Includes bibliographical references. / In the last decade, multiple diffusion tensor imaging (DTI) studies have revealed changes in the microstructure of white matter in bipolar disorder. The results are poorly replicated and inconsistent, however, with some authors suggesting a predominance of alterations in fronto-limbic white matter. Preliminary reading of the literature suggests that white matter changes as revealed by DTI may be more widespread throughout the brain. Two extant reviews have each been limited by including all affective disorders or by a methodology which ignores tracts and discards potentially meaningful data. This background in the review includes a detailed exposition of the main DTI techniques and shortcomings. The review aims to determine whether certain white matter tracts are affected preferentially in the brain, as opposed to more diffuse white matter involvement. It also aims to determine if there is an anterior-posterior gradient of abnormalities. This review systematically collates data relating to tract involvement as demonstrated by DTI, as well as data regarding anterior-posterior distribution of abnormalities. Medline and EMBASE databases are searched systematically to select original papers comparing a bipolar group with healthy controls, using DTI, in adults, and reporting at least fractional anisotropy (FA). Subject, scan and analysis characteristics are extracted. Details of affected tracts are collated, as is the y-axis (anterior/posterior) of the most affected ('peak') voxels.

The diagnosis of Schizophrenia in children has historically been the source of much psychiatric controversy, especially with regard to classification, treatment and prognosis. This was further complicated by the broad category for the diagnosis of psychotic disorders in childhood in the Diagnostic and Statistical Manual of Mental Disorders (DSM 11).This included Schizophrenia in childhood, autism, and other psychotic conditions. The work of Kolvin (1971 a-f) and Rutter (1972), have been instrumental in separating autism and Schizophrenia into distinct categories. This review is not aimed at being an exhaustive coverage of all the literature on Schizophrenia in childhood, but is focused on classification, phenomenology, epidemiology, differential diagnosis, etiology, course, cross-cultural factors, and treatment. The adult literature has been referred to, when there is no appropriate reference in the literature on children with Schizophrenia, in certain focused areas. Specific research questions will be discussed in depth in the appropriate sections. These are: 1) Is Schizophrenia with childhood onset a discretely homogenous entity or is the condition on a continuum with adult Schizophrenia? 2) Are the current classification systems diagnostically valid in children with Schizophrenia? 3) Do phenomenological descriptions of the condition assist the clinician diagnostically, given the financial constraints limiting the extent of special investigations, in the South African context? 4) The evidence concerning the etiology of Schizophrenia in childhood will be critically evaluated. 5) Do current treatment models have any relevance to clinical practice in South Africa, especially with regard to the need for cost-effective solutions? 6) Two cases obtained from the in-patient Unit of the Red Cross Hospital's Child and Family Unit will also be examined, in the light of the literature. As much of the literature prior to DSM III generally did not clearly differentiate between childhood Schizophrenia, autism and other heterogeneous conditions (Rutter, 1972), they have not been included, except for seminal papers. In addition the age groups in the papers do not always mention the pubertal status of the children, thus for the purpose of the review, primarily studies focusing on samples with onset prior to 13 years are included. These have lately been characterized in the literature as 'VEOS' (Very Early Onset Schizophrenia). In one of the few longitudinal studies of children with Schizophrenia, Werry, McClellan and Chard (1991), reported that more than half the sample (55%) which had been diagnosed as schizophrenic at first presentation, was found to have Bipolar Disorder at follow-up. It is possible that the papers reviewed may also reflect this once longitudinal follow-up has been completed. The results of longitudinal studies are awaited.

Background The Transgender Clinic at Groote Schuur Hospital (GSH) – a large government funded academic hospital in Cape Town, South Africa - assists with the mental health assessment of transgender individuals and facilitates access to other gender affirming services, such as hormone therapy, plastic and reconstructive surgery, psychosocial, and legal services. Objectives This clinical audit aimed to gain a clearer understanding of the service and areas within the service which could be improved. To this end the general compliance of the clinical services of the multidisciplinary team (MDT) as recommended by the World Professional Association for Transgender Health 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH SOC 7) was assessed. In addition, an analysis of the demographic and clinical characteristics of individuals attending the clinic and a review of waiting times and distance travelled to attend the clinic, was conducted. Methods The study was a clinical audit without a repeat data collection cycle. Participants included the MDT members working at GSH's Transgender Unit and individuals attending the Transgender Clinic from September 2018 to December 2019 (n = 50). All 11 MDT members were invited to participate in the study and were required to complete a data collection sheet related to their competency and experience. Data collection with respect to services provided, and waiting times for services, was captured from clinician administered standardized historytaking and assessment booklets and patient hospital folder reviews. Results All members of the MDT who participated met the WPATH SOC 7 competency requirements. The mean age of the individuals attending the GSH Transgender Clinic was 28 years. Forty-eight percent were employed, 36% unemployed and 16% full time scholars. The 7 mean waiting time for an initial appointment with mental health was 75 days, 73 days for endocrinology and 255 days for plastic surgery. Non- attendance at initial appointment was a factor across gender affirming services – 18% mental health service, 20.5% endocrinology and 27% plastic surgery. Forty-two percent of individuals screened positive for a co-occurring mental health condition with a third of these individuals having more than one mental health disorder. Mood and anxiety disorders co-occurred together most frequently. Seventy-five percent of individuals with an untreated or partially treated mental health concern were provided a therapeutic intervention at the time of initial assessment. The introduction of laboratory investigations being performed prior to the initial appointment with endocrinology resulted in a significant improvement in waiting time to the initiation of hormone therapy. Conclusion WPATH SOC 7 competency requirements were met by the GSH Transgender clinical team. Inconsistencies were found in the documentation of WPATH SOC 7 recommended clinician tasks within the mental health and endocrinology service. This is secondary to the layout of the standardized history taking and assessment booklet, and documentation of certain tasks being clinician dependent. Limited hospital resources and subsequent understaffing, long waiting times for appointments and gender-affirming surgery and lack of access to other services (e.g. fertility services) result in continued barriers to gender-affirming care.

The central premise of this thesis was that pain is a problem in persons living with HIV/AIDS (PLWHA), that this pain is biopsychosocial in nature, and as such may have different characteristics in different sub-groups. It was also hypothesised that pain in PLWHA can be effectively managed using a biopsychosocial treatment.

Catatonia is a neuropsychiatric condition characterized by physical presentations ranging from profound immobility to excessive motor activity. In the past, catatonia was considered a variant of schizophrenia. However, newer data suggests catatonia is a clinical expression of many different medical or psychiatric components. A prompt diagnostic evaluation should identify any underlying diseases with consideration of somatic pathologies, especially those affecting central nervous system function. The recognition of catatonia among providers is relatively poor. It is often seen as a historical diagnosis. Because of this, catatonia is often undiagnosed. If patients in catatonic states are not diagnosed, their condition is likely to progress with a risk of increased morbidity and potentially fatal outcome. Lorazepam or electroconvulsive therapy (ECT) are considered the standard of care for treatment of catatonia. Zolpidem has been used successfully as a rapid test for patients suspected to be catatonic.This case report explores zolpidem as a long-term treatment option when standard therapies are not tolerated or ineffective. In order to recognize catatonia, apart from thorough and repeated observation, a clinical examination is needed. The Bush-Francis Catatonia Rating Scale is a quantifiable examination designed to screen and diagnose the possibility of catatonia. We investigated Zolpidem’s impact on a patient’s Bush-Francis Catatonia Rating Scale score. Scores were collected weekly for two months. There were five different resident physicians who conducted these examinations. Results of this work identified a reduction in Bush-Francis Catatonia ratings in seven out of the eight weeks of this study, suggesting that there may be a link between Zolpidem use and a reduction in catatonic symptoms. Limitations to this study included the subjective nature of the rating scale, along with the potential for variability in assessment standards, stemming from the fact that multiple examiners were used to conduct ratings. Because catatonia is a medical emergency, it is of utmost importance to gather a detailed history and conduct a rigorous medical workup to help confirm the diagnosis. While Lorazepam and ECT remain the standard of care, this study demonstrates that there may be a potential benefit to the use of Zolpidem in catatonia.

Includes abstract. / Includes bibliographical references. / This study primarily aims at determining the correlates of Attention Deficit Hyperactivity Disorder (ADHD) among children and adolescents in Northern Nigeria. The secondary aims of the study include a comparison of the identified correlates with results from other developing countries and the developed nations. The results would also provide a rational basis for advocating preventive measures for targeted problems associated with ADHD in the study.

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Background. Psychotic Disorders affect more than 1% of the South African adult population and have a chronic course that is associated with high rates of morbidity and mortality. The implementation of early intervention strategies may reduce the severity of these disorders. Little is known about the effectiveness of these interventions in South Africa and few longerterm studies have been undertaken internationally. Aim. This study aimed to measure the effectiveness of an Early Intervention and Support (EISH) service at reducing readmission to hospital in patients with psychotic disorders. Setting. Valkenberg Psychiatric Hospital, Cape Town. The EISH Team is an outpatient service consisting of psychiatrists, a psychologist, an occupational therapist, psychiatric nurses and social workers. Methods. Retrospective cohort study. Hospitalisation during the two years after discharge from the index admission was measured in 100 subjects who attended EISH and 100 who had treatment as usual (TAU). Readmission rate, average length of stay (ALOS), and time to readmission to District Hospitals (DH) and Tertiary Psychiatric Hospitals (TPH) were calculated. Results. Readmission Rates were three times higher in TAU compared to EISH patients for both types of Hospital. For TAU subjects compared to EISH subjects: ALOS was longer (59 vs 13 days), and days to readmission were fewer (187 vs 320 days). All differences were statistically significant (ps < .05). Conclusion. EISH intervention at Valkenberg Hospital was useful in reducing readmission rate, ALOS, and time to readmission in patients with Psychotic disorders. Prospective controlled trials are required to confirm the efficacy of this intervention.