The African Textbook of Clinical Psychiatry and Mental Health (FINAL 1)

THE AFRICAN TEXTBOOK OF
CLINICAL PSYCHIATRY AND

MENTAL HEALTH
The African Textbook of Clinical Psychiatry and Mental Health
ii
THE AFRICAN TEXTBOOK OF

CLINICAL PSYCHIATRY AND
MENTAL HEALTH
Professor David Musyimi Ndetei
Assisted by
Prof. Christopher P. Szabo
Prof. Tarek Okasha
Dr. John Mburu
Together with
Dr. Benson Gakinya, Prof. Gad Kilonzo, Prof. Duncan Ngare, Dr. Anne Obondo, Dr. Francisca
Ongecha-Owuor, Prof. Ruthie Rono, Prof. Mohamedi Boy Sebit, Dr. Musisi Seggane
THE AFRICAN MEDICAL AND RESEARCH FOUNDATION

Nairobi, 2006
iii
The African Medical and Research Foundation (AMREF)

P. O. Box 27691 00506, Nairobi, Kenya
Tel: +254 20 6993000
Fax: +254 20 609518
Website: www.amref.org
2006 The African Medical and Research Foundation

All rights reserved.
AMREF would like to acknowledge the generous contribution of Vronestein, Netherlands towards the
production of this publication
ISBN-10: 9966-874-71-2
ISBN-13: 978-9966-874-71-9
The publishers will consider any request for permission to reproduce sections of this publication with the
intention of increasing its availability for study purposes. AMREF would be grateful to learn how you are
using this book, and welcomes constructive comments and suggestions. Please address any correspondence
to:
Publications Editor
Directorate of Learning Systems
AMREF Headquarters
PO Box 27691 00506, Nairobi, Kenya
Email: amrefhlm@amrefhq.org
Illustrations and cover design by Elijah Njoroge

Layout and book design by Joy Muthoni Mita
Printed by:
iv
DEDICATION
This book is dedicated to those individuals and their families who toil with mental health related issues but have
no voice and suer silently, without hope. Indeed, there is hope for them.
It is my expectation that the students and professionals who read through these pages will be inspired to become
vehicles and instruments of change in clinical practice and policy, and in the process bring hope to these
people.
The book is also dedicated to my mother, Kalekye and my family.
David Musyimi Ndetei
In memory of my late father, John Ndetei Nzuki
vi
It is my dream that all citizens of this continent will have access to qualied and trained personnel, and
appropriate management that is aordable, eective, and without discrimination or stigmatisation.
The Walk towards the Promise
Inaugural lecture by David Musyimi Ndetei,
Professor of Psychiatry, University of Nairobi,
Kenya, 13th September 2001
vii
Table of Contents
Foreword ................................................................................................................................................xi
Preface ....................................................................................................................................................xiii
Acknowledgements ...............................................................................................................................xv
Section I: Psychiatry and Mental Health in Context

1.
2.
3.
4.
5.
6.
7.
Introduction to Mental Health and Clinical Psychiatry ...............................................................3

History of Psychiatry ..................................................................................................................6
Psychiatric and Mental Health Training .......................................................................................11
The Burden of Mental Illness........................................................................................................14
The Economic Burden of Mental Disorders in Africa ..................................................................18
Stigma and Mental Disorders2 ......................................................................................................20
Mental Health: From the Perspective of a Paediatrician and Surgeon .........................................24
Section II Part A: Clinical Psychology

8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Human Development and Life Cycle............................................................................................31

Personality and Personality Traits .................................................................................................48
Human Learning ...........................................................................................................................55
Human Motivation and Emotions .................................................................................................59
Memory and Forgetting.................................................................................................................62
Communication and Communication Skills .................................................................................66
Psychological Testing....................................................................................................................69
Stress and Stress Management ......................................................................................................73
Crisis and Crisis Management ......................................................................................................80
Critical Incident Stress Debrieng (Psychological Debrieng) ....................................................85
Section II Part B: Medical Sociology and Anthropology

18.
19.
20.
21.
22.
23.
Introduction to Medical Sociology and the Family .....................................................................91

Health and Illness Behaviours.......................................................................................................96
Culture, Health and Illness ............................................................................................................101
Culture and Mental Health ............................................................................................................107
Mental Health, Spirituality and Religion ......................................................................................115
Culture, Spirituality and Management ..........................................................................................119
Section III: Behavioural Neurosciences

24.
25.
26.
27.
28.
Neuroanatomy and Psychiatry ......................................................................................................125

Psycho-neurochemistry .................................................................................................................134
Psychoendocrinology ....................................................................................................................142
Psycho-neurological Investigations ..............................................................................................144
Genetics of Mental Disorders .......................................................................................................147
viii
Section IV: Clinical Adult Psychiatry

29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
Aetiology in Psychiatry .................................................................................................................153

Psychopathology ...........................................................................................................................156
Psychiatric Interview, Assessment and Classication ...................................................................162
Somatoform and Dissociative Disorders.......................................................................................174
Mood Disorders.............................................................................................................................190
Anxiety and Adjustment Disorders ...............................................................................................214
Alcohol and other Substance Related Disorders ...........................................................................228
Sexual Disorders, Paraphilias and Gender Issues .........................................................................254
Personality Disorders ....................................................................................................................277
Schizophrenia and other Psychotic Disorders ...............................................................................287
Suicide and Suicidal Behaviour ....................................................................................................304
Liaison Psychiatry .........................................................................................................................311
HIV/AIDS and Mental Health ......................................................................................................320
Organic Psychiatry ........................................................................................................................329
Epilepsy .........................................................................................................................................348
Old Age and Mental Health ..........................................................................................................360
Forensic Psychiatry .......................................................................................................................367
Psychiatric Emergencies ...............................................................................................................381
Sleep Disorders .............................................................................................................................389
Section V: Child and Adolescence Psychiatry

48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
Child Psychiatry: An Overview ...................................................................................................404

Adolescent Psychiatry: An Overview ..........................................................................................410
Mental Retardation ........................................................................................................................413
Pervasive Developmental Disorders .............................................................................................417
Disruptive Behaviour Disorders....................................................................................................423
Anxiety Disorders of Childhood and Adolescence .......................................................................431
Mood Disorders in Children and Adolescents ..............................................................................437
Psychotic Disorders in Childhood and Adolescence.....................................................................441
Tic Disorders .................................................................................................................................446
Sexual and other Types of Child Abuse ........................................................................................450
Eating Disorders ............................................................................................................................454
Other Disorders and Presentations ................................................................................................460
Section VI Part A: Physical Treatments

60.
61.
62.
Ethno-Psychopharmacology and its Implications in the African Context ....................................470

Psychopharmacotherapy ...............................................................................................................478
Electroconvulsive Therapy (ECT) ................................................................................................489
Section VI Part B: Non-Biological Treatments

63.
64.
65.
66.
Psychotherapy ...............................................................................................................................495
Cognitive Behaviour Therapy (CBT)............................................................................................504
Counselling ...................................................................................................................................507
Group, Marital and Family Therapies ...........................................................................................510
ix
67.
68.
Loss and Bereavement Therapies..................................................................................................516

Occupational Therapy, Rehabilitation, Community Psychiatry and Social Support Networks ....522
Section VI Part C: Emerging Trends

69.
70.
Complementary and Alternative Medicine in Psychiatry .............................................................531

Nursing in Mental Health ..............................................................................................................535
Section VII: Research and Ethics

71.
72.
73.
Research and Bio Statistics in Mental Health ...............................................................................549

Ethics in Psychiatric Research ......................................................................................................559
Ethics in the Practice of Psychiatry and Mental Health ................................................................567
Section VIII: Postscript

74.
The Practice of Psychiatry in Africa - A Personal Experience ......................................................577
Appendices
Appendix 1: WMA Declaration of Helinski 2000 .................................................................................582
Appendix 2: International Ethical Guidelines for Biomedical Research ...............................................586
List of Contributors .................................................................................................................................591
Index .......................................................................................................................................................595
Foreword
When Professor David Ndetei invited me to write a foreword for the book The African Textbook of Psychiatry
and Mental Health, I accepted to do so with much pleasurewithout even seeing the manuscriptfor several
partly independent reasons.
First, of all continents, Africa is undoubtedly most in need of qualied people who can competently deal
with mental health problems problems that are becoming even more frequent than before and have even
more serious consequences than they had in the past. There are many reasons for this epidemic of mental ill
health, including extreme poverty, the growing prevalence of infections and other diseases aecting the brain,
still decient perinatal care leading to injuries of the newborn, and nutritional deciencies that are reducing
the capacity to withstand physical or mental disorders. The situation is made worse by the reduction and even
disappearance of the traditional social structures that have helped people in need, particularly in urban areas.
Unfortunately, however, it seems that the same ominous trend is also be ing extended to the rural areas where,
already today, the traditional social networks are no longer as strong as they had been and can no longer buer
the multitude of problems that face people in Africa. There is thus an urgent need to bring together knowledge
that will be useful in dealing with mental disorders, in training health care workers and in activities that might
promote mental health and help to prevent mental illness.
Second, the knowledge needed must be assembled and presented by experts who are steeped in the cultures
in which it will be used. Recent years have seen the development of a multitude of psychiatric textbooks and
mental health care manuals: most of them have however been written by psychiatrists living in developed
countries with little or no experience or information about the situation in the developing countries. These texts
are useful as a source of facts that, however, need to be embedded in the doctrine of care developed for other
settings. The decision by a group of experts in Africa to jointly produce a textbook of psychiatry in Africa is
therefore an important step towards an agreement on ways of providing mental health care in Africa. It is my
fervent hope that the work of this group and the work of others in the area of education and other domains will
mark the beginning of the renaissance of African psychiatry that had been in the eyes of the world when Lambo,
Assuni, Tigani el Mahi, Raman, German, Smith and others in the early 1960s made through their achievements
and spirit. They made everybody feel that psychiatry in Africa might become the model for psychiatry in the
developing and in the industrialised world.
Third, the stigma of mental illness does not only aect the person who suers from it: it spreads to the family of
the patient and to all that has to do with mental illness. It marks mental health institutions and services many
of which are in a poor state because the resources for their improvement are lacking and for other reasons
and it has marked the discipline of psychiatry. It is therefore important to produce materials that will present
the huge advances of mental health knowledge to the medical students and to other health professionals and
convince them of the fact that mental health care can be based on solid evidence and therefore requires just as
much attention and resources as do services provided by other disciplines and services.
Fourth, we live in a period of intensied brain drain with an exodus of trained personnel. This is particularly
painful and harmful because it involves a high proportion of qualied sta in the less developed countries. Brain
drain is not a novelty in the eld of medicine: there were always young doctors who left their country to gain
additional experience and knowledge, to see the world or to make more money. What is new, however, is that
at present governments in several countries in the industrialised world actively recruit people from developing
countries and oer them very attractive conditions. What is also new is that the recruitment of experts from the
developing countries has become easier because the conditions in their home countries have worsened. What
is also new is that those who left for training or short-term employment are less likely to come back than was
the case before. I believe that the ight of academic sta to richer countries has, at least in part, to do with the
diculties of doing research, providing service and training thus making it very dicult to be proud of ones
department or programme. To change this situation and improve the working atmosphere the departments of
psychiatry in the developing countries will have to make an enormous eort: the production of locally written
xi
textbooks and the reform of teaching that can go hand in hand with the production of training materials is part
of this striving and will help to augment the prestige of the departments and make those who are working in
them feel proud and motivated to do even more.
For these reasons and because I believe that psychiatrists in Africa can make a major contribution, not only
to improve mental health care in their continent, but also to develop psychiatry worldwide, I welcome this
book and hope that others will follow thus helping to make psychiatry in Africa a winning proposition for all
concerned for the mental health professionals, for the society and, last but certainly not least, for people with
mental disorders, their families and those who are close to them.
Norman Sartorius, M.D., Ph.D.

Professor of Psychiatry, University of Geneva, Switzerland and former Director of the Division of Mental Health of
the World Health Organisation
xii
Preface
The concept for this book was rst mooted by the editor in the early 1990s. Various academic psychiatrists,
nurses, psychologists, rehabilitation specialists and psychiatric social workers embraced the idea, and started
writing enthusiastically, only to be confronted by insurmountable logistical, technical and geo-political barriers.
In many ways the manuscript was completed but remained on the shelf, only to be overtaken by events, such as
new concepts and practices and curriculums, thus requiring a fresh start.
The Department of Psychiatry, University of Nairobi, Kenya, in consultation with the WHO Mental Health
Division Geneva, embarked on the process of revising its undergraduate curriculum in the mid 1990s. This
revised curriculum put emphasis on the holistic concept of mental health, and therefore increased recognition
of the critical place of behavioural sciences. The approach recognised that mental health was bigger than clinical
psychiatry and that clinical psychiatry could not be complete unless practised in the bigger context of mental
health. Other medical schools in the region were moving in the same direction a multi-disciplinary approach.
The need for teaching materials thus increasingly became a priority.
No doubt one of the greatest curse of medical and related human resource in developing countries is brain
drain (Ndetei et al 2004, International Psychiatry 6: 15-18). The meagre resources in these countries are used
to train for the rich western countries. Further, even if we were not loaded with this burden, the gap between
demand for Appropriate, Aordable, Available and Accessible (the 4As) mental health and psychiatric services
continues to widen in developing countries due to social, economic, political and stigma reasons. Even within
a given country, the gap highly varies between urban and rural areas, so that number of personnel per countrys
population can be totally misleading. Many countries in Africa have less than one psychiatrist for every 2
million people.
There is, therefore, need to allocate more resources, energy and eort to the training of non-specialist personnel
who will be deployed at the levels where services are most needed. In this regard, eorts and resources should
focus on equipping medical students with adequate skills in mental health and psychiatry that will enable them
to function eectively at primary health care level. The students are equipped with similar skills to function this
way in relation to physical medical problems. Thus, there is no reason why they cannot be similarly equipped in
managing mental health and psychiatric problems.
Even where fully trained psychiatrists are available they cannot work in isolation and will need the inputs of
psychologists, psychiatric social workers, psychiatric nurses, occupational therapists and even the clergy, who
should have a working knowledge on mental health issues and management. They all complement each other
on strengths and limitations, to minimise the latter and enhance the former. To the extent possible, they should
share some common scripts and the more of this the better for the consumers of the services i.e. people with
mental health problems, their families and other support systems. It is hoped that this book will provide the
forum that addresses all the above challenges and required linkages.
The target groups for this book include medical students, psychology students, nurses, clinical ocers,
occupational psychiatric therapists, clergy, and any other related professionals. The book will also be useful for
the general practitioner and other health care professionals who interact with patients. Although the primary
focus is undergraduates, graduate and post-graduate students, other professionals will nd sections relevant to
their needs. Students or other specialists will nd sections of this book very handy, especially the chapters that
cover an integrative approach in medicine.
The title of this book captures a series of statements: the Pan-African collective eort in authorship and editorship
by active and current academicians on the Continent; a philosophy on the approach, minimum standards on
teaching, practice and delivery of psychiatry and mental health; and the interdependence of all the stakeholders
in the African context. It is also a statement that while Africa recognizes specialists, their role has limitations
that make them relatively unavailable at the level of service delivery. But, also, there are viable alternatives. It is a
statement that psychiatry and mental health has a place and a future in Africa. This book is part of that future.
xiii
This book is not about psychiatry that is uniquely African only found in Africa. But it is about psychiatry
and mental health in Africa. I would like to agree with Africas pioneering psychiatrist, the late Prof. Lambo
that all people are mentally the same. What dierentiates them is culture. Paraphrased, there are no unique
African psychiatric disorders, but socio-cultural and economic factors may inuence the way the same disorders
present, help is sought, and services are availed. It is also a contribution to the practice of psychiatry in a wider
global perspective, for Africa is part and parcel of the global community and what happens here can no longer
be viewed as of peripheral signicance.
The writing of this book was a collective eort of various scholars. This eort has been facilitated by several
factors, some of them almost incidental. Over the years medical schools invited me either as an external
examiner, visiting professor or as a speaker, or I called on them if I happened to be in town for other reasons.
This exposure helped me to see both individual strengths and weaknesses, of all Departments I visited out of
which I focused only on the collective strengths. Then the sta were quick to agree with me on the principle of
collective strength and to suggest other areas I had not quite seen. Together we had a collective vision and dream
on how to realise them. In this book, we are pooling together our strengths in expertise and then re-distributing
them equitably.
One of my most inuential mentors, Professor Norman Sartorius was at his best, once again, mentoring me
through this process. Students, patients, their relatives, and their support systems have also been a source of
very unique mentoring. I have been most impressed by the way the students whether medical, psychology or
other related disciplines, have greatly appreciated and embraced the concepts of this book even before they were
put together in this form. The patients, their families and support systems have, by far, been my best practicaloriented, non-theoretical teachers. They taught me, not by word of mouth, (although some did), but through
experience on what they needed, what worked, what produced desired changes and not just what I thought.
That patients with mental illnesses are indispensable partners in their health care team. This is best illustrated
by a patient who wrote a section in this book (From the other side of the doctors desk). It is also graphically
illustrated by the story of Suzanne Johnston (British Medical Journal 2006, Vol. 332 pp.30-32) who even
allowed use of her photograph. These two stories, told from dierent contexts are strikingly similar in content.
In this book I want to make a statement that I totally agree with what they taught me and which my colleagues
and I give back to them. This we do through our students in psychiatry and mental health.
The two most important and basic considerations on the nal product and design of this edition were reasonable
adequacy of the contents and the minimum possible and reasonable cost to the student so that the book met all
the 4As described above. The contents were made possible by the contributors and the cost by grants from Africa
Mental Health Foundation, a grant to the publisher (AMREF), the ex-gratia permission from the American
Psychiatric Association to reproduce from DSM-IV-TR, the time and expertise donated by all contributors and
a modest design of the book.
I appreciate all the invaluable support, mentoring and teaching by all concerned persons and the contributors.
I attribute all that is good in and about this book to them.
However I take full responsibility for any shortcomings. With so many contributors, all from dierent backgrounds
and writing styles, it was not a realistic task to eliminate all repetitions and to completely synchronize the styles,
or even notice all important omissions. I desperately need to have all these pointed out to me, by both students,
teachers and where possible patients, their families and any support systems. These should be sent to me through
my email or physical address. Any suggestions on improvements are also most welcome. All of these will be taken
into account as we prepare for the next edition, in the not too distant future. The reader is politely reminded
that this edition is just but a beginning, with all the attendant teething problems of any new venture.
Prof. David M. Ndetei

P.O. Box 48423 00100, Nairobi, Kenya
E-mail: dmndetei@uonbi.ac.ke or dmndetei@mentalhealthafrica.com
Website: http://www.africamentalhealthfoundation.org
xiv
Acknowledgements
Very many people were involved in and facilitated the process of the production of this publication. The
University of Nairobi, Department of Psychiatrys undergraduate curriculum formed the seed for the contents
of this book, upon which many individuals provided useful additions and critique. Prof. Norman Sartorius gave
useful guides, the Editor of the South African Psychiatry Review, Prof. Christopher P. Szabo provided space for
a write-up on the concept of the book and the African Mental Health Foundation, through a grant, supported
all the logistics and compilation of the initial material.
I would also like to acknowledge the African Medical and Research Foundation (AMREF) who supported
the nal review process, by bringing together a small group of psychiatrists, psychologists and sociologists
who compiled a second draft of the manuscript. They met in Nairobi from 16th to 19th January 2006. The
group comprised the following: Prof. Ruthie Rono, Prof. Duncan Ngare, Dr. Anne Obondo, Dr. John Mburu,
Dr. Francisca Ongecha-Owuor, Dr. Benson Gakinya, Prof. Christopher Szabo, Prof. Gad Kilonzo, Dr. Musisi
Seggane and Prof. Mohamedi Boy Sebit.
Many other people provided inputs on the contents of the publication. These include amongst others, Prof.
Ahmed Okasha, past President of World Psychiatric Association, Prof. Mario Maj, President elect World
Psychiatric Association, Prof. Rachel Jenkins, Prof. Tuviah Zabow, Prof. Oye Gureje and Nhlanhla Mkhize.
I am also grateful to the American Psychiatric Association for granting us the permission to reprint materials
from DSM-IV TR.
I am especially grateful to the following postgraduate students from the Department of Psychiatry, University
of Nairobi, for very useful inputs:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Dr. Lukoye Atwoli, MBchB, Registrar in Psychiatry

Dr Joseph Thuo N. MBchB, Registrar in Psychiatry
Gideon Odhiambo B.A (Social work), Student in MSc in Clinical Psychology
Mr. Chrispinus Marumbu (BSc. Nursing), Student in MSc in Clinical Psychology
Elizabeth Mbatha B.A (Sociology) Student in MSc. in Clinical Psychology
Dr. Ian Kanyanya M. MBchB, Registrar in Psychiatry
Dr. Irungu Muthukia, MBchB, Registrar in Psychiatry
Dr. Mburu Mbugua J. MBchB, Registrar in Psychiatry
Dr. Moses R. Mwenda MBchB, Registrar in Psychiatry
Dr. W.D.C. Kinyanjui MBchB, Registrar in Psychiatry
Dr. Lillian Bunyasia-Asuga MBchB, Registrar in Psychiatry.
I am also grateful to the following from Africa Mental Health Foundation (AMHF): Norah Mutheu, Dinah
Nduleve, Christine Wayua, Solomon Stallone Akanga, and Ruth Wangu Walioli.
Serah Wadom Mwanyiky helped in editing the initial draft.
Finally, I would like to acknowledge the contribution of Grace Ndunge Mutevu, my personal assistant who coordinated most of the activities during compilation of the book.
My family was most supportive during the long hours taken up by this book.
xv
xvi
Section I:
Psychiatry and Mental

Health in Context
1
Introduction to Mental Health and
Clinical Psychiatry
David M. Ndetei, Ruthie Rono, Fred Kigozi
The dictionary denes mental as of the mind.

The mind is in turn dened as the seat of
consciousness, thought and feeling. Mental health
therefore would mean a state of well being of the
mind.
MENTAL HEALTH
According to the World Health Organisation

(WHO) mental health is dened as an essential and
integral part of health as a whole. Just as health
is not merely the absence of disease, so mental
health is not simply the absence of mental disorder
or illness, but also includes a positive state of
mental wellbeing. To many of us, mental health
is intricately associated with behaviour, discipline
and psychosocial wellbeing. Several factors affect
mental states of health. These factors include the
individual, family, friends and the community at
large.
Mental health is a priority area globally.
According to WHO:
450 million people worldwide are affected
by mental, neurological or behavioural
problems.
There are about 873,000 suicide cases every
year.
Mental illnesses cause immense suffering.
People with these disorders are often subjected
to social isolation, poor quality of life and

increased mortality. These disorders are the
cause of staggering economic and social
costs.
At least one in every four patients visiting a
health service has a mental, neurological or
behavioural disorder, but most of these are
neither diagnosed nor treated.
Mental illnesses affect and are affected by
chronic conditions such as cancer, heart
and cardiovascular diseases, diabetes and HIV/
AIDS. Untreated, they result in unhealthy
behaviour, non-compliance with prescribed
medical regimens and diminished immune
functioning. Cost-effective treatments exist
for most disorders and, if correctly applied,
could enable most of those affected to become
functioning members of society.
Barriers to effective treatment of mental illness
include lack of recognition of the seriousness
of mental illness and lack of understanding
about the benets of the services. Policy
makers, insurance companies, health and
labour policies, and the public discriminate
between physical and mental problems.
Most middle and low income countries devote
less than 1% of their health expenditure to
mental health. Consequently, mental health
policies, legislation, community care and
health facilities are not given the priority they
language, thoughts and emotions. Psychology

also seeks to understand how these processes
work. Branches of psychology include human
development,
social
psychology,
clinical
psychology, industrial psychology and counselling
psychology. Clinical psychology is closely related
to psychiatry in that clinical psychologists are
involved in the assessment of a wide range of
psychiatric problems, for example, phobias and
obsessive-compulsive disorders. They are also
involved in treatments, for example, cognitive
behavioural therapy and group therapy.
deserve. (Source: http//www.who.int/mentalhealth/en/ retrieved 16/1/06)
PSYCHIATRY
Psychiatry is an art as well as a medical science
concerned with mental processes of the individual,
the interaction between the doctor, the patients
and their relatives and workmates, in the process
of identifying the problem and carrying out
appropriate action. Psychiatrys generalised
approach stresses the unity of the body and mind.
The skill is acquired through observational data
and consequent development of principles based
on such data, thus making psychiatry the practice
of medicine and a scientic discipline.
Relationship with anthropology

Anthropology is derived from the Greek language
meaning the study of man. Anthropology aims
at holistic study of mankind including its origin,
development, social and political organisations,
religion, languages, art and artifacts. Branches
of anthropology include medical anthropology,
physical
anthropology
and
socio-cultural
anthropology. Physical anthropology is the study
of evolution of the human species and explanation
of the causes for the present diversity of human
populations. It includes studies of the arts,
musical instruments, weapons, clothes, tools and
agricultural implements of different populations
and all other aspects of technology which human
beings use to control shape, exploit and enhance
their social and natural environments.
Medical anthropology is a branch of anthropology
concerned with a wide range of biological
phenomena especially in connection with health
and diseases. Socio-cultural anthropology deals
with comparative study of present day human
societies and their cultural systems.
RELATIONSHIP BETWEEN
PSYCHIATRY AND
BEHAVIOURAL SCIENCES
There is a close relationship between psychiatry
and the social sciences professions in the provision
of holistic mental health services. Below is a
description of the relationship between psychiatry
and each of the disciplines involved in mental
health service provision.
Relationship with sociology

Sociology is the discipline which studies and
analyses human behaviour, the patterns of
interactions and relations in a social context.
Branches of sociology include rural sociology,
medical sociology, political sociology, sociology
of education, sociology of religion, sociology of
philosophy, law and society. All these branches
are important because they make important
contributions in sociological inquiry thereby
helping in the solution of sociological problems.
However, the focus here is on medical sociology
which is directly linked to psychiatry.
Medical sociology focuses on social interaction
between the patient and the doctor, and between
groups of people in hospitals or medical school
and among laymen in the community. It examines
the relationship between culture, personality traits,
values and norms.
ABOUT THE BOOK

This publication is multi-disciplinary in approach
and is written by a team of experts who are actively
involved in the teaching of behavioural sciences
and medicine.
Over the years it has become increasingly
evident that psychiatric illnesses form a major
part of the day-to-day problems. Many patients
are presenting with conditions which directly or
indirectly arise from stressful conditions. With
increasing demands on life, a highly competitive
lifestyle and a desire to succeed many people need
psychological help and counselling. It is therefore
Relationship with psychology

Psychology is the study of basic psychological
processes such as perception, learning, memory,
4
Introduction to Mental Health and Clinical Psychiatry in Africa
Section IV deals with the major aspects of clinical

psychiatry in adults. These include the various
causes of mental illness, signs and symptoms of
mental illness and how one should document and
classify mental disorders. The other chapters deal
with various types of disorders and behaviours,
such as suicide and suicidal behaviour.
Section V deals with child and adolescent
psychiatry.
Section VI covers the various treatments. The rst
part deals with biological and physical treatments,
while the second part describes the non-biological
or non-physical treatments. The third part covers
complementary and alternative medicine and the
nal section examines the area of nursing.
Section VII is on research and ethics. Mental
health has a great future in Africa, but this can only
be realised through evidence-based policies. Indeed
this applies to all medical problems in Africa. The
solutions must not only be evidenced-based but
must be economical and realistic. It is therefore
considered important that the future medical
professionals in Africa be exposed to principles of
research as early as possible.
Experience is the best teacher. Section VIII
contains a post-script from one of the longest
serving psychiatrists in Africa, Professor Allan
Haworth (University of Zambia). He has experience
spanning over 4 decades and was still active at
the time of writing this publication. It combines
his experiences from pre-independence to postindependence Zambia.
Although the primary targets for this book are
medical and paramedical students in mental health
and psychiatry, it will have an appeal to other
professionals and specialists.
imperative that health workers are equipped with

adequate knowledge and skills to be able to obtain
a psychiatric diagnosis. Therefore, mental health
needs to be emphasised as a key component in
the curriculum in order to improve the quality of
medical training in Africa.
This book has been divided into eight sections:
Section I takes a brief look at the development
of psychiatry and mental health. It also looks at the
various disciplines that constitute the mental health
discipline. The theme advanced is that mental
health is bigger than clinical psychiatry and clinical
psychiatry practised on its own is incomplete. The
economic burden of mental health and stigma in
the African context has also been discussed. This
section on stigma was reproduced with permission
from the World Psychiatry Association.
Section II is divided into three parts. The rst
one deals with clinical psychology. This section
also covers stress and its management. With the
increase of disasters, both man-made and natural,
crisis management has become a primary need at
primary health care level. The second part looks
at how social factors and structures, especially the
family, are critical to mental health and the practice
of clinical psychiatry. This chapter also explores the
relationship between health and illness behaviour.
The nal section is on medical anthropology and
looks at the relationship between culture and
health, illness, mental health and the increasingly
important area of spirituality.
Section III deals with behavioural neurosciences
that are relevant to mental disorders. It covers
anatomy, endocrinology and neurochemistry.
It also discusses the neurological investigation
relevant to psychiatry and the genetics of mental
disorders.
2
History of Psychiatry
David M. Ndetei, John Mburu
was classied into four temperaments sanguine, c

holeric, melancholic and phlegmatic.
Others prominent scholars such as Plato and
Aristotle contributed a lot in understanding mental
illness during their times. Plato (428-348 BC)
described the concepts of health, as harmony
between body and mind and disharmony between
the two was the cause of mental disorders. Plato
also alienated four types of mental illnesses,
prophetic, telestic or ritual, poetic, and erotic.
During the pre-literate cultures and Biblical times,

early medicine was intertwined with religion;
priests served as physicians and therefore illnesses
were perceived as mental and reecting a spiritual
disturbance. The mentally ill were regarded as
possessing supernatural powers and thought of as
sacred and in some situations, were treated with
respect.
THE CONTRIBUTION
OF HIPPOCRATES AND
CONTEMPORARIES
MIDDLE AGES
The early religions and middle ages were
characterised by the fall of the Roman Empire,
epidemics and decline of scientic thinking. The
study of the mentally ill reverted to religion and
superstition (demonology). Mental illnesses were
regarded as punishment for sin, hence torture was
prescribed to exorcise demons. In 1487 AD two
Dominican monks published a book, Malleus
Malecarum (The Witches Hammer), outlining
various methods of torture for witches and mental
patients. Abnormal thought processes like hearing
voices, and odd beliefs were attributed to the
devil.
It was the era of emergence of humanism in
which the burning of witches and mental patients
continued alongside a return to creative scientic
The Hippocratic School of Medicine approached

the study of medicine in a holistic way where
social, spiritual, physical and psychological factors
were held responsible for the cause of mental
disorders. The school proposed that the capacity
to feel, dream and think was located in the brain.
Medical concepts of mental disorders were well
documented by Hippocrates (460-370 BC) in
the 4th century where interaction of four body
humours namely; blood, black and yellow bile, and
phlegm were considered the aetiology of mental
disorders. According to the Hippocratic hypothesis
these humours were due to the combination of
four basic qualities of nature; namely heat, cold,
moisture and dryness. During this era personality
psychiatric literature. His earlier attempt in the

analysis of symptoms resulted in categories such
as melancholia, mania, dementia and idiocy.
Melancholia was a disturbance of intelligence,
mania was excessive nervous excitement without
delirium, and dementia was disturbances in the
thought process, while idiocy was obliteration of
intellectual faculties and affects. He taught through
his writing and character, thus the birth of academic
psychiatry.
Jean Etienne Dominique Esquirol, Pinels most
distinguished pupil, was appointed to Salpetriere
in 1812. He instituted lectures in psychiatry and
attracted students from beyond France. He also
set up ten psychiatric hospitals and wrote a lot on
psychopathology.
Vincenzo Chiarugi worked at the Hospital
Bondicis in Italy and advocated, It is a supreme
moral duty and medical obligation to respect the
insane individual as a person. No physical force
or restraints were applied save for strait jackets for
violent patients.
William Tuke and Lindley Murray opened the
York Retreat in England in 1796, where patients were
treated as guests with kindness and understanding.
They encouraged a friendly atmosphere, free from
mechanical and medical restraints or manual work.
Four years earlier Dr. Andrew Duncan in 1792, then
Professor of Medicine at Edinburgh University
and President of the Royal College of Physicians,
Edinburgh, had sponsored an appeal, leading to
the establishment of the Royal Edinburgh Mental
Hospital in 1813.
The reforms which were pioneered in England
by Tuke were followed by the introduction of a bill
in Parliament for the better treatment of the insane
known as the Wynns Act of 1808, for providing
better care and maintenance of lunatics being
paupers or criminals of England.
Thomas Laycock, a professor of Medicine at
Edinburgh University and Lecturer in Medical
Psychology and Mental Diseases published a
book entitled, Mind and Brain in 1860. As an
example of his imaginative foresight he stressed
the reciprocal action of body and mind and stated
that a practical knowledge of mental science
is essential to parents, jurists and legislators,
governors of jails, schoolmasters, and teachers,
ministers of the gospel, naval and military ofcers
and employers of labour. In his view, psychiatry
was not a narrow specialty but a discipline for
general application in studying the conduct of
Man.
thinking. In 1405 AD, the rst mental hospital

was opened at Valencia in Spain. Patients lived in
deplorable conditions and inhumane treatments like
blood-letting, inducing vomiting and purgatives
continued but on a smaller scale.
The rights of mentally ill persons received
recognition when the father of legal medicine Paolo
Zacchia (1584-1659) wrote, Only a physician
was condent to judge the mental condition of a
person. Thomas Sydenham (1624-1689) initiated
the clinical approach in modern medicine by
describing in detail symptoms of mild mental
illness.
MODERN (MORAL) ERA OF

THE TREATMENT OF MENTAL
ILLNESS
This era dates from the end of the 18th century and
may be divided into four periods:
The period of humane reform,
The introduction of no-restraint,
The hospital period,
The social and community period.
The Moral Treatment Era was characterised by
restoration of dignity of mental patients through
abolition of restraints and establishment of large
mental hospitals with better clinical care. There
was increased realisation that mental illnesses were
not restricted to any particular group in society.
Pioneers of moral treatment included Phillipe
Pinel from France (1745-1826), Vincenzo Chiarugi
from Italy (1759-1820) and William Tuke from
Britain (1732-1822). Advocacy groups pressurised
governments to improve mental health services.
Humane reform
One of the most outstanding players in the period
of humane reform was Dr. Phillipe Pinel who
worked at the Bicetre Hospital, in Paris which
accommodated about 200 male patients. In 1794,
instead of blows and chains, he introduced light and
fresh air, cleanliness, workshops and promenades,
but above all kindness and understanding. The
results were outstanding. His prescriptions were
later transferred to the female mental hospital,
Salpetriere.
Pinel was not only an excellent hospital
administrator and physician, but also set very high
standards of medical care and practice. He insisted
on good case taking and made contributions to
to all specialties, and also has the advantage of

removing stigma so traditionally associated with
mental illness. Several landmarks examples can be
cited:
1. Jean Martin Charcot (1825-1893) claried the
role of psychological factors in the production
of physical symptoms by studying hysteria.
2. Sigmund Freud (1856-1939), amongst
other things, highlighted stages of normal
psychological development and their relevance
to personality disturbances and mental illness.
3. Emil Kraeplin (1856-1926) classied mental
illness and hypothesized they could be due to
coarse brain disease.
Examples of landmarks in development of
treatments:
1. Community-based approaches to mental health
were introduced in the early 20th century.
Mental hygiene, child guidance clinics and
mental hospitals were brought closer to the
people.
2. Manfred Sakel introduced insulin-coma therapy
for schizophrenia in 1933.
3. In 1917 Julius von Wagner Jauregg introduced
malaria therapy for syphillis.
4. Psycho-surgery (removing parts of the brain
thought to cause mental disorder) was practised
in 1936 by Egas Moniz.
5. In 1938 Ugo Cerletti and Lucio Bini discovered
electroshock therapy (passage of small currents
through brain to induce a convulsion).
6. Effective chemotherapy was introduced in the
early 1950s and had a great impact in reducing
mental hospital population In 1952 Delay
and Deniker who pioneered the synthesis of
chlorpromazine (Largactil) introduced it for
treating psychosis.
7. Roland Kuhn discovered an antidepressant drug
called Imipramine in 1957.
The Hospital Period: Seclusion vs Isolation

The modernisation of psychiatric hospitals has
resulted in numerous benecial changes in the
following areas: administration, infrastructure,
medical and nursing staff, psychiatric social
workers, occupational therapists, psychologists,
chiropodists and hairdressers.
The transition to modern hospital care of mental
patients was bridged by a short-lived concept.
This involved seclusion, but not isolation, for
dangerous, impulsive patients who could not be
trusted. It comprised single and padded rooms
which were locked, and in which the patients were
conned. This arrangement had several advantages:
it prevented struggling with the patient, it prevented
serious accidents, there was much less necessity to
use powerful sedatives and it eased the burden and
responsibility of the medical and nursing staff.
As the medical and nursing staff increased, it
became evident that the vast majority of the socalled single room cases responded more positively
when cared for and nursed in open wards where
they could be adequately supervised.
The Hospital and the Community

The mental hospital today has established outside
contacts and interests which previously did not
exist. In addition to in-patients, administrative
and clinical duties, they also involve themselves
in activities such as: out-patient clinics, child
guidance clinics, domiciliary consultations, and
medical-legal work. Instead of closed high wall
hospitals there has been a move towards open-door
systems where the wards are unlocked, patients are
given the freedom of the grounds and adjoining city
or country side and day and night hospital visits.
There are determined efforts to treat patients in
their homes through home visits, family practice
units, clinical psychologists, psychiatric social
workers and health visitors. The aim is to reduce
mental hospital admission rates and to maintain
patients at work so long as it is compatible with
their well-being.
HISTORICAL DEVELOPMENT
OF PSYCHIATRY IN AFRICA
THE EVOLUTION OF LIAISON

PSYCHIATRY
The history of psychiatry in Africa seems to have

followed the same pattern found in the western
culture, that is, primitive non-scientic, humanistic,
and lastly scientic stages. As Asuni observed,
in Nigeria the changes have taken place over a
relatively shorter period of time and therefore
overlap is more evident.
Liaison psychiatry has also evolved. It involves

the establishment of closer liaison with general
practitioners, medical, surgical and other
specialists. This relationship is of mutual benet
to England to treat an eminent Nigerian who had

become psychotic there
Although the presumed psychopathology bears
many similarities found in western culture at
various stages of psychiatry, it is noteworthy that
extreme physical therapeutic approaches such
as ogging, binding and starving were hardly
practised in Africa. Tradition demanded that the
mentally ill be looked after like any other sick
person. They were taken to traditional healers for
diagnosis and treatment. This practice was also
found in Nigeria (Asuni (1972)). Lambo (1966),
a pioneer psychiatrist in Africa trained in modern
western psychiatry, used the same model in the
design of the Afro Psychiatric Hospital in Nigeria
where the sick person and his family would be
admitted together for sometime. In Tanzania,
Rappaport & Dent (1979) observed the extended
family group approach to psychotherapeutic
treatment and remarked, nothing we had seen
in a western clinic could compete with the deep
power of this ritual. The development period of
the rst and second stages of psychiatry cannot be
historically pinpointed, and unfortunately, recorded
Kenyan history makes little reference to medicine
and still less to mental illness.
The primitive/non-scientic and

humanistic stages
These seem to have developed concurrently. In the
primitive non-scientic stage, psychiatric illnesses
were attributed to supernatural powers and the
spirits of dead ancestors who were punishing the
sick person or the relatives of the sick (Prince
(1960), Asuni (1972)). The illnesses were also
attributed to sorcery and witchcraft invoked by
neighbours, relatives and distant clans as revenge,
punishment or simply because of jealousy. It is
important to note also that psychiatric illness
due to physical conditions was well appreciated.
Malaria (cerebral malaria), cannabis intoxication,
trypanosomiasis and head trauma were recognised
as causes of madness.
There are no documented detailed descriptions
of mental illness in most African societies
equivalent to the classical work by Prince (1964)
on the Yoruba of Nigeria, in which he described
local terminologies and theories of causation for
what was clearly schizophrenic illnesses, mania,
depression, hysteria, anxiety, delirium tremens,
epilepsy and psychosis associated with epilepsy
and organic brain syndromes. This was impressive
phenomenology considering that it was not stored
in written form, but was passed on verbally through
successive generations of traditional healers. What
can be adduced is that such psychiatric diagnostic
equivalents were well known in most societies
although they were not documented. The closest
Carothers (1953), then working in Kenya, came to
forming such an impression was when he observed
the African has greater difculty recognising
the strangeness of psychotics than the European
layman, implying that some of the psychotic
phenomena were acceptable within the societies
Some of the treatments were similar to those
found in western culture at the equivalent stages
and took such forms as offerings to appease the
ancestral spirits, rituals in atonements for wrongs
done, craniotomy to release the evil spirits (among
the Turkana in Kenya), and herbs to treat the primary
physical causes of the madness (e.g. malaria) or the
psychiatric illness. The success rate, according to
folklore was satisfactory in the majority of cases.
The chemical nature of these herbs was not studied
by scientic means but an idea of their nature may
be obtained from Princes studies (Prince (1960,
1964)) who in 1960 wrote, it is interesting that in
1925, long before tranquilisers or shock therapies
were known to European psychiatry, Chief
Adetona, with his Rauwola medicine, travelled
The scientic stages

Western psychiatric services in most African
countries have evolved at different paces and
very few countries have satisfactory and adequate
services. The gradual transference of psychiatric
management from the African traditional style
to that of western culture was in one sense a
regrettable step in that the care of the mentally ill
was taken from the relatives, which, was a move
away from a benecial therapeutic climate to a
sterile custodial one. New psychiatric units were
introduced in hospitals. This was a time when
the western inuence was inltrating into Africa
and there was outright condemnation of the local
cultural methods and beliefs.
Nevertheless it marked the start of the scientic
approach, for although we know little of the
early developments, it was one of the bases from
which Carothers, Asuni and Prince wrote so
much on psychiatry in Africa. Carothers (1947,
1953)) provided some of the early detailed
records of psychiatry in Kenya. He described a
whole spectrum of psychiatric diagnoses. Though
his methodological designs are suspect (he
used non-medical civil administrators to collect
epidemiological psychiatric data) he quotes a
psychiatric morbidity prevalence of 0.1 per 1,000

in the population and compares it with 4 per 1,000
found in England and Wales in1938, thus implying
that psychiatric morbidity in England and Wales was
at least 40 times more than in Kenya. Interestingly,
Gower (1938), working in West Africa, held the
opposite but extreme view for he wrote and was
quoted by Carothers (1953) if we are sane
all primitive Negroes are raving mad. Ndetei
& Muhangi (1979) from Kenya have since then
corrected the impression created by Carothers.
Lambo (1954) has succinctly criticised some of
Carothers prejudicial, impressionistic writings.
Further reading
1. Asuni, T. (1972): Psychiatry in Nigeria over the years.
Nigeria medical journal 2, 54-58.
2. Carothers, J.C. (1953): The African mind in health and
disease. A study of ethnopsychiatry. WHO Monogr.
Ser. Geneva.
3. Lambo, T.A. (1966): The village of Aro. In King, A.
(ed.): Medical care in developing countries. Oxford
University Press, Nairobi, Chapter 20.
4. Ndetei D.M. (1980): Psychiatry in Kenya yesterday,
today and tomorrow an overview. Act Psychatrica
Scandinavia 62: 201-211.
5. Ndetei D.M. (2001): The walk toward the promise: A
view of mental health in global, Kenyan and individual
perspectives. Inaugural lecture, University of Nairobi,
13th September 2001. University of Nairobi Press.
6. Prince R. (1960): The use of Rauwola for the
treatment of psychoses by Nigerian traditional doctors,
American Journal of Psychiatry, 117, 147-149.
7. Prince R. (1964): Indigenous Yoruba psychiatry.
In Kiev, A. (ed.): Magic, faith and healing. Studies
in primitive psychiatry. Collier-MacMillan Ltd.,
London, pp. 84-120.
8. Rappaport, H. and P.L. Dent (1979): An analysis
of contemporary East African folk psychotherapy.
British Journal of Medical Psychology, 52,49-54.
The present and the future

Mental health issues are as urgent in Africa as
they are in the West. However, Africa remains
considerably constrained by lack of resources, and
in particular human resources, most of whom are
lost to the West. There is need to come up with the
most cost-effective ways to address mental health
issues in Africa, ranging from research to human
resource development.
Mental health will continue to be a challenge
in Africa. How we meet that challenge tomorrow
depends on what we do today. This book is part of
that tomorrow.
10
3
Psychiatric and Mental Health Training
David M. Ndetei, Godfrey Lule, Ahmed Mohit, John Mburu, Lukoye Atwoli, Monique Mucheru
a holistic approach to management of disease,

incorporating the biological, psychological and
social factors. They provide the foundation for
understanding and practice of psychology and
psychiatry just like the basic sciences are to the
practice of internal medicine.
Behavioural sciences prepare the students to
understand their own personalities and also to
manage patients with different personality needs.
It also helps in the students own development as
a person; appreciating oneself and achieving the
status of self-actualisation.
Behavioural sciences impart skills that enhance
doctor-patient relationship. It expounds on
the phenomena of transference and countertransference, which facilitate in diagnosis and the
creation of a therapeutic alliance during treatment of
complex psychosocial disorders. Being conversant
with behavioural sciences improves work relations
that include how best to relate with colleagues at the
workplace. Medical and paramedical practitioners
work for long hours and sometimes under pressure,
hence are prone to developing burn-out syndrome.
Behavioural science provides skills that they can
utilise for stress management.
Most diseases, for example, hypertension,
bronchial asthma and peptic ulcers have been
proven to have a psychological origin and are
referred to as psychosomatic disorders. These
are best understood and managed by studying
behavioural sciences. There are some disease
states, especially chronic or terminal illnesses
which present with both physical and psychological
Psychiatric and mental health training in most parts

of Africa is a relatively new and developing eld.
Over the years, it has become increasingly evident
that mental illnesses form a major part of the dayto-day problems that present to a non-specialist
medical or clinical ofcer. Many patients present
with conditions, which directly or indirectly arise
from stressful situations. With increasing demands
on life, a highly competitive lifestyle and a desire
to succeed, many people need psychological help
and counselling as opposed to drug prescriptions.
The number of trained mental health
professionals in many African countries is far
below the demand. The few that are available
mainly deal with psychotic illnesses. This leaves
out, by far, the largest number of people needing
mental health care. It is not unusual not to have a
single psychiatrist in some countries. It is therefore
necessary that the non-specialist clinician be
equipped with adequate skills to be able to obtain a
psychiatric diagnosis or a mental health formulation
and manage such cases and also recognise at what
stage to refer. The common and universal practice
of referring any confused patient to the nearest
psychiatric institution without making any effort to
make a diagnosis should be abandoned.
Medical science usually focuses on the causes,
pathogenesis, diagnosis, management and control
of diseases affecting humanity. Behavioural
sciences focus on the psychological and social
determinants of health. It is that aspect of social
science that incorporates sociology, psychology
and anthropology. Behavioural sciences encourage
11
are interrelated and intertwined. He described a

relationship between biological, psychological and
social factors in relation to disease, in causation,
vulnerability,
precipitation,
manifestation,
management, prognosis and outcome, and more
importantly in the sustenance of health.
symptoms. It is important therefore for the medical

practitioner to not only treat the physical, but also
to provide counselling and other therapies to take
care of the patients psychological needs. Thus the
training of medical students should put emphasis
on this approach that has been popularly referred
to as the biopsychosocial model.
Biological system
This comprises the anatomic, structural,
biochemical and genetic determinants of disease
and their impact on the patients biological,
psychological and social functions.
THE BIOPSYCHOSOCIAL
MODEL
George Engel described the biopsychosocial model
of disease and divided it into 3 major parts, which
Figure 3.1: Towards an Integrated Bio-Psycho-Social (BPS) Model
BP
BPS
PS
BS
BP
BPS
PS
BS
S
Illustration by Prof. D. M. Ndetei
12
Psychiatric and Mental Health Training
serves the same purpose as with other interventions

including a psychotropic.
The biopsychosocial model highlights the
need for doctors and all medical and paramedical
professions, whatever their specialisation, to be
thoroughly familiar with patients and clients
psychology and social or cultural milieu, emotional
response and their interaction with health care
providers, rather than just making a diagnosis and
prescribing medicine.
The future of the practice of medicine will be
in the integration and not compartmentalisation of
biological, psychological, social and even spiritual
factors. Inclusion of behavioural sciences in the
medical training curriculum is the only way to
achieve this goal.
This holistic approach should be employed,
regardless of the primary nature of the ill-health.
Each system may affect and be affected by any of
the other systemsa fact that health professionals
should take into account.
Psychological system
The past, present, and anticipated factors together
with motivation and personalities have a bearing
on disease, both in its impact on the individual
and his reaction to it. Attitudes to safe or unsafe
environments, use of prescribed medicines,
substances such as alcohol, nicotine, sexual
behaviour and dietary habits may affect and
in turn be affected by physical conditions and
socio-cultural factors. Indeed, quite often most
psychological disorders have very clearly
demonstrated biochemical basis not much different
from diabetes (lack of insulin), for example.
Thus psychiatric disorders have physical and
psychological components.
Social system
The emphasis here is on cultural, environmental and
familial and societal inuence on the expression and
experience of illness. It should be noted that each
of these systems may affect or be affected by the
other systems. The role of religion, faith and belief
systems in health is important. People are attached
to their beliefs through the heart and mind. The
mind is the seat of emotions, with all the possible
consequences physical and psychological. If
religion gives mental relief in adversity, then it
Further Reading
1. Desjarlais, R., Eisenberg, L., Good, B., and Kleinman,
A. World mental health, problems and priorities in
low-income countries, (1995). Oxford University
Press, New York.
13
4
The Burden of Mental Illness
From the other side of the doctors desk: A true life story of a patient1
Healing from illness is a journey of discovery. So

is accurate diagnosis and treatment. The response
observed from the rst step of diagnosis, or the
treatment undertaken by the physician, opens
up new ways of understanding the cause of the
illness, as well as the most appropriate responses.
Should the response be encouraging, treatment
along existing lines with appropriate adjustments
becomes the most advisable option. Should the
initial action prove inadequate, then it becomes
imperative to abandon the initial path and return to
the diagnostic drawing board. Either way, the results
of action taken determine the course of action in
the next phase. To the extent that this is true, no
completely denitive response to an illnessor for
that matter any human problemcan be divined
from the word go.
This is the case, no matter what textbooks tell
you about absolute certainties in medical science.
Karl Popper, a philosopher of science, argues
that scientic discovery progresses in the same
manner, through a series of assumptions and
their refutation via the experimental method. Any
truly professional world is one in which accepted
hypotheses, or beliefs in cause-effect relationships,
are subjected to constant real-life experiments and
the chance that original diagnoses could be proved
wrong or partly true, by hard-nosed empirical
evidence. Intuition in discovering new ground in
that manner is the essence of scientic progress.
It is for that reason, I believe Albert Einstein when

he wrote that, Imagination is more important than
knowledge.
This essay, however, is not about the philosophy
of scientic discovery or the sociology of medical
practice. Rather, it is a plea by a social scientist
who has suffered from depression, to the readers
of this volume to be more open-minded in their
treatment of mental illness. There is a lot we still
do not know and need to explore. If the most
effective progress is made by constant change in
the light of evidence, then we must be open to new
experiences that become available to us on our own
initiative, from our peers or from journal articles.
There is another source of new evidence that we
often ignorethe patient.
I write this chapter to advance the case of the
patient as one of the most reliable sources of
healing. It is not intended, in any way, to demean the
signicance of routine scientic and professional
diagnosis, and treatment. It seeks to add value to
the professional skills learnt in medical school in
a manner that could help to reduce the margin of
error that is inevitable in all human decisions. This
chapter draws from two major sources: one is my
personal experience as an out-patient; the second is
my encounter with mental illness in my professional
life as a professor in the social sciences.
This is a life story of an eminent professor of economics who has taught in Africa and America, and is a worldwide consultant on
economic issues. It is a story of how he struggled with depression.
14
professionally arrogant in some cases. By failing to

discuss the diagnosis with me, however, I lost the
benet of their knowledge that would have helped
me and the doctors I subsequently consulted.
Diagnosis and self-diagnosis

One of the most important elements in healing
from disease has to be a two-way communication
between doctor and patient, in which the latter
is given the full benet of the doctors diagnosis
and treatment. We should never underestimate
the intelligence of the sick. Granted, the patient
may not always understand the full complexity
of medical science. As literacy spreads in Africa,
more patients will become inquisitive enough to
read what they can on their own, to monitor the
signs and trends of the illness, all of which makes
for better treatment by the doctor.
It was not until adulthood that I understood
what I was suffering from. Thanks to doctors in
Kenya and outside who were willing to engage
me about my self-diagnosis, and to discuss their
diagnosis with me. After each visit with them I felt
more condent. Through this process of patientdoctor interaction I have learnt more about what
triggers depression in my case, and which remedies
work best. As I move from one country to the next,
I bring the accumulated baggage of experience to
the doctor I see, and that makes treatment and my
life easier. After four decades of consultation, I
now have a diagnosis of my mental condition that
I feel is most consistent with how I feel. I have
a continuing low-order depression that becomes
accentuated by anxiety due to pressures at work or
in my social life. Fortunately, I have never had to
be hospitalised for the illness. Sometimes I go for
as many as 10 years before it strikes, but when it
returns, it weighs me down. I experience feelings of
despair and loss of self-condence, a sense of being
overwhelmed by the problems of the world, loss of
interest in simple things of life, continuous anxiety,
insomnia and palpitations. Over time I have learnt
to monitor the signs and to take remedial action. I
have learnt a great deal about the illness and the
successive drugs and modes of therapy that have
been used to treat it. With medicine, exercise and
by spacing out my work schedule, I have been able
to manage the illness.
I experienced severe disappointment with some
medical professionals along the way. No doubt
some of the doctors I consulted were some of the
most intelligent people I have ever met and nearly
all of them meant well. But communication with
patients was not their strength. In a patronizing
manner, they took patient history, asked some
questions, took time to examine me, even sent
me for laboratory tests, and then handed out
prescriptions. They were detached and aloof, even
The dangers of diagnosis without

communication
In 1961, at age 15, and in colonial Kenya, I sat the
Kenya Preliminary Examination, the national endof-primary school examination. It was not unusual
in those days for an entire class of 40 or so, to
send one or two students to the few high schools
reserved for Africans. Anyone in our situation who
felt anxious could therefore have been excused.
There were hardly any opportunities left for those
who failed the examination.
I desperately wanted to go to high school. I spent
time reading ction. H. Rider Haggards novel
based on the Zulu kingdom is one that I distinctly
recall, but I was also helping out with duties at
home on my fathers farm, and visiting friends.
Then I began to notice the slow, but sure creep of
insomnia. At rst it was just a nuisance that I could
ignore. But then it got worse, allowing me only a
few hours of sleep followed by empty gazes on the
roof punctuated by tossing and turning in bed. The
novels now took longer to nish.
Luckily, when I explained this to my parents
they were neither cynical nor inclined to mystical
or magical explanations. I was taken to one of the
few African physicians then practising in Nairobi.
The doctor wanted to know if I had ever suffered
from epilepsy, the answer to which was no. This
question gave me an early clue as to the direction
he was heading: he suspected something was not
right in the mind. I thought then that he was wrong,
but there was no conversation to be had between a
15-year old and such a reputable physician. In the
end he put me on treatment without saying what he
thought the problem wasa series of injections of
what I suspect was valium (diazepam). There was
no attempt to communicate with me. Had he cared
to inform my parents or me what his diagnosis
was, it might have saved us all a lot of subsequent
difculties.
The prescription worked and I had a restful
period. Results of the examinations were announced
and the outcome reinforced the sense of personal
comfort that I was already feeling. I had scored
the highest grades possible and been admitted to
the high school of my dreams. The anxiety had
subsided, giving way to optimism. At the time, I
could not relate anxiety to stress and insomnia.
15
the results were out. Again, it was a dream come

true, emerging from a severe bout of anxiety and
depression.
As a postgraduate student, I nally found a doctor
ready to engage me in a conversation about his
diagnosis. It was during the nal months before my
comprehensive doctoral examinationsa terror for
all students who had graduated from my department.
Unlike what had happened a few years earlier in
Nairobi, the doctor brought me face-to-face with
the connection between examination anxiety and
the illness. We went over the limited benets I had
obtained from valiumor a variant thereofthat
he had prescribed for me. He was persuasive. You
are a very educated person, he told me, do not
let the stigma of consulting psychiatrists deter you
from consulting doctor-so-and so. The rest was
easy. He guided me to the people who would really
help meclinical psychologists and psychiatrists.
Finally correct diagnosis and good communication
had met, and my health and anxiety took a turn
for the better. I peeped deep into my psyche and
for the rst time I began to see who I really was.
Recalling incident after incident since I was 15, I
wondered what had led to this. Now I read more
about affective disorders and their cure than I ever
had. I felt like someone who had conquered an
enemy by studying its real nature.
That experience was to come to me the hard way

much later. In the meantime I passed my national
examinations after Forms Four and Six with
ying colours. I was not worried about anxiety or
depression for a while.
That moment ceased at the end of my second
year at university. I had then made up my mind
to pursue scholarship as a career, which meant
that I needed to pass well enough to enrol for
postgraduate studies to a prestigious university
abroad. I was also required to graduate at the top
of my class. I knew that the few postgraduate
scholarships available went to the best of the best.
As the nal examinations of the second year drew
near, anxiety crept in. Looking back at this, it was
quite irrational. Overall, my work was among the
best in class. At least one lecturer had promised to
support my application for postgraduate studies.
Still unaware of what the previous diagnoses had
been, I could not relate the tell-tale signs provoked
by the oncoming examinations.
I knew that I was feeling sick, had lost appetite
and insomnia had struck. I had learnt on my own
that a lot of exercise helped me rest and study,
even though I was not sure why. I exercised, but
never got full respite from the illness. The full
happiness one would have expected on my personal
achievements eluded me. So I went to the general
practitioner at the university clinic. There was little
communication between us.
In desperation, I visited another physician
in Nairobi. At the then princely sum of Ksh 20
(equivalent to 0.25 US dollar) I was shown to the
examination room and soon I was reciting my
experience to him. I recall that palpitations were a
particular nuisance to me. He listened intently and
took a reading of my vitals. I recall that he asked
me to do a number of sit-ups before taking my
heartbeat again. He took out his prescription pad
and without a word, scribbled the prescription: two
weeks of a pale yellow tablet that many years later I
came to know as Valium (diazepam). The medicine
worked but it was not yet clear to me what I was
suffering from.
I did well in my exams. The dean of my faculty
told me that the marks I had received were truly
outstanding. I proceeded for my holidays feeling
elated. The palpitations and insomnia were gone.
When the nal examinations for the third year were
announced I was at the top. I had already received
admission for post-graduate studies to two of the
most prestigious universities in North America. I had
also been nominated and awarded a distinguished
international postgraduate scholarship long before
The dangers of wrong diagnoses

But that is only part of the story. I have narrated
the episode that preceded my entry to high school,
a correct diagnosis that was not explained to me
and was thus lost to all subsequent doctors I saw.
In the middle of my high school the anxiety struck
again. I was doing well at school. Even at the worst
of times I was passing my exams. But somehow I
began to feel I was not doing well enough. It was
the age of puberty. Again insomnia and a sense
of despondency set in. What followed was an
experience no patient ought to experience.
My rst stop was King George VI Hospital, as
Kenyatta National Hospital in Nairobi was known
at the time. The results were disastrous. The
attending nurse took my temperature, and did a
few other things I do not recall. The doctor who
was supposed to help me, a serious glum looking,
young moustached gentleman, with a stethoscope
hanging from his neck asked me what was wrong.
I went into the details of insomnia, palpitations,
indecisiveness and anxiety that I had rehearsed
so well. What he did thereafter actually worsened
my case. He took the hospital record card with
my name and the nurses observations on it, and
16
in turn determined ones career choice in university.

I do not know for sure, but my days of gloom, as
was to happen so often afterwards, may have had
something to do with an approaching, decisive
deadline and the mortal terror of failing, even when
by most rational analysis that eventuality seemed
quite remote.
My last encounter with misery-producing
diagnosis came towards the end of my undergraduate
education. The university clinic doctor listened
to my case with patience. He never gave me a
prescription. What I remember is his impatience,
and read cursorily through the le. Do you realize
that you seem to feel this way always before the
examinations? I do not know how I answered him
but whether I said yes or no was surely not going
to help me. I needed a professional reason for why
this was the case and something to help me deal
with it. But even without any treatment, the bit of
communication about the panicking syndrome by
the university doctor was of immense importance
to me. Henceforth, I included it in my repertoire of
symptoms. This helped all the caregivers I was to
see subsequently. It also helped me to understand
myself better.
proceeded to tear it bit by bit, throwing the shreds

into the dustbin, as I watched. All the time he was
staring straight at me with mirth written all over
his face. Go to your local dispensary and get
some medicine there, he said. I was devastated.
Probably it was my fault, I thought, may be I am a
hypochondriac.
I went to the dispensary at the time staffed by
a clinical ofcer. He did his best, prescribing a
large dose of pain relievers. I took them for a few
days and felt even worse, so I gave up. All this
heightened my anxiety. The thought kept recurring
that I may have done something to induce this
illness. Probably the doctor at King George VI
had seen through this young man with no medical
problem who was wasting his and the hospitals
time. I began to internalise the guilt, to look for the
cause of the problem within me. The more I did,
the worse I felt. The physicians guiding motto is
above all do no harm. That principle was violated
in a particularly vicious manner that morning. It
was a while before I went to see another doctor.
He too was a general practitioner, another one
of the few African doctors with a medical degree
from India. He was then and always in a serious
mood, not one given to discussion, least of all with
a high school youngster. Still in school uniform, I
explained my problems to him the best I could. He
drew a blood sample from my arm. I was asked
to wait for the results, then he made his diagnosis,
sharing none of it with me of course. I was curious
all the time and when he stepped outside, I looked
at the card and saw what he was about to treat me
for. He had written tachycardia. He gave me a
prescription, red coated tablets in a small khaki
envelope, and gave me another appointment. That
evening I went to my high school library and read
all I could about tachycardia. I read still more in the
days that followed to nd any clues that sounded
familiar with what I felt, but I found none. I took
the red pills, but did not get any better. Tachycardia,
I thought, what an elusive disease.
The remission from this round of illness did not
come from the red pills, which I soon abandoned.
Rather, it came from a change in circumstances
that had little to do with the doctors or me. I can
say this now with the benet of hindsight. It was
not so clear then, but halfway through my rst four
years of high school, I began agonising about what
I was going to do after the Form four examinations.
It was not an idle worry. By the time one entered
Forms ve and six, they would have already chosen
between the science and the arts stream. This
Effective patient-doctor communication

My epiphany came from the general physician
who handled my crisis in the run-up to my doctoral
examinations. He treated me as an equal. He told
me his treatment had reached its limits. I needed to
see someone more qualied than he was in mental
health. I went on to pass my examinations and my
examiners judged my proposal among the best they
had seen. The cloud over my mind gave way to
the freshness of a beautiful spring. It was to be ten
years before I had to see a doctor with anxiety. My
career prospered, as did my young family.
Even when circumstances changed after those
ten years, I knew what to do and what to avoid.
My encounters with primary care physicians and
psychiatrists in different countries are richer and
more fullling than the rough handling I had in
my earlier life. We can discuss prescriptions and
non-prescription treatment. Over the years, the
devastation caused by anxiety and depression
has subsided. I get remission going on for one or
several years, and I can predict the causes better
when panic strikes. When it strikes, a two-way
communication channel between psychiatrists and
I helps me nd a way out.
17
5
The Economic Burden of Mental Disorders in Africa
Ababi Zergaw, Atalay Alem, Damen Hailemariam
of their high prevalence, chronicity and early age

of onset. Often, they have a devastating effect on
functioning and quality of life. In todays world,
5 of the 10 leading causes of disability are mental
health problems. Furthermore, because of their
early age of onset, mental disorders have powerful
adverse effects on life course transition such as
educational attainment, teenage, child bearing and
cause marital instability and violence.
Unless attention is paid to the design, development
and evaluation of alternative low-cost methods for
the delivery of mental health care, the burden that
society and health services will experience will
continue to rise. This is so, in light of demographic
changes and epidemiological transitions, as well
as social factors that include changing family
structure and rising rates of urbanisation, migration
and mobility, and alcohol and drug use.
Compared to other economic studies in
the continent conducted on other diseases
like tuberculosis, malaria and HIV/AIDS,
economic studies on mental health are rare.
Therefore, availability of economic burden
studies on mental health to inform policy and
decision-making is minimal. Nevertheless, the
few available studies have demonstrated that the
burden of mental disorders on individuals and
their families are substantial. Studies conducted
in Nigeria compared costs of out-patient treatment
of schizophrenia with those of diabetes mellitus.
Patients with schizophrenia and their relatives lost
more working days than patients with diabetes and
their relatives. This study has also shown that the
Mental disorders cause extensive morbidity and

human suffering in many societies. In Africa,
where human suffering is exacerbated by many
other socio-economic and political factors, the
problem caused by mental disorders is grave. In the
continent, neuro-psychiatric conditions constitute
about 4 percent of the total burden of disease.
Moreover, the relationship between disease burden
and allocated health resource is disproportionate.
Eighty percent of countries in Africa spend less
than 1 percent of their total health budget on mental
health. This is further worsened by a shortage of
trained health personnel.
Economic evaluation studies which can help in
health policy and decision-making are rare, despite
the fact that resources are scarce. Economic
evaluation is about choice, which is concerned
with the best alternative use of limited resources.
It is a tool to identify the most efcient way of
meeting a stated objective. Its main function is to
allow policy-makers, managers and clinicians to
make choices by assessing the cost and benets
of achieving the stated objectives by different
alternative methods.
ECONOMIC BURDEN
EVALUATION
Mental disorders are among the most burdensome
of all classes of diseases. They may not in
themselves be fatal, but are burdensome because
18
The Economic Burden of Mental Disorders in Africa
result in distress, disability, reduced productivity

and lowered quality of life. They have devastating
effects on sufferers, their families, health systems
and the wider society. These disorders impose
a range of costs on individuals, families and
communities as a whole that include direct, indirect
and intangible costs. Direct costs are actual money
expenditures and in-kind contributions incurred
by patients, their families, and third parties, to
purchase medical goods and services. Costs of
non-medical goods and services ordinarily incurred
to obtain medical services such as transport to
medical facilities, are additional direct costs.
In-kind contributions are donations of goods or
services that would otherwise have to be purchased
through actual cash outlays. These include shelter,
food and utilities. Indirect costs are losses in
productivity associated with symptoms, disability
and premature death. Indirect costs include the
value of lost opportunities to work in the general
economy because of sick leave, disability leave
and unemployment associated with illness or in the
household. Relatives who divert time from work
to provide care or assistance with household work
also incur opportunity costs.
Intangible costs entail pain and suffering as well
as changes in quality of life. Intangible costs, which
are central to complete understanding of the impact
of illness, are not ordinarily considered in assessing
the economic burden of illness, because they cannot
be successfully quantied in a monetary sense, but
are nevertheless signicant. They include effects
on the patient (e.g., despair and the side effects
associated with medication) and on the carer (e.g.,
isolation, uncertainty, stress). Collectively, these
may be treated as intangible costs or as important
facets of patient or carer quality of life.
In the continent there is an urgent need to conduct
economic burden studies due to mental disorders
where loss of productivity is substantial. It is also
essential to understand that not treating mental
illnesses is more expensive than treating them.
cost of drugs was a signicant predictor of cost of

illness for both schizophrenia and diabetes.
Another study conducted on 44 schizophrenic
subjects on rst admission or in out-patient followup care at the state psychiatric hospital at Port
Harcourt, Rivers State of Nigeria, has investigated
and revealed that rural familes experienced more
nancial burden compared to those living in urban
areas. One South African study pointed out that
the introduction of follow-up by a psychiatric
nurse after discharge reduced the number of readmissions and the duration of stay in the hospital.
This was coupled with increased attendance at the
out-patient clinic.
A Kenyan study has shown that in the scal year
1998/99, Kenya lost approximately US$13,350,840
due to mental and behavioural disorders. This
study reported that the total economic cost of
mental and behavioural disorders per admission
was US$2,351. The study has also shown that the
unit cost of operating and organising psychiatric
services per admission is US$1,848, the out-ofpocket expenses borne by patients and their families
per admission US$51, and the productivity loss per
admission, US$453.
In a rural area of Ethiopia the burden due to
mental disorders has been shown to be signicant
such that depression and schizophrenia ranked 7th
and 8th among the 10 leading causes of burden of
disease in the area; contributing to about 11 percent
of the total disability adjusted life years lost. This
means that about 591 healthy life years were lost
for every 1000 people in the study area.
Most of the economic burden studies were
hospital-based, and on self-selected population
groups. However, there is a need to have populationbased studies since many people may not seek
treatment for mental health problems on time. In
addition, the small sample size of the economic
burden studies may not enable an estimate of the
extent of the burden, making their generalisation
for larger population groups questionable.
Further Reading
1. Kirigia, JM., and Sambo, LG., Cost of mental and
behavioural disorders in Kenya, (2003) Annals of
General Hospital Psychiatry, vol. 2: 2-7.
Categorisation of economic costs

Mental disorders such as schizophrenia, because
of the early onset, severe and persistent nature,
19
6
Stigma and Mental Disorders2
David M. Ndetei, Norman Sartorius, Lincoln Khasakhala,
Francisca Ongecha-Owuor
Mental illnesses cause severe disability and

suffering to patients, their relatives and the
society. Living with a mentally ill person leads to
restrictions of social and leisure activities not only
for the mentally ill, but the whole family. Mentally
ill people and their relatives are usually rejected
and stigmatised by the society. Stigma is dened
as feelings of disapproval that people have about
particular illnesses or ways of behaving. The
family members are looked upon as people who
are responsible for the illness. Thus, supporting
someone with a mental illness is a difcult life long
effort that is very stressful. The other problem faced
by these families includes nancial difculties. The
nancial loss arises due to the patients inability to
work and the expenditure incurred on management
of the illness. The relatives may be compelled to
work less hours or give up their jobs because of
their care-giving responsibilities.
Stigma associated with mental illness is a chief
obstacle to successful treatment and management.
It often leads to discrimination that needlessly
exacerbates the problems of individuals with
mental disorders. Such discrimination limits the
amount of resources for the treatment, availability
of housing, employment opportunities and social
interaction; problems that in turn further increase
the stigma associated with mental illness. Stigma
related to mental illness is in three forms:
The patient may be stigmatised by health care

providers, relatives and society.
The relatives also experience stigma from
the society, given that some communities
associate mental illness with a curse or taboo.
The mental health workers are also stigmatised
by other medical professionals as well as
society; hence, this compounds the success in
treatment of mental disorders.
Popular attitudes towards the mentally ill are
deep-seated and can be seen in the stigmatising
language that is often used to describe people
who are mentally illnuts or psycho.
Some people still refer to psychiatric hospitals
as nuthouses or loony bins. Using these
insensitive words when referring to people
with mental illness or their treatment centres
reinforce the stigma that already surrounds the
mentally ill.
The care-giver is an important ally in ensuring that
the mentally ill person follows the treatment that
has been prescribed, provides nancial assistance
and housing, assists the ill person with daily
activities, such as shopping, cooking and washing
clothes; monitors their symptoms, negotiates
with employers and social agencies and provides
emotional support. People with mental illness and
their families also have an important role to play in
planning and delivering treatment services.
Most of the material in this chapter is adopted from the World Psychiatric Association section on Stigma, with the kind permission
of its Chairman, Professor Norman Sartorius
20
Stigma and Mental Disorders
The risk of violence in persons with mental

illnesses appears to be very similar to that in
the healthy population, when substance abuse
is factored out.
The risk of sexual offences associated with
mental illness is low.
Only a small percentage of those with mental
disorders are responsible for the violent
behaviour that occurs in association with the
disorder.
MYTHS ON MENTAL ILLNESSES

Many myths about mental illness persist. Most
people do not accept mentally ill persons even if
they have been treated and are feeling better. Some
of the myths about mental illness are described
below.
People with mental illness cannot work

Fact: people with mental illness work, even if
they have symptoms. Several studies have shown
that people with major mental illnesses fare better
if they work. The ability to hold a job is not
necessarily related to the severity of the persons
illness. British and American studies have shown
that people with schizophrenia are more likely to
stay out of hospital, if they are employed. Work is a
vital part of rehabilitation; it increases self-esteem,
reconnects the ill person to the community and
provides a meaningful way to ll time.
All people with mental illnesses are

mentally retarded
People with mental illness are violent
Jail is an appropriate place for people with

mental illnesses
Fact: mental illness and mental retardation are

entirely different conditions. Most mental illnesses
occur in people of all levels of intelligence, and
often in talented and creative people. Some mental
illnesses like schizophrenia may cause cognitive
problems such as poor concentration and difculty
with abstract thinking. However, it does not affect
overall intelligence.
Fact: mental disorders and violence are closely

linked in the public mind. Sensationalised
reporting by the media may be responsible for
this. Other contributing factors are the popular
misuse of psychiatric terms like psychotic and
psychopathic. The stereotype of the violent
mental patient causes public fear and avoidance
of the mentally ill. People with mental illnesses
in general are no more dangerous than healthy
individuals from the same population. Individuals
with schizophrenia do show a slightly elevated
rate of crimes of violence, but such acts are almost
always committed by those who are not receiving
proper treatment. People with schizophrenia are
far more violent toward themselves than others.
Eight things to keep in mind about the stereotype
of violence:
Treatment dramatically reduces the risk of
violence.
The risk of violence is not necessarily due
to illness, but rather to a combination of
disorders.
The contribution of those with mental illness
to the overall incidence of crime is relatively
small.
The violence associated with mental illness is
most often directed at a family member.
People with mental illness do not pose a risk to
children.
Fact: jails and prisons typically have very

inadequate psychiatric services. Mentally ill
prisoners receive little or no treatment. Moreover,
they are subjected to double punishment. If they
are housed with the general prison population,
their abnormal behaviour leads to beatings and
abuse by other prisoners. If they are segregated for
their protection, they lose all social contact and the
isolation often worsens their symptoms.
People never recover from a psychotic

illness
Fact: this misconception leads to hopelessness
and despair. It may also cause families to neglect
or abandon ill relatives. The disorder takes many
different courses, with varying outcomes. Some
people have episodes of illness lasting weeks or
months with full remission of their symptoms
between each episode; others have a uctuating
course in which symptoms are continuous, but rise
and fall in intensity; others have very little variation
in the symptoms of their illness over time. At one
end of the spectrum, some people with psychosis
recover completely from the illnessall
their psychotic symptoms disappear and they
return to their previous level of functioning. Others
continue to have some symptoms, but are able to
lead satisfying and productive lives, while at the
other end of the spectrum is a course in which the
21
treatment. During the onset of the illness or during

periods of relapse, people may have some difculty
with decision-making. A persons ability to make
these decisions may change during the course of
the illness. Research shows that patient and family
involvement improves outcomes and increases the
likelihood of the patient adhering to the treatment
plan.
Negative portrayals of people who experience
mental illness in television, movies and other
media outlets, continue to perpetuate the stigma
and further activate discrimination. As one woman
observed,
illness never abates. Only about one-third of people

with schizophrenia do not recover signicantly and
may have to be institutionalised.
Mental illness is contagious

Fact: fear of contagion results in people avoiding
those who have a mental disorder. Fear of
contagion also lead to the stigmatisation of family
members, mental health professionals and places
of treatment.
Mental illness is caused by evil spirits

or witchcraft
When you go into the hospital for a broken leg,

people send owers or they visit you. If you go to
the hospital for a mental illness, people do not send
owers or visit.
Fact: there is a multitude of misconceptions about

the cause of mental illness, but mental disorder
is not caused by a curse or an evil eye, Gods
punishment for family sins or lack of faith in God or
reading too many books. It is not a form of demonic
possession. The genetic hypothesis has shown that
relatives of people with mental illness have a greater
risk of developing the illness than others. This risk
is progressively greater in relatives who are more
genetically similar to the person with the mental
illness. Genetic factors appear to be important in the
development of the mental illness, but they are not
sufcient to explain the entire pattern of occurrence.
Mental illness is not a simple, inherited disease,
but rather a complex genetic disease, which may
have a variety of triggers. Researchers believe
that a predisposition to develop mental disorder is
inherited, but an environmental trigger must also
be present to bring on the disease. Possible triggers
are:
complications during the mothers pregnancy
or labour.
prenatal exposure to a virus, specically during
the fth month of the mothers pregnancy,
when most brain development occurs.
complications during pregnancy and delivery
increase the risk, probably because of damage
to the developing brain.
a pregnant woman who contracts a viral
illness may have a child with a greater risk
of developing schizophrenia. However,
maternal viral infections probably account for
only a small fraction of the increased risk of
schizophrenia.
stress, particularly the stress of adolescence.
Many patients report that consistent support from

parents, friends, medical professionals or teachers
was a major factor in their rehabilitation. Here
is a quote from Elizabeth who had experienced
discrimination:
One night the police pulled me over for expired
plates on my car. It was dark. The lights were ashing.
I was terried and shaking. When the policeman
approached my car, I was so scared I couldnt speak.
He accused me of being uncooperative. I managed
to say that I had schizophrenia. What does that
have to do with anything? he said, crazy, loony,
schizo, and laughed out loudly.
Another mentioned that:

We are simply labelled Mathari (national referral
mental hospital in Kenya) cases. If we laugh, we
laugh like Mathari cases. If we weep, we weep like
Mathari cases. If we have wonderful ideas they are
from Mathari cases. There is nothing we can do
good or bad without it being dismissed as coming
from a Mathari case. (Source: D.M. Ndetei, The
Walk, Towards the Promise. Inaugural Lecture,
University of Nairobi, 2001).
REDUCING STIGMA AND

DISCRIMINATION
In order to reduce stigma and discrimination, it
is necessary to change peoples attitudes through
education and outreach programmes, change
public policy and laws to reduce discrimination
and increase legal protection for those with mental
illness.
Strategies to reduce stigma and improve the
quality of life for individuals with mental illness
include:
People with mental illness are not able to

make decisions about their own treatment
Fact: most people with mental illness are able and
eager to participate in decision-making about their
22
Stigma and Mental Disorders
Cultural and religious issues are very important.

They inuence the value placed by society on
mental health, the presentation of symptoms,
illness behaviour, access to services, pathways
through care, the way individuals and families
manage illness and the way communities respond
to illness.
Increase use of treatment strategies that control

symptoms, while avoiding side effects.
Initiate community educational activities
aimed at changing attitudes toward people
with mental illness.
Include anti-stigma education in the training
of teachers and health care providers.
Improve psycho-education of patients and
families about ways of living with the
disease.
Involve patients and families in identifying
the discriminatory practices.
Put emphasis on development of medications
that improve quality of life and minimise
stigmatising side effects.
Further Reading
1. www.antipsychiatry.org/stigma
2. Norman Sartorius (1997). Fighting schizophrenia
and its stigma. A New World Psychiatric Association
Educational Programme. British Journal of Psychiatry,
April 170:297.
23
7
Mental Health: From the Perspective of
a Paediatrician and Surgeon
Rachel Musoke, Josephat Mulimba
and reading remains a good way of spending time

with children. When they are older then playing
games with them is another useful activity. Mothers
are often the ones in more contact with young
children presumably because of breastfeeding.
However, fathers have an emotional role to play in
ensuring the mental wellbeing of their children and
they should participate in childcare activities.
Working parents are usually under pressure to
nd time for their children. They may do so by
planning their work schedules, coming home as
soon as working hours are over or taking leave
when children are on holiday. Child minders are
valuable but they cannot replace parental love. The
responsibility of demonstrating love lies with the
parents and guardians.
One factor that plagues children of single parents
is the fate of the absent parent. Some children are
not told who their fathers are, while others are
forbidden to make contact. A lot of conicts go on
through the minds of these children. Consequently
such children become maladjusted. However,
some single parents have brought up well-adjusted
children depending on various factors including
parenting competence.
THE PAEDIATRICIANS
PERSPECTIVE
Children undergo numerous changes as they
develop from a totally dependent infant to a
partially independent adolescent. These changes
occur in phases at different ages during which
they need love, discipline and some independence,
within safe limits, in order to achieve good mental
health.
Children may be accepted, but not necessarily
loved. On the other hand, the parents may love a
child, but the child may be unaware that it is loved.
Parents must practically demonstrate love to their
children since a loved child is likely to be stable,
well behaved and condent. Many people have the
misconceived notion that loving a child too much
spoils it. On the contrary, unloved children are
spoilt, unruly and usually selsh. They are likely to
become irresponsible adults. Child should be loved
for who they are and not because of what they have
achieved. Some parents may only show love when
children excel and therefore they will always strive
to please. However, when they fail they show a lot
of anxiety. The stress that results may even make
the performance worse, leading to a vicious cycle.
Giving materially is not the same as giving
love. Loving a child means being there for it. In
these days of media entertainment there is little
interaction between family members. Story telling
Siblings sharing love

A single child has all the love and attention a
parent can give, but when there is more than one
child, rivalry, jealousy and anger may develop
in the older sibling. Young children have some
24
Mental Health: From the Perspective of a Paediatrician and Surgeon
difculty accepting additions to the family. The

responsibility of looking after younger siblings puts
a tremendous strain on the older child who loses
out on play that is important for healthy emotional
and physical development. Some parents obviously
favour one child leading to resentment by others.
The favoured child may also feel uncomfortable
about the situation. Another problem parents
create is comparison in terms of achievements or
appearance, usually through lack of realisation that
each child is different.
them wherever parents go to work, the daily childparent contact is completely cut off except during
scheduled parental visiting days.
Factors that affect children in school include
unrealistic expectations in academic performance,
too much homework at the expense of extra
curricular activities, excessive or unfair punishment
and bullying. When children are unhappy in school,
they may be too scared to tell their parents and
may present with falling sick often with atypical
illnesses.
Role reversal
The child
Where children assume adult roles prematurely,

such as when parents are sick, missing or dead they
experience enormous emotional turmoil. The worry
of permanently losing a sick parent or a divorce
puts the children under a lot of pressure that may
manifest as behavioural and emotional instability.
Broadly, children fall into two categories: the

easy and difcult child. A childs personality is
predetermined genetically. Easy children tend to be
quiet and undemanding. They usually want to please
and get approval of everyone they are in contact
with. They receive little attention and possibly love
because people around them assume that they are
happy even when they are hurting. People may not
notice when these children are angry, because anger
is not outwardly expressed. This group of children
are easily controlled or manipulated by others.
Difcult children are demanding, always arguing,
stubborn and most often want to solve their own
problems. They are natural leaders, but tend to be
anti-authority.
Extended family, friends and the

community
Africa is evolving from a situation where children
belonged to the community to the so-called nuclear
family, especially in urban areas. Fortunately in
rural communities there is still a lot of shared care
of children. That sense of belonging makes most
children happy and content. Friends tend to take
the place of relatives for the urban children.
Some children get to live partially or permanently
with a relative sometimes from an early age.
The child can interpret this as lack of love and
abandonment by its own parents. In this case it
may be difcult for the child and parents to really
bond resulting in total detachment.
The older child and adolescent

Adolescents want to be recognised in their own
right. During adolescence one is oscillating
between being a child and an adult and the
transitional time is beset by turmoil. How children
go through this period partly depend on their earlier
life experiences, as well as how they are guided.
If parents did not establish dialogue and trust they
may have problems dealing with their children.
Allowing the child to be independent is important
for personality development. With parental
guidance, a child goes through stages where they
are totally dependent to almost total independence
as adolescents. They gradually become responsible
for their actions at the same time knowing that there
is somebody to guide them through difculties.
Making mistakes is part of the game as long as
the mistake is not detrimental to their life. Instead
of punishment, they should be encouraged to
improve where they are failing. If a child is doing
right, but is not in conformity with his peers, he
should be supported by his parents. Closeness and
love by parents and other adults greatly helps the
child to learn to be a responsible person. When
School
Upon joining school, children are partially
separated from their parents and put under the
care of strangers. Initially it could be traumatising,
especially for the preschool child who feels
abandoned and reacts by crying.
In schools the child has to follow new sets of
rules, interact with strange adults, children and
learn to share with them. There may be a change of
language so that the child is unable to follow what
is going on. In the long run some children settle
and are happy in their new environment while
some show persistent behavioural aberrations.
Frequent change of schools for whatever reason,
affects the child in similar ways as joining school
for the rst time. Although putting children in
boarding schools is a better option to dragging
25
including mental health can be addressed and

ensure adequate nutrition throughout childhood.
This will help prevent or reduce incidences of
childhood psychiatric complications and disorders
such as mental retardation.
Parents are usually worried about the survival
of a child suffering from an acute illness. The
paediatrician should counsel the parents and ensure
the illness is not discussed in the presence of the
child since this may cause them psychological
helplessness. Chronically ill children often ask
why they are different, why are they not able to
play like other children, and why they have to
take medication everyday. Paediatricians should
concentrate on counselling them depending on
their ages.
There is a lot that is not being addressed in
childrens mental health. There is an urgent need
to reconsider paediatric training and practice in
order to enhance the mental heath component of
children.
independence is denied the child may become

angry, frustrated and rebellious.
Discipline
The whole idea of discipline is to teach or educate.
It does not mean control and can be either positive
or negative. Positive discipline is loving discipline
which is rm, reasonable and exible, but not
permissive. Children are complimented when they
have done something good. When mistakes occur
in positive discipline the child is listened to before
being punished and the punishment chosen is not
excessive. Children who are positively disciplined
are happy and resourceful individuals. They will
try to excel in most of their activities.
Negative discipline seeks to control the child
who is forced to comply with whatever the parents
want. It is deceptive and promises are unmet.
The child eventually learns that these are empty
promises and rebels. Negative discipline makes
children angry, resentful and rebellious. Sometimes
this anger is suppressed, which is dangerous as it
leads to depression. The anger may be vented on
somebody else who was not originally the cause
of the problem. Their achievements are often
below their capabilities, because of their negative
attitudes to work.
MENTAL HEALTH AND

SURGERY
When a patient visits a surgeon, it is usually
assumed that after history taking, examination and
investigations, an organic problem will be identied,
excised and the patient cured. This, unfortunately,
is not always the case. A patient may, after the
most exhaustive history taking, examination and
investigation, be found to have no organic problem.
The patient may have a psychosomatic problem.
There are patients with organic problems whose
conditions are worsened by their psychological set
up. It should be remembered that any patient going
for any type of surgery may experience anxiety.
Patients with psychiatric problems who also have
surgical problems may require modications to
their treatment. An example is a patient with a
fracture who also has schizophrenia; operation and
mobilisation on crutches, which may be a logical
treatment for another patient, may not do. Trauma
that leads to injuries requiring compensation often
trigger a series of psychological problems, which
may be incurable unless the issue of compensation
is acted upon. The expected compensation or
denite lack of it rapidly brings about a cure.
Chronic ailments including surgical ones
lead to chronic anxiety which if not recognised
may jeopardise the patients recovery. In major
catastrophic disasters in which injuries occur,
survivors require psychological support as part
The paediatricians role in mental health

Mental health is rarely considered in child health
programmes though it is very important. It is
ignored because it seems to be subtle, difcult
to dene, and is not emphasised during medical
training. In the developing world, most of the
paediatricians time is spent caring for very sick
children, leaving little time to interact with well
children. Early childhood programmes focus on
the child up to 5 years largely because of the high
morbidity and mortality in this period. Even in
these programmes other health care workers rather
than the paediatricians do the bulk of the work.
It is not often that the paediatrician comes into
contact with expectant parents though it would be
the best time to start preparing the parents for their
new roles, especially if they are expecting their
rst child.
In most African countries there are more
paediatricians than psychiatrists, therefore
paediatricians should take more interest in
childrens mental health issues. At medical level,
paediatricians should prevent problems that lead to
brain injury, advocate improved maternal nutrition,
encourage women to utilise health care facilities
during pregnancy where child health issues
26
Mental Health: From the Perspective of a Paediatrician and Surgeon
stopping in the middle of the head, may point to a

possible mental disorder. In locomotor problems,
where a patient is not responding as expected by
the surgeon, it is good at times to watch the patient
when he is not aware. Many a story has been told
where the patient was seen walking quite well, but
on reaching the clinic was unable to walk. Expected
compensation is a common cause of this.
Some patients continuously assign themselves
diseases, which have been found absent in them.
A patient, for example, will insist that he has a
tumour and that the surgeon is just not telling him
the truth. Such patients on enquiry have seen many
doctors before with similar complaints.
of overall management apart from surgical

interventions.
Preparing patients for surgery involves several
aspects and depends on whether it is emergency
or elective. The diagnosis, procedure and possible
complications should be carefully explained to the
patient and the family. Asking the patient to sign
on the dotted line without an explanation is wrong.
Fear in patients arises from being in hospital, which
is a strange place. Theatres usually instill fear in
patients and many of them wonder, as they are
led like a lamb to the slaughter, whether they are
making a one-way trip. Appropriate counselling by
the surgeon and other counsellors including nurses
does a lot to allay this fear.
The counselling process in a surgical set-up
includes responding to some questions the patients
often ask: What are the chances that I will be
normal after this surgery? This is particularly
common. What the patient really wants to know is
whether there will be any complications following
the surgery. For example, with back surgery,
there are prophets of doom, who preach that any
operation close to the spinal cord is incompatible
with normal postoperative sexual intercourse and
walking. The risks of either occurring are pretty
small, but it serves well to assure the patient. Other
questions that patients may pose include, Have
you seen or done operations of this kind before?
and How much will this operation cost? It is not
possible to enumerate all the questions that patients
ask; sufce it to say that it is good to answer them
as reassuringly as possible.
Some organic disorders of surgical and

psychiatric interest
There are various organic disorders that may cause
changes in a patient and mimic psychological
problems. Trauma to the brain causes subdural
haematoma and presents with delirium.
Infections resulting in space-occupying lesions
like tuberculoma or septic abscess can lead to
changes very difcult to distinguish from a
psychiatric illness. Endocrinological disorders such
as goitre may cause changes akin to psychiatric
disorders such as depression. Orthopaedic factors
such as low back pain are common and the majority
of low back pains have no obvious causes even
after exhaustive investigations.
Further Reading
1. Richard H. Granger and Elsa L. Stone, Collaboration
Between Child Psychiatrists and Paediatricians in
Practice, (2002). In Child and Adolescent Psychiatry
Ed. Melulin Lewis, Lippincott Williams & Wilkins,
pp 1116-1118.
Pointers to mental problems

A patient complaining of low back pain with
migration to both upper limbs, the skull and
27
28
Section II Part A:
Clinical Psychology
29
30
8
Human Development and Life Cycle
Anne Obondo, Duncan Ngare, David M. Ndetei, Eddie Mbewe,
O. Morakinyo, Ruthie Rono, Ama S. Addo
of the mind or physical body must be treated if

both are affected. This branch of psychology is
concerned with the application of psychological
principles to the practice of medicine.
WHAT IS CLINICAL
PSYCHOLOGY?
Nature of clinical psychology
Denition of psychology
Clinical psychology determines the personality

types of coping and examines the attitudes of
an individual in response to subjective and
objective stressors. Clinical psychologists
help to determine the genetic, biochemical and
physiological factors and reactions in illnesses.
Behavioural methods are applied to help the
person match the coping and management skills
to the persons abilities, character, and personality
style. This is done after a detailed assessment of
the patient to ensure that appropriate care is given.
They then coordinate and provide psychological
care, and order for the assessment and treatment
procedures. These include the behavioural, biobehavioural, psycho-physical, neuropsychological,
intellectual, forensic, vocational and psychosocial
assessments and mental status examination.
The clinical treatment approaches used include:
individual, group, family psychotherapy, behaviour
modication, hypnosis, bio-feedback, crisis
intervention, pain management and rehabilitation
services.
Psychology is the science of behaviour. Psychologists

study a large variety of behaviours in humans and
animals and try to explain these behaviours by
studying the events that cause them. Psychology
is both a profession and a scientic discipline.
Psychology as an academic discipline has twelve
major branches which include: physiological
psychology, psycho-physiology, comparative
psychology, social psychology, behaviour
analysis, behaviour genetics, cognitive psychology,
experimental neuropsychology, developmental
psychology, personality psychology, cross-cultural
psychology and clinical psychology.
Clinical psychology is the branch of psychology
that focuses on psychological testing, assessment,
diagnosis of mental disorders and provision of
psychotherapy in the management of mental
disorders. Clinical psychology also involves
teaching and planning of services in mental
health.
It is based on the fact that the body and mind
are one indivisible structure. All diseases whether
31
During the 7th and 8th weeks the embryos

sexual development begins with the appearance
of a genital ridge called the indifferent gonad.
The rst prenatal month has got the most rapid
growth in the life cycle.
HUMAN DEVELOPMENT AND

THE LIFE CYCLE
Conception to birth
The period of the foetus
Life begins with the fusion of two cells, a sperm and

an egg (ovum) in the fallopian tube of a woman.
The sperm penetrates through the wall of an ovum,
forming a zygote. From the moment of conception,
it will take approximately 266 days for this tiny
one-celled zygote to become a foetus ready to be
born.
Prenatal development is often divided into 3
major phases:
This begins from the 9th week to birth.

All organ systems become integrated in
preparation for birth. It is a period of renement
of all organ systems.
The foetus attains the age of viability at the
beginning of the 3rd trimester, usually between
22-28 weeks.
Third month
First Trimester
The foetus begins to perform many interesting

manoeuvres like kicking its legs, making sts
and twisting its body.
The digestive and excretory systems are
working.
Sexual differentiation is progressing rapidly
and the sex of the foetus can be detected by
the end of the 3rd month by ultrasound.
Germinal period (period of the zygote)

Lasts from conception through implantation,
when the developing zygote becomes rmly
attached to the wall of the uterus.
Normally lasts about 14 days.
The inner layer of the blastocysts will become
the embryo
The outer layer forms the amnion chorion,
placenta
and
umbilical cordsupport
structures that help sustain the developing
prenatal organism.
Second trimester
This is the 4th-6th months of pregnancy.
By the 4th month, the foetus is 8-10 inches
long and weighs about 6 ounces. Motor activity
includes rened actions like thumb suckling or
kicking (can be felt by mother), heartbeat and
hardening of the skeleton. The foetus assumes
a distinctly human appearance, but stands no
chance of survival outside the womb.
During the 5th and 6th months, the nails harden,
skin thickens, eyebrows and eyelashes and
scalp hair appear. Sweat glands are functioning
and heartbeat is audible. The foetus visual and
auditory senses are functional.
The period of the embryo

Lasts from the beginning of the 3rd week
through the 8th week of pregnancy.
It is the period when all major organs are
formed and begin to function.
By the 3rd week the embryonic disk is rapidly
differentiating into 3 cell layers: the outer
(ectoderm) becomes the nervous system,
skin and hair; the middle layer (mesoderm)
becomes the muscles, bones and circulatory
system and the inner layer (endoderm)
becomes the digestive system, lungs, urinary
tract and other vital organs like the pancreas
and liver.
In the 3rd week a portion of the ectoderm folds
into a neural tube that soon becomes the brain
and spinal cord.
By the end of the 4th week, the heart has
formed and begins to beat. The eyes, ears, nose
and mouth are beginning to form and buds that
will become arms and legs suddenly appear.
Third trimester
These are the 7th to 9th months of pregnancy.
Growth continues and all organ systems mature
in preparation for birth. The foetus reaches the
age of viability.
It becomes more regular and predictable in its
sleep cycles and motor activity.
A layer of fat develops under the skin.
Activity becomes less frequent during the last
2 weeks before birth.
32
do so subconsciously. Replacement of children

decreases grief in parents and these children are
usually over-protected.
Psychological aspects of pregnancy

Pregnancy is accompanied by biological,
physiological and psychological changes.
Depending on various factors, most females regard
pregnancy with a positive attitude if:
The pregnancy is well planned.
The partner is present.
There is maternal competence.
There is a role model, especially ones own
mother.
There are no conicts concerning the
mothering role.
However, a few females may present with emotional
disturbance and cognitive dysfunction. Whatever
the case, there are some common psychological
issues that occur during pregnancy.
Effects of medication on pregnancy

Upto about one-third of pregnant females
use psychotropics whose teratogenic effects remain
unclear. One should avoid these drugs unless it is
extremely necessary. They also produce symptoms
in infants such as sedation and hypotonia.
The wish in most mothers to nurse their babies
has increased and it is the most ideal situation, but
this does not always happen. Guilt feelings develop
if a mother is unable to nurse and breastfeed due to
effect of medicines or other medical reasons.
Culture-bound syndromes
Madonna complex: a psychological set of
mind, in which males view pregnant females
as sacred and not to be deled by sexual acts.
Couvade syndrome: a culture-bound syndrome
in which the father rests in bed as though he is
the one who gave birth to the child.
Pregnancy and marriage

Pregnancy is an expression of a sense of selfrealisation and identity of a female. It is a very
satisfying condition and for most females lack of
it is a cause of self-doubt regarding their gender
and sexual role. Pregnancy redenes the role of the
couple and means dealing with new responsibilities
as parents.
Infertility, mental health and pseudocyesis

Infertility may occur due to various reasons. In
situations where such diagnosis has been conrmed,
the female presents with several psychological
responses including denial, anger, frustration and
depression. The process of acceptance may be dealt
with by developing a condition called pseudocyesis.
This is false pregnancy with classic symptoms
of pregnancy and was rst described in 300 BC
by Hippocrates. The female has classic symptoms
of pregnancy except that she does not deliver
even after the expected gestation period. These
symptoms are amenorrhoea, nausea, enlargement
of breasts and abdominal distension (may be due
to broids). Cause of pseudocyesis include:
Somatic delusion not subject to reality testing
such as pregnancy test or psychotherapy.
Pathological wish to get pregnant or in some
cases the fear of getting pregnant.
Complication of hysterectomy or sterilisation.
Pregnancy and sexual behaviour

The effects of pregnancy on sexual behaviour vary
in couples:
Sexual drive may increase or decrease.
Fear of pregnancy is associated with reduced
drive.
Discomfort associated with pregnancy reduces
sexual drive.
Psychological set of mind, in which pregnant
females are viewed as sacred and not to
be deled by sexual acts, called Madonna
complex.
Some males view pregnant women as ugly,
thus avoiding sexual activity.
Intercourse is erroneously regarded as harmful
to the foetus.
Extra-marital relations in males usually occur
during the third trimester.
Mental disorders associated with child

birth
Effects of pregnancy loss (including abortions)
There are two such disorders that include

postpartum blues and psychosis. They present
as typical disorders and can mimic most of the
classied psychiatric disorders. However, they
only occur in association with childbirth and that is
why they are not classied as separate disorders.
When abortion takes place within the rst 12 weeks,

it may be a relief to the female. However, abortions
that occur later are associated with emotional
turmoil. If abortion is denied, the suicide risk tends
to increase in some females. Couples may wish to
replace such pregnancy losses and at times they
33
Primitive reexes
Postpartum blues
Postpartum blues are characterised by the following
symptoms: state of sadness, dysphoria, frequent
tearfulness and clinging dependency. The course
of postpartum blues takes several days and may be
caused by rapid rise in hormonal levels, stress of
childbirth and responsibility of motherhood.
Babinskifanning and then curling the toes

when the bottom of the foot is stroked.
Palmer graspingcurling of the ngers around
objects that touch the babys palm.
Moroloud noise or sudden change in the
position of babys head will cause the baby
to throw his arms outward, arch the back and
then bring the arms towards each other as if to
hold onto something.
Swimmingan infant immersed in water will
display certain movements of the arms and
legs and involuntarily hold its breath.
Steppinginfants held upright so that their
feet touch a at surface will step as if to walk.
Postpartum psychosis
Basically these are severe symptoms compared
to postpartum blues and they may include severe
anxiety, hallucinations, delusions, depression and
thoughts to harm baby or self. Postpartum psychosis
occurs in approximately 1 to 2 per 1000 deliveries
and is predominantly a female disorder though in
some cultures it may occur in the husbands. The
risk factors for postpartum psychosis include family
history of mood disorder and previous history of
mood disorder in the patient.
Congenitally organised behaviour

These are early behaviours of newborns that do not
require specic external stimulation and that show
more adaptability than simple reexes. These are
looking, suckingnot always reexive, e.g. during
sleep and crying.
The newborn
Babies are born equipped with a range of abilities
and capabilities:
Sensory capacities
Infancy and toddlerhood
Babies are born sensitive to a range of frequencies

of womens voices and sense of smell. Two-dayold infants can learn to pair information coming
from different sensory modalities associated to a
particular voice with a particular face.
Physical development
In the rst 2 years most babies gain about 9 kg and
grow about 38 cm in height. Growth and maturation
in infancy for the most part proceed in a denite
order although individual differences exist. The
sequence of development is to a great extent due to
gradual maturation of cells in the brain. Hence the
brain plays a critical role in physical development.
Reexes
Infants also come equipped with a wide range of
reexes. A reex is an automatic response to an
event; an action that does not require thought.
The reexes may be survival reexes (have
adaptive value) or primitive reexes (not useful)
as follows:
Development of the nervous system

At birth the brain contains over 100 billion nerve
cells or neurons, but the networks of nerve bres
that interconnect them are relatively rudimentary.
During the rst few years of an infants life there
are major spurts of growth in this network, enabling
the emergence of new capabilities, including selfregulation and certain cognitive skills. Over the
course of the early years, neural pathways in the
brain that are used become strengthened and further
developed and those that are not used atrophy.
Brain maturation alters the infants physiological
states, bringing deeper sleep, more denitive
wakefulness, greater self-regulation of alertness
and increasingly regular sleep patterns. The nervous
system grows rapidly during the early years. At
birth the human brain weighs 350 g and by the end
of rst year, it weighs 1000 g.
Survival reexes
Breathingrepetitive
inhalation
and
expiration.
Eye blinkclosing and blinking the eyes.
Papillary reexconstriction of pupils to
bright light, dilation to dark surroundings.
Rooting turning the head in the direction of
touch.
Suckingsucking on objects placed into the
mouth.
Swallowing.
34
Co-ordination of secondary schemes (8-12

months): object permanence is acquired, the
realisation that objects exist even when they
cannot be seen.
Tertiary circular reaction (12-18 months):
infants heightened interest in creating changes
in their environment fuels primitive reasoning
skills. Beginning of simple trial and error
behaviour.
Invention of new means through mental
combinations (18-24 months): they create
mental images that enable them to devise new
ways of dealing with their environment. They
think before they act.
The different parts of the brain develop at different

rates and follow a unique timetable. The hind brain
is responsible for bodily functions necessary for
survival. Its maturation is based on the development
of brain parts as well as the muscle and skeletal
system. The development of motor abilities during
the rst two years allows the infant to discover the
world. Gross motor skills involve large movements
such as running and jumping; ne motor skills
involve small, precise movements, such as picking
up a coin.
Locomotion is the ability to move from one
location to another. At 2 months, infants can raise
their chest by means of arms support. By 5 months
they can sit upright when supported, forward
mobility is evident at 6 months, at 8 months
crawling begins and they take their rst step at 1315 months.
Prehension is the ability to grasp objects
between the ngers and opposable thumb. The
neonate is born with a grasp reex, which subsides
at approximately 4 months, and prehension
occurs between 5-6 months. Prehension follows
a sequential pattern of development, particularly
those involving neuromuscular control and coordinated hand and eye movement. Childrens
artwork illustrates their increasing neuromuscular
ability. Handedness (the preference for and
subsequent predominant use of one hand) develops
at approximately 2 years of age.
Concept development
Advancement in cognitive functioning relies heavily
on the establishment and renement of concepts. A
concept is a mental image that represents an object
or event. At this time there are changes in shape,
size, spatial, class and time concepts of particular
importance as follows:
Shape and size: accurate shape and size
concept rely considerably on perceptual
constancythe tendency of objects to appear
the same under different viewing conditions.
Spatial concepts: youngsters do not realise
that an object can take a different spatial
appearance. Hence, they may have difculty
telling whether an object has been placed to
the left or right, behind or in front of another.
Class concept: they may have problems in
grouping objects.
Time concept: they have a limited concept of
time. Their understanding of it revolves around
their daily activities. They almost exclusively
use present tense when talking.
Mental development
Cognition refers to thinking, perceiving and
understanding. Jean Piagets theory of cognitive
development gives insight into how mature
thinking unfolds. He calls the rst stage of
cognitive development the sensorimotor stage that
occurs during the rst 2 years of life. Six sub-stages
comprise the sensorimotor period, each of which
facilitates overall mental development as follows:
Reex activities (0-1 month): during their rst
month, infants are limited to only primitive
reex activities such as crying or sucking.
Later the infant can discriminate between
objects that can be sucked and those that
cannot.
Primary circular reactions (1-4 months): should
an infant discover a pleasurable behaviour
pattern, chances are it will be repeated for its
own sake, e.g. thumb sucking.
Secondary circular reactions (4-8 months):
infants attempt to reproduce interesting events
in the external environment that might have
been rst caused by accident.
Cognition and memory

Children are capable of holding only a few words or
ideas in their minds. They frequently have difculty
remembering events that happened weeks, days or
even only hours before. This is due to the small
amount of information in their long-term memory
store. This improves with age due to metacognition
and metamemory abilities. Metacogniton is ones
awareness of how a cognitive process can be applied
to a given mental task, e.g. rehearsal of events so
that they can be remembered. Metamemory refers
to how ones own memory abilities can be used to
prevent forgetting.
35
a fairly stable sequence. From crying, cooing,

babbling, holophrase and early sentences.
Crying: represents the earliest infants
vocalisations. There are many different
varieties of criesfrom whimpering, fussy,
to colicky cry. Each cry usually has meaning,
and is differentiated by pitch. Crying is not a
language, but a type of communication. During
the rst 6-8 weeks of life, crying is the main
vocalisation.
Cooing and babbling: between the second and
third month cooing emerges. It includes such
sounds as gurgling and mewing and generally
indicates the infant is pleased, happy or even
excited. It is a form of communication, though
not a language and follows no grammatical
rules. It diminishes in all children at
approximately 8 months. It also consists of
vowel sounds.
Babbling: emerges at about 6 months. It
consists of vowels and consonants. Children
from a variety of linguistic backgrounds babble
in a similar fashion. Language stimulation by
adults is benecial.
Holophase stage: occurs on average between
12 to 18 months. Children appear to learn
words that relate to important people, food,
toys, body parts and animals. The early words
are primarily concrete nouns and verbs.
Early sentence: by approximately 18 months,
children start using two-word expressions.
Usually these utterances consisting of single
words that exist as separate entities e.g. toy go.
Telegraphic sentences follow the development
of two words expressions. They are short and
simple and consist mainly of nouns and verbs.
They are called telegraphic because they lack
some words.
Development of sensory organs

Vision
The visual system develops rapidly. By 4 months
infants visual accommodation and focusing
abilities are close to those of mature adults.
Brightness sensitivity matures by approximately 3
months. Ability to see small objects with increasing
clarity is also evident during early infancy. Colour
perception is also evident at an early age. By
approximately 4 months the visual spectrum of the
primary colour categories of red, blue, and yellow
can be perceived. Depth perception allows a person
to distinguish downward slopes, descending steps
or edges of precipices. Infants are able to perceive
depth as early as the crawling stage.
Auditory
The auditory system also matures rapidly as
children learn the associative value of sounds. At
about 4 months, infants are aware of the sound
of a familiar voice and will turn their heads in
the direction of the sound. At 5 months they can
discriminate vocal expressions of emotions when
those expressions are presented in conjunction
with a face. Infants can distinguish different sound
frequencies at approximately 6-8 months.
Taste and smell
During the rst few months of life, infants are able
to discriminate between sweet, sour, bitter and
salty tastes.
Touch
During toddlerhood, touch is one of the most
pleasurable of the childs sensations. The sense
of touch adds a great deal of cognitive awareness
during these years, especially when exploring the
sensations of hardness and softness, roughness and
smoothness and warmth and cold, which are at
their peak.
Personality and social development

During the early years, personality and social
growth are largely shaped by the family. From
early interactions with parents, children get a
better understanding of themselves and their
social surroundings. This awareness of oneself and
society is called social cognition, and is gained
through primary socialisation process.
Language development
The study of language development is known as
psycholinguistics. The brain and the vocal cords
enable humans to match symbolic representations
with comparable meaningful vocalisations. The left
hemisphere is the part of the brain most directly
associated with languages. No one theory fully
explains language development although three
theories have been proposed; behavioural, social
learning and innate theories. Innate theory is
considered the most inuential of the three.
The development patterns of language follow
Attachment
This is the bond between the caregiver and the
infant. It shapes early personality and social
development of the infant. Children at this time
develop a strong attachment to both parents or
36
researchers are not able to record infant feelings.

The most common emotional expression during
this stage includes: crying, laughter and humour,
fear and anxiety, and anger and aggression.
With age, emotions become more complex and
differentiated.
Personality and social growth are inuenced by
play. During these years, play is often exploratory,
manipulative or destructive. Playful interactions
with the environment help foster an early sense
of competence. Moreover, children will be
able to observe the effects of their action on the
environment.
caregivers. Attachment starts to form during the

rst year of a childs life. Behaviours that promote
parent-child attachment include holding, touching,
smiling and making eye contact. Four theories try
to explain how attachment occurs:
Behavioural theorystresses that attachment
is learnt.
Cognitive developmental theoryviews the
attachment process as a reection of the infant
developing mental abilities.
Ethological theoryproposes that an infants
social response develops largely through
innate tendencies.
Psychoanalytical theoryputs emphasis
on instincts. That attachment is shaped by
instinctive psychic energy, which at this stage
is directed towards the mother, because she is
perceived as a source of pleasure.
Possible clues to the development of the attachment
are:
The selective social smilesmile directed
only to familiar social stimuli (5-6 months).
Stranger anxietyafter 6 months. A child is
able to distinguish a stranger.
Separation anxietyby 12 months. A child
shows distress when separated from the
caregiver.
Personality development
Freud and Erikson devised theories of personality
development that cover the years of infancy
and toddlerhood. Freud in his psychosexual theory
denes the rst 18 months of life as the oral stage
of development and suggests that the mouth is
the primary source of pleasure and satisfaction to
the developing child. Hence, much of the childs
interaction with the environment is through contact
with the mouth. If there is satisfaction during
the oral stage, there will be normal personality
development and if not, xation will occur.
According to Erickson the two psychosocial
stages of importance during infancy and toddlerhood
are basic trust versus basic mistrust and autonomy
versus shame and doubt. Basic trust versus basic
mistrust occurs during the rst year of life. The
infant learns to deal with the environment through
the emergence of trustfulness or mistrust. Trust
is a feeling that some aspects of the environment
are dependable. It arises if the infants physical
and psychological needs are met. The opposite
is true of mistrust. Autonomy versus shame and
doubt occurs by the age of 1 to 3 years. Infants
become increasingly aware of their environment.
They realise the self is an entity separate from
the environment, hence, their need to exercise
autonomy.
Gender role development

This begins during the years of infancy and
toddlerhood and often reect parental gender
expectation.
Cognitive development theory suggests
that gender role emerges through the childs
growing cognitive awareness of his or her
sexual identity.
Behavioural theory proposes that the
environment conditions stimulate gender
role behaviour through the mechanisms of
reinforcement and punishment.
Social learning theory suggests that the
environment shapes individuals through
modelling and imitation.
Psychoanalytic theory proposes that a child
develops gender roles by interacting closely
with a parent and imitating the parents
behaviour.
Early childhood (2 to 6 years)

Physical growth and development during early
childhood are quite rapid though not as in infancy.
The body proportions continue to change and motor
skills become more rened. By age 5 an average
child is 3.5 feet tall and weighs about 43 pounds.
There is no difference in height between the sexes.
By the end of the sixth year, the head has attained
Emotional development
Emotions are described as changes in arousal
levels. They are difcult to measure because
37
Piaget referred to the second stage of cognitive

development as pre-conceptual thought. This stage
occurs between 2 to 4 years and is part of the much
longer pre-operational thought stage. Several
cognitive developments occur during this stage
including:
Symbolic functioning: the ability to
differentiate signiers (words and images)
from signicates (the objects or events to
which signiers refer), i.e. an act of reference
where a mental image is created to represent
what is not present. This is commonly
manifested in their new play behaviour.
Egocentrism: a style of thinking that inhibits a
person from seeing another persons point of
view (self-orientation). This is evidenced in
communication (collective monologue) where
they talk to one another, than with one another.
Also in their playparallel play (appearing to
play together, but each in their own play).
Animism: this refers to attributing life to
inanimate objects. They see all objects as
having properties like those of people.
Articialism: the belief that everything in the
world including natural objects and events has
been created by humanity.
Immanent justice: refers to the notion that
the world is equipped with a built-in code or
system of law and order. They try to explain
why something went wrong.
about 90 percent of its adult size and most of its

adult weight. The postural patterns also become
quite evident during the early years. Physical and
psychological factors responsible for this include:
Force of gravitywith age, body proportions
change and the centre of gravity drops lower
at the trunk making it easier for the child to
maintain balance equilibrium.
Type of body buildwhether heavy or light,
and the strength of bones and rmness of the
muscles.
Interaction with the environmentfactors like
nutrition, rest and activity.
Proper nutrition is essential. It enhances cognitive
and quantitative development. Lack of it may cause
retardation.
Motor skill development
The development of motor skills is accelerated
rapidly by such activities as jumping, climbing,
running and riding. Both gross and ne motor
skills advance during early childhood. Gross
motor skills require the co-ordination of large
body parts including such activities as tumbling
and rope skipping. Fine motor skills require the coordination of small body parts, mainly the hand.
Activities include, learning to write, turning pages
of a book and using scissors. Stages of motor skill
development follow the sequence:
Cognitive phasethe child seeks to understand
the motor skill and what it requires.
Associative phaseis characterised by trial
and error learning.
Autonomous
phaseperformance
is
characterised by efcient responses and fewer
errors.
Motor skill development is the product of maturation
and experience. Artwork greatly contributes to ne
motor skill development. By the end of the preschool period, children can produce recognisable
pictures that provide valuable insight into their
development and the perception of surroundings.
Concept development
The development of advanced cognitive skills
relies on the ability to acquire and categorise
new concepts from the environment, including
modications and variations of shape, size, space,
quality and time. Perceptual advances aid concept
development, although the pre-schoolers are
hindered by limited attention and attending skills.
Accurate shape and size discrimination during
childhood results from learning experiences and
is affected by a number of perceptual conditions,
including distance and the relationship between
one object and another. Perceptual discrimination
improves during early childhood, but the accurate
perception of shape and size still remains elusive.
Advancement in understanding spatial relationships
are limited during early childhood, they nd it
difcult to comprehend such spatial discrimination
as near or far. Children are not able to discriminate
quantities logically, independent of misleading
perceptual cues, for instance, more, less, few and
many.
Mental development
Progression of higher order facility is inuenced
heavily by pre-school childrens continuing
mastering of spoken languages. Hence, language
and thought are closely related developmental
processes and reect the youngsters general
cognitive activity. Cognitive advances enable
language development to accelerate, and also
enables the pre-schoolers to think qualitatively. Jean
38
Young children refer almost exclusively to the

present before they do the future or the past. Preschoolers also have difculties distinguishing
morning from afternoon and the day of the week.
Usually childrens understanding of time is bound
by the recency of situations. In most cases, they
learn hours, followed by the half hours and then
quarter hours. They are able to name the days
of the beginning and end of the week before the
middle ones.
widespread among them. The amount of anger and

aggression seems to remain stable, but its mode
of expression changes. Undirected physical anger
outbursts begin to decline after the second year.
The use of threats and insults increases. Children
mostly express instrumental aggression (directed
at acquiring objects, territory or privileges).
Factors inuencing anger and aggression include
gender, home environment, imitation, modelling
and reinforcement.
Family inuences on the developing child
Pre-schoolers are able to fabricate multi-word

sentences, complete with fairly complex syntactical
constructions. They also advance in pragmatic (use
of language in social context) skills during early
childhood. Several factors contribute to their
overall language acquisition:
Familial settings in which a child is reared,
particularly its socio-economic level, is
believed to inuence language development.
Upper and middle class parents are able
to provide proper language instructions,
stimulating environment like reading material
and reinforcements. In the African context
the extended family provides an extensive
opportunity for interaction which accelerates
the learning process.
The course of language development appears
to be related to childrens general intelligence
levels. Children with above average intelligence
begin to talk at an early stage, acquire words
at a rapid pace and use grammatically correct
sentences.
Bilingualism promotes cognitive exibility
and creative expression.
Twins frequently have slower overall rates of
language development compared to singletons.
This could be due to the fact that they may not
have initiative to make their behaviour known
to others and lack of stimulation from parents
who may divide their time between them,
among other factors.
The family transmits appropriate behaviours,

values and knowledge to children and also provides
an emotional setting in which the youngsters can
experience love and acceptance. Certain factors
related to the childs interactions with the family
include:
Sibling relations: represent an intimate
connection, one that teaches the importance
of reciprocity and mutuality, as well as the
sharing of privileges and affection. Unsettled
feelings between siblings may result in sibling
rivalrya form of competition between
children of the same family for the attention of
the parents.
Child discipline: is dened as the teaching
of acceptable form of conduct or behaviour.
Parental discipline can either be authoritarian,
authoritative, permissive or neglecting.
Parents who employ authoritarian control
attempt to shape and control their children
by enforcing a set standard of conduct. The
emphasis is on obedience and use of punitive,
forceful measures. Authoritative control is
characterised by attempts to direct childrens
activities but in a more rational fashion. Firm
control is used, but verbal give and take is
also stressed. Reasons for discipline are also
communicated to the child. Permissive control
is usually non-punitive and parents behave in an
accepting and a formative manner towards the
child without placing any demands. The child
is consulted about policy decision and given
explanation for family rules. The authoritative
method of control appears to produce the most
favourable home climate.
Child maltreatment: can take the form of
physical, sexual and emotional abuse and
neglect or abandonment. Parents may abuse
their children due to pressures from work,
home, nancial difculties, or a history of
maltreatment in the parents background
Emotional reactions and expressions become
highly differentiated during early childhood.
This is due to increasing cognitive awareness,
expanding social horizons and new developmental
challenges. Pre-schoolers exhibit many new
fears, owing to their emotional susceptibility and
because they cannot understand many objects and
events. Fear of darkness and imaginary creatures is
39
and low levels of self-esteem. All forms of

maltreatment impact negatively on the child.
elimination and retention of faeces. Adult reaction

during this stage will determine the childs later
behaviour. Parents who force early toilet training
may produce children who are obsessively clean
and neat. On the other hand, parents who neglect
toilet training may produce children who will
later exhibit slovenliness and indifference. Many
children at this age (the terrible twos) resent adult
authority and learn that they can retaliate through
retention of faeces and violent expulsion of them at
inappropriate times.
During the phallic stage (4 to 6 years) children
derive pleasure by manipulating and fondling the
genitals. The Oedipus complex is at work in boys
while girls experience the Electra complex. Boys
start competing unconsciously with their fathers
for their mothers, but due to castration anxiety,
they end up identifying with their fathers. Girls, on
the other hand, compete with their mothers for the
fathers attention. Fixation at this stage can produce
behaviour such as being unable to reach the level
of independence needed to function in society.
Erikson called this stage the initiative versus
guilt (ages 36). Children during this stage set
out to prove they have a will of their own. They
explore their environment and try to satisfy their
curiosity. Accompanying this high energy level are
rapidly developing physical skills, an increased
vocabulary, and the general ability to get around
and do new and different things. All this produces
an active child in pursuit of a variety of goals. If
adults give children an opportunity to exercise
their physical skills, answer their questions and
encourage fantasy, initiative is likely to result.
On the other hand, if children feel their questions
are annoying or a nuisance and that indulgence
in fantasy is a waste of time, guilt is likely to
surface.
School inuences
Early childhood education programmes provide
constructive learning experiences to young
children. They stress the importance of promoting
social, self-help and image skills. They also provide
a healthy learning environment and positive
guidance, discipline and emotional climate that
foster trust and security.
Peer group inuences
Moving from the family and being able to
interact with others is an important criterion of
social maturity. Peer group interaction provides
opportunities for children to further understand
their behaviour and the effect it will have on others.
Early group relations give children an opportunity
to increase their independence, competence and
emotional support. Peer relations may also provide
more complex and arousing sensory stimulations
than those available at home, offer new models of
identication, inuence self-concept development
and alter the character of childrens play. The peer
group during early childhood is quite selective,
usually consisting of individuals of approximately
the same age, who share a common play interest.
Peer groups also discriminate on the basis of
gender. Preference is on same sex playmates. Prosocial behaviour such as co-operation, comforting,
sympathising, sharing, altruism, and helping others
is present.
Play inuences
Play is an important social activity throughout
childhood. Through it children can better understand
themselves and how to relate to others. The
playgroup at this stage is usually small, restrictive
and short-lived. Many groups stop playing after 10
to 15 minutes. There are varieties of play and most
of them give the children the opportunity to develop
muscular coordination. The commonest forms are:
make believe or pretend plays, which encompass
imaginative skills and the socio-dramatic play.
Children play grown-up roles like parents, doctors
and teachers, all which may prepare them for later
life.
According to Sigmund Freud, children pass
through two psychosexual stages at this time: anal
and phallic stages.
During the anal stage (1 to 3 years) children
become aware of their bodys process of
elimination. Pleasure is derived from both the
Middle childhood (6 to 12 years)

Physical development on the whole is slow, but
steady. Children gain control and perfect motor
skills. As a result, overall co-ordination, balance
and renement in physical activities increase at
this time. Boys are taller than girls between the
ages of 6 and 8. By age 9, differences in height are
negligible and past the age of 9, the average girl
is taller than the average boy until the adolescent
growth spurt when boys catch up and surpass girls.
The same applies to weight.
There is change in physical appearance as the
rounded, chubby physiques give way to leaner
40
appearances as fat layers decrease in thickness and

change in overall distribution. There are no marked
gender differences in body proportion. Boys have
considerably more muscle tissue than girls who
have more fat than boys. The skeleton continues
to produce centres of ossication. The bones
harden and become more rigid. The circulatory
system grows at a slow pace, although by the
school years, the weight of the heart has increased
to approximately 5 times its birth weight. The
brain nears its mature size and weight. The head
circumference also increases. The weight of the
lungs increases almost 10 times by the end of middle
childhood. Breathing becomes slower and deeper
as the respiratory system works more economically
and shows greater elasticity. The digestive system
matures as reected by fewer stomach upsets. They
can digest a wide range of foods.
o Centringconcentrating on a single
outstanding feature of an object and
excluding its other characteristics.
o Transductive reasoningreasoning from
particular to particular without seeking
generalisation to connect them.
o Transformational reasoningobserving
an event having a sequence of changes to
understand how one state is transformed
into another.
o Reversibilitythe ability to trace one line
of thinking back to where it originated.
Concrete operation (7 to 11 years): The stage
of concrete operation is characterised primarily
by the ability to comprehend as follows:
o Conservationthe amount, quantity or
matter remains the same despite changes
made in its outward physical appearance.
o Classicationthe ability to understand
the concepts of sub-classes, classes and
class inclusion.
o Serialisationability to order objects
according to size.
Children can understand concrete characteristics
of objects, but still cannot understand abstractions.
Their thinking is restricted to the immediate and
physical.
Motor skill development

Both gross and ne motor skills advance at this
period, although the latter proceed at slower rates.
Numerous factors inuence the course of motor skill
attainment: rates of physical maturity, opportunities
to engage in physical activities and levels of selfcondence. Boys typically surpass girls in many
motor skill areas, but such accomplishments must
be placed in proper perspective.
Mental development
Concept development
Children advance in their mental abilities. They

become more systematic and objective, but are still
limited in abstract thinking
Children continue to rene and elaborate their

concepts, particularly those related to:
Shape and size concepts: they show greater
awareness of shape and size concepts and how
they relate to the environment and distance.
Spatial concepts: they have a fairly good
understanding.
Relational concepts: they can reason about
relational concepts such as left or right.
Quantity concepts: by age 8 most children can
add, subtract, multiply, divide and deal with
simple fractions.
Time concepts: they demonstrate an
understanding of clock time, days of the week,
months and seasons.
Concept of death: by pre-school year, ideas
about death become numerous and detailed.
Death-related thoughts and experiences are
expressed in songs, play and questions. Many
pre-school children conceive death as partial,
reversible and avoidable and because of their
Piagets stage of cognitive development

Intuitive thought and concrete operation stages
span the school years.
Intuitive thought stage (ages 4 to 7): This is a
sub-stage of the pre-operational thought stage.
Childrens thinking at this time is characterised
by immediate perception and experience
rather than mental operations. Egocentrism
still exists, but it often changes because of
the childrens cognitive advances. As a result,
these new mental structures release children
from a lower form of egocentrism, but trap
them in a higher form, namely an egocentric
orientation to symbols and the objects they
represent. Symbolic functioning represents an
important cognitive advancement, but other
modes of thought, particularly intellectual
advancement is restricted:
41
is greater use of gestures, pauses and facial

expressions.
egocentricity many view themselves as living

forever.
Development of problem-solving abilities
There is overall improvement in problem-solving

abilities. This is due to cognitive advancement,
developing memory abilities and intrinsic moti
vation. Metacognition (the application of some
cognitive processes to a selected cognitive task)
is also rened at this time. Cognitive styles and
conceptual tempos differ from child to child.
Interactions between the child and society expand

and become more complex in peer group relations,
school activities, sports and family.
There
is
greater
emotional
maturity:
more independence, exibility and emotional
differentiation. The most common emotions
include:
Fear and anxiety: there is a decline in some
fears like darkness. At the same time new fears
emerge most of which relate to family and
school, e.g. test anxiety, and fear of ridicule,
rejection and disapproval.
Anger and aggression continue to be expressed
physically: outbursts like kicking and hitting
are common. Verbal expression of anger is
also common. Generally at this stage children
express greater amounts of hostile aggression
(aggression intended to hurt another person).
Happiness and humour: children express
happiness as a result of acceptance or
accomplishments. They also enjoy listening to
jokes and understand them.
Love is expressed not only through hugging
and kissing, but also through sharing and
talking. This love is extended to animals too.
Learning disabilities
This is the difculty in processing, remembering
or expressing information, which hinder cognitive
development. Some common learning disabilities
include:
Dyslexia: functional limitation in reading.
Dysgraphia: difculty with the physical act of
writing.
Dyscalculia: difculty with calculations.
Language decit: difculty in expressing
oneself verbally.
Auditory decit: difculty in processing
information through the sense of hearing.
Spatial organisation decit: difculty in
perceiving dimensions of space.
Memory decit: trouble remembering facts or
what has transpired during learning episodes.
Attention decit disorder: difculty in
concentrating for extended periods of time.
Attention decit hyperactive disorder:
difculty in concentrating for extended periods
of time together with high levels of excitability
and impulsivity.
Social skills decit: difculty in understanding
elements of social interaction.
Moral development
Moral development advances at this stage. Piaget
emphasises the importance of cognitive
development to morality and identied the premoral, moral realism and relativism stages.
Pre-moral stage (before 5 years): children have
a limited awareness of rules and the reasons
for them.
Moral realism (5-10 years): this is where
some moral judgment begins. Children learn
rules from parents, but do not yet understand
the reasons for them. Instead the rules are
regarded as sacred and untouchable. Children
also feel that punishment compensates for
their transgressions.
Moral relativism (from age 10): children
become aware of both the meaning of rules
and the reasons for them. Rules are regarded
as a product of mutual consent and respect.
Overall psycholinguistic development continues
and it is especially noticeable in:
Vocabulary and semantic development: word
acquisition rates are rapid, but comprehension
of word meaning and relationships among
words is slow to develop.
Syntactic development: the use of compound
and complex sentences increases, while use of
incomplete syntactic structures decline.
Pragmatics: when speaking, school-age
children became increasingly more adept
at taking their listeners into account. There
42
They are also understood in relation to the

principles they uphold.
can comprehend more about their surroundings.

They seek to understand and make things that are
practical to them. Play intermingles with work
and becomes productive and the product is allimportant to childrens self-esteem. Children who
fail to be productive may feel inferior.
Family inuences
Children still need and rely on their parents, but
their boundaries with the outside world expand.
There is need for social independence, as children
want to spend more time outside the family. Many
also want to spend more time doing things on their
own. Children need to experience a favourable
home climate throughout this period. Shared
responsibility is part of this. The television plays
an important role in inuencing the children.
Televised violence may promote aggression in
children. However, controlled television viewing
can be useful for instruction and for enhancing and
enriching lives.
Adolescence
The word adolescence is from the Latin word
adolescere meaning to grow up in maturity.
Puberty and sexual responsiveness
Puberty is derived from a Latin word pubertas,
which means age of adulthood. This is the stage
of physical development during which primary
and secondary characteristics mature and people
become capable of having children. It is a gradual
process, which transforms the internal and external
childs body into that of an adult.
Primary sex characteristics are the sexual and
reproductive organs, genitals and internal organs,
e.g. penis, testis, ovaries, fallopian tubes, uterus
and vagina. Secondary sex characteristics: are
the non-genital features, e.g. breast, pubic and
facial hair, broadening of shoulders and waistline,
distribution of fat and voice break. Both primary
and secondary characteristics develop notably
during adolescence.
Hormones account for many changes that occur
at this time. Other factors that may be responsible
for puberty, apart from the hormones include the
brain. As a result of these hormonal changes, limb
lengthening is a signal of growth spurt, which is
also inuenced by sex hormones like testosterone,
oestrogen and progesterone. Both testosterone and
oestrogen direct the development of genital growth
and the reproductive system growth. Sex hormonal
development causes adolescents to be more aware
of sexual feelings, desires, and arousals, which
may lead to dating, mate selection or sexual
intercourse.
Growth spurt is an accelerated rate of physical
growth that occurs just before puberty. It continues
at a lesser rate throughout adolescence. It is one
of the most apparent physical changes of teenage
years, e.g. girls reach physical maturity earlier than
boys. They are superior in height between ages 11
and 13. By age 15 however, boys begin to develop
rapidly and surpass girls both in height and weight.
The skeletal structure of both sexes increases in
height, weight, proportion and composition. Girls
may reach their mature size by age 17, while boys
do so at age 19.
School inuences
Teachers exert a lot of inuence on the child.
They serve as role models. The examples they
set, the tone they establish for peer relations and
the feedback they give to children are important
inuences. The methods of classroom control,
whether democratic, authoritarian or laissez-faire
affect children differently.
Peer group inuences
Interactions intensify at this time. Peer groups are
very selectivesimilar sex; age, social status and
race are criteria for acceptance. Peer groups often
meet certain needs at this time, such as desiring
to be away from adults or in the company of likeminded individuals. Friendships are closer and
more meaningful. Boys are more oriented to groups
while girls are drawn to one-one friendships. Robert
Selman (1981) proposes four stages of friendship:
the playmateship stage (pre-school years), one way
assistance stage (early school years), fair weather
co-operation (latter school years) and intimate and
mutually shared relationships.
Personality development
Freud calls this the latency period (6-11 years).
It is marked by the diminishing of the biological
and sexual drives and is a relatively quiet period
of transition. There are no prominent instinct
urges developing within the child. However,
Freud acknowledges that new skills do emerge.
Paramount among them are skills promoting ego
renement, particularly those that strengthen and
protect the ego from frustrations and failure. These
he called defence mechanisms.
Erickson refers to this stage as the industry
versus inferiority stage (6-11 years). Children
43
social appearance, and are attention seekers. The

general problem of early maturation is the need to
adjust to the rapid growth. They tend to feel internal
disharmony and this may have an implication
on their sexual behaviour (begin physical sexual
relationship before they are psychologically
ready).
In females, ovaries increase in size and weight.

Menarche ranges from 10 to 15 years with majority
starting between 13 and 14. Menarche does not
necessarily mean attainment of reproductive
capacity. The subsequent monthly periods may
be irregular and occur without ovulation. Breast
development starts at ages 11 to 12, but can also
start at 14 years. The maturity may take another 3
years or longer. Female pubic hair starts to appear
after the breasts begin to develop. Sex hormones
are mainly responsible for the transformation of
the childs body to an adult shape.
Growth of testis and hormones for most boys,
start to accelerate by age 12. By 18 years, testicular
development is almost complete. Penile erections
are experienced and they increase in frequency and
can happen at any time and anywhere. Production
of seminal uid and rst ejaculation (spermache)
occurs by age 15. Initially, ejaculation has very few
sperms, hence cannot impregnate. Ejaculation of
semen that occurs at night sleep is called nocturnal
emissions (wet dreams). Development of male
pubic hair begins between ages 13 to 14. It starts
at the base of the penis and extend towards the
abdomen. Facial hair develops in a systematic
sequence. Starting from the corners of the upper
lip, then extending on the entire upper lip hence
acquisition of moustache. It starts smooth, but
becomes coarse with age. Later, hair appears on
the upper part of cheek and the middle line below
the lower lip. Finally it develops on the sides and
the borders of the chin. Much later it grows in front
of the ears. Other developments in males include:
increased activity of the sweat glands and marked
voice change. There is deepening of the voice as
a result of the lengthening of the vocal cords and
growth of the voice box (larynx).
Pronounced puberty changes affect adolescents
psychologically in the way they perceive
themselves and their pre-occupation with the
changes, especially on primary and secondary
sex characteristics. They must adjust to growth
spurt changes (therefore need help). The positivity
or negativity with which the adolescents view
themselves will greatly affect how they ultimately
evaluate themselves, e.g. menstruation, wet dreams,
erection, body size and organ size.
Generally, adolescents report higher levels of
personal satisfaction when they mature early than
late. Early maturers are more independent, self
condent, reliant and popular. This gives them a
positive body image. Late maturers have a poor
self-concept, are overly concerned about their
Motor development
There is an exhibition of steady increase in
strength, reactions and co-ordination abilities.
Males continue to surpass females in overall motor
skill development. Men have larger muscles and
are able to develop more force per gram of muscle
tissue. Hence, men are good in accuracy, speed and
overall body control, especially in activities that
call for endurance.
Mental development
Piagets formal operations cover the period from
11 to 15 years. It is a stage characterised by
new ways to understand and explore the world.
Entry into this stage is gradual and sometimes
unpredictable. Individuals may reach peak levels
of cognitive functioning in certain areas but not in
others. Childhood mental processes and operations
diminish, e.g. concrete operation.
Formal operation signies crystallisation and
integration of all previous cognitive stages.
Thinking becomes extremely rational and continues
to be rened in adulthood. Individuals can deal with
abstraction and hypothesis; can solve a problem by
providing alternatives, i.e. cognitive development
is exible. They can think about identity and their
future, because of the abstract reasoning power.
They, therefore, can think about occupational and
social roles. They are capable of generating new
ideas about themselves and life in general. Debates
are possible about a variety of issues, such as
politics, relationships, morals, legal issues, human
rights and ideal society. Important is the problem
solving strategy of adolescents through deductive
and inductive reasoning. Deductive is drawing
conclusions from sets of premises, syllogism (a
deductive inference consisting of two premises and
a conclusion), e.g. Tom is a man. Man is a mortal.
So Tom is mortal. Inductive means generalising
from specic, e.g. morality being generalised to a
harmonious society.
Language development improves. They ascend into
heights of language understanding and use, e.g.
44
understand symbols, metaphors, word meanings,

similes, idioms, and characterisation.
development in early adulthood is both qualitative

and quantitative.
Adolescence egocentrism
Qualitative mental dimension
This is a form of self-centeredness characterised

by what people are thinking about them and hence,
conceptualising own thoughts and at the same time
concern with other peoples thoughts resulting
in self-consciousness. Two types of thinking
(consequences) result: imaginary audience and
personal fable.
This can be referred to as post-formal

reasoning. Dialectical thought is a kind of
thinking that allows an individual to appreciate
contradictions and opposites. Adolescents have
tendencies of thinking that there is only one correct
answer to every problem, hence very subjective.
Adults see things as relative and non-absolute.
They begin to accept and respect the diversity of
opinion and the rights of others. Hence, they are
said to have a relativistic perspective. Young adults
also start deep reasoning, i.e. can deal well with
myths, metaphors and paradox (pragmatics).
Imaginary audience
It is a delusion that other people are concerned
about how adolescents behave and look. They feel
as though they are the centre of focus. They may
talk loudly, show off, walk in individualistic styles
and dress prominently. Imaginary audience can
make them feel elated or deated depending on the
situation and audiences. They are self-critical, but
also self-admiring.
Quantitative mental dimensions

Longitudinal studies show that there is a quantitative
mental change during adulthood. A study done to
test the hypothesis whether intelligence changes
with age found that:
Crystallised intelligence and visualisation test
scores improved with age.
No age-related change was found in cognitive
exibility.
Visual motor exibility demonstrated
signicant decrease with age (Baltes).
The ndings dispel the myth of intellectual decline
during middle and old age. Therefore, intellectual
functioning is characterised more by stability than
change and discontinuity in adult life. Therefore,
people with above average intelligence can improve
or maintain their ability until latter adulthood,
whereas adults with average intelligence may
experience a decline in some mental capacities.
Adulthood marks a time when individuals can
sustain or increase their qualitative and quantitative
mental capacities, because with advancement of
age, adults have acquired practical insight into life,
considerable real world learning, good judgment,
discretion and wisdom.
Personal fable
These are stories that adolescents fabricate and
tell about themselves. It reects their conviction
of personal uniqueness and immunity. They feel
invulnerable (nothing bad can happen to them),
e.g. cannot die, get pregnant or contract a disease.
Egocentrism diminishes by the end of adolescence,
because experience makes them realistic.
Early adulthood (20-40 years)

Quality and quantity increment in early childhood
is noticeable during this stage. The child gives
way to the appearance of a young adult and has
a lot of vitality. They are very attractive. Muscle
growth is complete and increases in strength up to
approximately 30 years. The heart and its blood
network (circulation) mature.
Motor development
From age 30, there tends to be an increase of fatty
tissue as compared to muscle tissue. Young adults
can participate in all sorts of activities, especially
between 20 and 30 years. These activities can take
place for a decade if they do not smoke or drink
and if they feed properly and exercise.

Adult maturity
Gordon Allport postulates that maturity is an
on-going process characterised by a series of
attainments:
Extension of the self (to encompass multiple
facets of the environment).
Relative
warmth
to
others
(social
development).
Emotional security.
Cognitive development
Cognitive development is a systematic and
complicated problem-solving activity. New
levels of creative thoughts are achieved. Mental
45
Realistic perception (the mature mind is able

to perceive the surroundings accurately).
Knowledge of self (self-insight). This can be
explained as knowing what one can and cannot
do.
Possession of skills and competences (all
facets of behaviour, i.e. physical, cognitive,
emotional, social and moral).
Establishing a unifying philosophy of life
(which embodies concepts over-guiding
purpose, ideals, needs, values and goals.
Erikson called this stage the intimacy versus
isolation stage. This means that early adulthood
is a time of intimate relationships. This will only
be achieved after solving the identity crisis of
adolescence. Individuals who know themselves
stand better opportunities of having intimate
relationships.
According to Daniel Levinsons theory (1978)
people are divided into eras, i.e. young and middle.
Each era consists of developmental periods marked
by distinct biopsychosocial tenets. He says there
is a transition period between these eras. The
transitions sometimes overlap. He describes 8 eras:
pre-adulthood. (0-22 years), early adulthood (1725), early adulthood transition (17-22), entry life
structure for early adulthood (22-28), transition
to middle adulthood (28-38), culminating life
structure for early adulthood (33-40), middle life
transition (40-45) and middle adulthood (40-45).
These transitions overlap and prepare an individual
to end one era and enter into the other.
The skin starts thinning, because of the sun,

age, cosmetics and less efcient blood circulation.
The face exhibits a lot of change, e.g. wrinkling
becomes the inevitable sign of aging; complexion
also changes and skin cancer is common; hair
becomes grey, begins to thin and replacement
becomes very slow. Hair loss is more pronounced
among men.
The cardiovascular system slows down by about
20 percent by age 50. There is general increase in
blood pressure and hardening of arteries; nervous
system decrease is negligible; respiratory system
decreases (75 percent at middle age compared to
100 percent at age 30), because of loss of lung
elasticity, the thorax becomes shorter, and chest
muscles become stiff and weaker. Inactivity makes
this worse. Vision starts to change; hearing starts
declining by age 40; health disorders are common;
obesity, hypertension, arteriosclerosis, cholesterol,
coronary artery diseases, cancer, osteoporosis and
arthritis. Menopause occurs at this stage and is
associated with decrease in oestrogen.
Middle adulthood (40-65 years)
Social and personality development
It is the longest life cycle and has numerous

challenges including old parents, rebellious
adolescents, politics, divorce and retirement.
In love and marriage, if all is well, marriages will

be stable. This stability comes from few nancial
worries, less household chores, more time with
each other, and adjustment to each others needs.
If not, divorce, and diverse marriage problems are
experienced.
Sherman indicates that empty nest syndrome
is experienced by those parents who lived a life
centred around the children. Parents are advised
to let go quite early. The opposite is true in the
western world where marital partners have more
time even to pursue academics and travel.
Research shows that sibling relationships persist
over the entire life cycle for most adults. There are
three types of sibling relations: extremely close
siblings, apathetic (indifferent) siblings and highly
revolting siblings. Most siblings are very close.
Close siblings were also the same in childhood.
Personality characteristics such as attitudes and
Mental development
Fluid intelligence is mental organisation and
re-organisation of information like in problemsolving. While this decreases with time, crystallised
intelligence increases over time. Sensory motor
change little with time. Short-term memory
declines slightly, especially when new information
is added, but there is signicant decline in longterm memory. This is because encoding and
retrieval processes become less efcient with age.
Physical growth and development for the majority
ends by early adulthood. Some individuals are
able, however, to improve on or sustain muscle
strength during middle adulthood. Most individuals
experience a slight loss due to decrease of body
muscle bres and gradual loss of the lean body
mass, and increase of subcutaneous fat. A slight
decrease in stature begins to occur, because there
is compression of the spinal column and disc
changes. Continued vitality is possible in this stage
by keeping physically t, proper nutrition and
lifestyle, medical care, good sleep, and avoiding
stress, drinking and smoking. This slows down the
aging process.
46
values seem to be replicated, i.e. carried on to

the next generation. Relationships are transmitted
across generations. Elder shows that children
whose parents had a high degree of marital conict
and who were unaffectionate subsequently had
tension in their own marriage and were ineffective
in disciplining their own children.
Middle-aged individuals play an important
role in intergenerational relationships, e.g. while
they are parents to a very demanding groupthe
adolescents and young adults, they are also sons
and daughters to another demanding group, their
aged parents. Stress can result in couples if they do
not realise this.
Death and dying

Death can and does occur at any stage. However,
old people are more aware of its eminence. Old
people are less afraid of death than others. Cultural
beliefs inuence the way people perceive and react
to dying and death. In the African culture there is a
lot of fear of the spirit world and death is also seen
as a taboo.
The dying patient
Elizabeth Kubler-Ross (1969) organised her theory
after interviewing dying patients. According to
her the dying process consists of ve interrelated
stages. She also says individual differences occur
where some may skip a stage, others may not go
through the stages in the given order, others may
get stuck in a particular stage. For others, the ve
stages may overlap:
Denial: this is where people may react with
shock, disbelief and denial.
Anger: when denial is no longer successful,
the patient experiences feelings of anger, rage,
envy or resentment.
Bargaining: the patient hopes that death can
be delayed and may promise God to do many
things if allowed to live.
Depression: as patients continue to experience
physical deterioration, they are engulfed
with a sense of great loss, hence, experience
depression. Two forms of depression may
surface: reactive depression (reacting to a loss
that has already occurred e.g. amputation) and
preparatory depression (depression in response
to impending loss or death).
Acceptance: this stage allows the dying to
express their feelings, settle and wait for their
death with quiet expectations. It is a period
almost devoid of feelings and patients may
request to be left alone most of the time.
Communication becomes more non-verbal
than verbal.
These stages may also apply to the bereaved.
Late adulthood (ages 65 years and above)

This is a new concept in psychology, because
people used to die early (before 65 years).
There is great decline in body functions, i.e.
cardiovascular, vision, and hearing. Illnesses are
common and sexuality declines.
Cognitive development
Crystallised intelligence (based on cumulative
learning) increases throughout life, while uid
intelligence (ability to perceive and manipulate
information) starts to decline. Cognitive skills can
be kept alive through mnemonics (use of imagery).
Old people who are prepared to retire adjust better.
Such are healthy, have saved, are active and have a
healthy social network of friends and family.
Social and personality development
Erikson views this as a time of looking back at what
one has achieved in life. Through many different
routes, this person may have developed a positive
outlook in each of the preceding periods.
Mental health
Many old people may suffer from depression and
diseases that may affect their mental health, causing
brain cells to deteriorate.
47
9
Personality and Personality Traits
Ruthie Rono, Lincoln Khasakhala, David M. Ndetei
Sanguine: individuals who had an abundance

of blood; they tended to be cheerful, optimistic
and active.
Phlegmatic: people who were listless, sluggish
and tired, because they had less phlegm.
Melancholic: people who were always sad,
brooding with melancholic temperaments
resulting from too much bile.
Choleric: people who were easy to excite and
also easy to anger, because of excess yellow
bile
DEFINITIONS
Personality may be dened as a distinctive and
relatively consistent way of thinking, feeling and
behaving that characterise a persons responses
to life situations. An individuals personality
comprises three components:
Components of identity that distinguish that
person from other people.
The behaviour is caused primarily by internal
rather than environmental factors.
The persons behaviour patterns seem to t
together in a meaningful fashion, suggesting
an inner personality that guides and directs
behaviour.
Distinctive behaviour pattern helps dene the
persons identity. People seem to behave somewhat
consistently over time and across different
situations.
These terminologies are still used as descriptive

adjectives by typologists, psychologists and
psychiatrists.
Trait theories
Allports cardinal, central and secondary trait
theory
Personality characteristics are unique attributes
of the individuals personal dispositions which
account for the consistency in pattern of behaviour
among individuals. Personality traits are thus
enduring patterns of perceiving, relating to and
thinking about the environment and oneself that
are exhibited in a wider range of contexts. The
traits unite a persons unique pattern of response
to a variety of environmental events. When
personality traits are inexible and maladaptive,
they will cause signicant functional impairment
or subjective distress to the characteristics of the
individual. There are three types of traits that
PERSONALITY THEORIES
What makes one person different from another? The
ancient Greeks thought the answer had something
to do with the four body uids, humours; blood,
phlegm or black and yellow bile. According to the
Greek physician Hippocrates (460-371 BC), there
are four possible personality types:
48
Personality traits characterise individuals

customary ways of responding to their world.
Our personalities are also exible due to
learning from experience and trying out various
responses to see which ones are more effective
(as we interact with our surroundings). People
who suffer from a personality disorder usually
do not have this exibility.
operate in individuals to provide a persons own

unique personality structure:
A cardinal trait: a powerful dominating

behaviour predisposition that provides the
pivot point in a persons entire life; such as
competitiveness, hatred, cruelty, loss and
reverence for life.
Central trait: this is present among all people,
forming major characteristics of personality,
such as sensitivity, honesty and generosity,
versus insensitivity, dishonesty and mean.
These are enduring and forming the building
blocks of personality.
Secondary traits: these are less generalised
and enduring; they affect individual behaviour
only in specic circumstances, such as the
dressing style, preferences or patterns of
exercises. They are changeable according to
environmental events.
THE DIFFERENT PERSONALITY

THEORIES
The psychodynamic perspective
Freuds psychoanalytic theory
According to Freud, the personality is divided
into three structures the Id, the Ego and
the Superego.
Cattells sixteen personality factor theory
The Id
According to this theory, individuals have different

dimensions of personality which are obvious,
called source traits, such as integrity, friendliness
and tidiness. These dimensions can be measured
in every day situation (life records) using a 16
personality factor (16PF) questionnaire to obtain
data of personality characteristics. After analysis,
the results are clustered, probably each cluster
indicating the operation of a single underlying
trait.
Trait theories offer the distinct advantage of
providing specic methods for measuring or
addressing basic characteristics that can be used
in comparing individuals. These theories share
the common assumption that traits may be used
to explain consistencies in behaviour and explain
why different people tend to react differently to the
same situation.
The Id exists within the unconscious mind. It is

the innermost core of personality and the only
structure present at birth. The Id is the source of all
psychic energy. It has no direct contact with reality
and functions in a totally irrational manner.
It operates according to the pleasure principle
(seeks immediate gratication or release regardless
of rational considerations and environmental
realities) and cannot directly satisfy itself by
obtaining what it needs from the environment (no
contact with the outer world).
In the course of development, a new structure
develops out of the Id (that has direct contact with
reality).
The Ego
The Ego functions primarily at a conscious level. It
operates on the reality principle, by testing reality
to decide when and under what conditions the Id
can safely discharge its impulses and satisfy its
needs. Sexual gratication within a consenting
relationship, for example, rather than allowing the
pleasure principle to dictate an impulsive sexual
assault.
Components
Temperament is the how of behaviour
and a biologically-based general style of
reacting emotionally and behaviourally to the
environment. Examples are: calm and happy,
irritable and fussy, outgoing and active, and
shy and inactive.
Character is the what of behaviour.
People tend to react in their own predictable
and consistent way. These consistencies
(personality traits) may be the result of
inherited characteristics, learned responses or
a combination of the two.
The Superego
This is the last personality structure to develop (age
4 or 5). It is the moral arm of the personality and
contains traditional values and ideals of society.
Ideals are internalised by the child through
identication with parents, who also use
49
important ways by stressing social and cultural

factors in personality development. Modern
object relations theorists focus on the mental
representation that people form of themselves,
others and relationships.
reinforcement and punishment to teach the child

what is right and what is wrong. Like the Ego,
the Superego strives to control the instincts of
the Id (especially sexual and aggressive impulses
that are condemned by society).
The dynamics of personality involve a continuous
conict between impulses of the Id and counter
forces of the Ego and Superego. When dangerous
Id impulses threaten to get out of control or when
danger from the environment threatens, the result
is anxiety. To deal with the threat, the Ego may
develop defence mechanisms, which are used to
ward off anxiety and permit instinctual gratication
in disguised forms.
Defence mechanisms deny or distort reality.
Some defence mechanisms permit the release of
impulses from the Id in disguised forms that will
not conict with forces in the external world or
with prohibitions of the Superego. The major
defence mechanisms are:
Repression: pushing into the unconscious
mind.
Denial: refusing to acknowledge anxietyarousing aspects of the environment.
Displacement: repressing an undesirable
impulse and then directing it at a safer
substitute target.
Intellectualisation: repressing an upsetting
event and treating the situation as an
intellectually interesting event.
Projection: repressing unacceptable impulse,
then attributing to and projecting onto other
people.
Rationalisation: constructing a false, but
plausible explanation for an anxiety-arousing
behaviour.
Reaction formation: repressing an anxietyarousing impulse, then releasing an exaggerated
expression of the opposite behaviour.
Sublimation: releasing a repressed impulse in
the form of a socially acceptable behaviour.
The humanistic perspective

This puts emphasis on the subjective experiences
of the individual and thus deals with perceptual
and cognitive processes. Self actualisation is
viewed as an innate positive force that leads people
to realise their positive potential if not thwarted by
the environment.
Carl Rogers Self Theory
This theory attaches central importance to the
role of the self (an organised, consistent set of
perceptions and beliefs about oneself). The self
plays a powerful role in guiding our perceptions
and directing our behaviour. At the beginning of
their lives, children cannot distinguish between
themselves and their environment. They begin to
distinguish between the me and the not me as
they interact with their world.
There is need for self-consistency (an absence of
conict among self-perceptions) once self concept
is established and for congruence (consistency
between self-perceptions and experience). Experiences that are incongruous with the established
self-concept are a threat and may result in denial or
distortion of reality.
People are born with an innate need for positive
self-regard (acceptance, sympathy and love from
others). Positive regard is essential for healthy
development. Unconditional positive regard
implies that the child is inherently worthy of love.
Conditional positive regard is dependent on how
the child behaves.
Rogers described a number of characteristics
of the fully functioning person, such as feeling a
sense of inner freedom, self-determination, choice
in the direction of growth and no fear of behaving
spontaneously, freely and creatively. Rogerss
theory helped stimulate a great deal of research on
the self-concept including studies on the origins and
effects of differences in self-esteem, enhancement
and verication motives, and cultural and gender
contributions to the self concept.
Criticism of the psychoanalytic theory

A major shortcoming of the psychoanalytic theory
is that many of its concepts are ambiguous and
difcult to operationally dene and measure. How
can we measure the strength of an individuals Id
impulses, unconscious Ego defences and study
processes that are unconscious and inaccessible to
the person? However, inaccessibility to something
does not imply that it is non-existent. Neoanalytic
theorists modied and extended Freuds ideas in
Criticism of the Self Theory

Humanistic view relies too much on individuals
reports of their personal experiences. It is
impossible to dene an individuals actualising
50
unstable and emotionally reactive behaviour pattern

that involves moodiness, anxiety and depression.
Prediction studies indicate that the larger
number of more specic traits may be superior for
prediction of behaviour in specic situations.
However, traits have not proved to be highly
consistent across situations. They vary in stability
over time. Individuals differ in their self-monitoring
tendencies, and this variable inuences the amount
of cross-situational consistency they exhibit in
social situations.
Traits interact not only with situations,
but also with one another, thereby producing
inconsistency.
tendency, except in terms of the behaviour that it

supposedly produces.
Trait and biological perspective

Trait theorists
Trait theorists try to identify and measure the
basic dimensions of personality. They disagree
concerning the number of traits needed to
adequately describe personality. Cattell suggested
16 basic traits (personality dimensions).
Reserved
versus
Outgoing
Less intelligent
versus
More
intelligent
Affected by feelings versus
Emotionally
stable
Submissive
versus
Dominant
Serious
versus
Happy-golucky
Expedient
versus
Conscientious
Timid
versus
Venturesome
Tough minded
versus
Sensitive
Trusting
versus
Suspicious
Practical
versus
Imaginative
Forthright
versus
Shrewd
Self-assured
versus
Apprehensive
Conservative
versus
Experimenting
Group-dependent
versus
Self-sufcient
Uncontrolled
versus
Controlled
Relaxed
versus
Tense
Other theorists insist that as few as ve may
be adequate: openness, conscientiousness,
extraversion, agreeableness and neuroticism.
Eysenck suggests two major dimensions:
introversion-extraversion, sociable, active and
willing to take risks versus a tendency towards
social inhibition, passivity and caution.
Biological perspectives on traits

These state that there are differences in the
nervous system. Introversion-extraversion and
stability-instability are linked to the differences in
individuals normal pattern of arousal within the
brain (Hans Eysenck).
The biological perspective supports the possible
role of evolution in the development of universal
human traits and ways of perceiving behaviour. In
addition, studies comparing identical and fraternal
twins reared together or apart indicate that genetic
factors may account for as much as half of the
variance in personality test scores. Individual
experiences account for the rest.
Researchers are exploring relations between
personality factors and health. Evidence exists for
a Type A personality that is a risk factor in coronary
heart disease, a Type C cancer-prone pattern, and
the roles of optimism and conscientiousness in
promoting health and longevity.
Social cognitive theories

These are concerned with how social relationships,
learning mechanisms and cognitive processes
jointly contribute to behaviour. A key concept
is reciprocal determinism, relating to two-way
causal relations between personal characteristics,
behaviour and the environment.
Table 9.1
Introversion
Extraversion
Retiring
Reserved
Likes solitary activities
Does not attend parties
Outgoing and talkative

Wants many friends
Dislikes solitary
activities
Enjoys parties
Dominates social
situations
Reciprocal determinism
Person: personality characteristics, cognitive
processes and self-regulation skills.
Environment: stimuli from social or
physical environment and reinforcement
contingencies.
Behaviour: nature, frequency and intensity.
Stability-instability (neuroticism): represents a

continuum from high emotional stability to an
51
live under great pressure

demanding of themselves and others
have an exaggerated sense of time urgency
become very irritated at delays or failures to
meet their deadlines
tend to schedule more and more activities in
less and less time
try to do several things at once.
Type A men and women have about double the risk
of coronary heart disease (even when other physical
risk factors, e.g. obesity and smoking are taken into
account). However, not all components of the type
A pattern increase vulnerability to CVD.
The crucial component here seems to be negative
emotions. In addition, a cynical hostility marked
by suspiciousness, resentment, frequent anger,
distrust and antagonism seems to be particularly
important. They over-react physiologically to
events that arouse anger.
Rotters theory
Rotters theory views behaviour as inuenced
by expectancies and the reinforcement value of
potential outcomes as follows:
Expectancies: our perception of how likely
it is that certain consequences will occur if
we engage in a particular behaviour within a
specic situation.
Reinforcement value: basically how much we
desire or dread the outcome that we expect the
behaviour to produce.
Rotters concept of locus of control is a generalised
belief in the extent to which we can control the
outcomes in our life as follows:
Internal locus of control: people with an internal
locus of control believe that life outcomes are
largely under personal control and depend
on their personal behaviour. Internal locus of
control is positively related to self-esteem,
feelings of personal effectiveness, coping with
stress in a more active and problem-focused
manner versus externals, and less likelihood
to experience psychological maladjustment
(depression, anxiety).
External locus of control: people with an
external locus of control believe that their fate
has less to do with their own efforts than with
the inuence of external factors (chance, luck,
powerful others).
Type B personality
These individuals tend to be coronary-disease
resistant. They are:
more relaxed
more agreeable
have far less sense of time urgency.
Type C personality
These have a cancer-prone personality. They are:
highly sociable and nice people
very inhibited in expressing negative emotions.
Bottling up such emotions (anger or anxiety)
seems to get in the way of active coping
tend to feel helpless and hopeless in the face of
severe stress
passive, uncomplaining and compliant.
Banduras concept of self-efcacy

This is considered a key factor in how people
regulate their lives. It relates to our self-perceived
ability to carry out the behaviour necessary to
achieve goals in a particular situation and believes
that people whose self-efcacy is high have
condence in their ability to do what it takes to
overcome obstacles and achieve their goals.
PERSONALITY TYPES
(FRIEDMAN AND ROSENMAN)
PERSONALITY DEVELOPMENT
Personality develops through the interaction
of hereditary dispositions and environmental
inuences. Children grow physically, mentally,
socially, emotionally and form attachments and
relationships.
Type A personality
These are at risk of developing cardiovascular
disease (CVD). They are:
aggressive
usually in a hurry
have high levels of competitiveness and
ambition
Ericksons psychosocial theory

Personality develops through confronting a series
of 8 major psychosocial stages. Each stage involves
52
Integrity versus despair
a different crisis or conict over how we view

ourselves in relation to other people and the world.
Each crisis is present throughout life, but takes on
special importance during a particular age period.
This marks the nal crisis and usually occurs

during late adulthood (over 60). Older adults review
their life and evaluate its meaning. The person
experiences integrity (a sense of completeness and
fullment), if the major crises of earlier stages have
been successfully resolved. Older adults who have
not achieved positive outcomes at earlier stages
may experience despair, regretting that they cannot
relive their lives in a more fullling way.
Psychosocial stages of personality development

Basic trust versus basic mistrust
During the rst year of life we depend totally on
parents or other caretakers. Whether we develop
basic trust or mistrust depends on how adequately
our needs are met and how much love and attention
we receive.
Freuds psychosexual theory of personality

development
Autonomy versus shame and doubt
It states that personality is powerfully moulded

by experiences in the rst years of life. Children
pass through a series of psychosexual stages during
which the Ids pleasure-seeking tendencies are
focused on specic pleasure-sensitive areas of the
body (erogenous zones). Potential deprivations
or overindulgences can arise during any of these
stages, resulting in xation (a state of arrested
psychosexual development).
The adult personality is basically moulded by
how children deal with instinctual urges and social
reality during the oral, anal and phallic stages as
follows:
During the next two years, children become

ready to separate themselves from their parents
and exercise their individuality. If parents unduly
restrict children, or make harsh demands during
toilet training, children develop shame and doubt
about their abilities and later lack the courage to be
independent.
Initiative versus guilt
Ages 3-5 display great curiosity about the world.
Children develop a sense of initiative if allowed
freedom to explore and receive answers to their
questions. They can develop guilt about their
desires and suppress their curiosity if they are held
back or punished.
The oral stage: during infancy

Infants gain primary satisfaction from taking in
food and from sucking on a breast, thumb or some
other object. Excessive gratication or frustration
of oral needs can result in xation on oral themes
of self indulgence or dependency as an adult.
Industry versus inferiority

At ages 6-12 life expands into school and peer
activities. Children who experience pride and
encouragement in mastering tasks develop industry
(a determination to achieve). Repeated failure
and lack of praise for trying leads to a sense of
inferiority.
The anal stage: second and third years of life

Pleasure becomes focused on the process of
elimination. The child is faced with societys
rst attempt to control a biological urge (during
toilet training). Harsh toilet training can produce
compulsions, overemphasis on cleanliness, and
insistence on rigid rules and rituals. Extremely
lax toilet training results in a messy, negative and
dominant adult.
Intimacy versus isolation

Young adults (20-40) develop intimacy, that is, the
ability to open oneself to another person and to
form close relationships. Many people form close
adult friendships, fall in love and marry.
Generativity versus stagnation
The phallic stage: 4 or 5 years
One achieves generativity by doing things for

others, exercising leadership and making the world
a better place (through their careers, volunteer
work, raising children, or involvement in religious
and political activities). Many young adults also
make such contributions to society, but generativity
typically becomes a more central issue later in
adulthood (40-60).
At this stage, children begin to derive pleasure from

their sexual organs. The male child experiences
erotic feelings towards his mother, desires to
possess her sexually and views his father as a rival.
These feelings arouse strong guilt and a fear that
the father might castrate him (castration anxiety).
This conicting situation is the Oedipus complex.
53
Girls discover that they lack a penis and blame

the mother for their lack of the more desirable sex
organ. The female version of the Oedipus complex
is the Electra complex.
The phallic stage is a major milestone in the
development of gender identity as children normally
resolve these conicts by repressing their sexual
impulses and they move from a sexual attachment
to the opposite-sex parent to identication with the
same sex parent, boys taking on the traits of fathers

and girls those of their mothers.
The latency stage: about 6 years of age
Here, sexuality becomes dormant for about 6 years
and will re-emerge in adolescence as the beginning
of a life-long genital stage. Erotic impulses nd
direct expression in sexual relationships.
54
10
Human Learning
Caleb Othieno, Ruthie Rono, David M. Ndetei
changes, but also to develop teaching and treatment

methods in schools and clinical settings. Behaviour
therapy is developed as a result of these theories.
The main theories of learning are:
Classical conditioning (Pavlovian)
Operant learning (Skinnerian)
Social learning
Cognitive learning
Biologic learning.
DEFINITION
Learning refers to the relatively permanent change
in a persons behaviour brought about by repeated
experiences. The laymans view of learning may
be narrowthat of only learning of facts by
heart, or the acquisition of skills such as typing
and driving. However, in this denition, any
change is includedchanges in social behaviour,
language and other communication skills and
feelings of emotional expression, attitudes and
beliefs. Learning is not always intentional nor
is the learner even always aware that it is taking
place. Experience refers to the events in the
social and the physical environment of the learner
and is specied in order to exclude changes due to
maturation, senility, injury or illness. Relatively
permanent distinguishes between learning and the
performance of what is learned. Learning can only
be measured by observing behaviour. It cannot be
measured directly. Note that performance can be
inuenced by factors such as motivation, anxiety
and fatigue.
Classical conditioning (Pavlovian)

Ivan Pavlov, a Russian physiologist in the earlier part
of the 20th century demonstrated that dogs could be
conditioned to salivate in response to new stimulus,
such as a ringing bell or light, if this had been paired
or presented together with food several times. The
food is the unconditioned stimulus (US) and the bell
the conditioned stimulus (CS).
LEARNING THEORIES
The main learning theories are the classical
and operant conditioning. Some argue that classical
conditioning may be a variant of operant conditioning.
The learning theories have not only been used to
understand and explain normal human behaviour
Food
(unconditioned
stimulus)
salivation
(unconditioned
response)
Bell or light
paired with food
salivation
Bell (conditioned
stimulus, CS)
salivation
(conditioned
response, CR)
Laws of classical conditioning

The main effect of classical conditioning is to
increase the number of different stimuli that can
55
elicit a given reex or response. The CS must

precede the US by a very short period of time for
this type of learning to occur. The optimal length
varies with different CS-US combinations and with
different responses, but is often approximately
0.5 seconds. If the US-CS interval is too long, no
conditioning will occur and if the US precedes the
CS, conditioning does not usually occur. Classical
conditioning is a very simple form of learning and
has been demonstrated in atworms and decorticate
specimens. Therefore, conditioning can occur
without the learner being aware of the connections
between the CS, UR and US. In humans, however,
awareness may increase the effectiveness of
the conditioning procedure. Built-in or innate
characteristics of the animal also determine the
type of behaviour that can be conditioned.
to a red light. Alternatively, a circle and a square

drawing may evoke similar responses in an
organism.
Second order conditioning
When an organism has been conditioned, the
CS can act as an US and in turn be paired with
another new US to elicit similar responses in the
organism.
Discrimination
This refers to the process where one recognises the
difference between similar stimuli. Conditioned
discrimination is brought about through selective
reinforcement and extinction. A child, for example,
gradually learns that not all four-legged animals
are dogs. Experimental neurosis was described
as arising when an animal nds it increasingly
difcult to distinguish or discriminate between two
stimuli.
Acquisition
Each paired presentation of the CS and the US
is called a trial. The period when the organism is
learning the association between the CS and the
US is called the acquisition stage.
Operant conditioning (Skinnerian or

instrumental learning)
Thorndike in 1898 demonstrated that a cat
placed in a cage could be conditioned through
trial and error to learn how to deliberately press
a lever that delivers food pellets outside its cage.
The American psychologist, Burrhus Frederic
Skinner, later comprehensively studied this type
of associative learning. The learning in this case is
under the control of the individual, who operates or
inuences the environment, hence, the term operant
conditioning. The effect of operant conditioning is
to change the frequency with which an aspect of
behaviour occurs in a given setting. The frequency is
inuenced by the consequences of the behaviour. A
rat placed in a box with levers, accidentally presses
one that delivers food (the reward). Thereafter,
it will learn to do so when hungry. It might
continue doing so even in the absence of a reward.
Alternatively, a desired response may be made to
occur as best as possible and then the behaviour is
rewarded. The behaviour will eventually fade off if
it is not rewarded, every now and then. In real life
situations, a reward might be in the form of money,
praise, approval or certain privileges. In substance
use and addiction the reward is brain stimulation.
Various schedules may be used in reinforcing the
desired behaviour:
Fixed ratio, where reinforcement occurs after
a xed number of non-reinforced responses,
e.g. 20:1.
Reinforcer
Repeated pairing of the CS and the US strengthens
or reinforces the association between the two.
Varying time intervals
In simultaneous conditioning the CS begins a
fraction of a second or so before the onset of
the US and continues with it until the response
occurs. Hence, it is necessary to omit the US in
some trials to see if the conditioning has occurred.
Experiments show that learning is fastest when the
CS is presented about 0.5 seconds before the US
(delayed conditioning). In trace conditioning the
CS is presented rst and then removed before the
US starts (only a neural trace of the CS remains
to be conditioned).
Extinction or internal inhibition
If the conditioned stimulus is presented repeatedly
without being paired with food, the strength of the
response will gradually decline. This is known
as extinction.
Stimulus generalisation
An organism conditioned to respond to a certain
stimulus will respond to other similar stimuli in
the same way; a dog that has learned to respond
to yellow light will also respond in the same way
56
Human Learning
Fixed interval, where reinforcement is done at

xed intervals of time.
Variable ratio, where reinforcement ratio is
varied constantly.
Variable interval, where the time between
reinforcements is varied.
Schedules of reinforcement have a powerful
effect on the strength of the learned behaviour.
Other factors include characteristics of the learner
and the n ature of the reinforcer. Behaviour that
is learned under intermittent reinforcement is
more resistant to change and better learned than
continuous reinforcement schedule conditions.
Fixed ratio schedules usually produce a stable rate
of response. By gradually increasing the number of
responses per reinforcement it is possible to obtain
very high ratios; the learner performing hundreds
of responses. When the reinforcement is presented
there may be a pause followed by a return to the
high rate of response. Variable ratio schedules
also result in very high response rates, but are not
characterised by high post-reinforcement pauses.
resembles that elicited by the unconditioned

(reinforcing) stimulus. Salivation is a dogs normal
response to food. In operant training the reinforced
behaviour bears no resemblance to the behaviour
normally elicited by the reinforcing stimulus.
Respondent (classical conditioning behaviour) is
directly under the control of a stimulus. Operant
conditioning, on the other hand, just seems to
happen. The operant behaviour operates on the
environment to produce some effect.
Social learning theory

This theory combines principles of both operant
and classical conditioning, and puts emphasis on
human interactions. It refers to learning inuenced
by otherslearning by imitating the behaviour of
other people. Other terms used are role modelling
and identication. In clinical situations: watching
one perform a dreaded task, for example, a child
playing fearlessly with dogs may modify phobic
behaviour. Commercial advertisers are well aware
of this form of learning and use models that they
think target populations can identify with. In
health promotion campaigns such as campaigns
against drug use, the educators may decide to use
individuals from the same culture and age group to
enhance the change. Note that although the person
learns by imitating others, personal factors are also
involved. The behaviours have to be rewarded if
they are to become part of the persons repertoire.
Behaviour occurs as a result of the interplay
between cognitive and environmental factorsa
concept known as reciprocal determination.
Types of operant conditioning

Reward training, where a rat presses a lever
more often, because it obtains a reward of
food.
Aversive conditioning, where painful events
such as noise or elec
Punishment training, involves administering
an aversive stimulus after an undesirable
behaviour. That particular response would
then be weakened or eliminated. It is not much
favoured, because although it eliminates one
type of behaviour, one cannot predict what the
organism will use to substitute it.
Avoidance training refers to a situation where
behaviour is learned, because it enables the
learner to avoid something unpleasant. If a
bell is rung a few seconds before a shock is
delivered the rat might learn to run away at the
sound of the bell, hence, avoiding the shock.
Escape learning, where the animal learns
to escape from a painful event, such as a
rat jumping from a chamber in which it is
subjected to an electric shock into a shock free
zone.
Shaping behaviour involves gradually
adjusting the behaviour by rewards until the
desired behaviour is reached.
There are differences between classical and operant
conditioning. In classical conditioning the response
Cognitive learning theory

The proponents of this theory argue that the human
being is not a passive organism, but is capable
of processing information and comprehending
the relationship between cause and effect. The
processed information is stored and may be
retrieved later when required. If the process
is faulty or it distorts real life situations, then
maladaptive behaviour may result. Aaron Beck
postulated that depressed patients have a negative
view of themselves, as they tend to focus only on
their failures. This leads to negative expectations
and low mood. A negative view of oneself leads to
negative interpretation of experiences and negative
expectations of the future.
Biological theories
Neurophysiologists have been able to demonstrate
certain changes in the nervous system of organisms
57
so. The laws of classical conditioning require that

the exposure be repeated, but in the case of a phobia
developing following a single event such as a bomb
blast, the maintaining factors are thought to play a
big role. Thus in the example just cited, the blast
and the injuries or frightening sights are associated
with the place and as in classical conditioning this
leads to conditioned fear. Since the person fears
the place and is rewarded (by not experiencing
any anxiety), each time he avoids the place the
behaviour is reinforced. Fear of that particular
place may become generalised, the person may
fear going into town and eventually even getting
out of the house.
Inaccurate health beliefs and misinterpretation
of bodily sensations are thought to be responsible
for the development of somatoform disorders.
Restructuring the cognitive set is an important
therapeutic intervention. The application of similar
theories in depressive states has already been
described.
associated with learning. Broca and Wernicke

identied certain areas involved in language and
memory. By critically stimulating certain brain
sites, they were able to evoke certain memories.
In animals whose amygdala have been ablated,
learning is usually defective. Hypertrophy of
certain brain areas has also been associated with
learning. This is due to an increase in the number
of nerve connections between synapses. As new
pathways are created the chances of recall increase.
Other evidence for the biologic theories include the
experiments that show that if planarians (atworms)
that have been trained are ground up and fed to
untrained planarians, then the latter could be more
easily trained compared to controls. It is possible
then that in learning, some stable material, possibly
new ribonucleic acid (RNA) is formed in the brain
cells. Drugs that alter this process may enhance or
inhibit learning.
MALADAPTIVE LEARNING
HABITS AND HEALTH
PROBLEMS
Behavioural methods, approaches and

techniques in the management of health
problems
From the learning theories the methods of behaviour
therapy have developed. Behaviour therapy and
lately cognitive therapy techniques have been
applied in a wide range of medical and psychiatric
conditions. These include anxiety, depressive,
somatoform and addiction disorders, and even the
major psychoses.
The theories of learning have been used to explain

the development of certain psychiatric disorders.
These include anxiety disorders, depression
and somatoform disorders. It is easy to see how
one can be conditioned to fear certain objects or
situations if exposure to the event is paired with
a noxious stimulus, but in real life this is not always
58
11
Human Motivation and Emotions
Caleb Othieno, Ruthie Rono, David M. Ndetei
of expressing emotions. Motivation and emotion

are closely related; strong emotions may lead to
certain actions: anger may lead to aggression.
DEFINITION
A motive is something that has the power to initiate
action. In psychology, it refers to the underlying
factors that energise and direct behaviour. Motives
seek to explain why people do what they do when
they do them.
Motivation is usually divided into needs and
drives. Needs refer to the physiological aspects
of emotion, while psychological factors are
considered drives. Thus, one may talk of the
physiological need for food in a hungry animal and
the hunger drive that leads it to seek the food. In
human beings, the following types of motivation
are recognised: survival and social needs, and
curiosity motives. The motives that are aimed at
preserving life such as the need for food and water
comprise the survival needs. Examples of social
needs include sexual and maternal behaviour.
The curiosity motives, for example, explorative
behaviour cannot usually be directly related to the
survival needs of the organism.
Emotion is the feeling, tone or response to
sensory input from the external environment or
mental images. The outward component of emotion
manifests itself as smiles or gestures. Accompanying
emotions are the physiological responses. These
are expressed through the nervous system the
limbic system and the autonomic nervous systems.
Moods are states of emotional reaction that last for
only a limited period, while temperament (a part of
personality) refers to an individuals habitual way
PHYSIOLOGICAL BASIS OF
MOTIVATION
Hunger
The hypothalamus has been identied as the centre
that regulates feeding behaviour. In animals that
have parts of their hypothalamus removed or
damaged, feeding disorders are observed. It was
initially thought that the lateral hypothalamus (LH)
housed the feeding centre, while the ventromedial
hypothalamus (VMH), was the satiety centre.
Later experiments, however, have shown that
they may be more concerned with regulating the
set body weights rather than feeding per se. Thus,
in animals with lateral hypothalamus lesions
the normal body weight is set at a lower point
resulting in an emaciated animal. The converse is
true for ventromedial lesionsthe animal becomes
obese. The disturbances in feeding are therefore
geared to maintaining the new body weights and
after the initial adjustment period when the animal
underfeeds (LH lesions) or overfeeds (VMH
lesions) eating resumes, but in a modied pattern to
maintain the new body weights. In regard to body
uids, the antidiuretic hormone (ADH) is released
by the osmoreceptors in the hypothalamus in
response to dehydration. The hormone acts on the
59
seek to drink water. Furthermore, the kidneys will

conserve waterthus forming urine that is more
concentrated.
kidneys to increase the amount of water reabsorbed

from the tubules, thus preserving the body uids.
Social needs
Psychoanalytic Theories
Sexual and maternal needs are strong motivators

in all animals, including human beings. In human
beings, however, the innate instincts are modied
by social controls and needs. Thus, the basic
behaviour of seeking a partner, marriage and childbearing are tinted with cultural factors.
Sigmund Freud stated that human behaviour is

determined by two basic forces: the life instincts
(eros) and the death instincts (thanatos). The former
explains this behaviour that is directed towards
the preservation of life, such as sexual behaviour.
The latter leads to destruction, for example, the
aggressive nature of man.
Curiosity motives
Curiosity refers to the in-born drive or need to
manipulate and explore the environment. It seems
to be innate in that it is observed in children
from quite an early age. Children play with toys
and react to stimulation and novel situations
with pleasure. As they mature, they engage in
games that are more complex. It seems that the
exploration and stimulation provide the organism
with new and changing sensory input that are
essential for the integrated functioning of the
nervous system. Individuals that are deprived of
or placed in a situation where the sensory input is
severely diminished, begin to hallucinate and have
other sensory distortions.
Incentive (Behavioural) Theory

This theory is derived from the learning theories.
It holds that an organism is likely to engage in
a certain type of behaviour if it were rewarded
following food-seeking behaviour. Exploratory
behaviour or sensation seeking behaviour with no
tangible reward does not make sense using this
theory, although the survival needs and the sex
needs can be explained in this way.
Drive Reduction Theory

It is thought that tension builds up in an organism in
response to certain needs. As the goals are achieved,
for example obtaining food, the tension is reduced
and this is accompanied by a pleasurable feeling.
Like the incentive theory, the drive reduction theory
does not offer a satisfactory explanation for all the
human motives, in particular the tendency by some
individuals to seek tension-producing states.
Instincts
These innate biological forces predispose an
organism to act in certain ways. Some psychologists
postulate that all human thought and behaviour
are the result of instincts. Several instincts are
identied such as ight, repulsion and curiosity.
Humanistic Theory
This approach was proposed by Abraham Maslow.
He reasoned that human motivations were
organised in a hierarchy of needs. These are listed
below starting with the most complex or advanced
needs:
Self-actualisation needs: self-fullment and
realisation of ones potential.
Aesthetic needs: concerns about beauty, order
and symmetry.
Cognitive needs: the need for exploration and
to understand things.
Esteem needs: the need for competence and
achievement; and to gain approval and fame.
Love and need to belong: acceptance and
afliation to others.
Safety needs: security and freedom from
danger.
THEORIES OF MOTIVATION
Homeostasis and the Drive Theory
It is essential that the body maintain a constant
internal environment for its optimum functioning.
Corrective measures are in place to ensure that the
bodys temperature, body uids and the various
chemicals and hormones are maintained within a
certain range. In explaining the hunger drive, the
level of blood glucose acts as the main determinant.
When the levels fall below a certain limit the
organism feels hungry and will then seek food
in order to rectify the anomaly. In addition, food
stored in the body in the form of fat will be broken
down to boost the blood glucose levels. Likewise,
when the body uids are depleted, the animal will
60
Human Motivation and Emotions
Physiological needs: these are basic and

include hunger, thirst and sexual gratication.
He stated that the lower needs in the hierarchy
must be partly fullled before those at the next
level can assume importance. If they are not, then
the organism remains preoccupied with them until
the needs are met. Beauty and environmental
conservation may not mean much to a person
whose needs for food are not met.
EMOTIONAL STATES IN
DIFFERENT SITUATIONS
Theories of Emotion
James-Lange theory
It states that bodily changes are the primary
cause of emotions. Thus, a subject perceives a
situation followed by bodily changes, which lead
to the subjective experience of emotions. The
type of emotion elicited, such as anger or fear, is
determined by the pattern of physiological changes
that precede it.
MOTIVATION AND HEALTH

BEHAVIOUR
Cannons theory
Individuals do not always act in a way that is

benecial to their health, for example, smoking,
drinking, and eating unhealthy foods. Theories
of motivation have been used to understand
why such seemingly irrational behaviour occurs
and to formulate behaviour change. In alcohol
and substance abuse, motivating the individual to
change forms an important part of the therapy.
Cannon thought that after the subject perceives

a particular situation, the bodily changes occur
simultaneously with the cortical reactions.
The cognitive theory of Schachter and Singer
It includes elements of the rst two theories. After
a subject perceives a situation, no specic bodily
changes follow. This is accompanied by a better
understanding of the situation, which in turn elicits
more emotions and bodily changes that are more
specic.
61
12
Memory and Forgetting
Caleb Othieno, Ruthie Rono, Mohamedi Boy Sebit, David M. Ndetei
Semantic memory is the memory for automatic

skills that are acquired during life. It is also
necessary for the use of language.
Implicit memory for acquired skills such as
typing, riding a bicycle or driving a car.
Both the semantic and implicit types of memory
do not decline with age. Instead, one accumulates
information throughout life. In contrast, the
episodic type of memory declines with age.
MEMORY
Memory refers to those processes involved in the
acquisition of information, its subsequent retrieval
and use. The memory process can be divided into
three main components: registration, retention,
and recall and recognition.
Memory plays an important part in learning.
Learning implies retaining facts. If nothing is stored
from previous experience then no learning can take
place. Thinking and reasoning are also done with
remembered facts. Other phenomena that depend
on the continuity of memory are self-perception,
concepts about time: past, present and future. The
opposite of recall and recognition is forgetting.
Physiological basis of memory

Neurobiological basis of memory
The brain areas involved in memory are located in t
he hippocampus, amygdala, cortex and cerebellum.
Approximately 100 billion neurons are involved in
forming memories, including a layer of 4.6 million
in the hippocampus. Patients in whom the temporal
lobes, hippocampus have been removed are unable
to retain any material, although short-term memory
is not interfered with. In memory formation, it is
thought that an environmental stimulus forms
an electrical or chemical impulse, which passes
through the neurons to the brain. This triggers
the formation of connections between synapses.
An increase in synaptic connections occurs when
learning takes place. Long-term memories are
retained longer than short-term ones, because of
the longer duration of time that such memories
have had to link up with a number of locations in
the cortex. The more the connections, the better the
chances of contacting a neural pathway leading to
it.
Short and long-term memory

The following types of memory are recognised:
Immediate or short-term memory: for events
that have occurred within the past 30 seconds.
Recent memory: for events over the past few
hours or days.
Recent past memory: this refers to information
retained over the past few months.
Remote memory: refers to the ability to
remember events that have occurred in the
distant past.
Memory can also be classied according to
function as follows:
Episodic memory for discrete events.
62
Storage may be the critical factor in good memory.

Relating material to something already known
creates more pathways. Information processed
at the semantic level decays at a slower rate than
that of rote learning (learning without meaning or
comprehension). Short-term memory is adversely
affected by chronic emotional states and lack of
effort caused by psychological exhaustion or too
much input. Note that the same factors adversely
affect learning. The capacity of the short-term
memory is 5-9 bits.
Smell and emotions are linked to long-term
memories. Scent conveys information through
the olfactory nerve to the hippocampus, which
plays a role in the control of emotions. Increased
adrenaline from stress may enhance learning, but
if it is too much the learning is inhibited. Mood
also affects learning and recall of material. A happy
mood enhances memory.
The two process theory of memory

This theory proposes a short-term memory
(STM) with a limited capacity and the long-term
memory (LTM) with an unlimited capacity. It is
noted that the retrieval system of the latter is not
always successful. The long-term or secondary
memory includes recent, recent past and remote
memories. The STM or the primary memory is
also referred to as the immediate, working or
buffer memory. The physiological support for the
two-process theory, as noted earlier, is that patients
with damage to the temporal lobes hippocampus
have impaired LTM, but the STM is unaffected.
The problem therefore seems to be the inability
to transfer new material from STM to LTM. The
consolidation theory proposes that the memory
trace needs to undergo consolidation to become
stable. If there is interference before that happens,
then the material is forgotten. This may explain
the retrograde amnesia that occurs following head
injury, electroconvulsive therapy (ECT) and
alcoholic blackouts.
Varieties of memory processes

Re-integrative (Recollection): Refers to
the process where earlier experiences are
reintegrated or re-established based on partial
cues. Studies under hypnosis show that
memories from ages 7-10 can be recalled more
accurately under hypnosis than in the waking
state. It is thought that memory depends on the
development of language, so experiences that
occur much earlier may not be remembered.
Alternatively, the child may perceive the
world differently from an adult so attempts
to remember what was registered earlier fails.

Sometimes in recollection, the subject may be
quite convinced that what he remembers is the
truth, while the facts are different.
Recall: Giving the subject something to
learn then after a time lapse asking them to
remember the material is used to test recall.
Recall is affected by rationalisation to make
the material understandable; conventionalism
(common
place
limits);
omissions,
displacements, telescopy and confabulation.
Pleasant experiences are more likely to be
remembered than unpleasant ones.
Recognition: In recognition one acknowledges
that a fact is familiar although one may not
remember all the details. One may remember a
face, but cannot recall the circumstances under
which it was seen. A similar experience is the
dj vu (previously seen) phenomenon a
sense of familiarity that is sometimes aroused
in strange surroundings. This may be due to a
single recognition followed by generalisation
of the situation from experience.
Relearning: Even when something may seem
to be completely forgotten, it may be easier to
learn it the second time round. This is because
of the learning that occurred in the past,
although the subject does not recall. Hermann
Ebbinghauss studied this using nonsense
syllables. He learned 7 lists of unrelated items
until he could make 2 errorless repetitions.
After learning the rst list, he waited 20
minutes then relearned the list again to 2
errorless repetitions. After learning other lists
he waited for longer intervals 1 hour, 1 day,
2 days, 6 days and 31 days before relearning
each list. The amount of learned material
retained plotted as a function of time is called
the retention curve.
Eidetic images: These refer to the
photographic memory visual impressions
that persist after the actual visual stimulus has
been removed. It occurs in about 5 percent of
children and declines with age.
Retrieval processes
The retrieval is an active process supported by the
occurrence of the tip of the tongue phenomenon.
One may feel certain that he knows something,
but may not be able to recall it immediately. One
may also suddenly remember something without
being aware that it was being processed by the
mind. This implies that an active search goes on
involuntarily.
63
dependent). Other theories concerning forgetting

are: decay through disuse, interference effects and
motivated forgetting. Recent theories concerning
the neurobiological basis of learning including
RNA and the memory trace, lend support to the
earlier theories.
Clinical conditions or situations in which memory

needs to be assessed include:
Organic diseases: Low intelligence, acute brain
syndromes (delirious states) due to infections
such as encephalitis and head injury.
Anoxic brain damage following systemic
diseases, myocardial infarction, respiratory
embarrassment and carbon monoxide
poisoning.
Temporal lobe surgery and cerebral tumours.
Alcohol-related disorders: alcoholic blackouts,
alcohol-induced dementia.
Wernicke-Korsakoff psychosis.
Cerebral vascular disorders: subarachnoid
haemorrhage due to trauma or aneurysms and
transient global amnesia caused by decreased
blood ow to the parietal temporal region of
the left hemisphere.
Degenerative disorders causing dementia
such as Alzheimers disease and Huntingtons
chorea.
Benign forgetting of old age.
Anterograde amnesia due to electroconvulsive
therapy: this resolves invariably within weeks
and in most cases, within a few days.
Depression and anxiety.
Dissociative disorders.
Malingering/ctitious
disorders:
these
are characterised by inconsistent ndings
and retention of personal details. The
precipitants are usually stressful events related
to money, legal or disturbed relationships.
Psychoanalysis: involves the recollection of
earlier experiences, some of which may be
subconsciously blocked or forgotten.
Free recall.
Decay through disuse

It is assumed that with the passage of time, memory
traces in the brain fade. This, however, may not
necessarily be true. Motor skills such as riding a
bicycle or driving a car are retained for long. It is
also known that old people may vividly remember
their childhood experiences, but are unable to recall
what they had for breakfast.
Interference effects
New learning may interfere with material that had
previously been learnt. This is known as retroactive
inhibition. Prior learning may also interfere with
the learning and recall of new material proactive
inhibition. These effects have been demonstrated
using the nonsense syllables. However, learning
beyond bare mastery makes the person less
susceptible to interferences of either the proactive
or retroactive types.
Motivation and repression

Inaccessibility of learned material is sometimes due
to repression. In these cases, the retrieval would be
unacceptable to the individual, possibly because of
the anxiety or guilt that might be activated.
MOTIVATION, MEMORY AND

COMPLIANCE TO MEDICAL
ADVICE AND INSTRUCTIONS
Memory involves three separate, but related events
as follows:
Encoding and storing the information.
Retaining it over a period of disuse.
Retrieving it at the time of recall.
It is possible to intervene at all these stages in
improving memory. One can improve in encoding
and storage by the following techniques:
Mental imagery and recallmethod of loci.
Dual encoding systems: non-verbal imagery
and verbal symbolic processes.
Organisation of memory and hierarchical
organisations.
NATURE OF FORGETTING
It is thought that memories are never actually
completely erased under normal circumstances.
The fact that electrical stimulation of parts of
the brain may elicit memories long forgotten or
those that the subject was unaware of, support the
permanency of memories. Forgetting may be due
to loss of information or inability to retrieve the
information. The latter case occurs when critical
cues to retrieve the information is lacking (tip of the
tongue phenomenon). In the former case, an actual
decay of the memory trace is said to occur (trace
64
Chunking: since the capacity of the STM

cannot be increased beyond its capacity of
7 2 if one has to retain larger amounts of
information in the STM, it has to be chunked
together.
Self-recitation,
practice
or
rehearsal,
and elaborative rehearsalworking out
associations.
Relearning and repetition.

Over-learning.
Drugs
that
enhance
storage
include
strychnine, nicotine, caffeine and amphetamines.
65
13
Communication and Communication Skills
Anne Obondo, Lincoln Khasakhala, David M. Ndetei,
Victoria Mutiso, Francisca Ongecha-Owuor
begins the session by nding out what the problem

is.
INTRODUCTION
Ability to be honest and compassionate
Communication is an important tool in health care

through which signs and symptoms are expressed
and understood. The process of communication
helps resolve the mystery of the people we meet.
It is used to bridge some differences that exist
between people and can bring much satisfaction
and joy in our relationships.
Medical workers need to communicate bad news

gently and honestly, and with compassion. For
example, it is important to say I am sorry to say
this but yes the diagnosis is one of cancer.
Ability to empathise
The health professional has to be very familiar
with the case because this will provide him
with the ability to respond to certain situations
appropriately.
GUIDELINES TO GOOD
COMMUNICATION SKILLS
Ability to listen
Time
The health professional should set the ball rolling

and let the patient or relatives determine the
direction of the communication. However, the
health worker should be able to answer questions
raised by the patient and relatives.
Adequate time for the patient or client to tell

their own story, and to feel they have been
adequately heard and understood. Health workers
need adequate time to respond and explain their
decisions.
Ability to understand
Preparation
A health worker should be able to understand the

question asked by the patient or by the relative by
probing. This will help the health worker discover
why the question was asked in the rst place.
Only by determining the real reason behind the
question will the health worker be able to address
For appropriate intervention, the medical worker

needs to study the case carefully and in consultation
with other colleagues. During consultation, a
quiet room or area where distractions are minimal
should be used. The therapist or medical worker
66
Communication and Communication Skills
Observation of posture and gait provides information

about the individuals perception of himself and
about physical problems or limitations. Postures
that are stooped, relaxed, awkward or always
erect provide evidence of how a person expresses
himself generally. It also suggests an individuals
self-concept by indicating his emotional status
at the time of observation. Clothing signies
authority, social position, nancial status, religious
persuasion, cultural inuence and self-concept,
whereas physical characteristics also denote the
level of health.
Eye contact or no eye contact are both vital
parts of ones facial expression either expressing
willingness to maintain social contact or social
withdrawal. Dominance can also be communicated
through eye contact or mutual glances. Hands
are expressive parts of our bodies that convey
messages such as feelings, attitudes and ideas
that may be positive, negative or even neutral
depending on the pattern of communication.
Messages conveyed may vary with culture and
environment.
the issues to the full satisfaction of the patient and

family.
Ability to care
Sometimes when dealing with patients, health
workers tend to leave them with no alternative
arrangement for follow up. It is important that
such alternative arrangements are made so that
the patient and relatives are helped to come to
terms with the situation and perhaps reinforce or
clarify what had already been said.
Consistency
Consistency in information given to the patient
and his relatives is very important. The health
worker should appraise all the other health care
workers involved e.g. family doctor, specialist,
nurse so that the patient or relatives are not given
conicting information which may confuse them.
CHANNELS OF
COMMUNICATION
Listening
Listening is a highly specialised perceptual process
used to absorb and attach meaning to patients
ideas. The health worker is able to assess beliefs,
feelings and ideas of patients which is useful in
setting goals for management of such patients.
Listening is the primary sensory skill used to
effect therapeutic communication with a patient
and his relatives. Listening involves paying
attention to what the patient has to say or showing
interest in his needs, problems and expectations.
Interest and sincerity is determined by the ability
to maintain eye contact. The more we listen to the
patient the more effort he is willing to make in
expressing ideas and perceptions clearly.
When the patient is talking, the following
should be considered:
Tone of voice: this is the channel through
which to detect the incongruency between
what a patient says and what he means.
Rhythm of words: for example, monotonous.
Rapidity of his speech: is it usual or unusual
for him? This needs verication by those
who know him well.
Relevance of patients verbal communication:
a patient may verbally communicate some
message which may be inappropriate in an
interpersonal situation yet it may express a
Non-verbal communication
Observation
Observation is important because it is used to
elicit additional information from patients by
observing non-verbal behaviours. It is important
to observe what a patient does, what happens to
him, and how he moves and looks. It is also a
primary source of data when patients are unable
or unwilling to provide information. An accurate
description of what is seen or observed is basic to
care of the patient.
The non-verbal clues given by the patient
or their relatives are very important. Through
observation, the health worker will detect the
many ways the patient reinforces and contradicts
verbal messages. It is important to observe the
harmony and disharmony of all the signals.
The home environment and family interactions
are clues to the socio-economic status, safety, age
and cultural make up. The design of a home and
its furnishings e.g. the general look of the home
(neat, casual, disarranged) its size, suitability
for those who live in it, utilisation of space for
privacy, work or play and reception given to the
visitors should be noted. Studying the styles of
living people adopt provide a more complete
picture of a family and its lifestyle.
67
problem appropriate to his need that he cannot

deal with directly.
Use of phrases: such as I expect, I hope,
There is no point, What is the use?,
Dont bother may suggest expectations or
non-expectations.
Assessment of themes: for example, listening
to theme of wellness, loneliness, loss and
humour.
also the natural smell of the environment in which

people live. Families living in the slums become
desensitised to odours that directly affect their
health.
Verbal communication
Talking
Communicating verbally is a skill that most
people have developed and is sometimes used
by individuals to succeed. Failure of certain
individuals may be due to poor communication.
For a person to be able to communicate effectively,
he needs to have knowledge of the subject and
should be willing to explore the topic with another
person and to listen to points of view different from
his own.
Wellness:
The reason for their hospital attendance
this may help identify the patients areas of
wellness.
The period he considered himself well or what
he might do when he gets well
Loneliness:
Language used
I dont care
Nobody cares,
Even God has deserted me.
Withdrawal from interpersonal relationships.
Misunderstanding in communication can occur

when the terms and words used and their meanings
are not mutually understood.
Interpretation of message conveyed and received
In communication, there is a communicator and
a receiver. There is no communication unless the
message is conveyed, received and acted upon.
The communicator must be clear about what he
wants to communicate and how he communicates
it. Interpretation and reception of messages will
depend on the receivers state of mind, his needs
at the moment and the impact of the speakers
effectiveness in communicating with him.
Loss:
For example, I was quite active before this pain
on my back started. The threat of loss is inherent
in anything that someone feels is personally
signicant. As loss is expressed, listening becomes
a means of lending ego until a patient nds resources
within himself to function adequately again.
Touch, taste and smell
These are symbols of communication often
utilised particularly in nursing care and
community rehabilitation and management.
FEEDBACK IN
COMMUNICATION
Touch
The act of touching is an instance of non-verbal
communication which is culturally determined.
There are certain uses of touch that are accepted
within territorial limits that otherwise may not
be tolerated by patients. Using touch effectively,
appropriately and comfortably is a dilemma often
faced in an attempt to provide total patient care.
Feedback is the process of correction and

evaluation of what is being said and understood by
the parties involved in a communication exercise.
There are two types of feedback: internal (by self)
and external (by others). External feedback can be
either positive or negative.
Feedback is the last and most important link
in communication. It is a process of correction
and evaluation through which communication is
modied. From it, the patient learns what areas
of strength they should maintain and which ones
they should improve on. There is therefore need
to be skilled in giving and receiving feedback.
Taste
This sense provides sensory data on which
impressions of patients and their families are
based.
Smell
This refers to the smell of perfumes or deodorants
that people wear, the natural smell of people and
68
14
Psychological Testing
Ruthie Rono
THE NATURE OF
PSYCHOLOGICAL TESTS
TYPES OF PSYCHOLOGICAL
TESTS
A psychological test is an objective and standardised

measure of a sample of behaviour. They are tools
used by psychologists and psychiatrists to obtain
objective measures of a patients psychological
status. Psychological tests vary in the behaviours
they cover and in the way they are administered.
They could be administered individually, in a group
or by computer.
The tests can be grouped into four categories:
cognitive/developmental; academic/achievement;
neuropsychological/perceptual and emotional/
personality.
Psychological tests are traditionally used to:
Measure individual differences
Identify mentally handicapped persons
Examine and diagnose persons with severe
psychological or psychiatric problems
Classify children according to ability e.g. slow
learners
Select personnel in the job industry
Select or classify military personnel for
proper task assignment
Determine the appropriate therapeutic
approach for clients
Carry out basic research such as in the case
of monitoring and documenting the course of
mental health treatment and recovery.
These include:
Achievement and aptitude tests
Intelligence tests
Neuropsychological tests
Personality tests.
Achievement and aptitude tests

These are usually used within educational and
employment settings. They are used to measure
how much a person knows about a certain topic or
the capacity the person has to master material in a
specic area, such as mechanical work.
Intelligence tests
These are used to measure the intelligence or the
basic ability to understand ones world, assimilate
its functioning and apply this knowledge to
enhance the quality of life. It measures ones
potential. Intelligence tests are not a measure of
achievement.
Intelligence testing resulted from the work
of Alfred Binet and Theodore Simon who developed
the Binet-Simon scale in 1905 to differentiate
between normal and mentally handicapped
children. The concept of IQ was introduced by
Lewis Terman in 1916 when he translated and
revised the Binet-Simon scales and created the
69
Stanford Binet Intelligence Scales. Terman used the

ratio of mental age to chronological age to obtain
an individuals IQ. In this concept, for example, a
child of ten years with a mental age of ten would
have an IQ of 100 which is the average IQ score.
The mental age-chronological age concept works
only for children.
The concept of IQ is no longer used by
psychologists. They use the term intelligence which
is measured based on an individuals deviation from
standardised norms, with 100 being the average.
Intelligence tests are frequently employed as
preliminary screening instruments to be followed
by tests of special aptitudes. They are used
clinically for identication and classication of
mentally retarded persons. Examples of this group
of tests are:
The Stanford-Binet and Wechsler Scales
Standard-Binet Intelligence Scale
Stanford-Binet (4th edition) cover qualitative,
spatial, and short memory tasks.
The test batteries are used for ages 2 years to adult
level.
The Basal level is reached when four items on two

consecutive levels are passed. The Ceiling level is
reached when three out of four or all four items
on two consecutive levels are failed. The Wechsler
scales include:
1. The Wechsler Preschool and Primary Scales
WPPSI-R (1989) for 3 to 7 years olds
2. The Wechsler Intelligence Scale for Children
(WISC III,1991) for 6 to 16 year olds
3. Wechsler Adult Intelligence Scales (WAIS R)
for 16 to 74 years.
Other tests in this category include:
(a) The Kaufman Scales designed for the same
uses as the Wechsler and Stanford-Binet
scales. The main focus of these scales is the
information processing assessment. They
include the:
Kaufman Assessment Battery for
Children (K-ABC). The test comprises
7 subtests that measure simultaneous
processing requiring synthesis and
organisation of spatial and visuoperceptual content and 3 subtests that
assess sequential processing requiring
serial or temporal arrangement and utilise
verbal, numerical and visuo-perceptual
content as well as short-term memory.
The battery also includes an achievement
scale of six subtests designed to measure
factual knowledge taught in school.
The Kaufman Adolescent and Adult
Intelligence Test (KAIT) (Kaufman &
Kaufman, 1993) was designed to measure
intelligence for 11 to 85 year olds. It
attempts to measure uid and crystallised
intelligence.
The Kaufman Brief Intelligence Test
(K-BIT) 1990 was designed as a quick
screening instrument to estimate the
level of intellectual functioning for 4 to
90 year old clients.
(b) The Differential Ability Scales (DAS) by
C.D Elliot (1990)
(c) The DAS-NAGLIER Cognitive Assessment
System measure basic cognitive functions
that are involved in learning presumed to be
independent from schooling.
(d) Other scales for infants and children include
the Bayley Scales of Infant Development
(1993), McCarthy Scales of Childrens
Abilities (MSCA- McCarthy, 1972) and the
Piagetian Scales.
Administration and scoring

The administration of the Stanford-Binet involves
the following:
Four booklets of printed cards for ip-over
presentation of test items
Test objects e.g. blocks, form board, multicoloured or different shaped beads, a large
picture of unisex and multi-ethnic dolls, record
booklets, guide for admission and scoring.
One needs to be highly trained in administering,
scoring and interpreting it. The examiner is also
expected to observe respondents work method
and problem solving approaches, and to judge
the emotional or motivational characteristics, e.g.
ability to concentrate, activity level, self condence
and persistence. There are 15 tests covering four
major cognitive areas. These are:
verbal reasoning
abstract or visual reasoning
quantitative reasoning
short-term memory.
These are administered in a mixed sequence to
maintain interest and attention. The administration
is a two-stage process. Stage 1 involves a vocabulary
test for routing to determine entry level. In stage 2
the examiner determines a basal level and ceiling
level for each test in terms of the individuals actual
performance.
70
Psychological Testing
are unlikely to be truthfully answered in the

favourable direction. Infrequency score (F) is
determined from a set of 60 items. A high F score
may be indicative of scoring errors, carelessness in
responding, gross eccentricity, psychotic processes
or deliberate malingering. Correction score (K)
provides a measure of test taking attitude which
is believed to be more subtle. A high K score is
indicative of defensiveness or the attempt to fake
good. A low K score may represent excessive
frankness or self criticism or the attempt to fake
bad.
The MMPI-A was specically developed for use
with adolescents. It incorporates the same features
as the MMPI-2. It includes all the 13 basic scales
but accommodates younger test takers through the
reduction of the overall length of the test to 478
items.
Other tests in this category include the Millon
Clinical Multiaxial Inventory (MCMI-III) by
Millon, Millon & Davis, 1999. This inventory is
grounded in the biopsychosocial view of personality
functioning and psychopathology and its scales are
consistent with the DSM- IV classication system.
It contains 175 brief, self-descriptive statements
to be marked True or False by the client. The
score prole consist of 24 clinical scales each
based on 12 to 24 overlapping items. The scales
are classied as shown below.
Neuropsychological tests
These measure decits in cognitive functioning
such as the ability to think, speak and reason.
These deciencies may result from some brain
damage that may occur due to strokes or brain
injury. Neuropsychological tests are mainly used
to assess or diagnose brain damage and require
the application of knowledge about cognitive,
personality, neural and general physiological
functioning in both normal and pathological ranges.
Tests in this category include:
The Bender Visual Motor Gestalt Test
Benton Visual Retention Test
The use of electro-encephalography
Neuro-imaging techniques such as Magnetic
Resonance Imaging (MRI).
Personality tests
Personality tests measure the basic personality
types. These tests are mainly used for diagnosis
of psychopathology. One of the most common is
the Minnesota Multiphasic Personality Inventories
(MMPI) series. The MMPI has been revised and
reconstituted into two separate versions: the
MMPI-2 and the MMPI-Adolescent (MMPI-A).
The MMPI-2 consists of 567 items of afrmative
statements to which the test taker gives a True or
False response. The items range widely in content
and cover areas such as affective, neurological and
motor symptoms; general health; sexual, political
and social attitudes; educational, occupational,
family and marital questions. It also covers many
well known neurotic or psychotic behaviour
manifestations such as obsessive-compulsive
disorders, delusions and hallucinations, ideas of
reference, phobias, and sadistic and masochistic
trends. The MMPI-2 yields 10 basic clinical
scales. These are:
1. HS: Hypochandriasis
2. D: Depression
3. HY: Hysteria
4. PD: Psychopathic deviate
5. Mf: Masculinity-femininity
6. Pa: Paranoia
7. Pt: Psychasthenia
8. Sc: Schizophrenia
9. Ma: Mania
10. Si: Social introversion
The MMPI-2 also has validity scales. Lie Score
(L) is based on a group of items that may make
the respondent appear in favourable light but
Clinical personality patterns
Schizoid
Avoidant
Depressive
Dependent
Histrionic
Narcissistic
Antisocial
Aggressive (sadistic)
Compulsive
or
passive
(negativistic)
Self-defeating.
Clinical syndromes
71
Anxiety
Somatoform
Bipolar manic
Dysthymia
Alcohol dependence
Drug dependence
Post traumatic stress disorder.
aggressive
Unusual verbalisations are tallied and used to

detect severe psychopathology according to a
standardised scoring guide. Whole responses
are associated with conceptual thinking, colour
responses are associated with emotionality and
human movement responses are associated with
imagination and fantasy life. Information from
others sources such as interviews and case history
records are used. Other types of inkblot tests are
the Exners comprehensive system and Holtman
inkblot technique. The inkblot technique can be
used for children and adults.
The pictorial technique include the Thematic
Apperception Test (TAT) and the Rosenzweig
pictureFrustration Study. The verbal techniques
use word association tests.
The performance techniques include the Drawing
Techniques such as the Draw- A- Person (D-A-P)
technique and Play techniques and Toy tests used
with children.
Psychological tests assess a wide range of human
characteristics and require professional expertise to
administer. In the use of psychological tests, mental
health professionals need to adhere to professional
ethical standards so as to protect their clients. Of
particular importance are the ethical considerations
concerning user qualications and professional
competence, protection of privacy, condentiality,
and appropriate procedures for communicating test
results to clients.
The severe syndromes are thought disorder, major

depression and delusional disorder. The severe
pathology pattern includes schizotypal, borderline
and paranoid. The scale also has modifying indices
which are disclosure, desirability and debasement.
It also has a validity index (Anastasi & Urbina
1997).
Projective
Techniques
are
personality
assessment tools that use disguised, unstructured
testing procedures. They originated from Freudian
psychoanalysis theory and clinical settings.
It focuses on the whole or global approach to
personality as opposed to specic traits. It has been
found to be effective in revealing covert, latent or
unconscious aspects of personality. The test stimuli
are ambiguous and only brief instructions are given.
It is expected that the test materials will serve as
a screen on which respondents project thought
processes, needs, anxiety and conicts. The types
of projective techniques include:
1. the Inkblot
2. pictorial
3. verbal
4. performance techniques.
The Rorschach Inkblot technique utilises 10
stimulus cards about the size of a regular sheet of
paper, each with symmetrical inkblots. Six of the
blots are black with various shades of grey while
four are in colour. A client is shown each card at
a time and asked to say what it represents. The
examiner notes the responses, reaction time and
duration of response; positions in which the cards are
held; spontaneous remarks; emotional expressions
and other accidental behaviour during the test. The
psychometrician questions the client systematically
regarding the parts and aspects of each of the blots
to which associations were given hence the client
gets the opportunity to clarify earlier responses or
their formal characteristics such as human gures,
human details, animal gures, art objects, sexual
perceptions or landscape.
Further Reading for Chapters 8-14

1. Neil R. Carlson and William Buskit: Psychology: The
Study of Behaviour. 5th Ed. Allyn and Bacon. (1997)
Dodge Fernald: Psychology. Prentice-Hall.
2. Anastasi, Anne & Urbina, Susana (1997).
Psychological Testing. New Jersey. Prentice Hall.
3. Linda Brannon and Jess Feist (eds) (1992). Health
Psychology. An introduction to behaviour and health.
2nd Ed. Wadworth Inc.
4. Child and Adolescence Psychiatry. A Comprehensive
Textbook Edited by Melvin Lewis (2002). Published
by Lippincott Williams & Wilkins.
72
15
Stress and Stress Management
Abdulreshid Abdullahi Bekry, David M. Ndetei, John Mburu,
Anne Obondo, Donald Kokonya
DEFINITION
CAUSES OF STRESS
Stress is a physical and psychological response to

harmful or potentially harmful circumstances. It is
a state of severe physiological and psychological
tension. It can also be dened as a non-specic
response of the body to any demand.
Stressors can be sudden, overwhelming or

cumulative. Some examples include:
Life crises e.g. accidents, death of spouse or
divorce.
Transitions e.g. divorce, bereavement and
retirement.
Catastrophesnatural and otherwise, e.g.
earthquakes and oods.
Daily hassles, little things in life that go
wrong.
Frustration and conicts.
Uncertainty, doubt and inability to predict the
future.
Physical and social environment such as lack
of a clean, tidy environment or lack of space.
Self, for example, Type A personality which
is associated with high levels of arousal, guilt
and irrational feelings.
Interpersonal relationships can be a source of
satisfaction or stress.
WHAT ARE STRESSORS?

A stressor is a stimulus which causes stress,
e.g. bereavement, divorce or a critical event such
as robbery or the demands of life. Our responses to
stress are inuenced by:
Personality (our strength)
The burden (type) of the stressor. Traumatic
stress is so intense that it overwhelms normal
psychological defences.
Ones subjective interpretation of the stressors.
Interpretation of the stressor takes two forms:
primary appraisalwhether the event is
positive, neutral or negative, and secondary
appraisalare the coping strategies sufcient
to deal with the challenge?
73
STRESS AND OUTPUT
Figure 15.1: The relationship between pressure/stressors and stress

PRESSURE/STRESSORS
THE INDIVIDUAL
OUTCOME/STRESS
To achieve ordinary or
extraordinary pursuits in life
Genetic,
biological,
personality,
physical, psychological and social
status, environment, past and present life
experiences, future expectations, coping
styles, culture immunity factors.
Achievements in life pursuits,

physical, psychological and social
health status and related symptoms,
behaviours,
etc.
Adjustments
Disorders (see text) clinical
syndromes/disorders.
INDIVIDUALISED MEANING
is stressed? Usually not. They tend to see

him as merely sickly or abnormal.
(iii) Do health care professionals recognise
when their clients are stressed? Usually
not. They tend to over-investigate along
physical lines.
4. The Solution: Health Education to both the
client and support system, including the
professionals on how to recognise and manage
stress.
5. Prognosis: Most people can be helped to cope
with or minimise normal life stresses while
leading relatively normal and productive
lives.
Figure 15.2 demonstrates the Pressure/Stressor/
Stress and output curve. Different people take
different curve patterns but within the same general
principle.
For the same results of output for different people,

it would require different contributory factors.
1. Normal to mild stress: When pressure to
achieve is positively correlated with output.
Symptoms of stress, if present are not
disabling.
2. Moderate to severe stress: When pressure to
achieve does not lead to an increase in output.
Symptoms of stress become increasingly more
and severe and achieve clinical proportions.
The stress symptoms take a more predominant
position.
3. Pathological Stress: When increase in
pressure is negatively correlated with output,
is accompanied by debilitating symptoms
and the output declines. The stress symptoms
become the primary focus. There are usually
clinical syndromes and disorders which require
attention on their own.
RESPONSES TO STRESS
Other Considerations
1. Pressure and stressors and to some extent
stress are normal and at times are necessary
drives for people to achieve certain goals in
life.
2. There is no normal life without pressure
to achieve. It becomes abnormal when the
pressure to achieve produces signs and
symptoms that become the problem.
3. The Challenges:
(i) Does the stressed individual know the
sign and symptoms of stress? Most
people do not know and just think they
are suffering merely from a physical or
unexplained illness.
(ii) Do family members, friends and
workmates know when one of their own
Psychological responses
In the behavioural area, the individual may
display self-destructive life styles and risk-taking
behaviour, such as excess drug intake, suicidal
gestures and self neglect. They may start stuttering.
They may also experience frustration and become
aggressive.
Anxiety can be the most dangerous psychological
symptom of stress. It may manifest with physical
symptoms of autonomic hyperarousal and activity.
Depression can also be a sign of stress, but if it
persists to the stage of resistance and exhaustion, it
can be a real danger. One may also suffer inhibited
sexual desire.
74
OUTPUT
Figure 15.2: The pressure/stressors/stress and output curve

Maximum
0 to Minimum
PRESSURE/STRESSORS/STRESS
Maximum/innite
A B = Increase in pressure leads to increase in out-put with no or minimal stress-related symptoms

BC = Increase in pressure does not lead to a corresponding increase in outcome. There are mild to moderate stress related
symptoms
CD = Increase in pressure leads to a decline in output and increasing more stress-related symptoms
Note: The curve varies greatly for different people with different AB, BC and CD intervals. There may be a shift to the left
or to the extreme right, with a very short AB for some people and for others may remain on AB phase even under extreme
pressure.
Spiritual signs and symptoms of excessive stress

may include doubts about ones faith, loss of self
condence or loss of purpose. At times there is
renewed faith in God.
ability to ght invading bacterial and viruses. One

may develop allergies, cancers and autoimmune
disorders such as rheumatoid arthritis.
Physiological responses
CONTROLLING THE CAUSES OF

STRESS
The body prepares itself either to ght or for

ight. After the escape from dangerous situations
the animal relaxes. However, in situations where
the individual is subjected to chronic stress some
physical symptoms may appear.
Controlling the environment

Avoid noisy surroundings.
Try to live in a space which is reasonably
large.
Keep your surrounding clean and neat.
Take time to enjoy nature, often through
picnics.
Save free time for relaxation and recreation.
Dedicate enough time to your partner and
family.
Try to create, where you can, a good working
environment.
HEALTH AND STRESS

All the bodys reactions to stress affect health. The
target systems include:
Cardiovascular system
Neurological system
Gastro-intestinal system
Immune system
Musculo-skeletal system
Endocrine system.
Prolonged exposure to stressors produce a number of
bodily symptoms. Chronic stress can lead to ulcers,
high blood pressure and heart disease. It can also
impair the immune system decreasing the bodys
Bodily control
75
Choose the healthy way to eat and drink.

Rest.
Drink a lot of water.
Do moderate, regular exercises.
Avoidance-avoidance conict
Avoid all types of drugs and toxic stimulants.

Do not use any type of tranquilising drug
unless it is prescribed by a physician.
Breathe properly (breathing as relaxation
technique).
Both alternatives are unpleasant and yet one has to

choose either. A patient has an abdominal tumour,
which causes unbearable discomfort. Alternatively,
surgery, which has very little success rate, is the
only available remedy and yet the patient needs to
be relieved of the pain. It becomes naturally very
difcult to choose either of these two alternatives.
Mental control
Plan your activities without becoming a slave
to your own plans, objectives or to those of
others.
Think positively.
Maintain a positive mental attitude.
Worry constructively and free yourself from
worry.
Share your talents.
Choose to be assertive.
Accept your mistakes and change them as
much as possible into challenges.
Free yourself from guilt.
Practise relaxationcan be taught by a clinical
psychologist or psychiatrist.
Approach-avoidance conict
This occurs when fullling a motive which will
have both pleasant and unpleasant consequences. A
young male doctor is torn between getting married
or not. Being married is attractive and socially
fullling, but it also means added responsibilities
and restrictions.
Double-approach-avoidance conict
The individual is torn between goals, which have
both pleasant and unpleasant consequences. A
young female doctor wants to obtain a masters
degree that is only available in a foreign country,
which she is afraid of going to. At the same time, she
is in love with a young man from a different tribe.
Her family does not approve of the relationship,
but she does not want to lose him. Which way does
she go?
CONFLICT AND ADJUSTMENT

Frustration
Adjustment to conicts
Frustration is the blocking of a motive by some

kind of obstacle. It is universal. An obstacle could
be a trafc jam, personal shortcoming, conicting
motives or conicts. The frustrated individual
becomes intolerant and physically aggressive,
more prone to misunderstanding others and more
likely to speak hurtful words.
Reactions to frustrations and conicts are sources

of stress that can cause physical and psychological
symptoms, just giving up, displaying self-pity, or
optimism and heroism in a few individuals. Stress
is not necessarily bad. At times, it helps the person
reach desired goals. General adaptation syndrome
is a sequence of responses that individuals go
through during stressful circumstances as follows:
Conict
Phase 1 (alarm phase)
Conict is the simultaneous arousal of more

incompatible motives, resulting in unpleasant
emotions, such as anxiety or anger. It is a pair of
goals that cannot be attained.
The body mobilises its resources to meet the

threats. There is a clear warning that a stress agent is
present, e.g. too much work, difculty completing
or avoiding a complex task. This often happens in
students when examinations are just about to be
done.
Types of conicts
Approach-approach conict
Phase 2 (resistance phase)
There are two goals, and to attain one means that the
other goal must be given up. For example, a nal
year medical student cannot often afford to be in
late night parties and expect to excel academically.
Therefore parties are given up although the student
misses them a lot.
There is an attempt to resolve the stress due to

fear of failure and frustration. Intially one does not
know what to do, but later makes some adjustments
and appears to be doing well. One may use defence
76
mechanisms to cope. Students may arrange to

study in groups, use the library more often and
associate more often with their lecturers. Majority
of individuals overcome this phase and minimise
the stress.
DEFENCE MECHANISMS
Defence mechanisms are the unconscious
strategies that people use to deal with negative
emotions. They limit awareness so that lifethreatening and anxiety cues can be excluded.
They are invoked automatically as psychological
measures, which allow stressful situations to be
coped with by distorting reality. Inadequate use of
defence mechanisms can lead to overt anxiety or
depression. The defence mechanisms:
do not alter the stressful situation.
have an element of self deviation.
help during rough times, but delay the solutionseeking behaviour.
are unconscious processes as opposed to other
methods of coping with problems.
If it is the dominant mode of responding, it may
become a personality maladjustment.
Phase 3 (exhaustion)
This occurs when one cannot withstand the threat
any more and fails to resist the stress. Signs of
stress start appearing. They may be physical or
psychological, for example, fatigue, anxiety or
depression. Poor adjustment to stress is associated
with aggression, risk-taking, wishful thinking,
denial and dangerous escapism.
Coping strategies
Problem-focused
Dening the problem.
Coming up with alternatives.
Weighing the alternatives costs and
benets.
Choosing among alternatives.
Implementing the chosen alternatives.
Common Defence Mechanisms

Repression
Emotion-focused
This is considered the central and basic

psychological defence mechanism. Other defence
mechanisms only come into play when repression
fails. Thoughts or feelings which our consciousness
nd unacceptable are repressed. Thus, repression is
a way of dealing with unbearable aspects of inner
life; so that aggressive or sexual feelings, fantasies
or desires are thrust into the unconsciousness. It
is considered to be a mental process arising from
the pleasure principle (Id) and the reality principle
(Ego), indicating that when impulses and desires
are in conict with enforced standards of conduct
(Superego), painful emotions arise and the conict
is resolved by repression. Hence, normality is once
again attained and sustained.
These are used when the problem is uncontrollable.

There are two types:
Behavioural strategies
Exercising
Using alcohol or other drugs
Venting anger
Seeking emotional support from friends.
Cognitive strategies
Temporarily setting aside thoughts about the
problem.
Changing the meaning of the situation.
Reappraising the situation.
Displacement
This is the transfer of affect, usually fear or anger
from one person, situation or object to another. An
example is the wife who is furious and irritated
by her husband for always coming home late or
giving her no support with the children. She vents
her anger, not on her husband, but on the children.
Other coping strategies
Isolating oneself
Thinking about how badly one feels
Worrying
Repetitively thinking about how bad things
are.
Engaging in pleasant activity e.g. going to
parties.
Rationalisation
Rationalisation is the process of justifying by
reasoning after the event. This is the act of providing
77
logical and believable explanations for behaviour,

to persuade self and others that the irrational
behaviour is justied and therefore should not be
criticised.
aggressor. The same applies to a father who was a

victim of child abuse.
Identication
People who feel inferior may identify themselves
with successful causes, organisations or persons in
the hope that they will be perceived as worthwhile.
In this case, identication is utilised as a defence
mechanism against anxiety of inferiority.
Projection
During projection an individual unconsciously
disowns an attitude or attribute of his own and
ascribes it to someone else. An example is when a
child tells the mother, Mummy the dog will bite
you, while actually he is the one who feels like
biting the mother. Another example is I hate you
becomes you hate me.
Compensation
This consists of the masking of perceived
weaknesses or developing certain positive traits
to make up for limitations. People who are
intellectually inferior may develop the physical
aspects of their bodies. People who are socially
incompetent may develop their intellectual
capacities and spend most of their time in lonely
academic pursuits.
Isolation
In this defence mechanism, dangerous memories
are allowed back into the consciousness, but the
associated motives and emotions are not recalled.
Hence, the memories are isolated from their
associated feelings. This mechanism is sometimes
seen in people who suffered severe physical or
psychological trauma such as in concentration
camps.
Ritual and undoing

Anxiety is sometimes reduced when people use
methods to make right the wrong they feel for some
perceived misdeed. A rejecting father may attempt
to alleviate his guilt by showering his child with
material goods.
Denial
This is the involuntary and automatic distortion of
an obvious aspect of external reality. When a doctor
informs a patient that he has cancer, this fact may
be denied at subsequent interviews even though
a clear concise explanation was given which the
patient obviously understood.
HEALTH PROFESSIONALS AND

WORK STRESS
Reaction formation
Every profession has some work stress, although

some are more stressful than others. For example,
studies have shown that doctors and lawyers work
under a lot of stress and tend to drink more alcohol
compared to other professionals.
In this case, the repressed wish is warded off by

its diametrical opposite. The young girl who hated
her sister and was punished many times for this
behaviour, may shower her sister with exaggerated
love and tenderness, but the repressed hostility can
still be detected underneath the loving exterior.
General sources of stress

Poor working conditions
- Lack of facilities to facilitate recovery
- Lack of equipment
- Lack of ofce space as is the case in most
public hospitals
Poor relationships e.g. professional conicts
with colleagues over duty roster or patients
Long working hours
Heavy workload e.g. having many patients
and heavy clinical load and responsibilities
Not receiving gratitude from clients
When the health worker has high goals and
cannot achieve them
Sublimation
This occurs when potentially dangerous urges are
given a socially acceptable expression. Thus sexual
or aggressive impulses instead of being given free
expression are sublimated to other activities, which
are carried out with great vigour and often with
great success.
Introjections
In this defence mechanism the victim takes
in and swallows the values of others. In
concentration camps, some of the prisoners deal
with overwhelming anxiety by accepting the
values of the enemy through identication with the
78
Feel drained, empty and fragmented

Feel impaired of therapeutic skills
When transference interferes with the treatment

process. Transference is the process whereby
the patient or client projects onto the therapist
past feelings or attitudes they had towards
signicant people in their lives. The feelings
experienced in transference may include love,
hate, anger, ambivalence and dependency.
Counter-transference occurs when the health
worker projects onto their client past feelings
or attitudes they had towards signicant
people in their lives e.g. early childhood
unresolved conict due to emotionally intense
relationships. Counter-transference can exist
as a result of being overprotective of a patient,
rejection of patients or dual relationship
Dealing with severely ill patients or when a
patient dies.
Symptoms of burnout:
Daydreaming and fantasies

Cancellation of important appointments
Tendency to abuse drugs e.g. heavy drinking
Therapy sessions lose their excitement and
spontaneity
The health workers social life suffers
Health workers are reluctant to explore the
causes and cures of their conditions.
Coping with work stress
A high degree of self-awareness and a
deep respect and concern for patients are
safeguards.
Ability to build therapeutic relationships
with the patient is important because this
will go a long way in lessening anxiety in the
relationship
The health worker should be able to recognise
transference and counter-transference in the
relationship and deal with it.
Outcome of stress
Professional burnout
Burnout is a state of physical, emotional and mental
exhaustion characterised by:
Physical depletion, feelings of hopelessness,
helplessness or powerlessness
Negative attitude towards oneself, others,
work and life
Fatigue, loss of energy and loss of enthusiasm
Further Reading
1. Lazarus P. S. (1966). Psychological Stress and the
Coping Process. McGraw-Hill. New York.
79
16
Crisis and Crisis Management
David M. Ndetei, Francisca Ongecha-Owuor
Abdulreshid Abdullahi Bekry, Ruthie Rono
It is at this point that a stressful event becomes a

crisis situation.
Individuals go through many stressful situations
and learn to make the necessary adjustments to deal
with the problems that they face. These adjustments
may involve the way of looking at problems, and
changing the situation or environment. This is
known as coping. Coping involves making changes,
controlling the situation, avoiding the stressful
situation, changing the way one thinks about the
problem and changing the way one responds to the
problem.
WHAT IS A CRISIS?
There is no simple denition for the term crisis.
It is used to describe a state of emotional upset. It is
a state of disequilibrium and disorganisation. It is
a situation in which the affected individual is faced
with a problem which needs an urgent solution. A
crisis situation is overwhelming and may involve
danger to the individuals personal security. A
characteristic feature of a crisis is the search by the
affected person for a solution.
When events are overwhelming, the affected
persons become disorganised. They initially feel
powerful and mobilise extra reserves to ght the
stressful event; the muscles become tense; the heart
beats faster and works extra hard to pump blood to
the muscles that need food and oxygen in the ght
against the stress. The individuals become mentally
alert and their pupils become dilated. Extra heat
generated by increased muscular activity is lost
through sweating.
When the threat of personal danger posed by
the event is over, the muscles relax, the heart rate
drops, sweating stops, mental alertness drops and
the pupils assume their usual size. The individual
is then said to have achieved a state of relaxation.
When stress together with the accompanying sense
of threat persists, the level of mental alertness and
the state of readiness persist. The end result is the
development of a stress-related state of fatigue.
TYPES OF CRISES
There are two main types of crises: maturational or
transitional and situational crises
Maturational crisis
This is part of growing up and occurs as a result of
human development from one developmental stage
to another. Maturational crises include such crucial
stages as beginning school, leaving home, beginning
rst employment, marriage and retirement. At
each stage one is forced to make adjustments,
resolve anxiety and conicts necessitated by the
transition. Successful resolution of a maturational
crisis normally leads to personal growth, emotional
stability and good mental health. Unsuccessful
resolution may result in unresolved anxiety and
80
or adjustment disorder. It thus calls for immediate

action.
internal conicts, which may lead to unstable

emotional disposition, depression, maladaptive
behaviour or disorders of personality.
SOURCES OF CRISES
Situational crisis
This results from a specic and intense
environmental stressor, hazardous event or threat
to ones life. These include:
Loss of a dearly beloved person, possession or

status.
A severely disabling accident, e.g.
causing paraplegia, amputation or severe
disgurement.
Natural or unnatural disasters causing
unanticipated change in one's life circumstances
or loss, e.g. oods, earthquakes, cyclones or
war.
Being diagnosed with a potentially fatal
disease such as AIDS or inoperable cancer, or
confronted by a life-threatening situation e.g.
after being bitten by a highly poisonous snake,
being trapped in a mine, cave or an aeroplane
facing the possibility of a crash.
Coronary thrombosis/myocardial infarction
(heart-attack).
Being raped.
Being arrested for a serious offence.
Break-up of a relationship, e.g. divorce or
termination of an engagement.
Failure of examination.
Forced retirement.
Separation or threatened separation of a child
from its parents.
Stressful events often occur in human experience
without undue effects. A series of such events do
have a cumulative effect and one last event may act
as the triggering stressor, however trivial this may
be. Thus, people who normally experience crises
might have been under difcult life circumstances
for sometime before the development of the crisis.
The crisis usually assumes special meaning for
the individual, affecting ones self-esteem, or
threatening their sense of security and dignity.
People who experience crises are usually not
prepared for the event causing the crisis, and
therefore have very limited resources to cope with
the stressful event.
Suicidal behaviour
Suicide is dened as the human act of self-iniction,
self-intentional cessation. Suicidal behaviour is
due to the following factors:
Biological factors: vulnerability to depression,
which is the leading cause of suicide.
Psychological factors: hostility, despair,
shame, guilt, dependency and helplessness.
Intra-psychic factors.
Interpersonal factors, for example, rejection
and feelings of inferiority.
Family history of suicide, which can cloud
the life of a person who may later commit
suicide.
Attempted suicide
During suicidal acts death is not always the
objective. Where the goal is to attract attention, the
act is called attempted suicide. Attempted suicide
should be taken seriously and the survivor assessed
for suicide intent. This helps the assessor predict
occurrence of future suicide.
Accidents
Accidents are events that occur unexpectedly.
They may cause physical injuries, destruction of
property, loss of life and destruction of lifestyles and
livelihoods. Accident proneness is the tendency to
have accidents as a result of psychological causes
such as perceptual distortions, personality type and
aggressive tendency in dealing with conict.
Death and bereavement
Thanatology is the study of the phenomenon
of death, emotional and psychological process
involved in reaction to death, grief, bereavement
and mourning.
Emotional and psychiatric disorders linked
to situational crises tend to be self-limiting and
usually never last more than 6 weeks. A crisis period
must always be regarded as a form of medical or
psychiatric emergency. An unresolved situational
crisis may lead to suicide, violence, homicide,
acute stress reaction, post-traumatic stress disorder
MANIFESTATION OF CRISES
People in crisis experience varying features of
anxiety, depression, shame, guilt, anger, problems
with thinking and coping with ordinary day-to-day
81
There is an urgent need for help in overcoming

the situation.
The situation has disrupted the life of the
individual.
The individual feels uncertain about what
might happen next.
experiences and change in behaviour patterns. The

affected individual loses the ability to settle down;
becomes restless, cannot sleep, loses appetite
for food and is unable to relax emotionally and
physically. The person is worried, anxious, tense
and pre-occupied with the problem. In time, the
individual begins to suffer from the physical effects
that result from a persistent state of muscular tension
and state of readiness. The person becomes jittery
and may be aware of the heart pounding away. The
person might sweat a lot, feel dizzy, light-headed
and may tire easily.
Memory may be defective with the person failing
to remember the contents of conversations or other
events. One might begin to avoid social contact,
or ordinary activities, hobbies or pastimes. Instead,
they might become preoccupied with aspects of
the situation which gave rise to the crisis state.
Guilt might develop and the person might blame
himself or herself for the crisis. Intense depressive
feelings might develop along with suicidal feelings.
Feelings of unreality might develop with loss of
pleasure feelings for social activities and company,
which used to evoke pleasurable feelings. On the
other hand, the individual might become angry,
irritable and exhibit outbursts of aggression over
trivial events.
The clinical behavioural manifestations of a
crisis state can be summarised as follows:
The individual is unable to function in the
usual manner.
The person withdraws from the usual social
groups or contacts.
The person feels distant or detached from other
people.
The person acts impulsively.
The person might refuse or reject help from
others.
The person demands too much attention from
others.
The person might behave as if nothing wrong
had happened.
The features of crises situations that distinguish a
crisis from a stressful event include:
There is a triggering unexpected event.
The situation is overwhelming and
uncomfortable.
The situation is distressful.
The situation creates a sense of powerlessness,
danger or humiliation.
There is a sense of loss of control over personal
affairs.
SEVERITY OF CRISIS STATES

Not all crisis states are of the same magnitude. The
severity of a given crisis depends on an individuals
previous experience with and ability to handle
stressful events. This of course depends on the
persons pre-morbid personality. People with long
history of stressful experiences tend to suffer more
severe forms of crises than the average person.
Individuals who have a personal or family history
of mental disorders also tend to be vulnerable to
severe crisis states. Lack of a signicant social
support system, or the existence of signicant
family or marital discord tend to predispose to
severe forms of crisis.
ASSESSMENT OF CRISIS STATE

A crisis assessment is a difcult, but necessary
step. In many crisis situations there is no time for
an elaborate assessment, especially where life is in
danger, e.g. the person may be threatening to jump
off a tall building, bridge or cliff, hang himself,
shoot or stab himself or may be threatening the life
of others.
Thus, the emergency may be such that there is
little or no time for full assessment. Intervention
must be given immediately through rapid, but
tactful establishment of rapport with the patient,
followed by gentle and pleading persuasion away
from danger. However, where there is no immediate
threat to life or as soon as the dangerous situation is
averted, data must be collected.
Levels of crisis assessment

Crisis assessment is essential in determining the
nature of appropriate help that the affected person
needs. An appropriate assessment consists of two
levels:
Level 1
This is concerned with the assessment of the risk
of suicidal behaviour, assault or homicidal threat
or action. Since the experience of a crisis might
82
Biographical data about the patient, including

biomedical data and a brief psychosocial
history.
All factors which have contributed to the
current crisis. Focus must be on the current
problems.
How the patient perceives the crisis
and stressors causing it.
How the family perceive the crisis.
The health worker's objective evaluation of the
nature and seriousness of the crisis compared
to the patient's perception and that of the
family.
Any underlying psychological, social or
personality problem, e.g. psychiatric illness,
emotional disorder, substance abuse and
marital strife.
The patient's usual coping mechanisms and
other coping skills or strategies which can be
utilised to cope with the current crisis.
The available social or human resources
which can be mobilised and utilised to assist
the patient cope with or overcome the current
crisis.
Assessment of the current mental state.
Assessment of the current physical medical
state as warranted by the crisis.
People in crisis also experience some of the
following signs and symptoms, which should be
evaluated and taken into account as part of the
management
involve the risk of personal injury to the person

concerned or others in the life of the individual,
assessment at level 1 is important and should be
carried out in all cases.
Level 2
This is concerned with the assessment of the impact
of the crisis situation on the individual. Assessment
at level 2 aims at dening the origins of the crisis
situation; the development of the crisis; the
manifestations and impact of the crisis situation on
the individual; what actions the individual might
have taken to control the crisis; what personal,
family, and interpersonal resources are available;
and the social and cultural atmosphere of the
person in crisis. The primary objective of the crisis
assessment process is crisis resolution. To do this,
emphasis is placed on the identication of immediate
problems that can be addressed in the actual crisis
management process. History of the persons usual
problems-solving skills and strategies should be
obtained. An assessment of available social support
system should be made along with an evaluation
and the nature of the emotional atmosphere within
which the person in crisis lives. The subjective
experience and interpretation of the crisis situation
should also be assessed as this will determine the
risk of self-destructive behaviour.
The crisis assessment process might need to be
extended to the entire family or community, as
certain crisis situations often involve whole families
or communities as may occur during disasters.
The assessment interview
Psychological
The actual aim of the interview is to identify recent

events that preceded the crisis state, including the
reasons for seeking help. Detailed inquiry seeks to
establish what happened within the 24 to 48 hours
before the actual onset of the crisis. Such an inquiry
will establish the presenting current problems,
nature of help already sought, and details of social,
occupational, and family responsibilities of the
person.
Information on social and family responsibilities
will be useful in re-assigning family responsibilities,
should it be necessary. Later on, an assessment of
the mental state of the person should be made.
In particular, the presence of suicidal ideation,
the levels of agitation, anxiety, restlessness and
distress should be noted. The physical state of
the person should be noted, including the degree
of dehydration, and the presence and extent of
physical injury. This includes the following:
Unexplained fear (anxiety).

Irritability.
Sadness, tearfulness and a feeling of
helplessness.
Labile mood (mood that changes rapidly).
Forgetfulness, misplacing items, poor recall.
Brooding over the same issue for an endless
period.
Apathy (reduced interest in surroundings).
Somatic
Headache, body aches and pains, fatigue.
Pounding heart, missed heartbeats, fear of
heart stopping.
Feeling as if one is short of air (air hunger).
Poor appetite.
83
accepting or rejecting responsibility (recognising that one is at least partly responsible for
the problem and can deal with it or that one is
not responsible and need not react).
This approach is often not adaptive (avoidance may
delay attention to physical illness). Maladaptive
coping strategies reduce emotional response in
the short-term, but lead to greater difculties
in the long-term (use of alcohol or drug abuse,
deliberate self-harm, histrionic behaviourexcept
when culturally sanctioned in bereavementand
aggressive behaviour. One needs good judgment
when choosing an appropriate coping strategy.
The Alcoholics Anonymous (AA) recognise
this fact in their prayer which says To be granted
the courage to change what can be changed, the
serenity to accept what cannot be changed, and the
wisdom to know the difference.
Behavioural
Reduced level of activity, lack of energy.
Over-activity and restlessness (inability to
settle).
Poor, lack of, or too much sleep.
Loss of regard for personal care, appearance
and well-being.
Excessive alcohol consumption.
Suicide behaviour.
Interpersonal
Lack of pleasure for social contact.
Inability to share emotions with others.
Disagreements and arguments over trival
issues.
Acts of violence on imsy reasons.
Excessive dependence on others.
Direct coping
Here the individual makes an objective analysis
of the problem, how it came about and how one
is responding. Individuals develop clear ideas of
what they wish to achieve to solve the problems
(goals) and come up with mental road maps or lists
of approaches to reach the desired end.
Individuals who employ a step-by-step approach
in analysing the situation and choosing the best
option for dealing with the problem are likely to
cope better and learn from the experience. This is
their problem-solving strategy:
seek help from others
obtain information or advice
problem solvingmaking and implementing
plans to deal with the problem
confrontationdefending ones rights or
persuading another person to change their
behaviour.
COPING WITH CRISES

There are two types of coping in a crisis: avoiding
the problems is defensive coping, and meeting
the problem head-on is direct coping.
Defensive coping
In defensive coping, the individual either runs
away from the problem and avoids going near the
stress-inducing situation, or blocks it out of their
mind and denies that the situation is stressful. In
defensive coping, therefore, the individual uses
emotion-reducing strategies. These include:
ventilation
avoidance (refusing to think, avoiding people
or reminders)
positive reappraisal (recognising that the
problem has led to some good, e.g. selfbetterment)
84
17
Critical Incident Stress Debrieng
(Psychological Debrieng)
Francisca Ongecha-Owuor, David M. Ndetei
SETTING OF A
PSYCHOLOGICAL DEBRIEFING
DEFINITION
Critical incident stress debrieng (CISD) is
also known as psychological debrieng. It is a
structured intervention designed to promote the
emotional processing of traumatic events, through
the ventilation and normalisation of reactions and
preparation for possible future experiences. It helps
survivors:
Understand and manage intense emotions
Identify effective coping strategies and
Receive support from peers.
CISD aims at minimising the adverse effects of the
normal stress response.
1.
2.
HISTORY
Critical incident stress debrieng was rst used to
mitigate the stress among ambulance personnel,
resulting from the traumatic events they confronted
in the course of their work. It has since been modied
to include other groups of personnel working in
different traumatic situations. Today, psychological
debrieng (PD) is the term frequently used.
3.
85
The setting will take into consideration the

following:
The participants
Their leader
The timing of the debrieng
The location
The procedure.
It should be attended by:
People who have experienced the same
critical event and either work together or
know each other.
Only those directly involved in the
incident.
In some instances it may include family,
friends and strangers drawn in the incident
by chance.
It should ideally be conducted by a specialised
trained team which may include:
Mental health workers
Physicians
Nurses
Chaplains
4.
5.
6.
Timing:
When everyone involved has had enough
rest.
It should be conducted 8 to 72 hours after
the event.
The session should run for 2 to 3 hours,
depending on the number involved and the
complexity of the critical incident.
Setting: Since it deals with a traumatic event
whose effects have not been resolved it is
important to ensure:
Tranquillity
Safety
Lack of distraction
An emotionally neutral place, well
ventilated, well lit and sheltered from the
elements of the event.
There should be a maximum of 25 people per
group.
2.
Phase 3: Thought phase

1.
THE SEVEN PHASES OF CISD

2.
Phase 1: Introduction, the setting and roles

1.
2.
3.
4.
5.
6.
The facilitator briey explains the purpose of

the debrieng process with an assurance to
the participants that the symptoms that they
may be experiencing are normal reactions by
normal people to an abnormal event.
Introduction of both the debrieng team and
participants with specic information on
name, home, vicinity and whether or not there
has been previous experience with disaster.
The group agrees on ground rules which are:
participation is encouraged
length of time the session should take
that everyone must stay until the end
there will be no breaks.
The reasons for these are explained:
To prevent any adverse events since a lot of
intense emotions will be aroused and these
need to be detected and dealt with
Reducing any disruptions.
Notes are not to be taken.
The facilitator then asks if anyone cannot meet
these requirements and reconcile accordingly.
3.
Participants are asked to describe cognitive

reactions or thoughts about their experience,
especially the most prominent thoughts or
thoughts that have been ignored since the
event.
The facilitators can ask specic questions:
each participant to recall thoughts about
the one thing you constantly think about
what were their rst thoughts when the
event occurred
what are their thoughts now that the
immediate threat is over
what thoughts they will carry with them.
To normalise a participants cognitive
reaction, the facilitator may interrupt to ask if
other participants have had similar thoughts
and again reassure them that these are normal
reactions.
Phase 4: Reaction phase

1.
Phase 2: Fact phase

1.
What happened
Where they were
What they did and what they experienced
via their senses (sight, smell, touch, hearing
and taste).
Alternatively the facilitator may facilitate this
by asking questions:
Where were you when it happened?
What did you do rst?
Then what did you do?
What do you remember seeing, smelling
and hearing?
Where was your family?
Where were other people?
Is there anything anyone said to you that
stands out in your memory?
Asking participants to describe from their own

perspective,
86
Participants are encouraged to discuss the

emotions they experienced during and after
the disaster by asking:
How they felt when the event occurred
How they are feeling now and
How this experience has affected their:
- marriage
- work
- appetite
- sleep
Critical Incident Stress Debrieng (Psychological Debrieng)
2.
3.
4.
- interest in sex and

- any other areas of functioning.
This is the most delicate phase.
The articulation of painful or frightening
feelings and emotional catharsis is
considered therapeutic for some survivors
The participants in the debrieng have not
been previously assessed by the facilitators,
on their coping skills such as coping
strengths, psychiatric history and quality
of social support
Limited time and possibly no follow-up
opportunity may result in arousal of intense
emotions that may not be manageable in
the circumstances, even if the facilitator is
highly trained and experienced.
For the above reasons, the facilitator should
take a conservative approach, i.e. not
exploring emotional material that generates
overwhelming feelings of vulnerability,
helplessness and anxiety.
The facilitator needs to normalise these
emotions as common reactions.
3.
4.
Phase 5: Symptoms (Stress reaction) phase

1.
2.
Stress reactions are reviewed in a temporal

context:
What survivors experienced while the
disaster was taking place
What stress reactions have lingered
What they are experiencing at present.
This helps participants recognise the various
forms of stress reactions:
emotional
cognitive
biological
psychosocial.
5.
6.
Phase 6: Teaching phase

1.
2.
Throughout the process of debrieng there is

a lot of teaching that takes place. During this
phase the facilitator should:
Assess what participants know, and dont
know
Ensure that they have accurate information
about stress reactions and stress
management strategies
Decide what information is most relevant to
the participants given the time constraint.
Educational topics addressed include:
Denition of traumatic stress, common
stress reactions
7.
The reactions of children and elderly

people
Fight-ight-freeze response
The fact that in the midst of disaster the
victims experience some physiological
changes due to the outburst of adrenaline
and thus will have a pounding heart, tensed
muscles, fast breathing and sweating. Point
out that it is like:
- Irritation and anger (the desire to ght
back),
- Fear and worry (the desire to ee
from danger),
- So much fear that it causes temporary
immobilisation (freezing).
Explain that each response has potential
survival value as follows:
Fighting back means taking action to
stop further harm from happening
Taking ight can mean nding a safe
place
Freezing can buy time to evaluate the
situation and plan an intelligent response.
Inform them that survivors often feel guilty or
ashamed for having reacted in these normal
ways, believing that they should somehow
have been immune to the bodys healthy
response of getting geared up automatically
in the face of danger. They should realise that
it is the emotional shock of trauma, the terror,
grief, helplessness, horror and confusion that
is the real problem, not the normal reactions
of ght, ight or freezing. They are reassured
that with the passage of time their symptoms
will taper off.
Verbal and written (if available) instructions
are distributed describing stress reduction
techniques.
Lists of mental health providers (all of whom
have the requisite specialised training and
experience in traumatic stress) are provided
for participants who may desire further help.
It is presumed at this point that participants are
now back to a normal cognitive level.
Phase 7: Closing (Re-entry) phase

This phase brings the debrieng to an end.
Each participant is allowed to give one last
comment or closing statement which helps the
facilitator:
- Understand what needs to be done next
- Whether there is need for further counselling
87
or a particular physical need presenting

itself.
The socialisation (refreshments with free
informal association) at the end of the closing
phase provides attendees a transition between
the debrieng process and the resumption of
their daily lives.
2.
FACTORS INFLUENCING THE

DEBRIEFING PROCESS AND
OUTCOME
1.
2.
3.
4.
5.
6.
7.
8.
COMMON STRESS REACTIONS

OF PRIMARY VICTIMS (AFTER
TRAUMA)
Trauma exposure:
Multiple versus single (multiple makes it
worse)
Perceived life threats (depends on the
individuals total interpretation of the event.
Most of this interpretation is unconscious)
Concomitant physical injuries
Loss of either lives or property would
complicate the debrieng process by
lengthening its duration as well as arousing
very intense emotions that may be difcult
to handle.
Physical injuries may delay the timing of the
debrieng if there are emergency issues as
well as accompanying physical pain that may
hinder active participation thereby not being
fully benecial to the attendee
Situations of perceived continued life threat:
it may be difcult to reassure the survivor or
normalise the reactions experienced
Individual factors which include training,
experience and acceptability of facilitators
Whether the survivors had been exposed to
trauma before
The availability of support networks
Gender factors
Group factors such as size, cohesiveness,
debrieng environment and timing of
debrieng after trauma all inuence the
process and outcome of debrieng.
Four clusters of stress symptoms commonly

experienced by individuals following a traumatic
event:
1. Emotional: Shock, anger, disbelief, terror,
guilt, irritability, helplessness, loss of pleasure
in activities, regression to earlier developmental
phase
2. Cognitive: Impaired concentration, confusion,
distortion, self-blame, intrusive thoughts,
decreased self-esteem
3. Biological: Fatigue, insomnia, nightmares,
hyperarousal, somatic complaints
4. Psychosocial: Alienation, social withdrawal,
increased stress within relationships, substance
abuse, vocational impairment.
Further Reading
1. Mitchel, JT. When disaster strikes: the critical incident
debrieng process, (1983). Journal of Emergency
Medical Services 8: 36-9
2. Armstrong K., O Callaham W. Marmar CR. Debrieng
Red Cross disaster personnel: the multiple stressor
debrieng model, (1991). Journal of Trauma Stress 4,
581-93.
3. Talbor A. Manton M. Dunn PJ Debrieng the debriefers:
an intervention strategy to assist psychologists after a
crisis, (1992). Journal of Trauma Stress 3: 45-62.
RISKS OF PSYCHOLOGICAL
DEBRIEFING
1.
to traumatic experiences. Therefore, they

also need to go through a debrieng process
after the closing phase. During the debrieng,
the facilitators discuss what went well, what
could and should be done differently and how
individually they are coping with the emotions
stirred by the debrieng.
Mandatory psychological debrieng may
lead to passive participation and resentment.
Hence there is need to solicit for voluntary
participation.
Service providers i.e. facilitators may become

secondary victims, as a result of listening
88
Section II Part B:
Medical Sociology
and Anthropology
89
90
18
Introduction to Medical Sociology and the Family
Anne Obondo, Eddie Mbewe, O. Morakinyo
OTHER SUB-DISCIPLINES OF
SOCIOLOGY
DEFINITION OF SOCIOLOGY
The word sociology was rst coined by Auguste
Comte in 1837. He combined the Latin word
socio meaning society with the Greek word
logy meaning science. Briey, sociology is the
science of society. It is dened as the scientic
methods used to study social relationships between
people as individuals and groups, and the inuence
of social conditions on these relationships.
Hebert Spencer viewed sociology as the study of
social control, politics, religion, family, individual,
communities and social stratication. Max Weber
viewed sociology as a science, which attempts to
understand social action. In other words, according
to him sociology is the study of social acts and
relationships. Similarly, Durkhiem also stressed the
interaction among social institutions that constitute
society. All the four founders agreed that sociology
was an attempt to understand human society as one
whole by examining the relationship among its
various parts. Sociology, therefore, is the discipline
which studies and analyses human behaviour, the
patterns of interaction and relations in a social
context.
Sociology as a discipline has different subdisciplines which include amongst others, urban
sociology, rural sociology and medical sociology.
Medical sociology began as a specialised eld
in the 1940s. This branch of sociology attempts
to understand the relationship between social
behaviour and health. It tries to understand the
social, environmental and cultural determinants of
health and disease.
Medical sociology dened

Medical sociology is concerned with the social
causes and consequences of health and illness.
What makes medical sociology important is the
critical role social factors play in determining the
health of individuals, groups and the larger society.
Over time medical sociology has grown into two
distinct branches i.e. sociology of medicine and
sociology in medicine. In the former, sociologists
working in university sociology departments apply
sociological theories and concepts to understand
the functioning of health care institutions as well
91
same way as that of the west. Instead we observe

that consanguinity (people of the same blood) is
the common type where one of the relatives either
from the fathers or mothers side live with the
nuclear family. The nuclear family most often has
kinsmen within reach who may be called upon in
emergency situations.
as how the health professionals relate amongst

themselves and patients. In the latter, medical
sociologists work with other health professionals in
medical institutions to provide solutions to health
problems.
THE FAMILY, MARRIAGE AND

ITS RELATIONSHIP TO HEALTH
Extended family
The extended family includes grandparents,
uncles, aunts, cousins, nephews and nieces
usually traceable through blood relationships over
generations. In such a situation, the aspects of
patrilineal and matrilineal have a major inuence
when it comes to assigning roles to members of the
family. In the latter, it is the uncles and aunts from
the mothers side who usually have a say in any
major decision-making.
Some special attention needs to be paid to
emerging trends in family types in our society.
This is as a result of the acquired human
immunodeciency syndrome (AIDS) which has
wiped out a large proportion of the sexually active
and bread-winning age group. Most families have
disintegrated and regressed from relative comfort
into poverty. The result is single parent, or child- or
grandparent-headed families.
The family is regarded as the basic unit of society.

Societies are derived from family units. Thus, the
family as an institution serves to legitimise sex,
marriage, parenthood and reproduction of new
members into society, without which society would
disappear.
Denition
The family is a social group characterised by
common residence, economic co-operation and
reproduction. It includes adults of both sexes and
one or more children, own or adopted. A family has
also been dened as any union between a couple
with or without children, or single adults living
with their own or adopted children.
A family in its simplest form includes a husband
and a wife and their offspring (nuclear family). It is
a universal and dynamic unit. Members of a family
play different roles at different times, because
members pass through a life cycle and also, because
it exists in a society which is dynamic.
Single parent family

There are single parent families, which are either
headed by male or female parents. While this may
not be viewed as an uncommon phenomenon,
what ought to be stressed is the rate at which such
families are emerging. In the past it was possibly
due to divorce or death of one parent resulting from
some rare conditions, while now it is largely due
to HIV/AIDS which has dealt a devastating blow
on the family structure.
Type of families
These include nuclear, extended, polygamous,
single parent, child- and grandparent-headed
families. Family patterns vary in relation to ethnic
background, race, age, marital status and roles
played by each person. Other attributes of family
include the aspects of tracing descent from either
of ones parents. Thus, we have patrilineal and
matrilineal type of families. In patrilineal families
the offspring traces the descent through the fathers
line, while in matrilineal the offspring traces the
descent through the mothers line, in which case
uncles have more say in terms of decisions that
touch on family matters.
Child-headed family
Child-headed families are usually a result of the
devastating effect of HIV/AIDS. While 20 to 30
years ago this was unthinkable, we not only have to
deal with child-headed families, but disintegrated
families where children have resorted to begging
in the streets. The children end up assuming adult
roles at an immature age. The aspect of childheaded families is akin to street kids syndrome
as most of the time it is children who spend time on
the streets begging. The psychological effects on
these children, whose progress in life is suddenly
changed for the worst, cannot be overemphasised.
They nd it virtually impossible to be absorbed by
the extended family system mainly due to the fact
Nuclear family
A nuclear family mainly consists of a father, mother
and children living together under one roof. The
child or children may have been born or adopted
into the family. In Africa the typical isolated
nuclear family, does not seem to exist in exactly the
92
that death would have taken all their dependable

relatives like uncles and aunts.
Economic production
The family, in addition to procreation, has an
important economic function. It is engaged in
economic production for its own survival and for
the social and economic development of a country.
It also allows division of labour to take place
between men and women. Some duties are broken
down by gender, for instance, land clearance,
house building and cattle rearing. However, it is
not uncommon nowadays to see a compromise
of gender roles in almost every culture.
Grandparent-headed family
Deaths among young couples, not only results in
child-headed families, but also poses a challenge
to the elderly people who have to look after their
grandchildren.
Functions of the family

Regulation of sex and reproduction
Sex is important in a marriage and its importance
ranks rst in the hierarchy of needs. Sexual
intercourse in marriage is the duty of both the
partners and a right that must be accorded. Social
gratication is achieved, although not necessarily
through regular sexual contact as in marriage.
However, the general practice postulates that
social functions be performed by the legal partner
and hence, conception must also be by the legal
partner.
Factors contributing to family problems

Urbanisation
Urbanisation has led to the disintegration of
the extended family. Men and women migrate
to cities in search of employment. Urban areas
are characterised by poor housing and living
conditions and problems of diseases, especially in
the slum areas. High population density in cities
has also resulted in impersonal relationships since
it becomes difcult to develop intimate social
relationships with too many people.
Alcoholism and drug abuse are rife. Sex
ratio is also unequal in urban areas, leading to
increase in prostitution and high illegitimacy
rates, which affects family stability. When sex
ratio is imbalanced, problems arise, e.g. husbands
establishing second homes, and may cut links with
their home and family.
Housing design in the cities also affects family
relationships, because houses in urban areas cannot
accommodate relatives. There is also lack of
privacy in the slum areas where the unit is a single
room. Children and parents share the same space
for sleeping, eating and some leisure activities.
Children are likely to be affected psychologically.
The cash economy has also altered family
structure and functioning. Division of labour has
changed drastically, forcing families to change
internal sex roles and authority patterns.
Care and socialisation

The family also functions to regulate inheritance
and give protection to children. Unlike many other
animals, human beings are born utterly helpless.
Children must be socialised into the complex
network of norms, values and culture. They must
learn everything, from which words to use, how to
eat, dress, to what they can reasonably expect from
life. Neither physical care nor socialisation need be
the exclusive responsibility of the childs parents,
but also that of a large network of aunties, uncles,
grandparents and cousinsthe extended family.
Socialisation is the process where the individual
personality is prepared to take an autonomous
role in the society. It is also an interactive process
between the mother and the child, where the child
learns to identify with the mother and internalise
her values.
Initially the child identies with the mother. The
child ultimately learns to distinguish between the
mother and the family sub-systems. Later the child
learns the large family concept and how it ts into
the social framework.
Marital problems
Conicts in marriages are more common today
than in the traditional African family. Selection in
marriages today is an individual affair, whereas in
the traditional African society it was a family affair
and relationships were well dened for the couple,
which resulted in less conict or no conict at all.
Huge sums of money spent on weddings today lead
to nancial strain thus creating conict in marriages
and adjustment problems.
Acquisition of sex roles

Children are made aware of their sexes right from
infancy through activities and when different
behaviours are demanded from boys and girls.
From an early age, boys and girls learn about and
acquire socially approved sex roles.
93
Separation between a husband and wife because

of employment, has generated a lot of problems
for the woman who has to look after the children
single-handedly, attend to the farm, and attend to
numerous demands made on her by the in-laws.
She actually becomes a servant of the family.
Failure to perform well leads to poor relationship
between the husband and wife. The woman, feeling
unsupported, may walk away from the marriage.
Separation also leads to lack of development of
the home, problems of disciplining the children are
solely left to the woman and there may be a lack of
sense of belonging on the part of children.
Polygamy today has resulted in numerous
problems. Educated men marry without the
knowledge of the rst wife, who is expected to live
with her co-wife. Such behaviour leads to family
instability. The family suffers nancially, because
family resources are wasted in other forms of extramarital relations. Polygamy in the urban setting
may be unmanageable, because of the cost of
housing and food. The wives are likely to compete
for assistance and when there is inequality conict
may result. Polygamy, which has in the past been a
noble practice in Africa, creates untold conict in
todays families leading to instability.
Problems in marriage
Role confusion.
Increased burden on women in the labour
force.
Arrival of children, especially when one or
two children are pre-scholars.
Disruption of normal life results in
disagreements on how to handle child caring.
A husband may become jealous when too
much attention is given to the children.
Divorce
Divorce refers to the dissolution of a marriage. In
traditional systems divorce resulted in the woman
returning to her family, and depending on the
circumstances, a portion of the bride wealth could
be returned. In patrilineal systems, children would
normally stay with the mother until they are older,
then they would go to live with the father.
Reasons for divorce are usually role conicts.
Deviation from the traditional wives role of caring
for the husband and children within the family
context affects the marital relationship. When the
women are involved in career-related activities
more than they should be, there exists the potential
for reduced marital quality. In addition, marriages
in which the wife earns higher wages or the
husband is unemployed run the risk of divorce. If
the husband is supportive then this role conict can
be diffused.
The following factors may lead to instability in
marriages:
Financial instability. When the husband is
unable to provide for his family nancially
Alcoholism or any other mental impairment
Polygamy
Ill-treatment and neglect of wife by husband
Marriage forced by parents against their
daughter's wish
Rejection of a husband by the wife's family
Poor relationship between wife and mother-inlaw
Poor sexual relationship or lack of sexual
relationship between the spouses
Infertility.
Divorce seems to have been more peaceful and less
disturbing to the spouses and children in traditional
African systems. Currently, however, divorce is
highly disruptive since many people use the courts
Working mothers
Working mothers are faced with various challenges
which include working and caring for children.
This calls for engaging house-helps who may not
care for the children adequately and may physically
or sexually abuse them. The house-help might also
be sexually exploited by the husband, resulting in
family conict and instability.
Marriage
Marriage is a legal union between man and woman
for the purpose of living together and procreating.
Traditionally, marriage is an institution and
arrangement for and between kin groups designed
to effect rights and obligations between two
people and groups of kin. Marriage also serves the
purpose of continuity of lineage and establishment
of alliances.
Benets of a marriage
The fullment of the need for interpersonal
interaction on a very intimate level with the
opposite sex (including fullment of sexual
needs).
Marriage can be a source of increasing maturity
and personal development.
94
to ght over children and property. Uncertainties

over legal rights and conicting normative systems
make such ghts more common today.
Divorce usually marks a problem in adolescent

adjustment and hence, rebellion. There is a higher
likelihood of transmission of intergenerational
marital instability. Children of divorced parents
often lack the interpersonal skills of bargaining,
negotiation, problem-solving and conict
resolution.
Divorce may also lead to alcoholism or depression
in one or both of the spouses. It can also lead to
suicide.
Consequences of divorce
Several studies have shown that juvenile
delinquency is usually associated with broken
homes. Boys of divorced parents show a higher
rate of behavioural disorders and problems with
interpersonal relationships.
Divorce leads to two families in distress instead
of onedevastating both the children and spouse.
Children of such families have lower self-esteem.
They are characterised by psychosomatic illness,
delinquent behaviour and parent-child adjustment
problems.
Further reading
1. Huxley P. (1998) Social Work Practice In Mental
Health. Gowe. Publishing Company, Vermont.
2. Lask J. And Lask B. (1981). Child Psychiatry And
Social Work. Tavistock, London.
95
19
Health and Illness Behaviours
Duncan Ngare, Anne Obondo, Stella Neema, Benedicta Yetunde Oladimeji,
David M. Ndetei, Jeremiah Chikovore
HEALTH BELIEF MODEL
HEALTH BEHAVIOUR AND

LIFESTYLES
This model is one of the most inuential sociopsychological perspectives used to explain how
preventive behaviours are acquired. Behaviours
undertaken by individuals in relation to health are
inuenced to a large extent by self perceptions.
Thus, if an individual perceives himself as being
susceptible to a certain illness or disease they
are likely to take some positive action to prevent
themselves from getting the condition. Similarly,
the severity of a disease as well as the perceived
threat of the disease will also inuence the
likelihood of taking action. However, while this
would be the expected course of action there are
other factors which could modify the desired action,
therefore resulting in a different action being taken
or no preventive action being taken at all. These
factors are called modifying factors which include
demographic variables such as sex, age, ethnicity
and race; socio-psychological variables such as
personality, social class, peer and reference group
pressure; structural variables such as knowledge
about the disease, prior contact with the disease;
cue to action; mass media campaigns; advice from
others; reminder postcard from physician or dentist;
illness of a family member or friend; newspaper
or magazine article. It further argues that the
likelihood of taking action is also dependent, not
As health professionals it is important to understand

the relationship between human behaviour and
health. Human behaviour, which is the sum of
the activities that individuals engage in can be
broadly classied into health and illness behaviour.
The former are those behaviours or activities
that individuals will engage in, consciously or
unconsciously, to prevent illness occurrence or to
maintain a healthy state. The latter refers to those
activities that ill individuals will undertake in
order to restore a healthy state. This is important
because it informs our knowledge in preventive
medicine and health seeking behaviour of different
individuals.
Healthy lifestyles are ways of living that
promote good health and longer life expectancy.
Healthy lifestyles include contact with health
care professionals, but the majority of activities
lie outside the formal health care systems. These
activities include good diet, rest and relaxation,
avoidance of stress, alcohol and drug abuse, and
proper hygiene. Life choices are determined by an
individuals socio-economic status, age, sex, class,
race and ethnicity. The choices have a positive or
negative effect on the body and mind.
96
Health and Illness Behaviour
only on the inuence of the modiers, but also on

the consideration of the perceived benets minus
perceived barriers of the preventive action. This
model is crucial for the understanding of how our
clients conceptualise preventive and promotive
health behaviours and the kind of considerations
that they make. It has been employed successfully
in many studies of preventive health behaviour.
account for social change and the fact that conict

is regarded as always dysfunctional. This led to
the formulation of a counteracting theory of social
conict.
STRUCTURAL FUNCTIONALISM
AND SYSTEMS THEORY
The symbolic interactionist approach to human

behaviour views human group life from the
perspective of the individual. It sees the individual
as a creative, thinking organism who is able to
choose his or her behaviour instead of reacting
mechanically to the inuence of social processes.
This approach is of profound importance in trying to
understand stress in society. It also helps to clearly
understand the concept of social stigma as a social
construction originating from the interaction of the
individual and society. In this era of HIV/AIDS
the issue of stigma is so important that we must
comprehend it in order for us to be able to address
the problem and assist those who are affected.
SYMBOLIC INTERACTION
THEORY
This theory postulates that units within a structure

function to maintain that structure. Various parts
of the body, like the heart and kidney have certain
functions to perform in the body. Similarly, in the
family the father and the mother perform the roles
of providing education, food and shelter for the
children who in turn have to respect their parents.
The family as a social structure is maintained by
continuous role interaction among the various
units. The units therefore function to maintain the
structure.
Every social system is characterised by a
functional unit, i.e. the various parts function in such
a harmonious manner that they are well integrated
and regulated. Conict is avoided and the social
system therefore tends towards equilibrium. The
main functions of the social systems are pattern
maintenance, referred to as the AGIL function.
Where A stands for adaptation, G stands for goal
attainment, I stands for integration and L stands for
maintenance and tension management.
These functions are important for an individuals
well-being in the society. In the case of adaptation,
an individual has to adjust to his environment to be
able to function normally. In goal attainment there
are certain goals people want to attain and failure to
attain such goals may lead to problems of low selfesteem. Regarding integration, it is important for
an individual to be integrated into their community,
because in the absence of this, various problems
may ensue. Isolation of individuals may result in
problems such as alcoholism and drug dependence
or psychological disturbance. Maintenance and
tension management is a function measured by
the various institutions in the community and the
functions they perform, e.g. the family, school and
health institutions. All the functions performed
by institutions are important for the individuals
well-being. The main weakness of structural
functionalism and systems theory is the inability to
Social meaning of stigma

The word stigma was used by the Greeks to
refer to bodily signs, usually inicted cuts or
burns, designed to expose the unfortunate bearer
as a slave, criminal or social outcast. Today, it is
applied more generally to any condition, attribute
or trait which marks an individual as culturally
unacceptable or inferior. In different communities
similar conditions can yield different reactions
where one disease condition may be stigmatised
in one but not in another. As health practitioners
we must be aware of this fact as we deal with our
patients.
SOCIAL CONFLICT THEORY

This theory argues that conict in relations is
normal because conict itself can be functional.
Conict helps to sharpen appetite for action, since
many begin to think quite sharply in response to
conict or threat, in order to nd a way out of it.
They demonstrate remarkable solidarity when
exposed to external threats of danger, and thus,
a system behaves like a biological organism
threatened with extinction when responding to
danger. Social conicts help a group to redene its
goals and group boundaries through a screening
process. Social conict generates creativity and
97
the nding by the medical worker that the

patient has a disordered function of the body
the patients symptoms conforming to a
recognisable clinical pattern.
In medical sociology, disease is seen as an adverse
physical state, consisting of a physiological
dysfunction within an individual; an illness is
a subjective state, pertaining to an individuals
psychological awareness of having a disease
and usually causing that person to modify his or
her behaviour; while sickness is a social state,
signifying an impaired social role for those who
are ill.
Illness can be deemed to be a deviance because it
is an unwelcome state. Illness represents a deviation
from culturally established norms or standards
of good health. Therefore, anyone acknowledged
to be ill properly desires and is the recipient of
treatment to correct the state of body or mind.
A sick person is exempted from their usual roles
or responsibilities due to the nature of their ill state.
From this perspective it can be argued that the
individual is not doing what is expected of him or
her and has digressed from the norm. If the person
is, however, responsible for the illness or has faked
illness he or she is classied as a malingerer. As
a malingerer, the behaviour deviates from what
is expected and required of that individual, and is
therefore deviant.
A third perspective that can be used to view
illness as deviance is through the stigmatising
illness. Some illnesses, such as AIDS are regarded
as deviant by lay populations. Society seems to
view AIDS patients as if they have done what is
not acceptable, that is, having sexual intercourse.
Illness behaviour can be dened as those
activities undertaken by a person who feels ill for
the purpose of dening that illness and seeking
relief from the illness. Illness behaviour refers to
the varying ways individuals respond to bodily
indications, how they monitor internal states,
dene and interpret symptoms, make attributions,
take remedial actions and utilise various sources
of formal and informal care. Although individuals
respond to illnesses differently, there are various
stages they undergo. The ve stages are:
symptom experience
assumption of the sick role
medical care contact
dependent-patient role
recovery and rehabilitation.
innovativeness; this being a crucial determinant of

social change and development.
Relationships are often in conict. It is wrong
in most societies to covet another mans wife, but
when a man and a woman are seriously attracted
to each other the norm of avoiding entering into
any illicit relationship may not work. If the
husband nds out, then conict arises. Hence, at
the level of real human action, conict is endemic.
However, while conict is normal and can be seen
not to disintegrate society, society is hardly ever in
equilibrium.
The proponents of social conict theory say that
equilibrium theory consciously becomes a support
for the status quo. Instead of being a lens which
sharpens our perspective and puts social reality in
focus, it becomes a pair of rose-coloured glasses
which distort reality, screening out the harsh facts
of conict.
ILLNESS BEHAVIOUR AND

DEVIANCE
The Deviance Theory
This theory uses the concept of anomie to explain
deviant behaviour, e.g. suicide or attempted suicide.
It focuses on conditions that ultimately produce
a breakdown in regulatory norms such as rapid
social change or economic crisis and prosperity. As
a result of these conditions there is normlessness
which leaves the society and individuals without
moral guidance and therefore, they experience all
sorts of problems.
It uses deviance to explain different kinds of
suicide in society, which is also used to explain
other types of individual and societal malfunctions,
such as drug abuse and alcoholism. An alcoholic
may be considered deviant when drinking takes
the form which deviates from socially controlled
traditions and customs or regulatory norms.
Illness and deviance

Illness is viewed medically as deviance from a
biological norm of health and feeling of well-being.
A person is therefore seen as ill if their symptoms,
complaints, or the results of a physical examination
or laboratory tests indicate an abnormality.
Traditional identifying criteria for disease are:
the patients experience of subjective feelings
of sickness
98
Health and Illness Behaviour
also seen as being in need of care. However, it is

important to realise that all these privileges are
considered not only temporary but also conditional.
Therefore the patient is expected to co-operate with
the doctor and to strive to leave the undesired state.
Parsons analysis of the roles of the doctor and the
patient is summarised below.
The relationship between a patient and a doctor
and the attendant roles can be summarised as
follows:
On the part of the patient the sick role entails
certain obligations and privileges. They:
o Must want to get well as quickly as
possible
o Should seek professional medical advice
and co-operate with the doctor
o Are allowed (and may be expected) to shed
some normal activities and responsibilities
o Are regarded as being in need of care and
unable to get better on their own.
The doctor has both expectations and rights
o The doctor is expected to:
- Apply a high degree of skill and
knowledge to the problems of illness
- Act for the welfare of patients and
community rather than for own
self interest, desire for money and
advancement
- Be objective and emotionally detached
(i.e. should not judge patients behaviour
in terms of personal value system or
become emotionally involved with
them)
- Be guided by rules of professional
practice.
o The doctor is granted the following rights:
- To examine patients physically and to
enquire into intimate areas of physical
and personal life
- Considerable autonomy in professional
practice
- Occupies position of autonomy in
relation to the patient.
Three basic types of doctor-patient relationship can
be observed in relation to respective roles. These
are:
1. Activity-passivity,
The doctor does something to a patient who
is not able to respond as happens when the
patient is unconscious i.e. the doctor has
complete control over the patient.
Although an illness experience may not involve all

the stages and can be terminated at any particular
stage through denial, each stage requires the sick
person to take different kinds of decisions and
actions.
The Sick Role Theory

The concept of the sick role is based on the
assumption that being sick is not a deliberate choice
of the sick person, though illness may occur as a
result of motivated exposure to infection or injury.
The sick persons are considered deviant because
they cannot help it. The specic aspects of the
sick role can be described in four basic categories:
The sick persons are exempted from their
normal social roles. An individuals illness is
the ground for exemption from social roles
and responsibilities. For this exemption to
be accepted by society the illness has to be
certied legitimate by a medical practitioner.
The exemption also depends on the nature and
severity of the illness.
The sick person is not responsible for the
condition. It is assumed that the illness is not
self-inicted.
The sick person should try to get well. Given
that the sick person is not responsible for
the illness he or she is expected to have the
willpower to get well. Illness is considered
undesirable and therefore the sick person is
expected to desire to get out of the undesirable
condition and regain normal health
The sick person should seek technically
competent help and co-operate with the
physician.
DOCTOR-PATIENT
INTERACTION
The way the doctor interacts with the patient
has been a subject of study for decades. It is
important because depending on the circumstances
surrounding a certain treatment the relationship
might differ. The doctor and the patient have been
assigned specic roles by society. The patients
role, for example, is seen as one that is temporary
and undesirable and therefore the patient has an
obligation to return to a state of health as soon
as possible. The patient is also accorded certain
privileges such as giving up social activities or
responsibilities due to their condition. They are
99
their patients. The patient is no longer that passive

being who would get information from their doctor
without uttering a word. The society has gone
through transformations in terms of social and
economic development which has in turn impacted
on the change in this relationship. Although our
relationships will basically remain to the greater
extent as described by different scholars, we need to
appreciate the fact that our clients will be different
and therefore we have to adjust accordingly for
our treatments to be acceptable and effective. This
dictates that we understand our patients very well.
The behavioural sciences are therefore important
in facilitating this role.
2.
Guidance-co-operation,
The doctor tells the patient what to do and
the patient co-operates or obeys as happens
when the patient is acutely unwell i.e. the
patient is dependent on the doctor.
3. Mutual co-operation.
The doctor helps the patient to help himself
or herself as happens in psychotherapies
i.e. the doctor and the patient are partners.
It is important to recognise that the relationship
continues to change with changing times. For
example, there are times when the patient could not
question what their doctor told them. These days
medical information is readily available. This ease
of availability of information has transformed the
practice of medicine especially in the developed
world. Even in the African continent we have
seen drastic changes in how the doctors relate to
Further reading
1. Huxley P. (1998) Social Work Practice In Mental
Health. Gowe. Publishing Company, Vermont.
2. Lask J. and Lask B. (1981). Child Psychiatry And
Social Work. Tavistock, London.
100
20
Culture, Health and Illness
Stella Neema, Nhlanhla Mkhize, Gad Kilonzo,
Nora M. Hogan, Jeremiah Chikovore, David M. Ndetei
practices relate to biological changes in the human

organism, in both health and disease.
INTRODUCTION
Culture, health and illness
Anthropology is the holistic study of humankind

that includes its origin, development, social and
political organisation, religion, languages, art and
artefacts. Derived from the Greek word meaning
the study of man, anthropology has been
considered as the most scientic of the humanities
and the most humane of the sciences. As an academic
discipline it has several branches which include
physical/human social and cultural, environmental
and medical anthropology. This chapter primarily
addresses issues related to medical anthropology.
Culture is dened as a set of guidelines, which

people inherit as members of a particular society. It
includes knowledge, beliefs, art, morals, customs
and any other capabilities and habits acquired by
the person as a member of society. It comprises
systems of shared ideas, systems of concepts and
rules, and meanings that underlie and are expressed
in the ways that human beings live. Culture is
dynamic.
Cultural background has an important inuence
in many aspects of peoples lives including
their beliefs, behaviours, perceptions, emotions,
language, religion, rituals, family structure, diet,
dress, body image, and attitude towards illness, pain
and other forms of misfortune. It should be noted,
however, that it is not only culture that may have
an inuence on an individual; other factors include
age, gender, appearance, personality, intelligence,
experience, educationboth formal and informal.
Socio-economic factors such as social class,
economic status, occupation and the network of
social support from other people are also factors
inuencing the health status of individuals.
Political factors also inuence peoples
behaviour. People may have high levels of anxiety
What is medical anthropology?

Medical anthropology is the branch of social
and cultural anthropology, which is concerned
with a wide range of biological phenomena,
especially health and disease. It is a bio-cultural
discipline concerned with both the biological and
socio-cultural aspects of human behaviour and
particularly the ways in which the two interact to
inuence health and disease. Medical anthropology,
therefore, is concerned with how people in different
cultures and social groups explain the causes of ill
health, the types of treatment they believe in and
the people to whom they turn if they do become
ill. It is also the study of how these beliefs and
101
worker. The anthropologist, on the other hand,

will consider what people know about malaria, the
local terminologies used to describe malaria, and
the help and health seeking or treatment practices.
In that way, a better understanding of the context in
which malaria is experienced is elicited for better
intervention strategies.
in their daily lives not because their culture makes

them anxious, but because they are suffering
discrimination or persecution from other people.
Students of culture and illness should therefore take
into consideration the impact of social, economic
and political factors.
Cultural relativism
Relativism is the view that cultures are varied and
may not be comparable as they are unique in their
own right. According to this view, cultures have to
be appreciated and understood in their contexts.
Beliefs or practices that seem to be normal may
be considered strange in another culture. Eating
grasshoppers, women kneeling while greeting an
adult person, or squatting while giving birth, may
all seem strange to those outside the culture where
they are practised. Similarly, a health worker may
nd it strange if a patient mentions family spirits
as the cause of a disease and that these spirits need
to be consulted as part of the cure. So, cultural
relativism is the view that no culture is superior
to another and that beliefs, values, behaviours and
practices of all cultures are rational and should not
be judged on the standards of other cultures.
However, there are arguments that cultural
relativism does not mean that one does not make
a value judgement. This would mean that practices
like ritual sacrice, wife battering, and cannibalism
should be overlooked. Radical relativism is
problematic: it makes it impossible to adjudicate
between competing cultural points of view.
HEALTH AND ILLNESS

The culture of a society constructs the way its
members think, perceive and feel about sickness
and healing. It is thus important to conduct a
cultural analysis of the presenting problem in order
to identify culture-based concepts of health and
illness (including its causes and treatment options)
and to understand help-seeking pathways. Health
problems should be viewed as cultural phenomena:
they are associated with the persons conditions of
existence, communicated in culturally-prescribed
ways, labelled in accordance with cultural concepts,
and experienced in a manner that is inuenced by
prevailing cultural ideas.
Health problems and living conditions

Health problems often originate in peoples living
and working conditions (e.g. poor, crowded
places and slums) and life styles (e.g. smoking,
unprotected sexual intercourse, having several
sexual partners).
The cultural communication of health

problems
Ethnocentrism
Ethnocentrism is the view that ones own culture
is superior to all other cultures. In ethnocentrism,
other peoples cultures are evaluated with reference
to ones own cultural assumptions, values and
customs. Other peoples beliefs and practices are
seen as inferior or wrong.
Health problems are communicated to others in

ways that are culturally prescribed. A sick person
in one culture may be expected to show pain, while
in another culture suffering in silence is prized.
Among some groups in central Uganda, especially
the Baganda, people express bereavement by
crying loudly and chanting many words about
the deceased. However, this is not acceptable
in the southern parts of the country, among the
Banyankole. In some cultures, people aficted
with disease are secluded, while in other cultures
they are expected to be in the company of others.
Anthropology and contextualisation

In order to gain insight into peoples way of life,
practices and ideas, one has to examine them in
their context. To have a better understanding and
interpretation of phenomena, one has to contextualise
them. Unlike the natural sciences where the object
of research is taken out of its context and reduced
to smaller parts, anthropology includes all relevant
contextual information about the object. In the
study of malaria, a medical professional will draw
blood to check for the malaria parasites. Once
found, anti-malaria drugs are dispensed. Nothing
much is said between the patient and the health
Labelling and explaining health problems

Health problems are labelled and explained in
accordance with existing cultural concepts. Some
cultures believe that illness is caused by imbalances
between hot and cold states. If an illness is described
as hot then cold remedies are prescribed to
102
combat the heat. Other cultures believe in spirit

causation of illness. A distinction is drawn between
benevolent spirits, which are believed to provide
prosperity, fertility and luck when invoked, and
the malevolent ones, which cause afiction and,
sometimes death. People can also subscribe to
biomedical as well as traditional explanations of
illness. Most people know that malaria is caused
by parasites carried by mosquitoes, yet others
attribute it to eating a lot of mangoes and maize or
playing in the rain (for the children).
with both an objective and a subjective reality.

A persons experience of ill health includes both
behavioural changes and feelings of being sick,
each of which are intimately related to the persons
social context. It is possible for an individual
to have a disease, yet be unaware of it. It is also
possible for one to feel and act ill without showing
evidence of any objectively veriable diseases. In
the former, there is no illness though there may be
disease. Without consciousness of ill health there
can be no such thing as illness behaviour.
The cultural experience of health problems
Sickness
The manner in which people experience health

problems is inuenced by prevailing cultural ideas.
An illness may be regarded as fatal in one culture
while the same illness is regarded as harmless
in another culture. Such perceptions may affect
peoples help-seeking behaviours, as well as their
responses to and experience of that illness. Among
the Basoga of Eastern Uganda, it is believed that
hydrocoele (empanama omushuha), affecting men,
is a sign of wealth and not a disease. Similarly
among the Baganda, there is a belief that if a man
has a sexually transmitted disease (STD), especially
gonorrhoea, it is a disease of the brave (obulwadde
bwabazira).
Clinicians should be aware of these sociocultural inuences that affect ill health and its
treatment when interacting with patients. Otherwise
biomedicine will be rendered irrelevant if the
illness experienced is not addressed.
The term sickness refers to the inuence of society at

large on illness and the individual suffering from ill
health. Society gives those aficted a sick role and
they are relieved of their normal responsibilities.
Disease without illness and illness without

disease
It is important to note that there are situations
where illness is present, while the disease is absent.
Alternatively, the disease could be present without
an illness.
Illness without disease
In situations where illness is present and disease
is absent, the persons feel unwell. They describe
their situation as health problems that need medical
attention. These are their feelings or subjective
appraisal of their situation. However, when
diagnostic tests and other physical examinations
are conducted, nothing is detected. The persons are
well as diagnosed by a medical expert though they
feel unwell. Psychosocial problems or physical
sensations for which there are no physical causes
are among the problems that bring feelings of being
unwell. These include:
Stressful disorders
Psychosomatic disorders e.g. irritable
colon, hyperventilation syndrome
Hypochondria
Folk illnesses such as demon possession, high
blood pressure (susto), and too much gas in
the intestines (ekintu/ekirwaire)
It is very difcult for the medical expert to explain
to the patient and family members that there is
nothing wrong, because the aficted person has
already identied and perhaps even labelled the
problem. The problem is culturally experienced:
it is expressed in the familys accepted language
of distress. This could possibly be one of the
factors causing non-compliance and lack of faith
The distinction between disease, illness and

sickness
Most individuals do not distinguish between
disease, illness and sickness. In most cases, these
concepts are used interchangeably.
Disease
Disease is dened in biomedical terms. It is a
biological or medical conception of pathological
abnormalities in peoples bodies. Diseases are
indicated by certain abnormal signs and symptoms,
which can be observed, measured, recorded,
classied and analysed according to clinical
standards of normality or abnormality. Biomedical
disease presents no data for sociological analysis;
it reveals no social facts.
Illness
Illness is the individuals experience of a
conditionit refers to the persons lived experience
of the disease. It is an explicitly social phenomenon
103
have coined the term masculinity crisis to refer

to the responses of those men who fail the test of
manhood. This crisis has a negative impact on
mens well-being and health. In Zimbabwe, men
who spend time away from their families as migrant
labourers experience high levels of anxiety. The
anxiety stems partly from the fear that their wives
or partners could be engaged in illicit sexual affairs.
Reports of men assaulting their partners whom they
suspect of being sexually involved with other men
are not uncommon.
in biomedical care among such patients. In most

cases, such patients visit various health facilities
several times looking for a cure. The treatment
prescribed by the medical expert may fail to deal
with the illness. Generally 50 percent of visits to
the doctor are for complaints without ascertainable
biological bases.
The medico-centric orientation disregards illness:
it does not take into consideration cultural beliefs
and explanations. This has led to patient mistrust
of and dissatisfaction with professional health care.
Some patients resort to non-biomedical care such as
traditional and faith healers as a result. Clinicians
should attend to both illness and disease, bearing
in mind that patients cultural categories play a big
role in the perception and labelling of symptoms
and treatment expectations.
The distinction between masculine and

feminine activities and emotions
Through socialisation, a distinction is often drawn
between feminine and masculine behaviours
and emotions. Men are expected to be physically and
mentally strong. Men often build muscular bodies
and exude an air of invincibility in their gait to live
up to this image. Those that express feminine
mannerisms (e.g. those that cry or acknowledge
pain with ease) are considered effeminate. This
means that men may delay presenting for health
care. When they eventually do, they may omit the
less visible symptoms or those symptoms they
consider mild. Instead, they may opt to focus
on symptoms with socially acceptable levels of
seriousness, which in their opinion clearly warrant
intervention. This means that illnesses are not
detected early enough for treatment.
Disease without illness

In this situation the medical expert does tests and
physical examinations and nds disease present
in body uids and cells. The person, however,
does not feel ill or complain that there is anything
wrong. Such a person may not take medications
prescribed by the health practitioner. Alternatively,
he may fail to complete the course, which could
lead to resistant strains of the disease. HIV/AIDS
and some STDs that manifest among women are
good examples.
THE RELATIONSHIP BETWEEN

CULTURE AND HEALTH
Violence associated with bride price

Bride price traditionally forms part of the marriage
transactions in most sub-Saharan African countries,
parts of Asia and the Middle East. Incidentally,
bride wealth, be it dowry (Asia and Middle East)
or bride price (Africa) seems to cause a certain
measure of violence, especially against women. In
Zimbabwe, men objected to sexual activity among
their unmarried girl relatives and daughters. One
of the reasons was that sexual activity threatened
bride wealth returns on the girl. Evidence of sexual
activity was therefore met with physical and verbal
violence.
It could be argued that the violence now
associated with bride price may signify the
increasing monetary value of the transaction.
Previously, bride price was a symbolic gesture in
most societies: it could be paid in various ways,
ranging from labour to livestock. In a context where
money has become central to survival and prestige,
the institution also appears to have undergone
dramatic transformation.
People are socialised to take on certain roles and

responsibilities in society. Some of these roles are
detrimental to health. The roles people play may
motivate behaviours that place them at risk. Four
common risk factors are discussed: the expectation
that men should be bread-winners, the distinction
between masculine and feminine behaviours
and emotions, violence associated with bride price,
and the value placed on the virginity of unmarried
girls. Effects of culture on the clinical presentation
of symptoms are briey discussed.
Men should be bread-winners

In most cultures, it is generally expected that men
should provide for their families. The manhood
of those who fail in this role may be questioned.
Continued failure may lead to other high-risk
behaviours such as excessive drug and alcohol
consumption, violence and suicide. Some writers
104
The value placed on the virginity of

unmarried girls
The popular sector

This comprises the lay, non-professional domain of
society, where illness is rst recognised, dened and
treated. Initiation of health care activities begins in
this domain. The popular sector incorporates the
following activities:
Therapeutic options that are utilised without
payment and consultation.
Self care, treatment and medication.
Advice given by relatives, friends and
neighbours.
Healing and counselling in churches, mosques
or temples.
The family is the main source of health care in this
sector. This is where the problem is rst identied
and suggestions made on what to do. Healers
and advice givers in this domain include women,
mostly the mothers, grandmothers and aunts who
are knowledgeable about the health problems and
remedies for those problems. Up to 90 percent of
health care takes place in this sector.
Home remedies provided by this sector include
local herbs. Food can also be used as medicine, an
example being soup from tiny sh in Uganda called
nkeje, given to children when they have measles.
In the popular sector, certain individuals tend to
act as health advisers more than others:
Those with a long experience of particular
illnesses or types of treatment.
Those with extensive experience of certain life
events (e.g. women who have raised several
children).
Paramedics such as nurses and hospital
workers, who are consulted informally about
health problems.
Doctors wives or husbands who share some
of their spouses experience if not trained.
Members or ofcials of certain healing
churches or cults.
One of the disadvantages of this sector is that overreliance on home remedies when the condition is
life threatening could delay life-saving treatment.
Many culturesincluding sub-Saharan Africa

countriesplace a high value on the virginity of
unmarried girls. Without similar expectations, men
and young boys may express their masculinity
by having multiple sexual partners, and in some
instances, by deowering girls. According to press
reports, virginity tests performed on unmarried
young girls have resurfaced in several southern
African countries, as communities struggle to
deal with the AIDS pandemic. However, some
organisations in Zimbabwe expressed concern
with this development, arguing that targeting only
girls merely exposes them to men who might feel
the virgin girls are safer to have sex with. Girls
conrmed to be virgins may also be exposed to
the risk of rape by men who think having sex with
virgins is a cure for AIDS.
HEALTH SYSTEMS AS
CULTURAL SYSTEMS
A health system is synonymous with the medical
system. On the other hand, a cultural system is a
coherent whole of beliefs, norms, arrangements,
institutions and patterns of interaction. Ideas and
practices concerning health may be called a health
or medical system. A health system includes beliefs
related to causes of illness, norms governing
choices and evaluation of treatment, roles, power
relationships, interactions, setting and institutions.
Traditional healers in most parts of Africa
dispense biomedicines to their clients in addition
to local remedies. Traditional birth attendants in
Uganda have provided ergometrine injections to
mothers after delivery. Biomedical doctors have
also used alternative therapies such as acupuncture.
In Uganda a renowned biomedical doctor was
dispensing herbal tablets called mariandina to treat
AIDS. Mainstream doctors opposed his actions,
but the patients reported relief from the remedy.
In any given society there are three overlapping
and interconnected sectors of health care: the
popular, folk and professional sectors. Within the
three sectors, individuals have different beliefs
about the causes of illness, and help seeking
practices. The three sectors may or may not overlap
in some settings. However, there are points of
entrance and exit.
The folk sector

This is the intermediate position between the
popular and the professional sectors. This sector
consists of a heterogeneous group of traditional
healersboth sacred and secularthat include
bone setters, herbalists, traditional birth attendants,
faith healers, shamans, diviners and tooth
105
extractors. Some work as individuals, while others

are organised in associations of healers with rules
that govern them. Most of these folk healers
share the worldviews of the communities they
operate in, including views concerning the causes
of the ailments and the cures. They have little or
no formal training, acquiring their skill mostly
through inheritance or apprenticeship. It should be
noted that some healers can be located somewhere
between the folk and professional sectors, such
as those who practise acupuncture, homeopathy,
meditation and hypnosis.
The professional sector

This consists of well organised, legally sanctioned
medical experts. These include physicians,
paramedics and other professions, such as
ayurvedic, yunan and Chinese medicine. The
professional sector is the benchmark by which the
folk and popular sectors are measured.
In most developing countries, there is a shortage
of personnel and resources in the professional sector.
Sometimes people cannot afford consultation fees
and drugs charged by those in the professional
sector. As a result, they often resort to the folk and
popular sectors before consulting the professional
sector.
106
21
Culture and Mental Health
A.B.T. Byaruhanga-Akiiki, Nhlanhla Mkhize, David M. Ndetei
Diseases of the digestive system
THE NATURE OF MENTAL

ILLNESS
With regard to diseases of the digestive system, one

may fail to eat, drink or even swallow food. Some
eat but get severe reactions. In such cases, some
Africans argue, poisoning of the stomach organs
with physical or non-physical means (in Bunyoro,
bihara) or the poisoning of any organ using physical
or non-physical means (in Buganda, ddogo) is at
work! This means that Satan or resentful spirit
persons have taken hold of ones stomach, thus
causing pain or obstructing the functioning of the
stomach. The person may then be prevented from
fullling his divine mission as he may waste a lot
of money in hospitals, but there is no cure.
Mental illness in the Western classication

systems, include schizophrenia, psychosis, p
aranoia, depression, delirium and anxiety. In
Africa, the above categories of mental illness are
not recognised. In some African societies, there
are diviners (Bunyoro-Toro), baraguzi who are
believed to be capable of diagnosing the causes
of mental illness through consultations with the
spirit world. The reality, however, is that many
suffer without knowing the cause. The picture is
complicated by psychosomatic ailments, which
make it difcult for both traditional and modern
doctors to prescribe medication.
Diseases of the prostrate gland

When diagnosed, diseases of the prostate gland
can be treated (e.g. surgically). Seen spiritually, the
cause is latent. Men are considered to have been
born with original sin. The seed of sin is in the
male sperm; it is contained in the genes. The whole
situation becomes very complicated, because of
the complex interaction of lineages, mistakes
committed by individuals or the mistakes of
husband and wife. Adultery may also be diagnosed
as the cause of the prostate problem. In such cases,
to get cured, one rst has to pay indemnity in cash
or kind.
Mental illness and disease: The role of

ancestors
In African traditions, ancestors play an important
role in the conceptualisation of the causes of
mental illness and disease. Since time immemorial,
ancestorsalive or deadhave always had power
to bless or curse. In the event of a curse, the one
cursed may suffer from a serious mental disorder.
One becomes sad, unhappy and mentally deranged.
The curse can affect ones physical body or
property. The diagnosis and treatment of the curse
are considered beyond western medicine.
Diseases of the circulatory system

The heart is part of the circulatory system and is
often associated with stress or mental pressure.
107
A heart can develop a disease because of joy or

sadness. Besides, evil persons or Satan are believed
to put a lot of worries, insecurity and fears in ones
mind and heart, leading one to needless disturbing
thoughts. In such cases, one experiences a lot of
pain. If one suffers great stress for many days, one
may die of shock. It is advisable to consult modern
medicine as well as people of faith in order to
restore ones health. Traditional religious wisdom
teaches that for heart problems, the most precious
medicine given by God is love! So, people are
advised to resolve all through the medicines of
faith and love.
CONTRIBUTIONS FROM
CULTURAL PSYCHOLOGY
Cultural psychology is the study of the way cultural
traditions and social practices regulate, express and
transform the human psyche, resulting less in psychic
unity for humankind than in ethnic divergences in
mind, self and emotion. Cultural psychology also
postulates that subject and object, self and other,
psyche and culture, person and context, gure and
ground, and practitioner and practice, live together,
require each other, and dynamically, dialectically,
and jointly make each other up. It recognises the
dynamic interdependence between human action
and culture.
Diseases of the respiratory system

Human beings cannot go a single moment without
breathing. The respiratory system can become
ill as a result of physical causes; the person
suffers from high or low fevers for a long time.
Biochemical medicine can be used to treat the
fevers. The problem arises when the medicines
have no effectwhere fevers recur, causing the
body to break down. The person ends up suffering
psychologically, physically and nancially.
Culturally, English speakers have coined the term
that some diseases are caused by spiritual germs.
This is where, it is believed that Satan or other evil
spirits grab onto peoples respiratory systems and
torment them. Sometimes the disease moves from
one part of the body to another. One time it may
be a cough, another time it is the fever. Sometimes
symptoms appear in the form of typhoid fever.
There is no medicine for such diseases.
The relationship between culture and

mental health
There are two major competing paradigms
concerning the relationship between culture and
mental disorder: universalism and relativism.
Universalism, the dominant model of mental
illness in the biomedical sciences, assumes that
underlying psychological processes are the same
across all cultural groups. This is known as psychic
unity. Culture is thought to mask basic underlying
psychological universals. The view that culture
only modies the expression of psychological
distress is consistent with universalism. Culture
is thought to exercise an exterior actionit
affects only the symptomatic form that psychiatric
disorders take in different cultures. The clinicians
role under these circumstances is to strip off the
layers of culture to uncover the basic underlying
bases of human distress. Diagnostic categories
are thought to be equivalent. The universality of
conceptual and diagnostic categories developed
in the west has been questioned. Universalists are
victims of category fallacy, which is the tendency
to impose their own conceptual categories on
deviant behaviours observed in other cultures.
The universal applicability of western-derived
assessment instruments has also been questioned.
From a relativistic perspective, culture plays
a fundamental role in psychopathology: it is
impossible to speak of mental illness behaviour
without taking cognisance of the cultural context in
which it is manifest. Culture is not just an exogenous
force that exerts an inuence on behaviour; mental
Depression and mental derangement

One may be depressed when in deep agony and
unable to escape from a painful life. Generally,
patients suffering from depression hate the company
of others. They are gloomy and unable to correctly
express their thoughts. Mentally deranged patients
cannot fully express what is in their mind. From
the spiritual perspective, depression and mental
derangement are the same, coming from Satan and
evil spirits that cause mental difculty, leading to
anxiety, fear and fright. These are associated with
feelings of loneliness, isolation, sorrow, despair,
humiliation and anger. Eventually, some commit
suicide.
108
formulation. However, it assumes that culture only

inuences symptom expression; the underlying
disorder is presumed to be universal. Further, the
culture-bound syndromes described are limited
to culturally different groups. The term culturebound syndromes refers to localised or culturespecic disorders. Culture-bound disorders present
with a cluster of symptoms or behavioural changes
that are recognised by locals and responded to in
a particular manner. Folk diagnostic categories
have been developed to refer to these localised
troubling sets of experiences. An example is
amafufunyane, a form of spirit possession which
the Nguni of South Africa attribute to sorcery.
Critics note that disorders such as anorexia nervosa
and chronic fatigue syndrome could be regarded as
western culture-bound syndromes, attributable to
the meanings assigned to the (female) body and
work in western culture. However, these were
not included in the DSM-IV list of culture-bound
syndromes, thus reinforcing the view that culture
only pertains to minority groups or people in
distant, places.
Culture plays a central role in diagnosis. It
suffuses all aspects of the diagnostic process and the
rst task for the clinician is to determine whether
the presenting symptoms can be explained by the
patients cultural patterns. For example, hearing
voices is not uncommon among some religious
groups. Among the Nguni in South Africa, there
is a condition known as ukuthwasa, an ancestral
calling (usually involuntary) to become a traditional
healer. It is characterised by hearing voices. This
could be misconstrued as a symptom of psychosis.
However, individuals initially considered to be
undergoing ukuthwasa are sometimes re-classied
as mentally ill if hearing voices does not lead to a
positive outcome (becoming a traditional healer).
The distinction between positive ukuthwasa
and negative ukuthwasa is not an easy one. The
clinician should consult with a multi-disciplinary
team, including traditional healing experts, when
confronted with such cases.
illness and culture are mutually embedded. The

relativistic position has been brought to the fore.
Universalism ignores peoples real life suffering,
concentrating only on a limited range of symptoms.
It tends to focus on the disease, rather than illness.
The feelings of hopelessness associated with
depression in western culture constitute a desired
state of affairs for Buddhist monks, who see
hopelessness as a vehicle to achieve salvation.
The solution to the problem of culture does not
reside in either universalism or relativism. Radical
relativism makes cross-cultural comparisons
impossible, thus ruling out any possibility of
developing a unied theory of knowledge. Others
have argued that a unied theory of knowledge could
be developed from the bottom up by conducting
studies in different cultures. Another potential
problem with relativism is that there is a danger
of stripping culture of its ideological and political
character, especially if it is only conceptualised
psychologically, in terms of values and beliefs.
CULTURE AND DIAGNOSIS

Cultural factors are increasingly recognised in
mental health literature. In 1993 the American
Psychological Association published guidelines
highlighting how to frame assessment and
interventions with respect to the patients culture,
including religion and indigenous practices,
the patients support systems and psycho-social
stressors. The DSM-IV acknowledges the
importance of locating assessment and diagnosis
in relation to the patients culture. The introduction
to the DSM-IV notes that:
Special efforts have been made in the preparation
of DSM-IV to incorporate an awareness that the
manual is used in culturally diverse populations in
the United States of America and internationally.
Clinicians are called on to evaluate individuals
from numerous different ethnic groups and
cultural backgrounds (including many who are
recent immigrants). Diagnostic assessment can
be especially challenging when a clinician from
one ethnic or cultural group uses the DSM-IV
Classication to evaluate an individual from a
different ethnic or cultural group. A clinician who
is unfamiliar with the nuances of an individuals
cultural frame of reference may incorrectly judge
as psychopathology those normal variations in
behaviour, belief or experience that are particular
to the individuals culture.
CULTURE AND AETIOLOGY

Problems and misfortune may be seen in a group,
rather than individual terms. Among the Shona of
Zimbabwe, a relatives actions may affect the whole
family, for instance in cases of murder. Solutions
must therefore involve clans. Moreover, whereas
in Western understandings the consultation process
The DSM-IV includes a framework for taking culture

into consideration in psychiatric and psychological
109
enabling, predisposing, evaluation, perception and

experience factors.
involves a physically present patient, in some

African settings, the patient could be absent, with
treatment sometimes taking place miles away from
where the patient lives.
In New Guinea, it has been observed that a
sick person withdraws into a wretched state,
shuns company and certain foods, eats alone, and
begrimes himself or herself with dust and ashes.
The patient is said to display rather than report
illness. This withdrawal is said to be an attempt to
deceive the evil spirits that caused the illness into
believing that they have succeeded.
Whilst on a eld trip in a rural area in southern
Zimbabwe, one of the authors of this chapter
stumbled upon different accounts of illness. A
second wife narrated how her predecessor had
been divorced for refusing to confess her sexual
misdemeanours (aramba kudurira mwana). As
a result, it was believed, her child had refused to
breastfeed and eventually died. In another account,
a belief was said to be common that as long as a
married man has sex with his wife, it is his wife
that is capable of killing him. The wife was always
blamed for her husbands death. This is despite
the fact that men in the community were migrant
labourers who confessed to having extramarital
sexual relationships, and were therefore exposed
to HIV/AIDS.
These examples illustrate different accounts of
the causes of illness. Understanding these may help
medical and health policy practitioners appreciate
why people behave the way they do with regards
to health matters.
Enabling factors
These are factors such as the availability,
accessibility and affordability of health services.
Services might not be accessed easily due to long
distance. Alternatively, people may not have the
means (e.g. monetary) to access health services.
Predisposing factors (socio-demographic factors)
Socio-demographic factors such as social class
inuence the utilisation of health services. People
of low social class are known to delay seeking
health care, perhaps due to the accessibility factors
mentioned earlier.
Evaluation factors
The chosen place of delivery depended on the
pregnant mothers or health workers evaluation of
the pregnancy (i.e. healthy or not healthy). Chances
of delivering at a health facility were higher if the
pregnancy was evaluated negatively.
Perception factors
Place of delivery also depended on how the
pregnancy and the hospital were perceived. If the
hospital is generally perceived as a place visited
by the sick and the pregnancy is not perceived as
a sickness, women are less likely to deliver in a
health facility.
Experience factors
Experienced women who have delivered at home
feel more comfortable about delivering at home.
Apart from beliefs and the practices highlighted
earlier that inuence exposure to illness, cultural
factors also play a role in shaping peoples
understanding of the causes of illness (aetiology)
and hence, how it is dealt with (treatment).
The following examples illustrate how culture
inuences perceived causes of illness.
SOCIAL AND CULTURAL

DETERMINANTS OF HEALTH
SEEKING BEHAVIOUR
Health seeking behaviour usually depends on the
type and severity of symptoms, the cause of the
illness and the labels and aetiologies attached to
it. Other factors include socio-economic status,
age, sex, educational level, occupation, residence
(urban or rural) and family role. Social and cultural
determinants of health seeking behaviour are:
characteristics of the condition, the patient, the
healer and service.
Culture and health: the benets and

pitfalls
Understanding cultural and social factors inuencing
health is important for the medical practitioner as it
provides a more complete view of health problems.
Aubel et. al. studied communication patterns
between patients and health workers in . They found
that lay understandings of illness were in general
derogated, and home management practices and
traditional consultations discouraged. What was
signicant, though, was that mothers identied
Models and concepts regarding health care

utilisation
The utilisation of health care services depends on a
number of factors. A distinction is drawn between
110
international boundaries are becoming uid,

thus making such generalisations even more
problematic. They should assess a persons ethnic
identity through a careful consideration of his or
her developmental and family history. Patients
could be asked to describe their grandparents and
parents country of origin, religion and primary
language. The extent to which patients rely
on extended family networks for help is another
indicator of their degree of closeness or distance
from their primary reference group. The familys
participation in cultural practices should also be
assessed.
no less than a dozen types of diarrhoea, each with

specic management techniques. Raguram et. al.
studied clinical depression in India. They found
that pains reported by patients are the pains that
people in similar situations experienced in their
daily lives. When patients explanations become
disconnected from health workers understandings,
the health worker might become impatient. It is
therefore important that health workers initiate
culturally informed inquiries, so that interventions
may become relevant to the content of the problem,
its context, and the underlying structure of beliefs
and expectations.
There are instances where an over-reliance on
the concept of culture in health policy and practice
may become counter-productive. There have been
examples of misuse of anthropology or cultural
data. A case was reported in 1991 where a European
anthropologist wrote a report in an un-reviewed
journal that monkeys blood was rubbed into cuts
as love magic in Eastern Democratic Republic of
Congo (DRC), and that this might be the source
of AIDS. This report was found to have originally
been invented by an ethnographer at the urging of
his European publisher who sought exotic stories
to boost the sales of his book.
When practitioners cannot cure a disease, they
advise patients to go and settle matters with the
family. This referral practice has been justied on
the grounds that most people presume that fatal
conditions are socially or supernaturally caused.
However, the poor service received even by those
people seeking biomedical care is often ignored.
The existence of a folk belief model was used to
excuse the lack of measles vaccine in Lubumbashi
(Democratic Republic of Congo) in the late 1970s.
One of the ofcials said that uneducated mothers
would not bring their children for vaccination
anyway. However, it turned out that the mothers
were in fact interested, but that malnutrition and
poverty meant that even after vaccinating their
children, mortality levels remained at the same
levels as before. Thus, issues of inequity were
sidelined in favour of explanations that favoured
doing nothing.
Immigrant and refugee populations

The increasing number of immigrant and refugee
populations in many African states necessitates a
careful analysis of the patients migration history,
which is an important part of cultural identity
for recent immigrants. In the case of refugees,
the health worker needs to explore the degree
of loss and trauma to self and family members.
Immigrants and refugees experience the stresses
of being extracted from one social stratication
system and inserted into another. This leads to loss
of supportive social networks and acculturation
problems.
In assessing the mental health of immigrant and
refugee populations the following psychosocial
aspects and issues must be explored.
It is also important to note the following:
The health worker is advised not to stereotype
people on the basis of group identity. Some
people reject their cultural traditions in
order to identify with the traditions of the
dominant group, while others have developed
mechanisms enabling them to participate in
the activities of both cultures.
The health workers task is to identify how
cultural identity affects the patients mental
health. An arranged marriage could be a source
of great distress for a young and independent
woman. Further, fear of being isolated and
disowned by ones family group poses an
additional source of stress. The health worker
should assess the persons cultural identity and
level of acculturation as described earlier.
Health workers should familiarise themselves
with the competencies and standards required
to work effectively with multi-cultural
individuals.
Implications for practice

Health practitioners should be careful not to
make decisions about an individual based on
the stereotypes associated with that individuals
racial, ethnic or linguistic group. National and
111
1. Pre-migration history
Issues: Country of origin, education, socio-economic status, community and family support, political
issues, war, trauma.
2. Experience of migration
Issues: Migrant versus refugee: Why did they leave? Who was left behind? Who paid for their trip?
Means of escape
3. Degree of loss
Issues: Loss of family members, relatives, friends, material losses: business, careers, properties,
4. Traumatic experience
Issues: Physical: Torture, rape, starvation, imprisonment
Psychological: Rage, depression, guilt, grief, post-traumatic stress disorder of cultural milieu,
community, religious and spiritual support.
5. Work and nancial history
Issues: Original line of work, current occupation, socio-economic status.
6. Support systems
Issues: Community support, religion, family
7. Medical history
Issues: Beliefs in traditional medicines, somatic complaints, familys concept of illness. What
do family members think the problem is? Its cause? What do they do for help? What result is
expected?
8. Level of acculturation
Issues: First or second generation, languages spoken, degree of identication and interaction with
local culture (host community) versus socialising, mainly with members of ones original culture.
9. Impact on development
Issues: Level of adjustment; assess extent to which living in new culture is being negotiated, such as
attainment of housing, employment, mastery of public transport.
(Adapted from Lee, 1990)
beyond the borders of the therapeutic houra

situation that emanates from their conception
of human relationships as lasting and mutually
interdependent. Requests of this nature are
not an indication of the absence of personal
boundaries and should not be pathologised as
such. They stem from a particular perception
of human relationships. Failure to realise this
may lead to loss of therapist credibility (the
perception that the therapist is capable of
dealing with the clients problem) and giftgiving (the perception that the client has gained
something from the therapeutic relationship).
Values
It is important for the health practitioner to take note
of how these values impact on their relationship
with the patient:
The division of therapeutic sessions according
to segments of 50 minutes each, which forms
an important part of the therapeutic frame,
is more in line with the Anglo-American
conception of time.
The expectation that the patient should take
charge of therapy sessions, with the therapist
providing reassurance and acceptance, tends to
suit western, educated and verbal clients who
share this assumption. African clients, most
of whom are likely to be having pressing and
concrete real life problems, may expect the
therapist to be actively involved in assisting
them.
The client-therapist relationship is perceived
by traditional African clients to extend
Language
Language is the mental health practitioners most
important tool. Social constructionists have noted
that it is by means of language that we appraise
reality. Clinicians should try to learn the main
language of the patients whom they serve.
112
Inappropriate affect.
Poor family relationships (the individuals
symptoms interferes with his or her ability to
full family obligations). Cited from Idemudia,
(2004).
Beliefs about health and illness

Group and individual identity are derived from
shared beliefs. Further, the manner in which the
self is dened has implications for how health and
disease are understood. In the west, physical illness
is explained primarily in terms of germ theory: it is
biological in origin. This explanation is extended
to mental health problems, where biological and
psychological explanations (in terms of intrapsychic factors) have dominated thinking. The
majority of problems brought to mental health
practitioners stem from patterns of interaction
within families, communities and the broader
social sphere. The following sections discuss
ways of understanding illness in different cultural
contexts.
Illness and explanatory models

It is important to take into account patients
explanatory models of their illness. Explanatory
models consist of notions about the causes of
illness, timing, onset, and its pathophysiology,
severity and natural history, and treatment options
available to the individual. This is because the
explanatory model used by the clinician is often
not the same as the one used by the patients. While
acknowledging biomedical causation of illness,
patients also hold additional explanatory models
accounting for their illness in terms of cultural
and spiritual factors. Family members could see
mental illness as indicative of a breakdown in the
relationship between the family and the ancestors.
Under such circumstances, the family becomes the
focus of treatment, the affected individual being
perceived as a means through which ancestral
displeasure is manifested. It is thus important for
the clinician to inquire about the causes of the
illness. It is important for the clinician to ask the
patient or family what has happened, why it is
happening and at this point in time, and what they
think will happen if the condition goes untreated.
Beliefs about the causes of illness (Why am I

sick?)
Biological, psychological, spiritual and other
reasons may be used to explain the cause of the
illness. It is important to understand how patients
view their illness in order to develop effective
assessment and intervention plans. This may also
help the health worker to identify other members
of the multi-disciplinary team who may be coopted to assist with the management of the patients
condition.
Contrary to the biological orientation of western
psychiatry, the view of illness in traditional African
thought is comprehensive. It incorporates biological,
social, as well as spiritual dimensions. Illness in
traditional Africa is considered an indication of
distress in social and communal relationships. The
healthy person is harmonised with self, others,
nature, the spirit world and universe by connections,
interactions, and meetings, using an oral tradition.
An example of this view of illness given by Nzewi
maintains that the Ibo of Nigeria distinguish ve
ways through which psychosocial disorders could
be identied. These are:
Benecial reciprocitywhen an individual
is unable to socialise adequately with his or
her neighbours; the need to maintain good
interpersonal relationships with others being
one of the most highly prized virtues.
Degree of shame people experience (nonconformity). Well-adjusted people are
expected to evidence some degree of shame if
their behaviour deviates from societal norms.
Absence of shame is indicative of mental
illness.
Disorientation with respect to time and
inappropriate behaviour and speech.
Somatisation of psychiatric symptoms

To some extent, culture denes the way community
members express physical and mental disturbances.
Complaints and symptoms are expressed in
the idiom of the community. Tanzanians may
often express emotional discomforts in physical
symptoms. Physicians have called this hapa
hapa syndrome. The patient is very distressed
and complains of multiple physical pains. Mental
evaluation usually reveals emotional discomfort,
anxiety or depression.
There are other ways in which culture denes
the presentation of symptoms. The content of
patients delusions (irrational false beliefs that
are not in keeping with ones cultural beliefs
and amenable to logical persuasion) also varies
according to their culture. Patients might believe
that the hyena, computer, or laser beams from
satellites are controlling their thoughts and actions.
The disturbance is the same (thought control),
but the way it is expressed is due to the different
cultural expression of the symptom. This is called
pathoplastic inuence of culture.
113
often co-exist with anxiety symptoms, and patients

do not draw sharp distinctions between these
experiences.
The somatisation of psychiatric symptoms is not
unique to African patients. It has been observed
in a number of societies, including some western
societies. The body becomes an important vehicle
for communicating psychological distress in most
non-western societies. The clinician should thus
question the patient about bodily symptoms that do
not have an organic basis to establish a diagnosis
of depression.
A word of caution is necessary in dealing with
somatising patients. While people who present
with somatic complaints could be depressed, health
workers should not dismiss somatic complaints
as merely psychogenic. This could deny patients
much needed physical care. This is particularly so in
cases where resources are limited and the exclusion
of medical conditions cannot be undertaken. They
should move away from focusing on somatisation
as a symptom and concentrate on the meaning of
somatisation in the patients life.
It has now been established that depression and

psychiatric disorders in general are very common
in developing societies. Those at the bottom
of the social stratication system experience a
disproportionate amount of mental health problems
and are least likely to receive professional help.
Depression is one of the most important causes of
morbidity and disability in developing societies,
where it is often exacerbated by poverty. It is most
pronounced among women, who constitute the
most disadvantaged segments of society.
The reason depression was thought to be nonexistent or negligible in Africa was that guilt, one
of the key symptoms of depression in standard
classication systems, is largely absent among
African patients. Instead, depression tends to be
somatised. Nigerians who are depressed complain
of burning bodily sensations, heaviness or heat
in the head, and crawling sensations in the head
or legs. Depressed Zimbabweans present with
multiple somatic complaints. Likewise, depressed
Zulu patients (South Africa) present with bodily
symptoms such as headache, back pain (iqolo)
and stomach ache (isisu). Symptoms of depression
114
22
Mental Health, Spirituality and Religion
Tarek Okasha, David M. Ndetei
understanding and describing human experience

and behaviour.
Recent psychiatric literature and contemporary
socio-political developments suggest a need to
reconsider the place of religion and spirituality
in psychiatry. Despite the secularising effects of
science, the presence and inuence of religiosity
remains substantial not only in traditional, but
in western culture as well. The literature puts
emphasis on the central importance of religion and
spirituality for mental health, and the difculty of
integrating these concepts with scientic medicine.
Psychiatry would benet if the vocabulary and
concepts of religion and spirituality were more
familiar to trainees and practitioners. Patients
would nd better understanding from mental health
workers, and fruitful interdisciplinary dialogue
about mutual issues of ultimate concern might
ensue.
Psychiatry and religion both draw upon rich

traditions of human thought and practice. In fact,
psychiatry is the branch of medicine that most
prominently incorporates the humanities and social
sciences in its scientic base and in its treatment
of illness. The rich intellectual traditions of Chris
tianity, Judaism, Islam, Hinduism and Buddhism
have made unique contributions to the treatment of
the mentally ill. Throughout history, these religious
traditions have made major contributions to
peoples perceptions of mental illness. They have
also offered a range of treatment options.
SPIRITUALITY AND RELIGION

Spirituality refers to the experience of contact with
a higher power. Five aspects of spirituality that
should be considered by the psychiatrist include
looking for the meaning of life, human solidarity,
wholeness of the person being body, mind and spirit,
moral aspects and awareness of God. Religion
contains so many unrelated variables that it cannot
be considered as a one-dimensional concept. It is
the outward practice of a spiritual system of beliefs,
values, codes of conduct and rituals.
Throughout history, the functions of religious
practices and healing were performed by a
single individual. With the explosive growth of
scientic knowledge in the twentieth century,
the roles of religious and medical healers were
separated. Psychiatry and religion are parallel
and complementary frames of reference for
THE ROLE OF RELIGION IN

MENTAL HEALTH
Religion has many psychological functions. It is
a source of support for the ego throughout life.
Religion plays a major role during life events
such as birth, death, life passages, marriage, childrearing, and ageing. It also functions as a source
of meaning in the individuals life. There is a
very clear relationship between religious beliefs
and mental well-being In a 12-year review of all
articles appearing in the American Journal of
115
Psychiatry and the Archives of General Psychiatry,

72 percent of the religious commitment variables
were benecial to mental health: participation
in religious rituals, social support, prayer and a
relationship with God were benecial in 92 percent
of citations.
Religion also provides a worldview by means
of which we understand ourselves, our purpose in
the world and the nature of the universe in general.
All religions offer some type of explanation
concerning the origin of the universe, how life is
maintained, and what happens when life ceases to
exist. All religions attempt to give their followers
explanations of the meaning of life, including
rationales for the reality of human suffering.
Religious symbols, beliefs, myths and rites enable
individuals and groups to deal with the ultimate
conditions of existence that are experienced by
members of every society.
Most importantly, religion plays a major role
in symptom formation, psychopathology and
management of many psychiatric patients. The
expression of symptoms may differ according
to the religious upbringing of the patients. In a
study in Egypt, almost 60 percent of obsessive
compulsive Muslim patients were found to present
with religious content. This gure was comparable
to that of patients with a Jewish upbringing, but
higher than that of British and Indian patients.
The content of delusions and hallucinations is
frequently of a religious nature. The dissociation
and conversion disorders are over-represented with
ideas of possession, witchcraft, envy and djinnies
inuence, which have cultural-religious bases.
Religious leaders could also play a major role in
changing the attitude of the population. When
health professionals in Egypt wanted to promote
family planning or address narcotics, religious
clergy were an asset.
Religion also plays an important role in causal
attributions and patient management. Psychological
symptoms are attributed not only to individual
factors such as weakness of personality but also to
factors such as the disconnection of the relationship
between the individual and God. Likewise,
treatment options take into consideration external
power such as God. Statements such as if God
is willing, I seek refuge in God, and God is
the healer, are widespread throughout Africa and
the Arab world, indicating a belief that there are
instances where human beings are not in control.
Faith in God may have biological effects, be it
on physio-chemistry and the immune or endocrine
systems. Feelings of joy, peace and comfort on

the part of the believer could be associated with
an increase in endogenous opioids, the facilitatory
neurotransmitters like GABA, and the sensitivity
of serotonin receptors. The positive relationship
between mood and the immune system has a direct
role in ghting pain, illness, and even death. Faith
possibly provides relief from pain, peace with
the self, and altruism. Lack of interest in worldly
possessions could be a mental health asset as well.
TRADITIONAL AND RELIGIOUS

HEALERS
Traditional and religious healing play a major role
in most peoples lives in developing societies.
According to WHO, close to 80 percent of the
population in developing societies rely on traditional
and religious healers for health care. Healing takes
place mostly within the persons community:
it involves the family as a whole. Physical,
emotional and spiritual needs are all catered for.
One of the factors that attract people to traditional
healing is its communal nature, as opposed to the
individualistic orientation of western medicine.
Traditional and religious healers are also likely
to explain symptoms and to provide treatment
options that resonate with the patients worldview.
The main differences between traditional African
societies and western societies are summarised in
Table 22.1. Health workers should use this table
with caution as there are likely to be individual
differences on how people select and use aspects
of their culture.
Traditional and religious healers in primary
psychiatric care, deal with minor neurotic,
psychosomatic and transient psychotic states using
religious and group therapies, suggestion devices,
amulets and incantations.
Okasha has suggested a model curriculum for
the training of mental health workers. Its objectives
are to establish the knowledge, skills and attitudes
components to enable them deal effectively with
various patients, especially those presenting with
religious beliefs.
The knowledge component

Health workers should demonstrate competence
in dening the religious and spiritual aspects of a
persons life. This encompasses the understanding
of the:
116
Mental Health, Spirituality and Religion
Table 22.1: A comparison of traditional African and western values

TRADITIONAL SOCIETY
WESTERN SOCIETY
Family and group oriented
Individual oriented
Extended family (not so geographical as before, but

conceptual)
Nuclear family
Status determined by age and position in the family,

care of elderly
Status achieved by own efforts
Relationship between kin obligatory
Determined by individual choice
Arranged marriages with an element of choice

dependent on interfamilial relationship
Choice of marital partner, determined by

interpersonal relationship
Extensive knowledge of distant relatives
Restricted only to close relatives
Decision-making dependent on the family
Autonomy of individual
Locus of control external
Locus of control internal
Respect and holiness of the decision of the physician
Doubt in doctor-patient relationship
Rarely malpractice suing
Common
Deference is Gods will
Self-determined
Doctor-patient relationship is still healthy
Mistrust
An individual can be replaced. The family should

continue and the pride is in the family ties
Irreplaceable, self pride
Pride in family care for the mental patient
Community
Dependence on God in health and disease, attribution

of illness and recovery to Gods will
Self-determined
Okasha, 2000
unique impact of religious and spiritual

experiences on physical and psychological
development
in
infancy,
childhood,
adolescence and adulthood.
differential diagnostic features of religious and
spiritual experiences at both the individual and
organisational level.
religious and spiritual factors that affect the
course and treatment of psychiatric disorders.
impact of religious and spiritual experiences
on the relationship between the medical
worker and patient, including transference
and counter-transference.
effect of the religious and spiritual issues
on medical ethics as applied to psychiatric
practice.
various religious and spiritual experiences and
traditions, each with its unique perspective on
transpersonal issues.
The skills component

Health workers should demonstrate competence in
interviewing spiritually committed patients with
sensitivity to communication styles, vulnerabilities,
and strengths as follows:
Listening to the spiritual issues in the patients
personal narratives, and eliciting accurate and
complete histories that reect an understanding
of the importance of these issues in patients'
lives.
Assessing and diagnosing patients, and
formulating treatment plans, in a manner that
reects an understanding of patients' spiritual
experiences.
Recognising the features that differentiate
normative religious and spiritual experiences
from pathological phenomena.
Providing appropriate psychotherapeutic
interventions that reect an understanding of
patients spiritual experiences.
117
evolution to provide some relief for the inevitable

problems that occur in the course of family and social
interactions. In that respect, both are important
in the maintenance of health and recovery from
illness. They also prepare people psychologically
and otherwise to deal effectively with problems in
life. The common elements of a very widespread
pattern of symbolic healing represented here in the
language of psychiatry, but correlatively echoed
in the behavioural aspects of religion, include the
special relationship between the healer and the
patient, shared worldview, expectant hope of the
patient, naming of the illness, attribution of cause,
prescription of treatment by the healer, and the
central role of suggestion. The challenge, then,
is to combine traditional scientic and religious
conceptual schemes in such a way that the patients
benet.
Science and technology have made lives easier,
but they do not teach how to live. Taking spirituality
and religion seriously could possibly lead to better
mental health. Likewise, harmony between the self
and the environment could be improved. It could
also add meaning to lives.
Recognising and using specic transference

and counter-transference reactions (negative
reactions may indicate unresolved therapist
issues in this area).
Recognising possible biases against religious
and spiritual issues in the psychiatric literature
and understanding their origins.
The attitude component

Health workers should demonstrate in their
behaviour and demeanour an awareness of their
own religious and spiritual experiences and the
impact of these experiences on their identity and
worldview. This includes the following:
An awareness of their own attitudes toward
various spiritual experiences and the possible
biases that could inuence their assessment and
treatment of patients with these experiences.
Empathy and respect for patients from various
religious and spiritual backgrounds.
Patient care.
Both mental health and religion are institutions
that were developed over the course of cultural
118
23
Culture, Spirituality and Management
A.B.T. Byaruhanga Akiiki
CULTURE-BOUND DISORDERS
OTHER TREATMENTS
Folk illnesses are syndromes that affect members

of a particular group. These illnesses have peculiar
symptoms and signs. Culture-bound syndromes
have not been adequately classied, because they
are culture-specic. They are caused and maintained
by culture-specic psychological factors such as
beliefs, values and attitudes.
Culture-bound syndromes are generally associated
with urbanisation and cultural change. With culture
change, individuals adaptive mechanisms and
social support systems are overwhelmed, leading
to anxiety, depression and a sense of isolation.
In diagnosis, the health worker should consider
whether the culture to which the patient belongs
regards the syndrome as pathological or not, failing
which they may impose their own cultural ideas on
the observed behaviour.
Culture-bound syndromes are generally treated
according to their predominant symptoms using
antidepressants, anxiolytics and tranquilisers.
Brief psychotropic chemotherapy usually achieves
temporary remission. Counselling that includes
family members is also useful. Culture shock is
also minimised if refugees are clustered in a few
central locations rather than dispersed throughout
the nation. Community education and awareness of
mental illness could be helpful.
From the African point of view, the treatment of

mental illness is most important. This is reected
in the saying: Health is better than wealth and
mental health is the best. Treatment involves
the restoration of harmony, balance and correct
alignment.
The treatment of poor relationships at whatever
leveleither on earth or in the spirit worldis
very complex. It is a big challenge to all health
practitioners, be they modern or traditional. Some
African traditional healers talk of consulting with
spirits. Afrming relationships with good spirit
persons is therapeutic, whereas relationships with
evil spirit persons are pathological. Evil spirit
persons are believed to cause all sorts of mental
illnesses. It is also believed that the majority of
behaviour disorders are inherited. This makes
treatment more complex. These beliefs have not
been empirically veried, however, health workers
need to be aware of them because they inuence
peoples perceptions of the causes of illness and
the treatments sought.
In the west, there is an observation that
biochemical medicine fails to treat patients as whole
living persons. It does not account for the spiritual
as well as physical dimensions of patients. This
explains why patients are sometimes dissatised
with biomedical care. In Europe and America
119
for the sake of others and loved others while they

lived in the physical world, are allowed to reside in
a better part of the spirit world after they shed their
physical bodies. Those who do not live a good life
on earth end up in the lower part of the spirit world;
literally sick with spiritual diseases like hatred and
jealousy.
such dissatisfaction is driving modern patients to

the so-called alternative, complementary, holistic,
traditional and natural remedies. There is a continual
need for a balanced and critical evaluation of what
holistic medicine can and cannot realistically
provide. Medical practitioners have to include
aspects of this thinking in their practice.
There are marvellous developments that have
taken place in modern medicine, especially in the
past century. Biomedicine has made tremendous
strides in eliminating contagious infectious diseases,
reducing infant mortality and extending the human
life span. It is said that generally peoples lives in
the so-called rst world are far safer, cleaner and
happier due to improvements of public hygiene
and emergency medicine. Unfortunately, a good
number of modern developments are giving rise to
new problems: economic, ethical, biological and
spiritual. There is not enough money to provide
everyone with high-tech treatment, even in the
west.
Many modern developments in biochemical
medicines are leading to ethical problems. This
includes issues such as how to prioritise health care
needs and delivery services. Further, the use of
antibiotics and sterilisation has given rise to strains
of super-bacteria resistant to these agents. Postindustrial diet and lifestyles challenge humankind
with new diseases like cancer and HIV. While
the role of health workers has changed from one
of caregiver to one of being clinical technicians,
the psycho-spiritual needs of patients are often
ignored. This increases the need for religious or
spiritual treatment.
Faith and the treatment of mental illness

Faith is very important in the treatment of mental
illness as in all healing. Apart from religious
specialists, leaders, teachers, health workers
and almost all human beings qualify as Gods
instruments to treat themselves or others. In the
treatment of mental disorders, therapy involves
truthful communication, through counselling,
which cleanses the mind, body and emotions. Often
there is need for additional physical rituals.
Counselling and guidance

In the western tradition, the aim of counselling and
guidance is to bring the patients system back on
track. This involves self-analysis, psychoanalysis,
and helping the patient treat himself or herself.
From the African point of view, patients are
encouraged to have faith and to obey God and
lawful authorities. Unity, respect, co-operation,
harmony, understanding, forgiveness and patience
with other people are all seen as antidotes for
mental illness. Gods thoughts, words and actions
or those of His agents, constitute the best medicine
for mental illness.
From the African religious and cultural points of
view, authority is very important in the treatment
of mental disorders. God remains the number one
healer.
Life in the spirit world

The African view of medicine takes a holistic
standpoint: it afrms the existence of both the
Master Creator and the spirit world. The lifestyles
of those in the spirit world are no different from
those of the living: people in the spirit world live
in houses, wear clothes and eat and drink. They are
believed to communicate among themselves and
with people on Earth. Further, spirit lings (people in
the spirit world) both experience and practise love
at different levels, just as earthlings (people living
on earth) and womb lings do. Thus it is believed
that the two worlds mingle most intimately.
Earthlings cherish the little information they have
about life in the spirit world. This is especially so
with the teaching that ones life on earth determines
ones status in the spirit world. The experience and
practice of love is most fundamental in both worlds.
There is a belief that those spirit persons who lived
CULTURE AND MENTAL

HEALTH: IMPLICATIONS FOR
TREATMENT
Mental health practitioners in Africa should take
culture into consideration in planning interventions.
They should therefore develop the necessary
knowledge, competencies, skills and attitudes to
deal with all types of patients.
Depression could be diagnosed as a brain disease
which should be treated with antidepressants.
Alternatively, it could be diagnosed as dhat
syndrome, as is the case in India. Dhat syndrome
is characterised by symptoms such as fatigue, loss
of interest, insomnia, severe headaches, weakness,
120
Culture, Spirituality and Management
heart palpitations, and suidicial feelings. These

symptoms would lead to a diagnosis of major
depression in western psychiatry. In India, these
symptoms are associated with the loss of the
essential element (semen) in the body due to
excessive sexual intercourse. In this case culturally
appropriate treatment would include abstinence.
In African societies, harmony between the
community and their ancestors is critical to the
diagnostic procedures of a traditional healer.
Harmony exists if the family has met its sociospiritual obligations to the ancestors. Ancestral
displeasure resulting from failure to meet these
obligations results in illness. Diagnosis is
concerned with more than what am I suffering
from? It also considers questions such as why
the illness is happening at this point in time
and why it is affecting a particular individual.
Rigorous diagnostic questioning of the patient is
not emphasised; the healer focuses on interpreting
the patients experiences (e.g. by means of dream
analysis). Appropriate treatment such as a ritual
offering, restores the balance between ones family
and the ancestors. This does not mean that other
treatment options are not considered.
There is strong evidence suggesting that
schizophrenia has a better outcome in developing
countries or rural areas in comparison to the
developed world or urban areas. This has led
to suggestions that culture has a protective or
therapeutic element in schizophrenia. There is a
lot of literature exploring the relationship between
schizophrenia and expressed emotion (EE). It

has been suggested that if the family is tolerant
of schizophrenic individuals, accepting them
and making an effort to nd them employment
appropriate to their level of functioning, the
outcome is better. It is hypothesised that negative
outcomes result from a critical and intolerant
attitude on the part of family members and the
community. Intolerance and personal isolation are
typical of large industrialised societies.
RACIAL TRANSFERENCE
AND COUNTER-TRANSFERENCE
A health practitioner should be prepared to deal
with cultural transference and counter-transference.
Patients may believe that health worker of their own
ethnic group is less competent than one of another
group. The opposite is also true, where patients
perceive a clinician of their own ethnic group as
a special hero. It is thus important for clinicians to
be aware of the impact of their ethnicity, race or
culture on the clinician-patient relationship. This
awareness could be achieved through personal or
group supervision, where clinicians come together
to reect on their own values.
The following questions should be discussed in
groups situations where there is need for cultural
identity awareness.
Table 23.1
i.
What is your ethnic background? What has it meant to belong to your ethnic group? How has it felt to
belong to your ethnic group? What do you like about your ethnic identity? What do you dislike?
ii. Where did you grow up, and what other ethnic groups resided there?
iii. What are the values of your ethnic group?
iv. How did your family see itself, as similar to or different from other ethnic groups?
v. What was your rst experience with feeling different?
vi. What are your earliest images of race or colour? What information were you given about how to deal with
racial issues?
vii. What are your feelings about being white or a person of colour?
a. To whites: How do you think people of colour feel about their colour identity?
b. To people of colour: How do you think that whites feel about their colour identity?
(Adapted from Pinderhughes, E, 1989)
121
and life and death have cultural dimensions. In

other words, these aspects are dened from the
points of view of the people concerned. Culture is
a very important variable as far as conceptions of
health and illness are concerned.
THE THERAPEUTIC VALUE

OF MAINTAINING GOOD
RELATIONSHIPS
In many parts of Africa, there is an assumption
that some illnesses defy western scientic
methods of diagnosis and treatment. This applies
to psychosomatic, spiritual and mental illnesses.
People automatically resort to folk-practitioners
who have cultural ways of handling such illnesses.
It is not only the less educated who utilise the
services of traditional healers, even some of the
most educated do so when the chips are down.
The goal of African medicine is holistic treatment;
it caters for the patients physical, mental, social,
environmental and spiritual well-being.
African spirituality
The term spirituality does not translate easily in
African languages, and no African language denes
spirituality. Since time immemorial, Africans
know that the human being has a body and a nonphysical mind (soul) when alive. When one dies,
the invisible soul becomes the ghost or spirit. The
soul has all the characteristics of a human being in
terms of spiritual senses and capabilities.
The disembodied spirit person knows, loves,
feels and communicates. In short, the dead remain
honourable members of their families, clans,
societies and communities at different levels;
capable of communicating with those living on
earth. They support, protect and help the living in
many ways. They also participate in life activities
of their descendants, relatives, friends and even
enemies. The philosophy embedded in this thinking
sounds amazing, surprising, incredible and
unimaginable. It is truly the legacy of spirituality
in traditional African religious thought.
AFRICAN SPIRITUALITY, FAITH

AND MENTAL HEALTH
Health practitioners of whatever categories
have to be cognizant of the fact that they are
commissioned to treat people as whole persons
body, mind, soul and spirit. There is an assumption
that religious commitment has benecial health
effects. Spirituality should play a greater part
in care and prevention of physical, mental and
spiritual disorders. Truly then, in putting healing
powers in so many herbs and other creatures, the
Master Creator and Master of Science to whom
healers in Africa traditionally pray, remains the
healer number one.
There are ve related phenomena namely:
African spirituality, treatment of mental illness,
counselling and guidance, nature of mental illness,
ancestors and mental illness.
Further reading for Chapters 20-23

1. Byaruhanga-Akiiki, A.B.T. (1998). Traditional
healing and mental health. Paper read at a Workshop
for Parents/Carers of people with chronic mental
health. Pope Paul Memorial Community Centre.
Sept.24, 1998.
2. Lee, Sang Hun (1996). Life in the spirit world and on
earth. Paragon.
3. Makinde, A. (1990). African philosophy, culture and
traditional medicine. Chicago, Ill.
4. Michael, K. (1988). The missionary and the diviner.
Orbis
5. Orley, J. (1995). Culture and mental illness (Uganda
case). Oxford.
6. Shorter, A. (1991). Jesus and the witchdoctor: an
approach to healing and wholeness. Heinemann.
7. Thairu, K. (1975). The African civilization: Utamaduni
ya Kiafrica. EALB.
African religion and culture

In Africa, it is well known that all human theories
and practices of medicine, as well as conceptions
of physical or mental illness, diagnosis, treatment,
122
Section III:
Behavioural Neurosciences
123
124
24
Neuroanatomy and Psychiatry
John Mburu, David M. Ndetei, Francisca Ongecha-Owuor, Benson Gakinya
The pathophysiology of majority of psychiatric

disorders is now better understood following many
advances made in the elds of neuroanatomy, brain
imaging, neurochemistry and neurophysiology.
Neurosciences can be justiably considered
the biomedical foundation of psychiatry and
psychology since they offer clear understanding of
human experiences and behaviour.
GROSS ANATOMY OF THE

BRAIN
The brain is a highly complex organ consisting
of two hemispheres, which are connected by
the corpus callosum and other smaller commissural
tracts. The brain has an extension called the spinal
cord. The spinal cord and the brain constitute
the central nervous system (CNS). The brain has
gray and white mater. The three areas of the gray
mater are cerebral cortex, cerebellar cortex, and the
sub-cortical cerebral and cerebellar nuclei.
Occipital Cortex
Cerebellar Cortex
Figure 24. 1: Mid sagittal view of the brain
125
The cerebral cortex is heavily folded with

convolutions (gyri) and ssures (sulci or grooves)
and contains about 70 percent of the nerve cells in
the CNS. The cerebral cortex has four lobes, namely
the frontal, parietal, temporal and the occipital
lobe. The part called the brain stem comprises
the medulla oblongata, pons and mesencephalon.
The peripheral nervous system consists of cranial
and peripheral nerves. The function of the peripheral

nervous system is to relay sensory information to
the CNS and conduct motor information from the
CNS to the periphery. A third system is referred
to as the autonomic nervous system, whose main
function is to innervate the internal organs.
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Figure 24.2: The ventricular system
information in psychiatry; neurotransmitter

metabolites contained in the CSF can be
biological markers and a measure of response
to pharmacological treatment. Blockade in CSF
drainage causes CSF pressure to rise within the
ventricles resulting in hydrocephalus. Computed
tomography (CT) scan of such brains show
dilated ventricles. The other disorder is known as
normal pressure hydrocephalus which presents as
treatable dementia with enlarged ventricles. This
is a rare condition. Symptoms of normal pressure
hydrocephalus include abnormal gait, urinary
incontinence and progressive dementia. Treatment
of hydrocephalus is surgical and involves shunting
the CSF from the ventricular system, to either the
atrium or peritoneal space.
Ventricular system
This consists of two lateral ventricles each with
an anterior and posterior horn, third and fourth
ventricles all located within the depth of the brain
mass. The central part of the ventricular system
is located between the two lateral ventricles. A
communication called inter-ventricular foramen
of Monro connects to the third ventricle at the
midposterior section of the central part of the
ventricular system. Cerebral spinal uid (CSF)
circulates within these ventricles.
Clinical implications
Cerebrospinal uid (CSF) reects neurochemical
activity in the brain. It is a source of research
126
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Figure 24.3: Sagittal view of the skull and brain
inammation of one of the meningial layers results

in meningitis.
Meninges
The brain is covered by layers of tissue referred to
as meninges in the following order from without,
dura mater which is attached to the skull, the
arachnoid mater is beneath the dura mater, the
space in-between is called the sub-dural space.
The third layer is known as the pia mater and is
attached to the cerebral cortex. The space inbetween is called the subarachnoid space which
is lled with cerebro spinal uid (CSF). Sub-dural
haematoma, epidural haematoma and meningitis
are associated with neuro-psychiatric disorders.
Whereas subdural haematoma is due to slow
blood accumulation beneath the dura mater caused
by ruptured veins, epidural haematoma is due to
rapid accumulation of blood between the dura
mater and skull caused by rupture of an artery. The
latter is a life threatening condition. The patient may
show signs and symptoms of delirium, behavioural
and psychological symptoms. The infection or
Neurons and glia

A neuron is the basic functional unit of the nervous
system. Neurons are also called nerve cells. Glial
cells (neuroglia) are a class of neuronal cells in CNS.
There are four types of glial cells, the astrocytes,
oligodendrites, ependymal and microglia cells.
The latter two types of cells line the brain
ventricles and the central canal of the spinal cord.
They facilitate the ow of the CSF. The glial cells
also contribute to blood brain barrier (BBB), a
semi-permeable membrane between blood vessels
and the brain.
The ability of compounds to pass from the blood
into the brain and vice versa depends on their
molecular size, electrical charge, solubility, and
specic transport syste m. The BBB is important in
regulating the brain chemistry.
127
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Figure 24.4: Parts of the brain associated with specic functions

days later and went back to work six months after
the accident.
Mr. K was a 35-year-old married salesman, well
mannered, loving, admired individual, and was
a successful businessman. Upon resuming duty,
Mr. K was on several occasions noted to be
caressing female workmates and lacked etiquette
and manners. It was noted that although Mr. K
worked, he on most occasions provided details
and information that was rather untrue. As time
went on, he became uninterested in his duties;
became more irritable and hostile. Making
simple decisions affecting the life of his young
family and work became very difcult. Mr. K
received a suspension letter from his employer on
account of his incompetence. The wife described
her husband as a changed person.
Cerebral cortex
Seventy (70) percent of the neurons are located in
the cerebral cortex. It is the most developed area
of the brain and its injury causes characteristic
neuropsychiatric symptoms. The cerebral cortex has
four different anatomical lobes, each performing
some core functions through reciprocal connection
to each other.
Frontal lobe
This is basically involved in motor behaviour,
expressive language, ability to concentrate and
attend, reasoning and thinking, and orientation
to time, place, and person. Lesions in the frontal
cortex cause frontal lobe syndrome where all these
functions are disordered. This may manifest as gross
change in personality characterised by the following
symptoms: inappropriate behaviour, disinhibition,
irritability, labile mood, depressive feelings, lack
of motivation, difculties with attention and
expressive aphasia (Brocas Aphasia).
This case illustrates the behavioural and

psychological symptoms of frontal lobe syndrome.
The injury that occurred two years ago led to total
change of Mr. Ks personality.
Temporal lobe
Case vignette 1
Two years ago, Mr. K was involved in a road
trafc accident in which he sustained a depressed
fracture on the frontal skull and craniotomy had
to be performed. He regained consciousness four
This consists of a group of neurons including the am

ygdala, hippocampus and limbic system. The main
functions of this lobe are memory development,
storage and retrieval especially in the hippocampus
gyrus, language comprehension, interpretation of
128
of these hallucinations. Evaluation revealed that

Mrs. P had a fast growing tumour on the dominant
hemisphere that had caused tremendous pressure on
the contra lateral temporal lobe. Surgical treatment
was followed by recovery.
gustatory and olfactory sensation and regulation of

emotions and certain sexual and aggressive drives.
The temporal lobe is of interest to psychiatry
due to three clinical syndromes associated
with lesions in the region namely, Kluver Bucy
syndrome, Korsakoffs syndrome and aggression.
Lesions in the temporal lobe may mimic thought
disorder where there is uent but incoherent
speech. Kluver Bucy Syndrome is characterised
by placidity, apathy, bulimia, hyper-sexuality,
visual and auditory hallucinations, amnesias,
aphasias, dementia and seizures. Causes of Kluver
Bucy syndrome include tumours, trauma, herpes
encephalitis, Alzheimers disease and bilateral
temporal surgery.
Korsakoffs syndrome is characterised by
amnesia, either retrograde or anterograde, due
to chronic thiamine deciency associated with
alcoholism. Aggression is a common psychiatric
symptom and it is now postulated to have an
association with the limbic system. This is
suggested by the docility of animals with lesions
of the limbic system. An important observation is
that lesions of amygdala may lead to symptoms
similar to those of schizophrenia, depression or
mania. It is important that before diagnosis is made
the differential diagnosis of amygdala lesions is
excluded
Parietal lobe
This is the part of the brain that receives, identies
and associates, visual, tactile and auditory sensory
inputs. It is involved in the development of
intelligence and verbal processing. Dysfunctions of
the dominant parietal lobe include, Gerstmanns
syndrome, alexia, agraphia and aphasia.
Gerstmanns syndrome is characterised by agraphia
(failure to write), the patient may have left-right
disorientation and difculties doing calculations
(acalculia). Alexia is an acquired disorder in
reading ability. There is loss of the ability to
grasp the meaning of written or printed words and
sentences. It is not the same as dyslexia, which is a
developmental problem in reading.
Agraphia is the acquired inability to write and
always accompanies the aphasias. Aphasia is a
disturbance in speech due to organic brain disorder.
The patient has difculties expressing thoughts
verbally. There are four types of aphasia:
Motor
Sensory
Nominal
Syntactical.
Motor aphasia occurs when one lacks the ability
to speak, although comprehension remains intact.
Sensory aphasia is the inability to comprehend the
meaning of words or the use of objects. Nominal
aphasia is where there are difculties in nding the
right name for an object and the patient uses vague
words like it and thing. Syntactical aphasia is
inability to arrange words in proper sequence.
If the lesion is on the non-dominant parietal lobe
the patient suffers from illness denial also called
anosognosia. The patient completely denies that
they have, for example, suffered a stroke. There is
also impaired spatial abilities, inability to recognise
body parts (autotopagnosia), and difculty in
dressing and constructional apraxia. There is selfspatial neglect.
Case vignette 2
Mrs. P, a 38 year old, progressively developed
strange symptoms over a period of 6 months that
were characterised by euphoria, silly manners
and irritability. Although she liked music and
art a lot, her abilities to sing and paint or recall
obvious things decreased tremendously in the
course of the illness. To her friends she was
described as uninhibited. For example, she made
sexual advances to strangers and at times had
temper tantrums. She made fascinating claims
that the mayor of the city was responsible for
the persistent and intense taste and smell of
rotten eggs around her She was referred to a
psychiatric unit due to the progressive signs of
dementia in which she was unable to understand
spoken language. A computerised brain scan
revealed a tumour.
Mrs. P displays a short history of disturbed

behaviour, which includes mood disturbance,
diminished language comprehension and inability
to control her sexual and aggressive drives. Her
cognitive function was also affected, where the
memory was impaired, had receptive aphasia and
developed olfactory and gustatory hallucination.
She even had explanatory delusions of the source
Case vignette 3
Mr. J, a 55 year old, retired teacher was
progressively noted to have problems reading
bible verses (alexia) at his local church where
he served as a lay preacher. His capacity to
129
preach dramatically became impaired and the

congregation was concerned that his sermons
no longer had meaning since he could not
communicate effectively (aphasia).
As time went by the bank manager alerted Mr.
Js relatives about his difculties in signing
documents in the bank and that he found it difcult
to calculate his nances and transactions in the
bank (agraphia and acalculia).
Two months down the line relatives reported
that Mr J had gradually lost his ability to name
objects, had become very vague and words in his
speech were poorly arranged losing the intended
meaning (nominal and syntactical aphasia).
By the fourth month of his illness he had
developed left hemiplegia. Despite this obvious
physical disability Mr. J denied having any
illness. (anosognosia due to lesion on the nondominant hemisphere)
health deteriorated and he complained of severe

headaches, weakness and inability to walk
or stand. There was a ve-month progressive
history.
Mr. T had just been released from prison, and
was only frustrated by the loss of his job and
humiliation of being jailed for a crime he felt
he was not individually responsible for. General
practitioners had put him on several treatments
for malaria and other ailments, but eventually
committed him to psychiatric hospital for
possible conversion reaction.
Careful history and examination revealed that Mr.

T. was of a good pre-morbid personality. There were
no head injury and the onset of his illness, though
gradual, got worse very rapidly. Neurological
examination revealed cerebellar dysfunction and
that he had partial blindness. Mr. T. was referred to
neurologists, but died ve days later. Postmortem
results revealed a large tumour in the occipital lobe
embedded in the calcarine gyrus and herniating into
the cerebellum. This case shows how psychological
symptoms may predominate over neurological
symptoms and cause delay in diagnosis.
This case illustrates parietal lobe dysfunctions due

to a lesion on the dominant hemisphere caused by
a tumour, which later caused pressure to the nondominant parietal lobe causing hemiplegia which
the patient denied.
Occipital lobe
Basal ganglia
Its chief function is the interpretation of visual

images and visual memory. The lesions in this lobe
may result in visual illusions, hallucination and
blindness. Since major psychiatric disorders such
as schizophrenia present with visual disturbances
the health worker should attempt to exclude
organic causes of such perceptual disturbances to
avoid misdiagnosis.
Basal ganglia consist of a group of nuclei that

contain cholinergic neurons. It has corpus striatum,
substantia nigra and innominata, and subthalamic
nuclei. It is involved in initiation of movement. This
anatomic area is associated with a number of clinical
disorders such as Parkinsons disease, Huntingtons
chorea, Wilsons disease and Fahr syndrome. These
are neurological disorders mostly associated with
symptoms of psychosis, depression and dementia.
Untreated schizophrenics show many movement
disorders: extreme opening and closing of eyes,
aring of the nose, grimacing, protrusion of the
tongue, and shaking of head all of which imply an
involvement of the basal ganglia.
Case vignette 4
Mr. T, a 25-year-old single man, was admitted into
a psychiatric ward with a history of progressive
irritability and complaints that the television
screen was irritating his eyes. He would get
into trouble with relatives as he insisted that
the television should be off all the time. His
130
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Figure 24.5: Areas of the brain associated with schizophrenia
traumatic lesions and tumours have been known to

cause Parkinsons disease.
In pathophysiological terms, there is loss of cells
in the substance nigra, a decrease in dopamine
and degeneration of dopa-minergic tracts. Using
a dopamine precursor L-dopa that is able to
cross the blood brain barrier is the cornerstone of
treatment. Amantadine, which acts synergistically
with L-dopa, can also be used in treatment.
Parkinsons disease
This is a basal ganglia disorder. The clinical
features of Parkinsons disease are tremors, which
are characteristic pin rolling and are prominent
especially when the patient intends to initiate an
action. They disappear with sleep. Rigidity is a
disabling symptom and is described as cogwheel
type of rigidity, which is most apparent in the neck
and upper extremities. Akathisia is a symptom
characterised by inability of the patient to sit still.
The symptom tends to present very early in the
course of the illness. The gait becomes shufing
and the patient bends forwards as though chasing
their centre of gravity while walking.
Depression and dementias are common in
Parkinsons disease. There is 50-90 percent
incidence of depression, and it is higher in males
than females. Prevalence and incidence gures are
unknown in our region, but in developed countries
it is estimated at 200 per 100,000 persons during
adult life.
Parkinsons disease may be environmentally
induced. Thus, infections resulting into encephalitis,
neurotoxicity, especially with carbon monoxide,
Huntingtons chorea
It was described by George Huntington in 1872.
It is an autosomal dominant motor disorder.
The diagnosis depends on identication of
progressive choreiform movements and dementia.
The presence of a family history of the disorder
makes the diagnosis stronger. It commonly occurs
in middle life and has no specic treatment though
antipsychotic medication may be used to treat
accompanying psychotic and personality changes.
It is a rare disease.
The onset is insidious with progressive
choreiform movements, and psychiatric symptoms
that may include preceding personality changes
and inability to adapt to the environment. Dementia
131
which, may afict as many as 90 percent of patients, is

called subcortical dementia when there is associated
movement disorder. Depression is a psychiatric
symptom affecting 40 percent of the patients while
suicide is a major complication. Psychosis occurs in
as many as 20 percent of the patients.
Aetiologically it is an autosomal dominant disorder
with complete penetrance causing atrophy of caudate
nuclei as visualised on computed tomography.
The specic gene involved is yet to be identied.
However, it is thought that human chromosome four
is the site of the genetic abnormality. There is gradual
progression with death occurring 15-20 years after
the onset. The only effective treatment is genetic
counselling, but antipsychotic medication tends to
offer some symptomatic relief of the choreiform
movements.
the differential diagnosis. Clinical features include

Parkinson movement disorder, neuro-psychiatry
symptoms and calcication of the basal ganglia on
computed tomograms
Thalamus, hypothalamus and pineal body

Thalamus is located above the hypothalamus and
consists of various nuclei. It is an integral part of
the limbic system. Thalamus is involved with
perception of pain. The nociceptors (pain receptors)
receive nerve impulses from the peripheral organs
that are relayed and eventually ascend along spinothalamic and reticulothalamic tracts to the thalamus,
from where the impulses are relayed to the somatic
sensory cortex. Dysfunctions of the thalamus are due
to many factors including tumours which produce
severe pain syndrome.
Pain transmission to the thalamus can be inhibited
by projections from periaqueductal region of the
midbrain and the nucleus raphe of the medulla.
These regions have high concentrations of opiate
receptors and these endogenous opiates (endorphins
enkephalins) play a role as neurotransmitters for
the control of pain. The hypothalamus is located
beneath the thalamus and on either side of the third
ventricle. It has many nuclei and those relevant to
psychiatry include: mamillary, supra-chiasmatic,
optic and paraventricular nuclei. The hypothalamus
has several connecting pathways to other parts of
the brain. It is a major integrating and output system
of the entire CNS. It controls biological rhythms and
regulates the immune systems. It is also involved with
appetite and sexual regulation, since it is a part of the
limbic system. The pineal gland secretes melatonin
which is useful in sleep regulation and also secretes
various peptides.
Wilsons disease
It is due to hepato-lenticular degeneration. Related
symptoms include a number of motor disorders.
Clinical features are found in two organs: the CNS
where irritability, depression, psychosis, dementia
of the sub-cortical type, rigidity and dysarthria
occur; and liver failure characterised by jaundice,
Kayser-Fleischer rings in the cornea, blue moons on
the nger nails and apping tremors of the arms.
Aetiologically, Wilsons disease is an autosomal
recessive disorder associated with the abnormalities
in copper metabolism. Ceruloplasmin levels are
low and copper which is supposed to bind to this
enzyme is left free and deposited both in the liver
and the lenticular nuclei, thus causing damage to
these organs.
Fahr Syndrome
This is clinically similar to negative symptoms of
schizophrenia and must always be considered in
132
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Figure 24.6: Areas of the brain associated with Bipolar Disorder
The second important function of the brain stem is

hosting of the medial forebrain bundle, the nuclei
of ascending biogenic-amine pathways. Thus, there
are high concentrations of dopamine, noradrenalin
and serotonin levels in the brain stem
Cerebellum
Consist of cerebellar cortex, the middle cerebellum
vermis and deep cerebellar nuclei. There are
projections to the cerebral cortex and other brain
areas such as the limbic system, brain stem and the
spinal cord. Functions of the cerebellum are control
of movement and posture and therefore its lesions
will cause loss of balance. It is also involved in
higher mental functions.
Reticular activating system

This is a system of loosely organised network
of neurons located in the brain stem, which receive
input from cerebellum, basal ganglia, hypothalamus
and cerebral cortex. The reticular activating
system also sends projections to the hypothalamus,
the thalamus and the spinal cord. Since the
reticular activating system is responsible for
the state of alertness and wakefulness, those
psychiatric disorders where motivation and arousal
are affected, may be due to pathology within the
reticular activating system.
Brain stem
The brain stem comprises three parts: the
mesencephalon, pons and medulla oblongata.
Functions of the brain stem are control of
cardiovascular activity, sleep and levels of
consciousness. It is also involved in respiratory
activities. All these physiological activities are
under involuntary control.
133
25
Psycho-neurochemistry
Francisca Ongecha-Owuor, David M. Ndetei, John Mburu, Benson Gakinya
the detection of the neurotransmitter by the receptor

proteins (synaptic connection) leading to activation
of post-synaptic neuron causing membrane
depolarisation (excitation) or hyperpolarisation
(inhibition). The activities that take place in the
synapse are important in the understanding of
many other physiological changes that are relevant
to psychiatry. The synapse is the major site of
action for neuro-messengers and drugs used in
psychiatry.
The human brain is made up of cells called neurons.

These cells comprise four parts: cell body,
dendrites, the axon and the pre-synaptic terminal.
A gap called the synapse exists between a presynaptic terminal and the next neuron. There are
several millions of these neurons in the brain
whose main function is information processing
following either excitation or inhibition. Neurons
communicate to and with each other through signal
transduction and chemical neurotransmission.
Signal transduction refers to the general process
by which electrical signals (the nerve impulse) are
converted into chemical signals (neurotransmitter
release) by the pre-synaptic neuron and the process
by which the chemical signals are converted back
into electrical signals by the post-synaptic neuron.
Chemical neurotransmission refers to the release of
a neurotransmitter by the pre-synaptic neuron and
SYNAPSE
There are three types of synapses: chemical
(humoral), electrical (gap junctions) and conjoint.
Chemical synapses use neurotransmitters to relay
Figure25.1: The Nerve Structure
134
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Figure 25.2: Nerve Ending
Biogenic neurotransmitters include cate-cholamines

(dopamine, epinephrine and norepinephrine);
indole amines (serotonin, also called 5-hydroxy
tryptamine), quaternary amines (acetyl-choline)
and ethyl amines (histamine).
Research techniques used to study neurotransmitters involve measuring the neurotransmitter synthesising enzymes, quantities
of neuro-transmitters and neuro-transmitter
metabolites that are found in samples of blood, urine
and cerebrospinal uid. Clear understanding of the
nature of receptors allows the neuroscientists and
clinicians to appreciate the mechanisms involved
in the actual disease pathology and what remedies
to develop.
messages while electrical synapses use electric

current and ow of charged ions to relay messages.
Conjoint synapses contain both chemical and
electrical synapses. Synapses can either be
excitatory or inhibitory, depending on whether
they induce membrane depolarisation (excitation)
or membrane hyperpolarisation (inhibition),
following release of the neuro-messengers and its
effect on the post-synaptic neuron.
NEURO-MESSENGERS
Neuro-messengers, also known as neurotransmitters or neuro-modulators, are grouped
as biogenic amines, amino acids, peptides and
endocanna-binoids. Biogenic amines constitute
about 5-10 percent of the available neuromessengers in the CNS while amino acids
constitute approximately 60 percent. Peptides
which constitute the rest of the CNS neuromessengers include encephalins which act on
the opiate receptors; B-endorphins, substance
P, vasopressin, cholecystokinin (CCK), neurotensin
(NT), thyrotrophin releasing hormone (TRH),
neuropeptide Y., adrenocorticotropin hormone
(ACTH), corticotrophin releasing factor (CRF) and
rexins. They all play a role in behaviour regulation.
Endocannabinoids are some of the least understood
neuro-messengers.
NATURE AND FUNCTIONS OF

RECEPTORS
Receptors are made up of proteins and are found in
neuronal membranes. They are located on both the
pre-synaptic and post-synaptic neurons. Receptors
are congured in such a way that each receptor
only recognises a specic neurotransmitter. They
are designed in the key and lock format where
a lock will only accept the correct key for the
locking or unlocking operation to occur. The
molecular structures of receptors have also been
studied using the techniques of pharmacological
135
The function of the receptors involves translating

the rst messenger into the second. The rst
messenger could either be a neuro-messenger,
hormone or nerve impulse. The second messengers
include cyclic adenosine monophosphate (cAMP),
cyclic guanosine monophosphate (cGMP) and
calcium ions. When a receptor is stimulated, it can
then activate adenylate cyclase to produce cyclic
AMP (or open chloride ion channels), to change
the neuronal electric potential and hence, transmit
messages and cause information processing to take
place in the brain.
and molecular biology, where the specic amino

acid sequences of receptors have been identied.
Two types of receptors are the polypeptide chains
and nicotinic acetylcholine receptors. Polypeptide
chains include the following sub-types of receptors,
the adrenergic, the D2 dopaminergic and the MI
muscarinic.
Nicotinic acetylcholine receptor is a complex of
several proteins. When acetylcholine binds on this
receptor complex, ion channels are opened which
allow ions to traverse the membrane and initiate
metabolic changes. The efcacies of receptors
depend on their sensitivity to neurotransmitters,
which could be either supersensitivity or
subsensitivity. Such sensitivity determines how
receptors respond to neurotransmitters once they
are released into a synapse. Sensitivity of receptors
depends on three receptor-related changes, that
is, the number of receptors available, the afnity
for the neurotransmitters and the efciency of the
receptors which may be high or low.
There are three types of receptors; ionlinked receptors (ionotropic receptors) which
are protein structures upon which binding of
the neurotransmitter open ion channels within
milliseconds, the G protein receptors whose
actions are linked to binding of guanyl nucleotides
and membrane-linked kinase receptors.
HOW THE CHEMISTRY OF

THE NEURONS INFLUENCES
BEHAVIOUR
Biogenic amines were the rst neurotransmitters to
be discovered. They are synthesised in the nerve
terminals.
The role of dopamine in psychiatry

Dopamine-containing neuronal cell bodies
are located in the nigrostriatal, mesolimbic,
mesocortical, and tubero-infundibular path-
Figure 25.3: Synthesis of Dopamine and Catecholamines (Noradrenaline and Adrenaline)

TYROSINE
Tyrosine hydroxylase (Tetrahydrobiopterin)
DOPA
L-aromatic amino acid decarboxylase
(Pyridoxal phosphate)
DOPAMINE
Breakdown (See separate chart)
Dopamine-beta hydroxylase
(Ascorbic acid)
NORADRENALINE/NOREPINEPHRINE
Phenylethanolamine N-methyltransferase
ADRENALINE/EPINEPHRINE
136
of supersensitive post-synaptic dopamine receptors

following chronic blockade. Lack of dopamine
due to degeneration of neurons in the basal ganglia
results in Parkinsons disease, which is characterised
by rigidity, akathisia and tremors.
Dopamine acts as a prolactin release inhibiting
factor in the anterior pituitary, which is the main
source of prolactin, a hormone that induces lactation
and breast engorgement. Antipsychotic drugs that
block dopamine receptors in the tuberoinfundibular
pathways lead to excess prolactin release. This
may result in gynaecomastia (enlarged breasts),
galactorrhea and amenorrhea.
There is a relationship between dopamine
and psychopathology of schizophrenia. It is
postulated that hyperactivity of the dopaminergic
systems results in symptoms of schizophrenia.
Circumstantial evidence is obtained from the fact that
antagonising or blocking dopaminergic pathways
with antipsychotics results in the alleviation of
schizophrenic symptoms such as hallucinations
and thought disturbances. Secondly, the use of
dopamine-like substances such as amphetamines
may exacerbate or induce schizophrenia-like
symptoms.
ways. Dopamine is synthesised from tyrosine

through hydroxylation by tyrosine hydroxylase
to form dihydroxyphenylanine (DOPA). This is
followed by decaboxylation to dopamine by DOPA
decaboxylase. Dopamine is metabolised by two
enzymes, the monoamine oxidase (MAO) and the
membrane-bound catechol-O-methyl transferase
(COMT). The end product is called homovallinic
acid (HVA).
There are 5 major types of dopamine receptors.
The D1 and D5 receptors are members of the D1like family of dopamine receptors, whereas the
D2, D3, D4 receptors are members of the D2-like
family. Activation of the D1-like family receptors
is typically excitatory, while D2-like activation is
typically inhibitory.
The D2 family of receptors is the most relevant
in psychiatry. The function of dopamine involves
the initiation and co-ordination of movements. The
clinical potency of antipsychotic drugs is associated
with their binding afnity to the D2 receptors
in the caudate and putamen whose blockage
produce unwanted motor disturbances such as
extra pyramidal side effects (Pseudoparkinsonism)
and tardive dyskinesia, a compensatory development
Figure 25.4: Breakdown of Dopamine
DOPAMINE
Monoamine oxidase
Catechol-o-methyltransferase
DIHYDROPHENYLACETALDEHYDE
3-METHOXY-4-HYDROXYPHENYLETHYLAMINE
Monoamine oxidase
Aldehyde dehydrogenase
DIHYDROXYPHENYLACTIC ACID
3-METHOXY-4-HYDROXYPHENYLACETAL DEHYDE
Catechol-o-methyltransferase
HOMOVALLIC ACID (HVA)

(3-methoxy-4-hydroxy-phenylacetic acid)
(Transported for excretion)
137
Thirdly, the metabolites of dopamine tend to increase

during schizophrenic illness indicating excess
dopamine. Finally the efcacy of anti-psychotic
drugs depends on their blockade of dopaminergic
receptors, especially the D2 receptors.
Another role of dopamine is in the
pathophysiology of mood disorders. Mania is
theoretically due to dopaminergic hyperactivity,
while depression is due to dopaminergic
hypoactivity. For example, patients suffering from
Parkinsonism are treated with L-dopa (levodopa),
which is a precursor of dopamine.
Secondly, L-dopa is used to treat depression
associated with Parkinsonism or other types of
depression. Thirdly, symptoms of tardive dykinesia
worsen when a patient is depressed (low levels
of dopamine) and improve during mania (high
levels of dopamine). Lastly, dopamine levels
and its metabolites are high in mania and low in
depression.
The role of norepinephrine and epinephrine

Norepinephrine (noradrenaline) is formed by the
action of dopamine -hydroxylase, which converts
dopamine to noradrenaline. Noradrenaline is
metabolised by the monoamine oxidase (MAO)
and catechol-O-methyl transferase (COMT) to 3methoxy-4-hydroxyphenylglycol (MHPG). In the
periphery, it is metabolised to vanylmandellic acid
(VMA). Adrenergic neurons are fewer compared
to the noradrenergic neurons located in the locus
ceruleus within the pons. From locus ceruleus
neuronal projections go to brain stem, cortex
(concerned with arousal), spinal cord, thalamus,
hypothalamus and limbic system (concerned with
drive, motivation, mood and response to stress).
Norepinephrine plays a major role in the
pathophysiology of mood disorders. Monoamine
hypothesis of mood disorder assumes that
depression is due to too little noradrenergic and
serotonergic activity. Evidence is adduced from the
Figure 25.5: Breakdown of Noradrenaline

NORADRENALINE
Catechol-Omethyltransferase
Monoamine
Oxidase
3, 4-DIHYDROXYPHENYLGLYCOLALDEHYDE
Aldehyde
dehydrogenase
DIHYDROXYMANDELIC
ACID
Aldeyhde
reductase
DIHYDROXYPHENYLGLYCOL
NORMETANEPHRINE
Monoamine
Oxidase
3-METHOXY-4-HYDROXY
PHENYLGLYCOL (MHPG)
Aldeyhde
reductase
3-METHOXY-4-HYDROXYPHENYLGLYCOL
ALDEHYDE
(Conjugated)
3-METHOXY-4-HYDROXYMANDELIC ACID
(VANILLYLMANDELIC ACID, VMA)
(Transported)
138
in the treatment of lithium-induced tremors, social

phobia and akathisia.
fact that tricyclic antidepressants and monoamino

oxidase inhibitors (MAOIs) result in improvement
of depression. Tricyclic antidepressants block reuptake of norepinephrine and serotonin, increasing
their concentration in the synapse.
The role of serotonin

The highest concentration of neurons is in the upper
pons and mid-brain. A precursor amino acid called
tryptophan is acted upon by the enzyme tryptophan
hydroxylase and an amino acid decarboxylase
and is converted to 5-hydroxyl-tryptamine also
called serotonin. Serotonin is metabolised into 5hydroxyindoleacetic acid (5-HIAA). Serotonin is
involved in pain regulation and has antidepressant
properties. Agents that selectively block the reuptake
of serotonin cause accumulation of this amine,
which is positively correlated with amelioration
of depressive symptoms. Low levels of serotonin
are implicated in the pathophysiology of mood
disorders, anxiety, violence and schizophrenia.
Due to blockade of the 1 receptors, sedation

and hypotension are experienced as side effects.
MAOIs inhibit the oxidation of adrenaline and
noradrenaline and their consequent accumulation
ameliorates symptoms of depression.
Clonidine (catapres), an 2 agonist
antihypertensive, is also useful in the management
of heroin withdrawal symptoms. It acts by
stimulating pre synaptic 2 receptors and therefore
minimising the adrenergic activity associated with
the withdrawal symptoms.
-blocking agents such as propranolol (inderal)
used as an antihypertensive has also proven useful
Figure 25.6: Synthesis and Breakdown of 5-Hydroxytryptamine - Serotonin

TRYPTOPHAN
Tryptophan hydroxylase
(tetrahydrobiopterin)
5-HYDROXYTRYPTOPHAN
L-aromatic amino acid
decarboxylase (Pyridoxal phosphate)
5-HYDROXYTRYPTAMINE (SEROTONIN)
Monoamine
oxidase
N-methyltransferase
BUFOTENIN
5-HYDROXYINDOLEACETALDEHYDE
Sulphotransferase
SEROTONIN-OSULPHATE
Adelhyde dehydrogenase
Adelhyde reductase
5-HYDROXYTRYPTOPHOL
5-HYDROXYINDOLEACETIC
ACID
(Conjugated)
(Transported)
139
receptors include the nicotinic receptors and

the muscarinic. Acetylcholine is implicated in
the pathology of a number of degenerative and
other psychiatric disorders: dementia, Downs
syndrome, Parkinsons and Alzheimers disease.
Acetylcholines muscarinic receptors are blocked
by many psychotropic drugs, causing the side
effects of blurred vision, dry mouth, pseudoparkinsonism and constipation.
The role of acetylcholine

Acetylcholine neurons are located in the midand hind-brain and have projections from the
nucleus basalis of Meynert to the hippocampus.
Acetylcholine is synthesised from choline and
acetyl coenzyme A through the action of choline
acetyl transferase enzyme. It is metabolised by
acetyl cholinesterase to form choline which can be
reutilised to synthesise acetylcholine. Acetylcholine
Figure 25.7: Synthesis and Breakdown of Acetylcholine
CHOLINE + ACETYL CO-ENZYME A (AcCoA)
Back to the presynaptic

neuron to be re-cycled
Choline acetyltransferase
ACETYLCHOLINE (Ach)
Acetylcholinesterase (AchE) or Butyrylcholinesterase,
BuchE (also known as pseudocholinesterase/non
specic cholisnesterase)
ACETIC ACID
CHOLINE
blockade is the mechanism of action of anti-allergic

medications. Some antidepressants act through
blocking H2 receptors, for example, doxepin. Of
the amino acid neurotransmitters, gamma amino
butyric acid (GABA) and glutamate are the
most important. GABA neurons are distributed
throughout the brain with high concentrations in
the amygdala, basal ganglia, hypothalamus and the
limbic system. The enzyme glutamate decarboxylase
converts glutamate to GABA. Benzodiazepines,
barbiturates, alcohol and neurosteroids act through
GABA receptor complex. Thus, GABA is the main
inhibitory neurotransmitter in the CNS, while
glutamate is excitatory.
Confusion and delirium occur following excessive

blockade of the central nervous cholinergic
receptors, a condition referred to as neuroleptic
malignant syndrome. Acetylcholine has been
implicated in mood disturbances where overactivity of cholinergic pathways has been associated
with depression and sleep disorders.
Other neurotransmitters
Other neurotransmitters of signicance in
psychiatry include histamine and amino acids.
There are three types of histamine receptors, H1,
H2 and H3 whose blockade is the basis of sedation
associated with antihistamine drugs. Histamine (H1)
140
Figure 25.8: Synthesis and Breakdown of GABA

GLUTAMIC ACID
Glutamic acid decarboxylase (Pyridoxal phosphate)
GAMMA-AMINOBUTYRIC ACID (GABA)
GABA: Glutamate aminotransferase (Pyridoxal phosphate)
SUCCINIC SEMIALDEHYDE
Succinic Semialdehyde dehydrogenase
(nicotinamide adenosine dinucleotide, NAD)
SUCCINIC ACID
TO THE KREBS CYCLE
Peptides may perform different functions in

different target organs. The same peptide may
function as a hormone in one setting and as a
neurotransmitter in another. Vasopressin acts as a
hormone when released by the pituitary and as a
neurotransmitter when released by neurons.
Peptides are involved with regulation of stress
and pain, especially the endogenous opioids as
well as in the normal homeostatic regulation of

mood. Neurotensin, somatostatin and vasopressin
have been implicated in the pathology of schizop
hrenia, Huntingtons chorea and mood disorders
respectively.
Many more neurotransmitters have been
discovered and new ones are being discovered.
Their functions and roles are being studied.
141
26
Psychoendocrinology
John Mburu, Francisca Ongecha-Owuor, Benson Gakinya, David M. Ndetei
thus reducing dopamine activity just like

the antipsychotics. If female patients on L-dopa
for treatment of Parkinsons disease develop
dyskinesia, and are given oestrogen, the dyskinesia
improves by reducing dopamine in nigrostriatal
pathways. Chorea is due to low dopaminergic
activity. In pregnancy, the oestrogen levels
diminish dopaminergic activity and chorea may be
a complication. Oestrogen containing pills are also
known to induce chorea.
Endocrine disorders such as hypothyroidism
or hyperthyroidism, Cushings syndrome
(hyperadrenalism), and Addisons disease
(hypoadrenalism) tend to be associated with classic
psychiatric presentations such as depression,
psychosis, hypomania, anxiety and irritability, which
often precede the endocrine symptoms. Whether
a disease process is diagnosed as a psychiatric or
an endocrine disorder depends more on whether
a particular person has more marked behavioural
or hormonal abnormalities. Schizophrenic patients
have ventricular enlargement. Enlargement around
the third ventricle tends to interfere with the
hypothalamus.
Psychoendocrinology is dened as the study

of the interaction between the nervous system
and endocrine system. The latter consists of the
pituitary, thalamus, hypothalamus, pineallocated
in the brain and the target glands thyroid, parathyroid,
thymus, breasts, adrenal and the gonads located
in the periphery. The hypothalamus produces
releasing or inhibitory factors that inuence the
anterior pituitary gland to release hormones. These
hormones inuence the peripheral endocrine
glands to release hormones into the circulation.
The posterior pituitary produces vasopressin
and oxytocin hormones. The vasopressin hormone
is involved in the control of blood pressure, uid,
and electrolyte balance. The release of vasopressin
is inuenced by pain, stress, morphine, barbiturates
and alcohol. The functions of oxytocin include,
stimulating glandular contractions of the breast
and uterine contraction during parturition.
INTERACTION BETWEEN THE

ENDOCRINE AND NERVOUS
SYSTEMS
CHRONOBIOLOGY
If oestrogen is administered together with

antipsychotic
medication, there is a higher
increase in the number of dopamine receptors.
This is clinically evident in tardive dyskinesia
(antipsychotic-induced motor system symptom)
which is more prevalent in women than men.
The explanation for this is that oestrogen tends
to increase the number of dopamine receptors,
Chronobiology is the study of biological rhythms

in the following biological functions: endocrine
secretion, neurotransmitter synthesis, receptor
numbers, enzyme levels and brain electrical
activities, which vary with time of the day, week,
142
Psychoendocrinology
subjective experience of fatigue and dysphoric

mood, which is also experienced on travelling east
to west.
Depression is accompanied by disturbances of
sleep cycle with early morning awakening. This
is a phase advanced phenomenon. Seasonal mood
disorders have also been noted in some individuals
who tend to experience fatigue. As soon as the sleep
cycle is normalised many patients with depression
experience some relief.
month or year. The following cycle lengths have

been found to occur in human beings: infradian
cycle takes less than a day, circadian cycle
approximately 24 hours, ultradian cycle more than
one day and circaseptan cycle approximately one
week. Finally the circannual cycle is a cycle taking
approximately one year. Examples of rhythms
are sleep-wake cycle, hormone levels, body
temperatures and menstrual cycles in females.
In normal and good health, these rhythms are in
normal relationship with each other, and are said
to be in phase. Disease states tend to disrupt the
phases and one of the rhythms may be out of phase.
The rhythm may occur before the due time and is
said to be in phase advance or begins later than
usual and is said to be in phase delay. The body
has synchronisers, which ensure that the rhythms
are in phase. The supra-chiasmatic nuclei of the
hypothalamus are thought to be the site responsible
for synthesising and releasing synchronisers. The
synchronisers are also called time givers or time
clues. Exogenous synchronisers include the light
day cycle, patterned meals, time and the eight to
ve work days.
PSYCHOIMMUNOLOGY
This is the study of the interaction between the
immune and nervous systems. Immunological
mechanisms can cause psychiatric disorders
by allowing neurotoxins such as viruses to
infect the brain. A good example is the human
immunodeciency virus (HIV) that causes acquired
immunodeciency syndrome (AIDS). Immune
systems can interfere with normal endocrine and
brain tissue resulting in autoimmune diseases.
However, it is not clear how psychiatric disorders
affect the immune system. It is postulated that
certain psychological disorders or stressors have
a role in immune suppression. Systemic lupus
erythematosus (SLE) is an example of an immune
disorder in which there are associated psychiatric
symptoms that appear as the initial presentation,
although the actual pathophysiology remains
unknown. Grief reaction and depression are known
to be associated with certain immune changes such
as decrease in T cell proliferation, natural killer cell
activity and overall number of lymphocytes.
Relevance to psychiatry
Jet lag and mood disorders are the two conditions
that are clinically important to the practice of
psychiatry. Passengers travelling from west to
east tend to gain time. This is an example of phase
advance, which opposes the natural tendency. The
individual has to cope with a situation where the
body needs time to adjust to the new schedule
of exogenous clues. There is an accompanying
143
27
Psycho-neurological Investigations
Benson Gakinya, John Mburu, Francisca Ongecha-Owuor, David M. Ndetei
EEG frequencies are divided as follows:

Delta activity where there are less than 4 cycles
(<4HZ) per second. These waves are normally
present in sleep.
Theta activity is characterised by 4 to 8 cycles
per second (4-8HZ) and is also present during
sleep.
Alpha activity has 8 to 13 cycles per second
(8-13HZ) and is present in the normal awake
adult with closed eyes.
Beta activity occurs where the frequency is
more than 13 cycles per second (>13HZ).
Beta activity replaces alpha activity when the
person is stimulated or opens his eyes.
The EEG recordings may be inuenced by scalp
muscle activity. While reading the EEG one
assesses frequencies, amplitude, distribution of the
wave forms and paroxysmal events such as spikes
and wave bursts, abnormally slow or fast activity,
abnormal asymmetry and suppression of EEG
amplitude.
BRAIN IMAGING
A variety of techniques are now available that
can take an image of the living human brain.
These include computed tomography (CT) used to
assess the structure of the brain, positron emission
tomography (PET) assesses both the structure
and functions of the brain, while electroencephalography (EEG) assesses the brains electrical
activity. Other techniques used for clinical and
research purposes are evoked potential (EPs),
polysomnography and magnetic resonance imaging
(MRI). Magneto-encephalography (MEG) and
single positron emission tomography (SPECT) are
mainly for research purposes.
ELECTROENCEPHALOGRAPHY
(EEG)
This was developed by Hans Berger in 1929 and is
widely used in psychiatry and neurology. Clinically,
EEG is used in evaluation of epilepsy, dementia,
delirium, brain injury and research activities. The
technique of EEG involves placing electrodes on
the scalp in specic positions according to the
international 10-20 system. The system is based on
measurements made from nasion (depression at the
bridge of the nose) to the inion (raised position of
the skull at the back of the head) and also from the
left to right auricular depression (slight valleys just
in front of and above the earlobes).
POLYSOMNOGRAPHY
This is an EEG recording that is performed on a
person who is asleep. Other measurements are done
simultaneously and they include electromyogram
(EMG), electrocardiogram (ECG), blood oxygen
saturation, galvanic skin response, penile
tumescence, body movements, temperature,
and gastric acid secretion. Clinical indications
144
Psycho-neurological Investigations
images of the brain. Lesions larger than 0.5 mm

can be visualised.
The indications of a CT scan are the evaluation
of patients with stroke, tumours, trauma, and in the
work-up of psychiatric patients presenting with
confusion and dementia of unknown cause. CT
scan is mandatory in patients presenting with rst
episodes of psychosis or depression, especially
after age 50, in the rst episode of psychiatric
symptoms such as aphasia, and convulsions in a
person with a history of alcohol abuse, tremors and
seizures.
Other indications include movement disorders
of unknown cause such as prolonged catatonia,
and in psychiatric research in which the ventricles,
cortical and cerebral sizes and brain symmetry are
studied. CT scan is unable to detect some lesions,
because they are too small, the density of the lesion
is not distinguishable from that of healthy tissue or
due to their position in the brain.
for polysomnography in psychiatry include the

study of the normal and abnormal sleep architecture
in individuals. Out of these studies two types of
sleep patterns have been found. One is the rapid
eye movement (REM) sleep and the second one
is the non-rapid eye movement (non-REM) sleep.
There are four stages of normal sleep:
Stage I: stage of light sleep. The EEG shows
alpha activity when an adult lies
down with their eyes closed.
Stage II: alpha activity gradually disappears.
Stage III: delta activity becomes more prevalent
as stage IV approaches.
Stage IV: deep sleep characterised by delta
wave activity.
During the REM stage, the high amplitude slow
waves are replaced by beta-like activity (>13 HZ).
The wave activity resembles that of an awake, alert
person although the person is asleep. During this
time the eyes oscillations are faster as though the
person is awake. The REM stage occurs several
times during sleep and is associated with dreams.
MAGNETIC RESONANCE
IMAGING (MRI)
EVOKED POTENTIALS (EP)

Magnetic resonance imaging is a superior technique
to CT scan. A strong magnetic eld is applied to
the brain and causes hydrogen nuclei to become
aligned in a certain way and produce characteristic
electromagnetic energy. The released energy is
analysed by a computer to produce a nal image.
Indications of MRI are same as those for CT scan,
but it is likely to yield more ndings due to its
ability to distinguish grey matter from white matter.
It is also able to detect lesions less than 0.5mm.
However, MRI is unable to pick calcication and
cannot be used in patients with cardiac pacemakers,
metal or steel such as metal skull plates.
Evoked potentials (EP) is essentially an EEG

except that it is intended to measure how the
cortex responds to a particular sensory stimuli. A
visual stimulus is evoked and presented several
times, while the EEG recording is made. The brain
electrical activity on the EEG that follows each
repeated stimuli is then averaged by a computer
to reduce non-stimuli related activity. The result is
a smooth curve (the EP) which has various peaks
and valleys.
Clinically, people with certain predisposition,
for example alcoholism, have been found to have
characteristic EPs which can be used as a biological
marker. It has been used to predict alcoholism in
siblings of alcoholic parents. EPs have been used
in the evaluation of de-myelinating disorders such
as multiple sclerosis.
SINGLE PHOTON EMISSION

TOMOGRAPHY (SPECT)
AND POSITRON EMISSION
TOMOGRAPHY (PET)
COMPUTED TOMOGRAPHY (CT)

Single photon emission tomography (SPECT) and
positron emission tomography (PET) are similar
in that they use organic compounds that have been
labelled with positron-emitting isotopes. Such
radioactive substances are introduced into the
body and once they reach the brain they produce
rays that are detected and analysed by a computer
This is a very common technique which is based

on x-ray technology where x-ray photons emitted
from a source are passed through the tissue being
studied. The resulting data is fed into a computer
and presented as saggital transverse and coronal
145
to produce tomographic images of the brain which

can be visualised. Functional aspects of cortical
and subcortical areas of the brain can therefore be
studied.
In conclusion, brain imaging techniques are
now highly advanced and have led to better
understanding of the various functions and

defects within the human brain. All brain imaging
techniques have direct clinical signicance in
diagnosis and assessment of impact of treatment.
146
28
Genetics of Mental Disorders
John Mburu, Francisca Ongecha-Owuor, Benson Gakinya, David M. Ndetei
Three-quarters of the genes every child receives

are identical to those received by every other child.
They are called monomorphic genes and dene
characteristics that make a person recognisably
human. One-quarter of the genes are called
polymorphic genes and they dene each person as
an individual. Except for monozygotic twins, it is
not possible for two individuals to receive exactly
the same combination of genes.
Genetics is the study of the hereditary mechanisms

in a population. Over the last 30 years the genetics
of human diseases have been revolutionised. By
1992, about 2372 human genes had been mapped,
611 of which are known to contribute to medical
disorders. Some psychiatric disorders have been
known to run in families and hence the need to
study the various processes of inheritance.
MECHANISMS OF HEREDITY
Patterns of genetic transmission

Genes that affect a particular trait, for example, the
ability to curl the tongue, are referred to as paired
alleles. Every person receives a pair of alleles for
a given characteristic, one from each biological
parent. When both alleles are the same, the person
is homozygous (identical alleles) and heterozygous
when the alleles are different.
There are two types of inheritance to genetic
material: dominant and recessive. Dominant
inheritance is when a person is heterozygous for
a particular trait, but only the dominant allele
expresses itself. On the other hand, the expression
of a recessive trait occurs only when a person
receives the recessive allele from both parents
referred to as recessive inheritance. Observable
characteristics of a person, for example, maleness
or height is referred to as the phenotype while
genotype refers to genetic make-up of a person
which contains both expressed and unexpressed
characteristics.
Genes and chromosomes

The basic unit of heredity is the gene. It contains
all the inherited materials passed from biological
parents to children. Each cell contains 80,000
to 100,000 genes. Genes are made up of the
chemical, deoxyribonucleic acid (DNA), which
carries the biochemical instructions to the cells to
synthesise the proteins that enable them to carry
out each specic body function.
Each gene seems to be located by function in a
denite position on a rod-shaped structure called a
chromosome. A chromosome is one of the 46 rodshaped structures that carry the genes. Every cell
has 23 pairs of chromosomes. Through meiosis,
the pairs are halved so that each gamete or sex cell
(ovum or sperm) contains 23 single chromosomes.
During fertilisation the 23 chromosomes from the
sperm join the 23 chromosomes from the ovum so
that the zygote receives 46 chromosomes.
147
affective disorders, in the relatives of patients

with eating disorders and of sociopathy in relatives
of patients with somatisation disorder.
WHY GENETICS IN MENTAL

HEALTH?
Twin studies
The aim of studying genetics is to establish and

specify the genetic component of the aetiology
of psychiatric syndromes. This will assist in
determining to what extent a psychiatric disorder
is genetically caused, the DNA re-arrangement
of the genetic contribution, the biophysiological
abnormalities associated with the gene involved
and the process by which genetic abnormalities
lead to symptoms.
Given that most psychiatric disorders have a
multi-factorial aetiological contribution, genetic
studies will help distinguish the non-genetic
components of psychiatric syndromes that act
independently of or interact with vulnerable
genotypes to produce or increase the likelihood of
a disorder. Genetics studies also help in improving
the diagnostic criteria by determining genetic
associations between sub-types of a disorder.
Twin studies examine the concordance or the

coincidence of a disorder in monozygotic (MZ)
genetically identical and dizygotic (DZ) or fraternal
twins. These studies are useful for separating the
genetic and environmental inuences. They are also
useful for looking at protective and precipitating
factors. Monozygotic twins share the same ovum
and contain identical genetic material. It is expected
that a genetic disorder should occur, that is, be
concordant in monozygotic twins more often than
in dizygotic twins. Dizygotic twins develop from
two different ova and are not different from nontwin siblings in average genetic material shared.
Adoption studies
Adoption studies are based on the fact that adoption
separates the two major inuences parents have on
their children, namely genes and rearing. Adoption
studies are useful in studying the effect the
environment has on the expression of genes. They
answer the question of whether a disorder is familial
due to genetic factors or the shared environment.
There are different types of study designs. Adopted
study designs involve the study of adopted away
children of a parent with a disorder. If it is found
that these children have a higher rate of developing
a psychiatric disorder despite being reared by
normal adoptive parents, then a genetic factor from
the biological parents is implicated. Under these
type of studies, the monozygotic twins are studied
by rearing them together in the same environment
either with biological or adoptive parents or rearing
them apart in different environments, one with a
biological parent and the other with an adoptive
parent. The cross-fostering method involves
studying children born of non-disordered parents
adopted into a family with a disordered parent.
THE STUDY OF GENETICS IN

PSYCHIATRY
These are family, twin, adoption and high-risk
studies.
Family studies
In family risk studies the affected persons are rst
identied. They are called index cases or probands.
The prevalence of the particular psychiatric
disorder among the relatives of the probands is
then determined. The prevalence of this particular
psychiatric disorder among the relatives is then
compared with its prevalence in the general
population. Generally, the rst-degree relatives
(mother, father and siblings) are more likely to
have the disorder of the proband than are more
distant relatives or the general population.
Family studies may reveal an increase not only
in the disorder in question, but also in other types
of psychopathology. At times this increase has
been in milder or related disorders (syndromes)
of the major disorder, such as dysthymia in the
relatives of patients with major depression or
unipolar depression in the relatives of patients with
bipolar depression. In other illnesses, more distant
syndromes have appeared such as an increase of
High-risk studies
These distinguish the offspring of disordered parents
from those of control subjects. The children are
followed from early ages and their characteristics
noted over a span of time. It offers researchers a
naturalistic experiment that has the potential
to answer the questions of whether a disorder is
familial, because of genetic transmission or the
shared environment.
148
Genetics of Mental Disorders
wise concordance rate for MZ twin pairs and 14

percent rate for DZ pairs.
Genetics of common psychiatric disorders

Schizophrenia
Family studies
Adoption studies
The children of mothers with bipolar illness or major
depression have higher rates of major affective
disorders than do the adopted away children of
mothers with other psychiatric conditions.
Various studies have consistently demonstrated

elevated morbid risk for schizophrenia in rstdegree relatives of schizophrenic probands in the
range of 5.6 percent for parents, 10.1 percent for
siblings and 12.8 percent for children, compared
with those in the general population that was 0.9
percent. This suggests that schizophrenia is a
familial syndrome.
High-risk studies
Studies of children of parents with major affective
disorders have quite consistently reported high
rates of social and psychiatric impairment, such as
increased prevalence of major depression, conduct
disorder, attention decit disorder (ADD), anxiety,
substance abuse and poor social functioning among
these children.
Twin studies
Estimates of proband concordances have varied
and this may reect differences in diagnostic
criteria, across studies. However, concordance
for monozygotic and dizygotic twins have been
estimated at 59.2 percent and 15.2 percent,
respectively
Alcohol-related disorders
Family studies
Many studies have demonstrated that alcoholrelated disorders are familial since the risk in
rst-degree relatives is seven-fold. The presence
of alcohol-related disorders in biological parents
predicted the same disorder in their male offspring
even in cases where the latter were reared by
unrelated adoptive parents. Alcohol-related
disorders co-exist with antisocial personality
disorder and affective disorders which complicate
diagnosis thus resulting in varied ndings. The risk
of alcohol-related disorders was found to be 16
percent in the fathers and 7 percent in the siblings
of alcoholic subjects versus a risk of 1.6 percent
and 0.5 percent for the relatives of matched control
subjects by Pitts and Winokur in 1966.
Adoption studies
All the four varieties of adoption studies have been
applied to schizophrenia and the role of genetic
inuences have been demonstrated. For example,
an adoptee study carried out by Heston in 1966
found signicant greater risk for schizophrenia
among the offspring of schizophrenic mothers
separated at birth than among adopted away
offspring of controlled mothers.
High-risk studies
By one year of age high-risk infants are more
likely than controlled infants to show anxious
attachment behaviour and sensory motor decits,
traits which persist over time. High-risk studies
are useful in predicting pre-morbid features of
schizophrenia among high-risk children.
Twin studies
The results for twin studies have produced varied
results with some reporting rates of up to 59
percent for the MZ versus 36 percent for DZ males,
25 percent and 5 percent for female MZ and DZ
twins, respectively.
Mood (Affective) Disorder

Family studies
High family rates of affective disorders have been
found in a number of studies. First-degree relatives
of bipolar probands have an elevated morbid risk for
both bipolar and major depressive illness, whereas
relatives of major depressive illness probands
have an elevated risk for major depression but not
bipolar disorder.
GENE AND CHROMOSOMAL

ABNORMALITY
Defects and diseases are due to abnormalities in
genes and chromosomes, including mutations,
which are permanent alteration in genes or
chromosomes. Not all gene and chromosomal
abnormalities manifest at birth. For example, TaySachs degenerative disease of the central nervous
Twin studies
Twin studies have supported the importance
of genetic factors in the transmission of major
affective disorders to the rate of 65 percent pair
149
system (CNS) which occurs at 6 months and

Huntingtons diseases which occurs during middle
age.
Autosomal Chromosomal Abnormality
Those relevant to psychiatry are Klinefelters

syndrome, Triple X, Turners syndrome, Fragile X
and XYY.
Down Syndrome is the most common and well

described autosomal syndrome. It is a chromosomal
aberration
disorder
typically
involving
chromosome 21 (Trisomy 21). Mental retardation
is the overriding feature accompanied by various
emotional difculties, behavioural disorders and
rarely, psychotic disorders.
Klinefelters syndrome
Sex-linked disorders
This sex-linked chromosomal abnormality has a

genotype of XXY. Phenotypically, the individual is
a male with underdeveloped sexual characteristics,
small testes and sterility and may often have
gender disturbances, emotional instability, mental
retardation and learning disorders.
Sex-linked conditions are associated with

mental retardation in both males and females.
Examples are Lesch Nyan syndrome and glucose
dehydrogenase deciency.
Triple X
Gene abnormalities are either dominant or

recessive. The dominant conditions are rare and
examples include neurobromatosis in which
mild mental retardation occur in up to one-third
of those with the disease. Recessive conditions
constitute the largest group and include most
of the inherited metabolic conditions such
as galactosaemia and phenylketonuria. The latter
presents with bizarre movements of the body and
upper extremities, temper tantrums and mental
retardation.
Sex chromosomal abnormalities
Gene abnormalities
Genotypically XXX, and phenotypically a female

with normal appearance. However, the individual
may have menstrual irregularities, learning disorder
and mental retardation.
Turners Syndrome
Genotypically XO, and phenotypically a female
of short stature, webbed neck, no menses,
underdeveloped sex organs with incomplete
development of secondary sexual characteristics.
Further reading for Chapters 24-28

1. Synopsis of Psychiatry: Behavioural Sciences Clinical
Psychiatry: 9th edition (2003). Editors: Benjamin J.
Saddock, Virginia Alcott Sadock. Lippincott Williams
& Wilkins
2. Textbook of Psychiatry 2nd edition (1994). Editors:
Robert E. Hales, Stuart Yudofsky and John A. Talbott.
Published by American Psychiatric Press Incorp.,
Washington D.C
Fragile X
The syndrome results from a mutation on the Xchromosome at what is known as the Fragile site.
Phenotypically they have enlarged long head, ears,
short stature, hyperextensible joints and postpubertal macro-orchidism. They are known to
suffer mental retardation, impaired speech and are
hyperactive.
XYY Abnormality
This affects males, who are usually tall and of low
intelligence quotient (IQ). They display abnormal
aggressive behaviour.
150
Section IV:
Clinical Adult Psychiatry
151
152
29
Aetiology in Psychiatry
Tarek Okasha, Khalifa Mrumbi, Gad Kilonzo, Seggane Musisi,
Christopher P. Szabo, Mohamedi Boy Sebit, David M. Ndetei
Aetiology in psychiatry can be classied into three

broad categories namely: biological, psychological
and social factors. However, it is often not easy to
draw a sharp distinction between the predominant
inuences of each of these factors in the causation
of mental illness in the individual.
PSYCHOLOGICAL FACTORS
A number of psychological theories exist that have
attempted to explain the basis of psychopathology
and clinical presentations. Below are some
examples of these theories.
BIOLOGICAL FACTORS
Psychoanalysis formulated by Sigmund

Freud
Constitutional factors refer to genes that

control various aspects of human life including
intellect, temperament, body size and the bodys
biochemistry. Such factors may predispose an
individual to developing a mental illness. Physical
illnesses, chemical intoxications, trauma involving
the brain and infections may lead to the development
of a psychiatric disorder. Neurochemical studies
indicate that episodes of major neuropsychiatric
disorders may be due to imbalances of
neurotransmitter levels in specic regions of the
brain. Violence and suicide behaviour in depressed
individuals has been associated with low levels
of serotonin in the limbic area of the brain. Episodes
of major depression are believed to result from
low levels of either serotonin or noradrenaline and
manic episodes, to enhanced activity of dopaminecontaining neurons.
Psychoanalytic theory is based on the premise

that impaired psychosexual development in early
childhood will lead to the development of
psychopathology in adult life. According to this
theory, the mind consists of three distinct structures:
the Id, the Ego and Superego. According to
Freud, all behaviour is caused or determined by
psychological factors. All our actions including
dreams, errors, and slips of the tongue or pen have
meaning. Humans are all born with innate instincts
which govern behaviour. Unsatised instincts
create tension within the individual, and these
manifest in the form of psychological illness. When
individuals understand the nature and sources of
their symptoms through therapy, a cure is achieved.
The problem with Freuds theory of psychoanalysis
is that all symptoms have to be traced to unresolved
sexual conicts in the life of the individual.
153
physical health and diminished psychological

coping ability. The mortality rate among bereaved
elderly spouses increases signicantly within the
rst two years of the death of the partner. The
inuence of stress in the precipitation of mental
disorder is stronger in the case of depressive
disorders. However, this does not mean that all
cases of depressive illness, or indeed, of any other
episode of mental disorder, arise as a direct result
of a stressful life event. Individuals may develop
a major episode of mental disorder in response
to the most trivial precipitating life event but
remain relatively stable when faced with a major
catastrophe.
The psychosocial theory of Erik Erickson

This theory is an extension of the psychoanalytic
theory of Sigmund Freud and includes social
and cultural dimensions. The theory emphasises
the development of the opposing dimensions of
life namely; trust and mistrust; identity and role
confusion, intimacy and isolation, generativity and
self-absorption, and integrity and despair.
The attachment theory of Bowlby

This theory is premised on the observation that
babies are totally dependent upon their parents
or caregivers for their survival. The development
of a warm and caring relationship between the
infant and the caregivers is important for the
survival of the baby. This development depends
on the reciprocal behaviours of the baby and the
caregiver. Initial behaviours of the infant that
elicit nurturing responses from the parent include
sucking, cuddling, looking, smiling, crying and
even sleeping.
Infants are usually afraid of strange and difcultto-understand situations, and will react with fear if a
new face appears on the scene. The presence of the
caregiver usually provides security for the infant to
get used to strangers, explore the environment and
develop social skills. Successful interaction with
the family and peers is perhaps the most important
factor in the development of social skills. The lack
of adequate social attachment during infancy and
childhood leads to lack of trust and difculties in
establishing lasting relationships with others in
adulthood.
CULTURAL FACTORS
A variety of social and cultural beliefs exist in Africa.
Such beliefs attempt to explain mental disorders in
terms of personal deeds, general social conduct and
individual or collective group relationships with
ancestral spirits. Mental illness results from a variety
of factors, such as possession by spirits who want
a home to reside in, punishment by angry ancestral
spirits for alleged evils committed, witchcraft as a
result of envy or the presence of a lizard or worm
in the brain of the victim. Most forms of mental
disorder, including depression and anxiety, are
not easily recognised as illnesses, although some
communities may be able to recognise the physical
and behavioural manifestations of these disorders.
Traditional cultural formulation of mental disorders
has important implications for therapy and use of
hospital treatment facilities.
SOCIAL FACTORS
CONCLUSION
It is usual for episodes of mental disorder to occur
in association with stressful life events. Examples
include suffering from a severe life-threatening
illness, bereavement, separation, divorce, loss of
employment, recent promotion and anniversary of
the death of a relative. The impact of the stressful
life events is particularly great if the event has a
signicant meaning to the individual. The impact
is also greater for those individuals who rely
on outside social support in coping with their
problems. Thus, the impact of stress is particularly
great if no outside social support is available at the
right time.
The experience of stress is associated with
signicant immuno-suppression resulting in poor
No single theory is sufcient to explain the

phenomena and mechanisms involved in the
development of mental illness. It is best to adopt
the biopsychosocial model of disease for an
adequate understanding of disease processes. It is
becoming obvious that the biological, psychological
and social factors in peoples lives interact with
one another to inuence all aspects and response
to treatment. Comprehensive management of all
health problems requires the appropriate application
of physical, social and psychological principles.
154
Aetiology in Psychiatry
2. N.R. Carlson. (1990). Psychology. The Science of

Behaviour. 4th edition. Allyn and Bacon. Boston.
Boston.
Further Reading
1. H.G Harmatz. (1978). Abnormal psychology, Prentice
Hall, Inc., Engelwood, New Jersey.
155
30
Psychopathology
John Mburu, David M. Ndetei, Benson Gakinya, Francisca Ongecha-Owuor,
Seggane Musisi, Gad Kilonzo, Christopher P. Szabo, Mohamedi Boy Sebit
of dynamic, unconscious, psychic determination

and the role of childhood development in shaping
the adult mind. All major schools of thought view
developmental success and failures as central to
the evolution of adult character and inuential in
the pathogenesis of mental illnesses.
Diverse aspects of human experiences including
psychiatric symptoms, dreams, occupational
choices and selection of partners were perceived
to have meaning with thoughts, behaviours, feeling
and symptoms being the common pathways of the
unconscious process of the mind. Several intrapsychic factors operate simultaneously to produce
a certain set of symptoms. By observing hysterical
patients, Freud designed the construct of the
unconscious mind in which he noted that the long
forgotten memories re-emerged in the process of
treatment. These led him to conclude that the human
mind has a censor that dims certain memories,
thoughts and feelings that were unacceptable.
Such unacceptable materials were repressed from
the conscious mind and only became evident as
symptoms of mental illness. As a result of this
work, Freud initially developed the topographical
theory of the mind that included the conscious, preconscious and the unconscious, which gave way to
the structural theory that included the Id, the Ego
and the Superego.
In the structural theory, the mind goes through
various stages of development that Freud
associated with libido energy and called them
sexual stages of development. Failure to navigate
Psychopathology is the study of abnormal states of

mind. It can be viewed as an attempt to understand
the disease processes of the mind in terms of signs
and symptoms, including their causes and how
they develop. There have been two main schools
of thought regarding psychopathology:
The dynamic or psychoanalytic which
emphasises the unconscious processes. It was
founded by Freud at the beginning of the 20th
century but has been contested in recent times
on the basis of its lack of scientic validity.
Clinical or descriptive psychopathology which
puts emphasis on phenomenology. This is the
understanding of the mental phenomena in
terms of signs and symptoms.
DYNAMIC PSYCHOPATHOLOGY
The dynamic system starts with the patients
description of their mental experiences and the
medical workers observation of behaviour. It
then seeks to explain the causes of abnormal
mental events by postulating unconscious mental
processes. It was developed in an attempt to make
the human experience and behaviour intelligible
without leaving out their irrational components.
The contributions of Freud have undergone
considerable revision over the past 100 years
evolving to the psychoanalytic school of thought.
Included in his original work were the crucial role
156
Psychopathology
stressful experiences like bereavement, severe

illness and loss of income or livelihood.
through either of the stages successfully is

associated with certain character traits and even
symptoms. Using a similar model, Erik Eriksson
developed the epigenetic principles that were more
elaborate and included several stages in a human
life cycle. Failure to go through either of the stages
successfully was associated with development of
symptoms of mental illness.
Psychoanalysis is therefore valuable in
understanding and explaining psychopathological
mechanisms in spite of great strides made in
biological research.
Disturbances of attention
Attention refers to the ability to direct ones activity.
It is the amount of attention exerted in focusing
on certain portions of an experience; the ability
to concentrate. It may be impaired in dissociative
states, anxiety states and in depressed patients.
Patients experiencing psychotic symptoms may
appear inattentive due to their concentrating on
psychotic experiences at the exclusion of all other
external experiences. The examples of disturbances
in attention include:
Distractibility which is the inability to
concentrate; attention is easily diverted to
other activities that are irrelevant. It commonly
occurs in manic states.
Trance, a dream-like state when attention is
focused on one thing and the person seems
oblivious of his surroundings. It occurs
in hypnosis and dissociative disorders.
Selective inattention in which one blocks
away from consciousness things that generate
anxiety.
Hypervigilance in which excessive attention is
concentrated on a stimuli. It is often secondary
to paranoid and delusional states.
DESCRIPTIVE
PSYCHOPATHOLOGY
This is the objective description of abnormal
states of mind. It is concerned with the conscious
experience and observable behaviours and denes
the essential qualities of morbid mental experiences.
These descriptive states include:
Disturbances of consciousness
Consciousness is the state of awareness of the self
and the environment. Its disturbances are more
often associated with apparent brain pathology, for
example brain tumours, infections of the central
nervous system, epilepsy, narcolepsy and physical
trauma. Levels of consciousness may range from
a slight alteration noticeable as confusion to deep
unarousable coma. Altered states of consciousness
include:
Clouding of consciousness, which describes
a state of unclear mindedness or thinking
that may be associated with disorder of
perception, attention, registration, orientation
and attitudes.
Stupor which is a lack of response and
unawareness of surroundings.
Delirium which is a dream-like change in
consciousness that is often accompanied by
an impaired reality testing. The patient may
be anxious, confused, disoriented, restless and
might experience hallucinations.
Coma: deep unconsciousness.
Depersonalisation: disturbance in the way one
experiences the self
Derealisation: a disturbance in the way one
experiences ones physical environment
The latter two are associated with psychological
stress and often occur in persons undergoing
Disturbances in emotions
Emotion is the feeling or response to sensory input
from the external environment or mental images. Its
sustained and pervasive inward subjective feeling is
referred to as a mood while its related somatic and
behavioural changes (the outward expression of the
emotion) is the affect. The affect and the mood may
be incongruent as occurs in schizophrenia. Affect
is said to be blunted when there is a reduction in
the intensity of outward expression. The affect is
at when there are no outward signs to express the
emotional feeling. Rapid changes in emotion occur
when the mood is labile as in bipolar disorders.
Mood
This is the emotional state subjectively experienced
by the patient. It is inuenced by the patients
experiences and expectations, as well as the
presence of disease. An individual is expected to
be anxious when anticipating something good or
bad, sad in grief, and euphoric in victory. Mood
may, however, be altered by use of psychoactive
substances like alcohol and opiates. The variations
in mood include
157
Depression: a pathological feeling of sadness.

Dysphoric mood: an unpleasant mood.
Euthymic mood: normal moodneither elated
nor depressed.
Irritable mood: easily offended leading
to anger.
Elevated mood: cheerful, happy mood.
Euphoria: intense elation of mood.
Anhedonia: loss of interest or the inability to
enjoy previously pleasurable activities.
Apathy: blunted emotion associated with loss
of energy and drive.
Disorders of form of thoughts (disorders in the

ow and structure of thoughts)
Autistic thinking: preoccupation with the
inner, private world.
Neologisms: new word created by a patient or
a normal word used to mean a different thing.
World salad: several words put together with
no clear meaning.
Incoherence: thinking that does not ow
logically.
Echolalia: psychopathological repetition of
words or phrases said by another person.
Derailment: sudden or gradual deviation in the
ow of thoughts without blocking.
Flight of ideas: rapid thought manifested by
fast verbalisation and shifting of ideas which
tend to be connected to one another.
Thought block: sudden interruption in the
stream of thought before an idea or thought is
completed.
This disorder commonly occurs in schizophrenic
patients, though ight of ideas is seen in elated
mood disorder patients (mania). Patients with
various levels of intelligence and at different ages
may show variable degrees of deviations in the
thought processes which may not necessarily be
abnormal.
Motor behaviour
These are externally observable behaviours that
depict aspects of psyche, for example impulses,
motivations, drive, instincts and wishes. They
may be observed in all forms of mental illness and
include:
Echopraxia: imitation of one persons
movements by another.
Catatonia: abnormalities in motor functioning
as may be seen in schizophrenia.
Catalepsy: a position maintained for a long
time.
Catatonic excitement: purposeless motor over
activity, which sets on suddenly as may be
seen in schizophrenic patients.
Negativism: resistance to efforts to move on
for no reason
Cataplexy: sudden temporary loss of muscle
tone
Mannerism: habitual involuntary movement
and attitudes.
Mutism: voicelessness without an underlying
organic pathology
Akathisia: subjective feeling of restlessness
and the need to keep on moving; usually an
adverse effect of antipsychotic treatment.
Compulsion: an uncontrollable urge to perform
an act repeatedly.
Disorders of content of thought

Delusion
False unshakable belief not consistent with the
persons intelligence or cultural belief. Various
types of delusions occur with different illnesses
e.g. delusions of grandeur in manic patients,
anhedonia in depression, and delusions of control
in schizophrenia. There are different types of
delusions:
Persecutory: paranoid
Reference: that objects, people or events have
a special signicance to the patient
Grandiose or expansive: exaggerated selfimportance, ability, wealth, associations with
important people
Guilt or worthlessness
Nihilistic: patient believes he does not exist,
extreme pessimism
Hypochondriac: belief in ones illness contrary
to all medical evidence
Thought
Thinking can be described as a goal-directed ow
of ideas, symbols and associations leading to
reality-oriented conclusion. Thinking is said to be
normal when a logical sequence occurs.
158
Psychopathology
Religious: special relation with God.

Jealousy: doubt about the delity of the sexual
partner
Sexual or amorous delusion (love delusions)

also called de Clerambaults syndrome
Delusions of alienation.
Table 30.1
DSM-IV-TR Denition of Delusion and Certain Common Types Associated with Delusional
Disorders
Delusion A false belief based on incorrect inference about external reality that is rmly sustained despite
what almost everyone else believes and despite what constitutes incontrovertible and obvious proof of
evidence to the contrary. The belief is not one ordinarily accepted by other members of the persons culture
or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is
regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction
occurs on a continuum and can sometimes be inferred from an individuals behavior. It is often difcult to
distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable
belief or idea but does not hold it as rmly as is the case with a delusion). Delusions are subdivided
according to their content.: Some of the more common types are listed below:
BizarreA delusion that involves a phenomenon that the persons culture would regard as totally
implausible.
Delusional jealousy The delusion that ones sexual partner is unfaithful.
ErotomanicA delusion that another person, usually of higher status, is in love with the individual.
GrandioseA delusion of inated worth, power, knowledge, identity, or special relationship to a deity or
famous person.
Mood-congruent(Dened below)
Mood-incongruent(Dened below)
Of being controlledA delusion in which feelings, impulses, thoughts, or actions are experienced as
being under the control of some external force rather than being under ones own control:
Of referenceA delusion whose theme is that events, objects, or other persons in ones immediate
environment have a particular and unusual signicance. These delusions are usually of a negative or
pejorative nature, but also may be grandiose in content. This differs from an idea of reference, in which the
false belief is not as rmly held nor as fully organized into a true belief.
PersecutoryA delusion in which the central theme is that one (or someone to whom one is close) is being
attacked, harassed, cheated, persecuted, or conspired against.
SomaticA delusion whose main content pertains to the appearance or functioning of ones body.
Thought broadcastingThe delusion that ones thoughts are being broadcast out loud so that they can be
pc others.
Thought insertionThe delusion that certain of ones thoughts are not ones own, but rather are inserted
into ones mind.
Mood-congruent psychotic featuresDelusions or hallucinations whose content is entirely consistent
with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions
or hallucinations would involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment. The content of the delusion may include themes of persecution if these are based on selfderogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions
or hallucinations would involve themes of inated worth, power, knowledge, or identity, or a special
relationship to a deity or a famous person. The content of delusion may include themes of persecution if
these are based on concepts such as inated worth or deserved punishment.
Mood-incongruent psychotic featuresDelusions or hallucinations whose content is not consistent
with the typical themes of a depressed or manic mood. In the case of depression, the delusions or
hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment. In the Case of mania, the delusions or hallucinations would not involve themes of inated
worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. Examples of
mood-incongruent psychotic features include persecutory delusions (without self-derogatory or grandiose
content), thought insertion, thought broadcasting, and delusions of being controlled whose content has no
apparent relationship to any of the themes listed above
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.
159
Overvalued ideas
Sensory distortions
These are similar to delusions but less rmly

held and can therefore be reasoned away. They
can occur in normal persons undergoing stressful
experiences.
They arise from changes in intensity and quality

of the stimuli or the spatial form of the perception.
They include:
Disorders of control of thought (alienation)
Increase in intensity of sensation, also known as

hyperaesthesia. It may result from intense emotions
or lowering of the physiological threshold, thus
a patient may perceive a cow as a lion. These
disturbances may occur as a result of delirium states,
anxiety, and even in hypochondriacal states.
Changes in intensity
These are delusions of control of ones thoughts by

outside forces. They commonly occur in psychotic
disorders such as schizophrenia and include:
Thought withdrawal in which other people or
agents remove ones thoughts from the mind.
Thought insertion where other people or forces
are putting thoughts into ones mind against
their wish.
Thought broadcasting in which ones thought
is made known to others without being talked
out by the one thinking.
Changes in quality
These are visual distortions usually brought
about by effects of toxic substances which colour
perception. They are not hallucinations but
qualitative changes of perception caused by use of
a substance e.g. seeing green as blue following use
of alcohol.
Obsession
Changes in spatial forms
Pathological persistence of an irresistible thought

or feeling that cannot be eliminated from the mind
easily. The patient recognizes these as his own
thoughts, but he cannot get rid of them. This often
happens in obsessive-compulsive disorders.
This is also called dysmegalopsia and occurs in the

visual eld. The patient may see things as smaller
(micropsia) or bigger (macropsia or megalopsia)
than they actually are. These often result from
retinal diseases, disorders of accommodation
and temporal lobe lesions. Micropsia is also
called lilliputine hallucinations.
Phobia
A pathological irrational fear occurring in particular
situations and leading to avoidance of the feared
object or situation.
Sensory deceptions
These are divided into illusions and hallucinations.
Illusions arise from false interpretation of stimulus
and could be as a result of fantasy, intense emotions
and lack of perceptual clarity or disease.
Speech
This generally refers to the communication through
the use of words and language. It includes:
Pressure of speech: the patient talks a lot and
rapidly and it may be difcult to follow the
speech. It is common in manic states.
Poverty of speech: scanty speech as occurs in
psychomotor retardation or depression.
Dysarthria: difculty in articulation.
Aphasia: disturbances in speech outputmay
be motor or sensory.
Hallucination
This is a false sensory perception not associated
with real external stimuli. It may be in any of the
ve sensory modalities (visual, olfactory, auditory,
gustatory, touch). They should be differentiated
from vivid mental images which arise from ones
mind in an ordinary thinking process. Hallucinations
occur at the same time as normal perceptions. The
normal hallucinations include:
Hypnagogic hallucinations, which are false
perceptions that occur while waking up from
sleep.
Hypnagogic hallucinations that are false
perceptions that occur while falling asleep.
The abnormal hallucinations occur in mental illness
and include:
Perception
These can be divided into disorders of sensory
distortion and sensory deceptions. In distortions,
there is a real stimulus which is perceived in a
distorted way while in deception, perception occurs
without an external stimulus.
160
Psychopathology
The hallucinations may be mood congruent in

which the content is consistent with the prevailing
mood. They may also be mood incongruent in
which the content is inconsistent with the mood
like it occurs in some schizophrenic patients.
Auditory hallucination in which the patient

hears a sound or a voice without any stimulus.
The voices may include music, animal sounds
or even conversations between people or
with the patient. They could be familiar or
unfamiliar to the patient and could also be
derogatory or pleasant. They are common in
psychotic disorders e.g. schizophrenia. The
different types of auditory hallucinations are:
o Third person hallucinations in which
voices talk among themselves about
the patient usually associated with
schizophrenia.
o Commentary voices a voice or voices
talking or describing what the patient is
doing or thinking.
o Second person hallucinations talking
directly to the patient. Depending on their
content they could be due to depression or
schizophrenia. In depression the patient
normally agrees with what the voices say
but in schizophrenia the patient normally
resents the voices.
Visual hallucinations involving sight of both
formed images e.g. people or unformed images
e.g. light. They occur commonly in medical
disorders affecting the CNS but may also be
present in psychotic patients.
Tactile hallucinations, which include false
perception of touch (haptic), surface sensation
as in amputated limb (phantom limb) or
even crawling sensation on or under the skin
(formication). These occur in substance abuse
as well as mental illnesses.
Olfactory and gustatory hallucinations are
common in medical conditions affecting the
CNS e.g. epilepsy.
Cognitive disturbances
Memory
This is most affected in medical illnesses that affect
the brain e.g. dementias and other degenerative
disorders. Para amnesias may also occur in some
patients going through stressful life experiences e.g.
bereavement and terminal illnesses or following
abuse of substances like alcohol. This presents
as an impairment of immediate, intermediate
or long-term memory and is clinically noticeable
as confabulation (unconscious lling up of lapses
in memory by made up experiences the patient
believes), dj vu or jamais vu.
Intelligence
This is the ability to constructively integrate and
utilise new information with previous experience.
It includes aspects of mathematical and language
abilities, abstraction and concrete thinking
and judgement-making abilities. These are
affected in mental retardation, dementias and in
psychotic disorders. They usually lead to patients
experiencing difculties in their workplace and
relationships.
Further Reading
1. Synopsis of Psychiatry: Behavioural Sciences Clinical
Psychiatry: 9th edition (2003): Editors: Benjamin J.
Saddock, Virginia Alcott Sadock. Lippincott Williams
& Wilkins
161
31
Psychiatric Interview, Assessment and Classication
David M Ndetei, Francisca Ongecha-Owuor, John Mburu,
Benson Gakinya, Fikre Workneh
receive the full attention of the medical practitioner.

The sitting positions determine how the interview
proceeds and what is said during the interview.
To facilitate easy communication and to reduce
discomfort, the patient should sit at right angles to
the clinician with the distance between the patient
and the clinician permitting easy communication
without shouting and at the same time avoiding
the discomfort of close physical proximity. Some
practitioners advocate that there should be no table
between the patient and the clinician and that the
clinician should not wear a white gown, but these
are not universally practised.
THE PSYCHIATRIC INTERVIEW

The psychiatric interview is the most important
tool in psychiatry. It is used to understand the
patients problem, elicit signs and symptoms, make
appropriate diagnosis, initiate treatment and predict
outcome. The psychiatric interview offers patients
an opportunity to express themselves and others
in a non-critical and non-judgmental atmosphere.
It is based on a good working knowledge of
psychopathology and the principles of dynamic
psychiatry. The medical practitioner should know
what to ask, how to ask, when to ask and how to
interpret the response of the patient.
There are various reasons why a patient consults
a mental health worker. The individual may see
a mental health worker voluntarily because of
disturbing experiences or because of pressure from
the family, relatives, friends or employer. Others
may have been forced through the courts. Their
willingness to communicate varies depending on
the nature of the underlying illness and on the
circumstances under which they came to see the
medical worker.
General principles in psychiatric

interviews
Active observation and awareness of behaviour
This begins from the moment the patient walks into
the consultation room. The gait, physical appearance
and greetings, as well as the general attitude to the
interview are all important. The clinician should
focus on the verbal as well as the non-verbal
communication. Non-verbal communication
such as facial expressions, hesitancy during the
interview, absence of eye contact and constant
checking around the room, are all important cues.
The setting of the psychiatric interview
Assessment and evaluation is a two-way process
The setting of the interview should provide privacy

and assure condentiality. The patient should
While the medical worker is assessing the patient,

the patient is also evaluating the medical worker on
162
sensitivity and genuine desire to help. The patient

may not reveal a great deal about himself unless he
senses that the clinician is interested and concerned
about him. If, for instance, the medical worker
looks at his watch, it may give the impression that
he nds the patient boring. The best interview is one
where there is a good rapport and shared feelings of
mutual respect and understanding. The interviewer
has to develop the art of listening. Statements like
as I told you before are warning signals by the
patient that the medical worker is not paying full
attention.
example, they may end up suggesting it to the

patients. The important point is when and how
to ask such questions. When the patient is telling
the clinician his feeling of hopelessness, posing
a question such as Dont you think of suicide?
is not appropriate. It would be appropriate to ask,
When you feel so low, do you sometimes feel
that life is not worth living? and to proceed from
there.
The clinician should focus on feelings and
emotionally charged areas should be explored. At
times the patient may show resistance and these
should be kept in mind for further discussion later
in the interview or some other day. Sensitive topics
should be handled carefully and tactfully. It is best
to introduce them gradually. Many people, for
example, may nd it difcult to talk about their
sexual life. The clinician should show concern and
understanding for such feelings. Remarks such as
I know that most people nd it difcult to talk
about their sexual life, but I feel it is important that
you tell me something about your sexual life, may
encourage the patient to begin the discussion.
Acceptance of the behaviour of the patient

All behaviour including what appears at rst sight
as odd has a meaning to the patient. Such behaviour
may invite ridicule and laughter. The clinician
should accept such odd behaviour. Acceptance
does not, however, mean approving it.
Avoid arguments with the patient
Avoid getting drawn into an argument with the
patient. It may be the patients way of relating to
others or seeking help. The clinician should try to
nd the underlying relationship problems.
Focus on interpersonal relationships

When taking family history in general medicine,
the focus is mainly on the age of the parents and
siblings, their health and, if dead, the cause of
death. The emphasis is almost exclusively on
hereditary disease. In psychiatric interviews,
while due attention is given to these issues, the
important areas are the interpersonal sense of love,
acceptance, security and discipline. These facts
reveal the psychodynamic factors responsible in
shaping the personality of the patient.
Do not assume you understand the patient

At all times the clinician should make sure he
understands what the patient says or feels. Very
often what the patient expresses may be about
problems close to our own, for example, ordinary
feelings like depression. One has to nd the depth
of the depression, whether he cries, has feelings
of hopelessness and suicidal thoughts and the
presence or absence of associated symptoms, such
as change in appetite and weight, and disturbance
of sleep.
One method of clarifying ones thoughts of what
the patient says and feels, is for the clinician to
summarise a number of times during the interview
by repeating what the patient has said and the
feelings the patient has expressed. The patient can
correct the clinician if he has been misunderstood.
Avoid being moralistic or judgmental

Some patients may come to the interview, expecting
the worst with a great deal of anxiety or guilt.
That is one of the main reasons why people avoid
sharing their problems and feelings. The clinician
should avoid being moralistic or judgmental.
Show empathy
Stress on feelings
Empathy is direct identication with, understanding

of, and experience of another persons situation,
feelings and motives. Carl Roger denes empathy as
sensing the clients inner world of private personal
meaning as if it were your own, but without losing
the as if quality.
The feeling of the patient may be difcult for the

new clinician to understand. First, the beginner
may feel awkward and at a loss of what to do with
an outpouring of feelings, for example, crying
by the patient. The patient should be offered the
opportunity to unburden these feelings, which may
have a cathartic effect.
The second dilemma encountered by novices is
when a patient talks about suicidal feelings. For
Try to tolerate silence

The novice may nd it difcult when the patient
does not respond to the posed questions right away.
163
The period of silence may be as a result of the

patient trying to sort out his thoughts, or the patient
may not wish to respond to that particular question,
probably due to the illness itself or feelings aroused.
Often the clinician may try to ll the silence with
more questions. Such an approach creates more
problems in the interview process.
THE PSYCHIATRIC
ASSESSMENT
The psychiatric history is obtained from the patient
as well as from the family, relatives or friends. This
is because in some cases the patient may not be
responsive or may be confused and in others the
history given by the patient may be inaccurate.
An alcoholic, for example, tends to conceal his
drinking or a schizophrenic patient may not reveal
his abnormal experiences, such as delusions or
hallucinations.
An accurate history and mental status
examination are the cornerstones of diagnoses
and treatment in psychiatry. The ndings should
be as comprehensive as possible and it should be
recorded systematically. Mental status examination
can be done in one session. The interviewer selects
an area that is essential as the interview proceeds.
In seriously sick, agitated or confused patients,
the observation of behaviour and a brief history may
be all that is required to begin treatment. A more
detailed history and mental status examination can
be obtained later from relatives or can wait until
the patient improves.
Clinical judgment, experiences and common
sense determines what to ask and the areas on
which to put emphasis. This ability to judge and
discriminate is acquired through experience
and knowledge of psychopathology. The art of
interviewing is rened and polished through
practice and by observation of more experienced
interviewers.
The stages in a psychiatric interview

The initial phase
This phase begins from the rst contact with the
patient. The clinician should greet the patient
and introduce himself. Both of them should sit
comfortably. The patient should be addressed
properly and correctly in keeping with traditional
norms, age, sex and social status.
Questions such as What was the reason you
wanted to see me? may open the interview. If the
patient was referred by another health worker, a
summary of the note may help start the interview.
Questions should be open-ended and simple.
Questions that begin with why are usually
difcult to answer, and create resistance, thus
should be avoided. The interviewer should also
avoid technical terms. The initial phase mainly
covers the patients illness.
The middle phase
This part of the interview focuses on the background
of the patient, his upbringing, family life,
educational and vocational life, and interpersonal
relationships, both past and present. The medical
practitioner tries to nd out the inuences of these
factors on personality and current problems of the
patient.
When do you write the psychiatric history?
Closing phase
It is best to write the entire history and mental

status examination at the end of the session. It is,
however, important to write down important points
like dates and the presence of psychopathological
symptoms during the interview, since one may not
recall all these later.
It is important to give the patient some minutes

before closing the interview to ask questions or
express the points that were not covered during
the interview. Questions such as, Before we nish
for the day, is there any question you wanted to
ask? or Are there points which you feel that you
wanted to discuss now?
This may open new areas for interview. The
patient may raise points already discussed showing
the areas of his particular concern. It is important
to discuss the patients areas of concern and the
feelings associated with it.
When do you interview the family?

In severely disturbed patients, it is important to
involve the family during the initial interview. A
great deal of information may be obtained from the
family, which may not be readily available from
the patient.
164
or extended family? In the latter, grandparents or

other members of the family may play an important
role. For each family member it is important to
note the name, age, sex, marital status, occupation,
and their relationship, past and present, with the
patient, and state their current health condition. If
dead, the age at time of death and cause of death
should be enquired. Find out if the parents or any
of the siblings are partially or totally economically
dependent on the patient and how he feels about
it. Find out if there is any family history of mental
illness among the nuclear and extended family.
Components of the psychiatric history

Identifying data
The name, age, sex, marital status, residence,
religion and occupation of the patient need to be
clearly noted down.
The referral system
Note the sources of referral, whether by a health
worker, brought by family members or self accord,
indicating the main reasons for referral.
Chief complaint
Personal history
The chief complaint is a brief statement of why the

patient seeks help. It should contain the description
of the problem and should be stated in the patients
own words. Where a patient does not see himself
as needing help or in the case of a patient being
unable or unwilling to speak, the chief complaint
can be obtained from relatives. The source should
be recorded.
The past period of the life of the patient should be

reviewed. The aim is to obtain a comprehensive
picture of the patient and to nd out factors in his
past which may explain his psychological make-up,
personality and present problems. Since it is neither
possible nor practical to cover all the past personal
history, more detailed early developmental history
may be necessary in children than in adults. The
personal history may be divided into the following
periods:
History of present illness

The patients problems are explored in detail and
in chronological order. It starts from the time when
the patient started feeling discomfort, which may
predate on his social interactions with others both
at home and work, its consequences on his family
life and his occupation are investigated. Other
symptoms associated with the chief complaints
are documented in this section. The present illness
should contain the psychosocial stress factors in
the life of the patient, as well as physical illness
and their time relationship with the presenting
symptoms.
It may not be possible to get all the details of
the present illness in one session. There may also
be gaps in the history of the patient or his relatives
may not provide a chronological narration of the
present illness. The psychiatrist needs to organise
the history in such a way that one reading it can get
a good picture of the illness.
Pregnancy, birth and early development up to

around 6 years
The interviewer should ask the following
questions:
Was the pregnancy unwanted, or out of
wedlock and what were the consequences on
the relationship of mother and child and other
members of the family?
Was there any problem during pregnancy and
delivery?
Was it an extended or nuclear family? In
the case of an extended family, who in the
family was closely attending to the patients
needs? The interpersonal relationship of the
individuals in the family unit, its cohesiveness,
and the socio-economic situation of the family
should be investigated.
Have there been signicant incidents in the
family like separation, divorce, illness and
death of signicant people? Was there any
problem with separation and socialisation?
How was the performance at school? Were
there any early neurotic traits like nail biting
or thumb sucking?
This section tries to understand the early childhood
developmental stages of the patient, and whether
needs were met or frustrated.
Past psychiatric and medical illnesses

This contains the physical and emotional illnesses
of the patient in the past, the type of investigation
and their results, diagnoses, treatment received and
outcome of such interventions.
Family history
The components of the family history depend on the
type of family and its composition. Is it a nuclear
165
Six years to puberty
with sexual problems, a detailed sexual history is

necessary. The patients attitude towards sex, the
sexual partners, sexual experiences in the past, its
frequency, the moral and religious attitude of the
patient and the feelings associated with it, are areas
to evaluate.
This section focuses on the individuals sense

of identity, participation in structured activities,
whether they like school, their school performance,
type of discipline and attitude towards authority
(both at home and in school), peer group activities
and its inuence on the patient, as well as coping
mechanisms.
Mental status examination

Inevitably, there is bound to be an overlap in what
is recorded in the present illness and the ndings
of the mental status examination. A great deal of
the mental status examination is obtained during
the interview about the present illness. In some
cases information on delusions or hallucinations
may not be readily obtained from the patient.
Such information, however, may be obtained from
relatives. Sometimes the patient may reveal such
information only after treatment and following
improvement. In order to avoid pitfalls in reporting
psychopathology the interviewer should be familiar
with culturally accepted beliefs, which may appear
to be a delusion or hallucination. The following
outline is generally accepted in reporting mental
status examinations ndings:
Adolescence to 19 years
This is a period of heightened sexual awareness. The
onset of puberty for girls and rst menstruation and
the reactions to it are important. Did the girl have
any pre-knowledge about it? In some societies the
girls may have been married or betrothed before
menarche. Boys are concerned about sexual matters
and masturbation related anxiety and worry about
physical as well as mental illnesses. In the older
ones a sense of guilt, school achievements, social
relationship both at home and in school with other
students and teachers should be explored. What are
the patients professional interests and future goals,
involvement in any extra-curricular activities?
Daily activities and social contacts are explored for
the patient who did not go to school.
General appearance
Note the grooming, posture, gait, physical
characteristics, facial expression, eye contact,
motor activity and specic mannerisms. Note the
state of awareness or consciousness, drowsiness,
clouding of consciousness, stupor, delirium,
eeting consciousness and coma.
Occupational history
The age and which work the patient rst engaged
in, any income generating activity or employment,
the nature of work, social and occupational
relationships, job satisfaction, growth and
improvement or deterioration in the job are
considered. Repeated absenteeism from work or
deterioration of work activity, for example, may
indicate alcoholism, depression or schizophrenia.
Speech
Note the rate, pitch, volume, clarity, speech
abnormalities, such as dysarthria.
Marital history
Mood
The interviewer should ask the age when the

patient got married, whether the marriage was a
personal decision or arranged by the family, and
the individuals feelings towards the marriage. If
the decision was a personal one, a negative reaction
to the marriage by one or both families may have
a signicant impact. The health and personality of
the marriage partner plays an important role in the
relationship, so does the religion if different from
the partners. The birth dates of children, their
health and educational achievements are assessed.
Mood refers to expression of emotion, which is

subjective, while affect is objective. Note the
variability or range, intensity and appropriateness.
Emotion is a complex state with psychic, somatic
and behavioural aspects. Mood would be described
as dysphoric, euthymic, expansive, irritable,
labile, elevated, euphoric, ecstatic, depressive
or anhedonic. Affect is said to be appropriate or
inappropriate, blunted, restricted, at or labile.
In some cases the patient may have difculty
expressing feelings or emotions referred to as
alexithymia.
Sexual history
Extra care is necessary in interviewing patients
about their sexual life. The medical practitioner
should try to elicit information without
embarrassing the patient. If the patient presents
Thoughts
Two components of thoughts are assessed: the
thought process and thought content. Thought
process, includes the ow of ideas and quality
166
of associations: the process of thinking should

include rate and ow of ideas. Thoughts can
be racing or totally slowed down. There may be
circumstantiality, blocking or perseveration as
occurs in schizophrenia. Thought broadcasting and
insertion are pathognomic features of schizophrenia.
Associations dened as the relationships between
ideas can be exhibited by loosening, ight of ideas,
neologisms, word salad or echolalia.
Thought
content
includes
distortions,
delusions, ideas of reference, depersonalisation,
derealisation,
preoccupations,
obsessions,
phobias, somatic concerns, suicidal or homicidal
ideation. In suicidal and homicidal ideation the
interviewer needs to assess the thoughts, plans,
feelings, and potential for actions and deterrents
to action.
subtracting 7 from 100 (serial seven) up to 65 or

3 from 20 (serial three) or by means of simple
problems.
Perception
Intelligence
Enquiries about perceptual disturbances require

careful approach and should evaluate the
presence or absence of illusions, hallucinations,
depersonalisation, or derealisation. Hallucinations
should focus on all the ve sense organs (sight,
hearing, taste, touch and smell) involved, with
their contact, frequency and circumstances of their
occurrence recorded.
Determine the general level of intelligence

compared with his level of education, and social
and cultural background vis-a-vis the mental
age. This can be objectively assessed using the
intelligence quotient (IQ).
Memory
Memory is assessed in three categories, immediate
(recall), recent and remote. Immediate memory,
which pertains to retention and recall involves
events occurring in the last few seconds to minutes,
can be assessed by giving the patient telephone
numbers with 5 to 6 digits and asking them to
repeat. Recent memory is hours to 2-3 days, thus
involves asking patients what they ate for breakfast
or where they were in the last few days. Remote
memory involves past years events. Important
family or historic dates in the patients sociocultural context may be used.
Judgement
Does the patient understand the harmful
consequences of his behaviour to himself, the
family and community? Would the patient make
wise decisions, for example, in case of re,
drowning or any life-threatening situation?
Cognitive functions
Sensorium
Disturbance of consciousness usually denotes
organic brain conditions. Determine the level of
consciousness and any uctuations if present. This
may range from mild clouding of consciousness
to stupor or coma.
Insight
The awareness of the patient about his illness
and its implication varies depending on whether
the patient is psychotic or non-psychotic. The
psychotic is said to have insight if he realises that
he is sick and that his delusions and hallucinations
are normal experiences. A neurotic, on the other
hand, is said to have insight if he understands that
his symptoms are due to environmental factors or
internal emotional causes.
Orientation
This is to check if the patient knows the time, place
and person. Does the patient know the time of day,
day of the week, month and year? The responses
expected are determined by the social and cultural
background of the patients. For place, ask about
familiar places. For person, ask about his name,
age, names of children, parents and siblings. These
should be counter-checked with family members.
MINI-MENTAL STATUS
EXAMINATION
Attention and concentration

Naming three objects to the patient or giving a
telephone number which the patient is told to repeat
after the interviewer can assess whether they are
attentive. By this time in the interview process one
can gauge a patients attention span by how they
answer the questions and their participation in the
whole process. On the other hand, concentration
can be determined using simple calculations like
The Mini-Mental Status Examination questionnaire

can be used in surveys as well as in clinical practice
by clinicians as well as trained non-mental health
workers. It can differentiate organic mental illness
from non-organic mental illness easily. Before
anybody can use it they need to be trained by an
experienced user. It tests for:
167
Orientation:
o Place: name of place where the clinical
setting is located, town, country and
region
o Time: year, month, date, day of the week,
season of the year
Registration of names of three objects
Attention and calculation - the 7 from 100
series up to 65
Recall of the three objects
Language: confrontation naming, repetition,
comprehension of simple instructions, reading
and performing and sentence construction,
Construction of simple designs.
It is however critical that such instruments be
locally adopted and validated.
Finally physicals are done. Investigations are
ordered depending on the history and ndings on
the physicals.
Has he received any treatment in the past

and what were the outcomes? Knowledge
of the kind of procedures and examinations
performed, the diagnoses made, treatments
given and the outcome of treatment will save
unnecessary extra expenditure of time and
money.
To facilitate decision-making in psychiatric
diagnosis, the following decision tree could be used:
the rst important decision to make is whether the
patient is psychotic or not. This is because it is more
urgent to treat a psychotic patient. If psychotic, it is
further differentiated into organic and non-organic
and into the different sub-divisions in the decision
tree. Such a decision is based on knowledge of
psychopathology, the psychiatric history and
the mental status examination results. The same
principle applies in the non-psychotic condition.
SUMMARY, FORMULATION AND

DECISION-MAKING
Classication in psychiatry attempts to bring

some order into the great diversity of phenomena
encountered in clinical practice. It enables health
professionals to communicate easily about the
nature of a patients problem, prognosis and
treatment. There are two main sets of classication
used in psychiatry:
The International Classication of Diseases,
version 10 (ICD 10) -- chapter V by the World
Health Organisation (WHO)
The Diagnostic and Statistical Manual for
Mental Disorders, fourth edition (DSM-IV
TR).
These two classications only deal with the major
psychiatric illnesses. The DSM-IV TR takes a
holistic approach, hence the biopsychosocial
model. In this book the DSM-IV TR classication
has been adopted. Its multiaxial approach is
described in detail below.
PSYCHIATRIC CLASSIFICATION
All the signicant ndings from the interview, mental

status examination, physical ndings and other
tests are summarised and evaluated. The nal goal
is to make a diagnosis and differential diagnosis to
treat the patient and also predict the outcome with
or without intervention. The formulation should try
to answer the following questions:
Who is this person? This section tries to
assess his upbringing, the signicant events
and conicts in the life of the patient, about
his likes and dislikes and how he deals with
people and situations.
Why is he seeking help now? Included in this
section are the summary of the reasons for
seeking help, the present illness and mental
status ndings. In some cases the problem has
existed for a long time. The reason for seeking
help may be due to a pressing life situation. An
alcoholic may seek help, because of a pending
divorce or the threat of losing his job.
Who are the signicant people in his life?
This deals with the human relationships past
and present.
MULTIAXIAL ASSESSMENT3
A multiaxial system involves an assessment on
several axes, each of which refers to a different
domain of information that may help the clinician
plan treatment and predict outcome. There are
This account is adopted from and reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association.
168
environmental problems, and level of functioning

that might be overlooked if the focus were on
assessing a single presenting problem. The
multiaxial system promotes the application of
the biopsychosocial model in clinical, educational
and research settings.
ve axes included in the DSM-IV multiaxial

classication:
Axis I:
Clinical Disorders
Other Conditions That May Be a
Focus of Clinical Attention
Axis II:
Personality Disorders
Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental
Problems
Axis V:
Global Assessment of Functioning
The use of the multi-axial system facilitates
comprehensive and systematic evaluation with
attention to the various mental disorders and
general medical conditions, psycho-social and
Axis I: Clinical Disorders

Other Conditions That May Be a Focus of
Clinical Attention
Axis I is for reporting all the various disorders
or conditions in the Classication except for
Personality Disorders and Mental Retardation
(which are reported on Axis II). Also reported on
Axis I are Other Conditions That May Be a Focus
of Clinical Attention.
Table 31.1
Axis I
Clinical Disorders
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
(excluding Mental Retardation, which is diagnosed on Axis II)
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classied
Adjustment Disorders
Other Conditions That May Be a Focus of Clinical Attention
Axis II: Personality Disorders
When an individual has more than one Axis I

disorder, all of these should be reported. If more
than one Axis I disorder is present, the principal
diagnosis or the reason for visit should be indicated
by listing it rst. When an individual has both
an Axis I and an Axis II disorder, the principal
diagnosis or the reason for visit will be assumed to
be on Axis I unless the Axis II diagnosis is followed
by the qualifying phrase (Principal Diagnosis)
or (Reason for Visit). If no Axis I disorder is
present, this should be stated. If an Axis I diagnosis
is deferred, pending the gathering of additional
information, this should also be stated.
Mental Retardation
Axis II is for reporting Personality Disorders
and Mental Retardation. It may also be used for
noting prominent maladaptive personality features
and defence mechanisms. When an individual has
both an Axis I and an Axis II diagnosis and the
Axis II diagnosis is the principal diagnosis or the
reason for visit, this should be indicated by adding
the qualifying phrase (Principal Diagnosis) or
(Reason for Visit) after the Axis II diagnosis.
169
Table 31.2
Axis II
Mental Retardation
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder
Personality Disorder Not Otherwise
Specied
Mental Retardation
Some general medical conditions may not

be directly related to the mental disorder but
nonetheless have important prognostic or
treatment implications
The choice of pharmacotherapy is inuenced
by the general medical condition
When a person with diabetes mellitus is
admitted to the hospital for an exacerbation of
schizophrenia, then insulin management must
be monitored.
When an individual has more than one clinically
relevant Axis III diagnosis, all should be reported.
Axis III: General Medical Conditions

This is for reporting current general medical
conditions that are potentially relevant to the
understanding or management of the individuals
mental disorder. The purpose of distinguishing
general medical conditions is to encourage
thoroughness in evaluation and to enhance
communication among health care providers.
General medical conditions can be related to mental
disorders in a variety of ways. In some cases it is
clear that the general medical condition is directly
aetiological to the development or worsening of
mental symptoms and that the mechanism for this
effect is physiological. When a mental disorder is
judged to be a direct physiological consequence of
the general medical condition, a Mental Disorder
Due to a General Medical Condition should be
diagnosed on Axis I and the general medical
condition should be recorded on both Axes I and
III.
In those instances in which the aetiological
relationship between the general medical condition
and the mental symptoms is insufciently clear to
warrant an Axis I diagnosis of Mental Disorder Due
to a General Medical Condition, the appropriate
mental disorder (e.g. Major Depressive Disorder)
should be listed and coded on Axis I; the general
medical condition should only be coded on Axis
III.
There are other situations in which general
medical conditions are recorded on Axis III because
of their importance to the overall understanding
or treatment of the individual with the mental
disorder:
An Axis I disorder may be a psychological
reaction to an Axis III
Axis IV: Psychosocial and Environmental

Problems
Axis IV is for reporting psychosocial and
environmental problems that may affect the
diagnosis, treatment, and prognosis of mental
disorders (Axes I and II). So-called positive
stressors, such as job promotion, should be listed
only if they constitute or lead to a problem, as when
a person has difculty adapting to the new situation.
In addition to playing a role in the initiation or
exacerbation of a mental disorder, psychosocial
problems may also develop as a consequence of
a persons psychopathology or may constitute
problems that should be considered in the overall
management plan.
When an individual has multiple psychosocial
or environmental problems, the health worker
may note as many as are judged to be relevant. In
general, only those psychosocial and environmental
problems that have been present during the year
preceding the current evaluation should be noted.
However, the health worker may choose to
note psychosocial and environmental problems
170
information is useful in planning treatment and

measuring its impact and in predicting outcome.
The reporting of overall functioning on Axis V can
be done using the Global Assessment of Functioning
(GAF) Scale given below. The GAF Scale is useful
in tracking the clinical progress of individuals in
global terms, using a single measure. The GAF
Scale is rated with respect to psychological, social,
and occupational functioning. The instructions
specify, Do not include impairment in functioning
due to physical (or environmental) limitations.
The GAF scale is divided into 10 ranges of
functioning. Making a GAF rating involves picking
a single value that best reects the individuals
overall level of functioning. The description of
each 10-point range in the GAF scale has two
components: the rst part covers symptom severity,
and the second part covers functioning. The
GAF rating is within a particular decile if either
the symptom severity or the level of functioning
falls within the range. For example, the rst part
of the range 41-50 describes serious symptoms
(e.g., suicide). In situations where the individuals
symptom severity and level of functioning are
discordant, the nal GAF rating always reects
the worse of the two. For example, the GAF rating
for an individual who is a signicant danger to self
but is otherwise functioning well would be below
20. Similarly, the GAF rating for an individual
with minimal psychological symptomatology
but signicant impairment in functioning (e.g. an
individual whose excessive preoccupation with
substance use has resulted in loss of job and friends
but no other psychopathology) would be 40 or
lower.
In most instances, ratings on the GAF scale
should be for the current period (i.e., the level of
functioning at the time of the evaluation) because
ratings of current functioning will generally reect
the need for treatment or care. In order to account
for day-to-day variability in functioning, the
GAF rating for the current period is sometimes
operationalised as the lowest level of functioning
for the past week. In some settings, it may be
useful to note the GAF scale rating both at time
of admission and at time of discharge. The GAF
Scale may also be rated for other time periods (e.g.,
the highest level of functioning for at least a few
months during the past year). The GAF Scale is
reported on Axis V as follows: GAF = , followed
by the GAF rating from 0 to 100, followed by the
time period reected by the rating in parentheses.
For example, (current), (highest level in past
year), (at discharge).
occurring prior to the previous year if these clearly

contribute to the mental disorder or have become a
focus of treatment.
In practice, most psychosocial and environmental
problems will be indicated on Axis IV. However,
when a psychosocial or environmental problem is
the primary focus of clinical attention, it should
also be recorded on Axis I.
For convenience, the problems are grouped
together in the following categories:
Problems with primary support groupdeath
of a family member; health problems in the
family; disruption of family by separation,
divorce, or estrangement; removal from the
home, remarriage of parent; sexual or physical
abuse; parental overprotection; neglect of
child; inadequate discipline; discord with
siblings; birth of a sibling
Problems related to the social environment
death or loss of a friend; inadequate social
support; living alone; difculty with
acculturation; discrimination; adjustment to
life-cycle transition (such as retirement)
Educational problemsilliteracy; academic
problems; discord with teachers or classmates;
inadequate school environment
Occupational
problemsunemployment;
threat of job loss; stressful work schedule;
difcult work conditions; job dissatisfaction;
job change; discord with boss or co-workers
Housing problemshomelessness; inadequate
housing; unsafe neighbourhood; discord with
neighbours or landlord
Economic
problemsextreme
poverty;
inadequate nances; insufcient welfare
support
Problems with access to health care services
inadequate health care services; transportation
to health care facilities unavailable; inadequate
health insurance
Problems related to interaction with the
legal system, crimearrest; incarceration;
litigation; victim of crime
Other psychosocial and environmental
problemsexposure to disaster, war, other
hostilities; discord with non-family caregivers
such as counsellor, social worker or physician;
unavailability of social service agencies.
Axis V: Global Assessment of Functioning

Axis V is for reporting the clinicians judgment of
the individuals overall level of functioning. This
171
with life, no more than everyday problems or

concerns (e.g., an occasional argument with family
members).
80-71 If symptoms are present, they are
transient and expected reactions to psychosocial
stressors (e.g., difculty concentrating after
family argument); no more than slight impairment
in social, occupational or school functioning (e.g.,
temporarily falling behind in schoolwork).
70-61 Some mild symptoms (e.g., depressed
mood and mild insomnia) or some difculty in
social, occupational or school functioning (e.g.,
occasional truancy, or theft within the household),
but generally functioning pretty well, has some
meaningful interpersonal relationships.
60-51 Moderate symptoms (e.g., at affect and
circumstantial speech, occasional panic attacks)
or moderate difculty in social, occupational, or
school functioning (e.g., few friends, conicts with
peers or co-workers).
50-41 Serious symptoms (e.g., suicidal ideation,
severe obsessional rituals, frequent shoplifting) or
any serious impairment in social, occupational,
or school functioning (e.g., no friends, unable to
keep a job).
40-31 Some impairment in reality testing or
communication (e.g., speech is at times illogical,
obscure, or irrelevant) or major impairment
in several areas, such as work or school, family
relations, judgment, thinking, or mood (e.g.,
depressed, avoids friends, neglects family, and is
unable to work; child frequently beats up younger
children, is deant at home, and is failing at
school).
30-21 Behaviour is considerably inuenced by
delusions or hallucinations or serious impairment
in communication or judgment (e.g., sometimes
incoherent, acts grossly inappropriately, suicidal
preoccupation) or inability to function in almost all
areas (e.g., stays in bed all day; no job, home or
friends).
20-11 Some danger of hurting self or others
(e.g., suicide attempts without clear expectation
of death; frequently violent; manic excitement) or
occasionally fails to maintain minimal personal
hygiene (e.g., smears faeces) or gross impairment
in communication (e.g., largely incoherent or
mute).
10-1 Persistent danger of severely hurting self
or others (e.g., recurrent violence) or persistent
inability to maintain minimal personal hygiene
or serious suicidal act with clear expectation of
death.
In order to ensure that no elements of the GAF

scale are overlooked when a rating is being made,
the following method may be applied:
STEP 1: Starting at the top level, evaluate each
range by asking is either the individuals
symptom severity or level of functioning
worse than what is indicated in the range
description?
STEP 2: Keep moving down the scale until the
range that best matches the individuals
symptom severity or the level of
functioning is reached, whichever is
worse.
STEP 3: Look at the next lower range as a doublecheck against having stopped prematurely. This range should be too severe
on both symptom severity and level of
functioning. If it is, the appropriate range
has been reached (continue with step 4).
If not, go back to step 2 and continue
moving down the scale.
STEP 4: To determine the specic GAF rating
within the selected 10-point range,
consider whether the individual is
functioning at the higher or lower end of
the 10-point range. For example, consider
an individual who hears voices that do not
inuence his behaviour (e.g., someone
with long-standing schizophrenia who
accepts his hallucinations as part of his
illness). If the voices occur relatively
infrequently (once a week or less), a rating
of 39 or 40 might be most appropriate.
In contrast, if the individual hears voices
almost continuously, a rating of 31 or 32
would be more appropriate.
Global Assessment of Functioning (GAF)

Scale
This gives a score that ranges from a possible
maximum of 100 to a possible 0 as indicated
below.
Code
100-91 Superior functioning in a wide range of
activities, lifes problems never seem to get out of
hand, is sought out by others because of his many
positive qualities. No symptoms.
90-81 Absent or minimal symptoms (e.g., mild
anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of
activities, socially effective, generally satised
172
Non-axial format
Throughout this book the DSM-IV-TR

classication is used, with permission from the
American Psychiatric Association. The DSM-IVTR Code numbers, where such codes are in use,
are reproduced in the tables.
Health workers who do not wish to use the

multiaxial format may simply list the appropriate
diagnoses. Those choosing this option should
follow the general rule of recording as many
co-existing mental disorders, general medical
conditions, and other factors as are relevant to the
care and treatment of the individual. The Principal
Diagnosis or the Reason for Visit should be listed
rst.
Further reading
1. Concise Textbook of Clinical Psychiatry Second
Edition:Derived from Kaplan & Sadocks Synopsis
of Psychiatry, 9th Edition. (2004) Editors: Benjamin J.
Sadock & Virginia A. Sadock Published by Lippincott
Williams & Wilkins
2. Diagnostic and Statistical Manual Disorders Fourth
Edition (2000): DSM-IV-TRTM Published by American
Psychiatric Association
0 Inadequate information.
Note: Use intermediate codes when appropriate,
e.g., 45, 68, 72.
173
32
Somatoform and Dissociative Disorders
Nora M. Hogan, David M. Ndetei, Gad Kilonzo, Richard Uwakwe
The current classication of somatoform disorders

reects recent historical changes in the theoretical
understanding of somatisation and dissocation.
Prior to the third edition of DSM in 1980, all
mental disorders that were considered to be
forms of somatoform were grouped together.
Since 1980, the term hysteria has been dropped
from DSM-IV/ICD-10 and the terms conversion
and dissociation used to distinguish conditions
with physical (sensorimotor disturbances) and
mental (disturbance of cognition and awareness)
symptoms, respectively.
Somatoform disorders are characterised by
physical complaints that appear to be medical
in origin, but cannot be explained in terms of a
physical disease, the results of substance abuse, or
by another mental disorder. In order to meet DSMIVs criteria for a somatoform disorder, the physical
symptoms must be serious enough to interfere with
the patients employment, relationships, or other
areas of functioning, and must be symptoms that
are not under the patients control. These disorders
are classied as follows (DSM IV-TR):
Somatisation Disorder (SD)
Hypochondriasis
Conversion Disorder
Body Dysmorphic Disorder
Pain Disorder.
DIAGNOSIS
As these disorders are associated with physical
symptoms. Patients are often diagnosed in a
general medical clinic and are referred to mental
health workers after a long process of unnecessary
surgery, laboratory tests, or other treatments.
Accurate and efcient diagnosis of somatoform
disorders is important and essentially requires:
A medical work-up: a thorough physical
work-up to exclude medical and neurological
conditions, or to assess their severity.
Comorbidity: in addition to ruling out medical
causes, a medical worker who is evaluating a
patient for a somatoform disorder will consider
the possibility of other psychiatric diagnoses
or of overlapping psychiatric disorders.
EPIDEMIOLOGICAL SURVEYS
Clinical and epidemiological surveys over the past
two decades suggest that acute forms of somatoform
disorders are invariably present in all primary care
settings. Prevalence rates and sex ratios vary. In
most somatoform disorder categories, a female
preponderance exists and onset can be as early as
childhood, adolescence or early adulthood.
174
MORTALITY AND MORBIDITY
misdiagnosed as suffering from a medical condition

and suffer iatrogenic complications due to invasive
diagnostic procedures or surgical operations.
Somatoform disorders do not appear to

independently increase the risk of death. However,
patients with somatoform disorders may be
SOMATISATION DISORDER
Table 32.1
300.81 Somatisation Disorder
A.
B.
C.
D.
A history of many physical complaints beginning before age 30 years that occur over a period of several years
and result in treatment being sought or signicant impairment in social, occupational, or other important areas
of functioning.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the
course of the disturbance:
(1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head,
abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or
during urination)
(2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g.,
nausea, bloating, vomiting other than during pregnancy, diarrhoea, or intolerance of several different
foods)
(3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g.,
sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding,
vomiting throughout pregnancy).
(4) one pseudoneurological symptom: a history of at least one symptom or decit suggesting a neurological
condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis
or localised weakness, difculty swallowing or lump in throat, aphonia, urinary retention, hallucinations,
loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such
as amnesia; or loss of consciousness other than fainting)
Either (1) or (2):
(1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known
general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
(2) when there is a related general medical condition, the physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the history, physical examination, or laboratory
ndings
The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).
Table 32.2
300.82 Undifferentiated Somatoform Disorder
A.
B.
C.
D.
E.
F.
One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints).
Either (1) or (2):
(1) after appropriate investigation, the symptoms cannot be fully explained by a known general medical
condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
(2) when there is a related general medical condition, the physical complaints or resulting social or occupational
impairment is in excess of what would be expected from the history, physical examination, or laboratory
ndings
The symptoms cause clinically signicant distress or impairment in social, occupational, or other important
areas of functioning.
The duration of the disturbance is at least 6 months.
The disturbance is not better accounted for by another mental disorder (e.g., another Somatoform Disorder,
Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder).
The symptom is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
175
lowered self-esteem, guilt and hopelessness),

may need to be elicited.
Hyperventilation occurs in about 60 percent of
patient with panic attacks and it is important to
note its diverse somatic manifestations.
Personality disorders may predispose a person
to amplify somatic symptoms.
Abnormal psychosocial situation or stressors
need to be evaluated.
Patients belief or perception about physical
symptoms may need to be explored.
Existence of any abnormal hostility towards
medical workers who have previously treated
the patient may need to be dealt with.
There may be co-morbid substance abuse.
In assessment it is important to:
Pay attention to certain aspects of the clinical
history especially, somatic complaints that
may have occurred during periods of adversity
or life change.
Enquire about parental illness especially during
the patients formative years and its effect on
the patient (parent able or unable to care for the
patient).
Physical illness and hospitalisation in childhood
can have an enduring psychological effect,
especially if it is accompanied by parental overconcern and injudicious advice from doctors
(leading to long absences from school).
In taking history of current physical symptoms,
it is important to take note of what was going
on in the patients life at the time.
Epidemiology
Based on the most restrictive DSM-1V criteria SD
is relatively rare with prevalence rates as low as
0.1 percent. Lifetime prevalence rates for women
may be as high as 2 percent. Lifetime prevalence
rates among men maybe as low as 0.2 percent. The
disorder is more common in rural areas and among
the educationally deprived.
A study in Belgium reported that somatisation
syndrome is the third highest psychiatric disorder,
with a prevalence rate of 8.9 percent. The rst and
second most common psychiatric disorders were
depression and anxiety disorders.
Sex ratios
There may be a ratio as high as 20 females to every
1 male.
Onset
The average age of onset is 15 years and the
condition generally becomes full blown by the
early 20s and then slowly and gradually improves,
such that after the age of 40, it has settled down to,
perhaps, less than 50 percent of what it was in the
early 20s. New onset of unexplained SD in older
adults should prompt a search for occult medical
illness or evidence of major depression associated
with somatisation.
Aetiology
The aetiology of somatisation and SD is not only
multi-factorial, but also exceedingly complex. In
addition, there are some indications that there may
be a heredity basis. Approximately 20 percent of
rst-degree female relatives will have SD. If you
have a female patient there is a 1 in 5 chance that
her rst-degree female relative, e.g. mother or sister
will have SD. However, there is a 1 in 5 chance that
her rst-degree male relative will develop antisocial
personality or be alcoholic.
Differential diagnosis
Medical disorders: The differential diagnosis
of SD includes medical disorders that present
with non-specic, vague or multiple somatic
symptoms. There are three factors that
might suggest a diagnosis of SD rather than
a general medical condition: involvement
of multiple organ systems, early onset and
chronic course without the development of
physical signs or structural abnormalities and
absence of laboratory abnormalities that are
characteristic of the general medical condition.
It is important to rule out medical conditions
characterised by vague, confusing somatic
symptoms (e.g. multiple sclerosis, systemic
lupus erythematosus, hyperparathyroidism).
Schizophrenia with multiple somatic delusions
needs to be differentiated from the nondelusional somatic complaints of SD.
Assessment and diagnosis

Psychiatric assessment includes:
A review of patients medical case record.
Full comprehensive psychiatric history with a
focus on the aspect of particular importance in
patients somatising.
Rule out depression. About 50 percent of
patients attending a general hospital somatising
are shown to have affective disorders and mode
of expression is primarily somatic. The more
cognitive component of depression (sadness,
176
all that is required for some somatisers. Patients

who respond easily to reassurance probably have
somatic symptoms in the context of anxiety and mild
depression. However, a hypochondriacs illness
may be sustained by seeking reassurance from
health workers. It is important to attempt to give
the patient a plausible explanation for somatisation
and information that is relevant to the patients
clinical condition. For example, a stabbing chest
pain may be ascribed to overstretching or tension
of muscles. Explanation should be congruent with
the patients socio-cultural background. Timing of
reassurance is important and not effective if given
before results of investigations or before the patient
has been allowed to air his concerns and has felt
understood. Information intended to reassure must
be accurate. Ambiguous statements, such as thats
not bad for your age are not helpful.
Preparing the patient for referral is an important
step that needs to be dealt with tactfully. It is
important to avoid giving the message that the
patient is not genuine, not ill, bothers doctors
unnecessarily or is mad, and that you are not just
packing him off to a psychiatrist. If the referring
health worker says something like I cannot nd
anything wrong with you. I think you need to see a
psychiatrist, is likely to be equated by the patient
as saying you are imagining it and I think you
are mad. If anger or resentment at the referral
becomes evident, these negative emotions should
be dealt with.
Major depression may present with somatic

complaints most commonly headache,
gastrointestinal disturbance or unexplained
pain. Individuals with SD have physical
complaints recurrently throughout their lives
regardless of their current mood state, whereas
physical complaints in depressive disorders
are limited to episodes of depressed mood.
Anxiety disorders: In panic disorder, multiple
somatic symptoms are also present, but these
occur primarily during the panic attack.
Generalised anxiety may also have a multitude
of physical complaints associated with general
anxiety, but the focus of the anxiety and worry
is not limited to the physical complaints.
Other somatoform disorders: conversion
disorder in which certain physical symptoms
are present, but do not full the criteria for
SD.
Factitious disorder: may be differentiated by the
presence of voluntary control of symptoms.
Co-morbidity: Somatising patients are
signicantly more likely to experience comorbidity, particularly depressive, anxiety
disorder or substance abuse.
Course and outcome
Somatisation causes signicant impairment in
role function, for which there are no demonstrable
organic ndings or known physiological
mechanisms. As the onset is typically before
age 30, and the multiple unexplained complaints
generally persist for several years, somatisation is
a common cause of absenteeism from work. An
extraordinarily large portion of a medical workers
time and effort is spent with individuals who seek
medical attention, not simply because of the nature
of the symptoms, but more as a result of their
frequency, severity and persistence.
Psychosocial treatment interventions

Basically, treatment consists of helping the patient
acknowledge the reality of stressful factors in
his life, reduction of stress factors, encouraging
verbal expression of distress and shaping adaptive
strategies to enable him cope with future stress.
Different approaches can be adopted depending
upon the orientation of the medical worker
(behavioural, cognitive or psychodynamic) and the
nature of the patients problem. The most common
interventions include:
Psychodynamic theory, which has proposed
that unexplained physical symptoms are
produced to protect the somatiser from
traumatic, frightening or depressing emotional
experiences. If an individual fails to process
a trauma adequately, it is hypothesised, that
the original affect later may be converted into
physical symptoms. Short-term, dynamically
oriented treatments for somatisers focus on the
stress and emotional distress associated with
physical symptoms.
Management and treatment

Good management depends on establishing
the correct diagnosis as soon as possible after
presentations and communicating this to patients
in terms which they can understand and accept.
The aim is to prevent the development of a pattern
of abnormal illness behaviour, chronic somatising
which once established is notoriously difcult to
overcome.
Reassurance
If this is an early onset the patient may respond
to simple reassurance. Simple reassurance is
very powerful if given appropriately and may be
177
Figure 32.1: Explaining to the patient the nature of psychosomatic symptoms is part of the treatment
The cognitive-behavioural therapy (CBT) of

somatisation emphasises the interaction of
physiology, cognition, emotion, behaviour
and environment. Specically, an individuals
interpretation of physical sensations may bring
on heightened awareness of bodily sensations,
increased emotional distress, and self-defeating
behaviour (such as avoiding activities), all of
which may exacerbate the physical symptoms.
In turn, the environment, including family,
friends, and medical workers, may respond in
ways that reinforce the individuals somatic
distress. Short-term CBT has been used with
somatisers to alter dysfunctional cognitive
processes and behaviour. Cognitive therapy
teaches patients to identify associations
between thoughts and physical symptoms and
to modify dysfunctional beliefs.
Re-attribution approach involves getting the
patient to accept a psychological view of their
symptoms during the rst interview. Patients
more suitable for this approach are those who
have some psychological understanding, are
not overtly hostile and whose symptoms are
relatively mild or of a short duration. Goldberg
and colleagues have proposed a three stage
model to encourage somatising patients to
reattribute their bodily symptoms and relate
them to psychological problems as follows:
o Feeling understood.
o Changing the agendagradually asking
about how the symptom affects the persons
life.
o Making the link between bodily symptoms
and emotional disorder.
Withdrawing unnecessary medication may be an

element of the re-attribution process. As such, the
patient is invited to move from sick role to healthy
role. This process must be carefully handled.
Behaviour therapy for somatic complaints
uses the methods for pain management and
increasing of avoided activities through operant
conditioning.
Psychophysiologists have described several
mechanisms that produce somatic symptoms
in the absence of organic pathology. These
mechanisms
include
over-activity
or
dysregulation of the autonomic nervous system,
smooth muscle contractions, endocrine overactivity, and hyperventilation. Miscellaneous
techniques directed at reducing somatisers
physiological arousal and physical discomfort
have been studied within controlled experimental
designs, including hypnotherapy, progressive
muscle
relaxation,
electromyography
(EMG), biofeedback, auto-genic training and
multifaceted relaxation training programmes.
Exercise treatments have been developed
for somatisers in accordance with evidence
suggesting that exercise improves mood,
pain thresholds and sleep. One theory
explaining the benets of exercise proposes
that exercise produces increases in serum
levels of -endorphin-like immunoreactivity,
adrenocorticotropic hormone, prolactin and
growth hormone.
Group psychotherapy. The group treatment is
aimed to enhance emotional expression, peer
support and coping skills.
178
and begin to incorporate being sick into their

self-concept and the sick role into their repertoire
of social behaviours. The early start of somatisation
and the relatively long hospital career in some
patients, emphasise the importance of developing
means by which those at risk of somatisation
can be identied early so that their utilisation of
medical services can be tracked prospectively and,
hopefully, effective interventions can be devised.
Prognosis: clinical features that predict

good response to treatment
No single predictive factor has been identied.
However, some general rules serve as a guide.
Psychological treatment is more likely to be
successful if:
The patients attribution of his symptoms can
be altered from organic to psychological or
rather the idea that there are multiple causes
for symptomsthe full range of aetiological
factors that apply.
The patient is able to agree to treatment
goals.
The patient engages in the treatment.
Patients with more dysfunctional illness beliefs
and assumptions about aetiology have a worse
outcome. Once symptoms have been established,
the management becomes difcult, because the
patients perception of the illness differs sharply
from that of the health practitioner. A breakdown
in the relationship is common and patients
unsuccessfully consult a succession of clinicians in
the hope of meeting one who can offer them relief.
This patient is on the path to chronicity.
HYPOCHONDRIASIS
Hypochondriasis is a somatoform disorder
characterised by a belief that real or imagined
physical symptoms are signs of a serious illness,
despite medical reassurance and other evidence to
the contrary.
Clinical features
In common language hypochondriac indicates
a person who thinks he is ill or merely imagines
that he has symptoms. The essential features are
the conviction that the disease exists, fear of the
disease and preoccupation with bodily symptoms
and signs. The physical symptoms are typically
normal always subjective physical signs (like
headache, belly pain, dizziness, fatigue, nausea
and numbness), which are misinterpreted as more
dangerous than they really are (e.g. I have a
headache, I must have a brain tumour). Common
physical symptoms that may be misinterpreted
include borborygmi, abdominal bloating and
crampy discomfort, cardiac awareness, and
sweating and dermatological concerns.
Preventive intervention
Somatisation disorder is commonly identied
during middle age. It should be noted that one of the
criteria for the diagnosis is a longstanding history
of multiple, unexplained medical complaints.
Thus, the natural history of somatisation probably
begins as early as adolescence or even childhood.
Children may develop a mental representation of
illness and its personal and social consequences,
Table 32.3
300.7 Hypochondriasis
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the persons
misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not
restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D. The preoccupation causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalised Anxiety Disorder, Obsessive-Compulsive
Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform
Disorder.
Specify if:
With Poor Insight: if, for most of the time during the current episode, the person does not recognise that the
concern about having a serious illness is excessive or unreasonable
179
It is important to understand that hypochondriasis

is not a way of seeking attention from others by
prentending to be sick. Individuals honestly believe
that they are suffering from a medical condition,
the symptoms are real and they feel misunderstood.
Most individuals are not concerned with the pain
but rather with what the physical symptoms may
imply in terms of real disease.

A supportive relationship with a health worker is the
mainstay of treatment. There should be one primary
provider to avoid unnecessary diagnostic tests and
procedures. The health worker should inform the
person that no organic disease is present, but that
continued medical follow-up will help control the
symptoms. Specialist referral may be considered.
Various forms of psychotherapy may be useful.
Assessment and diagnosis

Hypochondriasis must be positively diagnosed.
It is not enough to exclude physical disease. The
exaggerated health anxiety or obsessive irrational
fear must also be found. A thorough physical
examination is indicated to rule out any pertinent
medical conditions, along with a psychosocial
history and a mental status examination. Patients
with hypochondriasis often seek exhaustive
batteries of tests, which are often excessive relative
to their symptoms.
Prognosis
Generally, the disorder is chronic, unless the
psychological factors or any related underlying
mood disorders are addressed. People with
hypochondriasis seldom acknowledge that their
illness has a psychological component and usually
reject mental health treatment.
CONVERSION DISORDER
Course
Historically the terms conversion, hysteria and
conversion hysteria were used interchangeably
to describe a condition characterised by a single
somatised symptom, often a pseudoneurologic
one, for example, blindness. With the introduction
of the DSM classication system, the hypothesis
was that an individuals somatic symptoms
Hypochondriasis may persist over a number of

years, but usually occurs as a series of episodes
rather than continuous treatment-seeking. The
are-ups of the disorder are often correlated with
stressful events in the patients life. Depression
with somatisation must be excluded and properly
treated.
Table 32.4
300.11 Conversion Disorder
A. One or more symptoms or decits affecting voluntary motor or sensory function that suggest a neurological
or other general medical condition.
B. Psychological factors are judged to be associated with the symptom or decit because the initiation or
exacerbation of the symptom or decit is preceded by conicts or other stressors.
C. The symptom or decit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
D. The symptom or decit cannot, after appropriate investigation, be fully explained by a general medical
condition, or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience.
E. The symptom or decit causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning or warrants medical evaluation.
F. The symptom or decit is not limited to pain or sexual dysfunction, does not occur exclusively during the
course of Somatisation Disorder, and is not better accounted for by another mental disorder.
Specify type of symptom or decit:
With Motor Symptom or Decit (e.g., impaired coordination or balance, paralysis or localised weakness,
difculty swallowing or lump in throat, aphonia, and urinary retention)
With Sensory Symptom or Decit (e.g., loss of touch or pain sensation, double vision, blindness, deafness,
and hallucinations)
With Seizures or Convulsions: includes seizures or convulsions with voluntary motor or sensory components
With Mixed Presentation: if symptoms of more than one category are evident
180
muscle weakness) and Guillain-Barr syndrome

(motor and sometimes sensory).
Psychiatric conditions that must be differentiated
include the following: dissociative disorder,
psychotic disorders, mood disorders, factitious
disorders and malingering, pain disorder or sexual d
ysfunction, somatisation disorder, undifferentiated
somatoform disorder, adjustment disorder.
represented a symbolic resolution of an

unconscious psychological conict that reduced
anxiety and served to keep conict away from
awareness (primary gain). The DSM-IV uses the
term conversion disorder and simply requires that
psychological factors are judged to be associated
with the symptoms or decit as the initiation or
exacerbation of the symptoms is often preceded by
conict and other stressors.
Conversion disorders are characterised by a
sudden loss of neurological-like function, usually
in the context of a severe stressor. It is dened as a
condition that presents as an alteration or loss of a
physical function, suggestive of a physical disorder.
However, conversion disorder is more precisely
understood as the expression of an underlying
psychological conict or need.
Course
Generally, individual conversion symptoms are
self-limited, usually last for days to weeks and
may resolve spontaneously. The symptom itself
is not life-threatening, but the development of
complications as a result of the symptom can be
debilitating. Over 90 percent of patients recover
within a month, and most do not have recurrences.
Data for hospitalised patients suggest that more
than half of patients with this disorder have
improved at the time of discharge. However, 20-25
percent relapse in the rst year
Associated characteristics of conversion

disorder
La belle indifference
This is dened as a relative lack of concern about the
nature or implications of the symptom manifested
on the part of the patient.
Treatment
Patients with conversion disorder are suggestible,
but reassurance that symptoms will go away is
rarely effective unless it is predicted that it may
be gradual with specic recommendations for
exercises or referral to a physiotherapist. It is
also important to communicate to patients that
their symptoms have been taken seriously and
acknowledge the stress and strains in the patients
life. Suggesting that symptoms will persist for
a time may provide time to establish therapeutic
relationships. The patient should be allowed to
eliminate the symptoms as slowly as is needed and
with dignity. Colluding family members must be
carefully handled and the symptoms explained. A
health workers tasks include:
Providing education about conversion disorder,
while carefully ruling out contributing medical
conditions and attending to the views of the
patient and family.
Discussion of the interplay between emotional
and physical stress can be helpful to the patient
and family.
Referral to a trained professional in mental
health diagnosis and treatment may be
necessary if progress is not made in coping
with symptoms.
The health worker must be satised with the
completeness of the physical evaluation and should
use discretion regarding the extent of the organic
work-up.
Primary versus secondary gain

The resolution of the emotion that underlies
the physical symptom or the extent to which a
conversion symptom diminishes the unpleasant
emotion and communicates symbolically the
unconscious wish by keeping the internal conict
out of awareness is called the patients primary
gain. Secondary gain is achieved when the patient
has been removed from the uncomfortable situation
by virtue of the symptom.
Somatic compliance
The choice of symptoms (e.g. inability to swallow
or speak, going blind or deaf; or having seizures, or
convulsions) symbolically reect the psychological
trauma and effectively achieves the primary gain.
Symptoms are more common on the left side than
the right.
Differential diagnosis: making the

diagnosis
Medical conditions that may mimic conversion
symptoms include the following: multiple sclerosis
(with blindness secondary to optic neuritis),
myasthenia gravis (with muscle weakness), periodic
paralysis (with muscle weakness), myopathies
(with muscle weakness), polymyositis (with
181
arthritis, muscle aches and cramps, or pelvic pain.

In some cases the patients pain appears to be
largely due to psychological factors, but in other
cases the pain is derived from a medical condition
as well as the patients psychology.
PAIN DISORDER
Pain disorder as a category of somatoform disorder
covers a range of patients with a variety of ailments,
including chronic headaches, back problems,
Table 32.5
Pain Disorder
A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of
sufcient severity to warrant clinical attention.
B. The pain causes clinically signicant distress or impairment in social, occupational, or other important
C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or
maintenance of the pain.
D. The symptom or decit is not intentionally produced or feigned (as in Factitious Disorder or
Malingering).
E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria
for Dyspareunia.
Code as follows:
307.80 Pain Disorder Associated With Psychological Factors: psychological factors are judged to have
the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition
is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This
type of Pain Disorder is not diagnosed if criteria are also met for Somatisation Disorder.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Table 32.6
307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition:
both psychological factors and a general medical condition are judged to have important roles in the onset,
severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical
site of the pain (see below) is coded on Axis III.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Note: The following is not considered to be a mental disorder and is included here to facilitate differential
diagnosis.
Table 32.7
Pain Disorder Associated With a General Medical Condition: a general medical condition has a major
role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present,
they are not judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain.) The
diagnostic code for the pain is selected based on the associated general medical condition if one has been
established or on the anatomical location of the pain if the underlying general medical condition is not yet
clearly establishedfor example, low back (724.2), sciatic (724.3), pelvic (625,9), headache (784.0), facial
(784.0), chest (786.50), joint (719.40), bone (733.90), abdominal (789.0), breast (611.71), renal (788.0), ear
(388.70), eye (379,91), throat (784.1), tooth (525.9), and urinary (788.0).
182
treated, external reinforcements are removed and

possible underlying conditions, such as depression,
are effectively treated.
Appropriate medical investigations should be
carried out in respect of the systems or anatonomical
sites implicated. Pure pain may be difcult to
exclude or differentiate from psychogenic pain as
they are not mutually exclusive. The features are
as follows:
Physical pain tends to uctuate in intensity
and is highly sensitive to emotional, cognitive,
attentional and situational inuences, whereas
pain that does not vary and is not affected by any
of these factors is likely to be psychogenic.
Pain
must
be
distinguished
from
other somatoform disorders in which pain is
one of the core features.
Malingerers consciously provide false reports.
They usually have clearly identiable goals
and rewards to achieve, secondary to the
pain.
Psychiatric disorders such as schizophrenia,
major depressive or anxiety disorders often
present with associated pain symptoms that
may not be physical.
Identifying and treating a depressive disorder
that may be associated with the pain may
signicantly reduce the subjective experience
of pain.
Treatment
With acceptance of a biopsychosocial model of
pain, therapists use a variety of biopsychosocial
interventions aimed at addressing such factors. An
illness such as chronic pain may require attention
to numerous factors interacting in non-linear
relationships.
General treatment approaches used by
clinicians have focused on identifying and
altering psychological and social factors that
can inuence pain and disability.
Cognitive
behaviour
therapy,
selfhypnosis, behaviour therapy and pain control
programmes are useful. To be effective, all
treatment approaches require that the medical
worker establish a supportive relationship
with the patient that will help prevent
unnecessary medical and surgical procedures
and treatments. Psycho-education about the
nature of the pain disorder is also effective.
Medication. Antidepressants reduce pain
intensity in patients with psychogenic pain
or somatoform pain disorder and they help
ameliorate any underlying depression.
Course and outcome
BODY DYSMORPHIC DISORDER

(BDD)
Pain can transition from abrupt acute onset to

chronic pain disability in stages, from weeks to
months. Chronic pain disorder can be distressing
and totally disabling with the patients assuming
the sick role. This excuses patients from their
normal responsibilities and social obligations,
which may become a potent reinforcer for not
becoming healthy. It is better if psychological
factors associated with the pain are identied and
The primary distinguishing feature of BDD is an

obsessive preoccupation with an imagined defect
in ones physical appearance (width of the lips or
shape of the nose) or an exaggerated distortion of a
minimal or minor defect.
Table 32.8
300.7 Body Dysmorphic Disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the persons
concern is markedly excessive.
B. The preoccupation causes clinically signicant distress or impairment in social, occupational, or other
C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body
shape and size in Anorexia Nervosa).
183
Patients obsessed with facial deformities may

resort to compulsive face picking and skin digging,
sometimes to the point of actually scarring the
face. Patients may become obsessed with a pimple,
and in their attempt to get it out they dig their nails
into their skin. If that does not work they may try
tweezers and sometimes even carving the pimple
out with a knife. Self-mutilation may also take the
form of face picking or pulling on the nose with
pliers to even it out. Other behavioural responses
to BDD obsessions include compulsive mirror
checking, episodic avoidance of mirrors, excessive
grooming, camouaging, reassurance seeking,
surgery and unnecessary usage of dermatological
products.
confused with BDD are neglect caused by a parietal

lobe brain lesion and gender identity disorder.
Onset and course
The average age of onset is in mid-adolescence,
and the course tends to be chronic and uctuates
over the course of time with new imagined defects
being added over time.
Treatment
The following steps may be the most effective way
of managing the patient:
The clinician should acknowledge the patients
concern.
The clinician should seek additional
information to determine the severity of the
disorder.
A discussion about how much time and worry
is devoted to the perceived defect will help.
The clinician should also ask what the patient
has done to remedy the defect, and how the
defect has altered the patients social, academic
or occupational activities.
Psychoeducation about the nature of the
disorder can be very helpful, particularly if
patient conviction about their defect is not too
strong or symptoms do not have a delusional
quality.
The potential benets of psychiatric referral
may be discussed.
Most
often
these
patients
need
pharmacological interventions combined with
cognitive approach. Effective medications
include clomipramine, uoxetine, uvoxamine
and pimozide. Selective serotonin reuptake
inhibitors (SSRIs) are effective for BDD, even
if symptoms are delusional. The medication
may not always cure the disorder, but it makes
the person more amenable to psychotherapy
and hopefully more open to receiving ongoing
treatment. In some cases, these medications
are lifesaving, especially for those who
have attempted suicide in despair over their
appearance.
Differential Diagnosis
Anorexia nervosa
This is where the persons obsessive interest is in
their weight, body shape and size. A differential
diagnosis of anorexia nervosa may be made.
BDD is different from eating disorders, because it
involves other factors besides ones weight or body
size. Those with BDD have several cognitive
distortions about how they look.
Delusional disorder, somatic sub-type
The strength of the overvalued idea at times may
be close to delusional. Patients in this class might
qualify for a diagnosis of another syndrome relevant
to the self-image, delusional disorder, somatic subtype.
Major depressive disorder
Chronic BDD is often associated with or can lead
to major depressive disorder, because patients
cannot convince others of the problem and are not
able to change. In one study, more than 90 percent
of respondents were found to have had a major
depressive episode in their lifetimes. Some 70
percent had suffered an anxiety like social phobia.
Psychotic disorder
It is important to distinguish BDD from psychotic
patients and those with highly disturbed global and
body self-images. Other conditions that might be
184
Table 32.9
300.82 Somatoform Disorder Not Otherwise Specied
This category includes disorders with somatoform symptoms that do not meet the criteria for any specic
Somatoform Disorder. Examples include:
1. Pseudocyesis: a false belief of being pregnant that is associated with objective signs of pregnancy,
which may include abdominal enlargement (although the umbilicus does not become everted), reduced
menstrual ow, amenorrhea, subjective sensation of foetal movement, nausea, breast engorgement and
secretions, and labour pains at the expected date of delivery. Endocrine changes may be present, but the
syndrome cannot be explained by a general medical condition, that causes endocrine changes (e.g., a
hormone-secreting tumour)
2. A disorder involving non-psychotic hypochondriacal symptoms of less than 6 months duration
3. A disorder involving unexplained physical complaints (e.g., fatigue or body weakness) of less than 6
months duration that are not due to another mental disorder
symptoms in the absence of (signicant) external

incentives, which can be attributed to a need to
assume the sick role.
Patients with this disorder knowingly fake
symptoms, but do so for psychological reasons.
FACTITIOUS DISORDERS
Factitious disorder represents the intentional
production of physical or psychological signs and
Table 32.10
Factitious Disorder
A. Intentional production or feigning of physical or psychological signs or symptoms.

B. The motivation for the behaviour is to assume the sick role.
C. External incentives for the behaviour (such as economic gain, avoiding legal responsibility, or improving
physical well-being, as in Malingering) are absent.
Code based on type:
300.16 With Predominantly Psychological Signs and Symptoms: if psychological signs and symptoms
predominate in the clinical presentation
With Predominantly Physical Signs and Symptoms: if physical signs and symptoms predominate in the
clinical presentation
300.19 With Combined Psychological and Physical Signs and Symptoms: if both psychological and
physical signs and symptoms are present but neither predominates in the clinical presentation
Table 32.11
300.19 Factitious Disorder Not Otherwise Specied
This category includes disorders with factitious symptoms that do not meet the criteria for Factitious
Disorder. An example is factitious disorder by proxy: the intentional production or feigning of physical or
psychological signs or symptoms in another person who is under the individuals care for the purpose of
indirectly assuming the sick role
185
clinical approach. Re-dening the factitious illness

as psychiatric with continued involvement of a
primary clinician and family support are helpful
to successful management. Underlying psychiatric
disorders need to be thoroughly evaluated and
treated, especially depression. An essential
and probably most difcult step is to secure an
enduring and stable patient-clinician relationship.
To achieve this goal, most clinicians advocate a
non-confrontational strategy and reframing the
factitious manifestation as a cry for help.
They usually prefer the sick role and may move

from hospital to hospital in search of care. They are
usually loners with an early childhood background
of trauma and deprivation and are unable to
establish close interpersonal relationships. Unlike
the malingerers, they follow through with medical
procedures, are at risk of drug addiction and may
suffer the complications of multiple operations.
Other forms include Munchausens and Ganser
Syndrome, as well as Factitious Disorder by
Proxy or Munchausen Syndrome by Proxy. The
major feature of factitious disorder by proxy is the
deliberate production or feigning of physical or
psychological symptoms in another person who is
under that individuals care, usually a child. The
motive for the perpetrators behaviour is thought
to be a psychological need to assume the sick role
by proxy.
DISSOCIATIVE DISORDERS
A mentally healthy person has a unitary sense
of self as a single human being with a single
personality. The essential feature of dissociation
is an alteration in this unitary state, which results
in a lack of connection in a persons thoughts,
memories, feelings, actions or sense of identity.
The disturbance may be sudden or gradual,
transient or chronic. Individuals with dissociative
disorders can experience headaches, amnesias,
time loss, trances, and out-of-body experiences.
This group of conditions include: Dissociative
Amnesia, Dissociative Fugue, Dissociative Identity
Disorder, and Depersonalisation Disorder.
The following disorders need to be ruled
out to establish a precise diagnosis: genuine
psychiatric pathology, neurological disorders,
other somatoform disorders and malingering
(where there is external motivation for symptom
production). The patient with factitious disorder
produces symptoms without external motivation.

Dissociative amnesia (formerly known
as psychogenic amnesia)
Overall, the results of psychotherapy are not

encouraging. Therefore, treatment should be based
on focusing on the management of the disorder
rather than on a cure. An appropriate index of
suspicion and non-judgemental confrontation and
psychiatric consultation facilitate a successful
The essential feature is reversible memory

impairment due to psychological causes usually
following a severe physical or psychological
conict or stressor.
Table 32.12
300.12 Dissociative Amnesia (formerly Psychogenic Amnesia)
A. The predominant disturbance is one or more episodes of inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary
forgetfulness.
B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder,
Dissociative Fugue, Posttraumatic Stress Disorder, Acute Stress Disorder, or Somatisation Disorder
and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a
neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma).
C. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
186
by the assumption of a new identity and inability

to recall some or all of ones past. Perplexity and
disorientation may occur.
Dissociative Fugue
Dissociative fugue is characterised by sudden,
unexpected travel away from home or ones
customary place of daily activity and is characterised
Table 32.13
300.13 Dissociative Fugue (formerly Psychogenic Fugue)

A. The predominant disturbance is sudden, unexpected travel away from home or ones customary place of
work, with inability to recall ones past.
B. Confusion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is
not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
(Copyright 2000). American Psychiatric Association
states, which may eventually take on identities of

their own. These entities may become the internal
personality states of a DID system. Changing
between these states of consciousness is often
described as switching. These alternate states
may appear to be very different, but they are all
manifestations of a single person.
Dissociative Identity Disorder (DID)

In the DSM-IV multiple personality disorder
(MPD) was changed to DID, reecting changes in
professional understanding of the disorder resulting
from signicant empirical research. DID may be
seen as a process where repeated dissociation may
result in a series of separate entities, or mental
Table 32.14
300.14 Dissociative Identity Disorder (formerly Multiple Personality Disorder)

A. The presence of two or more distinct identities or personality states (each with its own relatively enduring
pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the persons behaviour.
C. Inability to recall important personal information that is too extensive to be explained by ordinary
forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic
behaviour during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures).
Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
occurs in an individuals self-awareness such that

they feel detached from their own experience, with
the self, body and mind. These periods of unreality
can last for days, weeks or months. As a result
of this sustained distress, the sufferer can rapidly
become deeply depressed and anxious. It can then
be difcult to establish whether this is a result of,
or the cause of the depersonalisation.
Depersonalisation disorder
Transient feelings of unreality are quite normal
in healthy individuals. Alternatively, they can be
a co-symptom of psychiatric or physical illness,
in which case they will often disappear when
the sufferer recovers from their primary illness.
However, in depersonalisation disorder, a change
187
Table 32.15
300.6 Depersonalisation Disorder
A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of,
ones mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalisation experience, reality testing remains intact.
C. The depersonalisation causes clinically signicant distress or impairment in social, occupational, or
other important areas of functioning.
D. The depersonalisation experience does not occur exclusively during the course of another mental
disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder,
and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g., temporal lobe epilepsy).
disorders
(especially
intoxication
and
withdrawal), anxiety disorders, personality
disorders, epilepsy and substance abuse.
Depersonalisation may be a symptom in
schizophrenia, mood disorders, other mental
Table 32.16
300.15 Dissociative Disorder Not Otherwise Specied

This category is included for disorders in which the predominant feature is a dissociative symptom (i.e.,
a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the
environment) that does not meet the criteria for any specic Dissociative Disorder. Examples include
1. Clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this
disorder. Examples include presentations in which a) there are not two or more distinct personality
states, or b) amnesia for important personal information does not occur.
2. Derealisation unaccompanied by depersonalisation in adults.
3. States of dissociation that occur in individuals who have been subjected to periods of prolonged and
intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while captive).
4. Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity,
or memory that are indigenous to particular locations and cultures. Dissociative trance involves
narrowing of awareness of immediate surroundings or stereotyped behaviours or movements that are
experienced as being beyond ones control. Possession trance involves replacement of the customary
sense of personal identity by a new identity, attributed to the inuence of a spirit, power, deity, or other
person, and associated with stereotyped involuntary movements or amnesia and is perhaps the most
common Dissociative Disorder in Asia. Examples include amok (Indonesia), bebainan (Indonesia),
latah (Malaysia), pibtoktoq (Arctic), ataque de nervios (Latin America), and possession (India). The
dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious
practice.
5. Loss of consciousness, stupor, or coma not attributable to a general medical condition.
6. Ganser syndrome: the giving of approximate answers to questions (e.g., 2 plus 2 equals 5) when not
associated with Dissociative Amnesia or Dissociative Fugue.
settings, traditional healers may have a role to

play. These treatments have included behaviour
modication therapies, psychodrama, relaxation
therapy and various psychotherapies of a traditional
nature. The use of symbolism and ritual is deeply
entrenched in the African traditional healers
practices. Practitioners of meditation describe
Management
Dissociative disorders can be responsive to
individual psychotherapy, or talk therapy, as
well as to a range of other treatment modalities,
including medications (for co-morbid psychiatric
conditions) and hypnotherapy. Outside of western
188
states of possession which contain many features of

depersonalisation. They often describe therapeutic
experiences which help deeply distressed patients
by allowing them abreaction and carthasis.
Further Reading
1. American Psychiatric Association (1980). Diagnosis
and Statistical Manual of Mental Disorders (DSM
111), 3rd Edition. Washington: American Psychiatric
Association
189
33
Mood Disorders
David M. Ndetei, Caleb Othieno, Seggane Musisi, Gad Kilonzo
disease as the leading source of disease burden

worldwide.
Major risk factors for depression appear similar
in developed and developing countries and
include family history of the disease, life events,
chronic social adversity, poverty, and gender. The
course of depression is inuenced by several factors,
including the type, causes, severity, duration prior
to treatment, and underlying presence of chronic
minor depression. Depression in children and
adolescents is often chronic and continues into
adulthood with higher rates of overall impairment
and signicant rates of attempted suicide.
Because depression typically results from a
combination of causes, effective prevention and
treatment demands a multifaceted approach. In
developing countries, this may translate into a
combination of health care health education,
community care and socio-economic development.
Effective pharmacotherapies and psychosocial
treatments exist for depression. Though no
treatment has been shown to cure all forms of the
illness, a large number of effective and low-cost
treatments are available.
INTRODUCTION
Mood disorders are a group of psychiatric
disorders whose main feature is a peculiar and
characteristic state of altered mood or feeling.
Such an altered mood state may be in the form of
extreme happiness (manic disorder) or unusual
sadness (depressive disorder). The dividing line
between what may be regarded as abnormal mood
state, and therefore an illness, is often difcult to
draw. This difculty often gives rise to delayed
or inappropriate diagnoses being made with
subsequent inappropriate medication being offered
to those in distress. An abnormal and distressing
mood state has the following additional features:
is persistent and is experienced by the individual
or family or other relatives as distressing and
requiring professional help, and leads to helpseeking behaviour.
Summary of ndings on depression in

developing countries4
Depression, estimated to be the leading cause of
disability worldwide, accounts for more than 1
in 10 years of life lived with disability, as well as
for signicant premature mortality due to suicide
and physical illness. By 2020, unipolar major
depression will rank second only to ischemic heart
Primary mood disorders

Bipolar Mood Disorder: mania alternating with
major depressive episodes or manic episodes
alone.
4.
Source: N. Sartorius, W. Gulbinat, G. Harrison, E Laska and C. Siegel. Long-term follow-up of schizophrenia in 16 countries.
A description of the international study of schizophrenia conducted by the World Health Organisation. Social Psychiatry and
psychiatric Epidemiology, 31: 249-258 1966.
190
Mood Disorders
system, such as thyroid abnormalities,

Cushings syndrome or Addisons disease can
lead to mood disturbances. A number of drugs,
used to treat medical conditions, such as antihypertensives or steroids may also cause mood
disturbances.
Substance induced mood disorder: mood
disorders may coexist with substance use
disorder. The use of substance in the rst
instance could lead to a mood disorder.
Alternatively, having a mood disorder can
lead to substance use.
Major Depression Disorder: characterised by

one or more depressive episodes.
Dysthymic Disorder: symptoms are similar to
those of major depression, but are less severe.
Cyclothymic Disorder: symptoms are similar
to those of bipolar I disorder, but are less
severe.
Secondary mood disorders

Mood disorder due to a medical condition:
systemic diseases and disorders of the endocrine
Table 33.1
A CLINICAL OVERVIEW OF MOOD DISORDERS
1.
2.
3.
4.
5.
6.
7.
8.
9.
(A) Different types of Mood Disorders

Major Depressive Disorder is characterised by:
One or more Major Depressive Episodes, (at least 2 weeks of depressed mood or loss of
interest plus at least four additional symptoms of depression).
Dysthymic Disorder is characterised by:
At least 2 years of depressed mood for more days than not, plus
Additional depressive symptoms that do not meet criteria for a Major Depressive Episode.
Depressive Disorder Not Otherwise Specied
Depressive features that do not meet criteria for any of the other specied depressive disorders
(described in the text) including Adjustment Disorder With Anxiety and Depressed Mood (or
depressive symptoms about which there is inadequate or contradictory information).
Bipolar I Disorder is characterised by:
One or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes.
Bipolar II Disorder is characterised by
One or more Major Depressive Episodes accompanied by at least one Hypomanic Episode.
Cyclothymic Disorder is characterised by
At least 2 years of numerous period of hypomanic symptoms that do not meet criteria for a Manic
Episode and numerous periods of depressive symptoms that do not meet criteria for a Major
Depressive Episode.
Bipolar Disorder Not Otherwise Specied
Disorders with bipolar features that do not meet criteria for any of the specic Bipolar Disorders
dened in this section (or bipolar symptoms about which there is inadequate or contradictory
information).
Mood Disorder Due to a General Medical Condition
Prominent and persistent disturbance in mood that is judged to be a direct physiological consequence
of a general medical condition.
Substance-Induced Mood Disorder is characterised by
Prominent and persistent disturbance in mood that is judged to be a direct physiological consequence
of a drug of abuse, a medication, another somatic treatment for depression, or toxin exposure.
10. Mood Disorder Not Otherwise Specied
Disorders with mood symptoms that do not meet the criteria for any specic Mood Disorder and in
which it is difcult to choose between Depressive Disorder Not Otherwise Specied and Bipolar
Disorder Not Otherwise Specied (e.g., acute agitation).
191
B. Further Clinical Overview

1. Mood Episodes
Major Depressive Episode
Manic Episode
Mixed Episode
Hypomanic Episode
2. Depressive Disorders
Major Depressive Disorder
Dysthymic Disorder
Depressive Disorder Not Otherwise Specied
3. Bipolar Disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Bipolar Disorder Not Otherwise Specied
4. Other Mood Disorders
Mood Disorder Due to ... [Indicate the General Medical Condition]
Substance-Induced Mood Disorder
Mood Disorder Not Otherwise Specied
C. Speciers to describe current or most recent Mood Episode
1. These are for the following purposes
Increase diagnostic specicity,
Create more homogeneous subgroups,
Assist in treatment selection and
Improve the prediction of prognosis.
2. Speciers describing the most recent mood episode
Mild, Moderate, Severe Without Psychotic Features,
Severe With Psychotic Features,
In Partial Remission,
In Full Remission (for Major Depressive Episode, for Manic Episode, for Mixed Episode,
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
3. Speciers describing course of recurrent episodes
Longitudinal Course Speciers (With or Without Full Inter-episode Recovery)
With Seasonal Pattern
With Rapid Cycling
Adopted and Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (Copyright 2000). American Psychiatric Association.
192
Mood Disorders
CLINICAL DEPRESSION
Table 33.2: 1CD-10 Criteria for depressive episode
General
Key symptoms (n=3)
Ancillary symptoms
Episode must have lasted at least two weeks with symptoms nearly every day
Change from normal functioning
Depressed mood
Anhedonia
Fatigue/loss of energy
Weight and appetite change
Sleep disturbance
Subjective or objective agitation/retardation
Low self esteem/condence
Self reproach/guilt
Impaired thinking/concentration
Suicidal thoughts
Criteria
Mild episode: 2 key, 4 symptoms in total Moderate episode: 2 key, 6 symptoms

in total Severe episode: 3 key, 8 symptoms in total
Exclusions
No history ever of manic symptoms Not substance related Not organic
A description of the International study of schizophrenia conducted by the World Health Organisation. Social Psychiatry and
feelings of sadness and lack of interest in previously

enjoyable activities.
Clinical presentation
Major Depression (Unipolar Disorder) is a mood
disorder characterised by profound and sustained
Table 33.3

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent
a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss
of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood incongruent
delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and
adolescents, can be irritable mood
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
everyday as indicated by either subjective account or observation made by others.
(3) signicant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider
failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every
day (not merely self-reproach or guilt about being sick)
193
(8)
B.
C.
D.
E.
diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specic
plan, or a suicide attempt or a specic plan for committing suicide
The symptoms do not meet criteria for a Mixed Episode.
The symptoms cause clinically signicant distress or impairment in social, occupational, or other
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are characterised by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Table 33.4
296.2x Major Depressive Disorder, Single Episode
A. Presence of a single Major Depressive Episode.
B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not
superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specied.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion
does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment
induced or are due to the direct physiological effects of a general medical condition.
If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or
features:
Mild, Moderate, Severe Without Psychotic Features/ Severe With Psychotic Features
Chronic
If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of
the Major Depressive Disorder or features of the most recent episode:
In Partial Remission, In Full Remission
Chronic
Table 33.5
Criteria for Severity/Psychotic/Remission Speciers for current (or most recent) Major Depressive
Episode
Note: Code in fth digit. Can be applied to the most recent Major Depressive Episode Major Depressive
Disorder and to a Major Depressive Episode in Bipolar Disorder only if it is the most recent type of mood
episode.
.x1-Milod: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result
in only minor impairment in occupational .functioning or in usual social activities or relationships with
others.
194
Mood Disorders
.x2-Moderate: Symptoms or functional impairment between mild and severe

.x3Severe Without Psychotic Features: Several symptoms in excess of those required to make the
diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities
or relationships with others.
.x4Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the
psychotic features are mood-congruent or mood-incongruent:
Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely
consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism,
or deserved punishment.
Mood-incongruent Psychotic Features: Delusions or hallucinations whose content does not
involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment. Included are such symptoms as persecutory delusions (not directly related to depressive
themes), thought insertion, thought broadcasting, and delusions of control.
.x5In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are
not met, or there is a period without any signicant symptoms of a Major Depressive Episode lasting less
than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was
superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given, once the full
criteria for a Major Depressive Episode are no longer met.)
.x6In Full Remission: During the past 2 months, no signicant signs or symptoms of the disturbance
were present.
.x0Unspecied.
Table 33.6
Criteria for Melancholic Features Specier
Specify if:
f
With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in
Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it
is the most recent type of mood episode)
A. Either of the following, occurring during the most severe period of the current episode:
(1) loss of pleasure in all, or almost all, activities
(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when
something good happens)
B. Three (or more) of the following:
(1)
distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different
from the kind of feeling experienced after the death of a loved one)
(2)
depression regularly worse in the morning
(3)
early morning awakening (at least 2 hours before usual time of awakening)
(4)
marked psychomotor retardation or agitation
(5)
signicant anorexia or weight loss
(6)
excessive or inappropriate guilt
195
Table 33.7
Criteria for Atypical Features Specier
Specify if:
With Atypical Features (can be applied when these features predominate during the most recent 2 weeks
of a Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when
the Major Depressive Episode is the most recent type of mood episode, or when these features predominate
during the most recent 2 years of Dysthymic Disorder)
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)
B. Two (or more) of the following features:
(1) signicant weight gain or increase in appetite
(2) hypersomnia
(3) leaden paralysis (i.e., heavy, leaden feelings in arms or lees)
(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood
disturbance) that results in signicant social or occupational impairment
C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.
Table 33.8
296.3x Major Depressive Disorder, Recurrent
A. Presence of two or more Major Depressive Episodes
B. Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in
which criteria are not met for a Major Depressive Episode.
C. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not
D. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion
does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatmentinduced or are due to the direct physiological effects of a general medical condition.
features:
Mild, Moderate, Severe Without Psychotic Features/
Severe With Psychotic Features
Chronic
the Major Depressive Disorder or features of the most recent episode:
Chronic
Specify:
Longitudinal Course Speciers (With and Without
Interepisode Recovery)
With Seasonal Pattern
196
Mood Disorders
Table 33.9
Criteria for Longitudinal Course Speciers, with or without interepisode recovery
Specify if (can be applied to Recurrent Major Depressive Disorder or Bipolar I or II Disorder):
With Full Interepisode Recovery: if full remission is attained between the two most recent Mood
Episodes
Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood
Episodes
Table 33.10
Criteria for Seasonal Pattern Specier
Specify if:
With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I Disorder,
Bipolar II Disorder, or Major Depressive Disorder, Recurrent)
A. There has been a regular temporal relationship between the onset of Major Depressive Episodes in
Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of
the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter).
Note: Do not include cases in which there is an obvious effect of seasonal-related psychosocial
stressors (e.g., regularly being unemployed every winter).
B. Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic
time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal
seasonal relationships dened in Criteria A and B, and no non seasonal Major Depressive Episodes
have occurred during that same period.
D. Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal
Major Depressive Episodes that may have occurred over the individuals lifetime.
Table 33.11
Criteria for Chronic Specier
Specify if:
Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive
Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of
mood episode)
Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.
197
Table 33.12
300.4 Dysthymic Disorder
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or
observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and
duration must be at least one year.
B. Presence, while depressed, of two (or more) of the following:
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difculty making decisions
feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been
without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode has been present during the rst 2 years of the disturbance (1 year for
children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive
Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission
(no signicant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In
addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be
superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when
the criteria are met for a Major Depressive Episode.
E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have
never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as
Schizophrenia or Delusional Disorder.
G. The symptoms are not due to the direct physiological effects of substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
Specify if:
Early Onset: if onset is before age 21 years
Late Onset: if onset is at age 21 years or older
Specify (for most recent 2 years of Dysthymic Disorder):
Table 33.13
311 Depressive Disorder Not Otherwise Specied
The Depressive Disorder Not Otherwise Specied category includes disorders with depressive features that
do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With
Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood. Sometimes depressive
symptoms can present as part of an Anxiety Disorder Not Otherwise Specied. Examples of Depressive
Disorder Not Otherwise Specied include:
1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g.,
markedly depressed mood, marked anxiety, marked affective lability, decreased interest in activities)
regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset
of menses). These symptoms must be severe enough to markedly interfere with work, school, or usual
activities and be entirely absent for at least one week postmenses.
2. Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than
the ve items required for Major Depressive Disorder.
198
Mood Disorders
3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring
at least once a month for 12 months (not associated with the menstrual cycle).
4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs during
the residual phase of Schizophrenia
5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise
Specied, or the active phase of Schizophrenia.
6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to
determine whether it is primary, due to a general medical condition, or substance induced.
as bereavement, interpersonal problems and

poor examination results may be reported in a
proportion of cases. The aetiology of primary
mood disorders is considered to be multi-factorial.
Aetiological factors include genetic, biochemical,
psychological, social and personality factors.
Many African patients do not volunteer feelings

of sadness, loneliness or guilt. Instead they have
physical complaints such as headaches, muscle and
joint pains, as well as generalised malaise. This
leads to many laboratory investigations and selfreferral to various health workers, as well as diverse
treatments without amelioration of symptoms.
The clinical condition can be recognised by
direct enquiry about the depressed mood (whether
or not it is referred to as the physical pains), lack of
pleasure, negative anticipation of the future, lack
of energy, sleep disturbance, lack of appetite and
lowered libido. Ideas of suicide and suicide attempt
are commonly experienced. Psychotic features
may be present. The hallucinations or delusions,
however, are congruent with the depressed mood,
self-deprecation and negative anticipation of the
future. Patients often believe they are suffering
from a serious and incurable physical condition.
Genetic factors
Clinical observations and family and genetic studies
indicate that affective disorders run in families.
Twin follow-up studies indicate that the chances
for an identical twin developing bipolar affective
disorder is 40 percent if the other twin is already
sick with the illness. Among dizygotic twins this
concordance rate is 11 percent.
Biochemical factors
It is now widely understood that mood disorders
are associated with abnormal brain biochemistry
involving various neuro-transmitters including
noradrenaline and serotonin (5-hydroxytryptamine). It has also been suggested that abnormal
functioning of certain hormone systems, particularly
involving cortisol and thyroid hormones, may be
responsible for episodes of major depression.
Epidemiology
It is estimated that depression affects 3 percent
of men and 4-9 percent of women. The lifetime
prevalence for depression is 8-12 percent for men
and 20-26 percent for women. About 12-20 percent
of individuals who experience an acute episode
of depression will develop a chronic depressive
syndrome mainly due to inappropriate diagnoses
and wrong drug management; and 15 percent of
persons who suffer from depression will eventually
die of suicide. This makes depression the leading
cause of deaths in psychiatric practice.
The lifetime risk of developing a manic disorder
is 1-2 percent. Manic illness occurs in relatives of
patients with the disorder much more frequently
than in relatives of patients with depression.
Psychosocial factors
Various
environmental
factors
and
psychosocial stressors may precipitate a mood
disorder. Examples include recent bereavement,
job loss, failed relationships, business failure and
failure in a major school examination.
Personality factors
Clinical experience suggests that those who develop
major depressive disorder tend to be either anxious,
fearful or insecure in their feelings or rigid, strict,
meticulous, orderly and uncompromising in their
interpersonal relationships.
Aetiology
Primary mood disorders usually arise without
any obvious causes. Stressful events such
199
BIPOLAR DISORDER
The distinctive features of a manic episode and hypomanic episode are summarised in Tables to 33.14
- 33.18.
Table 33.14
Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least
one week (or any duration if hospitalisation is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four
if the mood is only irritable) and have been present to a signicant degree:
(1) inated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) ight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation.
(7) excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a Mixed Episode.
D. The mood disturbance is sufciently severe to cause marked impairment in occupational functioning or
in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to
self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication,
electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
Table 33.15
Criteria for Severity/Psychotic/Remission Speciers for current (or most recent) Manic Episode
Note: Code in fth digit. Can be applied to a Manic Episode in Bipolar I Disorder only if it is the most recent
type of mood episode.
.x1-Mild: Minimum symptom criteria are met for a Manic Episode.
.x2-Moderate: Extreme increase in activity or impairment in judgment.
.x3-Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to
self or others.
.x4-severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic
features are mood-congruent or mood-incongruent:
Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely
consistent with the typical manic themes of inated worth, power, knowledge, identity, or special
relationship to a deity or famous person.
Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve
typical manic themes of inated worth, power, knowledge, identity, or special relationship to a deity or
famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose
ideas or themes), thought insertion, and delusions of being controlled.
200
Mood Disorders
x5In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there
is a period without any signicant symptoms of a Manic Episode lasting less than 2 months following the
end of the Manic Episode.
x6In Full Remission: During the past 2 months no signicant signs or symptoms of the disturbance
were present.
x0Unspecied.
Table 33.16
Mixed Episode
A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration)
nearly every day during at least a 1-week period.
B. The mood disturbance is sufciently severe to cause marked impairment in occupational functioning or
in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to
self or others, or there are psychotic features.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication,
electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
Table 33.17
Hypomanic Episode
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days,
that is clearly different from the usual non-depressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four
if the mood is only irritable) and have been present to a signicant degree
1. inated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. ight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation.
7. excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business
investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person
when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to
necessitate hospitalization, and there are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g.,
medication, electro-convulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II
Disorder.
201
This condition is characterised by recurrent

episodes of mania, which may or may not alternate
with episodes of major depression. The clinical
manifestations of bipolar disorder vary according
to the level of severity. The main feature of
mania in bipolar disorder is extreme happiness.
Associated with this are increased sociability,
prominent ideas of well-being, inated self-image,
and reduced need for sleep. Appetite is usually
not lost, but the individual has no time to sit down
and eat. As a result, the individual may become
severely dehydrated and under-nourished. Sexual
activity is usually increased and rape tendencies
are common. Individuals are active, energetic, and
talkative. They are impulsive, and irritable and
cannot tolerate the reluctance of other people to
understand and participate in their numerous plans,
which are often impractical. Affected persons may
be combative. Concentration and attention span

may be diminished with impaired consciousness
resulting in poor short-term memory. However, in
less severe states manic disorder may be associated
with a sharp sensor acuity resulting in the person
noticing minute details in the texture and colour of
objects, as well as errors in ones language.
The psychotic features of manic disorder include
visual and auditory hallucinations and delusions of
grandeur or persecution. Commonly, the complaint
and delusion themes are the usual controversial
topical social issues of the day. Whatever the
combination of symptoms, manic illness is very
easy to recognise.
Hypomania is a less severe form of the disorder
and does not disrupt the normal life patterns of the
individual markedly.
Bipolar I Disorders, Bipolar II Disorders

and Cyclothymic Disorders
Table 33.18
ICD-10 Criteria for Diagnosis of Bipolar Disorder
F.30 Manic Episode
Three degrees of severity are specied here, sharing the common underlying characteristics of elevated
mood, and an increase in the quantity and speed of physical and mental activity. All the subdivisions of
this category should be used only for a single manic episode. If previous or subsequent affective episodes
(depressive, manic, or hypomanic), the disorder should be coded under bipolar affective disorder.
F.32 Depressive Episode
In typical depressive episodes of all three varieties described below (mild, moderate, and severe), the
individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading
to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common, Other
common symptoms are:
(a) reduced concentration and attention;
(b) reduced self-esteem and self-condence;
(c) ideas of guilt and unworthiness (even in a mild type of episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite
The lowered mood varies, little from day to day, and is often unresponsive to circumstances, may show
a characteristic diurnal variation as the day goes on. As with manic episodes, the clinical presentation
shows marked individual variations, and atypical presentations are particularly common in adolescence.
In some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression,
and the mood change may also be masked by added features such as irritability, excessive consumption
of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional symptoms, or by
hypochondriacal preoccupations. For depressive episodes of all three grades of severity, a duration of at
least 2 weeks is usually required for diagnosis, but shorter periods may be reasonable if symptoms are
unusually severe and of rapid onset.
Source: World Health Organisation. The ICD-10 classication of Mental and Behavioural Disorders. Clinical description
and diagnostic guidelines. World Health Organization, Geneva, 1992.
202
Mood Disorders
There is no known course of primary prevention

for bipolar disorder. Risk factors and the physical
and psychological symptoms of the disorder can
be reduced and controlled but not eliminated
following diagnosis. Treatment for bipolar disorder
often requires a combination of medications,
few of which have been tested in developing
countries. Acute episodes of mania are best treated
with antipsychotic medications or high doses of
mood stabilisers; acute episodes of depression
can be treated with antidepressant medication
and electroconvulsive treatment. Once acute
symptoms are under control, active treatment with
mood stabilizers, possibly including psychosocial
interventions, must be undertaken to prevent the
illness from becoming increasingly severe.
Summary of Findings: Bipolar Disorder in

Developing Countries5
Bipolar disorders account for about 11 percent of
the neuropsychiatric disease burden and about 1
percent of the total disease burden in developing
countries. Between 25 and 50 percent of patients
in developed countries with bipolar disorder are
estimated to attempt suicide, and as many as 15
percent complete the act.
Predisposition to bipolar disorder may be
inherited; other apparent risk of precipitating
factors include substance abuse, living in an urban
setting, and lack of education. The signicant
impact of social and environmental factors on
the presentation, course, and incidence of bipolar
disorder argues for increased research in developing
countries.
Table 33.19
296.0x Bipolar I Disorder, Single Manic Episode

A. Presence of only one Manic Episode and no past Major Depressive Episodes.
Note: Recurrence is dened as either a change in polarity from depression or an interval of at least 2 months
without manic symptoms.
B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise
Specied.
Specify if:
Mixed: if symptoms meet criteria for a Mixed Episode
If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episode, specify its current
clinical status and/or features:
Mild, Moderate. Severe Without Psychotic Features/ Severe
With Psychotic Features
If the full criteria are not currently met for a Manic Mixed, or Major Depressive Episode, specify the current
clinical status of the Bipolar I Disorder or features of the most recent episode:
Tables 33.19 to 33.26 summarise the various types

of Bipolar I Disorders. Table 33.27 summarises
the distinctive features of Bipolar II Disorder and
Table 33.29 summarises the clinical features of
Cyclothymic disorder.
There are six separate criteria sets for Bipolar
I Disorder: Single Manic Episode, Most Recent
Episode Hypomanic, Most Recent Episode Manic,
5
Most Recent Episode Mixed, Most Recent Episode

Depressed and Most Recent Episode Unspecied.
Bipolar I Disorder and Single Manic Episode, is
used to describe individuals who are having a rst
episode of mania. The remaining criteria sets are used
to specify the nature of the current (or most recent)
episode in individuals who have had recurrent mood
episodes.
.Source: N. Sartorius, W. Gulbinat, G. Harrison, E Laska and C. Siegel. Long-term follow-up of schizophrenia in 16 countries.
203
Table 33.20
296.40 Bipolar I Disorder
Most Recent Episode Hypomanic
A. Currently (or most recently) in a Hypomanic Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically signicant distress or impairment in social, occupational, or other
D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and
are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic
Disorder Not Otherwise Specied.
Specify:
Longitudinal Course Speciers (With and Without
Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Table 33.21
Criteria for Rapid-Cycling Specier
Specify if:
With Rapid Cycling (can be applied to Bipolar I Disorder or Bipolar II Disorder).
At least four episodes of a mood disturbance in the previous 12 months that meet criteria for a Major
Depressive, Manic, Mixed, or Hypomanic Episode.
Note: Episodes are demarcated either by partial or full remission for at least 2 months or a switch to an
episode of opposite polarity (e.g., Major Depressive Episode to Manic Episode).
Table 33.22
296.4x Bipolar I Disorder, Most Recent Episode Manic
A. Currently (or most recently) in a Manic Episode.
B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and
If the full criteria are currently met for a Manic Episode, specify its current clinical status and/or features:
Mild, Moderate, Severe Without Psychotic Features
If the full criteria are not currently met for a Manic Episode, specify the current clinical status of the Bipolar
I Disorder and/or features of the most recent Manic Episode:
204
Mood Disorders
Specify:
Longitudinal Course Speciers (With and Without Interepisode Recovery)
With Rapid Cycling
Table 33.23
296.6x Bipolar I Disorder, Most Recent Episode Mixed
A. Currently (or most recently) in a Mixed Episode.
B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and
If the full criteria are currently met for a Mixed Episode, specify its current clinical status and/or features:
If the full criteria are not currently met for a Mixed Episode, specify the current clinical status of the Bipolar
I Disorder and/or features of the most recent Mixed Episode:
Specify:
With Rapid Cycling
Table 33.24
296.5x Bipolar I Disorder,
Most Recent Episode Depressed
A. Currently (or most recently) in a Major Depressive Episode.
B. There has previously been at least one Manic Episode, or Mixed Episode. The mood episodes in
Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise
Specied.
features:
Chronic
the Bipolar I Disorder and/or features of the most recent Major Depressive Episode:
205

Chronic
Specify:
Longitudinal Course Speciers (With and Without Interepisode Recovery) With Seasonal Pattern (applies
only to the pattern of Major Depressive Episodes)With Rapid Cycling
Table 33.25
Criteria for Postpartum Onset Specier
Specify if:
With Postpartum Onset (can be applied to the current or most recent Major Depressive, Manic, or Mixed
Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder; or to Brief Psychotic
Disorder)
Onset of episode within 4 weeks postpartum
Table 33.26
296.7 Bipolar I Disorder, Most Recent Episode Unspecied
A. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or
a Major Depressive Episode
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically signicant distress or impairment in social, occupational, or other
D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and
The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Specify:
With Rapid Cycling
Table 33.27
296.89 Bipolar II Disorder (Recurrent Major Depressive Episodes With Hypomanic Episodes)
A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode.
C. There has never been a Manic Episode (see p. 169) or a Mixed Episode.
D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and
206
Mood Disorders
E. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
Specify current or most recent episode:
Hypomanic: if currently (or most recently) in a hypomanic Episode.
Depressed: if currently (or most recently) in a Major Depressive Episode.
features:
Mild, Moderate, Severe Without Psychotic Features/ Severe With Psychotic Features Chronic
If the full criteria are not currently met for a Hypomanic or Major Depressive Episode, specify the clinical
status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is
the most recent type of mood episode):
Chronic
Specify:
With Rapid Cycling
Table 33.28
296.80 Bipolar Disorder Not Otherwise Specied
The Bipolar Disorder Not Otherwise Specied category includes disorders with bipolar features that do not
meet criteria for any specic Bipolar Disorder. Examples include
1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet
symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive
Episodes
2. Recurrent Hypomanic Episodes without intercurrent depressive symptoms
3. A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic
Disorder Not Otherwise Specied
4. Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a
diagnosis of Cyclothymic Disorder
5. Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to
207
Table 33.29
301.13 Cyclothymic Disorder
A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods
with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In children and
adolescents, the duration must be at least 1 year.
B. During the above 2-year period (1 year in children and adolescents), the person has not been without the
symptoms in Criterion A for more than 2 months at a time.
C. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the rst 2 years
of the disturbance.
Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may
be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic
Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and
Cyclothymic Disorder may be diagnosed).
D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
mood disorder and mood disorder not otherwise

specied. They are summarised in Tables 33.30 to
33.32.
OTHER MOOD DISORDERS

Included here are mood disorders secondary to
a general medical condition, substance-induced
Table 33.30
293.83 Mood Disorder Due to ... [Indicate the General Medical Condition]
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized
by either (or both) of the following:
1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
2. elevated, expansive, or irritable mood
B. There is evidence from the history, physical examination, or laboratory ndings that the disturbance is
the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (e.g. Adjustment Disorder With
Depressed Mood in response to the stress of having a general medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
Specify type:
With Depressive Features: if the predominant mood is depressed but the full criteria are not met for a
With Major Depressive-Like Episode: if the full criteria are met (except Criterion D) for a Major
Depressive Episode.
With Manic Features: if the predominant mood is elevated, euphoric, or irritable
With Mixed Features: if the symptoms of both mania and depression are present but neither
predominates
208
Mood Disorders
Coding note: Include the name of the general medical condition on Axis I, e.g., Mood Disorder Due to
Hypothyroidism. With Depressive Features; also code the general medical condition on Axis III).
Coding note: If depressive symptoms occur as part of a pre-existing Vascular Dementia, indicate the
depressive symptoms by coding the appropriate subtype, i.e., Vascular Dementia, With Depressed Mood.
Table 33.31
Substance-Induced Mood Disorder
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterised
by either (or both) of the following:
1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
2. elevated, expansive, or irritable mood
B. There is evidence from the history, physical examination, or laboratory ndings of either (1) or (2):
1. the symptoms in Criterion A developed during, or within a month of Substance Intoxication or
Withdrawal
2. medication use is aetiologically related to the disturbance
C. The disturbance is not better accounted for by a Mood Disorder that is not substance induced. Evidence
that the symptoms are better accounted for by a Mood Disorder that is not substance induced might
include the following: the symptoms precede the onset of the substance use (or medication use);
the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of
acute withdrawal or severe intoxication or are substantially in excess of what would be expected given
the type or amount of the substance used or the duration of use; or there is other evidence that suggests
the existence of an independent non-substance-induced Mood Disorder (e.g., a history of recurrent
Major Depressive Episodes).
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance
Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication
or withdrawal syndrome and when the symptoms are sufciently severe to warrant independent clinical
attention.
Specic Substance
Coding note: For other somatic treatments (e.g., electroconvulsive therapy), the code for Other Substance
should be used.
Specify type:
With Depressive Features: if the predominant mood is depressed
With Manic Features: if the predominant mood is elevated, euphoric, or irritable
With Mixed Features: if symptoms of both mania and depression are present and neither predominates
Specify if
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the
symptoms develop during the intoxication syndrome
With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms
develop during, or shortly after, a withdrawal syndrome
209
Table 33.32
296.90 Mood Disorder Not Otherwise Specied
This category includes disorders with mood symptoms that do not meet the criteria for any specic Mood
Disorder and in which it is difcult to choose between Depressive Disorder Not Otherwise Specied and
Bipolar Disorder Not Otherwise Specied (e.g., acute agitation).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American
Psychiatric Association.
Table 33.33
DSM-IV-TR Research Criteria for Mixed Anxiety-Depressive Disorder
A. Persistent or recurrent dysphoric mood lasting at least 1month.
B. The dysphoric mood is accompanied by at least 1 month of four (or more) of the following symptoms:
(1) difculty concentrating or mind going blank
(2) sleep disturbance (difculty falling or staying asleep, or restless, unsatisfying sleep)
(3) fatigue or low energy
(4) irritability
{5) worry
(6) being easily moved to tears
(7) hypervigilance
(8) anticipating the worst
(9) hopelessness (pervasive pessimism about the future)
(10) low self-esteem or feelings of worthlessness
C. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition.
E. All of the following:
(1) criteria have never been met for major depressive disorder, dysthymic disorder, panic disorder, or
generalized anxiety disorder
(2) criteria are not currently met for any other anxiety or mood disorder (including an anxiety or mood
disorder, in partial remission)
(3) the symptoms are not better accounted for by any other mental disorder
Management
The differential diagnoses of mood disorders

include all organic conditions e.g. HIV/AIDS
which cause manic-like syndromes or depressive
syndromes. A consideration of schizophrenia
should be borne in mind, particularly if third
person auditory hallucinations are present, as are
other symptoms such as passivity phenomena and
thought disorder.
Management of depression
The approach to management is a biopsychosocial
one. Optimal benets are achieved from a
combined approach. The use of antidepressants
and psychotherapy, achieves better and more
sustained benets than either alone. It is important
that a denitive diagnosis of a probable depressive
210
Mood Disorders
disorder is correctly made and an effective drug

therapy begun early, to prevent the development
of chronic states of the disorder, reduce personal
distress and prevent suicidal behaviour. This will
require careful patient history taking, together with
a high index of suspicion that one may be dealing
with a problem of a depressive disorder. Clinically,
the possibility of secondary mood disorders must be
considered. In addition, the role of environmental
and psychosocial factors must be assessed. Whilst
most individuals can be managed as outpatients,
some may require hospitalisation, e.g. those who
are suicidal, psychotic, or those unable to eat, drink
or care for themselves.
Should a relapse occur, treatment may need to be

continued for at least 2 years.
Psychological management
Initially, patients with depression need to be
supported and given psycho-education about their
illness. This includes explaining their symptoms,
drugs to be used and the possibility of side effects.
Later on psychological therapy aims at improving
social functioning, focusing on the depressed
persons interpersonal functioning and correcting
cognitive distortions.
Cognitive therapy focuses on the distorted
thinking of depressed patients (negative thoughts,
negative interpretations of past and present
experiences or events, as well as pessimism).
This may include assignments where the patient
is assisted to examine and critically test out
erroneous assumptions, which are derived from
the depressive experience (preparing a log of
daily tasks and outcomes in order to critically
assess the construct I fail in everything I do). It
is important to involve the spouse and family and
to provide education of persons concerned in care
regarding the illness, emotional support, as well
as consideration of interpersonal issues with the
consent of the patient.
Biological Treatment
The range and classication of antidepressants are
discussed in the chapter on Biological Therapies.
Whilst no single class is more effective than
the other, the choice of antidepressant will be
determined by cost, availability, side effect prole,
history of previous response and the presence of
other medical conditions and treatments which
the patient may be having. Toxicity and suicide
overdose must be borne in mind especially in regard
to tricyclic antidepressants. It should be noted that
initial response to treatment may take 14-21 days at
an optimal dose. However in African patients, the
doses used are often less than that recommended by
manufacturers. The reasons for this are discussed in
the chapter on Ethno-Psychopharmacology. In the
African setting, and depending on the ethnic group,
it is advisable to start with much lower doses and
build up the doses, based on clinical response and
side effects. It is also advisable to keep abreast with
independent evaluation of drugs, particularly with
newer molecules, on emerging unwanted effects.
Social management
Socially, explanations should be made to caretakers
or signicant other persons in the lives of the
individual concerned about the nature of illness,
treatment modality, its course and prognosis, and
what to expect and do, to gain the co-operation of
the person. Relatives should be informed about the
danger of suicide in depressive illness and should
be requested to take open expressions or subtle
indications of suicide behaviour in the patient
seriously, and take measures to prevent suicide
occurrence by active surveillance and by ensuring
prompt treatment for the patient.
In Africa, mental illness is often explained on
the basis of home problems, witchcraft, or the
works of wicked people. To win the co-operation
of patients and their relatives, and to promote
optimal compliance, tactful permission may need
to be granted to individuals concerned to consult
with their traditional healers or elders at home.
The optimal time to grant such permission is when
clinical improvement has been noted by the hospital.
To achieve this, one may have to request for 10
to 15 days of further treatment before granting
Other physical treatments

These include electroconvulsive therapy (ECT),
sleep deprivation and light therapy. ECT is indicated
in cases of poor response to antidepressants or
in severe depression when the patient may be
in a stupor and rapid response is desired. Sleep
deprivation does improve depression, but the
effects are not long lasting. Light therapy is said to
be effective in cases of seasonal affective disorders
(SADs). It essentially involves periodic exposure to
strong light. It is difcult to ascertain the duration
of treatment for individual patients with depression.
The recommended practice is to continue treatment
for 6-8 months before discontinuing medication.
211
the request. Such permission should indicate the

compatibility of traditional and modern systems
of treatment, with each form complementing the
other. Explicit reassurance should indicate that the
patient should feel free to report back to the clinic
when the need arises. The reality of this problem
is that whether one accepts it or not the average
patient, either on his or her own volition, or under
pressure from relatives and family, will want to
consult with traditional healers. To allow patients
and their relatives to consult with traditional
healers may therefore serve to maximise ones
clinical effectiveness. Where the psychiatrist might
fail, the traditional healer might succeed through
the use of psychodrama.
Management of Bipolar Disorder (Mania)

The mainstay of the management of bipolar
disorders are the mood stabilisers. These are
used in combination with the neuroleptics or
antidepressants depending on the clinical phase.
Mood stabilisers include lithium carbonate,
valproate, carbamazepine, lamotrigine, gabapentin
and topiramate. Neuroleptics such as haloperidol
or risperidone are added in manic states or to
control psychotic symptoms. Benzodiazepines
may be added to control agitation and insomnia.
The period of maintenance therapy is usually 1
to 2 years. Patients often need counselling to help
them accept this. The use of antidepressants alone
during the depressive phases of bipolar disorder is
not recommended due to the risks of precipitating
a manic episode.
Table 33.34: Critical Challenges in the Stages of Pharmacological and Psycho Social Treatment Bipolar Disorder
Stage
Goals of Treatment
Issues for Patient/Family
Acute
Gain control over severe symptoms
Trauma and shock, dealing with police and/

or hospitalisation (in some cases), making
sense of what has happened
Stabilisation
Hasten recovery from the acute episode,

address residual symptoms/impairment,
encourage medication compliance
Adapting to post-episode symptoms and

social-occupational decits, nancial stress,
accepting a regular medication regime,
uncomfortable discussions about medication
and illness, denial about the realities of the
disorder
Maintenance
Prevent recurrences, alleviate residual

affective symptoms, continue to
encourage medication compliance
Fears about the future, accepting the illness

and the vulnerability to future episodes,
coping with ongoing decits in social-occupational functioning, issues surrounding
long-term medication adherence
Prior to initiating treatment with mood stabilisers

relevant laboratory investigations need to be
undertaken together with ongoing monitoring of
serum levels. Severe manic states not responding
to drug therapy is also an indication for ECT.
When there are more than two attacks of mania
then mood stabilisers can be considered. It is
recommended that an episode should be treated for
at least 18 months before discontinuing medication.
A relapse usually occurs within 6 to 24 months
after treatment is stopped. A proportion of cases
remit spontaneously within 6 to 8 months without
treatment.
Summary of the management of a patient

with mood disorder
Conrm the diagnosis and review the
symptoms to see if they meet the standard
criteria.
Rule out other medical conditions by
performing a physical examination.
Consider the common diseases occurring in
your area that may present as mood disorders.
Rule out infectious diseases such as malaria,
typhoid, HIV infections and metabolic
disturbances.
212
Mood Disorders
countries. Thus, amitriptyline is often used at

50 mg for severe depressive states.
In case of poor or non-response to treatment,
review diagnosis, consider alternative drugs
and treatment, including electroconvulsive
therapy. Consult a psychiatrist, where
available.
Mood disorders need to be treated for an
adequate duration to prevent relapse. Patient
education and counselling are therefore
crucial.
Consider the effect of substances such as

alcohol, khat (amphetamine-like substance)
and prescribed drugs that may cause mood
disturbances.
Decide on out-patient or in-patient
management depending on suicide risk in
depression, insight, social support, concurrent
medical conditions and need to investigate and
stabilise on drugs in acute phase of illness.
In bipolar disorders the mainstay of
drug treatment are the mood stabilisers.
Antipsychotics such as haloperidol and
risperidone are used to augment the mood
stabilisers in the acute stages.
All the antidepressants are equally effective.
Therefore, the choice is based on the
availability, cost and the side-effects prole.
Currently the SSRI are the drugs of choice,
because of their safety prole. The tricyclic
antidepressants are usually effective at lower
doses than those recommended in the western
Further reading
1. Concise Textbook of Clinical Psychiatry 2nd Edition:
Derived from Kaplan & Sadocks Synopsis of
Psychiatry, 9th Edition. (2004). Editors: Benjamin J.
Williams & Wilkins
2. Diagnostic and Statistical Manual Disorders 4th
Edition 2000: DSM-IV-TRTM Published by American
213
34
Anxiety and Adjustment Disorders
Gad Kilonzo, Seggane Musisi, Mohamedi Boy Sebit,
David M. Ndetei, Christopher P. Szabo
breathing, nausea, dry mouth, diarrhoea and

frequent urination.
3. Behavioural responses: avoidance of certain
situations and impaired task performance.
Anxiety disorders may be classied as follows:
Generalised anxiety disorder (GAD)
Panic disorder
Phobic disorders agoraphobia, specic
phobias and social phobia
Obsessive compulsive disorder (OCD)
Post-traumatic stress disorder (PTSD)
Secondary to general medical condition/
substances
INTRODUCTION
Anxiety is a state of tension and apprehension with
hyperactivity of the autonomic nervous system as
a natural response to perceived threat. In anxiety
disorders the frequency and intensity of anxiety
responses are out of proportion when compared to
situations that trigger them. Anxiety may interfere
with daily life.
Anxiety disorders have three components:
1. Cognitive component: subjective feelings of
apprehension, a sense of impending danger
and a feeling of inability to cope.
2. Physiological responses: increased heart
rate, blood pressure, muscle tension, rapid
Table 34.1
A CLINICAL OVERVIEW OF ANXIETY DISORDERS

1.
2.
3.
A Panic Attack
A discrete period in which there is the sudden onset of intense apprehension, fearfulness or terror,
often associated with feelings of impending doom.
During these attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort,
choking or smothering sensations, and fear of going crazy or losing control are present.
Agoraphobia
Anxiety about, or avoidance of, places or situations from which escape might be difcult (or
embarrassing) or in which help may not be available in the event of having a Panic Attack or paniclike symptoms.
Panic Disorder Without Agoraphobia
214
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Recurrent unexpected panic Attacks about which there is persistent concern.

Panic Disorder With Agoraphobia
Both recurrent unexpected Panic Attacks and Agoraphobia.
Agoraphobia Without History of Panic Disorder
Presence of Agoraphobia and panic-like symptoms without a history of unexpected Panic
Attacks.
Specic Phobia
Clinically signicant anxiety provoked by exposure to certain feared object or situation, often
leading to avoidance behavior.
Social Phobia
Clinically signicant anxiety provoked by exposure to certain types of social or performance
situations, often leading to avoidance behaviour.
Obsessive-Compulsive Disorder
Obsessions (which cause marked anxiety or distress) or compulsions (which serve to neutralize
anxiety).
Posttraumatic Stress Disorder
Re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal
and by avoidance of stimuli associated with the trauma.
Acute Stress Disorder
Symptoms similar to those of Posttraumatic Stress Disorder that occur immediately in the aftermath
of an extremely traumatic event.
Generalised Anxiety Disorder
At least 6 months of persistent and excessive anxiety and worry.
Anxiety Disorder Due to a General Medical Condition
Prominent symptoms of anxiety that are judged to be a direct physiological consequence of a
general medical condition.
Substance-Induced Anxiety Disorder
Prominent symptoms of anxiety that are judged to be a direct physiological consequence of a drug
of abuse, a medication, or toxin exposure.
Anxiety Disorder Not Otherwise Specied
Prominent anxiety or phobic avoidance that do not meet criteria for any of the specic Anxiety
Disorders dened above (or anxiety symptoms about which there is adequate or contradictory
information).
Typical worries include excessive worries about

work or social performance, exaggerated concern
about nances and the possibility of becoming ill
or having an accident.
GENERALISED ANXIETY
DISORDER (GAD)
Common Symptoms of GAD
Persistent, generalised and excessive feelings

of anxiety not attached to any particular specic
situations, but rather caused by a general tendency
to worry excessively. Anxiety may last for months
with the signs present almost continuously. There is
a sense of impending disaster, though not specic.
There may be signs of autonomic hyperarousal
such as excessive sweating, stomach upset or
diarrhoea.
Nervousness, restlessness, trembling, shortness of

breath, sweating, muscle tension, feeling jittery,
tense and constantly on edge, trouble falling or
staying asleep, poor concentration, irritable mood,
depressed mood, palpitations, frequent urination,
easily fatigued, light-headedness and difculty
in making decisions. Table 34.2 summarises the
DSM-IV-TR diagnostic criteria for GAD.
215
Table 34.2
300.02 Generalised Anxiety Disorder
(Includes Overanxious Disorder of Childhood)
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6
months, about a number of events or activities (such as work or school performance).
B. The person nds it difcult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least
some symptoms present for more days than not for the past 6 months). Note: Only one item is required
in children.
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difculty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difculty falling or staying asleep, or restless unsatisfying sleep)
D. The focus of the anxiety and worry is not conned to features of an Axis I disorder, e.g., the anxiety or
worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social
Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close
relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple
physical complaints (as in Somatisation Disorder), or having a serious illness (as in Hypochondriasis),
and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically signicant distress or impairment in social,
occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during
a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
DSM-IV diagnostic codes and cannot be diagnosed

as separate entities. Table 34.3 summarises the
distinctive features of a panic attack.
PANIC DISORDER
Panic attacks and agoraphobia occur in the context
of several disorders. They do not have their own
Table 34.3
Panic Attack
Note: A Panic Attack is not a codable disorder. Code the specic diagnosis in which the Panic Attack occurs
(e.g., 300.21 Panic Disorder With Agoraphobia)
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed
abruptly and reached a peak within 10 minutes:
(1) palpitations, pounding heart, or accelerated heart rate
(2) sweating
(3) trembling or shaking
(4) sensations of shortness of breath or smothering
(5) feeling of choking
(6) chest pain or discomfort
(7) nausea or abdominal distress
(8) feeling dizzy, unsteady, lightheaded, or faint
216
(9)
(10)
(11)
(12)
(13)
derealisation (feelings of unreality) or depersonalization (being detached from oneself)

fear of losing control or going crazy
fear of dying
paresthesias (numbness or tingling sensations)
chills or hot ushes
Symptoms of panic attacks can be terrifying and

distressing. They may last a few minutes, or longer.
In most cases, panic attacks occur in the absence of
any identiable stimulus. Attacks may be followed
by persistent concern about having another panic
attack. Their unpredictable quality makes them
mysterious and terrifying. Many people with panic
attacks develop agoraphobia (a fear of public
places) for fear of having an attack in public.
Panic disorder can be classied as being with
or without agoraphobia. Panic disorders with
or without agoraphobia tend to appear in late
adolescence or early adulthood (mid 20s). They
are more frequent in females.
tightness or pain in the chest, a choking sensation,

feeling of unreality, dry mouth, muscle tension,
tingling ngers or feet, difculty in gathering
thoughts or speaking, urge to ee, nausea, blurred
vision and feeling of having heart attack, losing
control or going mad.
AGORAPHOBIA
Agoraphobia is not a DSM-IV TR codable disorder
and cannot be diagnosed as a separate entity. It
is coded as Panic Disorder With Agoraphobia,
Agoraphobia Without History of Panic Disorder.
However the distinctive features of Agoraphobia
are summarised in Table 34.4.
Common symptoms of a panic attack

Trembling, shortness of breath, faintness, hot or
cold ushes, sweating, dizziness, pounding heart,
Table 34.4
Agoraphobia
A. Anxiety about being in places or situations from which escape might be difcult (or embarrassing) or in
which help may not be available in the event of having an unexpected or situationally predisposed Panic
Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations
that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and
travelling in a bus, train, or automobile.
Note: Consider the diagnosis of Specic Phobia if the avoidance is limited to one or only a few specic
situations, or Social Phobia if the avoidance is limited to social situations.
B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with
anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
C. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social
Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specic Phobia (e.g.,
avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of
dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance
of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving
home or relatives).
217
Agoraphobia may be a complication of panic

disorder. It usually leads to avoidance of a variety
of feared situations (being home alone and alone
away from home; travelling in buses, trains,
planes; crowded areas; elevators; and bridges).
Some individuals cope with feared situations with
difculty. They feel relieved when accompanied
by someone else.
It usually develops after the individual has

experienced a panic attack or panic-like symptoms.
Panic symptoms may or may not continue to occur
once this disorder has developed.
Tables 34.5 to 34.7 summarise the codable
disorders of agoraphobia.
Table 34.5
300.01 Panic Disorder Without Agoraphobia
A. Both (1)and (2):
Recurrent unexpected Panic Attacks
at least one of the attacks has been followed by 1 month (or more) of one (or more) of the
following:
- persistent concern about having additional attacks
- worry about the implications of the attack or its consequences (e.g., losing control, having a heart
attack, going crazy)
- a signicant change in behaviour related to the attacks
B. Absence of Agoraphobia.
C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g.,
occurring on exposure to feared social situations). Specic Phobia (e.g., on exposure to a specic phobic
situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession
about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe
stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).
Table 34.6
300.21 Panic Disorder With Agoraphobia
A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks.

(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the
following:
- persistent concern about having additional attacks
- worry about the implications of the attack or its consequences (e.g., losing control,
having a heart attack, going crazy)
- a signicant change in behaviour related to the attacks
B. The presence of Agoraphobia.
C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g.,
occurring on exposure to feared social situations). Specic Phobia (e.g., on exposure to a specic
phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an
obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated
with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or
close relatives).
218
Table 34.7
300.22 Agoraphobia Without History of Panic Disorder
A The presence of Agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or
diarrhoea).
B Criteria have never been met for Panic Disorder.
C The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
D If an associated general medical condition is present, the fear described in Criterion A is clearly in excess
of that usually associated with the condition.
danger involved. However, they feel helpless to

deal with these fears. Instead, they make strenuous
effort to avoid the phobic situation or object.
PHOBIC DISORDERS
Phobias are strong and irrational fears of certain
objects or situations. The word is derived from
phobos, the Greek god of fear. People with phobias
realise that their fears are out of proportion to the
Social phobia
Table 34.8 summarises the diagnostic criteria for
social phobia.
Table 34.8
300.23 Social Phobia (Social Anxiety Disorder)
A. A marked and persistent fear of one or more social or performance situations in which the person is
exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act
in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there
must be evidence of the capacity for age-appropriate social relationships with familiar people and the
anxiety must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of
a situationally bound or situationally predisposed Panic Attack- Note: In children, the anxiety may be
expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be
absent.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or
distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes
signicantly with the persons normal routine, occupational (academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse,
a medication) or a general medical condition and is not better accounted for by another mental disorder
(e.g.. Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic
Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated
to it, e.g., the fear is not of stuttering, trembling in Parkinsons disease, or exhibiting abnormal eating
behaviour in Anorexia Nervosa or Bulimia Nervosa.
Specify if:
Generalised: if the fears include most social situations (e.g., initiating or maintaining conversations,
participating in small groups, dating, speaking to authority gures, attending parties). Note: Also consider
the additional diagnosis of Avoidant Personality Disorder.
219
The key feature of social phobia is excessive fear of

situations in which the person might be scrutinised,
evaluated and judged negatively. Individuals fear
doing something embarrassing or acting in a way
that may be humiliating. Fear of specic social
situations results in avoidance. A more generalised
social phobia may lead to almost complete social
isolation. Social phobia is often under-recognised
by medical workers, because they either confuse it
with shyness or judge the secondary depression or
substance dependence to be the primary disorder.
If a person says, People make me anxious or
nervous, consider social phobia.
Common situations feared include speaking in
public, writing in the presence of others, eating or
drinking in public or using public toilets. Common

(embarrassing) symptoms include blushing, nausea,
shaking and the urge to go to the toilet.
Social phobia is as common as panic
and agoraphobia disorders. It is experienced by
both men and women. It is a chronic disorder
that uctuates over time and may cause marked
impairment in social and occupational functioning
if untreated.
Specic phobias
specic phobia
Table 34.9
300.29 Specic Phobia (formerly Simple Phobia)
A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a
specic object or situation (e.g., ying, heights, animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may
take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the
anxiety may be expressed by crying, tantrums, freezing, or clinging.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be
absent.
D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes signicantly with the
persons normal routine, occupational (or academic) functioning, or social activities or relationships, or
there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The anxiety, Panic Attacks, or phobic avoidance associated with the specic object or situation are not
better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear of
dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance
of stimuli associated with a severe stressor). Separation Anxiety Disorder (e.g., avoidance of school).
Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder
With Agoraphobia, or Agoraphobia Without History of Panic Disorder.
Specify type:
Animal Type: if the fear is cued by animals or insects. This subtype generally has a childhood onset.
Natural Environment Type: if the fear is cued by objects in the natural environment, such as storms,
heights, or water. This subtype generally has a childhood onset.
Blood-injection-injury Type: if the fear is cued by seeing blood or an injury or by receiving an injection
or other invasive medical procedure. This subtype is highly familial and is often characterised by a strong
vasovagal response.
Situational Type: if the fear is cued by a specic situation such as public transportation, tunnels, bridges,
elevators, ying, driving, or enclosed places. This subtype has a bimodal age-at-onset distribution, with one
peak in childhood and another peak in the mid-20s. This subtype appears to be similar to Panic Disorder
With Agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset.
Other Type: if the fear is cued by other stimuli. These stimuli might include the fear of choking, vomiting,
or contracting an illness; space phobia (i.e., the individual is afraid of falling down if away from walls or
other means of physical support); and childrens fears of loud sounds or costumed characters.
220
Specic phobias may include fear of dogs,

spiders, snakes, elevators, heights and enclosed
spaces, airplanes, still water, injections, illness or
death. Common symptoms consist of trembling,
accelerated heart rate, difculty breathing, lightheadedness and sweating. Phobias can develop
at any point in life. Many of them develop during
childhood, adolescence and early adulthood. Once
phobias develop, they seldom go away on their
own. Phobias may broaden and intensify over

time and are twice as common among women than
men. Phobias that begin during childhood usually
disappear without treatment. However, phobias
that develop later in life are usually more chronic.
Obsessive Compulsive Disorder (OCD)

Table 34.10 summarises the DSM-IV-TR diagnostic
criteria for OCD.
Table 34.10
300.3 Obsessive-Compulsive Disorder
A. Either obsessions or compulsions:
Obsessions as dened by (1). (2), (3), and (4):
1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during
the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. the thoughts, impulses, or images are not simply excessive worries about real-life problems
3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralise
them with some other thought or action
4. the person recognises that the obsessional thoughts, impulses, or images are a product of his or
her own mind (not imposed from without as in thought insertion)
Compulsions as dened by (1) and (2):
1. repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
2. the behaviours or mental acts are aimed at preventing or reducing distress or preventing some
dreaded event or situation; however, these behaviours or mental acts either are not connected
in a realistic way with what they are designed to neutralise or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognised that the obsessions or
compulsions are excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a
day), or signicantly interfere with the persons normal routine, occupational (or academic) functioning,
or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to
it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of
Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation
with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness
in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a
Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
Specify if:
With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the
obsessions and compulsions are excessive or unreasonable
Usually the OCD has two components: cognitive

(thoughts of being infected by germs) and
behavioural (washing and cleaning rituals). Either
can occur alone.
Obsessions are persistent, repetitive, intrusive
and unwelcome thoughts, images and impulses
that invade the individuals consciousness. They
are often abhorrent to the person, but very difcult

to dismiss or control. Thoughts are recognised as
being generated within the individuals own mind
versus thought insertion found in schizophrenia.
Obsessional thoughts focus on contamination,
disasters, violence, harm to self or others,
blasphemy, sex or other distressing things.
221
Nightmares and disturbed sleep.

Becoming numb to the world and avoiding
stimuli that remind one of the trauma.
Being easily startled.
Amnesia about important aspects of the
traumatic event.
Concentration and memory difculties.
Depressed or irritable mood.
Social withdrawal.
Experiencing extreme guilt about surviving
the catastrophe when others did not.
Traumas caused by human actions such as rape
and torture, tend to precipitate more severe
PTSD reactions than do natural disasters such as
hurricanes and earthquakes. After rape, victims
may feel nervous and may fear retaliation by
the rapist. Experience of sudden ashbacks or
nightmares that force them to relive the traumatic
experience is common. Many victims continue to
have nightmares and are frightened when alone,
outdoors or in crowds. There are usually reports of
decreased enjoyment of sexual activity long after
the rape.
The psychological wreckage caused by PTSD
may increase vulnerability to the later development
of other disorders. Women who experienced PTSD
had double the risk of developing a depressive
disorder and three times the risk of developing
alcohol-related problems in the future. About a half
of all adults experience a PTSD event, but only 5
percent of males and 11 percent of females develop
PTSD. It is a severe disorder that is difcult to
treat.
Table 34.11 summarises the DSM-IV-TR
diagnostic criteria for PTSD.
Compulsions are persistent, repetitive and

uncontrollable behavioural urges to perform
certain behaviours, such as washing or cleaning
rituals, resisted only with great difculty. They are
often responses to obsessive thoughts and function
to reduce anxiety associated with thoughts.
Compulsive rituals result in temporary relief.
Behavioural compulsions are extremely difcult to
control. Rituals include washing, checking things
repeatedly, cleaning, counting, or doing tasks in
a specic and rigid order. Failure to perform the
compulsive act leads to tremendous intensity of
anxiety (perhaps even a panic attack). Like phobic
avoidance responses, compulsions appear to reduce
anxiety. Men and women are equally likely to be
affected.
OCD may lead to avoidance of certain objects
or situations (e.g. dirt and not leaving the house
to avoid locking doors); life disruption; frustration;
irritation to individual, family, friends and
workmates; depression and anxiety.
Post-traumatic Stress Disorder (PTSD)

This is a long lasting anxiety response following a
traumatic or catastrophic event. Typical traumatic
events include violent assault, being kidnapped,
held as a prisoner of war, victims of natural or
man-made disasters, being diagnosed with a lifethreatening illness, torture, terrorist attack, and
witnessing or learning about an unexpected death
of another person.
Usually, PTSD develops within 3 to 6 months of
the traumatic event. Major symptoms include:
Severe symptoms of anxiety, arousal and
distress that were not present before the trauma
on exposure to trauma cues.
Reliving the traumatic event recurrently in
ashbacks, dreams, images and fantasy.
Table 34.11
309.81 Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
1. the person experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or
others
2. the persons response involved intense fear, helplessness, or horror. Note: In children, this
may be expressed instead by disorganized or agitated behaviour
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or
perceptions. Note: In young children, repetitive play may occur in which themes or aspects of
the trauma are expressed.
222
2.
recurrent distressing dreams of the event. Note: In children, there may be frightening dreams
without recognisable content.
3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative ashback episodes, including those
that occur on awakening or when intoxicated). Note: In young children, trauma-specic reenactment may occur.
4. intense psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not
present before the trauma), as indicated by three (or more) of the following:
1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest or participation in signicant activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a
normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more)
of the following:
1. difculty falling or staying asleep
2. irritability or outbursts of anger
3. difculty concentrating
4. hypervigilance
5. exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically signicant distress or impairment in social, occupational, or other
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor
symptoms. Table 34.12 summarises the DSM-IVTR diagnostic criteria for Acute Stress Disorder.
Acute Stress Disorder

This disorder has clinical features similar to PTSD
though it differs in terms of onset and duration of
Table 34.12
308.3 Acute Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:
1. the person experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or
others
2. the persons response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has three (or more)
of the following dissociative symptoms:
1. a subjective sense of numbing, detachment, or absence of emotional responsiveness
2. a reduction in awareness of his or her surroundings (e.g., being in a daze)
223
C.
D.
E.
F.
G.
H.
3. derealisation
4. depersonalisation
5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
The traumatic event is persistently re-experienced in at least one of the following ways: recurrent
images, thoughts, dreams, illusions, ashback episodes, or a sense of reliving the experience; or distress
on exposure to reminders of the traumatic event.
Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings,
conversations, activities, places, people).
Marked symptoms of anxiety or increased arousal (e.g., difculty sleeping, irritability, poor concentration,
hypervigilance, exaggerated startle response, motor restlessness).
The disturbance causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning or impairs the individuals ability to pursue some necessary task, such
as obtaining necessary assistance or mobilizing personal resources by telling family members about the
traumatic experience.
The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks
of the traumatic event.
The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and
is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.
OTHER TYPES OF ANXIETY DISORDERS

These include:
1. Anxiety due to General Medical Conditions (Table 34.13)
2. Substance Induced Anxiety Disorder (Table 34.14)
3. Anxiety Disorder not Otherwise Specied (Table 34.15)
Table 34.13
293.84 Anxiety Disorder Due to ...
[Indicate the General Medical Condition]
A. Prominent anxiety, Panic Attacks, or obsessions or compulsion predominate in the clinical picture.
C. The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder With
Anxiety in which the stressor is a serious general medical condition).
E. The disturbance causes clinically signicant distress or impairment in social, occupational, or other
Specify if:
With Generalised Anxiety: if excessive anxiety or worry about a number of events or activities predominates
in the clinical presentation
With Panic Attacks: if Panic Attacks predominate in the clinical presentation
With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical
presentation
Note: Include the name of the general medical condition on Axis I, e.g., Anxiety Disorder Due to
Pheochromocytoma, with Generalised Anxiety; also code the general medical condition on Axis III.
224
Table 34.14
Substance-Induced Anxiety Disorder
A. Prominent anxiety. Panic Attacks, or obsessions or compulsions predominate in the clinical picture.
1. the symptoms in Criterion A developed during, or within 1 month of, Substance Intoxication
or Withdrawal
2. medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by an Anxiety Disorder that is not substance induced. Evidence
that the symptoms are better accounted for by an Anxiety Disorder that is not substance induced might
include the following: the symptoms precede the onset of the substance use (or medication use); the
symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute
withdrawal or severe intoxication or are substantially in excess of what would be expected given the
type or amount of the substance used or the duration of use; or there is other evidence suggesting the
existence of an independent non-substance-induced Anxiety Disorder (e.g., a history of recurrent nonsubstance-related episodes).
Withdrawal only when the anxiety symptoms are in excess of those usually associated with the intoxication
or withdrawal syndrome and when the anxiety symptoms are sufciently severe to warrant independent
clinical attention.
Specify specic substance
Specify if:
With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates
in the clinical presentation
With Panic Attacks: if Panic Attacks predominate in the clinical presentation
With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical
presentation.
With Phobic Symptoms: if phobic symptoms predominate in the clinical presentation
Specify if
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms
develop during the intoxication syndrome
Table 34.15
300.00 Anxiety Disorder Not Otherwise Specied
This category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any
specic Anxiety Disorder, Adjustment Disorder With Anxiety, or Adjustment Disorder With Mixed Anxiety
and Depressed Mood. Examples include
1.
2.
Mixed anxiety-depressive disorder: clinically signicant symptoms of anxiety and depression, but the
criteria are not met for either a specic Mood Disorder or a specic Anxiety Disorder
Clinically signicant social phobic symptoms that are related to the social impact of having a general
medical condition or mental disorder (e.g., Parkinsons disease, dermatological conditions, Stuttering,
Anorexia Nervosa, Body Dysmorphic Disorder)
225
3.
4.
Situations in which the disturbance is severe enough to warrant a diagnosis of an Anxiety Disorder but
the individual fails to report enough symptoms for the full criteria for any specic Anxiety Disorder
to have been met; for example, an individual who reports all of the features of Panic Disorder Without
Agoraphobia except that the Panic Attacks are all limited-symptom attacks
Situations in which the clinician has concluded that an Anxiety Disorder is present but is unable to
with cognitive behaviour therapy being the most

effective approach.
MANAGEMENT PRINCIPLES OF
ANXIETY DISORDERS
Social management
This includes education and support involving
family and relevant support structures.
Rule out organic or physical pathology as well

as mood and substance abuse problems.
Educate about the nature of any of the anxiety
disorders according to the individuals needs.
Provide training in strategies to control anxiety
symptoms.
Appropriate referrals of patients to relevant
expertise.
Avoid unnecessary medication, particularly
sedative medication.
ADJUSTMENT DISORDER
This is a short period of distress and emotional
disturbance following the occurrence of a
signicant life change. Typical stressors include
bereavement, divorce, marriage, new occupation,
migration, business difculties, refugee status,
chronic illness, natural disasters, retirement and a
new baby in the family.
Biological management
Various agents are effective. Benzodiazepines (short
and long-term) may be used for symptom relief.
Antidepressants (especially the SSRIs and TCAs)
have shown efcacy in longer term management
of GAD, PD, OCD and PTSD. Co-morbid features
of mood disorder are not uncommon and should
be appropriately treated. A variety of other agents
e.g. Beta-blockers (for sympathetic hyperarousal
in specic phobias) and antihistamines (e,g.
hydroxyzine in GAD) have shown efcacy for
symptom control.
Common symptoms
Anxiety; depressed mood; insomnia; stressrelated physical symptoms (headaches, abdominal
distress, chest pain and palpitations); interference
with performance of daily routines; aggressive
or antisocial behaviour; and bed-wetting, thumbsucking, babyish speech (children).
Diagnostic criteria
The symptoms begin within one month (maximum
3 months) of a clearly dened stressor. The
symptoms are similar to those of anxiety disorders.
Table 31.16 summarises the DSM-IV-TR diagnostic
criteria for Adjustment Disorders.
Psychological management
Various approaches to management are used for
these disorders depending on clinical presentation
226
Table 34.16
Adjustment Disorders
A. The development of emotional or behavioural symptoms in response to an identiable stressor(s)
occurring within 3 months of the onset of the stressor(s).
B. These symptoms or behaviours are clinically signicant as evidenced by either of the following:
1. marked distress that is in excess of what would be expected from exposure to the stressor
2. signicant impairment in social or occupational (academic) functioning
C. The stress-related disturbance does not meet the criteria for another specic Axis I disorder and is not
merely an exacerbation of a pre-existing Axis I or Axis II disorder.
D. The symptoms do not represent Bereavement.
E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an
additional 6 months.
Specify if:
Acute: if the disturbance lasts less than 6 months
Chronic: if the disturbance lasts for 6 months or longer. By denition, symptoms cannot persist for more
than 6 months after the termination of the stressor or its consequences. The Chronic specier therefore
applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to
a stressor that has enduring consequences.
Adjustment Disorders are coded based on the subtype, which is selected according to the predominant
symptoms. The specic stressor(s) can be specied on Axis IV.
309.0 With Depressed Mood: when the predominant manifestations are symptoms such as depressed mood,
tearfulness, or feelings of hopelessness
309.24 With Anxiety: when the predominant manifestations are symptoms such as nervousness, worry, or
jitteriness, or, in children, fears of separation from major attachment gures
309.28 With Mixed Anxiety and Depressed Mood: when the predominant manifestation is a combination
of depression and anxiety
309.3 With Disturbance of Conduct: when the predominant manifestation is a disturbance in conduct in
which there is violation of the rights of others or of major age-appropriate societal norms and rules (e.g.,
truancy, vandalism, reckless driving, ghting, defaulting on legal responsibilities)
309.4 With Mixed Disturbance of Emotions and Conduct: when the predominant manifestations are both
emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct (see above subtype)
309.9 Unspecied: for maladaptive reactions (e.g., physical complaints, social withdrawal, or work or
academic inhibition) to stressors that are not classiable as one of the specic subtypes of Adjustment
Disorder
Coding note: In a multi-axial assessment, the nature of the stressor can be indicated by listing it on Axis
IV (e.g. Divorce).

Edition (2000): DSM-IV-TRTM Published by American
3. Textbook of Anxiety Disorders (2002) Edited by Dan
J. Stein & Eric Hollander Published by The American
Psychiatric Publishing Inc.
Further reading
Edition: Derived from Kaplan & Sadocks Synopsis of
Psychi atry, 9th Edition. (2004). Editors: Benjamin J.
Williams & Wilkins
227
35
Alcohol and other Substance Related Disorders
David Basangwa, David M. Ndetei, Mary Kuria, Francisca Ongecha-Owuor,
Abdulreshid Abdullahi, John Mburu, Benson Gakinya
Use
DEFINITIONS
Relative to a licit substance, use refers to a situation

where a person takes a psychoactive substance
with no subsequent harm to health, social and
occupational function.
Drug
This refers to any chemical agent that once taken
in the body is capable of causing physiological
and psychological changes. The term drug is
interchangeably used with substance.
Abuse
Is a pathological pattern of use where one
experiences loss of control, and begins to suffer
health, social and occupational effects. Table 35.1
summarises the essential features of substance
abuse.
Psychoactive substance
This is a chemical compound that produces
emotional, cognitive or behavioural changes which
may be pleasurable or desirable to the user, with
adverse medical consequences and is socially
unsanctioned because of its undesirable effects on
the user and others.
Tolerance
The need for more of the drug in order to achieve a
similar effect realised before at a lower dose.
Table 35.1
Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically signicant impairment or distress, as
manifested by one (or more) of the following, occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulll major role obligations at work, school, or
home (e.g., repeated absences or poor work performance related to substance use; substance-relate
absences, suspensions, or expulsions from school; neglect of children or household)
(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile
or operating a machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
228
Alcohol and Other Substance Related Disorders
(4) continued substance use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical ghts)
B. The symptoms have never met the criteria for Substance Dependence for this class of substance
Adopted and Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (Copyright 2000). American Psychiatric Association.
effects and to further avoid the discomfort of its
absence. Dependence can be both physical and
psychological as summarised in Table 35.2.
Dependence
Dependence refers to the compulsion to take the
drug on a continuous basis in order to feel its
Table 35.2
Substance Dependence
A maladaptive pattern of substance use, leading to clinically signicant impairment or distress, as manifested
by three (or more) of the following, occurring at anytime in the same 12-month period:
(1) Tolerance, as dened by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or desired
effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria
sets for Withdrawal from the specic substances)
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) The substance is often taken in larger amounts or over a longer period than was intended
(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple
doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its
effects
(6) Important social, occupational, or recreational activities are given up or reduced because of substance
use
(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by the substance (e.g.,
current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite
recognition that an ulcer was made worse by alcohol consumption)
Specify if:
With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)
Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is
present)
Course speciers:
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
229
Substance Intoxication
Its features are summarised in Table 35.3.
Table 35.3
Substance Intoxication
A. The development of a reversible substance-specic syndrome due to recent ingestion of (or exposure to)
a substance. Note: Different substances may produce similar or identical syndromes.
B. Clinically signicant maladaptive behavioural or psychological changes that are due to the effect of
the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment,
impaired judgment, impaired social or occupational functioning) and develop during or shortly after use
of the substance.
C. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
Substance Withdrawal
Its general features are summarised in Table 35.4.
Table 35.4
Substance Withdrawal
A. The development of a substance-specic syndrome due to the cessation of (or reduction in)
substance use that has been heavy and prolonged.
B. The substance-specic syndrome causes clinically signicant distress or impairment in social,
C. The symptoms are not due to a general medical condition and are not better accounted for by
another mental disorder.
Types of substances abused
Agent (Alcohol and other substances)
The following are the commonly abused groups

of substances: alcohol, amphetamine and
amphetamine-like substances, cannabis, cocai
ne, hallucinogens, inhalants, nicotine, opioids,
phencyclidine, sedative-hypnotics/anxiolytics.
Substances generally vary in their ability to induce

dependence as well as the speed at which this can
happen. The dependence potential of heroin is many
times greater than that of cannabis and so is the
rapidity of development of dependence. Substance
dependence develops following repeated use of a
psychoactive substancethe users psychological
attitude and response is altered to the extent that
the individual may require the substance in order
to function normally. These substances act on
the brain at neuronal level by interfering with the
neurotransmitter system (production, release or
breakdown) and brain structures are altered leading
to development of dependence.
Psychoactive substances have a euphoric and
calming effect. This is why they are repeatedly used,
eventually leading to development of tolerance.
Withdrawal from prolonged use of a substance,
AETIOLOGICAL FACTORS IN
ALCOHOL AND SUBSTANCE
ABUSE
In spite of years of research, it is difcult to state
with condence what the specic causes of abuse
and dependence are in a particular individual.
However, it is known that an interaction of three
main factors: the agent, host and environment, play
a signicant aetiological role.
230
manifests in a syndrome which is characterised

by physical and psychological discomfort. One
therefore avoids this uncomfortable state by taking
the substance on a continuous basis.
Expectancy
Individuals who are prone to alcohol and substance

abuse have some inherent predisposing factors.
These include:
The effect of a substance is inuenced by what the

user expects from use of the substance. Societies
also develop their own superstitions about the
effects of certain substances. Such expectations
can sometimes be achieved even when there
is no pharmacological basis for the effect. The
superstitions related to substance abuse can then
be further reinforced.
Genetic factors
Mental set
Dependence on alcohol has a degree of genetic

predisposition. Studies have proven that prevalence
of alcoholism among parents and siblings of
alcoholics is about two and a half times that of the
general population, and that the morbidity risk of
alcoholism for an individual with an alcoholic
parent is approximately 25 percent.
This refers to the emotional attitude regarding the

use of a substance and can be negative, positive or
neutral. A negative attitude subsequent to inuence
of religion, social, political or family beliefs will
lead to rejection of the substance. A positive attitude
will be one that encourages use of the substance.
The individual (host)
Age
Family drug abuse
Certain substances are abused more by people in

certain age groups than others. Tranquilisers and
antidepressants are abused more by people over 30
years of age. On the other hand, illicit substances
are abused more by the younger age groups.
Alcohol and tobacco tend to be well spread over
the ages.
It has been observed that alcohol-dependent people

have a history of higher incidence of alcohol
abuse with one or both of their parents. This is
explained on the basis of the modelling theory.
According to the theory, children often accept
and copy the behaviour of their elders when they
grow up. Alcohol and substance abuse may be
one of these behaviours. Such children will then
develop an accepting attitude to use of substances
as a mechanism of recreation and for coping with
problems in life. This is particularly common in
young users of alcohol and heroin.
Gender
Due to various socio-cultural-economic factors there
are gender differences in the pattern of substances
use. Males tend to start abusing substances early in
life and tend to develop dependence far more often
than females.
Peer pressure
Environmental factors
Human beings have a need to belong to social

groupings and conforming to the norms of the
group. Pressure within the group may result in the
individual member acquiring habits that may be
maladaptive such as alcohol or substance use so as
to have a sense of belonging or acceptance.
An individuals environment has a signicant

impact on the behaviour that individual acquires.
In environments where supply and availability of
substance is widespread, susceptible individuals
may begin to use the substance. Other factors
that enhance substance use and abuse are poverty,
unemployment, dysfunctional families, migration
and rapid urbanisation. Demand reduction legislations that are either inadequate defective or
un-enforced contribute to escalating supply and
demand of substances. Some cultural norms
dictate the patterns of alcohol and substance use, in
circumstances where rules are set as to how, when,
and who should consume the substance. Liberal or
permissive societies are associated with high rates
of alcohol and substance abuse.
Personality
Psychodynamic theorists describe a typical person
who develops an alcohol problem as an oraldependent personality. It is believed that oral
gratication of such an individual was not satised
in early life. This lack of satisfaction results in
development of an individual who is driven to
secure oral satisfaction through devices such as
drinking, smoking and eating. Such personality
may be characterised by self-doubt, passivity and
dependence.
231
and social effects in societies. Alcohol, also known

as ethanol or ethyl alcohol, is produced by a simple
process of yeast acting on sugar (fermentation).
ALCOHOL
This is the most widely abused substance the world
over. It is also the drug that gives most serious health
Table 35.5
A CLINICAL OVERVIEW OF ALCOHOL USE AND ALCOHOL-INDUCED DISORDERS (DSMIV-TR codes given)
(A) Alcohol Use Disorders
303.9 Alcohol Dependence
305.00 Alcohol Abuse
(B) Alcohol-Induced Disorders
303.00 Alcohol Intoxication
291.81 Alcohol Withdrawal Specify if: With Perceptual Disturbances
291.0 Alcohol Intoxication Delirium
291.0 Alcohol Withdrawal Delirium
291.2 Alcohol-Induced Persisting Dementia
291.1 Alcohol-Induced Persisting Amnestic Disorder
291.5 Alcohol-Induced Psychotic Disorder, With Delusions
Specify if With Onset During Intoxication/With Onset During Withdrawal
291.3 Alcohol-Induced Psychotic Disorder, With Hallucinations
Specify if: With Onset During Intoxication/With Onset During Withdrawal
291.89 Alcohol-Induced Mood Disorder
291.89 Alcohol-Induced Anxiety Disorder
291.89 Alcohol-Induced Sexual Dysfunction
Specify if: With Onset During Intoxication
291.89 Alcohol-Induced Sleep Disorder
291.9 Alcohol-Related Disorder Not Otherwise Specied
as body weight, body fat, gender, age, nutritional

status, physical health and emotional state.
Metabolism
After ingestion, 10 percent is absorbed in the
stomach while the rest is absorbed from the small
intestines. Metabolism takes place in the liver with
the help of both alcohol and aldehyde dehydrogenase
enzymes. The amount of alcohol in the blood will
thereafter depend on how much one drinks, as well
Physiological effects
Table 35.6 summarises the features of alcohol
intoxication.
232
Table 35.6
303.00 Alcohol Intoxication
A. Recent ingestion of alcohol.
B. Clinically signicant maladaptive behavioural or psychological changes (e.g., inappropriate sexual or
aggressive behaviour, mood lability, impaired judgment, impaired social or occupational functioning)
that developed during, or shortly after, alcohol ingestion.
C. One (or more) of the following signs, developing during, or shortly after, alcohol use:
(1) slurred speech
(2) inco-ordination
(3) unsteady gait
(4) nystagmus
(5) impairment in attention or memory
(6) stupor or coma
D. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder,
Alcohol belongs to a group of the central nervous

system (CNS) depressants. The degree of
depression (sedation) is dependent on the amount
of alcohol available in the CNS. Other body
effects include cutaneous vasodilatation, increased
salivation and gastric secretion, increased output of
adrenal steroids, and suppression of the antidiuretic
hormone leading to diuresis.
Cardiovascular system
Alcohol predisposes to high blood pressure and
alcoholic cardiomyopathy.
Reproductive system
Alcohol leads to loss of libido, erectile dysfunction
and consequent infertility. For pregnant mothers
who consume large amounts of alcohol, the baby
may suffer from general growth retardation, low
intelligence and congenital abnormalities.
Chronic effects
Following chronic use, alcohol is capable of
causing damage to all body systems. The amount
of damage will depend on amounts taken, duration
of drinking, type of alcoholic drink and other
individual factors.
Psychological effects
These result from a direct toxic effect, withdrawal
or nutritional deciencies. The immediate effects
are pathological intoxication and alcoholic
blackout. Withdrawal gives rise to two main forms
of withdrawal states (with or without delirium)
Digestive system
Alcohol predisposes to multiple oral problems,
oesophagitis, cancer of the oesophagus, gastric
ulcers, liver cirrhosis and pancreatitis.
Withdrawal state (withdrawal syndrome)

Table 35.7 summarises the essential features of
alcohol withdrawal
Table 35.7
291.81 Alcohol Withdrawal
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
1. autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
2. increased hand tremor
3. insomnia
4. nausea or vomiting
5. transient visual, tactile, or auditory hallucinations or illusions
6. psychomotor agitation
233
7. anxiety
8. grand mal seizures
C. The symptoms in Criterion B cause clinically signicant distress or impairment in social, occupational,
or other important areas of functioning.
mental disorder.
Specify if:
With Perceptual Disturbances: This specier may be noted in the rare instance when hallucinations with
intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium, intact reality
testing means that the person knows that the hallucinations are induced by the substance and do not represent
external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of SubstanceInduced Psychotic Disorder, With Hallucinations, should be considered.
general reduction in income. Students will suffer

poor academic performance. At family level,
domestic violence is a common occurrence and
usually results in dysfunctional families, separation
or divorce. Children from such families develop
serious emotional disorders, usually leading to
poor academic performance.
At the community level, substance abuse is
associated with high crime rates and indiscipline.
At the national level, the burden of caring for the
substance-dependent individuals is enormous.
Such persons contribute to loss of many manhours through absenteeism, repeated treatments for
associated morbidity-like depression and physical
ailments.
Withdrawal state with delirium

It is a more serious condition and usually
manifests 3 to 4 days after the total cessation or
reduction in usual amounts of alcohol taken. The
commonest form of withdrawal state is delirium
tremens. Delirium tremens is self-limiting and
short-lived, but could be fatal. Initially the clinical
picture resembles that of withdrawal state without
delirium, but as the condition progresses the person
becomes delirious and confused. Clinical features
include prodromal symptoms of insomnia, anxiety,
fear, restlessness, tremors and convulsions. As
the condition progresses there is clouding of
consciousness, disorientation and profound
confusion. Vivid visual and auditory hallucinations
occur together with illusions. There is associated
over-activity of the autonomic nervous system.
The condition tends to get worse in the night.
Delusions, agitation and sleep disturbances may be
moderate to severe.
Diagnosis for alcohol use problems

a.
Long- term effects

Nutritional deciencies lead to Wernickes
encephalopathy, Korsakoffs psychosis and
alcoholic dementia. Also common are a number
of psychiatric disorders that include alcoholic
hallucinosis, amnesic syndrome, depression,
suicidal behaviour, psychosexual disorders and
personality deterioration.
Social effects
b.
Alcohol use and abuse leads to dysfunctional

social and occupational functions at individual,
family, community and national level. At
individual level there is a common problem of
personality deterioration. Such people lack a
sense of responsibility. In economic terms, there is
234
CAGE is a common simple and effective

screening tool. The following questions are
asked:
Have you ever tried to cut down on your
drinking? (C)
Do you get annoyed when people talk about
your drinking? (A)
Do you ever feel guilty about your drinking?
(G)
Do you ever take an early morning drink?
(E)
(A positive answer is 2 or more yes
responses).
Other screening tools include:
Alcohol use disorders identication test
(AUDIT).
Short Michigan alcohol screening test (SMAST).
c.
names include: marijuana, hashish, njaga, ganja,

kikoola, kipapi and dagga. It is the most commonly
abused illegal substance. Cannabis has many
active substances the commonest of which is 9tetrahydroxy-cannabinol (THC).
Laboratory investigations/markers:
Macrocytosis (raised MCV).
Raised gamma glutamyl transferase
(GGT).
Blood alcohol concentration (BAC).
Breath alcohol levels
Common forms of use

Dry leaves are usually smoked alone or mixed with
ordinary tobacco. The fresh leaves are boiled in
water and taken with tea. The same leaves can also
be chewed or eaten fresh.
Table 35.8 summarises features of Cannabis
intoxication
CANNABIS SATIVA
This is a green owering plant that is widely grown
in the tropical regions of Africa. Other common
Table 35.8
DSM-IV-TR Cannabis-Related Disorder
Cannabis use disorders
Cannabis use dependence
Cannabis abuse
Cannabis-induced disorders
Cannabis intoxication
Specify if:
With perceptual disturbances
Cannabis intoxication delirium
Cannabis-induced psychotic disorder, with delusions
Specify if:
With onset during intoxication
Cannabis induced psychotic disorder, with hallucinations
Specify if:
Cannabis-induced psychotic disorder
Specify if:
Cannabis-induced anxiety disorder
Specify if:
Cannabis-related disorder not otherwise specied
235
Table 35.9
292.89 Cannabis Intoxication
A. Recent use of cannabis.
B. Clinically signicant maladaptive behavioural or psychological changes (e.g., impaired motor
coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that
developed during, or shortly after, cannabis use.
C. Two (or more) of the following signs, developing within 2 hours of cannabis use:
(1) conjunctival injection
(2) increased appetite
(3) dry mouth
(4) tachycardia
mental disorder.
Specify if:
With Perceptual Disturbances: This specier may be noted when hallucinations with intact reality testing
or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the
person knows that the hallucinations are induced by the substance and do not represent external reality. When
hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic
Disorder, With Hallucinations, should be considered.
Table 35.10
DSM-IV-TR Diagnostic Criteria for Cannabis-Related Disorder Not Otherwise Specied
The cannabis-related disorder not otherwise specied category is for disorders associated with the use of
cannabis that are not classiable as cannabis dependence, cannabis abuse, cannabis intoxication, cannabis
intoxication delirium, cannabis-induced psychotic disorder, or cannabis-induced anxiety disorder.
of the three. Once taken, khat produces euphoria,

suppresses appetite and hunger, and makes one
alert. Thus it is used for relaxation, to facilitate
communication at social events and to suppress
sleep and fatigue in work situations.
Health effects
Cannabis causes mild sedation and stimulation.
It gives a feeling of relaxation and well-being,
sharpened sensory awareness, a slowed sense of time,
increased appetite, delusions and hallucinations.
Users may also experience increased heart rate
and red eyes. Chronic and heavy use of cannabis
can lead to lung diseases including cancers,
immune suppression, amotivation syndrome and
interference with male reproductive functions.
Common forms of use

The leaves are chewed fresh, sometimes together
with chewing gum or soft drinks. Other users
combine khat with alcohol and other substances of
abuse.
CATHA EDULIS (KHAT)
Health effects
Khat produces dependence, tolerance and
withdrawal symptoms. Oral-dental complications,
gastritis and constipation do occur. In men
spermatorrhoea and erectile dysfunction have been
reported. Some individuals experience psychosis
with prominent paranoia and hallucinations.
However, khat is a crop of signicant economic
This is a crop that is indigenous to Eastern Africa

and Yemen. It is also known as miraa, mairungi
and khat. It has been used for a long time,
because of its psycho-stimulant effects. The main
chemical constituents include cathinone, tanmis
and norephedrine. Cathinone is the key element
236
value in many countries. It therefore remains a legal

substance. The clinical features of khat are similar
to those of Amphetamine, thus intoxication and
withdrawal can be summarised using information

on Amphetamine.
Table 35.11
Amphetamine Use Disorder
Amphetamine Dependence
Amphetamine Abuse
Amphetamine-Induced Disorders
Amphetamine Intoxication
Specify if: With Perceptual Disturbances
Amphetamine Withdrawal
Amphetamine Intoxication Delirium
Amphetamine-Induced Psychotic Disorder, With Delusions
Amphetamine-Induced Psychotic Disorder, With Hallucinations
specify if: With Onset During Intoxication
Amphetamine-Induced Mood Disorder
Amhetamine-Induced Anxiety Disorder
Amphetamine-Induced Sexual Dysfunction
Amphetamine-Induced Sleep Disorder
Specif if: With Onset During Intoxication/With Onset During Withdrawal
Amphetamine-Induced Not Otherwise Specied
Table 35.12
292.89 Amphetamine Intoxication
A. Recent use of amphetamine or a related substance (e.g., methylphenidate).
B. Clinically signicant maladaptive behavioural or psychological changes (e.g., euphoria or affective
blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger;
stereotyped behaviours; impaired judgment; or impaired social or occupational functioning) that
developed during, or shortly after, use of amphetamine or a related substance.
C. Two (or more) of the following, developing during, or shortly after, use of amphetamine or a related
substance:
(1) tachycardia or bradycardia
(2) pupillary dilation
(3) elevated or lowered blood pressure
(4) perspiration or chills
(5) nausea or vomiting
(6) evidence of weight loss
(7) psychomotor agitation or retardation
(8) muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
(9) confusion, seizures, dyskinesias, dystonias, or coma
mental disorder.
237
Specify if:
Table 35.13
292.0 Amphetamine Withdrawal
A
B
C
D
Cessation of (or reduction in) amphetamine (or a related substance) use that has been heavy and
prolonged.
Dysphoric mood and two (or more) of the following physiological changes, developing within a few
hours to several days after Criterion A:
(1) fatigue
(2) vivid, unpleasant dreams
(3) insomnia or hypersomnia
(5) psychomotor retardation or agitation
The symptoms in Criterion B cause clinically signicant distress or impairment in social, occupational,
The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
white lady, brown sugar, junk and muggo. This

plant is widely grown in the Middle East. Morphine
and codeine are the key medicinal products of
the poppy, using opium as a raw material. From
morphine, heroin can be illegally produced by a
simple chemical process.
HEROIN AND OTHER OPIATES

Opium is a coagulated juice from the unripe capsule
of a owering plant called Papaver somniferum.
Other common names for heroin include boy,
Table 35.14
Opioid Use Disorders
Opioid Dependence
Opioid Abuse
Opioid-Induced Disorders
Opioid Intoxication

Opioid Withdrawal
Opioid Intoxication Delirium
Opioid-Induced Psychotic Disorder, With Delusions
Opioid-Induced Psychotic Disorder, With Hallucinations
Opioid-Induced Mood Disorder
238

Opioid-Induced Sexual Dysfunction
Opioid-Induced Sleep Disorder
Opioid-Related Disorder Not Otherwise Specied
into the veins, a situation that poses challenges in

the wake of the HIV/AIDS pandemic.
Table 35.15 summarises the feature of opioid
intoxication.
Common forms of use

Consumption is mainly through smoking of the drug
mixed with either tobacco or marijuana, sniffed or
snorted from a foil that is heated from underneath
(chasing the dragon). Heroin can also be injected
Table 35.15
292.89 Opioid Intoxication
A. Recent use of an opioid.

B. Clinically signicant maladaptive behavioural or psychological changes (e.g., initial euphoria followed
by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or
occupational functioning) that developed during, or shortly after, opioid use.
C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of
the following signs, developing during, or shortly after, opioid use:
1. drowsiness or coma
2. slurred speech
3. impairment in attention or memory
mental disorder.
Specify if:
With Perceptual Disturbances: This specier may be noted in the rare instance in which hallucinations
with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact
reality testing means that the person knows that the hallucinations are induced by the substance and do not
represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of
Substance-Induced Psychotic Disorder, With Hallucinations, should be considered.
for those who use the injectable form due to sharing

of contaminated needles.
Withdrawal effects include lacrimation,
rhinorrhea sneezing, yawning, sweating, tremors
and goose skin. Chills and shivering set in. There
is associated abdominal pain, muscle cramps,
diarrhoea and vomiting. Increased irritability
with dysphoric mood also occur.
Table 35.16 summarises the features of opioid
withdrawal.
Health effects
Development of dependence is high with use of
heroin. The user experiences an intense pleasurable
feeling (rush or euphoria). There is a degree of
analgesia and drowsiness. The eyes are red and the
pupil constricted. Others may experience nausea,
cough suppression or depressed respiration. Overdosage and toxicity are common effects.
In the long-term, there is damage to the nasal
septum, respiratory infections and constipation.
There is an increased risk of HIV/AIDS, especially
239
Table 35.16
292.0 Opioid Withdrawal
A. Either of the following:
1. cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or
longer)
2. administration of an opioid antagonist after a period of opioid use
B. Three (or more) of the following, developing within minutes to several days after Criterion A:
(1) dysphoric mood
(3) muscle aches
(4) lacrimation or rhinorrhea
(5) pupillary dilation, piloerection, or sweating
(6) diarrhoea
(7) yawning
(8) fever
(9) insomnia
mental disorder.
Table 35.17
DSM-IV-TR Diagnostic Criteria for Opioid-Disorder Not Otherwise Specied
The opioid-related disorcer not otherwise specied category is for disorders associated with the use of
opioids that are not classiable as opioid dependence, opioid abuse, opioid intoxication, opioid withdrawal,
opioid intoxication delirium, opioid-induced psychotic disorder, opioid-induced mood disorder, opioidinduced sexual dysfunction, or opioid-induced sleep disorder.
Health effects
COCAINE
After taking cocaine, the user experiences a feeling

of physical and mental well-being. There is increased
alertness and energy. Hunger is suppressed and there
is signicant reduction of fatigue with resultant
malnutrition. The pupils dilate, with an increased
heart rate, body temperature and blood pressure.
Irritability and violent behaviour are also common.
With larger doses, hallucinations, talkativeness and
hyper-excitability may ensue. Short-lived paranoid
psychosis has also been reported. High doses can
also lead to convulsions or stroke from cerebral
haemorrhage.
This is a white powder that is extracted from

the leaves of the coca bush (Erythroxylon coca).
Common street names for cocaine include snow,
lady, bazuka, crude, un and snow dust. Coca is
mainly grown in South America.
Common forms of use

Use is mainly by snorting or smoking. It can be
smoked either directly or mixed with tobacco and
also injected subcutaneously or intravenously.
240
Table 35.18
Cocaine Use Disorders
Cocaine Dependence
Cocaine Abuse
Cocaine-Induced Disorders
Cocaine Intoxication
Cocaine Withdrawal
Cocaine Intoxication Delirium
Cocaine-Induced Psychotic Disorder, With Delusions
Cocaine-Induced Psychotic Disorder, With Hallucinations
Cocaine-Induced Mood Disorder
Cocaine-Induced Anxiety Disorder
Cocaine-Induced Sexual Dysfunction
Cocaine-Induced Sleep Disorder
Cocaine-Related Disorder Not Otherwise Specied
cocaine intoxication
Table 35.19
292.89 Cocaine Intoxication
A. Recent use of cocaine.
B. Clinically signicant maladaptive behavioural or psychological changes (e.g., euphoria or affective
blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger;
stereotyped behaviours; impaired judgment; or impaired social or occupational functioning) that
developed during, or shortly after, use of cocaine.
C. Two (or more) of the following, developing during, or shortly after, cocaine use:
(1) tachycardia or bradycardia
(3) elevated or lowered blood pressure
(4) perspiration or chills
(6) evidence of weight loss
(7) psychomotor agitation or retardation
(8) muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
(9) confusion, seizures, dyskinesias, dystonias, or coma
mental disorder.
Specify if:
241
HIV/AIDS infection is common in injecting drug

users and damage to the nasal septum in those
that snort. Cocaine causes both physical and
psychological dependence. On withdrawal, there
is increased sleep, depression, anhedonia, anxiety,
irritability and some agitation. These withdrawal
symptoms can last up to a week depending on

duration and amount of use though generally peaks
2 to 4 days after cessation.
Table 35.20 summarises the diagnostic criteria
for cocaine withdrawal
Table 35.20
292.0 Cocaine Withdrawal
A Cessation of (or reduction in) cocaine use that has been heavy and prolonged.
B Dysphoric mood and two (or more) of the following physiological changes, developing within a few
hours to several days after Criterion A:
(1) fatigue
(2) vivid, unpleasant dreams
(3) insomnia or hypersomnia
(5) psychomotor retardation or agitation
C The symptoms in Criterion B cause clinically signicant distress or impairment in social, occupational,
D The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
Table 35.21
DSM-IV-TR Diagnostic Criteria for Cocaine-Related Disorder Not Otherwise Specied
The cocaine-related disorder not otherwise specied category is for disorders associated with the use of cocaine
that are not classiable as cocaine dependence, cocaine abuse, cocaine intoxication, cocaine withdrawl, cocaine
intoxication delirium, cocaine-induced psychotic disorder, cocaine-induced mood disorder, cocaine-induced anxiety
disorder, cocain-induced sexual dysfunction, or cocaine-induced sleep disorder.
have varying degrees of abuse potential. Since

many are domestic or industrial chemicals, they are
easily obtained in homes, fuel stations or hardware
shops. Abuse is by snifng from cotton or a piece
of cloth that is soaked with the chemical. Others
directly inhale the chemical from a container or
plastic bag.
SOLVENTS
Also called inhalants, this group represents the
many chemicals that are inhaled to get high. They
include varnish, petrol, glue, aerosols, thinner, nail
polish remover and cleaning detergents. They all
Table 35.22
Inhalant Use Disorders

Inhalant Dependence
Inhalant Abuse
Inhalant-Induced Disorders
Inhalant Intoxication
Inhalant Intoxication Delirium
Inhalant-Induced Persisting Dementia
Inhalant-Induced Psychotic Disorder, With Delusions
242

Inhalant-Induced Psychotic Disorder, With Hallucinations
Inhalant-Induced Mood Disorder
Inhalant-Induced Anxiety Disorder
Specify if: with Onset During Intoxication
Inhalant-Related Disorder Not Otherwise Specied
Health effects
Inhalant Intoxication
Table 35.23
292.89 Inhalant Intoxication
A
Recent intentional use or short-term, high-dose exposure to volatile inhalants (excluding anaesthetic
gases and short-acting vasodilators).
B Clinically signicant maladaptive behavioural or psychological changes (e.g., belligerence,
assaultiveness, apathy, impaired judgment, impaired social or occupational functioning) that developed
during, or shortly after, use of or exposure to volatile inhalants.
C Two (or more) of the following signs, developing during, or shortly after, inhalant use or exposure:
(1) dizziness
(2) nystagmus
(3) inco-ordination
(4) slurred speech
(5) unsteady gait
(6) lethargy
(7) depressed reexes
(8) psychomotor retardation
(9) tremor
(10) generalised muscle weakness
(11) blurred vision or diplopia
(12) stupor or coma
(13) euphoria
The symptoms are not due to a general medical condition and are not better accounted for by another mental
disorder
Table 35.24
DSM-IV-TR Diagnostic Criteria for Inhalant-Related Disorder Not Otherwise Specied
The inhalant-related disorder not otherwise specied category is for disorders associated with the use of
inhalants that are not classiable as inhalant dependence, inhalant abuse, inhalant intoxication, inhalant
intoxication delirium, inhalant-induced mood disorder, or inhalant-induced anxiety disorder.
243
mind and behaviour. It is because of this effect

that people may take them outside prescription
schedules, which sometimes leads to dependence.
Benzodiazepines are the most frequently
prescribed medicines, especially for control of
anxiety and sleep disorders. Examples include
Alprazolam (Xanax), Diazepam (Valium),
Chlordiazepoxide (Librium) and Flunitrazepam
(Rohypnol).
These include acute CNS depression, organ

damage, especially of the heart, liver and kidneys.
Chronic use predisposes to paranoia and hostility.
SEDATIVES
Sedatives
include
the
benzodiazepines,
barbiturates, methaqualone and meprobamate. Both
benzodiazepines and barbiturates have legitimate
medical value for which they are intended. They are
therefore, supposed to be prescription medicines.
When taken, their effect is primarily on the brain,
Common forms of use

The drugs are used either by injection or simply
taken as tablets or capsules.
Table 35.25
Sedative, Hypnotic, or Anxiolytic Use Disorders
Sedative, Hypnotic, or Anxiolytic Dependence
Sedative, Hypnotic, or Anxiolytic Abuse
Sedative, Hypnotic, or Anxiolytic Intoxication
Sedative, Hypnotic, or Anxiolytic Withdrawal
Sedative, Hypnotic, or Anxiolytic Intoxication Delirium
Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium
Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia
Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic Disorder
Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder With Delusions
Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder
With Hallucinations
Specify if: With Onset During Intoxication/With Onset During Withdraw
Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder
Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder
Specify if: With Onset During Withdrawal
Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual Dysfunction
Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep Disorder
Sedative-, Hypnotic-, or Anxiolytic-Related Disorder
Not Otherwise Specied
Health effects
Tables 35.26 and 35.27 summarise the diagnostic
criteria for Sedative Intoxication and Withdrawal
respectively.
244
Table 35.26
292.89 Sedative, Hypnotic, or Anxiolytic Intoxication
A. Recent use of a sedative, hypnotic, or anxiolytic.
B. Clinically signicant maladaptive behavioural or psychological changes (e.g., inappropriate sexual or
aggressive behaviour, mood lability, impaired judgment, impaired social or occupational functioning)
that developed during, or shortly after, sedative, hypnotic, or anxiolytic use.
C. One (or more) of the following signs, developing during, or shortly after, sedative, hypnotic, or anxiolytic
use:
(1) slurred speech
(2) inco-ordination
(3) unsteady gait
(4) nystagmus
(5) impairment in attention or memory
(6) stupor or coma
A. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
Table 35.27
292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal
A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
1. autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
2. increased hand tremor
3. insomnia
4. nausea or vomiting
5. transient visual, tactile, or auditory hallucinations or illusions
6. psychomotor agitation
7. anxiety
8. grand mal seizures
mental disorder.
Specify if:
With Perceptual Disturbances: This specier may be noted when hallucinations with reality testing or
auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the
person knows that the hallucinations are induced by the substance and do not represent external reality.
When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorders With Hallucinations, should be considered.
When administered, they cause relief of tension,

mental stress and anxiety. They also give a
positive feeling of calmness, relaxation and wellbeing in anxious individuals. There is improved
coping with situational pressure or psychological
problems. They also help to improve sleep. With
prolonged use, there are long-term effects that
include headache, irritability, confusion, memory

impairment, depression, insomnia and tremor.
Risks associated with injecting include transmission
of HIV/AIDS and hepatitis. Many of the users can
develop tolerance and dependence. Withdrawal
symptoms usually include insomnia, anxiety,
hypersensitivity and tremors.
245
it is a drug of abuse with no particular medical

value. It is taken orally either alone or mixed with
other substances like cannabis.
METHAQUALONE
Methaqualone is a non-barbiturate synthetic CNS
depressant. Also called mandrax, parest or qualude,
OTHER SUBSTANCES
Table 35.28
Hallucinogen Use Disorders
304.50 Hallucinogen Dependence
305.30 Hallucinogen Abuse
Hallucinogen-Induced Disorders
Hallucinogen Intoxication
Hallucinogen Persisting Perception Disorder (Flashbacks)
Hallucinogen Intoxication Delirium
Hallucinogen-Induced Psychotic Disorder, With Delusions
Hallucinogen-Induced Psychotic Disorder, With Hallucinations
Specify if: With Onset During Intoxication Hallucinogen-Induced Mood Disorder
Specify if: With Onset During Intoxication Hallucinogen-Induced Anxiety Disorder
Hallucinogen-Related Disorder Not Otherwise Specied
Other examples include psilocybin and mescaline.

Table 35.29 summarises the general features of
Hallucinogens Intoxication.
Hallucinogens
The commonest is the synthetic drug lysergic acid
diethylamide (LSD). There are other forms found
in different plants such as the morning glory seeds.
Table 35.29
292.89 Hallucinogen Intoxication
A. Recent use of a hallucinogen.

B. Clinically signicant maladaptive behavioural or psychological changes (e.g., marked anxiety or
depression, ideas of reference, fear of losing ones mind, paranoid ideation, impaired judgment, or
impaired social or occupational functioning) that developed during, or shortly after, hallucinogen use.
C. Perceptual changes occurring in a state of full wakefulness and alertness (e.g., subjective intensication
of perceptions, depersonalization, derealisation, illusions, hallucinations, synesthesias) that developed
during, or shortly after, hallucinogen use.
D. Two (or more) of the following signs, developing during, or shortly after, hallucinogen use:
(2) tachycardia
(3) sweating
(4) palpitations
(5) blurring of vision
(6) tremors
(7) inco-ordination
E. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
246
Table 35.30
Diagnostic criteria for 292.89 Hallucinogen Persisting Perception Disorder (Flashbacks)
A. The reexperiencing, following cessation of use of a hallucinogen of one or more of the perceptual
symptoms that were experienced while intoxicated with the hallucinogen (e.g., geometric
hallucinations, false perceptions of movement in the peripheral visual elds, ashes of color,
intensied colors, trails of images of moving objects, positive after-images, halos around objects,
macropsia, and micropsia).
B. The symptoms in Criterion A cause clinically signicant distress or impairment in social,
occupational, or other important areas of functioning
C. The symptoms are not due to a general medical condition (e.g anatomical lesions and infections
of the brain, visual epilepsies) and are not better accounted for by another mental disorder (e.g.,
delirium dementia, Schizophrenia) or hypnopompic hallucinations.
Table 35.31
DSM-IV-TR Diagnostic Criteria for Hallucinogen Related Disorder Not Otherwise Specied
The hallucinogen-related disorder not otherwise specied category is for disorders associated with the use
of hallucinogens that are not classiable as hallucinogen dependence, hallucinogen abuse, hallucinogen
intoxication, hallucinogen persist perception disorder, hallucinogen intoxication delirium, hallucinogeninduced psychotic disorder, hallucinogen-induced psychotic disorder, or hallucinogen-induced anxiety
disorder.
preparations. Excessive intake could lead to

intoxication. Summarised in Table 35.32.
Caffeine
This is a widely consumed substance in the form
of a beverage. It is also found in various medicinal
Table 35.32
305.90 Caffeine Intoxication
A. Recent consumption of caffeine, usually in excess of 250 mg (e.g., more than 2-3 cups of brewed
coffee).
B. Five (or more) of the following signs, developing during, or shortly after, caffeine use:
(1) restlessness
(2) nervousness
(3) excitement
(4) insomnia
(5) ushed face
(6) diuresis
(7) gastrointestinal disturbance
(8) muscle twitching
(9) rambling ow of thought and speech
(10) tachycardia or cardiac arrhythmia
(11) periods of inexhaustibility
(12) psychomotor agitation
mental disorder (e.g., an Anxiety Disorder).
247
Table 35.33
DSM-IV-TR Caffeine-Related Disorders
Caffeine-Induced Disorders
Caffeine Intoxication
Caffeine Induced Anxiety Disorder
Specify if:
With Onset During Intoxication
Caffeine-Induced Sleep Disorder
Specify if:
With Onset During Intoxication
Caffeine-Related Disorder Not Otherwise Specied
Table 35.34
DSM-IV-TR Research Criteria for Caffeine Withdrawal
A.
B.
Prolonged daily use of caffeine.

Abrupt cessation of caffeine use, or reduction in the amount of caffeine used, closely followed by
headache and one (or more) of the following symptoms:
(1) marked fatigue or drowsiness
(2) marked anxiety or depression
D. The symptoms are not due to the direct physiological effects of a general medical condition (e.g.,
migraine, viral illness) and are not better accounted for by another mental disorder.
Table 35.35
DSM-IV-TR Diagnostic Criteria for Caffeine-Related Disorder Not Otherwise Specied
The caffeine-related disorder not otherwise specied category is for disorders associated with the use of
caffeine that are not classiable as caffeine intoxication, caffeine-induced anxiety disorder, or caffeineinduced sleep disorder. An example is caffeine withdrawal.
singly targeted for new markets. It is therefore

becoming an important substance of abuse. It leads
to dependence and withdrawal effects. These are
summarised in Table 35.37.
Nicotine
This substance accounts for signicant medical
complications. Developing countries are increaTable 35.36
DSM-IV-TR Nicotine-Related Disorders
Nicotine use disorder
Nicotine dependence
Nicotine-induced disorder
Nicotine withdrawal
Nicotine-related disorder otherwise specied
248
Table 35.37
292.0 Nicotine Withdrawal
A. Daily use of nicotine for at least several weeks.
B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours
by four (or more) of the following signs:
(1) dysphoric or depressed mood
(2) insomnia
(3) irritability, frustration, or anger
(4) anxiety
(5) difculty concentrating
(6) restlessness
(7) decreased heart rate
(8) increased appetite or weight gain
mental disorder.
Table 35.38
DSM-IV-TR Diagnostic Criteria for Nicotine-Related Disorder Not Otherwise Specied
The nicotine-related disorder not otherwise specied category is for disorders associated with the use of
nicotine that are not classiable as nicotine dependence or nictone withdrawal.
Phencyclidine
This substance was once used as a human intravenous anaesthetic and analgesic. It can lead to intoxication
as summarised in Table 35.40.
Table 35.39
Phencyclidine Use Disorders I
Phencyclidine Dependence
Phencyclidine Abuse
Phencyclidine-Induced Disorders
Phencyclidine Intoxication
Phencyclidine Intoxication Delirium
Phencyclidine-Induced Psychotic Disorder, With Delusions
Phencyclidine-Induced Psychotic Disorder, With Hallucinations
Phencyclidine-Induced Mood Disorder
Phencyclidine-Induced Anxiety Disorder
Phencyclidine-Related Disorder Not Otherwise Specied
249
Table 35.40
292.89 Phencyclidine Intoxication
A. Recent use of phencyclidine (or a related substance).
B. Clinically signicant maladaptive behavioural changes (e.g., belligerence, assaultiveness, impulsiveness,
unpredictability, psychomotor agitation, impaired judgment, or impaired social or occupational
functioning) that developed during, or shortly after, phencyclidine use.
C. Within an hour (less when smoked, snorted, or used intravenously), two (or more) of the following
signs:
(1) vertical or horizontal nystagmus
(2) hypertension or tachycardia
(3) numbness or diminished responsiveness to pain
(4) ataxia
(5) dysarthria
(6) muscle rigidity
(7) seizures or coma
(8) hyperacusis
mental disorder.
Specify if:
or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that
the person knows that the hallucinations are induced by the substance and do not represent external reality.
When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations, should be considered.
Polysubstance
Table 35.41
304.80 Polysubstance Dependence
This diagnosis is reserved for behaviour during the same 12-month period in which the person was repeatedly
using at least three groups of substances (not including caffeine and nicotine), but no single substance
predominated. Further, during this period, the Dependence criteria were met for substances as a group
but not for any specic substance. For example, a diagnosis of Polysubstance Dependence would apply
to an individual who, during the same 12-month period, missed work because of his heavy use of alcohol,
continued to use cocaine despite experiencing severe depressions after nights of heavy consumption, and
was repeatedly unable to stay within his self-imposed limits regarding his use of codeine. In this instance,
although the problems associated with the use of any one substance were not pervasive enough to justify
a diagnosis of Dependence, his overall use of substances signicantly impaired his functioning and thus
warranted a diagnosis of Dependence on the substances as a group. Such a pattern might be observed, for
example, in a setting where substance use was highly prevalent but where the drugs of choice changed frequently. For those situations in which there is a pattern of problems associated with multiple drugs and the
criteria are met for more than one specic Substance-Related Disorder (e.g. Cocaine Dependence, Alcohol
Dependence, and Cannabis Dependence), each diagnosis should be made.
Specify if: With Physiological Dependence/Without Physiological Dependence
Specify if: Early Full Remission/Early Partial Remission/Sustained Full Remission/Sustained Partial
Remission/In a Controlled Environment/On Agonist Therapy
250
example, Benzhexol widely used in psychiatry is

increasingly being abused. Table 32.24 summarises
this group of other drugs and emerging drugs.
Others
New substances keep on emerging and other known
medical drugs become substances of abuse. For
Table 35.42
Other (or Unknown) Substance-Related Disorders

The Other (or Unknown) Substance-Related Disorders category is for classifying Substance-Related Disorders
associated with substances not listed in this section. Examples of these substances include anabolic steroids,
nitrite inhalants (poppers), nitrous oxide, over-the-counter and prescription medications not otherwise
covered by the 11 categories (e.g., cortisol, antihistamines, benztropine), and other substances that have
psychoactive effects. In addition, this category may be used when the specic substance is unknown (e.g., an
intoxication after taking a bottle of unlabeled pills).
SUBSTANCE ABUSE AND

HIV/AIDS
PRINCIPLES OF MANAGEMENT
Even with good prevention programmes, there will
always be people who will require professional
assistance. Substance abuse or dependence is a
treatable disease. Management of substance-related
disorder aims at assisting individuals to attain
reasonable state of function and involves taking the
patient through a multi-disciplinary programme.
Thus comprehensive management needs to
address medication response where applicable,
motivation, craving, psychological and emotional
issues, psychiatric co-morbidity, social and family
inuences, health, vocational, legal and family
consequences. The management process involves
detoxication, rehabilitation, relapse prevention,
after-care, social and vocational rehabilitation.
There is a direct relationship between use of

alcohol and other substances, and HIV/AIDS.
The mode of transmission is through needle
sharing for the intravenous drug users (IVDU).
Often, intoxication leads to poor judgement and
consequently predisposing concerned individuals
to unprotected sex, rape and sexually transmitted
diseases all of which increase the chances of
acquiring HIV/AIDS.
CO-MORBIDITY
Alcohol and other substance-related disorders often
co-exist with other psychiatric disorders, referred
to as dual diagnosis or co-morbidity. During
assessment and management of such patients, it
is important to consider the following facts: that
substance use disorders and withdrawal syndromes
may mimic psychiatric disorders and vice versa
resulting in delayed diagnosis. Substance use can
initiate, trigger or exacerbate an existing psychiatric
disorder thus complicating management. Some
individuals have used substances to self medicate
for disturbing psychiatric symptoms such as
hallucinations, depression and anxiety thus
masking the psychiatric symptoms and worsening
the disease process. Delayed recovery and relapses
are common amongst such patients.
Detoxication
This is the rst stage in treatment and is the process
of helping the individual to stop using psychoactive
substances without experiencing painful withdrawal
effects. Physical and psychiatric assessments are
performed and accompanying ailments managed
accordingly. Detoxication, which usually lasts
3 to 7 days, can be medical or psychological and
the setting may be in- or out-patient. The choice is
determined by the severity of symptoms, type of
substance used, the individual and environmental
circumstances.
In medical detoxication, medication is used to
manage the withdrawal symptoms. Patients who
251
require medical detoxication, benet from its

combination with psychological detoxication.
During medical detoxication, a substitute
medication similar to what was being used by the
client is given: alcohol Chlordiazepoxide; valium
Chlordiazepoxide; cannabis Haloperidol;
cocaine Ritalin; and heroin Methadone. In
some countries, some of the substitute medications
may not be available, especially for heroin
and cocaine. In such situations symptomatic
relief of the presenting withdrawal symptoms
in combination with psychological support is
recommended.
Psychological
detoxication
is
usually
employed in states of mild withdrawal symptoms.
Psychological means are used to assist the client
to stop consuming the substance without suffering
the withdrawal symptoms. Medical detoxication
alone without any psychosocial treatment results in
a high relapse rate of 80-95 percent within a year.
headaches, and to view these as signals of possible

relapse. Once the relapse indicators are identied,
a plan to intervene needs to be quickly enacted.
Learning from previous relapses is critical. The
relapse starts with triggers. Triggers are people,
places, objects, feelings and times which cause
cravings.
How to prevent relapse

Prevent exposure to triggers by staying away
from certain people, places and objects.
Stop the thoughts that may lead to relapse
using techniques such as thought stopping
which include:
o Relaxation: take three slow, deep breaths.
o Snapping: wear a rubber band loosely on
your wrist and every time you become
aware of a triggering thought, snap the
band and say NO to the thought
o Visualisation: imagine an on/off switch in
your head that you can turn off to stop
triggering thoughts
Schedule your time. Structure your day and ll
blocks of free time with activities.
Do something completely different.
Medications useful in relapse prevention, especially
for alcohol include Disulram, Naltrexone and
Acamprosate.
The role of psychological treatments

Psychological treatments target behavioural,
social and psychological triggers that contribute to
continued substance use. They are used to motivate
the client to stop using substances and to improve
interpersonal functioning. During such treatments,
clients are taught life skills and how to deal
with family problems and pressure from friends
who use substances. They are also taught relapse
prevention techniques by increasing involvement
in substance-free social, vocational, and family
activities. Clients are encouraged to make lifestyle
changes and address problems resulting from years
of dependence.
After-care
The after-care programme ensures that the client
follows up treatment and also serves to review the
clients status. This is achieved through effective
participation in self-help or support groups such as
alcoholic anonymous (AA), narcotic anonymous
(NA), family groups (AL, Anon), teenagers groups
(Al Teens).
Rehabilitation
This is a very important component of the treatment
cycle. It focuses on full recovery, which involves
preparing the client for social re-integration.
It further involves helping the client in skill
development and job training. Where possible,
employment opportunities are also extended to the
client.
Social and vocational rehabilitation

Social re-integration facilitates re-entry of the
client into society. This should be done through
family and community meetings. Stigma reduction
campaigns also play a big role in assisting client
acceptability in society.
The minimum duration of the management
process for the acute phase is about 4-8 weeks. The
follow-up period could last up to 12 months.
Relapse prevention
Relapse prevention is a process of not starting
substance use again through counselling. The
process of relapse follows a predictable pattern.
Signs of impending relapse can be identied by the
therapist and the patient. There are warning signs in
behaviour and thinking that patients can be taught
to monitor. They need to learn the indicators of
stress and anxiety such as insomnia, nervousness or
Treatment of the dually diagnosed client

The appropriateness of a treatment model for
an individual depends on the dual disorder
combination, symptom severity and degree of
252
impairment. However, all treatment programmes

should be comprehensive and designed to:
Engage clients, which is the process of
initiating and sustaining their participation in
the ongoing treatment process.
Accommodate various levels of severity and
disability.
Accommodate various levels of motivation
and compliance.
Accommodate clients in different phases of
treatment.
Therefore different levels of care ranging from
the more to less intense treatments should be
available.
Further reading
1. Cherskov M. (1985). Chemical dependence: A
major problem for youths. American Medical News.
November (8) : 29-30.
2. Gossip M & Grant M. (1990). Preventing and
controlling Drug abuse. WHO Geneva.
3. Levine S. (1992). The true causes of Substance Abuse.
World Health Forum C (13): 120-121 Geneva.
4. Coping with Substance Abuse: (1992). A many sided
task: WHO forum (13) IOT-111. Geneva.
253
36
Sexual Disorders, Paraphilias and Gender Issues
Khalifa Mrumbi, David M. Ndetei, Emilio Ovuga,
Anne Obondo, Benson Gakinya, Francisca Ongecha-Owuor
symptoms like vaginal discharge. This situation

is not surprising considering the nature, delicacy
and sensitivity of the problem. It is never easy for
someone to admit to having sexual difculties.
In Africa, statistics on sex issues are
difcult to obtain, mainly because the subject
is still considered a taboo. Lately, other sexual
deviations have permeated the society including
homosexuality, fetishism and masochism. These
will be discussed briey in this chapter.
SEXUAL DISORDERS
There are few documented epidemiological studies
on sexual disorders. Even those statistics available
are largely based on clinical experiences of isolated
cases which are either detected by medical workers
assessing other complaints or presented voluntarily
by clients. The detected disorders are more common
among women who complain of symptoms such
as depression, poor sleep or gynaecological
Table 36.1
Summary of Sexual and Gender Identity Disorders
1.
2.
3.
4.
The Sexual Dysfunctions

The Paraphilias
Gender Identity Disorders
Sexual Disorder Not Otherwise Specied
The psychophysiology of sexual responses
The male sexual response
Masters and Johnson assume normal sexual

behaviour as having four phases in the sexual
response cycle. These phases, namely: excitement,
plateau, orgasm and resolution occur before, during
and after sexual encounter.
The excitement stage in the male is characterised by

erection and swelling of the penis. The changes that
accompany this phase are due to the engorgement
with blood which ows more into the penis as a
result of a spinal reex action. The testicular size
increases by 50 percent. In addition, the ridge at
254
the base of the glands of the penis enlarges. The

testes are further pulled up to the perineal oor.
The orgasm phase in the male is distinguished by
a series of muscular contractions that terminate in
ejaculation. The semen is collected in the seminal
vesicles and the connected bulb-like ampullae. The
ampullae contract to force their contents into the
urethra or duct of the penis. Whereas the prostate
gland contracts to add its uids, it is the contractions
of the bu lb, vas deferens, seminal vesicles and
urethra that eject the semen with considerable
force. Other changes that occur during the orgasm
phase include vigorous gasping and contraction of
muscles of the neck, abdomen, buttocks and limbs
as well as minor alterations in the nipple. The latter
alterations take place in both the male and female.
The orgasm phase is replaced by the resolution
phase which in the male is characterised by rapid
loss of erection of the penis and returning to its
normal size. This is followed by the disappearance
of sex ush and descending of the testes. The
heightened breathing and heart rate also resume
their normal rates. Following the resolution phase,
the male cannot be aroused to an erection. This
refractory period may last several minutes to about
half an hour in most men. However, the time that
elapses before the onset of the next erection varies
and it is determined by various factors including
age, emotions and medical states.
Usually these rhythmic muscular contractions

range from 3 to 12 in number. Imminent orgasm
is signalled by the darkening of the inner lips
of the vagina. Likewise, the uterus experiences
rhythmic contractions. Unlike men, women can
still experience a series of orgasms with continued
stimulation. Their sexual excitement does not fall
before the plateau phase.
Returning to normality of tissues around
the nipples, disappearance of the sex ush and
widespread perspiration characterise the resolution
phase. Moreover, the clitoris retreats and relaxes,
the outer vaginal barrel increases in diameter, the
uterus shrinks and the passage from the vagina to
the cervix or uterus enlarges. These changes in turn
facilitate easier entrance of sperm deposited in the
vagina by the male. All these alterations take place
within seconds. Complete resolution may require
as long as half an hour.
Summary of the Sexual Response

1.
2.
The female sexual response

The moistening of the vagina with a lubricating
uid signies the early excitement phase of the
female. This phase occurs within seconds of the
onset of sexual excitement. The walls of the vagina
react to excitement by perspiring also resulting
from the vascular engorgement of the vagina.
As the excitement phase in the female continues
other physiological changes occur. These involve
the enlargement of clitoris and swelling of the
breasts. Then there is the swelling of the inner and
outer lips of the vagina and the expansion of the
vaginal barrel. The heart rate and blood pressure
increases.
The plateau phase in the female is manifested by
the swelling of the outer third of the vagina which
reduces its diameter by half. Reduction in diameter
of the vagina increases the frictional stimulation of
the penis. As the inner vagina enlarges, the clitoris
becomes more erect.
The orgasmic phase in the female is distinguished
by rhythmic muscular contractions of the outer
third of the vaginal barrel and surrounding tissues.
3.
4.
255
Desire:
Fantasies about sexual activity
Desire to have sexual activity.
Excitement:
Subjective sense of sexual pleasure
Accompanying physiological changes:
(a) In males
penile tumescence and
erection.
(b) In females
vasocongestion in
the pelvis, vaginal lubrication and
expansion, and swelling of the external
genitalia.
Orgasm:
Peaking of sexual pleasure,
Release of sexual tension
Rhythmic contraction of the perineal
muscles and reproductive organs.
In the male
the sensation of ejaculatory
inevitability, followed by ejaculation of
semen.
In the female
contractions ( not always
subjectively experienced as such) of the
wall of the outer third of the vagina.
In both males and females
anal
sphincter contracts rhythmically.
Resolution:
Sense of muscular relaxation and general
well-being.
The males are physiologically refractory to
further erection and orgasm for a variable
period of time.
Most African parents still exercise control over the

sexual behaviour of their children. The only form
of legitimate sexual outlet for many is marital sex.
Virginity, especially in females is encouraged.
Conversely, other parents encourage their children
to experiment with sex outside wedlock without
any censorship. However, the cultural and religious
inuences are currently being challenged by the
impacts associated with globalisation.
The females may respond to additional

stimulation almost immediately.
Cultural and religious inuences towards

sex and sexual behaviour
Cultural and religious beliefs are strong
determinants of attitude towards sexual behaviour.
The manner, approach, expression and preference
of sexual activity are to a large extent regulated by
these forces. Some cultures view sex not only as a
private matter but also as taboo. This is reected
in the parents refraining from discussing any
issues related to sex with their children. The Cuna
of South America, for example, remain totally
ignorant about sexual issues until marriage.
Manipulation of genitals, sex play among
children of both sexes and even observation of adult
sexual activity are tolerated and encouraged by
permissive cultures. This type of sexual behaviour
is encouraged in the belief that if children are not
exposed to, or denied an opportunity to exercise
sexual activity they may be unable to produce
offspring later. This practice is common among the
Chewa of Africa.
While some people over-indulge and view sex as
something indispensable to the extent of equating
it with food, others have a contradicting view.
They undervalue it, detest the act and associate
it with degradation, impurity and uncleanness.
Accordingly, this group may prefer to remain
celibate as a way of preserving their cleanliness
and chastity.
Still, others believe that heterosexuality within
the prescribed limits is considered noble, clean
and naturally inherent. Their view, however, is
conditional. Sex has to be practised according to
the prescribed and dened divine principles and
morals and observance of its desired and acceptable
objectives.
Sexual behaviour in some cultures is governed
by certain terms and regulations. Sexual intercourse
with a girl who has not undergone puberty rites is
punishable by death for both partners among the
Ashanti of Africa.
Incest is almost globally regarded as a serious
crime. Anyone who commits it is liable to severe
punishment. Other forms of sexual behaviour
such as homosexuality, masturbation, premarital
and extramarital practices are not only frowned
upon by religions and some cultures, but strongly
condemned.
Denition of sexual dysfunctions

Sexual dysfunctions are dened as the persistent
impairment of the normal patterns of sexual interest
or response. In other words, these are disorders
characterised by individuals failure to respond
normally in key areas of sexual functioning, making
it difcult to enjoy sexual intercourse.
Common sexual disorders

Since successful sexual performance is linked
to self-esteem, its failure may be extremely
distressing. Despite this fact, many people rarely
present their sexual problems to health care centres.
Sexual problems are more distressing among men
than women. This is ascribed to mens sexual role
and biological constitution. A wide range of causes
from biological, psychological to social, can
interfere with sexual functions.
Individuals with this disorder suffer from
recurrent and persistent lack of pleasure and show
unwillingness to participate in sex. The disorder
may vary in degree from an intense feeling of
revulsion to any sexual advance to varying sexual
arousal without orgasm. About half of the women
seeking help for sexual disorders have impaired
sexual interest. Women presenting with complaints
of low libido outnumber men by far.
The aetiological factors attributed to hypoactive
sexual desire disorder are mainly psychogenic:
inadequate stimulation, early traumatic sexual
experience, lack of physical attraction, feelings of
hostility and guilt, mistrust, resentment, unrealistic
expectations, poor self-esteem, negative body image
and depression. Other factors include fears of pain,
losing control, discovery by others and failure.
Anxieties or threats of pregnancy, contraction
of diseases such as AIDS or other venereal
diseases, may precipitate the disorder. Sometimes
organic causes may be involved. Among them are
anatomical defects, recent childbirth and effects of
drugs.
256
Hypoactive sexual desire disorder

Table 36.2
Diagnostic criteria for 302.71 Hypoactive Sexual Desire Disorder
A. Persistently or recurrently decient (or absent) sexual fantasies and desire for sexual activity. The
judgment of deciency or absence is made by the clinician, taking into account factors that affect sexual
functioning, such as age and the context of the persons life.
B. The disturbance causes marked distress or interpersonal difculty.
C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual
Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Due to Psychological Factors
Due to Combined Factors
Diagnostic indicators for this disorder include

difculties in marital relationship, history of
avoidance behaviour of sexual activity, lack of
sexual interest and complaints about poor or lack

of response by the partner. Anxiety and guilty
feelings may manifest.
Sexual aversion disorder

Table 36.3
Diagnostic criteria for 302.79 Sexual Aversion Disorder
A. Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual
contact with a sexual partner
C. The sexual dysfunction is not better accounted for by another Axis 1 disorder (except another
Sexual Dysfunction).
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
257
This disorder is characterised by persistent and

recurrent distaste to and avoidance of genital
sexual contact with a partner, therefore causing
interpersonal difculties and distress. There are
primary (lifelong) and secondary (acquired) types
of aversion disorders. In primary disorder, genital
sexual contact has never been experienced whereas
in secondary disorder, genital sexual contact had
been experienced in the past. The disorder may
be situational in which case genital sexual contact
is possible with different partners and in different
settings. It is rare in men, but more common in
women. Bancroft, reports that 2 percent of 111
males and 5 percent of 78 females presented with
the problem of lack of sexual enjoyment.
Psychological factors play a major role in the
genesis of sexual aversion disorder. A female
who has had a life event of early sexual traumatic
experience such as a rape attempt will exhibit this
disorder whenever she relives the experience.
Cognitive aspects such as low self-esteem or low
opinion of self, hostile feelings towards the partner,
fear of pregnancy and social factors like marital
conicts and affective disorders such as depression

and anxiety are among the factors that cause sexual
aversion disorder.
Certain organic causes have been implicated
in the aetiology. These can be summarised as
follows:
Endocrine: diabetes mellitus, hypothyroidism,
hyperthyroidism, Addisons disease, Cushings
syndrome, hormonal imbalance
Cardiovascular (hypertension)
Neurological diseases: multiple sclerosis,
lesions or injury to the spinal cord
Urological: uraemia, renal failure
Liver diseases
Non-specic debilitating illnesses
Gynaecological cancer: cancer of breast,
bladder, colorectal and genitals
Pharmacological agents: antihypertensives,
diuretics, tricyclic antidepressants, alcohol
and other substances
Nutritional deciencies: Vitamin A, zinc
Sexual arousal disorder

Table 36.4
Diagnostic criteria for 302.72 Female Sexual Arousal Disorder
A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate
lubrication-swelling response of sexual excitement.
C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (Copyright 2000). American Psychiatric Association.
In this disorder, recurrent or persistent male

erectile and female arousal or genital response
failure occurs. As for males erectile disorder, also
called impotence, there is an inability or failure to
obtain full erection or to maintain it long enough
for satisfactory sexual performance. There are two
kinds of erectile disorder, primary and secondary
types. In the primary type the person has never

achieved an erection. In the secondary type the
individual is currently unable to achieve and
maintain an erection. The females arousal failure
is characterised by failure of vaginal lubrication
manifested by dryness, which may be due to lack
of sexual interest.
258
Psychological factors also play a prominent part

in sexual arousal disorders either on their own or
in combination with physical factors. Performance
anxiety is common in men. Men become
overwhelmed and preoccupied by tension and
anticipation of failure, whenever sexual encounter
is attempted which is reinforced by the previous
failure. The failure can be situational.
Other maintaining factors for erectile disorder com

prise guilty feelings, perceived loss of physical
attraction, poor communication between the
couple, hostile attitudes and mistrust. Individuals
with impaired self-image and inadequate sexual
information are prone to develop sexual arousal
dysfunction.
Table 36.5
Diagnostic criteria for 302.72 Male Erectile Disorder

A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an
adequate erection.
B. The disturbance cause marked distress or interpersonal difculty.
C. The erectile dysfunction is not better accounted for by another Axis I disorder (other than a Sexual
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Erectile disorder may culminate in dysfunctional

sexual relations leading to depression and
parasuicide. In males it is perceived as loss of
masculinity and inability to procreate associated
with a sense of profound worthlessness.
A number of precipitating psychological factors

include childbirth, infertility or unfaithfulness,
unreasonable expectations, dysfunction in the
partner, aging, anxiety, depression, early traumatic
sexual experience and fear of pregnancy. Other
factors are religion, restrictive upbringing and
ignorance about sex.
Orgasmic disorders
Table 36.6
Diagnostic criteria for 302.73 Female Orgasmic Disorder

A. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase.
Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis
of the Female Orgasmic Disorder should be based on the clinicians judgment that the womans orgasmic
capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual
stimulation she receives.
B. The disturbance causes marked distress or interpersonal difculty
C The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual
259
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Male and female orgasmic disorders are

characterised by normal sexual excitement
phase but there is persistent or recurrent delay in
achieving orgasm. In primary orgasmic disorder,
the person has never reached orgasm. In secondary
orgasmic disorder, the person may have reached
orgasm in the past. Furthermore, the person may

experience orgasm, but in certain circumstances,
for example, when fantasising. In men, the disorder
is characterised by persistent delay or complete
ejaculatory failure although the erection is normal.
Table 36.7
Diagnostic criteria for 302.74 Male Orgasmic Disorder
A. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase
during sexual activity that the clinician, taking into account the persons age, judges to be adequate
in focus, intensity, and duration.
C. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another
Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Common psychological causes of orgasmic disorder

are depression, poor sexual techniques or passivity
role due to cultural reasons especially in women,
lack of affection and sexual boredom. Further
causes include aversion towards partner, fear of
pregnancy, disturbed interpersonal relationship
between the couple and shame induced by religious
beliefs.
Some diagnostic indicators are the females
complaint about her partners premature ejaculation,
marital conict, poor sexual communication, lack

of interest in sexual activity and depression.
Premature ejaculation
The diagnosis is made when the male regularly
ejaculates before, upon or immediately after
penetration without achieving satisfactory
stimulation. Factors that affect duration of the
excitement phase such as age, novelty of the sexual
partner, the frequency and duration of coitus should
be considered.
260
Table 36.8
Diagnostic criteria for 302.75 Premature Ejaculation
A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on or shortly after penetration
and before the person wishes it. The clinician must take into account factors that affect duration of the
excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual
activity.
C. The premature ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal
from opioids).
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Diagnostic factors that are indicative of premature

ejaculation disorder involve avoidance of sex or
long abstinence and difculties in relationships.
Delayed ejaculation is said to occur when
ejaculation takes too long to occur. Retrograde
ejaculation is ejaculation into the bladder. There is
invariably an organic basis for this. The person gets
the normal sensation of ejaculation but no semen
comes out. Instead it is only passed out together
with urine.
Rapid ejaculation is a conditioned response that

occurs in early coital history. It may also occur
as a result of fear of being watched or discovered
by others, especially when sexual intercourse is
performed illegally or takes place in inappropriate
situations. Factors such as negative attitude
towards the female, focus on achieving orgasm,
fatigue, hostility, inexperience and environmental
stress are implicated in the aetiology of premature
ejaculation. When it persists, it is often caused by
fear of failure. Premature ejaculation constitutes
a problem that is widely experienced by younger
men. Where organic causes are suspected, the
common ones are urethral disorders such as local
disease of the posterior urethra or prostatitis and
degenerative neurological disorders like multiple
sclerosis.
Sexual pain disorders

Sexual pain disorders are characterised by genital
pain associated with sexual intercourse. There are
two types, vaginismus and dyspareunia.
Vaginismus
Table 36.9
Diagnostic criteria for 306.51 Vaginismus (Not due to a general medical condition)
A. Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that
interferes with sexual intercourse.
C. The disturbance is not better accounted for by another Axis I disorder (e.g., Somatisation Disorder) and
is not due exclusively to the direct physiological effects of a general medical condition.
Specify type:
Lifelong Type
Acquired Type
261
Specify type:
Generalized Type
Situational Type
Specify:
The disorder is characterised by involuntary

spasms or contractions of the perineal muscles
surrounding the outer third part of the vagina when
penetration is attempted. It may occur prior to, or
during penetration. Penile penetration becomes
impossible when there is contraction of pelvic oor
muscle to the degree that the vagina does not dilate.
As a result, extreme cases of vaginismus may lead
to non-consummation of marriage.
This disorder is often psychogenic in origin and
is triggered by fears of penetration, pregnancy
and contracting diseases. Hostility and traumatic
sexual experience such as rape, incest, molestation
and strong religious beliefs, constitute the
psychological causes of vaginismus. Where organic
causes are responsible, the pain may result from

gynaecological lesions, inammation, obstetric
trauma, hymenal remnants and atrophy of the vagina
of a senile woman. Vaginismus can be detected by
fear or intolerance exhibited by the woman during
vaginal examination. The diagnostic clues are
unconsummated marriage, painful intercourse and
menstrual difculties.
Dyspareunia
Dyspareunia refers to experiencing of genital pain
on sexual intercourse. Pain after partial or initial
penetration or supercial dyspareunia may be an
indication of inadequate vaginal lubrication, which
in turn, is due to insufcient stimulation.
Table 36.10
Diagnostic criteria for 302.76 Dyspareunia (Not due to a general medical condition)
A. Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female
C. The disturbance is not caused exclusively by Vaginismus or lack of lubrication, is not better accounted
for by another Axis I disorder (except another Sexual Dysfunction), and is not due exclusively to the
direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical
condition.
Specify type:
Lifelong Type
Acquired Type
Specify type:
Generalized Type
Situational Type
Specify:
Due Psychological Factors
Other factors associated with dyspareunia include

painful lesions, scars and muscle spasms of the
vagina. When the pain is felt on deep penetration,
the probable cause is pelvic pathology such as
pelvic infection, inammation, carcinoma of cervix
and ovarian cysts. In men, urethral penile infection,

inammation and structural abnormalities may be
the causes of dyspareunia.
In some parts of Africa where circumcision of
women is practised, especially that of intermediate
262
rigid brous tissues which have lost their elasticity.

Vaginismus and dyspareunia disorders tend to coexist.
and pharaonic types, pain may be experienced. The

pain may be attributed to tight circumcision and
Subtypes of primary sexual dysfunctions

Table 36.11
Subtypes of Primary Sexual Disorders
Subtypes are provided to indicate the onset, context, and aetiological factors associated with the Sexual
Dysfunctions. If multiple Sexual Dysfunctions are present, the appropriate subtypes for each may be noted.
These subtypes do not apply to a diagnosis of Sexual Dysfunction Due to a General Medical Condition or
Substance-Induced Sexual dysfunction.
One of the following subtypes may be used to indicate the nature of the onset of the Sexual Dysfunction:
Lifelong Type. This subtype applies if the sexual dysfunction has been present since the onset of sexual
functioning.
Acquired Type. This subtype applies if the sexual dysfunction develops only after a period of normal
functioning.
One of the following subtypes may be used to indicate the context in which the Sexual Dysfunction
occurs:
Generalised Type. This subtype applies if the sexual dysfunction is not limited to certain types of
stimulation, situations, or partners.
Situational Type. This subtype applies if the sexual dysfunction is not limited to certain types of stimulation,
situations, or partners. Although in most instances the dysfunctions occur during sexual activity with a
partner, in some cases it may be appropriate to identify dysfunctions that occur during masturbation.
One of the following subtypes may be used to indicate etiological factors associated with the Sexual
Dysfunction:
Due to psychological Factors. This subtype applies when psychological factors are judged to have the
major role in the onset, severity, exacerbation, or maintenance of the Sexual Dysfunction, and general
medical conditions and substances play no role in the etiology of the Sexual Dysfunction.
Due to Combined Factors. This subtype applies when 1) psychological factors are judged to have a role
in the onset, severity, exacerbation, or maintenance of the Sexual Dysfunction; and 2) a general medical
condition or substance use is also judged to be contributory but is not sufcient to account for the Sexual
Dysfunction. If a general medical condition or substance use (including medication side effects) is sufcient
to account for the Sexual Dysfunction, Sexual Dysfunction Due to a General Medical Condition and/or
Substance-Induced Sexual Dysfunction is diagnosed.
embarrassment and shame and perhaps the fear

of the consequences of the dysfunction, such as
marital disruption, forces clients to bear with the
suffering.
Settings in which sexual complaints are
encountered include gynaecology, urology,
infertility services, psychiatry and family planning
clinics. Men tend to reveal their sexual problems
more often than females due to their perceived
sexual roles as well as pressure or demand from
their female partners.
Presentation modes of sexual problems

Sexual dysfunctions may present with somatisation
and mimic organic disorders. The presentation
occurs in the guise of emotional or psychological
complaints,
more
commonly
depression,
marital disharmony or insomnia. Sometimes
gynaecological symptoms like vaginal discharge,
infertility or requests to change contraceptive pills
might be used as a media.
Very often, sexual dysfunctions are not readily
volunteered by patients themselves. They often
admit to having sexual problems after they have
been prompted by the medical worker. Direct
presentation of sexual problems is rare, particularly
among African women. Stigma, in terms of
Investigation of sexual disorders

Sexual dysfunctions arise from the multiplicity of
aetiological causes. As such, a multidisciplinary
263
approach to assessment of sexual dysfunctions

becomes imperative. Initially, the couple is seen
separately and then in conjoint assessment sessions
where thorough history and physical examinations
are undertaken. Thorough evaluation is necessary
for the purpose of accurate and proper diagnosis
and requires the investigation of three dimensions,

namely: biological, psychological and social
factors.
The following tables give an indication of
possible causes of sexual dysfunctions.
Table 36.12
Diagnostic Criteria for Sexual Dysfunction Due to ... [Indicate the General Medical Condition]
A.
Clinically signicant sexual dysfunction that results in marked distress or interpersonal difculty
predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory ndings that the sexual
dysfunction is fully explained by the direct physiological effects of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (e.g.. Major Depressive
Disorder).
Note: Include the name of the general medical condition on Axis I, e.g., Male Erectile Disorder Due to
Diabetes Mellitus; also code the general medical condition on Axis III
Table 36.13
Diagnostic criteria for Substance-Induced Sexual Dysfunction
A. Clinically signicant sexual dysfunction that results in marked distress or interpersonal difculty
predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory ndings that the sexual
dysfunction is fully explained by substance use as manifested by either (1) or (2):
(1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication
(2) medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by a Sexual Dysfunction that is not substance induced.
Evidence that the symptoms are better accounted for by a Sexual Dysfunction that is not substance
induced might include the following: the symptoms precede the onset of the substance use or dependence
(or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after
the cessation of intoxication, or are substantially in excess of what would be expected given the type or
amount of the substance used or the duration of use or there is other evidence that suggests the existence
of an non-substance-induced Sexual Dysfunction (e.g., a history of recurrent non-substance-related
episodes).
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the
sexual dysfunction is in excess of that usually associated with the intoxication syndrome and when the
dysfunction is sufciently severe to warrant independent clinical attention.
Code [Specic Substance 1-Induced Sexual Dysfunction:
(291.89 Alcohol; 292.89 Amphetamine [or Amphetamine-Like Substance)
292.89 Cocaine; 292.89 Opioid; 292.89 Sedative, Hypnotic or Anxiolytic; 292.89 Other [or Unknown]
Substance)
Specify if:
With Impaired Desire
With Impaired Arousal
With Impaired Orgasm
With Sexual Pain
Specify if:
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the
symptoms develop during the intoxication syndrome.
264
Table 36.14
302.70 Sexual Dysfunction Not Otherwise Specied
This category includes sexual dysfunctions that do not meet criteria for any specic Sexual Dysfunction.
Examples include
1. No (or substantially diminished) subjective erotic feelings despite otherwise-normal arousal and
orgasm
2. Situations in which the clinician has concluded that a sexual dysfunction is present but is unable to
determine whether it is primary, due to a general medical condition, or substance induced
the onset of sexual disorders or in exacerbating

them. Traumatic events like divorce, death in the
family, job stress, infertility, childbirth and rape are
usually implicated in these disorders. Interpersonal
strained relationships and self-image are additional
areas for assessment.
Biological investigations
Depending on the availability of resources and
clinical presentation investigations should be
carried out starting with the more relevant ones.
The investigations may include: sex hormonesoestrogens, androgens and other hormones, blood
sugar, Haemogram, micro-nutrients, urinalysis.
Where special investigations such as Nocturnal
Penile Tumescence (NPT) are available, they
can be used to distinguish psychogenic erectile
dysfunction from organic disorder.
Intervention for sexual disorders

Intervention in the sexual disorder, particularly
when psychological treatment is indicated is not
void of difculties. Conict of professional beliefs
and ethics between the therapist and client may
occur, thus erecting a barrier between the two. The
therapist may not for religious or cultural reasons,
be ready to involve the clients partner, who is not
legally married, in the treatment. Similarly, the
client may object to the therapists suggestion to
masturbate as part of the treatment. It is important
for the therapist to be aware of their own belief
systems so that they do not interfere with the
intervention process. In cases where they may feel
uncomfortable to handle any given sexual problem,
the best thing to do is to refer the client to another
therapist.
Psychological investigations
Information about the nature and course of the
sexual problem is sought, for example, how it
started, under what circumstances and how it
has progressed. The clients family background
and childhood for the purpose of establishing
negative attitudes towards sex should be obtained.
Assessment of stressful situations, strong emotional
states and fears the individual may be experiencing
is necessary. Information on recent changes in the
client, his environment, sexual information, type of
relationship with partners, interests and psychiatric
history, also need to be gathered. It is important
to assess the individuals misconceptions about
sexuality and sexual responses as well as the
partners experience and sexual techniques. Use of
alcohol and other psychoactive substances, clients
appearance and mood or mental state, including
depression and anxiety should be explored.
Other aspects to be noted include predisposing,
precipitating and maintaining factors and more
importantly, what the presented problem means to
the client. Access to information pertaining to all
these aspects will provide the basis for which the
decision whether the dysfunction is psychogenic or
organic can be made.
Biological intervention
Treatment of sexual dysfunctions of organic origin
will be dictated by the diagnosis. In Africa, some
of the recently introduced methods of treatment
include intracavernosal injections of vasoactives,
such as papaverine and phentolamine which
are physical treatments for erectile dysfunction.
Yohimbine is a drug useful in men with psychogenic
erectile dysfunction and for whom psychological
therapy is not possible. Hormone replacement
therapy is indicated for women who have sexual
dysfunction secondary to genito-urinary atrophy
and for those whose loss of libido is secondary to
declining levels of oestrogen.
Social investigations
Oral Medications
Gathering information on various life events

is always crucial since they can have a role in
Sildenal (Viagra): is a biological drug therapy

for managing erectile disorder. It is taken
265
modication. Behaviour therapy in combination

with psycho-education has a favourable treatment
outcome. It puts emphasis on treating the partners
as a unit rather than as separate individuals.
Essentially, marital therapy and sensate focus
exercises are also indicated in almost all types of
sexual disorders. The assumption is that many times,
deteriorated marital relationship is a precursor
of a sexual dysfunction in one member of the
couple. This situation generates anxiety that may
keep on maintaining the problem. Anxiety can be
appropriately and adequately managed by sensate
focus technique. In marital therapy, the couple may
be instructed to try the tease technique in which the
partner keeps caressing the man. If the man gets
an erection, the partner stops caressing him until
he loses it. In essence, sensate focus exercises are
intended to reduce performance anxiety.
One of the important steps in behaviour therapy
is to facilitate better sexual communication in a
marriage. Communication training is designed
to improve sending skills such as eye contact,
voice projection, body posture, and receiving
skills including active listening, verication and
acknowledgement, and rewarding the partner
playing the senders role. In its original form,
behaviour therapy in some instances requires a
surrogate or substitute, where a male client has
no female partner in order to accomplish this
principle.
The couple is then taught the anatomy and
physiology of sexual response. This step is followed
by assignments or graded tasks and exercises
usually carried out at home involving four stages:
non-genital sensate focus, general sensate focus,
vaginal containment without movements and
containment with movements.
In the non-genital sensate focus, mutual
stimulation or touching of the body is allowed, but
not the genitals or intercourse. The major aim of
this exercise is to experience tactile and pleasurable
sensations resulting from being touched, massaged
and caressed and to explore pleasurable sites of
each others body.
When this stage is successfully performed, the
couple is given permission to proceed to stimulating
the entire body with the exception of intercourse.
The couple then moves on to the next stage with
permission to engage in sexual intercourse without
movements. This stage is then followed by sexual
intercourse and the ban on making movements
is lifted. The general principle governing these
graded exercises is that only when the couple is
orally and produces positive results in about

40 to 70 percent of clients. This drug increases
the ow of blood to the penis within one hour
of ingestion thereby activating erection during
sexual activity. Sildenal is contraindicated in
patients with certain cardiovascular diseases.
Tadalal (Cialis): Contraindications are mainly
cardiovascular diseases.
Psychosocial intervention
Treatments for sexual disorders focus on three
dimensions: reducing a patients performance
anxiety or increasing stimulation or both. Several
options exist and are applied depending on the
expertise of the therapist and nature of the sexual
problem.
Education and simple counselling will involve
following areas:
1. Psychoeducation whose aim is to allay myths
2. Simple counselling aimed at allaying myths,
exploring with an aim of improving lovemaking
techniques and communication
3. Behaviour theories methods:
Marital and sensate focus which are applied
in all sexual disorders.
Marital relations-anxiety treatment in
marital therapy and sensate focus
In all forms of sexual dysfunctions, provision of
basic information and education on the aetiology
constitutes an important component. The rationale
is that this component is capable of allaying myths
and misconceptions about sex that the clients may
harbour. Consequently, the information provided
will make the clients understand the nature of their
dysfunctions.
Simple counselling is concerned with providing
basic information concerning normal sexual
response, countering certain myths and
misconceptions surrounding sexual activity and
offer guidance on specic techniques such as
trying various positions during lovemaking. It also
attempts to increase the level of communication of
the couples to enhance sexual performance.
Behavioural interventions
Sensate focus exercises (behaviour therapy)
This is a structured treatment format or technique
introduced by Masters and Johnson based on
behavioural theories. It is based on the principle
that sexual dysfunctions are learned maladaptive
behaviours which can be altered by behaviour
266
between her thumb and forenger at the level of

the frenulum. When the male partner is about to
ejaculate he signals his partner to tightly apply the
squeeze technique by squeezing the tip of the male
organ. The procedure is slightly painful and it has
to be repeated many times until the male partner
no longer ejaculates too soon. This technique
aims at facilitating the learning of voluntary
control over ejaculation. Control is achieved by
fostering the patients awareness of, and increasing
his tolerance for the pleasurable genital sensations
that accompany the intense sexual excitement
which precedes orgasm.
comfortable with one step are they allowed to

proceed to the next. The exercises involve change
of role playing in which one partner becomes the
giver and the other recipient and vice versa.
The main goal of these prescribed exercises is
to deal with the factors that contribute towards
sexual problems such as inhibition, anger,
anxiety, insecurity, guilt and low self-esteem.
These negative factors are replaced by favourable
onestogetherness, intimacy, pleasuring and
understanding without the pressure or expectations
of sexual performance.
Any difculties or obstacles that arise during
the implementation of the prescribed tasks at
home are discussed with the therapist. Partners
are also offered suggestions concerning different
coital positions in accordance with the nature of
the problem at hand. Sensate focus is indicated in
almost all forms of sexual dysfunctions. It takes
about three weeks to overcome the problem and it
depends on the tactile sensations.
Among the common sensate focus strategies
utilised for female arousal and orgasmic disorders
are self-exploration, enhancement of body
awareness and directed masturbation training.
Self-stimulation of the clitoris and the use of sexual
aids like a vibrator to increase stimulation may be
recommended. Also, the use of fantasy may help to
improve orgasm. The objective of these techniques
is to distract the client from obsessive selfobservations. Other strategies such as providing
information and education on aetiology, attitude
re-orientation, anatomy and physiological response
to stimulation, anxiety management and sensate
focus exercise, should be considered part of the
treatment.
In men, apart from sensate focus exercises,
sexual fantasies are used to treat impaired sexual
arousal disorder. Fantasies are primarily designed
to increase the arousal. The focus is also on assisting
the couples in resolving their general relationship
and on the use of sensate focus programme. Focus
sensate is highly effective in those cases where the
aetiology is a simple fear of failure. The anxiety
performance, which is usually predominant in
erectile dysfunction, can be diminished by sensate
focus exercises in which demands and pressure
from the female partner to perform are suspended.
Stop-start techniques
Squeeze technique serves as an alternative or
supplementary method to stop-start technique
which involves manual stimulation of the mans
sexual organ. Whenever the male partner is close
to ejaculation, he informs his partners to apply the
stop-start technique and then resumes after few
minutes. This process is followed by short periods
of vaginal entry when the male has acquired
condence at delaying ejaculation preferably with
the woman in the superior position. Information and
education on the aetiology of premature ejaculation
and sensate focus are also relevant here.
The programmes offered for vaginismus
disorder, consists of helping the woman become
more comfortable with her genitals and gradual
exposure to different types of vaginal penetration.
A woman may practise tightening and relaxing her
vaginal muscles until she gains more voluntary
control over them. The technique of exposure can
also be employed for sexual phobia. Relaxation
training, systematic desensitisation techniques
tailored to manage anxiety are important.
The aim of treatment for vaginismus disorder
is to extinguish the conditioned spasm of the
muscles surrounding the vagina. Systematic in vivo
desensitisation can be used. The technique involves
gradual dilation of the spastic introitus using a
vibrator, which is claimed to be effective. Insertion
of the patients nger or the use of lubricant may
also be helpful.
Cognitive and social interventions
Effectual awareness and self-instruction training
techniques are commonly used. In affectual
awareness technique, clients visualize sexual
scenes in order to discover any feelings of anxiety,
vulnerability and other negative emotions they may
have concerning sex. In self-instruction training,
patients are cognitively helped to examine and
Squeeze techniques
Squeeze technique is a method commonly used
to treat premature ejaculation. In this technique
the female partner holds the males sexual organ
267
to expect miracles, an attitude that is reected in

their dependence on clinicians and non-adherence
to prescribed tasks. These features need to be
thoroughly explored and dealt with appropriately.
The number of sessions conducted to overcome the
presented sexual problem is not xed. Generally,
patients are seen after every 2 weekssufcient
time to carry out prescribed assignments. They
may require 3 to 20 sessions or more depending on
the nature or complexity of the sexual problem.
change their negative reactions to sex. In other

words, they learn to replace negative statements
during sex with positive or coping statements.
Other therapies
Other forms of treatment for sexual dysfunctions
comprise individual and group therapy. Individual
therapy aims at examining intra-psychic factors
(conicting forces within the individual), whereas
group therapy tries to look into inter-personal
problems in clients with sexual problems.
Moreover, group therapy is envisaged to provide a
strong support system for those ashamed, anxious
or guilty about a particular sexual problem.
PARAPHILIAS
The word paraphilia is derived from two Greek
words meaning to the side of and love. They are
unusual fantasies, sexual urges and behaviours that
are recurrent and sexually arousing. They can range
from near normal behaviours to behaviours that
could hurt the person and others in the community.
The DSM-IV-TR and ICD 10 classications
of paraphilias are similar and require that the
individual experience recurrent intense sexual
urges and fantasies involving unusual objects and
activities, either acts on the urges or is markedly
distressed by them and that the preference be
present for at least 6 months. Paraphilic arousal
may be transient in some people who act out
their impulses only during periods of stress and
conict or may be obligatory to achieving sexual
arousal and gratication for some. The commonly
discussed paraphilias include paedophilia, Frotteur
ism, voyeurism, exhibitionism and sexual sadism.
One person may have multiple paraphilias.
Paraphilias are practised by a small proportion of
the population, but their insistence and repetitive
nature result in high frequency of such acts. The
actual prevalence may not be known as only a few
come to the attention of the doctors or even police.
Among legally identiable cases, paedophilia
is the most commonly reported mainly because
its victims are children and therefore likely to be
reported.
General guidelines, good practice and

practical issues
The role of the medical worker is to assist
individuals and spouses in overcoming their
sexual problems. However, they have to be
aware of their own boundaries. Not all medical
workers are comfortable with dealing with sexual
problems for various reasons. Examples include
handling homosexuality and couples who are not
ofcially married. In such instances the medical
worker should refer the clients.
Moreover, the clinician should be careful not
to reinforce what may be perceived by the client
as stigma. A clinician who becomes anxious and
embarrassed when discussing sexual matters is
likely to convey a negative message to the client that
the presented topic is a taboo, thereby reinforcing
embarrassment and shame.
Sensitivity to clients cultural and religious
backgrounds when introducing various treatment
methods is crucial. Some clients may regard
using sexual aids such as vibrators, masturbation
or erotic materials or literature as degrading,
humiliating, and in conict with their spiritual
convictions. Usually this is a type of resistance
which is not expressed directly or verbally, but
conveyed through excuses or failure to comply
with the prescribed assignments. The clinician
has mandate to suggest all possible methods of
overcoming sexual problems to the client, but he
is not expected to coerce the patient into accepting
a particular treatment package, which contradicts
their core belief systems.
In Africa, clients are rarely aware of the
fact that psychosocial factors can cause sexual
dysfunctions. As a result, they tend to expect and
demand organic diagnosis and insist on medication.
This demeanour and mentality may hamper the
interventional efforts. At other times, clients tend
Aetiology
The aetiology falls into two groups namely
psychosocial and biological. In the psychoanalytic
models, people with paraphilias have failed to
complete the normal developmental process toward
heterosexual adjustment. Improper identication
with the opposite-sex parent or improper choice
of objects for libido catharsis is suggested as the
cause of the paraphilias and disorders of gender
identity. People with paedophilia and sexual
268
and cultural practices. Of all paraphilias, the most

common form is paedophilia. For personal or
social reasons most of those people who engage
in paraphilic acts rarely come into contact with
mental health professionals unless they have come
into conict with society and the law.
sadism have a need to dominate and control

their victims to compensate for their feelings of
powerlessness during the Oedipal complex. Other
theories attribute the development of paraphilias
to early childhood experiences that condition and
socialise children to commit a paraphilic act. Child
abuse and molestation can predispose a person to
accept and desire continued abuse and insults as an
adult. Acts of paraphilia may occur as a result of
intoxication with alcohol or illicit drugs, dementia,
and personality change due to general medical
condition, manic excitement or schizophrenia. A
large proportion of persons referred for treatment
are noted to have organic ndings including
abnormal hormone levels, soft neurological signs,
chromosomal abnormalities and EEG recordings,
including seizures.
Diagnosis and clinical features

The diagnostic criteria in both DSM-IV-TR and
ICD-10 include the presence of pathognomonic
fantasies and an intense desire to act out on
the fantasy. The fantasy must cause distress
to the patient, contain unusual sexual material
that is relatively xed and show only minor
variations. Arousal and orgasm depend on the
mental elaboration or the behavioural playing out
of the fantasies. Sexual activity is ritualistic and
stereotyped, making use of degraded, reduced or
dehumanised objects.
Epidemiology
The prevalence of paraphilias in Africa is unknown
but is likely to vary due to varying sociological
Paedophilia
Table 36.15
302.2 Paedophilia
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or
behaviours involving sexual activity with a prepubescent child or children (generally age 13 years or
younger).
B. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or
interpersonal difculty.
C. The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.
Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a
12- or 13-year-old.
Specify if:
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both
Specify if:
Limited to Incest
Specify type:
Exclusive Type (attracted only to children)
Nonexclusive Type
Paedophilia is sexual urge towards arousal or

activity with a pre-pubescent child, usually aged
less than 13 years and at least 5 years younger than
the perpetrator. People with paedophilia may be
attracted to girls while others to boys and some,
to both girls and boys. The acts of paedophilia
may comprise undressing and looking at the naked
child, touching and fondling the childs erotic

zones, personally undressing and masturbating as
the child looks on or penetrating the childs mouth,
vagina or anus with the nger, penis or other object
with or without force being applied on the child.
The child victim may be threatened with grievous
bodily harm, death or may be granted extreme
269
care and affection by the perpetrator in order

to prevent disclosure. People with paedophilia
commonly shift the blame for their behaviour
on their victims who they may accuse of being
sexually provocative or of enjoying the sexual
encounters. Some societies in Uganda believe and
rationalise that having sex with pre-pubescent girls

would make them grow into beautiful and attractive
women, or that such relationships have preventive
or medicinal effect on low back pain in older men.
Paedophilia, particularly involving males, tends to
run a chronic course.
Exhibitionism
Table 36.16
302.4 Exhibitionism
behaviours involving the exposure of ones genitals to an unsuspecting stranger.
This form of paraphilia is the exposure of the

genitalia by a male to an unsuspecting female
stranger, which may be accompanied by a fantasy
that the stranger would be sexually aroused. The
person who exhibits his genitals may fantasize
sexual arousal and masturbate in the process of or
immediately after genital exposure. The exhibitioner
may derive considerable sexual gratication from
the surprise, disgust or fright expressed by the

victim. Exhibitionism usually begins before the
age of 18 years but may arise in older age. Genital
exposure, usually by older citizens and not meeting
diagnostic criteria for exhibitionism exists in some
cultures in East Africa as a signal and symbol of
curse for extreme misconduct involving younger
members of concerned families.
Fetishism
Table 36.17
302.81 Fetishism
behaviours involving the use of nonliving objects (e.g., female undergarments).
B. The fantasies, sexual urges, or behaviours cause clinically significant distress or impairment in social,
C. The fetish objects are not limited to articles of female clothing used in cross-dressing (as in Transvestic
Fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator).
The word Fetishism is derived from a Portuguese

term which implies an artistically created artifact.
It conveys a special symbolism or magical meaning
and varies from a particular physical attribute
or body part to a truly inanimate sexual symbol.
It involves the use of womens underpants, bras,
stockings, shoes, earrings, bracelets among others
for the purpose of achieving sexual arousal and

gratication. The individual with this disorder
may masturbate as he holds, fondles or smells
the fetish items or ask the sexual partner to wear
them to enable him derive gratication from
sexual intercourse with her. Fetishism begins
in adolescence and tends to run a chronic course.
270
Transvestism
Table 36.18
302.3 Transvestic Fetishism
A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies,
sexual urges, or behaviours involving cross-dressing.
B. The fantasies, sexual urges, or behaviours cause clinically significant distress or impairment in social,
Specify if:
With Gender Dysphoria: if the person has persistent discomfort with gender role or identity
Transvestism is the recurrent act of cross-dressing,

usually by a heterosexual male in female dressing
for the purpose of achieving sexual arousal and
gratication. While cross-dressed the person with
transvestism may fantasise that he is both his male
and female sex object. The disorder begins with
cross-dressing in childhood or adolescence and may
progress to occasional solitary cross-dressing and
eventually in regular involvement in a transvestic
subculture in which the individual may entirely
dress like a woman, wear make-up, behave like a
female and may request for hormonal therapy and
surgical procedure to become a woman. A favoured

item of cross-dressing may assume erotic value
over time and may be used during masturbation
and even sexual intercourse. In other cases, crossdressing may lose its erotic sexual arousing role
and instead become an antidote for anxiety or
depression during episodes of stress. In a rare
clinical experience in Uganda a bisexual adolescent
with better developed feminine genitalia sought
care for sexual dysphoria over having been brought
up as a male.
Sexual Masochism
Table 36.19
302.83 Sexual Masochism
behaviours involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise
made to suffer.
B. The fantasies, sexual urges, or behaviours cause clinically significant distress or impairment in social
This form of paraphilia involves seeking recurrent

real humiliation or pain from physical injuries or
psychological abuse in order to achieve sexual
gratication. The physical acts to which the
individual may subject him or herself include
beating, being tied, stabbing, cutting, receiving

electrical shocks, piercing or psychological
abuse before or during sexual intercourse or
rape. Sexual masochism tends to be chronic and
accidental deaths have been reported.
Sexual Sadism
Table 36.20
302.84 Sexual Sadism
behaviours involving acts (real, not simulated) in which the psychological or physical suffering
(including humiliation) of the vict im is sexually exciting to the person.
B. The person has acted on these sexual urges with a non-consenting person, or the sexual urges or
fantasies cause marked distress or interpersonal difculty.
271
In this type of paraphilia the individual derives sexual

excitement and gratication from the physical and
psychological suffering and humiliation that the
victim goes through before or during the paraphilic
act. Perpetrators of sexual sadism exert considerable
control over their victims by carrying out acts
such as physical restraint, blindfolding, whipping,
pinching, beating, burning, electrical shocking,
raping, cutting, stabbing, strangulation, torture,

mutilating or killing. Sexual sadism is reported to
begin in early adulthood though sadistic fantasies
may originate in childhood. Sexual sadism may be
practised with non-consenting or willing victims.
Some individuals with the disorder who experience
sadistic fantasies during sexual intercourse do
not act on their fantasies. Sexual sadism may be
chronic, lead to arrest or death of the victim.
Voyeurism
Table 36.21
302.82 Voyeurism
behaviours involving the act of observing an unsuspecting person who is naked, in the process of
disrobing, or engaging in sexual activity.
Voyeurism also known as scopophilia is the recurrent

act of observing unsuspecting, usually strangers as
they undress or engage in sexual intercourse for the
purpose of sexual arousal and gratication. Orgasm
may ensue during masturbation in the course of
peeping or subsequently in response to the memory
of the observed details. Similar behaviour not
meeting criteria for voyeurism is practised by some

Ugandan cultures to boost the morale and virility
of the male during his rst night in marriage, and to
enable the bride prove her virginity and subsequent
faithfulness to her chosen husband. Voyeurism as a
disorder begins in early teenagehood and tends to
run a chronic course.
Frotteurism
Table 36.22
302.89 Frotteurism
behaviours involving touching and rubbing against a non-consenting person.
Frotteurism is a form of paraphilia, which involves

a male rubbing his erect penis against the thigh or
buttocks of a non-consenting female, usually in
crowded situations including buses and lifts. As
the individual rubs himself, he may fantasize that

he is in a caring sexual relationship with the victim.
Frotteurism occurs between the ages of 15 and 25
years, and is rare after the age of 25 years.
272
Other paraphilias
Table 36.23
302.9 Paraphilia Not Otherwise Specied
This category is included for coding Paraphilias that do not meet the criteria for any of the specic categories.
Examples include, but are not limited to, telephone scatologia (obscene phone calls), necrophilia (corpses),
partialism (exclusive focus on part of body), zoophilia (animals), coprophilia (faeces), klismaphilia (enemas), and urophilia (urine).
intelligence, presence of normal adult attachment

and presence of only one paraphilia
Necrophilia
Necrophilia is the act of having sex with a corpse.
In some Ugandan cultures a widower would be
expected as part of burial rituals to have sex with
his dead wife as a sign of his continued love and
devotion.
Management of paraphilias
Interventions include:
External control by peers, family members
and supervisors. Prison sentences are usually
not helpful.
Drug therapy in appropriate cases, for
example, antipsychotics in schizophrenia,
antidepressants in depression and antiandrogens like Depo-Provera to reduce sexual
drive.
Cognitive behavioural therapy to disrupt learned
paraphilic patterns and modify behaviour
to make it socially acceptable. Social skills
training, sex education, cognitive restructuring
and development of victim apathy are
included. Behavioural techniques, including
desensitisation and relational training may be
used.
Insight oriented psychotherapy is a longstanding treatment approach. It helps the
patient understand the dynamics and events
that cause the paraphilia to develop, help them
deal with the life stresses better and enhance
the capacity to relate to a partner.
Zoophilia (Bestiality)
Bestiality is the recurrent sexual activity between
a human being and an animal, and may occur in
schizophrenia, dementia or substance induced
personality change psychiatric disorder.
Partialism
Victims concentrate their sexual energies on only
one part of the body to the exclusion of the others.
Masturbation
This is considered abnormal only when it is
the only type of sexual activity performed in
adulthood, occurs with such frequency as to
indicate a compulsion or a sexual dysfunction and
is consistently preferred to sex with partner.
Incest
This is sexual relations between closely related
people. There is a wide variation across different
cultures on who is a close enough relative to avoid
sexual relationship. Each cultural group norms
must be the standard measure of abnormality for
that group. However, nearly all cultural norms
prohibit father-daughter, son-mother, brother-sister
and grandchild-grandparent sexual relationships.
GENDER ISSUES
The terms sex and gender are often used
interchangeably but can be differentiated in the
following ways. Sex is dened in biological terms
based on anatomical and physiological differences
between male and female. Gender refers to
everything else associated with an individuals
sex including attributes, roles, behaviours and
personality characteristics. However, certain
attributes may be inuenced by a combination of
learning and biology. The word gender replaced
Course and prognosis

Poor prognosis is associated with high frequency
of the paraphilic act, absence of guilt and shame
and co-morbid use of substance. On the other hand,
good prognosis is associated with self-referral to the
medical worker, previous history of coitus, normal
273
women as an attempt to re-dene the approach,

with a view to understanding more comprehensively
the absence of substantive balance of relation
between the two sexes. Gender as such is a social
construct, which focuses on the assertion that the
expectations and responsibilities of both men and
women are not always biologically determined.

The analysis of womens issues within a gender
perspective seeks to present a balanced and nonsexist view with respect to participation of both
men and women in social, economic and political
spheres of livelihood.
Gender identity
Table 36.24
Gender Identity Disorder
A.
A strong and persistent cross-gender identication (not merely a desire for any perceived cultural
advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the
following:
(1) repeatedly stated desire to be, or insistence that he or she is, the other sex
(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing
only stereotypical masculine clothing
(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies
of being the other sex
(4) intense desire to participate in the stereotypical games and pastimes of the other sex
(5) strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other
sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he
or she has the typical feelings and reactions of the other sex.
B.
Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or
testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion
toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities;
In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis,
or assertion that she does not want to grow breasts or menstruate, or marked aversion toward
normative feminine clothing.
In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with
getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or
other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he
or she was born the wrong sex.
C.
D.
The disturbance is not concurrent with a physical intersex condition.

The disturbance causes clinically signicant distress or impairment in social, occupational, or other
Code based on current age:
302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults
Specify if (for sexually mature individuals):
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both
Sexually Attracted to Neither
Gender identity is seen from the time of birth when

the child is named, clothed and provided with toys.
However, infants and toddlers are usually unaware
of either sex or gender until they are about 2 years
of age. Gradually, gender identity is acquired as
the child develops a sense of self that includes

maleness and femaleness. As children grow up
they begin to appreciate and accept that gender is a
basic attribute of each individual and animals.
274
Table 36.24
302.6 Gender Identity Disorder Not Otherwise Specied
This category is included for coding disorders in gender identity that are not classiable as a specic Gender
Identity Disorder. Example include
1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia)
and accompanying gender dysphoria
2. Transient, stress-related cross-dressing behaviour
3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex
characteristics of the other sex
in the elds. These gender role stereotypes have

continued to inuence the behaviour and the
expectations of men and women.
There are indications that gender stereotypes are
fading away. For example, assertiveness. Studies
indicated that there are no sex differences in this
respect as it was back in the 1930s when it was
found that men were more assertive than women.
Changes in cultural inuences also indicate changes
in gender stereotypes. Gender role differences
are also experienced at home and in the work
place. Women politicians are normally described
as aggressive, tough, tyrannical, mean, cold and
competitive.
Traditionally, gender roles received powerful

support throughout the culture from family, peers,
and every aspect of the media. However, there is
evidence that the concept of childrens stories,
movies, television programmes and advertising is
shifting away from traditional portrayals. Young
people are therefore becoming less bound by
traditional stereotypes.
Behaviour associated with gender roles
This is the degree to which an individual identies
with the gender stereotypes of his or her culture.
Traditionally, men are expected to be powerful,
dominant and self-assertive. Even body posture
is gender stereotyped. For example, men sit with
their legs apart and arms away from the trunk while
women sit with their upper legs against each other
and arms against the trunk. Women who adopt the
male posture are seen as masculine and men who
adopt the female posture are seen as feminine.
To what extent is behaviour associated with
these dimensions? Traditional masculinity creates
interpersonal problems. For example, among
adolescent males, masculinity is associated
with having multiple sex partners. Femininity is
associated with low-self esteem.
The extreme gender role identication such
as hyper-masculinity and hyper-femininity are
associated with exaggerated versions of the
traditional role identication. The hyper-masculine
(or macho) man expresses callous sexual attitudes
towards women, enjoys danger as a source of
excitement, believes in violence and is comfortable
with rape. The analogous extreme for women is
hyper-femininity. The hyper-feminine woman
believes that relationships with men are of central
importance to her life, is a target of sexual coercion
and is attracted to hyper-masculine men.
Traditional gender roles are still powerful today
and receive strong cultural support. In recent times,
gender differentiation in the world of computer
games and other software suggest gender stereotypes
Gender stereotypes
This occurs when comprehension is associated
with maleness and femaleness in ones culture.
There are many determinants of gender stereotypes,
some subtle and some blatant, which result in the
understanding of the gender stereotypes especially
when children reach adolescence. Due to exposure
of children to stereotypes through the media and
observing parents and peers, children gradually
acquire gender stereotypes of their culture. For
example, it is alright, for girls to cry and boys to
ght. Games, clothes, hairstyles and chores around
the home tend to be gender-specic. In the African
culture, men are always in a class of their own with
women being second-class citizens.
The media propagates how women should look,
behave and be treated. Women are usually used in
advertisements to play about with the emotions
of men who constitute the largest portion of the
working force or consumers of such products.
Most advertisements are usually accompanied by
a beautiful woman scantily dressed with make-up
to win men over. The commercials urge women to
enhance their appeal to men, or gain their approval
through the use of products. In this sense the
position of a woman in the society as secondary to
that of the man is perpetuated by the media.
275
Self perception
Poverty
There are differences in self-perception between

men and women. For example, women are much
more likely to express concern and dissatisfaction
about their bodies and the general physical
appearance and even ageing is viewed to be more
negative for women than for men. Eating disorders
and their relationship with weight perception are
more common in the West than in Africa because
in the traditional African culture men are less
concerned about the weight of their romantic
partners than is the case with Western cultures.
Poverty may be dened as the inability to attain a

minimal standard of living. Women because of their
lower status are more likely to fall into the vicious
cycle of poverty and to remain poor unless steps
are taken to enable them to liberate themselves.
Gender bias is a primary source of poverty because
it prevents women from obtaining education,
training and health services.
Poverty alleviation for women means, not just
an increase in their incomes, but greater access
to productive resources such as land, capital, and
technology, plus opportunities to develop skills
needed to improve their lives.
The consequences of gender differences

Violence against women
Reproductive issues
Violence against women includes any act of

gender-based violence that results in or is likely to
result in physical, sexual, or psychological harm
or suffering to women including threats of acts
such as coercion or arbitrary deprivation of liberty,
whether occurring in public or private life. The
list of violence against women covers acts such
as rape, sexual abuse, harassment, intimidation and
discrimination in places of work.
In situations where men command resources
and make decisions, many women battle to
survive emotionally and physically. Wife beating
is common all over the world and among all
classes. This is because physical violence serves
to reinforce womens subordinate position within
the family. Deprivation and seclusion are meant to
keep women in their place and part of being in that
place can be having children.
The fact that majority of women in developing

countries are in the low-income bracket and thus
have low bargaining power means that relationships
increase their risk of STD/HIV infection. In
addition, due to economic hardships, women can
be forced to engage in risky sexual behaviour.
They also have limited power over their husbands
promiscuity, which puts them at risk of infections.
Further reading
1. Bancroft, J. (1983), Human Sexuality and its Problems.
Churchill Livingstone, Edinburgh.
2. Masters, W.H. and Johnson, V.E. (1970). Human
Sexual Inadequacy. Little Brown, Boston.
3. Kaplan, H.S. (1974). The New Sex Therapy: Active
treatment of sexual dysfunctions. Bruner/Mazle, New
York.
276
37
Lincoln Khasakhala, David M. Ndetei, Abdullah Abdelrahman, Benson Gakinya
evidence of inheritance in causation of personality

disorder. Cluster A personality disorders (paranoid,
schizoid and schizotypal) are more common in
biological relatives of schizophrenic patients than
in the controls. Cluster B personality disorders
(antisocial, border line, histrionic and narcissistic)
are associated with antisocial behavioural traits and
alcoholism while cluster C personality disorders
(obsessive-compulsive, avoidant and dependant)
have higher concordance in monozygotic twins.
Personality is the relatively stable and predictable

emotional and behavioural traits that characterise
persons in their day-to-day living. They assist an
individual to respond to a wide range of situations.
When these traits are inexible and maladaptive
and causing distress and impairment in the
functional abilities of an individual, they constitute
a personality disorder. These represent signicant
deviations from the way average individuals in a
given culture perceive, think, feel and relate to one
another.
The disorders manifest in late childhood or
adolescence (before the age of 17 years) and
persist into adulthood. Many people exhibit traits
that are not limited to a single personality disorder.
The diagnostic criteria are listed in the ICD-10 and
DSM-IV-TR classications.
Individuals with personality disorders are often
unaware of their conditions and are likely to reject
treatment. Their symptoms are alloplastic (capable
of adopting and altering external environment)
and egosyntonic (acceptable to the ego). As a
result, they are not anxious and routinely ignore
complaints from other members of the society.
Temperamental factors
Temperamental factors in childhood might also be
associated with personality disorder in adult life.
A disparity between the parents and childrens
temperament may lead to personality difculties
in adulthood. Poor parent t, that is, a poor match
between the temperament and child rearing practices
may lead to certain personality disorders.
Biological factors
The male sex hormones testosterone and 17estradial are associated with aggression and sexual
behaviour in some primates. Their role in human
beings is not clear but could be similar. Endorphins,
which are endogenous neurotransmitters that
have effects similar to those of morphine and
other exogenous opiates, are associated with
passive personality traits. Levels of 5-Hydro-indole
acetic acid (5-HIAA), a metabolite of serotonin
are low in patients who attempt suicide, and those
with impulsive and aggressive traits. Abnormal
AETIOLOGY
Genetic studies
These have been widely studied using standard
genetic study methods which have demonstrated
277
EEG changes have also been demonstrated in

patients with antisocial and borderline personality
disorders.
obsessive (rigid, dominant, harsh) and narcissistic

(selsh and aggressive). Defence mechanisms
are the unconscious mental processes that the
ego uses to resolve conict between the instincts
(wish and need) and reality and conscience. They
assist the person relieve themselves of anxiety and
depression and abandoning them may be difcult.
They are therefore important in determining the
type of personality one portrays to the public and
which denes them as individuals.
Table 37.1 gives the general diagnostic criteria
for a diagnosis for a personality disorder.
Psychoanalytic theory
Sigmund Freud, the father of psychoanalysis,
suggested that personality traits are due to xation
at one of the psychosexual stages of development
and from interplay between impulses and the
environment. He used the term character to
describe organisation of the person and identied
several such characters: oral (passive and dependent),
anal (precise, parsimonious and punctual),
Table 37.1
General diagnostic criteria for a Personality Disorder

A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of
the individuals culture. This pattern is manifested in two (or more) of the following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is inexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically signicant distress or impairment in social, occupational, or
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early
adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental
disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., head trauma).
their emotions and use the defence of projection,

that is, attribute to others impulses they are unable
to accept. They have restricted affect and emotions
and are impressed by and pay closer attention to
power and rank. They may appear business-like and
efcient but always generate fear and conict. This
disorder is life-long.
Psychotherapy is the treatment of choice. The
therapist should be forthright in dealing with these
patients. An honest apology when in the wrong and
not excuses is required. These patients dont t in
group therapies and their treatment should therefore
be individualised. It is important to set clear
limits in therapy as their behaviour can at times
be very threatening. Behaviour therapy is used to
improve social skills and diminish suspiciousness.
Pharmacotherapy is used to deal with agitation and
anxiety (Valium) with small doses of neuroleptics
(Thioridazine, Haloperidol) being used in severe
forms of agitation and quasi-delusional thinking.
TYPES OF PERSONALITY
DISORDERS
Cluster A personality disorder
Paranoid personality disorder
This is characterised by persistent and longstanding suspicion, sensitivity and mistrust of
people. They avoid responsibility for their actions,
blame others, are hostile, angry and irritable and
often interpret the actions of other people as being
deliberately demeaning and threatening. They tend
to be pathologically jealous and argumentative.
They are usually un-emotional and fail to maintain
friendly relationships. In some cases they may show
stubbornness and a feeling of self-importance.
The prevalence is higher in males than females.
It is more common among biological relatives of
schizophrenic patients. These patients externalise
278
Table 37.2
301.0 Paranoid Personality Disorder
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent,
beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
(1) suspects, without sufcient basis, that others are exploiting, harming, or deceiving him or her
(2) is preoccupied with unjustied doubts about the loyalty or trustworthiness of friends or
associates
(3) is reluctant to conde in others because of unwarranted fear that the information will be used
maliciously against him or her
(4) reads hidden demeaning or threatening meanings into benign remarks or events
(5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick
to react angrily or to counterattack
(7) has recurrent suspicions, without justication, regarding delity of spouse or sexual partner
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic
Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general
medical condition.
Note: If criteria are met prior to the onset of Schizophrenia, add Premorbid, e.g., Paranoid Personality
Disorder (Premorbid).
necessarily life-long. The percentage of those who

proceed to schizophrenia is not known.
On examination, patients are aloof, avoid eye
contact and appear eager to end the conversation.
They may be fascinated by inanimate objects
and metaphysical construct. These patients have
no schizophrenic relatives and unlike avoidant
personality have no wish for intimacy. They only
differ from schizotypal by their degree of oddities.
Psychotherapy is the mainstay of treatment. As
trust develops, they reveal a plethora of fantasies
and fear even of merging with the therapist. They are
reserved in group sessions and should be protected
against other aggressive patients. Pharmacotherapy
with small doses of antipsychotic, antidepressants
and psycho stimulants may be effective in some
patients.
Schizoid Personality Disorder

Patients display a lifelong pattern of social
withdrawal. They are emotionally cold, self
sufcient, detached and have limited ability to
express warmth or anger towards others. They
prefer solitary activities (e.g. reading) and are
preoccupied with a variety of fantasies. They
generally lead a lonely life. Their sexual life
may exist only in fantasy and they often remain
unmarried. They prefer lonely non-competitive
solitary jobs that other people nd difcult to
tolerate and tend to work at night to avoid contact
with others. The prevalence is about 7.5% in the
general population with a male:female ratio of 2:1.
It should be differentiated from schizophrenia,
schizotypal and avoidant personality disorders.
The schizoid personality disorder usually begins
in childhood and may be long-lasting but not
Table 37.3
301.20 Schizoid Personality Disorder
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of
emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
(1) neither desires nor enjoys close relationships, including being part of a family
(2) almost always chooses solitary activities
(3) has little, if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or condants other than rst-degree relatives
279
(6) appears indifferent to the praise or criticism of others

(7) shows emotional coldness, detachment, or attened affectivity
Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the
direct physiological effects of a general medical condition.
Note: If criteria are met prior to the onset of Schizophrenia, add Premorbid, e.g., Schizoid Personality
The disorder should be differentiated from

schizophrenia, borderline and paranoid personality
disorder. The disorder is related to schizophrenia
in terms of phenomenology, genetics, outcome
and response to treatment. Some patients may be
involved in the occult, strange religious practices
and cults. Ten percent of these patients eventually
commit suicide.
Treatment includes psychotherapy similar to that
offered to schizoid patients. Neuroleptics are used
in psychotic patients while antidepressants are
indicated in the depressed patient.
Schizotypal Personality Disorder

The patients are eccentric, suspicious, and show
poor interpersonal relationships. They are strikingly
odd even to lay people and have a tendency to
experience extrasensory perception e.g. telepathy
including magical thinking and superstitions.
When subjected to stress, they may experience
brief psychotic symptoms, for example, ideas of
reference, illusions and derealisation. Their inner
world is full of imagination and fantasies while their
speech is odd and often has no meaning to others.
In severe cases they may develop depression.
The prevalence is approximately 3 percent of
the general population. The sex ratio is unknown.
Table 37.4
301.22 Schizotypal Personality Disorder
A. A pervasive pattern of social and interpersonal decits marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of
behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by ve (or
more) of the following:
(1) ideas of reference (excluding delusions of reference)
(2) odd beliefs or magical thinking that inuences behaviour and is inconsistent with subcultural
norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or sixth sense; in children and
adolescents, bizarre fantasies or preoccupations)
(3) unusual perceptual experiences, including bodily illusions
(4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or
stereotyped)
(5) suspiciousness or paranoid ideation
(6) inappropriate or constricted affect
(7) behaviour or appearance that is odd, eccentric, or peculiar
(8) lack of close friends or condants other than rst-degree relatives
(9) excessive social anxiety that does not diminish with familiarity and tends to be associated with
paranoid fears rather than negative judgments about self
Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.
Note: If criteria are met prior to the onset of Schizophrenia, add Premorbid, e.g., Schizotypal Personality
280
is before the age of 15 years and is often diagnosed

as a conduct disorder. Prison population have a
high prevalence of his disorder. It is 5 times more
common in rst-degree relatives with the disorder
than among controls.
Where childhood hyperkinetic disorder (ADHD)
is associated with conduct disorder, there is
increased risk of developing adult antisocial
personality disorder. It is a chronic disorder with a
poor prognosis. Depressive disorders, somatisation
disorder and substance abuse are some of the
recognised co-morbid disorders. Important
investigations include a thorough neurological
evaluation including an EEG. Soft neurological
signs suggest minimal brain damage.
Psychotherapy is administered in a hospital setup where the patients are conned. They may be
engaged in group therapy. Pharmacotherapy is
used to deal with symptoms of anxiety, rage and
depression.
Cluster B Personality Disorder

Antisocial personality disorder
This disorder is also called dissocial disorder in
ICD-10. The individuals with antisocial personality
disorder may present as normal and sometimes
even pleasant. However, they often have a history
of disregard for, and violation of the rights of
others. They are often known to lie, steal, ght and
abuse substances. The disorder begins in childhood
with symptoms occurring earlier in girls than
boys. As adults, they cannot be trusted and do not
adhere to societal norms. They often fail to sustain
relationships and have no concern for the feelings
of others. They are intolerant to frustration and
often indulge in impulsive behaviour. They have
a tendency to violence and many get involved in
repeated crimes.
The prevalence of antisocial personality is 3
percent in men and 1 percent in women. The onset
Table 37.5
301.7 Antisocial Personality Disorder
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15
years, as indicated by three (or more) of the following:
(1) failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly
performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal prot
or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical ghts or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour
or honour nancial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or
stolen from another
B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder with onset before age 15 years.
D. The occurrence of antisocial behaviour is not exclusively during the course of Schizophrenia or a
Manic Episode.
some association with somatisation disorder. The

patients tend to exhibit fewer symptoms with age.
Due to their attention seeking behaviours, some
patients get in trouble with the law, may abuse
drugs or be promiscuous. In interviews, they are
cooperative and eager to give details, make frequent
slips of the tongue and generally use very colourful
language. Their major defence mechanisms are
dissociation and repression. Differential diagnosis
includes somatisation disorder and borderline
personality disorder.
Histrionic personality disorder

This type of personality disorder is characterised
by excessive display of emotions, dramatisation
and extroversion. The individual has attention
seeking behaviour and are over-concerned with
physical attractiveness. Their relationships are
supercial and dont last long. They tend to be
dependent on others, demanding and have endless
need for reassurance. The prevalence of histrionic
personality is around 2-3 percent in the general
population with more females than males. There is
281
The patients are usually unaware of their feelings

and clarication of the same is important
in psychotherapy. Psychoanalysis, group or
individual is probably the treatment of choice.

Pharmacotherapy is useful in treatment of anxiety
and depression.
Table 37.6
301.50 Histrionic Personality Disorder
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and
present in a variety of contexts, as indicated by ve (or more) of the following:
(1) is uncomfortable in situations in which he or she is not the centre of attention
(2) interaction with others is often characterized by inappropriate sexually seductive or provocative
behaviour
(3) displays rapidly shifting and shallow expression of emotions
(4) consistently uses physical appearance to draw attention to self
(5) has a style of speech that is excessively impressionistic and lacking in detail
(6) shows self-dramatization, theatricality, and exaggerated expression of emotion
(7) is suggestible, i.e., easily inuenced by others or circumstances
(8) considers relationships to be more intimate than they actually are
Borderline personality disorders
state of crisis. It affects 1-2 percent of the general

population, being twice as common in women as
men. They employ projective identication as their
main defence mechanism. The disorder is stable as
patients change little over time.
Psychotherapy is the treatment of choice
but usually difcult for both the patient and
therapist. Patients do well in hospital settings
in which they receive intensive individual and
group therapies. Additionally, occupational,
recreational and vocational therapies are helpful
to these patients. Medications are useful to deal
with specic symptoms that interfere with the
overall functioning of the patient. These include
antidepressants, anxiolytics and mood stabilisers
as the symptoms may dictate.
Patients with this disorder have a pattern of

instability in personal relationships, self image and
affect and have marked impulsivity. They stand
on the border between psychosis and neurosis and
have unstable mood behaviour. They are unable
to maintain relationships. They have continuous
feeling of boredom and marked fear of abandonment
often leading to damaging behaviour, e.g. stealing,
reckless spending or uncontrolled gambling. They
may have a labile affect, uncontrollable anger, stressrelated paranoia or dissociation, show unpredictable
behaviours and experience short-lived psychotic
episodes. This disorder overlaps with histrionic,
narcissistic and anti-social personality disorders
with some scholars questioning the validity of this
diagnosis. They almost always appear to be in a
Table 37.7
301.83 Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked
impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by ve (or more)
of the following:
(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behaviour covered in Criterion 5.
(2) a pattern of unstable and intense interpersonal relationships characterised by alternating between
extremes of idealization and devaluation
(3) identity disturbance: markedly and persistently unstable self-image or sense of self
(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance
abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour
covered in Criterion 5.
282
(5) recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability,
or anxiety usually lasting a few hours and only rarely more than a few days)
(7) chronic feelings of emptiness
(8) inappropriate, intense anger or difculty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical ghts)
(9) transient, stress-related paranoid ideation or severe dissociative symptoms
disorders. There is a higher than usual risk in

the offspring of parents with the disorder. It is
chronic and difcult to treat. These patients handle
aging very poorly as they inappropriately cling to
youthful attributes and values, for example, beauty
and strength. They are therefore more vulnerable
to mid-life crisis. Psychotherapy is difcult as
the patients are unwilling to renounce narcissism
for progress to be made. Psychoanalysis may
be attempted. Patients with mood swings and
depression may benet from mood stabilisers and
antidepressants.
Narcissistic personality disorder

Narcissism is a pattern of grandiosity, need for
admiration and lack of empathy. Narcissistic
individuals have a heightened sense of selfimportance and entitlement. They believe they are
unique in some way and behave accordingly. They
are envious of others, arrogant and expect favours
from others but do not reciprocate these favours.
Affected persons have fragile self-esteem and are
prone to develop depression. The prevalence is one
percent in the general population and the disorder
overlaps with histrionic and anti-social personality
Table 37.8
301.81 Narcissistic Personality Disorder
A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy,
beginning by early adulthood and present in a variety of contexts, as indicated by ve (or more) of the
following:
(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be
recognized as superior without commensurate achievements)
(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
(3) believes that he or she is special and unique and can only be understood by, or should associate
with, other special or high-status people (or institutions)
(4) requires excessive admiration
(5) has a sense of entitlement, i.e., unreasonable expectations of especially favourable treatment or
automatic compliance with his or her expectations
(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
(8) is often envious of others or believes that others are envious of him or her
(9) shows arrogant, haughty behaviours or attitudes
called anxious personality disorder. They avoid

occupations requiring close interpersonal contact
and only become involved if they are certain to be
liked. They perceive themselves as being inferior
and socially inept hence avoid personal risks
because of embarrassment. Their main personality
trait is timidity.
The disorder shows signicant overlap with
borderline, schizoid, schizotypal, dependent,
Cluster C Personality Disorder

Avoidant personality disorders
Patients are persistently anxious and show great
sensitivity to criticism or rejection by others,
which may lead to social withdrawal. They show
a great desire for companionship and are generally
shy. They display a pattern of social inhibition,
feelings of inadequacy and hypersensitivity to
negative evaluation. In ICD-10, the disorder is
283
paranoid and self-defeating personality. Social

phobia is also a differential diagnosis.
The prevalence is 1-10 percent. They desire
social interaction unlike the schizoid patient but
are prone to developing anxiety and depression
when their support system fails. The patients are
able to function normally if they live in a protected
environment. Some marry and have children

but live their lives surrounded only by family
members. Assertiveness training and other forms
of behavioural therapy are applied. Adjuvant
anxiolytics and antidepressant therapy may be
required.
Table 37.9
301.82 Avoidant Personality Disorder
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
(1) avoids occupational activities that involve signicant interpersonal contact, because of fears of
criticism, disapproval, or rejection
(2) is unwilling to get involved with people unless certain of being liked
(3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed
(4) is preoccupied with being criticised or rejected in social situations
(5) is inhibited in new interpersonal situations because of feelings of inadequacy
(6) views self as socially inept, personally unappealing, or inferior to others
(7) is unusually reluctant to take personal risks or to engage in any new activities because they may
prove embarrassing
schizoid, schizotypal personality disorders and

some forms of anxiety disorders like agoraphobia.
They are at an increased risk of depression
especially associated with loss of the person they are
dependent on. The prognosis is however favourable
with treatment. Treatments include insightoriented psychotherapy, which enables patients
to understand the antecedents of their behaviour
and with the support of the therapist become more
independent, assertive and self-reliant. Respect for
feelings of attachment no matter how pathological
is important in the treatment process. Other
benecial therapies include behavioural therapy,
assertive training, family and group therapies.
Patient with anxieties, for example panic attacks
require additional treatment with anxiolytics and
antidepressants.
Dependent Personality Disorder

This disorder is characterised by pervasive patterns
of dependent and submissive behaviour related to an
excessive need to be taken care of. The patients are
indecisive, lack initiative and avoid responsibility.
They fear being alone and usually seek others on
whom they can depend. They are often pessimistic,
passive and cannot express aggressive feelings.
They cling to others for fear of abandonment and
often persevere maltreatments for long periods. The
disorder is more common in females and constitutes
2.5 percent of all personality disorders. Persons
with chronic physical illnesses in childhood are at a
higher risk of developing this disorder in adulthood.
The differential diagnosis includes histrionic,
Table 37.10
301.6 Dependent Personality Disorder
A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and
fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by ve
(or more) of the following:
(1) has difculty making everyday decisions without an excessive amount of advice and reassurance
from others
(2) needs others to assume responsibility for most major areas of his or her life
(3) has difculty expressing disagreement with others because of fear of loss of support or approval.
284
Note: Do not include realistic fears of retribution.

(4) has difculty initiating projects or doing things on his or her own (because of a lack of self-condence
in judgment or abilities rather than a lack of motivation or energy)
(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering
to do things that are unpleasant
(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for
himself or herself
(7) urgently seeks another relationship as a source of care and support when a close relationship ends
(8) is unrealistically preoccupied with fears of being left to take care of himself or herself
although men are more affected than women. It

often affects rst-born children.
There is a genetic component as rst-degree
relatives of disordered individuals are affected
more frequently than the general population. The
defence mechanism they use is rationalisation,
isolation, intellectualisation, reaction formation
and undoing. The course is variable and not
predictable. The disorder should be differentiated
from delusional disorder, schizophrenia and major
depressive disorder. These patients often know they
are suffering and seek treatment. Free association
and non-directive therapy are treatments of choice,
though counter transference problems are common.
Medications may be used to alleviate anxiety and
other symptoms.
Obsessive Compulsive Personality Disorder

This is characterised by emotional constriction:
orderliness, perseverance, stubbornness and
indecisiveness. In the ICD-10 the disorder is called
Anankastic personality disorder. Distinct patterns
of perfectionism and inexibility are salient
features of the disorder. The patient becomes
preoccupied with rules, regulations, neatness, order
and achievement of perfection. The individuals are
mostly formal, serious and generally lack a sense
of humour. They marginalise or alienate other
people and are often uncompromising. Their fear of
mistakes renders them indecisive. They can tolerate
prolonged routine work and any disturbance or
change of their routine causes them considerable
anxiety. The prevalence of the disorder is unknown
Table 37.11
301.4 Obsessive-Compulsive Personality Disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control,
at the expense of exibility, openness, and efciency, beginning by early adulthood and present in a variety
of contexts, as indicated by four (or more) of the following:
(1) is preoccupied with details, rules, lists, order, organization, or schedules, to the extent that the
major point of the activity is lost
(2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project
because his or her own overly strict standards are not met)
(3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
(not accounted for by obvious economic necessity)
(4) is overconscientious, scrupulous, and inexible about matters of morality, ethics, or values (not
accounted for by cultural or religious identication)
(5) is unable to discard worn-out or worthless objects even when they have no sentimental value
(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of
doing things
(7) adopts a miserly spending style toward both self and others;
(8) money is viewed as something to be hoarded for future catastrophes
(9) shows rigidity and stubbornness
285
Other Types of Personality Disorders

Table 37.12
301.9 Personality Disorder Not Otherwise Specied
This category is for disorders of personality functioning (refer to the general diagnostic criteria for a
Personality Disorder on that do not meet criteria for any specic Personality Disorder. An example is the
presence of features of more than one specic Personality Disorder that do not meet the full criteria for
any one Personality Disorder (mixed personality), but that together cause clinically signicant distress
or impairment in one or more important areas of functioning (e.g., social or occupational). This category
can also be used when the clinician judges that a specic Personality Disorder that is not included in the
Classication is appropriate. Examples include depressive personality disorder and passive-aggressive
personality disorder.
Passive-aggressive personality disorders
MEASUREMENT INSTRUMENTS
FOR PERSONALITY
Persons with this disorder have concealed

obstructionism, stubbornness, procrastination and
inefciency. This behaviour is a manifestation of
underlying aggression which is expressed passively.
In DSM-IV, the disorder is called negativistic
personality disorder. They lack a clear vision
about their lives, lack condence and are typically
pessimistic about the future. Suicide attempts are
common though only 1 percent succeed in it. The
disorder needs to be differentiated from histrionic
and borderline disorders.
Treatments include supportive psychotherapy
and confrontation, which may be more helpful in
changing the patients behaviour. Antidepressants
should be prescribed if and when clinical conditions
dictate.
There is a growing list of instruments used in

diagnosis and assessment of personality disorders.
They include self-rated instruments and structured
interviews:
Structured clinical interview for DSM-IIIR,
SCID by Spitzer et al
Personality diagnostic questionnaire 4, PDQ4
International personality disorder examination
IPDE, based on ICD-10.
Personality assessment schedule PAS.
The dimensional assessment of personality
problems by Liveley et al.
It is worth noting that the eld of personality
disorders is far from settled and change may be
forthcoming in the future in terms of classication,
diagnosis and management.
Other Personality Disorders

There are other personality disorders listed in the
DSM-IV include:
Depressive: characterised by lifelong traits
that fall along the depressive spectrum. They
are anhedonic, duty bound, self doubting and
chronically unhappy.
Sadomasochistic
personality
disorders:
characterised
by
elements
of sadism, masochism or both.
Further Reading
1. Kaplan, H.I, Sadock, B. J and Grebb, J. A, Personality
Disorders in: Synopsis of Psychiatry (1995). Middle
East Ed. Mass publishing Co. Cairo, Egypt.
2. Gelder,M. Gath, D. and Mayou,R. Personality and its
Disorders. In: Concise Oxford Textbook of Psychiatry
(1994) Oxford University Press
3. Goodman, R and Scott, S. Child Psychiatry, (2005),
Blackwell, London
286
38
Schizophrenia and other Psychotic Disorders
Caleb Othieno, Abdullah Abdelrahman, David M. Ndetei, Mohamedi B. Sebit ,
Seggane Musisi, Gad Kilonzo, Christopher P. Szabo
greater chronic disability than any other mental

disorder, in part because of its early age of onset
and the stigma of insanity
In both developed and developing countries,
schizophrenia is associated with excess mortality
from a variety of causes associated with poor
self-care, inadequate nutrition, heavy smoking,
and medical neglect. At least part of this excess
mortality is preventable.
A high proportion of better outcomes for
schizophrenia in developing countries has been
reported by numerous investigators. The reasons
for this are unknown, but involve interactions
between specic genetic and environmental factors.
Research on this topic could have fundamental
implications for the management and treatment of
schizophrenia in both developing and developed
countries.
Schizophrenia and other psychotic illnesses
can be controlled with a variety of treatments
that offer signicant returns in terms of symptom
improvement, quality of life and reintegration into
the community. The choice of an antipsychotic
therapeutic agent, however, must involve a balance
between several potentially conicting factors:
clinical efcacy, prole and incidence of adverse
effects, acceptability and likelihood of treatment
adherence, and cost-effectiveness.
INTRODUCTION
Schizophrenia is a term that was coined by the
German psychiatrist, Bleuler in 1911 replacing the
term Dementia Precox, which had been proposed by
Emil Kraeplin in 1898. It refers to a severe mental
disorder that results in personality deterioration
and loss of touch with reality that manifest as
hallucinations and delusions. Schizophrenia
may be considered a syndrome characterised by
certain signs and symptoms. Initially considered
a functional disorder with no organic or medical
cause, research in the neurosciences suggests that it
has a biological cause. A number of drugs are now
available that can control most of the symptoms of
the disorder.
SUMMARY OF FINDINGS
SCHIZOPHRENIA IN
DEVELOPING COUNTRIES6
The average lifetime risk of schizophrenia is about 1
percent. Compared to its incidence and prevalence,
the social and economic costs of schizophrenia
are disproportionately high. The condition causes
Source: Committee on Nervous system disorders in Developing countries. Board on Global Health, Institute of Medicine.
Neurological, Psychiatric and Developmental Disorders National Academy Press, Washington D.C. 2001
287
Figure 38.1: Untreated schizophrenic patient
bond; the term schizotypal personality describes

those who, in addition to their deciencies in social
relationships, show negative thinking, perception,
communication and behaviour. The premorbid
personality should be differentiated from the
prodromal phase of the disorder.
EPIDEMIOLOGY
Schizophrenia affects about one percent of the
general population. The male:female ratio is 1:1,
but the disease has an earlier onset in males with a
peak in the 15-25 year old age group compared to
that in females which is 25-35 years. Close relatives
of those affected have a higher risk of developing
the disorder. Thus, monozygotic twins of
schizophrenic patients have a prevalence rate of 47
percent, and children of schizophrenic patients, 40
percent. In society there is an observed downward
social drift, suggesting that affected individuals
either move into lower classes, or fail to rise up,
because of the illness. In cities, the incidence of
schizophrenia in children of schizophrenic parents
is twice that of those in rural areas, suggesting that
social stressors may inuence the development of
schizophrenia in persons at risk. Schizophrenic
patients occupy about half of psychiatric hospital
beds. Approximately 50 percent of schizophrenic
patients have attempted suicide. No specic
personality type is envisaged, but many people
who develop schizophrenia show traits such as
hypersensitivity, shyness, unsociability, lack
of emotion and paranoid attitudes. Difculty
in personal relationships and social isolation
inevitably result. The term schizoid personality is
used to describe persons with reduced capacity to
HISTORY OF SCHIZOPHRENIA
In 1898, Kraeplin classied the severe mental
illnesses into two main groups: the manicdepressive psychoses and dementia praecox. He
dened the latter as occurring in clear consciousness
and affecting the internal connections of the mind.
This was seen as disturbances in the emotional and
volitional spheres. He further divided them into the
catatonic, hebephrenic and paranoid types. Eugene
Bleuler in 1911 coined the term schizophrenia to
describe the split in the psychic functions and also
added a fourth type, simple schizophrenia. His
diagnosis criteria for the disorder, known as the
4As, were as follows:
1. Association: loosening of associations
described as the thought disorder.
2. Affect: disturbances in emotions.
3. Autism: the subjective withdrawal into ones
own inner world of fantasy.
288
Table 38.1
A CLINICAL OVERVIEW OF SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
1. Schizophrenia
Clinical features:
A disturbance that lasts for at least 6 months and
Includes at least 1 month of 2 or more active-phase symptoms.
The symptoms include: delusions, hallucinations, disorganised speech, grossly disorganised or
catatonic behaviour, negative symptoms).
Subtypes
Paranoid,
Disorganised,
Catatonic,
Undifferentiated,
Residual
2. Schizophreniform Disorder is characterised by
A symptomatic presentation that is equivalent to Schizophrenia except
A duration of 1 to 6 months (unlike schizophrenia where a duration of at least 6 months is
required)
The absence of a requirement that there be a decline in functioning
3. Schizoaffective Disorder is a disturbance in which:
A mood episode and the active-phase symptoms of Schizophrenia occur together
Were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent
mood symptoms.
4. Delusional Disorder
At least 1 month of non-bizarre delusions without other active-phase symptoms of
Schizophrenia.
5. Brief Psychotic Disorder
A psychotic disturbance that lasts more than 1 day and remits by 1 month.
6. Shared Psychotic Disorder
7.
8.
9.
A disturbance that develops in an individual who is inuenced by someone else who has
an established delusion with similar content
Psychotic Disorder Due to a General Medical Condition

Psychotic symptoms are judged to be a direct physiological consequence of a general medical
condition.
Substance-Induced Psychotic Disorder
Psychotic symptoms are judged to be a direct physiological consequence of a drug of abuse, a
medication, or toxin exposure.
Psychotic Disorder Not Otherwise Specied
Psychotic presentations that do not meet the criteria for any of the specic Psychotic Disorders
dened above or psychotic symptomatology about which there is inadequate or contradictory
information.
4. Ambivalence: The occurrence of strong,

but conicting feelings directed towards the
same object.
These concepts were difcult to describe and
apply. Therefore, Kurt Schneider in 1959 made an
attempt to operationalise the denition further by
describing certain signs and symptoms that were
pathognomonic of schizophrenia.
Schneiders rst-rank symptoms of

schizophrenia
Voices commenting: hallucinatory voices
commenting on ones actions in the third
person.
Voices discussing or arguing: hallucinations
of two or more voices discussing or arguing
about oneself.
289
Audible thought (cho de la pense): hearing

ones own thoughts aloud.
Thought insertion: the insertion, from an
outside source of thoughts that are experienced
as not being ones own.
Thought withdrawal: the withdrawal of
thoughts from the mind by an alien agency.
Thought broadcast: the experience that ones
thoughts are broadcast and made accessible to
others.
Made will, made inuence: the experience that
ones will is controlled by an alien inuence.
Made acts: the experience that acts executed
by ones own body, are the actions of an alien
agency, rather than oneself.
Made affect: the experience of emotion
that is not ones own, attributed to an alien
inuence.
Somatic passivity: bodily function is controlled
by an alien inuence.
Delusional perception: the attribution of a
totally unwarranted meaning (delusion) to a
normal perception.
AETIOLOGY
Schizophrenia is not a single disorder but a group
of different illnesses. Therefore, the aetiology is
multi-factorial. The model for integrating these
aetiological factors is the stress-diathesis model. It
postulates that an individual may have a specic
vulnerability (diathesis), which, when acted upon
by some outside stresses causes the symptoms of
schizophrenia to appear. In the most general stressdiathesis model, the stress can be either biological
or environmental. The biological component can
be either as a result of brain tumour, infection or
environmental stressors, which can be a family
conict or death of a close relative. The biological
basis of a diathesis can be further shaped by
epigenetic inuences, such as drug abuse,
psychosocial stress or trauma. Until a specic
aetiological factor for schizophrenia is identied,
the stress-diathesis model is the most practical way
to conceptualise the available data and theories.
Table 38.2: Risk Factors and Antecedents of Schizophrenia

Risk Factor or Antecedent
Estimated Effect Size

(odds ratio or relative risk)
Familial (family member -with schizophrenia)

Biological parent
Two parents
Monozygotic (identical) twins
Dizygotic (non-identical twins)
Nontwin sibling
Second-degree relative
7.0-10.0
37.0
45.0-50.0
14.0
9.0-12.0
1.1
Social and demographic

Low socioeconomic status
Single marital status
Stressful life events
Migrant/minority status (e.g., Afro-Caribbeans in U.K.)
Urban birth
3.0
4.0
1.5
1.7-10.7
1.4
Pregnancy and birth-related

Obstetric complications
Birth weight < 2000 g
Birth weight < 2500 g
Perinatal brain damage
2.0-4.4
6.2
3.4
6.9
Neurodevelopmental
Early central nervous system infection
Epilepsy
Low 1Q (< 74)
Social adjustment difculty in childhood and adolescence
4.8
2.3
8.6
30.7
A description of the international study of schizophrenia conducted by the World Health Organisation. Social Psychiatry and
290
Neurotransmitters
CLINICAL SIGNS AND

SYMPTOMS
The major neurotransmitter hypothesis for

schizophrenia states that there is a hyperactivity of
dopaminergic systems. All effective antipsychotic
drugs bind to dopamine receptors. Drugs that
increase dopamine (e.g. amphetamine and cocaine)
aggravate or trigger schizophrenia. There is some
evidence that ephinephrine activity is increased in
schizophrenia, leading to increased sensitisation,
which cannot be properly ltered out by the
brains of schizophrenics. Another hypothesis is
that of decreased Gamma Aminobutyric Acid
(GABA) activity resulting in hyperactivity of
dopaminergic neurons.
General considerations
There is no clinical sign or symptom that is
pathognomic for schizophrenia, as each can be
seen in other psychiatric disorders. Therefore, in
diagnosis, mental status examination, together with
past history is important. The assessment should
involve current level of functioning as compared
with the past family history. Other mental disorders
have to be excluded. The diagnosis schizophrenia
should not be made unless there are characteristic
disturbances of thought, perception, mood, conduct
or personalitypreferably in at least two of these
areas. Effort should be made to specify one of
the sub-types of schizophrenia, according to the
predominant symptoms (Tables 38.4 and 38.5). It is
necessary to take into account the intellectual ability,
language prociency and cultural background. It is
important to conduct the interview in accordance
with the glossary of mental symptomswhere
they are classied accordingly, and the boundaries
between similar symptoms are imposed. In a crosscultural interview, the presence of a local language
translator is crucial.
Neuropathology
Many postmortem studies have reported increased
numbers of D2 receptors in the basal ganglia and
limbic system. Pathological studies in schizophrenics
have recorded consistent structural defects in these
systems, resulting in increased gliosis and some
neural atrophy in the periventricular diencephalon,
decreased number of cortical neurons in prefrontal
regions, and decreased volume of the amygdala,
hippocampus, and parahippocampal gyrus.
The majority of CT studies of the brains of
schizophrenics have reported enlargement of
lateral and third ventricles in about 50 percent
of patients and cortical atrophy of the cerebellar
vermis. In some cases, PET shows decreased
frontal and parietal lobe metabolism and relatively
high posterior metabolism. Cerebral blood ow
(CBF) studies reveal abnormality of frontal lobes
blood ow.
Clinical features
The clinical features of schizophrenia are varied,
but can be classied.
Reality distortion
This leads to delusions and auditory hallucinations. It
was initially thought that the auditory hallucinations
were more common among schizophrenics and
that visual hallucinations signied the presence of
an organic or medical condition, but this has not
always been the case.
Genetic theory
Relatives of schizophrenics are at risk. Incidence
of schizophrenia in such families is higher than
in the general population. While in the general
population the incidence is one percent, incidence
in rst-degree relatives is 10-12 percent. In
children where both parents are schizophrenics
it is 40 percent. Adoption studies reveal a risk to
an adopted child which is the same as if the child
had been brought up by his biological parents.
Children born to non-affected parents but raised by
a schizophrenic parent do not have the same risk.
Disorganisation
This manifests as thought disorder, inappropriate
affect and bizarre behaviour. The formal thought
disorder results in incoherent speech. In severe
cases, the words may be so mixed up (word salad)
making it difcult to understand.
291
Table 38.3: An Overview of the ICD-10 and DSM-IV Criteria for Diagnosis of Schizophrenia
ICD-10 Schizophrenia (F20)
DSM-IV Schizophrenia (295)
One month or more of at least one of the following

symptoms:
(a) thought echo, withdrawal, insertion, broadcasting
(b) delusions of control and passivity
(c) voices; 3rd person, commentary, coming from
part of body
(d) persistent delusions
A. One month or more of at least two of the following

symptoms:
(a) delusions
(b) hallucinations
(c) disorganized speech
(d) grossly disorganized or catatonic behavior
(e) negative symptoms
or at least two of the following:

(e) persistent hallucinations accompanied by
delusions
(f) incoherence, irrelevant speech, neologisms
(g) catatonic signs
(h) negative symptoms
(i) signicant consistent change in personal
behavior
Exclude:
Full manic or depressive episode preceding
the onset of schizophrenic symptoms Organic brain
disease Alcohol or drug intoxication or withdrawal
B. Social and occupational dysfunction

One or more areas affected (work, relationships, selfcare)
C. Duration
Continuous symptoms and signs for >
6 months These 6 months must include:
At least 1 month of symptoms meeting criterion
A
Various combinations of prodromal and residual
symptoms Exclude:
Schizoaffective and mood disorder
Substance use or a medical condition Autism or
pervasive developmental disorder
Source: World Health Organisation. The ICD-10 Classication of Mental and Behavioural Disorders. Clinical description
and diagnostic guidelines. World Health Organization, Geneva, 1992.
DSM-IV Criteria Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Psychomotor poverty (core negative symptoms).

Avolitionlack
of
initiative,
decreased
spontaneous movement, poverty of speech and
blunted or attened affect are the main negative
symptoms. Others are poor grooming, anhedonia
and social withdrawal.
A classication based on the presence of positive
symptoms (Type I) and negative symptoms (Type
II) had been suggested. The latter were associated

with poor response to the antipsychotic drugs and
the presence of structural brain changes. Type I on
the other hand had good response to the typical
antipsychotic drugs and minimal or no structural
brain abnormalities.
Table 38.4: Major Diagnostic Criteria for Schizophrenia

Schizophrenia
A. Characteristic symptoms: Two (or more) of the following, each present for a signicant portion of time
during a 1-month period (or less if successfully treated):
(1)
(2)
(3)
(4)
(5)
delusions
hallucinations
disorganised speech (e.g., frequent derailment or incoherence)
grossly disorganised or catatonic behaviour
negative symptoms, i.e., affective attening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a
voice keeping up a running commentary on the persons behaviour or thoughts, or two or more voices
conversing with each other.
292
B. Social/occupational dysfunction: For a signicant portion of the time since the onset of the disturbance,
one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly
below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to
achieve expected level of interpersonal, academic, or occupational achievement).
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., activephase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal
or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or
more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual
experiences).
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With
Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed
Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have
occurred during active-phase symptoms, their total duration has been brief relative to the duration of the
active and residual periods.
E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another
Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least a month (or less if successfully treated).
Schizophrenic Subtypes
There are several subtypes of schizophrenia
summarised in the table below:
Table 38.5: Subtypes of schizophrenia
Schizophrenia Subtypes
The subtypes of Schizophrenia are dened by the predominant symptomatology at the time of evaluation.
295.30 Paranoid Type
A type of Schizophrenia in which the following criteria are met:
A. Preoccupation with one or more delusions or frequent auditory hallucinations.
B. None of the following is prominent: disorganized speech, disorganized or catatonic behaviour, or
at or inappropriate affect.
295.10 Disorganised Type
A type of Schizophrenia in which the following criteria are met:
A. All of the following are prominent:
(1) disorganized speech
(2) disorganized behaviour
(3) at or inappropriate affect
B. The criteria are not met for Catatonic Type.
295.20 Catatonic Type
A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:
(1) motoric immobility as evidenced by catalepsy (including waxy exibility) or stupor
(2) excessive motor activity (that is apparently purposeless and not inuenced by external stimuli)
(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a
rigid posture against attempts to be moved) or mutism peculiarities of voluntary movement as
evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped
movements, prominent mannerisms, or prominent grimacing echolalia or echopraxia
293
295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for
the Paranoid, Disorganized, or Catatonic Type.
295.60 Residual Type
A type of Schizophrenia in which the following-criteria are met:
A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or
catatonic behavior.
B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or
two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd
beliefs, unusual perceptual experiences).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental disorders, Fourth Edition, Text Revision
hospital, especially if they are living alone or have

inadequate social support.
DIFFERENTIAL DIAGNOSIS
Investigations
Other psychotic disorders
It is essential to perform a physical examination

and laboratory tests to rule out other medical
conditions including malaria, typhoid and HIV/
AIDS. Chief among these are the infective
disorders and substance use. Simple toxicology
screensurine tests for opiates, cannabis and
amphetamines are available in some laboratories.
Where this is lacking, careful history and telltale
signs such as stained burnt ngers in cannabis
smokers and needle marks in intravenous drug
users are helpful. Khat intoxication should also
be borne in mind. Brain imaging is necessary in
suspected intracranial pathology or head injury, but
it is not routinely done in resource-poor countries
and centres, because of the costs and availability
of facilities.
Other psychotic disorders are: schizophreniform

psychosis and schizoaffective disorder; psychotic
disorders due to medical conditions; mood disorders;
and those due to drugs such as amphetamines, khat
(catha edulis), cannabis, cocaine and steroids.
Medical conditions
Infections: for example syphilis, AIDS, viral
encephalitis
Head trauma and cerebrovascular accidents.
Intracranial space occupying lesions: for
example tumour or abscess.
Epilepsy.
Metabolic disorders: for example hyper or
hypothyroidism.
Treatment
Comorbid disorders
Biological and pharmacological
Substance use: alcohol and drug dependence;

cannabis-induced psychosis; conduct disorder or
other antisocial behaviours.
The introduction of neuroleptics starting with

chlorpromazine in the 1950s revolutionised the
treatment of schizophrenia. It made the patients
more manageable. The antipsychotic drugs target
symptoms such as hallucinations and delusions. A
wide range of drugs are now available. In selected
cases, patients may benet from drug combinations,
but it is more common to use single antipsychotics
and change over if they are ineffective after a 6week trial period. Some of the commonly used
antipsychotic drugs are:
MANAGEMENT
In a patient with an acute attack or remission of
schizophrenia, a decision has to be made whether
or not to admit the patient to hospital. Factors
to consider include severity of the symptoms,
concurrent medical conditions, social support
available and risk of harm to self and others.
Thus, patients with orid symptoms and grossly
disorganised behaviour are better managed in the
The typical (for details see Table 61.1)

1. Conventional antipsychotics
2. Phenothiazines: Chlorpromazine
294
3. Butyrophenones: Haloperidol
4. Piperazines: Fluphenazine and Triuoperazine
5. Thioxanthines: Thiothixene
In addition to the above, other drugs such

as carbamazepine also have antipsychotic
properties. Lithium carbonate is probably more
effective in cases with marked affective symptoms
or schizoaffective disorders.
Electroconvulsive therapy may be used in cases
of catatonic schizophrenia for rapid response.
Atypical antipsychotic (for details see Table 61.2)

They comprise Clozapine, Olanzapine, Quetiapine,
Risperidone and Ziprasidone
Table 38.6: The typical anti-psychotics
Generic name of drug
Phenothiazines aliphatic:
Chlorpromazine)
Average daily dose in mg or

monthly
Potency ratio composed with

l00mg chlorpromazine
100-300mg 8 hourly
1:1
Phenothiazines-piperazine:
Triuroperazine
Perphenazine
Fluphenazine decanoate
Fluphenazine hydrochloride
Phenothiazines Piperidine:
Thioridazine
Pericyazine
5-10mg 8 hourly
8-32mg /24 hours
25-100 IM per month
2- 6 mg 8 hourly
1:50
1:10
200-600
75
1:1
1:10
Butyrophenones:
Haloperidol
2-40
1:50
Thioxanthene:
Flupenthixol Decanoate
20-40mg per month
Others:
Zuclupenthixol decanoate
Zuclopenthixol acetate
Clothiapine
Pimozide
Sulpiride
200 400mg IM monthly

50-150 mg IM every 2-3 days
120 - 160
2-6mg daily
800
1:40
1:1
*The above doses are just guidelines. The practitioner is advised to familiarise themselves with prevailing practices.
social abilities, self-sufciency, practical skills

and interpersonal communication. Adaptive
behaviours are reinforced by praise or tokens
which can be redeemed for desired items (e.g.
more hospital privileges, cigarettes). Consequently,
the frequency of maladaptive or deviant behaviour
(e.g. talking loudly, talking to oneself in public,
bizarre posturing), is reduced.
Psychosocial treatments and rehabilitation

Most schizophrenic patients benet from the
combined use of antipsychotics and psychosocial
treatment. Psychotherapy alone is no substitute
for drug therapy. The task is not to choose
either drugs or psychotherapy, but to integrate
psychosocial therapies with pharmacotherapy.
Psychosocial rehabilitation now includes such
services as supervised shelters, training in social
and occupational skills, lessons in daily hygiene
and food preparation, and rehabilitation in specic
areas of functional impairment.
Family therapy
It has been demonstrated that specic approaches
to family therapy can reduce the relapse rates of
some schizophrenic patients. Families with socalled high expressed emotion can have hostile,
critical, emotionally over-involved or intrusive
interactions with the schizophrenic patient. If these
behaviours are directly modied, the relapse rate
for such patients may be dramatically reduced.
Behavioural therapy
Treatment planning for schizophrenia should
address both the abilities and decits of the
patient. Behavioural techniques use token
economies and social skills training to increase
295
Acute or gradual onset: prognosis is better in

acute onset with a clear triggering factor as
opposed to gradual onset.
Premorbid personality: premorbid social
withdrawal and other schizoid traits predict
a poor outcome. Those with social contacts
outside the home have a better prognosis.
Comorbid disorders: these include depression,
substance use and the presence of structural
brain changes. The last two are associated with
a poor prognosis.
Age at onset and having a family history of
schizophrenia have not been consistently
associated with either a poor or good
outcome.
Group therapy
Group therapy with schizophrenic patients
generally focuses on real-life plans, problems
and relationships. Group therapy is particularly
effective in reducing social isolation, increasing
sense of cohesiveness, and improving reality
testing for patients with schizophrenia. Groups led
in a supportive manner, rather than an interpretive
one, appear to be more helpful for schizophrenic
patients.
Social skills training
Social skills can be dened as those interpersonal
behaviours required to attain instrumental goals
necessary for community survival and independence
and to establish, maintain, and deepen
supportive and socially rewarding relationships.
Applying behaviour analysis principles to identify
and remedy decits in social behaviours, the medical
worker uses a variety of techniques including
focused instructions, role modelling, feedback, and
social reinforcement.
MORTALITY
Schizophrenics have a higher mortality than that
of the general population and suicide remains
the leading cause of death. Other causes include
accidents, cardiovascular disorders, respiratory
infection, thyroid disorders, secondary substance
abuse and HIV infection.
Individual psychotherapy
Supportive psychotherapy is the type most often
employed. Establishing a relationship is often a
particularly difcult task; the schizophrenic patient
is desperately lonely, yet defends himself against
intimacy and trust and is likely to become suspicious,
anxious, hostile or regressive. Scrupulous observance
of distance and privacy, simple directness, patience,
sincerity, and sensitivity to social conventions are
preferable to premature informality.
OTHER PSYCHOTIC DISORDERS

The following disorders may be considered under
this group: acute and psychotic disorders; brief
schizophreniform
psychosis;
schizoaffective
disorder; psychotic disorder due to a general
medical condition; substance induced psychotic
disorder; shared psychotic disorder; delusional
disorders, culture-bound psychotic syndromes and
post-partum psychosis.
COURSE AND PROGNOSIS

The notion that schizophrenia is a chronic
disease with an invariably downward progression
and deterioration in personality is no longer
true. Complete remission is possible after an
acute psychosis. Following an acute attack and
the remission of symptoms, maintenance therapy
should be continued for at least one year.
There is no xed set of accurate predictors
of outcome in schizophrenia, but the following
prognostic factors have been studied:
Negative symptoms: the presence of these
indicate a poorer prognosis.
Sex: females tend to be better socially
adjusted.
Marital status: prognosis is better in those who
are married.
Acute and brief psychotic disorders

This refers to the psychotic states of rapid onset (48
hours or less) with pleomorphic symptomatology
changing and variable. The symptoms may be
similar to those of schizophrenia. In these cases,
the term schizophreniform psychosis (DSM-IV)
is used. The term schizophreniform was proposed
by Gabriel Langfeldt in 1939, who argued that by
denition, schizophrenia was chronic and at least 5
years of observation was required for the diagnosis
to be made. There is usually an identiable stressor
such as bereavement or other psychological trauma
in these acute or brief psychotic disorders. Wimmer
in 1916 had given the term psychogenic psychosis
to describe reactive psychoses occurring after
296
schizophrenia, bouffe dlirante (puff of madness)

or cycloid psychosis. In the acute psychoses, full
recovery occurs within 3 months. A small number
of patients may develop persistent disabling
states.
psychosocial trauma. The following additional

terms are also used: acute polymorphic psychotic
disorder without symptoms of schizophrenia,
delire demble (immediate delusion), and acute
polymorphic psychotic disorder with symptoms of
Table 38.7: Features of Brief Psychotic Disorder
298.8 Brief Psychotic Disorder
A. Presence of one (or more) of the following symptoms:

(1) delusions
(2) hallucinations
(3) disorganised speech (e.g., frequent derailment or incoherence)
(4) grossly disorganised or catatonic behaviour
Note: Do not include a symptom if it is a culturally sanctioned response pattern.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full
return to premorbid level of functioning.
C. The disturbance is not better accounted for by a Mood Disorder With Psychotic Features, Schizoaffective
Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical condition.
Specify if:
With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently
in response to events that, singly or together, would be markedly stressful to almost anyone in similar
circumstances in the persons culture
Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently
in response to events that, singly or together, would be markedly stressful to almost anyone in similar
circumstances in the persons culture
With Postpartum Onset: if onset within 4 weeks, post-partum
Schizoaffective Disorder
Table 38.8
295.70 Schizoaffective Disorder
A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive
Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for
Schizophrenia.
Note: The Major Depressive Episode must include Criterion A1: depressed mood.
B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the
absence of prominent mood symptoms.
C. Symptoms that meet criteria for a mood episode are present, for a substantial portion of the total duration
of the active and residual periods of the illness.
D. The disturbance is not due to the direct physiological effects [of a substance (e.g., a drug of abuse, a
medication) or a general medical condition].
Specify type:
Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and
Major Depressive Episodes)
Depressive Type: if the disturbance only includes Major Depressive Episodes
297
The classication of psychotic disorders having

both schizophrenic and affective symptomatology
has always generated a lot of controversy. DSM-IVTR denes schizoaffective disorder as a disorder
with concurrent symptoms of both schizophrenia
and mood disorder, which cannot be diagnosed as
either one or the other.
when both the mood and schizophrenic symptoms

are pronounced. Schizophreniform disorder
affective type diagnosis can be made if the duration
of illness is less than 6 months.
Treatment
The absence of uniformity in dening
schizoaffective
disorder
also
complicates
the treatment. Schizomanic patients respond
positively to Lithium or Carbamazepine, but the
combination with neuroleptics is a better choice.
There are options for schizodepressive patients
(e.g. depressive and catatonic or paranoidal) using
neuroleptics having anti-depressant properties
such as sulpiride, antidepressants or ECT in
refractory cases. In maintenance therapy, Lithium
or Carbamazepine should be used.
Diagnostic criteria for Schizoaffective Disorder

The border between schizophrenia and mood
disorders is not sharply delimited once one looks
at the different criteria of different systems. For
example, the symptomatology of schizoaffective
disorder can, for example, be depressive and
paranoidal, depressive and catatonic, or manic
and paranoidal. Additional features that can help
in diagnostic formulation are the tendency to
cyclic course with good remissions and more
benign natural course of illness when compared to
schizophrenia. The diagnosis should be made only
Schizophreniform Disorder
The clinical features are summarised below.
Table 38.9
295.40 Schizophreniform Disorder
A. Criteria A, D, and E of Schizophrenia are met.
B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month
but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be
qualied as Provisional.)
Specify if:
Without Good Prognostic Features
With Good Prognostic Features: as evidenced by two (or more) of the following:
(1) onset of prominent psychotic symptoms within 4 weeks of the rst noticeable change in usual behaviour
or functioning
(2) confusion or perplexity at the height of the psychotic episode
(3) good premorbid social and occupational functioning
(4) absence of blunted or at affect
submissive person in whom the symptoms are

induced. More than two people may be involved
starting from the primary patient in which case
they are known as folie trois, folie cinq up to
folie douze.
Shared Psychotic Disorder

A patient who has had a long relationship with
another psychotic patient may develop similar
symptoms of the primary patient. In the reported
cases, the disorder typically involves two people
(folie deux) the dominant person and the
298
Table 38.10: Shared psychotic disorder

297.3 Shared Psychotic Disorder (Folie a Deux)
A. A delusion develops in an individual in the context of a close relationship with another person(s), who
has an already-established delusion.
B. The delusion is similar in content to that of the person who already has the established delusion.
C. The disturbance is not better accounted for by another Psychotic Disorder (e.g.. Schizophrenia) or a
Mood Disorder With Psychotic Features and is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
described: persecutory, litigious, somatic, jealous,

erotomanic, grandiose and mixed and unspecied.
The litigious variety (querulous paranoia)
involves a delusion of being wronged in some
way. The differential diagnoses in the persecutory
disorder include paranoid schizophrenia, paranoid
and antisocial personality disorders; substancerelated disorders, organic brain disorders
including dementia, epileptic disorders and
obsessive-compulsive disorder.
Delusional Disorders
Delusional Disorders include those clinical states
in which delusions are the main or prominent
feature and the criteria for other conditions such as
schizophrenia (which may present with delusions)
are not met. The epidemiology of these disorders
has not been fully determined. The disorders are
likely to run a life-long course and to show increased
psychopathology with the passage of time. The
following types of delusional disorders have been
Table 38.11
297.1 Delusional Disorder
A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned,
infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 months
duration.
B. Criterion A for Schizophrenia has never been met.
Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the
delusional theme.
C. Apart from the impact of the delusion(s) or its ramications, functioning is not markedly impaired and
behaviour is not obviously odd or bizarre.
D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative
to the duration of the delusional periods.
Specify type (the following types are assigned based on the predominant delusional theme):
Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual
Grandiose Type: delusions of inated worth, power, knowledge, identity, or special relationship to a
deity or famous person
Jealous Type: delusions that the individuals sexual partner is unfaithful
Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently
treated in some way
Somatic Type: delusions that the person has some physical defect or general medical condition
Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates
Unspecied Type
299
and behaviours that include impulsivity, lack of

remorse and delinquency.
Somatic subtype
This disorder has also been described as
monosymptomatic hypochondriacal psychosis. The
delusions may involve the skin or could be related
to ugliness or misshapen body parts (dysmorphic
delusions), the body odour or halitosis (bad
breath). The delusions involving the skin include
parasitosis the thought that there are parasites
under the skin. Abnormal sensations (dysaesthesis)
could occur and in some cases may be associated
with trichotillomania and onychotillomania.
The differential diagnoses include paranoid
schizophrenia, substance-related disorders, other
organic brain disorders, severe depressive disorder
with hypochondriacal delusions, somatoform
disorder with hypochondriacal delusions,
somatoform disorder especially body dysmorphic
disorder, obsessive-compulsive disorder and
factitious disorder.
Delusional disorderjealous sub-type

This involves unreasonable jealousy, thoughts
and behaviour based on dubious evidence. In this
disorder, there could be a recognisable psychiatric
illness or a personality disorder characterised by
jealousy, suspiciousness and over-possessiveness.
The jealousy persists and reinforces itself over
time.
Persistent delusional symptoms and disorders
The paranoid spectrum ranges from delusional
disorder to paraphrenia and paranoid schizophrenia.
Possible aetiology include genetic factors, organic
brain lesion, chronic alcoholism (pathological
jealousy), substances such as amphetamines
and cocaine, temporal lobe or limbic involvement
and an excess of dopamine activity in certain brain
parts.
Psychodynamic theories include regression from
a homosexual phase to a primary narcissistic phase;
homosexual feelings unacceptable to the individual
are transformed by projection into suspiciousness
and rejection.
Delusional disordererotomanic type

Delusions of love, usually relating to a public gure
or celebrity occur in this disorder. Invariably the
intentions are never declared directly to the targeted
person. Instead, the affected individuals insist
that they communicate secretly. The differential
diagnosis includes schizophrenia especially the
paranoid type in which the erotomania coexists
with other delusions, orid hallucinations and
more widespread thought disorders. A major mood
disorder in the depressive or manic phase as well
as organic disorders should be ruled out. When
untreated, the disorder is likely to worsen over
time and forensic complications may occur.
Delusional disordermixed and unspecied

types
Other disorders associated with persistent delusion
include:
Delusional misidentication syndromes
(DMIS).
Capgras syndrome (illusion of doubles).
Fregoli syndrome: the belief that one or more
individuals have altered their appearance to
resemble familiar people, in order to persecute
or defraud the individual.
Intermetamorphosis: A becomes B and B
becomes C and so on.
Doppelgnger phenomenon: the syndrome of
subjective doubles.
Delusional disordergrandiose type

The differential diagnoses in this disorder include
mania, schizophrenia, and organic disorder such as
cerebral syphilis, affecting especially the prefrontal
cerebral lobes, which cause labile mood, disinhibited
behaviour and some degree of cognitive decits. In
antisocial personality disorder, the individual feels
above the law and may express grandiose ideas
Psychotic Disorders due to General Medical Conditions

Table 38.12
293.XX Psychotic Disorder Due to ... [Indicate the General Medical Condition]
A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or laboratory ndings that the disturbance
is the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder.
300
Code based on predominant symptom:

.81 With delusions: if delusions are the predominant symptom
.82 With Hallucinations: if hallucinations are the predominant symptom
Coding note: Include the name of the general medical condition on Axis I, e.g., Psychotic Disorder Due to
Malignant Lung Neoplasm, With Delusions; also the general medical condition on Axis III.
Note: If delusions are part of Vascular Dementia, indicate the delusions by the appropriate subtype, e.g.,
Vascular Dementia, With Delusions.
Substance Induced Psychotic Disorder

Table 38.13
Substance-Induced Psychotic Disorder
A.
Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight
that they are substance induced.
(1) the symptoms in Criterion A developed during, or within a month of. Substance Intoxication
or Withdrawal
(2) medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced.
Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance
induced might include the following: the symptoms precede the onset of the substance use (or medication
use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of
acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given
the type or amount of me substance used or the duration of use; or there is other evidence that suggests
the existence of an independent non-substance-induced Psychotic Disorder (e.g., a history of recurrent
non-substance-related episodes).
Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or
withdrawal syndrome and when the symptoms are sufciently severe to warrant independent clinical
attention.
Specify the Substance
Specify if
With Onset During Intoxication: if criteria are met for intoxication with the substance and the symptoms
develop during the intoxication syndrome.
develop during, or shortly after, a withdrawal syndrome.
Psychotic Disorders Not Otherwise Specied

Table 38.14
298.9 Psychotic Disorder Not Otherwise Specied
This category includes psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech,
grossly disorganized or catatonic behaviour) about which there is inadequate information to make a specic
diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do
not meet the criteria for any specic Psychotic Disorder.
Examples include
1. Postpartum psychosis that does not meet criteria for Mood Disorder With Psychotic Features,
Brief Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, or SubstanceInduced Psychotic Disorder
301
2.
3.
4.
5.
Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted, so that the
criteria for Brief Psychotic Disorder are not met
Persistent auditory hallucinations in the absence of any other features
Persistent non-bizarre delusions with periods of overlapping mood episodes that have been present
for a substantial portion of the delusional disturbance
Situations in which the clinician has concluded that a Psychotic Disorder is present, but is unable to
determine whether it is primary, due to a general medical condition, or substance induced
Post-partum Psychosis
This presentation occurs within 8-12 weeks of
delivery. In DSM-IV-TR terms it is classied as
Psychotic Disorder Not Otherwise Specied
Culture-Bound Psychotic Syndromes

A number of cultural variants of the syndromes,
though occurring mainly in non-western cultures,
are similar to the more classical syndromes
described in DSM-IV. They are discussed briey
in this text.
Some of these are:
Bouffe dlirante literary means a puff of
madness. It is an acute short-lived psychotic
state described among the French.
Amok is a disorder described among the
Malaysians characterised by dissociative
episode with persecutory idea and aggressive
behaviour. The term amok is derived from
a Malaysian word that means to engage
furiously in battle. The syndrome consists of a
sudden, unprovoked outburst of wild rage that
causes the affected person to run about madly.
Afterwards they are exhausted and have no
memory of the event. Some of them may
commit suicide. The underlying cause could
be due to schizophrenia, bipolar disorder or
major depression. A general medical disorder
such as epilepsy or a brain lesion could also
cause similar symptoms.
Shin-byung is a dissociation and possessive
disorder described among the Koreans.
Spell is a trance-like state seen in the southern
parts of the United States of America.
Koro is a delusion that the patients penis is
shrinking and may disappear into the abdomen.
The syndrome occurs in Southeast Asia and
China. In women, there is a fear of shrinkage
of the labia, vulva and breast. Cultural fears
about nocturnal emission, masturbation and
sexual over-indulgence may give rise to
the condition. It may also be the result of a
delusional disorder or part of another psychotic

disorder.
Piblokto (arctic hysteria) occurs among
Eskimos and affects mainly women. They
may scream, tear off clothing, imitate the cry
of animals or birds, throw themselves on the
snow or run about wildly. The attacks typically
last 1-2 hours. After the attack, the person
appears normal and has no recollections of the
episode. It is considered a hysterical state or
a dissociative disorder.
Wihtigo or Windigo pychosis is a delusion that
one has been transformed into a giant monster
that eats human esh. The fear of being
transformed into a wihtigo also occurs when
the person has minor symptoms concerning
the alimentary tract.
Latah also known as a startle reaction
is
characterised
by
automatic
obedience, echopraxia and echolalia in
response to minimal stimuli. The syndrome
has been described in Southeast Asia, and
among the Bantus of Africa.
Dht is a syndrome characterised by weakness,
fatigue, palpitations and sleepiness that patients
attribute to semen loss through the urine. The
exclusive occurrence and uniqueness of the
disorder among Indians has been disputed in
recent years.
Aetiology
These short-lived psychotic episodes are thought
to be expressions of overcharged mechanisms of
defence or individual psychological fragility. The
prognosis is usually favourable, but the illness may
recur in subsequent pregnancies.
Management
Indications for antipsychotic medication are as
described earlier for schizophrenia. Psychosocial
treatments are as dictated by the prevailing culture.
Specic emphasis needs to be given to the care of the
child and for its protection as well as safeguarding
302
the welfare of the mother. ECT has been found to

be quite useful in post-partum psychosis.

Further reading
Edition: Derived from Kaplan & Sadocks Synopsis
of Psychiatry, 9th Edition. (2004). Editors: Benjamin J.
Williams & Wilkins
303
39
Suicide and Suicidal Behaviour
Emilio Ovuga, Noah K. Ndosi, David M. Ndetei, Gad Kilonzo
Suicide is the intentional act of killing oneself.

Attempted suicide, also known as para-suicide, is
the unsuccessful attempt by an individual to end
his or her own life by taking a potentially lethal
action.
A foiled suicide attempt is a potentially lethal
self-destructive action, which has been prevented
by timely intervention by other persons. Death
wishes are the repeated experiences, contemplation,
or expression by an individual of a wish to die by
either natural causes or a self-destructive action.
In the majority of cases, suicidal action does not
occur abruptly, but progresses through stages
beginning with a eeting wish to die, sometimes
communicating the wish to someone, considering
the best method of dying, making plans to die
and nally executing the plan. Often, suicidal
individuals are undecided about the intentions to
end their lives. Sometimes attempted suicides are
related to a wish to obtain help in dealing with an
intolerable situation.
It is usually assumed that those who engage in
suicidal actions do so, because they wish to die.
When a suicidal attempt fails, several factors might
account for such a failure, including poor planning
or inadequate knowledge of the most effective
method to use. Watchful relatives might have
noticed evidence of self-destructive tendencies in
the individual which might have necessitated active
surveillance and hence, suicide prevention. It is
therefore essential that all forms of self-destructive
behaviour are taken seriously.
PREVALENCE
The prevalence of suicide in Africa is not known.
There are some indications that suicide and
attempted suicide rates are close to those reported
in other regions of the world, especially among
young adults. Thus, though suicide was said to
be rare among Africans, clinical experience now
supported by research indicates that this is rapidly
changing.
Attempted suicide is more prevalent among
women, the uneducated, unemployed and those
who are divorced or separated. Successful suicide
is more common among Christians than Muslims.
The global suicide rates among the youth are
particularly worrying, with a 9.1 percent mortality
among teenagers.
The methods for committing suicide vary.
Firearms, motor vehicle emissions and the use of
sharp instruments are more common in the west,
while hanging is the most commonly used method
in Africa. Other methods include jumping from a
height, poisoning and self-impelling with a knife.
Out of those who attempt suicide, 40 percent will
do it again and 10-15 percent will eventually die of
suicide. The annual suicide rate among those who
attempt it is 1-2 percent.
304
Figure 39.1: A suicidal patient is an emergency

They are in a state of acute crisis.
Those who have already attempted suicide feel
angry and guilty over their actions. However,
some may be happy they are still alive, while
others feel extremely sorry that they did not
succeed.
People who engage in self-destructive acts
lack self-control and may act impulsively
during moments of the act when they are under
intolerable stress.
Only suicidal people threaten suicide.
Suicidal persons lack the ability to communicate
their needs to others. It is usually difcult
for other people to recognise the complaints
suicidal individuals have.
People who engage in suicidal behaviour often
believe that their relatives are emotionally
uncaring and do not involve themselves in
their affairs. This is particularly more so
among adolescents or individuals in dependent
positions.
Suicidal people nd the world confusingthat
is, simultaneously bad and good, evil yet kind
and frustrating yet helpful.
During the period immediately leading to
the time of a probable suicide act, suicidal
persons progressively lose interest in life,
contemplate death more and more, become
generally aggressive, lose interest in social
ATTITUDES, MYTHS AND FACTS

ABOUT SUICIDE BEHAVIOUR
In many African communities suicide is believed
to be the result of witchcraft or bad omen. This
belief often makes it difcult to get suicidal
people to talk freely about their feelings. The fact
is suicide behaviour may be the result of emotional
trouble, social stress, and physical illness or mental
disorder.
Some people also believe that those who talk
about or threaten to commit suicide will not do
so. The fact is people who communicate a wish to
die or commit suicide might do so if no preventive
action is taken. Allowing someone with suicidal
feelings to talk about his or her experience enables
the person to achieve emotional relief, and provides
the opportunity for the individual to share his or
her personal difculties with a professional helper
and to develop skills and strategies to cope with
the problems.
CHARACTERISTICS OF
SUICIDAL PERSONS
Self-destructive individuals have the following
features:
305
events in childhood, such as parental separation

or death before the age of 15 years. Suicidal
behaviour may be due to any or a combination of
the following factors:
Problems in interpersonal relationships,
particularly between adolescents and their
parents; affecting love affairs; and difculties
in marriage. Suicidal persons usually feel that
their relatives are uncaring, unsympathetic,
and overly critical in their attitudes. By
committing suicide, the persons concerned
hopes to punish their relatives or remind them
of their responsibilities towards them.
Loss of face
General economic difculty or a failed
business venture.
Chronic physical illness, such as chronic pain,
cardiac disease, cancer, AIDS and epilepsy.
Psychiatric disorder, particularly depression,
schizophrenia, alcoholism, and other
substance use disorder. Suicide in depression
is based on the overall negative attitudes and
beliefs held by a person towards themselves.
Suicide in schizophrenia may follow a long
history of the illness and may be executed by
the individual who appears to be under good
drug control, during a period of remission
when the individual is able to evaluate his or
her life situation and take effective decisions.
In acute psychotic disorders, suicide may be in
response to threatening hallucinations or very
intense persecutory delusions. In this case, the
individual considers suicide to be a better and
courageous way to die.
Suicidal behaviour may also occur as a
result of political zeal, religious fanaticism,
belonging to a terrorist organisation and
cultural inuence.
Suicidal acts may be the result of an
interaction between these factors and the
individuals personality traits, his or her
coping abilities, and the nature and amount of
social support available to him or her.
contact, communicate their wish to die, and

make plans and preparations to die. These
features, if recognised, are a useful warning
sign of impending suicide and should be taken
seriously in clinical practice.
Suicidal people believe that their action will
end their troubles on earth.
Suicidal people generally do not have a wide
range of problem-solving skills. Suicidal
behaviour is considered to be one of the few
skills potentially self-destructive people have.
Clinical experience and research show that
suicidal people have unhappy childhood
experiences, such as parental or caretaker loss
through death, separation or divorce, long
lasting marital and family conicts between
parents, Cchild abuse and delement, and
parental history of depression and substance
dependence.
They have a history of suicide in the family,
among friends and neighbours.
MOTIVATION IN SUICIDE
BEHAVIOUR
Why do people attempt to end their lives? Many
of these reasons are not obvious and can only
be uncovered during an interview held in an
understanding and non-judgmental atmosphere.
Some of these include:
End personal problems, suffering and pains
A means to peace, rest and comfort
Punish enemies and uncaring family and
relatives
Satisfy enemies or unburden family and
relatives
Join the dead loved relatives
Punish oneself (for imagined or real personal
failures and sin)
Intense psychic pain (sadness and distress)
Process of growth and development (reincarnation)
Cry for help.
CLINICAL MANIFESTATION
The commonest presenting feature of suicidal
behaviour is a failed attempted suicide. The severity
of the clinical condition normally depends on the
method used, the time interval between the suicidal
act and admission time, and the nature of injury.
AETIOLOGY
It has been suggested that suicidal behaviour may
be genetically determined. Some individuals may
be predisposed to suicidal behaviour by stressful
306
Some patients may arrive in a coma for instance,

in organophosphate overdose, in a critical condition
with convulsions and sweating.
Suicidal behaviour may be discovered during
routine history taking, a practice which should be
encouraged. This is especially important because
many of those who commit suicide visit a medical
worker in the few months preceding their death.
Guidelines for suicide risk assessment

The following guidelines should be borne in mind
to facilitate the detection of suicide risk during
routine clinical work:
Assume that the possibility of suicide risk
exists at all times in clinical practice
Take any communication of suicide or death
wish seriously
Routinely enquire about death or suicide wish
in individuals requiring psychiatric treatment,
or in persons with chronic debilitating physical
illness
Encourage individuals with death or suicide
wishes to talk about it
Determine and assess the seriousness of the
wish to die
When in doubt, refer the patient to the nearest
psychiatric treatment facility
Be understanding, sympathetic and nonjudgmental when listening to a suicidal
individual
Use how, what, when, where or which
questions and avoid why questions to
encourage a smooth free of dialogue with the
suicidal patient
Be alert to pick indirect clues to suicidal ideas
during history taking. Examples include: I
feel I have had enough of life; I feel I have
reached the end; I curse the day I was born;
and they will regret one day.
ASSESSMENT FOR SUICIDE

RISK
Effective therapeutic and preventive services
for self-destructive people require an adequate
understanding of the origins, meaning and
relevance of the self-destructive act in every case.
Those who consider suicide seriously often go
undetected. Suicide intent scores may also not be
signicantly correlated with the communication
of intent to die. It is possible, in busy out-patient
clinics, to underestimate or overlook the extent of
an individuals subjective distress and wish to die
and either dismiss him or her.
In order to make the best use of the risk assessment
situation, it is useful to regard death wishes as
an essential distress signal requiring immediate
professional help. The expression of every death
wish should form the basis of an appropriate
management plan whether suicide risk is considered
low, moderate or high. Mild suicidal ideations
have been shown to be related to the highest future
suicide rates. The likelihood of a future suicide
occurrence is not related to current suicide attempts,
but rather the seriousness of current suicidal wishes
and, possibly, the ongoing perception, opinion, and
interpretation of the external world. On the basis
of this, the routine detection and assessment of
the seriousness of death wishes or suicide threats
should be determined.
Suicidal individuals often feel ashamed of
themselves over their suicidal behaviour due to
cultural or religious reasons. On the other hand,
individuals who regard their suicidal behaviour
as a personal affair might show overall negative
attitude towards the assessment process. The risk
assessment process should, therefore, not create
feelings of shame, guilt or personal rejection in
the individual. Reassuring remarks should make it
easier for the clinical evaluation to proceed.
CLINICAL ASSESSMENT
The aims of assessment of suicidal behaviour are
to:
Ascertain the presence, nature and intensity of
suicidal feelings
Ascertain the presence and risk of suicide
Ascertain the degree and nature of injury
Estimate the level of clinical severity
Assess the likely risk of the repetition of a
suicide act, or the execution of a suicide plan
Establish a basis for the formulation of a suicide
prevention and/or management program for
the individual.
Clinical assessment should consist of a full
history (psychiatric, social and physical), physical
307
examination, mental state assessment, and the

assessment of suicide risk.
dead. I wish I was never born. I fear I

am going to die. I feel I am dead.
Doctor: It is understandable that you should
feel so sad and discouraged under
these circumstances
Reports of the expressions of death wishes at home,
irritability, destructiveness, unprovoked acts of
aggression, wandering behaviour, isolation, and not
eating, should be explored with relatives as part of
the risk assessment procedure. Once the slightest
clue to the possible existence of a death wish has
been detected, direct questions should be put to the
individual such as: Are there occasions when you
feel you were better off dead? Have you considered
dying in response to your hardship? How would
you wish to die?
When no clues are available the subject of death
may be introduced as follows: Is there a family
history of suicide? Do you know of a relative who
committed suicide? Does the wish to die occur to
you sometimes?
Detailed history
Clinical assessment should begin with a detailed
history regarding the present and previous episodes
of suicidal behaviour. The required information
should be obtained from the person concerned. If this
is not possible, the people escorting the individual
should be requested to provide the information.
History should identify any stressful life event
which might have affected the individual; quality
of interpersonal relationships; family structure and
stability; economic situation; and physical and
mental health of the individual. Previous episodes
of medical treatment may be signicant. Previous
suicide attempts, if revealed, will be useful in the
assessment of risk of further suicide attempts. The
availability of social support systems, their strengths
and weaknesses should be noted.
In addition to a psychiatric evaluation, a
comprehensive risk assessment should also include
the evaluation of all aspects of the individuals
life, including their worldview, socio-economic
status and functioning, role status, social milieu,
and religious and cultural beliefs. The means for
carrying out a suicide act should form an integral
part of the risk assessment.
The assessment process

The assessment process should always incorporate
efforts to understand the meaning, objectives and
implications of the death or suicide wish for the
individual and relatives. Such questions are often
useful: What makes you want to die or kill yourself?
What do you hope to gain in dying? How is suicide
better than natural death? What effect will your death
have on your relatives? Assessment of suicide risk
should include the following evaluation:
Physical assessment
Physical examination should aim to assess the
degree of injury and the immediate risk of danger
to life resulting from a suicide attempt. Efforts
should be made to identify any chronic debilitating
or stigmatising physical conditions such as cardiac
and renal diseases, chronic obstructive airways
disease, malignancy, HIV/AIDS and epilepsy.
Evidence of suicide plan

Those who die of suicide will have usually planned
their suicide act before. However, the exception to
this rule involves those who respond to psychotic
experiences or stressful situations impulsively.
Mental status assessment
Impulsive suicidal behaviour
During an assessment of the mental state of the

suicidal person, attention should be paid to mood
disturbance. In addition, the nature of the persons
pre-occupation with death should be noted. The
nature of hallucinations should be dened. The
persons assessment of his or her life situation, the
quality of interpersonal relationships and level of
insight should be noted.
The assessment should use spontaneous
comments of the patients about their predicament.
They include the following:
Patient: Life is hard. I do not care about
anything. Sometimes I wish I was
This may be due to personality disorder, or

interpersonal problems with parents or as a result of
troubled love affairs. Impulsive suicidal behaviours
may eventually result in a successful suicide and
should be taken seriously, particularly if the current
episode is a repeat attempt. The absence of a suicide
plan should not be taken as evidence of lack of
determination as a signicant proportion of suicidal
individuals do not wish to reveal their suicide
intentions out of fear of being prevented.
Presence of a suicide note
High-risk suicidal persons usually leave, or plan
to leave behind a farewell note explaining why
308
o The individual desires death more than

life. There is usually a positive history of
suicide behaviour.
o Plans for suicide indicate that there is no
chance of rescue and death is likely to
occur even if accidental rescue occurs.
In moderate risk suicide behaviour:
o The individual is usually ambivalent
o Plans for rescue may be available.
Low risk suicide behaviour:
o Is characterised by a desire for life more
than a desire to die.
o Denite plans for rescue are made before
the suicide attempt is executed. These
are common in manipulative personality
disorders, such as borderline personality
disorder.
they have opted to end their lives. The presence of

a note underlines the determination of a suicidal
persons wish to die.
Availability of method or killing oneself
Suicidal persons usually consider a variety of
methods that they can use in executing their
suicide plans. The more determined an individual
is the more deadly the method of death that will be
chosen. Males usually choose violent methods of
dying, such as the use of rearms, jumping from
a height, and hanging. Females on the other hand
often use self-poisoning.
Circumstances and timing of a planned suicide
Successful suicides take place when there is no one
around, in a secure place such as behind a locked
door, and at times when there is usually no hope
of rescue, usually early in the morning or after
midnight.
MANAGEMENT OF SUICIDAL
BEHAVIOUR
The presence of chronic physical illness

The experience of a chronic physical illness may
lead to signicant loss of hope in life, the loss of
a sense of control over ones life, fear of loss of
personal independence in life and, of course, the
fear of dying! An individual with these experiences
may consider suicide to be a better alternative way
of dying. Others may include:
Evidence of mental illness, such as depression,
mania, anxiety disorder, schizophrenia, chronic
alcoholism or serious personality disorder.
Previous history of suicide behaviour.
Successful suicide usually follows previous
episodes of failed suicide attempts.
Family history of suicide behaviour. There
may be a positive history of suicide behaviour
among family members of seriously suicidal
individuals.
Recent personal loss such as loss of
face, divorce/separation, business failure, job
loss, or death in the family.
The following are important principles to follow:

To save the life of the suicidal patient.
To prevent further suicide attempts.
To treat any physical injuries that may have
been sustained by the suicidal person.
To treat underlying psychiatric disorder,
physical illness or address social problem.
To prevent recurrence of suicidal feelings.
The general management strategy will depend
on the nature of injuries sustained by the person
during a suicide attempt. Physical injures may
require surgery, while the effects of overdose
may require resuscitation with intravenous uid
infusion, or gastric lavage and use of antidotes.
Serious injury to the throat usually requires a
tracheotomy. Psychiatric illness requires specic
treatments including medication, psychotherapy
and social therapy (especially family). Appropriate
therapy for physical illness or injuries is thus
required along with supportive counselling and/or
psychotherapy.
Accompanying mental conditions should be
adequately treated. Associated personality disorder
or substance abuse must be adequately addressed.
Attention to stressful social factors needs to be paid
and the services of a social worker should be sought
whenever possible. Referral to an appropriate
mental health facility is useful in case of doubt.
HIGH, MODERATE AND LOW

RISKS
A suicide risk is usually categorised as high,
moderate and low risk for purposes of planning
and optimal management.
In high risk suicide behaviours:
309
for follow-up. Despite this limitation, denite

follow-up plans should be drawn up with suicidal
individuals to ensure possibilities for continued
contact with them.
The persons with high-risk suicide behaviour

should be admitted to hospital. Round the clock
observation to prevent possible suicide attempt
in hospital should be ensured. Patient access to
any possible means for a suicide attempt should
be curtailed until he or she is out of danger. ECT
may be indicated to offer quick relief to severely
depressed suicidal patients. Treatment on outpatient basis may be recommended for an individual
with moderate risk, especially if adequate social
support system is available. Where out-patient
management is decided upon, the individual
should enter into a contract of non-involvement
in any suicide behaviour over an optimal period
of time when treatment is underway. Surveillance
to prevent suicide attempt should be kept on by
the family and relatives until the patient is out of
danger. Low risk cases usually require no treatment
other than crisis management measures. Suicidal
individuals usually do not honour appointments
Further reading
1. R. Levy and B. Goldman (2992). Emergency
Psychiatry. Review of General Psychiatry. 3rd Edition.
H. H. Goldman (ed). Prentice-Hall International Inc.
p470 -73
2. G. McGrath and M. Bowker (1987). Common
Psychiatric Emergencies. IOP Publishing Limited.
P161-180
3. G.E. Murphy (1972). Clinical Identication of
Suicidal Risk. Arch. Gen. Psychiatry, 27: 356-359
4. E.B.L. Ovuga (1986). Current Issues in Suicide
Prevention: Reection on the Proceedings of the
Thirteenth International Congress for Suicide
Prevention and Crisis Intervention. East Africa
Medical Journal 63: 477- 482.
310
40
Liaison Psychiatry
Seggane Musisi, David M. Ndetei
and all teaching hospitals in North America had

psychiatric consultation-liaison services.
DEFINITION
Consultation-liaison psychiatry is a psychiatric
sub-specialty that caters for the provision of
psychiatric care in a general hospital or community
setting alongside other medical services. Integration
calls for holistic care of patients. It includes
diagnostic, therapeutic, teaching and research
activities.
WHY LIAISON PSYCHIATRY?

Over 40 percent of patients in hospital wards have
diagnosable mental illnesses needing treatment.
The most frequent diagnoses are depression,
anxiety and organic brain syndromes. Untreated
psychiatric illness in the medically ill is associated
with increased morbidity, length of hospital stay and
ultimately, cost of care. This often leads to wasteful,
costly and inefcient use of medical services and
time. Unrecognised psychiatric illness complicates
diagnosis and treatment.
Liaison psychiatry aims:
To provide psychiatric treatment to patients:
o with primarily psychiatric illnesses who
present in general hospital wards for a
variety of reasons, e.g. depression and
anxiety disorder.
o with general medical or surgical
illnesses who then develop psychiatric
complications, e.g. HIV delirium, drugrelated psychoses (such as steroids),
post-partum psychosis and post-operative
delirium.
o who have medical or surgical illnesses and
concomitant psychiatric illness, e.g. mania
HISTORY
Consultation-liaison psychiatry, originated in
psy-chosomatic medicine as the role of the
psychiatrist was to reconcile the medico-biological
approach with the psychosocial one to present a
comprehensive psychiatric treatment in a practical
and meaningful way in medical settings. The rst
designated psychiatric consultation-liaison service
was in Albany hospital in New York in 1902.
However, psychiatric consultation to medical and
surgical wards rst became popular in the 1920s.
After World War II, model consultation liaison
psychiatric teams became established in New York
and by the 1960s, most psychiatric training centres
in America had consultation-liaison psychiatric
services. By the 1970s Lipowski had popularised
consultation-liaison psychiatry so much that most
medical and surgical wards demanded the service
311
Establish the level of urgency of each

consultation.
Determine the central questionthe time to
address all biopsychosocial issues a patient
may have, especially in in-patient settings.
Be exibleperform consultations in inpatient and out-patient settings.
Review medical data and collect essential
information.
Use the biopsychosocial modelconsider
predispositions, precipitants and strengths.
Make a well reasoned differential diagnosis
consider medical, neurological, and psychiatric
syndromes.
Make specic recommendations that are brief,
goal-oriented, and free of psychiatric jargon.
Discuss ndings and recommendations with
patients.
Follow-up the patient in the hospital and
arrange out-patient care after discharge.
Recognise and teach the value and role of
medical psychotherapy for patient consultations.
with fracture on traction or a cardiac

patient who is depressed.
o who have a psychiatric illness, but with
a medical complication, e.g. a patient
with depression who then takes a suicidal
overdose of drugs, or a schizophrenic
patient who cuts himself secondary to
bizarre delusional beliefs.
o who have psychosomatic disorders
demanding both psychiatric and medical
care, e.g. anorexia nervosa.
o who have neuropsychiatric disorders, e.g.
dementia, Tourrettes disorder, temporal
lobe epilepsy and Huntingtons chorea.
To clarify diagnosis in difcult differential
diagnoses, e.g. depressive stupor versus stroke
and conversion disorders with loss of limb
function.
To liaise with consulting staff about referred
patients:
o to allay staff and patient anxiety and
conicts over management issues, e.g.
substance-addicted patients and noncompliant diabetics.
o to interpret psychiatric symptoms to staff
and patients, and enhance treatment goals.
o to set up treatment goals where these are
not clear.
To teach staff, treatment teams and all cadres
of students regarding psychiatric illnesses.
To provide a treatment and psychiatric service
to health staff.
To carry out research on:
o mental illnesses and services in general
hospital settings
o psychiatric service delivery in general
hospitals
o mental illnesses in new and challenging
physical illnesses, e.g. HIV/AIDS.
CONSULTATION-LIAISON
SERVICES
These include general liaison and specialised
liaison services. The general liaison service caters
for all consultations from any part of the hospital.
This is common in smaller hospitals. It also covers
psychiatric emergencies and crisis intervention in
addition to the non-emergency routine consultations
and referrals. Such a service often needs to be
associated with or arrange out-patient follow-up
of its patients who have been seen during their
hospital stay.
The specialised liaison service, on the other
hand, is attached to specic specialised wards of
the hospital, e.g. paediatric liaison service, the
burns unit, transplantation unit, coronary care unit,
intensive care unit, obstetric and gynaecology unit
and dialysis unit.
THE LIAISON TEAM

This is often a multi-disciplinary team headed by a
psychiatrist. Other staff include a psychiatric nurse,
social worker, psychologist, occupational therapist,
and often various cadres of medical students. The
psychiatrist heading the team should:
Be available, accessible and able.
Respond promptly to consultation requests.
The day-to-day running of the liaison

service
A general liaison service begins the day with a
liaison team sit down round to do the following:
Review all newly received consultations and
determine the degree of urgency.
312
Liaison Psychiatry
in simple terms the suggested psychiatric

opinion, which should include reasons
for consultation, presenting complaints,
pertinent history, mental status examination
ndings, diagnosis, limited investigations
and the suggested psychiatric treatment.
o A discussion (the liaison part) with the
referring staff regarding the patient, paying
particular attention to making sure that the
reasons for the consultation are adequately
addressed.
o Follow-up previously consulted patients to
ensure that the suggested interventions were
effected, e.g. the prescribed medications
were obtained and are being taken in the
right doses.
o Review the progress of the patient after the
initial visit.
o Arrange for psychiatric follow-up on
discharge or transfer to the psychiatric
ward.
The following is an example of a psychiatric
consultation liaison report:
Discuss the cases seen in the previous days

to determine which ones need follow-up
reviews.
Conduct a hospital-wide walk-around ward
round, where the team visits each consulted
patient on their ward.
A thorough psychiatric evaluation is done for
each patient, which involves the following:
o A review of the reasons for the consultation
and what the referring team wants.
o A review of the patients medical record,
paying particular attention to the medical,
surgical and obstetric history, physical
diagnosis, investigations carried out,
medications being given and future
planned treatment, e.g. limb amputation on
a surgical ward.
o A thorough and full psychiatric history
followed by a full mental status
examination.
o The mental health worker writes out a
clear and crisp report stating clearly and
Date
10th Jan 2006
Referring Physician
Consultant Psychiatrist
:
:
Dr. Buuza Mukasa

Dr. Damu Muwanga
Name of Patient
:
Mrs. Ani Oyo
Ward
:
4B
(a) Presenting Problems. Thank you for consulting us to see Mrs. Ani Oyo who attempted suicide 3
days ago by overdosing on medication. Mrs Ani Oyo is a 48-year-old married lady with a long
history of marital discord and who had been attending the mental out-patient clinic for treatment of
depression. She had been taking Amitryptiline 100mg nightly and she swallowed all her two-week
supply of medication following a serious argument with her husband; hence the admission to your
service in a semi-comatose state two days ago.
(b) History. I note that she has been fully medically resuscitated and all physical investigations including
her HIV test are negative. Her electrolytes and ECG are normal. This is her rst suicide attempt.
On further questioning she admitted to having been particularly depressed over the last 2 months
over her husbands excessive drinking and extra-marital affairs. She had been sleeping poorly,
had lost appetite and weight and felt particularly weak all the time. She denied hearing voices nor
seeing anything around. Mrs. Ani Oyo does not take alcohol nor any other substances. She denied
past manic episodes. Besides her antidepressant medication, she is not on any other drugs and her
physical health is good. She has two grown-up children both of whom attend university and are
doing well.
(c) Mental status examination. Mrs. Ani Oyo presented as a depressed and bitter lady who spoke
slowly, was tearful all the time, but regretted the suicide attempt and its effect on her children.
She had no delusions and no hallucinations. Her cognition was intact and she had insight into her
problems. She was willing to be helped.
313
(d) Opinion. Diagnostically Mrs. Ani Oyo has developed a major depressive illness in a setting of
prolonged marital discord leading to a suicide overdose on her tricyclic antidepressant medication
of Amitryptiline. In terms of treatment, we have arranged a meeting with the husband, switching
her antidepressant medication to the SSRI, uoxetine 20mg once a day after one weeks washout
period. We have arranged daily follow-up for supportive counselling while in hospital by our team
psychologist. The patient should be transferred to the psychiatric ward upon medical clearance
from the overdose. Meanwhile, keep her on constant 24-hour observation to avoid further suicide
attempts. Thank you for asking us to participate in the care of this patient.
Signed:
Name of Psychiatrist.
Exclude depression, conicts or hallucinosis, with
threatening voices.
Common reasons for consulting a

psychiatrist
A manifestation of a psychiatric illness, e.g.
mania or psychosis.
A suicide attempt or hinting on a plan.
Diagnostic uncertainty. Usually when investigations have produced no plausible
explanations for the patients symptoms, either
their presence, persistence or severity.
The patients complaining continues despite
the best surgical or medical efforts, which
should have settled the problem.
The patient is disturbing the ordered harmony
of the ward.
The staff are under strain over this patient,
because of demanding behaviour, hostility or
ability to manipulate, or because they have
become emotionally concerned about the
patients illness.
The patient seems to have psychiatric disorder,
or has a history of one.
The patients have nowhere to go or cannot
take care of themselves.
The patient has asked to see a psychiatrist.
Substance abuse.
Depression
Suicidal risks must be assessed in every
depressed patient; presence of cognitive defects
in depression may cause diagnostic dilemma with
dementia; check for history of substance abuse
or depressant drugs (e.g. reserpine, propranolol);
use antidepressants cautiously in cardiac patients,
because of conduction side effectsuse SSRIs.
Rule out stroke for severe depressive illness with
profound psychomotor retardation or psychotic
features with nihilistic delusions (Cotards
syndrome) or depressive stupor.
Agitation
This
is
often
related
to
cognitive
disorders, withdrawal from drugs (e.g., opiods,
alcohol, sedative-hypnotics). Haloperidol and
benzo-diazepines are the most useful drugs for
excessive agitation. Use physical restraints with
great caution. Examine for command hallucinations
or paranoid ideation and rule out toxic reaction to
medication. If sleepless, over-talkative, euphoric
or irritable, rule out mania.
Hallucinations
The most common cause in hospital is delirium
tremens. Onset is usually 3 to 4 days after
hospitalisation in intensive care units. Check for
sensory isolation, rule out brief psychotic disorder,
schizophrenia and cognitive disorder and treat with
antipsychotic medication.
COMMON CONSULTATION
RESPONSES IN LIAISON
PSYCHIATRY
Suicide attempt or threat
Sleep disorder
If the risk of suicide is present, transfer the

patient to a psychiatric unit or begin a 24-hour
nursing observation (constant observation).
Common cause is pain. Early morning awakening

is associated with depression and difculty falling
314
Liaison Psychiatry
asleep is associated with anxiety. Use anti-anxiety

or antidepressant agents, depending on the cause
and rule out early substance withdrawal.
(Lorazepam or Clonazepam). Start lithium

prophylaxis as indicated. Arrange for long-term
follow up in a psychiatric out-patient clinic.
No organic basis for symptoms
Delusions
Rule
out
conversion,
dissociative,
somatisation, factitious disorders. Malingering,
glove and stocking anesthesia with autonomic
nervous systems symptoms are seen in conversion
disorder; multiple body complaints in somatisation
disorder (Bricketts syndrome); wish to be
hospitalised in factitious disorder (Munchausens
syndrome). There is obvious secondary gain
in malingering (compensation case, Ganser
Syndrome). Consider dissociative fugue, amnesia
or identity disorder.
This is not a very uncommon cause for consultation.

Usually it occurs in the presence of other obvious
signs and symptoms of gross mental disorder,
such as in schizophrenia. These are usually known
psychiatric patients who have developed a physical
illness and nd themselves admitted in hospital.
Post-partum psychotic illnesses are also a common
cause for psychiatric consultation. Occasionally
somatic delusions can cause diagnostic confusion in
patients who, otherwise, have intact personalities.
The general principles of treatment of psychosis
should be followed using antipsychotic medications
such as haloperidol or triuoperazine. Caution
should be exercised for post-operative conditions
involving the abdomen as paralytic ileus or
urinary retention can occur with, especially,
phenothiazines combined with anticholinergics.
Disorientation
In delirium versus dementia, review metabolic
status, neurological findings, substance use
history and polypharmacy. Prescribe small
dose of antipsychotics for major agitation;
benzodiazepines may worsen condition and
cause sundowner syndrome (ataxia, confusion).
Modify environments so patient does not
experience sensory deprivation. Investigate
underlying cause and treat it, e.g. cholinesterase
inhibitors for Alzheimer. Advise on activities of
daily living (ADL) and patient safety.
MENTAL DISORDERS DUE

TO A GENERAL MEDICAL
CONDITION7
A Mental Disorder Due to a General Medical
Condition is characterised by the presence of
mental symptoms that are judged to be the direct
physiological consequence of a general medical
condition. The term general medical condition
refers to conditions that are coded on Axis III.
Maintaining the distinction between mental
disorders and general medical conditions does
not imply that there are fundamental differences
in their conceptualisation, that mental disorders
are unrelated to physical or biological factors or
processes, or that general medical conditions are
unrelated to behavioural or psychosocial factors or
processes. The purpose of distinguishing general
medical conditions from mental disorders is to
encourage thoroughness in evaluation and to
provide a shorthand term to enhance communication
among health care providers.
The following categories of psychiatric
conditions have a physical basis.
Catatonic Disorder Due to a General Medical
Condition
Non-compliance or refusal to consent to

procedure
Explore relationship of patient and treating doctor.
Negative transference is the most common cause
of non-compliance. Fears of medication or of
procedure require education and reassurance.
Cognitive disorder is the main cause of impaired
judgment in hospitalised patients.
Mania
This is a common cause of consultation on the
medical ward, especially rst episode psychosis.
Review history including past psychiatric
and family history of affective disorder, substance
abuse and seizures. Rule out any underlying illness
which could cause secondary mania, e.g. HIV,
treatment with steroids (Prednisone), thyrotoxicosis
and brain tumour.
Treat the episode with antipsychotic (haloperidol)
and benzodiazepines to calm the patient down
Adopted from and reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
315
Personality Change Due to a General Medical

Condition
Mental Disorder Not Otherwise Specied Due
to a General Medical Condition,
Delirium Due to a General Medical Condition
Dementia Due to a General Medical
Condition
Amnesic Disorder Due to a General Medical
Condition
Psychotic Disorder Due to a General Medical
Condition
Mood Disorder Due to a General Medical

Condition
Anxiety Disorder Due to a General Medical
Condition
Sexual Dysfunction Due to a General Medical
Condition
Sleep Disorder Due to a General Medical
Condition
Tables 40.1 to 40.3 summarise the diagnostic
criteria for three psychiatric conditions due to
General Medical Conditions.
Table 40.1
293.89 Catatonic Disorder Due to ... [Indicate the General Medical Condition]
A. The presence of catatonia as manifested by motoric immobility, excessive motor activity (that is apparently
purposeless and not inuenced by external stimuli), extreme negativism or mutism, peculiarities of
voluntary movement, or echolalia or echopraxia.
C. The disturbance is not better accounted for by another mental disorder (e.g., a Manic Episode).
Include the name of the general medical condition on Axis I, e.g., Catatonic Disorder Due to Hepatic
Encephalopathy; also code the general medical conditions on Axis III.
Table 40.2
310.1 Personality Change Due to ... [Indicate the General Medical Condition]
A. A persistent personality disturbance that represents a change from the individuals previous characteristic
personality pattern. (In children, the disturbance involves a marked deviation from normal development
or a signicant change in the childs usual behaviour patterns lasting at least 1 year).
C. The disturbance is not better accounted for by another mental disorder (including other Mental Disorders
Due to a General Medical Condition).
Specify type:
Labile Type: if the predominant feature is affective liability
Disinhibited Type: if the predominant feature is poor impulse control as evidenced by sexual indiscretions,
etc.
Aggressive Type: if the predominant feature is aggressive behavior
Apathetic Type: if the predominant feature is marked apathy and indifference
Paranoid Type: if the predominant feature is suspicious-ness or paranoid ideation
Other Type: if the presentation is not characterized by any of the above subtypes
Combined Type: if more than one feature predominates in the clinical picture
Unspecied Type
Include the name of the general medical condition on Axis I, e.g., Personality Change Due to Temporal
Lobe Epilepsy;
316
Liaison Psychiatry
Table 40.3
293.9 Mental Disorder Not Otherwise Specied Due to a General Medical Condition
This residual category should be used for situations in which it has been established that the disturbance is
caused by the direct physiological effects of a general medical condition, but the criteria are not met for a
specic Mental Disorder Due to a General Medical Condition (e.g., dissociative symptoms due to complex
partial seizures).
Include the name of the general medical condition on Axis I, e.g., Mental Disorder Not Otherwise Specied
Due to HIV Disease;
Psoriasis
Psychogenic excoriation
Pruritus vulvae
Hyperhidrosis
6. Immunological:
Rheumatoid arthritis
Systematic lupus erythematosus
7. Neurological and Musclo-skeletal
Low back pain
Migraine, vascular and cluster headaches
Tension (muscle contraction headaches)
Pain Disorder: Pain threshold and
perception
8. Dental:
Depressive facial pain
Oral infections
9. Infections:
Especially viral infections
10. Oncology Psycho-oncology is a fast evolving
discipline based on the evidence that psychiatric
and psychological inputs and interventions
may inuence the coping with and prognosis
of certain types of cancer.
For all the above examples psychological factors
play signicant roles in the causation, precipitation,
presentation, maintenance, management and
outcome. For most other physical conditions
there is clinically signicant psychological and
psychiatric co-morbidity in upto 40% of patients in
general medical facilities. More often than not this
co-morbidity goes unnoticed.
The following tables summarise the DSM-IVTR Diagnostic Criteria for Psychological Factors
Affecting General Medical Conditions and DSMIV-TR for Premenstrual Dysphoric Disorder, the
latter to illustrate a common Gynecological Disorder
with signicant psychological manifestation.
PSYCHOLOGICAL FACTORS
AFFECTING GENERAL
MEDICAL CONDITIONS
Psychological factors affecting medical conditions
or leading to psychosomatic disorders are thought
to be stress related and are mediated through:
Neurotransmitter response to stress
Endocrine response to stress
Immune response to stress
Life events
Examples of clinical condition include:
1. Gastro-intestinal system
Gastroesophageal reux disease
Peptic ulcer disease
Ulcerative colitis
Crohns disease
2. Cardiovascular system:
Coronary heart disease (in Type A
Personality)
Valvular heart disease (e.g. mitral valve
relapse in panic disorder coronary artery
by pass).
Hypertension
3. Respiratory system:
Asthma
Hyperventilation syndromes
4. Metabolic
Hyperthyroidism
Hypothyroidism
Diabetes Mellitus
Adrenal Disorders
Obesity
5. Skin:
Atopic Dermatitis
317
Table 40.4
DSM-IV-TR Diagnostic Criteria for Psychological Factors Affecting General Medical Conditions
A. A general medical condition (coded on Axis III) is present.
B. Psychological factors adversely affect the general medical condition in one of the following ways:
(1) the factors have inuenced the course of the general medical condition as shown by a close
temporal association between the psychological factors and the development or exacerbation of,
or delayed recovery from, the general medical condition
(2) the factors interfere with the treatment of the general medical condition
(3) the factors constitute additional health risks for the individual
(4) Stress-related physiological responses precipitate or exacerbate symptoms of the general medical
condition.
Choose name based on the nature of the psychological factors (if more than one factor is present, indicate
the most prominent):
Mental disorder affecting... [indicate the general medical condition] (e.g., an Axis I disorder such as
major depressive disorder delaying recovery from a myocardial infarction)
Psychological symptoms affecting... [indicate the general medical condition] (e.g., depressive symptoms
delaying recovery from surgery; anxiety exacerbating asthma)
Personality traits or coping style affecting ... [indicate the general medical condition] (e.g., pathological
denial of the need for surgery in a patient with cancer; hostile, pressured behavior contributing to cardiovascular
disease)
Maladaptive health behaviors affecting ... [indicate the general medical condition] (e.g., overeating;
lack of exercise; unsafe sex)
Stress-related physiological response affecting... [indicate the general medical condition] (e.g., stressrelated exacerbations of ulcer, hypertension, arrhythmia, or tension headache)
Other or unspecied psychological factors affecting... [indicate the general medical condition] (e.g.,
interpersonal, cultural, or religious factors)
Table 40.5
DSM-IV-TR Research Criteria for Premenstrual Dysphoric Disorder
A. In most menstrual cycles during the past year, ve (or more) of the following symptoms were present for
most of the time during the last week of the luteal phase, began to remit within a few days after the onset
of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being
either (1), (2), (3), or (4):
(1) markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
(2) marked anxiety, tension, feelings of being keyed up, or on edge.
(3) marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to
rejection).
(4) persistent and marked anger or irritability or increase interpersonal conicts.
(5) decreased interest in usual activities (e.g., work, school, friends, hobbies).
(6) subjective sense of difculty in concentrating.
(7) lethargy, easy fatigability, or marked lack of energy.
(8) marked change in appetite, overeating, or specic food cravings.
(9) hypersorhnia or insomnia.
(10) a subjective sense of being overwhelmed or out of control.
(11) Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a
sensation of bloating, weight gain.
Note: In menstruating females, the luteal phase corresponds to the period between ovulation and the onset
of menses, and the follicular phase begins with menses. In nonmenstruating females (e.g., those who have
had a hysterectomy), the timing of luteal and follicular phases may require measurement of circulating
reproductive hormones.
318
Liaison Psychiatry
B. The disturbance markedly interferes with work or school or with usual social activities and relationships
with others (e.g., avoidance of social activities, decreased productivity and efciency at work or
school).
C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major
depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be
superimposed on any of these disorders).
D. Criteria A, B and C must be conrmed by prospective daily ratings during at least two consecutive
symptomatic cycles. (The diagnosis may be made provisionally prior to this conrmation.)
Further reading
1. Vingoe F. J. (1981): Clinical Psychology and
Medicine: An Interdisciplinary Approach. Oxford:
Oxford University Press.
319
41
HIV/AIDS and Mental Health
Caleb Othieno, Abdullah Abdelrahman, Mohamedi B. Sebit,
Seggane Musisi, David M. Ndetei, Emilio Ovuga
own multiplication. With time, viral replication

leads to massive invasion of the host cells and
this culminates in the destruction of the immune
cell population, making the host vulnerable to
secondary infection.
One of the most devastating afictions of human kind

worldwide is the human immunodeciency virus
(HIV) that leads to Acquired Immunodeciency
Syndrome (AIDS). An estimated 40 million people
in the world live with HIV/AIDS and by the end
of 2005, 25 million people had died from AIDSrelated diseases. Sub-saharan Africa is the hardest
hit region in the world. The disease was initially
associated with homosexuals, prisoners, druginjecting users, prostitutes and other disadvantaged
minority groups in high-income countries.
However, no human community is now immune
from the disease. In Africa, disease transmission
is known to occur primarily through sex between
heterosexual couples, blood transfusion and
mother-to-child transmission, either in utero, at
birth or during breastfeeding.
HIV/AIDS will perhaps remain the worlds
most dreaded epidemic of all times. A diagnosis of
the condition usually puts a rude end to personal
plans and effectively confronts the individual with
the reality of death.
MENTAL HEALTH PROBLEMS

IN HIV/AIDS
The psychiatric manifestations of HIV/AIDS are
multiple and these may be due to the following:
The virus invasion of the brain in up to
90 percent of cases resulting in acute
inammation, micro-abscesses, vacuolation,
and other degenerative changes.
Seroconversion from non-clinical to clinical
AIDS stage.
Suspicion that one may be HIV-positive also
known as the worried well.
Physical changes associated with disease
progression, for example, progressive weight
loss, skin rashes, and subtle loss of functional
ability in daily activities.
Opportunistic infections including tuberculosis,
cryptococcal infection, toxoplasmosis.
Secondary spread of cancer such as lymphoma,
Kaposis Sarcoma.
News of positive HIV-test result.
IMMUNOBIOLOGY
HIV targets the host CD4+ T-lymphocytes
and macrophages that help ght off invading
microbes. HIV uses the host genetic replication
processes within the host lymphocyte for its
320
with HIV, neuropsychiatric manifestations are the

rst sign of the disease, and overall, 50 percent
of individuals with HIV develop subcortical
dementia. When emotional reactions to the disease
are added, virtually all HIV/AIDS patients suffer
from neuropsychiatric complications. Anxiety,
depression, mania and other psychosis are
commonly associated with HIV. In some cases it is
difcult to tease out the psychosocial reactions and
the complications of direct consequences of viral
invasion.
Photophobia, headache, stiff neck, motor
weakness, sensory loss, changes in level of
consciousness and peripheral neuropathy may
suggest HIV invasion of the CNS. Neuropsychiatric
manifestations may also be due to opportunistic
infections or cancers. Frequently encountered
conditions include cryptococcal meningitis,
cerebral toxoplasmosis, lymphoma of the brain,
parvovirus infection, herpes virus, encephalitis,
cytomegalovirus, tuberculosis, candidal meningitis
and cerebral abscesses.
MENTAL HEALTH ASPECTS

Evidence of disorders in cognitive functioning
may occur both in HIV-infected individuals
who are asymptomatic, as well as in those with
active symptoms of AIDS. Features of cognitive
dysfunction among asymptomatic individuals
include:
impaired attention and concentration
psychomotor slowing, clumsiness, mild
memory impairment leading to absent-mindedness, misplacing items and forgetfulness
difculty with abstract thinking, divided
attention and shifting cognitive sets.
Features of cognitive impairment in symptomatic
individuals include: problems with language, visual
and spatial disorientation, apraxias, movement
disorders and behavioural disorders.
Psychiatric disorders in HIV/AIDS are important
for several reasons. Most people with HIV/AIDS
died within 2-3 years of diagnosis in the early
years of the epidemic, but the disease is now
considered to be chronic as effective antiretroviral
(ARV) drugs can prolong life for many years.
Moderate to severe psychiatric illness is prevalent
among people with HIV/AIDS in health facilities.
However, psychiatric illness in this population
group is hardly recognised and majority of the
cases receive little care.
Psychiatric illness may arise not only due to viral
invasion of the brain, the action of neurotoxins
released from the destruction of host lymphocytes
and macrophages, or medical complications of HIV
infection, but also in persons with previous history
of mental illness, pre-morbid personality disorder
or family history of mental illness. The following
psychiatric disorders may occur in persons with
HIV/AIDS:
Adjustment disorder with depressed or anxious
mood;
Manic disorder; depressive disorder;
Anxiety
disorders,
particularly
panic
disorder, generalised anxiety disorder,
obsessive-compulsive disorder, agoraphobia;
Schizophrenia; HIV-associated dementia;
delirium; alcohol or other substance
dependence; suicide and attempted suicide.
Seventy-ve to 90 percent of autopsies done on
patients dying of HIV/AIDS reveal brain changes
due to the disease. In 10 percent of people infected
Complications and manifestations

Encephalopathy (AIDS Dementia Complex)
HIV infects glial cells, especially astrocytes and
immune cells in the CNS leading to manifestations
of multinucleated giant cells, microglial nodules,
diffuse astrocytosis, perivascular lymphocyte
cufng, cortical atrophy and white matter
vacuolation and demyelination. Patients present
with sub-acute encephalitis resulting in progressive
sub-cortical dementia without focal neurological
signs. The clinical picture includes apathy,
social withdrawal, hyper-reexia, spastic or ataxic
gait, paraesthesias and increased muscle tone.
Sub-cortical dementia presents with a number of
differentiation features from cortical dementia as
Development of sub-cortical dementia is
invariably a poor prognostic feature if anti-viral
medications are not instituted early with 50 to 75
percent of patients dying within 6 months.
Twenty to 30 percent of HIV-infected individuals
develop HIV-associated dementia. Patients present
with cognitive and motor dysfunction. Peripheral
neuropathy is also common. Cognitive dysfunction
involves concentration and memory decits,
inattention and later global dementia and mutism.
Motor decits include motor inco-ordination, ataxia
and later paraplegia. Evolution of this condition
takes several weeks to a few months. The CD4 count
321
Table 41.1: Sub-cortical versus Cortical Dementia in HIV/AIDS

Function
Sub-cortical Dementia
Cortical Dementia
Language
No aphasia (anomia if severe)
Early aphasia
Calculation
Preserved until late
Involved early
Frontal system abilities (executive

functions)
Disproportionately affected
Degree of impairment consistent

with other involvement
Speech
Dysarthric
Articulate until late
Posture
Bowed or extended
Upright
Co-ordination
Impaired
Normal until late
Motor speed and control
Slowed
Normal
Adventitious movements
Chorea, tremor, tics, dystonia
Absent
generally recommended. Tricyclic antidepressants

such as amitriptyline, imipramine, nortriptyline
or desipramine may be prescribed, although
selective serotonin re-uptake inhibitors such as
uoxetine or sertraline may be preferred due to
their less sedating effects.
is often below 200, although dementia can occur

even at higher CD4 lymphocyte counts. The only
treatment for HAD is institution of Highly Active
Anti-Retroviral Therapy (HAART), although
even this is not always successful. Attention to
activities of daily living (ADL), and any associated
symptoms, e.g. seizures and insomnia should be
managed accordingly.
Bipolar Affective Disorder

Nine percent of individuals infected with HIV
develop mania. The cause can be due to the effects
of the virus, opportunistic infections, antiretroviral
(ARV) drugs or a primary affective afiction.
Secondary mania presents with elevated mood (an
exaggerated feeling of well-being for no apparent
rational reason), excessive energy, rapid thoughts
and speech, decreased need for sleep, and delusions
and hallucinations consonant with the elevated
mood.
Treatment is with antipsychotic medications and
mood stabilisers if recurrent. In the setting of HIV
disease, serum levels of lithium are sometimes
difcult to equilibrate. Carbamazepine or sodium
valproate may thus be preferred for mood
stabilisation. If sodium valproate is used, careful
attention ought to be taken in monitoring liver
function among patients with liver disease. Mania,
particularly when associated with sub-cortical
dementia, is treated with low doses of antipsychotic
medications. Haloperidol 1 to 5 mg nocte or bid may
be a good starting dose or uphenazine in the same
dose. However, higher dosages may be needed,
hence, the need to titrate dosage to patients need.
Carbamazepine or sodium valproate each in doses
of 200 to 400 mg once to twice a day doses may be
provided for mood stabilisation.
Depression
Twenty percent of HIV-infected individuals develop
major depression. The following are diagnostic
features:
Depressed mood, decreased interest in
activities.
Anhedonia (loss of pleasure in activities), clear
sensorium.
Weight loss or weight gain, insomnia
or hypersomnia.
Fatigue or loss of energy, generalised feelings
of worthlessness.
Impaired ability of mental concentration.
Excessive or inappropriate guilt, recurrent
thoughts of death.
Profound sense of not being well
(disproportionate to severity of current medical
problem).
The main treatment is to administer antidepressants.
It should be started with low doses and increased
slowly. Slow increases in dose avoid overmedication
and decrease side effects. Low doses often achieve
effective results among patients with late stage
HIV disease. Depressed patients in Africa respond
to much lower doses of antidepressants than those
322
depressants such as alcohol and hypnosedatives or opiates, withdrawal from

these drugs should be tapered off with an
appropriate medication. Benzodiazepines
such as chlordiazepoxide, and clonazepam,
in the case of hypno-sedatives, and opiates
such as methadone, can be employed for this
purpose. Electrolyte and water imbalance
should be corrected. Attention should be paid
to correct the nutritional status, including
provision of vitamins. Thiamine at the
strength of 100 mg per day should be provided
in cases of detoxication from alcohol.
Treatment of comorbid conditions. Attention
should be paid to treatment of any associated
emotional conditions as well as physical
problems.
Maintenance treatment and relapse prevention.
Treatment needs to be individualised based
on the needs of a particular patient. Attention
should be paid to re-socialisation and recreation of social support systems that
may have been squandered by substance
dependence related behaviours. Efforts should
be taken to identify triggers to substance
use. Since relapse is the rule rather than the
exception, the client should be prepared for it
and a plan put in place for early intervention.
Attention also needs to be taken to identify
possible stresses and prepare the client to deal
with them more adaptively. The client needs
to identify an important goal or achievement
in life that is more valuable than the transitory
pleasures obtained from substance use as a
focus for motivation for change. Referral to
support groups, such as AA, is often helpful.
Delirium
Patients with advanced HIV disease who suffer
delirium and dementia and are on several
medications may be difcult to diagnose. Since
low dose antipsychotic medications may benet all
these conditions, a trial is recommended. Delirium
is sometimes exacerbated under these conditions
and this may help to clarify the diagnosis. The
best drug is haloperidol 2 to 5mg once or twice
daily. A benzodiazepine, such as Lorazepam 1 to
2 mg nocte may give additional benecial effects,
especially in very agitated and sleepless patients.
Suicide
Risk factors for suicide include having friends
who have died of HIV, recent discovery of positive
HIV status, relapses of disease, problems arising
out of HIV stigma and presence of dementia or
depression.
Pre- and post-test counselling, as well as
ongoing counselling of all HIV patients is helpful.
Any associated depression should be vigorously
treated with antidepressants.
Panic Disorder and other anxiety disorders
This often presents as an unpredictable attack
of severe anxiety not related to any particular
situation. Common features include shortness of
breath; fear of dying or of going crazy, and an
urgent desire to ee regardless of consequences.
Treatment is with antidepressants at lower doses
than those for depression. In acute situations,
short-term treatment with an anxiolytic such as
Alprazolam once to three times daily is useful.
Supportive counselling must always accompany
drug management.
Other anxiety disorders often associated with
HIV/AIDS include generalised anxiety disorder,
obsessive-compulsive disorder, agoraphobia and
adjustment disorder with depressed mood.
Worried Well and HIV phobics

These are HIV negative individuals who have
difculties accepting their negative serostatus.
They are worried that they are infected with HIV
and anxious about the possibility that they may
still be in the window period, or that there have
been some technical mistakes in the HIV tests.
This is in spite of repeated tests that indicate their
good fortune. Careful attention should be paid to
assessing their mental condition, including life
situations, to attend to any stresses or conicts
in life. They may have a need for a conding
relationship and this can be provided in a counselling
situation geared towards improving interpersonal
relationships. Obsessive-compulsive disorder must
be excluded.
Substance Use Disorder

Substance use may follow the distress associated
with HIV seropositivity as a maladaptive coping
mechanism or it may precede and contribute to
infection with HIV. In substance use, dependency
and craving get out of control. The substance
is such that it reinforces the self-administration
behaviour that ultimately leads to dependence.
Treatment follows a number of stages.
Detoxication (in-patient or out-patient
settings): In the case of dependence on
323
or lead to loss of employment. Chronic physical

weakness may seriously interfere with activities of
daily living. Physical pain or emotional distress may
lead to the development of substance dependence.
Frank psychiatric disorder may arise in vulnerable
individuals with prior history of mental illness or
substance dependence, and pre-morbid personality
disorder or those with family history of mental
disorder.
PSYCHOSOCIAL IMPACT OF
HIV/AIDS
Society expects individuals to be sexually active,
and to be morally upright in the manner in which
they lead their sexual lives. The appearance of
HIV/AIDS exposes the individual as morally
blameworthy, sexually loose and careless,
particularly when everyone ought to know how
to protect themselves from contracting the deadly
disease. As a result HIV/AIDS causes signicant
shame, guilt, self-blame, and loss of self-esteem.
The initial reactions of the individual with
HIV/AIDS comprise brooding over own sexual
conduct, the conduct of sexual partners, plans for
personal advancement, failure to live up to the
expectations of family, friends and relatives, the
prospect of passing through the long and painful
process of dying and eventually death. Fear of the
reality of impending death may lead to episodes of
panic attack with loss of sleep, appetite and loss
of interest in daily activities. During this phase the
individual with HIV/AIDS may experience a lot of
resentment, both on the self and others, particularly
sexual partners. Shame and guilt feelings might
force the individual to shun friends and other
social relations. Provision of social care may be
hampered by unpredictable outbursts of irritability
and anger directed at those who provide nursing
care either at home or at a health facility. As the
disease progresses, the individual may experience
helplessness, a sense of alienation and loneliness,
and lack of self-worth, or the urgent need to
accomplish unnished business before dying.
Thoughts leading to suicide or suicide attempt
may occur. As death approaches, the individual
may resign to fate and accept the inevitable despite
concerns for the welfare of dependents and personal
material property. At this point the individual may
turn to God for salvation and spiritual power.
CLINICAL ASPECTS OF HIV

DISEASE
HIV-associated illnesses may be due to the systemic
effects of the virus on the body systems, or secondary
to the effects of the virus and medication on
specic organs. Many of these illnesses aggravate
the emotional and other psychosocial disorders
that the individual may already be experiencing.
The signs and symptoms of systemic involvement
include fever, night sweats, general malaise and
weakness, and progressive weight loss. Signs and
symptoms of organ-specic illness include those
relevant to:
Head, eyes, ears, nose and throat, oral thrush
and ulcerations, silky hair, alopecia, gingivitis
and stomatitis
Respiratory tract: commonly pulmonary
tuberculosis, community acquired pneumonia
and pneumocystis carii pneumonia
Gastrointestinal tract involvement: infective
diarrhoea and peptic ulcer disease
Haematologic: anaemia, neutropenia, and
thrombocytopenia
Dermatologic: infective dermatoses, herpes
zoster rash and Kaposis sarcoma
Central nervous system disease: cryptocccal
meningitis, toxoplasmosis, seizure disorder
and motor abnormality
Effect of medication: alopecia and diarrhoea.
THE SOCIO-ECONOMIC IMPACT

GENERAL PRINCIPLES IN THE
CLINICAL ASSESSMENT AND
MANAGEMENT
HIV/AIDS
has
profound
socio-economic
consequences. These affect the basic human
needs for food, nances, clothing, education,
employment and medical care. Lack of funds may
lead to inadequate or poor nutrition, and inability
to meet medical costs of treatment, thus hastening
disease progression. Children of school going
age may drop out of school. Stigmatisation and
discrimination may deter employment possibility,
Clinical assessment
HIV/AIDS is a disease that involves all body systems
and affects virtually all spheres of the individuals
life. Manifestations of the disease may depend on
324
with house work and general cleaning, and access

new supply of medication.
Since people living with HIV/AIDS present with
a wide range of medical and psychosocial needs,
services for them should be exible and tailored to
individual needs. Care plans should be adapted to
meet the changing clinical needs of every patient
over time. The possible range of services include
psychotherapy, rehabilitation services, other social
support services, clinical care and planning for the
future.
The full range of services that any patient requires
should be well coordinated and integrated. Clinical
and service providers involving several disciplines
might wish to use the team approach to service and
care provision to meet each patients needs. Service
plans should be sensitive to the individuals social
background and take into account their cultural
expectations.
The nature and setting of a service plan should
not stigmatise patients. Clinical outcome will be
optimised when care providers relate to patients with
respect that promotes their self-worth and dignity.
Clinical care should promote healthier behaviour,
and the need to reduce risky behaviour should
be one of the primary goals of therapy. Attempts
should deliberately be made to empower patients
and their social support systems to be responsible
for important decisions regarding their care.
the clinical stage of the illness, ranging from the

subtle cognitive dysfunction in the asymptomatic
individual to the frankly psychotic person. Clinical
evaluation for psychiatric illness or other general
health care should, therefore, be comprehensive
and incorporate all elements of the biopsychosocial
model. A comprehensive clinical assessment should
therefore involve not only the clinician, but also
psychologist, social worker, occupational therapist,
the neurologist and the psychiatrist.
The following areas should be covered in the
assessment: demographic data; presenting
problems; psychiatric history; personal history,
including educational background and employment
history; social history including family and
marital histories; medical history; alcohol or
other psychoactive substance use history; sexual
history in terms of the risk level and the number of
sexual partners; social support system; individual
coping skills; personal strengths; nancial and
other resources; religious afliation and spiritual
practices; mental status assessment; evaluation of
physical status and overall clinical assessment of
the problem.
Management
Management objectives
The individual living with HIV/AIDS faces multiple
challenges and obstacles, thus clinical management
should cover all possible aspects of these difculties.
Therapy should aim to achieve the following:
Rapid and early control of distressing
symptoms
Limit progression of clinical status such as
neurocognitive decline
Prevent or limit relapse into active psychiatric
illness
Improve quality of living
Enhance return to employment as it applies
Promote independent living as it applies
Mobilise social support system
Link the patient to appropriate sources of social
resources.
Management activities and guidelines

The following activities should form part of the
overall services that should be considered for the
individual living with HIV/AIDS:
Assess clinical status to determine the nature
of current mental health disorder, associated
underlying and aggravating factors and
potential protective factors
Assess the patients needs for comprehensive
care and management
Develop a service plan that incorporates all
issues identied during assessment
Link the patient to available services
Monitor the patients progress as the patients
needs are likely to change from time to time. It
is important that attention is paid to potential
side effects of psychotropic medication, side
effects of antiretroviral medication and adverse
reactions arising from drug-drug interaction
Carry out activities to prevent relapse, promote
mental health and positive living, and reduce
risky behaviour
Management principles
People living with HIV/AIDS need access to
comprehensive medical and psychosocial services
that depend primarily on the stage of their
individual clinical situation. Services may be
tailored to enhance access to affordable or free
transportation to attend clinical review, assistance
to obtain food, clothing, provide child care, help
325
Involve the patient and the signicant care

provider in his social support system.
Management activities may best be provided in
phases. It is, however, necessary to stress that
these phases be conceptualised as continuous with
each fading into the next. During the acute phase,
which may last for a period of up to 2 weeks,
medication may be provided to stabilise the clinical
situation. During the next phase of management,
basic human needs may be provided including
food, shelter and care for dependents. During
the third phase, the clinician may provide factual
information about the patients clinical status and
encourage him to recognise and accept the need
for treatment. Active treatment is then provided
to help the patient develop appropriate attitudes,
behaviours, competence and determination to
accept and engage in treatment. As the patients
clinical state improves, the clinician engages the
patient in activities that help him to understand the
situation better and show appropriate competence
in performing daily activities.
example, uoxetine, nefazodone) may also reduce

the metabolism of some protease inhibitors thus
increasing their side effects.
Psychotherapy
People living with HIV/AIDS present with variable
stories lled with fear, anger, sadness, shame, and
guilt. AIDS brings people face-to-face with their
personal difculties and failures, many of which
may become magnied. Issues of life and death,
religion, faith, family matters, plans in life, role
and status in society, and personal integrity, ll
the mind of the person living with HIV and may
inuence the disease process, as well as adaptation
to the illness. Psychotherapy enhances the process
by which individuals examine their feelings,
thinking, behaviour, motivations, interpersonal
relationships, and purpose in life, thereby creating
self-awareness, healthy coping strategies, and
strong motivation to lead meaningful lives.
Self-esteem
The vulnerable individual with HIV/AIDS may
experience profound loss of self-esteem, shame,
guilt and self-blame for having been infected.
These experiences may contribute to depression
and suicidal behaviour. Therefore, they should be
routinely covered in psychotherapy with people
living with HIV/AIDS.
Pharmacotherapy
There are two main classes of antiretroviral
agents (ARVs), the reverse transcriptase inhibitors
(nucleoside-NRTI and non-nucleoside-NNRTI) and
the protease inhibitors (PI). Examples of nucleoside
reverse transcriptase include: Zidovudine (AZT
or ZDV), Didanosine (ddI), Zalcitabine (ddC),
Stavudine (d4T), Lamuvidine (3TC) and Abacavir.
The non-nucleoside reverse transcriptases are
Nevirapine, Delavirdine and Efavirenz. Protease
inhibitors include Ritonavir, Indinavir, Saquinavir
and Nelnavir. Triple therapy where two reverse
transcriptase and one protease inhibitor are used is
recommended to reduce treatment failure in case
of viral mutations. However, the choice of drugs
depends on specic mode of action, drug-drug
interactions with the ARV and other medications
the patient is taking. The goals of antiretroviral
therapy (ART) are suppression of HIV replication,
improvement of quality of life and promotion of
immune reconstitution.
ARVs have several side effects and it is
important to note that protease inhibitors are
metabolised by the hepatic cytochrome P450
oxidase system (specically the 3A isoenzyme)
which also metabolises psychotropic agents such
as benzodiazepines, selective serotonin retake
inhibitors (SSRI) and tricyclic antidepressants
(TCA). They can therefore increase their levels in
blood leading to toxicity or unwanted prolonged
effects. Similarly, some psychotropic agents (for
Parenting
The demands associated with HIV/AIDS may
disrupt normal parenting and this may further
aggravate the already low self-esteem of the
parent.
Fear
People living with HIV/AIDS may experience
pathological fear regarding rejection and loss of
social support, disease progression and impact on
their lives, and the pain of death and dying.
Disclosure
As a result of fear, the person living with HIV/
AIDS may choose not to disclose their HIV status
and risk infecting the possibly HIV negative spouse
or risk giving birth to an infected newborn.
Loss of loved ones
Prior bereavement as a result of HIV/AIDS may
aggravate the psychological trauma of a person
who contracts HIV. Survivor guilt may be evident
and the older individual living with HIV may wish
to die and join the departed family members.
326
group psychotherapy individual members derive

inspiration from the experience of other members
and take responsibility for personal decisions and
in managing of their mental health and HIV/AIDS
issues. Group psychotherapy sessions may be
facilitated by a team member or a professional.
Issue of compliance
Compliance refers to the ability of an individual
to adhere to medical advice and remain on often
multiple drug regimens and report for regular
medical reviews. Compliance may be affected by
the mental status of the individual, duration of
illness, the availability and cost of medication,
and the degree of adaptation of the individual to
ill health.
Psychoeducation
Psychoeducation is a form of psychotherapy whose
goal is to provide information on HIV/AIDS to
patients and their caregivers. Information provided
may differ according to the specic needs of
each patient. This form of psychotherapy may be
provided by the clinician or invited guest speakers
to groups of patients, and may cover topics such
as safe sex, discordant couples, medication and its
side-effects, HIV/AIDS in pregnancy and during
lactation and managing mental health problems.
Lazarus syndrome
As individuals with a long history of illness with
HIV notice signicant improvement, they may
experience signicant levels of increased energy,
well-being and a signicant reduction of symptoms.
Conversely, they may paradoxically experience
symptoms of depression, sadness, social isolation
and impairment in social functioning. This latter
reaction may be associated with suicidal behaviour
and should be routinely assessed.
Couple and family therapy

This form of psychotherapy provides an opportunity
for the spouse and other signicant family members
to join therapy in order to optimise the positive
outcome of psychosocial interventions. Through
family therapy, dysfunctional family relationships
may be addressed to promote adequate clinical
improvement.
Religious belief
People who live with HIV often develop strong
religious and spiritual beliefs that help them cope
with their situation, stimulate personal resources for
living and integrate meaning into their experience
of living with HIV. It is therefore important to
evaluate the religious and spiritual belief systems
of the patient living with HIV.
In many situations in Africa, few psychotherapists
are available to provide services for those in need.
Under the circumstances, professional counselling,
which may be regarded as a less structured
form of psychotherapy is the rational option.
Counselling helps people living with HIV to
examine their problem-solving patterns in relation
to current difculties including adjustment and
coping with HIV/AIDS, managing family affairs,
condentiality, sourcing help, social support and
HIV/AIDS-related information. The following
forms of psychotherapy may be used in addressing
HIV/AIDS issues.
Cognitive behavioural therapy

Cognitive behavioural therapy addresses negative
irrational belief systems and accompanying
dysfunctional behavioural practices of individuals.
It may be used to address these in relation to HIV/
AIDS.
BARRIERS TO MENTAL
HEALTH CARE
People living with HIV/AIDS face several barriers
when trying to access mental health services.
These barriers may be grouped into the following
categories:
Individual psychotherapy
One-to-one psychotherapy or counselling to
address patient concerns regarding HIV status as
well as clinical management, is employed in the
initial stages for individuals who enter the mental
health care system for the rst time.
Personal factors
Group psychotherapy
The health care system
Negative personal reaction to the diagnosis

of HIV/AIDS may hinder seeking help in the
long-term.
Fragmentation of the health care system

may hinder access to care for mental health
Psychotherapy conducted for a group of patients

facilitates change and manages mental health issues
in HIV/AIDS among individual group members. In
327
sources. This involves the integration of mental

health services in other social sector services that
range from providing legal services in drafting
a will or other legal document; helping family
members access basic human needs such as food,
shelter and clothing; helping children obtain
education; and referring the patient to other
medical specialists for appropriate services. Thus
the concept of comprehensive care is a holistic
care where needs of HIV/AIDS patients, palliative
care and rehabilitation, physical, clinical, social,
psychological and spiritual care are all considered
ideal.
problems that is a non-comprehensive onestop setting.

Lack of knowledge and skills among health
care providers may make it harder for mental
health problems to be recognised, diagnosed
and treated.
Societal attitudes, practices and prejudice

Negative attitudes among health care providers
may hinder their ability to provide appropriate
care to persons living with HIV/AIDS.
Societal and cultural beliefs and practices that
view HIV/AIDS as being due to witchcraft or
due to the actions of supernatural powers may
prevent patients from accessing appropriate
mental health services early.
Further reading
1. Boardman J. and Ovuga E. (1997). Rebuilding
Psychiatry in Uganda. Psychiatric Bulletin, 21: 649655.
2. Cournos F. and Forstein M. (Eds.) (2000). What
Mental Health Practitioners Need To Know About
HIV and AIDS. Jossey-Bass. Number 87, Fall 2000.
3. Ovuga E. (1997). Overview of HIV/AIDS and Mental
Health in Uganda. Parapraxis, 3(2): 35-39.
Integration of HIV/AIDS services

To be effective, services for individuals who
suffer from mental illness and are also HIV
positive should be accessed from several potential
328
42
Organic Psychiatry
David M. Ndetei, Caleb Othieno, Owiti Fredrick,
Mohammedi Boy Sebit, Gad Kilonzo
psychiatric units, just as psychiatric patients

present to internists or neurologists. The eld of
neuropsychiatry is not very well developed in
Africa. Research in neuropsychiatry is hampered by
a host of factors in the African continent. Yet there
is a clear relationship between certain neurological
diseases and primary mental disorders. Health
and mental health professionals in Africa should
have basic knowledge about neuropsychiatric and
neurodegenerative diseases. Neurodegenerative
diseases refer to the diseases that affect the nervous
system through neuronal cell death.
THE SPECIAL CASE FOR

AFRICA
Most African countries have very few psychiatrists
for their teeming population. Nigeria has less than
100 psychiatrists to contend with a population of
close to 130 million people! Generally, in Africa,
the psychiatrist to patient ratio is 1:2,000,000.
In the same vein, neurologists are few. Oftenly,
patients with neurological diseases present to
Figure 42.1: Organic conditions can present with a psychiatric disorder

329
extraneous factors such as infections, deciencies

and intoxications. In these conditions the illness
may initially present with psychiatric symptoms
such as depression.
Many theories have been elaborated to explain
all mental illnesses in terms of organic changes,
while others have claimed that psychiatric
problems can in themselves induce organic changes
(psychosomatic disorders), which in some respects
differ from organic psychiatry. Therefore, organic
psychiatry is the study of those organic diseases,
which are commonly associated with psychiatric
symptomatology.
DEFINITION
Medical conditions, which induce brain dysfunction
and lead to the appearance of characteristic
psychological symptoms and symptom-complexes
are designated as organic disorders. The causes
of brain disturbance are many and can occur as
direct consequences of head injuries, cerebral
infections, degenerative diseases, vascular diseases
or tumours (Table 42.1). Diseases in other organs
can indirectly affect the brain function. In addition,
the disturbance may be caused by a variety of
Table 42.1: Causes of organic brain syndrome
Infections (Cerebral)
Malaria (falciparum); Typhoid fever; Syphilis; Trypanosomiasis; Bacterial

meningitis; Viral meningitis, Toxoplasmosis, HIV/AIDS.
Infections (Systemic)
Septicaemia; Typhoid fever; Bronchopneumonia; Milder infections in children

and the aged
Hypoxia
Carbon monoxide poisoning
Metabolic
Electrolyte imbalance; Vitamin B group deciency; Porphyria; Liver and renal

diseases, spontaneous hypoglycaemia
Endocrine
Thyrotoxicosis; Myxoedema Cushings syndrome; Diabetic ketoacidocis
Cerebral tumour
Primary; Metastatic
Head injury
Acute injury (concussion, sub-dural haematoma); Post-traumatic encephalopathy

(punch drunk syndrome); Chronic sub-dural haematoma
Vascular disease
Sub-arachnoid haemorrhage; Multi-infarct dementia
Degenerative disease
Alzheimers disease; Picks disease; Alzheimer type; Presenile dementia; Senile

cerebral atrophy; Huntingtons chorea
Substance use
Alcohol; Barbiturates; Cannabis; Hallucinogens
PATTERNS OF ORGANIC CEREBRAL DISEASES

Table 42.2
DSM-IV-TR Cognitive Disorders
Delirium
Delirium due to a general medical condition
Substance-induced delirium
Delirium due to multiple etiologies
Delirium not otherwise specied
Dementia
Dementia of the Alzheimers type
Vascular dementia
Dementia due to other general medical conditions
Dementia due to HIV disease
Dementia due to Head trauma
Dementia due to Parkinsons disease
330
Organic Psychiatry
Dementia due to Huntingtons disease

Dementia due to Picks disease
Dementia due to Creutzfeldt-Jakob disease
Dementia due to other general medical conditions
Substance-induced persisting dementia
Dementia due to multiple etiologies
Dementia -riot otherwise specied
Amnestic disorders
Amnestic disorder due to a general medical condition
Substance-induced persisting amnestic disorder
Amnestic disorder not otherwise specied
Cognitive disorder not otherwise specied
Dementia (chronic organic brain syndrome):

chronic organic brain syndrome is characterised
by persisting and usually progressive
impairment of intellectual functions for other
higher cerebral functions. If accompanied
by marked deterioration of personality and
behaviour, the term dementia is applied. Such
mental symptoms always indicate intracranial
structural damage.
Other cognitive disorders
Generally, the three characteristic cerebral disease

patterns include:
Delirium (acute organic brain syndrome): This
denotes a temporary and reversible disturbance
in the brain function. The salient feature of this
condition is clouding of consciousness.
Amnestic syndrome: the central feature is
specic memory defect. Mental impressions
are retained only momentarily and the
ability to memorise is lost. The memorising
defect can occur as a transient or permanent
phenomenon.
Table 42.3: Evaluation of organic brain disorders
a)
b)
c)
d)
A complete history taking is important

Physical examination, including neurological examination.
Mental state examination
Laboratory radiological and other physical investigations such as:
Complete blood cell count with differential; Serum electrolytes and glucose; Blood urea nitrogen;
Creatinine clearance test; Liver function tests; serological test for HIV and syphilis; Thyroid function
tests; Serum vitamin B12 and Folate; VDRL/Khan Test; Urinalysis; Electrocardiogram; Chest X-ray;
Brain Computerized Tomography or Magnetic Resonance Imaging and EEG.
e) Neuropsychological testing
f) Optional tests: Cerebral blood ow; lumbar puncture.
regarded as delirium. Profound impairment of

consciousness may lead to stupor or coma.
DELIRIUM
Pathophysiology
Acute organic brain syndrome is characterised by

clouding of consciousness. In delirium there are
additional features such as restlessness, illusions
and psychotic features in the form of auditory
or visual hallucinations and delusions. The mildest
degrees of clouding, for example, muzzy feelings
associated with mild fever are not generally
Consciousness requires an activated cerebral cortex.

Activation is a function of the mid-brain reticular
activating system (RAS), which relays sensory
information to the cortex. Lesions directly
involving the RAS are relatively uncommon,
and in the great majority of cases it is by toxic,
331
metabolic conditions or the remote effects of

lesions involving other regions of the brain. In the
former case, the polysynaptic structure of the RAS
makes it sensitive to the effects of many drugs
and metabolites. Any structural lesion of the CNS
associated with raised intracranial pressure sooner
or later gives rise to impairment of consciousness,
because of the peculiar nature of the blood
supply to the central region of the brain stem
and diencephalons. These structures are supplied
by perforating arteries leaving the basilar artery
and its main branches at right angles. The parent
vessels at the sites of origin of these branches are
relatively immobile, being ensheathed in dura
mater. As intracranial pressure rises, displacement
of the brain stem occurs, and because the short

straight course of the perforating arteries leaves
little reserve for movement, they readily become
stretched and, even torn if the movement is sudden
and extreme as in head injuries.
Aetiology
Delirium is more readily provoked in children and
the elderly. Indeed, with old people it is impossible
to identify a satisfactory cause in many cases.
Clinical features
The main symptom and sign of delirium is the
clouding of consciousness (Glasgow Coma Scale
8) as indicated in Table 42.4.
Table 42.4: The Glasgow Coma (Consciousness) Scale

Eye opening
Best verbal response
Best motor response
5. Normal
4. Spontaneous
3. To speech
2. To pain
1. None
5. Oriented
4. Confused, but talking in sentences
3. Uttering inappropriate sounds
2. Incomprehensible sounds (no words)
1. None
5. Obeys verbal commands

4. Localising to pain
3. Flexion to pain
2. Extension to pain
1. None
Note: The higher the score the better the level of consciousness and vice versa
differentiated, so that his fantasies and fears become

real. He may frequently feel persecuted, and visual
auditory or tactile hallucinations may overshadow
his perception of the environment. His normal
affective response to external stimuli is blunted,
but his reaction to his own convictions and inner
experiences may be extreme. The resulting fear
and panic may pose a serious therapeutic problem,
for such patients may be terror stricken, disregard
such impediments as intravenous cannulae and
attempt to escape, perhaps through an upper storey
window. Less commonly the affect is depressed
and occasionally elated.
Many patients remain apathetic, though others at
times are restless and unco-operative or irritable,
excitable or even violent. Some show disinhibited
behaviour. Restlessness and hallucinations are
often worse at night and associated with insomnia.
Urinary and faecal incontinence is common.
Other symptoms of delirium include: impaired

attention; spatial disorientation; misidentication;
temporary memory impairment; disturbance in
mood; perplexity; uctuating course; insomnia or
somnolence; psychotic features: hallucinations,
illusions, and delusions.
The syndrome of delirium is superimposed on
the characteristic features of the causal condition.
The onset may be abrupt, but sometimes it comes
on over several days. At rst it may be apparent
only in the evenings or when the patient is relaxed.
There may be difculty in concentration, loss of
interest, ready fatigue and disturbed sleep with
vivid dreams. Following this prodromal period,
clouding of consciousness becomes apparent; the
patient becomes disoriented in time and place; his
recent memory is faulty and his other cognitive
functions, notably comprehension and reasoning
are impaired.
Grasp, concentration and judgement are affected
so that the patient becomes inattentive, confused
and distractible. Perceptual discrimination is
impaired and delusions occur; the patients
imaginary world and the real world are no longer
Diagnostic categories of delirium

Tables 42.5 - 42.9 summarise the various diagnostic
categories of delirium.
332
Organic Psychiatry
Table 42.5
293.0 Delirium Due to ... [Indicate the General Medical Condition]
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability
to focus, sustain, or shift attention.
B. A change in cognition (such as memory decit, disorientation, language disturbance) or the development
of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving
dementia.
C. The disturbance develops over a short period of time (usually hours to days) and tends to uctuate during
the course of the day.
D. There is evidence from the history, physical examination, or laboratory ndings that the disturbance is
caused by the direct physiological consequences of a general medical condition.
Note: If delirium is superimposed on a pre-existing Vascular Dementia, indicate Vascular Dementia, With
Delirium.
Note: Include the name of the general medical condition on Axis I, e.g., Delirium due to Hepatic
Encephalopathy; also code the general medical condition on Axis III.
Table 42.6
Substance Intoxication Delirium
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced
ability to focus, sustain, or shift attention.
dementia.
C. The disturbance develops over a short period of time (usually hours to days) and tends to uctuate
during the course of the day.
D. There is evidence from the history physical examination, or laboratory ndings of either (1) or (2):
(1) The symptoms in Criteria A and B developed during Substance Intoxication
(2) Medication use is etiologically related to the disturbance
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the
cognitive symptoms are in excess of those usually associated with the intoxication syndrome and when
the symptoms are sufciently severe to warrant independent clinical attention.
Table 42.7
Substance Withdrawal Delirium
of a perceptual disturbance that is not better accounted for by a pre-existing, established or evolving
dementia.
D. There is evidence from the history, physical examination, or laboratory ndings that the symptoms in
Criteria A and B developed during, or shortly after, a withdrawal syndrome.
333
Note: This diagnosis should be made instead of a diagnosis of Substance Withdrawal only when the cognitive
symptoms are in excess of those usually associated with the withdrawal syndrome and when the symptoms
are sufciently severe to warrant independent clinical attention.
Table 42.8
Delirium Due to Multiple Etiologies
dementia.
D. There is evidence from the history, physical examination or laboratory ndings that the delirium has
more than one aetiology (e.g., more than one etiological general medical condition, a general medical
condition plus Substance Intoxication or medication side effect).
Coding note: Delirium due to Multiple Aetiologies does not have its own separate code and should not be
recorded as a diagnosis. For example, to code a delirium due to both hepatic encephalopathy and withdrawal
from alcohol, the clinician would list both Delirium Due to Hepatic Encephalopathy and Alcohol Withdrawal
Delirium on Axis I and II hepatic encephalopathy on Axis III.
Table 42.9
780.09 Delirium Not Otherwise Specied
This category should be used to diagnose a delirium that does not meet criteria for any of the specic types
of delirium described in this section.
Examples include:
1. A clinical presentation of delirium that is suspected to be due to a general medical condition or substance
use but for which there is insufcient evidence to establish a specic aetiology
2. Delirium due to causes not listed in this section (e.g., sensory deprivation)
Table 42.10: Treatment of delirium

a) If it is in the hospital, the patient should be in a quiet restful setting that is well lighted.
b) Maintain the same personnel who serve the patient.
c) Occupational therapist should see into it that reminders of day, time, and situation should be prominently
displayed in the patients room.
d) Medication for behaviour management should be limited to those cases in which behavioural interventions
have failed:
i. Only essential drugs should be prescribed and polypharmacy should be avoided.
ii. Avoid sedative-hypnotics and anxiolytics except such drugs like haloperidol in small doses.
iii. Unmanageable behaviour may require low-dose of neuroleptics or short half-lives benzodiazepines
e.g. lorazepam 1mg twice daily.
334
Organic Psychiatry
syndrome is rarely pure, being commonly

accompanied by elements of mild dementia. In
other cases the damage is incomplete so that partial
syndromes occur.
As the patient recovers from the acute
encephalopathic illness and consciousness becomes
clear, the gross defect of recent memory stands out.
Immediate recall being unaffected, the patient can
repeat a string of numbers or syllables, but as soon
as his attention is deected by a question or random
thought, they are gone. Intact remote memory
leaves the patient with language, his knowledge of
the customs of his particular society and a body
of experience that allows him to behave normally
and converse rationally even intelligently on
familiar topics. When asked about events that
have occurred since the onset of his illness, he
may speak with an assurance and conviction that
conceal the utter inaccuracy of his statements.
This is confabulation. It is an epiphenomenon into
which the patient has no insight.
The patients memory impairment leads
to disorientation in time and, in unfamiliar
surroundings, to disorientation in place. It also
interferes seriously with his learning ability so that
an extraordinary contrast is presented between the
complexity of his previously learned behaviour
and his inability to learn a simple new task. The
characteristic affective change is apathy, blandness
or even mild euphoria. Disturbing events make
little impact on the individual and any emotional
response on his part is transient.
AMNESTIC SYNDROME
In amnestic syndrome there is impairment or loss
of recent memory with preservation of immediate
recall, remote memory and other cognitive
functions.
Pathophysiology
The recording of memories is a function of
the limbic system, notably the hippocampi, the
hippocampal gyri, the mamillary bodies and their
connections. Bilateral damage to these structures
impairs the ability to register new information to
memory. As the limbic system plays an important
role in the experience of emotion, affective changes
also occur.
Aetiology
The commonest condition, giving rise to the
dysmnesic syndrome is chronic alcoholism. The
onset is preceded in most cases by an episode of W
ernickes encephalopathy. As in arsenic poisoning
and in other conditions associated with acute
thiamine (vitamin B1) deciency, there is bilateral
damage to the mamillary bodies. In other cases
there is involvement of the medial aspects of both
temporal lobes, such as with bilateral infarction,
neurosurgical interference, bilateral invasive
tumours and acute necrotic encephalitis resulting
from herpes simplex virus infection. A transient
dysmnesic syndrome is not uncommon during
recovery from a head injury or a subarachnoid
haemorrhage. Occasionally, it may persist in both
instances.
Diagnostic categories of amnestic disorders

The various diagnostic categories of amnestic
disorders have been summarised in tables 42.1142.14.
Clinical picture
The pathological states just listed frequently
involve other areas of the brain so that a dysmnestic
Table 42.11
294.0 Amnestic Disorder Due to ... [Indicate the General Medical Condition]
A. The development of memory impairment as manifested by impairment in the ability to learn new
information or the inability to recall previously learned information.
B. The memory disturbance causes signicant impairment in social or occupational functioning and
represents a signicant decline from a previous level of functioning.
C. The memory disturbance does not occur exclusively during the course of a delirium or a dementia.
D. There is evidence from the history, physical examination, or laboratory ndings that the disturbance is
the direct physiological consequence of a general medical condition (including physical trauma).
335
Specify if:
Transient: if memory impairment lasts for 1 month or less. When the diagnosis is made within the rst
month without waiting for recovery, the term provisional may be added. Chronic: if memory impairment
lasts for more than 1 month.
Note: Include the name of the general medical condition on Axis I, e.g. Amnestic Disorder Due to Head
Trauma; also the general medical condition on Axis 111.
Table 42.12
Substance-Induced Persisting Amnestic Disorder
A. The development of memory impairment as manifested by impairment in the ability to learn new
information or the inability to recall previously learned information.
B. The memory disturbance causes signicant impairment in social or occupational functioning and
represents a signicant decline from a previous level of functioning.
C. The memory disturbance does not occur exclusively during the course of a delirium or a dementia and
persists beyond the usual duration of Substance Intoxication or withdrawal.
D. There is evidence from the history, physical examination, or laboratory ndings that the memory
disturbance is etiologically related to the persisting effects of substance use (e.g., a drug of abuse, a
medication).
Specify Substance
Table 42.13
294.8 Amnestic Disorder Not Otherwise Specied
This category should be used to diagnose an amnestic disorder that does not meet criteria for any of the
specic types described in this section.
An example is a clinical presentation of amnesia for which there is insufcient evidence to establish a
specic aetiology (i.e., dissociative, substance induced, or due to a general medical condition).
Table 42.14
294.9 Cognitive Disorder Not Otherwise Specied
This category is for disorders that are characterized by cognitive dysfunction presumed to be due to the direct
physiological effect of a general medical condition that do not meet criteria for any of the specic deliriums,
dementias, or amnestic disorders listed in this section and that are not better classied as Delirium Not
Otherwise Specied, Dementia Not Otherwise Specied, or Amnestic Disorder Not Otherwise Specied.
For cognitive dysfunction due to a specic or unknown substance, the specic Substance-Related Disorder
Not Otherwise Specied category should be used.
Examples:
1. Mild neurocognitive disorder: impairment in cognitive functioning as evidenced by neuropsychological
testing or quantied clinical assessment, accompanied by objective evidence of a systemic general
medical condition or central nervous system dysfunction.
2. Postconcussional disorder: following a head trauma, impairment in memory or attention with associated
symptoms
336
Organic Psychiatry
Table 42.15
DSM-IV-TR Research Criteria for Postconcussional Disorder
A. A history of head trauma that has caused signicant cerebral concussion.
Note: The manifestations of concussion include loss of consciousness, posttraumatic amnesia, and, less
commonly, posttraumatic onset of seizures. The specic method of dening this criterion needs to be
established by further research.
B. Evidence from neuropsychological testing or quantied cognitive assessment of difculty in attention
(concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning
or recalling information).
C. Three (or more) of the following occur shortly after the trauma and last at least 3 months:
(1) becoming fatigued easily
(2) disordered sleep
(3) headache
(4) vertigo or dizziness
(5) irritability or aggression on little or no provocation
(6) anxiety, depression, or affective lability
(7) changes in personality (e.g., social or sexual inappropriateness)
(8) apathy or lack of spontaneity
D. The symptoms in Criteria B and C have their onset following head trauma or else present a substantial
worsening of preexisting symptoms.
E. The disturbance causes signicant impairment in social or occupational functioning and represents a
signicant decline from a previous level of functioning. In school-age children, the impairment may be
manifested by a signicant worsening in school or academic performance dating from the trauma
F. The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for
by another mental disorder (e.g., amnestic disorder due to head trauma, personality change due to head
trauma).
Lesions causing deep midline damage such

as pituitary tumours, craniopharyngioma,
tuberculous meningitis and head injury.
The illness is characterised by lateral nystagmus,
external rectus paralysis and paralysis of conjugate
gaze resulting in ataxia, and neuropathy and
confusion state. These symptoms can appear in
various combinations and diagnosis does not
depend on all being present in a given case.
If left untreated, delirium and coma may ensue.
Administration of thiamine dramatically reduces
the high mortality. The ophthalmoplegia generally
fades within days of thiamine therapy, while
nystagmus, ataxia and neuropathy recover more
slowly. In addition, lateral nystagmus commonly
persists. The confusional state subsides within 2
weeks, but as it clears, a Korsakoff memorizing
defect becomes obvious in a proportion of cases. It
has become more generally accepted that Wernickes
encephalopathy and Korsakoffs syndrome are not
two separate diseases, but successive stages of a
single disease.
Immediately the Wernickes or Korsakoffs
symptoms are recognised, 50 mg thiamine is given
Types of amnestic syndromes

Wernickes Encephalopathy
This is a thiamine deciency encephalopathy,
but specic pathogenesis of lesions and their
selective localisation in the mamillary bodies,
periacquiductal grey matter and part of thalamus,
remain so far unexplained. The lesions that
principally affect the grey matter are characterised
by congestion of small blood vessels with or without
haemorrhages, proliferation of capillaries lined by
swollen endothelial cells, red cell proliferation and
a general loosening of ground substance.
Clinical conditions predisposing to Wernickes
encephalopathy include:
Persistent vomiting from whatever cause
(e.g., hyperemesis gravidarum).
Chronic alcoholism, hence the condition also
referred to as Alcoholic Encephalopathy.
Lesions of the stomach, duodenum or jejunum
causing malabsorption.
Extreme dietary deprivation due to famine
conditions and chronic gastrointestinal tract
(GIT) candidiasis in HIV infection.
337
intravenously, supplemented by a similar amount

intramuscularly for several days, after which
normal eating habits are established. Thereafter,
weekly injections of parentrovite for 6 months
are required. Large amounts of carbohydrates
should not be given until the body is saturated with
thiamine. Treatment of underlying predisposing
clinical conditions is essential.
Transient Global Amnesia

Transient global amnesia is characterised by
episodes of loss of recent memory. Each episode
results from transient ischaemia of the medial
aspects of both temporal lobes caused by vertebrobasilar insufciency.
The condition occurs in the middle-aged and
elderly people. An attack begins abruptly and
may last for several hours. The patient is unable
to register new information in the memory traces,
but remote memory is little if at all affected.
There may be a period of retrograde amnesia
extending backwards from the onset of the attack
for as long as three hours. Similarly to dysmnesic
syndrome, the patient retains his sense of personal
identity, but may experience some confusion and
anxiety associated with a strange depersonalised
feeling. Confabulation does not usually occur. The
prognosis for the attack is good.
Korsakoffs Syndrome
It is sometimes referred to as the alcohol amnestic
disorder. This amnestic syndrome is caused by
chronic thiamine deciency and associated with
alcoholism. Although there may be more areas of
the brain affected, the amnesia in this syndrome
is due to damage mainly in the mamillary bodies,
the thalamus and the hippocampus. Once the
neuronal damage is done, treatment with thiamine
is not effective in restoring the memory.
Thiamine deciency could result from
intestinal malabsorption, prolonged intravenous
hyperalimentation and gastric carcinoma. The
clinical features of Korsakoffs syndrome include
difculty in learning new information, leading to
anterograde amnesia. The patients may also have
retrograde amnesia.
Temporal Lobe
Lesions of the temporal lobe may give rise to:
Memorizing defect (dysmnestic syndrome).
Temporal lobe epilepsy
o Visual eld defects. The optic radiation
traverses the temporal lobe to reach the end
calcarine ssure.
o Dysphasia. The patient has difculty
in nding appropriate words to express
himself or employs the wrong word in a
particular context. There is disorganization
in their speech and language. Naming
ability is impaired. There may be relative
failure to understand spoken or written
words, therefore repetition and words
used being in the wrong context. Speech
defects in temporal lobe arise as a result of
involvement of posterior third of superior
and middle temporal gyri and inferior
parietal regions.
Lesions of the Hippocampal gyrus and

Hippocampus
Memorising defects were rst noticed following
bilateral temporal lobe resection, carried out for
the relief of psychosis and epilepsy. Other lesion
occurring in this area cause memorizing defects
such as acute necrotizing encephalitic caused by
herpes simplex virus involving the amygdaloid,
hippocampus and hippocampal gyrus which
causes amnestic syndrome.
Transient amnestic syndrome is recognised
after subarachnoid haemorrhage, carbon dioxide
poisoning and cerebral hypoxia. A differential
diagnosis in all these cases is the hysterical
amnesia, where by the memory loss may coexist
with organic disorders.
In head injuries and subarachnoid haemorrhage,
the dysmnesic syndrome is frequently transient
and the prognosis is good. In other cases, there
is often irreversible structural damage and the
prognosis is correspondingly poor. In alcoholics,
progressive brain destruction may continue, to the
extent dysmnesic syndrome merges slowly into
a dementia. Treatment is that of the underlying
condition.
Parietal Lobe
Sensory cortex gives rise to loss or impaired
sensation on the contra lateral part of the body.
Posterior lesions produce more elaborate
parietal lobe signs.
Apraxia (in ideomotor or ideational) is the
inability to imitate gestures and actions to
command when the patient understands the
request and does not suffer from paresis.
It is associated with partial lobe disease or
dominant hemisphere.
338
Organic Psychiatry
Dressing apraxia. There is impaired order and

manipulation of dressing. Dressing is lopsided,
for instance, the patient may ignore his left
arm.
Body image distortion. The patient may
neglect the left side of the body. In addition,
he may show indecision and inconsistency in
identifying ngers.
Construction apraxia. Impaired ability to copy
two dimensional designs is present. There
could be difculty in writing (dysgraphia), an
absence of paresis and difculty in calculation
(dyscalculia).
Multi-infarct dementia.
Head injury.
Prevalence
The prevalence of dementia increases with age.
Among 65-69 year olds, the rate is 2 percent. It
rises to 5 percent for 75-79 year olds and to more
than 20 percent for 85-89 year olds.
Alzheimers disease
Alzheimers disease accounts for 50 percent of all
dementia. First described in young adults, it was
thought to be atypical senile dementia. The cause
is unknown and thought to be multi-factorial.
Pathological changes in Alzheimers disease are
also found in normal elderly people, but with less
severity. The pathological changes include severe
neuronal loss and neuritic silver staining plaques,
which are aggregates of laments with a core of
amyloid and neurobrillary tangles. The laments
consist of twisted and tangled neurobrils of
degenerated nerve cells. Choline acetyltransferase
(CAT) is reduced in the cortex. Predominantly the
frontal and parietal lobes are involved.
DEMENTIA
Dementia refers to the chronic progressive brain
dysfunction that leads to impaired memory,
personality changes and intellectual deterioration.
There are two types: presenile dementia that occurs
before the age of 65 years and senile dementia that
occurs after the age of 65 years. The specic brain
diseases cause reactions like:
Alzheimers disease.
Huntingtons chorea.
Dementia due to infections such as syphilis
(general paralysis) and HIV-associated
dementia.
Clinical features
The rst signs are mild memory loss and
forgetfulness. Subtle personality changes may
be noticed by close associates. Depressive and
paranoid illness may erupt at the early stage and
obscure the underlying organic defect.
Table 42.16: Some causes of dementia

Type
Causes
Degenerative and late onset
Alzheimers disease (early onset); Picks disease; Huntingtons

chorea; Crutzfeldt-Jacob disease; Normal pressure hydrocephalus
Tumours
Neoplasms
Traumatic
Severe single closed/opened head injuries; Repeated head injury in

boxers; Sub-dural haematoma
Infections and related conditions
Encephalitis of any cause; Human Immunodeciency Virus;

Neurosyphilis; Cerebral sarcoidosis
Vascular
Multi-infarct dementia; Arteritis
Toxic
Alcohol; Heavy metal poisoning (lead, arsenic and thallium)
Anoxia
Anaemia; Post-anaesthesia; Cardiac arrest

Chronic respiratory failure; Carbon monoxide
Vitamin lack
Sustained lack of B12, folate, thiamine and nicotinic acid
339
Disorientation in territorial space and time become

apparent with time. Initial minor difculty in word
nding progresses to massive loss of vocabulary
with an associated dysarthria. There is progressive
memory loss which is non-specic involving both
recent and remote events. Misidentication at this
stage is observed. Emotional liability with rapid
swings from tearful to laughter or brief ashes of
motiveless and anger are frequent. The end stage

is profound dissolution of all faculties, with total
memory loss, jargon dysphasia emaciation, limb
contractures and incontinence. Anticholinesterase
agents such as donepezil may give temporary
relief.
for dementia of the Alzheimers type.
Table 42.17
294.1x Dementia of the Alzheimers Type
A. The development of multiple cognitive decits manifested by both
(1) memory impairment (impaired ability to learn new information or to recall previously learned
information)
(2) one (or more) of the following cognitive disturbances:
(a) aphasia (language disturbance)
(b) apraxia (impaired ability to carry out motor activities despite intact motor function)
(c) agnosia (failure to recognize or identify objects despite intact sensory function)
(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
B. The cognitive decits in Criteria A1 and A2 each cause significant impairment in social or occupational
functioning and represent a signicant decline from a previou osyphilis, HIV infection)
(3) substance-induced conditions
E. The decits do not occur exclusively during the course of a delirium.
F. The disturbance is not better accounted for by another Axis I disorder (e.g.. Major Depressive Disorder,
Schizophrenia).
Code based on presence or absence of a clinically signicant behavioural disturbance:
294.10 Without Behavioural Disturbance: if the cognitive disturbance is not accompanied by any clinically
signicant behavioural disturbance.
294.11 With Behavioural Disturbance: if the cognitive disturbance is accompanied by a clinically
signicant behavioural disturbance (e.g., wandering, agitation).
Specify subtype:
With Early Onset: if onset is at age 65 years or below
With Late Onset: if onset is after age 65 years
Coding note: Also code 331.0 Alzheimers disease on Axis III. Indicate other prominent clinical features
related to the Alzheimers disease on Axis 1 (e.g., Mood Disorder Due to Alzheimers Disease, With
Depressive Features, and Personality Change Due to Alzheimers Disease, Aggressive Type).
inclusion are sometimes observed, but their absence

does not exclude the diagnosis.
Picks Disease
Picks disease, described in 1892, is a rare form of
presenile dementia, which is transmitted by single
dominant gene. The brain shows mild generalized
atrophy with gross circumscribed lobal atrophy
involving the frontal and temporal lobes. The
salient histopathological feature is a severe outfall
of nerve cells in the frontal and temporal lobes and
all trace of normal architecture and lamination is
lost. Ballooned cells and cells with silver staining
Clinical features
Those affected are between 52 and 57 years and the
average duration of the disease is from six to seven
years. The early signs are those of personality
change due to frontal lobe atrophy. Flamboyant
antisocial behaviour is sometimes observed. Insight
into the personality change is wholly lacking. The
340
Organic Psychiatry
known means of identifying the carriers, therefore

all members of an affected family should be
genetically counselled not to have children.
National medical linkage system together with
formation of registration of pedigrees of affected
families would help in ensuring identication of
early cases.
mood is mildly euphoric or stolid and placid, with

eeting outbursts of anger.
Speech defects mark the middle stage of the
disease and take the form of nominal aphasia. This
presents initially as failure to remember nouns and
progresses to severe reduction of all elements of
vocabulary. Circumlocutory phrases are used to
convey the meaning of forgotten words initially
and perseveration becomes prominent. In time,
speech is reduced to a string of substantives with the
occasionally interpolated adjective. Disturbance of
gait is lacking in Picks disease. Apraxia is a late
feature. Psychotic manifestations found early in
Alzheimers are rarely witnessed in Picks disease.
The nal stage is one of marked dementia. The
patient becomes bedridden with contractures of the
limbs and cachexia develops similar to Alzheimers
disease.
General Paralysis
This was one of the commonest organic psychosis
of mid-life period, but it is now rare. The latent
period between primary infection of syphilis and the
manifestation of general paralysis varies from 5 to 25
years, and the average interval is 10 years. Men are
affected more than women. Pathologically, there is
shrunken brain covered with an opaque, thickened
and adherent pia-arachnoid. Convolutional atrophy
is most profound in the frontal and temporal lobes
and the ventricles are dilated. There is loss of
cortical lamination, and nerve cells, and marked
astrocytic proliferation. Cortical vessels are
surrounded by cuffs of lymphocytes and plasma
cells. Spirochaetes can be demonstrated in the
cortex by dark ground illumination.
Personality changes may be the rst
manifestation of the disease, because of the frontal
lobe predilection. Insidious memory defects and
associated depression of varying degrees are
present. The established disease can take several
forms. The most common is a slowly progressive
dementia with no special featuressimple
dementing type. Other variants are the depressed
type and the small proportion present with mania
exhibiting grandiose delusion, associated in the
popular mind with general paralysis.
Small unequal irregular pupils that fail to react to
light (but do so for accommodation) are present in
more than half the cases. Tremor of the face, lips,
tongue and ngers, and a weakness terminating
in spastic paralysis are characteristic signs
(reexes are depressed or absent in taboparesis).
Speech is characteristic, slurring of words and
spastic dysarthria. Cerebrospinal uid shows
raised protein content and a rise in cell counts.
The Cerebral Spinal Fluid (CSF) and serum give
a positive Wasserman Reaction (WR). Early
diagnosis and prompt treatment with penicillin
produces clinical improvement.
Huntingtons Chorea
This is a hereditary disease that was rst described in
1872. It is characterised by continuous involuntary
movements and slowly progressive dementia.
It is transmitted by a single dominant autosomal
gene with full penetration. Sporadic mutations
have been reported in Africa. The disease appears
between the ages of 35 and 45. There is generalised
cortical atrophy most marked in the frontal lobes,
and corpus striatum.
The onset is insidious, with occasional grimace,
shrugs or body twist, intermittent tapping of nger
or feet, which give the impression of general
dgetiness. In established cases, choreiform
movements are usually obvious in the face, head
and arms. Head nodding, torticollis and facial
twitching are common. At a later stage, an athetoid
movement of the limbs becomes apparent. No part
of the body is exempt and speech, swallowing,
respiration and locomotion are affected. Insight
is retained early in this disease leading to extreme
sensitiveness to the reactions of other people to
the disabling involuntary movements and reactive
depression. Mood disorders in form of depression
and rarely mania may precede the involuntary
movements by 3 to 20 years. Physical activity may
be maintained until late in the disease. Some show
a profound dementia in the nal stage.
There is no known treatment for the disease,
but phenothiazines, in small doses alleviate the
emotional disturbance. Involuntary movements
may be ameliorated by thipropazate (20 mg thrice
daily) or tetrabenezine (25-200 mg daily).
Prevention of the disease is the only way of
reducing the appearance of disease. There is no
HIV-associated Dementia
HIV causes cognitive disturbance with varying
severity from minor cognitive disorder to severe
cognitive impairment. The true prevalence and
incidence in HIV infection is unknown. However,
341
it is present in between 8 to 16 percent of patients

with AIDS syndrome, but is more than 31 percent
in some African countries. It can be the presenting
manifestation of HIV infection and thus, lead to the
diagnosis of AIDS. It is frequently characterised
by multi-nucleated cell encephalitis and evidence
of productive HIV infection of macrophages and
monocytes.
Neuropsychiatric manifestations of HIV/
AIDS vary and may precede the neurological
manifestations. The dementia is sub-cortical
type, characterised by psychomotor slowing,
inattentiveness, forgetfulness and volitional stupor,
and difculties with problem solving and reading.
Patients appear apathetic, with reduced spontaneity
and social withdrawal. In a small percentage of
affected individuals the illness may initially present
atypically as an affective disorder, psychosis or
seizures. They may have tremor, ataxia hypertonia
and positive frontal lobe signs.
The diagnosis HIV-1 associated should be
made after excluding active CNS opportunistic
process like Cryptococcus, papovavirus and
Creutzfeldt Jacob Disease (CJD). Laboratory
evidence for systemic HIV infection (ELISA
Test, with/or Western blot, P24 antigen or tissues

culture markers). There is no satisfactory treatment
of HIV-1 associated dementia. However, there
is accumulating evidence that zidovudine and
related drugs may ameliorate the features of
early dementia. Treatment of neuropsychiatric
complications of AIDS patients depends on clinical
presentations.(For more details on the HIV/AIDS
aspects on the brain see chapters on HIV/AIDS
neuropsychiatric and mental health aspects).
Atherosclerotic (Multi-Infarct) Dementia

This accounts for less than 10 percent of all cases
of dementia. It occurs as a result of repeated
stroke with progressive focal loss of function. It
is found in elderly people who have had repeated
strokes from middle life, hypertension, diabetes
mellitus and were smokers. There are varied focal
neurological signs in the presence of dementia.
These include paralysis, dysphasia, visual eld
defects and apraxia. The treatment is based on
controlling of blood pressure and cholesterol level,
including administration of Aspirin, 650mg daily.
for Vascular Dementia.
Table 42.18
290.4x Vascular Dementia (formerly Multi-lnfarct Dementia)
information)
functioning and represent a signicant decline from a previous level of functioning.
C. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reexes, extensor plantar
response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence
indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white
matter) that are judged to be aetiologically-related to the disturbance.
D. The decits do not occur exclusively during the course of a delirium.
Code based on predominant features:
290.41 With Delirium: if delirium is superimposed on the dementia
290.42 With Delusions: if delusions are the predominant feature
290.43 With Depressed Mood: if depressed mood (including presentations that meet full symptom criteria
for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to
a General Medical Condition is not given.
290.40 Uncomplicated: if none of the above predominates in the current clinical presentation
342
Organic Psychiatry
Specify if (can be applied to any of the above subtypes):

With Behavioural Disturbance: if there is clinically signicant behavioural disturbance (e.g., wandering)
Coding note: Also code cerebrovascular condition on Axis III.
Head Injury
Frontal lobe syndrome
Chronic disabilities following head injury include

post concussional syndrome, epilepsy, dementia and
chronic sub-dural haematoma. Post-concussional
syndrome starts within a few days or a week after
the accident. The syndrome consists of headaches,
giddiness and nervous instability with undue
fatigue of body and mental exhaustion. There is
intolerance to light and noise. Insomnia, anxiety
and depression are common manifestations.
The symptoms are often reversible and variable
in severity. In some patients, the disability is
largely inuenced by the patients predispositions
(premorbid personality) other than injury and
in some patients the disabilities are inuenced
by compensation claims.
The frontal lobe syndrome is characterised by

loss of foresight; it is not so much the inability
to predict consequences as the capacity to ignore
them. Cognitive functions otherwise are little, if at
all, affected.
Aetiology
The features of the frontal lobe syndrome occur
in many disorders associated with diffuse cerebral
damage, but when this happens, they are frequently
overshadowed by the evidence of damage to other
regions of the brain. In many conditions that
culminate in dementia, a frontal lobe syndrome
may be the earliest manifestation. The isolated
syndrome occurs with bilateral frontal lobe damage
resulting from trauma, involvement by invasive
tumours and bilateral infarction, and sometimes as
a sequel to meningitis or encephalitis.
Post-Traumatic Dementia
This type of dementia can occur as a result of
severe diffuse cortical damage. It manifests as
innite variation of global cerebral dysfunction,
from mild forgetfulness, impaired concentrations
and lack of spontaneity, to severe personality
change and intellectual impairment. Repeated
head injury, particularly in boxers, can result
in punch-drunk syndrome. In those affected,
there is varying combination of pyramidal, extrapyramidal and cerebellar signs. Common early
signs are dysarthria and ataxic gait. Extra-pyramidal
features may postdate the cerebellar defects (facial
immobility, rigidity, course resting tremor). Later,
intellectual impairment ensues. Memorising
defects and personality change with rage reactions
are common. A chronic psychosis may be exhibited
with persistent morbid jealousy syndrome or
paranoid schizophreniform psychosis.
Clinical features
In the fully established syndrome the patient lives
for the moment without thought for the future.
He is uncaring in his conduct of everyday affairs,
thoughtless, unreliable and untrustworthy. His
concentration is poor except for brief periods
of evanescent enthusiasm. Lying or dishonesty
may be adopted as the easiest solution to some
momentary difculty. Anxiety and depression are
foreign to the patient; his mood is either one of
shallow euphoria and inappropriate jocularity or
one of dispirited apathy and withdrawal. He may
become dirty, slovenly and untidy, and his eating
habits may deteriorate. Urinary and even faecal
incontinence may occur. Because the patient lacks
self-awareness, his friends and relatives are often
more distressed about his condition than he is.
343
Dementia Due to Other General Medical Conditions

Table 42.19
294.1x Dementia Due to Other General Medical Conditions
information)
C. There is evidence from the history, physical examination, or laboratory ndings that the disturbance is
the direct physiological consequence of a general medical condition other than Alzheimers disease or
cerebrovascular disease (e.g., HIV infection, traumatic brain injury, Parkinsons disease, Huntingtons
disease. Picks disease, Creutzfeldt-Jakob disease, normal-pressure hydrocephalus, hypothyroidism,
brain tumour, or vitamin B12 deciency).
Code based on presence or absence of a clinically signicant behavioural disturbance:
294.10 Without Behavioural Disturbance: if the cognitive disturbance is not accompanied by any clinically
signicant behavioural disturbance.
294.11 With Behavioural Disturbance: if the cognitive disturbance is accompanied by a clinically
signicant behavioural disturbance (e.g., wandering, agitation).
Note: The general medical condition on Axis III (e.g., HIV infection, head injury, Parkinsons disease,
Huntingtons disease, Picks disease, Creutzfeldt-Jakob disease)
Substance-Induced Persisting Dementia

Table 42.20
Substance-Induced Persisting Dementia
information)
C. The decits do not occur exclusively during the course of a delirium and persist beyond the usual duration
of Substance Intoxication or Withdrawal.
D. There is evidence from the history, physical examination, or laboratory ndings that the decits are
etiologically related to the persisting effects of substance use (e.g., a drug of abuse, a medication).
344
Organic Psychiatry
Dementia Due to Multiple Aetiologies

Table 42.21
Dementia Due to Multiple Aetiologies
information)
C. There is evidence from the history, physical examination, or laboratory ndings that the disturbance has
more than one aetiology (e.g., head trauma plus chronic alcohol use. Dementia of the Alzheimers Type
with the subsequent development of Vascular Dementia).
Note: Dementia Due to Multiple Aetiologies does not have its own separate code and should not be
recorded as a diagnosis
Dementia Not Otherwise Specied

Table 42.22
294.8 Dementia Not Otherwise Specied
This category should be used to diagnose a dementia that does not meet criteria for any of the specic types
described in this section.
An example is a clinical presentation of dementia for which there is insufcient evidence to establish a
specic aetiology.
Diagnostic clues to the presence of underlying

bodily disease in patients presenting psychiatrically
may be found in the initial history, mental state and
physical examination, special tests and subsequent
course of the patients disorder. The most important
of these clues are organic symptoms in the mental
state examination, especially impairments of
cognitive function. Most of the other clues are
obvious, but they are often overlooked. These clues
are set out in the order in which they are likely to
appear clinically. Note that the history alone is not to
be relied upon. Often in an early organic state, there
are no such direct indications. Conversely, patients
with functional disorders, especially depression,
will often complain of memory difculties even
though their memory is functioning normally as
judged by clinical testing.
DIAGNOSIS OF ORGANIC
PSYCHIATRIC DISORDERS
Organic states, such as toxic confusional states and
dementias, are not difcult to diagnose once they
are well established. The trick, however, is to be
able to diagnose them at the earliest possible stage,
so that appropriate treatment can be started and
(where possible) permanent damage avoided. This
calls for careful testing of the cognitive functions.
However, most patients will be anxious about their
performance. Anxiety is by far the most common
cause of spuriously abnormal cognitive function
test results, hence the need to reduce the patients
anxiety so as to get meaningful results.
345
Examination of the CNS must be scrupulously

done with attention to the optic fundi for signs of
intracranial pressure. Abnormalities of the pupil
size or reaction occur in syphilis. Nystagmus
may suggest drug intoxication. Transient external
ocular movement disorders may be an essential
sign for diagnosis of Wernickes encephalopathy.
Evidence of focal neurological defects in motor or
sensory systems (including visual eld defects and
anosmia) could suggest a space occupying lesion
or cerebrovascular disease. Neck stiffness may
indicate meningitis or subarachnoid haemorrhage
and evidence of ear infection may raise the
possibility of cerebral abscess.
History
The specic cause can be determined in the course
of history taking and examination. However, the
causes are elusive and it is essential to consider
systematically a wide range of possibilities. It is
helpful in approaching a given case to consider
rst the possible causes arising within the CNS
itself, then the derangements of cerebral function
consequent upon disorder in other body systems.
The antecedent history will give important
clues and it is essential that a relative or close
acquaintance should be seen; the time and mode of
onset and the evolution of symptoms must always
be carefully established. Careful enquiry should
be made for a history of head injury, seizures,
alcoholism, substance abuse, recent illness or
anaesthesia. It is always important to enquire about
medication recently prescribed. Family history of
organic disorder, especially dementia or general
medical conditions such as heart disease, diabetes
and epilepsy should be elicited. Enquiries on
the personal history and employment history may
give a background for the assessment of present
intellectual level. Previous personality compared
to the present may indicate organic change such
as frontal lobe disinhibition. Organic personality
change is a gradual exaggeration of personality
traits to produce a cartoon or caricature of the
patients former self. The traits exaggerated are
usually the less savoury ones such as irritability
and querulousness.
Course and outcome

Even if there is nothing to suggest organic
pathology in the initial presentation, a patient
whose condition fails to improve, but deteriorates
or changes unexpectedly in any other way, should
be reviewed with this possibility in mind. One of
the most common causes of failure to respond to
antidepressants, is unrecognized bodily disease.
Deterioration in cognitive functioning over a period
of time is particularly suggestive here, hence, the
need for meticulous testing and recording of these
functions in the initial assessment of the patient.
TREATMENT OF DEMENTIA
The main aim of treatment is to maintain the patient
in the community. If this is not possible, the patient
should be rehabilitated and re-integrated into the
community as soon as possible. Those in institutions
should obtain and maintain maximum social
adaptation e.g., social training for symptomatic
alleviation of behaviour problems and receive care
and nursing attention.
Physical examination
During examination one must pay attention to
any appearance of physical ill health, which
may denote metabolic disorder, an infective
process or carcinoma. The general examination
may indicate anaemia and endocrine disorders
such as myxoedema. Dehydration may suggest
diabetic pre-coma or uraemia. Muscular twitching
suggests uraemia, electrolyte disturbance or
hypoglycaemia. High fever may indicate cerebral
malaria or pyogenic meningitis. There may be
intermittent low grade pyrexia for tuberculous
meningitis, encephalitis or cerebral abscess.
Skin lesions include viral exanthemata, purpura
of meningocaemia or mucocutaneous lesions of
vitamin deciency. Oral candidiasis, purpuric
rash, herpes zoster scars and wasting, may suggest
underlying HIV infection. Hypertension must be
assessed. Likewise, evidence of cardiac failure and
heart block, respiratory infection or failure must be
noted. Hepatic or splenic enlargement should also
be checked.
Methods
Pharmacological therapies, for instance,
thioridazine for restless and aggressive
behaviour and hypnotics for sleep.
Maintain optimum physical health e.g.,
adequate diet, treatment of anaemia, and
urinary obstruction.
Behavioural problems
Incontinence of urine: Often reduced by
mobilisation, habit training, and regular toilet
regardless of patients needs.
346
Organic Psychiatry
Practical support includes the provision, where

appropriate, of house-help, meals-on-wheels,
day care centres or clubs and health visitor by
district nurse or community psychiatric nurse.
Nocturnal restlessness: Mobilisation and day

activity should be encouraged, hypnotics and
phenothiazines at night.
Restless, aggressive, disturbed behaviour habit
training and occupation.
Attention-seeking or paranoid accusations
should be nursed tactfully.
Further reading
1. Organic Psychiatry: The Psychological Consequences
of cerebral disorder: Third Edition (1999) Edited by:
William Alwyn Lishman Published by: Blackwell
Science Limited
2. Levy, R. and Post, F. (1982): The Psychiatry of Late
Life, Blackwell Scientic
3. Pitt, B. (1982): Psychogeriatrics, 2nd Edition, Churchill
Livingstone. Lond. and Edin.
4. Skuster D. Z., Digre K. B. and Corbett J. J. (1992)
Neurologic conditions presenting as psychiatric
disorders. Psych. Clin. North Am. 15, 311
5. Taylor D. and Luis S. (1993): Delirium. J. Neurol.
Neurosurg. Psychiatry 56, 742
Social treatment
Establish a simple xed regime and routine
e.g., rising, sleeping, eating, hygiene regularly
attended to at the same time each day.
Maintain activity i.e., out of bed keep going.
Habit training: persistent corrections of social
incompetences i.e., maintain stimulation,
interests and occupation e.g., occupational
therapist should engage the patient in simple
ward tasks.
347
43
Epilepsy
David M. Ndetei, Caleb Othieno, Gad Kilonzo, John Mburu
epilepsy per 1000 members of the population

varies. Among children under 5 years of age, 2
percent suffer from convulsions during fever.
DEFINITION
Epilepsy is an abnormal and excessive electrical
activity arising from the brain. This activity is
recurrent with periods of normal electrical activity
in between episodes. Each abnormal discharge is
associated with abnormal motor activity, abnormal
behaviour or disordered mental and emotional
activity. Each episode is accompanied by loss of,
or a disturbance in the level of awareness of the
affected individual who will not subsequently
recall the events that might have taken place during
that episode. An individual is said to suffer from
epilepsy if he has had at least two distinct episodes
of an epileptic attack, which ts the characteristic
features of the disorder in a period of 2 years, and
has evidence of an abnormal electrical activity
on EEG.
Key observations on epilepsy in developing

countries8
In 2001 the committee on nervous system disorders
in developing countries, Board on Global Health
of the Institute of Medicine made the following
observations regarding epilepsy in developing
countries:
Eighty percent of the more than 40 million
people with epilepsy live in developing
countries, where cultural factors frequently
exacerbate the burden of disease on patients
and their families. Even when assistance is
sought, a treatment gap as high as 90 percent
still affects some rural populations in lowincome countries.
Many risk factors for epilepsy have been
identied, including birth trauma, parasitic
infections (most notably cysticercosis),
bacterial and viral infections, head injuries,
febrile seizures, and genetic factors. Local
variation in risk factors at least partly explains
the marked heterogeneity in the prevalence
and incidence of the disease throughout the
world.
EPIDEMIOLOGY
Epilepsy is one of the most common ailments
involving the CNS in Africa. Prevalence of
epilepsy has been estimated at 2-5 per 1000
members of the general population. In areas where
the onchocerciasis affects at least 70 percent of
the population, the number of individuals with
8.
A.E. Watts. A Model for Managing Epilepsy in a Rural Community in Africa. British Medical Journal 298:805-807, 1989. R.A.
Scott, S.D. Lhatoo, and J.W.A.S. Sander. The Treatment of Epilepsy in Developing Countries: Where do we go from here?
Bulletin of the World Health Organisation 79(4), 2001
348
Epilepsy
Key preventive measures likely to signicantly

reduce the incidence of epilepsy include
prenatal care, avoidance of labour and delivery
complications, safety measures against head
injuries, control of infectious and parasitic
diseases, and genetic counselling for potential
marriage partners who have the disease.
Phenobarbital is recommended for the
treatment of partial and generalized tonicclonic epilepsies in developing countries due to
its efcacy for a wide range of seizure types, its
low cost, and its superiority to both phenytoin
and carbamazepine in recent community level
studies.
The lack of adequate drug production facilities

and high prices for imported drugs restrict
the availability of anti-epileptic drugs in
developing countries.
CLASSIFICATION AND TYPES

OF EPILEPSY
The following classication has been used to
emphasise whether the epilepsy has an identiable
focus of onset in the brain or not.
Table 43.1
Partial seizures beginning focally
Simple motor or sensory (without impaired

consciousness).
Complex partial (secondarily generalised;
with impaired consciousness).
Generalised seizures without focal onset
Tonic-clonic convulsion
Myoclonic, atonic
Absences
Unclassied
o Simple partial evolving to generalised

seizures
o Complex partial evolving to generalised
seizures
o Simple partial evolving to complex partial
evolving to generalised seizures
The terms petit mal and grand mal are no longer
used. Petit mal was used to describe these three
features: absence, akinetic and myoclonic attacks as
a type of primary generalised epilepsy. Grand mal
was used to infer primary generalised epilepsy with
involvement of motor and sensory functions and
loss of consciousness.
The commission on classication and terminology

of the International League Against Epilepsy (ILAE)
1981, recommended the following classication of
focal features:
Simple partial seizures (consciousness not
impaired):
o With motor symptoms
o With somatosensory or special symptoms
o With autonomic symptoms
o With psychic symptoms
Complex partial seizures (with impairment of
consciousness):
o Beginning as simple partial seizures then
progressing to impairment of consciousness
o With impairment of consciousness at onset:
- With impairment of consciousness only
- With automatism, fugues or twilight
states
Partial seizures evolving to secondarily
generalised seizures:
9.
International classication of epilepsies and

epileptic syndromes9
Localisation-related (focal, local, partial)
epilepsies and syndromes.
1.
Idiopathic (with age-related onset). At present,

the following syndromes are established, but
more may be identied in the future:
Commission on Classication and Terminology of the International League Against Epilepsy, Proposal for revised classication
of epilepsies and epileptic syndromes. Epilepsia 30:389-399, 1989.
349
Epilepsy with Generalised Tonic Clonic

Seizures (GTCS) awakening.
Other generalised idiopathic epilepsies, if they
do not belong to one of the above syndromes,
can still be classied as generalised idiopathic
epilepsies.
Benign childhood epilepsy with centrotemporal spike;

Childhood epilepsy with occipital
paroxysms; and
Primary reading epilepsy
2.
3.
Symptomatic: This category comprises

syndromes of individual variability, based
mainly on anatomical localisation, clinical
features, seizures types, and aetiological
factors (if known).
(a) Epilepsy is characterised by simple
partial seizure with the characteristics of
seizures arising from:
frontal lobes
parietal lobes
temporal lobes
occipital lobes
multiple lobes and
locus of onset unknown.
(b) Characterised by complex partial
seizures, that is, attacks with alteration of
consciousness, often with automatisms;
characterised by seizures arising from:
frontal lobes
parietal lobes
temporal lobes
occipital lobes
multiple lobes and
(c) Characterised by secondarily generalised
seizures with seizures arising from:
frontal lobes
parietal lobes
temporal lobes
occipital lobes
multiple lobes and
2.
Crytogenic or symptomatic (in order of age)

West syndrome (infantile spasms, BlitzNick-Salaam Kramfe)
Lennox Gastaut syndrome
Epilepsy with myoclonic-astatotic seizures
and
Epilepsy with myoclonic absences.
3.
Symptomatic
(a) Nonspecic aetiology
Early myoclonic encephalopathy
(b) Specic syndromes
Epileptic seizures may complicate
many disease states.
Under this heading are included those
diseases in which seizures are a presenting or
predominant feature.
4.
Epilepsies and syndromes undetermined as

to whether focal or generalised
5.
With bold generalised and focal seizures

Neonatal seizures
Severe myoclonic epilepsy in infancy
Epilepsy with continuous spike waves
during slow-wave sleep and
Acquired epileptic aphasia (LandauKleffner syndrome).
6.
Without unequivocal generalised or focal

features
All cases with Generalised Tonic Clonic
(GTC) where clinical and EEG ndings do
not permit classication as early generalised
or localisation-related, such as in many cases
of GTCS during sleep.
Unknown as to whether the syndrome is

idiopathic or symptomatic.
Generalised epilepsies and syndromes

1. Idiopathic (with age-related onset-listed in
order of age)
Benign neonatal familial convulsions
Benign myclonic epilepsy in infancy
Childhood absence epilepsy (pyknolepsy)
Juvenile absence epilepsy
Juvenile myoclonic epilepsy (impulsive
petit mal) and
Special syndromes
1. Situation-related seizures (Gelegenheitsanfalle)
Febrile convulsions
Isolated seizures or isolated status
epilepticus
Seizures occurring only when there is
an acute metabolic or toxic event due to,
350
Epilepsy
for example, alcohol, drugs eclampsia,

nonketotic hyperglycaemia or uraemia.
Genetic factors
Many people will convulse if sufciently stressed,
e.g. by a fear-arousing situation. However, certain
individuals are genetically predisposed to suffer
from convulsions or epilepsy if sufciently
exposed to epilepsy-causing factors. Genetically
predisposed individuals are not born with epilepsy,
but are born with the tendency to suffer from
epilepsy under certain situations. There is a 1 in 36
chance that a close relative will also suffer from this
condition. If one spouse suffers from epilepsy, the
chances of any of the offspring suffering from the
condition will be reduced if the other spouse does
not suffer from the condition and there is no family
history of epilepsy. It has been estimated that there
is a 1 in 100 chance that a relative of a person with
epilepsy will suffer from a major mental illness;
and a 1 in 12 chance that a relative will suffer from
a migraine headache.
TRADITIONAL AFRICAN
BELIEFS
Beliefs about epilepsy are many and are found in
societies throughout the world. The beliefs vary
from one society to another. A frequent belief is
that epilepsy is due to possession by evil spirits or
the devil. The bad spirits leave the affected person
during a t and inhabit anyone who touches the
person. Transmission of the spirit is thought to occur
through saliva, urine, perspiration, or even wind
passed by the patient (atus) during convulsion.
Epilepsy is thus believed to be infectious. No one
dares to touch a person during or immediately after
a t for this reason.
The Madi in northern Uganda believe that
epilepsy is a curse and punishment that results from
some wrong committed by a family member of
either a previous or the present generation against
someone in or outside the family. If someone
commits homicide, the spirit of the deceased will
return periodically to affect a member of the family
later. Accordingly, epilepsy is called leke, meaning
a curse.
The Wapogoro tribe in northern Tanzania believe
that if a person with epilepsy watches the slaughter
of a chicken, he will suffer convulsions. Persons
with epilepsy are not allowed to watch chickens
being slaughtered as the violent jerking of the
dying chicken will provoke seizures. The Baganda
believe that the child with epilepsy is born with a
lizard in the brain. As the child grows, so does the
lizard. When the lizard moves, the child suffers a
t. If the child sustains burns during a t, it is proof
that he cannot be cured.
Febrile convulsions
They are seizure disorders, which develop during the
course of any high fever, most frequently affecting
children aged 2 years to 3, though older children
may also be affected. Children with a family history
of febrile convulsions or epilepsy tend to suffer
more readily than children from other families.
Seizures in this disorder result from a sudden rise
of body temperature of over 38C and will continue
as long as the fever remains. The convulsions can
be controlled by the use of phenobarbitone along
with paracetamol and tepid sponging to lower the
childs body temperature. Febrile convulsions are
extremely dangerous to the young childs brain if
left unchecked for at least 15 minutes.
Post-traumatic epilepsy
This may be categorised into two: early and late
epilepsy. Early epilepsy occurs within the rst
week following an injury and accounts for 5
percent of patients admitted in hospital with nonmassive injuries. It is particularly frequent in the
rst 24 hours after head injury. Focal seizures are
common as generalised seizures. Status epileptic
occurs in about 10 percent cases. The risk is high
in children and patients with prolonged posttraumatic amnesia, an intracranial haematoma and
a compound depressed fracture.
Late epilepsy occurs in about 5 percent of all
patients admitted to hospital after a head injury. It
presents in the rst year, but in some cases the rst
CAUSES OF EPILEPSY
In primary epilepsy, there is no cause (idiopathic)
for the disorder. In secondary epilepsy, however,
a variety of causes can usually be identied
during history taking, physical examination and
laboratory investigations. In persons who suffer
from epilepsy, at least 6 out of every 10 cases fall
within the secondary epilepsy category. Many of
the causes of secondary epilepsy are preventable.
351
for a variable period of time ranging from a few

minutes to 2 or 3 hours. The person wakes up with
body aches, intense headache, and complete lack
of memory of the events that took place during the
attack.
attack can occur 10 years after the injury. Usually

the seizures are generalised, but temporal lobe
epilepsy (complex-partial seizures) occurs in 20
percent. It is prevalent in patients who have early
epilepsy, intracranial haematoma and compound
depressed fracture during injury.
The atypical epilepsies

Trigger factors in attacks of epilepsy
The atypical cases of epilepsy are as common as

the typical ones. These types belong either to the
absences group of seizures, the secondary or focal
seizures.
Certain factors make the electrical activity of

the brain unstable and tend to provoke attacks in
individuals with epilepsy. The following are some
of the common factors:
Sleep: Individuals usually develop attacks
of epilepsy from 30 minutes to 2 hours after
falling asleep, or between 4.00 and 6.00 a.m.
Flickering lights: Susceptible individuals may
develop attacks as the light from the television
screen begins to icker, or as the lights in a
dance hall begin to icker.
Day-long fast: Children with epilepsy may
suffer an attack as they return home from
school in the evening, having had nothing to
eat the whole day.
Alcohol: The individual dependent on alcohol
gets an epileptic attack each time during a
hangover period. The person learns how to
avoid getting an attack by ensuring that he
drinks regularly.
Absences
These seizures are usually a disorder of children
and may end by the time of puberty. Attacks
of absences last for very brief periods of 15-30
seconds each, and there may be several hundred
per day. The problems of affected children are not
appreciated by caretakers or teachers. The typical
episode takes the form of repeated blank stares into
space. During the episode that child is both blind and
deaf. The child loses consciousness and is totally
unaware of their environment. The child does not
fall, however, and remains sitting or standing. In
addition, they may appear blank in the face, stop
talking momentarily and resume conservation at
the end of the attack in a totally different topic
unrelated to what was being discussed. Children
who suffer from absences are often accused of
being naughty or lazy. Such children also tend to
sleep heavily. At school the child is considered
dull as the frequent attacks interfere with effective
learning.
Akinetic seizures are less common variants
of absences which are characterised by repeated
sudden loss of muscle tone, resulting in unexplained
stumbling and falls. Such mishaps usually occur
while the child is playing. The falls are associated
with total loss of consciousness lasting 15-30
seconds each.
THE DIFFERENT
PRESENTATIONS OF EPILEPSY
Epilepsy can present in a variety of ways. Some
presentations pose no problem in recognising the
illness. These are described as typical cases of
epilepsy. Other forms of the illness are, however,
not so easy to recognise because of the way they
manifest themselves.
Partial or focal seizures
The typical case of epilepsy
A partial seizure may manifest solely in the form

of an abnormal motor, behaviour disorder, mental
activity or state of emotion.
This presents in a way that is familiar to most people.

The attack strikes suddenly without warning. The
attack may be preceded by a variable period of
vague ill feeling characterised by weakness, some
headache, emotional dullness, depressed mood or
state of fear and apprehension. The attack usually
begins with a loud harsh cry. The individual falls
heavily to the ground, goes stiff all over and then
goes into violent rhythmic jerks which last 2 to
3 minutes during which the persons may bite
the tongue and lips, or pass urine or faeces. The
individual then goes into a deep sleep that lasts
Auras
The nature of auras or warning signs as they
are called depends on the area of the brain from
where the electrical abnormality originates.
The episode of epilepsy begins with an unusual
experience, which might last for a few seconds
or minutes, after which a convulsive episode or
other abnormality ensues. The ensuing episode is
352
Epilepsy
is at home, but the epileptic attack makes the

whole place look so unfamiliar that the person
might feel lost.
Jacksonian march: Quite often an aura takes
the form of jerks starting either in the face,
ngers or foot. The jerks increase in strength
and spread to involve adjacent muscle groups
until all the body becomes affected before the
individual loses consciousness, and convulsion
set in. If the jerks are not strong the spread of
the march may be limited in extent and the
individual may not lose awareness nor suffer
generalized convulsions.
always accompanied by total loss or an abnormal

state of awareness during which the individual is
usually not fully aware of what may be happening.
The person usually remembers the experience of
the aura, but may not recall the events that take
place thereafter. The auras usually take the form
of one of the ve senses and may be accompanied
by abnormal mental activity. The tragedy of these
experiences is that relatives and family members
often dismiss what patients tell them about their
experiences during seizure episodes. As a result,
vital information in the form of auras may be lost
and diagnosis delayed. These include:
Unpleasant smell: An unfamiliar, unpleasant
and nauseating smell of something rotten
is a common prodromal sign of epilepsy.
Sometimes, however, the smell may be
pleasant, e.g. smell of a sweet perfume.
Voices and sounds: An epileptic attack may
be preceded by the experience of voices or
sounds which may be very close and loud, or
very faint and distant.
Visions: Likewise, the individual may
experience visions of people, animals and
insects, which may be far and tiny, but seen in
clear detail, or very close and large.
Touch: The individual might experience
sensation of small insects crawling on the
skin, usually beginning in the face, hand or
foot and spreading to involve adjacent areas,
then half the body before crossing over to
involve the opposite side of the body with loss
of consciousness. The experience of touch
may take the form of numbness or cold water,
which spread in a similar fashion.
Taste: In a few cases of epilepsy, an attack may
be preceded by the experience of a strange
taste likened to the taste of a piece of metal
or coin placed in the mouth. Such a sensation
may be accompanied by the feeling of an
uncomfortable experience in the upper part of
the abdomen described as the urried activity
of butteries ying about in the abdomen.
Some patients report this as rumbling noises
in the abdomen.
Abnormal mental activity: As an aura in
epilepsy, it takes many forms. The most
common form is the feeling of familiarity
(deja vu) in which the individual feels that he
has already passed through the experience he
is going through. A less common experience
is the feeling of strangeness (jamais vu) in
which everything that the individual is passing
through is very strange and new. The person
Mental illness
Schizophrenia-like illness: The individuals
mental experiences may proceed from that
of the aura to the experience of hallucination,
thought disorder, delusions of external control,
and paranoid delusions.
Depression and suicide: The persons with
epilepsy might experience protracted feelings
of unexplained depressed mood, irritability,
self-seclusion, ideas of worthlessness and
suicidal feelings. Suicide is a real and potential
danger in epilepsy.
Manic-like illness: An individual with
epilepsy may present with an illness which
may be indistinguishable from manic illness,
characterised by elated mood, inated selfimage, increased sociality and generosity,
irritability, delusions of grandeur and a chain
of endless plans. However such onset of mood
disturbances start and stop suddenly with no
recall by the patient.
Paranoid disorder: Epilepsy is one of the
leading causes of mental illness characterised
by extreme suspiciousness, mistrust, delusions
of reference, misinterpretations of the intention
of other people, and endless complaints
levelled against innocent members of the
neighbourhood or work environment.
RECOGNISING EPILEPSY
Secondary epilepsy can be recognised only
through careful history taking, which may take a
long time to complete, or which may have to be
repeated for more than one or two sessions. Ones
attitude during history may facilitate or inhibit
the recognition of the illness. The willingness to
listen patiently to what the patient and relatives
have to say combined with intelligent questioning
353
3.
4.
5.
6.
with an understanding attitude helps bring

forth information that can be useful in making a
diagnosis. Most importantly, one should have a
good basic working knowledge of epilepsy. The
disorder is characterised by the following:
Attacks are episodic, and stereotyped.
Attacks are separated by periods of normal
mental activity.
Each episode is followed by a genuine lack of
memory of the events of the episodes, or at
most, only patchy memory for those events. In
a minority of cases, epileptic episodes may not
be associated with any loss of memory.
In more than 50 percent of the cases, one may
uncover one of the typical auras associated
with an impending epileptic seizure.
There may be a history of febrile convulsion
in the individual or among other members of
the family.
Phenytoin sodium
Sodium valproate
Ethosuximide
Clonazepam.
(b) Newer Anti-epileptics

1.
2.
3.
4.
5.
6.
7.
Vigabatrin
Lamotrigine
Oxcarbazepine
Gabapentin
Tiagabine
Topiramate
Zionisamide.
(c) Others
1.
2.
3.
4.
5.
6.
Primidone
Clobazam
Sulthiame
Troxidone
Diazepam
Acetazolamide (limited by a rapid onset of
tolerance)
7. Nitrazepam in myoclonic epilepsies
in infancy, childhood and adolescence in
combination with sodium valproate
8. Dextroamphetamine Sulphate in simple
absences in children who show hyperkinetic
or other behavioral disorders.
Psychiatric differential diagnosis

Conversion syndrome with ts
Psychogenic fugue states
Aggressive outburst
IMPORTANCE OF RECOGNISING
EPILEPSY
It is important to recognise epilepsy and institute
correct treatment early. A variety of drugs for
effective treatment are available. Early treatment
is highly rewarding. Effective treatment
may lead to early cure or control, promote
personal independence and improve quality of life
for the individual.
Phenobarbitone
Phenobarbitone is affordable and can be used as
a rst line drug in the treatment of convulsion,
particularly among children and in rural health
units. Depending on the age of an individual, the
dose varies from 15 to 120 mg per day, administered
as a single or 2 to 3 divided doses. Phenobarbitone
causes drowsiness. Its use in pregnancy may lead
to congenital malformations such as cleft palate
or deciency states of vitamin B group. Some
individuals may develop side effects e.g., skin
rashes thus discontinuing the drug.
DRUGS USED IN THE

TREATMENT OF EPILEPSY
A variety of drugs are now available for the
treatment of epilepsy. However, the variety in
some countries may be limited due to the high
cost of some of the drugs. Due to competition and
availability of generic preparations the costs are
reducing over time.
Phenytoin
Phenytoin is the rst drug recommended for the
treatment of epilepsy particularly among adults.
Among children, its use should be limited only to
those aged at least 10 years. The dose of phenytoin
varies from 100 to 300 mg as a single dose or in
divided doses. It is a better drug to use for school
children as it induces less drowsiness and mental
(a) Conventional
1. Phenobarbitone
2. Carbamezapine
354
Epilepsy
control generalised as well as partial seizures. The

drug is highly unstable and tends to decompose
readily when exposed to moisture. However,
tablets marketed in aluminum foils, are available
whereby each is prepared in strengths of 200mg.
The drug is administered in doses of 200 to 600 mg
as a single or in divided doses per day. Any tablet
of valproate which has changed or decomposed as
a result of exposure to moisture should not be used
as this may lead to the immediate development of
severe and generalised itchy skin rashes.
Other drugs include vigabatrin, lamotrigine,
oxcarbazepine and gabapentin. However, these are
either not available in most African countries and
where available, are very expensive.
dullness. However, the drug may lead to serious

cosmetic problems among the youth due to gum
hypertrophy and the poor oral hygiene that it
induces. A more serious side effect is the itchy skin
rashes which appear within the rst week of the
commencement of treatment. The use of the drug
should be discontinued if skin rashes develop.
Like phenobarbitone, phenytoin may induce
deciency states of folic acid vitamin B group.
When this happens the individual develops loss of
balance and an unsteady gait. Toxic effects of the
drug manifest as unexplained falls not akin to the
original epileptic attacks. It is marketed in tablet,
capsule and intravenous preparation.
Carbamazepine
It controls most seizures and it is preferred for
school goers and those involved in mental and
academic activities. The dose of carbamazepine
varies from 100 mg daily to 1200 mg in 2
to 3 divided doses. Apart from its benecial
effects on seizures, carbamazepine also controls
aggressive behaviour, paranoia, depressive and
manic complications of epilepsy effectively. The
commonest and only serious complication of
carbamazepine is the development of itchy skin
rashes, which may lead to a serious illness, referred
to as erythema multiforme. This may proceed to the
development of the life-threatening illness known
as the Stevenson-Johnsons syndrome. If skin
rashes do not develop within two weeks the drug
should be continued. Carbamazepine is available
in the form of tablets and syrups.
MANAGEMENT GUIDELINES
Control of seizures is made easy only if management
guidelines are followed:
Questioning should aim to identify any trigger
factors associated with seizure episodes,
frequency of attacks per day, and when seizures
are most frequent.
Identify the clinical type of the seizure
disorder. This helps in the selection of the most
appropriate drug for a particular individual.
Ascertain if the illness might be as a result of a
treatable cause such as a blood clot within the
skull or a cerebral abscess.
Identify the nature of social environment
within which the individual lives. Attention
should be paid to any possible difculties
affecting the individual. In addition, identify
any special concerns of the individual. Coping
strategies employed by the family in dealing
with the problems of the individual helps in
overall management.
Identify any other forms of treatment that the
individual might have received previously.
Ethosuximide
It comes in the form of bright red elongated
capsules or syrups and is the most effective drug
for the control of absence seizure. The drug is so
effective that if the diagnosis of an absence seizure
is correct, attacks dramatically cease within less
than a week of starting treatment. In addition,
ethosuximide may be useful in the control of the
mental and abnormal behavioural manifestations
of partial seizures where carbamazepine has failed.
The dose varies from 250 to 750 mg daily (in 2 to 3
divided doses). Like carbamazepine, ethosuximide
is a suitable drug for use in relation to mental and
academic activities among school goers and those
who work. The drug is said to lead to biochemical
induced respiratory disorder at high doses.
However, this side effect is rare.
PRINCIPLES OF DRUG
MANAGEMENT
Use only one drug at a time beginning with the
lowest effective dose suitable for the person
concerned. In 9 out of 10 cases, a single drug
administered in adequate doses can control
seizures. Poor control of seizures is associated
with multiple drugs used at the same time,
and can cause unnecessary toxic reactions.
Sodium Valproate
It is a broad spectrum anti-epileptic drug used to
355
express any concerns that might not have been

adequately discussed.
Complete control of seizures can be expected
within 6 months if the right drug is administered
correctly in 50 percent of the cases. A signicant
reduction in the frequency and severity of seizures
can be expected in a further 30 percent cases within
the same time period.
Multiple drugs used for the same individuals

usually make it difcult for anyone to evaluate
the effectiveness of any of the drugs being
used. It would also be difcult to identify the
drugs causing adverse reactions which might
develop in the course of treatment.
If the individual is being seen for the rst
time, the condition should be reviewed within
2 weeks so that adjustments in drug doses can
be made.
Drugs selection should be governed by the
results of history and clinical examination,
and where possible, an EEG.
If seizures occur only during sleep, one
single dose of the selected anti-convulsant
administered half an hour before retiring to
bed is sufcient. In this case the dose will
be twice what would be recommended in the
morning. Depending on the persons age, the
dose of carbamazepine should be 200 mg
taken 30 minutes before the person retires to
bed in the evening.
If seizures occur both day and night, the
required dose should be divided into two.
The carbamazepine should be administered in
doses of 100 to 200 mg taken at breakfast and
half an hour before retiring to bed. On only
rare occasions will the individual require an
anti-convulsant three times a day.
If seizures are associated with symptoms and
signs of mental illness, an appropriate drug to
control the mental disorder should be used. In
the case of depressive illness amitriptylline
administered in a dose of 25 to 75 mg taken
at bedtime is usually sufcient. In the case
of manic or schizophrenic-like illness,
chlorpromazine in doses of 200 to 300 mg per
day may be sufcient.
Drug management of epilepsy is not sufcient
unless explanations are made to the individuals
and the family or caretaker. Explanations should
be given in a simple language. Instructions on
how medications ought to be taken should be
clear. Information of possible side effects to
be expected should also be provided. A course
of follow-up should be charted out with the
individual or the responsible family member.
Best results may be expected if the family is
involved in the formulation of management
plans.
Opportunity should be provided for the
individual and responsible family member to
ask questions concerning the illness, and to
CONTROL OF FEBRILE
CONVULSIONS
Febrile convulsions are best controlled when the
mother of an affected child is involved. The aim of
such control is to prevent the future development of
epilepsy in a susceptible individual. The following
measures should be taken together for maximum
benet.
Every mother of a child who suffers from
febrile convulsions should be taught rst aid
measures aimed to lower body temperature
before denitive management at a health unit
is provided.
The mother should be encouraged to seek
treatment for any febrile illness early.
Fever can be controlled by removing excess
clothing, placing a cold cloth on the forehead
or the nape, or administering paracetamol.
Every child who has had at least 2 episodes
of febrile convulsions should ideally be
maintained on prophylactic medication
using phenobarbitone for a period of at least 3
years. If this cannot be done routinely, treatment
with phenobarbitone should be provided for at
least 2 weeks each time the child has a febrile
illness with or without convulsions.
Every mother of a child with febrile convulsion
should be encouraged to provide similar
control measures for other children who are
usually at risk of developing the disorder if not
on prophylactic treatment.
FIRST AID DURING SEIZURES

Some individuals with epilepsy can predict an
impending seizure and will move away from a
replace, a body of water, or dangerous objects
such as a big piece of stone, and will sit down on a
chair. Even then there are chances that a person can
still suffer injuries during a seizure if the person is
356
Epilepsy
inappropriately handled. If an individual is aware

of an impending attack of convulsion, he can learn
to bite on a rubber or padded mouth gag before
the seizure strikes. In seizures without warning,
it is not advisable to try to force the individuals
mouth open, as doing so will only result in injury
to the gums and lips. The best that can be done is
to move them away from positions and situations
that might promote injury. Once the seizure is over,
the individual should be positioned to lie on the
left side with the neck slightly extended to keep the
mouth and airways open to prevent the aspiration
of respiratory secretion or vomitus. If the individual
does not fall asleep immediately after a seizure, he
might become delirious and try to move or run, thus
predisposing him to accidents. Such an individual
should be restrained with minimal force until the
delirium is over.
Avoid or limit the harmful effects of any

obvious trigger factor. If a child gets ts in
response to ickering lights from a television
set, the effect can be minimised by covering
one eye with an eye pad so that the child
continues to watch the television. If ts occur
due to fasting spells, regular snacks will usually
prevent further seizures. The effect of high
fever can be prevented by prompt treatment.
Treatment for epilepsy is considered to have
been effected only after a further 2 years of
daily treatment in the correct dosage and
frequency, recommended for the individual
patient even though ts cease to occur.
EDUCATION FOR PEOPLE WITH

EPILEPSY
There is nothing that people with epilepsy cannot

do. However, for the public safety and the safety
of the patient, there are few things that should be
observed:
Individuals with epilepsy should not be
permitted to drive motor vehicles until they
have been proven to be free of seizures on EEG
after 3 years of anticonvulsant treatment.
Persons with epilepsy should not be permitted
to work at heights such as at construction
sites, and electricity and telephone poles. Such
individuals should not be allowed to work on
electricity installations.
People with epilepsy should not be allowed to
go swimming unaccompanied.
WHAT CAN PEOPLE WITH

EPILEPSY DO AND NOT DO?
Epilepsy is a neuropsychiatric condition. However,

the problems associated with it are often social
and psychological. Social and psychological
management as well as the provision of concise
information about the condition often facilitates
the control of the illness. People with epilepsy and
their families expect cure from treatment within the
shortest possible time. As a result, follow-up may
be haphazard and treatment outcome disastrous for
both the medical worker and the patient, as well as
the family. To improve management outcome the
health care provider must work with the patient and
the family. The following information is useful.
Epilepsy may be due to a scar in the brain. This
scar is the site from which abnormal electrical
activity originates.
Each t facilitates a subsequent t occurring.
Infrequent and irregular treatment makes it
difcult to control epilepsy.
Regular treatment prevents seizures and
promotes healing.
It takes a long time to heal. Fits will not stop
immediately.
It takes time to nd the right drug in the correct
dosage for each person. Treatment is not the
same for different individuals; different people
need different drugs in different frequencies
and amounts.
Avoid alcohol; it makes an anti-epileptic drug
ineffective.
OPPORTUNITIES FOR
COUNSELLING
Opportunities for counselling arise at all stages
of health care provision, right from the time of
initial history taking and assessment to subsequent
reviews, home visits and special investigations.
Issues that require counselling include the provision
of information about epilepsy, explaining how
drugs ought to be taken, providing information
on drug side effects, explaining how to limit the
harmful effects of trigger factors in seizures, the
importance of continued medication and regular
visits to the hospital. In addition, patients and their
families will usually have a variety of questions
to ask about epilepsy and related issues if they are
given the opportunity to do so. Specic examples of
357
two mobile clinics were established by linking

with an existing mobile health programme for
children under ve years of age. After two years
461 patients were registered in the programme. Of
the 254 patients treated for epilepsy in the rst 18
months, 68 percent continued treatment beyond six
months. Among those same individuals, 56 percent
no longer suffered seizures, showing signicant
improvement over the pre-treatment occurrence of
one seizure per month in 88 percent of this group.
In the hospital and mobile clinics, diagnosis was
based on seizure history and use of a modied
form of the revised International League Against
Epilepsy (ILAE) classication. EEG and CT
scanning were not available. Only patients having
two or more seizures in a year were treated
with anticonvulsants. Simple explanatory models
were used during the rst visit with patients and
family members. Descriptions of the disease and
treatments include:
Epilepsy is due to a scar on the brain,
sometimes caused by meningitis, sometimes
following cerebral malaria, or sometimes
inherited. Treatment aims to stop seizures
from occurring in order to allow the scar to
heal.
It takes a long time for the scar to heal, and
one would not consider reducing, and possibly
discontinuing treatment for at least two years.
Seizures will not stop immediately. The
medicine needs time to work effectively. It
may take several months to determine the
dose of drugs needed for each patient. Patients
should not become discouraged during this
time.
If side effects such as a rash occur, the patient
must stop taking the drug immediately and
report to the hospital.
Alcohol should be avoided. No other
restrictions for diet are recommended.
Phenobarbitone and phenytoin were the only
medications used because of their availability in
the community and suitability for administration by
trained nurses or community health workers who
were familiar with their use. The population of the
region was largely subsistence farmers; therefore, it
was determined that medication must be provided
free of charge to enable adequate treatment.
Record cards were distributed to patients to
remind them of the next scheduled treatment,
what might require discussion include: questions of

inheritance, marriage and family life, opportunities
for education, fears about the development of
mental illness, the chances for cure and how long
treatment is expected to continue for optimal results.
It will readily become obvious that certain issues
require to be discussed over several occasions, thus
indicating their importance to the patient and their
families. Sometimes patients do not seem to pay
attention as explanations are made or questions
answered. Therefore, explanations should be made
in a simple language and unhurriedly.
DIFFICULTIES EXPERIENCED
BY PEOPLE WITH EPILEPSY
Social prejudice, discrimination and stigma
Social isolation, seclusion and rejection
Limited opportunities for education and
employment
Limited ability to explore personal potential
fully
Low self-esteem, condence and worth.
A MODEL FOR MANAGEMENT

OF EPILEPSY IN AFRICA THE
MALAWI MODEL 10
In Malawi, as in many developing countries, people
with epilepsy travel to various traditional healers
seeking treatment. These traditional healers often
encourage patients to ingest a mixture of roots that
precipitates purging or vomiting. Unless they are
suffering from burns sustained during an epileptic
seizure, patients rarely seek care at a hospital.
Through community publicity and education
about the availability of biomedical treatment,
a programme sought to encourage individuals
suffering from epilepsy in rural Africa to seek
regular care at a hospital or health centre.
After the eight months, 11 patients were
attending the hospital for treatment. After an area
action committee conducted a targeted information
campaign, 70 more patients were receiving
treatment after three months. Because many of the
patients walked long distances to access treatment,
10.
A.E. Watts. A model for managing epilepsy in a rural community in Africa. British Medical Journal 298:805-807, 1989. R.A.
Scott, S.D. Lhatoo, and J.W.A.S. Sander. The treatment of epilepsy in developing countries: Where do we go from here? Bulletin
of the World Health Organisation 79(4), 2001
358
Epilepsy
In recognising the nancial limitations of lack of

medically trained professionals in the region, the
programme design sought to balance efcacy with
simplicity of use. From 1980 to 1998 in Malawi
no change in the physician to patient ratio of .05
per 1000 people was experienced. Therefore, the
programme relied heavily on the use of trained
nurses and community health workers.
The success of the Malawi model provides
a useful framework for other communities;
however, limitations in the sustainability of the
programme must be noted. Delivery of effective
care through this programme greatly diminished
upon the departure of the founding physician from
the country. Clearly, community knowledge and
education about available treatments for epilepsy
were essential to the programme; however, future
efforts would benet from a better understanding
of community attitudes toward epilepsy and health
care that could be gained by engaging not only
primary health care centres but also important
groups such as religious, political, and social
leaders. A wide community-based approach may
lead to long-term, vested interest in the success and
continuation of the programmes.
to track medication dosage, and to record the

numbers of seizures between visits to the hospital
or clinic. For the patients, the record cards clearly
illustrated the number of tablets to be taken daily.
The supervising physician, nurses and community
health workers were able to use the information
from the cards to determine any needed changes to
drug treatment or dosing frequency.
Publicity in communities through widely known
organisations or individuals was instrumental
in the initial registration of patients and for
maintaining their adherence to treatment. After
an article proling the programme appeared in
a national medical journal, more district and
community health centres moved to establish
similar models. As additional programmes were
developed, the following guidelines were created
for the management of epilepsy in community
health centres:
Publicise the availability of treatment
Educate patients and staff
Use
simple
anticonvulsant
regimens
with phenobarbitone or phenytoin
Maintain adequate supplies of drugs
Offer drugs at no charge
Conduct monthly review clinics with a
physician
Ensure patient always sees the same health
worker
Use mobile clinics.
As a result of the promotion of these guidelines, the
number of patients seeking treatment at the hospitals
and designated clinics increased signicantly.
These ndings suggest that people with epilepsy
can overcome the myths and mistaken beliefs
about the disease allowing health programmes for
the effective treatment of epilepsy to be adopted
and administered in rural areas of the developing
world.
Further reading
1. Organic Psychiatry: The Psychological Consequences
of cerebral disorder: Third Edition (1999) Edited by:
William Alwyn Lishman. Published by: Blackwell
Science Limited
2. Scrambler, G. (1989) Epilepsy, London: Tavistock, .
3. MOH (1997) Policy Implications of Adult Morbidity
and Mortality End of Phase 1 Report, Ministry of
Health, United Republic of Tanzania, August 1997,
pp 98 99.
4. Neurological, Psychiatric and Developmental
Disorders: Meeting the Challenge in the
Developing World (2001). National Academy Press,
Washington.
359
44
Old Age and Mental Health
Richard Uwakwe, Manohar Dhadphale, David M. Ndetei,
Nakasujja Noeline, Hitesh M. Maru, Seggane Musisi
Enlarged ventricles
Thickened meninges
Minor and selective loss of nerve cells
Decline in quantity of nerve processes
Senile plaques
Neurobrillar tangles and granulovacuolar
degeneration
Ischaemic lesions
Decline in neurotransmitter system and
changes in brain protein synthesis.
The standard United Nations denition of old age

is 60 years. The branch of mental health which
deals with the assessment, diagnosis and treatment
of mental disorders in old people has various terms
including geriatric psychiatry, psychogeriatrics,
geropsychiatry or old age psychiatry. There
are two major reasons for the development of
psychogeriatrics. First, the population of old people
worldwide is rapidly expanding. Secondly, the
mental health needs of older people are different
from those of the younger population. Census
gures are often difcult to get in most African
countries. Nonetheless, projections by the United
Nations indicate that in the decades ahead, the
population of older people in Africa will rise nearly
ve-fold.
PSYCHOGERIATRICS IN AFRICA
The area of psychogeriatrics is not very well
developed in most African countries. The
majority of African psychiatrists practise as
general psychiatrists. In Nigeria, only two health
institutions (the University College Hospital,
Ibadan and Nnamdi Azikiwe University Teaching
Hospital, Nnewi) operate specialist old age mental
health clinics. Even then there is no provision
for training in the sub-speciality of geriatric
psychiatry in Nigeria. The practical implication is
that most elderly Africans with mental disorders
are not attended to by psychiatrists, much less
psychogeriatricians.
THE AGEING PROCESS

Ageing refers to the adverse effects of the passage
of time and also indicates the desirable process
of maturing. Older people show physical and
intellectual decline, psychological and behavioural
changes, and alteration in the social and emotional
functioning.
The weight of the human brain decreases by
approximately 5 percent between the ages of 30
and 70 years, 10 percent by the age of 80 and 20
percent by the age of 90 years. Various changes in
the aging brain include:
360
Figure 44.1: The elderly may experience physical and intellectual decline
to use routine diagnostic criteria for adult mental

disorders in the practice of psychogeriatrics.
CLASSIFICATION AND
DIAGNOSIS OF MENTAL
DISORDERS IN OLD AGE
CLINICAL APPROACH TO
DIAGNOSIS
Mental disorders in old age are modied by multiple

factors. The wear and tear of old age in many cases
result in multiple diseases in an individual, with
a high combination of both physical and mental
disorders. Many old people may have suffered losses
(death of peers, spouses, friends, family members,
and loss of functional ability or retirement). These
factors, together with the biological, other social
and cultural changes associated with ageing,
profoundly affect the clinical manifestation of
mental disorders in older age.
Elderly people may have limited attention
span, decreased tolerance for ambiguity and are
impatient. Diagnostic patterns and criteria designed
for and standardised on younger patient population
are denitely inappropriate for effectively assessing
psychopathology in the elderly. In this regard, both
the ICD-10 and DSM-IV are not ideal for use in old
age. These diagnostic manuals recognise the need
for a different section of emotional and behavioural
disorders rst evident in childhood and adolescence,
but entirely neglect mental health in old age. Hence,
many researchers and medical workers continue
All necessary areas should be covered in history

taking. African culture demands great respect for
the elderly and the medical worker must be aware
of this. Sexuality is important in old age and should
not be neglected. The condential and private nature
of sexuality makes some health professionals shy
away from probing into this area.
The medical worker should assess the needs of
the patientpsychological, physical and social.
Comorbidity and multiple pathology appears to be
the pattern in many African older patients. Mental
state examination should be based on culturally
and educationally appropriate tests. It may be more
appropriate to talk about local events, village chiefs,
African traditional titles, farming seasons, farming
implements, crops and community meetings. It
would be ridiculous to ask an illiterate elderly
African to copy designs or do serial subtraction
tests.
Denition of psychopathology must be culturally
based on the proper perspective. An African
traditional priest is expected to hear the voices of
361
(acute organic brain syndrome or acute confusional

state).
and discuss with the gods they serve, especially

in oracular consultations. This phenomenon is
certainly not a hallucinatory experience. A mental
or cognitive state examination in older Africans
will only be valid to the extent that the tests applied
are culturally and educationally valid.
Thorough
physical,
including
detailed
neurological examination must be performed in
all old patients, including bladder and bowel.
Ordinary urinary or bowel retention may present
as pseudodementia. Check whether the patient uses
spectacles or hearing aids. A patient with cataracts
may present with what may be confused with visual
hallucinations associated with the schizophrenia
spectrum disorders (compare Charles Bournette
syndrome). There should always be a high index
of suspicion for the possibility of either a coexisting or purely physical disease, especially in
the sudden onset of the rst episode of an abnormal
mental state in old age. The presence of CNS
features (example, headaches, seizure, lowered
consciousness, dyscalculia, poor memory, attention
and concentration, fever and visual hallucinations)
should alert the medical worker to look for an
organic cause.
Laboratory investigations will depend on
the clinical suspicion. Limited facilities and
nances should dictate the necessary laboratory
investigations. The medical worker should not
embark on indiscriminate routine tests and highly
sophisticated investigations. The ability and skill
to make impeccable clinical diagnosis without
laboratory investigations is essential in many
centres in Africa. Interpretations of test results are
sometimes doubtful, for example, detection of the
malaria parasite in a psychotic 67 year-old man.
Many normal non-hospital patients have malaria
parasites in their blood. Malaria may also co-exist
rather than be the explanation for an abnormal
mental state.
Aetiology
A systemic illness, cardio or cerebrovascular and
metabolic disorders; any systemic infection or
dysfunction; sub-dural haematoma; epilepsy; drug
side effects or withdrawal effects of alcohol, miraa
(khat) and cannabis. Acute infections like cerebral
malaria, HIV and typhoid must be excluded.
Management
Most confused patients need to be admitted to
an inpatient unit. The efforts should be directed
towards nding the cause and its treatment.
General measures such as nursing the patient in
a well-lit and warm room and monitoring of his
vital functions as well as maintaining nutrition
and hydration, would be necessary. Sedatives or
other drugs should be used. It may be necessary
to administer antibiotics. A range of antipsychotic
agents may be used in the management of delirium.
These include haloperidol or other antipsychotic
agents. A benzodiazepine may be added especially
in case of extreme agitation or insomnia.
Anxiety and phobic states

The situation in the developing world is not
adequately researched, but experience suggests
that a number of elderly people attend psychiatric
clinics for anxiety symptoms. Most patients
present with somatic complaints, but would readily
agree to having psychological symptoms such as
anxiousness or feeling generally low. Furthermore,
changing socio-economic and demographic changes
have contributed to insecurity in old age.
It is not uncommon for elderly people to have
phobias. Their fears need to be understood and
sensitively addressed. In the last 10 years, sporadic
cases of elderly abuse have been reported. If
someone complains about being hit, the medical
worker should take corrective action and not
dismiss it lightly.
The management of anxiety and phobic disorders
is similar to that in the younger age group. However,
attention should be paid to identify whether the
patient has cognitive impairment or depressive
illness. Routine thorough physical examination
and laboratory tests should always be carried out.
Simple supportive or group therapy and good
explanation for patients symptoms is all that may
be required. Do not forget to enquire about alcohol
intake at every visit.
CLINICAL DISORDERS IN
OLD AGE
Acute organic states: delirium
The main features of delirious states are:
disorientation, confusion and disorders of attention.
Other symptoms are uctuating disturbance
of attention, reduced wakefulness, insomnia,
apprehension, perceptual disturbances and agitation
362
worker should always try to be honest, tactful and

sensitive during the discussion that may follow the
initial assessment.
The treatment should be continued for 6 months or
more after the recovery. Always screen for dementia.
Many depressed patients may have pseudodementia
due to psychomotor retardation, lack of interest or
poor concentration. This condition is reversible and
should not be confused with Alzheimers disease.
In resistant, high suicidal risk patients and those
who have psychomotor retardation and severe guilt
feelings consider giving ECT. Old age per se is
not a contraindication to ECT. However, patients
suitability to undergo general anaesthetic should
be carefully evaluated.
Depression in the elderly

Genetic causes are usually considered important in
young people with depression. However, this is less
relevant if an old person gets depressed for the rst
time after the age of 65 years. Severe depression is
associated with the depletion of biogenic amines in
the brain. The catecholamines are lowered in the
hind brain of ageing animals. This depletion is the
cause of depression in the elderly.
Most elderly patients who present with depression
go unrecognised or receive inappropriate treatment.
Physical illness and depression often go together.
Therefore, it is important to treat any underlying
physical illness in addition to depression.
Old age is also considered an age of loss,
bereavement, and fall in income and status due to
retirement. It is, therefore, not surprising that many
medical workers believe that psychosocial factors
do contribute to the aetiology of depression.
The presentation of depression in the elderly
is similar to that occurring in younger people.
However, somatisation is more often seen in
the elderly. Persistently lowered mood, loss of
weight, insomnia, psychomotor retardation, lack
of concentration, and social withdrawal also occur.
Depressive psychosis is characterised by guilt
feelings, delusional ideas, severe hypochondriasis
and suicidal ideas.
Late paraphrenia and schizophrenia-like

psychoses
Kraepelin rst used the term late paraphrenia
to describe a group of patients, who had marked
paranoid delusions and many characteristics of
dementia praecox. However, it was later considered
as a variant of schizophrenia and was forgotten. Roth
revived it and dened it as a syndrome characterised
by well-organised paranoid delusions with or
without auditory hallucinations, existing in the
setting of well-preserved personality and affective
response. This condition often occurred late in life,
hence, the term late paraphrenia to distinguish it
from schizophrenia. The major features of this
condition were auditory hallucinations, delusions of
persecution and evidence of rst rank Schneiderian
symptoms. Many patients with poor memory or
attention might show marked suspiciousness and
falsely accuse their family members. Sensory
impairment such as impaired hearing or diminished
vision may often contribute to paranoia.
The treatment requires experience and skill
to manage an elderly paranoid patient. The cooperation of the family and carer is important.
Someone trusted by the patient may play a signicant
role in restoring good doctor-patient relationship.
The rst step is to establish a good rapport and try
to win a patients condence. Memory should be
tested to rule out signicant impairment and also
take care of the sensory decits by correction of
impaired vision and hearing. Adequate doses of
antipsychotic or antidepressant medication should
be prescribed in severe cases.
Suicide in the elderly

Elderly people are more determined to kill
themselves and should always be considered in
the high-risk category. Most suicide attempters
have an underlying serious physical illness. The
major risk factors are persistent lack of sleep,
recent bereavement, delusions of guilt, nihilistic
ideas or deep depression. Sleep disturbance with
early morning wakening, diurnal variation of
mood and pessimistic outlook about the recovery
and use of alcohol can also be a cause. Women
are considered as lower suicide risk than men.
All suicidal ideas or warnings should be taken
seriously.
Management
A thorough clinical interview, followed by a
complete physical examination and appropriate
laboratory tests are important as most elderly
patients have a physical age-related problem.
Before prescribing a suitable antidepressant, the
patients heart condition should be monitored by
doing an ECG. The patient should be given enough
time to explain the nature of illness. The medical
Neuro-degenerative diseases in the elderly

There are many neurodegenerative diseases and
their aetiology or pathological mechanism are
not exactly the same, but involve amongst other
363
cortical, mixed and unspecied type. Diagnostic

criteria are sudden or abrupt onset (vascular event),
stepwise decline (recurrent vascular events) and
presence of arteriosclerosis, focal neurological
signs, patchy cognitive decits, but with relative
preservation of the personality, nocturnal
confusion and evidence of cardiovascular disease
or hypertension.
There is gross or localised changes in the brain
tissue with atrophy and ventricular dilatation. There
is evidence of pathological changes associated
with ischaemia or infarction and no characteristic
neurochemical changes.
things neurotransmitters, proteins and genetic

components. Neither the DSM-IV nor ICD-10
provides any classication for neurodegenerative
disorders.
Dementia is the most common organic mental
disorder in the old. It has been dened as the
global and often irreversible impairment of higher
mental functions including loss of memory, and
the capacity to solve day-to-day problems as well
as social skills and use and control of emotions.
There are both irreversible and reversible causes
of dementia.
It has been estimated that there are 18 million
people with dementia in the world today, two
thirds of them in the developing world. The gure
is expected to rise to 34 million by 2025. There is
profound lack of awareness, and ignorance about
dementia; many lay people still consider it a part
of normal and inevitable part of the ageing process.
Examples of dementias in the elderly include:
Lewy body dementia (LBD)

It is characterised by Lewy bodies in the cerebral
cortex and substantial nigra. It is associated with
reduction of acetylcholine transferase activity in the
neocortex and dopamine in the caudate nucleus.
Diagnostic features include uctuating cognition,
pronounced variation of attention and alertness,
and recurring well formed visual hallucinations.
Spontaneous features of Parkinsonism may be seen
and there is marked sensitivity to antipsychotic
drugs. The patient may have repeated falls, transient
disturbance of consciousness, systematised
delusions and hallucinations in non-visual
modalities.
Alzheimers disease (AD)

This is the commonest type. Over 60 percent of
dementia cases will have AD. Diagnostic criteria
as per ICD-10 are insidious onset, cognitive
features such as confusion, disorientation, inability
to remember the recent events, poor short-term
memory, deterioration in carrying out daily
activities of living and slow psychosocial decline.
One must exclude:
Organic conditions such as hypothyroidism,
hypercalcaemia, vitamin B12.
Niacin
deciency,
normal
pressure
hydrocephalus, AIDS, sub-dural haematoma.
Sudden, apoplectic onset, with neurological
signs of focal damage such as hemiparesis,
sensory loss, visual eld defects and
neuromuscular inco-ordination.
Substance use disorders such as alcohol
dementia
There is generally reduction in the brain tissue
characterised by widening of sulci, narrowing of
gyri and ventricular dilatation. Histological changes
are senile plaques and neurobrillary tangles,
deposition of amyloid in the walls of the blood
vessels and subcorticular grey matter. The severity
of cognitive impairment and neurotransmitter
changes are associated with the number of senile
plaques.
Other dementias
Less frequent are the frontotemporal and those
associated with vitamin deciencies or infections.
They include dementia in Picks, Parkinsons,
Huntingtons and Wilsons diseases; progressive
supranuclear palsy; spinocerebellar degeneration;
normal pressure hydrocephalus; toxic metabolic
disorder; Jakob Creutzfeldts disease; viral
infections, like HIV/AIDS; chronic bacterial
infection; syphilis; meningitis; and other CNS
infections.
Dementia screening
Before making a diagnosis of dementia, the patient
should undergo a full dementia screen which
routinely consists of full blood count, Erythrocyte
Sedimentation Rate (ESR), urea and electrolytes,
thyroid and liver function tests, vitamin B12 and
folate levels, routine urinalysis, chest and skull xrays, CT-scan, and serology for syphilis and HIV/
AIDS. Other investigations should be undertaken
depending on the patients condition.
Domestic assessment of the elderly living at
home should be carried out. One should consider
the following:
Vascular dementia
ICD-10 divides vascular dementia into many
categories such as acute onset, multi-infarct, sub-
364
diagnosis is conrmed it will require tact and skill

to declare it to the family. The patients family
will need help, advice and assistance from the
medical and social agencies to cope with difcult
situations. Inevitably the disease will progress and
a few individuals families will not be able to cope
at all and will request admission of the patient into
a nursing home or hospital.
Most patients with dementia have behavioural
problems such as restlessness, agitation and
waking up at odd hours to go to work as they
have forgotten about their retirement. They may
also have hallucinations, delusions, disinhibition
and require small doses of antipsychotic or other
suitable medication.
Road safety: Is this person safe on the road?

Activities of daily living (ADLs): Can the
person dress, wash, look after his personal
hygiene, cook, eat and sleep well? Can he
handle daily domestic chores and make
complaints known to the person living with
him?
Social interaction: Is it appropriate, getting
isolated or suspicious?
Safety matters: Is he able to operate an electric
or gas cooker? Is he safe in the bathroom?
Quality of life: Is he enjoying the quality of
life according to his potential?
Financial matters. Are there any chances of
being nancially exploited? Is he or his carer
capable of protecting his interests?
In the west, social workers, community nurses,
community occupational or physiotherapists are
part of a community mental health team for the
elderly, who undertake home assessment and
monitor the situation. In Africa, the local medical
practitioner, who in all probability will be a nonspecialist would be expected to lead the process of
training of the primary care worker to share some
of the clinical responsibility for the patient, and to
train relatives on how to look after the patient.
Drugs used in the treatment of dementia

Acetylcholine decit is common in Alzheimers
disease
(AD).
Drugs
that
inactivate
acetylcholine esterase and the enzyme that
metabolises acetylcoline in the synaptic cleft
have been developed. Donepezil, galantamine and
rivastigmine are currently available for treating AD.
Many more drugs are at various levels of research
and marketing. The cost of treating mild to moderate
cases was prohibitive, but recently the prices
have considerably come down. The drugs have
shown encouraging results in slowing the decline
of cognitive functions and the clinicians should use
them on appropriate patients. Cognitive functions,
as well as the quality of life should be monitored.
If the patient does not show any response at the
highest tolerable dose for six months the treatment
should be stopped. These drugs, however, are still
prohibitively expensive and not available in most
African settings though the availability of generic
products in the future may change this. Pychotropics
may be used for behavioural and psychotic
symptoms. Antidepressants and benzodiazepines
can be prescribed if there are indications for their
use.
Diagnosis and management of dementia

Good history taking is the key to diagnosis. Ask
the patient about the duration and mode of onset.
Get collateral information on progress of the
disease from someone who has been living with the
sufferer. Suspect vascular dementia if the onset was
with neurological signs. Pay particular attention to
the transient ischaemic attacks followed by almost
full recovery, although close examination may
show some residual symptoms and incomplete
recovery. One may also observe stepwise decline
in cognition. Similarly LBD will show typical
systematised visual hallucinations, some motor
features of Parkinsonism and sensitivity to
antipsychotic medication in addition to memory
impairment.
The diagnosis of Alzheimers disease (AD) is
usually not difcult. Insidious onset, increasing
cognitive and general decline in social functioning
are the cardinal features. Treat such cases with
utmost sensitivity as many sufferers may have
been very capable and successful people in their
prime and were treated with respect. Once the
EMERGING CHALLENGES FOR

THE CARE OF THE ELDERLY IN
AFRICA
Traditionally in Africa and Asia, families have
cared for their elderly members. With changing
socio-economic situations and rapid urbanisation
a breakdown of traditional support system the
365
Primary health care workers can be trained to share

the burden of elderly care.
The elderly in Africa should not be detached from
their families. Grown up children and relatives of
the elderly should be given guidance, support and
counselling in the care of their ageing relatives e.g.
in providing Activities of Daily Living (ADL).
This will allow maintenance of the elderly in the
community environments they are familiar with.
Putting an elderly person into a residential home,
even when one is available should be the last
option.
younger members may not be able to play a role

expected of them, hence, the health planners, nongovernmental organisations (NGOs) and others
should plan for the changed scenario. The African
mental health worker needs to advise the family
accordingly. In the developing world, elderly
patients will have to be treated on general psychiatric
wards as few African countries can afford the cost
and human resources needed to run a special old
age psychiatry service. The priority should focus
on integrating elderly care into existing mental
health care models. There is the need to train health
professional at all levels, and to make them aware
of the burden of increasing psychiatric morbidity in
the older population, which is expected to increase
two-fold in the next twenty years.
The mental health professional should provide
encouragement, guidance and direction to the local
effort. In the hospital setting, improved training in
identifying early dementia, proper management
of depression and other psychiatric conditions in
the old can improve their quality of life. Shortterm admission of an elderly confused person to a
psychiatric or medical ward is sometimes necessary
and beds should be provided for such contingencies.
Physicians see a large number of elderly patients,
but current training does not always prepare them
for managing dementia or depression in the elderly.
Further Reading
1. Core Psychiatry (Eds Wright P, Stern J, Phelan M)
W.B Saunders, 2000. Psychiatry of Old Age.
2. Mental Health Problems in Old Age (Eds Gearing B,
Johnson M, Hillier T) John Wiley, 1988
3. Geriatric Psychiatry (Eds Bussey, Blazer DG)
American Psychiatric Press, 1989
4. Caring For The Alzheimer Patient A Practical Guide
(Eds Dippel RL, Hutton JT) Prometheus Books,
Buffalo, New York
5. Psychiatry In The Elderly, (Eds Jacoby R, Oppenheimer
C) Oxford Medical Publications, 1991.
6. Roth, M. (1955). The Natural History of Mental
Disorder in Old Age. Journal of Mental Science 101:
281 301.
366
45
Forensic Psychiatry
Frederick Owiti, David M. Ndetei, Hitesh M. Maru,
Margaret Mugherera, Seggane Musisi
Report writing and the giving of evidence

Understanding and using security measures
Treatment of chronic psychiatric disorders
Knowledge of mental health laws, particularly
applied to offenders
Psychological treatment of behaviour disorder
Knowledge of relevant aspects of criminology
and the criminal justice system.
The medical practitioner working with forensic
clientele needs knowledge of two sets of laws:
those relating to patients seen in ordinary clinical
practice (civil) and those relating to mentally
disordered offenders (criminal). The rst set of
laws (concerned with ordinary patients) consists of
two main groups:
laws regulating clinical practice, particularly
compulsory detention of patients in hospitals
and the giving of treatment without the
patient's consent.
laws dealing with issues such as the patient's
capacity to make a will or care for his own
property.
The second set of laws deals with mentally
disordered offenders; i.e., criminal offenders who
suffer from mental disorder or mental retardation.
Problems posed by these offenders to psychiatry
and the law include: criminal responsibility; tness
to plead; and practical questions such as whether
an offender needs psychiatric treatment.
Forensic psychiatry is a specialty of mental

health that deals with the interface of psychiatry
and the law. This includes evaluation and care of
mental patients under civil commitment, criminal
procedure code and disposition of civil cases
where psychiatric opinion is required. The need for
forensic psychiatry partly arises from the common
interests of the law and mental health with regard
to:
Need for humane treatment of mental patients
who are not competent to provide informed
consent for their treatment
Disposition of mental patients who come
into conict with the law so that they are not
punished for crimes that are products of their
mental disorder
Disposition of child custody and other issues
pertaining to minors taking into consideration
the best interests of such minors.
Forensic psychiatry is also concerned with
assessment of dangerousness of individuals who
may not yet have committed an offence. Certain
patients may require treatment and rehabilitation in
secure environments, such as special hospitals like
forensic psychiatric hospitals.
In addition to competence in general psychiatry,
a forensic psychiatrist develops skills in the
following areas:
Assessment of behavioural abnormalities
367
Testimonial privilege protects the patients

right to privacy. The psychiatrist may not
reveal information about patients against
their will. Some exceptions to the doctrine
of testimonial privilege are hospitalisation
proceedings, court-ordered examinations
(military or civilian), child custody hearings
and malpractice claims.
The psychiatrist needs knowledge, not only of the

law, but also of the relationship between particular
kinds of crime and psychiatric disorders for the
management of such problems.
THE LAW IN RELATION TO

ORDINARY PSYCHIATRIC
PRACTICE
Informed consent to treatment

This means that the patient has a clear and
full understanding of the nature of a treatment
procedure and its probable side-effects and freely
agrees to receive the treatment. In treatments, such
as established forms of medication, it is sufcient
for the psychiatrist to explain the nature of the
treatments probable side-effects. A special consent
form must be signed for ECT. Proper informed
consent requires that the patient be informed about
the particular treatment, alternative treatments
and their potential risks and benets; that the
patient understand this information; and freely and
knowingly gives consent. The psychiatrist should
document the patients consent, preferably with a
signed form. Exceptions to the rules of informed
consent include:
Emergencies. Usually dened in terms of
imminent physical danger to the patient or
others.
Therapeutic privilege. Information that in the
opinion of the psychiatrist would harm the
patient or be anti-therapeutic may be withheld.
There
are
two
aspects
of
medical
ethics; condentiality and informed consent to
treatment. In psychiatry the principles are the same
as in general medicine, but certain points need to
be stressed.
Condentiality
This is very important in psychiatry, because
information collected is private and very sensitive.
In general, the psychiatrist should not collect
information from other informants without the
patients consent. The guiding principle is to
try and act in the patients best interest, and to
obtain information as much as possible from
relatives rather than employers. The therapeutic
relationship gives rise to a legal and ethical duty
of condentiality, which requires the physician to
hold secret all information provided by a patient.
Breach of condentiality can result in damages
for defamation, invasion of privacy or breach of
contract.
Some exceptions to the duty of condentiality
include the requirements to report contagious
diseases, gun and knife wounds, and child abuse as
follows:
The duty to warn. The most important
exception is the duty to warn, which requires
psychotherapists to warn potential victims
of their patients expressed intention to harm
the victim. In 1976 the Tarasoff II decision
broadened the original ruling by requiring the
therapist to take some action in the face of the
threat of harm to another (the duty to protect).
Release of information. A patient must consent
to disclosure of information in his record before
the psychiatrist can release that information.
The actual physical record is the legal property
of the psychiatrist or the institution. However,
the patient has the legal right to his psychiatric
records. The psychiatrist may claim therapeutic
privilege as noted earlier, but disclosure must
be made to a representative of the patient,
usually the patients lawyer.
Compulsory admission and treatment

In all countries there are laws to protect a mentally
disordered person and to protect society from the
consequences of his mental disorder. In a particular
society, the laws vary with the political system.
Generally, the need for compulsory psychiatric
treatment is less in societies that provide good
psychiatric treatment.
Laws governing hospitalisation

The power of the state to conne an individual
(legally known as commitment) is based on two
separate concepts:
The police power of the state to protect society.
The issue here is the dangerousness of the
individual;
The parens patriae power of the state in which
the needs of the individual are of concern. The
issue here is the need for treatment.
368
Forensic Psychiatry
mental illness (dangerousness to self or others,

need for care and treatment, or lack of judgment to
care for themselves).
Types of admission procedures

Patients may be admitted to a psychiatric hospital
in one of the four ways:
Voluntary. Written application for admission
with limitations placed on release (to allow for
conversion into involuntary admission).
Involuntary. If patients are a danger to
themselves (suicidal) or to others (homicidal),
they may be admitted to the hospital after
a friend or relative applies for admission
and two physicians conrm the need for
hospitalisation.
Emergency. A temporary form of involuntary
commitment for patients who are senile,
confused, or unable to make their own
decisions. In an emergency admission, the
patient cannot be hospitalised against his will
for more than 15 days.
Referred by court either for assessment or
committed for treatment.
Procedural safeguards
Specic procedural safeguards for meeting the
requirements of due process include application
requirements and physicians evaluation.
The right to treatment

The right of an involuntarily committed patient
to active treatment, and to which kind of facility,
is normally prescribed by a Mental Health Act.
Different countries have different operational
Mental Health Acts in this respect, while some
do not have any. Practitioners should familiarise
themselves with provisions for their respective
countries in all legal aspects in relation to mental
health.
Right to refuse treatment

One of the most controversial legal issues is the
right to refuse treatment.
Criteria for commitment

All specic criteria for commitment under the
various procedures will require the presence of
Figure 45.1: The doctor will be called upon to assess people who have come into contact with
law enforcement agencies
of civil law the psychiatrist will handle issues such

as: tness to drive, testamentary capacity, torts and
contracts, receivership, marriage contracts and
guardianship. The psychiatrist may be asked to
submit a written report on a patients state of mind in
relation to these issues, or proceedings concerning
divorce, compensation or other matters.
CIVIL LAW
Civil law deals with laws concerning property,
inheritance and contracts. It deals with the rights and
obligations of individuals to one another. In matters
369
an otherwise legal contract is seriously mentally

ill when the contract is made and the condition
directly and adversely affects the persons ability to
understand what he is doing (contractual capacity).
The psychiatrist must evaluate the condition of
the party seeking to void the contract at the time
that the contract was supposedly entered into.
The psychiatrist must then render an opinion as to
whether the psychological condition of the party
caused an incapacity to understand the important
aspects or ramications of the contract.
A marriage contract is not valid if at the time of
marriage either party was so mentally disordered
as not to understand the nature of the contract.
Fitness to drive
Questions of tness to drive in relation to most
psychiatric disorders, especially in major mental
illnesses, have arisen. Reckless driving may result
from suicidal inclinations or manic disinhibition.
Panicky or aggressive driving may result from
persecutory delusions, and indecisive or inaccurate
driving from dementia. Fitness to drive also arises
in relation to psychiatric drugs particularly those
affecting concentration and attention.
Testamentary capacity
This term refers to the capacity to make a valid will.
If someone is suffering from a mental disorder at
the time of making a will, then the validity may be
in doubt. In order to decide whether or not a testor
is of sound disposing mind, the doctor should
use four legal criteria as to whether:
the testor understands what a will is, and what
its consequences are
he knows the nature and extent of his property,
though not in detail
he knows the names of close relatives and can
assess their claims to his property
he is free from any abnormal state of mind that
might distort feelings or judgements relevant
to making the will.
In conducting an examination, the doctor should not
only see the testor, but also the relatives and friends
to check the accuracy of factual statements.
On mental competence, psychiatrists are often
called upon to give an opinion about a persons
psychological capacity or competence to perform
certain civil and legal functions, e.g., to make a will
and manage ones nancial affairs. Competence is
context related, i.e., the ability to perform a certain
function for a particular legal purpose. It is especially
important to emphasise that incompetence in one
area does not imply incompetence in any or all
other areas.
Guardianship
This involves a court proceeding for the appointment
of a guardian if there is a formal adjudication of
incompetence. The criterion is whether, by reason
of mental illness, the person can manage his
affairs.
MALPRACTICE
The denition of malpractice literally denotes bad
professional activity. Malpractice can be more
broadly dened as occurrences in a professional
practice that result in injury to the patient, which
are the consequence of the psychiatrists lack of
care or skill. There need not be an intention to hurt
the patient.
Elements to be proved in malpractice - the

4Ds
Duty. A standard of care; a requirement to
exercise a particular degree of skill and care.
The duty is predicated on the existence of a
professional, i.e. therapist-patient, relationship.
There is no duty to cure.
Dereliction. A failure to exercise this care, i.e.
a breach of this duty. Dereliction may be due
to carelessness, incompetence, inappropriate
treatment, or failure to obtain the proper
consent.
Direct causation. A direct, or proximate,
causal relationship between the dereliction of
duty and the damage to the patient. Sometimes
phrased as but for the dereliction of the duty,
the damage would not have occurred.
Damages. Some specic damage or injury to
the patient must be proved.
Torts and contracts

Torts are wrongs for which a person is liable in
civil law as opposed to criminal law. They include:
negligence, libel, slander, trespass and nuisance. If
a person of unsound mind commits a wrong, then
any damages awarded in a court of law are usually
only nominal, i.e., the legal denition of unsound
mind is restrictive.
If a person makes a contract and later develops
a mental disorder, then the contract is binding.
The law may void the contract when a party to
370
Forensic Psychiatry
Personality disorder especially anti-social

and borderline personality often associated
with violent crime, in association with comorbid substance abuse.
Alcohol and substance use: alcohol leads to
disinhibition, poor judgment and is strongly
associated with violent crime. Alcohol
intoxication may also lead to driving offences
and public drunkenness. Drug intoxication is
also associated with violent crime and offences
may be committed to fund drug habits.
Schizophrenia: there is conicting evidence
concerning schizophrenia and crime, but it
appears as though schizophrenic patients
commit more violent crimes than the general
population. These crimes are associated
with command hallucinations and paranoid
delusions accompanied by strong affect.
Most offences committed by schizophrenics
are minor and are manifestations of social
incompetence.
Mood disorders
o Depression is associated with shoplifting
and, in rare cases, homicide, or infanticide
in postnatal depression.
o Usually due to mood-congruent delusions
(e.g. everyone would be better off dead)
and are often followed by suicide.
o Offences by manic patients usually
reect nancial irresponsibility or acts
of aggression, which are often not serious.
o Sexual impropriety may also occur.
Mental retardation
o Sexual offences (especially indecent
exposure), as well as arson.
Epilepsy
o Fits themselves are not a signicant cause
of crime.
o Epileptic automatisms are an extremely
rare cause of crime.
Dementia may be associated with sexual
offences, trespassing and other omissions.
Chromosomal abnormality: XYY constitution
has been associated with criminality.
The mental disorders associated with violent
crime, i.e. personality disorders (especially
psychopathy), alcohol and substance dependence
and paranoid psychotic disorders, may have an
additive effect to the risk of future violence when
they occur in combination. Remember that delusions
of jealousy (Othellos syndrome) are common
with alcohol abuse and are linked to violent crime
Common causes of malpractice lawsuits in

psychiatry
Suicide. The suicide of a psychiatric patient
often raises the question of malpractice and is
the most common basis of malpractice lawsuits
in psychiatry. Hence, careful documentation
of the treatment of a suicidal patient is
necessary.
Improper somatic therapy. The negligent
administration of medications or electroconvulsive therapy is the second largest source
of malpractice lawsuits in psychiatry. Tardive
dyskinesia and fractures are the concerns.
Negligent diagnosis. This is a relatively
rare basis for a lawsuit, but it may be used
when there is a failure to properly assess the
dangerousness of a patient.
Sexual activity with the patient. It is an area of
increasing concern and now a crime. Sexual
activity with a patient has been deemed
unethical and has been found to be a breach of
contract as well as malpractice.
Informed consent. The alleged failure of the
psychiatrist to obtain proper informed consent
is often the basis of the malpractice lawsuit.
Preventing liability
Clinicians should provide only the care they
are qualied to offer.
The decision-making process, the clinicians
rationale for treatment, and an evaluation of the
costs and benets should all be documented.
Consultations help guard against liability,
because they provide a second opinion and
allow the clinician to obtain information about
the peer groups standard of practice.
MENTAL ILLNESS AND CRIME

The vast majority of patients suffering from a mental
illness have never committed an offence, and most
offences are not committed by people with mental
illness. However, there is a signicantly higher
prevalence of mental illness among prisoners than
in the general population. Yet, this does not mean
that mental illness causes people to offend. In fact,
most evidence indicates that crime and mental
illness are only weakly associated.
Certain mental disorders, however, have shown
some association with both violent and non-violent
crime and can be summarised as follows:
371
Intent. The main principle is that the person

perceives and intends that his act or omission
will produce unlawful consequences.
Recklessness.
Is
deliberately
taking
unjustiable risk.
Negligence. When a person brings about a
consequence which a reasonable and prudent
man would have foreseen and avoided.
Blameless inadvertence. One reasonably fails
to foresee the consequence of his act.
When a person is charged with an offence, the
defence can be made that he is not culpable, because
he did not have sufcient degree of mens rea. This
defence, can be raised in several ways:
Not guilty by reason of insanity (under
McNaughton rules).
Diminished responsibility (not guilty of
murder, but guilty of manslaughter, which
requires a lesser degree of criminal intent).
Incapacity to form an intent, because of
an automatism. For example, where a person
kills or is party to a killing of another, he shall
not be convicted of murder if he was suffering
from such abnormality of mind (whether
arising from condition of arrested, retarded
development of mind or any inherent causes
induced by disease or injury) as substantially
impaired his mental responsibility for his acts
and omissions in doing or being party to the
killing.
Successful pleas have been based on conditions
such as emotional immaturity, mental instability,
psychopathic personality, reactive depressed state,
mixed emotions of depression, disappointment and
exasperation, and premenstrual tension. A further
example is that if a mother kills her child in the
rst year of its life, she cannot be held legally
responsible for murder, but only for the lesser
charge of infanticide.
such as battering and homicide. On the other hand,

stalking offences may be committed with paranoid
erotomania (De Clerambault syndrome).
THE ROLE OF THE

PSYCHIATRIST
Psychiatrists and the law
A psychiatrist may be asked to give advice in
relation to tness to plead, mental state at the time
of the offence, diminished criminal responsibility
and the psychiatric management of offenders.
As an expert, the psychiatrist should strive for
objectivity and scrupulously leave advocacy to the
lawyers. He should remain a friend of the court,
by assisting it in clarication and understanding as
well as on opinion.
Fitness to plead
The issue may be raised by the defence, prosecution
or judge. If the accused is found unt to plead, the
order is made committing him to hospital, where
he may be detained for some time. In determining
tness to plead, it is necessary to determine how
far the defendant can:
Understand the nature of the charge
The difference between pleading guilty and
not guilty, instruct counsel, challenge jurors or
assessors
Follow the evidence presented in court. These
enables him to defend himself, a requirement
for a trial.
Fitness to plead is questionable because of the
persons mental state or intellectual capacity.
However, problems of comprehension and
communication from whatever cause may be the
issue, for example, a deaf and dumb person, sane
and normal intelligence, may be unt to plead.
Assessment involves a full consideration of
psychiatric, medical and other factors that may
affect a persons capacity to fully comprehend and
participate in the criminal process.
GIVING EVIDENCE IN COURT

The psychiatric report
In cases where the court has requested for
a psychiatric assessment, it often expects a written
report from a medical practitioner. The report should
be in simple language that can be understood by a
layperson. If a technical word has to be used, the
meaning must be provided.
Mental state at the time of the offence

Before anyone is convicted, the prosecution must
prove that he carried out an unlawful act (actus
reus) and had a certain guilty state of mind at that
time, (mens rea). Categories of mens rea vary from
crime to crime as follows:
372
Forensic Psychiatry
from shooting at the Prime Minister. The judges

drew up rules which were not enacted in the law,
but provided guidance as follows:
Psychiatric reports for criminal

proceedings
The medical practitioner carrying out the assessment
must be condent of the legal issues relevant to
the case. Interviews should, if possible, include
that of close relatives. The assessment should be
comprehensive and often requires more than one
interview. Key information to be collected when
assessing for a psychiatric report:
Previous psychiatric, medical and surgical
history (illnesses, medication)
Past history
Alcohol and drug history
Childhood and adolescence developmental
history
Family history (mental illness, offending)
Marital history
Educational and employment record
Probable outcome of treatment.
Issues on which an opinion may be required in the
psychiatric report are:
Mental state at time of interview and of the
alleged offence
Competence to attend court and make a
defence
Criminal responsibility
Dangerousness.
It is essential that every psychiatric report has a
comprehensive psychiatric diagnosis, prognosis,
treatment and the most appropriate environment
(disposal) for rehabilitation. Psychiatric reports are
critical to due process of law, especially in relation
to a person who may be mentally abnormal.
To establish a defence on the ground of insanity,

it must clearly prove that, at the time of committing
the act, the party accused was labouring under such
a defect of reason, from disease of the mind, as not
to know the nature and quality of the act he was
doing or if he did know it, that he did not know what
he was doing was wrong.
If an offender is found not guilty by reason of

insanity the court must order his admission to
a hospital specied by the relevant Government
department. The McNaughtons rules have no
statutory basis, but they are accepted by the courts
as having the same status as statutory law.
In contrast to competence to stand trial, the
question of criminal responsibility involves a
time in the past during which the criminal act was
committed. The outcomes are different: nding of
incompetence to stand trial usually only delays the
legal proceedings, whereas a successful insanity
plea results in exculpation in the form of a verdict
of not guilty by reason of insanity.
Diminished responsibility
Diminished responsibility is a defence to a
charge of murder; it is not available on other
charges. A successful defence results in a verdict
of manslaughter. Based on the accused persons
mental state (abnormality of mind), this defence
is related to others, such as provocation or excessive
force in self-defence, which have the same effect
that is of mitigation.
It is an important defence. Not only does a
manslaughter conviction carry less stigma than
one for murder, but sentencing options are broader.
Life imprisonment is the maximum sentence for
manslaughter, but lesser sentences are usual if
public safety is not a prime consideration. In certain
cases, perhaps where a mother kills her young
child, a bond may be an appropriate penalty.
The defence of diminished responsibility
include:
The onus of proof is on the accused person
Abnormality of mind is a broad term and
refers to a state that a reasonable man would
consider abnormal
Medical conditions and psychiatric disorders,
including personality disorders that would
not come within McNaughton rules may
be accepted by the court as producing an
abnormality of mind
TYPES OF DEFENCE
Not guilty by reason of insanity
0n 20th January 1843 Daniel McNaughton from
Glasgow, shot and killed Edward Drummond, a
private secretary to the Prime Minister, Sir Robert
Peel. During the trial, a defence of insanity was
presented on the grounds that McNaughton had
suffered from delusions for many years. He believed
he was persecuted by spies, and had gone to the
police and other public gures seeking help. His
delusional system gradually focused on the Tory
Party, and decided to kill their leader, Sir Robert
Peel. He killed Peels secretary, but was prevented
373
The court, in deciding the question of

abnormality of mind, may go against medical
testimony if there is strong, conicting
evidence
Substantial impairment is not dened, total
impairment is not required and trivial will not
sufce
If a verdict of manslaughter is returned, the
court may take into consideration provocation
or self-defence which could affect sentencing.
Automatism
To be punishable, an act must be voluntary, i.e.
a willed act. The defence of automatism may be
raised if a criminal offence results from movements
not controlled by the mind. The law of automatism
is complex. If this defence is raised, the prosecution
has the onus of rebutting it. If it is based on a mental
disorder amounting to a disease of the mind in the
McNaughton sense, the prosecution may ask for
a verdict of insane automatism. Automatism and
insane automatism have different consequences. A
successful defence of automatism brings complete
acquittal. Detention at the Head of State pleasure
follows a nding of insane automatism. Automatism
defences have been based on epileptic states, sleepwalking, acting during dreams, hypoglycaemia in
diabetics and concussion.
Medical practitioners, psychiatrists in particular,
asked to assess persons in respect of this defence
should request for an explanation of the law, obtain
all possible information about the alleged offence
(the accuseds statements and eyewitness accounts)
and do a thorough examination. This also applies to
cases where the issues are of intent, voluntariness
or intoxication.
is shoplifting, which shows a very wide

distribution by age.
Children are over-represented in property
offences. The reverse is true for offences against
the person (violent and sexual offences).
Homicide offences involve victims known to
the offender in about 80 percent of cases.
Sexual offences commonly involve victims
known to the offender. This is especially true for
offences against children, but less so for rape.
Indecent exposure is an exceptionvictims are
normally strangers.
Prisoners are predominantly from lower socioeconomic groups.
Property offences
Most criminal convictions are for property
offences, usually minor in nature and committed
by juveniles. Few of these involve physical danger
to the victims. Injury to victims is possible if threat
of violence is inherent in the offence, as in armed
robbery, or if the unexpected occurs, such as the
unannounced return of a home owner.
Arson, a serious property offence with a wide
range of motivations, may involve threats to life
to a degree not always predicted by the perpetrator.
Need and greed motivate most property offenders,
but there could be other motives.
The referral may be due to unusual features being
noted, or perhaps a pattern of repetitive or selfdefeating offending. There could be a motivation
behind this.
Seriously disturbed individuals may steal for the
most mundane of motives; social factors usually
predominate and motives are simple malice, sexual
deviation, depression, cry for help and the need for
punishment.
NATURE OF OFFENCES
Shoplifting as a property offence
Shoplifting is an important example of a
seemingly simple crime. Yet a complex product
of community attitudes, marketing methods,
shopping habits and store policies on prosecution,
combine with individual factors to produce the
convicted shoplifter, normally a straightforward
thief who may be deterred by the rst experience
of apprehension.
Shoplifting is most common among teenage
offenders although shoplifters come close to being
a cross-section of the community.
A small, but important proportion of shoplifters
have medical, psychiatric, marital and social
The following are a few criminological facts found

across all countries and cultures.
Offenders and victims tend to share similar
demographic characteristics, including criminal
records. Females are over-represented as
victims.
Crime correlates with other indices of social
disadvantage.
The large majority of arrests are for minor
offences, many of them relate to drinking and
driving.
Male offenders aged 20 to 35 years are
responsible for most crimes. The exception
374
Forensic Psychiatry
problems requiring evaluation. Frequently, they

have not presented for help before, and intervention
is indicated. A few offend repeatedly, sometimes in
response to particular stresses or recurring illness.
Personal injury
In cases involving claims for damages for personal
injury resulting from industrial or motor vehicle
accidents, request for an examination for the
purpose of providing a medico-legal report may
come from the lawyers for either the claimant or
the respondent. It is desirable to have copies of all
available medical records concerning the injury.
Sexual offences
Consent is the central issue in serious cases of sexual
assault. Public attitudes change towards sexual
behaviour and sexual crimes, and so does the law,
though more slowly. There is still some value in
dividing offenders into aggressive and passive
groups, for purposes of prediction, treatment and
prevention. The sub-groups suggested below are of
males with the following disorders:
Major psychiatric disorders (psychoses).
Their crimes result from the disorder, with reoffending reduced by treatment.
Personality disorders, especially antisocial
in type. The offence is often opportunistic,
associated with other antisocial behaviour and
not repeated. Many rapists are in this category.
Paraphilia (sexual deviation). This group
commits most of the repetitive crimes that
are the product of compulsive sexual urges
and behaviour. Examples include fetishism,
paedophilia and sadism. Sometimes a variety
of deviant behaviours occur together or in a
developmental sequence. Only a proportion of
offenders against childrenthe most worrying
onesare in this group.
Offenders acts are more as a result of
situational factors, personal stress and less
serious or transitory disorders. They may not t
the categories mentioned earlier and diagnoses
are often the adjustment disorder type. Many
offenders against children within families often
t this category.
The offence or act does not, on its own, establish
the diagnosis or prognosis. The most worrying
acts may result from situational factors and
personal stress, with little chance of repetition.
The greatest concern is to identify, treat, or if
possible, deter those offenders with a driven,
deviant quality, whose acts seriously endanger
others.
DANGEROUSNESS
Assessing Dangerousness
The key principle in assessing dangerousness
concerns an ethical conict between protecting
the community from a potentially violent offender
and respecting the human rights of the individual.
Despite much research, the ability of experts to
predict whether an individual will behave violently
in the future is still not completely reliable. The
approaches to the prediction of violence include
unaided clinical risk assessment.
The predictive value of mental illness as a factor
is weaker than the history of past violent conduct.
Moreover, the rarity of serious crimes such as
murder and the uncertain nature of future situational
factors further complicate the task of prediction in
any individual case.
The practice now is to direct attention to risk
groups where prediction in the short or medium
term may be more reliable. These diagnostic groups
include:
Schizophrenic psychoses
These include:
Older male paranoid schizophrenics with
systematised delusions of persecution, but
relatively intact personalities;
Younger, more passive males prone to act
violently and impulsively, perhaps due to
hallucinatory commands.
Morbid jealousy (pathological jealousy)
There is a very high risk of violence, possibly
murderous, associated with delusions of indelity.
Violent offences
Mood disorders
Violent offenders respond to a non-judgemental

approach and with only extreme rarity, present any
personal threat to doctors. Some violent offenders
need psychiatric treatment.
Characteristic features may include:

violence, which is usually associated with
depression, rarely with mania
375
disinhibiting drugs such as the benzodiazepines),

fantasies of violence, and their own selfassessment. A detailed sexual history may also be
vital. Remember that relatives can give valuable
information and opinions.
Homicidal threats must be taken seriously as
they may present a difcult clinical problem. The
need to warn potential victims can become an issue
that overrides normal medical condentiality.
married women with severe depression

young children being frequent victims
history of suicide attempts and recent
expression of intent
heightened risk immediately after treatment or
discharge from hospital
murder-suicide, sometimes called extended
suicide.
Episodic dyscontrol syndrome
Factors associated with dangerousness
This shares many features with intermittent

explosive disorder (DSM-IV). It is characterised
by specic episodes of violent and aggressive
behaviour that may involve harm to others or
destruction of property.
History
One or more previous episodes of violence
and repeated impulsive behaviour
Evidence of difculty in coping with stress
Previous unwillingness to delay gratication
Sadistic or paranoid traits.
Organic brain disorders

These include epilepsy; brain damage; pre-senile
and senile dementias. The patients at risk here tend
to be older and suffer brain damage, usually with
complicated psychosis.
Offence
Bizarre violence, lack of provocation and regret
and in denial.
Alcohol abuse or dependency
Mental state
This is a risk factor in normal people, and increases

the risk of violence in all diagnostic categories.
A thorough assessment of a patient thought to
be dangerous, may not lead to a clear opinion of a
predictive kind, but should result in the identication
and evaluation of important factors relevant to
possible future violence and its prevention. A
careful psychiatric history with a detailed enquiry
into past and recent violent episodes goes a long way
towards this. People often talk freely about their
violence and self-assessments may be accurate.
Morbid jealousy, paranoid beliefs plus a wish to

harm, deceptiveness, lack of control, threats to
repeat violence and attitude to treatment.
Circumstances
Provocation or precipitation likely to recur, alcohol
or drug abuse and social difculties and lack of
support.
IMPULSE-CONTROL
DISORDERS THAT MAY HAVE
FORENSIC IMPLICATIONS
The psychiatric interview to assess

dangerousness
The following areas need to be assessed, the rst
being the most important:
previous episodes of violence
age, sex, and cultural factors
psychiatric diagnosis
dynamic diagnosis
recent stress
victims behaviour
resources or possibilities for treatment.
Patients must be questioned about weapons, alcohol
and drugs (especially the amphetamines and
These include:
1. Intermittent Explosive Disorder
2. Kleptomania
3. Pyromania
4. Gambling
5. Trichotillomania this may be mistaken for
suicidal attempt.
Their DSM-IV-TR Diagnostic Criteria is
summarised in tables 45.1 to 45.6:
376
Forensic Psychiatry
Table 45.1
DSM-IV-TR Diagnostic Criteria for Intermittent
Explosive Disorder
A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive
acts or destruction of property
B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any
precipitating psychosocial stressors
C. The aggressive episodes are not better accounted for by another mental disorder (e.g., antisocial
personality disorder, borderline personality disorder, a psychotic disorder, a manic episode, conduct
disorder or attention decit/hyperactivity disorder) and are not due to the direct physiological
effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head
trauma, trauma, Alzheimers disease).
Table 45.2
DSM-IV-TR Diagnostic Criteria for Kleptomania
A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or monetary
value
B. Increasing sense of tension immediately before committing the theft
C. Pleasure, gratication, or relief at the time of committing the theft
D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or
hallucination
E. The stealing is not better accounted for by conduct disorder, a manic episode, or antisocial personality
disorder
Table 45.3
DSM-1V-TR Diagnostic Criteria for Pyromania
A. Deliberate and purposeful re setting on more than one occasion.
B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction to re and its situational contexts (e.g.,
paraphernalia, uses, consequences).
D. Pleasure, gratication, or relief when setting res, or when witnessing or participating in their
aftermath.
E. The re setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal
criminal activity, to express anger or vengeance, to improve ones living circumstances, in response
to a delusion or hallucination, or a result of impaired judgment (e.g., in dementia, mental retardation,
substance intoxication).
F. The re setting is not better accounted for by conduct disorder, a manic episode, or antisocial personality
disorder.
377
Table 45.4
DSM-1V-TR Diagnostic Criteria for Pathological Gambling
A. Persistent and recurrent maladaptive gambling behaviour as indicated by ve (or more) of the
following:
(1) is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping
or planning the next venture, or thinking of ways to get money with which to gamble)
(2) needs to gamble with increasing amounts of money in order to achieve the desired excitement
(3) has repeated unsuccessful efforts to control, cut back, or stop gambling
(4) is restless or irritable when attempting to cut down or stop gambling
(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of
helplessness, guilty, anxiety, depression)
(6) after losing money gambling, often returns another day to get even (chasing ones losses)
(7) lies to family members therapist, or others to conceal the extent of involvement with gambling
(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to nance gambling
(9) has jeopardized or lost a signicant relationship, job, or educational or career opportunity because of
gambling
(10) relies on others to provide money to relieve a desperate nancial situation Caused by gambling
B. The gambling behaviour is not better accounted for by a manic episode
Table 45.5
DSM-IV-TR Diagnostic Criteria for Trichotillomania
A. Recurrent pulling out of ones hair resulting in noticeable hair loss
B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the
behavior
C. Pleasure, gratication, or relieve when pulling out the hair.
D.The disturbance is not better accounted for by another mental disorder and is not due to a general medical
condition (e.g., a dermatological condition)
E. The disturbance causes clinical signicance distress or impairment in social, occupational, or other
important area of functioning
Table 45.6
DSM-IV-TR Diagnostic Criteria for Impulse-Control Disorder Not Otherwise Specied
This category is for disorders of impulse control (e.g., skin picking) that do not meet the criteria for any
specic impulse control disorder or for another mental disorder having features involving impulse control
described elsewhere in the manual (e.g., substance dependence, a paraphilia).
378
Forensic Psychiatry
The approach to the person being interviewed

must be straightforward, with the circumstances
of the referral being discussed and the
psychiatrists role and obligations explained.
PREPARATION OF REPORTS
The psychiatric assessment and pre-sentence report
is important for a number of reasons. The courts
decision has immediate and long-term implications
for the liberty and welfare of offenders and, in cases
where there is psychiatric disorder, for the provision
of treatment. A number of people with medical and
psychiatric problems are noticed for the rst time
when they commit acts that bring them to the lower
courts. Successful intervention at the sentencing
stage may help to explain criminal conduct and
also assist in the provision of treatment. It may
reduce the cost to the community of inappropriate
or long periods of imprisonment.
The inuence of the psychiatric pre-sentence
report is difcult to gauge. It is probably greatest
in those cases where a psychiatric disorder is
diagnosed and realistic treatment recommendations
are given. Psychiatric explanations of offences
may assist and sometimes the simple exclusion of
psychiatric illness in an offender is important.
A psychiatric report should be able to stand
on its own. It can do this if the process of
assessment, sources of information, facts, opinions
and recommendations are set out logically,
using simple clear language that a layman can
understand. Reports made up entirely of opinions
may be of immediate use if one trusts the writer,
but they quite rapidly become useless or prone
to misinterpretation. It must be remembered that
reports live for decades in les, possibly to be used
for purposes not originally foreseen or intended,
perhaps to the detriment of the patient.
The ingredients necessary for a comprehensive
assessment and report include:
A proper referral, which denes issues of
concern.
Adequate documentation, which should
accompany a referral. If it does not, it should
be requested for.
Court papers, probation reports and previous
psychiatric and medical reports are usually
needed.
Authority to examine clinical les should be
obtained.
Investigations or medical examination may
need to be done.
The patient should be interviewed at length in
satisfactory circumstances and a relative seen
if possible. Copious notes should be taken and
retained.
Contents of the report

The format of the report varies, but should comprise
the following:
Begin with name and charge.
Start with the when, where, for how long and
how often the patient was interviewed and
who else was seen.
All other sources should be referred to, e.g.
magistrate, chief, nurse, hospital report,
prisons report and school reports.
It should indicate names of any colleagues or
specialists referred to.
It should give a brief description, e.g. Mr.
Njuguna is an unmarried 26-year-old car tter.
This should be followed by chronological
personal history based on factors in infancy,
childhood, adolescence and marriages.
Family history may follow to support a
diagnosis.
Previous medical and psychiatric history must
be recorded.
The summary of any known criminal history
is recorded.
These sections can be followed by accounts of
charges against and when (briey).
THE CARE OF MENTALLY ILL

OFFENDERS
Mentally disordered offenders have a right
to care similar to that of mental patients
who are not offenders. Ethical issues such as
consent, condentiality and autonomy also apply
in the same manner. To ensure that universally
accepted rights and ethical principles in the care
of mentally disordered offenders are adhered to,
national laws must have clear procedures governing
the care of mentally disordered offenders. The aim
would be to provide hospital and communitybased care largely aimed at preventing mentally
disordered offenders from re-offending. Mentally
ill offenders are not homogenous as regards
their security, support and supervision needs.
The national forensic psychiatric service should
therefore have varying levels of care and these
should be clearly dened in the law.
379
to ensure that all health care providers including

psychiatric and non-psychiatric primary health care
workers, social workers and probation ofcers are
able to carry out risk assessment thus preventing
mentally disordered offenders from re-offending.
Settings for forensic psychiatric care

There are several settings in which forensic
psychiatric care are given. Special facilities have
been proven useful for care of patients who need
a particularly high level of security, supervision
and support. Forensic units can also be created
in psychiatric hospitals with the aim of providing
specialised care. Mentally disordered offenders
who do not require a high level of security can be
cared for in psychiatric or non-psychiatric wards of
general hospitals. Patients who require supervision
after in-patient care and those who do not require
admission can be adequately followed up at primary
health care level.
Psychiatric services are also often required in
the prisons as short-term crisis work, such as in
assessment of prisoners for court reports and on
the long-term care of prisoners who have chronic
mental illness. Psychiatric wards in prison hospitals
which are supervised by a multi-disciplinary team
of medical ofcers, psychiatric clinical ofcers and
nurses and social workers are useful for appropriate
planning and provision of appropriate care.
Visiting psychiatrists can be appointed by the
prison authorities to provide part-time specialist
care and in-service training of both medical and
non-medical staff. Forensic psychiatric care is
similar to general psychiatric care in that proper
diagnosis is followed by appropriate treatment.
Diagnosis depends on history taking, mental state
examination and obtaining of information from
other sources. The treatments given are similar to
those used in general psychiatry. What is different
is the greater emphasis laid on continual assessment
(risk assessment) of the potentially dangerous
consequences of the patients mental condition.
Special care is taken to safeguard the protection of
the patient, staff and general public.
Risk assessments of mentally disordered
offenders should be multi-disciplinary, involving
both medical and non-medical staff and should
continue after discharge or release. Hence, the need
Psychiatric care in the prisons

Psychiatric morbidity among remand prisoners is
high, though the prevalence of mental disorders
among convicted prisoners is similar to that of the
general population. Substance abuse, antisocial
personality disorder and anxiety disorders are
the most common disorders seen among remand
prisoners. Commonly found among convicted
prisoners are schizophrenia, epilepsy, depression
and antisocial personality disorders. Contributory
factors include over-crowded, unhygienic prison
conditions where prisoners have little access to
health care, decent beddings and meals.
Medical practitioners working in the prisons
are often faced with having to assess and treat
mentally ill prisoners. Shortage of medical staff in
the prisons may not allow mandatory psychiatric
screening of all prisoners. Therefore, medical staff
may need to depend heavily on psychiatric referrals
from prisoners and prison warders. It is therefore
important that non-medical prison staff are trained
to recognise mental illness. To encourage selfreferral, awareness of the services available should
be created among the prisoners. The prevalence
of psychiatric disorders among prisoners can
be reduced by ensuring that the legal, physical,
psychological and spiritual needs of prisoners are
promptly addressed.
Further reading
1. Principles and Practice of Forensic psychiatry. (1990).
Edited by Robert Bugloss and Paul Bowden Churchill
Livingstone 1990
2. E.B.L. Ovuga (1991). What are Criteria for Criminal
Responsibility? East Africa Medical Journal 68 (10):
820-26.
380
46
Psychiatric Emergencies
Emilio Ovuga, David M. Ndetei, Nakasujja Noeline, Seggane Musisi
DIAGNOSTIC POSSIBILITIES OF
PSYCHIATRIC EMERGENCIES
INTRODUCTION
Psychiatric emergencies refer to situations in
clinical practice in which urgent decisions and
action are required in the management of a clinical
problem to prevent injury or possible damage to
the individual, others or property. Sometimes mere
fear that such injury or damage may occur is the
real problem as in panic attacks. Such situations
usually arise in the course of day-to-day clinical
problems.
Psychiatric emergencies can be associated with

virtually any of the major psychiatric diagnoses.
However, the following are the common problems
that present management problems in clinical
practice:
Affective disorders
Various organic disorders
Alcohol or other substance use disorders
Personality disorders
Dissociative and conversion disorders
Schizophrenic disorders
Non-psychotic disorders (panic, conversion or
disso-associative disorders)
Complications with drug treatment of
psychiatric disorders.
The effects of physical illness.
COMMON SITUATIONS OF
PSYCHIATRIC EMERGENCY
Common psychiatric emergency situations include
suicidal behaviour, homicidal threats, drug and
alcohol intoxication, withdrawal states, child
battering or abuse, sexual abuse, assault or child
disappearance from home. The development of acute
mental symptoms e.g., panic disorder, conversion
disorder or dissociation may also be treated as a
psychiatric emergency.
Affective disorders
These can be associated with both manic and
depressive episodes. Manic patients make
381
numerous plans which cannot usually be

implemented. Their inated self-image coupled
with delusions of grandeur make it difcult for
ordinary people to tolerate them. The combination
of circumstances and the nature of manic illness
predispose the patient to aggressive and violent
confrontations. The patient might therefore come to
the clinic with injury, severe excitement, physical
weakness, exhaustion and dehydration.
Infections with the AIDS virus

These are now a common cause of excitable
and disruptive behaviour (HIV-associated mania)
as has been the case with typhoid fever.
Dementia
Dementia may present with restlessness at night,
particularly in unfamiliar ward situations and may
require to be recognised as a possible cause of an
emergency. Co-existent acute organic disorder or
depression in the elderly may obscure the signs
of dementia and delay diagnosis and appropriate
management for dementia.
Severe depression
This may be associated with marked loss of pleasure
for practically everything in life. The patient may
be in a poor nutritional and physical state from
not having eaten for several days. In about 10
percent of cases, the patient is brought to hospital
with a history of suicidal attempt. Six percent of
suicidal patients also have homicidal tendencies
often directed against their dependents. Extreme
self neglect and profound depressive stupor
with inability to self-feed or care call for urgent
intervention. Suicide and suicide attempt is an ever
looming danger in depression.
Underlying physical illnesses

These often pose a real danger to the lives of
patients. Efforts must be made to look for organic
disorders in all patients who present with an acute
psychiatric disorder. Conditions like pneumonia,
malaria, tuberculosis and urinary tract infections,
especially in the elderly, may be clinically silent
but present with prominent signs of an acute state of
confusion. Psychosis associated with hypertensive
crises has become fairly common among the
afuent members of the community.
Acute organic states

These may present with erratic and dangerous
behaviour. The experience of threatening visual and
auditory hallucinations lead to hostile combative
and suspicious attitudes in patients, thus making life
intolerable for the family, relatives and society.
Antisocial personality disorder

Antisocial personality disorder, especially in
hospitalised patients, may incite other patients to
disobey staff or engage in behaviours which may
disrupt the general order in the ward. Patients with
paranoid personality may make it appear as if
everyone is out to harm them. Such individuals are
not easily convinced to give up their mistrusting and
suspicious attitude and the tendency to misinterpret
the actions and intentions of other people.
Epilepsy
Epilepsy is particularly notable for its association
with dangerous behaviour during the seizure period.
Status epilepticus is a special emergency which
may lead to death of the patient. An unattended
seizure may lead to aspiration of the vomitus.
Schizophrenic disorder
Alcohol withdrawal and hallucinatory

syndromes
Schizophrenic disorder of the paranoid and catatonic

excitement may be associated with serious attacks
on persons or property. This may be retaliatory
in nature based on persecutory delusions, or in
response to auditory and or visual hallucinations.
These may be associated with persecutory

delusions and hostile attitudes accompanied with
combative behaviour. Established delirium tremens
may require special nursing skills. It is important
to denitively detect and exclude undercurrent
physical illness such as malaria. A mortality rate
in delirium tremens is estimated at 15-20 percent.
Morbid jealousy associated with alcohol abuse
makes the spouses of affected persons prone to
physical assaults.
Dissociative disorders
These may lead to individuals leaving home or
engaging in violent or excitable behaviour. Patients
who walk away from home may spend several
days without food and clean water. Dissociative
emergencies usually include dissociative fugue
and amnesia.
382
Psychiatric Emergiencies
Conversion disorders
Acute toxicity in treatment with lithium
These are usually alarming to family and carers,

but are not particularly injurious or dangerous to
anyone. In rare circumstances, they may involve
whole communities as in the case of mass hysteria,
which has been commonly seen in girls boarding
schools. This often presents as a community
emergency to which the psychiatrist may be asked
to attend to immediately.
This may lead to an acute toxic reaction including

tremors, abdominal cramps, vertigo, nausea,
vomiting, mental confusion and coma.
Child abuse
Child abuse is a serious social problem and may take
the form of physical injury, verbal threats or abuse,
persistent intimidation, neglect, and withholding
of special favours, severe corporal punishment,
sexual abuse or delement. Severe physical injury
is often inicted on children under the guise of
instilling discipline by parents or care-takers.
Sexual abuse of young children is a problem and
could lead to the development of future emotional
disorders, impaired intellectual functioning and
development of warm trusting social relationship,
and sexually transmitted infections or pregnancies
in older (teenage) children. Recently, with the
many wars in Africa, abduction of children has
become increasingly common. They are used as
child soldiers or for sexual exploitation. Refugee
children and those in Internally Displaced
Peoples(IDPs) camps, are particularly vulnerable
to abuse by adults or older children.
Non-psychotic states such as panic attacks

These may require immediate attention even if
they are not life-threatening and will not cause
injury or destroy property. Differentiation should
be made through systematic and comprehensive
physical examinations from physical conditions
such as heart attack, asthma, epilepsy, alcoholic
hypoglycaemia, impending diabetic coma, head
trauma, and thyrotoxicosis.
Medication effects
Medication effects may cause psychiatric
emergencies arising in the course of the drug
management of a psychiatric illness. Treatment
with major tranquilisers may give rise to acute
dystonic reactions involving the face, tongue, neck
and shoulders. They may also cause high fevers
like Neuroleptic Malignant Syndrome (NMS).
NMS should be considered in the differential
diagnosis and work-up of any febrile illness in
areas where malaria, typhoid fever, meningitis
and other febrile conditions are endemic. NMS,
which is like the anaesthetic-induced malignant
hyperthermia, develops within the rst 2 or 3
days of the onset of neuroleptic therapy. If not
recognised and managed early, this condition
leads to coma and death may ensue within a few
days. Its management includes discontinuing
all anti-psychotic medication, and the use of
benzodiazepines and life support. Switching to an
atypical antipsychotic is recommended if this can
be afforded. Dantrolene may be useful.
MANAGEMENT PRINCIPLES
The effective management of any psychiatric
emergency requires a comprehensive assessment
of the patient concerned. This should include taking
a detailed history of the problem. A full physical
assessment along with a comprehensive mental
status examination and relevant laboratory
investigations should be made. The following tips
should be used always to facilitate the effective
management of emergencies for hospitalised
patients:
All impending emergencies on a psychiatric
ward are predictable.
The effective control of any emergency
requires a combination of effective drug use
with proper understanding of the impact of
the environmental stressors, social factors
and psychological basis of the unwanted
behaviour.
The management of any emergency requires a
collective team approach.
Management should not encourage appeasing
promises by staff to patients engaged
in disruptive behaviour.
Central anticholinergic syndrome

This may follow overdose with tricyclic antidepressants, antipsychotic or antiparkinsonian
agents. This condition may be difcult to
differentiate from NMS, but is characterised by
cardiac, autonomic and temperature instability,
sweating, tremulousness and delirium. Management
is by gastric lavage, cardiac and life support and
slow parenteral administration of physostigmine
(antilirium).
383
The health facility should always be prepared

to respond to any type of emergency rapidly
and efciently.
Staff should always report to the team any
threat of harm or disruption from patients in
time.
Warning signs of a management problem in the
ward include:
Suspiciousness, social withdrawal and
complaints directed to staff or other patients
A noticeable change in behaviour pattern from
the usual
Verbal threats directed at staff or other
patients
Refusal to participate with others in activities
on the ward
Refusal to eat, disturbed sleep and refusal to
take medication
Clues from previous clinical evaluation
suggesting troublesome behaviour
A patient with any of the listed problematic
diagnoses associated with aggressiveness.
The following should be noted for patients who are
being evaluated for the rst time at the out-patient
setting:
Signs of physical illness including fever,
anaemia, jaundice, cyanosis, lymphadenopathy
or evidence of any occult physical disorder
Signs of physical injury, lacerations, abrasions,
tying, fractures and sepsis
Evidence of neurological disease
Signs of nutritional deciency and endocrine
abnormality
Special features of mental disorder suggesting
suicidal behaviour, suspiciousness, terrifying
hallucinations, depressed mood, lack
of tolerance, aggressive tendency or mood
elation.
Evidence of child battering, abuse, rape or
other forms of sexual abuse in a child.
calmly, but reasonably loud enough to ensure that

the individual does not misinterpret what is being
said. The person should be requested to co-operate
with staff. At the end of discussion, the person will
usually agree to participate in further management
plans including alterations in drug schedules.
Patience and tact are required when handling an
emergency involving a child or adolescent. Such a
child often has genuine fears in revealing the true
nature of his or her problems.
When the tactful and friendly approach fails,
staff should respond as a group, use minimal force
to restrain the persons and sedate them with an
adequate dose of a tranquiliser. Patients usually
respond favourably to chlorpromazine administered
in a dose of 100-200 mg intra-muscularly. A minor
tranquiliser like diazepam 10-20 mg may be added
for exceptionally desired quick deep sedation. This
may even be given intravenously. Intramuscular
Haloperidol 10 mg combined with intramuscular
promethazine 25-50 mg are all given as a start
dose and rapid tranquilisation without recourse
to the use of unnecessary physical restraint. Drug
treatment should be followed by further attempt
by staff to talk to the patient. Medication should
continue in appropriate doses every 8 hours until
clinical improvement is noticed. If the underlying
nature of the illness is a major depressive
disorder, an antidepressant such as the tricyclic
Amitryptiline or Imipramine should be used
starting with 25 mg nightly for 3 days. The dose of
the antidepressant may then be increased by a dose
of 25 mg depending on clinical response. Selective
serotonin re-uptake inhibitors like Fluoxetine
20mg, Paroxetine 20mg or Sertraline 50 to 150
mg may be used alternatively. If the patient suffers
from a bipolar affective disorder, a mood stabiliser
such as Lithium Carbonate should be added in a
dose of 1G/24 hours in divided doses to maintain
a serum lithium level of 0.5 to 1.2mmol/L. Sodium
Valproate in the dosage of 1G/24 hours is also
equally effective. In the case of a rapidly cycling
affective illness, carbamazepine in doses of 200400mg twice a day should be used. In case of nonresponse, ECT may be considered especially with
suicidal and catatonic tendencies. One must always
be aware of possible treatment resistant cases
which need aggressive management.
As drug control is being effected, attempts to
search for physical illness should be made as well
as relevant laboratory investigations. Appropriate
treatment will then depend on the nature of illness
identied. In an out-patient setting, early referral
to a psychiatric in-patient facility must be made in
Denitive Management Plan

The most effective management plan for psychiatric
emergencies requires the early detection of
problems, particularly in the hospital ward setting.
Once early signs are noticed, efforts should
be made to talk to the person concerned. Staff
behaviour should portray a friendly non-threatening
atmosphere. This is achieved more easily if staff
remain calm. A safe distance should be maintained
between the patient and oneself. Staff should speak
384
order to limit suffering for the patient and family.

This should be done after an initial sedation to
facilitate easy transportation. If the psychiatric
facility is accessible it is recommended that the
patient should not be sedated until the psychiatrist
has assessed the individual. The social management
of any emergency may require the involvement of
patients guardians, or the family in cases involving
children and adolescents.
like those intoxicated with excessive alcoholic

beverages.
The violent patient

Violence can be caused by environmental factors
such as negative attitudes of others towards the
patient, frustration, or being deliberately excluded
from participating in normal activities. Acute
episodes of schizophrenia, affective disorder, or
organic mental disorder may often be associated
with violence, especially if the care-givers lack
skills in establishing and maintaining rapport with
the patient. The following approaches may be used
in calming and controlling a violent patient:
Most psychotic patients usually calm down
if approached in a friendly, calm, relaxed and
reassuring manner. Call the patient by his
favourite name, greet him and try to shake his
hand. Try to establish a friendly relationship
with the patient. Do not get discouraged if
the response appears hostile. Most psychotic
patients eventually respond positively to
sustained efforts to establish rapport.
Discourage people from crowding the patient.
Sometimes a disturbed patient calms down
when those accompanying him are asked to
leave. However, when staying with such a
patient, one should position himself in such a
way that both the person and the patient have
access to the door. This makes the patient feel
less threatened, while also providing the person
with the possibility of escape should that be
necessary. If the patient is armed, he must be
disarmed as soon as possible. He should be
persuaded to hand over the weapon, while at
the same time reassured protection. However,
if persuasion fails, every other means must be
used to disarm and control him. Never attempt
to control a psychiatric patient on your own.
Restraint of a violent patient should be done
by 4 to 5 people. The patient should be
approached quickly at a moment when his
attention has been distracted. Each person
should hold a specic part of the body i.e., the
legs held at the knees, arms held just below the
shoulders and immobilised backward, and the
head should be gripped from behindtaking
care not to be bitten.
Unnecessary force must not be used and the
patient must never be abused, threatened
or humiliated. He should be taken to a
secure single room, counselled or sedated
with an appropriate tranquiliser such as:
Restraint
Physical restraints and seclusion in a quiet isolation
room still have a role in the management of
extremely violent psychiatrically ill patients. There
should be properly written out guidelines and
protocols regarding when and how to use physical
restraint. However, physical restraint should be
used therapeutically and humanely. Psychiatric
intensive care units are the best and most effective
environments to apply these procedures.
Suicide attempts and overdoses
Psychiatric emergencies involving overdoses in
young children should be prevented with clear
instructions to parents not to leave drugs within
easy reach of children. Where such a mishap has
taken place, detailed information about the drugs
being used by adults at home should be obtained.
The prevention of suicidal behaviour requires the
denitive identication and assessment of the risk
of suicide in every individual being seen for the
rst time. Tricyclic antidepressants and anxiolytic
agents should not be dispensed for more than one
week at a time until the risk of suicide diminishes.
An assurance by a patient not to engage in suicidal
behaviour may be of help. Staff and relatives should
be requested to ensure effective surveillance over
the patient to prevent the occurrence of a suicide
act.
Role of acute physical illness
The management of a psychotic disorder is
sometimes made difcult by co-existing physical
illness. The presence of febrile illness may lead
to undue weakness or impair the ingestion of
adequate amounts of uids and food, resulting in
exhaustion, dehydration, coma and death. Besides,
the inadequate ingestion of medication as a result
of physical illness may delay the effective control
of psychotic behaviour. Careful history should aim
to identify the medical history of individuals who
present at the emergency department with an acute
psychiatric disturbance. Individuals on anti-diabetic
medication, may lapse into hypoglycaemic coma
385
Chlorpromazine 50-100 mgs bd or tds by

mouth or Haloperidol 10-20 mgs bd orally or
intramuscularly combined with promethazine
25 to 50 mg orally or intramuscularly. Referral
to a psychiatrist must be arranged as soon as
possible.
This allows them to release their emotions and is

referred to as catharsis.
Social skills training
Aggressive people tend to lack social skills such
as: effective communication, making requests,
encouraging negotiation and making complaints.
AGGRESSION
Anger management
Aggressive individuals if shown further aggression
tend to act even more aggressively. However,
if taught, non-violent responses to stimuli that
would evoke aggression along with strategies to
control anger, the individual develops the ability to
empathise and inhibit further aggression.
Aggression is a form of behaviour whose goal is to

hurt, injure or harm someone or property. The drive
for the intention may be conscious or unconscious.
Disappointment follows if the attempt fails or is
foiled. The behaviour may be directed towards
others or self.
Aggression may be one of the most serious
results of mental illness, resulting in fear of the
mentally ill and their stigmatisation. It may be
associated with violent crime, such as robbery,
murder and homicide.
Drug treatment
Current information regards use of drugs as
follows:
Lithium is useful in some violent patients and
impulsively indulgent adolescents
Anticonvulsants are useful if there is seizureinduced aggression
Antipsychotics help if the patient suffers from
a psychotic disorder, e.g. schizophrenia and
mania.
Antidepressants are effective in reducing
anxiety and violence in depressed patients,
especially if aggression is directed at oneself.
Stimulants (as in Attention Decit Disorder
(ADD)) are used in aggressive children.
Management
This is divided into two: the aggression (and
aggressor) and the victims of aggression.
Management of aggression and the aggressor
This starts with a thorough clinical history and
assessment to establish any underlying primary
problem like a psychiatric illness, interpersonal
problem or substance abuse. The aims of treatment
are to prevent:
injury or death
disability (physical, psychological and social)
violence including physical or sexual abuse.
Management of the victim of aggression

Victims of aggression have a high chance of
developing long-term depression or post-traumatic
stress disorder and phobia. These individuals
present with the following symptoms:
sense of helplessness
rage at being a victim
sense of being permanently damaged, a rage
of being molested
inability to trust or be intimate with others,
and may fail in institutions
persistent pre-occupations with the cure and
seeking justice. This pre-occupation may
become an obsession
loss of faith or belief in their religion
accompanied by personality changes as
happens in complex post-traumatic stress
disorder (PTSD).
The following principles are required to help
victims of aggression:
Treatment techniques
These are of ve types: punishment, catharsis,
training in social skills, anger management and
drug treatment.
Punishment
This has been shown to be highly ineffective as
it often puts the aggressor into more aggressive
outbursts. The aggressor views punishment as
direct assault and reacts in revenge. Probably mild
forms of punishment such as disapproval may be
useful.
Catharsis
Violent individuals want an opportunity to freely
discuss their feelings and explain their behaviours.
386
Unemployed
School drop-out, semi-illiterate to illiterate
Long history of being a loner with no interest
in social relations and activities
Chronic abuse of alcohol or dugs
History of psychiatric hospitalisation
Frequent history of violence or impulsive
behaviour
Prone to anxiety
Has poor self-image, tendency to violence
Acts out in destructive socially unacceptable
ways while stressed
Unable to use recourses available or to
recognise that there is help
History of prior arrest
Has a history of previous homicide and views
killing of another as a worthwhile act
May have a weapon.
crisis intervention and debrieng immediately

following the aggression
support and offering help, including decisionmaking and giving security
appropriate and immediate referral in case of
injuries or complications
medication (minor tranquilisers) to relieve
anxiety, tension and sleep problems
long-term treatment for complications of
violence such as PTSD. This may involve
medication (eg. antidepressants), psychotherapy
and behaviour therapies (CBT)
rehabilitation with nancial and legal redress
(retribution with justice)
prevention of further instances of aggressive
attacks.
HOMICIDE AND HOMICIDAL

THREATS
Management
A detailed assessment of the homicidal risk is
mandatory. No one clinical characteristic predicts
homicide. However, the greater the number of these
characteristics, the greater the risk. The following
need to be done:
Inform the potential victims
Inform the relevant legal authorities
Psychiatric referral (for the individual and a
separate one for the potential victim)
Possible treatment of the underling psychiatric
problem.
Homicide is an act or conveying of a wish to

kill other individuals usually within the family,
among other persons known to the individual or
strangers. Those making threats may do so under
the inuence of alcohol or other drug intoxication
during arguments, or without provocation.
Disordered personality may be evident. Poor
interpersonal relationships may be in evidence
in the homes of affected persons. Within the
family history, depressive disorder with suicidal
behaviour may be elicited. Primary psychotic
disorder characterised by persecutory or paranoid
or delusions and threatening hallucinations may be
responsible. It may also be secondary to substance
abuse or personality disorder.
Homicidal psychotic individuals may carry
out multiple killings before they kill themselves.
Proper attention to psychotic illness and effective
surveillance for and its control is the only way to
protect society against homicide.
LEGAL ASPECTS OF
EMERGENCY PSYCHIATRY
Emergency psychiatric treatment may be provided
by securing compulsory admission under existing
legislation when the individual does not accept to
be treated or is unable to give consent for treatment.
Request for compulsory admission of an individual
may be made by family members or other relatives
who are above 18 years. Friends, colleagues, or
other persons who have been with the individual
for at least 15 days and have good knowledge of
the person during that time may also request for
compulsory treatment. Medical practitioners, who
have in the course of medical examination, identied
reasonable grounds for compulsory treatments,
may certify the individual for admission. Other
Clinical presentations or associations

The clinical characteristics of homicidal individuals
are:
Early violence, battered child and poor parental
modelling
Poor at social activities and no achievements
No signicant others are available
Very unstable personal developmental history
Low socio-economic status
387
Memory for recent and remote events

Perceptual disorders (illusions, hallucinations,
identity)
Delusions
Affective state and response.
In particular, the relationship between the
individuals behaviour and mental content should
be noted as this observation will help clarify the
level of criminal responsibility of the person for an
alleged crime, if any. The persons account of what
he may have been alleged to have done should be
noted verbatim, if possible. In subsequent clinical
reviews, the persons memory for the episodes of
the current disturbed behaviour should be noted to
help formulate forensic decisions.
individuals who are usually empowered to request

for compulsory admission include police ofcers,
judges and local or traditional leaders in whose
jurisdiction the individual resides. Such compulsory
admission and treatment are usually provided for
by the relevant Mental Health Act of a particular
country.
Compulsory removal of an abused child is the
legal responsibility of every citizen including
neighbours, medical practitioners, health care
professionals, social welfare workers and members
of law enforcement agencies. It is usually provided
for by the relevant Child Protection Act of a
particular country. The guiding principles of this
act are:
Protection of the child from harm (including
from any form of abuse)
Provision of the child with security, shelter and
food
Prevention of child neglect including clothing,
health care, nurturing and abandonment
Promoting the childs development, schooling
and growth.
The prevention or management of psychiatric
emergencies requires progressive sensitisation and
education of the public on their role in providing
timely health care to those in need of therapy and
to prevent injury to the sick and members of the
public. There must be appropriate legislation in
place to protect the patient, public and health care
provider.
The practice of emergency psychiatry for medical
practitioners requires the careful documentation of
all observations: physical, psychological and social.
This is necessary as the information obtained may
form the basis of subsequent legal decisions.
Besides, carefully documented clinical observations
are required to justify certication and to protect
individuals from false claims by unscrupulous
persons. The noted observations should make it
possible for anyone else to decide on the mental
ability of the individual concerned to:
Appreciate the need for external assistance
Identify relatives, family and friends
Give rational instructions to other people
Follow arguments and discussions.
Observation reports for the court should set out to
identify the:
Persons level of orientation to self, place, and
time
Ability to learn new information
PROGNOSIS
The prognosis of most psychiatric emergencies
is good once the underlying cause is carefully
assessed, understood and appropriate action taken.
The most rewarding conditions to manage in this
sense are the acute organic states where the cause
is effectively treated. Where the underlying cause is
related to personal factors such as substance abuse,
or persistent abnormal personality traits, the patient
might continue to visit the emergency or casualty
department with recurrent episodes of emergency,
such as suicide or homicidal behaviour, child
abuse and domestic violence. These problems
may eventually be fatal, thus pointing to the need
for one to involve other health care workers in the
management of psychiatric emergencies.
One needs to appreciate that a good prognosis
depends on the optimal management of the psychiatric
emergency which often requires psychotherapeutic
approaches. This approach requires patience and
a willingness not to resort to medication except to
control agitation and excitement, and for psychoeducation of the patient and family about the need
to continue receiving follow-up psychiatric care.
Patients may require careful evaluation and workup with tactful explanation about the need for them
to use available psychosocial services.
Further reading
1. R.Levy and B.Goldman (1992). Emergency Psychiatry.
In General Review of Psychiatry. H.H.Goldman
(Editor). Prentice-Hall International Inc. U.S.A. p47076
2. Lloyd G.G. (1991). Textbook of General Hospital
Psychiatry. Churchill Livingstone, Edinburgh. P20314, Chapter 10
388
47
Sleep Disorders
Caleb Othieno, David M. Ndetei
occur during this phase. Normal sleep progresses

through the NREM stages and REM sets in from
around 90 minutes after the sleep starts. The cycle
is repeated throughout the night but the NREM
sleep predominates during the early stages of sleep
while the proportion spent in REM sleep increases
towards the morning. The pattern of sleep varies
with age. Children sleep more soundly as the
slow wave sleep predominates. As an individual
ages, the proportion of time spent in stage 1 sleep
increases while stages 3 and 4 decrease. The total
sleep time varies among individuals but generally
decreases with age. Newborns may spend 16-18
hours asleep in a day. This decreases to 10 hours
in young children and 8 hours in adolescents.
Most adults sleep 7 hours or less. These facts are
important when assessing a sleep disorder.
Wakefulness is maintained by cortical
noradrenaline, dopamine and acetylcholine
from terminals of brainstem neurones. In sleep,
the activity of the ascending reticular system
diminishes. It is thought that NREM sleep depends
on activity in the basal forebrain systems, while
the pons is primarily responsible for control of
REM sleep. The theories on the functions of sleep
include:
Physical and psychological restoration and
recovery
Energy conservation
Memory consolidation
Discharge of emotions
Brain growth
Sleep disturbance can occur in a wide range of

psychiatric and medical conditions. The sleep
disorder could be a primary condition or part of
the symptoms of an underlying medical disorder.
Alternatively, long standing medical conditions
may give rise to sleep disorders. Thus in patients
with complaints of sleep disturbance, it is essential
to rule out psychiatric disorders. But whether the
latter is present or not, treatment should be initiated
early to prevent psychological disturbance or to
modulate its course.
BASIC ASPECTS OF NORMAL

SLEEP
Nature of sleep
Sleep is a reversible state of reduced awareness
and responsiveness to the environment. Two
distinct phases are recognised: the Non-Rapid Eye
Movement (NREM) and the rapid eye movement
(REM). Both are active processes. The NREM
is divided into 4 stages. Normal sleep starts with
the rst stage and occupies about 5 percent of the
total sleep time. The second stage accounts for 50
percent of the total sleep time and it is distinguished
by sleep spindles and K complexes from the EEG
recordings. Slow waves characterise stages 3
and 4, hence the name slow wave sleep. These
are the deepest levels of sleep and they make up
about 1020 percent of the sleep time. The REM
sleep comprises 20-25 percent of the total sleep
time. Characteristically, most of the dreams
389
Maintenance of immune systems

Various other biological functions
Sleep disturbance includes loss of sleep, impaired
quality of sleep and inappropriate timing due
to circadian rhythm disorders. Total sleep loss
leads to deterioration in cognitive functions and
mood disturbance. Partial sleep deprivation leads
to impaired daytime performance and disturbed
behaviour. Examples include irritability, fatigue
and impaired concentration. Prolonged sleep
deprivation leads to disorientation, illusions,
hallucinations, persecutory ideation, inappropriate
behaviour and restricted awareness. Frequent
periods of microsleep may be seen with automatic
behaviour. Evidence for some of these observations
comes from animals deprived of sleep. Prolonged
sleep deprivation results in loss of temperature
regulation and multiple systems failure. Chronic
partial sleep deprivation has adverse effects on
mood, behaviour and cognitive functions.
Sleep architecture: the amount and distribution of

the sleep stages.
CLASSIFICATION OF SLEEP
DISORDERS
Several types of classications are used. The DSMIV-TR classication is presented here:
1. Dyssomnias
Primary insomnia
Primary hypersomnia
Narcolepsy
Breathing related sleep disorder
Circadian rhythm sleep disorder (sleep-wake
schedule disorder):
o Delayed sleep phase
o Jet lag
o Shiftwork
o Unspecied
Dyssomnias not otherwise specied
2. Parasomnias
Nightmare disorder (dream anxiety
disorder)
Sleep terror disorder
Sleepwalking disorder
Parasomnia not otherwise specied
3. Sleep disorders related to another mental
disorder
4. Other sleep disorders
5. Substance-induced sleep disorders
Common terminologies in the study of

sleep
Polysomnography: various electrophysiological
measures are used to study sleep. These include
EEG recordings, electro-oculographic activity,
electromyograms, oral and nasal airow breathing
patterns, oxyhaemoglobin levels and carbon
dioxide saturation in exhaled air.
Sleep continuity: determines the periods of
wakefulness between the cycles of sleep. Sleep
continuity is greatest in early childhood and least
at the extremes of ages (infants and the elderly).
The frequency of brief arousals gradually increases
from teenage to old age.
Dyssomnias
Circadian sleep-wake rhythms: refers to the natural

alternating sequence of sleep and wakefulness that
occur through the 24-hour period. Neonates show
3-4 hour sleep-wake cycles. By one year of age
sleep shifts to night and wakefulness to daytime.
The dyssomnias are primary disorders of initiating

or maintaining sleep or of excessive sleepiness. The
disturbance could involve the amount and quality
of sleep or the timing.
Sleep latency: the period between the time one

gets into bed and the time sleep sets in.
Primary insomnia
This is a common disorder that is estimated to affect
30-40 percent of the general adult population. In
addition to the complaints of difculty initiating
or maintaining sleep, the individuals may not feel
refreshed after sleep (non-restorative sleep). This
may lead to daytime fatigue and cause signicant
distress or impairment in social occupational
functioning. For the diagnosis to be made the
symptoms should be persistent for one month.
The differential diagnosis includes: narcolepsy,
breathing-related sleep disorder, circadian rhythm
Multiple sleep latency: consecutive measures of

the sleep latency.
Repeated test of daytime wakefulness: measures
the individuals ability to remain alert.
Intermittent wakefulness: the period spent awake
after the initial onset of sleep, usually at the end of
the sleep cycles.
Sleep efciency: the proportion of time spent
asleep in relation to the total time spent in bed.
390
Sleep Disorders
sleep disorder or parasomnia. Underlying medical

conditions such as depressive and anxiety disorders,
and delirious states have to be ruled out.
Polysomnography may demonstrate increased

sleep latency, intermittent wakefulness and
decreased sleep efciency. Other changes include
Table 47.1
Dyssomnias
307.42 Primary Insomnia
A. The predominant complaint is difculty initiating or maintaining sleep, or nonrestorative sleep, for at
least 1 month.
B. The sleep disturbance (or associated daytime fatigue) causes clinically signicant distress or impairment
in social, occupational, or other important areas of functioning.
C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-related
Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia.
D. The disturbance does not occur exclusively during the course of another mental disorder (e.g.. Major
Depressive Disorder, Generalised Anxiety Disorder, a delirium).
The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
Specify if
Recurrent: If there are periods of excessive sleepiness that last at least 3 occurring several times a year for
at least 2 years.
have to occur almost daily for a period of one

month for the diagnosis to be made. In addition,
clinically signicant distress or impairment in
social and occupational functioning should be
present. Other sleep disorders, mental conditions,
medical conditions and substance use have to be
ruled out. Distinction also has to be made from
habitual long sleepers who require greater than
the average amounts of sleep. The disorder begins
between 15 and 30 years of age and affects 5-10
percent of those who present to sleep disorder
clinics.
increased stage 1 sleep and decreased stages 3 and

4. Evidence of excessive physiological reactivity
such as increased muscle tension, tension headache
and gastric distress may be seen. Sometimes the
subjective complaints by the patient do not match
the laboratory ndings.
Primary hypersomnia
In this condition, the major complaint is of
excessive sleepiness occurring either as prolonged
sleep episodes or daytime sleep episodes. For
example, even after 8-12 hours of sleep an adult
with the disorder does not feel refreshed. These
Table 47.2
307.44 Primary Hypersomnia

A. The predominant complaint is excessive sleepiness for at least 1 month (or less if recurrent) as evidenced
by either prolonged sleep episodes or daytime sleep episodes that occur almost daily.
B. The excessive sleepiness causes clinically signicant distress or impairment in social, occupational, or
C. The excessive sleepiness is not better accounted for by insomnia and does not occur exclusively during
the course of another Sleep Disorder (e.g.. Narcolepsy, Breathing-related Sleep Disorder, Circadian
Rhythm Sleep Disorder, or a Parasomnia) and cannot be accounted for by an inadequate amount of
sleep.
D. The disturbance does not occur exclusively during the course of another mental disorder.
391
Specify if:
F.
Recurrent: if there are periods of excessive sleepiness that last at least 3 days occurring several times
a year for at least 2 years.
into the transition between sleep and wakefulness.

These manifest as hypnopompic or hypnagogic
hallucinations. Sleep paralysis may occur at the
beginning or end of sleep. The effects should not be
due to general medical conditions or substance use.
Although the individual is refreshed after the sleep
attack, the sleepiness returns within a few hours.
Two to 6 episodes may occur in a typical day. Low
stimulation or engagement in monotonous tasks
may precipitate the condition. The sleep may occur
in inappropriate situations, for example when
driving, thus endangering the individuals life.
Narcolepsy
This is a relatively rare condition, aficting only
0.02-0.16 percent of the general adult population.
Male and females are affected in equal proportions.
It characteristically starts during adolescence.
The characteristic feature of the condition is
repeated irresistible attacks of refreshing sleep
that occur daily over a period of at least 3 months.
Associated features include cataplexy (sudden
bilateral, reversible loss of muscle tone that
end within minutes), and recurrent intrusions of
elements of rapid eye movement (REM) sleep
Table 47.3
347 Narcolepsy
A. Irresistible attacks of refreshing sleep that occur daily over at least 3 months.
B. The presence of one or both of the following:
(1) cataplexy (i.e., brief episodes of sudden bilateral loss of muscle tone, most often in association with
intense emotion)
(2) recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between
sleep and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep
paralysis at the beginning or end of sleep episodes
C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or another general medical condition.
It is estimated that concurrent medical disorders or

history of another mental disorder is found in 40
percent of the cases. Comorbidity commonly occurs
with mood disorders (especially major depression
and dysthymia), substance related disorders
and generalised anxiety disorder. Parasomnias such
as sleepwalking disorder, bruxism and enuresis
are more common among patients suffering from
narcolepsy. In the laboratory a sleep latency period
of less than 5 minutes and the appearance of REM
sleep during two or more out of a 5-nap session in
the multiple sleep latency test is pathognomonic of
narcolepsy. The differential diagnoses include sleep
deprivation; primary hypersomnia and breathing
related sleep disorder. Hypersomnia related to
substance use or other medical conditions should
also be ruled out.
Breathing-related sleep disorder

Roughly 1-10 percent of the adult population
suffer from breathing-related sleep disorder.
Nocturnal sleep is characteristically disrupted as
a result of ventilation abnormalities, leading to
excessive daytime drowsiness or insomnia. The
following forms have been identied: obstructive
sleep apnoea syndrome, central sleep apnoea
syndrome and the central alveolar hypoventilation
syndrome. The sleeplessness is thought to be due
to the frequent arousals from sleep at night as
the individual ghts for breath. The individual is
characteristically not refreshed by the sleep. The
diagnosis should not be made if the symptoms can
be accounted for by other mental disorders, general
medical condition or substance use. However, the
sleeplessness from breathing-related disorder can
392
Sleep Disorders
lead to various psychological and personality

changes. These include memory disturbance, poor
concentration, irritability, anxiety disorder, sexual
dysfunction among males, and developmental
and learning problems in children. Breathingrelated sleep disorders should also be distinguished
from narcolepsy, primary hypersomnia and
circadian rhythm sleep disorders. Risk factors
include obesity. Upper airway obstruction may
be attributed to the excessive soft tissues in these

individuals. This leads to loud snoring. However
diagnosis should not be based solely on this as
children with breathing related disorders may not
snore. There are also asymptomatic adults who
snore. Nevertheless agitated arousals and strange
sleeping postures may give a clue to the diagnosis.
Secondary enuresis occurs in some children.
Table 47.4
780.59 Breathing-Related Sleep Disorder
A. Sleep disruption, leading to excessive sleepiness or insomnia, that is judged to be due to a sleep-related
breathing condition (e.g., obstructive or central sleep apnea syndrome or central alveolar hypoventilation
syndrome).
B. The disturbance is not better accounted for by another mental disorder and is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or another general medical
condition (other than a breathing-related disorder).
Coding note: Also code sleep-related breathing disorder on I Axis III.
In the laboratory, hypopnoeas are characterised

by a reduction in the airow and oxyhaemoglobin
levels. Characteristic Cheyne-Stokes respiration
may also be demonstrated in the laboratory. The
breathing problems are accompanied by changes in

the cardiac functions. In serious cases ventricular
arrythmias and sinus arrest occur.
Circadian Rhythm Sleep Disorder

Table 47.5
307.45 Circadian Rhythm Sleep Disorder (formerly Sleep-Wake Schedule Disorder)
A. A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is
due to a mismatch between the sleep-wake schedule required by a persons environment and his/her
circadian sleep-wake pattern.
B. The sleep disturbance causes clinically signicant distress or impairment in social, occupational, or
C. The disturbance does not occur exclusively during the course of another sleep disorder or other mental
disorder.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
Specify type:
Delayed Sleep Phase Type: a persistent pattern of late sleep onset and late awakening times, with an inability
to fall asleep and awaken at a desired earlier time
Jet Lag Type: sleepiness and alertness that occur at an inappropriate time of day relative to local time,
occurring after repeated travel across more than one time zone
Shift Work Type: insomnia during the major sleep period or excessive sleepiness during the major awake
period associated with night shift work or frequently changing shift work
Unspecied Type (e.g., advanced sleep phase, non-24-hour sleep-wake pattern, irregular sleep-wake pattern,
or other unspecied pattern)
393
Previously this category of disorders was called the

sleep-wake schedule disorder. It is characterised by
a persistent or recurrent pattern of sleep disruption
leading to excessive sleepiness or insomnia that
is due to a mismatch between the sleep-wake
schedule required by the persons environment
and his circadian sleep-wake pattern. Social and
occupational distress is required for the diagnosis to

be made. Exclusion of other sleep disorders, mental
disorders as well as general medical conditions and
substance use should be made. The following types
are recognised: delayed sleep phase type, jet lag
type, shift work type and the unspecied types.
Table 47.6
307.47 Dyssomnia Not Otherwise Specied
The Dyssomnia Not Otherwise Specied category is for insomnias, hypersomnias, or circadian rhythm
disturbances that do not meet criteria for any specic Dyssomnia. Examples include
1. Complaints of clinically signicant insomnia or hypersomnia that are attributable to environmental
factors (e.g., noise, light, frequent interruptions).
2. Excessive sleepiness that is attributable to ongoing sleep deprivation.
3. Restless legs syndrome: This syndrome is characterized by a desire to move the legs or arms,
associated with uncomfortable sensations typically described as creeping, crawling, tingling,
burning, or itching. Frequent movements of the limbs occur in an effort to relieve the uncomfortable
sensations. Symptoms are worse when the individual is at rest and in the evening or night, and they
are relieved temporarily by movement. The uncomfortable sensations and limb movements can
delay sleep onset, awaken the individual from sleep, and lead to daytime sleepiness or fatigue.
4. Periodic limb movements: These are repeated low-amplitude brief limb jerks, particularly in the
lower extremities. These movements begin near sleep onset and decrease during stage 3 or 4 nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. Movements usually occur
rhythmically every 20-60 seconds and are associated with repeated, brief arousals. Individuals are
often unaware of the actual movements, but may complain of insomnia, frequent awakenings, or
daytime sleepiness if the number of movements is very large. Individuals may have considerable
variability in the number of periodic limb movement from night to night. Periodic limb movements
occur in the majority of individuals with restless legs syndrome, but they may also occur without
the other symptoms of restless legs syndrome.
Situations in which the clinician has concluded that a Dyssomnia is present but is unable to determine
whether it is primary, due to a general medical condition, or substance induced.
of the quality of sleep but of unusual behaviour

during sleep. The following conditions are listed
in the DSM-IV: nightmare disorder, sleep terror
disorder, sleep walking disorder, and parasomnias
not otherwise specied.
Parasomnias
Parasomnias are sleep disorders associated with
abnormal behaviour or physiological events.
These may occur at different phases of sleep.
Characteristically the individuals do not complain
Nightmare disorder
Table 47.7
307.47 Nightmare Disorder (formerly Dream Anxiety Disorder)

A. Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely
frightening dreams, usually involving threats to survival, security, or self-esteem. The awakenings
generally occur during the second half of the sleep period.
B. On awakening from the frightening dreams, the person rapidly becomes oriented and alert (in contrast
to the confusion and disorientation seen in Sleep Terror Disorder and some forms of epilepsy).
C. The dream experience, or the sleep disturbance resulting from the awakening, causes clinically
signicant distress or impairment in social, occupational, or other important areas of functioning.
394
Sleep Disorders
D. The nightmares do not occur exclusively during the course of another mental disorder (e.g., a delirium,
Posttraumatic Stress Disorder) and are not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition.
This was formerly known as Dream Anxiety

Disorder. It is characterised by repeated awakenings
from the major sleep period or naps with detailed
recall of extended and extremely frightening dreams,
usually involving threats to survival, security or
self-esteem. The awakenings generally occur during
the second half of the sleep period. On awakening,
the person becomes rapidly oriented and alert (in
contrast to the confusion and disorientation seen in
sleep terror disorder and some forms of epilepsy).
The dream experience or sleep disturbance resulting
from the awakening, causes clinically signicant
distress or impairment in social, occupational
or other important areas of functioning. Other
mental disorders such as post-traumatic stress
disorder have to be excluded. The disorder should
also not be directly attributed to other medical

conditions or substance use. Characteristically the
awakenings occur during REM sleep as evidenced
by the polysomnography recordings. Associated
physiological changes include increased heart rate,
respiratory rate and increased frequency of eye
movements.
The condition is quite common and is estimated
to occur in 10-50 percent of children aged 3-5
years. About half of the adult population report
occasional nightmares, with females reporting the
disorder twice to four times more often than males.
The differential diagnosis includes sleep terror
disorder, breathing related disorder, narcolepsy,
panic attack and parasomnia disorder not otherwise
specied.
Sleep terror disorder

Table 47.8
307.46 Sleep Terror Disorder
A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the rst third of the major
sleep episode and beginning with a panicky scream.
B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during
each episode.
C. Relative unresponsiveness to efforts of others to comfort the person during the episode.
D. No detailed dream is recalled and there is amnesia for the episode.
E. The episodes cause clinically signicant distress or impairment in social, occupational, or other
The main features include recurrent episodes of

abrupt awakening from sleep, usually occurring
during the rst third of the major sleep episode and
beginning with a panicky scream. Intense fear and
signs of autonomic arousal, such as tachycardia,
rapid breathing and sweating accompany the attack.
Often no dream is clearly recalled and the person is
generally unresponsive to efforts of others to awaken
or comfort him during the episode. On waking
up, the individual is confused and disoriented. In
cases where a dream is recalled, it lacks the clarity
associated with nightmares. The episodes can be

accompanied by sleepwalking. Substance use
(alcohol and sedatives), sleep deprivation, sleepwake schedule disruptions, fatigue, and physical
and emotional stress are predisposing factors. It is
important to note that children with this disorder do
not show increased incidences of psychopathology
or mental disorders compared to the general
population. Adult psychopathology is more likely
to be associated with sleep terror. The common
comorbid disorders include Post Traumatic Stress
395
Disorder, Generalised Anxiety Disorder and

personality disorders such as dependent, schizoid,
and borderline personality disorders.
Polysomnography studies show that sleep terror
starts during deep NREM sleep but as the episode
progresses, theta and alpha activity is seen on the
EEG recordings. These indicate partial arousal.
The differential diagnoses for sleep terror disorder
include nightmare disorder, sleepwalking disorder
and seizure disorder. Sleep terror begins between
4-12 years and resolves spontaneously during
adolescence.
Sleepwalking disorder
In sleepwalking disorder the person has a history of
repeated episodes of rising from bed during sleep
and walking about. This usually occurs during
the rst third of the major sleep episode. During
the episode the person has a blank, staring face,
is relatively unresponsive to the efforts of others
to communicate, and can be awakened only with
great difculty. The person usually does not recall
the event on awakening.
Table 47.9
307.46 Sleepwalking Disorder
A. Repeated episodes of rising from bed during sleep and walking about, usually occurring during the rst
third of the major sleep episode.
B. While sleepwalking, the person has a blank, staring face, is relatively unresponsive to the efforts of
others to communicate with him or her, and can be awakened only with great difculty.
C. On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for
the episode.
D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental
activity or behaviour (although there may initially be a short period of confusion or disorientation).
E. The sleepwalking causes clinically signicant distress or impairment in social, occupational, or other
Parasomnia not otherwise specied

Table 47.10
307.47 Parasomnia Not Otherwise Specied
The Parasomnia Not Otherwise Specied category is for disturbances that are characterised by abnormal
behavioural or physiological events during sleep or sleep-wake transitions, but that do not meet criteria for
a more specic parasomnia. Examples include:
1. REM sleep behaviour disorder: motor activity, often of a violent nature, that arises during rapid
eye movement (REM) sleep. Unlike sleepwalking, these episodes tend to occur later in the night
and are associated with vivid dream recall.
2. Sleep paralysis: an inability to perform voluntary movement during the transition between
wakefulness and sleep. The episodes may occur at sleep onset (hypnagogic) or with awakening
(hypnopompic). The episodes are usually associated with extreme anxiety and, in some cases, fear
of impending death. Sleep paralysis occurs commonly as an ancillary symptom of Narcolepsy and,
in such cases, should not be coded separately.
Situations in which the clinician has concluded that a Parasomnia is present but is unable to determine
whether it is primary, due to a general medical condition, or substance induced.
396
Sleep Disorders
Under this category are the disorders that do not

meet the full criteria of the parasomnias listed
above and also those in which the clinician is unable
to determine whether the disorder is primary, due
to general medical condition or substance induced.
Two examples of parasomnia not otherwise
classied are described below.
can occur at sleep onset (hypnagogic) or while

awakening (hypnopompic).
Sleep disorders related to other psychiatric

conditions
Sleep disorders can occur in a wide range of
psychiatric disorders but they are more prominent
in the following disorders. Often the sleep disorder
could be the main presenting complaint.
Mood disorders
Anxiety disorders
Panic disorder
Post-traumatic stress disorder
Schizophrenia
Eating disorders
Normal and pathological ageing
REM sleep behaviour disorder

In sleep behaviour disorder, violent motor activity
occurs during the REM sleep. Characteristically,
they occur later in the night (in contrast to
sleepwalking) and are associated with vivid dream
recall.
Sleep paralysis
This refers to those situations in which the individual
is unable to perform voluntary movements during
the transition between wakefulness and sleep. It
Table 47.11
307.42 Insomnia Related to ... [Indicate the Axis I or Axis II disorder]

A. The predominant complaint is difculty initiating or maintaining sleep, or non-restorative sleep, for at
least 1 month that is associated with daytime fatigue or impaired daytime functioning.
B. The sleep disturbance (or daytime sequelae) causes clinically signicant distress or impairment in
social, occupational, or other important areas of functioning.
C. The insomnia is judged to be related to another Axis I or Axis II disorder (e.g.. Major Depressive
Disorder, Generalized Anxiety Disorder, Adjustment Disorder With Anxiety) but is sufciently severe
to warrant independent clinical attention.
D. The disturbance is not better accounted for by another Sleep Disorder (e.g.. Narcolepsy, BreathingRelated Sleep Disorder, a Parasomnia).
Table 47.12
307.44 Hypersomnia Related to ... [Indicate the Axis I or Axis II disorder]
A. The predominant complaint is excessive sleepiness for at least 1 month as evidenced by either prolonged
sleep episodes or daytime sleep episodes that occur almost daily.
B. The excessive sleepiness causes clinically signicant distress or impairment in social, occupational, or
C. The hypersomnia is judged to be related to another Axis I or Axis II disorder (e.g.. Major Depressive
Disorder, Dysthymic Disorder) but is sufciently severe to warrant independent clinical attention.
D. The disturbance is not better accounted for by another Sleep Disorder (e.g.. Narcolepsy, BreathingRelated Sleep Disorder, a Parasomnia) or by an inadequate amount of sleep.
The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition.
397
angiotensin-converting enzyme inhibitors
Sleep disorders related to substance use

The following are drugs that may cause sleep
disturbances:
Drugs for treating neurological disorders

anticonvulsants, antiparkinsonian medications
Drugs used to treat general medical disorders
Drugs used to treat psychiatric disorders
antihistamines
analgesics
antiemetics
beta blockers
bronchodilators
theophylline
appetite suppressants
sleeping pills
Antidepressants, neuroleptics
Miscellaneous agents (drugs of abuse and
alcohol)
Nicotine, Amphetamines, cocaine, LSD,
mescaline, marijuana, ethanol Opiates Sedativehypnotic drugs Stimulants
Table 47.13
Substance-Induced Sleep Disorder
A. A prominent disturbance in sleep that is sufciently severe to warrant independent clinical attention.
(1) the symptoms in Criterion A developed during, or within a month of Substance Intoxication or
Withdrawal
(2) medication use is etiologically related to the sleep disturbance
C. The disturbance is not better accounted for by a Sleep Disorder that is not substance induced. Evidence
that the symptoms are better accounted for by a Sleep Disorder that is not substance induced might
include the following: the symptoms precede the onset of the substance use (or medication use); the
symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute
withdrawal or severe intoxication or are substantially in excess of what would be expected given the
type or amount of the substance used or the duration of use; or there is other evidence that suggests the
existence of an independent non-substance-induced Sleep Disorder (e.g., a history of recurrent nonsubstance-related episodes).
E. The sleep disturbance causes clinically signicant distress or impairment in social, occupational, or
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal
only when the sleep symptoms are in excess of those usually associated with the intoxication or withdrawal
syndrome and when the symptoms are sufciently severe to warrant independent clinical attention.
Specify type:
Insomnia Type: if the predominant sleep disturbance is insomnia
Hypersomnia Type: if the predominant sleep disturbance is hypersomnia
Parasomnia Type: if the predominant sleep disturbance is a Parasomnia
Mixed Type: if more than one sleep disturbance is present and none predominates
Specify if:
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms
develop during the intoxication syndrome
398
Sleep Disorders
Over-the-counter medications
Nasal decongestants,
sleeping pills
anorectics,
caffeine,
Sleep disorders related to other medical

conditions
Sleep disturbance including sleep-wake disturbance
occur in a wide range of medical disorders. Some
of these are listed below.
Neurodegenerative disorders
Alzheimers disease
Parkinsons disease
Progressive supranuclear palsy
Huntingtons disease
Torsion Dystonia
Spinocerebellar ataxias
Degenerative diseases of motor neurones
Multiple sclerosis
Traumatic brain injuries
Fatal familial insomnia
Idiopathic recurrent stupor
Stroke and sleep-wake disturbance
Sleep and epilepsy
Neuromuscular disorders
Sleep and headache syndromes

Cardiovascular disease
Acute myocardial infarction
Congestive cardiac failure
Systemic hypertension
Respiratory diseases
Bronchial asthma
Chronic obstructive pulmonary disease
Gastrointestinal diseases
Peptic ulcer
Reux oesophagitis
Endocrine diseases
Myxoedema
Diabetes mellitus
Acromegaly
Chronic renal failure
Fibromyalgia syndrome
Paroxysmal nocturnal haemoglobinuria
Sickle cell disease
Dermatological disorders
AIDS
Multiple system atrophy (Shy-Drager syndrome)
Table 47.14
780.XX Sleep Disorder Due to ... [Indicate the General Medical Condition]
A. A prominent disturbance in sleep that is sufciently severe to warrant independent clinical attention.
B. There is evidence from the history, physical examination, or laboratory ndings that the sleep disturbance
is the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (e.g., an Adjustment Disorder in
which the stressor is a serious medical illness).
E. The disturbance does not meet the criteria for Breathing-Related Sleep Disorder or Narcolepsy.
F. The sleep disturbance causes clinically signicant distress or impairment in social, occupational, or
Specify type:
.52 Insomnia Type: if the predominant sleep disturbance is insomnia
.54 Hypersomnia Type: if the predominant sleep disturbance is hypersomnia
.59 Parasomnia Type: if the predominant sleep disturbance is a Parasomnia
.59 Mixed Type: if more than one sleep disturbance is present and none predominates
Coding note: Include the name of the general medical condition on Axis I, e.g., Sleep Disorder Due to
Chronic Obstructive Pulmonary Disease, Insomnia Type; also code the general medical condition on Axis
III.
399
Comfortable bed and quiet environment for

sleep
Regular exercise, timing and tness
Stable and appropriate diet; avoiding large
meals near bedtime
Dene individual sleep requirements
Establish parameters for bedtime period
(threshold time and rising time)
Eliminate daytime napping
Differentiate rest from sleep
Schedule sleep periods with respect to needs
Establish 7 day per week compliance
Remove incompatible activity from bedroom
environment
Rise from bed if wakeful (>20min)
Avoid recovery sleep as compensation
Establish stability from night to night
Adjust the sleep period as sleep efciency
improves
DETECTION AND ASSESSMENT

OF SLEEP DISTURBANCE
Sleep history
Sleep diary
Past medical and psychiatric history including
treatment
Review of systems
Physical and mental examination: check for
systemic illness cardiorespiratory, neurological
for example, Parkinsons disease
Video and actigraphy (wrist-watch like devices)
can be used to monitor the patient at home
Polysomnography:
physiological
studies
to record EEG, electrooculogram and
electromyogram allows a hypnogram to be
compiled for further studies
Other tests: daytime sleepiness, Multiple
latency tests: a latency time of 5 minutes or less
is pathological in adults.
HLA typing for the investigation of narcolepsy
Nocturnal penile tumescence for diagnosing
psychogenic impotence
Psychomotor tests for children
Specic measures
Behavioural treatment (mainly for insomnia
or childhood sleeplessness)
o Positive associations
o Modication of inappropriate behaviour
o Sleep consolidation
Chronological (for circadian sleep-wake
rhythm disorders)
o Sleep phase rescheduling
o Light therapy
Medications
o Hypnotics: should be used selectively and
for short term only. They may be used in
insomnia and nightmares.
o Stimulants such as methlphenidate and
amphtamines are indicated in cases of
excessive sleepiness such as hypersomnia
and narcolepsy.
o Melatonin can be used in some circadian
rhythm disorders
Physical measures
o Continuous positive airway pressure in
obstructive sleep apnoea (OSA)
Surgery
o Adenotonsillectomy
or
Uvulopalatopharygoplasty (in some cases of
OSA)
TREATMENT AND
MANAGEMENT
General principles
Explain the problem, reassure where appropriate,
encourage good sleep hygiene and provide support
as necessary. Where possible, treat any underlying
condition (medical or psychiatric) causing the sleep
disturbance. Safety or protective measures should
be put in place in cases of dangerous parasomnias.
Education and measures to improve the sleep
hygiene may involve explaining the following:
The need for sleep and its functions
Sleep patterns across the lifespan
Sleep as a process with stages/phases
Factors adversely affecting sleep
The effects of sleep loss
Undesirable effects of caffeine and other
stimulants
Moderation of alcohol consumption
Use of the bedroom for sleeping only
400
Sleep Disorders
Further reading
Edition 1994: DSM-IVTM Published by American
401
402
Section V:
Child and Adolescent

Psychiatry
403
48
Child Psychiatry: An Overview
Christopher P. Szabo
from risk and pathology. A multi-dimensional

perspective that borrows from paediatrics,
developmental psychology, speech and language
therapy, occupational therapy, physical therapy,
and other disciplines is essential to effectively work
with children, who are able to provide only limited
behavioural and verbal clues to help the medical
worker understand complex, mutually inuencing
aetiological factors. In addition, a relationship
perspective is essential to understand the power
of relationships both in the childs development
and in collaborative assessment, intervention,
and treatment planning with the parents. Multiple
assessments over time often are needed, because
children change rapidly in response to internal and
external stressors.
Epidemiological studies from developed countries

indicate that 14 to 20 percent of children have one
or more psychiatric disorders in the moderate to
severe range and the overall prevalence is rising.
Community studies have shown a range of 7-14
percent. Data, although limited, from the developing
countries also suggests a roughly similar picture.
PSYCHIATRIC ASSESSMENT OF
CHILDREN
Psychiatric assessment and intervention with
children is a unied process oriented towards
prevention. Childhood is a time of rapid change
that lays the foundation for future development.
The health workers primary effort is aimed at
facilitating the childs rapid change towards
healthy development and strengthening parental
and extended environmental support systems.
Parents are primary in the treatment team,
because children are maximally dependent on
them. Facilitation of change, therefore, must
be accomplished primarily through the parents.
Children must therefore be understood, evaluated,
and treated in the context of the family or primary
care giving unit and within additional signicant
contexts, including relationships with other
important caregivers and extended family, school,
day-care centre, and the larger culture.
In assessing children, a developmental
perspective is essential to differentiate normality
The family or child interview

Psychiatric assessment of children requires
gathering data from those who are most familiar
with the childs current and past functioning,
including the child and parents or other primary
caregivers. The assessment format may vary, but
should always be responsive to the needs of the
family.
History-taking and documenting
The index childs identication data:
Reason for referral.
Presenting problems or parents concerns.
The parents' account of the child's presenting
difculties and their expectations of how
404
the childs capacity for and interest in interpersonal

relatedness are assessed in the context of interactive
play.
the health worker may help are of primary

importance. Explore the parents' concerns,
including the child's current difculties, and
the impact of the child's symptoms on each
parent, the couple, and the family as a whole.
Obtain a history of the child's past and current
development in the family context. Gather a
history of the parents' childhood experiences
and assess the degree to which these contribute
to their view of the child's present behaviour.
Obtain a picture of the biopsychosocial
functioning of the parents and family within
their home, community, and wider culture.
Gather data on familial, medical and
psychiatric disorders that may be of genetic or
environmental signicance for the aetiology
or treatment of the child's difculties.
Observe the parents with their child during
free play and structured activity.
Obtain a detailed history of all developmental
aspects pertaining to the biological, cognitive,
temperamental, and socio-emotional life of the
child, with special focus on early concerns that
may relate to the presenting concerns. Areas
covered should include the child's physical,
cognitive, and emotional development;
early behavioural organisation; the degree
of individuation; unique strengths and
vulnerabilities; and the response to previous
stressors.
Child mental status exam

Appearance
Size, level of nourishment, dress and hygiene,
apparent maturity compared with age, dysmorphic
features (abnormal head size, eye or ear shape) and
cutaneous lesions
Apparent reaction to the situation
Initial reaction to setting and to strangers:
explores, freezes, cries, hides face, curious,
excited, apathetic or anxious.
Adaptation: when and how the child begins
exploring faces, toys and strangers.
Reaction to transitions: from unstructured
to structured activity, when examiner begins
to play with infant, cleaning up and when
leaving.
Self regulation
State regulation: an infants state of
consciousness ranges from deep sleep through
alert stages to intense crying. Predominant
state and range of states observed during
session; patterns of transition, e.g. smooth
versus abrupt; capacity for being soothed
and self-soothing; and capacity for quiet alert
state.
Sensory regulation: reaction to sounds, sights,
smells and light or rm touch.
Hyper-responsiveness or hypo-responsiveness
and type of response. They include apathy,
withdrawal,
avoidance,
fearfulness,
excitability, aggression or marked behavioural
change and excessive seeking of particular
sensory input.
Unusual behaviour:
o Mouthing after 1 year of age
o Head banging
o Smelling objects
o Spinning, twirling, hand-apping, ngericking, rocking, toe-walking
o Staring at lights or spinning objects
o Repetitive, preservative, or bizarre
verbalisations or behaviours with objects
or people
o Hair-pulling, ruminating or breathholding.
Clinical observation
The systematic observation of children is a critical
source of information for diagnosis and treatment
planning. It should encompass individual and
interactional behaviours as well as the emotional
and developmental functioning of the child.
Observation of the child interacting with the parents,
with a focus on the quality of the parent-child
behavioural and affective interactions, is central
to the assessment process. Initial observations are
usually obtained during history-taking with the
family.
An interactive play setting is necessary. At least
15 to 20 minutes of family play observation is
needed. Unstructured parent-child or family play
provides optimal opportunity for interactional
observation.
A variety of other approaches, including
structured activities and the childs response to
brief parental separation and reunion, may also be
useful, depending on the childs developmental
age and nature of the problem. The parents and
405
Activity level
Speech and language
Overall level and variability: describe

behaviour, e.g. squirming constantly in parent's
arms, sitting quietly on oor or in infant seat,
constantly on the go, climbing on desks and
cabinets, exploring the room, pausing to play
with each of six to eight toys.
Attention span: capacity to maintain
attentiveness. Longest and average length of
sustained attention to a given toy or activity.
Distractibility: with regard to infants, visual
xing and following at 1 month, tracking at 2
to 3 months, attention to own hands or feet and
faces, duration of exploration of object with
hands or mouth.
Vocalisation and speech production

Quality, rate, rhythm, articulation and volume.
Receptive language
Comprehension of others speech as seen in verbal
or behavioural response, e.g. follows commands,
points in response to where is questions;
understands prepositions and pronouns (include
estimate of hearing, especially in child with
language delay, e.g. response to loud sounds and
voice; ability to localise sound).
Expressive language
Level of complexity, e.g. vocalisation, jargon,
number of single words, short phrases and full
sentences.
Over-generalisation, e.g. uses kitty to refer
to all animals.
Pronoun use, including reversal.
Echolalia, either immediate or delayed.
Unusual or bizarre verbalisations.
Pre-verbal children: communicative intent, e.g.
vocalisations, babbling, imitation, gestures,
such as head shaking and pointing; caregiver's
ability to understand infant's communication;
and child's effectiveness in communication.
Frustration tolerance
Ability to persist in a difcult task despite failure.
Capacity to delay reaction if easily frustrated,
e.g. aggression, crying, tantrums, withdrawal and
avoidance.
Aggression
Modes of expression, degree of control, or
preoccupation with aggression and appropriate
assertiveness.
Motor
Muscle tone and strength, mobility in different
positions, unusual motor pattern, e.g. tics, seizure
activity; intactness of cranial nerves, e.g. movement
of face, mouth, tongue, and eyes, including feeding,
swallowing, and gazing (note excessive drooling).
Thought
The usual categories for thought disorder almost
never apply to young children. Primary process
thinking, as evidenced in verbalisations or play, is
expected in this age group. The line between fantasy
and reality is often blurred. Bizarre ideation;
perseverance; apparent loose associations; and
the persistence of pronoun reversals, jargon, and
echolalia in an older toddler or preschooler may
be noted in a variety of psychiatric disorders,
including pervasive developmental disorders.
Gross motor co-ordination

Infants: pushing up, head control, rolling,
sitting and standing.
Toddlers: walking, running, jumping, climbing,
hopping, kicking, throwing and catching a ball
(it is useful to have something for the child to
climb on, such as a chair).
Specic fears
Fine motor co-ordination
Feared object and worry about being lost or

separated from parent.
Dreams and nightmares.
Content is sometimes obtainable in children
aged 2 to 3 years. The child does not always
perceive it as a dream, e.g. "a monster came in
the front door".
Infants: grasping and releasing, transferring

from hand to hand, using pincer grasp, banging
and throwing.
Toddlers: using pincer grasp, stacking,
scribbling and cutting. Both ne motor and
visual-motor co-ordination can be screened
by observing how the child handles puzzles,
shape boxes, a ball and hammer toy, small cars
and toys with connecting parts.
Dissociative state
Sudden episodes
inattention.
406
of
withdrawal
and
Eyes glazed; "tuned out".

Failure to track ongoing social interaction.
Dissociative state may be difcult to
differentiate from an abscence seizure,
depression, autism or deafness. The context
may be helpful, e.g. child with a history of
neglect freezes in a dissociative state as mother
leaves room.
Neurologic or audiologic evaluation may be
warranted.
Structure of play (ages approximate)

Sensorimotor play
0-12 months: mouthing, banging, dropping
and throwing toys or other objects.
6-12 months: exploring characteristics of
objects, e.g. moving parts, poking, pulling.
Functional play
12-18 months: childs use of objects shows
understanding and exploration of their use or
function, e.g. pushes car, touches comb to hair and
puts telephone to ear.
Affect and mood

The assessment of mood and affect may be more
difcult in young children, because of limited
language, lack of vocabulary for emotions, and
use of withdrawal in response to a variety of
emotions from shyness and boredom to anxiety
and depression.
Early symbolic play

18 months and older: child pretends with increasing
complexity; pretends with own body to eat or
sleep; pretends with objects or other people, e.g.
feeds mother; child uses one object to represent
another, e.g. a block becomes a car; child pretends
a sequence of activities, e.g. cooking and eating.
Modes of expression
Facial, verbal, body tone and positioning.
Range of expressed emotions: affect, especially
in parent-child relationship.
Responsiveness: to situation, content of discussion, play and interpersonal engagement.
Duration of emotional state: need history or
multiple observations.
Intensity of expressed emotions: affect, especially in parent-child relationship.
Complex symbolic play

30 months and older: child plans and acts out
dramatic play sequences and uses imaginary
objects. Later, child incorporates others into
play with assigned roles.
Imitation, turn-taking and problem-solving as
part of play.
Content of play
The childs choice and use of toys often reect
emotional themes. It is desirable to have on
hand toys that tap different developmental and
emotional domains. An overfull playroom may be
overwhelming or over-stimulating, and reduces
meaningful observations. Young toddlers of both
sexes often gravitate to dolls, dishes, animals, and
moving toys, e.g. cars. The examiners choice of
specic materials may facilitate the expression of
pertinent emotional themes. A child traumatised
by a dog bite may more likely re-enact the trauma
if a dog and doll gures are available. The childs
reaction to scary toys, such as sharks, dinosaurs,
or guns, should be noted, especially if they are
avoided or dominate the session. Does aggressive
pretend play become real and physically hurtful?
By age 2 to 3 years, a childs animal or doll play
can reveal important themes about family life,
including reactions to separation, parent-child
and sibling relationships, experiences at day care,
quality of nurturance and discipline, and physical
or sexual abuse. The examiner must use caution
Abnormal perception
Hallucinations are extremely rare, except in the
context of a toxic or organic disorder, then usually
visual or tactile.
Play
In young children, play is especially useful in the
evaluation of the childs cognitive and symbolic
functioning, relatedness, and expression of
affect. Themes of play are helpful in assessing
older toddlers. The management and expression
of aggression are assessed in play as in other areas
of behaviour. Play may be with toys or childs own
or anothers body, e.g. peek-a-boo, rough housing;
verbal, e.g. sound imitation games between mother
and infant; interactional or solitary. It is important
to note how the childs play varies with different
familiar caregivers and with parents versus the
examiner.
407
Attachment behaviours
in interpreting play, viewing it as a possible

combination of re-enactment, fears and fantasy.
Observe for showing affection, comfortseeking, asking for and accepting help, cooperating, exploring, controlling behaviour
and reunion responses.
Describe age-related disturbances in these
normative behaviours. Disturbances often
are seen in abused and neglected children,
e.g. fearfulness, clinginess, over-compliance,
hyper-vigilance, impulsive over-activity,
and deance; restricted or hyperactive
and distractible exploratory behaviour and
restricted or indiscriminate affection and
comfort-seeking.
Cognition
Using information from all the areas, especially
play, verbal and symbolic functioning, and
problem-solving, roughly assess childs cognitive
level in terms of developmental intactness, delays,
or precocity.
Relatedness
To parents
How "in tune" is the child and parent seem?
Does the child make and maintain eye, verbal
or physical contact?
Is there active avoidance by the child? Note
infant's level of comfort and relaxation being
held, fed, "moulding" into caregiver's body.
Does the child move away from caregiver and
check back or bring toys to show, to put into
his or her lap, to play with together or near the
caregiver?
Comment on physical or verbal affection,
hostility, reaction to separation and reunion,
and use of transitional objects (blanket, toy,
caregiver's possession).
Describe differences in relating if more than
one caregiver is present.
INTERDISCIPLINARY
ASSESSMENT AND REFERRAL
Given the interaction between the individual,
family, larger environment, and risk and protective
factors that may contribute to the presenting
concerns, inter-disciplinary assessment is
recommended.
The adjunctive assessments may include
assessments in other settings (home, child care
agency or school) and by other disciplines,
including paediatrics, developmental paediatrics,
psychology, neurology, genetics, nutrition,
ophthalmology, audiology, speech and language
therapy, occupational therapy, physical therapy,
and social and educational services.
To examiner
Young children normally show some hesitancy
to engage with a stranger, especially after 6 to 8
months of age. Appropriate wariness in young
children may result in a period of watching the
examiner; staying physically close to a familiar
caregiver before engaging; or showing some
constriction of affect, vocalisation or play.
After initial wariness, does the child relate?
Does the child engage too soon or not at all?
How does relatedness with a stranger compare
to that with a parent?
Is the child friendly versus indiscriminately
attention-seeking, guarded versus overanxious?
Can examiner engage the child in play or
structured activities to a degree not seen with
caregiver?
Does the child show pleasure in successes if
the examiner shows approval?
DIAGNOSTIC FORMULATION
The diagnostic formulation represents the synthesis
of the biopsychosocial and cultural inuences that
contribute to, maintain or ameliorate the infants
or toddlers difculties. When answers to these
questions are provisional, a differential diagnosis
provides a decision tree by which diagnosis and
treatment options may be claried over time.
Diagnostic classication schemes include the
International Classication of Diseases, (ICD) and
the Diagnostic and Statistical Manual of Mental
Disorders (DSM).
The diagnostic formulation expands categorical
diagnosis by identifying, to the fullest extent
possible, the predisposing factors and current
precipitants of the infants difculties. The
408
and extended environmental context. Further

assessments, treatment referrals, and communication
of ndings to outside sources should be discussed
as part of the treatment planning process. Sharing
the ndings with other providers, including
paediatricians, schools, social service personnel, or
parents mental health providers, helps co-ordinate
the complex environmental support system children
need. Early multimodal interventions for child
psychiatric disorders, taking advantage of the great
potential for intervention gains of the childhood
developmental period, alleviate both primary and
secondary developmental complications.
Child psychopathology outcome will depend
on whether the childs psychiatric morbidity is
amplied or contained by individual, family, and
school, cultural and therapeutic forces.
formulation and recommendation processes evolve

collaboratively with the family as a continuation of
the assessment process.
TREATMENT PLANNING
On the basis of the ndings, diagnostic
formulation, and available resources, treatment
recommendations are developed with the family.
The resources available to a family, as well as
the unique combination of individual and family
capacities for learning and change, are considered.
The discussion with the parents, reviews
the complexity of the assessment process,
including the inter-disciplinary, developmental,
and multi-generational elements. The childs
attachment temperament; and social, emotional,
cognitive, physical and language development are
characterised. Relative strengths and weaknesses
are claried. Risk factors, protective factors, sociocultural experience, and biological factors are
components of the discussion.
An individualised treatment plan is designed
to capitalise on the strengths of the child, parents,
Further reading
Textbook Edited by Melvin Lewis. (2002). Published
by Lippincott Williams and Wilkins.
409
49
Adolescent Psychiatry: An Overview
Christopher P. Szabo
INTRODUCTION
THE ADOLESCENT
ASSESSMENT
The denition of adolescence varies. Some use

a purely age-driven denition, e.g. between 12
and 18 years of age. Alternatively, it is dened
as the period between childhood and adulthood.
However, it has been recognised that adolescence
has various stages, i.e. early, middle and late. Each
stage is characterised by variations in levels of both
physical and psychological maturity, as well as the
extent to which developmental tasks associated
with this developmental phase have been achieved.
Maturity develops with increasing self-awareness,
emerging self-esteem and emotional sophistication,
where the adolescent can experience, describe and
understand emotions. Developmental tasks include
separation from caregivers, a clearer sense of
sexual identity, the dening of value systems and
concerns for career and the future.
The DSM-IV-TR does not have adolescentspecic diagnoses. It does, however, speak of
disorders usually rst diagnosed in infancy,
childhood or adolescence. A range of conditions,
e.g. schizophrenia may initially present at this time,
and conditions typical of childhood, e.g. attention
decit hyperactivity disorder may not present for
clinical attention until adulthood.
The assessment process needs to take a number

of variables into account. These might inuence
the outcome, not just of the initial and subsequent
interviews, but also the problem for which help is
being sought. Each one of these variables will be
addressed individually.
The patient
The adolescents are constantly evolving as they
move through this developmental stage. As a
consequence they might report and vary clinically
on different occasions. This should not necessarily
be viewed as inconsistency on their part, but
as a function of an evolving disease process. In
addition, levels of self-awareness may inuence
reporting. The mode of referral may impact on how
adolescents present. If they are brought unwillingly
they may be reluctant to disclose information.
Further, sensitivity to what others might think
of them may inhibit critical components of
establishing a meaningful therapeutic relationship,
involve overcoming resistance and promoting
trust. An awareness and understanding of possible
barriers is helpful.
410
Adolescent Psychiatry: An Overview
or war). The consequence of poverty may see

adolescents placed in situations where what would
be regarded as criminal activity, e.g. theft, become
matters of survival or where due to poverty,
educational advancement is devalued. Divorce and
the break-up of the home have led to increasing
numbers of single parent families; HIV/AIDS has
seen increasing numbers of orphans. The reality
of substance abuse has increased, together with all
the consequences. Due to a societal shift towards
age constrained social interaction, adolescents
spend less time with older people and are thus
more vulnerable to potentially inappropriate
peer inuences. Finally, the power of the media
cannot be underestimated. Awareness of trends is
necessary. All of these factors need to be borne in
mind as a context to the assessment process.
The interviewer
The interviewer plays an important role in
the process, not simply by virtue of gathering
information, but also on how they conduct themselves during the process. A need for consistency
in terms of statements made and attitudes towards
issues is important. Adolescents are sensitive to
inconsistencies, which may compromise trust.
Therefore, the clinician must be clear in terms of
their own belief systems. One may readily overidentify, e.g., see the fact that one consumed alcohol
on occasion as an adolescent without experiencing
problems as reason to sanction such behaviour.
Counter identication in the same scenario may
see the clinician vehemently antagonistic to such
behaviour, because they never had a drop of alcohol,
when in fact this is not actually a problem for the
patient. In either situation, appropriate action may
not be taken. This may undermine intervention by
affecting the relationship.
PRESENTATIONS IN
ADOLESCENT PSYCHIATRY
The family
This is a time where peer relations become
increasingly important. Families may be threatened
by this inuence, specically by the adolescent
functioning more independently outside of the
family inuence. Thus, families may view normal
behaviour as problematic. Hence, it is always
critical to see the family not only to establish their
understanding of problems, but also to assess
the consistency of relating the situation between
parents, as well as obtain the individual history
of each parent. Similar to the interviewer, parents
may over- or counter-identify with the adolescents
behaviour.
Middlescence is a parallel process-taking place
in adults that involves redening their place in the
world, separation from their own parents (possibly
due to death) and a waning rather than emerging
sexuality. This process may diminish parental
involvement in the lives of their adolescents due to
preoccupation with their own issues. Parents tend
to focus on behaviour whereas the patient might
focus more on emotions. It is important that the
clinician not try to be the better parent as objectivity
is critical.
Main groups
Culture
Anxiety disorders
The adolescent is sensitive to the environment,

more so because they begin to operate increasingly
outside of the home. A range of environmental
factors can shape behaviour. Increasingly, families
are moving for reasons of economic benet or
as a consequence of conict (either in the home
Adult anxiety disorders do occur.
The prevalence tends to vary as a function of criteria

used to diagnose the population studied. There is
no increase in adolescent psychopathology over
time, although epidemiological data is variable.
Overall, it seems that anything up to 20 percent of
adolescents may require some form of intervention
as a consequence of emotional disturbance. Such
presentations can generally be classied according
to the 3 groups: denite psychiatric disorders,
disturbances of mood or behaviour inuenced by
family or social factors and transient reactions to
circumstances. Within the context of DSM, the
latter two categories would be classied as V-codes
and Adjustment Disorders, respectively.
Denite psychiatric disorders

(predominant groups)
Psychotic disorders and other psychotic
presentations
Schizophrenia, bipolar disorder or organic e.g.
seizure disorders
Mood disorders
Major depression: whilst it is a recognised
entity, we need to be aware of over-diagnosing
to avoid under-recognising.
411
Sex ratio: the female preponderance noted in

adulthood begins to emerge in adolescence
with females presenting more frequently than
males.
Suicide: this is a concern and the risk must be
assessed.
Diagnosis is often problematic due to the absence
of a longitudinal pattern. Sufce it to say that socalled adult conditions begin to manifest during
adolescence. Making a denitive diagnosis for
individuals presenting clinically with psychosis
can be difcult and medical conditions should
always form part of the differential diagnosis.
Whilst bipolar disorder may present with psychosis
(especially in the manic state) this condition is
classied as a mood disorder. A specic concern
exists in terms of suicide, the prediction of which
is problematic. However, it is important that a risk
assessment for each patient is undertaken. This
constitutes a lecture in itself. The concern for over
usage of antidepressants in this age group does
call for a review of the meaning of depressive
symptoms. In this regard, consideration of the
context of these symptoms might suggest that the
psychosocial interventions are more appropriate as
rst line approaches to treatment.
Management
As with all psychiatric conditions, a biopsychosocial
approach is mandatory if one is to deliver holistic
treatment. In light of the powerful role context plays
in mediating clinical presentation in adolescents,
very often psycho-social approaches are more
appropriate rst line interventions.
The aim has been to give a broad overview of
adolescent psychiatry. Each component is part of
the framework, which allows for a comprehensive
assessment to take place. This has obvious
implications for management and outcome.
Further reading
Textbook Edited by Melvin Lewis. (2002). Published
by Lippincott Williams & Wilkins.
Edition (2000). DSM-IV-TRTM Published by American
3. American Psychiatric Association. Practice Guidelines
for the Treatment of Eating Disorders, second edition.
(2000). In Practice Guidelines for the Treatment
of Psychiatric Disorders. Washington: American
4. Garner DM, Garnkel PE (eds). Handbook of
Treatment for Eating Disorders, Second Edition.
New York: The Guildford Press, 1997. Kaplan HI,
Sadock BJ (eds). Synopsis of Psychiatry, 8th edition.
Philadelphia: Lippincott, Williams & Wilkins.
412
50
Mental Retardation
Thaddeus P. M. Ulzen, David M. Ndetei, Christopher P. Szabo
In the 16th Century, the English Courts of

Wards and Liveries differentiated idiots from
lunatics. Krapelins initial diagnostic scheme
also differentiated mental retardation (MR)
from psychiatric illness. In the 19th Century, the
recognition that mental retardation and mental
illness could coexist was recorded in the American
Journal of Insanity as Imbecility with Insanity.
There has been some confusion in the terminology
and classication of psychiatric disorders related

to that of the intelligence. Terms such as mental
sub-normality, MR, mental handicap, mental
deciency, feeble-mindedness and aligophrenia
have been used almost interchangeably. The term
MR is now widely accepted.
DSM-IV-TR diagnosis for mental retardation is
Table 50.1
Note: This is coded on Axis II.
Mental Retardation
A. Signicantly subaverage intellectual functioning: an IQ of approximately 70 or below on an
individually administered IQ test (for infants, a clinical judgment of signicantly subaverage intellectual
functioning).
B. Concurrent decits or impairments in present adaptive functioning (i.e., the persons effectiveness in
meeting the standards expected for his or her age by his or her cultural group) in at least two of the
following areas: communication, self-care, home living, social/interpersonal skills, use of community
resources, self-direction, functional academic skills, work, leisure, health and safety.
C. The onset is before age 18 years.
Code based on degree of severity reecting level of intellectual impairment:
317 Mild Mental Retardation: IQ level 50-55 to approximately 70
318.0 Moderate Mental Retardation: IQ level 35-40 to 50-55
318.1 Severe Mental Retardation: IQ level 20-25 to 35-40
318.2 Profound Mental Retardation: IQ level below 20 or 25
319 Mental Retardation, Severity Unspecied, when there is a strong presumption of Mental Retardation
but the persons intelligence is untestable by standard tests (e.g., for individuals too impaired or uncooperative,
or with infants).
413
DEFINITIONS
Mental retardation is a standardised IQ score of
at least two standard deviations below the mean
and impairment in at least two out of eleven
areas of adaptive functioning when compared
to peers of the same age and culture. The World
Health Organisations denition of MR stresses
two essential components, both of which should
be present before a person can be considered as

mentally retarded. These are:
Intellectual functioning that is signicantly
below average.
Marked impairment in the ability of the
individual to adapt to the daily demands of the
social environment
Intelligence is the ability to learn from experience
to solve problems, to adapt to the demands of the
social environment and form abstract concept.
145
CLASSIFICATION OF MR
Mild MR (IQ 55-70), 85%.

Moderate MR (IQ 40-55), 10%.
Severe MR (IQ 25-40), 3-4%.
Profound MR (IQ < 25), 1-2%.
EPIDEMIOLOGY
The prevalence of MR is between 1-3 percent
depending on criteria used. Male:female ratio is
1.5:1. Non-biologic or socio-cultural MR is
common in lower socio-economic groups.
AETIOLOGY
Mental retardation has diverse origins with over
350 known causes. Over 40 percent of cases have
no known aetiology. The common chromosomal
causes account for about 30 percent of identied
cases.
COMMON CHROMOSOMAL
CAUSES OF MENTAL
RETARDATION
Downs syndrome
Fragile X syndrome
Foetal alcohol syndrome
PATHO-BEHAVIOURAL
SYNDROMES
Downs syndrome (trisomy 21): Alzheimers
dementia after age 40 and depression are
commonly present.
Fragile X syndrome (q 27, long arm of X
chromosome): attention decit/hyperactivity
disorder (ADHD) is present in up to 80 percent
of patients.
Prader-Willi syndrome (Chromosome 15
deletion): obesity and hyperphagia are
common problems.
Williams
syndrome
(chromosome
7
deletion): supravalvular aortic stenosis
and hypertension.
Infancy/childhood: CNS infections, head

trauma, neurological disease, brain tumour,
hypothyroidism, radiation, lead intoxication,
asphyxia and severe malnutrition.
Socio-cultural adversity: includes parental
factors, like low IQ, lack of psychosocial
stimulation, child abuse and neglect.
EVALUATION
Mental retardation is established by standardised
psychological tests. Cultural biases of such
instruments must be accounted for in reaching
conclusions about individuals examined.
A history of adaptive functioning is often available
from caregivers and others. A thorough physical
examination should rule out physical impairments,
such as hearing and visual impairments.
OTHER BIOLOGICAL RISK

FACTORS FOR MR
Prenatal: maternal illness (toxaemia, diabetes);
maternal infections, e.g. toxoplasmosis, rubella,
CMV, herpes simplex, HIV, syphilis; drugs;
brain malformations; maternal malnutrition;
intrauterine growth retardation.
Perinatal: extreme prematurity, blood
group incompatibility, brain trauma and
cerebrovascular accidents.
Deafness
Cerebral palsy
Traumatic brain injury
Specic learning disabilities
Communication disorders
Borderline intellectual functioning
Pervasive developmental disorders.
Figure 50.2: Mentally retarded children can be educated
TREATMENT CONSIDERATIONS
COMMON PRESENTING
SYMPTOMATOLOGY IN MR
PATIENTS
Interventions directed at improving adaptive

functioning are applied in schools and
vocational settings and at home.
Co-morbid psychiatric disorders such as major
depression, bipolar disorder, anxiety and
schizophrenia are often missed and should be
a central focus of treatment.
Lack of speech makes careful history taking
from caregivers essential in addition to
observed mental status phenomena by the
examining physician.
Frequently physical or medical conditions in
the MR rst present as behavioural change.
Treatment should be multimodal including
medical, psychiatric, parental, educational and
behavioural interventions. This should always
include long-term planning.
These are aggression, self-injurious behaviour,

stereotype, copraxia, pica and rumination.
RELATIONSHIP BETWEEN
MENTAL ILLNESS AND MR
It is now recognised that patients with MR have
a higher prevalence of psychiatric illness than the
general population. The prevalence of psychiatric
disorders is 4 to 6 times that of the general
population.
AETIOLOGY OF
PSYCHOPATHOLOGY IN MR
PATIENTS

It is important to recognise that MR need not be
a life-long problem. There are many reversible
causes and many preventive measures can be
activated to affect outcome positively. Accurate
and early diagnosis will aid in a better long-term
prognosis for many patients identied.
Damage to the cortical and subcortical substrate of

the brain which is inherent in MR confers a special
vulnerability to psychiatric conditions. Decreased
ability to cope with the complex demands of
society and inadequate cognitive capacity to
resolve emotional conicts lead to increased risk
of psychiatric disorders.
Poor professional attention leads to unrecognised
psychiatric problems which become complicated.
Further reading
1. Akins, K. (1974). Mental Subnormality in Handbook
of Psychiatry editors Solomon, P. and Patch V.D. page
554-573 Large Medical Publication, Los Altes Cal.
2. American Psychiatry Association Diagnostic and
Statistical Manual of Mental Disorders 3rd. edition.
(DSM III) 1980 Washington, DC. A.P.A.
3. Mental Retardation Prevention Amelioration
and Service Delivery by the Joint Commission on
International Aspects of Mental Retardation (1980)
A report commissioned by WHO Joint Commission
ILSMH, Brussels, Belgium.
4. World Health Organisation, (1992). ICD-10
Classication of Mental and Behavioural Disorders
Geneva WHO.
5. World Health Organisation, (1992). Assessment of
People with Mental Retardation WHO, Geneva.
ROLE OF THE PRIMARY

PHYSICIAN
The family physician or general practitioner is
the rst professional likely to be consulted about
a child developing slower than expected. It is
important not to adopt a wait and see approach
or to tell parents that their child is likely to catch
up. The sooner the parents are appraised of the
extent of the childs decit, the sooner they can
be supported in dealing with the disappointment,
loss and grief. A realistic appraisal of the childs
prospects, which are not uniformly poor can then
assist in long term treatment planning.
416
51
Pervasive Developmental Disorders
Christopher P. Szabo, Rachel Kangethe
appropriate to developmental level; lack of

spontaneous seeking to share enjoyment, interests,
or achievements with other people; and lack of
social or emotional reciprocity.
Pervasive developmental disorders are conditions

that become apparent early in a childs life, affecting
major developmental systems (social, cognitive,
and language). These disorders include:
Autistic disorder
Aspergers disorder
Childhood disintegrative disorder
Retts disorder
Qualitative impairments in communication

These include delay in, or total lack of development
of spoken language in individuals with adequate
speech, marked impairment in the ability to initiate
or sustain a conversation with others; stereotyped
and repetitive use of language or idiosyncratic
language; and lack of varied, spontaneous makebelieve play or social imitative play appropriate to
developmental level.
AUTISTIC DISORDER
Autistic disorder is also known as infantile autism.
In 1867, Henry Maudsley was the rst psychiatrist
to pay serious attention to very young children
with severe mental disorders involving marked
deviation, delay and distortion in the developmental
process. In 1943 Leo Kanner, in his classic paper
Autistic Disturbance of Affective Contact coined
the term infantile autism. Autistic disorder
is characterised by sustained impairments in
reciprocal social interactions, communication
deviance and restricted stereotypical behaviour
patterns.
Restricted repetitive and stereotyped

patterns of behaviour, interests, and
activities
Preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal
either in intensity or focus; apparently inexible
adherence to specic, non-functional routines
or rituals; stereotyped and repetitive motor
mannerisms, such as hand or nger apping or
twisting, or complex whole-body movements.
Diagnostic criteria overview
Persistent preoccupation with parts of

objects
Qualitative impairment in social interaction
There are delays or abnormal functioning in at least

one of the following areas, with onset prior to age 3
years: social interaction, language as used in social
communication, and symbolic or imaginative
play.
Marked impairment in the use of multiple nonverbal behaviours, include: eye-to-eye gaze, facial
expression; failure to develop peer relationships
417
Table 51.1
299.00 Autistic Disorder
A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and
(3):
(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial
expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
(e.g., by lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to
compensate through alternative modes of communication such as gesture or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a
conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental
level
(3) restricted repetitive and stereotyped patterns of behaviour, interests, and activities, as manifested by
at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that
is abnormal either in intensity or focus
(b) apparently inexible adherence to specic, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or nger apping or twisting, or complex
whole-body movements)
(d) persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1)
social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for by Retts Disorder or Childhood Disintegrative Disorder.
higher concordance rates in monozygotic than in

dyzygotic twins. Organic factors that have been
demonstrated include: dilatation of anterior horn
of the lateral ventricle; increased serotonin efux;
specic viral infections; trauma to the developing
CNS; increased risk for the development of seizures
is noted in adolescence; and its frequent occurrence
in association with other syndromes such as MR,
epilepsy, severe allergies, fragile X.
Epidemiology
Autistic disorder is found in every country and
region of the world, and in families of all racial,
ethnic, religious and economic backgrounds.
Emerging in childhood, it affects about 1 or 2
people in every 1000. It has a male predominance
of about 4 to 1. About 50 percent of autistic disorder
cases have severe MR, 30 percent cases have mild
to moderate MR, and 20 percent cases have IQs in
the normal range.
Clinical presentation
Autistic disorder is characterised by a pattern of
delay and deviance in the development of social,
communicative, and cognitive skills. It presents
in a wide spectrum of severities. The disorder
arises in the rst years of life, disrupting various
developmental processes and typically affects a
persons ability to communicate, form relationships
with others, and to respond appropriately to the
environment.
Aetiology
There is no evidence that psychosocial factors and
parenting abnormalities cause autistic disorder.
Evidence strongly points to autistic disorder
being an organically based neurodevelopmental
disorder.
The risk of the disorder in the siblings of autistic
children is 3 to 4 times higher than that of the
general population. Twin studies also indicate
418
Pervasive Development Disorders
o Childs medical records

o Medical and neurological evaluations,
including audiometric evaluations, awake
and sleeping EEGs, CT scan (brain)
o Metabolic and chromosomal screening.
Cognitive-intellectual factors:
o Non-verbal skills
o Verbal skills
o Educational assessment
Psychological factors.
Family and social factors.
Social-related disturbances are the most consistent

and reliable indication of autistic disorder. Most
children with the disorder seem to have tremendous
difculty learning to engage in the give-and-take
of everyday human interaction. Even in the rst
months or years of life, autistic children exhibit
low social interactiveness, avoid eye contact, rarely
smile, hardly imitate, tend to be aloof, prefer being
alone, and resist attention and affection such as
hugs and cuddling. Isolated in worlds of their own,
people with autism appear indifferent and remote
and are unable to form emotional bonds with
others. Imaginative and symbolic functions are also
impaired resulting in characteristic autistic play
and behaviour consisting of rituals, stereotypes,
motor mannerisms, and preoccupations with parts
of objects. The disorder also typically affects a
persons ability to communicate.
Clinically, common initial presenting complaints
include concerns about a childs lack of language,
inconsistencies in responsiveness, or concern that
the child might be deaf!
Treatment
Involvement of parents and teachers in the
treatment has also emerged as a major factor in
treatment success. Several treatment approaches
have evolved since autism was rst identied.
These are:
Behavioural therapy to increase skills as
well as reducing the severity and frequency
of disruptive behaviours.
Education programmes can expand their
capacity to learn, communicate, and relate to
others.
Medications can be used to help alleviate
certain symptoms.

Autistic disorder is a chronic and often a severe
disorder, with a guarded prognosis. About twothirds of children with autistic disorder remain
severely handicapped, 50 percent remain without
spoken language, about one-third develop seizure
disorders often during adolescence, and only
about one-sixth make fair social adjustment. Poor
prognostic factors for autism include: very low
intelligence (severely and profoundly retarded
ranges of intelligence), signicantly delayed motor
milestones, a lack of any communicative speech
by 5 years of age, profound unresponsiveness to
sounds, clear evidence of neurological impairment
(e.g. epilepsy, denitely abnormal EEG), and
chromosomal abnormalities.
Family support
A combination of early intervention, behavioural
therapy, special education, family support, and in
some cases, medication, greatly improves the dayto-day life of children with autistic disorder. It is
likely that the core features and phenomenology of
autistic disorder are consistent around the world,
but there is a wide variety of culturally different
approaches to management and service provision.
A number of other conditions within this
diagnostic category are included i.e. Aspergers
Syndrome, Childhood Disintegrative and Retts
disorders. These conditions are part of the autism
spectrum disorders. Principles of assessment and
treatment are contained within those for autistic
disorder.
Evaluation and diagnostic procedures

Organic factors:
o Developmental history
o Maternal medical records
419
ASPERGERS DISORDER
Table 51.2
299.80 Aspergers Disorder
A. Qualitative impairment in social interaction, as manifested by at least two of the following:
(1) marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial
expression, body postures, and gestures to regulate social interaction
(2) failure to develop peer relationships appropriate to developmental level
(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
(e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
(4) lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behaviour, interests, and activities, as manifested by at
least one of the following:
(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that
is abnormal either in intensity or focus
(2) apparently inexible adherence to specic, nonfunctional routines or rituals
(3) stereotyped and repetitive motor mannerisms (e.g., hand or nger apping or twisting, or complex
whole-body movements)
(4) persistent preoccupation with parts of objects
C. The disturbance causes clinically signicant impairment in social, occupational, or other important
D. There is no clinically signicant general delay in language (e.g. single words used by age 2 years,
communicative phrases used by age 3 years).
E. There is no clinically signicant delay in cognitive development or in the development of ageappropriate self-help skills, adaptive behaviour (other than in social interaction), and curiosity about
the environment in childhood.
F. Criteria are not met for another specic Pervasive Developmental Disorder or Schizophrenia
or rituals; and stereotyped and repetitive motor

mannerisms, such as hand or nger apping; and
persistent preoccupation with parts of objects.
The disturbance causes clinically signicant
impairment in social, occupational or other
important areas of functioning. There is no clinically
signicant general delay in language (e.g. single
words used by age 2 years, communicative phrases
used by age 3 years).
There is no clinically signicant delay in
cognitive development or in the development of
age appropriate self-help skills, adaptive behaviour
(other than in social interaction), and curiosity
about the environment in childhood.
In children with this pervasive developmental

disorder, language, curiosity and cognitive
development proceed normally, while there
is substantial delay in social interaction and
development of restricted, repetitive patterns of
behaviour, interests and activities.
Qualitative impairment in social

interaction
These include marked impairment in the use of
multiple non-verbal behaviours such as eye-toeye gaze, facial expression; failure to develop peer
relationships appropriate to developmental level; a
lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people; and
lack of social or emotional reciprocity.
Restricted repetitive and stereotyped patterns of
behaviour, interests and activities.
Preoccupation with one or more stereotyped
and restricted patterns of interest that is abnormal,
either in intensity or focus; apparently inexible
adherence to specic, non functional routines
CHILDHOOD DISINTEGRATIVE
DISORDER
Children with this disorder appear to develop
normally for the rst two years of life, but then lose
skills in areas such as language, play, and bowel
420
Pervasive Development Disorders
control and manifest impaired social interaction

and communication associated with restrictive,
repetitive, stereotyped behaviours.
Apparently there is normal development for at
least the rst 2 years after birth as manifested by
the presence of age-appropriate verbal and nonverbal communication, social relationships, play,
and adaptive behaviour.
There is clinically signicant loss of previously
acquired skills (before age 10 years), such as
Table 51.3
299.10 Childhood Disintegrative Disorder
A. Apparently normal development for at least the rst 2 years after birth as manifested by the presence of
age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behaviour.
B. Clinically signicant loss of previously acquired skills (before age 10 years) in at least two of the following
areas:
(1) expressive or receptive language
(2) social skills or adaptive behaviour
(3) bowel or bladder control
(4) play
(5) motor skills
C. Abnormalities of functioning in at least two of the following areas:
(1) qualitative impairment in social interaction (e.g., impairment in nonverbal behaviours, failure to
develop peer relationships, lack of social or emotional reciprocity)
(2) qualitative impairments in communication (e.g., delay or lack of spoken language, inability to
initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied makebelieve play)
(3) restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities, including
motor stereotypes and mannerisms
D. The disturbance is not better accounted for by another specic Pervasive Developmental Disorder or by
Schizophrenia.
expressive or receptive language; social skills or

adaptive behaviour; bowel or bladder control;
play; and motor skills. In addition, there are
abnormalities of functioning in a number of areas
such as social interaction, communication and
the possible development of restricted, repetitive,
and stereotyped patterns of behaviour, interests,
activities and mannerisms.
RETTS DISORDER
Children with this disorder appear to develop
normally at rst, but their head growth slows
down, they lose social engagement and hand
skills, and they develop stereotyped movements
Table 51.4
299.80 Retts Disorder
A. All of the following:
(1) apparently normal prenatal and perinatal development
(2) apparently normal psychomotor development through the rst 5 months after birth
(3) normal head circumference at birth
B. Onset of all of the following after the period of normal development:
(1) deceleration of head growth between ages 5 and 48 months
(2) loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent
development of stereotyped hand movements (e.g., hand-wringing or hand washing)
(3) loss of social engagement early in the course (although often social interaction develops later)
(4) appearance of poorly coordinated gait or trunk movements
(5) severely impaired expressive and receptive language development with severe psychomotor
retardation
421
subsequent development of stereotyped hand

movements (e.g. hand-wringing or handwashing).
Loss of social engagement early in the course
(although often social interaction develops
later).
Appearance of poorly co-ordinated gait or
trunk movements; severely impaired expressive
and receptive language development with
severe psychomotor retardation.
of the hands and poorly co-ordinated gait or trunk

movements. There is also psychomotor retardation
and impairment of language development.
Apparently, there is normal prenatal and perinatal
development, psychomotor development through
the rst 5 months after birth and normal head
circumference at birth. After this period of normal
development, there is:
Deceleration of head growth between 5 and 48
months.
Loss of previously acquired purposeful hand
skills between ages 5 and 30 months with the
Table 51.5
299.80 Pervasive Developmental Disorder Not Otherwise Specied (Including Atypical Autism)
This category should be used when there is a severe and pervasive impairment in the development of
reciprocal social interaction associated with impairment in either verbal or nonverbal communication skills
or with the presence of stereotyped behaviour, interests, and activities, but the criteria are not met for a
specic Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant
Personality Disorder. For example, this category includes atypical autismpresentations that do not meet
the criteria for Autistic Disorder because of late age at onset, atypical symptomatology, or sub-threshold
symptomatology, or all of these.
Further reading
1. Diagnostic and Statistical Manual Disorders (1994)
Fourth Edition 1994: DSM-IVTM Published by
American Psychiatric Association
422
52
Disruptive Behaviour Disorders
Thaddeus P. M. Ulzen, Hitesh M. Maru, Christopher P. Szabo
Poor modulation of arousal levels to meet

situational demands.
Strong inclination to seek immediate
reinforcement.
With a consensus of core symptoms being: poor
sustained attention, impulsivity and hyperactivity.
Disruptive behaviour disorders typically include:

Attention Decit Hyperactivity Disorder
Oppositional Deant Disorder
Conduct Disorder
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
Diagnostic criteria
Must meet criteria set in DSM-IV-TR for ADHD
which include:
Onset of symptoms before age 7 years.
Duration of symptoms for at least 6 months.
Pervasiveness of symptoms in multiple
settings.
The primary decits include:

Lack of investment, organisation and
maintenance of attention and effort in
completing tasks.
Inability to inhibit impulsive action.
Table 52.1
Attention-Decit/Hyperactivity Disorder
A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
(b) often has difculty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to nish schoolwork, chores,
or duties in the workplace (not due to oppositional behaviour or failure to understand
instructions)
(e) often has difculty organising tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(such as school-work or homework)
423
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least
6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often dgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or
adults, may be limited to subjective feelings of restlessness)
(d) often has difculty playing or engaging in leisure activities quietly
(e) is often on the go or often acts as if driven by a motor
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difculty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age
7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and
at home).
D. There must be clear evidence of clinically signicant impairment in social, academic, or occupational
functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder
(e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Code based on type:
314.01 Attention-Decit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met
for the past 6 months
314.00 Attention-Decit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is
met but Criterion A2 is not met for the past 6 months
314.01 Attention-Decit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if
Criterion A2 is met but Criterion A1 is not met for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no
longer meet full criteria, In Partial Remission should be specied.
Table 51.2
314.9 Attention-Decit/Hyperactivity Disorder Not Otherwise Specied
This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do
not meet criteria for Attention-Decit/Hyperactivity Disorder. Examples include:
1. Individuals whose symptoms and impairment meet the criteria for Attention-Decit/Hyperactivity
Disorder, Predominantly Inattentive Type but whose age at onset is 7 years or after
2. Individuals with clinically signicant impairment who present with inattention and whose symptom
pattern does not meet the full criteria for the disorder but have a behavioural pattern marked by
sluggishness, daydreaming, and hypoactivity
424
Family factors. Twin studies have reported 59

versus 33 percent and 81 versus 29 percent in
monozygotic and dizygotic twins, respectively.
Out of relatives of children with ADHD, 11 percent
of parents had antisocial personality disorder, 25.1
percent of rst-degree relatives had ADHD, 24.3
percent had antisocial personality disorder and
27.1 percent had a mood disorder.
Perinatal aetiological factors - Maternal alcohol
and drug abuse, prolonged labour, pre- and postmaturity, poor maternal nutrition, brain trauma
infections, iron deciency, lead poisoning,
glucose-6-phosphate dehydrogenase deciency
and phenylketonuria.
Genetic factors. Genetic variations leading to
relative hypodopaminergic status: variation of
DAT1 (dopamine transporter gene); Dopamine
(D4) receptor.
Diagnosis
The medical practitioner should use objective
instruments to assess the childs behaviour and
abilities. A physical examination should be
undertaken including hearing and visual testing. A
family assessment should also be done.
Objective instruments
Broad-based psychopathological instrument,
e.g. child behaviour checklist (CBCL),
Conners scale (CTRS/CPRS).
ADHD specic instrument, e.g. ADD/
H comprehensive teachers rating scale
(ACTERS) and DSM-IV criteria.
Useful psychological tests
Tower test measures planning, persistence
and forethought.
Math test for working memory and problemsolving abilities.
Time estimation test measures visual
attention and subjective sense of time
intervals.
Auditory attention test.
Stop signal paradigm measures the ability to
inhibit a planned action.
Change task measures inhibition of action
and ability to shift to an alternative action.
Neurological clues to aetiology

Pre-frontal cortexabnormal maturation
of frontal lobes noted in PET scan studies
are associated with decient executive
functioning.
Cerebellar vermis is thought to have a role in
the regulation of motivation.
Basal ganglia have a role in modulation of
emotion and movement.
Mythological causes of ADHD

Epidemiology
These include too much or too little sugar, aspartame,

food sensitivity and additives or colouring, lack of
vitamins, television and video games, ourescent
lighting and allergies.
The prevalence is approximately 2-9 percent of

the childhood population with no variation by
class or ethnicity. ADHD presents together with
other disruptive behaviour disorders, as 30-40
percent of child psychiatric clinic populations.
The observed onset is 3-4 years of age and it is
pervasive in all settings. The gender ratio of boys
and girls 3:1.
Common co-morbid conditions

Mood disorders, anxiety, specic learning
disabilities, mental retardation, tic disorders, e.g.
Tourettes disorder, oppositional deant disorder,
conduct disorder and somatisation disorder.
Aetiological factors
Other associated problems
These include temperament, aggression as a

trait, family history, perinatal factors and genetic
factors.
Temperament. A difcult temperament is often,
but not invariably reported. It includes: withdrawal
from novelty, low adaptability, high intensity and
negative mood.
Aggression. Longitudinal studies suggest that
aggression may manifest in infancy as irritability
and un-cooperative behaviour. It is a remarkably
stable phenomenon and is predictive of poor
outcomes.
Social skills problems, low self esteem, immaturity,

enuresis and encopresis, motor coordination
decits, sleep disturbances and speech disorders.
Long-term outcome
Persistence of symptoms, conduct, emotional and
social problems, and unpredictable educational
attainment.
Persistence of symptoms: In adolescence, 70-80
percent and in adulthood, 50-60 percent.
425
Conduct
problems:
antisocial
personality
disorder25 percent; substance abuse/alcohol2535 percent, adolescents 10-15 percent; moves 3
times; auto accidents 3 times; trafc citations 4
times; and legal involvement20-50 percent.
Emotional problems: Increased suicide attempts,
10 percent; sexual dysfunction, 20 percent; and
low esteem, 65 percent.
Social problems: Interpersonal difculties, less
assertive, and few close friends.
Educational attainment: High school dropout, 35
percent; college graduation, 5 percent; and grade
retentions/failures, 24-35 percent.
The psychostimulants remain the standard

pharmacological treatment approach, with other
agents to be considered based on initial treatment
response or patient-specic clinical requirements.
Psychostimulants
Special educational, psychological and behavioural

approaches, and pharmacological interventions can
be used.
There is a 70-80 percent response rate to stimulants.

The most commonly prescribed is methylphenidate
(Ritalin), which is best started at 2.5-5mg/day,
reaching an optimum dose of 0.3-2mg/kg/day.
Dextroamphetamine (Dexedrine) is twice as potent
as methylphenidate. It is sometimes more effective
in pre-school children whose response to Ritalin
is sometimes erratic or paradoxical. Amphetamine
sulphate (Adderall) is a long-acting amphetamine
compound. Long acting methylphe-nidate
preparations include Ritalin LA, Metadate CD and
Concerta with the length of action ranging from 812 hours.
General principles for treatment
Antidepressants
Multi-modal treatment produces the best results.

Medication without another modality is strongly
discouraged. This is a chronic disorder and
treatment planning must reect this reality.
Tricyclic antidepressants: Imipramine, Nortrityline

and Desipramine may be used for ADHD treatment
in patients who are non-responsive to stimulants.
TCAs have been shown to be 60-70 percent
effective. Buproprion (Wellbutrin) has also been
used with limited efcacy.
Treatment
Educational approaches
Prescribing more immediate consequences for
actions in the classroom.
Increased use of external prompts for time
intervals and rules.
Break instructions into smaller steps.
Provide structured learning environment.
Use cues to remind child of homework.
Antihypertensive medications
Alpha agonists.
Clonidine should be initiated at 0.025 mg bid
and dosed up to 4-5 micro-grams/kg/day.
Guanfacine should be prescribed at a dosage
of 1-2mg/day.
Atomoxetine
Psychological and behavioural approaches
Norepinephrine is used as a re-uptake inhibitor for

the treatment of ADHD. It is initiated at 0.5mg/kg/
day and target dose of 1.2mg/kg/day.
Parents and teachers should consistently use

the same behavioural modiers.
Social skills training may be helpful.
Individual psychotherapy is of minimal use.
Behavioural based family therapy is
recommended.
Parent groups are highly effective.
Common side effects of psychopharmacological

agents
Methylphenidate and amphetamines: decreased
appetite, insomnia, labile moods, headaches,
dyspepsia, tics (rare), psychosis (rare), tachycardia
(rare) and hypertension (rare).
Tricyclic antidepressants: anticholinergic side
effects include dry mouth, blurred vision,
constipation, urinary hesitancy and tachycardia.
Antihistaminergic side effects include sedation,
carbohydrate craving and weight gain. Cardiac
side effects include AV node slowed conduction
and should not be used in patients with left bundle
branch block or prolonged QT intervals.
Psychopharmacological interventions
Psychostimulants include methylphenidate,
dextroamphetamine and mixed amphetamines.
Tricyclic antidepressantsImipramine, Desipramine and Nortryptiline.
Buproprion.
Clonidine (an anti-hypertensive).
Atomoxetine.
426
Bupropion: agitation, tremor, headaches, insomnia,

weight loss and dry mouth.
Clonidine: sedation, depression, hypotension and
rebound hypertension.
Atomoxetine: reduced appetite, dyspepsia and
dizziness.
Uncomplicated ADHD can be managed in

conjunction with a psychologist who will evaluate
the child to rule out comorbid psychiatric disorders,
specic learning disabilities and intellectual
decits. Complicated cases must be referred to a
child and adolescent psychiatrist.
Non-traditional and unproven treatments
CONDUCT DISORDER (CD)
These include megavitamins and amino acids,

feingold diet, sensory integration therapy,
EEG biofeedback therapy, vision therapy,
chiropractic manipulations and primrose oil and
other natural products.
The diagnostic criteria (DSM-IV) include a

repetitive and persistent pattern of behaviour
in which basic rights of others or major ageappropriate societal norms or rules are violated.
Such behaviour is associated with aggressive
conduct; property damage or loss; deceitfulness
or theft; and serious violations of rules. The onset
may be in childhood or adolescence, with mild,
moderate or severe forms of the disorder.
Role of the primary physician

The general practitioner is most likely to be the
rst professional to be notied by parents or school
ofcials of symptoms of disruptive behaviours.
Table 52.3
Conduct Disorder
A. A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate
societal norms or rules are violated, as manifested by the presence of three (or more) of the following
criteria in the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
(1) often bullies, threatens, or intimidates others
(2) often initiates physical ghts
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle,
knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in re setting with the intention of causing serious damage
(9) has deliberately destroyed others property (other than by re setting)
Deceitfulness or theft
(10) has broken into someone elses house, building, or car
(11) often lies to obtain goods or favours or to avoid obligations (i.e., cons others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years
(14) has run away from home overnight at least twice while living in parental or parental surrogate
home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
B. The disturbance in behaviour causes clinically signicant impairment in social, academic, or occupational
functioning.
C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
427
Code type based on age at onset:

312.81 Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of Conduct
Disorder prior to age 10 years
312.82 Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of Conduct
Disorder prior to age 10 years
312.89 Conduct Disorder, Unspecied Onset: age at onset is not known
Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems
cause only minor harm to others (e.g., lying, truancy, staying out after dark without permission)
Moderate: number of conduct problems and effect on others intermediate between mild and severe
(e.g., stealing without confronting a victim, vandalism)
Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause
considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting
a victim, breaking and entering)
Predictive factors for aggression in youth differential

diagnosis. These include normal oppositional
behaviour, oppositional deant disorder, ADHD,
specic learning disabilities and MR.
Epidemiology
This condition has a prevalence, of 3-7 percent.
Males predominate, although numbers are rising
for females. It is associated with impaired and
chaotic families. ADHD can be a risk factor and
co-morbid psychiatric disorders are often present.
Treatment approaches
These
include
psychotherapy,
modication and pharmacotherapy.
Aetiology
Difcult temperament
Inconsistent discipline by parents, e.g. ignoring
good behaviour but paying undue attention to
bad behaviour.
Association with a negative or delinquent peer
group.
Parental modelling of impulsive and rulebreaking behaviour.
Genetic predisposition.
Marital conict in the home.
Frequent moves in pre-school years.
Poverty.
Low IQ or brain damage.
behaviour
Psychotherapy
Individual psychotherapy directed at the child or
adolescent is usually ineffective. Systemically
based approaches encompassing group and family
therapy, and parent training, produce better results,
e.g. multi-systemic therapy.
Behaviour modication
Parent management training programs and
cognitive-behaviour modication, often in
combination with parent training are useful.
Psychopharmacological treatment
Various agents have been used with inconsistent
results, particularly if aggression is a signicant
component of the clinical presentation:
Lithium Carbonate has been used if explosive
affect is a consideration.
Carbamazepine, the anticonvulsant, has
been used because some youth present with
abnormal EEGs though they often do not
conrm epilepsy.
Propranalol is sometimes used for youth with
explosive rage reactions.
Neuroleptics are sometimes used in severely
aggressive children and youth with suspicious
hostility.
Associated features
These include substance abuse, high risk sexual
and other behaviours, specic learning disorders,
lower than average intelligence, ADHD, PTSD and
mood disorders.
Risk factors for delinquency
Impulsivity, poor concentration, low achievement,
antisocial parent, large family, low family income,
broken family, poor parental supervision and
parental conict.
428
Stimulants may be indicated if ADHD is a

comorbid condition.
Various antidepressants have been prescribed
to address comorbid mood and anxiety
symptoms.
transmitted diseases, unplanned pregnancies and

substance abuse.
OPPOSITIONAL DEFIANT
DISORDER (ODD)
Environmental interventions
Community-based recreational and mentorship
programmes can be useful. Often educational
challenges such as learning disabilities are present
and increase the sense of failure experienced by these
youth. Sometimes legal sanctions are necessary
to force adherence to treatment programmes.
These youth are at high risk for injuries and are
exposed to considerable psychological losses and
trauma. They are at risk for HIV and other sexually
These children have a chronic pattern of behaviour

characterised by stubborn attitude, negativism,
hostility and deant behaviour without violating
the rights of others. The problems initially manifest
at home and then progress to school and the larger
community. They present with temper tantrums,
irritability, argumentativeness, non-compliance,
blaming others and vindictiveness.
Table 52.4
313.81 Oppositional Deant Disorder
A. A pattern of negativistic, hostile, and deant behaviour lasting at least 6 months, during which four (or
more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively dees or refuses to comply with adults requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehaviour
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindictive
Note: Consider a criterion met only if the behaviour occurs more frequently than is typically observed in
individuals of comparable age and developmental level.
B. The disturbance in behaviour causes clinically signicant impairment in social, academic, or
occupational functioning.
C. The behaviours do not occur exclusively during the course of a Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not
met for Antisocial Personality Disorder.
Table 52.5
312.9 Disruptive Behaviour Disorder Not Otherwise Specied
This category is for disorders characterized by conduct or Oppositional deant behaviours that do not
meet the criteria for Conduct Disorder or Oppositional Deant Disorder. For example, include clinical
presentations that do not meet full criteria either for Oppositional Deant Disorder or Conduct Disorder, but
in which there is clinically signicant impairment.
429
Learning disorders, MR and conduct disorders

may be diagnostic considerations.
Epidemiology
About 6-10 percent of children have ODD and the
male:female ratio is 3:1.
Treatment
Behaviour modication using environmentally
positive and negative contingencies to increase
positive and decrease negative behaviours
is the approach of choice. This requires
signicant parental involvement.
Teachers and parents need to have consistency
in their interventions with the child.
In children with coexisting ADHD, stimulant
medication may be helpful.
Explosive irritability may herald the onset of
bipolar disorder in childhood.
Evaluation
Broad-based child psychopathology scales such as
the Child Behaviour Checklist (parent and teacher
versions) or Conners Parent and Teacher Rating
Scales are useful in aiding in the diagnosis and
differentiating of ODD from ADHD and conduct
disorder.
Aetiology
Difcult temperament.
Modelling of adult or parental oppositional
behaviour.
Parental inconsistency in setting fair, rm and
consistent limits.
Further reading
1. Lahey BB, Loeber R, Quay HC et al. (1992).
Oppositional Deant Disorder and Conduct Disorders.
Issues to be resolved for DSM IV. J Am Acad Child
Adolesc Psychiatry 31: 383.
2. Loeber R. (1990) Development and Risk Factors of
Juvenile Antisocial Behaviour and Delinquency. Clin
Psychol rev 10: 1-41.
3. Henggeler SW & Borduin CM. (1990). Family
Therapy and Beyond: A Multisystemic Approach to
Treatment of Behaviour Problems of Children and
Adolescents. Pacic Grove CA Brooks/Cole.
Differential Diagnosis
Impulsivity of ADHD should be differentiated
from ODD though both disorders may
coexist.
Specic learning disorders and MR may
present with oppositional behaviour in the
school context.
430
53
Anxiety Disorders of Childhood and Adolescence
Linda Kelly, Christopher P. Szabo
Anxiety disorders (AD) are among the commonest

of psychiatric disorders in children and adolescents.
There has been lack of clarity about several factors
including their link with adult psychiatric disorders,
the efcacy of psychopharmacology, how chronic
these disorders are and the socio-demographic
features. There is a dearth of research, particularly
studies of good clinical trials of medication.
It is sometimes difcult to distinguish AD from
normal anxiety. Fears are common in children of all
ages. Mostly, they are transitory and part of normal
development (e.g. fear of the dark). Only when there
is avoidant behaviour does the fearfulness interfere
with functioning and may require treatment. The
most common symptoms are over-concern about
competence, excessive need for reassurance, fear
of the dark, fear of harm to attachment gures and
somatic complaints. Younger children and girls are
more anxious. Anxiety is associated with lower
academic achievement. In adolescents, sources of
anxiety include consolidation of identity, sexual,
social acceptance and independence conicts.
The most commonly reported symptoms of
adolescence are fear of heights, public speaking,
blushing, worry over past behaviour and selfconsciousness. Affectionless control, i.e. home
environments perceived as low on warmth and
high on over-protection seems to be a risk factor for
the development of AD in children. Other family
factors associated with AD in children include
rigid organisation and control, with signicant

avoidant behaviour. The most anxious children are
those who reported the most external (parental)
control. There is a higher rate of anxiety disorders
in children of adults with AD. This can be 7 times
higher.
CLASSIFICATION
Separation anxiety disorder (SAD)
The essential features of SAD are excessive worry
about separation from attachment gures. It is
the commonest disorder in pre-pubertal children.
The mean age of presentation is 9.1 years. It
occurs more in Caucasian, lower socio-economic
and single parent families. Gender ratio is equal
in SAD. Children with SAD show different
symptoms to those with other ADs, e.g., fear of
getting lost is common in SAD than the fear of
germs, illness and bee stings. Younger children
report nightmares about separation. There may be a
relationship between SAD and later panic disorder
or agoraphobia. SAD seems to be a non-specic
precursor to a number of adult conditions including
depression and anxiety disorders. Children with the
disorder must have symptoms for at least half the
time and they must cause interference in function
or social communication.
431
Table 53.1
309.21 Separation Anxiety Disorder
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those
to whom the individual is attached, as evidenced by three (or more) of the following:
(1) recurrent excessive distress when separation from home or major attachment gures occurs
or is anticipated
(2) persistent and excessive worry about losing, or about possible harm befalling, major
attachment gures
(3) persistent and excessive worry that an untoward event will lead to separation from a major
attachment gure (e.g., getting lost or being kidnapped)
(4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation
(5) persistently and excessively fearful or reluctant to be alone or without major attachment
gures at home or without signicant adults in other settings
(6) persistent reluctance or refusal to go to sleep without being near a major attachment gure or
to sleep away from home
(7) repeated nightmares involving the theme of separation
(8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or
vomiting) when separation from major attachment gures occurs or is anticipated
B. The duration of the disturbance is at least 4 weeks.
D. The disturbance causes clinically signicant distress or impairment in social, academic (occupational),
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for
by Panic Disorder With Agoraphobia.
Specify if:
Early Onset: if onset occurs before age 6 years
Somatic complaints.
Marked self-consciousness or susceptibility to
embarrassment or humiliation.
They present at an older age than SAD children
and have an equal sex ratio. They tend to come
from middle and upper class families. Eighty-ve
percent of those with anxiety disorders have GAD.
The mean age of onset is 10 years. GAD has equal
gender ratio until adolescence. After adolescence,
females are more predominant than males with the
condition. It is more common in Caucasian, middle
and upper class families.
Whilst the conditions, which follow, do not appear

in the DSM-IV-TR category of Disorders First
Diagnosed in Infancy, Childhood and Adolescence,
they are included here as they are certainly
recognised clinically in children and adolescents.
Generalised Anxiety Disorder (GAD)

This condition is characterised by excessive
worry about the future and past events as well as
behaviours, concern about competence and selfconsciousness. Only 1 of 6 symptoms (restlessness,
fatigue, difculty with concentration, irritability,
muscle tension, sleep disturbances), are needed for
the diagnosis in children.
Over-anxious children report more fears about
social and performance concerns, being criticised,
teased or making mistakes. They have unrealistic
worries about the future. The most common
symptoms are:
Unrealistic worry over future events.
Preoccupation with appropriateness of
individual behaviour in the past.
Over-concern about competence in a variety
of areas.
Social Phobia (previously Avoidant

Disorder; also known as Social Anxiety
Disorder)
This condition is characterised by persistent fear
of social or performance situations in which the
person is exposed to unfamiliar people or scrutiny.
Social phobia is frequently comorbid with other
anxiety disorders. It usually has an onset in early
to mid-adolescence. Equal numbers of males and
females suffer from the disorder. Social phobia is
432
constriction and avoidance of reminders of the

trauma. The difference between severe and mild
PTSD has been associated with disturbances in
sleep and concentration. In children with ongoing
trauma (e.g. sexual abuse), there are complications
to the diagnosis of PTSD, because of complicating
factors (poverty, neglect, alcoholism or drug abuse
in the parents). However, many develop PTSD
symptoms. There may be a familial predisposition
to developing PTSD. Risk factors include: early
separation from parents, neuroticism, pre-existing
anxiety and depression and family history of an
AD.
more common in girls in Caucasian, middle and

upper class children.
Panic disorder (PD)

This condition is characterised by recurrent
spontaneous episodes of panic associated with
physiological symptoms. In adult community
samples the incidence of PD is 0.6-1 percent. The
age of onset peaks at 15-19 years. There is evidence
of the heritability of PD. Most instruments for
measuring AD in children do not screen for PD.
In adolescents, about 9.6 percent have panic
disorder. There have been reports of panic-like
symptoms in pre-pubertal children. Panic disorder
begins most commonly in adolescence and young
adulthood. Rates of PD increase as sexual maturity
increases. Puberty seems to be a vulnerability
factor in the development of PD. Those adolescents
who have spontaneous panic attacks report greater
severity of attacks, more depression and greater
lifestyle changes as a result of the attacks.
Obsessive Compulsive Disorder (OCD)

The clinical features are similar to adult
symptoms (one third to a half of adults with
OCD describe symptoms starting in childhood
or adolescence). Children may have compulsions
without associated obsession, which may be due
to cognitive immaturity (up to 40 percent). The
mean age of onset is about 10 years. Genetic
factors play a part. There is an association
with Paediatric Autoimmune Neuropsychiatric
Disorders Associated with Streptococcal Infections
(PANDAs). The course may be chronic or episodic.
One third spontaneously remit. Associations exist
with eating disorders, Tourettes disorder, other
anxiety disorders, depression, ADHD, CD and
ODD and substance abuse.
Simple phobia and fears

Simple phobias are specic, isolated, persistent fear
of circumscribed stimuli, e.g. school. Associated
avoidant behaviour interferes with the normal
functioning of the child. Mild fears are common in
children. Girls fear more than boys. The commonest
fears expressed by American children are being hit
by a car, not being able to breathe, a bomb attack,
getting burned by re, falling from a high place,
burglar breaking into the house, earthquake, death,
getting poor grades and snakes. About 7.5 percent
of children have mild phobias and 0.2 percent have
severe phobias. Animal phobias usually start before
5 years. Social phobia usually start after puberty
and 40 percent improve with age.
Selective mutism
This condition was previously elective mutism
and classied under speech and language
disorders. The dominant feature is lack of use of
speech which is specic to certain situations, e.g.
public places or with strangers. It is not common
and occurs more in girls than boys. These children
are often shy, negative, controlling or oppositional.
Over-protective mothers are also more common.
Although selective mutism is not strictly an anxiety
disorder, it is placed in the DSM-IV TR category of
Disorders First Diagnosed in Infancy, Childhood
and Adolescence. Specically anxiety disorders
are commonly associated with this presentation.
Post Traumatic Stress Disorder (PTSD)

Children over the age of 3-4 years usually engage
in post-traumatic play or re-enactment behaviour
and have nightmares. In addition, they show more
distortion in their sense of time and a striking
foreshortened view of the future. Those with
severe PTSD have more intrusiveness, emotional
433
Table 53.2
313.23 Selective Mutism (formerly Elective Mutism)
A.
B.
C.
D.
E.
Consistent failure to speak in specic social situations (in which there is an expectation for
speaking, e.g., at school) despite speaking in other situations.
The disturbance interferes with educational or occupational achievement or with social
communication.
The duration of the disturbance is at least 1 month (not limited to the rst month of school).
The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language
required in the social situation.
The disturbance is not better accounted for by a Communication Disorder (e.g., Stuttering) and does
not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or
other Psychotic Disorder.
EPIDEMIOLOGY
ASSESSMENT
Anxiety disorders are among the commonest of

psychiatric disorders in children and adolescents.
Prevalence rates range from: 4-4.7 percent for
SAD, 2.9-4.6 percent for GAD, 2.49.2 percent
for simple phobia, 1.6 percent for social phobia,
1.2 percent for Agoraphobia, 0.6 percent for panic
disorder and 1 percent for OCD.
It is important to put emphasis on:

Onset, development and context of anxiety
symptoms, with associated stressors.
Development, medical, school and social
history.
Family history of psychiatric disorders.
Mental status examination and assessment of
school function.
Structured interviews and rating scales should also
be undertaken. These are available (including selfreport and parent report measures and clinician
rating scales). Using a variety of measurements
increases accuracy in diagnosis.
Diagnostic interviews should be done with the
child alone and with parents and maternal anxiety
noted as this may lead to over-reporting of anxiety
symptoms in their children.
Predisposing factors
A range of predisposing factors exists. These
include:
Temperament. Behavioural inhibition to the
unfamiliar (i.e. shyness, fearfulness, withdrawal
in novel situations) seems to be an enduring trait.
Children with high behavioural inhibition also have
physiological markers (e.g. faster heart rate and
increased acceleration of heart rate, with difcult
tasks, increased vocal cord tension). Lower selfesteem, less exibility, greater rigidity and more
resistance to change are also present.
Attachment. Insecure attachment may also be a
risk factor for the development of childhood ADs.
Ambivalently attached children have more anxiety
disorders.
Stress. Environmental stress is associated with
ADs, especially in the development of simple
phobias.
Familial. The risk of developing an AD is
higher if ones parents have anxiety disorders or
depression.
Comorbidity
One third of children with AD meet criteria
for two or more anxiety disorders with major
depression ranges from 12-47 percent, up to
69 percent in adolescents. About 40 percent or
more children with major depressive disorders
(MDD) have concurrent AD or SAD. These
tend to be older children with more severe
anxiety symptomatology.
15-24 percent of children with SAD or GAD
also have ADHD.
5 percent of children have both GAD and SAD.
Psychopathology and poor physical health are
434
function and tardive dyskinesia outweigh any

possible benet of using neuroleptics. They are
only recommended in children with Tourette's
syndrome, severe behavioural problems or
psychosis.
signicantly commoner in mothers of children

with co-morbid anxiety and depression,
compared with mothers of children with
depression alone.
OUTCOME OF AD IN CHILDREN
Family and school counselling

Treatment of infants and pre-schoolers should aim
to improve the interaction and bonding between
parent and child. It should help parents with
their anxieties and aim to decrease stresses in
the family. In children and adolescents, treatment
should take a multimodal approach. One needs
to consider feedback and education to parents
and the child about the disorder. There should be
consultation with the primary care physician and
school personnel.
AD in children often follows a chronic course and

may have low remission rates. Forty-six percent of
children with AD become ill for at least 8 years
and many relapse after recovery. SAD shows
the highest remission rates of 96 percent and the
lowest is panic disorder at 70 percent. However,
it has been suggested that there is a relationship
between SAD in childhood and PD or agoraphobia
in adulthood, so the condition may not remit as
much as transform into an adult disorder. About
50 percent of adult in-patients and 22 percent of
out-patients with agoraphobia reported SAD in
childhood. Two-thirds of those who recover do so
within the rst year of follow-up.
Behavioural and cognitive-behavioural

treatment
Behavioural treatment targets overt behaviour
and emphasises treatment in the context of family
and school. There is no focus on aetiology or
intrapsychic conict. Cognitive-behavioural
therapy emphasises changing cognitions associated
with the patients anxiety. It instructs the patient
to reconstruct their thinking into more positive
framework, leading to more adaptive behaviour.
Children learn coping self-statements and parents
learn to reconstruct their distorted perceptions
about their children. In school refusal, the aim
is to get the child to separate and go to school.
Systematic desensitisation and exposure both
work as does operant conditioning and ooding.
Other techniques used include relaxation training,
modelling and role-playing. Cognitive therapy
works best on children from 10 years and
upward.
TREATMENT
It has been speculated that the long period of time
when children are ill with ADs may be due to the
low rate of treatment offered or used. Studies show
a broad range of treatments with a lack of coherence
or consensual plan. An approach to treatment
should encompass and consider the following:
Pharmacological treatment
This should not be the sole intervention, but
an adjunct to behavioural or psychotherapeutic
interventions. Interventions that help promote
active mastery are important to prevent symptom
relapse after discontinuation of medicine.
Antidepressant agents: Citalopram (SSRI) is
most commonly used and has the least sideeffects.
Tricyclic antidepressants are not used much
any more due to adverse side effects and lack
of efcacy.
Benzodiazepines should be avoided in
children.
Beta-blockers have been found to be useful in
anxiety/panic disorder.
Buspirone (a non-sedating anxiolytic) has not
been found to be useful.
Neuroleptics. The risks of impaired cognitive
Psychodynamic therapy (Play therapy)

This form of therapy focuses on underlying fears and
anxieties, and issues of separation, independence
and self-esteem.
Research remains in its infancy and child
psychiatrists are left with little systematic
guidelines for pharmaco-thereutic treatment.
Important discoveries have been the nding that
behavioural inhibition seems to be an early and
persistent temperamental risk factor associated with
neurobiological markers for AD. Other advances
have been the reclassication of selective mutism
as a type of social phobia and the recognition that
vulnerability to panic is a function of pubertal
changes.
435
developmentally inappropriate social relatedness,

usually in the context of grossly pathological care.
It has two variants the Inhibited Type (DSM-IV
-R Criteria A (1) and the Disinherited Type (DSMIV-TR Criteria A (2).
The course of this condition depends on
individual factors in the child and the caregivers,
severity and duration of associated psychosocial
deprivation, and the nature of the intervention.
Intervention is in the form of providing appropriate
supportive environment.
Table 53.3 summarises the DSM-IV-TR
diagnostic criteria.
The development of practice parameters of

focused, specic, cognitive-behavioural packages
for the treatment of ADs and the early intervention
of SSRIs are also important advantages. More
long-term studies are needed to address issues of
the stability of childhood diagnoses and remission
rates.
REACTIVE ATTACHMENT
DISORDER OF INFANCY
OR EARLY CHILDHOOD
This rare condition occurs within the rst 5 years
of life. It manifests with markedly disturbed and
Table 53.3
313.89 Reactive Attachment Disorder of Infancy or Early Childhood

A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts,
beginning before age 5 years, as evidenced by either (1) or (2):
(1) persistent failure to initiate or respond in a developmentally appropriate fashion to
most social interactions, as manifest by excessively inhibited, hypervigilant, or highly
ambivalent and contradictory responses (e.g., the child may respond to caregivers with
a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen
watchfulness)
(2) diffuse attachments as manifest by indiscriminate sociability with marked inability
to exhibit appropriate selective attachments (e.g., excessive familiarity with relative
strangers or lack of selectivity in choice of attachment gures)
B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental
Retardation) and does not meet criteria for a Pervasive Developmental Disorder.
C. Pathogenic care as evidenced by at least one of the following:
(1) persistent disregard of the childs basic emotional needs for comfort, stimulation, and
affection
(2) persistent disregard of the childs basic physical needs
(3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g.,
frequent changes in foster care)
D. There is a presumption that the care in Criterion C is responsible for the disturbed behaviour in
Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion
C).
Specic Type
Inhibited Type: if Criterion A1 predominates in the clinical presentation
Disinhibited Type: if Criterion A2 predominates in the clinical presentation
3. Cheer, S.M. and Figgitt, D.P. (2001). Review of the

Therapeutic Potential in the Management of Anxiety
Disorders in Children and Adolescents, in Paediatric
Drugs, Vol. 3 No. 10 pp 763-781.
4. Brian Robinson, (2001) Handbook of Child Psychiatry
for Primary Care. Oxford 1996 Textbook of Psychiatry
for Southern Africa: By Robertson, Allwood and
Gagiano, Oxford Southern Africa, 2001.
Further reading
1. M. Rutter and E. Taylor (Eds) (2002). Child and
Adolescent Psychiatry. Modern Approaches: Fourth
Edition, Blackwell Science.
2. Bernstein, G.A., Borchardt, C. M., Ferwien, A.
R. (1996). Anxiety Disorders in Children and
Adolescents Review of the past 10 years in Journal
of the American Academy of Child and Adolescent
Psychiatry, Vol. 35, No. 9, pp 1110-1119.
436
54
Mood Disorders in Children and Adolescents
Linda Kelly, Christopher P. Szabo
Usually episodic but can be insidious in

children.
Rare prepubertally, onset in adolescence.
Behavioural disturbances very common.
MDD and BMD 1 are considered to be episodic
disorders but in this population may be insidious
in onset and not run a clear episodic course. Onset
is more common in adolescence. Behavioural
disturbances are common and may occur in the
context of the mood disorder and resolve as it does.
Chronology of symptoms will give clarity as to
whether the behaviour is part of the mood disorder
or a separate disorder, e.g. ADHD or conduct
disorder.
Today these disorders are understood to be

phenomenologically the same as the adult
disorders, but the presentation in children may
be atypical with a signicant inuence of the
particular age and developmental stage. Young
children may present with somatic complaints,
irritability and withdrawal, whereas adolescents
present with symptoms more similar to adults.
Childrens moods are very susceptible to the effects
of psychosocial stressors and it is common to nd
a history of abuse, neglect and parental discord.
CLASSIFICATION
They are classied the same way as adult mood
disorders (DSM-IV-TR).
Depressive: major depressive disorder (MDD)
and dysthymic disorder (DD).
Bipolar: bipolar type I (BMD I), bipolar type
II (BMD II) and cyclothymic disorder.
In MDD, there is irritable rather than depressed
mood and failure to make expected weight gains.
In DD irritable mood may replace depressed mood,
and the duration criterion is one year instead of two
in adults. The criteria is as follows:
More recognition that they are disorders.
Developmental effects on expression of
symptoms.
High incidence of psychosocial stressors.
EPIDEMIOLOGY
Whilst rare in pre-school children, these conditions
generally increase in frequency with age. MDD
occurs in school age (0.5-2.5 percent) and
adolescents (2-8 percent). It increases with age and
is more common in boys. As boys outnumber girls
in psychiatric clinics there may be a bias.
DD occurs in school age (2.5 percent) with a
high likelihood of developing MDD if the disorder
started early and lasts for over a year. But in
adolescence the prevalence rate for DD is less
than MDD as it is in adults. BMD often delay in
437
diagnosis until rst manic episode appears, which

is often in adolescence.
CLINICAL FEATURES
AETIOLOGY
Major Depressive Disorder

The onset is often insidious with delayed diagnosis.
In addition, other comorbid conditions, e.g. ADHD
and separation anxiety may confound the diagnosis.
The same diagnostic criteria used in adults apply.
This requires 5 of 9 symptoms for at least 2 weeks.
Adults have more problems with sleep and appetite.
Adolescents may show negative behavioural
changes and substance abuse.
Childhood onset often heralds severe illness
and impacts on all areas of functioning i.e. school,
peers and family life. Poor concentration, slowed
thinking, anhedonia and fatigue preoccupation
may all affect school performance. Symptoms may
vary according to developmental stage:
Pre-puberty: somatic complaints, psychomotor
agitation, mood congruent AH, withdrawn,
sad and with poor self esteem.
Adolescence: melancholia, psychomotor
retardation, delusions/psychosis, hopelessness
and pervasive anhedonia.
Common to both: suicidal ideation, depressed
or irritable mood, decreased concentration and
insomnia.
Genetics
One depressed parent doubles the risk for MDD,
and two depressed parents quadruple the risk.
Children with severe episodes of depression have
high rates of depression in family members. The
risk in rst degree relatives for BMD is 3-8 percent.
There is genetic overlap between BMD and MDD.
In twin studies, a genetic inuence for BMD seems
greater than for MDD.
Biological factors
The evidence for abnormalities in neurotransmitter
systems and the Hypothalamo-Pituitary-Axis
(cortisol hypersecretion), is weaker in children.
They also secrete less growth hormone in response
to insulin-induced hypoglycaemia. Whilst thyroid
function involvement is not evident as in adults,
lower free thyroxine levels (FT4) have been found
in depressed adolescents, with a normal thyroid
stimulating hormone (TSH).
Sleep
(Refer to the Tables under Mood Disorder in Adults).
Sleep studies are not as conclusive. There appears to

be increased growth hormone (GH) secreted during
sleep in depressed children than normal children.
Sleep studies either show adult characteristics,
reduced REM latency, increased number of REM
periods or no change.
Dysthymic Disorder
This disorder has an earlier age of onset than MDD.
About 70 percent of patients with DD eventually
diagnose with MDD. The longer, more recurrent
and frequent, and less related to stress, the more
severe the future mood disorder episodes.
There is debate as to whether these are the
same disorders with different presentations,
because of the common progression of DD to later
MDD. When stressful life events are followed
by depressive symptoms within 3 months, they
should be diagnosed as adjustment disorders and
do not necessarily predict future mood episodes.
Magnetic Resonance Imaging (MRI)

studies
Decreased brain frontal volume and increased
ventricular size have been found. MRI studies
seem to correlate with adult studies.
Social factors
Even identical twins do not have 100 percent
concordance for mood disorders, suggesting that
there is a role for non-genetic factors. Undesirable
life events, chronic adversity, loss or bereavement
and viral illnesses have all been looked at. The
most conclusive evidence is that the loss of a
parent before thirteen years, especially boys losing
fathers, may predispose to depression.
Bipolar Disorder
It is rare in pre-pubertal children and often starts
with depressive episodes and later manic episodes
in adolescence. Childhood manic episodes are
atypical, also less clearly episodic and resistant to
treatment. There may be overlap or shared features
with ADHD. Classic mania is more common in
438
Mood Disorders in Children and Adolescents
adolescents. Childhood presentations are often

atypical with less response to treatment. They may
display mood lability, rapid cycling, continuous, as
opposed to episodic symptoms, high distractibility
and poor attention. Differential diagnosis includes
ADHD, conduct disorder and schizophrenia.
ADHD is usually a long-term behaviour and is not
goal-directed. BMD often has the bipolar family
history. (A more comprehensive account appears
within this section under Psychotic Disorders in
Childhood and Adolescence)

The younger with a more severe initial episode
have a worse prognosis. Comorbid conditions
result in poor prognosis.
MDD
An episode has a mean duration of 9 months with
recurrence very likely and conversion to BMD
over time a possibility. The cumulative probability
of recurrence is 40 percent by two years and 70
percent by ve years. Adolescents (20 - 40 percent)
with MDD, will have a diagnosis of BMD within
5 years. Conict and turbulent psychosocial
circumstances worsen outcome. There are often
peer relationship problems, academic difculties
and self-esteem problems.
Cyclothymia
One uses the same criteria as for adults. Cyclothymic
disorder probably represents BMD I or BMD II
presentations, that occur early and do not meet
the full criteria. There is very little research in this
area.
DD
Bereavement
The mean duration clinically is 4 years. Comorbidity with MDD is 70 percent, co-morbidity
with BMD 13 percent and 15 percent with
eventual substance abuse. Suicide is a major risk.
Grief after death of a loved one may become

MDD as a result of guilt, death preoccupation,
preoccupation with worthlessness, psychomotor
retardation, serious functional impairment
and hallucinations. DSM-IV does not consider
bereavement to be a mental disorder and classies
it as a condition that may be a focus of clinical
attention. If bereaved children have symptoms
of depression for more than two months after the
loss, other symptoms may help to conrm if this is
MDD as opposed to normal grief.
BMD
The mean duration is about 3.7 years, often mixed
and rapid cycling, resistant to treatment and
recurrence common.
Suicide
It is uncommon in children and adolescents but is
increasing in prevalence. Suicide risk factors or
indicators include: previous suicide attempt; current
suicidal ideation; hopelessness; co-morbidity, e.g.
substance abuse; lack of social support; and family
history of suicide.
For schizophrenia/schizoaffective disorder,
substance-induced mood disorder, anxiety
disorders, disruptive disorders conduct, ODD
and ADHD.
Psychotic mania or depression may resemble
schizophrenia and need to be differentiated.
Substance-induced mood disorder may
look very similar, hence, look for history of
substance use and possible physical stigmata.
Anxiety and conduct disorders often occur
during mood disorders and it may be difcult
to ascertain whether they are part of the
disorder or an independent condition.
The same applies to ADHD-like symptoms, acute
mania and agitated depression.
Predisposing factors
Psychiatric illness, disturbed family life, physical
illness, substance abuse, conduct disorders
and physical abuse.
Precipitating factors
Discipline issues, romance, peer conict and
bereavement.
More males than females, and also more
violent methods. Suicide is rare in groups with
no psychopathology, which is very important
in identifying and treating those who do. Half
439
Tricyclic antidepressants are less efcacious in

youth than adults. They also have a serious side
effect prole that requires titration and are lethal
in overdose. Monitoring of cardiovascular status,
including ECG is very important. In addition,
it is important to monitor very closely because
depressive episodes may be the rst episode of
bipolar illness in children.
Mood stabilisers are the mainstay of treatment
for bipolar disorders. Lithium, Carbamazepine and
Valproate are all used.
Antipsychotics may be used in psychotic manic
or depressed states. Electro convulsive therapy
(ECT) is well validated in adults for specic
indications, but less in children. Generally, ECT
should be considered only in individuals with
severe treatment resistant to affective disorders
with psychosis, catatonia or persistent high-risk
suicidality.
of those who complete suicide have contact

with mental health system prior to death.
TREATMENT
Thorough assessment. Conduct developmental and psychosocial histories, including
a family history. An interview with the
child as well as with parents is important.
A psychological assessment may elucidate
the diagnosis, and rating scales may also be
useful.
Information from other sources. Information
from school should be obtained. Parents may
not notice depressive symptoms, but are able
to give better accounts of overt behavioural
difculties. Children themselves give better
accounts of their internal experience.
Address multiple problem areas. Areas
such as educational failure, impaired social
functioning, comorbid conditions, family
psychopathology and recent adverse life
events need to be identied and managed.
Treatment needs to be tailored to the child.
Psychoeducation is vital for both patient and
parents.
Does the child need hospitalisation?
Hospitalisation for safety of self or others
(suicidal or aggressive/homicidal in both
manic and depressive presentations), is
important as well as initiation of treatment.
Psychotherapy
This includes Cognitive Behaviour Therapy
(CBT), social skills training, relaxation therapy,
family intervention, education and therapy and
interpersonal psychotherapy for mild disorders.
Many psychological therapies are useful, but for
severe cases it is not as clear.
Family therapy is almost always a component
treatment for childhood affective disorders.
They may include education, encouraging more
effective conict resolution and addressing family
pathology that may be exacerbating or maintaining
symptoms.
Social skills training, problem solving, relaxation
and self-modelling strategies have all been found
to be useful and their use should be tailored to the
individual patient.
Pharmacotherapy
A range of agents i.e. antidepressants (SSRIs,
TCAs), mood stabilisers and antipsychotics are
used in treating the spectrum of mood disorders.
Of the antidepressants, the SSRIs are rst line
for depressive disorders. They are effective, have
a benign side effect prole and also have a low
lethality in overdose.
There is a 70 to 90 percent response rate in open
studies in children and adolescents. Side effects are
often behavioural and include motor restlessness,
dysphoria, excitability, disinhibition, insomnia and
aggression. Neuropsychiatric effects include mania
and delusions.
Further reading
1. Graham P, Turk J, Verhulst F (2001). Child Psychiatry
a Developmental Approach. Oxford University Press.
Third edition
2. Weller B, Calvert S, Weller R. (2003). Bipolar
Disorder in Children and Adolescents : Diagnosis and
treatment Current Opin Psychiatry 16 (4) :383-388.
440
55
Psychotic Disorders in Childhood and Adolescence
Susan Hawkridge, Christopher P. Szabo
of reality. Fantasy gures may be a feature of their

play and conversation, and may also be reported
as speaking to them. The diagnosis of delusions or
hallucinations in young children should be made
with great care.
Substance abuse in adolescents may lead
to under- or over-diagnosis of schizophrenia.
Youngsters who abuse substances may be selfmedicating pre-existing psychotic illness, and if
the symptoms are ascribed simply to the substance
abuse, underlying schizophrenia may be missed.
Conversely, adolescents who become psychotic
through substance use may be misdiagnosed as
having schizophrenia, if an adequate history taking
and examination are not performed. These patients
should be carefully monitored for recurrent episodes
and/or progressive deterioration.
Mental retardation, developmental disorders
and speech disorders may inuence expression and
description of symptoms.
Major psychiatric disorders such as schizophrenia

and bipolar disorder can have their onset in
childhood or adolescence. Psychosis may also
occur in younger patients as a result of medical
conditions, substance use or medication side
effects. A patient with features suggestive of
psychosis should be medically examined before
a psychiatric diagnosis is considered, and where
possible, specialist opinion sought.
EARLY ONSET SCHIZOPHRENIA

Early onset is dened as onset before the age of
18 years, and very early onset before the age of
12 years. Very early onset of schizophrenia is rare,
and symptoms of psychosis in a child under the age
of 12 years should be assumed to be secondary to a
general medical condition until proven otherwise.
Diagnostic Criteria
Prevalence and epidemiology
These are the same as for adults. If illness lasts for less
than 6 months, the diagnosis of schizophreniform
disorder is used.
Very early onset of schizophrenia is estimated to

occur in less than 1 in 20,000 children, and there
is a male predominance of 1.5:1. Onset before
5 years is very rare and it is unclear whether the
diagnosis can reliably be made at this age. Early
onset schizophrenia is estimated to occur in 1-2 per
1000 adolescents. It appears to be more common
in lower income communities. The IQ range of
affected individuals is usually below average to
average.
(See chapter on Schizophrenia in Adults)
Developmental Aspects
Disorganised behaviour or speech is not
uncommon in children, particularly if they are ill,
over-excited, extremely hyperactive, very anxious
or mentally handicapped. In addition, very young
children do not have a rmly established concept
441
have all been associated with an increased risk of

schizophrenia and higher frequency of relapse.
Clinical description
The precursors of schizophrenia are inconsistent.
There may be attention or conduct problems,
social inhibition or withdrawal, and extreme
sensitivity to perceived criticism. A constellation
of neurological soft-signs and behavioural
abnormalities is common in children who later
develop schizophrenia. A positive family history
of schizophrenia is often found and there are high
rates of substance abuse in males.
There are three patterns of onset: acute, insidious
(more common) and insidious with a supervening
acute episode. Males are more likely to have early
onset schizophrenia, but when females do their
average age of onset is often younger than that of
males.
Frequently encountered symptoms include
hallucinations, formal thought disorder and affective
blunting. These are more common than delusions
or catatonia in younger patients. Poverty of ideation
is rare. Positive symptoms are associated with an IQ
of over 85 and an older age at onset. Eighty percent
of patients experience auditory hallucinations,
usually persecutory in nature, and often giving
commands, conversing or commenting on the
patients activities. Fifty percent have delusions,
most frequently persecutory, somatic, grandiose or
religiose. Ideas of reference are common. Fewer
patients (40 percent) present with formal thought
disorder. In very young patients this can be very
difcult to diagnose.
Investigations
These should include a screen for drugs, a full
neurological work-up and EEG. In-patient
observation may sometimes be necessary in the
establishment of a diagnosis. Once the acute episode
has resolved, IQ testing, communication skills
assessment and adaptive behaviour assessment
should be done prior to decisions being made about
the childs rehabilitation programme and future
management.
The most important differential diagnosis is that
of delirium. Once general medical conditions have
been excluded, multiple collateral sources and
several interviews are needed. In younger children,
developmental and communication disorders must
be considered in the differential diagnosis, and the
effect of developmental stage on the expression of
symptoms must be borne in mind.
Substance abuse, prescribed medications and
seizures can also give rise to psychotic episodes.
Careful differentiation from bipolar mood disorder
is essential, as treatment strategies differ markedly.
Occasionally, the symptoms of OCD (Obsessive
Compulsive Disorder) or body dysmorphic disorder
may suggest delusions. It is important that the whole
range of functioning is considered when making
a diagnosis of schizophrenia. There are frequent
occurrences of isolated reported hallucinations
giving rise to a diagnosis of schizophrenia,
with all its implications and unfortunate stigma.
Hallucinations, auditory or visual, are sometimes
reported by young children or mentally retarded
individuals in the absence of any other symptoms
of schizophrenia. A period of observation and an
attempt to understand the possible signicance of
the isolated hallucination are necessary before an
assumption of psychotic illness is made.
Aetiology and pathogenesis

Biological factors such as neurological
developmental delays, complications of pregnancy
and delivery, EEG abnormalities and abnormal
information processing, have all been implicated
in the aetiology of schizophrenia. Genetic factors
appear to be of importance in predisposing an
individual to the development of the disorder.
Abnormalities in sensory and motor functioning,
attention decits and learning disabilities have also
been associated with schizophrenia.
Family and interpersonal factors have long
been investigated for a role in the pathogenesis
of schizophrenia. Communication abnormalities
within the family of origin appear to be common, and
there is a raised incidence of unusual personalities
(schizotypal or schizoid) in family members. High
expressed emotion is thought to be associated
with precipitation of relapse. Environmental and
social inuences such as stressful life events, poor
socio-economic conditions and substance abuse
Co-morbidity
Conduct disorder, substance use disorders, learning
disabilities and mental retardation are frequently
found comorbidity with schizophrenia, usually
predating the onset of psychosis. Young patients
with schizophrenia are prone to depression and
anxiety disorders, and these should be independently
treated. Loss of insight may limit the usefulness of
psychotherapeutic approaches, and antidepressants
may be required. Post-traumatic stress disorder
442
to this, the possibility of early entry into a sheltered

employment programme should be investigated.
Many young patients require medium term
hospital admission, particularly if home conditions
are unsatisfactory, or the patient is aggressive,
dangerous, vulnerable or very distressed. However,
dedicated facilities are extremely scarce, especially
for younger children, and many will end up in
adult-orientated institutions. This is undesirable
both from an ethical and a developmental point of
view.
may follow episodes of psychosis or admission to

psychiatric hospital and should be independently
addressed.
Treatment
Every child or adolescent with schizophrenia
should have an individualised treatment programme
involving multiple modalities. Medication is
regarded as essential, as there is some evidence
that non-treatment of psychosis may worsen the
long-term outcome. The major class of drugs used
is the antipsychotics, but there are potential longterm adverse effects, so informed consent, careful
monitoring and periodic review are essential. The
side-effect prole of the newer antipsychotics
appears to be signicantly better than that of the
traditional antipsychotics. There is good evidence
that the newer drugs are also effective in treating
the negative symptoms as well as the positive.
Ideally, these would be the medication of choice
for young patients, but they are unfortunately
expensive and not readily available to patients
in developing countries. There are also concerns
about the metabolic side effects of some of the
newer drugs.
Psychotherapy is not an effective treatment for
schizophrenia per se, but is a vital component of
the management of the disorder. The individual
and his/her family will both need psycho-education
and ongoing supportive psychotherapy. Specialised
forms of cognitive behaviour therapy (CBT) have
been used to help young patients deal with active
psychotic symptoms. Support groups for patients
and relatives play an important role in the provision
of an optimal environment for recovering patients.
In the post-acute phase of the illness, behaviour
modication programmes may be of benet in the
inpatient setting.
Ideally, children and adolescents with
schizophrenia would continue to attend school, in
order to allow for maximal academic and social
development, but this seldom occurs. Some wellresourced and informed schools are willing to
make special arrangements for such learners.
However, most often, the child simply falls
behind academically or develops behavioural
problems as a result of not being able to cope.
Even those who can be accommodated in their
original school are subject to relapse as a result
of the pressure of expectations. Many end up out
of school, unsupervised, and are easy targets for
negative elements in the community. Attendance
at a day programme for young patients with major
psychiatric illnesses is the best alternative. Failure
Outcome
Stability of diagnosis ranges from 30-70 percent
in studies. It is not uncommon for a young patient
who presents initially with what appears to be a
manic episode to present sometime later with a
second episode that is classically schizophrenic
in nature. A 30 year follow-up study of a 1933
series of childhood psychosis (denitions
differ from current diagnostic criteria) found only
1 doing satisfactorily. Institutionalisation was
associated with poor outcome, but whether this is
causative or consequent is not veriable. A better
prognosis was associated with a later onset (older
than 10 years), an acute onset, better premorbid
functioning, well-differentiated symptoms and a
greater degree of affective symptomatology. About
50% had the chronic form of the illness (i.e. with
no remissions) and medications had been of benet
only with regard to the positive symptoms. These
children were mostly treated with traditional antipsychotics. Later studies found that the outcome
was still generally poor.
Suicide occurred in 21 percent of males and 6
percent of females. Predictors of poor outcome
were poor pre-morbid functioning, being male and
having an early onset, delusions and at affect.
A delay longer than 4 weeks in treatment of the
presenting episode has been associated with a poor
outcome in some studies.
BIPOLAR DISORDER
The incidence of bipolar disorder in pre-pubertal
children is very low, but in adolescence it rises
to 0.6 percent. However, recent studies have
suggested that the disorder is much more common
than previously thought in children. There are some
concerns about the validity of the criteria used to
make the diagnosis in children, and the possible
consequences of over-diagnosing the disorder.
443
Aetiology
There is a strong genetic predisposition to bipolar

disorder, and the pattern appears to resemble
autosomal dominant transmission. There is often a
history of a stressor prior to the rst manic episode,
but the role of the environment appears to become
less signicant in later episodes.
Schizophrenia, borderline personality disorder,

conduct disorder and substance abuse must all be
considered in the differential diagnosis of a manic
episode. Pervasive developmental disorders and
AD/HD should be considered in younger patients.
Management
Clinical features
Severe depression and mania usually require

hospitalisation. This may be problematic in a
situation where dedicated units for younger
patients do not exist. Several common features
of manic episodes in young patients, namely
disinhibited hypersexuality, impulsive aggression
and intrusiveness, make these patients vulnerable
to abuse in an adult setting. If young patients have
to be admitted to adult facilities, extra care should
be taken to ensure their safety.
Medication in the acute phase is usually a
mood stabiliser (lithium, carbamazepine, sodium
valproate or lamotrigine), with adjunctive
use of antipsychotics (preferably atypical)
where appropriate, and benzodiazepines such
as lorazepam where necessary for containment.
The use of antidepressants in bipolar depressive
episodes may precipitate a manic episode,
which may predispose the child to rapid cycling.
Maintenance treatment is with a mood stabiliser.
Patients taking any mood stabiliser should have
their blood drug levels and other parameters
checked regularly, because of the risk of toxicity
and adverse effects.
Family support and psycho-education is essential
in order to encourage compliance and to ensure
that the diagnosis does not obscure the need for
attention to parenting style and family interactions.
Once the young patient has been stabilised,
supportive psychotherapy is useful in assisting the
child to come to terms with what has happened to
them. Behaviour during the acute phase may later
be embarrassing to the child, and return to their
peer group may be extremely stressful. In addition,
bipolar breakdowns may last for months, and the
child may miss out on developmental opportunities
afforded by their peer group. Particular attention
should be paid to the rehabilitation of young bipolar
patients, as their inter-episode functional capacity
may be unaffected, and a relatively normal life is
possible.
Early intervention in the prodromal phase or even
in asymptomatic young patients at risk has shown
equivocal benets so far, but should be considered
Symptoms of bipolar disorder in young patients

usually resemble those found in adults with the
disorder, and the diagnostic criteria are the same.
However, the developmental stage of the child may
inuence the expression of the symptoms. Mania
in children may take the form of hyperactivity,
distractibility, irritability or anxiety. A manic
episode in adolescence may present as an episode of
aggressive behaviour. In addition, younger patients
are prone to experience mixed episodes, with
rapid mood swings. The onset is often insidious,
with poor premorbid functioning and a treatment
lag often occurs. The rst episode is usually a major
depression, sometimes psychotic, but this may not
be noticed or treated if resources are inadequate.
Most young patients appear to come to the notice
of treatment centres only after a manic episode
has caused them to act in a dangerous or socially
inappropriate way.
An increase in the frequency of diagnosis of
the disorder has followed studies which suggest
that childhood bipolar disorder is different from
adult bipolar disorder. It is suggested that children
with the disorder do not have episodic cycles, but
are in a constant state of mood instability, with
irritability being the dominant feature. Grandiosity
and hypersexual behaviour are considered the
hallmarks of the disorder. This has led to many
children who would previously have been regarded
as having AD/HD and dysthymia/anxiety disorder,
being diagnosed as bipolar. It remains to be seen
whether long term outcome studies will support
this view, but in the interim, the diagnosis of prepubertal bipolar disorder should be made by a child
psychiatrist if possible.
(See chapter on Mood disorders in Adults)
Comorbidity
Conduct disorder, substance abuse and AD/HD
often co-exist with bipolar disorder, and may
complicate the diagnostic process as well as
management.
444
premorbid levels, but medication may inuence

the childs appearance and self-condence. Weight
gain is the most frequent complaint from young
patients taking lithium and some other mood
stabilising drugs.
where the risk is high and prodromal symptoms

are present. Psychotic episodes and functional
deterioration may be delayed.
Outcome
About 80 percent of young patients presenting with
a bipolar illness still need medication 10 years later.
Non-compliance and substance abuse are the most
frequent causes of relapse. Nevertheless, even with
treatment compliance, there is a signicant rate of
relapse. Functioning between episodes may be at
Further reading
1. Graham P, Turk J, Verhulst F (2001). Child Psychiatry:
A Developmental Approach. Oxford University Press.
Third edition.
2. Weller B,Calvert S, Weller R. (2003). Bipolar
Disorder in Children and Adolescents : Diagnosis and
Treatment Current Opin Psychiatry 16 (4) :383-388
445
56
Tic Disorders
Susan Hawkridge, Christopher P. Szabo
Tics are involuntary, sudden, rapid, recurrent

movements (motor tics) or vocalisations (vocal
tics). They may be simple (single movement or
simple sound) or complex (groups of movements
or phrases). Some may be dramatic and socially
impairing, such as coprolalia, in which a vocal
tic consists of an obscenity or echolalia, where
the patient repeats what he has just said. Tics can
sometimes be suppressed and may diminish during
sleep or focussed activity. There is a tendency for
them to worsen with stress.
Aetiology
There is a strong genetic component to the
vulnerability to tic disorders. They are more
common in monozygotic twins than in dizygotic
twins. In addition, there is a genetic link between
obsessive-compulsive disorder (OCD) and
Tourettes disorder, and family members of
those with Tourettes disorder have an increased
incidence of other tic disorders and OCD. There
are specic neurochemical and neuroanatomical
abnormalities, in that dopamine transmission
appears to be increased in some areas of the brain,
and noradrenergic circuits are also affected. There
may be a role for endogenous opioids. The basal
ganglia and fronto-striatal circuits appear to be the
neuroanatomical substrate.
TOURETTES DISORDER
Tourettes disorder is a type of tic disorder, rst
described by Georges de la Tourette in 1885. It
comprises multiple motor and vocal tics for more
than 1 year with onset before the age of 18 years.
They must cause impairment of functioning or
distress and the symptoms should not be caused by
a general medical condition or substance use.
Clinical features
Tics can vary over time in both site and severity,
giving a uctuating degree of severity and
complicating assessment of treatment efcacy.
They can affect any part of the bodyface and
head, arms and hands, body and legs, respiratory
and gastro-intestinal (GIT) systems. There is often
a prodromal irritability, with attention problems
and low frustration tolerance. In fact, up to 25
percent of patients have received stimulants before
the onset of their tics. Some tics are so forceful that
they cause injury to the patient.
Epidemiology
Tourettes disorder is found in 4-5 per 10,000 of
the general population. Onset is usually before 7
years for motor tics and 11 years for vocal tics.
The incidence in boys is three times higher than
in girls.
446
Tic Disorders
Table 56.1
307.23 Tourettes Disorder
A. Both multiple motor and one or more vocal tics have been present at some time during the illness,
although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, non-rhythmic, stereotyped
motor movement or vocalisation.)
B. The tics occur many times in a day (usually in bouts) nearly every day or intermittently throughout
a period of more than 1 year, and during this period there was never a tic-free period of more than 3
consecutive months.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a
general medical condition (e.g., Huntingtons disease or postviral encephalitis).
as children may be punished for what may be

perceived as intentional and irritating movements
and noises.
Associated features
Comorbid OCD occurs in 40 percent of patients
with Tourettes disorder, usually with later onset.
AD/HD occurs in more than 50 percent, usually
with earlier onset. Children with Tourettes are
often impulsive with poor affect regulation. They
may have non-specic EEG abnormalities, and
about 10 percent have structural abnormalities on
imaging.
Treatment
Some neuroleptic medications have been found
to be effective against tics. Haloperidol reduces
tics by up to 80 percent in most patients, at
a dosage of 0.25-0.5 mg/day up to 3 mg/day.
There are associated risks of cognitive dulling,
drowsiness, school phobia and tardive dyskinesia,
making informed consent mandatory. Pimozide
has been shown to be equally effective at a dosage
of 1-2 mg/day up to 6 mg/day. While it appears
to be less cognitively impairing, there is still some
sedation, and tardive dyskinesia may occur. In
addition, effects on cardiac conduction make this
medication unsuitable as a rst line of treatment.
Informed consent and a baseline ECG with
sequential monitoring are necessary. Risperidone
and sulpiride have been shown to be effective
against tics and have somewhat more benign
side effect proles, especially at low doses. All
neuroleptic drugs can be associated with signicant
weight gain and monitoring of metabolic indices is
warranted.
Other medications shown to have some
efcacy against tics include the alpha adrenergic
agonists clonidine, which improves tics in 40 70 percent of patients, and guanfacine. Onset of
improvement, however, is slow, sedation may be a
problem, and tolerance may develop. An additional
efcacy against AD/HD makes this a reasonable
choice for children with Tourettes disorder and
AD/HD. Care needs to be taken with cardiovascular
activity and the possibility of rebound hypertension
on sudden cessation. The dose range is 0.025 - 1mg
two or three times per day. In the past, some tricyclic
antidepressants have been used to treat the same
Other movement disorders must be excluded,
and in particular Sydenhams chorea should be
considered. A rising or falling ASO titre may indicate the post-streptococcal auto-immune condition.
Wilsons disease and Huntingtons chorea should
also be considered. Tremors, mannerisms or the
stereotypical movements found in autistic disorder
or mental retardation may be present with a similar
clinical picture, and some compulsions may be
difcult to distinguish from tics. In addition, some
tardive extrapyramidal side effects of neuroleptic
medications may be clinically indistinguishable
from them. These, however, tend to present much
later following chronic neuroleptic use. Stimulants
may precipitate tics which may or may not resolve
on cessation of the medication.

The disorder is usually life-long with remissions
and exacerbations. There may be serious emotional,
social, academic and occupational complications,
with a risk of depression and sometimes suicide.
In most patients, however, the tics are mild and
require no treatment. The functional outcome is
improved if family, school and friends are aware of
the disorder and educated about it. In particular, the
involuntary nature of the tics should be emphasised,
447
combination of disorders, but cardiac side effects

make this a less attractive option. Successful
treatment of tics has been documented with other
second generation antipsychotic medications such
as ziprasidone. There has been some success with
experimental agents such as nicotine patches, and
botulinum toxin. Neurosurgery appears to show
some promise in extremely resistant cases, but is
not readily available and carries signicant risks.
Psychosocial treatments have been studied,
and behavioural methods such as habit reversal,
mass practice and relaxation techniques may be
useful in reducing tic frequency. Psychotherapy
is not effective alone, but may be very helpful
in the management of psychological distress and
associated psychiatric disorders.
The medical management of AD/HD when
comorbid with tic disorders has been controversial.
However, it is now generally accepted that while
stimulant drugs may exacerbate tics, this is often
only a mild exacerbation and may be acceptable
if there is signicant improvement in AD/HD
symptoms.
CHRONIC MOTOR OR VOCAL

TIC DISORDER
These disorders present with either motor or vocal
tics, but not both. Chronic motor tics are more
common and may have been present for at least 1
year, caused impairment or distress, and had their
onset before 18 years of age. The prevalence in
the general population is 1-2%, and boys are more
often affected than girls. The symptoms usually
last 4-6 years and cease in early adolescence. A
genetic component is present, as in Tourettes
disorder. Diagnosis requires the exclusion of other
movement disorders. Medication is necessary only
if impairment is severe and the potential benets
outweigh the risks. Psychotherapy may be required
for psychological complications or psychiatric
comorbidity such as OCD, and behavioural
methods may be effective in teaching the child to
control tics to some extent.
Table 56.2
307.22 Chronic Motor or Vocal Tic Disorder
A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped
motor movements or vocalizations), but not both, have been present at some time during the
illness.
B. The tics occur many times a day nearly every day or intermittently throughout a period of more
than 1 year, and during this period there was never a tic-free period of more than 3 consecutive
months.
C. The onset is before the age of 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a
general medical condition (e.g., Huntingtons disease or postviral encephalitis).
E. Criteria have never been met for Tourettes Disorder.
stressor. In children with a genetic vulnerability to

tic disorders, progression to a chronic tic disorder
or Tourettes disorder is more common. If tics
are severe or have caused signicant emotional
problems, a full paediatric and psychiatric
evaluation should be obtained. Medication is used
only in exceptional cases.
TRANSIENT TIC DISORDER

This diagnosis is used when tics are present for
more than 4 weeks, but less than 1 year. Tics occur
in 5-24 percent of children, and in most remit
spontaneously. Such tics may be precipitated by a
448
Tic Disorders
Table 56.3
307.21 Transient Tic Disorder
A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor
movements or vocalizations)
B. The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive
months.
C. The onset is before the age of 18 years,
D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical
condition (e.g., Huntingtons disease or postviral encephalitis).
E. E. Criteria have never been met for Tourettes Disorder or Chronic Motor or Vocal Tic Disorder.
Specify if:
Single Episode or Recurrent
Table 56.4
307.20 Tic Disorder
Not Otherwise Specied
This category is for disorders characterised by tics that do not meet criteria for a specic Tic Disorder.
Examples include tics lasting less than 4 weeks or tics with an onset after age 18 years.
Further reading
1. Kuperman S. (2003). Tics and Tourettes Syndrome in
Childhood. Semin Pediatr Neurol. 2003 Mar;10(1):3540.
2. Leckman J. (2002) Tourettes Syndrome. Lancet. Nov
16;360 (9345):1577-86.
449
57
Sexual and other Types of Child Abuse
Khalifa Mrumbi, David M. Ndetei, Christopher P. Szabo
Sexual abuse includes sexual behaviour between a

child and an adult or between two children when
one of them is signicantly older or uses coercion.
The perpetrator and the victim may be of the
same sex or the opposite sex. Sexual behaviours
include:
Touching breasts, buttocks, and genitals,
whether the victim is dressed or undressed
Exhibitionism
Fellatio
Cunnilingus
Penetration of the vagina or anus with sexual
organs or objects.
Sexual abuse involves abuse of power by an adult
over a child, exploitation of a childs innocence and
status, a breach of trust, deception and intrusion.
Whilst the act is primarily physical, consequences
may be both physical and psychological.
There are other forms of child abuse which may
take the form of physical injury, verbal threats
or abuse, persistent intimidation, neglect, and
withholding of special favours, severe corporal
punishment, sexual abuse or child delement.
Severe physical injury is often inicted on children
under the guise of instilling discipline by parents
or care-takers.
Children who are prone to abuse are usually
under the age of ve. Such children may be
under the care of step-parents or parents who
were themselves abused, or may be mentally ill,
suffering from depressive illness or a psychosis.
Others are victims of parental marital discord

where the children are used by warring parents
to punish each other. Offenders in sexual abuse
or delement may be neighbours, step-parents,
and house boys. Aged grand fathers with features
of dementia may dele very young children aged
under ve. Substance abuse, including alcohol
dependence may be associated with child abuse.
Sexually abused children, like adults, may suffer
post-traumatic stress disorder, depression, fear,
lack of trust in other people, guilt feelings and
self-blame which may persist into adulthood and
interfere with the establishment of trusting loving
relationships.
Recently, with the many wars in Africa,
abductions of children have been increasingly
observed either to be used as child soldiers or
for sexual exploitation. Refugee children and those
in Internally Displaced Peoples Camps, (IDP)s,
are particularly vulnerable to abuse by adults or
other older children.
PSYCHOPATHOLOGICAL
SYMPTOMS OF SEXUALLY
ABUSED CHILDREN
Anxiety symptoms
Fearfulness, phobias, insomnia, nightmares (that
directly portray the abuse), somatic complaints,
Post-traumatic stress disorder (PTSD), increased
450
anger, depression, passivity, difculties focusing

and sustaining attention and withdrawal from usual
activities.
FACTORS ASSOCIATED WITH

MORE SEVERE SYMPTOMS
IN THE VICTIMS OF SEXUAL
ABUSE
Dissociative reactions and hysterical

symptoms
Periods of amnesia, day-dreaming, trancelike states, hysterical seizures and symptoms
of dissociative identity disorder.
Greater frequency and longer duration of

abuse
Sexual abuse that involved use of force or
penetration
Sexual abuse perpetrated by a closer relation
(childs father/stepfather).
Depressive symptoms
Low self-esteem (self-doubt), suicidal ideation and
self-destructive or mutilative behaviours.
Behavioural symptoms (acting out

behaviours).
CHARACTERISTICS OF CHILD
SEXUAL OFFENDERS
Delinquency, promiscuity and self-destructive

behaviour.
Disturbances in sexual behaviours

Sexual hyperarousal, sexual behaviours suggestive
of abuse: masturbating (with an object), imitating
intercourse and inserting objects into vagina/anus.
Other less specic (abnormal) sexual behaviours
Showing genitals to other children.
Touching genitals of others.
Age inappropriate knowledge of sexual
activity.
Sexually aggressive/pronounced seductive
behaviour towards others.
Promiscuous behaviour.
Avoidance of sexual stimuli through phobias
and inhibitions.
Sudden decline/change in school performance/
behaviour/peer relations.
Somatic complaints
Enuresis, encopresis, anal and vaginal itching,

anorexia, obesity, headache, fatigue, stomach ache,
urinary tract problems, gynaecological problems,
STD/HIV infections and pregnancy.
These symptoms and behaviours are not limited
to sexually abused children. Non-abused children
may exhibit any of these symptoms and behaviours.
Approximately one-third of sexually abused
children have no symptoms.
451
Come from many walks of life.

Timid and unassertive.
Poor impulse control.
Domineering interpersonal style.
Social and relationship decits (social
isolation, difcult forming emotionally close
and trusting relationships).
History of being sexually abused in childhood.
Seldom discernible on basis of personality
traits, occupation or age.
Vast majority are male.
Preference for sexual exploitation of children
and adolescents because:
o Of their age and innocence
o They cannot consent to such activities
o They cannot easily disclose the abuse to
someone.
Seldom resort to violence and force to gain the
childs compliance.
Are attentive to childs needs in order to:
o Gain the childs affection, interest and
loyalty.
o Minimise the chances that the child will
report the sexual activity.
Social isolation
Childrens hesitancy to disclose incidents of
sexual abuse, because of their close and special
relationship to the abuser
Offenders attempt to control or manipulate to
prevent discovery
Most kids worry that they are to blame for the
abuse; thus keep it a secret.
COMMON TECHNIQUES
SEXUAL OFFENDERS USE TO
GAIN COMPLIANCE
Win the trust of the childs mother

Marry a woman with an attractive child
Initiating a friendship
Playing games
Giving presents
Having hobbies that appeal to the child
Using peer pressure
Sexual behaviour takes place only after a
period of grooming (gradual indoctrination
into sexual activity).
OTHER TYPES OF CHILD ABUSE

Neglect
Most prevalent form of child maltreatment.
Failure to provide adequate care and protection
for children.
Physical neglect includes: abandonment,
expulsion from home, disruptive custodial
care, inadequate supervision, and reckless
disregard for a childs safety and welfare.
Medical neglect includes refusal, delay or
failure to provide medical care.
Educational neglect includes: failure to enrol a
child in school, allowing chronic truancy.
PHASES ASSOCIATED WITH

SEXUAL ABUSE
Engagement phase. Perpetrator induces the
child into a special relationship.
Sexual interaction phase. Sexual behaviours
progress from less to more intimate forms of
abuse.
Secrecy phase. Offender threatens the victim
not to tell.
Disclosure phase. When the abuse is
discovered.
Suppression phase. When the family pressures
the child to retract his/her statements.
Physical abuse (child battering)

It is any act that results in a non-accidental physical
injury, such as: beating, punching, kicking, biting,
burning and poisoning. Some physical abuse is
due to unreasonably severe corporal punishment or
unjustiable punishment.
Psychological abuse
This occurs when a person conveys to children that
they are worthless, awed, unloved, unwanted and
endangered. The perpetrator may abuse the child
by spurning, terrorising, isolating and berating.
SITUATIONAL FACTORS
INCREASING CHILDRENS
VULNERABILITY TO BEING
SEXUALLY ABUSED
Emotional abuse
This includes verbal assaults such as belittling,
screaming, threats, blaming and sarcasm;
unpredictable responses, persistent negative
moods, constant family discord and double
message communications.
Having family problems

Spending a lot of time alone
Seeming unsure of themselves
Attractiveness, trusting and young
Lax supervision
Parental unavailability, illness or stress
Spousal abuse
Lack of emotional closeness to the child
Low income
Ritual abuse
Cult-based ritual abuse involves bizarre or
ceremonial activity that is religiously or spiritually
motivated. Satanic ritual abuse may be physical,
sexual or psychological.
452
Further Reading
1. Sexual Violence against Children. In Principles
and Practice of Forensic Psychiatry. (1990). Edited
by Robert Bluglass and Paul Bowden, Churchill
Livingstone Edinburgh Page 567-570
453
58
Eating Disorders
Christopher P. Szabo, Khalifa Mrumbi
Eating disorder not otherwise specied

(EDNOS).
The eating disorders within the (DSM-IV) are those
best described and recognised. Both AN and BN
have sub-types, which allow for a more complete
description at a clinical level, but may also have
implications for prognosis. AN, binge eating or
purging sub-type may have the worst prognosis
with BN, non-purging type, the best. Although
AN and BN are best known, EDNOS entity most
likely applies to most eating disorder sufferers.
A diagnosis of EDNOS is usually made where a
sufferer does not meet the full criteria for either AN
or BN, but has features of an eating disorder.
Eating disorders are among the most prevalent and

lethal of all psychiatric disorders in contemporary,
urban, western settings. Whilst not considered to be
common in African populations, these conditions
have existed for decades in white South African
females and are emerging in greater numbers
amongst black South African females in urban
settings. A similar pattern might be predicted for
the rest of Africa.
DEFINITION
Thoughts: overvalued, excessive and inappropriate
thoughts and concerns about weight and shape.
Actions: efforts to address the concerns through
dietary manipulation.
Consequences: compromised at a physical,
emotional and cognitive level with negative
effects for social, occupational and academic
functioning
DIAGNOSTIC CRITERIA
Anorexia Nervosa (AN)
The primary diagnostic criteria relate to weight,
self-evaluation, fear and endocrine dysfunction.
The DSM-IV has specic criteria for diagnosing
AN. The rst relates to weight, i.e. less than 85
percent of expected for age and height. The second
looks at the presence of a distorted body image
or the inability to accurately assess ones own
body dimensions. This criterion also mentions
the inclination to evaluate oneself purely in terms
of weight, as well as an inability to recognise the
seriousness of ones condition. The third criterion
relates to the fear of being overweight even though
that is not the case. Finally, endocrine dysfunction
CLASSIFICATION
The DSM-IV TR classies eating disorders as
follows:
Anorexia Nervosa (AN). This includes
restricting sub-type and binge eating/purging
sub-type.
Bulimia Nervosa (BN). This includes purging
and non-purging sub-types.
454
Eating Disorders
in the form of absence of menstrual periods for

3 consecutive months is a criterion. All of these
criteria must be met to make the diagnosis.
Table 58.1
307.1 Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g.,
weight loss leading to maintenance of body weight less than 85% of that expected; or failure to
make expected weight gain during period of growth, leading to body weight less than 85% of that
expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which ones body weight or shape is experienced, undue inuence of
body weight or shape on self-evaluation, or denial of the seriousness of the current low body
weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual
cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone,
e.g., oestrogen, administration).
Specify type:
Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged
in binge-eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or
enemas)
Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly
engaged in binge-eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)
food ingestion and can take the form of vomiting

or laxative use. These behaviours need to occur at
least twice a week for 3 months. Self-evaluation,
just like AN, is unduly inuenced by weight. If
these features occur, but the diagnostic criteria
for AN are met, then the diagnosis of AN, binge
eating-purging sub-type must be made. To make a
diagnosis of BN, there must not be a diagnosis of
AN.
Bulimia Nervosa (BN)

The primary diagnostic criteria relate to binge
eating, compensatory behaviour frequency, selfevaluation and AN. The DSM-IV has specic
criteria required to make the diagnosis of BN. Binge
eating is dened as an objectively large quantity of
food consumed in a discrete period of time with a
feeling of loss of control. Purge behaviour follows
Table 58.2
307.51 Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterised by the following:
(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is
denitely larger than most people would eat during a similar period of time and under similar
circumstances
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating
or control what or how much one is eating)
B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a
week for 3 months.
D. Self-evaluation is unduly inuenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
455
Specic Type
Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in selfinduced vomiting or the misuse of laxatives, diuretics, or enemas
Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate
compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in selfinduced vomiting or the misuse of laxatives, diuretics, or enemas
EPIDEMIOLOGY
MANAGEMENT
Eating disorders occur predominantly in females,

usually Caucasian, mainly in the adolescent and
young adult years and most commonly in urban
settings. These conditions have become a global
phenomenon, beginning to emerge in males, older
and younger girls and women, as well as from
within cultures and ethnic groups not thought to
suffer from such conditions. Specically in South
Africa, there has been an increase in such patients
within the black population. Socio-economic status
is not thought to be a dening variable as sufferers
appear to have a range of backgrounds in this regard.
AN is estimated to have a prevalence of less than 1
percent within the vulnerable populations and BN
less than 4 percent. It is thought that EDNOS is
more prevalent, occurring in 10-14 percent. Hence,
in certain settings these are common conditions.
Professionals involved
Whilst eating disorders are generally treated by
psychiatrists or psychologists, a medical doctor
should always be involved specically for the
purposes of monitoring the physical status of the
patient. Increasingly, a range of other professionals
such as nutritionists and medical social workers
have become involved in treatment.
In- versus Out-patient

Most sufferers are treated as out-patients. The need
for hospitalisation is determined by their physical
status as well as the presenting symptoms and their
impact on patient functioning at all levels, i.e.
emotional, cognitive and behavioural. Based on
physical status, initial hospitalisation may be to a
medical ward and upon stabilisation to a psychiatric
facility preferably with a specialist eating disorder
program.
AETIOLOGY
These are complex conditions and accordingly the
aetiology is complex. No single factor has been
identied as causing an eating disorder, and the
aetiology is thought of as multi-factorial, more
specically as a consequence of both individual
and environmental factors interacting. Individual
factors might include certain personality styles,
e.g. perfectionism or a family history of eating
disorders, and environmental factors may include
disruptive home circumstances or change of school.
The most prominent risk factor appears to be
dieting. Most such dieting, whilst highly prevalent
amongst urban adolescents is seldom justied on
health grounds and is usually driven by aesthetic
concerns addressed through weight loss. This
contemporary societal phenomenon represents a
signicant environmental risk factor.
TREATMENT
General principles
Stabilisation of eating pattern: nutritional
rehabilitation
Stabilisation of eating takes different forms with
either AN or BN. With AN one attempts to restore
adequate quantity, variety and frequency of food
intake, with the emphasis on restoring weight.
With BN the same applies, but with emphasis on
controlling binge and purge behaviour. With AN,
weight restoration must not be rapid and although
one may require daily caloric intake in excess of
3000 cal. per day. The starting point is sometimes
as low as 1000 cal. per day. Aggressive restoration
456
Eating Disorders
of food intake can compromise the patients cardiac

status, which needs to be monitored through the
early stages of the process.
is often resistance to any form of intervention as a

consequence of lack of insight or fear of change.
These issues often dominate early intervention.
The form of psychotherapy usually indicated is
cognitive-behavioural therapy (CBT). In essence
the therapist attempts to assist the patient stabilise
aberrant behaviour as well as identify and correct
the thinking that has led to the behaviour. This form
of therapy is focused, structured and deals with the
here and now.
Normalisation of thoughts/beliefs: cognitive reh

abilitation. (see Specic Approaches)
Specic approaches
BioThe rst issue is to ensure survival of the
patient, whose physical status may be at risk as
a consequence of the disorder. These conditions
impact on all organ systems, hence the need
for specic knowledge regarding the physical
complications that require monitoring and medical
intervention as necessary. Most such problems
reverse with nutritional rehabilitation, hence, food
is the primary biological intervention. Medication
is used where required, but is generally not a rst
line intervention on psychiatric grounds.
Social
Social aspects of treatment relate directly to the
patient as well as the environment in which they
live. A therapist, beyond understanding theories
about social causation of illness, needs to have an
awareness of such factors as they might relate to the
patient. Patients are often vulnerable and sensitive
to perceived societal messages about who or what
they need to be. The inuence of the fashion and
dieting industries certainly come into play as does
the changing role of women in society. Enabling
the patient to engage in such issues in a constructive
way, is an important component of therapy.
Medication
Medication is generally used for the treatment of
comorbid medical problems, if at all, given that
most physical consequences of anorexia nervosa
are reversible bodily changes related to the
starvation state. From a psychiatric perspective,
the most commonly required agent is a low dose
of chlorpromazine used to contain any inclination
for overactivity, usually when in hospital. There
are no drugs indicated as primary treatment for
AN, however certain antidepressant drugs i.e.
the serotonin reuptake inhibitors e.g., uoxetine at
doses of up to 60 mg/day have been found helpful
in the treatment of certain BN sufferers. The use
of psychotropic agents is likely to be used for the
treatment of comorbid psychiatric conditions e.g.,
mood or anxiety disorders.
OUTCOME
The outlook for eating disorder sufferers varies
according to the condition. The prognosis in terms
of symptom resolution is better for BN than AN.
In terms of improvement, about 60 percent
of AN sufferers and 90 percent of BN sufferers
will experience improvement over time, with
appropriate treatment. Some patients may alternate
between either condition. Mortality varies from 620 percent of AN sufferers depending on duration
of follow-up. Irrespective of the actual gure, AN
has a higher than expected rate of mortality and
must be understood as a life threatening condition.
The same goes for BN. Given the difcult nature
of the conditions and patients, there is often a sense
of being able to do nothing for sufferers. In reality,
with appropriate understanding and intervention,
change for the better is possible.
PsychoPsychotherapy is the mainstay of intervention for

either AN or BN. The patient is obviously the focus
of such an intervention, but depending on the age
and marital status of the patient there is need for
family or, potentially, spousal involvement. There
Table 58.3
307.50 Eating Disorder Not Otherwise Specied

The Eating Disorder Not Otherwise Specied category is for disorders that do not meet the criteria for any
specic Eating Disorder. Examples include:
1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular
menses.
457
2.
3.
4.
5.
6.
All of the criteria for Anorexia Nervosa are met except that, despite signicant weight loss, the
individuals current weight is in the normal range.
All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate
compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less
than 3 months.
The regular use of inappropriate compensatory behaviour by an individual of normal body weight
after eating small amounts of food (e.g., self-induced vomiting after the consumption of two
cookies).
Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of
inappropriate compensatory behaviours characteristic of Bulimia Nervosa.
Other feeding and eating disorders of infancy or early childhood are summarised in the DSM-IV-TR Tables
58.4, 58.5, and 58.6.
Table 58.4
307.52 Pica
A. Persistent eating of non-nutritive substances for a period of at least 1 month.
B. The eating of non-nutritive substances is inappropriate to the developmental level.
C. The eating behaviour is not part of a culturally sanctioned practice.
D. If the eating behaviour occurs exclusively during the course of another mental disorder (e.g.. Mental
Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufciently severe to warrant
independent clinical attention.
Table 58.5
307.53 Rumination Disorder
A. Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of
normal functioning.
B. The behaviour is not due to an associated gastrointestinal or other general medical condition (e.g.,
oesophageal reux).
C. The behaviour does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If
the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental
Disorder, they are sufciently severe to warrant independent clinical attention.
Table 58.6
307.59 Feeding Disorder of Infancy or Early Childhood
A. Feeding disturbance as manifested by persistent failure to eat adequately with signicant failure to
gain weight or signicant loss of weight over at least 1 month.
B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g.,
oesophageal reux).
C. The disturbance is not better accounted for by another mental disorder (e.g.. Rumination Disorder) or
by lack of available food.
The onset is before age 6 years.
458
Eating Disorders
2. Garner DM, Garnkel PE (eds). (1997). Handbook of

Treatment for Eating Disorders, Second Edition. New
York: The Guildford Press.
3. Kaplan HI, Sadock BJ (eds). (1998). Synopsis of
Psychiatry, 8th edition. Philadelphia: Lippincott,
Williams & Wilkins.
Further reading
1. American Psychiatric Association. (2000). Practice
Guidelines for the Treatment of Eating Disorders,
second edition. In: Practice Guidelines for the
Treatment of Psychiatric Disorders. Washington:
APA, 627-697.
459
59
Other Disorders and Presentations
Christopher P. Szabo, Susan Hawkridge
ages exist at which this developmental milestone

should be achieved. Clinically there may either
be a failure to achieve this milestone or returning
to bedwetting after having stopped. In either
situation there needs to be an assessment of any
physical factors that might be contributing to
the presentation e.g. urinary tract infections,
epilepsy (nocturnal seizures) or indeed any
structural (anatomical) abnormalities. There is an
association with emotional factors and a thorough
history is required to establish any individual
or environmental factors e.g. family conict or
change of school, which might contribute especially
where the milestone had been achieved with the
emergence of bedwetting subsequent to that.
ELIMINATION DISORDERS
These conditions are characterised by problems
with bowel or bladder control, specically where
older children who should have developmentally
appropriate control are still soiling themselves.
The specic disorders associated with elimination
problems are enuresis and encopresis.
Enuresis
The primary presentation relates to ongoing bedwetting, with a failure of the child to achieve
appropriate nocturnal bladder control. A range of
Table 59.1
307.6 Enuresis (Not Due to a General Medical Condition)

A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
B. The behaviour is clinically signicant as manifested by either a frequency of twice a week for at least 3
consecutive months or the presence of clinically signicant distress or impairment in social, academic
(occupational), or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behaviour is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic)
or a general medical condition (e.g., diabetes, spina bida, a seizure disorder).
Specify type:
Nocturnal Only: passage of urine only during nighttime sleep
Diurnal Only: passage of urine during waking hours
Nocturnal and Diurnal: a combination of the two subtypes above
460
problem and parents may experience anger and

disappointment. Such issues need to be addressed as
part of a comprehensive approach to the problem.
Management
Before
initiating
symptomatic
treatment,
it is important to establish any individual
or environmental factors, which might be causing
the presentation with appropriate investigations.
Having excluded any physical causes and
established a primary diagnosis of enuresis,
management proceeds towards addressing the
problem.
Medication can be used and this usually takes
the form of a low dose (10-25mg) Tricyclic
antidepressant such as imipramine, taken at night.
In this instance the drug is not being used for
its primary indication i.e. major depression but
rather for its effects related to the anticholinergic
activity of the agent. Additional interventions
include both behavioural approaches in terms of
acknowledgement of the child for dry nights
through a star chart whereby such nights are noted
on a chart with a star. Any individual psychotherapy
should be undertaken as indicated together with
family work. Patients may feel ashamed of the
Encopresis
The primary presentation relates to inappropriate
faecal soiling. This is either as a consequence
of developmental issues or may be as a result
of psychological factors. As with enuresis, any
possible physical factors need to be excluded which
might lead to incontinence, as well as any other
causes such as gastro-intestinal infection. Typically
the stool in encopretic individuals is well formed
and not exclusively a nocturnal phenomenon. It
should be noted that there may be a presentation of
overow incontinence due to refusal to defecate.
The basis of such refusal needs to be understood
as whilst the presentation may be similar to that
of encopresis, the problem leading the presentation
may be different e.g. a child with obsessivecompulsive disorder who has contamination issues
and thus refuses to defecate.
Table 59.2
Encopresis
A. Repeated passage of faeces into inappropriate places (e.g., clothing or oor) whether involuntary or
intentional.
B. At least one such event a month for at least 3 months.
C. Chronological age is at least 4 years (or equivalent developmental level).
D. The behaviour is not due exclusively to the direct physiological effects of a substance (e.g., laxatives)
or a general medical condition except through a mechanism involving constipation.
Code as follows:
787.6 With Constipation and Overow Incontinence: there is no evidence of constipation on physical
examination or by history
307.7 Without Constipation and Overow Incontinence: there is no evidence of constipation on physical
examination or by history
responses from family and this is clearly an issue

in family work.
Management
As with enuresis it is imperative to exclude any
physical or medical factors, which might be
contributing to the presentation. A thorough history
and assessment of the individual and the family is
necessary, in attempting to establish the underlying
psychological factors. Apart from any individual
and family interventions required, the approach is
generally behavioural. Specically attempting to
create regular bowel functioning and defecation.
A star chart presentation elicits very powerful
LEARNING PROBLEMS
Learning problems are common presentations in
child and adolescent psychiatric settings. The basis
of such problems needs to be elucidated. These
may range from specic learning disorders and
intellectual impairment (mental retardation) to
461
academic problems associated with other conditions

or environmental factors. Such conditions may be
either psychiatric e.g. major depression or medical
e.g. epilepsy (both of which may cause cognitive
impairment), with environmental factors involving
relationship issues, changing grades or schools or
family circumstances. In certain instances where
children with problems at school are brought for
assessment to mental health settings it is important
to establish not only the nature of the problem,
but also determine their basis. This will inuence

subsequent management. Such management may
require formal tests of intellectual functioning
with an emphasis on educational or remedial
intervention. Alternatively, specic psychiatric
or medical factors may be determined. In such
an instance, psychiatric or medical intervention
is warranted. Whatever the management, family
involvement and liaison with the relevant
educational authorities are required.
Table 59.3
Learning Disorders (formerly Academic Skills Disorders)
315.00 Reading Disorder
A. Reading achievement, as measured by individually administered standardised tests of reading accuracy
or comprehension, is substantially below that expected given the persons chronological age, measured
intelligence, and age-appropriate education.
B. The disturbance in Criterion A signicantly interferes with academic achievement or activities of daily
living that require reading skills.
C. If a sensory decit is present, the reading difculties are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory decit is present, code the
condition on Axis III.
Table 59.4
315.1 Mathematics Disorder
A. Mathematical ability, as measured by individually administered standardised tests, is substantially
below that expected given the persons chronological age, measured intelligence, and age-appropriate
education.
B. The disturbance in criterion A signicantly interferes with academic achievement or activities of daily
living that require mathematical ability.
C. If a sensory decit is present, the difculties in mathematical ability are in excess of those usually
associated with it.
Coding note: If a -general medical (e.g., neurological) condition or sensory decit is present, code the
Table 59.5
315.2 Disorder of Written Expression
A. Writing skills, as measured by individually administered standardised tests (or functional assessments
of writing skills), are substantially below those expected given the persons chronological age,
measured intelligence, and age-appropriate education.
living that require the composition of written texts (e.g., writing grammatically correct sentences and
organized paragraphs).
462
C.
If a sensory decit is present, the difculties in writing skills are in excess of those usually associated
with it.
Coding note: If a general medical (e.g., neurological) condition or sensory decit is present, code the
Table 59.6
315.9 Learning Disorder Not Otherwise Specied
This category is for disorders in learning that do not meet criteria for any specic Learning Disorder. This
category might include problems in all three areas (reading, mathematics, written expression) that together
signicantly interfere with academic achievement even though performance on tests measuring each
individual skill is not substantially below that expected given the persons chronological age, measured
intelligence, and age-appropriate education.
MOTOR SKILLS DISORDERS

Table 59.7
315.4 Developmental Coordination Disorder
A. Performance in daily activities that require motor coordination is substantially below that expected
given the persons chronological age and measured intelligence. This may be manifested by marked
delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things, clumsiness,
poor performance in sports, or poor handwriting.
living.
C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular
dystrophy) and does not meet criteria for a Pervasive Developmental Disorder.
D. If Mental Retardation is present, the motor difculties are in excess of those usually associated with
it.
Coding note: If a general medical (e.g., neurological) cconditon or sensory decit is present, code the
DEVELOPMENTAL
COORDINATION DISORDER
COMMUNICATION DISORDER
phonological disorder (development articulation

disorders) and stuttering. They are summarised in
Tables 59.8-59.12.
These include expressive language disorder,

mixed receptive-expressive language disorder,
463
Table 59. 8
315.31 Expressive Language Disorder
A. The scores obtained from standardised individually administered measures of expressive language
development are substantially below those obtained from standardised measures of both nonverbal
intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or
having difculty recalling words or producing sentences with developmentally appropriate length or
complexity.
B. The difculties with expressive language interfere with academic or occupational achievement or with
social communication.
C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental
Disorder.
D. If Mental Retardation, a speech-motor or sensory decit, or environmental deprivation is present, the
language difculties are in excess of those usually associated with these problems.
Coding note: If a speech-motor or sensory decit or a neurological condition is present, code the condition
on Axis III.
Table 59.9
315.32 Mixed Receptive-Expressive Language Disorder
A. The scores obtained from a battery of standardised individually administered measures of both receptive
and expressive language development are substantially below those obtained from standardised measures
of nonverbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well
as difculty understanding words, sentences, or specic types of words, such as spatial terms.
B. The difculties with receptive and expressive language significantly interfere with academic or
occupational achievement or with social communication.
C. Criteria are not met for a Pervasive Developmental Disorder.
D. If Mental Retardation, a speech-motor or sensory decit, or environmental deprivation is present, the
language difculties are in excess of those usually associated with these problems.
on Axis III.
Table 59.10
315.39 Phonological Disorder (formerly Developmental Articulation Disorder)
A. Failure to use developmentally expected speech sounds that are appropriate for age and dialect
(e.g., errors in sound production, use, representation, or organisation such as but not limited to,
substitutions of one sound for another use of W for target/k/ sound/ or omissions of sounds such as
nal consonants).
B. The difculties in speech sound production interfere with academic or occupational achievement or
with social communication.
C. If Mental Retardation, a speech-motor or sensory decit, or environmental deprivation is present,
the speech difculties are in excess of those usually associated with these problems.
on Axis III.
464
Table 59.11
307.0 Stuttering
A. Disturbance in the normal uency and time patterning of speech (inappropriate for the individuals
age), characterized by frequent occurrences of one or more of the following:
(1) sound and syllable repetitions
(2) sound prolongations
(3) interjections
(4) broken words (e.g., pauses within a word)
(5) audible or silent blocking (lled or unlled pauses in speech)
(6) circumlocutions (word substitutions to avoid problematic words)
(7) words produced with an excess of physical tension
(8) monosyllabic whole-word repetitions (e.g., l-l-l-l see him)
B. The disturbance in uency interferes with academic or occupational achievement or with social
communication.
C. If a speech-motor or sensory decit is present, the speech difculties are in excess of those usually
associated with these problems.
on Axis III.
Table 59.12
307.9 Communication Disorder Not Otherwise Specied
This category is for disorders in communication that do not meet criteria for any specic Communication
Disorder; for example, a voice disorder (i.e., an abnormality of vocal pitch, loudness, quality, tone, or
resonance).
Pervasive Developmental Disorders
Table 59.13
DSM-IV-TR Diagnostic Criteria for Stereotypic Movement Disorder
A. Repetitive, seemingly driven, and non-functional motor behaviour (e.g., hand shaking or waving, body
rocking, head banging, mouthing of objects, self-biting, picking at skin or bodily orices, hitting own
body).
B. The behaviour markedly interferes with normal activities or results in self-inicted bodily injury that
requires medical treatment (or would result in an injury if preventive measures were not used).
C. If mental retardation is present, the Stereotypic or self-injurious behaviour is of sufcient severity to
become a focus; of treatment.
D.The behaviour is not better accounted for by a compulsion (as in obsessive-compulsive disorder), a tic
(as in tic disorder), a stereotype that is part of a pervasive developmental disorder, or hair pulling (as in
trichotillomania).
E. The behaviour is not due to the direct physiological effects of a substance or a general medical condition.
F. The behaviour persists for 4 weeks or longer.
Specify if:
With self-injurious behavior: if the behaviour results in bodily damage that requires specic treatment (or
that would result in bodily damage if protective measures were not used)
465
466
Treatments
and
Management
467
468
Section VI Part A:
Physical Treatments
469
60
Ethno-Psychopharmacology and its
Implications in the African Context
Ayoub R. Magimba, Sylvia F. Kaaya, Gad Kilonzo, David M. Ndetei
they are also present in other tissues, but in lower

amounts. Environmental and genetic factors affect
the activities of these enzymes which can lead to
enhanced or decreased drug biotransformation and
disposition of the drugs that are their substrates.
Mutations in gene coding for a drug metabolising
enzyme can give rise to enzyme variants with higher,
lower, or no metabolising activity. If the mutant
allele occurs with a frequency of at least 1-2 percent
in the normal population and causes a different drug
response or phenotype, this phenomenon is termed
a pharmacogenetic polymorphism. Polymorphisms
in drug metabolising enzymes divide the population
into at least two phenotypes, extensive and poor
metabolisers. Studies comparing the status of
these enzymes in Caucasian, Oriental and Bantu
populations have clearly demonstrated inter-ethnic
genetic variations in patterns of polymorphisms,
which produce clinically important population
differences in responses to many drugs.
The
Cytochrome
P450s
is
relevant
to psychotropics. These are listed below.
GENETIC POLYMORPHISM IN
NEURO-PHARMACOTHERAPY
Metabolism: pharmacological and
toxicological effects of drugs
Drugs acting on the central nervous systems show
great inter-individual and inter-ethnic variation in
effects. The factors responsible for this variability
range from the extent of drug-serum protein binding,
metabolism to active and inactive metabolites, and
variability in the amount or sensitivity of drug
target receptors.
Drug metabolism is a major determinant of
the pharmacological and toxicological effects of
an administered drug. Most psychotropic drugs
are lipophilic which enables them to cross the
blood brain membrane barrier to reach their target
receptors. Metabolism to water-soluble products
is necessary for drug elimination, failure of which
can lead to drug accumulation that is associated
with the intensication of adverse effects, some of
which can be fatal.
The major enzyme systems involved in the
biotransformation of many drugs are cytochrome
P450 (CYP), glutathione S-transferases (GST),
UDP-glucoronosyl transferases, sulfanotransferases and N-acetyltransferases (NAT). These enzyme
systems are mainly found in the liver although
Isozyme CYP1A2
Substrates
470
Clozapine
Clomipramine
Imipramine
Propranalol
Ethno-Psychopharmacology and its Implications in the African Context
Inhibitors: Fluvoxamine
Other characteristics
Others: Maprotiline, ecstasy(methyle

nedioxymethamphetamine),
mianserin,
venlafaxine, debrisoquine
Makes upto 5-10 percent of the total P450 in

the liver
Not expressed at birth
Activates promutagens and procarcinogens
Inhibitors: Fluphenazine, moclobemide

Genetic polymorphism (sparteine/debrisoquine type)
Many potent inhibitors
Ethnic variation: Absent (poor metabolisers)
in the livers of:
- 7-8 percent Whites
- 1-2 percent Blacks and Orientals
This absence is due to multiple inactivating
mutations in the CYP2D6 gene
Genotyping of extensive and poor metabolisers
possible.
CYP 2A6
Clinical relevance to psychotropic drugs not
well established
CYP 2C9
Substrate
Phenytoin
Make up 10-20 percent of the total P450 in the
liver
CYP 2C19
CYP3A4
Substrates
Substrates
Amitriptyline, citalopram, clomipramine,

diazepam, imipramine and moclobemide
Benzodiazepines: alprazolam, diazepam,

midazolam, triazolam
Others: carbamezapine, imipramine
Inhibitors: Fluvoxamine, Fluoxetine and

Moclobemide
Inducers: carbamezapine, dexamethasone, pheno

barbital, prednisolone
Makes up about 5 percent of the total P450 in

the liver
Absent: - from the liver in:
- 3 percent of Whites
- 20 percent of orientals (poor metabolisers)
Several inactivating mutations in the CYP2C19
gene
Genotyping of poor metabolisers is possible
Expressed in both the liver and the intestinal

mucosa
Make up about 25 percent of the total content
of P450 in the liver
Pronounced rst-pass metabolism for many
substrates
The CYP2D6 is the most important cytochrome
P450 in psychiatry
CYP2D6
Inhibition potential of antidepressants at

CYP450 enzyme systems
Substrates
B-blockers: propranalol
neuroleptics: perphenazine, haloperidol,
remoxipride,
risperidone,
thioridazine,
olanzapine, zuclopenthixol
SSRIS: uoxetine, paroxetine, uvoxamine
Tricyclic anti-depressants: amitriptyline,
nortriptyline, clomipramine, desipramine,
imipramine, n-desmethyl clomipramine, nort
riptyline, trimipramine,
Fluvoxamine has the high relative inhibition

potential at CYP450 enzyme system, in 1A2, 2C9/
19, 2D6 and 3A4, followed by uoxetine in all the
above except 1A2, and nefazodone for only 3A4.
Moderate to low inhibition potential is found
with tertiary tricyclics, uoxetine, paroxetine
for 1A2, sertraline and uoxetine for 2C9/19,
Secondary tricyclic for 2D6, sertraline and tricyclic
for 3A4. All the other anti-depressants have low to
minimum inhibition for the above isozymes.
471
had already attained drug plasma concentrations

within the sub-therapeutic drug dose range.
It is known that antipsychotic drugs have a
narrow therapeutic window and that usually
relatively low drug concentrations are required for
a therapeutic effect. Higher drug concentrations
only increase the risk of extra pyramidal side effects
without appreciable increase in antipsychotic
efcacy. If not identied, poor metabolisers may
thus be treated with unnecessarily high doses of
antipsychotic drugs, resulting in an increased risk
of disturbing side effects which in turn lead to
decreased patient compliance with the treatment.
Poor metabolisers are particularly at increased
risk for the accumulation of drug and resulting
drug-related toxicity in situations where a prodrug is metabolised to a pharmacologically active
metabolite.
CYP2D6
The now well-dened genetic polymorphisms at
the CYP2D6 gene locus were the rst defect in
drug metabolism to be specically associated with
altered expression of a P450 enzyme. This defect
has been shown to be responsible for pronounced
inter-individual variations in the metabolism of
many clinically important drugs, including the
marker substrates debrisoquine and sparteine.
CYP2D6 substrates are structurally diverse and,
as a consequence, can perform many different
pharmacological functions. Indeed, recent estimates
suggest that CYP2D6 may be responsible for the
metabolism of up to 25 percent of all prescribed
drugs.
Linking genotype to phenotype: Poor
metabolisers (PM) and Extensive metabolisers
(EM)
Variations in the distribution of CYP2D6

polymorphisms in populations
Pharmacokinetic studies on the metabolism and

disposition of a number of antipsychotic drugs and
antidepressants have been conducted in panels of
CYP2D6 poor metabolisers (PMs) and extensive
metabolisers (EMs) (Table 60.1).
In general, there is a two to ve times difference
between poor and extensive metabolisers in the
capacity to metabolise CYP2D6 substrates. PMs
obtain the same steady-state serum levels as EMs
at doses which are 50-80 percent lower than those
given to EMs. In the panel studies with haloperidol
and zuclopenthixol, poor metabolisers experienced
more side effects than extensive metabolisers at
the assumed sub-therapeutic doses. Administering
half of the dose administered to EMs to PMs
resulted in attaining drug plasma concentrations
compatible to that of the EMs. In panel studies
with sub-therapeutic doses of perphenazine, PMs
experienced more adverse effects than EMs, and
The molecular genetic basis for the different

phenotypes has been characterised very well for
Caucasians, Orientals and to a lesser extent for
African populations. At least 17 allelic variants of
CYP2D6 have been described.
Using a combination of restriction fragment
length polymorphism (RFLP) analysis and allelespecic amplication by polymerase chain reaction
(PCR), over 95 percent of persons carrying known
variant alleles can be identied. These genotyping
techniques have been used in many population
studies to characterise the frequency of allelic
variants of CYP2D6 in different population
groups.
The frequency and variations that have been
noted in the CYP2D6 activity in various ethnic
grouping can be summarised.
Table 60.1: Ethnic Differences in CPY2D6
Decreased
Allele
Caucasian
Orientals
African
Zimbabweans
Ethiopians
1.5
0.0
Not detected
0.0
0.0
10
5.0
50.0
Not detected
5.0
8.6
17
0.0
0.0
Not detected
34.0
90.
Allele
Caucasian
Orientals
African
Zimbabweans
Ethiopians
2.0
0.0
0.24
0.0
0.0
23.0
0.8
8.5
2.0
1.2
5.0
5.65
6.0
4.0
3.3
Absent
Note: In Africa, the only detected variants are in absent Allele 3 (0.24 percent), Allele 6 (8.50 percent) and Allele 5 (6.0 percent)
472
CYP2D6 genotyping studies that have been

conducted in sub-Saharan African populations,
demonstrate evidence for heterogeneous polymorphisms of cytochrome P450. A review of
studies conducted in the continent, with regards
to these polymorphisms indicated a prevalence of
0-19 percent of CYP2D6 that confers poor drug
metabolising status of its substrates in African
populations, compared to consistent 5-10 percent
prevalence in Caucasian populations. Genotyping
in Zimbabwean and Ethiopian populations, indicate
the absence of the detrimental CYP2D6*3 allele
and low prevalence of CYP2D6*4 suggesting a
low prevalence of poor metabolising status in these
populations. However, while the allelic variants
CYP2D6*4, 5 and 10, are common across most
ethnic groups, the allelic variant CYP2D6*17
(that also confers poor metabolising status) has
only been detected in black African populations,
with prevalence rates of 9 percent (n=122) in
Ethiopian populations, 20 percent (n=212) and
30 percent (n=176) amongst normal healthy
Tanzanian subjects and Tanzanian psychiatric
patients respectively, and 34 percent (n=104) in a
Zimbabwean population.
These variations lead to increased, decreased or no

change in activity, depending on which one of 17 or
more allelic variants of the CYP2D6 is involved.
Increased activity (allele 2)
Caucasian 1.0 18 percent
Orientals 0
African Not detected (ND)
Zimbabweans 1.0
Ethiopians 16.0
Through linking genetic to pharmacokinetic
studies, the molecular genetic basis for the status
of poor metabolisers has been shown to be the
occurrence of combinations of any of a number
of defective alleles, the most common being the
CYP2D6*4 allele (CYP2D6B) bearing a splice-site
mutation. Other less frequent detrimental alleles
are the CYP2D6*3 (CYP2D6A) with a frame shift
mutation and the CYP2D6*5 (CYP2D6D) being a
gene deletion. A rare variant, the CYP2D6*9 allele
(CYP2D6C) which bears a three base pair deletion
that leads to the production of a low activity
enzyme, but does not result in a poor metabolising
phenotypic expression, has been reported amongst
Caucasians.
The ultra rapid metabolising status in Caucasians
has been found to be linked to haplotypes with two or
more functional CYP2D6 genes of the CYP2D6*2
(CYP2D6L) variant. The CYP2D6*2 variant has
the same activity as the wild type CYP2D6*1 but
has a tendency to duplicate or amplify. Subjects
with the duplicate or amplied gene tend to have
very high CYP2D6 activity and accounted for
40 percent of ultra rapid metabolising status in a
Swedish study.
The CYP2D6 locus in Orientals has a number
of differences from what has been observed in
Caucasians. Oriental populations do not have
the CYP2D6*3 but only 0.8 percent CYP2D6*4
mutant variants. The CYP2D6*5 allele exists
at a frequency similar to that found amongst
Caucasians and might account for some of the poor
metabolising status reported in Orientals. However,
a CYP2D6 mutant (allele 10) occurs at low
prevalence in Caucasian populations (5 percent)
and at much higher prevalence (50 percent) in
Chinese and Japanese subjects. Subsequent studies
have demonstrated that this variant, CYP2D6*10
(CYP2D6J, Ch), was the basis of diminished
CYP2D6 activity in Oriental populations with the
mutant gene resulting in the production of a low
activity and unstable enzyme.
Clinical implications of CYP2D6

polymorphisms in psychiatric care
Studies on the clinical implications of differences
in the rate of metabolism of antipsychotic drugs
in Caucasoid (Europeans and white North
Americans) and Oriental (Chinese, Japanese
and Koreans) populations, indicate a majority
of ultra-metabolising status in the former with
resultant lower drug therapeutic effects; whereas
in Oriental populations the proportions with poor
metabolising status are higher with subsequent
higher vulnerability from moderate to severe side
effects of antipsychotic drugs. This observation
is of particular relevance to clinical psychiatry
and clinical pharmacology, as establishment of
antipsychotic drug doses that produce optimal
therapeutic with minimal adverse effects is crucial
for medication adherence, relapse prevention and
hence outcomes for many psychotic disorders.
Antipsychotic-induced extra-pyramidal adverse
effects are a serious problem in the treatment
of psychotic disorders. Acute extra-pyramidal
symptoms as a result of treatment occur in 75-90
percent of patients receiving rst generation antipsychotic drugs. Drug side effects have the potential
to impede drug adherence directly through their
experience and indirectly by increasing stigma as
473
a result of their visibility. Acute dystonic reactions

(ADR) for example, which occur during the rst
few days of antipsychotic drug treatment, are
often distressing and can be life threatening when
laryngeal involvement occurs. Twenty-three out
of 62 (37 percent) rst-episode psychotic patients
who were receiving antipsychotic drugs developed
acute dystonic reactions (ADR) after treatment with
haloperidol; ADR being signicantly associated
with young age, severity of illness and negative
symptoms at baseline. Such frightening adverse
effects may generate an aversion to the use of
antipsychotic drugs. Drugs such as thioridazine that
fall in the rst generation group of antipsychotic
drugs cause a pronounced prolongation of the
QTc interval, which can lead to ventricular
arrhythmias. Other distressing side effects include
weight gain, diabetes mellitus, sexual dysfunction,
cognitive dysfunction and consequent reductions
in quality of life. In addition to unpleasant
experiences with side effects, adverse effects such
as gait changes and drooling saliva as a result of
Parkinsonism are visible to others and may increase
the stigma attached to mental disorders.
noted in schizophrenics carrying the mutant allele

CYP2D6*2 and a trend in this direction amongst
those carrying the CYP2D6*10 gene. Another
study looked at 11 patients receiving olanzapine
to explore the association between CYP2D6
polymorphisms and the weight gain side effect of
the drug. When duration of treatment and drug dose
were adjusted, it was noted a signicantly higher
percent change in basal metabolic index amongst
patients carrying the heterozygous polymorphism
CYP2D6*1/*3 and CYP2D6*1/*4, when compared
to patients carrying the CYP2D6*1/*1 gene (ultra
metaboliser status).
Amongst 199 patients with schizophrenia,
the frequency of occurrence of CYP2D6*1 and
CYP2D6 mutations, all patients carrying the
homozygous detrimental alleles (CYP2D6*3,
CYP2D6*4, CYP2D6*5, CYP2D6*6) (N=4)
had EPS. However, the homo and heterozygous
functional alleles (CYP2D6*1 and CYP2D6*1/
*1) were equally distributed amongst patients
with and without EPS. Mihara et al noted a lack
of over-representation of detrimental CYP2D6
alleles in 9 patients with tardive dyskinesia.
Dettling et al found insignicant variations in
CYP2D6 functional and mutant alleles amongst
patients on (N=31) Clozapine with drug induced
agranulocytosis and patients (N=77) without this
adverse effect. Finally Hemelin et al noted a lack
of association between presence of CYP2D6
mutant alleles and the number and severity of
drug side effects amongst schizophrenic (N=39)
consecutive patients and 89 of French Canadian
origin. These ndings suggest an association
between homozygous polymorphisms conferring
poor metabolising status and the development of
EPS, as well as weight gain, the likely mechanism
being higher steady state haloperidol concentration
amongst poor metabolisers.
There is little information from sub-Saharan
Africa on the effects of CYP2D6 polymorphisms
on the occurrence of anti-psychotic drug side
effects amongst patients with psychotic disorders.
A pilot case control study done among psychiatric
patients in Tanzania to determine the association
between CYP2D6 genotype and development of
acute dystonic reactions among psychiatric inpatients on antipsychotic medication, revealed
a signicant association between dystonia and
occurrence of alleles conferring poor metabolising
status. The alleles CYP2D6*4/*4, CYP2D6*4/*5
and CYP2D6*5/*5 occurred amongst 44.9 percent,
36.7 percent and 22.4 percent respectively of
Evidence for associations between

polymorphisms and drug side effects
It has been noted that there is no difference in
genotype frequencies between patients with
psychotic disorders such as schizophrenia and
normal controls, suggesting CYP2D6 genotype
is not a factor in determining susceptibility to
the disease. There is existing evidence for an
association between polymorphisms of CYP2D6
and its phenotypic expression clinically in the
form of side effects, though methodological
problems make it difcult to be conclusive about
the mechanisms of this association. In studies
with control group designs, the evidence for this
association is apparent.
A study examined the association between
CYP2D6 activity and serum haloperidol steady
state concentration and antipsychotic drug induced
extra-pyramidal side effects in Japanese patients
with schizophrenia (N=320) and normal controls
(N=196). It reported signicantly higher frequency
of CYP2D6*2 (PM status) and a trend towards higher
frequency of CYP2D6*10 in the schizophrenic
patients susceptible to acute extrapyramidal
side effects (EPS). Similar differences were not
observed amongst patients with and without
Tardive dyskinesia. In this study, signicantly
higher steady state haloperidol concentrations were
474
amongst patients receiving the newer generation

drugs.
The probability of occurrence of tardive
dyskinesia a more long term and debilitating
extra-pyramidal side effect amongst patients
on second and third generation (often known
as atypical anti-psychotic drugs) anti-psychotic
drugs is reported to be 1 percent, as compared to 5
percent in patients using the older rst generation
antipsychotic drugs.
Though much recent research has focused on
development of drugs that can control psychotic
conditions effectively and in the least toxic manner,
the inherent advantages in the use of second and
third generation drugs may not be apparent in
many low-income countries due to their prohibitive
costs. Given the importance of drug adherence
for psychotic episode relapse prevention and
hence better treatment outcomes, the phenotypic
expression of ethnic specic polymorphisms of
CYP2D6 in both drug therapeutic and adverse
effects warrants the attention of clinicians in the
mental health care eld, particularly in low-income
countries.
patients with acute dystonia, compared to only 6.1

percent, 4.1 percent and 2.0 percent respectively of
ADR. Extensive metabolising status (CYP2D6*1/
*1) was protective against developing neuroleptic
induced dystonia.
The role of anti-cholinergic drugs
Amongst 646 (41 percent female) consecutive
admissions to a psychiatric acute treatment
facility where an overall prevalence of ADR of 5.3
percent is reported; ADR was higher in patients on
antipsychotic drugs alone (8.5 percent) compared
to those on antipsychotic drugs combined with
anticholinergic medication (2.5 percent). The
efcacy of anticholinergic drugs in treating extra
pyramidal side effects is not questionable, however,
controversy surrounds when to initiate therapy and
for how long. A review of the few double-blind,
placebo controlled trials on the value of concurrent
anticholinergic medication use at the outset of
treatment with antipsychotic drugs, suggests
support of the use of these agents to prevent ADR,
but methodological deciencies in many of the
studies prevent conclusive ndings .
The role of atypical antipsychotic drugs in
decreasing side effects and improving adherence
CONCLUSION
In a systematic review and meta-analysis of

randomised controlled trials comparing new
generation atypical antipsychotic drugs with
placebo and/or conventional (rst generation) antipsychotic drugs, 11 studies with a total of 2,032
patients provided comparative data on relapse for
new and conventional anti-psychotics. Overall
treatment failure was modestly but signicantly
lower with the newer drugs; an observation that
might be due to better adherence given the less
debilitating side effects of these drugs. In a study
of 189 persons with schizophrenia where survival
analysis using treatment events as a unit of measure
was used to compare outcomes in patients on
atypical (new generation) and conventional (rst
generation) drugs; patients on the former were
noted to have lower risk of medication change,
medication use gaps and re-hospitalisation.
Similarly, using pharmacy rell records to
compare medication adherence in out-patients on
new versus older generation drugs, Dolder et al,
noted moderately higher adherence rates at twelve
months in patients who received newer generation
drugs (adherent ll rate of 54.9 percent) compared
to patients on rst generation drugs (adherent
ll rate to 50.1 percent). However, the modest
improved adherence rates in this study suggest a
need for interventions to improve adherence even
Knowledge of the existence of CYP2D6

polymorphisms in populations with psychotic
disorders is useful for determining appropriate drug
doses and standards for drug treatment of these
conditions. Establishment of safe dosing should
take into consideration ethnic variations in drug
metabolising status, suggesting a need for across
ethnic group studies.
Patients and relatives beliefs about schizophrenia and medication may be of considerable
importance in determining adherence. Using as
a point of departure the health belief model to
understand medication adherence behaviours,
some authors suggest providing information
about benets and side effects as well as attitudes
of patients towards illness and medication may
play important roles in determining adherence
to treatments. Good prescribing practices could
perhaps improve adherence through reducing
anxiety and resentment towards continued use of
medication created by occurrence of side effects
through patients expectations of such effects, and
information on appropriate responses.
There is some indication that health education
alone might not sufce to improve medication
adherence. Evidence from a meta-analysis of
475
Patients ending up committing suicide are to

some extent a reection of inadequate clinical
skills in foreseeing and taking preventive
measure. It is easier to blame the drug than
clinical skills!
Quite often patient/relatives are not adequately
educated on their conditions, treatments sideeffects, benets, and expectations, again a case
of clinical skills.
The number of people who commit suicide
because they cannot access treatment for
the various reasons discussed above can be
expected to be higher than those who would
commit suicide using the drugs, usually
because of poor clinical skills.
All of the above are not to say people from Africa
should not have access to newer developments but
that such newer developments should not become
the impediment to appropriate, affordable, available
and accessible treatment.
39 intervention studies to improve medication

adherence in schizophrenia, revealed signicant
intervention effects in 33 percent; interventions
that included concrete problem solving (targeted
specically to problems of non-adherence) or
motivational techniques in addition to psychoeducation were more likely to be effective than
psycho-education alone. For improving medication
adherence in schizophrenia, there are potential
benets of models of community care such as
assertive community treatment and interventions
based on principles of motivational interviewing
that provide patients with concrete instructions
and problem-solving strategies, such as reminders,
self-monitoring tools, cues, and reinforcements.
Comprehensive studies that explore drug-related
and individual behavioural and genetic factors in
antipsychotic drugs adherence and doses amongst
psychiatric patients in Africa are required to inform
cost effective interventions that will improve
medication adherence.
The implications of a full appreciation of these
ethnic differences are far reaching. One of the
major reasons why many patients in Africa are not
on treatment is because the medicines preferred by
physicians on the basis of doses geared to Western
setting are too costly. In addition, equally effective
but far less costly medicine are not prescribed
either because there are newer medicines with less
side-effects (but expensive) or the side effects are
intolerable. The latter has a lot to do with issues of
metabolism.
Therefore, a more judicious prescription in
lower doses using less costly medicines with equal
efcacy as newer generation drugs will achieve the
following:
Less side-effects and therefore compliance
without compromising on desired results.
Increased affordability and therefore access to
treatment.
Many more people in Africa will be on
treatment without compromising on desired
effects.
Critics will advance the argument of toxicity in
overdose, especially in suicidal patients. While it
is true this is a risk, the following are also equally
true.
The modes of committing suicide in Africa are
not the same as in Western settings, where the
prescribed drug is the most common mode.
In Africa if drugs are used, these are usually
household drugs and not the prescribed drugs.
Further Reading
1. Bertilsson L; Dahl ML; Johansson I. Ingelman
Sundberg M; Sjquist (1995) F. Inter-individual
and interethnic differences in Polymorphic drug
oxidation. Implications for drug therapy with focus
on psychoactive drugs. In Pacic GM and Fracchia
GN ed. Advanced in drug metabolism in man Ch 4.
European Commission;: 85-136.
2. Collen Masimirembwa, Julia Hasler. (1997) Genetic
polymorphism of drug metabolising enzymes
in African populations: Implications for use of
neuroleptics and antidepressants. Brain Research
Bulletin, 44 (5): 561-71.
3. Akillu E., Persson I, Bertilsson L., Johansson,
I., Rodrigues, F., Ingelman-Sundberg M.(1996)
Frequent distribution of ultra-rapid metabolisers of
deprisoquine in an Ethiopian population carrying
duplicated and multi-duplicated functional CYP2D6
alleles. J. Pharmacol. Exp. Ther. 278; 441-444.
4. Collen M. Masimirebwa, Inger Johahnsson, Julia
A. Hasler and Magnus Ingelman-Sundberg (1999)
Genetic Polymorphism of Cytochrome P450 CYP2D6
in a Zimbabwean population. Pharmcogenetics 3,
275-280.
5. Collet Dandara; Collen Masimirembwa, Ayoub
Magimba, Jane Sayi, Sylvia Kaaya, Julia Hasler:(2001)
Genetic Polymorphism of CYP 2D6 and CYP2C19
in East and Southern African populations including
psychiatric patients. Eur. J Clinical Pharmacol. 57(1);
11-17.
6. Magimba.A. (2003) Derisoquine hydroxylase genetic
polymorphism and neuroleptic induced acute dystonic
reaction among psychiatric patients, Muhimbili
National Hospital, unpublished dissertation submitted
476
in partial fulllment for the MMED Psychiatry course;

Muhimbili University College of Health Sciences of
the University of Dar-es-Salaam, Ta nzania
7. Masimirembwqe CM, Hasler J, Bertilssm L,
Johansson I, Ekberg O, Ingelman-Sunberg M,. (1996)
Phenotype and genotype analysis of debrisoquino

Hydroxylase (CYP2D6) in a blade Zimbabwean
Population reduced enzyme activity and evaluation of
metabolic correlation of CYP2D6 probe drugs. Eur. J.
Clin Pharmacol 51:117-122.
477
61
Psychopharmacotherapy11
John Mburu, David M. Ndetei, Nelly Kitazi, Francisca Ongecha-Owuor, Seggane
Musisi, Gad Kilonzo, Christopher P. Szabo, Mohamedi Boy Sebit
THE BASICS OF
PSYCHOPHARMACOLOGY
BIOLOGICAL THERAPIES
Traditionally, pharmacological agents used to treat
psychiatric disorders are referred to as psychotropic
drugs, psychoactive drugs or psychotherapeutic
drugs. The main categories of these drugs are:
Antipsychotics or neuroleptics
Anti-depressants
Anti-anxiety (anxiolytics)
Mood stabilisers
Anti-convulsants
Psycho-stimulants
Others
However, this classication is not rigid since the
pharmacological effects overlap. There are also
other non-psychotropic drugs that are known
to treat psychiatric disorders such as clonidine
and propranolol. The study of how these drugs
are affected or affect the body is referred to as
psychopharmacology.
Psychopharmacology has two components:

the pharmacokinetics and pharmacodynamics.
Psychopharmacology is simply the study of the
bodys effects on drugs (pharmacokinetics) and
the study of the effects of drugs on the body
(pharmacodynamics).
Pharmacokinetics
Pharmacokinetics involves absorption, distribution,
metabolism and excretion. Drugs are intended to
act on target organs and for them to do so, they
must be absorbed, distributed and metabolised and
then excreted from the body. The fraction of the
total amount of drug taken that reaches the blood
concentration is referred to as bioavailability.
Various drugs have the maximum concentration
achieved in plasma, referred to as max and the time
required to reach this peak plasma concentration is
11.
Disclaimer: Any dosages given here are just guidelines. The prescribing clinician is advised to check on the manufacturers
guidelines before prescribing.
478
Psychopharmacotherapy
Drug effects can be classied as agonists

or antagonists. Agonists mimic endogenous
neurotransmitters. Antagonists bind to receptors
without causing an effect and they block the
action of agonists. Most antagonists are displaced
by agonists (competitive effect), while others are
non-competitive, therefore not displaced. After
repeated exposure to a drug there is diminished
response (tolerance), which may be due to
increased metabolism, reduced receptor sensitivity
or numbers, an effect called down regulation. The
way drugs affect the body will be highlighted as
each drug is discussed in the subsequent sections.
called t max. Elimination half-life, or t refers to the

time it takes for the plasma concentration to fall by
half. The route of administration has a direct effect
on the pharmacokinetics. Oral route is the most
common, but is associated with erratic absorption
and the fact that drugs are subject to rst pass
effect, that is, they are metabolised by the liver
soon after absorption. Intravenous method of drug
administration ensures the most rapid absorption
followed by the intramuscular route. Distribution
ensures equilibrium of the drug between the plasma
(central compartment) and tissues (the peripheral
compartment). While in the plasma, drugs bind on
the plasma proteins to various extents and this has
effect on their availability. The distribution of the
drug to the brain depends on the drugs afnity to
its brain receptors, its concentration in the brain
and its solubility through the blood brain barrier.
The blood brain barrier is basically capillaries in
the brain that allow lipid soluble molecules into the
brain. Fortunately, psychotropics are lipid soluble
and therefore reach the brain easily. Metabolism
of most drugs occurs in the liver, plasma, lung
and kidneys, and active or inactive compounds
are produced. Excretion of the metabolites occurs
through kidneys, lungs, bile, sweat, milk and
saliva.
The cytochrome P450 (CYP450) family of hepatic enzymes are very important in the metabolism
and drug interactions of most drugs used in treating
psychiatric disorders. Knowledge of the existence
of CYP2D6 polymorphisms in populations
with psychotic disorders is useful for determining
appropriate drug doses and standards for drug
treatment of these conditions. Establishment of
safe dosing should take into consideration ethnic
variations in drug metabolising status, suggesting
a need for cross-cultural studies.
GENERAL PRESCRIBING
PRINCIPLES
Initiation of therapy
Treatment of patients using psychotropic drugs
must be guided by scientic principles that are
tailored to the needs of individual patients. There
are some guidelines for selecting psychotropic
drugs:
Complete a thorough medical evaluation,
especially with regard to cardiovascular
system (CVS) and thyroid status.
Select drugs on the basis of side effect,
anticholinergic effect and CVS effect,
availability of the relevant therapeutic levels
and history of previous response.
Inform the patient and family of the risks
and benets. Emphasise the expected delay
in therapeutic response and anticipated side
effects.
Initiate and increase dose of pharmacological
drugs slowly.
If there is no signicant therapeutic effect
after one week, increase dosage to maximum
recommended dose over the next six weeks.
If there is no signicant improvement after
one week, obtain plasma level (if appropriate)
and adjust dose. Obtain electroencephalogram
(ECG) and plasma levels before each dose.
A therapeutic trial is dened as a 6-week
treatment with psychotropic drugs, with at
least 3 weeks on the highest tolerated safe
dose.
Special considerations in pharmacotherapy in
special populations:
Pharmacodynamics
Pharmacodynamics deals with aspects such as
receptor mechanisms, cellular component that binds
to drugs and therapeutic index, which is a relative
measure of toxicity. Therapeutic index represents
the ratio of the minimum plasma drug concentration
causing toxic effects and the mechanisms through
which tolerance develops.
Most psychotropic drugs inuence the functions
of specic neurotransmitters. The functions that
are affected may be the synthesis, storage, release,
re-uptake, degradation, the receptor site and other
postsynaptic mechanisms.
479
Documentation of plasma levels to which the

patient responded and could be used in suicidal
future treatment.
Potential of drug interactions that may lead to
an increase or decrease in plasma levels.
o Children should be given smaller doses

based on body weight.
o Geriatric patients should receive smaller
doses and look out for side effects such as
cardiac side effects.
o For pregnant or nursing women, drugs
should be avoided, especially lithium,
in the rst trimester. No drugs should be
prescribed unless the mothers life is at
risk.
o Mentally ill patients drug interaction and
metabolism should be always considered.
Educate patients on the diagnosis, duration of
treatment and side effects to expect. Obtain
informed consent after the patient has been
educated and agreed to treatment.
Maintenance therapy
Drug therapy should not be withdrawn before 4
to 5 symptom-free months. After this period the
psychotropic drugs are then tapered and treatment
discontinued, while monitoring the patients sleep,
energy and generally the mental state. Rapid
discontinuation of medication (that is over several
days) should be avoided as withdrawal symptoms
may occur. These symptoms are possibly due
to rebound cholinergic overdrive and are
characterised by insomnia, increase in anxiety,
somatic symptoms such as u-like malaise, and
diarrhoea. There may be a recurrence of behavioural
difculties that occur rapidly after discontinuation
of medicines as opposed to during a relapse where
recurrence is gradual.
The various types of commonly used
psychotropics are discussed below
Compliance to drug treatment

Patients and relatives beliefs about mental
disorders and medication may be of considerable
importance in determining adherence. Providing
information about benets and side effects as well as
attitudes of patients towards illness and medication,
may play important roles in determining adherence
to treatments. Good prescribing practices and
information on appropriate responses could
improve adherence through reducing anxiety.
ANTIPSYCHOTICS
Plasma levels and therapeutic monitoring
Antipsychotic drugs are indicated for treatment of

psychosis, as in schizophrenia and mania. They are
useful for sedation and tranquilisation. Psychosis
which is associated with other psychiatric and
organic disorders responds to antipsychotics.
There are also non-psychotic indications e.g
Tourrettes Disorder.
The rst pass effect, a hepatic metabolism of some

drugs, results in a wide variation of plasma levels
among patients. Thus, the question of monitoring
the plasma levels becomes unclear. However there
are indications through use of laboratory tests in
psychiatry. These are as follows:
Patient has not responded to an adequate trial
of the prescribed drug.
Patient is at high risk, because of age or
medical illness and requires treatment with
lowest possible effective dose.
Patient requires rapid increase in dose, because
of the extraordinary risk such as suicide
or violence.
Concern about patient compliance with
medication regimen.
Classication of antipsychotics
Antipsychotics can be classied as typical
and atypical (newer antipsychotics). Atypical
antipsychotics have increased efcacy for positive
and negative symptoms of schizophrenia. They
have decreased tendency to cause extra pyramidal
side effects. Atypical antipsychotics tend to have
wide therapeutic ratio.
480
Table 61.1: Typical antipsychotics

Generic name and trade name of
drug
Average daily dose in mg or monthly

(Check recommended dose from
manufactures and also refer to chapter
on Ethno-Psychopharmacology)
Potency ratio composed with

l00mg chlorpromazine
Phenothiazines aliphatic:
Chlorpromazine
100-300mg 8hourly
1:1
Phenothiazines-piperazine:
Triuoperazine
Perphenazine
Fluphenazine decanoate
Fluphenazine hydrochloride
5-10mg 8 hourly
8-32mg /24 hours
25-100 IM per month
2- 6 mg 8 hourly
1:50
1:10
Phenothiazines Piperidine:
Thioridazine
Pericyazine
200-600 mg
75 mg
1:1
1:10
Butyrophenones:
Haloperidol
2-40 mg
1:50
Thioxanthene:
Flupenthixol Decanoate
20-40mg per month
Others:
Zuclopenthixol decanoate
Zuclopenthixol acetate
Clothiapine
Pimozide
Sulpiride
200 400mg IM monthly

50-150 mg IM every 2-3 days
120 - 160 mg
2-6 mg daily
800 mg
Table 61.2: Atypical antipsychotics
effects, for example some atypical antipsychotics

achieve their effects without high D2 receptor but
with 5-HT receptor occupancy. It is important to
understand that nearly all antipsychotic drugs
are multi-receptor antagonists contributing to
both their therapeutic efcacy and side effect
proles. The role of atypical antipsychotic drugs in
decreasing neurological side effects and improving
adherence has been increasingly appreciated.
However, most recently the metabolic side effects
(Type II diabetes) associated with weight gain have
been highlighted. In addition, concern regarding
hypercholesterolemia and deranged lipid proles
suggest that cardiac status may be a concern when
prescribing these agents. This is in addition to
cardiac conduction problems such as prolongation
of the QTc interval. The probability of occurrence
of tardive dyskinesia, a long term extra-pyramidal
side effect occurs less commonly amongst patients
on atypical antipsychotics.
Recent research has focused on development
of drugs that can control psychotic conditions
effectively and in the least toxic manner. However,
the inherent advantages in the use of atypical
antipsychotics may not be apparent in many lowincome countries due to their prohibitive costs.
Check recommended dose from manufacture and also

refer to chapter on Ethno-Psychopharmacology
Type
Example
Dibenzodiazepines
Clozapine
Thieno benzodiazepine
Olanzapine
Benzo thiazepine
Quetiapine
Benzixasoles
Risperidone
Imidazolidinone
Sertindole
Substituted Benzamides
Amisulpride
Quinolinones
Aripiprazole
1:40
1:1
A newer atypical anti-psychotic is ziprasidone,

with also potential anti-depressant and anxiolytic
effects. Other atypical antipsychotics include
zotepine and ioxapine.
Mode of action of antipsychotics

Both typical and atypical antipsychotics share the
property of blocking the dopamine D2 receptor subtype. There are other dopamine receptors e.g., D3
and D4 whose activity is also affected by these drugs.
However, they have many other pharmacological
481
cognitive dysfunction and consequent reductions

in quality of life. In addition to side effects, adverse
effects such as gait changes and drooling saliva as a
result of Parkinsonism are visible to others and may
increase the stigma attached to mental disorders.
Side effects
Antipsychotic-induced side effects are a serious
problem in the treatment of psychotic disorders
with neuroleptics, especially extra-pyramidal
side effects (EPSE). Other side effects include
weight gain, diabetes mellitus, sexual dysfunction,
Table 61.3: Showing Potential Adverse Effects Associated With Antidopaminergic Action
1. Movement Disorder
Akathisia
Dystonia
Tardive dyskinesia
Pseudo-parkinsonism
3. Neurological Side Effects
Epileptogenic effects
Sedation
Central anticholinergic effects
(anticholinergic intoxication
Tardive dyskinesia
2. Endocrine Dysfunction
Hyperprolactinemia
Menstrual dysfunction
Sexual dysfunction
5. Antiadrenergic (Primary 1)
Dizziness
Postural hypotension
Reex tachycardia
6. Antihistaminergic
Hypotension through decreased bronchial
secretion
Sedation
Weight gain
4. Non Neurological Side Effects

Hypo-static hypotension
Peripheral anticholinergic effects
Skin effects
Ophthalmologic effectsretinits
pigmentosa
Cardio effectsECG change
Sudden death, cardiac effect
Weight gain
Haematological effectsleukopenia
(low incidence)
Jaundice (rare)
7. Multiple Neurotransmitter Systems

Agranulocytosis (and other blood
dysfunction)
Allergic reactions
Anorexia
Cardiac conduction abnormalities
Nausea
Vomiting
Seizures
Maintenance treatment
Classication of antidepressants
Beyond acute symptom resolution, maintenance

treatment is required. Ongoing dosing needs to be
titrated against the clinical requirement aiming at
the lowest effective dose.
Heterocylic (tricyclic tetracyclic)

Monoamine oxide inhibitors (MAOIs)
Selective Serotonin re-uptake inhibitors
(SSRIs)
-adrenoreceptor antagonists, also known
as Noradrenaline and serotonin specic antidepressants (NASSa)
Noradrenaline re-uptake inhibitors (NARIs)
Serotonin and noradrenaline re-uptake
inhibitors (SNRIs)
Selective norepinephrine re-uptake inhibitors
(NRI)
ANTIDEPRESSANTS
Traditionally antidepressants are classied
according to their structures, e.g. tricyclics or
tetracyclics or their effect on neurotransmitters,
e.g. reuptake and oxidase inhibitors and receptors
antagonists.
482
there is a two-week therapeutic lag in response

to treatment, despite neurotransmitters turnover
that occurs after initiation of treatment with
antidepressants.
Norepinephrine and dopamine re-uptake

inhibitors (NADRI) e.g. bupropion
Trazodone
Heterocyclic antidepressants (tricyclictetracyclic)
Mode of action heterocyclic

antidepressants
12
Table 61.4: Heterocyclic Antidepressants

Generic name
Dose mg/24 hrs
Amitriptyline
25-300mg
Clomipramine
25-250mg
Doxepin
25-300mg
Trimipramine
25-300mg
Imipramine
25-300mg
Desipramine
25-100mg
Nortriptylline
25-100mg
The mode of action of tricyclic and tetracylic

antidepressants involves reducing reuptake of
nor-epinephrine and serotonin as well as blocking
muscarinic acetylcholine/histamine receptors.
The main indications are in the treatment
of major depression episode, panic disorder
with agoraphobia and generalised anxiety disorder
(GAD). Other indications are in the treatment of
obsessive-compulsive disorders (OCD), eating
disorder, pain, enuresis, narcolepsy, post-traumatic
stress disorder (PTSD), migraine headaches and
bulimia.
Table 61.5: Monoamine oxidase inhibitors (MAOIs)

Generic name
Dose/24hrs
Iscarboxazid
50mg
Phenelzine
15-90mg
Tranylcypromine
50mg
Monoamine oxidase inhibitor drugs

Monoamine oxidase inhibitor drugs (MOAIs)
are less frequently used due to their side effect
prole and also because they have been replaced
by selective serotonin reuptake inhibitors (SSRIs)
which are accepted as the rst line drugs. However,
MAOIs may be used in cases of refractory
depression. The enzyme monoamine oxidase
(MAO) occurs in two forms, A and B. Monoamine
oxidase A acts selectively on norepinephrine and
serotonin, while monoamine oxidase B acts on
phenyl ethylamine. Both monoamines oxidase
A and B act on dopamine and tyramine. It is the
monoamine oxidase A inhibition that seems to
confer antidepressant effect. MAOIs inhibit both
MAO A and B enzymes. Drugs that inhibit both
MAOIs and B are called non-selective monoamine
oxidase inhibitor drugs (MAOI). Monoamine
oxidase inhibition can be either reversible or
irreversible. Irreversible inhibition permanently
disables the enzymes so that monoamine oxidases
must be re-synthesised. In reversible inhibition, the
enzyme is available to metabolise other substrates
immediately after inhibition. Reversible Inhibitors
of the Mono Amine Oxidase (RIMAs) include
Moclobemide and Buroforamine.
Clinical use of the MAOIs requires that the
patient adheres to some precautions. First, they
should avoid foods containing tyramine. Inhibition
Tricyclic drug treatment began in 1950. Iproniazid,

a drug initially meant for tuberculosis treatment
was noted to have mood elevating effect. It was
subsequently not used due to hepatic necrosis and
was withdrawn. Imipramine was synthesised from
chlorpromazine, which had been introduced in
1952, with the hope that it would be more effective
than chlorpromazine. It did not have antipsychotic
effects, but rather had more of antidepressant
properties.
In the early 1950s, it was proposed
that catecholamines were decient in depression
and elevated mania. Resperpine, a drug initially
used for treatment of hypertension depleted
these catecholamines causing depression. In the
1970s selective serotonin reuptake inhibitors
were developed based on the observation that
indoleamines (5HT) were functionally decient
in depression. The theory of neurotransmitters
deciency has been modied over the years since
then and the accepted thinking is that there are
changes in receptor regulation and intracellular
changes in mood disorders. This explains why
12
Check recommended dose from manufacturer and refer to chapter on Ethno-Psychopharmacology
483
of MOA in the intestines impairs metabolism of

tyramine that can in turn cause release of excessive
amount of norepinephrine from pre-synaptic
storage granules. Norepinephrine causes profound
-adrenargic activity, hence, elevated blood
pressure. This state is referred to as hypertensive
crisis or cheese reaction, because aged cheese
contains relatively high amount of tyramine. When
the product formed by decarboxylation of tyramine
is in high quantities, it acts as a neurotransmitter.
The second precaution is to avoid combining
MAOIs with SSRIs since this can result in a
condition called serotonin syndrome characterised
by hyper-metabolic reaction seen as tremors,
lethargy, restlessness, myoclonus jerks, and nally,
there is cognitive impairment hyperthermia and
maybe death.
The above two groups of anti-depressants are
generally referred to as the typical anti-depressants
whereas the following are referred to as the new
generation anti-depressants.
may mimic malignant neuroleptic syndrome.

SSRIs discontinuation should be gradual to prevent
its discontinuation syndrome, characterized by
dizziness, somatic symptoms, mood changes and
paraesthesia.
The use of SSRIs in patients receiving other
drugs for medical illness requires exercising care
due to drug-drug interaction. The P450 (CYP), 2D6
and 3A4 are inhibited or induced by many drugs,
and therefore, if given concomitantly may result
in altered metabolism leading to non-efcacy, side
effects or toxicity. All these drugs are available in
many parts of Africa.
Adrenoceptor antagonists
Mirtazepine (15-45mg/24 hours) and mianserin
(10-40mg/24 hours) are also called noradrenaline
and serotonin specic antidepressants (NASSa),
because they activate noradrenaline (NA) neurons
by blocking the negative feedback of NA or
presyneptic 2 receptors. Increased noradrenergic
activity stimulates 5HT neurone activity in
the brain stem. Due to blockage of 2 receptors,
especially on the 5HT terminals in the cortex, there
is increased release of 5HT. This translates into
increased activity in both NA and 5HT systems and
hence, NASSa.
Serotonin selective re-uptake inhibitors

(SSRIs)
The serotonin selective reuptake inhibitors (SSRIs)
are rapidly being accepted as the drugs of choice in
treatment of depression. The typical antidepressants
are less frequently used. SSRIs selectively block
the reuptake of 5-hydroxy-tryptamine (5HT). They
are all structurally different. They also differ in
their half-life, especially uoxetine, which has
the highest half-life. All of them are metabolised
through Cytochrome P450. The fact that different
SSRIs affect different sub-types of the CP450
enzyme complex makes them different from one
another.
Noradrenaline reuptake inhibitors (NARI)

Increased inhibition of the reuptake mechanism
results in elevated levels of nor-adrenaline. This
may have alerting effects and therefore, treat the
depressive symptoms. An example is reboxetine.
Serotonin and noradrenaline reuptake

inhibitor (SNRI)
Like the noradrenaline and serotonin specic
antidepressant (NASSa) group of antidepressants,
which exert their antidepressant properties by net
effect of elevated serotonin and noradrenaline,
the serotonin and noradrenaline reuptake inhibitor
(SNRI), also effectively acts by inhibiting the
reuptake of the two new transmitters, hence,
elevating their levels. SNRIs are also called duel
action reuptake inhibitors and the most common
available is venlafaxine given in the dose 37.5225mg/day
Table 61.6: Examples of SSRIs

Generic name
Dose/24hrs
Citalopram
20-60mg
Escitalopram
20-40 mg
Fluoxetine
20-60 mg
Sertraline
50-200mg
Fluvoxamine
50-300mg
Paroxetine
20-60mg
SSRIs are rapidly absorbed, metabolised in the

liver with minimal secretion in breast milk. They
are useful in elderly depressed persons. Unlike
the tricyclics, they are likely to have fewer side
effects. Serotonin syndrome, which is due to
increased 5-hydroxy-tryptamine (5HT) activity,
Other antidepressants
(i) Bupropion
Bupropion is an antidepressant with fewer side
484
effects. Blockade of dopamine reuptake or

noradrenergic neuronal transmissions are possible
modes of action. Doses range between 150 and
300mg/day. Recently, bupropion has been shown
to treat nicotine addiction.
Other benzodiazepines include: prazepam,

clorazepate, midazolam, quazepam, umazenil,
mitrazepam, lormetazolam, loprazolam, clobazam,
unitrazepam and brotizolam doses.
(ii) Trazodone
There are two types of benzodiazepine receptors

referred to as, BZ1 receptors and BZ2 receptors.
The role of the rst BZ1 receptors is to initiate
sleep, while cognition, memory and motor control
are under the inuence of the second type of
receptor, BZ2. If used for more than two weeks,
tolerance and dependence develop, and withdrawal
syndrome may develop once the intake is stopped.
Side effects of benzodiazepines are drowsiness
and amnesia. Indications of benzodiazepines
include anxiety, insomnia, depression, bipolar
disorder, panic disorder, social phobia and akithisia,
where any of its several clinical effects are required.
Benzodiazepines have medical indications for use
as anticonvulsant, muscle relaxant and in treatment
of alcohol withdrawal.
Mode of action of benzodiazepines
Trazodone is a triazopyradine derivative used for

treatment of depression. Chemically Trazodone
resembles Alprazolam, a typical antidepressant. It
has no anti-cholinergic adverse effects. However,
it may induce priapism, which can be treated with
-adrenergic agonist epinephrine (intracavernosal
1 mg per ml solution).
ANXIOLYTICS, SEDATIVES AND

HYPNOTICS
This group of drugs comprises of Benzodiazepine
and non-benzodiazepines .
Buspirone
Sedative - hypnotic agents in clinical use
This is an agonist or partial agonist on serotonin

type 1A receptors. Indications are treatment of
General Anxiety Disorder (GAD) and takes 2-4
weeks for response to occur. It is a non-addictive
drug. The dose is 30mg per day in divided doses.
These can be summarised as follows:
Novel nonbenzodiazepines
These are rapid-onset and are short-acting.
Examples: Zaleplon, Zolpiden, Zopiclone.
Benzodiazepines
Benzodiazepines are also called antianxietyanxiolytic or minor tranquillisers, and act as anxi
olytics, sedatives or hypnotics depending on the
dosage used in that order. Sedatives reduce daytime
activity, tempers, excitement, and generally calm
the patient. Anxiolytics decrease anxiety, while
hypnotics increase drowsiness and facilitate the
onset and maintenance of sleep.
Benzodiazepines
(a) Rapid-onset, short-acting, e.g. Triazolam
(b) Delayed onset, intermediate-acting e.g.
Temazepam, Estazolam
(c) Rapid onset, long-acting e.g. Flurazepam,
Quazepam
Sedating antidepressants: e.g. Tricyclic
antidepressants,
Trazodone,
Mirtazapine,
Nefazodone
Sedating antinhistamines These are usually self
prescribed by patient since they are usually available
over the counter. The clinician should enquire
about their use by the patient. Examples include
Diphenhydramine, Doxylamine, Hydroxyzine
Sedating anticholingergic: Usually used and
avialable the same way as sedating antihistamines
e.g. Scopolamine
Natural Products: e.g. Melatonin, Valerian
Older sedative-hypnotics: e.g. Chloral hydrate
Table 61.7: Types of Benzodiazepines

Generic name
Usual Dose/24 hrs
Chlordiazepoxide
15-100 mg
Diazepam
4-40 mg
Clonazepam
0.5- 4 mg
Clonazepam
0.5 4mg
Flurazepam
15-30 mg
Oxazepam
30-120 mg
Lorazepam
1-6 mg
Temazepam
15-30 mg
Alprazolam
1-4 mg
Triazolam
0.125-0.5 mg
485
not protein-bound and its volume of distribution is

approximately equal to that of the total body water.
It does not cross the blood-brain barrier rapidly,
hence acute overdose is not usually a big problem
but long-term intoxication takes time to resolve.
Lithium is almost entirely eliminated by the
kidneys whose function steadily decline with age
and under other physiological states like puerperium,
hence the variability in half-life ranging from about
18 hours in young people to about 25 hours in the
elderly. This, however, increases with long-term
treatment in majority of the patients. Lithium is
also secreted in most body uids including sweat,
tears, saliva, ejaculate and breast milk. Clearance
is increased with extra cellular volume expansion
as in pregnancy but decreases with sodium and
water depletion.
MOOD STABILISERS
These agents are primarily indicated in the
treatment of Bipolar disorder, typically the manic
phase. Whilst lithium is the gold standard in this
class, various anti-epileptic drugs have also been
found useful.
Table 61.8: Mood Stabilisers
Mood
stabiliser
Generic name
Average dose/
24hrs
Lithium
400-1000 mg
Anticonvulsants
Carbamazepine
400-1000 mg
Sodium
valproate
4001500 mg
Other mood
stabilizers
include
Clinical indication
Bipolar Disorders
Lamotrigine,
Gabapentin,
Topiramate
It is used for both short-term treatment and

prophylaxis. Due to its delayed response,
neuroleptics and benzodiazepines may be used
alongside lithium in the rst 3 weeks of treatment
for a manic episode. Toxicity (especially thyroid),
substance abuse or even non-compliance should be
suspected and investigated in patients who relapse
into depression while on prophylactic lithium
therapy. Maintenance therapy is recommended in:
Adolescent patient with a history of bipolar I
disorder
Patient with apparent precipitating factors
Patient with poor support systems
Patient 30 years old or more with high suicide
risk
Male patients.
Lithium
Lithium is the lightest of all solids in the periodic
table. It is a highly reactive element with wide
commercial application in rubber processing,
manufacture of long-life batteries, strengthening of
glass and ceramic including construction of nuclear
weapons besides it use in medicine. Discovered in
1817, it was rst introduced to medicine in the 1840s
for the treatment of bladder stones and management
of gout. It was later used in the treatment of anxiety
and poor sleep (anxioloytic and hypnotic). In 1949,
Australian John F.J. Cade noticed that Lithium
Urate caused lethargy when injected in animals and
successfully used it in treatment of patients with
mania. About the same time, the USA Food and
Drug and Administration banned the use of lithium
following reports of fatalities from its toxicity. This
ban remained in force until the 1970s following
two decades of research by Mogens Schou, among
other researchers, on its efcacy in treatment of
mood disorders.
Major depressive illness

It is used as an adjuvant treatment in patients who
have failed to respond to antidepressants alone and
in those patients with marked cyclicity of mood.
Schizoaffective disorders
Lithium is more likely to benet those patients
whose disorder clinically resemble bipolar mood
disorder more than schizophrenia.
Pharmacokinetics
Lithium has a narrow therapeutic index and therefore
knowledge of its pharmacokinetics is important in
maximising tolerance and minimising toxicity. It
is readily absorbed in the gastrointestinal tract (20
percent in the stomach and 70 percent in the small
intestine). Serum levels peak in 60 to 90 minutes
for most standard preparations and about 4 hours
for the controlled release formulation. Lithium is
Basic principles in lithium use

Establish a series of baseline parameters before
start of treatment. This is mainly due to the narrow
therapeutic margin of Lithium. This include:
a complete blood count (full haemogram)
Thyroid function test
486
Cardiac effects include T-wave attening,

arrhythmias and even arrest. Result from
potassium imbalance.
Toxicity: (due to high plasma concentrations)
early signs of toxicity include ataxia, dysarthria
and tremors which may progress to
seizures, delirious states, marked dysarthria,
convulsions and even coma and nally death
from cardiopulmonary complications. This
calls for emergency treatment which include
hydration, discontinuation of treatment and
dialysis. Severe congenital malformation
result if Lithium is used in rst trimester of
pregnancy.
Renal function lists including creatinine

clearance
Baseline ECG
Pregnancy test in all women of child bearing
age
Note that routine baseline tests should be repeated
at least twice in a year. Take a 12-hour serum
lithium levels. Ensure the levels are within the
range of 0.6-1.2 mmol/litre and 0.45-0.5 mmol/
l for therapeutic and maintenance respectively.
Remember to educate the patient continuously
on the need to avoid dehydration and maintain a
relatively stable salt intake. Do not stop lithium
abruptly. Take several weeks of gradual reduction
in dosage.
Valproic Acid
Dose and monitoring
Valproic acid is an anticonvulsant indicated for

bipolar disorders. It is thought to be regulator of
calcium and sodium channel function leading to
enhanced GABA activity and reduced Glutamate
activity in the brain.
The doses range between 400 to 1000 mg given in

divided doses. The serum lithium levels should be
determined after 5 days to achieve the therapeutic
serum level ranging from 0.6-1.2 mmol/l. Thereafter,
during prophylactic maintenance treatment, serum
levels should be monitored every 3 months, while
at 6 months the other tests should be repeated
Indications of valproic acid

Mania, rapidly cycling bipolar, bipolar disorder,
schizophrenic disorder, depression, especially if
there is no response to treatment including ECT,
and impulse control disorder. Other indications
include alcohol withdrawal and non-acute
aggressive behaviour. Certain pre-treatment
evaluation procedures must be done including
cardiac evaluations where a haematological blood
count, and liver function tests are done. EEG is not
necessary. Adverse effects include aplastic enaemia
(1 in 20,000), hepatitis, exfoliative dermatitis and
hypothyroidism
Adverse effects
These affect all body systems including:
Central nervous system in which we have
o Tremors most noticeable on overstretched
hands and which may be improved by
propranolol.
o Cognitive disturbances including dysphoria, impaired memory, lack of
spontaneity and slow reaction time.
Renal effects of polyuria and polydipsia
(also presenting with thirst), which result
from antagonism of antidiuretic hormone by
Lithium. Minimal change glomerulonephritis,
interstitial nephritis impaired renal functions
and renal failure may also occur.
Thyroid effects include reduction in levels of
circulating thyroid hormones (hypothyroidism)
and non-toxic goitre. Replacement therapy
should be considered.
Skin effects including dose dependent
cutaneous lesions e.g. acneiform, follicular
and maculopapular eruptions, ulcerations and
even hair loss. Discontinuation of therapy
should be considered if these effects persist or
get worse.
Weight gain
Carbamazepine
Carbamazepine is thought to act in a similar
fashion to sodium valproate. Another basis for
antimanic effect is the kindling concept in which
electrophysiological process where repeated subthreshhold stimulations of a neuron eventually
generate an action potential. The most serious
adverse effects are aplastic anaemia, agranulocytosis
and (signs of infection and bleeding should be
looked for) and exfoliative dermatitis.
Other various newer anti-epileptic agents e.g.
lamotrigine gabapentin and topiramine may have
a place in the treatment of Bipolar Disorder as
may benzodiazepines (e.g clonazepam) as well
as atypical antipsychotics (e.g. olanzapine and
ziprasidone).
487
Anticholinergics are used to treat side effects

induced by antipsychotic drugs, specically,
extrapyramidal symptoms (pseudo-parkinsonism
and akathisia). Acute dystonic reactions may
require injectable forms of the agent.
include, Diphenhydramine given in 25mg qid and

is indicated for treatment of Extra Pyramidal Side
Effects (EPSE) and promethazine given as 2550mg once a day. Hydroxyzine hydrochloridre is
given for its sedating properties as well as for the
treatment of generalised anxiety disorder. In the
case of inhibited male or female orgasm caused by
serotonergirc agents, Cyproheptadine is indicated.
Indications of antihistamines also include druginduced akathisia, lithium-induced tremors. Side
effects include weight gain, sedation, poor motor
co-ordination, dizziness and hypotension.
Table 61.9: Anticholinergics drugs
Clonidine
OTHER DRUGS USED IN

PSYCHIATRY
Anticholinergics
Generic name
Dose
Benztropine
0.5-2mg PO, tid-2mg IV IM
Biperiden
2-6mg tid, 2mg IM IV
Orphenadrine
Citrate
50-100mg 60mg IV
Procyclidine
2.5-5mg qid
Trihexyphenidyl
hydrochloride
2-5mg tid
Clonidine is an adrenergic receptor agonist used

as hypotensive agent. However, it has psychiatric
indications such as in treatment of opioid
withdrawal (0.15mcg BD), where it decreases
autonomic symptoms, hypertension, tachycardia,
dilated pupils, sweating and rhinorrhea. Clonidine
is also used in the treatment of Tourettes syndrome
and the maximum doses are 0.3mg/24 hrs. Potential
indications are treatment of Post Traumatic Stress
Disorder (PTSD) and other anxiety disorders.
Adverse effects of Clonidine include dry mouth
and eyes, fatigue, hypotension and constipation.
When used with antidepressants, the hypotensive
effects of clonidine could be decreased.
Side effects associated with anticholinergics are

intoxication, delirium, coma, seizures, extreme
agitation, hallucinations, severe hypotension
and supra-ventricular tachycardia. Peripheral
manifestations include ushing, mydriasis, dry
skin, hyperthermia and decreased bowel motility.
Co-administration with agents with high
anticholinergic activity, e.g. antipsychotics,
tricyclics, tetracyclics, MAOI, over-the-counter
cold preparations, may cause drug interactions
resulting into fatal anticholinergic intoxication.
Trihexyphenidyl hydrochloride causes dependency
and is increasingly becoming a drug of abuse.
These drugs should be prescribed judiciously and
only when clinically indicated.
Methadone
Methadone is a synthetic opiate derivative agonist.
It is a schedule II drug that requires administration
under strict rules and procedures. It is indicated
in detoxication of persons addicted to opiates.
Sympathomimetics (Psychostimulants)
Methylphenidate is used for treatment of attention
decit hyperactivity disorder (ADHD). Other drugs
used in this condition can be found in the chapter
on ADHD.
Antihistamines
Further reading
1. Stephen M. Stahl. (2000). Essential Psychopharmacology. Cambridge University Press.
Antihistamines have anticholinergic effects and

are used frequently in psychiatry for various
indications. The commonly used antihistamines
488
62
Electroconvulsive Therapy (ECT)
Benson Gakinya, John Mburu, Hitesh Maru, David M. Ndetei
the neuropsychiatric manifestations in epileptics,

it has potent anticonvulsant and mood stabilising
effects that can be benecial in affective disorder.
Electroconvulsive Therapy (ECT) is a safe and

effective treatment. Many health workers believe
that ECT is grossly under-used. The main reason
for under-use is the misconception and bias against
ECT, partly fuelled by widespread misinformation
and inaccurate reports alleging permanent brain
damage.
INDICATIONS FOR ECT

Major depressive disorder
PRINCIPLES OF ECT
This is the most common indication for ECT. It

should be considered as a treatment for patients
who have failed medication trials, not tolerated
medication, have severe or psychotic symptoms
and marked symptoms of agitation or stupor, are
acutely suicidal or homicidal and breastfeeding
mothers who require quick recovery.
The quality of electricity used in ECT can be

described by Ohms law in which V=IR (V-voltage,
I-current, R-Resistance). The intensity or dose of
electricity in ECT is measured in terms of charge
(milliampere/seconds or millicoulombs) or energy
(watts or Joules). Resistance is synonymous with
impedance. In the case of ECT, the contact of
electrode with body and the nature of the body
tissues are the major determinants of resistance. The
skull has high impedance while the brain has low
impedance. ECT machines that are now widely in
use can be adjusted to administer electricity under
conditions of constant current, voltage or energy.
Manic episodes
ECT is of benet in rapid control of mania. It
is equal to lithium in treatment of acute manic
episodes. The use of ECT for the treatment of
manic episodes in prophylaxis is generally limited
to those situations with specic contra-indications
to all available pharmacological approaches.
Schizophrenia
MODE OF ACTION
ECT is an effective treatment for symptoms of

acute schizophrenia, but this should be the last
option. Results on chronic schizophrenic patients
have generally been conicting with some studies
reporting positive improvement. Patients with
marked positive symptoms such as catatonia or
ECT tends to produce the same results as

antidepressants, though it is relatively faster in
producing a response. ECT is also thought to affect
the dopamine system and to stimulate neurogenesis
in preclinical models. Since ECT also diminishes
489
urinalysis, chest x-ray and an ECG. Dental

examination is advisable.
The patients ongoing medications should
be assessed for possible interactions with the
induction of a seizure and for drug interactions
with medication used during ECT. Presence of
cyclic antidepressants, MAOIs and neuroleptics
are generally acceptable. Benzodiazepine and othe
r anticonvulsants, lithium (cause postictal delirium
and prolonged seizure activity), and clozapine
(associated with development of late appearing
seizures) should be withdrawn. Lidocain increase
seizure threshold, the theophylline increase
duration of seizure and reserpine may cause
cardiorespiratory compromise during ECT, and
should be avoided.
affective symptoms are thought to be more likely to

respond to ECT. However, ECT combination with
pharmacotherapy may be more effective than the
latter alone and should be tried in cases of treatmentresistant schizophrenia and schizoaffective illness.
It must be noted that when ECT is used in
special population groups, e.g. during pregnancy
and in older people and children, medical workers
should exercise particular caution.
CONTRA-INDICATIONS
Contra-indications for ECT are categorised as
absolute and relative. In the absolute contraindications, ECT must not be administered
where there is recent myocardial infarction and
cerebrovascular accident, and raised intracranial
pressure. Relative contra-indications include
osteoporosis, space occupying lesion or history of
cerebrovascular accident; brain tumors or cerebral
infarction; history of myocardial infaction or cardiac
arrhythmias; cardiac pacemakers; aneurysms;
retinal detachment; pheochromocytoma; and
pulmonary disease. In these conditions, ECT
is considered high risk and requires additional
precautions. Use of ECT in the paediatric population
is not recommended.
MEDICATIONS USED AT ECT

Pre-medications
Patients should not be given anything orally for
6 hours before treatment. Before the procedure,
check the patients mouth for dentures and other
foreign objects and establish an intravenous
(I.V.) live. Except for brief interval of electrical
stimulation, 100 percent oxygen is administered at
a rate of 5 litres a minute during the procedure until
spontaneous respiration returns.
Anticholinergic drugs are administered before
ECT to minimise oral and respiratory secretions
and to block bradycardias and asystoles. Routine
use, however, is not mandatory and should only
be enforced on patients using B-blockers or with
ventricular ectopic beats. The most commonly
used drug is atropine, 0.3-0.6mg intramuscularly or
subcutaneously 3060 minutes before anaesthesia.
CLINICAL GUIDELINES
Patients and their families are often apprehensive
about ECT. The clinician must, therefore, explain
its benets and adverse effects, as well as alternative
treatment approaches. Informed consent process
should be clearly documented in the patients
medical records. It should include a discussion
of the disorder, its natural course and the option
of receiving no treatment. The use of involuntary
ECT should be reserved for patients who require
urgent treatment and for whom a legally appointed
guardian has agreed to its use.
General anaesthesia
Administration of ECT requires general anaesthesia
and oxygenation. Depth of anaesthesia should be
as light as possible to minimise adverse effects and
avoid elevating the seizure threshold associated with
much anaesthetic. Commonly used anaesthetics
include thiopental, methohexital and ketamine.
Muscle relaxants are administered within a minute
of anaesthesia induction to minimise the risk of
fractures and other injuries resulting from motor
activity during the seizure. Succinylcholine at doses
of 0.5-1.0 mg is commonly used. Atrocurium 0.51.0mg I.V. or curate, can be used on an in-patient
with history of pseudocholinesterase deciency.
Metabolism of succinylcholine in such patients is
PRE-TREATMENT EVALUATION
This is done like any other patient going through
general anaesthesia. It should include standard
physical, neurological and pre-anaesthetic
examination, including a complete medical history.
Laboratory evaluations should include at least
a full haemogram, serum, urea and electrolytes,
490
Electroconvulsive Therapy (ECT)
disrupted and prolonged, and apnoea may occur

necessitating emergency airway management.
The physician must have an objective measure that

a generalised seizure has occurred after stimulation.
They should either observe some evidence of
tonic-clonic movements or electrophysiological
evidence of seizure activity from EEG or EMG. To
be effective, a seizure in the course of ECT, should
have a duration of at least 25 seconds. If a particular
stimulus fails to cause a seizure of sufcient duration
after 4 attempts, an induction can be tried during the
course of treatment. However, the onset of seizure
activity is sometimes delayed for as long as 20 to
40 seconds after the stimulus administration. If
stimuli fail to elicit a seizure, contacts of electrodes
and the skin should be checked and the intensity
of stimulus increased by 25 to 100 percent. In
addition, the use of an alternative anaesthetic agent
should be considered.
The whole procedure from administration to
recovery from anaesthesia may take 10-15 minutes.
This procedure is repeated 2 or 3 times a week to
achieve good outcome, and 6 such treatments are
recommended.
Electrode placements
The electrical stimulus is applied via electrodes
placed either bitemporally (bilateral ECT) or
across one side of the head (unilateral ECT). To
ensure that the contact between the scalp and the
electrodes is adequate, the hair must be cleared,
and the electrodes made wet with normal saline
solution. The patient must be well secured on the
couch during the seizures induction, care being
taken to secure the neck in an extended position
to avoid fatal cervical fractures during strong
seizures.
In general, bilateral placement results in a
more rapid therapeutic response while unilateral
placement results in less marked cognitive adverse
effects after the treatment, especially within the
rst two months of treatment. Bilateral ECT places
electrodes bifronto-temporally; each electrode has
its centre about one inch above the midpoint of
an imaginary level drawn from the triagus to the
external canthus. With unilateral, one stimulus
electrode is typically placed over the non-dominant
fronto-temporal area. Several locations for the
second electrode have been proposed. However,
placement on the non-dominant centroparietal
scalp, just lateral to the midline vertex appears to
provide the most effective conguration.
NUMBER AND SPACING OF ECT

Treatment should continue until the patient
achieves maximum therapeutic response. The
point of maximal improvement is usually thought
to be that point at which a patient fails to continue
to improve after 2 consecutive treatments after the
sixth ECT.
Multiple monitored ECT (MMECT) involves
giving multiple ECT stimuli during a single session,
mostly two bilateral stimulations within 2 minutes.
This may be used in cases of very severe depression
and in patients with high anaesthetic risks.
Electrical stimulation
The electrical stimulation must be sufciently
strong to reach the seizure threshold. It is given in
cycles, each containing a positive and a negative
wave. The best results are expected, as a general
rule, with brief pulse square waves, electrical
dose about 2 to 2.5 times higher than the seizure
threshold. However, optimal electrical dosing
and electrode placement should be individualised
for each patient. Modern ECT machines use a
brief pulse waveform that administers electrical
stimulation in one to two millisecond time period.
Machines that use an ultra brief pulse are not as
effective as brief pulse machines.
A brief muscular contraction, usually strongest
in the patients jaw and facial muscles, is seen
concurrently with the ow of stimulus current,
regardless of whether a seizure occurs. The rst
sign of seizure is often a planter extension, which
lasts 10 to 20 seconds and marks the tonic phase.
This is followed by rhythmic clonic contractions
that decrease in frequency and nally disappear.
MAINTENANCE TREATMENT
ECT appears extremely effective in depressive
disorders, however the relapse rate is also
high especially in treatment-resistant patients.
Additional prophylactic treatment is required to
reduce relapse.
Short-term course of ECT induces a remission
in symptoms, but does not in itself prevent relapse.
Generally, maintenance therapy is pharmacological,
but ECT treatments (weekly, bi-weekly or
monthly) have been reported to be effective relapse
prevention treatments. Indications for maintenance
ECT treatment may include rapid relapse after
491
general anaesthesia are headache and nausea,

which can be easily managed using conventional
treatment.
initial ECT, severe symptoms, psychotic symptoms

and inability to tolerate medication.
FAILURE OF ECT TRIAL
Central nervous system effects

Memory impairment is an established side effect
of ECT. The anterograde amnesia is transient and
retrograde amnesia is restricted to events just prior
to each treatment. Few patients exhibit persistent
retrograde amnesia extending back in life. However,
following ECT course, almost all the patients are
back to their cognitive baseline after 6 months. The
degree of cognitive impairment during treatment
and the time it takes to return to baseline are in part
related to the amount of electrical stimulation used
during treatment.
To avoid excessive cognitive impairment, it is
recommended that further ECT treatment after
symptom relief is achieved must be avoided. There
is no justication to continue with treatment in an
effort to bolster response to ECT.
The data is primarily anecdotal, but many reports

indicated that the patients who had previously
failed to improve on antidepressants do improve
on the same medication after receiving a course of
ECT treatments even when the ECT seem to have
failed.
ADVERSE EFFECTS OF ECT

ECT is a relatively safe treatment procedure.
However, every treatment has inherent side effects
and for ECT, they are categorised as those related to
general anaesthesia such as respiratory depression.
Other side effects experienced upon recovery from
492
Section VI Part B:
Non-Biological Treatments
493
494
63
Psychotherapy
Ruthie Rono, Tom Onen, Gad Kilonzo, David M. Ndetei, Anne Obondo
The non-biological therapies are treatments of

emotional, behavioural, personality and psychiatric
disorders based primarily upon verbal or nonverbal communication with patients, environmental
support, occupational rehabilitation, social support,
community support and research needs of patients.
In some patients with chronic mental illness
the recovery remains incomplete without nonbiological treatment and as a result they lose their
basic vocational and social skills. Occupational
and rehabilitation programmes assist in restoring
the lost skills for maximum functioning. Nonbiological therapies include psychotherapy, social
support, occupational therapy, environmental
therapy and community-based rehabilitation.
Psychotherapy is the process where a medical
worker helps a patient to resolve his emotional
difculties and develop his abilities in becoming
more independent and self-satised. Individuals
learn to modify their behaviour, thoughts and
emotions, and how to relate with other people.
The medical worker deliberately establishes a
professional relationship with the patients with the
objective of:
Removing, modifying or retarding existing
symptom
Mediating disturbed patterns of behaviour
Promoting positive personality growth and
development.
Psychotherapy involves empathetically attempting
to understand why the patient has developed
the particular problems, engaging the patient in
intensive discussion for a number of sessions,

allowing the patient to freely ventilate his intimate
concerns, emotions, and experiences without any
censorship and suggesting ideas which the patient
may not have thought of as explanations for why
he is experiencing his problems.
APPLICATION OF
PSYCHOTHERAPY
Psychotherapy is applicable to all psychiatric
illnesses. It is primarily directed at the psychological
causal factors and may be used in the following
ways:
as a treatment in its own right
as a preliminary step to other psychiatric
procedures
as an adjunct on chemical, electroconvulsive
therapy (ECT) or surgical treatments.
Psychotherapy is most commonly applied for
treatment of neurosis, e.g. phobias, anxiety,
panic disorders, Obsessive Compulsive Disorder
(OCD), Post Traumatic Stress Disorders (PTSD),
sexual disorders, drug abuse, alcoholism,
insomnia, and bipolar disorders and depression.
Psychotherapy can also be used as an intervention
method for individuals, a group of people, and in
marital and family relationships. Irrespective of
theoretical preferences of intervention techniques,
most have the following components:
495
life. Psychoanalytic theory emphasises that all

adult problems roots can be traced back to ones
childhood. The theorists tend to look at individuals
as the composite of their parental upbringing and
how particular conicts between themselves get
worked out. Since an individuals development to
his present personality structure is viewed in terms
of whether he successfully manoeuvred through
the psychosexual stages of childhood, most mental
illnesses are seen as a result of unsuccessful
progression through childhood development. Due
to the unresolved childhood conicts remaining in
the subconscious, the individual may not be aware
of why they are the way they are. This may call for
therapy.
Fostering insight
Reducing emotional discomfort
Encouraging catharsis or expression of pentup feelings
Providing new information
Raising patient's faith and expectancy for
change
Assigning extra therapy tasks.
GENERAL OBJECTIVES
OF PSYCHOTHERAPY
Individuals with psychological problems can
change and learn more adaptive ways of perceiving,
evaluating and behaving. Therefore, psychotherapy
aims to:
Change maladaptive behaviour patterns
Minimise or eliminate environmental
conditions that may be causing problematic
behaviours
Improve an individuals skills and competencies related to work and social interactions
Improve interpersonal relationships
Help in resolving inner conicts and stress
handicapping and disabling personal distress
Modify
the
person's
distorted
negative cognition and perception about
himself, future and the world, while fostering
a clear-cut sense of self-identity.
Cognitive behavioural theory

Cognitive behavioural therapy emphasises
the cognitions or thoughts a person has as an
explanation as to how people develop and how they
sometimes get mental disorders. Cognitive theorists
generally believe in the role of social learning in
childhood development and the idea of modelling
and reinforcement. Peoples personalities come
from their experiences of learning, identication
of appropriate thoughts and feelings and imitation
of these behaviours, thoughts, and feelings. For
example, if ones parents do not cry when they are
emotional, children will also learn to hide their
feelings when they are emotional. Children learn
by observing and imitating others.
If one grows up in a maladaptive or unhealthy
environment, then they can develop mental
disorders later in life. It is therefore the environment
and other people one grows up with, that shapes
one into a healthy or unhealthy human being.
THEORIES OF
PSYCHOTHERAPY
Humanistic theory
There are a number of psychotherapeutic models
each with distinctive goals, basic assumptions,
concepts and theoretical treatment techniques
designed to bring about changes in the patients
maladaptive adjustment. The nature or course
of any treatment is determined by factors like
symptoms, patients maladjustment and environmental forces operating at the time.
Humanistic theorists believe that individuals can

be conscious of their own existence and that they
are also fully responsible for the choices they make
to further or diminish that existence. Humans are
responsible for the choices they make in their
lives with regards to their emotions, thoughts
and behaviours. The theory demonstrates that no
matter what kind of childhood one goes through
the person is ultimately in charge of how they react
to experiences and should not blame others or their
parents.
Psychodynamic/psychoanalytic theory
(Freud 18561938)
This is one of the oldest theories of psychology
in which patients are viewed within the model
of illness or what is lacking. Individuals are
seen as being from a dynamic that begins
in early childhood and progresses throughout
Eclecticism theory
This is based on individualism and pragmatism.
Eclectic approach in therapy involves viewing an
individual not just from a psychodynamic perspective
496
Psychotherapy
repressed memories, thoughts, fears and

conicts.
aims to achieve intellectual and emotional
insight into the underlying causes of the
patient's behaviour.
but also by using other active interventions such as

those found in the cognitive approach. An individual
is viewed from the perspective of his unhealthy
behaviour and thoughts and how these interact
to make up the individual human being who has
a problem. In eclecticism there is no guaranteed
way of approaching any given problem. Each
problem is tainted and changed by the individuals
own history and ways of viewing or perceiving his
own problems. Hence, depending on the problem
presented by the patient, the therapist may use
more theories of psychotherapy to help the patient
solve the dilemma.
Whatever theory a therapist subscribes to, the
most important thing is that the theory benets the
patient. The type of psychotherapy depends on the
case as well as the special skills of the therapist.
Therapeutic techniques in psychoanalysis

Free association
Other synonyms include psycho-catharsis,
confession, abreaction and mental ventilation.
The patient is:
granted permission to freely verbalise
everything that comes to his mind without
censorship.
encouraged to talk about personal and intimate
problems.
encouraged to talk about worries, memories,
impulses, anticipation and self-criticism.
This procedure takes place while the patient is
sitting or lying comfortably on a couch.
ASSESSING A PATIENT FOR

PSYCHOTHERAPY
Dream analysis
Factors to consider when assessing patients for
psychotherapy include:
The nature and severity of the disease.
The readiness of the patient to change.
Ability of the patient to understand the process
of therapy and work with the therapist.
In this dream contents are conceptualised as

symbolising and representing something else. A
dream is considered the royal road to the unconscious
as rst noted by Freud. The unconscious wishes
are expressed in versions that are sufciently well
disguised to avoid traumatising and waking the
sleeper. Dream analysis brings to the surface the
underlying problems aficting the patient.
TYPES OF PSYCHOTHERAPY
Analysis of resistance
Behaviour that imply resistance:
Missing treatment sessions
Coming late to treatment sessions
Refusal to lie on the traditional couch
Regularly falling asleep in therapy sessions
Unwillingness to speak about certain issues
The therapist takes advantage of this resistance by
helping the patient gradually learn to recognise and
ultimately abandon his habitual defence and face
his fears.
Psychoanalytic psychotherapy
This has many models, but they all have the same
basic similarities. Each:
strives to create a therapeutic atmosphere.
encourages the expression of previously
hidden thoughts and feelings.
stresses that the therapist should be nonjudgemental.
the therapist should:
o not impose his morals or values on the
patients.
o treat the information with condentiality.
o win the patients trust.
leads to emotional growth and personality
change.
endeavours to uncover unconscious determinants of every day conducts such as feelings,
Transference and counter transference

These occur in most situations when a therapist
meets a patient. They stem from therapeutic
alliance. This alliance is divided in three parts:
the therapeutic alliance, transference and countertransference.
In therapeutic alliance, there is a rational
(implicit) contract between a therapist and patient.
497
makes interpretation of the transference to the

patient so that they can understand and use it.
Counter transference is the response that is elicited
in the recipient (therapist) by the other (patient).
It includes the feelings evoked in the doctor by
the patients transference projections. They can be
a useful guide to the patients expectations of the
relationship and are easier to identify if they are
not congruent with the doctors personality and
expectations of his role.
Awareness of the transference-counter
transference relationship allows reection and
thoughtful response rather than unthinking
reaction from the doctor. The degree to which
the projected role is congruent with some aspects
of the personality of the therapist will affect the
likelihood of the therapist adapting to it. The
more congruent it is the more he can deal with the
transference projections.
Reactions are called therapist acting out. They
may occur when the therapist plays the role
unconsciously and is aware. They are not seen
as they are but as a response to anxiety or anger.
Reections are when therapists are aware of their
own thoughts, feelings and a sound grasp of whether
these deviate from normal professional behaviour
or good practice guidelines, such as:
Acquisitioning attitude towards ones own
feelings and motives.
Recognition that we all have a blind spot.
An understanding that staff are affected by
patients and patients by staff behaviour.
Recognition that patients often have strong
feelings towards staff.
Dealing with counter transference is important to
prevent staff burn out. Some useful strategies are:
reections
using a multi-disciplinary team to discuss what
a difcult patient projects into the treatment
relationships
using a psychotherapist to help understand what
the patient is unconsciously communicating in
his behaviour
undergoing personal therapy to become more
aware of ones own unconscious needs and
fears.
The contract may be straight forward with mutual

co-operation, or complicated by the patients
unconscious and unspoken wishes and needs (the
transference).
Transference is a phenomenon where feelings
and attitudes from a person or situation are
unconsciously transferred from the past onto
the present. As transference is unconscious, the
patient unwittingly projects a needed aspect of a
previously experienced and wished for relationship
to the therapist. The relationship of projection to
transference is as follows:
Transference involves the projection of a
mental representation of a previous experience
on the present.
Other people are treated as though they are
playing the complementary role needed for
projected relationship.
There are subtle (unconscious) behavioural
nudges to take on these feelings and
behaviour.
Factors that increase transference are:
Vulnerable personality, especially people
with borderline personality disorders.
Patients anxiety about his physical or
psychological safety, e.g. patient may long for
intimacy, but also fears it.
Settings of content with a service or key
worker.
In dynamic psychotherapy, one aims to resolve the
transference by making the patient recognise and
manage the unconscious feelings and expectations
which they bring to new relationships. In psychiatry,
transference must be recognised because it:
supports staff by helping them understand what
is going on in the relationship with the patient
to reduce anxiety and over-responsibility.
improves patient management by recognising
wishes that are not clearly articulated.
anticipates problem areas for patients
and hence, more appropriate therapeutic
provisions.
helps avoid staff acting out and improves
boundary maintenance.
Practical management of transference:
recognizes the importance of the relationship
to the patient.
should be reliable, e.g. keep appointments and
do tasks you promised to do for the patient.
keeps strict professional boundaries of doctorpatient relationship.
Limitations of psychoanalytic treatment model

Time-consuming. Therapy extends from few
months to 5 years or more, depending on the
nature of the problem.
498
Psychotherapy
is paired with a new stimulus, which produces

an incompatible or apposite response. The
original problematic condition response is
extinguished by this technique and a new
healthy behaviour is introduced simultaneously, e.g. in spider phobia.
Aversive counter conditioning. It is used
to reduce problematic behaviour that is
pleasurable, e.g. anti-abuse (disulphiram) to
alcoholics.
Covert conditioning. This is classical
conditioning, which occurs through imagery
technique rather than actual (in vivo)
experience. On average ve seconds may
sufce for a single exposure. The specic
order of imagined scenes are to be determined
by the patient. Imagined hierarchies are used,
because they are easier and cheaper. The
duration for image presentation depends on the
patient, difculty in constructing hierarchies
and therapist.
It is very expensive, particularly where patients

have to pay treatment fees.
It is more relevant when patient's problems
mainly originate in the past.
It focuses on the past and appears to neglect
the patients immediate problems.
Behaviour Therapy (BT)

Behaviour therapy (BT) relies heavily on principles
derived from classical (or Pavlovian) and operant
conditioning.
Goals of behaviour therapy
The objectives are to improve daily functioning,
reduce emotional distress, enhance relationships
and maximise human potential.
Classical conditioning
Classical conditioning occurs in daily life and may
be adoptive or maladaptive as follows:
Respiratory system. An asthmatic patient gets
an attack on seeing a cat nearby.
Circulatory system. Following a road
accident, where the individual had a pounding
heart, anxiety and sweating. This individual
experiences the same symptoms when in
trafc.
Digestive system. Vomiting and nausea in
response to sh may also progress to the sight,
smell or foods with sh.
Muscular system. Relaxation occurs after
ingestion of alcohol, thus relaxation is felt on
pouring the rst drink at home at the end of a
tense day.
Reproductive system. Sexual arousal and
pleasurable feelings in response to genital
stimulation.
Operant Conditioning (OC)

Consequences shape and modify behaviour in
Operant Conditioning (OC), also known as trial
and error learning. Behaviour that produces
good effects becomes more frequent (positive
reinforcers). Behaviour that produces bad effects
becomes less (negative reinforcers). Learning
occurs when the consequences are contingent
(interpreted to be casually linked) on the operant
behaviour.
Situational antecedent cues inuence behaviour
in OC. Any given operant behaviour may produce
good effect in one situation and bad effect on
another. Individuals learn and discriminate between
situations in which behaviour may be rewarded or
punished, e.g. in trafc, green light gives pleasure,
but red light produces fear of ticket. New complex
behaviour is learnt through reinforcement of
successive approximation of the desired goal.
The individual learns to respond differently to
two similar predictive cues through differential
reinforcement, i.e. one predicts reinforcement
and the other does not, or one predicts more
reinforcement than the other, e.g. a shopper may go
to shop A more often than B because he has learnt
that A has better and cheaper goods.
Principles of classical conditioning in behaviour

therapy
Extinguishing. The conditioned reex is not
paired with the original stimulus and as a result
the classically conditioned response weakens
and becomes useless.
Generalisation. Here a stimulus evokes a
similar conditioned response, e.g. fear of
particular dog may generalise to fear of all
dogs.
Discrimination. The individual learns to
respond differently to two similar stimuli, e.g.
big dog is more dangerous than a small one.
Counter conditioning. A conditioned stimulus
Systematic desensitisation
Systematic desensitisation, also known as counter
conditioning and reciprocal inhibition therapy, was
initially developed by Joseph Wolpe in 1958. The
desensitisation procedure involves four strategies:
499
Relaxation training.
Presentation of anxiety hierarchy consisting
of a list of stimulus situations that provoke
anxiety and are ranked upwards from the least
to most anxiety provoking.
Imagining or visualising of a scene.
When the patient has managed to relax with one
provoking stimulus, another anxiety provoking
stimulus in the hierarchy is introduced to him.
The patient is exposed to the actual in vivo
hierarchies of stimulus, gradually moving up to
more anxiety-provoking stimulus each time, to
maximum provoking stimulus. This is presented
repeatedly or continually until the patient is able
to tolerate it without anxiety. The therapist then
proceeds to the next item in the hierarchy until the
patient no longer experiences anxiety to the most
provoking situation. The patients will be expected
to transfer and generalise the acquired clinical
experience to real life situations without anxiety.
Problems may emerge during desensitisation, e.g.
difculty in relaxing, misleading or irrelevant
hierarchy and inadequacies of imagery.
In imagined (in vitro) hierarchies, the patient
is encouraged to visualise a series of increasingly
anxiety provoking scenes. On average, 5 seconds
may sufce for a single exposure. The specic
sequence of imagined scenes are to be determined by
the patient. Imagined hierarchies are used, because
they are easier and cheaper. The duration for image
presentation depends on the patient, difculty in
constructing hierarchies and therapist.
Implosion is similar to the procedure of ooding,

but the fundamental difference is that the implosion
of fearful stimuli that are more intense than those
actually found in real life are presented. Flooding
and implosion are effective in the treatment
of agoraphobia particularly those crowded or
empty places; OCD and a cluster of symptoms such
as panic attacks.
Modelling
These arise from the social learning theory that
most behaviour develops through:
Observation of the consequences of a models
behaviour may either inhibit or not the imitative
behaviour in an observer.
Experience involves having a patient observe a
live or symbolic, lmed or videotaped display
in which one or more models fearlessly perform
the behaviour, which the patient avoids.
Reinforcement. A student who witnesses his
schoolmate being given a television set as a
reward for excelling, is likely to be prompted
to study hard to attain the same level.
Modelling approach is used to treat social
withdrawal among adults and children, OCD,
lack of assertiveness, antisocial conduct such
as physical aggression, early infantile autism
and phobias.
Positive reinforcement
This is used in the treatment of abnormal
behaviours to strengthen all positive initiatives and
behaviours that the individual makes, e.g., a patient
with anorexia nervosa who gains weight can be
rewarded by allowing her out of bed connement.
Positive reinforcement is usually socially orientated
and is dispensed in the form of praise, recognition
and encouragement in dealing with children and
adolescents. Tangible objects such as food and
money are used as positive reinforcers.
Uses of systematic desensitisation

It is for the treatment of fears of almost everything,
including: anxiety-related disorders such as phobias;
fears of high and low places; open and closed places;
reptiles and insects; noise, death, socialising with
people and psycho-physiological/psychosomatic
disorders like ulcers, asthma, hypertension,
examination anxiety, impotence and frigidity.
Aversion therapy
Flooding and implosion
Aversive therapy is based on using punishment

or unpleasant stimulus as a vehicle to decrease or
change undesirable behaviours. Positive reinforcers
are removed or unpleasant stimuli are administered,
such as:
Use of electric shock to the hands, legs and feet
to stop unwanted behaviour.
Administration of emetic drugs that either
induce nausea or temporarily suppress
breathing.
Flooding and implosion are alternative techniques to

systematic desensitisation. In ooding, a non-relaxed
patient is exposed to anxiety-provoking stimuli of
high intensity for a long time. The exposure must be
long enough for anxiety to begin to disappear, often
for 2 to 4 hours. Patients may be accompanied into
the actual situations by the therapist, depending on
their needs and preferences. Exposure is normally
not terminated while the patient is still anxious,
to avoid reinforcement of behaviour. Flooding is
based on the principle of extinction.
500
Psychotherapy
Sometimes substances with foul smell or taste

are used.
Apormorphine or disulram (antabuse) is
administered together with alcohol, resulting
in nausea or vomiting. The patient begins
vomiting when he smells alcohol and abstains
from alcohol.
Aversion therapy is used in treatment of drug
abuse, including, alcohol and smoking; overeating
with secondary obesity; sexual perversions; and
enuresis.
Hypnosis
Structure of behaviour therapy
Autogenic training
Verbal and repetitive suggestions involving mental

imagery is used to relax the mind and body.
Hypnosis and self-hypnosis focus on formalised
suggestion, often involving mental imagery. With a
rhythmic and calming voice, repetitive suggestions
are used to guide the patient towards somatic
relaxation, e.g. the muscles of ones body are
relaxing more and more. Relaxation via hypnosis
is easy, but individuals respond differently to
hypnotic suggestions.
These are structured series of formalised

suggestions directed towards promoting body
sensations associated with relaxation. This is a
form of hypnosis and involves a series of 6 selfsuggestions referring to specic body sensations.
Patients are guided in the promotion of each group
of sensation, which lead to relaxation, e.g., heart is
beating quietly and strongly, stomach is full with no
pain and head is full of worries, which are going.
Strong emphasis is placed on passive
concentration, which encourages the patient to
acquire autogenic skills quickly. Many abbreviated
forms of autogenic training have been developed
and tend to make patients rapidly achieve states of
deep relaxation.
Initial behaviour analysis

Specic series of treatment tasks
Goal-directed and specic
Regular assessment and discussion with
patient
Review setting of new goals
Maintain gains by follow-up sessions and
ongoing homework assignment
Include microanalysis that focuses on the
conditions surrounding the presenting clinical
problems
Evaluation and macro analysis that relates the
presenting problem to other broader problem
areas (e.g. social skills decit, marital
problems).
Biofeedback
This is a machine-based detection and amplication
of tension-related physiological signals. Signals
are fed back to the patient who learns to sense and
modify signal. Information (visual and auditory
signals) is sent back to patient. The patient learns
to modify the signals that then lead to changing
of associated physiological systems to desired
directions, e.g. electrodermal activity, heart rate
and muscle tension. Biofeedback has a place in the
treatment of anxiety and panic disorders, encopresis
and psychosomatic disorders.
Relaxation training in psychiatry is used in
generalised anxiety disorders, phobias, depression,
chronic substance abuse, stress management, and
as adjunct to psychotherapy and the management
of certain physical illness.
Relaxation training
Meditation
This is a self-guided passive attention to a single
object of focus. Concentrative form is the most
popular; the individual is taught to attend passively
to a single object that is unchanging or repetitive
(a visual image, a repeated word or mantra or
body sensation, like breathing). The attention
is effortless. There is no directive guidance that
relaxation should occur.
Progressive muscle relaxation
This involves systematic contraction and relaxation
of major muscle groups. The individual is guided
in the tensing and relaxing of 16 major muscle
groups, one group at a time. Voluntary muscle
contraction allows the patient to sense differences
between tension and relaxation in muscle groups,
enabling subsequent muscle relaxation. As the
progressive muscle relaxation skill is developed,
patients are encouraged to combine muscle groups,
until relaxation is achieved through simple recall.
Other related therapies

Reality therapy
Postulated by William Glasser (1965) to counteract
psychoanalytic model for:
being permissive, disregarding morals and
values.
501
dealing with neurotics or psychotics.

its reliance on construction of past events.
Glasser introduced three concepts: reality,
responsibility and right.
A responsible person in the view of this model is

one, who interacts with others in an accountable
manner, lives up to morals and values, and keeps
promises. In the reality model the individual is
responsible for his own behaviour and therefore,
responsibility of behaviour change or modication
is totally placed upon him.
Upgrading and promoting morals and values

to resolve conicts confronting the patient.
Attaching importance to morality of behaviour
and needs than to feelings.
Attending to prevailing current issues and
topics concerning the patient's life. Reality
therapy does not attempt to involve itself in
the historical background, such as enquiring
about personality and identity related to past
events of the patient nor is it concerned with
the unconscious.
Factors which improve successes of reality therapy,
include:
Warm relationship between the therapist and
patient.
Therapists conscious understanding and
interaction with the patient and patience
throughout treatment period.
Patients commitment to modify behaviour.
Adherence agreement pertaining to treatment.
Right
Indications of reality therapy
Morals and values such as right behaviour and

good deeds promote and maintain ones good
mental health. Conversely, wrong behaviour and
bad deeds lead to low self-esteem of the person.
It is used in hospitals and schools in managing

delinquents, personality disorders and anger.
Reality
People become mentally ill, because they deny
themselves of the world of reality and instead create
an imaginative world full of fantasies. Criminals
and delinquents, according to this model, adopt
such behaviours due to lack of consciousness of
reality.
Responsibility
Art therapy
In this form of therapy the individual uses clay,
paint and other art medium to create images that
explore their feelings, dreams, fears and memories.
Creativity can provide a means of expression for
that which has no words and is often used by
children and adults suffering from depression,
facing loss, or recovering from trauma or sexual
abuse.
Therapeutic strategies
The major goals of reality therapy include efforts to
make the patient become more aware of the reality
around him. This is achieved by:
urging him to intermingle with successful and
responsible people leading to fullment to
satisfy his needs and become worthwhile.
increased awareness of other people whose
behaviour towards others is characterised by
responsibility.
brief discussion to convince the patient about
his illness and weaknesses to enable him
abandon his negative behaviour.
encouraging him to learn self-criticism and
evaluate his own behaviour and learn new
ways of coping with situations.
praising the patient as positive reinforcement
when he fulls his duty.
enabling the patient to adopt reasonable
ways of behaving that he has acquired in the
therapeutic session.
During the process of treatment, reality therapy
focuses on:
Play therapy
This is a therapeutic technique often used when
working with children. Through play therapy a
child can create a world they can master, practice
social skills, overcome frightening feelings and/
or experiences, and symbolically triumph over
traumas. This therapy works well for children that
may not have the verbal skills needed for other
types of therapy, and lets them express themselves
in a safe and fun way.
Gestalt therapy
Gestalt therapy puts emphasis on what is happening
in the here and now, to help individuals become
more self-aware and learn responsibility for and
integration of thoughts, feelings, and actions. The
502
Psychotherapy
goal of this therapy is to develop more internal

versus external support
2. Corey, Gerald (2005). Student Manual for Theory

and Practice of Psychotherapy. Australia. ThomsonBrooks/Cole
3. Goldenberg, Irene & Goldenberg, Albert (2004).
Family Therapy: An Overview. Australia. ThomsonBrooks/Cole
Further reading
1. Corey, Gerald (2005). Case Approach to Counselling
and Psychotherapy. Australia. Thomson-Brooks/
Cole.
503
64
Cognitive Behaviour Therapy (CBT)
Khalifa Mrumbi, Ruthie Rono, Duncan Ngare, Anne Obondo,
Benedicta Yetunde Oladimeji, David M. Ndetei
Cognitive Behaviour Therapy (CBT) helps

individuals understand how one thinks (cognitive)
and what one does (behaviour). It aims to reduce
dysfunctional emotions and behaviour by altering
behaviour and thinking patterns.
Stylistic errors. The individual systematically

either magnies or minimises events or
information, leading to negative conclusions.
Erroneous or inappropriate labelling of events
or outcome. Represents semantic errors.
HISTORY
THE ABC MODEL COGNITIVE

BEHAVIOUR THERAPY
Aaron Beck developed the idea of Cognitive

Behaviour Therapy (CBT) for treating depression
after noticing that depressed clients experienced
specic thoughts that they were only dimly aware
of. Unless their attention was directly focused on
them, they did not report these thoughts. These
thoughts or cognitions tended to rise quickly and
automatically. They were not subject to conscious
control.
To describe negative thinking in depression, they
postulated the presence of a negative cognitive
shift where positive information relevant to the
individual is ltered out (cognitive blockage),
while negative self-relevant information is readily
admitted. This cognitive shift was universal for all
types of depression whether of primary diagnosis
or secondary to some other disorder, such as
schizophrenia.
Beck classied these into three cognitive errors
that occur in depressed people:
Paralogical errors. The person draws
conclusion from events without evidence.
The relationship between distorted or irrational

beliefs and emotions that result are summarised as
follows:
1. Antecedents refer to the triggers for the problem
behaviour that can be internal (e.g., bodily
sensations, thoughts, images) or external (e.g.,
behaviour of others, environmental stresses,
specic situations). Activating event, e.g.
work, or colleague fails to acknowledge the
person.
2. The appraisal of these triggers and the meaning
the person attaches to them:
Inferences, e.g., My colleague has ignored
me, He must be angry with me, He
probably dislikes me.
Evaluation, e.g., It is awful if someone
dislikes you.
3. The emotional and behavioural responses.
An example of emotional consequence is the
person develops depression.
504
Cognitive Behaviour Therapy (CBT)
supplemented by home assignments to encourage

patients to have new experiences and break negative
chains of behaviour.
Cognitive behaviour therapy (CBT) combines

treatment approaches of both cognitive and
behavioural therapy. This was originally outlined
in the treatment manual, specically targeted to
depression as postulated by Beck.
INDICATIONS FOR CBT
SOME MYTHS ABOUT

COGNITIVE THERAPY
These include anxiety, panic, depression,

agoraphobia and other phobias, bulimia and
anoxia nervosa, social phobia, obsessive
compulsive disorder, post traumatic stress disorder,
schizophrenia, psychosexual disorders, childhood
emotional and conduct disorders and behaviour
problems in learning disabilities.
The past and the therapeutic relationship are

irrelevant in CBT.
CBT does not pay attention to a clients
feelings, involves thinking more positively
and is prescriptive.
Only the more intelligent clients will benet
from CBT.
STRUCTURE OF CBT SESSION

CBT relies heavily on self-help which enables the
patient to put into practice in everyday life what they
have leant in treatment sessions. It trains patients
to self-manage problems. At each session of CBT
the therapist works with patient in developing
a specic action plan of how to put into practice
what they have learnthomework between one
session and the next. This inter-session encourages
patient to put generalised skills learnt in session to
everyday life problems. Difculties encountered
by patient are discussed and resolved.
The therapist should build a practice review
time at the beginning of each session and use the
opportunity to review problems encountered. This
could be used as a basis for future work in and out
of the sessions. This is a key component of the
CBT approach.
It is vital to review the outcome of inter-session
tasks. This will help both therapist and patient
to discuss and plan future tasks. In each session
therapist should review:
What went well?
What went wrong?
What has been learnt as a result?
How can the patient put into practice what
they have learnt?
Cognitive behaviour therapy seeks to change a
persons irrational or faulty thinking and behaviour
by educating the person and reinforcing positive
experiences that will lead to fundamental changes
in the way that person copes. For instance, a person
who might get depressed over the way their life is
going may begin a downward spiral into thinking
negatively and irrationally. This only reinforces
the depressive feelings and lethargic behaviour.
SOME FACTS ABOUT

COGNITIVE THERAPY
CBT is empirically-based, structured and
problem-based.
A therapeutic alliance is essential.
Homework is an essential feature.
It has an educational factor.
Cognitive and behavioural interventions are
integrated.
CBT APPROACH
The CBT approach attempts to modify overt
behaviour by inuencing the patients thinking
processes. In this, dysfunctional cognitive processes
cause the emotional or psychological disorders.
Psychological problems result from negative,
distorted and unrealistic thinking that people hold
and depression results from the patients negative
beliefs about themselves, the world they live in and
their future. Anxiety symptoms arise in response to
cognitions of danger and vulnerability that is out
of proportion.
The cognitive model directly appeals to patients
reasoning by increasing their awareness of
dysfunctional thought processes and intellectual
explanation of symptoms. The therapist tries to
persuade the patients to adopt a more logical and
less emotional approach to life and to face problems
instead of running away, thereby minimising their
fear and tension. This rational confrontation is
505
So cognitive behavioural therapists will work on

helping the patient identify irrational thoughts,
refute them and help the patient change useless or
frustrating and unproductive behaviours (through
techniques such as modelling, role playing and
reinforcement strategies).
Cognitive behavioural therapists use a variety of
techniques which are usually dependent, to some
degree, on the patients presenting problem. For
instance, such a therapist will not use the same

techniques to help someone who is suffering from
fear of heights and another who is suffering from
depression.
Further reading
1. Goldfried M. R. and Goldfried A. P. (1975). Cognitive
Change Method in Helping People Change. F. H.
Kafner and A. P. Goldfried, Pergaman Press - London
1975.
506
65
Counselling
Khalifa Mrumbi, Anne Obondo, Ruthie Rono, Duncan Ngare, David M. Ndetei
Counselling is the process of assisting and guiding

clients to resolve personal, social and psychological
problems or difculties. According to Burnard
(1994) counselling is the process by which one
person helps another to clarify his life situation and
to decide further lines of action. The key points in
counselling involve:
Two people, a counsellor and the client.
The helping of the client by counsellor.
A situation in which the client has problems
and can sometimes be clearly identied and he
shares with the counsellor.
A therapeutic relationship that evolves through
interaction between a client and a therapist.
QUALITIES OF A COUNSELLOR
Personal warmth: one should be approachable
and open to patients or colleagues.
Genuineness: one either cares for the client
or does notone cannot take professional
relationships.
Empathy: it is the ability to understand
what the other person is going through. It
is also dened as the ability to perceive
accurately the feelings of another person
and to communicate this understanding to
him. Empathy in counselling can build the
relationship, stimulate self exploration, check
understanding, provide support, lubricate
communication, restrain the helper and pave
the way.
Unconditional positive regard: the client
is viewed with the dignity and valued as a
worthwhile human being. Unconditional
positive regard, then involves deep and
positive feelings for the other person.
Intuition: this is knowledge and insight that is
independent of the senses we just know.
It is likely that we all have instincts and that
when followed turn out to be right.
Caring: this is a process that offers people
(both carers and the cared for individual)
opportunities for personal growth. Major
aspects of caring include knowledge, patience,
honesty, trust, humility, hope and courage.
BASIC PRINCIPLES OF
COUNSELLING
Client knows best. He is the expert in his
problems and feelings.
Inter-presentation by another person rarely
helps.
It is important to enter the clients frame of
references. The counsellor should understand
the clients by viewing the world as they do.
A counsellors experience is not the same as
that of the clients.
Judgment and moralising are not appropriate.
Listening is the rst and last principle of good
counselling.
507
Knowledge: A counsellor must know certain

things about the client and also have the
knowledge to use and give the client.
Alternating rhythms: in all relationships, the
intensity uctuates. There appears to be a
natural cycle in the caring relationship, which
waxes and wanes.
Patience: caring for another person involves
taking ones time, whether with friends or
patients. It takes time and cannot be rushed.
Honesty: this involves the counsellor being
open to sharing with the client. To be honest
with others, one needs a degree of selfawareness of being able to honestly appraise
your own thoughts, feelings and beliefs.
Trust: allows patients to learn from their own
experiences and make decisions. It means
counsellors should trust their patients and
learn to let go. Often distrust in other people
demonstrates a distrust in ourselves.
Humility: A counsellor needs to be humble
and recognise his own inadequacies and
limitations. When humble, one can learn more
from patients and colleagues.
Hope: we cannot care without hope.
Courage: just as we cannot predict the future,
we cannot anticipate the outcome of our caring.
Thus, to care takes considerable courage.
Sense of humour: humour breaks tension
and brings relaxation to the counselling
relationship.
Directive counselling
It is a process of making decisions, suggestions or
offering advice to the client. It is no longer popular.
It has limited uses in few cases, e.g., a person who
is considering abortion and the newly diagnosed
diabetic.
Problem-solving
The rationale of problem-solving is that a patients
problem is caused by their everyday problems. If
problems are resolved, symptoms will disappear.
Problems are resolved using problem-solving
techniques.
Goals of problem-solving
Patient should understand links between
symptoms and the problems.
To dene clients current problems and to
teach problem-solving techniques.
To provide client with a positive experience of
problem-solving.
Stages of problem-solving
Explanation of treatment and its rational and
formulation of the problem list.
Clarication and denition of problem.
Setting achievable goals.
Generating solutions.
Choice of preferred solution.
Implementation of preferred solution.
Evaluation.
TYPES OF COUNSELLING
Cognitive behavioural counselling

This approach is aimed at changing the thought,
belief and behaviour of the patient. It is highly
structured looking at specic problems and aims to
enable a client to learn skills to help them deal with
present and future problems. Rational behaviour
therapy has been one of the most inuential of
the cognitive approaches. It involves disputing
irrational thoughts and conducting experiments
to discover new ways of behaviour. The basic
tenet of these approaches is the development of
collaborative relationships in which the client and
the counsellor work together to understand and
resolve problems (a therapeutic relationship).
Client-centred
Client-centred counselling is the most widely used.
It was rst used by Carl Rodgers in 1951, where he
noted that the client himself is best able to decide
how to nd solutions to his problems. The clientcentred position presumes that a person in need has
come to you for help. In order to be helped they
need to know that you have understood how they
think and feel. They must know that whatever your
own feelings about them, you accept them as they
are. You accept their right to decide their own lives
for themselves. In the light of this knowledge about
your accepting and understanding them, they begin
to open themselves to the possibility of change and
development. If they feel that their associations
are conditional upon them changing, they may feel
pressured and reject your help.
Psychodynamic counselling
Psychodynamic counselling gives prominence to the
early interpersonal relationship experiences which
are sources of insecurity. It also emphasises social
development associated with individuation and the
508
Counselling
or counsellor has to check whether the patient

has understood the information given and that its
meaning is comprehended or otherwise it will not
be utilised.
family life cycle. The task of the counsellor in this

method is to encourage the patient to talk about
their difculties and to reect on them as they
may have originated in childhood in response to
a mothers anger. Psychodynamic counselling may
also incorporate an element of problem-solving
and behavioural experimentation to assist with
the identication and rehearsal of new adaptive
interpersonal strategies.
Supportive Therapy
The patient is supported through his crisis or
disability to bring sufcient relief from symptoms,
resulting in satisfactory social adjustment. Crisis
examples are those diagnosed with HIV, diabetes
and cancer, and during periods of distress or
emotional catharsis.
Crisis counselling
This is a short and active intervention. It is based on
sound assessment of the situation which includes
family, patient, social network, nature of the stressor,
severity of the response of risk and available coping
resources including external support. The task here
is to help the patient redene the challenges and to
mobilise resources for its resolution. It is indicated
for excessive alcohol consumption, self harm which
are characteristics of adjustment disorders or frank
psychiatric breakdowns. Crisis counselling is also
an important component of community mental
health provision provided at self referral centres
operated by voluntary agencies or psychiatric
service centres.
Ego supportive procedures

Common techniques employed to achieve the
goals include: active listening and empathy;
acceptance; ventilation of feelings; therapists
ability to understand the feelings of the patient;
encouragement; reassurance and guidance;
confrontation; persuasion; remaining nonjudgmental; muscular relaxation; and externalisation of interests.
Supportive therapy has specic points of
emphasis:
The patient is not different from other people.
The symptoms the patient has do not make
him an outcast.
Problems are viewed as being universal and
do not differ from person to person.
The patient is encouraged to boldly face and
confront the problems he is having.
Every effort that is made by the patient to
overcome the symptoms is appreciated and
reinforced.
Supportive therapy is aimed at helping the
individual maintain his adaptive patterns.
Information-giving
It involves more than just giving information.
It helps patients focus on their own problems by
asking questions and nding answers. Patients
with schizophrenia or alcohol abuse require
information about the diagnosis, the causes and
potential consequences of their disorder. This
kind of information is important for mobilising
their motivation and compliance with treatment.
It is also important in genetic counselling and
crisis intervention. In this case the practitioner
509
66
Group, Marital and Family Therapies
Khalifa Mrumbi, Anne Obondo, Ruthie Rono, Duncan Ngare, David M. Ndetei
Group psychotherapy is the treatment of an

individual within a group through support and
encouragement from the members and the
therapist. Group therapy also helps individuals
develop interpersonal skills. For example, there are
parenting groups and cancer support groups. Group
members listen to the individual members opinions
and concerns and offer support and insight.
Broadly, it encompasses many kinds of groups
with goals that range from behavioural change
to educational exchange. It is a eld of clinical
practice and a specic approach within the realm
of psychotherapy. They are all aimed at alleviating
illness or distress with the help of a trained leader
by using group interaction as the agent for change.
TYPES OF GROUP
PSYCHOTHERAPY
Marital and family therapies
These are therapeutic modalities whose focus of
assessment and treatment is on the relationships
and not on the individual. Indications for marital
and family therapy include the following:
Internal factors
A person making a decision on whether to
remain in a relationship, realises that he has a
different sexual orientation than was originally
believed and is experiencing an internal crisis,
e.g. a mid-life crisis, and desires to change or
end the relationship.
Normal development changes in children such
as adolescence.
Developmental changes in adults, e.g. wife
desiring to return to a career after being a
home-maker.
HISTORICAL BACKGROUND
Group therapy was started in 1905 by Dr. Joseph
Pratt, a Boston physician, who rst noticed
that tuberculosis (TB) patients brought together
regularly had improved mutual support, lowered
depression and reduced isolation. Moreno, the
father of psychodrama, was the rst to use the term
group therapy.
External factors
A recent diagnosis of one of the family
members with a debilitating disease, e.g.,
HIV.
510
(each person choosing a partner who is perceived

as complementing part of them). However, the
chosen partner may fail to live up to the expectation
or may project onto the other unwanted aspects
of themselves. The therapist helps the couple
understand their emotional needs of each other by:
seeing couples together
organising for a different therapist to see the
couples individually
being active in therapy
making only interpretations about the
relationships.
Change in nancial status by partner, e.g., loss

of job.
Addition of members to the marriage, e.g.,
new born or children from previous marriage.
Children leaving home.
A decision to divorce.
Models for marital family therapy

Couples are seen together.
One member is treated individually by another
therapist.
All family members are seen together, but
concurrent individual therapy goes on with a
separate therapist.
Group therapy for families.
Families and couples learn from listening to
other families, leading to change.
Systems approach to couple therapy

The focus of treatment is on:
Hidden rules that govern the behaviours of the
couple towards each other.
The disagreement on and who makes those
rules.
The inconsistencies between the two levels of
interactions.
The therapist generally helps the couple recognise
their problematic areas of functioning and guides
them to reach a co-operative relationship. One or
two therapists may be used.
MARITAL THERAPY
Marital therapy is also referred to as couple therapy.
This is indicated for couples with unsatisfactory:
Sexual satisfaction
Personal autonomy
Alcoholism in one or both partners
Dominance-submission role
Money management
Fidelity
Responsibility over child-rearing
Expression of disagreements over a range
of issues and hostility as the relationship
appears to be the cause of emotional disorder,
unsatisfactory and likely to break up; and both
partners want to save a marriage.
In the therapy much attention is paid to:
the ways a couple interacts
all issues pertaining to the relationship, e.g.
sharing of values, concern for welfare of the
other partner, tolerance of differences and
agreed level of dominance and decisionmaking.
The therapists role is to adopt a target problem
approach and make couples identify the difculties
that they would like to put right.
Behavioural couple therapy

This therapy is brief and highly structured. The
therapist identies ways that undesired behaviour
between the couple is being reinforced by one of
its consequences. Each couple is asked to state
what alternative behaviour they desire from each
other. They agree on how and when this should
occur. Each partner rewards the other for changing
behaviour.
The behavioural system couple therapy

This method was developed by Crowe in 1990.
The two components of this therapy are:
Behavioural component: reciprocity, negotiating and training in communication.
System component
These are structural moves where:
one couple is asked to disagree with a dominant
one.
couples are asked to reverse roles.
sculpting is practised (partners take up
position) express position in the relationship
without words.
there is use of paradox, time tables and tasks.
Psychodynamic couple therapy

The central theory is that behaviour of a married
couple is largely determined by unconscious forces
511
Severely disorganised families for example

poor socio-economic circumstances, antisocial behaviour, violence and drug abuse.
Family therapy may be used with other
psychological approaches such as individual
therapy and supportive therapy.
In therapy:
the components are drawn starting with the
simplest.
treatment is 5-10 sessions over 3-6 months
the therapist focuses on both partners and
assists them to focus on mutual interactions,
encourages the couple to speak to each other
and comments on what they say and do during
the session and sets up tasks and injunctions.
system tasks focus on behaviours which occur
too often or rarely.
the couple makes the timetable indicating
when this would take place, and the duration
and frequency.
the paradoxical injunction is used only for
specic symptoms and in the context of a
caring relationship, and the couple is instructed
to do the opposite of what they are seeking
help for.
Crowe suggests that couple therapy should have
the following sequences: reciprocity negotiation,
communication training, induce arguments,
timetable and tasks, paradoxical injunction,
adjustment of therapy to the symptoms, and then
close treatment or use other strategies.
Contra-indications for family therapy

When the family members are unable to or are
completely unmotivated.
When the level of family disturbance is so
severe or long-standing or both that family
therapy may prove futile.
When the patient is too incapacitated to
understand the demands of family therapy, for
example in the midst of a psychotic episode a
patient is too affected by the illness.
Techniques in family therapy

Psychodynamic family therapy
The main focus of this therapy is the understanding
of family dynamics and treatments. The psychodynamic therapist aims at helping family members
obtain insight into themselves and the way they
interact. For example, Lieberman in trying to
integrate family systems attempted to understand
the present through the use of the past, so as to plan
for a new future. He postulated a trans-generation
therapy, which focused on the dimension of time
within the family system.
FAMILY THERAPY
This is therapy where several or all family members
take part in the treatment. These include parents,
children, grandparents and other members of the
extended family. The general aim of family therapy
is to improve communication, autonomy for each
member, agreement about roles, reduce conict
within the family and distress in the patient.
Structural family therapy

This refers to and uses a set of unspoken rules that
organise the ways in which family members relate
to one another, e.g., hierarchy and co-operation in
the family, set rules for behaviour and boundaries
amongst family members, to bring about change.
This therapy is usually short-term
Indications of family therapy

When symptoms appear to be expressing
pain and dysfunction of the family system or
problem manifest explicitly in family terms,
for example, marital conict, adolescentparent conict which dislocates family life.
When a family is experiencing major stressful
life events for example, accidental or suicidal
death, severe nancial embarrassment, serious
physical illness, loss of job or unexpected
departure of a child from home.
When separation difculties exist, for example,
adolescent separation problems.
When there are communication problems
within the family.
Behavioural family therapy

This involves the application of learning theory,
which acts by altering circumstances leading
to a behaviour. The primary objective is to
increase positive behaviour. Desired behaviours
are reinforced by being rewarded and undesired
behaviour ignored or replaced by desired behaviours.
Behaviour therapy is used widely in marital
or couple problems where couples are taught to
use positive reinforcements rather than negative
methods. It consists of increasing the positive
exchange between the couples.
512
This approach can be used in the treatment of

psychosomatic families where the presenting
problems are anorexia nervosa, diabetes or
asthma, and also to deal with youngsters who came
from emotionally deprived families, nancially
impoverished and headed by single parents who
cannot cope with the running of the family.
In behaviour family therapy concentration is on

enabling the family to accept the changes within
the family and realign relationships within the
family.
Systems-oriented family therapy
This therapy pays attention to inter-generational
issues and the wider family context. This is
because it is believed that the family is a system
whose problems are due to lack of psychological
differentiation of family members from their
origin.
Bowen originated the genogram for assessment
of family structure going back several generations.
His major therapeutic aim was to facilitate
differentiation of family members from families
of origin (he used ego mass), so that they function
independently and autonomously as members
of their own newly created families. To him
therapy is a matter of having family members
especially the parents, grandparents, and extended
families discover and come to terms with their
relationships.
This approach presumes that family problems
have their roots in the extended family system
that childrens problems are related to marital
relationships, which have their roots in families of
origin.
Eclectic family therapy

This is used to deal with a clinical problem using
simple short-term method. Subjects are commonly
adolescents. The therapists assess how the family
functions and factors are involved in the patients
problem. Areas of family functions considered
are:
structure using genogram
changes and events such as births and deaths
relationship, close and distant, loving, withdrawal.
pattern of interactions between two or more
family members.
The therapist then makes a hypothesis about what
should and can change and sets goals for change. In
addition, he considers the family changes that may
affect them or others and asks the family to identify
what has prevented them from making those
changes. The therapist ensures that interchange
in the sessions do not lead to further problems at
home.
Figure 66.1: Parents should spend quality time with their children
513
and pre-delinquent youth and also to treat conduct

disorders, adolescent drug abuse and violence.
The model includes four phases: an introduction/
impression phase, a motivation phase, a behaviour
change phase and a generalisation (more multi
system focus phase). Each phase includes
assessment, specic techniques of intervention and
therapist goals and qualications. The intervention
involves a strong cognitive component which is
integrated into systemic skill-training in family
communication, parenting skills, and conict
management skills.
OTHER ASPECTS OF FAMILY

AND COUPLE THERAPY
Analytic group therapy
Analytic therapy focuses on feelings, provides
long-term permanent change to reduce symptoms,
diminish painful moods and help the individual to
develop new ways to look at life. It also seeks to
help an individual build a strong inner self with the
ability to solve his own problems.
The curative factors in groups are interpersonal
learning, catharsis, group cohesiveness, insight,
development of socialising technique, essential
awareness, universality, instillation of hope,
altruism, and collective recapitulation of primary
family group, guidance and imitative behaviour.
The therapists role is to support the individuals
ideas and validate feelings while they look further
on how these feelings impact on their lives or
have resulted in unsuccessful problem handling.
As a result the individual will learn new ways of
handling their problems. The individual will also
be able to develop new skills to prevent problems
from occurring and gain control of their feelings.
GROUP THERAPY RULES

Each group should have ground rules, for example,
keeping time for meetings, remaining in the meetings
the entire session time and focusing on the problem
that brought them together. It is also important for
group members to observe condentiality and
acknowledge the leadership of the therapist.
The duration of group therapy may be 75-120
minutes. The frequency could be weekly, biweekly, monthly or twice monthly. The size of the
group could range from 4-10. Membership may be
either open (new members come in at any time of
therapy) or closed (no new members are accepted
until all sessions are completed). The sitting
arrangement is usually in a circle with no barrier
between members and the therapist.
Conjoint therapy
Conjoint therapy provides the couple with objective
information about their similarities and differences,
which contribute or distract from their relationship.
Couples can therefore use this information as a nonemotional framework for understanding each other.
This understanding therefore forms the foundation
for the relationship to stabilise and grow as they
learn ways to mediate their differences and negotiate
their needs. In addition, the customs or behaviours
of their parents are looked at objectively to assist in
helping them form their own unique marriage free
of unproductive inuences.
Group leader or therapist

The main role of a group leader is to help group
members to understand themselves through their
behaviours. The therapist is trained to be aware of
behaviour patterns, life scripting belief systems and
wounded emotional sensitivity through questioning,
interaction and using the self as an instrument
to experience. Through understanding complex
patterns the therapist can facilitate the untangling
of confusion, feelings, distorted perceptions and
self defeating behaviours.
Functional family therapy

The major goal of functional therapy is to improve
family communication and supportiveness
while decreasing intense negativity, which is
the characteristics of these families. Other goals
include helping family members identify what they
desire from each other, identify possible solutions
to family problems, and develop powerful
behaviour change strategies. Functional family
therapy is designed to treat families with delinquent
Stages in group development

Stage 1: (in or out)
Members are primarily concerned with acceptance
and non-acceptance. They seek to know other
members, nd similarities and learn the ground
rules. Communication is supercial and focused
on seeking, giving and gaining approval from the
leader.
514
Stage 2: (top or bottom) storming
Stage 4: termination
Members jockey for positions of control, dominance and power between each other and the
leader. Safety and trust are established. Members
seek to know how they are different and work to
be accepted as different. Criticism of one another,
hostility towards leader and disenchantment
with the group is typical. The group has great
expectation of the leader, but show disappointment
in the leaders failure to full their dreams.
Generally, this stage resurrects feelings around

three themes: death, separation and hope. These
stages occur in any form of group therapy, but their
intensity varies depending on the group. Stages
may recycle as group therapy progresses.
Further reading
1. Awaritefe A.A. (1996) Meseron Therapy. In Ebigbo P.
et al (Ed). The practice of Psychotherapy in Africa.
2. Birk L. (1973): Biofeedback: Behavioural medicine.
New York Grune & Stratton
3. Ebigbo P. et al (1996) Harmony Restoration Therapy:
In Ebigbo et al (Ed) The Practice of Psychotherapy in
Africa. Enugu: Chumez Enterprises (Nig).
4. Opler M.K. (1961): Ethnic differences in behaviour
and health practices in Galdson I (ed). The Family: A
Focal point for health education. New York: Academy
of Sciences
Stage 3: (near or far) working

Members concern themselves mainly with intimacy
and closeness. There is trust, co-operation and
openness in communication. The group is ready
to mature with focus, exibility, compassion, and
a great tolerance for affect, realistic expectation
of the leader and recognition of the value of other
members.
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67
Loss and Bereavement Therapies
Anne Obondo, David M. Ndetei, Ruthie Rono, Duncan Ngare
impending death. This anger may be displaced to

care givers, relatives or friends.
The experience of bereavement is normally a very

difcult and painful one. Bereavement is loss
through death of a close relative. There are other
losses which may not be referred to as bereavement
such as loss of a limb, property, divorce,
childlessness or loss of health.
When faced with loss, people frequently
experience a mass of intense confusion and often
conicting feelings usually grief reaction (a stage
of mourning). The grief process provides a helpful
framework for better understanding of this powerful
and complex experience. The phase an individual
goes through applies to any loss whether the loss
is due to death (bereavement) divorce, retirement,
loss of health or innumerable other losses. The
phase of the grieving process helps people come to
terms with the loss.
REACTION TO LOSS
The emotional process of expression of loss include
crying or outburst of anger, or when the bereaved
wear black clothes for a period of time. There are
several phases of reaction.
Shock or alarm
This is when the reality of the loss has simply not
sunk in. There is panic, restlessness and increased
muscle tension. For instance, a woman who has
lost a husband is lonely may show signs of shock
or alarmsuch as loss of appetite and weight,
palpitation, headaches, muscles aches and pains.
ADJUSTMENT TO TERMINAL
ILLNESS
Protest and searching

This is the phase of yearning and protest. The
person protests that the loss cannot be real, while
at the same time being confronted with evidence
that it is. The lost person is severely missed and the
bereaved sob for them, sometimes even walking
around looking everywhere for the deceased.
Others visit the graveyard in the hope of nding
the deceased. The components of this behaviour
are:
Alarm, tension and a state of arousal
Restless movements
Preoccupation with the lost person
The adjustment of the terminally ill deals

with anxiety, depression, anger and guilt. It is
associated with fear of severe pain, disgurement,
incontinence and death, and concern about the
future of family members. Attempts by relatives at
concealment only serves to increase fear of possible
consequences. Depression may be associated with
fear of separation from family and friends, as well
as loss of valued activities. Guilt feelings may
be associated with fear of excessive demands on
relatives. This results in anger over the injustice of
516
or loss, therefore, can result in psychiatric or

physical problems.
Masked grief: in this case there are no signs of
grieving at all. This is common in children and
adolescents and is dangerous, because it can
lead to psychological problems.
Exaggerated grief: the bereaved develops
symptoms such as phobias and also become
psychotic.
People, react differently to bereavement and loss.
There are those who come through the experience
of bereavement without breaking down, while
others need psychiatric or other medical help.
Loss of interest in personal appearance

Calling for the lost person
Directing of attention toward those parts of the
environment in which the lost person is likely
to be.
Anger and guilt

The bereaved expresses anger through irritability
and bitterness. Intense anger in the person can
lead to splits in relationship, isolation or loneliness
and insecurity. The bereaved may regret failure to
satisfy expectations. A widow may blame herself
for failing to encourage her husbands artistic
talents during his lifetime.
The social and cultural dimensions of

grieving or mourning
Acceptance
Culturally, there are variations in response to

bereavement or loss in terms of reaction, funeral
arrangements and coping with the loss. There are
individuals who may react to loss calmly and others
may behave like they are possessed or abnormal.
These are considered normal reactions to loss.
In the African culture there are funeral rites
which are ceremonial and intended to express
grief at the loss of the member of the community
and to express awe and concern in the presence
of death itself. Recovery from bereavement is
faster in many African communities, because
of the practical ways which symbolically help
individuals to recover. Among the Luo and the
Luhya communities of Kenya, widows wear their
husbands clothes, especially during tero buru
(mourning ceremony). Mourning by wailing is
encouraged and gossip is directed against a close kin
who did not wail. The end of the mourning period
is prescribed and masked by a ritual passage.
In many communities, symbolic mourning is still
practised which helps people cope with bereavement or loss, because they have a psychological
and social function in coping with or recovering
from bereavement.
This is when the bereaved accepts the fact that the

person is dead and gone forever. Acceptance leads
to better and open communication and meaningful
support. It must be noted that not all bereaved
persons reach this stage.
FORMS OF GRIEF
Normal grief reaction
Brief grief is immediate unprolonged expression
of feelings or reaction to the loss, e.g., outburst
of anger or crying. There is also the feeling of
numbness and blunting which lasts for a few hours
to a few days. There is outright disbelief and it is
the funeral service that brings home the reality of
what happened. Physical symptoms are also likely
to develop; some people may feel ill and shivery
and remain in bed for a couple of days. Behaviours
such as isolation, withdrawal, avoidance and
dreams help distract from thinking too much about
bereavement.
In anticipatory grief, there is awareness of the
impending death and the bereaved prepares for the
death, e.g., in the case of terminal illness.
The tasks of grieving

The process of grief is often described as hard work
and it is therefore useful to consider it in terms of
tasks of grieving. Successful achievement of the
tasks can lead to growth and greater psychological
strength. Failure to complete the tasks can lead to
complicated grief.
Task 1 accepting the loss: Intellectual and
emotional acceptance or recognition of the loss,
can result in working through the next task.
Abnormal grief reaction

Chronic grief: this is a prolonged grief reaction,
for example, mourning the dead for years and
years.
Delayed grief: in this case people do not grieve.
They behave as if nothing has happened, but
weeks and months later develop psychiatric
symptomsthe person is actually reacting to
the loss or death. Delayed reaction to death
517
Task 2 feeling the pain: Once the reality of the

loss has been intellectually recognised, the pain
of grief begins to be felt. This normally involves
bewildering confusion of difcult emotions, which
need to be recognised and experienced fully.
Task 3 adjusting: Change is inevitable when a
loss is suffered. The nature and degree of change
will vary, depending on the nature and closeness
of the loss, but the task is always to accept the
necessary changes and to nd appropriate ways of
successfully achieving them.
Task 4 letting go. This involves the difcult task
of saying goodbye, of releasing the lost person or
object and the emotional ties with them, so that life,
activities, relationships and interests can go on. It
is not necessary to forget, or to stop loving, but to
let go and move on.
Factors related to the nature and circumstances

of the bereaved person
Childhood experiences (especially loss of
signicant persons), how they coped with the
losses, will determine their reaction to the
present loss.
Previous mental illness (especially, depressive
illness): bereavement is likely to trigger off
psychiatric problems in an individual with a
previous history of mental illness than one
without. There are also personalities, which
are more prone to psychological problems
when under stress than others, e.g. neurotic
personalities.
Socio-economic status: the different social
classes react differently to death. The extent of
grief reaction will be determined by the socioeconomic status of the dead. Any kind of
stress will determine the intensity of reaction
to death.
Social support and isolation will determine
grief reaction: if there is a network of social
support for the bereaved, then there is little
likelihood of psychological problems. Isolation
may result in psychological problems. Friends
and relatives can provide a lot of support at
the time of bereavement. Professionals can
also provide social support to the bereaved;
or having someone to conde in is protection
against abnormal reaction to death or loss.
Cultural and familial factors can prevent
expression of feelings that emerge, e.g., in some
cultures people are not expected to cry. This can
be very harmful, because psychological trauma
is repressed and somatised. In such cultures,
trying to help individuals may be very difcult
and frustrating.
Open options: when there are options open to
the bereaved then reaction to death may not
result in psychiatric problems. In the case of
death of a loved one, if the spouse is involved
in another relationship this may help him to
forget or if the spouse is able to get a job and
is able to manage nancially, then reaction
to death may not be so intense. In certain
communities like among the Luos of Kenya,
there is encouragement of wife inheritance,
which protects the woman from developing
psychological problems as the inheritor takes
up the responsibilities of the deceased, both
emotionally and nancially.
In terms of the different sexes, females are
more likely to react intensely to bereavement,
Determinants of grief
There are a number of factors, which might make
grief more difcult. Experiencing any of these
factors will not necessarily lead to problems in
grieving, but their presence might alert you to
possible difculties.
Factors related to the nature of the death
Uncertainty over whether the death has
occurred
Unnatural violent, messy deaths
Sudden deathreaction to this kind of sudden
death is different from timely death e.g
terminal illness as it is more intensied
Unrecognised deaths
Unmentionable deaths
Preventable deaths
Multiple deaths
Deaths accompanied by many other losses.
Factors related to the nature of the relationship
with the deceased
Reaction to the death: extremely close
relationships may be more intense than
reaction to the death of a distant relative.
Strong attachment to the dead may cause intense
reaction. Also an ambivalent relationship may
cause intense reaction, because there are guilt
feelings when death is gratied. The bereaved
experiences intense guilt and prolonged
mourning.
Great dependence on the deceased may result
in intense reaction to his death.
518
Guilt of not being able to do enough for the

dying person.
Sorrow and depression are also present.
It is therefore important to recognise that the family
of a dying patient is not only coping with the
realisation that their loved one is dying, but also the
impending death of the family unit. Considering the
painful experience the family of the terminally ill
patient is going through, it is critically important to
include them in the patients treatment. This allows
for continued support of the patients maintenance
of identity, self worth, integrity and meaning, and
also foster opportunity for the patient and other
members to complete unnished business.
especially when the deceased was the

breadwinner of the family. This kind of loss is
likely to give rise to psychological problems.
Both young and old react to death of a
signicant person in their lives in the same
way although childrens reaction may be
masked and only manifest in psychological or
physical problems.
There are certain religions that do not encourage
mourning of the dead and in this case reaction
to death may be seriousleading to the
development of psychiatric problems. Others
go through rituals, which may be positive for
the bereaved. In most African cultures the
bereaved have to perform certain rituals before
and after the burial. These rituals are positive
for the well-being of the individual.
It is important to note that a person may face
all the above predictors and still not suffer a
breakdown after bereavement or he may have
none of them and yet suffer a breakdown.
Death is a universal human experience and
inevitable. In many cultures death is thought
to be caused by the unforeseeable and
unavoidable intrusions into society by external
and superhuman power. This is beyond human
comprehension. Nonetheless, the living must
somehow control it and when it comes, nd
ways of coping with it lest they become
overwhelmed by it.
Counselling
Crisis intervention in bereavement
The main concern is to restore emotional arousal to
near normal level since over-arousal interferes with
problem solving. This can be achieved by providing
reassurance and opportunities for the client to
express his emotional feelings. It is important to
encourage the client to be involved in the efforts to
ameliorate the situation that precipitated the crisis.
It is also important to employ problem-solving
counselling. This involves encouraging the client
to assess his problems against the assets he may
have, leading the client to suggest alternative
solutions and making the necessary choices. The
counsellor encourages, prompts and asks clarifying
questions. He avoids formulating the problems
or suggesting solutions directly. When the client
succeeds, it is important for him to realise that he
has learned a better way of solving a problem that
can be employed in the future. The following are
steps that can be followed:
Identify and list problems.
Consider what can be done.
Select one problem and carry out action most
likely to ameliorate the problem.
Review results and either choose another
solution or another problem if the rst problem
has been effectively dealt with.
Working with families before death

Before a family is prepared for the impending death
of a loved one, it is important to understand that the
family is a unit and system with parts. Therefore,
anything that affects one member affects the whole
system.
The open and closed family system are important characteristics to consider when evaluating
the potential for adoptive change and planning
interventions to maintain some level of functioning
in the family during crisis.
The common problems of a family of a dying
patient include:
Communication becomes difcult as each
member differs in their degree of acceptance.
Expectations are radically altered with
recognition that one member may not be part
of it.
Fears about harming or killing the ill person
due to inexperience exists.
Fears of inadequacy in managing potential
crises exists.
Helping troubled people

The rst concern for clients confronting death is to
alleviate physical pain and listen to the client who
will be a good guide on what he needs to know and
what concerns he has. It is important to attend to his
comfort e.g. household chores and care of children.
Make sure that the client is involved in identifying
areas of need and providing suggestions of what
needs to be done, including putting his personal
519
and family affairs in order. Offer opportunities for

the client to yield control to others on those matters
that he can no longer be involved. It is important
to offer realistic assurance to allay unrealistic fears
like abandonment. It is important to be truthful and
genuine.
Counselling of clients in acute reaction to stress
aims at reducing the excessive emotional response
by being a good listener, encouraging recall of
the events surrounding the stress and discussing
the stressful events, while clarifying any aspects
that may not be clear. This makes it possible for
the client to have a clear analysis of the problem.
It is then easier to encourage the client to employ
more effective coping strategies, such as problemsolving of any residual concerns.
To prevent abnormal grief for the bereaved, it
is important that individuals be involved in the
burial rituals and ceremony. In case of a stillborn,
it is important to name the stillborn and give him
a proper burial. The bereaved as well as those
experiencing abnormal grief should be engaged in
talking about their loss.
Counselling is a form of psychotherapeutic
intervention or treatment in which individuals and
groups are helped to cope and function without
symptoms.
Counselling the bereaved

Individual counselling
The bereaved is helped with the loss and
reassurance given whenever necessary.
The therapist provides empathetic listening.
This kind of support is also provided by a person who has experienced major bereavement,
as he understands what the other person is
going through.
Reassuring the bereaved that they are not
alone in the world helps reduce feelings of
insecurity.
Group counselling
A group of bereaved individuals will go a long
way in helping members to cope, because they
share experiences and know that they are not
alone, thus providing encouragement.
Group therapy helps people with a sense of
loneliness to gain strength through supportive
relationships.
Marital and family counselling
Traumatised
individuals
may
have
problems with their relationships. Violence
and child abuse may be the outcome of such
relationships.
Marital counselling should be directed towards
the improvement of sexual functioning, if it is
non-existent.
Counselling the family of a dying patient

The counsellor should identify, legitimise and
formalise their feelings of sorrow and depression
and help the family nd ways of coping with such
feelings. They should point out to the family how
distancing affects the patient and that crying or being
intensely upset does not mean that one is losing
control and indicate that these are normal reactions
that need to be expressed. They should convey to
the family that expression of a little emotion at
a time is valuable and encourage expression of
feelings in private places that are comfortable and
not threatening. The counsellor should focus on
enabling family members to experience the joys
and pleasures that are available despite continued
loss.
Counselling grieving children

Such children require reassurance that the
therapist will be there for them.
Parents should also be involved in helping
their children go through grief by reassuring
them about the loss. This helps children come
to terms with the loss.
At times older children provide support for
their parents to go through grief.
Social support
The bereaved need support to come to terms with
the loss and with the new roles in the family and
their positions as widows and widowers. Friends,
workmates and relatives must be involved when
trying to help a particular individual since care of
the bereaved is a community responsibility.
Acceptance of the bereaved with all the
problems and weaknesses, gives the bereaved a
Telling the children

Needs of children vary with age. Most children
over the age of 5 are able to understand if it is
explained in simple language, that mummy or
daddy is going to heaven or is leaving the earth.
Unforeseen problems surface if children are not
allowed to share in the family sorrow.
520
sense of belonging and helps them to move on.

In some communities, funerals are expensive
affairs requiring the bereaved to sometimes raise
funds to meet funeral expenses, for support of the
bereaved and education of the children. In cases, in
which the dead was the breadwinner of the family,
the bereaved should be provided with nancial

support.
Further reading
1. Lazarus P. S. (1966). Psychological Stress and the
Coping Process. McGrow-Hill. New York.
521
68
Occupational Therapy, Rehabilitation, Community
Psychiatry and Social Support Networks
Tom Onen, Anne Obondo, David M. Ndetei, Anna K. Karani, Mirriam Wagoro
expensive drug for free by his physician. However,

there were conditions of taking it three times a day
after meals. Unfortunately, he had not had a meal for
two days therefore could not accept the medicines
as he could not comply with the instructions.
THE STEPPING STONES TO

RECOVERY
In general, when in-patient and comprehensive
out-patient programmes are compared, people in
the community-based programmes show better
outcome for longer periods of time than those
treated in the hospital. Even people who are acutely
psychotic can be treated effectively in carefully
supervised and professionally staffed community
settings. There are three main components of
treatments for the mentally ill:
Medications to lessen symptoms and
prevent relapse.
Education to help patients and families solve
problems, deal with stress and cope with the
illness and its complications.
Social rehabilitation to help patients reintegrate into the community and regain
educational or occupational function.
Rehabilitation
Rehabilitation improves the quality of life of
people with mental illness and reduces relapse and
re-hospitalisation rates. The goal of rehabilitation
is to re-integrate the ill individual into life in the
community. In the past, the primary emphasis was
placed on returning the individual to work. It has
now been accepted that there are many other equally
important goals of the rehabilitative process:
To reduce symptoms that people experience
through the use of drug therapy and adverse
consequences of the illness.
To improve the individuals social
competence.
To increase family and social support in
the areas of employment, housing and
socialisation.
Several types of services are needed. After a
psychotic episode, the person with mental illness
may need to re-learn basic social and life skills.
This training is often provided by occupational
therapists or day hospital programmes.
Vocational rehabilitation and job placement
give the person meaningful productive activities
Medication
People with mental illness benet when medical
professionals work to nd the method of treatment
most suited for them. From the ill persons
perspective, continuity of care is important in
treatment. In addition, recipients of care are best
served when they have a voice in their treatment,
for example, where a patient was given a very
522
Occupational Therapy, Rehabilitation, Community Psychiatry and Social Support Networks
Figure 68.1: Encourage people with mental illness to engage in recreational activites
ordinating needed services is one successful model

for providing rehabilitation. Another approach
makes use of a team of mental health professionals
from different disciplines to provide services. The
team approach allows for maximum communication
among the patients caregivers and provides longterm continuity of care. Unfortunately, neither of
these models is widely used in most countries.
Indeed our greatest asset in the management of
mental health problems is our traditional family
and social support system. No technology or drugs
can substitute this.
Most psychiatric illness cause functional,
physical, intellectual and emotional disabilities.
Impairment occurs in the areas of social and
interpersonal relationship, e.g.
Daily living activity, learning and working
environments. This includes the inability to
choose jobs and set goals, control anger and
relate to others.
Rehabilitation and occupational therapy are
used to enable patients to be re-integrated into
and increase self-esteem. Enabling people with

mental illness to work also reduces welfare costs.
Recreational opportunities are another need. Peer
support groups provide socialisation, emotional
support, and give people an opportunity to learn
coping strategies that have worked for others.
Supportive counselling can help the person accept
the fact of his illness and deal with the losses it
entails.
People with mental illness often have trouble
locating the services they need. Typically different
services are provided by different agencies, each
with its own rules and bureaucracy. Accessing
services requires knowledge, perseverance and
planning. Even making and keeping an appointment
may be difcult for a person with low motivation
and impaired organisational skills. Ironically,
healthier individuals are the ones who are most able
to access services, while the severely aficted are
most likely to fall between the cracks, especially if
they lack family support.
Case management in which one professional is
responsible for advocating for the patient and co-
523
like attendance, punctuality and performance,

condence and assertiveness, and responsibility.
Career counselling helps in dening career
objectives to the patient and exploration of values,
which will enable him, visualise the work reality,
take action accordingly to get the job, know his
strengths, and orientate to ways of behaving well.
the community with a good level of social

functioning and capacity for independent
living or coping skills.
OCCUPATIONAL THERAPY
Occupational therapy is the treatment of individuals
through active participation in purposeful activities.
It helps an individual exercise control over his
environment by actively assuming responsibility for
himself, his domestic and work situation and also
develop interests, skills and abilities. Occupational
therapy is therefore an active method of treatment
with a profound psychological justication and
purposeful activity especially when the patient
actively and willingly collaborates. This implies
that the humanbeing through the use of his hands
can inuence the state of his own health.
Occupational therapy activities

A selection of a number of activities take into
consideration not only the needs and interests of
patients, but also environmental and gender factors
as well as the facilities available. Hospital-based
workshop activities or programmes may incorporate
a wide range of activities such as carpentry,
embroidery, painting, tailoring, electricity, typing
and husbandry activities, including tending herds
and milking cows, gardening, fetching rewood,
cooking and washing.
Other occupational activities are carpet-making,
weaving, recreational activities such as indoor
games and competition between the patients.
Enlightening and intellectual stimulation, interest
and relaxation activities include lectures, group
discussions, and reading of newspapers and
magazines.
The aim of occupational therapy

The aim of occupational therapy is to rehabilitate
patients for their return home and to help them
overcome anxiety at work or to deal with a
difcult working relationship. Patients suitable for
occupational therapy are those recovering from
mental illness or those requiring assistance in
returning to former employment or re-training.
Cognitive decits associated with the illness
itself are impaired speech, poor attention span
and inability to plan. Chronic psychiatric patients
lack skills to maintain their jobs or nd new ones.
Patients who are employed lack the ability to
adhere to schedules, interact effectively with coworkers and supervisors, solve problems or ask
others for help, and improve general performance.
Those looking for jobs may lack skills such as
interviewing and the ability to complete forms.
The mentally ill suffer deprivation of selfmaintenance skills of daily living (ADL) like
poor personal hygiene and grooming clothing,
money management, cooking, shopping skills,
housekeeping, and use of public facilities,
e.g., transport and other available community
resources.
Vocational rehabilitation is designed to address
skill decits that are essential to the patients
mastery of living environments. Work adjustment
training in skills necessary to maintaining a job is
indispensable in improving work and social skills
The role of occupational therapists

An occupational therapist works in co-operation
with the psychiatrist, psychologist, psychiatric
social worker, nurses and relatives of the patient,
employers, voluntary organisations as well as
governmental organisations. An occupational
therapist has two major roles to play, mainly
assessment and rehabilitation of the patient.
Assessment forms a considerable part of the
therapists daily work and the ability to do so
competently is one of the hallmarks of an effective
therapist. Assessment helps in planning adequate
occupational therapy programmes.
Rehabilitation is done through the use of
purposeful activities and attainment of satisfying
personal relationships by encouraging new skills,
perfecting poorly used ones or relearning forgotten
ones resulting in restored self condence and a
more mature sense of responsibility.
Occupational therapy is an instrument of
treatment used by the patient and therapist to
contribute to the resolution of psychological
problems. The patient is helped to develop those
524
have resulted from psychiatric illness and their

current assets and strengths include psychological,
social and physical needs. Rehabilitation plan is
determined for the identied needs to be given
the rst priority in view of the appraisal of the
patients level of functioning before the illness.
The assessment of the patients level of awareness
deciencies and his expectations for the future is
of great value.
Effective rehabilitation necessitates accurate
diagnosis; the patients decits, assets and strengths,
skills and performances in personal, domestic and
vocation, and psychological, social and physical
need as well as appraisal of the patients level of
functioning prior to illness.
aptitudes and attitudes which will enable him to

live comfortably.
REHABILITATION
Rehabilitation refers to the process of restoring
a person to previous full working capacity and
resumption of normal social activities or to the
highest level of function possible. Rehabilitation
programmes are client-centred.
Objectives of rehabilitation
To treat debilitating manifestations or positive
symptoms of psychiatric illness to bring mental
functioning and behaviour under control.
To prevent or treat the disabilities induced by
mental illness and re-integrate patients into
community life as soon as possible.
To help patients with long admission in
hospital to return to the community.
To support the chronic mentally ill within
the community to reduce prolonged stay in
hospital.
To rectify the patient's social environment.
To maintain the gains made by patients during
acute treatment.
To prevent or delay relapse over the long
period.
The rehabilitation process usually commences the
moment the patient is admitted to hospital. Areas
of assistance include:
Medical: most patients in rehabilitation require
medication for the symptoms of their disease.
Psychological: these include individual,
supportive and group therapy, and behavioural
programmes and social skills.
Social: most patients have difculty in
restarting life in the community. They are
encouraged to join normal community groups,
special clubs or social centres.
Rehabilitation techniques
These include individual therapy, supportive and
group therapy, psychodrama, assertiveness training,
anxiety management and relaxation training, art
therapy, recreational activities, exercises, activity
for daily living, social skills, home management
training, supervision of medication, support and
advice, role play, behaviour modication and social
function and environmental manipulation.
The mentally ill often have multi-dimensional
problems and these are best met by a multidisciplinary team approach. This team may include
all or several of the following: psychiatrist, general
doctors, psychologist, and general nurses, social
workers, occupational therapist, art therapist, nurse
attendants, psychiatric clinical ofcers, clinical
ofcers, family members, voluntary and charitable
organisation staff and community workers.
The multi-disciplinary approach is important
because it offers more comprehensive service,
easy access to service, better planning for care,
availability of support from colleagues or peers,
protection from burden of sole responsibility for
patients with challenging behaviour, more effective
management of caseload, opportunities for crosscover in case of sickness or leave, pooling resources
and skills and share responsibilities.
The commencement of rehabilitation
Types of rehabilitation
It starts the moment the patient is admitted to

hospital for treatment, but the full programme
is started when their mental state stabilises.
Psychopharmacological management in conjunction with the support of care providers forms
an effective method for achieving stabilisation
process. Assessment of the patients decits that
Hospital-based rehabilitation
The hospital-based care involve admission,
assessments and treatment of patients with chronic
mental illness who have relapsed, patients requiring
intensive rehabilitation e.g., forensic units or
medium secure units and occupational therapy.
525
lose personal assets: in some communities a

mentally ill person is not supposed to own land
or property. He has to have a guardian who in
most cases is a relative. The patient may lose
his assets while ill or during the long period of
hospitalisation, or relatives may have used his
absence or his mental state confusion to grab
and sell the assets.
Once the patient has been de-institutionalised
they are cared for by their families. However,
de-institutionalisation of patients becomes very
difcult in African settings because of lack of
proper after-care facilities.
The success of de-institutionalisation depends
on the provision of community care services
such as social worker skilled in after-care work,
availability of hostels, adult training centres,
special workshops, occupational therapy and job
placement services which must be supported by
better trained general practitioners and nurses in
the medical care of chronic mentally disordered
individuals. Community social services and health
services must complement each other. Multidisciplinary team approach is very essential and
should be concerned with early recognition of
mental stress. Home-based programmes to ease the
burden placed on the family should be provided.
Community-based rehabilitation
Community rehabilitation is care provided within
their own environments. Community-based
rehabilitation is important because it is cheaper
and uses local resources, which includes the
participation of families and the community. It
provides meaningful work and training experiences
for patients within their own communities where
they can exchange ideas and learn from each other.
COMMUNITY PSYCHIATRY
Community psychiatry is concerned with the
prevention and treatment of mental disorders and
rehabilitation of former psychiatric patients through
the use of organised community programmes. It
approaches patients through the resources of the
community.
Community psychiatry is concerned with community mental health, as a total system rather
than a single service. It is suited to the needs of
those served. These include the following services:
emergency, out-patient, in-patient, education for
children, services for the aged, follow-up for those
who had been hospitalised; alcohol, and drugs
abuse services.
The community also participate in decisions about
mental health care needs and programmes instead
of having them dened solely by professionals. The
expectation is that mental health services are apt to
be used when knowledgeable persons interpret and
educate the community about their availability.
Community services
Day hospital
They function on the principle of responsibility
sharing and offer services such as:
Observation, assessment and treatment of all
categories of adult mental illness.
supervision of medication.
supervision and preventing of relapses
by providing support and a stimulating
atmosphere.
provision of support and advice.
occupational and social activities.
therapies like:
o individual and group psychotherapy.
o behaviour modication.
o social skills and home management training.
They full a social function, e.g. dealing
with problems of isolation or loneliness,
leisure activities and meals where feasible.
The general principle governing the day hospital is
that patients daily programme has to be carefully
tailored and prescribed in a manner, to balance work,
De-institutionalisation
This is the process in which large numbers of
patients are discharged from public psychiatric
hospitals into the community to receive care in outpatient facilities. Patients who are institutionalised
in mental hospitals, prisons and orphanages are
not always ready to go home. Patients who are
institutionalised may:
lose personal friends due to breakdown in
communication between the patient and
friends.
lose personal possessions and property due to
their mental state and long hospitalisation.
lack contact with their relatives, because of
long distances between them and the hospitals
as well as the expenses that are incurred when
travelling.
526
of mental illness, secondary prevention should be

complementary to other measures being used. The
prevention of mental disorder is based on public
health principles and is divided into primary,
secondary and tertiary prevention.
rest and recreation for each day. Pharmacotherapy

and psychosocial therapy go hand in hand. The
comprehensive rehabilitation programme must be
reviewed regularly to succeed.
Out-patient
Primary prevention
These are useful for patients who have less severe

psychiatric disabilities. They provide:
assessments of new patients
review of known patients with enduring mental
illnesses and the purposes of Care Programme
Approach (CPA) with the multi-disciplinary
team
review of known patients for medical treatment
and supportive therapy
individual therapies
other specic therapies like CBT, and marital
and family therapy.
The goal of primary prevention is to prevent the

onset of a disease or disorder, thereby reducing its
incidence. This goal is accomplished by eliminating
causative agents and reducing risk factors. Primary
prevention also aims to eradicate stressful agents
and reducing stress. Such programmes include
pre-natal care to decrease the incidence of
mental retardation and organic mental disorder in
children.
Secondary prevention
This is prompt treatment of an illness with the
goal of reducing the prevalence of condition by
shortening the duration.
Day centres
They are primarily designed to care for patients
with problems of loneliness and isolation.
Services include provision of company to patients,
leisure activities, meals and sheltered working
environment. Day centres are not usually medically
staffed. There is considerable overlap in the type of
services offered by day hospitals and day centres.
Tertiary prevention
The goal of tertiary prevention is to reduce
the prevalence of residual defect or disability
caused by illness or disorders. In the case of
psychiatric conditions, tertiary prevention involves
rehabilitation efforts to enable those who have a
chronic mental illness to reach the highest level of
functioning feasible.
The role of the social worker in

rehabilitation
The work of the social worker involves assessment,
provision of social support, environmental
manipulation, counselling, mobilisation of
community services, community education followup and referral.
The social workers have a control role to play
regarding community services. They know best
what is available in particular areas and who the
contact person is. They advise patients and their
families about the kind of facility or service that
suits them and refers them accordingly.
SUPPORT NETWORKS
Social support should also be provided for the
patient within his environment. The environmental
support includes both formal and informal support
network and systems such as the community,
organisations and personal relationship within and
outside the family.
Lack of social support within the individuals
environment, may lead to psychiatric illness or a
relapse in already discharged patients. The family
is an important institution for the well being of an
individual. It is therefore important that the family
provides a favourable environment that is free from
role conicts, provides stable family relationships,
and one that is non-critical and accepting.
A community like the school, college, university
or a residential home fulls the function of
integration because people of diverse origins
are brought together, share common things and
provide emotional support to each other. Therefore
PREVENTION PROGRAMMES
In parallel with occupational and rehabilitation
programmes, prevention programmes play an
important role. Community psychiatry should
incorporate preventive measures in all its
dimensions. Promotion of mental health and
prevention of psychiatric and emotional disorders
must be treated as part of the rehabilitation
process. Likewise, in working on the detection
527
integration of an individual into the community

becomes very important for his wellbeing. It is
therefore important that the community provide a
friendly environment to which one is able to adjust
and be integrated.
An individuals workplace should provide
a conducive environment with good working
relationships and network of friends. Classroom
experiences provide opportunities for children
not only to acquire knowledge but to also mature
socially. If the teacher-child interaction and the
peer relationships are impaired then problems may
arise.
It is therefore important that the social
background of psychiatric patients be properly
studied to establish the social support network for
appropriate or effective management, both in the

hospital and in the community.
Further reading
1. Bellack, A.S. (1989). A Clinical Guide for the
Treatment of Schizophrenia, Plenum Press, New
York.
2. Brady, J.P. (1984). Social Skills Training for
Psychiatric Patients,II. The American Journal of
Psychiatry, 141, 491 - 498.
3. Chementones, Eugistic et al (1991). Compressive
Family and Community Health Nursing (3rd ed)
Mosby: St Louis Toronto.
4. Kraus, J.B., Slavinsky, A.T. (1982), The Chronically
Ill Psychiatric Patient and the Community. Blackwell
Scientic Publications, Boston.
528
Section VI Part C:
Emerging Trends
529
530
69
Complementary and Alternative Medicine in Psychiatry
Seggane Musisi, Elialilia S.Okello, Fikre Workneh, Stella Neema, Catherine Abbo
practitioners. In India and Nepal, Ayurvedic

medicine is popular.
In the Western world where modern conventional
medicine has been the standard of care, many
are now turning to alternative or complementary
therapies that include traditional medicine,
homeopathy, acupuncture and naturopathy. The
Journal of the American Medical Association
(JAMA) in its issue of November 11, 1998
stated Opening a professional dialogue between
physicians and practitioners of alternative
medicine is crucial to better health care for those
patients who choose alternative therapies. In
most African countries, the patient to psychiatrist
ratio is 1:2,000,000. This is in contrast to the
traditional practitioners who are estimated to give
a therapist: patient ratio of 1:120.
Globally, complementary and alternative medicine

(CAM) is increasingly used with allopathic
medicine, particularly for treating and managing
chronic illnesses. In Africa, this has often taken
the form of traditional medicine.
Traditional medicine includes diverse health
practices, approaches, knowledge and beliefs
incorporating plant, animal and mineral-based
medicines, spiritual therapies and manual
techniques in various combinations. In many
African settings, the role of traditional practitioners
has been recognised but their incorporation in
modern mental health care has not yet been put
in practice. Yet traditional medicine is considered
the pillar of health care in many developing
countries.
Traditional practitioners manage at least 80
percent of health care needs of rural inhabitants in
developing countries. At least 40 percent of clients
of traditional practitioners have mental health
problems. It had been suggested that to provide
primary health care for all by the year 2000, in
line with the Alma-Ata declaration, traditional
medicine needed to be accorded equal recognition
as conventional western medicine.
China, Vietnam and Korea are the only countries
in the world where traditional medical systems are
ofcially recognised as being at par with Western
medicine. The Chinese gave this recognition
in 1949, and Vietnam, in 1961. Recently, South
Africa ofcially recognised traditional healers
called sangomas as legitimate and certied health
GLOBAL OVERVIEW OF
PRACTICE OF TRADITIONAL
MEDICINE
Populations throughout Africa, Asia and Latin
America use traditional medicine to help meet
their primary health care needs. Apart from being
accessible and affordable, traditional medicine
is also often part of the wider cultural belief
system, and is considered integral to everyday
use and well-being. Concern about the adverse
effects of western medicine, a desire for more
531
Traditional healers, use all kinds of techniques to

effect healing. Abbo in 2003 classied these into
four, namely:
Phytotherapy and other medicaments (herbal,
organic-animal and non-organic remedies:
taken orally, smoked, inhaled or applied
topically)
Talking therapies (psychotherapies and
counselling)
Behaviour
modication
therapies
(symbolisms, rituals, drama and interactive
group therapies).
Spiritual (faith) healing (spirit consultations,
prayer and possession states or wearing
protective artefacts).
personalised health care and the rise in the number

of publications providing health information have
fuelled the increased use of traditional medicine. In
Africa, the indigenous beliefs in supernatural causes
of illnesses especially, mental illness promote the
use of traditional medicine.
The use of traditional medicine has created public
and health care challenges in terms of policy, safety,
efciency, quality, access and rational use. Policy
matters, health care providers, traditional medicine
providers and non-governmental organisations
(NGOs) have a duty to respond to these challenges
in order to help develop the potential of traditional
medicine as a source of acceptable health care.
TYPES OF ILLNESSES
TREATED BY TRADITIONAL
PRACTITIONERS
COMPLEMENTARY AND
ALTERNATIVE MEDICINE
In his study of Ndemu village life in North Western

Zambia, Schism and continuity in African
society, Turner in 1957 reported that there was
evidence to suggest that social and psychological
causes of illness were better understood by a
number of traditional practitioners. When tension
arose, the aggrieved persons usually sought help
from traditional healers. Jealousies often arise with
social discontent in the struggles of family members
to achieve social recognition and assert their
inherent property right. In such a society, Turner
further observed that there were elements, which
supported traditional medicine. The dominant
societal values operated through schism and
reconciliation. Thus a traditional healer occupied
an all-important place in the systems
Abbo in 2003, when studying traditional
practitioners in Uganda came to similar conclusions
as Turners. He noted that madness (psychosis) and
social problems were the most frequently treated
problems by traditional practitioners, followed by
social problems e.g. family and business problems
and spiritual and cultural problems.
Traditional medicine is often codied,
regenerated, taught and practised widely and
systematically. It benets from thousands of
years of experience. Conversely, it may be highly
secretive, mystical and rarely discussed with its
knowledge and practices only passed on orally.
It may be based on salient physical symptoms or
perceived supernatural forces.
The terms complementary and alternative and

sometimes non-conventional or parallel are
used to refer to a broad set of health care practices
that are not part of a countrys own tradition, or
not integrated into the dominant health care system
(Kaplan & Sadock, 2001). However, these practices
are widely used by the people of a given society. In
countries where the dominant health care system is
based on allopathic medicine, or where traditional
medicine has been incorporated into the health
care system, traditional medicine is often termed
as complementary or non-conventional
medicine.
INCORPORATING
COMPLEMENTARY MEDICINE
INTO NATIONAL HEALTH CARE
SYSTEMS
The World Health Organisation (WHO) has dened
three types of health systems to describe the degree
to which traditional medicine or Complementary
and Alternative Medicine (CAM) is an ofcially
recognised element of health care. These systems
are integrative system, inclusive system and
tolerant system.
532
Complimentary and Alternative Medicine in Psychiatry
parts are used (e.g. leaves, owers, barks, stems or

roots) or their dosage regimens and directions of
treatment.
Integrative system
In an integrative system, CAM is ofcially
recognised and incorporated into all areas of health
care provision. This means that CAM is included
in the relevant countrys national drug policy;
providers and products are registered and regulated;
CAM therapies are then available in hospitals
and clinics, relevant research is undertaken and
education in CAM is available.
POTENTIALLY HARMFUL
PRACTICES IN TRADITIONAL
HEALING SYSTEMS
Inclusive system
Traditional practitioners have sometimes received
negative publicity about their healing activities.
Some of this arises out of ignorance on the part
of the public with regard to traditional healing
practices. Some of the negative criticisms arise as
a result of biases and intolerance of other peoples
values and cultures. However, it is also true that
some traditional practitioners engage in overtly
unacceptable practices that ought to be condemned.
Some studies have shown that many of the harmful
activities that were identied arose from lack of
knowledge on the part of the traditional healer
including failure to recognise life-threatening
illnesses among their patients such as anaemia,
pneumonia, delirium and febrile convulsions in
children. The potential toxicity of some traditional
medicine herbs (phytotoxicity) should be
recognised, as well as dangerous prescriptions such
as human sacrices and use of human body parts.
All these call for a need to standardise, supervise
and regulate CAM.
This recognises CAM, but has not yet fully

integrated it into all aspects of health care, either
in health care delivery, education and training,
or regulation. CAM might not be available at all
health care levels. Countries operating an inclusive
system include Equatorial Guinea, Nigeria, and
Mali. Ultimately, countries operating an inclusive
system can be expected to attain an integrative
system.
Tolerant system
In countries with a tolerant system, the national
health care system is based entirely on allopathic
medicine, but some CAM practices are tolerated
by law e.g. Uganda. However, these countries
have not yet incorporated CAM in their health care
delivery systems.
CHALLENGES IN DEVELOPING
CAM POTENTIAL
Traditional medicine and mental illness in

primary care
To maximise the potential of CAM as a source of

health care, a number of issues must be tackled.
They relate to policy, safety, efcacy, quality,
access and rational use. Only 25 out of WHO 191
member states had developed a policy on CAM by
2002. Yet such a policy provides a sound basis for
dening the role of CAM in national health care
delivery, ensuring that the necessary regulatory
and legal mechanisms are created for promoting
and maintaining good practice, that is equitable
and assures authenticity, safety and efciency of
therapies.
CAM practices have developed within different
cultures in different regions. There has been no
parallel development of standards and methods
either national or international for evaluating them.
Evaluation of CAM products is also problematic.
This is especially true of herbal remedies, in that
their effectiveness and quality can be inuenced by
numerous factors, e.g., when they are picked, what
Common Mental Disorders (CMD), a term coined

by Goldberg and Huxley in 1992 to describe
disorders which are commonly encountered in
the community, and whose occurrence signals a
breakdown in the normal functioning are amongst
the most frequent disorders in the primary care
attendees. They are characterised by the clinical
presentation of somatic symptoms, anxiety, and
depression and are associated with signicant
disability. In Africa, epidemiological research
has almost entirely consisted of cross sectional
surveys of prevalence rates of mental illness using
methodological and diagnostic models developed
by European and American researchers. Traditional
practitioners, who are among the key primary health
care providers in Africa, are rarely included in such
studies. The 1993 World Health Report shows that
neurotic, stress-related and somatoform disorders
533
are the third most frequent causes of morbidity

worldwide. These CMDs have also been identied
as a signicant public health problem. In a recent
study, Muhwezi, 2004 clearly demonstrated that
these patients with subjective complaints of distress
were more likely to present in primary health care
centres and most met DSM-IV-TR criteria for
depression or dysthmia. Most allopathic medicine
practitioners and other mental health professionals
do not recognise them thus forcing patients to
seek alternative treatments. It is hoped that efforts
at incorporating traditional medicine in modern
mental health care delivery will eventually yield
results and stop Africas multitudes with mental

illness from seeking treatment from unqualied
healers.
Further Reading
1. Kiresuk TJ, Trachtenberg A, (2000): Alternative and
Complementary Health Practices. In Comprehensive
Textbook of Psychiatry, 7th Edition Vol.2 . Sadock
BJ & Sadock VA (Eds.). Lippincott Williams &
Wilkins Publishers, Baltimore MD, USA.
2. Albert HC, Wong MD (1998): Herbal Remedies
in Psychiatric Practice. Archives Of General
Psychiatry. 1998, 55:1033
534
70
Nursing in Mental Health
Anna K. Karani, Miriam Wagoro, Tom Onen
according to the underlying psychopathology and

its manifestations.
ROLE OF NURSES IN THE

MANAGEMENT OF THE
PSYCHIATRIC PATIENT
PLANNING NURSING
INTERVENTION
Psychiatric nursing training began in 1854 in

Scotland. Most African countries sent their
psychiatric nurses to train abroad before 1960.
Currently, they train registered or enrolled
psychiatric nurses locally.
Majority of the African medical training colleges
have included a component of psychiatric nursing
in their curriculum for basic and post-basic courses
so that each qualifying nurse has a minimum of 6
to 8 weeks of psychiatric nursing experience. Every
nurse must be able to assess psychiatric patients,
analyse data to formulate nursing diagnoses by
identifying mental, physical and social problems
of each particular patient. That includes the ability
to plan and implement individualised care based on
specic nursing diagnoses plus evaluation and if
necessary to re-formulate the care plan.
Nursing care objectives include preventing

possible self-injury, alleviating disorientation and
promoting optimal perception. Other objectives
include promoting adequate hydration, nutrition,
and providing education on the causes and
prevention of the disorders. It is important to
facilitate social re-integration in the family and
community.
The nursing objectives should cover the mental,
physical and social aspects of the patients health
needs. They should also be directed towards the
immediate, short- and long-term care of the patient
as well as secondary and tertiary prevention of the
condition.
NURSING DIAGNOSES
IMPLEMENTING THE NURSING

CARE PLAN
It is essential that nursing diagnoses are stated in

the patients chart. A nursing diagnosis is made
when the nurse can identify, clarify and prioritise
the specic needs and problems of the patient.
Nursing diagnoses vary from patient to patient
This involves organising the nursing intervention

as planned. Nursing interventions include all
nursing measures used to achieve the goals,
objectives and outcomes normally developed from
nursing diagnoses after the assessments. Examples
535
orientation, orientation, working and termination

phase.
In the pre-orientation phase the nurse examines
her own feelings, fears and anxiety about working
with the patient and also obtains information from
the patient. In the orientation (introductory) phase,
the nurse and patient become familiar with one
another. Some activities involved in this phase
include establishing a contract for intervention that
details the expectations and responsibilities from
both the nurse and patient. The strengths and the
limitations of the patient are identied, the nursing
diagnosis and goals are formulated followed by
establishing therapy contracts which are applicable.
A mutually acceptable contract ensures that terms
and conditions are decided and so effectiveness is
enhanced.
The working phase involves accomplishing
the goals of the relationship. The nurses and the
patient work together on the identied problems.
The treatment plan is reviewed from time to time
and any problems arising from the nurse-patient
relationship are resolved. These problems could be
resistance, transference and counter-transference.
The goal of the termination phase is to assist
the patient review what was learnt and to transfer
this learning to interaction with others. The nurse
needs to understand the patients level of loss of
relationship and also help him deal with it. The
patient may also express fear regarding prognoses
or future plans all of which must be addressed.
Therapeutic roles of a nurse are varied. They
include being a healthy role model, nurturing,
reality base, being a technician, a socialising agent
manager and teacher.
of how the modern psychiatric nurse in Africa can

utilise formulated nursing objectives to implement
individualised and holistic care for the psychiatric
patients are discussed below.
Prevent disorientation
Patients need to be approached well using gentle
reassuring words. This prevents them getting
frightened and so lessen defensive reexes. The
patient should be admitted in a quiet non-stimulating
environment, such as a single room, which is
neither too dark nor too bright. Crowding around
the patient should be discouraged. The presence of
a familiar relative is required in order to alleviate
fear, anxiety and agitation. The nurse must not get
irritated if the patient does not appear to respond,
resists or refuses initial efforts for help.
Prevent possible injury to self and others

Keep the patient from all potentially harmful
objects and try to establish rapport with them.
Often an aggressive patient becomes calm when
those accompanying him leave him with the nurse.
Restraint is often necessary if the patient does not
calm down though one should not do it alone.
Sometimes the presence of others intending to
restrain is enough to calm an aggressive patient,
but avoid threats.
Everybody should remain calm while restraining
a violent patient. The patient should be approached
at a moment when his attention has been distracted.
After restraint, the patient should be taken to a
secure room and sedated.
Evaluation
Evaluation is the process by which the nurse
determines the extent to which the goals the nursing
care plan has attained. It is an on-going process at
every stage of the process and should be carried
out in a purposeful and organised way. If the goals
are not achieved, then every stage is reviewed to
ensure that a correct diagnosis is made and the
correct plan is formulated.
THERAPEUTIC ROLES OF A
NURSE
Healthy role model
The nurses behaviour and attitude at the initial
stage may have a positive or negative affect on the
patients signicant others. The nurse acts as a source
of support, reassurance, comfort and information,
and helps the patient and his signicant others.
NURSE-PATIENT RELATIONSHIP
Conditions essential to the development of the
nurse-patient relationship include: self-awareness
and understanding, rapport, trust, respect, empathy,
generosity and active listening. There are phases
of nurses-patient relationship, which include pre-
Nurturing
The nurse helps the client accomplish activities
of daily living by providing complete or partial
assistance.
536
reference, looseness of association, mutism, clang

associating, echolalia and concrete thinking.
Reality base
The nurse distinguishes what is objectively real
from what is not, e.g., hallucination. By validating
normal feelings and experiences, the nurse helps
the patient perceive events objectively, which is
important for fostering patient communication.
The nurse represents social reality to the patient
by presenting societal values. She monitors the
patients responses, reactions by others regarding
the patients behaviours and provides alternatives
to meet the patients needs in appropriate and
socially acceptable ways.
Negative symptoms
These include:
No communication, withdrawal, no eye contact
and preoccupation with own thought
Talks bad about oneself, lacks energy and
motivation
Becomes confused, overwhelmed and lacks
knowledge of disease or treatment
Feels powerless in coping with the client alone,
none adherence to medication and treatment
Client may stop taking medication (due to side
effects) stops going to therapy sessions, social
isolation and defensive coping
Impaired verbal communication, alteration
of thought process, social isolation, impaired
social interaction, risk of loneliness.
Self-esteem disturbance, chronic low selfesteem, ineffective individual coping and selfcare decit
Ineffective family coping: compromised or
disabling, altered parenting, strain in caregiver
role, knowledge decit and non-adherence.
Technician
The nurse performs technical procedures such as
administration of drugs, preparing a patient for a
diagnostic procedure and taking and recording
vital signs.
Socialising agent
The nurse helps in re-socialising the patient by
giving them the opportunity to test their social
skills in various relationships.
Manager
The nurse manages and co-ordinates ward activities
and ensures efcient and effective patient care.
Interventions
Teacher
Schizophrenic with paranoia

Being non-judgemental, respectful and having
a neutral approach with the client.
Be honest and consistent with client regarding
expectations and enforcing rules, use of clear
and simple language.
Explain to the client what you are going to
do. The rationale is that, there is less chance
for a suspicious client to misconstrue intent
or meaning if content is neutral, approach is
respectful and non judgmental.
Suspicious people are quick to discern
dishonesty. Honesty and consistency provide an
atmosphere in which trust can grow. Minimise
the opportunity for miscommunication and
misconstruing the meaning of a message.
The nurse educates patients on early signs and

symptoms of relapse, effects of treatment, and
skills that promote socialisation.
Advocacy
Patients advocacy where quality care and rights
are not violated constitute a signicant role of a
nurse.
NURSING DIAGNOSES
AND INTERVENTIONS FOR
SCHIZOPHRENIA
Schizophrenic with hallucinations
Hallucinations
When the patient is hallucinating, take

necessary environmental precautions: notify
other staff, follow hospital protocol.
Arrange admission and clearly document what
patient says and any threats made.
The patient hears voices that others do not hear

telling them to hurt self or others, which means
they are experiencing sensory alteration.
Disordered thinking and beliefs

These include persecution, jealousy, grandeur,
537
Altered thought process as well as family

process and caregiver role strain.
Impaired verbal communication, social
interaction, altered nutrition, self care decit
and sleep pattern disturbance.
Reduce environmental stimuli e.g., lower

noise.
Stay with patient as they start to hallucinate.
Keep to simple, basic reality-oriented topics
of conversation. Help the patient focus on one
topic at a time.
Help the patient identify the needs that may
underlie the hallucinations. What other ways
these needs can be met.
Help the client to identify times when
the hallucinations are most prevalent and
frightening.
Engage the patient in simple physical activities
that channel energy such as writing, drawing,
crafts, walking, and exercises.
Work with the patient to nd which activities
help reduce anxiety and distract the patient
from hallucinations. Check for signs of
increasing fear, anxiety and agitation.
Interventions
Bipolar patient with risk to self-injury
Maintain low level of stimuli in patients
environment, e.g. away from loud noises.
Provide structural solitary activities with a
nurse or assistant.
Provide food and plenty of uids and redirect violent behaviour.
Acute mania may warrant the use of
antipsychotics and seclusion to minimise
physical injury from self or to others.
Observe for signs of side effects of
medication.
Bipolar patient with ineffective coping
NURSING DIAGNOSES AND

INTERVENTIONS FOR BIPOLAR
DISORDER
Administer medication as prescribed and

evaluate for efciency, side effects and toxic
effects.
Observe for destructive behaviour towards
self or others.
Intervene early just as manic behaviour begins.
Collect all valuables.
Maintain a rm, calm, and neutral approach at
all times.
Avoid getting involved in power struggles e.g.,
arguing with the client.
Access and recognise early signs of
manipulative behaviour and intervene
appropriately, e.g. taunting staff by pointing to
faults or oversight.
Signs and symptoms

Excessive motor activity, poor judgement,
lack of rest and sleep.
Poor nutritional intake, loud, hostile,
combative, aggressive, demanding, intrusive
and taunting behaviour.
Inability to control behaviour, manipulative,
angry and hostile verbal and physical
behaviour.
Impulsive speech and actions, racing thoughts,
grandiosity and poor judgement.
Gives away valuables, neglect the family,
impulsive major life changes e.g. divorce.
Continuous motor activitywandering,
distracted and disorganised.
Too frantic and hyperactive to sleep and
exhaustion.
Bipolar patient with impaired social interaction

When possible, provide an environment with
minimal stimuli.
Provide solitary activities requiring short
attention spans with mild physical exertion in
early phase of treatment.
Increase activity as patient gets better. When
less manic, patient may join other patients in
low key activities.
Nursing diagnosis
Risk of injury and violence directed at self or
others, ineffective individual coping,
538
Allow more time than usual for patient to nish

usual activities e.g., dressing and eating.
Work with patient to recognise negative
thinking and thoughts.
Teach patient to reframe or refuse negative
thought.
Prepare patient for cognitive behaviour therapy
(CBT).
THE NURSING DIAGNOSES

DEPRESSIVE DISORDERS
Depression
Signs and symptoms
History of previous suicide attempt
Leaving and willingly giving away possessions,
suicidal ideation, makes covert statements
regarding killing self, feeling worthless,
hopeless and helpless.
Lack of judgement, memory difculties,
poor concentration, negative rumination and
cognitive distortion.
Difculty with simple tasks, inability to
function as before, poor cognitive and problem
solving ability and verbalisation of inability to
cope.
Difculty in making decisions, poor
counteraction and inability to take actions.
Withdrawn, uncommunicative and shies away
from contact with others.
Rationale
Major decisions are best made when ones
mind is functioning well and decreases feelings
of pressure, anxiety and minimise feelings of
guilt.
Slowed thinking and difculty in concentrating
impairs comprehension thus requiring time to
formulate response. A routine that is fairly
respective and non-demanding is easier to
follow and remember.
Usual tasks may take long periods of time
and demands that patient hurries increases
anxiety.
Negative ruminations and feelings of
hopelessness are part of a depressed patients
faulty thoughts process.
Intervening in the process aids in healthier and
more useful outlook.
Potential nursing diagnosis

There is risk of suicide and self-mutilation.
There is altered thought process, ineffective
individual coping and altered family process.
There is altered role performance, decisional
conict, helplessness, hopelessness and
powerlessness.
Self-esteem disturbance
Impaired social interaction, social isolation
and risk for loneliness.
Depressed patient with chronic low selfesteem

Interventions
Work with the patient to identify cognitive
distortions that encourage negative selfappraisal, for example, self-blame, mind
reading and discontinuing positive attitudes.
Teach the patient to recognise negative image
and how to replace them with positive thoughts
and images.
Work with patient on areas, which they want
to improve by using problem-solving skills;
evaluate need for more teaching in this area.
Evaluate patients need for assertiveness
training skills.
Arrange training through group therapy or
individual therapy, cognitive behavioural
therapy (CBT) and role model assertiveness.
Encourage participation in support/group
therapy where others are experiencing similar
thoughts, feelings and situations.
Depressed patients with altered thought

process
Intervention
Identify patients previous level of cognitive
functioning (use informants).
Help the patient to postpone major life decisionmaking and minimise their responsibilities.
Use simple and concrete words and allow
patient plenty of time to think and frame
responses.
Help patient and family to structure
environment that can help re-establish the set
routines for patient.
539
8.
Organised plan: The presence of a specic

plan for suicide (date, time, place, means)
signies high risk.
9. No spouse: No spouse increases risk.
10. Sickness: Chronic debilitating and severe
illness is a risk factor. Suicidal risk is two times
higher amongst people with cancer, AIDS,
haemodialysis or delirium and respiratory
diseases.
Rationale
Cognitive distortions reinforce negative inaccurate
perception of self and the world by:
Taking one event and making a general rule
out of it. Persistent self-blame for everything
perceived as negative, assuming others do not
like you.
Focusing on negative qualities. Promote a
healthier and more realistic self-image by
helping the patient to choose more positive
actions and thoughts.
Feelings of low self-esteem can interfere with
usual problem-solving abilities. People with
low self-esteem often feel unworthy and have
difculties in asking appropriately for what
they need and want.
Decrease feeling of isolation and provide an
atmosphere where positive feedback and a
more realistic appraisal of self is available.
Note: For each of the above score 1 point if

positive. Guidelines for intervention: 0-2: treat at
home with follow-up care; 3-4: clearly follow-up
and consider hospitalisation; 4-5: strongly consider
hospitalisation; 7-10; hospitalise.
Overall guidelines for nursing

interventions in suicide prevention
Hospitalised patients: put on suicide precaution
Suicide precautions range from maintaining one to
one contact with a member of staff at arms length
all times, but patient may attend activities of the
unit, while maintaining contact with escorting
nurse. If there is fear of imminent harm, restraint
and seclusion may be required. The nurses follow
hospital protocol to keep detailed records in the
patients chart.
Depressed patient who has suicidal

ideations
Nurses aim at preventing suicide and also
relieving intense suffering of the depressed patient.
Assessment of suicidal patient is done using Sad
Persons Scale.
Outpatient cases
Nursing assessment for suicide using scale of

sad persons
1. Sex: Men kill themselves three times more
than women, although women make more
attempts than men.
2. Age: High-risk groups: 19 years or younger,
45 years or older, especially those over 65.
3. Depression: Studies report that 35-79 percent
of those who kill or attempt suicide manifested
a depressive syndrome.
4. Previous attempts: Out of those who commit
suicide, 65-70 percent had made previous
attempts.
5. Ethanol (Alcohol): Alcohol is associated
with up to 65 percent of successful suicide.
Approximately 15 percent of alcoholics
commit suicide. The rate is the same for drug
abusers.
6. Rational thinking loss: People with functional
or organic psychosis (schizophrenia, dementia)
are more apt to commit suicide than those in
the general population.
7. Social support lacking: A suicidal person
often lacks signicant others (friends, family),
meaningful jobs and religious or spiritual
support.
If patient is managed outside the hospital, the

family, friends, and signicant others must be
alerted of the risk, treatment plans, deepening signs
of depression and hopelessness. The telephone
number or emergency line should be given to
the family members and friends. Social support,
appropriate pharmacotherapy, psychotherapy and
socio-therapy are initiated. A return visit should be
scheduled.
Careful records should be kept in all instances,
documenting specic reasons why a patient was
or was not hospitalised. The medication should be
given in limited amount, for example a ve-day
supply with no rell.
Depressed patients with risk for selfdirected violence

Interventions
During the crisis the nurse should emphasise
that it is temporary and that chronic intolerable
pains can be survived if help is available.
Follow hospital protocol for suicide regarding
providing a safe environment. Suicide precaution should be observed.
540
Keep accurate and timely records. Construct a

no suicide contract between the suicidal patient
and nurse using clear and simple language.
Encourage patients to talk about their
feelings and problems and problem-solving
alternatives.
NURSING DIAGNOSES
DELIRIUM OR CONFUSION
Delirium patient
Rationale
Symptoms
Patients do not have perspective of their lives

because of tunnel vision.
Provide a safe environment during the time the
patient is actively suicidal and self-destructive.
Protection of a patients life at all costs during
crisis is part of the responsibility of nursing
staff.
Accurate documentation is vital. The chart
is a legal document as to patients on-going
status and interventions taken and by whom.
The no suicidal contract helps patient to know
what to do when they begin to feel overwhelmed
by pain. Talking about the feelings and looking
at alternatives can minimise suicidal acting
out.
Wandering, unsteady gaits, acts of fear from

hallucinations or illusions and forgetfulness.
Awake, disoriented and frightened during the
night (sun-downing) and too confused to take
care of basic needs.
The patient experiences hallucinations,
illusions and may become paranoid, thinking
that others are doing things to confuse them
(delusions).
Nursing diagnosis
There is risk of injury, sleep pattern disturbance,
fear, acute confusion, lack of self-care and an
ineffective individual.
Coping, altered nutrition, uid volume decit
and ineffective individual coping
There is sensory alteration, impaired environmental interpretation syndrome, altered thought
process, impaired memory, acute confusion,
impaired verbal communication, spiritual
distress, hopelessness and self-esteem
disturbance.
Grieving, ineffective family coping, altered
family process, impaired home maintenance
and care-giver role strain are also present.
Prevention of self-harm in the community

Intervention
Arrange for the patient to stay with family
or friends. If no one is available, admit to
hospital.
Encourage the patient to talk freely about
their feelings and help plan alternative ways
of handling anger and frustrations. Encourage
patient to avoid decisions until alternatives
can be considered during the time of crisis.
Contact family members, while arranging for
individual and family crisis counselling. If
anxiety is too high or patient has not slept in
days, a sedative may be prescribed.
The confused patient

Interventions
Introduce yourself and call the patient by name
during introductions at the beginning of each
contact.
Maintain face-to-face contact. Use simple,
short and concrete phrases.
Encourage family and friends (one at a time)
to take a quiet supportive role.
Keep the room well lit and comfortable.
Make an effort to assign the same personnel
at each shift to care for the patient. If
hallucinations and illusions are present,
reassure safety and clarify reality.
Rationale
Relieve isolation and provide safety and
comfort. Give patient alternative ways of
dealing with overwhelming emotions and
getting a sense of control over their life.
During crisis situations, people are unable to
think clearly or evaluate their options. Reestablish social ties, which diminish a sense of
isolation, and provide contact of individuals
who care about the suicidal person.
Relief of anxiety and restoration of sleep loss
can help the patient think more clearly and
restore some sense of well-being.
541
Encourage carers and family members to

follow family traditions (going to church) and
to use respite care amongst them.
Rationale
With short-term memory impairment, the
person is often confused and needs frequent
orienting to time, place and person.
If the patient is easily distracted, he needs help
to focus on one stimulus at a time. Patients may
not be able to process complete information.
Explanation prevents misinterpretation of
action.
Familiarity
lowers
anxiety
and
increases orientation. Lighting provides
accurate environmental stimuli to maintain
and increase orientation.
With illusion, misinterpreted objects or
sounds can be claried, once pointed out.
Consciousness uctuates: patient feels less
knowing where he is and who you are during
lucid periods. Terror and fear are often
projected onto the environment.
Arguing or becoming defensive only increases
the patients aggressive behaviours and
defences. Clear limits need to be set to protect
patient, staff and others.
Chemical and physical restraints are used as a
last resort.
Rationale
Point out areas, which may be of benet
for planning and preparation, legal issues,
nancial issues and care-giving techniques
and knowledge of what they can and cannot
change.
Identify specic areas needing assistance
and those that do not. Carers need to learn
new ways to intervene in situations that are
common with demented patients, e.g. agitation
and catastrophic reactions. These steps can
help make the home safe for the person with
dementia.
Encourage the patient to participate as
much as possible in family life. This helps
diminish feelings of isolation and alienation
temporarily.
Regular periods of care with one or other
members of the family relieves them to
continue with their lives and minimises
feelings of resentment. Any kind of long-term
illness within a family can place devastating
burden on all members.
THE NURSING DIAGNOSES

DEMENTIA
Nursing dementia of a patient with selfcare decit

This is when a patient needs to be fed and bathed.
Dressing and bathing
Patient can believe that their illusions or

hallucinations were real and it may take time for
them to come to terms with the experience.
Always allow the patients to perform all tasks

that they are capable of doing e.g, to wear their
own clothes.
Substitute fastening tapes for buttons and
zippers. Label the patients clothing as well as
other items.
Give step-by-step instructions whenever
necessary
Interventions
Assess what the carers and family know about
patients illness and educate them regarding
specic illnesses.
Provide a list of agencies and support groups
where family and carers can receive support
as well as identify areas that need intervention
and those that are presently stable.
Teach carers, family and friends on specic
interventions to use in response to situational
or social problems brought by the dementia.
Safety of patient must be assessed and
evaluated.
The family should make the home a safer place.
Encourage spending time with the patient at his
level of functioning, e.g. watching favourite
movies together.
Nutrition
Monitor uid intake of the patient. In addition, offer
amounts of small food that patient can walk around
with. During the period of hyperorality ensure that
the patient does not eat non-food items.
Bowel and bladder
Begin bowel and bladder programme early, starting
with bladder control. Evaluate the use of adult
disposable undergarments and label the bathroom
door as well as doors to the other facilities. Same
542
time of day for bowel movements and toileting

in early morning after meals and before bedtime
can help prevent inconsistencies. Additional
environmental clues can maximise independent
toileting.
Guidelines for nursing intervention in substance

misuse
Assess for feelings of hopelessness, helplessness and suicidal thinking.
Ascertain the patient by getting interventions
for any co-morbid medical and psychological
conditions, e.g. infections, depression and
anxiety.
Intervene with patients use of denial as well as
rationalisation, projection and other defences
that instil motivation for change.
Enlist support of the family members, confront
any tendency on their part to minimise the
problem or enable the patient to maintain
his addiction.
Insist on abstinence.
o Refer patient to self-help groups (Alcoholic
Anonymous (AA), Narcotic Anonymous
(NA)).
o Teach patient to avoid medications that
produce dependence.
o Encourage participation in psychotherapy.
o Emphasise personal responsibilityplace
the control with the patient by avoiding the
nurse becoming the all-knowing rescuer.
o Support
residential
treatment
appropriately, especially for patients with
multiple relapse.
o Educate the patient and family regarding
pharmacotherapy for certain addictions.
o Educate the patient about the physical
and developmental effects that taking the
substances can have on future children
(e.g. foetal alcohol syndrome, problems
with schools, social role performance).
Sleep
Patients may awaken frightened or cry out at night.
Therefore the room needs to be well lit. Hypnotics
may be given. Avoid the use of seclusion.
Sleep reinforces orientations and minimises
possible illusions. Hypnotics for short periods
can bring good nights sleep. It can also cause the
patient to become more terried and ght against
seclusion until exhausted.
NURSING PATIENTS WITH

SUBSTANCE ABUSE DISORDERS
Substance abuse
Signs and symptoms
Vomiting, diarrhoea, poor nutrition and
uid intake. Audio-visual hallucinations,
impaired judgement, memory decits,
cognitive impairment related to substance
intoxication or withdrawal.
Changes in sleep pattern, insomnia or excessive
sleep related to effects of withdrawals or
intoxication.
Lack of self-care in terms of basic health
needs. Feelings of hopelessness.
Family crisis and family pain, ineffectual
parenting, emotional neglect of others,
increased incidence of physical and sexual
abuse towards others.
Excessive substance abuse effects in all areas
of a persons life: loses friends, poor job
performance, illness rate increases, prone to
accidents and overdose.
Increased health problems related to substance
use and route of use.
Substance misuse
Intervention
It is important to work with the patient and
to keep the treatment plan simple in the
beginning. Let the patient write notes in order
to keep appointments and follow the treatment
plan. Encourage the patient to join relapse
prevention groups.
Encourage patients to nd role models, e.g.
other recovering people. Work with the
patient on identifying triggers that help drive
the addiction. Practise and role-play with
patients alternative responses to triggers.
Give positive feedback when the patient
applies new and effective responses to difcult
Nursing diagnosis
Altered nutrition
Risk of uid volume decit
Altered thought processes
Sleep pattern disturbance
Altered health maintenance self-care decit
Non-compliance and hopelessness
543
trigger situations. It is important to continue

to emphatically confront denial.
Continue working with the patient on personal
and social issues as well as feelings of selfesteem. Recommend family therapy.
Stress that substance abuse is a disease that
the entire family must conquer. Re-afrm that
sobriety can be achieved as emotional pain
becomes endurable.
that children are assessed and monitored so that

early detection and intervention can help or prevent
mental illness in these groups.
The following constitute different types of
disorders that require nursing: Attention decit and
disruptive disorder (childhood or adolescent on-set
type), hyperactivity disorder and conduct disorder,
psychosis, neurotic reactions, psychosomatic
reaction, adjustment reactions and habit disturbance.
The nurse should assess the following:
The quality of the relationship between the
child and parent or carer for evidence of
bonding, anxiety and tension.
The parents understanding of growth and
developmental parenting skills, and handling
of problematic behaviours.
The cognitive, psychosocial and moral
development for lags or decits, because of
immature developmental competencies.
Rationale
About 50 percent of patients may have mild
to moderate cognitive problems while using
substances. Cognition usually gets better with
long-term abstinence, but initially, memory
aids prove helpful, in anticipating and
rehearsing the patient to healthy responses to
stressful situations.
Role models serve as examples of how patients
can have effective ways to make necessary life
changes. Mastering the issues that perpetuate
substance use allows effective change, and
target areas for acquiring of new skills.
These areas of human life need healing in
order for growth and change to take place.
Enhanced strategies for dealing with conict
in the patients family are essential in recovery.
Family members also need encouragement to
face their own struggles. This helps minimise
shame and guilt to rebuild self-esteem.
Guidelines for nursing interventions for

mentally ill children and adolescents
These help the child reach his full potential by
fostering developmental competencies and coping
skills as follows:
To protect the child from harm and provide
for biological and psychosocial needs, while
acting as a parental surrogate.
To increase the childs ability to trust, control
impulses, tolerate frustration, concentrate,
recognise cause and effect, use interpersonal
skills to maintain satisfying relationships, and
play with enjoyment and creativity.
To foster the childs identication with a
positive role model so that positive attitudes
and moral values can develop, that enable
the child to experience feelings of empathy,
remorse, shame and pride.
To provide support, education and guidance
for the parent and carers.
To provide intervention and care similar to
those for adults with slight modications.
Relapse prevention strategies

Patients who abuse substances have mild to
moderate cognitive problems, while actively
using substances therefore should constantly
review instructions with health team members
and use a notebook to write down important
information and telephone numbers.
They should take advantage of cognitive
behavioural therapy to increase coping skills,
and identify important life skills needed for
recovery. Referral to relapse prevention groups
is essential.
Psychosis
Nursing mentally ill children and

adolescents
The most common psychotic disorders in children

include childhood schizophrenia, mania, and
depression. The psychotic features in children
resemble normal developmental behaviours. A
professional with knowledge and experience in
child and adolescence psychiatry is the best to make
the diagnosis. Managing children with psychiatric
problems is more difcult than managing adults
because behaviour may be part of his growth and
Mental disorders in childhood and adolescence

can be due to, biochemical, pre and perinatal
inuences, individual impairment and personal
psychosocial development. Vulnerability to risk
factors is due to complex interaction among factors
like constitutional endurance, trauma, disease and
interpersonal experiences. It is therefore, important
544
should be tolerant, accommodating and

accepting to encourage family to talk to
someone about their feelings.
development and the child is unable to express

himself verbally, but acts out his feelings and
attitudes. He is therefore concealed and needs
assistance to open up in order to be understood.
The role of a nurse is to:
spend most of their time with the patient.
observe the child and the family.
collect information from the child, family,
teachers and peer group.
visit the home to assess the child in his natural
environment.
care for the child in out- and in-patient care.
In providing care the nurse:
establishes a special relationship with the child
that is friendly.
avoids being judgemental.
allows the family express their feelings about
their childs behaviour.
engages the family in a positive relationship
with the medical team.
Further reading
1. Beck, C.B., Rawleens R.P. and William J.R. (1988),
Mental Health and Psychiatric Nursing. A Holistic Life
Cycle Approach. 2nd ed. C.V. Mosby Co. Missouri
2. Johnson Barbara (1997), Psychiatry Mental Health
Nursing, Adaptation and Growth. 4th edition. Lipincott.
New York ,Philadelphia.
3. St least W.G. & Sundeen, J.S. (1995), Principles and
Practice of Psychiatry Nursing, 5th, Edition. Mosby
Co. St. Louis, Toronto, London.
4. Taylor, M.C (1994), Essentials of Psychiatric Nursing,
14th edition. Mosby Co. St Louis.
5. Townsend, M.C. (1993), Psychiatric Mental Health
Nursing, Concepts of Care. A Davis. USA.
6. Jonasir, A.E. & Oquies L.J. (1998), Foundations of
Mental Health and Psychiatric Nursing. 2nd Edition.
Little. Brothers Co. Boston.
545
546
Section VII:
Research and Ethics
547
548
71
Research and Bio Statistics in Mental Health
Nora M. Hogan, David M. Ndetei, Gad Kilonzo, Japheth Mwenda Ndegwa,
Joseph Rotich, Robert Too
traditional healing. Should conicts arise, there

is need for them to be recognised and resolved
in a manner that respects both community and
professional perspectives. In addition Prof Ndetei
recommends that, underlying all our work there
must be "life stories" that trace the experience of
mentally ill people and their families. This is
central to the research process. It is this rich yield
of evidence that is at the core of our research,
policy and advocacy programme. In the nal
analysis, to maximise their usefulness, studies
must meet scientic standards to allow for crossnational comparisons
Research will enable countries in Africa to spend
their limited health care funds efciently. Globally,
great progress has been made over the past 20 years
in developing more rigorous and theoretically
grounded approaches to research in mental health.
Advances have been made in the eld of psychiatric
epidemiology, biological psychiatry, mental
health service delivery, psychiatric and medical
anthropology, public health, health economics
and mental health care policy research. Examples
of new research technologies include a more
valid and reliable psychiatric nosology, improved
methods to assess outcomes, more rigorously
designed clinical trials, innovative prevention
and intervention strategies, cost-benet analyses,
systematic programme evaluation strategies, and
ethnographic approaches to studying psychiatric
disorders.
INTRODUCTION
Prof. David Ndetei stated empathically at the WPA
(2004) it is only research scientically valid
and reliable research that will save us (in Africa).
Research is our tool to nding home-made solutions
to our mental health problems. He outlined the
main benets of research in helping to:
Understand the epidemiological patterns of
the various psychiatric problems.
Understand the socio-cultural and economic
aspects of the various psychiatric problems.
Prioritise the kind of training that is most
appropriate.
Decide what kind of service provision structure
is best.
Identify the most cost-effective strategies to
our problems.
Though many societies in Africa face similar
mental and social health concerns, diversity across
and within nations must be taken into account to
set priorities for research, build research capacity
and conduct research. It is essential that local and
cultural-based norms, values and traditional healing
practices be allowed to inuence local priorities for
research and action. Conicts may occur between
the priorities of researchers, who often base their
decisions on epidemiological data and community
members, who draw upon local knowledge and
549
The prevalence of psychiatric morbidity in Africa

is similar to, if not higher than that found in the
Western culture, yet there is a lack of resources,
there is no policy, and there are no evidence-based
structures.
The critical question is what kind of research
can be carried out? What research questions should
receive priority? What kind of epidemiological,
ethnographic, clinical science and health service
data are needed as a rst step? Which public health
intervention and public policies should receive
priority for research evaluation?
STEPS IN IMPLEMENTING A
RESEARCH PROJECT
Literature review (i.e. nd out what is known
about the problem to be investigated) and
justication of the need for the research.
Establish the aims, objectives and hypotheses
of the study.
Decide on the study design, area and
population, and the inclusion and exclusion
criteria, sample size, sampling method, and
study instruments.
Determine ways of coding and analysing of
the data. Set limits for signicance.
Come up with a proposal.
Carry out a pilot study.
Carry out the actual study.
Data analysis and report writing.
DEFINITIONS
Research is an activity aimed at advancement of
knowledge (scientic or non-scientic)
Method refers to a systematic procedure for
carrying out an activity. Methodology is a set of
rules, which species how knowledge should be
acquired, the form in which it should be stated and
how its truth and falsity should be evaluated. It is a
body of methods discipline.
The purpose of research is the collection of
information that will contribute to the solution of
a problem and therefore provides a basis of action
whether immediately or in the long term. Research
begins when an investigator perceives a problem
which requires a solution. A particular study is
decided upon that will contribute to this end and
embarks upon it through a research process. It
should be noted that not all questions are amenable
to research. For example metaphysical questions
cannot be researched. Do angels exist?
Study is a procedure and process designed to
yield evidence for the advancement of knowledge
(in science). Once a problem has been identied
and clearly described an appropriate hypothesis is
formulated and methods for testing are designed.
Formulating a topic for research: with a clear
purpose in mind one can now formulate the topic in
general terms. If the rationale for the investigation
is that maternal depression is unduly high in a given
population and there is insufcient information on
its causes for the planning of an action programme
the topic can broadly be stated as. The causes of
maternal depression in a dened area in a given time
period. At this early stage the topic may be rather
general or provisional but as more information is
gathered on previous work and present state of
knowledge the research question becomes more
rened and study objectives are described and
appropriate research methods identied.
RESEARCH METHODS
Research methods may be either qualitative or
quantitative. They differ in the type of data they
produce. Quantitative methods are useful for
determining the size and the scope of certain
problems. They generate data that is to be analysed
quantitatively. In the context of psychiatry and
mental health they are designed to determine the
extent and distribution of mental health disorders
and their cause in human populations with the aim
of effective management and preventive efforts.
The purpose of qualitative research is not to
prove the existence of relationships, but to describe
the system of relationships. Qualitative researchers
study things in their natural settings, attempting
to make sense of or interpret phenomena in terms
of the meaning that people bring to them. The
methodology is used to generate an understanding
of the issues of interest from the perspective and in
the language of the informants. They can answer
the how, what, and why questions related to these
problems. Qualitative methods are ideally suited
to explore sensitive mental health topics in depth
with small numbers of informants, like exploring
a patients experience of being a participant in
psychiatric or mental health research.
Unlike quantitative research, the sampling
frames used for qualitative research are usually
not representative. For this reason, the ndings do
not usually generalise from qualitative research to
550
Statistical methods, if not applied in the proper

perspective of the collected data, may lead to
false conclusions.
Statistical data must be uniform, in the sense
that they should be subject to a stable causal
system. There should not be much change in
the group of factors responsible for variation
in the data.
the population at large. The strength of qualitative

methods is clear in its ability to provide contextually
rich descriptions of issues, themes, and meanings
of life situations as experienced by participants,
more ethnographic approaches.
Both qualitative and quantitative methods are
widely used in psychiatric and mental health
research in general. Quantitative methods are used
primarily in epidemiology.
VARIABLES AND ATTRIBUTES

BIOSTATISTICS
Variables are things that one can measure, control,
or manipulate in research. Quantitative characters
are technically called variables while qualitative
ones are called attributes. An attribute cannot be
measured, but can only be classied under different
categories. A variable takes different values and
these values can be measured numerically in
suitable units. A variable whose values depend
on chance and cannot be predicted is called a
random variable or variate. Variates are of two
types, continuous and discrete or discontinuous. A
variate is said to be continuous, when it can take
any value within a specied interval. A continuous
variate can take an innite number of values within
a given interval, however small it may be. Height,
weight, temperature and density are examples of
continuous variates. A discrete variate, however,
can take only some isolated values e.g. the number
of children per family. They can only take whole
numbers like 0, 1, 2 and 3.
Due to the quantitative nature of epidemiological

studies, statistical techniques for measuring these
quantities have been developed and extensively
used. Some of the data that are of importance to
a health practitioner include: age, sex and social
group distribution of a population; the birth, death,
infant and maternal mortality rates; and incidence
and prevalence rates of diseases. Examples of
measurements commonly used in epidemiology are
prevalence and incidence. They are used to measure
the magnitude and spread of disease respectively.
To get the results the researcher must:
capitalise on existing health records and verify
them.
use simple techniques of recording, collecting,
coding and handling data.
interpret and present data in table, graphs and
diagrams in simple statistical terms.
be able to scientically analyse data, both
descriptively and inferentially.
compile reports for evaluation.
use report ndings to make epidemiological
decisions.
SCALES OR LEVELS OF
MEASUREMENTS
There are four levels of measurements:
1. Nominal scale. It is the lowest level of
measurement. In this scale, items are simply
identied as belonging or not to a particular
category. An example is gender, which is
normally either male or female.
2. Ordinal scale. In this scale, items or subjects
in different categories are not only different,
but they have an observed ordering between
elements of different categories or groups.
Blood pressure could be categorised as normal,
high, or very high. No specic numerical scale
is used, but it is implied that normal is better
than high which is also better than very high.
3. Interval scale. The distances between any
two numbers on the scale are of a known
STATISTICS
This is the subject of scientic study that deals with
the theories and methods of collecting, analysing
and interpreting data. It has several limitations:
It is applicable only to quantitative data. It
cannot be used to study events, which cannot
be expressed numerically.
It can be used to analyse only collective matters
and not individual events.
Statistical decisions are applicable only on
the average and in the long run. They may not
hold in a particular case.
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4.
Piloting: Before passing any questionnaire for use,

one should test it to check that it is effective. Ideally,
a questionnaire should be piloted on a group similar
to the one that will form the population of your
study. As a rule, piloting should be on about 5-10
percent of the nal sample number. However, the
results from the pilot study should not be included
in the nal results.
size. The scale is based on numbers and not

characteristics, as is the case with ordinal
and nominal. The units of measurement and
zero point are arbitrary. The ratio of any
two intervals is independent of the units of
measurement, e.g. temperature
Ratio scale. This is a scale with all the
characteristics of an interval scale and has a
denite zero point as its origin. Higher scales
can be reduced to lower ones.
Accuracy and precision: Accuracy refers

to validity. It is the extent to which a given
measurement is representative of the true value.
On the other hand, precision refers to reliability. It
is an indication of how repeatable a measurement
is.
DATA COLLECTION
Statistical data are of two types: primary and
secondary. Primary data are those, which are
collected for a specic purpose directly from the
eld of enquiry, and hence are original in nature.
Secondary data are such information, which have
previously been collected by some agency for some
purpose and are merely compiled from that source
for use in a different connection.
Types of data
Nominal data
One of the simplest types of data is nominal data,
in which values fall into unordered categories. As
an example, males might be assigned the value
1 and females 0. Attributes are labelled with
numbers rather than words, but both the order and
the magnitude of the numbers are unimportant.
Nominal data that take on one of two distinct
valuessuch as male and femaleare said to be
dichotomous or binary. However, not all nominal
data need be dichotomous as there may be three
or more possible categories into which the
observations can fall.
Methods of collecting primary data

The following methods are used for collection of
primary data:
Direct personal observation, enquiry observation or measurement.
Indirect oral investigation.
Questionnaires sent by mail.
Schedules sent through investigators.
Ordinal data
When the order among the categories becomes
important, the data are referred to as ordinal data.
Injuries may be classied according to levels
of severity, where 1 represents fatal injury, 2 is
severe, 3 are moderate and 4 are minor. A natural
order exists among groupings as a smaller number
represents a more serious injury. Still, one is not
concerned with the magnitude of these numbers.
Furthermore, the difference between fatal and a
severe injury is not necessarily the same as the
difference between moderate and a minor injury,
even when both pairs of outcomes are one unit
apart.
Questionnaires: It is used for collection of

primary data from individual persons through their
responses to the set of questions. The drafting of
a good questionnaire requires utmost skill and the
success of any investigation depends to a large
extent on tactful drafting of the questionnaire. The
following points should be observed in drafting a
questionnaire:
It should be as short as possible.
The individual questions should be simple,
unambiguous and precise.
Where possible, questions should be set to
elicit only two possible denite answers: yes
or no.
Questions should not be embarrassing and be
capable of yielding objective answers.
The units in which the information is to be
collected should be clearly and precisely
mentioned in the questionnaire.
Ranked data
A group of observations are rst arranged from
highest to lowest according to magnitude and
then assigned numbers that correspond to each
observations place in the sequence. In assigning the
ranks, one disregards the magnitude of observations
and considers only their relative positions.
552
neurosis or a descriptive summary of the correlation

between watching television violence and behaving
aggressively. To make this easy, various measures
are utilised including measures of central tendency
(mean, median, and mode); measures of spread,
variability or dispersion (range, variance, standard
deviation, and coefcient of variation); measures
of relative position (percentile rank and score,
and standard score); and measures of relations
and association (correlation and regression). On
the other hand, inferential statistics deals with
conclusions and generalisations of the whole
population using results of a sample population.
Various tests are used to measure signicance of
the ndings before inferences are made. These
tests may be parametric (t-tests, z-tests and
analysis of variance) or non-parametric (chi-square
tests, Mann-Whitney U tests, Wilcoxon t-tests and
Kruskal-Wallis tests). Some of the data analysing
methods that are commonly used are discussed.
Discrete data
Both ordering and magnitude are important for
discrete data. In this case the numbers represent
actual measurable quantities, rather than mere
labels. In addition, discrete data are restricted to
taking on only specied values, often integers or
counts that differ by xed amounts; no intermediate
values are possible. Note that a natural order exists
among the possible data values.
Continuous data
This is data that represent measurable quantities,
but are not restricted to taking on certain specied
values. In this case the difference between any
two possible data values can be arbitrarily small.
Examples of continuous data include time and
temperature. In all instances, fractional values are
possible. The only limiting factor for a continuous
observation is the degree of accuracy with which it
can be measured.
Measures of central tendency
Data summary and presentation
The most commonly investigated characteristic of

a set of data is its centre, or the point about which
the observations tend to cluster. These measures of
central tendency include mean, median and mode.
Every study yields data whose size can range from

a few measurements to thousands of observations.
To simplify the data, it may be categorised into
numerical, ordinal, ranked, discrete or continuous
groups. The data can then be presented in various
forms including tables, charts and graphs.
Mean is the most frequently used measure of

centrality (central tendency). It is calculated by
summing all the observation in a set of data and
dividing by the total number of measurements. The
mean can be used as a summary measure for both
discrete and continuous measurements. In general,
however, it is not appropriate for either nominal or
ordinal data.
Tables
A table refers to a group of gures systematically
arranged in the form of rows and columns. Such an
arrangement is essential for the revelation of the
signicant aspects of numerical information.
Median refers to the middlemost value in a

data set when the values of the data are ordered.
Mathematically, it is dened as the 50th percentile of
a set of measurements. It can be used as a summary
measure for ordinal data as well as discrete and
continuous data. If a set of data contains a total of
n (odd) observations, it is the middle value or the
[(n+1)/2]th largest measurement. If n is even, the
median is usually taken to be the average of the two
middlemost values, the [(n/2)]th and the [(n+1)/2]th
observation. The median is said to be robust; that
is, it is much less sensitive to unusual data points
than is the mean.
Charts and diagrams

Charts and diagrams are effective devices for vivid
presentation of statistical data. The main objective
of this type of presentation is to emphasise on the
relative position of different sub-divisions, rather
than to record details. The common types of charts
and diagrams are graphs, bar charts, pie charts and
pictograms.
DATA ANALYSIS
Mode is the observation that occurs with the

highest frequency. It can be used as a summary
measure for all types of data. The best measure
of central tendency for a given set of data often
depends on the way in which the values are
Descriptive statistics deals with organisation,

summation, interpretation, and communication of
quantitative information obtained from a research.
They might include summaries of symptom
checklist scores for a selected group of patients with
553
weaker, less accurate data as input than parametric

tests (like t-tests and analysis of variance). In
constructing bivariate tables, typically values on
the independent variable are arrayed on vertical
axis, while values on the dependent variable are
arrayed on the horizontal axis. This allows us to
read across from hypothetically causal values on
the independent variable to their effects, or values
on the dependent variable. Remember, association
does not equal causation; an observed relationship
between two variables is not necessarily causal.
distributed. If the distribution of the values is

symmetric and unimodal then the mean, median
and mode coincide. If the distribution is symmetric
but bimodal then the mean and median should be
approximately the same. A bimodal distribution
often indicates that the population from which the
data is taken consists of two distinct sub-groups
that differ in the characteristic being measured.
Measures of spread (Variability or

dispersion)
Measures of central tendency give us some idea of
the size of central values, while measures of spread
give us some idea of how the values of a distribution
cluster around the average. If the dispersion is small
many values cluster around the mean, whereas if
the dispersion is large a considerable proportion of
values are markedly different from the average.
Range is dened as the difference between the
largest and the smallest observation. Its usefulness
is limited since it considers only the extreme
values of a data set, rather than the majority of the
observations. Therefore, it is highly sensitive to
exceptionally large or exceptionally small values.
Inter-quartile range is a measure of variability that
is not easily inuenced by extreme values. It is
calculated by subtracting the 25th percentile of the
data from the 75th percentile. It encompasses the
middle 50 percent of the observations.
Variance quanties the amount of variability or
spread about the mean of a sample. It is calculated
by subtracting the mean of a set of data values from
each of the observations, squaring these deviations,
adding them up and dividing by the number of
observations less one. The standard deviation of a
set of data is the square root of the variance. In
practice, the standard deviation is commonly used
than the variance, because it has the same units of
measurement as the mean. In a comparison of two
groups of data, the group with the smaller standard
deviation has the more homogeneous observations
and the group with the larger standard deviation
exhibits the greater amount of variability.
Chi-Square Test is a non-parametric test of
statistical signicance for bivariate tabular analysis.
The hypothesis tested with chi-square is whether
or not two different samples (subject, patients) are
different enough in some characteristic or aspect
of their behaviour that we can generalise from
our samples that the populations from which our
samples are drawn are also different in the behaviour
or characteristic. Being a non-parametric test, a chisquare is a rough estimate of condence. It accepts
USE OF EPIDEMIOLOGY IN
MENTAL HEALTH RESEARCH
The various applications of epidemiology depend
on three levels of investigation that can be grouped
according to their intent: Descriptive, analytical
and experimental. A number of problems
peculiar to psychiatry have delayed progress in
psychiatric epidemiology because of a number
of methodological issues. Grouping morbidity
states for quantitative analysis requires explicit
classication of disorders reliably applied across
populations. Psychiatric nosology has been limited
by the heavy reliance on manifestational criteria
(e.g. signs, symptoms, clinical course and treatment
response) rather than causal criteria (toxin, trauma,
genetic vulnerability and metabolic defects).
Descriptive studies
Descriptive studies produce basic estimates of the
rates of disorders in a general population and its
subgroups. In the USA two national prevalence
studies of mental disorders greatly expanded our
understanding of the burden mental disorders place
on the population. The Epidemiological Catchment
Area (ECA) study in the early 1980s was a multisite
one year prospective study of mental disorder
prevalence, incidence and mental health service
use among over 20,000 adults in communities,
nursing homes, prisons and long stay psychiatric
hospitals. It provided the rst estimates of mental
disorder and service use rates according to the type
of explicit diagnostic criteria that were pioneered by
the third edition of DSM (DSM-111) and continued
in subsequent editions. This study was followed
by a cross-sectional National Comorbidity Survey
(NCS) of over 8000 adolescents and young adults
(aged 15-54 years) in the early 1990s which was
designed to upgrade information on prevalence
rates of disorders in DSM-111-R and to clarify
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opportunities for primary prevention of mental

disorders by intervention to reduce the chances that
high-risk individuals will develop an illness.
Quantitative population-based epidemiological
investigation can be used to measure the impact
of preventive interventions being tested. Such
assessment is important both to determine the
benets of the intervention for high-risk individuals
and to assess any unintended negative effects of the
intervention.
the sequence and duration of co-occurring mental

and addiction disorders in a younger population
group, in which co-morbid disorders were more
prevalent.
Although the study designs, diagnostic criteria,
diagnostic instruments and population age group
differed somewhat in the ECA and NCA studies
the prevalence rates for any mental and addictive
disorder were remarkably similar. In the ECA, it
was 28.1 of the population and in the NCS it was
29.5 percent.
SAMPLING
Analytical studies
Once the basic rates of illness are established,
one can identify groups in the population with
unusually high-rates of illness. Analytical studies
then explore the basis of variations in illness rates
among different groups, to identify risk factors
that may contribute to development of a disorder
and experimental studies that test the presumed
association between a risk factor and a disorder
and seek to reduce the occurrence of illness by
controlling the risk factor.
For example, in the 1930s psychiatric epidemiology found apparent high rates of schizophrenia
among low-income, inner city residents. The
rst problem in assessing such a nding is to
determine whether it reects a potentially higher
risk of developing schizophrenia among those
who live in such conditions or whether those who
have schizophrenia move into such areas through
downward social mobility. Recent studies indicate
that downward mobility or social selection is the
most likely explanation for the higher rates of
schizophrenia in those with lower economic status.
In contrast to schizophrenia studies of depression
among women and of substance use and antisocial
personality disorders among men have shown stronger
support for social causation hypothesis.
Difculties in sampling have centred around

applying complex sampling techniques, developing
acceptable case assessment instruments and
identifying potential risk factors that merit study in
large-scale investigations.
The epidemiological method requires two desirable conditions in the sample of the people under
study: a suitable reference population or universe
can be dened and individuals in the study can be
related to this dened universe in a specic way.
If these conditions are satised then results of the
study can be generalised to the universe. Once the
population study is dened and judged equivalent
to the universe, its members can be assessed to
determine their risk or illness status.
The choice of the type of sampling procedure to
use can only be decided in the light of the objectives
of the study, the construction of the population and
the resources available. The aim is to increase the
accuracy of the ndings for the given cost, time
and personnel.
A population is any collection of individuals
in which we may be interested. A sample has
to be chosen such that it carries a larger, if not
all, characteristics of the population. These
characteristics could be the same proportions
of men to women in the sample as in the whole
population, the same proportions in different age
groups, in occupational groups or with different
diseases.
Experimental studies
As risk factors are demonstrated, epidemiologists
can help reduce the contributing causes of the
disorder by intervening in the causal chain that
links a risk factor to occurrence of the disorder.
Experimental studies that test the presumed
association between a risk factor and a disorder
and seek to reduce the occurrence of illness by
controlling the risk factor.
Studies that modify a risk factor and assess the
impact of that intervention in reducing onset of
illness are the long-term goals of epidemiologists.
This type of intervention promises to elucidate
Sampling techniques
Simple random sampling
It is the process of selection of a group of units in
such a way that every unit of the population has an
equal chance of being included in the sample. In
practice, the members of the sample are drawn one
by one. There are two ways of drawing a simple
555
random sample: simple random sampling with

replacements and without replacements.
Simple random sampling with replacement is
when the sample members are drawn from the
population one by one, and after each drawing, the
selected population unit is noted and returned to
the population before the next one is drawn. This
means that at each stage of the sampling process,
all the population units (including those obtained in
earlier drawings) are considered for selection with
equal probability. Thus, the population remains the
same before each drawing and any of the population
units may appear more than once.
Simple random sampling without replacements
is when either the sample members are drawn all
at once, or drawn one by one in such a manner that
after each drawing the selected unit is not returned
to the population, when the next one is drawn. This
means that when drawing is made one by one, at
each stage of the sampling process the population
units already chosen are not considered for
subsequent selections, but the drawing is made with
equal probability only from those units not selected
in any of the earlier drawings. It is evident that in
simple random sampling without replacement from
a nite population, the size of the population goes
on diminishing as the sampling process continues.
Consequently, no population unit can appear more
than once in the sample.
purposive and random sampling, and combines the

advantages of both.
Stratied sampling is generally used when
the population is heterogeneous, but can be subdivided into strata within which the heterogeneity
is not so prominent. Some prior knowledge is,
therefore necessary for sub-division into strata,
called stratication. If a proper stratication can be
made such that the strata differ from one another as
much as possible, but there is much homogeneity
within each of them, then a stratied sampling
sample will yield better estimates than a random
of the same size.
Systematic sampling
Purposive sampling
Systematic sampling involves the selection of

sample units at equal intervals, after all the units in
the population have been arranged in some order. If
the population size is nite, the units may be serially
numbered and arranged. From the rst n of these,
a single unit is chosen at random. This unit and
every nth thereafter constitute a systematic sample.
If the characteristic under study is independent of
the units, then a systematic sample is practically
equivalent to a random sample.
A sample or cluster is selected on the basis of

individual judgment of the sampler. There is no
special technique for selecting a purposive sample,
but the sampler picks out a representative sample
according to his own judgment. Chance is not
allowed to play any role. Consequently there is
much scope for bias and the degree of accuracy
of the estimates is not known. Purposive sampling
may be useful when the sample is small, but as
the sample size increases the estimates become
unreliable due to accumulation of bias. The
advantage of purposive sampling is that, whereas a
random sample may vary widely from the average,
a purposive sample will not.
Multi-stage sampling
Multi-stage sampling refers to a sampling procedure, which is carried out in several stages. The
population is rst divided into large groups called
rst-stage units. These rst-stage units are again
divided into smaller units, called second-stage
units. The second-stage units are divided into thirdstage units and so on, until you reach the ultimate
units. Multi-stage sampling enables existing
divisions and sub-divisions of the population to
be used as units at various stages and permits the
eldwork to be concentrated, although a large area
is covered. In addition the second stage units need
to be carried out for only those rst stage units,
which are included in the sampling.
Stratied sampling
In stratied sampling, the population is sub-divided
into several parts, called strata; and then a subsample is chosen from each of them. All the subsamples combined, give the stratied sample. If the
selection from strata is done by random sampling,
the method is known as stratied random sampling.
The sub-division of the population into strata is
done by purposive method, but the selection of
the sub-sample from within the strata depends
purely on chance. Stratied random sampling
may, therefore, be viewed as a mixture of both
Snow-balling sampling
This occurs when a person with a given problem
provides information about other people with the
same problem who then give other contacts. The
process goes on until no more new information
comes from more recruits. This kind of approach is
useful in drug addicts or people operating secretly.
556
possible cause and may lead to the disease in the

future. It is also longitudinal, meaning that the
subjects are studied at more than one time. A cohort
study usually takes a long time. It involves keeping
track of large numbers of people, sometimes for
many years, and often very large numbers must be
included in the sample to ensure sufcient number
develop the diseases to enable comparisons to be
made between those with and without the factor. An
excellent example in Africa is the cohort studies of
mental disorders in a population in Ethiopia which
has been going on for several years.
Sampling in clinical and epidemiological

studies
Most medical data are not obtained using simple
random sampling, partly because the practical
difculties are immense. In a clinical trial the
comparison of two treatments is important and it is
hoped that the superior treatment in one place will
also be the superior treatment in another region. If
we are studying clinical measurement, it is hoped
that a measurement method that can be repeated
in one place will be repeatable in another, and that
two different methods giving similar results in one
place will also give similar results in another place.
Studies, which are not comparative, give more
cause for concern. The natural history of diseases
described in one place may differ in unpredictable
ways from that in another, due to environmental
differences and genetic make-up of the local
population.
Studies based on local groups of patients are
not without value. However, we need to be aware
of the limitations of the sampling method when
interpreting the results of such studies. In general,
most medical research has to be carried out using
samples drawn from populations, which are more
restricted meant to draw conclusions. One may
have to use patients in one hospital instead of all
patients, or the population of a small area rather
than that of the whole country. Findings from such
studies can only apply to the population from which
the sample was drawn. Any conclusions, which are
drawn about wider populations, such us all patients
with the disease in question, depend on evidence,
which is not statistical and often unspecied,
namely our general experience of natural variability
and experience of similar studies.
Broadly, there are two types of study designs:
descriptive and analytical/comparative studies.
Descriptive studies include cross-sectional studies
or surveys, case reports and series, and correlation
studies. Analytical studies include case control and
cohort studies, and experimental trials.
Case-control studies
It involves starting with a group of people with the
disease (the case), which are compared to a second
group without the disease (the controls). In an
epidemiological study, the exposure of each subject
to the possible causative factor is observed to see
whether this differs between the two groups.
The case-control study is an attractive method
of investigation, because of its relative speed and
cheapness compared to other approaches. However,
they have difculties in the selection of cases and
controls, and obtaining the data. Hence, casecontrol studies sometimes produce contradictory
and conicting results. The rst problem is the
selection of cases. This usually receives little
consideration beyond a denition of the type of
disease and statement about the conrmation of the
diagnosis. There are two main sources of control:
the general population and other patients with other
diseases. The latter may be preferred, because
of accessibility. The two populations are not the
same. Intuitively, the comparison is made between
the people with the disease and the healthy people,
not people with a lot of other diseases in order to
nd out how to prevent diseases and not how to
choose one disease or another.
CONCLUSION
Cross-sectional studies
It is clear that progress in research in mental

disorders has been hindered by a number of
methodological issues. The main problem being
that grouping morbidity states for quantitative
analysis requires explicit classication of disorders
reliably applied across populations. For instance,
psychiatric nosology has been limited by the heavy
reliance on manifestational criteria (e.g. signs,
symptoms, clinical course and treatment response)
rather than causal criteria (toxin, trauma, genetic
vulnerability and metabolic defects).
In this kind of study some sample of narrowly

dened population is taken and observed at a point
in time.
Cohort studies
In this approach, a group of people are taken,
the cohort, and observed whether they have the
suspected causal factor. They are then followed over
a period of time and observed for any development
of diseases. This is a prospective design with the
557
Without clearly dened nosological categories

it is difcult both to dene a case and develop a
case identication (diagnostic) technique that are
appropriate for large-scale populations studies.
However, the relatively new descriptive approach
of the DSM-1V and ICD-10 is an important
intermediate stage that will facilitate more rigorous
investigations of causal factors in clinical and
epidemiological studies.
2. Pincus HA, Lieberman J, Ferris S. (1998). Ethics in

Psychiatric Research: A Resource Manual for Human
Subjects Protection. Washington, DC: American
3. Pincus HA (ed). (1999). Ethics in Psychiatric Research.
Washington, DC: American Psychiatric Press.
4. Roberts LW, Roberts BB. (1999). Psychiatric research
ethics: An overview of evolving guidelines and current
ethical dilemmas in the study of mental illness. Biol
Psychiatry; 46:1025-1038.
Further reading
1. Brody BA. (1998). The Ethics of Biomedical
Research: An International Perspective. London, UK:
Oxford University Press.
558
72
Ethics in Psychiatric Research
Nora M. Hogan, Gad Kilonzo, David M. Ndetei,
Mohamedi B Sebit, Benson Gakinya
general. They are governed by the same principles

as noted in the practice of psychiatry.
INTRODUCTION
In this era of dramatic growth in research priorities
in mental health investigations, we have also
seen a heightened awareness of the distinctive
ethical problems arising from the participation of
psychiatric patients in research. In some countries
private, for-prot funding of experimentation has
signicantly increased. This transition has led to
conicts of interest and new ethical challenges.
The growing tension that exists between the need
to protect societys most vulnerable members
from exploitation and the ability through scientic
endeavours to lessen their suffering will hopefully
lead to efforts to advance both science and ethics.
There are indications, however, that mental
illness research will continue to expand within
a variety of diverse settings. Inevitably medical
workers in public, private and academic settings
will have considerable contact with psychiatric
research protocols in their professional work
and will be called upon to evaluate their ethical
acceptability. To ensure that growth in mental
health investigations is maintained it is imperative
that careful attention be paid to ethical aspects of
psychiatric research.
Ethical considerations in planning and carrying
out research activities in psychiatry are embedded
in ethics in biomedical and behaviour research in
HISTORY OF DEVELOPMENT OF
ETHICAL GUIDELINES
The thrill of scientic investigation and discovery,
the requirements of academic promotion and
competition and the joy of personal acclaim and
nancial reward may all tempt and at times seem
to sanction inappropriate ethical conduct. Even
though the history of science has shown that
scientic theories and research strategies cannot
be extricated from the judgment of values and
assumptions that impact negatively on other human
activities, careful consideration of risks to human
subjects in research is a fairly new phenomenon.
The development of ethical guidelines was
prompted to a great extent by the medical
professions past mistakes and an increasingly
sophisticated conceptual understanding of the
ethical aspects of research during and around
World War II, primarily in Germany. At the
postwar Nuremberg trials the atrocities of German
medical research included physicians tried for war
crimes, crimes against humanity, euthanasia of
those deemed unworthy of life and conducting
experiments on prisoners without their consent.
This resulted in Nuremberg Code 1947.
559
Table 72.1
Nuremberg Code
1. The voluntary consent of the human subject is absolutely essential. This means that the person involved should
have the legal capacity to give consent; should be so situated as to be able to exercise free power of choice,
without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of
constraint or coercion; and should have sufcient knowledge and comprehension of the elements of the subject
matter involved as to enable him to make an understanding and enlightened decision. This latter element
requires that before the acceptance of an afrmative decision by the experimental subject there should be made
known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be
conducted; all inconveniences and hazards reasonable to be expected; and the effects upon his health or person
which may possibly come from his participation in the experiment.
2. The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates,
directs or engages in the experiment. It is a personal duty and responsibility, which may not be delegated to
another with impunity.
3. The experiment should be such as to yield fruitful results for the good of society, unprocurable by other
methods or means of study, and not random and unnecessary in nature.
4. The experiment should be so designed and based on the results of animal experimentation and knowledge
of the natural history of the disease or other problem under study that the anticipated results will justify the
performance of the experiment.
5. The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.
6. No experiment should be conducted where there is an a priori reason to believe that death or disabling injury
will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects.
7. The degree of risk to be taken should never exceed that determined by the humanitarian importance of the
problem to be solved. Proper preparations should be made and adequate facilities provided to protect the
experimental subject against even remote possibilities of injury, disability, or death.
8. The experiment should be conducted only by scientically qualied persons. The highest degree of skill and care
should be required through all stages of the experiment of those who conduct or engage in the experiment.
9. During the course of the experiment the human subject should be at liberty to bring the experiment to an
end if he has reached the physical or mental state where continuation of the experiment seems to him to be
impossible.
10. During the course of the experiment the scientist in charge must be prepared to terminate the experiment at any
stage, if he has probable cause to believe, in the exercise of the good faith, superior skill and careful judgment
required of him that a continuation of the experiment is likely to result in injury, disability, or death to the
experimental subject
Source: Reprinted from Trials of War Criminals Before the Nuremberg Military Tribunals under Control Council Law No. 10, Vol.
2, pp 181-182. Washington, DC: U.S. Government Printing Ofce, 1949
The rst of the 10 principles of the Nuremberg

Code is the most important. It marked the rst time
the issue of voluntary consent was brought to the
fore. As ethicists continued to reect on this new
ethical value, it became clear that voluntariness
was only one element of the consent equation. The
second element was that consent must be informed.
There is a duty to disclose all options and risks
that a reasonable person would need to make an
informed choice.
The predominant value of acquiring scientic
knowledge was so strong during the post-war era
that it simply eclipsed the ethical considerations
related to human experimentation. In historically
tracing the exposure of abuses stemming from
the quest for knowledge the balance slowly
shifted in favour of the value of informed consent.

This reprioritisation put a heavy emphasis on the
protection of the human subject in research.
In 1948 the Universal Declaration of Human
Rights was adopted by the General Assembly of the
United Nations. Article 7 of the Covenant states
No one shall be subjected to torture or to cruel,
inhuman or degrading treatment or punishment.
In particular, no one shall be subjected without
his free consent to medical or scientic
experimentation.
It is through this latter statement that society

expresses the fundamental human value that is held
to govern all research involving human subjects
the protection of the rights and welfare of all
human subjects of scientic experimentation.
560
commission issued the Belmont Report: Ethical

Principles and Guidelines for the Protection of
Human Subjects of Research. The report presents
three major principles governing ethical research
involving human subjects:
respect for persons, promoting the dignity and
autonomy of research subjects and at times
excluding vulnerable individuals such as
children or people who are institutionalised or
cognitively impaired from participation
benecence, insisting that research design
be scientically sound and cause minimal
harm and maximal good at the level of the
individual
justice, ensuring that the segment of the
population that bears the largest burden and
risk in scientic inquiry also benets from it.
The Tuskegee experiment: Case study of

unethical research
In 1932 the US Public Health Service (PHS)
initiated an experiment in Macon County,
Alabama. Its aim was to determine the natural
course of untreated latent syphilis in black males.
The experiment included 399 syphilitic men, 201
uninfected controls. The ndings were published in
reputable journals and presented between 1936 and
1972. When the use of penicillin as an antibiotic
for syphilis became widespread in the 1940s,
Tuskegee participants did not receive it. Indeed,
PHS ofcials threatened to cut off the benets of
those who attempted to be treated elsewhere and
advised local black doctors not to see them. One
wonders how the risk/benet ratio was calculated
because the only incentives for participation
included free medical treatment for minor illnesses,
occasional hot meals, travel to and from the study
site, and burial stipends paid out to the deceased
persons family.
By 1969 approximately 100 men had died
from untreated syphilis, while numerous others
suffered painful disease-related complications.
Many unknowingly spread syphilis, which is
highly contagious, to their wives and children.
In the same year, the Centre for Disease Control
(CDC) declared that the study should continue. It
was not until 1972 when newspaper reports led the
Department of Health, Education and Welfare to
halt the experiment at a time when only 74 were
still alive. Twenty-eight to one hundred had died
directly from advanced syphilitic lesions. For the
most part, clinical investigators did not hide these
activities, except, ironically, from their research
participants. Not once did PHS doctors inform
participants of their real diagnosis, nor of the true
purpose of the study or the dangers to which it
exposed them. The sick men were led to believe
they were being treated for rheumatism, stomach
disorders, or bad blood, an umbrella phrase used
by rural blacks to describe a range of maladies,
including syphilis. In a public apology (May 1997),
President Bill Clinton admitted that the study was
racist and profoundly, morally wrong, and
that what the United States government did was
shameful.
The global response

The two key responders were the World Medical
Association (WMA) and the Council for
International Organisations of Medical Sciences
(CIOMS) in collaboration with the World Health
Organisation. (WHO).
Declaration of Helsinki (WMA)
In 1964 when ethical guidance on research in human
beings was mainly restricted to the Nuremberg Code
and most countries did not have relevant laws and
regulations, WMA adopted the ethical principles
for medical research involving human subjects in a
document entitled the Declaration of Helsinki. The
document was amended in 1975, 1983, 1989, 1996
and 2000 (World Medical Association Declaration
of Helsinki, 2000 Appendix I). It is described as
the fundamental document in the eld of ethics
in biomedical research and has inuenced the
formulation of international, regional and national
legislation and codes of conduct. It sets out ethical
guidelines for physicians engaged in both clinical
and non-clinical biomedical research with
An emphasis on the well being of the participant
over interest of science
Limited use of placebo
Need for written consent
Caution is necessary if participant is dependent
on the researcher.
Traditionally populations regarded as vulnerable
include:
People with mental impairments that affect
their capacity to make decisions
People in institutions
Response of the US government to the

unethical practices of the time
In the US, the National Commission for Protection
of Human Subjects of Biomedical and Behavioural
Research was established in 1974. In 1979 the
561
treatment in developed countries. It has been

argued that global health would be better served
by adopting a standard of the highest attainable,
and an expanded concept of the standard of care in
research has been offered, advocating that visiting
researchers need a deeper understanding of the
social, cultural, economic, and political context of
trials in developing countries.
Groups in need of additional safeguards

because they cannot protect their own
interests through valid informed consent.
The 2000 declaration expands the category
of vulnerability so broadly that it eliminates
persons with mental illness as a special
protection; if everyone is vulnerable, no one
is entitled to special protection.
International Ethical Guidelines for Biomedical
Research Involving Human Subjects prepared by
CIOMS in collaboration with the World Health
Organisation (WHO)
Other international and local guidelines

1. WHO Good Clinical Practice Consolidated
Guidance 1996
2. Good Clinical Practice Consolidated Guidelines
(GCPs), developed by the FDA provide a
unied standard for designing, conducting,
recording, and reporting trials that involve the
participation of human subjects.
3. In 1995 the International Conference on
Harmonisation of Technical Requirements for
Registration of Pharmaceuticals for Human Life
Standardise drug development and approval
process the Guidelines for Good Clinical
Practice for Trials on Pharmaceutical Products.
4. By this time many sources of ethical guidance
on human research exist, including general
guidelines and guidelines for specic types of
research (e.g. HIV preventive vaccine research),
and many countries now have their own laws,
regulations and guidelines written by specic
countries and regions such as Canada, United
Kingdom, Europe, Uganda, Australia, Zimbabwe and so on.
This international ethical guideline for biomedical

research involving human subjects was issued
by CIOMS in 1982, revised in 1993 and 2002.
(Appendix 2). The group that developed the
guidelines comprised representatives of ministries
of health, members of medical and other healthrelated disciplines, health policymakers, ethicists,
philosophers and lawyers from both developed and
developing countries.
CIOMS rst undertook to make this contribution
to medical sciences and the ethics of research with
their stated goal to make the Declaration of Helsinki
applicable in developing countries. It reects the
conditions and the needs of biomedical research
in developing countries, and the implications
for multinational or transnational research.
Observations reect research collaboration plagued
by differing interpretations of ethical standards of
doing research in developing countries, insensitivity
to the culture, combined with inequalities in
research funding.
Protection of vulnerable populations and the role
of ethics committees are important. For example,
Guideline 8 of CIOMS prohibits research that
involves subjects in under-developed communities
unless it is responsive to the health needs and
priorities of the community in which it is to be
carried out. The Helsinki Declaration does not
address this issue. If research is to be responsive
to the culture and priorities of the community
in which it is to be carried out then sponsoring
institutions should ask community members what
their priorities are.
The Declaration of Helsinki also retains the
requirement that new treatments should be tested
against the best current treatment. Critics argue
that this standard does not allow the testing of
low cost, sustainable treatments, such as aspirin
for coronary artery disease, which might yield
substantial health improvements in developing
countries but are inferior to the best current
ANIMAL RESEARCH
Many of the ethical questions about the justication
of animal research in psychiatry do not stand separate
from the matrix of difcult ethical problems in
biomedical and behavioural research. The problem
of ethical justication of animal research shares
important properties with other crucial questions
in the area of bioethics. The principles assume that
the production of human benet is the primary
purpose of research with animals.
Specialist ethical review boards for research
using animals do exist in many countries and where
they do not exist, it is encouraged that they should
be undertaken. No research using animals should
be undertaken without clearance from a competent
ethical review board specialising in use of animals
for research.
562
Informed consent and decisional capacity issues
GUIDELINES IN MENTAL
HEALTH RESEARCH
In psychiatry, informed consent may be

compromised by the altered mental state of the
patient. The loss of autonomy is not a discrete event
but rather a uctuating level of autonomy and in a
sense co-extensive with the legal concept of levels
competence. In other words, decisional capacity,
particularly when applied to psychiatric patients, is
not an all-or-none ability and tends to uctuate
over the course of illness and while participating
in research. As a result, psychiatric patients may
be able to make choices about specic kinds of
decisions related to the research participation and
at certain points but not at others.
CIOMS Guideline 15 addresses the problem of
informed consent involving individuals who by
reason of mental or behavioural disorders are not
capable of giving adequately informed consent. The
guideline states that before undertaking research
involving individuals who by reason of mental or
behavioural disorders are not capable of giving
adequately informed consent, the investigator must
ensure that:
such persons will not be subjects of research
that might equally well be carried out on
persons whose capacity to give adequately
informed consent is not impaired,
the purpose of the research is to obtain
knowledge relevant to the particular health
needs of persons with mental or behavioural
disorders,
the consent of each subject has been obtained
to the extent of that person's capabilities, and
a prospective subjects refusal to participate
in research is always respected, unless,
in exceptional circumstances, there is no
reasonable medical alternative and local law
permits overriding the objection.
But when they are clearly the only subjects suitable
for a large part of research into the origins and
treatment of certain severe mental or behavioural
disorders, the investigator must obtain the approval
of an ethical review committee to include in
research persons who by reason of mental or
behavioural disorders are not capable of giving
informed consent. The willing cooperation of such
persons should be sought to the extent that their
mental state permits, and any objection on their part
to taking part in any study that has no components
designed to benet them directly should always
be respected. The objection of such an individual
to an investigational intervention intended to be
of therapeutic benet should be respected unless
Ethical considerations in planning and carrying

out research activities in psychiatry are embedded
in ethics in biomedical and behaviour research
involving human subjects. However there are
problems and dilemmas specic to psychiatry.
Problems of applying ethical guidelines in

psychiatric research
The difculties in applying ethical concepts and
guidelines to psychiatric research involve complex
and interrelated factors centred around the fact
that many psychiatric patients who are recruited
as research subjects are potentially vulnerable
and incapable of making decisions about their
participation. Since this executive faculty of the
mind is to some degree compromised in mental
disturbances, there is a greater need to examine
the capacity of the affected individual to make
informed decisions and circumstances when it
is appropriate and humane to assist him to make
informed decisions. An important part of autonomy
is respect of this capacity in a person. An example is
that of a mentally disordered patient who exercises
the freedom to choose whether he wishes to be part
of research or not. So one of the biggest ethical
challenges in the eld of psychiatric research today
is establishing how decisional capacity is dened,
when or how often it should be assessed during
the course of a research project, and identifying
methods of restoring diminished capacity when
possible.
Though at times it may seem impossible, it is
absolutely imperative that accurate assessment
of informed consent and decisional capacity is made
in mental illness research. This includes not only
the potential participants ability to communicate,
assimilate, and comprehend relevant consent
material, but to be able to apply the meaning of the
research choice within the context of his life and
personal values, and to act autonomously.
Factors that impact on decision-making capacity
These include the pathophysiology of mental
illness, the psychotropic medications used to treat
mental illness symptoms, the intermittent need
for hospitalisation or institutionalisation, and the
psychosocial consequences of psychiatric disease
all affectand often impairthe capacity of
psychiatric patients to provide informed consent.
563
there is no reasonable medical alternative and local

law permits overriding the objection (Commentary
on CIOMS Guide 15)
The application of this ethical guideline is a
big challenge for a number of reasons. For one
a precondition for ethically adequate informed
consent is full disclosure of the studys purpose
and the nature of the illness under study. The
requirements for eligibility to participate should
also be made explicit. The proposed intervention,
its associated risks and benets and the risks
and benets of reasonable alternatives should be
verbally explained in a manner consonant with
the patients intellectual and educational level
and current psychiatric condition. The challenge
is how to adequately communicate to patients the
risks that accompany psychotropic drug studies
with design features such as randomisation,
placebo comparisons, washout periods, doubleblind methods, and unproven treatments. Such
experiments present extraordinary consent
problems for all human participants but particularly
for psychiatric patients.
Evidence from research indicates information
offered during consent disclosure sessions may
be poorly comprehended, retained, and recalled
by psychiatric patients when compared to general
medical patients. Much work is still needed to
clarify the interrelated areas of informed consent
and vulnerability in the context of psychiatric
patients participation in research.
powerlessness on interpersonal and societal levels.

Some jurisdictions do not permit third-party
permission for subjects lacking capacity to consent.
Legal authorisation may be necessary.
It is often argued that informed consent and
condentiality are not so empowering in some
traditional and Eastern societies, representing twothirds of the worlds population, and that family
and community consent is equally valid. However,
it is not uncommon for psychiatric patients to
possess multiple sources of vulnerability, e.g. a
depressed and stigmatised patient with AIDS. For
that reason, psychiatric investigators have a special
responsibility to protect their study participants by
ensuring that patients are enabled to give or refuse
informed consent freely.
Condentiality issues
Mental disorders are stigmatised conditions.
The researcher needs to take care to minimise or
avoid any stigmatisation during the whole process
and aftermath of research. The issues of privacy
and condentiality of information in psychiatry
are doubly important due to the sensitive nature
and potential of stigmatisation in this eld. The
burden of safeguarding condentiality is greatest
in studies in small community projects, and the
new era of electronic medical records makes this
obligation even more critical. There are a number
of circumstances where condentiality of research
data may not be fully protected. For example,
investigators may be obliged to release research
data in aggregate or in specic to funding agencies,
and particularly to members of data monitoring
boards (DMB) during routine site visits to research
facilities.
Given these possibilities, careful attention to
condentiality concerns requires that researchers
develop and utilise data collection and storage
practices that safeguard patient condentiality
internally, recognise the potential for access
to external entities and fully communicate
condentiality limitations to all research
participants prior to their enrolment.
Problems of proxy decision-making in research

Proxy decision-making commonly occurs when
patients are unable to make choices for themselves
in clinical and research contexts. In cases where
prospective subjects lack capacity to consent,
permission is obtained from a responsible family
member or a legally authorised representative in
accordance with applicable law. The agreement of
an immediate family member or other person with
a close personal relationship with the individual
should be sought (Guideline 15 CIOMS).
Studies have revealed serious problems in proxy
consent centred around conicts of interest that may
call their permission into question. Some relatives
may not be primarily concerned with protecting the
rights and welfare of the patients.
Patients who are mentally ill are open to harm
in human experimentation for several reasons.
Psychiatric patients may also be easily coerced
into research participation because of their
suffering, tremendous need for health care services,
institutionalisation experiences, and relative
Research design issues

It is well known that optimal scientic design
and ethical protections can be at cross-purposes.
Scientic uncertainty (equipoise) is necessary
to justify the activity of human experimentation,
and yet this same uncertainty creates seemingly
insoluble ethical problems when recruiting
potential research subjects to participate in studies
with unknown benets and harms. Placebo trials,
for instance, might denitively demonstrate the
564
skills related to ethics, and the potential exploitation

of individuals with severe mental illnesses. On the
other hand, advocates of clinical research argue
that protecting psychiatric patients from protocol
participation needlessly usurps their autonomy and
deprives them of opportunities for personal benet,
and that it is possible to ensure that psychiatric
patients are giving fully informed consent. They
further suggest that scientic neglect of psychiatric
disorders presents a great injustice toward millions
of individuals now and in the future.
By broad consensus, the inclusion of mentally
ill patients in research is considered defensible
only if two conditions are met: if members of less
exploitable groups cannot, for scientic reasons,
serve as participants in the experimental protocols,
They should never be subjects of research that
might equally well be carried out on persons in full
possession of their mental faculties, but they are
clearly the only subjects suitable for a large part of
research into the origins and treatment of certain
severe mental or behavioural disorders (Guideline
15 CIOMS) and if the protocols have absolutely
met criteria for being ethically sound. Even when
experimentation with psychiatric participants is
necessary and justiable, their involvement always
entails greater attentiveness to ethical issues and
strict guidelines.
Psychiatric research can be performed ethically, according to standards set throughout the
biomedical and behavioural sciences, so long
as researchers and institutions are respectful of
special ethical issues in human experimentation
and strive to include psychiatric study participants
fully in research decisions, investigators conduct
their studies in a manner that reects knowledge,
attention and respectfulness regarding the special
issues inherent to experimentation with vulnerable
mentally ill individuals.
effectiveness of therapeutic interventions, but very

prolonged medication-free periods in protocols
have been historically considered unethical when
proven treatments exist.
With a strong shift in the value balance in
favour of ethical soundness the selection of an
appropriate methodological approach cannot be
based solely on scientic criteria. Research designs
in psychiatry that have long been considered the
most scientically rigorous, such as those which
include placebo controls or medication-free
intervals are increasingly being scrutinised for the
level of risk posed to participants. Even experiments
that represent a minimal risk to participants need to
offer the potential for a nontrivial contribution to
scientic knowledge.
A huge challenge in applying ethical guidelines
with person who are mentally ill is that what
constitutes good-enough study designs, i.e., those
that minimise risk but may yield more ambiguous
or less denitive scientic results, in ethically
complex situations with psychiatric patients has
not yet been determined.
ETHICAL CONFLICTS THAT

REQUIRE SPECIAL ATTENTION
IN PSYCHIATRY
Unethical practices are many and varied: questionable experimental use of placebos in controlled
designs, scientically necessary but dangerous
wash-out periods in medication trials, exposure
to inordinate risks in non-therapeutic experiments,
inappropriate or insufcient consent processes,
exploitation of institutionalised and cognitively
compromised individuals, unacceptable riskbenet ratios, condentiality breaches, posthumous
publication of patient records, symptom provocation
studies, evidence of coercion, undisclosed conicts
of interest, misappropriations of funding and others.
As a result, some scientic endeavours in the area
of mental illness have been curtailed.
From the above review of problems one may
ask whether it is ever ethical for individuals with
mental illness to participate in research. This has
been a much-debated and controversial question.
Those who believe that clinical psychiatric research
is unethical raise concerns about poor informedconsent procedures, that it is never possible
to ensure that psychiatric patients are giving
fully informed consent, the dangers of human
experimentation, researchers lack of training and
HOW TO MINIMISE ETHICAL

MISCONDUCT
Psychiatric investigators must possess integrity and
competence, seek knowledge of both science and
ethics, and demonstrate delity to the principles of
respect for persons, benecence, and justice and
the doctrine of informed consent.
Strengthened capacity in research ethics
is needed in both developed and developing
countries, though the need is particularly acute in
developing countries, particularly to apply or adapt
565
their suffering, and through employing the use of

supplementary educational interventions such as
videotapes and information packets.
Additional techniques may include: involving
family members in decision-making, which would
seem appropriate particularly in the African
context, and assessing and educating proxy
decision-makers on ethical standards for research
participation. In addition, the improvement and
assessment of risks and benets of research
involving subjects incapable of making decisions
and identify prognostic factors that may predict
subjects who are vulnerable to becoming incapable
of taking decisions during a study would help.
Accurate self-observation and careful selfreection are highly valued tasks in clinical
psychiatry and other mental health professions.
Emphasising these same tasks is a distinct
contribution that psychiatry can make in the eld
of research ethics.
Psychiatric research poses special, but perhaps,
not unique or insurmountable ethical dilemmas.
Whatever their areas and levels of specialisation,
many medical personnel will be involved in
ongoing research activities in the course of the
practice or of their profession. They all deserve
to have a working knowledge on the principles of
research ethics.
international codes to local circumstances, develop

and enforce national codes, staff research ethics
boards, and implement research ethics processes.
It has been suggested that without some means of
strengthening capacity to promote and implement
such standards it is unlikely that research will be
more ethical throughout the world despite all the
revisions of international research ethics codes.
Moreover, institutions in which psychiatric research
endeavours are pursued must provide adequate
support and structure to foster ethical research
practices that should meet or exceed professional
ethical guidelines, for instance, with regard to
IRBs functioning and implementation.
However, to perform ethical research in the
future in Africa, efforts must be made not only to
apply what is known but to anticipate, investigate
and respond constructively to the special ethical
dilemmas newly emerging in the profession.
Continuing to explore the moral aspects of human
experimentation is itself an ethical imperative for
clinical science and psychiatry.
One essential rst step is to accurately identify
subjects incapable of independent choices. Efforts
undertaken to enhance psychiatric patients participation in research decisions need to be creative and
innovative. Some positive results have been found
through treating patients symptoms and alleviating
566
73
Ethics in the Practice of Psychiatry and Mental Health
Nora M. Hogan, Gad Kilonzo, David M. Ndetei,
Mohamedi B Sebit, Benson Gakinya
INTRODUCTION
THE HISTORY OF ETHICS
Ethics is the system of moral standards that govern

behaviour of a group of people or members of a
profession. It provides guiding principles on how
good and wise people ought to live and relate to each
other within professional groups and otherwise.
It also denes obligations and responsibilities, as
well as standards of acceptable behaviour.
Ethics is distinguished from morality which
refers to any relatively immutable system of values
and beliefs that generally determine what is good
and bad behaviour. Two or more actions each
deemed right often conict with one another and
a right action could effect a wrong result. Ethics
is about conicting values (mostly positive values)
such as autonomy versus benecence. Ethics when
viewed as a process of value balancing allows
ethical conicts and dilemmas to surface and be
resolved more easily.
Medical ethics pertains to a system of moral
standards for people in the healing profession.
Psychiatric ethics is a sub specialty which is a
system of principles that guide in determining
what actions are good, acceptable or right and
what actions are unacceptable or wrong in the
practice of psychiatry and mental health. Medical
and psychiatric ethics differ mainly in the relative
incapacity of persons with mental illnesses to make
decisions for themselves and their dependence on
others to restore that capacity.
The rst recorded conceptualisation of professional

ethical principles in western civilisation are
embodied in the Hippocratic Oath, named after the
celebrated Greek physician who was born around
460 BC. To enforce appropriate physician conduct
Hippocrates relied on the concept ethos (a Greek
word that can be equated with character) loosely
dened as the ability to do the right thing even
when no one is looking. Hipprocates saw ethos as
the best a professional can be.
The Hippocratic Oath was simple. The rst
admonition Do no harm enjoined physicians to
do good, reduce harm as much as possible, avoid
exploitation whether sexual, nancial or otherwise,
conduct ones life in a respectful manner and
maintain condentiality regarding information
received during the course of ministration of the
patients and their families. The patient also had
a set of obligations, which included compliance
with treatment, respecting ones own health and
payment of the bill.
By the middle ages there were groups of
physicians who committed themselves and
afrmed the voluntary but highly inspirational
code of conduct through which the public would
be reassured. The principle of benecence to
prevent and remove harm and promote well-being
continued to be the primary driving principle
567
who exercises the freedom to choose what form

of treatment he wants or whether he should accept
treatment at all.
In psychiatry, informed consent may be
compromised by the altered mental state of the
patient. The loss of autonomy is not a discrete
event but rather a uctuating level of autonomy
and in a sense co-extensive with the legal concept
of levels competence. The ethical principle of
autonomy may need, on occasion, to be balanced
with the principles of doing no harm, acting in the
best interest and serving justice. The degree and
extent to which assistance is provided in coming
to a decision should match the degree of mental
disturbance. In other words, the patient should
exercise his autonomy as much as possible. Ethics
in psychiatry provides guidelines on how this
should be done.
Regarding the principle of benecence, the
psychiatrist and other mental health professionals
are enjoined at all times to strive towards promoting
the well being of their clients and preventing harm.
Benecence obligates mental health professionals
to do good and pass onto others the benets
that they have received from the bounty of life.
Examples include healing patients and giving
instructions to students and colleagues. Ethics in
psychiatry also provide guidance in circumstances
when benecence ought to take preference over
patients exercise of autonomy. This happens when
the patients capacity to exercise autonomy is
adversely affected by mental disturbance.
In nonmalecence it is the duty of the mental
health professional to strive to do no harm to
the patient, to avoid either inicting physical
or emotional harm or increasing the risk of such
harm. A related principle is that of utilitarianism,
which requires that when there is a choice between
actions that will result in different number of
good outcomes, that action that would lead to the
best outcome should be taken. If there is a choice
between actions that will lead to undesirable
outcomes, the action leading to the least undesirable
outcome should be taken. Examples are choices
of psychopharmacological regimens; the regimen
with the best outcome and least side effects should
be undertaken. The correct course of action is that
which provide the most good and least harm.
The principle of justice demands the distribution
of benets and necessary burdens according to
needs and circumstances as they relate to members
of a relevant community where a course of action is
contemplated or being implemented. There should
be equal chances of receiving the benets of such
of medical and psychiatric practice until the late

1960s.
Unwritten codes of ethics have existed in
medicine since the time of Hippocrates right up to
the middle of the 20th century. The need to develop
more formal codes of ethics appears to have arisen
in response to factors like the rise of consumerism
and the emergence of third party reimbursement,
that is, insurance or government paying for the
patients treatment and care.
There are a number of arguments for and against
having a code of ethics. Several psychiatric
professional bodies have opted to have a separate
code (derived from existing ethical codes in
medicine). For example, the American Psychiatric
Association (APA) appointed a committee to
develop a code of ethics in 1972. The World
Psychiatric Association (WPA) developed a code
of ethics in 1977 and American Psychological
Association Code of Ethics was developed in
1953,
CORE ETHICAL PRINCIPLES

All codes of ethics reect the general consensus
about the general standards of appropriate
professional conduct. They outline ideal standards
of practice and professional virtues of practitioners.
Members are urged to use skilful and scientic
techniques, to self-regulate misconduct within the
profession and to respect the rights and needs of
patients families, colleagues and society. Such
urgings and expectations are reinforced by the core
ethical principles such as autonomy, benecence,
utility, respect, paternalism and justice.
Autonomy refers to personal freedom of action,
the capacity to deliberate alternative plans of
action and put those plans in place. An autonomous
choice has three elements: it is intentional, free of
undue outside inuence and made with rational
understanding. Emphasis is on freedom to exercise
the executive faculty of the mind with a strong sense
of personal responsibility for the conduct of ones
life within the constraints of competing demands
of community and society. Since this executive
faculty of the mind is to some degree compromised
in mental disturbances, there is a greater need to
examine the capacity of the individual so affected
to make informed decisions and circumstances
when it is appropriate and humane to assist him
to make informed decisions. An important part of
autonomy is respect of this capacity in a person.
An example is that of a mentally disordered patient
568
a course of action and equal chances of carrying

out the necessary burdens such as untoward effects
among members of the community. Fair distribution
of psychiatric services in quantity and quality is a
case in point.
Informed consent refers to the act of a
client agreeing to a course of action after he has
received adequate information that allows him to
make a wise decision. The elements of consent
include disclosure, capacity, and voluntariness. It
pre-supposes competence or capacity to understand
the information, to consider the various options
available and to choose the course of action that is
likely to have the best outcome. When presented with
a choice, the individual is able to make a reasonable
choice and provide a reason and justication for
the choice. The individual should be provided with
adequate disclosure of information about what he
is to consent to. This information should be what
is usually provided in the profession and should be
what a reasonable person would like to know. The
information should be comprehensible to the patient,
and sensitive to what a patient can handle.
Informed consent presupposes freedom in making
choices in the absence of coercion or any undue
inuence. In psychiatry this can be problematic
because the mental mechanism of comprehending
advantages and disadvantages of various courses
of actions may be impaired. It is the duty of the
mental health professional to make an assessment
of the mental capacity of the client and provide the
available information in a way that can be most
understandable to the client and demand a choice that
is within ability of the client to choose. To the extent
that the mental health professional assists the client
in making the decision or does make the decision, he
is exercising the principle of paternalism.
The principle of paternalism is the expression of
benecence. It is abridging an individuals liberty of
action for the individuals own good. In psychiatry,
paternalism is abridging of autonomy that is an
individuals freedom of action for his own good as
judged by the mental health professional. It is only
justied when capacity to exercise rational judgement
is impaired. In active paternalism one acts on behalf
of a person but not at his request. A common
example is the decision to admit to hospital and treat
a patient against his will (involuntary admission)
as provided for under civil commitment in mental
health acts. The unilateral act implies either that the
patients autonomy is intact but must be overridden
by the potential for dangerous behaviour or that
the patients capacity for autonomous choice is
impaired by the mental illness and must be ignored
here. Another example is in prescribing medicines

to a patient who is incompetent to provide informed
consent. In passive paternalism, one refuses to help
another to achieve some goal. An extreme case
in point is refusing to provide assisted suicide. A
physician may refuse to prescribe diazepam because
of fears of abuse by the patient.
Justication for paternalism may be mental
incapacity to make decisions, decisions made for
children, a likely or probable danger to the patient or
other people and when probable benets outweigh
probable risk of harm under the proposed course
of action. Psychiatrists have historically justied
benecent paternalism on the basis of their superior
knowledge, greater objectivity and powerful desire
to help their patients.
The paternalistic intervention should be
appropriately regulated, should be the least
restrictive, least humiliating and least insulting
alternative. This criterion argues that one remain
as respectful of the individual as much as possible
during the intervention.
RELEVANCE AND APPLICATION

OF THE CORE ETHICAL
PRINCIPLES
Many psychiatrists and mental health professionals
might have other principles as well as moral or
religious belief systems and ideals that guide
them ethically in their clinical decisions, but
the core principles of autonomy, benecence,
nonmalecence and justice are the minimum that
should guide them in their ethical decision-making
and professional organisations.
While the ultimate justication of these core
principles may be difcult, their relevance to ethical
decision-making is evident. No mental health
worker would assert that whether an act limits a
persons autonomy or self determination is morally
irrelevant or that a clients well being is irrelevant
in deciding what to do or that issues of justice are
irrelevant to ethical decision making. An ethical
code that conicted with these ethical principles
would stand in need of justication or more likely
revision. For example, WPA 1977 code of ethics was
revised in 1996 and the American Psychological
Association Code of Ethics developed in 1953 has
undergone 8 revisions.
However, the application of these principles
to situations has been the subject of considerable
debate in different cultures. For example, the
569
develop into boundary-violating behaviours over

time.
To avoid pitfalls it is generally expected that
therapists in mental health would not socialise
with clients. This also includes families of clients.
While accepting owers for condolences may be
on the safe side of the ethical boundary between
therapist and the client, obtaining a loan from the
bank through your client may be on the wrong
side of the ethical boundary. Maintaining healthy
boundaries with clients may be difcult in a small
community.
Boundary violation clearly occurs when a
therapist crosses or blurs the boundaries that
dene the therapeutic relationship and engages in
multiple role relationships. A distinction is made
between non-sexual boundary violations and
sexual boundary violations. Boundary violation
of a therapist-patient relationship occurs when it
is exploitative, gratifying the social or emotional
needs of the therapist and is not in the best interest
of the patient. An exploitation of the therapist-client
relationship for any purpose other than for the
treatment of the patient is unethical. It is the duty
of the therapist to maintain the healthy boundary.
For this reason conducting nancial business with
a former or current client is suspect, so is soliciting
funds for personal or charitable organisations
that one is involved in leading. This may include
research projects or care of patients. The situation
may be different when such donations are made
completely unsolicited.
emphasis on individual autonomy versus familycentered decision-making has been criticised as

representing an Anglo-American perspective that
may not be shared by other cultures that may place
greater importance on the community.
THE PSYCHIATRIST-PATIENT
RELATIONSHIP
The psychiatrist-patient relationship remains
the pivot upon which treatment turns. By its
very nature, it is a relationship in which patient
vulnerabilities are more exposed than in any other
branch of medicine. As such, psychiatrists and other
mental health professionals can hold considerable
inuence over their patients and must ensure that
this does not lead to exploitation for personal gain,
whether physical, emotional, religious, nancial,
sexual or for any other reason.
In psychiatric and psychotherapeutic practice,
boundaries delineate the personal and the
professional roles and the differences that should
characterise the interpersonal encounters between
the patient and the professional. Boundaries are
essential in psychotherapeutic relationships as a
protection for both therapist and patient. Clearly
established boundaries must be maintained to
allow professionals and patients to be secure in
their identities and roles.
Boundary issues can become problematic. The
issue of transference and counter-transference
may arise because the therapist-client relationship
in mental health professions leads to close
psychodynamic interaction. This often results in the
patient being suggestible and easily inuenced by
the therapist. Often, there are subconscious forces
at work that are rarely consciously recognised by
the client but which the therapist should strive to be
aware of. It is partly for this reason that the capacity
of clients to exercise their autonomy in decisionmaking in such relationships is questionable.
Boundary crossing may be dened as making
a change in the therapist role that could potentially
benet the client and does not do harm. It is
differentiated from boundary violations (which
cause harm). The problem is the distinction
between boundary crossing and boundary violation
is not clear. If boundary crossings are frequent
(e.g. repeated and excessive self-disclosure) it may
Boundary violation and sexual exploitation

in psychiatry and psychotherapy
A major concern in psychiatry is related to therapists
taking advantage of their clients in violation of a
sexual boundary between therapists and clients.
Where reported cases are available, it occurs with
disturbing frequency. The sexualisation of the
therapeutic relationship by a therapist and sexual
activity of any kind between a therapist and patient
is deemed to be unethical. It is also akin to rape
because consent cannot be considered to have
been obtained. This ethical proscription of sexual
relationships with clients also extends to relatives
of the client whose contact resulted from the index
therapeutic alliance. So any sexual activity between
therapist and former or current client including
their relatives is unethical.
570
with other agencies such as employers, insurance

agencies or legal counsels.
Clinical information used for teaching, research,
publications, or scientic gatherings should
be sufciently disguised to preserve patient
anonymity.
CONFIDENTIALITY AND
DISCLOSURE OF INFORMATION
In the Hippocratic Oath the physician swears that:
all that may come to my knowledge in the exercise
of my profession or outside of my profession or in
the daily commerce with men, which ought not to
be spread abroad, I will keep secret and will not
reveal.
Exception to this rule

This applies in situations where the psychiatrist
needs to warn the police or other potential
victims of a threat to life. In rare situations, courts
order psychiatrists to reveal condential patient
information without the consent of the patient.
Psychiatrists may be ethically prohibited but duty
bound to offer information that has legally been
requested by a sitting and competent magistrate of
the law. In this instance, only information that is
required by law should be divulged.
This oath to secrecy is especially apt for mental

health professionals who are likely to learn clients
innermost secrets which they may not even have
intended to reveal. Mentally disturbed patients are
also likely to reveal very sensitive information,
which is potentially embarrassing. Thus one
should avoid making conversation with even ones
condants such as a spouse or fellow doctor about
the life of clients or their family.
Breaching condentiality
Sharing information in multidisciplinary
teams
There are some circumstances where breaching

condentiality may be mandated by law (for
example, suspicion of child abuse or concerns
about a patients ability to operate a motor vehicle
safely). Like other physicians, psychiatrists and
mental health workers have an ethical obligation
to report these circumstances to the appropriate
authority. Although psychiatrists are required
to report such circumstances, the patient should
nevertheless be informed before condentiality is
breached.
Particular care must be taken when working in

multidisciplinary settings. Even in a clinical
setting, only that information that is germane to
obtaining clinical advice from colleagues can be
provided after appropriate informed consent has
been given. Shared information should be relevant
to the patients treatment by the multidisciplinary
team. Personal information that is not germane
to clinical care should not be divulged. Shared
information must remain condential within the
multidisciplinary team.
PERSONAL MORAL BIAS
Multidisciplinary collaboration in the care

of patient
In dealing with patients, psychiatrists not

infrequently encounter social behaviours (for
example, abortion, sexual conduct, divorce,
drug use, or extramarital indelity) that may not
be in keeping with their own moral standards.
Ethical psychiatrists will recognise their own
personal moral bias and refrain from allowing it to
interfere with their professional judgement in the
management of a psychiatric problem
Psychiatrists often collaborate with other nonmedical professionals within the mental health
eld, including psychologists, social workers,
counsellors, nurses, and others. Collaboration must
be done in a manner that ensures patient needs are
met by the expertise of the practitioner, regardless
of discipline. Clear role functions and professional
responsibilities should be specied and understood
by all the parties, particularly the patient.
PROFESSIONAL FEES
Request for release of information

Even in cases where a patient requests for release of
information, the clinician should restrict the release
to those aspects of the information that are pertinent
to the request. The same discretion applies when
informed consent has been proved to communicate
Fee policy should always be genuinely represented

and consistent with existing state laws. With
regard to consultation fees, the agreed amount
should be arrived at including mode of payment
571
with the understanding that no other gifts, nancial

or otherwise, will be accepted. In determining
professional fees both the nature of the service
provided and the ability of the client to pay have
to be considered. The therapists bill should reect
the services actually rendered. Fees for third
party services (for example, forensic or insurance
examinations) should be based on the nature of the
service provided. Contingency fees should not be
accepted, because they create problems in regard
to honesty and efforts to attain objectivity.
PATIENTS RIGHT TO ACCEPT

OR REJECT MEDICAL CARE
A psychiatrist may be asked to ascertain whether
a patient is competent to consent to medical
treatmentusually when the patient is refusing
treatment (for example, surgery, chemotherapy
or ongoing medical therapy). Psychiatrists should
limit their opinions to whether the presence of
a psychiatric disorder is rendering the patient
incompetent to reject or accept the recommended
medical care, remembering that refusing medical
treatment does not in itself necessarily imply
psychiatric disorder.
TERMINATION AND TRANSFER

OF PATIENTS
Termination refers to the process of ending therapy.
Effective termination and transfer of a patient have
to be clearly guided by policy. Having accepted
professional responsibility for a patient, one should
continue to provide services until they are no longer
required, until another suitable physician has
assumed responsibility for the patient, or until the
patient has been given adequate notice to terminate
the relationship.
The nature of certain psychiatric disorders and
the nature of the physicianpatient relationship
in the treatment of those disorders augments our
responsibility to ensure that patients are not subject
to arbitrary discontinuation of psychiatric services.
Mutual agreement to terminate regardless of who
initiates the process is often described as the ideal
approach to termination. The ethical obligation of
the therapist should be to act primarily in the best
interest of the client. The termination of care should
be adequately explained to a patient beforehand,
and the available alternatives should be discussed.
TRAINING AND EXPERTISE

Maintaining expertise
Most codes exhort that the professional should
maintain a reasonable level of awareness of
current scientic and professional information
(American Psychological Association Code 2002).
Continuing professional development and peer
review have become statutory obligations in many
places. The psychiatrist has an ethical obligation
to remain abreast of developments in the art and
science of psychiatry. The ethical practice of
psychiatry requires both sound training and lifelong
learning to maintain and improve his professional
knowledge, skills, and attitudes.
Ethical issues for residence in psychiatric

training
One of the many ethical conicts for trainees is
their dual role as physician and trainee. Trainees
may be reluctant to explicitly inform patients of
their level of experience. Ethically trainees and
their supervisors should ensure that patients are
aware of the trainees level of competence and the
degree to which they are supervised. Patients must
freely consent to be treated by trainees.
WORKING WITH THE FAMILY

OF THE PATIENT
Be considerate of the patients family and signicant
others and co-operate with them in the patients
interest. Psychiatrists recognise the need to obtain
the co-operation of relatives in providing collateral
information and supporting treatment plans. They
also recognise the need to assuage relatives anxiety
about the care of their family member. However,
psychiatrists should note that relatives needs come
second to the obligation to maintain condentiality
with the patient.
Competence to practise
To practise psychiatry competently and without
impairment one needs to consider the ethical
implications of the practising impaired physician.
Psychiatric colleagues are encouraged to intercede
in such situations by encouraging impaired
psychiatrist to seek appropriate professional help,
572
or by reporting to the appropriate regulatory body,

or both.
Issues in Community Health Care. Arnold Kaplan

HI and Sadock BJ. Synopsis of Psychiatry. Lippicott
Williams and Wilkins 8th Ed.
5. Kaplan H.I. and Sadock B.J. (1998). Synopsis of
Psychiatry. Lippicott Williams and Wilkins 8th
Edition.
6. ODonohue, W and Ferguson, K (Eds). (2003).
Handbook of Professional Ethics for Psychologist
Sage Publications.
7. Seedhouse D. Ethics (1988) The Heart of Health
Care. Wiley.
8. Singer P (Ed) (1994). Ethics. Oxford University
Press.
Further Reading
1. American Psychiatric Association. (1995). The
Principles of Medical Ethics with Annotations
Especially Applicable to Psychiatry. American
Psychiatric Association, Washington DC.
2. American Psychological Association. (2002). Ethical
Principles of Psychologists and Code of Conduct.
American Psychological Association Washington
DC.
3. Block S. Chodoff P (Eds.). (1993). Psychiatric Ethics.
Oxford University Press. New York.
4. Chadwick R and Levitt M (Eds). (1998). Ethical
573
574
Section VIII:
Post-Script
575
576
74
The Practice of Psychiatry in Africa A Personal Experience
Prof. Allan Haworth13
It is my conviction that we can use the techniques

of psychiatry not only in the usual clinical practice
with mentally ill persons, but also in general
medicine and in other interactions, including
counselling. As doctors we tend to focus upon
symptoms, signs, diseases and pathologies,
although we are constantly reminded that we ought
to be dealing with the whole person. When there
are many patients and the interaction is brief and
routine, as for example in an adult with malaria,
this is understandable. Suppose you had to deal
with a bread-winner who must have an operation in
order to be able to work, yet is terried of losing his
job, because of being away for too long while he
has the operation and his family is also fortifying
his fears of the operation itself. Our approach must
of necessity be one of exploration as we build up a
picture of the problem: physical, psychological or
social or a combination. This exploration may need
to be very brief and focused if we are dealing with
a simple self-limiting infection or a minor injury.
On the other hand, we may nd we need to try to
understand more of what it is like to live in some
part of this world which our patient inhabits.
MAKING A DIAGNOSIS
In medicine we learn to put together symptoms,
signs and the results of special investigations in
making a diagnosis and deciding upon management.
Experienced medical workers often do this by
pattern recognition. Usually the diagnosis is
arrived at step-by-step with differentials suggested
and checked or by relying upon the natural history
of the condition, as time passes.
If one examines the history of medicine we can
learn one important lesson with regard to the daily
practice of psychiatry. It often took a high degree
of curiosity and sometimes speculation to see a
connection between what are now established causes
and effects in many common diseases. One of the
best known is cholera. Even when a connection was
apparent, the why of this may have been poorly
understood and the mechanisms of the connection
may simply have been accepted. How can this be
applied in psychiatry? As we build up a picture of
our patient we may not notice connections between
certain events or between events and behaviours
13
Professor Haworth has practised and taught psychiatry in Zambia for over 4 decades. He teaches psychiatry at the University of
Zambia Medical School.
577
and so forth. As we note some behaviour which we

might not have expected, given what we know of
the patient, we do not bother to ask why.
At rst glance the amount of information
required in history taking may seem vast, but much
of what you learn may well be redundant and need
not be noted. You will hardly need information on
childhood development in an elderly patient, or on
primary education in a person with a university
degree. Similarly, you may well feel that other
material is not necessary when formally presenting
a patient, say at a case conference. Learning
how to attain the right balance between painting
an adequate picture and not making it too overinclusive is part of the art of psychiatry. You have
to remember that you are the artist, using your
technique to depict the person, and only that detail
which will be relevant.
As you learn more and more about an individual
or a family, you should be able to t the pieces
together to make a whole. With the limited time
available in most clinical practice, it may be
unnecessary to go into great detail about some
aspects of life. Yet it is often impossible to tell what
will be important although we can make some
guesses from our previous experience. Often the
guesses we make are based upon our expectations
of what would happen to the majority of people
in the same situation. Generalisations can be
misleading and it is important not to decide that
something should not happen, because it is unusual
or even seems wrong in some way. An open mind
is essential. Yet deviations in behaviour may also
indicate places of stress and conict in a persons
life and so must often plant a seed of suspicion,
which will need further attention. Many of our
expectations in the realm of behaviour are based
upon the concept of culture, but we can go beyond
this and consider every aspect of a persons life.
In order to build up the kind of picture to
which I have referred and especially to look out
for anomalies or curious features which might
indicate some pathology or the result of illness,
it is necessary to have an idea of what to expect.
Thus, it might be said that patients will stand out
from their background, because of their behaviour
as we recognise that it is in some ways inconsistent
norms of which we are aware. In practice we will
sometimes nd that we are using statistical norms
(what the majority do), while the patient will often
be under pressure because of idealised norms.
TALKING ABOUT SEX

It is often said that sex is a taboo subject in
traditional African culture. It is taboo to talk about
it in ordinary social intercourse, but on the other
hand, puberty rites focus upon sex and upon duties
in marriage. It is also said that a younger person
cannot discuss sexual matters with an older person
and often there can be no communication if a health
worker and patient are of different genders. In my
opinion, all these statements are wrong.
Find a non-emotive language in which to
communicate. Most scientic words carry little
emotion with them, e.g. vagina, genitalia, labia,
penis, scrotum and so on. An advantage of such
language is that it is also unambiguous. Talking
about sleeping or playing with someone is
ambiguous in a vernacular, whereas talking of
having sexual intercourse is quite clear. Try to avoid
what might be called street talk since this is often
offensive and brings out a strong negative reaction.
From your own experience you will nd that it is
easier to use sexual words in a foreign language
than in your own. This might mean educating
the couple on the meaning of the words you will
use. You might wish to use a diagram or picture to
ensure that there is no misunderstanding. Prepare
the couple well in advance. Get their permission
and commitment to talk about sex. Ensure that they
are ready to get started and remain observant for
signs of discomfort.
Talking about unusual forms of sex,
including masturbation, should come much later in
the discussion. The early questions should be about
normal sex often with the introduction that this is
part of your routine inquiries. Having dealt with
ordinary sex, it is sometimes necessary to check
on specic risky behaviours and further questions
on the sexual act itself may be necessary, e.g. use of
dry sex. You may need to explore extra-marital
or pre-marital sex. Avoid condemnatory words
such as adultery, but be prepared to explore ideas
of guilt should the patient introduce them, or be
prepared to follow-up when the spouse is accused
of adultery or some other behaviour, but do not
take sides, or appear to do so.
Most patients will eventually talk freely about the
most intimate aspects of their lives if the medical
578
The Practice of Psychiatry in Africa - A Personal Experience
the last time. What was drunk? How much? Last

time, before then and before that, for one week
or the last two or three weeks, depending upon
frequency. Then ask if this has been the usual
pattern of drinkingover how longdays, weeks,
months. If not, how is the pattern different?
worker can show that he is both knowledgeable

and respectful and can introduce topics in a
completely natural way, without any intimation of
being embarrassed. With married couples, it may
be necessary to talk with each member separately
at rst or at some point. The counsellor must be
able to gather and interpret information about
very private and sometimes socially condemned
behaviour related to sex. There is no simple
formula for getting people to talk about their own
sexual activities. Effective discussion of sensitive
topics will depend on the ability of the counsellor
to gear the communication to the emotional and
understanding of the patient. Provide a sense of
safety and security through a supportive relationship
by demonstrating your own familiarity with the
subject in talking about topics usually avoided in
social life or in medical interviews.
COMMUNICATION IN
PSYCHIATRY
The practice of psychiatry must of necessity begin
with adequate communication since without this
one can only make assumptions and speculate. It
is easy to make mistakes, even before a word has
been utteredsay on reading a referral letter. An
individuals name may wrongly suggest a particular
nationality, ethnic group or religious afliation.
It seems obvious that using language must
be our main means of communication. No
matter what emphasis is placed upon non-verbal
communication, we ultimately need to understand
what our patient or client is thinking and feeling,
clearly and in detail. This can only be done in words.
We may too often think that we are communicating
when we have a very inadequate knowledge of a
language or we do not realise that the person we
are talking with lacks basic information or skills
which we assume he has. There is a special danger
when using languages which are similar (e.g. many
Bantu languages), in that we may assume that we
understand when we guess at the meaning of an
unfamiliar word, or do not realis e that there are
subtle differences in meaning attached to certain
words, because of special emotional leadings.
It is important to recognise how important the
emotional element is in communication. Every
word we utter might be said to carry an emotional
component. Think of the ways in which you can say
some monosyllabic words such as Yes No If
But and so on. An important example relates to
the way in which we can talk about sexual matters.
It used to be suggested that the best way to inform
young people about sex was to use the terminology
they use, but this is either baby-talk or looked
upon as coarse and represents a reversal of adult
attitudes. When adolescents learn anatomical
terms, they are comfortable with themthey are
neutral. Likewise when one has learnt a second
language, many terms do not carry the same
(negative) emotional loading as in the mother
language. Advantage can be taken of these facts in
TAKING A DRINKING HISTORY

Since you are aiming to minimise negative emotions
when dealing with sensitive topics, always explore
the normal and acceptable before moving
onto less congenial topics, as a general principle.
I include this topic because it often gives some
difculty, is inadequately done and yet is very
important. Your aim is to nd out how much
alcohol is taken with what frequency, regularity
and variability and to discover what effects this
consumption has been having. You cannot explore
the quantity and frequency of drinking without
knowing which types of alcohol are available,
including illicit ones. So you should have had a
talk with informants who can describe the drinking
scene with some accuracy, including alternative
names, legality, price and where it is commonly
obtained. The quantity of actual ethyl alcohol
consumed (which is what you are interested in)
will depend upon its concentration in the beverages
consumed. You will need to know all about this as
well as the quantities usually served. It will be best
to have an illustrated reference table where you
work with details of the name of the beverage, the
alcohol concentration, pictures of the containers
used and the quantities in each container.
Another general principle concerning repetitive
behaviour is to move backwards from the present,
or the recent past. First you must nd out if your
patient drinks at all, if this is regular and whether
he has been drinking recently. Then ask for how
long the patient has been drinking and when was
579
talking about sensitive topics. At the same time it

is important to note that words which are relatively
neutral when used in one language may be adopted
into another with a different emotional tone and it
is important to become aware of these changes.
2.
3.
What to do
1.
4.
Ask the patient which language he normally

uses for communication and would like to
use in talking with you. Often a patient will
be over-condent in his ability to speak a
particular language, and this may mean that
you are both over-condent.
580
If he would prefer to use a language that you

do not know and an interpreter is available,
ask the patient if this will be acceptable.
Note that your patient may not always be
aware of the limitations of communication in
the language he is using.
If you have to make a compromise, say by
one or both of you using a language in which
you are not uent, keep this limitation in mind
and look out for areas where you are not sure
of what is meant. In practice, this may mean
checking rather often that something has been
understood.
APPENDICES
581
Appendix 1
WMA DECLARATION OF HELSINKI 2000
Ethical Principles for Medical Research Involving Human Subjects
Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended by the
29th WMA General Assembly, Tokyo, Japan, October 1975
35th WMA General Assembly, Venice, Italy, October 1983
41st WMA General Assembly, Hong Kong, September 1989
48th WMA General Assembly, Somerset West, October 1996
and the 52nd WMA General Assembly, Edinburgh, Scotland, October 2000
Note of Clarication on Paragraph 29 added by the WMA General Assembly, Washington 2002
Note of Clarication on Paragraph 30 added by the WMA General Assembly, Tokyo 2004
INTRODUCTION
1.
The World Medical Association has developed the Declaration of Helsinki as a statement of ethical
principles to provide guidance to physicians and other participants in medical research involving human
subjects. Medical research involving human subjects includes research on identiable human material
or identiable data.
2.
It is the duty of the physician to promote and safeguard the health of the people. The physicians
knowledge and conscience are dedicated to the fulllment of this duty.
3.
The Declaration of Geneva of the World Medical Association binds the physician with the words,
The health of my patient will be my rst consideration, and the International Code of Medical Ethics
declares that, A physician shall act only in the patients interest when providing medical care which
might have the effect of weakening the physical and mental condition of the patient.
4.
Medical progress is based on research which ultimately must rest in part on experimentation involving
human subjects.
5.
In medical research on human subjects, considerations related to the well-being of the human subject
should take precedence over the interests of science and society.
6.
The primary purpose of medical research involving human subjects is to improve prophylactic,
diagnostic and therapeutic procedures and the understanding of the aetiology and pathogenesis of
disease. Even the best proven prophylactic, diagnostic, and therapeutic methods must continuously be
challenged through research for their effectiveness, efciency, accessibility and quality.
7.
In current medical practice and in medical research, most prophylactic, diagnostic and therapeutic
procedures involve risks and burdens.
8.
Medical research is subject to ethical standards that promote respect for all human beings and protect
their health and rights. Some research populations are vulnerable and need special protection. The
particular needs of the economically and medically disadvantaged must be recogniSed. Special attention
is also required for those who cannot give or refuse consent for themselves, for those who may be
subject to giving consent under duress, for those who will not benet personally from the research and
for those for whom the research is combined with care.
9.
Research investigators should be aware of the ethical, legal and regulatory requirements for research
on human subjects in their own countries as well as applicable international requirements. No national
ethical, legal or regulatory requirement should be allowed to reduce or eliminate any of the protections
for human subjects set forth in this Declaration.
582
Appendix 1
BASIC PRINCIPLES FOR ALL MEDICAL RESEARCH

10. It is the duty of the physician in medical research to protect the life, health, privacy, and dignity of the
human subject.
11. Medical research involving human subjects must conform to generally accepted scientic principles, be
based on a thorough knowledge of the scientic literature, other relevant sources of information, and on
adequate laboratory and, where appropriate, animal experimentation.
12. Appropriate caution must be exercised in the conduct of research which may affect the environment, and
the welfare of animals used for research must be respected.
13. The design and performance of each experimental procedure involving human subjects should be
clearly formulated in an experimental protocol. This protocol should be submitted for consideration,
comment, guidance, and where appropriate, approval to a specially appointed ethical review committee,
which must be independent of the investigator, the sponsor or any other kind of undue inuence. This
independent committee should be in conformity with the laws and regulations of the country in which the
research experiment is performed. The committee has the right to monitor ongoing trials. The researcher
has the obligation to provide monitoring information to the committee, especially any serious adverse
events. The researcher should also submit to the committee, for review, information regarding funding,
sponsors, institutional afliations, other potential conicts of interest and incentives for subjects.
14. The research protocol should always contain a statement of the ethical considerations involved and
should indicate that there is compliance with the principles enunciated in this Declaration.
15. Medical research involving human subjects should be conducted only by scientically qualied persons
and under the supervision of a clinically competent medical person. The responsibility for the human
subject must always rest with a medically qualied person and never rest on the subject of the research,
even though the subject has given consent.
16. Every medical research project involving human subjects should be preceded by careful assessment of
predictable risks and burdens in comparison with foreseeable benets to the subject or to others. This
does not preclude the participation of healthy volunteers in medical research. The design of all studies
should be publicly available.
17. Physicians should abstain from engaging in research projects involving human subjects unless they
are condent that the risks involved have been adequately assessed and can be satisfactorily managed.
Physicians should cease any investigation if the risks are found to outweigh the potential benets or if
there is conclusive proof of positive and benecial results.
18. Medical research involving human subjects should only be conducted if the importance of the objective
outweighs the inherent risks and burdens to the subject. This is especially important when the human
subjects are healthy volunteers.
19. Medical research is only justied if there is a reasonable likelihood that the populations in which the
research is carried out stand to benet from the results of the research.
20. The subjects must be volunteers and informed participants in the research project.
21. The right of research subjects to safeguard their integrity must always be respected. Every precaution
should be taken to respect the privacy of the subject, the condentiality of the patients information and
to minimise the impact of the study on the subjects physical and mental integrity and on the personality
of the subject.
22. In any research on human beings, each potential subject must be adequately informed of the aims,
methods, sources of funding, any possible conicts of interest, institutional afliations of the researcher,
the anticipated benets and potential risks of the study and the discomfort it may entail. The subject
should be informed of the right to abstain from participation in the study or to withdraw consent to
participate at any time without reprisal. After ensuring that the subject has understood the information,
the physician should then obtain the subjects freely-given informed consent, preferably in writing. If
the consent cannot be obtained in writing, the non-written consent must be formally documented and
witnessed.
583
23. When obtaining informed consent for the research project the physician should be particularly cautious
if the subject is in a dependent relationship with the physician or may consent under duress. In that
case the informed consent should be obtained by a well-informed physician who is not engaged in the
investigation and who is completely independent of this relationship.
24. For a research subject who is legally incompetent, physically or mentally incapable of giving consent or
is a legally incompetent minor, the investigator must obtain informed consent from the legally authorized
representative in accordance with applicable law. These groups should not be included in research unless
the research is necessary to promote the health of the population represented and this research cannot
instead be performed on legally competent persons.
25. When a subject deemed legally incompetent, such as a minor child, is able to give assent to decisions
about participation in research, the investigator must obtain that assent in addition to the consent of the
legally authorized representative.
26. Research on individuals from whom it is not possible to obtain consent, including proxy or advance
consent, should be done only if the physical/mental condition that prevents obtaining informed consent
is a necessary characteristic of the research population. The specic reasons for involving research
subjects with a condition that renders them unable to give informed consent should be stated in the
experimental protocol for consideration and approval of the review committee. The protocol should
state that consent to remain in the research should be obtained as soon as possible from the individual or
a legally authorized surrogate.
27. Both authors and publishers have ethical obligations. In publication of the results of research, the
investigators are obliged to preserve the accuracy of the results. Negative as well as positive results
should be published or otherwise publicly available. Sources of funding, institutional afliations and
any possible conicts of interest should be declared in the publication. Reports of experimentation not
in accordance with the principles laid down in this Declaration should not be accepted for publication.
ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH

MEDICAL CARE
28. The physician may combine medical research with medical care, only to the extent that the research is
justied by its potential prophylactic, diagnostic or therapeutic value. When medical research is combined
with medical care, additional standards apply to protect the patients who are research subjects.
29. The benets, risks, burdens and effectiveness of a new method should be tested against those of the best
current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo,
or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists. See
footnote
30. At the conclusion of the study, every patient entered into the study should be assured of access to the best
proven prophylactic, diagnostic and therapeutic methods identied by the study. See footnote
31. The physician should fully inform the patient which aspects of the care are related to the research. The
refusal of a patient to participate in a study must never interfere with the patient-physician relationship.
32. In the treatment of a patient, where proven prophylactic, diagnostic and therapeutic methods do not
exist or have been ineffective, the physician, with informed consent from the patient, must be free to use
unproven or new prophylactic, diagnostic and therapeutic measures, if in the physicians judgement it
offers hope of saving life, re-establishing health or alleviating suffering. Where possible, these measures
should be made the object of research, designed to evaluate their safety and efcacy. In all cases, new
information should be recorded and, where appropriate, published. The other relevant guidelines of this
Declaration should be followed.
Note: Note of clarication on paragraph 29 of the WMA Declaration of Helsinki
The WMA hereby reafrms its position that extreme care must be taken in making use of a placebo-controlled trial and that in
general this methodology should only be used in the absence of existing proven therapy. However, a placebo-controlled trial may
be ethically acceptable, even if proven therapy is available, under the following circumstances:
- Where for compelling and scientically sound methodological reasons its use is necessary to determine the efcacy or safety
of a prophylactic, diagnostic or therapeutic method; or
584
Appendix 1
Where a prophylactic, diagnostic or therapeutic method is being investigated for a minor condition and the patients who
receive placebo will not be subject to any additional risk of serious or irreversible harm.
All other provisions of the Declaration of Helsinki must be adhered to, especially the need for appropriate ethical and scientic
review.
Note: Note of clarication on paragraph 30 of the WMA Declaration of Helsinki

The WMA hereby reafrms its position that it is necessary during the study planning process to identify post-trial access by study
participants to prophylactic, diagnostic and therapeutic procedures identied as benecial in the study or access to other appropriate
care. Post-trial access arrangements or other care must be described in the study protocol so the ethical review committee may
consider such arrangements during its review.
The Declaration of Helsinki (Document 17.C) is an ofcial policy document of the World Medical Association, the global
representative body for physicians. It was rst adopted in 1964 (Helsinki, Finland) and revised in 1975 (Tokyo, Japan), 1983
(Venice, Italy), 1989 (Hong Kong), 1996 (Somerset-West, South Africa) and 2000 (Edinburgh, Scotland). Note of clarication on
Paragraph 29 added by the WMA General Assembly, Washington 2002.
585
Appendix 2
International Ethical Guidelines for Biomedical Research Involving Human Subjects
(CIOMS) in collaboration with the World Health Organisation (WHO) GENEVA 2002
Guideline 1: Ethical justication and scientic validity of biomedical research involving human beings
The ethical justication of biomedical research involving human subjects is the prospect of discovering
new ways of beneting peoples health. Such research can be ethically justiable only if it is carried out in
ways that respect and protect, and are fair to, the subjects of that research and are morally acceptable within
the communities in which the research is carried out. Moreover, because scientically invalid research is
unethical in that it exposes research subjects to risks without possible benet, investigators and sponsors
must ensure that proposed studies involving human subjects conform to generally accepted scientic
principles and are based on adequate knowledge of the pertinent scientic literature.
Guideline 2: Ethical review committees
All proposals to conduct research involving human subjects must be submitted for review of their scientic
merit and ethical acceptability to one or more scientic review and ethical review committees. The review
committees must be independent of the research team, and any direct nancial or other material benet they
may derive from the research should not be contingent on the outcome of their review. The investigator
must obtain their approval or clearance before undertaking the research. The ethical review committee
should conduct further reviews as necessary in the course of the research, including monitoring of the
progress of the study.
Guideline 3: Ethical review of externally sponsored research
An external sponsoring organisation and individual investigators should submit the research protocol for
ethical and scientic review in the country of the sponsoring organisation, and the ethical standards applied
should be no less stringent than they would be for research carried out in that country. The health authorities
of the host country, as well as a national or local ethical review committee, should ensure that the proposed
research is responsive to the health needs and priorities of the host country and meets the requisite ethical
standards.
Guideline 4: Individual informed consent
For all biomedical research involving humans the investigator must obtain the voluntary informed consent
of the prospective subject or, in the case of an individual who is not capable of giving informed consent,
the permission of a legally authorised representative in accordance with applicable law. Waiver of informed
consent is to be regarded as uncommon and exceptional, and must in all cases be approved by an ethical
review committee.
Guideline 5: Obtaining informed consent: Essential information for prospective research subjects
Before requesting an individuals consent to participate in research, the investigator must provide the
following information, in language or another form of communication that the individual can understand:
1.
the direct benets, if any, expected to result to subjects from participating in the research
2.
the expected benets of the research to the community or to society at large, or contributions to scientic
knowledge;
3.
whether, when and how any products or interventions proven by the research to be safe and effective
will be made available to subjects after they have completed their participation in the research, and
whether they will be expected to pay for them;
4.
any currently available alternative interventions or courses of treatment;
5.
the provisions that will be made to ensure respect for the privacy of subjects and for the condentiality
of records in which subjects are identied;
586
Appendix 2
6.
the limits, legal or other, to the investigators ability to safeguard condentiality, and the possible
consequences of breaches of condentiality;
7.
policy with regard to the use of results of genetic tests and familial genetic information, and the
precautions in place to prevent disclosure of the results of a subjects genetic tests to immediate family
relatives or to others (e.g., insurance companies or employers) without the consent of the subject;
8.
the sponsors of the research, the institutional afliation of the investigators, and the nature and sources
of funding for the research;
9.
the possible research uses, direct or secondary, of the subject`s medical records and of biological
specimens taken in the course of clinical care (See also Guidelines 4 and 18 Commentaries);
10. whether it is planned that biological specimens collected in the research will be destroyed at its
conclusion, and, if not, details about their storage (where, how, for how long, and nal disposition) and
possible future use, and that subjects have the right to decide about such future use, to refuse storage,
and to have the material destroyed (See Guideline 4 Commentary);
11. whether commercial products may be developed from biological specimens, and whether the participant
will receive monetary or other benets from the development of such products;
12. whether the investigator is serving only as an investigator or as both investigator and the subject`s
physician;
13. the extent of the investigators responsibility to provide medical services to the participant;
14. that treatment will be provided free of charge for specied types of research-related injury or for
complications associated with the research, the nature and duration of such care, the name of the
organization or individual that will provide the treatment, and whether there is any uncertainty regarding
funding of such treatment.
15. in what way, and by what organisation, the subject or the subject`s family or dependants will be
compensated for disability or death resulting from such injury (or, when indicated, that there are no
plans to provide such compensation);
16. whether or not, in the country in which the prospective subject is invited to participate in research, the
right to compensation is legally guaranteed;
17. that an ethical review committee has approved or cleared the research protocol.
Guideline 6: Obtaining informed consent: Obligations of sponsors and investigators
Sponsors and investigators have a duty to:
refrain from unjustied deception, undue inuence, or intimidation;
seek consent only after ascertaining that the prospective subject has adequate understanding of the
relevant facts and of the consequences of participation and has had sufcient opportunity to consider
whether to participate;
as a general rule, obtain from each prospective subject a signed form as evidence of informed consent
investigators should justify any exceptions to this general rule and obtain the approval of the ethical
review committee (See Guideline 4 Commentary, Documentation of consent);
renew the informed consent of each subject if there are signicant changes in the conditions or
procedures of the research or if new information becomes available that could affect the willingness of
subjects to continue to participate; and,
renew the informed consent of each subject in long-term studies at pre-determined intervals, even if
there are no changes in the design or objectives of the research.
Guideline 7: Inducement to participate
Subjects may be reimbursed for lost earnings, travel costs and other expenses incurred in taking part in
a study; they may also receive free medical services. Subjects, particularly those who receive no direct
benet from research, may also be paid or otherwise compensated for inconvenience and time spent. The
587
payments should not be so large, however, or the medical services so extensive as to induce prospective
subjects to consent to participate in the research against their better judgment (undue inducement). All
payments, reimbursements and medical services provided to research subjects must have been approved by
an ethical review committee.
Guideline 8: Benets and risks of study participation
For all biomedical research involving human subjects, the investigator must ensure that potential benets
and risks are reasonably balanced and risks are minimised.
Interventions or procedures that hold out the prospect of direct diagnostic, therapeutic or preventive
benet for the individual subject must be justied by the expectation that they will be at least as
advantageous to the individual subject, in the light of foreseeable risks and benets, as any available
alternative. Risks of such 'benecial' interventions or procedures must be justied in relation to expected
benets to the individual subject.
Risks of interventions that do not hold out the prospect of direct diagnostic, therapeutic or preventive
benet for the individual must be justied in relation to the expected benets to society (generalisable
knowledge). The risks presented by such interventions must be reasonable in relation to the importance
of the knowledge to be gained.
Guideline 9: Special limitations on risk when research involves individuals who are not capable of
giving informed consent
When there is ethical and scientic justication to conduct research with individuals incapable of giving
informed consent, the risk from research interventions that do not hold out the prospect of direct benet
for the individual subject should be no more likely and not greater than the risk attached to routine medical
or psychological examination of such persons. Slight or minor increases above such risk may be permitted
when there is an overriding scientic or medical rationale for such increases and when an ethical review
committee has approved them.
Guideline 10: Research in populations and communities with limited resources
Before undertaking research in a population or community with limited resources, the sponsor and the
investigator must make every effort to ensure that:
the research is responsive to the health needs and the priorities of the population or community in
which it is to be carried out; and
any intervention or product developed, or knowledge generated, will be made reasonably available for
the benet of that population or community.
Guideline 11: Choice of control in clinical trials
As a general rule, research subjects in the control group of a trial of a diagnostic, therapeutic, or preventive
intervention should receive an established effective intervention. In some circumstances it may be ethically
acceptable to use an alternative comparator, such as placebo or no treatment.
Placebo may be used:
when there is no established effective intervention;
when withholding an established effective intervention would expose subjects to, at most, temporary
discomfort or delay in relief of symptoms;
when use of an established effective intervention as comparator would not yield scientically reliable
results and use of placebo would not add any risk of serious or irreversible harm to the subjects.
Guideline 12: Equitable distribution of burdens and benets in the selection of groups of subjects in
research
Groups or communities to be invited to be subjects of research should be selected in such a way that the
burdens and benets of the research will be equitably distributed. The exclusion of groups or communities
that might benet from study participation must be justied.
Guideline 13: Research involving vulnerable persons
Special justication is required for inviting vulnerable individuals to serve as research subjects and, if they
are selected, the means of protecting their rights and welfare must be strictly applied.
588
Appendix 2
Guideline 14: Research involving children

Before undertaking research involving children, the investigator must ensure that:
the research might not equally well be carried out with adults;
the purpose of the research is to obtain knowledge relevant to the health needs of children;
a parent or legal representative of each child has given permission;
the agreement (assent) of each child has been obtained to the extent of the child`s capabilities; and,
a child`s refusal to participate or continue in the research will be respected.
Guideline 15: Research involving individuals who by reason of mental or behavioural disorders are not
capable of giving adequately informed consent
Before undertaking research involving individuals who by reason of mental or behavioural disorders are
not capable of giving adequately informed consent, the investigator must ensure that:
such persons will not be subjects of research that might equally well be carried out on persons whose
capacity to give adequately informed consent is not impaired;
the purpose of the research is to obtain knowledge relevant to the particular health needs of persons
with mental or behavioural disorders;
the consent of each subject has been obtained to the extent of that person's capabilities, and a prospective
subject's refusal to participate in research is always respected, unless, in exceptional circumstances,
there is no reasonable medical alternative and local law permits overriding the objection; and,
in cases where prospective subjects lack capacity to consent, permission is obtained from a responsible
family member or a legally authorized representative in accordance with applicable law.
Guideline 16: Women as research subjects
Investigators, sponsors or ethical review committees should not exclude women of reproductive age from
biomedical research. The potential for becoming pregnant during a study should not, in itself, be used as
a reason for precluding or limiting participation. However, a thorough discussion of risks to the pregnant
woman and to her foetus is a prerequisite for the womans ability to make a rational decision to enrol in a
clinical study. In this discussion, if participation in the research might be hazardous to a foetus or a woman
if she becomes pregnant, the sponsors/ investigators should guarantee the prospective subject a pregnancy
test and access to effective contraceptive methods before the research commences. Where such access is not
possible, for legal or religious reasons, investigators should not recruit for such possibly hazardous research
women who might become pregnant.
Guideline 17: Pregnant women as research participants.
Pregnant women should be presumed to be eligible for participation in biomedical research. Investigators
and ethical review committees should ensure that prospective subjects who are pregnant are adequately
informed about the risks and benets to themselves, their pregnancies, the foetus and their subsequent
offspring, and to their fertility.
Research in this population should be performed only if it is relevant to the particular health needs of a
pregnant woman or her foetus, or to the health needs of pregnant
women in general, and, when appropriate, if it is supported by reliable evidence from animal experiments,
particularly as to risks of teratogenicity and mutagenicity .
Guideline 18: Safeguarding condentiality
The investigator must establish secure safeguards of the condentiality of subjects research data. Subjects
should be told the limits, legal or other, to the investigators ability to safeguard condentiality and the
possible consequences of breaches of condentiality.
Guideline 19: Right of injured subjects to treatment and compensation
Investigators should ensure that research subjects who suffer injury as a result of their participation
are entitled to free medical treatment for such injury and to such nancial or other assistance as would
compensate them equitably for any resultant impairment, disability or handicap. In the case of death as a
result of their participation, their dependants are entitled to compensation. Subjects must not be asked to
waive the right to compensation.
589
Guideline 20: Strengthening capacity for ethical and scientic review and biomedical research
Many countries lack the capacity to assess or ensure the scientic quality or ethical acceptability of
biomedical research proposed or carried out in their jurisdictions. In externally sponsored collaborative
research, sponsors and investigators have an ethical obligation to ensure that biomedical research projects
for which they are responsible in such countries contribute effectively to national or local capacity to
design and conduct biomedical research, and to provide scientic and ethical review and monitoring of
such research.
Capacity-building may include, but is not limited to, the following activities:
establishing and strengthening independent and competent ethical review processes/ committees
strengthening research capacity
developing technologies appropriate to health-care and biomedical research
training of research and health-care staff
educating the community from which research subjects will be drawn
Guideline 21: Ethical obligation of external sponsors to provide health-care services
External sponsors are ethically obliged to ensure the availability of:
health-care services that are essential to the safe conduct of the research;
treatment for subjects who suffer injury as a consequence of research interventions; and,
services that are a necessary part of the commitment of a sponsor to make a benecial intervention
or product developed as a result of the research reasonably available to the population or community
concerned.
590
List of Contributors
1.
Abbo, Catherine (Dr.) - MBChB (Makerere), M.Med (Makerere), Staff Psychiatrist and Lecturer,
Butabika Mental Hospital, Kampala, Uganda
2.
Abdelrahman, Abdullah (Dr.) Lecturer, Department of Psychiatry, University of Khartoum,

Sudan
3.
Abdullahi Bekry, Abdulreshid (Dr.) - BSc (Public Health), MD, Psychiatrist; Associate Professor
of Psychiatry, Consultant Psychiatrist; Former Head of the Department of Psychiatry, Addis Ababa
University, Ethiopia
4.
Addo, Ama (Dr.) - Consultant in Child & Adolescent and Learning Disability Psychiatry, Glasgow
(UK). Recently completed an undergraduate lecture tour at the University of Ghana Medical School,
Ghana
5.
Akiiki, A.B.T. Byaruhanga (Dr.) BA, MA, PhD, Dept. of Religious Studies and Philosophy,
Makerere University, Kampala, Uganda.
6.
Albertyn, Lynda (Dr.) - Principal Specialist, Division of Psychiatry, Department of Neurosciences,

University of the Witwatersrand, Johannesburg, South Africa.
7.
Alem, Atalay (Dr.) - MD, PhD, Associate Professor of Psychiatry, Department of Psychiatry, Faculty
of Medicine, Addis Ababa University, Ethiopia
8.
Anonymous - BA, MA, PhD (University of California-Berkeley, USA) Professor of Economics and
United Nations Consultant Economist
9.
Atwoli, Lukoye (Dr.) MBChB (Moi) Kenya Registrar in Psychiatry Department of Psychiatry, Faculty
of Medicine, College of Health Sciences, University of Nairobi, Kenya
10. Basangwa, David (Dr.) - MBChB (Makerere), MMed (Makerere), Consultant Psychiatrist, Butabika
Mental Hospital, Kampala, Uganda
11. Chikovore, Jeremiah (Dr.) - MPH, PhD, Lecturer in Psychology, Department of Psychiatry, College
of Health Sciences, University of Zimbabwe, Zimbabwe
12. Dhadphale, Manohar (Prof.) - MBBS, DPM (Lon), MRCPsych (UK), MD (University of Nairobi),
FRCPsych (UK), FIPS (Ind), Associate Professor, Dept of Psychiatry, University of Nairobi, Kenya
Visiting Professor, Pune, India, Senior Volunteer of the College, Consultant Psychiatrist in Old Age
retired in 2001, India
13. Gakinya, Benson (Dr.) - MBChB (Moi), MMed (Psych) (Nrb): Lecturer, Department of Behavioural
Sciences and Mental Health, School of Medicine, Moi University, Kenya, Research Associate Africa
Mental Health Foundation Kenya. Recipient, Prof. David M. Ndetei, Meritorius Award, University of
Nairobi
14. Hailemariam, Damen (Dr.) - MD, PhD, Associate Professor, Department of Community Health,
Faculty of Medicine, Addis Ababa University, Ethiopia
15. Hawkridge, Susan (Dr.) - Principal Specialist: Department of Psychiatry, University of Stellenbosch,
Stellenbosch, South Africa
16. Haworth, Allan (Prof.) OBE, MB, FRCPsych, DPM Professor of Psychiatry, University of Zambia,
Zambia
17. Hogan, Nora M (Dr.) - BSc (Dublin), MPhil (York, U.K), MAClin. Psychology (Chicago, USA)
Doctorate in Clinical Psychology (PsyD) (Chicago U.S.A), Senior Lecturer, Department of Psychiatry,
Muhimbili University College of Health Sciences, Tanzania
18. Kaaya, Sylvia F. (Dr.) - MD (Dar), M.Sc. Psych (Manchester), Senior Lecturer and Head Department
of Psychiatry, Muhimbili University College of Health Sciences, Tanzania
591
19. Kangethe, Rachel (Dr.) - MMed (Nairobi) MBchB. (Nairobi), Lecturer Department of Psychiatry,
School of Medicine, College of Health Sciences, University of Nairobi, Kenya
20. Karani, Anna K. (Dr.) - PhD (Nrb), MA (Wheaton), BScN AWA (USA), Senior Lecturer, Department
of Nursing Sciences, University of Nairobi, Kenya
21. Kelly, Linda (Dr.) - Senior Specialist: Division of Psychiatry, Department of Neurosciences, University
of the Witwatersrand, Johannesburg, South Africa
22. Khasakhala, Lincoln (Dr.) - MBchB (Nairobi), MSc Clinical Psychologist, Hon. Ofcer, Department
of Psychiatry, University of Nairobi (Kenya), Research Associate Africa Mental Health Foundation,
Kenya
23. Kigozi, Fred (Dr.) MBChB (Makerere), M.Med (Makerere), Senior Consultant Psychiatrist &
Director, Butabika Mental Hospital, Kampala, Uganda
24. Kilonzo, Gad P. (Prof.) - BA (Macalester), MBChB (Makerere), MMed (Dar es Salaam), FRCP
(University of British Columbia), MD (University of British Columbia) Past head of department
of psychiatry and Muhimbili University College of Health Sciences. Also appointed Professor of
Psychiatry by Kariuki Memorial University and the Bugando University College of Health Sciences,
Tanzania. Recipient of the Sertirowf Award for work on Drug and Alcohol Abuse, Tanzania
25. Kitazi, Nelly (Dr.) - BSc, MBBS, M.Med Psychiatry (Nairobi), Assistant Director, Medical Service
Ministry of Health, Deputy Medical Superintendent, Mathari Hospital, Hon. Lecturer, Department of
Psychiatry, University of Nairobi, Kenya
26. Kokonya, Donald (Dr.) MMedPsych (Nairobi) MBchB (Nairobi), Consultant Psychiatrist, Kakamega
General Hospital (Kakamega), Kenya Research Associate Africa Mental Health Foundation, Kenya
27. Kuria, Mary (Dr.) - MBchB. (Nairobi), MMed (Nairobi), Lecturer Department of Psychiatry, School
of Medicine, College of Health Sciences, University of Nairobi, Kenya
28. Lule, Godfrey (Prof.) - MBCHB (Makerere), M.Med (Nairobi) Associate Professor of Medicine,
Consultant physician & Gastroenterologist, Department of Medicine, College of Health Sciences,
University of Nairobi, Kenya
29. Magimba, Ayoub R. (Dr.) - MD (Dar), MMed (Dar), Head Department of Psychiatry and Mental
Health, Muhimbili National Hospital(MNH), Lecturer in Department of Psychiatry, Muhimbili
University College of Health Sciences Tanzania
30. Maru, Hitesh M. (Dr.) - MB; BS, MMed Psych (Nairobi), Medical Superintendent Mathari Hospital,
Assistant Director of Medical Services, Ministry of Health Nairobi, Hon. Lecturer, University of
Nairobi, Kenya, Research Associate Africa Mental Health Foundation, Kenya
31. Mbewe, Edward (Mr.) - MPH, BA, Dip Sc. Principle Lecturer/Researcher, Chainama Hills College
Hospital, Zambia
32. Mburu, John (Dr.) - MBChB, M Med (Psych) (Nrb), Lecturer/Former Chairman Department of
Psychiatry, School of Medicine, College of Health Sciences, University of Nairobi, Kenya
33. Mkhize, Nhlanhla J. (Dr.) - PhD, Senior Lecturer, School of Psychology, University of Natal, P/B
X01, Scottsville, South Africa
34. Mohit, Ahmed (Dr.) - Mental Health Division, WHO Ofce, Cairo, Egypt
35. Morakinyo, O. (Prof.) - Professor in Behavioural Sciences, Obafemi Awolowo, University, Ile-Ife,
Nigeria
36. Mrumbi, Khalifa (Mr.) - BA Psych (Khartoum), MSc Psych (Harare), PhD Candidate (Norway),
Assistant Lecturer, Department of Psychiatry, Muhimbili University College of Health Sciences,
Tanzania
37. Mucheru, Monique (Dr.) - MBChB (Nairobi), Registrar in Psychiatry Department of Psychiatry,
Faculty of Medicine, College of Health Sciences, University of Nairobi, Kenya
592
38. Mugherera, Margaret (Dr.) MBChB (Makerere), MMed (Makerere), DPH (London), Consultant
Psychiatry, Mulango Hospital, Kampala, Uganda
39. Mulimba, Josphat A.O. (Prof.) - MBChB (Nairobi), MMed (Nairobi), FRCS Associate Professor,
Department of Orthopaedic Surgery, College of Health Sciences, University of Nairobi, Kenya
40. Musisi, Seggane (Dr.) - MBChB (Makerere), Diploma in Psychiatry (Toronto), FRCP(C), Senior
Consultant Psychiatrist and Head, Department of Psychiatry, Makerere University Medical School,
Mulago Hospital, Kampala. Uganda. Formerly visiting Fulbright New Centaury Scholar at Oregon
Health Sciences University, Portland, USA Senior Consultant Psychiatrist. York Central Hospital,
Richmond Hill, Ontario, Canada
41. Musoke, Rachel (Prof.) (Kenya) MBChB (East Africa), MMed (Makerere), Associate Professor,
Department of Paediatrics and Child Health, University of Nairobi, Kenya
42. Mutiso, Victoria (Ms.) - B.Psy. Counselling, (Nairobi) MSc Clinical Psychology Student, Department
of Psychiatry, University of Nairobi (Kenya), Research Associate Africa Mental Health Foundation,
Kenya
43. Nakasujja, Noeline (Dr.) - MBChB (Makerere), MMed (Makerere), Staff Psychiatrist and Lecturer,
Dept. Of Psychiatry, Makerere University Medical School, Mulago Hospital, Kampala, Uganda
44. Ndegwa, Japheth Mwenda Maj (Dr.) - MBChB (Moi), M.Med Psych (Nairobi), Chief of Psychiatry,
Armed Forces Memorial Hospital, Nairobi, Kenya
45. Ndetei, David M. (Prof.) - MBChB (Nairobi), DPM (Lond), FRCPsych (UK), MD (Nairobi), Professor
of Psychiatry, University of Nairobi & Founding Director, Africa Mental Health Foundation (AMHF),
Kenya
46. Ndosi, Noah K. (Dr.) - M.D (East Germany), Diploma in Psychiatry (East Germany), Associate
Professor, Department of Psychiatry, Muhimbili University College of Health Sciences (MUCHS),
Tanzania
47. Neema, Stella (Dr.) BA (Makerere) MA (Makerere), PhD (Denmark), Medical Anthropologist and
Senior Researcher, Makerere University Institute of Social Research, Kampala, Uganda
48. Ngare, Duncan (Prof.) BA, MPH, DrPH, Associate Professor of International Health, School of
Medicine, Moi University, Kenya
49. Obondo, Anne (Dr.) - B.A. (Delhi), MSW (Bombay), DIP. PSW (Manchester), PhD (Nairobi),
Lecturer, Department of Psychiatry, School of Medicine, College of Health Sciences, University of
Nairobi, Kenya
50. Okasha, Tarek (Prof.) - Institute of Psychiatry, Faculty of Medicine, Ain Shams University, World
Psychiatric Association Zonal Representative for Northern Africa 3, Shawarby Street, Kasr El Nil,
Cairo, Egypt
51. Okello, Elialilia S. (Ms.) - BA (Dar es Salaam), MA (Makerere), Anthropologist and Lecturer, Dept.
of Psychiatry, Makerere University Medical School, Kampala, Uganda
52. Oladimeji, Yetunde Benedicta (Prof.) - PhD, Professor in Behavioural Sciences, Obafemi Awolowo
University, Ile-Ife, Nigeria
53. Onen, Tom S. (Dr.) - MBChB (Makerere) MRCPsych (UK), Senior Consultant Psychiatrist, Butabika
Mental Hospital, Kampala, Uganda
54. Ongecha-Owuor, Francisca (Dr.) - MMedPsych (Nairobi), MBChB (Nairobi), Consultant Psychiatrist,
Coast Provincial General Hospital (Mombasa) Kenya, Research Associate Africa Mental Health
Foundation, Kenya
55. Othieno, Caleb (Dr.) - MBChB, MMed (Psych) (Nairobi), Senior Lecturer/ Chairman, Department of
Psychiatry, School of Medicine, College of Health Sciences, University of Nairobi, Kenya
56. Ovuga, Emilio (Prof.) - MBChB (Makerere), M.Med (Makerere), PhD (KI), Associate Professor of
Psychiatry, Department of Psychiatry, Makerere University Medical School, Kampala, Uganda
593
57. Owiti, Fredrick (Dr.) - MBCHB. (Nairobi), MSc (London), MRC., Psych. (UK) Lecturer, Department
of Psychiatry, School of Medicine, College of Health Sciences, University of Nairobi, Kenya
58. Rono, Ruthie (Prof.) - (Kenya) BA, Psychology, USA, MA, Psychology, University of Cincinnati,
USA, PhD, Psychology, Kenyatta Associate Professor of psychology & Dean, School of Arts &
Sciences, United States International University, Nairobi, Kenya
59. Rotich, Joseph (Prof.) - PhD, MSc, BSc, Associate Professor of Biostatistics, Currently the Dean
School of Public Health, Moi University, Kenya
60. Ruttoh, James (Mr.) - Assistant Lecturer of Statistics, Department of Mathematics, Moi University,
Kenya
61. Sartorius, Norman (Prof.) MD, FRCPsy (UK), PhD, Dsc, Professor of Psychiatry, Department of
Psychiatry, University of Geneva Switzerland. Formerly Director, Division of Mental Health, WHO
Geneva; Past President World Psychiatry Association
62. Sebit, Mohamedi Boy (Prof.) - MBChB, MSc. Med. Neuropsy, PhD, Associate Professor, Department
of Psychiatry, University of Zimbabwe, Zimbabwe.
63. Szabo, Christopher P. (Prof.) - MBBCh, M Med, FCPsych, PhD, Chief Specialist, Professor &
Head of Clinical Psychiatry, Division of Psychiatry, Department of Neurosciences, University of the
Witwatersrand, Johannesburg, South Africa
64. Too, Robert (Mr.) - MSc, BSc, Assistant Lecturer in Biostatistics, Department of Epidemiology and
Nutrition, Moi University, Kenya
65. Ulzen, Thaddeus P. M. (Prof.) -Thaddeus P.M.Ulzen MD FRCP(C) FGCP FAPA, Professor &
Chair, Department of Psychiatry and Behavioral Medicine, College of Community Health Sciences,
University of Alabama School of Medicine, Visiting Scholar at the University of Ghana Medical
School, Foundation Fellow of the Ghana College of Physicians and Surgeons, and Member of the
External Faculty in Psychiatry.
66. Uwakwe, Richard (Dr.) - MBBS, FWACPsych, FMCPsych Senior Lecturer in Mental Health, Faculty
of Medicine, Nnamd Azikiwe University, Nigeria and Consultant Psychiatrist, Nnamdi Azikiwe
University Teaching Hospital Mmwi, Nigeria. Co- Ordinator, 1066 International Dementia Research,
African Region
67. Wagoro, Miriam (Ms.) - BSc Nursing, Student, University of Nairobi
68. Workneh, Fikre, M.D. (Dr.) Associate Professor of Psychiatry, Former Head, Department of
Psychiatry, Addis Ababa University, Ethiopia.
69. Zergaw, Ababi (Mr.) - BSc, MPh, Department of Community Health, Faculty of Medicine, Addis
Ababa University, Ethiopia
594
Index
A
Auditory hallucination 161

Auras 352, 353, 354
Autistic disorder 417, 418, 419, 447
Automatism 349, 350, 371, 372, 374
Autonomous phase 38
Autonomy 37, 53, 99, 379, 512, 568, 570
Autosomal chromosomal abnormality 150
Autosomal dominant motor disorder 131
Aversive conditioning 57
Avoidance-avoidance conict 76
Avoidance training 57
Avoidant personality disorder 279, 284, 422
Abortion 33, 508, 571

Acetylcholine 136, 140, 365, 389, 483
Addiction 56, 58, 186, 484, 543, 555
Addisons disease 142
Adjustment disorders 214, 226, 227, 411, 438, 509
Adolescence 22, 25, 43, 44, 45, 54, 166, 179, 184, 270, 293,
379
Adoption studies 148, 149, 291
Aggression 129, 277, 286, 371, 386, 405, 406, 407
AGIL function 97
Agoraphobia 218, 220, 284, 321, 323, 431, 434, 435, 483,
500
Agraphia 129, 130
Akathisia 131, 137, 139, 158, 488,
Alcohol abuse 145, 231, 371, 376, 382, 509
Alexia 129
Alpha activity 144
Amenorrhoea 33
Amitriptyline 213, 322, 471, 483
Amnesia 63, 64, 186, 222, 315, 338, 351, 382, 396, 451,
485, 492
Amnion chorion 32
Amphetamine 65, 213, 230, 237, 294, 300, 398, 426, 471
Amygdala 62, 128, 129, 140, 291
Anal stage 40, 53
Anger 24, 47, 52, 79, 108, 158, 177, 386, 461, 516, 541
Anhedonia 158, 242, 292, 322, 438
Animism 38
Anorexia nervosa 184, 312, 454, 455, 457, 500, 513
Anterograde amnesia 64
Anticholinergics 315, 488
Anticonvulsants 358, 386, 398, 490
Antidepressants 119, 120, 139, 140, 212, 213, 280, 386, 412,
426, 429, 440, 444, 482
Antidiuretic hormone 59, 233, 487
Antihistamines 226, 251, 398, 485, 488
Antipsychotics 142, 440, 443, 444, 480, 481
Antisocial personality disorders 299, 380, 555
Anxiety disorders 58, 176, 177, 183, 188, 214, 284, 323,
380, 431, 432, 434
Anxiolytics 119, 230, 282, 284, 485
Aphasia 128, 129, 160, 341, 350
Approach-approach conict 76
Approach-avoidance 76
Articialism 38
Art therapy 502, 525
Assessment interview 83
Associative learning 56
Associative phase 38
Attachment theory 154
Attention Decit Hyperactivity Disorder (ADHD) 410, 423,
488
Auditory decit 42
B
Basal ganglia 130, 137, 140, 291, 425, 446
Behaviour
analysis 31, 296, 501
genetics 31
therapy 55, 58, 178, 183, 226, 266, 278, 499, 501
Behavioural
disorders 19, 95, 150, 321, 361, 563, 565, 589
sciences 4, 11, 13, 100, 565
theory 37, 60
Benzodiazepine 140, 212, 226, 244, 315, 323, 334, 362,
365, 435, 444, 485
Bereavement 73, 81, 84, 102, 154, 157, 199, 226, 296, 326,
363
Beta activity 144
Binet, Alfred 69
Binet-Simon scale 69
Biogenic neurotransmitters 135
Biologic learning 55
Biopsychosocial model 12, 13, 154, 168, 169, 183, 312,
325
Biostatistics 551
Bipolar disorders 157, 203, 212, 213, 440, 486, 495
Blastocysts 32
Blood brain barrier 127, 131, 479
Body dysmorphic disorder 174, 183, 300, 442
Borderline personality disorders 278, 282, 396, 498
Boundary crossing 570
Boundary violation 570
Bowlby 154
Bradycardia 237, 490
Brain
fade 64
imaging 125, 146, 294
maturation 34
stem 126, 133, 332, 484
Bride price 104
Bronchial asthma 11, 399
Buddhism 115
Bulimia nervosa 219, 454, 455, 456, 458
Burnout 79
595
The African Textbook of Clinical

IndexPsychiatry and Mental Health
Commissural tracts 125

Community psychiatry 522, 526, 527
Comparative psychology 31
Compensation 26, 78, 343, 369, 400
Computed tomography (CT) 126, 144, 145
Concept development 35, 38
Conditioned discrimination 56
Conduct disorders 430, 439, 505, 514
Confabulation 63, 161, 335, 338
Condentiality 72, 162, 368, 379, 514, 567, 571
Conict and adjustment 76
Congenitally organised behaviour 34
Conjoint therapy 514
Conservation 41, 352
Conversion disorder 116, 174, 177, 181, 312, 315, 381
Coping strategies 326
Corpus callosum 125
Counter-transference 11, 79, 117, 118, 121, 497, 536, 570
Couvade syndrome 33
Critical incident stress debrieng (CISD) 85, 86
Culture-bound disorders 33, 109, 119
Cushings syndrome 142
CYP1A2 470
CYP2D6 471
CYP3A4 471
Cannabis sativa 9, 235

Cannons theory 61
Carbamazepine 295, 298, 322, 349, 355, 356, 428, 440, 487
Cardinal trait 49
Cardiovascular disease 3, 52, 364, 399
Cataplexy 158, 392
Catatonia 145, 158, 316, 440, 442, 489
Catecholamines 136, 363, 483
Cattells sixteen personality 49
Central nervous system 125, 149, 233, 324, 470
Central trait 49
Centring 41
Cerebellum 62, 130, 133
Cerebral cortex 126, 128, 133
Cerebral malaria 9, 346, 358, 362
Cerebrospinal uid (CSF) 135
Ceruloplasmin 132
Channels of communication 67
Character 49, 156, 157, 278, 279
Chiarugi, Vincenzo 7
Child-headed family 92
Childhood disintegrative disorder 417
Child
abuse 39, 78, 269, 306, 368, 383, 388, 415, 450, 520,
571
discipline 39
guidance clinics 8
Chiropodists 8
Choleric 6, 48
Cholinesterase inhibitors 315
Choreiform movements 131, 341
Christianity 115
Chromosomes 147, 149
Chronicity 18, 179
Chronic ailments 26
Chronic fatigue syndrome 109
Chronobiology 142
Circadian sleep-wake rhythms 390
Circannual cycle 143
Circaseptan cycle 143
Circulatory system 32, 107
Civil law 369
Classical conditioning 55, 56, 499
Class concept 35
Clomipramine 184, 470, 471, 483
Clonidine 139, 426, 427, 447, 478, 488
Closing phase 88, 164
Co-ordination of secondary schemes 35
Cocaine 229, 230, 240, 242, 252, 300
Cognition 35, 178, 278, 364, 365, 408, 435, 485, 496, 544
Cognitive
behaviour therapy 183, 226, 440, 443, 504, 505, 539
developmental theory 37
disorders 314, 330
disturbances 161, 487
functions 167, 332, 335, 343, 345, 365, 390
learning 55
learning theory 57
phase 38
problems 21, 544
psychology 31
theory 61
Coma 8, 157, 166, 167, 307, 337, 383, 385, 487
Commentary voices 161
D
Defence mechanisms 43, 50, 77, 169, 278, 281
Defensive coping 84
Delirium tremens 9, 234, 314, 382
Delta activity 144
Delusional disorders 159, 296, 299
Dementia 7, 130, 299
Demonology 6
Denial 47, 50, 78, 129, 376, 543, 544
Deoxyribonucleic acid (DNA) 147, 148
Dependent personality disorder 284
Depersonalisation disorder 186, 188
Depression 15, 19, 27, 34, 47, 108, 131, 191
Derealisation 157, 167, 280
Descriptive psychopathology 157
Detoxication 251, 252, 323, 488
Developmental psychology 31, 404
Deviance Theory 98
Dexamethasone 471
Dhat syndrome 120
Diabetes mellitus 18, 170, 258, 317, 342, 399, 474, 482
Dialectical thought 45
Diazepam 15, 16, 244, 384, 471, 485, 569
Digestive system 32, 41, 107, 233, 499
Diminished responsibility 372, 373
Direct coping 84
Disabilities 429
Disclosure 72, 270, 326, 368, 452, 569, 570
Discriminatory practices 23
Disease without illness 103, 104
Disequilibrium 80
Disorders of content of thought 158
Disorders of control of thought (alienation) 160
Displacement 50, 77, 332
Disruptive behaviour 382, 383, 419, 423, 425
Dissociative
disorder 181, 302, 424
fugue 186, 187, 315, 382
identity disorder 187, 451
Distractibility 157, 406, 439
596
Index
Divorce 94, 154, 165, 226, 265, 306, 309, 411, 516, 538
Dizygotic (DZ) twins 148, 149, 199, 425, 446
Dopamine 131, 136, 137, 142, 153, 364, 425, 446, 481, 483,
489
Double-approach-avoidance conict 76
Down Syndrome 150
Dream anxiety disorder 390, 395
Drive Reduction Theory 60
Drug abuse 84, 93, 96, 98, 231, 290, 376, 425, 433, 495,
501, 512
Dual encoding systems 64
Dynamic psychopathology 156
Dysarthria 132, 160, 166, 340, 341, 343, 487
Dyscalculia 42, 339, 362
Dysgraphia 42, 339
Dyslexia 42, 129
Dysmegalopsia 160
Dyspareunia 182, 261, 262, 263
Dysphoric mood 158, 238, 239
Dysthymic disorder 191, 397, 437, 438
Experience factors 110

Exploratory behaviour 60, 408
Extended family 9, 25, 39, 92, 93, 111, 165, 404, 512
Extinction 56, 97, 500
Extraversion 51
F
Factitious disorders 181, 315
Fact phase 86
Fahr syndrome 130, 132
Faith 13, 22, 75, 103, 108, 116, 120, 326, 386, 532
Family
functions 513
history 81, 82, 111, 131, 163, 165, 190, 291, 315, 379,
439, 442
problems 93, 252, 452, 513, 514
studies 148
therapy 295
types 92
Fantasy 40, 72, 160, 222, 267, 269, 279, 288, 406, 441
Febrile convulsions 350, 351, 356, 533
Feedback 43, 68, 296, 427, 435, 484, 540, 543
Fetishism 254, 270, 375
Fibromyalgia 399
Fitness to plead 367, 372
Flooding 435, 500
Fluid intelligence 46, 47
Folie Deux 299
Forgetting 35, 62, 64
Fragile X syndrome 150, 414
Freud, Sigmund 8, 40, 43, 49, 60, 153, 154, 156, 278, 496,
497
Frontal lobe 128, 340, 341, 343, 346, 425
syndrome 128, 343
Frotteurism 268
E
Early adulthood 45, 46, 174, 217, 221, 272
Early childhood 37, 38, 39, 40, 45, 79, 153, 186, 269, 436
Eating disorders 148, 184, 276, 397, 433, 454, 456
Echopraxia 158, 302, 316
Eclecticism theory 496
Ectoderm 32
Ego 43, 49, 50, 77, 115, 153, 156, 277, 509
Egocentrism 38, 41, 45
Eidetic images 63
Electra complex 40, 54
Electrical stimulation 64, 490, 491, 492
Electrocardiogram (ECG) 144, 363, 440, 447, 487, 490
Electroconvulsive therapy (ECT) 63, 64, 211, 295, 298, 363,
368, 384, 489, 495
Electroencephalography (EEG) 71, 144, 145, 269, 278, 348,
350, 356
Electromyogram (EMG) 144, 178, 491
Elimination disorders 460
Embryonic disk 32
Emotional development 37, 39, 42, 405
Emotional disorders 234, 383, 527
Empathy 118, 163, 283, 507, 509, 536, 544
Encephalopathy 321, 335, 337, 346, 350
Endocrine system 75, 142, 191
Endoderm 32
Environmental factors 48, 57, 167, 199, 203, 231, 287, 385,
411, 456, 460, 461
Epidural haematoma 127
Epilepsy 302, 348, 356, 357, 358, 371, 376, 395
Episodic memory 62
Erectile disorder 258, 259, 265
Ericksons psychosocial theory 52
Eros 60
Escape learning 57
Ethnocentrism 102
Ethological theory 37
Ethosuximide 354, 355
Euphoria 158, 236, 239, 335, 343
Euthanasia 559
Euthymic mood 158
Evil spirits 9, 22, 108, 110, 351
Evoked potentials (EP) 145
Exhibitionism 268, 270, 450
Expectancies 52
G
GABA 116, 140, 291, 487
GAF scale 171
Galactosaemia 150
Gender
identity disorder 184, 274
roles 37, 93, 275
stereotypes 275
Generalised anxiety disorder 214, 216, 321, 323, 392, 396,
432, 483
Generativity 53, 154
Gene abnormalities 150
Germinal period 32
Gerstmanns syndrome 129
Gestalt therapy 503
Glia 127
Glucose dehydrogenase deciency 150
Goitre 27, 487
Group therapy 4, 268, 281, 296, 362, 510, 514, 515, 520,
525, 539
Guidance-co-operation 99
G protein receptors 136
H
Hallucinations 116, 129, 137, 157, 161, 172, 199, 236, 291,
362, 407, 439, 537, 538
Hallucinogens 230, 246, 330
Head injury 63, 64, 130, 294, 335, 337, 339, 343, 346, 351
Health belief model 96, 475
597

Health seeking behaviour 96, 110

Heredity 147, 176
Heroin 139, 230, 231, 238, 252
Hinduism 115
Hippocampus 62, 63, 128, 140, 291, 338
Hippocrates 33
History taking 26, 211, 351, 353, 357, 361, 365, 416, 441,
578
Histrionic personality disorder 281
HIV/AIDS 3, 18, 92, 97, 104, 143, 239, 242, 245, 294, 342,
364, 411
Holophrase 36
Homeostasis 60
Homicide 81, 351, 371, 372, 386, 387
Homosexuality 254, 256, 268
Humane reform 7
Humanistic theory 60, 496
Huntingtons chorea 64, 130, 131, 141, 312, 339, 341, 447
Hydrocephalus 126, 364
Hyperactivity 544
Hyperemesis 337
Hypersomnia 193, 322, 391, 393, 400
Hypertension 11, 46, 250, 317, 342, 346, 415, 426, 447, 483,
500
Hyperthyroidism 142, 317
Hyperventilation 103, 176, 178, 317
Hypervigilance 157
Hypnagogic hallucinations 160
Hypnosis 31, 63, 106, 157, 501
Hypnotherapy 178, 188
Hypochondria 103
Hypochondriasis 174, 179, 180, 363
Hypomanic episode 200
Hypotension 139, 427, 482, 488
Hypothalamus 59, 132, 133, 138, 140, 142
Hypothyroidism 142, 258, 317, 364, 415, 487
Hypotonia 33
Hysteria 8, 9, 71, 174, 180, 302, 383
Inter-ventricular foramina 126

Interpersonal relationships 73, 163, 186, 280, 306, 308, 323,
326
Intra-psychic factors 81, 113, 156, 268
Introjections 78
Introversion 51, 71
Intuitive thought stage 41
Ion-linked receptors 136
Islam 115
J
James-Lange theory 61
Judaism 115
Judgement 102, 161, 167, 251, 332, 538, 543, 569, 571
Justice 367, 386, 387, 561, 565, 568, 569
K
Khat 213, 236, 294, 362
Kline Felters syndrome 150
Kluver Bucy syndrome 129
Korsakoffs syndrome 129
Kraeplin Emil 8
Kuhn, Roland 8
L
Laissez-faire 43
Language
decit 42
development 36, 39, 42, 44, 409, 422
disorders 433
Lateral hypothalamus 59
Late adulthood 47, 53
Lawsuit 371
Laycock, Thomas 7
Lazarus syndrome 327
Learning
disabilities 42, 415, 425, 427, 428, 429, 442, 505
problems 393, 461
theories 55, 58, 60
Lesch Nyan syndrome 150
Lewy body dementia 364
Liability 340, 371
Lilliputine hallucinations 160
Listening 67, 68, 88, 117, 163, 266, 307, 507, 509, 520, 536
Lithium 139, 295, 315, 322, 383, 440, 445, 480, 486, 490
Locomotion 35, 341
Locomotor problems 27
Locus of control 52, 117
Long-term memory 35, 62, 63, 161
Lorazepam 315, 323, 444, 485
Lowered quality of life 19
Low back pain 27, 270, 317
Lysergic acid diethylamide (LSD) 246, 398
I
Id 49, 50, 77, 153, 156
Idiocy 7
Illness behaviour 5, 23, 96, 98, 103, 108, 177
Illness without disease 103
Imaginary audience 45
Imipramine 8, 322, 384, 426, 461, 471, 483
Immanent justice 38
Immuno-suppression 154
Implicit memory 62
Implosion 500
Impotence 258, 400, 500
Incentive (Behavioural) Theory 60
Incest 256, 262, 273
Independence 24, 25, 40, 42, 43, 296, 309, 354, 431, 435
Indifferent gonad 32
Infancy 34, 36, 37, 53, 117, 154, 350, 354, 379, 425, 435
Infertility 33, 94
Informed consent 367, 368, 371, 443, 447, 560, 562, 563,
564, 565, 568, 569, 571
Infradian cycle 143
Inhalants 230, 242
Insomnia 88, 120, 172, 212, 226, 234, 245, 322, 362, 390,
400, 480
Instincts 37, 50, 60, 153, 158, 278, 507
Intellectualisation 50, 285
Intelligence tests 69, 70
M
Madonna complex 33
Magnetic Resonance Imaging (MRI) 71, 144, 145, 438
Magneto-encephalography (MEG) 144
Malingering 64, 71, 181, 186, 315
Malpractice 117, 368, 370, 371
Mamillary 132, 335, 337, 338
Marijuana 235, 239, 398
Marital
history 166, 373
instability 18, 95
598
Index
problems 93, 501

Masochism 254, 271, 286
Masturbation 166, 256, 267, 268, 271, 272, 302, 578
Maternal
competence 33
nutrition 26, 425
Medulla oblongata 126, 133
Melancholia 7, 438
Melatonin 132, 400, 485
Memory
decit 42, 333, 334
loss 338, 339
Meninges 127, 360
Meningitis 127
Mental
combinations 35
derangement 108
development 35, 38, 41, 44, 45, 46
status examination 31, 164, 166, 167, 168, 180, 291, 313,
383, 434
Meprobamate 244
Mesepencephalon 126
Mesoderm 32
Metacognition 35, 42
Metamemory 35
Methadone 252, 323, 488
Micropsia 160, 247
Middle adulthood 46
Middle childhood 40, 41
Mini-mental status examination 167
Minnesota Multiphasic Personality Inventories (MMPI) 71
Miraa 236, 362
Modelling 57
Monoamino Oxidase Inhibitors (MAOIs) 139, 482, 483,
488, 490
Monomorphic genes 147
Monozygotic (MZ) twins 147, 148, 277, 288, 446
Moral realism 42
Moral relativism 42
Moro 34
Morphine 142, 238, 277
Motor
behaviour 128, 158, 465
skills disorder 463
skill development 38, 41, 44
Multiple personality disorder 187
Multiple sleep latency 390
Murray, Lindley 7
Myths 21, 116, 266, 305, 359, 505
Neuropsychological tests 69, 71

Neurotensin 135, 141
Neuroticism 51, 433
Neurotransmitters 116, 135, 140, 142, 277, 291, 364, 479,
483
Newborn 34, 326
Nicotine 13, 65, 230, 248, 398, 448, 484
Nigrostriatal pathways 142
Non-axial format 173
Non-verbal communication 67, 68, 162, 495, 579
Noradrenaline reuptake inhibitors 484
Norepinephrine 138, 139, 426, 482, 483
Noxious stimulus 58
Nuclear family 25, 92, 117, 165
Nuremberg Code 560
O
Obsession 160, 217, 220, 386, 433
Obsessive compulsive disorder 214, 221, 433, 442, 495,
505
Occipital lobe 126, 130
Oedipus complex 40, 53
Oestrogen 43, 46, 142, 265, 455
Olfactory and gustatory hallucinations 161
Operant conditioning 55, 56, 57, 178, 435, 499
Operant learning 55
Oppositional deant disorder 423, 425, 428, 429
Oral stage 37, 53
Orgasmic disorders 260, 267
Orientation 128, 167, 168, 388, 536, 542
Osmoreceptors 59
Oxytocin 142
P
Paedophilia 268, 269, 375
Palliative care 328
Palmer grasping 34
Panic disorder 214, 216, 217, 218, 319, 381, 431, 433, 434,
483
Papillary reex 34
Paranoia 71, 107, 236, 244, 282, 299, 355, 363, 537
Parasomnia 390, 391, 392, 397, 400
Paraventricular nuclei 132
Parietal lobe 129, 184, 291, 338, 339, 350
Parkinsons disease 130, 131, 137, 142, 400
Partialism 273
Paternalism 568, 569
Pavlov, Ivan 55
Peer pressure 40, 231, 452
Peptic ulcers 11
Permissive control 39
Personal
fable 45
history 165, 325, 346, 379
Personality
development 25, 37, 43, 46, 50, 52, 53
disorders 169, 277, 279, 282, 283, 284, 286, 373, 375
needs 11
patterns 71
psychology 31
tests 69, 71
theories 48
traits 4, 48, 49, 277, 278, 306, 346, 388, 451
types 31, 48, 71
Phallic stage 40, 53, 54
Pharmacokinetics 478, 486
N
Narcissistic personality disorder 170, 283
Narcolepsy 157, 390, 392, 400, 483
Necrophilia 273
Negative discipline 26
Neuro-messengers 134, 135
Neuro-modulators 135
Neurochemical activity 126
Neurochemical studies 153
Neurochemistry 5, 125
Neurological disorders 130, 186, 261, 398
Neurons 34, 62, 127, 128, 130, 133, 134, 135, 136, 137, 153,
291, 389
Neuropathology 291
Neurophysiology 125
Neuropsychiatric disorders 153, 433
599

Phenobarbital 351, 471

Phenobarbitone 351, 354, 355, 356, 358, 359
Phenylketonuria 150, 425
Phenytoin 349, 354, 355, 358, 359, 471
Phlegmatic 48
Phobic disorders 214, 362
Physical
abuse 171, 439, 452
development 34, 37, 40, 43, 45, 46, 47
Physiological responses 59, 75, 214, 318
Piaget, Jean 35, 38, 42
Pia mater 127
Pinel, Phillipe 7
Plato 6
Play 7, 40
therapy 435, 502
Polypeptide chains 136
Polysomnography 144, 145, 390, 391, 395, 396, 400
Pons 126, 133, 138, 389
Positive discipline 26
Postpartum psychosis 34, 301
Postural patterns 38
Pre-moral stage 42
Pre-schoolers 25, 38, 39, 435
Pregnancy 32, 185
sexual behaviour 33
Prehension 35
Premature ejaculation 260, 261, 267
Prenatal exposure 22
Primary circular reactions 35
Primitive reexes 34
Proactive inhibition 64
Probands 148, 149
Progesterone 43
Projection 50, 78, 266, 278, 300, 498, 543
Projective Techniques 72
Prolactin 137, 178, 482
Property offences 374
Propranalol 428, 470, 471
Pseudocyesis 33, 185
Psychiatric
assessment 164, 176, 372, 379, 404
classication 168
interview 162, 164, 376
report 372, 373, 379
social worker 8
Psycho-education 23, 183, 211, 266, 388, 443, 444, 476
Psychoanalytic theory 37, 49, 50, 60, 153, 154, 278, 496
Psychodrama 510
Psychoendocrinology 142
Psychogenic 114, 183, 186, 256, 262, 265, 296
Psychoimmunology 143
Psycholinguistics 36
Psychological debrieng 85
Psychopathic 21, 71, 372
Psychophysiology 31, 254
Psychosis 9, 21, 107, 130, 145, 234, 296, 314, 382, 440,
544
Psychosocial
disorders 11, 113, 324
theory 154
Psychosomatic disorders 11, 103, 312, 317, 330, 500, 501
Psychotherapy 426, 496, 501, 510, 526, 540, 570
Psychotic
disorders 150, 294, 371, 411, 439, 479, 482, 544
symptoms 21
Psychotropics 33, 470, 479, 480
Puberty
16, 43, 44, 166, 256, 352, 433, 578
Q
Qualitative mental dimension 45
Quantitative mental dimensions 45
Quantitative reasoning 70
R
Rape 105, 202, 222, 251, 258, 262, 275, 276, 374, 384, 570
Rapid eye movement 145, 389, 392, 394, 396
Rationalisation 50, 63, 77, 285
Re-entry phase 87
Re-integrative process 63
Reaction formation 50, 78, 285
Reaction phase 86
Reaction to loss 516
Reactive Attachment Disorder 436
Reality therapy 502
Recall and recognition 62
Reciprocal determinism 51
Reduced productivity 19
Reexes 34, 243, 341, 342, 536
Refugees 111
Rehabilitation 21, 22, 31, 68, 251, 295, 328, 373, 457, 495,
526
Relapse 181, 211, 213, 251, 295, 323, 443, 486, 491, 522,
543, 544
Relativism 42, 102, 108, 109
Relaxation training 178, 267, 435, 500, 501, 525
Relearning 63, 65, 524
Religious healing 116
REM sleep behaviour disorder 389, 392, 395, 397, 438
Repression 50, 64, 77, 281
Research methods 550
Respiratory system 41, 46, 108, 317, 499
Retention 40, 62, 63, 64, 315, 362
Reticular activating system 133, 331
Retrieval 46, 62, 63, 64, 128
Retroactive inhibition 64
Reversibility 41
Reward training 57
Right to refuse 369
Rigidity 131, 132, 137, 285, 343, 434
Ritual 6, 9, 78, 102, 121, 188, 452, 517
Role reversal 25
Rotters theory 52
S
Sadism 268, 272, 286, 375
Sakel, Manfred 8
Sampling 550, 555, 556, 557
Sanguine 6, 48
Schizoaffective disorder 194, 289, 294, 297, 298, 439
Schizophrenia 18, 21, 130, 149, 204, 205, 206, 207, 208,
299, 371, 386, 443
Schizophrenic illnesses 9
Schizophreniform disorder 194, 203, 205, 298, 441
Schneider, Kurt 289
School inuences 40, 43
Seasonal affective disorder 211
Secondary circular reactions 35
Second order conditioning 56
Second person hallucinations 161
Second trimester 32
Sedatives 8, 244, 362, 395, 485
Selective inattention 157
600
Index
Selective mutism 433, 435

Self-actualisation 11, 50, 60
Self-diagnosis 15
Self-esteem 21, 40, 50, 95, 176, 256, 283, 326, 435, 439,
523, 539, 544
Self-iniction 81
Self-intentional cessation 81
Self-perceptions 50, 96
Self Theory 50
Semantic
development 42
memory 62
Sensorimotor 35, 60, 174, 407
Sensory
capacities 34
deceptions 160
distortions 160
Separation anxiety disorder 216, 218, 220, 431, 432
Serialisation 41
Serotonin 116, 133, 139, 153, 199, 322, 457, 482, 484
Sex-linked disorders 150
Sexual
behaviour 13, 33, 44, 60, 254, 256, 276, 375, 452
differentiation 32
exploitation 383, 450, 451, 570
history 166, 325, 376
offences 21, 371, 374, 375
pain disorders 261
response 254, 255, 265, 266
Stereotypes 111, 275, 419, 421

Stigma 16, 20, 22, 23, 97, 252, 263, 268, 287, 323, 358, 373,
442, 473, 482
Stressors 31, 73, 83, 170, 176, 199, 226, 288, 383, 404
Stress reaction phase 87
Stupor 157, 166, 167, 211, 312, 314, 382
Sub-dural haematoma 27, 127, 330, 343, 362, 364
Subarachnoid haemorrhage 64, 335, 338, 346
Subcortical dementia 132, 321
Sublimation 50, 78
Substance abuse 21, 61, 83, 161, 177, 203, 230, 234, 251,
371, 411, 426, 439, 441, 444, 543
Suicide
attempt 194, 199, 304, 313, 314, 324, 382, 439, 539
behaviour 84, 153, 211, 305, 306, 309, 310
plan 307, 308
prevention 304, 307, 540
risk 33, 213, 307, 308, 309, 363, 439, 486
successful 304, 308, 309, 540
wish 307, 308
Superego 49, 50, 77, 153, 156
Supra-chiasmatic 132, 143
Survival reexes 34
Sydenham,Thomas 7
Symbolic functioning 38, 41, 407, 408
Synapse 134, 136, 139
Systemic lupus erythematosus (SLE) 143, 176
Sex roles 93
Short-term memory 46, 62, 63, 70, 202, 364, 542
Sibling relations 39, 46
Sick Role Theory 99
Signal transduction 134
Simon,Theodore 69
Single parent family 92, 411, 431
Single photon emission tomography 145
Situational crises 80, 81
Sleepwalking disorder 390, 392, 396
Sleep paralysis 392, 396, 397
Sleep terror disorder 390, 394
Smoking 46, 52, 61, 102, 231, 239, 240, 287, 501
Social
cognition 36
cognitive theories 51
conict theory 97, 98
development 36, 42, 45, 443, 508
learning 36, 55, 496
learning theory 37, 57, 500
phobia 139, 184, 219, 432, 485, 505
psychology 4, 31
skills decit 42, 501
skills training 273, 295, 296, 386, 426, 440
Socialisation 36, 93, 165, 522, 537
Sodium valproate 322, 354, 355, 384, 444, 487
Somatisation disorder 148, 174, 179, 181, 216, 261, 281,
315, 425
Somatoform disorders 58, 169, 174, 175, 177, 183, 186,
533
Somatostatin 141
Spatial concepts 35, 41
Speech disorders 425, 441
Spirituality 5, 115, 118, 122
Stagnation 53
Tachycardia 17, 236, 241, 246, 250, 395, 426, 488

Tactile hallucinations 161, 332
Tardive dyskinesia 137, 142, 371, 435, 447, 474, 481, 482
Temperament 49, 59, 153, 277, 409, 425, 428, 430, 434
Temporal lobe 128, 160, 300, 312, 338, 352
Teratogenic effects 33
Tertiary circular reaction 35
Testosterone 43, 277
Thalamus 132, 133, 138, 142, 337, 338
Thanatology 81
Thanatos 60
Theta activity 144
Third person hallucinations 161
Third trimester 32, 33
Thought
phase 86
process 166, 537, 538, 539, 541
Toddlerhood 34, 36, 37
Tolerance 175, 228, 230, 236, 245, 267, 361, 384, 406, 511,
515
Tomographic images 146
Total disability 19
Tourettes Disorder 447
Traditional healers 9, 105, 119, 122, 188, 211, 212, 358, 531,
532
Trait theories 48, 49
Trance 157, 188, 302, 451
Tranquilisers 9, 119, 231, 383, 387
Transductive reasoning 41
Transference 9, 11, 79, 117, 121, 315, 497, 498, 570
Transformational reasoning 41
Transvestism 271
Trauma 26, 343, 407, 415, 425, 518, 544, 554, 557
Tricyclic antidepressants 139, 211, 213, 258, 322, 326, 385,
426, 440, 447, 485
601

Trimipramine 471, 483

Triple X 150
Trypanosomiasis 9, 330
Tuberculoma 27
Tuberculosis 18, 320, 324, 382, 483, 510
Tuke, William 7
Turners Syndrome 150
Twin studies 148, 149, 418, 425, 438
Type A personality 51, 52
Type B personality 52
Type C personality 52
reasoning 70
Violence 18, 21, 81, 84, 104, 139, 153, 221, 234, 275, 376,
385, 387, 480, 514, 520
Violent
behaviour 21, 240, 538
offences 375
Visual hallucinations 161, 291, 331, 362, 364, 365, 382
Visual system 36
Vocal tic disorder 448, 449
Vocational
and psychosocial assessments 31
impairment 88
rehabilitation 251, 252, 522, 524
therapies 282
Voyeurism 268
U
Ultradian cycle 143
Ultrasound 32
Universalism 108, 109
Urbanisation 18
Utilitarianism 568
W
Wechsler Scales 70
Will 72
Wilsons disease 130, 132
Witchcraft 9, 22, 116, 154, 211, 305, 328
Withdrawal 88, 139, 209, 230, 233, 239, 242, 245, 251, 314,
321, 382, 442
V
Vaginismus 261, 262, 267
Valium 15, 16, 244, 252, 278
Valproic Acid 487
Variables 551
Vascular dementia 209, 330, 342, 345, 364, 365
Vasopressin 135, 141, 142
Ventricular system 126
Ventromedial
hypothalamus 59
lesions 59
Verbal
communication 67, 68
X
XYY Abnormality
Z
Zygote
602
32, 147
150

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THE AFRICAN TEXTBOOK OF

CLINICAL PSYCHIATRY AND

The African Textbook of Clinical Psychiatry and Mental Health

THE AFRICAN TEXTBOOK OF

THE AFRICAN MEDICAL AND RESEARCH FOUNDATION

The African Textbook of Clinical Psychiatry and Mental Health

The African Medical and Research Foundation (AMREF)

2006 The African Medical and Research Foundation

Illustrations and cover design by Elijah Njoroge

The African Textbook of Clinical Psychiatry and Mental Health

In memory of my late father, John Ndetei Nzuki

The African Textbook of Clinical Psychiatry and Mental Health

Section I: Psychiatry and Mental Health in Context

Introduction to Mental Health and Clinical Psychiatry ...............................................................3

Section II Part A: Clinical Psychology

Human Development and Life Cycle............................................................................................31

Section II Part B: Medical Sociology and Anthropology

Introduction to Medical Sociology and the Family .....................................................................91

Section III: Behavioural Neurosciences

Neuroanatomy and Psychiatry ......................................................................................................125

Section IV: Clinical Adult Psychiatry

Aetiology in Psychiatry .................................................................................................................153

Section V: Child and Adolescence Psychiatry

Child Psychiatry: An Overview ...................................................................................................404

Section VI Part A: Physical Treatments

Ethno-Psychopharmacology and its Implications in the African Context ....................................470

Section VI Part B: Non-Biological Treatments

The African Textbook of Clinical Psychiatry and Mental Health

Loss and Bereavement Therapies..................................................................................................516

Section VI Part C: Emerging Trends

Complementary and Alternative Medicine in Psychiatry .............................................................531

Section VII: Research and Ethics

Research and Bio Statistics in Mental Health ...............................................................................549

Section VIII: Postscript

The Practice of Psychiatry in Africa - A Personal Experience ......................................................577

The African Textbook of Clinical Psychiatry and Mental Health

Norman Sartorius, M.D., Ph.D.

The African Textbook of Clinical Psychiatry and Mental Health

Prof. David M. Ndetei

Dr. Lukoye Atwoli, MBchB, Registrar in Psychiatry

The African Textbook of Clinical Psychiatry and Mental Health

Psychiatry and Mental

The African Textbook of Clinical Psychiatry and Mental Health

The dictionary denes mental as of the mind.

According to the World Health Organisation

to social isolation, poor quality of life and

The African Textbook of Clinical Psychiatry and Mental Health

language, thoughts and emotions. Psychology

deserve. (Source: http//www.who.int/mentalhealth/en/ retrieved 16/1/06)

Relationship with anthropology

Relationship with sociology

ABOUT THE BOOK

Relationship with psychology

Introduction to Mental Health and Clinical Psychiatry in Africa

Section IV deals with the major aspects of clinical

imperative that health workers are equipped with

The African Textbook of Clinical Psychiatry and Mental Health

was classied into four temperaments sanguine, c

During the pre-literate cultures and Biblical times,

The Hippocratic School of Medicine approached

psychiatric literature. His earlier attempt in the

thinking. In 1405 AD, the rst mental hospital

MODERN (MORAL) ERA OF

The African Textbook of Clinical Psychiatry and Mental Health