Operationalized Psychodynamic Diagnosis OPD-2: Manual of Diagnosis and Treatment Planning Editor: OPD Task Force Hogrefe & Huber Publishers USD75.00; pp332; ISBN: 978-0-88937-353-2 As the name suggests, this book acts as a manual for standardising psychodynamic diagnoses for the different mental and psychosomatic disorders classified in ICD 10 and the DSM IV. The title drew my attention immediately because I think this has long been lacking and such a book can be a valuable aid to our current practice. In the first chapter, the author explains that this book is based mainly on the work of the 'Operationalized Psychodynamic Diagnosis' taskforce, which was formed in 1992 by a group of psychoanalysts, psychosomatically oriented therapists and psychiatrists in Germany. They aimed to expand the symptom-based, description-oriented classification of mental disorders by adding some fundamental psychodynamic dimensions. A diagnostic inventory and manual called 'Operationalized Psychodynamic Diagnosis' (OPD) was then developed for use in clinical practice and as a training manual for experienced therapists. After many years of application in different settings including in- and out-patients, training, and research, and with the availability of research findings based on it, the task force has decided that now is the right time to offer a revised version, OPD-2. This revision takes it from a purely diagnostic instrument to one that also helps with treatment planning and change measurement. The rest of Chapter 1 discusses fundamental considerations made when designing the multi-axial diagnosis and the process of operationalisation of the psychodynamic and psychoanalytic constructs, which was not at all easy. The second chapter summarises the OPD-1 experiences and empirical findings used to develop OPD-2. The OPD-2 has 5 axes, with the first 4 being the psychodynamic axes identifying characteristics of patients as follows: firstly, how they experience their illness and the prerequisites they bring to treatment; secondly, their dysfunctional relationship patterns; thirdly, their unconscious conflicts; and fourthly, their structural characteristics and structurally based vulnerabilities which are very much equivalent to the concept of personality. The last axis concerns mental and psychosomatic disorders in line with chapter V of the ICD 10. Chapters 3 and 4 discuss the operationalisation and manualisation of the Axes of OPD-2, which are very useful for understanding the whole system and how to apply it in a standardised way in clinical settings and research. I find that the concepts are clear, and well illustrated by good use of case vignettes. Axis I on the experience of illness and prerequisites for treatment coincides with our concept of psychological-mindedness, but is not limited to it. It also includes motivation for change, secondary gain issues, and the strengths and resources that patients bring to treatment, which appear to go beyond the conventional emphasis on psychodynamics. Axis II on interpersonal relationships includes the interpersonal presentation of intra-psychic conflicts and structures, which are very much related to transference and counter-transference, the observation and assessment of which can now be documented in a more standardised way. Axis III on conflict and Axis IV on structure offer a very useful distinction between the 2 constructs, which helps very much with the selection of therapeutic stances, foci and techniques. With a low level of integration of structure, meaning, in our conventional terms, patients with more severe personality problems, the distinct occurrence of unconscious conflict, such as submission versus control, or need for care versus self-sufficiency becomes unclear, so the selection of these conflicts as treatment foci becomes unrewarding. …
Introduction Patients with severe psychiatric illnesses have a greater risk of suicide compared to the general population. (1) Suicide is the major cause of mortality in schizophrenia, (2) and deliberate self-harm (DSH) is a strong predictor of suicide in schizophrenia. (3) Deliberate self-harm is prevalent among patients with schizophrenia. One study reported a rate as high as 48% over a follow-up period of 14 to 17 years. (4) Five characteristics are considered significant predictors of DSH in schizophrenia: past or recent suicidal ideation, a history of DSH, a past depressive episode, drug abuse or dependence, and a higher number of psychiatric admissions. (4) Social and environmental factors, such as being married, (5) lack of stimulation and interaction with others have also been identified as risk factors for DSH. Deliberate self-harm can be extremely harmful and can lead to permanent damage that affects daily functioning; 2 examples are self-inflicted eye injuries, (6) such as enucleation, and genital self-mutilation, such as autocastration. (7) We report a Chinese patient with schizophrenia with repeated self-harm, including genital self-mutilation. This is an illustrative case demonstrating the risk factors for DSH, also prompting thought about the phenomenon of hypoalgesia. Case Report Mr. A, a 49-year-old Chinese man, had his first episode of DSH in 1992, 2 years after he was diagnosed with schizophrenia. Mr. A was born in Hong Kong, the youngest of 8 siblings. His eldest brother suffered from a psychiatric disorder--the exact nature of which could not be identified--and died in his 40s of unknown causes. Mr. A studied up to Form 1 then quit school due to poor academic results. He worked in factories and, more recently, as a cleaner. He had no history of substance abuse but had been smoking for 20 years. He married when he was 28 years old and had 2 sons. His wife left him 10 years ago, taking the 2 sons with her, following a quarrel over Mr. A's gambling on horse racing. They have had no contact since then. Mr. A moved to live with his father, with whom he felt he had a close relationship. After his father's death 2 years ago, he lived alone in a flat. He was described as quiet and introverted. Mr. A led a solitary life, enjoyed music and horse betting. Mr. A became known to the mental health service in 1990 when he started attending an outpatient psychiatric clinic for 2 episodes of psychotic symptoms. He was admitted to a psychiatric ward a year later for attacking 2 passers-by in the street as he felt they were talking about him. Prior to that incident, he had failed to attend his outpatient appointments and stopped taking his medications. He believed a computer located in the factory at which he had previously worked was producing itchiness, movements of his mouth, and pornographic ideas in his mind. After admission, he was prescribed with haloperidol and fluphenazine depot injections. His psychotic symptoms resolved. In 1992, Mr. A was admitted again, after he amputated his left index finger. One week prior to this event, he heard his thoughts being echoed as fragments of sentences. On the night of the amputation, he suddenly realised that someone wanted to harm his elder son while he was washing the dishes in the kitchen. Believing that he could prevent this by chopping off his left index finger, he acted on the idea immediately. He was fully conscious and did not experience any pain. His wife promptly called an ambulance. After an emergency operation, he was transferred to the psychiatric ward, when he reported hearing voices talking to each other. One voice told him that the reason for his finger-amputation was to release various "gods and fairies" to save the world. He believed the voices were from a traditional Chinese god and a devil, "Kwun Yam" and "Tin Gau" respectively. He had no regret about his act. He was transferred to a psychiatric unit after stabilisation of his physical condition. …
(ProQuest: ... denotes formula omitted.) Abstract Objective: To investigate the association between the tryptophan hydroxylase-2 (TPH2) gene (G1463A) polymorphism and unipolar depression in a southern Chinese Han population. Participants and Methods: The allelic and genotypic frequencies of TPH2 gene G1463A polymorphism were examined with the amplification refractory mutation system-polymerase chain reaction technique in 123 unipolar depressive patients and 122 healthy individuals. Patients and healthy controls were all from the Guangdong Han population in southern China. Results: No subjects among the cases or controls were found to carry any TPH2 1463A allele. Conclusion: There is no association identified between the TPH2 G1463A polymorphism and unipolar depression in the southern Chinese Han population. Key words: Genes; Mood disorders; Polymorphism, genetic; Tryptophan hydroxylase Introduction Depression is a common psychiatric disease which may lead to mental disability and suicide. The life-time prevalence of depression is about 5 to 17%.1 The incidence of depression is highly modulated with environmental factors, however, there is also a strong genetic contribution to the disease pathogenesis with an estimated heritability of 40 to 70%.1 Family studies, twin studies, and foster children studies show an association between genetic factors and depression.2 Until now, there are still no confirmed genes or related DNA sequences associated with the onset of depression. Therefore, studies to identify the genetic associations of depression will be an interesting area of concern. Results from psychopharmacology and neurobehavioural research show serotonin (5- hydroxytryptamine [5-HT]) dysfunction in the central nervous system is associated with the incidence of depression.2 Decreased level of 5-HT is associated with depressed mood, reduced appetite, insomnia, circadian rhythm disturbance, endocrine and sexual dysfunction, anxiety, and reduced activity.3 Furthermore, the central serotonin neural system is the target for most commonly prescribed antidepressants such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors.4 Central serotonin is synthesised at dorsal raphe nuclei of the brainstem.5 The biological processes related to serotonin in the body include its biosynthesis, storage, transportation, release, receptor binding, reuptake, and metabolism. Proteins and corresponding related genes which regulate these processes include tryptophan hydroxylase-1 and -2 (TPH1 and TPH2), vesicular monoamine transporter 2 (VMAT2), serotonin transporter (5-HTT), monoamine oxidase A (MAOA), and the serotonin receptors including: 5-HT1A, -2A, -2C, -3, -4, -5, -6, -7.6 Therefore, these serotonin-related genes are the candidates for research into the aetiology of depression. Tryptophan hydroxylase is the rate-limiting enzyme of 5-HT biosynthesis, which includes TPH1 and TPH2. The former (TPH1) is predominately expressed in peripheral organs such as the heart, lungs, duodenum, liver, and adrenal glands, and also in some parts of the brain. It is also the main regulator of peripheral 5-HT synthesis. The latter (TPH2) is neuron-specific and only expressed in the brain 5-HT neuron. In some regions of the brain (such as the hippocampus, frontal lobe, thalamus, hypothalamus, and amygdala), the expression levels of TPH1 and TPH2 are almost equal. However, TPH2 is predominately expressed in the brain stem where 5-HT neurons originate.7 Recent studies have shown inconsistent results regarding any association between TPH2 gene polymorphism and unipolar depression.8-16 In 2005, Zhang et al4 found that the human TPH2 gene coding region contains a functional polymorphism, G1463A, leading to the replacement of the 441 arginine position with histidine (R441H). This may cause approximately 80% of TPH2 function loss and significantly reduce 5-HT generation. …
Introduction Schizophrenia has been described as an ungraspable, deathlike calamity, not only to psychotic patients, but also to their kin. (1) The uncertainty associated with persistent mental illness often leads to unresolved grief associated with ongoing loss, which is consistent with the experience of chronic sorrow. (2) Schizophrenia thus takes a heavy toll on patients and their families. Aside from emotional, psychological, and financial difficulties, families of patients with schizophrenia often experience guilt, shame, and embarrassment that becomes a heavy burden. Many studies have investigated the importance of family relationships among individuals with schizophrenia. (3-9) Caring for a relative with schizophrenia is difficult. The term was first mentioned in 1950. (10) At that time, studies that investigated family burden found that caring for a relative with mental illness interferes with the daily lives of the families, with their social activities, work attendance, creates a financial burden and affects the relative's capacity to devote time and emotional resources to the patient's siblings and other healthy family members. (11) Studies from the 1980s contributed to a broader understanding of the treatment burden on caregivers and families. Gender studies reported that relatives of male patients experience limitations and greater lack of functioning than those of female patients. (12) Disturbed behaviour is a greater determinant of burden severity than the psychiatric diagnosis. (13) Moreover, the severity of psychotic symptoms and disability are related to higher levels of family burden. (14) In our department we observed that during the first hospitalisation, family members generally visit the patient, meet with therapists and are involved with the treatment. There is a direct relationship between the length of hospitalisation of the individual with persistent mental illness and the rift created with family members. Among patients with persistent mental illness, we sometimes see a disconnection with the families. The families might lose hope, become angry with the patient, and often prefer to follow the adage of sight, out of mind. Most studies support the idea that family interventions improve the family atmosphere and ease the treatment burden. (15,16) In order to balance the views of patients and their caregivers, families should be involved in the treatment process and support directed at them should be increased. Studies have investigated potential appropriate approaches to various family interventions, including: counselling, supervision or therapy, while attempting to suit specific treatments to each family according to perceived needs. (17) The literature relates to families with high expressed emotions, high intrusiveness, those that do not accept the illness and believe that with good will, the patient will be able to restore normal functioning. (18) Although in the last 3 decades many studies were performed on this topic, there is still a need to find additional useful methods for involving families in the treatment of their relatives and improve the means to support them. Family support programmes promote understanding of the disease, thereby reducing the intensity of distress they experience and help cope with their relatives' disorders. When families understand the patient's limitations and no longer attach blame, the relationships between all parties tend to improve. (19) What is the role of the therapists in the rift between family members and patients? Mental health caregivers often refrain from involving family members in the treatment of their patients. (20) Reasons may include a heavy workload, the feeling that treatment time should be devoted only to the patient, (21) the perception that the family is responsible for the illness, (22) and lack of awareness of the importance of family involvement. In a study performed in Italy, (11) the treatment burden of families of inpatients with anxiety disorders and obsessive disorders was compared with that of families of schizophrenia inpatients. …
Objective: To examine the rate of choking incidents and the associated factors among Chinese psychiatric patients in Hong Kong over a 12-year period. Methods: All choking incidents recorded in a large psychiatric unit in Hong Kong during the inclusive period January 1996 to December 2007 were retrospectively analysed with respect to demographic and clinical variables, and circumstantial factors at the time of the incident. Results: Nineteen choking incidents involving 17 patients were identified. In psychiatric inpatients, the mortality rate due to choking was 8-fold higher than that of the general population. Different age-groups exhibited different clinical characteristics related to the incidents. Medication side-effects and poor eating habits were implicated as contributory causes. Conclusion: Mental health professionals should have a high awareness of the increased risk from choking in psychiatric patients, identify those at high risk, and implement effective preventive measures. Key words: Airway obstruction; Eating; Feeding behavior ... (ProQuest: ... denotes formula omitted.) Introduction Persons with mental illness are at 3- to 5-fold higher risk of sudden death compared with the non-psychiatric population.1 Previous studies focused mainly on suicide and cardiac causes of sudden death.1 Choking has been reported as another important cause of death in these patients, but most of the literature refers to data prior to the 1980s.2 Few recent studies show mental illness as a significant risk factor for death by choking.1 In an analysis of choking deaths in Ireland over a 10-year period, Corcoran and Walsh3 found that 10% of sudden deaths among psychiatric inpatients were due to choking. Another study by Ruschena et al4 reported that in patients suffering from schizophrenia and organic brain syndrome, the relative risks of death by choking were 30 and 43 times that of the general population, respectively. The causes of such excess risk from choking in psychiatric patients are still unclear. Proposed risk factors include: medications (especially extrapyramidal side-effects of typical antipsychotics),1-5 seizures,5 tachyphagia,2,3 and circumstantial factors.1,3 Implementation of effective prevention may be difficult without identified causes. Despite the significance of sudden death by choking, there were no data among Chinese psychiatric patients. This study aimed to determine the rate of choking incidents in psychiatric patients attending a large psychiatric unit in Hong Kong. The association between choking in psychiatric patients and various special characteristics (illness, treatment, environmental factors) and outcomes following choking episodes were also examined. Methods All patients reported to experience choking incidents in the Psychiatric Unit of the Pamela Youde Nethersole Eastern Hospital (PYNEH) from the inclusive period January 1996 till December 2007 were identified using the Hospital Patient Accident / Incident Report System. The PYNEH is a regional acute general hospital having approximately 400 to 600 psychiatric beds during the study period. The Psychiatric Unit managed patients admitted to acute and subacute wards, as well as to rehabilitation and psychogeriatric wards. It also provided day-patient and outpatient psychiatric services. The medical records of all patients with choking incidents were reviewed. A 'choking incident' was defined as a sudden obstruction of the airway by food, or a food bolus in the larynx or the laryngopharynx (the cafe coronary).1,3 Information on each patient's demographics, psychiatric and physical diagnoses, pharmacological treatment, circumstances of the choking, management of the episode and outcomes were also retrieved. Chlorpromazine-equivalent dosages6,7 were estimated for all patients receiving antipsychotics. Statistical Analyses Statistical analyses were performed using the Statistical Package for the Social Sciences (Windows version 14. …
(ProQuest: ... denotes formula omitted.) Introduction In response to the significant increase in the number of young people (aged under 21 years) abusing psychotropic substances over 3 consecutive years, a Task Force for Youth Drug Abuse was formed in October 2007. Their report was released in November 2008. Among the recommendations, the assertion that ...the Administration should undertake a more in-depth study (on school-based drug tests)...tailored to the local school setting, identify success factors, suggest a promotion scheme for voluntary adoption by local schools, and address the various issues of concern...1 has caught most public attention. It was initially planned that the study be implemented in the 2009-2010 school year, with preliminary results and recommendations expected in the following school year. However, repeated instances of secondary school students being sent to the accident and emergency departments for management of intoxication with psychoactive substances while in schools or on public beaches sparked demands for early implementation of school-based drug testing in mid-2009. As a result, the secondary schools in Tai Po District were chosen to implement the Hong Kong SAR school-based drug-testing programme in late 2009. The decision to implement drug testing at schools has precipitated heated discussion in the community. Issues related to confidentiality, consent, and the availability of resources for intervention to students with positive test results have been raised. There is a dearth of data on the effectiveness of school-based drug testing as a means of combating psychoactive substance abuse and its potential harm. To address public concern, the Clinical Division on Substance Misuse and Addiction Psychiatry of the Hong Kong College of Psychiatrists embarked on a literature review of the current evidence on the effectiveness of school-based drug testing. Overseas Experience In the United States, government agencies and private employers have adopted drug-testing programmes since 1981. Their reasons for having drug-testing programmes were largely: (1) pre-employment checks; (2) drug detection for specific reasons, i.e. when there is reasonable suspicion of alcohol and drug use following an accident or bizarre behaviour; and (3) routine or random drug screening in the workplace for occupational health, safety concerns and productivity issues. The recent rise in illicit substance abuse among young people has led to a demand for drug screening in schools. The aims are to: (1) deter students from using illicit substances; (2) allow detection of young substance abusers to enable earlier multidisciplinary interventions that could lead to better outcomes. Following the 1995 US Supreme Court ruling (Vernonia School District v. Acton [515 US 646]) that random drug testing of high school athletes is constitutional and the 2002 US Supreme Court ruling that public schools have the authority to perform random drug tests on all middle and high school students participating in extracurricular activities (Board of Education v Earls [536 US 822, 122 S Ct 2559, 153 L Ed 2 days 735 {2002}]), the President's Office of National Drug Control Policy published a guidebook designed to encourage schools to incorporate drug-testing policies for all students. Many reports evaluating the effectiveness of these programmes for school-aged children have subsequently been published. Most rely on anecdotal evidence and journalistic comment with a lack of an evidence-based approach. Effectiveness of Drug Testing for Deterring Drug Use The majority of studies adopted a cross-sectional approach to determine the point prevalence of drug use as their outcome indicator after the implementation of drug-testing programmes.2-6 In the Hunterdon study,7 a change in the self-reported frequency of drug use before and after the implementation of drug-testing programmes was demonstrated, but the effect of other confounding factors (e. …
Introduction Alcohol dependence, a common psychiatric disorder in the general population, has a significant impact on public health. In recent years, alcohol dependence has become a major social and personal menace in most societies. According to the World Health Organization (WHO), (1) alcohol use disorders accounted for 1.4% of the global disease burden. Globally, alcohol consumption causes 3.2% of deaths (1.8 million) and 4.0% of the disability-adjusted life years lost (58.3 million) 2 The WHO also stated that there are causal relationships between alcohol consumption and more than 60 types of disease and injury. (2) Along with the costs incurred by alcohol-related illnesses, alcohol dependence contributes substantially to social, financial, and legal problems. Both pathological and chronic alcohol dependence are directly linked to markedly impaired family interactions, and other serious problems like domestic violence and spousal abuse. (3-5) Chronic alcohol dependence is associated with interpersonal violence and worsening patterns of interaction. Certain behaviours, such as aggression and impulsivity, are common in people with chronic alcoholic dependence. (4-6) Thus, understanding the characteristics of the drinker and the relationship between alcohol dependence and its negative consequences may help to clarify the development and prevention of alcohol-related problems. Some people are more likely than others to experience the consequences of alcohol use. These tend to be associated with being male (7-9); having high perceived stress and anxiety; dissatisfaction with, and poor quality of, life; lack of social support; economic strains; and chronic stress. (10,11) In a study done by Frankenstein et al, (12) spouses of alcohol-dependent individuals were found to have better problem-solving abilities when the husbands were drinking than when they were not drinking alcohol. Alcohol increased the positive interactions between spouses and alcoholic individuals. In another study, which compared 8 alcoholic and 8 non-alcoholic couples, the alcoholic couples had more negative interaction (hostility, blame, criticism) during the drinking period than the non-drinking period. (13) Alcohol has been consumed in India since antiquity. Many mythological texts portray alcoholic beverage drinking by the people of ancient India. The Indian alcohol-drinking pattern has changed dramatically over time. Previously, alcohol use was occasional and had ritualistic connotations; people usually used it during major social events only. But today, the common purpose of consuming alcohol is to get drunk. (14) In India, over 20% of all disability-adjusted life years are lost chiefly because of factors like 'poor health status of the people' and 'marked nutritional deficiencies', as well as 'high prevalence of alcohol addiction among the people'. (15) In northern India, the 1-year prevalence of alcohol use has been estimated as 25 to 40% in the general population, whereas in southern India this rate has been estimated as 30 to 50%. In southern India, the prevalence of alcohol use is higher among people of lower socio-economic status and those who have lower levels of education. (15,16) A large-scale survey over 32,000 people performed in 2001 found alcohol use rates of 20 to 38% in males and 10% among females. (14) There is a paucity of literature investigating the relationship between family interactions and alcohol dependence. The present study was carried out to examine the family interaction patterns in Indian families with alcohol-dependent persons. Methods Design This was a cross-sectional study examining differences between the interactions of the wives of clinically diagnosed alcohol-dependent men and wives of men with no known psychiatric morbidity and substance dependence, including alcohol dependence. The study was carried out among spouses of patients who came to the 'De addiction Centre' of the Central Institute of Psychiatry, a government-owned psychiatric hospital situated in the Ranchi district of Jharkhand State in India. …
Multiple sclerosis, a common demyelinating disorder, has been associated with mood symptoms for years. There are very few reports in which the psychiatric symptoms are either the presenting signs of multiple sclerosis or present simultaneously with neurological signs and symptoms. We present a case where the patient presented with overwhelmingly psychiatric manifestations-delusional parasitosis. The patient gave detailed descriptions of the shape, colour, and types of offending parasites: crawling, biting, burrowing. In such cases, therapy with antipsychotic medication is necessary. Despite treatment with antipsychotics, the patient's delusions persisted and detailed investigations led to a diagnosis of multiple sclerosis as the cause of her psychosis. The authors recommend that clinicians have a high index of suspicion and, after exploring all the common possibilities, should look for neurological causes in a patient with psychosis. Multiple sclerosis is one such condition, where the patient can present with psychotic symptoms even in the absence of neurological deficits. Key words: Antipsychotic agents; Delusion; Parasitic diseases; Psychotic disorders; Hypochondriasis Introduction Multiple sclerosis (MS), a common demyelinating disorder, has been associated with mood symptoms for years. Its association with psychosis has been described in the literature1-4 but not many cases have been reported. Psychosis as a first presentation of MS has always been a hot topic of debate5 but there are very few reports6-8 in which the psychiatric symptoms are either the presenting signs of MS or present simultaneously with the neurological symptoms. We report a case of an individual with MS presenting with a delusion of parasitosis as the first manifestation. There were no neurological signs and symptoms pertaining to MS in this case. Case report Ms B, a 49-year-old African American female with a lifelong history of eczema presented to Psychiatry Emergency (CRISIS) in September 2007 with a 6-month history of seeing and feeling bugs crawling on her skin and on her clothes. These bugs had not been seen by anyone else in her family. The patient reported that the bugs are a species of gnat that came from the everglades. She described different species of angel gnats, which she described as small and less aggravating and not coming near her if she kept her body clean, nasty which were bigger and looked like creatures from outer space and were always present, and misty gnats, aggravating gnats which were the worst ones that the patient could not see but which she could feel, saying they itch, sting and bite. She reported their presence all over her body except the genital areas because she used powder there and the gnats don't like the powder. She self- medicated with creams and insecticide sprays without any benefit and reported using alcohol, tylenol and benadryl for 3 weeks to the sensation of the bugs. She also reported hearing whispers in her house, when alone at home. These gradually disappeared and she has not heard them since. Her history included 3 episodes of depression. The first episode occurred after her first pregnancy, which ended in a miscarriage in 1983. The other 2 episodes were postpartum, occurring after the births of her 2 children (1985 and 1989). She denied being given any treatment for depression. She also gave a history of chronic eczema treated by many doctors with poor results. She said she drank alcohol occasionally at parties (1-2 glasses of wine twice a year) except for recently when she had tried to use alcohol to numb the skin sensation, reporting drinking 3 bottles of wine daily for 3 weeks. She denied any illicit substance use. Her family history was significant for a sister with seizures, a daughter with attention-deficit hyperactivity disorder, and the death of an elder sister 1 year earlier due to colon carcinoma. …
Introduction Electroconvulsive therapy (ECT) is a controversial treatment. In 2003, a systematic review and meta-analysis of its efficacy and safety in depressive disorders was sponsored by the UK Department of Health and performed by the UK ECT Review Group. (1) A major finding of that review was that there was substantial evidence to support the short-term efficacy of ECT in depressive disorders, and that it was superior to antidepressant drug treatment. By contrast, other studies raised concerns about the cognitive side-effects of ECT. (2,3) Empirical stimulus dose titration was proposed as a means of reducing such side-effects. (4,5) In Hong Kong, the utilisation of ECT is low. One study reported the number of persons receiving ECT in Hong Kong in 1998 to be 0.34 per 10,000 of the population, (6) which was much lower than the rate in western countries. (7,8) Also, only in the recent few years has empirical titration been widely practised by Hong Kong psychiatrists. Because of limited ECT research on Chinese patients and the relative lack of local experience with empirical titration, western guidelines have been adopted for this purpose. In particular, recommendations in the ECT Handbook of the Royal College of Psychiatrists were most often referred to. (5) However, western guidelines are based on studies carried out on Caucasians and it is uncertain whether they can be generalised to Chinese patients. With a view to assessing the validity of such an assumption, we describe our early experience of ECT practice after starting empirical titration in 2006 in an acute psychiatric unit in Hong Kong. Methods This was a retrospective review of case notes of patients who had received ECT in the Pamela Youde Nethersole Eastern Hospital in Hong Kong from June 2006 to April 2009. This regional hospital undertakes a full range of specialty services. Its psychiatric unit serves a population of 0.8 million and admits both voluntary and sectioned patients. Empirical stimulus dose titration was first introduced in June 2006 and carried out using a standard protocol. A total of 34 patients received ECT during the 3-year study period. All relevant patient medical and ECT records were retrieved. Data collected included: demographic and clinical characteristics, consent for treatment, ECT parameters, documented side-effects, and clinical response. The ECT treatments were administered with MECTA spECTrum 5000Q (MECTA Corporation, Tualatin [OR], US). The device administered bidirectional, brief, square-wave pulses, using a constant-current stimulus (24-1152 millicoulombs [mC]). The empirical titration method was chosen, unless the patient had a life-threatening psychiatric illness (e.g. high suicidal risk or refusal to eat) necessitating a rapid clinical response, in which case preselected dosing was used. Preselected dosing was also used for patients who had previously responded well to such dosing, or were taking a beta-blocker or were at increased cardiac risk for other reasons. We adopted the protocol recommended by MECTA Corporation for both empirical titration and preselected dosing. (9) Empirical titration started with a stimulus of 48 mC. If this failed to produce a seizure of at least 15 seconds, re-stimulation was performed at the next level of 96 mC, followed by 192 mC; no more than 3 stimulations were undertaken per patient, per session. After the seizure threshold was determined, a stimulus of 50% above the seizure threshold was delivered at the next session. For preselected dosing, a stimulus of 144 mC was administered for females and 288 mC for males, in the belief it corresponded to 50% above the assumed seizure threshold. In patients taking anticonvulsants or benzodiazepines, the latter drugs might be withdrawn or reduced in dosage before starting ECT. Patients were given intravenous thiopentone for anaesthesia and intravenous suxamethonium as a muscle relaxant. All the patients were adequately ventilated with 100% oxygen before the administration of ECT stimulus. …
Objective: To explore the relative contributions of different types of informal social support towards the well-being of caregivers for patients with dementia in Hong Kong. Participants and Methods: In this cross-sectional study, 134 caregivers for patients with dementia completed questionnaires assessing the informal social support available to them and its effect on their psychological well-being in terms of depressive symptoms and general life satisfaction. Results: Informal social support was significantly associated with the well-being of caregivers for persons with dementia. The emotional support provided by spouses and children was found to have significant correlation with enhanced life satisfaction and decreased depressive symptoms in the caregivers. Conclusions: Informal social support correlates strongly with psychological well-being in caregivers managing patients with dementia. Different sources and types of informal support can have differential effects on well-being. Key words: Caregivers; Depressive disorder; Personal satisfaction; Social support; Stress, psychological ... (ProQuest: ... denotes formula omitted.) Introduction Alzheimer's disease (AD) involves progressive degeneration of the brain, leading to impaired memory, thinking, behaviour, self-care and personality, and, eventually, death. In Hong Kong, approximately 60,000 people live with AD. This costs US$1,129.7 million in 2005, including US$260.6 million spent on home-based informal care.1 The ecological theory was developed by Urie Bronfenbrenner2 in the 1970s and has had a significant impact on the investigation of individual behaviour through multiple factors. According to this theory, every single person embeds into 4 layers: (1) the micro-system, the innermost layer; (2) the meso-system, the second layer; (3) the exo-system, the outer layer; (4) the macro-system, the outermost layer. In brief, the microsystem contains the structures with which the individual has direct contact, such as the family and school. The mesosystem refers to the connections between two or more micro-systems such as the family. The exo-system, which is a larger environmental system, exerts an indirect impact on the individual, and includes the social security and medical care systems. Lastly, the macro-system comprises the culture, the customs, and the legal, political, and economic systems, which in turn impact on all other systems. The ecological theory emphasises person-environmental exchanges across the lifespan. Through understanding the connections between caregivers and their different systems, professionals can better utilise the strengths of the systems and thereby choose the best possible interventions across the layers. In the ecological theory, social support and its influence originate from different systems to exert impact on the individual. Social support has the potential to help us understand the dynamic interactions between the individual and the social environment.3 Albee4 argued for the prominent role of social support in his analyses linking prevention to the epidemiology of psychopathology. A negative correlation has been found between social support and depression in older adults and the caregivers of patients with dementia.5,6 It has been shown that the survival and quality of life of people with dementia is related to the well-being of their caregivers.7 Caregivers may experience adverse psychological, physical, social, and financial consequences. Many caregivers become socially isolated soon after adopting the caregiver role, leading to lower levels of psychological well-being.8,9 The caregiver role is crucial to community care of patients with dementia. Social support may relieve the burden on caregivers and help them adapt better to the caregiving role.10-12 A recent meta-analysis of the dementia caregiver literature has established 2 major domains with important empirical influences on caregivers' adjustment in terms of burden and depression: firstly, the care demands posed by the care recipients' characteristics, and secondly the resources available to the caregivers. …
Introduction Childbirth is one of the most complicated events in human experience in terms of biological, psychological, and social perspectives. Childbirth is viewed by society as a joyful event. However the real experiences of mothers are often more complex than this idealized image. Instead of the expected fulfilment and tranquility, many women struggle with new sets of demands and expectations, loss of order and routine, feelings of being 'trapped', and having to endure sleepless nights. The transition in their role to the parenthood may also involve changes in relationships with their partners, career decisions, and social isolation. Other challenges may involve financial distress and housing problems (especially when a pregnancy is unplanned). The stresses and emotional upheaval in vulnerable women may predispose them to psychiatric morbidity. Most reports regarding psychiatric disturbances in the postpartum period fall into 3 groups--postpartum blues, postpartum depression, and postpartum psychosis. Some of the disturbances are part of what may be termed general psychiatric disorders, but some may be closely related to the reproductive process. Apart from the postpartum psychosis, other non-psychotic disorders are commonly subsumed under the rubric of antenatal and postnatal depression. There are dangers of grouping diverse disorders under a single heading.' Some studies show that anxiety disorders may be more common than depression.' Anxiety disorders in pregnancy and childbirth have a specific focal content, for which specific interventions may be indicated.' The focus of antenatal anxiety could be: fear of foetal abnormality, fear of foetal loss (especially after previous reproductive difficulties and losses),' fear of stillbirth, fear of childbirth, and fear of inadequacy as a mother. The focus of postnatal anxiety could be: fear of the newborn, based on the awesome responsibility of care'; some mothers develop infant-focused anxiety, or obsessive impulses and thoughts, with phobias about the baby.' Fear of cot death could result in exhausting nocturnal vigilance.' Moreover, many mothers are excessively troubled about the health and safety of their children. One in 10 women suffer from postnatal depression (PND) without psychotic features. (10) Prevalence rates vary depending on the population studied, the method of assessment, and the length of the postpartum period under evaluation. A striking feature of PND is that it impacts both mother and infant. Its effects include cognitive and social difficulties, difficulty in attachment and infant development. All such adverse effects may persist even after resolution of maternal symptoms. Postnatal depression also affects relationship with the partner, and appears to exacerbate problems that existed before the pregnancy, since a poor marital relationship has been described to be a risk factor for PND. (12) Relatively little attention has been given to the relationship between anxiety disorders and childbirth. The 2 conditions frequently co-exist. (13) It is highly likely that many women who report depression in the postpartum period also experience clinically significant levels of anxiety. Recent studies suggest that postpartum anxiety disorders are underestimated and are more common than depression. (14-18) A prospective study demonstrated that nearly 20% of postpartum women reporting dysphoria also experience panic and / or obsessive compulsive symptoms. Anxiety appears to be a common experience in women who are 4 to 6 months postpartum. There could be a biological basis for some postpartum anxiety. Me Ivor and colleagues (20) studied the growth hormone response to apomorphine (a test of D2 receptor sensitivity) in 14 puerperal women with a history of depression. The greatest increase in receptor sensitivity was found in the 3 women who developed postpartum anxiety disorders. Women exhibit increased levels of cortisol during pregnancy and at the beginning of the postpartum period. …
Objective: Stability of diagnosis is one measure of predictive validity for psychiatric syndromes. It is an under-studied area despite its clinical and research implications. This report aimed to critically review the literature concerning diagnostic stability in functional psychosis. Methods: Articles concerned with evaluating the diagnostic stability of functional psychosis and factors associated with diagnostic change were reviewed. Results: Despite methodological variation, schizophrenia was found to be the most stable diagnosis followed by affective psychosis. Other psychotic disorders were diagnostically unstable over time. Around one-fifth of patients with first-onset psychosis had their diagnoses revised at follow-up. Diagnostic change occurred early in the course of the psychotic illness. The major pattern of diagnostic shift was towards schizophrenia spectrum disorders, particularly schizophrenia. Few variables were identified as predictors of such diagnostic conversion and the evidence established thus far is inconclusive. Conclusions: The present analysis indicates that diagnostic uncertainty and temporal instability is common in the early phase of psychosis especially in less prevalent diagnostic categories. It also highlights the limitations of the contemporary nosological classification in functional psychosis. In the absence of biological markers, a diagnostic process taking into account longitudinal observations across consecutive episodes should be a major requirement for making a definitive diagnosis. Key words: Diagnosis, differential; Early diagnosis; Follow-up studies; Psychotic disorders Introduction Diagnosis is regarded as a sine qua non for clinical practice and research.1 It provides information about patients' symptom profiles, prognosis, treatment outcomes and sets the boundaries for research through delineating homogeneous patient groups.2 Unlike other branches in medicine where there is better understanding of the underlying biological processes, in psychiatry the diagnoses are still based on identification of clinical syndromes. The introduction of explicit operational criteria and rule-based classifications significantly improved diagnostic agreement.3 Nevertheless, adequate diagnostic reliability does not necessarily provide information about the construct of disorders.4 Owing to the lack of objective measurements for making definitive diagnoses, operationalised diagnoses should therefore be regarded as provisional and the validity of the diagnoses of psychotic disorders incorporated by the contemporary classifications cannot be taken for granted.3,5 It is stated that a valid diagnostic category should be defined by more fundamental characteristics such as physiological, pathological, or genetic abnormalities.3 In the absence of clinicopathological correlates, it is difficult to verify psychiatric syndromes.6 Outcome has been regarded as the most important and the most widely applicable criterion of validity in the context of clinical psychiatry.7 Stability of diagnosis over time, being an outcome measure, has been postulated as one criterion for diagnostic validity8,9 as it is the measure of the degree to which a diagnosis remains the same at subsequent evaluations.10 It is assumed that the more stable the diagnosis, the more likely it is to reflect a basic and consistent psychopathological or pathophysiological process and is hence more valid.11 Diagnostic revision can be attributable to a change in the clinical picture and methodological artifacts such as information variance, unreliable assessment, inconsistent application of diagnostic criteria, and low inter-rater reliability.12 In most epidemiological studies, a subject's lifetime diagnosis for longitudinal outcome analysis is usually based on the cross-sectional diagnosis derived from a baseline assessment.13 Yet it is known that any given patient's diagnosis can change over time. …
Objectives: To summarise Antipsychotic Trials of Intervention Effectiveness with respect to clinical outcomes following the treatment of schizophrenia. Methods: Articles were searched from PubMed with key words Clinical Antipsychotic Trials of Intervention Effectiveness, and published from January 2000 to April 2008. Studies reporting original research findings concerning clinical outcomes from such trials in patients with schizophrenia were selected for review. Results: Conventional and atypical antipsychotics had similar clinical effectiveness, neurocognitive and functional outcomes. Among atypical antipsychotics, olanzapine showed better effectiveness but worse metabolic outcomes. Medical co-morbidity was common among schizophrenic patients. Conclusions: With reference to findings from Antipsychotic Trials of Intervention Effectiveness in schizophrenia, review of local prescribing and monitoring practice is recommended. Key words: Antipsychotic agents; Review; Schizophrenia Introduction The Antipsychotic Trials of Intervention Effectiveness (CATIE) in schizophrenia study was the largest project ever conducted to evaluate treatment effectiveness in real-world schizophrenic patients. The CATIE was supported by the National Institute of Mental Health and costed about US$50 million, lasted 4 years and involved over 50 clinical sites in the United States. About 1,500 patients participated in this 3-phase study. Articles concerning this study have been published since 2003 and many findings have been reported in the ensuing years. A variety of topics have been covered, some of which caused debate about the management of schizophrenia, especially with respect to clinical outcomes. The aim of this study was to review CATIE findings in the context of clinical outcomes for schizophrenia treatment. Methods Reports of original research findings from the CATIE study about patients with chronic schizophrenia are included in this review. To identify appropriate studies, a literature search was conducted using PubMed with key words Clinical Antipsychotic Trials of Intervention Effectiveness, and for articles published from January 2000 to April 2008. The search strategy yielded 124 English-language studies. The abstracts were obtained for further inspection. Eight studies were about the CATIE project for Alzheimer's disease, 9 used samples from the CATIE project for other research, 4 used CATIE assessment instruments for other research, 65 publications were editorials, reviews or correspondences about CATIE project, and 13 were unrelated. The remaining 25 studies met the inclusion criteria and were reviewed, and among them 18 dealt with clinical outcomes arising from interventions with antipsychotics. Results The studies selected for review deal with 4 outcome categories, namely clinical effectiveness, cognition, functionality, and metabolic status. Effectiveness and Cost-effectiveness According to a study by Lieberman et al,1 74% of the patients discontinued their study medication within 18 months. The time to discontinuation of treatment (for any reason) was significantly longer in those treated with olanzapine rather than quetiapine (p
Introduction Deinstitutionalisation and the establishment of community-based based psychiatric services have been the major directions of service development for people with mental illness in Hong Kong over the past few decades. A variety of services, including residential, vocational, community networking, and supportive services, are now available. Nevertheless, these services are rather fragmented and lack coordination. (1) Different professionals from dif different agencies provide services for the same individual. It is not uncommon to find an overlapping of services and a lack of a key worker who plans and oversees the treatment of an individual. (2) Consequently, people with mental illness may not receive adequate or timely services. Although case management has been accepted and used as a major component of mental health services in many countries, it has not been practised in Hong Kong to address the issues of system rigidity, fragmentation, inaccessibility, and lack of accountability of mental health services found in Hong Kong. (2) In 2003, a local non-governmental or organisation that provides services for people with mental illness began to experiment with a case management model to address the above-mentioned pitfalls but case management has not been recognised or financially supported by the government of Hong Kong. This article reports on a comparison between the outcome variables of hospitalisation rate, symptomatology, life skills, and quality of life between people who received case management services in 2 halfway houses and those who received standard halfway house services. Case management is defined as a series of activities that aim to link the service system to a consumer and coordinate system components to achieve a successful outcome. (3) It essentially serves a problem-solving function and is designed to ensure continuity of services and overcome system rigidity, fragmentation, inaccessibility, and the lack of accountability of mental health services. It is commonly described as a flexible, planned, and individualised approach to service delivery that provides consumer choice and maximises the efficient use of formal and informal resources in service provision. (4-7) Numerous overseas studies have examined different models of case management for people with severe and persistent mental illness. (8,9) In a meta-analysis of 75 studies on the efficacy of case management, Mueser et al (10) found a consistent reduction in length of hospital stay for those in the case management groups. Holloway et al (11) reviewed a number of studies and found that people who received case management services had a statistically significant decrease in symptomatology when compared with those who did not. Two studies have found that people who received case management services showed an improvement in overall functioning and social adjustment, and an increase in global functioning as measured by the Global Assessment Schedule (GAS). (12,13) Stein and Test (14) found that case management improved the quality of life of clients. Wright right et al (15) also reported increased satisfaction in life for patients. Other studies reported that case management had positive effects on patients' social networks and relationships. (14,16,17) According to Aviram, (18) social workers in a case management team occupy a special role involving coordinating different disciplines, mobilising resources at the systems' levels, or organising consumers and the families into self-help and / or advocacy groups, and serving as authorisation and utilisation reviewers for case management companies under the managed care system. Moreover, as case managers, social workers also render supportive and psychotherapeutic counselling to people with severe mental illness in the community. (2) In short, social workers are always considered members of a case management team, and work closely and collaboratively with other professionals to provide services for people with severe mental illness. …
Introduction Body image refers to a person's perceptions, attitudes, and experiences about his / her body. Weight perception is an important part of this concept. Body weight perceptions are not in agreement with actual weight all the time. One study found that 12% of Taiwanese men and 57% of Taiwanese women overestimated their body shape. (1) Weight control behaviours are motivated by perceived weight rather than actual body mass index (BMI). (2) It has been shown that dissatisfaction with one's body weight is an important predictor for engagement in various weight loss activities. (1) This is also true for patients with schizophrenia. (3) Whether accurate or not, people who perceive themselves as overweight wish to, or even try to, lose weight. A discrepancy between the actual and perceived body weight can lead to harmful unnecessary weight reduction if a person perceives that he is overweight but is actually not. On the other hand, if a person is not aware that he is overweight, he is unlikely to get involved in a weight reduction programme. Attitudes towards body size and preferences for a particular level of fatness are mediated by local social and cultural factors. (4) Under the influence of 21st century culture, where thinness equals beauty, negative views towards fatness have been magnified. Studies of body weight perceptions among adolescents in Hong Kong have found poor agreement between BMI and perceived weight in adolescents, particularly in females who frequently overestimated their weight. (2) The weight perception in obese schizophrenic patients has been found to be fairly accurate in overseas studies (3) but there is little local data concerning the weight perception of patients with psychotic disorders. A group of schizophrenic patients were found to be significantly more likely to underestimate their weight than normal controls (46% versus 18%). (5) It would be interesting to compare the body weight perceptions of individuals with psychotic disorders with those of normal controls in Hong Kong. This study aimed to examine (1) the body figure and weight satisfaction and the accuracy of body weight perception in cohorts with psychotic disorders and those without psychotic disorders in Hong Kong; and (2) the relationship between perceived and actual body weight and weight change behaviour. Methods Samples The patient group was recruited at the Early Assessment Service for Young People with Psychosis (EASY) outpatient clinic of a psychiatric hospital serving a population of about one million in Hong Kong. Inclusion criteria were as follows: patients had a primary diagnosis falling into the schizophrenia spectrum disorder category as per the criteria of the International Classification of Disease--10th Revision (ICD-10) classification of mental and behavioural disorders; were able to give informed consent; and had adequate command and understanding of Chinese. Patients who were intellectually subnormal or were diagnosed with eating disorders were excluded. The controls were recruited from a local secondary school and were matched for age and educational level with the patient group. Inclusion criteria required that they were able to give informed consent and to communicate in written Chinese. Those who had histories of being diagnosed with schizophrenia spectrum disorders and eating disorders under the ICD-10, and those with a score higher than or equal to 2 on the Chinese version of the SCOFF questionnaire, which is a highly sensitive screening tool for eating disorders, (6) were excluded. The study was performed during 3 visits in 3 consecutive weeks to the clinic. Subjects who fulfilled the study selection criteria and were able to give consent were enrolled. Those who did not attend the clinic were interviewed when they came back for follow-up on another day. The diagnoses of the patient group were confirmed clinically by interviewing the patient and caregivers and reviewing the case notes. …
Operationalized Psychodynamic Diagnosis OPD-2: Manual of Diagnosis and Treatment Planning Editor: OPD Task Force Hogrefe & Huber Publishers USD75.00; pp332; ISBN: 978-0-88937-353-2 As the name suggests, this book acts as a manual for standardising psychodynamic diagnoses for the different mental and psychosomatic disorders classified in ICD 10 and the DSM IV. The title drew my attention immediately because I think this has long been lacking and such a book can be a valuable aid to our current practice. In the first chapter, the author explains that this book is based mainly on the work of the 'Operationalized Psychodynamic Diagnosis' taskforce, which was formed in 1992 by a group of psychoanalysts, psychosomatically oriented therapists and psychiatrists in Germany. They aimed to expand the symptom-based, description-oriented classification of mental disorders by adding some fundamental psychodynamic dimensions. A diagnostic inventory and manual called 'Operationalized Psychodynamic Diagnosis' (OPD) was then developed for use in clinical practice and as a training manual for experienced therapists. After many years of application in different settings including in- and out-patients, training, and research, and with the availability of research findings based on it, the task force has decided that now is the right time to offer a revised version, OPD-2. This revision takes it from a purely diagnostic instrument to one that also helps with treatment planning and change measurement. The rest of Chapter 1 discusses fundamental considerations made when designing the multi-axial diagnosis and the process of operationalisation of the psychodynamic and psychoanalytic constructs, which was not at all easy. The second chapter summarises the OPD-1 experiences and empirical findings used to develop OPD-2. The OPD-2 has 5 axes, with the first 4 being the psychodynamic axes identifying characteristics of patients as follows: firstly, how they experience their illness and the prerequisites they bring to treatment; secondly, their dysfunctional relationship patterns; thirdly, their unconscious conflicts; and fourthly, their structural characteristics and structurally based vulnerabilities which are very much equivalent to the concept of personality. The last axis concerns mental and psychosomatic disorders in line with chapter V of the ICD 10. Chapters 3 and 4 discuss the operationalisation and manualisation of the Axes of OPD-2, which are very useful for understanding the whole system and how to apply it in a standardised way in clinical settings and research. I find that the concepts are clear, and well illustrated by good use of case vignettes. Axis I on the experience of illness and prerequisites for treatment coincides with our concept of psychological-mindedness, but is not limited to it. It also includes motivation for change, secondary gain issues, and the strengths and resources that patients bring to treatment, which appear to go beyond the conventional emphasis on psychodynamics. Axis II on interpersonal relationships includes the interpersonal presentation of intra-psychic conflicts and structures, which are very much related to transference and counter-transference, the observation and assessment of which can now be documented in a more standardised way. Axis III on conflict and Axis IV on structure offer a very useful distinction between the 2 constructs, which helps very much with the selection of therapeutic stances, foci and techniques. With a low level of integration of structure, meaning, in our conventional terms, patients with more severe personality problems, the distinct occurrence of unconscious conflict, such as submission versus control, or need for care versus self-sufficiency becomes unclear, so the selection of these conflicts as treatment foci becomes unrewarding. …
Abstract Clinical experience and recent research indicate that demoralisation is frequently encountered in medical and psychiatric practice. The three case vignettes reported here illustrate the salient features of demoralisation in psychiatric practice, and are followed by a brief outline of this emerging concept and its significance for clinical practice. Key words: Adaptation, psychological; Anomie; Depression; Diagnosis ... (ProQuest: ... denotes formula omitted.) Introduction The dictionary meaning of 'demoralise' is deprive a person of spirit, courage, to dishearten, bewilder, to throw a person into disorder or confusion.1 The concept of demoralisation was introduced into psychiatry in 1974,2 initially in relation to According to Frank,3 demoralisation was thought to fit well the of candidates for psychotherapy, whatever their diagnostic label, as it was the chief problem of all patients who come to psychotherapy. A demoralised person was described as one who clings to a small round of habitual activities, avoids novelty and challenge, and fears making long-term plans and is in a state of hopelessness, helplessness, and isolation ... preoccupied merely with trying to survive.3 Anger, resentment, sadness, anxiety, puzzlement, discouragement and a frustrating sense of incompetence are the main emotions characterising demoralisation in its initial stage, turning into acceptance of fate, inaction and impasse, the giving-up - given-up complex.4 Demoralisation has rarely been mentioned in the psychiatric literature, even though demoralised patients are frequently encountered in medical and psychiatric practice.4-6 Earlier investigations indicated that a sizeable minority of the American population is demoralised and clinically and socially impaired,7 particularly those with medical or psychiatric disorders.8 Recent studies have confirmed that demoralisation is a significant factor in the psychological distress experienced by medically ill patients.9-11 As there is a paucity of studies on demoralisation in psychiatric patients, we present three case vignettes featuring demoralisation in patients referred for psychiatric assessment and briefly summarise the relevant literature. Case Vignettes Case 1 Mrs. A is a 51-year-old unemployed woman who separated from her husband 13 years ago. Still generously supported by her estranged husband, she lives alone in a rented flat. The couple married 28 years ago but because of the husband's infidelity, the marriage was plagued by serious conflict from the very start. Before their separation, two major family crises drove Mrs. A to despair, despondency and insomnia. She was diagnosed with depression in 1990 by a private practitioner and treated with a small dose of antidepressant and ceiling therapeutic doses of anxiolytics and hypnotics. She has remained on the same dose of anxiolytics and hypnotics since. Over the past 13 years - since separating from her husband - she has not presented with any psychiatric symptoms. She visited a psychiatric outpatient clinic to have her medication prescribed because she could no longer afford visits to the private practitioner. When seen at the clinic, she was lively, cheerful and talkative, giving the impression of a perfectly normal person with no observable psychiatric symptoms. All that she asked of the psychiatric services was that she be given regular prescriptions of the same medications she has been taking for nearly two decades. Mrs. A was made redundant 10 years ago and has since followed a rather monotonous daily routine. She sleeps until 3 p.m., buys takeaway food, watches television and listens to music, then buys food again or prepares dinner, takes her evening hypnotics and benzodiazepines and sleeps for 15 hours - avoid boredom, she says. Daily phone contact with her son, his weekly visits and occasional phone calls from her daughter, who lives overseas, have been her only social relations. …
