Emotional Health Insights

What is the British National Formulary or “BNF”?

2005-09-03T21:59:00.000Z

If you are not familiar with this book or the website that shares its content (http://www.bnf.org/) then it will be a revelation, and a reliable, good friend.

The BNF, as it is known, is a thick paperback produced twice a year with its date and edition number displayed prominently on its front cover. This format is now at the 49th edition – my own vintage is evident from my recollection of the pale blue cover of the 1st edition in 1981.

Well what is it? It is a book containing a list of pharmaceutical substances, what doctors, perhaps inappropriately, call “drugs” – that is medicines. It lists their uses, method of administration, side-effects, interactions, routes of administration, dosages and much more besides. It covers all disciplines of medicine and surgery. It contains no advertisements.

It aims to provide UK healthcare professionals with authoritative and practical information on the selection and clinical use of medicines in a clear, concise and accessible manner. Believe me, it does all that and more.

The psychiatry section is extremely comprehensive – comprising most of Section 4, the Central Nervous System medications. Here you can find the rationale for medication you have been prescribed and what it does. In the Appendices in the back of the book you will find listed interactions with any non-psychiatric medications you may take. Thus you will spot an increased risk of bleeding in those taking SSRI class antidepressants and non-steroidal anti-inflammatory drugs (NSAIDs) such as the widely available medication painkiller, ibuprofen – both can increase the risk of gastrointestinal bleeding. The same SSRI medication may interact with certain migraine medication – which? – it is all there. You may notice if you consult it when living abroad that the Proprietary (or trade / commercial) names may not be the same as those that you are accustomed to, in which case use the generic or proper chemical names which are given priority in the book.

Read the Preface if you are buying it. You will notice it covers drugs generally prescribed in the UK. Rightly it cautions that it is a book that is intended to be interpreted according to professional knowledge (written for doctors and allied health professionals), and doctors using it will supplement it by additional reading.

Who writes it? - the content is the responsibility of a Joint Formulary Committee comprising representatives of the two publishers (British Medical Association and Royal Pharmaceutical Society of Great Britain) and the Department of Health in the UK. The editorial team are pharmacists and doctors, and they use expert clinical advisers (including nurses and dental surgeons) to review and revise the text. Clinical specialists are consulted on specific clinical topics and reference is made to the work of expert bodies that produce clinical guidelines. In addition a huge range of written sources are consulted – textbooks, systematic reviews, pharmaceutical company literature, journals, and comments from readers. All this is distilled down into the BNF.

Who reads it? – virtually every healthcare professional in the UK. Every psychiatrist will have at least one to hand, as will colleagues in all other disciplines. An indispensable and key source of reference and a credit to those involved in its production.

Note the online version is accessible free on the Internet if you register – http://www.bnf.org/ .

Why are the Rich, Famous, and Influential Inadvertently Disadvantaged when it comes to the Management of their Emotional Health?

2005-08-29T21:54:00.000Z

It was with interest that I chanced upon "the Death of Dylan Thomas" (Nashold and Tremlett, 1997) when searching my bookshelves for an unread book to take on holiday - and I have to admit there were many unread. A chance to revisit another account of Dylan Thomas' drinking - I had wondered what the evidence was in this account for him having well established alcohol dependence (see Reflections on Laugharne and Alcohol). Well there is little evidence in that account of the tell-tale features - regular withdrawal sweats and shakes, continual round the clock drinking, impaired appetite, etc. The account suggests he would have had a binge pattern however, and his use would have been harmful. He did not seem to have been admitted with delirium tremens, but is said to have developed a coma (apparently due to hypoxic brain damage) allegedly related to treatment in a hotel room with parenteral morphine by his US physician (for presumed delirium tremens) - a situation possibly complicated by impaired glucose metabolism - which alcohol can also complicate.

What is well illustrated in this account however is the way an individual's special status (in this case celebrity) can render them vulnerable to anomalous medical management. Nashold and Tremlett are quite harsh on Thomas' physician (who had a very unconventional subject to treat), but also illustrate how celebrity status can result in ordinarily disciplined hospital procedures being turned upside down. It is a phenomenon not restricted to the physical treatment of patients - I have seen it on a number of occasions. There are a number of ways in which it manifests, which either individually or collectively put the patient at a disadvantage compared with their less illustrious or wealthy compatriots.

One immediate problem can be that the mental health professional can be lured from their office to a hotel room, home or other equally unsatisfactory situation. Why does this matter? In short, your normal routine is upset, you are liable to distraction. Even routine things such as recording the history can be difficult. Reference books and investigation tools are not to hand. Worse, confidentiality may be compromised; already limited time can be spent in speaking to everyone but the patient. Some of this informant or "collateral" information can be useful, but it can also be very misleading and can affect one's own history taking format, as one may be directed to not ask about X or Y, or be given other directions which if broken compromise one's relationship with the individual's family or associates.

Another problem is that of access - you may need to see the person once a week for an hour over a few months to both investigate and treat them. Such patients don't give anyone this sort of access; they are just too busy or are too often travelling. You might of course point out that you should not manage them if they can't come - well one is faced with the proposition that this is all the access that anyone can get and the argument that surely they deserve treatment like other people.

Another problem is that there can be direct interference with one's management from a host of previously involved professionals who while one is inclined to learn from and pay due professional respect to, but may find offering direct or indirect advice to one's patient.

Some patients in this category - possibly because of past adverse experience (or a surfeit of contacts and resources) will be engaged in the continuous checking of one's management resulting in seemingly random requests for different or alternative lines of management. This can be accommodated to a degree, and is not necessarily a bad thing, indeed it offers one a chance to explain the rationale of one's approach which can build confidence. However it can produce defensive practice which is not always good practice.

One can find that one's patient disappears, taken on by another professional under less than frank circumstances. One realises at that point one may be in a chain of doctors, the individual circumventing the normal procedures of maintaining medical continuity through handovers - one's hapless successor only realizing what has happened when it is too late. This can be brazen - the individual may even represent having found their new opinion less palatable than they expected. Flattery is often employed in good measure in these circumstances.

Sometimes one is treated in a less than respectful manner - the individual may be used to running the show and be disinclined to change their style for their psychiatrist. They may be used to those around them behaving in a referential or obsequious fashion - all this can be done by the psychiatrist, but it may well affect their performance, even make them nervous (after all we are human!).

These and other factors may have had bearing on the performance of Dylan Thomas' US physician.

If you are Rich, Famous or Influential how would I suggest you bring out the best in your psychiatrist? It will be self-evident from the above.

Give them time, allow them to see you in their familiar circumstances, or ask them how you can replicate a "consulting" situation in your hotel or home.

Put them at ease with your status and expectations - a little of the "common touch" is required.

Disclose your past history fully and explain any concerns that arise from this. Arrange for past results or written opinions to be available to your new doctor.

Ask questions of your doctor, and ask if there is a "range of opinion" or “alternative ways of viewing or managing the situation".

If contact is required outside the consultation ask how and when this is best done for the doctor.

You want a good opinion and thus you will be optimising the chances of getting it. If despite this the relationship is not to your satisfaction make time to talk it over in a friendly fashion - you will almost certainly gain information that helps you solve the problem with someone else, and possibly an introduction to the person with the special skills that are required, conceivably retaining this doctor for other problems or for introductions to more specialised doctors.

You might well find the same approach works with others that you need help from!

See also - Reflections on Laugharne and Alcohol

See also - An “Alcoholic” or an Individual with “Alcohol Dependence” – What’s the Difference?

UK Inpatient Services - Under Pressure?

2005-08-15T10:26:00.000Z

It is an unfortunate fact that recent seemingly positive developments in the UK in the community treatment of individuals with severe mental illness – usually people afflicted with schizophrenia, schizoaffective disorder, mania and depression (often complicated or caused by drug use) – has coincided in a de facto deterioration in the lot of inpatients. Why has this come about? Well to understand this you have to understand what has been occurring in the development of community services.

Community mental health teams (“CMHT’s”) have changed from solely being so-called “generic” teams to having additional more specialised and smaller teams. There are generic teams still, but with a different focus – either Assessment and Brief Therapy teams (“ABT” teams) or Continuing Care Teams. The former take people in to CMHT management and look after them for 3 or 4 months, whilst the later take over the management thereafter if the person has a chronic illness and need for care (and most people with severe mental illness do).

What are the new teams? They are of two main types – Home Treatment Teams and Assertive Outreach Teams. The former offer home treatment as an alternative to admission, and early discharge to home treatment for those who are admitted having originally been judged too ill for home treatment. The latter, Assertive Outreach Teams, receive referrals from the other CMHT’s of patients who are liable to be difficult to manage in the community – individuals who are not willing to take medication as prescribed, individuals who have a record of frequent breakdown, individuals who are difficult to access, and so forth.

You might think this sounds all well and good, and so it is in principle. In practice there are a number of problems. The first is that inpatient units tend to become places where there is a concentration of an increasingly ill patient group – a much more challenging environment for fellow patients and staff, typically with more behavioural disturbance – i.e. violence and intimidation. Less ill patients are either treated at home or discharged early.

You might ask, “Well surely this means at least you have fewer patients overall as inpatients?” In practice not – indeed many inpatient wards now routinely run at 110% occupancy and have frequent bed crises. Thus you have more and iller patients.

Well at least you can increase the staffing levels you might think. Unfortunately you can’t – infact by making more though smaller CMHT’s you have to move staff from the inpatient units to the community. Why? Well there is an essentially fixed allocation of medical posts and salaries, especially training posts – the junior grades of senior house officer (SHO) and specialist registrar (SpR, formerly known as a senior registrar). Thus you have fewer medical staff managing a rising population of iller and more disturbed inpatients. Not only this you are having a higher turnover of patients which results in more admission clerkings for the juniors, more patients to work up, more investigations to organise, more relatives to see, and more admission reports to write (also known as admission summaries), and more Mental Health Act hearings to attend (tribunal hearings for detained patients).

What is the effect? Not infrequently low morale, burnout, and a loss of trainees to the speciality of general adult psychiatry. For the patient a more disturbed environment with less individual time from staff members, especially doctors. For patient care – apart from the obvious - little time to really work-up the patient’s existing and past history and complete investigations before home treatment beckons.

Not a good system to be unfolding nationally. What would help? – an increase in the provision of medical staff (some would say moving resource from managerial posts to front line care, and undoubtedly this will need to be done as it seems unlikely that there will be significant new money), targeting and remedying effectively the reasons why some people keep breaking down and being readmitted (the unfortunate phrase “revolving door patients” is used for this group but better would be “patients for whom community care has failed and needs improving”), and appointing someone to effectively manage those inpatients who are well, but cannot be discharged. This group can amount to as much as a third to a half of the ward. At about £300 a day this is a big “loss” of resource. In say a 21-bedded ward this amounts to say 7 x £300 a day (£2100) a day, times 7 for a weekly figure of about £14,000 a week. Is this picked up by Audit studies? Well you know the answer – no. How many wards serve a borough? – about 5. How many boroughs in the UK? Not a comfortable thought.

Having followed this you might well ask why are the number of patients needing an inpatient stay going up, given Assertive Outreach and Home Treatment – two seemingly positive developments. The answer reflects a number of factors – poor control of outflow factors (the patients no longer needing admission but with no accommodation to go to –“bed-blockers”), pressure on forensic psychiatry budgets with more forensic patients going to general services rather than forensic units, rising use of stronger drugs in the population – especially cocaine and “skunk” cannabis, possibly better pathways into CMHT’s through better liaison between GP’s and non-governmental mental health organizations, and other reasons besides. Arguably better CMHT’s “attract” more patients – which is good.

It is a difficult predicament. Not only are the wards often full, but also patients are under pressure to accept less ideal accommodation to clear space for other admissions – a factor behind some early breakdowns and readmissions.

Should you need admission to hospital you can still expect to find kind, highly professional staff who are generally well-motivated. However if you find them busy, stretched, and at times preoccupied with behavioural disturbance you will perhaps understand why. One thing should be clear – it is improbable that you would ever be kept in hospital longer than is necessary, and it is likely you will be offered home treatment as soon as you are well enough to safely receive it.

Managing Recurring Issues in Children and Adolescents (and others).

2005-08-13T22:02:00.000Z

It is not uncommon to observe the same conflict again and again between parents and their young people. It seems that there are a range of factors that maintain these transactions. Personality and family theorists have written much on this subject and concepts such as “systems” have been used to describe the patterns. What should you do when you become aware of yourself caught up in one? Reacting to a whining child, admonishing an untidy adolescent, etc, etc.

Commonly there are many points of contention that one would like to remove, and probably a number that one's offspring would like to see removed from one’s own repertoire. “Stop nagging mom”, “Why do I have to”, etc, etc.

Typically one is caught up, as is the child, in a reflex reaction and that reaction tends to evoke a reflex reaction in the child – often that of ignoring the complaint or admonishment. There may be, as has been discussed elsewhere, factors that make such behaviour more likely – tiredness and pressures from elsewhere. Assuming these have been sought out and corrected or tempered, how should the situation be managed?

Well probably the first step is to take some quiet time to sit with a simple piece of paper to jot down on it all the behaviours or situations that one would like to remove – a problem shopping list. This list should be kept open as even after all seem sorted others will come to mind for attention – especially as the relationship will be affected by the child’s development and changes in their situation.

The next step is to examine that list and to determine the extent to which the items are discrete, as opposed to being linked. By this I mean if you have a home that has a broken window, poor boiler, hole in the carpet, and need of painting, then the problem may be that you either are out of time or money (or both). The point being that the half dozen worries you have about the house may relate to one or two more major issues, and so too with some of the issues on your list. It is useful to create a hierarchy of perceived difficulty with the items on the list – allowing you to start with the easier ones.

One problem that is often on the list is that of communication. It may be difficult much of the time to engage your child in conversation. There are many reasons for this that you need to analyse but it will relate to factors in both of you. With younger children bedtimes are a good time - especially when the child is supine and settled.

Time is needed, and extraneous interruptions must be limited.

The conversation must occur not just once but on a regular basis.

As has been mentioned elsewhere some like to have a formal “family discussion” – not necessarily including the whole family.

You have to listen as well as talk.

Tedious accusatory “speeches” will not be listened to any more than reactive remarks or comments. Don't moralise too much.

It is a good idea to start by discussing one item only as otherwise the targets set get so ambitious that they are either forgotten or seem too difficult.

Try to remain constructive not destructive and explain this to you child – we are trying to help each other.

Ask what might be helpful for you to do differently. For example suggest you could remind or reset the other, rather than carry on admonishing them as normal. Point out (and remember) that slips should now be regarded as opportunities to learn, rather than disasters.

What can you expect from your child? Not much to start with. What you are often going to be dealing with is long entrenched habits of behaviour. That is automatic patterns of reacting, not necessarily events that are planned or thought about. Can you quickly change the way is have your legs when you sit down to talk to someone – of course not. So too with your child’s conduct. They need a gentle reminder of what they should be working to do differently, and massive amounts of reinforcement when they change or even try to change. This has to be done in a fun, relaxed way. Not too much either as it becomes tedious and monotonous and will deter your child.

The problem for the child is how to break the habit – a reminder can be useful – for example wearing odd coloured socks, moving a watch to the other wrist, or something else subtle but noticeable. Further the person needs to understand that if they slip they should stop as soon as they remember, not continue and give up - that is catch themselves. If they do the latter they should restart and be more determined, or it should be picked up and reset at the next review discussion.

Rewards can focus the mind. For a young child lollipops or favourite sweets/candy - perhaps left tempingly on a high shelf - may be sufficient incentive. Something more substantial may encourage the adolescent – an iTunes download, or similar. Sometimes something less material is appropriate – choosing the pudding, a lift to a friend's home, or whatever would be appropriate in your family. It goes without saying that there has to be an agreed contingency for the rewards that is adhered to – possibly in writing.

Fairness, fun, affection are ingredients to include in good measure.

You will appreciate we have not talked about punishment, the old currency of threats should be dropped – has it helped? A new way is being introduced. You may well have picked up on something said by your child or adolescent that you should nor be doing – also try to stop – you will be aware that it is difficult and may well adopt the habit strategies suggested for your child.

If it doesn’t work make adjustments, pick an easier item, look at yourself – what might you be doing to maintain the situation? Talk it over more, ask for suggestions. If it does work, don’t be complacent, but keep up the discussions. Introduce a second item of conflict from the list, but keep going with the first.

If there is a diabolical breakdown so be it. Don’t get ruffled. Why was it. Do a “behavioural analysis”. Were you all tired, were there other pressures, and was it just a slip that got out of hand. Reset the situation, resume the plan, apologise if you got overwrought, encourage your child too if they did (but don’t humiliate them). Take a friendly approach – “Where did we go wrong?” as opposed to “I knew it, it was just a matter of time until you messed up”. Bring the best out, don’t create resentment.

See also - “I Won’t Mummi” How to Handle Stubbornness in a Normally Placid Child?

See also - Slipnot, Manson, Coolness and the Unnerving of Bourgeois Parents

Snakes, Worms, Shyness and “Social Phobia”

2005-08-10T06:38:00.000Z

Where to start. The first point to make is that both shyness and social phobias are dimensional quantities - we are all somewhere on the dimension - a theme that will become familiar to the reader of this website.

Shyness requires no explanation. A phobia comprises the development of fear and anxiety in a particular situation and a tendency to avoidance of that situation. A social phobia concerns fearfulness in social situations. It differs from agoraphobia (agora = a market place), where there is fear in open or exposed places and avoidance of them. Arachnophobia would be fear and avoidance of spiders.

We all tend to have pet fears – mine is snakes and this gives a clue to the developmental origins of phobic concerns. My earliest memories would be of my elder siblings returning from play on a local piece of heath land. Much of the talk would be about whether or not they had seen, trodden on, or been bitten by an Adder – the only venomous snake in the UK and one not infrequently encountered on that heath (and sometimes in our adjoining garden). The tone of the discussion was not one of pleasure, but of anxiety, respect, loathing and above all fear. Of course as a junior spectator one assimilated the same emotion. Later when with my wife in a tropical jungle I declined the opportunity to have my photograph taken with an exotic (but for me terrifying) five-foot serpent; my wife on the other hand willingly and in a relaxed fashion took the opportunity. Not only had I not wanted to touch the snake, but also as soon as we alighted from our canoe to walk the jungle trails I was apprehensively seeking out imaginary snakes with every footstep.

Years later I was gardening when my first child of 2 years remarked on the worm exposed by my digging. My wife’s reaction was to draw her back and remark that it was disgusting. However I intervened, talked about it along the lines of it being a mother and we should dig for the rest of the family, and said to my young observer that if she was really kind to it, I would allow her to hold it in her hand – an encounter that went without any concerns. For the rest of that childhood a happy relationship was had with “wormies”. It could have been very different.

The lessons I draw from this is that there is a developmental (growing-up) influence on the occurrence of some phobic concerns, phobic concerns can be induced by the reactions of those around us, and these can be enduring.

However clinical experience suggests that this is not always the case. Socially bold people do sometimes develop social phobias. My impression from observing for a common factor is that when an individual’s general levels of anxiety are sufficiently raised, then this may manifest as phobic anxiety (as an aside I should explain that phobic anxiety is an example of a Neurosis). I have seen it as a manifestation of alcohol-induced anxiety, as a manifestation of work-induced pressures, and in other situations where there is an uncommonly high level of induced anxiety.

In relation to the latter while an individual's inner world and experiences are important, so too is the situation. Experimental psychologists, particularly those with an interest in personality theory, have elegantly demonstrated what they term the “power” of situations. Thus one might be at the lower end of the dimension of shyness, but face a situation of considerable social challenge – meeting one’s sporting hero, an angry police-officer, or if one takes an extreme, the head of one’s religion or royalty. Clearly there is going to be differential social competence depending on the situation – from time to time one meets situations with real “power”. So too with social anxiety.

The actual leave of symptomatology is likely to be a product of one’s perception of the threat based on one’s experience (perhaps having been brought up by socially inexperienced or shy parents), the “power” of the situation at hand, and one’s background level of anxiety at that time.

The tendency in a good going phobia is to avoid the situation and this may aggravate the situation. There may be increasing fear in a normally reasonably managed situation; that experience when not undertaken may irrationally grow in threat.

How is it managed? – a big subject, but we will consider the principles.

Clearly any general aspects of the individual’s life that induce anxiety – physical or psychological need to be dealt with. Thus for example excess stimulant substances, metabolic diseases such as thyrotoxicosis, or occupational, family or financial threats would need to be dealt with.

Perhaps not surprisingly it can be alleviated by medication – a short-term anxiety-reducing drug such as a benzodiazepine (diazepam (also known by its trade name Valium) is the best known example). Thus twenty minutes after taking this medication a social fear could be overcome. However one cannot take such medication for long before the body becomes adjusted to its effects (what is called “tolerance”) and its efficacy wanes.

Anxiety lowering drugs that can be taken in the medium term without tolerance include most of the antidepressant drugs, as these also tend to have “anxiolytic” effects. However while these are taken they are useful, but quite a few people find their symptoms return after they are withdrawn – even after months or years.

Presently the preferred approach is psychological – behavioural and “cognitive” behavioural methods. While this is not my area of expertise, among the approaches used are methods such as “systematic desensitisation”. A list, that is an ordered hierarchical list, of feared situations is worked out with the patient. The patient is encouraged to confront the easiest (least-feared) situation, getting to overcome each item in turn, at a speed which the patient can manage. The person is taught that it is necessary to experience the anxiety that is induced, and taught about the symptoms of anxiety – both physical and mental – and how to control them. In particular the person is taught how anxiety rises and then falls back – typically in an hour or so. The idea is that exposed to the same level of threat the person experiences and adjusts to the threat – a process called “habituation”. Thus the induction of anxiety for a given item on the list becomes less and less after successive exposures to it. As well as actually undertaking the exercise in real life, some people find it helpful to sit in a quiet place and imagine the situation and effect of being in it – “imaginal exposure”.

As well as teaching desensitisation, there are a range of approaches that also consider the thinking that a person has about the situation that is feared, and helpful mental (or “cognitive”) strategies can be acquired.

In some situations other approaches may have value – I have encountered hypnotherapeutic suggestion overcoming months of phobic anxiety in moments (sometimes however there is gradual or rapid re-instatement afterwards). There was a vogue to use “flooding” or “implosion” – a psychological technique in which the person is exposed to their most feared items from their hierarchical list. In my case it would involve a trip to the reptile house of the nearest zoo and a night sitting in the snake enclosure – the idea being that after experiencing sustained fear eventually one would relax and realise that there is nothing to fear. Not nice and hence rarely used – fortunately! Also it clearly poses difficulty in terms of informed consent.

It could be argued that a degree of shyness is a virtue – it being a companion of humility and social discretion, and more acceptable than a relative lack of social inhibition, where social intrusiveness can be a handicap. Is it good to “work the room” with little insight. Excessive shyness however is a discomfort and a potential handicap – the implication of this account is that it can be overcome.

See also - Slipnot, Manson, Coolness and the Unnerving of Bourgeois Parents

An “Alcoholic” or an Individual with “Alcohol Dependence” – What’s the Difference?

2005-08-10T02:00:00.000Z

We use the term alcohol dependence to denote a person whose drinking is associated with certain features. Arguably the most important is the development of physical withdrawal features when the person is no longer drinking. What are these physical changes? Initially they comprise sweats, tremor, shakes, and pyrexia. They are probably mediated by the release of adrenal (from the adrenal glands situated just above the kidneys). There are other features too – a narrowing of the drinking repertoire towards strong (and cheap) sources of alcohol, a preoccupation with drinking related activity, craving for alcohol, and the relief of alcohol withdrawal symptoms by taking more alcohol.

An English and American wrote a well known scientific paper defining alcohol dependence (with the above features) – pointing out it is a medical syndrome – Griffith Edwards and Milton Gross – and these features are used in the two main psychiatric classifications (International Classification of Diseases (version 10) of the World Health Organization (UN) and the Diagnostic and Statistical Manual (version 4) of the American Psychiatric Association.)

What is the implication? Well one is that alcohol dependence is a physical condition like nicotine addiction and requires treatment as such, rather than a moral / judgemental approach. This may sound odd given the damage alcoholism causes the individual and their family and friends. However it is correct – alcohol dependence requires physical treatment, then more psychological management. Indeed the symptoms of alcohol withdrawal – that is the physical and mental effects - are so severe (and dangerous) in established alcohol dependence that the person should not stop abruptly, but gradually or with the help of “detoxification” medication.

While the early features of alcohol symptoms comprise those stated in the first paragraph above, with time there is an unfolding of progressively more severe (and adverse) symptoms – certainly enough to drive one back to drink. Indeed it seems that when the body has insufficient alcohol it produces withdrawal symptoms that perpetuate drinking as alcohol is the perfect remedy for them. This the drinker learns from experience and a pattern of 24 hour remedy drinking is established. Many alcohol dependent individuals, like smokers, do not actually enjoy their habit, and unlike the social drinker do not drink for the pleasure of inebriation – more to ward off or relief withdrawal symptoms.

And what are the further symptoms. First is stronger tremor and strong feelings of anxiety and restlessness. In the first 12 hours or so there is risk of a generalized epileptic seizure – a so-called “rum fit”. There may be double vision and incoordination. The blood pressure and heart rate rises. Mild to severe psychotic symptoms may manifest – typically paranoia with or without hallucinations. The hallucinations can be mild or “elemental” for example a sound or fleeting illusion, but may be fully formed and complex – for example in full consciousness seeing a rat on the bed. After 18 to 36 hours a more sinister development may occur – clouding of consciousness and the development of delirium – acute impairment of orientation in time and place and person, memory impairment, inattention and other features. In this state of delirium there is usually intense fear induced by the psychotic ideas and perceptions. By this time the individual may be behaving in an alarming fashion – responding in a restless, aggressive fashion. The state of arousal may be such that there is significant fluid loss and the hypertensive state may be replaced by hypotension and cardiovascular collapse.

The extent of the alcohol withdrawal syndrome is proportionate to the degree of alcohol dependence. Alcohol dependence is a dimensional quantity – that is there is a range of severities. It follows that at some point in the individual’s drinking career there is a crossover from heavy social or excessive drinking to mild alcohol dependence – the latter being heralded by the development of the alcohol dependence criteria above.

There is quite a lot more to alcohol dependence that will be discussed in other articles. A final point to introduce is the principle behind management. This is clear and simple – rather than exhort the “alcoholic” to stop drinking (which they can’t) or hide their drink (so precipitating alcohol withdrawal), the alcohol dependent individual has to be educated and guided to alcohol treatment services – the family doctor or local project being the first step.

See also - Reflections on Laugharne and Alcohol

See also - Why are the Rich, Famous, and Influential Inadvertently Disadvantaged when it comes to the Management of their Emotional Health?

“I Won’t Mummi” How to Handle Stubbornness in a Normally Placid Child?

2005-08-09T03:19:00.000Z

This is a very upsetting situation for all involved. The child may speak, shout or behave in a way that embarrasses or traumatises the parent, and the parent may use tones so firm or threatening that the observer may assume abuse is occurring – which sometimes may be the case. Either the parent or child may snap and transgress that thin line between what is acceptable and what is not. The situation requires unpicking – a luxury that is rarely possible in the heat of the confrontation but is frequently overlooked once the event has passed.

Even the most angelic child can at times manifest monstrous stubbornness or awkwardness, and if you witness it ask yourself, “Is this child grossly overtired?” As a parent I have observed this phenomenon through all the developmental ages of my children and if I am honest, witness it in my wife and myself. The knowledge that it is transient and exceptional can help the parent in this situation avoid overreaction, in particular from engaging in battle over what will not be an issue the following day. There may be other causes - worry about something, imitation of the conduct of a peer, or a genuine perception of unfairness on the part of the adult.

Tactical withdrawal is required – the parent must de-escalate the situation using a mixture of flexibility and firmness. Distraction, and appeasement are required in good measure – this can be done with confidence, and without any expectation that it will “reinforce” bad behaviour. There is no real bad behaviour just the irritability of a tired person. Of course the following day when all are rested the situation can be discussed briefly – exploring or pointing out its origins and encouraging better self-control and self expression if there is an underlying worry.

Attention may need to be made to the structure of the child’s day. Recurrent stubbornness or awkwardness may be being promoted by poor structure resulting in regularly late sleep times – sleep times themselves being a particularly difficult point of conflict. The parent must do there best to impose better structure. Children are often interested in discussion, when fresh. The need for earlier bedtimes can be talked about. Incentives may help such as guaranteed reading times, quite pre-sleep talk, a drink, or whatever. Rewards the following day may help start off the change – rewards which are not necessarily material, often something simple like choosing the supper or sitting in the front of the car, or so forth will suffice. If the situation is less to do with tiredness and more to do with worry or parental unfairness this requires considered, fair, discussion. Is one allowing enough talk time with one's child?

Though it may sound hackneyed, a family “meeting” may be called so that the discussion stands out above the normal bustle of family life. Such discussions must be democratic – not a one-sided moralising speech which the child will switch-off from. A plan should be set and a follow-up discussion held. Such plans in my experience typically fail the day they are set – if this is remembered then they can be reset, as opposed to giving up feeling that there is no hope. It is a common observation that such behavioural initiatives usually fail through a lack of diligence by the parents who may lose interest or not reset slips. Another type of discussion is that that can occur with one's child horizontal and settling for sleep or a story. Sometimes a story can be used to discuss an issue that has occurred in the day through the characters or context of the story.

If the psychiatrist is involved – a luxury most do not have – then the psychiatrist helps make the analysis of the situation, draws the child into the plan in a non-judgemental way, and can supervise the progress of the family, week on week. In my experience it may take three or four sessions to take the history and develop a working relationship with the child (plenty of “neutral” conversation assists this – casual chit-chat about the child’s life and interests). In the case of altering the routine the plan is discussed and refined over a few further sessions, and then launched. An atmosphere of fun and encouragement is created such that all feel good.

If adjustment to the parent's conduct is required this is considered and alternatives agreed for substitution. Such work is not necessarily done in front of the child.

An explanation of the prognosis is given. The normal occurrence initially of slow progress is explained to the parent, and how to “reset” rather than get back into a critical, confrontational frame of mind. Within three or four sessions more the situation is usually resolving well. Slips are minimised with just that label, but progress is lauded. Structure is created to the daily routine, the child is better rested (so too hopefully the parents), and where confrontation looms the parent deescalates and the child exerts more self-control. In parallel issues such as worries, parental unfairness, excess parental firmness, etc are worked on.

It can sometimes be difficult in sessions, as one may have to suggest a course of action to the parent in front of the child that may appear to undermine their authority. This can be overcome by explaining that such risk can be undertaken in a controlled, clinical situation, where adverse consequences (which in my experience do not occur) can be rectified.

This account presupposes that the child has no general tendency to awkwardness, and that the parents are generally well attuned and responsive to their child’s needs. Stubbornness and awkwardness may have other origins that will be considered elsewhere – for example it may be evident as we saw in the adolescent reacting to peer pressure.

See also - Slipnot, Manson, Coolness and the Unnerving of Bourgeois Parents

See also – Managing Recurring Issues in Children and Adolescents (and Others)

“In sooth, I know not why I am so sad …” How do Psychiatrists Diagnose Depression?

2005-08-08T19:04:00.000Z

“Write an essay on any medical condition you have come across in a Shakespeare play” was one of the essay titles in my medical school finals. I wasn’t looking forward to any of the other questions as they were on very technical aspects of medical treatment, but neither was I a person even averagely familiar with Shakespeare. To my relief I remembered that the only play I knew in depth, the Merchant of Venice, I had been examined on at school, and it began with one of the merchants stating that he did not why he was so sad – the chance to write about a psychiatric topic in medical finals presented and I took it with some relief.

When a person is referred with a presumptive diagnosis of depression one has to work out whether it really is depression and if so what subtype. After the preliminaries one starts by looking for depressive symptoms with questions like “How have you felt recently?”, followed up by “How did it make you feel?” etc until one has elicited as much as possible. It is then usually necessary to use direct questions aimed at evaluating whether key symptoms of depression are or have been present. With some people one’s desire to elicit the presence or absence of depressive symptomatology has to be tempered and may become quite roundabout – the individual may be very distressed or want to talk in that first meeting about a pressing concern.

What are the symptoms? – well the answer is they are quite commonly experienced complaints which taken individually are not specific to depression. Indeed the symptoms of depression can be induced by a range of medical conditions, and occur in people we would not regard as depressed. We sometimes group the symptoms into those that are more physical (also referred to as "biological" or "vegetative") and those that are not. Biological symptoms include sleep impairment, fatigue, early morning awakening, a diurnal variation in mood (often a low morning mood with recovery in the evening), and a loss of sexual interest (or “libido”). Other symptoms include sadness, a loss of interest in ones activities or friends (sometimes referred to as “anhedonia”), misplaced feelings of guilt, excess worry, hopelessness, helplessness, and pessimism. There are other symptoms too – for example many people describe a sense of “blackness” or “emptiness” which they recognise to be alien.

Another important aspect is whether suicidal thoughts have come to mind. They often do, only to be dismissed. Their appearance may unsettle the individual further – guilty thoughts, or the thought that “I must be bad if I am thinking like this”. Sometimes the thought that comes to mind is along the lines “I can understand how people are moved to take their lives when they feel like this”. More definite thoughts of suicide may be elicited – there may have been an element of active planning – a method considered, tablets bought, affairs put in order. There may have been a failed or aborted attempt. This is an area that requires careful exploration. The clinician has to be careful not to induce this type of thinking. Often a tangential or indirect approach is best, moving to more direct questioning when the subject has been opened up in a natural way.

Other aspects of the history taking are important – for example is there any evidence of periods of mood elevation (indicating bipolar depression, that is manic depression). Are there any features of agitation – an agitated depression indicating a more definite and severe depression. We ask about psychotic symptoms (these are symptoms such as hallucinations or delusional ideas) - another indicator of a more severe depression.

While interviewing the patient one makes observations of the patient's appearance. Is there evidence of self-neglect. Is there weight loss (one might literally observe a woman’s rings to jangle together on a thin hand). Is there a sad demeanour? Is the person impassive and resigned and lacking the ability to use normal or congruent facial expression. We specifically pay attention to their speech – is it of normal rate, volume, and rhythm, or softly spoken, monotonous and slowly delivered.

Further history is sought about the time course, past episodes, and on the impact on the person’s “activities of daily living” – work, relationships, self care, etc. Collateral information is especially valuable where an informant is available.

As well as eliciting the symptoms or phenomena of depression (“elucidating the phenomenology”), one is also concerned to understand the context – physical and psychosocial. From experience one learns to “think organic” – that is to consider the potential physical causes before assuming a psychological cause – one area where the psychiatrist being a doctor has advantage over a fellow professional without a medical training. I recall the case of a man who was attacked at his place of work and who was referred to me as an outpatient. I actively took the decision not to undertake physical investigation – surely here was obvious cause and effect. I regretted that decision as after a year his symptoms persisted and worsened, despite treatment. When eventually investigated by a colleague he was found to have thyroid disease that was almost certainly the cause of his symptoms. It has to be observed that generally metabolic and endocrine causes are rarely found, though toxic causes are not at all uncommon. By toxic one means substances – these range from alcohol and caffeine to hard drugs.

The psychosocial context is important and here one is familiar that the majority of like stressors fall into the categories of family, relationships, work, finance and accommodation. However the principle used is to encourage the individual to describe their worries, stress-points, and problems. Sometimes of course the problem is not immediately apparent to the person and it may only become evident to the psychiatrist and/or patient after a lot of discussion over a number of sessions. There are tools such as problem checklists and for children incomplete sentence lists which may assist accessing or checking certain potential problem areas.

One needs to gauge the level of the problem, what category it is best placed in, and try to assess the level of distress and the particular individual’s capacity to cope with it.

The above enquiry is how one goes about the assessment of depression. This can be augmented by the use of depression rating scales. These are scales either done by the subject, or completed by the psychiatrist according to the responses to questions – like a structured interview. Scales have many uses, not the least being to provide a yardstick by which change can be measured over time. Sometimes an assessment admission is required if there is risk – risk from self-harm, exploitation or deterioration.

My essay as a medical student would have been quite rudimentary, it is certainly the case that one continues to learn about the manifestations of depression. Thus it can be “masked” or concealed, present as an aspect of bereavement, be obscured by anxiety, present as life-threatening self-neglect, and so forth. We sometimes refer to the presence of a psychiatric disorder with substance misuse as “dual diagnosis” – depression commonly presents in this context.

The formulation of a set of depressive symptoms into a diagnosis and management plan will be considered in another article.

Slipnot, Manson, Coolness and the Unnerving of Bourgeois Parents

2005-08-08T02:57:00.000Z

Anxiety is one of the key critical psychological ingredients when it comes to considering emotional health. Clinically it is one of the most prevalent psychological presentations – presentations which for many years have been somewhat awkwardly termed the Neuroses – not to be confused with the adjective “neurotic”, a pejorative term of widespread use. Anxiety is a dimensional quantity – a quantity that one has to a varying degree. There is thus a clinical spectrum from very mild to extreme anxiety.

Anxiety disorders (or “the Neuroses”) are often termed examples of “Minor” Mental Disorder, and contrasted with “Severe” disorders such as schizophrenia and bipolar disorder. Mental health services in the UK have been traditionally targeted on the Major disorders. There are a number of reasons for this, notably the fact that the behavioural manifestations of the Major disorders are so difficult and distressing both for the sufferer and society that faced with funding limitations, these more extreme conditions are prioritised. However the point I wish to make is that Minor mental disorder is far from minor – it is a most common and distressing form of mental disorder, perhaps excepting depression.

Well back to the title subject - a manifestation of anxiety in adolescent conflict. A phenomenon one frequently sees in clinic (not I might add in NHS clinics (UK National Health Service) as it rarely penetrates the filters that litter the pathways into NHS outpatient care) is parental conflict with adolescents – adolescents preoccupied with apparently unsavoury teenage role models such as Slipnot, Marilyn Manson, and in my day Alice Cooper.

Such youth are prone to dress in an “extreme” or at least provocative way, indulge in body piercing, ask for a tattoo, and perhaps smoke, drink and/or experiment with drugs. They may start using curious phrases – such as “dis” (to show disrespect), and adopt the vernacular of American/Caribbean street culture. Above all they worship at the altar of “Coolness”. Everything is cool, but parental / school values which are “Sad”. The parental reaction is predictable and reflects the sum position of the parents on the dimension of anxiety. A dimension that at one end is characterised by inordinately low levels of anxiety and at the other such an excess that the parental approach is not just conscientious, but highly controlled micro-management. The combination of high parental anxiety and a child engaging in high level “Coolness” produces conflict – often presenting as extreme parental worry, and a teenager reacting to this with provocative, awkward, uncompromising behaviour. Such behaviour when on the extreme side we tend to term an “Oppositional Defiant Disorder” or ODD.

What is going on here? Well what seems to happen is that after middle childhood the child reaches a position of good school / peer / parent adjustment. There is all round family satisfaction (– though not always). Then this young adolescent enters what in England we call secondary / senior school. Peer adjustment is immediately threatened and the adolescent has to conform to survive, or at least to survive comfortably. The sensational or exceptional is regarded as daring or cool, and identification with, for example, Marilyn Manson provides status and/or protection from being branded “sad” or worse.

Some adolescents lead a double life, skilfully moving between mildly subversive peer group activities and their more regular home lives. It may well be that more anxious, indeed more conscientious, young adolescents are especially prone to this process. It sometimes appears to be the case that their parents are at the top end of the anxiety spectrum or dimension and have transmitted this tendency to their offspring by among other processes, example and shaping.

The conscientiousness of the parent brings about their reaction to their adolescent who in turn anxiously adheres to their peer group rejecting their parents’ guidance. As this gets intense it creates major conflict. I have seen school failure, children running away, arguments overflowing into assaultative behaviour, deliberate self-harm, etc.

Fortunately it is a situation that often improves when the adolescent becomes more secure with their peer group and school. Thus in my experience it is always more intense in the first half of adolescence. However the conflict if intense can be self–maintaining – the adolescent’s conduct never reaching the exacting standards of the overanxious parents.

In a sibship it is usually, but not always, more intense for the eldest – parents first experience unnerving adolescent peer group conduct in the oldest child who pioneers.

Clearly ripe territory for the astute rock band to exploit, which they do with spectacular commercial gain.

It is a tough situation as it can befall well-meaning, good parents and their offspring. Thus more anxious, and therefore arguably more conscientious parents get themselves into a destructive relationship with offspring that they have raised previously very creditably. Further the unconfident and/or anxious adolescent is not able to get confiding support from home, merely outraged criticism and discipline. Home is not the haven it needs to be for the adolescent faced with barely manageable peer pressure at school.

Contrary to the presenting history and their often-outrageous appearance, these are typically really enjoyable, nice young people to work with. I recall a young adolescent girl in this situation, dressed in a tall Mohican hairstyle, wearing slashed jeans and a studded jean jacket. Another young man presented dressed in black with a history of deliberate cutting. Their value system is infact often very close to that of their parents, not that they are going to broadcast this. They form warm therapeutic relationships and within three to six months the adolescent and parents will often have understood the situation, compromised, and created a constructive relationship. Sometimes it is less easy, especially where there was a history of significant behavioural or relationship difficulties before adolescence, or where the parental anxiety is extreme.

One would add that “conduct” disorder presents in many guises in adolescence, and this is but one of the more common.

Further one should add that despite such clinical patterns emerging, almost never are individual’s situations, dare I say “cases”, similar – there are always different issues and twists.

The situation described above is arguably not mental illness or disorder, but a normal life situation due in this case to peer group pressure and higher individual levels of anxiety. Psychiatrists are well positioned to manage these situations, and furthermore have a duty to avoid stigmatising their “patients” with mental health labels. While the funding authority or insurance company may need a label such as ODD, the individual and their family need to be told clearly that this scenario is a common life situation and indeed may reflect in the parents’ cases a high level of care and concern as opposed to disinterest and parental indifference.

Arguably as a parent it is better to err on the side of excess concern – indifference potentially produces other types of adolescent conduct problem.

We will return to anxiety in many forms in coming months.

See also - Snakes, Worms, Shyness and “Social Phobia”

See also – Managing Recurring Issues in Children and Adolescents (and Others)

Reflections on Laugharne and Alcohol

2005-08-07T01:23:00.000Z

Beginning my first web log the phrase "To begin at the beginning" came to mind which I recollect is a phrase (or paraphrase) of Dylan Thomas. It was on a hot summer's day, similar to today, some years ago that I sat on the short wall adjacent to the path leading to the boathouse where Dylan Thomas once lived with his family in Laugharne, South Wales - a spot that overlooks the shifting sands of a most picturesque estuary. Laugharne is worth visiting not only for its natural beauty, but because it will probably make you curious to read Dylan Thomas' work, and soon after read about the man. Visit Laugharne.

I have yet to follow it up but one aspect of Dylan Thomas' life that is of medical interest is his use of alcohol and quite how it contributed to his death. My recall of reading the book, "Dylan Thomas in America", (by Brinin) a dozen years ago is that the account made it difficult to make a clear link between his drinking and his death from the description given. Well how can people who drink excessively die? The answer is in a number of ways:-

The first is through accidents while inebriated - literally tripping up and suffering a head-injury - pavements, stairs or virtually anything.

Another is through drinking a prodigious amount such that the level of consciousness is progressively impaired - brain stem centres become affected such that respiration may be impaired, however of greater risk on the way there is aspiration of the gastric contents as the protective reflexes that protect the lungs from inhalation of solids or liquids are impaired. Sometimes this causes suffocation, sometimes aspiration pneumonia - an extremely dangerous situation in which gastric contents come into contact with the delicate lining of the lungs causing severe compromise. Sometimes steroids and antibiotics can save the person. Two groups come to mind as being vulnerable to this situation, young people and individuals apprehended drunk by the police and locked up in cells without regular observation. People should never be left to "Sleep it off" but should be observed regularly and ideally put in the recovery position so sickness would not be inhaled.

I remember another case where a woman experienced alcohol withdrawal seizures - generalized epilepsy - during detoxification and died. Alcohol dependent individuals are prone to withdrawal epileptic seizures and probably a percentage of these result in death, as in idiopathic (of unknown cause) epilepsy. Obstruction of the throat through "swallowing" the tongue, aspiration, and other mechanisms operate in this situation. The aim in "detoxifying" an individual is to give sufficient medication, usually chlordiazepoxide, to inhibit the manifestations of alcohol withdrawal and prevent seizures. The difficulty the prescribing physician has is to get the balance right between an exccess prescription with its attendant problems and giving too little and risking breakthrough symptoms and risking the occurrence of epilepsy. It is one of the relatively few situations where to slightly overprescribe is probably the safer course.

Another cause of death is what has been called the Refeeding syndrome. Alcoholism is often associated with malnutrition and when that is extreme there is a metabolic syndrome triggered by the person taking too much food too quickly, rather than building up their nutritional replenishment. It can trigger thiamine deficiency and cardiac failure, or phosphate and other electrolyte deficiencies causing cardiac arrest. These are not uncommon, though often missed by unsuspecting physicains or psychiatrists. one of the few potential causes of sudden death in an acute psychiatric inpatient unit.

There are many other causes of death from drinking - end stage cirrhosis of the liver being a notable and common cause.

Well I am not sure what affliction contributed to Dylan Thomas' sad demise in the States; I hope to review the accounts again in the future to see if there are actually any better descriptions of the role of alcohol, direct or indirect - there probably are.

Alcohol is dangerous stuff. Where to read about drinking - I suggest "the Treatment of Drinking Problems" by Edwards and others, now I believe in its third edition. It is very accessible and full of reliable, practical good sense which reflects mainstream opinion. I would go as far as saying you can't really help yourself or anyone experiencing alcohol related problems without having read this paperback.

Not much "Emotional" health in this first entry you might observe very correctly - indeed alcohol has massive effects on the emotional expression of the drinker and of course is often an important recourse for the individual faced daily with an abnormal emotional climate. Psychiatrists often make reference to the "biological" perspective - taking a physical, pharmacological or "organic" approach, as opposed to a more "psychological" or psycho-social perspective. In this web log I will move between the too - both are equally familar to me and in my clincal work I am constantly changing hats. Indeed in my training I have been fortunate in having long periods of exposure and training to masters of both. Today I have been drawn to the biological.

"Emotional" health requires consideration as a term. The OED seems to define the word "emotion" as referring to instinctive natural feelings. The aim of the observations, ideas and reflections in this site is to contribute to the wider understanding and acquisition of healthy natural feelings, healthy character, and healthy behaviour and communication.

See also - An "Alcoholic" or an Individual with Alcohol Dependence Syndrome

See also - Why are the Rich, Famous, and Influential Inadvertently Disadvantaged when it comes to the Management of their Emotional Health?