Common Psychiatric Conditions
There are many psychiatric conditions which require expert treatment. Listed here is some helpful information about a few of the more common psychiatric disorders and treatments.
We all know what it is to feel depressed and unhappy from time to time, and for most people such symptoms are short lived and pass off without the need for help. Accordingly, the mood of an individual can alter many times throughout the day in response to events and circumstances. Such fluctuations are usually short lived and of little significance. Because most are appropriate and understandable in the context of situations which provoke them, they are considered normal.
When mood changes occur which are more severe, sustained or recur over a period of time this can be a sign of mental illness that possibly requires medical help. The recognition of these conditions is important, because untreated they can cause prolonged suffering which may in turn lead to serious disruption of someone’s life and in a few cases the risk of suicide.
When someone is suffering from a depressive episode (sometimes referred to as clinical depression), the principal feature is a persistent lowering of mood. In the most severe form, the subject is unable to enjoy anything in life and as a consequence the world seems dull, grey and joyless. In addition to important changes in thinking, perception, concentration and memory, a number of physical and other changes can occur which are widely thought of as having special significance.
Sleep is disturbed, with the subject characteristically waking in the early hours and then unable to sleep any more. The morning may be experienced as the most difficult time of the day when mood is at its lowest and mental and physical activity almost impossible to initiate. As the day progresses, mood usually improves so that by the evening the subject feels relatively normal. Poor appetite is common and weight loss may be dramatic. Some patients stop eating and drinking completely and their management becomes a medical as well as a psychiatric emergency. Bowel function is frequently disordered, with constipation, a common complaint. Reduced energy leads to increased tiredness and a low level of activity. Patients sometimes take to their beds or sit in a chair for long periods with expressionless faces, hardly talking or moving and showing little interest in their surroundings. Alternatively they may show signs of extreme agitation with an inability to sit still, frequently pacing up and down or wringing their hands constantly asking for but deriving driving little reassurance from others. A reduced interest in sex and impotence are sometimes features of depression whilst some women may cease to menstruate.
Ideas of guilt, self-deprecation and worthlessness can occur which in extreme cases may become delusional in intensity. For example, sufferers sometimes believe that they are responsible for all the ills of the world, or convinced that they will be punished for some terrible crime. Delusional ideas may also be expressed about the physical state of their bodies. Severely depressed patients may believe that their intestines have rotted away or their blood vessels are filled with poison.
Severely depressed individuals may describe the future as black or hopeless and see no chance that matters can improve. Suicide, is therefore an ever present risk.
Very rarely in severe depression the sufferer experiences auditory hallucinations and is troubled by voices talking to him. Their content is frequently deprecatory saying such things as ‘you’re no good’ or ‘you deserve to suffer’.
The management of depression will depend to some extent upon the presenting features of the illness as well as it causation.
The severity of the illness is the main factor in determining whether someone should be treated at home or in hospital. The majority of cases are mild and can be managed successfully in outpatients or through the general practitioner. More severe cases may require admission to hospital, particularly if there is a serious risk of suicide or the person is unable to cope with their usual responsibilities. Patients not eating or drinking adequately, or who live alone may also require admission.
Treatment of depression includes
1. Physical treatments which include drug therapy and electroconvulsive therapy
2. Psychological treatments involving psychotherapeutic and cognitive techniques and
3. Social aspects of treatment utilising community support and rehabilitation
Antidepressants have been available since the 1950s and currently there are more than 30 different types to choose from. They appear to work by increasing the level of chemical messengers in the brain (notably serotonin and/or noradrenaline) which are involved with mood regulation.
Antidepressants don’t work immediately and take between 2-3 weeks before their mood lifting effect is evident. They are not ‘happy pills’ inasmuch that what they do is to normalise mood rather than create an ‘artificial high’.
All classes of antidepressants have side effects, but for most people they are mild and short lived. The reason why one preparation may be chosen over another is to alleviate specific symptoms, to avoid interactions with other drugs or in some cases of NHS prescribing, to reduce cost. For example, when agitation is a strong component of a depressive illness an antidepressant with sedative properties may be useful and if appetite and weight loss are prominent features, then a compound that increases appetite may help. SSRI antidepressants can’t be given with some types of migraine treatment and caution should be advised if anti-inflammatory drugs, such as ibuprofen, are used with them.
Patients sometimes worry that once prescribed an antidepressant they will stay on it forever. The usual length of time to remain on antidepressant medication varies between six months and a year, and dosages may be tailed off in anticipation of stopping the drug.
The SSRIs are widely used as a first line of treatment and this group includes fluoxetine (Prozac) and citalopram (Cipramil) Even though drugs in this group only work on one of the chemical messengers involved in mood regulation, they’re highly effective and also have a place in treating anxiety. Common side effects includes mild feelings of nausea in the first week of taking the drug, increased sweating, a change of bowel habits and a muzzy feeling in the head.
SNRI drugs such as venlafaxine and duloxetine may be used if SSRIs prove to be unsuccessful and some patients may respond particularly well to the older tricyclic compounds. This group of drugs tends to be used less commonly now because they are prone to produce troublesome side effects such as dry mouth, constipation and a tendency to feel faint if you stand up too quickly (postural hypotension). They are also not as safe in overdosage as some of the newer compounds.
There are a number of antidepressants such as reboxetine, mirtazapine and agomelatine which do not fall in to the categories listed above and may be used as alternatives to SSRIs or tricyclic antidepressants. Mirtazapine is helpful because it improves sleep and reduces anxiety although it can cause significant weight gain. Agomelatine is a more recently introduced compound which seems to have fewer side effects in respect of weight gain, sexual dysfunction and sedation.
The MAOI antidepressants were the first group of antidepressants introduced in the 1950s and these are now rarely used because they can have problematic interactions with certain foodstuffs (such as cheese and types of wine) making them less convenient and safe to use than newer compounds.
Sometimes doctors may use antidepressants in combination ( for example an SSRI and mirtazapine) when depression fails to respond to one compound alone.
ECT is a physical treatment used mainly in the treatment of severe depression but occasionally it is given to patients with drug resistant mania and rarely some types of schizophrenia.
Because it involves the passage of an electric current through the brain, the use of ECT is emotive. Despite this, the treatment is in fact very safe and the very small risk of fatality is mainly associated with the administration of the anaesthetic rather than the procedure itself. For these reasons, ECT is not usually considered as a first line treatment for depression, despite the fact that antidepressant drugs (and indeed the untreated illness) are themselves associated with significant rates of mortality.
ECT is the treatment of choice in patients with severe depression who have failed to respond to adequate courses of antidepressant medication. It is also offered where there is a serious risk to life through a refusal to eat or drink, self-neglect or active suicidal intent.
How ECT works is not clearly understood but it probably increases the sensitivity of nerve receptors in the brain to chemicals that control mood.
It is usually administered in the morning and the patient has nothing to eat or drink from midnight onwards. The subject is given a short-acting general anaesthetic and the anesthetist also administers a muscle relaxant to prevent severe spasms which would otherwise occur.
Once the patient is asleep, electrodes are placed on both temples and a short burst of current is passed between them for approximately 4 seconds to induce a fit. Because of the effect of the muscle relaxant, all that may be evident when watching the treatment is a slight twitching of the toes or flickering of the eyelids, although more powerful contractions of the limbs are sometimes observed.
The treatment is usually given twice a week and improvement is often noted after the third or fourth session. Most patients require between four and eight treatments for recovery of their depression although sometimes many more sessions are required.
As well as individuals becoming unhappy and depressed, mood disorders can sometimes involve a persistent elevation of mood with an increased sense of well-being which is referred to in milder forms as hypomania, and in severe cases as full-blown mania. The latter is uncommon, usually because help is sought or treatment instigated before the extreme phase of the condition is reached.
Individuals with bipolar disorder (sometimes referred to as manic-depression) have had at least two episodes of illness in which mood and activity levels are significantly disturbed; on some occasions being consistent with a diagnosis of mania or hypomania and on other occasions with that of a depressive episode. Patients who suffer only from repeated bouts of mania are also classified as having bipolar disorder as they have similar family histories, background personalities, age of onset and prognosis as those also have at least occasional episodes of depression.
Hypomanic patients typically have an abundance of energy which manifests itself in terms of speech, thought and action. Talk is characteristically increased and rapid and sometimes contains rhymes, jokes or puns. During conversation, the patient may suddenly burst into song or emphasise words with expansive theatrical gestures. As the condition progresses, speech can become unintelligible, not only due to excessive speed, but also because connections between thoughts and words become increasingly disjointed (flight of ideas). When asked, the patient may describe his thoughts as racing. A decreased need for sleep is often associated with frenetic planning and activity resulting in physical exhaustion. Although numerous tasks might be undertaken simultaneously, few if any are completed. Hypomanic patients are highly distractible with poor powers of concentration.
The subject’s appraisal of himself often alters too, varying from an increase in self-esteem to markedly grandiose ideas or delusions. In the belief that he is a person of great importance with special powers or talents, he may undertake spectacular ventures, such as attempting to meet personalities, politicians or royalty. At a more mundane level, advice may be offered on matters which are totally outside the realm of his knowledge.
Loss of financial constraint can result in the purchase of unusual or unnecessary items whilst money may be given away to casual acquaintances with serious debts incurred.
The appearance of manic patients is sometimes indicative of their condition, with bright and garish clothes being worn and females displaying excessive amounts of poorly applied makeup. Social activity usually increases such as renewing old acquaintances by telephoning them in the middle of the night! Disinhibited behaviour is common, especially in terms of heightened inappropriate sexual activity. Hallucinations when experienced are frequently understandable in the context of the altered mood state. Hearing the voice of God or Jesus telling the individual to lead others to salvation or believing that they are a person of great importance is not uncommon.
Although brief episodes of depression are common in manic illnesses, they are rarely sustained. However, when somebody describes a predominantly depressed mood and thought content, in the setting of manic behaviour this is known as a mixed affective state.
Some but not all patients with hypomania or mania will require hospitalisation. Even in the early stages of the illness, judgement may be impaired and when associated with reckless and disinhibited behaviour could lead to adverse consequences for the individual or their family. Lack of insight, combined with a subjective sense of well-being, may result in the patient refusing medication so that effective outpatient treatment is impossible. Admission to hospital under such circumstances not only provides a safe and secure environment but ensures regular compliance with drugs until recovery.
Patients with bipolar affective disorder usually require a mood stabilising drug such as lithium, carbamazepine, sodium valproate or lamatrogine. The choice of drug is sometimes determined by whether hypomanic or depressive episodes are more frequent, as well as the individual’s tolerance of different preparations or possible medical contraindications to one or another drug being taken.
Psychotherapy is a term that covers a number of different treatments, all of which use talking and listening to bring about relief from specific symptoms or to help people adjust and cope with the problems of everyday life.
Psychotherapy may be conducted with individuals, couples, families, small groups of approximately 6-10 people as well as with large groups of 20 or more. In all cases, the relationship that develops between the subject and the therapist is important in bringing about change.
In addition to the number of people involved, psychotherapy can be further considered in terms of duration of treatment and the complexity of the procedure. Some forms are relatively simple and conducted for a brief period of time (counselling is a form of brief psychotherapy with limited objectives) whilst others may last for years and are both intensive and emotionally demanding.
Nevertheless, neither duration nor complexity of treatment are necessarily equated with effectiveness, and sometimes a sympathetic and carefully taken history is itself a gratifying and therapeutic experience for the patient.
Psychotherapy can be broadly differentiated into supportive and dynamic types. Supportive psychotherapy is aimed at reducing anxiety, and carrying or supporting the individual at a time when continuing stress is likely to result in a breakdown of functioning.
Dynamic psychotherapy fulfils similar functions, but in addition aims to bring about change by detecting and resolving underlying psychological conflicts which are the root cause of disturbed personal relationships and the unpleasant symptoms which often accompany them. For this reason, it is frequently anxiety provoking although it does aim to provide support and comfort when needed.
Psychotherapy provides an opportunity for people to make sense of their problems and to discover ways of dealing with them more effectively. Many of those who enter therapy have already tried and failed to overcome their difficulties, which may have had an adverse affect on their morale. A consequence of therapy is therefore an increase in self-esteem and facilitating the release of emotion sometimes resulting in the lowering of arousal and the relief of distress.
Supportive psychotherapy aims to minimise disabling symptoms by encouraging the ventilation of feelings, demonstrating empathy with the individual’s worries and offering advice where appropriate. This can be accomplished without necessarily trying to understand the fundamental origins of the presenting difficulties. The majority of people with psychological problems respond to help at this level, and the procedure is frequently used in conjunction with other forms of treatment, such as psychotropic drugs or behavioural therapy.
Individual Dynamic Psychotherapy
Dynamic psychotherapy is practised in a number of forms which differ according to their aims and duration of treatment. In brief dynamic psychotherapy, weekly sessions are usually conducted over a period of 3-6 months, during which treatment focuses on the major conflicts which underlie presenting symptoms or personality problems. In intermediate analytical psychotherapy, patient and therapist normally meet two or three times per week over a period of six months to 3 years. The nature of the work undertaken may be very similar to that in psychoanalysis. The latter can last for several years with up to 5 sessions a week being held, during which time a detailed and intensive exploration is conducted into the patient’s behaviour and psychological functioning.
This form of treatment is based on the principle that maladaptive behaviour and abnormal mood states can be altered by changing thought patterns. It is mainly used in the management of depression and several studies have suggested that it is at least as effective as drug treatment.
One of the main objectives of cognitive therapy is to help individuals to be aware that they are largely responsible for the nature of their negative emotions and the manner in which they are perpetuated or exacerbated. It also offers ways of helping people deal effectively with such unwanted emotions.
According to cognitive theory, people who are depressed maintain their low mood by adopting a pattern of thinking which includes:
1. Focusing on misfortunes rather than pleasant happenings
2. Interpreting events in a negative way without considering alternative explanations (‘because my boss appeared angry this morning, he is obviously displeased with my work’)
3. Attributing excessive importance to trivial mishaps (‘forgetting to post that letter proves I am a useless secretary’)
4. Making unrealistic assumptions (‘I can only be happy if I earn a great deal of money’)
One aspect of therapy involves the subject noting his assumptions and patterns of thinking throughout each day, and recording them in a diary alongside his interpretation of significant events which occur (antecedents, behaviour, consequences). By regularly examining the entries with the patient, the therapist can be of assistance in a number of ways:
1. Helping him to adopt a more balanced perspective of his life (by demonstrating that pleasant happenings occur just as frequently as misfortunes)
2. Generating alternative explanations to his interpretation of events (your boss may have looked angry because he had a row with his wife)
3. Helping him to acknowledge his strengths and attributes, as well as his weaknesses (‘despite forgetting to post the letter, you managed to finish typing the Chairman’s report a day ahead of time’)
4. Generating alternatives to negative assumptions (‘your brother earns very little, and yet you say he is always cheerful’).
Over a period of time, maladaptive patterns of thinking are replaced by more creative ones, which in turn should lead to an elevation of mood, increased involvement in pleasurable pursuits and a more optimistic view of the future.
Used in moderation, alcohol confers a number of obvious advantages such as increased confidence, a sense of well-being and temporary relief from stress. The vast majority of drinkers experience no long-term ill effects, but in a minority, problems can develop through misuse.
The term alcoholic has serious limitations because the problems associated with alcohol misuse are so diverse and can occur with widely varying levels of consumption.
A more useful, practical descriptive term uses the term alcohol related disabilities, that can manifest as physical, psychological and social difficulties. The proportion of people who develop such problems within a population has been shown to rise in relation to total alcohol consumption.
The standard unit of alcohol is an important concept to understand, as it allows reasonably accurate measurements of alcohol consumption, irrespective of the type of beverage.
One standard unit of alcohol is approximately equal to a half a pint of beer, one single spirit, one glass of wine or one small glass of sherry. The average bottle of spirits contains 28 units and a bottle of wine between seven and 10 units of alcohol depending upon its strength.
It is generally accepted that the upper limit of alcohol consumption which constitutes safe drinking is 21 units per week for men and 14 units per week for women. This represents a man who drinks on average up to 10 pints of beer per week and a woman who consumes no more than two bottles of wine per week. Those who drink in excess of these amounts are at increased risk of developing many of the physical psychological and social complications associated with prolonged heavy drinking.
Problem drinkers are those whose alcohol consumption is either continuously or intermittently out of control thereby causing physical, psychological or social damage to themselves or other people.
Dependent drinkers are those in whom signs and symptoms of alcohol withdrawal develop when they stop drinking. The term alcoholic is commonly applied to this group, but the expression alcohol dependency syndrome is used in a wider context to describe not only a state of mental or physical disturbance when alcohol is stopped, but also recognisable patterns of drinking behaviour.
Once dependence is established, a wide range of symptoms can occur when alcohol is withdrawn. These eventually disappear with continued abstinence or if further drinking occurs. They may be conveniently divided into simple withdrawal symptoms, withdrawal fits and delirium tremens.
Alcohol abuse is associated with numerous physical disorders which can affect the central nervous system, the heart and endocrine glands, the blood and the musculoskeletal system as well as the liver.
Psychological impairment due to alcohol abuse in serious cases can lead to a dementia and a rare but serious condition called with Wernicke Korsakoff syndrome which affects the memory and day to day functioning.
The social consequences of excessive drinking become more evident as alcohol increasingly monopolises the drinker’s life.
Marital problems and divorce are common, with both the spouse and children at risk of being subjected to violence or neglect. Financial hardship and social deprivation often result from the reduced earning power of the drinker, as well as from a large part of the family budget being used to pay for alcohol.
Accidents at work and at home are three times more common amongst heavy drinkers than the general population. A significant number of road accidents in England and Wales are alcohol-related.
Criminal acts are strongly associated with alcohol abuse. These include a wide range of offences committed under the influence of alcohol as well as stealing in order to finance the habit. Half of all violent crimes are alcohol-related and 40% of the prison population admits to excessive drinking.
Employment records of men drinking in excess of 21 units of alcohol per week show that they have over twice as many days off work as those who maintain their intake below this level. Not surprisingly, they are more likely to be dismissed for poor time keeping and repeated absenteeism, as well as being prone to frequent job changes.
Treatment of alcohol abuse needs to be considered in terms of both general and specific measures.
Before entering into any form of therapy, the individual’s motivation and level of insight into the nature of his or her problem needs to be assessed. Denial is often evident and it may be necessary to speak to other family members to determine the true facts. Attending for ‘medical help’ is not in itself indicative of a desire to stop drinking, as the subject may have been pressured into doing so by his employer or spouse. Similarly, in those individuals where the problem is discovered indirectly, there is little point in starting a programme of treatment if they are clearly unwilling to stop drinking. Motivation is not an all or none phenomenon and may drinkers may need several attempts at giving up before they finally succeed.
Once a commitment to stop drinking has been made, the establishment of a good rapport between subject and therapist is the foundation of a successful outcome to treatment.
The setting of short-term realistic goals maximises the chance of a successful outcome. For example suggesting that the subject abstains from alcohol for two weeks in the first instance is more likely to engender a favourable prognosis than stating at the outset he must never drink again for the rest of his life. Others may find the AA philosophy of one day at a time more acceptable.
Appropriate reinforcers can be offered, such as demonstrating an improvement in physical health or by comparing the results of liver function test before and after a period of abstension. Further rewards may be negotiated, such as gaining a commitment from a spouse to stay with her partner whilst he remains drink-free. Once the initial goals have been achieved, the period of abstention can be extended by offering new incentives.
Encouraging the individual to draw up a balance sheet which lists the benefit versus the disadvantages of continued drinking can often be helpful. Alterations in lifestyle may help to minimise those cues which lead to drinking. For example, going home by an alternative route to avoid the pub, when meeting with work colleagues might otherwise result in round buying. Similarly, a man in a high risk occupation with easy access to alcohol is unlikely to succeed in his attempt to stop drinking unless he changes his job.
Drugs are sometimes used in detoxification to control simple withdrawal symptoms and prevent more serious side effects, such as delirium tremens or fits. Other drugs, such as Antabuse may be administered as a form of aversion therapy to prevent a relapse into drinking after abstinence.
Antabuse, can be taken in tablet form daily and if alcohol is then consumed a reaction occurs producing a chemical acetaldehyde which leads to nausea, vomiting, headache, fainting, abdominal cramps and flushing of the face which is sufficiently unpleasant to deter further drinking. The limitation of this form of treatment is that success depends upon the subject’s motivation to take the medication regularly. Unfortunately, a few individuals have been known to drink through their Antabuse treatment with disastrous consequences.
Various forms of psychotherapy are used in the management of alcohol abuse. Brief counselling sessions, group work and individual supportive and dynamic psychotherapy are all advocated. Empathy, warmth and genuineness are important components of all of these treatments.
Alcoholics Anonymous, is probably the most well-known form of group therapy and was started in the United States in the 1930s by a stockbroker and a surgeon both of whom were reformed drinkers. The philosophy of AA has now spread worldwide and promotes a policy of total abstinence from alcohol, whilst encouraging members to adopt an approach of ‘one day at a time’ in order to overcome their problems. Simple advice and mutual support are offered at group meetings, and although the effectiveness of this form of treatment has not been scientifically evaluated (because few records are kept) AA is probably helpful to many of its large following. Al-Anon-provides support for families of problem drinkers.
Dementia is a degenerative disorder in which brain cells die off leading to impairment of memory, thinking, intellect and personality. In dementing illnesses, deterioration can sometimes occur over several years, often with profound consequences for both patients and their families.
There are various causes of dementia and some treatments are available which can slow down the progress of the disease rather than reverse it.
Alzheimer’s disease is the commonest form of dementia and other forms such as multi-infarct dementia are caused by damage to blood vessels which cause groups of brain cells to die. There are also other rare forms of dementia such as variant CJD also known as mad cow disease.
Dementia usually has a gradual onset and in the early stages there may be little evidence of disability, other than the occasional lapse of recent memory which is often interpreted as normal forgetfulness. Aspects of the personality are sometimes exaggerated so that someone who has always been set in their ways may become increasingly rigid and inflexible in their manner. An understanding of what is happening is often retained during the early phases so that the sufferer can become anxious and depressed at the realisation of failing faculties.
As further deterioration develops, diminishing intellectual and memory loss is more apparent and this can sometimes lead to the development of persecutory beliefs particularly, if lost or misplaced articles are assumed to have been stolen.
Wandering at night or neglect of personal hygiene, diet and clothing are often a major cause for concern for relatives and other caregivers. Explosive displays of emotion in response to demands beyond the subject’s capabilities known as catastrophic reactions may also be seen. Thinking becomes slow and restricted and the sufferer may repeat themselves over and over again to the frustration of their carers.
In the later stages of the illness there is a progressive deterioration of the personality so that emotions become blunted, associated with apathy and loss of insight. Socially unacceptable behaviour such as aggressiveness, sexual disinhibition and incontinence often increase and are eventually accompanied by a general deterioration in physical health. Ultimately, the subject becomes bedridden with death frequently resulting from an associated physical illness.
The primary aim of management in cases of dementia is to maintain the quality of the subject’s life and standard of functioning at an optimal level for as long as possible. Patients should preferably be kept at home so as to minimise the confusion and disorientation which is likely to occur if he or she is placed in an unfamiliar environment. The maintenance of good physical health is important to prevent accelerated deterioration.
People with dementia rarely ask for help themselves and it is usually left to distraught relatives and other caregivers to enlist professional support. It is therefore vital to consider the demented patient together with those who support him in the community as a unit, and deal with their collective needs accordingly.
Drug treatment of dementia such as acetylcholinesterase inhibiting drugs are used in mild to moderate forms of the disease. Up to half of patients given these drugs will respond with a slower rate of decline in mental functioning.
To many lay people, schizophrenia means a split personality, a Jekyll and Hyde character who sometimes behaves quite normally and at other times is evil or mad. Unfortunately, this is a misinterpretation of a term which literally means ‘split mind’, and refers to a shattering or disintegration of the various mental functions which allow us to lead fulfilling and purposeful lives, rather than a division of the personality into two opposing types.
Schizophrenia is a very complex disorder which can have widely ranging symptoms. It is often referred to as a psychosis, a term which is applied to those conditions in which there is an impairment of mental function of such a degree, that it interferes with the ability to meet the demands of everyday life and to maintain adequate contact with reality. The latter can be lost through the individual either harbouring abnormal beliefs which are clearly false known as delusions, or experiencing perceptions or misinterpretations of their senses known as hallucinations and delusions.
In the early or acute stages of the illness suffers may be preoccupied with hearing voices which talk about them when nobody else is present or they believe that external forces, such as laser beams, control their actions. In addition, their speech may be incoherent or irrelevant and abnormalities of movement or posture may be evident.
In some cases, the condition may progress to a seemingly unrelated chronic state in which problems with social interaction and motivation occur. In this phase which is known as residual schizophrenia or a defect state, sufferers are completely apathetic, withdrawn and isolated as if their personality has been sucked out of them.
Drug treatment is the mainstay of therapy in the acute phase of schizophrenia and medication is often effective in normalising thinking by the elimination of abnormal beliefs and hallucinations. The drugs are not without side effects, although the new atypical antipsychotics are less prone to produce abnormal movement disorders but may have other problems associated with them such as severe weight gain.
Those sufferers who have little or no insight into their illness and refuse to take medication may be offered medication in the form of weekly or monthly injections known as depot preparations.
Support for the individual and their families is absolutely vital in reducing the impact of schizophrenia. Family-based therapy may attempt to assist the patient and family to reduce environmental stress as well as avoiding inactive and impoverished surroundings, which can reduce the number of social handicaps.
Occupational therapy is very important to enable sufferers to lead purposeful and useful lives and function to the best of their ability.
Everyone knows what it is to feel anxious, which is a very common experience in response to stress. Small amount of anxiety can benefit functioning by increasing efficiency, alertness and concentration. However, when anxiety increases so that it is out of proportion to any given set of circumstances it becomes a hindrance and may need treatment.
Sometimes people can identify the cause of anxiety states, but this is not always the case since attacks can also arise spontaneously. When the fear that develops leads to avoidance of the given situation it is referred to as phobic anxiety.
Anxiety disorders may be generalised and persistent or recurring in the form of unpredictable panic attacks.
Generalised Anxiety Disorder
In generalised anxiety disorder, anxiety persists and is sometimes referred to as ‘free-floating’ so that it doesn’t occur in specific situations or in response to a particular stimulus. Symptoms are usually present on most days for at least several weeks at a time and usually for several months. Symptoms include apprehension, a fear about the future and a sense of foreboding, difficulty in concentrating and feelings of irritability.
Increased muscle tension may be evident including headache caused by muscle tension in the scalp and neck, chest pain, backache and limb stiffness.
Physical symptoms caused by overactivity of part of the nervous system can result in breathlessness, palpitations diarrhoea and vomiting, abdominal cramps, dry mouth, sweating, restlessness, tremor and a need to pass urine.
Sleep disturbance is common and characteristically anxious people have difficulty getting off to sleep and may wake intermittently throughout the night.
Panic disorder is characterised by recurrent bouts of severe anxiety which are unpredictable and not confined to specific situations and circumstances. Several attacks usually occur within a period of one month under circumstances with no objective danger. The onset of an attack cannot be predicted in any particular situation. Between attacks, the individual usually feels calm and free of anxiety other than maybe a fear of further attacks occurring.
During an attack, which typically last for several minutes, symptoms include breathlessness, heart pounding, dizziness, tightness in the chest, feelings of sickness, sweating and a choking sensation. Feelings of unreality are frequently reported known as depersonalisation often associated with a fear of dying, losing control, causing a scene or going mad.
Simple support through talking and listening is of fundamental importance in helping anxious individuals. Behaviour treatment and teaching anxiety management and relaxation skills will enable sufferers to recognise and relieve muscular tension and to control irregularities of breathing. By becoming physically relaxed, mental relaxation follows as a matter of course.
A wide range of drugs are used in the treatment of anxiety states. Benzodiazepines such as diazepam and lorazepam are minor tranquillisers which became very popular for treating anxiety disorders as they are effective, safe in overdosage and initially thought to be nonaddictive. However, it is recognised that they do cause dependency and withdrawal symptoms (feeling tense, tremulous, sweaty and panicky) which commonly occur when the drugs are stopped. Consequently, they should only be prescribed in short courses and at a low dosage.
Beta-blockers, such as propranolol, are useful in the treatment of anxiety disorders when physical symptoms are prominent and distressing. These drugs are nonaddictive, but contraindicated in certain medical conditions such as asthma, heart failure and diabetes.
Antidepressant drugs can also be helpful in alleviating anxiety. The anticonvulsant pregabalin has also been shown to be an effective anxiolytic, and in some cases can produce spectacular improvement.
Normal fears are common amongst children and some adults. For example, a mild fear of heights, darkness, mice or spiders is considered to be within normal limits in our culture, provided it doesn’t interfere with an individual’s ability to carry on with everyday life. If the fear becomes more intense and handicapping it is called phobic anxiety.
In phobic anxiety
1. The fear is out of proportion to the demands of the situation
2. It cannot be reasoned or explained away
3. It is beyond voluntary control
4. The fear leads to avoidance.
The three main types of phobic anxiety are agoraphobia, social phobia and specific phobias.
The literal meaning of this term is ‘a fear of the marketplace’ but it is used in a wider context to include individual who become anxious or afraid in crowds, when they travel on public transport or in lifts and when they go shopping or leave the safety of their homes. The fear is often heightened in places that cannot easily be left, such as a crowded room or restaurant.
In social phobias which frequently have an onset in early adult life, there is a fear of being scrutinised or looked at by other people in comparatively small groups (as opposed to crowds) leading to avoidance of social situations. The sufferer usually expresses fear about behaving in an embarrassing or humiliating way (such as vomiting or fainting in public) and complains of blushing, shaking or nausea in anxiety provoking settings leading to avoidance behaviour.
Specific or isolated phobias are restricted to specific situations including fears of spiders, dogs, heights, flying, darkness or going to the dentist.
The mainstay of treating phobic anxiety disorders is through the behavioural treatment of exposure. This is based on the principle of encouraging the subject to reenter situations which provoke anxiety and to remain in them until the fear subsides.
Graded exposure is an approach whereby the subject is progressively exposed to the feared situation one step at a time. The therapist must first gain the subject’s trust, and explain that avoiding situations act to maintain the phobia. A hierarchy of anxiety provoking stimuli is then constructed with steps of increasing difficulty. In the case of an agoraphobic patient with a fear of leaving the house to go out shopping alone, stages might involve walking to the gate at the end of the front path, then to the bus stop at the end of the road, boarding a bus to go to the shops, entering a quiet shop to purchase one article, than buying groceries at a supermarket unaccompanied.
The individual is able to proceed up the hierarchy when the anxiety for the preceding state has become minimal. It is helpful if each attempt at exposure is recorded in a diary so that sufferers can monitor progress. If at any stage the level of anxiety becomes unbearable and running away is contemplated, control may be regained by relaxation training.
Obsessive compulsive disorder (OCD) sufferers either have obsessional thinking and/or compulsive behaviour.
Obsessional thoughts are recurrent ideas, images or impulses which come into the mind and are persistent, intrusive, unwelcome and usually upsetting. Attempts are usually made, albeit unsuccessfully, to ignore or resist them.
Compulsions or rituals are obsessional motor acts which are performed with reluctance, since they are regarded as absurd and out of character. The act is therefore carried out with a sense of compulsion coupled with a desire to resist. If resistance is attempted, anxiety mounts and can only be reduced by giving in. In severe cases, symptoms can be very distressing and crippling in their effect on a person’s life. Sufferers may spend hours on end preoccupied with their obsessions or performing rituals so that they are unable to work, relax and socialise.
Compulsions or motor acts are easier to treat than obsessions but in both cases behaviour therapy is the cornerstone of management.
Compulsive acts may be helped by response prevention. In this form of behaviour therapy the subject is instructed to desist under supervision from carrying out unwanted behaviour. This leads to an increase in anxiety, which eventually subsides along with the compulsive behaviour if the subject is able to desist from performing his rituals. Certain acts, such as compulsive handwashing are often associated with a fear of contamination. Under these circumstances it may be helpful for the subject to practise restraint by deliberately dirtying their hands and then resisting the urge to clean them.
Satiation is the treatment of choice in the management of obsessions. The person is asked to record his or her ruminations onto a tape that repeats itself every 20-30 seconds for a period of half an hour or even longer.
Disturbed sleep is a problem that everyone encounters from time to time, and many people complain of difficulty in sleeping or feeling tired the next day. Eight hours a night is generally accepted as the norm, but in reality there is a huge variation in requirements, some people needing no more than 3 or 4 hours whilst others need as much as 11 hours.
The key to understanding sleep requirements is down to quality not quantity, and how tired you feel during the day. If you are constantly nodding off or feeling perpetually fatigued then you are not sleeping enough.
Sometimes no clear cause can be established for sleeplessness, but in other cases insomnia arises as a result of stress, a change of routine or is attributable to excessive consumption of alcohol, caffeine or other stimulant drugs. Worrying about not sleeping is often self-perpetuating, and many people present with chronic insomnia of this kind.
Occasionally, insomnia is the presenting or prominent feature of a psychiatric or physical illness. For example, anxiety disorders are associated with difficulty in falling asleep as well as a tendency to waken repeatedly through the night. In depressive episodes, early morning waking may be a problem whilst in manic episodes or hypomania, there is a reduced need for sleep, so that those affected may not sleep for more than 1 or 2 hours per night.
Sleep apnoea is strictly speaking not a sleep problem but is due to respiratory obstruction during sleep, often associated with being overweight.
When insomnia is a symptom of a physical or psychological illness, treatment of the underlying disorder often leads to a resolution of the problem. Similarly, sleeplessness resulting from anxiety or worry requires an assessment of current difficulties, and the formulation of plans to overcome them.
In other cases, drugs that help sleep (hypnotics) such as benzodiazepines (like diazepam or nitrazepam) or the ‘z’ drugs (zopiclone or zimovane) are sometimes used, but should only be prescribed for brief periods in order to avoid dependence. Pregabalin, is a useful addition to the repertoire of sleep inducing drugs as it is the only preparation which increases slow wave sleep, associated with feeling refreshed the following day.
Behavioural programmes to induce better sleep can sometimes be very effective and have the added advantage of improving sleep without resorting to medication.
Many of the problems associated with poor sleep can be overcome by taking stock of common difficulties such as a snoring spouse, an old and lumpy bed, an overheated room or an uncomfortable pillow.
Bed needs to be seen as a place where you sleep rather than lying there thinking about sleep so that changing routine is frequently an important part of ‘sleep hygiene’. The following routine is often helpful
1. First, it is important to set a time for getting up, no matter how well or badly you’ve slept, and set your alarm clock accordingly.
2. From seven pm onwards, avoid all stimulants in the form of caffeine-containing foods, e.g. tea coffee, chocolate and cola drinks. Also avoid alcohol after 7pm as this will disrupt your sleep pattern.
3. It is not just ‘advertising hype’ but there is evidence to show that malted milk drinks, (not the chocolate variety!) can be helpful in inducing sleep.
4. Do not go to bed until you feel ready to fall asleep. Even if you have an established routine, of say, going to bed at 11pm, ignore this until you are ‘fit to drop’.
5. Once you are asleep, if you wake up, get up. Do not lie in bed for more than 5 minutes thinking and ruminating that you should be asleep. Once you are up, do something that is sleep inducing, such as reading a book, watching night-time TV or a video. Do not get up and make a cup of tea or coffee.
6. Stay up until once again you feel ready to go back to sleep. Whatever, time this is, you must then get up as prearranged when the alarm goes off. So, for example if you go to bed at 1.30am and wake at 3.30am and remain awake until 5.30am when you then go back to bed, you must get up at 7.30am, however tired you may be when the alarm goes off.
7. Under no circumstances catnap the following day and ensure you follow exactly the same routine the next evening.
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Weekend / early-morning consultations are available.
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Watford, Herts WD23 1RD
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