Addiction refers to the repeated use of psychoactive substances, to the extent that the user is periodically or chronically intoxicated, shows a compulsion to take the preferred substance, has great difficulty in voluntarily stopping or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means. The life of the addict may be dominated by substance use to the virtual exclusion of all other activities and responsibilities. Addictions affect performance at work, family and social relationships, and can have severe consequences to physical and psychological health. There are many different classes of drugs that can cause addiction: alcohol; benzodiazepines like diazepam, temazepam and alprazolam; opiates such as heroin, methadone, morphine; and stimulants like cocaine or amphetamines. Medical treatment of chemical dependence may involve detoxification and medication to help promote or maintain abstinence. Dependence on substances is associated with a withdrawal syndrome when substance use is interrupted. For some clients the substances they use will mean that withdrawal symptoms will be temporary and tolerable; for others, the first part of addictions treatment will involve medical detoxification, which will usually involve medications that substitute for the drug of dependence, and medications that alleviate other symptoms of withdrawal. Once the detoxification is completed, promotion of abstinence may include a combination of medication and/ or therapy delivered in residential programmes offering primary, secondary or tertiary care, or outpatient settings through fellowships such as Alcoholics, Narcotics or Cocaine Anonymous, (12 step treatment), or individual therapy that might involve Cognitive Behavioural Therapy (CBT), Eye Movement Desensitisation and Reprocessing (EMDR) or counselling. I have connections with a number of units in the UK, US, South Africa and Spain. For others who are unable to consider abstinence, treatment may be possible in the form of longer term maintenance, namely substituting the drug of dependence for another substance that is less harmful, prescribed by the doctor, giving patients the opportunity to consider healthier options away from street drugs and the problems associated with this lifestyle. If this is necessary, then I will refer you to a central London clinic specialising in maintenance. Over the last few years, other repetitive and harmful behaviours that share many of the characteristics of chemical addictions have been identified, such as gambling, sex, food, porn or the Internet. Once mood and anxiety disorders that can accompany these process addictions are excluded, treatments, as for the chemical addictions, will generally involve participation in fellowships such as Gambling Anonymous, individual therapy or group therapy or residential programmes.

Attention-deficit hyperactivity disorder is a developmental disorder manifesting as a behavioural syndrome characterised by 3 main symptoms: inattention, hyperactivity and impulsivity. As with any developmental disorders, a diagnosis of ADHD reflects an extreme of, or delay in, the rate that a normal trait is developing by comparison to same-age peers rather than an absolute loss of function, failure to develop or pathological fixed state. The primary problem in ADHD seems to be in executive function, which is hypothesized to contribute a shift in the source of control over human behaviour from: external events to mental representations related to those events; control by others to control by self; immediate reinforcement to delayed gratification; and the temporal now to the conjectured social future. The prevalence of ADHD ranges between 2-6% of children and the male: female ratio is approximately 3:1: 80% of the risk burden for the disorder is inherited. Approximately 20-40% of children continue to experience problems in the late adolescence and early adulthood, particularly with impulsivity and inattention, although hyperactivity symptoms typically decline is severity. Symptoms of inattention include failure to give close attention to detail, difficulty sustaining attention, not listening when spoken to, failing to follow through on instructions and complete tasks, difficulties organising tasks or activities, avoiding or disliking sustained mental effort, losing things needed for tasks, easily distracted by extraneous stimuli or forgetful in daily activities. Hyperactivity is characterised by fidgeting with hands or feet, socially inappropriate behaviour, wandering or running excessively, as well as subjective feelings of restlessness, difficulty engaging in leisure activities quietly, being ‘on the go’ or acting as if driven by a motor, or talking excessively. Impulsivity manifests in blurting out answers before questions completed, difficulty in waiting turn and interrupting or intruding on others. If these symptoms continue to interfere with vocational, social, marital or family functioning in adulthood, treatment is recommended. Medication is the first-line intervention for adult ADHD and the same drugs prescribed in childhood are used in adults, namely methylphenidate or amphetamine compounds, or if these are not tolerated, medication that also act to increase dopamine levels in the frontal cortex, such as desipramine or atomoxetine. Psychological interventions are aimed to help patients and their partners, families and work colleagues learn and adapt to their deficits. There are a number of interventions that might be helpful including CBT, self-management skills training, environmental re-structuring, psycho-education, individual psychotherapy, family therapy, marital or couples therapy, vocational counselling, or ADHD Coaching.

Anxiety is a normal reaction that happens to everyone at times of danger or in worrying situations. Most people will feel anxious before an interview, going into hospital or starting a new job. In these cases sleep, appetite and ability to concentrate can be affected. Anxiety can have physical symptoms: nervousness, trembling, muscular tensions, sweating, light-headedness, a feeling like the heart is beating faster or harder, dizziness, or the feeling you need to use the toilet. If everything goes well, the anxiety usually goes away but sometimes it can persist for longer. Anxiety can also be the result of experiencing stress over a long period of time. Some signs may indicate that anxiety or stress has become a problem, including if symptoms have become unpleasant and severe, you are very worried about something but there doesn’t seem to be a reason for it, or when it is affecting your day to day life and interfering with what you want to do. When anxiety becomes a disorder, symptoms are experienced in a number of ways. Generalised anxiety disorder (GAD) can be likened to chronic worry much of the time in the absence of stressors. As well as aforementioned symptoms, anxiety is “free floating”, i.e. it is not triggered by particular circumstances or situations, and nervousness is persistent, sometimes associated with fearing imminent illness or accident (in self or close others). In panic disorder, patients experience recurrent attacks of severe anxiety (panic), or are continuously preoccupied that they will suffer another attack. Panic attacks occur in other mental disorders. Patients can often remember exactly where they were when they suffered their first attack many years later. They are of sudden onset, peaking after a few minutes and resolving after approximately 15-20mins. These are not restricted to any particular situation and can therefore be unpredictable. Social phobia, or social anxiety disorder, is best likened to extreme and chronic shyness. The type of social situations in which the symptoms occur can range from specific and defined scenarios (such as public speaking) to more general social encounters. There are numerous other specific phobias where sufferers may go to great lengths to avoid such situations. One of the more common ones is agoraphobia, which involves fear of leaving home, riding on public transport, entering shops or crowded public places. Other examples include irrational fears about animals, heights, darkness, flying, certain foods, using toilets in public places, dentistry, blood or injury or vomiting. Phobias can coexist with panic disorder, generalised anxiety or depressive disorders. Obsessive compulsive disorder (OCD) is characterised by obsessional thoughts and/ or compulsive acts. These thoughts present as ideas, images, or impulses that enter the mind and are almost invariably distressing. Sufferers often try, unsuccessfully, to resist them. They are recognised as own thoughts, even though they are involuntary and unpleasant. Typical themes may involve worries about health, germs and contamination, having done (or being likely to do) something dangerous, sexual thoughts or images experienced as unpleasant, or feeling that things are “not right” or of being unsafe. Compulsive acts or rituals are repeated behaviours that the sufferer feels they must carry out to prevent the feared event occurring. They are neither enjoyable nor useful tasks, and may include excessive cleaning, washing, checking, repetitive acts or mental behaviours (e.g. counting or saying prayers). It is important to evaluate the type of anxiety disorder, as they have their own specific medical and psychological treatments.

Becoming low in mood is a normal emotional reaction that occurs when individuals experience, for example, the loss of someone close, a relationship break-up, or problems at work. ‘Normal’ low mood, however, remains reactive even in adversity with the ability to experience joy if circumstances change. In depressive disorders, mood is pervasively low; if it lifts, this is usually temporary. Depressive episodes can, for example, be precipitated by changing of the seasons, occur with physical or other psychiatric conditions, without obvious cause according to genetic vulnerability, or due to stressful life events; just because there is a good reason to feel low doesn’t mean one hasn’t developed a disorder. If a depressive illness has become established, low mood is associated with a number of other symptoms including reduced energy and pleasure in previously enjoyable activities; disturbed sleep and appetite; restless agitation or significant slowing of movement and thoughts; loss of confidence; and in severe cases, suicidal thoughts. The severity and duration, as well as the nature of past episodes and response to treatments, help determine the best intervention. This can range from watchful waiting to psychological therapy and medication. Depending on the nature and factors involved in your depression, there will be different therapeutic techniques (for example, cognitive behavioural, schema, interpersonal, integrative or psychodynamic) and types of medication that are more likely to be helpful. Once the depressive episode is beyond a certain level of severity, only a limited proportion of patients will improve without medical intervention. Yet, approximately 70% of cases respond well to treatment, re-establishing pre-episode levels of motivation and drive, and functioning with family, friends, work or education. Bipolar disorder, also referred to as ‘manic depression’, is a mood disorder manifesting in episodes of depression and elation that are distinct to the individual’s personality and entirely out of character. Bipolar I Disorder is characterised by more severe manic episodes whilst Bipolar II Disorder tends to have less severe manic episodes (hypomania) and more prolonged depressive episodes. The most common age of onset is mid-late 20s but it can arise in childhood and adolescence. A seasonal component is not uncommon with manic episodes more likely in the spring and summer with depressive ones more in the winter. Rapid cycling (4 or more mood swings a year) Bipolar Disorder can be particularly disruptive with mood swings occurring within hours. Severe episodes, either manic or depressive, can be associated with psychotic symptoms e.g. delusions and hallucinations. Symptoms of a manic episode include euphoria and over-optimism, inflated self-esteem and boasting, pressured speech and racing thought, overactivity and disinhibition, irritability and aggressive behaviour, poor judgment, increased libido, reckless and inappropriate behaviour e.g. overspending and drug/alcohol misuse, short attention span, and in mania, psychotic symptoms such as hallucinations and delusions. Depressive symptoms are as for depressive disorder, namely pervasively low mood, reduced energy and pleasure in previously enjoyable activities, disturbed sleep and appetite, restless agitation or significant slowing of movement and thoughts, loss of confidence, and in severe cases, suicidal thoughts. A number of factors are thought to predispose an individual to bipolar disorders. Family history significantly increases the likelihood of developing a bipolar disorder: approximately 20% of sufferers have a first-degree relative with a mood disorder. Imbalances of neurotransmitter (serotonin and noradrenaline) and hormonal metabolism have both been identified in precipitating manic and depressive episodes and illicit drugs and alcohol can exacerbate episodes. Traumatic or stressful events, bereavements and other losses can trigger both manic and depressive episodes. Effective treatment of bipolar disorder, where insight is often limited, especially in manic episodes, relies on an open and honest relationship with professionals, patient education and family support. Mood stabilising medications (e.g. lithium and anticonvulsants in particular Depakote) target the neurotransmitters involved in mood swings. Anti-psychotic medications (e.g. olanzapine and quetiapine) are sometimes necessary to deal with severe manic symptoms and psychotic symptoms occurring in both mania and depression. Antidepressants should be used with caution as they may trigger a manic episode. Cognitive Behavioural Therapy helps the individual learn strategies for predicting and better managing disturbances in mood, reducing relapses and minimising their negative impact. Individual and family therapy sessions help deal with previous adverse life events and relationship difficulties further minimising the risk of relapse.

The unique collection of ways a person thinks, feels and behaves makes up their personality. It has usually developed by the late teens or early twenties and in most cases, individuals’ personality is adaptive, allowing them to learn pro-social ways to get on reasonably well with others. For some people, however, patterns of thinking, feeling and behaving (often called personality ‘traits’) are established that remain longstanding, persistent and pervasive, and can make them experience significant problems in their life. They have difficulties establishing or maintaining relationships, getting on with friends, family or work colleagues, controlling their emotions and behavior, or learning from experience. As a result they can feel unhappy and distressed and/or find that they often upset or harm other people. In these circumstances, their personality structure may amount to disorder There are several different subtypes of personality disorder, but broadly they tend to fall into three groups or ‘clusters’, according to their emotional ‘flavour’: Cluster A personalities are suspicious or eccentric. Paranoid personality disordered individuals have a tendency to be suspicious of others, to hold grudges, to feel easily rejected and to think others are being nasty (even when evidence does not support this). Schizoids have a tendency to be emotionally cold or aloof, to dislike contact with others, to prefer their own company and to have a rich ‘fantasy’ world. Schizotypal PDs have a tendency to have odd ideas and to display eccentric behaviour, to exhibit a lack of emotion or inappropriate emotional reactions and to see or hear strange things (this may be related to the mental illness schizophrenia). Cluster B personalities are dramatic, emotional or erratic. Dissocial (also called antisocial) personalities demonstrate a tendency to have little consideration for the feelings of others, to get easily frustrated, to be aggressive and engage in criminal behaviour, to be impulsive, to find it difficult to learn from experience and to not experience guilt or remorse. Emotionally Unstable (borderline or impulsive) show a tendency to be impulsive, to have difficulties controlling emotions, to feel ‘empty’, to have low self-esteem, to self harm or make repeated suicide attempts, to establish relationships quickly but easily lose them, to feel paranoid or depressed and to sometimes hear ‘voices’, especially when stressed. Histrionic personalities have a tendency to be self-centered and to over-dramatise events, to be easily suggestible, to worry excessively about appearance, to crave drama and excitement and to experience rapidly shifting emotions. Narcissistic individuals show a tendency to feel very self-important, to harbour dreams of unlimited power, success and intellectual brilliance, to crave attention and/or to ask favours from others but rarely reciprocate, and a tendency to exploit others. Cluster C personalities are anxious and fearful. Anxious (avoidant) individuals demonstrate a tendency to feel near continuous anxiety and tension, to worry excessively, to feel insecure and inferior, to be very sensitive to criticism and to have an overwhelming need to be accepted and liked. Dependent personality disordered patients have a tendency to be passive and overly-reliant on others to make decisions, to feel hopeless and incompetent, to feel ‘abandoned’ by others and to experience difficulties coping with daily chores. Obsessive-compulsive (anankastic) individuals show a tendency to be perfectionistic, to experience excessive worry and doubt, to be preoccupied with minutiae, extremely cautious, to worry about doing the ‘wrong’ thing, to have high moral standards, to be judgmental, very sensitive to criticism and to have difficulty adapting to new/unfamiliar situations. The prevalence of personality disorder is estimated to be about 1 in 10, with particular subtypes being more common in men (eg. dissocial) and women (eg. emotionally unstable). People with personality disorder also seem to be more likely to suffer from other mental health problems such as depression or alcohol or drug problems. The exact cause of personality disorders is not known but a number of factors have been identified as likely contributors to the development of personality disorder. Some people with personality disorder have experienced physical and/or sexual abuse in childhood (especially emotionally unstable personality disorder), familial violence, or may have parents who drank alcohol excessively. Some evidence suggests that particular personality disorders occur more often in families where family members suffer from other mental health problems (for example schizotypal personality disorder in families where schizophrenia occurs) Some personality disorders can develop after brain injury. Recently, evidence has also emerged that the brains of people with antisocial personality disorder have very slight structural differences when compared to the brains of people without personality disorder. Treatment for people with personality disorder generally involves psychological therapies and less often medication. The type of therapy offered will usually depend on preferences of the sufferer, the particular difficulties they have, and sometimes, what treatments are available in a particular area. These can be offered either on a one to one and/or a group basis. Specific types of psychological treatments include Mentalisation, Dialectical Behaviour Therapy (DBT), Cognitive Therapy, Schema Focused Therapy, Cognitive Analytical Therapy (CAT) and Dynamic Psychotherapy. Antipsychotic medications can usually be prescribed in low doses to help with suspiciousness in the Cluster A personality disorders and with paranoid feelings and hearing ‘voices’ in Emotionally Unstable personality disorder. Antidepressants may help with mood instability, emotional difficulties, impulsivity and aggression in people with Cluster B personality disorders and can also reduce anxiety in those with Cluster C personality disorders. Mood-stabilisers can also help with rapidly fluctuating moods and can reduce impulsivity and aggression.

Psychosis is a syndrome observed in a number of mental illnesses such as schizophrenia, severe depressive episodes and mania. Some illicit drugs and alcohol can also cause psychotic symptoms, or they may result from medication (anti-Parkinsonian) and consequences of medical illnesses. Examples of psychotic symptoms include delusions, which are unshakeable beliefs that are false, maintained despite lack of proof or evidence to the contrary, and which are not culturally-bound or accepted by their religious background. Beliefs tend to be of a persecutory (being followed), conspirational (part of a conspiracy), or referential (others talking about them) nature, of grandiosity (being someone of great importance), or bizarre (where the content is so non-credible as for the clinician not have to require evidence to disprove it). Hallucinations are false perceptions, either visual, auditory, tactile, gustatory or olfactory, which are registered by the individual in the absence of an object giving rise to them. The experience of an hallucination strongly suggests the presence of an abnormal mental state and some types of hallucinations are only seen in certain disorders. The ability to construct thought patterns is disturbed giving rise to disorders of thought. The individual may jump from topic to topic without clear association between the two. Passivity experiences involve the belief that thoughts are being implanted into or taken from one’s mind, or that they are being ‘broadcast’ through some media, or that emotions and actions are being controlled by something/ someone external to themselves. Psychotic symptoms are often accompanied by changes in mood, which may be excessively high or depressed, and in movement that can range from excessive activity to immobility. A person may also have the experience of their thoughts being too fast or slow. This can lead to them having difficulties expressing ideas or maintaining a single spoken topic. In some cases, for example in schizophrenia, the sufferer’s personality, social and vocational functioning may be disturbed beyond the period of time that the patient suffers psychotic symptoms. On other occasions, the patient may experience more drawn out deficits in motivation, volition, mood and poverty of thought that may further impair overall functioning. An individual may experience a selection or all of the symptoms listed. Common to all of the symptoms is that they can be highly distressing for sufferers and their families. Because of the distressing content and nature of the symptoms, people with psychotic illnesses are sometimes at risk of behaviour that may cause harm to themselves or others. Depending on the severity of the symptoms, people with psychotic illnesses may receive inpatient or outpatient treatment. Anti-psychotic medication is the first-line treatment and is necessary in almost all cases where an individual suffers these symptoms e.g. psychotic depression, mania with psychosis and schizophrenia. Only in the rare occasions when the symptoms have resolved spontaneously after a few hours or days can the clinician consider not starting medication. Antipsychotics act on neurotransmitter systems to re-establish the appropriate balance in, for example, an overactive dopamine system. Cognitive behaviour therapy (CBT) has been shown to be an effective means of helping people to cope with psychotic symptoms when these are not entirely responding to medication alone. For example, they may learn to recognise that voices they hear cannot harm them or to question beliefs that they are at risk or being persecuted. It is sometimes necessary to rehabilitate patients with severe psychotic disorders to re-learn social and vocational skills.

Trauma can be experienced in the form of a single major event or a sustained experience of neglect or abuse during someone’s development that can give rise to adult conditions such as depression, anxiety, addictions or personality disorders. Post-traumatic stress disorder (PTSD) is a delayed or prolonged response to a traumatic event or situation. The event may have been either brief or long in duration but the person will have either been at risk of harm themselves, either perceived or real, or witnessed catastrophic events. Symptoms may occur from a few weeks to months after the event including: repeated reliving of the trauma in the form of intrusive memories (“flashbacks”); dreams or nightmares about the event; a sense of emotional “numbness”; detachment from other people; unresponsiveness to surroundings; inability to experience pleasure; avoidance of activities and situations reminiscent of the trauma; “hyperarousal” – a state of increased physical and psychological tension; “hypervigilance” – being particularly aware of potential threats; becoming more easily startled; insomnia; or anxiety and depression. Clearly the primary cause of PTSD is the event itself but not everybody who experiences a trauma will go on to suffer with PTSD symptoms. Therefore, other factors are likely to be relevant. There is evidence that some people are more vulnerable to stress whereas others have greater resilience. It is thought that genes play a part in these differences. PTSD symptoms are thought to be explained by a lack of regulation between areas of the brain involved with the processing of emotional memories. This means that the event is not fully processed and the brain therefore responds as if it is still at risk, releasing chemicals such as adrenaline. Traumatic events can undermine a person’s belief about the world being safe, or confirm beliefs that it is unsafe. This then impacts upon their strategies to cope. Avoidance of activities or places that remind a person of the trauma prevents them from processing the event and has a negative effect on their mood. The treatment of trauma will depend to a degree on its consequences, for example, addictions, anxiety or depressive disorders. However, some anti-depressant, antipsychotic and anxiolytic medications can help reduce the PTSD symptoms as well as the negative effects on a person’s mood. There are a number of interventions for PTSD. Cognitive Behaviour Therapy (CBT) involves learning strategies to manage the symptoms of PTSD as well as processing the memory of the trauma and addressing the avoidance that keeps the symptoms going. Eye Movement Desensitisation and Reprocessing (EMDR) works by helping a person to make sense of the traumatic memory whilst also using eye movements in order to help the brain processes involved in doing so.