Background. A court orders a forensic observation of a defendant to determine a defendant's fitness to stand trial and/or ability to appreciate wrongfulness of action (criminal responsibility) at the time of the alleged offence. Fitness to stand trial is the focus of this review rather than criminal responsibility. In this instance, the court requests an expert to determine whether the defendant's current mental state would significantly impair his or her ability to participate meaningfully in his or her own trial. In South Africa, this process involves multiple assessments by a multidisciplinary forensic psychiatry team in a dedicated forensic psychiatry unit. However, at present no standardised format has been adopted for such an evaluation, the findings of which may have dire consequences for the individual being assessed. Furthermore, there is a paucity of current literature on fitness to stand trial evaluation. Objectives. To establish whether fitness to stand trial is adequately assessed in the Western Cape, South Africa. A further objective is to establish whether mental illness is the sole factor that differentiates defendants fit to stand trial from those who are found not fit to stand trial, and whether defendants with mental illness are less likely to be asked the relevant questions to determine fitness to stand trial than those without mental illness. Methods. A descriptive, retrospective review was conducted (via the application of a checklist) of clinical records of the last 100 male defendants' ≥18 years of age admitted to the Valkenberg Hospital Forensic Psychiatry Unit prior to March 2015. Results. 30 defendants (30%) were found to have a psychiatric diagnosis. Of the 30 defendants, all were noted to have a serious mental illness (mostly psychotic disorder or cognitive impairment) and were found not fit to stand trial. Seventy (70%) of the defendants were found fit to stand trial by the expert panel. From the findings, it was noted that the forensic team asked and recorded the necessary factors to determine fitness to stand trial in 56% of the study population (based on frequency of responses: n = 894), with 32% of questions not appearing to have been addressed at all (especially those pertaining to role players in court and a defendant's understanding of his rights). Furthermore, various questions appeared to have been indirectly addressed in fewer than 50% of defendants. No significant difference was noted in how the forensic team conducted its assessments between those defendants found to have a serious mental illness and those without serious mental illness. Conclusion. The results of the study suggest the need for a more in-depth review of the forensic evaluation process in the Western Cape to further ascertain the benefits of using a checklist during the evaluation process. Furthermore, additional research would assist in determining the factors contributing to a number of questions not having been addressed and the consequences thereof.

Background: Comorbid anxiety disorders in psychotic illness are reported in the international literature as highly prevalent and have a significant negative impact on patient outcomes. Local literature describing such comorbidity in the South African population is limited and clinically, anxiety symptoms are seldom recognised or treated in patients with psychotic disorders. More data on prevalence rates across psychotic disorder diagnoses, as well as sociodemographic correlates would aid recognition, diagnosis, and treatment, and potentially improve clinical outcomes in this population. Method: We performed a secondary analysis of an existing database which comprised data from participants of three previous studies. The sample was made up of patients from Valkenberg Hospital and healthcare facilities in its catchment area. All patients had a diagnosis of a psychotic disorder. Socio-demographic information was collected using a structured questionnaire. Clinical information and diagnosis was determined using the Structured Clinical Interview for DSM (SCID-I). Rates of comorbid anxiety disorders were compared across various sociodemographic categories. Results: The overall prevalence of any anxiety disorder in the entire sample (N=226) was 14.6% (n=33), 95% CI [10.27-19.89%]. The most common anxiety disorder comorbidities were, in descending order, panic disorder (n=12, 5.31%; 95% CI [2.77-9.09%]), PTSD (n=9, 3.98%; 95% CI [1.84-7.42%]), specific phobia (n=7, 3.10%; 95% CI [1.25-6.28%]), anxiety disorder not otherwise specified (n=7, 3.10%; 95% CI [1.25-6.28%]), social phobia (n=4, 1.77%; 95% CI [0.48%-4.47%]), generalised anxiety disorder (n=4, 1.77%; 95% CI [0.48-4.47%]), substance-induced anxiety disorder (n=4, 1.77%; 95% CI [0.48-4.47%]) and obsessive compulsive disorder (n=2, 0.88%; 95% CI [0.11-3.16%]). There was a significant association between diagnosis and the presence of post-traumatic stress disorder (PTSD), with the schizoaffective disorder group having a higher rate of PTSD (13.3% vs. 3.3% in schizophrenia, 3.2% in substance-induced mood/psychotic disorder and 0% in bipolar I disorder) (Fisher's exact test, p=0.039). In turn, there was a trend level association between diagnosis and the presence of panic disorder (PD), with schizoaffective disorder patients having higher rates of PD (16.6% vs. 4.1% in schizophrenia spectrum, 3.2% in substance-induced mood/psychotic disorder and 2.2% in bipolar I disorder) (Fisher's exact test, p=0.052). A significant association was found between level of education and the presence of PTSD, with higher rates of PTSD in patients with seven or less years of education (8.8%) compared to lower rates in those with 8-12 years of education (5.3%) and > 12years of education (0%) (Fisher's exact test, p=0.020). Conclusion: The overall prevalence of anxiety disorders in psychotic illness was lower than what has been described in previous literature. Prevalence rates of individual anxiety disorders were also lower than previously published literature. Possible reasons for this include use of the SCID which utilises a strict diagnostic hierarchy, that the majority of the sample were in-patients, no use of self-report questionnaires or other anxiety-specific diagnostic instruments, or possible geographical and/or ethnic differences in South African patients. The most frequent comorbid anxiety disorders in our study were panic disorder and PTSD. This is out of keeping with other literature which has mostly found obsessive compulsive disorder and social anxiety disorder to be the most common anxiety comorbidities in psychotic illness. Further research into comorbid anxiety in psychotic disorders is needed, particularly amongst South African populations.

Background Sub-Saharan Africa, the epicenter of the global population of people living with HIV (PLHIV), is estimated to have more than 25 million PLHIV. In the era before the widespread availability of antiretroviral therapy (ART), anaemia (low serum haemoglobin) was a common clinical finding that was seen as a potential risk factor for HIV-associated neurocognitive impairment. The association between haemoglobin levels and neurocognitive function has not been assessed in a Sub-Saharan study population in the era of ART. Methods A cross-sectional secondary data analysis was performed to assess the association between serum haemoglobin level and neurocognitive function in 129 participants who had both neurocognitive test (global deficit score) and full blood count results performed as part of a randomised placebo controlled trial that evaluated the efficacy of lithium carbonate for the treatment of HIV associated neurocognitive disorders. Results The majority of our participants were female (87%) with a mean age of 37 ±7.78 years. Participants were all established on ART with a median CD4 count of 495 cells/µL (IQR=315- 629). The median haemoglobin level was 12.2 (IQR=11.6-13.00) and anaemia was present in 8.5%. Serum haemoglobin level was not associated with global deficit scores (GDS) and fewer years of education was the only independent risk association for GDS-defined neurocognitive impairment. Conclusion We found that in South Africans, who are established on ART, anaemia is less common than in the pre-ART era and importantly, that low-normal serum Hb levels do not present a risk for GDS-defined neurocognitive impairment. These findings are relevant as they show that aggressive management of low-normal Hb levels is not necessary provided individuals are otherwise clinically well and virally suppressed.

Background: Suicidal behaviour is increasing internationally and in South Africa and is considered a national public health problem (1). Literature has shown that substance use is a potentially modifiable risk factor for both fatal and non-fatal suicidal behavior (2- 6). In South Africa, 43 percent of patients who present to emergency departments with intentional or unintentional injuries meet the criteria for a substance use disorder (SUD) (7). The association between substance use and suicidal behavior has been well established, however, the exact nature of this relationship awaits further investigation and clarification. Aims: The proposed study’s aims are; (i)to determine the patterns of substance abuse and the prevalence of SUDs (past and current) among patients admitted following an act of DSH, (ii) to compare patterns of substance use and the prevalence of SUDs (past and current) among those admitted following an episode of DSH, those admitted to the emergency psychiatric unit for reasons other than DSH and medical patients admitted for reasons other than DSH, (iii) to determine if patterns of substance use or the diagnosis of substance use or the diagnosis of SUDs predicts hospital admission for DSH. It concurrently analyzed preliminary data in order to determine if outcomes of the larger study would be meaningful and significant. Methods: Seventy-six patients were recruited over a period of 19 weeks. Twenty-seven consecutive patients with a medically serious act of DSH were recruited and were matched with a control group based on age range and gender. Demographic data and substance use history were collected using; (i) a self reported questionnaire, (ii) Alcohol Use Disorders Identification Tests (AUDIT), (iii) Drug Use Disorders Identification Test (DUDIT) and (iv) SUD module of the structured clinical interview of the DSM. Results: Findings of the feasibility study indicated low recruitment numbers and data collection challenges. Causes of low recruitment number were multifactorial, including low base rates for self-harm, length of recruitment time, consenting capacity, tight control criteria, exclusion of manic and psychotic patients and declining of patients to participate. Data collection faced challenges including difficult navigation of hospital premises, long data collection times, limited understanding of questions, language barriers and lack of privacy. Formal suicide risk assessment was a challenge for some data collectors. Preliminary data confirmed that substance use is a significant risk factor for DSH. Conclusions: This feasibility study demonstrated the existing protocol can be used to generate meaningful data and identified specific steps to be altered in a scaled-up study. These steps included; expansion of study sites to more institutions to increase recruitment numbers, a wider range in matching criteria for control groups and improved orientation and training of data collectors regarding use of the data collection tool, navigation of the hospital premises, maintaining confidentiality and formal suicide risk assessments. Formal translation of the research tool into other languages was recommended. Despite low recruitment numbers, data collected from this study was meaningful.

Introduction: Bipolar disorder (BD) is a brain network disorder that affects cognitive and emotional functioning, and is associated with prefrontal and/or limbic dysfunction. Functional Magnetic Resonance Imaging (fMRI) allows identification of intrinsic brain networks (IBN), like the default mode network (DMN) and executive control network (ECN), which are consistent with previously established functional and anatomical relationships within the brain. Analysing the functional connectivity (integrity, extent and inter-relationships) of these networks, allows a deeper understanding of brain function in health and disease. In BD, there are functional connectivity changes in the DMN, ECN and cerebellar network (CERN). We evaluate IBN in BD, to explore changes in the functional connectivity between the cerebellum, fronto-cortical and paralimbic regions. Methods: Data from 14 BD subjects and 10 control subjects was analysed after fMRI. Changes were evaluated in 3 IBN (DMN, ECN and CERN) using an FMRIB Software Library (FSL) pipeline: MELODIC/ICA-AROMA, dual-regression, randomise and Local False Discovery Rate (FDR) to identify changes in functional connectivity bipolar subjects compared to controls. Results: Subjects with BD showed decreased connectivity between the CERN and a cluster in the right precuneus; and between the ECN and a cluster in the left OFC. There was also increased connectivity between the ECN and a cluster in the left temporal pole. No connectivity changes involving the DMN were identified. Voxels within the clusters were significant at p < 0.05 with local FDR. Peaks within the clusters remained significant after further Bonferroni correction for multiple comparisons (p < 0.017). Conclusion: The finding of altered functional connectivity in BD, in networks and regions involved in cognitive/emotional processes, highlights its complex neurobiology, and suggests that abnormal connectivity may help to explain the clinical picture. These findings should be replicated with larger samples, but may represent a further advance in understanding the role of functional connectivity in the pathology of BD, and contribute to laying the foundation for functional neuroimaging as a diagnostic tool in psychiatry.

Twenty seven consecutive black male patients who were admitted as acute admissions to FEH were examined in this thesis. The following demographic information characterized the sample group. a) Age: Bimodal distribution with peaks at 21-25 years and 31-35 years. Five patients were older than 35 years. b) Marital Status: In the sample. 59.2% were single. 11.1 % married and 29.6% the marital status was unknown. c) Number of Children: In the sample. 75% did not know how many children they had. Numbers ranged from no children (14.3%) to 2 children (7.1% of the sample). d) Employment Status: In the sample 81 .1 % were unemployed. e) Level of Schooling: In one third of cases, level of schooling was unknown. Most men did reach secondary level of education.

Background: Coulrophobia describes the experience of significant distress, fear and/ or revulsion when exposed to the image and/or person of a clown (Stevenson, 2010). It may start in childhood and continue into adulthood (Spratley, 2009). There is limited scientific literature on this topic despite multiple online support groups attesting to the reality of this condition. Methods: Data collection using a self-administered online questionnaire from Surveymonkey was made available via a link on the larger of these online support groups on Facebook. It explored socio-demographic information and symptom phenomenology -symptom severity, course, duration, comorbid illnesses, and extent of psychological distress and functional impairment - in individuals who self-report coulrophobia. Fear of clowns is more commonly associated with fear (45.3%) than disgust (37.9%). The possibility that fear of clowns comprises a specific phobia was also examined. Those from the fear predominant group are also more likely to fulfill DSM-5 criteria for specific phobia. Extent of psychological distress and functional impairment were measured and compared to symptom severity and duration. Results: There were 95 respondents to the online survey, of which 79 were female and 16 male showing it to be more common in females. The mean age of participants was 39.82 ±12.60 years, mean age of symptom onset 9.02 ±6.12 years and mean duration of 30.44 ±12.94years. It appears to have a chronic course from onset with 30.53% identifying a specific trigger and 22.11% a positive family history of coulrophobia. It is more commonly associated with fear than disgust (45.3%). Those from the fear predominant group are also more likely to fulfill DSM-5 criteria for specific phobia. The most common comorbid disorders are major depressive disorder, obsessive compulsive disorder, panic disorder and social anxiety disorder. Use of the Kessler Psychological Distress Scale indicated a significant level of psychological distress associated with coulrophobia. The greatest area of impairment in coulrophobia was in social functioning, measured by the Sheehan Disability Scale Functional impairment was strongly associated with severity of symptoms, but not with symptom duration. Conclusion: Coulrophobia is a phenomenon that warrants clinical attention, as it is associated with significant comorbidity, psychological distress, and impaired functioning.

Introduction. Consultation-liaison psychiatry is the subspeciality that provides for the psychiatric assessment and management of patients in a hospital setting, serving as an interface between psychiatry and other medical disciplines. This study aimed to provide an analysis of the Consultation-liaison psychiatry service at Groote Schuur Hospital. It was hypothesised that the hospital has a large burden of psychiatric illness amongst inpatients with unique characteristics and high rates of referrals related to HIV, alcohol and methamphetamine use. Methods. A retrospective review was performed of all inpatients referred for psychiatric consultation from other departments over a period of thirteen months. Patients referred by the emergency medical and surgical departments were excluded from this study, as they are seen by the department of emergency psychiatry. Results. A total of 452 patients (males n=174; females n=278) between the ages of 12 and 90 years were consulted, with the majority of the patients (82%, n=360) belonging to the age group of 18 to 59 years (mean age of 37 years). The referral rate to Consultation-liaison psychiatry was 0.95% (when combined with emergency psychiatry referrals the combined referral rate was 4.7%). Most referrals were from the department of medicine (56%, n=252), with the highest number of medical subspeciality referrals from neurology (6%, n=29). Request of a general review (69%) of current psychiatric symptoms (87%) occurred most frequently. The most common symptoms noted by the referring non-psychiatrist were mood symptoms (n=159; 36%), followed by suicidal behaviour (23%, n=102) and behavioural problems (21%, n=94). The mean number of psychiatric diagnoses following assessment was one (SD 1; 0:5), and most patients were assigned a definitive diagnosis (78%, n=342). Alcohol use disorder was diagnosed in 9% (n=41). Methamphetamine use was identified in 5% (n=22) of patients, with the majority being diagnosed with methamphetamine abuse. The use of other substances was identified in 9% (n=38). The HIV status was confirmed positive in 16% (n=70), with the majority of this group being female (67%). Most subjects had psychosocial and environmental problems (55%, n=249). Registrars performed a mean number of one consultation and the majority of patients were seen within 24 hours of the referral. Medication was initiated in 31% (n=139) of cases. The majority (65%, n=292) of patients were discharged from psychiatric care, and 14% (n=61) required admission to an inpatient psychiatric unit. Conclusion. The combined referral rate (consultation-liaison and emergency psychiatry) compares favourably to that of high-income countries, and is higher than any other published studies of this nature in low-income and middle-income countries. There was no substantial agreement between psychiatrist and non-psychiatrist diagnoses. As expected, mood disorders were the most common diagnoses, with only fair agreement between psychiatrist and non-psychiatrist clinicians. A high proportion of referred patients were substance users, but methamphetamine rates were lower than expected and the rate of HIV was higher than anticipated. The results presented here may facilitate improvements in the practice of Consultation-liaison psychiatry.

Includes bibliographical references. / The rationale of doing thorough medical screening of all psychiatric patients is clear, because there is a relationship between medical illness and mental illness. It remains unresolved which screening tests should be performed routinely in general psychiatric patients even though the prevalence of medical illness is relatively high. Even less is known about the prevalence of medical illnesses in criminal defendants referred for observation, most of whom do not have a serious psychiatric disorder. Special investigations may be necessary in the diagnosis of these medical conditions. Within the context of psychiatry as a whole, the population referred for forensic observation may be subject to more stringent investigation as a legal requirement. However there is little information available on this group regarding the prevalence of medical illnesses and the impact that these have on the psycho-legal assessment. This study will therefore seek to assess the current practice of routine investigations in assessing criminal defendants that have been referred to the forensic observation unit in order to assess whether these findings contribute significantly to the psycho-legal assessment, and to determine the prevalence of medical illness in this population. It is hoped that it will be possible to decide whether there is utility to do routine tests, essentially by coercion, in this group.

Includes abstract. / Includes bibliographical references. / The Autism Spectrum Disorders(ASD) are a group of neurobiological conditions of growing prevalence for which there is no known cure. International prevalence studies have determined that children and adolescents with ASD are a highly medicated population. This comes to light in the context of a paucity of data around the efficacy of commonly prescribed medications. There is no data around the prevalence of medication use in the ASD population in South Africa. The aim of this study is to determine the prevelance and patterns of medication use in children and adolescents with ASD in the Western Cape and to determine the relationship between demographic variables and behaviours and medication use.