Dr. Robert Cohen

Dr. Robert Cohen logo

Consultant Psychiatrist

Dr. Robert I. Cohen - MBBS, LRCP, MRCS DRCOG, MRCPsych Dip Crim

Contact Dr. Cohen

Recognised by all major medical insurers. Credit card payments welcome for self‑funded treatment.

Dr. Robert Cohen portrait
 

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.

1. Depression

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

2. Antidepressants

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.

3. ECT

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.

4. Bipolar Disorder

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.

5. Psychotherapy

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

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.

6. Cognitive Therapy

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.

7. Alcohol Abuse

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.

8. Dementia

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.

9. Schizophrenia

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.

10. Anxiety Disorders

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.

11. Phobias

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.

Agoraphobia

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.

12. Obsessive-compulsive Disorder

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.

13. Sleep Disorders

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.

14. Post-Traumatic Stress Disorder (PTSD)

Once called ‘Battle fatigue syndrome’ or ‘shell shock’, PTSD is an anxiety reaction to a traumatic event that can occur at any age. A traumatic event is one where we are in a life-threatening situation, or where we witness other’s dying or being injured i.e.

  • Serious accidents
  • Military combat
  • Violent personal assault
  • Terrorist attack
  • Natural / man-made disasters
  • Being taken hostage
  • Being a prisoner-of-war
  • Being diagnosed with a life-threatening illness.

PTSD can start immediately after the event or after a delay of weeks or months.

Symptoms of PTSD

Flashbacks and nightmares

Flashbacks to the event occur during waking periods, whereas nightmares are when you are asleep. Both can appear so realistic that you ‘re-live’ the experience, which triggers the same emotions and physical sensations of what occurred.

Flashbacks can be triggered by every day situations / items.

Avoidance & numbing

Avoid people so that you don’t have to talk about the experience. Avoiding places that remind you of the trauma. Busying yourself with work / hobbies etc to stop yourself from thinking about the trauma.

Numbing by way of breaking emotional links with people, trying to feel ‘nothing at all’ rather than the emotions associated with the trauma.

Being ‘on guard’.

You’re constantly on alert and looking out for danger. You are unable to relax. You are anxious and find it difficult to sleep. You will be jumpy and irritable.

Other symptoms can include:

Physical Manifestations

  • Muscle aches / pains
  • Diarrhoea
  • Irregular heartbeats
  • Headaches

Psychological Manifestations

  • Feelings of panic and fear
  • Depression

Behavioural Manifestations

  • Drinking alcohol excessively
  • Using drugs (including over the counter painkillers) to excess.

Treatment and Prognosis

As PTSD is both a physical and psychological condition the treatments are both physical and psychological. Treatments include:

Psychotherapy

  • Learning to think differently.

Cognitive Behavioural Therapy (CBT)

  • A talking therapy to change extreme ways of thinking.

Eye Movement Desensitisation & Reprocessing (EMDR)

  • Uses eye movements to process flashbacks and make sense of the trauma.

Group Therapy

Medication

  • SSRI antidepressants to treat any depression that is present to enable the underlying PTSD to be successfully treated.

The severity of the trauma and the length of time an individual has suffered from PTSD have an impact on prognosis. Many people will recover from PTSD, however the quicker treatment is initiated the more likely recovery is to be successful. For those that do not respond to treatment, PTSD can become a chronic psychiatric disorder that can persist for decades, and occasionally for life.

15. Bulimia Nervosa

Bulimia or binge-eating refers to episodes of excessive and uncontrolled food intake. Although bulimic symptoms can occur in both obesity and anorexia nervosa, they are also the central feature of the disorder known as bulimia nervosa.

For a definite, ICD 10 requires all of the following to be present.

  • A persistent preoccupation with eating, and an irresistible craving for food. The patient succumbs to episodes of overeating, in which large amounts of food are consumed in short periods of time.
  • Attempts are made to counteract the ‘fattening’ effects of food by one or more of the following: self-induced vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics. Diabetic patients with bulimia may choose to neglect their insulin treatment.
  • There is a morbid dread of fatness and the patient sets herself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician.

In contract to anorexia nervosa, body weight is frequently normal or above normal, and many women continue to menstruate.

The syndrome of bulimia nervosa is mainly confined to women, the age of onset tending to be later than for anorexia nervosa, usually in late adolescence or early adulthood. Few studies on the prevalence of the disorder have been carried out, although a recent survey of French adolescents suggests a rate of 1.1% in females and 0.2% in males. The rate of case referral appears to be increasing, possibly because of media exposure and a growing awareness amongst the medical profession that abnormal eating behaviour can exist in those of normal body weight.

Clinical Features

Characteristically, eating habits are grossly disturbed, and attempts at dietary restraint are disrupted by frequent binges, which are usually conducted in secret. Bingeing sometimes occurs in response to specific ‘cues’, such as an unpleasant event or a life crisis, or can be provoked by feelings of depression, loneliness or boredom.

Initially, binge-eating may relieve tension and be experienced as enjoyable, but as the amount of food consumed increases, it is rapidly followed by feelings of guilt, despair and loss of control. Carbohydrate-rich foods such as cakes, bread and biscuits are commonly chosen, and are frequently of a consistency which makes swallowing easy. Bulimics often binge at least two or three times a day (although it can be considerably more), and unless interrupted, each episode may continue until all the available food has been eaten or physical exhaustion occurs. Self-induced vomiting is extremely common and may be brought on in a number of ways. Some may regurgitate spontaneously by pressure on the abdomen, whilst others use fingers or specific objects (such as spoons) to stimulate the retching reflex. Most bulimics assume that self-induced vomiting will bring back all the food that has been eaten, whereas in reality up to two-thirds may remain in the stomach. Diuretic abuse, appetite suppressants, purging with laxatives, excessive exercise and dieting are additional methods employed to control weight.

Dichotomous thinking is a common feature of bulimia nervosa, the subject tending to view certain aspects of herself or her behaviour in uncompromisingly positive or negative terms. Consequently, she may see herself as either ‘fat or thin’, or her eating behaviour as ‘in or out of control’, which is often reflected by fluctuations in mood. Because bulimics are aware that their eating habits are abnormal, feelings of disgust and regret frequently occur during or after an episode of bingeing.

Preoccupations about food and eating often conflict with fears of obesity and a wish to be thin, or with a desire to reach and maintain an ‘ideal weight’. This commonly results in feelings of anxiety and tension, and a sense of depression or despair may ensue, sometimes leading to suicidal thoughts or acts. Other aspects of the bulimic’s life, in terms of relationships, sexual behaviour and drinking habits, may be equally chaotic. Some repeatedly indulge in antisocial or attention-seeking activities such as shoplifting, sexual promiscuity or self-mutilation, which may be related to alcohol or drug abuse.

Concentration is frequently impaired because of constant ruminations about body weight and size. Eating with others tends to be avoided and stringent efforts are often made to conceal their body shape from others and themselves. Body image is distorted by the sufferer not only feeling fat, but actually misperceiving and overestimating her body size.

Although weight usually remains within the normal range, physical complications can result in self-induced vomiting, diuretic or purgative abuse. Hypokalaemia may cause cardiac arrhythmias, tetany, paraesthesiae, seizures, muscle weakness and renal damage. Vomiting and the resultant acid regurgitation can produce erosion of dental enamel (perimolysis), painless enlargement of the salivary glands, hoarseness and oesophageal stricture, whilst purgative abuse may lead to development of steatorrhoea. Finger clubbing is sometimes evident, as well as calluses on the knuckles due to repeated abrasion against the teeth when inducing vomiting. Rarely, overeating can produce acute dilatation of the stomach.

Aetiology

A past history of anorexia nervosa is found in nearly half of all bulimic patients. Many have a familial tendency towards obesity, so that their diet needs to be constantly controlled in order to attain the degree of desired slimness. However, it has also been demonstrated that such individuals rapidly abandon all restraint over their food intake once they believe they have eaten something with a high calorific content.

Patients suffering from bulimia nervosa are extremely sensitive to minor changes in shape and weight, to which they respond in an excessive manner. Poor self-image may lead to great value being placed on the need to be slim, so that uncompromising and rigid dietary regulations are imposed, accompanied by frequent checks of weight and size. Extreme dieting is known to induce bingeing.

Focussing on a specific body weight with special significance leads to the unyielding pursuit of an improbable target weight, thereby increasing the urge to restrict food intake. However, the belief that bingeing can be counteracted by extreme compensatory mechanisms may in turn enhance the amount of food eaten and the frequency of bulimic episodes. Remorse and shame following bingeing and vomiting can also lower self-esteem, thereby creating a vicious cycle.

Difficulties relating to work, studying or relationships may exist, and bulimia can emerge in the face of parental divorce or separation. Sometimes, concerns about sexual orientation are expressed, whilst many individuals describe s history of childhood sexual abuse.

Management

Assessment should include details of the patient’s eating habits, which can be recorded by means of a diary. The amount and type of food consumed are noted as well as how frequently eating occurs. The degree of enjoyment (or lack of it) that is experienced in association with eating should be identified, and the degree of control the individual experiences over food intake recorded (whether bingeing is spontaneous or planned). The diary can also be used to note factors which trigger bingeing (e.g. stress, low mood, a need for comfort, the availability of certain foods). Methods used to control weight should be ascertained whilst social, cultural and family problems also need to be identified.

Information from the diary can be used as part of a cognitive-behavioural approach to treatment. For example, if specific foods are identified as triggering binges, avoiding them might increase the amount of control the subject has over eating. Similarly, changing other behavioural patterns which are linked with bingeing (e.g. avoiding passing a particular shop where food for a binge is always purchased) may help to normalise dietary intake. Simple advice about eating regular small meals, the link between starvation and bingeing, not eating alone, can assist in eliminating bulimic symptoms. Information should also be given about the dangers of self-induced vomiting, purgation and excessive dietary restraint. Therapy may be provided either individually or in groups, recent research suggesting that the former might be slightly more effective.

In addition to offering support, psychotherapy helps to focus on events and feelings which act as stimuli to binge-eating. The subject is helped to anticipate future problems and deal with them appropriately and effectively.

Antidepressant drugs also have a role in the management of bulimia nervosa, as it has been demonstrated that dieting prior to bingeing causes a reduction in the level of activity of serotonergic neurones in the brain.

16. Anorexia Nervosa

Description of clinical states resembling anorexia nervosa appeared in medical books as long ago as the seventeenth century, but the condition was first clearly outlined by Gull in 1874. It is a disorder primarily affecting adolescent girls and young women, with only 5-10% of cases occurring in males. Rarely, children approaching puberty and older menopausal women may be affected. Because secrecy and denial are common, its prevalence is difficult to determine accurately, although various studies have suggested it occurs in approximately 1% of adolescent females. It is more common amongst the middle and upper social classes, and tends to be limited to developed societies throughout the world.

The ICD 10 diagnostic requirements for anorexia nervosa are all of the following:

  • The occurrence of body-image distortion, whereby a dread of fatness persists as an intrusive, overvalued idea so that the individual imposes low weight threshold on her(him)self.
  • Body weight is maintained at least 15% below that expected (either lost or never achieved). Prepubertal subjects may fail to make expected weight gain during their growth period
  • Weight loss is self-induced by avoidance of ‘fattening foods’ and one or more of the following: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics
  • A widespread endocrine disorder (involving the hypothalamic-pituitary-gonadal axis), manifesting as amenorrhoea in worm and loss of sexual interest and potency in men. (An exception is vaginal bleeding in anorexic women receiving hormonal replacement therapy, such as the contraceptive pill). Growth hormone and cortisol levels may be raised. Peripheral thyroid metabolism and insulin secretion altered
  • If onset is prepubertal, pubertal changes are delayed or arrested (growth ceases, in girls, breast fail to develop and there is primary amenorrhoea, whereas in boys, genitalia remain juvenile). With recovery, puberty is often completely normal but the menarche is late.

Clinical Features

Symptoms characteristically begin within a few years of the onset of puberty, and sometimes develop from dieting in response to adolescent plumpness. In the early stages of anorexia nervosa, appetite is not diminished. At this time, the individual’s thoughts and behaviour appear to be governed by an internal conflict between hunger and a desire to eat, offset against a fear of losing control and gaining weight. A preoccupation with food is common, so that the subject will happily absorb herself in food-related activities. Many hours may be spent shopping for food and then hoarding purchases, and some anorectics resort to shoplifting in order to satisfy their fixation.

Food-related rituals are often conducted secretively, and the extent of weight loss may be concealed by wearing bulky clothing. Relatives sometimes collude with such behaviour, but even if the subject is directly confronted about her actions, such challenges are frequently met with the abject denial of anything being wrong. Consequently, medical help is usually sought by parents, by which time the patient will have already lost a considerable amount of weight. She may be reluctant to give details of the duration or extent of her problem, whilst vociferously objecting to any suggestion that she is underweight or needs to eat more. Distortion of body image is invariably present, resulting in the subject grossly overestimating the size of various parts of her body. In certain individuals, the hunger drive intermittently overcomes their fear of fatness and results in occasional bouts of uncontrolled excessive eating (bingeing), which may be followed by self-induced vomiting, laxative or diuretic abuse as a means of weight control.

Many anorectics remain remarkable energetic despite evidence of gross emaciation, and some use strenuous exercise as a way of further controlling their weight. Early morning wakening is a common symptom but in contrast to the type seen in depressive episodes, feelings of dysphoria are not marked at this time. However, some anorectics do become clinically depressed and may even be suicidal, whilst others display obsessional features of multiple phobic symptoms.

At referral, weight is often less than 35 kg and, in addition to a history of amenorrhoea,physical examination may reveal evidence of gross muscle wasting, dehydration, anaemia and other signs of starvation, although breast atrophy does not usually occur. The extremities are sometimes cold and blue (acrocyanosis) and ankle oedema may be present (occasionally associated with a low serum albumin). Pubic and axillary hair are retained, and a fine down (lanugo hair) also appears on the trunk and limbs. Bradycardia, hypotension and hypothermia can occur and constipation may be severe. Vomiting and laxative abuse sometimes cause a hypokalaemic alkalosis, which can result in the development of renal problems, cardiac arrhythmias and seizures. Growth hormone and plasma cortisol levels are raised, whilst those of gonadotrophin are reduced.

Aetiology

The interplay of several factors is probably involved in the development of this condition. Agenetic predisposition is suggested by an increased concordance rate amongst monozygotic compared with dizygotic twins. The mothers of anorectic children often have a history of psychiatric disorder, and in some cases, may have suffered from the condition themselves.

A common theme of the numerous psychological theories that have been advanced to explain the disorder proposes that avoidance of fattening foods is dud to a fear of mature body weight, and results in a regression to a more primitive (oral) level of functioning. By retaining the ‘body of a child’, problems of adulthood, sexuality and separating from parents need not be faced.

Abnormal family processes are seen by some as paramount in the causation of anorexia nervosa. The development of symptoms in the ‘patient’ is viewed as a means of avoiding conflict between family members, thereby allowing them to continue functioning as a unit. The pattern of interaction is such that members are frequently inflexible in their roles (rigidity), problems and disagreements are seldom resolved (lack of conflict resolution), individual identities are poorly defined (enmeshment), and there is evidence of over-protectiveness. The subject is often described as being a ‘model chid’ – shy and introverted in nature, and conscientious and compliant to the wishes of others. Family members frequently display an abnormal preoccupation with food and dieting.

The reduction in sex hormone levels and lowered basal metabolic rate which occur in anorexia nervosa have led to the proposal that the condition might result from a primary hypothalamic disorder. Although there have been few case reports of the condition developing in association with a hypothalamic tumour, post-mortem findings usually show no such abnormality. Since nearly all the physical changes are reversed when body weight is restored, they are most probably the effects of starvation.

The pursuit of thinness is to some extent encouraged by media pressure for women to conform to a ‘sexual stereotype’, in which femininity and attractiveness are equated with slenderness. A further emphasis is placed on the desirability of remaining slim and healthy, and the dangers of being overweight. This may explain why the condition is more common in females from middle and upper-class backgrounds, who are perhaps most susceptible to social pressures of this type. Certain groups, such as models and ballet students, seem to be at particular risk, since weight control is an integral part of their working lives.

The disorder sometimes follows a life event which, if perceived as a threat to the individuals self esteem, can lead to feelings of ineffectiveness. Under these circumstances, dieting behaviour may represent a means of regaining control, and is reinforced by feelings of attractiveness, the attention of others and a sense of achievement due to weight loss.

Management

Before commencing treatment, a careful assessment should be made of both the patient and her family. This not only serves to establish the diagnosis and explore the family dynamics, but also helps to gain the individuals trust and confidence, and achieve agreement upon a management plan. Additional information is usually obtained from another source, such as a relative, since the patient is frequently a reluctant recipient of psychiatric help. Details of personal and family background should be supplemented by a dietary, weight and menstrual history, together with information regarding self-induced vomiting or the abuse of purgatives. It is also important to determine the subject’s concept of her ideal weight and body image.

The mental state examination should aim to identify any evidence of depression or suicidal ideation, and to exclude other psychiatric disorders (such as schizophrenia) where abnormal ideas about food and eating may exist. A physical examination and investigations are performed to assess the extent of malnutrition, emaciation and other somatic complications, in particular electrolyte disturbance. Rarely, it may be necessary to consider alternative causes of weight loss or endocrine dysfunction, such as pituitary failure, thyrotoxicosis, malignancy, diabetes, occult tuberculosis or malabsorption.

Treatment should at first concentrate on restoring normal body weight. This is best achieved by setting a target weight and obtaining the individual’s agreement to remain in treatment until it has been reached. A programme of organised refeeding is then established over a period of 2-3 months. For many years it has traditionally been held that hospital admission is the treatment of choice in respect of anorexia nervosa, especially when weight loss is severe. However, an important study recently compared inpatient treatment with outpatient based therapies (individual and family group psychotherapy accompanied by dietary counselling). At 1 year follow-up there was no significant difference between the treatment approaches in respect of weight gain, the return of menstruation or aspects of psychosocial functioning.

Where hospital admission is considered necessary, various therapeutic regimens have been described, but most advocate an initial period of bed-rest combined with a programme of controlled refeeding, ensuring that at least 3000 calories are being eaten daily.

Successful treatment is dependant upon the nursing staff’s ability to establish a trusting relationship with the patient, and yet remain firmly in control when necessary (e.g. in determining the amount and type of food eaten). Such an approach requires patience and perseverance, since many anorectics are intent on deceiving their care givers by hiding food, swallowing excess water before being weighed or vomiting after meals. Even so, staff must maintain a supportive and caring role, and try to deal with problems as they arise.

With effective treatment, a weight gain of about 1-2kg/week can be expected. As weight increases, many patients who have been depressed begin to acknowledge an improvement in their mood and a reduction in their preoccupation with food. Individual or group psychotherapy is an important aspect of treatment, which creates an opportunity to encourage maturity and independence by dealing with issues such as the responsibilities of adulthood and fears about sexuality, as well as promoting normal attitudes towards food and weight. Some form of family therapy is usually indicated, particularly in younger girls where the family dynamics are clearly disturbed. Ongoing support and treatment are important aspects of after-care, and therapy will often need to be continued for a considerable time. With this aim in mind, a number of self-help organisations have been established, such as ‘Anorexic Aid’ and ‘Overeaters Anon’. There is no evidence that appetite stimulants, such as chlorpromaxine, are of any additional benefit in management, although antidepressants are sometimes prescribed if depressive symptoms are severe.

Prognosis

Although the short-term prognosis is generally good, the course of the illness is variable, and periods of remission are often interspersed with recurrent cycles of weight loss followed by re-admission to hospital. Factors associated with a poor outcome include a later age of onset, male sex, severe weight loss, bulimic symptoms, vomiting and purgative abuse, and a protracted illness.

Results of long-term studies indicate that approximately two thirds of patients have maintained a normal weight for several years following treatment, whilst the remainder are moderately or severely underweight. However, more than half of all anorectics continue to display abnormal eating habits, and suffer from persistent psychiatric symptoms and relationship difficulties.

Adequate follow-up and continuing support are important in order to deal with adverse events and personal crises when they arise, as well as attempting to minimise the frequency and severity of relapse. Despite this, 5% of cases end in death from starvation or suicide.

17. Serotonin Syndrome

The serotonin syndrome is a consequence of excessive stimulation of serotonin receptors in both the central and peripheral nervous system. It can occur when drugs which increase serotonin levels are administered in therapeutic dosages, overdosage or drug interactions. It is often overlooked by clinicians, predominantly because many doctors are unaware of the diagnosis (85% in one study of UK GPs).

Drugs which either directly increase serotonin (5HT) receptor stimulation (lithium, carbamazepine or buspirone, LSD), release stored 5HT (cocaine, codeine, moclobemide), reduce 5HT reuptake (SSRIs, venlafaxine, methadone) or reduce 5HT breakdown (St. John’s wort or MAOIs) are all capable of producing the serotonin syndrome alone or in combination.

Symptoms are variable and in mild cases may go unnoticed. The onset is usually within six hours of taking the drug or drugs responsbile. Tremor, akathisia and diarrhoea are early features. Agitation, and signs of autonomic overactivity may be evident with hypertension, tachycardia, increase in temperature, excessive sweating and papillary dilatation. In severe cases, confusion, coma and death may occur. Mild cases usually resolve within 24 hours with no medical intervention required. However, the drug or drugs that have provoked the syndrome should be stopped and caution exercised in their re-prescription.

Moderate cases may require the correction of cardiovascular disturbances and increased body temperature, and possibly the administration of 5HT2A antagonists. In severe cases admission to ITU is necessary with sedation, ventilation and neuromuscular paralysis.

18. Which Antidepressant?

Many patients who present to their GP with mild symptoms of depression will recover spontaneously so that an approach of ‘wait and see’ and using problem-solving strategies, is entirely reasonable in such cases.

In more severe cases, or where mild depressive symptoms have persisted for months or longer an antidepressant may be indicated possibly combined with CBT.

NICE guidelines suggest that a generic SSRI is prescribed in the first instance. Dosage should be titrated against symptomatic response, and if no change occurs after maximum dosage has been taken for six weeks, consider giving an antidepressant from a different class e.g. SNRIs such as venlafaxine or duloxetine, mirtazapine, agomelatine or a tricyclic compound.

Sometimes combining an SSRI with another compound can be effective. However, you need to be aware of the risk of the serotonin syndrome. If still no response, consider adding lithium in order to achieve a plasma level of 0.5-1.0mmol/l.

Other strategies include tryptophan, tri-iodothyronine.

ECT is of course useful in cases of refractory depression.