Psychiatric Nursing

Outline

v  Introduction

v  Sheltered workshop

v  Correctional homes

v  Day care centres

v  Half way homes

v  Partial hospitalisation

v  Institutions India

v  Conclusion

v  References

INTRODUCTION

Community psychiatric nurses play an essential part in community care by:

v  Supporting patients and their families

v  Evaluating the patient’s clinical state

v  Supervising drug therapy, and

v  Encouraging social interaction.¹

So, knowledge of available rehabilitation facilities is essential for the nurses

WHAT IS PSYCHIATRIC REHABILITATION?

v  A person is considered to have disabilities when he/she persistently cannot perform up to the standards expected by the society.

v  Psychiatric patients have three kinds of disabilities:

·         impairment of function directly due to psychiatric symptoms, e.g. persistent hallucinations, social withdrawal, slowness in behaviour;

·         social disadvantages, e.g. unemployment, homelessness, stigma attached to being A psychiatric patient;

·         adverse psychological reactions, e.g. low self-esteem, helplessness, hopelessness.

v  Psychiatric rehabilitation includes two processes:

·         identifying, preventing, or minimizing the above three disabilities;

·         helping the person to develop and use his/her assets.

v  Rehabilitation also involves community nurses, social workers, occupational therapists, and even voluntary workers.

FACILITIES

Psychiatric rehabilitation facilities can be divided into non-residential and residential

v  Non-residential facilities include psychiatric day hospitals, psychiatric day training centres, sheltered workshops, and social clubs.

v  Residential facilities include halfway houses, compassionate rehousing, and long stay care homes.

In-patient care

v  With provision for occupational and social services

v  Sheltered work and recreational facilities in the walking distance.

Day Hospital

v  Patients attend for assessment, supervision of treatment and social activities

Out-patient Clinics

v  in the Community to avoid missing of appointments

v  Follow up by a community nurse

Psychiatric Day Hospital

v  As implied by its name 'hospital', the primary aim of this facility is treatment of psychiatric illnesses rather than rehabilitation of patients' disabilities.

v  Hence the key professionals involved are doctors and nurses.

v  The advantages of day treatment over in-patient treatment include more contact with the community, less risk of dependency, less social stigma, and less family disruption.

Psychiatric Day Training Centre

v  Aim of day training centres is rehabilitation of patients' disabilities, rather than the treatment of psychiatric illnesses.

v  Hence, there are no doctors and nurses.

v  The key professionals involved are social workers and occupational therapists.

v  Patients are usually expected to stay in the centre for rehabilitative training for about nine months.

v  While receiving training in the centre, patients have to return to psychiatric out-patient clinics for follow-up from time to time.

Sheltered Workshop

v  aim of this facility is for patients to work, rather than to receive rehabilitation.

v  This is reflected by the fact that patients can earn salaries, though meagre, for their production in the workshop, whereas in all other rehabilitation facilities, patients have to pay fees instead.

v  Patients work in sheltered workshops instead of finding open employment because they cannot perform up to the standards of normal people.

v  Compared with psychiatric day training centre, sheltered workshop has a much lower staff-to-patient ratio and no occupational therapist .

v  Patients‘ works are supervised mainly by non-trained staff.

v  Many psychiatric patients receive rehabilitative training in psychiatric day hospital or day training centre first.

v  After they have acquired sufficient occupational skills, they are then referred to sheltered workshop to practise these skills.

Social Clubs

v  Social club does not aim to rehabilitate patients actively.

v  It mainly provides recreational activities for patients to socialise among themselves, to prevent patients from idling alone.

v  The club may also organise educational gruops for club members selectively.

Halfway House

v  halfway house is a residential  rehabilitation facility.

v  It is indicated when patients have adverse home environment or no home at all, or when patients need rehabilitation in their social and domestic skills.

v  Halfway houses have no occupational therapist  and do not aim to train patients' occupational skills.

v  Residents usually go out to work in the day time.

Compassionate Rehousing

v  This facility is indicated for rehabilitated patients who cannot return to their families but who do not need to be placed in institutions.

v  Used by Govt. of Honkong

Long Stay Care Home

v  It is indicated for socially disabled mental patients who cannot live independently and who need care.

v  It is expected that only a small proportion of its residents can eventually be discharged back to the community.

v  Long stay care homes differ from psychiatric hospitals.

v  Here, a few hours of may be made available per week.

Correctional homes

v  For young child who has been found guilty of an offence that would be categorised as a crime if committed by an adult.

v  Many are boys between the age of 15-17 years

v  Eg: Correctional Home at Madiwala, Bangalore…

Psychosocial Rehabilitation Institutions in India

v  Centre for Rehabilitation- CIP : Rehabilitation services in the form of Occupational Therapy Unit from 1922.

v  NIMHANS- Comprehensive care and rehabilitation for psychiatric and neuro patients, NIMHANS created a separate department in 1985.

v  The Richmond Fellowship Society (India)

v  Vishwas Day Care Centre with Vocational Training

v  VIMHANS (Vidyasagar Institute of Mental Health and Neuro-Sciences)-New Delhi

Institutions in Kerala

v  IMHANS is an autonomous institution established by the State Government of Kerala in 1983.

v  Mental Health Centre, Kozhikode

v  Mental health Centre, Thrissur & Thiruvanathapuram

v  Shraddha Rehabilitation Foundation- Mumbai

v  Institute of Psychiatry, Kilpauk, Chennai

v  Kusumagiri Mental Health Centre ( KMHC)

CONCLUSION

Psychiatric patients have various disabilities that require rehabilitation. There are insufficient rehabilitation facilities in India. Researches on the needs and effectiveness of various facilities are urgently required. Nurses should assess patients' disabilities and then they should refer disabled patients to the appropriate facilities for rehabilitation.

REFERENCES

1.       Chiu LPW. Psychiatric Rehabilitation in Hong Kong. Honkong University Journal,10:9, 9:1988.

Notes:

 TREATMENT:

v  Treatment of the underline cause- for example the management of hypertension in multi-infracts dementia.

v  Symptomatic management

o   Environment manipulation to reduce stress in day to day activities

o   Treatment of medical complications. Care of food and hygiene supportive care for the patient.

o   Anxiety can be treated by short acting benzodiazepines.

o   Depression can be treated with low doses of SSRIs.

o   Psychotic symptoms and disruptive can be treated with antipsychotic. Short term hospitalization.

 

v  Drug Therapy-

o   Cholinesterase inhibitors' (are thought to work by increasing the levels of acetylcholine in the synapses) Examples include donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl). They can improve memory, as well as slow down some of the changes in personality and mood. They may also be of benefit in Lewy body dementia.

o   NMDA Antagonists- Mementine

NURSING MANAGEMENT

v  Assessment:

o   Confusion with or without period of awareness.

o   Feeling of frustration

o   Impaired memory

o   Disinterest in surrounding

o   Socially inappropriate behavior

o   Decreased social interaction

v  Nursing diagnosis:

o   Self care deficit-bathing/hygiene; dressing /Grooming, Feeding and Toileting

o   Impaired Social interaction

v  Nursing Intervention:

o   Provide a safe environment

o   Establish good interpersonal relationship

o   Facilitate adequate grooming hygiene and other activities of daily living. Maintain adequate food and fluid intake

o   Facilitate adequate rest and sleep

o   Facilitate orientation Decrease socially inappropriate behavior and facilitate the development of acceptable social skill.

o   Increase interest in surrounding.

o   Involve the family and community in treatment and rehabilitation programme.

Notes:

INTRODUCTION

• Succession of losses common to nurses and often may not have time to resolve losses before another loss occurs
• Bereavement is a state of being deprived of something which doesn't have to refer to death but usually does.
• Grief is the reaction to bereavement which has many dimensions- physical, emotional, cognitive and spiritual response and it is a normal and healthy reaction. Grief is one of the powerful emotional states occur often with loss of a person, thing or place to which we are emotionally attached.
• Most stressful life event: death of spouse -Holmes and Rahe (1967).
• Cultural and Gender Differences must be taken care of when dealing with grief and loss.

TYPES OF GRIEF REACTION

1. Delayed Grief Reaction- delay in beginning of mourning process or slowing the process once started (Anniversary reaction; incomplete mourning at the time of loss )
2. Distorted Grief Reaction -depression or melancholia
3. Anticipatory Grief (Lindemann, 1944) -Reactions to losses that have not yet occurred and are not yet in process. For example, Spouse becomes so concerned with their adjustment in the face of a potential death and go through all the phases of grief prior to the actual death

FEATURES OF GRIEF REACTION

• Common Grief Responses
  Feelings
• Sadness
• Anger
• Guilt & self-reproach
• Anxiety
• Loneliness
• Fatigue
• Helplessness
• Shock
• Yearning
• Emancipation
• Relief
• Numbness

COMMON GRIEF RESPONSES
Physical Sensations

• Tightness in the chest
• Shortness of Breath
• Lack of Energy
• Panic Attack-like symptoms

Cognitions

• Disbelief
• Confusion
• Sense of Presence
• Lack of Concentration

Behaviors

• Sleep disturbances
• Appetite disturbances
• Social withdrawal
• Dreams of the deceased
• Absent-minded behavior

THEORIES ON BEREAVEMENT

• Elizabeth Kubler-Ross: Stages
• William Worden: Four tasks of grieving
• Robert Neimeyer: Rebuilding life and search for meaning

The Four Tasks of Mourning-Worden, 1991

• To Accept the Reality of the Loss
• To Work Through to the Pain of Grief
• To Adjust to an Environment in Which the Deceased is Missing
• To Emotionally Relocate the Deceased and Move on With Life

Seven Stages of Grief (Robert Kavanaugh)

• 1. Shock
• 2. Disorganization
• 3. Volatile Emotion
• 4. Guilt
• 5. Sense of loss & loneliness
• 6. Relief
• 7. Reestablishment *

NURSING PROCESS

Grief Assessment

• What was the relationship
• Nature of the Attachment
• Mode of Death
• Historical Antecedents
• Personality Variables
• Social Variables

Interventions

1. Help the survivor actualize the loss
2. Help the survivor to identify and express feeling
3. Assist Living Without the Deceased
4. Facilitate Emotional Relocation of the Deceased

Counseling Principles

• 1. Provide time to grieve
• 2. Interpret "normal" behavior
• 3. Allow for individual differences
• 4. Provide continuing support
• 5. Examine defense & coping styles
• 6. Identify pathology and refer

Predictors of Negative Bereavement Outcome

• Age and education
• Social support
• Opportunities for anticipatory grieving
• Relationship with spouse
• Number of concurrent life stressors
• Time since death
• Financial status

CONCLUSION

• Loss, grief and bereavement need to be assessed with ongoing intervention
• Nurses must recognize and respond to their own grief
• Interdisciplinary care is required for better results
• Completion of the Grieving Process
• No one can predict completion
• Grief work is never completely finished
• Healing occurs when the pain is less

"Mourning never ends.  Only as time goes on, it erupts less frequently."

                                                                                              - AWidow in her 60s

REFERENCES

1. Therese A. Rando Treatment of Complicated Mourning.  Research Press, Champaign, IL; 1993.
2. Worden W .  Grief Counseling and Grief Therapy, New York:  Springer Publishing Company: 1982
3. American Family Physician Article (www.aafp.org/afp/20020301/883.html</a>)
4. Lindemann E.  Symptomatology and management of acute grief.  Am J Psychiatry.  1944; 101: 141-8.

Notes:

INTRODUCTION

Amphetamine and amphetamine related substances are the second most widely misused drug in Asia and many other countries. Metamphetamine, a congener of amphetamine has become more popular in the recent years.

HISTORY

Amphetamine was first synthesized in 1887 and was introduced in to the clinical use in 1932 as an over the counter inhaler for the treatment of nasal congestion and asthma. 1n 1937 onwards it used for the treatment of narcolepsy, depression, post encephalitic Parkinsonism. The current FDA approved indications for amphetamine are for the treatment of attention deficit hyperactivity disorder and narcolepsy. In some countries it also uses for the treatment of obesity, depression, chronic fatigue syndrome, AIDS, and dementia.

PREPARATIONS

The major amphetamine preparations are

• Dextroamphetamine
• Metamphetamine (Desoxyn)
• A mixed detroamphetamine - amphetamine salt (Adderall)
• The amphetamine like compound methylphenidate (Ritalin)

These drugs go by such street names as ice, crystal, crystal meth and speed. Amphetamines are referred to as stimulants, sympathomimetics, analeptics and psycho stimulants. These are used to increase the performance and to improve the euphoric feeling. (Students studying for the exam, truck drivers, athletes for the competition,by soldiers during war time etc)

Other amphetamines like substances are ephedrine, psuedoepedrine, phenylepropanolamine (PPA). Amphetamine like dugs with abuse potential are also include phendimetrazine and diethylpropion, benzphetamine(Direx), and phentermine(ionamine).

EPIDEMIOLOGY

Amphetamine use occurs in all socioeconomic groups. According to DSM IV TR the life time prevalence of amphetamine dependence and abuse is 1.5% and the male to female ratio is 1.

ETIOLOGY

The familial, social, and psychological factors are relevant in the etiology of amphetamine misuse. Two-thirds to three-quarters of drug misusers have an underlying personality disorder, usually of the antisocial type,

CLINICAL FEATURES

• Amphetamine has a slower onset of action and a longer elimination half-life. Thus an amphetamine user may experience desired effects, unwanted mental effects, and withdrawal features over the course of a few days,
• A single 5mg dose increases the feeling of wellbeing and induces elation, euphoria and friendliness. Small doses usually improve performance and concentration. An associated decrease in fatigue, nightmares, fears, reduction of pain perception etc also seen.
• Mood is elevated, but these progresses to suspicion, in which true paranoid symptoms may be experienced and if use persists symptoms may become severe, or a more confused state develop.
• After stopping the drugs there are typically withdrawal effects of depressed mood, hyperphagia, and hypersomnia; such features are viewed as 'rebound' symptoms,
• It is commonly observed that amphetamine is non-addictive, or cause psychological but not physical dependence. It can be addictive' when individuals are injected amphetamine 10 or more times every day for many years,

Effects	Withdrawal effects
Increased energy Hyperactivity Euphoria Reduced appetite Insomnia Paranoid symptoms Confusion	Depression Irritability Agitation Craving Hyperactivity Hyperactivity Hypersomnia

NEUROPHARMACOLOGY

All the  amphetamines are rapidly absorbed orally(when compare to other stimulants like cocaine, its absorption rate is slow). And have rapid onset of action usually with in one hour when take orally. The classic amphetamines can take IV and the action will be very rapid in this route. Non described amphetamines and designer amphetamines can be inhaled (snorting). Tolerance develop with both classic and designer amphetamines. It is less addictive when compare with cocaine.

• The classic amphetamines produce primary effects by causing the release of catecholamines, particularly dopamine from the presynaptic terminals. It has effect on the dopaminergic neurons projecting from the ventral tegmental area to the cerebral cortex and limbic areas. This path way has been termed as reward circuit pathway and its activation is the major addictiong mechanism for the amphetamines.
• The designer amphetamines causes the release of the catecholamine's (dopamine and nor epinephrine) and of serotonin (the neurotransmitter implicated as the major neurochemical pathway of hallucinogens.). so the clinical effects of designer amphetamines are blend effect of classic amphetamines and those of hallucinogens.

DIAGNOSIS

DSM IV TR lists many amphetamine related disorders, but specific diagnostic criteria are available only for amphetamine intoxication, amphetamine withdrawal,  amphetamine related disorder not otherwise specified.

AMPHETAMINE (OR AMPHETAMINE-LIKE SUBSTANCE)-RELATED DISORDERS (DSM IV TR)

Amphetamine Use Disorders

304.40  Amphetamine Dependence a,b,c

305.70  Amphetamine Abuse

Amphetamine-Induced Disorders

292.89  Amphetamine Intoxication 

292.0  Amphetamine Withdrawal

292.81  Amphetamine Intoxication Delirium

292.xx  Amphetamine-Induced Psychotic Disorder

            .11 With Delusions

            .12 With Hallucinations

292.84  Amphetamine-Induced Mood Disorder,

292.89  Amphetamine-Induced Anxiety Disorder,  

292.89  Amphetamine-Induced Sexual Dysfunction,

292.85  Amphetamine-Induced Sleep Disorder     

292.9  Amphetamine-Related Disorder NOS

1.      Amphetamine dependence and amphetamine abuse

Amphetamine dependence dependence can result in a rapid downward spiral of a persons ability to cope with work, and family related obligations and stress. A person who abuse this drug requires high doses of amphetamine to to obtain the usual high and physical signs of amphetamine abuse(decreased weight and paranoid ideas) almost develop with the continuous use.

2. Amphetamine intoxications.

The symptoms of intoxication are mostly resolved after 24 hours and are generally completely resolved after 48 hours.

3.      Amphetamine withdrawal

After amphetamine intoxication, a crash occurs with symptoms of anxiety, dysphoric mood, lethargy, fatigue, night mares, head ache, profuse sweating, muscle cramps, stomach cramps etc. it will be peak in 2-4 days and are resolved with in one week. The most serious withdrawal symptom is depression which can be severe after the continuous use of the drug and also associated with suicidal ideations

4.      Amphetamine intoxication delirium

Delirium associated with amphetamine use generally result of high doses or of sustained use of the drug. The combination of amphetamine with other drugs and the use of amphetamine by the persons with pre existing brain damage also will lead to the development of delirium.

5.      Amphetamine induced psychotic disorder

Amphetamine induced psychotic disorder are similar to the clinical presentation of paranoid schizophrenia. The hall mark of amphetamine induced psychosis is paranoia. The amphetamine induced psychosis can be distinguished from paranoid schizophrenia by the clinical features such as visual hallucinations, ambivalence, association disturbances which are evident schizophrenia. The treatment of choice for this condition is the use of antipsychotics such as haloperidol.

6.      Amphetamine induced mood disorder

According to DSM IV TR the mood disorders associated eith amphetamine are during the intoxication and withdrawal states. Intoxication is associated with manic or mixed mood states where as withdrawal is associated with depressive symptoms

7.      Amphetamine induced anxiety disorders

Amphetamine induced anxiety disorders can also during intoxication and withdrawal periods. Amphetamines can induce symptoms which are similar to OCD, panic disorders, and phobia

8.      Amphetamine induced sexual dysfunction

Amphetamines can be use as an antidote to the sexual side effects of serotonergic agents such as fluoxetine, but they often misuse to enhance sexual experience. High doses and long term use are associated with erectile problems and other sexual problems. It is more evident in the intoxication states also.

9.      Amphetamine induced sleep disorder

Sleep disorders are present in intoxication as well as withdrawal states. Intoxication can cause insomnia and sleep deprivation and withdrawal can cause hyper somnolence and nightmares.

ADEVERSE EFFECTS

PHYSICAL

• Can produce most serous adverse effects which include cerebrovascular, cardiac and gastro intestinal effects. The life threatening conditions like MI, severe hypertension, CVA, and ischemic colitis are more common among abusers
• A continuum of neurological symptoms like twitching, tetany, seizures , coma, death etc can develop.
• IV use of the drug can cause the transmission of infectious diseases like AIDS and hepatitis.
• The non threatening adverse effects are flushing, fatigue, pallor, cyanosis, fever, bradycardia, palpitations, nausea, vomiting, bruxism, shortness of breath, tremor and ataxia.
• Pregnant women who use this drug often have babies of low birth weight, small head circumference, early gestational age and growth retardation

PSYCHOLOGICAL

• The adverse psycho logical effects include restlessness, dysphoria, irritability, hostility, confusion
• Amphetamine use can also lead to disorders like anxiety disorders, panic disorders, ideas of reference, paranoid delusions, and hallucinations
• Acute intoxication may present as a paranoid hallucinatory syndrome which closely mimic paranoid schizophrenia. The distinguish features of this are prominence of visual hallucinations, absence of thought abnormalities, presence of confusion.
• Tactile hallucinations in clear consciousness may occur in chronic amphetamine intoxication

TREATMENT

Treatment of intoxication

• Acute intoxication is treated by symptomatic management.(eg: hypepyrexia- cold sponging, seizures-diazepam, psychotic symptoms- haloperidol and hypertension-antihypertensives).
• Acidification of urine with oral NH4CL 500mg every 4 hours facilitates the elimination of amphetamines

Treatment of withdrawal symptoms

• The presence of suicidal depression requires hospitalization
• The treatment includes symptomatic management, use of antidepressants and supportive psychotherapy. The management of withdrawal syndrome is the first step of treatment of amphetamine dependence.
• Physicians should establish therapeutic alliance with the clients to treat the underlying depression and personality problems
• Bupropion can be use once the patient recover from the withdrawal symptom to enhance the feeling of well being.

REFERENCES

• Kaplan HI, Sadok BJ. Synopsis of psychiatry-behavioural science or clinical psychiatry.9^th edn. Hong Kong.William and Wilkinsons publications. 1998.
• GelderM,Gath D,Mayou R,Cowen P. New oxford text book of psychiatry. 4^th edn.Oxford. Oxford university press.2004
• Ahuja N.A short text book of psychiatry. 5^th edn. New Delhi. Jaypee brothers medical publishers.2004.
• Townsend MC. Psychiatric mental health nursing. 3^rd edn. Philadelphia. FH Davis publishers.

INTRODUCTION

Caffeine is the most widely consumed psychoactive substance in the world. Psychiatric symptoms and disorders can be associated with its excessive use. DSMIV TR lists several caffeine related disorders, eg-caffeine intoxication, caffeine induced anxiety disorder and caffeine induced sleep disorder. Other caffeine related disorders are caffeine withdrawal and caffeine dependence.

EPIDEMIOLOGY

Caffeine is contained in drinks, foods, prescription medicines and over the counter medications. An adult consumes about 200mg of caffeine per day on an average and 20-30% of adults consumes more than 500mg of caffeine per day. A cup of coffee contains around 100 to 150mg of caffeine; tea about one third as much. Many over the counter medications contains one third to one half as much caffeine as a cup of coffee and some migraine medication and over the counter medicines contains more amount of caffeine than a cup of coffee.   Cocoa, chocolate and soft drinks also contain significant amount of caffeine, enough to cause some symptoms of caffeine intoxication in small children when they ingest a candy bar or cola drink.

Caffeine consumption also varies by age. The average daily caffeine consumption of caffeine consumers of all age is 2.79mg/kg body weight. A substantial amount of caffeine is consumed by small children also.

COMORBIDITY

Persons with caffeine related disorders are more likely to have additional substance related disorders than are those with out diagnosis of caffeine related disorders. About two third of those who consume large amounts of caffeine daily also use sedative and hypnotic drugs. 

ETIOLOGY

After exposure to caffeine , continued caffeine consumption can be influenced by several factors, such as pharmacological effects of caffeine, caffeine's reinforcing effects, genetic predisposition to use caffeine and personal attributes of the consumer.

NEUROPHARMACOLOGY

Caffeine is more potent. The half life of caffeine in human body is 3-to 10 hrs, and the time of peak concentration is 30-60 min. Caffeine readily crosses the blood brain barrier. Caffeine acts primarily as an antagonist of adenosine receptors. Adenosine receptors activate an inhibitory G protein and thus inhibit the formation of the second messenger cyclic adenosine mono phosphate (cAMP). Caffeine intake result in an increase in intraneuronal cAMP concentrations in neurons with adenosine receptors. Three cups of coffee are estimated to deliver the amount of caffeine which occupy about 50% adenosine receptors

High doses of caffeine can affect the dopaminergic and noradrenergic system. Dopamine activity is enhanced by the caffeine activity, so it may be the reason of exacerbation of clinical symptoms in patients with schizophrenia in increased caffeine intake.

Subjective effects and reinforcement

Single low to moderate amount of caffeine can produce a subjective wellbeing in human beings and is generally indicated as pleasurable. caffeine causes increase in energy, motivation, capacity to work and concentration. Caffeine decreases the sleep and fatigue. 300-800mg of caffeine may lead to anxiety and nervousness. At low doses it act as a reinforce and this effect contribute to the regular use of caffeine.

Genetics and caffeine use.

Some genetic predispositions are present in caffeine use. Monozygotic and dizygotic twins have high concordance. It is more in monozygotic twins than dizygotic twins and heritability ranging from 33 to 77 percent.

Age, sex and race.

Studies suggest that middle age people use more caffeine, there is no much difference in caffeine use among male and females.

Special populations

Smokers consume more caffeine than non smokers. Studies shown that the higher rates of caffeine use in psychiatric patients populations than the general population. Patients who have anxiety disorders tend to use less amount of caffeine.

Effects on cerebral blood flow.

Caffeine result in cerebral vasoconstriction, with a resultant decrease in cerebral blood flow . cerebral blood flow improves after withdrawal from the caffeine. Many other studies reveals that caffeine can cause coronary artery constriction.

DIAGNOSIS

Diagnosis of caffeine related disorders and caffeine dependence are depend primarily on the comprehensive history of the patient. The history should cover whether the patient has experienced any symptoms, pattern of caffeine intake, whether the person had tried to stop the intake of caffeine etc.

The differential diagnosis of caffeine related disorders are anxiety disorders, panic disorders with or without agora phobia, bipolar II,  ADHD, and sleep disorder. The differential diagnosis should include the intake of OTC, anabolic steroids, and stimulants such as amphetamines. A urine sample is needed to screen for other stimulants.

CAFFEINE-RELATED DISORDERS (DSM IV TR CRITERIA)

Caffeine-Induced Disorders

305.90 Caffeine Intoxication

292.89 Caffeine-Induced Anxiety Disorder

292.85 Caffeine-Induced Sleep Disorder

292.9 Caffeine-Related Disorder NOS

I. Caffeine intoxication

Diagnostic criteria includes the recent consumption of caffeine, usually more than 250mg. common symptoms associated with caffeine intoxication are anxiety, psychomotor agitation, restlessness, muscle twitching, , psychophysiological complaints, nausea , dieresis, GIT upset, tingling in the fingers and toes. Consumption of more than one gram of caffeine can cause rambling of speech, confused thinking, cardiac arrhythmias, agitation, tinnitus and visual hallucinations.

DSM IV TR

A. Recent consumption of caffeine intake usually more than 250 mg(more than 2-3 cups of brewed coffee)

B. Five or more of following signs, developing during, shortly and after the caffeine use

• Restlessness
• Nervousness
• Excitement
• Insomnia
• Flushes face
• Dieresis
• GIT disturbances
• Rambling flow of thought and speech
• Tachycardia or cardiac arrhythmia
• Periods of inexhaustibility
• Psychomotor agitation

C. The symptom in criteria B causes significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to general medical conditions and are not better account for any other mental disorders.

II. Caffeine induced anxiety disorder

Caffeine induced anxiety disorder can occur during caffeine intoxication. The anxiety related to caffeine use can resemble the generalized anxiety disorder. The patient may be perceived ad wired, over talkative, and irritable. They may complaint of reduced sleep. Caffeine can induce and exacerbate panic attacks in persons with panic anxiety disorder.

III. Caffeine induced sleep disorder.

Caffeine induced sleep disorder can occur in acute intoxication. Caffeine is associated with delay in falling sleep, inability to remain in sleep, and early morning awakening.

IV. Caffeine related disorder not otherwise specified.

Caffeine dependence and caffeine withdrawal are not included in DSM IV TR. They are included in the classes- caffeine related disorder NOS

CLINICAL FEATURES

Signs and symptoms

After the ingestion of 50-100mg of caffeine , common symptoms includes increased alertness, a mild sense of wellbeing and a sense of improved verbal and motor performance. Caffeine ingestion is also associated with dieresis, cardiac muscle stimulation, increased intestinal peristalsis, increased gastric acid secretion and increased blood pressure.

Caffeine use and nonpsychiatric illness

• There are significant risks from caffeine use. They are cancer, heart diseases, reproduction problems etc.
• Caffeine use is contraindicated in generalized anxiety disorder, panic disorder, primary insomnia, pregnancy, gastro esophageal reflux disease.
• Caffeine increases the blood pressure.
• There is association between caffeine consumption and low birth weight babies.

TREATMENT

• Analgesics such as aspirin can use to control the head ache because of caffeine withdrawal. Rarely patients need benzodiazepines to manage the withdrawal effects. If benzodiazepines use for this purpose it should use invery small doses for 4-7 days.
• Person should recognize all sources of caffeine in his diet and control the caffeine intake. Because caffeine is use in the beverage form, it can be substituted with beverages which are noncaffenated. The patient should avoid stopping the caffeine intake abruptly, caffeine intake should taper first before proceed to the complete abstinence.

REFERENCES

• Kaplan HI, Sadok BJ. Synopsis of psychiatry-behavioural science or clinical psychiatry.9^th edn. Hong Kong.William and Wilkinsons publications. 1998.
• GelderM,Gath D,Mayou R,Cowen P. New oxford text book of psychiatry. 4^th edn.Oxford. Oxford university press.2004
• Ahuja N.A short text book of psychiatry. 5^th edn. New Delhi. Jaypee brothers medical publishers.2004.
• Townsend MC. Psychiatric mental health nursing. 3^rd edn. Philadelphia. FH Davis publishers