SCHIZOPHRENIA

The word Schizophrenia was first used by a Swiss Psychiatrist in 1911, from the combination of two Greek words, Schizein – to ‘split’, and Phren – meaning ‘mind’ therefore the understanding of Schizophrenia to the lay man meant Split Personality or Mind. However, it was meant to portray a split between the persons cognitive (a group of mental activities, including perception, recognition, and judgement) and the emotional aspects of the personality.

Schizophrenia has been described as a severe mental disorder, a group of mental disorders, sometimes called a syndrome, characterised by the disintegration of the thinking process, loosing contact with reality and emotional flattening.

Throughout the world it affects 1% of the population.

There appear as many views on how to diagnose the condition, as there is about whether the illness actually exists.

Some Psychiatrists believe there are primary and secondary symptoms, and if no primary symptoms are shown, then a diagnosis of Schizophrenia cannot be made. Others describe symptoms as Type I and Type II. Type 1 being associated with ‘positive’ symptoms, i.e. symptoms that are externalised, Hallucinations, Thought Disorder, and Delusions. Type II symptoms are of the negative type, such as Emotional Flattening, Poverty of Thought and Apathy. Some do not believe it exists at all.

Older terminology divides Schizophrenia into 4 types, some believe that there is only one syndrome, and symptoms are equivalent to a pick and mix, a bag full of symptoms, with some individuals having some of the symptoms, and others having a different mix. The need for diagnosis, whichever way a Psychiatrist thinks, is essential as to determine what treatments are to be applied.

There is also a Schizoid personality, which mimics the true syndrome, characterised by emotional coldness, inability to experience happiness or pleasure, unresponsive to praise or criticism, fantasising in extreme, with introspection and eccentricity. This is linked to a Personality Disorder rather than Schizophrenia. Hysterical behaviour can also mimic Schizophrenia in a Pseudo-Schizophrenia, where symptoms are similar but the underlying cause is an emotional, repressive or suggestive one rather than a Psychosis.

Schizophrenia when characterised into four types are: -

  • SimpleParanoid (Paraphrenia)
  • Catatoni
  • Hebephrenic

Before discussing these types it is helpful to define some symptoms and terms to be used.

LOSS OF AFFECT

An apparent inability to modulate mood, the individual may appear flat in mood, bland and emotionless, with immobile facial expression and monotonous voice. Affect means mood.

LACK OF VOLITION

The loss of will to act. This can affect all actions from small daily routines to major decisions. Volition is very similar to motivation, which the individual will also lack.

HALLUCINATION

A false perception. A sensory experience experienced only by the person, which has no basis in fact. It can be characterised by the 5 senses, of Visual (seeing), Olfactory (smell), Auditory (hearing) Tactile (feeling) Gustatory (taste)

DELUSION

A false fixed belief held by the individual, which cannot be removed by rational argument. Delusions are often fashionable; relating to issues of today, space travel, television, where 100 years ago there would be more religious in nature.

NEOLOGISM

A word invented by the individual but always used in context. Simply means ‘new word’. The word has meaning to the individual but no one else.

VERBIGERATION

A general mixing up of the words or phrases of a sentence resulting in a “word salad”. Example, cut up a sentence from a newspaper and cut each individual word, rearrange them so they are meaningless. Verbally this would be the same for verbigeration.

ECHOLALIA

The involuntary repetition of phrases or words overheard. It is a form of mimic without the prior intention. Example: if someone says ‘its a nice day Jeff.’ the individual will state, ‘its a nice day Jeff ’, in a parrot mode of repetition without the knowledge of the subject.

ECHOPRAXIA

The automatic repetition by sufferer of acts performed by others. These are carried out without expression or emotion. It is a form of mimic without prior intention. Example: if someone walks to the window, looks outside and sits down, the individual will do the same thing.

PERSEVERATION

The constant recurrence of an idea, or the tendency to keep repeating the same words or actions. Example: if it was continuos drinking if water it may be life threatening, as it would destabilise the minerals in the body

IDEAS OF REFERENCE

Incorrect interpretations of events as having direct reference to the self. Example: an individual often believes the Television is talking directly to them, or that signals are coming through the radio, directly to them.

INCONGRUITY OF AFFECT

A misplaced emotional response to a situation or event. Example: laughs when tears are required and cries when laughs are required.

EMOTIONAL LABILITY

The tendency for sudden changes of mood of short duration. At one point the individual is reasonable and responsive, then with no prior warning is volatile and aggressive then immediately returns to normality

NEGATIVISM

When the person does the opposite of what is required of him unwittingly presenting an unco-operative attitude. Example: when asked to close door, opens it. A useful tip is to ask them to do the opposite of what is wanted, i.e. when wanting the door closed, ask for it to be opened. It will then be closed.

NIHILISM

Feelings of not existing at all and hopelessness, that all is lost or destroyed. Often believe all or part of their body is dead. Example: the individual believes his legs have died, unaware that they are still walking and this would not be possible if they were dead.

CONCRETE THINKING

The literal interpretation of words and actions. Example: an individual when asked to take a seat might remove a chair from the room. Incapable of understanding anything other that the basic meaning of words and what may be behind them. It is important to set correct communication wavelengths in order to achieve objectives. Example, do not say ‘take a seat’ simply request ‘sit down on this chair’, and the objective will be achieved.

LACK OF INSIGHT

In Schizophrenia individuals do not normally have any appreciation or understanding of their illness. They may tell you that they are Schizophrenic, but lack the insight to understand its’ impact. Insight itself may lead to suicide in some cases.

COGNITION

Cognition is defined as ‘the act or actions of knowing’, and the failure of carers to note the lack of knowing in Schizophrenia can cause a carer to conclude a wrong judgement about the individuals motives or needs. It is the difference between an individual watching someone die and take no actions because of the lack of ‘the act or actions of knowing’ and someone with malice or negligence who knowing someone is going to die, and can do something about it but does not. These judgements included in the failures of the ‘act or actions of knowing’ include areas of Memory, Attention, Thought Disorder, Thought Content and Decision-Making.

SIMPLE SCHIZOPHRENIA.

This type of schizophrenia is noted for its lack of florid symptoms. The individual will normally present as emotionless, unworried, slow and may even present as a Learning Difficulty The often show low I.Q. Testing due to lack of motivation to complete the forms.

People with this illness are often socially isolated, withdrawn and show marked impairment of role functioning with odd behaviour and poor hygiene. They also show a short attention span and poverty of verbalisation and personality. They tend to make little social adjustment and few connections with other people, either holding isolating jobs, or unemployed, they wander the streets. Considerable numbers of homeless are thought to fall into this category. It is thought that they can manage mundane, unthinking work in an effective way, as it does not interfere with their thought processes. I.e. sweeping the roads.

PARANOID SCHIZOPHRENIA.

The main distinguishing feature of this illness is Paranoid Delusions. These are always of a persecutory or derogatory nature. The hallucinations can be of all of the senses. Paranoid individuals commonly experience hallucinations, which appear to confirm and support their delusions. For example a patient, who believes he is being poisoned by the people around him, may actually experience gustatory hallucinations, which confirm his suspicions. By their definition these hallucinations and delusions cannot be rationalised, so these individuals will remain difficult to establish rapport with, and because of their suspicion, any treatment is badly accepted causing the prognosis to be poor. Another factor in their poor prognosis is that unless closely supervised they tend to discontinue their treatment. The incidence of violence is high in this group. This does however tend to be slow in building up and careful observing and skilful handling can avert most incidents. Paranoid Schizophrenia tends to occur mostly in older people although this cannot be taken as a rule.

HEBEPHRENIC SCHIZOPHRENIA.

This form of Schizophrenia is mostly characterised by thought disorder and emotional incongruity. Behaviour tends to be highly excitable, hyper active, sometimes silly and childish. Neologisms, Verbigeration, Negativism, Echolalia and Echopraxia are common. The delusions held are commonly of a grandiose nature. Both delusions and hallucinations tend not to be of a persecutory nature but causing great excitement and over active bizarre behaviour. Violence in this state is normally sudden, without warning and of short duration.

CATATONIC SCHIZOPHRENIA.

In this category there are two state

CATATONIC STUPOR

The individual in this state will exhibit an extreme degree of lack of volition. They will adopt a posture, which will then be held for inordinately long hours. They show a waxy flexibility and will retain the posture of the body or the limb in which he or someone else has placed it. This condition is known as ‘FLEXIBILITAS CEREA’. However although the individual may not appear to be in touch with reality they remain totally aware and remember all that is said to or done for them whilst in this mute stuporous state.

CATATONIC EXCITEMENT

In this state this individual will exhibit wild, uncontrolled, totally disturbed behaviour. In this state they are capable of severe extremes of violence. The transition from one state to the other is rapid and sudden. However, since the advent of Phenothiazines this state has become extremely rare.

TREATMENT

There are two main categories of treatment for schizophrenia.

Treatment of the symptoms

Rehabilitation and prevention of further breakdown.

The standard treatment for Schizophrenia is medication with the Phenothiazine group, including Depot injections and other major tranquillisers. Sleep pattern may be co-ordinated with sedatives as well as Major Tranquillisers.)

There are now new medications, which are used to treat Schizophrenia, unrelated to the Phenothiazine group, (which are regarded as Typical Antipsychotic drugs.

This new group are known as Atypical Antipsychotic Drugs

Clozeril

Resperidone

Olanzapin

The rehabilitation of individuals far more difficult. In the first place by virtue of their illness may not susceptible to treatment.

It is imperative to stabilise their condition first. Once this has been achieved the individual must then be re-trained to return to his rightful place in society.

A steady process of re-education, therapy and care normally achieves rehabilitation.

Re-education may take the form of self-care groups, habit training, Drama therapy, Gardening, Industrial Therapy or such work based projects as Out-Reach.

These are all aids to improving the sufferers, which improves concentration, understanding and insight.

The care given to the individual is continued after leaving the hospital by the community nurses, at home, in Residential or Nursing Aftercare Homes, group homes and hostels.

Follow up care includes Day-care, Outpatient and General Practice Follow Up. C.P.N.s, Social Workers, Occupational Therapists and others may also be involved with Aftercare.

MANIC DEPRESSIVE PSYCHOSIS

In health, people predispose to Manic-Depressive disorders are frequently warm, outgoing people-liable to be moody but hale and hearty when mood is good

The friendliness and warmth of feeling is appreciated by many friends and popular with colleagues.

REASONS FOR DISORDER

Manic Depressive Psychosis is essentially a disturbance of mood in which elated periods alternate with phases of depression sometimes in rythmical cycles sometimes long periods of normal emotional reactions between attacks of mania / depression, others pass gradually from one phase to the other.

There is often a hereditary link with the illness. Further, if one parent has the bilateral disorder, there is a 25% chance of the child suffering the illness; if two parents have the disorder then there is a 50-75% chance of the child suffering the disorder. Whether this is related to hereditary factors or being learnt through family dynamics is not yet proven. It is said that it affects between one half to one per cent of the population

Elation

Flight of Ideas

Restlessness

Pressure of speec

Delusions of Grandeur. (i.e. great wealth, strength

Individuals movements are large

Word Association / Running

MAJOR PROBLEMS AND ISSUES

Need to rest-take adequate nourishmentIrritability with other

Restlessnes

Preventing harm to others / self through exhaustion or aggression

HYPOMANIA

Its importance in that whilst it is less severe than mania it can be more prolonged. Nursing and Care problems are similar but generally can be treated by observation and action to minimise potential crisis.

DEPRESSION – ENDOGENOUS

Endogenous means ‘From Within’. Depressive reactions may occur alternately with Manic or Hypomanic episodes and is known as bipolar. Some individuals show recurrent depressive phases only, which is known as unipolar. In between attacks they may feel very well indeed but never to the extent of developing Mania, Mania in this group is reached when the individual is described as normal. The depressive swing has the same intensity as Reactive Depression and must be treated just as seriously especially on decent into severe Depression or in its’ accent out of severe Depression when thoughts and actions are able to be put into deed. See Depression for more detail. Sleep patterns are affected, either a difficulty in getting to sleep, or more generally early morning wakening.

DEPRESSION – REACTIVE

Reactive Depression is as its name states, i.e. a reaction to a situation in which Depression is the end product. Death or loss of a close relation or friend, or even an animal. It could be the loss of a job or moving house. The reaction of the individual to the loss is of a major magnitude to that individual, even though others have coped with the change in circumstances.

BI-POLAR

Bi-Polar is another way of describing Manic Depression, seeing each end of the mood cycle as Poles, Bi being the prefix meaning ‘two’.

MIXED AFFECTIVE

This is where a Schizophrenic has also an underlying Manic-Depressive illness, and it may be unclear what the symptoms refer to. This is where the individual shows both kinds of symptoms, both Manic and Depressive, and it may be difficult to understand which phase is predominant.

SCHIZO-AFFECTIVE

This is where a Schizophrenic has also an underlying Manic-Depressive illness, and it may be unclear what the symptoms refer to.

CYCLOTHYMIC

Cyclothymic is a word that is used to describe the mood swings in Manic-Depressive Psychosis. In everyday use, a Cyclothymic Personality is someone who can swing from one mood of happiness to another dark and miserable mood within a short period of time. These individuals are not necessarily ill but their traits are notable by those who have contact with them.

MELACHOLIA

Melancholia is an older term or expression, which means a severe form of Depression. It is often used in the Depression associated with the elderly

DENIAL

The first attack of Mania, Hypomania or Depression is often led by a crisis in a person’s life – it is believed that Mania is a form of “denial” of the situation therefore, instead of Depression the person can swing into Mania.

PRESSURE OF SPEECH

This symptom is predominant in the ‘high’ state of the illness, where the individual gushes out thoughts and statements at an almost impossible rate, without adequate breaks and stops that inflect into normal conversation. Often the speech is rapid running and rhyming in nursery rhyme style.

FLIGHT OF IDEAS

Moving rapidly from one subject to another is called Flight of Ideas. It often is associated with pressure of speech, and both the pressure and the though processes cause the individual to move from one topic to another with usually a link between the subjects, even if it is not readily clear to the carer.

OVER-ACTIVITY

Superhuman endeavours can take place, where several jobs are taken on at one time, and the individual believes they are doing a splendid job, and does not realise that the quality and workmanship is usually of a poor or inappropriate standard. If a lounge is painted, and the individual is in full swing, they may paint the walls, doors and ceilings pink or red and they cannot see the inappropriateness of the colour scheme, or the paint drips on the door and carpet. And whilst they are busy in the lounge, they order 20000 bricks to build a 3 foot high six feet long wall.

DELUSIONS OF GRANDEUR

These individuals, with Delusions of Grandeur can spend vast sums of money believing themselves to be extremely rich, or can take on physical risks believing they have superhuman abilities. One individual believed he was so strong that he could stop a fast train by standing in front of it, needless to say, he was proved fatally wrong. Many people who write letters to the press often are in a high or grandiose mood.

SUDDEN CHANGES IN BEHAVIOUR

Volatility is a symptom to be aware of, where the individual appearing jovial and friendly and the life blood of the room, suddenly becomes very angry and abusive because of something said or done to which they dislike. This can be a dangerous point in the illness and needs careful management to prevent a physical outburst.

ALCOHOL ABUSE

Sociability is part of the Manic process. When healthy people are sociable, happy and in celebratory mood, they tend to celebrate with a drink. This is no different from the individual in a Manic state, they feel the need to celebrate and drink excessively, without realising the amount, or the harm that this is doing to them and their families. It can increase the likelihood of mood change and aggression.

AGGRESSION

Although the individual may appear to be in a good mood and extremely pleasant company and listened to by those around, they may quickly change mood, especially if a comment made is challenged or the right sort of reaction to the humour is not shown. It is not sensible to contradict any view in the acute phase as where their position is questioned; they can resort to threats as well as actual violence.

OVERPOWERING

Whilst for a time the individual is amusing and the centre of attraction, their presence and demeanour can be overpowering and weigh down on those who are around them, especially if they are at Home and the family has to suffer the rapid changes of mood, the elation, depression, anger, language, abuse and financial costs of the individuals extravagances.

IRRITABILITY

Individuals can become irritable moving in and out of various mood changes, they can believe that things are being done to annoy them, especially if they conceive “obstacles” which they believe are put in their way.

EXHAUSTION

Untreated, the individual would become exhausted physically, would not eat or drink due to continual activity and would become a major risk to self and / or others.

DISTRACTABILITY

Given the individual is very distractible, the distractibility can be used in order to help them by getting them away from perceived challenges and the ability to distract can prevent mood changes, irritability and aggression.

EATING AND DRINKING ISSUES

In acute phases, the individual does not have time to eat and drink, they are too busy, yet to the outsider, they are depleting themselves of reserves of food and fluid which because of their activity they need. They may be reluctant to take advice about this and may get angry when approached.

ELATION

Anyone who has nursed a Manic patient knows how stressful this can be on others, the individual is elated and feels on top of the world, makes plans for great actions and indulges in feverish activity though finishes nothing.

RESTLESSNESS

Hypersensitive to noise and any stimulus, word or sound will set of new train of thought or deed. Speech does not follow usual logic and the person’s happiness is infectious

SLEEP DISORDER

Sleep is always a problem, it is said that the lowest point of a Manic/Hypomanic phase is when it is time for bed, and often they have two to three hours sleep and are up at night engaged in fruitless activities.

TREATMENT

The important decision regarding treatment is to judge which way the illness may develop, once this is understood the issue of whether to give higher priority to high doses of a Major Tranquilliser or of Anti-Depressants. To judge that an individual is becoming more Depressed when they are becoming increasingly Hypomanic may cause a decision to prescribe Anti-Depressants, where the Hypomania is made worse. If the Schizophrenic is Depressed, psychotic symptoms may appear, though the individual may be given high doses of Major Tranquillisers, as there may be a belief that the psychosis is of a Schizophrenic origin, when it is depressive and an Anti-Depressant would be indicated to relieve symptoms. Example. A Schizophrenic was once admitted to hospital for Acute Care, his Schizophrenia was stabilised and was allowed weekend leave. He put a gun to his head and killed himself. The Schizophrenia was controlled but not the Depression.

MEDICATION

PHENOTHIAZINES

Sedation is necessary, usually in form of Chlorpromazine or Haloperidol. Although oral medication would be the preferred route, intra-muscular medication is sometimes required initially.

SEDATIVES

Night sedation is required to ensure an adequate sleep pattern. Often, as in most Mental Illnesses, the control of the sleep pattern is the key to stabilisation of the illness.

MOOD STABILIZERS

Lithium Carbonate or Anticonvulsant medication (has mood stabilising effect) are the choice of drugs used in order to prevent extremes of mood reoccurring. They are classified as Mood Stabilisers. Monitor. Blood Tests for Lithium Carbonate

ANTI-DEPRESSANTS

Anti-depressants to increase mood, if there is a Depressive element.

THERAPEUTIC INTERVENTIONS

OCCUPATIONAL THERAPY

Occupational Therapy is also helpful in motivation and digression from the illness. Individual and Group Therapy

ELECTRO-CONVULSIVE THERAPY (ECT)

ELECTRO-CONVULSIVE THERAPY is effective in the most serious and resistant cases to medication cases.

DESTIMULISATION

A quiet non stimulating atmosphere must be created and a calm quiet and deliberate slow speech by the carer coupled with absence of noise, quiet lighting

MONITORING OF FOOD AND DRINK

Monitor intake of food and drink; offer regular drinks and food. In the acute phase the individual may be too busy for taking meals and drinks so it may be advisable to offer snacks and keep a jug of squash close to them so they can access nutrition when it is offered or around. The opposite may also happen, where a gargantuan appetite for food and drink (including alcohol) may take place.

WEIGHT IMPLICATIONS

Because of the overactivity and the possible lack of nutrition, weight loss may be seen in a short period of time. Alternatively, due to excesses of food and drink, weight gain may be an indicator that the illness is acute and needs treatment.

DEPRESSION

TYPES

ENDOGENOUS : From within, no known cause. A part of Manic Depressive Psychosis.

REACTIVE : Reaction to life event, i.e. the death of a loved one.

VARIATIONS

SMILING :

Life threatening form, often has made up mind to commit suicide and as such free of anxiety and doubt. Lulls carers into a false sense of security. It is not uncommon prior to making a decision to commit suicide, that the individual begins to be happy, relaxed and make appointments to meet people. This gives the impression of an improvement in their mental condition, whereas the individual is really smokescreening and as such can end their life without others concern for their mental health. An observant nurse, carer or doctor must rule out this smiling depressive illness before they accept that a genuine improvement has occurred

MELANCHOLIC : Usually features in old age.

HYPOMANIC : Reverse form of Depression. The person is in a state of excitement and happiness, though in reality is depressed and will eventually be seen as such.

DELAYED RESPONSE : No outward reaction at the time of a sad event, but e.g. a spouse dies, and the person shows minimal emotion, friends and family discuss how well they have coped with bereavement, 6 months later cat dies and a severe depression ensues.

SIGNS AND SYMPTOMS

TREATMENTS AND INTERVENTIONS

PSYCHOMOTOR RETARDATION: Both Mental and Physical activity slows down.

THE BLUES: Mood blackens, the world is seen in dark colours, blues and blacks, no pink or red.

MONOSYLLABIC: One word answers to questions, sometimes no response.

POVERTY OF THOUGHT: Very little mental activity

INABILITY TO CONCENTRATE: Reading and conversation is affected

LETHARGY: Everything is too much bother

LACK OF VOLITION: No will to do anything.

MORBID RUMINATION: Of death and dying.

SELF NEGLECT: Hygiene and self-esteem.

DECREASED LIBIDO: Sex drive diminishes can add to problems

DELUSIONS OF PERSECUTION: Unworthiness, Psychotic Symptoms occur.

DEPERSONALISATION: A feeling of unreality or altered state, where mind is separated from body. A person gets up from his chair, walks around and comes back; he turns to the nurse and says ‘where has the person gone who was sitting in that chair’

WEIGHT ISSUES: Due to appetite loss or weight gain due to ‘eating there way through Depression.’

ALTERED SLEEP PATTERN: Difficulty in getting off to sleep or early morning wakening. May not want to get up from bed. Does not want to face the day.

SUICIDAL IDEATION: No point in living, psychological pain is too great to live with. Anxiety whilst internal mind arguments of whether to end it all, or not. Greatest danger is on the way down to severe depression and on the way back to normality. The person has negative insight and increased energy in this period and is most at risk. The risk when having ECT is greater on around the 3rd treatment. This is when the depression begins to lift from the lowest point and the person is able to be depressed enough to feel that there is no point in going on.

DIURINAL VARIATION: Mood swings during a day, sometimes feeling less depressed and hopeful, then later feels worse again. It is generally a positive feature that things are getting better. The person needs to be reassured that these feelings are a sign of improvement

Depends on the severity of the Depression. One or more of the interventions may be applied.

REST, REASSURANCE AND PSYCHO-T

THERAPY

MEDICATION:

Antidepressant. To improve mood

Sedation. To enable sleep pattern to recover

Lithium. Mood stabilisation.

Anti Psychotics. For psychotic features

See DRUGS USED IN PSYCHIATRY for further information.

OUT PATIENT APPOINTMENTS

DAY CARE: For in patient or outpatient care, either for Individual or Group interventions.

OCCUPATIONAL THERAPY: May help prevent rumination, motivation and concentration.

SUPPORT GROUPS: Such as MIND, HANDS, Manic-Depressive Society

RELEARNING: Relearn new approaches to life, as changes have taken place.

ACCOMMODATION: Housing issues may need to be raised, smaller home, sheltered accommodation, somewhere to live

ELECTRO-CONVULSIVE THERAPY: In very serious life threatening depression, this treatment may be given, usually voluntarily, or in rare cases, under Sections of the Mental Health Act 1983 for Treatment

See ELECTROPLEXY under TREATMENTS, THERAPIES AND INTERVENTIONS IN PSYCHIATRY

ANXIETY STATES.

Most people feel anxious before an important event, or when faced with danger. Anxiety reactions are natural at such times. It is associated with the natural animal instincts of flight, fight and fear. They disappear when the cause is removed. An Anxiety state, however, is a continual and irrational feeling of anxiety in the absence of any justifiable cause. The anxiety may amount to panic and interfere with mental and social functioning. It rarely remains “free floating” for long. Frequently it attaches itself to specific objects or situations, which are then avoided.

Anxiety states tend to be long lasting and fluctuate widely in severity. Individuals may complain of feeling anxious and irritable, but more often than not they are troubled by physical symptoms. These vary widely with each individual although each tends to keep a similar pattern over a period of time. Increased anxiety may progress to attacks of panic, when the individual feels his last moment has come, or that he is about to go mad, lose control of their actions fearing disgrace in public. The sense of unsteadiness that often accompanies this severe state of anxiety may increase to such a degree that the patient may collapse.

Restlessness and irritability often accompany anxiety. Concentration becomes difficult, short term memory is upset and the individuals tire easily. Sleep is frequently disturbed, partially dropping off to sleep and early morning wagering. Patients may become preoccupied with insomnia and work themselves into a state of near panic at bedtime at the prospect of another night awake. Hypnotics or large night-caps may be taken to excess. When the patient does eventually fall asleep, he may be woken by unpleasant dreams. Eventually when it is time to rise he feels exhausted and sleepy.

Occasionally this picture is reserved and sleep is increased, both in depth and duration.

Appetite for food is similarly affected, but is rarely seriously reduced, when it does occur it involves only a few pounds. Cardiovascular symptoms are common; palpitations, Tachycardia and pains over the chest often lead a patient to fear a heart attack.

Gastro-intestinal symptoms include difficulty with swallowing, nausea and vomiting, diarrhoea and / or constipation.

Gynaecological genito-urinal symptoms may occur, such as; menorrhagia, occasionally amenorrhoea, frequency of micturition, dysuria, pre-menstrual tension (PMT) is usually marked.

Muscle tension is increased and is responsible for headaches and pains around the neck, shoulders and spine. Fatigue is sometimes one of the main symptoms. Any exertion brings on a remarkable sense of exhaustion.

Depression of mood may also become prominent and at times it may be difficult to decide whether anxiety is the primary condition or secondary to depressive illness.

DEFINITION

Anxiety is an acute or chronic condition of mind which has both mental and physical components.

SPECIFIC REASON

Most people suffer anxiety prior to a stressful, even if enjoyable event, some are masters at hiding it and some are totally phased by the ordeal. It is not uncommon for Beta-Blocker medication to be prescribed prior to a driving test, to minimise cardio-vascular symptoms, which if the symptoms persist can cause panic attacks and be life threatening. Individuals, who have high blood pressure, once told, may have increased high blood pressure as a result. Job instability or physical disease may be a source of the problem, and can be rectified once the cause is dealt with and resolved. Where there is no resolution, anxiety will remain a significant problem that may become a chronic problem. Anxiety can also be a component of all Mental Illnesses and it is important to access the dominant symptoms to understand for instance whether the anxiety is causing the depression or whether the depression is causing the anxiety.

FREE FLOATING

This feature is prevalent when an individual perceives a problem that may not exist and extend their fears to other elements of daily life. There may not be a clear reason why the anxiety is predominant, as underlying subconscious mechanisms may be at work. The individual may become very distressed at not being able to understand the nature of the problem and why they are in that state.

PHOBIC

Anxiety can be compartmentalised and made safe for an individual. Where free floating anxiety is distressing as discussed above, to have a phobic anxiety, where the individual has irrational fears and tries to avoid the phobia.

SIGNS AND SYMPTOMS

RESTLESSNESS

Anxiety can cause the individual to pace and be unable to relax and sit down for reasonable periods of time. It is both a psychological and physiological symptom, and underpins the physical activity of the illness, as it is manifest in the person. Often characterised by the expectant father awaiting news of a new child.

IRRITABILITY

The focus of the individual is usually inward, and preoccupation of the anxiety, with the mental and physical energy needed to cope with the illness often causes the individual to be irritable and sometimes aggressive when both having to cope with their own symptoms and with someone else’s enquiries to them regarding the illness or other issues

INSOMNIA

As with all mental illnesses, anxiety provokes sleep patterns to alter, either on its own or with an underlying illness. Most of us have woken up in the middle of the night because of issues that need resolving, and a great deal of thinking is done to resolve an issue. Where that becomes an illness, the issues become irresolvable and only worry; fear and negative feelings are the outcome. As with most Mental Illnesses, resolving the sleep processes is a key to the treatment and resolution of the illness.

IMPOTENCY/FRIGIDITY

Sexual interest and activity are likely to diminish. Men may become impotent, and women frigid. On the other hand anxiety sometimes increases sexual tension and there is increased activity.

APPETITE ISSUES

The general picture of an anxiety sufferer is of a whispy thin individual smoking one cigarette after another. Either they do not eat because of the autonomic nervous system making them not feel hungry, or there is a reaction to the anxiety by eating and drinking to excess. But a considerable increase of weight can occur when anxiety leads to compulsive eating. But a considerable increase of weight can occur when anxiety leads to compulsive eating. Food in the stomach may make the individual feel tired and unwell.

CARDIO-VASCULAR

Rapid heart rate is felt either at the pulse, or as palpitations which makes the individual aware of the beating, pace and strength of the heart. This often co-insides with a high blood pressure that can be fatal if not treated.

BREATHING

A feeling of a tightening of the throat, combining with a feeling of not being able to catch their breath which can lead to hyperventilation and rapid respiration. Both Cardiovascular and Breathing problems can make the individual fee that they are not in control of themselves and can lead to a panic attack. Medical Intervention may be necessary even vital.

GASTRO-INTESTINAL

Dry mouth, nausea, vomiting and diarrhoea are physiological symptoms associated with anxiety. It is also important that all physiological components are analysed for other diseases prior to a diagnosis of anxiety, otherwise the individual will be at risk from the underlying disease.

MUSCULAR

Anxiety causes tension in muscles, which is why relaxation techniques are an effective way of relieving anxiety with the associated tension. Facial muscles can show knotting, as the jaw becomes tight, with perhaps grinding of teeth. Muscles of the back and neck also take the stress of the anxiety. Effective massage can help in this situation.

DEPRESSION

Constant anxiety will inevitably lead to a depression due to the inability to resolve underlying problem’s, with its chronic nature it ensures the cycle of anxiety-depression-anxiety symptoms.

MEMORY/CONCENTRATION LOSS

Poor memory and concentration are common in anxiety states. It may be the minds concentration on the anxiety within, blocks out other information which is necessary to absorb. The lack of memory and concentration adds to the anxiety of the individual who increases the worry that they are not in control of their minds.

PERSPIRATION/SWEATY PALMS

Another of the autonomic nervous systems reaction to anxiety is the release of fluids onto the skin. Most of us have had to perspire when in awkward situations or sweaty palms when being put in an anxiety situation. The outward appearance of anxiety does nothing to diminish its effects.

SUB-CONSCIOUS CONFLICTS

Freudian psychoanalysts see subconscious conflicts between forbidden inner impulses, particularly those of a sexual nature, and inhibitions, as the source of chronic anxiety. It is suggested that if such conflicts can be brought to light, then the anxiety will disappear. However, conscious conflicts can frequently be identified in patients with anxiety states i.e. an extra-marital affair, yet strong dependence on a spouse.

AMBITION

Ambition greater than a patient’s abilities. Reaching the height of their own incompetence in the workplace may increase the anxiety symptoms and both anger and inability take the place of competence and dynamics.

RESENTMENT

Resentment of a dependent, yet the strong desire to look after them. If these can be discussed, and if possible resolved, anxiety often fades. We all regret events in life at various stages but normally allow for experience.

DIFFERENTIAL DIAGNOSIS

THYROTOXIC STATES: Thyrotoxic States, initially may be mistaken for Anxiety as Sweating and Rapid pulse may be present. Anxiety may be felt before a the illness presents itself.

HYPOGLYCAEMIA: The sweating and palpitations associated with anxiety are also symptoms of hypoglycaemia, and if this is associated with Diabetes, then caution should be exercised when diagnosing or stating that the symptoms are of an anxious person.

AGRANULOCYTOSIS: Agranulocytosis has Anxiety symptoms such as Tachycardia; diarrhoea and vomiting, in which someone being treated for Anxiety Depression, which can be side effects of Anti – Depressive or Anti-psychotic drugs. A differential diagnosis should always be made before the symptoms are related to Anxiety.

UNDERLYING DISEASE: Anxiety may be the result of organic disease rather than the cause of physical symptoms. Therefore the diagnosis of an anxiety state should rest on positive evidence of an anxious and predisposed personality and/or severe stress in the recent past. Anxiety is absent in hypertension until the patient is informed of the condition. Anxiety itself raises blood pressure especially systolic. Depression is nearly always accompanied by anxiety symptoms. A patient in the early stages of dementia, before insight is lost, is understandably anxious and depressed.

TREATMENTS

ACUTE PHASE

Acute anxiety: (following a traumatic accident) needs heavy and immediate sedation. The longer it is allowed to persist, the more difficult the symptoms are to deal with.

Electro convulsive Therapy (see under ECT) may be helpful; great care is needed as ECT can make the average primary anxiety state worse.

CHRONIC PHASE

THERAPEUTIC APPROACHES

Psychotherapy at some level is required in all anxiety states. Simple explanation and reassurance about physical symptoms can bring about considerable improvement. Underlying problems and conflicts need to be explored and related to anxiety, although it is wise not to explore too deeply into the background of inadequate patients for fear of breaking down still more of their weak psychological defences. Both individual and group psychotherapy are at times needed.

Behavioural therapy is particularly useful in phobic anxiety states.

MEDICATION

Benzodiazepines such as Diazepam (Valium) are helpful; they may be required continuously for a time – between 6-20mg a day or when the need arises.

Many severe anxiety states, particularly when somatic symptoms or phobic anxiety are prominent features, respond well to a monoamine oxidase inhibitor (see under MAOIs) such as phenelzine (nardil) combined with a tranquilliser.

When there is a strong depressive component present a tricyclic or other anti-depressant is sometimes helpful. Occasionally, in cases of long-standing incapacitating anxiety. Continuous narcosis – 72 hours or so – may be necessary at times.

Barbiturates are still invaluable for acute anxiety.

RELAXATION TECHNIQUES: Relaxation Therapy (see under Relaxation Therapy) can be used individually or with a group. The patient can learn how to apply this technique himself whenever the need arises.

PROGNOSIS

This is good though relapses are likely. Much depends on a patient’s constitutional vulnerability and his ability to adapt his life so that what are for him, serious stresses, can be minimised.

SYMPTOMS AT A GLANCE

  • Poor concentration
  • Disturbed sleep pattern
  • Diminished sexual interest
  • Poor appetite
  • Palpitation
  • Tachycardia
  • Sweaty palms
  • Dry mouth
  • Difficulty in swallowing
  • Nausea
  • Vomiting
  • Diarrhoea and / or constipation
  • Indigestion
  • Menorrhagia
  • Dysuria
  • Amenorrhoea
  • Frequency of micturition
  • Marked PMT
  • Fatigue

PANIC ATTACKS

AETIOLOGY

Panic attacks typically begin in young adulthood, but can occur at any time during an adult’s life. Many researchers believe the body’s natural fight-or-flight response to danger is involved. For example, if a grizzly bear came after you, your body would react instinctively.

GENDER CLASSIFICATION

Women are more likely than men to have panic attacks.
SIGNS AND SYMPTOMS

CARDIAC AND RESPIRATORY

The heart speeds up and pounds, to a point that the suffer can feel it racing, the more aware they are of the heart beat and rate, the more anxious they become and paradoxically the faster the heart beats. Logically the faster the heart beats, the more oxygen is needed and physiologically the breathing increases, part due to the Panic and part due to the oxygen need. The body in the reality of the animal kingdom is being readied for a life-threatening situation. The same underlying mechanisms that would happen when a lion chases its prey. The difference is there is no obvious threat around, but something trips the body’s alarm system. The result will alsom have an effect to increase the blood pressure.

EMOTIONAL IMPACT

Panic attacks are almost a violent experience. The sufferer may feel like they are going insane. They feel like they are losing control in a very extreme way. The heart pounds really hard, things seem unreal, a sense of depersonalisation takes place, with a very strong feeling of impending doom. Panic attacks are almost a violent experience. The sufferer may feel like they are going insane. They feel like they are losing control in a very extreme way. Things seem un-real, a sense of depersonalisation takes place, with a very strong feeling of impending doom.

SENSATION

When a panic attack strikes, and the sufferer may feel sweaty, weak, faint, or dizzy. Hands may tingle or feel numb, and they might feel flushed or chilled. There may be chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. Sufferers worry when and where the next one will strike. In between times there is a persistent, lingering worry that another attack could come any minute.

DURATION

A panic episode usually begins abruptly, without warning, and peaks in about 10 minutes. It can last anywhere from a few minutes to half an hour or longer. Panic attacks are characterised by a rapid heartbeat, sweating, trembling, and a shortness of breath. Other symptoms can include chills, hot flashes, nausea, cramps, chest pain, and tightness in the throat, trouble swallowing and dizziness.

MORBID RUMINATION

It is likely that they may genuinely believe they are having a heart attack or stroke, or on the verge of death. Attacks can occur any time, even during a non-dream sleep.

ENVIRONMENTAL CONSIDERATIONS

Panic attacks and Panic disorder can be very disabling conditions for the people who suffer from them. Sometimes they can lead to avoidance of any activity or environment, which has been associated with feelings of panic in the past. This can in turn lead to more severe and disabling disorders such as agoraphobia.

TREATMENT

Treatment emphasising a three-pronged approach is most effective in helping people overcome this disorder: education, psychotherapy and medication.

PSYCHOTHERAPY

Education is usually the first factor in psychotherapy treatment of this disorder. The patient can be instructed about the body’s “fight-or-flight” response and the associated physiological sensations. Learning to recognise and identify such sensations is usually an important initial step toward treatment of panic disorder. Individual psychotherapy is usually the preferred modality and its length is generally short-term, under 12 sessions. An emphasis on education, support, and the teaching of more effective coping strategies are usually the primary foci of therapy. Family therapy is usually unnecessary and inappropriate.

RELAXATION AND IMAGINARY TECHNIQUES

Therapy can also teach relaxation and imagery techniques. These can be used during a panic attack to decrease immediate physiological distress and the accompanying emotional fears. Discussion of the client’s irrational fears (usually of dying, passing out, becoming embarrassed) during an attack is appropriate and often beneficial in the context of a supportive therapeutic relationship. A cognitive or rational-emotive approach in this area is best. A behavioural approach emphasising graduated exposure to panic-inducing situations is most-often associated with related anxiety disorders, such as agoraphobia or social phobia. It may or may not be appropriate as a treatment approach, depending upon the client’s specific issues.

All relaxation skills and assignments taught in therapy session must be reinforced by daily exercises on the patient’s part. If the client is unable or unwilling to complete daily homework assignments in practising specific relaxation or imagery skills, then therapy emphasising such skill sets will likely be unsuccessful or less successful. This pro-active approach to change (and the expectations of the therapist that the client will agree to this approach) needs to be clearly explained at the onset of therapy. Discussing these expectations clearly up-front makes the success of such techniques much greater.

GROUP THERAPY

Group therapy can often be used just as effectively to teach relaxation and related skills. Psycho-educational groups in this area are often beneficial. Biofeedback, a specific technique that allows the client to receive either audio or visual feedback about their body’s physiological responses while learning relaxation skills, is also an appropriate psychotherapeutic intervention.

MEDICATION

A lot of people who suffer from panic disorder can successfully be treated without resorting to the use of any medication. However, when medication is needed, the most commonly prescribed class of drugs for Panic disorders is the Benzodiazepines (such as clonazepam and alprazolam) and the SSRI antidepressants. It is rarely appropriate to provide medication treatment alone, without the use of psychotherapy to help educate and change the patient’s behaviours related to their association of certain physiological sensations with fear.

Clonazepam and alprazolam are the treatment of choice in the treatment of Panic Disorder. Clonazepam and alprazolam are preferred to antidepressant drugs because of their less severe side effects. He also states that it is preferred to try the anti-anxiety agents before moving on to the antidepressants because of the increased side-effect profiles. Some Benzodiazepines can be addictive and should be used with care. Treatment with Benzodiazepines should be discontinued by tapering it off slowly, because of the possibility of seizures with abrupt discontinuation.

SELF HELP

Self-help methods for the treatment of this disorder is not prioritised enough by professionals, mainly because very few professionals are involved in them. Many support groups exist within communities throughout the world, which are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and relaxation skills with people they meet within support groups. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.

PHOBIAS

DEFINITION

Phobias, intense, irrational fears of certain things or situations.

TYPES OF FEAR

Dogs, closed-in places, heights, escalators, tunnels, highway driving, water, flying, and injuries involving blood are a few of the more common ones. Phobias aren’t just extreme fear; they are irrational fear. Someone may be able to climb the world’s tallest mountains with ease but panic going above the 10th floor of an office building. Adults with phobias realise their fears are irrational, but often facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

AETIOLOGY AND GENDER

Specific phobias strike more than 1 in 10 people. No one knows just what causes them, though they seem to run in families and are a little more prevalent in women. Phobias usually first appear in adolescence or adulthood. They start suddenly and tend to be more persistent than childhood phobias; only about a fifth of adult phobias vanish on their own. When children have specific phobias–for example, a fear of animals–those fears usually disappear over time, though they may continue into adulthood. No one knows why they affect and stay with some people and disappear in others. It is said that in individuals under age 18 years, the duration is at least 6 months.

IRRATIONAL FEAR

Marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

FEAR STIMILUS

Exposure to the Phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situational bound or situational predisposed Panic Attack. In children, crying, tantrums, freezing, or clinging may express the anxiety. The person recognises that the fear is excessive or unreasonable, but is unable to free themselves from the idea that the fear is real. In children, this feature may be absent.

AVOIDANCE OF FEAR

The phobic situation is avoided or else is endured with intense anxiety or distress. The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine, occupational functioning, or social activities or relationships, or there is marked distress about having the phobia.

MEDICATION

The causes of social phobia and its treatment are similar to those of agoraphobia and simple phobia. Medications for this and other phobic disorders have been useful in two contexts. First, the minor tranquillisers or anxiolytics are excellent means of treating anxiety symptoms. However, they do not appear to block the actual process of panic attacks. Second, certain of the tricyclic antidepressants have been used in some patients, often in doses well below those used for the Affective Disorders.

Considerable success in controlling panic attacks, with and without agoraphobia, has been reported in recent years through the use of tricyclic antidepressants, especially imipramine and Mono Amine Oxidase Inhibitors (MAOI’s), such as Phenelzine. The dramatic reduction in panic attacks that follows such medication is the central factor in recovery from agoraphobic disorders. Sometimes the mere control of the panic is sufficient to allow patients to resume their customary activities. If anticipatory anxiety persists despite the disappearance of the acute panic attacks, Benzodiazepines or behavioural desensitisation or both are required to combat this more chronic form of anxiety. In addition, insight psychotherapy should be considered for those patients who fulfil the criteria for this form of treatment; with the acute, disabling symptoms under pharmacological control, such patients may be helped to resolve the psychological conflicts that frequently play a significant role in producing the surface symptoms.

ANTIDEPRESSANT DRUGS

Imipramine will block some panic attacks and Clomipramine appears to be useful; however, the latter appears of more use in Obsessive Compulsive Disorder and both have significant side effects. The MAO inhibitors are helpful for some patients.

ANXIOLYTIC DRUGS

The minor tranquillisers have a particularly important place in the treatment of the phobic disorders. Chlordiazepoxide (Librium) and diazepam (Valium) are both effective aids to the patient in his struggle with the phobic situation if they are taken in sufficient doses to produce a relaxation of tension and musculature.

BETA BLOCKERS

For a specific but severely debilitating social phobia such as stage fright in a professional performer, beta-adrenergic blocking agents may be prescribed.

PSYCHO-SOCIAL TREATMENT

With Agoraphobic, the clinician might have the patient imagine (perhaps in hypnotic trance) taking a fearful trip, remaining in the anxiety-producing fantasy as long as possible, then “returning” to the therapist’s office. This is repeated a number of times, and the patient is instructed to perform the same exercise as often as possible between sessions. Family members are frequently engaged to assist in the process and monitor the progress. Written journals and diaries may also be used.

In most patients, Panic attacks can be treated at the same time, in the same way. Sometimes attention to the physiologic cues of panic or mounting anxiety helps the patient to recognise and control panic symptoms.

PSYCHOTHERAPY

Psychotherapy can be a useful part of the treatment of the anxious or phobic patient. The term “psychotherapy” implies a wide variety of kinds of therapist-patient interaction, overlapping considerably with the behavioural treatments. It is almost impossible to work with a patient in any context without providing considerable interest, support, and understanding. Beyond this, the sufferer who has given up a symptom may suffer feelings of loss for the symptom itself, for the “equilibrium” of life-style, which has existed surrounding the symptom, or both. The opportunity for continuing counselling may be valuable.

Those sufferers who do not respond to the brief treatments often benefit from more in depth psychodynamic psychotherapy. The typical sufferer following treatment had improved more than untreated sufferers evaluated at the same time. The various modes examined included psychodynamic, cognitive, and humanistic, as well as behavioural and social, therapies.

BEHAVIOURAL THERAPY

The behavioural technique of “exposure” is an effective treatment, both short-term and long-term, for agoraphobic sufferers and many other Phobic sufferers. The use of exposure in fantasy, presenting increasingly anxiety-producing situations as discomfort dissipates at each level, is a form of systematic desensitisation. Exposure in vivo also involves gradual adaptation to anxiety-producing objects or situations, but the objects or situations are actually present during the treatment. Flooding, rapid exposure to almost overwhelming volumes of phobic material, also known as implosion, may be used in fantasy .

In general, the behavioural treatments, perhaps coupled with appropriate psychotherapy, have the greatest likelihood of effectiveness, and should be tried before medication is prescribed on any chronic basis.

OBSESSIVE COMPULSIVE NEUROSIS

DEFINITION

Obsessive Compulsive Disorder (OCD). People who have OCD worry a lot about little things. They are afraid of getting dirty or afraid of germs. They may spend a lot of time thinking about lucky or unlucky numbers. Or they want everything around them to be absolutely perfect. Everybody does these things sometimes. But people with OCD worry so much, they can sometimes spend the whole day thinking about these things and trying to fix everything. The more someone with OCD does this, the more uncomfortable they feel.

DEFINITION OF OBSESSION

A recurrent thought or feeling that is unpleasant and provokes Anxiety but cannot get rid of. Although an Obsession dominates the person, the sufferer understands its senselessness and they struggle to overcome it.

The essential feature of this disorder is recurrent obsessional thoughts. Obsessional thoughts are ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form. They are almost invariably distressing (because they are violent or obscene, or simply because they are perceived as senseless) and the sufferer often tries, unsuccessfully, to resist them. They are, however, recognised as the individual’s own thoughts, even though they are involuntary and often repugnant.

DEFINITION OF COMPULSION

The acting out of an Obsession, i.e. The sufferers Obsession (the thought) is to turn every light in every building they enter. The action of turning out those lights are the compulsion (the act),

Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. The individual often views them as preventing some objectively unlikely event, often involving harm to or caused by him or her. Usually, though not invariably, this behaviour is recognised by the individual as pointless or ineffectual and repeated attempts are made to resist it; in very long-standing cases, resistance may be minimal.

AETOLOGY

Nobody knows for sure how someone gets OCD. But it is is known that some doctors and scientists believe that OCD may run in families or come from a low amount of a special chemical in the brain. Some kids with OCD have another family member who has it, too. Obsessive-compulsive disorder is equally common in men and women, and there are often prominent anankastic features in the underlying personality. Onset is usually in childhood or early adult life. The course is variable and more likely to be chronic in the absence of significant depressive symptoms. Overall, Compulsory acts equally common in the two sexes but hand-washing rituals are more common in women and slowness without repetition is more common in men.

AUTONOMIC ANXIETY SYMPTOMS

Autonomic anxiety symptoms are often present, but distressing feelings of internal or psychic tension without obvious autonomic arousal are also common.

DEPRESSIVE SYMPTOMS

There is a close relationship between obsessional symptoms, particularly obsessional thoughts, and depression. Individuals with obsessive-compulsive disorder often have depressive symptoms, and patients suffering from recurrent depressive disorder may develop obsessional thoughts during their episodes of depression. In either situation, increases or decreases in the severity of the depressive symptoms are generally accompanied by parallel changes in the severity of the obsessional symptoms.

DIAGNOSIS

For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and is a source of distress or interference with activities. The obsessional symptoms should have the following characteristics:

They must be recognised as the individual’s own thoughts or impulses.

There must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists.

The thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense).

The thoughts, images, or impulses must be unpleasantly repetitive.

Includes:

  • Anankastic neurosis
  • Obsessional neurosis
  • Obsessive-compulsive neurosis

DIFFERENTIAL DIAGNOSIS

Differentiating between obsessive-compulsive disorder and a depressive disorder may be difficult because these two types of symptoms so frequently occur together. In an acute episode of disorder, precedence should be given to the symptoms that developed first; when both types are present but neither predominates, it is usually best to regard the depression as primary.

In chronic disorders the symptoms that most frequently persist in the absence of the other should be given priority.

Occasional mild phobic symptoms are no bar to the diagnosis. However, obsessional symptoms developing in the presence of Schizophrenia, Tourette’s syndrome, or organic mental disorder should be regarded as part of these conditions.

Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be able to specify one set of symptoms as predominant in some individuals, since they may respond to different treatments.

THOUGHT AND RUMINATION

These may take the form of ideas, mental images, or impulses to act. They are very variable in content but nearly always distressing to the individual. A woman may be tormented, for example, by a fear that she might eventually be unable to resist an impulse to kill the child she loves, or by the obscene or blasphemous and ego-alien quality of a recurrent mental image. Sometimes the ideas are merely futile, involving an endless and quasi-philosophical consideration of imponderable alternatives. This indecisive consideration of alternatives is an important element in much other obsessional rumination and is often associated with an inability to make trivial but necessary decisions in day-to-day living.

The relationship between obsessional ruminations and depression is particularly close: a diagnosis of obsessive-compulsive disorder should be preferred only if ruminations arise or persist in the absence of a depressive disorder.
COMPULSIVE RITUALS

The majority of compulsive acts are concerned with cleaning (particularly hand-washing), repeated checking to ensure that a potentially dangerous situation has not been allowed to develop, or orderliness and tidiness. Underlying the overt behaviour is a fear, usually of danger either to or caused by the patient, and the ritual act is an ineffectual or symbolic attempt to avert that danger. Compulsive ritual acts may occupy many hours every day and are sometimes associated with marked indecisiveness and slowness. Compulsive ritual acts are less closely associated with depression than obsessional thoughts and are more readily amenable to behavioural therapies.

PERSONALITY DISORDERS

DEFINITION

Individual traits that reflect ingrained, inflexible, and maladaptive patterns of behaviour that cause discomfort and impair a person’s ability to function

FACTORS INFLUENCING DIAGNOSIS

The exact cause of personality disorders is not known, however, several theories attempt to explain the cause. Biologic theorists believe chromosomal or nervous system disorders are the cause. Social theorists believe learned behaviour responses cause the disorders. Psychodynamic theorists use deficiencies in ego development to explain the causes. People with Personality Disorders in general do not take
responsibility for their own lives and feelings; instead, they tend to blame others. They lack sufficient coping mechanisms to be adaptive and deal with everyday stresses and problems. These disorders are manifested by difficulties in interpersonal relationships with others. The disorders are widespread

SIGNS, SYMPTOMS AND TESTS

Symptoms vary widely in individuals and differ with the diagnosis. Personal history that shows maladaption and a psychological evaluation may indicate personality disorders of various types.

TREATMENT

Treatment is generally not of the disorder, as the person does not accept they have a problem. Treatment is often of the side effect of the disorder, i.e. Drug or alcohol abuse, and attempts at suicide. Occasionally, family will intervene, or because of a court appearance or police or Social work involvement, they may seek help in order not to be sent to prison or to diminish an anti social act by being seen to be ‘ill’. In these cases family and group therapy may be used in an outpatient setting.

COMPLICATIONS

  • problems with interpersonal relationships
  • problems with career
  • conflicts with law and regulation
  • abuse of Alcohol, Drugs, People, Utilities
  • depression

PROGNOSIS

Prognosis is variable. Many personality disorders may diminish during middle age. Antisocial and borderline personality disorders have a poor prognosis (probable outcome). Mild schizoid and passive-aggressive has a better prognosis (probable outcome) with treatment.

SUBGROUPS

The disorders have only been recently categorised and include the following:

ANTI-SOCIAL PERSONALITY DISORDER

Also known as Psychopathic Personality; Sociopathic Personality; Personality Disorder

DEFINITION

A pattern of irresponsible behaviour that lacks morals and ethics and brings the person into conflict with society. The person is usually known for their antisocial acts. They do not consider it is their problem, and can be confrontational if issues are brought to their attention.

FACTORS INFLUENCING DIAGNOSIS

The cause of this disorder is unknown, but biological or genetic factors may play a role. The predominant feature of an antisocial personality is that it is higher in people who have an antisocial biological parent. Although the diagnosis is limited to those over 18 years of age, there is always a history of antisocial behaviour before age 15 demonstrated by repetitive lying, truancy, delinquency, and deception. As an adult, there is a pattern of unlawful behaviour, failure of job and family responsibility, reckless personal behaviour, promiscuity, failure to sustain long-term relationships, and aggressive behaviour. There is a lack of a moral code and / or emotion in situations that warrant such emotions. Superficial charm and wit can be highly developed and skilfully used for their own ends. This disorder tends to occur more often in men and in people whose predominant role model had antisocial features.

SYMPTOMS

  • lack of concern for society’s expectations and laws
  • unlawful behaviour
  • violates rights of others (property, physical, sexual, legal, emotional)
  • physical aggression
  • lack of stability in job, home life
  • lacks remors

TREATMENT

Effective treatment of antisocial behaviour and personality is limited. Group psychotherapy can be helpful. If the person can develop a sense of trust, individual psychotherapy or cognitive behavioural therapy can also be beneficial.

PARANOID PERSONALITY DISORDER

DEFINITION

An unwarranted tendency to interpret the actions of other people as deliberately threatening or demeaning.

FACTORS INFLUENCING DIAGNOSIS

People with a paranoid personality disorder are suspicious of other people, and they are usually unable to acknowledge their own negative feelings towards others. They do not lose touch with reality. The cause of this disorder is unknown, but there appears increased in families with a schizophrenic member.

SCHIZOID PERSONALITY DISORDER

DEFINITION

A pattern of indifference to social relationships, with a limited range of emotional expression and experience

FACTORS INFLUENCING DIAGNOSIS

People with a Schizoid personality do not have and do maintain a grip on reality. People with this disorder are unable to relate to other people and are often reclusive, may never marry, or live (as older adults) with their parents. The disorder usually has its onset in early adulthood.

SIGNS AND SYMPTOMS

  • does not experience strong emotions
  • does not desire or enjoy close relationships
  • avoiding social activities that involve significant interpersonal contact
  • feelings of detachment or estrangement from others
  • has no close friend
  • indifferent to praise or criticism
  • aloof, cold affect
  • exhibits little observable change in mood
  • a psychological evaluation reveals Personality trait

TREATMENT

People with this disorder rarely seek treatment. The treatment is difficult due to their resistance to form any type of relationship with a health professional.

PERSONALITY DISORDER

DEFINITION

A pattern of excessive emotionalism and attention seeking, need for approval, and inappropriate seductiveness that usually begins in early adulthood.

FACTORS INFLUENCING DIAGNOSIS

The cause of this disorder is unknown, but learned and inherited characteristics may play a role. It occurs more frequently in women than men. People with this disorder are usually able to function at a high level and are successful socially and at work. They may seek treatment for when romantic relationships end. They fail to develop insight into their own situation, because they easily forget or repress unpleasant experiences. Responsibility for failure or disappointment is usually blamed on others.

SYMPTOMS

  • constantly seeking reassurance or approval
  • excessive sensitivity to criticism or disapproval
  • inappropriately seductive in appearance or behaviour
  • overly concerned with physical appearance
  • exaggerated emotion
  • a need to be the centre of attention
  • low tolerance for frustration or delayed gratification
  • rapidly shifting emotions with shallow facial expressions

TREATMENT

Treatment is often associated with dissolved romantic relationships. There is usually a good response to antidepressant medication. Psychotherapy for the underlying disorder may be of benefit.

NARCISSISTIC PERSONALITY DISORDER

DEFINITION

A disorder of the personality characterised by an abnormal love of self, self-centred, being self-absorbed, and an inability to empathise with the effects of one’s behaviour on others.

FACTORS INFLUENCING DIAGNOSIS

The cause of this disorder is unknown, but one theory proposes that the parents of people who develop this disorder needed their children to be talented or special in order to maintain their own self-esteem. This disorder usually begins by early adulthood. Narcissistic people are unable to perceive themselves and others accurately. They often feel entitled to special treatment by others and can become demanding, angry, and easily offended.

SYMPTOMS

  • reacts to criticism with feelings or rage, shame or humiliation
  • takes advantage of others to achieve own goals
  • self-important
  • exaggerates achievements and talents
  • preoccupation with fantasies of success, power, beauty, intelligence, or ideal love
  • unreasonable expectations of favourable treatment
  • requires constant attention and admiration

lacks empathy

TREATMENT

There is no known cure for this personality disorder; however, psychotherapy may help the person relate to others in a more positive and rewarding way.

BORDERLINE PERSONALITY DISORDER

DEFINITION

An individual trait that reflects ingrained, inflexible, and maladaptive patterns of behaviour characterised by impulsive and unpredictable actions, mood instability, and unstable interpersonal relationships.

FACTORS INFLUENCING DIAGNOSIS

The exact cause of borderline personality disorder is not known. However, several psychological hypotheses rely on biological, social, and psychological factors to understand people with this disorder. The person with a borderline personality is impulsive in areas that have a potential for self-destruction. Relationships with others are intense and unstable. The person will go through frantic efforts to avoid real or imagined abandonment by others, and express mood instability and inappropriate anger. There may also be identity uncertainty concerning self-image, long-term goals or career choice, sexual, choice of friends, and values.
People with this disorder tend to see things in terms of extremes, either all good or all bad. They view themselves as victims of circumstances and take little responsibility for themselves or for their problems. Risk factors include abandonment issues in childhood or adolescence, sexual abuse, disruptive family life, and poor communication within the family. This personality disorder is often associated with pseudo-schizo, histrionic, narcissistic, and antisocial personalities. It tends to occur more often in women.

SYMPTOMS

  • unstable interpersonal relationships
  • frequent displays of temper
  • inappropriate anger
  • recurrent gestures
  • feelings of emptiness and boredom
  • intolerance of being alone
  • impulsiveness in at least 2 of the following areas: money, sexual relationships, reckless driving, shoplifting

TREATMENT

People with borderline personality disorder tend not to be compliant with treatment. However, the following therapy may be helpful in some cases.
Self-destructive behaviour may be modified through peer relationships in social and therapeutic environments. Peer reinforcement of appropriate behaviour may be successful because difficulties with authority often impede learning. Group therapy can be helpful in modifying specific impulsive behaviours, as peer pressure in the group may restrain rash behaviour.

Drug therapy includes the use of mood stabilisers such as Carbamazepine, and low-dose Neuroleptics when manic or features are present.

AVOIDANT PERSONALITY DISORDER

DEFINITION

A pattern of social discomfort, fear of negative evaluation, and timidity begins in early adulthood.

FACTORS INFLUENCING DIAGNOSIS

People with avoidant form relationships with others only if they believe they will not be rejected. They are preoccupied with their own shortcomings. Loss and rejection are so painful that these people will choose loneliness rather than risking themselves in a relationship.

SYMPTOMS

  • is hurt by criticism or disapproval
  • has no close friends
  • reluctance to become involved with people
  • avoids activities or occupations that involve interpersonal contact
  • shy in social situations out of fear of doing something wrong
  • exaggerates potential difficulties

TREATMENTS

A person with this disorder may eliminate some of the disabling defences if a positive relationship is formed with a health professional. However, the likelihood that a person with this disorder will seek treatment is remote.

DEPENDANT PERSONALITY DISORDER

DEFINITION

An inability to function without significant reliance on a forceful or dominant person providing direction.

FACTORS INFLUENCING DIAGNOSIS

The cause of this disorder is not known. There do not appear to be biological factors. The disorder usually appears in early or middle adulthood. People with this disorder do not trust their own ability to make decisions, and feel that others have better ideas. Separation and loss may devastate them, and they may go to great lengths, even suffering abuse, to stay in a relationship.

SYMPTOMS

  • unable to make decisions
  • passive
  • avoids personal responsibility
  • avoids being alone
  • feels devastated or helpless when relationships end
  • unable to meet ordinary demands of life
  • preoccupied with fears of being abandoned
  • easily hurt by criticism or disapproval

TREATMENT

There is no specific treatment for this disorder. Psychotherapy may be useful in gradually helping people to make choices that affect their own life.

COMPULSIVE PERSONALITY DISORDER

DEFINITION

The avoidance of feelings and intimacy causes a rigid adherence to rules and order.

FACTORS INFLUENCING DIAGNOSIS

This disorder tends to occur in families. Biological and developmental factors may play a causal role. A person with this disorder shows perfectionism and inflexibility, usually beginning in early adulthood. Perfectionism may interfere with the ability to complete a given task because rigid standards cannot be met. People with this disorder may emotionally withdraw when ill, or when not in control. Individuals who are high achievers, competitive, sense urgency in everything, or are often hostile or aggressive are at a high risk for this disorder.

SYMPTOMS

  • perfectionism
  • inflexibility
  • preoccupation with details, rules, lists
  • reluctance to allow others to do things
  • excessive devotion to work
  • restricted expression of affection
  • lack of generosity
  • inability to throw things away, even if there is no value in the object

TREATMENT

There is no specific treatment; however, therapy or counselling may be of value.

PASSIVE-AGGRESSIVE PERSONALITY DISORDER

DEFINITION

Passive resistance to demands for social and occupational performance beginning in early adulthood.

FACTORS INFLUENCING DIAGNOSIS

People with this disorder resent responsibility, and show it through behaviours rather than through open expression of their feelings. Procrastination and inefficiency are behaviours used to avoid responsibility. The cause of this disorder is unknown. Biological or genetic factors do not appear to play a role.

SYMPTOMS

  • procrastination
  • intentional inefficiency
  • avoiding responsibility by claiming
  • complaining
  • blaming others
  • resentment
  • sullenness
  • does not express hostility or anger openly
  • fears authority
  • resists suggestions from others

TREATMENT

Counselling may be of value in helping the person identify and change the behaviour.

ALCOHOL AND ALCOHOL DEPENDENCE

EFFECTS OF ALCOHOL

The depressant effects of alcohol on the CNS effect, first the higher cerebral functions responsible for concern about personal behaviour and self-restraint. The result being freedom from anxiety and apparent stimulation with vivacity of speech and action.

As drinking progresses, response to stimuli are slowed and muscle control impaired clumsiness, ataxia and nystagmus develop.

Alcohol adversely affects information-processing powers, such as the ability to solve problems or to memorise, and also reduces the performance in complex reactions; a prime example being driving a car.

TOLERANCE

Some resistance to the effects of alcohol develops with repeated consumption. Adaptation to alcohol is confined to persons who consume excessive quantities but also occurs in “social” drinkers who take alcohol frequently in moderate amounts.

Because of tolerance to drink alcoholics need to consume considerable quantities before the desired effect is reached.

In the advanced stages of dependence on alcohol, tolerance can drop. Decreased turn over of alcohol should be easy to detect in alcoholics with loss of tolerance.

The level of alcohol required for a lethal dose in an alcoholic is not considerably higher than in a non-alcoholic.

PHYSICAL DEPENDENCE AND WITHDRAWAL

Dependence on alcohol has psychological and physical aspects; –

Tremor is an early feature, at first only present in fingers and hands, though it may be accompanied by a feeling of internal muscular quivering.

Like many forms of tremor the tremble induced by withdrawal is aggravated by scrutiny. Gross tremor involves other regions than the hand, first the tongue and finally the whole of a limb and trunk are involved in shaking. Sweating is an acute result of alcohol intake, but is also a withdrawal symptom.

Anxiety, depression, restlessness and irritability may develop. Sensations as though the stomach was shaking, with nausea and vomiting are other features of alcohol abstinence syndrome.

Insomnia is common often with vivid dreams. In most cases the features do not progress to delirium tremens (DT’s). The signs and symptoms are pronounced by second day and reach a peak by the third and then subside.

DELIRIUM TREMENS

Visual hallucinations are very common. The images are sometimes of large objects, e.g. life size, but are more normally of small (less than life size) animals and birds.

The images may involve objects that in reality are large, but in DT’s are scaled down to a size between 10-40cm. The traditional ‘pink elephants’ are an example. Hallucinations of an auditory nature are also frequent. Delusions, when present are of a paranoid type.

The predominant effect is anxiety progressing to fear. Anger and suspicion are also present. Restlessness may develop. Physically the condition of dehydration and deficiency of sodium, potassium and magnesium.

In severe forms, hypothermia, cardio-vascular collapse and death may ensue.

DEVELOPMENT OF DEPENDENCE

At an early stage in their drinking career, alcoholics tend to show a greater desire for drink than their companions do, sneak drinks between social events and imbibe before and after the same.

Relief drinking occurs to counteract tension, depression and other disagreeable moods. Increased time, money and mental preoccupation are spent on alcohol and guilt feelings may develop as a result.

Memory blackouts occur. Excuses are made for drinking and people or circumstances blamed. A liquid lunch becomes usual. Increased friction at home is often noticeable.

Working capacity suffers and absenteeism occurs. Money is converted from the housekeeping to buying alcohol. Suicide attempts may occur.

The common incidence of alcoholism is in middle-aged women been attributed to the menopause or to depression.

PHYSICAL DISABILITIES

The style of living of these people may contribute to somatic ill health.

Dementia; – Reduced ability to understand new information. Powers to comprehend and solve problems are weakened. Deterioration of complex perceptual processes.

Memory inadequate for recent events with disorientation to time and place. Self-judgement and restraint is reduced and emotional life flattened.

Lack of desire and insight. There are graduations in the severity of dementia in alcoholics. Some socially alienated lead shadowy existences of self-neglect and persistent drinking.

It is appropriate to affirm that the majority of alcoholics do not show gross brain damage, although the proportion with minor degrees with cerebral dysfunction is debatable.

KORSAKOFFS PSYCHOSIS

Most striking clinical feature of this is impaired memory for recent events for which the patient may fabricate stories, to fill the gap, this is known as confabulation. Other aspects of Korsakoffs Psychosis are a lack of drive and bland euphoria or slight depression

CEREBELLAR DEGENERATION

Destructive lesions in the cerebella cortex can develop in alcoholics. The long-term result of chronic excessive alcohol consumption on the cerebellum may be more extensive and frequent than realised. Ataxia, often temporary is not uncommon.

SUBDURAL HAEMATOMA

Intoxicated persons are liable to fall and injure their heads and this may result in bleeding inside the skull. The clinical features may not develop until after a few weeks. The effect must not be mistaken for abstinence delirium.

PERIPHERAL NEURITIS

The alcoholic patient with this can be symptomless or complain of parathesia, pain or lack of sensation in the hands and feet. Tendon reflexes diminished or absent. More severe cases suffer muscular atrophy and foot drop.

GASTRO INTESTINAL TRACT

Cancer of the oesophagus has an increased incidence among alcoholics. Pancreatitis can develop. Several liver complaints can occur including; Cirrhosis, jaundice and severe metabolic disturbance.

PSYCHOLOGICAL DISABILITIES

DEPRESSION

Depressive mood is a common accompaniment of excessive drinking. A mood of unhappiness develops because of the consequences imposed on the alcoholic by drinking. The personality of some alcoholics is basically that of a depressive. Depression can occur as a hangover symptom. Depression may develop during abstinence of alcohol.

For a more dishonest motive, alcoholics sometimes report depression, in order to obtain a sick note to cover absenteeism from work due to drink.

JEALOUSY

Morbid doubts about partner’s fidelity, unfounded accusations of unfaithfulness. Sexual difficulties due to alcohol eg. Impotence may lead to jealousy, fear of spouse “looking elsewhere”.

ALCOHOLIC HALLUCINOSIS

Prolonged state of auditory hallucinations, which occur in clear consciousness often, accompanied by delusions. There are no other signs e.g. Thought disorders, affective incongruity, that might suggest schizophrenia.

RECOGNITION OF ALCOHOL DEPENDENCE

Alcoholism remains in many instances a state of denial. Relatives are often the first to seek help.

Fortunately although alcoholics may avoid voluntary disclosure of their dependence and may initially deny their problem, they often wish their problem could receive recognition.

A sympathetic yet insistent interviewer is frequently able to elicit from the drinker the extent and consequence of the alcohol consumption. Often immediate relief of guilt in subject is apparent with realisation that help is eventually at hand.

TREATMENT

Drug treatment of physical dependence relieves symptoms and reduces likelihood of withdrawal features.

CHLORMETHIAZOLE

Advantages of being both a sedative and anticonvulsant. Possible course of treatment:

TREATMENT DAY

Often the person has had a ‘last drink’, prior to attending then comes for treatment after this. At this stage treatment should be delayed until it is safe to commence.

If however he has not had a drink, then 3 tablets, repeated once if necessary.

MORNING. MIDDAY. NIGHT.

Day 2 2 3 3

Day 3 2 2 3

Day 4 1 2 3

Day 5 1 2 2

Day 6 0 1 2

Day 7 0 1 1

Day 8 0 0 1

Day 9 0 0 0

Dependence is a hazard in prolonged usage.

AUTISM / ASPERGERS SYNDROME

DEFINITION OF AUTISM

Autism is marked by severe communication difficulties and an inhibited ability to form relationship, often with a difficulty of development of language. They use abstract concepts and often defined behaviour, limiting how they can live their lives. Often envisaged as childhood Schizophrenia, although they are not known to be connected. Autism appears to be the final end product of several different disorders that share similar social, language and neurological abnormalities.

GENDER

Males outnumber females by approximately 5 to 1. The cause is currently unknown, but inheritance plays at least some role, since there is a high concordance in identical twins but not fraternal twins.

AETIOLOGY

One of the problems with Autism is that the diagnosis is based on subjective criteria and not everyone can agree on how it should best be classified. Autism is a relatively rare multi-factorial disorder that affects between 3 and 5 out of every 10,000 school-aged children. Autism is usually diagnosed in children 2-4 years of age, but signs may be evident much earlier. Some autistic children meet important developmental milestones, such as talking and walking, even ahead of schedule.

It is thought that it could be caused by a related Seratonin influence, as it is said that it reabsorbs Serotonin after it has been released. Additional risk factors might include rubella, and problems during pregnancy, labour and delivery. It is believed that in Autism, up to 75% of autistic children may also be retarded. Many autistic children are also at increased risk of developing seizure disorders, especially during their teen years.

SIGNS AND SYMPTOMS

The autistic child may arch backwards when picked up

Act limp to avoid the physical contact.

Some Autistic children don’t fuss at all, while others may be agitated or extremely fussy, even self-injurious.

Lack of eye contact.

Abnormal sleep patterns,

Sensory impairments

Food preferences.

These symptoms are extremely variable in individual children.

The insistence on sameness, and autistic children often function best with a strict routine.

New schools, holidays and of new foods may cause intolerance.

PERVASIVE DEVELOPMENTAL DISORDER

The umbrella diagnosis is Pervasive Developmental Disorder, which not only includes Autism, but several others as well, including; Childhood Disintegrative Disorder. The criteria used to make the diagnosis of autism are not absolute, and change from time to time. However, since Pervasive Developmental Disorder is becoming known in schools and more and more children are becoming labelled, it is becoming more and more difficult to discern “true Autism” from all the other disorders in the Pervasive Developmental Disorder category. Potentially even more confusing in the realisation that all cases of autism are not the same.. It is often distressing to parents when some of these children later lose some of these skills, so -called ‘regressive autism’. Other autistic children had developmental delays from the onset.

THEORIES

In autism, there appears to be at least 4 medical problems that may coexist in affected individuals:

Problems with the cerebellum and cerebrum

Impaired nutrient absorption (leaky gut)

Defective cell-mediated immunity

Neurotransmitter defects (Serotonin)

The problems with the affect balance, attention, and proprioception (perception resulting from stimuli to muscles and tendons). It is thought that Autistic children have ‘faulty wiring’ of the brain so they do not fully perceive the world the way we do. Accordingly, they often don’t respond to their names, engage in unusual behaviours, don’t look you in the eye, and have problems with speech and socialising with others. Without intervention, affected children may retreat into their own world and become oblivious to human contact.

TREATMENT

Autism need not be a diagnosis that implies a poor prognosis. With early intervention, fantastic strides have been made and many affected children can become mainstreamed in school. However, intervention is best done early and with intensity.

There is no consensus as to the best approach to manage this disability. If you speak with 10 parents, you’ll likely get 12 opinions as to how to proceed. Most doctors are used to treating medical problems with drugs; psychologists want to counsel, occupational and speech therapists have their own approaches. The treatment options are not without lots of controversy, but they have good track records for effectiveness and safety.

APPLIED BEHAVIOURAL ANALYSIS

Applied Behavioural Analysis uses learning theory to teach autistic children how to play, interact and perform basic skills. For the most part, the therapy is done one-on-one with a therapist and the Autistic child and this intervention can occupy 30-40 hours a week. Behaviourists often utilise occupational and speech therapists in their programs.

FOOD ALLERGY AND TOLERANCE

It is though also that intestinal problems makes Autistic children more susceptible to food allergy and food intolerance. It is possible that some of the abnormal behaviours seen in Autism are the result of toxic breakdown products of certain food ingredients such as casein and gluten. Others may be do to food intolerance and sensitivity to food items.

The immune problems and neurotransmitter defects are only now being more completely studied in Autism. It is known that children with Autism do have abnormalities in their immune systems that make them more susceptible to certain infections.

ASPERGERS SYNDROME

DEFINITION

Asperger’s Disorder is a milder variant of Autistic Disorder. Both Asperger’s Disorder and Autistic Disorder are in fact subgroups of a larger diagnostic category. This larger category is called either Autistic Spectrum Disorders or Pervasive Developmental Disorders.

AETIOLOGY

In Asperger’s Disorder, affected individuals are characterised by social isolation and eccentric behaviour in childhood. There are impairments in two-sided social interaction and non-verbal communication. Though grammatical, their speech is peculiar due to abnormalities of inflection and a repetitive pattern. Clumsiness is prominent both in their articulation and gross motor behaviour. They usually have a circumscribed area of interest, which usually leaves no space for more age appropriate, common interests. Some examples are cars, trains, French Literature, doorknobs, hinges, cappuccino, meteorology, astronomy or history.

GENDER

minimum prevalence of Asperger’s Disorder was 0.36 % (0.55 % of all boys, and 0.15 % of all girls), and

male/female ratio was 4:1.

TREATMENT

There is no specific treatment or “cure” for Asperger’s Disorder. All the interventions outlined below are mainly symptomatic and/or rehabilitational.

THERAPEUTIC INTERVENTIONS

Individual psychotherapy to help the individual to process the feelings aroused by being socially handicapped

Parent education and training

Behavioural modification

Social skills training

Educational interventions

MEDICATION

For hyperactivity, inattention and impulsivity: Psycho-stimulants (methyphenidate, dextroamphetamine, metamphetamine, pemoline), Clonidine, Tricyclic Antidepressants (desipramine, nortriptyline)

For irritability and aggression: Mood Stabilisers (valproate, carbamazepine, lithium), Beta Blockers (nadolol, propranolol), Clonidine, Naltrexone, Neuroleptics (risperidone, haloperidol)

For preoccupations, rituals and compulsions: SSRIs (fluvoxamine, fluoxetine), Tricyclic Antidepressants (clomipramine)

For anxiety: SSRIs (sertraline, fluoxetine), Tricyclic Antidepressants (imipramine, clomipramine, nortriptyline)

STUDIES

In a total population study of children between ages 7-16 in Goteborg, Sweden

In another total population study, prevalence of Autistic Disorder was 0.024 % in Canada.

BIOLOGICAL THEORIES

Despite the now widely accepted fact that biological factors are of crucial importance in the aetiology of autism, so far the brain imaging studies have shown no consistent pattern, no consistent evidence of any type of lesion, and no single location of any lesion in subjects with autistic symptoms. This inconsistency in the results of various brain imaging studies has been attributed to the fact that people with autism represent a highly heterogeneous group in terms of underlying pathology. Therefore there is an ongoing effort to specify more homogenous subgroups among autistic individuals to enhance the accuracy of etiologic inquiry.

Therefore it may be expected that there are fewer major structural brain abnormalities associated with Asperger’s Disorder than with autism. It is thought that a very small number of structural brain abnormalities have been so far associated with Asperger’s Disorder, which include left frontal macrogyria, bilateral opercular polymicrogyria, and left temporal lobe damage. Detailed neuropsychological testing may support these findings providing information about the performances of individual right or left hemispheric brain regions

ASBERGERS VERSES AUTISM- THE DIFERENCES

It is believed that in Asperger’s Disorder:

onset is usually later

outcome is usually more positive

social and communication deficits are less severe

circumscribed interests are more prominent

verbal IQ is usually higher than performance IQ (in autism, the case is usually the reverse)

clumsiness is more frequently seen

family history is more frequently positive

neurological disorders are less common

EATING DISORDERS

DEFINITION

A disorder of eating that affects a persons physical and mental health, which taken to its’ ultimate state will lead to the untimely death of an individual.

WHO IS AFFECTED

Each year thousands of people in the United Kingdom are affected by serious and sometimes life-threatening eating disorders. The vast majority of those afflicted with eating disorders are adolescent and young adult women. One reason that women in this age group are particularly vulnerable to eating disorders is their tendency to go on strict diets to achieve an “ideal” figure. Researchers have found that such stringent dieting can play a key role in triggering eating disorders.

A very small percentage of adolescent girls develop Anorexia nervosa, a dangerous condition in which they can literally starve themselves to death. A slightly higher percent of young women develop Bulimia nervosa, a destructive pattern of excessive overeating followed by vomiting or other “purging” behaviours to control their weight. These eating disorders also occur in men and older women, but much less frequently.

MORTALITY

The consequences of eating disorders can be severe. For example, one in ten cases of anorexia nervosa lead to death from starvation, cardiac arrest, other medical complications, or suicide. Fortunately, increasing awareness of the dangers of eating disorders–sparked by medical studies and extensive media coverage of the illness–has led many people to seek help. Nevertheless, some people with eating disorders refuse to admit that they have a problem and do not get treatment. Family members and friends can help recognise the problem and encourage the person to seek treatment.

ANOREXIA NERVOSA

People who intentionally starve themselves suffer from an eating disorder called anorexia nervosa. The disorder, which usually begins in young people around the time of puberty, involves extreme weight loss–at least 15 percent below the individual’s normal body weight. Many people with the disorder look emaciated but are convinced they are overweight. Sometimes they must be hospitalised to prevent starvation. Karen Carpenter, the singer with the duo ‘The Carpenters’ died from this illness

BULIMIA NERVOSA

People with Bulimia nervosa consume large amounts of food and then rid their bodies of the excess calories by vomiting, abusing laxatives or diuretics, taking enemas, or exercising obsessively. Some use a combination of all these forms of purging. Because many individuals with bulimia “binge and purge” in secret and maintain normal or above normal body weight, they can often successfully hide their problem from others for years. Princes Diana was known to suffer at one tome from this illness.

There are other eating disorders as well, such as

AETIOLOGY

There are three main areas that in combination, likely cause most people’s eating disorders. These areas include personality factors, genetics and the environment, and biochemistry. Most people with eating disorders share certain personality traits: low self-esteem, feelings of helplessness, and a fear of becoming fat. In anorexia, bulimia, and binge eating disorder, eating behaviours seem to develop as a way of handling stress and anxieties.

People with anorexia tend to be “too good to be true.” They rarely disobey, keep their feelings to themselves, and tend to be perfectionists, good students, and excellent athletes. Some researchers believe that people with anorexia restrict food — particularly carbohydrates — to gain a sense of control in some area of their lives. Having followed the wishes of others for the most part, they have not learned how to cope with the problems typical of adolescence, growing up, and becoming independent. Controlling their weight appears to offer two advantages, at least initially: they can take control of their bodies and gain approval from others. However, it eventually becomes clear to other that they are out-of-control and dangerously thin.

People who develop Bulimia and binge eating disorder typically consume huge amounts of food — often junk food — to reduce stress and relieve anxiety. With binge eating, however, comes guilt and depression. Purging can bring relief, but it is only temporary. Individuals with bulimia are also impulsive and more likely to engage in risky behaviour such as abuse of alcohol and drugs.

Eating disorders appear to run in families — with female relatives most often affected. This finding suggests that genetic factors may predispose some people to eating disorders; however, other influences–both behavioural and environmental — may also play a role. One recent study found that mothers who are overly concerned about their daughters’ weight and physical attractiveness might put the girls at increased risk of developing an eating disorder. In addition, girls with eating disorders often have father and brothers who are overly critical of their weight. Biochemistry continues to be investigated as a potential cause as well, with the focus on brain neurotransmitters. Medications can often help to counteract the effects of neurotransmitters, which may be excessive or lacking within the brain.

INSOMNIA

NORMAL SLEEP

CIRCADIAN RYTHYM

Is a periodic rhythm which synchronises the body into the twenty-four hour day/night cycle which affects most animals and in humans develops shortly after birth. The “internal oscillator” that maintains the rhythm at approximately 24 hours decelerates substantially at the time of adolescence. The internal oscillator returns to 24 hours during most of adulthood and often accelerates with advanced age.

SLEEP VARIENTS

The amount of time needed for sleep is extremely variable, it varies with each individual. Margaret Thatcher was said when Prime Minister to have only four hours sleep at night. Insomnia is the most common complaint about sleep. It is said that an individuals sleep needs does not change with age. Therefore, If a person suddenly needs more or much less sleep in old age than was needed as a younger person does, a sleep disorder is present

SLEEP TIPS

Go to bed only when sleepy

Use the bed only for sleeping; do not read, watch television, or eat in bed

If unable to sleep, get up and move to another room.

Stay up until you are definitely sleepy and then return to bed.

If sleep does not come easily, get out of bed again. The goal is to associate your bed with falling asleep easily.

Repeat the last step as often as is necessary throughout the night

Set the alarm and get up at the same time every morning, regardless of how much you have slept through the night. Do not nap during the daytime.

SLEEP TACTICS

Focusing on quiescent tasks that occupy the mind such as reading, watching television, or listening to music promotes relaxation and sleep

BODY TEMPERATURE

Sleep induction is associated with a decline in core body temperature

Exercising regularly in the late afternoon or early evening can promote sleep

Spending 20 minutes in a hot tub a few hours before going to bed may promote sleep

ENVIRONMENT

Temperature extremes are deleterious to REM sleep

Loud intermittent noises can be masked by “white noise” devices

Avoid illuminated bedroom clocks

FOOD AND DRINK

A light bedtime snack can promote sleep; hunger is a sleep disrupter

Small amounts of alcohol promote the onset of sleep. As the alcohol becomes metabolised, sleep may become fragmented.

All caffeine containing foods and beverages can disturb sleep.

UNREQUITED SLEEP

Excess of alpha EEG waves associated with complaints of fatigue, aches and pain

Intrusion of alpha waves in REM sleep can be diminished with tricyclic antidepressants

Restless leg” syndrome often ameliorated with clonazepam

Pseudoinsomniacs” can respond to Benzodiazepines; daytime sleepiness and insomnia can both decline

 

INSOMNIA. QUO VADIS

Insomnia is the perception or complaint of inadequate or poor-quality sleep because of one or more of the following:

  • Difficulty falling asleep
  • Waking up frequently during the night with difficulty returning to sleep
  • Waking up too early in the morning
  • Unrefreshing sleep.

The number of hours of sleep a person gets or how long it takes to fall asleep does not define insomnia. Individuals vary normally in their need for, and their satisfaction with, sleep. Insomnia may cause problems during the day, such as tiredness, a lack of energy, difficulty concentrating, and irritability. Insomnia can be classified as transient (short term), intermittent (on and off), and chronic (constant). Insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Insomnia is considered to be chronic if it occurs on most nights and lasts a month or more.

INSOMNIA. CAUSAL FACTORS

Certain conditions seem to make individuals more likely to experience insomnia. Examples of these conditions include:

  • Stress
  • Anxiety
  • Medical Ailments
  • The use of certain medications
  • Advanced age (insomnia occurs more frequently in those over age 60)
  • Female gender
  • A history of depression.
  • drugs/medications

There are many causes of insomnia. Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following:

  • Change in the surrounding environment
  • Sleep/wake schedule problems such as those due to jet lag
  • Medication side effects
  • Stress
  • Environmental noise
  • Extreme temperatures

 

CHRONIC INSOMNIA

Chronic insomnia is more complex and often results from a combination of factors, including underlying physical or mental disorders. One of the most common causes of chronic insomnia is depression. Other underlying causes include:

  • Sleep apnoea
  • Narcolepsy
  • Restless legs syndrome
  • Parkinson’s disease
  • Thyrotoxic States
  • Arthritis,
  • Kidney disease
  • Heart failure
  • Asthma
  • Caffeine excess
  • Alcohol abuse
  • Illicit or other substances abuse

Disrupted sleep/wake cycles as may occur with shift work or other night-time activity schedules; and chronic stress.

In addition, the following behaviours have been shown to perpetuate insomnia in some people:

  • Excessive napping in the afternoon or evening
  • Irregular or continually disrupted sleep/wake schedules
  • Expecting to have difficulty sleeping and worrying about it
  • Ingesting excessive amounts of caffeine
  • Drinking alcohol before bedtime
  • Smoking cigarettes before bedtime

These behaviours may prolong existing insomnia, and they can also be responsible for causing the sleeping problem in the first place. Stopping these behaviours may eliminate the insomnia altogether.

GENDER AND AGE

Insomnia is found in males and females of all age groups, although it seems to be more common in females (especially after menopause) and in the elderly. The ability to sleep, rather than the need for sleep, appears to decrease with advancing age.

DIAGNOSTICS

Patients with insomnia are evaluated with the help of a medical history and a sleep history. The sleep history maybe obtained from a sleep diary filled out by the patient or by an interview with the patient’s bed partner concerning the quantity and quality of the patient’s sleep. Specialised sleep studies may be recommended, but only if there is suspicion that the patient may have a primary sleep disorder such as sleep apnoea or narcolepsy.

TREATMENT

Transient and intermittent insomnia may not require treatment since episodes last only a few days at a time. For example, if insomnia is due to a temporary change in the sleep/wake schedule, as with jet lag, the person’s biological clock will often get back to normal on its own. However, for some people who experience daytime sleepiness and impaired performance as a result of transient insomnia, the use of short-acting sleeping pills may improve sleep and next-day alertness. As with all drugs, there are potential side effects. The use of over-the-counter sleep medicines is not usually recommended for the treatment of insomnia. Treatment for chronic insomnia consists of:

Diagnosing and treating underlying medical or psychological problems.

Identifying behaviours that may worsen insomnia and stopping (or reducing) them.

Possibly using sleeping pills.

LONG TERM NIGHT SEDATION

The long-term use of sleeping pills for chronic insomnia is controversial. A patient taking any sleeping pill should be under the supervision of a physician to closely evaluate effectiveness and minimise side effects. In general, these drugs are prescribed at the lowest dose and for the shortest duration needed to relieve the sleep-related symptoms. For some of these medicines, the dose must be gradually lowered as the medicine is discontinued because, if stopped abruptly, it can cause insomnia to occur again for a night or two.

BEHAVIOURAL TECHNIQUES

Trying behavioural techniques to improve sleep, such as

Relaxation therapy

Sleep Restriction Therapy

Reconditioning.

RELAXATION THERAPY

There are specific and effective techniques that can reduce or eliminate anxiety and body tension. As a result, the person’s mind is able to stop “racing,” the muscles can relax, and restful sleep can occur. It usually takes much practice to learn these techniques and to achieve effective relaxation.

SLEEP RESTRICTION

Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. They may benefit from a sleep restriction program that at first allows only a few hours of sleep during the night. Gradually the time is increased until a more normal night’ sleep is achieved.

CONDITIONING

Another treatment that may help some people with insomnia is to Condition them to associate the bed and bedtime with sleep. For most people, this means not using their beds for any activities other than sleep and sex. As part of the reconditioning process, the person is usually advised to go to bed only when sleepy. If unable to fall asleep, the person is told to get up, stay up until sleepy, and then return to bed. Throughout this process, the person should avoid naps and wake up and go to bed at the same time each day. Eventually the person’s body will be conditioned to associate the bed and bedtime with sleep.

ADVOCACY

In recent times Advocacy has played a role in helping people to stand up for their rights. This can be both of benefit to and detriment to an individual, although the detriment is never admitted. It benefits those who seek an avenue to gain an advantage, even if that is a right. The system also allows the individual using the Advocacy system to have a voice even when it is not in their best interest.

It also allows the Advocate to walk away without ‘guilt’ as they can suggest that they were only acting on the individuals behalf. Psychiatrists, Social workers and others often see the Advocate as someone who is casting an eye over their performance, (as most professionals feel they are advocates for their patients/clients. Below is information as to what Advocacy is and is not, as sited by the Somerset Advocacy Service.

INFORMATION

Advocates help find information needed about benefits, medication, housing, education and support groups

FREE

There is no charge for this service

CONFIDENTIAL

All information is confidential and is only shared if the client wishes

WRITING LETTERS

Letters can be written on client’s behalf to organisations such as Health, Social Services, Housing and Education

SPEAKING UP

An Advocate can be someone who ‘Speaks Up’ on behalf of the client, or be there when the client wishes to ‘Speak Up’ on their own

CLEAR LANGUAGE

They will translate information into simple clear language

Advocacy is not:

ADVICE

Advice will not be given, but access will be given to information, or options giving various avenues of availability

COUNSELLING

Counselling is not provided but access to information on counselling is given

BEFRIENDING

Information about Befriending is given, but not an Advocacy service

SOCIAL WORK

Advocacy is a separate agency from Social Services, but Advocates can help access Social Service involvement

LEGAL ADVICE

Legal advice is not given, but access to a legal advocate can be made on your behalf

GUARANTEED OUTCOME

There are no guaranteed outcomes, but advocates can help to work towards this

NON JUDGMENTAL

Advocates will not judge client’s choice or decision

RELATIVES/CARERS

Advocacy is only for the client and not extended to relatives or carers.

ADVOCACY EQUAL OPPORTUNITY POLICY

Advocates intent is to ensure equality of opportunity and response so that no person shall be disadvantaged during their relationship on grounds of age, race, ethnic origin, religion, gender, marital status, parental status, disability, unrelated criminal convictions, or because of their sexual orientation or proclivities. Advocacy opposes racism, sexism, ageism, and all forms of discrimination based on ethnic origin, disability, marital status, parental status, parental status, religious beliefs, unrelated criminal activity. Advocates will reserve the right to refuse their service to anyone who clearly demonstrates any of the aforementioned forms of discrimination.

ADVOCACY COMPLAINTS

Clients who are unhappy with an Advocates service and wish to complain, have three stages in which to seek satisfaction.

Discuss the complaint directly with the Advocate concerned who will respond within 10 days.

Complain to the Advocacy Project Manager who will respond within 10 days.

Complain to the Advocacy Project Committee, who will respond in one month.

This does not compromise or exclude other legal / procedural rights

EPILEPSY

Epilepsy often is regarded as a disease or disorder of the young. It in fact occurs throughout the decades from the beginning to the end of life. It is the most common neurological condition; with over 300000 sufferers in the United Kingdom, which is 1 in 200 of the population.

Epilepsy is NOT a Mental Illness, yet its’ symptoms often bring into the equation, the psychiatrist or psychologist because of Aggressive or Psychotic symptoms that cause the sufferer or their family to seek help, or they fall foul of the law and psychiatric reports are requested.

DIAGNOSIS

Apart from a history taken from the individual, or someone who knows them well, and a physical examination of them by a doctor, other tests can be applied. These include blood and urine tests, which may reveal kidney or liver malfunction, which may be a cause of the epilepsy. Infection in the vulnerable may be found. E.E.G (Electro Encephalograghy may show where the focus of the electrical activity is activated, Skull X-rays may detect tumours, fractures or other abnormalities that may have causative factor. CAT (Computerised Axial Tomography) may reveal abnormalities such as haemorrhage, tumour or atrophy of the brain, which is causing epilepsy.

GRAND MAL – MAJOR EPILEPTIC FIT

If standing, the patient falls to the ground unconscious, sometimes admitting a strangled cry. All the muscles of the body contract simultaneously, producing rigid extension of the legs and arching the back, and usually flexion of the arms. Respiration is arrested and the face is suffused and cyanosed. The tonic stage is brief and often only a few seconds and is succeeded by the clonic convulsion. This consists of repeated generalised relaxation followed by sudden return of rigidity resulting in violent jerking of limbs and clenching of teeth. As breathing is now possible, the clonic stage can persist for several minutes. The jerking occurs at increasing intervals with more prolonged periods of relaxation and eventually ceases, leaving the patient flaccid deeply comatose and breathing heavily. This stage can last for a few minutes to half an hour or longer and then consciousness returns, but often with a period of confusion and drowsiness leading to sleep. In primary generalised major epilepsy there is no immediate warning and therefore no chance of avoiding injury in falling. During the convulsion stage the tongue or cheek may be bitten. Major fits occur in primary and secondary generalised epilepsy that has originated in a focal cortical discharge. Here there may be an immediate warning or Aura before consciousness is lost.

PETIT MAL- MINOR EPILEPTIC FITS

Also known as ‘Absences’. Simple local focal activity that may last for as little time as a blink to sudden loss of attention for a short while, then returning to normality. Normally does not cause severe difficulties in daily activities. Some jobs such as working with machinery should be avoided.

TEMPORAL LOBE

50% of temporal lobe epileptics have disorders of personality. Although the motor seizure is the primary indicator of Epilepsy and the decisive one in diagnosis, there are minor or equivalent symptoms, as well as delirium, twilight states and dementia to be included in the mental disorders of this illness. The association of these with lesions of the temporal lobe is well established. Hallucinations, which may be olfactory, (smell) gustatory, (taste) or visual, disturbed recognition and sense of reality; and automatic behaviour with clouding and consciousness are all features of the temporal lobe syndrome. 25% have psychotic episodes often dominated by paranoid or schizophrenic features. Psychomotor Epilepsy does not invariably originate in the temporal lobe. Instead of a major fit the patient may become unconscious or pass into a twilight state, which for a few minutes or longer wanders about in a dazed way and does inappropriate things, having afterwards complete amnesia of all this; or there may be a complete interruption of action or speech during which the patient remains immobile or makes automatic or aimless movements. Epileptic Furor is a delirious state in which acts of violence may be committed, it lasts often for several days, is accompanied by disorientation and hallucinosis, and is much rarer than is supposed. Twilight zones may precede the motor attack, follow it or be accompanied by a few violent clonic movements.

JACKSONIAN

A symptom of a cerebral lesion. The convulsive movements are often localised and close observation of the onset and course of the attack may greatly assist diagnosis.

CHILDHOOD

In very young children, seizures happen and can be very disturbing to families, and fear of having a brain damaged child is apparent. Infantile seizures occur more frequently in male babies, they are typically sudden, without warning and of short duration, one to two seconds is not uncommon. In many cases seizures are caused by the child having a high temperature and their Hypothalamus in the brain is not yet fully functional to control temperature, and seizure occurs. This normally subsides by the time the child is 2 years of age.

ELDERLY

The elderly may develop epilepsy for a variety of reasons. The ageing process itself may reduce the ability of the brain’s resistance to seizures. Changes such as hardening of the arteries may diminish blood flow and oxygen to the brain and may precipitate a seizure. Underlying disease may also be a cause, such as Cerebral Vascular Accidents (CVAs’), the Dementia’s such as Alzheimer’s disease, or physical disorders such as Renal Failure.

AURA

A premonition, peculiar to an individual which often precedes an epileptic fit. An ‘experienced epileptic, who understands the feelings as a warning prior to a fit may often put themselves in a lying position and await the seizure. This prevents them having unnecessary injuries and minimises damage to themselves and prevents structural breakage’s, such as windows, furnishings and fitment’s.

SEIZURE

TONIC

From the word ‘Tone’ which means tension in muscles (including normal). Contraction of muscles in a slow rigid manner, where there is stiffness of the neck and arching of the back. It is a shorter duration than the clonic phase.

CONIC

From the word ‘Clonus’ which means muscular rigidity and relaxation, which occurs spasmodically. The second stage of a Grand Mal seizure. Clonic movements are of rhythmic repeated jerking movements and can last for several minutes.

POST SEIZURE (ICTAL) ACTIVITY/FUGUE

A period of altered awareness during which a person may wander for hours or occasionally days and purposeful actions although their memory may lost. Cases of murder have been overturned on the basis of Diminished Responsibility due to this symptom. Also may occur in Schizophrenia and Hysteria.

BLINK

In Petit Mal, a single blink may be all that is seen. This may be missed by the carer, yet may happen many times throughout the day.

ATTENTION SPAN

Whilst we all at times loose the ability to concentrate, in epilepsy, this is due to seizure activity, and whilst a conversation is taking place, the individual may simply drift off and not hear or understand what the conversation was about.

FALL

In Petit and Grand Mal, an initial fall to the ground may happen, causing injuries, including the possibility of head injury, often requiring stitches. Those who suffered from epilepsy before modern drugs, often have a ‘Cauliflower Ear’ and a broken nose. Some severe epileptics wear a crash helmet in case of a severe fall from the seizure. In Petit Mal this is called Atonic Seizure or ‘drop attack’.

AGGRESSION

PERSONALITY TRAIT

PSYCHOTIC EPISODES

Apart from seizures Epileptics are prone to swings of mood, towards anger, shallow sentimentalism or depression- which may pass into a fugue, during which the patient wanders is not aware of their actions. In extreme cases murder has been reduced to manslaughter during a fugue.