Acute psychotic disorders F23

Includes acute schizophrenia-like psychosis, acute delusional psychosis, and other acute and transient psychotic disorders

Presenting complaints Patientsmayexperience:

hallucinations,eghearingvoiceswhennooneisaround strangebeliefsorfears apprehension,confusion perceptualdisturbances aggression,frequentadjudications selfharm foodrefusal(theymaysuspectthatfoodisbeingpoisoned).

Stafforrelativesmayaskforhelpwithbehaviourchangesthatcannotbeexplained,includingstrangeorfrightening behaviour,egwithdrawal,suspiciousnessandthreats. Afirstonsetpsychosismaypresentatfirstaspersistentchangesinfunctioning,behaviourorpersonality(eg withdrawal),butwithoutfloridpsychoticsymptoms. N1Thefirstepisodeofpsychosismostcommonlyoccursinthelate teensandearly20s(seeFirstonsetpsychosis,page131). Diagnostic features Recentonsetof:

hallucinations:falseorimaginedperceptions,eghearingvoiceswhennooneisaround delusions:firmlyheldideasthatarefalseandnotsharedbyothersinthepatientssocial,culturalorethnicgroup,eg

patientsbelievetheyarebeingpoisonedbyneighbours,receivingmessagesfromthetelevisionorbeinglookedatby othersinsomespecialway disorganisedorstrangespeech agitationorbizarrebehaviour extremeandlabileemotionalstates. Differential diagnosis

Physicaldisordersthatcancausepsychoticsymptomsinclude:

druginducedpsychosisand alcoholichallucinosis Itisnotpossibletotellfromthesymptomsalonewhetherpsychiatricsymptomsaresubstanceinduced,whetherthe patienthasapsychoticdisorder,orbothasubstancemisuseandapsychoticdisorder.Checktheirpsychiatrichistory, keepanopenmind(eginateenageroryoungadult,asubstanceinducedpsychosismightbetheearlystagesof schizophrenia)andchartsymptomsovertime(seeComorbidity,page191).Also: infectiousorfebrileillnessand epilepsy. SeeDeliriumF05forotherpotentialcauses(page41). ChronicpsychoticdisordersF20#:ifpsychoticsymptomsarerecurrentorchronic. BipolardisorderF31:ifthesymptomsofmania,egelevatedmood,racingspeechorthoughts,exaggeratedselfworth, areprominent. Depression(depressivepsychosis)F32#,ifdepressivedelusionsareprominent. Essential information for the patient and primary support group

Agitationandstrangebehaviourcanbesymptomsofamentalillness.

 Acuteepisodesoftenhaveagoodprognosis,N2butthelongtermcourseoftheillnessisdifficulttopredictfromanacute

episode. Advisethepatientandmembersoftheprimarysupportgroupabouttheimportanceofmedication,howitworksandthe possiblesideeffects. Continuedtreatmentmaybeneededforseveralmonthsaftersymptomsresolve. IfthepatientrequirestreatmentundertheMentalHealthAct1983,advisethefamily,ifpossible,abouttherelatedlegal issues(seeUseoftheMentalHealthAct,page163). Advice and support of the patient and primary support group

Assesstherisksandconsiderwhetheramovetothehealthcarecentre(orestablishmentwithahealthcarecentre)is

indicated.Ifthereisasignificantriskofsuicide,violenceorneglect,closeobservationinasecureplaceortransfertoan NHShospitalmayberequired.ConsidertheuseoftheMentalHealthActfortransferespecially,butnotsolely,ifthe patientrefusestreatment. Orderaurinedrugscreenformedical(notdisciplinary)purposes(seeComorbidity,page191). Ifitisdecidedthatitissafeforthepatienttoliveonanordinarylocation,seekpatientpermissiontoinvolvethe residentialmanagerandotherrelevantstaff(egworkshopmanager,teacher,chaplain)inimplementingamanagement plan,includingthelocation,activities,theearlyresponsetosignsofrelapseandthemonitoringofmedication.Discussthe following: Ensurethesafetyofthepatientandthosecaringforhim/her: Staff,listeners/buddies,familyorfriendsshouldbeavailableforthepatientifpossible. Ensurethatthepatientsbasicneeds(egfood,drink,accommodation)aremet. Minimisestressandstimulation,egreducingnoise,shouting,bullying,teasing. Donotarguewithpsychoticthinking(youmaydisagreewiththepatientsbeliefs,butdonottrytoarguethattheyare wrong). Avoidconfrontationorcriticism,unlessitisnecessarytopreventharmfulordisruptivebehaviour.N3Respondgently andwithreassurancetoslowresponsestoorders(egslownessingoingintocell).Useofcontrolandrestraintshouldbea lastresort. Encourageresumptionofnormalactivitiesaftersymptomsimprove. Theinformationsheetonmanagingdifficultbehaviour(psychosis)onthediskmaybehelpfultostaff. Especiallyifthepatientbecomesdepressed,consideroptionsforsupport,educationandreassuranceabouttheirpsychotic illness,includingpossiblerelapseandtheirfuturelifechances.Mentalhealthstaffmaybeabletoprovideindividual counselling,goalplanningandmonitoringofearlywarningsignsofrelapse. Referral and throughcare Referraltothesecondarymentalhealthservicesshouldbemadeunderthefollowingconditions: asanemergency,iftheriskofsuicide,violenceorneglectisconsideredsignificant urgentlyforallfirstepisodestoconfirmthediagnosisandtoarrangecareplanningandtheappointmentofakeyworker. Specificinterventionsforpeopleexperiencingtheirfirstepisodeofpsychosis,includingspecificpsychoeducationofthe patientandprimarysupportgroup,shouldbedeveloped5 forallrelapses,toreviewtheeffectivenessofthecareplan,unlessthereisanestablishedpreviousresponsetotreatment anditissafetomanagethepatientintheestablishment ifthereisnoncompliancewithtreatment,problematicsideeffects,failureofcommunitytreatmentorconcernsabout comorbiddrugandalcoholmisuse. Particularlyonrelapse,referralmaybetothecommunitymentalhealthteamortoamemberofit,suchasacommunity psychiatricnurse(CPN),aswellastoapsychiatrist(formoredetails,seeManagingtheinterfacewiththeNHSandother agencies,page149). Ifthereisfever,alteredconsciousness,rigidityand/orlabilebloodpressure,stoptheantipsychoticmedicationand referimmediatelytotheoncallphysicianforinvestigationofneurolepticmalignantsyndrome. Ifreleaseisplanned,workcooperativelywithprobationorthethroughcareplanningofficerstoensurethatappointments withageneralpractitionerandspecialistinmentalhealthcarearearrangedandthathousing,moneyforfood,clothesand heatingarearranged. Ifreleaseisnotplanned,informthelocalmentalhealthservicesthatthepatientmaypresenttoA&Eintheareaand advisethemtolookoutforhim/her(formoreinformationonreferralandthroughcare,seeManagingtheinterfacewiththe NHSandotheragencies,page149).

Medication

Antipsychoticmedicationcanreducepsychoticsymptomsover1014days.Whereaccesstoaspecialistisspeedyand ExamplesofdrugsyoumaywishtousebeforethepatientseesaspecialistincludeanatypicalantipsychoticN6(eg
symptomsrelativelymild,especiallyforafirstreferral,thespecialistmayprefertoseethepatientunmedicated. olanzapine,510mgday1,orrisperidone,46mgday1)oratypicaldrug(eghaloperidol,1.54mguptothreetimesper day)(seeBNF,Section4.2.1).Patientsexperiencingafirstepisodeofpsychosisrequirelowerdosesofmedicationandmay benefitfromanatypicaldrug.N7Inacaseofrelapsewherethepatienthaspreviouslyrespondedtoadrug,restartthat drug.Thedoseshouldbethelowestpossibleforthereliefofsymptoms.8 Antianxietymedicationmayalsobeusedfortheshortterminconjunctionwithneurolepticstocontrolacuteagitation anddisturbance(seeBNF,Section4.1.2).(Examplesincludediazepam,510mguptofourtimesperday,orlorazepam,1 2mguptofourtimesperday.)Ifrequired,diazepamcanbegivenrectallyorlorazepamIM(thoughthismustbekept refrigerated). Monitorcompliance(egcallupforareviewifmorethantwodosesaremissed)andcheckthatthepatientisnotbeing pressuredorbulliedintogivingthemedicationtosomeoneelse. Continueantipsychoticmedicationforatleast6monthsaftersymptomsresolve.9Closesupervisionisusuallyneededto encouragepatientagreement. Bealerttotheriskofcomorbiduseofstreetdrugs(egopiates,cannabis,benzodiazepines). Monitorforsideeffectsofthemedication: AcutedystoniasorspasmsmaybemanagedwithoralorinjectableantiParkinsoniandrugs(seeBNF,Section4.9.2)(eg procyclidine,5mgthreetimesperday,ororphenadrine,50mgthreetimesperday). Parkinsoniansymptoms(egtremor,akinesia)maybemanagedwithoralantiParkinsoniandrugs(seeBNF,Section 4.9.2)(egprocyclidine,5mgthreetimesperday,ororphenadrine,50mgthreetimesperday). WithdrawalofantiParkinsoniandrugsshouldbeattemptedafter23monthswithoutsymptomsasthesedrugsare liabletomisuseandmayimpairmemory. Akathisia(severemotorrestlessness)maybemanagedwithdosagereductionorblockers(egpropranolol,3080 mgday1)(seeBNF,Section2.4).Switchingtoanatypicalantipsychotic(egolanzapineorquetiapine)mayhelp. Othersideeffects,egweightgainandsexualdysfunction. Formoredetailonantipsychoticdrugsandtheirdifferingsideeffectprofiles,seeMaudsleyPrescribingGuidelines10.The2001 edition(ISBN1853179639)isavailablefrom:ITPS.Tel:01264332424. Resources for patients and primary support groups ManicDepressionFellowship:02077932600 (Supportandinformationforpeoplewithmanicdepressionandtheirfamiliesandfriends) MINDInfoline:08457660163(outsideGreaterLondon):02085221728(GreaterLondon) (Nationaltelephoneinformationserviceonmentalhealthissues) NationalSchizophreniaFellowship:02089746814(adviceline:MondayFriday,10:30am3pm) (Adviceandinformationforpeoplesufferingfromschizophrenia,andtheirfamiliesandcarers) SANEline:08457678000(7nightsaweek,12pm2am) (Nationalhelplineformentalhealthinformationandsupporttoanyonecopingwithmentalillness) Resourceleaflets: CopingwiththeSideeffectsofMedication Workingwithaprisonerwhohasaseverementalillness

Including acute stress reaction

Adjustment disorder F43.2

Presenting complaints

Patientsfeeloverwhelmedorunabletocope. Theremaybestressrelatedphysicalsymptomssuchasinsomnia,headache,abdominalpain,chestpainandpalpitations. Patientsmayreportsymptomsofacuteanxietyordepression. Patientsmayseekdrugstohelpthemdealwiththeirfeelings. Alcoholusemayincrease.

Diagnostic features

Acutereactiontoarecentstressfulortraumaticevent. Extremedistressresultingfromarecentevent,orpreoccupationwiththeevent. Symptomsmaybeprimarilysomatic. Othersymptomsmayinclude:

loworsadmood anxiety worry feelingunabletocope.

Anacutereactionusuallylastsfromafewdaystoseveralweeks. Differential diagnosis Acutesymptomsmaypersistorevolveovertime.Ifsignificantsymptomspersistformorethan1month,consideran alternativediagnosis. Ifsignificantsymptomsofdepressionpersist,seeDepressionF32#(page47). Ifsignificantsymptomsofanxietypersist,seeGeneralisedanxietyF41.1(page64). Ifsignificantsymptomsofbothdepressionandanxietypersist,seeChronicmixedanxietyanddepressionF41.2(page 33). Ifstressrelatedsomaticsymptomspersist,seeUnexplainedsomaticcomplaintsF45(page94). Ifsymptomsareduetoaloss,seeBereavementZ63(page23). Ifanxietyislonglastingandfocusedonmemoriesofaprevioustraumaticevent,seePosttraumaticstressdisorder F43.1(page82). Ifdissociativesymptoms(suddenonsetofunusualordramaticsomaticsymptoms)arepresent,seeDissociative (conversion)disorderF44(page15). Essential information for the patient and primary support group

Stressfuleventsoftenhavementalandphysicaleffects.Theacutestateisanaturalreactiontoevents. Adjustmenttoimprisonmentiscommonlystressful(especiallyifthepatientisinprisonforthefirsttime,hasahigh
publicprofileorisasexualoffender)withunderstandableconcernsabouttheirfamilyandthecase. Stressrelatedsymptomsusuallylastonlyafewdaysorweeks. Allpeopleareaffectedbytheirenvironment.Symptomsarelikelytobefewerandlesspersistentiftheenvironmentcan beimproved(egareductioninthefearofbullying/assault,moretimeoutofthecell,contactwithfamily,accesstowork andopportunitiestobecreative). Advice and support of the patient and primary support group N11

Reviewandreinforcethepositivestepsthepatienthastakentodealwiththestress. Identifythestepsthepatientcantaketomodifythesituationthatproducedthestress.Thereisaproblemsolvingsheeton
thedisk.Ifthesituationiswithintheprison(egbullying),supportthepatientindealingwithit(egdiscussthe problemwithresidentialmanager,withpatientpermission).

 Ifthesituationcannotbechanged,discusscopingstrategies.Explorewhetherthepatientisusingdestructivestrategies(eg
drugs,aggression,selfinjury).Encourageexercise,art,reading,workandcontactwithothers.Consideractingasthe patientsadvocatetoincreaseaccessto,forexample,suitableworkplacementsthatinvolvecontactwithsupportive people,artmaterialsandexercise. Ifthestressorisrecentimprisonmentitself,ensurethepatienthascopyofthePrisonersInformationBook.Seethediskfora copyoftheJustImprisoned?leafletandtheResourcedirectory(page316)foragenciesthatoffersupport.Ifthepatient cannotread,advisehim/hertoapproachthepersonalofficerorlistener/buddywithquestions. Identifyrelatives,friends,staffandhelplinesabletooffersupport,eglistener/buddy,Samaritans,chaplainandpersonal officer. Shorttermrestandrelieffromstressmayhelpthepatient.Encourageareturntousualactivitieswithinafewweeks. Encouragethepatienttoacknowledgethepersonalsignificanceofthestressfulevent. Offeringafurtherconsultationwithamemberoftheprimarycareteamtoseehowthesituationdevelopscanbevaluable inhelpingthepatientthroughtheepisode. Medication Mostacutestressreactionswillresolvewithouttheuseofmedication.Skilledgeneralpractitioneradviceandreassuranceis aseffectiveasbenzodiazepines.N12However,ifsevereanxietysymptomsoccur,considerusingantianxietydrugsforupto 3days.Ifthepatienthassevereinsomnia,usehypnoticdrugsforupto3days.Dosesshouldbeaslowaspossible(seeBNF, Sections4.1.1and4.1.2). Referral SeeReferralcriteriafornonurgentreferral(page152).Itisusuallyselflimiting.Routinereferraltothesecondarymental healthservicesisadvisedif: symptomspersistandgeneralreferralcriteriaaremetand youareunsureofthediagnosis. Considerrecommendingacounsellor,ifavailable,orvoluntary/nonstatutorycounselling13services,ifavailable,inall othercaseswheresymptomspersist. Resources for patients and primary support groups Childline:08001111(24hourfreephonehelpline) (Forchildrenandyoungpeopleintroubleordanger) CitizensAdviceBureau(seethelocaltelephonedirectory) (FreeadviceandinformationonSocialSecuritybenefits,housing,familyandpersonalmatters,moneyadvice,andother issues) Relate:01788573241 (Counsellingandpsychosexualtherapyforadultswithrelationshipdifficulties.Foragenciesthatprovideopportunities forcreativeactivityinprisons,seetheResourcedirectory,page316) SamaritansHelpline:08457909090(24hours,7daysperweek) (Supportbylisteningforthosefeelinglonely,despairingorsuicidal) VictimSupport:08453030900(supportline:MondayFriday,9am9pm;SaturdayandSunday,9am7pm;Bank Holidays,9am5pm) (Emotionalandpracticalsupportforvictimsofcrime) UKRegisterofCounsellors:08704435232 (ProvidesthenamesandaddressesofBACPaccreditedcounsellors) Resourceleaflets: ReactionstoTraumaticStress:WhatToExpect GettingaGoodNightsSleep

Alcohol misuse F10

Presenting complaints Patientsmaypresentwith: adepressedmood nervousness insomnia physicalcomplicationsofalcoholuse(egulcer,gastritis,liverdisease,hypertension) accidentsorinjuriesduetoalcoholuse aggression,frequentadjudications poormemoryorconcentration evidenceofselfneglect(egpoorhygiene) failedtreatmentfordepression. Theremayalsobe: legalandsocialproblemsduetoalcoholuse,egdrinkdrivecharges,drivingwhenpreviouslydisqualifiedbecauseof alcoholuse,assault,maritalproblems,domesticviolence,childabuseorneglect,and signsofalcoholwithdrawal,egsweating,tremors,retching,hallucinations,seizures. Patientsmaysometimesdenyorbeunawareofalcoholproblems.Imprisonmentmaybringtheirfirstexperienceof withdrawal.Staffmayrequesthelpbeforethepatientdoes.Problemsmayalsobeidentifiedduringroutinereception screeningor23daysfollowingreception. Diagnostic features

Harmfulalcoholuse:

heavyalcoholuse(eg>28unitsperweekformen,>21unitsperweekforwomen) overuseofalcoholhascausedphysicalharm(egliverdisease,gastrointestinalbleeding),psychologicalharm(eg depressionoranxietyduetoalcohol)orhasledtoharmfullegalconsequences(egimprisonment). Alcoholdependence:presentwhenthreeormoreofthefollowingarepresent: Astrongdesireorcompulsiontousealcohol. Difficultycontrollingalcoholuse. Withdrawalsymptoms(egagitation,tremors,sweating,nausea,headache)evenwhendrinkingisceased. Tolerance,egdrinkslargeamountsofalcoholwithoutappearingintoxicated. Continuedalcoholusedespiteharmfulconsequences. Bloodtestssuchasglutamyltransferase(GGT)andmeancorpuscularvolume(MCV)canhelpidentifyheavydrinkers. AdministeringtheAUDITquestionnairemayalsohelpdiagnosis.IfAUDIT>8,useoftheSeverityofAlcoholDependence Questionnaire(SADQ)canhelpidentifytheseverityofdependence.CopiesoftheAUDITandSADQareonthedisk. Differential diagnosis Symptomsofanxietyordepressionmayoccurwithheavyalcoholuse.Alcoholusecanalsomaskotherdisorders,egsocial phobiaandgeneralisedanxietydisorder.Assessandmanagesymptomsofdepressionoranxietyifthesymptomscontinue afteraperiodofabstinence(seeDepressionF32#orAnxietyF41.1,pages47and33). Drugmisusemayalsocoexistwiththeseconditions. Essential information for the patient and primary support group

Alcoholdependenceisanillnesswithseriousconsequences. Ceasingorreducingalcoholusewillbringmentalandphysicalbenefits. Drinkingduringpregnancymayharmthebaby. Formostpatientswithalcoholdependence,thephysicalcomplicationsofalcoholabuseorapsychiatricdisorder,

abstinencefromalcoholisthepreferredgoal.14Sometimes,abstinenceisalsonecessaryforsocialcrises,toregaincontrol overdrinkingorbecauseoffailedattemptsatreducingdrinking.Becauseabruptabstinenceoccursuponreceptioninto prisonandcauseswithdrawalsymptomsinpeopledependentuponalcohol,detoxificationundermedicalsupervisionina DetoxificationUnitisnecessary.

 Insomecasesofharmfulalcoholusewithoutdependenceorwherethepatientisunwillingtoquit,controlledorreduced
drinkingisareasonablegoalbutmayonlybepursuedafterrelease. Relapsesarecommon.Controllingorceasingdrinkingoftenrequiresseveralattempts.Theoutcomedependsonmany factors,includingthemotivationandconfidenceofthepatient,theoffendingbehaviour,polydruguse,theirmoodor othermentaldisorder. Advice and support to the patient and primary support group 15 Forallpatients: Discussthebenefitsandcostsofdrinking(includingthelinksbetweendrinkingandoffending)fromthepatients perspective. Givefeedbackinformationaboutthehealthrisks,includingtheresultsofGGTandMCV. Emphasisethepersonalresponsibilityforchange. Giveclearadvicetochange. Assessandmanageanyphysicalhealthproblemsandnutritionaldeficiencies(egvitaminB,thiamine). Considertheoptionsforproblemsolvingortargetedcounsellingtodealwithlifeproblemsrelatedtoalcoholuse. Ifthereisnoevidenceofphysicalharmduetodrinkingorifthepatientisunwillingtoquit,acontrolleddrinking programmeisareasonablegoalifthepatientisabouttobereleased: Negotiateacleargoalfordecreaseduse(egnomorethanacertainnumberofdrinksperday,withacertainnumberof alcoholfreedaysperweek). Discussstrategiestoavoidorcopewithhighrisksituations(egrelease,socialsituationsandstressfulevents). Introduceselfmonitoringprocedures(egadrinkingdiary)andasaferdrinkingbehaviour(egtimerestrictions, decelerationofdrinking). Forpatientswithphysicalillnessand/ordependencyorfailedattemptsatcontrolleddrinking,anabstinenceprogrammeis indicated. Forpatientswillingtostopnow: Discussthesymptoms,risksofdetoxificationandmanagementofalcoholwithdrawal(especiallyiftheyhavenoprevious experienceofdetoxification). Discussthestrategiestoavoidorcopewithhighrisksituations(egrelease,socialsituationsandstressfulevents). Makespecificplanstoavoiddrinking(egwaystofacestressfuleventswithoutalcohol,waystorespondtofriendswho stilldrink). Helppatientstoidentifyfamilymembersorfriendswhowillsupportceasingalcoholuse. Consideroptionsforsupportafterwithdrawal. Forpatientsnotwillingtostoporreducenowandwhoareabouttobereleased,aharmreductionprogrammeisindicated: Donotrejectorblame. Clearlypointoutthemedical,legalandsocialproblemscausedbyalcohol. Considerthiaminepreparations. Makeafutureappointmentwiththegeneralpractitioner/primarycaretoreassesstheirhealthandalcoholuse. Forpatientswhodonotsucceedorwhorelapseortransfertousingadifferentdrugwhileinprison: Identifyandgivecreditforanysuccess. Discussthesituationsthatledtorelapse. Returntoearlierstepsabove.

Selfhelporganisations(egAlcoholicsAnonymous),voluntaryandnonstatutoryagenciesareoftenhelpful.16 Medication

Inprison,itisoftendifficulttoconfirmapatientshistoryofprevioussubstanceuse.Therefore,detoxification shouldalwaysbeundertakeninasupervisedinpatientsetting(seePrisonServiceOrder3550:ClinicalServicesfor SubstanceMisusers). Forpatientswithmildwithdrawalsymptoms,frequentmonitoring,support,reassurance,adequatehydrationand nutritionaresufficienttreatmentwithoutmedication. 17 Patientswithamoderatewithdrawalsyndromerequirebenzodiazepinesinadditiontofrequentmonitoring,support, reassurance,adequatehydrationandnutrition.Detoxificationshouldonlybeundertakenbypractitionerswith appropriatetrainingandsupervision.

 Patientsatriskofacomplicatedwithdrawalsyndrome(egwithahistoryoffitsordeliriumtremens,ahistoryofvery

heavyuseandhightolerance,significantpolydruguse,severecomorbidmedicalorpsychiatricdisorder)orarea significantsuicideriskmayrequireatransfertoanNHShospital. Chlordiazepoxide(Librium),10mg,isrecommended.Theinitialdoseshouldbetitratedagainstwithdrawalsymptoms, withinarangeof540mgfourtimesperday.(SeeBNFsection4.10.)Thisrequiresclose,skilledsupervision. Thefollowingregimeniscommonlyused,althoughthedoselevelandlengthoftreatmentwilldependontheseverityof alcoholdependenceandindividualpatientfactors(egweight,sex,liverfunction): Days1and2: 2030mgQDS Days3and4: 15mgQDS Day5: 10mgQDS Day6: 10mgBD Day7: 10mgnocte Chlormethiazoleisnotrecommendedforcravingordetoxificationunderanycircumstances.18 Dispensingshouldbedosebydoseandsupervisedtopreventtheriskofmisuseoroverdose. Thiamine(150mgday1individeddoses)shouldbegivenorallyfor1month.19Asoralthiamineispoorlyabsorbed, transferthepatientimmediatelytoA&Eforparenteralsupplementationifanyoneofthefollowingispresent:ataxia, confusion,memorydisturbance,deliriumtremens,hypothermiaandhypotension,opthalmoplegia,orunconsciousness. ThesemayindicatetheonsetofWernickesencephalopathy. Dailyobservationisessentialinthefirstfewdays,thenitisadvisablethereaftertoadjustthedoseofthemedication,to checkforseriouswithdrawalsymptomsandtomaintainsupport. Anxietyanddepressionoftencooccurwithalcoholmisuse.Thepatientmayhavebeenusingalcoholtoselfmedicate.If symptomsofanxietyordepressionincreaseorremainafteranabstinenceofmorethan1month,seeDepressionF32# orGeneralisedanxietyF41.1(pages47and64).Selectiveserotoninreuptakeinhibitor(SSRI)antidepressantsare preferredtotricyclics(TCAs)becauseoftheriskoftricyclicalcoholinteractions(fluoxetine,paroxetineandcitalopramdo notinteractwithalcohol)(seeBNF,Section4.3.3).Foranxiety,benzodiazepinesshouldbeavoidedbecauseoftheirhigh potentialforabuse20(seeBNF,Section4.1.2). Forfurtherinformationonalcoholdetoxification,seeDrugMisuseandDependenceGuidelinesonClinicalManagement.21 Forinformationonbriefinterventionsforpeoplewhosedrinkingbehaviourputsthematriskofbecomingdependent,see BriefInterventionGuidelines.22 Referral Considerreferral: totheDetoxificationUnitifthepatientisdependentuponalcohol toinvolvetheinhouseorsecondarymentalhealthservicesinadditionifthepatienthasanassociatedmajorpsychiatric disorder,orifthesymptomsofmentalillnesspersistafterdetoxificationandabstinence forcounsellingtargetedatproblemsassociatedwith/triggeringdrinkingandrelapsepreventionwork,ifavailable. Beforerelease: Ifpossible,arrangeforongoingrehabilitationsupportinthecommunity.Ifitisavailable,specificsocialskillstrainingN23 (whichaimstoimprove,forexample,relationshipskillsandassertiveness)andcommunitybasedtreatmentpackages N24 (whichprovidehelpwithfindingajobandsociallife)bothmaybeeffectiveinreducingdrinking. Referpatientswithamentalillnesswhoaremisusingalcoholandwhoexpresssomemotivationtoreducetheirusetoa specialistNHSalcoholservice,amentalhealthserviceorboth.Ideally,carewillbeprovidedbyateamskilledintreating bothmentalillnessandsubstanceabuse.25Ifeitherthepsychiatricorsubstancemisuseproblemappearstopredominate, referinitiallytothatservice.Maketherationaleclearintheletter/fax.Ifbothtypesofdisorderareofequalsignificance, thennegotiatewithbothagenciesaboutthepreferredinitialreferralroute.Itmaybethattheindividualwillrequire supportandinputbybothagencies.Someagenciescanprovideservicesjointly.Liaisewiththeservicetoensure continuedprescriptionofpsychotropicmedication,ifappropriate. Stresstothepatientthatrelapsesaretobeexpected,arenotsignsoffailureandwillnotmeanalossofyoursupportand respect. SeeComorbidity(page191). Resources for patients and primary support groups AlAnonFamilyGroupsUKandEire:02074030888(helpline:MondayFriday,10am10pm);01412217356

(Supportforfamiliesandfriendsofalcoholicswhetherstilldrinkingornot).Also: Alateen:foryoungpeopleaged1220affectedbyothersdrinking AlcoholicsAnonymous:08457697555(24hourhelpline) (HelplinereferstotelephonesupportnumbersandselfhelpgroupsacrosstheUK,formenandwomentryingtoachieve andmaintainsobriety) Drinkline:08009178282(freephonenationalalcoholhelpline:MondayFriday,9am11pm;SaturdayandSunday,6 pm11pm) Thefollowingorganisationsprovideleafletstosupportbriefinterventionsforpeopleatriskofbecomingdependenton alcohol: AlcoholFocusScotland:01415726700 HealthEducationBoardforScotland:01315365500 HealthPromotionEngland:02077259030 NorthernIrelandCommunityAddictionService:02890664434 SecularOrganisationsforSobriety(SOS):02086989332 (Nonreligiousselfhelpgroup)

Bereavement Z63
Presenting complaints Anacutegriefreactionisanormal,understandablereactiontoloss.Thepatient: feelsoverwhelmedbyloss ispreoccupiedwiththelostlovedoneand maypresentwithsomaticsymptomsfollowingloss. Griefmaybeexperiencedonthelossofalovedoneandalsowithothersignificantlosses(egthelossofachildtakeninto care,ajob,lifestyleorlimb,thebreakdownofarelationship).Itmayprecipitateorexacerbateotherpsychiatricconditions andmaybecomplicated,delayedorincomplete,leadingtoseeminglyunrelatedproblemsyearsaftertheloss. Diagnostic features Normalgriefincludespreoccupationwiththelossofthelovedone.However,thismaybeaccompaniedbysymptoms resemblingdepression,suchas: loworsadmood disturbedsleep lossofinterest guiltorselfcriticism restlessness guiltaboutactionsnottakenbythepersonbeforethedeathofthelovedone seeingthedeceasedpersonorhearingtheirvoice thoughtsofjoiningthedeceased. Thepatientmay: withdrawfromtheirusualactivitiesandsocialcontacts finditdifficulttothinkofthefutureand increasetheiruseofdrugs. Differential diagnosis DepressionF32#.Bereavementisaprocess.Ahelpfulmodelistothinkoffourtaskstobecompletedbythebereaved person: acceptingtherealityofthelossthepatientmayfeelnumb experiencingthepainofgrief adaptingtotheworldwithoutthedeceasedand lettinggoofthedeceasedandmovingon. Considerdepressionif: thepersonbecomesstuckatanypointintheprocess afullpictureofdepressionisstillpresent2monthsafterthelossor therearesignsthatthegriefisbecomingabnormal(severedepressivesymptomsofretardation,guilt,feelingsof worthlessness,hopelessnessorsuicidalideationofaseverityordurationthatsignificantlyinterfereswithdailyliving). Thereisahigherriskofanabnormalgriefreactionunderthefollowingcircumstances:wherethebereavedpersonissocially isolatedorhasahistoryofdepressionoranxiety;wherethebereavedkilledthedeadpersonortheirrelationshipwas ambivalentinotherways;wherethedeadpersonwasachild;andwherethedeathwasviolent,occurredbysuicideor occurredsuddenlyintraumaticcircumstances(especiallyifthebodyisnotpresent). Essential information for the patient and primary support group

Importantlossesareoftenfollowedbyintensesadness,crying,anger,disbelief,anxiety,guiltorirritability. Bereavementtypicallyincludesapreoccupationwiththedeceased(includinghearingorseeingtheperson). Adesiretodiscussthelossisnormal. Informpatients,especiallythoseatgreaterriskofdevelopinganabnormalgriefreaction,oflocalagencies,suchasCruse

BereavementCare,whichofferbereavementcounsellingandaimtohelpguidepeoplethroughtheirnormalgrief.26

 Informpatientswhohavelostorfearlosingachildtothecaresystemofagenciesthatofferadviceandsupport(see

Resourcesbelow).Informthemthattheycanstillbepartoftheirchildrenslives,egbyexchangingnewsinlettersor talkingfacetoface.Ifchildrenareincare,anapplicationcanbemadeforchildrentovisitinprivateconditionsor,ifthisis notdesired,applicationcanbemadetovisitthechildrenattheirhome.Visitingordersneednotbesurrenderedforthis purpose.

Advice and support to the patient and primary support group

Enablethebereavedpersontotalkaboutthedeceasedandthecircumstancesofthedeathorotherloss. Encouragethefreeexpressionoffeelingsabouttheloss(includingfeelingsofsadness,guiltoranger). Offerreassurancethatrecoverywilltaketime.Somereductioninburdens(egwork)maybenecessary. Explainthatintensegrievingwillfadeslowlyoverseveralmonths,butthatremindersofthelossmaycontinuetoprovoke

feelingsoflossandsadness. Takeintoaccounttheculturalcontextoftheloss.27 Medication Avoidmedicationifpossible.Ifthegriefreactionbecomesabnormal(seeDifferentialdiagnosisabove),seeDepression F32#,page47,foradviceontheuseofantidepressants.Disturbedsleepistobeexpected.Ifsevereinsomniaoccurs,the shorttermuseofhypnoticdrugsmaybehelpful,buttheiruseshouldbelimitedto2weeks(seeBNF,Section4.1.1).Avoid theuseofanxiolytics. Referral Recommendthechaplainandvoluntaryorganisations,egCRUSE,forsupportthroughthenormalgrievingprocess. Probationofficersmayprovidepracticaladviceandsupportforwomenwhosechildrenhavebeentakenintocare. Referraltothesecondarymentalhealthservicesisadvised: ifthepatientisseverelydepressedorshowingpsychoticfeatures(seetherelevantdisorder)and nonurgently,ifthesymptomshavenotresolvedby1yeardespitebereavementcounselling. Consideraninhousecounsellor,ifavailable,ornonstatutorybereavementcounsellors13inallothercaseswheresymptoms persist. Referbereavedpeoplewhohavelearningdisabilitiestothespecialistdisabilityteamoraspecialistlearningdisability counsellor. Resources for patients and primary support groups AfterAdoptionHelpline:08456010168(Monday,WednesdayandThursday,10am12pm,2pm4pm;Tuesday,10am 12pm,2pm7pm;01618394932(office);Email:aadoption@aol.com(office) 1214ChapelStreet,ManchesterM37NN (Forpeoplewhosechildrenhavebeenadoptedormaybeadopted,thosewhohavelostachildtoadoptionandarenow caringforanotherchild,andthosewhohavebeenadoptedthemselvesintheNorthWest,YorkshireandWales.Provides information,advice,support,individualandgroupcounsellingbyperson,telephoneandletter;alsobooksandtapes,and trainingforprofessionals.Experienceofprovidingcounsellingtoaprisonundercontract) CompassionateFriendsHelpline:01179539639(MondaySunday, 9:30am10:30pm) (Befriendingandsupportforbereavedparents,grandparentsandsiblings) CruseBereavementCareHelpline:08701671677 (Onetoonebereavementcounselling;selfreferralpreferred) FamilyRightsGroup:08007311696(freephoneadviceline:MondayFriday,1.303.30pm);08007830697(freephone advicelineinTurkish:Tuesday, 10am12pm);02079232628(office) ThePrintHouse,18AshwinStreet,LondonE83DL.Email:office@frg.unet.com (Callersspeakinconfidencetoasocialworkerorsolicitorwhooffersadviceandwritteninformationfreeofcharge. Offersadvice,advocacyandpublicationstofamilieswhosechildrenareinvolvedwithsocialservices.Advicesheets, someinTurkish,Somali,Punjabi,UrduandBengali,includeonesonreunitingchildrenwiththeirfamilies,assistancefor youngpeopleleavingcare,childprotectionandmanymore.Adoption:GuideforBirthFamilies.2.50pluspostageand packing)

FoundationfortheStudyofInfantDeaths(FSID):02072332090(24hourhelpline) Papyrus:01706214449 RosendaleGH,UnionRoad,Rawtenstall,RosendaleBB46NE (Referstosupportgroupsforparentsofyoungpeoplewhohavecommittedsuicide) StillBirthandNeonatalDeathSociety(SANDS):02074365881(MondayWednesday,Friday,10am3pm) (Information,emotionalandphysicalsupporttoparentswhohavelostababy) TalkAdoption:08088081234(nationalhelpline:MondayFriday,3pm9pm);(confidentialemail: helpline@talkadoption.org.uk) (Foryoungpeopleunder25whohavechildrenwhohavebeenormaybeadoptedorhavebeenadoptedthemselves)

Bipolar disorder F31

Presenting complaints Patientsmayhaveaperiodofdepression,maniaorexcitement,withthepatterndescribedbelow.Referralmaybemadeby othersduetolackofinsight,complainingofaggression,frequentadjudications,selfharmorfoodrefusal. Diagnostic features Periodsofmaniawith: increasedenergyandactivity elevatedmoodorirritability rapidspeech lossofinhibitions decreasedneedforsleepand increasedimportanceofself. Patientmaybeeasilydistracted. Patientmayalsohaveperiodsofdepressionwith: loworsadmoodor lossofinterestorpleasure. Thefollowingassociatedsymptomsarefrequentlypresent: disturbedsleep poorconcentration guiltorlowselfworth disturbedappetite fatigueorlossofenergyor suicidalthoughtsoracts. Eithertypeofepisodemaypredominate.Episodesmayalternatefrequentlyormaybeseparatedbyperiodsofnormal mood.Inseverecases,patientsmayhavehallucinations(hearingvoicesorseeingvisions)ordelusions(strangeorillogical beliefs)duringperiodsofmaniaordepression. Differential diagnosis

AlcoholmisuseF10orDrugusedisorderF11(pages18and55)cancausesimilarsymptoms. Antisocialpersonalitydisorder:itcanbedifficulttoassessmoodifthepatientspremorbidpersonalityisnotknown.If
possible,obtaininformationfromtheirrelatives,stafforformergeneralpractitioner. Essential information for the patient and primary support group

Unexplainedchangesinmoodandbehaviourcanbesymptomsofanillness. Effectivetreatmentsareavailable.Longtermtreatmentcanpreventfutureepisodes. Ifleftuntreated,manicepisodesmaybecomedisruptiveordangerous.Manicepisodesoftenleadtolegalproblems,lossof

ajoborfinancialproblems(inthecommunity)andproblemswithdebt,adjudicationsorhighrisksexualbehaviour(in prison).Whenthefirst,mildersymptomsofmaniaorhypomaniaoccur,referralisoftenindicatedandthepatientshould beencouragedtoseethedoctorstraightaway. Informpatientswhoareonlithiumofthesignsoflithiumtoxicity(seeMedicationbelow). Advice and support to the patient and primary support group

Ifitisdecidedthatitissafeforthepatienttoliveonordinarylocation,seekpatientpermissiontoinvolvetheresidential

managerandotherrelevantstaff(egworkshopmanager,teacher,chaplain)inimplementingamanagementplan, includingthelocation,activities,signsoflithiumtoxicityandplannedresponsetorelapseormoodswings.Informstaff thatbipolardisordercarriesthehighestsuicideriskofallmentaldisorders. Duringdepression,assesstheriskofsuicide.(Hasthepatientfrequentlythoughtofdeathordying?Doesthepatienthave aspecificsuicideplan?Hashe/shemadeserioussuicideattemptsinthepast?Canthepatientbesurenottoacton suicidalideas?)Closesupervisionbystaffmaybeneeded.Askabouttheriskofharmtoothers(seeDepressionF32# andAssessingandmanagingpeopleatriskofsuicide,pages47and204). Duringmanicperiods:

avoidconfrontationunlessnecessarytopreventharmfulordangerousacts advisestaffthataggressionmaybeasignoftheillnessandtoavoidautomaticuseofdisciplinaryaction assesstheriskofviolence(seeAssessingriskofviolenceinAggression, page282) advisecautionaboutimpulsiveordangerousbehaviour closeobservationbystaffisoftenneeded ifagitationordisruptivebehaviouraresevere,transfertoaprisonhealthcarecentreorNHShospitalmayberequired. Duringdepressedperiods,consultthemanagementguidelinesfordepression(seeDepressionF32#,page47). Describetheillnessandthepossiblefuturetreatmentstothepatient. Encouragestafftoreferthepatientwhensignsofdepressionarise,evenifthepatientisreluctant. Workwiththepatientandstafftoidentifyearlywarningsymptomsofmoodswingstoavoidamajorrelapse. Forpatientsabletoidentifyearlysymptomsofaforthcominghigh,advise: ceasingtheconsumptionoftea,coffeeandothercaffeinebasedstimulants avoidingstimulatingorstressfulsituations planningforagoodnightssleep takingrelaxingexerciseduringtheday,eggymorrelaxationexerciseinthecell avoidtakingmajordecisionsor ifrelevant,takingstepstolimitcapacitytospendmoney.28 Medication

Ifthepatientdisplaysagitation,excitementordisruptivebehaviour,antipsychoticmedicationmaybeneededinitially29

(seeBNF,Section4.2)(eghaloperidol, 1.54mguptothreetimesperday).Thedosesshouldbethelowestpossibleforthereliefofsymptoms,30althoughsome patientsmayrequirehigherdoses.Ifantipsychoticmedicationcausesacutedystonicreactions(egmusclespasms)or markedextrapyramidalsymptoms(egstiffnessortremors),antiParkinsonianmedication(seeBNF,Section4.9),eg procyclidine,5mgorallyuptothreetimesperday,maybehelpful.Routineuseisnotnecessary. Benzodiazepinesmayalsobeusedintheshortterminconjunctionwithantipsychoticmedicationtocontrolacute agitationanddisturbance31(seeBNF,Section4.1.2).Examplesincludediazepam(510mguptofourtimesperday)or lorazepam(12mguptofourtimesperday).Ifrequired,diazepamcanbegivenrectally,orlorazepamIM(althoughit mustbekeptrefrigerated). Lithiumcanhelprelievemania 32anddepression,33andcanpreventepisodesfromrecurring.34Oneusually commencesorstopstakinglithiumonlywithspecialistadvice.Somegeneralpractitionersareconfidentaboutrestarting lithiumtreatmentafterarelapse.Alternativemoodstabilisingmedicationsincludecarbamazepineandsodiumvalproate.If usedintheacutephase,lithiumtakesseveraldaystoshoweffects.Iflithiumisprescribed: thereshouldbeaclearagreementbetweenthereferringgeneralpractitionerandthespecialistaboutwhoismonitoring thelithiumtreatment.Lithiummonitoringisideallycarriedoutusinganagreedprotocol.Ifcarriedoutinprimarycare, monitoringshouldbedonebyasuitablytrainedperson thelevelsoflithiuminthebloodshouldbemeasuredfrequentlywhenadjustingthedose,andevery3monthsinstable patients1014hourspostdose(desiredbloodlevelis0.40.8mmoll1).N35Ifbloodlevelsare>1.5orthereisdiarrhoea andvomiting,stopthelithiumimmediately.Ifthereareothersignsoflithiumtoxicity(egtremors,diarrhoea,vomiting, nausea,confusion),stopthelithiumandcheckthebloodlevel.Renalandthyroidfunctionshouldbecheckedevery23 monthswhenadjustingthedose,andevery6monthsto1yearinstablepatients.36 Neverstoplithiumabruptly(exceptinthepresenceoftoxicity)relapseratesaretwiceashighunderthese conditions.37Lithiumshouldbecontinuedforatleast6monthsaftersymptomsresolve(longertermuseisusually necessarytopreventrecurrences). Ifthepatientisonordinarylocation,ensurethataresidentialmanagerand,ifthepatientgoestothegymfrequently, thephysicaleducationstaffareawareofthesignsoflithiumtoxicity.Theleafletonlithiumtoxicityonthediskmaybe helpful. Antidepressantmedicationisoftenneededduringphasesofdepressionbutcanprecipitatemaniawhenusedalone(see DepressionF32#,page47).Bupropionmaybelesslikelythanotherantidepressantstoinducemania.38Dosesshould beaslowaspossibleandusedfortheshortesttimenecessary.Ifthepatientbecomeshypomanic,stoptheantidepressant. Referral Referraltotheinhouseorsecondarymentalhealthservicesisadvised: asanemergencyifthepatientisveryvulnerable,egifthereissignificantriskofsuicideordisruptivebehaviouror urgentlyifsignificantdepressionormaniacontinuesdespitetreatment.

Nonurgentreferralisrecommended: forallnewpatientsforassessment,careplanningandallocationofkeyworkerundertheCareProgrammeApproach beforestartinglithium todiscussrelapsepreventionand forwomenonlithiumplanningapregnancy. Whereapatientisdiagnosedwithbipolardisorderforthefirsttime,informhis/hersolicitor,withpatientpermission,asthe illnessmayhaverelevancetotheoffence. Ifreleaseisplanned,workcooperativelywithbothprobationorthroughcareplanningofficerstoensurethat appointmentswithageneralpractitionerandspecialistmentalhealthcarearearranged,andthathousing,moneyforfood, clothesandheatingarearranged. SeeManagingtheinterfacewiththeNHSandotheragencies(page149)formoreinformationonreferraland throughcare. Resources for patients and primary support groups ManicDepressionFellowship:02077932600 (Advice,support,localselfhelpgroupsandpublicationslistforpeoplewithmanicdepressiveillness) ManicDepressionFellowship(Scotland):01414001867 Resourceleaflets: LithiumToxicity InsideOut:AGuidetoSelfManagementofManicDepression.Availablefrom:ManicDepressionFellowship,CastleWorks, 21StGeorgesRoad,LondonSE16ES MaryEllenCopeland.LivingWithoutDepressionandManicDepression:AWorkbookforMaintainingMoodStability.USA: NewHarbinger.11.95Oakland2001

Chronic fatigue, fatigue syndrome and neurasthenia F48.0

Presenting complaints Patientsmayreport: alackofenergy achesandpains feelingtiredeasilyor aninabilitytocompletetasks.

Diagnostic features

Mentalandphysicalfatigue,madeworsebyphysicalandmentalactivity. Tirednessafterminimaleffort,withrestbringinglittlerelief. Lackofenergy.

Othercommon,oftenfluctuating,symptomsinclude: dizziness headache disturbedsleep inabilitytorelax irritability achesandpains,egmusclepain,chestpain,sorethroat decreasedlibidoand poormemoryandconcentration. Thedisordermaybeprecededbyinfection,traumaoranotherphysicalillness. Fatiguesyndromeisconsideredtobesevereandchronicwhensubstantialphysicalandmentalfatiguelastsmorethan6 months,significantlyimpairsdailyactivitiesandwheretherearenosignificantfindingsonphysicalexaminationor laboratoryinvestigation.Itisassociatedwithothersomaticsymptoms.39 Differential diagnosis

Manymedicaldisorderscancausefatigue.Afullhistoryandphysicalexaminationarenecessary,whichcanbe

reassuringforthedoctorandtherapeuticforthepatient.Basicinvestigationsincludeafullbloodcount,erythrocyte sedimentationrate(ESR)orCRP,thyroidfunctiontests,ureaandelectrolytes,liverfunctiontests,bloodsugarandC reactiveprotein.Amedicaldisordershouldbesuspectedwherethereis: anyabnormalphysicalfinding,egweightloss anyabnormallaboratoryfinding unusualfeaturesofthehistory,egrecentforeigntravel,orthepatientisveryyoungorveryoldor symptomsoccurringonlyafterexertionandunaccompaniedbyanyfeaturesofmentalfatigue. DepressionF32#(page47)ifaloworsadmoodisprominent. ChronicmixedanxietyanddepressionF41.2(page33). PanicdisorderF41.1(page67)ifanxietyattacksareprominent. UnexplainedsomaticcomplaintsF45(page94)ifunexplainedphysicalsymptomsareprominent. Depressionandanxietymaybesomatised.Social,relationshiporotherlifeproblemsmaycauseorexacerbatedistress. Postviralfatiguesyndromeandbenignmyalgicencephalomyelitis(classifiedunderG93.3Neurologicaldisorders)are diagnosedwherethereisexcessivefatiguefollowingaviraldiseaseandthesymptomsdonotfulfilthecriteriaforF48.0. Fatiguesyndromes,bothchronicandnot,bothwithandwithoutanestablishedphysicalprecursor,maybeclassified underF48.0Neurasthenia.Inpractice,thereisextensiveoverlapinsymptoms(upto96%).Thechoiceofcodingreflects differentrecordingpracticesanduncertaintyabouttheaetiologyofthesesyndromes.Althoughclassificationis controversial,treatmentissimilarwhateverchoiceismadeaboutcoding. Essential information for the patient and primary support group

Periodsoffatigueorexhaustionarecommonandareusuallytemporaryandselflimiting.

 Treatmentformildtomoderatefatiguesyndromeispossibleandusuallyhasgoodresults,althoughtheoutcomefor
fatiguesyndromethatissevereandchronicismorevariable.40 Advice and support to the patient and primary support group

Explorewhatthepatientthinkshis/hersymptomsmean.Offerappropriateexplanationsandreassurance(egsymptoms

aregenuinelydisablingandnotallinthemindbutthatsymptomsfollowingexertiondonotmeanphysicaldamageand longtermdisability). Adviseagradualreturntousualactivities.Thismaytaketime. Thepatientcanbuildendurancewithaprogrammeofgraduallyincreasingphysicalactivity.Startwithamanageable levelandincreasealittleeachweek. Emphasisepleasantorenjoyableactivities.Encouragethepatienttoresumeactivitiesthathavehelpedinthepast. Discusssleeppatterns.Encouragearegularsleeproutineandavoiddaytimesleep(seeSleepproblems[insomnia] F51,page91). Avoidexcessiverestand/orsuddenchangesinactivity. Severechronicfatigueislesscommonthanuncomplicatedchronicfatigue.Inseverechronicfatigue,abehavioural approach,includingcognitivebehaviouraltherapyand/oracautiousgradedprogrammeofexerciseandassessmentofand assistancewithactivitiesofdailyliving,canbehelpful.41,42Ideally,thiswouldtakeplaceinaprimarycaresettingusing clinicalpsychologists,nursepractitioners,practicecounsellors,physiotherapists,occupationaltherapistsorothersuitably trainedpractitioners. Medication

Todate,nopharmacologicaltreatmentforchronicfatiguehasbeenestablished.43 Depressionandanxietyarecommoninseverechronicfatigueandmayrespondtopharmacologicaltreatment.Intreating
depression,selectiveserotoninreuptakeinhibitors(SSRIs)(seeBNF,Section4.3.3)maybeneutraloractivating,and tricyclicantidepressants(TCAs)(seeBNF,Section4.3.1)atfulldosagemaybesedating. Intheabsenceofdepression,considerlowdosetricyclicantidepressants(egamitriptyline,50100mgday1,or imipramine,20mgday1)(seeBNF,Section4.3.1),whichmaybeeffectiveforpainandpoorsleep.44,45 Referral SeeGeneralreferralcriteria(page152). Considerreferraltoaphysicianifthegeneralpractitionerisuncertainaboutdiagnosis(seeDifferentialdiagnosisabove). Referraltothesecondarymentalhealthservicesoraliaisonpsychiatrist,ifavailable,shouldbeconsideredifthereare: comorbidmentaldisorders,egeatingdisorderorbipolardisorder asignificantriskofsuicide(seeAssessingandmanagingpeopleatriskofsuicide,page204)or noimprovementdespitetheabovemeasures. Resources for patients and primary support groups InstituteofPsychiatryswebsite(URL:http://www.kcl.ac.uk/cfs)includesafullpatientmanagementpackageforthe moreseveresymptomsofchronicfatiguesyndrome.Itincludesinformationaboutthedisorderandsuggestionstoaid selfmanagement.Itisausefulresourceforthepractitionerwhoisworkingwiththepatienttoovercomethecondition TrudieChalder.CopingwithChronicFatigue.1995Sheldon,London.Selfhelpmanualshowntoimprovetheoutcomein primarycarepatientswithchronicfatigue MSharpe,FCampling.ChronicFatigueSyndrome:TheFacts.Oxford:OxfordUniversityPress,2000.Selfhelpadvicefor moreseveresymptoms ForareviewoftheevidenceforthefullrangeoftreatmentsforCFS/ME,seeBagnallAM,WhitingT,WrightJ,Sowden AJ.TheEffectivenessofInterventionsUsedintheTreatment/ManagementofCFSand/orMyalgicEncephalomyelitisinAdultsand Children.York:NHSCentreforReviewsandDissemination,UniversityofYork,2001.URL: http://www.york.ac.uk/inst/crd/cfsrep.pdf

Chronic mixed anxiety and depression F41.2

Presenting complaints Thepatientmaypresentwithoneormorephysicalsymptoms(egvariouspains,poorsleeporfatigue)accompaniedbya varietyofanxietyanddepressivesymptomsthatwillhavebeenpresentformorethan6months.Thesepatientsmaybewell knowntotheirdoctorsandhaveoftenbeentreatedbyavarietyofpsychotropicagentsovertheyears. Diagnostic features

Loworsadmood. Lossofinterestorpleasure. Prominentanxietyorworry. Multipleassociatedsymptomsareusuallypresent,eg:

disturbedsleep disturbedappetite tremor suicidalthoughtsoracts fatigueorlossofenergy drymouth palpitations lossoflibido poorconcentration tensionandrestlessness dizziness irritability.

Differential diagnosis

Ifmoreseveresymptomsofdepressionoranxietyarepresent,seeDepressionF32#orGeneralisedanxiety41.1

(pages47and64). Ifsomaticsymptomspredominate,whichdonotappeartohaveanadequatephysicalexplanation,see UnexplainedsomaticcomplaintsF45(page94). Ifthepatienthasahistoryofmanicepisodes(egexcitement,elevatedmood,rapidspeech),seeBipolardisorderF31 (page26). Ifthepatientisorhasrecentlybeendrinkingheavilyorusingdrugs,seeAlcoholmisuseF10andDrugusedisorders F11#(pages18and55). Unexplainedsomaticcomplaints,alcoholordrugdisordersmayalsocoexistwithmixedanxietyanddepression. Essential information for the patient and primary support group

Stressorworryhavemanyphysicalandmentaleffectsandmayberesponsibleformanyoftheirsymptoms.Symptoms
arelikelytobeattheirworstattimesofpersonalstress.Aimtohelpthepatienttoreducehis/hersymptoms. Theseproblemsarenotduetoweaknessorlaziness:patientsaretryingtocope. Regularstructuredvisitscanbehelpfulstatetheirfrequencyandincludearrangedvisitstootherprofessionals(to assesstheprogressofanyphysicaldisorderandgiveanyadviceonhandlinglifestresses). Advice and support to the patient and primary support group

Ifphysicalsymptomsarepresent,discussthelinkbetweenphysicalsymptomsandmentaldistress(seeUnexplained Iftensionrelatedsymptomsareprominent,adviseonrelaxationmethodstorelievephysicalsymptoms.TheManaging Adviseareductionincaffeineintake,46ifappropriate,andabalanceddiet,includingplentyofcomplexcarbohydrates

Anxietyleafletonthediskincludesarelaxationexercise. andvitamins.47 Discusswaystochallengenegativethoughtsorexaggeratedworries: Identifyexaggeratedworriesorpessimisticthoughts(egwhenavisitordoesnotarriveontime,thepatientworriesthat theynolongerwantcontactwiththem). somaticcomplaintsF45,page94).

Discusswaystoquestiontheseexaggeratedworrieswhentheyoccur,eg Iamstartingtobecaughtupinworryagain.Myvisitorisonlyafew minuteslate.Hewillprobablybeheresoon. Structuredproblemsolvingmethods48canhelppatientstomanagecurrentlifeproblemsorstressesthatcontributeto anxietysymptoms.Supportthepatienttocarryoutthefollowingsteps: Identifyingeventsthattriggerexcessiveworry.(Forexample,ayoungwomanpresentswithworry,tension,nausea andinsomnia.Thesesymptomsbeganaftershelearnedthathersonhadbeenbehavingbadlyinschoolfollowingher conviction). Listingasmanypossiblesolutionsasthepatientcanthinkof,egdiscussingherconcernswithaclosefriendorrelative, applyingforanextendedfamilyvisit,writingtohersonsgeneralpractitioner,contactingavoluntaryorganisationthat helpsfamiliesofprisoners. Listingtheadvantagesanddisadvantagesofeachpossiblesolution.(Thepatientshoulddothis,perhapsbetween appointments). Choosinghis/herpreferredapproach. Workingoutthestepsnecessarytoachievetheplan. Settingadatetoreviewtheplan.Identifyandreinforcethingsthatareworking. Helpthepatientplanactivitiesthatarerelaxing,distractingorconfidencebuilding.Exercisemaybehelpful.49,50If necessary,consideradvocatingforimprovedaccesstoappropriateactivities. Assesstheriskofsuicide.(Hasthepatientthoughtfrequentlyaboutdeathordying?Doesthepatienthaveaspecific suicideplan?Hashe/shemadeserioussuicideattemptsinthepast?Canthepatientbesurenottoactonsuicidalideas?) SeeAssessingandmanagingpeopleatriskofsuicide(page204). Encourageselfhelpbooks,tapesand/orleafletsifappropriate.51Ifthepatienthasreadingdifficulties,amemberofthe healthcareteamoranothermemberofstaffmaybeabletodiscussthecontentsoftheleafletsManagingDepressionand ManagingAnxiety(whichareonthedisk)withhim/her.

Medication

Medicationshouldbesimplified:itshouldbereviewedperiodicallyandthepatientshouldonlybeprescribedadrugifit Anantidepressantwithsedativepropertiescanbeprescribedifmarkedsymptomsofdepressionoranxietyarepresent,
isdefinitelyhelping.Multiplepsychotropicsshouldbeavoided. butwarnofdrowsiness N52(seeBNF,Section4.3)Fortheseveritythresholdforinitiatingantidepressantsandforspecific guidanceonthesedrugs,seeDepressionF32#(page47). Hypericumperforata(knownasStJohnsWortandavailablefromhealthfoodstores)isoftentakenformildandmoderate symptomsofdepression. 53Ithasmildmonoamineoxidaseinhibitory(MAOI)properties,54soitshouldnotbecombined withotherantidepressantsandcautionmayintheorybeneededwithdiet.N55Hypericumisanactiveagentand interactionswithprescribeddrugsmayoccur.Forfurtherinformation,seetheadvicefromtheCommitteeforSafetyof Medicines.N56 Referral SeeGeneralreferralcriteria(page152). Referraltoinhouseorsecondarymentalhealthservicesisadvised: ifthesuicideriskissignificant(seeAssessingandmanagingpeopleatriskofsuicide,page204)or nonurgentlyforpsychologicaltreatments,asavailable. Considerrecommendingvoluntary/nonstatutory/selfhelporganisations.Stress/anxietymanagement,N57problemsolving,N58 cognitivetherapy,59cognitivebehaviouraltherapyN60orcounselling 13maybehelpfulandmaybeprovidedinprimarycareorthe voluntarysector,aswellasinthesecondarymentalhealthservices.

Resources for patients and primary support groups Formoreresources,seeDepressionF32#andGeneralisedanxietyF41.1(pages47and64). Listeners/buddies,chaplain,theSamaritans CITA(CouncilforInvoluntaryTranquilliserAddiction):01519490102(MondayFriday,10am1pm) CavendishHouse,BrightonRoad,Waterloo,Liverpool

(Confidentialadviceandsupport) Samaritans:08457909090(24hour,7daysperweekhelpline) (Supportbylisteningforthosefeelinglonely,despairingorsuicidal) Resourceleaflets: ManagingAnxiety ManagingDepression HelpingYouCope:AGuidetoStartingandStoppingTranquillisersandSleepingTablets.Availablefrom:MentalHealth Foundation,UKOffice,20/21CornwallTerrace,LondonNW14QL.Tel:02075357400;Fax:02075357474; Email:mhf@mhf.org.uk;URL:http://www.mentalhealth.org.uk

Includes schizophrenia, schizotypal disorder, persistent delusional disorders, induced delusional disorder and other non-organic psychotic disorders

Chronic psychotic disorders F20#

Presenting complaints Patientsmaypresentwith: difficultieswiththinkingorconcentration reportsofhearingvoices strangebeliefs,eghavingsupernaturalpowersorbeingpersecuted extraordinaryphysicalcomplaints,eghavinganimalsorunusualobjectsinsideonesbody poorhygiene problemsinmanaginglifeinprison,work,educationorrelationships selfharm foodrefusal(mayhavedelusionsthatfoodisbeingpoisoned)or problemsorquestionsrelatedtoantipsychoticmedication. Stafforasolicitormayseekhelpbecauseofapathy,withdrawal,poorhygieneorstrangebehaviour. Diagnostic features

Chronicproblemswiththefollowingfeatures:

socialwithdrawal lowmotivation,interestorselfneglector disorderedthinking(exhibitedbystrangeordisjointedspeech). Periodicepisodesof: agitationorrestlessness bizarrebehaviour hallucinations(falseorimaginedperceptions,eghearingvoices)or delusions(firmbeliefsthatareoftenfalse,egthepatientisrelatedtoroyalty,receivingmessagesfromthetelevision, beingfollowedorpersecuted). Differential diagnosis

DepressionF32#(page47)ifaloworsadmood,pessimismand/orfeelingsofguilt. BipolardisorderF31(page26)ifsymptomsofmaniaexcitement,elevatedmoodorexaggeratedselfworthare

prominent. AlcoholmisuseF10orDrugusedisordersF11#(pages18and55).Chronicintoxicationorwithdrawalfromalcohol orothersubstances(stimulants,hallucinogens)cancausepsychoticsymptoms. Patientswithchronicpsychosismayalsoabusedrugsand/oralcohol. Essential information for the patient and primary support group

Agitationandstrangebehaviourcanbesymptomsofamentalillness. Symptomsmaycomeandgoovertime. Medicationisacentralcomponentoftreatment.Itwillbothreducecurrentdifficultiesandpreventrelapse. Safe,stablelivingconditions(egfreedomfrombullying,occupation)areaprerequisiteforeffectiverehabilitation. Voluntaryorganisationscanprovidevaluablesupporttothepatientandsupportgroup.

Advice and support to the patient and primary support group

Seekthepatientspermissiontodiscussatreatmentplanwithstaffinvolvedinthecareofthepatientandobtaintheir

supportforit.Amultidisciplinarycareplanmightconsideroptionsforlocation,occupation,waysofminimising unnecessarystress,anearlyresponsetosignsofrelapseandthemonitoringofmedication.Combinationlocationsmaybe appropriate,egshelteredworkduringtheday,healthcareorVulnerablePrisonersUnit(VPU)atnight.Jointlyestablish

appropriateexpectationsfortheindividual,toavoidinappropriaterelegationtobasicstatus.Theinformationleafleton thediskforstaffaboutpsychoticdisordermaybehelpful. Explainthatmedicationwillhelppreventrelapse,andinformthepatientofthesideeffects.Bevigilanttoensurethatthe patientisnotpersuaded/bulliedintogivingthemedicationtosomeoneelse.(Theyhavecurrency,asantipsychoticsmay haveasedativeandantiParkinsoniandrugsamoodelevatingeffect) Encouragethepatienttofunctionatthehighestreasonablelevelinworkandotherdailyactivities. Minimisestressandstimulation: Donotarguewithpsychoticthinking. Avoidconfrontationorcriticism. 3Staffshouldrespondgentlyandwithreassurancetoslowresponsestoorders(eg slownessingoingintoacell).Useofcontrolandrestraintshouldbealastresort. Duringperiodswhenthesymptomsaremoresevere,restandwithdrawalfromstressmaybehelpful. Keepthepatientsphysicalhealth,includinghealthpromotion,obesityandsmoking,underreview.61Weightgainrelated tomedicationcanbeextreme.Heavysmokersmayusetobaccotocounteractthesedativeeffectsoftheirantipsychotic medication.Ifthishappens,consideralesssedatingantipsychotic.Ifyoususpectcooccurringsubstancemisuse,checkfor possiblephysicalproblems(eganaemia,chestproblems)andnutritionaldeficiencies. Iftheillnesshasarelapsingcourse,workwiththepatientandstafftotrytoidentifyearlywarningsignsofrelapse. Encouragethepatienttobuildrelationshipswithkeymembersofthehealthcareteam,egbyseeingthesamedoctoror nurseateachappointment.Usetherelationshiptodiscusstheadvantagesofmedicationandtoreviewtheeffectivenessof thecareplan. Foradviceonthemanagementofagitatedorexcitedstates,seeAcutepsychoticdisordersF23(page11). IfcareissharedwiththeinhouseorNHSmentalhealthservices,agreewiththemwhoistodowhat. Especiallyifthepatientbecomesdepressed,consideroptionsforsupport,educationandreassuranceabouttheirpsychotic illness,includingpossiblerelapseandtheirfuturelifechances.Mentalhealthstaffmaybeabletoprovideindividual counselling,goalplanningandmonitoringofearlywarningsignsofrelapse. Ifthepatientisalsousingsubstances: Expressconcernforthepatientswellbeingandavoidmoraldisapproval(egImreallynothappyaboutyoutaking drugsasitmakesyourschizophreniaworse).Focusonbuildingarelationshipwiththepatient,notonpushingan unmotivatedpatienttowardsabstinence. Discussthebenefitsandcostsofdruguse(includingtheimplicationsofcontinuinganyformofillicitdrugusewhilein prison)fromthepatientsperspective.Assessthepatientscommitmenttochange.Thoughtdisorder,suspiciousnessand depressionmaymakeitdifficultforthepatienttomakesuchacommitment. Educatethepatientabouttheeffectofalcoholandotherdrugsonthebodyandonschizophrenia(egDrugssuchas cannabis,LSD,stimulantsandecstasyallexacerbatethemoodyouareinwhenyoutakeit,andsocanmakeyoumore paranoid,anxiousordepressed).Feedbacktheresultsoftests,egurinetests,changesinweightorotherphysical examinations. Consideroptionsfordealingwithprisonrelatedproblemsthatmaybeincreasingthesubstanceuse(egboredom, bullying,lowleveldepression).Consider: encouragingthepatienttospendmoretimeoutofthecellandinenjoyableactivities,egattendeducation,gym,work liaising,withpatientpermission,withwingofficersaboutreducingstressontheunit(egnoise,bullying,teasing)or increasingactivities encouragingthepatienttotalktoanytrustedfriendorstaffmember(egpersonalofficer,teacher,listener,chaplain) ifdaytodayproblemsariseratherthanturningtodrugs. Formoreinformation,seeComorbidity(page191). Medication

Antipsychoticmedicationmayreducepsychoticsymptoms(seeBNF,Section4.2.1).Examplesincludehaloperidol(1.54

mguptothreetimesday1),oranatypicalantipsychotic N6(egolanzapine,510mgday1,orrisperidone,46mgday1). Thedoseshouldbethelowestpossibleforreliefofsymptoms.Thedrugshavedifferentsideeffectprofiles.Indicationsfor atypicaldrugsincludeuncontrolledacuteextrapyramidaleffects,uncontrolledhyperprolactinaemiaandpredominant, unresponsive,negativesymptoms(egwithdrawalandlowmotivation).Formoreinformationonthedifferenttypesof antipsychoticdrugsandtheirsideeffectprofiles,seeMaudsleyPrescribingGuidelines.10 Informthepatientthatcontinuedmedicationwillreducetheriskofrelapse.Ingeneral,antipsychoticmedicationshould becontinuedforatleast6monthsfollowingafirstepisodeofillness,andlongerafterasubsequentepisode.N9 Monitorcomplianceandthecallupforreviewifmorethantwodosesaremissed.

 If,afterteamsupport,thepatientisreluctantorerraticintakingmedication,injectablelongactingantipsychotic

medicationmayensurethecontinuityoftreatmentandreducetheriskofrelapse.N62Itshouldbereviewedat46 monthlyintervals.Doctorsandnurseswhogivedepotinjectionsinprimarycareneedtrainingtodoso.63Ifavailable, specificcounsellingaboutmedicationalsoishelpful.N64Advisethenurseadministeringthemedicationtoseekoutthe patientshouldhe/shefailtoattendanappointment. Discussthepotentialsideeffectswiththepatient.Commonmotorsideeffectsinclude: AcutedystoniasorspasmsthatcanbemanagedwithantiParkinsoniandrugs(seeBNF,Section4.9)(egprocyclidine,5 mgthreetimesperday,ororphenadrine,50mgthreetimesperday). Parkinsoniansymptoms(egtremorandakinesia),whichcanbemanagedwithoralantiParkinsoniandrugs(seeBNF, Section4.9)(egprocyclidine,5mguptothreetimesperday,ororphenadrine,50mgthreetimesperday).Withdrawalof antiParkinsoniandrugsshouldbeattemptedafter23monthswithoutsymptomsasthesedrugsareliabletomisuseand mayimpairmemory. Akathisia(severemotorrestlessness)maybemanagedwithdosagereduction,orblockers(egpropranolol,3080 mgday1)(seeBNF,Section2.4).Switchingtoalowpotencyantipsychotic(egolanzapineorquetiapine)mayhelp. Otherpossiblesideeffectsincludeweightgain,galactorrhoeaandphotosensitivity.Patientssufferingfromdrug inducedphotosensitivityareeligibleforsunscreenonprescription. Referral Referraltothesecondarymentalhealthservicesisadvised: urgently,iftherearesignsofrelapse,unlessthereisanestablishedpreviousresponsetotreatment nonurgently: toclarifydiagnosisandensurethemostappropriatetreatment ifthereisnoncompliancewithtreatment,problematicsideeffectsorbreakdownofthelivingarrangements,eg problemsonordinarylocationorwithoccupation forallnewpatientswithadiagnosisofpsychosistoobtaininformationaboutandreviewanyexistingcareplan forallpatientswhoalsoabusesubstancestoreviewtheirmedicationtoensurethatunwantedsideeffects(egsedation) arenotincreasingdruguse. Patientswitharangeofmentalhealth,occupational,socialandfinancialneedsarenormallymanagedbyspecialistservices. ReferralforakeyworkerundertheCareProgrammeapproachshouldalwaysbeconsidered. Thecommunitymentalhealthservicesmaybeabletoprovidecompliancetherapy,N64familyinterventions,N65 cognitivebehaviourtherapy 66andrehabilitativefacilities. Referpatientswhoaremisusingsubstancesandexpresssomemotivationtoreduceforsubstanceabusecounselling.25 Liaisewiththesubstancemisuseservicetoensurethecontinuedprescriptionofantipsychoticmedication.Stresstothe patientthatrelapsesaretobeexpected,arenotsignsoffailureandwillnotmeanalossofyoursupportandrespect(see Comorbidity,page191). Ifreleaseisplanned,workcooperativelywithbothprobationorthroughcareplanningofficerstoensurethat appointmentswithageneralpractitionerandspecialistmentalhealthcarearearrangedandthathousing,moneyforfood, clothesandheatingarearranged. Ifreleaseisnotplanned,informthelocalmentalhealthservicesthatthepatientmaypresenttoA&Eintheareaand advisethemtolookoutforhim/her. Formoredetailonthroughcare,seeManagingtheinterfacewiththeNHSandotheragencies(page149).

Resources for patients and primary support groups HearingVoicesNetwork:01618345768 (Selfhelpgroupstoallowpeopletoexploretheirvoicehearingexperiences) MINDInfoline:08457660163(outsideLondon);02085221728(GreaterLondon) NationalSchizophreniaFellowship:02089746814(adviceline:MondayFriday,10:30am3pm);02073309106(office) NationalSchizophreniaFellowship(NorthernIreland):02890402323 NationalSchizophreniaFellowship(Scotland):01315578969 SANELine:08457678000(12pm2am,7nights) Educationandworkshopsmayprovideopportunitiesforcreativeexpression EducationorPsychologyDepartmentsmayprovidebasicsocialskillstraining Resourceleaflets: CopingwiththeSideeffectsofMedication WorkingwithaPrisonerwithSevereMentalIllness EarlyWarningSignsForm HealthyLivingwithSchizophrenia.London:HealthEducationAuthority1998.Availablefrom:MarsdonBookServices.Tel: 01235465565 RColeman,MSmith.WorkingWithVoices.Handsell,1997NewtonleWillows.Workbooktohelpvoicehearersmanage theirvoices

Delirium F05
Presenting complaints

Staffmayrequesthelpbecausethepatientisconfusedoragitated. Patientsmayappearuncooperativeorfearful. Deliriummayoccurinpatientshospitalisedforphysicalconditions.

Diagnostic features Acuteonset,usuallyoverhoursordays,of: confusion(patientappearsdisorientedandstrugglestounderstandsurroundings)and cloudedthinkingorawareness. Oftenaccompaniedby: poormemory agitation emotionalupset lossoforientation wanderingattention hearingvoices withdrawalfromothers visionsorillusions suspiciousness disturbedsleep(reversalofsleeppattern)and autonomicfeatures,egsweating,tachycardia. Symptomsoftendeveloprapidlyandmaychangefromhourtohour. Deliriummayoccurinpatientswithpreviouslynormalmentalfunctionorinthosewithdementia.Milderstresses(eg medicationandmildinfections)maycausedeliriuminolderpatientsorinthosewithdementia. Differential diagnosis Identifyandcorrectthepossibleunderlyingphysicalcausesofthedelirium,suchas: alcoholintoxicationorwithdrawal drugintoxication,overdoseorwithdrawal(includingprescribeddrugs) infection metabolicchanges,egliverdisease,dehydration,hypoglycaemia headtrauma hypoxiaor epilepsy. Ifsymptomspersist,delusionsanddisorderedthinkingpredominate,andnophysicalcauseisidentified(seeAcute psychoticdisordersF23,page11). Essential information for the patient and primary support group Strangebehaviourorspeechandconfusioncanbesymptomsofamedicalillness. Advice and support to the patient and primary support group 67

Takemeasurestopreventthepatientfromharminghim/herselforothers,egremoveunsafeobjects,restrainifnecessary
butusetheminimumamountofrestraintrequiredandtakeextracaretoensurenophysicalharmtothepatient(see RestraintinAggression,page282). Supportivecontactwithfamiliarpeoplecanreduceconfusion. Providefrequentremindersoftimeandplacetoreduceconfusion.

 Atransfertohospitalmayberequiredbecauseofagitationorbecauseofthephysicalillnessthatiscausingdelirium.

Thereisanappreciablemortalityratewithdelirium.Patientsmayneedtobeadmittedtoamedicalwardinorderto diagnoseandtreattheunderlyingdisorder.Inanemergency,wherethereisrisktolifeandsafety,amedicallyillpatient maybetakentoageneralhospitalfortreatmentundercommonlaw.Insuchacase,amedicaldoctormaymakethis decisionwithoutinvolvementofapsychiatrist(seeEmergencytreatmentundercommonlaw,page168).

Medication 68

Avoidtheuseofsedativeorhypnoticmedications(egbenzodiazepines)exceptforthetreatmentofalcoholorsedative Antipsychoticmedicationinlowdoses(seeBNF,Section4.2.1)maysometimesbeneededtocontrolagitation,psychotic
withdrawal. symptomsoraggression.Bewareofdrugsideeffects(drugswithanticholinergicactionandantiParkinsonianmedication canexacerbateorcausedelirium)anddruginteractions.

Referral Referraltothesecondarymentalhealthservicesisrarelyindicated.Referraltoaphysicianisnearlyalwaysindicatedif: thecauseisunclear thecauseisclearandtreatablebuttreatmentcannotsafelybeprovidedwithintheestablishmentor drugoralcoholwithdrawal,overdoseoranotherunderlyingconditionnecessitatinginpatientmedicalcareissuspected.

Dementia F00#
Presenting complaints

Patientsmaycomplainofforgetfulness,adeclineinmentalfunctioningoroffeelingdepressed,buttheymaybeunaware
ofmemoryloss.Patientsandstaffmaysometimesdeny,orbeunawareof,theseverityofmemorylossandother deteriorationinfunction. Stafforthepatientssolicitormayaskforhelpinitiallybecauseoffailingmemory,disorientationandchangein personalityorbehaviour.Inthelaterstagesoftheillness,theymayseekhelpbecauseofbehaviouraldisturbance, wanderingorincontinenceoranepisodeofdangerousbehaviour. Dementiamayalsobediagnosedduringconsultationsforotherproblems,asstaffmaybelievedeteriorationinmemory andfunctionisanaturalpartofageing. Changesinbehaviourandfunctioning(egpoorpersonalhygieneorsocialinteraction)inanolderpatientshouldraisethe possibilityofadiagnosisofdementia. Diagnostic features

Declineinmemoryforrecentevents,thinking,judgement,orientationandlanguage. Patientsmayhavebecomeapparentlyapatheticoruninterested,butmayalsoappearalertandappropriatedespitea Declineineverydayfunction,egdressing,washing. Changesinpersonalityoremotionalcontrolpatientsmaybecomeeasilyupset,tearfulorirritable,aswellasapathetic. Commonwithadvancingage(5%over65years,20%over80years),69veryrareinyouthormiddleage.

Progressionisclassicallystepwiseinvasculardementia,gradualinAlzheimersandfluctuatinginLewybodydementia (fluctuatingcognition,visualhallucinationsandParkinsonism),buttheclinicalpictureisoftennotclearcut. Owingtotheproblemsinherentintakingahistoryfrompeoplewithdementia,itisveryimportantthatinformationabout thelevelofcurrentfunctioningandpossibledeclineinfunctioningshouldalsobeobtainedfromaninformant(egrelative whovisitsfrequentlyorresidentialstaff). Testsofmemoryandthinkinginclude: theabilitytorepeatthenamesofthreecommonobjects(egapple,table,penny)immediatelyandrecallthemafter3 minutes theabilitytoidentifyaccuratelythedayoftheweek,themonthandtheyearand theabilitytogivetheirnameandfullpostaladdress. Averyshortscreeningtestissetoutintheresourcesectiononthedisk. Differential diagnosis Examineandinvestigatefortreatablecausesofdementia.Thecommoncausesofcognitiveworseningintheelderlyare: urinarytract,chest,skinorearinfection onsetorexacerbationofcardiacfailure prescribeddrugs,especiallypsychiatricandantiParkinsoniandrugs,andalcoholand cerebrovascularischaemiaorhypoxia. Lesscommoncausesinclude: severedepression severeanaemiaintheveryold vitaminB12orfolatedeficiency hypothyroidismandhyperparathyroidism slowgrowingcerebraltumour renalfailureand communicatinghydrocephalus. Suddenincreasesinconfusion,wanderingattentionoragitationwillusuallyindicateaphysicalillness(egacuteinfectious illness)ortoxicityfrommedication(seeDeliriumF05,page41). Depressionmaycausememoryandconcentrationproblemssimilartothoseofdementia,especiallyinolderpatients.If loworsadmoodisprominent,oriftheimpairmentispatchyandhasdevelopedrapidly,seeDepressionF32#(page47). deteriorationinmemoryandothercognitivefunction.

Helpfultestsinclude:MSU,fullbloodcount(FBC),B12,folate,LFTs,TFTs,U&E,Ca2+andglucose. Essential information for the patient and primary support group

Dementiaisfrequentinoldagebutisnotinevitable. Memorylossandconfusionmaycausebehaviourproblems(egagitation,suspiciousness,emotionaloutbursts,apathyand
aninabilitytotakepartinnormalsocialinteraction). Memorylossusuallyproceedsslowly,butthecourseandlongtermprognosisvarieswiththediseasecausingdementia. Discussthediagnosis,thelikelyprogressandprognosiswiththepatientand,withpatientpermission,withhis/her primarysupportgroup. Physicalillnessorotherstresscanincreaseconfusion. Advisestaffthatthepatientwillhavegreatdifficultyinlearningnewinformation.Avoidplacingthepatientinunfamiliar placesorsituations Thesupplyofinformationondementiaforstaffinvolvedincareofthepatientisessential. Advice and support to the patient and primary support group

Seekpatientpermissiontodiscussatreatmentplanwithstaffinvolvedinthecareofthepatientandobtaintheirsupport

forit.Regularlyassesstherisk(balancingsafetyandindependence),especiallyattimesofcrisis.Asappropriate,discuss arrangementsforsupportintheestablishment. Considercontactingthepatientssolicitor,withpatientpermission,todiscussthepossibleapplicationforreleaseon groundsofillhealth. Regularlyreviewthepatientsabilitytoperformdailytaskssafelyaswellastheirbehaviouralproblemsandgeneral physicalcondition. Ifmemorylossismild,considertheuseofmemoryaidsorreminders. Encouragethepatienttomakefulluseoftheirremainingabilities. Encouragemaintenanceofthepatientsphysicalhealthandfitnessthroughgooddietandexercise,plusswifttreatmentof intercurrentphysicalillness. Discusstheplanningoflegalandfinancialaffairs.AninformationsheetisavailablefromtheAlzheimersSociety(see ResourcesDirectorypage316). Aprobationofficermaybeabletoprovidefurtherinformation. Medication

Trynonpharmacologicalmethodsofdealingwithdifficultbehaviourfirst.Forexample,staffmaybeabletodealwith

repetitivequestioningiftheyaregiventheinformationthatthisisbecausethedementiaisaffectingthepatientsmemory. Antipsychoticmedicationinverylowdoses(seeBNF,Section4.2.1)maysometimesbeneededtomanagesome behaviouralproblems(egaggressionorrestlessness).Behaviouralproblemschangewiththecourseofthedementia; therefore,withdrawthemedicationeveryfewmonthsonatrialbasistoseeifitisstillneededanddiscontinueifitisnot. Bewareofdrugsideeffects(egParkinsoniansymptoms,anticholinergiceffects)anddruginteractions(avoidcombining withtricyclicantidepressants(TCA),alcohol,anticonvulsantsorLdopapreparations).Antipsychoticsshouldbeavoided inLewybodydementia.70 Avoidusingsedativeorhypnoticmedications(egbenzodiazepines)ifpossible.Ifothertreatmentshavefailedandsevere managementproblemsremain,useverycautiouslyandfornomorethan2weeks;theymayincreaseconfusion. Aspirininlowdosesmaybeprescribedforvasculardementiatoattempttoslowdeterioration. InAlzheimersdisease,considerreferringthepatienttosecondarycareforanassessmentandtheinitiationof anticholinesterasedrugs71dependingonlocallyagreedpolicies. Referral

Refertoaspecialisttoconfirmdiagnosisincomplicatedoratypicalcases. Callacaseconferencewiththerelevantstaff(egprobationofficer,residentialstaff,occupationaltherapist,ifavailable)to
arrangethepracticalitiesofmanagingthepatientintheestablishment. Refertoaphysicianifthereiscomplexmedicalcomorbidityorasuddenworseningofdementia. Refertothepsychiatricservicesifthereareintractablebehaviouralproblemsorifadepressiveorpsychoticepisode occurs.

Ifreleaseisplanned,workcooperativelywithbothprobationorthroughcareplanningofficerstoensurethatappointments withageneralpractitioner,specialistmentalhealthcareandsocialcarearearranged,andthathousing,moneyforfood, clothesandheatingarearranged. Formoredetailonthroughcare,seeManagingtheinterfacewiththeNHSandotheragencies(page149).SeePSI21/2001 fordetailsofthePrisonServicerequirementsabouttheprovisionofcoordinatedhealthandsocialcaretoolderpeoplein prison.

Resources for patients and primary support groups AlzheimersSocietyandCJDSupportNetwork:0845300336(helpline); 02073060606(office) (Supportandadvicetopeoplewithdementiaofallkinds,ienotjustAlzheimers,andtheirfamilyandfriends) AgeConcernEngland:0800009966(freephonehelpline:MondaySunday, 7am7pm);02087657200(office) (Informationandadvicerelatingtoolderpeople) AgeConcernNorthernIreland:02890245729 AgeConcernCymru:02920399562 AgeConcernScotland:01312203345 HelptheAged:02072530253 CounselandCare:02074851550(MondayFriday,10:30am12pm,2pm4pm) (Adviceandinformationonissuesincludingresidentialcare,forolderpeopleandtheircarers) BenefitsEnquiryLine:0800882200(freephone) (Forpeoplewithdisabilities) CarersNationalAssociation:02074908818;08088087777(carersline:10am 12pm,2:30pm4pm) HCayton,NGraham,JWarner,AlzheimersAtYourFingertips.Class,1997London.11.95.Agoodbookforpatientsand carersthatanswerscommonlyaskedquestionsaboutalltypesofdementia

Depression F32#
Presenting complaints Thepatientmaypresentinitiallywithoneormorephysicalsymptoms,suchaspainortirednessallthetime.Further enquirywillrevealalowmoodorsevereandpersistentlossofinterest. Irritabilityorincreasedaggressionissometimesthepresentingproblem. Awiderangeofpresentingcomplaintsmayaccompanyorconcealdepression.Theseincludeanxietyorinsomnia,worries aboutsocialproblemssuchasfinancialormaritaldifficulties,increaseddrugoralcoholuse,or(inanewmother)constant worriesaboutherbabyorfearofharmingthebaby. Somegroupsareathigherrisk(egthosewhohaverecentlygivenbirth,thosegivenalifesentenceoralongersentence thantheyexpected,andthosewithphysicaldisorders,egParkinsonsdiseaseormultiplesclerosis). Diagnostic features

Loworsadmood. Lossofinterestandpleasureformostofthedayforatleast2weeks.
Plusatleastfourofthefollowing: disturbedsleep disturbedappetite;foodrefusal increasedirritabilityandaggression guiltorlowselfworth pessimismorhopelessnessaboutthefuture fatigueorlossofenergy agitation(egpacing)orslowingofmovementorspeech diurnalmoodvariation poorconcentration suicidalthoughtsoracts lossofselfconfidence decreasedlibido. Symptomsofanxietyornervousnessarealsofrequentlypresent. Themoreseverethedepression,usuallythegreaternumberofsymptomsand(mostimportantly)thegreaterthedegreeof interferencewithnormalsocialoroccupationalfunctioning.Biologicalsymptomsaremorecommoninmoresevere depression. Differential diagnosis

AdjustmentreactionF43.2(page15).Wheresymptomsarecausedbyrecentstress(egbeinggivenaprisonsentenceor

bullying;lossofconfidencemaybecausedbytheindividualspositionintheprisonhierarchy).Depressionisdiagnosed whensymptomsaresevereandcontinueformorethan1month,irrespectiveofwhetherornottheyarelinkedtolife stresses. AlcoholmisuseF10orDrugusedisorderF11#(pages18and55)ifheavyalcoholordruguseispresent.Substance misusemaycauseorincreasedepressivesymptoms.Itmayalsomaskunderlyingdepression.Depressivesymptoms improvein80%ofpatientsafterdetoxification.Depressionisdiagnosedifmajorsymptomspersistorworsenafteralcohol, stimulantoropiatewithdrawal(seeComorbidity,page191). AcutepsychoticdisorderF23(page11)ifhallucinations,eghearingvoices,ordelusions,egstrangeorunusualbeliefs, arepresent. BipolardisorderF31(page26)ifthepatienthasahistoryofmanicepisodes,egexcitement,rapidspeechandelevated mood. ChronicmixedanxietyanddepressionF41.2(page33). Somemedicationsmayproducesymptomsofdepression(egblockers,otherantihypertensives,H2blockers,oral contraceptivesandcorticosteroids). Unexplainedsomaticcomplaints,anxiety,alcoholordrugdisordersmaycoexistwithdepression. Essential information for the patient and primary support group

 Feelingsofhelplessness,hopelessness,anxietyandemotionalswingsareallsymptomsoftheillness.Theydonotmean

thatyouaregoingmad.Depressionisacommonillnessandeffectivetreatmentsareavailable. Itisnormaltobesadwhenseparatedfromfamilyandfriends.Depressionisdiagnosedwhensymptomsaresevereand goonforalongtime.Thenpeopleoftenneedhelptoreducethesymptomssothattheycantackletheirproblemsandget onwithlife. Somepeopleusedrugsandalcoholasawayofescapingfrompainfulfeelingsandthesemaycomebackwhenthedrugs arestopped.Ifyouarestill depressedafewweeksafterbeingdrugfree,itusuallymeansthatthereisaproblemwithdepression.Thiscouldbean opportunitytotryanddealwith someoftheproblemsthatcontributedtoyourdepressionandtoyoursubstanceuse. Depressionisnotweaknessorlaziness. Depressioncanaffectpeoplesabilitytocope. Recommendinformationleafletsoraudiotapestoreinforcetheinformation.51Ifthepatienthasreadingdifficulties,a memberofthehealthcareteamoranothermemberofstaffmaybeabletodiscussthecontentsoftheleafletManaging Depression(itisonthedisk)withhim/her. Advice and support for the patient and primary support group

Assesstheriskofsuicide.Askquestionsaboutthoughts,plansandintent(egHasthepatientoftenthoughtofdeathor

dying?Doesthepatienthaveaspecificsuicideplan?Hashe/shemadesuicideattemptsinthepast?Canthepatientbe surenottoactonsuicidalideas?Involvethementalhealthteam.Thereshouldbeclosesupervision,movetohealthcare centreoruseofcaresuitemaybeneeded(seeAssessingandmanagingpeopleatriskofsuicide,page204). Askaboutriskofharmtoothers(seeAssessingriskofviolenceinAggression,page282). Identifythecurrentlifeproblemsorsocialstresses,includingprecipitatingfactors,andwhathelphe/sheneedsin resolvingthem.Wingofficersmaybehelpful,especiallywhereproblemsinvolvethewinghierarchy.Focusonsmall, specificstepspatientsmighttaketowardsreducingorimprovingmanagementoftheseproblems(foragenciesproviding helpforparticularproblems,seeResourcedirectory,page316).Advisethepatienttoavoidmajordecisionsorlifechanges whilehe/sheisdepressed. Planshorttermactivitiesthatgivethepatientenjoymentorbuildconfidence.Exercisemaybehelpful.72 Ifappropriate,adviseareductionincaffeineintake46anddruguse. Supportthedevelopmentofgoodsleeppatternsandencourageabalanced diet.47 Encouragethepatienttoresistpessimismandselfcriticism,nottoactonpessimisticideas(egendingamarriage)andnot toconcentrateonnegativeorguiltythoughts. Identifysomeonethepatientcanconfidein.Encouragehim/hertoseekpracticalandemotionalhelpfromothers.Inform thepatientabouttheroleandavailabilityoftheprisonhealthcareteamandanyothersupportavailable.Consider supportinghim/hertoobtainadditionaltelephonecallstofamilyandfriendsoutsideorextendedfamilyvisits. Ifphysicalsymptomsarepresent,discussthelinkbetweenphysicalsymptomsandmood(seeUnexplainedsomatic symptomsF45,page94). Involvethepatientindiscussingtheadvantagesanddisadvantagesoftheavailabletreatments.Informthepatientthat medicationusuallyworksmorequicklythanpsychotherapies. N74,N75Wherepatientschoosenottotakemedication, exploretheirreasonsanddispelanymisconceptions,butiftheyremainofthesamemind,respecttheirdecisionand arrangeanotherappointmenttomonitorprogress. Afterimprovement,planwiththepatienttheactiontobetakenifsignsofrelapseoccur. Liaison and advice to residential and other staff Askthepatientspermissiontodiscussthefollowingwiththeotherstaffcaringforhim/her.Informhim/herthatyouwill onlydothiswiththeirpermission,exceptwherethereisasignificantriskofsuicideorharmtoothers. Discusstheoutcomeoftheassessmentofriskanddiscusswaysofmanagingtheriskincludingthelevelofmonitoring required.Discussthelocation,includingthesharedroomorcaresuite.Discusstheoptionsforstaffsupportoutlinedon theleafletonthedisk. Advisestaffnottomakejudgementsaboutwhethergivinguponlifeistobeexpectedinthefaceofthepatientslife situation. Informstaffofthelikelyimpactoftheillnessontheindividualsfunctioning,egirritabilityandaggressioncancausean increaseinargumentswithotherinmatesorwithvisitors.

 Promotecontactwithfamilyandfriends,egextendedfamilyvisits,telephonecalls. Consideradvocatingforaccesstoanappropriateactivity,egartmaterials,suitableworkplacement. Ifthepatientsillnessmeansthathe/shecannolongermanagehis/herpreviousroutine,egworkplacement,discussthe

optionsforreplacementactivities,egart,exercise,easierwork. Medication

Thereisnoevidencethatpeoplewithonlyfeworverymilddepressivesymptomsrespondtoantidepressants.76 Antidepressantsareeffectiveevenwhendepressionislinkedtothepresenceoflifestressesorphysicalillness.Treatment Discusstheaimsofthetreatmentandthesideeffects;explorethepatientsperceptionsoftreatment.

isindicatedbytheseverityanddurationofsymptoms. Moderatetosevereepisodeswillneedtreatmentwithantidepressants.Considermedicationatthefirstvisit.

Choice of medication

Atpresent,thereisnoevidencetosuggestthatanyantidepressantismoreeffectivethanothers.77,78However,theirside effectprofilesdifferand,therefore,somedrugswillbemoreacceptabletoparticularpatientsthanothers(seeBNF,Section 4.3). Ifthepatienthasrespondedwelltoaparticulardruginthepast,usethatdrugagain. Ifthepatientisolderorphysicallyill,usemedicationwithfeweranticholinergicandcardiovascularsideeffects. Ifthepatientissuicidal,avoidtricyclicantidepressants(TCAs)orconsidersupervisedingestion. Ifthepatientisanxiousorunabletosleep,useadrugwithmoresedativeeffects,butwarnofdrowsinessandproblems withmachinery. Ifthepatientisabouttobereleasedandisunwillingtogiveupalcohol,chooseoneoftheSSRIantidepressantswhichdo notinteractwithalcohol(egfluoxetine,paroxetineandcitalopram).(SeeBNFSection4.3.3) Hypericumperforata(knownasStJohnsWortandavailablefromhealthfoodstores)isoftentakenformildandmoderate symptomsofdepression,bothacuteandchronic.53Ithasmildmonoamineoxidaseinhibiting(MAOI)properties54soit shouldnotbecombinedwithotherantidepressantsandcautionmaybeneededwithdiet.N55Hypericumisanactiveagent andinteractionswithprescribeddrugsmayoccur(forfurtherinformation,seetheadvicefromtheCommitteeforSafety ofMedicines N56). Ifantidepressantsareprescribed,explaintothepatientthat: themedicationmustbetakeneveryday thedrugisnotaddictive improvementwillbuildupover23weeksafterstartingthemedication mildsideeffectsmayoccur,egdrymouth,blurredvision,sedationwithTCAsandagitationandstomachupsetwith selectiveserotoninreuptakeinhibitors(SSRIs),buttheyusuallyfadein710daysand stressthatthepatientshouldconsultthedoctorbeforestoppingmedication.Allantidepressantsshouldbewithdrawn slowly,preferablyover4weeksinweeklydecrements. Continuefulldoseantidepressantmedicationforatleast46monthsaftertheconditionimprovestopreventrelapse.79,80

Reviewregularlyduringthistime.Consider,jointlywiththepatient,theneedforfurthercontinuationbeyond46months. Ifthepatienthashadseveralepisodesofmajordepression,considercarefullylongtermprophylactictreatment. N81Obtain asecondopinionatthispoint,ifavailable. IfusingTCAmedication,buildupover710daystotheeffectivedose,egdothiepin:startat5075mgandbuildto150 mgnocte;orimipramine:startat2550mgeachnightandbuildto100150mg.N82 Withdrawantidepressantmedicationslowlyandmonitorforwithdrawalreactionstoensurethatremissionisstable. GradualreductionofSSRIscanbeachievedbyusingsyrupinreducingdosesortakingatabletonalternatedays. Referral Thefollowingstructuredtherapies,deliveredbyproperlytrainedpractitioners,havebeenshowntobeeffectiveforsome peoplewithdepression.N83 Cognitivebehaviouraltherapy(CBT). Behaviourtherapy. Interpersonaltherapy. Structuredproblemsolving.

Patientswithchronic,relapsingdepressionmaybenefitmorefromCBToracombinationofCBTandantidepressantsthan frommedicationalone.84,85Counsellingmaybehelpful,especiallyinmildercasesandiffocusedonspecificpsychosocial problemswhicharerelatedtothedepression,egrelationships,bereavement.N13 Referraltothesecondarymentalhealthservicesisadvised: asanemergency,ifthereisasignificantriskofsuicideordangertoothers,psychoticsymptoms,severeagitationor retardationwithimpairedfood/fluidintakeand asanonemergency,if: significantdepressionpersistsdespitetreatmentinprimarycare(antidepressanttherapyhasfailedifthepatient remainssymptomaticafterafullcourseoftreatmentatanadequatedosage.Ifthereisnoclearimprovementwiththefirst drug,itshouldbechangedtoanotherclassofdrug)or thereisahistoryofseveredepression,especiallybipolardisorder. Ifdrugoralcoholmisuseisalsoaproblem,seetheguidelinesforthesedisorders. Involvenonhealthcaresupport(egchaplain,counsellor,listener/buddy,voluntarysupportgroup)inallothercases wheresymptomspersist,wherethepatienthasapoorornonexistentsupportnetwork,orwheresocialorrelationship problemsarecontributingtothedepression.86 Severelydepressedadolescentsaredifficulttoassessandmanage,andreferralisrecommended(seeEmotionaldisorders inyoungpeople,page126). Formoredetailsonreferral,seeManagingtheinterfacewiththeNHSandotheragencies(page149).

Resources for patients and primary support groups AssociationforPostNatalIllness:02073860868 DepressionAlliance:02076330557(answerphone) SAD(SeasonalAffectiveDisorder)Association:01903814942 Samaritans:08457909090(24hour,7daysperweekhelpline) UKRegisterofCounsellors:08704435232 (ProvidesalistofBACPaccreditedcounsellors) Resourceleaflets: Problemsolving CopingwithDepression DorothyRowe.Depression:WayOutofYourPrison.Anexplanatorybook ErikaHarvey.TheElementGuidetoPostnatalDepression:YourQuestionsAnswered.Shaftesbury:Element,1999

Dissociative (conversion) disorder F44

Presenting complaints Patientsexhibitunusualordramaticphysicalsymptomssuchasseizures,amnesia,trance,lossofsensation,visual disturbances,paralysis,aphonia,identityconfusionandpossessionstates.Thepatientisnotawareoftheirroleintheir symptomstheyarenotmalingering. Diagnostic features Physicalsymptomsare: unusualinpresentationandare notconsistentwithknowndisease. Onsetisoftensuddenandrelatedtopsychologicalstressordifficultpersonalcircumstances. Inacutecases,symptomsmay: bedramaticandunusual changefromtimetotimeor berelatedtoattentionfromothers. Inmorechroniccases,patientsmayappearundulycalminviewoftheseriousnessofthecomplaint. Differential diagnosis Carefullyconsiderthephysicalconditionsthatmaycausesymptoms.Afullhistoryandphysical(includingneurological) examinationareessential.Theearlysymptomsofneurologicaldisorders(egmultiplesclerosis)mayresembleconversion symptoms. Ifotherunexplainedphysicalsymptomsarepresent,seeUnexplainedsomaticcomplaintsF45(page94). DepressionF32#(page47).Atypicaldepressionmaypresentinthisway. Essential information for the patient and primary support group

Physicalorneurologicalsymptomsoftenhavenoclearphysicalcause.Symptomscanbebroughtaboutbystress. Symptomsusuallyresolverapidly(fromhourstoafewweeks),leavingnopermanentdamage.
Advice and support to the patient and primary support group

Encouragethepatienttoacknowledgerecentstressesordifficulties(thoughitisnotnecessaryforthepatienttolinkthe Givepositivereinforcementforimprovement.Trynottoreinforcesymptoms Advisethepatienttotakeabriefrestandrelieffromstress,thentoreturntousualactivities. Adviseagainstprolongedrestorwithdrawalfromactivities.

Medication Avoidanxiolyticsorsedatives. Inmorechroniccaseswithdepressivesymptoms,antidepressantmedicationmaybehelpful. Referral Seegeneralreferralcriteria(page152). Nonurgentreferraltothesecondarymentalhealthservicesisadvisedifconfidentofthediagnosis: ifsymptomspersist ifsymptomsarerecurrentorsevereor ifthepatientispreparedtodiscussapsychologicalcontributiontosymptoms. Ifyouareunsureofthediagnosis,considerreferraltoaphysicianbeforereferraltothesecondarymentalhealthservices. Ifreleaseisplanned,workcooperativelywithbothprobationorthroughcareplanningofficerstoensurethat appointmentswithageneralpractitionerandspecialistmentalhealthcarearearrangedalongwithotherneedssuchas housing. Formoredetailonthroughcare,seeManagingtheinterfacewiththeNHSandotheragencies(page149). stressestocurrentsymptoms).

Resource for patients and primary support groups UKRegisterofCounsellors:08704435232 (SuppliesnamesandaddressesofBACaccreditedcounsellors).

Drug-use disorders F11#

Presenting complaints Patientsmaypresentinastateofwithdrawalor(morerarely)ofintoxicationorwithphysicalcomplicationsofdruguse,eg abscessesorthromboses.Theymayalsopresentwiththelegalorsocialconsequencesoftheirdruguse,egprosecutionor debt.Occasionally,covertdrugusemaymanifestitselfasbizarre,unexplainedbehaviour. Patientsmayhave:depressedmood,nervousnessorinsomnia. Patientsmaypresentwithadirectrequestforprescriptionsfornarcoticsorotherdrugs,arequestforhelptowithdraw,or forhelpwithstabilisingtheirdruguse. Signsofdrugwithdrawalincludethefollowing. Opioids:nausea,sweating,aching,stomachcramps,gooseflesh,dilatedpupils Sedatives:anxiety,tremors,perceptualdistortions,fits Stimulants:depression,moodiness,hunger,excessivesleep. Staffmayrequesthelpbeforethepatient(egbecausethepatientisirritableorhasapositiveresulttoadrugtest).Whatever theirmotivationforseekinghelp,theaimoftreatmentistoassistthepatientinremaininghealthyuntil,ifmotivatedtodoso andwithappropriatehelpandsupport,he/shecanachieveadrugfreelife. Diagnostic features

Drugusehascausedphysicalharm(eginjurieswhileintoxicated),psychologicalharm(egsymptomsofmentaldisorder
duetodruguse)orhasledtoharmfulsocialconsequences(egcriminality,lossofjob,severefamilyproblems) Habitualand/orharmfulorchaoticdruguse Difficultycontrollingdruguse Strongdesiretousedrugs Tolerance(canuselargeamountsofdrugswithoutappearingintoxicated) Withdrawal(eganxiety,tremorsorotherwithdrawalsymptomsafterstoppinguse).

Diagnosiswillbeaidedbythefollowing. History:includingareasonforpresentation,pastandcurrent(ieinthepast4weeks)druguse,ahistoryofinjectingand theriskofHIVandhepatitis,pastmedicalandpsychiatrichistory,social(andespeciallychildcare)responsibilities, forensichistoryandpastcontactwithtreatmentservices Examination:motivation,physical(needletracksorcomplications,egthrombosisorviralillness),mentalstate Investigations:haemoglobin,LFTs,urinedrugscreen,hepatitisBandC,HIV. Differential diagnosis

AlcoholmisuseF10(page18)cancoexist.Polydruguseiscommon Symptomsofanxietyordepressionmayalsooccurwithheavydruguse.Ifthesecontinueafteraperiodofabstinence(eg PsychoticdisordersF23,F20#(page11and36) Acuteorganicsyndromes.

about4weeks),seeDepressionF32#andGeneralisedanxietyF41.1(pages47and64)

Essential information for the patient and primary support group

Drugmisuseisachronic,relapsingcondition.Controllingorstoppinguseoftenrequiresseveralattempts.Itisparticularly
hardwhenthepatientalsohasanothermentaldisorder.Relapseiscommon Abstinenceshouldbeseenasalongtermgoal.Harmreduction(especiallyreducingintravenousdruguse)maybeamore realisticgoalintheshorttomediumterm Stoppingorreducingdrugusewillbringpsychological,socialandphysicalbenefits UsingsomedrugsduringpregnancyrisksharmingthebabyN87 Forintravenousdrugusers,thereisariskoftransmittingHIVinfection,hepatitisorotherinfectionscarriedbybody fluids.Discusstheappropriateprecautions,egusecondomsanddonotshareneedles,syringes,spoons,waterorany otherinjectingequipment Wherethepatientalsohasapsychoticdisorder,advisethatsubstanceabusemakesacutesymptomsofpsychosis(eg hallucinations)worse,evenwhenantipsychoticmedicationistaken.

Advice and support to the patient and primary support group

Adviceshouldbegivenaccordingtothepatientsmotivationandwillingnesstochange.88Forsomepatientswithchronic, relapsingopioiddependence,thetreatmentofchoiceismaintenanceonlongactingopioids(usuallymethadone).89 Forallpatients,dothefollowing. Discussthebenefitsandcostsofdruguse(includingthelinksbetweendruguseandoffending)fromthepatients perspective Feedbackinformationaboutthehealthrisks,includingtheresultsofinvestigations Emphasisethepersonalresponsibilityforchange Giveclearadvicetochange Assessandmanagethephysicalhealthproblems(egdeepveinthrombosis[DVT],abscesses,infections,hepatitis,HIV, anaemia,chestproblems)andnutritionaldeficiencies Considertheoptionsforproblemsolvingortargetedcounsellingtodealwithlifeproblemsrelatedtodruguse. Forpatientsnotwillingtostoporchangetheirdruguseimmediately,dothefollowing. Donotrejectorblame Adviseonharmreductionstrategies(egifthepatientisinjecting,adviseontherisksofneedlesharing,notinjectingalone, notmixingalcohol,benzodiazepinesandopiates)(seethepatientleafletHarmReductiononthedisk) Clearlypointoutmedical,psychological,socialandoffendingproblemscausedbydrugs Makeafutureappointmenttoreassesshealth(egwellwomanchecks,immunisation)anddiscussdruguse. Ifreducingdruguseisareasonablegoal(orifapatientisunwillingtoquit): Negotiateacleargoalfordecreaseduse Discussstrategiestoavoidorcopewithhighrisksituations(egrelease,socialsituations,stressfulevents) Planforselfmonitoringproceduresuponrelease(egadiaryofdruguse)andforsaferdrugusebehaviours(egtime restrictions,slowingdownrateofuse) Consideroptionsforcounsellingand/orrehabilitation. Ifmaintenanceonsubstitutedrugsisareasonablegoal(orifapatientisunwillingtoquit): Negotiateacleargoalforlessharmfulbehaviour.Helpthepatientdevelopahierarchyofaims,egstoppingillicituseand maintenanceonprescribed,substitutedrugs,reductionofsubstitutedrugs Discussstrategiestoavoidorcopewithhighrisksituations,egrelease,socialsituationsorstressfulevents Considerwithdrawalsymptomsandhowtoavoidorreducethem Consideroptionsforcounsellingorrehabilitation,orboth. Forpatientswillingtostopimmediately: Considerwithdrawalsymptomsandhowtomanagethem Discussstrategiestoavoidorcopewithhighrisksituations,egrelease,socialsituationsorstressfulevents Makespecificplanstoavoiddruguse,eghowtorespondtofriendswhostillusedrugs Identifyfamilyorfriendswhowillsupportstoppingdruguse Consideroptionsforcounsellingorrehabilitation,orboth. Forpatientswhodonotsucceedorwhorelapseortransfertoadifferentdrugwhileinprison: Identifyandgivecreditforanysuccess Discusssituationsthatledtotherelapse Returntotheearliersteps. SelfhelporganisationssuchasNarcoticsAnonymousareoftenhelpful. Medication Towithdrawapatientfrombenzodiazepines,converttoalongactingdrugsuchasdiazepamandreducegraduallyover26 months(seeBNF,Section4.1).Formoreinformation,seeGuidelinesforthepreventionandtreatmentofbenzodiazepine dependence.90 Withdrawalfromstimulantsorcocaineisdistressingandmayrequiremedicalsupervision.Theriskofsuicideandself harmduringandfollowingwithdrawalfromstimulantsandcocaineisparticularlyhigh.Formoreinformation,see Comorbidity(page191). Bothlongtermmaintenanceofapatientonsubstituteopiates(usuallymethadone)andwithdrawalfromopiatesshould bedoneaspartofasharedcarescheme.91Amultidisciplinaryapproachisessentialandshouldincludedrug

counselling/therapy N92andpossiblefuturerehabilitationneeds.93Thedoctorsigningtheprescriptioniswholly responsibleforprescribing;thiscannotbedelegated.Formoreinformation,seeDrugMisuseandDependence:Guidelineson ClinicalManagement.94 Carefulassessment,includingurineanalysisand,wherepossible,doseassessment,isessentialbeforeprescribingany substitutemedication,includingmethadone.Addictsoftentrytoobtainahigherthanneededdose.Dosageswilldepend ontheresultsoftheassessment Forlongtermmaintenanceorstabilisationbeforegradualwithdrawal,thedoseshouldbetitrateduptothatneededboth toblockwithdrawalsymptomsandthecravingforopiatesN95 Forgradualwithdrawalafteraperiodofstabilisation,thedrugcanbeslowlytapered(egby5mgperfortnight) Dailydispensingandsupervisedingestionarerecommended IntheUKatpresent,methadonemixtureBNF1mgml1isthemostoftenusedsubstitutemedicationforopioid addiction96(seeBNF,Section4.10).Other,newerdrugsare,ormaybecome,available(egBuprenorphine97).Specialist adviceshouldbeobtainedbeforeprescribingthese WithdrawalfromopiatesforpatientswhosedruguseisalreadywellcontrolledcanbemanagedwithLofexidine98(see BNF,Section4.10). Referral Considerreferral: ToaDetoxificationUnitifthepatientisdependentupondrugs Involvetheinhouseorsecondarymentalhealthservicesinadditionifthepatienthasanassociatedseverepsychiatric disorder,orifthesymptomsofmental illnesspersistafterdetoxificationandabstinence.Ideally,treatmentshouldbeprovidedbycliniciansskilledintreating bothsubstancemisuseandmentaldisorder25 Tocounselling,assessment,referral,adviceandthroughcareservices(CARATS)workersforcounsellingtargetedat problemsassociatedwith/triggeringdruguseandrelapsepreventionwork Toinhouserehabilitationprogrammesandtherapeuticcommunities. Beforerelease: Ifpossible,arrangeingoodtimeforongoingrehabilitationsupportinthecommunity.Helpwithlifeproblems, employmentandsocialrelationshipsisanimportantcomponentoftreatment99 Wherethepatienthasbothamentalillnessandadrugmisuseproblemandexpressessomemotivationtoreduceuse,if eitherthepsychiatricorsubstancemisuseproblemappearstopredominate,refertheminitiallytothatservice.Makethe rationaleclearintheletter/fax.Ifbothtypesofdisorderareofequalsignificance,thennegotiatewithbothagenciesabout thepreferredinitialreferralroute.Itmaybethattheindividualwillrequiresupportandinputbybothagencies.Somecan provideservicesjointly.Ideally,amodifiedformofmotivationalinterviewingthattakesaccountoftheadditional problemsofapatientwithaseverementalillnesswillbeused.Liaisewiththeservicetoensurecontinuedprescriptionof psychotropicmedication,ifappropriate Stresstothepatientthatrelapsesaretobeexpected,arenotsignsoffailureandwillnotmeanalossofyoursupportand respect. SeeComorbidity(page191).

Resources for patients and primary support groups ADFAMNational:02079288900(helpline) (Forfamiliesandthefriendsofdrugusers) CITA(CouncilforInvoluntaryTranquilliserAddiction):01519490102(MondayFriday,10am1pm) CavendishHouse,BrightonRoad,Waterloo,Liverpool (Confidentialadviceandsupport) HeroinAdviceline:02077299904 (Advice,supportandinformationtodrugusersandtheirfriendsandfamiliesonallaspectsofdruguseanddrugrelated legalproblems) NarcoticsAnonymous:02077300009 NationalDrugsHelpline:0800776600(24hourfreephone) (Confidentialadvice,includinginformationonlocalservices) ReleaseOutofHours:02076038654(helpline:MondayFriday,6pm10pm;SaturdayandSunday,8am12midnight) Resourceleaflets: HarmMinimizationAdvice DrugUseDiary

Eating disorders F50

Presenting complaints Thepatientmayindulgeinbingeeatingandextremeweightcontrolmeasuressuchasselfinducedvomiting,excessiveuse ofdietpillsandlaxativeabuse.Thismayberecognisedfirstonreceptionintoprisonwhenlowweightisrecorded,oritmay becomemoreapparentafteraperiodinprisonwhenabnormaleatingbehaviourshavebeenobserved. Bothanorexiaandbulimiamaypresentasphysicaldisorders,egamenorrhoea,seizuresandcardiacarrhythmiasthat requiremonitoringortreatment. Diagnostic features Commonfeaturesare: unreasonablefearofbeingfatorgainingweight extensiveeffortstocontrolweight,egstrictdieting,vomiting,useofpurgatives,excessiveexercise denialthatweightoreatinghabitsareaproblem lowmood,anxiety/irritability obsessionalsymptoms relationshipdifficulties increasingwithdrawaland schoolandworkproblems. Patientswithanorexianervosatypicallyshow: severedietingdespiteverylowweight:bodymassindex(BMI)< 17.5kgm2 (BMI=weight[kg]/height[m2]) adistortedbodyimage,ieanunreasonablebeliefthatoneisoverweightand amenorrhoea. Patientswithbulimiatypicallyshow: bingeeating,ieeatinglargeamountsoffoodinafewhoursand purging:attemptstoeliminatefoodbyselfinducedvomitingorviadiureticorlaxativeuse. Apatientmayshowbothanorexicandbulimicpatternsatdifferenttimes.Bingeeatingmaybeverydifficultinaprison settingandtheinabilitytousethiscopingmechanismmayresultinincreasedanxietyandtheuseofalternativemaladaptive copingstrategies,egdeliberateselfharm,aggression. Themedicalconsequencesofsevereweightlossincludeamenorrhoea,dentalproblems,muscleweakness,renalstones, constipationandliverdysfunction.Medicalcomplicationsofpurgingincludedentalproblems,salivaryglandswelling, kidneystones,cardiacarrhythmiasandseizures. Eatingdisordersarerarerinmenthaninwomen.Thereisanassociationbetweeneatingdisordersandchildhoodabuse. Differential diagnosis

DepressionF32#(page47)mayoccuralongwithbulimiaoranorexia. Physicalillnessmaycauseweightloss. Theremaybecoexistingproblemssuchasdrugsandalcoholmisuseorselfharm.

Essential information for the patient and primary support group

Purgingandseverestarvationmaycauseseriousphysicalharm.Anorexianervosacanbelifethreatening. Purgingandseveredietingareineffectivewaysofachievinglastingweightcontrol. Selfhelpgroups,leafletsandbooksmaybehelpfulinexplainingthediagnosisclearlyandinvolvingthepatientin

treatment. Advice and support to the patient and primary support group Theprisondoctorcanundertakesomesimplestepstotreateatingdisorders,ideallywiththehelpofthecounsellors, healthcarestaffand/oradietitian. Inanorexianervosa:

 Expectdenialandambivalence.Elicitthepatientsconcernsaboutthenegativeeffectsofanorexianervosaonaspectsof

theirlife.Askthepatientaboutthebenefitsthatanorexiahasforthem,egthefeelingofbeingincontrol,feelingsafe,being abletogetcareandattentionfromfamily.Donottrytoforcethepatienttochangeifhe/sheisnotready. Educatethepatientaboutfoodandweight. Weighthepatientregularlyandcharttheirweight.Setmanageablegoalsinagreementwiththepatient(egaimfora0.5kg increaseperweek;thisrequiresacalorieintakeofabout2500kcalday1).Asupportivememberofstaffwhothepatient trustsmaybeabletohelpthepatientachievethis.Consultationwithadietitianmaybehelpfultoestablishthenormal calorieandnutrientintakeandtheregularpatternsofeating. Areturntonormaleatinghabitsmaybeadistantgoal. Providecounselling,ifavailable,abouttraumaticlifeeventsanddifficulties(pastandpresent)thatseemsignificantinthe onsetormaintenanceofthedisorder(seeCounsellingandotherpsychologicaltherapiesbelow). Inbulimianervosa: Useacollaborativeapproach. Afooddiarycanbeausefultherapeutictoolindiscussionswiththepatient. Educatethepatientabouttheneedtoeatregularlythroughouttheday(threemealsplustwosnacks)toreduceurgesto binge. Setmutuallyagreed,gradualgoalstoincreasenumberofmealseaten,thevarietyoffoodsallowed,andtoreduce vomitingandlaxatives. Helpthepatientidentifythepsychologicalandphysiologicaltriggersforbingeeatingandmakeclearplanstocopemore effectivelywiththesetriggerevents,egplananalternativebehaviour. Discussthepatientsbiasedbeliefsaboutweight,shapeandeating(egcarbohydratesarefattening)andencouragea reviewoftheirrigidviewsaboutbodyimage,egpatientsbelievenoonewilllikethemunlesstheyareverythin.Donot simplystatethatthepatientsviewiswrong. Providecounselling,ifavailable,aboutthedifficultiesunderlyingormaintainingthedisorder,egchildhoodabuse, relationshipdifficultiesorconcurrentproblemswithsubstanceabuse(seeCounsellingandotherpsychologicaltherapies below). Additional advice to staff (with patient permission)

Supportwillberequiredaroundeatingtoreduceanxietyatthosetimescriticalcommentsorexhortationstoeatwillnot Encouragingreasonablelevelsofactivityandexercisetopromoteahealthylifestyleisimportantandcanhelpinre Helptodevelopalternativecopingstrategies.Attendanceateducationand/orworkwillbehelpful. Explanationsaboutthedisorderandthetreatmentapproachesforpersonalofficerswillhelpthembesupportiveofthe

patientdaytoday. Medication establishingeatinghabitsandappetite. help.

Inbulimianervosa,antidepressants(egfluoxetine,60mg)areeffectiveinreducingbingeingandvomitinginaproportion
ofcases.N100However,compliancewithmedicationmaybepoor(seeBNF,Section4.3). Nopharmacologicaltreatmentforanorexiahasbeenestablishedtodate.N101Psychiatricconditions(egdepression)may cooccurandmayrespondtopharmacologicaltreatment. Orderbloodtestsforureaandelectrolytes. Referral Referforurgentassessment(ifpossible,tothesecondarymentalhealthserviceswithexpertiseineatingdisorders)if: BMI<13.5kgm2,especiallyiftherehasbeenrapidweightloss potassium<2.5mmoll1 thereisseverebonemarrowdysfunctionwithlossofplatelets thereisevidenceofproximalmyopathy therearesignificantgastrointestinalsymptomsfromrepeatedvomiting,egbloodinvomitus thereissignificantriskofsuicideor thereareothercomplicatingfactors,egsubstanceoralcoholabuse. Refertospecialistmentalhealthservicesforassessmentifthereisalackofprogressdespitetheabovemeasures.

Counselling and other psychological therapies

Ifavailable,considerfamilytherapyforappropriatepatients,includinganorexicpatients(under18years),102individual psychotherapyforanorexicpatientsover18,andcognitivebehaviouraltherapy103forthosewithbulimia.Ifdetentionin prisonhasrevealedaneatingdisorderforthefirsttime,liaisonwithcommunityprovidersforaccesstotherapeutic interventionsonreleaseisimportant. Considernonstatutory/voluntaryservices/selfhelpgroups. Wherethepatientisonremandoronashortsentence,andespeciallyifthetraumaticlifeeventsincludeseverechildhood abuse,appropriatetypesofhelpwillencouragethepatienttofocusonthepresentandhelphim/herdealwithcurrent problemsforwhichsolutionsmaybepossible. Resources for patients and primary support groups EatingDisordersAssociation:01603621414(helpline:9am6.30pm) (Selfhelpsupportgroupsforsufferers,andtheirrelativesandfriends.Assistsinputtingpeopleintouchwithsourcesof helpintheirownarea) CentreforEatingDisorders(Scotland):01316683051 (Information,privatepsychotherapy,selfhelpmanuals,informationpacksandahelpline) AnorexiaBulimiaCareline(NorthernIreland):02890614440 OvereatersAnonymous:01454857158(recordedmessage) (Selfhelpgroupsforthosesufferingfromeatingdisordersorovereating) Resourceleaflet: FoodandBehaviourDiary USchmidt,JTreasure,1993,GettingBetterBit(e)byBit(e)SurvivalGuideforSufferersofBulimiaNervosaandBingeEating Disorders.LawrenceErlbaum,1993Hove.(Selfhelpmanualofprovenefficacyforsufferersofbulimiaandbingeeating disorders)104 JTreasure.AnorexiaNervosa:ASurvivalGuideforFamilies,FriendsandSufferers.London:PsychologyPress,1997 BoththeabovebooksareavailablefromtheInstituteofPsychiatry:URL: http://www.iop.kcl.ac.uk/IoP/Departments/PsychMed/EDU/GuidedSelfCare.stm;orthedistributorsTaylor& Francis.Tel:01264343071 CGFairburn.OvercomingBingeEating.NewYork:Guilford,1995.Advicetestedincontrolledresearch

Generalised anxiety F41.1

Presenting complaints Thepatientmaypresentinitiallywithtensionrelatedphysicalsymptoms(egheadacheorapoundingheart)orwith insomnia.Enquirywillrevealprominentanxiety. Diagnostic features Multiplesymptomsofanxietyortensioninclude: physicalarousal,egdizziness,sweating,afastorpoundingheart,adrymouth,stomachpainsorchestpains mentaltension,egworry,feelingtenseornervous,poorconcentration,fearthatsomethingdangerouswillhappenandthe patientwillnotbeabletocopeand physicaltension,egrestlessness,headaches,tremorsoraninabilitytorelax. Symptomsmaylastformonthsandrecurregularly.Oftentheyaretriggeredbystressfuleventsinthosepronetoworry. Differential diagnosis

AlcoholmisuseF10orDrugusedisordersF11#(pages18and55)ifheavyalcoholordruguseispresent.Anxietyis

acommonsymptomduringdetoxification/withdrawal.Itmayalsounderliesubstancemisuseandbecomeprominent afterwithdrawal.Substancesmaybeusedtoselfmedicateforanxiety.Ifsymptomsofanxietyremainorincrease followingdetox,suspectanunderlyinganxietydisorderand/orbenzodiazepinedependence(seeComorbidity,page191). DepressionF32#(page47)ifaloworsadmoodisprominent. ChronicmixedanxietyanddepressionF41.2(page33). PanicdisorderF41.0(page67)ifdiscreteattacksofunprovokedanxietyarepresent. PhobicdisordersF40(page79)iffearandavoidanceofspecificsituationsarepresent. Certainphysicalconditions(egthyrotoxicosis)ormedications(egmethylxanthines,agonists)maycauseanxiety symptoms. Anxietycanbeasymptomofposttraumaticstressdisorder.PosttraumaticstressdisorderF43.1(page82). Essential information for the patient and primary support group

Stressandworryhavebothphysicalandmentaleffects. Wheredrugsoralcoholhavepreviouslybeenusedtodealwithunderlyinganxiety,prisonpresentsanopportunityto Learningskillstoreducetheeffectsofstress(notsedativemedication)isthemosteffectiverelief.105

Advice and support to the patient and primary support group learnalternativewaysofdealingwithit.

Encouragethepatienttouserelaxationmethodsdailytoreducethephysicalsymptomsoftension.TheManagingAnxiety

leafletonthediskincludesarelaxationexercise.Ifthepatienthasreadingdifficulties,amemberofthehealthcareteam orothermemberofstaffmaybeabletogooverthecontentsoftheleafletwiththepatient. Adviseareductionincaffeineconsumption,ifappropriate.46 Trytoavoidusingcigarettes,otherdrugsoralcoholtocopewithanxiety. Helpthepatientplanactivitiesthatarerelaxing,pleasurableorconfidencebuilding.Exercisemaybehelpful.49,50If necessary,consideradvocatingforimprovedaccesstoappropriateactivities. Identifyandchallengeexaggeratedworriestohelpthepatientreduceanxietysymptoms: Identifyexaggeratedworriesorpessimisticthoughts,egwhenavisitordoesnotarriveontime,thepatientworriesthat theynolongerwantcontactwiththem. Discusswaystoquestiontheseexaggeratedworrieswhentheyoccur,egIamstartingtobecaughtupinworryagain. Myvisitorisonlyafewminuteslate.Hewillprobablybeheresoon. Structuredproblemsolvingmethods48canhelppatientstomanagecurrentlifeproblemsorstressesthatcontributeto anxietysymptoms.Supportthepatienttocarryoutthefollowingsteps: Identifyingeventsthattriggerexcessiveworry.(Forexample,ayoungwomanpresentswithworry,tension,nausea andinsomnia.Thesesymptomsbeganaftershelearnedthathersonwasbehavingbadlyinschoolfollowingher conviction).

Listingasmanypossiblesolutionsasthepatientcanthinkof(egdiscussingherconcernswithaclosefriendorrelative, applyingforanextendedfamilyvisit,writingtohersonsgeneralpractitioner,contactingavoluntaryorganisationthat helpsfamiliesofprisoners). Listingtheadvantagesanddisadvantagesofeachpossiblesolution.(Thepatientshoulddothis,perhapsbetween appointments). Choosinghis/herpreferredapproach. Workingoutthestepsnecessarytoachievetheplan. Settingadatetoreviewtheplan.Identifyandreinforcethingsthatareworking). Identifypossibleresourcesforproblemsolving,relaxation,yoga(egcounsellor,voluntaryagencyteaching meditation/relaxation;seeResourcesDirectory page316). Medication Medicationisasecondarytreatmentinthemanagementofgeneralisedanxiety.105,106Itmaybeused,however,if significantanxietysymptomspersistdespitethemeasuressuggestedabove. AntianxietymedicationN107(seeBNF,Section4.1.2)canonlybeusedfor 2weeks.Avoidshortactingbenzodiazepines; considerdiazepam.Longertermusemayleadtodependenceandislikelytoresultinthereturnofsymptomswhen discontinued. Antidepressantdrugs,108egimipramine,clomipramine,paroxetineorvenlafaxine,maybehelpful,especiallyifthe symptomsofdepressionarepresent.Theydonotleadtodependenceorreboundsymptoms,butcanleadtowithdrawal symptomsandsoshouldbetaperedgradually(seeBNF,Section4.3). Blockersmayhelpcontrolphysicalsymptomssuchastremor.109 Referral SeeGeneralreferralcriteria(page149). Nonurgentreferraltothesecondarymentalhealthservicesisadvisedifthepatientssymptomsaresufficientlysevereor enduringtointerferewithhis/hersocialoroccupationalfunctioning. Ifavailable,considercognitivebehaviouraltherapyoranxietymanagement. N110Selfcareclassesandassisted bibliotherapycanalsobeeffectiveintheprimarycareofmilderanxiety.111,112 Resources for patients and primary support groups NoPanicHelpline:01952590545(10am10pm);08007831531(freephoneinfoline) (Helpline,informationbookletsandlocalselfhelpgroupsforpeoplewithanxiety,phobiasobsessions,panic) PrisonPhoenixTrust:01865512521/512522 PrisonPhoenixTrust,POBox328,OxfordOX27HF.Fax:01865516011 (Teachesandencouragestheuseoftechniquessuchasmeditationandyogaamongprisoners,throughcorrespondence andanetworkofteachers) StresswatchScotland01563574144(helpline);01563570886(office) (Advice,information,materialsonpanic,anxiety,stressphobias.Thirtyfivelocalgroups) TriumphOverPhobia(TOP)UK:01225330353 (Structuredselfhelpgroups.Producesselfhelpmaterials) Resourceleaflets: CopingwithAnxiety MindPublicationsproducesbookletsonUnderstandingAnxietyandotherrelevanttopics.Availablefrom:MindEngland andWales.Tel:02085192122;NorthernIrelandTel:02890237937;Scotland:Tel:01415687000 AliceNeville.WhosAfraid?CopingWithFear,AnxietyandPanicAttacks.Arrow,1991

Panic disorder F41.0

Presenting complaints Patientsmaypresentwithoneormorephysicalsymptoms(egchestpain,dizzinessorshortnessofbreath)orunexplained episodesofintensefear.Furtherenquiryshowsthefullpatterndescribedbelow. Diagnostic features Thepatientexperiencesunexplainedattacksofanxietyorfear,whichbeginsuddenly,developrapidlyandmaylastonlya fewminutes. Thepanicsoftenoccurwithphysicalsensationssuchaspalpitations,chestpain,sensationsofchoking,churningstomach, dizziness,feelingsofunrealityorfearofpersonaldisaster(losingcontrolorgoingmad,suddendeathorhavingaheartattack). Apanicoftenleadstofearofanotherpanicattackandavoidanceofplaceswherepanicshaveoccurred. Differential diagnosis Manymedicalconditionsmaycausesymptomssimilartopanic,egarrhythmia,cerebralischaemia,coronarydisease,asthma orthyrotoxicosis.Itisnotuncommonforindividualswiththeseconditionsadditionallytosufferfrompanic.Historyand physicalexaminationshouldexcludemanyoftheseandshouldreassurethepatient.However,avoidunnecessarymedical testsortherapies. Drugsmayinducethesymptomsofpanic. PhobicdisordersF40(page79)ifpanicstendtooccurinspecificsituations. DepressionF32#(page47)ifaloworsadmoodisalsopresent. Essential information for the patient and primary support group

Paniciscommonandcanbetreated. Anxietyoftenproducesfrighteningphysicalsymptoms.Chestpain,dizzinessorshortnessofbreatharenotnecessarily

signsofaphysicalillness;theywillpasswhenanxietyiscontrolled.Explainhowthebodysarousalreactionprovidesthe physicalbasisfortheirsymptomsandhowanxietyaboutaphysicalsymptomcancreateaviciouscycle.Adiagrammay behelpful. Panicanxietyalsocausesfrighteningthoughts(egfearofdying,afeelingthatoneisgoingmadorwilllosecontrol)and viceversa.Thesealsopasswhenanxietyiscontrolled. Mentalandphysicalanxietyreinforceeachother.Concentratingonphysicalsymptomswillincreasefear. Apersonwhowithdrawsfromoravoidssituationswherepanicshaveoccurredwillonlystrengthenhis/heranxiety. Advice and support to the patient and primary support group N106

Advisethepatienttoidentifytheearlywarningsignsofanimpendingpanicattackandtakethefollowingstepsatthefirst
signofapanic: Staywhereyouareuntilthepanicpasses,whichmaytakeupto1hour.Donotleavethesituation.Startslow,relaxed breathing,countinguptofouroneachbreathinandeachbreathout.Breathingtoodeeply(hyperventilation)cancause someofthephysicalsymptomsofpanic.Controlledbreathingwillreducethephysicalsymptoms.Dosomethingtofocus yourthinkingonsomethingvisible,tangibleandnonthreatening,eglookatapictureonthewall. Ifhyperventilationissevere,sitdownandbreatheintoapaperbagsothattheincreasedcarbondioxidewillslowdown yourbreathing(unlessthepatienthasasthmaorcardiovasculardisease). Concentrateoncontrollinganxietyandnotonthephysicalsymptoms Tellyourselfthatthisisapanicattackandthatthefrighteningthoughtsandsensationswilleventuallypass.Notethe timepassingonyourwatch.Itmayfeellikealongtimebutitwillusuallyonlybeafewminutes. Identifyexaggeratedfearsthatoccurduringpanic,egpatientsfearsthathe/sheishavingaheartattack. Discusswaystochallengethesefearsduringpanic,egthepatientremindshim/herself:Iamnothavingaheartattack. Thisisapanic,anditwillpassinafewminutes. Ifpossible,identifysomeone(amemberofthehealthcareteamorotherstaffmember)whothepatienttrustswhomay supporthim/herintakingtheaboveactions. Monitorand,ifnecessary,reducecaffeineintake. Trytoavoidusingcigarettesorotherdrugstocopewithanxiety.

 Selfhelpgroups,books,tapesorleafletsmayhelpthepatientmanagepanicsymptomsandovercomefears.113Ifthe

patienthasreadingdifficulties,amemberofthehealthcareteamoranothermemberofstaffmaybeabletodiscussthe contentsoftheleafletManagingAnxietyonthediskwithhim/her.

Medication Manypatientswillbenefitfromtheabovemeasuresandwillnotneedmedication,unlesstheirmoodislow. Ifattacksarefrequentandsevereorifthepatientissignificantlydepressed,antidepressants,includingtricyclics(TCAs) andselectiveserotoninreuptakeinhibitors(SSRIs),maybehelpful.N114Paroxetineandcitalopramarecurrentlylicensed forpanic(seeBNF,Section4.3).Therecanbeaslightworseningofsymptomsinitially,soadvisethepatienttoplan reducedactivitiesfortheweekfollowingthefirstprescription. Encouragepatientstofacefearswithouttheuseofbenzodiazepines.However,wherethefearedsituationisrare, occasionalshorttermuseofantianxietymedicationmaybehelpful.N115Regularusemayleadtodependenceandis likelytoresultinareturnofsymptomswhendiscontinued. Referral SeeGeneralreferralcriteria(page149). Nonurgentreferraltothesecondarymentalhealthservicesoracounsellorwithappropriatespecialtrainingisadvised forassessmentforcognitivebehaviouralpsychotherapyforpatientswhodonotimproveorthosewhoselifestyleisseverely compromised.(Thiscanbeparticularlyeffectiveforpatientswithpanicdisorder.116,117)Cognitivebehaviouraltherapy (CBT),whichhasbeendevelopedinspecialistsettings,alsoappearstobeeffectiveinprimarycare.118 Paniccommonlycausesphysicalsymptoms;avoidunnecessarymedicalreferralforphysicalsymptomsifyouarecertain ofthediagnosis. Considerselfhelp/voluntary/nonstatutoryservices. Resources for patients and primary support groups NoPanicHelpline:01952590545(10am10pm);08007831531(freephoneinfoline) (Helpline,informationbookletsandlocalselfhelpgroupsforpeoplewithanxiety,phobias,obsessionsandpanic) StresswatchScotland:01563574144(helpline);01563570886(office) (Advice,information,materialsonpanic,anxiety,stressphobias.Thirtyfivelocalgroups) TriumphOverPhobia(TOP)UK:01225330353 (Structuredselfhelpgroups.Producesselfhelpmaterial) Resourceleaflets: ManagingAnxiety MindPublicationsproducesbookletsonHowToCopeWithPanicAttacksandotherrelevanttopics.Availablefrom:Mind EnglandandWales:Tel:02085192122;NorthernIreland:Tel:02890237973;Scotland:01415687000 IsaacMarks.LivingwithFear.NewYork:McGrawHill1978.Selfhelpmanual AliceNeville.WhosAfraid?CopingWithFear,AnxietyandPanicAttacks.Arrow,1991

Personality (behavioural) disorders F6069

Introduction Manypeopleinprisonhaveapersonalitydisorder.Somehavesufferedextremesofabuseandneglectaschildrenleadingto verydisturbedbehavioursandwaysofrelatingtoothers.Peoplewithpersonalitydisordersareverydifficulttomanage. However,treatablementaldisordersoccurfrequentlyinpeoplewithpersonalitydisorders.Theaimsofthisguidelineareto helpprimarycarestafftodothefollowing. Formandmaintainatherapeuticrelationshipwiththesepatients: totreatcomorbidmentalandphysicaldisorders torecogniseandreinforcethepatientscapacitytochangetheirimmediatesituationattimesofcrisisand tooffersupportandthuscontributetoavoidingfurtherdeterioration. Identifythosepatientswhomaybenefitfromfurtherassessmentandtreatmentfortheirbehaviouralproblemsby specialists. Participateinthemultidisciplinarymanagementofverydifficultpatients. Presenting complaints Mostpatientspresentwithcomplaintsofanotherdisorderratherthanthepersonalityproblemitself.Theymaypresentwith anxiety,depression,eatingproblemsordeliberateselfharm,ortheymayrepeatedlyseekpsychotropicmedication.People withpersonalitydisordermayexperiencehighlevelsofdistress.Stafforotherinmatesmayexpressconcernaboutthe patientsbehaviour,egoverlyhostileand/orfrequentattemptsatselfharm.Thepatientspersonalityproblemoften interfereswithtreatmentforanothermentaldisorder. Diagnostic features Thefeaturesofpersonalitydisorderaredisplayedinapatientsbehaviourandrelationships,andmayalsoaffectthe organisationaroundthem.

Behaviour
Thepatientdisplaysalongterm,stablepatternofexperienceandbehaviourthatstartedinearlylife,deviatesmarkedly fromculturalnormsandleadstodistressandimpairment.Thepatientbehavesinthiswaymostorallthetime,insomeor allofarangeofsettings(egwork,home,whenoutwithfriends,inprison)withoutlearningfromthenegativeresponsesof otherstowardsthem.Therearemanydifferentkindsofpersonalitydisordersandinprisonpeoplemostoftenhavefeatures ofmorethanonetype.Thetypesofpersonalitydisordersmostcommonlyfoundinprisonarethefollowing.

Antisocial or dissocial personality disorder

Mostindividualsinprisonareinclinedtowardsanantisociallifestyle.Sometimesthisrisestothelevelofadisorder.The featuresofthedisorderincludethefollowing. Adisregardforandaviolationoftherightsofothers,egviolence,theft,crueltytoanimals. Deceitfulness. Recklessdisregardforsafety. Consistentirresponsibilityandadisregardforrulesandregulations. Inabilitytomaintainrelationshipsforanylengthoftime. Lowtoleranceforfrustration,leadingtoaggressionorviolence. Lackofremorse;atendencytoblameothersorrationalisetheirownbehaviour. Tendencynottolearnfromexperience,particularlyfrompunishment. Oftensuperficiallycooperativeandcharming.

Emotionally unstable disorder (also known as borderline personality disorder)

Individualsmaybeemotionallyunstableand,insome,thismayrisetothelevelofadisorder.Thefeaturesofthedisorder includethefollowing. Unstableandintenseinterpersonalrelationships,egextremesofidealisinganddenigratingtheotherperson,sometimes friendly,sometimesintenselyangry,fearfulofabandonment. Highlyreactive,suddenmoodswings,egintense,inappropriateanger,transient,stressrelatedparanoidthoughts.

 Chronicfeelingofemptiness,clingingdependencyandterrorofbeingleftalone. Markedimpulsivenessthatispotentiallyselfdamaging,egrecklessdriving,sexualpromiscuity,excessivespending Poorabilitytoplanaheadandtosolveproblems.

Paranoid personality disorder
Manyindividualsinprisondisplayparanoidcharacteristicsand,insome,thismayrisetothelevelofadisorder.The featuresofthedisorderincludethefollowing. Distrustandsuspiciousness,egunjustifiedsuspicionsthatothersareexploitingorharminghim/her,reluctancetoconfide inothers,bearsgrudges,willnotacceptrationalexplanation. Beingtense,anxious,irritableorangry. Preoccupationwithjusticeandrules. sprees,bingeeating.

Individual relationships
Theindividualsproblemsandfeelingsoffear,humiliation,angerandneedareplayedoutintheirrelationships.For example,theymay: bullyandattempttodominatethosearoundthem,egvianonverbalintimidation,criticalquestioning,threatsof complaintsorviolence usecharm,flattery,friendlysupporttoobtainspecialprivilegesordevelopaspecialrelationshipthatgoesbeyondthe boundariesofaprofessionalrelationship becomeverydependentuponyouorotherstaff beresistanttoauthorityor becriticalofyouorotherswhoareworkingwiththem. Thegenuinedistressthepatientfeelsmaybeexperiencedbytheotherpersonasmanipulation.

Organisational relationships
Theintensefeelingsanddisturbedbehavioursandrelationshipscommonlyaffectbothstaffteamsandtherelationships betweendepartments.Forexample,thepatientmayidealiseanddenigratedifferentmembersofstaffcausingthefavoured staffmembertodoubtthegoodwillorprofessionalabilityofthedenigratedone.Thismaycausedivisionandconflict withinthehealthcarestaffteamandthehealthcarestaffandotherstaff,egdisciplineofficers,probationofficers,chaplain, psychologist. Differential diagnosis Personalitydisordercommonlycoexistswithmentaldisorder.Ahistoryfromarelativeorclosefriendmaybeusefulto distinguishthetwo.Personalitydisorderisadisorderofrelatingtoothersandthosesymptomsbecomevisiblein relationshipswithothers.Thesymptomsofmentalillnessarevisiblewhenthepatientisalone.Inmentalillness,the patientsbehaviourbecomesdifferentfromwhatisnormalforthatpatient.Inpersonalitydisorder,thebehaviourisnormal forthatpatientbutisdifferentfromthenorminhis/herculture. Ifbehaviour,egoutofcharacteraggression,hasdevelopedforthefirsttimeinadulthood,isofrecentonsetoris temporary,considerthefollowing. DepressionandAnxietydisorders(pages47and33).Aggressionand/orirritabilitymaybeasignofdepression. Acuteorchronicpsychosis(pages11and36). Posttraumaticstressdisorder(page82). Adjustmentdisorder(page15). Abuseofstimulantsorhallucinogenicdrugs(seeDrugmisuse,page55). Medicalconditioncausingpersonalitychange,egbraininjury,dementia. Also,considerthepatientscultural,socialandfamilybackground.Checkthatthepersonsbehaviourisconstantacrossa numberofdifferentsettings.Forexample,ask:Doevenlittlethingsgetyouveryangry?Wasthistrueathomeaswellas hereinprison?Checktheavailablerecordssuchastheinmatemedicalrecord(IMR)andprobationrecords.Ifcriminal behaviourisundertakenforgainandotherfeaturesareabsent,considernomentalorbehaviouraldisorder. Diagnosisofpersonalitydisorderisdifficultasmanyofthediagnosticfeaturesarepresent(thoughinalesserdegree)in allpeople.Aformaldiagnosisofpersonalitydisordershouldonlybemadebyaspecialistandwherethereisreasonto

believethatsuchadiagnosiswillleadtothepatientbeingofferedimprovedmanagement,egassessmentformedicationor transfertoatherapeuticprison. Comorbidity Apersonmayhaveapersonalitydisorderandamentaldisorder.Mentaldisorder(egpsychosis,anxiety,depression)may emergeintimesofstress.Forexample,apersonalitydisorderedprisonerspendingtimeinsegregationmayexperience psychoticsymptoms. Selfharm(egcutting,drugoverdoses)iscommoninborderlineandantisocialtypes,especiallywheretherearerealor perceivedrelationshipproblems,rejectionsorlosses. Depressionandsubstanceabusearecommonandincreasetheriskofsuicide. Someonewithpersonalitydisordermayexperiencepsychoticepisodeswhenunderparticularstress. Mostpeopleinprisonwithpersonalitydisordershowfeaturesofmorethanonetypeofpersonalitydisorder. Information for the patient and primary support group Withpatientpermission,thefollowinginformationmaybegiventoothers. Changeispossiblebutitisverydifficultandrequiresinsight(ietheabilitytoseethatthepatientplayssomepartin causingormaintaininghis/herowndistress;thatitisnotallthefaultofothers)andsubstantialmotivation.Wherethat motivationispresent,longtermspecialisttreatmentisrequired. Depression,anxiety,transientpsychoticillnessandsubstanceabusecanbetreated. Problemsolvingskillscanhelpthepatientcopewithparticularproblems,buttheywillnotchangetheoverallpersonality. Treatmentofanysort(includingforassociatedconditions)requiresthepatientsactiveinvolvement.Therelationshipwith theprofessional(s)concernediscrucial. Advice and support to the patient

All patients

Showrespectforthepatientandaffordthemdignity,butdonotexpecttolikethem. Consideryourownsafetyatalltimes(seeManagingaggression,page282). Assesstheriskofdangertoyourself,othersandthepatient(depressionandselfharmingbehaviourarecommon). Beveryclearaboutyourroleanditsboundaries.Forexample:

thetiminganddurationofappointments donotbuyorbringthingsinforpatients donotdiscussyourownpersonaldetailswiththemand donotdevelopaspecialrelationshipthatissecretfromyourcolleagues. Behonest,thoughsympathetic,incommunications.Keeppromises;conversely,donotmakepromisesyoucannotkeep. Communicatewithothersinyourteamand,asmuchasispossiblewithinconfidentiality,withstaffinotherdepartments whoareinvolvedwiththepatient.Tellthemabouttheapproachyouaretaking.Ensureaconsistentapproach. Treatcomorbidconditions. Focusonimmediate,everydayproblems.Theaimisnottocurethepersonalitydisorderbuttohelpthepatientdealwith everydaylife. Liaise,withthepatientspermission,withotherstaffwhomaybeabletohelpaddressanyimmediate,practicalproblem. Forexample,wingstaffaboutbullying,probationaboutresettlementfollowingrelease.Beawareofthepotentialfor divisionandconflictbetweenstaff(seeOrganisationalrelationshipsabove).Ifproblemsoccur,tryseeingthepatient togetherwiththeotherstaffconcerned. Supportandreinforceanylegalactionsorintereststhatdevelopselfesteem,egwork,creativity,education,exercise.Help themtodevelopanyexistingstrengths,butaimlow.Modestsuccesscanbuildintolargergainslater;failurescanundo goodwork.

Very difficult patients

Itisessentialthatverydifficultpatientsaremanagedinamultidisciplinaryway.Considerconveningacaseconference involvinghealthcare,mentalhealthstaff,worksupervisor,residential(wing)manager,probationofficer,psychologistand chaplainasappropriate.Agreeamanagementplanandinformthepatientofthatplaninthepresenceofallparticipants.

Sharingresponsibilitycanreducestress/burnoutandriskofdependenceonapatientworker(seeManagingprisonerswith complexpresentationsandverydifficultbehaviours,page202).

Antisocial behaviours

Aimtomaintainanopenandtrustingatmosphere. Identifyclearlythereasonthepatientisseekinghelp.Askthepatient,WhydidyoucometotheCentre?Whatdoyou Startfromthestandpointthatthereisalegitimateproblemunderlyingmostrequests,egImaynotbeabletohelpyou

thinkareyourdifficulties? withmedicationatthiscentre.Icouldperhapshelpyouifyouwerepreparedtotellmewhyyouthinkyouneedthis medication.ButotherwisethereisnothingIcandoforyou. Donotacceptallinformationatfacevalue.Seekfurtherevidencetosupportthepatientsstatements.Forexample,ifthe patientsayshe/sheisdepressed,seekoutsymptomsnormallyassociatedwithdepressionusingopenquestionssuchas Whatotherproblemshaveyoubeenexperiencing?Whathaveyoubeendoingwithyourtime?ratherthanclosed questionssuchasAndhaveyoulostinterestinthethingsyounormallyenjoy?Allowthepersonadequatepersonal spacedonotcrowdthem. Donottakethepatientscommentspersonally. Allowthepatientachancetotalkfreelyabouthis/herconcerns. Setlimitsandclearguidelinesaboutexpectedbehaviour,egverbalabusewillnotbetolerated. Itissafesttotreatallpatientsinthisway,asyoumaynotknowinadvancewhicharedifficult.

Emotionally unstable (borderline) behaviours

Setclearlimits.Haveaveryclearmanagementplan:howfrequentlyyouwillseethepatient,whatexpectationstheyhave Trytoavoidexpressingangerorirritationwiththepatientremainoutwardlycalmandobjective.Aimtobefirmyet Itmaybecounterproductivetotellpatientsthatyoubelievethemtohaveapersonalitydisorder.Itmaybebettertouse

caringanddonotarguewiththepatient. termssuchasexceptionallysensitive,ietheyreactwithmorepain,fearandangertotheupsanddownsoflifethando mostpeople,andsotendtoexperiencemanycrisesintheirlives.Youcanthenattempttoagreeaplanwiththepatient, andwithotherstaff,tohelpthemdealabitbetterwiththeircrisesandotherdaytodayproblemswhentheyarise. Makeanagreementaboutcontactbetweenscheduledappointments,egallowonlyscheduledappointments,ordefine whatconstitutesanemergencywhichwillmeanthatanunscheduledappointmentisallowed. Establishateamapproach.Establishaclearprotocolforhowallmembersoftheteamwillrespondtothispatientifon dutyduringacrisis.Crisiscontactsshouldbebrief,focusedandgoaloriented.Ifpossible,givethepatientsome responsibilityforresolvingthecrisis.Thecrisiscareplanshouldinvolveotherstaffwhoareinvolvedinrespondingto incidentsofselfharm,egchaplain,personalofficer,suicidepreventionteam. Whileformalcontracts,sometimessignedbyallrelevantparties,cansometimeshelp,theyrequiremeticulousattentionto detail,requireregularupdatinginthelightofprogressordeteriorationandshouldnotbeintroducedwhenthe professionalsconcernedareangry. andwhatyoucanrealisticallyofferthem.

Paranoid behaviours

Assessdangerousness,especiallyifthepatientisaggressiveaswellasparanoid.Beawareofhiddenweaponsasparanoid

patientsmayhideweaponstoprotectthemselves. Avoidoverfriendlyorinquisitivebehaviourbeprofessional. Listentothepatientsconcerns. Acceptbutdonotconfirmthepatientsbeliefs. Planclearandmutualgoals,egHowcanweworkthisouttogether? Explaineverything,alltreatments,medications,etc. Empathisewiththepatientsanxiety,egIrealiseitcanbeupsettingtotalkaboutyourselftosomeoneyoudontknow well.Ifyouhavequestions,pleaseask. Shareinformationwiththepatient,egallowhim/hertoreadlettersyouhavewrittenabouthim/her.Writelettersbearing inmindthatthepatientmayseeacopyatsomestage. Keepcarefulnotes,documentinginteractionswhereappropriate.Paranoidpatientsmaybelitigious.

Advice and liaison with wing and other staff

Ifhostilityorparanoiaisfocusedonaparticularinmate,memberofstaff,ortypeofinmatesuchasaparticularethnic

group,makestaffaware.Stepsshouldbetakentoprotectstaffandinmateswhomaybeinvolvedinthepatientsparanoid thinking.Forexample,aparanoidinmateshouldnotshareacell. Recommendthatthesepatientshaveanexperiencedofficeraspersonalofficer.Thereshouldnotbeonlyoneunskilled personworkingalone. Ensurethemanagerofthewing/unitwherethepatientislocatedhasacopyoftheinformationsheetonPersonality Disorders,whichisonthedisk. Theprisonregimeisanimportantpartofmanagement.Discusswork,education,exerciseandopportunitiestobecreative. Staffworkingwiththisgroupofindividuals,whetheronwingsorinthehealthcarecentre,needsupervisionandsupport topreventbreachesofroleboundaries,egdevelopingaspecialrelationshipthatissecretfromcolleagues. Forverychallengingpatients,identifyacore,multidisciplinarygroup(wingmanager,psychologistandothersas appropriate)todevelopandmonitoramanagementplan. Medication Offertreatmentforassociatedillness. SeeDepressionandAnxiety(pages47and33)foradviceonmedicationfortheseconditions.Ifthepatientisabusing substances,interactionswithprescribedmedicationarepossibleandtheefficacyofantidepressantsislessened. Benzodiazepinesshouldbeavoidedbecauseofpossibleinteractionswithillegalsubstances. Peoplewithapersonalitydisordermaysufferepisodesofpsychosiswhenunderstress.Forinformationabout medication,seepage70. Therearenodrugsforthetreatmentofpersonalitydisorder.Medicationmaybetriedforcertainbehaviouralproblems, thoughevidenceofeffectivenessisweak.Carefulassessmentofthebenefitversussideeffectsmustbemade.Decisions aboutpatientconsentandcapacityarealsoparticularlydifficult.Therefore,acarefulclinicalevaluationbyaspecialistis requiredbeforemedicationforthelongtermtreatmentofbehavioursassociatedwithpersonalitydisorderisstarted.119If thereisapoorrelationshipbetweentheclinicianandpatient,thereisadangerofmedicationbeingusedbytheclinician purelyforcontrolorbythepatienttoselfharm,ortoselltoothers.Drugsthataspecialistmayprescribeinclude: Sedativeantipsychotics:maybehelpfulifparanoidordissocialbehavioursareprominentandthepatientishighly aroused. Antipsychoticdrugs:mayhelppatientswhoharmthemselvesimpulsivelyandthosewhodisplaysymptomssuggestive of(butfallingshortof)frankpsychoticillness.120 Serotoninreuptakeinhibitor(SSRI)antidepressants:havebeenreportedasusefulinreducingaggressioninsome patientswithdissocialandborderlinepersonalitydisorder.121 Carbamazepinetreatment:hasbeenshowntohelpreduceaggressivebehaviour,especiallyinpatientswithahistoryof headinjury,genuineamnesiaforassaults,thedjvuphenomenon,olfactoryhallucinationsandabnormalitiesshownby electroencephalographyorbrainimaging.122Carefulmonitoringisrequired. Dealing with cutting or self-harm in the context of personality disorder Admissiontopsychiatrichospitalorprisonhealthcarecentreshouldbefortreatmentofcomorbiddisordersorindicatedby suiciderisk.Admissionshouldbepartofacarefullypreparedcrisisplan,agreedinadvancebyallparties.Inpatient contracts,drawnupandsignedbythepatientandstaff,maybehelpfulbutmustnotmakesupportcontingentonceasingof theselfharmingbehaviourimmediatelyandshouldnotbedrawnupwhencliniciansareangry(forfurtheradvice,see Assessmentandmanagementfollowinganactofselfharm,page211).Noteveryonewhocuts,burnsorotherwise mutilatesthemselvesdisplaysthefullpatternofbehaviourofapersonalitydisorder. Specialist consultation or referral Referurgentlytomentalhealthservicesif: paranoiaismarked,excessive,thereisapasthistoryofextremeviolenceandthepatientisthreateningviolence(forensic servicesaretobepreferred,ifavailable)and psychoticillnessisevident. Referforassessmenttomentalhealthservicesifyouareunsureifthediagnosisispersonalitydisorder,mentalillnessor both.

Althoughtheevidencebaseforthefollowingtreatmentsispoor,thesepsychologicalinterventionsmaybeusefulfor patientsmotivatedtoundertakethem. Angermanagement: Ifthepatientshowsproblemscontrollingandexpressinganger,iftheyhaveno,oronlyverymild,paranoidfeatures, andtheycandiscusstheirownbehaviour,angermanagementmaybeusefulinreducingmaladaptivebehaviouratleast intheshortterm.123 Ifproblemsincontrollingangeroraggressionhaveledtothecrimethepatienthascommittedandthepatienthasat least1yearoftheirsentencestilltoserve,thepatientmaybeeligibleforoneoftherelevantPrisonServiceoffending behaviourcourses. Formoredetails,seeOffendingbehaviourprogrammes(page117). Structuredproblemsolvingmaybeusefulforassociatedproblemsthattriggerselfharmingbehaviour,thoughithasnot beentestedspecificallyinpersonalitydisorderedpatients.120 Assertivenesstraining,anxietymanagement,socialskillstrainingorcognitivebehaviourtherapymayhelpifthe patientischronicallyoveranxious,dependentandfearful.124 Dialecticalbehaviourtherapyhasbeenshowntoreducethefrequencyofdeliberateselfharminpeoplewithemotionally unstable(borderline)personalitydisorder.Thistherapyiscomplicatedandtimeintensivetoadminister.125 Psychotherapyforpersonalitydisorderedpatientsneedstobelongnotshortterm.119 ConsiderreferraltoHMPGrendonUnderwoodifthepatienthas: acuriosityandawishtotelltheirstory psychologicalmindedness motivation abilitytoseethatotherpeoplemighthaveanotherpointofview morethan2yearsleftincurrentsentence noappealagainsttheirsentence,currentorpending objectiveevidenceofbeingfreeofsubstancemisusefor6months nopsychoactivemedicationfor3monthsorwhileatGrendonor satisfactoryreportsfromthewingofficer,probationofficer,chaplain,psychologistandmedicalofficer. Otherprisontreatmentcentres(TCs)includeHMPWormwoodScrubs(MaxGlittUnit),HMPDovegateTCandthelifers TCatHMPGartree.

Prerelease plans
Ensurepatientsareassessedingoodtimeforboththeriskandtreatmentfacilitiesthatmayhelpthemiftheyarewillingto engageintreatment.Thisisparticularlyimportantforemotionallyunstablepatientswhoreactbadlytorealorimagined abandonment. Fordetailsofprereleaseplanningappropriateforallpatients,seeManagingtheinterfacewiththeNHSandother agencies(page149). Facilitiesthatprovideservicesforpeoplewithapersonalitydisorderincludethefollowing. HendersonHospital:acentrallyfundedoutreachservicebasedinBirminghamandCrewethattreatspeoplewith enduringemotional,relationshipandbehaviouralproblems,includingimpulsive,violentandselfharmingbehaviourand otherassociatedproblems.PatientsareexpectedtobefreeofmedicationandnotcurrentlydetainedundertheMental HealthAct1983.SouthEastandLondonNHSRegions,contact:DrAlexEsterhuyzen,HendersonHospital,2Homeland Drive,SuttonSM25LT.Tel:02086611611.WestMidlandsandSouthWestNHSRegions,contact:DrIanBirtle,Main House,c/oSouthBirminghamMentalHealthNHSTrustTherapeuticCommunityService,22SummerRoad,Acocks Green,BirminghamB277UT.Tel:01216783244;NorthernandNorthWestNHSRegions,contact:DrKeithHyde,Webb House,c/oMentalHealthServicesofSalford,VictoriaAvenue,CreweCW27SQ.Tel:01270580770.Forpatientsfrom outsidetheseareasorthosefromScotland,WalesandNorthernIreland,contacttheNHSMentalHealthTrustnearestthe patientshomeaddress. CassellHospital:treatswomenwithlessseverepersonalitydisorders.1HamCommon,RichmondTW107JF.Tel:020 89408181. FrancisDixonLodge:providesgrouporientatedselfhelpprogrammesforthosewithpersonalityandemotional difficulties.GipsyLane,LeicesterLE50TD. Tel:01162256800.

Resources for patients and primary support groups Listenerorbuddyscheme.Wherethepatientisconsidereddangerous,stepsshouldbetakentoprotectlisteners,eg personalalarms AlcoholicsAnonymous:08457697555(24hourhelpline) (GivestelephonesupportnumbersandselfhelpgroupsacrosstheUKformenandwomentryingtoachieveand maintainsobriety) Borderlinewebsite:URL:http://www.BPDCentral.com (Mainlyforfamiliesofpeoplewithborderlinepersonalitydisorder) GamblersAnonymous:02073843040 POBox88,LondonSW100EU (Providesadviceandsupporttopatientswithaddiction/habitdisorders) NarcoticsAnonymous:02077300009(helpline);02072514007(office) 202CityRoad,LondonEC1V2PH (Providesadviceandsupporttopatientswithdrugdisorders) Samaritans:08457909090 UnderstandingPersonalityDisorders.Availablefrom:MINDPublications, 1519Broadway,LondonE154BQ.Tel:02085192122.Leafletwithstraightforwardexplanations.Itisusefulforfamily members,staffandothers

Phobic disorders F40

Includes claustrophobia, agoraphobia and social phobia

Presenting complaints Patientsmayavoidorrestrictactivitiesbecauseoffear.Theymayhavedifficultytravellingintheprisontransportvan, takingpartinassociationoreatinginfrontofothers.Somecommonphobias(egagoraphobia,socialphobia)maynot manifestinclosedprisonconditions,butmaybecomeevidentwhenthepatienttransferstomoreopenconditions. Patientssometimespresentwithphysicalsymptoms,egpalpitations,shortnessofbreathorasthma.Questioningwill revealspecificfears. Diagnostic features Thepatientexperiencesanunreasonablystrongfearofpeople,specificplacesorevents.Patientsoftenavoidthesesituations altogether. Commonlyfearedsituationsinclude: eatinginpublic openspaces beingconfinedinanenclosedspace crowdsorpublicplaces travellinginbuses,cars,trainsorplanesor socialevents. Patientsmayavoidbeingalonebecauseoffear. Differential diagnosis

PanicdisorderF41.0(page67)ifanxietyattacksareprominentandnotbroughtonbyanythinginparticular. DepressionF32#(page47)ifaloworsadmoodisprominent.
Panicdisorderanddepressionmaycoexistwithphobias. Manyoftheguidelinesbelowalsomaybehelpfulforspecific(simple)phobias,egfearofwaterorofheights. Essential information for the patient and primary support group

Phobiascanbetreatedsuccessfully. Avoidingfearedsituationsallowsthefeartogrowstronger. Followingcertainstepscanhelpsomeoneovercomefear.

Advice and support to the patient and primary support group 105

Assessthepatientsunderstandingoftheproblemandtheirreadinesstochange. Encouragethepatienttopractisecontrolledbreathingmethodstoreducephysicalsymptomsoffear(seeadviceonPanic Askthepatienttomakealistofallsituationsthathe/shefearsandavoidsalthoughotherpeopledonot. Discusswaystochallengetheseexaggeratedfears(egpatientremindshim/herself,Iamfeelinganxiousbecausethereisa Helpthepatienttoplanaseriesofprogressivelymorechallengingstepswherebytheyconfrontandgetusedtofeared

largecrowd.Thefeelingwillpassinafewminutes). situations: Identifyasmall,firststeptowardthefearedsituation,egiftheyareafraidofeatinginpublic,eatthemealinthecell, takeacupofcoffeeintothediningarea,sitdownbutdonotdrinkit. Practisethiseachdayuntilitisnolongerfrightening. Ifenteringthefearedsituationstillcausesanxiety,carryoutslowandrelaxedbreathing,sayingthepanicwillpass within3060minutes(seeadviceonPanicdisorderF41.0,page67). Donotleavethefearedsituationuntilthefearsubsides.Donotmoveontothenextstepuntilthecurrentsituationis mastered. disordersF41.0,page67).

Moveontoaslightlymoredifficultstepandrepeattheprocedure,egeatamealinthecellbutsitwithafriendin thediningareaanddrinkacupofcoffee. Takenoantianxietymedicineforatleast4hoursbeforepractisingthesesteps. Askafriendormemberofthehealthcarestafftohelpplanexercisestoovercomethefear.Selfhelpgroupscanassistin confrontingfearedsituations. Keepadiaryoftheconfrontationexperiencesdescribedabovetoallowstepbystepmanagement. Avoidusingbenzodiazepinestocopewithfearedsituations. Medication Withtheuseofthesebehaviouralmethods,manypatientswillnotneedmedication. N105 Ifdepressionisalsopresent,antidepressantmedicationmaybeindicated.ParoxetinemaybehelpfulinsocialphobiaN126 (seeBNF,Section4.3.3). Encouragepatientstofacefearswithouttheuseofbenzodiazepines.Wherethefearedsituationisrare,however, occasionalshorttermuseofantianxietymedicationmaybehelpful.N115Regularusemayleadtodependenceandis likelytoresultinareturnofsymptomswhenitisdiscontinued. Formanagementofperformanceanxiety,egfearofpublicspeaking,blockersmayreducethephysicalsymptoms.109 Referral SeeGeneralreferralcriteria(page152). Nonurgentreferraltothesecondarymentalhealthservicesisadvised: ifdisablingfearspersistand topreventproblemswithlongtermsicknessanddisability. Ifavailable,cognitivebehaviouralpsychotherapyandexposure127maybeeffectiveforpatientswhodonotimprovewith simplemeasuresoutlinedabove. Recommendselfhelp/nonstatutory/voluntaryservices,egTriumphOverPhobia,inallothercaseswheresymptoms persist.

Resources for patients and primary support groups StresswatchScotland:01563574144(helpline);01563570886(office) (Advice,information,materialsonpanic,anxiety,stressphobias.Thirtyfivelocalgroups) TriumphOverPhobia(TOP)UK:01225330353 (Structuredselfhelpgroupsforthosesufferingfromphobiasorobsessivecompulsivedisorder.Producesselfhelp materials) Resourceleaflet: ManagingAnxiety IsaacMarks.LivingWithFear.NewYork:McGrawHill.Selfhelpmanual

Post-traumatic stress disorder F43.1

Presenting complaints Thepatientmaypresentinitiallywith: irritability memoryand/orconcentrationproblems associateddifficultiesininterpersonalrelationships impairedoccupationalfunctioning lowmood lossofinterestand physicalproblems. Presentationmaybedelayedforseveralmonthsfollowingthetrauma. Diagnostic features

Historyofastressfuleventorsituation(eithershortorlonglasting)ofanexceptionallythreateningorcatastrophicnature,

whichislikelytocausepervasivedistresstoalmostanyone.Thetriggereventmayhaveresultedindeathorinjuryand/or thepatientmayhaveexperiencedintensehorror,fearorhelplessness. Intrusivesymptoms:memories,flashbacks,nightmares. Avoidancesymptoms:avoidanceofthoughts,activities,situationsandcuesreminiscentofthetrauma,withasenseof numbness,emotionalblunting,detachmentfromotherpeople,unresponsivenesstosurroundingsoranhedonia. Symptomsofautonomicarousal,eghypervigilance,increasedstartlereaction,insomnia,irritability,excessiveangerand impairedconcentrationand/ormemory. Symptomsofanxietyand/ordepression. Drugand/oralcoholabusearecommonlyassociatedwiththiscondition. Significantfunctionalimpairment. Wherethetraumaticeventisrelatedtotheindexoffence,thepatientmaybereluctanttotalkaboutit,especiallybeforethe trial,thuscomplicatingadiagnosis. Differential diagnosis

DepressionF32#(page47)ifpreoccupationwith,andruminationsabout,apasttraumaticeventhaveemergedduring PhobicanxietydisordersF40(page79)ifthepatientavoidsspecificsituationsoractivitiesafteratraumaticevent,but Obsessivecompulsivedisorderifrecurrent,intrusivethoughtsorimagesoccurintheabsenceofaneventofexceptionally

threateningorcatastrophicnature. Essential information for the patient and primary support group hasnoreexperiencingsymptoms. adepressiveepisode.

Traumaticorlifethreateningeventsoftenhavepsychologicaleffects.Forthemajority,symptomswillsubsidewith

minimalintervention.TheinformationleafletReactionstoTraumaticStress:WhattoExpectonthediskmaybehelpfulin reinforcinginformation.Ifthepatienthasreadingdifficulties,amemberofthehealthcareteamoranothermemberof staffmaybeabletodiscussitscontentswithhim/her. Forthosewhocontinuetoexperiencesymptoms,effectivetreatmentsareavailable. Posttraumaticstressdisorder(PTSD)isnotaweaknessanddoesnotmeanthepatienthasgonemad.Thepatientneeds supportandunderstandingandmustnottobetoldtosnapoutofit. Advice and support to the patient and primary support group

Educatethepatientand,withpatientpermission,staffaboutPTSD,thushelpingthemunderstandthepatientschangesin Avoidingdiscussionabouttheeventthattriggeredtheconditionisusuallyunhelpful,butbeawareofculturaldifferences
attitudeandbehaviour. inthewaysofcopingwithpastdifficulties.Encouragethepatienttotalkabouttheeventwhentheyarereadyandintheir

ownway.Thismayincludenottalkingaboutmoreextremeexperiences.Therecognitionthatcertainexperiencesare therebutunutterablecanbepositive.1 Explaintheroleofavoidanceofcuesassociatedwiththetraumainreinforcingandmaintainingfearsanddistress. Encouragethepatienttofaceavoidedactivitiesandsituationsgradually.Itmaybepossibletoinvolvestaffinsupporting thepatientinthis,egininitiallyaccompanyingthepatientintoanareawheretheywereassaultedandarenowavoiding. Explainthatsuppressionofpainfulmemoriesandthoughtsmayreinforcethemandmakethemmorepersistent. Encouragethepatient,ifpossible,simplytoallowthethoughtstopassthroughhis/herheadandnottosuppressthem actively. Wherethepatienthasbecomescaredofgoingtosleepbecauseofrepeatednightmares,itmaybehelpfulforthemtotalk withsomeonetheytrustaboutthedream,ortowriteitdown,describingitindetail,perhapsseveraltimes,andtoremind themselvesItsadream.Itcannothurtme. Askaboutsuiciderisk,particularlyifmarkeddepressionispresent(seeAssessingandmanagingpeopleatriskof suicide,page204). Encouragethepatienttouseanyexisting,availablesourcesofsupportorsolace,egchaplainandotherreligiousleaders, traditionalhealers,friends,listeners/buddies,theSamaritans. Trytoavoidusingcigarettesorotherdrugstocopewithanxiety. Medication

Considerantidepressantforconcurrentdepressiveillness(seeDepressionF32#,page47). Antidepressantmedication,includingtricyclics(TCAs)andselectiveserotoninreuptakeinhibitors(SSRIs),maybeuseful
forthetreatmentofintrusionandavoidancesymptoms N128(seeBNF,Section4.3).Drugtreatmentsforthiscondition generallyneedtobeusedinhigherdosesandforlongerperiodsthanthoseusedfortreatingdepression.Theremaybea latentperiodof8weeksormorebeforetheeffectsareseen. StartleandhyperarousalsymptomsmaybehelpedbyblockersN128(seeBNF,Section2.4). Referral SeeGeneralreferralcriteria(page149).

Referral to the secondary mental-health services is advised if the patient is still having severe intrusive experiences and avoidance symptoms, and there is a marked functional disability despite the above measures. If available, consider behaviour therapy (exposure) or cognitive techniques.N129,N130 The specialist assessment should include cultural factors. Where possible, advise patients of agencies able to provide appropriate therapy after release.
SeeImmigrationdetaineesandPeoplewhohavebeensexuallyassaulted(pages326and260)formoreinformation abouttheneedsofthesegroups. Resources for patients and primary support groups CombatStress:01372841600 (FormerlyknownastheExServicesMentalWelfareAssociation,itsupportsmenandwomendischargedfromthearmed servicesandMerchantNavywhosufferfrommentalhealthproblems,includingPTSD.Hasaregionalnetworkof welfareofficerswhovisitpeopleathomeorinhospital.Somepracticalandfinancialhelp) MedicalFoundationfortheCareofVictimsofTorture:02078137777 (Providessurvivorsoftorturewithmedicaltreatment,socialassistanceandpsychotherapeuticsupport) RefugeeSupportCentre:02078203606 (Providescounsellingtorefugees,asylumseekers;plustrainingandinformationtohealthandsocialcareprofessionals onpsychosocialneedsofrefugees) TraumaAftercareTrust(TACT):08001696814(24hourfreephonehelpline);01242890306 (Providesinformationaboutcounsellingandtreatment) VictimSupportSupportline:08453030900(MondayFriday,9am9pm;SaturdayandSunday,9am7pm;Bank Holidays,9am5pm);02077359166 (Emotionalandpracticalsupportforvictimsofcrime)

1ProfessorPapadopoulos,TavistockClinicRefugeeCentre,personalcommunication,quotedinCVSConsultantsandMigrantandRefugee CommunityForum.AShatteredWorld:TheMentalHealthNeedsofRefugeesandNewlyArrivedCommunities.London:CVSConsultants,1999.

Sexual disorders F52

Sexual disorders female

Presenting complaints Patientsmaybereluctanttodiscusssexualmatters.Theymayinsteadcomplainofphysicalsymptoms,depressedmoodor relationshipproblems.Theremayhavebeensexualabuseinchildhoodorlater. Patientsmayaskforadviceaboutproblemswithpartnersoutside,orinside,theprison.Theymaybeconfusedabouttheir sexualorientation.Theymayaskforhelpinadjustingtosexuallifestylechangesthatrelateonlytotheirtimeinprison. Occasionally,arequestforhelpwithgenderreassignmentmaybemade. Specialproblemsmayoccurinculturalminorities. Patientsmaypresentsexualproblemsduringaroutinecervicalsmeartest. Diagnostic features Commonsexualdisorderspresentinginwomenare: alackorlossofsexualdesire,arousalorenjoyment vaginismusorspasmodiccontractionofvaginalmusclesonattemptedpenetration dyspareunia(paininthevaginaorpelvicregionduringintercourse)or anorgasmia(aninabilitytoachieveorgasmorclimax). Differential diagnosis

Ifaloworsadmoodisprominent,seeDepressionF32#(page47).Depressionmaycauselowdesire,ormayresult

fromsexualandrelationshipproblems. Relationshipproblems:wherethereispersistentdiscordintherelationship,relationshipcounsellingshouldprecedeor accompanyspecifictreatmentofthesexualdysfunction. Gynaecologicaldisorders,egvaginalinfections,pelvicinfections(salpingitis)andotherpelviclesions(egtumoursor cysts),althoughvaginismusrarelyhasaphysicalcause.Gynaecologicalcomplaintsanddisordersarecommoninwomen inprison.Itisimportanttotakethemseriouslyandconsiderinvestigationandreferraltospecialistphysicalhelpas appropriate. Adjustmenttosexuallifestylechangesintheprisonsituation,egtemporarylesbianismorbisexuality.Considergiving sexualhealthinformationandcounselling.Considerthepossibilitythatthepatientisbeingexploitedorbullied. Alcoholintoxicationandchronicabuseofillicitdrugs(egopioids,cocaine,amphetamines,sedatives,anxiolytics)may decreasesexualinterestandcausearousalproblems. Sideeffectsofmedication,egselectiveserotoninreuptakeinhibitor(SSRI)antidepressants,oralcontraceptives, blockers. Physicalillnessesmaycontribute,egmultiplesclerosis,diabetes,spinalinjury Lackofdesiremayberelatedtoconfusionaboutsexualorientation,especiallyinyoungpeople. Rarely,sexualproblemsmayrelatetothepatientsfeelingthatsheisreallyamanandthatshewishestobecomeaman physically.Thisisverydifficulttomanageinprisonastheusualcommunitymanagement(livingasamanand/or treatmentwithmalehormonesforatleast1yearbeforeanyirreversiblesurgicalstepsaretaken)isespeciallydifficult.Be awareofthedangerofbullyingandofseriousselfmutilation.Obtainexpertadvice,includingfromtheprisonHealth PolicyUnit,andrefertoaforensicpsychiatrist,whomayinturnrefertoagenderidentityclinic.Considerrelocation withintheprisontoreducetheriskofbullying. Lack or loss of sexual desire

Essential information for the patient and partner

Thelevelofsexualdesirevarieswidelybetweenindividuals.Lossoforlowsexualdesirehasmanycauses,including relationshipproblems,earliertraumas,fearofpregnancy,postnatalproblems,andphysicalandpsychiatricillnessesand stress.Theproblemcanbetemporaryorpersistent.

Advice and support to the patient and partner

Discussthepatientsbeliefsaboutsexualrelations.Checkwhetherthepatientand/orthepartnerhaveunreasonablyhigh expectations.Askthepatientabouttraumaticsexualexperiencesandnegativeattitudestosex.Acceptthatthismaytake morethanoneappointment.Giveadviceabouttreatmentapproachesthatmaybeappropriateinthecommunity.Informthe patientthatdoctorsoftenseepartnerstogetheraswellasindividually.Suggestplanningsexualactivityforspecificdays. Suggestwaysofbuildingselfesteem(egexercise,education),andadvisetimeandspacetoherself. Vaginismus

Essential information for the patient and partner

Vaginismusisaninvoluntaryspasmofthepubococcygealmusclesaccompaniedbyintensefearofpenetrationand anticipationofpain.Itisusuallycausedbypsychosocialfactors(egpreviousnegativesexualexperiences).Itcanbe overcomewithspecificpsychosexualtherapy.

Advice and support to the patient and partner

Exercisesarerecommendedforthepatient,and,later,forthepartner,withgradeddilatorsorfingerdilation,accompanied byKegelexercises,relaxationexercises,treatmentforanxietyandcouplecounselling.Treatmentoftenrequiresintensive therapy,butithasapromisingoutcome. Dyspareunia

Essential information for the patient and partner

Therearemanyphysicalcauses,bothofdeepandsuperficialdyspareunia.Insomecases,however,anxiety,poorlubrication andmuscletensionarethemainfactors.Evenwheretherehasbeenaphysicalcauseandithasresolved,anticipationofpain mayfrequentlymaintainthedyspareunia.

Advice and support to the patient and partner

Checkifthepatientexperiencesdesire/arousal/lubrication.Relaxation,prolongedforeplayandcarefulpenetrationmay overcomepsychogenicproblems.ReferraltoagynaecologistorGUMclinicisadvisableifsimplemeasuresareunsuccessful. Anorgasmia

Essential information for the patient and partner

Manywomencannotexperienceorgasmduringintercoursebutcanoftenachieveitbyclitoralstimulation.

Advice and support to the patient and partner

Discussthecouplesbeliefsandattitudes.Encourageselfpleasuring,manuallyorbyusingavibrator.Thecoupleshouldbe helpedtocommunicateopenlyandreduceanyunrealisticexpectations.Books,leafletsoreducationalvideosmaybeuseful (seeResourcesbelow). Referral Afterrelease,patientscanreferthemselvesto: Relate BrookAdvisoryCentres familyplanningclinicsand genitourinarymedicineclinics Considerreferraltoapsychosexualspecialistifthepatientanddoctorcannotenterintoaprogrammeoftreatmentorif primarycaretreatmenthasfailed.

Sexual disorders male

Presenting complaints

Patientsmaybereluctanttodiscusssexualmatters.Theymaycomplaininsteadofphysicalsymptoms,depressedmoodor relationshipproblems. Patientsmayaskforadviceaboutproblemswithpartnersoutside,orinside,theprison.Theymaybeconfusedabouttheir sexualorientation.Theymayaskforhelpinadjustingtosexuallifestylechangesthatrelateonlytotheirtimeinprison. Occasionally,arequestforhelpwithgenderreassignmentmaybemade. Specialproblemsmayoccurindifferentcultures.Sexualproblemsareoftensomatised,expectationsmaybehigh,and psychologicalexplanationsandtherapiesmaynotbereadilyaccepted. Diagnostic features Commonsexualdisorderspresentinginmenare: erectiledysfunctionorimpotence prematureejaculation retardedejaculationororgasmicdysfunction(intravaginalejaculationisgreatlydelayedorabsentbutejaculationcan oftenoccurnormallyduringmasturbation)or alackorlossofsexualdesire. Differential diagnosis

DepressionF32#(page47). Problemsinrelationshipswithpartnersoftencontributetosexualdisorder,especiallythoseofdesire.Wherethereis

persistentdiscordintherelationship,relationshipcounsellingshouldprecedeoraccompanyspecifictreatmentofthe sexualdysfunction. Adjustmenttosexuallifestylechangesintheprisonsituation,egtemporaryhomosexualityorbisexuality.Considergiving sexualhealthinformation,counsellingaboutharmminimisationandaccesstocondoms.Considerthepossibilitythatthe patientisbeingexploitedorbullied(seeVictimsofsexualassault,page260). Alcoholintoxicationandchronicabuseofillicitdrugs(egopioids,cocaine,amphetamines,sedatives,anxiolytics)may decreasesexualinterestandcausearousalproblems. Rarelysexualproblemsmayrelatetothepatientsfeelingthatheisreallyawomanandthathewishestobecomea womanphysically.Thisisverydifficulttomanageinprisonastheusualcommunitymanagement(livingasawoman and/ortreatmentwithfemalehormonesforatleast1yearbeforeanyirreversiblesurgicalstepsaretaken)isespecially difficult.Beawareofthedangerofseriousselfmutilationandofbullying.Obtainexpertadvice,includingfromtheprison HealthPolicyUnit,andrefertoaforensicpsychiatrist,whomayinturnrefertoagenderidentityclinic.Consider relocationwithintheprisontoreducetheriskofbullying. Specificorganicpathologyisararecauseoforgasmicdysfunctionorprematureejaculation. Physicalfactorsthatmaycontributetoerectiledysfunctionincludealcoholabuseandchronicabuseofillicitdrugs(eg opioids,cocaine,amphetamines,sedatives,anxiolytics),diabetes,hypertension,smoking,medication(egantidepressants, antipsychotics,diureticsandblockers),multiplesclerosisandspinalinjury. Patientsmayhaveunreasonableexpectationsoftheirownperformance. Lackofdesiremayberelatedtoconfusionaboutsexualorientation,especiallyinyoungpeople. Erectile dysfunction (failure of genital response, impotence)

Essential information for the patient and partner

Erectiledysfunctionisoftenatemporaryresponsetostressorlossofconfidenceanditrespondstopsychosexualtreatment especiallyifmorningerectionsoccur.Itmayalsobecausedbyphysicalfactors(neurological,vascular),bymedicationor maybesecondarytotheageingprocess.

Advice and support to the patient and partner

Advisethepatientandtheirpartnertorefrainfromattemptingintercoursefor23weeks.Encouragethemtopractise pleasurablephysicalcontactwithoutintercourseduringthattime,commencingwithnongenitaltouchingandmoving throughmutualgenitalstimulationtoagradualreturntofullintercourseattheendofthatperiod.Progressionalongthis continuumshouldbeguidedbythereturnofconsistent,reliableerections.Abookcontainingselfhelpexercises(see Resourcesbelow)maybehelpful.Informthepatientandhispartnerofthepossibilitiesofphysicaltreatmentbypenile rings,vacuumdevices,intracavernosalinjectionsandmedication.

Medication

Oral:sildenafil50100mgtakenonanemptystomach4060minutesbeforeintercourseenhanceserectionsin80%of

patients,whetherthecauseispsychogenicorneurological.131Bewareofdangerofinteractionwithcardiacnitrates(see BNF,Section7.4.5). Intraurethral:MUSE(prostaglandinE1)1251000ginserted10minutesbeforeintercourseproduceserectionsin4050% ofpatients 132(seeBNF,Section7.4.5). Intracavernosal:prostaglandinE1520ginjected10minutesbeforeintercourseproduceserectionsin8090%of patients,133butlongtermacceptabilityislow. Thesemedicationsarelesseffectiveinpredominantlyvasculogeniccases. SeethecurrentNHSExecutiveguidelinesforprescriptionoftheabove,eitherprivatelyorontheNHS. Premature ejaculation

Essential information for the patient and partner

Controlofejaculationispossibleandcanenhancesexualpleasureforbothpartners.

Advice and support to the patient and partner

Reassurethepatientthatejaculationcanbedelayedbylearningnewapproaches,egthesqueezeorstopstarttechnique. Thisandotherexercisesaresetoutinselfhelpbooks(seeResourcesbelow).Insomecases,delaycanalsobeachievedwith clomipramineorselectiveserotoninreuptakeinhibitor(SSRI)medication,butrelapseisverycommononcessation.Local anaestheticsprays,ifusedcautiously,candelayejaculation. Orgasmic dysfunction or retarded ejaculation

Essential information for the patient and partner

Thisisamoredifficultconditiontotreat;however,ifejaculationcanbebroughtaboutinsomeway(egthrough masturbation)theprognosisisbetter.Individualpsychotherapymayberequired.

Advice and support to the patient and partner

Recommendexercisessuchaspenilestimulationwithbodyoilormasturbationclosetothepointoforgasm,followedby penetration. Lack or loss of sexual desire

Essential information for the patient and partner

Thelevelofsexualdesirevarieswidelybetweenindividuals.Lackorlossofsexualdesirehasmanycauses,including physicalandpsychiatricillnesses,stressandrelationshipproblemsand,rarely,hormonaldeficiencies.Itmaymerely representdifferentexpectations.

Advice and support to the patient and partner

Encouragerelaxation,stressreduction,opencommunication,appropriateassertivenessandcooperationbetweenpartners. Educationalleaflets,booksorvideosmaybehelpful. Referral Whenreleased,patientscanreferthemselvesto: Relate familyplanningclinicsand genitourinarymedicineclinics. Considerreferralifthepatientanddoctorcannotenterintoaprogrammeoftreatmentorifprimarycaretreatmenthas failed: Toaurologistforerectiledysfunctionifitisunresponsivetomedicationandcounselling. Toapsychosexualspecialistiftheproblemispredominantlypsychogenic.

Resources for patients and primary support groups BeaumontSocietyInfoline:01582412220(24hours,7daysperweek) 27OldGloucesterStreet,LondonWC1N3XX (Nationalselfhelporganisationfortransvestites,transsexuals,andtheirpartnersandfamilies.Adviceandinformation onissuesofcrossdressingandgenderdysphoria;socialfunctions) BrookAdvisoryCentres:02076178000(24hourhelpline) (Freecounsellingandconfidentialadviceoncontraceptionandsexualmattersespeciallyforyoungpeople[thoseunder 25]) OutSideIn:01689835566 POBox119,HighStreet,OrpingtonBR69ZZ (Befriendingpenpalserviceforgayandlesbianprisoners) Relate:01788573241 (Relationshipcounsellingforcouplesorindividualsover16.Sextherapyforcouples.Clientspayonaslidingscale) Booksforwomen: HeimanJ,LoPiccoloJ.BecomingOrgasmic:ASexualGrowthProgramforWomen.EnglewoodCliffs:PrenticeHall,1988.Self helpexercisesforanorgasmia BrownP,FaulderC.TreatYourselftoSex.Harmondsworth:Penguin,1977 GoodwinAJ,AgroninMarcE,MD.AWomansGuidetoOvercomingSexualFearandPain.Oakland:NewHarbinger,1997 Booksformen: HowtoCopewithDoubtsAboutYourSexualIdentityandGenderDysphoria.Availablefor1.00eachfrom:Mind Publications,1519Broadway,LondonE154BQ.Tel:02085192122 Zilbergeld,B.MenandSex.London:Fontana,1980.Selfhelpexercisesforerectiledysfunctionandprematureejaculation YaffeM,FenwickE.SexualHappiness.London:DorlingKindersley,1986

Sleep problems (insomnia) F51

Presenting complaints Patientsaredistressedbypersistentinsomniaandaresometimesdisabledbythedaytimeeffectsofpoorsleep. Diagnostic features

Difficultyfallingasleep. Restlessorunrefreshingsleep. Frequentorprolongedperiodsofbeingawake.

Differential diagnosis

Shorttermsleepproblemsmayresultfromstressfullifeeventssuchascomingintoprisonforthefirsttime,bullying, Persistentsleepproblemsmayindicateanothercause,forexample:
acutephysicalillnessesorchangesintheirschedule. DepressionF32#(page47)ifaloworsadmoodandlossofinterestinactivitiesareprominent. GeneralisedanxietyF41.1(page64)ifdaytimeanxietyisprominent. PosttraumaticstressdisorderF43.1(page82)ifthepatientfearsgoingtosleepbecauseofrepeatednightmares. Sleepproblemscanbeapresentingcomplaintofalcoholmisuseorsubstanceabuse(seeAlcoholmisuseF10or SubstanceabuseF11#,pages18and55).Apatientmayalsoseekbenzodiazepinesbecausehe/sheisstilldependentupon them.Enquireabouttheircurrentsubstanceuseandthepresenceofotherwithdrawalsymptoms.Withdrawalfrom benzodiazepinesneedssometimestobeverygradual(monthsnotweeks) Profoundsleepdeprivationisapartoftheexperienceofmajordrugwithdrawal.Sleepproblemsmaypersistforsome weeksthereafter.Treatmentmaybeindicatedduringtheveryearlystagesofwithdrawal. Considermedicalconditionsthatmaycauseinsomnia,egheartfailure,pulmonarydisease,painconditions. Considermedicationsthatmaycauseinsomnia,egsteroids,theophylline,decongestants,someantidepressantdrugs. Considerlifestylecauses:thepatientmayspendmostofthedayasleepinhis/hercell. Ifthepatientsnoresloudlywhileasleep,considersleepapnoea.Itmaybehelpful,withpatientconsent,totakeahistory fromthecellmate.Patientswithsleepapnoeaoftencomplainofdaytimesleepinessbutareunawareofnighttime awakenings. Thepatientmaybeseekingdrugstosellormaybebeingpressuredbyotherstoobtaindrugsontheirbehalf.Wingstaff mayhaveusefulinformationwherethisissuspected. Essential information for the patient and primary support group

Temporarysleepproblemsarecommonattimesofstressorphysicalillness. Sleeprequirementsvarywidelyandusuallydecreasewithage. Improvementofsleepinghabits(notsedativemedication)isthebesttreatment.134 Worryaboutnotbeingabletosleepcanworseninsomnia. Stimulants(includingcoffeeandtea,especiallyiftakenintheevening)cancauseorworseninsomnia.

Advice and support to the patient and primary support group

Encouragethepatienttomaintainaregularsleeproutineby:

relaxingintheevening keepingtoregularhoursforgoingtobedandgettingupinthemorning,tryingnottovarythescheduleorsleepinon theweekend gettingupattheregulartimeevenifthepreviousnightssleepwaspoorand avoidingdaytimenapssincetheycandisturbthenextnightssleep. Daytimeexercisecanhelpthepatienttosleepregularly,buteveningexercisemaycontributetoinsomnia.Consider promotingdaytimeexercisethroughcustody/sentenceplanning. Simplemeasuresmayhelp,egamilkdrinkoruseofearplugsoreyeshades. Recommendrelaxationexercisestohelpthepatienttofallasleep. Advisethepatienttoavoidcaffeineintheevenings.

 Ifthepatientcannotfallasleepwithin30minutes,advisehim/hertogetupandtryagainlaterwhenfeelingsleepy. Selfhelpleafletsandbooksmaybeuseful.TheGettingaGoodNightsSleepleafletonthediskincludesarelaxationexercise
.Ifthepatienthasreadingdifficulties,amemberofthehealthcareteamoranothermemberofstaffmaybeabletogo throughthecontentsoftheleafletwiththepatient. Sleepdiariesareoftenusefulintheassessmentandmonitoringofprogress. Medication

Treattheunderlyingpsychiatricorphysicalconditions. Makechangestomedication,asappropriate. Considerstrictlyshorttermuseofahypnoticintheveryearlystagesofwithdrawalfromdrugsifsleepdeprivationis Hypnoticmedicationmaybeusedintermittently.135Theriskofdependenceincreasessignificantlyafter14daysofuse.

Avoidhypnoticmedicationincasesofchronicinsomnia(whereinsomniaisexperiencedformostnightsoveratleast3 weeks). Considerthetimingandmethodofadministeringthemedication.Sedativesgivenat4or5pmbysupervisedingestion willbelesseffectivethansedativestakenlaterintheevening. Valerianmayhaveaweakeffectonsleepbutwithoutahangovereffectthenextday.136 Referral SeeGeneralreferralcriteria(page152). Ifavailable,considerreferraltotheinhousetherapeuticdaycentreforrelaxationsessions. Referraltothesecondarymentalhealthservicesisrarelyhelpful. Refertoasleeplaboratory,ifavailable,ifmorecomplexsleepdisorders(egnarcolepsy,nightterrors,somnambulism)are suspected. Wheresymptomsaresevereandlonglastingandtheabovemeasuresareunsuccessful,considerreferraltoaclinical psychologistorspeciallytrainedcounsellor,ifavailable,fortherapiessuchassleephygienetraining.N137,138 Resources for patients and primary support groups BritishSnoringandSleepApnoeaAssociation:01249701010 1DuncroftClose,ReigateRH29DE.Email:snoreshop@britishsnoring.demon.co.uk;URL: http://www.britishsnoring.demon.co.uk InsomniaHelpline:02089949874(helpline:MondayFriday,6pm8pm) NarcolepsyAssociationUK(UKAN):02077218904 CravenHouse,1stFloor,121Kingsway,LondonWC2B6PA.Email:info@narcolepsy.org.uk Resourceleaflet: GettingaGoodNightsSleep profound.Explaintheriskofdevelopingdependenceonthesemedicationstothepatient.

Unexplained somatic complaints F45

Presenting complaints

Anyphysicalsymptommaybepresent. Symptomsmayvarywidelyacrosscultures. Complaintsmaybesingleormultipleandmaychangeovertime.

Diagnostic features Medicallyunexplainedphysicalsymptoms(afullhistoryandphysicalexaminationarenecessarytodeterminethis): Frequentmedicalvisitsinspiteofnegativeinvestigations. Symptomsofdepressionandanxietyarecommon. Somepatientsmaybeprimarilyconcernedwithobtainingrelieffromphysicalsymptoms.Othersmaybeworriedabout havingaphysicalillnessandbeunabletobelievethatnophysicalconditionispresent(hypochondriasis). Differential diagnosis

DrugusedisordersF11#(page55),egseekingnarcoticsforreliefofpain. Ifloworsadmoodisprominent,seeDepressionF32#(page47).Peoplewithdepressionareoftenunawareofeveryday
physicalachesandpains. GeneralisedanxietydisorderF41.1(page64),ifanxietysymptomsareprominent. PanicdisorderF41.0(page67)misinterpretationofthesomaticsignsassociatedwithpanic. ChronicmixedanxietyanddepressionF41.2(page33). AcutepsychoticdisordersF23(page11)ifstrangebeliefsaboutsymptomsarepresent,egbeliefthatorgansare decaying. Anorganiccausemayeventuallybediscoveredforthephysicalsymptoms.Psychologicalproblemscancoexistwith physicalproblems. Depression,anxiety,alcoholordrugdisordersmaycoexistwithunexplainedsomaticcomplaints. Essential information for the patient and primary support group

Stressoftenproducesorexacerbatesphysicalsymptoms. Whenpeopleareforcedtoremaininactiveforlongperiods,itisnaturalforthemtofocusonbodilysensations.The Thefocusshouldbeonmanagingthesymptoms,notondiscoveringtheircause. Curemaynotalwaysbepossible;thegoalshouldbetolivethebestlifepossibleevenifthesymptomscontinue.

Advice and support to the patient and primary support group 139 sensationsmaybecomeexaggeratedintheprocess.

Acknowledgethatthepatientsphysicalsymptomsarerealtothem. Askaboutthepatientsbeliefs(whatiscausingthesymptoms?)andfears(whatdoeshe/shefearmayhappen?). Askhowthepatientspendshis/herday.Howlongdotheyspendinthecell?Encourageexerciseandenjoyableactivities.The

patientneednotwaituntilallsymptomsaregonebeforeundertakingactivities.Ifnecessary,advocateforincreasedaccessto appropriateactivities.Ifthepatientisundercellularconfinement,advocateforaccesstoartmaterialsand,ifliterate,toreading materials. Beexplicitearlyonaboutconsideringpsychologicalissues.Theexclusionofillnessandexplorationofemotionalaspects canhappeninparallel.Investigationsshouldhaveaclearindication.Itmaybehelpfultosaytothepatient,Ithinkthis resultisgoingtobenormal. Offerappropriatereassurance,egnotallheadachesindicateabraintumour.Advisepatientsnottofocusonmedical worries. Discusstheemotionalstressespresentwhenthesymptomsarose. Explainthelinksbetweenstressandphysicalsymptomsandhowaviciouscyclecandevelop,egStresscancausea tighteningofthemusclesinthegut.Thiscanleadtothedevelopmentofabdominalpainorworseningofexistingpain. Thepainaggravatesthetighteningofthegutmuscles.Adiagrammaybehelpful. Relaxationmethodscanhelprelievesymptomsrelatedtotension,egheadache,neckorbackpain.

 Treatassociateddepression,anxietyorsubstancemisuseproblems. Forpatientswithmorechroniccomplaints,timelimitedappointmentsthatareregularlyscheduledcanpreventmore
frequent,urgentvisits.140 Structuredproblemsolvingmethodsmayhelppatientstomanagecurrentlifeproblemsorstressesthatcontributeto symptoms.48 Helpthepatientto: identifytheproblem listasmanypossiblesolutionsasthepatientcanthinkof listtheadvantagesanddisadvantagesofeachpossiblesolution(thepatientshoulddothis,perhapsbetween appointments) supportthepatientinchoosinghis/herpreferredapproach helpthepatienttoworkoutthestepsnecessarytoachievetheplanand setadatetoreviewtheplan.Identifyandreinforcethingsthatareworking. Medication Avoidunnecessarydiagnostictestingorprescriptionofnewmedicationforeachnewsymptom.Rationalisepolypharmacy. Wheredepressionisalsopresent,anantidepressantmaybeindicated(seeDepressionF32#,page47) Lowdosesoftricyclicantidepressant(TCA)medication(egamitriptyline,50100mgday1,orimipramine,20mgday1) maybehelpfulinsomecases,egwherethereisheadacheoratypicalchestpain.141,142 Referral

Patientsarebestmanagedinprimaryhealthcaresettings.Consistencyofapproachwithinthepracticeisessential.Seeing
thesamepersonishelpful.Considerreferraltoapartnerorothermedicalofficerforasecondopinion.Documenting discussionswithcolleaguescanreducestressbysharingresponsibilitywithintheprimarycareteam. Nonurgentreferraltothesecondarymentalhealthservicesisadvisedongroundsoffunctionaldisability,especiallyan inabilitytowork,andforthedurationofsymptoms. Cognitivebehaviourtherapy,ifavailable,mayhelpsomepatients,thoughthewillingnessofpatientstoparticipateis sometimespoor.N143 Refertoaliaisonpsychiatrist,ifavailable,forthosewhopersistintheirbeliefthattheyhaveaphysicalcausefortheir symptoms,despitegoodevidencetothecontrary. Avoidmultiplereferralstomedicalspecialists.Documenteddiscussionswithappropriatemedicalspecialistsmaybe helpfulfromtimetotimeas,insomecases,underlyingphysicalillnesseventuallyemerges. Resources for patients and primary support groups Listeners,buddies,chaplainsandpersonalofficersmayofferemotionalsupportand/orhelpwithpracticalproblems Resourceleaflets: CopingwithDepression GettingaGoodNightsSleep ManagingAnxiety.Containsinstructionsforarelaxationexercise