Mental Health Awareness In The Church, Thembalethu, November 2017

  1. ANTHROPOLOGY

From a Christian perspective, the way we view human beings plays a role in how we view mental health. My own roots lie in the Reformed tradition and my views are from a Western cultural perspective. Neither the Reformed tradition nor the Western perspective are homogeneous in thinking – in all traditions and cultures there can be vast differences within any one tradition and culture. Although I mention my own background, I am personally of the belief that much of this background is true only in theory. We live with an explosion in ways of communication today, making knowledge widely available in a deeply pluralistic world. My own thoughts and views are constantly influenced by many different people, authors, disciplines and views from all traditions and cultures, which makes it difficult to think of myself only in terms of a particular tradition and culture.
Not only the Christian tradition, but also psychology as a discipline has developed different schools of thinking about human beings. The views of the Christian tradition are based on the interpretation of the Bible and those of psychology on research. The philosophical traditions of different times also have an important influence on both religious and psychological thinking.
The anthropological model, which, in my opinion, helps us best to integrate knowledge gained from both Bible interpretation and psychology, is a unitary model. This sees human beings as a unity so that part of being human means that we cannot live in isolation, that we are part of the systems around us, like family and community.

“The health of the whole society and the health of each individual are inextricably linked together.”

The complexity of dealing with a unitary view of human beings often successfully misleads us into dealing with each other in terms of only one dimension of a person. The practice of medicine is often guilty of dealing with only the physical body, while in the church, we are guilty of dealing with the person as only a spiritual being, with a so-called separate soul. Our overemphasis of only one aspect has often cast psychology and theology as opposites – rather than merely different – in our approaches to personhood.
A unitary anthropological approach is aware of the Greek influence in reading the Bible. The Greek philosopher Plato thought about humans in terms of soul and body. In his view, the soul is immortal and is the good part of the human, while the body is the mortal part, within which we keep the soul imprisoned. For Plato, it is the soul and the spiritual that are important, while the physical world of matter and the body are less important.
The Bible also uses words like soul, body, and spirit – like Plato did – and for a very long time these words were interpreted in terms of Greek philosophy. Through the ages, many scholars have challenged the interpretations of these words in the light of the Bible as a whole. While Greek philosophers had very specific interpretations of these words (body, soul, spirit), Biblical authors used these words in different contexts both differently and interchangeably. It would seem that, in the Bible, there were actually not such fixed views for these words.
Instead, there is much more of a holistic view of humankind in the Bible than was originally thought. The whole of reality belongs to God and there is not a bad physical reality and good spiritual reality.
The authors of the New Testament do not refer to “soul” as a separate entity, but to the fact that we are living beings. This is also visible in many translations where the original “soul” is translated as “life” (John 10:11; Matt 2:20). In the NT, the word “spirit” refers to the ability to communicate with God and to serve God (Rom 1:8-9; Rom 8:15-16). Other similar words used in the NT are “heart” (Matt 6:21); “conscious” (Rom 2:15); and “mind” (Luk 24:45).

“Die Griekse filosowe sou sê: ’n Mens het ’n siel en het ’n liggaam, terwyl die skrywers van die Ou en die Nuwe Testament eerder sou sê: ’n Mens is siel, is liggaam, is gees …”. [The Greek philosophers would say: A human being has a soul and has a body, while the writers of the Old and New Testament would rather say: A human being is a soul, is a body, is a spirit …]

The body refers to that part of us that consists of physical matter which we can touch and which we bury at death. Intertwined with our body is that part of us that represents our emotions and our spiritual dimension. This close interaction is especially clear in the interaction of what happens in our brain.
The human brain is one of nature’s most complex structures and scientists are still a long way from understanding its mechanics. The human brain is a “multi-dimensional” universe full of complicated geometric shapes. The mind is home to shapes and structures that have as many as 11 dimensions. This is strange to us, who often struggle to think in terms of just three dimensions. Shapes that are three-dimensional have height, width and depth, like any object in the real world.
The more complex geometric shapes in the brain form when a group of brain cells – known as neurons – merge to make what scientists call a “clique”. Every neuron connects to its neighbour in a specific way to form an object with complex interconnections. The more neurons that join in with the “clique”, the more “dimensions” the object has.
The mind is seen as the seat of our consciousness, the essence of our being. Traditionally, the mind is described as the product of brain activity; of the firing of neurons. We have now come to understand that the mind is much more than its physical activity. Our minds extend beyond our physical selves. In other words, your mind is not simply your perception of experiences, but those experiences themselves. It is impossible to completely disentangle our subjective view of the world from our interactions (Dan Siegel).

“Siegel realized the mind meets the mathematical definition of a complex system in that it’s open (can influence things outside itself), chaos capable (which simply means it’s roughly randomly distributed), and non-linear (which means a small input leads to large and difficult to predict result). In math, complex systems are self-organizing, and Siegel believes this idea is the foundation to mental health. Again borrowing from the mathematics, optimal self-organization is: flexible, adaptive, coherent, energized, and stable. This means that without optimal self-organization, you arrive at either chaos or rigidity—a notion that, Siegel says, fits the range of symptoms of mental health disorders… Finally, self-organization demands linking together differentiated ideas or, essentially, integration. And Siegel says integration—whether that’s within the brain or within society—is the foundation of a healthy mind.”

From a neuroscientific perspective, the brain and body is constantly in flux. The brain and the body work together in the context of our physical environment to create a sense of self.
When we discuss mental health problems or unhealthy and dysfunctional behaviour, it is important to work with a holistic view of the person. Spirituality does not function as something separate from an integrated part of being a person. We cannot care for the soul as if it is something separate from the whole being. We cannot care for the body as if it is soulless.
Unfortunately, when emotional problems are dealt with and approached from an isolated spiritual prespective, such as by the church, they are exacerbated.

2. HISTORICAL REVIEW

Mental illness have been feared, mocked and made fun of for many ages. These attitudes towards mental illness reflect the views and dominant culture of specific periods. For very long periods of time, mental illness was associated with religious possession, witchcraft and sorcery.
Mental illness isn’t a uniquely modern phenomenon. The genetic influences that stand behind some types of mental illnesses, along with the physical and chemical assaults that can spark illnesses in some people, have always been part of human life. But the ways in which the people affected are treated by their peers, as well as the help ill people might get from their doctors, have undergone a significant revision. In fact, the ways in which modern cultures both understand and deal with mental illnesses have undergone a radical transformation. However, much work remains to be done if people who have mental health concerns are to reach their true potential.
2.1 PREHISTORIC TIMES (2000 BC)
Mystical views dominate this period. There was no division between health care, magic, and religion. And no understanding of why diseases occurred. Strange behaviour was attributed to the supernatural. Treatment included spells cast by shamans, exorcisms of evil spirits.
2.2 GREEK-ROMAN ERA (8TH CENTURY BC – 5TH CENTURY AD)
Ancient civilisations like the Romans and Egyptians considered mental health problems to be of a religious nature, although numerous mental problems were identified, like mania; dementia; delusions and hallucinations, and what was known as hysteria.
Some thought a person with a mental disorder might be possessed by demons, and thus prescribed exorcism as a form of treatment.
Traditionally there was a strong belief in unnatural forces in the air. It was built on an encompassing belief that there is no distinction between the spiritual and the physical or material worlds. In this understanding everything is spiritual: animals, mountains, plants, rocks, rivers, thunder, wind, and even shadows.
Unnatural forces were used as an explanation for all sorts of things that happened in nature and also for people’s behaviour. The way to deal with it was through rituals and ceremonies. Often, forms of blood-letting were used to get rid of evil spirits. Individuals were often offered and burned alive to make sure the evil spirits did not infect the community. When something bad happened to a community, it was important to find someone to carry the blame.
In the time of the Greeks (8th century BC – 600 AD), many gods existed. Emotional disintegration was seen as a sign from the gods.
It was only from about the 5th century BC that the focus changed to the individual and that attempts were made to understand the individual. The Greek physician Hippocrates (460-367 BC), separated the discipline of medicine from religion and rejected the belief that illness is a punishment from the gods. He believed that mental illness was physiologically connected. He was credited with the belief that diseases were caused by certain dysfunctions of the body and were also the product of environmental factors, diet and living habits. Medicine at the time knew almost nothing of human anatomy and physiology because of the cultural taboo against the dissection of humans.
In the era of the Romans (100 BC 500 AD) the idea that our emotions can caused certain mental disturbances was acknowledged. The Romans Cicero and Soranus already suggested that it was important to talk about your problems to prevent mental disturbances.
2.3 MIDDLE AGES (5TH TO 15TH CENTURY AD)
This period describes the era of the diminishing influence of the Roman empire. In Rome, the power shifted from the Caesar towards the Pope.
The Christian worldview influenced the thinking of the Western world in this period. The Christian philosophy of the time, influenced by Greek philosophy, made a clear distinction between soul and body; the spiritual and the material. The immortality of the soul and a better life after death was also emphasised. The focus was not on the body, but on the existence of the soul. Many cathedrals were built, demonstrating belief in the church.
In the late 12th to early 13th century, reaction against the church’s powerful position started to develop. People started to question the power and authority of the church. Under the influence of universities in Europe, people started to change their views. This was also the time of seafarers discovering new continents. More new discoveries would follow in the years to come. In certain quarters, the church reacted to the movement away from the church. A new interest in evil and evil powers grew. Many people with different views were seen as witches and put on trial for witchcraft. In this atmosphere, people with mental health problems were isolated and locked up in dungeons.
To summarise: There were strong arguments for the existence of witches. People were trained to identify witches and how to treat witches and devil-possessed people. The salvation of the immortal soul was more important than the comforts of the possessed body, so terrible physical punishment was acceptable to get rid of the devil. Instruments of punishment existed.
2.4 THE AGE OF REASON
A number of important things happened during and after the 15th century. The printing press of Johannes Gutenberg (1440) revolutionised the duplication of information. By 1500 several cities in Europe had printing presses and an estimated twenty million copies of books were already printed. The Reformation, represented by Martin Luther, is dated to 1517 when he challenged the homogeny and power of the Catholic Church. In the world of science, new views were developed. Nicolaus Copernicus (1473-1543) developed his theory that the sun – and not the earth – was at the centre of the (known) universe.
• 1407: The first facility specifically for mental health is established in Spain.
• Since the 16th century people with psychological disorders were diagnosed with an illness, but they were seen as dangerous and locked up and mostly neglected.
• 1700s: Advocacy for mentally ill persons occurred in France. Phillipe Pinel, displeased with the living conditions in hospitals for those with mental disorders, ordered a change of environment. Patients were allowed time outside as well as more pleasant surroundings, like sunny rooms. He forbade the use of shackles or chains as restraints.
Unfortunately there was still a general belief that “mad” people were like animals and should be treated like animals, which was shared even by some medical practitioners. In the eyes of the law, mentally ill people were discriminated against. Somebody had to be appointed as their guardian.
• 1800: Separate institutions, called asylums, were built to house those who some referred to as “lunatics”.
Mental illness was still considered by many as a moral weakness and there were still those who believed that mentally ill people were possessed by the devil.
• 1840s: American Dorothea Dix fights for better living conditions for the mentally ill. For over 30 years she lobbies for better care and finally gets the government to fund the building of 32 state psychiatric facilities.
• 1883: German psychiatrist Emil Kraepelin studies mental illness and begins to draw distinctions between different disorders. His notes on the differences between manic-depressive disorder and schizophrenia are still used today.
• Early 1900s: Using psychoanalytical theories, Sigmund Freud and Carl Jung treat their patients for mental illness. Many of the theories they employed are still in use and discussed today as well as being used as a basis for the study of psychology.
• From the 1930s medical treatment for those with mental illness developed. Some of the methods, like the full-scale removal of teeth and the induction of fevers and hypothermia, we all frowned upon today.
By the late 1950s and early 1960s, new medications began to change the face of psychiatry. First-generation anti-psychotic medicine profoundly improved the lot of institutionalised psychotic patients, as did newly developed antidepressants for the severely depressed.
In 1952 the first edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders was published. It used a glossary of descriptions of the diagnostic categories and was the first official manual of mental disorders to focus on clinical use.
In 1980, the DSM was radically revised by the American Psychiatric Association. Patients were thereafter diagnosed by “meeting criteria” for one or more defined disorders. But this was not without controversy – which is not yet fully resolved.
Although many psychiatrists and psychologists hold a very balanced view, there exists a rift between biological psychiatry and psychotherapy.
Research took on new dimensions with the development of brain scans. But it is equally clear that we are nowhere near yet being able to analyse and treat human psychology at the neural level. The distinction between the medical and psychological approaches will likely become less sharp in the years ahead as particular genetic or other biological differences are linked to psychological vulnerabilities. Nonetheless, the uneasy tension between biological and psychological psychiatry will not end soon, and we are better off embracing this instead of choosing sides. It is to be hoped that psychiatry would keep on claiming a wide purview, from the cellular basis of behaviour, to individual psychology, to family dynamics, and finally to the community and social phenomena that affect us all.
A holistic view of the person is important in this regard.
3 THE WORLD WE LIVE IN
We are each the product of millions of years of evolution. For many centuries our main concerns were the basic necessities, like the provision of adequate food, shelter and safety, and submitting primitive wisdom and skills to the next generation. The process of change and the speed of adaption were relatively slow. Change took place over centuries. This does not mean that life was easy and without tremendous challenges.
The last five hundred years brought a tremendous acceleration in the pace of change. Modern society is fast changing and most people struggle to keep up. The rate of progress in technology and the comprehensive way in which changes takes place – not only in one sector, but all sectors of society – require a different approach to life from us. Society is more complex and there are so many more choices. Many of them demand new knowledge, skills and competencies. This leaves us with little room for either contemplation or complacency.
These changes have an effect on countries, communities, families and the individual. There are shifts in the structure and values of communities and many forms of traditional support disappear or are not relevant anymore.
The stress levels of people are rising, which can be seen in the massive amounts of tranquillising chemicals society consumes. Some of these are prescription drugs, while others are non-prescriptive, like alcohol and illegal drugs.
4 HEALTHY AND UNHEALTHY ACTIONS
I prefer to use the words healthy/ functional and unhealthy/ dysfunctional actions rather than the terms “normal” and “abnormal”. Unhealthy/ dysfunctional behaviour interferes with the wellbeing of the individual, the family or community. Unfortunately, I do not have an alternative for the term “disorder”, which is widely in use in psychology and psychiatry.
Although psychiatry handbooks set out criteria to help us to determine what are healthy and unhealthy actions, there is still a large grey area requiring interpretation. It can sometimes still be difficult to determine whether a person’s actions are healthy or unhealthy. We are all different and our make-ups (personalities) are different. Culture also has an influence on our behaviour.
We must learn to make a distinction between a person who is eccentric, meaning he/she does things or thinks differently from others, and a person who acts in unhealthy ways. Dysfunctional behaviour consists of more than only deviating from society’s norms. The question is not whether society accepts forms of behaviour, but whether the outcome of forms of behaviour fosters wellbeing and fulfilment rather than destruction.
We are more than only the physical bodies we can touch and weigh. We have an emotional side, often described in terms of our consciousness. My physical body and my emotional side interact with each other. When a person gets the message of the death of a loved one, the physical response can be that of tears. It is not the tears that make the person sad. We also shed tears when we slice an onion or because of hay fever. It is the inner consciousness of loss and sorrow that causes the physical reaction of crying. We cannot determine how deep that sorrow is just by looking at the number of tears. A person who shows more tears or cries harder than others does not necessarily feel the most pain. Some people will more often show their pain in outward, external forms than others. Inner pain cannot easily be measured.
We each have a personality with a self-consciousness of who we are and our own particular ability of self-management. This means we are able to decide to do or not to do certain things: to take decisions in terms of right and wrong, good and bad. Our personality makes each of us a unique person. That makes us different from an animal which reacts only to its instincts, or a computer that is programmed.
We can think of our behaviour, within our culture and context, as being on a continuum – with healthy behaviour at one end and unhealthy behaviour at the other end. Unhealthy/ dysfunctional actions and behaviour point in the direction of a possible illness that requires treatment.
Disintegration of behaviour becomes visible when this psychosocial-physical unity of the patient starts to change or becomes disorganised. This is when a person has less self-control, less ability to act purposefully and often acts aimlessly. A person might be under pressure to act in a particular way even to the point where it becomes an involuntary action.
It is quite possible that a person can be aware of this disintegration of their behaviour. A person may experience feelings of uncertainty, that things have become too much; a lack of concentration; difficulty in thinking things through; emotional over-reactions, and they cry easily. It is also possible that the opposite can happen – feeling emotionally dead and experiencing no deep feelings at all. There can be an over-dependence on others or emotional outbursts and other violent reactions. Heightened levels of anxiety are easy to recognise.
It may also be that a person does not become aware of the changes in their behaviour and attitude, but that those who are in close contact with them, like family members or colleagues at work, become aware of this disintegration of behaviour.
It is also possible that these events will last only a day or two, or a week or two. You can receive terrible news and experience a disintegration of behaviour and actions for only the next day or two, before becoming your “old self”, or experiencing the integration of your personhood, again.
5 CATEGORIES OF DISORDERS/ DISINTEGRATION
The individual is a functional unit and it is artificial to constantly try to determine whether behaviour is caused by organic or psychological reasons. This becomes clear when a well-integrated person withstands brain damage better than a rigid, immature person. However, since the nervous system is the centre for the integration of behaviour, there are limits to the amount of brain damage an individual can tolerate without exhibiting impaired functioning. The bottom line is that we should think holistically about the causes and treatment of different disorders. How exactly the interaction takes place between what we identify as biological/ organic factors and psychosocial factors is unknown to us.
But to help us to make sense of the huge amount of information, we unfortunately have to use specific diagnostic criteria and divisions. The Diagnostic and Statistical Manual (DSM) of Mental Disorders is an attempt to formulate objective criteria and it has been referred to as a tool and universal authority for the purposes of psychiatric diagnoses. It is important to have criteria serving as protocols, including to safeguard clients. A psychiatrist in South Africa and one in Nigeria, for example, should use the same criteria to diagnose a condition. At the same time, the majority of clinicians (psychiatrists and psychologists) would agree that you cannot use the criteria in isolation. You have to clinically evaluate a person in his/her own context. In the human sciences, objectivity should be seen differently, because of the complexity of human beings. It is thus not strange that each new edition of the DSM contains major changes to the previous one.
The disorders we discuss here occur in all societies and cultures. Rich and poor, young and old, male and female – are all at risk.
6 ORGANIC MENTAL DISORDERS
Conditions with a severe destruction or malfunctioning of the brain. The severity depends on the area of the brain affected.
6.1 SYMPTOMS
a) Memory or other intellectual impairment
b) Impairment of orientation – time and place
c) Impairment of learning, comprehension, judgement
d) Emotional impairment – over-reactivity
e) Movement interference: being catatonic – with disturbances in motor (muscular) movement; immobility, or a rigid positioning of the body.
f) Delirium – rapid onset of disorganisation of mental processes; disturbance in brain metabolism
g) Psychotic episodes (a loss of contact with reality)
h) Personality change; impairment in moral and ethical sensibilities
6.2 CAUSES
• Dementia; lack of oxygen; high fevers; nutritional deficiencies; drug intoxication; injuries; diseases (syphilis; meningitis); strokes; tumours
7 ANXIETY-BASED DISORDERS
Everyone feels anxious or nervous once in a while. That is normal. But being extremely anxious or worried for most days for six months or longer is not normal. This is called “generalised anxiety disorder”. The disorder can make it hard to perform everyday tasks.
There is a generalised feeling of fear and apprehension. This fear is unrealistic, irrational, of disabling intensity and lasts for several months. It is not confined to a single life circumstance.
Persons with an anxiety disorder live in a constant state of tension, worry, and diffuse uneasiness. They are oversensitive in interpersonal relationships, feel inadequate and depressed and struggle to make decisions.
People with extreme or severe anxiety feel very worried or “on edge” much of the time. They can have trouble sleeping or forget things. Plus, they can have physical symptoms. For instance, people with severe anxiety often feel very tired and have tense muscles. Some get stomach aches or feel chest “tightness”.
The question to ask yourself is:
* Is there a change in how anxious I am? Am I more anxious than previously?
* Do I get overly anxious about things that other people handle more easily?
Is there anything I can do on my own to feel better?
a) Exercise can help many people feel less anxious.
b) It’s also a good idea to cut down on or stop drinking coffee and other sources of caffeine. Caffeine can make anxiety worse.
c) Make an appointment at your clinic or doctor.
Treatment can include a combination of therapy and medicine.
There is no reason to feel embarrassed about being treated for anxiety. Anxiety is a common problem. It affects all kinds of people.
Keep in mind that it might take a little while to find the right treatment. People respond in different ways to medicines and therapy, so you might need to try different approaches before you find the one that helps you best. The key is to not give up and to let your doctor or nurse know how you feel along the way.
People with anxiety disorders often have to deal with some anxiety for the rest of their life. For some, anxiety comes and goes, but gets worse during times of stress. The good news is, many people find effective treatments or ways to deal with their anxiety.
7.1 PANIC ATTACKS
Shortness of breath, palpitations, sweating, dizziness, etc.
Panic disorder is a condition that can make a person feel very scared and anxious for short periods of time. When this happens, it is called a “panic attack”. The attacks can also cause chest pain and breathing problems, leading people to visit doctors or emergency rooms.
● Feeling very scared and nervous; fear of dying; fear of fear; fear of places or situations (agoraphobia).
● Have physical symptoms such as: chest pain; shortness of breath; a fast heartbeat; headache; stomach ache; dizziness; excessive sweating
These attacks happen without warning and can last several minutes to an hour.
People with panic disorder might also:
● Worry about having panic attacks in the future
● Avoid situations that might cause them to have a panic attack
● See doctors or go to emergency rooms when they have panic attacks
Treatment includes therapy and medicine.
7.2 OBSESSIVE-COMPULSIVE DISORDER (OCD)
The prevalence of OCD is between 1 and 2 percent. In adulthood, females are affected at a slightly higher rate than males, although males are more commonly affected in childhood.
It often occurs with other forms of anxiety disorders, with 76 percent of those affected having a lifetime history of, for example, panic disorder, social anxiety disorder, generalised anxiety disorder, and specific phobias.
It also goes hand in hand with other disorders; 63 percent of those affected have a lifetime history of a mood disorder, most commonly major depressive disorder (41 percent). And 23 to 32 percent have a co-morbid obsessive-compulsive personality disorder. Up to 29 percent of individuals with OCD seeking treatment have been found to have a lifetime history of a tic disorder, especially in males who had an onset of OCD in childhood.
Many people have low levels of an obsession and/or compulsion, but function reasonably well. Certain kinds of work require such precision that some level of over-perfectionism is actually necessary to do the work properly. Historically there are many examples of people who succeeded because of an obsession to reach their goal. Columbus persisted for 18 years in his efforts to secure financial backing for his expedition to the Indies (Asia) – and although he didn’t reach Asia, he came across the Americas instead. Darwin assembled evidence for 22 years before he would present his ideas on evolution.
Problems arise when a person experiences thoughts and behaviour as involuntary, which consumes excessive time or interferes with occupational and social functioning. The person will also experience distress, which is to say, excessive stress.
Other examples are obsessive thoughts that do not lead to any action. The thoughts become a source of torment for the person. Examples are thoughts of committing immoral acts; attempting suicide; or poisoning a person whom the client actually loves.
In general, the performance of compulsive acts or a ritualistic series of acts usually brings about reduced tension or satisfaction. This also means that resisting the compulsion can increase anxiety.
People with OCD experience obsessions, compulsions, or in the majority of cases, both. Whether obsessions lead to compulsions or compulsions lead to obsessions is still debated in the field.
Obsessions are repetitive and persistent thoughts (eg, of contamination), images (eg, of violent or horrific scenes), or urges (eg, to stab someone). Obsessions are not pleasurable or experienced as voluntary. They are intrusive, unwanted, and cause marked distress or anxiety in most individuals. A person suffering from OCD attempts to ignore, avoid, or suppress obsessions or to neutralise them with another thought or action (eg, performing a compulsion).
Compulsions (or rituals) are repetitive behaviours (eg, washing, checking) or mental acts (eg, praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession (eg, washing rituals in response to obsessive fears of contamination) or according to rules that must be applied rigidly in order to achieve a sense of “completeness”. The aim can be to reduce the distress triggered by obsessions or to prevent a feared event (eg, becoming ill). However, these compulsions are either not connected in a realistic way to the feared event (eg, arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (eg, showering for hours each day). Compulsions may also be performed in response to a sense of “incompleteness” (eg, a need to perform actions until “just right”). Compulsions are not acted on for pleasure, although some individuals experience relief from anxiety or distress by acting on them.
The frequency and severity of obsessions and compulsions vary among people with OCD: some have mild to moderate symptoms (spending one to three hours per day obsessing about or acting on compulsions), whereas others have near constant obsessions or compulsions that can be incapacitating.
The specific content of obsessions and compulsions varies widely among individuals. However, there are certain identifiable themes, also described as “symptom dimensions”. People with OCD often have symptoms in multiple dimensions, which include:
● Cleaning – Fears of contamination and cleaning rituals
● Symmetry – Symmetry obsessions and repeating, ordering, and counting compulsions
● Forbidden or taboo thoughts – Examples include aggressive, sexual, and religious obsessions, and related compulsions
● Harm (eg, thoughts or images about harm befalling oneself or others and checking compulsions)
Research studies suggest that genetic and environmental factors contribute to the aetiology of obsessive-compulsive disorder (OCD). Numerous lines of research implicate certain brain circuits in contributing to the condition.
Studies suggest that there is a genetic contribution to OCD with greater genetic influences in paediatric-onset OCD than in adult-onset OCD. The precise genes involved in OCD are not known, though work in this area is ongoing.
8 MOOD DISORDERS (AFFECTIVE DISORDER)
A mood disorder involves a persistent undesirable emotion or affect of sufficient intensity for a significant period of time. Although this emotion is normally negative, it can also be elated or manic. Those affected experience their mood as maladaptive.
Most people, from time to time, experience swings in their mood between positive and negative. Circumstances can make us extremely happy or sad. Experiences of loss and trauma can push a well-balanced person temporarily to a state of emotional upheaval. Sadness, discouragement, pessimism and a sense of hopelessness are all unpleasant mood disturbances, but many people recover in reasonable time. Some clinicians prefer to call these adjustment “disorders”. The normal process of grief is an example. A depressed mood might, however, help us to adapt to different and new circumstances and to make the necessary adjustments.
The diagnosis of a mood disorder must meet certain criteria and is thus more than the temporary reaction to circumstances. There is also a grey area between “mood disturbance” and “mood disorder”, where it is not absolutely clear where the one ends and the other one begins.
8.1 MAJOR DEPRESSION/ UNIPOLAR DEPRESSION
Depression is a disorder that makes you sad, but it is different than normal sadness. Depression can make it hard for you to work, study, or perform everyday tasks.
Depression is the most common psychiatric disorder and the most common mental health condition among patients seen in primary care. It is estimated that only 50 percent of patients with major depressive disorder (MDD) are identified, except where clear policies are in place to screen people for depression.
This is the best known and well-researched of all forms of disorders. It is common both cross-culturally and historically and is identified in Egyptian, Greek, Hebrew and Chinese writing from many centuries ago. The list of people who suffered (at hindsight) from depression is long: Moses; Dostoevsky; Queen Victoria; Lincoln, Tchaikovsky, Freud, and many others.
There is no age restriction. It is diagnosed in children from the age of three years old and there is no upper age limit. Females are slightly more at risk than males.
Depression is highly prevalent throughout the world, and the prevalence appears to be increasing. Community surveys of adults in different countries found a lifetime prevalence of major depression in the range of 8 to 12 percent. Reasons for the lower prevalence of depression in some countries may reflect true variation in the determinants of depression due to cultural or genetic factors, sample selection biases, and problems with the cross-cultural portability of diagnostic criteria. Depression is more difficult to detect in cultures where patients are more likely to present with somatic symptoms rather than emotional symptoms. Rates of depression may be particularly high in those people with diseases of the central nervous system (eg, stroke, traumatic brain injury, Parkinson’s disease), cardiovascular disorders, cancer, and conditions involving immune and inflammatory mechanisms (eg, systemic lupus erythematosus).
A major depressive syndrome or episode manifests with five or more of the following symptoms present most of the day nearly every day for a minimum of two consecutive weeks. At least one symptom is either depressed mood or loss of interest or pleasure.
● Depressed mood. Feel sad, down, hopeless most of the day, almost every day.
● Loss of interest or pleasure in most or all activities. They no longer enjoy or care about doing the things they used to like to do.
● Insomnia or hypersomnia.
● Change in appetite or weight. Decreased or increased appetite.
● Psychomotor retardation or agitation.
● Low energy. Decreased activity, effectiveness and productivity.
● Poor concentration. Trouble making decisions.
● Thoughts of worthlessness or guilt.
● Recurrent thoughts about death or suicide.
The symptoms cause substantial distress or impair psychosocial functioning, and they are not the direct result of the physiological effect of a substance or general medical disorder. Further, the symptoms cannot be explained as a response to significant loss, though the clinician should still carefully consider the possibility of depression if symptoms extend beyond what is normative following a loss.
Treatment should include counselling as well as medicine.
The symptoms of depression are a little different for teenagers than for adults. Some teenagers are moody or sad a lot of the time. That makes it hard to tell when they are really depressed. Teenagers who are depressed often get “annoyed” or “bothered” easily. They might even pick fights with people. Also, when treating a teenager, doctors and nurses usually suggest trying counselling first, before trying medicine. Even so, some depressed teenagers need medicine. And most experts agree that medicine for depression is safe and appropriate to use in teenagers who really need it.
Some anti-depression medicines can cause problems for unborn babies. But untreated depression during pregnancy can also cause problems. If you want to get pregnant, tell your doctor but do not stop taking your medicines. The two of you can plan the safest way for you to have your baby.
In severe instances, delusions, hallucinations or mute and unresponsive symptoms may also be present.
There are less severe forms of depression known as cyclothymia (which includes hypomania) and dysthymia. Also called persistent depressive disorder, it is less disabling and intense but is a chronic condition and an affected person is often described as negative or not socially involved by others. Persistent depressive disorder (dysthymia) is characterised by depressive symptoms that last for at least two years, with a depressed mood present for most of the day and for more days than not.
8.2 POSTPARTUM DEPRESSION
Postpartum depression is a kind of depression that some women get after having a baby. “Postpartum” is another word for the period of time shortly after a woman gives birth. This is not a separate form of depression, but refers to the time women are vulnerable to attack by depression. However, there is no established consensus as to what time frame constitutes the postpartum period. Most women with postpartum depression start having symptoms within a month after giving birth. But it can be up to 12 months before a woman starts having symptoms.
After having a baby, many women get a mild type of postpartum depression called postpartum blues. Within two or three days of giving birth, women with postpartum blues might:
● Be moody, irritable, or anxious
● Have trouble concentrating or sleeping
● Have crying spells
In women with postpartum blues, these symptoms are not severe and usually go away within two weeks. But in women with postpartum depression, the symptoms are more severe and last longer. Women who have a history of depression are more likely to get postpartum depression than women who have never been depressed.
It can be hard to tell if a woman has postpartum depression, since some of the symptoms might also be caused by the stress of taking care of a newborn. For example, it’s normal for new mothers to sleep too much or too little; feel tired or lack energy; have changes in their appetite, weight, and desire to have sex.
But women with postpartum depression might not be able to sleep even when their babies sleep. Or they might have so little energy that they cannot get out of bed for hours. They might also feel:
● Anxious, irritable, and angry
● Guilty or overwhelmed
● Unable to care for their baby
● Like a failure as a mother
Treatments for depression can also be used to treat postpartum depression. The two main treatments for depression are:
● Taking medicines to relieve depression
● Talking with a therapist (such as a psychiatrist, psychologist, nurse, or social worker)
Women who are breastfeeding might need to avoid certain medicines. When a nursing mother takes medicine, small amounts of the medicine can be found in her breast milk. This might be unhealthy for the baby. But not treating depression can also be harmful for both the mother and her baby. Your doctor can help you decide if you need medicine and the best one to take.
8.3 BIPOLAR DISORDER
Bipolar disorder (sometimes called “manic depression”) is a brain disorder that causes extreme changes in mood and behaviour. Bipolar disorder can run in families. It is distinguished from major depression by at least one episode of mania. Even if a person is exhibiting only manic features it is assumed that there is also a depressive component.
People with bipolar disorder can feel much happier or much sadder than normal. If you have bipolar disorder, you might feel very happy for many days and then feel very sad. A manic episode refers to an elevated, euphoric mood, often interrupted by occasional outbursts of irritability or even violence, especially when others refuse to go along with the manic person’s schemes. Symptoms include:
An increase in physical activity and restlessness
An increase in mental activity and thoughts; many new ideas. Difficulty in completing thoughts
High levels of verbal, and sometimes written, output
Inflated self-esteem; feelings of grandeur and power
Person sleeps little
Letting go of personal inhibitions; displaying inappropriate sexual behaviour and advances
May ignore personal hygiene
Hyper-religious and claiming extraordinary skills; x-ray vision; talking to the dead
Uncontrollable spending, sexual activity, and bad decision-making.
When your mood is very happy, you can also:
● Get angry quickly
● Be more active than normal
● Feel like you have special powers
● Feel like you don’t need sleep
● Make poor choices without thinking
● Start lots of things and not finish them
People with bipolar disorder might have trouble at work or school. They might not get along well with their family and friends. Treatment is counselling and medicine.
You might also need to stay in the hospital for a short time. When a bipolar disorder mood episode starts, you might be at risk of hurting yourself or others. You might hear voices that other people do not hear. You might believe things that are not true. But if you are at the hospital, the doctors can treat these symptoms and keep you safe.
There is a Bipolar I and Bipolar II diagnosis. A bipolar I diagnosis is possible after one manic episode even if there is no history of a depressive episode. The manic episode is normally very dramatic and loss of contact with reality occurs. It often requires hospitalisation. Bipolar II diagnosis requires major depressive episodes, but the manic episodes are often less intense and known as hypomanic episodes. A person does not lose contact with reality in this phase but often has an inflated view of themselves.
8.4 SCHIZOAFFECTIVE DISORDER
There are persons with mood disorders (depressive and bipolar) whose mental processes are so deranged that they are psychotic. At that specific moment their symptoms are reminiscent of those of a schizophrenic disorder.
Schizoaffective disorder is a condition in which the patient meets the diagnostic criteria for both schizophrenia and a major mood disorder, and both sets of symptoms are prominent in the patient’s course of illness. The diagnosis requires the patient to have had at least one two-week period of illness during which he/she experienced hallucinations and/or delusions in the absence of any prominent mood episode.
There are differences in opinion on whether it is then still a mood disorder or schizophrenia. However, it does differ from schizophrenia in some ways. It seems to have an episodic pattern with a very good prognosis.
8.5 CAUSES IDENTIFIED
It is important to understand that the causes of mood disorders are multiple and dealing with them requires a holistic approach. Some of the causes identified are.
8.5.1 GENERAL MEDICAL CONDITION:
Illnesses that affect the rest of your body can have an effect on your mood. Chronic pain can also causes a depressive episode, while depressive people often have a lower pain threshold. There are several illnesses and medical conditions identified:
Alzheimer’s disease; strokes; Cushing illness; Parkinson’s disease; syphilis; brain tumours; HIV; chronic anaemic condition; chronic infections; porphyria; thyroid gland and a vitamin shortage, especially B1, B12 and folic acid.
8.5.2 BRAIN CHEMISTRY
Neurotransmitters (dopamine; serotonin; noradrenaline) are naturally occurring brain chemicals that likely play a role in depression. Research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability play a significant role in depression and its treatment.
8.5.3 INHERITED TRAITS
Having a first-degree relative with major depressive disorder or other depressive disorders. Persistent depressive disorder appears to be more common in people whose blood relatives also have the condition. Researchers are trying to find genes that may be involved in causing depression.
8.5.4 LIFE EVENTS
Major traumatic events such as the loss of a loved one, financial loss, unemployment, loss of a limb or a high level of stress can trigger persistent depressive disorder in some people.
8.5.5 PERSONALITY TRAITS
These include negativity, a low self-esteem, being too dependent, self-critical or pessimistic.
8.5.6 SUBSTANCE INDUCED
Abuse of alcohol or the use of marijuana can trigger a mood disorder. It is also a chicken-and-egg situation because many people use alcohol or drugs to feel better because they already have an undiagnosed or untreated depressed mood. Alcohol can improve a person’s mood initially, but the long-term effect is that of a depressant.
There are also medically prescribed medicines that can have an effect on your mood. One example is something like cortisone. This does not mean that you should not take it, but that you should be aware that it may influence the mood of some people who already have a predisposition towards a mood disorder.
Illegal drugs like amphetamine (speed); methamphetamine (tik) and cocaine are some of the drugs that hold danger for all psychiatric disorders.
8.6 RISK FACTORS
● Prior depressive episode
● Family history
● Female gender
● Childbirth (ie, postpartum depression)
● Childhood trauma
● Stressful life events
● Poor social support
● Serious medical illness
● Dementia
● Substance abuse
8.7 PREVENTION STRATEGIES
Strategies that may help ward off symptoms include the following:
• Take steps to control stress, to increase your resilience and to boost your self-esteem.
• Reach out to family and friends, especially in times of crisis, to help you weather rough spells.
• Get treatment at the earliest sign of a problem to help prevent symptoms from worsening.
• Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.
8.8 SCHIZOPHRENIA AND DELUSIONAL (PARANOID) DISORDERS
Schizophrenia is a brain disorder that prevents you from thinking clearly. It can cause you to see or hear things that aren’t there, or to believe things that aren’t true. Schizophrenia has a worldwide prevalence approaching 1 percent.
The main feature here is a disturbance of thought processes and a distortion of reality. It is also much more of a behavioural disorder, because of the psychological breakdown. It is not the same as a mood disorder, although panic attacks and high anxiety may accompany the other features and extreme mood swings are possible. Other features are withdrawal from social interaction and paranoid behaviour.
● Positive symptoms: In this case, “positive” does not mean “good.” Positive symptoms are abnormal experiences or behaviours that start because of schizophrenia. Examples of positive symptoms include:
Hallucinations: Hallucinations are when you hear, see, feel, smell, or taste things that aren’t there. For example, people with schizophrenia often hear voices in their head telling them to do things when there isn’t really anyone talking.
Delusions: Delusions are when you believe things that are not true. For example, people with schizophrenia sometimes believe they are a famous person who is dead.
Disorganised thinking or speech: People with schizophrenia have trouble thinking in an organised way. They can talk and talk about a lot of things before getting to the point. Sometimes they make up words or say things that do not make any sense.
● Negative symptoms: In this case, “negative” does not mean “bad.” Negative symptoms are normal behaviours that stop because of schizophrenia. Examples of negative symptoms include:
• Not showing much emotion and not changing your facial expression
• Not moving or talking much
• Not taking showers or keeping clean
• Not having much interest in spending time with people or having fun
● Cognitive symptoms: Cognitive symptoms are symptoms that affect your ability to think clearly. People with schizophrenia have trouble:
• Learning and remembering
• Understanding speech or other forms of communication
• Making sense of new information
• Solving problems
● Emotional symptoms: People with schizophrenia often also have symptoms of anxiety or depression.
The medicines for schizophrenia often reduce symptoms, but they take some getting used to. Sometimes people need to try a few different medicines before finding the ones that work best and cause the fewest problems.
The medicines used to treat schizophrenia can cause uncomfortable side-effects. If your medicines cause side-effects, talk to your doctor about them. He or she might be able to lower your dose, switch you to a different medicine, or help to manage side-effects in other ways.
To keep schizophrenia under control, you usually must take medicines for the rest of your life. It’s important to take them exactly as directed. Otherwise, your symptoms could get worse.
It can also be useful for you and your family to take part in a type of therapy called “family psychoeducation”. This programme can teach you and your loved ones some important concepts and skills, such as:
● That schizophrenia is a biological illness and not anyone’s fault
● Ways to keep your condition from getting worse
● Ways to deal with your symptoms so that they are less stressful
Schizophrenia occurs throughout the world. The prevalence of schizophrenia (ie, the number of cases in a population at any one time point) approaches 1 percent internationally. Age of onset is typically during adolescence; childhood and late-life onset (over 45 years) are rare. Slightly more men are diagnosed with schizophrenia than women, and women tend to be diagnosed later in life than men. Modal age of onset is between 18 and 25 for men and between 25 and 35 for women, with a second peak occurring around menopause. There is also some indication that the prognosis is worse for men.
8.8.1 RISK FACTORS
A number of epidemiologic risk factors have been associated with the development of schizophrenia, including:
● Living in an urban area
● Immigration
● Obstetrical complications
● Late-winter or early-spring birth – perhaps reflecting exposure to the influenza virus during neural development
● Advanced paternal age at conception
8.8.2 CAUSES IDENTIFIED
Although there is abundant evidence for genetic risk factors, the specific genes involved in the aetiology of schizophrenia have not been identified..
● Obstetrical complications: Various perinatal problems, grouped together for analysis as “obstetrical complications”, increase the risk of later development of schizophrenia two-fold
● Pregnancy during famines in the Netherlands (1944 through 1945) and in China (1959 through 1961) has been associated with a two-fold risk of schizophrenia in the offspring in studies based on subsequent hospital records. This may indicate maternal nutrition is a factor in the development of schizophrenia.
● Increased prenatal maternal stress has been proposed as the common pathophysiological mechanism underlying risk factors, such as famine, bereavement, and antenatal infection.
● Infections: Several epidemiologic findings have suggested the possible role of certain infectious agents as potential risk factors for the development of schizophrenia. Numerous epidemiological studies have found a rise in schizophrenia prevalence in cohorts born during influenza epidemics.
● Studies have varied on whether herpes simplex virus type 2 maternal infection increases the risk for schizophrenia. Some studies have found the risk increases by from 60 percent to more than 400 percent, while other studies have found no increased risk.
● Measles antibodies are higher in people with schizophrenia, especially in those with recent-onset of psychosis, than in controls.
● Bacterial infections during childhood that result in hospitalisation are related to an increased risk for developing schizophrenia.
The mechanism by which infections increase the risk of schizophrenia is unclear. There is little evidence to suggest that the risk is associated with direct damage to the central nervous system (CNS) by the infectious agent. A more likely explanation is that infection by certain agents triggers an immune response in a mother that is passed through the placenta to the developing foetus, which compromises the blood-brain barrier and allows antibodies, which cross-react with CNS proteins, to enter the developing nervous system
Inflammation: Increased immune system activation leads to higher levels of circulating pro-inflammatory cytokines. Increased pro-inflammatory cytokine levels have been frequently observed in schizophrenia. Cytokines can alter the blood-brain barrier, or be produced locally in the CNS by activated microglia, and may be responsible for psychosis, its exacerbation, or cognitive impairment.
In addition to the association between schizophrenia and some infections, there is other evidence for abnormal immune activation in people with schizophrenia. Autoimmune disorders have been associated with a higher prevalence of schizophrenia. A notable exception is rheumatoid arthritis, in which schizophrenia rates are lower than expected based on rates in the general population.
Cannabis use: Epidemiological studies suggest that cannabis use is a risk factor for the development of psychosis. Well-controlled, prospective studies following hundreds of people have subsequently supported the hypothesis that cannabis use is the risk factor and psychosis the result. The increased risk posed by cannabis use depends on other risk factors.
Immigration: Numerous studies in multiple countries have observed a higher prevalence of schizophrenia in immigrant populations compared to native-born populations. This increased relative risk can be as high as four-fold, depending on the study. An increased risk appears to extend to second-generation immigrants as well. Several possible explanations for the association between immigrants and schizophrenia have been proposed.
Schizophrenia may be overdiagnosed in immigrant populations, however, and further research suggests that this cannot entirely explain the increase in risk observed. While the stress of immigration and being part of an outsider group may contribute to the development of schizophrenia, studies have found associations between the amount of social discrimination experienced by immigrant groups and the rate of schizophrenia. That is, immigrant groups experiencing more discrimination have higher rates of schizophrenia than immigrant groups experiencing lower rates of social discrimination. This finding has been observed in several immigrant groups in several countries.
The increased risk of schizophrenia in immigrants may also be related to vitamin D deficiency, especially among individuals who move to more northern latitudes.
The increased smoking behaviour observed in people with schizophrenia has led to the hypothesis that nicotine, which stimulates a subset of acetylcholine receptors, is correcting a fundamental neurochemical problem in schizophrenia. Treatment with nicotine or a nicotinic cholinergic drug can normalise some eye-tracking and EEG abnormalities observed in people with schizophrenia and may acutely improve some aspects of cognition. However, nicotinic acetylcholine receptors can affect many other neurotransmitter systems.
People with schizophrenia have higher rates of depression, several anxiety disorders, substance use disorders, and suicide compared to people without schizophrenia. Approximately 15 to 20 percent of patients with schizophrenia have the deficit form of schizophrenia, characterised by primary, enduring negative symptoms such as decreased expressiveness, apathy, flat affect, and a lack of energy.
The disorder appears to proceed from a complex interaction between genes and the environment. Several neurotransmitter systems are involved in the pathology of schizophrenia, including dopamine, glutamate, GABA, and acetylcholine. These represent the current best targets for pharmacological intervention in the disorder.
8.9 CHILDHOOD DISORDERS
8.9.1 AUTISM SPECTRUM DISORDER (ASD)
Autism spectrum disorder (ASD) is a biologically based neurodevelopmental disorder characterised by impairments in two major domains: 1) deficits in social communication and social interaction and 2) restricted repetitive patterns of behaviour, interests, and activities [1]. ASD encompasses disorders previously known as autistic disorder (classic autism, sometimes called early infantile autism, childhood autism, or Kanner’s autism), childhood disintegrative disorder, pervasive developmental disorder (not otherwise specified), and Asperger disorder (also known as Asperger syndrome).
Evaluation for ASD should include a comprehensive assessment, preferably by a team that has expertise in the diagnosis and management of ASD. The evaluation should include a complete history, physical examination, neurologic examination, and direct assessment of the child’s social, language, and cognitive development. Sufficient time should be set aside for standardised parental interviews regarding current concerns and behavioural history, as well as structured observation of social and communicative behaviour and play.
The most important thing the primary care clinician can do is to listen to the parents and take their concerns seriously. Although primary care clinicians typically feel comfortable conducting the etiological search (eg, identifying associated disorders, performing the medical history and examination, and coordinating genetic, metabolic, and neurologic evaluations as necessary), they usually seek the help of ASD specialists in making the definitive diagnosis of ASD.
Ideally, children identified by primary care providers to be at risk for ASD should be referred for a comprehensive specialty evaluation. In some cases, this may result in a significant delay in making the diagnosis. Thus, primary care clinicians should be familiar with the components of the comprehensive evaluation. Based on those pieces of the evaluation that can be competently completed in primary care (eg, review of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] diagnostic criteria, use of a diagnostic instrument), children may receive a provisional diagnosis if the primary care provider feels that a thorough evaluation has been accomplished, while a comprehensive evaluation or a definitive diagnosis is awaited. In addition, primary care providers who have significant concerns about a potential delay in any of the key areas — social communication, social interaction, or behaviour — should simultaneously refer the child to the appropriate servicing agency (ie, either Early Intervention or the department of education of the public school system).
The primary care provider can suggest and/or refer the child for several other interventions while the comprehensive specialty evaluation is awaited. These interventions vary depending upon the parents’ concerns.
● Review of the developmental history, with particular attention to early social-emotional and language milestones, play skills, behaviour, and any regression
● Parental concerns regarding hearing, vision, and speech/language
● Specific information regarding early communicative behaviours, such as pointing, use of eye contact, and response to name
● History of repetitive, ritualised, or stereotypical behaviours, such as hand flapping
● Unusual visual behaviour, or preoccupation with parts of toys
● Frequent tantrums and trouble tolerating change or transition
● History of possible seizures
● Self-injury
● Significant disturbance in eating (including pica) or sleep
8.9.2 ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Since the first description of ADHD, more than 10 000 clinical and scientific publications have been published on the disorder.
“(However), research shows that genetic (hereditary) and neurological (such as pregnancy and birth complications, brain damage, toxins and infections) factors are the main causes of ADHD, rather than social factors (such as poor parenting and diet). ADHD is one of the most strongly genetic conditions – it runs in families, with a heritability chance of almost 60% for a child if a parent has ADHD, …” (Schoeman 2017:15)
ADHD is a syndrome with two categories of core symptoms: hyperactivity/impulsivity and inattention.
Each of the core symptoms of ADHD has its own pattern and course of development. The complaint regarding symptoms of ADHD may originate from the parents, teachers, or other caregivers.
Hyperactive and impulsive behaviours almost always occur together in young children. The predominantly hyperactive-impulsive subtype of ADHD is characterised by the inability to sit still or inhibit behaviour.
Symptoms of hyperactivity and impulsivity may include [1]:
● Excessive fidgetiness (eg, tapping the hands or feet, squirming in seat)
● Difficulty remaining seated when sitting is required (eg, at school, work, etc)
● Feelings of restlessness (in adolescents) or inappropriate running around or climbing in younger children
● Difficulty playing quietly
● Difficult to keep up with, seeming to always be “on the go”
● Excessive talking
● Difficulty awaiting one’s turn
● Blurting out answers too quickly
● Interruption of or intrusion upon others
Hyperactive and impulsive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years, peaking in severity when the child is seven to eight years of age. After seven to eight years of age, hyperactive symptoms begin to decline; by the adolescent years, they may be barely discernible to observers although the adolescent may feel restless or unable to settle down. In contrast, impulsive symptoms usually persist throughout life.
Many of the children also have other co-morbid systems like anxiety.
Treatment should include a good sleep routine; behavioural therapy as well as medication appropriate to the severity of the condition.
Behaviour therapy and environmental changes that can be used by parents or teachers to shape the behaviour of children with ADHD:
● Maintaining a daily schedule
● Keeping distractions to a minimum
● Providing specific and logical places for the child to keep schoolwork, toys, and clothes
● Setting small, reachable goals/ targets.
● Rewarding positive behaviour.
● Identifying unintentional reinforcement of negative behaviours
● Using charts and checklists to help the child stay “on task”
● Limiting choices
● Finding activities in which the child can be successful (eg, hobbies, sports)
● Using calm discipline (eg, time out, distraction, removing the child from the situation)

In March 2017, the Goldilocks and The Bear Foundation was launched, initiated by a psychiatrist, Dr Renata Schoeman. It aims to offer ADHD screening and early intervention in underserved communities and schools. The aim of the Foundation, initially, is to screen 500 children per month. They also have a broader aim:
“We aim to provide access to mental-health services for all children who currently do not have access to care – whether it is due to lack of awareness and knowledge, or due to services being absent in their respective areas.” (Schoeman 2017:16)
8.9.3 TOURETTE’S SYNDROME
Tourette’s syndrome is a rare disorder that causes people to make unusual movements or sounds, called “tics”. Common examples of tics include blinking and throat clearing. People with the disorder have little or no control over their tics. Many people with Tourette syndrome have mild symptoms, but some have more severe ones.
Most people with Tourette’s syndrome start showing signs of the disorder before they are 11 years old. In about half of children with Tourette’s syndrome, the tics go away by the time they turn 18. Tics that continue into adulthood gradually improve over time in many people. But in some people, the tics return later in life.
The symptoms include:
Motor tics – These are tics that involve unusual movements. They can be mild (called “simple motor tics”) or more extreme (called “complex motor tics”). Examples of motor tics include:
• Blinking
• Briefly making a face as if angry or in pain (called a “grimace”)
• Shrugging the shoulders
• Jerking the head
• Walking in a strange way
• Kicking, jumping, or moving the body in odd ways
• Scratching
• Making obscene gestures
● Vocal tics – These are tics that involve unusual sounds or words, or phrases that don’t make sense or seem odd. Examples include:
• Throat-clearing, grunting, or other noises
• Swearing
• Repeating words or phrases (including echoing what other people say)
People with Tourette’s syndrome often know that they are going to have a tic before it happens.
Children and adults with Tourette’s syndrome don’t need medical treatment unless their tics are severe. A person with Tourette’s syndrome might need treatment if he or she is having problems:
● Talking with other people
● Attending school or working at a job
● Doing everyday things such as bathing, dressing, and eating
A person might also need treatment if the tics are causing pain or injury.
Treatment includes:
● Medicines – Certain medicines used to treat different mental health conditions can reduce the number of tics a person has.
● Botulinum toxin (brand name: Botox) – This is a medicine that is given by injection. It works by blocking or calming the nerve signals that make the muscles jerk or twitch.
● Habit-reversal training – This treatment involves working with a therapist who teaches people with Tourette’s syndrome to recognise when they are about to have a tic. They then train themselves to make an alternative movement that would make it hard for the tic also to occur. This treatment is not available everywhere.
9 CLOSING
It is important to take a holistic view when dealing with illness, and even more so dealing with unhealthy and dysfunctional behaviour. Mental disorders are best understood as a bio-psychosocial condition: It often seems to be medical in origin, but is affected and influenced by the environment as well as the social and emotional aspects of each person.
Diagnoses should be made with sensitivity. Every individual is more than any box we may put them in. We know that the diagnostic boxes are not watertight and open to change. Anyway, people are more than a diagnosis. Treatment should find a healthy balance between medication and therapy. A crucial aspect for dealing with anyone affected by mental health disorders or diseases is to remember that whatever the symptoms are, behind those symptoms live a human being. That person most often lives with distress, pain and confusion and might even be aware that the way they operate in the world is not considered a healthy way to be.
FREDERIK B O NEL
URCSA THEMBALETHU 23 NOVEMBER 2017

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