Antidepressants SSRI group

SSRIs (selective serotonin reuptake inhibitors) (Box 23.3) have been available on the UK market since 1989, and have been widely prescribed. Their prescription to child patients however, has become very controversial, because of lack of evidence of effectiveness in this patient group, and also concern over increased suicide risk. Recent NICE guidance is that 'antidepressant medication should not be used for the initial treatment of children and young people with mild depression' even in...

Anxiety and stress related disorders

Anxiety and stress-related disorders can be considered as an exaggerated response to stress. In contrast to psychosis, such patients are free from delusions and hallucinations, and usually retain insight. These disorders include the following range of common, related, and overlapping conditions generalized anxiety states continuous, unfocused, 'free-floating' anxiety panic disorder episodes of acute, severe anxiety specific phobias anxiety related to specific objects (e.g. spiders) or...

Anxiolytic drugs

Anxiolytic drugs such as benzodiazepine are best taken only when symptoms actually occur, or shortly before the patient has to face an anxiety-provoking situation. Regular medication encourages tolerance and dependence, and for this reason benzodiazepines are recommended for short-term use only. Unfortunately, because of fears of addiction, these drugs may now be in danger of being underused. In patients with stable personality, with a likely short-term situation such as acute distress...

Conversion and dissociative disorders ICD F44 formerly called hysteria

Conversion disorder is the current term for syndromes in which there is loss of physical function, such as paralysis of a limb, blindness, or fits, that cannot be explained by physical disease. The condition is regarded as not intentionally produced, thereby distinguishing it from factitious disorder (see below). It tends to develop acutely in stressful circumstances. Such symptoms appear to express an emotional conflict or need, and may bear some symbolic relationship to the nature of the...

Frequency

How common is depression This obviously depends on how it is defined, immediately taking us into controversial areas. The standard answer to this question starts with 'major depressive disorder', as defined in the DSM. Community surveys have shown that extraordinarily high numbers of the general public satisfy diagnostic criteria for 'major depression' at any one time for example, estimates of at least 10 per cent are often quoted, and it is held that 20 per cent or more of the population will...

Generalized anxiety disorder anxiety state

The prevalence of pure generalized anxiety disorder is about 3 per cent of the population, and a further 8 per cent have mixed anxiety and depressive disorder. Physical and or mental symptoms of anxiety, as listed above, are present most of the time in the absence of real danger, and are 'free-floating' rather than focused on any particular stimulus. Most acute episodes seen in primary care are precipitated by obvious stressors, and respond to supportive interviews designed to help the patient...

Indications

Depressive illness is the main indication. An MRC research study in 1965 showed that ECT is superior to antidepressant drugs for treating severe depression. Most depressed patients, however, are given drugs as the first-line treatment, ECT being reserved for use in the following circumstances when life is threatened by suicidality when life and health are threatened by refusal of food and drink when antidepressant drugs have failed when antidepressant drugs are contraindicated for medical...

Legal status and availability

Injectable amphetamines are class A, and oral amphetamines class B drugs. They used to be widely prescribed for depression (in the 1950s and 1960s) and for obesity (until quite recently). They are stimulants, and are thus related to cocaine (see below). They are now only licensed for treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents as part of a comprehensive treatment programme, and for narcolepsy or obstructive sleep apnoea syndrome. Inappropriate...

Mechanisms of change

The same mechanisms operate as in individual therapy, but those treated in groups have the advantage of being able to share their problems and ways of coping with others similarly affected. As the introduction of newcomers may retard progress and arouse hostility, 'closed' groups with a fixed lifespan and the same members throughout are ideal, if not always practicable. A good size is 5-10 members. Outpatient groups usually meet once a week for 1-2 hours. Groups run on psychoanalytic lines may...

Medication

Antidepressant medication is probably the most frequently used treatment. The main types of antidepressants are tricyclic antidepressants, SSRIs, and MAOIs. They are discussed in more detail in Chapter 23. SSRIs are widely used in general practice. However, they are probably weaker drugs in more severe depressive states hence, by the time patients have been referred to secondary care, they have probably already failed to improve on SSRIs. There is no logic in switching from one drug to another...

Mental features of depression

The cardinal symptom of a depressive illness is of course a pervasive depression of mood. This must go beyond the everyday experience of, for example, 'I'm really depressed about the gas bill.' The mood must be low, flat, and empty, and not able to be cheered up by things that the patient formerly enjoyed. There are those in psychiatry who feel that depression can be diagnosed without depression of mood being obvious to the patient or readily apparent to the psychiatrist. It is just conceivable...

Mode of action

This is unknown, but may relate to alterations in neurotransmitter sensitivity. ECT causes many physiological changes, including slowing of the EEG, and increased secretion of sympathetic amines, prolactin, and other pituitary hormones, but none of these correlate reliably with clinical response. Some sceptics claim that ECT is effective just because it results in confusion, which makes the patient forget depressing thoughts. Production of an adequate fit, arbitrarily defined as a generalized...

Myths

Many patients are horrified when ECT is first suggested. The public perception, reinforced by certain sections of the media, is of 'unmodified' ECT as it used to be given 50 years ago without an anaesthetic. There were frequent physical complications such as broken teeth and bones, plus the dehumanizing character of the experience for example, patients were often treated one after another in a public ward, with no privacy and no tranquillizing medication. Modern administration of ECT is very...

Other drugs

Many patients with pronounced mood instability or depression - or more commonly flatness - of mood can be prescribed mood stabilizers or antidepressants. If the question arises, there is often a strong case for at least trying the effect of such medications response is unpredictable. Sometimes there is an improvement. Even if there is no benefit, at least the practitioner will have tried, and will therefore have been seen to have listened to the patient, his family, and or his care coordinator....

Personality

It is probable that the effects of genetic loading, adversity in childhood, and psychological factors such as negative thinking come together in forming a particular type of personality that has a higher risk than the average of developing depressive illness. People with such a personality type include the anxious or dependent, those who have long-term difficulties in coping with stress, and those with constitutional tendencies to gloom, sometimes referred to as dysthymia. In younger people,...

Physical complications

The mortality rate in alcoholics is about three times the general population rate. Liver damage includes acute hepatitis, fatty infiltration, and cirrhosis. In men, cirrhosis seldom develops until heavy drinking has continued for at least 5 years, but women are more vulnerable. Cirrhosis has a high mortality rate even in those who become totally abstinent. In pregnancy, heavy drinking may cause abortion, stillbirth, or the 'foetal alcohol syndrome', comprising microcephaly and other...

Picks disease

Pick's disease is regarded as one of the frontotemporal lobe dementias although it is a rare cause of dementia overall, it may account for up to 5-10 per cent of early-onset cases. Some cases are familial, probably caused by a dominant gene. Onset is between the ages of 50 and 60, and women are affected twice as often as men. Cerebral atrophy occurs, with loss of neurons and gliosis, most marked in the frontal and temporal lobes. Characteristic Pick bodies (cortical inclusions) are seen....

Posttraumatic stress disorder PTSD

Psychiatry has always recognized that mental disorders can follow traumatic events. The names have tended to change over the years, including 'shell shock', 'war neurosis', or 'battle fatigue'. However, it was only in 1980 that DSM-III described PTSD it appears in ICD also, and the diagnosis has evolved significantly since its introduction. PTSD is described in survivors of major traumatic experiences of a kind outside the normal range of human experience. Such experiences include large-scale...

Pregnancy

Broadly speaking, pregnancy appears to protect against psychiatric disorder, an effect having probable survival value in evolutionary terms. First onset of psychiatric disorder during pregnancy is rare, existing disorders tend to become less severe, and suicide rates during pregnancy and the puerperium are low. However, women with a history of chronic or recurrent psychiatric disorder require continuing assessment and care during pregnancy, and monitoring to detect and treat any worsening after...

Prevention of PTSD

'The road to hell is paved with good intentions' might be our watchword here, at least in respect of well-meaning efforts to prevent PTSD. Efforts to encourage - or even require - those who have been exposed to trauma to talk things over with a counsellor or other adviser, either individually or in a group, come under the heading of debriefing. To many, both in the mental health professions and in the wider community, it would seem natural and obvious that such an endeavour would be helpful....

Prognosis

From 70 to 90 per cent of episodes of affective illness recover within a few months even without treatment. The rest become chronic and may last for years. Prognosis is better if treatment begins early during the episode. Even if their first episode has recovered, 70-80 per cent of patients will suffer one or more further attacks at some stage in their lives. Some patients become ill at regular intervals, or at the same time each year, often spring or autumn. Bipolar patients may alternate...

Psychiatry in primary care

A quarter or more of consultations in primary care (general practice) appear to have a substantial psychological component, although the patient's presenting complaint is usually a somatic one and the underlying emotional disturbance may not be recognized by the doctor. Mixed neurotic symptoms, often accompanied by social or interpersonal problems, predominate. About 90 per cent of patients with psychiatric disorder are managed solely in primary care, and many episodes resolve quickly without...

Psychological and social effects

Cannabis usually produces sedation, but it can exaggerate an unpleasant pre-existing mood state of anger, depression, or anxiety. Psychotic symptoms, including perceptual distortions, visual hallucinations, and confusion, can occur. The use of cannabis is often implicated in worsening the clinical course of schizophrenia, precipitating onset or relapse and retarding recovery. Sustained long-term use is believed to cause an 'amotivational syndrome' of apathy and cognitive defect, partially...

Psychological and social approaches

Systematic reviews indicate that most of the brief approaches that have been trialled are effective in reducing consumption, but that longer-term psychological treatments (including dynamic, behavioural, or supportive psychotherapy, individual or group, on an inpatient or outpatient basis) have little or no additional benefit. The trend is firmly toward inexpensive community treatments with input from health, social, and probation services. However, inpatient alcoholic units still exist,...

Psychological factors

Research has substantiated the clinical experience that patients with depression frequently have had adverse experiences in childhood, especially inadequate parenting or loss of a parent, especially the mother. This may lead to lack of confidence and low self-esteem as an adult, making the person more likely to have a depressive episode when they encounter, as we all inevitably do, adverse events. The cognitive theory of depression was popularized by Beck. It proposes that depression of mood...

Psychological methods see Chapter

A continuing supportive relationship with a trusted professional forms a valuable part of the treatment of all depressed patients. Occupational therapy can also be most helpful in encouraging the patient to resume the full range of daily activities. Cognitive therapy, designed to modify habitual negative thinking patterns which contribute to depressed mood, is as effective as drug treatment in moderate or mild depression. Interpersonal therapy, focused on relationships with others, is also...

Psychological treatment

The ordinary forms of counselling - the sort widely available, sometimes in GP surgeries - are popular with patients. However, there is little evidence of effectiveness the evidence base is for structured forms of psychological treatment such as behaviour therapy and cognitive-behavioural therapy (CBT). For example, take the treatment of a specific phobia, such as that of water, using CBT principles. Components of treatment would include the following leading to the building up of a trusting...

Psychological treatments see Chapter 22

Psychotherapy in its briefer forms may be helpful, but not in dementia (Burns et al., 2005). Intensive exploratory work is inappropriate because major changes in personality or attitudes are not likely to be achieved. Individual or group treatment may be focused on adaptation to bereavement or the other losses of old age. Marital therapy may be indicated, because conflicts in a marriage often become more obvious when the partners are brought into constant contact by retirement or restricted...

Psychoses

Childhood psychosis is rare, affecting 40 per 100 000 children. Types of such psychoses include disintegrative (developmental) psychosis, in which a child aged 2-8 years, previously normal, becomes emotionally withdrawn, loses speech, deteriorates intellectually, and shows emotional and behavioural disturbance. Schilder's disease, lipoidosis, and SSPE (subacute sclerosing panencephalitis, due to the measles virus) are among the causes of this rare condition. Schizophrenia occasionally starts in...

Psychosurgery

Psychosurgery is brain surgery carried out to relieve a patient's suffering by changing mood or behaviour. Latest UK figures indicate that only seven operations were done for the 2-year period 2004-5 (Schulze-Rauschenbach et al., 2005). It has thus become a near obsolete-treatment, probably carried out for only the most intractable cases of obsessive-compulsive disorder. The history of psychosurgery serves to illustrate the way that the relative influences of the biological and the...

Psychotropic drugs see Chapter

Antidepressants are especially useful (Gill and Hatcher, 1999). Even for patients who have good cause to be depressed, these drugs can help improve mood and relieve associated symptoms such as insomnia and pain. Antipsychotic drugs are used to control agitation or behaviour disturbance in patients with organic brain syndromes. ECT is occasionally indicated for relief of severe depression, and is safe in physically ill patients provided they are fit for anaesthetics and do not have raised...

PTSD controversies

It will be apparent that the definition of a traumatic event has been widened in successive editions of the DSM almost any accident could be described as a 'threat to one's physical integrity', and 'witnessing an event' is surely qualitatively different from being involved. This has led to people having received compensation for harassment in the workplace on the basis of PTSD, when the initial definition of PTSD related to serious physical trauma. As indicated above, there are doubts about the...

Recent advances

Psychotherapy continues to develop, fuelled partly by notions - not totally realistic - that it represents a more fundamental solution to problems than other therapies, such as medication, which may be seen as 'merely drugging the problem'. Indeed, the provision of mass CBT has even been suggested as a solution for social problems layard.pdf). Dialectical behaviour therapy for borderline personality disorder (Palmer, 2002) represents a novel way of seeking to help some of the most damaged and...

References

Post-traumatic stress disorder. Clinical Evidence (15th edn), pp. 1453-1469. London BMJ Books. jsP. Butler, R. et al. (2006). Depressive disorders. Clinical Evidence (15th edn), pp. 1366-1406. Gale, C. and Browne, M. (2006). Generalised anxiety disorder. Clinical Evidence (15th edn), pp. 1407-1418. London BMJ Books. meh 1002 1002.jsp. Hay, P. and Bacaltchuk, J. (2006). Bulimia nervosa. Clinical Evidence (15th edn), pp. 13151331. London BMJ Books. 1009.jsp. Jung, C. (1971)....

School attendance problems

School refusal is reluctance to attend school, due either to fear of teachers or other children (school phobia), or fear of leaving the mother (separation anxiety). The mother often covertly encourages it because she herself is depressed or immature, and reluctant to be separated from the child. The child may complain of headache or abdominal pain on school mornings. Treatment includes psychotherapy for the child and mother, dealing with any contributory factors at school, and encouragement to...

Schizophrenia see Chapter 4 and paranoid disorders see Chapter

A small proportion of psychotic illnesses (probably less than 10 per cent) start after the age of 65. This is usually the paranoid form with good preservation of general personality. (The term paraphrenia may be used.) It is important to check for sensory impairment, which may be contributing to the problem by increasing the patient's isolation and reinforcing any paranoid tendency. Social activity, as through a day centre or residential home, may be helpful if the patient will accept it....

Senile dementia of Alzheimer type SDAT Epidemiology

SDAT accounts for over half of all cases of dementia in old age. It is present in 5 per cent of people over age 65 and 20 per cent of people over 80. Women are affected nearly twice as often as men, probably mainly reflecting women's longer lifespan. AD is also the commonest of the primary 'presenile' dementias, with onset earlier in life, say, between the ages of 40 and 60. Genetic predisposition exists and a link with allele e4 of apolipoprotein E is established. About 20-30 per cent of the...

Sideeffects of drugs

The older drugs cause extrapyramidal side-effects commonly, particularly increases in muscle tone (stiffness), and tremor risperidone and the other atypi-cals can also cause these, though less frequently. The main problem with the atypical medications has been weight gain, and olanzepine seems to be notable for this it seems to have an appetite-stimulating effect, and cases of diabetes (Koro et al., 2002) have also been recorded. There is also a risk of stroke (Ballard et al., 2006) in elderly...

Simple schizophrenia

'Simple schizophrenia' (another term now seldom used) is characterized by negative symptoms, with gradual deterioration of the personality, flattening of affect, withdrawal from reality, and loss of drive, resulting in a lifestyle of social isolation and self-neglect. Positive symptoms may be few therefore, in some cases, it is debatable whether a diagnosis of schizophrenia is actually justified. However, such patients can be among the most disabled patients with schizophrenia, unable to...

Social stress

Depressed patients report more 'life events', especially loss events, than general population controls during the few months before their illness onset. About 80 per cent of depressive episodes appear to be precipitated by life-event stress. Chronic social difficulties, lack of confiding relationships, and absence of a supportive social network are important mediating factors. The role of life events is strongest in respect of first episodes of depression. In subsequent episodes, the role of...

Structured interviews and questionnaires

These instruments are used mainly in research work. Their purpose is collection of data in a reliable standard form, minimizing the bias, which can arise from variation in individual interview technique. They can be administered by trained personnel other than psychiatrists. Well-known examples of structured interviews are the Present State Examination (PSE) and its later development, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), which is analysed by computer (CATEGO program)...

Tactile hallucination tangentiality tardive dyskinesia

Delusion about the body for example, the bowels have turned to stone. Mental mechanism in which the self or others are viewed as either good or bad it is seen, for example, in patients with personality disorder, who skilfully divide staff teams and set them against each other in an effort to avoid dealing with their own issues. Repetitive and unrewarding behaviours such as rocking, tapping, etc. Condition in which a hostage or other vulnerable person seems, paradoxically, to display loyalty...

Temporal lobe lesions

Personality change may take the form of increased aggression and emotional lability, or resemble that seen with frontal lobe lesions. Temporal lobe epilepsy may develop. This condition, even more than other types of epilepsy, has important psychiatric aspects. It is associated with neurotic disorder, mood disorder, schizophrenia, and high suicide rate. Intellectual deficits can be verbal or non-verbal depending which side is involved. Memory defects occur with bilateral lesions. Neurological...

The aftermath of suicide effects on those involved

Bereavement counselling and practical help may be required in the immediate aftermath of the death, which will almost always be a very difficult time for relatives. In the longer term, the relatives of those who died by suicide are at high risk of psychiatric illness and social problems, and many take years to adjust, if they ever do, to a death which frequently seems like an act of aggression as well as of self-destruction. Sometimes, suicide can even seem to be an act with a violent aspect,...

Transmissible spongiform encephalopathies prion dementias

These are rare forms of dementia, caused by accumulation of abnormal prion proteins in the brain. Prion stands for proteinaceous infectious particle, a unique form of infective agent, as it contains no genetic material. Prions are now accepted as the cause of a group of transmissible spongiform encephalopathies including scrapie (in sheep), chronic wasting disease (in deer), and bovine spongiform encephalopathy (BSE) ('mad cow disease'). Human examples of these disorders include...

Tics and Gilles de la Tourette syndrome

A tic is a repetitive, purposeless movement such as blinking or grunting, partly under voluntary control. Tics may develop in normal children, and are exacerbated by emotional disturbance. They are best ignored, and usually disappear spontaneously, but, if not, then behaviour therapy may help. Gilles de la Tourette syndrome comprises multiple tics and compulsive utterances. Tics first affect the facial muscles, and then spread to other parts of the body. Involuntary utterances then occur, such...

Unwanted effects

Benzodiazepines, even in overdose, are not toxic. Apart from drowsiness, they may have a few unwanted effects in the young, healthy person, but the elderly may experience marked side-effects of which the neurological and psychiatric ones are most important. These include confusion, depression, drowsiness, amnesia, impaired psychomotor performance including an effect on driving, ataxia, dysarthria, and headache. Some subjects experience 'paradoxical' effects of excitement, aggression, or...

What about the new drugs

There has been a wave of new drugs, both antipsychotics (atypicals) and antidepressants (SSRIs, etc.), as well as others. The manufacturers have claimed that these new drugs are as effective as older drugs, but have fewer side-effects. They do seem to have a more favourable side-effect profile in some cases, although their adverse effects are now beginning to emerge for example, weight gain and diabetes with olanzepine. In medicine, as in life, one does not get anything for nothing, however,...

Neuropsychiatric complications

Delirium tremens (DTs), an indication of physical dependence, can be precipitated by abrupt withdrawal of alcohol in a heavy drinker, caused, for example, by the end of a drinking bout, efforts to give up drinking without professional advice, intercurrent illness, hospital admission, or arrest imprisonment. Confusion, fever, visual or tactile hallucinations, and fits may occur. Delirium tremens is a medical emergency with an appreciable mortality, and should be treated by physicians. Treatment...

Premenstrual syndrome

Many women report depressed mood, irritability, or anxiety, often combined with physical symptoms such as breast tenderness, headaches, bloated feelings, and weight gain, for up to 2 weeks before the onset of menstruation. Premenstrual tension has been used successfully as a defence in criminal trials, although this is exceptional. Regarding treatment, a wide variety of interventions has been systematically reviewed diuretics and pyridoxine are considered to have good evidence of effectiveness....

Limitations and problems of classification

Although a great deal of work has been devoted to making the official international classification systems both reliable and valid, it must be acknowledged that they are still imperfect. The descriptive categories are continually being revised for example, 'panic disorder' and 'post-traumatic stress disorder' were only recently listed as diagnoses, although the clinical phenomena have been recognized for many years. The boundaries between some of the clinical syndromes are not absolute, as...

Course of alcohol abuse

The traditional view, which may well apply to some of the most severely affected, is of a relentlessly progressive disorder. Alcohol problems commonly begin when social drinking becomes heavier for psychological reasons, such as living in a hard-drinking environment, or stressful work or family circumstances. This stage of psychological dependence is followed in some cases by development of physical dependence, manifested by loss of control over the amount consumed, and withdrawal symptoms...

Differential diagnosis of paranoid states

Paranoid symptoms are found in many of the common psychiatric conditions described elsewhere in this book, including schizophrenia, affective disorders (depressive illness and mania), drug and alcohol misuse, and the dementias. The following list describes some other syndromes in which paranoid symptoms are a main feature Persistent delusional disorder (older terms include paranoid psychosis, paraphrenia, and paranoia) delusions are present, but, in contrast to paranoid schizophrenia, there are...

Cognitivebehavioural therapy CBT

CBT has become established as the psychotherapy of choice, being perceived as effective and cost-effective. It remains important to understand the twin strands of CBT. Behaviour therapy per se is now less prominent. However, cognitive therapists are happy to admit that their treatment involves components of behaviour therapy, such as activity scheduling, and that the term 'cognitive therapy' is effectively shorthand for CBT. The principles of cognitive therapy and behavioural therapy will now...

Cerea flexibilitas waxy flexibility

Pressure and heart disease it is also used to treat physical manifestations of anxiety, such as palpitations. Content of delusion obviously implausible in view of patient's background and culture. Reduction in range and intensity of emotional expression. French term for brief psychotic disorders. Neurological term for generalized motor slowness. Unconscious grinding of the teeth while awake or asleep associated with mental disorder. Eating disorder characterized by abnormal eating patterns,...

Antidepressants

Sedative tricyclics such as trimipramine are often given in anxiety disorders. Their full benefit may take several weeks in depression, but their useful hypnotic and anxiolytic properties are immediate and dose-related. For example, trimipra-mine 25 mg nocte regularly plus 25 mg mane p.r.n. will help sleep and make available a safe antianxiety treatment for daytime use in a patient with mild anxiety symptoms. Antidepressants are effective in panic disorder. MAOIs should be tried if other...

Psychiatric reports criminal

Court reports should be written in non-technical language, as they will be used by lawyers and other lay persons. All technical words, even those commonplace to psychiatrists, such as 'schizophrenia', should be explained. Before beginning work, the wise psychiatrist obtains the written agreement of the person requesting the report to pay his fee, as this work is not part of NHS practice. A proper letter of instruction is essential. This must set out the points on which the psychiatrist is to...

Physical somatic biological vegetative symptoms

Physical symptoms are just as common as psychological ones and often form the presenting complaint when depressed patients consult in general practice. Core symptoms of depression include pain and tiredness. These have been recognized since the early days of psychiatry. (Indeed, a more insightful way of looking at the problem would be to retreat from the somewhat arbitrary mind body split in which, at any rate in Western societies, we view the experience of distress.) Pain and fatigue and...

Antidepressants MAOI group

MAOIs (monoamine oxidase inhibitors) increase brain concentrations of monoamine neurotransmitters by inhibiting the enzymes concerned in their breakdown. They are effective for depression, anxiety, and phobic states, and sometimes achieve dramatic responses in patients who have failed to respond to tricyclics. They may have a particular place in so-called atypical depression 'with reversed biological features, e.g. increased sleep, increased appetite, mood reactivity, and rejection sensitivity'...

Chronic fatigue syndrome ICD neurasthenia F480

The term chronic fatigue syndrome may be applied to a patient whose persistent tiredness lacks a physical pathology to account for it. The diagnosis of neurasthenia was popular in the late nineteenth century, and its symptoms included fatigue after minimal effort, loss of interest, irritability, poor concentration, and sleep disturbance. Similar syndromes have attracted great interest in recent years under new names such as chronic fatigue syndrome, post-viral syndrome, and myalgic...

Chronic pain ICD F454 persistent somatoform pain disorder

This syndrome involves persistent severe pain that cannot be explained by a physical disorder. An example would be a patient who has had an operation for back pain, but still has severe pain, or a patient who has been in a minor road traffic accident and sustained whiplash injuries, but is still complaining of incapacitating neck pain years later. This can be a controversial category. In some cases, there are obvious psychological factors at play, but many of these patients vehemently deny any...

Assessing physical symptoms in psychiatric practice

The assessment depends in part upon the setting. In some cases, for example, the patient on antipsychotic medication who complains of a shakiness of the hands, the most likely diagnosis extrapyramidal side-effects of medication will be obvious. Another common instance of side-effects of medication is the patient on tricyclic antidepressants, who complains of a dry mouth. However, it is always important to remember that the emergence of a physical symptom could represent the first sign of an...

Neurochemistry

Brain concentrations of monoamine neurotransmitters, and or sensitivity of their receptor sites, appear to be altered in affective disorders. Noradrenaline NA and or 5-hydroxytryptamine 5-HT, serotonin are implicated in depressive illness dopamine is implicated in mania. Evidence for neurotransmitter involvement includes the following points Most drugs that are effective in treating depression increase the availability of NA and or 5-HT in the brain. Antihypertensive drugs, such as reserpine,...