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.,...

Chapter References

Akiskal, H.S., Judd, L.L., Gillin, J.C., and Lemmi, H. (1997). Subthreshold depressions clinical and polysomnographic validation of dysthymic, residual and masked forms. Journal of Affective Disorders, 45, 53-63. 2. Meier, W., Lichterman, D., Minges, J., Heun, R., and Mallmayer, J. (1992). The risk of minor depression in families of probands with major depression sex differences and familiality. European Archives of Psychiatry and Clinical Neuroscience, 242, 89-92. 3. Kendler, K.S., Neale,...

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...

Enduring personality changes after traumatic experiences JLC

ICD-10 has two categories for personality changes those occurring after catastrophic situations, and those starting after psychiatric illness. Either diagnosis should be made only when there is evidence of a definite personality change, including cognition, behaviour, and interpersonal relationships. The changes must not be a manifestation of a current mental disorder or the residue of a previous mental disorder. It must not be an exacerbation of a pre-existing personality disorder. The...

Information processing

In the first half of the twentieth century academic psychology was predominantly behaviouristic in its orientation, concentrating on relations between stimuli (input) and responses (output) and largely ignoring the processes that take place between input and output. Given the ambition to develop a true science of behaviour, this reluctance to dwell upon non-observables in the 'black box' is understandable, but the approach had serious limitations. (56,57) For example, early century...

Course and prognosis Time course of symptoms

For the vast majority of PTSD cases, symptoms begin immediately after the traumatic event. Delayed onset is found in a minority (11 per cent or less) of the cases. (6) A series of prospective longitudinal studies suggest that a large proportion of people who initially develop PTSD recover within the first year after a traumatic event. For example, a study of rape victims found that 94 per cent met PTSD criteria (with the exception of the symptom duration criterion) in the 2 weeks after the...

Diagnosis and differential diagnosis of epilepsy

Diagnosis of epilepsy in patients with mental retardation follows basically similar rules to those used with other epileptic patients. Thus, the diagnosis of epilepsy is clinical and includes two or more unprovoked seizures during a relatively short period of time. However, some details concerning particularly the differential diagnosis of epilepsy differ in patients with mental retardation compared with the epileptic population with normal intelligence. Clinical investigation of epileptic...

Behavioural and psychological symptoms of dementia

Depression, anxiety, emotional lability and incontinence, and other psychiatric symptoms are frequent in vascular dementia. Depression, abulia, emotional incontinence, and psychomotor retardation are especially frequent in subcortical vascular dementia disease. ( 36) Cardinal features of vascular dementia disease are incorporated in the Hachinski Ischaemia Score (5 ' (Ta.b.le,.5). In a recent neuropathological series, stepwise deterioration (odds ratio, 6.0), fluctuating course (odds ratio,...

Imaging blood flow change and hypofrontality

From the outset of the functional neuroimaging of schizophrenia there has been discussion as to whether the frontal lobes of patients are 'less active' than those of normal subjects. The term 'hypofrontality' has indicated either reduced activity 'at rest' or a failure of activation (relative to a baseline condition) when the subject performs a given cognitive task 1.4) Studies by Weinberger's group, using the Wisconsin Card Sorting Task whilst scanning, demonstrated that schizophrenic cohorts...

Neurochemistry and neuropharmacology of memory disorders

The Korsakoff syndrome is relatively unusual among memory disorders in that there is a distinct neurochemical pathology with important implications for treatment. Since animal studies in the 1930s and 1940s, and the important observations of De Wardener and Lennox (51) and others in malnourished prisoners of war, it has been known that thiamine depletion is the mechanism which gives rise to the acute Wernicke episode, followed by a Korsakoff memory impairment. However, the genetic factor that...

Environmental insults at the early developmental stages

Maternal obstetric complications are widely cited as an established risk factor in schizophrenia. (81) Several explanatory models have been proposed. 1. Severe obstetric complication, such as perinatal hypoxia and resulting hippocampal damage, can prepare the ground for adult schizophrenia even if genetic liability is weak or absent. 2. A genetic predisposition sensitizes the developing brain to lesions resulting from randomly occurring less severe obstetric complications. 3. A genetic...

Anorexia nervosa

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Cognitive content of anxiety disorders

Although there is no substitute for a careful assessment of each patient's ideation, research shows that most anxiety disorders are characterized by a specific type of fearful ideation and successful therapy generally focuses on such ideation. (7) Panic disorder is characterized by a fear of an immediately impending internal disaster (for example heart attack, cessation of breathing, mental derangement) and a sense of loss of control over physical and mental functions. Many of panic patients'...

Restoring a healthy weight

Unless the weight loss is rapid or extreme, or the patient's health is endangered by physical complications, weight restoration can usually be accomplished on an outpatient basis. Before focusing on weight gain, however, it is best to devote several sessions to the establishment of a collaborative working relationship and the development of a treatment plan. Thereafter, weight gain and the subsequent maintenance of a healthy weight must be an integral part of treatment. A target weight range...

Destigmatization

If the cardinal contributory factors to stigmatization are ignorance, fear, and hostility, then the antidotes are information, reassurance, and a vigorous antidiscriminatory campaign on the part of policy-makers and opinion-formers. It is generally accepted that if progress is to be made in the destigmatization of mental illness and the provision of more positive accurate images of psychiatric illness and psychiatry, the professionals involved in mental health issues together with patients,...

Quantitative morphometric studies of brainstem nuclei

The dorsal raphe nucleus and median raphe nuclei supply most of the serotonin innervation to the cortex. Using an antibody to tryptophan hydroxylase, which selectively stains serotonin neurones, and a computer-aided imaging system, cells in the brainstems of suicide victims and controls have been counted and morphologically analysed 1 Suicides have a mean cell density in the dorsal raphe nucleus of 120 neurones mm, while controls have 80 neurones mm 2 The critical factor, however, is the total...

Molecular epidemiology of schizophrenia

Notwithstanding the difficulties accompanying the genetic dissection of complex disorders, novel methods of genetic analysis will eventually identify genomic regions and loci predisposing to schizophrenia. The majority are likely to be of small effect, although one cannot exclude the possibility that genes of moderate or even major effects will also be found, especially in relation to the neurophysiological abnormalities associated with schizophrenia. Clarifying the function of such genes will...

The bipolarunipolar distinction

In 1957, Karl Leonhard(20) observed that, within the broad category of manic-depressive illness, some patients had histories of both depression and mania, whereas others had depressions only. He then noted that patients with a history of mania (whom he termed bipolar) had a higher incidence of mania in their families when compared with those with depressions only (whom he termed monopolar). In 1966, Jules Angst*21.) and Carl Perris(22) independently provided systematic family history data to...

Confabulation disorders

Confabulation can be subdivided into 'spontaneous' confabulation, in which there is a persistent, unprovoked outpouring of erroneous memories, and 'momentary' or 'provoked' confabulation, in which fleeting intrusion errors or distortions are seen in response to a challenge to memory, such as a memory test. (43) Confabulation is widely believed to be particularly associated with the Korsakoff syndrome, but this is incorrect. Confabulation arises in confusional states and in frontal lobe...

The availability of alcohol treatment services

The availability of alcohol services is likely to affect the overall impact of public health measures to reduce alcohol use disorders. There is some evidence that the availability of alcohol treatment services has an effect on the prevalence of alcohol use disorders at a population level. Mann et al.(80) found that increased treatment services in Ontario, Canada, were associated with decreased hospital discharges for liver cirrhosis. A similar study in North Carolina examining the 20-year...

The methodology of studies of dementia in Parkinsons disease

Research to establish the status of dementia in Parkinson's disease has confronted a range of methodological issues. (H) A major problem in research on dementia in Parkinson's disease has been in the diagnosis of Parkinson's disease itself. The original description of paralysis agitans by Parkinson was, in fact, the identification of a syndrome rather than of a disease. The part played by such agents as heavy metals, infection, and vascular disease was recognized more than 50 years ago. More...

The current meaning of conversion and dissociation

Freud's notion that hysterical symptoms arose from the conversion of emotional energy to a physical symptom has remained in the labels for them in both ICD-10 and DSM-IV. In both classifications, classical hysterical symptoms are described as based upon unconscious motives and emotional conflict, with the complication that there is a split in mental processes between what is known and what is unknown between the symptom and the conflict that has caused it. In both ICD-10 and DSM-IV dissociative...

Pharmacological interventions for opiate users maintenance and withdrawal

Methadone may be used as substitute opiate drug, prescribed long term with the aim of achieving stable (non-injecting) opiate dependence (methadone maintenance) or it may be prescribed in the short term to aid withdrawal. In the latter case, a methadone mixture (usually linctus) is prescribed in a reducing dose over 10 to 21 days. Assessing the methadone dose equivalent of reported street heroin use is difficult because of the reliance on self-report and the variable purity of illicit heroin....

Early adolescent gender identity disorder

GID continuing into adolescence merges with GID of adulthood. Management issues address the young teenager's continuing gender dysphoria and the consequent social problems. There may be considerable peer group alienation. Depression may develop. School avoidance may develop. Awareness of sexual attraction to same-sex persons may be an additional source of conflict. Parents may be unaware of their teen's GID. GID in adolescents presents medical, legal, and ethical dilemmas for clinicians. The...

Culturally stereotyped reactions to extreme environmental conditions arctic hysteria

'Arctic hysteria' is a vague general term used by outside observers for often dramatic behavioural reactions shown by indigenous inhabitants of arctic and subarctic areas in stress situations, in which the person affected experiences a temporary state of dissociated consciousness induced by acute anxiety. (1,3,> Physical deprivation, mineral and vitamin deficiencies, and the psychological stresses of surviving in an extreme climate have been adduced to explain phenomena of 'arctic hysteria'....

Continuous measures of morbidity

Case ascertainment might be assumed to be the sine qua non for any progress in the epidemiology of mental disorders. But to use the traditional expression 'case ascertainment' nicely illustrates the very problem that has to be re-thought, because it implies a categorical structure in the morbidity that we wish to study. In a population, there are traditionally cases and non-cases. As expressed by Pickering, (23) 'Medicine in its present state can count up to two, but not beyond'. He was...

Immunological abnormalities in mental illness

The topic of immunological abnormalities that occur in conjunction with major mental illnesses needs to be separated into those associated with depression (affective disorders) and those associated with schizophrenia, a much more muddled area of research. Given that the central nervous system and the immune system have intimate linkages, which are being ever more fully elucidated by psychoneuroimmunology, it would seem to follow that major functional perturbations in one system would be...

Behavioural phenotypes in relation to mental illness

Recently the concept of a behavioural phenotype has been introduced as an attempt to assess the interrelationship between specific behaviours and genetic disorders. In addition to specific behaviours, an increased prevalence of psychiatric syndromes have been reported in association with particular genetic and other syndromes. The possible link between a behavioural phenotype and the particular psychiatric disorder of a mentally retarded person is a highly challenging issue for investigators...

Preventive detention of dangerous offenders

Mental health law is one mechanism by which governments seek to control certain antisocial citizens problems arise in attempting to match a legal definition with a clinical diagnosis. The United Kingdom government has recently announced its intention to introduce legislation to permit the 'indeterminate but reviewable detention of dangerously personality disordered individuals whether or not before the courts for an offence'. ( 2) The implications are profound, though the precise nature of the...

Value judgements in psychiatric diagnosis an explanation from ethical theory

Diverse explanations have been offered for the prominence of overt value judgements in psychiatric diagnosis. For some it endorses the radical antipsychiatry position that psychiatry is not a part of medical science. (18) Others have argued that it reflects the primitive state of the sciences underpinning psychiatry. (2 23) Ethical theory, by contrast, the area of moral philosophy concerned with the meanings and implications of value terms, offers an explanation which is fully consistent both...

Excitation and depression

During acute exacerbations of schizophrenia, excitation, manifest as irritability, sleeplessness, agitation, and motor overactivity, is common. Depression is also common around the time of an acute episode of schizophrenia, (1i> and is often a feature of the prodromal phase of the illness. It is not uncommon for patients presenting in the first episode of schizophrenia to report having suffered bouts of minor depressive symptoms over a period of several years. Depression also occurs during...

Behavioural phenotypes

'Behavioural phenotypes' is a relatively new concept and in a broad sense seems to mean an association between a constellation of specific behaviours and a specific disorder, often of genetic aetiology. (3d) As most of the behavioural phenotypes described so far are associated with conditions leading to mental retardation, this concept is particularly relevant to this chapter. The behaviours that have been reported under various behavioural phenotypes could broadly be described under the...

Histogenesis of the spinal cord

The neural tube initially consists of a single layer of neuroepithelial cells surrounding a central canal filled with the cerebrospinal fluid. The outer surface of the future spinal cord has an external limiting membrane, and the inner surface bordering the central canal has an inner limiting membrane. The entire wall of the neural tube is called the ventricular zone.(2) The cells of the neural tube proliferate, and the surface of the spinal cord enlarges. The cord then thickens as cells divide...

On being a patient

Kay Redfield Jamison and Richard Jed Wyatt Chapter, References It is difficult to be a psychiatric patient, but a good doctor can make it less so. Confusion and fear can be overcome by knowledge and compassion, and resistance to treatment is often, although by no means always, amenable to change by intelligent persuasion. The devil, as the fiery melancholic Byron knew, is in the detail. Patients, when first given a psychiatric diagnosis, are commonly both relieved and frightened relieved...

Motor symptoms and signs

Motor symptoms and signs may be due to a neurological disorder causing organic brain syndrome, such as rigidity in Parkinson's disease, or may be related to emotional states such as restlessness or tremor in anxiety. However, there is a further group of symptoms which affect voluntary movements and often occur in functional psychoses. These symptoms are neither unequivocally neurological nor clearly psychogenic in origin and are termed motility disorder by some authors. Table.,, gives a...

Definition of counselling

The term counselling is broadly used and defined, and arriving at a concise definition can be difficult. Fundamental problems include the lack of definition of the boundaries between counselling and psychotherapy, and the lack of clear indications of the methods used. (4) There are many uses of the words 'counselling' and 'counsellor', and Feltham(5) points out that neither the British Association of Counselling nor the American Counseling Association have either proprietary rights of the terms...

The cognitivebehavioural account of anorexia nervosa and bulimia nervosa

Cognitive distortions are a prominent feature of anorexia nervosa and bulimia nervosa, and they have long been regarded as their 'core psychopathology'. For example, in the 1970s the psychotherapist Bruch(1> emphasized the 'relentless pursuit of thinness' of patients with anorexia nervosa, and Russell,(2) in the original paper on bulimia nervosa, highlighted these patients' 'morbid fear of becoming fat'. In both disorders thinness and weight loss are idealized and sought after, whereas there...

Depressive personality disorder JLC

This personality disorder is not included in ICD-10 or DSM-IV, although it is considered as a subject for further study in the latter. However, the concept of depressive personality was well recognized in previous decades (e.g. by Kraepelin and Schneider). Depressive personality was seen as a pattern of brooding, pessimism, and low self-confidence,(2) and as a tendency to physical lassitude and suffering. Phenomenological accounts ( 20) emphasize dependency, orderliness, and adherence to social...