Our treatment approach is dedicated by simple principles ..
The treatment team at the Nirmal Hospital, Deaddiction & Rehabilitation Centre embraces a variety of medication treatment and behavioural approaches that are supported by strong scientific evidence and designed to improve outcomes for clients suffering from addictive disorders. We believe that individuals face several challenges in dealing with substance – related issues and accordingly we have designed a personalized treatment approach that has the best possibility of achieving the successful outcome of abstinence.
At Nirmal Hospital, Deaddiction & Rehabilitation Centre medical management is supervised by a licensed and qualified Psychiatrist to control distressing symptoms and improve the quality of life.
Medications are generally used with the following four goals:
1. Problems for acute and maintenance treatment of co-occurring psychiatric disorders.
2. For symptom – specific improvement (E.g. Withdrawal Symptoms, treatment of insomnia)
3. To achieve abstinence or reduction in use of alcohol and drugs.
4. To reduce relapse into alcohol or drug use.
Behaviour treatment approach:-
1. Cognitive behaviour therapy (CBT).
2. Motivational enhancement therapy (MET)
3. Relapse prevention therapy (RPT)
4. Group therapy
5. Twelve step facilitation (TSF)
6. Individual therapy
7. Rational Emotive Behaviour Therapy(REBT)
Psychiatric Illnesses treated at Nirmal Hospital, Deaddiction & Rehab Centre, Miraj
1. ANXITY / DEPRESSION / PHOBIA:-
In this condition patient feels depressed Lonely, Feels like Crying, Reduced Appetite, Feeling sad, Weight loss, occasionally wait gain, Patient gets suicidal ideations, Lack of confidence, feels worthless, hopelessness, worthlessness etc.
In this condition patient gets unknown fear, Suspiciousness towards peoples as talking about him planning something in food to kill him or her. Patients becomes aggressive / abusive / assaultive / gets hearing of voices in absence of anyone, mattering to self, smiles / weeps without reason. Sometimes patient becomes withdrawn, does not mix with others, Neglects personal care& hygiene, does not take bath In chronic stage, passes urine and stool at inappropriate places.
3. SOMATO FORM DISORDER:-
In this condition patient gets multiple physical complaints E.g. pain in chest / Abdomen, Headache, Low backache, pain in extremities, Heaviness of Head, Dryness of, mouth, Hyper acidity patients feels he has same major illness despite of all reports are normal, sexual symptoms, menstrual problems etc.
4. OBSESSIVE COMPULSIVE DISORDER:-
In this condition patients gets unwanted / un necessary repeated intrusive thoughts, Repeated checking doors, tap water, lights, locks etc. Repeated counting, Repeated hand washing, behaviour , Excessive cleanliness, Excessive use of water, taking long time for bath etc.
Headache may be Local / diffused, dull or throbbing, episode or continuous, precipitated by sleep or particular food like ice – cream, chocolate etc. Relieved by sleep, Medicines, depending upon type of Headache. So Patient may need EEG/CT/MRI Brain like investigations.
In this illness patient gets lock jaw, up rolling of eyeballs, tongue bite, frothing from mouth, voids urine in clothes, may get vomiting, Headache with total or partial lass of consciousness . To diagnose Epilepsy EEG Should be done May require MRI / CT Scan to know the exact cause.
In this condition patient feels be feel great, talks big things, feels happy, joyful, spending sprees, some patients becomes overactive / Aggressive, violent with Decreased need of sleep. May get grandiose ideas etc.
8. GERIATRIC ILLNESS / old age Problems / Dementia:-
In this condition patients gets forgetfulness, unable to recall past events, unable to recognize peoples / places, poor orientation to time / places / person. Patients makes mistakes at work, repeatedly asks for tea, food even if he was already given etc.
9. CHILD PROBLEMS:-
Fear of going to School, fear of examination in student, poor scholastic performance, unable to concentrate at studies, stammering, speech, stuttering, bed wetting, Hyper activity , Mental Retardation , thumb sucking, pica etc….
10. Sex Problems:-
Psychiatric Patients gets complaints like…
1. Feels generalized weakness, Gets anxiety before performance
2. Difficulty in Maintaining Erection
3. Difficulty in initiation and Maintaining Erection
4. Lack of Erection
5. Feels as having small size genitalia
6. Curvature of penis Lt / Rt side
7. H/O Masturbation
8. Feeling guilty about Masturbation
9. H/O Night fall
10. Passing That through urine
11. H/O exposure
SUBSTANCE (DRUGS) USE ,ABUSE AND DEPENDENCE:-
Designated classes of pharmacological agents (i.e. Substance) :1) Alcohol 2) Anabolic steroids 3) Caffeine 4) Cannabis 5) Cocaine 6) Hallucinogens 7) Inhalants 8) Nicotine 9) Opioid 10) Drugs – Sedatives, Hypnotism and anxiolytics
* Physical Dependence – Refers to the physical (physiological) effects of multiple episodes of substance use. i.e. Ideas of tolerance or withdrawal appears in criteria for dependence.
* Intoxication – Term is used for a reversible non dependent experience with a substance that produces impairment.
* Psychological dependence – also referred to as habituation, is characterized by a continuous or intermittent craving for the substance to avoid a dysphonic state.
* Substance withdrawal – development of substance specific syndrome due to the cessation or reduction in substance use.
DSM IV Diagnostic criteria for substance Dependence
Manifested by three or more of the following occurring in any time in 12 months period
1) Tolerance – Markedly diminished effect with continued use of the same amount of substance a need for markedly increased amounts of substance to achieve intoxication or desired effect.
2) Withdrawal Symptoms – These symptoms are variable depending upon the substance.
3) Substance is often taken in larger amounts or over a longer period.
4) There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5) Great deal of time is spent in activities necessary to obtain. The substances e.g. driving long distances.
6) Important social, occupational or recreational activities are given up or reduced because of a substance use.
7) Substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem.
Diagnostic criteria for alcohol Intoxication:-
1) Recent injection of alcohol
2) One (or more) signs – slurred speech In coordination Unsteady gait Nystagmus (Antegrade grade amnesia) – Impairment in attention or memory Stupor or coma
3) Significant maladaptive behaviour or psychological changes. (i.e. inappropriate sexual or aggressive behaviour mood, liability, impaired judgment, impaired social or occupational functioning)
Alcohol withdrawal : –
- Classical signs – tremulousness i.e. shakes or jitters (although spectrum of symptom may expand to psychotic and perceptual symptoms i.e. delusions and hallucinations)
2. Tremors – develops 6-8 hrs after cessation of drink
3. Delusion, hallucinations – begin in 8-12 hrs.
4. Delirium tremens during 72 hrs.
5. Conditions which can predispose to or aggravate withdrawal symptoms – include fatigue, malnutrition, physical illness and depression.
6. Seizures – Seizures (Rum fits) – begin in 12-24 hrs.
7. Seizures are stereotyped, generalized and tonic Clonic in character.
8. Patients often have more than one seizure 3-6 hrs after 1st seizure.
9. Status epileptics is relatively rare & occurs in less than 3 % of patients.
10. Rx of Rum fits – Usually anticonvulsant is not required for withdrawal seizures. Anticonvulsant if stated immediately – anticonvulsant should be discontinued once the cause of seizures is recognized.
Diagnostic criteria for alcohol withdrawal
- A) Cessation or reduction in alcohol use B) Two or more of the following symptoms are seen –
1) Automatic hyper activity (e.g. sweating or pulse rate greater than 100)
2) Increased hand tremor
4) Nausea or vomiting
5) Transient visual, tactile or auditory hallucinations or illusions
6) Psychomotor agitation
8) Grand mal seizures
- Tobacco • Gutkha • Cigarette • Bidi • Mawa • Tapkir
Nicotine withdrawal : (A) Daily use of nicotine for at least several weeks. (B) Abrupt cessation of nicotine use or reduction in the amount of nicotine used, followed with in 24 hours by 4 or more of the following signs
1) Dysphonic or depressed mood
4) Difficulty in concentrating
5) Irritability, frustration or anger
7) Decreased heart rate
8) Increased appetite or weight gain
Phases of treatment for Alcohol Dependence:-
- Pre-Treatment :
2. Motivational Interviewing
3. Role of family members and physicians
- Detoxification :
1. Diazepam (20-60 mgs Per day) or Chlordiazepoxide (50-60 mgs. per day)/Lorazepam
2. Thiamine (or as part of Vitamin B-Complex) 50 mgs. Thrice a day orally or 100 mgs. IM daily
3. Supportive Measures viz fluids, electrolytes etc.
- Intensive Treatment :
1. Brief Intervention / Simple advice
2. Disulfiram (only with consent) Anti craving drugs (NTX, Acamprosate)
3. Group Therapy
4. Family Therapy
5. Behaviour Therapy
- Posttreatment / Aftercare:
1. Treatment contact
2. Relapse Prevention
3. Social Rehabilitation
4. Occupational Rehabilitation
5. Continued Supervision
TREATMENT REGIMENS FOR ALCOHOL WITHDRAWAL
* Fixed-scheduled dosing
* Chlordiazepoxide orally every 6h for 3d (50-100 mg per dose day 1, then 25-50 mg per dose)
* Diazepam 5-20 mg orally every 2h while symptomatic until resolution
* For delirium tremens Diazepam 10 mg intravenously, then 5 mg every 5 min until calm but awake.
* If unable to take oral medication or in the presence of hepatic synthetic dysfunction (hypoalbuminemia, elevated prothrombin time), intramuscular, sublingual, oral or intravenous (for delirium tremens only) lorazepam 1-4 mg may be substituted. Oral oxazepam 30-60 mg or lorazepam may be substituted in the elderly and those at risk of excessive sedation or its complications.
* All patients should receive thiamine 50-100 mg daily.
* Treatment of Alcohol Withdrawal Seizures
* The seizure generally resolves spontaneously. Benzodiazepines, carbamazepine, and probably Phenobarbital prevent seizures, but phenytoin is ineffective preferably diazepam, chlordiazepoxide, or lorazepam, all shown to prevent initial and recurrent seizures.
* Treatment of Delirium Tremens – 20-50 % of patients die eventually if not treated, there is 5-10 % mortality even with treatment .
* It requires immediate hospitalization in untreated cases.
* Treatment of choice is intra venous diazepam (10 mg every 20 minutes till patient is sedated or signs and symptoms of withdrawal subsides) * Or IV lorazepam 2-8 mg
Treatment for alcohol dependence continues
* Anti craving agents – * Topiramate- 50-200 mg,
* Acamprosate – 333 mg 2 tab TID
* Carbamazepine – 300 – 1000
* Naltrexone – An analogue of naloxone, is a relatively pure opioid antagonist – with highest affinity of for the mu-opiate receptor type.
* Naltrexone reduced alcohol craving, days of drinking per week, and the rate of relapse among those who drank.
When administered at 50 mg/day for 3 months.
Treatment For Alcohol Dependence Continues
* Selective Serotonergic Reuptake Inhibitors- Fluoxetine 20 mg, Escitalopram 10,20 mg. Sertraline 25,50 mg Fluoxamine-50 mg
* Topiramate – Antiepileptic and adjuvant mood stabilizer. It inhibits release of dopamine in meso-cortico-limbic pathway by augmenting GABA and inhibiting specific glutaminergic pathway. It also inhibits carbonic anhydrase enzyme Dose is 25 to 300 mg. per day.
* Ondansetron – a selective 5HT3 receptor antagonist. It reduces urge to intake
* Combinations of above drugs can be used.
TREATMENT OF SPECIFIC COMORBID CONDITIONS- about 50 % cases
* Alcoholic patients with major depression.
* Alcoholic patients with anxiety depression.
* Alcoholic patients with Somatoform disorders.
* Alcoholic patients with Obsessive compulsive disorder.
* Alcoholic patients with Dissociative disorder.
* Alcoholic patients with Mood disorders/Swings- mania and depression.
* Alcoholic patients with Personality disorders.
* Alcoholic patients with Schizophrenia / other psychotic disorder.
* Alcoholic patients with other substance dependence
A] Pharmacotherapy For Nicotine Dependence
* The nicotine gum : is usually used during the first few months of a quit attempt.
* Nicotine gum is available in 2 and 4 mg.
* Most patients can start reducing use of gum after 3-4 weeks.
B] Nicotine Therapy:-
* Bupropion : The mechanism of action is unknown
* Action- Enhancing dopamine levels in the mesolimbic system
C] Other Pharmacotherapies For Nicotine Dependence
Includes agents that make smoking aversive (e.g. silver acetate) clonidine, blocking agents (e.g. mecamylamine, naltrexone) and medications to decrease withdrawal problem or replace the positive effects of nicotine (e.g. anxiolytics, antidepressants, stimulants, anorectics)
Management of Opioid Abuse and Dependence:-
* Opioid Agonist Pharmacotherapy
* Methadone : Methadone is a m opioid receptor agonist and produces the typical morphine like effects in people, including euphoria, drowsiness, analgesia, respiratory depression nausea, vomiting. constipation, itching and constriction of pupils. Methadone is 20-30 mg, with 5 to 10 mg increases every other day as tolerated. usual dose of ranges from 30-100 mg.
* Levomenthol acetate (LAAM) – – is derivative of methadone. Its long duration of action (48-72 hrs) allows dosing at 48-72 hr interval for opioid maintenance treatment.
* Buprenorphine : buprenorphine, is a partial m opioid against and a weak k opioid antagonist . Buprenorphine formulated as a sublingual tablet is available alone or in a combination tablet containing Buprenorphine and Naloxone in a ratio of 4:1
* Opioid antagonist pharmacotherapy Naltrexone, an opioid antagonist blocks opioid receptors competitively. Single daily dose of 50 mg, doses of 100-150 mg can block opioid effects for 48-72 hrs.
* Psychotherapy– Cognitive-behavioural therapy, relapse prevention and psychotherapy (individual, family and group therapy)
11. ELECTROCONVULSIVE THERAOY (ECT)
Electroconvulsive therapy (ECT) is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions.
ECT often works when other treatments are unsuccessful and when the full course of treatment is completed, but it may not work for everyone.
Much of the stigma attached to ECT is based on early treatments in which high doses of electricity were administered without anesthesia, leading to memory loss, fractured bones and other serious side effects.
ECT is much safer today. Although ECT may still cause some side effects, it now uses electric currents given in a controlled setting to achieve the most benefit with the fewest possible risks.
Why it’s done
Electroconvulsive therapy (ECT) can provide rapid, significant improvements in severe symptoms of several mental health conditions. ECT is used to treat:
- Severe depression, particularly when accompanied by detachment from reality (psychosis), a desire to commit suicide or refusal to eat.
- Treatment-resistant depression , a severe depression that doesn’t improve with medications or other treatments.
- Severe mania, a state of intense euphoria, agitation or hyperactivity that occurs as part of bipolar disorder. Other signs of mania include impaired decision-making, impulsive or risky behavior, substance abuse, and psychosis.
- Catatonia, characterized by lack of movement, fast or strange movements, lack of speech, and other symptoms. It’s associated with schizophrenia and certain other psychiatric disorders. In some cases, catatonia is caused by a medical illness.
- Agitation and aggression in people with dementia, which can be difficult to treat and negatively affect quality of life.
12. PSYCHOLOGIST TEST
Psychological test is classified into several types including intelligence test, aptitude tests, vocational tests, aptitude tests, personality tests. Psychological testing is primary used for psychological diagnosis, Job screening academic placement, identifying specific Behavior, research purposes ect. The most commonly used test is the Rorschach, TAT & MMPI Psychological Testing is Divided into four primary types.
1) Clinical Interview.
2) Assessment of Intellectual Functioning (IQ).
3) Personality Assessment.
4) Behavior Assessment.
A Psychological test used to a measure on individual’s Different Abilities.
A peculiar altered state of consciousness distinguished by certain marked symptoms, the most prominent and invariable of which are the presence of continuous alpha waves on the electroencephalograph, hyper suggestibility in the subject, a concentration of attention on a single stimulus, and a feeling of “at oneness” with the stimulus. Hypnotic states may be induced by various techniques applied to oneself or by another.
The hypnotic state may be induced in a large percentage of normal individuals, or may occur spontaneously. It is recognized as having an affinity with normal sleep, and likewise with a variety of trance-like conditions, among which may be mentioned somnambulism, ecstasy, and the trances of Hindu yogis and fakirs, and various tribal shamans. In fact, in one form or another, hypnosis has been known in practically all countries and periods of history.
Hypnotism, once classed as an occult science, has gained, though only within recent years, a definite scientific status, and no mean place in legitimate medicine. Nevertheless, its history is inextricably interwoven with occult practice, and even today much hypnotic phenomena is associated with the psychic and occult, so that a consideration of hypnotism remains a necessary component in any mature understanding of the occult world science of both our own time and the past.
14. Stress Management Techniques
Treatment for stress relief usually involves a combination of methods that can include lifestyle changes
Counselling, or ‘therapy’ as it is commonly known, falls under the umbrella term ‘talking therapies’ and allows people to discuss their problems and any difficult feelings they encounter in a safe, confidential environment. The term can mean different things to different people, but in general, it is a process people seek when they want to change something in their lives, or simply explore their thoughts and feelings in more depth.
A counsellor, or therapist, is not there to sit you down and tell you what to do. Instead, they will encourage you to talk about what’s bothering you in order to uncover any root causes and identify your specific ways of thinking. They may then look to create a plan of action to either help you reconcile your issues, or help you to find ways of coping.