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The Royal College of Psychiatrists Improving the lives of people with mental illness

Organic psychiatry

Cape Town

Organic psychiatry was what attracted me to an elective in Cape Town and I was not disappointed. Differential diagnoses for psychotic presentations included HIV or opportunistic cerebral infections, temporal lobe epilepsy and tik (methamphetamine) psychosis – the single largest mental healthcare burden on the psychiatric wards. Tik is described as an ‘epidemic’ by psychiatrists here because its use has exploded among the urban poor of the townships. Methamphetamine can be easily manufactured using basic items including ephedrine and ammonium fertiliser, making it widely available (and commonly produced in rural farming areas). Cheap, tik is described as ‘the poor man’s cocaine’, since its effects last much longer. It is highly addictive and associated with aggression, hypersexuality and violence – resulting in high crime rates in communities already plagued by gangs, gun and knife crime.

Road sign
Most of the patients I met with tik psychosis were admitted for their own or others’ safety, until they had recovered in about a week. In others, however, methamphetamine formed the trigger for a much more enduring psychotic illness, in some the starting point for lifelong Schizophrenia. In Cape Town, tik played a role much like that of cannabis in the UK: patients who became abstinent from the substance recovered better, while those who returned to tik abuse, widespread among their peers, tended to relapse.

On the neuropsychiatry ward (five beds in a city with 17.8% HIV prevalence),I observed two unusual cases of psychosis and Multi Drug-Resistant tuberculosis in young women who were HIV negative. This presentation was unfamiliar to the team. After extensive research, they considered the most likely cause to be a rare neurotoxic response to Quinolone antibiotics prescribed for MDR TB. Another woman on the ward had a more predictable picture of HIV encephalopathy associated with an extremely low CD4 count. What intrigued me about these cases was the clear need to treat mental illness with physical therapy. In Britain, the law clearly distinguishes between treatment of the mind and the body. The Mental Health Act allows for treatment against a patient’s wishes for a disorder of the mind, but not for one of the body. This was upheld in a case where a patient with paranoid schizophrenia (Re: C) was able to refuse amputation of his gangrenous leg, despite it being life-threatening, because he had capacity to make that decision about his physical health, however unwise. This leads to difficulties with physical treatment (such as refeeding) for psychiatric disorders (such as anorexia nervosa).

Cape Town

In Cape Town, there were so many possible organic aetiologies for psychiatric presentations that doctors had to prescribe physical treatment for psychiatric disorders, in their patients’ best interests. For example, in the many patients with depression, psychosis or dementia directly attributable to their HIV infection, the treatment simply was Anti-Retroviral Medication – and this is what was prescribed. However, infectious disease specialists were loath to commence ARVs in patients who lacked the insight to commit to a life-long course, since the risks of non-compliance are high. Observing the practice of neuropsychiatry in Cape Town brought home to me theinconsistencies in the mind/body dualism upon which mental health legislation is founded. It may have its roots in religious separation of the ‘soul’ from the body, or in Cartesian traditions that reject the materialist view that mind and body are one. But artificially separating the mind from the body prevents us from seeing the whole person and encourages you to ignore physical complaints when treating the mind or forget psychiatric concerns when treating the body. I saw how this is potentially very dangerous, clinically, not to mention, detrimental to the relationship with a patient. It was exciting in Cape Town to observe the genuine enactment of the oft-quoted buzzword, holistic healthcare, as doctors considered every aspect of the individual in their diagnosis, treatment and management.

The Valkenberg Psychiatric Hospital shield - the raven 'valk' Valkenberg Psychiatric Hospital

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Re: Organic psychiatry
Thanks Dr Keynejad for this interesting overview of organic psychaitry in Cape Town. With regards, to mind-body dualism; Dr Hill is in his forward to the first edition of Organic Psychiatry, by Lishman, stated that It is only in the present century that psychiatry has begun to break free from the constraints of philosophy. Dr Lishman in his preface to the second edition defined organic psychiatry clearly as encompassing endocrine, toxic, and metabolic disorders.
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About this blog

Roxanne Keynejad

 

Roxanne Keynejad is a final year graduate entry Medicine student at King's College London, having studied a first degree in Psychology with Philiosophy at the University of Oxford.

 

She is spending four weeks of her elective studying psychiatry at Groote Schuur and Valkenberg Hospitals, Cape Town, for which she received bursaries from the Royal College of Psychiatrists elective bursary fund and the Institute of Medical Ethics.