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Coming off of Anti depressants

Posted on March 8, 2014 by JmaC

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The aim of this leaflet is to help you decide about when and how to come off antidepressants.

Some people find coming off antidepressants is quite easy. But others may get withdrawal or a return of the depression.

We asked people to tell us what it was like for them to come off antidepressants. This leaflet brings together the views of the 817 people who completed our survey and shared their experiences.

Survey findings

In our survey, the most common drug stopped was citalopram. This was taken by 235 people. Fluoxetine was next, taken by 173 people, followed by venlafaxine (109), sertraline (89), escitalopram (51), mirtazapine (38), paroxetine (29) and duloxetine (26).

36% stopped their antidepressant suddenly. Males were more likely to do this (m=44%, f=34%). Younger people were also more likely to stop suddenly (59% of 18-24 year-olds compared with just 20% of the over-65s).

512 (63%) people in our survey experienced withdrawal when stopping their antidepressants.

Some drugs were more likely than others to cause withdrawal. In the table below we have split the drugs into three groups (high, medium and low withdrawal).

High

Medium

Low

% with
withdrawal % with
withdrawal % with
withdrawal
Venlafaxine 82% Sertraline 62% Fluoxetine 44%
Escitalopram 75% Citalopram 60% Mirtazapine 21%
Paroxetine 69%
Duloxetine 69%

Bipolar

Posted on March 8, 2014 by JmaC

http://www.bipolar4lifesupport.co on line support group

Bipolar disorder is a serious, chronic (long-term) condition where you have periods of depression (lows) and periods of mania or hypomania (highs). Treatment with mood stabiliser medicines such as lithium, anticonvulsants or antipsychotic medicines aims to keep your mood within normal limits.

What is bipolar disorder?

Bipolar disorder is sometimes called manic depression or bipolar affective disorder. In this condition you have periods where your mood (affect) is in one extreme or another:
•One extreme is called depression, where you feel low and have other symptoms.
•The other extreme is called mania (or hypomania if symptoms are less severe), where you feel high or elated along with other symptoms.

The length of time you spend in each extreme can vary. It is usually for several weeks at a time or longer. Bipolar disorder is very different from the mood swings that moody people have which last a few minutes or hours.

You can have any number of episodes of highs and lows throughout your life. In between episodes of highs or lows there may be gaps of weeks, months or years when your mood is normal. However, some people swing from highs to lows quite quickly without a period of normal mood in between. This is called rapid cycling. (If you have the rapid cycling form of the condition you have at least four mood swings per year.)

Note: some people with bipolar disorder can have periods where they have mixed symptoms where they quickly alternate between depressive symptoms and manic symptoms (usually within a few hours). This is known as a mixed bipolar episode.

Tourette’s Syndrome

Posted on March 5, 2014 by JmaC

Tourette’s syndrome is a condition that causes you to have involuntary movements or noises called tics. It starts in childhood and is associated with various other problems such as behavioural problems and attention deficit hyperactivity disorder (ADHD). It can often be well managed with psychological treatments, and sometimes medication.

What is Tourette’s syndrome?

Tourette’s syndrome is a disorder that starts in childhood. The prime symptom is to have repeated tics. A tic is a sudden movement or sound that is repeated over and over. A tic has no purpose and, in general, you cannot help doing it. For example, repeated blinking, repeated throat clearing, repeated head nodding, etc. Tics are very common in children and usually last less than one year. However, children with Tourette’s syndrome have many types of tics of sudden movements and noises, and the tics persist for more than a year. The syndrome is named after the person who described the condition in 1885, Dr Georges Gilles de la Tourette.

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What causes Tourette’s syndrome?

The cause is not known. There are various theories which include the following:

Genetic. It is generally believed that abnormalities in genes are responsible for most cases of Tourette’s syndrome. Genes are passed on to a child from each parent and determine what we look like, how our body functions and even what diseases we may get. A child is more likely to develop Tourette’s syndrome if they have a father, mother, brother or sister with it also.

Neurological. Some studies have shown that there are some minor defects in the structure and working of the brain in children with Tourette’s syndrome. Studies also suggest that there may be a problem with one of the brain’s chemicals called dopamine. There is not a lot of information available about the detail or significance of these changes.

Environmental. Although it has not been proven, there is some evidence that problems during pregnancy or childbirth may increase the risk of a child developing Tourette’s syndrome. This may include problems such as prolonged labour, high levels of maternal stress in pregnancy, or babies with very low birthweight. There is also possibly a connection with a particular infection with the streptococcal germ in some children with Tourette’s syndrome. This is a fairly recent discovery and not very much is known about the link.

How common is Tourette’s syndrome?

Tourette’s syndrome is much more common than previously thought. About 1 in 100 children has the condition, although it varies in how mild or severe it is. It is about three times more common in boys than in girls.

What are the symptoms of Tourette’s syndrome?

The main symptom is multiple (many) tics. These are classified as either motor (movement) or vocal tics.
•Motor tics include things such as blinking, head turning, head nodding, kicking, mouth pouting, mouth opening, mouth twitches, etc.
•Vocal tics include things such as throat clearing, coughing, sniffing, yelling, or making animal sounds.

Tics occur very commonly in children who do not have Tourette’s syndrome. In fact, up to 1 in 5 children will develop a tic at some stage. These tics are often minor and of little significance, usually come and go, and often go away within a year.

In Tourette’s syndrome, a child develops multiple tics which occur many times a day (often in bouts), and the tics last for more than one year. The tics cause some degree of difficulty in school or social function. The condition begins between 2-14 years of age (the average age is 7).

There are several other symptoms that sometimes occur. These include:
•Coprolalia – the involuntary use of obscenities and swear words. This is perhaps the most famous symptom which the media tend to focus in on. However, this only occurs in about 1 in 10 children with Tourette’s syndrome. Note: it must be emphasised that if this occurs, the child cannot help swearing, and it is not a reflection on their moral character or upbringing.
•Echophenomena – copying what others say and do.
•Palilalia – repeating your own words.
•Non-obscene socially inappropriate (NOSI) behaviours – such as saying inappropriate or rude personal comments.

Are there any other problems?

If a child has Tourette’s syndrome they are also likely to have one or more related conditions. It is not clear why these other conditions occur at the same time. Only about 1 child in 10 with Tourette’s syndrome has no other associated problem. The most common conditions seen with Tourette’s syndrome are listed below with how often they occur in children with Tourette’s syndrome.
•Obsessive-compulsive disorder (OCD), or obsessive-compulsive behaviour (OCB). This occurs in about 5 in 10 children with Tourette’s syndrome.
•Attention deficit hyperactivity disorder (ADHD, or ADD). This occurs in about 6 in 10 children with Tourette’s syndrome.
•Learning difficulties. These occur in about 3 in 10 children with Tourette’s syndrome.
•Mood disorders such as depression or anxiety occur in about 2 in 10 children with Tourette’s syndrome.
•Conduct disorders. These occur in about 1-2 in 10 children with Tourette’s syndrome.
•Self-harming behaviours such as head banging occur in about 3 in 10 children with Tourette’s syndrome.
•Behavioural problems. Up to 8 in 10 children with Tourette’s syndrome will also have some degree of behavioural problems.

How is Tourette’s syndrome diagnosed?

There is no test for Tourette’s syndrome. The diagnosis is made after a careful discussion with you and your child as well as a physical examination to rule out other disorders. This will usually be done by a specialist neurologist (a doctor with a special interest in the brain and nervous system). Some tests may be done to make sure that there are no other conditions which could account for the tics.

What is the treatment for Tourette’s syndrome?

Psychological (talking) treatments

Various psychological treatments can help to ease the symptoms and problems of Tourette’s syndrome. These include cognitive behavioural therapy (CBT), habit reversal training and exposure and response prevention therapy. These treatments aim to help the child to recognise and control their tics. Often children are able to learn to suppress the tics during the day at school, but will need an outlet to release them at home.

Education and support

There is some evidence that providing parents and children with Tourette’s syndrome with information about the condition, results in better outcomes. It is recommended that you get in contact with the support group listed below, as they can provide further information on the condition and can even put you in contact with others in the same situation.

It is very important that your child’s school teacher and others who are involved in your child’s care should be informed and educated about the best way to manage this condition. Your child’s teacher can have a very positive impact on your child’s behaviour and development if they understand the problems that may be present.

In addition to any usual treatments, individual children may respond to different approaches. Parents and teachers can build on whatever works. For example, some children can gain more control of their lives through the medium of dance.

Medication

In more severe Tourette’s syndrome, medicines can sometimes help to reduce the occurrence of tics. The medicines that are mostly used are from the group known as antipsychotics: haloperidol, risperidone, pimozide, arpiprazole and sulpiride. The medicine clonazepam – a benzodiazepine – is also sometimes used. The aim of treatment with medicines is to control the tics to a point that will enable your child to function well while minimising side-effects. The tics may not disappear completely.

Management of other conditions

If your child has other conditions present with Tourette’s syndrome, then it is important that these should also be treated and managed well.

Other treatments

The use of surgery in Tourette’s syndrome is only recommended for people with severe symptoms who do not respond to other treatment. Deep brain stimulation using electrodes implanted into the brain has produced encouraging results in limited trials. However, more research is needed to see whether it is safe to be used more generally.

Some other thoughts and controversies about Tourette’s syndrome

There are various controversies and differences of opinion about certain aspects of Tourette’s syndrome. For example:
•Some people view any treatment to be controversial. Some children and teenagers do not want to change, and sometimes side-effects of medication can be worse than the condition itself.
•Some people would argue that it is not necessarily a disease and is a natural part of their personality, which has positive aspects to it. For example, some people with Tourette’s syndrome lead vivid lives ‘on the edge’, with extravagance, and audacity – sometimes with a rich fantasy world.

What is the outlook (prognosis)?

Many children with Tourette’s syndrome improve over time. By the time they are adults, in many cases the symptoms have eased considerably or have gone. However, some children with this condition will continue to have marked symptoms into adulthood and, although the tics tend to stabilise over time, some new tics may develop.

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Dyslexia

Posted on March 5, 2014 by JmaC

The term dyslexia is used to describe difficulty in the acquisition of reading, writing and spelling skills but not all poor readers are dyslexic. The child’s learning difficulties may be caused by:
•Visual problems through not being able to recognise shape and form.
•Reading speed, accuracy or comprehension.
•Phoneme segmentation (cannot see or hear the components and then put them together to create meaning and to spell the words).

The Diagnostic and Statistical Manual Fourth Edition (DSM-IV) criteria for the diagnosis of dyslexia are:
•Reading achievement substantially below that expected for the person’s age, measured intelligence and age-appropriate education.
•The disturbance in reading ability interferes with academic achievement or activities of daily living that require reading skills.
•If a sensory deficit is present, the reading difficulties are in excess of those usually associated with the specific sensory deficit.

Acquired dyslexias
•This is reading impairment following some form of brain insult in individuals with previously normal levels of reading ability.
•It is frequently associated with aphasia where patients will exhibit a type of dyslexia in keeping with their form of aphasia, eg fluent aphasics will have difficulties understanding printed word meanings while non-fluent aphasics will have trouble with grammatical aspects of reading.

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Epidemiology

Dyslexia affects all kinds of people regardless of intelligence, race or social class:
•Estimates of prevalence vary according to the definition of dyslexia and the way in which it is assessed. The British Dyslexia Association suggest that 4% of the population will be severely dyslexic (requiring support at school and beyond) and a further 6% may have mild or moderate dyslexia.[1]
•Some reports suggest that up to four times as many boys as girls are dyslexic. However, this may not reflect the true situation as affected boys may be more likely to be disruptive in class and therefore recognised as needing outside help. Girls’ language skills exceed boys’ language skills throughout most of school and therefore boys are more likely to appear as failing.
•There is a genetic predisposition for reading difficulties.[2] It appears that a number of genes at different loci (rather than a single locus) may be responsible.

Presentation

Dyslexia usually presents at about the age of 7 or 8 years as the child’s difficulties become clear in the school setting. Common signs of dyslexia include:
•Hesitant and inaccurate reading.
•Need to re-read materials to gain an understanding.
•Difficulty with sequences, eg putting dates in order.
•Erratic spelling.
•Reversal of letters (occurs in all children but less frequently than those with dyslexia).
•Auditory language problems or visual spatial problems, which may contribute to difficulties with reading and spelling.
•Inability to distinguish sounds or shapes on the page.
•Associated features include poor spelling and handwriting, and mathematical difficulties.

Assessment
•Assessment is usually carried out by an educational psychologist following a referral from a parent or teacher.
•Standardised measures, such as the Weschler Intelligence Scale for Children, are used to assess general intellectual ability. More specific tools (eg the Dyslexia Early Screening Test for testing early years, the Dyslexia Screening Test and the Aston Index) are used.
•The educational psychologist then investigates whether a child does not understand the meaning of words (semantic difficulty) or cannot see or hear the components and then put them together to create meaning and to spell the words (phoneme segmentation).

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Dyslexia Action
British Dyslexics

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Associated problems
•About 50% of those with dyslexia also have dyscalculia (difficulty with acquiring arithmetical skills).
•It is important to identify language difficulties or any hearing problems which may be the underlying cause or contribute to the reading and spelling difficulties.
•There is an overlap between attention deficit hyperactivity disorder (ADHD) and a reading disorder. Children with a reading disorder are twice as likely as other children to have ADHD and children with ADHD are twice as likely to have a reading disorder.
•Dyspraxia is more common in people with dyslexia.
•Short-term memory, mathematics, concentration, personal organisation and sequencing may be affected.

Management

There are a number of educational methods that can help people with dyslexia overcome their difficulties with reading and writing:
•Children with dyslexia require specialist teaching; many schools now have specialist provision for dyslexic children.
•Providing supportive home and school environments is essential. Parents and teachers should be strongly encouraged to praise and support the child.
•Teaching should be multi-sensory (include visual, auditory, movement and tactile elements), as children with dyslexia learn better when they can use as many different senses as possible, eg writing the letter in the air at the same time as saying the letter and its sound. Teaching should also be highly structured.
•Phonics: the sounds that the letters represent are emphasised so that the child gradually connects the visual pattern of words to the auditory pattern of words.
•Computers: many children with dyslexia find it easier to work with a computer than write in a book, with the additional benefit of using the spell checker. Computer software programs are available to teach phonemic recognition and can provide effective adjuncts to tutoring and classroom intervention.
•Eye checks: regular eye checks are particularly important for any child or adult who has difficulties with reading or spelling and who may be dyslexic. Eye problems do not cause literacy problems, but can be a contributory factor.[1]
•Colour overlays: some people with dyslexia are light- or colour-sensitive (Meares-Irlen syndrome), eg bright sunlight or fluorescent light may cause particular difficulties, black print on shiny white paper may be uncomfortable for the eyes, whiteboards may be too shiny, pattern glare may also be a problem. Transparent colour overlay filters (eg Irlen coloured overlay lenses) can be used to improve reading performance.[3] It may also be helpful to have coloured paper for writing and adjust the colours and brightness on computer screens.
•A number of other educational methods have been studied, eg exercise based therapy, which remains controversial.[4][5]

Complications
•Rates of behavioural problems, social maladjustment, anxiety, withdrawal, and depression are higher in children with reading disorder.
•Social problems may increase as children get older as they fall further behind with reading skills.

Prognosis
•Although some compensation can occur over time, dyslexia is usually persistent and can have a severe effect on academic achievement.[6]
•The effectiveness of treatment depends on the initial severity of the dyslexia. The earlier the intervention, the better the outcome.
•With appropriate intervention (speech and language therapy) and teaching, affected children with expressive phonological and vocabulary difficulties can achieve an adequate literacy level to function in society, although their reading abilities may still lag behind their peers.[7]
•Outcomes for patients with expressive syntax difficulties are more mixed, and interventions for those with receptive language difficulties need more research.
•However, many people affected by dyslexia have good ability in lateral thinking and shine in such fields as the arts, creativity, design and computing.

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Attention Deficit Disorder

Posted on March 5, 2014 by JmaC

Attention deficit hyperactivity disorder (ADHD) is a common condition that mainly affects behaviour. It is usually diagnosed in children but can affect adults. Symptoms include persistent restlessness, impulsiveness and/or inattention. The diagnosis is made after a detailed assessment. Treatment includes parent training programmes and sometimes medication. Diet may be a factor and may be worth considering.

What is attention deficit hyperactivity disorder?

Attention deficit hyperactivity disorder (ADHD) is also known as attention deficit disorder (ADD) and hyperkinetic disorder. It is a fairly common condition that mainly affects a child’s behaviour. There may also be problems with the child’s intellectual, social and psychological development as a result of the behaviour.

Related blogs Q

ADHD – don’t be labelled for life

What are the symptoms of attention deficit hyperactivity disorder?

Children with ADHD show persistent restlessness, impulsiveness and/or inattention. These features are seen in more than one setting. For example, at school and at home. They are also seen in more than one activity. For example, in schoolwork and in relationships. They occur at a level greater than expected for their age and cause significant disruption to the child’s daily life.

There are three subtypes of ADHD:
•Hyperactive-impulsive subtype. Some features of this type of ADHD are that a child may fidget a lot, run around in inappropriate situations, have difficulty playing quietly and may talk excessively. They may interrupt others and have trouble waiting their turn in games, in conversations and also in queues.
•Inattention subtype. In this subtype, a child may have trouble concentrating and paying attention, may make careless mistakes, may not listen or follow through on instructions and may be easily distracted. They may also be forgetful in daily activities, lose essential items such as school books or toys, and have trouble organising activities.
•Combined subtype. If a child has this subtype, they have features of both of the other subtypes.

Children with ADHD are also more likely than average to have other problems such as anxiety and depression, conduct disorders and co-ordination difficulties. Some children with ADHD also have reading difficulties and dyslexia.

Note: many children, especially those under the age of five, are inattentive and restless. This does not necessarily mean that they have ADHD.

What causes attention deficit hyperactivity disorder?

The cause of ADHD is not known. It is thought that there may be subtle changes in parts of the brain which control impulses and concentration. Although the main cause of ADHD is not known, various factors are thought to increase the risk of a child developing ADHD. These include:
•Genetics. Genes are passed on to a child from each parent. Our genes determine how our body functions, what we look like and sometimes what diseases we will get. Some studies have shown that certain genes are related to ADHD. A child may therefore be more likely to have ADHD if there is another family member such as mother, father, brother or sister with ADHD.
•Antenatal problems. If a mother drinks alcohol, smokes or takes heroin while she is pregnant, this may increase the risk of her child developing ADHD.
•Obstetric problems. This means problems that occur when a baby is born, such as a difficult labour causing lack of oxygen to the brain. Babies with very low birthweight have an increased risk of developing ADHD.
•Severe deprivation. If a child is severely neglected early in life, this may increase their risk of developing ADHD.

Factors in a child’s upbringing such as poor parenting, watching a lot of TV or DVDs, family stress, etc, do not cause ADHD. However, such factors may make the behaviour of a child with ADHD worse. Diet may be a factor (discussed further later).

How common is attention deficit hyperactivity disorder?

ADHD affects around 5 in 100 school-aged children in the UK. It is around three times more common in boys than in girls. Although ADHD is usually diagnosed in children aged 3-7 years, it may not be recognised until much later in life. Sometimes it is not diagnosed until adulthood.

How is attention deficit hyperactivity disorder diagnosed?

There is no simple test to diagnose ADHD. If your child’s teacher or doctor suspect that your child may have ADHD, it is likely that your child will be referred to a specialist who will be able to confirm the diagnosis by doing an assessment, and start any treatment. This specialist may be a specialist paediatrician (children’s doctor), a child psychiatrist, a member of your local Child and Adolescent Mental Health Service, or an adult psychiatrist. The type of specialist depends on the age of your child and also the availability of services in your local area.

The assessment may involve a discussion with you and your child as well as a physical examination. The specialist may ask for a report from the school and may even want to observe your child doing certain tasks. You and your child may also see a nurse or other healthcare professionals for further testing and assessment.

There are a few aims of this assessment. These include:
•To confirm whether your child definitely has ADHD.
•To make sure that there are no other reasons that explain your child’s behaviour. For example, a hearing difficulty, epilepsy or thyroid problem.
•To identify any other problems your child may have. For example, anxiety, low self-esteem or a learning difficulty.

For a doctor to make a firm diagnosis of ADHD, there are strict criteria that need to be fulfilled. For example, the symptoms of inattention and/or hyperactivity and impulsivity need to be present for at least six months. They also need to be causing problems in your child’s life as well as being different from what would be expected for their age. They also must have started to occur before the age of seven, and be present in more than one setting. For example, at home and at school. In addition, other causes for your child’s symptoms may need to be ruled out. For example, depression or anxiety.

What are the treatment options?

The treatments recommended depend on how severe the condition is as well as the age of your child. Ideally, treatment should involve a team of professionals, experienced and trained in ADHD. The team may include a doctor, teacher, nurse, social worker, occupational therapist, mental healthcare professional or psychologist. Treatments include drug and nondrug treatments.

Nondrug treatments for attention deficit hyperactivity disorder

Generally, for preschool children or for older children with mild-to-moderate ADHD, the first step is usually for you (parent or guardian) to be referred to a parent training programme. Sometimes your child will also be referred for a group treatment programme aimed at improving behaviour. The parent programme may include such things as:
•Learning skills to manage and reduce problem behaviour.
•Learning more effective ways to communicate with your child.
•Helping you to understand your child’s emotions and behaviours.

Your child’s schoolteacher may be invited to be involved in the treatment process. They may be able to use certain techniques in the classroom to help your child learn and function better. Family therapy may also be helpful.

In more severe ADHD, or where the above treatments have not succeeded, medication is usually recommended.

Drug treatments for attention deficit hyperactivity disorder

There are three main drugs licensed for the treatment of ADHD in the UK. Methylphenidate (trade name of Ritalin®) is the most commonly used drug. Atomoxetine and dexamfetamine are other drugs that may also be used. Drug treatments are not usually given to children aged under six years. Drug treatment is done under the supervision of a specialist in childhood behavioural disorders.

How effective is drug treatment?

The drugs used for ADHD have been used for many years and in many children with good effect. A number of studies have shown that drug treatment with or without intensive behavioural training programmes is more effective than behavioural training programmes alone.

How does the methylphenidate work?

Methylphenidate is a type of stimulant drug. It works by increasing the amount of a brain chemical called dopamine in certain parts of the brain. The parts that it works on are responsible for self-control and attention. Increasing the amount of dopamine in these areas of the brain stimulates them to work better. This then helps to focus your child’s attention and improve concentration.

How do I give methylphenidate to my child?

Usually, your child will start on a low dose such as 5 mg three times a day and will be carefully monitored for side-effects. This dose is often increased gradually, usually over 4-6 weeks, to a maximum of 20 mg three times daily according to how well it is working and whether side-effects occur. The most common side-effects to look out for with methylphenidate are insomnia (difficulty with sleep), loss of appetite and weight loss.

Once the total daily dose has been determined, it may be possible for your child to switch to a once-daily long-acting version of methylphenidate.

When your child is on medication, they should be reviewed regularly to check that the dose is working and that there are minimal side-effects. Your child will also have their height, weight, pulse and blood pressure measured at regular intervals.

It is good for this review to include feedback from those who are in regular contact with your child, such as teachers, family members and other carers.

How quickly does methylphenidate work?

The short-acting methylphenidate begins working within about 20 minutes and lasts for 3-4 hours. The longer-acting version takes longer to start working but lasts for about 12 hours and gives a more stable level of drug in the bloodstream throughout the day. It may take several weeks to see the full benefit of medication.

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HACSG – The Hyperactive Children’s Support Group
Dyscovery Centre

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How long will my child be on medication?

It is common to continue medication for several years. Once children become teenagers, it is recommended to trial off the medication each year. This is to make sure that medication is still necessary.

Sometimes methylphenidate causes unacceptable side-effects or is not effective. In this situation one of the two other drugs mentioned above may be used. Dexamfetamine is another type of stimulant. Atomoxetine is a different type of drug that works on a chemical called noradrenaline in the brain.

There are other drugs that may be used for ADHD but these are usually only recommended if the above drugs are not effective.

Are the drugs safe?

The use of drugs to treat ADHD is controversial. This is mostly because some people are worried about their effectiveness as well as the possibility of side-effects. Also, there is the possibility of the drugs being misused or abused. However, guidelines from the National Institute for Health and Clinical Excellence (NICE) advise that they are still useful and important in the treatment of severe ADHD and in milder forms when other treatments have not been effective. The benefits of drugs usually outweigh any risks in children with ADHD, aged over six years and in adolescents.

The drugs do not seem to have an addictive potential when used in children. There are reports of the drugs being abused in teenagers and adults. However, it is likely that the risk of substance abuse with street drugs such as cocaine in someone with untreated ADHD is greater than the risk of abuse of the prescribed drugs.

This controversy is largely unfounded because both scientific studies and years of experience have shown that these drugs are generally safe and effective.

What about diet?

Dietary changes for the treatment of ADHD have been widely used for many years. They take the form of:
•Supplements with substances thought to be lacking. For example, supplements of fatty acids such as omega 3 and omega 6, and/or:
•Cutting out foods thought to be harmful. For example, cutting out foods containing artificial colouring and other additives.

An authoritative guideline on ADHD was published by NICE in 2008. The guideline came to the conclusion that there is no good evidence that dietary changes can help children with ADHD. However, NICE advised that “assessment of ADHD should include asking about foods or drinks that appear to influence their hyperactive behaviour. If there is a clear link, healthcare professionals should advise parents or carers to keep a diary of food and drinks taken and ADHD behaviour. If the diary supports a relationship between specific foods and drinks and behaviour, then referral to a dietitian should be offered.”

Since the NICE guideline was issued, some interesting new research has been published . A study (cited at the end) followed 100 children with ADHD over several weeks. The researchers compared a group of children with ADHD who were given a strict restricted diet with those who were not. Of those in the restricted diet group over half showed a marked improvement in their symptoms. Not many foods were included in the restricted diet. The foods allowed consisted of those thought least likely to cause symptoms and allergies, such as rice, turkey, lamb, a few vegetables, pears and water. However, it is thought that if symptoms improved with a strict diet, new foods can then be gradually introduced over time to see which food or foods may trigger worsening symptoms.

This new study is encouraging. However, further research is needed to confirm the findings and to establish the place of dietary changes in the treatment of ADHD.

So, in short, diet probably does not cause ADHD, but a change in diet may help in some cases, but not in all cases. It may be that some children are negatively affected by certain foods or additives. If you notice that a particular ingredient or food makes your child’s symptoms worse, then take a note of it and discuss this further with your doctor or a dietician. And also, it has to be stressed – do not try a strict restrictive diet for your child by yourself. If you think that diet may be a factor, it is strongly advised that you ask your GP to refer you to a qualified dietician. A dietician can advise, and make sure that any limited diet contains the full range of nutrients that a growing child requires.

It is, however, recommended that all people with ADHD have at least a normal healthy balanced diet, and also do some regular exercise.

Is there anything else available for older children or adults?

In older children, there may be some benefit gained from psychological treatment such as cognitive behavioural therapy (CBT) or social skills’ training. These techniques aim to teach your child more about why they act and react the way that they do. They also give them strategies to use to help them to improve their behaviour and daily functioning.

In adults, medication is recommended as part of a comprehensive treatment programme. This should also include psychological treatment, advice on behavioural management and assistance with education and employment.

What is the prognosis (outlook)?

Up to 8 in 10 children with ADHD will continue to experience symptoms into their teenage years. This decreases to about 5 in 10 who continue to have some symptoms into adulthood. With age, the symptoms may alter. For example, a child who was always restless may feel a lot of inner tension as an adult. It is also likely that the symptoms will reduce in severity and cause less disruption over time. As mentioned, treatment can often improve symptoms.

Children with ADHD are more likely than average to have other problems as adults, such as unemployment, relationship difficulties, substance misuse and crime. However, treatment aimed at improving behaviour at an early age aims to reduce the long-term impact of the condition.

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Body Dysmorphic Disorder

Posted on March 5, 2014 by JmaC

Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance, or excessive concern over a slight physical anomaly. It is characterised by time-consuming behaviours such as mirror gazing, comparing one’s appearance with others, excessive camouflaging to hide the defect, skin picking and seeking reassurance.[1] Symptoms often begin in adolescence.[2] One study suggested that patients with BDD pay more attention to facial appearance in others, compared to controls.[3] Another found that BDD sufferers have a tendency to misinterpret the neutral facial expressions of others in a negative way.[4]

Epidemiology

Population studies suggest a point prevalence rate of 0.72-2.4%.[5] International studies suggest that 6-15% of patients attending cosmetic surgery and dermatology clinics are estimated to have body dysmorphic disorder (BDD).[2] Data concerning sex predominance are sparse. One study of medical students found a higher preponderance in males[6]

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Differences between body dysmorphic disorder and obsessive-compulsive disorder[2][7]

Although there are many similarities between the two conditions – which often co-exist – some differences have been identified. Patients with body dysmorphic disorder (BDD) have significantly poorer insight than those with obsessive-compulsive disorder (OCD) and are more likely to be delusional. They are also significantly more likely to have lifetime suicidal ideation, as well as lifetime major depressive disorder and a lifetime substance use disorder. See also separate Obsessive-compulsive Disorder article.

The General Practitioner’s role[8]

The National Institute for Health and Clinical Excellence (NICE) recommends referral to a specialist multidisciplinary team offering age-appropriate care. This is unlikely to be available in many areas, due to lack of resources but it is worth getting in touch with local mental health trusts to see what is currently available. The GP’s role depends on expertise but it should be remembered that drug management should be part of a package which includes psychological care.

In all patients, however, the GP will need to:
•Identify cases.
•For patients at risk of body dysmorphic disorder (BDD) (depression, social phobia, substance misuse, obsessive-compulsive disorder (OCD),[9] eating disorder, mild disfigurement or blemish seeking dermatology or cosmetic surgery referral), ask the following questions: •Do you worry a lot about the way you look and wish you could think about it less?
•What specific concerns do you have about your appearance?
•On a typical day, how many hours a day is your appearance on your mind? (More than one hour a day is considered excessive).
•What effect does it have on your life?
•Does it make it hard to do your work or be with friends?

•Assess severity – ie how much it is affecting the patient’s ability to function in everyday life.
•Assess risk of self-harm or suicide and presence of comorbidity such as depression.
•Arrange referral to appropriate secondary care provision.
•Ensure continuity of care to avoid multiple assessments, gaps in service and a smooth transition from child to adult services (many patients have lifelong symptoms).
•Promote understanding – make patients/families aware of the involuntary nature of symptoms. Consider patient information leaflets, contact numbers of self-help groups, etc.
•Consider the bigger picture – cultural, social, emotional and mental health needs.
•If the patient is a parent, consider child protection issues.

Management in adults[8]

Patients with mild functional impairment can be managed with low-intensity psychological treatment. This may involve:
•Individual cognitive behavioural therapy (CBT) plus ‘exposure and response prevention’ (ERP)*.
•Individual CBT and ERP by telephone.
•Group CBT.

*ERP is a technique in which patients are repeatedly exposed to the situation causing them anxiety (eg exposure to dirt) and are prevented from performing repetitive actions which lessens that anxiety (eg washing their hands). This method is only used after extensive counselling and discussion with the patient, who knows fully what to expect. After an initial increase in anxiety, the level gradually decreases. This is extremely therapeutic, as the patient feels that they have confronted their worst fears without anything terrible happening.
•Adults with mild symptoms should be offered a selective serotonin reuptake inhibitor (SSRI) if they cannot engage in low-intensity psychological treatment, if such treatment has failed, or if they opt not to have more intensive psychological treatment.
•Adults with moderate symptoms or where low-intensity psychological treatment has failed should be offered high-intensity CBT and ERP (more than 10 hours per patient) or an SSRI.
•Adults with severe symptoms – offer high-intensity psychological therapy plus an SSRI.

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Management in children[8]
•Mild dysfunction – offer guided self help. As for moderate-to-severe if this fails.
•Moderate-to-severe – offer cognitive behavioural therapy and exposure and response prevention (CBT ERP) as for adults but involve family/carers: individual or group depending on the preference of the patient.
•If psychological treatment fails, factors which might require other interventions may be involved, eg co-existence of comorbid conditions, learning disorders, persisting psychosocial risk factors such as family discord, presence of parental mental health problems. In children over the age of 8, adding an SSRI might be appropriate, following multidisciplinary review (but see below concerning safety issues).

Using SSRIs[8][10]

See separate article Selective Serotonin Reuptake Inhibitors and below:
•SSRIs in adults – evidence for use of SSRIs in obsessive-compulsive disorder (OCD) is stronger than for body dysmorphic disorder (BDD). Caution is advised in view of increased risk of suicidal thoughts and self harm in people with depression. It is unclear whether this applies to people with OCD or BDD in absences of other comorbidity; further guidance is awaited.

When prescribing, discuss the following and provide written supporting material: •Craving and tolerance do not occur.
•There is a risk of discontinuation/withdrawal symptoms on stopping the drug, missing doses, or reducing the dose.
•There is a range of potential side-effects, (see individual drugs) including worsening anxiety, suicidal thoughts and self harm, which need to be carefully monitored, especially in the first few weeks of treatment.
•There is commonly a delay in onset of up to 12 weeks, although depressive symptoms improve more quickly.
•In high-risk patients, prescribe limited quantities, keep in contact, especially during first few weeks, and actively monitor for akathisia (restlessness and the urge to move), suicidal ideation, increased anxiety, agitation.
•Monitor all patients around the time of dosage changes.
•NICE recommends fluoxetine as there is more supporting evidence than for other SSRIs.
•If there is no response to a standard dose, check compliance, check interaction with drugs and alcohol, then consider titrating to maximum dose according to the Product Characteristics.
•Continue for at least twelve months; withdraw gradually.

•SSRIs in children and young people (8-18 years) •Caution is advised as there is a risk of self harm or suicide in patients with depression. They are only prescribed by specialists, in conjunction with psychological therapy following assessment by a child and adolescent psychiatrist who should also be involved in dosage changes and discontinuation.
•Fluoxetine is the first-line SSRI for BDD. In the presence of depression, follow NICE guidance for treatment of childhood depression.
•Discuss adverse effects, dosage, monitoring. etc. with the patient/family/carers as per adults (see above).

Treatment failures (applicable to adults, children and young people)[2][8]

The following in conjunction with specialist assessment and multidisciplinary review:
•Try another SSRI.
•Change to clomipramine – but this has greater tendency to produce adverse effects. Do baseline ECG and check blood pressure; start with a small dose, titrate according to response, and monitor regularly.
•Antipsychotics – sometimes used to augment the effect of an SSRI.
•Inpatient treatment – for ‘last resort’ treatment failures.
•Residential/supportive care – for patients with chronic severe dysfunction.
•Patients with BDD do not usually benefit from surgical treatment.[11]

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Cognitive and Behavioral therapy

Posted on March 5, 2014 by JmaC

Cognitive and behavioural therapies are both forms of psychotherapy (a psychological approach to treatment) and are based on scientific principles that help people change the way they think, feel and behave. They are problem-focused and practical. (Please also refer to the separate article Psychotherapy and its Uses.)

In 2005 the Government made a commitment to improve the availability of psychological therapies, the preferred method being cognitive behavioural therapy (CBT) for patients, especially in depressive and anxiety disorders. This led to the launch of the Improving Access to Psychological Therapies (IAPT) programme in 2007.[1]

Definitions

Behavioural therapy

This is a treatment approach based on clinically applying theories of behaviour that have been extensively researched over many years. It is thought that certain behaviours are a learned response to particular circumstances and these responses can be modified. Behavioural therapy aims to change harmful and unhelpful behaviours that an individual may have.

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Cognitive therapy

This was developed later and focuses on clinically applying research into the role of cognitions in the development of emotional disorders. It looks at how people think about, and create meaning about, situations, symptoms and events in their lives and develop beliefs about themselves, others and the world.[2] These ways of thinking (harmful, unhelpful or ‘false’ ideas and thoughts) are seen as triggers for mental and physical health problems. By challenging ways of thinking, cognitive therapy can help to produce more helpful and realistic thought patterns.

Cognitive therapy was developed in the 1960s by Aaron Beck, an American psychiatrist. He felt that his patients were not improving enough through simple analysis and believed that it was their negative thoughts that were holding them back. At around the same time, another therapist, Albert Ellis, was also realising that people’s negative thoughts and irrational thinking could be underpinning mental health problems. He developed a form of cognitive therapy that has come to be known as rational emotive behavioural therapy (REBT).

Subtypes of cognitive therapy
•Rational emotive behavioural therapy (REBT): this is based on the belief that we all have sets of very rigid, and perhaps illogical, beliefs that can make us mentally unhealthy. It teaches the patient to recognise and spot the beliefs that could be causing them harm and to replace them with more logical and flexible ones.
•Cognitive analytic therapy (CAT): this is another form of cognitive therapy that combines some of the ideas of cognitive therapy with the more analytical approach of psychodynamic psychotherapy. The client and the therapist work together to look at what has hindered changes in the past, in order to understand better how to move forward in the present.[3] It was founded by Dr Anthony Ryle in the 1970s. The therapy sessions explore the patient’s past and childhood and determine why any problems have happened. They will then look at the effectiveness of any current coping mechanisms that the patient may have and will help the patient find ways to improve these. The work is very active. Diagrams and written outlines may be created to help recognise and challenge old patterns and coping mechanisms that do not work well, and provide revised mechanisms.[3] There is a professional organisation known as the Association for Cognitive Analytic Therapy (ACAT) with a wealth of explanation about the therapy on the website (see link in Internet and further reading section below).

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Psychotherapy and its Uses
Panic Disorder
Counselling in Primary Care
Agoraphobia

CBT

The term ‘cognitive behavioural therapy’ (CBT) has come to be used to refer to behavioural therapy, cognitive therapy and therapy that combines both of these approaches. The emphasis on the type of therapy used by a therapist can vary depending on the problem being treated. For example, behavioural therapy may be the main emphasis in phobia treatment or obsessive compulsive disorder (OCD) because avoidance behaviour or compulsive actions are the main problems. In depression, the emphasis may be on cognitive therapy.

The rest of this article focuses on CBT.

Conditions that can be treated by cognitive behavioural therapy

There is a strong evidence base for the effectiveness of CBT. It can be used in a wide number of mental health and physical conditions. The National Institute for Health and Clinical Excellence (NICE) has recommended its use as a treatment option for a number of diagnoses.

Examples of conditions that can be treated by CBT include:
•Depression[4] – low-intensity CBT (eg 6-8 sessions over 10-12 weeks) is recommended for mild- and moderate-severity depression. Computerised CBT (cCBT) is also recommended for both these severities. Severe depression will need high-intensity CBT, ie 16-20 sessions over 6-9 months, in combination with antidepressants. A cCBT package called ‘Beating the Blues®’ is one option recommended by NICE to deliver CBT in mild and moderate depression.
•Generalised anxiety disorder (GAD) and panic disorder – high-intensity CBT is recommended for GAD and low-intensity for panic disorder. There are cCBT packages available for panic disorder.
•Obsessive compulsive disorder (OCD)[5] – mild OCD should be treated with low-intensity CBT, with which accompanying exposure and relapse prevention (ERP) is recommended. CBT can take the form of brief, individual CBT, using self-help materials, or by the telephone or, alternatively, by group CBT, which may help. If this fails, or OCD leading to moderate functional impairment is present, then high-intensity CBT (including ERP) with medications is advised by NICE.
•Body dysmorphic disorder (BDD)[5] – mild functional impairment caused by this disorder should be treated with CBT (including ERP). Moderate functional impairment will require more intensive CBT or medical therapy, and severe functional impairment will usually require a combination of these.
•Post-traumatic stress disorder (PSTD)[6] – all sufferers should be offered trauma-focused CBT on a regular and continuous basis (usually 8-12 sessions).
•Other conditions where CBT maybe useful, but NICE guidance is lacking include: •Bulimia
•Chronic fatigue syndrome
•Drug and alcohol addiction
•Chronic pain
•Schizophrenia
•Bipolar disorder
•Learning disability
•Sexual and relationship problems
•Habits
•Anger problems
•Sleep disturbance problems

obsessive compulsive disorder

Posted on March 5, 2014 by JmaC

Obsessive-compulsive disorder (OCD) may be characterised by the presence of obsessions or compulsions but commonly both.
•Obsessions are unwanted intrusive thoughts, images or urges that repeatedly enter the person’s mind.
•Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. They can be overt (observable by others), eg checking a door is locked; or they can be covert, eg a mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Epidemiology[1]

Studies vary but the figure for prevalence ranges from 1.7-4%.[2] Population surveys produce different results from audits of clinical samples and seem to suggest a predominance of females. Current research in paediatric OCD is investigating a genetic predilection in some families.[3]

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Management of obsessive-compulsive disorder[1][4][5]

The GP’s role

The National Institute for Health and Clinical Excellence (NICE) recommends referral to a specialist multidisciplinary team offering age-appropriate care. This is unlikely to be available in many areas, due to lack of resources; however, it is worth getting in touch with local mental health trusts to see what is currently available. The GP’s role depends on expertise but it should be remembered that drug management should be part of a package which includes psychological care.

In all patients, however, the GP will need to:
•Identify cases – for patients at risk of OCD (depression, anxiety, body dysmorphic disorder (BDD), substance misuse, or eating disorder), ask the following questions: •Do you wash or clean a lot?
•Do you check things a lot?
•Is there any thought that keeps bothering you that you would like to get rid of but cannot?
•Do your daily activities take a long time to finish?
•Are you concerned about putting things in a special order or are you very upset by mess?
•Do these problems trouble you?

•Assess severity, ie how much it is affecting the patient’s ability to function in everyday life.
•Assess the risk of self harm or suicide and the presence of comorbidity such as depression.
•Arrange referral to appropriate secondary care provision.
•Ensure continuity of care to avoid multiple assessments, gaps in service and a smooth transition from child to adult services (many patients have lifelong symptoms).
•Promote understanding – make patients/families aware of the involuntary nature of symptoms. Consider patient information leaflets, contact numbers of self-help groups, etc.
•Consider the bigger picture – cultural, social, emotional and mental health needs.
•If the patient is a parent, consider child protection issues.

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Personality Disorders and Psychopathy
Selective Serotonin Reuptake Inhibitors

Management in adults

Patients with mild functional impairment – can be managed with low-intensity psychological treatment. This may involve:
•Individual cognitive behavioural therapy (CBT) plus exposure and response prevention (ERP).
•Individual CBT and ERP by telephone or internet.[6][7]
•Group CBT.
•A couples-based course, which has been developed for patients in long-term relationships.[8]

One randomised comparative trial concluded that group CBT was an effective treatment but did not exclude the possibility that individual therapy was superior.[9]

One study found that two prominent features of OCD – overestimations of danger and inflated beliefs of personal responsibility – benefited equally from CBT.[10]

Inference-based treatment (IBT) is a method of psychological treatment sometimes used as an adjunct to CBT in OCD patients with obsessional doubt.[11]

*ERP is a technique in which patients are repeatedly exposed to the situation causing them anxiety (eg, exposure to dirt) and are prevented from performing repetitive actions, which lessens that anxiety (eg, washing their hands). This method is only used after extensive counselling and discussion with the patient who knows fully what to expect. After an initial increase in anxiety, the level gradually decreases. This is extremely therapeutic, as the patient feels that they have confronted their worst fears without anything terrible happening. One study found that, providing there was adherence to a standardised treatment manual, the experience (or inexperience) of the therapist did not affect the outcome
•Adults with mild symptoms should be offered a selective serotonin reuptake inhibitor (SSRI) if they cannot engage in low-intensity psychological treatment, if such treatment has failed, or if they opt not to have more intensive psychological treatment.
•Adults with moderate symptoms or where low-intensity psychological treatment has failed should be offered high-intensity CBT and ERP (more than 10 hours per patient) or an SSRI.
•Adults with severe symptoms should be offered high-intensity psychological therapy plus an SSRI.

Antipsychotic medications

Posted on March 4, 2014 by JmaC

Antipsychotics are medicines that are mainly used to treat schizophrenia or mania caused by bipolar disorder. There are two main types of antipsychotics: atypical antipsychotics and older antipsychotics. Both types are thought to work as well as each other. Side-effects are common with antipsychotics. You will need regular tests to monitor for side-effects while you take theses medicines.

What are antipsychotics?

Antipsychotics are a group of medicines that are mainly used to treat mental health illnesses such as schizophrenia, or mania (where you feel high or elated) caused by bipolar disorder. They can also be used to treat severe depression and severe anxiety. Antipsychotics are sometimes also called major tranquillisers.

There are two main types of antipsychotics:
•Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.
•Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

Antipsychotics are available as tablets, capsules, liquids, and depot injections (long-acting). They come in various different brand names.

Older antipsychotics have been used since the 1950s and are still prescribed today. Newer antipsychotics were developed in the 1970s onwards. It was originally thought that these medicines would have fewer side-effects than the older type of antipsychotics. However, we now know that they can also cause quite a few side-effects.