Theses and Dissertations (Psychiatry)

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Validity and reliability of the Vigour Assessment Scale and an invigoration task in remitted but avolitional schizophrenia
(University of Pretoria, 2019) Van Staden, C.W.; a.dlagnekova@gmail.com; Roos (Dlagnekova), Antonia Gueorguieva
In the first empirical study on vigour outside an occupational context, this study examined the validity and the reliability of the Vigour Assessment Scale (VAS) in patients with remitted but avolitional schizophrenia. The validity and the reliability of an imagery-cognitive invigoration task were also examined. The scale and the invigoration task provide means by which to address, scientifically and clinically, the lack of vigour that underpins avolition in schizophrenia, which is a common problem persisting after acute episodes and contributing to marked impairment in socio-occupational functioning. Avolition often responds poorly to treatment and defies other treatment targets that are dependent on vigour. The vigour of 242 outpatients was assessed on the VAS alongside assessments of workplace vigour, behavioural inhibition and activation, procrastination, fatigue, anxiety, depressive features, and active involvement in growing as a person. Patients furthermore participated in an invigoration task (n=76) that was repeated a month later (n=70) for the examination of its effect in a proof-of-concept quasi-experimental one-group sequentially-repeated pre-test/post-test study design. Validity of the VAS was observed in its concurrence with existing instruments of similar kind and its discriminant ability to discern vigour from dissimilar constructs. Concurrence was observed in moderate to strong correlations (r=-0.5 to 0.72) between the VAS and measures approximate to vigour. Discriminant validity was supported by statistically highly significant differences (p<0.001 to 0.003) between the VAS and measurements of procrastination, fatigue, depression, behaviour inhibition and activation, personal growth and initiative, and anxiety. Reliability of the VAS was observed in its internal consistency, split-half reliability, test-retest reliability and standard error of measurement. An exploratory factor analysis yielded six factors, being Task Drive, Indecisiveness, Creative Efforts, Social Disinterest, Active Mobilisation and Torpidity. Internal consistency was excellent with Cronbach alpha coefficients all above 0.8. Split-half reliability testing resulted in a strong correlation between halves (r>0.8). Reliability was further supported by a strong correlation (r=0.8) between initial and repeat VAS measurements. The VAS consistently produced a small standard error of measurement (5.38 or less within a total score range of 77). Validity of the invigoration task was supported by statistically significant differences in VAS scores before and after the two occasions when the task was performed (p<0.001). The effect sizes indicated that the task produced changes that were of a medium (d=0.51) to very large extent (d=1.64). The reliability of the task was supported by its having this effect on two occasions a month apart. The VAS now provides an instrument to assess vigour for diagnostic and therapeutic purposes. Although validated in schizophrenia, it may also prove useful in other clinical or healthy populations, subject to further validation. The proof of concept for the invigoration task warrants a subsequent randomised controlled trial to establish its efficacy by controlling for potential confounding influences. Once established as efficacious in this and other populations, the task holds potential for augmenting standard services and targets in schizophrenia, other clinical populations for whom vigour may be a sensible treatment target, and non-clinical populations affected by burnout or who wish to enhance their vigour as a virtue.
The qualitative development of a practical and ethical framework for the integration of spiritual aspects into the health practitioner’s consultation
(University of Pretoria, 2019-11) Van Staden, C.W.; ellenore.meyer@up.ac.za; Meyer van den Heever, Ellenore D.
Spiritual care of patients is considered a fundamental component of quality, compassionate health care. In the African context spirituality is seen as a vital component of whole-person care (Louw, 2014; De la Porte, 2016). However, a practical and ethical framework has not been available by which to integrate spiritual aspects into the consultation between patient and practitioner. The development of a framework in this study expands on the recommendations made by the authors of the standards for spiritual care (Puchalski, Vitillo, Hull & Reller, 2014). This accounts for the structure, process and outcome elements of spiritual care within health service design (Daaleman, 2012). The framework is the product of this study, rooted in the perspectives of various role-players in spiritual care. This qualitative study used a case study design that accounted for the perspectives of three kinds of role-players within health care, viz. spiritual health care scholars, health practitioners and patients, sampled purposefully from private practice, Daspoort Clinic and the University of Pretoria High Performance Centre in South Africa respectively. Practical guidance items extracted from literature were drafted into an initial framework. They were then subjected to a process of development, revision and refinement through participant contributions through individual interviews and a focus group. Structural coding was used in the analysis as to yield various iterations of the practical and ethical framework presented in its final format in this thesis. The framework describes eight principles for quality spiritual care, with specific quality requirements for each principle. It makes recommendations on how to implement the principles. The framework also describes possible catalysts and impediments to quality spiritual care. Findings are also presented on how the framework was derived from the contributions of the various participants. From the health experts, the benefits and ways of incorporating spirituality were underscored and taken up in the framework. Patients contributed to the framework mainly by underscoring the importance of a suitable attitude of the practitioner and a sincere person-to-person engagement. The inter-disciplinary team underscored the importance of incorporating spiritual rituals and accounting for their potential complications. The framework may be used to inform and guide individual practice, inter-disciplinary health management and policy development. In research, the framework may be developed further to address what the ethical boundaries would be for introducing spiritual rituals within the health context, anticipating that such will need to be context-sensitive and responsive.
A comparison of psychosocial and psychiatric features of mentally capable versus mentally incapable individuals referred by the courts for forensic psychiatric observation in relation to an alleged sexual offence
(University of Pretoria, 2018) Roos, Johannes Louw; Pretorius, Herman Walter; funekas@yahoo.com; Sokudela, Funeka Brenda
This is a mixed research methods study based at the forensic mental health unit of Weskoppies Psychiatric Hospital in Pretoria, Gauteng Province, South Africa. The overarching aim of the study was to help add insights that could indirectly inform the wider discourse on sexual offending in society and to the body of knowledge on the prevention of sexual violence – including in forensic mental health. Qualitative and quantitative methods were applied through concurrent and transformative mixed research methods, premised on the philosophical stance of pragmatism. Records of individuals accused of sexual offences were explored and in-depth interviews with individuals accused of sexual offending and / or other types of charges referred for observation in terms of the Criminal Procedure Act, 51, 1977 (CPA 1977) were conducted. Psychiatric and psychosocial features and general perspectives on sexual offending were explored. Data collection was done from the end of 2014 to the end of 2015. In terms of findings, the record-based component of the study revealed that the majority of those referred were mentally capable, were known to the victims and lived in close proximity to them. Boys and girls, elderly women and socially isolated individuals seemed the most vulnerable irrespective of the mental capacity of the accused at the time of an alleged incident. In-depth interviews revealed scepticism, myths and new locally relevant ways of defining sexual violence. Socio-economic determinants of health seemed to render potential perpetrators of sexual offending vulnerable to violence and included adverse childhood events, poverty, unemployment and inequality. Experiences during and after arrest revealed possible human rights violations of alleged offenders by communities and law enforcement systems. Mental illness worsened stigma even in the hands of law enforcement systems. Central phenomena viz. ‘the perceived oppression of men’ and ‘vulnerability’ of potential victims and potential perpetrators emerged. A tentative theory of ‘vulnerability’, as an explanation and an approach to preventing sexual and other forms of violence in society, is proposed for both victims and potential perpetrators. Public health, socio-ecological frameworks of sexual violence prevention and other explanatory and prevention frameworks on sexual offending seem aligned to the study’s findings. Patriarchy, collective violence inherited from South Africa’s past, social cognitive theory on learning, trauma re-enactment, and other factors seem to play a role. In terms of mixed research contributions, a need for robust ways of studying diverse populations such as South Africa is emerging. Further, an initial stance of studying prevention of sexual violence from a victim-centred advocacy lens, has been transformed to yield accused individuals’ advocacy issues as well. Multi-system prevention approaches involving at-risk potential perpetrators, and not just victims, seem to be the next frontier for research and interventions. The study reveals insights that may contribute to the field of violence prevention.
The qualitative affordances of active and receptive music therapy techniques in major depressive disorder and schizophrenia-spectrum psychotic disorders
(University of Pretoria, 2017) Van Staden, C.W.; musictherapy2@up.ac.za; Lotter, C.B.
Background and objectives: Whilst Active and Receptive Music Therapy techniques have been widely researched and are employed within a range of contexts and with diverse client populations, this study reports on their specific qualitative musical and verbal affordances in major depressive disorder and schizophrenia-spectrum psychotic disorders. The study also describes and compares the respective and joint contributions of the music therapy techniques in giving rise to the affordances as well as reporting on the similarities and differences within and between diagnostic groups. This is the first study of its kind within the South African context. Methods: A qualitative research approach using a case study design, sampled purposefully twenty patients of the above mentioned diagnostic groups for participation in this study comprising a course of eight twice weekly music therapy sessions. The primary data sources were transcribed video recordings of therapy sessions and an individual in-depth semi-structured interview after the course of therapy. Clinical session notes served as a corroborative data source. In-depth content and thematic analysis explored and compared qualitative affordances during music therapy comprising active and Receptive Music Therapy techniques. The qualitative affordances under investigation were i) musical qualities, and ii) verbal expressions. Emerging from these affordances were the respective and combined affordances of the music therapy techniques as well as the similarities and differences between the diagnostic groups. Findings: Thirteen themes emerged from the analysis of clients' verbatim verbal responses to both active music making and Receptive Music Therapy techniques. These themes are: i) not to feel; ii) to do or not to do; iii) grappling with the desired future; iv) hurt and fear of undesirable outcomes; v) sadness, brokenness and futility; vi) anger, trust and vulnerability; vii) desire for connection with and affection of others; viii) barricaded from being present, now; ix) tensing and un-tensing; x) personal relating to one’s musical expression; xi) reflections on the music and music making in therapy; xii) resilience and courage and xiii) invigoration and liberation. The Active Music Therapy techniques comprising clinical improvisation, structured musical exercises, drumming, vocal work, songwriting and movement, gave rise to ten themes expressing the musical affordances. The themes that emerged were i) reciprocal responding; ii) the explicit use of symbols through music; iii) regularity; iv) disturbance and difficulty; v) turning points; vi) energy bursting or lacking; vii) bodily synchrony; viii) intensified emotional expression; ix) exploring new territory and Active Music Therapy techniques comprising clinical improvisation, structured musical exercises, drumming, vocal work, songwriting and movement, gave rise to ten themes expressing the musical affordances. The themes that emerged were i) reciprocal responding; ii) the explicit use of symbols through music; iii) regularity; iv) disturbance and difficulty; v) turning points; vi) energy bursting or lacking; vii) bodily synchrony; viii) intensified emotional expression; ix) exploring new territory and x) resolution and arrival. The emerging themes express the extent of musical and verbal expression of all clients representing both diagnostic groups. Most saliently among clients with depression the affordances were the themes on accessing creativity, accessing and articulating internal feelings, experiencing resilient parts of self, reflecting on and integrating symbolic material, motivation to act and extending musical and verbal expression during social interaction. Among clients suffering from schizophrenia spectrum disorder, the most striking affordances were experiences of regularity and flow within disorganization, orientation to ‘here and now’ experiences through active music making and working with symbolic material expressed on a continuum of concrete to abstract. Clients from both diagnostic groups experienced a reduction in unwanted symptoms as expressed through increased energy levels, experiences of pleasure in music making and spontaneous musical and verbal self-expression. Conclusion: This study revealed qualitative affordances of specific music therapy techniques expressed through verbal content and musical qualities. These showed responses within a therapeutic relationship that express inter- and intra-personal connection, give voice to what is not always verbally accessible and facilitate multi-sensory, creative experiences, increased motivation, emotional expression, and the reclamation of energy, spontaneity and resilience.
Meanings of loneliness : the subjective experience of psychiatric patients
(University of Pretoria, 2015) Van Staden, C.W.; kobus.coetzee@up.ac.za; Coetzee, Jacobus Cornelius
The aim of this study was to explore the subjective experiences of loneliness by some psychiatric patients. The subjective lived experiences of research participants were examined in a qualitative research design that was considered most suitable to uncover the essences and meanings of the experience of loneliness. The particular phenomenological method used was Interpretative Phenomenological Analysis (IPA). IPA is concerned with how experience presents itself in consciousness and follows a hermeneutic approach to meaning. Six participants from a psychiatric hospital context were selected by purposive sampling. In-depth interviews were used to collect the data. Meaning units were indentified and grouped according to patricipants. Thereafter essential themes were identified to which existential phenomenological lenses were applied. The lenses were the life-world existentials of spatiality, temporality, corporeality, relationality and spirituality as well as four dimensions of existence namely the eigenwelt, mitwelt, umwelt and überwelt. The study found that the way in which some spaces were experienced might invoke feelings of loneliness as well as comfort feelings of loneliness. The experience of loneliness had an effect on felt and lived space and vice versa. The situatedness of loneliness in time influenced the nature or quality of the experience of loneliness. Loneliness was also experienced through the body in both psychical symptoms such as anxiety and physical pain as well as physical sensations in the body. The body was the means through which people related to one another, being a physical relation through which loneliness was both felt and overcome. In the life-world existential of relationality, the lack of meaningful relationships was associated with feelings of loneliness. Being with people did not neccesarily alleviate loneliness but the quality of that connection could lessen feelings of loneliness. In the life-world existential of spirituality the experience of loneliness was impacted on by a sense of spiritual identity, faith, hope and love in relating to the greater world or universe. To engage in creative activities, finding a spiritual connectedness to the world, and through relating to God or a higher power, paraticipants could feel less lonely and more integrated in their lived world experience. In the existential dimension of the eigenwelt loneliness presented as a personal experience that called on the individual to take a self-reflective stance towards their loneliness experience. A tension was revealed between the need to connect and the need to be alone. Loneliness was often seen as resulting from a lack of connectedness between the self and the other. In the umwelt the perception of the environment and one‟s engagement with the environment significantly affected the quality of the loneliness experience. In the überwelt some participants saw loneliness as a meaningful journey. Seeing the meaning that underpin events could ease feelings of loneliness. Religion or spirituality was experienced as a binding force but it could also contribute to feelings of loneliness. Some participants felt that fate brought about loneliness. The present study provided an in-depth understanding of the phenomenon of loneliness with a specific sensitivity to the psychiatric context. The nature of the data seemed to be unsaturable, suggesting much depth to and variety in the loneliness experience. This suggests further that the loneliness experience may be an example of phenomenon for which saturation of data can not be obtained, which is in defiance of the usual aim for saturation of data in qualitative research. Future studies need to examine this aspect upon which qualitative methodologists have reflected relatively little so far. The findings of this study are constrained by the specific context and the population being male participants of a Afrikaans-speaking socio-cultural background. This homogeneity may also be considered as a strength of the study, augmented by a similar language and cultural background of the researcher. A further strength was that the researcher, being a clinical psychologist could deploy developed skills in listening, eliciting personal responses, containing emotionally sensitive revelations, and for understanding inter alia unspoken interactions and emotions that are inevitable in an in-depth interview. This present study contributes to our understanding of the complex phenomenon of loneliness, illustrating the multidimensional and intricate nature thereof, the value of adopting an existential phenomenological approach and the richness this approach affords. It revealed sharing of themes as well as diverse and rich meanings expressed in experiences of loneliness.
The therapeutic relationship as reflected in the experiences of hospitalised psychiatric patients : an explorative-descriptive study
(University of Pretoria, 2015) Kruger, Christa; manfred.bohmer@up.ac.za; Bohmer, M.W.
BACKGROUND Mental health problems are on the increase, yet mental health care is a low priority worldwide. A recent report on mental health in the USA in 2015 stated that nearly 20 per cent of adults in the USA suffer from mental illness. In South Africa up to 80 per cent of individuals with common mental disorders do not receive treatment. There are also questions about the efficacy of treatment for mental disorders. For example, there is no evidence that treatment outcomes in depression are better than they were a quarter of a century ago. Consistent findings of research indicate, however, that a good therapeutic alliance can improve the outcome of treatment. But do physicians engage with their patients and build good therapeutic relationships? This question is especially pertinent in a psychiatric training institution, such as Weskoppies Hospital, the main psychiatric training hospital of the University of Pretoria. This study was undertaken to explore experiences and therapeutic relationships of patients in Weskoppies Hospital, to develop a model and substantive theory of therapeutic relationships and to comment on registrar training. 2. METHODS An explorative-descriptive qualitative collective instrumental case study was done. Thirty in-depth semi-structured interviews were conducted with 15 inpatients of Weskoppies Hospital. Purposive sampling was used to ensure maximum variation and richness of information. Transcribed recordings were organised using the computer programme ATLAS.ti. Grounded theory methods were used for the data analysis. 3. RESULTS Only three patients described a good to very good therapeutic relationship with their registrars. Two other patients, although positive about certain qualities of their registrars, still had reservations about their interactions. Eleven patients had spent lengthy periods in closed wards. None of the three patients who described a good relationship with their registrars had been subjected to any coercive measures. Registrars rotate four-monthly, most have a symptom-based, biological approach and are used to seeing their patients only once a week due to a high workload. Encounters between staff and patients were mostly superficial; fellow patients became very important to most patients. The findings point to a lack of containment. Therefore, a model and substantive theory of therapeutic relationships in a psychiatric hospital was developed in which the concept of containment was placed at the centre. Containment should ideally be provided through a personal, professional relationship with the registrar/psychiatrist or with another team member. This, however, needs to be embedded in a containing environment, since whatever happens in a hospital cannot be seen in isolation, but is part of a complex inter-related system and has to be seen from a systems point of view. 4. CONCLUSION This model and substantive theory may contribute to a better understanding of the complexity of the situation in a psychiatric hospital. The findings show that a greater focus on therapeutic relationships is needed in the training of registrars. Providing a personal form of containment may lessen the need for coercive measures. Strict guidelines are furthermore needed to limit and control the use of coercive measures.
Genetic variation and clinical variables contributing to Schizophrenia in a Founder Population from South Africa
(University of Pretoria, 2014) Ker, James A.; Van Heerden, W.F.P. (Willem Francois Petrus), 1958-; erna.fourie@up.ac.za; Roos, J.L. (Johannes Louw)
Thirty publications are submitted. They deal with findings of the genetic architecture of schizophrenia in an Afrikaner founder population and clinical related variables pertaining to this population. The initial research findings supported the appropriateness of the Afrikaner population for mapping complex traits using both linkage and linkage disequilibrium (LD) approaches. Basic sample descriptors and cardinal symptoms of schizophrenia in the US and South African populations were equivalent. It was concluded that the results from our genetic study of schizophrenia in the Afrikaner sample will be applicable to other populations. It was found that early non-psychotic childhood deviance (in the first ten years of life) distinguished a distinct subtype of schizophrenia patient, and that the form of early deviance manifested, was meaningful linked to later disease outcome; and that it may be a possible endophenotypic marker in schizophrenia but not in bipolar disorder. Schizophrenia genetic research used linkage analysis, association studies and exome sequencing studies as it became available in the last few years. We addressed the role of the individual genes from the 22q11 locus (prototype CNV described in schizophrenia). Systematic screening of the 26 genes residing in this locus identified PRODH2, ZDHHC8, NOGO Receptor 1 (RTN4R) gene as contributing to schizophrenia risk associated with this region. Linkage genome-wide scans, using both less dense (10cM) and more dense scans (2cM), identified a locus on chromosome 1 and 13. Recent fine mapping on chromosome 13q32-34 and brain expression analysis implicates MYO16 in schizophrenia (not included in the 30 publications). For the first time a probound with a uniparental disomy (UPD) of the entire chromosome 1, was identified, which further support the involvement of chromosome 1 in schizophrenia. We confirmed the previous reported rate of 2% frequency of 22q11 deletions in adult schizophrenia Afrikaner patients and provided a two-stage screening protocol to identify these patients in clinical practice. As more patients were recruited for this study certain comorbid conditions became obvious including marijuana use/abuse and obsessive compulsive disorder (OCD) and obsessive compulsive symptoms (OCS). Approximately half of the male patients and a quarter of the female patients used or abused marijuana. Male users of marijuana with prominent early non-psychotic deviant behaviour in the first 10 years of life had the lowest mean age of criteria onset (18.4 years) with a poor prognosis. The prevalence of OCD/OCS in this population was 13.2% and differs from other ethnic groups in South Africa, and was associated with significant psychopathology and poor prognosis. As the research progressed the emphasis has changed from familial cases with the disease to sporadic cases (non-familial). We offered the first clear view of the genetic landscape of schizophrenia. We found that rare de novo structural mutations at many different loci are significantly enriched and contribute to schizophrenia vulnerability in sporadic cases with the disease. We also demonstrated that genes contribute to familial schizophrenia, while new mutations are less prominent. The study of schizophrenia in the Afrikaner founder population has helped to clear the view of the genetic landscape of schizophrenia.
Emotionally triggered involuntary violent behaviour not attributed to a mental disorder : conceptual criteria and their reliability
(University of Pretoria, 2015) Van Staden, C.W.; Joubert, Pierre M.
Emotionally triggered involuntary violent behaviour not attributed to a mental disorder: conceptual criteria and their reliability. This study conceptualised emotionally triggered involuntary violent behaviour (ETIVB), developed criteria for the identification of ETIVB, and examined their validity and reliability. South Africa criminal courts allow for a defence called “non-pathological criminal incapacity”. It refers inter alia to extreme emotional arousal triggering involuntary violent behaviour. This is usually called an “emotional storm” or a so-called “psychological blow automatism”. Psychiatrists are often called to give expert testimony in this regard, but there is no conceptual clarity or criteria upon which to base it. This difficulty is compounded by the requirement set by the criminal courts that the behaviour may not be attributed to a mental disorder (in this thesis the terms mental disorder and mental illness are used interchangeably). The first advance in obtaining clarity was afforded by focusing on the behaviour as distinct from 1) legal and jurisprudential considerations as well as 2) whether the behaviour is (not) attributed to mental disorder. The subsequent research questions driving the study were, “what counts as ETIVB?” In particular, what counts respectively as „emotional triggered‟, „involuntary‟, „violent‟, and „behaviour‟. Through conceptual methods suggested in the work of J.L. Austin, draft ETIVB-criteria were developed and then repetitively applied to a set of 28 cases. Twenty seven of these cases involved a charge of murder. The other one had behaved violently, but was not charged. The criteria were refined and their content validity derived by a repetitive to-and-fro process between comparative exploration of the concepts and their empirical application to the set of cases. The criteria were formulated into an instrument by which a psychiatrist can identify ETIVB. In addition provision was made to record whether ETIVB is, or is not, attributed to specific causes including mental disorder, but only as an attribution that follows after ETIVB has been identified. The ETIVB-instrument was subjected to reliability testing among 14 psychiatrists and 10 psychiatrists in training. They applied the ETIVB-criteria to a set of 5 externally validated case summaries. The participants had first been trained in the use of the instrument by considering other example cases. Statistical analyses of inter-rater reliability were performed. The modified kappa agreement ranged from 0.388 (fair) to 0.636 (substantial) across study cases for all criteria A.1 – H.1. The criteria for violence had exceptionally high inter-rater agreement, all being 0.947 and higher. The complexity of the ETIVB-construct transpired when inter-rater reliability analyses were compared between cases in that different cases posed different challenges for inter-rater agreement. The reliability testing across cases however, showed which less agreed-upon items would benefit from refinement.
Depressive disorders in primary school children : development of a screening instrument and refinement of DSM-IV criteria to account for developmental stage
(University of Pretoria, 2001) Kruger, Christa; upetd@up.ac.za; Van der Westhuizen, Deborah
Die rol van persoonlikheid en streshanteringsvaardighede by pasiente met fibromialgie sindroom (Afrikaans)
(University of Pretoria, 2006-10-28) Scholtz, J.G.; upetd@up.ac.za; Enslin, Charlene
Please read the abstract in the section 00front of this document
Psychoneuroimmunology in terms of the two main stress axes: Sickness behaviour as trigger for development of mental disorders
(University of Pretoria, 2003) Roos, J.L. (Johannes Louw); upetd@up.ac.za; Viljoen, Margaretha
Please read the abstract in the section 00front of this document
A cross-sectional descriptive study of clinical features and course of illness in a South African population with bipolar disorder
(University of Pretoria, 2012) Roos, J.L. (Johannes Louw); dr.stof@mweb.co.za; Grobler, Christoffel
There is generally a lack of studies examining prevalence and phenomenology of bipolar disorder in Africa. In literature, a unipolar manic course of illness in particular is reported to be rare. The purpose of this study was to investigate and describe the course of illness and clinical features in a cross-section of patients diagnosed with bipolar disorder attending public hospitals in Limpopo Province, South Africa and to determine the rate of a unipolar manic course in this sample of patients. This was a descriptive, cross-sectional study of patients presenting with a history of mania between October 2009 and April 2010, to three hospitals in Limpopo Province. A purposeful sample of 103 patients was recruited and interviewed using the Affective Disorders Evaluation. This study confirms that a unipolar manic course is indeed much more common than rates suggested in present day literature with57% of the study sample only ever experiencing manic episodes. The study also confirms the debilitating nature of bipolar disorder with more than two-thirds being unemployed in spite of a quarter of the study subjects having a tertiary education. The high rates of attempted suicide, history of violence and history of drug abuse all furthermore points to the devastating effects bipolar disorder has on individuals and their families. Treatment choice appeared to be a combination of a mood-stabilising agent in combination with an anti-psychotic. It was found that two-thirds of study subjects had consulted with faith- or traditional healers. Significant gender differences appeared in that females were more likely to suffer from comorbid anxiety disorders, have a history of sexual trauma, and be HIV positive whilst men were more likely to have a forensic- and substance-abuse history, experience hallucinations and receive clozapine. Patients presenting with a unipolar manic course of illness, as described in this thesis, may contribute to the search for an etiologically homogeneous sub-group which presents unique phenotype for genetic research and the search for genetic markers in mental illness. A unipolar manic course therefore needs to be considered as a specifier in diagnostic systems in order to heighten the awareness of such a course of illness in bipolar disorder, with a view to future research.

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