Oxford Handbook of Clinical Specialties (9 edn)
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Quite a few doctors hope to make patients better by taking responsibility for ordering the mileau interieur, and the credit when things go well. In psychiatry this approach is wrong. Mental health is about people (not patients) taking responsibility for themselves and their programme of change. The psychiatrist knows that his or her job is done, not when the patient is cured but when he becomes self-actuating, insightful, and interacting with the world in creative (not necessarily satisfactory) ways. So if you are hoping for a chapter dealing with mental disorders as if they were lung diseases with certain signs and agreed treatments this chapter will disappoint. Isn’t it woolly, a reader complained, to have pages on listening, dignity, etc? “Just tell me what to do.” Well, here goes. Interpersonal problems: just do what you think you should do. Anxious? Get on with it: relax; try β-blockers. Depressed? ssris, tricyclics or get wired (ect); think positive. Manic? Try lithium. Psychopathic? Tough luck. Schizophrenic? Antipsychotics; if dangerous, lock up. Psychotherapy for everything else. Phew! That’s got it over with. Now sit back and rest. Or sit back and listen…if you listen, you may be able to help, rather than beat people over the head with formulaic solutions to problems they don’t quite have.
Doctors have never been very important because nothing that happens to our bodies ever really matters. In historical terms, what happens to our bodies rarely outlives our own times. Even the exceptions to this prove a different rule: we recall forever human images burnt on to stone at their moment of immolation in Nagasaki and Hiroshima. What happened to these people was important, and transcended their times. But it is all the more true that it isn’t the way they lived, but the way they died that is important, and it is not the body or its image on stone which is important, but the image left on our minds. And so it is with psychiatrists, psychologists, and psychiatric nurses who play such vital roles in colouring our lives with hope or despair, who mitigate our madness, giving meaning, purpose, and dignity to the mental sufferings of so many of us. So when we think of them going about work, think of them burnishing humanizing images not on stone, but on the mind itself. How they do it is the subject of this chapter.
Screaming but unheard: images born of paranoid schizophrenia. Neil Houghton, the artist, says: “I was born in Bolton with a pencil in my hand. Always deep in thought and not mixing much with others. I have always been troubled with confusing and scary thoughts…diagnosed as schizophrenia. This painting is from a series chronicling a bad episode.”©Neil Houghton Gallery. When we asked him what message he would like to send doctors learning about mental illness, he replied “Patients can offer a valuable insight into their own illness.” This value he points to is troubling, hard-won, but, ultimately, liberating.
“Terror grips when these things happen; the signs, the lights, the storm within: death by instalments… I’m a daily subscriber.”First principles
Chaque homme porte la forme entière de l’humaine condition
A thought experiment
Before reading further, cover the next paragraph with a card and write on it what you are trying to achieve as a mental health worker. Next, turn the card over and write down what was actually in your mind as unstated goals when you were last treating someone. So often our unconscious aim is just symptom control, obedience, or simply (simply!) normality. But if you were the patient (luck changes in a moment) what would you want? The aim of this page is to help you find out, by considering one person’s answer.
The essence of mental health
Healthy (lucky!) humans are able: …To love and be loved; without this asset, humans, more than all other mammals, fail to thrive.
To embrace change—and face fear in a spirit of practical optimism.
To take risks, free from endless worst-case-scenario-gazing.
To satisfy the requirements of the group—if the person so desires.
To deploy joie de vivre, and a wide range of emotional responses, including negative emotions, such as anger (pain’s most motivating antidote).
To make contact with reality: not too rarely or too often. Human kind cannot bear very much reality.
To say “I was wrong” and learn from life and to have enough self-knowledge to heal the self and others, but not so much as to become demoralized.
To inhabit fantasy worlds, enabling hope and creativity to flourish.
To feel a sense of security, not always predicated on one’s status in society.
To enjoy self-expression—balanced by sensitivity to others’ vulnerabilities.
To feel a sense of awe and to risk enchantment (and hence disenchantment).
To have a sense of humour to compensate if the foregoing is unavailable.
Go, go, go, said the bird: human kind Cannot bear very much reality. Time past and time future What might have been and what has been Point to one end, which is always present.
Four Quartets, ts eliot
Happiness1 need not be an ingredient of mental health, as the merely happy are supremely vulnerable to events.
The essence of mental illness
Whenever a person’s thoughts, feelings, or sensory impressions cause him objective or subjective harm that is more than transitory, a mental illness may be said to be present. Often the harm is to society, but this is not part of the definition of mental illness, as to include it would open the door to saying that, for example, all rapists or all those opposing the society’s aims are mentally ill. One feature of mental illness is that one cannot rely on patients’ judgment, and the judgment of family, gp, or psychiatrist has a role. If there is disparity, let it be ‘one person one vote’, if voters are acting solely in the interests of the patient. Psychiatrists have no special voting rights (or else concepts of mental illness get too medicalized). Just because psychiatrists and gps are not allowed more than one vote, this does not stop them from illuminating the debate by virtue of their special knowledge.
For convenience, English law saves others from the bother of specifying who has a mental illness by authorizing doctors to act for them. This is a healthy state of affairs only in so far as doctors remember that they have only a small duty to society, but a larger duty to their patient.
Learning disability (mental impairment)
This is a condition of arrested or incomplete development of mind owing to low intelligence, p364.
Apart from showing sympathy, nothing is more to be desired than giving our patients dignity—not the dignity that they deserve (who among us would merit an ounce of dignity on this measure?) but the dignity that confirms to our patients that, mad, bad, or rambling, they are, root and branch, body and mind, just as human as their doctors—perhaps more so, because they are suffering.1 Let patients
Decide on modes of address, ‘Miss Hudson’ may be preferred to ‘Amy, dear’. Dignity entails giving choices, and then respecting them.
Know who we are (eg wear name badges). But don’t label patients (“Go and see the new schizophrenic on Mary ward”). If you put a patient in a box the next thing you’ll do is put a lid on it—and stop thinking.
Wear their own clothes—and clothe them decently if they have none.
Choose whether to take part in research—and whether to see students.
Have personal space—both to stow their belongings, and to walk in, in private, whether alone, or with visitors.
Participate in their treatment plans; explain about common side effects.
Know what to do if a crisis develops. It’s a great help to know that you will be seen in 4 hours rather than be left to moulder all weekend.
These 7 points are congruent with nice (2012) and Human Rights law which lays out the right to life, freedom from inhuman or degrading treatment and torture, respect for privacy, the right to a fair hearing and freedom of expression. Some of these rights are inalienable, and unrevokable, even in time of war (on uk soil). So defences such as ‘the ward was busy that day’ or ‘there was no money to buy this service’ are unlikely to impress judges.
In practice, many mental health wards may do more harm than good (violence, verbal abuse, and sexual harassment eg from other patients).
Maslow states that a healthy personality (ie fully functioning and self-actualizing) entails the meeting of a hierarchy of needs:
Biological needs (eg oxygen, food, water, warmth).
Love, affection, and ‘belongingness’ needs.
Esteem needs (self-respect, and need for respect from others: see top box). The latter is 2-fold: being valued for what you can do or bring to your community or family—and, above all, to be valued for who you are.
To be aware of the inner self and to understand our inner nature.
To transcend cultural conditioning.
To transcend the trifling and to grapple with life’s serious problems.
To refresh consciousness by appreciating beauty and all good things.
To feel joy and the worth of living. www.connect.net/georgen/maslow.htm
Uncomfortably numb on the lp ward…“Amy, dear, we are just going to put a tiny little needle in your back…you wont feel a thing….
Odd ideas
It is important to decide if a patient has delusions, hallucinations (that the patient believes are real), or a major thought disorder (see below), because if present the diagnosis must be: schizophrenia, an affective disorder, an organic disorder, or a paranoid state (or a culturally determined visionary or spiritual experience), and not a neurosis or a personality disorder.
Patients may be reluctant to reveal odd ideas. Ask gently: “Have you ever had any thoughts which might now seem odd; perhaps that there is a conspiracy against you, or that you are controlled by outside voices or the radio?”
Hallucinations
Delusions
Ideas of reference
Ways to distinguish delusions/hallucinations from obsessional thoughts
Hearing the thought as a voice (a hallucination)—eg from a psychosis.
The voice is ‘put into my head’—thought insertion (hallucination + delusion).
The voice is ‘my own voice’ but intrusively persistent (obsessional neurosis).
Major thought disorder
If hallucinations/delusions are present, ask:
What other evidence is there of mental illness? Hearing the voice of one’s dead spouse is common, and does not mean pathology.
Could the odd ideas be adaptive, and the patient be better off ‘ill’? A woman once believed she saw planes flying over her home, and that this data was taken from her head by the Ministry of Defence. She ‘knew’ she was playing a key role in defending Britain. When she was cured of her delusions (Ibsen’s ‘life-lie’2) she killed herself. An odd story; or is it so odd? According to the great poets, everything we cherish is an illusion, even our sense of distinctive self-hood, and without this primordial delusion, madness beckons.
A typical problem is trying to diagnose a young man presenting with hallucinations and/or delusions. The question often is: Are these odd ideas due to schizophrenia, drug abuse, or physical illness?
Most auditory hallucinations not associated with falling asleep or waking up are caused by schizophrenia or depression.
In 90% of those with non-auditory hallucinations (eg seeing things), the cause is substance abuse, drug withdrawal, or physical disease.
Evidence that substance abuse is to blame includes:
The history: Ask the patient, the family, and friends about abuse. Be precise about timing. If ≥4 weeks elapse between abuse and starting of odd ideas, substance abuse is an unlikely cause (but substance abuse may be an enabling factor promoting later psychosis).1
Severity of symptoms: If symptoms are severe, and the quantity of drug ingested is trivial, the drug is unlikely to be causative.
Drug-seeking behaviour: Be on the lookout for this.
Physical examination: This may reveal signs of drug abuse (eg injection marks ± cellulitis), chronic alcohol abuse (eg spider naevi, liver palms, atrophic testes), or a physical medical illness (eg brain tumour).
Blood or urine tests may disclose the substance abused or give a hint of abuse (mcv⬆ and gamma gt⬆ in alcohol abuse).
Imaging: Consider cns imaging if the patient is elderly with nothing to suggest substance abuse, or if there are cns signs.
nb: middle-age is not a typical time for schizophrenia to present: alcohol abuse or a primary cns condition is more likely.
We all have odd ideas: it–s our reactions to them and beliefs about them which are mad or sane or both.
Doctors are always getting hung up on hallucinations, those tokens used in games of clever diagnosis, without bothering to acquire real knowledge of what it’s like to have them. For doctors who have never experienced hallucinations, Professor Yellowlees has devised a virtual reality experience on Second Life: a complex, unruly 3D world where we doctors and our avatars get sucked into virtual clinics… Floors can fall away, leaving us walking riskily on stones above clouds. The eyes of a portrait flash ‘shitface’ as we pass, and a politician on an in-world tv might move in a single breath from platitudes to shouting “Go and kill yourself, you wretch!”. When it gets to the stage of our reflection in a mirror bleeding its eyes out before expiring, most of us switch off. But our patients cannot quit so easily. Virtual reality is just one way of sensitizing us to their struggles: other ways are through blogs, painting (p313), and tragedy (the Ophelia effect).Voices in the margin are saying ‘get lost, ohcs’.
Introduction to psychiatric skills
On starting psychiatry you may feel unskilled. A medical problem will come as a relief—you know what to do. Do not be discouraged: you already have plenty of skills (which you will take for granted). The aim of this chapter is to build on these. No one can live in the world very long without observing or feeling mood swings, and without devising ways to minimize what is uncomfortable, and maximize what is desirable. Anyone who has ever sat an important exam knows what anxiety is like, and anyone who has passed one knows how to master anxiety, at least to some extent. We have all survived periods of being ‘down’, and it is interesting to ask how we have done this. The first element is time. Simply waiting for time to go by is an important psychotherapeutic principle. (Voltaire teasingly remarked that the role of the doctor is to amuse the patient until nature effects a cure.) Of course, there are instances when waiting for time to go by leads to fatal consequences. But this does not prevent the principle from being useful.
Another skill with which we are all more or less adept is listening. One of the central tenets of psychiatry is that it helps our patients just to be listened to. Just as we all are helped by talking and sharing our problems, so this may in itself be of immense help to our patients, especially if they have been isolated, and feel alone—which is a very common experience.
Just as spontaneous regeneration and improvement are common occurrences in psychiatry, so is relapse. Looking through the admissions register of any acute psychiatric ward is likely to show that the same people keep on being re-admitted. In one sense this is a failure of the processes of psychiatry, but in another sense each (carefully planned) discharge is a success, and a complex infrastructure often exists for maintaining the patient in the community. These include group support meetings, group therapy sessions, and social trips out of the hospital. We all have skills in the simple aspects of daily living, and in re-teaching these skills to our patients we may enable them to take the first steps in rebuilding their lives after a serious mental illness.
So time, listening, and the skills of daily living are our chief tools, and with these simple devices much can be done to rebuild the bridges between the patient and his outside world. These skills are simple compared with the highly elaborate skills such as psychoanalysis and hypnosis for which psychiatry is famous. The point of bringing them to the fore is so that the newcomer to psychiatry need not feel that there is a great weight of theoretical work to get through before he starts doing psychiatry. You can engage in the central process of psychiatry from day 1. Use the knowledge and experience gained as a foundation on which to build the constructs required for the more specific and effective forms of psychotherapy.
As one history-taker said, “They wanted facts. Facts! They demanded facts…as if facts could explain anything!”
The good listener is not silent, but reflective—a mirror not a message. Mirrors do not judge but they enable self-judgment. Unless some criminal act is underway, it really does not matter what we think about our patients. What matters is how the patient thinks about him- or herself and his or her near-ones—and how these thoughts can be transformed.
If we judge people they will not trust us. No trust ≈ no healing.
If we judge, patients will leave us for others perhaps less well qualified.
There is no evidence that judging improves outcomes. Worse outcomes are likely if the patient feels alienated.
Patients know if we feel bad about them. They may internalize this, and assume that things will always be bad because they themselves are bad.
Despite these bullets, there is a problem that won’t go away. If we find ourselves talking to perpetrators rather than victims, we may not be wise to suspend judgment forever. If a crime is afoot putting others at risk, you may need to break confidentiality. Discuss this with a colleague. Ask yourself whether Nazi and Rwandan doctors were too nonjudgmental with their fellow patients. If ‘tout comprendre c’est tout pardonner’1, then to pardon all actions is to abdicate our moral selves. What is the consequence of this—for us, and for our patients? Unless we exercise judgment, it might be thought, we may be condoning evil. ‘For evil to flourish in the world, all that is required is for the good to remain silent’. If we remain silent long enough, then will our own moral sense sicken, and die? What human duties do doctors have which trump anything that goes on in the consulting room? Whenever you think the time may have come to judge, check with yourself that it is not from outrage, or disgust, or through the exercise of pride, or from a position of power that you are judging—but reluctantly, and from duty. The dreadful history of some doctors in the twentieth century teaches that we must be human first, and physician-scientists second.
Dr. Quarrell’s letter—“My dear Elvet…
In judging others, we expend energy to no purpose…but if we judge ourselves, our labour is always to our profit… Thomas à Kempis.
Listening (and swallowing)
Taking a history sounds like an active, inquisitorial process, with lists of questions, and the tone of our page on this process (p322 & mental state examination, p324) seems to perpetuate this error. It isn’t a question of taking anything. It’s more about receiving the history, and allowing it to unfold. 
If you only ask questions, you will get only answers as replies.
As the history unfolds, sit back and listen. This sounds easy, but during a busy or difficult day you will find your mind wandering (or galloping away)—over the last patient, the next patient, or some aspect of your own life. You may find yourself worrying about having to ‘section’ this patient or see the relatives afterwards. By an act of Zen, banish extraneous thought, and concentrate totally on the person in front of you—as if your life depended on it. Concentrate on the whole person—the language, the words, the nonverbal cues, and get drawn into their world. Initially don’t even think of applying diagnostic labels. Open your mind and let everything flood in. Listening is hard. We wish we did it better. We all need to practise it more.
Avoid interruptions and seeming to be too purposeful, at least for the first few minutes (or days). Expect periods of silence. If prompts are needed try “and then how did you feel?” or just “and then…”; or repeat the last words the patient spoke. Don’t be anxious if the patient is not covering major areas in the history. Lead on to these later, as the interview unfolds. Early in your career you will have to ask the relevant questions (p322) in a rather bald way (if the information is not forthcoming during the initial unstructured minutes), but it is important to go through this stage as a prelude to gaining information by less intrusive methods. Always keep in mind the chief aims of making a diagnosis, defining problems, and establishing a therapeutic relationship.
Listening enables patients to start to trust us. Depressed patients often believe they will never get better. To believe that they can get better, patients need to trust us, and this trust is often starts the therapeutic process. In general, the more we listen, the more we are trusted. Our patients’ trust in us can be one of our chief motivations, at best inspiring us to pursue their benefit with all vigour. A story bears this out. One day, in 334 bc, Alexander the Great fell ill with fever. He saw his doctor, who gave him a medicine. Later he received a letter saying his doctor was poisoning him as part of a plot (it was an age of frequently fatal intrigues). Alexander went to his doctor and silently drank the medicine in front of him—then gave him the letter. His confidence was rewarded by a speedy recovery. We think it is unreasonable to expect quite this much trust from our patients, and one wonders what can have led Alexander to such undying trust in his doctor. We suspect that his doctor, above all else, must have been a good listener.
Doctor:“How long have you been drinking that heavily?”
Patient:“Since I’ve been married.”
Doctor: [impatiently]“How long is that?”
Patient: [giggling]“For years”. Perhaps the doctor hears ‘4 years’.
Swallowing a world.
Eliciting the history
Introduce yourself; explain how long the interview may take. Describe its aim; emphasize that “here is a safe place to talk”. Find out how the patient came to be referred, and what his expectations are. If the patient denies any problems or is reluctant to start talking, don’t hurry. Try asking “How are you?” or “What has been happening to you?” or “What are the most important things?” “Does anyone else think there is a problem?” “Who does it effect most?” These are beautiful questions because they impose no categories, and seeing what categories your patients imposes, unprompted, will often tell you rich things. Listen, without interrupting, noting exact phrases. By inhabiting and using the categories your patient gives, you may enter his world. 2 minutes may be needed for this phase—or 2 years—depending on how unspeakable and distressing his or her thoughts are. Events surrounding war, torture, rape, and family dislocations may take years before they can be told.
Presenting symptoms
Agree a problem list with the patient early on, and be sure it is comprehensive, eg by asking “If we were able to deal with all these, would things then be all right?” or “If I were able to help you, how would things be different?”. Then take each problem in turn and find out about onset, duration, effects on life and family; events coinciding with onset; solutions tried; reasons why they failed. The next step is to enquire about mood and beliefs during the last weeks (this is different from the mental state examination, p324, which refers to the mental state at the time of interview). Specifically check for suicidal thoughts, plans, or actions—the more specific these are, the greater the danger. Discussing suicide does not increase the danger. Questions to consider: “Have you ever felt so low that you have considered harming yourself?” “Have you ever actually harmed yourself?” “What stopped you harming yourself any more than this?” “Have you made any detailed suicide plans?” “Have you bought tablets for that purpose?” Depression—ie low mood, anhedonia (unable to feel pleasure), self-denigration (“I am worthless”; “Oh that I had not been born!”), guilt (“It’s all my fault”), lack of interest in hobbies and friends plus biological markers of depression (early morning waking, ⬇appetite, ⬇sexual activity, ⬇weight); mania (p354); symptoms of psychosis (persecutory beliefs, delusions, hallucinations, p316); drug and alcohol use; obsessions; anxiety; eating disorders (eg in young women; often not volunteered, and important). Note compulsive behaviour, eg excessive hand-washing.
The present
Birth, growth, and development
How has he spent his life? Ask about school, play (alone? with friends?) hobbies, further education, religion, job, sex, marriage. Has he always been shy and lonely, or does he make friends easily? Has he been in trouble with the law? What stress has he had and how has he coped with it? nb: noting early neurotic traits—nail-biting, thumb-sucking, food fads, stammering (not really a neurotic feature)—rarely helps.
Premorbid personality
Before all this happened, how were you? Happy-go-lucky↔driven, gentle↔sadistic,1 tense↔laid-back, happy↔depressed, social↔antisocial? Impulsive, selfish, fussy, irritable, rigid, insecure/schizotypal,2 shy, hostile, competitive? Talk to whoever accompanies him, to illumine premorbid personality and current problems. But don’t let her speak for the patient (at least make sure the patient has the first and last word).
Relevant medical history
eg on retroviral drugs, or frequent asthma attacks. Next, examine the mental state (p324 & p353). You may now make a diagnosis, or decide that labelling is unwise. Ensure the areas above are covered in the light of any diagnosis so that the questions “Why did he get ill in this way at this time?” and “What are the consequences of the illness?” are answered.
When in doubt, get further help.
“I’m not going to be a victim all my life just because I was abused!”
Doctor:“When you are like this, what’s most difficult?”
Dawn:“Looking after the children—and going out to work”.
Doctor:“Which is harder?”
Dawn:“Well, going out to work; sometimes the children help. Jo and Nick.”
Doctor:“Anyone else?”
Dawn:“Well—my husband? Fat chance, even when he’s sober.”
Doctor:“So the children don’t take after him, then?”
Dawn:“Lord no! Not yet, anyway—but all the blokes in his family drink like fish, so I’m worried for Nick when he gets that bit older.”
Doctor:“You worry more about him than Jo?”
Dawn:“Yes—even though Jo cannot read yet, which is a worry. But she’s got a way of looking after us somehow. She’ll be all right—she’s like her gran.”
Doctor:“She still looks after you all sometimes?”
Dawn:“Well, she did, but she died last year, and then I went back on drugs.”
All families evolve their own ways of communicating, and much goes on under the surface. In this dialogue, Dawn instigates a dozen categories or concepts. In an unconscious tour d’horizon, she draws a map for us, and as we impose none of our own suggestions, we can be fairly sure they represent some of the chief landmarks in her world. Don’t place people and events on other people’s maps: let them populate their own. Don’t superimpose the quasi-objective platitudes and longitudes of time and place. It is better to let the map grow organically. You yourself are on the map, partly revealing and partly hiding the other elements. Move around a bit, and by a process of psychological parallax3 you can estimate how far your patient is from the centre of her life.
The mental state examination (mse)
This assesses state of mind at the time of interview. Take notes under the following headings.
Appearance and behaviour: Eg signs of self-neglect; slowness, anxiety, or suspiciousness.
Mode of speech: Speech rate, eg gabbling (pressure of speech), or slow/retarded. Note content.
Mood: Note thoughts about harming self or others. Gauge your own response to the patient. The laughter and grand ideas of manic patients are contagious, as to a lesser extent is the expression of thoughts from a depressed person.
Beliefs: Eg about himself, his own body, about other people and the future. Note abnormal beliefs (delusions) eg that thoughts are overheard, and ideas (eg persecutory, grandiose). See p316.
Unusual experiences or hallucinations: “Sometimes when people are low they have unusual experiences; have you heard anything unusual recently?” Note modality, eg visual.
Orientation: In time, place, and person. What year? What season? What month/day of week? Is it morning or afternoon? What is your name?
Short-term memory: Recall a name & address 5min after learning it. Ensure he really has learned it before waiting for the 5min to elapse.
Concentration: Months of the year backwards.
Patient’s insight and degree of your rapport.
Long-term memory: Current affairs recall. Who is the monarch/head of state? This tests other functions, not just memory.
Any odd thoughts?
Might your thoughts be being interfered with?
Do you feel anyone is controlling you?
Is anyone putting thoughts into your head?
Do other people access or hear your thoughts?
Is anyone harming you?
Any plots against you?
Do you hear voices when there’s no one nearby? What do they say? Echoing you? Telling you off?
Do you see things that others cannot see?
Are you low/depressed?
Is life worth living?
Can anything give you pleasure?
Sleep and appetite ok?
Energy levels ⬆ or ⬇?
Can you concentrate ok?
Are you feeling guilty?
Is your confidence low?
Are you wanting to harm anyone? Yourself?
Any worries/anxieties?
Non-verbal behaviour
Why are we annoyed when we blush, yet love it when our friends do so? Part of the answer to this question is that non-verbal communication is less well controlled than verbal behaviour. This is why its study can yield valuable insights into our patients’ minds, particularly when analysis of their spoken words has been unrevealing. For example, if a patient who consistently denies being depressed sits hugging himself in an attitude of self-pity, remaining in a glum silence for long periods of the interview, and when he does speak, using a monotonous slow whisper unadorned even by a flicker of a gesticulation or eye contact—we are likely to believe what we see and not what our patient would seem to be telling us.
| Items of non-verbal behaviour: | Dress: |
|---|---|
• Gaze and mutual gaze • Facial expression • Smiling, blushing • Body attitude (eg ‘defensive’). | • Hairstyle • Make-up • Ornament (ear-rings, tattoos, piercings). |
| Signs of auditory hallucinations: | Anxious behaviour: |
|---|---|
• Inexplicable laughter • Silent and distracted while listening to 'voices' (but could be an 'absence' seizure, p206) • Random, meaningless gestures. | • Fidgeting, trembling • Nail-biting • Shuffling feet • Squirming in the chair • Sits on edge of chair. |
| Signs of auditory hallucinations: | Anxious behaviour: |
|---|---|
• Inexplicable laughter • Silent and distracted while listening to 'voices' (but could be an 'absence' seizure, p206) • Random, meaningless gestures. | • Fidgeting, trembling • Nail-biting • Shuffling feet • Squirming in the chair • Sits on edge of chair. |
| Signs of a depressed mood: | |
|---|---|
• Hunched, self-hugging posture • Little eye contact | • Downcast eyes; tears • Slow thought, speech, and movement. |
| Signs of a depressed mood: | |
|---|---|
• Hunched, self-hugging posture • Little eye contact | • Downcast eyes; tears • Slow thought, speech, and movement. |
A true description of mental states entails valid knowledge about current emotions plus their reactions to those emotions. These reactions are themselves emotional (eg being relieved that one’s sense of remorse over x feels authentic), as well as being the bedrock out of which beliefs and attitudes are formed. These interactions make a picture to an observer which is complex, paradoxical, subjective, error-prone, contradictory—and fascinating.
Describing and communicating mental states is the central puzzle that confronts not just psychiatrists and our patients, but also artists. Poets and songwriters summon up diverse mental states (herein lies their genius) but none can control them or their infinite progeny (what happens next). This is the province of psychiatry. If we could control mental states at will at least half our job would be done (no doubt there would be unfortunate side effects). Drugs, psychotherapy, and behavioural methods are the tools available for this task, and they all, crucially, impinge on mental state. You cannot tell if these methods are helping if you cannot access your patient’s mental state, which is why the page opposite is so important. If you think you can access mental states just by applying the formulaic regimen opposite, you will often fail, as any trip into the mind of another is not just a voyage without maps, it is ultimately a creative and metaphysical enterprise.
On this view, knowledge of mental states is doubtful, but often this is not so, eg a baby being put to the breast after separation from her mother, or an audience giving a standing ovation, or screaming fans waving at an idol, and we know without doubt that these mental states comprise unalloyed satisfaction, pleasure, and adulation. So often it’s non-verbal behaviour that allows valid judgment about mental states: don’t rely on words alone—those capricious (but indispensable) tokens of disguise and deception.
Viola: “I am all the daughters of my father’s house, and all the brothers too.” Twelfth Night
Perfect identity integration = ego death.
Know thyself…know thyselves.
How to avoid doctor-dependency
A patient may become over-dependent on his or her doctor in many spheres of medicine. This is a particular danger in psychiatry because of the intimate and intense rather one-sided or asymmetrical relationship which may be built up between the patient and psychiatrist—who will often know more about a patient’s hopes and fears than any close friend. This encourages the patient to transfer to the therapist thoughts and attitudes that are often directed to parent-figures. This process (known as transference) powerfully stimulates doctor-dependency, sometimes with serious consequences.
Other risk factors for doctor-dependency:
Signs of non-therapeutic dependency
Repeated phoning for advice, inability to initiate any plan without help from a therapist, and disallowing of your attempts to terminate treatment (eg by threatening relapse).
Assessing whether dependency is a problem
Clearly, in the examples above, the patient’s dependency on his doctor is non-therapeutic. At other times, for example, early in treatment, doctor-dependency may help. In these circumstances the danger is that the doctor will be flattered by his patient’s dependency on him. Most therapists either want to be loved by their patients or want to dominate them (or both), and it is important to know, in each session with each patient, just where you lie within the space marked out by these axes. Ask yourself: “Why do I look forward to seeing this patient?” “Why do I dread seeing Mr X?” “Why do I mind if this patient likes me?”
When you feel good after seeing a patient always ask yourself why (it is so often because he is becoming dependent on you).
Avoiding dependency
Planning and agreeing specific, limited goals with patients is one way of limiting dependency. If the patient agrees from the outset that it is not your job to provide him with a new job, wife, or family, he is more likely to have realistic expectations about therapy.
Planning discharge from the start of therapy helps limit doctor-dependency. Discharge is easy from the outpatient departments, but for the gp the concept of discharge is diluted by the fact of his contractual obligations. The patient is quite within his rights to turn up the day after being ‘discharged’ and demand that therapy be started all over again. The gp must have more subtle methods at his disposal to encourage the patient to discharge himself. For example, he can learn to appear completely ineffective, so that the dependency cycle (patient presents problem→doctor presents solution→patient sabotages solution→doctor presents new solution) is never started. Another method is to bore your patient by endlessly going over the same ground, so that the patient seizes control and walks out as if to say “I’ve had enough of this!”.
The foregoing makes patients out to be perpetual seekers after succour and emotional support—and so they may be. But a great mystery of clinical medicine is that, spontaneously and miraculously, many apparently irremediably dependent patients can change, and start leading mature and independent lives. So don’t be downcast when you are looking after such people: there is much to be said for simply offering a sympathetic ear, staying with your patient through thick and thin, and waiting for time to go by and for the wind to change. Of course, the wind may change back again, but, if it does, you will not be back at square one, for you will be able to inject the proceedings with the most powerful psychotherapeutic agent of all, namely hope.
How to improve quality of care
Ancient principles for improving quality
New principles
In areas such as surgery, performance-management and quality centre around:
Efficacy
Safety
Equity (equal access to benefits)
Choice
Holistic patient experience/compassion. How do these precepts shape up in the world of psychiatry? Let’s take a look, one at a time.
Efficacy:
But beware: how do you quantify success for people whose illness precludes them from seeing themselves as being ill? Patients may have their delusions and hallucinations treated so that none are left: but this does not equate with 100% quality of care if the problem is not the delusions and the hallucinations but rather urban alienation (p391), poverty, or unemployment. The hallucinations may be a way of coping with the latter. See p316.
Safety:
Choice:
Offering a choice as to which hospital to be compulsorily incarcerated in seems like tokenism. Also, sectorization (each team having its own geographical area) precludes choice. But because choice does not work in some areas it does not mean it has no role in others. It is legitimate to regard choice of psychotherapy, drugs, or both as a marker of quality of care in depression.
Equity:
Holistic patient experience/patient satisfaction.
This is discussed on p510.
Some clinicians reject the new methodology: “What we have to do is get away from measurements and statistics and calculations and pieces of paper published by politicians and get back to what we know intuitively is the correct way to help people.” But what if our intuitions are wrong or contradictory? Is it possible to combine the best of the old and the new? Maybe…Synthesis
(old+new) Find out who wants what→If the patient’s views are known, comply with them→make a commitment in your heart to put your patient first→do what it takes to make your patient better→attack all diseases with vigour→promote health where possible→palliate where cure is impossible→update care in the light of evidence→set yourself targets by all means, provided one target is not to let targets skew the care you give→take steps to find out if you have actually done what you intended (audit, p506).
Motivating professionals
Only pay them if your quality goals are met? A favourite nhs tactic, but undermining of the notion of professionalism and prone to valuing the measurable over more important goals. If we had to select just one winning idea from this page to take forward to our next patient we would go with Hippocrates: make a commitment in your heart to put your patient first. This is very hard: just try it. (Did you notice how compassion got squeezed out of this page? How did that happen? Why does this always happen?)
How to talk with young people about sex
Language is important. It may be medical (eg ‘coitus’); slang (eg ‘fucking’); or socially acceptable (eg ‘having sex’). It is not advisable to use slang as people think you are trying to be fashionable. Most will expect socially acceptable language; slang may shock and may put up barriers. But occasional mirroring of the patient’s words can gain rapport. Ask if your words are acceptable.
Don’t appear embarrassed. It is easier for people to open up if they think that you aren’t going to blush, tell them off, or, worst of all, laugh. Don’t act shocked and don’t judge; give the wrong impression and they will stop being honest with you—see p319 for further discussion of this vital point.
Act as if you have plenty of time to listen—all the time in the world.
Asking about sexual abuse
Have you been in any relationships that made you feel uncomfortable? Has anyone touched you in a way that made you feel embarrassed? I am wondering if anyone has hurt you in a sexual way.
Confidentiality
How to perform a risk-assessment
This is a common problem: the courts, the gp, or the relatives want to know “Will he be violent again if he takes the medication?”. A great deal—a man or woman’s freedom, no less, may depend on our answers. The philosophical problems with giving a straight answer to these questions are given in the box below. Regression analysis shows that 4 factors are paramount:
How to use the full range of psychiatric services
Current uk community psychiatric services can be categorized as follows:
Intensivist teams: Crisis and Home Treatment, eg with 24-h phone helpline.
Support and recovery teams—Community mental health teams (cmht); asssertive outreach; rehabilitation.
Drug and Alcohol teams: part of a wide range of substance abuse services.
Inreach mental health services—residential care, acute hospital liaison, primary care liaison teams (pcl)—integrated cpns/Psychiatrists with gp practices/Hospitals with good links into secondary community services.
iapt services (improved access to psychological therapies)—offer a wide range of community-based therapies eg cbt (p373), group therapy, etc.
Typically all these services are multidisciplinary (to a varying degree) with Nurses, ots, Physios, Psychologist, Psychiatrists and Social workers.
Many of these community services are supported by 3rd-sector (voluntary) organizations eg mind, Alzheimer’s society, and other local organizations and charities that provide drop-in centres, group or individual therapy, homecare, advocacy, educational information etc.
How to help patients not to be manipulative
Fireships on the lagoon
Setting limits
One way of avoiding becoming caught up in this web of maladaptive behaviour is to set limits, as soon as this behaviour starts. In a small minority of patients, the therapist may recognize that their needs for time, attention, sedation, and protection are, for all practical purposes, insatiable. Whatever a therapist gives, such patients come back for more and more, and yet in spite of all this ‘input’ they don’t get any better. The next step is to realize that if inappropriate demands are not met, the patient will not become sicker (there may be vociferous complaints!). This realization paves the way for setting limits to behaviour, specifying just what is and is not allowed.
Take for example the patient who demands sedation, threatening to “lose control” if it is not given immediately, stating that he cannot bear living another day without sedation, and that the therapist will be responsible for any damage which ensues. If it is decided that drugs do not have a part to play in treatment, and that the long-term aim is for the patient to learn to be responsible for himself, then it can be simply stated to the patient that medication will not be given, and that he is free to engage in destructive acts, and that if he does so this is his responsibility.
The therapist explains that in demanding instant sedation he usurps her professional role, which is to decide these matters according to her own expert judgment, and that such usurpation will not be tolerated. If there is serious risk of real harm, admission to hospital may be indicated, where further limits may be set. If necessary, he is told that if he insists on ‘going crazy’ he will be put in a seclusion room, to protect others.
Drastic measures: sometimes you have to cut yourself free…discuss with a colleague first, and explain to the patient that continuing contact is not in their best interests as you are unable to make any headway. “Your case needs a fresh pair of eyes…” This may be safer than the kind of confrontations that Henrik Ibsen dangerously engineers: “When I look back on your long career, it’s as if I saw a battlefield strewn at every turn with shattered lives.”The Wild Duck 1884
How to help patients be less lonely
We live, as we dream—alone. Conrad; Heart of Darkness
Do not assume that loneliness means social isolation. Someone who has brief visits 3 times a day, from, say, a nurse, a care assistant, and a ‘meals on wheels lady’ is not socially isolated, but may be very lonely. But if he or she gets on well with just one of these visitors, this can be enough to banish loneliness. So this is the first lesson: be nice to people, and take trouble to find out their hopes and fears. But more is possible: in general, it is depressing waiting for the doorbell to ring, so tailor your suggestions in the light of your patient’s mobility. This needs initiative on your patient’s part, but do not think you must treat your patient’s depression before you tackle a lonely lifestyle: tackling this may be the route out of depression. Areas to think about include:
What facilities already exist? Is there a local pub, day centre, or lunch club available? “God, I wouldn’t be seen dead in one of those places!” we so often hear. But take time to point out that it does not matter initially whether they get anything out of a social interaction. After all, they may meet someone of like mind, so enabling these artificial crutches to be thrown away.
Is the person religious? There may be activities and outings to plan and talk about, and reminisce over, even if not actually enjoyed at the time.
Housing: if the person is planning a move, will they be near family, and other people who speak their own language (metaphorically and literally)?
Alternative therapies, eg massage and aromatherapy, can relieve loneliness.
Adult education is a good (expensive) way to make friends; as new skills are acquired, confidence improves, and socializing becomes more pleasurable.
Involvement with community action groups may be a source of friends (and a source of frustration and disappointment—but do not expect your interventions to be without side effects: the thing is to plan for them).
Details of local community activities can be found in the uk at the local Council for Voluntary Services. Other organizations advertise at libraries.
While at the library, ask about joining a book club.
Befriending schemes can be very helpful to those who are housebound.
Technology forums such as the Internet may provide relief from boredom and loneliness—and for some this will offer the best chance of meeting with a kindred spirit, unlimited by the constraints of time and space.
Befriending others, and offering phone support is an option, whether or not one is housebound. Ask local authorities to help to get suitable phones.
How to recognize and treat your own mental illnesses
Can true spiritual mastery over a power ever be won by someone who is counted among her slaves? If the time comes when our mental state seriously reduces our ability to work, we must be able to recognize this and take appropriate action. The following may indicate that this point is approaching:Drinking alcohol before ward rounds or surgeries.
The minimizing of every contact with patients, so that the doctor does the bare minimum which will suffice.
Inability to concentrate on the matter in hand. Your thoughts are entirely taken up with the workload ahead.
Irritability (defined as disagreeing with >1 nurse/24h).
Inability to take time off without feeling guilty.
Feelings of excessive shame or anger when reviewing past débâcles. To avoid mistakes it would be necessary for us all to give up medicine.
Emotional exhaustion—eg knowing that you should be feeling pleased or cross with yourself or others, but on consulting your heart you draw a blank.
Prospective studies suggest that introversion, masochism, and isolation are important risk factors for doctors’ impairment.
The first step in countering these unfavourable states of mind is to recognize that one is present. The next step is to confide in someone you trust. Give your mind time to rejuvenate itself.
If these steps fail, various psychotherapeutic approaches may be relevant, eg cognitive behavioural therapy (p373), or you might try prescribing the symptom. For example, if you are plagued by recurring thoughts about how poorly you treated a patient, set time aside to deliberately ruminate on the affair, avoiding distractions. This is the first step in gaining control. You initiate the thought, rather than the thought initiating itself. The next step is to interpose some neutral topic, once the ‘bad’ series of thoughts is under way. After repeated practice, the mind automatically flows into the neutral channel once the bad thoughts begin, and the cycle of shame and rumination is broken. In addition…learn from the experience!
If no progress is made, the time has come to consult an expert, such as your general practitioner. Our own confidential self-help group for addiction and other problems is the British Doctors’ and Dentists’ Group and may be contacted via the Medical Council on Alcohol (tel. 020 7487 4445uk). If you are the expert that another doctor has approached, do not be deceived by this honour into thinking that you must treat your new patient in any special way. Special treatment leads to special mistakes, and it is far better for doctor–patients to tread well-worn paths of referral, investigation, and treatment than to try illusory short cuts.
Hands-off! Don’t get too drawn into treating your own mental illness without consulting a colleague.
Definition
Falling performance and personal accomplishments, emotional exhaustion, negative affect, poor leadership, and depersonalization brought on by months or years of overexposure to emotionally demanding situations at work, on the battlefield, or at home.
Measurement
Risk factors
For doctors:
Risk factors for psychiatric nurses:
For medical students:
For military personnel:
Past history of physical trauma is predictive.
Have you felt this way?
Signs of burnout:
Stress and depression
Fatigue
Emotional exhaustion
Motivation⬇; apathy⬆
Libido⬇
Insomnia
Guilt or denial
Paranoia/isolated
Demoralization
Amnesia
Indecision
Temper tantrums
Low personal accomplishment
Depersonalization
Vicarious traumatization
Irritability/impatience
Management
(Difficult) Some may respond to plans such as these:
Diagnose and treat any depression (p336–7).
Allow time for the person to recognize that there is a problem.
More hobbies, and more nice holidays.
Advice from wise colleagues in the specialty (regular follow-up). Mentoring consists in forming a supportive relationship with an independent colleague for the sole purpose of support.
Learn new professional skills—or consider early retirement.
Set achievable goals in work and leisure (eg protected time with family).
Prevention
we are all responsible for each other’s burnout. By being attentive to our own and others’ feelings of troubled conscience we all have a role in preventing the burnout of our colleagues. We need opportunities to reflect on our troubled consciences. Appraisals (p508) and less formal routes to this awareness are becoming more accepted by professionals.Patients in disgrace: the fat-folder syndrome
The sorrow that has no vent in tears may make other organs weep.80Francis J Braceland
Autosuggestion/dissociation (formerly ‘hysteria’)
Our stream of consciousness doesn’t progress from cradle to grave as a single line: there are separations (dissociations) and confluences, for example, when we daydream, or drive to Porlock with no recollection of the scenery along the way, only of our inner landscape. Dissociation may be adaptive, eg by annihilating pain in near-death events (fig 1). Another example: a man who was homosexually raped had no conscious memory of this, but felt irresistible urges to write insulting letters about the perpetrator.
This lady has the knack of dissociating her body and replacing it with the airy nothingness of a summer sky. Roland Penrose, the artist, intuited this adaptive response to extreme events in her past: he did not know when he painted this that at aged 7 that Lee Miller, whose portrait this is, was raped, and had suffered traumatic douches to deal with the ensuing gonorrhoea. Nor could he have known that in 1945 she would be the first photographer to document the overflowing ovens of Nazi concentration camps, no doubt using her dissociative skills to keep her camera steady. How did she end up as the leading fashion photographer of her day? The nested funnels at the foot of the picture suggest an answer: the mind has an infinite capacity to distil one experience through another, and to channel experiences in new, creative ways.
Types of dissociation
Amnesia is the commonest type: see box. Depersonalization: Feeling of being detached from one’s body or ideas, as if one were an outsider, observing the self; “I’m in a dream” or “I’m an automaton” (unrelated to drugs/alcohol) eg from stress.
Dissociative identity disorder: The patient has multiple personalities which interact in complex ways. It is present in 3% of acute psychiatric inpatients.
Fugue: Inability to recall one’s past ± loss of identity or formation of a new identity, associated with unexpected, purposeful travel (lasts hours to months, and for which there is no me).
Follow-up
(~6yrs) shows that ~5% of those referred to a cns hospital who had hysteria/dissociation diagnosed turned out to have organic illness.
Treatment
Exploring life stresses may help. Be ready to recognize psychological components of physical illness, and get expert psychiatric help, while leaving the door open for new diagnoses.
Has a physical cause been carefully discounted? (Drugs, epilepsy, etc.)
Is the patient young? Beware making the first diagnosis if >40yrs old.
Have the symptoms been provoked by stress? Ask the family.
Do related symptoms ‘make sense’ (eg aphonia in a news-reader)?
What is the pattern of amnesia? If for distant and near memories, then dissociation is more likely (vs organic causes) than if the amnesia is for shorter-term memory.
Indifference to major handicap, la belle indifférence, is of little diagnostic use, see fig 1.
Is malingering likely? The answer is usually ‘No’, except in prisons and the military (when secondary gain is easy to identify).
Why do some doctors preferentially diagnose somatic illness? Why, when confronted by unexplained symptoms, do we often subconsciously try to fit them to a physical ailment? The reason is usually that prescribing a pill is easier than changing, or regulating, intrapsychic events. The patient and the doctor may collude with this approach, and then get angry when it yields nothing. Alternatively, some doctors are so used to diagnosing psychopathology that they are all too prone to launch into treating someone’s depression and malaise, rather than their endocarditis or brucellosis. There is no single correct approach. We all make errors: the point is to find out in which direction you tend to make errors, then allow for this in your work.
Depression
Each year 40% of us have quite severe feelings of depression, unhappiness, and disappointment. Of these, 20% experience a clinical depression, in which low mood occurs with sleep difficulty, change in appetite, hopelessness, pessimism, or thoughts of suicide. Diagnosis of major depression:
Loss of interest or pleasure—anhedonia in daily life with dysphoric mood (ie ‘down in the dumps’) plus ≥4 of the following (the first 5 are ‘biological’ symptoms)—present nearly every day for at least 2 weeks:
Poor appetite with weight loss (or, rarely, increased appetite).
Early waking—with diurnal mood variation (worse in mornings).
Psychomotor retardation (ie a paucity of spontaneous movement, or sluggish thought processes), or psychomotor agitation.
Decrease in sexual drive and other appetites.
Evidence of (or complaints of) reduced ability to concentrate.
Ideas of worthlessness, inappropriate guilt or self-reproach.
Recurrent thoughts of death and suicide, or suicide attempts.
Why is depression often missed?
Ignorance
Preoccupation with physical disease
Psychiatric labels are hated
Doctors & patients collude “not to open that can of worms”
It’s hard to spot depression coexisting with other illness.
Classification
Classify as:
Mild; moderate; severe.
With/without biological features.
With/without delusions or hallucinations.
With/without manic episodes (ie bipolar not unipolar). These replace the old reactive/endogenous labels. ΔΔ:Cyclothymic disorder; substance-induced mood disorder; schizophrenia, dementia; mood disorder due to a general medical condition.
Why we get depressed: some ideas
Biochemistry: there are excess 5-hydroxytryptamine (5ht2) receptors in the frontal cortex of brains taken from suicide victims. See ohcm p442.
Stressful events (births, job loss, divorce, illness): seen in 60%.
Freudian reasons:
depression mirrors bereavement, but loss is of a valued ‘object’, not a person. There is ambivalence with hostility turned inwards.
Management
There is no clear distinction between the low moods we all get and illness needing vigorous treatment, but the lower the mood and the more marked the slowness, the more vigorous the treatment needs to be.
Psychological treatment (eg cognitive therapy, p373) is part of the treatment of all depression; it may be all that is needed in milder depressions.
Reasons to admit: Social circumstances; high suicide drive; isolation.
(see p340)
Sometimes antidepressants need to be prescribed as a matter of urgency—eg if suicide is likely (see below) or, for example, if a mother’s functioning is so impaired so that she cannot look after her family. If you cannot persuade the patient to start therapy, enlist the help of his or her family, and of a colleague. They may be able to persuade the patient where you have failed.
Those who have had low mood or loss of desire for pleasure (anhedonia) most of the day for at least the last 2 weeks and who show ≥4 of the following 7 markers of severe depression are at especial risk of suicide.
Suicide plan or ideas of self-harm.
Unexplained guilt or worthlessness.
Inability to function (eg psycho-motor retardation or agitation).
Concentration impaired.
Impaired appetite.
Decreased sleep/early waking.
Energy low/unaccountable fatigue
Enquire about these whenever depression is possible.
Has he planned the time?1 Has he planned the method?
treatment may still be needed if these criteria are not met: listen to the story. People often don’t accept that they are depressed as “There is nothing to make me depressed”. It helps to suggest that they could still be depressed, and that treatment could be very helpful. Give them time to go away and think about it, perhaps discussing it with someone they know (get consent). Try “Would your wife (or partner) say you were depressed? Please could you ask and let me know?” Such patients often return enriched by dialogue and reflection, and are successfully treated. This may not be over-medicalizing a patient’s symptoms .There is evidence that such patients are simply inexperienced in understanding their depression: when they next become depressed, their views much more nearly match those of their doctor.
This is undesirable as patients lives are medicalized and drugs with significant side effects are needlessly given—as has been happening in the uk following nice and qof recommendation of use of the phq-9 diagnostic tool.97
In some areas prescriptions for antidepressants have tripled from 1992–3 to 2006–7 without clear benefits.
Depressed mothers: do the needs of her children dictate the speed and risks of therapy? Drs have infinite ways to blackmail women…
Suicide and attempted suicide
Distinguish suicide from non-suicidal self-harm (eg a cry for help—common, but every non-fatal event may be fatal next time,1 hence treating both here; it is most prevalent in teenage girls; >1%/yr). Suicide is commoner in islands and east Europe, and rarer in Islamic peoples. Incidence: 106/yr (~1/1000uk). Risk ⬆ if: bipolar disorder; depression; borderline personality disorder (p366); anorexia; substance abuse; past self-harm; farmers; vets; doctors and all other prisoners; poor problem-solving; recession/unemployment; serious illness; spring sunshine (affects serotonin neurotransmission and impulsivity).Understanding suicide
Suicide
Self-harm may be a way of:
Communicating a message, or gaining power by escalating conflict, often after an argument with a partner. Immaturity, inability to cope with stress, weak religious ties, and availability of drugs (psychotropics and alcohol are popular poisons) are also important, as is ‘copy-cat’ behaviour: when celebrities try suicide, others follow.
Antecedents of suicide:
Assessment3
Think of a target with 3 concentric rings. The inner ring is the circumstances of the attempt: what happened that day; were things normal to start with? When did the feelings and events leading up to the act start? Get descriptions of these in detail. Was there any last act (eg a suicide note)? What happened after the event? Was this what he/she expected?
The middle ring
is the background to the attempt: how things have been over the preceding months. Might the attempt have been made at any time over the last months? What relationships were important over this time?
The outer ring
is the family and personal history (p322).
Now…come to the bulls eye, the intention lying behind the act, and the present feelings and intentions. Does the attempt reflect a wish to die (a grave, not-to-be-ignored sign); a wish to send a message to someone; or to change circumstances? Ask: “If you were to leave hospital today, how would you cope?” Examine the mental state (p324; is there is any mental illness?) Summary:
Any plan? What? When? Where?
Are the means available?
Ever tried before? How seriously?
Preparations (making a will, giving things away).
Before arranging hospital admission, ask what this is for. Is it only to make you feel happier?—or to gain something that cannot be gained outside hospital. Ask: Why will discharge be safer in a few weeks rather than now?
After the assessment, there are 3 stages in trying to help survivors
Agree a contract offering help (p339), by negotiation. Discuss confidentiality, then talk with family as to how problems are to be tackled. Treat depression.
The psychiatrist may become enmeshed in these webs of suicide threats, and may wrongly assume that because someone threatens suicide, they should be admitted to hospital (compulsorily if necessary) so that they can be kept under constant surveillance, and suicide prevented. This reasoning has 3 faults. The first is the idea that it is possible to prevent suicide by admission. There is no such thing as constant surveillance. Second, admission may achieve nothing if it removes us from the circumstances we need to learn to cope with. Third, we must distinguish between suicide gestures, which have the object of influencing others’ behaviour, and a genuine wish to die.3
Before death, many suicide victims see a gp, and it is wise to be alert to undercurrents of suicide which only sometimes surface during consultations. Ask unambiguously about suicide plans (p322). On deciding that a threat is more manipulative than genuine, very experienced therapists may influence the person’s use of suicide behaviour by forcing him to face the reality of his suicide talk, eg by asking: “When will you kill yourself?” “How will you do it?” “Who will discover the corpse?” “What sort of funeral do you want? Cremation, burial, with or without flowers?” “Who will come?”
See opposite for risk factors for suicide; they may be of no help in individual cases, so aim to think dynamically of risks and protective factors (eg family support), with suicide occurring after key events that accumulate risk.
Take all suicide threats seriously—but emphasis differs depending into which group the patient falls. Aim to form a contract with the patient, eg:
The therapist will listen and help if the patient agrees to be frank, and to tell the therapist of any suicide thoughts or plans.
Agreement about which problems are to be tackled is made explicit.
Agree the type of change to aim for and who will be involved in treatment (eg family, friends, gp). Agree the timing and place of sessions.
An agreement to collaborate with the therapist, and to do any homework.
Cutting can relieve stress; in helping people reduce the need to self-harm they may find addressing these questions helpful:
Have I got a solid support system I can call on if I feel like cutting?
Have I got 2–3 people I feel comfortable to talk to about cutting with?
Have I got a list of things I can do as an alternative to cutting?
Have I got a place to go if I need to leave home so as not to hurt myself?
Can I get rid of everything I might use to harm myself, without panicking?
Am I prepared to feel scared, frustrated while cutting down my cutting?
Which antidepressant? Sample regimens
nice
Past history of good response to tricyclics, now suicidal: Try lofepramine, 70mg/12h (less likely to be fatal in overdose; less risk of fatal arrhythmias).
Depression if elderly: ?Avoid ssri; halve dose of tricyclic (ses may be worse).
Depression in those insisting on driving: Paroxetine (20mg each morning, increased by 10mg increments; max: 50mg/24h) is safer than tricyclics. It is the ssri most associated with the unpleasant dystonias on withdrawal.
Depression + disordered sleep pattern: Tricyclic, eg dosulepin, as above. If suicidal mirtazapine (blocks 5ht2, h1, and 5ht3—15mg at bedtime, max 45mg) may have a role. Warn not to rely on the ‘fact’ that daytime sleepiness usually wears off after a few weeks. nb: ordinary ssris can aggravate insomnia. Sleep is such a restorative for some patients, so give them the best chance.
Pregnancy/breastfeeding: Tricyclics may be best; p408; get expert help.
Depression with obsessive–compulsive features: Clomipramine or an ssri.
Depression with Parkinson’s disease: ssri (nortriptyline 2nd choice).
Depression at menopause: hrt may help but ⬆ breast cancer risk, p256.
Depression+sexual dysfunction: Mirtazapine or bupropion.
Worried about drug interactions: Citalopram and sertraline have lowest risk. Most ssris inhibit cyp450 enzymes so can ⬆levels of many drugs.
Side effects—
ssri:
Citalopram & sertraline:
Tricyclics:
Amitriptyline—common se: sedation, dry mouth, urine retention, blurred vision, postural hypotension, tachycardia, constipation. Other se: arrhythmias; convulsions (dose-related). Clomipramine, dosulepin, doxepin as for amitriptyline. Imipramine and lofepramine less sedating than amitriptyline. Trimipramine more sedating than amitriptyline.
) may be the least bad option. Before prescribing: get informed consent from the teenager and the parent/carer. Ensure meticulous follow-up, and ensure that it really is a major depression you are treating, using detailed questionnaires to aid diagnosis.We can feel perplexed with antidepressants; it can feel like trial and error when prescribing them. What works well in one person may not help another. There seems to be an ever increasing choice of drugs and conflicting information on safety. In this context, the following may be helpful:
Advice to give a patient when treating depression
Discuss side effects, not all side effects are undesirable (ssris may help premature ejaculation). Warn that there may be an initial worsening of symptoms in the first weeks so persevere before therapeutic effects are seen.
Theories of antidepressant action
8 pharmacological actions are known, and over 20 antidepressants exist. How do all they lead to a similar response? Why is there a delay? 2 theories: The
neurotransmitter receptor hypothesis:
Postulates that a change in receptor sensitivity by desensitization and down-regulation of different receptors (not just ⬆neurotransmitter at the synapse) leads to clinical effects after a few weeks. The
monoamine hypothesis of antidepressants on gene expression:
), tai chi (p753), Yoga, social interaction, psychotherapy (p370), counselling (p380), reading clubs, meditation, poetry (reading/writing). Join a club, eg Ramblers. Rest from work. People may not want drugs, equating them with moral failure? If still unconvinced, an alternative therapy, eg St John’s wort, may be acceptable?Electroconvulsive therapy (ect)
Mechanism
Indications
nice recommends ect is used only to gain rapid (if short-term) improvement of severe symptoms after an adequate trial of other treatments has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
Severe depression
Contraindications
Recent subdural/subarachnoid bleed; no consent (p402; involve relatives, but they cannot consent for an adult). Cautions Recent stroke mi, arrhythmia, cns vascular anomalies.
se:
Technique
Check the patient’s identity and that ‘nil by mouth’ for >8h.
Ensure a detailed medical history and physical examination has been done, and any illnesses investigated and treated as far as possible. High anaesthetic risk?—See p614; seizure threshold ⬆ if on concurrent benzodiazepines or anticonvulsants; also ⬆risk of heart complications if on tricyclics. Liaise between psychiatric and anaesthetic staff. Do benefits outweigh risks?
ect is frightening; give calm reassurance away from the site where ect is going on. (Patients should not witness other patients having ect.1)
Ensure that fully equipped resuscitation trolleys are present including a functioning defibrillator, suction apparatus, and pulse oximeter.
Ensure anaesthetist (senior & ect trained) knows of allergies ± drugs interfering with ga. For countering ect-induced vagal stimulation, she may use atropine before using an ultra-short-acting anaesthetic agent with muscle relaxation (eg suxamethonium) to minimize the seizure’s muscular component.
The ect machine: checked recently? Reserve machine to hand? What charge/energy is to be given? Which waveform will be used (bidirectional or modified sinusoidal, or unidirectional)? See manufacturer’s information.
Put jelly on the electrode sites (not enough to allow shorting). See fig 1.
When the anaesthetist gives the word, give the shock. Be prepared to restrain the patient if paralysis is incomplete. While the current passes, the muscles will contract. This will cease as the current ceases. After ~10sec, further clonic spasms occur, lasting ~1min. The only sign may be lid fluttering. Clonus is probably needed for ect to be fully effective.
Then coma position and bp/pulse, etc until conscious. Ask the anaesthetist to try iv midazolam for those (few) who get very agitated during recovery.
Electrode position: a–b =10cm; a is 4cm from the green dotted line.
There is no universal answer, but there is evidence that therapeutic effects of ect are proportional to seizure length. Be sure that you have adequate training on this issue by the consultant in charge of the session. Dose is better measured in millicoulombs (mC) than milliamps. It depends on seizure threshold, which varies 40-fold among patients. A moderately ‘suprathreshold’ dose (eg 200% above seizure threshold) usually gives seizures of adequate duration, while aiming to minimize cognitive side effects—according to the Royal College of Psychiatrists ect Handbook.
What’s it like to have ect?
“It’s frightening, it’s quick, and it works—and I might give it a go.” (jml)
Anxiety neurosis/generalized anxiety disorder gad
Anxiety is a universal experience (♀:♂ ≈2:1); it is, according to some reckonings, the chief factor limiting human potential; it causes much suffering, costing the uk ≳£5 billion/yr. Neurosis refers to maladaptive psychological symptoms not due to organic causes or psychosis, and usually precipitated by stress. Apart from free-floating anxiety and depression, such symptoms are: fatigue (27%), insomnia (25%), irritability (22%), worry (20%), obsessions, compulsions, and somatization (p640)—all more intense than the stress precipitating them would warrant. Symptoms are not just part of a patient’s normal personality, but they may be an exaggeration of personality: a generally anxious person may become even more so, ie develop an anxiety neurosis, as a result of job loss. The type of neurosis is defined by the chief symptom (eg anxiety, obsessional, depressive). Before diagnosing neurosis, consider carefully if there is underlying depression needing antidepressants.Generalized anxiety disorder (gad): anxiety +3 somatic symptoms and present for ≥6 months
Panic disorder
Phobia, eg agoraphobia
Post-traumatic stress disorder
Social anxiety disorder
Obsessive–compulsive disorder
Tension, agitation; feelings of impending doom, trembling; a sense of collapse; insomnia; poor concentration; ‘goose flesh’; ‘butterflies in the stomach’; hyperventilation (so tinnitus, tetany, tingling, chest pains); headaches; sweating; palpitations; poor appetite; nausea; ‘lump in the throat’ unrelated to swallowing (globus hystericus); difficulty in getting to sleep; excessive concern about self and bodily functions; repetitive thoughts and activities (p346). Children’s symptoms: Thumb-sucking; nail-biting; bed-wetting; foodfads.
Causes
Genetic predisposition; stress (work, noise, hostile home), events (losing or gaining a spouse or job; moving house). Others: Faulty learning or secondary gain (a husband ‘forced’ to stay at home with agoraphobic wife).
Treatment
Symptom control:
Listening is a good way to ⬇anxiety. Explain that headaches are not from a tumour, and that palpitations are harmless. Anything done to enrich patients’ relationship with others may well help.
Regular (non-obsessive!) exercise:
Meditation:
Cognitive–behavioural therapy
Behavioural therapy
employs graded exposure to anxiety-provoking stimuli.
Drugs
augment psychotherapy:
Progressive relaxation training:
Hypnosis
Prognosis
Anxiety is the engine in us, and also our steering wheel, weaving us in and out of the fast or slow lanes of our lives. Some of us seek out anxiety as a way of feeling alive (the tightrope walker, or the falconer, placing the meat for his bird between his own eyes). The lives of others are dominated by the imperative of minimizing anxiety, to the extent that some of us never leave home, either physically or metaphorically. Anxiety implies heightened awareness, which is why it is one of the dominant colours in the artist’s metaphysical palette. The artist makes us anxious so that we see familiar objects differently. Anxiety, up to a point, makes us sit up, and take note; beyond a certain level (different in all of us, and different at different times) anxiety is counter-productive: we become preoccupied with the feeling itself, which chokes our ability to act (angere =to choke gives us anxiety and angina).
Bagpipes
Seneca (ad65)1
Surfing
Sea-bathing
Self-hypnosis
Exercise
Pretending to be a tree
Playing with dolphins
Other neurotic disorders
Phobic disorders
involve anxiety in specific situations only, and leading to their avoidance. These are labelled according to specific circumstance: agoraphobia (agora, Greek for market place) is fear of crowds, travel, or situations away from home; social phobias (where we might be minutely observed, eg small dinner parties); simple phobias, eg to dentists, intercourse, Friday the 13th (triskaidecophobia), spiders (arachnophobia, p372), beetles (paint them red with black spots on and they are charming ladybirds). There may also be free-floating ‘fear of fear’, or fear of disgracing oneself by uncontrollable screaming.
Obsessive–compulsive disorder (ocd)
Compulsions are senseless, repeated rituals. Obsessions are stereotyped, purposeless words, ideas, or phrases that come into the mind. They are perceived by the patient as nonsensical (unlike delusional beliefs), and, although out of character, as originating from themselves (unlike hallucinations or thought insertion). They are often resisted by the patient, but if longstanding, the patient may have given up resisting them. An example of non-verbal compulsive behaviour is the rambler who can never do a long walk because every few paces he wonders if he has really locked the car, and has to return repeatedly to ensure that this has, in fact, been done. Cleaning (eg hand-washing), counting, and dressing rituals are other examples.
Pathophysiology:
Treatment:
What’s it like to have ocd? Quotations from the blogsphere:
Depersonalization
Derealization
These are psychosensory feelings (akin to depersonalization) of detachment or estrangement from our surroundings. Objects appear altered: buildings may metamorphose in size and colour. The patient acknowledges the unreality of these ideas, but is made uneasy by them.
Dissociation
:
Behaviour therapy (p372 ± antidepressants) if he really wants to change.
Near-death; war; rape; earthquake; torture; crimes of passion; shipwreck
Relieving stress
Acute stress reactions
Fearful; horrified; dazed
Helpless; numb, detached
Emotional responsiveness⬇
Intrusive thoughts
Derealization (p346)
Depersonalization
Dissociative amnesia
Reliving of events
Hypervigilance
Concentration⬇
Restlessness
Autonomic arousal: pulse⬆; bp⬆; sweating⬆
Headaches; abdo pains
Post-traumatic stress disorder
Treatment:
as demonstrated by the many soldiers who have benefitted from Jonathan Shay’s book Achilles in Vietnam. In narrative exposure therapy, adults or children are asked to describe what happened in great detail (what they saw, heard, smelled, felt, the movements they recall and how they felt and thought at the time). Initial distress is marked, but as sessions are long, habituation ensues as more and more details are recalled. Emphasize integrating emotional and sensory memory within a detailed autobiographic narrative. After 4 sessions, scores on intrusion and avoidance may drop markedly; but don’t expect despression to resolve. Eye movement desensitization and reprocessing (emdr) may also have a role.Prevention:
Rehearse teamwork—and techniques of stress inoculation (by exposure), and desensitization (by helping real casualties, eg if preparing for war). Keeping combatants in tight-knit groups cemented by the ties of mutual interdependency is recommended by military strategists. nb: morphine use at the time of injury may be protective. www.killology.com
Eating disorders: anorexia and bulimia nervosa
Eating disorders are common—don’t expect your patient to fit neatly into any category: ‘Eating disorder not otherwise specified’ is the commonest type; categories such as purging disorder and non-fat-phobic anorexia nervosa are newly proposed categories that may be appropriate to use.
Anorexia nervosa
The most fatal of all mental illnesses (~20%, if severe). There is a compulsive need is to control eating, as if worth equates with shape (a notorious western cult). Low self-worth is common and weight loss becomes an over-valued idea even when weight is very low. This is achieved by over-exercising, induced vomiting, laxative abuse, diuretics, or appetite suppressants. Many also have episodes of binge eating, followed by remorse, vomiting, and concealment.
Diagnostic criteria:196
Weight <85% of predicted (taking into account height, sex, and ethnicity, p181), or bmi ≤17.5kg/m2.
Fear of weight gain, even when underweight, leading to dieting, induced vomiting, or excessive exercise.
Feeling fat when thin.
Amenorrhoea: 6 consecutive menstrual cycles absent unless on the Pill (in women), or ⬇libido♂.
Epidemiology:
Prevalence:
0.7% in teenage girls and no restriction to a particular ethnic group.
Incidence in primary care:
Cause:
crf hypothesis;1 55% concordance in monozygotic twins in some areas.
Comorbidity/risk factors:
Other signs:
Fatigue; cognition⬇ (cerebral atrophy) altered sleep cycle; sensitivity to cold; dizziness; psychosexual problems; dental caries; constipation; fullness after eating; subfertility/amenorrhoea; ⬇wcc; anaemia; ⬇platelets; glucose⬆⬇; ⬇K+; ⬇; ⬆bicarbonate; ⬆lft; ⬆amylase if binging/purging; ⬆T3/T4; normal or ⬇tsh; ⬇lh; ⬇oestrogen; ⬆gh; ⬆cortisol; ⬆cck; normal prolactin; ⬇renal function; osteoporosis if malnourished; bp⬇; ⬆qt interval; amorphous ovaries. In early onset disease, functional mri shows ⬇blood flow to the temporal lobe unilaterally. Also: ⬇visuo-spatial ability; ⬇visual memory; ⬆speed of information processing.
scoff questionnaire:
ΔΔ:
Depression, Crohn’s/coeliac disease, hypothalamic tumours.
Red flags––risk⬆⬆ if:
bmi <13 or below 2nd centile Wt loss >1kg/wk T°: <34.5° Vascular: bp <80/50; pulse <40; Sa O2 <92%; limbs blue and cold Muscles: unable to get up without using arms for leverage. Skin: purpura Blood (mmol/L): K+ <2.5; Na+ <130; ⬇ <0.5. ecg: long qt; flat t waves.
Treatment:2
Monitor q–t interval. There is wide variability in the availability of psychological therapies and no uniform approach. Cognitive therapies (p372), analytic, interpersonal, supportive, or family therapy (±parent-to-parent consultations3) may be tried. In children and adolescents consider family therapy. Olanzapine may help (unlicensed use).Re-feeding syndrome:
Prognosis:
Binge eating disorder/bulimia
Definition:
Epidemiology:
Cause/associations:
Urbanization (not a risk factor for anorexia); premorbid obesity. Commoner in ♀ relatives of anorectics, suggesting a shared familial liability. Genetic contribution of 54–83%.
Natural history:
Age of onset: ~18yrs.
Symptoms:
Fatigue, lethargy,4 feeling bloated, constipation, abdominal pain, oesophagitis, gastric dilatation with risk of gastric rupture, heart conduction abnormalities, cardiomyopathy (if laxative use), tetany, occasional swelling of hands and feet, irregular menstruation, erosion of dental enamel, enlarged parotid glands, calluses on the back of the hands (Russell’s sign, from tooth marks during induction of vomiting), oedema (use of laxatives and diuretics), metabolic alkalosis, hypochloraemia, hypokalaemia, metabolic acidosis (if laxative use), less commonly hyponatraemia, hypocalcaemia, hypophosphataemia, hypomagnesaemia, abnormal eeg, abnormal menstrual cycle, blunted response of tsh and growth hormone to thyroid releasing hormone.
Treatment:
Prognosis:
Organic reactions (delirium; dementia)
Acute organic reactions
(Acute confusion, delirium) The key feature is impaired consciousness with onset over hours or days. It is difficult to describe; take any opportunity to be shown it. You have the sense when trying to communicate that your patient is not with you. He is likely to be disoriented in time (doesn’t know day or year) and, with greater impairment, in place. Sometimes he is quiet or drowsy; sometimes agitated, and you are called when he is disrupting the ward. Or he may be deluded (for example, accusing staff of plotting against him/her) or hallucinating. If there is no past psychiatric history, and in the setting of a physical illness or post-surgery, a confusional state is particularly likely—especially if symptoms are worse at the end of the day.
Differential diagnosis:
If agitated, consider anxiety (usually readily distinguished on history-taking). If onset uncertain, consider dementia.
Causes:
Tests:
u&e, fbc, blood gases, glucose, cultures (blood, msu), lft, ecg, ct, cxr±lp.
Management:
Find the cause. Optimize surroundings and nursing care. Examine with above causes in mind; do tests; start relevant treatment, eg O2.
Nurse ideally in a moderately lit quiet room with same staff in attendance. Reassure and re-orientate often. A compromise between a quiet room and a place where staff can keep under surveillance has to be made. Monitor bp.
Chronic organic reactions (dementia)
6% of those ≳65yrs.
Cardinal signs:
Global intellectual deterioration without impairment of consciousness—plus memory loss. Get a history from friends/relatives. Exclude depression (may need a drug trial). Behaviour: restless; no initiative; repetitive, purposeless activity; sexual disinhibition; social gaffes; shoplifting; rigid routines.
Speech: syntax errors; dysphasia; mutism.
Thinking: slow, muddled; delusions. Poor memory. No insight.
Perception: illusions, hallucinations (often visual).
Mood: irritable, depressed; affect blunt; emotional incontinence (much crying).
Tests:
fbc; b12; folate (mcv⬆ suggests alcoholism, or low b12 or folate); esr (malignancy); u&e, lft, ɣgt, Ca2+ (renal/hepatic failure, alcoholism, malignancy, endocrinopathy (Ca2+ ⬆ or ⬇). tsh (hypothyroidism).
Serology: syphilis (ohcm p419)±hiv.
Management:
Involve the patient in her own therapy. Exclude the treatable. Relatives may feel unable to look after the immobile, incontinent, aggressive, patient who keeps wandering. Good palliative care, walking frames, catheters, day care, holiday admission, an attendance allowance, electronic tagging2 ± an lasting power of attorney can help. If not, long-stay institutional care may be needed. Agitation: mmm before drugs, as above.Protective agents (possibly):
| Causes of organic reactions | ||
|---|---|---|
| Acute (delirium) | Chronic (dementia) | |
Degenerative | ⋆Alzheimer’s; Huntington’s (ohcm p694); ⋆Lewy-body (ohcm p478), cjd & Pick’s (p650) | |
Other cns | Cerebral tumour or abscess; sub-dural haematoma; epilepsy; acute post-trauma psychosis | Tumours; subdural haematoma; multiple sclerosis; Parkinson’s; normal pressure hydrocephalus |
Infective⋆ | Many, eg meningoencephalitis; septicaemia; cerebral malaria; trypanosomiasis | Late syphilis; chronic or sub-acute encephalitis; cns cysticer-cosis; cryptococcosis; hiv |
Vascular | Stroke (or tia); hypertensive encephalopathy; sle | Thromboembolic multi-infarct (arteriosclerotic) dementia |
Metabolic | ⋆u&e⬆⬇; ⋆hypoxia; ⋆liver and kidney failure; non-metastatic cancer; porphyria; ⋆alcohol withdrawal | Liver and kidney failure non-metastatic or metastatic cancer |
Endocrine | Addisonian or hyperthyroid crisis; diabetic pre-coma; hypoglycaemia; hypo/hyperparathyroidism | |
Toxic | ⋆Alcohol; many drugs (check data-sheet/statement of product characteristics); lead; arsenic; mercury | ⋆‘Alcohol dementia’; barbiturate abuse; too much manganese or carbon disulfide |
Deficiency | Thiamine; b12; folate; nicotinic acid | Thiamine; b12; folate; nicotinic acid |
| Causes of organic reactions | ||
|---|---|---|
| Acute (delirium) | Chronic (dementia) | |
Degenerative | ⋆Alzheimer’s; Huntington’s (ohcm p694); ⋆Lewy-body (ohcm p478), cjd & Pick’s (p650) | |
Other cns | Cerebral tumour or abscess; sub-dural haematoma; epilepsy; acute post-trauma psychosis | Tumours; subdural haematoma; multiple sclerosis; Parkinson’s; normal pressure hydrocephalus |
Infective⋆ | Many, eg meningoencephalitis; septicaemia; cerebral malaria; trypanosomiasis | Late syphilis; chronic or sub-acute encephalitis; cns cysticer-cosis; cryptococcosis; hiv |
Vascular | Stroke (or tia); hypertensive encephalopathy; sle | Thromboembolic multi-infarct (arteriosclerotic) dementia |
Metabolic | ⋆u&e⬆⬇; ⋆hypoxia; ⋆liver and kidney failure; non-metastatic cancer; porphyria; ⋆alcohol withdrawal | Liver and kidney failure non-metastatic or metastatic cancer |
Endocrine | Addisonian or hyperthyroid crisis; diabetic pre-coma; hypoglycaemia; hypo/hyperparathyroidism | |
Toxic | ⋆Alcohol; many drugs (check data-sheet/statement of product characteristics); lead; arsenic; mercury | ⋆‘Alcohol dementia’; barbiturate abuse; too much manganese or carbon disulfide |
Deficiency | Thiamine; b12; folate; nicotinic acid | Thiamine; b12; folate; nicotinic acid |
denotes a leading cause.
Example of advice addressed to relatives/carers of demented people
Alzheimer’s disease is progressive, but some problems, eg aggression, may improve in time. Both rate of change and length of life vary greatly. Should you try to explain to your relative what the diagnosis is? There is no easy answer. The advantage of frank talking is that he can participate in his care (the vexed issue of stopping driving may be easier to handle). Also, in the early stages, he can consent to plans. Most would want to be informed if they got Alzheimer’s.
Take opportunities to talk of your predicament with other people in the same position. This is often just as useful as talking to doctors. The Alzheimer’s Disease Society exists to put you in touch: uk tel: 020 7306 0606.
Accept offers of help, eg with carer programmes, and of daycare and respite care:1 you certainly deserve, and need, a break from time to time.
Help for carers:uk
Carers Allowance (>£58/wk2)
Attendance Allowance
Council tax rebate from Social Services
Local voluntary organizations
Annual health checks to look after the emotional/physical lives of carers
Direct payments
Lock up any rooms in the house which you do not use. Your relative will not notice this restriction—and this may make your life much easier.
Lock drawers which contain important papers or easily spoiled items to prevent him storing odd things in them, such as compost, or worse.
Remove locks from the lavatory—so he/she cannot get locked in.
Prepare yourself psychologically for the day when he/she no longer recognizes you. This can be a great blow, unless you prepare for it.
Psychiatric aspects of Alzheimer’s disease (ad) nice2010
A common scenario. “Doctor, I think my memory is failing. I go into a room full of people I know and cannot remember a single name: the only name to come is Alzheimer….” Is this mild cognitive impairment (and relatively static) or is it ad? (progressive). What most doctors do is some sort of memory test, but a better approach is to get a history from a friend/spouse (“Does he ever get lost in familiar territory/at home? trouble with shopping, and counting out cash etc) and then do some visuo-spacial tasks, eg “Draw a house with a door, a side, a chimney and a few windows” or “draw a clock face and put the numbers in and set to time to 2 : 30.” A drawing is useful because it is a permanant snapshot of an unfolding process, and can be compared over time. Clock drawing is also part of systematic diagnostic methods—the tym test (Test Your Memory, ohcm p85). See box 1 for a brief memory test.
Cause
Risk factors
1st-degree relative with ad; Down’s syndrome; homozygosity for the apolipoprotein (Apo) e e4 allele; picalm, cl1 and clu gene mutations; vascular risk factors such as ⬆bp, diabetes, dyslipidaemia, ⬆homocysteine,1 atrial fibrillation; ⬇physical and cognitive activity; depression. Evidence on smoking and alcohol is inconsistent: ≳2u/day of alcohol accelerated onset of ad by 5yrs in one study (others say red wine may be protective); ≳20 cigarettes/day≈2yrs; ApoE e4 genotype≈3yrs. Delaying onset by 5yrs would ⬇prevalence by ~50%.
Presentation
In stage i of ad there is amnesia and spatial disorientation. In stage ii (some years later): personality disintegration, eg with aggression, psychosis, agitation, depression, and focal parietal signs, eg dysphasia, apraxia, agnosia, and acalculia. Parkinsonism may occur. She may use her mouth to examine objects (hyperorality). stage iii Neurovegetative changes with apathy (or ceaselessly active—akathisia), wasting, immobility, and incontinence, ± seizures and spasticity.
Mean survival:
7yrs from clinical (overt) onset.
Drugs
Get expert help to increase cns acetylcholine by inhibiting the enzyme causing its breakdown (donepezil; rivastigmine; galantamine). Memantine, a nmda (n-methyl-d-aspartate) receptor antagonist, may help moderate to severe ad. Cautions: creatinine⬆; epilepsy. se: confusion, headache, hallucinations, tiredness; rarer: vomiting, anxiety, hypertonia, cystitis, ⬆libido. Dose: initially 5mg each morning; ⬆ in steps of 5mg at intervals of 1wk to 10mg/12h.
Practical help
Prevention
Check that he is fully awake and not in pain.
Present year and own age | 2 | Name of your country’s | 1 |
Time to nearest hour | 1 | president, ruler or premier | |
Recognition of people | 1 | Memorize address (42 West St, Hull) | 1 |
Name of place | 1 | Date of world war (i or ii) | 1 |
Birthday (day & month) | 1 | Count backwards from 20 to 1 | 1 |
Present year and own age | 2 | Name of your country’s | 1 |
Time to nearest hour | 1 | president, ruler or premier | |
Recognition of people | 1 | Memorize address (42 West St, Hull) | 1 |
Name of place | 1 | Date of world war (i or ii) | 1 |
Birthday (day & month) | 1 | Count backwards from 20 to 1 | 1 |
Temporal lobe function
Other pointers to dementia
Increasingly, do you find that…
You forget what you are saying or reading in mid-sentence?
You have to rely on lists whereas previously this was not necessary?
Thought is slow or imprecise, harmonizing poorly with motor control?
Mental agility is lacking, with powers of concentration declining?
Is there difficulty executing fast movements of eyes or limbs, or difficulty in walking?—eg with spastic ataxic gait or quadriparesis of hiv–1 associated cognitive/motor complex, or psychomotor retardation, ± release reflexes such as a snout response, or hyperactive deep tendon reflexes.
Bedside tests of frontal lobe function
Verbal fluency and initiation: Ask the patient to recall as many words as possible in 1 minute starting with ‘s’ ; fewer than 10 is abnormal.
Cognitive estimates: Ask to give educated guesses to questions which they are unlikely to know the answer, eg “How old is the oldest person in the country?” “How many camels are there in Holland?”
Abstract thinking: Proverb interpretation (however interpretation highly dependent on educational, cultural factors). Explain the linkage between pairs: eg poem & statue; praise & punishment; orange & banana.
Tests of ‘response inhibition’ and ‘set shifting’—eg a triangle and square test: draw an alternating sequence of triangles and squares—and ask the patient to copy what you are doing. Only the grossly impaired will keep drawing just one of the shapes (perseveration).
Clock drawing test: ‘draw a large clock face, put the numbers in, put the hands in to show ten past five’. Tests frontal (executive) and dominant parietal (praxis) function, and is an adjunct to mental test scores.
“My mother has Alzheimer’s…”
“Each morning she wakes up smiling and walks out not knowing she has soiled herself… She doesn’t know why she is being stripped and washed. It’s like a daily physical and emotional rape. Her cries echo in my ears even when she is not crying. In her lucid moments she says, “Anu, I don’t know what I’m doing. Why is this happening to me?”.
This page is dedicated to Anu & her family.
Mania and bipolar affective disorder
Quote from Zoë’s mother:240
“‘There’s been a fatality on the line…’ Neither of us guessed it was you, even though you’d tried to kill yourself before. We called it a nervous breakdown when Bristol University sent you home for ‘undisciplined behaviour.’ As our memories faded and you seemed set for a brilliant career, no one spoke about this first episode. “I’ve been to the bottom,” you used to say, “I’m strong.” We put the horror behind us. It was over. Then when your charisma and enthusiasms grew wild again, and aggressive, we said “Zoë is just being Zoë”. We were in denial and so were you. We followed your lead. You gave up your job and against everyone’s advice, went to Morocco “to find myself”. I loved the emails you sent in those first weeks, full of enthusiasm about Islamic culture, learning Arabic and meeting the love of your life. Then the emails grew wilder, your projects more farfetched, but we suspected nothing until we arrived to find you in full blown mania: attacking the hotel staff, knocking my glasses off my nose, refusing to eat, hectoring everyone in earshot with grandiloquent schemes to save the universe…Perhaps you were too fine for us? The beat of the drum you danced to didn’t fit with our drab, calculating world; or was it random misfirings, turning your reactions from vivid to florid?” Letter to a Lost Daughter D. Schwarz; Chipmonka Prevalence may be increasing in those <19yrs old (0.25% in 1994; 1% in 2003).Signs of mania
Mood:
Irritability (80%), euphoria (71%), lability (69%).
• Cognition:
Grandiosity (78%); flight of ideas/racing thoughts (71%); distractibility/poor concentration (71%); confusion (25%), many conflicting lines of thought urgently racing in contrary directions; lack of insight.
Behaviour:
Rapid speech (98%), hyperactivity (87%), ⬇sleep (81%), hypersexuality (57%), extravagance (55%).
Psychotic symptoms:
Delusions (48%), hallucinations (15%). Less severe states are termed hypomania. If depression alternates with mania, the term bipolar affective disorder is used (esp. if there is a history of this). During mood swings, risk of suicide is high. Cyclical mood swings without the more florid features (as above) are termed cyclothymia.
Causes
Physical:
Infections, hyperthyroidism; sle; thrombotic thromocytopenic purpura; stroke; water dysregulation/Na+⬇; ect.
Drugs:
Bipolar disorder:
(Age at onset: <25.)
In a 1st attack
Ask about:
Treating acute manianice
Assess:
Psychotic symptoms (p316); cycling speed; suicide risk. 
for acute moderate/severe mania: olanzapine 10mg po, adjust to 5–20mg/day (se: weight⬆; glucose⬆), or valproate semisodium, eg 250mg/8h po (Depakote®; may be ⬆ rapidly to 1–2g/24h). nb: some people are most fulfilled and creative when manic and don’t want to change; others recognize, in retrospect, that use of mental health law (a last resort) was a turning point.
Prophylaxis
consider a tighter range if elderly (⬆sensitivity to Li+ neurotoxicity).Check Li+ levels weekly (~12h post-dose) until the dose has been constant for 4wks; then monthly for 6 months; then 3-monthly, if stable; more often if on diuretic, nsaids, ace-i (all ⬆ Li+) or on a low-salt diet or if pregnant (?avoid Li+).
If Li+ levels are progressively rising, suspect progressive nephrotoxicity.
u&e + tsh 6-monthly; Li+ se: hypothyroidism; nephrogenic diabetes insipidus). Avoid changing brands [Li+⬇⬆]. Ensure you can contact urgently if Li+ >1.4mmol/L. Toxic signs: vision⬇; d&v; K+⬇; ataxia; tremor; dysarthria; coma.
Risk of suicide is high if:
Previous suicide attempt
Family history of suicide
Early onset of bipolar disorder
Extent of depressive symptoms (eg hopelessness)
Increasingly bad affective signs
Mixed affective states
Rapid cycling
But don’t rely on drugs. Often people with mania won’t take them anyway. As one bipolar writer said “I do not believe that a complex problem can be solved simply by popping pills…I thrive in the extremes of my cycles, and the words pour from my mind and hand. All that evaporates in wellness,1 so I imagine it would dissolve completely if I chemically alleviated my malady. I will not dilute my intensity and drain my writing. I feel dead in wellness, so I fear that I would feel just as lifeless if I was ‘cured.’ My identity is also still so blended with this disorder. It is a fundamental part of me and shapes my world. I accept this disorder as a forming force in my life and value how it has made me. It tested me; it made me stronger; it made me different; it gave me my creativity…It is not just a disease to be remedied; it is a real part of me that I need to learn to cope with and adapt to. I need to discover how to control it, rather than allow it to dominate me so that I can live with it as a vital aspect of my life.” Cognitive therapy (p373) is of great value in helping people (who retain some insight) ride their cycles without falling off.Blogs subverts ideas of disease and cure: “I feel dead in wellness”
Note that abrupt cessation of lithium precipitates acute mania in up to 50% of patients. Discontinuation should be gradual over 2–4 weeks.
Antidepressants with lithium
are said by expert committees to be best. Taper from 2 to 6 months after remission to minimize manic relapse.
Schizophrenia: current concepts
Prevalence:0.3–0.66%
Schizophrenia is a common chronic/relapsing condition often presenting in late teens/early 20s with psychotic symptoms (hallucinations, delusions); disorganization symptoms (incongruous mood, abnormal speech and thought); negative symptoms (apathy, self-neglect, blunted mood, ⬇motivation, withdrawal); and, sometimes, cognitive impairment., It has major implications for patients, work and families.Incidence:
~0.15 : 1000/yr.
Prevalence:
~1%.
What’s in a name?
A word on ‘psychosis’:
In its florid form, psychosis is the archetype of the layman’s ‘madness’ But, the usual picture is less obvious: the patient may be sitting alone, quietly attending to his or her voices. If hallucinations, delusions, or a thought disorder (defined on p358) are present, the cause ‘must’ be either schizophrenia and related disorders, a disorder of affect (mania or depression or both, p336), or be organic (eg drug misuse, head injury). So the term psychosis is not in itself a diagnosis, but is a useful term to employ, while the underlying diagnosis is being formulated. Beware labelling people; remember that even during the best of times, only a thin veil separates us from insanity.
Genes & environment
Is schizophrenia a neurodevelopmental disorder?
mri
Social factors:
Auditory hallucinations
Dopamine dysregulation and aberrant salience
Antipsychotics
reduce the underlying dopaminergic drive and this attenuates the abnormal attribution of salience. So people stop hallucinating or they stop thinking their neighbours are persecuting them, but they still believe that last week there really were voices telling them to do things.
How do patients explain what is happening?
Schizophrenia: diagnosis
Schizophrenia entails distorted thinking and perception, eg delusions and hallucinations. These are common, eg in 1) Affective psychoses (depression, bipolar disorder); 2) Substance abuse psychotic disorders (eg alcohol, cannabis); 3) Psychosis due to a medical disorders (eg brain tumour); and 4) Schizophenia-like non-affective disorders (brief psychotic disorder; delusional disorder; schizophreniform disorder). When diagnosing schizophrenia look for:Thought insertion: “He’s is putting ideas into my head” Thought broadcasting: “People overhear my thoughts”. Thought withdrawal: “Thoughts are being taken out of my head”, or repeating of thoughts—écho des pensées.
Hallucinatory voices giving a running commentary on a patient’s behaviour, or discussing the patient among themselves.
Persistent delusions of other kinds that are culturally inappropriate and completely impossible (“Rasputin has put a transmitter in my brain”).
Persistent hallucinations in any modality (somatic, visual, tactile) which occur everyday for weeks on end.
Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech—knight’s move thoughts that change direction, flying off at tangents, with odd logic, or neologisms (made up words).
Catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, echopraxia (involuntary imitation of the movements).
Negative symptoms (apathy, paucity of speech, blunting or incongruity of affect, eg laughing at bad news) usually resulting in social withdrawal.
(1–5 are co-extensive with Schneider’s 1st rank symptoms of schizophrenia.)
Diagnostic guidelines for schizophrenia
The main criterion is at least one very clear symptom (and usually two or more if less clear-cut) belonging to any of the groups 1–4 above, or symptoms from at least two of groups 5–8. Because many people have brief psychosis-like symptoms, do not diagnose schizophrenia unless symptoms last for ≳6 months and symptoms are present much of the time for at least one month, and there is marked impairment in work or home functioning. Also, ‘rule out’ other causes of psychosis (eg bipolar disorder, drugs/alcohol, cns tumours, head injury).
icd-10 distinguishes the following subtypes of schizophrenia: Paranoid (commonest subtype, here hallucinations and/or delusions are prominent). Hebephrenic (age of onset 15–25yrs, poor prognosis, changes in mood prominent with fleeting fragmented delusions and hallucinations). Catatonic (characterized by stupor, excitement, posturing, waxy flexibility, and negativism). In simple and residual types, negative symptoms predominate.
Frequent symptoms
Lack of insight,97% auditory hallucinations,74% ideas of reference,70% paranoia,66% flat affect,66% persecutory delusions.62%
Frequent behaviours
Social withdrawal,74% apathy,56% lack of conversation,54% anhedonia (inability to feel pleasure),50% psychomotor retardation,48% overactivity,41% self-neglect,30% posturing ± odd movements.25%
Better prognosis if:
(after the Maudsley Prescribing Guidelines)
A person can be violent as a result of psychiatric illness, substance misuse, personality disorder, or physical illness. Or it may be the result of adverse ward environments: overcrowding, noise, alienation, and nowhere to go (no blue skies or green fields). This is the danger if sequestration on the ward is the result of withdrawal of privileges for ‘bad behaviour’.
Recognize early warning signs: tachypnoea, clenched fists, shouting, chanting, restlessness, repetitive movements, pacing, gesticulations. Your own intuition may be helpful here. At the first hint of violence, get help. If alone, make sure you are nearer the door than the patient.
Do not be alone with the patient; summon the police if needed.
Try calming and talking with the patient. Do not touch him. Use your body language to reassure (sitting back, open palms, attentive).
Get his or her consent. If he does not consent to treatment, emergency treatment can still be given to save life, or if serious deterioration.
Use minimum force possible. Rapid tranquillization (rt) is the use of medication in controlling behaviour. It should only be used as a last resort when non-pharmacological methods of behaviour control have failed.
De-escalation Time-out Placement, as appropriate.
⬇
Offer oral treatment. If the patient is prescribed a regular antipsychotic, lorazepam 1–2mg or promethazine 25–50mg avoids risks associated with combining antipsychotics. Oral options if not already on regular oral or depot antipsychotic: (olanzapine 10mg, quetiapine 100–200mg, risperidone 1–2mg or haloperidol 5mg). Avoid using more than one antipsychotic to avoid qt prolongation (rapid tranquilization predisposes to arrhythmias).
Repeat after 45–60min. Monotherapy with buccal midazolam 10–20mg may avoid the need for im drugs (unlicensed).
⬇
If 2 doses fail or sooner if the patient is placing themselves or others at significant risk—consider im treatment. Consider the patient’s legal status and consider consulting a senior colleague. Options:
Lorazepam 1–2mg im (dilute with equal volume of water for injections) Have flumazenil to hand ∵ respiratory depression. Be cautious if very young or elderly, and those with pre-existing brain damage or impulse control problems, as disinhibition reactions are more likely.
Promethazine 50mg im is useful in a benzodiazepine-tolerant patient. Promethazine has slow onset, but is often effective. Dilution is not needed before im injection. It may be repeated up to 100mg/day. Wait 1–2h to assess response. It is an extremely weak dopamine antagonist
Olanzapine 10mg im; don’t combine olanzapine with im benzodiazepine.
Aripiprazole 9.75mg; vs olanzapine it’s less hypotensive but ?less effective.
Haloperidol 5mg is last-choice as incidence of acute dystonia is high; ensure im procyclidine is to hand. Repeat after 30–60min if insufficient effect.
⬇
Consider iv treatment if an immediate effect is needed: Diazepam up to 10mg as Diazemuls® over ≥5min. Repeat after 5–10mins if insufficient effect (up to 3 times). Have flumazenil to hand.
⬇
Seek expert advice from consultant or senior clinical pharmacist on call. Options are limited. im amobarbital, paraldehyde & ect have been tried.
⬇
Montor vital signs every 5–10min for 1h, and then half-hourly until ambulatory (if he refuses, observe for signs of pyrexia, hypotension, oversedation and wellbeing. If unconscious, monitor oximetry. A nurse must accompany until ambulatory. Monitor ecg, u & e & fbc if high-dose im antipsychotics used.
The liquid cosh creates perfect institutionalized zombies—or it may be no worse than padded cells or manacles?
Schizophrenia: management
Advice and monitoring
Typical or atypical?
Typical antipsychotics (chlorpromazine, haloperidol 0.5–3mg/8h po) help symptoms in ~¾ of those with acute schizophrenia; they are less good for negative symptoms. Blockade of d2 receptors is the main reason for their antipsychotic effect—and the cause of side effects that often make people stop their tablets. Treating extrapyramidal side effects (epse)
Parkinsonism: ⬇dose, change to atypical, or try procyclidine 2.5mg/8h po; increase if necessary; max 30mg/24h
Acute dystonia can occur within hours of starting antipsychotics.
:
Procyclidine 5–10mg im or iv (may take ½h to work), repeat after 10min, max 30mg/24h
Akathisia—occurs within hours to weeks of starting antipsychotics, restlessness may be very distressing; so use lowest possible dose or change to atypical—treatment may be needed with propranolol ~20mg/ 8h po ± cyproheptadine 4mg/6h po
Tardive dyskinesia (chewing, grimaces, choreoathetosis) may be irreversible; but try tetrabenazine 12.5–50mg/6–24h po.
Symptomatic hyperprolactinaemia:
Galactorrhoea, amenorrhoea, oligomenorrhoea, female/male infertility. Reduce dose or switch to quetiapine. If not tolerated try amantadine 100mg/24h po; max 200–300mg/24h po.
Atypical antipsychotics
Not all trials agree.Which antipsychotic?
; specialist monitoring is needed). Sertindole is only available on a named patient basis due to significant qtc prolongation and fatal arrhythmias. Except for clozapine which definitely causes less epse, there is no clear advantage for any one atypical antipsychotic over another, so side effects are important in tailoring treatment to the individual patient. Most unwanted effects are dose-related, so ‘start low increase slow’. All antipsychotics ⬇seizure threshold (esp. zotepine & clozapine).Special patient groups
Hyperprolactinaemia:
Sexual dysfunction:
Weight gain
Diabetes mellitus:
Cardiovascular effects:
Daytime drowsiness:
~40% of those on clozapine (30% if on olanzapine or risperidone; 15% if on amisulpride, quetiapine, or sertindole).
Managing acute episodes of schizophrenia
If acutely disturbed use the rapid tranquillization protocol (p359)
Approach patients with optimism and empathy
Provide comprehensive information and consult any advance directive
Discuss antipsychotic choice with the patient and start promptly if distressed and symptoms not tolerable, otherwise refer to specialist in the mental health service (mhs).
Dose example:
Quetiapine 25mg/12h on day 1; 50mg/12h on day 2; 100mg/12h on day 3; 150mg/12h on day 4; then adjust according to response (eg 300–450mg daily in 2 doses; max 750mg/24h).
Add-on neuroprotection
Managing risk and psychosocial aspects303
Risk is divided into risk to self, others, and risk of self-neglect. Look at past psychiatric and forensic history. Is there past violence or suicidal or self-harming behaviour? Ask yourself where is the patient to be treated? Do they have insight? Can they be managed at home? (via early intervention/home treatment teams), or do they need to be an in-patient (Mental Health Act). Risk assessments are an important component of the management of a person with mental health problems: p329.
Failure to respond
Psychological interventions
towards the end of acute episodes look at treating residual symptoms, eg difficult thoughts, voices, negative symptoms. Aim for quick recovery and relapse prevention through education ± cbt, p372–4.
Enlist the family’s support
Social support:
It is possible that particular social circumstances may result in alterations in dopamine that make relapse more likely. Addressing issues with housing, employment, support groups, benefits and social skills training are all just as important as being concordant with medication.
Aftercare:
“I don’t want to go on with the tablets…”
Substance and behavioural addictions
(See ohcm p374)
Essence
“Visiting prostitutes is unfulfilling, empty, terrible…but I keep going.”
Epidemiology of drug addiction
Causes
Suspect drug addiction if:
Arrests for larceny, to buy drugs
Odd behaviour, eg visual hallucinations, elation, mania
Unexplained nasal discharge (cocaine sniffing)
The results of injections: marked veins; abscesses; hepatitis; hiv
Repeated requests for analgesics, with only opiates acceptable.
Clinical presentation313
Acute intoxication:
Follows administration of alcohol or other psychoactive substances resulting in disturbances of level of consciousness, cognition, perception, affect, or behaviour.
Harmful use:
A pattern of psychoactive substance use that is causing actual damage to the mental or physical health of the user
Dependence syndrome:
3 or more of the following:
Strong desire or sense of compulsion to take the substance (craving).
Difficulty in controlling substance use (onset, termination, level of use).
A physiological withdrawal state when reducing or ceasing substance use.
Tolerance: increased doses are required to produce the original effect.
Progressive neglect of alternative pleasures or interests.
Persisting use despite clear evidence of harmful consequences.
Opiate detoxification and methadone maintenance
Psychological support:
Tailor to specific needs (residential or outpatient care, in groups or 1-to-1). Counselling, motivational therapy, cognitive therapy (p372), Alcoholics Anonymous, ‘12 steps programme’, family therapy (p386) are all valuable ways to address triggers, motivation to change, and relapse prevention. Counsel about hiv & hepatitis C risk, needle exchange, and safe sex.
Relapse prevention
As strong cravings precede relapse, anti-craving drugs seem to be a promising but unvalidated approach. See acamprosate, p363.
Barbiturate withdrawal may cause seizures±death; withdraw as an inpatient (⅓ of the previous daily dose as phenobarbital; lower the dose over 2wks).
Alcohol-related problems
See p513 for prevention
Alcohol causes as much harm as smoking and hypertension. Abuse implies that repeated drinking harms a person’s work or social life. Addiction implies:
Difficulty or failure of abstinence
Narrowing of drinking repertoire
Increased tolerance to alcohol
Often aware of compulsion to drink
Priority is to maintain alcohol intake
Sweats, nausea, or tremor on withdrawal.
Ask about
Alcohol & organ damage
Liver:
(normal in 50% of alcoholics). Fatty liver: Acute, reversible; hepatitis; 80% progress to cirrhosis (liver failure in 10%) Cirrhosis: 5yr survival 48% if alcohol intake continues (if it stops, 77%).
cns:
Poor memory/cognition; cortical/cerebellar atrophy; retrobulbar neuropathy; fits; falls; accidents; neuropathy; Korsakoff’s/Wernicke’s encephalopathy (ohcm p728; urgent parenteral vitamins are needed).
Gut:
d&v; peptic ulcer; erosions; varices; pancreatitis.
Marrow:
Hb⬇; mcv⬆
Heart:
Arrhythmias; bp⬆; cardiomyopathy; fewer mis (?benefit only if ≳55yrs).
Skeleton:
Sperm:
Malignancy:
gi & breast.
Social:
Alcohol and drug levels
Regular heavy drinking induces hepatic enzymes; binging inhibits enzymes; it’s probably not a good idea to indulge in both and hope for the best. Be alert with phenytoin, warfarin, tolbutamide, etc. nb: paracetamol may cause ⬆n-acetyl-p-benzoquinoneimine (it is hepatotoxic).
Withdrawal signs
(Delirium tremens) Pulse⬆; bp⬇; tremor; fits; visual or tactile hallucinations, eg of insects crawling under the skin (formication). :
Admit; monitor vital signs (beware bp⬇).
Treatment
Non-drug, physician-based brief interventions for problem drinkers:
(Education, counselling, goal-setting + monitoring of ɣgt in those who have social or physical problems from alcohol, but who do not exhibit full dependency.) 50% of trials show that ɣgt falls in the intervention group, but none show clear improvement in alcohol-related morbidity. More costly regimens fare no better.
Homelessness
Intellectual disability and learning disabilities330
Definition
Epidemiology
27 per 1000 (80% have iq 50–70). People with learning difficulties are at ⬆risk for mental illness compared to the general population.
The Patient
Physical: Sensory and motor disabilities, epilepsy, incontinence. Psychiatric: All psychiatric disorders can occur but the presentation is modified by low intelligence. In the diagnosis of psychiatric disorder, emphasis is given to the behavioural manifestation of the disorder.
Causes
Physical causes are found in 55–75% of severely learning disabled individuals. Chromosomal abnormalities: Down’s syndrome, fragile X syndrome p648. Antenatal causes: Infections, alcohol, hypoxia, nutritional growth retardation, hypothyroidism. Perinatal causes: Cerebral palsy. Post-natal causes: Injury, infections, impoverished environment.
Forensic issues
Assessing learning-disabled people
Cause(s) of the learning disability
Associated medical conditions
Intellectual and social skills development
Psychological and social functioning
Dialogue with and support for carers.
Care of people with learning disability
Regular assessment of attainments and disabilities
Arrange special needs teaching at school and training/occupation
Housing and social support to enable self-care
Medical, nursing, and other services, as outpatients, day patients, or inpatients
Psychiatric and psychological services usually from a community-based multidisciplinary team.
Treatment of psychiatric disorders
Side effects of medication may not be apparent as learning-disabled patient may not be able to draw attention to them
Antipsychotics can lower seizure threshold and patients with learning disability are more likely to get seizures
Behavioural therapy is widely used.
To have a professional skilled in dealing with your condition
To receive treatment based on sound evidence
To have treatment in a setting which is decent, humane, and non-abusive
Regimes must promote a fulfilling social life
Active participation in all decisions taken about care.
Ensure full assessment within the context of joint strategic needs assessment by Social Services, gps, and other professionals fully trained in ‘partnership working’.
Include the person in all decisions affecting him or her.
Promote enriching activity to counter idle humdrum impoverished living.
Listen to concerns of both the person and their carer.
Derive personalized care plans via dialogue with the person and carer(s).
Explain what the options are, ideally in terms that he/she understands.
Help him or her decide from a defined list of genuine choices.
Don’t hurry through consultations “to get back to normal people”; spend more time; go slowly. Not being able to give a good history doesn’t mean you can skip this bit: it means you must use other methods to get the information, eg discussions with carers or direct observation.
Don’t be pleased because they are not complaining of anything. No reported symptoms and no complaints about circumstances does not let you off the hook! You may need to insist to carers that a nasty but apparently painless ulcer be treated—or that a fire-escape be unblocked.etc etc
Check for physical illnesses which may otherwise go unreported.
Don’t reach too readily for drugs to curb behaviour. Consider all options.
Be aware of local authority Protection of Vulnerable Adults protocols.
No tokenism! (paying lip service to the above without intending change).
Are all lives of equal value? We are better doctors if we believe so.
Personality disorders and psychopathy
Personality comprises lasting characteristics which make us who we are: easygoing or anxious; optimistic or pessimistic; placid or histrionic; ambitious or stay-at-home; fearless or timid; self-deprecatory or narcissistic1 (self-love, founded on a grandiose belief in one’s unique superiority). Personality can change and develop quite quickly, eg after religious conversion in which a timid man is remoulded into a fearless activist. Personality is a spectrum lying between the above opposites. Statistical analysis reveals that all these distinctions overlap, and are describable in terms of a few orthogonal dimensions (eg neuroticism/psychoticism; introvert/extrovert). Those with abnormal personalities are defined as occupying the extremes of the spectrum. Abnormal personality only matters if it is maladaptive, causing suffering either to its possessor or his associates. In general, psychological symptoms which are part of a personality disorder are harder to treat than those arising from other causes.| dsm-iv classification of personality disorders 341 | ||
|---|---|---|
| Cluster | Description | Disorder |
A | Odd or eccentric behaviour | Paranoid; schizoid; schizotypal (p323) |
B | Dramatic or emotional behaviour | Antisocial (psychopathic); Borderline; histrionic; narcissistic1 |
C | Anxious or avoidant behaviour | Avoidant; dependent; obsessive–compulsive |
| dsm-iv classification of personality disorders 341 | ||
|---|---|---|
| Cluster | Description | Disorder |
A | Odd or eccentric behaviour | Paranoid; schizoid; schizotypal (p323) |
B | Dramatic or emotional behaviour | Antisocial (psychopathic); Borderline; histrionic; narcissistic1 |
C | Anxious or avoidant behaviour | Avoidant; dependent; obsessive–compulsive |
Psychopathy
‘He dislikes showing his feelings, and he’d rather be cruel than put his real feelings into words…he doesn’t care for anyone and perhaps he never will’. So says Dostoevsky; lesser psychologists dwell on reckless, antisocial acts, impulsivity, lack of guilt ± social and legal nonconformity. Dostoevsky’s definition lasts because of its brevity—and that telling word perhaps. Can we change? What must change before psychopaths can love? This perhaps blowing in from 19th-century Russia sends a shiver down our 21st-century spines: perhaps all the psychopaths we lock up might be able to change. What needs to be unlocked? Read Crime and Punishment to find out.
Borderline personality disorder
Other personalities
Drs as psychopaths…
People with dangerous and severe personality disorder (dspd3) and people with other psychopathic features form the bulk of forensic psychiatry. Therapeutic psychiatry is sometimes unfairly criticized for abandoning psychopaths—as if they were too much trouble. This easy criticism does not take into account civil liberties: patients must either want treatment, or they must have a treatable mental illness before they can be detained.
Renewable sentences and protective custody?
Methods of trying to treat dspd include cognitive therapy and anti-libininal drugs (not always amounting to chemical castration).4
nb:
dspd units at Broadmoor and Rampton hospitals have not chalked up successes matching their huge expense.Prof Peter Tyrer; 2010 As a leading dspd psychotherapist says: “The only way that somebody with personality disorder is going to make progress is through their own efforts. They can be helped by professionals, but nobody else can do it for them in terms of arriving at that understanding of their own responsibility for what’s happened.”Tony Maden;2010 tinyurl.com/yeyvyyk
Hyperarousal (frequent sexual rumination/preoccupation, difficulties in controlling sexual arousal, high levels of sexual behaviour).
Intrusive sexual fantasies or urges.
Dangerous paraphilias (sadism; necrophilia). Highly repetitive paraphilic offending such as voyeurism or exhibitionism may also respond to drugs.
In the context of an offender in the community, the offender’s manager must get prior authority to use anti-libidinal medication, and request the offender’s gp to refer the offender to the ‘approved psychiatrist’.
Withdrawal of psychotropic drugs
Withdrawing benzodiazepines
The withdrawal syndrome may well be worse than the condition for which the drug was originally prescribed. So try to avoid benzodiazepine use, eg relaxation techniques for anxiety, or, for insomnia, a dull book, sexual intercourse, and avoiding night-time coffee may facilitate sleep. If not, limit hypnotics to alternate nights.
30% of those on benzodiazepines for 6 months experience withdrawal symptoms if treatment is stopped, and some will do so after only a few weeks of treatment. Symptoms appear sooner with rapidly eliminated benzodiazepines (eg lorazepam vs diazepam or chlordiazepoxide). It is not possible to predict which patients will become dependent, but ‘passive dependent’ or neurotic personality is partly predictive. Symptoms often start with anxiety or psychotic symptoms 1–2 weeks after withdrawal, followed by many months of gradually decreasing symptoms, such as insomnia, hyperactivity, panic, agoraphobia, and depression. Irritability, rage, feelings of unreality and depersonalization (p334, p346) are common; hallucinations less so. Multiple sclerosis may be misdiagnosed as there may be diplopia, paraesthesiae, fasciculation, and ataxia. Gut symptoms include d&v, abdominal pain, and dysphagia. There may also be palpitations, flushing, and hyperventilation symptoms. The problem is not so much how to stop benzodiazepine treatment, but how to avoid being manipulated into prescribing them unnecessarily. This is addressed on p330.
How to withdraw:
Augment the patient’s will to give up (stress disadvantages of continuous ).
Withdrawal is harder for short-acting benzodiazepines, so change to diazepam.
Agree a contract to prescribe a weekly supply, and not to add to this if it is used up early.
Withdraw by ~2mg/week of diazepam. Warn to expect withdrawal symptoms, and not to be alarmed.
Withdrawing antidepressants:
Discontinuation symptoms
maois:
Common:
Agitation, irritability, ataxia, movement disorders, insomnia, cognition⬇, slowed or pressured speech. Occasionally:
Hallucinations, paranoid delusions. The most troublesome maois: tranylcypromine, when metabolized, has amphetamine-like properties so can have true withdrawal syndrome.
Tricyclics:
Common:
’Flu symptoms; insomnia; ⬆dreaming. Rarer:
Movement disorders; mania; arrhythmias. The most troublesome tricyclics: amitriptyline; imipramine.
ssris:
Common:
| Example of cross-tapering based on the Maudsley regimen 355 | ||||
|---|---|---|---|---|
| Week 1 | Week 2 | Week 3 | Week 4 | |
Withdrawing amitriptyline from 150mg/24h | 100mg/24h | 50mg/24h | 25mg/24h | Nil |
Introducing sertraline | 25mg/24h | 50mg/24h | 75mg/24h | 100mg/24h |
| Example of cross-tapering based on the Maudsley regimen 355 | ||||
|---|---|---|---|---|
| Week 1 | Week 2 | Week 3 | Week 4 | |
Withdrawing amitriptyline from 150mg/24h | 100mg/24h | 50mg/24h | 25mg/24h | Nil |
Introducing sertraline | 25mg/24h | 50mg/24h | 75mg/24h | 100mg/24h |
Cautions
When swapping from maois or tranylcypromine to any other antidepressant, withdraw and wait for 2 weeks (the time taken for monoamine oxidase to be replenished); for moclobemide wait 24h. Do not co-administer clomipramine and ssris or venlafaxine. Beware fluoxetine interactions (may still occur for 5 weeks after stopping, due to long half-life).
Introducing the psychotherapies1
As usual, it was dialogue that combed out my muddle.Arthur Miller Timebends 88
Medicine has three great branches: prevention, curing by technical means, and healing—and psychotherapy is the embodiment of healing: a holistic approach in which systematic human dialogue becomes a humanizing enterprise for the relief of suffering and the advancement of self-esteem. Questions such as “What is the meaning of my life” and “what is significant?” are answered in a different way after exposure to a gifted psychotherapist. Changes occur in cognition, feelings, and behaviour. This is why psychotherapy is dangerous and exciting: it changes people. Hence the need for supervision and ongoing training and self-awareness on the part of the therapist.
Psychotherapy stands in stark contrast to the increasingly questioned technical, machine-based realm of medicine, and we accord it great prominence here, in the hope that our explicit descriptions, and their reverberations throughout our books will produce corresponding reverberations in our minds and in our daily work in any branch of medicine, to remind us that we are not machines delivering care according to automated formulae, but humans dealing with other humans. So, taken in this way, psychotherapy is the essence of psychiatry—and the essence of all psychotherapy is communication. The first step in communication is to open a channel. The vital role that listening plays has already been emphasized (p320).
It is not possible to teach the skills required for psychotherapy in a book, any more than it is possible to teach the art of painting in oils from a book. So what follows here (p372–5) is a highly selective tour round the gallery of psychotherapy, in an attempt to show the range of skills needed, and to whet the reader’s appetite. It is not envisaged that the reader will try out the more complicated techniques without appropriate supervision.
The psychotherapies may be classified first in terms of who is involved in the treatment sessions: an individual, a couple, a family, or a whole group; and secondly they may be classified by their content and methods used: analytic, interpersonal, cognitive, behavioural.
Behavioural therapies
(more details: p372) aim to change behaviour, eg if avoiding crowded shops (agoraphobia) is the issue, a behavioural approach focuses on the avoidance-behaviour. Such approaches will define behavioural tasks that the patient is expected to carry out between sessions.
Cognitive therapy
(p374) focuses on thoughts and assumptions, promulgating the idea that we respond to cognitive representations of events, not to raw events alone. If this is so, cognitive change may be required to produce emotional and behavioural change. So in the above example of agoraphobia, the therapist would encourage articulation of thoughts associated with entering crowds. The patient might report that she becomes anxious that she might be about to faint—fearing that everyone will think her a fool. These thoughts would be looked at using a Socratic approach: “Have you in fact ever fainted? How likely would you be to faint? If someone fainted in front of you in a shop, what would you think? Are they foolish?”
Long-term psychoanalytical therapies
(p382) are concerned with the origin and meaning of symptoms. They are based on the view that vulnerability arises from early experiences and unresolved issues, eg from childhood. The therapist adopts a non-dominant stance, encouraging the patient to talk without inhibitions. The therapist encourages change by suggesting interpretations for the content of the patient’s talk.
Which psychotherapy is most successful?
This is tackled on p388.
There are important differences in how people use the term psychotherapy. The first recorded definition states that
Psychotherapy includes every description of therapeutics that cures by…intervention of the psychical functions of the sufferer.F Eeden 1892 Med Mag
This definition is worth bearing in mind because, uniquely, it focuses on the content of the intervention made by the patient, not on the specifics of the therapist’s intervention. The most general modern definition, and the one employed in this section, is summarized thus:
Psychotherapy denotes treatment of mental disorders and behavioural disturbances using…support, suggestion, persuasion, re-education, reassurance, and insight in order to alter maladaptive patterns of coping, and to encourage personality growth.Dorland&s Medical Dictionary
Some commentators draw a distinction between counselling and psychotherapy—but using the above definition (or any definition that recognizes the great heterogeneity of psychotherapy) no valid distinction can be made, unless it is between the various types of psychotherapy. The main issue to bear in mind is that psychotherapy can be more or less specific, and more or less involved in, and driven by, theory.
So is ‘just being nice to patients’ in the course of one’s medical activities an example of psychotherapy at work? The answer is ‘no’—not because being nice is therapeutically neutral, but because one’s attention is not focused on planning change through the systematic use of interpersonal techniques.
The issue of training is very important, and here are some questions that might usefully be addressed to anyone offering psychotherapy:
Is there proof of efficacy? Ask for evidence of long-term results.
What qualifications does the therapist hold? Is he or she supervised?
Is the recommended regimen tailored to the patient’s unique needs?
How will progress be monitored?
Is confidentiality assured?
Is there support and follow-up after the formal programme ends?
Inside the speech-bubble: The therapist is precariously supported by a tripod of confidentiality, training and peer-based supervision. The couch hardly ever exists in practice, but it stands for a place where anything can happen—where we sit side-by-side with our shadow selves and hear the stuff of dreams, nightmares, and realities, uncushioned by workaday self-deceptions. It contains its own labyrinth. ©Miriam Longmore
Behavioural therapy
Behavioural therapy aims to change a person’s behaviour using one of several techniques depending on the condition. When used in conjunction with cognitive therapies (see p374) the term cognitive-behavioural therapy is used (cbt).
Exposure/flooding/implosion
Indication:
Phobias.
Technique:
The anxiety-provoking object or situation is presented in vivo or in imagination (prolonged in vivo in flooding).
Implosion involves imagined exposure to stimuli in a non-graded manner.
The patient then stays with the anxiety-provoking stimuli until there is habituation (ie he becomes accustomed to the anxiety by frequent exposure), and the avoidance response is extinguished.
Relaxation training
Indication:
Mild/moderate anxiety.
Technique:
Link the relaxed state with pleasant, imagined scenes so that relaxation can be induced by recalling the imagined scene.
Systematic desensitization
Indications:
Phobic disorders.
Technique:
Response prevention
Technique:
Involves exposure to an anxiety-provoking stimulus (eg a toilet seat for patients fearing contamination).
The patient is subsequently prevented from carrying out the usual compulsive behaviour or ritual until the urge to do so has passed
Indications:
Obsessions.
Thought stopping
Technique:
The patient is asked to ruminate and then taught to interrupt the obsessional thoughts by arranging a sudden intrusion, eg snapping an elastic band on the wrist.
Indications:
Obsessional thoughts occurring without compulsive rituals.
Undesired sexually deviant thoughts.
Aversion therapy/covert sensitization
Technique:
Aversive therapy involves producing an unpleasant sensation in the patient in association with an aversive or noxious stimulus (eg electric shocks, chemically induced nausea, pain) with the aim of eliminating unwanted behaviour.
Covert sensitization involves the use of aversive stimuli in imagination (eg the approach of a policeman to arrest him/her for his/her undesirable behaviour).
Indications:
Alcohol dependence syndrome (disulfiram used to induce nausea if alcohol is consumed).
Sexual deviations.
Cautions:
Punishment procedures are generally ineffective unless patients are taught more appropriate behaviours.
Social skills training
Technique:
Aims to modify a patient’s social behaviour in order to help overcome difficulties in forming/maintaining relationships.
Video is used to define and rate elements of a patient’s behaviour in standard social encounters
The patient is then taught more appropriate behaviour by a combination of direct instruction, modelling, video-feedback and role play.
Indications:
Patients with social deficits due to a psychiatric disorder.
Token economy
Technique:
Positive reinforcement improves behaviour: tokens are given when desirable behaviour is displayed. These can later be exchanged for goods or privileges.
Indications:
Problems:
Patients become mercenary as they only behave well in exchange for tokens.
It does not prepare people for a world where rewards are subtle and delayed.
Modelling and role play
Technique:
The acquisition of new behaviours by the process of imitation.
Indications:
Lack of social skills and assertiveness.
Behaviour therapy in impulse control disorders (sex, shopping, gambling)
Hypersexuality after brain injury:
Exposure response therapy
is used eg in obsessive-compulsive behaviour (eg obsessive cleaning of some putatively contaminated object). The therapist gradually exposes the client to contaminated objects, preventing the compulsion by reducing anxiety about contamination, eg by breathing techniques.
cbt (cognitive-behaviour therapy)
helps change how we think and hence how we feel. Fig 2 is a vicious circle if thoughts are negative and lead to hostile, negative actions. By defining these relationships, cbt lets us see how thoughts and feelings interact; by changing thoughts, the cycle is broken or turned into a virtuous cycle—eg to prevent relapse after voluntary abstinence vis-à-vis impulse control disorders (eg bulimia). For purely cognitive therapy, see p374.
cbt.
Cognitive therapy
Key concepts
Beck suggests that a person who habitually adopts ways of thinking with depressed or anxious cognitive distortions will be more likely to become depressed or anxious when faced with minor problems. The cognitive distortions in cognitive theory include: Arbitrary inference—conclusions drawn with little or no evidence to support them. Selective abstraction—dwelling on insignificant (negative) detail while ignoring more important features or stimuli. Overgeneralization—drawing global conclusions about worth/ability/performance on the basis of single facts. Magnification/minimization—Gross errors of evaluation with small bad events magnified and large good events minimized. These mechanisms lead to distortions within the cognitive triad of the self, the world and the future.
In cognitive therapy, the patient first learns to identify cognitive distortions from present or recent experiences with the use of daily records/diaries.
The patient records such ideas and then learns to examine the evidence for and against them, ie tests out beliefs in real life.
The patient is encouraged to undertake the pleasurable activities that were given up at the onset of depression or anxiety.
In this way, cognitive restructuring takes place when the patient is able to identify, evaluate and change the distorted thoughts and associated behaviour.
Techniques
Patients are evaluated to get a good history and background information to better understand the nature of the difficulties for which treatment is being sought.
Assessment tools or questionnaires may be used.
Treatment usually takes place on a weekly basis and focuses on current issues.
A treatment plan is formulated with clear goals and objectives and progress is monitored.
The number of sessions varies with the type of difficulties being treated.
Patient’s participate actively in their own therapy.
Indications365
General:
The patient prefers to use psychological interventions, either alone or in addition to medication.
The target problems for cbt (extreme, unhelpful thinking; reduced activity; avoidant or unhelpful behaviours) are present.
No improvement or only partial improvement has occurred on medication.
Side effects prevent a sufficient dose of medication from being taken over an adequate period.
Significant psychosocial problems (eg relationship problems, difficulties at work or unhelpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone.
Specific:
Cautions:
It is difficult to carry out therapy if the patient is feeling severely depressed and has very poor concentration. There is a need to pace sessions so as not to disappoint or overwhelm the patient. Patients may have difficulty talking about their feelings of depression, anxiety, shame or anger.
We respond to cognitive representations of events, not raw data. Mood and thoughts can form a vicious cycle. Using the example of depression: low mood leads to gloomy thoughts and memories (eg dwelling on exams you did badly in, rather than those in which you performed well). These gloomy thoughts make you feel more depressed (mood) and this lowering of mood makes your thoughts even more gloomy. Cognitive therapy tackles this circle by tackling the thoughts. Take, say, the thought: “I’m a failure, and all my friends are avoiding me”. In cognitive therapy the process is to:
Clarify the thought exactly; don’t let it be just a vague negative belief.
Look for evidence for and against the proposition in the thought.
Look for other perspectives.
The therapist encourages the patient to find other explanations by challenging him, eg by examining what “I’m a failure” means. “What are the main areas in your life?” “What do you count as success or failure?” Catastrophizing denotes how we see disasters in small mishaps, eg “he didn’t like my hat…he doesn’t like me…nobody likes me”. There are many kinds of biased thinking that cognitive therapy helps us to recognize: eg black and white thinking, over-generalizing (as when one failure as a symbol of everything).
Is it possible to apply these lessons in primary care? Yes; if full training is offered. Randomized trials of cbt in primary care with less extensive training (4 half-days) and hence with more realistic costs have been disappointing. The lesson is: if the benefits of cbt are to be brought to primary care, what is needed is time: time to learn a new skill, and, above all, time to exercise it.
The nhs has been recruiting cognitive therapists to meet the needs of all those with moderate and severe depression and anxiety who might benefit from it. Cost: £170 million. Projected savings (by getting people back to work) £12 billion/yr. Until access is improved computerized cbt is one option.
Depression Relief® is a self-help, educational internet program for those feeling depressed. jml signed up for the course to bring readers a 1st -hand account. Initial assessment suggested he was significantly depressed as there was nowhere to say that his early-morning waking was not from depression but from eagerness to get on with authoring ohcs pages.etc etc Quite correctly, he was told “You may also wish to consider seeing your doctor or healthcare professional if your symptoms do not improve or become worse. You should definitely do this if you are feeling hopeless and don’t want to go on…”. Sections include: “Taking the 1st step to controlling your depression”; “You can move your mood”; “Actions speak louder than words”; “Focus on the positive”; “Redefine your problems”; “Don’t go blaming yourself”; “Relax away your sorrows”; “Using your imagination”; “Get physical”; “Open up and share your feelings”.
Here are some snippets to get the flavour: “After a week or two of writing down your positive thoughts in your mood log, you will be ready to learn how to use these positive thoughts to change your negative thinking.”
Impression: professional; humorous (not too); surprisingly humanizing.
The computer will see you now&.
Group psychotherapy
Groups are interactive microcosms in which the patient can be confronted by the effect his behaviour and beliefs have on others, and be protected during his first attempts to change.1 This implies that group psychotherapy (as with all psychotherapies) is only practical for those who want to change.
General indications
We know that the most suitable patients are:
Those who enter into the group voluntarily, not as a result of pressure from relatives or therapists;
Those who have a high expectation from the group, and do not view it as inferior to individual therapy;
Those who have adequate verbal and conceptual skills. See also psychodynamic psychotherapy p382.
Specific indications
Technique
Clearly the selection procedure needs to be carried out by an experienced psychotherapist. He will aim for a group of, say, 6–8 members balanced for sex, and avoiding mixing the extremes of age. He will decide if the group is to be ‘closed’, or whether it will accept new patients during its life. He will usually take on a co-therapist of the opposite sex, and he will prepare the patients in detail before the group starts. The life of the group (eg 18 months) will develop through a number of phases (‘forming’→‘norming’→‘storming’). First there is a settling-in period when members seem to be on their best behaviour, seeking to be loved by the therapist, and looking to him for directive counselling (which he rarely provides). Next is the stage of conflict, as the patient strives to find his place in the group other than through dependency on the leader. Frustration, anger, and other negative feelings are helpful by testing the group’s trustworthiness. It is worth learning that expressing negative feelings need not lead to rejection—and this is a vital prelude to the next stage of intimacy, in which the group starts working together.
Typically the therapist steers the group away from outside crises and searches for antecedent causes towards the here and now—eg by asking “Who do you feel closest to in the group?” or “Who in the group is most like you?” “Who would you say is as passive (or aggressive) as you are?” He/she must avoid sacrificing spontaneity, and learn to use what the group gives, eg “You seem very angry that John stormed out just now”. He avoids asking unanswerable questions, especially those beginning “Why?”. He promotes interaction, observation, and learning. Special methods used to augment this process include written summaries of group activities, video, and psychodrama.
Intensive group cognitive therapy
Cautions
Those who are unlikely to benefit include those with severe depression, acute schizophrenia, or extreme schizoid personality (cold, aloof, hypersensitive introverts); hypochondriacs; narcissistic (self-admiring) or paranoid (suspicious and pessimistic about the role of others); sociopathic types (they have low thresholds for frustration and little sense of responsibility)—but sociopathy is difficult to treat by any means, and group therapy may be the least bad option, as other members of the group may provide the only valid mirror that can be held up to these people, and other people may provide the impetus for change. See psychodynamic psychotherapy, p382.
Play therapy
Children don’t say what they really think…They can’t say what they hope in case it’s gone in a flash if anyone truly says no. AS Byatt Babel Tower 144
Through play a child becomes aware of what he or she knows. When that knowledge is disturbing, play can re-form, recast and redeem that knowledge. Parents hold the key cards for influencing a child’s behaviour—love, mutually understood channels of communication, systems of rewards, and knowledge of right and wrong. It is the families without these, which are most likely to need the help of professionals. Never underestimate a child’s capacity for insight: don’t expect children’s methods of communicating insight to mesh with adult’s. Play, rather than talk, may be its medium.The 10 rules:
Take time early on to make friends with the child. Don’t rush.
Accept the child on his own terms—exactly as he or she is.
Avoid questioning, praising, or blaming. Be totally permissive.
Don’t say “Don’t”, and only restrain to prevent serious imminent harm.
Show the child that he or she is free to express any feeling openly.
The responsibility for making choices is always the child’s alone.
Follow wherever the child leads: avoid directing the conversation.
Use whatever he gives you. Reflect his or her feelings back to him.
Encourage the child to move from acting-out his feelings in the real world, to expressing them freely in words and play.
Prepare the parents for change in the child.
Child and therapist play together to give the child a way to verbalize his innermost fantasies. As Virginia Axline explained to one of her 5-year-olds, play therapy is “a time when you can be the way you want to be. A time you can use any way you want to use it. A time when you can be you”.Axline V: Play Therapy Dibs: in Search of Self
Art therapy
The person becomes his or her own therapeutic agent. What higher ideal is there in medicine? It is far ahead of our drug-based models of care, and taps into ancient ideas about health, self-healing, and the proper relationship among humans.Crisis intervention
Occupying the interval between the spilling of our lives and their congealing into history, crisis intervention recognizes that moments of maximum change are times of greatest therapeutic opportunity.1 Debate these questions:
What events have led to these difficulties? Thoughts/actions in the last days.
What is his mental state now (p324)? Depressed? Suicidal? Psychotic?
In the past how has he been able to combat stress and to resolve crises?
What solutions to this crisis have been tried? How have they failed?
Who are the significant people in his life? Can you rely on any of them?
Therapeutic strategy
If he has been very badly affected by the crisis, you may insist on postponing all normal obligations/responsibilities to allow concentrated contact (‘intensive care’) in a therapeutic environment—eg a hospital or crisis unit.
Take practical steps to safeguard patient’s commitments (eg transport of children to foster parents).
Choose the best way of lowering arousal (time spent talking is often preferable to administering anxiolytics, which may only serve to delay the natural process of adaptation). If the patient is shocked, stunned, or mute, take time to establish the normal channels of communication.
As soon as the person is receptive, promote a sense of hope about the outcome of the crisis. If there is no hope (a mother, consumed by grief, after losing all her children in a fire), then this too must be addressed.
The next step is to encourage creative thinking about ways whereby the patient might solve the problems. Start by helping him think through the consequences of all options open to him. Then help compartmentalize his proposed solutions into small, easily executed items of behaviour.
Crisis intervention teams must be responsive, immediate, accessible, and available out of hours—anywhere.
As the immediate crisis passes, and the patient has reasonable psychological functioning, it will be necessary to put him back in charge of his own life. A period of counselling is likely to be appropriate. This is described on p380. Making a contract about therapy is important in encouraging the patient to transfer from the ‘sick role’ to a self-dependent, adult role.
Crisis intervention often focuses on loss of face, loss of identity, or loss of faith—in oneself, in one’s religion, one’s goals, or one’s roots.
All home-care packages for severe mental illness need crisis management plans. Where implemented, this keeps the vulnerable in contact with staff (nnt≈13 over 1yr) and reduces family burden (nnt≈3), and is a more satisfying form of care for patients and families. It is also said to be cheaper. In one trial, availability of a crisis-resolution team reduced admission rates from 59% to 22% at 8 weeks—and was highly cost-effective.Acknowledging and using our own feelings
Are you afraid of uncomfortable questions? Here are some asked by a very experienced psychotherapist.1
Are you a saint? or have you ever…
Felt so bored and irritated by certain patients you want to quit?
Longed for the consultation to end, at any price?
Can you say you have never felt a flicker of sexual interest in a patient?
Have you never imagined the death of certain patients and the relief that would bring, not just to them but to us, their impotent carers?
Have you never resented the demands of people for whom illness seems to have become a way of life?
Whose thoughts have not sometimes drifted off towards their own concerns—to the need for sleep, food, or distraction or to some family, career, or future plans?
We may imagine doing all sorts of things to our patients. The crime is not the thought but the deed. The vital thing is to not to bury these things but to know that they are just that: imaginings. Perhaps we can use them in the service of our work? If the stressed, isolated doctor had been aware of and able to voice his fantasies maybe he would not have end up in custody or in bed with his sexually abused, vulnerable and depressed patient.
The key to good doctoring is not regulation or revalidation, but fostering the ability to put ourselves in our patients’ shoes. And we can use the feeling patients engender in us to understand how the patients nearest and dearest are frustrated, perplexed and deluded. For example, excessive worry about a patient may be the result of being infected by the patient’s anxiety—beyond what is reasonable. This is know as projective identification.
Why does bad or harmful practice continue, despite gmc guidelines? It is because we are motivated by forces of which we are unaware.
Counselling
Good novelists (and counsellors) are somehow large enough to embody the world—so their characters (clients) are not just recreated in their own image. Nothing human is alien to them. Such exercise of the imagination is what enables virgins to counsel prostitutes—which they can, if they are submerged in and are fully aware of human affairs outside themselves.
Indications
Current problems and stresses (eg experiencing acute psychological distress in response to life events or relationship problems).
Brief anxiety disorders, especially when anxiolytic drugs not required.
Technique
Painting the triptych (fig 1)
Listening, understanding, and reflecting
Note how past stress has been coped with
Producing an agreed full list of problems
Redefining problems in terms of attainable goals
Use of therapeutic contracts to negotiate small behaviour changes
Aim for adult relationships between patient, family, and therapist, eg with a contract vis à vis duties, frequency, and duration of therapy, and what is expected of the client (homework), eg learning anxiety-reducing techniques, and carrying out rewards, eg cooking an extra-nice meal with the family if the client achieves an anxiety-provoking task such as shopping
Talking out (not acting out) anger in safe but cathartic ways
Reassurance. The therapist must not only give overt reassurance, but also by his demeanour he must reassure the patient that whatever he reveals (eg incest or baby battering), he will not be condemned.
Nondirective counselling is a triptych of blanks: Where do you want to go? How will you get there? How will you know you have arrived? Just fill in the blanks….
Not all counselling is nondirective: problem-solving models of counselling (box) are sometimes directive, and may be appropriate if you know the client well.
Caution
‘Giving expert advice’: patients may need medical, legal or financial advice. It may be best if this comes from a specialist agency not involved in the counselling
Patients with personality disorder, where the problems are too deep seated to be changed by counselling. Here there must be an awareness of the need to refer such patients for more formal psychotherapy.
Supportive psychotherapy
There are many people who seem to need continuous psychotherapy, as they that find daily activities pose unending stress. The smallest decisions are insurmountable problems, and the patient, lacking even a glimmer of insight, seeks support at every turn. What can we offer here?
Indication
Relevant to all forms of psychiatric disorder.
Technique
Listening to what (s)he is saying, picking up verbal and non-verbal cues. Ensure a reasonably full account of the situation and problems
Reassurance: relieve fears, boost self-confidence and promote hope,
Explain to a patient why they are experiencing certain symptoms
Guidance and suggestion with regard to a particular problem
Expression of feelings eg anger, frustration and despair within a supportive setting.
Caution
Patients can become dependent on the therapist and not be able to cope when therapy comes to an end—see p326 for how to deal with this.
Counselling has long been a central activity in primary care. Don’t think of this as the expert handing down treatment to poor, benighted patients. It’s more of a joint exploration between two humans who know each other reasonably well. On occasion, roles may be reversed—for example, following a medical disaster, a doctor, who may be blameless, may become so relentlessly and excoriatingly self-questioning that despair ensues. In these circumstances, it has been known for counselling and support from the original victim or one of his or her relatives to restore the doctor to health, and avert resignation.
Many uk general practices employ or have access to counsellors. This huge growth reflects the fact that people love to be listened to, and that gps themselves may not have the time or inclination to satisfy this need. It is hard to prove the effectiveness of counselling, especially as skills and training vary markedly. But this does not mean it is ineffective.
In some patients, problem-solving strategies are used, with the counsellor using a non-directive approach.
In fostering coping strategies, the therapist helps the patient to make the most of the position they are in (eg afflicted by a chronic disease).
In cognitive therapy, we concentrate on elucidating negative thinking, and help patients learn how to intervene in negative cycles of thinking.
Therapeutic communities (tcs) are a popular treatment for the rehabilitation of iv drug users and dealing with personality disorders—in both the usa and Europe. The rationale is that the benefits of peer-feedback (group therapy) can be magnified in the microcosm of a therapeutic community. Also these communities provide a safe environment for those with complex needs.
Psychodynamic psychotherapy
Key concepts:
1 The unconscious:
Individual dynamic psychotherapy is based on the premise that a person’s behaviour is influenced by unconscious factors (thoughts, feelings, fantasies). Evidence for the existence of unconscious activity include
2 Psychological defences:
Our immune system protects our physical integrity, and our psychological vulnerabilities are shielded by psychological defences. In both cases, overactive defences can lead to trouble, eg:
Psychotic defences:
Delusional projection/paranoia
Denial
Distortion.
Immature defences:
Neurotic defences:
Mature defences.
3 Transference and countertransference:
Assessing suitability
Psychological understandibility:
The patient’s difficulties must be understandable in psychological terms.
Psychological mindedness:
The capacity to think about problems in psychological terms.
Motivation:
There must be motivation for insight and change.
Intelligence and verbal fluency:
The ability to communicate thoughts and feelings through talking.
Introspectiveness:
The ability to reflect and think about their feelings.
Dreams:
The capacity to remember dreams.
Ego strength:
The ability to tolerate frustrating or distressful feelings without engaging in impulsive behaviour.
Capacity to form relationships:
There should be a history of at least one sustained relationship in the past or current life.
Specific indications
Dissociative/conversion disorders
Depression
Psychosomatic disorders
Personality disorders
Relationship problems
Grief.
Technique
The therapist provides a secure frame—a regular time and place and her own consistency and acceptingness. The patient narrates vignettes about himself and his life (~3/session). The therapist listens carefully, to the stories and to her reactions to them. She then makes linking hypotheses, or interpretations that offer meaning. Previously inexplicable behaviour begins to make sense. Meanwhile, the patient forms a close relationship with the therapist based on empathy, genuineness, and non-possessive warmth (shown experimentally to be key factors) and sometimes challenge. These may be novel experiences for the patient that can be internalized as he works through difficulties safely. Reactions to ending will bring up past unprocessed losses.
The Id is king: Whenever he battles with his conscience—he wins!
What the hell! I’ll do it now and repent tomorrow.
Repeated admissions, many suicide attempts, repeated risk-taking, and severe somatization suggest insufficient ego strength for psychotherapy.
A history of repeated failed ventures or dropping out of relationships.
In general, patients with acute psychosis are less amenable.
Severely depressed patients may be too slowed up and too unresponsive.
Over-sedation may hinder capacity to access feelings (?reduce doses).
Patients who are actively abusing alcohol or illicit drugs are problematic.
No real motivation to change or grossly unreal expectations of therapy.
Joyce: the young mother’s story
Sex therapy for couples
Sexual history
Early experiences; present practices; any hints pointing towards transexualism, commercial sex work, or drug abuse? Orientation to either or both sexes. Difficulties with other partners? When did you meet? What attracted you to each other?
Drugs
Alcohol, hypotensives (erectile dysfunction, ed); ssris (delayed ejaculation); β-blockers, finasteride, the Pill, and phenothiazines (loss of libido).
Other causes of ed:
(ohcm p222): diabetes, cord pathology, prolactin⬆, drugs.
Principles of behavioural therapy for sexual difficulties comprise:
Defining the task which the couple wishes to accomplish.
Reducing the task to a number of small, attainable steps.
Asking the couple to practise each small step in turn.
At the next session, discussing difficulties encountered.
Ameliorating maladaptive attitudes.
Setting the next task.
Example: premature ejaculation and vaginismus:
A ban on attempted sexual intercourse (to remove fear of performance failure). Education and ‘permission’ giving (ie to talk about and engage in ‘safe’ sexual fantasies) is vital.
Touching without genital contact, ‘for your own pleasure’, initially, with any non-genital part of the body, to explore the range of what pleases, and then to concentrate on whatever erogenous zones are found (‘sensate focus’).
Touching as above ‘for your own and your partner’s pleasure’.
‘Homework’ using a vaginal dilator and lubricating jelly.
Touching with genital contact, first in turn, later together. Problems in taking the initiative may now surface. In premature ejaculation, the partner stimulates the penis, and as orgasm approaches the man signals to his partner, who inhibits the reflex by squeezing his penis at the frenulum.
Concentrate on playing down the distinction between foreplay and intercourse, so that anxiety at penetration is reduced.
Vaginal containment in the female superior position so that she can stop or withdraw whenever she wants. She concentrates on the sensation of the vagina being filled.
Periods of pelvic thrusting, eg with a ‘stop–start’ technique.
Lust, romantic love, and attachment
Treat sexual problems holistically—eg there may be relevant medical, drug, or other psychopathologies (depression is common).
Psychological events have physical sequelae, and physical events have psychological sequelae.
All pleasure, including all erotic pleasure, is either purely sensory or arises from associations of ideas: this offers many points of intersection for negative operators, such as distraction, spectatoring, guilt, anxiety, fear of failure, pain, and inappropriate stimulation.
when in doubt…communicate. This is the basis of the salutogenesis approach to sexual health. Salutogenesis asks not what disease is present but how and individual or a couple stay healthy. And the answer is often ‘through communication’ and ‘by being intimate’. Intimacy may be a more powerful determinant of health than improved diet, stopping smoking, genetic vulnerabilities, and prescription drugs.Systemic practice (family therapy)
What used to be called family therapy is now better known as systemic practice, which is an evolving body of ideas and techniques focusing on a person’s difficulties within the context of the people and culture that surround them. Therapy is based on the assumption that most people have the resources and potential for resolving life’s difficulties. Therapists may work with individuals or families. Screening rooms may be used where co-therapists observe family interactions during therapy via a one-way screen.
Narrative therapies425
consider that knowledge is developed by story-telling not through the logico-scientific method, working on the basis that there is no single truth about the reasons for problems but that ‘truths’ are constructed via conversations between therapist and therapee. People can be maintained in problem-saturated lives by ‘viewing themselves in the context of a dominant knowledge’. By constructing an alternative knowledge, they can be liberated to challenge the problem. Narrative therapists help by restoring people’s control over their problems via externalizing the problem. Faecal soiling is popularly viewed as an act committed by the child as a response to family dysfunction. But if it is viewed as a struggle between the family and the problem by identifying the ‘sneaky poo’ as the enemy, then the family can be engaged in a battle against it. The use of written letters is also considered a useful tool.
Brief solution focused therapy426
makes use of a structured approach to draw on people’s resilience, and motivate problem solving. It centres conversations on solutions, not problems. “If it works, do more of it. If it doesn’t work do something different. No problem happens all the time.”
| Session 1 | Session 2 and beyond |
|---|---|
1 Why have you come? | 1 What’s got better? |
2 How may we be of help? | 2a Elicit: Ask about positive changes |
3 The miracle question (below) | 2b Amplify: Ask for details on +ve changes |
4 Exception questions | 2c Ensure he notices and values change |
5 Spectograms | 2d Start again. Ask what else is better. |
6 Agreed achievable tasks | 3 Ending. How can you get back on track? |
| Session 1 | Session 2 and beyond |
|---|---|
1 Why have you come? | 1 What’s got better? |
2 How may we be of help? | 2a Elicit: Ask about positive changes |
3 The miracle question (below) | 2b Amplify: Ask for details on +ve changes |
4 Exception questions | 2c Ensure he notices and values change |
5 Spectograms | 2d Start again. Ask what else is better. |
6 Agreed achievable tasks | 3 Ending. How can you get back on track? |
‘Miracle’ question:
“If you woke up and a miracle had occurred in the night, how would you know? How would your life be different?”
Exception question:
Search with the client for possible exceptions.
Spectograms:
“On a scale of 0 to 10, how much would you like your miracle to happen?” “What would have to happen/What would you have to do to make your score move from 3 to 4?”
Dimensions of family functioning428,429
(McMaster model) The 6 dimensions allowing any practitioner to describe family functioning are:
Problem solving: Can the family act together to solve everyday emotional and practical problems? Can they identify a problem, develop, agree, and enact solutions, and evaluate their performance? Success may be dependent upon functioning in other dimensions.
Congruence of verbal and non-verbal communications: Are communications clear and direct or are there hidden agendas or hidden meanings? Do people listen to one another?
Roles: Who is in charge and how are executive decisions made? Who provides for the family? Who is concerned for the child’s education and emotional development? Families may function most effectively when roles are appropriately allocated and responsibilities explicit.
Affective involvement: Relationships in families tend to exist on a continuum from over-involved (enmeshed) to disinvolved (dis-engaged). Empathic involvement is ideal. This depends on development, as greater involvement is needed for babies than adolescents. Enmeshment may lead a child to be so anxious about a parent that they feel unable to leave them, and avoid school as a consequence.
Affective responsiveness: How do individual family members respond emotionally to one another both by degree and quality? Welfare feelings would include love, tenderness, and sympathy. Emergency feelings would include fear, anger, and disappointment.
Behavioural control: How is discipline maintained? Is there negotiation? Is it flexible? Chaotic? Absent? (depends on quality of communication).
Dysfunctional family patterns
Triangulation: When parents are in conflict, each demands the child sides with them. When the child sides with one, they are automatically considered to be attacking the other. The child is paralysed in a no-win state where every movement is a perceived attack on a parent.
Scapegoating:
When an individual is singled out by the family as the sole cause of the family troubles. This serves to temporarily bury conflicts that the family fear will overwhelm them.
⬆Expressed emotion:
Derived from a family interview: reflects hostility, emotional over-involvement, critical comments, and contact time.
Comparing the psychotherapies430
Westen’s dictum
What follows does not entirely avoid the trap Westen alludes to. Also be aware of many different variations on a theme, eg cognitive and analytic therapy (cat) and dbt (dialectical behaviour therapy).1Principal recommendations and levels of evidence2
Psychological therapy should be routinely considered as an option when assessing mental health problems.B
Patients who are adjusting to life events, illnesses, disabilities or losses may benefit from brief therapies such as counselling.B
Post-traumatic stress symptoms may be helped by psychological therapy, with most evidence for cognitive-behavioural methods. Routine debriefing following traumatic events is not recommended.A
Depression may be helped (but is often not cured) by cognitive therapy or interpersonal therapy. A number of other brief structured therapies for depression may be of benefit, such as psychodynamic therapy.A
Anxiety disorders with marked symptomatic anxiety (agoraphobia, panic disorder, social phobia, obsessive-compulsive disorders, generalized anxiety disorders) are likely to benefit from cognitive-behaviour therapy.A
Psychological intervention should be considered for somatic complaints with a psychological component with most evidence for cbt in the treatment of chronic pain and chronic fatigue.C
Eating disorders can be treated with psychological therapy. Best evidence in bulimia nervosa is for cbt, interpersonal therapy (ipt) and family therapy for teenagers. Treatment usually includes psycho-educational methods. There is little strong evidence on the best therapy type for anorexia.C
Structured psychological therapies delivered by skilled practitioners can contribute to the longer-term treatment of personality disorders.C
Evidence
Psychological therapy shows benefits over no treatment for a wide range of mental health difficulties
There is evidence of counselling effectiveness in mixed anxiety/depression, most effective when used with specified client groups, eg postnatal mothers, bereaved groups
cbt has been found helpful. Some evidence of efficacy has been shown for other forms of psychological therapy. Single-session debriefing appears to be unhelpful in preventing later disorders
cbt and ipt (interpersonal psychotherapy) can effectively reduce symptoms of depression. Benefit has also been found for other forms of psychological therapy, including focal psychodynamic therapy, psychodynamic interpersonal therapy and counselling
cbt effectively reduces symptoms of panic and anxiety. Behaviour therapy and cognitive therapy both appear effective in treatment of obsessional problems
Psychological therapies have benefit in a range of somatic complaints including gastrointestinal and gynaecological problems. cbt has been found more effective than control therapies in improving functioning in chronic fatigue and chronic pain
Efficacy of cbt and ipt in bulimia has been established. Individual therapies have shown some benefit in anorexia, with little to distinguish treatment types. Early onset of anorexia may indicate family therapy, and later onset, broadly based individual therapy
A number of therapy approaches have shown some success with personality disorders, including dialectical behaviour therapy, psychoanalytic day hospital programme and therapeutic communities.
Index on child mental health problems
This section (to p398) deals with some aspects of childhood mental health—but many issues in child psychiatry overlap with pages in the adult section of this chapter, and also with paediatrics. The psychiatry of attempted suicide is a good example. Many of these patients will be in the last phases of childhood, and it is unclear which service will suit them best. As ever, take a holistic view of your patient, and design a care plan which takes these facets into account.
Abuse, p146
Alcohol abuse, p363
Anorexia and bulimia, p348
Asperger’s syndrome, p638
Attention deficit disorder, p212
Autism, p394
Bedwetting, p211
Bullying, p395
Cultural issues in mental health, p492
Depression: children/adolescents, p390
Drug addiction, p362
Dyslexia, p396
Existential crises p390
Family therapy, p386
Holistic assessment p99–100
Language disorders, p215
Parasomnias, p392
Play therapy, p377
Psychosis and psychosis-like symptoms in children, p391
School refusal, p212
Sleep disorders, p392
Substance abuse, p362
Suicide, p338
Talking to young people about sex, p328
Tics & Tourette syndrome, ohcm p714
Mental health in adolescence
Adolescents face major mental health challenges owing to existential crises (p390), changing looks, emerging sexualities, identity problems, exam pressure, family break-up, ready availability of drugs and alcohol, media pressures, and the onset of adult responsibilities (eg when they get pregnant). Psychotic illness also often starts in adolescence, and may be partly related to urban stress (p391).
What can we do to help? Paediatricians, psychologists, psychiatrists, counsellors, gps, and so on all have a role of course—but access to them depends on the fact that a problem has occurred. This is often a bit late—which is why teachers have such an important role in promoting mental health.
Of course, we all want to know what mental illness are prevented—but this is to ask the wrong question. Mental health issues will never be cured or go away—they are part of what it means to be an adolescent. The question is more “How are these adolescents adjusting to their self-made world?” and “Is adolescence proving to be a humanizing or an alienating experience?” The answers to these questions are more metaphysical than quantitative.
We often have the impression that the incandescent adolescent sitting in front of us is burning too brightly within his sullen shell—and our foreknowledge of his impending death in a shoot-out, stabbing, or drug-overdose seems inevitable. What is not inevitable is that he should go to his grave without anyone having tried to help. The following pages may serve as a first step.
Depression in children2% and adolescents5%
Accepting that the big task of adolescence is forging new independent identities, it comes as no surprise that the main signs of depression in this group spell ersatz: a German word we use to mean fake.1 Existential hopelessness related to dawning awareness of freedom to narrate one’s own life and death; relationship & sexual problems; anger in the face of conflicting adult values; tearfulness when it all goes wrong, and overzealous attachment to false gods (eg causing body image dissatisfaction and self-harm).
| Features as seen in adults: | Features common in childhood: |
|---|---|
Low mood | Defiance; running away from home |
Loss of interest and self-esteem | Separation anxiety ± school refusal |
Socially withdrawn | Complaints of boredom; poor school work |
Psychomotor retardation | Antisocial behaviour |
Tearful; feelings of guilt | Insomnia (often initial, not early waking) |
Anxiety | Hypersomnia |
Lack of enjoyment in anything | Eating problems |
| Features as seen in adults: | Features common in childhood: |
|---|---|
Low mood | Defiance; running away from home |
Loss of interest and self-esteem | Separation anxiety ± school refusal |
Socially withdrawn | Complaints of boredom; poor school work |
Psychomotor retardation | Antisocial behaviour |
Tearful; feelings of guilt | Insomnia (often initial, not early waking) |
Anxiety | Hypersomnia |
Lack of enjoyment in anything | Eating problems |
One-to-one interviewing is usually best. Consider the possibility of concealed factors (eg past child abuse, bullying, p395). Parents can be interviewed separately (ask the child’s permission, and see the child alone, again, if appropriate, after seeing the parents, to report back: this helps avoid seeming to collude with the parents). nb: parents are often unaware of depression in their children.
Assessment is often hard: questions may be answered by silence or a shrug. If not getting anywhere, keep listening, or offer silences—but do not give up.
Always ask about thoughts of suicide/self-harm. Any past attempts? 15–20% make further attempts (⬆risk if: conduct disorder, ⬆alcohol use, hopelessness, or in local authority care). Self-harm may be a form of communication—a message in a bottle; not always ‘picked up’ and sometimes it is difficult to decipher the teenager’s exact intentions. Refer urgently if risk is considered significant. Adolescents with conduct disorders can be manipulative and extremely difficult to assess—an urgent second opinion is frequently of help.
Management
Ideally this should be a combined approach:
Psychological: encourage verbalizing of moods; explore the vocabulary of internal states. Counsellors, good teachers, and youth workers help here.
Cognitive therapy (cbt, p373) helps (often unavailable in primary care).
Evaluate risk/benefit ratio (try to include parents in the discussion).
Monitor suicide ideation ≳weekly for 1st month, then ≳every other week.
Before an antidepressant is initiated, a safety plan should be in place with an agreement with the patient and family that the patient will be kept safe and will contact a responsible adult if suicidal urges get too strong.
Hearing unwanted tunes (earworms) is common: if there is any psychopathology, it will be more likely to be obsessions rather than psychosis.
Some hallucinations should receive very serious attention:
Those which are imperative (“kill so-and-so”) or exciting strong emotions.
Those heard unambiguously outside the head.
Those referring to ideas that the person feels are not their own.
Multiple voices talking at once, and especially voices talking to each other.
Causes of odd ideas
Tests
Management
Early intervention helps, and may reduce chances of later chronic schizophrenia, so refer promptly. If you are the child’s gp, ensure there is a treatment plan with a named worker, incorporating antipsychotics (if indicated, p360) with psycho-educational, psychotherapeutic, and social components. New antipsychotics (p361) are rarely specifically licensed for children, but their use in well-monitored environments is encouraging. ses are legion; they may not be as bad as older drugs see p361.,Social interventions in deprived urban areas
Autonomy for housing estates (Housing Associationuk may help)
Wardens drawn from the local community
Training schemes
Clubs (for art/self-expression)
Sport
Debates
Skills/time banks (where those with skills deposit hours of help which others can ‘cash’)
Children’s centres
Saturday school/healthy living
Prostitution and drug abuse initiatives agreed with police
Prognosis
Sleep problems and the parasomnias
Not falling asleep
Waking at 3am
(ready to play, or wanting entry to parent’s bed)
For those not appreciating these visitations from the pure of heart, consider refusing to play and buy earplugs to lessen the impact of screaming—or let the child into the bed. Or try extinguishing the behaviour by attending to the child ever more distantly: cuddle in bed→cuddle on bed→sitting on child’s bed→voice from doorway→distant voice. Try to avoid hypnotics. If essential, consider Weldorm Elixir® (cloral betaine); dose if >2yrs: 30mg/kg, max 1g/day.
Other sleep disturbances
Hunger/colic (infants); poor routines (preschool); worry (adolescence). Bedroom tv may be to blame. Try behavioural therapy before hypnotics. Day-time sleepiness: Causes: night sleep⬇; depression; sleep apnoea (ohcm p186); narcolepsy;1 encephalitis lethargicans (rare in children): suspect this whenever sleepiness occurs with extrapyramidal effects, oculogyric crises, myoclonus, inversion of diurnal rhythms, obsessions, and mood change. Possible causes: influenza; flu vaccination; measles; q fever; mycoplasma; hypothalamic lymphoma. mri: subcortical involvement.
Sleepwalking & parasomnias2
Of all our non-insane automatisms, somnambulism is the most familiar and striking, literally (rarely) as households may be endangered when the bloodiest dreams of junior somnambulists are enacted. The young are by far the best sleepwalkers (the old may emulate them eg if stress is augmented by excess alcohol or caffeine use, and lack of stage IV sleep—our deepest sleep). Any psychic event associated with sleep may be termed a parasomnia. Parasomnias comprise:
Arousal disorders (sleep-walking; night terrors; ‘confusional arousal’)
Sleep–wake transition disorders (rhythmic head-banging disorder)
rem sleep parasomnias (rapid eye movement sleep associated nightmares, sleep paralysis, hallucinations, and rem sleep behaviour disorder (box 1).
Others.1
Suffering from night terrors is often a familial problem. The child awakens frightened, hallucinated, and inaccessible—and is obviously alarmed.
It is common to observe movement in children during sleep: it is their repetitive nature which allows the diagnosis of rhythmic movement disorder. The movement may be body-rocking, leg-rolling, or head-banging (this ‘jactatio capitis’ may lead to subdurals, fractures, eye injuries, and false accusations of abuse). Tongue-biting may suggest epilepsy. But do not try to be too obsessive in differentiating parasomnias from nocturnal epilepsy, for 3 reasons:
Our definition of epilepsy is tested to destruction by the parasomnias (‘epilepsy is intermittent abnormal brain activity manifesting as simple or complex seizures’).
Those with clearly defined parasomnias are at risk of developing tonic–clonic nocturnal seizures later in life.
Antiparasomniacs:
We sleep in one of two states: rapid eye movement sleep (rem sleep ≈25% of all sleep) and non-rapid eye movement (nrem, which has 4 stages). In rem sleep, breathing is irregular, bp rises, and tone lapses (atonia; paralysis). eeg during rem sleep is similar to that in wakefulness and associates with dreaming. Tricyclics, ssris, and serotonin-norepinephrine reuptake inhibitors may all suppress rem.
In rem sleep behaviour disorder, rem paralysis is incomplete or absent, with acting out of dreams that are vivid and violent (with shouting, punching, kicking, flailing etc enough to endanger bed-partners).
Parkinson’s disease, dementia (may be an early sign), alcohol and drug withdrawal (eg ssri).
Muscle tone ⬆ during rem sleep.
Sleep alone; remove all dangers from the sleep environment. Put the mattress on the floor. Clonazepam 0.5mg at bedtime may help.
When we sleep we trawl forbidden seas, arranging and being rearranged by the flotsam and jetsam of our waking lives. As our nets descend through the various stages of sleep, our Sovereign Reason or Will usually remains quietly on deck, but if by chance it descends with the nets then, like the tail wagging the dog, it adopts and propagates a life of its own, which may be full of danger. Because our vessel has been vacated, Marie-Celeste-style, we are judged, in Law, not to be responsible for our actions while asleep—be they theft, arson, or homicide. Without will or wind, our vessel, like Coleridge’s Mariner’s (see poem below), is moved ‘onward from beneath’ by secret forces. So here we have the model of Reason and Will residing, during sleep, either upstairs or downstairs: but in sleep paralysis, neither is the case—the tail cannot wag the dog, nor the dog wag his tail. Sleep paralysis may involve complete paralysis of all voluntary muscles, even the diaphragm. For anyone who has experienced it, it is frightening, unforgettable, and difficult to describe—like being aware during anaesthesia with total neuromuscular blockade.
Till noon we quietly sailed on
Yet never a breeze did breathe:
Slowly and smoothly went the ship,
Moved onward from beneath.
Under the keel nine fathom deep,
From the land of mist and snow,
The spirit slid: and it was he
That made the ship to go.
The Rime of the Ancient Mariner Samuel Taylor Coleridge (part v)
Autism spectrum disorders (asds)
Cause
Genes (on chromosome 11p12 ± neurexin) play a part. If one child is affected, risk of the next pregnancy being affected is ~5–10%. Blood glutathione levels are low and this may jeopardize cns & gi antioxidant activity. There is associated epilepsy in 30%. Any association with mmr vaccine (p151) is thought to be due to changing definition of autism at the time that mmr was introduced.Diagnosis
Impaired reciprocal social interaction (‘A’ symptoms)
Unawareness of the existence and feelings of others (treating people as furniture; being oblivious to others’ distress or need for privacy).
Abnormal response to being hurt: he doesn’t come for comfort; or makes a stereotyped response, eg just saying “Kiss it better kiss it better kiss it…”.
Impaired imitation (eg does not wave ‘bye-bye’ or copies/echoes without understanding, eg waves on passing a door when no one is in fact leaving).
Repetitive play: eg solitary, or using others as mechanical aids.
Bad at making friends (lack of empathy). If he tries at all, the effort will lack the social conventions, eg reading the phone directory to uninterested peers.
Impaired imagination (‘B’ symptoms; part of abnormal communication)
Little babbling, few facial expressions or no gestures in infancy.
Avoids mutual gaze; no smiles when making a social approach; does not greet his parents; stiffens when held.
Does not act adult roles; no interest in stories; no fantasy/pretend play.
Odd speech, eg echolalia (repetitions); odd use of words (“Go on green riding” for “I want a go on a swing”); odd use of pronouns (“You” instead of “I”).
Difficulty in initiating or sustaining reciprocal roles in conversations.
Poor range of activities and interests (‘C’ symptoms)
Stereotyped movements (hand-flicking, spinning, head-banging).
Preoccupation with parts of objects (sniffing or repetitive feeling of a textured object, spinning wheels of toys) or unusual attachments (eg to coal).
Marked distress over changes in trivia (eg a vase’s place).
Insists on following routines in precise detail.
Narrow fixations, eg lining up objects, or amassing facts about weather.
Treatment
Drugs
Diet:
Outlook
70% remain badly handicapped; 50% have useful speech; 15% lead an independent life.
Bullying
Boys will be boys… The unacceptable alibi?
Every individual should have the right to be spared oppression and repeated, intentional humiliation, in school as in society at large. Bullying is important not just because it is unacceptable, but also because it leads to depression, somatization, withdrawal, submissive behaviour, school phobia, vomiting, sleep disturbance, drug abuse, poor communication, and suicide.Incidence
Bullying behaviour
Rumour-spreading→excluding others→racial abuse→hostile staring→punking1→victimization→pushing→violence→torture→murder.
Risk factors
Interventions
School-based anti-bullying interventions
Homosexual bullying:
On a universal level, we can recognize that we are all potential bullies, when stressed, frightened, overworked, or threatened by uncontrollable events (such as patient demand). We stop ourselves from being bullies, more or less successfully, by intrapsychic appeals to well-respected mentors who ‘would never behave like that’, and by communicating our feelings to our colleagues directly before they are forced underground only to resurface as bullying. Try: “I’m feeling rather stressed at the moment: tell me if I seem bullying or hectoring—but we’ve got to get this job done, and I suggest doing it like this…”
False accusations of bullying
Dyslexia
Reading ability usually goes hand-in-hand with intelligence, but when this is not so, and someone with, say, an iq of 130, finds reading difficult, the term dyslexia is often used. The term ‘specific learning difficulty’ is preferred by some people, as ‘dyslexia’ is often a term used by parents to help cope with having a child whose general intellectual skills, including reading, are less than hoped for. nb: dyslexia can be associated with other speech and language disorders: consider referral to a speech and language therapist (salt).
Essence
There is a problem with appreciating phonemes, eg that ‘cat’ comprises /c/, /a/, and /t/. Breaking up unfamiliar words into phonemes and having a go at stringing them together is the central act of learning to read. This is what needs to be taught, educationalists say, and children should not be made to rely on unstructured guesswork (the ‘look and say’ approach) which is now discredited as the sole means of equipping children for reading.
Biology
Perhaps dyslexia reflects weak connectivity between anterior and posterior parts of the language areas of the brain, and the angular gyrus. Positron emission images show that when dyslexic adults perform rhyme judgments and verbal short-term memory tasks they activate less than the full set of centres normally involved with these tasks. www.shianet.org/~reneenew/hist.html
Tests
Management
Patient pathways: descending the ‘dark spiral’1 of madness, as tweeted from a straightjacket in 1855
The next pages concern the psychiatrist as jailer. To reflect on this let us follow one patient’s journey, along the edge of chaos, to his straightjacket via a series of verbatim tweets from the manic streets of Paris (with proposed timings).
3pm Bought two velvet screens covered with hieroglyphic figures…to consecrate the forgiveness of heaven.
4pm Met my friend George…wet through and tired out…laid on his bed.
6pm Marvellous goddess appeared to me saying “I am the same as Mary, the same as your mother”.
7pm Said to George “Let’s go out”.
7.15pm Crossing Pont des Arts explaining the transmigration of souls to him.
7.20pm Told George…I have the soul of Napoleon in me commanding me to do great things.
7.30pm In the Rue Du Coq I bought a hat. While George is waiting for my change I went to the Palais-Royal…everyone staring at me.
7.50pm A persistent idea is fixing itself in my mind…there are no more dead.
8pm Went through the Galerie de Foy saying “I have committed a sin…”.
8.10pm Somewhat interested in little girls dancing in rings.
8.15pm Café de Foy…Dense crowd…nearly suffocated.
8.20pm Extricated by 3 friends…into a cab…taken to Hospice De La Charité.
3.02am Walking about various wards…I’m like a god with powers of healing.
3.05am Laying my hands on some patients now.
3.20am Going up to a statue of the Virgin Mary…
3.21am Taking off its crown of flowers in order to test the power in me.
3.29am Talking in an animated way of the ignorance of men who think they can be cured by science.
3.40am Bottle of ether on the table…
3.42am Drinking it in one gulp
3.43am Hospital assistant with face like an angel trying to stop me
3.45am Tell him he does not understand my mission.
3.55am Doctors coming along.
4am Harangue on the impotence of their art.
4.02am Thrusting me into a straightjacket
6am Am in an asylum outside Paris…
proclaiming it to be an infinite hallucination set in a jewel of immense value. We honour Gérard De Nerval here to remind ourselves that the next patient we imprison using mental health laws deserves our infinite respect, however rough their diamonds appear to be.Compulsory treatment: law in England
(1983, 2007)
ac approved clinician
amhp approved mental health professional
asw approved social worker
cto community treatment order
echr European Convention on Human Rights
ect electro-convulsive therapy
gscc General Social Care Council
imca independent mental capacity advocate
imha independent mental health advocate
lhb local health board
lssa local social services authority
mca Mental Capacity Act 2005
mhac Mental Health Act Commission
mhrt Mental Health Review Tribunal
nhsft nhs foundation trust
pct primary care trust
rc responsible clinician
rmo responsible medical officer
sct supervised community treatment
soad Second Opinion Appointed Doctor
Before reading the subsequent pages which reflect the 1983 Mental Health Act it is vital to understand how the Act has been amended and added to by the 2007 Mental Health Act—which does not replace it—but rather sits beside it.
Imperatives governing use of Mental Health Acts
(required in the 2007 act)
Respect patients’ past and present wishes and feelings.
Minimize restrictions on liberty and involvement of patients in planning, developing and delivering care and treatment appropriate to them.
Avoid unlawful discrimination.
Pay due attention to the effectiveness of treatment.
Respect the views of carers and other interested parties.
Respect for diversity, including, in particular, diversity of religion, culture and sexual orientation (within the meaning of the Equality Act 2006).
Patient wellbeing and safety, and public safety need balancing.
2007 Mental Health Act
In 2007, three key measures were introduced:
Community treatment orders (ctos) allow compulsory treatment in the community. As a safeguard, there is a duty to consider what risk there would be of a deterioration of the patient’s condition if he were not detained (as a result, for example, of his refusing the treatment he requires for his mental disorder). ctos have the same duration and renewal periods as section 3 (p400): 6 months initially, then renewed for 6 months, then renewed annually.
The criteria for a cto is that the patient is detained after an application for admission for treatment, and it is necessary for his health and safety or for the protection of other persons that he receives treatment, which can be provided outside hospital (subject to a power of recall). cto roles:
Ensuring the patient receives the treatment stipulated.
Preventing harm to the patient’s health or safety.
Protection of others.
People diagnosed with severe antisocial personality disorders are now within the scope of mental health law and can be detained even if they have committed no crime, if they are deemed a danger to themselves or others.
Other provisions:
A new statutory advocacy service for detained patients, and:
Children are protected from being put in adult wards (section 140).
2 professionals from diverse disciplines must now agree to detention renewal.
No ect can be given in the face of capacitous refusal, other than in emergency. Emergency ect can only be given if it is immediately necessary to save life or immediately necessary to prevent a serious deterioration.
16- and 17-year-olds’ capacitous refusal of treatment cannot be overridden by parental authority; a soad is needed for ect to be given; and there must be a referral for a mhr Tribunal annually for patients who do not request a hearing.
There is a new ‘treatability’ test, ensuring compulsory treatment must be of ‘therapeutic benefit’. The wording is: ‘Any reference in the Act to medical treatment, in relation to mental disorder, shall be construed as a reference to medical treatment the purpose of which is to alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations.’
Stage 1
Preliminary examination:
Decisions to begin assessment and initial treatment of a patient under compulsory powers must be based on a preliminary opinion by two doctors and a social worker (or another suitably trained mental health professional) that a patient needs further assessment or urgent treatment by specialist mental health services and, without this, might be at risk of serious harm or pose a risk of serious harm to others.
Stage 2
Formal assessment/initial treatment under compulsory powers:
A patient will be given a full assessment of his or her health and social care needs and receive a formal care plan; the initial period of assessment and treatment under compulsory powers is up to 28 days; after that, continuing use of compulsory powers must be authorized by a new independent decision making body, the Mental Health Tribunal, which gets advice from independent experts as well as taking evidence from the clinical team, the patient ± his or her representatives, and other agencies, as appropriate.
Stage 3
Care and treatment order:
The Tribunal (or the Court in the case of mentally disordered offenders) can make a care and treatment order to authorize the care and treatment specified in a care plan recommended by the clinical team. This must be designed to give therapeutic benefit to the patient, or to manage behaviour associated with mental disorder that might lead to serious harm to other people. The 1st 2 orders can be up to 6 months each; subsequent orders may be for periods of up to 12 months.
nb:
one new provision is that it is now possible for people with dangerous personality disorders to be detained before a crime has been committed.
A soad certificate must be issued authorizing the treatment. The soad is appointed in the normal way by the mhac. The criteria for the soad authorization is simply that ‘it is appropriate for the treatment to be given’. With soads, the certifying doctor has a duty to consult 2 statutory consultees but no duty to consult the patient or the responsible clinician.
The treatment is immediately necessary and the patient has capacity and consents to its administration; or…
The treatment is immediately necessary and the patient lacks capacity, but a deputy or the court of protection consents to it on his or her behalf.
The patient lacks capacity and may resist the treatment, but force may be justified as proportionate response to the likelihood of serious harm to the patient, and the treatment is either immediately necessary to save the patient’s life; or (not being irreversible) is immediately necessary to prevent serious deterioration; or (being neither irreversible nor hazardous) is immediately necessary to alleviate serious suffering; or (being neither irreversible nor hazardous, and the minimum interference necessary) is immediately necessary to prevent the patient from behaving violently or being a danger to her/himself or others.
Compulsory hospitalization
(for 2007 law, see p398)
Provisions under the 1983 Act (in England)
The patient must have a mental disorder and need detention for treatment of it, or to protect himself or others, before compulsion may be used (if voluntary means have failed).
Admission for assessment (Mental Health Act1 1983, section 2)
The period of assessment (and treatment) lapses after 28 days.
Patient’s appeals must be sent within 14 days to the Mental Health Tribunal (composed of a doctor, lay person, and lawyer).
An approved social worker (or the nearest relative) makes the application on the recommendation of 2 doctors (not from the same hospital), one of whom is ‘approved’ under the Act (in practice a psychiatric consultant or senior registrar). The other doctor should ideally know the patient in a professional capacity. If this is not possible, the Code of Practice recommends that the second doctor should be an ‘approved’ doctor.
Section 3: admission for treatment (for ≤ 6 months)
The exact mental disorder must be stated.
Detention is renewable for a further 6 months (annually thereafter).
2 doctors must sign the appropriate forms and know why treatment in the community is contraindicated. They must have seen the patient within 24h. They must state that treatment is likely to benefit the patient, or prevent deterioration; or that it is necessary for the health or safety of the patient or the protection of others.
Section 4: emergency treatment (for ≤ 72h)
The admission to hospital must be an urgent necessity.
May be used if admission under section 2 would cause undesirable delay (admission must follow the recommendation rapidly).
An approved social worker or the nearest relative makes the application after recommendation from one doctor (eg the gp).
The gp should keep a supply of the relevant forms, as the social worker may be unobtainable (eg with another emergency).
It is usually converted to a section 2 on arrival in hospital, following the recommendation of the duty psychiatrist. If the second recommendation is not completed, the patient should be discharged as soon as the decision not to is made. The Section should not be allowed to lapse.
Detention of a patient already in hospital: section 5(2) (≤ 72h)
The doctor in charge (or, if a consultant psychiatrist, his or her deputy, applies to the hospital administrator, day or night.
Plan where the patient is to go before the 72h has elapsed, eg by liaising with psychiatrists for admission under section 2.
Nurses’ holding powers: section 5(4) (for ≤ 6h)
Any authorized psychiatric nurse may forcibly detain a voluntary ‘mental’ patient who is taking his own discharge against advice, if such a discharge would be likely to involve serious harm to the patient (eg suicide) or others.
During the 6h the nurse must find the necessary personnel to sign a section 5 application or allow the patient’s discharge.
Section 7: application for guardianship
Enables patients to receive community care if it cannot be provided without using compulsory powers.
Application is made by an ‘approved social worker (asw)’ or ‘nearest relative’ and also needs two medical recommendations.
The guardian, usually a social worker, can require the patient to live in a specified place, to attend at specified places for treatment and to allow authorized persons access.
Renewal of compulsory detention in hospital: section 20(4)
The patient continues to suffer from a mental disorder and would benefit from continued hospital treatment.
Further admission is needed for the health or safety of the patient—which cannot be achieved except by forced detention.
Section 25: supervised discharge
This is as a result of the Mental Health (Patients in the Community) Act 1995—incorporated within the 1983 Act.
It allows formal supervision to ensure that a patient who has been detained for treatment under the Act receives follow-up care.
The application is made at the time of detention for treatment by the Responsible Medical Officer. It is supported by an asw and a doctor involved in the patient’s treatment in the community.
A supervisor is appointed who can convey the patient to a place where treatment is given.
Section 117: Aftercare & the Care Programme Approach (cpa)
Section 117 requires provision of after-care for patients who have been detained on the ‘long sections’ (3, 37, 47, or 48). The cpa is not part of the Act but stipulates that no patient should be discharged without planned aftercare: the systematic assessment of health and social needs, an agreed care plan, the allocation of a keyworker, and regular reviews of progress.
Section 136
(for ≥72h) allows police to arrest a person ‘in a place to which the public have access’ who is believed to be suffering from a mental disorder. The patient must be conveyed to a ‘place of safety’ (usually a designated a&e department—better than a police station; a police station is rarely a place of safety and most people dying in police custody will have mental health problems and will have been on the receiving end of excess force employed by undertrained officers). In a hospital there can be a full assessment by a doctor (usually a psychiatrist) and an approved social worker. The patient must be discharged after assessment or detained under section 2 or 3.
Section 135
This empowers an approved social worker who believes that someone is being ill-treated or is neglecting himself to apply to a magistrate to search for and admit such patients. The asw or a registered medical practitioner must accompany the police.
English Mental Health Act Law relevant to consent
Consent to treatment comes in Part 4 of the Mental Health Act; it applies to:
Treatments for mental disorder.
All formal patients unless detained under sections 4, 5, 35, 135 and 136. The Act doesn’t apply to those subject to Guardianship or Supervised Discharge, who have the right to refuse treatment, except in emergencies.
Where a person is deemed to have given their consent to treatment under Section 57 or Section 58, the person can withdraw that consent at any time. The treatment must then stop and the appropriate procedures followed, unless discontinuing treatment would cause ‘serious suffering’ to the patient, in which case continued treatment may be justified.
Section 57: treatments requiring consent and a 2nd opinion
Some treatments are deemed so restricting that patients cannot automatically have them even if they do consent. Also, 3 people (1 doctor and 2 others who cannot be doctors) must certify that the person concerned is capable of understanding the nature, purpose and likely effects of the treatment and has consented to it (competence). They are appointed by the Mental Health Act Commission. Treatments falling into this category are destruction of brain tissue, or functioning and implantation of hormones to reduce male sex drive.
Section 58: treatments requiring consent or a 2nd opinion
Applies to people who are detained under certain Sections without consent, or where the person is not able to consent, eg to ect or drugs for a mental disorder if 3 months since the person first had the drugs during their current period of detention under the Act. In the first 3 months the treatment can be given without consent. The 3-month period starts from when drugs are first given.
If the person is capable of understanding the nature, purpose and effects of the treatment and consents to it, the Responsible Medical Officer (rmo) must certify that understanding and consent are present. If the person is capable of understanding the nature, purpose and likely effects of the treatment and doesn’t consent to it, or has ⬇capacity so cannot consent, then a doctor is appointed by the Mental Health Act Commission to give a 2nd opinion. She must consult 2 professionals involved in the patient’s treatment; one must be a nurse.
The certificates must state the treatment plan in precise terms, eg the number of ect treatments. If the plan changes, new certificates are required.
The provisions of Section 58 don’t prevent urgent treatment (sect 62).
Section 62: urgent treatment
The requirements of Section 57 and Section 58 need not be followed for urgent treatment to save the patient’s life or to…
Prevent serious deterioration, so long as the treatment is not irreversible.
Alleviate serious suffering (if the treatment isn’t irreversible or hazardous).
Prevent the patient behaving violently or endangering self or others, so long as the treatment is neither irreversible nor hazardous, and is not excessive.
Section 37: Hospital Orders made by Courts
This allows a Court to send a person to hospital for treatment, or to make the person subject to Guardianship, when the outcome might otherwise have been a prison sentence. The Order is instead of imprisonment, a fine, or probation. The person concerned…
Will have been convicted by a Magistrates Court or Crown Court of an offence punishable with imprisonment (except in the case of murder, where the Court has to impose a sentence of life imprisonment in all cases).
May not have been convicted, but may be charged with an imprisonable offence. Without convicting the person, the Court can make a Hospital Order under Section 37 if there is mental illness or severe mental impairment.
The initial period is 6 months from the Order’s date. It can be renewed under Section 20 for 6 months and then annually. The Court must be satisfied that…
There really is a mental illness, as evidenced by 2 doctors who must agree at least in part as to the type of mental illness or impairment present…and…
The nature and degree of the mental disorder makes it appropriate for the person to be detained in hospital for medical treatment (that the treatment is likely to alleviate or prevent a deterioration of the person’s condition in the case of psychopathic disorder or mental impairment)…and…
Making a Section 37 Order is the best way to deal with the person…and …
A specific hospital is willing and able to admit the person within 28 days.
Section 61: review of treatment
Where a treatment plan is being carried out under Section 57 (or 58 without consent), the rmo must report to the Mental Health Act Commission if the period of detention is renewed under Section 20.
The Commission may demand a report at any other time if it wishes.
The Commission can cancel the certificate under which treatment is given.
In the case of people subject to Restriction Orders a report on the treatment being given must be provided for the Commission:
6 months after the restriction order or direction is made, and
At times when the rmo reports to the Home Office on the person’s condition.
Deprivation of liberty safeguards (dols)
Use:
eg after being admitted to a rest home during an infection when a patient lacked capacity, and the doctor ‘acted in his best interests’. dols provide the person with a representative, and…
dols allow a challenge in the Court of Protection against ‘false imprisonment.’
dols give a right for deprivation of liberty to be reviewed regularly.
Source: patient.co.uk/doctor/
Capacity matters, not age. Parents’ wishes are not supreme if the child has capacity (above). If you take a decision for a patient, you must have a ‘reasonable belief’ that capacity is lacking and that the act is in his/her best interests.
Clinical situations
Deliberate self-harm
Restraint:
The Mental Health Act is an enabling act (it needn’t be used in all valid situations). Its use gives certain legal safeguards for patients and staff. ‘A 40 year old female with alcohol problems has been admitted to hospital following a head injury 2 days ago. She has shown fluctuating levels of confusion, agitation and is now trying to leave the ward.’ Here, due to refusal or lack of capacity, the transient nature of the disturbance, and the need for intervention, common law is applicable. If stronger measures are needed, or the situation persists, it is wise to use the Mental Health Act to detain a patient with delirium; however it is not commonly used.
Seasonal affective disorder (SAD)
Some people find that depressions start in winter, and remit in spring or summer. It is postulated that disordered secretion of the indole melatonin from the pineal gland is to blame in some patients with sad. Melatonin, the hormone of darkness, is secreted by the pineal only at night, eg at 30μg/night.
Dysregulated circadian rhythms and novel antidepressants
Treatment choices
As a rule, the more that typical winter symptoms (hypersomnia, carbohydrate craving and weight gain) predominate, the more likely that light therapy should be a treatment of first choice. But if winter episodes are characterized by early morning wakening and weight loss, and especially if there are non-seasonal recurrences, traditional antidepressants are advised.
Light therapy
However, evidence in this area is often contradictory, and it is probably unwise to rush into recommending light for all patients whose recurrent depressions start in the autumn or winter. This might have the undesirable effect of enticing such patients to book unaffordable winter holidays to exotic locations—with inevitable disappointments and recriminations.
Community care
Since the early 1980s, most uk inpatients with psychosis have had the focus of their care moved from hospital to the community. The aim has been to save money and improve care, but in the uk this policy is now being partly reversed. Has community care failed, or have there been successes? Five questions keep recurring, each (ominously) prefixed by a ‘Surely…’
Surely hospitals will always be needed for severely affected people? In general, the problem is not the severity of the mental illness, but its social context which determines if community care is appropriate.
Surely if inpatient psychiatric beds are not available, however good the daytime team is in the community, some patients will still need somewhere to go at night? The implication is that the skills available in bed-and-breakfast accommodation may be inadequate at times of day when there is no other support, other than the general practitioner. Studies that have looked at this have certainly found an increase in non-hospital residential care in those selected for community care, and this increase may be as much as 280% over 5yrs. In the uk, new proposals guarantee 24-hour open access to skilled help, but it is not known what pressures this will put services under.
Surely community care will involve a huge bureaucracy in pursuit of the unattainable goal of 100% safety? This will be so if every patient has a lengthy care plan and repeated risk assessments. Concern for safety may also spawn a non-therapeutic custodial relationship.
Poverty and mental illness
Emergency shelters
Transitional accommodation
Long-term housing.
In the uk, as in many other Western countries, what started out as an enlightened policy of looking after people with mental health problems in the community (p405) has resulted in large numbers of psychiatric patients living on the street in great poverty—relieved by occasional admissions to often overcrowded acute units. This ‘revolving door’ model of care has failed many patients, not least because continuity of care is compromised.
Income Supportuk
is an income-related (means-tested) benefit paid to those who do not have enough money to live on. Income is subtracted from a standard fixed income level (the ‘applicable amount’), and the difference is the amount of Income Support payable. The person’s capital is also taken into account. Income Support is a non-contributory benefit. This means that a person does not have to have paid any National Insurance contributions in order to qualify for Income Support. The rates of Income Support are fixed each year by government and are usually increased every April. Income Support acts as a ‘passport’ to certain other help. A claimant and her/his partner will automatically qualify for:
Free school meals
Free prescriptions
Free dental care
Vouchers for spectacles
Free milk and vitamins for expectant mothers and children under 5
Free vitamins for nursing mothers
Maximum housing benefit
Maximum council tax benefit.
Epidemiology
Poverty, reoffending, and mentally ill offenders536
Two contrasting ideas:
The economic arguments for keeping non-violent mentally ill criminals out of prison and rehabilitating them are self-evident.
Prison provides an ideal opportunity to treat people who are mentally ill who might otherwise be hard to reach. They should have optimum treatment to improve their quality of life, as well as to lessen the risk of reoffending.
‘The innkeeper acquainted all in the inn with the lunacy of his guest (Don Quixote), about his standing vigil over his armour and the knighting he expected. They marvelled at so odd a form of madness and went to watch him at a distance, and saw that with a serene expression he sometimes pranced to and fro; at other times, leaning on his lance, he turned his eyes to his armour without turning them away for a long time. Night had fallen; but the moon shone with such a lustre as might almost vie with the sun who lent it; so that everything our new knight did was seen clearly by everyone. Just then it occurred to one of the mule-drivers in the inn to water his pack of mules, and for this it was necessary to move Don Quixote’s armour, which was on the trough; our knight, seeing them approach, called in a booming voice:
“Oh thou, whosoever thou art, reckless knight, who would touch the armour of the most valiant knight whoever took up arms! Take heed what thou doest, and touch it not, unless thou wouldst pay for thy audacity with thy life.”
The muleteer cared not a jot for this reasoning—it would have been better for him if he had, for it meant caring for his health. Instead, picking the armour up by the straps, he tossed it a good distance. And seeing this, Don Quixote lifted his gaze to the skies and, turning his thoughts (as it seemed) to his lady Dulcinea, he said:
“Help me, my lady, in this the first insult aimed at this thy servant’s breast; in this my first crisis let not thy grace and protection fail me.”
And, continuing this line of argument, and dropping his shield, he raised his lance in both hands and gave the mule-driver such a clout on the head as to demolish him; if this first blow had been followed by a second, he would have had no need for a doctor (‘maestro’) to cure him. Having done this, Don Quixote picked up his armour and began to pace again with the same gravity as before. A short time later, unaware of what had happened—for the first mule driver lay stunned—a second approached, also intending to water his mules, and when he began to remove the armour so as to get to the trough, without so much as a by-your-leave or even a word, Don Quixote let slip his shield and raised his lance, and without quite reducing the second mule-driver’s head to smithereens, he thrice sliced it, fracturing the skull in four places. When they heard the noise, all the people in the inn hurried over, among them the innkeeper. When he saw this, Don Quixote took up his shield, placed his hand on his sword, saying:
“Oh queen of beauty, whose spark and fire warms the sickness in my heart (debilitado corazón mío)! From your greatness, it is time that you do bend your eye on this thy slavish knight, who expects so vast an exploit.”
Postnatal depression
Natural history
Although most postnatal depression resolves in ≲6 months, don’t put off treatment, and just hope for the best.
Consider these facts:
For the patient, 6 months is a long, long time.
For the infant, 6 months is more than a long time: it’s literally an age.
Suicide is a waste, but for a young family, a mother’s suicide is especially destructive—unthinkable, indeed, for those who have not experienced it.
What’s it like having postnatal depression?
Here is a blog:
Help
Have a low threshold for referring to multidisciplinary teams in mother-and-baby units. The first step is to try not to be caught unawares by a major depression that apparently strikes like a bolt from the blue, but which, in reality, has been building up over time. Pregnancy and infant–motherhood is supposed to be a time of unclouded joy. We often collude with this view. We are always hearing ourselves saying: “Oh Mrs Salt, what a lovely baby! You must be so pleased—and you always wanted a little boy. We are so delighted for you…” But what if she is not delighted? She hardly dares confess her traitorous thoughts that she is unaccountably sad, that she spends the nights crying, and that her exhausted days are filled with a sense of foreboding that she or some other agency will harm the child. The place to start to pre-empt these feelings is in the antenatal clinic. Involve fathers; explain: “When the baby comes you’ll need help and rest—don’t think you can do it all yourself: become a team—eg taking turns in getting the baby off to sleep”. In the puerperium give permission for the new mother to tell her woe. When this is revealed, counselling, and input from a health visitor and a psychiatrist is wise, as is close follow-up. You may need to arrange emergency admission under the Mental Health Act: but the point of being prepared for postnatal depression is to avoid things getting this bad. Interventions for persistent depression need to address relationship difficulties as well as depressive symptoms.Pharmacology
1 I’ve been able to laugh … see the funny side of things: | As much as always could |
Not quite so much now | |
Definitely not so much | |
Now not at all | |
2 I’ve looked forward with enjoyment to things: | As much as I ever did |
Rather less than before | |
Definitely less than before | |
Hardly at all | |
3 ★I’ve blamed myself unnecessarily when things went wrong: | |
Yes, most of the time | |
Yes, some of the time | |
Not very often | |
No, never | |
4 I’ve been anxious or worried for no good reason: | No, not at all |
Hardly ever | |
Yes, sometimes | |
Yes, very often | |
5 I’ve felt scared/panicky for no very good reason: | Yes, quite a lot |
Yes, sometimes | |
No, not much | |
No, not at all | |
6 ★Things have been getting on top of me: | |
Yes, most of the time I haven’t been able to cope at all | |
Yes, sometimes I haven’t been coping as well as usual | |
No, most of the time I have coped quite well | |
No, I have been coping as well as ever | |
7 ★I’ve been so unhappy that it is difficult to sleep: | Yes, most of the time |
Yes, sometimes | |
Not very often | |
No, not at all | |
8 ★I’ve felt sad or miserable: | Yes, most of the time |
Yes, quite often | |
Not very often | |
No, not at all | |
9 ★I’ve been so unhappy that I’ve been crying: | Yes, most of the time |
Yes, quite often | |
Only occasionally | |
No, never | |
10 ★Thoughts of harming myself have occurred to me: | Yes, quite often |
Sometimes | |
Hardly ever | |
Instructions Underline what comes closest to how you have felt in the last 7 days. | Never |
1 I’ve been able to laugh … see the funny side of things: | As much as always could |
Not quite so much now | |
Definitely not so much | |
Now not at all | |
2 I’ve looked forward with enjoyment to things: | As much as I ever did |
Rather less than before | |
Definitely less than before | |
Hardly at all | |
3 ★I’ve blamed myself unnecessarily when things went wrong: | |
Yes, most of the time | |
Yes, some of the time | |
Not very often | |
No, never | |
4 I’ve been anxious or worried for no good reason: | No, not at all |
Hardly ever | |
Yes, sometimes | |
Yes, very often | |
5 I’ve felt scared/panicky for no very good reason: | Yes, quite a lot |
Yes, sometimes | |
No, not much | |
No, not at all | |
6 ★Things have been getting on top of me: | |
Yes, most of the time I haven’t been able to cope at all | |
Yes, sometimes I haven’t been coping as well as usual | |
No, most of the time I have coped quite well | |
No, I have been coping as well as ever | |
7 ★I’ve been so unhappy that it is difficult to sleep: | Yes, most of the time |
Yes, sometimes | |
Not very often | |
No, not at all | |
8 ★I’ve felt sad or miserable: | Yes, most of the time |
Yes, quite often | |
Not very often | |
No, not at all | |
9 ★I’ve been so unhappy that I’ve been crying: | Yes, most of the time |
Yes, quite often | |
Only occasionally | |
No, never | |
10 ★Thoughts of harming myself have occurred to me: | Yes, quite often |
Sometimes | |
Hardly ever | |
Instructions Underline what comes closest to how you have felt in the last 7 days. | Never |
Ask to score answers 0, 1, 2, or 3 according to increased severity; some (★above) are reverse scored (3, 2, 1, 0). Add scores for 1–10 for the total. Let her complete the scale herself, eg at the 8-week check-up, unless literary difficulty. A score of 12/30 has a sensitivity of 77% for postnatal depression (specificity: 93%).
Never trust this sort of thing totally! ~40% lie on the form, being afraid that health visitors would call in social services (± removal of baby).
Validity
Prognosis of children whose mothers have postnatal depression
Read this chapter with dsm-v: a diagnostic and statistical manual that codifies all mental illness, but note that this flawed book ignores the social context of symptoms, and over-medicalizes them.
We thank Dr Anish Patel, our Specialist Reader, and Dr Rashmi Singh, our Junior Reader, for their contribution to this chapter.
Logotherapy, Shakespeare, and healing through meaning… “razing out the written troubles of the brain and other rooted sorrows”—Macbeth
Don’t exhaust your patient by ordering every possible test!
3 millennia of failed explanations…from the blogsphere: When the voices take over I call it “gettng posessed”. Thephining is not the way out
After 236 sessions with Joyce the therapist strikes gold, but…oh boy! Joyce had to pay for it!
Do our sufferings make us more human? Only if we can breathe meaning into them. Toothache doesn’t make us more human because it has no meaning beyond the obvious and banal; but there is a kind of suffering ‘which is a more effective key, a more rewarding principle for exploring the world in thought and action than personal good fortune’. (Deitrich Bonhoeffer). This suffering makes our souls. Not all our patients regret their psychological illnesses: sometimes, in retrospect, these patients refer to their break through, not their breakdown. It is this power to grow and to transform experience which is human and humanizing. This is also why, paradoxically, illness is not the opposite of health. For humans, the true opposite to health is being stuck In Status Quo—that state which brooks no development. So if you find yourself writing isq (in status quo) in patients’ notes you are invoking a kind of death.
‘The moment I put my foot on the step the idea came to me without anything seeming to have paved the way for it, that the transformations I’d used to define the Fuchsian functions were identical with those of non-Euclidean geometry…the idea came with…suddenness, and immediate certainty.’
Tout comprendre c’est tout pardoner—‘To understand all is to forgive all’. I have found it necessary to inscribe this phrase around the bell of my stethoscope. This bell then tolls in my mind’s ear whenever my patient is making me angry or despairing—in other words whenever I have not understood. ‘ Tout comprendre c’est tout pardoner’ is the most magnanimous phrase ever created, and was first promulgated by Madame Anne Louise Germaine de Staël: “ tout comprendre rend très indulgent”—”To understand all is to become very lenient.”
The phrase was stolen by Tolstoy in the last chapter of Book 1 of War … Peace. Can we forgive this theft? Of course; not just because the theft gave anonymous immortality to Madame de Staël, but because Tolstoy probably needed to believe he had created it to sustain him in the illusion of his own infallible magnanimity, without which his great literary enterprise would have been impossible. Vive nos illusions: Vive nos illusions magnifique!The converse of this aphorism is the Parris dictum: “When people are anxious it isn’t clever to make a virtue of listening. Sometimes our patients simply need to be told.” Sometimes they need space for selfexpression. Which approach is right—when? We only know this by knowing our patients: this entails listening, which is why, 9 times out of 10, Storr is right: but 9 out of 10 is not always.
Narcissism+paranoia ≈“authoritarian”. When paranoid, antisocial, narcissistic, schizoid, and schizotypal elements conjoin with sadism we have a perfect storm (Hitler, Stalin, Saddam Hussein, Kim Jong-iletc are such examples). As ever, if you identify this combination, get senior help (from the Royal Navy? or the Pope? or John Lennon?).
Schizotypal ≈ the socially anxious, friendless loner with magical thinking, odd fantasies ± clairvoyance.
Parallax=apparent angular displacement of a celestial body due to a change in the position of the observer. With a baseline of known length between 2 observations, the distance to the object becomes known.
Hypnotic phenomena share features with conversion (hysterical) symptoms, eg lack of concern, involuntariness with implicit knowledge, and a compliant tone (la belle indifference). Theories of consciousness postulate an altered relationship between self-awareness and the supervisory attentional system in both conditions (fontal and cingulate cortex are implicated).
Most subside spontaneously, but if they do not it is important to refer early to a psychiatrist, before associated behaviour becomes habitual.Poets, medical students (such as John Keats) and other harmless or immortal romantics tend to favour midnight as the proposed time for self-destruction: see p553 for Keats’ midnight death wish “to cease upon the midnight with no pain.” For once, Keats was wrong: just before lunch is in fact the favoured time for suicide (11am) in some communities.
Once a person has self-harmed, the risk of death by suicide rises by a factor of 50–100. BMJ 2011 1167
Suicide is powerful: Mohammed Bouazizi (a poor street vendor in Sidi Bouzid, Tunisia) set himself alight after humiliation by an official wanting a bribe, on Dec 17 2010, so sparking the demise of 4 Arab dictators.
Use clinical judgment and assessment tools: medscape.com/viewarticle/730857_5?src=emailthis
If in doubt about the energy with which we may pursue our own destruction,let us call to mind a notable Japanese pilot who, during World War II, persistently volunteered to be a Kamikazi pilot to run suicide missions against US ships, in the defence of Okinawa. The authorities just as persistently refused his request—he had a wife and 3 daughters. He kept on reapplying, determinedly. Not wanting to risk her husband’s failure again, and not wanting to stand in Destiny’s way, his wife killed their 3 daughters, and then herself, so removing the obstacle to her husband’s mission—and on May 28, 1945, he finally took to the air, and achieved his end.
nice says: ‘the decision to discharge a person without follow-up after an act of self-harm shouldn’t be based solely on the presence of low risk of repetition of self-harm and the absence of a mental illness, because many such people may have a range of other social and personal problems that may later increase risk. These problems may be amenable to interventions’.
snri = serotinin and noradrenaline reuptake inhibitor. Avoid if bp⬆, u&e⬆⬇, or heart disease. Specialist use only if >300mg; monitor bp if on >200mg/day. Starting dose: 37.5mg/12h po. se: Constipation; nausea; dizziness; dry mouth; bp⬆; adh⬆; Na⬇; T°⬆; dyspnoea, hallucinations, arthralgia etc: see bnf.
Had Rockland asylum banned witnessing ect, the greatest poem extolling the humanity of mental illness vs military-industrial greed could not have arisen. Carl Solomon’s post-ect babble flowed directly into Allen Ginsberg’s Howl: “I saw the best minds of my generation destroyed by madness, starving hysterical naked, dragging themselves through the negro streets at dawn looking for an angry fix, / Angelheaded hipsters burning for the ancient heavenly connection to the starry dynamo in the machinery of night… I’m with you in Rockland in my dreams you walk dripping from a sea-journey on the highway across America in tears.”
⋆“Men do not care how nobly they live, but only how long, but it is within the reach of every man to live nobly, but within no man’s power to live long. ⋆Life without the courage for death is slavery. ⋆Most powerful is he who has himself in his own power. ⋆Toil to make yourself remarkable by some talent or other. ⋆Fire is the test of gold; adversity, of strong men. ⋆There is no great genius without some touch of madness.”
The Papez circuit of emotion runs from the hippocampus to the amygdala and thence to serotonergic pacemaker cells in the dorsal raphe nucleus (drn). The drn projects to the dentate gyrus directly and indirectly via pacemaker cells in the entorhinal cortex. The direct route promotes neurogenesis in the dentate; the indirect route has 2 purposes: to imprint ongoing moments of consciousness onto new dentate cells for retention as memory, and to provide –ve feedback for regulation. Pathologic overdrive of the drn causes overdrive of the entorhinal cortex, which leads to excitotoxic cell death of neurons in the hippocampus involved in the –ve feedback loop. The disinhibited amygdala and drn then orchestrate the syndromes of chronic stress. Recovery from chronic stress requires repopulating the dentate gyrus and restoring the feedback loop.
Anorexics possibly differ from others in being unable to adapt to corticotrophin releasing factor (crf) elevations. Signs of crf dysfunction and hpa-axis hyperactivity: ⬆physical activity, ⬇reproductive hormones, ⬇sexual behaviour, amenorrhea, hypotension, bradycardia, anxiety, ⬇social interaction, ⬆vigilance, ⬇immune system function, ⬇food intake, impaired weight gain, affecting both energy intake and utilization.
Screen if bmi⬇; amenorrhoea; poor growth if >8yrs; unexplained vomiting; poorly-compliant type 1 dm.
Parents describe parent-to-parent consultations as an intense emotional experience that helps them to feel less alone, to feel empowered to progress, and to reflect on changes in family interactions.
If hypersomnia, hyperphagia, and hypersexuality are features, suspect the Kleine–Levin syndrome.
DaTSCAN comprises ioflupane labelled with radioactive iodide. It is injected during spect imaging to detect loss of dopaminergic neuron terminals in the striatum. Specificity in Lewy body dementia: ~100%.
Supported by the Alzheimer’s Soc. (if it’s not a substitute for 1st class care); restraint is unacceptable.
Social Servicesuk often refuse 24h help saying that needs aren’t complex enough; Courts may reverse this.
Ineligible if: receiving state pension; <35h of care/wk; income >£95/wk after tax; a full-time student.
Real hypersexuality (libido⬆) is rare. Most inappropriate sexual behaviors are related to disinhibition or lack of taking into account contextual environment and feelings of others.
A counter argument from the periodically depressed poet Thomas Krampf: “one can have a vision but no vision is worth anything if one is too sick to implement it”—and many writers have found their creativity flourish more when treatment is underway. M Berlin 2008 Poets on Prozac, Baltimore.
Narcissus was the 1st celebrity to be famous just for being beautiful. He carelessly spurned all lovers, including Echo. Mortified by his callousness, all but her voice was consumed by grief. This disembodied voice now repeats for us the 3 cardinal facts about narcissists:
They never understand others.
Loving a narcissist is a recipe for death.
dspd: give something an acronym and it half exists. Add an nnt (~5!) and the trick is done; we rush to memorize, categorize and research it. To study its causes perhaps we should confront our imagined worlds of myth, language, legalisms, and pure and impure invention, rather than value-free biological or mental health categories. But to be thoroughly sceptical about this scepticism: show us any value-free construct.
Antilibidinal drugs may ⬇testosterone to young-boy levels—but risk liver damage, breast growth, hot flushes, depression and ⬇bone density, eg oral cyproterone acetate (Androcur®). Long-acting drugs (leuprolide, goserelin, triptorelin) can be injected and may be better. ssris are sometimes used (unreliably) to ⬇libido and sexual preoccupation and compulsive re-offending.
Further reading: I Levi Basic Notes in Psychotherapy, Petroc Press isbn 1-900603-50-0
Miriam was the threshing-floor on which he threshed out all his beliefs. While he trampled his ideas upon her soul, the truth came out for him…because of her, he gradually realized where he was wrong. And what he realized, she realized.’DH Laurence p227 of Sons and Lovers But Lucy was mute. Can it be worth taking such a patient to group therapy? Mira accused her of not pulling her weight—this was unhelpful—but another group member piped up with something like “You can be in another world where there’s too much space and meaning to speak…she can only hear your complaining like dead leaves rustling. What you say may have force here… not where she is…listen to her silence.”AS Byatt 2003 p77 of A Whistling Woman
See Sylvia Plath 1963 A Birthday Present in Ariel, Penguin, 50
bmj 2002; 325: 722.1. Good doctor, bad doctor—a psychodynamic approach; Jeremy Holmes (whom we thank for permission to quote from his excellent article).
Projecting our own undesirable impulses to another, so pretending that the subjective is objective.
Displacement: redirection of an undesired intense emotion towards someone neutral and harmless.
Reaction formation: doing the opposite of true desires (eg training to be a pilot to cover up fear of flying).
In sport, for example, we sublimate (and make safe) brutal urges into rituals of formal competition.
cat is collaborative programme for looking at the way a person thinks, feels and acts, and the events and relationships that underlie these experiences (often from childhood or earlier in life). It combines understandings from cognitive psychotherapies and psychoanalytic approaches into an integrated whole.
A Based on a consistent finding in a majority of studies in high-quality systematic reviews or evidence from high-quality studies. B Based on ≥1 high-quality trial, a weak or inconsistent finding in high-quality reviews or a consistent finding in reviews that don’t meet all the high-quality criteria. C Based on evidence from single studies that don’t meet all the criteria of ‘high-quality’. D Based on evidence from structured expert consensus.
All constructed identities are fakes, adult or adolescent, but in adulthood we have more time to reassemble our selected fakes into coherent patterns. For this reason adults are not simply burnt-out adolescents.
Sleep-related dissociative disorder, sleep enuresis, exploding head syndrome, hypnagogic or hypnopompic hallucinations, catathrenia (end-inspiratory apnoea + groaning), sleep-related eating disorders, drug-induced parasomnias, myoclonus nocturnus; nocturnal bruxism, ie teeth grinding..
Punking is male-on-male violence, humiliation, and shaming to affirm masculinity, toughness, dominance and control.
When boys who believe they merit privilege are instead harassed or called gay, they can be driven to avenge ‘wrongs’, and assert a victorious masculinity. Mass shootings may result.Un arc-en-ciel étrange entoure ce puits sombre, Seuil de l’ancien chaos dont le néant est l’ombre Spirale engloutissant les Mondes et les Jours!
Translation ©JML
Around this tunnel plays a strange rainbow arc On the edge of primeval chaos whose hollow form is the spiral dark That swallows up Worlds and Days!
This Act operates in England; Scottish law is different. The situation in the uk is changing and these pages should be read along with current legislation in the area where you are working.
High rates of postnatal relapse occur if past psychosis, perhaps triggered by postdelivery fall in estrogens, causing dysregulation of cns dopaminergic systems. Oestrogens may not prevent this, but of the 40% of women relapsing, those on the high doses of estradiol (800μg/day) need less psychotropics, and are discharged sooner than those on low doses.
