Major Depressive Disorder

also known as depression, is a psychiatric disorder characterised by a pervasively low mood and loss of interest or pleasure in usual activities for  two weeks or longer. It is associated with physiological changes such as appetite and weight, sleep, energy and libido. It usually causes an impaired motivation and insight and judgement and in function. According to the World Health Organisation (WHO) it is the most disabling condition in the world.   There is no laboratory test to confirm the diagnosis major depression.

The course of the disorder varies from  once-off episode to a lifelong disorder with recurrent relapses. The most common age of onset is between the ages of 30 and 40, with a later peak between 50 and 60 years. Statistically, major depression occurs more often in women than in men, although men are at higher risk for suicide.

25% of the general population have at least one episode in their lifetime. In untreated cases, 15% commit suicide.  As time progresses, with more relapses underlying, Bipolar Mood Disorder is often exposed.

Psychological, social and biological causes play a role. Neurotransmitters (brain chemicals) serotonin and noradrenaline and others are implicated. Most antidepressants increase the active levels of these neurotransmitters.

Psychological factors are involved, and psychotherapy is used to address them. Social intervention is frequently indicated. Hospitalisation may be necessary in cases associated with self-neglect or when there is a significant risk of suicide. Electroconvulsive therapy (ECT) is used in severe or resistant cases. ECT, if indicated, has an 80% success rate.

Antidepressants are widely used. The addition of CBT nearly doubles the remission rate. The duration of remission determines the long-term prognosis. If treated correctly, 80% of patients will improve and 60% will recover completely.

Anxiety Disorder

is an umbrella term covering several different forms of abnormal, pathological anxieties, fears and phobias.

In psychiatry, “fears”, “anxiety” and “phobia” have distinct meanings. The words are often used interchangeably in casual conversation. Clinically, a phobia is defined as a “persistent or irrational fear”. Fear is defined as “an emotional and physiological response to a recognised external threat”. Anxiety is “an unpleasant emotional state, the sources of which are not always clear”.

It is important to distinguish between different anxiety disorders as accurate diagnosis is more likely to result in effective treatment and a better prognosis.

Anxiety disorders are frequently accompanied by multiple physiological symptoms that may lead to fatigue, exhaustion and pain. Depression is frequently comorbidly present with anxiety disorders.

Surveys have shown that as many as 18% of Americans may be affected by anxiety disorders.

Since the Covid-19 pandemic, 55% of the South African population fulfils the criteria of an Anxiety Disorder.

Typical anxiety disorders are:       

• Generalised Anxiety Disorder

• Panic Disorder

• Specific Phobias

• Social Phobia

• Post-Traumatic Stress Disorder

The causes and treatment are biological, psychological and social. A combination of antidepressants and CBT is highly successful in most cases.

Social Phobia

(Social Anxiety Disorder) is frequently never diagnosed nor treated. It is characterised by a marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or possibly to scrutiny by others.

The person fears humiliation and scrutiny and this provokes anxiety. The person avoids the situations or endures it with distress, but realises that the fear is excessive. It therefore affects her/his global functioning.

Social phobia often leads to other problems such as depression or substance problems.

The prognosis is very good when treated with a combination of CBT and medication.

Specific Phobias

involve an intense and irrational fear of specific objects or situations that cause terror.

These phobias can be classified into many types eg: Blood-injection-injury Type (such as fear of seeing blood), Animal Type, Natural Environment Type (such as heights or storms),  Situational Type (such as enclosed places) or Other Type (if fear is triggered by other stimuli).

Bipolar Disorder

is a serious psychiatric condition. It was previously known as manic depression or bipolar affective disorder. The current term refers to the cycling between high and low episodes (poles). It is defined by the presence of one or more episodes of an abnormally elevated mood (clinically referred to as mania or, if milder, hypomania).

Depressive episodes (the other “pole”) are more common than manic episodes. With mixed episodes, both manic and depressive features are present at the same time. These episodes are usually separated by periods of a “normal” mood.

In some individuals, depression and mania may alternate rapidly.  This is called rapid cycling. Severe manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. The disorder is sub-divided into bipolar I, bipolar II, and other types. In the latest Diagnostic and Statistical Manual of the American Psychiatric Association (DSM V) it is seen as a bipolar spectrum disorder.

The onset of symptoms generally starts in late adolescence or early adulthood. Diagnosis is based on the person’s self-reported experiences or through observed behaviour. Episodes of abnormality are associated with distress,  global functional impairment and a greater risk of suicide, especially during depressive episodes (up to 30% in untreated cases).

In some cases, it can be a devastating long-lasting disorder. In mild cases, however, hypomania can be associated with creativity, goal-striving and positive achievements.

Approximately five percent of the population are affected. Men and women are equally affected. Genetic factors are involved in at least 80% of patients. Because it is mainly caused by biological (or genetic) factors, the treatment is primarily biological by means of mood stabilisers and other drugs. Psychotherapy plays an important roll and involves education, (including the families) keeping patients compliant, relapse prevention and rehabilitation.

In serious cases where there is a risk of harm to self or others, involuntary hospitalisation may be necessary.

These cases generally involve severe manic episodes with dangerous behaviour or depressive episodes with suicidal risk. There are widespread problems with social stigma, stereotypes and prejudice against individuals with a diagnosis of bipolar mood disorder.  The diagnosis seen in DSM V have become more inclusive: a spectrum disorder.

The condition ranks amongst the world’s 10 most disabling conditions. It cannot be cured, but the majority of adequately treated people with this diagnosis live absolutely normal lives, provided they remain compliant with the treatment, especially the medication.

Generalised Anxiety Disorder (GAD)

is defined as excessive and pervasive worry, accompanied by a variety of physical symptoms such as restlessness, fatigue, poor concentration, irritability, pain and sleep disturbance. The anxiety causes significant distress or impairment in social, occupational
or other important areas of functioning.

GAD affects up to 10% of the general population. The mean duration is 38 years, if left untreated. It often leads to secondary comorbid psychiatric disorders, such as depression, other anxiety disorders and substance disorders. Many people develop an addiction to prescribed tranquillisers.

People with GAD visit doctors such as GP’s and cardiologists far more frequently than non-affected people.

A combination of medication (usually antidepressants) and CBT and MBCT is highly successful in most cases.

Schizophrenia

is a neuro-psychiatric diagnosis that describes a mental disorder characterised by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganised speech and thinking. It is associated with significant social or occupational impairment.

The onset of symptoms is typically during adolescence. Approximately one percent of the population is affected.

Due to the many possible combinations of symptoms, there is debate about whether the diagnosis represents a single disorder or a number of discrete syndromes.

Schizophrenia is not the same as dissociative identity disorder (previously know as multiple personality disorder or split personality).  The two are often confused in popular culture.

Increased dopamine activity in parts of the brain is consistently found in schizophrenic individuals. The mainstay of treatment is antipsychotic medication. This type of drug primarily works by reducing dopamine activity.

Schizophrenia is a serious illness. However, early and “aggressive” treatment with newer medications can significantly improve the prognosis. Increasingly more people with this diagnosis lead normal lives.

Dementia

Alzheimer’s Disease is the most common cause of dementia.  It manifests itself in memory problems, impaired executive functioning and other symptoms. A person’s global cognitive functioning is affected.

The duration of the disease before death is between two and 20 years, with an average of eight years.

Five percent of the population are affected by the age of 65 years and 20-40% of people aged 85 suffer from it.

It is a progressive condition and there is currently no cure. However, some medications can temporarily delay the progress. There is a hopeful chance that new treatment options may be available in the near future to prevent it.

Other dementias include vascular dementia and mixed dementia (both Alzheimer’s and vascular dementia). There are also other rare dementias such as Lewy Body Disease.

Attention–deficit hyperactivity disorder (ADHD)

is a neuropsychiatric disorder affecting about 3-5% of the world’s population. It typically presents itself during childhood and is characterised by a persistent pattern of impulsiveness and inattention, with or without a component of hyperactivity.

ADHD in children is twice as common in boys than in girls. This is not the case in adults.  It is generally a chronic disorder. Ten to 60%  of  people who are diagnosed in childhood continue to meet the diagnostic criteria in adulthood. As they mature, adolescents and adults with ADHD are likely to develop coping mechanisms to compensate for their impairment. There is therefore usually a reduction in hyperactivity.

ADHD has a strong genetic component (over 80%). Treatment usually involves a combination of medications, behaviour modification, lifestyle changes, and psychotherapy. Stimulant medication is  appropriate and generally a safe treatment for ADHD. The most commonly used form is methylphenidate (the original trade name is Ritalin). The treatment with stimulants is effective in up to 70% of cases.

Untreated cases lead to many other secondary psychiatric problems such as poor self-esteem, substance dependence, and anxiety and mood disorders. The phases towards adulthood in untreated cases are described as “developmental delay, continuous display, and functional decay”.

Post-Traumatic Stress Disorder (PTSD)

is preceded by an emotional stressor such as rape, violent crime or war which was of a magnitude that would be traumatic for almost everyone. Symptoms include:  (1) re-experiencing the trauma through dreams and waking thoughts (2) persistent avoidance of reminders of the trauma and numbing of responsiveness to such reminders. (3) persistent hyper-arousal. The condition causes impaired functioning.

PTSD affects 1-3% of the adult population in the West. The incidence is much higher in South Africa.

People with PTSD frequently develop other psychiatric disorders such as depression and substance disorders.

The treatment comprises medication (mainly antidepressants) and CBT. The prognosis is good in optimally treated individuals.

Panic Disorder

happens when a person gets recurrent panic attacks. She/he worries that it may recur and worries about the implications of the attack (e.g. losing control, having a heart attack, or “going crazy”).

A panic attack is a discrete period of intense fear or discomfort in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes:

• Palpitations

• Sweating

• Trembling or shaking

• Shortness of breath

• Choking feeling

• Chest pain or discomfort

• Nausea or abdominal distress

• Dizzy or feeling faint

• Tingling sensation

• Chills or hot flushes

• Fear of losing control or going crazy

• Fear of dying

It often becomes a chronic, debilitating disorder. Depression or substance problems often complicate it in chronic cases.

Treatment consisting of a combination of medication and CBT is highly successful.

Obsessive-Compulsive Disorder (OCD)

is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations and compulsions. It causes severe distress and negatively influences the person's global functioning.

OCD affects 2-3% of the general population. The causes are diverse but seem mainly biological in origin. Research has shown that it is associated with abnormal functioning of the basal ganglia of the brain.

The treatment is complicated and should be supervised by a psychiatrist. The most successful intervention is a combination of CBT and high medication dosage (mainly antidepressants). Treatment is, however, unsuccessful in approximately a third of patients.It is no longer categorised as an anxiety disorder by theDSM V, but as a discreet biological disorder with psychological secondary complications.New biological treatments technique like Deep Brain Stimulation are very promising.