Comorbidity

Pain disorder is commonly associated with anxiety and depression, and an additional diagnosis of anxiety disorder or mood disorder can be made if the criteria for both diagnoses are satisfied. This dual diagnosis can be useful if, for example, a depressive disorder develops in the presence of a long-standing pain disorder. Any temporal relationship can occur, however, with pain onset preceding, developing simultaneously, or following the onset of a mood disorder. Other common comorbid diagnoses...

Scope of developmental neuropsychiatry

The scope of developmental neuropsychiatry is broad(2) and includes the following. 1. Neurodevelopmental disorders that are described in other chapters of this book, including attention-deficit and hyperactivity disorders ( Chapter 9.2.3), pervasive developmental disorders and childhood-onset schizophrenia ( Chapter 9.2.2), obsessive- compulsive disorder and Tourette's syndrome (Chapter .9.2.6), and specific developmental disorders (Chapter 9.2.1). 2. Neurogenetic disorders with behavioural...

Schizophrenia and other psychotic disorders Studies between 1898 and 1975

Subsequently to Alzheimer, Southard reported cortical atrophy in schizophrenia and mentioned that association areas of the cerebral cortex were most affected in this disorder 10,) Buscaino(U> described various histopathological changes, mainly in the basal ganglia, which he assumed to be responsible for catatonia-like and stereotyped behaviour. Another approach to the neuropathology of psychiatric diseases had been made by Vogt and Vogt and their coworkers, who reported cellular alterations...

Formulation of definitions of alcohol dependence 19481974

From the time of its inception in 1948, WHO played a major role in formulating public health definitions of 'alcoholism', 'addiction', and 'dependence' through a series of expert committees. Early definitions stressed the sociological rather than the physical aspects of dependence. (7) 'Alcoholics' were defined as (7) those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance or an interference with their bodily and mental...

Explaining the development of offending

In explaining the development of offending, a major problem is that most risk factors tend to coincide and tend to be interrelated. For example, adolescents living in physically deteriorated and socially disorganized neighbourhoods disproportionally tend also to come from families with poor parental supervision and erratic parental discipline and tend also to have high impulsivity and low intelligence. The concentration and co-occurrence of these kinds of adversities makes it difficult to...

Structure process and content the dynamic elements of a group

Regardless of the therapist's method, people usually start in groups with a form of serial monologue. Out of this arise the capacities to talk and to listen which are often undeveloped or even non-existent at the outset of therapy but which are its core constituents. From talking and listening comes self-disclosure, and out of this emerges identification which, in due course, leads to dialogue and differentiation. Therefore the conductor must give a place to monologue whilst, at the same time,...

Diagnosis and differential diagnosis

The most cost-effective method of diagnosing paraphilias is to conduct a comprehensive psychiatric history, to use psychophysiological assessment methods to determine sexual interest, and to differentiate organic or psychiatric disorders that can impact on an individual's sexual interest and activity. Interviewing the potential paraphiliac, especially a paraphiliac who has been involved in felonies, requires a non-judgemental clinician. The first step in the interview process is to obtain a...

Chapter References

Clinical psychiatry (3rd edn). Bailliere Tindall and Cassell, London. 2. Simeon, D., Gross, S., Guralnik, O., Stein, D., Schmeidler, J., and Hollander, E. (1997). Feeling unreal 30 cases of DSM-III-R depersonalization disorder. American Journal of Psychiatry, 154, 1107-13. 3. Brauer, R., Harrow, M., and Tucker, G.J. (1970). Depersonalization phenomena in psychiatric patients. British Journal of Psychiatry, 117, 509-15. 4. Sedman, G. (1970). Theories of...

Legal control of recreational drugs

Until the middle of the nineteenth century there was a free market in drugs in Europe and the United States, with access to everything from alcohol to opium and coca restricted only by the depth of one's pocket. Two developments did much to upset the status quo. In 1805, a pharmacist's apprentice separated a chemical from raw opium and named it morphine after the Greek god of dreams. Isolation of codeine, thebaine, and papaverine soon followed. Then in 1858 a Scottish surgeon invented a device...

Modelling normal sexual functionthe sex survey

One obvious way of describing normal sexual function is to ask people what they do. Two classic sex surveys were conducted by Kinsey and his coworkers who reported the results of interviews with 12 000 males in 1948 (19 and 8000 females in 1953.(11) Their technique of sampling was to interview everyone in specific cooperating groups (clubs, hospital staff, universities, police force, school teachers, etc.). This gave samples of convenience but not a valid sampling of the population. Despite...

Demand and utilization

Need must be distinguished from demand and utilization demand is an economic term, a measure of the quantity of services consumers seek to obtain. Demand is more dynamic than need, in the sense that it is influenced by many factors, including system-level factors such as the cost to the consumer (price), available alternatives and their prices, and individual factors such as education, the effects of advertising, distances, and social pressures including stigma. A simplified economic model of...

Bodily preoccupations

Individuals with BDD are preoccupied with the idea that some aspect of their appearance is unattractive, deformed, or 'not right' in some way. Concerns usually focus on the face or head but can involve any body area. (5,10> The skin, hair, and nose are most often disliked (e.g. acne, scarring, lines, or pale skin, hair thinning, or a large or crooked nose). Concern with bodily asymmetry (e.g. 'uneven' buttocks) is common. Although the concern usually focuses on specific areas, it may involve...

Why do negative thoughts and beliefs persist

If the world is not as dangerous as anxiety disorder patients assume, why do they not notice this and correct their thinking For many patients with chronic anxiety disorders, the persistence of their fears can seem strangely irrational, at least at first glance. Consider, for example, panic disorder patients who think during their panic attacks that they are having a heart attack. Before they come for treatment they may have had several thousand panic attacks, in each one of which they thought...

Sibling rivalry disorder

This disorder should only be diagnosed if there is a degree of emotional disturbance, usually following the birth of an immediately younger sibling, which is both unusual in degree and associated with abnormalities of social interaction. Clinically, the child shows abnormally intense negative feelings towards an immediately younger sibling characterized by two or more symptoms of regression tantrums sleep difficulties dysphoria oppositional or attention-seeking behaviour with one or both...

Speech and language disorders

A common question asked of clinicians in general practice, child health, and child psychiatry concerns the long-term consequences of delayed speech and language development in the early years of life.(1) A previously held view was that most young children with speech and language problems would eventually develop normally. But this is an optimistic view it is more likely to be true of children without major mental and physical handicaps. Allied questions which have to be addressed are whether...

Psychological factors Personality

It is now widely accepted that alcoholics do not present a homogeneous premorbid personality profile. However, some distinctive trait clusters have been identified which seem to characterize different types of alcoholics.(35) One such group (type 1) tend to score low in novelty seeking and high in harm avoidance and reward dependence. Another group (type 2) is formed by the natural thrill seekers, who appear to ignore harmful consequences and punitive responses. This latter cluster, which...

Physical sequelae of crime

Apart from the immediate direct physical injuries caused by crime, there are often indirect negative health consequences. In general, people who have experienced crime have a poorer perception of their physical health, more limitations on their physical functioning, and more chronic medical conditions. (23) Physical and sexual assault are associated with increased cigarette consumption, alcohol and other drug abuse, health-care neglect, risky sexual behaviour, and eating disorders. (24)...

Comorbidity and differential diagnosis

Social phobia may increase the risk for other psychiatric disorders. (9,2 21.> In the National Comorbidity Survey (NCS), 81 per cent of persons with primary social phobia met the criteria for at least one other lifetime psychiatric disorder.(22) Odds ratios for other DSM-IIIR disorders given social phobia were 7.75 for simple phobia, 7.06 for agoraphobia, 4.83 for panic disorder, 3.77 for generalized anxiety disorder, 2.69 for post-traumatic stress disorder, 3.69 for major depression, 3.15...

Diagnostic subtypes of mood disorders in DSMIV

Major depressive (unipolar) disorder is characterized by depressive episodes without any hypomanic or manic states the patient is either depressed or average in mood, but experiences no mania. 2. Bipolar disorder is characterized by manic or hypomanic states the patient is either depressed, euthymic (normal in mood), or hypomanic manic. Bipolar disorder differs from unipolar disorder by including manic states. No matter how many times a patient is depressed, only one manic hypomanic episode is...

Limitations of the psychoanalytic approach

A series of limitations render child psychoanalysis vulnerable to being seen as impractical, non-scientific, and uneconomical 1. lack of operationalization in most descriptions of technical interventions, with the effectiveness of interventions supported almost entirely by evocative case illustrations 2. inadequate specificity regarding technical interventions appropriate for children with a particular diagnosis or clinical presentation 3. limited evidence of efficacy, particularly evidence...

Why do people take drugs

A very common misconception is that drug misuse is simply a search for fun. In fact, people take drugs for many reasons other than to get the buzz or high. Indeed, studies have shown that straightforward pleasure seeking is the primary reason for initiation of drug use in fewer than 20 per cent of individuals. While the high or buzz is the most obvious pleasurable effect, many people also describe using drugs to feel comfortably numb, pleasantly drowsy, or full of energy and confidence. Many...

Diagnosis classification and differential diagnosis of schizophrenia

The diagnosis of schizophrenia Diagnostic criteria Basis of classification Athepretica Schneider's. .first. ranK sympto.ms Differential. diagnosis Otherpsychiairic .disorders The presence of imo,o,d, i,n,,c,o,,ng,r,ue,n,t delusions. (lOlr lha. .U.C,i.n.ati.0.n.S) Thei d1u,r,ati,o,n a,n,d, a,c,ute,n,e,ss, o,f. .onset criteria Social, and occ.upati.o.n.aLd.ist.urha.n.ce The diagnostic process Chapter References

Clinical features Hair pulling sites

Scalp hair is pulled out in approximately 80 per cent of cases, resulting in diverse patterns of bald patches and or hair thinning. (3) One pattern of hair loss, tonsure ( 1), is characterized by a circular denuded patch over the top of the scalp. Fig. 1 Tonsure pattern of hair loss in trichotillomania. Most patients pull from multiple hair sites. The most common sites, in descending order of frequency, are the scalp, eyelashes, eyebrows, pubis, face, and the extremities.(4) Rarely, hair is...

The influence of psychodynamic theories

Research has shown that psychoanalysis, in the form originally promulgated by Freud and his followers, is no more effective in relieving neurotic symptoms than other less demanding and less expensive forms of psychotherapy. Freud's theory of dreams, which he himself considered to embody his deepest insight, has not stood the test of time. Nor have his views on religion, anthropology, and art. Although many of his psychopathological interpretations are open to question, he was a great clinical...

Psychological mutism

There are two forms of psychological mutism traumatic and selective 3 32) Both are dramatic and rare. Traumatic mutism has an acute onset following a psychological shock or injury. Some consider it to be a hysterical phenomenon as it is not associated with any disorder of the structures subserving speech functioning (lips, tongue, palate, or vocal cords). Furthermore, the patient is able to cough normally. The literature suggests that it is common, but a wide clinical survey has attested to its...

Bipolar disorders Diagnostic issues

While classical bipolar disorder with episodes of euphoric mania interspersed with episodes of depression is one of the clearest clinical syndromes in psychiatry, the boundaries of bipolar disorder remain contested. As case definition is central to epidemiology, all the contested boundaries of bipolar disorder could influence prevalence rates and our understanding of risk factors. Some of the major boundary issues for bipolar disorder include the overlap of bipolar disorder with psychotic...

Why knowledge of causation is important

Mental retardation is a confusing concept. Mentally retarded people have more differences than common features. Developmental delay may appear in different ages and with different degrees of severity in different children. The age and severity vary both between and within different aetiologies. The development of a child can come to a stop or can even regress. There is a multitude of confirmed causes of mental retardation. Single aetiologies are rare and the clinical picture within the same...

Indications and contraindications

Several controlled trials show that oxcarbazepine has similar efficacy to carbamazepine in the treatment of partial and tonic-clonic seizures, as well as neuropathic pain syndromes, including trigeminal neuralgia. Like carbamazepine, it is not effective in treating absence seizures. A few controlled trials demonstrate oxcarbazepine's efficacy in the treatment of acute mania.(26) Oxcarbazepine is contraindicated in patients with known hypersensitivity to the drug. Because of theoretical concerns...

Normal psychological response to cancer diagnosis

The diagnosis of cancer for most people results in a predictable psychological pattern of distress over several weeks. The meaning of cancer is usually that of possible death, with pain, possible disability or disfigurement from treatment, loss of independence and self-esteem, and possible loss of significant relationships due to changed appearance or disability. This normal response is characterized by three phases initial denial, an acute turmoil phase, and a period of adaptation. (7) It is...

The principles of clinical assessment in general psychiatry

Cooper and Margaret Oates Introduction assessment effects. on activities Ca. ,ego.r.i,e.s oJE informationi .subjective, obie,C.i.v.e, a,n.d , scientific The diagnostic process . disorders. and diagnoses The sequence synthesistand review From. complaints formulation Psychodynamics and. the life story Contextual infl.U.ence.S on , assessment Assessment as a. .mul i.d,iscipl .inary, .activity Leadership Key worke,rs, and, c,are. rogra,mEes Reasons .forthe development of structured...

Specific developmental disorder of motor function Clinical features and classification

Many children to whom this category applies, were previously diagnosed as having 'minimal brain dysfunction'. This term is no longer used. The essential clinical features of the disorder include the following (ICD-10). An impairment of motor co-ordination that is significantly below the expected level on the basis of age and general intelligence assessed by an individually administered and standardized test. The difficulties in co-ordination should already have been present early in...

Managing anxiety and other emotional sequelae resulting from impaired cognition

Anxiety and depression are frequently seen in memory-impaired people. Kopelman and Crawford (29> found depression in over 40 per cent of 200 consecutive referrals to a memory clinic. Evans and Wilson (39 found anxiety to be common in attenders of a weekly memory group. Dealing with these emotional problems should be an integral part of memory rehabilitation. Obviously, listening, trying to understand, and providing information are key factors in encouraging families to cope with their...

Can we identify patients for whom immediate medication prescription may be unnecessary

A common design feature is a 7- to 10-day single-blind initial placebo run-in period ( IPR) prior to a double-blind phase. The purpose of the IPR is to remove patients with an increased chance of placebo effect. Typically, much improved patients do not enter a double-blind phase, but minimally improved patients continue into the double-blind phase. We found that patients minimally improved during a single-blind placebo period had a better prognosis whether subsequently assigned to drug or...

Epilepsy and epilepsyrelated behaviour disorders among people with mental retardation

Diagnosis., and differential diagnosis of epilepsy Epilepsy.and., epileptic. .s.yn.d.ro.me.s at. .different ages Infancy Later .c.hiild.h.o.o,d a,n.d adolescence Adulthood .andold age Behavioural disorders due to epilepsy Occurrence of epilepsy related to menta retardation Aetiology.and. pathogenesis. ofepilepsy Treatment. ofepilepsy Antiepilepticdrugtherapy Behavioural disorders caiused by an1tiepileRtic drufls Prognosis Conclusions Chapter. References Epilepsy is defined as two or more...

Specific developmental disorders of scholastic skills

'Specific developmental disorders of scholastic skills' (ICD-10) or 'Learning disorders' (DSM-IV) include disorders characterized by one or more significant impairments in acquisition of reading, spelling, or arithmetical skills. ICD-10 suggests that the category 'Mixed disorder of scholastic skills' (F81.3) be used as an ill-defined, but necessary, category in which arithmetical and reading or spelling skills are significantly impaired, although not because of general mental retardation or...

Lesch Nyhan syndrome

This X-linked recessive condition, which almost exclusively affects boys, was first described in 1964 by William Nyhan. (24) Although often described as a rare condition, the incidence rate quoted for this condition varies widely between 1 in 10 000 and 1 in 380 000 live births. The usual mode of inheritance is from a carrier mother to her affected son. The syndrome is caused by an inborn error of purine metabolism, resulting in an abnormally high level of xanthine and uric acid in the blood of...

Cognitivebehaviour therapy for anxiety disorders

HistoricaldeveloRment ofcognitive-behaviour therapy Cognitivecontentof. .anxiety, disorders Generalized anxiety d1is,ordsr Obse,ssjye,-som u, s,ive disorder Post-traumatic. . .stress. .disorder Why do. .negative. thoughts. . and belie.fs.fiersist Avoidance,, escape and safety-se.eking be.hayiours Attentional. deployment SRlo,ntaneou,s, y.l occurring .images Emotional .reasoning Memory processes Rumination Treatment Developing. .an. .j,d.i,os.yncrat,ic mpd.ei, of the patient,,s pro,b,lem...

Introduction history of ideas

Two different approaches may be discerned in the conceptualization of anorexia nervosa. 1. The medicoclinical approach defines the illness in terms of its clinical manifestations the main landmarks were the descriptions by William Gull in 1874 (. > and Charles Lasegue in 1873.(2) 2. The sociocultural approach is unlike the more empirical clinical approach and takes causation into account by viewing the illness as a response to prevailing social and cultural systems. This was best argued by...

Hypersomnia associated with infectious disorders

Excessive sleepiness occurring during the acute phase of a bacterial or viral infection, without any other symptom of central nervous system involvement, is commonplace in medicine. Its mechanism may involve certain cytokines. There are other conditions, also presenting with excessive sleepiness, which may be life threatening. The most frequent of these is African trypanosomiasis (sleeping sickness) caused by the haemoflagellate Trypanosoma brucei. The incubation period of the parasite lasts...

Complications of the hyperthymic temperament History

Although well described by classical German psychiatrists (e.g. Schneider(20)), the hyperthymic type appears neither in DSM-IV nor in ICD-10. A lifelong disposition, hyperthymia must be distinguished from short-lived hypomanic episodes. Alternatively, this disposition can be characterized as trait hypomania. It derives from the ancient Graeco-Roman sanguine temperament, believed to represent the optimal mixture of behavioural traits. They are full of zest, fun-loving, and prone to lechery their...

Pharmacokinetics

Nicotine is absorbed through the skin, and through the lining of the mouth and nose, the rate of absorption being enhanced in an alkaline environment and reduced in an acidic environment. Because of the large surface area of the lungs the mildly acidic smoke of cigarettes is absorbed almost immediately and completely on inhalation, giving rise to high concentration arterial nicotine boli which reach the brain in less than 10 s. (17) Nicotine has a distributional half-life of about 15 min and a...

Personality change

Personality change after head injury results in more suffering than any other single sequel. (3,33) In general, the personality change goes hand in hand with cognitive impairment. However, a severe personality change is occasionally found in somebody with almost no impairment of cognitive function. Normal test scores for memory and intellect do not rule out brain injury as a cause of personality change after head injury. It is not easy to predict who will develop a change in personality after...

Culturally related syndromes

The, concept .of 'culture-bound, syndromes', or, l'clU t.U.re.-SPeCifi,C, , .d,i.S.Orde.rS, Locallfolk idioms, pf distres.s Susto.,. espantotMedo Culturally stereotyped reactions to extreme environmental conditions. .('arctic hysteria') Syndromes.related to a cultural emphasis.on fertility .a.n.d firocrea.tion .'.G.enit.al.shrinking.'. syndrome koro, suo-vang). 'Semen losslsyndroms., shen-kluelLd& Mi., Mryan, , sukra., prameha Syndrpmes re ated., to.,a, .cultural em.p.hasis pn le.arnt.,...

Abstinence or controlled drinking

Harmful or hazardous use of alcohol without severe dependence can sometimes revert to risk-free drinking. Patients with social supports (family and job) and without impulsive personalities and many social problems are most likely to succeed. For others, including most of those dependent on alcohol, the goal of abstinence is better. In patients attending specialized outpatient clinics, the proportion who can sustain problem-free drinking for at least 1 year is small 5 per cent is a typical...

Biological predisposition

Compared to controls, a significantly larger percentage of men with family history of alcoholism present a lesser physiological response to alcohol in terms of both subjective sensations and objective measurements (postconsumption plasma cortisol levels and body sway). A lower sensitivity is assumed to lead to heavier drinking and predicts the eventual development of alcoholism. The authors of this prospective follow-up study concluded that the 'innate' low response to alcohol is an independent...

Female genital functions during normal sexual arousal External

The external female genitalia consist of the outer (majora) and inner (minora) labia containing erectile tissue that surround the vaginal introitus. Normally the outer labia meet and cover the introitus, but in some women the inner labia protrude even when they are sexually unaroused. Sexual arousal creates vasocongestion especially in the labia minora which protrude through the majora adding approximately 1 to 2 cm to the length of the vagina. The labia minora become erotically sensitive to...

Dysthymia cyclothymia and related chronic subthreshold mood disorders

Subthresholdaffectiyeconditions The dysthymicspectrum History Clinical picture and. .diagnostic, .considerations Clinical management Preyentionopportunities Clinical features. and diagnostic .considerations rritabie periods Romantic-conjugal. .failure yneyensGhool.a .WSrk record Alcohol.and. drug abuse Financial extravagance Course. .patterns Aetiol o gicanl aspects Clinical .management Compiicationsof. thehyperthymictemperament History Epidemiology Diaqnosticaspects Aetiological aspects Course...

Anticipation and expanded trinucleotide repeat sequences

Anticipation implies that a disease occurs at a progressively earlier age of onset and with increased severity in successive generations. This may explain the non-Mendelian pattern of inheritance observed in some inherited diseases. This phenomenon has been observed in several neurological diseases including myotonic dystrophy, fragile X syndrome, Huntington's disease, and more recently in spinobulbar muscular atrophy, type 1 spinocerebellar ataxia, and spastic paraplegia. (55) Anticipation has...

Folie deux a phenomenon which may accompany illnesses with delusionl9798 and

This phenomenon is listed as a psychiatric disorder in DSM-IV (Shared Psychotic Disorder, 297.3) and in ICD-10 (Induced Delusional Disorder, F24) but there is a conceptual difficulty in regarding it as a psychotic illness in its own right, as will be discussed shortly. Folie deux is a venerable term used to describe a situation in which mental symptoms, usually but not invariably delusions, are communicated from a psychiatrically ill individual (the 'primary patient') to another individual (the...

The middle phase working with negative automatic thoughts

Once behavioural methods have been mastered, patients learn to identify and question negative automatic thoughts, so as to reduce distress and find constructive solutions to their problems. The main tool here is the Dysfunctional Thoughts Record, illustrated in Fig 3, which summarizes a lengthy discussion that took place when the patient experienced a serious setback midway through treatment. Fig. 3 Dysfunctional Thoughts Record. Fig. 3 Dysfunctional Thoughts Record. Identifying negative...

The impact of psychotherapy on the brain

In the past, psychotherapy was often regarded as the treatment for 'psychologically based' disorders, while pharmacotherapy was prescribed for disorders that were considered to be 'biologically based.' This distinction is rapidly becoming obsolete with advances in imaging techniques that demonstrate how psychotherapy alters the brain.(23,24* Both behaviour therapy and fluoxetine appear to produce similar decreases in cerebral metabolic rates in the head of the right caudate nucleus when used in...

Technical and practical limitations of PET and SPET compared with other imaging modalities

PET and SPET excel in the measurement of neurochemical parameters in vivo at very low (subnanomolar) concentration. (1 ,2> Such sensitivity cannot be matched by other in vivo methods such as proton magnetic resonance spectroscopy (millimolar range). However, radiation dosimetry limits the number of scans that subjects may receive. Full quantitation can often be achieved with PET, unlike SPET. However, for imaging blood flow change, functional magnetic resonance imaging ( MRI) now offers the...

Drug interactions

Many patients may be taking other medications and many are prescribed more than one psychotrophic drug at a time. Because of this, it is important that clinicians are aware of drug-drug interactions. Drugs that impair the cytochrome P-450 microsomal enzyme system in the liver can interact with other drugs that are dependent on hepatic metabolism. For example, barbiturates and carbamazepine which induce hepatic enzymes can accelerate tricyclic metabolism and reduce steady state blood levels....

Anorexic mothers as parents

A patient who is improving may conceive despite having a suboptimal weight and still not menstruating. (81) A mother may also develop the illness after having borne children. In a series of eight mothers, nine out of 13 of their children suffered from food deprivation, identified by reductions in weight for age and in height for age as shown on Tanner-Whitehouse charts.(96) The anorexic mothers had no intention of abusing the children and indeed were affectionate towards them. They adopted...

Standard brain spaces statistical parametric mapping and databases

A challenge for functional brain imaging is to maximize the detection of small signal changes whilst maintaining precision in the description of where signal change has occured.(23 and Many centres have approached these tasks, particularly for flow studies, by using one or more of the following smoothing image data stereotactic transformation of PET images, from individual subjects, into a standard brain space and voxel by voxel analysis of signal change using statistical tests that account for...

Advantages and disadvantages of the local community level for planning

We need to consider first the scale at which local planning should take place. In terms of a geographically defined 'community', for example, the size of such a local population will vary between countries and regions, but is generally between 50 000 and 250 000 of the total residents. In some countries the scale of the local level is smaller where a single team is the main service provider (as in South Verona, Italy), whereas in other settings (e.g. Victoria, Australia) the main unit of...

Depressive disorders one two or three principal types

The extended debate as to whether the depressive disorders are best conceptualized as comprising one or more distinct disorders warrants overview. The 'unitarian' view posits one depressive disorder, varying essentially by severity. The strict 'binarian' view argues for two separate types. Debate did not commence this century. Altschule(6) suggested that St Paul distinguished between two types of depression, one 'from God' and the other 'of the world' (Corinthians 7 10), and that several...

A genetic marker for noveltysensationseeking behaviour

In January 1996 two independent teams reported that a particular chromosomal 'locus' was associated with a well-established trait of human temperament the hunger for novelty and excitement that lies behind impulsivity or sensation-seeking behaviour. (1.I and 29 A polymorphism in the sequence of the gene expressing the D4 dopamine receptor (D4DR), located on the short arm of chromosome 11, explained 10 per cent of the genetic variance due to this trait. Individuals with the longer repeat allele...

Integrating the neuronal and synaptic findings

There is an encouraging convergence between neuronal and synaptic findings in schizophrenia. In particular, the decreases in presynaptic and dendritic markers are in keeping with the smaller neuronal cell bodies, since the size of the latter is proportional to the dendritic and axonal spread of the neurone. It is also consistent with the findings of increased neuronal density, in that dendrites and synapses are the major component of the neuropil and, if this is reduced, neurones will pack more...

Modifying the EPOR model into the DEOR model

The first weakness of the EPOR model is that it was derived from the study of a highly selected group of American men and women volunteers who could arouse themselves to orgasm in a laboratory, on demand, and allow themselves to be watched filmed or measured for scientific and altruistic (or perhaps exhibitionistic) purposes. The second weakness was the lack of interobserver agreement about the changes observed and of confirmation of their sequential reliability. Robinson (21) examined the E...

Assessment goal setting and initial formulation

The assessment aims to provide a detailed description of the presenting problem that is consistent with a cognitive-behavioural formulation of the child's difficulties. The assessment should also provide information about the child's social context and about his or her strengths and weaknesses. The initial interview begins with a thorough review of the presenting problems and any associated symptoms. In collaboration with the child and family the therapist carries out a detailed analysis of...

Disorders of lipid metabolism

Intervention studies have shown that cholesterol reduction using diet, drugs, or surgery reduces the risk of developing or worsening coronary disease. In general, a 1 per cent reduction in low-density lipoprotein-cholesterol has been associated with roughly a 2 per cent reduction in disease end-points. (59 General agreement exists that eating less saturated fat and cholesterol, and adopting a diet and exercise habits to reduce obesity will benefit the health of most people. Exercise has a much...

Delirium in psychiatric patients

It is important not to miss uncommon presentations of delirium in psychiatric patients, especially in the elderly. Prevalence is high amongst older psychiatric inpatients. occasionally, neurological causes of delirium, such as epilepsy and problems with anticonvulsant medication, may need to be dealt with, especially by child and learning disability psychiatrists management should be in collaboration with physicians. In adult psychiatry, delirium tremens is probably the most common form of...

Problems with repression

Multiple personality disorder is only one of the diagnoses which are explained by the idea of repression an idea which is now being questioned. Taking repression to mean unawareness of rejected material, Holmes(40) concluded in 1974 that it had been impossible, despite 60 years of experiments, to provide convincing evidence that repression occurs. He suggested that it was time to drop the concept. Repression has been the basis of a number of highly implausible claims which grew vigorously in...

Other somatoform conditions

A number of specific somatic syndromes have been described over the last several decades. These specific syndromes are sometimes defined by the particular somatic symptoms experienced (e.g. fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome) and sometimes by particular beliefs about aetiology (e.g. multiple chemical sensitivity, systemic candidiasis, electrical allergy). In every case, controversy persists about whether the somatic symptoms should be considered 'medically...

Alcoholinduced psychosis delirium tremens

In delirium tremens the symptoms of alcohol withdrawal described earlier are accompanied by a reduced level of consciousness, disorientation in time and place, impairment of recent memory, insomnia, and perceptual disturbances. The latter include misinterpretation of sensory stimuli and hallucinations most are visual, but auditory and haptic hallucinations also occur. The hallucinations may be Lilliputian or of normal size, and may be of complex, frightening, and extremely realistic scenes. The...

The nineteenth century turning point French clinical psychiatry

In 1854, Jean Falret(5) described a circular disorder (la folie circulaire), which for the first time expressly defined an illness in which 'this succession of mania and melancholia manifests itself with continuity and in a manner almost regular'. The same year, Baillarger(6) described essentially the same thing (la folie double forme), emphasizing that the manic and depressive episodes were not different attacks but rather different stages of the same attack. For the first time,...

Acquisitive offending

It is frequently suggested that users of illicit drugs are forced to commit acquisitive crime through economic necessity. In an English study of police arrestees, (8) among those who reported using drugs, 46 per cent believed that their drug use and crime were connected. The most frequent reason given was the need for money to buy drugs. On urine testing, those arrestees who were positive for opiates, methadone, or cocaine reported two to three times the illegal income of those who had not...

Anima animus and shadow

In the course of analysis of their dreams, patients would encounter various typical 'primordial images' or archetypes which are experienced as being of profound significance. For example, the primordial image of the opposite sex, which in men is named the 'anima', may be someone resembling Rider Haggard's 'She'. The aptly named 'She' is not only spectacularly beautiful, but also an immortal priestess with access to divine wisdom. 'She' is not an actual woman, but an image of the eternal...

Sexual pain disorders

Sexual pain disorders are divided into two dysfunctions non-organic dyspareunia and vaginismus. Dyspareunia, genital pain in either a male or female, is characterized by recurrent and persistent genital pain before, during, and after sexual activity. Exclusively a female dysfunction, vaginismus is an involuntary spasm of the musculature of the outer third of the vagina which makes penetration difficult or impossible. Non-organic dyspareunia and vaginismus may only be diagnosed in the absence of...

Contemporary concepts

Chodoff and Lyons(69> clarified the terminological confusion surrounding hysterical personality, differentiating it from conversion reaction. In DSM-II, the concept was influenced by the psychoanalytic heritage. In DSM-III, the term histrionic personality disorder, coined by Brody and Sata, (70> was used, reflecting the diagnostic importance of external features such as dramatization, emotional instability, and attention-seeking. The change in terminology was in tune with the descriptive...

Nonthalamic subcortical afferents to the cerebral cortex

A variety of nuclei send afferents to the cerebral cortex. These fall into two categories fibres from the so-called isodendritic core of the brainstem and basal forebrain, which are non-reciprocal and aminergic, and the two-way interconnections with the claustrum. Acetylcholine and the basal forebrain A system of cholinergic nuclei extend from the septum verum anteriorly, through the nuclei of the diagonal band of Broca to the basal nucleus of Meynert in the substantia innominata, ventral to...

Phencyclidine delirium

Unlike acute intoxication with other hallucinogens, phencyclidine delirium is commonly associated with neurological disturbances. A continuum of effects is noted depending on dose.(8) Psychiatric symptoms occur early in drug use, with stupor and coma occurring later. Shortly after drug use, patients appear confused and ataxic. Analgesia in fingers and toes may be described. Phencyclidine can produce complex hallucinations resembling LSD intoxication. Differentiating the two drugs in emergencies...

Efficacy of couple therapy

The efficacy of couple therapy is not an easy topic to discuss. Problems arise as to how one should assess efficacy, and while most authors would agree that a measurable improvement in marital adjustment is a valid measure of improvement, some authors dismiss that as being too subjective or too superficial. On the other hand, to use divorce as an outcome variable might be seen as being too strict on the therapy, since divorce happens for many reasons, and it might not actually be a bad outcome...

Deterrent medication Disulfiram

If taken in a sufficient dose for at least the preceding 3 to 4 days, disulfiram causes an unpleasant reaction to develop 15 to 20 min after alcohol enters the body. The reaction is due to accumulation of acetaldehyde, the intermediate metabolite of ethanol. The reactions includes flushing, headache, pounding in the chest or head, tightness in breathing, nausea, and sometimes vomiting. Hypotension can occur and is potentially dangerous. (Calcium carbimide has a similar action but is no longer...

Possibilities for prevention

There is insufficient knowledge of the natural course of transient sleep disorders. Mention has been made of adjustment sleep disorder and of the association of life events and stressors with the onset of insomnia. Systematic research is required to establish the 'setting conditions' for the secondary maintenance of insomnia beyond an initial normative reaction to events. Perhaps there is an interaction with a predisposing tendency to light sleep, or with introspection and worry. The...

Dangerousness risk and the prediction of probability

The limits on engagement in , riskassessment. by. .mental health professionals Practicalities of prediction Actuarial and clinical approaches A model for assessing and . managing. the. probability. of.violence Pre-existing . vulnerabilities Mental.disorder Substanceabuse Long-term, social.and., .interpersonaLfactors Probability. . of vio. e.n.t be.h.a.vio.ur Prediction is very difficult, especially about the future. Risk assessment and risk management now occupy a prominent position in...

Assertive community outreach

The assertive community treatment model developed in Madison, Wisconsin (originally called 'training in community living' (35> ), has attracted a huge amount of interest worldwide. The intervention is particularly targeted at seriously mentally ill people who are high service users it has also been seen as relevant for people who are hard to engage in services. Assertive community treatment provides a comprehensive range of treatment, rehabilitation, and support services through a...

Acute stress reactions

Introduction Clinical features Classification Diagnosis and differentialdiagnpsis Stressor criterion Sir.u.ct.u ed clln.i cal. .interview for . D.SM-.I.Y., .d. s.sp.c.j.at.i.ve d.i.sp,rde.rs St.r.u.ct.u.rsd c J,n.i cal. .interviewifpr DSM-M. .(SCID) Stanford acute streisis .reaction questionnaire Differential. diagnoses Post-traumatic.stress .disorder Adjustment disorder Psychological explanations. of 'e.-experiencing symptoms D slspciat pn . and, . . other. . processes, th,at. i.mpe,d,e...

Writers on internal mechanisms as causes simultaneous structural or synchronic causality

Theodor Meynert (1833-1892), who was Professor of Psychiatry at Vienna, developed a view of mental illness based on the following assumptions. 1. All psychological processes had an organic basis (Meynert believed in a form of eliminative materialism (37)). 2. The brain was a network of innate and acquired reflex arcs (for a discussion of the relevance of reflex arc theory to nineteenth-century neurosciences, see 3. Because 'association' pathways co-ordinated and stored information and connected...

Other drugs including lithium carbamazepine and buspirone

Many other drugs, including lithium, carbamazepine, and buspirone, have been examined in children and adolescents with psychiatric disorders. Lithium There have been several studies of the effects of lithium treatment in children and adolescents. In a (short-term) placebo-controlled study of lithium given to young individuals with early-onset bipolar disorder followed by later substance abuse, lithium was efficacious for both disorders. (39) Active responders had a mean lithium serum level of...

Associations with age and sex

There is adequate evidence that schizophrenia may have its onset at any age in childhood as well as past middle age although the vast majority of onsets indisputably fall within the interval 15 to 54 years of age. Onsets in men peak steeply in the age group 20 to 24 years thereafter the rate of inception remains more or less constant at a lower level. In women, a less prominent peak in the age group 20 to 24 years is followed by another increase in incidence in age groups older than 35. While...

Problem use addiction dependence and craving

These are some of the most commonly used terms in discussions of drug misuse but at the same time they are also the most problematic. The use of drugs in any circumstance, therapeutic or otherwise, can be associated with problems, although the nature and scale of these varies (see Table 1). The terms problem use and misuse usually refer to use of drugs (presciption or other) for pleasure but with disregard for the personal or social dangers. For example, alcohol misuse can lead to irresponsible...

Evidence for genuine recovered memories

Over 20 longitudinal and retrospective studies have now found that a substantial proportion of people reporting child sexual abuse (somewhere between 20 and 60 per cent) report periods in their lives (often lasting for several years) when they could not remember that the abuse had taken place. (89,) Although the rates vary between studies, broadly similar findings have been obtained by clinical psychologists, psychiatrists, and cognitive psychologists in both clinical and community samples. As...

Disorders of self and body image Disorders of self

These describe the abnormal inner experiences of I-ness and my-ness which occur in psychiatric disorders. Scharfetter has added the characteristic of awareness of being or ego vitality to the four formal characteristics previously described by Jaspers feeling of awareness of activity, awareness of unity, awareness of identity, and awareness of the boundaries of self. (2,,54) This disorder is demonstrated by nihilistic delusions, which frequently occur in severe depressive illness and are a...

Clinical features of bereavement and normal grief

Although the terms bereavement, grief, and mourning are often used interchangeably, the Committee on Health Consequences of the Stress of Bereavement suggests the following definitions. Bereavement is the loss of a loved person through death (coded in ICD-10 as Z63.4 and in DSM-IV as V62.82). Mourning is the voluntary social expression of that loss. Grief is the involuntary emotional and related behavioural reaction to that loss. Women are not only more at risk of bereavement than men, but they...

Psychosocial vulnerability

The part played by severe events in depression has proved to be a particularly effective platform for exploring psychosocial vulnerability. The importance of this question was, in fact, illustrated in Table 1 where, despite the fact that the majority of onsets were preceded by a severe event, only one-fifth of those who experienced a severe event developed depression. While, as already discussed, taking account of event type somewhat reduces this ratio, it is still necessary to ask why only a...

Delusional disorder general features and introduction to the subtypes

We have already outlined the diagnostic criteria for delusional disorder in DSM-IV and ICD-10 and have amplified these with descriptions of many of the clinical phenomena associated with the illness. It has been emphasized that this is a stable and readily recognizable disorder, provided that the clinician is informed of the essential criteria and has dealt with at least several cases to familiarize him- or herself with its very characteristic 'feel'. With this experience it becomes much more...

School context and experiences

School life forms a further central aspect of children's social worlds.(13' Schools are charged with key roles in the socialization of children and adolescents, and school life brings its own particular demands and challenges. Starting and changing schools are significant, sometimes troublesome, events for children although most young children adapt well, a significant minority show some disturbance when they start school, and both attainment levels and self-perceptions are affected for many...

An amotivational syndrome

Anecdotal reports that chronic heavy cannabis use impairs motivation and social performance have been described in societies with a long history of cannabis use, such as Egypt, the Caribbean, and elsewhere.(2) Among young American adults who were heavy cannabis users in the early 1970s, there were clinical reports(2) of individuals who became apathetic, withdrawn, lethargic, and unmotivated, apparently as a result of chronic heavy cannabis use. This constellation of symptoms was described as an...

Herpes encephalitis

This can give rise to a particularly severe form of amnesic syndrome.(25) The majority of cases are said to be primary infections, although there may be a history of a preceding 'cold sore' on the lip. Characteristically, there is a fairly abrupt onset of acute fever, headache, and nausea. There may be behavioural changes. Seizures can occur. The fully developed clinical picture with neck rigidity, vomiting, and motor and sensory deficits seldom occurs during the first week. (26) Diagnosis is...

What makes a stressor traumatic

In everyday language, many upsetting situations are described as 'traumatic', for example divorce, loss of job, or failing an examination. However, a field study designed to establish what kinds of stressors lead to the characteristic symptoms of PTSD, showed that only 0.4 per cent of a community sample developed the characteristic symptoms of PTSD in response to such 'low magnitude' stressors.(6) Thus, in diagnosing PTSD, it appeared necessary to employ a strict definition of what constitutes...

Types and functions of traditional practitioners

Different categories of traditional practitioners can be defined according to their predominant functions and to the types of procedures they employ. Herbalists deal primarily with the therapeutic application of plant remedies. Plant and animal items used in traditional medicine may in some cases have symbolic or 'placebo' functions. However, many plant remedies have not yet been scientifically scrutinized and a number of investigated plants in use by traditional healers have been shown to...

Casefinding

Case-finding designs fall into three broad groups case detection in clinical populations (persons in contact with services), door-to-door surveys (including census investigations of entire communities and surveys of population samples), and birth cohort studies. Each method has its advantages and limitations. While case-finding through the mental health services provides a relatively easy access to a substantial proportion of all persons with schizophrenia, the cases currently in treatment may...

Exposure combined with cognitive restructuring

Cognitive restructuring is an intervention originating from Beck's cognitive therapy (66) and Ellis's rational emotive therapy.(67) In cognitive restructuring, individuals are 1. to identify negative thoughts that occur during stressful or anxiety-provoking situations 2. to evaluate the accuracy of those thoughts as compared with objective information derived via repeated questioning or as a result of planned 'behavioural experiments' 3. to derive rational alternative thoughts based on the...

Functional impairment

Individuals with social phobia experience significant impairment in social, educational, and vocational functioning. (58) They may find it difficult to initiate or maintain social or romantic relationships, avoid classes that require public presentations, discontinue their education prematurely, or take jobs below their ability to avoid social or performance demands. They are more likely to be single, less well educated, and to receive financial assistance than persons without the disorder. (9)...

Histogenesis of the brainstem and cerebellum

During histogenesis of the brainstem and spinal cord the motor, sensory, somatic, and visceral zones are organized similarly. At the level of the fourth ventricle the arrangement is different the dorsal plate of the spinal cord is moved to a lateral position in the brainstem so that the various zones of the hindbrain are arranged in a lateral-to-medial sequence In the brainstem, proneurones not only migrate radially, as in the spinal cord, but also tangentially and longitudinally. This complex...

Differential main subsidiary and alternative diagnoses

A differential diagnosis should be placed in the case records in a prominent place, with a clear indication of who made it ('diagnosis' will be used in this section because of current conventions, but the difference between identifying a disorder and inferring an underlying diagnosis already noted must be kept in mind). When the patient suffers from more than one disorder it is usually possible to select one as the main diagnosis and specify the other(s) as additional or subsidiary diagnoses....

Differential diagnosis

Making a diagnosis of conduct disorder is usually straightforward since parents readily volunteer the symptoms, although it is essential to obtain an independent report from school so as not to overlook behaviour in that context. Sometimes the diagnosis may be inappropriate since antisocial behaviour may arise as part of other disorders such as autism or mania, or not be severe enough to warrant a diagnosis. More commonly the diagnosis is correct but comorbid conditions are missed. The...

Specific speech articulation disorder

The main feature of the disorder is the child's failure to use speech sounds appropriate for his or her mental age, while other language skills are within the normal range. Difficulties include errors in sound production and use, especially substitution of one sound for another. Difficulties in speech sound production usually interfere either with academic achievement or social communication. There are several degrees of severity reaching from mild or no impairment of speech intelligibility to...