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If you have been taking a benzodiazepine or Z drug long-term (for more than four weeks) then it can be difficult to stop it because of withdrawal effects. However, this can be overcome by a variety of ways. One method is to switch whatever medicine you are on to an equivalent dose of diazepam. You can then gradually reduce the dose of diazepam at a pace that suits you. This keeps any withdrawal effects to a minimum. The dose reduction is commonly done over several months before coming off diazepam completely

What are benzodiazepines and Z drugs?

Benzodiazepines are a group of medicines that are sometimes used to treat anxiety. Examples include: diazepam, lorazepam (Ativan®), chlordiazepoxide, alprazolam and oxazepam. Some are also used as sleeping tablets. These include: temazepam, loprazolam, lormetazepam, nitrazepam.

Zaleplon, zolpidem, and zopiclone are other sleeping tablets but, strictly speaking, are not benzodiazepines. They are known as the Z drugs. However, they act in a similar way (they have a similar effect to benzodiazepines on the brain cells).

When you first start taking a benzodiazepine or Z drug, it usually works well to ease the symptoms of anxiety, or to cause sleep. You can usually stop a benzodiazepine or Z drug without any problems if you take it for just a short time (less than 2-4 weeks).

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What happens if you take a benzodiazepine or Z drug for longer?

Tolerance

After a few weeks of taking a benzodiazepine or Z drug each day, the body and brain often become used to the medicine. In many people it gradually loses its effect. The initial dose then has little effect and so a higher dose is needed for it to work. In time, the higher dose does not work, and so an even higher dose is needed, and so on. This effect is called tolerance.

Dependence (addiction)

There is a good chance that you will become dependent on a benzodiazepine or Z drug if you take it for more than four weeks. This means that withdrawal symptoms occur if the tablets are stopped suddenly. In effect, you need the medicine to feel ‘normal’. Possible withdrawal symptoms include:
•Psychological symptoms – such as anxiety, depression, panic attacks, odd sensations, nightmares, feeling as if you are outside your body, feelings of unreality, or just feeling awful. Rarely, a serious mental breakdown can occur (psychosis).
•Physical symptoms such as sweating, being unable to sleep, headache, tremor, feeling sick, feeling unsteady, palpitations, muscle spasms, and being oversensitive to light, sound and touch. Rarely, convulsions (seizures) occur.
•In some cases the withdrawal symptoms seem like the original anxiety symptoms.

The duration of withdrawal symptoms varies, but often lasts up to six weeks and sometimes longer. Some people who have taken these medicines for a long time continue to have minor withdrawal symptoms for several months after stopping. Withdrawal symptoms can start a few hours after but can be up to two days after stopping the tablets. They tend to be worst in the first week or so before gradually easing.

You may end up continuing to take the medicine to prevent withdrawal symptoms but, because of tolerance, it no longer helps the original anxiety or sleeping problem.

Some people who take a benzodiazepine or Z drug on a long-term basis believe that the medicine is still helping to ease anxiety or sleeping problems. However, in fact, in many people the medicine is just preventing withdrawal symptoms.

Why should I stop taking a benzodiazepine or Z drug?

Studies have shown that coming off benzodiazepines and Z drugs can have many benefits. For example, the benefits of stopping long-term benzodiazepines in elderly people were investigated in a trial of 139 people over the age of 65 years. This study found that stopping treatment:
•Had no long-term adverse effects on sleeping or anxiety symptoms.
•Improved memory and reaction times, while people who continued taking benzodiazepines declined in both these areas.
•Increased levels of alertness.
•Improved quality-of-life measures for physical and social functioning, and vitality.

Studies have shown that in people who continue to take benzodiazepines long-term, there is:
•An increased risk of fractured hips in older people, especially when they are on other medicines that increase the effect of benzodiazepines.
•Impairment of mental function and memory in older people. This has sometimes been wrongly diagnosed as dementia.
•An increased risk of injury in car crashes (due to the affect on alertness).

So, in summary, coming off a long-term benzodiazepine or Z drug:
•Is likely to improve your memory, reaction time, alertness, and quality of life.
•Reduces your risk of falls, accidents, fractured bones, and other injuries.

How should I stop taking a long-term benzodiazepine or Z drug?

If you have been taking a benzodiazepine or Z drug for over four weeks and want to stop it, it is best to discuss the problem with a doctor.

Some people can stop taking benzodiazepines and Z drugs without any difficulty, as they have only minor withdrawal effects which soon ease off. However, for a lot of people the withdrawal effects are too severe to cope with if the medicine is stopped suddenly. Therefore, it is often best to reduce the dose gradually over several months before finally stopping it. Your doctor can advise on dosages, time scale, etc.

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Diazepam withdrawal plan

A common plan is to switch from whatever benzodiazepine tablet or Z drug that you are taking to diazepam. Diazepam is a ‘long-acting’ benzodiazepine that is commonly used. With diazepam, the dose can be altered very gradually and with greater ease compared to other benzodiazepines.

Your doctor will be able to prescribe the dose of diazepam equivalent to the dose of your particular type of benzodiazepine or Z drug. After this, you can decide with your doctor a plan of how to reduce the dose gradually. A common plan is to reduce the dose by a small amount every 1-2 weeks. The amount the dose is reduced at each step may vary, depending on how large a dose you are taking to start with. Also, the last few dose reductions before finally stopping completely may be less than the original dose reductions, and done more gradually.

The gradual reduction of dose keeps any withdrawal symptoms to a minimum.

Sometimes other medication may be prescribed to help you cope with symptoms while you are coming off benzodiazepines. For example, you may be offered antidepressants if depression emerges whilst you are on a withdrawal programme, or beta-blockers if you need help to control anxiety.

Some tips that may help
•Before coming off a benzodiazepine or Z drug it may be best to wait until any life crisis has passed, and your level of stress is as low as can be.
•Consider starting whilst on holiday, when you have less pressure from work, fewer family commitments, less stress, etc.
•Consider telling family or friends that you are coming off a benzodiazepine or Z drug. They may give you encouragement and support.
•Consider joining a local self-help group. Advice and support from other people in similar circumstances, or who have come off a benzodiazepine or Z drug, can be very encouraging.
•If you are taking other addictive medicines in addition to benzodiazepines, then you may need specialist help for coming off the various medicines. Your doctor will be able to advise you or refer you on to local services which can help.

Other ways of tackling anxiety and sleeping problems

Benzodiazepines and Z drugs are not the long-term answer to anxiety or sleep problems.

If you have anxiety symptoms, there are other ways of tackling your symptoms. For example, learning to relax, or joining an anxiety management group. If anxiety symptoms persist or are severe, your doctor may advise on other treatments such as cognitive behavioural therapy (CBT).

There are separate leaflets that may help called ‘Anxiety – Generalised Anxiety Disorder’, ‘Anxiety Disorders’, ‘Cognitive Behavioural Therapy (CBT)’, and ‘Stress – Tips on How to Avoid It’.

Tips on how to improve sleep can be found in our leaflets ‘Insomnia (Poor Sleep)’, ‘Insomnia – Sleeping Tablets’, and ‘Sleeping Problems – Self Help Guides’.

A final note

Most people who have taken a benzodiazepine or Z drug can successfully come off it. After switching to diazepam (described above), the pace and speed of withdrawal varies greatly from person to person. Go at a pace that is comfortable for you after discussion with your doctor. For many people, the gradual withdrawal and eventual stopping of diazepam takes several months. However, some people take up to a year to reduce the dose gradually before finally stopping it.

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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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Chronic fatigue syndrome/ME is a condition where you have long-term disabling tiredness (fatigue). Most people with chronic fatigue syndrome/ME also have one or more other symptoms such as muscular pains, joint pains, disturbed sleep patterns, poor concentration, headaches. The cause is not known. Treatments that may help in some cases (but not all) include a programme of graded exercise therapy (GET) and cognitive behavioural therapy (CBT).

What is chronic fatigue syndrome/ME?

Chronic fatigue syndrome (CFS)/ME is a condition that causes marked long-term fatigue and other symptoms which are not caused by any other known medical condition.
•CFS stands for chronic fatigue syndrome. Chronic means persistent or long-term.
•ME stands for myalgic encephalomyelitis. Myalgic means muscle aches or pains. Encephalomyelitis means inflammation of the brain and spinal cord.

However, there is controversy about the nature of this condition. There is no test to diagnose the condition. The diagnosis is made in people who have a certain set of symptoms (which can vary in their type and severity). There is even controversy about what to call this condition.
•The term CFS is often used by doctors. This is because the main symptom is often fatigue and the condition is chronic (persistent). Also, there is no evidence of inflammation in the brain or spinal cord which is implied by the term encephalomyelitis.
•The term ME is the preferred term by many people with the condition. Some people with this condition feel that the word fatigue is an everyday word which does not reflect the different and severe type of fatigue that they have. Also, although fatigue to some extent occurs in most cases, it may not be the main or only symptom.
•Some people believe that there are two separate conditions – CFS and ME. Other people believe that the two conditions are the same – but symptoms can vary.

Until these issues are resolved, many people now use the umbrella term of CFS/ME.

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What causes chronic fatigue syndrome/ME?

The cause of CFS/ME is not known. There are various theories – but none has been proved. A popular theory is that a viral infection may trigger the condition. It is well-known that fatigue is a symptom that can persist for a short time after having certain viral infections. For example, infection with the glandular fever virus or the influenza virus can cause fatigue for several weeks after other symptoms have gone. However, most people recover within a few weeks from the fatigue that follows known viral infections.

Even if a viral infection is a trigger of CFS/ME, it is not clear why symptoms persist when there is no evidence of persisting infection. Also, the symptoms of many people with CFS/ME do not start with a viral infection.

Factors that are thought to contribute to some people developing CFS/ME include:
•Inherited genetic susceptibility (it is more common in some families).
•Viral infections such as glandular fever.
•Exhaustion and mental stress.
•Depression.
•A traumatic event such as bereavement, divorce or redundancy.

The following factors are thought to make CFS/ME worse:
•Recurring viral or bacterial infections.
•Not being active enough, or even being too active.
•Stress.
•Poor diet.
•Being socially isolated and/or feeling frustrated and depressed.
•Environmental pollution.

It is hoped that research will clarify the cause of CFS/ME in the future.

Who gets chronic fatigue syndrome/ME?

CFS/ME can affect anyone. It is estimated that CFS/ME affects about 1 in 300 people in the UK, possibly more. It is about three times as common in women as in men. The most common age for it to develop is in the early twenties to mid-forties. In children the most common age for it to develop is 13-15 years, but it can develop at an earlier age.

How is chronic fatigue syndrome/ME diagnosed?

There is no test that proves that you have CFS/ME. A doctor will usually diagnose CFS/ME based on your symptoms. Some tests are usually done to rule out other causes of your fatigue or other symptoms. For example, blood tests may be done to rule out anaemia, an underactive thyroid gland, and liver and kidney problems. All these tests are normal in people with CFS/ME.

The medical definition of CFS/ME states that symptoms should have lasted for at least four months in adults and three months in children and young adults.

What are the symptoms of chronic fatigue syndrome/ME?

The onset of symptoms can be fairly sudden (over a few days or so), or more gradual.

Fatigue

The most common main symptom is persistent fatigue (tiredness). The fatigue is of new onset. That is, it has not been lifelong but started at a point in time and causes you to limit your activities compared with what you were used to. It is often felt to be both physical and mental fatigue, and said to be overwhelming, or to be like no other type of fatigue. For example:
•It is very different to everyday tiredness (such as after a day’s work).
•It is not eased much by rest.
•It is not due to, or like, tiredness following overexertion.
•It is not due to muscle weakness.
•It is not loss of motivation or pleasure which occurs in people who are depressed.

The fatigue is often made worse by activity. This is called post-exertional malaise. However, the post-exertional malaise usually does not develop until the day following the activity. It then takes several days to improve.

Other symptoms

In addition to fatigue, one or more of the following symptoms are common (but most people do not have them all). In some people, one of the following symptoms is more dominant than the fatigue and is the main symptom:
•Mental (cognitive) difficulties such as poor concentration, poor short-term memory, reduced attention span, poor memory for recent events, difficulty to plan or organise your thoughts, difficulty finding the right words to say, sometimes feeling disorientated.
•Sleeping difficulties. For example, early waking, being unable to sleep, too much sleep, disrupted sleep/wake patterns.
•Pains – most commonly, muscular pains (myalgia), joint pains and headaches.
•Recurring sore throat, often with tenderness of the nearby lymph glands.
•A range of other symptoms has been reported in some cases. For example, dizziness, nausea (feeling sick) and palpitations.

Physical or mental exertion will often make your symptoms worse.

Severity of symptoms

The severity of CFS/ME can roughly be divided into three levels:

Mild cases – you can care for yourself and can do light domestic tasks, but with difficulty. You are still likely to be able to do a job, but may often take days off work. In order to remain in work you are likely to have stopped most leisure and social activities. Weekends or other days off from work are used to rest in order to cope.

Moderate cases – you have reduced mobility and are restricted in most activities of daily living. The level of ability and severity of symptoms often varies from time to time (peaks and troughs). You are likely to have stopped work and require rest periods. Night-time sleep tends to be poor and disturbed.

Severe cases – you are able to carry out only minimal daily tasks such as face washing and cleaning teeth. You are likely to have severe difficulties with some mental processes such as concentrating. You may be wheelchair-dependent for mobility and may be unable to leave your home except on rare occasions, and usually have severe prolonged after-effects from effort. You may spend most of your time in bed. You are often unable to tolerate any noise, and are generally very sensitive to bright light.

Note: most cases are mild or moderate.

What is the treatment for chronic fatigue syndrome/ME?

There is no known cure for CFS/ME although treatment may help to ease symptoms. You are likely to be referred to a specialist who will be able to offer you support and treatment. Treatments that may be considered include the following.

Management of your symptoms

Painkillers may help if muscle or joint pains are troublesome symptoms. Eating little and often may help any nausea. Specific diets have not been shown to be beneficial.

Depression can occur in people with CFS/ME (as it is with many other chronic diseases). Depression can make many symptoms worse. Antidepressants may be prescribed if depression develops.

Management of your quality of life and function

Managing your sleep

It is likely you will be given advice about your sleep. Any changes to your sleep pattern (for example, having too little, or even too much, sleep) may actually make your fatigue worse. This includes sleeping in the daytime, which should ideally be avoided. Any changes to your sleep pattern should be done gradually.

Managing rest

Rest (rather than actual sleep) is very beneficial. You should introduce rest periods into your daily routine. These should ideally be limited to 30 minutes at a time and be a period of relaxation.

Relaxation

Relaxation can help to improve pain, sleep problems and any stress or anxiety you may have. There are various relaxation techniques (such as guided visualisation or breathing techniques) which you may find useful when there are built into your rest periods.

Diet

It is very important that you have a well-balanced diet. You should try to avoid any foods and drinks that you are sensitive to. Eating small, regular meals which contain some starchy foods is often beneficial.

Specific treatments

One or more of the following may be recommended as part of your treatment:

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Graded exercise therapy

Graded exercise therapy (GET) means a gradual, progressive increase in exercise or physical activity, such as walking or swimming. The level of exercise recommended will depend upon your symptoms and current level of activity. Graded exercise is a structured treatment during which you are closely monitored. It is not the same as going to the gym or doing more exercise by yourself. It should be tailored to suit each individual case. Ideally, it should be supervised by a physiotherapist or occupational therapist who is used to treating people with CFS/ME.

Graded exercise can improve symptoms for some people. However, some people report that they do not find it beneficial.

Cognitive behavioural therapy

Cognitive therapy is based on the idea that certain ways of thinking can fuel certain health problems. Behavioural therapy aims to change any behaviours that are harmful or not helpful. Cognitive behavioural therapy (CBT) is a combination of cognitive and behavioural therapy. The use of CBT does not imply that the cause of an illness is psychological. CBT is one of the most effective treatments for CFS/ME.

Although CBT does not aim to cure the condition, it helps to improve symptoms, coping strategies and day-to-day functioning. For people with CFS/ME the core components of CBT would normally include: energy/activity management, establishment of a sleep routine, goal setting, and psychological support.

So which specific treatment is most effective? A large research trial was published in 2011 which compared the two treatment options listed above. 641 people with CFS/ME (but who were not bed-bound) took part in the trial. They were split into four groups. One group received standard medical care alone. The other three groups received standard medical care plus Adaptive Pacing Therapy (APT), or CBT, or GET. Adaptive pacing therapy was invented for the trial and is used as a control, just for comparison. After one year the results showed that 41 in 100 people had improved with CBT, and 41 in 100 had improved with GET. With normal medical care, 25 in 100 people had improved and 31 in 100 for the APT group. The conclusion of this study was that CBT and GET were the most effective treatments, but there was only small benefit over normal medical care. Also, that APT was unlikely to give any extra benefit to normal medical care.

It was also worth noting in this trial that all the treatments had limited effects. Yes, it was found that a good number of people improved (had less severe symptoms) with each treatment. However, only about 3 in 10 people treated with CBT or GET in this trial (the treatments found to be most effective) recovered fully.

General support

Depending on the severity of illness, other support may be needed. For example, carers, nursing support, equipment and adaptations to the home to help overcome disability.

If you are employed, your doctor will be able to advise you about whether you should take time off work. And, if you take time off work, when you may be ready to go back to work. It may be that you need to work doing slightly different hours or even with different duties. If you have an occupational health department at work, they are likely to be involved with you also regarding work and going back to work if you take time off.

Complementary treatments

As there is only limited success with conventional treatments, it is understandable that people turn to complementary practitioners. Many people with CFS/ME find various therapies helpful. However, there is not enough research evidence to support the use of complementary therapies for the treatment of CFS/ME.

There is also insufficient evidence to recommend the use of supplements (for example, vitamins).

Managing setbacks (relapses)

It can be common to have setbacks when symptoms become worse for a while. These can have various triggers – for example, poor sleep, infection or stress.

Your doctor may discuss with you strategies which may help during a setback. These may include relaxation techniques, talking with your family, and maintaining your activity and exercise levels, if possible. However, it may be necessary for you to reduce or even stop some of your activities and increase the amount of rest you have during a setback.

Following a setback you should usually be able gradually to return to your previous activity level.

What is the outlook (prognosis)?

In most cases, the condition has a fluctuating course. There may be times when symptoms are not too bad, and times when symptoms flare up and become worse (a setback). The long-term outlook is variable:
•Most people with CFS/ME will show some improvement over time, especially with treatment. Some people recover in less than two years, while others remain ill for many years. However, health and functioning rarely return completely to previous levels.
•Some people will continue to have symptoms or have relapses of their symptoms.
•In some cases, the condition is severe and/or persists for many years. Those who have been affected for several years seem less likely to recover.
•The outlook in children and young people is usually better.

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What are the symptoms of phobia?

If you come near to, or into contact with, the feared situation you become anxious or distressed. In addition you may also have one or more unpleasant physical symptoms. These can be, for example, a fast heart rate, palpitations, feeling sick, shaking (tremor), sweating, dry mouth, chest pain, a ‘knot in the stomach’, and fast breathing.

The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

You may even become anxious by just thinking of the feared situation. You end up avoiding the feared situation as much as possible, which can restrict your life and cause suffering.

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There are different types of phobia

Social anxiety disorder

This is also known as social phobia and it is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or ‘performing’ in front of other people, especially strangers. You fear that you will act in an embarrassing or humiliating way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. See separate leaflet called Social Anxiety Disorder for more details.

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Agoraphobia

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Agoraphobia

This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations.

For example, you may have a fear of:
•Entering shops, crowds, and public places.
•Travelling in trains, buses, or planes.
•Being on a bridge or in a lift.
•Being in a cinema, restaurant, etc, where there is no easy exit.

But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become anxious and distressed, and have an intense desire to get out. Therefore, to avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time. See separate leaflet called Agoraphobia for more details.

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Other specific phobias

There are many other phobias of a specific thing or situation – for example:
•Fear of confined spaces or of being trapped (claustrophobia).
•Fear of certain animals.
•Fear of injections or needles.
•Fear of vomiting.
•Fear of being alone.
•Fear of choking.
•Fear of the dentist.
•Fear of flying.

However, there are many others, some quite rare.

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What is the treatment for phobias?

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) helps you to change certain ways that you think, feel and behave. It is a useful treatment for various mental health problems, including phobias.
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety, depression and phobias. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or attitudes which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your response to the feared object (anxiety and avoidance) is not helpful. The therapist helps you to change this. Various techniques are used, depending on the condition and circumstances. For example, for agoraphobia the therapist will usually help you to face up to feared situations, a little bit at a time. A first step may be to go for a very short walk from your home with the therapist who gives support and advice. Over time, a longer walk may be possible, and then a walk to the shops, then a trip on a bus, etc. The therapist may teach you how to control anxiety when you face up to the feared situations and places. For example, by using deep breathing exercises. This technique of behavioural therapy is called exposure therapy where you are exposed more and more to feared situations, and learn how to cope.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.

CBT is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious.

Note: unlike other forms of talking treatments (psychotherapy), CBT does not look into the events of the past. CBT aims to deal with your current thought processes and/or behaviours, and helps to change them where appropriate.

CBT usually works well to treat most phobias, but does not suit everyone. However, it may not be available on the NHS in all areas. See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.

Antidepressant medicines

These are commonly used to treat depression, but they also help to reduce the symptoms of phobias (particularly agoraphobia and social phobia), even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and anxiety is helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good and it is too early to tell if the medication is working.
•Antidepressants are not tranquillisers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons and they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety and phobic disorders. Examples of SSRIs are escitalopram and sertraline.
•Note: after first starting an antidepressant, in some people anxiety symptoms can become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first weeks of treatment to see how you manage.

A combination of CBT and an SSRI antidepressant may work better in some cases than either treatment alone.

Benzodiazepines

Benzodiazepines such as diazepam are sometimes called minor tranquilizers but they can have serious side effects. They often work well to ease symptoms of anxiety. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not a useful long-term treatment of phobias. However, a short course, or even a single dose, may be useful for a phobia which occurs rarely. For example, if you have a fear of flying in a plane, a short course just before a flight may help.

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Schizoaffective disorder was first described in the 1930s. This psychiatric condition has features of both schizophrenia and mood disorders, eg depression. Questions have been raised about whether it truly exists as a disease entity, although the term is still in common use by psychiatrists.[1][2]

The cause is unknown. Various factors have been mooted, including genetic[3], nutritional, viral, prenatal and metabolic (involving neurotransmitter dysfunction).[4]

Epidemiology

Schizoaffective disorder is less common than schizophrenia – there are no figures on the incidence and prevalence in the United Kingdom.

Schizoaffective manic patients have been reported to comprise 3-5% of all patients admitted to typical psychiatric hospital units.

The condition commonly presents in early adulthood and women are more often affected.

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Diagnosis[5]
•Schizoaffective disorder occurs when, during the same illness, there is major depressive, manic or a mixed episode. This occurs along with the symptoms of schizophrenia.
•Delusions or hallucinations need to be present for at least two weeks when the mood symptoms are not present.
•Symptoms of mood disturbance are present for a significant length of the illness.
•The disturbance is not due to other causes, eg organic illness, substance misuse, medication (see ‘Differential diagnosis’, below).

The schizoaffective illness can be described as:
•Bipolar type – when a manic or a mixed episode occurs.
•Depressive type – the illness has mainly depressive episodes.

Presentation

This can be divided into major depressive episode, manic episode, mixed episode and schizophrenia.[5]

Major depressive episode
Five of the following symptoms should be present for at least two weeks. One symptom must be either depressed mood or loss of interest or pleasure: •Depressed mood.
•Decreased pleasure in activities.
•Weight loss or weight gain or appetite change.
•Insomnia or hypersomnia.
•Psychomotor agitation or retardation.
•Fatigue.
•Feelings of guilt or worthlessness.
•Decreased concentration.
•Recurrent thoughts of death or suicidal notions.

Manic episode
Persistently elevated or irritable mood for at least one week. Three of the following need to be present (or four if the patient has an irritable mood): •Inflated self-esteem or grandiosity.
•Reduced need for sleep.
•Pressure of speech.
•Flight of ideas and racing thoughts.
•Easily distracted.
•Increase in goal-directed activity with psychomotor agitation.
•Excessive involvement in high-risk activities, eg shopping sprees.

Mixed episode
Features of both manic episode and major depressive episode are present – but only for one week.
Schizophrenia symptoms
Two or more of the following are present during one month of the illness: •Delusions – if bizarre, then no other symptoms are required to make the diagnosis.
•Hallucinations – if in the form of a running commentary or two voices, then no other symptoms are necessary to make the diagnosis.
•Speech abnormalities, eg incoherent speech and/or speech derailment.
•Behavioural abnormalities, eg disorganised or catatonia.
•Negative symptoms, eg apathy or lack of emotions.

Differential diagnosis

It is important to ascertain that the disorder is not caused by any underlying process. Main groups of differentials include:
•Substance misuse, eg cannabis.
•Organic illness, eg hypothyroidism, delirium.
•Medication side-effects.
•For a depressive episode, it is necessary to ensure that it cannot be explained by recent life events, eg recent bereavement or loss of employment.
•Other psychiatric illness, eg dementia, delusional disorder.

Investigations

This will mainly be to rule out underlying causes and may include:
•Baseline bloods: FBC, renal and liver function, TFTs, HIV test.
•Urine or plasma toxicology.
•CXR to exclude pneumonia in the elderly.
•Other imaging if clinically indicated, eg patients with abnormal neurology may require CT or MRI scanning.

Associated problems

Patients affected by schizoaffective disorder can also have a number of other problems. These can include:
•Learning difficulties.
•Abnormal personality, eg antisocial or dependent.
•Psychosis.

Complications
•Poor social integration and function.
•Self-neglect.
•Difficulties with relationships.
•Substance misuse, eg alcohol.
•Suicidal behaviour.
•Homicidal thoughts.

Management[4]

Urgent hospital admission should be arranged for patients who are thought to be a threat to themselves or others, or who are too disabled to care for themselves.

Community services may be vital in keeping patients out of hospital or in managing the step-down into the community after hospital discharge. Specialist services which may be required include community psychiatric nursing and occupational therapy as well as more pragmatic support such as transport to and from hospital appointments, pharmacy delivery services and help in managing domestic and financial affairs.

There are few large trials that have specifically studied the drug treatment of schizoaffective disorder and there are no consensus guidelines. Treatment is based largely on the treatment of schizophrenia.[1] Antipsychotics are the mainstay of treatment, sometimes combined with psychological therapies.

Treatments can be divided as:
•Treatment of an acute exacerbation of schizoaffective disorder – antipsychotics are useful and it may be that atypical antipsychotics have some qualities superior to typical antipsychotics, eg risperidone or olanzapine.
•Long-term treatment of schizoaffective disorder – this involves the use of antipsychotics with psychological treatments. Antipsychotics improve patients with schizoaffective disorder, being more efficacious in those with bipolar type. Atypical antipsychotics may be more effective in schizoaffective disorders but more research is required here. Clozapine is sometimes used in resistant cases.
•Treatment of ongoing depressive symptoms in schizoaffective disorder – in this situation a trial of antidepressants is warranted and these may need to continue for longer periods of time. Sertraline or fluoxetine are often used. Occasionally, electroconvulsive therapy may be required.
•Mood stabilisers such as lithium may be useful in the bipolar type. Carbamazepine and valproic acid are other drugs in this category which have been used with some good results.

Psychological treatments involve – cognitive behavioural therapy, family interventions, counselling, art therapy and supportive psychotherapy. This is similar to the treatment of schizophrenia. The National Institute for Health and Clinical Excellence (NICE) in fact includes schizoaffective disorder as one of the ‘negative symptoms’ of schizophrenia and recommends psychological treatment accordingly.[6]

Prognosis

The bipolar type of schizoaffective disorder has a better prognosis than the depressive type, as the latter usually results in long-term mood disturbances.

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