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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 1 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. 2 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: 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 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. 3 Pay attention to the following: 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: 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 4 1. The history When taking a history, ensure the following information is gathered. Identifying data 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 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 Past and current medical illness Use of any medications 5 Exclude past head injury, epilepsy, tuberculosis, syphilis, HIV, cardiac disease, diabetes and endocrine disorders. Drug and alcohol history Detailed account of all substance use Use a non-judgemental manner that promotes the free flow of information Forensic history Current legal or criminal matters History of past forensic issues Family history 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 Early life and development Education Employment Psychosexual relationships Religion and culture Social circumstances. Premorbid personality 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. 6 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. 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 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. 7 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: expansive, elevated and euphoric irritable. In depression, the affect may be described as: low, sad, flat or blunted anxious or depressed. In psychosis, the affect may be described as: 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 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: 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 8 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. 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. 9 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). 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 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 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 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. 10 Memory 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 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 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 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 11 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 5 100, 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 12 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. 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: 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 13 instrument, and if impairments are evident, more formal neuropsychological testing is indicated. a) Memory-Registration 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: 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: 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 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 14 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. 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 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 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, 15 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 Axis I: Clinical diagnoses Axis II: Disablements Axis III: Contextual factors. The ICD-10 categories of mental disorders 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. 16 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: 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. 17 Investigations can be divided into the following categories: Haematological Urine studies Cerebrospinal fluid Neuroimaging Other Haematological investigations Consider the following: Full blood count 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 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: 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 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: 85 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 86 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 94 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. 96 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. 97 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. 100 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. 102 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 103 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. 104 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 105 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. 106 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. 107 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. 110 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. 111 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 114 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 115 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 116 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. 117 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 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