About Mental Health

Understanding Schizophrenia
Schizophrenia can have a devastating negative impact on the social development of the patient and social relationships especially within the family circles.
Making the Diagnosis of Schizophrenia
The diagnosis of schizophrenia is based on certain categories of observations/experiences. These include:
1. A given set of symptoms that must have existed for a significant proportion of the previous one month if not treated or less if treated.
2. Social and occupational deterioration along several parameters.
3. Chronicity of at least six months since the illness process started.
It is also a requirement for the diagnosis of schizophrenia that the above conditions should not be attributed primarily to medical conditions, substance abuse, or other psychiatric conditions.
Features of Schizophrenia
Hallucinations
The general definition of a hallucination is a perception without an external stimulus. In hallucinations, one sees things, hear voices, taste, smell, or feel things that do not exist in reality---that is, other people cannot experience them, yet to you they are as real as if they existed in reality---that is, you are not pretending.
A Word of Caution
A hallucinated person is not pretending. They actually hear the voices. Therefore, do not argue with them to the effect that there is indeed no voice since nobody else can hear it. They find that kind of argument very offensive because you are by implication telling them that they are “mad.”
Delusions
Delusions are the other main symptoms of schizophrenia. A delusion is normally defined as a false belief that is held with absolute conviction of its truth although such a belief is not in conformity with the person’s culture or level of education. In other words, what is judged to be an abnormal belief is so judged using what others of some cultural background and educations consider to be an acceptable possibility.
Disorders of Thought(Thinking) and Speech
Schizophrenic patients may talk in a way that the listener has difficulty following. Under normal circumstances we follow what other people are saying if they talk at a pace that is not too fast and not too slow and also one in which their speech is jointed---that is, what they are saying is logically connected with what was said just before and what will be said next.
You can imagine the confusion to the listener if a person uttered five different sentences that were not related at all! Or even if related, they were said so fast you could not connect them or said so slowly as if they belonged to different compartments.
You may also be unable to follow what the patient is saying if he interjects his speech with words that do not belong to any known spoken language and whose meanings are probably only known to the person speaking. Or it could be that you are not able to really understand what the patient is saying because he is not able to go straight to the point he wants to make because he goes around what he really wants to say by telling stories that are not really relevant to the point they want to make.
Disorders of Emotions In Schizophrenia
There are several disorders of emotions that are associated with schizophrenia.
1. Some schizophrenic patients have flattened and blunted affect that does not change with the mood of what is happening around them. It is like they are devoid of feelings. Their mood will remain the same irrespective of whether or not the mood of the people around is one of happiness or sadness. It is like whatever happens, they never laugh or cry. This symptom is known as blunted or flat affect. This is a serious symptom of schizophrenia since it is hardly affected by drugs or most treatment for schizophrenia. It is regarded as one of the negative symptoms of schizophrenia.
2. Other schizophrenic patients express emotions that are totally contrary to what is expected. For example, just imagine how out of tune a person can be when in a funeral when all people are crying or showing feelings of sadness the person is laughing. Or it could be the other way round---when people are in a partying mood and laughing, the patient is crying. This is aptly known as inappropriate affect. It is one of the symptoms that suggest a schizophrenic illness that is hard to respond to treatment and suggests a bad outcome. It is one of the so-called negative symptoms of schizophrenia.
3. Especially in the early stages of schizophrenia or when some of the symptoms of schizophrenia come back full-blown---such as frightening or threatening hallucinations--- a schizophrenic patient can during those periods get excited, irritable, sleepless, agitated and move around (motor overactivity) as if in fright. This is understandable---hallucinations can be frightening especially when they start to occur for the first time. Depression can also occur at these stages. Depression can indeed be the very first sign in the early stages leading to the development of schizophrenia. Depression is common in a chronic schizophrenic condition.
Disorders of Movement
It has been postulated that some schizophrenic patients have a disturbance in the motor coordination in the brain. The most dramatic demonstration of this is the so-called catatonic symptoms. A schizophrenic patient with catatonia can maintain one fixed posture for hours on end. He is like a fixed wax sculpture that can be pushed into different positions and left there.
If you lift his right arm upward, bend it at the elbow at a right angle and bend the hand at the wrist also at a right angle so that you form a “U” with right angles and then you push his head backward, he will remain in that position for a long time, until you bend him into other positions. The opposite of this can occur when the patients seems to be excessively active and moving around. Catatonic schizophrenia symptoms are rarer than in the past, but they do occasionally present.
Disorders of Volition Motivations and The Will
Volition is the act of using one’s will in choosing or making a decision. Volition is negatively affected in schizophrenia leading to avolition---an apparent inability or lack of the will to make a decision of what one wants to do, leading to prolonged periods of indecision, and under activity like remaining in bed or sitting, doing nothing. Disorders of volition are regarded as negative symptoms of schizophrenia.
The Social and Occupational Dysfuntions Associated with Schizophrenia
These are not by themselves symptoms of schizophrenia but are a consequence of schizophrenic illness resulting from the disabilities that can follow. A few examples will suffice:
1. Decreased work performance---either in the usual employed or self-employed work
2. If it is a student, there is a gradual deterioration in academic performance after an initial period when the student was doing well prior to the onset of the schizophrenic illness.
3. Overall there is a decline in life expectations so that the original goals of life are not achieved---whether they are social functioning, career expectation, academic goals.
4. The various symptoms of schizophrenia as described above will have a negative impact in the patients relationship with family members, neighbors, workmates, school or college or university mates, etc., leading to a wide spectrum of poor or disrupted or completely abandoned interpersonal relationships.
5. The schizophrenic patient gradually neglects himself in terms of personal hygiene, personal grooming, personal tidiness, and cleanliness. A person who used to be smart will start wearing the same clothes for many days without changing them; will go for several days without taking a shower or bath until the relatives raise concern and even so, he may be very reluctant and request to be left alone.
Issues of Insights
A schizophrenic patient does not know that he is sick. He believes all the symptoms that he is going through are real live experiences. He will therefore resist any attempts to convince him that he needs help and will instead tell off the relatives as the ones who need to see a doctor. He will insist he is feeling well; he has no aches; he is physically fit and has not felt the need to see a doctor.
Different Combinations of Symptoms
Not everybody has all the symptoms of schizophrenia at the same time. Some hear voices but do not have any of the negative symptoms or thought disorder.
Treatment Options for Schizophrenia
These can be divided into two main groups:
1. The use of drugs---pharmacotherapy
2. Psychosocial treatment
Side Effects of the Drugs Used in the Treatment of Schizophrenia
These can be divided into two main categories---those that do not affect the nerves and those that affect the nerves.
Those that Do not Affect the Nerves
1. Dizziness: This is a result of what is referred to postural hypotension. It is common with the older generation drugs. It occurs most frequently during the first few days of treatment, especially if high doses are given. It is characterized by feeling dizzy that can result in a faint or a fall. These can be easily controlled by asking the patient to get up slowly from any lying, squatting or sitting position and, if need be, supported.
2. Dryness that involves several parts of the body, mostly the mouth and the nose. These side effects can be reduced by reducing the dose. In the case of dry mouth, the patient can overcome this by rinsing the mouth frequently or chewing gun that does not contain sugar.
3. Other related side effects include blurred vision, constipation, and difficulty in passing urine.
4. Symptoms related to sex organs
- Breast enlargement
- Secretion of milk by the breast (called galactorrhea---caused by the secretion of an hormone called prolactin)
- Impotence in men
- Irregular or loss of menses in the female
- Reduced sex desire in women
Note: 5. A predisposition to diabetes
6. Skin conditions---allergic skin reaction in a small percentage of patients
7. Pigmentation of the retina is seen in a small percentage of people taking a drug known as thioridazine
8. Weight gain
Side Effects that Affect the Nerves
1. Sedation
2. Increased risk for epileptic attacks
3. Muscular contractions and spasms that can involve the muscles of eyes (resulting in eyes being pulled upward and outward); the neck (causing the neck to be pulled to one side), tongue (causing it to protrude); muscles of the larynx causing stammer.
4. Parkinsonian effects---muscle stiffness; tremor of the hands; stiffness in walking resulting in a shuffling gait; stooped posture of the body and drooling.
5. Akathisia---This is restlessness and agitation causing the patient to pace relentlessly. The symptoms cannot be controlled by the patient’s will.
6. Tardive dyskinesia---this tends to start after prolonged use of antipsychotics and is characterized by uncontrollable irregular movements of the mouth, head, and trunk.
Some Take-Home Messages for Drugs
1. Apart from clozapine, there is little evidence that there are large differences in the effectiveness of any of the typical or atypical antipsychotics. Neither is there any evidence that a particular antipsychotic (typical or atypical) will work better than another.
2. If one does not work change to another.
3. The atypical drugs have less side effects than the typical.
4. Clozapine is currently the choice if any of the above (at least one atypical) do not work. However, apart from its ability to reduce seizures, it has adverse effects on the bone marrow in less than 2% of the people and therefore requires strict monitoring.
5. Antipsychotic drugs should be combined with other psychosocial treatment and for the patient, Cognitive Behavioural Therapy (CBT), in particular.
Electroconvulsive Therapy (ECT)
This is an effective treatment with:
1. No side effects except short-lived forgetfulness.
2. A predictable course–-given over a limited period of time.
It is an option for patients who are not responding adequately to drugs. However, drugs should be continued during and after ECT.
Psychosocial Therapies for the Treatment of Schizophrenia
All of these are meant to increase the social and occupational skills of the patient so that he retains and/or improves his interpersonal relations with the family/friends while at the same time retaining his occupational skills. All of the psychosocial support system must be socioculturally and economically contextualized. Most developing countries do not have the privilege of public supported day centres or subsidized houses that the schizophrenic patients can live in on their own away from hospital or their homes. Neither is there an easy availability of jobs even for those who are physically or mentally well. Therefore, the responsibility of the care of the schizophrenic patient falls squarely on the family’s shoulders.
The family is particularly relevant since they are the caregivers. Like the patient they need to be educated on the nature of the condition and its symptoms and how they present; the drugs, the side effects, why it is important for the patient to take the drugs regularly. They should be given the opportunity to ask questions even on issues of genetics and any blame within the family. The family would need to be educated on how to relate with and express emotions to the patient.
Group therapy for the patients, even when they at the hospital, will help them to articulate the issues that concern them and also learn coping skills and mistakes to avoid from each other. Individualized psychological support is a viable option. CBT has been shown to work. In this you help the patient to understand his illness; how to focus and build on the positive aspects of his life (Details of CBT are to be found in a different chapter).
Self-Help for Schizophrenic Symptoms
1. Learn all you can about your condition–-the early signs and symptoms, so that you can raise your own red flag early and do something about. Learn about the drugs used and their side effects, how and why they should be taken and for how long. You can get this information by talking to a health professional or by reading. This book is meant to educate you and your relatives.
2. Learn about your rights---that you are entitled to be treated like any other patient and that if other people stigmatize you, it is their problem not yours. If you have the opportunity, remind them they are wrong. (Read also the relevant chapter on this book about your rights)
3. Study carefully the things that unduly cause you stress and avoid them if you can and if you cannot discuss them with a caring person or the doctor. Read as much as you can about stress and stress management. (See relevant sections in this book)
4. Do not stay idle---keep yourself busy.
5. Take good care of your health through physical exercises such as walking, working in the garden, helping in the house, etc., eating a balanced diet with fresh vegetables and fruits; avoid drugs.
6. Though it is difficult to ignore symptoms such as voices, keep on reminding yourself that they have no power over you and cannot harm you.

• Fear and worry are the cardinal features of an anxiety disorder.
• A worried and anxious person may know what it is they are worried about but sometimes they cannot put a finger on what they are anxious about.
• Anxious people tend to have many physical symptoms such was sweating, increased heart rate, shortness of breath, dizziness, loose motions, stomach upsets, and increased breathing rate.
• Other common symptoms of worry and anxiety include tiredness, weakness and poor sleeping habits, especially inability to fall asleep, remain asleep or get refreshing sleep, because they cannot relax.
• Also common are poor appetite, difficulty having sex, headaches, and aches and pains which seem to migrate from one part of the body to another (In Kenya, this phenomenon is described in Kiswahili as the “hapa na hapa syndrome”).
• Other physical symptoms which may arise include trembling, twitching, muscle tension, irritability, sweating and/or hot flushes, light-headedness, feeling out of breath, nausea, a feeling of a lump in the throat, and increased frequency of passing water. Anxious people tend to have poor concentration, tire easily, and sometimes suffer depression.

Types of Anxiety Disorders
There are some specific types of anxiety or fears. These include:
• Generalized anxiety disorder (GAD),
• Social phobia,
• Agoraphobia
1. Generalized Anxiety Disorder (GAD)---GAD is much more than the normal anxiety people experience day to day. It is chronic and exaggerated worry and tension, even though nothing seems to provoke it. People with this disorder always anticipate disaster, often worrying excessively about almost anything such as health, money, family, or work, though often it is hard to pin-point the justifications for the worry. The thought of simply getting through the day provokes anxiety. People with this disorder usually realize that their anxiety is more intense than the situation warrants. The symptoms are similar to those already described for anxiety disorders in general. GAD has a gradual onset going back to childhood or adolescence, but can also begin in adulthood. It affects women more than men and often occurs in relatives of affected persons. In general, the symptoms of GAD seem to diminish with age.
2. Simple phobia---anxiety caused by a specific object or circumstance such as fear of heights, or flying or specific animals. It is one of the most common anxiety disorders for both young and old. When one is not in the feared situation, then the person is free of symptoms which may include shortness of breath, trembling, and muscular aches.
3. Social phobia---This is anxiety associated with social situations, such as being in a social gathering, in an enclosed place (claustrophobia) such as a classroom, public theatre, or speaking in public.
4. Agoraphobia---the fear of being in open public places. It may cause people to refuse to leave their homes. Indeed the term “agora” is derived from an ancient Greek name for a market place.
5. Panic disorder---These attacks are episodic and are characterized by increased sweating, increased heartbeat and breathing and the fear that something terrible, including death is going to happen. There may or may not be a precipitant for the attack. Panic attack is not the same as agoraphobia, although a great deal of people with panic disorder also suffers from agoraphobia.

Treatment for Anxiety Disorders
Many people with anxiety disorders can be helped with treatment. This includes medication or specific forms of psychotherapy:
a) Medications can be very effective at relieving anxiety symptoms rather than curing them. There is a very wide selection of such medication. Different people respond differently to the various medications. These are usually started on a small dose before gradually increasing to a full dose. Every medication has side effects, but they usually become tolerated or diminish with time. The side effects are best discussed with the doctor who can either vary the dose or type of medication.
b) Cognitive-behavioural therapy (CBT) teaches patients to understand how their thinking patterns contribute to their symptoms and how to change their thoughts so that symptoms are less likely to occur. They are also taught how to relax. This awareness of thinking patterns is combined with well thought-out exposure to the feared situations to help people confront their feared situations positively and constructively.
c) Group therapy (or self-help groups) involves people suffering from the same condition getting together. They support each and share their experiences, especially those that work. Group therapy is a very effective form of treatment.

Bipolar Disorder (Manic Depression)
Someone with bipolar disorder will have severe mood swings involving low mood or depression on one end and a high mood on the other extreme. These usually last several weeks or months and are far beyond what most people experience. They are:
1. Low or “depressive” feelings of intense depression and despair;
2. High or “manic”---feelings of extreme or excessive happiness and overactivity;
3. Mixed despair---for example, depressed mood with the restlessness and over activity of a manic episode.

There are Four Types of Mood Disorders
1. Bipolar I
There has been at least one high, or manic episode, which has lasted for longer than one week. Some people with bipolar I will have only manic episodes, although most will also have periods of depression. If untreated, manic episodes generally last three to six months. Depressive episodes last rather longer---6 to12 months without treatment.

2. Bipolar II
There has been more than one episode of severe depression, but only mild manic episodes. A mild manic episode is called “hypomania.”

3. Rapid Cycling
More than four mood swings happen in a 12-month period. This affects around one in 10 people with bipolar disorder, and can happen with both types I and II.

4. Cyclothymia
The mood swings are not as severe as those in full bipolar disorder, but can be longer. This can develop into full bipolar disorder.
Bipolar disorder runs in families, and therefore suggests a strong genetic predisposition. It is a disease that involves those areas of the brain which control our moods. It is often controlled with medication. Episodes can sometimes be brought on by stressful experiences or physical illness. The symptoms of a mood disorder depend on which way your mood has swung, whether it is in a depressive or manic phase.

Depressive Phase
The symptoms are the same as those described for depression but in bipolar disorder, the feeling of depression is worse. It goes on for longer and makes it difficult or impossible to deal with the normal things of life. If you become depressed, you will notice some of these changes.

Manic Phase
This is the extreme opposite of depression. It is characterized by an extreme sense of well-being, energy, and optimism. If these symptoms are intense, they can affect thinking and judgment, and make one believe that they are more worthy than they really are. A person in this phase tends to make bad poorly thought-out decisions. They become disinhibited in thought and behaviour. Because of disinhibition, they behave in embarrassing, harmful and---occasionally---dangerous ways such as engaging in irresponsible sexual behaviour and creating disruptions in both relationships and work. Bipolar disorders are cyclic and in between the depressive and manic phase there is a “normal” period which can last from months to years.

A. Classification of Manic Symptoms:
1. Emotional
• very happy and excited
• irritated with other people who do not share the patient’s optimistic outlook
• feeling more important than usual

2. Thinking
• full of new and exciting ideas
• moving quickly from one idea to another
• hearing voices that other people can't hear

3. Physical
• full of energy
• unable or unwilling to sleep
• more interested in sex

4. Behaviour
• making plans that are grandiose and unrealistic
• very active, moving around very quickly
• behaving unusually, that is, uncharacteristic behaviour because of disinhibition
• talking very quickly---other people may find it hard to understand what they are talking about
• making odd decisions on the spur of the moment, sometimes with disastrous consequences
• recklessly spending money
• over-familiar or recklessly critical with other people
• less inhibited in general and more specifically in sexual behaviour and social relations and alcohol indulgence. This places them at a high risk for sexually transmitted disease, including HV/AIDS.
• Lack of insight: Especially during the first manic attack, the person does not think or believe that there is anything the matter with them although familiar acquaintances can see that there is something wrong. The person may even take offence at such a suggestion, and they are indifferent to other people’s feelings.

5. Psychotic symptoms
In severe manic episode the person tends to have grandiose beliefs about him/herself---that they are on an important mission or that they have special powers and abilities. They may even experience hearing voices which other people do not hear. However, these experiences are in agreement with or can be understood since they are as a result of the emotional symptoms. For example, the person may hear a voice saying they are important and they will easily agree with those voices because they are already feeling important.
Many people with bipolar disorder continue to experience mild depressive symptoms and problems in thinking in between mood swings even when they seem to be better.

Treatment of Bipolar Disorders
Since bipolar disorders involve mood swings, the drugs that are used are meant to prevent the swings and maintain the person in between. They are therefore aptly referred to as mood stabilizers. There are several in the market.

When to Start on Mood Stabilizer and for How Long
The more manic episodes one has had, the more likely one is to have another one. The risks for relapse do not change much with age. After just one episode, it is difficult to predict how likely and when another one will take place. There is therefore no need to start on a mood stabilizer unless the episode was very severe and disruptive. If there is a second episode, there is an 80% chance of further episodes. A mood stabilizer is usually recommended at this point. The mood stabilizer should be for at least two years after one episode of bipolar disorder, and for up to five years if there have been frequent previous relapses, psychotic episodes, alcohol or substance misuse, and continuing stress at home or at work. If there are frequent and troublesome mood swings, then the mood stabilizer should be continued for much longer.

The Use of Antipsychotic in Manic illness
In the initial stages when the patient comes for treatment, he/she may be very excited and restless. There is need to calm him/her down by using medicines such as haloperidol and other antipsychotic drugs. He/she may need to be sedated with other drugs such as chlorpromazine and diazepam. The scenario of a manic patient being brought to hospital can be dramatic---a very active and talkative person with endless energy being escorted by several exhausted and tired relatives, often with the assistance of police. The patient may be restrained by ropes or handcuffs.

Psychological Treatments
In between episodes of mania or depression, psychological treatment can be helpful. This should include:
• Psychoeducation---finding out and learning more about bipolar disorder;
• Mood monitoring---helps one to pick up when the mood is swinging;
• Mood strategies---to help stop mood swinging into a full-blown manic or depressive episode;
• Help to develop general coping skills;
• Cognitive Behavioural Therapy (CBT) for depression.

Pregnancy and Mood Stabilizers
Pregnancy is a very important consideration for people who have bipolar disorder especially if they are on a mood stabilizer. The decision about whether or not to remain on the mood stabilizer during pregnancy will have to be based on careful considerations which the patient must go through with her doctor. These considerations include:
1. Lithium is still safer than all the other mood stabilizer and is safer after 29 weeks of pregnancy;
2. The highest risk is during the first three months of pregnancy;
3. A baby should breastfeed when the mother is on lithium;
4. The decision on whether or not to take lithium or any mood stabilizer during pregnancy would have to be weighed carefully against the risks for relapse and the risks to the baby associated with lithium. The final decision lies with the woman.

A. Bipolar on the Depression Phase
If a patient is on a mood stabilizer and gets depressed, an antidepressant is usually added. However, the following are taken into account:
1. There is the possibility that the antidepressant can push the patient to a manic phase. However, SSRIs are less likely to do this than TCAs;
2. The person who has had a recent manic episode or is a rapid cycling bipolar is the more likely to be pushed to a manic phase and therefore a mood stabilizer alone is a safer option.
3. If there is history of manic episode, any added antidepressant should be for a relatively shorter time than when there has never been history of a manic episode;
4. If there have been repeated attacks of depressive episodes without a manic episode, then both the mood stabilizer and the antidepressant can be continued on a long term to prevent relapse of the depressive phase;
5. In the event it is considered necessary to put a patient on an antidepressant in spite of the history of manic episodes, the patient and the relative must be informed of the risks and much closer follow-up prescribed so that the antidepressant can be stopped at the earliest sign of manic features.
In mixed affective disorder---where features of mania coexist with depressive symptoms:
1. Do not use antidepressants;
2. Use either a mood stabilizer or an antipsychotic drug or both of them depending on the clinical picture;
3. The antipsychotic drugs help to reduce the overactivity, grandiosity, sleeplessness, and the agitation associated with the mania. The choice of which antipsychotic will depend on the availability and cost, but where these are not an issue, then the newer generation antipsychotics such as olanzapine and risperidone are to be preferred to chlorpromazine and haloperidol. This is because the latter have more short-term side-effects such as stiffness, shakiness, and muscular contractions.

Personal Tips for a Person with Mood Swings
1. Learn how to recognize all the symptoms of mania, and diarise them as they appear. This will assist you to seek help before they get out of control and in the process prevent destructive episodes or hospital admissions.
2. Read as much as possible about the condition. Be in charge.
3. Learn about stress and how to manage it so that stresses that are part of daily life do not overwhelm you and possibly precipitate a manic episode.
4. Improve personal relationships, especially with close confidantes by telling them of your condition and how it can adversely affect relationships. This will enable them to understand and be supportive of you when under attack.
5. Occupy yourself (without overworking yourself) with activities that take your focus away from the illness.
6. Exercise regularly.
7. Involve yourself in activities that are relaxing and nondestructive.
8. Keep regular check-ups with your healthcare provider and do not change or stop medication without consulting with him/her. This is more so with lithium which initially requires regular monitoring of levels in your kidneys and thyroid. When stable, these check-ups can be done every three to six months.
9. Your relatives and close confidantes need to be educated as well so that they can recognize early symptoms, the need for maintenance, appreciate and handle both the manic and depressive episode and the suicidal risks.
10. Discuss with your relatives and your healthcare provider how to handle your finances and treatment in the event you go into a manic or depressive episode. Make plans as to what should be done about your family and especially your children should you become manic or severely depressed.

Tips for Relatives and Friends
(a) When in the depressive phase the same tips as discussed under depression apply.
(b) When in the manic phase:
i. Manic patients can be highly disruptive and argumentative. Avoid direct confrontations.
ii. Manic patient tends to over-indulge in pleasurable activities such as drugs (alcohol included), irresponsible sexual behaviour, extravagance, and unplanned spending. Help to persuade them against those.
iii.Educate yourself on the early symptoms of the condition and read as much as possible about the condition.
iv. Make sure the patient keeps appointments
v. Make sure you know in advance where to seek for help in the event you could not handle the situation of the patient.
vi. Children of manic or depressed people will not understand the condition. They react with anxiety and confusion. It is at this time that the children will need the support of the adults around them, which will include a gentle explanation of what is going on with the sick relative or patient. Assurance that they are not to blame is necessary.
vii.Looking after a manic patient can be energy-draining. Make sure you get help from the rest of the family members and if need be, take him to hospital.

Alcohol

Alcohol is addictive. Some of the warning signs include:
1. You need a drink to start the day or to function
2. You shake, sweat, and feel anxious / tense a few hours after your last drink
3. You can drink a lot without becoming drunk
4. You need to drink more and more to get the same effect
5. You find it difficult to stop even if you try
6. You continue drinking even though you can see it is interfering with your work, family and relationships
7. You forget events that happened when you were drunk.
Dealing with Alcohol Addiction
1. Acceptance
One of the biggest problems for anybody with a drinking problem is the acceptance that they have a drinking problem. 2. Keeping a Diary
Be truthful to yourself on how much or often you drink by either keeping a diary of past behaviour (preferably) or by trying to recount your past drinking behaviour.
Record at least the following:
• The type or types or subtypes (name them) of alcoholic drinks that you take
• How often you drink them in a day or week or month
• How much you drink
• Where you drink and with whom
• How it has affected your health, family, finances, work, relationship, maybe issues with the police
• Why you actually drink
• Why you actually cannot stop drinking
If the above simple questions about yourself are dealt with sincerely and honestly when you are alone, this may go a long way in delineating more clearly the issues involved around your drinking.
3. Making a Decision
Many people who make individual decisions not to drink can successfully stop drinking on their own or with the assistance of family or close friends, especially if their drinking habits/behaviour began early in their lives. However, there are those who will not be able to do so by using the initial stages described above. Such people need help.

Cannabis/ Marijuana /Bhang

Cannabis is taken primarily for its pleasant effects of feeling high, which include a sense of relaxation, happiness, sleepiness, increased intensity of colours, and a better appreciation of music. However, Cannabis has its own unpleasant effects that occur 1--10 minutes after intake. These include confusion, hallucinations, anxiety, and suspiciousness. A mixture of pleasant and unpleasant effects is common depending on the prevailing mood and circumstances. Although these effects are temporary, the drug itself may remain in the body for weeks. Cannabis acts like a long-term depressant and may reduce motivation of the person.
Educational impacts
Besides the above effects that are felt by the user, cannabis can have profound effects on the educational and learning capabilities and potential in an individual. These include reduced concentration, ability to organize and utilize information. Some studies have suggested a link between cannabis use in young people and poor school performance. The explanation for this is complex and may not be straightforward since children who abuse cannabis may be living in conditions that are not very conducive to excelling in school work.
Impacts on adult users
For the same reasons that cannabis users may have impaired educational and learning capabilities, working adults may have poor work output because of absenteeism from work and poor concentration. It can have a similar effect on social life. During flight simulations (not real flying), cannabis has been shown to affect the pilot’s concentration, leading to more mistakes (minor and major) in those who had smoked cannabis up to four hours before the start of the experiment, compared to those who had not taken cannabis. The effects could last up to about 24 hours. The same has been observed in drivers; those who use cannabis are involved in more major and minor accidents.
Effects of Cannabis on the Brain
Various parts of the brain are affected leading to various signs and symptoms.
• The pleasure causing parts of the brain---leading to sensations of relaxation, painlessness and well-being, and eventually addiction in some people.
• The cerebellum---concerned with coordination of body movement and therefore marijuana can lead to manifest limpness while walking.
• The hippocampus that is linked to the limbic system concerned with emotions, leading to emotional disturbances.
• Forebrain---concerned with our intelligence and judgement.
• Note that the parts of the brain that are damaged by marijuana are the parts that control emotions, memory, and judgement.
• Development of mental illness---cannabis can induce various types of mental disorders such as unusual beliefs, thinking,
• Suspicion, and hallucinations---the so-called cannabis psychosis.
• Absenteeism from school and deviant behaviour in children.
• Interference with driving skills and therefore risky driving.
• De-motivation syndromes in long-term use, characterized by loss of interest in all meaningful or productive activities so that all that the patient is concerned with is obtaining and smoking marijuana.
Treatment for Addiction
This involves two phases:
1. Detoxification---that is, taking the person off the drug and treating the signs and symptoms caused by the withdrawal. Detoxification can take place in outpatient facilities or in the community. If the symptoms of withdrawal are severe, then the patient can be admitted. Increasingly, detoxification uses anti-doses of the hard drug, either given as tablets, syrups, injections, or implants.
2. Rehabilitation---When people are detoxified, they are helped to maintain abstinence through skills that help them to stay off the drug. Rehabilitation can take place in rehabilitation centers but increasingly in the community with favorable results. Community detoxification can be highly cost-effective. It also includes self-help groups such as the Alcoholics Anonymous.
Self-Help Tips to reduce substance use
1. Try decreasing or abstaining from those substances e.g. alternate between drinking alcohol and other liquids such as water, juice or soda; try to chew gum / find something to keep your hands and your mind busy instead of smoking a cigarette or using any substance.
2. Try avoiding the places, people or occasions that trigger you to use more alcohol or other addictive substances.
3. Pay attention to your emotions – they can also trigger you to use more. Counselling, exercise, and a healthy lifestyle can help you manage your emotions better and use less.
4. When you are tempted to use alcohol or other substances, think about the negative consequences that come with your use: negative health, social and financial consequences are common with addictive substance use.
5. Seek help if you have difficulties: Ask your friends, family and professionals for help in staying away from those substances.
In Kenya, the following organizations offer counseling, support and referrals in dealing with addiction.
The National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA) – They have a free Helpline, open 24hours a day every day. Call 1192
Alcoholics Anonymous (AA) Kenya
They also have a free helpline and hold free weekly support group meetings. Call 0700153832 or write to inquiries@aa-kenya.or.ke For meeting schedules visit: www.aa-kenya.or.ke

For the diagnosis of PTSD to be made, there must be clinical evidence that the person was affected in some specified way. The first criteria for PTSD can be summarized as follows:
The person has been exposed to a traumatic event in which both of the following were present:
1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others; and,
2. The involved person’s response was intense fear, helplessness, or horror.
The symptoms that are necessary for a diagnosis of PTSD to be made can be grouped into three categories.
1. Re-experiencing the event
2. Avoidance
3. Hyperarousal

Re-experiencing occurs if one or more of the following happens:
1. The person has recurrent and intrusive distressing recollection of the event in question. This may take the form of vivid images (i.e., believes he can see it with his eyes happening right there in his presence). However, it may not be images but “live” thoughts of what happened. It may not be any of these but perception in his mind that it is happening again.
2. When the person goes to sleep, he has recurrent dreams of the traumatic event in the form of nightmares. They may wake up screaming. Many people with these symptoms will be afraid of falling asleep because they do not want to get those dreams.
3. Acting or feeling as if the traumatic event was reoccurring. This needs elaboration and examples. Many people were affected after the terrorist bomb blast in Nairobi in 1998. One such person who was referred for psychiatric care particularly remembered the loud noise of the blast. On one occasion, he was walking in the streets of Nairobi when there was a tyre burst. Immediately, he believed the terrorists had come back and had exploded another bomb. He ran around scared and screaming, “they are back, they are back!”
4. There is intense psychological distress at exposure to internal or external cues (reminders) that symbolize or resemble an aspect of the traumatic event. This is best illustrated by another story by the same survivor of the bomb blast. Every time he heard the siren of an ambulance, he screamed “they have struck again and now people are being ferried to the hospital.” The reader will probably remember people who feel and behave as if a dreaded event is happening again when they see reminders of what happened.
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble the event. Physiological reactivity means that the person’s bodily functions, that is, increased heart beat, increased breathing rate, and dilated eye pupils, are as would happen when a person is in real danger. These are symptoms of acute fear and fright.
Children may present re-experiencing in a different way. This takes the form of plays that mimic what they saw, happen. If they saw their father being shot with a gun, they will play a shooting game. However, they express themselves in drawings that depict what they saw.
Avoidance can manifest in several ways, although only a minimum of three are required to qualify for this group of symptoms:
1. The person makes deliberate efforts to avoid thoughts, feelings, or conversations that are associated with the traumatic event.
2. Making deliberate efforts to physically avoid activities, places, or people that remind him or her of the traumatic event.
3. Inability to recall (shutting out) an important aspect of the trauma.
4. Included under avoidance are several symptoms that are typical or highly suggestive of depression, but which, nevertheless, serve to protect the individual from the recollection or even thoughts or concern related to the event.
These are:
(i) Markedly diminished interest or participation in important activities, such as family or social activities.
(ii) Feeling of disconnect from other people, preferring to be left alone.
(iii) Feeling of emotional detachment from others---not able to feel for others.
(iv) A feeling of having nothing to look forward to or expecting everything to go awry or something bad to happen.

Increased Arousal
For the symptoms to qualify for this group of symptoms then at least two are required out of the five listed below:
1. They have persistent difficulty in falling asleep or staying asleep---When they retire to bed, they will take longer to fall asleep than they normally do or did before the traumatic event. They cope with this in several possible ways---either listen to music or read or just get out of bed and pretend to be busy. Those who smoke may find themselves smoking more or those who drink may drink more as a way of trying to relax and get some sleep. Others medicate themselves sometimes using drugs they should not use to induce sleep. It is not unusual for some to sedate themselves with cough or allergy drugs, or other medicines that a friend has told them about (read the chapter on drugs, section on nonprescribed drugs). It is dangerous to use certain types of medicines unless they are prescribed by a qualified health professional. Beside difficulties in falling asleep in the first place, even if one ends up falling asleep in the first place, he gets inadequate sleep---they keep on waking up at the slightest noise or disturbance. It is like they are half asleep and half awake.
2. They are irritable---They get upset about things that ordinarily would not upset them. These upsets are accompanied by outbursts of anger. This can be highly disruptive within family circles and with social friends, even in the work situation. If it is the father who is irritable, the families get very badly affected. He may be mistakenly thought of by the children and other family members as being uncaring or even cruel. It can be particularly painful to the children if it is the mother whom they normally associate with love, care, and tenderness, is irritable. This is particularly so if the irritability takes the form of both verbal and physical aggression. If it is a child who is irritable, then the consequence can be grave to the child, especially if it is mistaken for rudeness and insolence to the parents and other adults, such as school teachers. Irritability in the work situation can be equally disastrous. If it is the boss who is irritable, then everybody is kept on their toes. If it is a junior person who is irritable, this could be mistaken for insubordination with serious consequences. So, watch out for irritability and handle those with this condition with understanding: talk to them; ask them to seek for help, etc.
3. Difficulty in concentration---When people cannot concentrate, it means they cannot keep their mind focused on one thing at a time. It is like their minds wander off to other things instead of remaining focused on the task at hand. If you tell them your name, they will not remember it after a few seconds or minutes. If you read a newspaper, you cannot remember what you have just read. Somebody will keep his money and then forget where he kept it and instead believe it was stolen, and start accusing his friends or family members of stealing his money. If it is a child in class, he cannot follow what the teacher is saying and therefore will not remember what the teacher said. And if he is given a book to read he will not remember what he read. It is therefore not surprising that his class performance will deteriorate fast. This is particularly of great concern if important national examinations are round the corner. The unfortunate thing is that the child could be accused of not caring for his classes or performance and may get a verbal lashing from the parents or the teachers.
4. Hypervigilance---This is a state of being on the alert as if anything unexpected and undesirable could happen anytime. It is not difficult to recognize a person who is in this state. He is tense and obviously not relaxed. If he sits on a chair or on a sofa, he will sit on the edge, as if in a hurry to leave. Instead of sitting in a reclining backward position, he will sit bending forward with his hands on the knees or armrest, ready to get away at the shortest notice. Instead of his forehead being smooth, it will be wrinkled.
5. Exaggerated startle response---The person reacts to any external stimuli with a startle. A slight sharp noise or a bang will set him forth in the upright position; as if afraid something terrible was just about to happen. He will breathe fast, his heart rate will increase, the pupils of his eyes will dilate and he may sweat.
It is important that the symptoms described above should occur after at least four weeks after the reference traumatic event. They could have started immediately or soon after the event, but unless four weeks are over, they do not qualify for PTSD. Alternatively, the events can occur for the first time much later after the four weeks. If they occur for the first time after six months, then it is referred to as delayed onset PTSD.

Progressive mental deterioration in old age has been recognized and described throughout history. Mental disorders among the elderly have wide-ranging impact not only on the individual but also on their families and care givers.
Dementia and Alzheimer’s Disease
Alzheimer’s disease is one of the most common causes of dementia. Dementia is just a clinical syndrome that is an indication of a serious problem with brain function. Many diseases of the brain, heart problems, diabetes, some diseases that relentlessly attack the brain such as Parkinson’s diseases, Huntington’s disease, Creutzfeldt Jakob, cancers inside the brain, diseases of the liver, kidney, liver, thyroid, etc. can all present as dementia. Generally when people get older they seem to stand a higher risk of dementia especially Alzheimer’s ‘disease dementia. However, it must be noted that dementia is a very serious disease and not part of normal ageing. Dementia and Alzheimer’s disease affects people in different ways. The impact depends on how a person was before the onset of the disease. It is a good idea to conceptualize the disease as occurring in three stages even though the symptoms of each stage are not necessarily exclusive of the particular stage.
1. In the early stage there may be difficulty remembering recent events. The person may misplace keys, personal items, and sometimes accuse co residents of having stolen those items. Difficulty with language, problems with decision-making, getting lost in rather familiar places may occur. The person may not be aware of the time of day, where the individual is or may have difficulty recognizing familiar people. As the disease progresses the problems continue to increase and become more evident.
2. At the middle stage memory problems become very serious and the person may no longer remember the names of family members and friends. Speech becomes more difficult. At some point the person can hardly cope without assistance with simple daily tasks such as cooking, washing, dressing, and going to the toilet, etc. The person may wander and not return home because he/she no longer knows their way about even in the neighborhood.
3. During the late stage the person is totally dependent on others and cannot do anything on their own. The person can no longer understand or interpret events, walk, eat, or do other normal activities. There may be a display of abnormal experiences and inappropriate behaviours.
The exact cause of Alzheimer’s disease is not known. Many complex theories have been put forward such as abnormal behaviour of some serum proteins. Early diagnosis is important to help caregivers plan ahead. Health professionals such as psychiatrists who are familiar with the disease are often able to recognize the disease and determine which type of dementia is involved. Many people simply call dementia Alzheimer’s disease. This is because many cases of dementia in old age are due to Alzheimer’s’ disease. There are drugs that are now being used to treat those who have dementia of the Alzheimer’s type. An important rich resource in dementia matters is Alzheimer’s Diseases International (www.alz.co.uk). This organization has helped to raise awareness worldwide. They have also developed useful ways to help caregivers handle the difficult behaviour problems associated with dementia. In Kenya, the Kenya Alzheimer’s Association (KAA) organizes for several groups of caregivers to meet and support each other. It is important to take an older person who is suspected of having dementia to see an expert for a proper diagnosis. It must be remembered that there are many diseases that can cause difficulty with memory. Dementia is not the same as memory impairment. Most people who have dementia will have memory problems but not all memory problems are dementia. Even when a memory problem is due to dementia, the type of dementia differs. Forgetfulness is not a normal part of the ageing process; it is always a sign of some serious disease that requires medical attention.