35

Board of Management

Chair man: Dr Fazal Mehmood Uppal Tel no: 217067

Finances: Dr Mohammad Akram Awan.Tel no 215215.

Pakistan Society of Family Physicians.

352 E Satellite Town Gujranwala,

E.mail:< drsar@brain.net>.pk.<http: //www.pakjfm.com>

<saleem@ranahospital.com>

An Editorial from British Medical Journal.

BMJ 2000; 320:1420-1421 (27 May)

Established psychiatric diagnostic schemes such as the International Classification of Diseases and the Diagnostic and Statistical Manual were developed to classify the psychological and behavioural disease found among psychiatric inpatients. Although their scope has broadened with successive revisions, they remain more applicable to the 2% of the population who are seen by psychiatrists than to the much larger proportion who are considered to have mental health problems by their general practitioner. General practitioners have long argued that the process enshrined in psychiatric diagnostic systems helps in managing only a tiny proportion of the psychiatric problems they encounter.

Panel Interview

Of

Prof Dr Ijaz Haider

MBBS, MRCPsych (London) DPM,

FRCPsych (London), Ph.D. (Edinburgh)

RCS (England), RCP (London), PAM (Pak)

Professor of Psychiatry.Allama Iqbal Medical College Lahore.

Visiting Psychiatrist, Jinnah Hospital Lahore

Zonal representative of World Psychiatric Association,

WHO Consultant.

Clinic: 5-Race course Road, Near Chowk Shadman Colony, Opposite Circuit House, Lahore, and Tel no 6304923,7586542.

• Panel consisted of Dr Danish Malik, Dr Hasan Mehmood Rajput, Dr Arshad Javaid Sh and Dr Saleem Akhtar Rana.Choice of questions was with the panel. Any error in reporting is the responsibility of editorial board.

• Interview lasted for more than two hours. Wide-ranging issues were discussed. Replies were very candid and practicable. Local Circumstances were reflected in the wealth of experience and huge education of our expert. Panel was obliged to be benefited by the lifetime experience of a very intelligent, competent, sharp, uptodate professional who is at the peak of his carrier. We were overwhelmed by the simplified approach, based upon sharply defined ideas, for the benefit of family physicians. WHO and WPA must be very lucky to have such a person. It was a nice experience.

Following text has been prepared from the answers given to questions of the panel.

Doctor Patient relationship.

This is the most important aspect of psychiatric management. Following key elements must be inculcated in the behaviour of doctors.

Gain the confidence of Patient.

Family physicians are usually busy and sitting among many patients. Psychiatric patients may not like to talk in huge crowd. Talk to them sympathetically. Listen to them as much as patient desires. If these two elements are fullfilled 50 % of therapy is done there and then. Assure the patient about the secrecy of contents of his history and reassure him that his history or secrets will be kept top confidential and no one will get to know these, (just to elaborate). Don’t rush the patient. He will not fully confide in first session. You need second or third visit before he feels comfortable and confident that he can discuss the compulsions, obsessions or the things worrying him. Family physicians can call them back daily, even, for few minutes. If situation demands tell the patient and family to come back in your relative free time. Reassure them that you want to listen and examine in detail. You are planning special attention for you! This will go a long way to win the confidence of the patient and family.

Never say No cure for any disease since Allah Almighty is all-powerful.

Do not say to patient or family that patient has no disease. You may clarify that patient has no physical illness. When they come to you they have a problem, which is very serious disease. Never tell them that you could not understand the disease. It will dampen their spirits. No matter how poor or hopeless prognosis is (e.g. mental retardation), never ever disappoint and staightway tell the family/patient that there is no treatment for this condition. They have come to you with great expectations. You can always do something. At least you can listen and reassure. Whatever good can be done do it. Assure the patient that things will become better with treatment and time. This is almost always so. Patient and family have problem. They have to seek help. If you will disappoint then they will not sit down back in their homes and accept your advice but they are bound to knock at other doors. Why not yours?

Answer all questions.

Patient and family have many many questions about the disease, treatment, prognosis and many other aspects. Answer all questions to the satisfaction of them. Again do not tell them that we do not know this or that. Give some plausible explanation to the best of your ability. Unknown aetiology should not be translated to patients that sorry we don’t know. It creates uncertainity in the minds of patient and family. Satisfy them. Explain according to locally acceptabe cultural context and ensure follow up and compliance.

Laugh with the patient.

Just to relax the patient and family are pleasant. Try to make the atmosphere light by reassuring words, sharing some jokes or titbits with patient or family. It will help to gain the confidence and evaluate emotional response.

Do not forget to offer Confidentiality.

Many patients will not tell the doctor about their real worries, tensions, compulsions, obsessions untill they are dead sure that their secrets will be well kept. Do not forget to offer confidentially at some stage of your management. Many a times just you’re listening to patients real thoughts completes the therapy and takes half of the illness away.

On Referal to Specialists.

• If family physicians complain that they do not get their patient’s feed back or they do not receive the advice, they are right. System of referal is at fault.

• Which specialist to refer and reason for referal. Please be precise in your reason for referal. Is it diagnosis or management or simple opinion?

• Refer to that specialst that you know well and who understands your language? With whom you are on good wavelength. Meet him. Invite him. Consult him about the patient you are refering to him and share the contents of the problem.

Adopt a proper system of referal.

• Print forms as family physicians. Please provide specialist all information about disease, family backgrounds, economic situation (you can always seek concession) etc. Please always commit a provisional diagnosis. Specialist may not be always right. Your opinion about the diagnosis is a very special help. Never be afraid of making a mistake. Who does not?

• On the same form leave the space for comments of specialist? Ask specific questions from specialist, about which, you are seeking advice. Instruct your patient to get this part of the form filled by the specialist and report back to you. This will ensure compliance on both ends. Patient, in his own interest, comes back to you. To know your opinion about the treatment of specialist.

• If this sytem is followed then you can always give a phone call before refering or after recieveing him back, to clarify any point. Never hesitate. It is your right and privillige.

On New Drugs.

Unfortunately most of the education, we receive, after graduation is from Medical representatives. They highlight only those points, which favour their product. We should always educate ourselves. We should always ask what advantage new and expensive drugs have over old ones. Very rare side effects like tardive dsykinesia (which you may never see in your life) should not lead us from old time tested and cheap drugs. Newer drugs usually in promotional material compare antidepressents with tricyclics and antipsychotics with largectil. These are still the gold standards. Usual claim is that new products are as effective as these gold standards. Advantage is claimed on side effects. Ask yourself how many times you have seen the side effects. Go for cheaper drugs and prescribe according to patient’s affordability and therapeutic efficacy.

Management of Hysteria.

• Never declare to patient or family that there is no disease. This is definite disease and there is a definite protocol to treat it.

• First and foremost thing is to listen very sympathetically. Examine in detail. If there is any investigation to be ordered, do it. Then assure the patient and family that no body has ever died with this disease. It is always cured. It may take sometime but it is going to be totally cured. Own the patient. Reassure him.

• Treat with Largectil and Diazepam in proper dosage, to manage the crisis. Continue it for few days. About hospital admission, do calculate that going back to same environment, which you want to avoid, may not cause recurrence of symptoms.

• There are always some internal conflicts at the background. These may be related to Job, environment or personal life of patient. Patient may confide in you, usually, later on, not on first visit. Advise parents not to treat hysteria with marriage. If circumstances permit, energies of patient should be diverted to some beneficial activity such as household duties, education, cooking classes embroidery etc.

• Do not forget to advise the family that this type of problems may happen again. Nothing to worry about. Bring patient back to me.

Malingering

Usually a motive of benfit to be gained is quite obvious. This differentiates it from hysteria.

Panic Disorders.

Tofranil and diazepam or Tryptanol and diazepam in combination used in judicious doses can control the symptoms. Later on patient can be labeled appropriately and treated.

Anxiety/Depression.

Typical symptoms are a common knowledge. How to differentiate anxiety from Depression? He defined a very simple yardstick. Any mood disorder going beyond two weeks should be labelled as depression. It should be treated as depression.

Benzodiazepines.

Duration of action should be main criteria to choose one. Longer acting is usually what is required in most circumstances. For example Diazepam or Librium or lorazepam. Short acting ones like alprazolam have to be repeated.

Use of benzodiapines for arrythmias or tachycardia is not recommended. Specific cardiac drugs are now easily available and quite effective. To promote these specifically for cardiac problems or tachycardia is not justified.

Main use of benzodiazepines is nowadays only for the time period; you give antidepressents to eastablish their effect.

Hypnotics.If drug is needed to induce sleep then use long acting ones. There is a special group of drugs known as hypnotics. These include mogadan and Dormicum and add 25 mgs of largectil, which will acts as good hypnotic.

Antidepressents.

All antidepressents are safe, effective and these should be cheap also to suit the pocket of patient.

Dosage of Flouxetine should be flexible. He uses upto 80 mgs daily.40 mgs daily is quite common in his practice.

SSRI can be combined with low doses of tricyclics. For example 3 tab of Tofranil can be combined with 40 mgs of Flouxitine.

To avoid or expedite the delay of relief with tricyclics and related drugs, he advises to start with 50-100 mgs daily build to 150-175 mgs daily. People, who need these drugs, do not show intolerable side effects. Alternatively Tofranil 25 mgs tid for 3 days and on 4^th day onwards it can be increased to 50 mgs tid very easily. It will establish the response at earliest, on 4^th or 5^th day.

Tofranil and Amitryptaline 175 mgs daily can be used for 7 days straight away without any untoward effects. Normal effects will be there in one-week time.

If there is psychomotor retardation and activation is needed then Tofranil and flouxitene are prefered. If sedation is required then tryptanol or Lantanon is the best.

Mood and mood stabilizers.

• Mood can be defined as what you can see on the face and say about the mental state of the patient after observing his facial expression, condition of clothing, characteristics of gait, volume and tone of voice, listening to him and the total imression you get about the feelings of the patient. Sad, Happy, Worried isolated disinterested agitated etc.

• Lithium alone or in combination with carbamazepine is a true mood stabilizer. Valporate is still under study. Lithium can be safely prescribed.1-2 tabs daily usually do not cause problem. Lithium levels done once only, give idea about the metabolism by the liver and the level is maintained at 0.5 –0.9 mgs/litre.

Psychosomatic disorders.

Professor Ijaz Haider has advised a very simple approach. Once patient is labeled as having this disorder after examination and investigation, symptoms should be taken as physical form of depression.

Management should be exactly as of depression. Doses should be similar. Prognosis is as good as that of depression.

Psychosexual disorders.

• Prof Ijaz Haider feels very strongly about the oppurtunities, which we as doctor have to render our services on this issue. Lot of misery and even many suicides can be avoided.

• This is the sector of health, which we are not dealing optimally. This is the domain mainly of family physicians.

• First thing is education about sexual matters. Doctors should make sure that at proper age parents and even doctors educate youngsters. Many young males commit suicide next day after marriage because they could not “perform well”. There must be somebody to tell them before this catastrophy that majority of couples can not and do not do it on first day.

• About tackling such patients we fail on following points.

• We fail to gain their confidence. Provide good atmosphere. Isolation where they can talk freely.

• When we take history we are not thorough. We must use crude language and phrases to enquire about different components of intercourse and points of weaknesses. Nothing should be left unexplored as we have been taught in Physiology.Nothhing should be supposed. Each and every detail must be brought under discussion.

• Confedentiality must be maintained and assured.

• Gain the confidence of the patient and assure him of total confidentiality.

• Never take complaints of patients lightly. Give them as much weight as patient is giving.

• Quack sex clinics are successful only and only because above mentioned they are practicing approaches in much rigorous ways then we are doing. Their advertisements are highlighting same ideas and they are trapping the patients only by using the language and concerns of the patients. Doctors need lot of improvement on this front to enjoy good practice.

• Once a problem is scietifically defined then treatment for a doctor is no problem.

Old age and dementia.

• After 35 years of age and not 55 years, all mental and physical faculties start slow downhill course. Speed is different in different individuals and thus aging starts at 35 years can be felt at 45 years and visible at 55.

• Before we blame senile dementia for loss of memory or other symptoms, we must judge about all faculties. Day to day performance in all sectors. If there is total deteriation then memory loss can be a part of this. If there is single faculty affected alone then there may be some other cause or patient may be malingering or functional.

• Mild behaviourral problems such as abusive language, related with senile dementia can be treated with 1-2 mgs of flaunxol, 10 mgs of Melleril or Largectil.

Aetiology of Pschiatry Disorders.

Many symptoms are common in all these conditions. Many a times it is difficult to label anyone of these immediately. For diagnosis of these illnesses following diagrams may be helpful. Each triangle represents one disorder. Three sides of triangle represent 3 major aspects to be noted in particular in each patient.

Tiangle No 1 Development of Personality/Aetiology of Psychiatric disorders.

Genetics.

Precipitating factors Environmental Factors

Triangle no 2:Manifestations of Depression

Mood Disorders

Psychomotor Retardation Biological symtoms and suicide.

Triangle No 3 for manifestations of Psychosis

Thought Disorder

Disturbances of Behaviour Disturbances in emotions

On Councilling.

To a question that whom to refer and how to refer to psychotherapist, Prof Ijaz Haider answered that a psychotherapist has to be

Older person

Married Person

Trained in his trade

Knowledgeabe about the patient, his family and his disease.

In his opinion all these qualities are present in family physicians. They should do the councilling. Family members can contibute a lot.

If patient can afford and proper person is available then two sessions are enough.

Section by Dr Danish Malik

MBBS. (K.E), D.Psych (London)

Common Psychiatric Emergencies.

Dr Danish Malik.

Many chronic ailments present with such symptoms that they assume the protocol of medical emergencies. Family is distressed and worried. They seek immediate relief. Family physicians can examine the patient, give assurance to family, and initiate drugs whether parenteraly or orally. Later on they can refer if they decide so.

Conditions. Manifestations Treatment. /Day

• Akathisia Agitation,restlessness Reduce antipsychotics,Inderal in

Muscle discomforts 30-120 mgs. Benadry, Ativan etc.

• Alcohal Auditory hallucination Inj Serenace i/m 5-30 mgs in

Psychotic Disorder. Often fearful divided doses.

• Alcohal Irritability,Nausea Fluid electrolyte balance,Sedation

Withdrawal Vomiting, insomnia with benzodiazepines, 100 mgs of

Malaise thiamine.

• Benzodia- Sedation, Ataxia Supportive Measures.

Zepine intoxication. Slurring of speech. Midazolam; 7.5 mgs –40 mgs.

• Bereavement. Guilyt feelings,irritability Benzodiazepines for sleep.Anti-d

Insomnia, Somatic symptoms epressives not indicated.

• Acute Psychotic Emotional disturbance Hospitalization.

Disorder. Extreme Lability in Low doses of antipsychotics.

Mood.Homicidal ideation Largectil 50-300 mgs.

Cuts, burns and marks all

Over body. Substance abuse.

• Cannabis Delusions,Panic Ativan 1-4mgs,Antipsychotics if

Intoxication. Dysphoria, Cognitive psychotic symptoms appear.

Impairment.

• Delusional Involuntary threats to Hospitalization. i/mSerenace

Disorder others. 5-30 mgs. Largectil 50-300 mgs.

• Suicidal attempts Suidal ideation,self neglect Hospitalization immediately and

(Depressive) substance abuse, Depression must be managed.
ECT may be required.

• Dystonia Intensive involuntary Reduce dose of antipsychotic,

Spasms of muscles of Larazepam 1-2 mgs, I/M phenergan.

Neck, tongue, face, jaw Kemadrin should not be given.

Eyes or trunk.

• Hyperventilation Anxiety,terror Shift alkalosis by breathing into

Giddiness, Fainting paper bags. Alperazolam upto 6mgs.

Blurring vision.

• Insomnia Depression ,irritability Rule out depression or anxiety and

Early morning agitation treat accordingly.

Frightening dreams. Fatigue.

• Manic Episode Violent impulsive Hospitalization.Antipsychotics i/m.

Aggressive, Restless Serenace to control aggression

Pressure of speech Largectil for sedation. I/V Valium

• Panic Disorder Panic,terror,acute onset ECG,Inderal 10-30 mgs,Alprazolam

Upto 2 mgs. Tricyclic anti depresants

Upto 150 mgs/day.

• Phobias panic,anxiety,fear Same as above

• Post partum Affective symptoms are Rule out organic cause.Antipsychotic

Psychosis not common. Schizophrenic Safe guards against suicide.

Or manic symptom usaully occurs.

• Tardive Usually after prolonged No effective treatment.

Dyskinesia antipsychotics use. Reduce the dose

Dyskinesic movements of mandible, tongue, face or trunk.

• Substance Abdominal pain,Insomnia, Antipsychotic drug withdrawl

Withdrawal Drowsiness, delerium treated with anticholinergics.

Seizures, manic or schizophrenic symptoms.

• Neuroleptic Hyperthermia,Rigidity of Discontinue antipsychotic.Start

Malignant muscles, Parkinsonian bromocriptine. Oral hydration,

Syndrome symptoms. Catatonic cooling, monitor CPK

States 10-30 % fatal.

• Vit B 12 Confusion,Mood Give B 12

Defeciency and behavioural changes

• Major Dep Agitation, delusions Give Largectil inj. Hospitalisation.

Episode with High risk of suicide Antidepressents/ECT

Psychotic features. Or homicide with symptoms

Of major depression.

• Dementia Violent outbreaks, Start with Melleril 10 mgs

Psychotic symptoms and largectil 25 mgs. Increase

Confusion may be there. Gradually.

• Catatonic Marked psychomotor Monitor vitals.Serenace 10-60 mg

Schizopherinia disturbance (either Largectil 50-300 mgs. ECT

Excitement or stupor) Inj Flaunxol.

Exhaustion can be fatal.

• Lithium Toxicity Vomiting,Abdominal pain Hospitalization

Profuse diarrhoea, Gastric Lavage

Severe tremors, Ataxia, coma, seizures, Confusion, Focal neurological signs.

Neurosis

Dr Hasan Mehmood Rajput

This is a group of affective disorders where anxiety is a predominant symptom. Anxiety is a common, normal, usually beneficial emotion. It becomes pathological when it starts affecting life pattern negatively. In more severe forms it simply cripples the daily life.

Anxiety as a disorder has two components.

1. Free-Floating anxiety generally known as Anxiety Disorder.

2. Phobic Anxiety.

Types of Anxiety Disorders.

Generalized anxiety disorder.

Mostly females are affected. Usual age 20-35 years.

Presenting features.

• Somatic complaints:These are usually long lastig and can persist for more than one month.These may include

• Tachycardia, Blood Pressure may be increased.

• GI symptoms,like,Nausea,Increased Acidity,Epigastric pain

• Neurological e.g headache,near syncope.parasthesias

• Frequency of micturation.

Phobic Disorders.

Usually short lived, recurrent, unpridictable episodes of anxiety accompanied by marked phsyiologic manifestations.

Common clinical features.

• Patients with recurrent attacks become demoralized depressed agoraphobic and hypochondriacal.

Panic Disorder.

Clinical Features.

Obsessive-Compulsive Disorder.

Irrational ideas or impulse persistently intrudes into awareness.

Obsessions are constantly recurring thoughts such as fear of catching bacteria.

Compulsions are repeated actions such as washing hands again and again.

Dissociative Disorders.

Amnesias, multiple personality, depersonizaion are all dissociative disorders

Steps for diagnosing an anxiety disorder.

Listen: to the patient’s description of the pattern of complaints.

Enquire: about other symptoms of anxiety. Look for clusters of symptoms.

Evaluate: patient’s appearance, behaviour, mood, affect, flow and contact of speech, thought contents and intellectual functions.

Examine: Do a physical examination to rule out organic problems. Order relevant investigations.

Inform patient about the possibility of anxiety disorder. Explore the patient’s attributions and beliefs.

Clarify: Search for evidence of an associated disorder presenting with anxiety such as depression, drug abuse or Alcohalism.

Treatment of Anxiety Disorders. Benzodiazepines and Buspirone are anxiolytics of choice in most of generalized anxiety. Diazepam 5-10 mgs 6-8 hourly is proper dose.

Beta-Blockers are helpful in controlling somatic symptomsPanic attacks

Sublingual dose of Lorezepam 0.5 mgs-2 mgs or Alprazolam 0.5mgs-1 mgs is enough. Antidepressants should be combined.

Stress and Cardiac Diseases.

Many patients of anxiety have somatic symptoms related to cardiovascular system. This does not carry much significance.

But there is evidence that if patient continues to live in stressful condition risk for myocardial ischaemia goes up. One of the explanations for this rise is as follows.

Metal stress activates platelets and in the presence of increased levels of catecholamines the platelets are more likely to stick together so increased risk of IHD.There is evidence of moderate rise of catecholamines in un complicated infarctions. In complicated infarctions marked rise in catecholamines happens. Benzodiazepines suppress the rise of catecholamines. So having a protective benefit in the background of recent AMI.Benzodiazepines also inhibit the platelet aggregates by an inhibitory affect on platelet activating factors.

Section by Dr.Arshad Javaid Sheikh

MBBS, DTC (WHO), M.A.C.P (USA)

Fellow Toranoman Institute of Diagnostic Ultrasound (Pak)

Nomania Road, Gujranwala, Tel 221035.

Mood Disorders.

Episodes of clinicaly disturbed mood can be broadly divided into

• Manic Episode

• Depressive Disorders.

Manic Episode.

It is almost the opposite of depression.

Clinical Features.

• Mood is often euphoric or elated. Sometimes it can be irritable, hostile and aggressive.

• The patient’s energy levels are raised and many patients feel that they do not need to sleep. Sleep is reduced and patient wakes up early.

• Appetite is increased.

• Sexual desires are heightened.

• Speech is rapid and patient changes topics rapidly.

• Patients may have grandiose ideas. They may believe that they are prophets or destined to lead the nation.

• Insight into almost all matters is impaired.

Etiology.

Gentic factors play a predominant role although environmental factors are also important.

Treatment.

Mainly drugs. Appropriate psychological management also helps.

Serenace: This is drug of choice. Dose can vary from 5 to 30 mgs daily. Treatment has to be continued for weeks and moths. In the meantime opinion of Psychiatrist should be obtained.

Lithium Carbonate (Neurolith, Camcolit)

This is used in prophylaxis of mania and in acute mania. Dose varies from 800 mgs to 1200 mgs/day.

Carbamazepine.This is used mainly for prophylaxis of mania and depression and for those patients who do not respond to lithium. Dose 400-1200 mgs/day

Depression.

It is helpful to grade the severity.

Mild Depression

Moderate Depression: The other two can be discussed as variant of this pattern.

Severe Depression.

Clinical Features of Moderate Depression.

Appearance of a typical patient

A sad person enters in your clinic. There is sad and at the same time anxious look on the face. There are vertical furrows on the brow and angles of mouth are downturned. Posture is stooped. He or she walks slowly as if unwilling to take any future steps in the life. Talks in slow monotonous voice.

Typical complaints.

He may describe any one of the above mentioned features. His family may be accompanying him. They may volunteer that patient is not taking interest in any thing or in any person. He is withdrawn from the people. Usual day to day jobs become a great burden for him. Mood is slow but easily irritable. Enquiries may bring out thoughts about suicide. These enquires must be made in all patients. Concentration is poor. He may complain about the loss of memory. But it is not true loss. True loss of memory must lead physician to look for organic brain disorder.

Severe Depression

All features of moderate depression are present with great intensity. There may be following additional features.

Delusions

Hallucinations.

Content of these is usually about guilt, worthlessness, ill health and poverty. These are very grave findings. Suicidal risk is at greatest when these additional features appear. Best possible care must be provided.

Mild Depression.

These patients fall into two groups.

Patients in Goup one resemble moderate depression with less intenstiy.

Group Two

Additional symptoms in this group are usually not present in moderate or severe depression. These are Phobias, Anxiety, and Obsessions.

Presence of these symptoms were sometimes taken as this is an entirely different group

Diagnostic Criteria in Family Practice.

Criteria A to D must be met.

Depressed mood and decreased interest or loss of pleasure must be present for more than 2 weeks, daily. At least 3 of the following must be accompanying these .
Significant loss or gain in weight
Insomnia or Hypersomnia
Agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt.
Poor concentration or in decisiveness.
No organic cause
No bereavement
No delusions or hallucinations in the absence of mood symptoms.
This symptomology must not be superimposed on Schizophrinia or other psychosis.

Aetiology of Depression.

Genetic Factors:

Statistical evidence pedigree studies support genetic factors as a cause.

Precipitating Factors.

Family background: Unhappy childhood, sexual abuse, and dysharmony of parents or loss of parents.

Physical Illness

Chronic physical ill health predisoses to depression. Brain injury is well linked to some cases of subsequent Schizophrinia and depressive illness.

Stressful Life Events.

A wide range of incidences.

Social Factors.

Many patients ar isolated. In other circustances people around the patient may be contributing to illnes. Social deprivation is associated with various conditions. Such as Attempted Suicide

Alcohalism

Drug Dependence.

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Differential Diagnosis

Depression and Anxiety.

Symptoms in Depression in Anxiety

Duration (most important) >two weeks. <Two weeks.

Suicidal Idea Present Absent

Anxiety not dominate Predominant

Wt Loss Present May be

Sad Mood Present Absent

Apathy Present Absent

Insomnia Early Late

Lack of interest Present Absent

Depression and Mania

Symptoms Depression Mania

Appearance Sad, dejected Looks well

Mood Sad Elevated

Activity Slow Overactive

Speech Slow Rapid

Libido Decreased Increased.

Appetite Decreased Increased.

Depression and Schizopherinia.

Symptoms Depression Schizopherinia

Orientation. Intact disrupted

Thought Disorder None Dominant symptom

Hallucinations Very rare only Dominant symptom

With mood changes without mood disorder

Delusions. As above as above

Aggression absent Frequent

Emotions Sad Flat.Neither happy not sad.

Cipram. (Citalopram).

From issue No. 251 (August, 1998) of Medical Sciences Bulletin

Cipram is a new addition in USA to the selective serotonin reuptake inhibitors (SSRI's), which may now be considered the preferred agents for the treatment of this depression. It has been used for many years in Europe. Marketed since 1989 in Europe, citalopram is the market leader among SSRI's in several countries and is used by approximately 8 million people worldwide.

A study compared the use of citalopram and fluoxetine in a psychiatric-based setting and in a general practice. However, in the general practice setting, citalopram showed a greater incidence of complete recovery after 2 weeks. (Advertisement)

Psychosis.

Dr Danish Malik

Schizophrenia

Introduction

Schizophrenia is a relatively common form of psychotic disorder (severe mental illness). Its lifetime prevalence is nearly 1%, its annual incidence is about 10-15 per 100 000, and the average general practitioner cares for 10-20 schizophrenic patients depending on the location and social surroundings of the practice.

Onset before the age of 30.

Aetiology

Genetic: Risk of having this condition is 35 % if both parents are affected.

12 % if only one parent is affected

2.5 % if second degree relative is affected.

Personality: There is strong evidence that association between Schizoid premorbid personality and Schizophrinia is present.

Environment: Lower social class is more prone. People born in winter are also more prone. Birth trauma may predispose to this condition.

Biochemical Abnormalities:

Disturbances in dopamine turnover or dopaminergic receptors distub serotonergic transmission.

Clinical features

Symptoms are characterised most usefully as positive or negative, although the traditional diagnostic subcategories (hebephrenic, paranoid, catatonic, and simple) have mixtures of both Positive symptoms and signs

Positive Symptoms.

• Third person auditory hallucinations

• Running commentary on person's actions

• Two or more voices discussing the person

• Voices speaking the person's thoughts

• Alien thoughts being inserted into or withdrawn from person's mind

• Person's thoughts being broadcast or read by others

• Person's actions being caused and controlled by some outside agency

• Bodily sensations being imposed by some outside agency

• Delusional perception (a delusion arising suddenly and fully formed in the wake of a normal perception)

• Hallucinations—These are false perceptions in any of the senses: a patient experiences a seemingly real voice or smell, for example, although nothing actually occurred

• Delusions—These are false beliefs held with absolute certainty, dominating the patient's mind, and untenable in terms of the sociocultural background.

Negative Symptoms.

.

Management.

Chronic Phase:

For poor compliance following depot preparations can be used.

Drug Duration Dose range.

Flupenthixol deconate 2-4 weeks. 20 –40 mgs.

(Flaunxol) usually for negative sympoms.

Clopenthixol deconate 2-4 weeks 200 –600 mgs

(Clopixol) Usaully for positive symptoms.

Psychological Treatment

Mania and other Psychosis

Management

• Acute aggresion as described above.

• Anitpsychotics.

• If patient presents in depressive phase then give antidepressents.

• For bipolar disorder:Mood stabilizers as follows

• Lithium carbonates upto 800 mgs/day in divided doses. Keep the levels between 0.5to 0.9 mgs/litre.

• Carbamazepine upto 800 mgs /day in divided doses.

• Sodium Valporate upto 1000 mgs /day.

Section by Mrs Tanveer Khalid

Personality Disorders.

.

• Term, personality, refers to the pattern of characteristics, way of thinking behaving and emotional reactions to a wide variety of circumstances.

• Personality development is a very complex process, which depends upon the interplay between the genetic endowment and environment.

• The personality characteristics, which are called “TRAITS”, give the uniqueness to the individual. These traits determine the behavior in normal circumstances but some of this present in an exaggerated form under stressful situation.

• Features of personality make certain people more vulnerable to develop neurotic illness.

• Personality disorders comprise of traits which are persistent.inflexible and maladaptive and cause social and occupational malfunctioning or subjective distress. These traits are recognizable in adolescence and persist throughout adult life.

• A diagnosis of personality disorder is made when abnormality is persistent throughout life and abnormal behaviour change is not recent. Physical disorders also have to be excluded.

Some common types of personality patterns are followings.

• Obsessional personality disorder

• Dependent // //

• Paranoid // //

• Passive // //

• Schizoid // //

• Narcissistic // //

• Anxious and avoident //

• Borderline // //

• Dyssocial or antisocial or psychopathic personality.

• Histronic personality disorder.

Dyssocial (Antisocial or psychpathic) Personality.

This group is most extensively studied. Its validity is better established than all other types. This is the most severe form of personality disorder. People with this disorder fail to make an effective adjustment with rest of the society due to their nonconforming behaviour to the norms of society.

Important features.

• Self centred,fail to make loving relationship,

• Impulsive, tend to overreact.

• Manifests early. During the time of secondary schooling.

• Deliquent behaviour, truancy, running away from School.

• Aggressive behaviour before the age of 15.Use of weapons in fights. Cruelty to animals and other people. No fear of consequences. Often break law.

• Forced sexual activity

• Persistent lying and stealing.

• All these lead to repeated arrests.

• Failure to plan ahead, inability to function as responsible parent.

Histrionic Personality

Importan features.

• Self dramatization

• Craving for novelty and excitement

• Self centred approach

• Overdemanding inspite of their own shallowness.

• Try to be centre of attention.

• Easily influenced by others.

• They are not fully developed and not fully equiped for adult relationships which is required for emotional adjustment. They develop neurotic reactions to painful complicated processes of adjustment.

Obsessional Personality Disorders.

These personalities vary in intensity from comarative normalicy to meticulous conscientiousness to inflexibly rigid and unrealistic perfectionism. These persons are preoccupied with schedules, rules and trivial details. They lack adaptability to new situations. Change upsets them. They prefer a safe routine they know. They show little emotion. So unexpressed thoughts of anger and resentment give rise to obsession thoughts and images of aggressive kind. These unrealistic attitudes result in obsessive compulsive illness.

Dependent Personality Disorder.

• Presence of dependence and submisse behaviour

• Exessive need for excessive advice transfer of responsibility to others.

• They are inable to take initiative and find difficult to function independently. They always have to rely on others.

Paranod Personality Disorder.

The central features of this kind of abnormal personality are suspiciousness and sensitivity to criticism and lack of trust on others, as a result he appears touchy and does not make friendships easily and may avoid involvment in-groups. These persons have a tendency to morbid jealousy and a trend to find conspiracy behind innocent events. They appear argumentative and stubborn and tend to percieve threats where non-exists. They have ideas, which can be easily taken as persecuting delusions.

Schizoid Personality disorders.

Important features.

• Lack of emotions. Socially detached.Withdrawn.Aloof.

• Cold, Callous, Vague, Indecisive.

• Incapable of expressing their emotions, anger or tenderness.

• Live in fantasy world i.e their own shell.

Borderline Personality Disorder.

People with this disorder are described as showing inability in a variety of areas, including interpersonal behaviours, mood and self image.

Followings are diagnostic criteria.

• Impulsive behaviour, damaging to the person.

• A pattern of unstable and intensive interpersonal relationships alternating between over idealization and devaluation.

• Variable mood with depression, irritabiltiy and anxiety.

• In appropriate anger with inability to control it.

• Recurrent suicidal threats and behaviour.

• Doubts about personal identity.

• Chronic feelings of emptiness and boredom.

Management.

• It is said that men can not change their nature. All that can be changed is their situations. Management mainly concerns with helping the person to develop a life style that conflicts less with this nature and tends to avoid adding to his problems.

• A thorough assessment is the first step. Information from a reliable informant is essential before diagnosis. Label should not be applied. Rather different characteristics should be defined.

• Treatment is aimed at building favourable features and modifying the unfavourable ones.it includes councilling, dynamic psychotherapy and cognitive therapy. Councilling helps those who lack confidence and find difficulty in making relationships. Motivation of patient is very important. Treatment by psychodnamic therapy emphasizes on analysis of currrent behaviour and should be carried out individually.

• Assertive trainging is helpful in passive aggressive disorders and social skills training are likely to be of value in avoident behaviour.

• Inability to deal with anger is major problem. Behavioural approaches for the treatment of anger have been developed.

• Psychopaths need confrontation frequently. Group therapy has beneficial effects in some cases. Admission to a community can help. Institutional care is required for dangerous and aggressive type of psychopaths. Medicines are required for associated psychiatric disorders.

Psychiatric Disorders in Elderly.

Dementia.

There is generalized impairment of intellect, memory and personality, with no impairment of consciousness.

Clinical Features.

Impaired memory, more obvious for recent events then the remote ones.

Slow thinking and impaired cognitive faculties.

Disordered, inappropriate, distractable and restless behavior.

Change in personality. Mood Disorders.Hallucinations.Delusions.

Dementia can be grouped as follows.

Dementia of Alzheimer type: Commonest type. Progress is gradual for first 2-4 years. Disorientation changes in behavior and intellectual impairment are key factors.

Vascular Dementia: This includes multiple infarcts in brain due to vascular occlusions, Binswangers disease and lacunar state.

Dementia due to other causes: Wide range of cuases. Lewy body disease, Parkinsonism, neoplasias, infections, toxins, alcohal abuse and metabolic disorders.

Treatment.

No specific treatment. Low doses of serenace, benzodiazepines or thioridazine to reduce agitation, anxiety and depression.If patient is deluded, hallucinated or overactive then phenothiazine may be appropriate. Optimal dose has to be titrated.

If symptoms of depression are there then antidepressants can be tried.

Behavioral training can be used to cope with memory deficits.

Mood Disorders in elderly.

Depressive disorders increase with age. Suicidal rate also goes up with age. Symptoms of severe retardation, agitation, delusions, hallucinations are more common. Hypochondriacal complaints become more common. Antidepressants are effective. Half of normal dose should be starting point. It should be continued for several months. ECT is appropriate for severe and distressing agitation, suicidal ideation or stupor.

Delirium.

Prexisting dementia, defective hearing or vision, Parkinson’s disease and advanced age predispose to delirium. Confusion, poor concentration, impairment of consciousness awareness of environment may be present. Behavior may be variable at different times. Overactivity, irritability and inactivity may be rotate. Visual perception may be distorted.

Treatment: Use minimum drugs. Goal of keeping the patient calm during day may be served with serenace. Start with low dose.2-5 mgs i/m can be first dose. Effective dose is between 3-20 mgs. Short acting benzodiazepines may be used to induce sleep during night.

Mania

It accounts for 5-10 % of affective disorders of old ages. Clinical features are same as in young. Depressive episode usually occurs immediately after the manic episode in old age. Same drugs as in younger age are useful. Dose should be reduced.

Schizophrinia and paranoid states.

Persecutory delusions are prominent feature. Auditory, Tactile and olfactory hallucinations may be there. Antipsychotic drugs are quite effective. Hospital admission may be needed to reach at effective dose and to watch for side effects. Rehabilitation with behavioural techniques for social skills is important.

Internet Section.

A patient who changed my practice

The Internet and a "small miracle"

Di Jelley, general practitioner, North Shields.

Friend of my daughtrer, Miss A 6 years old,will not speak in School. I have known A since she was a baby, watching her and two younger siblings pass through the baby clinic and reach normal development milestones. A was always a quiet child in company, but I was surprised to hear my daughter, in A's class at nursery, remark one day, "You know Mummy, A never speaks at school." There was no hint of developmental delay, and at home A interacted quite normally with her family. The transition to primary school saw a persistence of A's determined silence,no verbal interaction at all with her class mates or her teachers, although her basic literacy and numeracy skills developed in line with those of her peers. By the beginning of her second year at school A had still not uttered a single word at school. She also refused to remove her shoes and socks for physical education in front of others and would eat nothing all day, neither school dinners nor a packed lunch. A's parents asked for a specialist review, wondering if any form of therapy would lead to more normal childhood interaction. No specific help resulted from this psychiatric assessment, but at least A now had a label "selective mutism," and in today's world a label by itself can begin to unlock doors.

I have to say my heart sank a little at the sight of sheets of internet printouts in A's mother's hand when she came in to see me a couple of weeks after the psychiatric clinic appointment.A series of case reports and parents' stories of children seemingly similar to A who had responded dramatically to short courses of fluoxetine.

This drug is not licensed for children in the United Kingdom, but our local drug information pharmacist was able to locate a small trial describing its use in children with selective mutism.A's parents and I talked about the concerns relating to the use of unlicensed medication, and I thought that I had to share my reservations explicitly.

Within two weeks of starting the drug, A was recording taped messages for her teacher and beginning to participate in physical education. After six weeks she is chattering happily with her friends at school and has been to her first party alone. She has been transformed into a totally "normal" 6year old, and her parents are slowly withdrawing the fluoxetine.I am convinced that the use of fluoxetine has played a central part in this huge change in A's behaviour, and I am equally sure that without the Internet her parents could not have accessed this information.

Cognitive behaviour therapy

Simon J Enright, consultant clinical

Psychologist Department of Clinical Psychology, Fair Mile Hospital,

Wallingford OX10 9HH

Cognitive behaviour theory

The link between psychological problems and faulty patterns of thinking and behaviour is the target. Negative thinking in depression has its origins in attitudes and assumptions arising from experiences early in life. Such assumptions can be positive and motivating, but they can also be too extreme, held too rigidly, and be highly resistant to revision. Problems arise when critical incidents occur that contradicts a person's goals and beliefs. For example, the assumption "My worth is dependent on my success" might cause a person to be vulnerable to an event like failing to get a job at interview. Once activated by the critical incident, the core assumption leads to the production of spontaneous negative automatic thoughts such as "I am a worthless failure." Such thoughts lower mood and increase the likelihood of further negative automatic thoughts since research has shown that specific types of affect will automatically increase the accessibility of thoughts congruent with that mood.

Once a person is depressed a set of cognitive distortions known as the cognitive triad (negative view of oneself, current experience, and the future) exert a general influence over the person's day to day functioning, and negative automatic thoughts become increasingly pervasive. Other biases in information processing also act to consolidate the depression, whereby patients exaggerate and overgeneralise from minor problems and selectively attend to events that confirm their negative view of themselves.

Summary points

• Cognitive behaviour therapy ascribes a central role to conscious thought, beliefs, and behaviour in the perpetuation of disability

• The therapy is a brief, problem oriented approach that aims to help patients to identify and modify dysfunctional thoughts, assumptions, and patterns of behaviour

• It is now the treatment of choice for many mental health disorders and has extensive application to general medicine, supported by increasing numbers of clinical research studies

• Behavioural factors will also serve to exacerbate the depression. Sufferers' activity levels begin to reduce. Reduced exercise may also be associated with a lowering of mood.

• Cognitive behaviour theory does not claim that negative thinking and abnormal behaviour cause depression but rather that these factors exacerbate and maintain the emotional disturbance.

Cognitive behaviour therapy

The cognitive behaviour therapist and patient work together to identify specific patterns of thinking and behaviour that underpin the patient's difficulties. Treatment continues between sessions with homework assignments both to monitor and challenge specific thinking patterns and to implement behavioural change.

Depression

Treatment is based on a two pronged attack:

First, using cognitive techniques to alter maladaptive assumptions containing negative information about the self in relation to the world and the future; and,

Second, ameliorating reduced levels of behavioural activity, exercise, and positive experience. The dominance of negative thought patterns leads to a systematic negative bias in the perception and interpretation of information, which in turn underpins the motivational, behavioural, and physical symptoms of depression. Cognitive techniques train patients to identify, evaluate, and alter the faulty thinking that distorts reality.

Behavioural methods are complementary and activate patients to test out alternative assumptions in reality.

The efficacy of cognitive therapy in treating depression is well documented. Research has primarily been conducted with outpatients with unipolar, non-psychotic depression. A recent review of 15 studies concluded that cognitive behaviour therapy was at least as effective as medication in treating depressed outpatients, the combination of the two treatments was more effective than either one alone, and most of the studies found that cognitive behaviour therapy was equally applicable to more severe and more endogenous types of depression. In comparison with other psychological treatments for depression, cognitive behaviour therapy also fares well.

General practitioners should note the following factors when deciding on patients' suitability for cognitive behaviour therapy:

Patients should be requesting a practical method of treatment to resolve a specific problem rather than a more nebulous wish for "understanding myself better" or "wanting to be happy"

Patients must be willing to consider and gradually accept a psychological model that highlights the importance of patients' thoughts and behaviours in the aetiology of conditions

Patients must actively contribute to the process of therapy by completing assessment forms, keeping diaries, and performing homework tasks.

Drugs used in Psychiatry.

Dr Danish Malik

Generic Trade Dose/day Indications Side Effects.

Name Name Divided

Benzodiazepines.

Alprazolam Xanax Upto 8mgs Anxiety, Panic disorders Ataxia, Confusion.

Diazepam Valium 2-60 mgs Sedation/Anxiety Respiratory Arrest

Larazepam Ativan 1-6 mgs Anxiety/Insomnia Dizziness.

Nitrazepam Mogodon 5-10 mgs as above as above

Clonazepam Rivotril 2-8 mgs Panic, Epilepsy as above

Chlordiazepoxide Librium 150 mgs Anxiety/depression. Headache and as above

Clorazepate Tranxene 30 mgs as above Dizziness and sedation.

Temazipam Restoril 30-60 mgs Insomnia as above

Clobazepam Frisium 30 mgs Anxiety/Epilepsy Tiredness, Confusion,
headache, dry mouth

Antidepressants Tricyclics and related other drugs.

Clomipramine Anafranil upto 300 mg Depression, Panic Disorder Typical of this group

Obs-cump disorder,Phobia

Imipramine Tofranil as above Retarded depresion. Anticholinergic effects

Enuresis

Amitryptaline Tryptanol 30-200 mg Depression Sedation + typical

Prothiadine Prothiadin upto 300 mg Depression Constipation + Typical

Maprotaline Ludiomil 30-300 mg Depression Typical +Hypotension

Mianserene Lantanon upto 120 mg Depression as above

Trazodone Deprel upto 300 mg Depression Sedation, hypotension

Venlafaxene Effexor as above

SSRis

Flouxetine Prozac 20-80 mg Depression Restlessness, Irritability,

Headache, nausea, vomitig.

Fluxamine Faverin 50-300 mgs Depression GIT symptoms

Citalopram Cipram 20 mgs Depression G I T symptoms.

Sertaline Zoolaft 50-100 mg Depression too recent a drug.

Antpsychotics.

Chlor Largectil 75-1000mg Hypomania EPS, Dystonia, Hypo-

Promazine Schizophrinia tension, Confusion,

Haloperidol Serenace 5-30 mg Mania, Schizopherina, EPS, Restless

Organic Psychosis, In tics Irritability, Confusion

Flupenthxol Flaunxol 1-6 mg Negative symptoms EPS, Dyskinesia, Of Schizophrinia dry mouth, Tachcardia

As above Depo inj Depression also

Thoridazine Melleril 30-60mg Mania, Schizph, low dose Restlessness, confusion

In dementia hypotension,

Clozapine Clozaril 25-300 mg Resistent Schizph Salivation, Tachcardia

Sweating, Agranulocytosis

Fluphenazine Modecate 12-25 mg Ch Schzph EPS, Dystonia, Akathe-

Inj sia, Confusion, Tard Dys

Respirodone Resperal 2-8 mg Schizophrinia Irritability, weight gain

Zuclopenthixol Inj Clopixol 200-400mgs/2-4 weeks.for Schizophrinia. EPS.

Mood Stabilizers

Lithium Camcolit 100-800 mg Bipoalr disorder G I T symptoms, Pulse

Priadal Blurred vision, Tremors

Valporate Epival 15-60 mg Antiepileptic G I T symptoms, weight

Epilim Mood stabilizer Tremors.

Carbamezepine Tegretal 200-800 mg Mood stabilizer G I T symptoms, blood

Antiepileptic dyscrazias, Hepatitis

Tg Neuralgia Dermatitis.

Miscellaneous

Procyclidine Kemadrin 5-30 mg Drug induced EPS

Bromocriptine Parlodel 5-15 mg Drug induced EPS Nausea, headache

Alcohal withdrawl Dizziness, vomiting

Tardive Dyskinesia Abdominal cramps.

Condolence Message for Dr Bashir A Malik.From WONCA Australia

Dear Dr Rana

I was shocked to read of the murder of Dr Bashir Malik, President of the Pakistan Society of Family Physicians Lahore, which is an Associate Member of WONCA.

Dr Malik was a well-known and highly respected figure in medical circles in Pakistan and beyond. We in WONCA know of his great work in bringing family medicine to Pakistan, and his devotion to the Pakistan Society of Family Physicians Lahore.

WONCA's deepest sympathy goes to his family, his colleagues and the Pakistan Society.

Despite this terrible tragedy, his work will live on and his memory will be cherished always.

Professor Wes Fabb

Chief Executive Officer World Organization of Family Doctors - WONCA

Locked Bag 11, Collins Street East Post Office Melbourne Victoria 8003 Australia

Email: wonca@bigpond.com

WONCA Website: www.wonca.org

From Bangladesh

I am very much overwhelmed with sorrow to hear the sad demise of Dr.Bashir A Malik, President, Pakistan Society of Family Physician, Lahore, Pakistan. Peace is on his departed soul. I got E-mail from Prof.Wes Fabb about that. Let me know details of his Bio-data and a short history of his incidental death. I want to publish it in the Desk-File. I think we will ever remember him for his contribution in the movement of establishing Family Medicine in the country and in the Region as a whole.

Dr. M. Nurul Islam.RVP, WONCA -MESAR. Email: Liz @ bdlink.com, imc@bdcom.com