Nompumelelo Zungu-Dirwayi

Community attitudes toward and knowledge of mental illness in South Africa.

Although recent advances in psychiatry have increased our understanding of psychiatric disorders,many people with chronic or severe psychiatric disorders may be unaware that effective treatment is available. It is possible that ignorance and stigma prevent such persons from seeking appropriate help, and that community attitudes and beliefs play a role in determining the help-seeking behaviour and successful treatment of the mentally ill. Nevertheless, there is little research on the attitudes of lay persons toward mental illness within the South African community. The aim of this study was to investigate the knowledge and attitudes of the general South African public toward mental illness, specifically regarding the causes of illness and treatment options. The study design employed a questionnaire survey. Structured interviews (n = 667) were conducted with members of the general public. One of eight vignettes, portraying depression, schizophrenia, panic disorder or substance abuse, with subtle or obvious symptoms, was presented to each respondent. The main findings were that cases were most often conceptualised as stress-related or due to a lack of willpower rather than as medical disorders. Treatment advocated was more often to talk the problem over than to consult professional medical help. Psychotherapy was the preferred treatment option, particularly in vignettes where symptom presentation was subtle, and in cases of substance abuse. These data suggest that stigma and misinformation regarding mental illness exist, influencing preferred treatment modality and help-seeking behaviour. More work needs to be done to educate the public about the psychobiological underpinnings of psychiatric disorders and about the value of effective treatments. A better understanding of these disorders amongst the public would presumably lessen stigmatisation and encourage the use of currently available and effective interventions.

Trauma and posttraumatic stress disorder in an urban Xhosa primary care population: prevalence, comorbidity, and service use patterns.

Despite increased awareness of the prevalence and morbidity of psychiatric illnesses, relatively few studies have been undertaken in primary care settings in the African context. The authors determined the prevalence of trauma exposure and posttraumatic stress disorder (PTSD) in a South African township primary health care clinic and assessed associated demographic factors, comorbidity, service use, service satisfaction, and quality of life. Subjects were directly interviewed using translated, standardized instruments to assess variables described. Retrospective chart analysis assessed clinician case identification and psychotropic drug-prescribing habits. Of the 201 participants, 94% reported exposure to traumatic events (mean, 3.8). Trauma was associated with single status (p = .01), and PTSD was associated with poverty and single status (p = .04). Both sexes were equally likely to develop PTSD. PTSD (current; 19.9%), depression (37%), and somatization disorder (18.4%) were the most common diagnoses. Comorbidity with PTSD was high and included depression (75%, p < .01), somatization (35%, p < .01), and panic disorder (25%, p < .01). Levels of functional impairment were higher for subjects with PTSD, depression, and somatization than for those without (p < .05). PTSD comorbid with depression compounded impairment (p = .04). Levels of trauma, PTSD, and depression did not increase service use or dissatisfaction with services. Clinicians did not identify trauma (0%) or psychopathology (0%), and psychotropic medication was prescribed for only 1% of participants. In this population, trauma and PTSD were highly prevalent and associated with significant unidentified morbidity and comorbidity. Patients remain untreated for years in the current system of primary care consultations.

An open trial of citalopram in adolescents with post-traumatic stress disorder

In this preliminary, 12-week open-label study, eight adolescents with moderate to severe post-traumatic stress disorder (PTSD) were treated with citalopram (the most selective of the selective serotonin reuptake inhibitors) in a fixed daily dose of 20 mg, and rated at 2-week intervals. The Clinician-Administered PTSD Scale (Child and Adolescent Version) was the primary measure used to assess treatment outcome. Core PTSD symptoms (re-experiencing, avoidance, and hyperarousal symptoms) showed statistically significant improvement at week 12 on the Clinician-Administered PTSD Scale (Child and Adolescent Version) (CAPS-CA), with a 38% reduction in total CAPS scores between baseline and endpoint. Citalopram failed to effect improvement on self-reported depressive symptoms. All seven adolescent completers were rated as much improved or very much improved on Clinical Global Impression Improvement scores. Citalopram was well-tolerated overall with reported adverse experiences being relatively benign. However, larger, controlled trials are needed to consolidate these preliminary results.

Single photon emission computed tomography in posttraumatic stress disorder before and after treatment with a selective serotonin reuptake inhibitor

BACKGROUND Posttraumatic stress disorder (PTSD) is recognized as a disorder mediated by specific neurobiological circuits. Functional imaging studies using script-driven trauma imagery and pharmacological challenges have documented altered cerebral function (activation and deactivation) in several brain regions, including the amygdala, hippocampus, prefrontal cortex and anterior cingulate. However, the neural substrates of PTSD remain poorly understood and the effect of selective serotonin reuptake inhibition on regional cerebral activity is deserving of further investigation. METHODS Eleven adult patients (seven men, four women) (mean age+S.D.=33.6+/-9.2 years) with a DSM-IV diagnosis of PTSD, as determined by the Structured Clinical Interview for DSM-IV (SCID-I) and the Clinician-Administered PTSD Scale (CAPS), underwent single photon emission computed tomography (SPECT) with Tc-99m HMPAO pre- and post-8 weeks of treatment with the selective serotonin reuptake inhibitor, citalopram. Symptoms were assessed at baseline and at 2-week intervals with the Clinician-Administered PTSD Scale (CAPS), Montgomery-Asberg Depression Rating Scale (MADRS), and the Clinical Global Impression Scale (CGI). Image analysis of baseline and post-treatment scans was performed using Statistical Parametric Mapping (SPM). RESULTS Treatment with citalopram resulted in significant deactivation in the left medial temporal cortex irrespective of clinical response. On covariate analysis, a significant correlation between CAPS score reduction and activation in the left paracingulate region (medial prefrontal cortex) was observed post-treatment. No significant pre-treatment differences were observed between responders and non-responders in anterior cingulate perfusion. CONCLUSIONS These preliminary findings are consistent with clinical data indicating temporal and prefrontal cortical dysfunction in PTSD and preclinical data demonstrating serotonergic innervation of these regions. However, further studies, in particular in vivo receptor imaging studies, are needed to confirm whether these regional abnormalities correlate with clinical features and treatment response.

Muscle dysmorphia : A South African sample

Abstract It has recently been suggested that muscle dysmorphia, a pathological preoccupation with muscularity, is a subtype of body dysmorphic disorder (BDD). There are, however, few studies of the phenomenology of this putative entity. Twenty‐eight amateur competitive body builders in the Western Cape, South Africa, were studied using a structured diagnostic interview that incorporated demographic data, body‐building activities and clinical questions focusing on muscle dysmorphia and BDD. There was a high rate of muscle dysmorphia in the sample (53.6%). Those with muscle dysmorphia were significantly more likely to have comorbid BDD based on preoccupations other than muscularity (33%). Use of the proposed diagnostic criteria for muscle dysmorphia indicated that this is a common and relevant entity. Its conceptualization as a subtype of BDD seems valid. The disorder deserves additional attention from both clinicians and researchers.

Forgiveness: Toward an Integration of Theoretical Models

Studies on forgiveness have only recently emerged in the psychological literature. Despite evidence that forgiveness is associated with positive therapeutic outcomes, the concept has received little theoretical consideration in mainstream psychology. Existing definitions and models of forgiveness differ widely, and little attempt has been made to integrate these diverse approaches. Based on a review of the Medline and Psychlit databases, the present article evaluates current conceptualizations of forgiveness in the psychological literature. The values and limitations of each approach are discussed with reference to two case studies: a close interpersonal relationship and a human rights violation presented to the Truth and Reconciliation Commission in South Africa. A new theoretical model, integrating the most valuable aspects of existing approaches, is proposed.

Functional brain imaging in obsessive-compulsive disorder secondary to neurological lesions.

Obsessive‐compulsive disorder (OCD) may result from a range of neurological lesions in frontal and basal ganglia areas. However, relatively few studies have explored functional brain imaging in acquired OCD.

The psychiatric sequelae of human rights violations: A challenge for primary health care

High rates of psychiatric morbidity have been documented in survivors of gross human rights abuses. Nevertheless, there has been relatively little focus on such patients in the context of primary care medicine. A sample of 134 survivors of gross human rights violations was assessed using a structured interview to determine exposure to violations and psychiatric status. In addition, psychiatric treatment history was probed with an open-ended interview. The study found that of the 95 of 134 (72%) participants who were assessed and found to have a current psychiatric diagnosis, only three were receiving treatment for such a disorder. Many subjects had presented to primary care clinics with somatic symptoms and had been prescribed benzodiazepines. Reasons for not reporting trauma or not seeking treatment included issues revolving around fear and mistrust, privacy and confidentiality, re-experiencing the trauma, and lack of awareness. Misdiagnosis and ineffective treatment of survivors of human rights abuses are likely to pose a significant drain on primary care resources. Accurate diagnosis and appropriate treatment are important challenges in primary care settings.

Pros and cons of medicalization: The example of trauma

Since the time of Hippocrates, and no doubt even before, there have been vocal and articulate critics of medical practice and values. In the modern era, philosophers and sociologists of medicine have introduced and developed the notion of ‘medicalization’ to describe how a range of different phenomena become seen as ‘disorders’ that require ‘therapy’ (Conrad and Schneider 1980). Typically this term is used in a critical way, that is the extension of medical discourse is seen as inappropriate, and it is argued that interventions other than ‘therapy’ are more appropriate. The BMJ recently devoted a number of pages to debating the limits of medicine (Moynihan and Smith 2002). Psychiatry is particularly often criticized for overextending its reach. Not all people who are suffering for one reason or another should be labelled with ‘depression’, and given ‘pharmacotherapy’. Similarly, it is pointed out that not all active kids should be labelled with a ‘diagnosis’ of hyperactivity, nor ‘treated’ with stimulating agents such as methylphenidate. These kinds of medicalization, it is argued, result in the inappropriate objectification of human suffering and deviance, and in inappropriate prescription of a pill for every ill (Sedgwick 1982). Articles that take this point of view have again recently been published in the BMJ (Double 2002). Areas within psychiatry that seem particularly contested are those involving trauma and violence. It has been argued, for example, that Western psychiatric models of ‘traumatization’ and ‘recovery’ are often inappropriately applied (Summerfield 2002). Similarly, proponents of biological models of violence have been roundly criticised for focusing on individuals at the expense of socio-political theories and interventions (Stein 1994). In the BMJ and elsewhere, such critics emphasize that constructs such as ‘posttraumatic stress disorder’ or ‘impulsive-aggression’ are peculiarly Western, and that ‘talk therapy’ and medication are inappropriate in situations where problems are moral rather than medical (Stein 1994; Summerfield 2002). It is important to recognize the potential value of this kind of critique. Such work emphasizes that science is not merely about the-world-out-there, but also is bound up with a range of social constructions including scientific language and practices (Bhaskar 1978). It reminds us that medicine is not simply a technical and factual field, but also is based in particular kinds of values (Fulford 2002). And it points out that psychiatry cannot be reduced to molecular neurobiology and psychopharmacology, or the provision of a band-aid of ‘counselling’, but also is necessarily about psychological meaning, social contexts, and taking action (Stein 1991; Stein et al. 2002). There are arguably good clinicians and bad clinicians, and the practise of better clinicians may well be consistent with many of the values put forward in critiques of medicine and psychiatry. When a clinician responds to any condition, whether it be a general medical or a psychiatric disorder such as depression or posttraumatic stress disorder, merely in terms of a cookbook diagnosis and accompanying algorithm, so ignoring the person with the condition, the meaning of their symptoms, and the social context, then the standard of care is concomitantly low. Conversely, an emphasis on the person with the condition, the meaning of symptoms, and the social context is precisely the realm emphasized by good practitioners of psychological medicine and psychiatry (Eisenberg 1995). Indeed, it is crucial also to recognize the limitations of these kinds of critique of medicine and psychiatry. Science is not merely about social construction, it involves an ever more powerful appreciation of the causal mechanisms that underlie normal and abnormal somatic and psychological phenomena (Bhaskar 1978). The values of medicine are not necessarily irrational or unfair, but can be wise, and with debate, can be improved further (Stein 1991). Psychiatry is not only about meaning and socio-cultural contexts, but also has much to contribute to understanding the psychosocial mechanisms that underlie somatic and psychological phenomena, and to determining how best to help those who suffer from somatic and psychological symptoms (Stein 1993). Consider, for example, depression and attention deficit hyperactivity disorder. Although there is room for debate about medical values; there is a wealth of data that people with these particular conditions suffer distress and disability (Kessler et al. The World Journal of Biological Psychiatry, 2006; 7(1): 2 /4