a trusting caregiver.
Collect collateral information from significant others to determine
the circumstances of abuse if there has been a disclosure.
Elicit a description of the abuse, the type of abuse, whether a single
event or chronic, and details of the alleged perpetrator.
52
Assessment of risk factors for ongoing abuse
The purpose of the assessment is to determine the risk to the child and
the type and level of intervention for the family. Assess:





overall functioning of the child; psychologically, socially and
scholastically
the mental state of the child
the physical status of the child
parent factors, including level of parenting skills, a possible history
of abuse and the mental state of the parent
family functioning, including family circumstances, level of support
and quality of attachments and relationships among family
members.
Interview with the child
Conduct the interview in a safe, non-threatening and child-friendly
environment. Maintain a reassuring and respectful tone, devoid of
emotions of shock or surprise.
As possible indicators of abuse, watch for:




the child may be unusually docile or fearful, guarded or suspicious
the child may show no expectation of being comforted, may be
wary of physical contact and appear hyper-vigilant
the child may be excessively compliant and show a desire to meet
the parents' needs, or he or she may display a fear of going home
the sexually abused children may display a lack of personal
boundaries and can be over-familiar or seductive towards the
clinician.
Management
The various aspects and role players are briefly discussed below.
Reporting suspected abuse
Although any person can report suspected abuse, the Children’s Act (No.
38 of 2005) states that the following professionals have a mandatory
obligation to report any case of suspected abuse:




Police officers
Doctors and nurses
Religious leaders
Educators
53


Traditional leaders
Social workers.
Role of the social worker



The social worker in a designated child protection organisation
investigates all incidents of alleged child abuse, neglect and
abandonment according to the Children’s Act (No. 38 of 2005).
The social worker must ensure correct referral and action to protect
the child from further maltreatment.
If the child is at risk of further abuse while in the care of the parent
or caregiver, the social worker has the statutory power to remove
the child into emergency foster care or to a place of safety.
Role of the police


The role of the police officer is to protect the victim, ensure his or
her safety, and to investigate the criminal case.
He or she must take a statement and refer the case to a member of
the Family Violence, Child Protection and Sexual Offences Unit
(FCS) to interview the victim, collect the necessary evidence using a
crime kit, and make the appropriate referrals for support and
counselling.
Medical management
The medical practitioner’s primary objective is to provide quality
healthcare. He or she should:




take a history
perform a physical examination
treat physical injuries, and
offer immediate psychological and social support in conjunction with
other professionals involved in the care of the victim.
In cases of suspected sexual abuse, only an authorised clinician or district
surgeon should examine the child, gather the forensic evidence, and offer
emergency prophylaxis against pregnancy, STIs and HIV, preferably
within 72 hours of the abuse.
Because of the medico-legal implications of abuse and neglect, the
practitioner should work closely with the police to gather evidence for the
prosecution of the case.
54
Psychological assessment
Children who present with emotional or behavioural disturbances as a
result of abuse should be referred for a psychiatric evaluation and
management of conditions such as anxiety disorders, depression and
PTSD. Chronically abused children may benefit from long-term individual
therapy. Some children could benefit from social skills group
interventions. A small percentage of children may require admission to a
psychiatric facility to deal with the more severe emotional effects of
abuse.
CHILDREN WITH BEHAVIOURAL OR EMOTIONAL
DIFFICULTIES
(Refer to Chapter 21 of the main text for complete information)
Children may present to primary healthcare facilities with a number of
behavioural or emotional complaints, often associated with physical
complaints. Primary healthcare workers perform a vital role in the early
detection, medical screening and management of mental health problems
in children and families.
Causes of behavioural and emotional difficulties include:






exposure to trauma
difficult home environments
parent-child problems
academic difficulties
social difficulties
psychiatric disorders.
A child suspected of having a psychiatric disorder should usually be
referred to the mental health services or other relevant specialist services
for assessment. Some of these disorders are discussed below.
Attention deficit/hyperactivity disorder (AD/HD)
Between 5% and 10% of school-going children have persistent
inattentiveness and/or hyperactivity and/or impulsivity, starting before
age 7 years, present in more than one situation, and leading to significant
educational and social difficulties. Other medical, substance-related,
emotional or intellectual causes must be excluded before the diagnosis of
AD/HD is made.
Where possible, these children should be assessed by clinical mental
health professionals and may be given medication if the diagnosis is
confirmed.
55
Conduct disorder
Children who consistently violate major social norms, for example by
lying, stealing, displaying violent behaviour, engaging in theft, vandalism
or truancy, for more than six months, are usually diagnosed with conduct
disorder. However, children displaying such behaviour may suffer from a
mood or psychotic disorder, and screening by a mental health
professional should be sought before the diagnosis is made.
If a conduct-disordered child is beyond the control of his caregivers, social
services should be informed immediately.
Tic disorders
A tic is a repetitive involuntary rapid movement or sound. Motor tics can
occur in any muscle group, but are most common in facial and upper limb
and torso muscles. Children with motor tics usually present with abnormal
blinking or facial twitching, but may also have head, neck, arm,
abdominal or leg movements. Vocal tics (sounds) may take the form of
grunts, sniffs, words or phrases. Up to 25% of children will have transient
motor tics during childhood. These are regarded as a developmental
phenomenon and require no treatment except reassurance, unless they
are causing the child social embarrassment.
Motor or vocal tics persisting for more than one year are regarded as
chronic tic disorders, and when they are both present for more than a
year the diagnosis of Tourette’s disorder may be made. In the absence of
other problems, tic disorders can be managed by paediatric services.
However, Tourette’s disorder is frequently accompanied by obsessivecompulsive behaviour, and then referral to child mental health services is
required.
Enuresis
Enuresis is the voiding of urine into clothing or in bed. When it occurs
after the child has developed bladder control, it may indicate that the
child is stressed in some way. After possible medical causes, for example
urinary tract infection, diabetes, epilepsy and other neurological disorders
have been excluded, investigate possible psychological causes. These
include traumatic events or recent changes in the child’s life, such as the
birth of a sibling, family relocation or parental separation. If the child has
other symptoms such as disturbed behaviour or depressed mood, referral
to mental health services is needed.
Children who have not attained bladder control by the mental age of 5
years are usually regarded as having a maturational delay rather than a
psychiatric disorder. Their enuresis usually takes the form of bed-wetting,
56
and initial treatment is a ‘star chart’, on which the child receives a star for
every dry night. A certain number, depending on the baseline, of dry
nights in a week earns the child a reward. Progress may be assisted by
some fluid restriction before going to bed, but children dehydrate easily
and this should not be extreme.
Encopresis
Encopresis is the unintentional or intentional voiding of faeces in
inappropriate places after the age of four years. It may be caused by an
overflow of liquid faeces secondary to constipation, anxiety-related
diarrhoea or due to psychological factors. These may be ‘regressive’ as in
a return to previous developmental stage after a stressor, or ‘aggressive’
in the intentional soiling as an expression of anger. Sometimes children
with AD/HD do not attend in time to their need to defecate and as a result
may appear to be encopretic.
Medical causes, for example Hirschsprung’s disease, must be excluded,
and treatment should be multi-disciplinary. The constipated child may
require bowel washout with or without laxatives, and the caregiver may
need dietary advice and information. A star chart can help the child to
establish a regular toilet routine, and the family needs to be encouraged
to help the child to achieve bowel continence rather than teasing or
punishing him/her. Stressors should also be identified and attended to.
Mood disorders
Symptoms of depression may be similar to those in adults, with the
exception that in children the mood may be more irritable than
depressed, or the depression may be reflected in behavioural changes.
When asking a child to describe his or her mood, age-appropriate
vocabulary should be used, for example ‘sad’ or ‘cross’. Sleep and
appetite disturbance, loss of interest in activities the child usually enjoys
or social withdrawal may be present, and the child may become clinging
and anxious.
Once general medical causes have been excluded, children who appear to
be depressed should be referred to child mental health services if
possible, where psychosocial treatment is the first choice. In more severe
cases, medication, usually fluoxetine, may be used. There are concerns
around possible adverse effects of antidepressants in children and
adolescents. Therefore, any young patient taking these medications
should be carefully monitored for agitation and suicidal thinking or
behaviour.
Children may suffer from bipolar disorder, although this is relatively rare.
The diagnosis is difficult to make in prepubertal children and requires
57
evaluation by a child mental health specialist. Mania in children may
present with an irritable rather than an elevated mood, grandiosity
inconsistent with the child’s developmental stage, hypersexuality not
related to sexual abuse, and persistent rapidly switching mood
abnormalities. In adolescents, the disorder is more likely to resemble the
adult form.
Anxiety disorders
Children may develop adult anxiety disorders such as panic disorder,
obsessive-compulsive disorder (OCD), post-traumatic stress disorder
(PTSD) and generalised anxiety disorder (GAD). Any child who has panic
attacks or irrational and excessive fears that are inappropriate for their
developmental stage should be assessed by child mental health services.
Younger children with OCD may not be able to articulate their anxieties
but present with rituals and avoidance behaviour that impairs their ability
to function normally at home and at school. Panic disorder should be
suspected in children with apparently treatment-resistant asthma.
Separation anxiety disorder is usually identified in a child who refuses to
part from their caregivers in order to attend any activity outside the
home. Separation anxiety is a normal developmental phenomenon, and
should have abated by the time a child attends school. If the child is
persistently anxious when separated from his or her caregivers, or refuses
to separate, questioning usually elicits a fear that something will happen
to the child or his or her caregivers when they are apart.
Developmental disorders
Abnormalities or delays in a child’s developmental progress should alert
the clinician to the possibility of a developmental disorder. Paediatric
assessment is needed before the child is referred to mental health
services because many developmental syndromes require specialist
medical or genetic assessment.
Children presenting with behavioural problems in the context of abnormal
development may suffer from intellectual disability or autism spectrum
disorders. Those with intellectual disability may not be able to understand
social rules, and their behaviour may be characteristic of younger
children. Intellectually disabled children with behavioural problems at
school should be referred to education system support structures for
evaluation and assistance. If the problems are present at home as well,
assistance and parent training may be sought from community-based
support groups or Intellectual Disability Services.
58
Autism is a relatively rare disorder in which the child has deviant
development in three areas: social interaction, communication and
behaviour. Typically, an autistic child does not seek comfort from or make
eye contact with caregivers, has severely delayed or absent language
development, and displays ritualistic and unusual behaviours including
rocking, spinning and abnormal play. Basic testing for hearing impairment
should be carried out before referral to child mental health services.
Psychotic disorders
Schizophrenia and related disorders may rarely present in childhood, but
are more common in adolescence. In very young children, it may be
difficult to distinguish hallucinations and delusions from developmentally
appropriate fantasies. In addition, thought disorder may not be apparent
in a child whose language development is immature. If a very young child
is thought to be hallucinating or confused, a thorough examination for
possible causes of delirium should be conducted. If this proves negative,
referral to specialist child mental health services is required.
In older children and adolescents, hallucinations or delusions may be
more easily identified. Other causes of psychotic symptoms in older
children include intoxication with a stimulant or hallucinogenic drugs.
Caregivers do not always know whether the child is abusing substances,
and drug screening may be helpful.
An approach to the diagnosis of psychiatric disorders
All children presenting with behavioural or emotional complaints should
initially be screened for medical conditions that could present with such
symptoms.
An approach to the diagnosis of psychiatric disorders
Presenting complaint
Bed-wetting (or daytime
wetting)
What to look for



Faecal soiling
Failure to progress at school
Infection/neurological or endocrine
disorders
Developmental delay
Stressors


General medical condition, e.g.
Hirschsprung’s disease
Stressors
Family dysfunction

Intellectual disability

59






Disruptive/ 'bad' behaviour
Hearing or visual impairments
Learning disabilities
Problems at school (e.g. bullying, sexual
harassment, poor or no teaching)
Problems at home (e.g. abuse, poverty,
parental substance abuse, parental
mental illness)
Depression
Anxiety disorders





Parental dysfunction (poor discipline,
parental depression, substance abuse,
etc)
Intellectual disability
AD/HD
Tic disorders
Depression
Bipolar disorder
Refusal to attend school



Truanting
Problems at school
Anxiety disorders
Poor social interaction (from
early childhood)


Autistic spectrum disorders
Intellectual disability
Social withdrawal (when child
has previously been socially
active)



Anxiety disorders (e.g. social phobia,
panic disorder, PTSD)
Depression
Substance use disorder
Irritable/aggressive behaviour



Depression
Mania
Substance abuse
Substance abuse



Depression
Substance use disorder
Physical or sexual abuse
Antisocial behaviour



Depression
Intellectual disability
Conduct disorder

60
Bizarre behaviour



Delirium
Psychosis
Intellectual disability
An approach to the management of psychiatric
disorders
All children and adolescents must be screened for relevant medical
conditions prior to a psychiatric diagnosis being considered.
Suspected diagnosis
Intellectual disability
Assessment
Developmental assessment (paediatric assessment if
available)
Management
a) Treat any physical problems b) Case management
Referral
Education support system/early childhood development
programme
Suspected diagnosis
Learning disabilities
Assessment
Exclude hearing/vision impairment
Management
Case management
Referral
Educational assessment and support
Suspected diagnosis
Autistic spectrum disorders
Assessment
Exclude hearing impairment
Management
Case management
Referral
Paediatric or mental health services
Suspected diagnosis
AD/HD
Assessment
a)Request report from teacher b)Baseline ECG and
cardiovascular status
61
Management
Consultation with mental health service. Medical
management where indicated
Referral
a) Parent training/support
b) Education support system
c) Mental health services if other psychiatric disorders
present or if no response
Suspected diagnosis
Conduct disorder
Assessment
Ask about recent stressors
Management
Address stressors
Referral
Social services
Suspected diagnosis
Tic disorders
Assessment
a) Ask about recent infections b) ASO titre if indicated c)
Look for AD/HD and OCD
Management
a) If no distress or impairment, observe and follow up
regularly
b) Educate parents and school about condition
Referral
a)Paediatric/psychiatric assessment if medication indicated
b) Support groups
Suspected diagnosis
Enuresis
Assessment
Screen for intellectual disability, infection or neurological
causes
Management
a) Star chart b) Imipramine if necessary
Referral
Paediatrician if no improvement
Suspected diagnosis
Encopresis
Assessment
a) Screen for Hirschsprung’s disease or anal fissure and
other medical/surgical problems b) Explore family
62
functioning
c) Ask about recent stressors
Management
a)Treat constipation if present b)Dietary advice if needed
Referral
Paediatrician if no improvement
Mental health services if family dysfunction present
Suspected diagnosis
Delirium
Assessment
Find medical cause
Management
a) Treat cause b) Sedate if necessary with low dose
haloperidol
Referral
a)Refer as indicated by cause
b)Refer paediatrics/ internal medicine if no cause can be
found
Suspected diagnosis
Substance use disorder
Assessment
a) Assess for intoxication/ withdrawal
b) Assess for other psychiatric disorders
Management
a) Treat withdrawal if present
b) Sedate in consultation with mental health service as
needed
Referral
a) Substance abuse services
b) Mental health service if other psychiatric disorders
present
Suspected diagnosis
Psychosis
Assessment
a) Exclude general medical condition
b) Ask about substance use
Management
a) Sedate if necessary
(haloperidol and/or lorazepam)
Referral
a) Refer to nearest child and adolescent psychiatry service
b) Telephonic consultation if immediate referral not
possible
63
Suspected diagnosis
Depression
Assessment
a) Ask about recent stressors
b) Screen for suicidal ideation
Management
a) Address stressors
b) Follow up frequently
Referral
Mental health services if severe, if any suicidal ideation, or
if no improvement in four weeks
Suspected
diagnosis
Bipolar disorder
Assessment
Exclude substance intoxication
Management
Sedate if
necessary
Referral
a) Refer to nearest child and adolescent psychiatry service
b) Telephonic consultation if immediate referral not possible
Suspected diagnosis
Anxiety disorders
Assessment
Ask about specific anxiety symptoms
Ask about recent stressors
Management
Address stressors if present
Referral
Mental health services for assessment
Management of psychosocial causes of behavioural problems
Suspected diagnosis
Problems at school (e.g. bullying, sexual harassment, poor
or no teaching)
Assessment
Explore school-related problems and stressors
Management
a) Inform school authorities where necessary
b) Ensure child’s safety
Referral
a) Education support system
b) Social services if abuse is suspected
64
Suspected diagnosis
Problems at home (e.g. abuse, poverty, parental
substance abuse, parental mental illness)
Assessment
Investigate home-related problems and stressors
Management
a) Inform social services if abuse is suspected
b) Address parental mental illness if present
Referral
Social services
Suspected diagnosis
Parental dysfunction (poor discipline, parental depression,
substance abuse, etc)
Assessment
Interview parents to assess for mental illness
Management
Address parental mental illness if present
Referral
Social services and parent training and support groups
where available
Suspected diagnosis
Truanting
Assessment
Screen for psychiatric disorder
Ask about problems at home and at school
Management
Case management
Referral
Social services and educational support services
THE DISTURBED ADOLESCENT
(Refer to Chapter 22 of the main text for complete information)
Adolescence is a period of important physical and psychological changes
and social transitions during which teenagers are changing from children
into adults. Socially they are preparing themselves for the move from
being dependent on their families to being independent and responsible
adults.
Physically and physiologically there are the changes of puberty that occur
at the beginning of adolescence. Intellectually there is a move from
primary school to high school, where thinking is at a more abstract level,
while at the same time behaviour remains impulsive. At a time of
expectation and uncertain possibilities, adolescence is also a period of
vulnerability. It is also the time for the emergence of many of the severe
psychiatric disorders.
65
Evaluation of the adolescent
An adolescent is not a ‘small adult’, and special consideration needs to be
given to how one approaches and assesses the adolescent. It is important
to emphasise the notion of confidentiality, as many adolescents are
reluctant to reveal their concerns if they feel that these may be disclosed
to parents or others.
The initial assessment should include an assessment of the severity of the
problem and the nature of the risk. The risk assessment includes risk to
self and to others. If possible, the adolescent should be offered a second
opportunity to be seen alone with the healthcare professional to ensure,
without compromising safety, that disclosure of any kind is kept
confidential.
The severity of the presenting condition will determine whether in-patient
or outpatient care is needed. If in-patient care is needed, the immediate
risk needs to be addressed. This assessment should include a physical
examination to exclude any medical condition that may be the cause of
the presenting problem.
Following the assessment, arrangements should be made to transfer the
patient to a level 2 in-patient adolescent unit or hospital facility where
further assessment may take place. Very few psychiatric disorders require
in-patient admission and most can be managed within a community
setting if there are adequate resources. In southern Africa, because there
are very few community resources available for adolescents, the threshold
for admission tends to be lower.
In general, conditions requiring admission in the southern African context
include:





first onset of a psychotic episode
psychotic presentations that cannot be managed in the community
mania, with or without psychosis, presenting with risky behaviour
actively suicidal patients
extremely violent and aggressive patients where a psychiatric
disorder is suspected, as opposed to antisocial behaviour. Police
intervention and support may be required for violent people
presenting at clinics.
Where adolescents can be treated as outpatients, a decision should be
made as to whether the local community resources or clinic may be able
to provide a sufficient service, or whether a referral to a child and
adolescent outpatient psychiatry unit is indicated.
66
General principles of treatment
In treating all patients, and especially adolescents, the principles
discussed below apply.
Respect, understanding and consent







Aim to build a supportive and collaborative relationship with the
adolescent and his or her carers. A good therapeutic alliance
contributes significantly to the success of any treatment
programme.
Always be respectful of the adolescent’s knowledge and
understanding of their problems.
Be sensitive to any stigma, teasing or bullying concerning mental
illness.
Always take into account the views of the adolescent and involve
them and their carers in treatment decisions.
Legislation in South Africa states that adolescents are able to make
decisions about their treatment at the age of 16 years.
Assess the ability of the adolescent to understand treatment.
Respect confidentiality, while at the same time informing the
adolescent in what circumstances confidentiality may be broken.
Provide information




Always try to provide relevant age-appropriate information about
diagnosis, assessment, support, self-help facilities, psychological
and medication treatment.
Where medication is indicated, provide information about side
effects.
Always try to provide written information.
Provide information about support groups and voluntary
organisations where available.
Support for the parent or carer



Parents/carers of the adolescent may also have mental health
problems that need addressing and referral to appropriate services.
Offer parenting support where indicated.
Refer parents/carers to local support groups where available.
THE DIFFICULT ADULT PATIENT
(Refer to Chapter 23 of the main text for complete information)
In primary healthcare settings, patients are often labelled ‘difficult’. In
very broad terms, there are two ways of looking at difficult patients: the
67
diagnosis may be difficult or the management of the patient may be
difficult. In the first group, personality problems, general medical
conditions, substance abuse and language and cultural issues should be
considered. In the second group, the difficulty lies in the relationship
between the clinician and the patient.
Diagnostic difficulties







Multiple diagnoses
Presentation not amenable to diagnostic categorisation
Substance abuse
Contributory general medical conditions
Personality factors
Prominent physical symptoms
Language and cultural differences.
Multiple diagnoses
Diagnostic problems arise when more than one diagnosis applies. The
tendency to oversimplify and attribute a wide range of symptoms to a
single cause within the biomedical framework is rarely sufficient. If there
is a substance-abuse problem, a personality disorder or significant
psychological and social contributing factors in addition to the most
evident diagnosis, difficulties will also arise.
Diagnostic categories
Symptoms rarely fit neatly into diagnostic categories, and difficulties can
arise when attempts are made to confine a cluster of symptoms into a
single diagnostic category. As categories are rarely mutually exclusive, it
is more appropriate to consider the majority of symptoms in dimensional
rather than categorical terms. A simple diagnostic category such as an
anxiety disorder does not account for the distress and disability
experienced by the patient.
Substance abuse
A common diagnostic difficulty is related to the presence of substance
abuse and other physical problems. Alcohol and other substance-abuse
problems are frequently overlooked. This is partly due to patients'
tendency to deny or minimise the problem and a lack of thorough
investigation on the part of clinicians.
General medical conditions
Delirium and dementia are the two principal groups of medical disorder
that can cause difficulties. The hallmark of delirium is the sudden onset of
68
fluctuating levels of consciousness. Dementia, on the other hand, is
characterised by the gradual onset of a global impairment of cognitive
functioning in clear consciousness. Diagnostic difficulties arise when a
delirium develops in association with a dementia. Other general medical
conditions that may present with confusing psychiatric symptoms include
HIV/AIDS, syphilis, diabetes, systemic lupus erythematosus (SLE),
thyroid disorders and malignancies.
Personality problems
Personality problems can cause diagnostic difficulties; the contribution of
personality factors to the presenting symptom may be disregarded, or the
concept of a personality disorder, and its subdivisions, may be regarded
as uncertain and imprecise. Management difficulties, which are discussed
later in this chapter, may also occur. The key features of personality
disorders are a pattern of long-term maladaptive behaviours that emerge
in adolescence and lead to a significant impairment of psychological and
social functioning.
Physical symptoms
Physical symptoms often indicate psychological distress. The symptoms
tend to be persistent, resistant to treatment and vaguely described in
emotional terms. Patients are anxious, depressed and angry, and there is
a temporal association with psychological and social stressors.
Language and cultural difficulties
In southern Africa, diagnostic difficulties may arise as a result of language
and cultural differences. It is therefore appropriate that the first point of
contact is with a healthcare worker who understands the language,
meaning and context of the presenting symptom. Diagnostic difficulties,
with the resulting frustration and lack of success, are more likely to occur
at the secondary and tertiary levels, where a greater divergence of
cultures may exist between patient and practitioner.
Difficult-to-manage patients
The more common problems are:





the
the
the
the
the
passive and dependent patient
manipulative and seductive patient
hostile patient
unco-operative patient
somatising patient.
69
These categories themselves represent stereotypes and are certainly not
mutually exclusive: they may nevertheless represent problematic
behavioural traits that cause difficulties in both assessment and
management.
The passive and dependent patient
The passive and dependent patient lacks or displays limited motivation to
be well. Doctors assume their patients come to them to be relieved of
their symptoms. They may become frustrated if the patient does not
respond to the standard treatment, and the patient is labelled 'difficult'.
The manipulative and seductive patient
The manipulative and seductive patient also tests the assumptions a
clinician tends to make. This assumption is that the reason the patient
visits the clinician is the reason given by the patient. However, the patient
may have another purpose or agenda. This lack of being open or explicit
in the relationship leads to the patient being labelled 'difficult'.
The hostile patient
The hostile patient appears dissatisfied with the help that is offered. The
hostility bears no relation to what is communicated. It is either
inappropriate or disproportionate. The clinician may feel that the patient
is antagonistic, which may cause anxiety or a defensive reaction.
The unco-operative patient
The unco-operative patient is either unwilling or unable to co-operate.
This lack of co-operation may take various forms: overt, in the form of
hostility; or covert, as in passive dependency. Its most extreme forms are
mutism or catatonia. More common and subtle forms are sporadic
compliance or non-adherence to treatment plans.
The somatising patient
The somatising patient regularly presents with various physical
complaints. The symptoms involve different systems and refer to different
sites of the body. The symptoms are vaguely described and are not
disabling. The patient is not unduly distressed. The patient focuses on the
physical symptoms and appears reluctant to consider the possible
relevance of psychological and social factors.
70
THE AGITATED OLDER PATIENT
(Refer to Chapter 24 of the main text for complete information)
Difficult or challenging behaviours, otherwise known as the behavioural
and psychological symptoms of dementia (BPSD), are common in elderly
patients. In fact, BPSD affects up to 90% of individuals with dementia. If
untreated, these symptoms lead to a number of undesirable outcomes,
including poor quality of life, increased caregiver burden, caregiver
burnout, premature placement in nursing homes, and escalating health
costs. Examples of BPSD include repetitious or socially inappropriate
behaviours, aggression, depression and psychosis.
Assessment
A useful approach to BPSD is to consider the causes to arise from any of
four possible areas:




medical
psychiatric
environmental
pharmacological.
Exclusion of delirium



Take a thorough history, examination and appropriate
investigations.
Exclude an underlying delirium.
Note that the delirium may be superimposed upon an existing
dementia resulting in significant cognitive impairment, making the
diagnosis more challenging.
History




Take a detailed history to exclude causative or aggravating factors
Elicit information, preferably separately, from:
o the patient
o primary caregiver, and
o family members.
History must include a thorough enquiry into past medical and
psychiatric history, noting current and previous treatment including
antidepressants, benzodiazepines and electroconvulsive therapy.
Mood, anxiety and psychotic symptoms may not be readily
volunteered by the patient, and therefore should be specifically
enquired about.
71



Chronic conditions, pain and constipation may all result in
behavioural disturbance. Over the counter (OTC) drug use and
substance abuse should be enquired about
Symptom enquiry includes an ‘ABC’ assessment whereby
A = antecedent
B = behaviour, and
C = consequences
Precipitant and perpetuating factors are noteworthy, particularly for
the later implementation of behavioural strategies.
Families/caregivers are encouraged to draw up a 24-hour behaviour
chart in order to identify problematic periods, for example at bath
time.
Medications commonly implicated in behavioural
disturbance in the elderly








Benzodiazepines
Medication with anticholinergic properties such as tricyclic
antidepressants and first-generation neuroleptics
Codeine-containing medications
Cold and flu remedies
Antibiotics
Centrally acting antihypertensives such as methyl dopa, reserpine
and propanolol
Theophylline
Anti-Parkinsonian medication.
Examination and investigations


Undertake a complete physical examination at each visit.
Investigations are guided by findings on both history and
examination.
Consider a urine dipstick and random blood glucose at every followup in patients with BPSD.
Behaviour assessment tools


A number of reliable, validated tools are available for the
assessment of behavioural and neuropsychiatric symptoms in
dementia.
The Neuropsychiatric Inventory Questionnaire (NPI-Q) provides
useful information about behavioural symptoms, including severity,
as well as caregiver distress.
72
Management
Non-pharmacological management strategies
These should be considered as a first treatment option in all patients with
BPSD. However the choice of strategy depends on the behavioural
symptoms as well as the underlying cause, if identifiable. Thus pain
resulting in agitation or aggression should be treated with appropriate
analgesic measures, whereas depression or loneliness may respond to
psychotherapeutic techniques. Behavioural management approaches need
to be clearly explained to caregivers, and their effects monitored.
Non-pharmacological interventions are broadly divided into the following
four strategies:
1. Cognitive or emotion-oriented therapies, eg, validation therapy;
reminiscence therapy or simulated presence therapy.
2. Sensory stimulation interventions, eg, acupuncture; music therapy;
massage or touch therapy; and aromatherapy.
3. Behaviour management techniques, eg, ensuring a set routine;
using distraction techniques and provision of clear, one-step
instructions.
4. Other psychosocial interventions, eg, animal therapy and exercise.
Pharmacological management
When choosing an appropriate medication, consider:




the presenting psychiatric syndrome (for example anxiety or
depression)
co-morbid medical illnesses
concurrent medications, and
previous response to treatment.
Good practice guidelines emphasise that a careful risk‒benefit assessment
must be undertaken for each individual patient prior to commencing
treatment, and that the lowest possible dose is administered for the
shortest possible period of time.
Principles of prescribing in older adults


Be aware that up to a quarter of older adults are on four or more
medications, which may make drug interactions an inevitable aspect
of prescribing.
Avoid excessive or unnecessary medications to limit these drug
interactions.
73


Be aware that older adults may exhibit altered drug metabolism due
to decreased renal clearance or hepatic dysfunction. Therefore
prescribe the lowest effective dose with slow upward titration and
stringent monitoring of side effects.
Add or switch medications one at a time, so that a clear
understanding of treatment and effect can be established.
Cognitive enhancers
Cholinesterase inhibitors (ChEI) are approved for use in mild to moderate
Alzheimer’s dementia. Although indicated for cognitive impairment, all
three available drugs have been shown to have some positive impact on
BPSD. Efficacy is thought to be similar when comparing different agents
although tolerability may differ from one drug to another. GIT side effects
occur most commonly, usually at the start of treatment or following dose
adjustments.
Memantine is a glutamate receptor (NMDA) antagonist and is licensed for
use in moderate to severe Alzheimer’s dementia. Memantine tends to be
well tolerated and may improve behavioural symptoms.
Underlying psychiatric conditions
Depression, anxiety and psychotic disorders should be treated with the
appropriate medication. As a rule, low starting doses with slow titration
upwards are recommended in the elderly.
Benzodiazepines are associated with an increased risk of falls, fractures,
cognitive impairment, drug dependence and withdrawal, and should be
avoided in geriatric patients.
ALCOHOL AND OTHER SUBSTANCE USE DISORDERS
(Refer to Chapter 25 of the main text for complete information)
The escalation in substance use disorders in South Africa in recent years
has been accompanied by considerable changes in the preferred
substances of abuse. Profiles of substance misuse range from hazardous
and harmful use, to dependence.
Local trends
Substance abuse has followed a fairly predictable pattern in South Africa
for many years, with alcohol as the dominant substance of abuse, and
cannabis and the cannabis-mandrax combination, called ‘white-pipe’, as
numbers two and three respectively.
74
Over the last few years, there have been some drastic changes. The most
dramatic of these has been the introduction of crystal methamphetamine
(‘tik’) into the Western Cape, which was popularised in 2002.
Methcathinone (‘cat’) has also grown in popularity, especially in Gauteng.
More recently, there has been a worrying increase in heroin use. Heroin is
either used alone or in conjunction with other drugs, eg, cocaine,
cannabis and antiretroviral medication.
The number of male users still significantly outnumbers that of females in
South Africa, but drug use is growing among women. There is also an
alarming tendency for users to start using at a younger age.
Classification for substances of abuse
Substances are classified as ‘uppers’ or stimulants of the central nervous
system (CNS), ‘downers’ or CNS depressants, and ‘psychedelics’, or
hallucinogens, a family of drugs characterised by their ability to cause
perceptual distortions, and alter mood and thought processes.



Examples of CNS depressants: alcohol, mandrax, sedativehypnotics such as benzodiazepines, opioids such as heroin,
morphine and codeine, volatile solvents such as aerosol propellants,
petrol, glue and anaesthetic gasses
Examples of CNS stimulants: cocaine, amphetamines,
methcathinone, ephedrine, methylphenidate, appetite suppressants,
nicotine
Examples of psychedelics: LSD, magic mushrooms (psilopsybin),
dissociative anaesthetics such as ketamine.
Some substances of abuse have more than one of these effects: Ecstasy
has both stimulant and hallucinogenic effects; Cannabis has both mild
depressant and hallucinogenic effects.
The differences between misuse, hazardous use, harmful
use, abuse, addiction and dependence




Misuse implies the use of a substance in excess of, or in a different
way to its prescribed or intended use.
Hazardous use is a pattern of substance misuse that increases
someone’s risk of harmful consequences to him or herself.
Harmful use is a pattern of substance misuse that actually damages
the individual’s physical or mental health.
Substance abuse is a term defined by DSM-IV as a maladaptive
pattern of substance use that leads to impairment or distress and
manifests itself by any of the following (’the 4 R’s’):
o
the user fails to fulfil important obligations at work, school or
home (role failure)
75
or uses substances in a manner that is physically hazardous
(risky drug taking)
o or has legal problems (run-ins with the law)
o social or interpersonal problems (relationship problems) due
to or exacerbated by the substance.
Addiction is an old and contested term, used in the early twentieth
century to describe the compulsive substance-taking behaviour
seen in some substance users.
Dependence is a term than was introduced by the WHO to replace
addiction. It draws on both the physical and psycho-behavioural
aspects of compulsive drug misuse and is used by both the ICD-10
and DSM-IV classification systems.
o


There are three symptom/sign domains, namely:
1. physical adaptation of the body to the substance (tolerance,
withdrawal)
2. loss of control over taking of the substance (strong desire or sense
of compulsion to take the drug, difficulties in controlling substancetaking behaviour, a desire or unsuccessful efforts to cut down or
control use)
3. salience: the substance takes over the person’s life (a great deal of
time is spent obtaining or using the drug or recovering from its
effects, progressive neglect of alternative pleasures and interests,
or important activities and continued use despite clear evidence that
it is harmful).
The DSM-5™ integrates the diagnoses of substance abuse and
dependence into a single disorder called a substance use disorder, with
mild, moderate and severe sub-classifications.
Management of substance use disorders
Effective interventions for substance use disorders should involve a
reduction in the supply or availability of substances of abuse, a reduction
in demand for them, and a reduction in the harm from substance use.
One way of approaching this is to look at the three levels of prevention:



Primary prevention: This involves preventing the initiation of
substance misuse.
Secondary prevention: This involves early detection and
appropriate and effective treatment to prevent harm from
substance misuse, described as indicated interventions.
Tertiary prevention: This involves limiting harm from substance
dependence, either through harm reduction interventions or by
providing effective substance abuse rehabilitation.
76
Harm reduction is a public health approach that acknowledges that
stopping all substances may not be desirable or achievable by all, and
views any intervention that reduces risk to the individual or community as
a positive step. This may include encouraging patients to consume
smaller amounts of substances, and addressing dangerous behaviours
while under the influence, for example drunk-driving or providing clean
needles to injection drug users.
The health worker’s role in tertiary prevention includes identifying
substance disorders and motivating the individual to seek help, ensuring
they have contact details of local substance services for referral, ensuring
they are up to date with the latest pharmacotherapy for detoxification and
maintenance of abstinence, and knowing what to do if a person refuses
treatment, including harm reduction strategies or committal procedures.
Detoxification may be required as the first step of treatment, but on its
own is very unlikely to be successful. Even when patients undergo
rehabilitation, it is important to remember that substance dependence is a
chronic and relapsing disease, and many persons need more than one
intervention before they reach their ultimate goal of sobriety. Each
intervention increases the likelihood of success for further interventions.
One should not feel discouraged if an individual is not able to remain
sober after a single rehabilitation programme.
The treatment of substance dependence
Brief interventions





These are time-limited, personalised feedback to patients at risk, in
order to change their substance use behaviour.
They are provided in a supportive and non-judgemental manner,
and link substance use to medical problems or risk of medical
problems.
Consultations may range from 5 minutes of brief advice to 15--30
minutes of brief counselling.
Brief interventions are low in cost and research has confirmed the
effectiveness of these basic interventions.
Important elements of effective brief interventions are described by
using the acronym FRAMES.
77
Brief interventions: (FRAMES)
Feedback
Feedback of personal
risk or impairment
‘The cause of your stomach pain is
gastritis, and alcohol seems to have
contributed to this.’
Responsibility Emphasis on personal
‘What you do with this information I’m
responsibility for change giving you is up to you.’
Advice
Clear advice to change
‘The best way you can reduce your risk of
gastritis is to cut down or stop drinking.’
Menu
A menu of alternative
change options
‘Would you like information on safe
drinking?’
‘I would like to help and support you as
far as possible. Do you want help or
advice on how to cut down/stop?’
‘Can I tell you about options available for
help in our area?’
Empathy
Therapeutic empathy as Warm, caring, non-judgemental
a counselling style
Self-efficacy
Enhancement of patient ‘I know that if you put your mind to
self-efficacy or
something, you mean serious business.’
optimism
‘I believe that you can do this.’
Motivational interviewing
This is a useful interpersonal communication style, rather than a formal
counselling technique. It has changed the way of dealing with substance
problems and various other undesirable behaviours, such as nonadherence to medication and life-style changes.
Motivational interviewing is based on the model for the stages of change.
Five stages are described:





Pre-contemplation: the person is unaware of their problem and
does not see any need to change his or her behaviour.
Contemplation: the person begins to weigh up the pro’s and cons
of continuing with the status quo versus the pro’s and cons of
change. They begin to experience some ambivalence regarding their
habit.
Determination: the balance is tipped, and a decision is made to do
something, or nothing, about the habit.
Action: a strategy for change is chosen and then pursued.
Maintenance: efforts are made to maintain the gains made in
order to avoid returning to previous undesired behaviours. A person
can maintain gains and permanently exit the cycle or lapse, when
the self-imposed restriction is briefly violated. The person views this
78
as a ‘challenging mistake’ and rapidly returns to the new behaviour
pattern, or relapses, returning to the old undesired behaviour
patterns. Relapse is recognised as a frequently occurring event. It is
not viewed as failure, but rather as a potentially positive learning
experience that increases the chances of success next time round.
The cycle of change (Prochaska and DiClemente)
Insight into realities about oneself can be painful and it is thus normal or
natural to resist change. A range of defences is used to protect one’s
sense of self. These include: denial (‘it is not really a problem’),
minimisation (‘it’s only a small problem’), projection (‘it’s really my wife
that’s got the problem’) or rationalisation (‘my behaviour is
understandable if you take my circumstances into account’).
Important elements of motivational interviewing






Support self-motivation: Patients are more likely to change
undesired behaviour if they have defined their own problem, and
have argued for change themselves.
Express empathy: Change is best enhanced through positive reenforcement and when the therapist expresses acceptance and
affirmation.
Avoid arguments: The therapist should disengage from negative
emotional attitudes like silence or hostility and continue to
communicate respect and acceptance.
Develop discrepancy: The patient is encouraged to develop his or
her own solution to the problem that they themselves have defined.
Roll with resistance: It is important to avoid power struggles or
arguments. Statements demonstrating resistance are not
challenged, but instead the counsellor ‘rolls with resistance’, shifts
the focus, or invites a new perspective.
Support self-efficacy: The therapist should always increase the
person’s hope that he or she can make substantial changes.
Common substances of abuse
Alcohol
Alcohol is the third leading cause of death and disease in South Africa,
and it has been estimated that up to 30% of South Africans drinkers drink
at levels of risk.
79
Safe drinking guidelines are:





less than 21 units / week for men, and for women less than 14 units
/ week
not daily (at least 2 alcohol-free days/week)
not all on one day (avoid binges)
not during pregnancy
never before or during driving, swimming, active sport or use of
machinery, electrical equipment, ladders or in other potentially
dangerous situations.
A unit of alcohol can be considered as the following:


10 ml alcohol = 8 g alcohol = 1 unit
The number of units can be estimated using this simple formula:
Number of Units = volume of alcohol in ml x alcohol percentage /
1000
eg, Bottle of spirits: (40%) (750ml) = 30 U; Bottle of wine:
(13,5%) (750 ml) = 10 U; Can of beer: (5%) (500ml) = 2,5 U.
Management of alcohol use disorders
The general principles discussed under management of substance use
disorders apply. Various regimes may be used for alcohol detoxification.
The most widely accepted regime includes replacing alcohol with a longacting benzodiazepine, for example diazepam, or oxazepam in the case of
severe liver impairment.
The initial dose used is that which suppresses withdrawal symptoms
without causing intoxication. This is then gradually reduced. It is easiest
to use a fixed dose regime, but flexibility should be allowed. Such a
regime would include diazepam three to four times daily, tapering down
over 5‒7 days; thiamine four times daily; and vitamin B complex daily for
one month. Vitamins should be continued in cases with cognitive
impairment or a poor diet.
Uncomplicated detoxification can be offered on an outpatient basis, but
suspected complications require referral for hospitalisation. Factors that
should raise suspicion of possible complications include a history of
withdrawal delirium or previous convulsions, psychosis or suicidality,
severe liver pathology, severe withdrawal symptoms, physically severely
compromised patients, or previous failed outpatient detoxifications.
Detoxification in these patients is best done on an in-patient basis.
Ensure that the individual is enrolled in a psychosocial rehabilitation
programme and encourage him or her to attend aftercare support groups,
such as Alcoholics Anonymous, to prevent relapse.
80
Sedative-hypnotics and anxiolytics
Detoxification from benzodiazepines and the non-benzodiazepine
hypnotics, or ‘z-drugs’, is a lengthy process. It therefore requires a sound
therapeutic relationship between the patient and doctor. There is usually
great reluctance on the part of the patient to stop their medication, and if
not motivated to stop they will try to obtain medication from other
sources.
The first step is to determine the level of tolerance. Short-acting
benzodiazepines should be replaced with equivalent doses of a long-acting
benzodiazepine, such as diazepam. The ideal dose is one that relieves
withdrawal without causing intoxication. Once the baseline
benzodiazepine requirement has been established, the dose can gradually
be reduced.
Methaqualone/Mandrax
Mandrax use disorders should be managed according to the general
guidelines discussed above. Diazepam in reducing doses can be used for
detoxification.
Opioids
The term opiate refers to natural products derived from opium such as
morphine, codeine and diacetylmorphine (or heroin). Opioid refers to any
substance that acts on the mu opioid receptors in the brain and thus
includes opiates and synthetic derivatives (such as Pethidine®,
Wellconal®, Doloxene®, Valoron® and methadone). This distinction is
relevant, because urine drug screens for opiates will not test positive for
synthetic opioids.
Opioid withdrawal
Withdrawal symptoms can generally be divided into four groups:




Gastrointestinal distress, including diarrhoea, nausea or vomiting
Pain, typically either arthralgia or myalgia or abdominal cramping
Anxiety, dysphoria, irritability
Insomnia.
81
Management of opioid use disorders





Manage overdoses with naloxone (Narcan®) administered slowly
intravenously at 2‒3 minute intervals.
Remember that the duration of action of naloxone is much shorter
than that of most opioids of abuse, and thus careful observation and
repeated doses of naloxone may be necessary.
Management of opioid use disorders is complex and is best left to
workers with expertise in this field.
Patients need to undergo detoxification and psychosocial
rehabilitation. Methadone, buprenorphine, buprenorphine/naloxone
and clonidine can be used for detoxification.
Alternatively, opioid substitution treatment (OST) can be used in a
suitable patient. The medications used for OST include methadone,
buprenorphine and buprenorphine/naloxone combination.
CNS stimulants



Cocaine/Crack-cocaine (‘rock’): Cocaine is a powerful, though
short-lasting CNS stimulant, vasoconstrictor and local anaesthetic.
Cocaine hydrochloride is cocaine in powder form and it is usually
snorted or injected intravenously (‘mainlined’). ‘Crack’ is the street
name for cocaine that has been processed from cocaine
hydrochloride to a free base, so that it may be smoked.
Amphetamines, including Crystal Methamphetamine
(‘Tik’):Amphetamines are synthetic drugs, structurally related to
the naturally occurring stimulant, ephedrine. Crystal
methamphetamine is a heavily concentrated, crystallised form of
methamphetamine that can be smoked but is also injectable.
Methcathinone (‘Cat’): Methcathinone is the synthetic equivalent
of cathinone, a stimulant alkaloid found in Khat, the name given to
leaves of the tree-shaped plant Catha edulis.
Management of stimulant use disorders
Stimulant use disorders pose a unique problem. Stimulants are often
viewed as less addictive because they do not cause the severe physically
withdrawal symptoms requiring medical detoxification in alcohol,
sedative-hypnotic or opioid dependence.
Stimulant dependence does not require medical detoxification. Patients
are often irritable and explosive and have severe cravings. Treatment
includes support, empathetic counselling and occasionally, symptomatic
pharmacotherapy. Users need assessment and treatment for medical and
mental health complications, especially depression and psychosis. There is
good evidence for the use of intensive long-term outpatient rehabilitation.
82
Cannabis
Cannabis contains over 400 compounds, the most potent being delta 9tetrahydrocannabinol (THC). Hashish is very potent cannabis made mostly
from this resin and hashish oil is the concentrated resin distillate.
Cannabis is usually smoked, but can also be taken orally, usually baked
into cakes or else taken as an extract.
Management of cannabis use disorders
Cannabis dependence is managed according to general guidelines already
discussed.
Withdrawal symptoms are generally not severe and detoxification is rarely
necessary, but uncomfortable symptoms can be treated with reducing
doses of diazepam.
SYMPTOMS NOT EXPLAINED BY MEDICAL ILLNESSES
(Refer to Chapter 26 of the main text for complete information)
At the primary level of healthcare a high proportion of presentations
involve physical symptoms that cannot be adequately understood in
terms of the physical findings. Such symptoms commonly include
headaches, backaches, abdominal pains and fatigue.
The symptoms are often enduring and resistant to treatment. They are
vaguely described in an emotional language and there may be other nonspecific symptoms at other sites. Frequently there is an associated mood
disorder and the presence of significant psychological and social stressors.
Conceptual problems and confusions in terminology
There is as yet no satisfactory or widely accepted terminology for this
group of disorders. The term 'somatoform disorder' was adopted in the
DSM-IV classification system, superceded by ‘somatic symptom disorder’
in the DSM-5™. The term 'idiopathic', or unknown, is perhaps a modest
and more scientifically honest terminology.
The DSM-IV classification system divides the somatoform disorders into a
number of subcategories, which are described as follows:


Pain disorder: Pain is the predominant focus of clinical attention.
Psychological factors are considered significant in the onset,
severity, exacerbation or maintenance of the disorder.
Conversion disorder: Unexplained symptoms or deficits affecting
voluntary motor or sensory function suggest a neurological or other
83





general medical condition. Psychological factors are considered to
be associated with the symptoms.
Somatisation disorder: This is described as a poly-symptomatic
disorder that begins before the age of 30, extends over a number of
years and comprises a combination of pain and gastro-intestinal,
sexual and neurological symptoms.
Undifferentiated somatisation disorder: Unexplained physical
symptoms persist for at least 6 months, but do not meet the criteria
for somatisation disorder.
Hypochondriasis: This describes the preoccupation with a fear of
having, or the idea of having, a serious disease based on the
misinterpretation of bodily symptoms.
Body dysmorphic disorder: A preoccupation with an imagined or
exaggerated defect in physical appearance.
Somatoform disorder not otherwise specified: An ill-defined
group which represents somatoform disorders that do not meet the
criteria for specific somatoform disorders.
The DSM-5™ system employs the term ‘somatic symptom and related
disorders’ and reduces the number of these disorders and subcategories.
The diagnoses of somatisation disorders, hypochondriasis, pain disorder,
and undifferentiated somatoform disorders have been excluded. Illness
anxiety disorder has replaced hypochondriasis. Conversion disorder is
otherwise described as ‘functional neurological symptom disorder’.
Differential diagnosis for unexplained symptoms
In the situation where there are no physical findings to explain the
symptom, or the symptom is out of proportion to the known medical
disorder, a number of possibilities may be considered:






an as yet unidentified general medical condition with prominent
psychological symptoms
a general medical condition associated with prominent psychological
factors
a mood disorder, including the spectrum of anxiety, depression and
dysthymia
somatoform or somatic symptom disorders whereby physical
symptoms suggest a physical illness, cannot be accounted for by
the physical findings, and significant psychological and social
stressors are evident
psychotic disorders
factitious disorders and malingering.
These diagnostic interpretations are not mutually exclusive and may be
additive or interactive.
84
The problem of chronic pain
Chronic pain is a public health problem in that it represents an enormous
burden to society in terms of human suffering, demands on the health
services and losses to the economy, particularly through lost productivity.
Chronic pain is usually gradual in onset and persists beyond the time
expected for resolution, by convention 3‒6 months. It is not a universal
phenomenon and it is less understandable in terms of a response to a
stimulus. It is a multi-factorial phenomenon and therefore a biomedical
model is inadequate. Diagnosis and prognosis are uncertain, and for these
reasons chronic pain is difficult to treat.
Management




The crucial first step in management is the acknowledgement of the
validity or reality of the symptom.
After establishing a relationship of trust, attempt to promote
healthier, more effective ways of coping with the pain.
The formulation is explained to the patient clearly and using the
appropriate non-technical terminology, and appropriate goals of
treatment are negotiated.
Shift attention from the search for causes to the identification of
perpetuating or maintaining physical, psychological and social
factors. Cognitive-behavioural therapy, and appropriate medication
may be used to achieve these ends.
THE MEDICALLY ILL PATIENT
(Refer to Chapter 27 of the main text for complete information)
Because of the historical split between mind and body and between
psychiatry and general medicine, presenting problems have tended to be
seen as either physical or psychological, and thus the domain of either
general medicine or psychiatry. This mind-body dualism has led to the
fragmentation of patient care and a division between psychiatry and the
rest of medicine.
Psychiatric disorders or symptoms tend to be overlooked in physical
illness and physical problems are often neglected in the diagnosis and
treatment of psychiatric disorders. An integrated approach at the primary
healthcare level should provide more holistic and effective care.
Given the dualistic assumptions of a separation of psychiatric disorders
and general medical conditions, the associations might be practically
organised as follows:
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

General medical conditions giving rise to psychiatric disorders:
o consequences
o causation
o medication side effects.
Psychiatric disorders giving rise to general medical conditions:
o psychiatric disorders presenting with physical symptoms
o psychiatric disorders precipitating general medical conditions
o psychiatric disorders aggravating general medical conditions
o psychiatric medications giving rise to general medical
conditions.
Psychiatric and general medical conditions occurring together by
chance.
Psychiatric consequences following the diagnosis of a
medical illness
When presented with the bad news of a serious physical illness, the
patient exhibits a range of responses, including denial, anger, anxiety and
depression.
Simple supportive measures such as listening, allowing the patient to
express his or her anxieties, and providing appropriate reassurance and
information are usually sufficient to help prevent serious psychiatric
complications. If the psychological consequences are more serious and
qualify as disorders, most commonly anxiety and depression, or
adjustment disorders, these should be treated as described in the
relevant chapters.
Psychiatric disorders caused by a general medical
condition
The primary care physician should always consider the possibility of an
underlying general medical condition causing a psychiatric disorder,
particularly if the patient is presenting for the first time, if the
presentation is not typical, or if symptoms develop in the context of an
established medical condition.
Psychiatric disorders caused by a general medical conditions
Depression




HIV/AIDS
Other infections
Neoplasms
Epilepsies
Psychoses





HIV/AIDS
Herpes simplex encephalitis
Neurosyphilis
Epilepsies
Multiple sclerosis
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









Endocrine and metabolic
disorders
Multiple sclerosis
Parkinson's disease
Other degenerative disorders
Cerebrovascular disease
Neoplasms
SLE
Head injuries
Toxins
Nutritional disorders (vitamin B
complex, folate)






Anxiety





Cerebrovascular disease
Toxins
Degenerative disorders
SLE
Head injuries
Other causes of delirium and
dementia
Manic-like disorders
Epilepsies
Nutritional deficits
Metabolic disorders
Endocrine disorders
Multiple sclerosis






HIV/AIDS
Neurosyphilis
Hyperthyroidism
Multiple sclerosis
Cerebrovascular disease
Head injuries
Psychiatric disorders caused by medication
Delirium
Psychotic symptoms

Anti-anxiety drugs

Appetite suppressants

Antidepressants

Antimalarials

Hypnotics

Anti-Parkinsonian drugs

Anti-epileptic drugs

Corticosteroids

Analgesics

Ephedrine/pseudoephedrine

Anticholinergics

Antituberculosis drugs (isoniazid)
87

Beta-blockers

Antiretroviral therapy (ART) (efavirenz)

Digoxin

Anticonvulsants (vigabatrin, topiramate)

Cimetidine

Isotretinoin (roaccutane)
Mood disturbances
Behavioural disturbances

Antihypertensive drugs

Antipsychotics

Oral contraceptives

Corticosteroids

Antipsychotics

Anticonvulsants

Anticholinergics

Isotretinoin (roaccutane)

Antimalarials

Benzodiazepines

Anti-anxiety drugs
(NB: benzodiazepines)

Corticosteroids

Antiretroviral therapy (ART)
While this list is not comprehensive, it illustrates the need for constant
vigilance and monitoring of patients on psychiatric medication. Patients
most likely to develop medication side effects are the elderly, children and
those with intellectual disability or pre-existing medical and neurological
conditions.
Psychiatric disorders presenting with physical
symptoms
A number of possibilities are suggested by physical symptoms presenting
in the absence of, or disproportionate to, a known underlying physical
problem. There might be an undetected physical illness, the patient may
be depressed, or the patient may have a somatoform or somatic symptom
88
disorder. Other possibilities include a factitious disorder, malingering or,
more rarely, a psychotic illness.
Psychiatric disorders precipitating a general medical
condition
This group of disorders includes illnesses that were described as
psychosomatic disorders in the past. Some examples of these common
conditions include asthma, peptic ulcer disease, rheumatoid arthritis,
ulcerative colitis and hypertension. It more recently became clear that
there was no reason to believe that a specific group of disorders
originated in psychological disturbance, but that relapses in the illnesses
may be precipitated by stress.
Psychiatric disorders complicating an existing general
medical condition or resulting in physical harm to the
patient
A number of psychiatric disorders may lead to significant physical harm or
death. The most common are depression and deliberate self-harm,
substance abuse, psychotic disorders and eating disorders.
Medical illness due to psychiatric medication
Antipsychotics












Extrapyramidal symptoms
Neuroleptic malignant syndrome
Seizures
Tardive dyskinesia
Hyperprolactinaemia
Prolonged QTC interval
Hyperlipidaemia
Hyperglycaemia
Anaemia
Leucopenia
Thrombocytopenia
Hypotension
Moodstabilisers





Lithium toxicity
Renal impairment
Thyroid impairment
Liver disease
Dermatological conditions
Antidepressants




Cardiac conduction deficits
Seizures
Hypotension
Serotonin syndrome
89
While this list is not comprehensive, it illustrates the need for constant
vigilance and monitoring of patients on psychiatric medication. Patients
should, as far as possible, be informed of potential side effects prior to
commencement of medication and should be regularly monitored
according to standard treatment guidelines. Particular attention should be
placed on managing weight gain and on promoting a healthy lifestyle
through appropriate diet and exercise.
Psychiatric and medical disorders occurring together
by chance
Psychiatric disorders, through a wide range of interacting factors,
including lack of self-care and treatment effects, constitute a risk for
general medical disorders and reduced lifetime expectancy.
It is therefore of critical importance that the primary care physician
remains vigilant and does not compromise on normal standards of care
for the mentally ill patient.
NEUROPSYCHIATRIC ASSESSMENT: TRAUMATIC
BRAIN INJURY, EPILEPSY
(Refer to Chapter 28 of the main text for complete information)
Neuropsychiatry is at the interface of neurology and psychiatry. The
clinical discipline is a specialised field in psychiatry that focuses on the
understanding, diagnosis and management of patients with behavioural
disturbances associated with neurological or medical conditions. The area
broadly covers delirium, dementia and other disorders of higher cortical
functioning due to general medical conditions.
Cognitive disorders
The DSM-IV classifies cognitive disorders into the following groups:
delirium, dementia, amnestic disorder and mental disorders due to a
general medical condition. In DSM-5™ the diagnoses of dementia and
amnestic disorder are subsumed under the term major neurocognitive
disorder (NCD). Mild neurocognitive disorder is a new term describing less
disabling syndromes that might nevertheless be a focus of concern.
Cognitive domains
Higher cognitive functions fall within six broad domains:


Attention and concentration
Language
90




Memory
Higher order sensory processing
Higher order motor processing, and
Executive functions.
Bedside neuropsychiatric assessment
The neuropsychiatric examination is designed to elucidate deficits within
the six broad cognitive domains listed above. The bedside assessment
should be regarded as a screening test, and where deficits are found
these should be further investigated by standardised neuropsychological
testing.
For students, a logical and systematic approach to bedside testing is:
1. Perform a mental state examination (MSE), paying particular
attention to the patient’s ability to attend and concentrate as well as
to any disturbance in language.
2. Do a mini-mental status examination (MMSE).
3. If cognitive deficits are detected (or in the case where mild
cognitive deficit is suspected), perform additional bedside cognitive
tests to those described below.
4. Where appropriate, refer the patient for formal neuropsychiatric
assessment.
The mini-mental status examination (MMSE)
This is a short screening test for cognitive impairment. It takes
approximately five minutes to administer, and covers a variety of
cognitive functions. It is easy to establish an achievement score and
thereby obtain an idea of a patient’s level of cognitive functioning.
Unfortunately, it is a relatively crude test and mild cognitive impairment
needs to be ascertained using other tests.
A score of 24 or less out of 30 indicates global cognitive impairment. This
impairment can result from delirium or dementia. It is important to keep
in mind that the score is also influenced by age and level of education.
Further bedside neuropsychiatric testing
Consider the following:
Attention and concentration

The Glasgow coma scale is useful when the patient has an
impaired level of consciousness. A detailed description of the
patient’s state of consciousness is also necessary.
91

The alphabet test is done by reading a random sequence of letters
with the letter A occurring more frequently, and requesting the
patient to tap whenever he or she hears the letter A.
Language






Spontaneous speech: Give the patient the opportunity to talk and
then listen in turn to the fluency of speech, and to the grammatical
correctness of his or her language and ascertain whether or not
paraphrasing occurs.
Comprehension: Ask the patient to carry out a 1‒4 stage
command. Start with a 1‒stage command and increase the
complexity to 4. ‘Point to the roof with your finger.’ ‘Point to the
roof with your finger, then to the floor, then to the chair and then to
the door.’ Impairment of comprehension is called sensory
dysphasia or Wernicke’s dysphasia.
Repetition: Ask the patient to repeat a short phrase, for example
‘no ifs, ands or buts’. Having difficulty with repetition is closely
associated with damage to the arcuate fasciculus and therefore the
impairment is called conduction aphasia.
Naming: Ask the patient to name objects, for example a pen or
watch. Impairment is referred to as nominal dysphasia.
Writing: Ask the patient to write a short sentence. It must make
sense and be reasonably grammatically correct. Impairment is
calleddysgraphia.
Reading: Ask the patient to read a short sentence with an
instruction so that you can see that he or she understood it.
Impairment is calleddyslexia or alexia.
Memory

The bedside testing of memory presents a problem because a
structured test is required to adequately evaluate memory. It is
especially difficult to evaluate memory at the bedside when slight
impairment is present. One could ask questions such as: ‘What did
you have for breakfast?’ or ‘What was on the TV news last night?’
These, however, require objective verification.
Higher order sensory processing


Tactile agnosia: Ask the patient to close his or her eyes and
identify familiar objects that you place first in one hand and then
the other. The objects can include car keys, a pen or money.
Visual object agnosia: Ask the patient to identify objects that you
show him or her. Should he or she not be able to name the object,
a distinction must be made between agnosia and aphasia. Give a
description of the object (for example: ‘This is something that you
92

can use to write on paper.’). Visual recognition is hereby cued with
a verbal description. If the person still cannot name the object,
aphasia is most likely.
Prosopagnosia: This can be tested by asking the patient to
identify family in family photographs, or identify familiar
personalities in photographs.
Higher order motor processing



Ideomotor apraxia: Ask the patient to perform simple
movements, for example: ‘Show me how you comb your hair.’
Ideational apraxia: Ask the patient to perform a series of
movements, for example: ‘Show me how you unlock a door with a
key, open the door and enter.’
Constructional ability: Ask the patient to draw simple line
drawings, for example a three-dimensional cube, triangle or
rectangle.
Executive functions



Red-green test: Ask the patient to say red every time that you say
green, and to say green when you say red. Start off by saying
‘green’ or ‘red’ a few times. Make it more difficult with a couple of
short series like: ‘Green, red’ and ‘Red, green’. The patient must be
able to inhibit an incorrect response.
Months of the year backwards.
Alternating hand movements: (so-called Luria I and II
movements.) With Luria I both hands are opened and closed
alternately. With Luria II the patient must alternate one hand
between a flat hand, a fist and the side of the hand on a surface.
Traumatic brain injuries
Head injuries are generally caused by penetrating or non-penetrating
injuries. In cases of penetrating head injuries, for example from a bullet
or knife wound, brain injury occurs along the tract of the missile or the
knife. Focal damage is more likely and loss of consciousness may be
absent in spite of extensive damage. Complications include infection and
bleeding. Cognitive damage and emotional changes can be explained by
the localisation of the tract in the brain.
Non-penetrating head injuries usually occur as a result of motor vehicle
accidents. The brain is injured because of the rapid acceleration or
deceleration forces acting on the brain. In this section, non-penetrating
head injuries are discussed in greater depth.
93
The degree of severity of a head injury is ascertained by evaluating the
duration of loss of consciousness, the depth of the coma (Glasgow coma
scale [GCS]) and the duration of post-traumatic amnesia (PTA).
Classifications of severity
Glascow coma scale (eye-opening, motor response, verbal response)



13‒15: mild
9‒12: moderate
3‒8: severe.
Post-traumatic amnesia




< 1 hour: mild
<12 hours: moderate
>24 hours severe
>1 week: very severe.
Neuropsychiatric syndromes following head injury
Cognitive impairment
Cognitive impairment is common after a traumatic brain injury. The
degree of impairment corresponds to the severity of head injury and the
amount of recovery time since the injury.
Following a head injury, the most common residual impairments are
disturbances of attention and concentration, visual and verbal memory
impairments, impairments of executive function and language
disturbances. No specific pharmacological treatment is currently available
for cognitive impairment following head injury and the recommended
treatment is cognitive rehabilitation.
Personaliity changes
Personality changes are common after a head injury, but it may be
difficult to measure these changes objectively. The patient usually has
limited insight and is not able to accurately describe his or her own
personality. A detailed interview with a family member or caregiver is
necessary to ensure that relatively subtle nuances of personality change
are noted.
Possible personality changes following head injury:


irritability and aggression
apathy
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

disinhibition
emotional lability.
Pharmacological treatment of the personality change is difficult and
should be undertaken with caution. Target symptoms should be identified
and treated for a trial period of three months. Should medication not
appear to be effective it should be discontinued or changed.
Aggression is commonly treated with anticonvulsants, antipsychotics or
antidepressants. Apathy may be treated with dopamine agonists or
amphetamines. Depression presenting as apathy should always be
considered. Disinhibition and lability may respond to mood stabiliers or
anticonvulsants.
Post-concussional disorder
Minor head injuries often cause less severe, but persistent cognitive,
somatic and behavioural symptoms, which can be classified as a
characteristic syndrome.
They include the following symtoms:



Cognitive cluster: poor concentation, poor memory
Somatic cluster: headaches, dizziness, fatigue, visual or hearing
problems
Behavioural/psychiatric cluster:irritability, anxiety, depression,
emotional lability, reduced spontaneity, social isolation.
Other psychiatric disorders
Mood disorders, including depression and mania, anxiety and psychosis
are more common after head injuries than in the general population.
There is an increased risk of suicide.
Post-traumatic stress disorder symptoms may relate to the events
surrounding the traumatic event. These disorders are treated in the same
way as described elsewhere in this text.
Epilepsy
Epilepsy is the most common chronic neurological condition in the general
population. Itis a chronic condition and a syndrome, characterised by
repeated seizures.
Seizures are classified as partial and generalised seizures. Partial seizures
encompass epileptiform activity in localised brain areas, while generalised
seizures involve the whole brain.
95
Classification of epilepsy
A. Partial (focal seizures)
1. Simple (consciousness preserved)
2. Complex (consciousness impaired)
B. Partial seizures with secondary generalisation
C. Generalised seizures
1. Absence
2. Tonic-clonic
3. Tonic
4. Clonic
5. Myoclonic
6. Atonic
D. Unclassified
Symptoms of complex partial convulsions


Pre-ictal symptoms: Increasing tension, irritability and depression
may form the prodromal features of epilepsy hours or days before
the seizure.
Ictal symptoms: Auras in complex partial epilepsy include
autonomic sensations, for example fullness in the stomach, blushing
and change in breathing, cognitive sensations, for example déjà
vu,jamais vu, forced thoughts and dream states, affective
conditions such as fear, panic, depression and euphoria,
and automatisms, including lip smacking, chewing and rubbing
movements.
Changes in perception may involve a wide range of modalities, including
visual, tactile, gustatory and olfactory hallucinations.
Brief, disorganised and disinhibited behaviour may be evident during an
ictal event. Organised and goal oriented aggressive behaviour does not
occur during an epileptic episode. Cognitive symptoms include amnesia
for the period of the seizure, as well as a patchy amnesia for the period of
recovery after the seizure. Post-ictal phenomena include a transitory
delirium or possibly a self-limiting psychosis characteristically following a
lucid interval.
Interictal symptoms

Mood and anxiety symptoms: Depression and mania may occur
in epilepsy and tend to be more common when the epileptic focus
affects the temporal lobe of the non-dominant hemisphere. Anxiety
disorders such as generalised anxiety, panic attacks and phobias
may also occur. Depression and anxiety disorders are the most
common psychiatric disturbances in epileptic patients.
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



Cognitive changes: The wide range of cognitive disorders that
may be observed in patients with epilepsy arise from a number of
interacting factors, including the cause of epilepsy, the
consequences of repeated seizures, treatment effects and
psychosocial problems. Nevertheless the majority of those living
with epilepsy do not show cognitive impairments.
Personality changes: The historic concept of an ‘epileptic
personality’ has no validity. Personality changes occur more
commonly with temporal lobe epilepsy. Changes in sexual behaviour
manifest as hyper- or hyposexuality. This patient’s conversation is
excessively slow, pedantic, tedious and characterised by
unnecessary detail. Hypergraphia and excessive religiosity or a
preoccupation with spiritual matters are also described.
Psychotic symptoms: Interictal psychotic conditions are more
common than ictal psychoses. Schizophreniform symptoms may
occur in patients with epilepsy and tend to emerge 10–15 years
after the onset of particularly temporal lobe seizures.
Violence: Episodic violence poses a problem in some epileptic
patients, especially when it originates in the temporal or frontal
lobes. As mentioned before, the aggressiveness and violence are
not goal-directed and are more common in the post-ictal stage.
Treatment
Peri-ictal psychiatric disorders arise from the seizure activity itself and are
therefore managed by treating epilepsy with the appropriate anticonvulsants. Inter-ictal disorders are multi-factorial, and appropriate
management therefore includes biological or pharmacological as well as
psychosocial components.
HIV/AIDS AND MENTAL HEALTH
(Refer to Chapter 29 of the main text for complete information)
HIV and AIDS-related psychiatric disorders are common, and can present
with a range of psychiatric symptoms. HIV infection increases the risk of
developing mental disorders in people living with HIV/AIDS (PLWHA), and
in turn, having a mental disorder increases the risk of acquiring HIV
infection.
Mechanisms of disease in HIV-positive patients
HIV infection can result in psychiatric disease through a variety of
mechanisms:

The stress of the diagnosis may precipitate a psychiatric illness such
as a major depressive episode or an adjustment disorder.
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





A person with a pre-existing psychiatric illness may become HIV
positive. Severely mentally ill and disabled people are at risk for
contracting HIV secondary to sexual abuse, poor informationprocessing capabilities, poor reality testing, social drift and poor
impulse control.
The HI virus affects the brain directly.
Complications of the immune-compromised state (eg, infections,
malignancies, hypoxia, septicaemia).
Side-effects of medication may cause illness, for example, efavirenz
has many psychiatric side effects such as mania and depression,
izoniazid can cause psychosis, and zidovudine (AZT) may cause
depression or mania.
It is common to have a combination of items 1‒5 above.
The possibility of an independent association, ie, that HIV and
mental illness co-exist, but one does not impact on the other,
should also be considered.
Common psychiatric disorders in PLWHA
Depression
It is important to consider a diagnosis of depression in PLWHA, as its
detection and treatment can greatly influence the consequences of
infection, especially improving chances of adherence to antiretrovirals
(ART), improving overall health, and improving quality of life.
Because of similarities and overlap between symptoms of depression and
HIV infection, for example lethargy, fatigue, and loss of appetite,
detection and diagnosis can be difficult and is thus often missed.
The risk of suicide is increased in PLWHA, particularly at the time of
diagnosis, during times of deterioration of physical health, and following
losses as a result of the illness.
Treatment depends on the severity of symptoms and available resources,
and may range from various counseling interventions, to antidepressant
medication, and psychotherapy.
Anxiety disorders
While the evidence is unclear as to whether the rates of all of the anxiety
disorders are increased in PLWHA, studies have indicated increased
anxiety symptoms in PLWHA in general as compared with HIV-positive
individuals. It is clear however that the prevalence specifically of PostTraumatic Stress Disorder (PTSD) is increased in PLWHA.
98
Psychotic disorders
The pathophysiology of psychosis and other forms of severe mental
illnesses in HIV is complex. Psychosis may be a manifestation of a
primary psychiatric illness, or due to delirium, cerebral opportunistic
infection, direct results of the virus on the brain, effects of alcohol or
drugs, or as part of a neurocognitive disorder.
It is useful to divide psychosis into those predating HIV infection, newonset psychotic disorders, and those associated with medical conditions,
for example delirium.
Psychotic disorders predating HIV infection
The causes include schizophrenia, bipolar disorder, and depression with
psychotic features. These illnesses are often chronic in nature, the nature
of the disorders, for example impaired insight and executive functions,
and the increased psychological stress of HIV infection, can predispose to
precipitation of the disorder or relapse.
New-onset psychotic disorders
These are the direct results of the virus on the brain, and can occur in the
presence of HIV-associated cognitive impairment, in the absence of
cognitive impairment, or as an aspect of the presentation of HIV-induced
mood disorders. The diagnosis of these disorders indicates the need for
prompt initiation of antiretroviral medication.
Psychosis related to medical conditions, substance intoxication or
withdrawal, or as result of medication (delirium)
Delirium may present with an alteration in consciousness, a fluctuating
course, and psychotic symptoms.
The exclusion of cerebral opportunistic infections or metabolic disorders
may require blood tests, lumbar puncture, and brain imaging. The priority
of management is then to treat the underlying cause.
Various drugs used to treat HIV, or the complications of HIV, have been
implicated in causing psychotic symptoms. Efavirenz is the most likely of
the antiretroviral medications to cause neuropsychiatric disturbances,
including sleep disturbances and mood and psychotic symptoms.
Substance abuse
The relationship between substance abuse and HIV/AIDS is complex and
multi-faceted, as discussed below.
99
Abuse and risk-behaviour
It is widely accepted that alcohol, and in a similar way stimulants, for
example methamphetamine, increase sexual risk-taking behaviours,
thereby increasing risk of transmission, and acquisition of HIV.
Alcohol/substance abuse among PLWHA
PLWHA are at greater risk of alcohol and substance abuse for several
reasons, including as a method of coping with difficult feelings and
circumstances as a consequence of the diagnosis.
Alcohol/substance abuse and adherence to ART
Research has indicated that people who abuse substances are less likely
to initiate ART or to stay adherent.
Alcohol and substance abuse and disease course
It is well established that alcohol, as well as abuse of certain drugs, for
example methamphetamine, can have deleterious effects on the immune
system, and may hinder immune reconstitution in someone who is on
ART. Also, alcohol and substance abuse has been shown to worsen the
disease course of infectious diseases such as TB and HIV.
Cognitive disorders
The cognitive deficits seen in PLWHA are known as HIV-associated
neurocognitive disorders (HAND). HAND is characterised by impairments
in motor and psychomotor function, difficulties with attention, memory
deficits, impaired executive function, as well as problems with social
behaviour and decision-making.
Approximately 30‒50% of PLWHA have HAND. HAND is divided into three
categories based on severity:



Asymptomatic neurocognitive disorder (ANI). This is mild
neurocognitive impairment without functional deficits. It is seen in
about a half to two thirds of those with HAND.
Mild Neurocognitive Disorder (MND). This is a mild to moderate
cognitive disorder with functional impairment that interferes in
activities of daily living (ADLs). It is observed in about 15% of
people with HAND.
HIV-associated Dementia (HAD). This is characterised by severe
cognitive impairment and functional decline. It affects
approximately 10% of people with HAND.
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Currently, it is recommended that if an HIV-associated dementia is
present, ARVs should be initiated, even if the CD4 count is above the
usual threshold for commencement. The probability of improvement of
neuropsychological function with initiation on ARVs is high, but the more
severe the deficits, the less likely the reversal of symptoms.
Psychotropic prescribing in HIV
Be cautious in view of potential interactions between ARVs and
psychotropic drugs. In addition, consider the potential neuropsychiatric
side effects of specific ARVs. Also consider the pill burden in HIV.
In general, medication should be prescribed at low doses initially, and
increased according to tolerability and response, as PLWHA may be more
sensitive to adverse effects, for example the extra pyramidal side effects
of antipsychotic medication.
Antidepressants


The antidepressant of choice is citalopram as it does not have
significant interactions with ARVs.
Where citalopram is not available, fluoxetine is equally effective.
Care must be taken if fluoxetine is prescribed with ritonavir or
nevirapine, as fluoxetine levels may be increased.
Mood stabilisers




Lithium should be avoided, as PLWHA may be more sensitive to the
side effects, especially in association with HAND. In addition to the
risks of neurotoxicity, patients with renal impairment may not be
able to excrete lithium effectively.
Sodium valproate may be used with caution in patients with either
manic or depressive syndromes. Close monitoring for side effects
needs to be applied.
Lamotrigine may be used in depressive episodes, but monitor for
liver toxicity and rashes. A slow dose titration is advised.
Carbamazepine should be avoided, due to significant interactions
with ARVs, especially ritonavir, as well as the risk of bone marrow
suppression.
Benzodiazepines

Lorazepam and oxazepam are the safest choices. It is important to
be aware that in patients with neurocognitive impairments,
paradoxical effects may occur.
101
Antipsychotics


The second-generation antipsychotics, for example risperidone,
generally produce fewer extrapyramidal side effects (EPSEs) than
first-generation agents. However, there is a risk of metabolic
syndrome with changes in weight, and glucose metabolism. When
combined with ARVs which also have the potential to cause
metabolic syndrome, this can be problematic.
Where risperidone is not available, low dose haloperidol may be
used. Caution is advised due to its propensity to cause EPSEs.
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SECTION 4: PROBLEMS ASSOCIATED WITH
CLINICAL SYNDROMES
THE ANXIOUS PATIENT: ANXIETY AND RELATED
DISORDERS
(Refer to Chapter 31 of the main text for complete information)
Anxiety is a response to an anticipated stimulus that is perceived as
potentially challenging or harmful. It serves an evolutionary function and
can enhance performance. Anxiety becomes a disorder when it is
associated with distress and impairs function. Anxiety has mood,
cognitive, physical and behavioural elements.
Anxiety disorders in the DSM-5™



The chapter on anxiety disorders includes:
o Panic Disorder
o Social Anxiety Disorder
o Generalised Anxiety Disorder (GAD)
o Separation Anxiety Disorder.
Chapter on Obsessive-Compulsive and Related Disorders includes:
o Obsessive-Compulsive Disorder (OCD)
o Body Dysmorphic Disorder
o Hoarding Disorder
o Trichotillomania (Hair Pulling Disorder)
o Excoriation (Skin Picking Disorder).
The chapter on Trauma and Stress-related Disorders comprises:
o Post-Traumatic Stress Disorder (PTSD)
o Acute stress disorder
o Adjustment disorders.
Social phobia (social anxiety disorder) and specific
phobia





Phobias are excessive, irrational fears of specific objects, places or
situations. Patients with specific and social phobia may experience a
panic attack on exposure to the feared stimulus or other signs of
autonomic arousal and avoidance behaviour.
The triggers of a panic attack differ in phobia and panic disorder.
Panic attacks in social phobia are characterised by blushing and
trembling
Panic attacks in panic disorder characteristically involve a sense of
choking or suffocation.
Individuals with social phobia almost always experience symptoms
of anxiety, for example tremors, sweating, gastrointestinal
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discomfort, diarrhoea and blushing, in their feared situation. They
often underachieve at school and at work owing to their anxiety and
avoidance, have difficulty being assertive, and manifest poor social
skills, for example poor eye contact. It is useful to have a high
index of suspicion in patients who describe themselves as shy or
who admit to difficulties in social interactions.
Depression and substance abuse are frequent sequelae of social
phobia, and may be associated with suicidal ideation. It is important
to screen patients who present with these disorders for social
phobia.
Management







Both pharmacotherapy and cognitive-behaviour therapy are the
mainstays of treatment for social phobia. A combination of these is
often used.
Psychoeducation is also a crucial component of management.
B-blockers are effective for short-term relief of performance
anxiety, and may be given shortly before the person participates in
the relevant social situation.
The SSRIs are the treatment of choice for social phobia.
Irreversible monoamine oxidase inhibitors (MAOIs) may be equally
effective, but SSRIs tend to be better tolerated and do not require
dietary restrictions.
Medication is less well studied in specific phobias, but small trials
indicate that SSRIs may also have a role.
Patients with specific or social phobia may also respond well to
cognitive-behavioural therapy (CBT).
Generalised anxiety disorder








Symptoms are numerous and varied.
Characterised by excessive and continual worry and tension.
Accompanied by both psychic symptoms, for example poor
concentration, restlessness, irritability, and somatic symptoms, for
example muscle tension, headaches, fatigue.
Symptoms need to be present for at least 6 months to make the
diagnosis.
Few patients seek psychiatric treatment, although many seek
treatment from medical specialists for somatic symptoms.
High level of co-morbidity poses a challenge in the differential
diagnosis.
Patients typically present with co-morbid mood, anxiety, or
substance use disorders.
Physical cause should be suspected when the onset of anxiety is
associated with recent changes in medication or accompanies signs
and symptoms of medical illness.
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Rule out drug-induced conditions such as benzodiazepine
withdrawal, alcohol withdrawal, and stimulant abuse.
Management




Mainstays of symptomatic management include pharmacotherapy
and psychotherapy.
Favour SSRIs and the serotonin and noradrenaline reuptake
inhibitors (SNRIs) as first-line agents due to their safety and
tolerability profile.
Acute treatment may include a short course of benzodiazepines, to
assist in the more rapid control on anxiety.
Psychosocial treatments include education about the anxiety,
cognitive restructuring such as teaching patients to substitute
positive thoughts for anxiety-provoking ones, and relaxation
exercises.
Obsessive-compulsive disorder (OCD)






The diagnostic criteria for OCD in DSM-5™ include the presence of
‘obsessions’ that are persistent, intrusive thoughts or images that
increase anxiety, and ‘compulsions’ that are physical, or mental
rituals that are often in response to obsessions and which are aimed
at decreasing anxiety.
Most patients with OCD have both obsessions and compulsions. The
presence of obsessions without compulsions is uncommon.
The patient must recognise, at some point in the disorder, that the
obsessions and compulsions are unreasonable.
The most common obsessions and compulsions concern the fear of
contamination and concerns about perceived danger.
There are a group of disorders that overlap with OCD, and that are
incorporated in the new DSM-5™ chapter on Obsessive-Compulsive
and Related Disorders. These include body dysmorphic disorder,
hypochondriasis, Tourette’s syndrome and trichotillomania.
Most patients with OCD conceal these symptoms from others,
including medical professionals. Thus it is important to include
screening questions for OCD.
Management




Involves a combination of pharmacotherapy and cognitivebehavioural therapy.
As in all the anxiety disorders, psycho-education is crucial.
Medications used for OCD are clomipramine and the serotonin
reuptake inhibitors.
It is important to emphasise that response is often slower in OCD
than in other disorders, so that an adequate trial of medication is
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twelve weeks. In addition, response may require significantly higher
doses of medication.
Patients with tics may require augmentation with dopamine
blockers.
Patients who receive cognitive‒behavioural therapy are less likely to
relapse.
Post-traumatic stress disorder (PTSD) and acute
stress disorder (ASD)





In the DSM-5™, post-traumatic stress disorder (PTSD) is grouped in
a chapter that includes trauma and stressor related disorders,
reactive attachment disorder, acute stress disorder (ASD), and
adjustment disorders.
Although PTSD was first described in the context of combat, it is
increasingly recognised following civilian traumas, for example
sexual or physical assault, natural disasters, and motor vehicle
accidents. These events can be traumatic for the person who has
experienced, witnessed or been confronted with an event.
The diagnosis requires exposure to one or more traumatic events
causing actual or threatened death, serious injury, or threat to the
physical integrity. It also requires the development of three
symptom clusters:
o re-experiencing, for example nightmares, flashbacks
o avoidance or emotional numbing
o hyperarousal, for example exaggerated startle response,
hypervigilance, irritability.
Whereas PTSD is by definition present for one month or longer, ASD
is limited to four weeks in duration. The symptoms that define ASD
overlap with those for PTSD, although there are a greater number
of dissociative symptoms for ASD.
Screen for commonly occurring co-morbid disorders.
Management




Generally, specific treatment for PTSD can only be begun once the
safety of the patient has been established, in that, for example,
there is no ongoing domestic or community violence.
Again, management is likely to involve a combination of
pharmacotherapy, psychotherapy, and psycho-education.
Individual cognitive‒behavioural therapy involves working with
cognitions to change emotions, thoughts and behaviours.
Exposure therapyuses careful, repeated, detailed imagining of the
trauma in a safe, controlled environment, to help the survivor face
and gain control of the fear and distress that was overwhelming
during the trauma.
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

SSRIs are considered the first-line drug treatment. All three
symptom clusters of PTSD have been shown to respond to this class
of medications.
Other antidepressants that have demonstrated efficacy include the
tricyclic antidepressants (TCAs), SNRIs, and MAOIs.
Panic disorder and agoraphobia





The hallmark feature of panic disorder is the spontaneous,
unexpected, and repeated occurrence of panic attacks.
A panic attack is the sudden and unexpected onset of acute anxiety
or discomfort, with at least four physical and autonomic symptoms
of anxiety, which then then gradually subsides over the next ten to
twenty minutes.
Agoraphobia is the fear of experiencing a panic attack, typically in a
public place, from which escape may seem impossible or
embarrassing. Patients with agoraphobia fear having a panic attack
in a place where access to a doctor or clinic may be hard to come
by.
Referral to a psychiatrist typically occurs when no obvious physical
cause for the anxiety has been found.
Patients with panic disorder may present with co-morbid depression
or substance abuse. Co-morbidity with other anxiety disorders is
also common, especially generalised anxiety disorder and social
phobia.
Management






Treatment of panic disorder often involves pharmacotherapy alone
or a combination of pharmacotherapy and cognitive-behavioural
therapy.
It is often useful to first begin with medication and then augment
with cognitive-behavioural therapy, increasing sessions of cognitivebehavioural therapy before finally tapering the medication once the
patient has attained remission.
Psycho-education is also an important component of management.
SSRIs and SNRIs are generally preferred as first-line agents
because they are more tolerable than the traditional TCAs and
MAOIs.
Panic disorder patients are likely to be extremely sensitive to
antidepressant doses. Therefore the rule is to begin at a lower dose
than usual and then to gradually increase the dose to a maximum
antidepressant dose.
While antidepressants are extremely helpful, they may take several
weeks to work.
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
In cases where there is extreme anticipatory anxiety, a short course
of a high-potency benzodiazepine may be useful. Similarly, when
patients present with an acute attack, benzodiazepines may be
used.
THE UNHAPPY OR DEPRESSED PATIENT
(Refer to Chapter 33 of the main text for complete information)
Depression is a common human experience and may result from loss,
stress or significant changes in the environment. Depressive disorders
occur when low mood persists, becomes incapacitating, and causes the
person to function poorly at work or in their relationships with others.
Epidemiology




Depressive disorders are among the most common and disabling of
psychiatric conditions.
Lifetime prevalence of major depressive disorder was found to be
about 10% of the general population.
Depression can also be a lethal disorder, with up to 15% of
sufferers attempting suicide. A large proportion of these individuals
will complete suicide.
Be aware that the diagnosis of depression and treatment with
antidepressant drugs are increasing and the diagnostic criteria are
broadening. This has lead to a growing concern about medicalising
and medicating unhappiness.
Clinical features
Mood
changes
Biological
changes
Cognitive changes
Behavioural
changes
Low mood
Anhedonia
Irritability
Disturbed sleep
pattern
Loss of appetite
Loss of libido
Loss of energy
Pain
Hopelessness
Loss of self-esteem and
worthlessness
Guilt
Impaired attention and
concentration
Psychomotor
slowing
Agitation
Social withdrawal
Self-neglect
108
The mental state examination of the depressed patient
Certain features of depression may be evident on the mental state
examination.





Appearance and behaviour - the expression may be downcast,
with evidence of self-neglect, poor eye contact, diminished
spontaneity and diminished or increased psychomotor activity.
Speech may be slow and monotonous.
The moodmay be described as low, or the patient may express the
depression using particular cultural idioms. Affective expression in
depression varies from bland and restricted to anxious, dysphoric
and agitated.
Thinking may be altered in depression, from slowed flow to
poverty of ideation. In psychotic depression there may be a
loosening of associations, delusions of nihilism (for example ‘I am
worthless', ‘I will be dying shortly') and perceptual disturbances,
most commonly defamatory and command-type auditory
hallucinations. These phenomena are described as mood congruent,
in that the content is consistent with a depressed mood.
Cognitive impairment can occur, with disturbed memory, attention
and executive functions.
Differential diagnosis
General medical conditions
A large number of medical conditions may be associated with depression.
Some of these are listed below. The mechanism of association may be
due to the condition itself, a reaction to having a medical condition, a
result of the medical treatment of the condition, or a combination of these
factors.
Some general medical conditions associated with depression
Neurological disorders:





Epilepsy
Multiple sclerosis
Parkinson's disease
Cerebrovascular disease
Trauma.
Endocrine disorders:


Adrenal disorders (Cushing's, Addison's)
Thyroid disorders
109


Parathyroid disorders
Menses-related.
Infectious and inflammatory disorders:





HIV/AIDS
Infectious mononucleosis
SLE (systemic lupus erythamatosis)
Tuberculosis
Rheumatoid arthritis.
Miscellaneous disorders:




Malignancies (NB: pancreatic CA and other GIT neoplasms)
Uraemia (and other renal diseases)
Vitamin deficiencies
Cardiopulmonary disease.
Depression secondary to substance use
The most widespread substance of abuse, alcohol, is a common and
independent cause of depressive illness. The use of alcohol is considered
to increase twofold the likelihood of having major depression. These
depressive episodes occurred in the absence of a period of intoxication or
withdrawal.
Numerous pharmacological agents are associated with depression. Some
common examples include opiates, anti-inflammatories, corticosteroids,
efavirenz, beta-blockers, methotrexate, oral contraceptives and
benzodiazepines.
Suicide assessment and risk



Every patient presenting with depression must be questioned about
suicide.
Remember that all suicide attempts may be life-threatening,
however apparently harmless the method might seem.
Asking questions about thoughts of death and suicide does not
increase the risk of suicide.
Physical examination and special investigations

Enquire about and investigate any physical condition that may be
contributing to depression. For uncomplicated depression in primary
care, no investigation may be required other than a careful history
and clinical examination.
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In severe depression, haemoglobin, thyroid function and syphilis
serology should be done. Other tests may be performed as clinically
indicated.
Cultural aspects of depression


The expression of distress across cultures and regions may reflect
important differences in the way particular groups view mental
health, the concept of the body and the self, and the expression of
emotion.
Depression in South African sub-populations may be expressed
differently from the criteria described in DSM-5™. For example, in
the Xhosa language, there is no word that directly describes
depression. Feelings of sadness or distress may be referred to in
somatic terms such as 'heavy spirit' or 'difficulties in breathing', or
in quasi-psychotic terms, such as feelings of being bewitched or
oppressed by others.
Classification
A number of depressive disorders and types are currently grouped and
classified in the DSM-5™. Significant changes from the previous DSM-IV
include the renaming of dysthymia as ‘persistent depressive disorder’, the
inclusion of ‘premenstrual dysphoric disorder’ and the removal of the
exclusion criteria of bereavement. Therefore, in the DSM-5™ diagnostic
criteria, depressive symptoms occurring within two months of
bereavement may be diagnosed as a major depressive episode.
Major depressive disorder






This is a serious condition, with a high morbidity and mortality.
Five or more depressive symptoms (depressed mood, anhedonia,
appetite disturbance, sleep disturbance, psychomotor agitation or
retardation, fatigue, feelings of worthlessness or guilt, poor
concentration or indecision, recurrent thoughts of death or suicide)
must be present over at least two weeks.
At least one symptom is either depressed mood or anhedonia.
Symptoms must cause distress or impaired functioning for the
diagnosis to be made.
Ask the patient about possible manic or hypomanic episodes. If
present, then a diagnosis of bipolar mood disorder should be
considered.
In severe cases of major depression, psychotic features may also
occur.
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Persistent depressive disorder (dysthymia)


This is characterised by milder depressive symptoms than major
depression, which persist for at least two years, with a symptomfree period of only two months in each year.
Major depression often occurs after the onset of dysthymia and is
described as a 'double depression'.
Recurrent brief depression and minor depression


This refers to both recurrent episodes of depression that may last
less than two weeks, but which are debilitating, and to longer
episodes of depression, with fewer than five criteria for major
depression.
Individuals with recurrent brief depression have an increased risk of
suicide compared to the general population.
Adjustment disorder




The association between depression and loss is common.
Not all depressive episodes that follow a stressor develop into major
depressive episodes.
Where a stressor has resulted in impaired function or distress,
together with depressed mood, then the diagnosis of adjustment
disorder with depressed mood is most appropriate.
These disorders do not have the same serious prognosis as a major
depressive episode.
Bereavement




The normal human response to bereavement should not be
diagnosed as a depressive disorder.
While DSM-IV allowed for a two-month bereavement period with
clinical symptoms of depression, the current DSM-5™ requires
clinicians to exercise their judgement when assigning diagnoses.
It is regarded as normal for bereaved individuals to experience the
presence of those who have died in the time after bereavement.
This may take the form of hallucinations or vivid dreams. Sleep
disturbance, excessive crying, psychomotor changes and thoughts
of death may also occur.
The clinician should be guided by the reactions of close family
members, cultural norms, and the course of the bereavement. If
functional impairment is extreme and the individual describes
feelings of hopelessness, a major depression may need to be
considered.
112
The treatment of depression
Severity and setting



Mild depression: If the person is only mildly affected, is able to
function and has a supportive system, counselling, support and
effective psychotherapies such as cognitive-behavioural therapy or
interpersonal therapy may be appropriate. In the absence of access
to therapy, and where the depression is debilitating, the use of
antidepressants may be considered.
Moderate to severe depression: If the episode is moderate to
severe, and if there is significant distress or functional impairment,
then medication with or without psychotherapy should be
considered. Treatment may be undertaken at primary care clinics
and outpatient settings.
Complicated depression: If the episode is severe, is associated
with psychotic symptoms or if a suicide attempt has occurred, the
patient should be referred to a specialist service for assessment. In
these cases, an admission to hospital may be warranted. Depressive
disorders that occur in conjunction with other medical or psychiatric
problems, or are resistant to treatment, should also be referred to
specialist clinics.
Medication
The medications of choice for depression are the antidepressant groups.
Current evidence suggests that all the antidepressants are equally
effective.
Selective serotonin re-uptake inhibitors (SSRIs)
The SSRIs are a group of drugs with similar but not identical effects. They
are safer in overdose than tricyclic antidepressants (TCAs). The SSRI's
are now commonly used as first-line treatment, because of their
tolerability and relatively low cost. There are a number of drugs in this
class, including fluoxetine, citalopram, escitalopram, sertraline,
fluvoxamine and paroxetine. Side effects include headache, nausea,
insomnia, agitation and sexual dysfunction.
Serotonin-noradrenaline re-uptake inhibitors
Venlafaxine is an inhibitor of the serotonin, noradrenaline and dopamine
transporters. The extended release preparation may be administered once
daily. Some elevation of blood pressure may be seen at higher doses, and
this should be monitored in patients with a history of hypertension.
Duloxetine, in contrast, does not appear to induce hypertension. It has
also been registered for use in chronic pain and urinary urge incontinence.
113
Other antidepressants


Buproprion is an inhibitor of both noradrenaline and dopamine reuptake. It possibly spares some depressed individuals from the
sexual side effects commonly seen with serotonergic agents. It is
regarded as having a lower tendency to induce rapid cycling or to
induce mania. Adverse effects include anxiety, agitation, dizziness,
nausea and increased risk of seizures.
Mirtazepine is a novel tetracyclic which antagonises the
noradrenalin alpha 2 receptor, as well as the serotonin 2A receptor.
Antihistaminic effects include weight gain and sedation. It is devoid
of cardiotoxic effects, and for this and the above reasons is
considered to be a good choice in the depressed elderly.
Psychotherapy
Any of the following therapies may be indicated:



Cognitive-behavioural therapy
Interpersonal psychotherapy
Psychodynamic psychotherapy
CHAOTIC HIGHS AND DESPERATE LOWS: THE
BIPOLAR DISORDERS
(Refer to Chapter 34 of the main text for complete information)
Bipolar mood disorder (BD) is also called 'manic depression' and affects
approximately one percent of the population.
Clinical features
In primary care, making a correct diagnosis of BD begins with identifying
the clinical syndromes of mania and hypomania. This requires specific
enquiry, as these features may not be regarded as indicators of illness,
and are usually under-reported. Patients usually present to health care
services while having a depressive episode.
Mania


The DSM-5™ criteria for a manic episode include a distinct period of
persistently elevated, expansive or irritable mood and increased
goal-directed activity or energy for at least one week.
Other symptoms include inflated self-esteem, decreased need for
sleep, distractibility, talking more than usual, a subjective feeling
that thoughts are racing, agitation and engagement in activities that
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have a high potential for painful consequences (eg, sexual
indiscretions).
The disturbance is sufficiently severe to cause impairment in
occupational functioning, or to necessitate hospitalisation, or there
are psychotic features.
Hypomania





Hypomania refers to an attenuated level of mania.
A hypomanic episode is a distinct period of abnormally elevated,
expansive or irritable mood that lasts at least 4 days.
However, there is no marked impairment in functioning, psychotic
features or need for hospitalisation.
An increase in efficiency, accomplishments or creativity may be
observed.
Collateral information is crucial, as the individual may perceive
nothing unusual or wrong, while those close to them give a clearer
account of the mood changes.
Diagnostic difficulties
Co-morbid substance misuse


Practitioners should be alert to the possibility that any episode of
mania or psychosis, even if associated with drug use, may well be
the first presentation of a bipolar disorder.
It is important to establish whether the episode of mood elevation
or irritability preceded the use of stimulants, and whether the
patient may have used sedative substances to self-medicate
irritability or a sleep disturbance.
Depression


In BD depression may present in the characteristic way, but there
are higher rates of severe and atypical symptoms, including rapid
shifts in the mental state, hypersomnia, psychomotor retardation,
psychotic symptoms and suicidality.
Bipolar depression is often resistant to conventional antidepressant
treatment, but may respond rapidly to a mood stabiliser.
Mixed states


These are important to identify because they are associated with
increased risk of suicide.
An interview with a person who is engaging, talkative, and even
laughing, but saying he feels like dying and suddenly becomes
tearful, leaves the clinician muddled, unsure of suicide risk or
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diagnosis, and even irritated, and should raise the possibility of a
mixed state.
These presentations might include rapidly switching from manic to
depressed, or depressed with a mixture of accompanying manic
symptoms, especially agitation, irritability and aggression, and
pressured speech with flight of ideas.
Bipolar disorder subtypes
Distinguishing BD subtypes has implications for treatment and prognosis.



BD Type I is characterised by one or more episodes of mania or a
mixed affective episode, and this is usually, but not always
accompanied by a history of major depressive episodes.
BD Type II is characterised by one or more episodes of
hypomania, and a history of recurrent depressive episodes. Type II
may present as a hypomanic reaction to a new antidepressant
medication, and only when symptoms persist for weeks after
discontinuing antidepressants is the diagnosis made clear.
Rapid Cycling BD refers to 4 or more episodes of depression,
mania or hypomania within 12 months. There may be periods of
remission between episodes, but residual symptoms may persist
unrecognised. Rapid cycling BD responds less well to medication
than other forms of BD.
Cyclothymia


This refers to a persistent state of marked mood variability for at
least two years, but with no discrete episode meeting the diagnostic
criteria for a manic or depressive episode.
It is thought to represent a personality type, which in some cases is
associated with BD, especially the BD II subtype.
Management
Acute manic episode
After excluding a general medical condition, the management of an
episode of hypomania or mania requires the following:


A detailed assessment and a commitment to care: manic patients
can often be persuasive, insisting that they are well and do not
need treatment. Assess the risks posed by failure to intervene,
including damage to reputation, finances, occupation and
relationships, and danger to life.
A safe environment that enables containment. Give special
consideration to children and the elderly or physically frail. This may
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





indicate management at home if symptoms are mild, but this is
likely to put a severe strain on the family if the episode lasts more
than a few days, and a hospital admission is often required.
Antidepressant treatment should usually be withdrawn.
Antipsychotics are first-line medications. Treatment with an atypical
antipsychotic such as olanzapine, risperidone or quetiapine is
preferable to reduce the risk of neurological side effects. Typical
antipsychotics such as haloperidol or chlorpromazine are as
effective.
Mood stabilisers are used both to treat the episodes in the acute
phase and to prevent recurrences. Valproate is the first choice
agent because it is safe and sedating at high doses. Valproate is
relatively contra-indicated in women of reproductive age as it is
teratogenic. Folate should be co-prescribed to reduce risk of neural
tube defects. Lithium is preferred if there is a history of a previous
good response. Carbamazepine is indicated if there has been a
previous good response, but should be started at low doses.
Benzodiazepines may be useful in the acute phase. In the first one
or two weeks additional sedation may be of benefit.
Electro-convulsive treatment (ECT) under specialist care may be
considered in selected cases.
Supportive psychotherapy and family sessions are required to assist
with acceptance of the diagnosis and the consequences of reckless
and dangerous behaviour, and lifestyle changes required to reduce
the risk of relapse.
Depressive episode in BD




Assess in detail to ensure a correct diagnosis, which is critically
important. Problems arise particularly if symptoms are atypical and
if the report of a depressed mood may not match the clinician’s
observations during the interview.
Assess suicide risk and ensure safety. Any access to tablets should
be removed. If safety at home is inadequate and suicide risk is
high, an admission to a general hospital or specialist unit should be
considered.
If the depressive symptoms are mild, the addition or
adjustment of a mood stabiliser should be considered. If not on a
mood stabiliser, lithium, lamotrigine or an antipsychotic with
antidepressant properties should be used after discussion of risks
and benefits. The option or addition of cognitive therapy should be
considered
In BD Type I with moderate or severe depression, either an
antipsychotic with antidepressant properties, or an anti-manic mood
stabiliser in combination with an SSRI antidepressant should be
started. In BD Type II with moderate or severe depression, an SSRI
antidepressant may be started and lamotrigine considered.
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



If depression is severe, an admission to hospital may be
indicated and ECT should be considered.
If psychotic symptoms are observed, a low dose of
antipsychotic should be started.
Frequent mental state reviews are necessary, and supportive
psychotherapy should be offered.
If SSRI antidepressants are not acceptable because of side effects
or a history of manic switching, other antidepressants may be
considered. Specialist advice should be sought.
Long-term prevention of relapse of bipolar disorder




Education about the illness and medication is fundamental to a
satisfactory long-term outcome. This requires an understanding by
the family and patient about the need for medication and early
intervention at times of relapse.
Lithium, valproate, carbamazepine, lamotrigine and the antipsychotic group all represent effective long-term treatment options.
Stopping long-term treatment when symptoms are well controlled is
not advisable.
If an unplanned pregnancy occurs during remission of symptoms
the medication regime should be reviewed, but once the first
trimester is over there may be no value in stopping the treatment.
Specialist advice is required.
With regard to psychotherapy, cognitive behavioural therapy has
been shown to reduce the rate of relapse, especially in depressive
episodes, and to improve adherence to medication.
ODD IDEAS, VOICES, DISORGANISED BEHAVIOURS
AND THE LOSS OF INSIGHT: THE SCHIZOPHRENIA
SPECTRUM AND OTHER PSYCHOTIC DISORDERS
(Refer to Chapter 35 of the main text for complete information)
Psychosis is an ill-defined, generic term. In broad terms it refers to the
spectrum of severe psychiatric disorders that lead to disorganised
behaviour, impaired function, and a lack of insight. Delusions and
hallucinations are often, but not invariably present.
Psychotic disorders are broadly divided into functional disorders and
psychotic disorders due to medical conditions. The two principal functional
disorders are the schizophrenias and the bipolar disorders, with a
considerable overlap between the two groups.
118
Clinical features






Schizophrenia is more appropriately described as a group of
disorders.
Now classified into positive, negative, disorganised, affective and
cognitive symptom clusters.
Positive features include delusions, hallucinations and various forms
of thought disorders.
Negative features include social withdrawal, emotional blunting, and
a loss of volition or a drive to action.
The disorganised group shows disturbances of thinking and
behaviour.
It is inappropriate to consider these subcategories as rigid or
mutually exclusive. The symptom clusters are more accurately
conceptualised in dimensional terms.
Differential diagnosis of schizophrenia






Delirium
Intoxication and withdrawal from psycho-active substances
Psychoses due to a general medical condition
Psycho-active substance-induced psychotic disorder
Culture-specific disorders
Other psychiatric disorders: delusional disorders, schizo-affective
disorders, bipolar disorders, depressive disorders with psychotic
features, schizophreniform disorders, brief psychotic disorders.
There are no pathognomonic or syndrome-defining clinical features of
schizophrenia. The diagnosis is made up of a characteristic pattern of
signs and symptoms over time. In terms of assessment, a differential
diagnosis therefore needs to be considered:




In the acute setting, first always consider the possibility of
a delirium.
Psychotic symptoms may also arise from general medical
conditions without changes in consciousness levels. Some of the
more common disorders include cerebral infections, particularly
HIV/AIDS, neurosyphilis, brain trauma and epilepsy.
Substances may either induce non-specific psychoses or precipitate
schizophrenia in vulnerable persons. In substance-induced
psychotic disorder, there is a temporal association between the
exposure to the psychoactive substance and the onset of psychotic
symptoms.
In sub-Saharan Africa the cultural context requires the
consideration of more culture-specific idioms of distress such as
‘ukuthwasa’ and ‘amafufunyane’.
119




If a prominent mood component is evident and the criteria for a
bipolar disorder are not met, a schizo-affective disorder may
enter into the differential.
A major depressive episode with psychotic symptoms may be
differentiated from schizophrenia in that the delusional content in
depressed or manic states tends to be mood-congruent.
Delusional disorders are characterised by a later onset, the
absence of the characteristic perceptual abnormalities and thought
disorders of schizophrenia, and delusional content of a less bizarre,
more plausible nature.
Brief psychotic disorders and schizophreniform
disordersshould strictly not be included in the differential diagnosis
as these disorders are defined in terms of the duration of
symptoms, brief psychotic disorders being of less than a month's
duration, and schizophreniform disorders of less than six months'
duration.
If a patient presents with predominately negative symptoms, the
following differential diagnoses should be considered:







depression
side effects of medication
general medical condition (NB: HIV/AIDS / other neurodegenerative
disorders)
learning disability/dementia
preoccupation/distraction due to positive symptoms/catatonia
environmental factors (eg, under-stimulation)
unwillingness to co-operate/personality factors.
The role of substance use
A distinction needs to be drawn between intoxication, substance-induced
psychotic disorders and psychiatric disorders precipitated by psychoactive
substances. A number of agents can cause psychotic symptoms, in
particular amphetamine-related substances including methamphetamine
or tik, and cannabis.
Management
Comprehensive care


Comprehensive management requires attention to the biological
and psychosocial dimensions of the predisposing, precipitating,
perpetuating and protective factors.
Remediable predisposing factors may include, for example, hostile
and conflictual relationships within the family.
120


Precipitating events may be substance abuse and the
discontinuation of treatment.
Perpetuating factors frequently include non-adherence or irregular
use of antipsychotic medication, and a supportive and stable family
and community may represent protective factors.
Phases of treatment


Treatment may be usefully separated into acute and maintenance
phases. During the acute phase the emphasis tends to fall on
pharmacological treatment, with or without hospitalisation,
For the maintenance phase, psychological and social interventions
gain more prominence.
First episode



Patients presenting with a first episodes should, if possible, be
managed at a specialist level.
The indication for hospitalisation depends on a number of factors,
including the degree of behavioural disorganisation, the capacity of
the patient to understand the need for intervention and to cooperate, and the degree of support available to the patient.
Involuntary hospitalisation may be required if the patient is clearly
ill, is refusing treatment, and treatment is required for the health
and safety of the patient and for the protection of others.
Relapses


Relapses may be managed at the primary level, and the same
indications for hospitalisation apply as for first episodes.
Indications for referral to the specialist levels of care include
frequent relapses, which may represent inadequacy of care at the
primary level, resistance to treatment and complex presentations,
which may include co-morbid conditions, frequently substance
abuse and mood disorders.
Pharmacological treatment
First-generation agents vs second-generation agents
There is an ongoing debate about the use of the newer-generation
antipsychotic agents as opposed to the conventional agents, particularly
in first-episode schizophrenia presentations.
121
First-generation agents


Advantages:
o effective
o affordable.
Disadvantages:
o higher incidence of extra-pyramidal side effects
o limited effectiveness in negative forms, neurocognitive
impairments and approximately 20% do not respond to
treatment.
Second-generation agents


Advantages:
o fewer extra-pyramidal side effects
o possible benefit in negative forms, neurocognitive deficits and
mood problems associated with schizophrenia
Disadvantages:
o metabolic syndrome (obesity, hyperglycaemia, dyslipidaemia)
o cardiac conduction abnormalities
o high cost/ limited availability.
Initiating treatment





Commence treatment as soon as the diagnosis has been made with
a degree of confidence.
In the context of substance abuse, withhold treatment for five to
seven days and treat symptoms of distress and behavioural
problems with benzodiazepines.
First-episode patients are particularly sensitive to extrapyramidal
symptoms and therefore, if possible, the newer agents are to be
recommended. If a patient has previously responded well to a
conventional antipsychotic, it is advisable to resume this regime.
The principle is 'the lowest possible dose to achieve a sufficient
antipsychotic effect'.
If the patient fails to respond to 2 classes of anti-psychotic
medications, a decision to use clozapine should be considered.
Indications for Clozapine


Sound evidence of benefits in treatment resistance and
extrapyramidal symptoms.
Less conclusive evidence of its benefits in associated mood
disorders, neurocognitive deficits and negative forms of
schizophrenia.
122
Continuing treatment





A small proportion of patients, approximately 20%, will experience
only one episode.
The great majority will experience recurrences, and the risk of
relapse is increased approximately five-fold following
discontinuation of treatment.
With the restoration of a degree of insight, every attempt should be
made on the part of the clinician to develop a co-operative alliance
with the patient and to negotiate a feasible treatment plan. The
active participation of the patient in this process is an important
means of improving adherence.
Treatment in first-episode schizophrenia should continue for a year.
Treatment in subsequent episodes will depend on a number of
factors, but should be continued for at least 3‒5 years.
Psychological treatment




Cognitive-behavioural therapy: Therapy is aimed at addressing
cognitive difficulties as well as diminishing the impact of delusions
and hallucinations.
Psycho-education: Aims to impart information about the illness
and its symptoms to patients and families in order to help them
cope more effectively.
Family therapy: This takes many forms, ranging from support to
therapy aimed at changing the attitudes and relationships within
family systems that predispose to relapse.
Social skills training: Social skills training employs a range of
strategies to improve self-care, foster independence and enable
people to adjust as best as possible to living in the community.
Social interventions
Social support is a critical factor in the outcome of schizophrenic illnesses.
Interventions are principally directed at supported housing, supported
employment and the provision if necessary of disability grants.
TRANSIENT EPISODES OF DISTURBED
CONSCIOUSNESS: DELIRIUM
(Refer to Chapter 36 of the main text for complete information)
Delirium is primarily a disturbance of consciousness and impaired
cognitive functioning as a result of diffuse brain dysfunction. The
disturbance typically represents a sudden and significant decline from a
previous level of functioning.
123
Delirium is common, though frequently unrecognised, and is associated
with significant mortality and morbidity.
Clinical features of delirium














A change in the level of consciousness, manifested by a reduced
clarity or awareness of the environment, is the central abnormality.
The level of consciousness characteristically fluctuates.
Typically, there is deterioration in the patient's condition in the
evenings.
Responsiveness and levels of arousal may be either diminished,
when the patient appears drowsy and withdrawn, or increased, as
observed in the agitation of patients experiencing alcohol
withdrawal.
Lucid intervals are characteristic of delirium, which often mislead
clinicians into believing that the patient is well or recovered.
Changes in behaviour are variable and there may be increased or
decreased activity. In general, there is less spontaneous, flexible
and adaptive behaviour.
Speech is often difficult to follow due to dysarthria.
The mood may be anxious, irritable or fearful. Mood states tend to
be labile, fleeting and inconsistent. The affect is characteristically
perplexed.
Thinking is slow and muddled and tends to be more concrete and
literal. Thought processes are fragmented, incoherent and
impoverished.
Comprehension is impaired, with an inability to distinguish between
internal and external worlds.
There may be ideas of reference and delusions which, in contrast to
psychotic disorders, are transient and fragmented.
Visual misperceptions are frequently observed.
There are distortions, illusions and misidentifications, and patients
may have the impression that either the world about them or they
themselves are not real.
Although auditory, tactile, gustatory and olfactory misperceptions or
hallucinations may occur, visual hallucinations are more common.
Patients experiencing benzodiazepine or alcohol withdrawal typically
describe visual hallucinations of small animals or people; the
sensation of ants crawling under their skin, known as 'formication',
is characteristic of alcohol withdrawal.
Memory is markedly affected. In contrast to the dementias,
registration rather than recall is affected, and new learning is
impaired. There is amnesia or forgetfulness for the period of
diminished consciousness, and an impaired awareness of
surroundings and the passage of time.
124


Disorientation of time or place is common, but disorientation of self
is less so.
Insight and judgement are to variable extents impaired.
Distinguishing delirium from psychosis
Features suggesting a delirium rather than a psychosis include:






non-auditory misperceptions or hallucinations
the absence of a prior psychiatric history
the presence of a co-existing medical or surgical condition
an altered level of consciousness
an acute or subacute onset, and
a fluctuating course of the symptoms.
Distinguishing delirium from dementia




Delirium is common in elderly patients, particularly in those who
have a degree of cognitive impairment.
Cognitive disturbances, in particular memory impairment, occur in
both delirium and dementia.
The patient with dementia is usually alert and does not have the
fluctuating level of consciousness characteristic of a delirium.
A rapid deterioration in the level of functioning should alert one to
the likelihood of a delirium, and a medical cause should be sought.
Causes of delirium









Delirium is seldom caused by a single factor.
The condition is best conceptualised as an encephalopathy, which
arises from the complex interactions between predisposing factors
and precipitating insults.
Predisposing factors :
age younger than 10 years or older than 65 years
cognitive impairment, for example dementia
previous head injury
intellectual impairment
visual or hearing impairments
dehydration and malnutrition.
Possible causes of delirium
Drugs and toxins
(either intoxication or
withdrawal)

Alcohol and other psychoactive agents, such as
stimulants, hallucinogens, hypnotics, anxiolytics,
anti-convulsants and analgesics are common
causes
125


Infections
Anticholinergic drugs, antituberculosis drugs,
cytotoxics and anti-Parkinsonian drugs can also
cause delirious states
Industrial poisons and heavy metals are less
common causes




Cerebral — encephalitis/ meningoencephalitis,
abscesses
Extracerebral
pneumonias
urinary tract infections
Septicaemias
Metabolic


Electrolyte disturbances
Acid/base disturbances
Organ failure




Cardiac
Respiratory
Hepatic
Renal
Endocrine





Pituitary
Thyroid
Parathyroid
Adrenal
Pancreas (NB: hypoglycaemia)
Epilepsy





Pituitary
Thyroid
Parathyroid
Adrenal
Pancreas (NB: hypoglycaemia)
Head injuries


Generalised: ictal, post-ictal
Complex partial
Cardiovascular
disorders





Transient ischaemic attacks
Emboli
Thromboses
Haemorrhages
Heart failure
Malignancies

Primary

126
Deficiencies


Secondary
Non-metastatic



Thiamine
Niacin
B12, folate
Alcohol withdrawal (the most common cause of delirium)
Clinical features



3‒12 hours after withdrawal: Tremulousness, nausea,
irritability, hallucinations and other perceptual disturbances in a
clear consciousness.
12‒18 hours after withdrawal: Increased agitation, autonomic
changes, generalised seizures (if focal, consider the possibility of
trauma, or causes other than withdrawal).
48‒72 hours after withdrawal: Delirium tremens, altered level
of consciousness, autonomic hyperactivity, disorganised behaviour.
Management of alcohol withdrawal






If symptoms of moderate to severe withdrawal, patient aged over
50, or history of seizures, admit to hospital.
Close observations: blood pressure, temperature, respiratory rate,
level of consciousness.
Fluid replacement: 5% dextrose, titrate against above measures.
High-potency vitamin supplementation.
Sedation: use diazepam and titrate against symptoms. Withdraw
gradually over 7‒10 days.
Monitor and investigate complications:
o infections – NB: chest or urinary tract
o electrolyte disturbances
o hypoglycaemia
o head injury
o liver failure
o renal failure
o seizures
o bleeding (gastric ulceration or oesophageal varices)
o Wernicke's encephalopathy: delirium, unsteadiness, changes
in eye movement, that without treatment (thiamine), may
progress to alcohol amnesia or dementia
o hypothermia/hyperthermia
127


o coincident intoxication
Organise follow-up
Plan rehabilitation.
Management of delirium





Identify those with predisposing factors
Address the likely causes
Provide supportive care
Prevent complications
Manage behavioural symptoms.
Specific management
Appropriate investigations should be conducted to identify the underlying
causes, bearing in mind that these causes are often multiple and
interactive. The following is a useful first-line screen:







full blood count and erythrocyte sedimentation rate (ESR)
urea and electrolytes
liver function tests
thyroid function tests
random blood sugar
urinalysis
chest X-ray.
Management of behavioural symptoms




Behavioural symptoms should be treated with medication only in
circumstances where the symptoms of delirium place the patient or
other people at risk, or where they interfere with essential therapy
such as rehydration.
All non-essential drugs should be withdrawn, and symptomatic
pharmacological treatment should be kept to a minimum to avoid
further depression of consciousness.
Haloperidol is usually the agent of choice. It is useful in controlling
agitation during the day. It is less sedating and causes less
hypotension than chlorpromazine.
In patients who do not settle on haloperidol, lorazepam may be
used either as an oral or as an intramuscular dose. The intravenous
use of lorazepam should be reserved for emergencies.
128
FORGETFULNESS AND OTHER DISTURBANCES OF
COGNITIVE FUNCTION: THE DEMENTIAS
(Refer to Chapter 37 of the main text for complete information)
Dementia represents a global deterioration in memory, personality and
intellect affecting a person's cognition, behaviour and functioning. The
incidence increases with age. The most common forms in the elderly are
Alzheimer’s disease and the vascular dementias.
Cognitionis the process of obtaining, organising and using intellectual
information.
Associated cognitive deficits include:





memory impairments
aphasias or language disturbances
apraxias or impaired motor activity
agnosias, which isthe failure to recognise objects or people
disturbances in executive functioning such as the planning,
organising and carrying out of tasks.
The patient shows no disturbance of consciousness, that is, a lack of
awareness of surroundings, as observed in delirium.
Differential diagnoses
The initial differential evaluation is usually between memory impairment,
depression and delirium. Though these can co-exist with a dementing
illness, or even be a warning sign of its presence, they need to be
excluded, as they require treatment in their own right.
Delirium constitutes a medical emergency.
Clinical evaluation



Take a history, perform both a mental state and a physical
examination
Perform further investigations when indicated
Elicit information from a reliable informant in order to assess the
diagnostic, functional and social aspects of the patient.
Diagnostic assessment


Determine the presence or absence of dementia, as well as the coexistence of depression and delirium.
Look for the causes of the dementia.
129





Establish the course and nature of the dementia, which may give an
indication of its aetiology. Patients with vascular (especially multiinfarct) dementia, and to some extent alcohol-induced dementia,
will present with:
patchy memory-loss and fluctuating disturbances in language and
behaviour, with a relatively well-preserved personality in the earlier
phases, characterised by appropriate social interaction
sudden rather than a slow, insidious onset of dementia
step-wise deterioration rather than a steady, even pattern
attacks of dizziness, frequent falls/fainting spells, nocturnal
confusion and urinary frequency, particularly at night.
Neuropsychiatric symptoms and functional assessment
This determines the degree of severity of illness and the level of care
required.


Behavioural symptoms usually consist of wandering, aggression,
disinhibition, restlessness, apathy, abnormal eating and insomnia.
Psychological symptoms consist of disturbances in mood, including
anxiety, depression, agitation and mania, and psychotic symptoms.
The behavioural and psychological symptoms of dementia (BPSD), and
the neuropsychiatric symptoms (NPS) start early in the disease process
and have an impact on the patient, caregiver, community and medical
services. The BPSD are one of the most important determinants of entry
into institutional care.
Cognition and behaviour also impact on the patient's level of function.
Thus, determining whether patients can wash, dress, feed and toilet
themselves (basic activities of daily living); or can still perform more
complicated tasks such as taking their medication, shopping, cooking and
managing finances (instrumental activities of daily living) are an
important component of the assessment.
Social assessment
Elicit information regarding:






where the person lives
who takes care of the individual
the extent to which they are coping
employment
economic resources
medico-legal matters.
130
Mini-mental status examination (MMSE)





The MMSE is done routinely at 6—12 month intervals in elderly
individuals.
Patients need to be literate, requiring usually a minimum of seven
years' schooling, and need to be alert.
The MMSE was originally designed to distinguish dementia from
patients with a depressive ‘pseudo-dementia’.
Depressed patients will obtain a high MMSE score.
Demented patients will score 26 or less out of a maximum score of
30.
Physical examination

A physical examination, with the emphasis on the neurological
examination, must be undertaken in all patients.
Investigations
Cost restraints and other practicalities often dictate the number of
investigations that can be performed. Generally, in typical or advanced
cases of dementia, investigations have little to offer towards treatment.
Patients that should be more thoroughly investigated include:




those below 65 years of age
when onset is recent and the course rapid
when the course of the disease fluctuates markedly
when physical examination reveals a neurological deficit.
Special investigations help to improve or rule out treatable or
exacerbating causes of dementia. The full 'organic work-up' entails a full
blood count, plasma viscosity, urea and electrolytes; liver, thyroid and
parathyroid function tests, random blood sugar, niacin, Vitamin B12, redcell folate, and a lipogram. Additional tests include VDRL, HIV and
urinalysis.
More specialised investigations encompass a CT or MRI scan, specifically
with measurements of the medial temporal lobes, as well as psychometric
testing.
The abbreviated version of the 'organic work-up' consists of the following:





finger prick haemaglobin and glucose
potassium and creatinine
thyroid stimulating hormone
gamma-GT and alkaline phosphatase
calcium and phosphate, vitamin B12 and red-cell folate
131


VDRL
Urine analysis.
Management
Biological management
As a general principle, half to two-thirds of the adult dose of the
psychotropic agent is usually adequate. A 'start low, go slow' policy is
recommended and patients should be weaned off drugs rather than
stopping them abruptly.
Currently there is no cure for Alzheimer's disease or vascular dementia
and the clinician therefore attempts to slow down its course and control
the symptoms, so as to improve cognition, behaviour and function.
The anti-dementia drugs not only improve memory, behaviour and
function, but also induce subtle changes in the patient with Alzheimer's
disease, such as a return of personality, spontaneity, social engagement
and an interest in their surroundings.
Pharmacological treatment for Alzheimer's disease
1. Acetylcholinesterase inhibitors (AChEls):
o donepezil
o rivastigmine
o galantamine
o NMDA receptor antagonist: Memantine
2. Psychotropic agents for residual symptoms, eg, mood and
behavioural disturbances
3. Control of cardiovascular risk factors.
Psychological management of the patient
Patients are usually unaware of their problem but will have fleeting
glimpses of insights into their illness in the early phase. This should be
addressed sympathetically and positively.





Recommend a safe and familiar routine.
Restrict afternoon 'naps' to 20 minutes in order to avoid insomnia.
Modulate factors that may aggravate the sense of well-being, such
as noisy, boisterous children, frequent moves.
Define a safe area for wanderers, to establish peace of mind for the
caregiver.
Avoid restraints whenever possible, and treat pharmacologically if
necessary.
132
Psychological management of the caregiver
The caregiver is vulnerable as emotional reserves and resources are
limited. Key issues to be addressed are:




psycho-education
support from family, friends, religious institutions and NGOs must
be sought. All families should be referred to support organisations
such as Dementia SA or Alzheimer's SA.
respite-careis essential and should be frequent. Looking after
demented patients is hard work, and the prevention of caregiver
burnout should be a priority.
treatment for the caregiver, if necessary, and implement
environmental changes rather than simply encouraging them to
‘hold on’.
Social management: Financial affairs and wills


If unable to handle own affairs, consider handing control to a
reliable and trustworthy member of the family by way of a power of
attorney. Transfer of authority by means of power of attorney is
preferable in early dementia, where competency is still preserved.
Failing this, curatorship should be sought.
Driving




Assess all cases on individual merit.
Patients must be able to drive in conditions affording good visibility
and then in daytime only, on non-busy suburban roads, and always
accompanied by a caregiver.
The MMSE should be at least 20-22/30 or above and the patients
must still be able to do the pentagon test, which tests for visuospatial ability.
Reassess at three-monthly intervals.
Elder abuse



Abuse includes physical as well as 'acts of omission' or negligence
that lead to the detriment of the health and well-being of the
person.
This would therefore include physical, psychological, sexual,
financial and material aspects of neglect or harm.
Report to HEAL (Halt Elder Abuse Line – toll free 0800 003081) for
investigation and management.
133
PROBLEMS ASSOCIATED WITH PERSONALITY
DISORDERS
(Refer to Chapter 38 of the main text for complete information)
Personality disorders represent persistent, long-standing maladaptive
patterns of behaviour that cause significant distress and impairment of
functioning. These disorders are more appropriately conceptualised in
dimensional rather than categorical terms: the distress and impaired
functioning are the defining criteria, and they separate this group of
disorders from the wide range of emotional and behavioural problems
encountered in the general population.
Diagnosis
The diagnosis of a personality disorder should not be made after a single
evaluation. Observation of ongoing and repetitive behavioural patterns
should be confirmed either by ward staff, or collateral information should
be obtained from family members or significant others.
Categorical approach
Clusters of personality disorders
Cluster A
Odd/eccentric
Cluster B
Dramatic/emotional
Cluster C
Anxious/fearful
Paranoid
Antisocial
Avoidant
Schizoid
Borderline
Dependent
Schizotypal
Histrionic
Obsessive-compulsive
Narcissistic
Paranoid personality disorder


Typically distrusts the motives or behaviour of others as deliberately
demeaning or threatening, suspecting deceit or exploitation.
Questions the loyalty of those close to them and often bear ongoing
grudges.
Schizoid personality disorder


Tend to be detached from all social relationships and have limited
emotional expression.
Appear not to need nor enjoy close relationships, preferring to be
solitary.
134

May be indifferent to praise or criticism by others.
Schizotypal personality disorder


Pervasively uncomfortable with close relationships, although not to
the same extent as with schizoid personality disorder.
Show social and interpersonal deficits, cognitive or perceptual
distortions, and eccentric behaviours. These features might include
ideas of reference or idiosyncratic forms of thinking.
Antisocial personality disorder



Characterised by a pervasive disregard for and violation of the
rights of others.
Disregard social norms and may be deceitful, impulsive, aggressive,
and reckless, disregarding the safety of others.
A lack of remorse and a failure to learn from experience is a
characteristic of this group.
Borderline personality disorder



Pervasive disturbance of interpersonal relationships, self-image and
affect.
Characterised by marked efforts to avoid rejection, leading to
unstable and intense relationships, identity disturbance and
impulsivity.
Stress-related dissociative experiences or persecutory ideation may
also be present for brief periods.
Histrionic personality disorder


Characterised by excessive emotionality and attention-seeking
behaviour, leading to discomfort when the individual is not the
centre of attention.
May also be inappropriately seductive or provocative, with rapidly
shifting emotions.
Narcissistic personality disorder


Displays a pervasive pattern of grandiosity and a need for constant
admiration, with a marked lack of empathy for others.
Perceived as arrogant or aloof, and are often interpersonally
exploitative.
135
Avoidant personality disorder


Characterised by pervasive social inhibition due to feelings of
inadequacy and fears of being criticised .
Tend to avoid interpersonal contact unless being assured of being
accepted.
Dependent personality disorder


Present with an excessive need to be taken care of, and have
submissive and clinging behaviour.
May have separation anxiety and are indecisive, resulting in unduly
seeking advice and needing reassurance from others.
Obsessive-compulsive personality disorder



Tend to be preoccupied with order, perfectionism and mental and
interpersonal control, at the expense of flexibility and efficiency.
May be overly conscientious, finding it difficult to delegate.
May show excessively moral, rigid and stubborn tendencies.
Personality disorder not otherwise specified (NOS)

This category is used when the general criteria for a personality
disorder are met, but there are not sufficient criteria to meet the
diagnosis of any of the specific personality disorders.
Dimensional approach
A substantially reformulated approach to the assessment and diagnosis of
personality pathology was initially recommended for the DSM-5™. These
include revised general criteria for personality disorder, a limited set of
personality disorder types, based on core impairments in personality
functioning and pathological traits, with an overall measure of severity of
personality dysfunction.
The following six specific personality disorder types are defined:
1.
2.
3.
4.
5.
6.
Antisocial
Avoidant
Borderline
Narcisstic
Obsessive- compulsive
Schizotypal.
The levels of personality functioning are assessed based on the severity of
disturbances in self and interpersonal functioning.
136
Five broad personality trait domains are defined:
1.
2.
3.
4.
5.
Negative affectivity
Detachment
Antagonism
Disinhibition vs compulsivity
Psychoticism.
Also consider component trait facets, for example impulsivity and rigid
perfectionism.
The major implication for the changes would be that the personality
domain is intended to describe the personality characteristics of all
patients, whether they have a personality disorder or not.
Managing personality disorders
The management of personality disorders presents particular challenges.
Patients are generally not able to regard their own personalities
objectively. This suggests that patients with personality disorders often
have limited insight into the role that their personality functioning plays in
their own distress or the distress they may cause others.
There is also significant overlap in some of the presenting symptoms of
Axis II and Axis I disorders in the DSM-IV system. The clinician is often
expected to make a diagnosis after a single evaluation, and although this
is possible with most Axis I disorders, the diagnosis of a personality
disorder should only be made after collateral information or other
observations have confirmed the stability of symptoms and behavioural
patterns over time.
Most patients with personality disorders present for treatment due to comorbid conditions such as depression, substance abuse or anxiety
disorders. In these cases, the co-morbid condition would need to be
treated as appropriate, but the clinician should be aware that ignoring the
presence of a personality disorder does have negative prognostic
implications and should therefore be addressed.
Psychotherapeutic interventions
Well-structured and theoretically consistent programmes are required for
the management of personality disorders. Various individual, family and
group therapeutic approaches have demonstrated a degree of success.
Because of the nature of the presenting symptoms, borderline personality
disorder has received the most attention: dialectical behavioural therapy
(DBT) has been studied most intensely, followed by mentalisation based
therapy, transference-focused psychotherapy, schema-focused therapy,
137
and systems training for emotional predictability and problem-solving
(STEPPS).
Pharmacotherapeutic interventions
Importantly co-morbid conditions such as depression or anxiety should be
identified and treated when present. Some patients may have sufficiently
severe symptoms arising from personality disorders to warrant
pharmacological treatment independent of co-morbid problems.
Possible pharmacotherapeutic interventions
Symptom
Treatment suggestions
Volatility, irritability
Lithium; sodium valproate; carbamazepine;
lamotrigine; SSRIs; antipsychotics (low dose)
Emotional lability
Lithium; SSRIs; antipsychotics (low dose);
depot flupenthixol
Self-mutilating behaviour
Carbamazepine; lithium; opioid antagonists
Anxiety
SSRIs; MAOIs; β-blockers; low-dose
antipsychotics
Psychotic-like symptoms (magical
thinking, odd beliefs, illusions,
etc.)
First- and second-generation antipsychotics
It should be emphasised that the aim is not to treat personality disorders
with drugs, but to alleviate problematic symptoms.
In-patient treatment
A substantial number of patients in psychiatric hospitals, particularly in
therapeutic wards, have diagnosable personality disorders. Borderline
personality disorder is a regular co-occurrence in patients with suicide
threats, and any treating unit needs to have the basic skills required to
deal with the particular demands of these patients.
Clinicians often feel manipulated by patients who threaten with suicide
and whose symptoms rapidly improve after admission. This may be
described as ‘contingent’ or ‘instrumental’ suicidality and is often
characterised by the following:


Suicide threats that are linked to the admission decision, and recede
after that decision has been made.
There may be co-occuring problems such as:
o homelessness
138
o
o
o
o
o
being single
substance abuse
legal difficulties
antisocial or borderline personality disorders
relative absence of features suggesting a depressive disorder.
In these cases hospitalisation may be counterproductive, and for some
patients a regressive measure. Nevertheless, the decision not to
hospitalise a suicidal patient is difficult and should only be made after
consultation with colleagues.
THE PATIENT AND THE FAMILY AFFECTED BY AN
INTELLECTUAL DEVELOPMENTAL DISORDER
(Refer to Chapter 39 of the main text for complete information)
Intellectual developmental disorder (IDD) is not a mental illness but a
lifelong condition that brings with it many potential social, medical and
mental health challenges that vary as the individual and family move
through different life stages.
Diagnosis
IDD is one of a group of neurodevelopmental disorders that include IDD,
communication disorders, autism spectrum disorder, attention
deficit/hyperactivity disorder, specific learning disorder, and motor
disorders.
For a diagnosis of intellectual developmental disorder (IDD) to be made,
the following three criteria must be met:



There must be deficits in general mental abilities such as reasoning,
problem-solving, planning, abstract thinking, judgement, academic
learning, and learning from experience.
There must be impairment in adaptive functioning relative to the
individual’s peers in terms of age and sociocultural background.
Adaptive functioning refers to how well a person meets the
standards of personal independence and social responsibility in one
or more aspects of daily activities such as communication, social
participation, functioning at school or work, or personal
independence at home or in community settings. The limitations
result in the need for ongoing support at school, work or in
independent life.
All symptoms must have an onset during the developmental period.
The deficits and impairments described above are measured in a variety
of different ways and include measures of IQ (intelligence quotient) and
adaptive behaviour scales.
139
Levels of severity
Levels of severity of IDD are determined by assessing function in three
different domains: the conceptual domain, the social domain and the
practical domain.
Level of severity
Mild
Conceptual domain
Conceptual difficulties often not detected in preschool.
Limitations are noticed with the start of formal schooling,
and difficulties are encountered in the acquisition of
academic skills
In adults, abstract thinking, planning and other executive
functions are impaired
Social domain
Immature social interactions, eg, difficulty accurately
perceiving peers’ social cues
Communication and language are concrete, and there may
be difficulties regulating emotion and behaviour in an ageappropriate fashion
Social judgement is immature
Practical domain
Personal hygiene skills will usually be acquired but may be
acquired later than usual
May need support for more complex tasks such as
shopping, transportation, banking, etc.
May be able to work in a competitive work environment
that does not emphasise conceptual skills.
Need support with healthcare and legal decisions and with
learning a vocation. Support needed to raise a family
Level of severity
Moderate
Conceptual domain
Conceptual skills lag behind peers throughout
development. Preschool: language and pre-academic skills
develop slowly
School years: reading, writing, mathematics, concepts of
time and money progress slowly
Adult: academic skill is at a primary rather than secondary
school level. Ongoing assistance is needed daily to
complete day-to-day conceptual tasks
Social domain
Marked differences from peers in social and
communicative behaviour throughout development
Spoken language is primary tool for communication, but is
less complex than peer.
140
Motivation for relationships, including romantic
relationships, is intact, but perception and interpretation of
social cues may not be accurate
Social judgement and decision-making abilities are limited,
and assistance is required with life decisions
Friendships with typically developing peers are often
affected by communication or social limitations. Support is
needed in work settings
Practical domain
Able to care for basic needs as an adult (including eating,
dressing, elimination and hygiene) and to participate in
household chores, but will require an extended period of
teaching and possibly ongoing support
Independent employment possible with extensive support
from co-workers, supervisors and coaches with respect to
social expectations, complexities of the job, and ancillary
responsibilities such as scheduling, transportation, health
benefits and money management
A variety of recreational skills can be developed, but
typically require additional support. Maladaptive behaviour
is present in a significant minority
Level of severity
Severe
Conceptual domain
Attainment of conceptual skills is extremely limited
May understand use of objects as tools, may be able to
complete simple cause-and-effect actions with objects
Lacks concepts involving number, quantity, time and
money. Caretakers provide all supports for this area
throughout life
Social domain
Generally uses nonverbal communication to initiate and
respond to social attention and interactions. Language, if
used or understood, involves names of objects and people
and simple phrases tied to everyday events
May respond to direct emotional communication and
understand simple social cues, but in general lacks
understanding of social context Relationships involve
family, caretakers and other long-term ties and are more
typical of attachment relations than of reciprocal
friendships
Practical domain
Requires support for all activities of daily living including
eating, dressing, bathing and elimination. Requires
supervision at all times. May make choices for preferred
objects, activities and people. Cannot make responsible
141
decisions regarding well-being of self or others. As an
adult, participation in practical and vocational activities
requires ongoing support and assistance. Recreational
activities require long-term teaching and ongoing support.
Maladaptive behaviour including self-injury is present in a
significant minority.
Management of the person with an IDD and of their
family
Consider the points discussed below.
Breaking the news
The way in which the diagnosis is given to a family influences their ability
to adjust to the diagnosis. Some suggestions for breaking the news:






Tell both parents together.
Be aware of the potentially devastating nature of the news.
Provide the most specific diagnosis possible, but translate medical
terminology into lay terms.
Be aware of the emotional charge of words with negative
connotations.
Allow parents to vent their emotions.
Leave room for hope without being unrealistic.
Supporting the family
The family needs emotional support, similar to that required in
bereavement, as they have to face the loss of the dreams they held for
their child. Parents may experience shock, denial, grief, guilt or even
anger towards the healthcare provider. The aim is to move towards a
phase of adaptation where parents begin to make a realistic appraisal of
the situation and start planning for the future.
Parents and families also have many practical needs such as advice
regarding facilities and resources, tax deductions or the availability of
social grants for their child. They may also require referral to other
healthcare providers such as physiotherapists or occupational therapists
for help with feeding or positioning their child if there are associated
physical disabilities.
Promoting optimal early development
Optimal development is facilitated by early detection of the problem. This
is achieved by screening of the entire population at early health checks,
142
usually carried out by a community health nurse. Assessment should take
place at a secondary level by a multidisciplinary team who then decide on
the necessary interventions.
Education
In terms of the South African Constitution, every child has a right to basic
education. Currently a segregated system of education exists in South
Africa: those children with an IQ above 50 are educated in mainstream
schools; those with an IQ of between 30 and 50 are educated in special
schools (termed LSEN schools – schools for learners with special
educational needs, previously known as training centres); and those with
IQs below 30 are catered for at special care centres.
Managing medical problems
The associated disabilities of cerebral palsy, epilepsy and sensory
disabilities require management in their own right. Other problems
frequently encountered in people with IDD are recurrent infections,
nutritional deficits, dental caries and constipation.
Residential care
Children develop best within the family setting. If this is not possible
within the biological family then foster placement should be considered.
Admission to a hospital or residential facility is best reserved for
treatment of specific problems or to give the family respite.
Challenges in adolescence
Although the mental and emotional development of people with IDD may
lag behind that of their peers, their physical maturation does not. During
adolescence there is usually the emergence and recognition of sexual
awareness and possible onset of masturbation, and the onset of
menstruation in girls. Both these milestones need to be addressed preemptively to avoid emotional or behaviour problems.
The person with IDD should receive education regarding sexuality and
puberty in a manner that is appropriate for their level of mental and
emotional development. Some girls with IDD struggle to manage
menstruation and it may be appropriate in these circumstances to use
depot contraception in an attempt to induce amenorrhoea.
143
Sexuality
People with all levels of IDD may experience sexual desires and sexual
pleasure. Unfortunately they are also especially vulnerable to sexual
abuse.
Carers often voice concerns regarding the expression of sexuality in
people with an IDD as well as regarding potential sexual exploitation and
abuse. It is important for people with IDD to be guided to express their
sexual desires in a manner that is acceptable within the society in which
they live. It is equally important to discuss the possibility of pregnancy
and sexually transmitted infections with the person with IDD, where
possible, and with the carers.
Psychiatric problems (co-morbidity)
Mental illness occurs with greater frequency in those with an IDD than in
the general population, yet it often remains undiagnosed due to the
difficulties with communication. The person with IDD struggles to
communicate his or her distress verbally with precision, and the mental
healthcare worker struggles to get the history and mental state exam
needed to formulate a diagnosis. Referral to secondary or tertiary care is
often required.
Disorders that are seen quite commonly in those with IDD are depression,
compulsive behaviours, for example self-injury, obsessive-compulsive
disorder (OCD) and other anxiety disorders.
Treating mental illness and challenging behaviour in
people with an IDD
Ascertaining the cause of challenging behaviour
Severe mental illness will nearly always cause a change in behaviour, but
not all changes in behaviour are disruptive, and not all changes in
behaviour are secondary to mental illness.
Consider these factors when a person with IDD presents with a change in
behaviour:

Could this change in behaviour be caused by a medical problem?
o pain from headaches, dental problems or an ear infection may
result in self-injury or withdrawal
o hypothyroidism may cause depressive symptoms
o hyperthyroidism may cause manic symptoms
o constipation may result in discomfort that causes aggression
towards self or others.
144



Could this change in behaviour be caused by medication or side
effects of medication?
o this is especially likely if medication has recently been
commenced or a dose changed.
Could this change in behaviour be caused by mental illness?
o there is no direct correlation between any particular behaviour
and a particular diagnosis. That is, aggression does not
always imply that the person with an IDD is psychotic or
depressed. However, close examination of the behaviour and
what precedes it will often enable a careful practitioner to
ascertain if there is indeed, for example, increased irritability,
decreased energy levels, disorganisation of behaviour,
possible hallucinations.
Could this change in behaviour be the result of something in the
environment?
o this is perhaps the commonest cause of changes in behaviour
and problematic behaviour, and requires skill to ascertain
exactly what is causing the problem and how to solve it
o the first step is to take a careful history from the patient as
well as his or her carers
o ideally there should be a period of observation in the natural
environment
o referral may be indicated if the cause is not obvious, the
situation does not resolve, or the behaviour is causing harm
to the patient or those in their environment.
Medical management of a psychiatric illness
Once a mental illness has been diagnosed, people with IDD should be
treated with the same medications used in the general population. Certain
precautions should, however, be noted:


People with an IDD tend to be more sensitive to medication and its
side effects, and it is always prudent to start with a low dose and
increase cautiously to reach therapeutic levels.
People with IDD may exhibit paradoxical reactions to certain
medications more frequently than the general population.
The most common behaviours that result in people with IDD being
brought to a mental healthcare worker are aggression and sexual
behaviour that is considered inappropriate by the carers or the
community. It is imperative that an attempt is made to ascertain the
cause of the behaviour, and the cause removed or the environment
altered to decrease the behaviour, before medication is considered.
145
Therapeutic and social input
People with IDD can benefit from a number of different forms of
psychological and social input, depending on the problem, the severity of
the IDD, and the nature of the environment in which they live.
Behaviour modification
Ideally, medication should never be used for behaviour problems unless a
mental illness is diagnosed as the cause of the problem. If no medical or
psychiatric cause is found for the problem behaviour, behaviour
modification strategies can be implemented. These include:




giving consistent verbal reprimand whenever the behaviour occurs
giving consistent verbal praise when behaviour is stopped or
alternative more acceptable behaviours occur in the setting that
usually provokes the undesired behaviour
instituting a time out: the individual is removed from the reinforcing
situation every time the behaviour occurs. The period of isolation
should be brief, no more than ten minutes, and the individual must
be aware that carers are within range should help be required.
asking for restitution: this involves rectifying the damage that was
caused by the behaviour. The restitution task must be within the
capabilities of the individual and must never be degrading. The
purpose is to teach the individual that behaviours have
consequences.
146
SECTION 5: ETHICS, PHILOSOPHY AND THE
LAW
THE MENTAL HEALTH CARE ACT
(Refer to Chapter 43 of the main text for complete information)
Psychologically impaired individuals may present with behaviour that
could be detrimental to their own health, or to the safety of others. These
individuals include those with mental illness and intellectual disability. The
aim is to provide for the individual's own protection as well as the
protection of the community.
The procedures outlined and to be followed in the Mental Health Care Act
(No 17 of 2002) depend on the severity of the disturbed state and the
amount of insight that the patient retains into their need for
management. The emphasis is intended to be more on treatment and
protection than merely on the detention of the patient as in earlier
legislations.
Objectives of the Act
The objectives are summarised in the points below:





intervention in the best interests of the user
provision of care at all levels
least restrictive environment
active integration with general healthcare
active involvement of families/carers in admission procedures
expectation of benefit from treatment rather than custodial care.
Human rights
The Mental Health Care Act (No 17 of 2002) aims to protect the rights of
mentally ill people. These include the right to dignified and humane
treatment, freedom from discrimination in terms of access to all forms of
treatment, the right to privacy and confidentiality, the right to protection
from physical or psychological abuse, and the right to adequate
information about their clinical status.
Admission and treatment should always be carried out in the patient's
best interests in the least restrictive environment.
It is important to note that the reporting of incidents of exploitation and
abuse is a requirement addressed in the Act. Any person witnessing any
form of abuse against a mental healthcare user (patient) must report this
147
to the Mental Health Review Board (MHCA form 2), or may lay a charge
with the South African Police Service.
Mental Health Review Boards



Established in every region with a health establishment providing
mental healthcare, treatment and rehabilitation services.
Tasked to ensure the protection of the rights of persons committed
into care.
Must consist of a mental healthcare practitioner, a member of the
legal profession, and a member of the community.
Admission to hospital for care and assessment
Patients are admitted under three categories depending on the level of
restriction. These three categories are voluntary, assisted or involuntary.
Voluntary care
This is the least restrictive, and preferred situation. Principles of voluntary
care:




the
the
the
the
user
user
user
user
is mentally ill and in need of treatment
is competent to make an informed decision
consents to treatment
can benefit from treatment.
Assisted care
The admission procedures for assisted patients, or patients not opposing
the application, are of a less formal or compulsory nature than that of
involuntary admissions.
The principles of assisted care are:






the user is mentally ill and in need of treatment
there is a likelihood of harm to self or to others due to mental
illness
admission is required for care, treatment and rehabilitation, and for
protection of financial interests or reputation
the user is not competent to make an informed decision
the user does not refuse treatment
the user can benefit from treatment.
148
The assisted admission process includes the following:




application (MHCA form 04)
assessment by two mental healthcare practitioners (one of whom
should be a medical practitioner) (MHCA form 05)
admission to hospital for care (MHCA form 07)
report to Review Board.
Involuntary care
If the person is severely mentally ill and is placing him- or herself or
others at risk as a result of that illness, and is refusing the admission for
treatment that he or she requires, that person will require involuntary
hospitalisation.
The guiding principle should be the best interests of the patient. Patients
should not be involuntarily admitted for convenience or for any other
reasons.
The principles of involuntary care are:






the user is mentally ill and in need of treatment
there is a likelihood of harm to self or to others, due to mental
illness
admission is required for care, treatment and rehabilitation, and
for protection of financial interests or reputation
the user is not competent to make an informed decision
the user refuses treatment
the user can benefit from treatment.
The involuntary admission process includes the following:







application(MHCA form 04)
examination by two mental healthcare practitioners (MHCA form 05)
72-hour assessment at an appropriate level of care
MHCA form 06 completed at the end of 72-hour observation
discharge (MHCA form 3) or transfer to a specialist hospital (MHCA
form 8), depending on assessment findings
report to Review Board
report to High Court.
Emergency care of patients incapable of making informed
decisions
Any person or health establishment that provides emergency care,
treatment and rehabilitation services to a mental healthcare user, or
admits the user in circumstances in which the user could not make an
149
informed decision, must report this fact in writing in the prescribed
manner to the relevant Review Board within a 24-hour period. Further
procedures in terms of the appropriate category must then be made.
The principles of emergency care are:







the user is mentally ill and in need of treatment
delay may result in death or irreversible harm to the user, serious
harm to self or others, serious damage or loss of property of self or
others
the user is not competent to make an informed choice
the user is refusing treatment
the user can benefit from treatment
the user may be detained only for 24 hours.
the user must be reported to the review board.
Consent to treatment and operations for illness other
than mental illness
An involuntary mental healthcare user or an assisted mental healthcare
user who is capable of consenting to treatment or an operation should
decide whether to have treatment or an operation or not. Where a mental
healthcare practitioner deems a user to be incapable of consenting to
treatment or an operation, owing to mental illness or intellectual
disability, then a curator, if a court has appointed one, a spouse, the next
of kin, a parent or guardian, a child over the age of 18, a brother or
sister, or a partner or associate, may consent to the treatment or
operation.
The Head of Health Establishment (HHE) where the mental healthcare
user resides may grant consent to treatment or an operation only if none
of the above persons is available, if attempts have been made to locate
them. The HHE should be satisfied that the most appropriate intervention
is to be performed and the medical practitioner who is going to perform
such operation recommends the treatment or operation.
Intervention by members of South African Police Service
(SAPS)
If a member of the SAPS has reason to believe, from personal observation
or from information obtained from a mental healthcare practitioner, that a
person, owing to his or her mental illness or severe or profound
intellectual disability, is likely to inflict serious harm on him- or herself or
on others, the member must apprehend the person and take him or her
to an appropriate health establishment for assessment.
150
The person is handed over into the custody of the HHE or any other
person designated by the HHE to receive such persons. If, after the
assessment, the person apprehended is considered likely to inflict serious
harm on him- or herself or on others, owing to mental illness or
intellectual disability, he or she must be admitted to the health
establishment for a period not exceeding 24 hours in order for an
application to be made for involuntary admission.
Appeals
The right of appeal against admission is available to patients, relatives or
other interested persons. Such appeal may be made to the Mental Health
Review Board of the area (MHCA form 15). Patients should be advised of
their status, the avenues of appeal and the manner of discharge open to
them.
151
SECTION 6: MANAGEMENT
BASIC PRINCIPLES OF COUNSELLING
(Refer to Chapter 44 in the main text for complete information)
An important task for the healthcare worker is to develop counselling
skills. Counselling can be understood as a deliberate way of interacting
with patients to enable them to cope with, and gain a degree of mastery
over their presenting problems.
Primary healthcare workers need to be practical and solve problems, but
in counselling they also need to listen, support, reflect and clarify in order
to help people solve their own problems. Counselling, in conjunction with
other forms of treatment, is a basic element of the management of most
psychiatric and non-psychiatric, health-related disorders.
To be effective, the counsellor needs to have certain personal qualities as
well as interpersonal, conceptualisation, intervention and cultural
competence skills. These are covered in the text that follows.
Personal qualities
The counsellor should:




be warm, trustworthy, understanding, accepting and empathetic
towards the patient irrespective of the predicament
always keep an open mind and respect the patient
develop empathetic listening and communication skills
be aware of cultural sensitivity.
The counsellor should not be judgemental or dismissive, even when the
patient's predicament is a result of his or her own actions, for example
HIV infections due to unprotected sex or emphysema due to chronic
smoking.
Conceptualisation skills cluster
As counselling progresses after the initial contact, the counsellor becomes
increasingly involved in the patient's world and worldview. The counsellor
must become part of the patient's world in order to be empathic, but at
the same time must remain sufficiently objective to help the patient find
new solutions. Therefore the counsellor must display a balance of
congruence, honesty, empathy and professional responsibility.
152
Intervention skills cluster
Many intervention skills represent little more than common sense and the
provision of appropriate information. Other interventions are more specific
to the counselling relationship: the counsellor may need to be innovative
and deploy a set of skills depending upon the characteristics of the patient
and the presenting problem. Usually interventions are geared towards the
patient committing to a course of health-enhancing behavioural, as
opposed to ill-health sustaining, actions, irrespective of the etiology of the
problem being confronted.
Cultural competence skills cluster
All counsellors should become multi-culturally sensitive and be aware of
the need to respect cultural, ethnicity, gender and race differences.
General recommendations include those listed below.




Be aware of your own cultural heritage and affiliations, and of the
impact your own culture has on the counselling relationship.
Be familiar at least with the cultures of people who differ from
yourself, particularly those likely to consult you.
Be realistic and honest about your own range of experiences as well
as issues of power, privilege and poverty; be aware of the great
impact that poverty has on ethnicity; think about the positions you
hold that contribute to power, oppression and privilege.
Remember, as a counsellor, that it is incumbent on the practitioner,
not the patient, to be educated about various dimensions of culture
and its effects on behaviour, health and attitudes. For example, if
the clinician is uninformed about a cultural belief regarding
depression, or explanations of HIV causality, different from his or
her own perspective, the clinician should show an interest in the
patient's understanding of the phenomenon. An important aspect of
cultural competence is to show an interest in and respect for the
patient's cultural context and explanatory style.
The core counselling skills
Counselling involves a set of core skills clusters that interact and inform
each other through the process of counselling: listening, clarifying,
reflecting, summarising, problem-solving and evaluation.

Attending and listening: Effective listening is the cornerstone of
counselling. It provides the basis for making sense of the patient's
problem and helps him or her feel understood. Listening requires
active attention. It is not a passive or simple process.
153
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




Questioning: The counsellor should rely mainly on open-ended
questions as opposed to limiting closed-ended questions.
Clarifying: During the process of listening, the counsellor should
ask a few key questions to ensure he or she has understood the
patient correctly and to draw the patient out further. This
questioning process is called 'clarifying'.
Reflecting: Reflecting is the process of communicating to the
patient how the counsellor has understood the patient's feelings and
perceptions. Reflecting is a very simple but powerful way of helping
the patient feel understood, and encourages further communication.
Summarising: This draws on the understanding the counsellor has
developed by listening, clarifying and reflecting.
Enabling problem-solving: Sometimes a decision needs to be
made, or the patient needs to make clear plans of action to resolve
the problem. The counsellor should not make decisions for the
patient but should enable the patient to reach his or her own
decisions.
Evaluating: The counsellor needs to evaluate the effects or
benefits of the counselling process. Feedback from the patient is
usually sufficient but often the counsellor will need to gain the
patient's permission to garner feedback from other sources, such as
family members.
Pitfalls to avoid in counselling include:







impatience
interrupting
being judgemental
taking control
having a patronising attitude
showing ethnic, racial, cultural and gender prejudices
assuming your own perspective represents the norm.
COGNITIVE BEHAVIOURAL AND OTHER BRIEF
PSYCHOLOGICAL THERAPIES
(Refer to Chapter 46 in the main text for complete information)
The aim of this section is to introduce primary care practitioners to some
of the most widely practised and evidence-based short-term
psychotherapies that are useful for a range of mental health problems. A
shared feature of these various interventions, distinguishing them from
psychoanalytical approaches, is that they are goal directed, structured
and time limited.
154
Cognitive behavioural therapy (CBT)
The ‘cognitive model’ proposes that many mental health symptoms are
associated with distorted thinking. It describes the interplay of distorted
thinking with mood, behaviour and physical symptoms.
In adults, CBT is effective in the treatment of:







anxiety disorders
mild and moderate depression
eating disorders
non-specific pain problems
personality disorders
substance use disorders
insomnia.
In children or adolescents, CBT is effective for:







anxiety disorders
depression
body dysmorphic disorder
eating disorders
obsessive-compulsive disorders
post-traumatic stress disorders
attention deficit hyperactivity disorder (ADHD).
The principles of CBT include the following:







CBT is designed to treat specific problems, which are jointly
identified by the patient and therapist.
The goal of CBT is to help patients make changes in their lives
through learning experiences and not only to better understand
their problems or themselves.
CBT is goal oriented, and these goals are agreed upon early on in
therapy.
CBT is focused on current problems and is time-limited, the duration
being usually between 8-20 sessions.
CBT is educational, aimed at the patient acquiring skills and
knowledge that assist in controlling or regulating thoughts,
emotions and behaviours.
The patient is expected to work outside the therapy sessions on
problems, using skills learnt with the therapist, described as home
tasks.
The active roles of the patient and therapist are fundamental, and a
‘collaborative’ relationship is required where responsibility for
progress is shared.
155
Exposure therapy


This is used primarily to treat anxiety disorders, where certain
situations are perceived to be dangerous and associated with
intense fear.
Exposure therapy requires the development of a graded list, or
hierarchy of feared situations, and careful and gradual exposure
first to less ‘dangerous’, then to increasingly feared situations.
Problem-solving therapy (PST)





This is a brief psychological treatment based on CBT principles.
It has been used to train non-specialist health workers in primary
care interventions.
PST has primarily been used for depression and crisis intervention
in patients who self-harm.
It is a useful first step in the management of generalised anxiety
disorders.
The intervention lasts 4-6 sessions, and is essentially focused on
learning skills to generate and implement solutions to current
problems.
Mindfulness-based stress reduction (MBSR)





This is a structured programme that uses mindfulness as an
approach to treat physical and mental health problems.
Anxiety, depression, pain, and other physical complaints and
medical disorders can be successfully treated with this intervention.
MBSR is characterised by continuous awareness of physical
sensations, perceptions, affective states, thoughts and images.
‘Mindful awareness’ implies paying attention, without thinking about
or evaluating perceptions that arise during periods of practice.
MBSR is a group programme that focuses on the progressive
acquisition of mindful awareness.
Mindfulness-based cognitive therapy (MBCT)


A psychological therapy that is designed and has been shown to aid
in preventing the relapse of depression.
It uses CBT methods, psycho-education, mindfulness and
mindfulness meditation.
156
Dialectical behaviour therapy (DBT)




Initially developed to treat people with borderline personality
disorder.
DBT combines cognitive-behavioural techniques for emotion
regulation with techniques of distress tolerance, interpersonal
effectiveness, and mindfulness.
DBT is effective in treating patients with borderline personality
disorders and self-injurious behaviours.
DBT classically involves a combination of individual and group
components.
Interpersonal therapy (IPT)





Takes ideas from psychodynamic psychotherapy and cognitivebehavioural theories.
Techniques include homework, structured interviews, and
assessment tools.
IPT assists the patient to regain control of mood disturbances and
functioning.
Has been shown to be successful in treating patients with
depression in primary care.
Has also been modified to treat substance abuse, dysthymia or
persistent depressive disorders, bulimia and bipolar mood disorders.
Supportive psychotherapy (SPT)



Derives from psychodynamic, cognitive-behavioural, and
interpersonal theories.
Is useful in patients with relatively severe problems that are
unlikely to benefit from psychoanalytic approaches (eg, psychoses
and severe mood disorders, personality disorders, eating disorders
and substance abuse disorders).
In SPT the therapist engages actively in an encouraging, supportive
relationship with the patient. The objective of the therapist is to
reinforce the patient's existing healthy, adaptive patterns of
thinking and behaviour to reduce conflict and symptoms of distress.
Psycho-education


This is the education offered to patients with mental health
problems, and, ideally, to their family members as well. The
patient's own strengths, resources and coping skills are reinforced.
Psycho-education is central to the management of patients with
psychotic illnesses, severe mood and anxiety disorders, eating
disorders and personality disorders.
157

The goal is for the patients and their family to accept, understand,
and be better equipped to deal with the presenting illness, and to
reduce the burden of both internal and social stigma.
PHARMACOLOGICAL AND OTHER PHYSICAL
TREATMENTS IN PSYCHIATRY
(Refer to Chapter 52 of the main text for complete information)
Pharmacological treatments in psychiatry are effective and should be used
in combination with psychological and social interventions. The broad
aims of treatment are to relieve distress, restore optimal function and
prevent relapses.
It is important that the prescriber provides enough information to the
patient regarding the need for the medication, likely side effects, and the
proposed duration of treatment. Entering into a co-operative therapeutic
alliance with the patient, and encouraging his or her active participation in
the treatment plan improves adherence to treatment.
Classes of psychotropics: The anxiolytics and
hypnotics
Benzodiazepines
The benzodiazepines represent a group of medications that enhance
gamma-aminobutyric acid (GABA) activity. The benzodiazepines may be
classified into four groups on the basis of their elimination half-life:




Ultra-short (< 6 hours), eg, midazolam, triazolam
Short (6‒12 hours), eg, oxazepam, temazepam
Intermediate (12‒24 hours), eg, lorazepam, alprazolam
Long (> 24 hours), eg, diazepam, nitrazepam.
Prescribing points






Mode of action: potentiates inhibiting action of GABA
Shared sedative-hypnotic, anxiolytic, muscle-relaxant, anti-epileptic
properties
Select according to half-life
Agents with short half-life more useful for sedation; those with
longer half-life for the treatment of anxiety
General indications for treatment of anxiety, insomnia and alcohol
withdrawal
Also useful to control agitation in the short term in psychotic states
158


Owing to potential to cause dependency, should not be prescribed
regularly for longer than 4 weeks
Avoid abrupt cessation or drug withdrawal.
Side effects and adverse effects







Dependency syndrome (tolerance and withdrawal symptoms)
Drowsiness, confusion, depression, lack of psychomotor coordination, paradoxical reactions
Memory impairments, particularly in the elderly
Effects potentiated by alcohol, therefore particularly hazardous
when driving and operating machinery due to lack of psychomotor
co-ordination
Caution in pregnancy and breastfeeding
Caution with elderly due to falls and increased risk of hip fractures
Contra-indicated in respiratory depression.
Benzodiazepine withdrawal strategies









Check package inserts to decide on dosages.
Use a flexible regime and adjust to patient response.
Err on the side of caution with slow and gradual withdrawal.
Switch from short- or intermediate-acting agents to long-acting
agents.
Reduce by 10 mg/day every 1‒2 weeks to daily dosage of 50 mg.
Reduce by 5 mg/day every 1‒2 weeks to daily dosage of 30 mg.
Reduce by 2 mg/day every 1‒2 weeks to daily dosage of 20 mg.
Reduce by 1 mg/day every 1‒2 weeks until stopped.
Provide only 1 week's supply at a time.
Non-benzodiazepine anxiolytics and hypnotics


Beta-blockers (eg, propranolol) are used to treat the peripheral
manifestations of particularly performance anxiety, including
sweating, tremors and palpitations. They may also alleviate
akathisia, or restlessness associated with the use of antipsychotics.
These agents are contra-indicated in patients with asthma and may
worsen depressive symptoms in some people.
Zolpidem and zopicloneare non-benzodiazepine hypnotics that exert
their effects as partial agonists of the GABA complex. They are
considered to have less dependency potential and less likelihood of
causing cognitive impairments than benzodiazepines. At high doses
they lose their specificity and act like benzodiazepines.
159
Antidepressants
Biochemically, severe depressive states are associated with a
dysregulation of certain neurotransmitters (noradrenaline, serotonin and
dopamine) or abnormalities in their mechanisms of action.
Antidepressants act by increasing the concentration of these neurotransmitters in the central nervous system.
General prescribing points










Discuss with the patient: benefits, side effects, adverse effects,
delayed onset of action, withdrawal effects, and alternative and
additional non-pharmacological treatments.
Avoid use in mild depression or distress in reaction to life events.
Efficacy similar across groups: selection made according to sideeffect profile.
1‒2 weeks, at therapeutic doses, before onset of action.
Start at low dose and titrate gradually upward to therapeutic level.
Treat first episode for at least six months after resolution of
symptoms.
Longer courses of treatment for subsequent episodes.
Withdraw medication gradually to avoid discontinuation syndrome
(flu-like symptoms, restlessness, insomnia).
Use with caution and not in isolation in bipolar mood disorders.
There is a ‘black box warning’ on all antidepressants regarding
increased risk of suicide in children, adolescents and young adults
up to age 24.
Side effects based on interaction with neurotransmitter
systems






Blockade of muscarinic acetylcholine receptors: dry mouth, blurred
vision, constipation, urinary retention
Blockade of histamine receptors: sedation, weight gain
Blockade of alpha 1 receptors: hypotension, dizziness
Blockade of dopamine receptors: motor abnormalities
Increase of serotonergic transmission: sexual dysfunction, gastrointestinal discomfort, headache
Increase in noradrenergic transmission: agitation, increased and
irregular heart rate
Tricyclic antidepressants (TCAs)



Block the re-uptake of noradrenaline and serotonin
Also act on muscarinic, acetylcholine and histamine receptors
Cholinergic side effects include dry mouth, urinary retention, and
constipation
160




Sedation and weight gain are the principal side effects of
antihistamine activity
TCAs are potentially lethal in overdose, and should not be used in
patients at risk of suicide
Use carefully in the elderly and in people with cardiac disease and
epilepsy
Also used in anxiety disorders, and in low dosages in chronic pain
and enuresis in children.
Tetra-cyclic antidepressants





Less cardiotoxic than the tricyclic agents
Cause fewer cholinergic side effects
Not as toxic in overdose and have sedative properties
Useful for insomnia
May cause bone marrow suppression
Tetracyclic and tricyclic antidepressants
Examples



Amitriptyline
Imipramine
Mianserin (tetracyclic)
Mode of action

Block noradrenalin and serotonin re-uptake at the presynaptic
membrane, increasing noradrenergic and serotonergic transmission.
Main side effects and adverse effects


Sedation, anticholinergic effects, postural hypotension, cardiac
arrythmias, potentially lethal in overdose due to cardiotoxicity
Mianserin: haematological abnormalities, sedation, lower risk of
cardiotoxicity.
Contra-indications


Recent myocardial infarction
Cardiac arrhythmias.
Indications



Moderate to severe depressive disorders and anxiety states
Nocturnal enuresis in children, at low dosages
Neuropathic pain and other forms of chronic pain, at low dosages
161

Migraine prophylaxis, at low dosages.
Selective serotonin re-uptake inhibitors (SSRIs)




Used primarily in depression
Also useful in the treatment of conditions such as obsessivecompulsive disorders and eating disorders
Do not appear to affect other major neurotransmitter systems and
therefore have more favourable side effect profiles and are much
less toxic in overdose
No clear evidence of their superiority in the treatment of depressive
symptoms compared to tricyclic agents.
Indications



Moderate to severe depression
Anxiety disorders
Bulimia nervosa.
Serotonin and noradrenalin re-uptake inhibitors (SNRIs)
Examples


Venlafaxine
Duloxetine.
Mode of action

Serotonin and noradrenalin re-uptake inhibition without
anticholinergic side effects, increasing serotonergic and
noradrenergic activity.
Main side effects and adverse effects





GIT effects (anorexia, nausea, constipation, diarrhoea, abdominal
pain/discomfort)
Hypertension
Palpitations
Dizziness
Insomnia or drowsiness.
Indications


Venlafaxine: moderate and major depressive disorders, anxiety
disorders
Duloxetine: moderate and major depressive disorders, chronic pain
disorders.
162
Monoamine oxidase inhibitors (MAOIs)
Examples


Reversible agents (RIMAs): moclobemide
Irreversible agents: tranylcypromine.
Mode of action


Inhibits monoamine oxidase, thereby increasing serotonergic and
noradrenergic activity
Reversible inhibitors inhibit only monoamine oxidase A and
therefore allow for metabolism of tyramine by mono-oxidase B.
Side effects and adverse effects


Irreversible agents: hypertensive crises if combined with tyraminecontaining foods, for example cheese and meat extracts;
drowsiness, insomnia, headaches, dizziness
Reversible agents: sleep disturbances, nausea, agitation, confusion.
Indications



Irreversible agents: treatment-resistant depressive disorders
Reversible agents: moderate to major depressive disorders, social
phobia
The use of the irreversible MAOIs are not recommended at primary
healthcare level due to multiple and potentially serious side effects,
drug interactions, and the availability of other effective and safer
agents.
Other antidepressant agents
Agomelatine


Novel antidepressant with melatonergic receptor agonist and
selective 5HT2C receptor antagonism activity
Liver function monitoring is essential.
Bupropion




A dopamine reuptake inhibitor
Indicated for depressive disorders and nicotine addiction
Insomnia, agitation, weight loss, nausea and constipation are
relatively common side effects
Contra-indicated in seizure disorders.
163
Trazodone



This is a serotonin reuptake inhibitor and serotonin 2-antagonist
Less likely to cause sexual side dysfunction
Possible side effects include sedation, dizziness, headache, nausea
and priapism.
Mood stabilisers


Used in the treatment of bipolar mood disorders
The most commonly used is lithium carbonate, although antiepileptic agents and second generation anti-psychotic agents are
also employed.
Lithium
General prescribing principles







Narrow therapeutic ‘window’; risk of toxicity
Renal, cardiac and thyroid function should be assessed before
starting therapy
Patients should be informed of indications for use, side effects, toxic
effects and interactions with other agents that may precipitate
toxicity
Monitor plasma levels until therapeutic range of 0,6-1,0 mmol/l is
reached
Blood levels should be taken 12 hours after last dose
Once stable, monitor levels every 3 months. Renal functions and
TSH should be monitored every 6 months
Lithium should be withdrawn slowly over a period of approximately
4 weeks.
Mode of action

Complex and uncertain: probably exerts effects through action on
second-messenger systems.
Side effects




Transient gastro-intestinal symptoms, fine tremor, thirst, polydipsia
and polyuria, weight gain
Hypothyroidism in the longer term
Impaired renal function (benign for the great majority, but
interstitial nephritis in a small minority)
Toxic effects (> 1,5 mmol/l): Anorexia, nausea, vomiting and
diarrhoea, drowsiness, coarse tremor, ataxia leading to seizures,
164
delirium and death if not treated urgently (renal dialysis > 3
mmol/l).
Hazardous interactions



Thiazide diuretics
Non-steroidal anti-inflammatory drugs
ACE inhibitors.
Indications



Maintenance prophylactic treatment of bipolar mood disorders
Treatment of mania in the acute phase, augmentation in treatmentresistant depression
Possible benefit in aggression, self-injurious behaviours
Contra-indications



Pregnancy (particularly in first trimester: Ebstein's anomaly,
neonatal goitre)
Renal impairment
Cardiac disease.
Sodium valproate
Mode of action

Complex and uncertain, probably multiple actions on ion channels of
the cell membrane, and augmenting GABA inhibition.
Dosing

Routine monitoring of blood concentrations not helpful. Monitor
FBC, renal, liver functions +/- 6 monthly
Side effects and adverse effects





Potentially hepatotoxic, therefore liver function should be monitored
regularly
Nausea, lethargy, weight gain, oedema, haematological
abnormalities, polycystic ovaries, hair loss
Teratogenic (neural tube defects): should therefore be avoided in
pregnancy
If pregnancy possible or uncertain, folic acid supplementation
recommended
Ensure adequate contraception if prescribed to a woman of childbearing potential.
165
Indications



Maintenance therapy for bipolar mood disorders
Treatment of mania
Epilepsy.
Carbamazepine
Mode of action

Probably through enhancement of inhibitory GABA transmission;
possibly also acts on sodium and potassium channels at the
membrane level.
Side effects and adverse effects




Dizziness, drowsiness, anorexia, nausea, vomiting, skin rashes,
haematological abnormalities, hyponatraemia due to syndrome of
inappropriate secretion of antidiuretic hormone (SIADH)
Induces metabolism of many agents, importantly antipsychotics,
antidepressants and oral contraceptives
Avoid in pregnancy and breastfeeding
If indicated, folic acid supplementation recommended.
Indications




Maintenance treatment of bipolar mood disorders
Acute phase of mania
Epilepsy
Trigeminal neuralgia and other neuropathic pain disorders.
Contra-indications



Atrioventricular block
Blood disorders
Bone-marrow depression.
Lamotrigine
Mode of action

Probably through inhibition of sodium channels and glutamate
release.
166
Side effects and adverse effects





Skin reactions (transient to severe hypersensitivity reactions)
Nausea, vomiting and diarrhoea
Headache
Fatigue
Dizziness.
Indications


Mood stabilisation in bipolar mood disorders
Some evidence of particular benefit in treating bipolar II disorders.
Antipsychotics
Antipsychotic drugs exert their effects by acting principally as dopamine
antagonists. These agents symptomatically treat psychotic symptoms
such as delusions, hallucinations and thought disorders, and restore
functioning to a variable degree. They also have non-specific calming or
sedating effects, and can be useful to control agitation without affecting
the level of consciousness.
Antipsychotic agents are conventionally classified into first-generation
(‘typical’) and second-generation (‘atypical’) antipsychotic agents.
First-generation/typical agents
The typical antipsychotics are defined by their potent D2 receptor activity.
Blockade of the D2 receptors in the nigro-striatal pathway results in the
characteristic extrapyramidal side effects.
Typical antipsychotics are further divided into high-potency and lowpotency agents, according to their affinity to the D2 receptors. Higherpotency agents are associated with a higher rate of extrapyramidal side
effects; lower potency agents are associated with a greater degree of
sedation.
Other side effects include






Increased prolactin (leading to galactorrhoea, gynaecomastia,
menstrual disturbances)
Skin reactions (particularly photosynthetic reactions to
chlorpromazine), haematological abnormalities
Cardiac arrythmias
Weight gain
Sexual dysfunction
Tardive dyskinesia
167

Neuroleptic malignant syndrome.
Neuroleptic malignant syndrome



This is potentially life-threatening and probably under-diagnosed
Clinical features include delirium, muscle rigidity, hyperthermia,
autonomic instability, raised CPK and leukocytosis
Manage by stopping antipsychotic; benzodiazepines, monitor vital
functions, refer as clinically indicated.
Depot or longer-acting preparations



2‒4 week duration of action
Does not necessarily improve adherence to treatment: use should
be negotiated with patient
Examples include:
o fluphenazine decanoate
o zuclopenthixol decanoate
o flupenthixol decanoate
o risperidone (requires refrigeration).
Second-generation/atypical agents
The atypical antipsychotics represent a heterogenous group of drugs with
diverse receptor interactions. They were initially defined in terms of their
action of blocking both dopamine and serotonin 5HT2 receptors. Broadly,
their affinity for the D2 receptors is lower than that of the older agents,
and they are less liable to cause extrapyramidal symptoms.
As a group, they are as effective as the typical agents in reducing the
positive features of psychosis. The various claims that second-generation
agents are more effective in treating the negative features, cognitive
deficits, and mood disorders associated with schizophrenia, are based on
inconsistent or insufficient evidence.
These are a heterogeneous group, as each of these newer agents has a
profile of benefits and side effects.
Side effects





Cardiac: QT prolongation, risk of arrythmias ('torsade de pointes')
Impaired glucose tolerance, diabetes
Dyslipidaemias
Weight gain
Sexual dysfunction (desire, arousal, orgasm).
168
Clozapine


Indications:
o treatment resistance (failure to respond to two different
classes of antipsychotics at adequate dosages for sufficient
time, i.e. 6‒8 weeks).
o intolerable side effects, particularly EPSEs
o mood disturbances
o negative features
o neurocognitive impairments.
Main side effects and adverse effects:
o agranulocytosis (< 1 %): WBC before starting treatment, then
weekly for 18 weeks, and thereafter monthly
o patients need to be informed of side effects, need for
monitoring, and early signs of infection
o other serious side effects include myocarditis, toxic
megacolon, and seizures at high dose.
o sedation, weight gain, excessive salivation.
Olanzapine


Side effects: Sedation, weight gain, disturbances of glucose and
lipid metabolism
Advantages: Lower incidence of sexual dysfunction, extrapyramidal
symptoms.
Risperidone


Side effects: EPSEs at higher dosages, elevated prolactin
Advantages: Lower incidence of sedation and lower risk of weight
gain, disorders of glucose and lipid metabolism.
Amisulpride


Advantages: At lower doses might alleviate negative symptoms. At
higher doses treats positive symptoms without significant
extrapyramidal side effects
It is used as an augmentation agent with clozapine for treatmentresistant schizophrenia.
Quetiapine


Side effects: Sedation
Advantages: Well tolerated with dose titration, prolactin not
elevated, fewer complications of sexual dysfunction
169
Ziprasidone


Side effects: Some concern regarding dosage-related cardiac
dysrhythmias
Advantages: Less likely to cause weight gain and impaired glucose
tolerance; intramuscular preparation available.
Aripriprazole

Advantages: Low risk of EPSEs. Possible benefit in control of mood
symptoms and negative features of schizophrenia. Not associated
with weight gain, glucose intolerance and sexual dysfunction.
NON- PHARMACOLOGICAL PHYSICAL TREATMENTS
These are reserved for specialist use only.
Electroconvulsive treatment (ECT)
Negative perceptions of this potentially life-saving treatment have arisen
because in the past neither anaesthesia nor muscle relaxants were used,
and informed consent was not considered to be a requirement. Modern
anaesthesia and advanced delivery systems make this a safe and effective
therapy for the correct indications.
The therapeutic element is the convulsion. Unilateral placement is
associated with fewer side effects whereas bilateral placement is
considered to achieve a more rapid response. A standard course is three
treatments a week for two weeks. The patient must give informed
consent for both the anaesthetic and the ECT.
Side effects include injuries if the muscle relaxation is insufficient, and
short-term memory impairments related to age and the number of
treatments.
Indications for ECT






Severe depression, associated with psychosis, or with immediate
suicide risk
Psychomotor stupor or catatonia
Life-threatening insufficiency of fluid and food intake arising from
the above conditions
Treatment-resistant depression
Treatment-resistant mania
Circumstances where treatment is urgently required but the
appropriate medication is contra-indicated.
170
Novel remedies for which there is at present insufficient evidence of
clinical usefulness include light therapy, vagal nerve stimulation,
transcranial magnetic stimulation, and deep brain stimulation.
171