**Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents**

Afusat Olanike Busari

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53046

### **1. Introduction**

When asked what developmental stage is diagnosed with conduct disorder the primary an‐ swer would be adolescent. However, based on research the greatest damage to society is the result of actions by delinquent adolescents but conduct disorder begins below the age of 7 (Scott, 2007). The researcher hypothesis suggests conduct disorder has a multi-factorial cau‐ sation which includes biologic, psychosocial and numerous facets of the family unit. The re‐ search reveals a negative combination of these factors may predispose young children to exhibit symptoms of conduct disorder. The following questions will hopefully be answered: (1) What causes conduct disorder? (2) Can conduct disorder be prevented or predicted? (3) Does parenting style promote symptoms of conduct disorder? and (4) What are the inter‐ vention programmes that can be used to manage conduct disorder in adolescents.

### **2. Definition of conduct disorder**

According to Evans (2003) conduct disorder is a steady pattern of harming others or their property, lying, stealing, or breaking societal rules of behaviour. Remote instances of acute behaviour, running away, or vandalism is not enough to merit a diagnosis of conduct disor‐ der. Most children exhibit instances of poor judgment and bad behaviour at least one time in their childhood. The distinction is children with conduct disorder break the rules over and over again, exhibit aggressive behaviour, and show no regard for others. The behaviour is not considered conduct disorder until the symptoms are displayed for one year or more. The disturbances in behaviour result in significant clinical impairment with social skills, aca‐ demics and occupational functioning (American Psychiatric Association, 1994).

© 2013 Busari; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Conduct disorder is differentiated from other psychiatric disorders diagnosed in children by the following criteria: "persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated" American Psychiatric Associa‐ tion (as cited from Tehama, 2007). According to them conduct disorder is a psychiatric syn‐ drome occurring in childhood and adolescence which characterized by a longstanding pattern of violations of rules and antisocial behaviors. They interpret conduct disorder as:

control are susceptible to long-term changes in functioning Bremner&Vermetten, 2001 (as cited in Crowell et al., 2006). Parasympathetic nervous system (PNS)-linked cardiac activity has been associated with emotional regulation capabilities Porges, 1995 (as cited in Crowell et al., 2006) in contrast to deficiencies in sympathetic nervous system (SNS)-linked cardiac

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

http://dx.doi.org/10.5772/53046

47

During gestation the brain is vulnerable to the effects of environmental stressors; this state‐ ment applies to both prenatal and postnatal development Hulzink et al., 2004 (as cited in Van Goozen et al., 2007). Environmental factors which can affect brain development are:

Baumrind (as cited in Marsiglia et al., 2007) classified three parenting styles: authoritarian, authoritative, and permissive. For the purpose of this research authoritarian parenting styles will be discussed. The characteristics of an authoritarian parent according to this researcher, are extremely restrictive and demanding rules. Parents who utilize this style tend to hamper children's autonomy and force them to follow stringent rules by threatening harsh punish‐ ment. This type of parenting may lead children to believe they are not responsible for their actions; by contrast, when actions are questions they assume it is not their fault. According to numerous psychological theories parent-child relationship can generate psychological disorders such as anxiety, identity confusion and conduct disorder (Dwairy, et al., 2006). Hoeve et al., (2008) concluded from their study a strong link between parenting styles and delinquency trajectories; therefore, they recommended future research include parenting

styles in measuring serious behaviours which are classified as conduct disorders.

child abuse; (2) community violence; (3) parental abuse (McCabe et al., 2005).

dressing repetitive visits to the office or the emergency room for treatment.

The link between exposure to violence in the home and community is a crucial risk factor for conduct disorder according to research by Elze et al., 1999; Fergusson &Horwood, 1998; ; Kaplan et al., 1998 (as cited in McCabe et al., 2005). Violence exposure can take place in many places within the child's environment including: (1) victimization and witnessing

Culture and societal norms make up the macro-system which is seen as the most distant fac‐ tors; the eco-system is seen as a midlevel factor; and the micro-system is seen as the most proximal position to the child. Lynch &Cicchetti, 1998 (as cited in McCabe, et al., 2005) stress risk factors which have the most impact are the factors which are more proximal to the child. Family stresses: (1) substance abuse; (2) violence; and (3) social isolation etc. increase a child's risk of conduct disorder or other mental health disorders. Garrison et al., 1992 (as cit‐ ed in Baker et al., 2007) reveals several studies have documented the relationship between childhood psychosocial issues and primary care visits. Pediatricians consistently under identify mental health problems in children. Behavioural problems have been linked to an increase in family stressors: (1) divorce; (2) relocation; and (3) financial issues Lavigne et al., 1998 (as cited in Baker et al., 2007). Pediatrician should be aware of these factors when ad‐

activity have been linked with reward inconsiderateness.

**•** Atypical child interaction from a depressed mother

**•** Poor nutrition

**•** Maternal psychopathology

Conduct disorder is a common childhood psychiatric problem that has increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violation of rules and/or lying. For a diagnosis these behaviors must occur for a least a six-month period.

### **3. Causes conduct disorder**

The conditions that contribute to the development of conduct disorder are considered to be multifactorial, with many factors (multifactorial) contributing to the cause. Neuropsycholog‐ ical testing has shown that children and adolescents with conduct disorders seem to have an impairment in the frontal lobe of the brain that interferes with their ability to plan, avoid harm, and learn from negative experiences. Childhood temperament is considered to have a genetic basis. Children or adolescents who are considered to have a difficult temperament are more likely to develop behaviour problems. Children or adolescents from disadvantag‐ ed, dysfunctional, and disorganized home environments are more likely to develop conduct disorders. Social problems and peer group rejection have been found to contribute to delin‐ quency (Salaam 1992). Low socioeconomic status has been associated with conduct disor‐ ders (Busari & Adejumobi 2012). Children and adolescents exhibiting delinquent and aggressive behaviours have distinctive cognitive and psychological profiles when compared to children with other mental health problems and control groups (Aderanti 2006). All of the possible contributing factors influence how children and adolescents interact with other people.

The etiology of conduct disorder consists of the correlation of genetic, family and social fac‐ tors. The child may inherit limited baseline autonomic nervous system activity, resulting in a need for greater stimulation to attain optimal arousal. This hereditary aspect may explain the high level of sensation-seeking activity associated with the disorder (Johnson et al., 2002). Several studies have revealed the role of autonomic under-arousal in conduct-disor‐ dered adolescents (Crowell et al., 2006). According to McBurnett&Lahey, 1994 & Scrapa & Raine, 1997 (as cited in Crowell et al., 2006) conduct disorder and antisocial behaviour in adulthood are marked by autonomic under-arousal which included reduced electro-dermal responding (EDR) and heart rate. Beauchaine, 2003 (as cited in Crowell et al., 2006) revealed both elementary children and adolescents have reduced sympathetic and parasympathetic linked cardiac activity when diagnosed with conduct disorder.

The importance of this research is evident when considering the critical period of preschool when noradrenergic, serotonergic, and dopaminergic systems which administer behavioural control are susceptible to long-term changes in functioning Bremner&Vermetten, 2001 (as cited in Crowell et al., 2006). Parasympathetic nervous system (PNS)-linked cardiac activity has been associated with emotional regulation capabilities Porges, 1995 (as cited in Crowell et al., 2006) in contrast to deficiencies in sympathetic nervous system (SNS)-linked cardiac activity have been linked with reward inconsiderateness.

During gestation the brain is vulnerable to the effects of environmental stressors; this state‐ ment applies to both prenatal and postnatal development Hulzink et al., 2004 (as cited in Van Goozen et al., 2007). Environmental factors which can affect brain development are:

**•** Poor nutrition

Conduct disorder is differentiated from other psychiatric disorders diagnosed in children by the following criteria: "persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated" American Psychiatric Associa‐ tion (as cited from Tehama, 2007). According to them conduct disorder is a psychiatric syn‐ drome occurring in childhood and adolescence which characterized by a longstanding pattern of violations of rules and antisocial behaviors. They interpret conduct disorder as:

Conduct disorder is a common childhood psychiatric problem that has increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violation of rules and/or lying. For a diagnosis these behaviors must occur

The conditions that contribute to the development of conduct disorder are considered to be multifactorial, with many factors (multifactorial) contributing to the cause. Neuropsycholog‐ ical testing has shown that children and adolescents with conduct disorders seem to have an impairment in the frontal lobe of the brain that interferes with their ability to plan, avoid harm, and learn from negative experiences. Childhood temperament is considered to have a genetic basis. Children or adolescents who are considered to have a difficult temperament are more likely to develop behaviour problems. Children or adolescents from disadvantag‐ ed, dysfunctional, and disorganized home environments are more likely to develop conduct disorders. Social problems and peer group rejection have been found to contribute to delin‐ quency (Salaam 1992). Low socioeconomic status has been associated with conduct disor‐ ders (Busari & Adejumobi 2012). Children and adolescents exhibiting delinquent and aggressive behaviours have distinctive cognitive and psychological profiles when compared to children with other mental health problems and control groups (Aderanti 2006). All of the possible contributing factors influence how children and adolescents interact with other

The etiology of conduct disorder consists of the correlation of genetic, family and social fac‐ tors. The child may inherit limited baseline autonomic nervous system activity, resulting in a need for greater stimulation to attain optimal arousal. This hereditary aspect may explain the high level of sensation-seeking activity associated with the disorder (Johnson et al., 2002). Several studies have revealed the role of autonomic under-arousal in conduct-disor‐ dered adolescents (Crowell et al., 2006). According to McBurnett&Lahey, 1994 & Scrapa & Raine, 1997 (as cited in Crowell et al., 2006) conduct disorder and antisocial behaviour in adulthood are marked by autonomic under-arousal which included reduced electro-dermal responding (EDR) and heart rate. Beauchaine, 2003 (as cited in Crowell et al., 2006) revealed both elementary children and adolescents have reduced sympathetic and parasympathetic

The importance of this research is evident when considering the critical period of preschool when noradrenergic, serotonergic, and dopaminergic systems which administer behavioural

linked cardiac activity when diagnosed with conduct disorder.

for a least a six-month period.

46 Mental Disorders - Theoretical and Empirical Perspectives

**3. Causes conduct disorder**

people.


Baumrind (as cited in Marsiglia et al., 2007) classified three parenting styles: authoritarian, authoritative, and permissive. For the purpose of this research authoritarian parenting styles will be discussed. The characteristics of an authoritarian parent according to this researcher, are extremely restrictive and demanding rules. Parents who utilize this style tend to hamper children's autonomy and force them to follow stringent rules by threatening harsh punish‐ ment. This type of parenting may lead children to believe they are not responsible for their actions; by contrast, when actions are questions they assume it is not their fault. According to numerous psychological theories parent-child relationship can generate psychological disorders such as anxiety, identity confusion and conduct disorder (Dwairy, et al., 2006). Hoeve et al., (2008) concluded from their study a strong link between parenting styles and delinquency trajectories; therefore, they recommended future research include parenting styles in measuring serious behaviours which are classified as conduct disorders.

The link between exposure to violence in the home and community is a crucial risk factor for conduct disorder according to research by Elze et al., 1999; Fergusson &Horwood, 1998; ; Kaplan et al., 1998 (as cited in McCabe et al., 2005). Violence exposure can take place in many places within the child's environment including: (1) victimization and witnessing child abuse; (2) community violence; (3) parental abuse (McCabe et al., 2005).

Culture and societal norms make up the macro-system which is seen as the most distant fac‐ tors; the eco-system is seen as a midlevel factor; and the micro-system is seen as the most proximal position to the child. Lynch &Cicchetti, 1998 (as cited in McCabe, et al., 2005) stress risk factors which have the most impact are the factors which are more proximal to the child. Family stresses: (1) substance abuse; (2) violence; and (3) social isolation etc. increase a child's risk of conduct disorder or other mental health disorders. Garrison et al., 1992 (as cit‐ ed in Baker et al., 2007) reveals several studies have documented the relationship between childhood psychosocial issues and primary care visits. Pediatricians consistently under identify mental health problems in children. Behavioural problems have been linked to an increase in family stressors: (1) divorce; (2) relocation; and (3) financial issues Lavigne et al., 1998 (as cited in Baker et al., 2007). Pediatrician should be aware of these factors when ad‐ dressing repetitive visits to the office or the emergency room for treatment.

Parental psychopathology and parenting behaviour may be potentially important risk or protective factors in developmental outcomes for these children with concurrent conduct problems. Parental stress and maladaptive parenting may foster the development of con‐ duct disorder Johnson & Mash, 2001 (as cited by Chronis et al., 2007). The researchers pro‐ pose maternal smoking is a significant factor in conduct disorder because nicotine may interrupt fetal brain development. According to them, "Our study suggests that cigarette smoking may be one of the first prenatal risk factors for this very serious disorder" (Univer‐ sity of Chicago Medical Center, 1997).

antisocial behaviour influence these children throughout adulthood and influence the child‐

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

http://dx.doi.org/10.5772/53046

49

The influences of individual factors are multifaceted and confusion. Family dysfunction is repetitively identified as one of the crucial factor for conduct disorder in adolescence. Poor parental supervision is the preeminent predictor of violence and vandalism committed by boys. Psychosocial disturbances in children and adolescence bring together a comprehen‐ sive range of research to shed light on these young people who become parents of tomor‐ row; these parents who were diagnosed with conduct disorder predispose their child to the

The public debate concerning the relationship between family characteristics and children with conduct disorder continues to raise questions which researchers hope to answer. A lon‐ gitudinal survey of children suggests ineffective parenting style is the strongest predictor of delinquent behaviour in children between the ages of 8 and 11 years. In addition, aversion tactics, low socioeconomic status and the number of siblings in the home are associated with higher probability of children exhibiting delinquent behaviour and conduct disorder (Bu‐ sari&Adejumobi 2012). Somerstein (2007) reveals the common family dynamic in many indi‐

rearing environment (Jafee et al., 2006).

viduals' histories of male terrorist is authoritarian parents.

**•** aggression or serious threats of harm to people or animals;

**•** deliberate property damage or destruction (i.e. fire setting);

**•** repeated violation of household or school rules, laws or both; and

**•** persistent lying to avoid consequences or to obtain tangible goods or privileges

(3) the child is often truant from school which usually begins before the age of 13.

The American Psychiatric Association (1994) provides further symptoms which support the clinician in diagnosis of conduct disorder. The child will often bully, threaten or intimidate others. They may intentionally set fires with the objective of harming others. The violation of rules would include: (1) often staying out late at night regardless of parental prohibitions which can begin before the age of 13; (2) has run away from home more than two times; and

Additional features of conduct disorder include an indifference to the welfare of others and little if any remorse about harming others. Adolescents often verbalize outward remorse to avoid punishment but do not exhibit any guilt. They do not require an objective basis to conclude others are a threat to them. Because of this demeanor they may lash out aggres‐ sively without being provoked (Scott., 2007). During normal child development aggression and fighting is pertinent for defensive issues which do not escalate into anti-social behav‐ iours; but, persistent anti-social behaviour collectively handicaps during childhood and

**4. Symptoms of conduct disorder**

The clinical features of Conduct Disorder are:

same disorder (Pearce, 1996).

According to the ecological-transactional model child abuse has the greatest impact on child functioning. Kaplan et al., 1998 states several studies have correlated child maltreatment to an increase risk of conduct disorder (as cited in McCabe et al., 2005). A study at University of Chicago Medical Center (1997) reveals a link between smoking during pregnancy and the likelihood of having a son with conduct disorder. The researchers analyzed records of 177, 7-12 year-old boys who were referred for outpatient treatment for behavioural problems. The study indicated 24 percent of the mothers who reported smoking more than a half-pack of cigarettes per day during pregnancy, 80% of their sons had conduct disorder. This was in contrast to conduct disorder in 50% of the boys whose mothers did not smoke (University of Chicago Medical Center, 1997). According to the researcher "Our study indicates that re‐ gardless of other factors, smoking during pregnancy can have serious behavioural outcomes in children" (University of Chicago Medical Center, 1997).

The longitudinal and experimental studies on children who are raised in orphanages, chil‐ dren's homes, and foster homes have established the adverse effects of long-term institu‐ tional care on children's personality development according to the American Academy of Child and Adolescent Psychiatry, 2005 (as cited in Chronis et al., 2007). Consistent research has shown a correlation between institutional child rearing and hyperactivity and inatten‐ tion (Busari & Ojo 2011). Both of these symptoms are precursors of conduct disorder Roy et al., 2000 (as cited in Chronis et al., 2007).

The research repeatedly exposes children who are diagnosed with ADHD and conduct dis‐ order are predisposed for (1) risky sexual behaviour; (2) substance abuse; (3) delinquency; and (4) driving risks Barkley et al., 1993 (as cited in Chronis et al., 2007). The most disturb‐ ing fact is children who are diagnosed with ADHD and conduct disorder are at a greater risk of chronic criminal offenses Lyman, 1998 (as cited in Chronis et al., 2007). They identi‐ fied children with conduct disorder at a greater jeopardy for continual offending and ex‐ plained their perseverance by the correlation of their behaviour, neuropsychological and physiological deficits are comparable to adult psychopaths.

Childhood conduct disorder is a major risk factor for adult disorders especially anti-social behaviour. The key to diagnosing these children is to identify the origin of antisocial behav‐ iour which is found in (1) difficult temperament and (2) ineffective socialization (Van Goo‐ zen et al., 2007). Conduct disorder in childhood which persists through adolescence is associated with co-morbidity, recurrence and resistance to treatment Moffit(2005). The study shows children and adolescence who struggle with signs and symptoms of conduct disorder continue to struggle throughout adulthood with psychosocial problems. The trajectories of antisocial behaviour influence these children throughout adulthood and influence the child‐ rearing environment (Jafee et al., 2006).

The influences of individual factors are multifaceted and confusion. Family dysfunction is repetitively identified as one of the crucial factor for conduct disorder in adolescence. Poor parental supervision is the preeminent predictor of violence and vandalism committed by boys. Psychosocial disturbances in children and adolescence bring together a comprehen‐ sive range of research to shed light on these young people who become parents of tomor‐ row; these parents who were diagnosed with conduct disorder predispose their child to the same disorder (Pearce, 1996).

The public debate concerning the relationship between family characteristics and children with conduct disorder continues to raise questions which researchers hope to answer. A lon‐ gitudinal survey of children suggests ineffective parenting style is the strongest predictor of delinquent behaviour in children between the ages of 8 and 11 years. In addition, aversion tactics, low socioeconomic status and the number of siblings in the home are associated with higher probability of children exhibiting delinquent behaviour and conduct disorder (Bu‐ sari&Adejumobi 2012). Somerstein (2007) reveals the common family dynamic in many indi‐ viduals' histories of male terrorist is authoritarian parents.

### **4. Symptoms of conduct disorder**

Parental psychopathology and parenting behaviour may be potentially important risk or protective factors in developmental outcomes for these children with concurrent conduct problems. Parental stress and maladaptive parenting may foster the development of con‐ duct disorder Johnson & Mash, 2001 (as cited by Chronis et al., 2007). The researchers pro‐ pose maternal smoking is a significant factor in conduct disorder because nicotine may interrupt fetal brain development. According to them, "Our study suggests that cigarette smoking may be one of the first prenatal risk factors for this very serious disorder" (Univer‐

According to the ecological-transactional model child abuse has the greatest impact on child functioning. Kaplan et al., 1998 states several studies have correlated child maltreatment to an increase risk of conduct disorder (as cited in McCabe et al., 2005). A study at University of Chicago Medical Center (1997) reveals a link between smoking during pregnancy and the likelihood of having a son with conduct disorder. The researchers analyzed records of 177, 7-12 year-old boys who were referred for outpatient treatment for behavioural problems. The study indicated 24 percent of the mothers who reported smoking more than a half-pack of cigarettes per day during pregnancy, 80% of their sons had conduct disorder. This was in contrast to conduct disorder in 50% of the boys whose mothers did not smoke (University of Chicago Medical Center, 1997). According to the researcher "Our study indicates that re‐ gardless of other factors, smoking during pregnancy can have serious behavioural outcomes

The longitudinal and experimental studies on children who are raised in orphanages, chil‐ dren's homes, and foster homes have established the adverse effects of long-term institu‐ tional care on children's personality development according to the American Academy of Child and Adolescent Psychiatry, 2005 (as cited in Chronis et al., 2007). Consistent research has shown a correlation between institutional child rearing and hyperactivity and inatten‐ tion (Busari & Ojo 2011). Both of these symptoms are precursors of conduct disorder Roy et

The research repeatedly exposes children who are diagnosed with ADHD and conduct dis‐ order are predisposed for (1) risky sexual behaviour; (2) substance abuse; (3) delinquency; and (4) driving risks Barkley et al., 1993 (as cited in Chronis et al., 2007). The most disturb‐ ing fact is children who are diagnosed with ADHD and conduct disorder are at a greater risk of chronic criminal offenses Lyman, 1998 (as cited in Chronis et al., 2007). They identi‐ fied children with conduct disorder at a greater jeopardy for continual offending and ex‐ plained their perseverance by the correlation of their behaviour, neuropsychological and

Childhood conduct disorder is a major risk factor for adult disorders especially anti-social behaviour. The key to diagnosing these children is to identify the origin of antisocial behav‐ iour which is found in (1) difficult temperament and (2) ineffective socialization (Van Goo‐ zen et al., 2007). Conduct disorder in childhood which persists through adolescence is associated with co-morbidity, recurrence and resistance to treatment Moffit(2005). The study shows children and adolescence who struggle with signs and symptoms of conduct disorder continue to struggle throughout adulthood with psychosocial problems. The trajectories of

sity of Chicago Medical Center, 1997).

48 Mental Disorders - Theoretical and Empirical Perspectives

al., 2000 (as cited in Chronis et al., 2007).

in children" (University of Chicago Medical Center, 1997).

physiological deficits are comparable to adult psychopaths.

The clinical features of Conduct Disorder are:


The American Psychiatric Association (1994) provides further symptoms which support the clinician in diagnosis of conduct disorder. The child will often bully, threaten or intimidate others. They may intentionally set fires with the objective of harming others. The violation of rules would include: (1) often staying out late at night regardless of parental prohibitions which can begin before the age of 13; (2) has run away from home more than two times; and (3) the child is often truant from school which usually begins before the age of 13.

Additional features of conduct disorder include an indifference to the welfare of others and little if any remorse about harming others. Adolescents often verbalize outward remorse to avoid punishment but do not exhibit any guilt. They do not require an objective basis to conclude others are a threat to them. Because of this demeanor they may lash out aggres‐ sively without being provoked (Scott., 2007). During normal child development aggression and fighting is pertinent for defensive issues which do not escalate into anti-social behav‐ iours; but, persistent anti-social behaviour collectively handicaps during childhood and leads to deprived adjustment during adulthood. The child often endures negative responses by their peers and high levels of disapproval from their parents (Scott, 2007).

**• Aggressive conduct.** Aggressive conduct causes or threatens physical harm to others and

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

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51

**• Violation of rules.** Violation of ordinary rules of conduct or age-appropriate norms may

The symptoms of conduct disorder may resemble other medical conditions or behavioural

A child psychiatrist or a qualified mental health professional usually diagnoses conduct dis‐ orders in children and adolescents. A detailed history of the child's behaviour from parents and teachers, observations of the child's behaviour, and, sometimes, psychological testing contribute to the diagnosis. Parents who note symptoms of conduct disorder in their child or

may include the following: **◦** Intimidating behaviour

**◦** Cruelty to others or animals

**◦** Forcing someone into sexual activity, rape, molestation

**• Deceitfulness.** Deceitful behaviour may include the following:

**◦** Vandalism; intentional destruction to property

**• Destructive conduct.** Destructive conduct may include the following:

**◦** Bullying

**◦** Arson

**◦** Lying **◦** Theft

**◦** Shoplifting **◦** Delinquency

include the following:

**◦** Very early sexual activity

**◦** Running away

**◦** Pranks **◦** Mischief

problems.

**◦** Truancy (failure to attend school)

**7. How is conduct disorder diagnosed?**

**◦** Physical fights

**◦** Use of a weapon(s)

Children who are diagnosed with conduct disorder judge the world as an antagonistic and intimidating place. They may tattle on friends or blame others for the harm they have caused. They have few if any friends because of their limited interpersonal skills. Peers and family members may view them as irritating because of their indifference to their actions. They often have low self-esteem internally but externally they appear tough, cocky or selfassured (Evans, 2003).

### **5. Prevalence of conduct disorder among the adolescents**

Conduct disorder has become a major health and social problem; it is the most common psy‐ chiatric problem diagnosed among children. Around the world the prevalence of conduct dis‐ order is 5% (Scott, 2007). A study conducted by Sujit et al., (2006) reveals 4.58% of boys and 4.5% of girls are diagnosed with conduct disorder worldwide. In their study of 240 students in four schools in Kanke childhood conduct disorder was found in 73% and in adolescent 27%. Mild conduct disorder was found in 36%, moderate in 64% and severe conduct disorder in none. Lying, bullying and cruelty to animals were the primary symptoms (Sujit, 2006).

Conduct disorder affects 1 to 4 percent of 9- to 17-year olds in the United States. The disor‐ der is more predominate in boys than girls and more common in cities than in rural areas (U.S. Department of Health and Human Services, 1999). Between 6 to 16 percent of boys and 2 to 9 percent of girls meet the criteria to be diagnosed with conduct disorder. It is estimated 40 percent of these children will grow up to be adults with antisocial personality disorder (Searight, 2001).

Epidemiological studies state approximately 2% of girls and 9% of boys are afflicted with this disorder. Adolescents with more external signs and symptoms would amplify the per‐ centage to one third or one half of all children and adolescent clinic referrals Kazdin et al., 1992 (as cited by McCabe et at., 2005).

### **6. What are the symptoms of conduct disorder?**

Most symptoms seen in children with conduct disorder also occur at times in children with‐ out this disorder. However, in children with conduct disorder, these symptoms occur more frequently and interfere with learning, school adjustment, and, sometimes, with the child's relationships with others.

The following are the most common symptoms of conduct disorder. However, each child may experience symptoms differently. The four main groups of behaviours include the following:

	- **◦** Intimidating behaviour
	- **◦** Bullying

leads to deprived adjustment during adulthood. The child often endures negative responses

Children who are diagnosed with conduct disorder judge the world as an antagonistic and intimidating place. They may tattle on friends or blame others for the harm they have caused. They have few if any friends because of their limited interpersonal skills. Peers and family members may view them as irritating because of their indifference to their actions. They often have low self-esteem internally but externally they appear tough, cocky or self-

Conduct disorder has become a major health and social problem; it is the most common psy‐ chiatric problem diagnosed among children. Around the world the prevalence of conduct dis‐ order is 5% (Scott, 2007). A study conducted by Sujit et al., (2006) reveals 4.58% of boys and 4.5% of girls are diagnosed with conduct disorder worldwide. In their study of 240 students in four schools in Kanke childhood conduct disorder was found in 73% and in adolescent 27%. Mild conduct disorder was found in 36%, moderate in 64% and severe conduct disorder in

Conduct disorder affects 1 to 4 percent of 9- to 17-year olds in the United States. The disor‐ der is more predominate in boys than girls and more common in cities than in rural areas (U.S. Department of Health and Human Services, 1999). Between 6 to 16 percent of boys and 2 to 9 percent of girls meet the criteria to be diagnosed with conduct disorder. It is estimated 40 percent of these children will grow up to be adults with antisocial personality disorder

Epidemiological studies state approximately 2% of girls and 9% of boys are afflicted with this disorder. Adolescents with more external signs and symptoms would amplify the per‐ centage to one third or one half of all children and adolescent clinic referrals Kazdin et al.,

Most symptoms seen in children with conduct disorder also occur at times in children with‐ out this disorder. However, in children with conduct disorder, these symptoms occur more frequently and interfere with learning, school adjustment, and, sometimes, with the child's

The following are the most common symptoms of conduct disorder. However, each child may experience symptoms differently. The four main groups of behaviours include the following:

none. Lying, bullying and cruelty to animals were the primary symptoms (Sujit, 2006).

by their peers and high levels of disapproval from their parents (Scott, 2007).

**5. Prevalence of conduct disorder among the adolescents**

assured (Evans, 2003).

50 Mental Disorders - Theoretical and Empirical Perspectives

(Searight, 2001).

1992 (as cited by McCabe et at., 2005).

relationships with others.

**6. What are the symptoms of conduct disorder?**

	- **◦** Vandalism; intentional destruction to property
	- **◦** Arson
	- **◦** Lying
	- **◦** Theft
	- **◦** Shoplifting
	- **◦** Delinquency
	- **◦** Truancy (failure to attend school)
	- **◦** Running away
	- **◦** Pranks
	- **◦** Mischief
	- **◦** Very early sexual activity

The symptoms of conduct disorder may resemble other medical conditions or behavioural problems.

### **7. How is conduct disorder diagnosed?**

A child psychiatrist or a qualified mental health professional usually diagnoses conduct dis‐ orders in children and adolescents. A detailed history of the child's behaviour from parents and teachers, observations of the child's behaviour, and, sometimes, psychological testing contribute to the diagnosis. Parents who note symptoms of conduct disorder in their child or

teen can help by seeking an evaluation and treatment early. Early treatment can often pre‐ vent future problems. Further, conduct disorder often coexists with other mental health dis‐ orders, including mood disorders, anxiety disorders, posttraumatic stress disorder, substance abuse, attention-deficit/hyperactivity disorder, and learning disorders, increasing the need for early diagnosis and treatment. Parents should consult their child's doctor for more information.

primarily interested in the heterotypic comorbidity (e.g., Angold et al., 1999) involving the disruptive behaviour disorders and depression. The term heterotypic continuity is used to refer to the continuity of psychopathology in different forms over time, such as children with ODD being more likely to become depressed in adulthood (e.g., Copeland, Shanahan, Costello, &Angold, 2009). This is in contrast to homotypic continuity, which refers to the continuity of the same type of psychopathology over time, such as depression in adoles‐

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

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53

Cognitive therapy is an active, structured form of psychotherapy that is designed to rapidly and effectively reduce and eliminate psychological symptoms. Cognitive is simply a fancy word that means thoughts. Cognitive behaviour therapy, sometimes known as CBT is a form of psychological treatment that focuses on the thoughts and behaviours that accompa‐

Traditionally, CBT has been relatively brief treatment compared to other types of psycho‐ therapy. CBT is focused on achieving defined and measurable treatment goals. Progress to‐ wards these goals is regularly assessed to ensure that treatment is progressing in an efficient

There is a significant amount of scientific evidence demonstrating that CBT is effective in treating a wide variety of psychological difficulties including depression, anxiety, panic at‐ tacks, phobias, obsessive compulsive disorder, social anxiety and shyness, and post- trau‐ matic stress disorder. The evidence suggests that CBT is not only effective in helping people get better but it is also effective in minimizing relapse or helping people stay better. Cogni‐ tive behaviour therapists (CBT) emphasise the process of learning in improving and main‐ taining behaviour. The client is encouraged to identify connections between thoughts and

CBT often involves problem solving skills training. This type of training has been widely evaluated and there is evidence for its efficacy in the short term in treating aggression and conduct disorders in children. CBT is used for a range of problems for children and adults. It places emphasis on certain cognitive techniques that are designed to produce changes in thinking and therefore changes in behaviour or mood (Busari & Uwakwe 2001). CBT also emphasises the learning process and the ways in which external environments can change both cognition and behaviour. CBT for children and adolescents usually includes a range of behaviour performance-based procedures, and often involve the family or school in therapy. It may include individual work, group sessions, or both. The length of treatment varies con‐

For children with conduct disorder CBT usually has a strong focus on social cognitions and interpersonal problem-solving. Programmes are often quite long and may take up to 25 or 30 weekly sessions. The therapist is active and involved and tries to develop a collaborative

siderably and depends on the severity of difficulties experienced.

cence showing continuity in the form of depression in adulthood.

**10. What is cognitive therapy?**

ny psychological distress.

and effective manner.

their responses to social situations.

### **8. Prevention of conduct disorder in childhood**

As with oppositional defiant disorder (ODD), some experts believe that a developmental se‐ quence of experiences occurs in the development of conduct disorder. This sequence may start with ineffective parenting practices, followed by academic failure, and poor peer inter‐ actions. These experiences then often lead to depressed mood and involvement in a deviant peer group. Other experts, however, believe that many factors, including child abuse, genet‐ ic susceptibility, history of academic failure, brain damage, and/or a traumatic experience in‐ fluence the expression of conduct disorder. Early detection and intervention into negative family and social experiences may be helpful in disrupting the development of the sequence of experiences that lead to more disruptive and aggressive behaviour

### **9. Relationship between conduct disorder, depression and opposition disorder**

Many studies have shown that conduct disorder (CD) and depression often co-occur in late childhood and adolescence and have historically been regarded as the primary point of co‐ morbidity between internalizing and behavioral disorders. On the other hand, recent evi‐ dence suggests that oppositional defiant disorder (ODD), and not CD, may best explain the comorbidity between disruptive behaviour disorders and depression. ODD typically onsets before CD and depression, changes in ODD symptoms predict changes in symptoms of CD and depression from one year to the next, and ODD in childhood and adolescence predicts depression in adulthood. Emerging evidence suggests that there are affective and behaviou‐ ral dimensions of ODD symptoms, and those affective ODD symptoms (and not the behav‐ ioural symptoms) best predict later depression.

These results are highly relevant not only for our understanding of the etiology of the disor‐ ders, but also for optimizing early interventions aimed at reducing irritability in some ODD children. The new findings also stimulate new questions to be addressed with future re‐ search. In this review, the comorbidity between disruptive behaviour disorders (opposition‐ al defiant disorder [ODD] and conduct disorder [CD] ) and depression will be considered. The term comorbidity is used to indicate the concurrent co-occurrence of two disorders, but like Angold, Costello, and Erkanli (1999), the researcher do not use concurrent to imply that the two disorders onset or terminate at exactly the same time. In addition, the researcher is primarily interested in the heterotypic comorbidity (e.g., Angold et al., 1999) involving the disruptive behaviour disorders and depression. The term heterotypic continuity is used to refer to the continuity of psychopathology in different forms over time, such as children with ODD being more likely to become depressed in adulthood (e.g., Copeland, Shanahan, Costello, &Angold, 2009). This is in contrast to homotypic continuity, which refers to the continuity of the same type of psychopathology over time, such as depression in adoles‐ cence showing continuity in the form of depression in adulthood.

### **10. What is cognitive therapy?**

teen can help by seeking an evaluation and treatment early. Early treatment can often pre‐ vent future problems. Further, conduct disorder often coexists with other mental health dis‐ orders, including mood disorders, anxiety disorders, posttraumatic stress disorder, substance abuse, attention-deficit/hyperactivity disorder, and learning disorders, increasing the need for early diagnosis and treatment. Parents should consult their child's doctor for

As with oppositional defiant disorder (ODD), some experts believe that a developmental se‐ quence of experiences occurs in the development of conduct disorder. This sequence may start with ineffective parenting practices, followed by academic failure, and poor peer inter‐ actions. These experiences then often lead to depressed mood and involvement in a deviant peer group. Other experts, however, believe that many factors, including child abuse, genet‐ ic susceptibility, history of academic failure, brain damage, and/or a traumatic experience in‐ fluence the expression of conduct disorder. Early detection and intervention into negative family and social experiences may be helpful in disrupting the development of the sequence

**9. Relationship between conduct disorder, depression and opposition**

Many studies have shown that conduct disorder (CD) and depression often co-occur in late childhood and adolescence and have historically been regarded as the primary point of co‐ morbidity between internalizing and behavioral disorders. On the other hand, recent evi‐ dence suggests that oppositional defiant disorder (ODD), and not CD, may best explain the comorbidity between disruptive behaviour disorders and depression. ODD typically onsets before CD and depression, changes in ODD symptoms predict changes in symptoms of CD and depression from one year to the next, and ODD in childhood and adolescence predicts depression in adulthood. Emerging evidence suggests that there are affective and behaviou‐ ral dimensions of ODD symptoms, and those affective ODD symptoms (and not the behav‐

These results are highly relevant not only for our understanding of the etiology of the disor‐ ders, but also for optimizing early interventions aimed at reducing irritability in some ODD children. The new findings also stimulate new questions to be addressed with future re‐ search. In this review, the comorbidity between disruptive behaviour disorders (opposition‐ al defiant disorder [ODD] and conduct disorder [CD] ) and depression will be considered. The term comorbidity is used to indicate the concurrent co-occurrence of two disorders, but like Angold, Costello, and Erkanli (1999), the researcher do not use concurrent to imply that the two disorders onset or terminate at exactly the same time. In addition, the researcher is

**8. Prevention of conduct disorder in childhood**

of experiences that lead to more disruptive and aggressive behaviour

ioural symptoms) best predict later depression.

more information.

52 Mental Disorders - Theoretical and Empirical Perspectives

**disorder**

Cognitive therapy is an active, structured form of psychotherapy that is designed to rapidly and effectively reduce and eliminate psychological symptoms. Cognitive is simply a fancy word that means thoughts. Cognitive behaviour therapy, sometimes known as CBT is a form of psychological treatment that focuses on the thoughts and behaviours that accompa‐ ny psychological distress.

Traditionally, CBT has been relatively brief treatment compared to other types of psycho‐ therapy. CBT is focused on achieving defined and measurable treatment goals. Progress to‐ wards these goals is regularly assessed to ensure that treatment is progressing in an efficient and effective manner.

There is a significant amount of scientific evidence demonstrating that CBT is effective in treating a wide variety of psychological difficulties including depression, anxiety, panic at‐ tacks, phobias, obsessive compulsive disorder, social anxiety and shyness, and post- trau‐ matic stress disorder. The evidence suggests that CBT is not only effective in helping people get better but it is also effective in minimizing relapse or helping people stay better. Cogni‐ tive behaviour therapists (CBT) emphasise the process of learning in improving and main‐ taining behaviour. The client is encouraged to identify connections between thoughts and their responses to social situations.

CBT often involves problem solving skills training. This type of training has been widely evaluated and there is evidence for its efficacy in the short term in treating aggression and conduct disorders in children. CBT is used for a range of problems for children and adults. It places emphasis on certain cognitive techniques that are designed to produce changes in thinking and therefore changes in behaviour or mood (Busari & Uwakwe 2001). CBT also emphasises the learning process and the ways in which external environments can change both cognition and behaviour. CBT for children and adolescents usually includes a range of behaviour performance-based procedures, and often involve the family or school in therapy. It may include individual work, group sessions, or both. The length of treatment varies con‐ siderably and depends on the severity of difficulties experienced.

For children with conduct disorder CBT usually has a strong focus on social cognitions and interpersonal problem-solving. Programmes are often quite long and may take up to 25 or 30 weekly sessions. The therapist is active and involved and tries to develop a collaborative relationship that stimulates the child to think for him or herself. The approach aims to give the child the opportunity to try things out and develop new skills

Ho1: There is no significant difference in the level of reduction of conduct disorder of partic‐

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

http://dx.doi.org/10.5772/53046

55

Ho2: There is no significant difference in the level of reduction of conduct disorder of partic‐

Ho3: There is no significant difference in the level of reduction of conduct disorder of partici‐ pants from separated and those from intact homes exposed to cognitive behaviour interven‐

Ho4: There is no significant difference in the level of reduction of conduct disorder exhibited by participants form polygamous and those from monogamous home after therapeutic

The design adopted for this study was a two group (experimental vs control) pretest-post test design with dependent variable (conduct disorder) and independent variable (Cognitive Behaviour Therapy). Participants were assigned to either experimental or control group by

The participants of is study were 350 adolescents pre-selected using conduct disorder ques‐ tionnaire. The participant's ages between 10-19 years from five secondary schools selected through stratified random sampling techniques in Ibadan metropolis of Oyo State, Nigeria. Out of 350 (72%) 252 were males while (28%) 98 were females 58% (203) were from monoga‐ mous home while (42%) 147 were from polygamous homes. (84%) 294 were from intact fam‐

The instrument used for collecting data was conduct disorder questionnaire (CDQ) de‐ signed by the researcher. It consists of two sections with section A consisting of Demograph‐ ic data such as age, sex, religion, type of home, type of family, class, etc. while section B consists of 37 items eliciting information on conduct disorder of the participants. These items requires the participants to indicate their degree of agreement with each item on a five point likert type scale ranging from 1 (most unlike me) to 5 (very much like me). Total scores range thus from 37 to 185. High score indicate highest level of conduct disorder. These in‐ strument (conduct disorder questionnaire) was cross-validated with two other instruments (Juvenile Delinquency Questionnaire and Anti-social Behaviour Scale) in a pilot study among randomly selected adolescents in the Junior secondary School, different form the participants (n= 150). The result when correlated with conduct disorder questionnaire was (.

ipants in the experimental and those in the control group

randomly alternating sign-up at counter balanced times.

ily while (16%) 56 were form separated family.

tion

treatment

**13.1. Design**

**13.2. Participants**

**13.3. Instrument**

**13. Methodology**

ipants based on gender after exposure to therapeutic treatment

### **11. Problem solving skills training**

A basic ingredient in CBT is to improve the problem-solving abilities of children and adoles‐ cents with conduct disorder. The training helps them to deal with external problems that may provoke behaviours. The child is first encouraged to generate potential solutions to a problem. The child and the therapist then decide on the best solution and identify steps in implementing it. The child practices these steps, and finally the whole process is evaluated.

There is some evidence that suggests that clients that develop new ways of thinking get bet‐ ter from psychological difficulties. When clients develop skills that enable them to identify, evaluate and change their thoughts they are likely to get better. In fact, there is proof, in the form of research studies that suggests that when clients develop these new thinking skills that they tend to get better and stay better, or have a lower chance of relapse (Busari 2012).

Cognitive behaviour therapy aims at changing clients' beliefs by treating beliefs as testable hypothesis to be examined through behavioural experiments jointly agreed upon by the cli‐ ents and the therapists. The therapist does not tell the client that his belief is wrong but rath‐ er asks questions to elicit the meaning, function, usefulness, and consequences of clients' beliefs (Busari, 2000).

Cognitive behaviour therapy also challenges adolescents to make conscious choices and to accept full responsibility for their choices (Martye 2004). Cognitive behaviour therapy has been found to be very effective in the treatment of all forms of antisocial behaviours such as stealing (Obalowo, 2004), socially undesirable behavior, faulty thinking.frustration, recidi‐ vism and delinquent behaviour (Busari & Adejumo 2012). Cognitive Behaviour Therapy al‐ so involves self-management which explains the self- which believes that individuals have potential for self-actualization. The proponent of this theory believed that human beings have inherent tendency to develop their "self" in the process of interpersonal and social ex‐ periences, which they have in the environment (Chauman 2000). Since individual has the potential for self-actualization, self-management techniques will make the delinquent indi‐ vidual take part in the management of his own behaviour. Research work cited in Juvenile Justice Bulletin (1999), Gardner 2003), revealed that self-management is effective in modify‐ ing deviant behaviours. The present study therefore investigates the effectiveness of cogni‐ tive – behaviour programme in the management of adolescents conduct disorder.

### **12. Hypotheses**

The following four null hypotheses were formulated and tested to guide this study at 0.05 level of significant.

Ho1: There is no significant difference in the level of reduction of conduct disorder of partic‐ ipants in the experimental and those in the control group

Ho2: There is no significant difference in the level of reduction of conduct disorder of partic‐ ipants based on gender after exposure to therapeutic treatment

Ho3: There is no significant difference in the level of reduction of conduct disorder of partici‐ pants from separated and those from intact homes exposed to cognitive behaviour interven‐ tion

Ho4: There is no significant difference in the level of reduction of conduct disorder exhibited by participants form polygamous and those from monogamous home after therapeutic treatment

### **13. Methodology**

### **13.1. Design**

relationship that stimulates the child to think for him or herself. The approach aims to give

A basic ingredient in CBT is to improve the problem-solving abilities of children and adoles‐ cents with conduct disorder. The training helps them to deal with external problems that may provoke behaviours. The child is first encouraged to generate potential solutions to a problem. The child and the therapist then decide on the best solution and identify steps in implementing it. The child practices these steps, and finally the whole process is evaluated.

There is some evidence that suggests that clients that develop new ways of thinking get bet‐ ter from psychological difficulties. When clients develop skills that enable them to identify, evaluate and change their thoughts they are likely to get better. In fact, there is proof, in the form of research studies that suggests that when clients develop these new thinking skills that they tend to get better and stay better, or have a lower chance of relapse (Busari 2012).

Cognitive behaviour therapy aims at changing clients' beliefs by treating beliefs as testable hypothesis to be examined through behavioural experiments jointly agreed upon by the cli‐ ents and the therapists. The therapist does not tell the client that his belief is wrong but rath‐ er asks questions to elicit the meaning, function, usefulness, and consequences of clients'

Cognitive behaviour therapy also challenges adolescents to make conscious choices and to accept full responsibility for their choices (Martye 2004). Cognitive behaviour therapy has been found to be very effective in the treatment of all forms of antisocial behaviours such as stealing (Obalowo, 2004), socially undesirable behavior, faulty thinking.frustration, recidi‐ vism and delinquent behaviour (Busari & Adejumo 2012). Cognitive Behaviour Therapy al‐ so involves self-management which explains the self- which believes that individuals have potential for self-actualization. The proponent of this theory believed that human beings have inherent tendency to develop their "self" in the process of interpersonal and social ex‐ periences, which they have in the environment (Chauman 2000). Since individual has the potential for self-actualization, self-management techniques will make the delinquent indi‐ vidual take part in the management of his own behaviour. Research work cited in Juvenile Justice Bulletin (1999), Gardner 2003), revealed that self-management is effective in modify‐ ing deviant behaviours. The present study therefore investigates the effectiveness of cogni‐

tive – behaviour programme in the management of adolescents conduct disorder.

The following four null hypotheses were formulated and tested to guide this study at 0.05

the child the opportunity to try things out and develop new skills

**11. Problem solving skills training**

54 Mental Disorders - Theoretical and Empirical Perspectives

beliefs (Busari, 2000).

**12. Hypotheses**

level of significant.

The design adopted for this study was a two group (experimental vs control) pretest-post test design with dependent variable (conduct disorder) and independent variable (Cognitive Behaviour Therapy). Participants were assigned to either experimental or control group by randomly alternating sign-up at counter balanced times.

### **13.2. Participants**

The participants of is study were 350 adolescents pre-selected using conduct disorder ques‐ tionnaire. The participant's ages between 10-19 years from five secondary schools selected through stratified random sampling techniques in Ibadan metropolis of Oyo State, Nigeria. Out of 350 (72%) 252 were males while (28%) 98 were females 58% (203) were from monoga‐ mous home while (42%) 147 were from polygamous homes. (84%) 294 were from intact fam‐ ily while (16%) 56 were form separated family.

### **13.3. Instrument**

The instrument used for collecting data was conduct disorder questionnaire (CDQ) de‐ signed by the researcher. It consists of two sections with section A consisting of Demograph‐ ic data such as age, sex, religion, type of home, type of family, class, etc. while section B consists of 37 items eliciting information on conduct disorder of the participants. These items requires the participants to indicate their degree of agreement with each item on a five point likert type scale ranging from 1 (most unlike me) to 5 (very much like me). Total scores range thus from 37 to 185. High score indicate highest level of conduct disorder. These in‐ strument (conduct disorder questionnaire) was cross-validated with two other instruments (Juvenile Delinquency Questionnaire and Anti-social Behaviour Scale) in a pilot study among randomly selected adolescents in the Junior secondary School, different form the participants (n= 150). The result when correlated with conduct disorder questionnaire was (. 763) at 0.01. A test-retest method was used to establish the reliability of the instrument. A reliability coefficient of 0.83 was obtained, thus indicating that the instrument was highly re‐ liable. Some of the items in the instrument (conduct disorder questionnaire) include:

equality, social justice etc. others include communication skills, assertiveness, negotiation. When asked why they engage in conduct disorder the participants mentioned cruelity by parents, teachers and other siblings, inadequate provision of needed materials, lack of love

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

http://dx.doi.org/10.5772/53046

57

In the sixth session participants were taught to replace negative conducts, behaviours and

**•** To avoid punishment rules must be strictly obeyed. In this session the process of learning in improving and maintain behaviour was emphasized. The participants were encour‐ aged to identify connections between thoughts and their responses to social situations.

During the seventh session the participants were taught that the various negative thoughts and behaviors were learned and therefore can be unlearned. They were therefore trained in the emphasis of certain cognitive techniques that are deigned to produce changes in think‐ ing and therefore changes in behavior or mood. They were taught on how learning process and the ways in which external environments can change both cognition and behaviour. They were taught how to strongly focus on social cognitions and inter-personal problem-

**Session eight** witnessed review of previous session activities rehearsal, role play and ad‐

The control group were given a brief educational review in conduct disorder but no treat‐ ment was applied to them both the pre and post -test measures were also administered on

**Follow-up:** Six weeks after the treatment programme, conduct disorder questionnaire was administered on the participants. The results obtained from the data indicates that cognitive behaviour therapy was effective in the management of conduct disorder among adolescent.

**Data analysis:** The data obtained from this study was analysed using analysis of co-variance

In order to estimate the effects of the independent variable in the observed differences in the pre- and post- treatment scores of the participants on the dependent measures,an Analysis of Covariance (ANCOVA) was ran, using the pre- test scores as covariates and the post- test scores a criterion. ANCOVA is used to adjust for the initial differences that existed between the groups, since they were randomly selected. Thus, this study adopted ANCOVA to test

feelings with positive ones; for example they were asked to substitute statement like

and affection by relations, etc.

solving techniques.

them.

(ANCOVA).

**14. Results**

the hypotheses formulated.

ministration of post-test instrument.

**•** Rules are not meant to be strictly obeyed with


### **13.4. Procedure**

This study was carried out in three phases. In the first phase, the participants were screened through conduct disorder questionnaire (CDQ). In the second phase, the participants were randomly assigned to the treatment group (cognitive behaviour therapy) and the control group respectively. At phase three, the experimental group went through eight weeks (1 hour a week) of intensive training consisting of discussion/lecture, discussion of the previ‐ ous assignment given to the participants, summary and given of assignment for the next ses‐ sion. Instructions and explanations on the task involved in the experimental group such as lectures, discussion and assignment were given to all participants.

In the first session, participants introduced themselves to one another and the therapist fam‐ iliarized them with the entire programme, she also created a good climate for discussion ses‐ sions. Pre-test questionnaire was administered to the participants. A contract was then made between the therapist and the participants such as agreeing on the venue, and time of meet‐ ing for the next eight sessions. The participants were encouraged to participate actively in the discussions and to do hoe work/assignments.

The second session witnessed conceptualization of Cognitive Behaviour Therapy (CBT) which was discussed with participants as an active, structured form of psychotherapy de‐ signed to rapidly and effectively reduce and eliminate psychological symptoms. The partici‐ pants were taught that CBT is a form of psychological treatment that focuses on the thoughts and behaviours that accompany psychological distress.

In the third session the participants and the therapist discussed negative effects of conduct disorder to include school drop- out, inferiority complex, low self-esteem, lack of ambition, lack of decision making skills, inability to set goals and make plans inability to clarify val‐ ues, feelings of guilt, unhappiness etc.

During the fourth session participants were asked to write down various conduct disorder experienced. Among the conduct disorder experienced as mentioned by the participants in‐ clude truancy, aggression, theft, violation of rules, stealing, disobedience to parents and teachers etc.

The fifth session witnessed, teaching of various personal skills needed by the adolescents to make life meaningful to them. Various personal skills taught the adolescents include deci‐ sion making goal setting, values of honest, honour, respect, self-control, responsibility, equality, social justice etc. others include communication skills, assertiveness, negotiation. When asked why they engage in conduct disorder the participants mentioned cruelity by parents, teachers and other siblings, inadequate provision of needed materials, lack of love and affection by relations, etc.

In the sixth session participants were taught to replace negative conducts, behaviours and feelings with positive ones; for example they were asked to substitute statement like


During the seventh session the participants were taught that the various negative thoughts and behaviors were learned and therefore can be unlearned. They were therefore trained in the emphasis of certain cognitive techniques that are deigned to produce changes in think‐ ing and therefore changes in behavior or mood. They were taught on how learning process and the ways in which external environments can change both cognition and behaviour. They were taught how to strongly focus on social cognitions and inter-personal problemsolving techniques.

**Session eight** witnessed review of previous session activities rehearsal, role play and ad‐ ministration of post-test instrument.

The control group were given a brief educational review in conduct disorder but no treat‐ ment was applied to them both the pre and post -test measures were also administered on them.

**Follow-up:** Six weeks after the treatment programme, conduct disorder questionnaire was administered on the participants. The results obtained from the data indicates that cognitive behaviour therapy was effective in the management of conduct disorder among adolescent.

**Data analysis:** The data obtained from this study was analysed using analysis of co-variance (ANCOVA).

### **14. Results**

763) at 0.01. A test-retest method was used to establish the reliability of the instrument. A reliability coefficient of 0.83 was obtained, thus indicating that the instrument was highly re‐

This study was carried out in three phases. In the first phase, the participants were screened through conduct disorder questionnaire (CDQ). In the second phase, the participants were randomly assigned to the treatment group (cognitive behaviour therapy) and the control group respectively. At phase three, the experimental group went through eight weeks (1 hour a week) of intensive training consisting of discussion/lecture, discussion of the previ‐ ous assignment given to the participants, summary and given of assignment for the next ses‐ sion. Instructions and explanations on the task involved in the experimental group such as

In the first session, participants introduced themselves to one another and the therapist fam‐ iliarized them with the entire programme, she also created a good climate for discussion ses‐ sions. Pre-test questionnaire was administered to the participants. A contract was then made between the therapist and the participants such as agreeing on the venue, and time of meet‐ ing for the next eight sessions. The participants were encouraged to participate actively in

The second session witnessed conceptualization of Cognitive Behaviour Therapy (CBT) which was discussed with participants as an active, structured form of psychotherapy de‐ signed to rapidly and effectively reduce and eliminate psychological symptoms. The partici‐ pants were taught that CBT is a form of psychological treatment that focuses on the

In the third session the participants and the therapist discussed negative effects of conduct disorder to include school drop- out, inferiority complex, low self-esteem, lack of ambition, lack of decision making skills, inability to set goals and make plans inability to clarify val‐

During the fourth session participants were asked to write down various conduct disorder experienced. Among the conduct disorder experienced as mentioned by the participants in‐ clude truancy, aggression, theft, violation of rules, stealing, disobedience to parents and

The fifth session witnessed, teaching of various personal skills needed by the adolescents to make life meaningful to them. Various personal skills taught the adolescents include deci‐ sion making goal setting, values of honest, honour, respect, self-control, responsibility,

liable. Some of the items in the instrument (conduct disorder questionnaire) include:

**•** Fighting is okay, so far you are not caught

56 Mental Disorders - Theoretical and Empirical Perspectives

**•** Rules are not meant to be strictly obeyed

**13.4. Procedure**

**•** Running away from school to avoid punishment is okay **•** Stealing is not bad so far you don't exceed what you need

lectures, discussion and assignment were given to all participants.

thoughts and behaviours that accompany psychological distress.

the discussions and to do hoe work/assignments.

ues, feelings of guilt, unhappiness etc.

teachers etc.

In order to estimate the effects of the independent variable in the observed differences in the pre- and post- treatment scores of the participants on the dependent measures,an Analysis of Covariance (ANCOVA) was ran, using the pre- test scores as covariates and the post- test scores a criterion. ANCOVA is used to adjust for the initial differences that existed between the groups, since they were randomly selected. Thus, this study adopted ANCOVA to test the hypotheses formulated.


**Source of variation**

Source of variation

using ANCOVA.

**DF SS MS** F-ratio

Between group 5 156528.0 31305.6

Within group 344 107293.6 311.9 Total 349 263821.6 31617.5

to variations in participants' conduct disorder scores.

Between group 5 78299.5 15659.9

Within group 344 1836157.6 5337.65 Total 349 1914451.1 20997.55

Critical value F(5,344 = 125.9; P>0.05

conduct disorder scores.

therefore, the null hypothesis was rejected at 0.05 level of significance.

**DF SS MS** F-ratio

Critical value F(5,344 = 194.57; P>0.05

Obs.

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

**Table 3.** Pre and post-treatment comparison participants from intact and those form separate family using ANCOVA.

The between group differences, shows that a main significant effect of treatment (Cognitive Behaviour Therapy)on participants' mean level of conduct disorder (Dependent Variable) scores existed F(5,344=194.57;p>0.05. Treatment was found to have contributed significantly

As indicated in table 3, the outcome of pre and post treatment details among participants from intact and those form separated family showed that there was statistical significant dif‐ ference in the results obtained contrary to the postulated null hypothesis. Consequently,

**Table 4.** Pre and Post-treatment comparison of participants from Monogamous and those from Polygamous Homes

There was a significant main effect of treatment (Cognitive Behaviour Therapy) on partici‐ pants' mean level of conduct disorder scores (Dependent Variable) F(5,344=125.9;p>0.05.Post treatment comparisons revealed its significant contribution to variations in participants'

In table 4, the compared computed pre-and post –treatment outcome of participants from monogamous and polygamous homes showed that there was statistical significant differ‐ ence following the alpha level of 0.05. The findings revealed that the critical value of

F(5,344)=125.9; P>0.05 evidently failed to support the predicted null hypothesis.

Obs.

F-ratio Crit.

194.57 2.72 Reject Ho

F-ratio Crit.

125.9 2.72 Reject Ho

**Test decision**

59

http://dx.doi.org/10.5772/53046

**Test decision**

**Table 1.** Post-treatment Comparison of Cognitive Behaviour Therapy (CBT) and the Control Group using ANCOVA.

With regard to between group differences, there was a significant main effect of treat‐ ment(Cognitive Behaviour Therapy) on participants' mean level of conduct disorder (De‐ pendent Variable)scores, F(7,342=18.74;p>0.05.Treatment was found to have contributed significantly to variations in participants' conduct disorder scores.

As shown in table 1, the computed outcome of pre and post treatment evaluation revealed that the null hypothesis was not confirmed at 0.05 alpha level. The finding showed that the critical value F (7,342) = 18.74 has P>0.05 and thus simultaneously indicated that a statistical significant difference existed in the investigated conditions.


**Table 2.** Pre and post-treatment comparison of male and female participants using ANCOVA.

A significant main effect of treatment (Cognitive Behaviour Therapy) on participants' mean level of conduct disorder (Dependent Variable) was evident F(3, 346,=47.91;p>0.05.Post treat‐ ment comparison outcome of pre and post -test indicates treatment was found to have con‐ tributed significantly to variations in participants' conduct disorder scores.

As shown in table 2, the compared pre and post-treatment outcome with the critical value F (3,346) = 47.91 and P>0.05 showed that there was statistical significant difference between male and female participants exposed to cognitive behaviour therapy. The null hypothesis therefore was not supported.


**Table 3.** Pre and post-treatment comparison participants from intact and those form separate family using ANCOVA.

The between group differences, shows that a main significant effect of treatment (Cognitive Behaviour Therapy)on participants' mean level of conduct disorder (Dependent Variable) scores existed F(5,344=194.57;p>0.05. Treatment was found to have contributed significantly to variations in participants' conduct disorder scores.

As indicated in table 3, the outcome of pre and post treatment details among participants from intact and those form separated family showed that there was statistical significant dif‐ ference in the results obtained contrary to the postulated null hypothesis. Consequently, therefore, the null hypothesis was rejected at 0.05 level of significance.


Critical value F(5,344 = 125.9; P>0.05

**Source of variation**

**Source of variation**

**DF SS MS** F-ratio

significantly to variations in participants' conduct disorder scores.

**DF SS MS** F-ratio

**Table 2.** Pre and post-treatment comparison of male and female participants using ANCOVA.

tributed significantly to variations in participants' conduct disorder scores.

significant difference existed in the investigated conditions.

Between group 3 54948.3 18316.1

Within group 346 156911.0 453.5 Total 349 211859.3 18769.6

Critical value F (7,346 = 47.91; P>0.05

therefore was not supported.

**Table 1.** Post-treatment Comparison of Cognitive Behaviour Therapy (CBT) and the Control Group using ANCOVA.

With regard to between group differences, there was a significant main effect of treat‐ ment(Cognitive Behaviour Therapy) on participants' mean level of conduct disorder (De‐ pendent Variable)scores, F(7,342=18.74;p>0.05.Treatment was found to have contributed

As shown in table 1, the computed outcome of pre and post treatment evaluation revealed that the null hypothesis was not confirmed at 0.05 alpha level. The finding showed that the critical value F (7,342) = 18.74 has P>0.05 and thus simultaneously indicated that a statistical

A significant main effect of treatment (Cognitive Behaviour Therapy) on participants' mean level of conduct disorder (Dependent Variable) was evident F(3, 346,=47.91;p>0.05.Post treat‐ ment comparison outcome of pre and post -test indicates treatment was found to have con‐

As shown in table 2, the compared pre and post-treatment outcome with the critical value F (3,346) = 47.91 and P>0.05 showed that there was statistical significant difference between male and female participants exposed to cognitive behaviour therapy. The null hypothesis

Obs.

Between group 7 6376.44 910.92

58 Mental Disorders - Theoretical and Empirical Perspectives

Within group 342 17681.4 51.7 Total 349 24057.84 962.62

Critical value F (7,342 = 18.74; P>0.05

Obs.

F-ratio Crit.

18.74 2.81 Reject Ho

F-ratio Crit.

47.91 3.72 Reject Ho

**Test decision**

**Test decision**

**Table 4.** Pre and Post-treatment comparison of participants from Monogamous and those from Polygamous Homes using ANCOVA.

There was a significant main effect of treatment (Cognitive Behaviour Therapy) on partici‐ pants' mean level of conduct disorder scores (Dependent Variable) F(5,344=125.9;p>0.05.Post treatment comparisons revealed its significant contribution to variations in participants' conduct disorder scores.

In table 4, the compared computed pre-and post –treatment outcome of participants from monogamous and polygamous homes showed that there was statistical significant differ‐ ence following the alpha level of 0.05. The findings revealed that the critical value of F(5,344)=125.9; P>0.05 evidently failed to support the predicted null hypothesis.

### **15. Discussion of the findings**

The result of the first hypothesis shows that there was a significant difference in the level of reduction of conduct disorder of participants in the experimental and those in the control group.

This findings is in line with the findings of Mathye (2004) which reveals that family size is a variable which makes major contribution to the explanation of degree of participation of children in anti-social behaviour such as delinquent acts, rebelliousness, conduct disorder etc. He further expantiate that large family is believed to be negatively related to high rate of anti-social behaviours and that as family increases a child's undesirable behaviour increases. The findings also appear to be consistent with the finding that poor living conditions may slow down growth and maturity among growing children and thrown them off their "pro‐ grammed curve" that is off the curve that they normally follow under optimal conditions.

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

http://dx.doi.org/10.5772/53046

61

The main objective of this study was to investigate the effects of cognitive behaviour therapy on the management of conduct disorder among adolescents. This study provided substan‐ tial evidence to support the fact that cognitive behaviour therapy was effective in the reduc‐

Clearly the research reveals the correlation of diverse factors which promote conduct disor‐ der. Parenting styles play a key role in promoting an environment which is conductive to this disorder. It follows therefore that therapist need to educate their clients, public, parents, families etc. on the negative effects authoritarian parenting styles have on their children.

The research suggests that children with conduct disorder become adults with anti-social behaviour and other psychological problems. The disorder is more than a fussy child it is a serious issue which parents, teachers and the mental health professionals needs to address. Another aspect to consider is the link between nicotine and conduct disorder. Pregnant women need to be warned against smoking during and after pregnancy. There are signifi‐

[1] Aderanti, R. A. (2006). Prevalent of adolescents' delinquent behavioral patterns: An issue in counseling psychology and implications for national development. A paper presented at the 1st National Conference of Colelge of Applied education and Vocai‐

toanl Technology. Tai Solarin University of Education, Ijagun (unpublished)

**16. Conclusion / recommendation**

tion of conduct disorder among the adolescents.

cant risks with cigarette smoking during pregnancy.

**Author details**

**References**

Afusat Olanike Busari

University of Ibadan, Ibadan, Nigeria

This result corroborates the findings of Wolinsky and Miller (2006) when they found that cognitive training would affect the cognitive ability targeted by that training and these ef‐ fects would be maintained over time. It also indicates that maintained on improvements in cognitive ability would have a positive transfer effect on everyday function.

Gardner (2003) also confirms the effectiveness of cognitive behaviour therapy in treating re‐ belliousness, delinquency and conduct disorder. According to him, cognitive factors play an important and well documented roles in these undesirable behaviors since the way people think has a controlling effect on their action and that replacement of negative habits with positive ones and rethinking will help individual to generate more adaptive behaviour. Moreover, an individual cognition is important in the acquisition of a new behaviour.

Results emanated from hypothesis two indicates that there exists significant difference in the level of reduction of conduct disorder of male and female participants.

This finding agrees with that of Rathus (1996) who suggested that females who have become involved in criminality must somehow be more male-like than their law abiding counter‐ parts. Some researchers have suggested that where the females have been involved in crime, they have typically played a more passive compliance role, their male counterparts are ac‐ tually responsible for the planning and execution of the crime. Moreover, it was observed that females restricted their criminal activities to such female crimes as shoplifting, incorrigi‐ bility, sex offences or running away whereas males participates in offences like homicide, forcible rape, aggravated assault, robbery, burglary, and auto-theft.

The findings from the result of hypothesis three reveals that there exist significant difference in the response to treatment of participants form intact and those from separated homes. Pa‐ rents are responsible for the upbringing and development of their children and make provi‐ sion for their basic needs such as food, education, shelter, protection etc. the family integrates the child into the community. Families raise children to learn the cultural norms. They are the teacher of the rules which in most cases are not written down but may be passed from one generation to another through the process of socialization. In a situation where the two parents are not living together proper upbringing of the children might be impossible. Actions and behaviours which do not promote positive development and growth of the children are likely to be the end product of separated parents whereas the op‐ posite is find in the intact homes (Busari & Adejumobi, 2012).

Results from the findings of the fourth and the last hypothesis indicates that there was sig‐ nificant difference in the level of education of conduct disorder of participants form monog‐ amous and those from polygamous homes after exposure to treatment.

This findings is in line with the findings of Mathye (2004) which reveals that family size is a variable which makes major contribution to the explanation of degree of participation of children in anti-social behaviour such as delinquent acts, rebelliousness, conduct disorder etc. He further expantiate that large family is believed to be negatively related to high rate of anti-social behaviours and that as family increases a child's undesirable behaviour increases. The findings also appear to be consistent with the finding that poor living conditions may slow down growth and maturity among growing children and thrown them off their "pro‐ grammed curve" that is off the curve that they normally follow under optimal conditions.

### **16. Conclusion / recommendation**

**15. Discussion of the findings**

60 Mental Disorders - Theoretical and Empirical Perspectives

group.

The result of the first hypothesis shows that there was a significant difference in the level of reduction of conduct disorder of participants in the experimental and those in the control

This result corroborates the findings of Wolinsky and Miller (2006) when they found that cognitive training would affect the cognitive ability targeted by that training and these ef‐ fects would be maintained over time. It also indicates that maintained on improvements in

Gardner (2003) also confirms the effectiveness of cognitive behaviour therapy in treating re‐ belliousness, delinquency and conduct disorder. According to him, cognitive factors play an important and well documented roles in these undesirable behaviors since the way people think has a controlling effect on their action and that replacement of negative habits with positive ones and rethinking will help individual to generate more adaptive behaviour. Moreover, an individual cognition is important in the acquisition of a new behaviour.

Results emanated from hypothesis two indicates that there exists significant difference in

This finding agrees with that of Rathus (1996) who suggested that females who have become involved in criminality must somehow be more male-like than their law abiding counter‐ parts. Some researchers have suggested that where the females have been involved in crime, they have typically played a more passive compliance role, their male counterparts are ac‐ tually responsible for the planning and execution of the crime. Moreover, it was observed that females restricted their criminal activities to such female crimes as shoplifting, incorrigi‐ bility, sex offences or running away whereas males participates in offences like homicide,

The findings from the result of hypothesis three reveals that there exist significant difference in the response to treatment of participants form intact and those from separated homes. Pa‐ rents are responsible for the upbringing and development of their children and make provi‐ sion for their basic needs such as food, education, shelter, protection etc. the family integrates the child into the community. Families raise children to learn the cultural norms. They are the teacher of the rules which in most cases are not written down but may be passed from one generation to another through the process of socialization. In a situation where the two parents are not living together proper upbringing of the children might be impossible. Actions and behaviours which do not promote positive development and growth of the children are likely to be the end product of separated parents whereas the op‐

Results from the findings of the fourth and the last hypothesis indicates that there was sig‐ nificant difference in the level of education of conduct disorder of participants form monog‐

cognitive ability would have a positive transfer effect on everyday function.

the level of reduction of conduct disorder of male and female participants.

forcible rape, aggravated assault, robbery, burglary, and auto-theft.

posite is find in the intact homes (Busari & Adejumobi, 2012).

amous and those from polygamous homes after exposure to treatment.

The main objective of this study was to investigate the effects of cognitive behaviour therapy on the management of conduct disorder among adolescents. This study provided substan‐ tial evidence to support the fact that cognitive behaviour therapy was effective in the reduc‐ tion of conduct disorder among the adolescents.

Clearly the research reveals the correlation of diverse factors which promote conduct disor‐ der. Parenting styles play a key role in promoting an environment which is conductive to this disorder. It follows therefore that therapist need to educate their clients, public, parents, families etc. on the negative effects authoritarian parenting styles have on their children.

The research suggests that children with conduct disorder become adults with anti-social behaviour and other psychological problems. The disorder is more than a fussy child it is a serious issue which parents, teachers and the mental health professionals needs to address.

Another aspect to consider is the link between nicotine and conduct disorder. Pregnant women need to be warned against smoking during and after pregnancy. There are signifi‐ cant risks with cigarette smoking during pregnancy.

### **Author details**

Afusat Olanike Busari

University of Ibadan, Ibadan, Nigeria

### **References**

[1] Aderanti, R. A. (2006). Prevalent of adolescents' delinquent behavioral patterns: An issue in counseling psychology and implications for national development. A paper presented at the 1st National Conference of Colelge of Applied education and Vocai‐ toanl Technology. Tai Solarin University of Education, Ijagun (unpublished)

[2] American Psychiatric Association.(2000). Diagnostic and statistical manual of mental disorders (4th ed. Tex. t Revision). Washington D.C.: Author.

[16] National Institute for Health & Clinical Excellence.(2007). Conduct disorder pro‐ grams {Electronic Version}. Community Care, Retrieved June 22, 2012 http://

Cognitive Behaviour Therapy in the Management of Conduct Disorder Among Adolescents

http://dx.doi.org/10.5772/53046

63

[17] Obalowo, Y. O. (2004). Cognitive restructuring and contigency management in the treatment of stealing behavior among some Nigerian adolescents. Unpublished Ph.D

[18] Ray, D. (2007). Two counseling interventions to reduce teacher-child relationship Stress {Electronic version}. Professional School Counseling, 10(4), 428-440. http://

[19] (1990). Screening for Signs and Symptoms of Juvenile Delinquency in Secondary School Students.In Kajola Local Government area of Oyo State.An Unpublished B.Ed

[20] Scott, S. (2007). Conduct disorder in children.BMJ 2007. Retrieved July 13, 2012 from

[21] Somerstein, L. (2007). I came with a sword on judgment day: a psychoanalytic look at

[22] Stevenson, K. (1999). Family characteristics of problem kids.Canadian Social Trends.

[23] U.S.Department of Health and Human Services. ((1999). Mental Health: A report of the Surgeon General {Electronic Version}.Rockville, MD. Retrieved July 13, 2010 from

[25] Van Goozen et al. (2007). The evidence for a neurobiological model of childhood anti‐

[24] U.S. Department of Justice.(2000). Juvenile Justice Bulletin. Washington, D.C.

www.nice.org.uk/page.aspx?0=529846, 1672(1672), 32-33.

Thesis, Olabisi Onabanjo University, Ago-Iwoye.

http://www.bmj.com/cgi/content/full/334/7595/646

terrorist enactments. Psychoanalytic Review, 94 (5).

http://mentalhealth.samsha.gov/publications

social behavior. *Psychological Bulletin*, 149-182.

www.goliath.ecnext.com/coms2.

Project, University of Ibadan , 127.


[16] National Institute for Health & Clinical Excellence.(2007). Conduct disorder pro‐ grams {Electronic Version}. Community Care, Retrieved June 22, 2012 http:// www.nice.org.uk/page.aspx?0=529846, 1672(1672), 32-33.

[2] American Psychiatric Association.(2000). Diagnostic and statistical manual of mental

[3] Barton, A., et al. (2007). Functional Family Therapy: blueprint for violence Preven‐ tion.Institute of Behavioral Science. Retrieved June 19, 2011 from http:www.colora‐

[5] Busari, A. O. (2000). Stress Inculcation Training and Self Statement Monitoring Tech‐ niques in the Reduction of Test Anxiety Among Adolescent Under Achievers in Iba‐ dan Metropolis, Nigeria. An unpublished Ph.D Thesis, University of Ibadan , 309.

[6] Busari, A. O. ., & Uwakwe, C. B. U. (2001). The Effects of Stress Inoculation Training‐ Techniques in the Management of Worry as a self Handicapping Strategy in Intellec‐ tualPerformance. Nigerian Journal of Emotional Psychology and Sport Ethics 3:, 6-12.

[7] Busari, A. O., & Ojo, R. A. (2011). Empowering Youth in Remand Home Against Risk Taking Behaviours for Effective Transition to Independence. Ethno Medicine. 5(3)In‐

[8] Busari, A. O. (2012). Cognitive Training Intervention and Daily Functioning Im‐ provement among the Retirees of University of Ibadan, Nigeria. European Journal of

[9] Busari & Adejumobi(2012). Cognitive Behaviour Therapy in the Management of Ju‐ venile Delinquency; being a paper presented at the International Conference on Sus‐ tainable Development in Africa. Held at R.S. Amegashie Auditorium University of

[10] Edelson, S. M. (2004). Self-management center for autism. Retrieved from the web

[11] Garner, J. R. (2003). Cognitive Rehabilitation. Retrieved from the web November 22,

[12] Hoeve et al.(2008). Trajectories of delinquency and parenting styles.Journal of Abnor‐ mal Child Psychology, 36 (2), 223-235. Retrieved May 23, 2011 from http://

[13] Hoagwood, K., et al. (2007). Empirically-based school interventions targeted at aca‐ demic and mental health functioning. *Journal of emotional and behavioral disorders*, 66

[14] Marsiglia et al.(2007). Impact of parenting styles and locus of control on emerging psychosocial success. Journal of Education and Human Development, 1. Retrieved

[15] Mathye, L. V. (2004). Therapeutic techniques for treatment of adolescents with rebel‐

disorders (4th ed. Tex. t Revision). Washington D.C.: Author.

[4] Functional Family Therapy Website. (2007). http://www.fftinc.om.

Globalization and Development Research.3(1) , 143-153.

Ghana, Legon, Accra, Ghana between 25th- 27th July.

April 29, 2012 from: http://www.scientificjournals.org

November 22, 2011 http://www.ojdpncjrs.org

www.pubmedcentral.nih.gov/

do.edu/cspv/blueprints/model/programs/FFT.html

62 Mental Disorders - Theoretical and Empirical Perspectives

dia, 217-222.

2010

EOF-92 EOF.

lious behavior.


**Chapter 4**

**Anxiolytics Use in the Families with (Non)dependent**

**Member: Relation to Dependence Indicators, Self and**

Social neuroscience seeks to explain social behavior in terms of information processing mechanisms that motivate and guide social behavior and in terms of neurobiological mecha‐ nisms (genetic, hormonal, biochemical, physiological) that underline social behavior [1]. So‐ cial neuroscience could be defined quite broadly as exploration of interdependence between processes, traditionally belonging to social psychology and particular neurological factors [2]. Because of the complexity of human social interaction (exchange, communication), social neuroscience needs to combine and integrate multi–level analysis across different domains [1, 2]. It's worth repeating Cacioppo & Berntson [3] connecting multi – level approach: "The doctrine of multilevel analysis specifies that microanalyses of a psychological phenomenon can be particularly effective when pursued in addition to or in conjunction with molar anal‐ yses." Relation "brain – culture" could be defined also as a typical thematic part of social anthropo – psychology, expression, etymologically and recognizably showing to fields of thematically origin. Particular aspects of social neuroscience are connected also with some new areas of contemporary social psychology, with the questions of (bio) - psycho - social evolution, the questions of mate preferences included [4]; it's also connected with social psy‐ chosomatics, particularly with social cognition and with a view of the person's information – processing capability [5]. Three routes of social cognition are distinguished: capacity to mentalize, to mimic and understand others' motor actions and our capacity to empathize [6]. The social environment is multifaceted and compromises a dynamic set of environmen‐ tal and behavioral interactions that influence the connections among individuals such as pa‐

> © 2013 Rus-Makovec et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

> © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

and reproduction in any medium, provided the original work is properly cited.

**Family Perceptions Including Social Neuroscience**

Maja Rus-Makovec, Karin Sernec and Velko S. Rus

Additional information is available at the end of the chapter

**Perspective**

**1. Introduction**

http://dx.doi.org/10.5772/53307

**Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and Family Perceptions Including Social Neuroscience Perspective**

Maja Rus-Makovec, Karin Sernec and Velko S. Rus

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53307

### **1. Introduction**

Social neuroscience seeks to explain social behavior in terms of information processing mechanisms that motivate and guide social behavior and in terms of neurobiological mecha‐ nisms (genetic, hormonal, biochemical, physiological) that underline social behavior [1]. So‐ cial neuroscience could be defined quite broadly as exploration of interdependence between processes, traditionally belonging to social psychology and particular neurological factors [2]. Because of the complexity of human social interaction (exchange, communication), social neuroscience needs to combine and integrate multi–level analysis across different domains [1, 2]. It's worth repeating Cacioppo & Berntson [3] connecting multi – level approach: "The doctrine of multilevel analysis specifies that microanalyses of a psychological phenomenon can be particularly effective when pursued in addition to or in conjunction with molar anal‐ yses." Relation "brain – culture" could be defined also as a typical thematic part of social anthropo – psychology, expression, etymologically and recognizably showing to fields of thematically origin. Particular aspects of social neuroscience are connected also with some new areas of contemporary social psychology, with the questions of (bio) - psycho - social evolution, the questions of mate preferences included [4]; it's also connected with social psy‐ chosomatics, particularly with social cognition and with a view of the person's information – processing capability [5]. Three routes of social cognition are distinguished: capacity to mentalize, to mimic and understand others' motor actions and our capacity to empathize [6]. The social environment is multifaceted and compromises a dynamic set of environmen‐ tal and behavioral interactions that influence the connections among individuals such as pa‐

© 2013 Rus-Makovec et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

rent and child, husband and wives, groups etc. These connections from the social network can have an impact on brain development and function and can be both a risk and a protec‐ tive factor against drug abuse [7]. Social neuroscience perspective seems to be one of the most suitable disciplines for understanding the field of psychotropic substance use and abuse. That is why we tried to introduce the social neuroscientific perspective in the field of anxiolytic (ab)use by parents in families with and without dependent family member in our research.

tions. Hypothetical construct of the balance between excitation and inhibition is reticular formation (RF). Psychotropic depressants (alcohol, benzodiazepines) and stimulants (caf‐ feine, amphetamine) have direct influence on different parts of RF. According to Eysenck, depressants have extravert and stimulants have introvert effect, both being also typical pat‐

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

http://dx.doi.org/10.5772/53307

67

Other piece of mosaic of the important de facto neuro scientific research, had been the re‐ search connecting active and consistent minorities and their influence on majority judg‐ ments and (sensory) perception, using the phenomenon of negative after effect [15] as the final dependent variable [16, 17]. Results of these experiments showed, although the de‐ pendent variable was the visual illusion, but illusion, based on central intervention, that also centrally determined phenomena could be influenced by minority (active and consistent) in‐ fluence and that conversion could be sometimes additionally explained with complementa‐

**1.3. Listing of some social psychological thematic, differently connected with factual parts**

If we neglect so brutal and evident causes like head damage, which is also an exclusive element of behaviorist learning definition, elements of factual »social neuroscience« could be found also in many other cases, lets mention only research and applied phenomena of ideomotoric/visualization; than many aspects of NLP (neuro–linguistic programming); so‐ cio– and psycho–pathology of dependence behavior; sleeping and dreams, including dif‐ ferent interpretations (metaphorical symbolism of dreams in classical Freudian psychoanalysis, archetype conception in Jung's concept of collective subconsciousness); associacionist antecedents of contemporary social cognition [18-20]; a great deal of EEG classical research and applied practice; cognitive theories of emotion, respective any theo‐ ry of emotion, including the function of limbic system; brain and body reactions; alpha learning conditions; biofeedback; conditioning (Pavlov, Sokolov, Teplov) and (neo)behav‐ iorist approaches, also on the domain of social behavior; placebo–effects, particularly re‐ searches in the last years, proving activation of relevant brain areas as consequence of persuasive/suggestive placebo effect; bio–psycho–social aspects of aggression and aggres‐ siveness; different psychoanalytic conceptions connected with unconscious brain process‐ es (Freud, Jung, Adler, Lacan, Erikson, Klein); screening of organic brain damage related to alcohol abuse as important for treatment planning [21]. Mentioned damage is highly connected also with degree and duration of alcohol dependence. That's why we decided to take into account the very slight approximation of this probability in the sense of AU‐ DIT (Alcohol Use Disorder Identifying Test) [22] estimation of intensity of alcohol de‐ pendence abuse. This estimation was treated as co–variate in the design, where the hypothesis about the differences in self perceptions regarding the anxiolytics usage status

From this point of view, the whole classical behaviorism could be interpreted as introduc‐ tion into the social neuroscience, while social behavior is interpreted as more or less direct

terns of social behavior.

**of social neuroscience**

was taken into account.

ry neuro – physiological consequences.

### **1.1. Brains and social psychology: Social neuroscience, social psychology and interdisciplinary perspectives**

According to Illeris [8], inseparability of emotional and cognitive functions regarding the brain basis of their location seems to be one of the prevailing contemporary beliefs of con‐ temporary neuroscience. Social psychological contributions to the neurosciences served to the intensive development of the psychoneuroimunological field and immune responses are strongly influenced by the central nervous system (CNS) [9].

Social behavior could be connected with the brain functions and even structure also indi‐ rectly. Factually, we can hypothesize some connection, deriving from some evident and experimentally proved information. One of them is, for example, association between learning - cognitive style and hemisphericity. Torrance associated learning styles (left more analytical, right - more synthetic and integrative hemispheric), characteristic also for social learning with dominant specialized functions of brain hemispheres [10]. Sphere only prevails, while the brain functions as a whole. More generally, we can conclude, that social neurosciences phenomena results in different outputs of activity, work, per‐ formance (effectiveness, efficacy), group structure and processes, climate, culture, com‐ munication and evaluation as interactive function of CNS activity. Information processing and decision making seem to be an important part of (social) neuroscience. According to Klavora [11], factors influencing information processing are the quality of sensory input information, the quality and effectiveness of sensory receptors, the speed of processing the stimulus information. Psychophysiological background and socio – psycho – neuro – logical relevancy of such a multilevel approach has been systematically developed by Ca‐ cioppo and collaborators [3, 8, 12]. The area of psychophysiology is connected with dif‐ ferent efforts of neurophysiologists, experimental psychologists, psychiatrists and different technical professions [12]. Understanding behavioral flexibility, especially in the form of cultural variation, demands the understanding of the whole psychological "archi‐ tecture", which guides social interaction [13].

#### **1.2. Factual beginnings of social neuroscience? Eysenck, Moscovici, Personnaz**

Pieces of mosaic of social neuroscience had existed already before. H. J. Eysenck's model, explanation of extra – introversion is such a possible example [14]. Habitually heightened level of central activation is supposed to be connected with introvert, and lowered level with extravert. That's why the extravert people, according to Eysenck, search new exogenous in‐ formation and attempt to maintain ample social network of social relations and communica‐ tions. Hypothetical construct of the balance between excitation and inhibition is reticular formation (RF). Psychotropic depressants (alcohol, benzodiazepines) and stimulants (caf‐ feine, amphetamine) have direct influence on different parts of RF. According to Eysenck, depressants have extravert and stimulants have introvert effect, both being also typical pat‐ terns of social behavior.

rent and child, husband and wives, groups etc. These connections from the social network can have an impact on brain development and function and can be both a risk and a protec‐ tive factor against drug abuse [7]. Social neuroscience perspective seems to be one of the most suitable disciplines for understanding the field of psychotropic substance use and abuse. That is why we tried to introduce the social neuroscientific perspective in the field of anxiolytic (ab)use by parents in families with and without dependent family member in our

According to Illeris [8], inseparability of emotional and cognitive functions regarding the brain basis of their location seems to be one of the prevailing contemporary beliefs of con‐ temporary neuroscience. Social psychological contributions to the neurosciences served to the intensive development of the psychoneuroimunological field and immune responses are

Social behavior could be connected with the brain functions and even structure also indi‐ rectly. Factually, we can hypothesize some connection, deriving from some evident and experimentally proved information. One of them is, for example, association between learning - cognitive style and hemisphericity. Torrance associated learning styles (left more analytical, right - more synthetic and integrative hemispheric), characteristic also for social learning with dominant specialized functions of brain hemispheres [10]. Sphere only prevails, while the brain functions as a whole. More generally, we can conclude, that social neurosciences phenomena results in different outputs of activity, work, per‐ formance (effectiveness, efficacy), group structure and processes, climate, culture, com‐ munication and evaluation as interactive function of CNS activity. Information processing and decision making seem to be an important part of (social) neuroscience. According to Klavora [11], factors influencing information processing are the quality of sensory input information, the quality and effectiveness of sensory receptors, the speed of processing the stimulus information. Psychophysiological background and socio – psycho – neuro – logical relevancy of such a multilevel approach has been systematically developed by Ca‐ cioppo and collaborators [3, 8, 12]. The area of psychophysiology is connected with dif‐ ferent efforts of neurophysiologists, experimental psychologists, psychiatrists and different technical professions [12]. Understanding behavioral flexibility, especially in the form of cultural variation, demands the understanding of the whole psychological "archi‐

**1.1. Brains and social psychology: Social neuroscience, social psychology and**

strongly influenced by the central nervous system (CNS) [9].

tecture", which guides social interaction [13].

**1.2. Factual beginnings of social neuroscience? Eysenck, Moscovici, Personnaz**

Pieces of mosaic of social neuroscience had existed already before. H. J. Eysenck's model, explanation of extra – introversion is such a possible example [14]. Habitually heightened level of central activation is supposed to be connected with introvert, and lowered level with extravert. That's why the extravert people, according to Eysenck, search new exogenous in‐ formation and attempt to maintain ample social network of social relations and communica‐

research.

**interdisciplinary perspectives**

66 Mental Disorders - Theoretical and Empirical Perspectives

Other piece of mosaic of the important de facto neuro scientific research, had been the re‐ search connecting active and consistent minorities and their influence on majority judg‐ ments and (sensory) perception, using the phenomenon of negative after effect [15] as the final dependent variable [16, 17]. Results of these experiments showed, although the de‐ pendent variable was the visual illusion, but illusion, based on central intervention, that also centrally determined phenomena could be influenced by minority (active and consistent) in‐ fluence and that conversion could be sometimes additionally explained with complementa‐ ry neuro – physiological consequences.

### **1.3. Listing of some social psychological thematic, differently connected with factual parts of social neuroscience**

If we neglect so brutal and evident causes like head damage, which is also an exclusive element of behaviorist learning definition, elements of factual »social neuroscience« could be found also in many other cases, lets mention only research and applied phenomena of ideomotoric/visualization; than many aspects of NLP (neuro–linguistic programming); so‐ cio– and psycho–pathology of dependence behavior; sleeping and dreams, including dif‐ ferent interpretations (metaphorical symbolism of dreams in classical Freudian psychoanalysis, archetype conception in Jung's concept of collective subconsciousness); associacionist antecedents of contemporary social cognition [18-20]; a great deal of EEG classical research and applied practice; cognitive theories of emotion, respective any theo‐ ry of emotion, including the function of limbic system; brain and body reactions; alpha learning conditions; biofeedback; conditioning (Pavlov, Sokolov, Teplov) and (neo)behav‐ iorist approaches, also on the domain of social behavior; placebo–effects, particularly re‐ searches in the last years, proving activation of relevant brain areas as consequence of persuasive/suggestive placebo effect; bio–psycho–social aspects of aggression and aggres‐ siveness; different psychoanalytic conceptions connected with unconscious brain process‐ es (Freud, Jung, Adler, Lacan, Erikson, Klein); screening of organic brain damage related to alcohol abuse as important for treatment planning [21]. Mentioned damage is highly connected also with degree and duration of alcohol dependence. That's why we decided to take into account the very slight approximation of this probability in the sense of AU‐ DIT (Alcohol Use Disorder Identifying Test) [22] estimation of intensity of alcohol de‐ pendence abuse. This estimation was treated as co–variate in the design, where the hypothesis about the differences in self perceptions regarding the anxiolytics usage status was taken into account.

From this point of view, the whole classical behaviorism could be interpreted as introduc‐ tion into the social neuroscience, while social behavior is interpreted as more or less direct function of centrally positioned associations Stimulus – Response, which are the basic point of any behavioral pattern.

The net effects of inhibiting the diffuse GABA are anxiety reduction, behavioral disinhibi‐ tion, sedation and euphoria, what is all connected also with interpersonal communication, family perception, perceived depression and self – concept. That's why we can expect, that chosen psychopharmaceutical medications can at least partially influence (facilitate or inhib‐ it) particular social behavioral patterns, particularly connecting (declared) depression, inter‐ personal relations in primary social environment and social implications of some other dependence behavior. These implications, manifested in different complex social situations could be quite subtle, sometimes hidden in "social mimicry", mostly connected with alcohol and other psychoactive substances abuse. One of the very opportune measures of such im‐ plications, according to our opinion, could be (sub) scores of SASSI (Substance Abuse Subtle Screening Inventory) instrument, which is declared to be the instrument which "breaks

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

http://dx.doi.org/10.5772/53307

69

It seems that relations between concrete forms and contents of social interaction (complex patterns of cooperation, competition, conformism, cohesiveness, role learning, group deci‐ sion, leadership, conflicts, negotiations, mediations) and CNS (re) actions are yet to be re‐ searched. That's why the choice of family social climate has two advantages: we treat it as a kind of experiential common denominator of different social interaction effects, while cli‐ mate is an integrating experience, deriving from diversified processes of social interaction. Inducing climate as dependent variable, we focus on one of most relevant and integrating level of social experience. Simultaneously, (perceived) climate is one of the most essential parts of micro culture. Analyzing climate, we simultaneously analyze an important part of family culture. On the other side, evaluation of climate is inseparably connected with differ‐ ent self concepts (esteem, confidence, consciousness, efficacy belief) and self – evaluation. In actual text "functional" is supposed to be such a category of self – evaluation, when person‐ al bipolar attributes express the continuum of everyday adaptive/functional behavior. We suppose that psychopharmaceutical medications (anxiolytics) contribute to the change of retrograde functional self – evaluations, while medicaments are supposed to be a reason of

That's why in actual article, we'd like to analyze possible relations between psychopharma‐ ceutical medications (anxiolytics) usage (in the last year) status and some other relevant per‐ ceptions: evaluation of own family, self – esteem, self – perceived depression and substance abuse indicators. We can express the general level of our research problem with the ques‐ tion: Which are the relations between A. last year psychopharmaceutical medications use status and B. particular perceptions, connecting family, self and substance abuse depend‐ ence? The question about (anxiolytics) usage (in the last year) has been formulated as fol‐ lows: "Did you use prescribed psychopharmaceutical medications such as anxiolytics

H.1: we hypothesized, that self–esteem, evaluation of own family and level of depression as predictors significantly differentiate, regardless co–variate inclusion, between users and non–users of anxiolytic pills in the last year, so in the case of mothers, as in the case

through denial" [30].

improvement of mood level.

because of your emotional problems in last year?"

We formulated three expectations:

of fathers.

#### **1.4. Brain, behavior and social interaction in mood and dependence disorders**

Ernst Fehr and collaborators [23] report about neurologic basis of social interactions, even on economic field (neuroeconomy). Such an approach could be helpful in explaining some irrational moments in otherwise rational cost – benefit dilemma resolution. According to Fehr, it even seems, that hormone oxytocin influences the experience of trust. Depression and anxiety is also a standard covariate of psychotropic medication treatments. That's why it's understandable, that psychopharmaceutical medications could have, in any group, an impact on different areas, levels and aspects of social interactions (communication, social ex‐ change). Regarding alcohol dependence an understanding of action of alcohol on central gamma – amino butyric acid (GABA) receptors may significantly contribute to the incentive side of explanation of this disorder [3].

Although alterations in brain function can influence the symptoms which seem to be func‐ tional personality change, the inverse process is also possible. Depression, as an example of non–organic personality change, can result in symptoms, which are similar to alterations in brain functions - pseudo dementia, for example - which can disappear, when patients are treated with antidepressant medication. The relation between the psychopharmaceutical medications (non)use and different social representations of self and social environments, being an essential part of any social interaction (communication, social exchange and influ‐ ence), is not at all one – way process. Anyway, in actual research, such a complexity of rela‐ tions was not elaborated, while also the existent empirical methodology in behavioral sciences does not yet dispose with models, permitting analysis of two way processes, result‐ ing in different effects of mutual partially simultaneous, partially sequential influences. However, it is well known, that epigenetic effects during development lead to a cascade of neurobiological changes, including enhanced emotionality [24].

Psychopharmaceutical medications affect brain neurotransmission processes for therapeutic purposes; however, psychotropic substances can be abused and alter behavior into nonfunctional/non-adaptive one. Altered brain neurobiology is the basis of dependence syn‐ drome, with profound alteration on cognition, emotion and behavior of dependent person, which influence one's social interaction profoundly [25]. Mood and anxiety disorders are the most frequent cooccurent mental disorders accompanying dependence syndrome and most frequent symptoms in important others of dependent patients [26]. Mood and anxiety disor‐ ders and dependence syndrome are most frequently treated by antidepressants and anxio‐ lytics as psychopharmaceutical medications [27].

Progression on to drug dependence after the exposure appears to be genetically influenced; however, dependence is both a biological disorder and a cultural category [28]. The addic‐ tive process is introduced as an interaction of impairments in three functional systems: moti‐ vation-reward, affect regulation, and behavioral inhibition. From a cultural perspective, drug dependence is seen as being related to peer pressure and conformity as well as to eco‐ nomic and cultural factors [29].

The net effects of inhibiting the diffuse GABA are anxiety reduction, behavioral disinhibi‐ tion, sedation and euphoria, what is all connected also with interpersonal communication, family perception, perceived depression and self – concept. That's why we can expect, that chosen psychopharmaceutical medications can at least partially influence (facilitate or inhib‐ it) particular social behavioral patterns, particularly connecting (declared) depression, inter‐ personal relations in primary social environment and social implications of some other dependence behavior. These implications, manifested in different complex social situations could be quite subtle, sometimes hidden in "social mimicry", mostly connected with alcohol and other psychoactive substances abuse. One of the very opportune measures of such im‐ plications, according to our opinion, could be (sub) scores of SASSI (Substance Abuse Subtle Screening Inventory) instrument, which is declared to be the instrument which "breaks through denial" [30].

It seems that relations between concrete forms and contents of social interaction (complex patterns of cooperation, competition, conformism, cohesiveness, role learning, group deci‐ sion, leadership, conflicts, negotiations, mediations) and CNS (re) actions are yet to be re‐ searched. That's why the choice of family social climate has two advantages: we treat it as a kind of experiential common denominator of different social interaction effects, while cli‐ mate is an integrating experience, deriving from diversified processes of social interaction. Inducing climate as dependent variable, we focus on one of most relevant and integrating level of social experience. Simultaneously, (perceived) climate is one of the most essential parts of micro culture. Analyzing climate, we simultaneously analyze an important part of family culture. On the other side, evaluation of climate is inseparably connected with differ‐ ent self concepts (esteem, confidence, consciousness, efficacy belief) and self – evaluation. In actual text "functional" is supposed to be such a category of self – evaluation, when person‐ al bipolar attributes express the continuum of everyday adaptive/functional behavior. We suppose that psychopharmaceutical medications (anxiolytics) contribute to the change of retrograde functional self – evaluations, while medicaments are supposed to be a reason of improvement of mood level.

That's why in actual article, we'd like to analyze possible relations between psychopharma‐ ceutical medications (anxiolytics) usage (in the last year) status and some other relevant per‐ ceptions: evaluation of own family, self – esteem, self – perceived depression and substance abuse indicators. We can express the general level of our research problem with the ques‐ tion: Which are the relations between A. last year psychopharmaceutical medications use status and B. particular perceptions, connecting family, self and substance abuse depend‐ ence? The question about (anxiolytics) usage (in the last year) has been formulated as fol‐ lows: "Did you use prescribed psychopharmaceutical medications such as anxiolytics because of your emotional problems in last year?"

We formulated three expectations:

function of centrally positioned associations Stimulus – Response, which are the basic point

Ernst Fehr and collaborators [23] report about neurologic basis of social interactions, even on economic field (neuroeconomy). Such an approach could be helpful in explaining some irrational moments in otherwise rational cost – benefit dilemma resolution. According to Fehr, it even seems, that hormone oxytocin influences the experience of trust. Depression and anxiety is also a standard covariate of psychotropic medication treatments. That's why it's understandable, that psychopharmaceutical medications could have, in any group, an impact on different areas, levels and aspects of social interactions (communication, social ex‐ change). Regarding alcohol dependence an understanding of action of alcohol on central gamma – amino butyric acid (GABA) receptors may significantly contribute to the incentive

Although alterations in brain function can influence the symptoms which seem to be func‐ tional personality change, the inverse process is also possible. Depression, as an example of non–organic personality change, can result in symptoms, which are similar to alterations in brain functions - pseudo dementia, for example - which can disappear, when patients are treated with antidepressant medication. The relation between the psychopharmaceutical medications (non)use and different social representations of self and social environments, being an essential part of any social interaction (communication, social exchange and influ‐ ence), is not at all one – way process. Anyway, in actual research, such a complexity of rela‐ tions was not elaborated, while also the existent empirical methodology in behavioral sciences does not yet dispose with models, permitting analysis of two way processes, result‐ ing in different effects of mutual partially simultaneous, partially sequential influences. However, it is well known, that epigenetic effects during development lead to a cascade of

Psychopharmaceutical medications affect brain neurotransmission processes for therapeutic purposes; however, psychotropic substances can be abused and alter behavior into nonfunctional/non-adaptive one. Altered brain neurobiology is the basis of dependence syn‐ drome, with profound alteration on cognition, emotion and behavior of dependent person, which influence one's social interaction profoundly [25]. Mood and anxiety disorders are the most frequent cooccurent mental disorders accompanying dependence syndrome and most frequent symptoms in important others of dependent patients [26]. Mood and anxiety disor‐ ders and dependence syndrome are most frequently treated by antidepressants and anxio‐

Progression on to drug dependence after the exposure appears to be genetically influenced; however, dependence is both a biological disorder and a cultural category [28]. The addic‐ tive process is introduced as an interaction of impairments in three functional systems: moti‐ vation-reward, affect regulation, and behavioral inhibition. From a cultural perspective, drug dependence is seen as being related to peer pressure and conformity as well as to eco‐

**1.4. Brain, behavior and social interaction in mood and dependence disorders**

of any behavioral pattern.

68 Mental Disorders - Theoretical and Empirical Perspectives

side of explanation of this disorder [3].

neurobiological changes, including enhanced emotionality [24].

lytics as psychopharmaceutical medications [27].

nomic and cultural factors [29].

H.1: we hypothesized, that self–esteem, evaluation of own family and level of depression as predictors significantly differentiate, regardless co–variate inclusion, between users and non–users of anxiolytic pills in the last year, so in the case of mothers, as in the case of fathers.

H.2: we expect, that the change of self–evaluation in last few years significantly differ be‐ tween users and non–users, so in the case of fathers, as in the case of mothers.

main thematic area of the questionnaire, which contains different information about dem‐ ographic, socio – economic and socio – cultural status, anamnesis information about health status in different periods of life cycle, life style information, about suicidal idea‐ tion, exposure to different kinds of violence, different dependence behaviors (alcohol, nic‐ otine, drugs … ), info about intra – familiar processes, climate and, partially, culture, retrograde and actual self – evaluation, level of self-esteem and depression, evaluation of family climate, experiences with psychopharmacological treatment etc.. Validity was identified not only with coefficient of internal consistency (Table 1), which assures only the construct validity: from previous researches [31] validity of majority of summative scales was verified also with chosen outer criterion, consecrating almost equally needed

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

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71

In actual report the following scales and questions from the total questionnaire were includ‐ ed into research: Zung's self – rating depression scale - 20 items [32], Rosenberg's self – es‐ teem scale - 10 items [33]; original semantic differential for estimation of the climate in the proper family (15 bipolar continuums, selected according the demands of summative scale construction). Semantic differential - evaluation of the social climate in own family con‐ tained the following bipolar attributes on 7 – point bipolar continuums: good/bad, relaxed/ not-relaxed, aggressive/non-aggressive, pleasant/unpleasant, tolerant/intolerant, unorgan‐ ized/organized, non-conflicting/conflicting, not-developing/developing, enjoying/not- enjoy‐ ing, with insight/without-insight, with future/without future, charged/uncharged, not understanding/ understanding, without support/with support, with love/without love.

Actual and retrograde (»How do you evaluate yourself in time point about five years ago?«) functional self – evaluation bipolar attributes of self – evaluation scale: nervous/ calm, optimistic/pessimistic, with problems/without problems, lonely/with friends, inde‐ pendent/ dependent, with insight/without insight, mainly reposed/mainly tired, satisfied with/dissatisfied with, with bad habits/with good habits, successful in learning/unsuccess‐ ful in learning, non-creative/creative, self-conscious/self-unconscious, no-communicative/

According the authors belief about data validity, the missing values were not substituted

Also the missing values appeared which influence different number of valid cases in certain final reports and so diminish a little bit even the generalization on the basis of initial sample. For the occasion of this research, the Substance Abuse Subtle Screening Inventory SASSI [9] was for the first time applied in Slovenia. Instrument has two forms, for adolescents and for the parents. SASSI identify two probability categories of dependence: high and low sub‐ stance dependence probability. SASSI was adapted to Slovene version according to all de‐

AUDIT (Alcohol Use Disorder Identifying Test) [21] approach to identify the (alcohol) de‐ pendence degree of fathers was also applied. According to value = 8, two categories were obtained, one of the expressing low probability for alcohol connected problems, another ex‐ pressing high probability for alcohol use which is hazardous or harmful to the health. So as

time to construction as to validation of the instrument.

communicative.

with missing values.

mands of forward – backward translation.

H.3: we also hypothesized, that the groups of users and non–users significantly differ in cor‐ respondent SASSI subscores, so in the case of mother, as in the case of fathers.

In families, having a dependent member, dependence is also the main area of different per‐ ceptions, social representations and social interactions. That's why, in our research, the esti‐ mated dependence of each family member was included, where possible, as covariate. In our case, the alcohol dependence aspect was identified and taken into account as co–variate in sense of AUDIT estimated seriousness of alcohol dependence.

### **2. Method**

### **2.1. Participants**

There were three types of families, each type attempting to "mirror" approximate propor‐ tion of such a type in Slovene society: a. families with no referred dependent member, nei‐ ther parents, nor adolescent (about 56% of the whole sample); b. families with drug dependent children (about 16% of the whole sample) and c. families with alcohol dependent father (about 28% of the whole sample). If there were more than one adolescent child in the same family, only the eldest one was included. The average age of adolescents was M = 17.22 years, with SD = 1.27 years, with 45 percents of female and 55 percents of male re‐ spondents. From n = 183 valid cases (families) and excluding all missing, N = 159 "valid" mothers (mean age M = 42.85, SD = 4.68) and n = 147 fathers (with mean age M = 45.47, SD = 4.68) appeared in calculations.

It's worth underlining, that neither by mothers, nor by fathers, significant differences were found in age (users – no: n = 157, M = 42.70, SD = 4.66; users – yes: n = 22, M = 44.00, SD = 4.64; t(177) = - 1.21, p = 0.23 for mothers and users – no: n = 141, M = 45.56, SD = 5.06, users – yes: n = 16, M = 44.94, SD = 4.65; t(155) = 0.47, p = 0.64 for fathers) and education (t(179) = 1.54, p = 0.12 for mothers and t(155) = 0.87, p = 0.38 for fathers) and that no significant covari‐ ate effect of age had appeared neither by mothers (Pillai F = 0.57, p = 0.63), nor by fathers (Pillai F = 0.97, p = 0.41). On the other side, significant covariate effect of education was found for mothers (Pillai F = 6.32, p = 0.00, η<sup>2</sup> = 0.10), but not changing the significancy level of the independent variable (Pillai F = 2.62, p = 0.05, η<sup>2</sup> = 0.046); contrary to mothers, no such an effect was found for fathers (Pillai F = 1.35, p = 0.26, η<sup>2</sup> = 0.03).

#### **2.2. Instruments**

Relatively comprehensive questionnaire with 567 variables was applied, measuring differ‐ ent status and personal, subjective and objective characteristics (mothers and fathers 225 variables each, adolescents 117 variables). The whole questionnaire was applied so in in‐ dividual, as in small group conditions. It seems that the conditions of data collecting in‐ fluenced the number of missing, more of them being in small group conditions. The main thematic area of the questionnaire, which contains different information about dem‐ ographic, socio – economic and socio – cultural status, anamnesis information about health status in different periods of life cycle, life style information, about suicidal idea‐ tion, exposure to different kinds of violence, different dependence behaviors (alcohol, nic‐ otine, drugs … ), info about intra – familiar processes, climate and, partially, culture, retrograde and actual self – evaluation, level of self-esteem and depression, evaluation of family climate, experiences with psychopharmacological treatment etc.. Validity was identified not only with coefficient of internal consistency (Table 1), which assures only the construct validity: from previous researches [31] validity of majority of summative scales was verified also with chosen outer criterion, consecrating almost equally needed time to construction as to validation of the instrument.

H.2: we expect, that the change of self–evaluation in last few years significantly differ be‐

H.3: we also hypothesized, that the groups of users and non–users significantly differ in cor‐

In families, having a dependent member, dependence is also the main area of different per‐ ceptions, social representations and social interactions. That's why, in our research, the esti‐ mated dependence of each family member was included, where possible, as covariate. In our case, the alcohol dependence aspect was identified and taken into account as co–variate

There were three types of families, each type attempting to "mirror" approximate propor‐ tion of such a type in Slovene society: a. families with no referred dependent member, nei‐ ther parents, nor adolescent (about 56% of the whole sample); b. families with drug dependent children (about 16% of the whole sample) and c. families with alcohol dependent father (about 28% of the whole sample). If there were more than one adolescent child in the same family, only the eldest one was included. The average age of adolescents was M = 17.22 years, with SD = 1.27 years, with 45 percents of female and 55 percents of male re‐ spondents. From n = 183 valid cases (families) and excluding all missing, N = 159 "valid" mothers (mean age M = 42.85, SD = 4.68) and n = 147 fathers (with mean age M = 45.47, SD =

It's worth underlining, that neither by mothers, nor by fathers, significant differences were found in age (users – no: n = 157, M = 42.70, SD = 4.66; users – yes: n = 22, M = 44.00, SD = 4.64; t(177) = - 1.21, p = 0.23 for mothers and users – no: n = 141, M = 45.56, SD = 5.06, users – yes: n = 16, M = 44.94, SD = 4.65; t(155) = 0.47, p = 0.64 for fathers) and education (t(179) = 1.54, p = 0.12 for mothers and t(155) = 0.87, p = 0.38 for fathers) and that no significant covari‐ ate effect of age had appeared neither by mothers (Pillai F = 0.57, p = 0.63), nor by fathers (Pillai F = 0.97, p = 0.41). On the other side, significant covariate effect of education was found for mothers (Pillai F = 6.32, p = 0.00, η<sup>2</sup> = 0.10), but not changing the significancy level of the independent variable (Pillai F = 2.62, p = 0.05, η<sup>2</sup> = 0.046); contrary to mothers, no such

Relatively comprehensive questionnaire with 567 variables was applied, measuring differ‐ ent status and personal, subjective and objective characteristics (mothers and fathers 225 variables each, adolescents 117 variables). The whole questionnaire was applied so in in‐ dividual, as in small group conditions. It seems that the conditions of data collecting in‐ fluenced the number of missing, more of them being in small group conditions. The

= 0.03).

tween users and non–users, so in the case of fathers, as in the case of mothers.

respondent SASSI subscores, so in the case of mother, as in the case of fathers.

in sense of AUDIT estimated seriousness of alcohol dependence.

70 Mental Disorders - Theoretical and Empirical Perspectives

**2. Method**

**2.1. Participants**

**2.2. Instruments**

4.68) appeared in calculations.

an effect was found for fathers (Pillai F = 1.35, p = 0.26, η<sup>2</sup>

In actual report the following scales and questions from the total questionnaire were includ‐ ed into research: Zung's self – rating depression scale - 20 items [32], Rosenberg's self – es‐ teem scale - 10 items [33]; original semantic differential for estimation of the climate in the proper family (15 bipolar continuums, selected according the demands of summative scale construction). Semantic differential - evaluation of the social climate in own family con‐ tained the following bipolar attributes on 7 – point bipolar continuums: good/bad, relaxed/ not-relaxed, aggressive/non-aggressive, pleasant/unpleasant, tolerant/intolerant, unorgan‐ ized/organized, non-conflicting/conflicting, not-developing/developing, enjoying/not- enjoy‐ ing, with insight/without-insight, with future/without future, charged/uncharged, not understanding/ understanding, without support/with support, with love/without love.

Actual and retrograde (»How do you evaluate yourself in time point about five years ago?«) functional self – evaluation bipolar attributes of self – evaluation scale: nervous/ calm, optimistic/pessimistic, with problems/without problems, lonely/with friends, inde‐ pendent/ dependent, with insight/without insight, mainly reposed/mainly tired, satisfied with/dissatisfied with, with bad habits/with good habits, successful in learning/unsuccess‐ ful in learning, non-creative/creative, self-conscious/self-unconscious, no-communicative/ communicative.

According the authors belief about data validity, the missing values were not substituted with missing values.

Also the missing values appeared which influence different number of valid cases in certain final reports and so diminish a little bit even the generalization on the basis of initial sample.

For the occasion of this research, the Substance Abuse Subtle Screening Inventory SASSI [9] was for the first time applied in Slovenia. Instrument has two forms, for adolescents and for the parents. SASSI identify two probability categories of dependence: high and low sub‐ stance dependence probability. SASSI was adapted to Slovene version according to all de‐ mands of forward – backward translation.

AUDIT (Alcohol Use Disorder Identifying Test) [21] approach to identify the (alcohol) de‐ pendence degree of fathers was also applied. According to value = 8, two categories were obtained, one of the expressing low probability for alcohol connected problems, another ex‐ pressing high probability for alcohol use which is hazardous or harmful to the health. So as SASSI, also the AUDIT validity could be tested regarding the classification by the side of ex‐ perts (therapists). The rates of agreement between the experts and decision rules are descri‐ bed also as data validation [9]. In our research, both kinds of estimation almost perfectly coincided with classificational distinction from the side of experts –therapists (SASSI: χ<sup>2</sup> (2, n = 161) = 1.27, p = ns for nondependent mothers, but with 50 % of cells with expected counts less than 5; χ<sup>2</sup> (2, n = 167) = 91, p = 0.00 for (non)dependent children, with 16.7% of cells with expected counts < 5, and χ<sup>2</sup> (2, n = 139) = 84.90, p = 0.00, with 0% of expected counts < 5, for (non)dependent fathers).

**3. Results**

Anxiolytics in the Last Year - Mothers

spondent users.

4.28, p = 0.00).

Table 2.

Arithmetic Means and Standard Deviations of mothers' dependent variables are shown in

family climate no 75.46 19.93 152

self-esteem no 40.06 6.59 152

depression no 37.56 8.21 152

sion score – mothers; covariate = SASSI estimation of dependence seriousness by mothers.

riate effect was found as non – significant (F = 0.57, p = 0.63 (p = ns)).

**anxiolytics M SD n**

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

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73

yes 63.52 22.07 21

yes 35.95 7.39 21

yes 43.05 10.63 21

Note: family climate = evaluation of climate in own family – mothers (higher score means more positive evaluation); self-esteem = Rosenberg's self – evaluation score – mothers (higher score means higher self – esteem); Zung's depres‐

One factor MANOVA, exploring differences in self – esteem, perceived depression and fam‐ ily climate by parents as a function of their anxiolytic usage status (usage: yes vs. no) was applied for successive inclusion of one (mothers), two (mothers and fathers) and three (mothers, fathers, children) covariates (AUDIT for parents and therapists' estimation (TE) of dependence intensity for adolescents). Multivariate effect was found as significant (Pillai's, Wilks, Hotelling, all p = 0.14 and all Levene tests of equality of error variances with df1 = 1 and df = 171 were highly un–significant, p >>.05 (p = ns)); Box M test was significant (F = 3.79, p = 0.001), what means, that demand of equality of covariances (multivariate analogy with homogeneity of variances in univariate approaches) was not satisfied. Because F test is the robust one, we anyway continued with data analyses. Mothers' AUDIT estimation cova‐

Univariate access showed significant differences (p < 0.05) for each of three dependent varia‐ bles, expressing significantly more positive evaluation of own family climate (F (1,172) = 5.01, p = 0.026), higher self – esteem (F (1,172), p = 0.01) and lower degree of perceived de‐ pression (F (1,172 = 7.35, p = 0.007) for mothers non – users of anxiolytic pills, than for corre‐

Discriminate analysis was computed also in order to estimate the relative contribution of studied variables to the discrimination of mothers, users and non – users of psychotropic pills. Taking into account no other covariates, the first and the only one extracted discrimi‐ nate functions was highly significant (Wilks Lambda = 0. 94, χ<sup>2</sup> (3) = 10.98, p = 0.01. The null hypothesis about the homogeneity of covariance's was not accepted (Box's M = 27.21, F =

**Table 2.** Arithmetic Means and Standard Deviations for Dependent Variables Regarding Usage vs. Non-Usage of


Note: group 1 = family without dependent member (n = 104); 2 = family with dependent adolescent child (n = 29); 3 = family with alcohol dependent father (n = 52)

**Table 1.** Internal Consistency – Cronbach's Alpha Coefficients – For Summative Scales, Responded from the Side of Fathers and Mothers for Each of Three Groups/Family Types

The following sub scores are obtained with SASSI 3: FVA = face valid alcohol; FVOD = face valid other drugs; SYM = symptoms; OAT = obvious attributes; SAT = subtle attributes; DEF = defensiveness; SAM = supplemental addiction measure; FAM = family vs. controls; COR = correctional. Maja Rus Makovec had obtained also a permission for back – translation/adap‐ tation and research use of SASSI from the author.

Kolmogorov – Smirnov test showed, that almost all summative scores (actual and retro‐ grade self perception; evaluation of own family climate; self – esteem) did not differ signifi‐ cantly from normal distribution (p>.05), while for SASSI subscores the alternative hypotheses were accepted. Internal consistency of almost all (except one version of self – evaluation) summative scores was satisfactory (all Cronbach alphas mostly > 0.85).

Research was approved from the side of Ethical commission of Health Ministry of Slovenia.

### **3. Results**

(2, n

SASSI, also the AUDIT validity could be tested regarding the classification by the side of ex‐ perts (therapists). The rates of agreement between the experts and decision rules are descri‐ bed also as data validation [9]. In our research, both kinds of estimation almost perfectly coincided with classificational distinction from the side of experts –therapists (SASSI: χ<sup>2</sup>

= 161) = 1.27, p = ns for nondependent mothers, but with 50 % of cells with expected counts less than 5; χ<sup>2</sup> (2, n = 167) = 91, p = 0.00 for (non)dependent children, with 16.7% of cells with

Actual self evaluation 14 0.84 0.67 0.79 Retrograde self evaluation 14 0.80 0.84 0.85 Perceived family climate 15 0.89 0.92 0.83 Self – esteem 10 0.87 0.93 0.82 Perceived own depression 20 0.90 0.95 0.90

Actual self evaluation 14 0.82 0.82 0.71 Retrograde self evaluation 14 0.79 0.75 0.86 Perceived family climate 15 0.93 0.91 0.87 Self – esteem 10 0.83 0.82 0.80 Perceived own depression 20 0.88 0.87 0.76

Note: group 1 = family without dependent member (n = 104); 2 = family with dependent adolescent child (n = 29); 3 =

**Table 1.** Internal Consistency – Cronbach's Alpha Coefficients – For Summative Scales, Responded from the Side of

The following sub scores are obtained with SASSI 3: FVA = face valid alcohol; FVOD = face valid other drugs; SYM = symptoms; OAT = obvious attributes; SAT = subtle attributes; DEF = defensiveness; SAM = supplemental addiction measure; FAM = family vs. controls; COR = correctional. Maja Rus Makovec had obtained also a permission for back – translation/adap‐

Kolmogorov – Smirnov test showed, that almost all summative scores (actual and retro‐ grade self perception; evaluation of own family climate; self – esteem) did not differ signifi‐ cantly from normal distribution (p>.05), while for SASSI subscores the alternative hypotheses were accepted. Internal consistency of almost all (except one version of self –

Research was approved from the side of Ethical commission of Health Ministry of Slovenia.

evaluation) summative scores was satisfactory (all Cronbach alphas mostly > 0.85).

(2, n = 139) = 84.90, p = 0.00, with 0% of expected counts < 5, for

Alpha Group 2 Alpha Group 3

Group 1

expected counts < 5, and χ<sup>2</sup>

72 Mental Disorders - Theoretical and Empirical Perspectives

Evaluations from the side of mother

family with alcohol dependent father (n = 52)

Fathers and Mothers for Each of Three Groups/Family Types

tation and research use of SASSI from the author.

**Evaluations from the side of father No of items** Alpha

(non)dependent fathers).

Arithmetic Means and Standard Deviations of mothers' dependent variables are shown in Table 2.


Note: family climate = evaluation of climate in own family – mothers (higher score means more positive evaluation); self-esteem = Rosenberg's self – evaluation score – mothers (higher score means higher self – esteem); Zung's depres‐ sion score – mothers; covariate = SASSI estimation of dependence seriousness by mothers.

**Table 2.** Arithmetic Means and Standard Deviations for Dependent Variables Regarding Usage vs. Non-Usage of Anxiolytics in the Last Year - Mothers

One factor MANOVA, exploring differences in self – esteem, perceived depression and fam‐ ily climate by parents as a function of their anxiolytic usage status (usage: yes vs. no) was applied for successive inclusion of one (mothers), two (mothers and fathers) and three (mothers, fathers, children) covariates (AUDIT for parents and therapists' estimation (TE) of dependence intensity for adolescents). Multivariate effect was found as significant (Pillai's, Wilks, Hotelling, all p = 0.14 and all Levene tests of equality of error variances with df1 = 1 and df = 171 were highly un–significant, p >>.05 (p = ns)); Box M test was significant (F = 3.79, p = 0.001), what means, that demand of equality of covariances (multivariate analogy with homogeneity of variances in univariate approaches) was not satisfied. Because F test is the robust one, we anyway continued with data analyses. Mothers' AUDIT estimation cova‐ riate effect was found as non – significant (F = 0.57, p = 0.63 (p = ns)).

Univariate access showed significant differences (p < 0.05) for each of three dependent varia‐ bles, expressing significantly more positive evaluation of own family climate (F (1,172) = 5.01, p = 0.026), higher self – esteem (F (1,172), p = 0.01) and lower degree of perceived de‐ pression (F (1,172 = 7.35, p = 0.007) for mothers non – users of anxiolytic pills, than for corre‐ spondent users.

Discriminate analysis was computed also in order to estimate the relative contribution of studied variables to the discrimination of mothers, users and non – users of psychotropic pills. Taking into account no other covariates, the first and the only one extracted discrimi‐ nate functions was highly significant (Wilks Lambda = 0. 94, χ<sup>2</sup> (3) = 10.98, p = 0.01. The null hypothesis about the homogeneity of covariance's was not accepted (Box's M = 27.21, F = 4.28, p = 0.00).

Structure matrix showed relatively rare structure of relative predictive importance of inde‐ pendents/predictors. All coefficients of correlations between constructed (summative scores) manifest variables and discriminate functions were relatively very high and almost equal (climate (0.81), self – esteem (0.81), perceived depression (0.82)).

Discriminate analysis was also computed in order to estimate the relative contribution of studied variables to the discrimination of fathers, users and non – users of anxiolytic pills. The first and the only one extracted discriminate functions was non – significant with (Wilks Lambda = 0.97, Chi sq. (3) = 3.78, p = 0.29). The null hypothesis about the homogeneity of covariance's was otherwise accepted (Box's M = 6.02, F approx = 0.93, p =.47), but the further

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

MANOVA was found as non - significant also when additional AUDIT and TE covariates (for fathers and children) were successively included into analysis (Pillai, Wilks, Hotelling, Roy, all p > 0.00 (p = ns)). Risk level of the effect of independent variable (anxiolytic usage status) did not change in sense of significancy (p > 0.05). Having mothers' (F = 0.17, p =.91)

No significant differences were found between mothers users vs. non – users of in fathers' perceived difference between actual and retrograde self – evaluation, but significant differ‐ ence (p = 0.05) was found in perceived difference between actual and retrograde self – evalu‐ ation for mothers. Similar, but non – significant trend was found also for difference between relative fathers' differences regarding mothers' anxiolytics usage, and yet interestingly: in both cases the difference is negative, what means that retrograde summative functional self – evaluation was more positive than the actual one after about one year long period of its

no 0.20 11.41 157

no - 0.69 9.30 128

Note: Levene F for mothers = 3.04, p = 0.08, for fathers F = 0.19, p = 0.66

= 0.24) AUDIT as covariates, it was F = 1.33, p =.27, η<sup>2</sup> =

**M SD n t- test P**

yes - 5.19 14.75 21 1.96 0.05

yes - 4.78 11.42 14 1.53 0.13

E1 = actual self – evaluation (higher score means more positive self – evaluation); E2 = retrograde ("five years ago") self

No significant differences were found between fathers users vs. non – users of anxiolytics fathers' perceived difference between actual and retrograde self – evaluation and also not in perceived difference between actual and retrograde self – evaluation for mothers (Table 5).

**Table 4.** Arithmetic Means and Standard Deviations for Differences Between "Actual" and "Retrograde" Self –

evaluation for Mothers and for Fathers Regarding the Anxiolytics(Non) Usage by Mothers

= 0.08), it was F = 1.81, p =.15, η<sup>2</sup>

= 0.04).

http://dx.doi.org/10.5772/53307

75

analysis was omitted.

usage (Table 4).

E1-E2 mothers

E1-E2 fathers

– evaluation

and fathers' (F = 15.79, p = 0.00, η<sup>2</sup>

**anxiolytics mothers**

0.03, and adding children's TE (F = 4.07, p =.01, η<sup>2</sup>

According to the values of group centroids for significant (p < 0.05) discriminate function, it could be suggested, that the discriminate function differentiates "strongly" between female (non) users of anxiolytics.

MANOVA was found as significant also when additional AUDIT and TE covariates (for fa‐ thers and children) were successively included into analysis (Pillai, Wilks, Hotelling, Roy, all p = 0.00). Anyway, risk level of the effect of independent variable ((non)anxiolytic usage status) changed: having mothers' (F = 0.50, p = 0.68, η<sup>2</sup> = 0.009) and fathers' (F = 2.91, p =.036, η2 = 0.05) AUDIT as covariates, it was F = 3.43, p = 0.02, η<sup>2</sup> = 0.06, and adding children's TE (F = 6.33, p = 0.00, η<sup>2</sup> = 0.106), it was F = 2.25, p = 0.08, η<sup>2</sup> = 0.04.

One factor MANOVA, exploring differences in self – esteem, perceived depression and family climate by parents as a function of their anxiolytic usage status (usage: yes vs. no) was applied for successive inclusion of one (mothers), two (mothers and fathers) and three (mothers, fathers, children) covariates (AUDIT for parents and therapists' estimation (TE) of dependence intensi‐ ty for adolescents). Multivariate effect was found as non - significant (Roy's, Pillai's, Wilks, p >. 05). Box's M test of equality of covariance matrices was highly non - significant (F = 0.93, p = 0.47 (p = ns)), what confirmed the equality of co – variances. Fathers' AUDIT estimation covariate ef‐ fect was found as non – significant (F = 0.05, p = 0.98 (p = ns)).

Univariate access, of course, only confirmed non - significant differences (p >> 0.05) for each of three dependent variables, for perceived climate (F(1, 151) = 0.76, p = 0.38), level of self – esteem (F(1, 151) = 0.39, p = 0.53 (p = ns)) and level of depression ( F (1,151 = 0.68, p = 0.41) for fathers non – users of psychotropic pills, than for correspondent users (Table 3).


Note: family climate = evaluation of climate in own family – mothers (higher score means more positive evaluation); self-esteem = Rosenberg's self – evaluation score – mothers (higher score means higher self – esteem); Zung's depres‐ sion score – mothers; covariate = SASSI estimation of dependence seriousness by fathers.

**Table 3.** Arithmetic Means and Standard Deviations for Dependent Variables Regarding Usage vs. Non- usage of Anxiolytics in the Last Year - Fathers

Discriminate analysis was also computed in order to estimate the relative contribution of studied variables to the discrimination of fathers, users and non – users of anxiolytic pills. The first and the only one extracted discriminate functions was non – significant with (Wilks Lambda = 0.97, Chi sq. (3) = 3.78, p = 0.29). The null hypothesis about the homogeneity of covariance's was otherwise accepted (Box's M = 6.02, F approx = 0.93, p =.47), but the further analysis was omitted.

Structure matrix showed relatively rare structure of relative predictive importance of inde‐ pendents/predictors. All coefficients of correlations between constructed (summative scores) manifest variables and discriminate functions were relatively very high and almost equal

According to the values of group centroids for significant (p < 0.05) discriminate function, it could be suggested, that the discriminate function differentiates "strongly" between female

MANOVA was found as significant also when additional AUDIT and TE covariates (for fa‐ thers and children) were successively included into analysis (Pillai, Wilks, Hotelling, Roy, all p = 0.00). Anyway, risk level of the effect of independent variable ((non)anxiolytic usage status) changed: having mothers' (F = 0.50, p = 0.68, η<sup>2</sup> = 0.009) and fathers' (F = 2.91, p =.036,

One factor MANOVA, exploring differences in self – esteem, perceived depression and family climate by parents as a function of their anxiolytic usage status (usage: yes vs. no) was applied for successive inclusion of one (mothers), two (mothers and fathers) and three (mothers, fathers, children) covariates (AUDIT for parents and therapists' estimation (TE) of dependence intensi‐ ty for adolescents). Multivariate effect was found as non - significant (Roy's, Pillai's, Wilks, p >. 05). Box's M test of equality of covariance matrices was highly non - significant (F = 0.93, p = 0.47 (p = ns)), what confirmed the equality of co – variances. Fathers' AUDIT estimation covariate ef‐

Univariate access, of course, only confirmed non - significant differences (p >> 0.05) for each of three dependent variables, for perceived climate (F(1, 151) = 0.76, p = 0.38), level of self – esteem (F(1, 151) = 0.39, p = 0.53 (p = ns)) and level of depression ( F (1,151 = 0.68, p = 0.41)

**anxiolytics M SD n**

yes 75.81 19.36 16

yes 39.50 7.80 16

yes 38.62 7.91 16

Note: family climate = evaluation of climate in own family – mothers (higher score means more positive evaluation); self-esteem = Rosenberg's self – evaluation score – mothers (higher score means higher self – esteem); Zung's depres‐

**Table 3.** Arithmetic Means and Standard Deviations for Dependent Variables Regarding Usage vs. Non- usage of

for fathers non – users of psychotropic pills, than for correspondent users (Table 3).

family climate no 74.69 19.07 136

self-esteem no 39.18 6.87 136

depression no 36.47 7.08 136

sion score – mothers; covariate = SASSI estimation of dependence seriousness by fathers.

Anxiolytics in the Last Year - Fathers

= 0.04.

= 0.06, and adding children's TE (F

(climate (0.81), self – esteem (0.81), perceived depression (0.82)).

= 0.05) AUDIT as covariates, it was F = 3.43, p = 0.02, η<sup>2</sup>

fect was found as non – significant (F = 0.05, p = 0.98 (p = ns)).

= 0.106), it was F = 2.25, p = 0.08, η<sup>2</sup>

(non) users of anxiolytics.

74 Mental Disorders - Theoretical and Empirical Perspectives

= 6.33, p = 0.00, η<sup>2</sup>

η2

MANOVA was found as non - significant also when additional AUDIT and TE covariates (for fathers and children) were successively included into analysis (Pillai, Wilks, Hotelling, Roy, all p > 0.00 (p = ns)). Risk level of the effect of independent variable (anxiolytic usage status) did not change in sense of significancy (p > 0.05). Having mothers' (F = 0.17, p =.91) and fathers' (F = 15.79, p = 0.00, η<sup>2</sup> = 0.24) AUDIT as covariates, it was F = 1.33, p =.27, η<sup>2</sup> = 0.03, and adding children's TE (F = 4.07, p =.01, η<sup>2</sup> = 0.08), it was F = 1.81, p =.15, η<sup>2</sup> = 0.04).

No significant differences were found between mothers users vs. non – users of in fathers' perceived difference between actual and retrograde self – evaluation, but significant differ‐ ence (p = 0.05) was found in perceived difference between actual and retrograde self – evalu‐ ation for mothers. Similar, but non – significant trend was found also for difference between relative fathers' differences regarding mothers' anxiolytics usage, and yet interestingly: in both cases the difference is negative, what means that retrograde summative functional self – evaluation was more positive than the actual one after about one year long period of its usage (Table 4).


Note: Levene F for mothers = 3.04, p = 0.08, for fathers F = 0.19, p = 0.66

E1 = actual self – evaluation (higher score means more positive self – evaluation); E2 = retrograde ("five years ago") self – evaluation

**Table 4.** Arithmetic Means and Standard Deviations for Differences Between "Actual" and "Retrograde" Self – evaluation for Mothers and for Fathers Regarding the Anxiolytics(Non) Usage by Mothers

No significant differences were found between fathers users vs. non – users of anxiolytics fathers' perceived difference between actual and retrograde self – evaluation and also not in perceived difference between actual and retrograde self – evaluation for mothers (Table 5).


**SASSI anxiolytics**

**SASSI anxiolytics**

**usage**

FVAm yes 159 90.01

FVODm yes 159 90.31

SYMm yes 159 88.58

OATm yes 159 87.43

SATm yes 159 90.40

DEFm yes 159 92.80

SAMm yes 159 87.52

FAMm yes 159 92.17

CORm yes 159 88.20

no

tional; f = fathers.

**usage**

CORf no 141 77.70

RAPf no 141 80.06

**Table 6.** Results of Mann Whitney Nonparametric Test for SASSI Subscores for Fathers

Differences were not found for other subscores of SASSI (Table 7).

**n Mean Rank Z p**

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77

**n Mean Rank Z p**

yes 16 90.44 - 1.07 0.28

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

yes 16 69.69 - 0.93 0.35

no 22 98.16 - 0.70 0.48

no 22 95.95 - 0.96 0.34

no 22 108.45 - 1.96 0.05

no 22 116.82 - 2.49 0.01

no 22 95.36 - 0.43 0.67

no 22 78.02 - 1.25 0.21

no 22 116.16 - 2.43 0.01

no 22 82.55 - 0.82 0.41

no 22 111.25 - 1.96 0.05

Note: FVA = face valid alcohol; FVOD = face valid other drugs; SYM = symptoms; OAT = obvious attributes; SAT = sub‐ tle attributes; DEF = defensiveness; SAM = supplemental addiction measure; FAM = family vs. controls; COR = correc‐

Significant differences (p<0.05) by mothers were found for category »symptoms« SYMm, ob‐ vious attributes OATm, correctional CORm and supplemental addiction measure SAMm.

Note: Levene F for mothers = 0.14, p = 0.71 (p = ns), for fathers Levene F = 11.74, p = 0.01.

E1 = actual self – evaluation (higher score means more positive self – evaluation); E2 = retrograde ("five years ago") self – evaluation

**Table 5.** Arithmetic Means and Standard Deviations for Differences Between "Actual" and "Retrograde" Self – evaluation for Mothers and for Fathers Regarding the Anxiolytics(Non) Usage by Fathers

Significant differences (p<0.05) by fathers were found for other drugs' use FVODf, for cate‐ gory »symptoms« SYMf, and for obvious attributes OATf. Differences were not found for other subscores of SASSI (Table 6).


Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and... http://dx.doi.org/10.5772/53307 77


Note: FVA = face valid alcohol; FVOD = face valid other drugs; SYM = symptoms; OAT = obvious attributes; SAT = sub‐ tle attributes; DEF = defensiveness; SAM = supplemental addiction measure; FAM = family vs. controls; COR = correc‐ tional; f = fathers.

**Table 6.** Results of Mann Whitney Nonparametric Test for SASSI Subscores for Fathers

**anxiolytics fathers**

76 Mental Disorders - Theoretical and Empirical Perspectives

other subscores of SASSI (Table 6).

**usage**

FVAf no 141 77.94

FVODf no 141 77.20

SYMf no 141 76.30

OATf no 141 76.47

SATf no 141 77.71

DEFf no 141 80.93

SAMf no 141 77.29

FAMf no 141 79.14

**SASSI anxiolytics**

E1-E2 mothers

E1-E2 fathers

– evaluation

**M SD n t- test P**

yes 0.07 8.95 15 0.10 0.92

yes - 0.19 17.89 16 - 0.14 0.89

E1 = actual self – evaluation (higher score means more positive self – evaluation); E2 = retrograde ("five years ago") self

Significant differences (p<0.05) by fathers were found for other drugs' use FVODf, for cate‐ gory »symptoms« SYMf, and for obvious attributes OATf. Differences were not found for

**n Mean Rank Z p**

yes 16 88.34 - 0.87 0.38

yes 16 94.88 - 2.66 0.01

yes 16 102.78 - 2.29 0.02

yes 16 101.28 - 2.09 0.04

yes 16 90.41 - 1.09 0.28

yes 16 62.00 - 1.59 0.11

yes 16 94.09 - 1.41 0.16

yes 16 77.75 - 0.12 0.91

**Table 5.** Arithmetic Means and Standard Deviations for Differences Between "Actual" and "Retrograde" Self –

no 0.36 10.80 126

no - 0.81 8.82 135

Note: Levene F for mothers = 0.14, p = 0.71 (p = ns), for fathers Levene F = 11.74, p = 0.01.

evaluation for Mothers and for Fathers Regarding the Anxiolytics(Non) Usage by Fathers

Significant differences (p<0.05) by mothers were found for category »symptoms« SYMm, ob‐ vious attributes OATm, correctional CORm and supplemental addiction measure SAMm. Differences were not found for other subscores of SASSI (Table 7).



We can say, that all results together show important differences between male and fe‐ male participants. Female participants show the evident trend of significant differences in their family climate and in self (esteem/depression) perceptions, while the male partici‐ pants in our research do not. It seems that mothers with emotional problems communi‐ cate about them with medical doctors (which prescribe them anxiolytics), and fathers do

Anxiolytics Use in the Families with (Non)dependent Member: Relation to Dependence Indicators, Self and...

http://dx.doi.org/10.5772/53307

79

By mothers, for example, we did not find significant differences between the (non)users in face valid other drugs scores (FVOD); higher score on either scale means that clients acknowledge usage, consequences of usage and loss of control. Higher scores mean that the client is willing to admit to having a problem with alcohol/drugs. The face valid items are relatively easy for clients to manipulate. Results show, that female participants do not perceive anxiolytics as "other drugs", but fathers do. It can be said that fathers show more critical view towards anxiolytics use. However, in a Norwegian populationbased cohort study of anxiety, depression and sleep, benzodiazepine (anxiolytics) were associated with a higher risk of severe anxiety, depression and sleep outcomes; benzodia‐ zepine use was not found to be associated with a higher risk of problematic alcohol use [34]. Results of our small (clinical) study are similar in way: in fathers there has been a group with alcohol problem, but it did not associate with anxiolytic use, but mood prob‐

Perspectives from multiple perspectives are required to fully understand individual vulner‐ ability to addictions [6]. Our small piece of work points to vulnerability of mothers with drug abusing children to anxiolytic (ab) use. On the other hand, in primates social rank (dominant to subordinate) has been found inversely related to locomotor activity and co‐ caine self administration. In other words, monkey with high levels of locomotor activity tend to be subordinate in rank and self-administer cocaine avidly. PET imaging showed al‐ so, that there was an inverse relationship between Dopamine D2 receptor availability and co‐ caine self administration [35]. – It would be interesting to research the connection between mothers' social status in family with/without dependence problem, brain neurotransmitters

We perceive the following advantages of our research: it seems that the research problem have been up to date quite rarely investigated; the research contributed to some aspects of so called decision rule validation of SASSI (sub scores), while just the anxiolytics (non) usage could be one of those approach approximation for chosen sub scores, defined as chemically determined; difference between the actual and retrograde self – evaluation (of functionality in the everyday life) seems to be quite a suitable measure of relative subjec‐ tive success/failure; including the AUDIT and TE covariates of dependence seriousness, we tried to assure the necessary minimum of (a posteriori) statistical control and partial interpretability in the sense of consequences; users and non – users of anxiolytics did not significantly differ in age and education, what, together with AUDIT covariates, eventu‐ ally contributes to attempt of more clear identification of anxiolytics effects; families with dependent member represented quite an adequate environment for anxiolytics usage ef‐

not.

lems (in mothers) did.

fect study.

availability and their proness to anxiolytic abuse.

Note: FVA = face valid alcohol; FVOD = face valid other drugs; SYM = symptoms; OAT = obvious attributes; SAT = sub‐ tle attributes; DEF = defensiveness; SAM = supplemental addiction measure; FAM = family vs. controls; COR = correc‐ tional; m = mothers.

**Table 7.** Results of Mann Whitney Nonparametric Test for SASSI Sub scores for Mothers

### **4. Discussion**

An example of the principle of multiple determinism of the social neuroscience can be found in the extensive literature on drug abuse. Endogenous brain opioid receptor systems repre‐ sent the neurophysiologic basis for cognitive, psychological and affective actions. The proxi‐ mate and powerful determinants of drug abuse include the social factors of family dynamics, economics and different other social environments [3]. It's what we had tried to begin to analyze in our article.

Interactions between social processes and the underlying neural substrates facilitate the un‐ derstanding of the holistic consequences of the drug administration. Molar features of phe‐ nomenon (like self and own family perceptions) have also their micro – molecular correlations (like presumed anxiolytic pills influence/function), as complements of the multi‐ level approach.

In our research, for self and family climate perceptions, we rejected all alternative hy‐ potheses in the case of fathers, while by mothers they were mostly accepted. The only exception was, when children's TE (therapists' estimation of drug abuse) was included as co – variate, when multivariate effect was significant on p = 0.08 risk level and univari‐ ate approach showed significant differences (p < 0.05) between mothers anxiolytics (non)users only for level of self esteem. Results suggest, that children's TE could be maybe treated as new independent variable and that anxiolytics (non)use effects on self and family perceptions by mothers' in families with dependent member depend more on children than on husbands health (dependence) status. Taking into account relatively small number (n = 21) of anxiolytics users mothers and non – significant, but relatively low risk level, p = 0.08, we can infer, that children dependence status could be interpret‐ ed more as relatively most important factual reason of anxiolytics' usage by mothers, what both effect mothers' self and family perceptions.

In the framework of this research design, this general trend could not be persuasively for‐ mulated more in detail. Anyway, it seems that patterns of social behavior, expressed by SASSI (sub) scores specifically enough express the connections with anxiolytics (none) us‐ age. In the case of SASSI (sub) scores, hypotheses were partially accepted, partially rejected, but mostly in accordance with our expectations.

We can say, that all results together show important differences between male and fe‐ male participants. Female participants show the evident trend of significant differences in their family climate and in self (esteem/depression) perceptions, while the male partici‐ pants in our research do not. It seems that mothers with emotional problems communi‐ cate about them with medical doctors (which prescribe them anxiolytics), and fathers do not.

**SASSI anxiolytics**

tional; m = mothers.

**4. Discussion**

level approach.

begin to analyze in our article.

**usage**

78 Mental Disorders - Theoretical and Empirical Perspectives

RAPm yes 159 89.86

what both effect mothers' self and family perceptions.

but mostly in accordance with our expectations.

**Table 7.** Results of Mann Whitney Nonparametric Test for SASSI Sub scores for Mothers

**n Mean Rank Z p**

22 99.25 - 0.89 0.37

Note: FVA = face valid alcohol; FVOD = face valid other drugs; SYM = symptoms; OAT = obvious attributes; SAT = sub‐ tle attributes; DEF = defensiveness; SAM = supplemental addiction measure; FAM = family vs. controls; COR = correc‐

An example of the principle of multiple determinism of the social neuroscience can be found in the extensive literature on drug abuse. Endogenous brain opioid receptor systems repre‐ sent the neurophysiologic basis for cognitive, psychological and affective actions. The proxi‐ mate and powerful determinants of drug abuse include the social factors of family dynamics, economics and different other social environments [3]. It's what we had tried to

Interactions between social processes and the underlying neural substrates facilitate the un‐ derstanding of the holistic consequences of the drug administration. Molar features of phe‐ nomenon (like self and own family perceptions) have also their micro – molecular correlations (like presumed anxiolytic pills influence/function), as complements of the multi‐

In our research, for self and family climate perceptions, we rejected all alternative hy‐ potheses in the case of fathers, while by mothers they were mostly accepted. The only exception was, when children's TE (therapists' estimation of drug abuse) was included as co – variate, when multivariate effect was significant on p = 0.08 risk level and univari‐ ate approach showed significant differences (p < 0.05) between mothers anxiolytics (non)users only for level of self esteem. Results suggest, that children's TE could be maybe treated as new independent variable and that anxiolytics (non)use effects on self and family perceptions by mothers' in families with dependent member depend more on children than on husbands health (dependence) status. Taking into account relatively small number (n = 21) of anxiolytics users mothers and non – significant, but relatively low risk level, p = 0.08, we can infer, that children dependence status could be interpret‐ ed more as relatively most important factual reason of anxiolytics' usage by mothers,

In the framework of this research design, this general trend could not be persuasively for‐ mulated more in detail. Anyway, it seems that patterns of social behavior, expressed by SASSI (sub) scores specifically enough express the connections with anxiolytics (none) us‐ age. In the case of SASSI (sub) scores, hypotheses were partially accepted, partially rejected,

By mothers, for example, we did not find significant differences between the (non)users in face valid other drugs scores (FVOD); higher score on either scale means that clients acknowledge usage, consequences of usage and loss of control. Higher scores mean that the client is willing to admit to having a problem with alcohol/drugs. The face valid items are relatively easy for clients to manipulate. Results show, that female participants do not perceive anxiolytics as "other drugs", but fathers do. It can be said that fathers show more critical view towards anxiolytics use. However, in a Norwegian populationbased cohort study of anxiety, depression and sleep, benzodiazepine (anxiolytics) were associated with a higher risk of severe anxiety, depression and sleep outcomes; benzodia‐ zepine use was not found to be associated with a higher risk of problematic alcohol use [34]. Results of our small (clinical) study are similar in way: in fathers there has been a group with alcohol problem, but it did not associate with anxiolytic use, but mood prob‐ lems (in mothers) did.

Perspectives from multiple perspectives are required to fully understand individual vulner‐ ability to addictions [6]. Our small piece of work points to vulnerability of mothers with drug abusing children to anxiolytic (ab) use. On the other hand, in primates social rank (dominant to subordinate) has been found inversely related to locomotor activity and co‐ caine self administration. In other words, monkey with high levels of locomotor activity tend to be subordinate in rank and self-administer cocaine avidly. PET imaging showed al‐ so, that there was an inverse relationship between Dopamine D2 receptor availability and co‐ caine self administration [35]. – It would be interesting to research the connection between mothers' social status in family with/without dependence problem, brain neurotransmitters availability and their proness to anxiolytic abuse.

We perceive the following advantages of our research: it seems that the research problem have been up to date quite rarely investigated; the research contributed to some aspects of so called decision rule validation of SASSI (sub scores), while just the anxiolytics (non) usage could be one of those approach approximation for chosen sub scores, defined as chemically determined; difference between the actual and retrograde self – evaluation (of functionality in the everyday life) seems to be quite a suitable measure of relative subjec‐ tive success/failure; including the AUDIT and TE covariates of dependence seriousness, we tried to assure the necessary minimum of (a posteriori) statistical control and partial interpretability in the sense of consequences; users and non – users of anxiolytics did not significantly differ in age and education, what, together with AUDIT covariates, eventu‐ ally contributes to attempt of more clear identification of anxiolytics effects; families with dependent member represented quite an adequate environment for anxiolytics usage ef‐ fect study.

Weaknesses of our research could be the following: research design is quasi – experimental, a kind of "ex post facto", without (direct) systematic and sensible manipulation of inde‐ pendent variable, without relevant control of (eventual) extraneous variables. That's why re‐ lations between chosen dependents and independent could not be interpreted in the pure sense of causal relation. Effect sizes (eta square) are mostly (very) low; neurobiological ef‐ fects are taken into account only indirectly, without sophisticated technological measure‐ ments. Also the distributions of AUDIT covariate estimations significantly differed from the normal one, what is normal taking account the character and purpose of the instrument. In‐ ternal consistency of instruments, as the additional demands for statistic calculations (homo‐ geneity of covariance) were not ulimatively respected. The structure of demographic, socio – economic and socio – cultural status of target participants do not permit spreader societal or cultural generalizations.

**Author details**

Slovenia

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2 University Psychiatric Hospital Ljubljana, Slovenia

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81

[1] Ochsner KN, Lieberman MD. The emergence of social cognitive neuroscience. Amer‐

[2] Decety J, Keenan JP. Social neuroscience: A new journal. Social Neuroscience 2006; 1:

[3] Cacioppo JT, Berntson GG. Social psychological contributions to the decade of the brain: doctrine of multilevel analysis. In. Kruglanski A, Higgins T (eds.). Social psy‐

[4] Buss DM. Mate preferences in 37 cultures. In: Kruglanski A, Higgins T (eds.). Social

[5] Taylor SE, Brown JD. Illusion and well being: a social psychological perspective on

[6] Singer T. The past, present and future of social neuroscience: A European perspec‐

[7] Schnur P, Shurtleff D. Social neuroscience: Application to addiction. Drug and Alco‐

[9] Caccioppo JT, Berntson GG, Lorig TS, Norris CJ, Rickett E, Nusbaum H. Just because you're imaging the brain doesn't mean you can stop using your head: a primer and set of first principles. Journal of Personality and Social Psychology 2003; 85: 650–661.

[10] Torrance EP. Hemisphericity and creative functioning. Journal of Research of Devel‐

[11] Klavora P. Foundations of kinesiology – studying human movement and health. Tor‐

Anyway, results could be discussed also from the aspects of personal and micro – group (family) culture. According to Trice and Beyer [36], social climate is one of the essential parts (elements) of micro and macro group culture. From this point of view, also the in‐ dividualistic – collectivistic orientation could be treated not only relatively, as underlined from some authors in last decade [37], but also on different micro and macro levels. At‐ tachment to the values of the secondary family could mean also a typical micro–collectiv‐ istic orientation [38], without any anticipation of positive or negative connotations. In our research, evaluation of family climate is a central psychological variable, which correlate with some other indicators of group/family culture, like characteristic ways of communi‐ cation, habits and rituals, perceived distribution of power/ influence, relevant social rep‐ resentations etc. From this aspect, we can conclude, that family culture is partially connected with brain – anxiolytics usage by females in Slovenia as representative part of Central European culture.

### **5. Conclusion**

Social neuroscience finally ends one of the important phases of the developing of social psy‐ chology, which intensely obtained quantitative and qualitative accelerations in »eighties«, with applied social psychology, partially derived from societal and cross-cultural trends of development, what resulted in new relations to new interdisciplinary areas, and from social cognition, which revitalized the importance of social interaction, language/linguistic, social knowledge, taxonomy of meaning and categorization processes with prototypical percep‐ tions. Neuroscience researches could be guided by different definitions of the field. One of the main objectives, goals, and purposes is only to understand better the relation between the brain, its related systems and social interaction. According to them, the instruments of social neuroscience are limited only by the imagination of the researcher: so creative uses of traditional approaches, as developments of new techniques are welcome [2]. That's why we see our research as a micro attempt of the contribution to this field.

### **Author details**

Weaknesses of our research could be the following: research design is quasi – experimental, a kind of "ex post facto", without (direct) systematic and sensible manipulation of inde‐ pendent variable, without relevant control of (eventual) extraneous variables. That's why re‐ lations between chosen dependents and independent could not be interpreted in the pure sense of causal relation. Effect sizes (eta square) are mostly (very) low; neurobiological ef‐ fects are taken into account only indirectly, without sophisticated technological measure‐ ments. Also the distributions of AUDIT covariate estimations significantly differed from the normal one, what is normal taking account the character and purpose of the instrument. In‐ ternal consistency of instruments, as the additional demands for statistic calculations (homo‐ geneity of covariance) were not ulimatively respected. The structure of demographic, socio – economic and socio – cultural status of target participants do not permit spreader societal or

Anyway, results could be discussed also from the aspects of personal and micro – group (family) culture. According to Trice and Beyer [36], social climate is one of the essential parts (elements) of micro and macro group culture. From this point of view, also the in‐ dividualistic – collectivistic orientation could be treated not only relatively, as underlined from some authors in last decade [37], but also on different micro and macro levels. At‐ tachment to the values of the secondary family could mean also a typical micro–collectiv‐ istic orientation [38], without any anticipation of positive or negative connotations. In our research, evaluation of family climate is a central psychological variable, which correlate with some other indicators of group/family culture, like characteristic ways of communi‐ cation, habits and rituals, perceived distribution of power/ influence, relevant social rep‐ resentations etc. From this aspect, we can conclude, that family culture is partially connected with brain – anxiolytics usage by females in Slovenia as representative part of

Social neuroscience finally ends one of the important phases of the developing of social psy‐ chology, which intensely obtained quantitative and qualitative accelerations in »eighties«, with applied social psychology, partially derived from societal and cross-cultural trends of development, what resulted in new relations to new interdisciplinary areas, and from social cognition, which revitalized the importance of social interaction, language/linguistic, social knowledge, taxonomy of meaning and categorization processes with prototypical percep‐ tions. Neuroscience researches could be guided by different definitions of the field. One of the main objectives, goals, and purposes is only to understand better the relation between the brain, its related systems and social interaction. According to them, the instruments of social neuroscience are limited only by the imagination of the researcher: so creative uses of traditional approaches, as developments of new techniques are welcome [2]. That's why we

see our research as a micro attempt of the contribution to this field.

cultural generalizations.

80 Mental Disorders - Theoretical and Empirical Perspectives

Central European culture.

**5. Conclusion**

Maja Rus-Makovec1\*, Karin Sernec2 and Velko S. Rus3

1 University Psychiatric Hospital Ljubljana & School of Medicine, University Ljubljana, Slovenia


### **References**


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[28] Goodman A. Neurobiology of addiction. An integrative review. Biochemical Phar‐

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[29] Boyarsky BK, Dilts S, Frances RJ et al. Responsibility and Choice in Addiction. Psy‐

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[31] Rus VS. Sociopsihologija kot sodobna paradigma socialne psihologije (Sociopsychol‐ ogy as contemporary paradigm of social psychology). Ljubljana: Univerza v Ljublja‐

[33] Rosenberg M. Society and the adolescent self – image. Princeton: Princeton Universi‐

[34] Nordfjaern T. A population-based cohort study of anxiety, depression, sleep and al‐ cohol outcomes among benzodiazepine and z-hypnotic users. Addictive Behaviors

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[36] Trice HM, Beyer JM. The Cultures of Work Organizations. New Jersey: Englewood

[37] Oyserman D, Coon H, Kemmelmeier M. Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin

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**Chapter 5**

**Management of Delirium**

http://dx.doi.org/10.5772/52756

nation, urinary incontinence.

tion (Attard et al., 2008).

**1. Introduction**

Narong Maneeton and Benchalak Maneeton

Additional information is available at the end of the chapter

Delirium is categorized in the cognitive disorders, characterized by acute onset, global im‐ pairment in cognitive, emotional, mental, and behavioral functioning, fluctuating level of consciousness, attention impairment, decreased or increased psychomotor activity and the disturbance of sleep-wake cycle. Emotional and behavioral abnormalities are common pre‐ sented with some neurological manifestations, e.g., tremor, asterixis, nystagmus, incoordi‐

Delirium is a behavioral disturbance and serious complication commonly found in consulta‐ tion-liaison psychiatry. Its prevalence and incidence rates are varied, possibly depend on se‐ verity of illness, patient population, the method of assessment and the diagnostic criteria. Prevalence of delirium ranges from 10% to 30% and its incidence is between 3% and 29% for patients admitted in general hospitals (Siddiqi et al., 2006, Maneeton et al., 2007a, Praditsu‐ wan et al., 2012). High prevalence and incidence are noted in elderly and severely ill pa‐ tients. For instance, the prevalence of delirium in elderly and ICU patients are up to 40%

An occurrence of delirium is associated with miserable clinical outcomes. It often increases morbidity, mortality, length of hospitalization, institutionalization, and poor functional out‐ come (Siddiqi et al., 2006, Cole et al., 2009, Fong et al., 2012). The mortality rate is higher in

Delirium is often under recognized by health professionals. There are many faces for the clinical presentation of delirium. It can be caused by a variety of etiology. To prevent and minimize the consequences of delirium, physician should prompt intervenes for this condi‐

and reproduction in any medium, provided the original work is properly cited.

© 2013 Maneeton and Maneeton; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

and 80%, respectively (Bledowski and Trutia, 2012, Praditsuwan et al., 2012).

patients with hypoactive subtype of delirium (Yang et al., 2009).

### **Chapter 5**

## **Management of Delirium**

Narong Maneeton and Benchalak Maneeton

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52756

### **1. Introduction**

Delirium is categorized in the cognitive disorders, characterized by acute onset, global im‐ pairment in cognitive, emotional, mental, and behavioral functioning, fluctuating level of consciousness, attention impairment, decreased or increased psychomotor activity and the disturbance of sleep-wake cycle. Emotional and behavioral abnormalities are common pre‐ sented with some neurological manifestations, e.g., tremor, asterixis, nystagmus, incoordi‐ nation, urinary incontinence.

Delirium is a behavioral disturbance and serious complication commonly found in consulta‐ tion-liaison psychiatry. Its prevalence and incidence rates are varied, possibly depend on se‐ verity of illness, patient population, the method of assessment and the diagnostic criteria. Prevalence of delirium ranges from 10% to 30% and its incidence is between 3% and 29% for patients admitted in general hospitals (Siddiqi et al., 2006, Maneeton et al., 2007a, Praditsu‐ wan et al., 2012). High prevalence and incidence are noted in elderly and severely ill pa‐ tients. For instance, the prevalence of delirium in elderly and ICU patients are up to 40% and 80%, respectively (Bledowski and Trutia, 2012, Praditsuwan et al., 2012).

An occurrence of delirium is associated with miserable clinical outcomes. It often increases morbidity, mortality, length of hospitalization, institutionalization, and poor functional out‐ come (Siddiqi et al., 2006, Cole et al., 2009, Fong et al., 2012). The mortality rate is higher in patients with hypoactive subtype of delirium (Yang et al., 2009).

Delirium is often under recognized by health professionals. There are many faces for the clinical presentation of delirium. It can be caused by a variety of etiology. To prevent and minimize the consequences of delirium, physician should prompt intervenes for this condi‐ tion (Attard et al., 2008).

© 2013 Maneeton and Maneeton; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This chapter aims to summarize current strategies for managing and preventing delirium caused by a variety of etiology, except substance withdrawal delirium. In addition, etiolo‐ gies, clinical manifestations and risk factors are also addressed.

**3.3. Disorientation**

riods of sleeping time.

**3.5. Psychomotor disturbance**

**3.6. Perceptual disturbance**

tinence.

**3.7. Dysfunction of higher cortical function**

**4. Predisposing and risk factors**

**3.4. Sleep-wake cycle abnormality**

Most patients are disoriented to time, place and/or person.

Sleep-wake disturbance is usually noted in delirium. The patients may be sleepy during the day and stay awake at night. The sleep pattern is characterized by brief and fragmented pe‐

Management of Delirium http://dx.doi.org/10.5772/52756 87

Arousal disturbance is common and usually related to the abnormality of reticular activat‐ ing system. Currently, psychomotor behavior of delirium is categorized into four subtypes, including normal, hypoactive, hyperactive, and mixed (Yang et al., 2009). Hyperactive delir‐ ium is characterized by agitation, restlessness and hypervigilance. Lethargy, somnolence, apathy, depression, catatonia and quiet confusion are common for hypoactive delirium. For

Because most delirious patients cannot discriminate and integrate the sensory stimuli around them, illusions and hallucinations are common in this population. The patients are

Although the DSM IV-TR does not include language difficulties, most patients have speech abnormality, such as rambling, irrelevancy and incoherent. Impairment of memory, espe‐ cially the short-termone, can be found in most patients. The impaired short-term memory may be explained by the loss of concentration, perceptual disturbance, and/or malfunction of the hippocampus. Since delirium is a global cerebral dysfunction, higher cortical dysfunc‐ tion such as dysphasia, dyspraxia, dysgraphia, is also common. In addition, the patients may have other neurological signs, e.g., tremor, asterixis, incoordination and urinary incon‐

Individuals are differently susceptible to delirium. Despite the exposing to the same causa‐ tive factor, individuals are not equally prone to develop delirium. Predisposing and risk fac‐ tors appear to play a role in the susceptibility to delirium. There have been numerous studies on predisposing and risk factors of delirium. For instance, Inouye and Charpentier (1996) demonstrated the five independent precipitating factors for delirium, including use of physical restraints, malnutrition, more than three medications taken, use of bladder catheter

the mixed subtype, it manifests both psychomotor hypoactivity and hyperactivity.

easily frustrated or distracted when they encounter new information.

### **2. Definition**

According to the *Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revi‐ sion* (DSM-IV-TR), delirium due to a general medical condition is defined by four criteria: a. disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with re‐ duced ability to focus, sustain, or shift attention; b. a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturb‐ ance that is not better accounted for by a preexisting, established, or evolving dementia; c. the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day; d. there is evidence from the history, physical exami‐ nation, or laboratory findings that the disturbance is caused by the direct physiological con‐ sequences of a general medical condition(American Psychiatric Association, 2005).

For the ICD-10, delirium not induced by alcohol and other psychoactive substances is de‐ fined as an etiologically nonspecific organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behavior, emotion, and the sleep-wake schedule. The duration is variable, and the degree of severity ranges from mild to very severe (World Health Organization, 1993).

### **3. Clinical manifestation**

The hallmark of delirium is rapid and fluctuated disturbance of consciousness, orientation and global cognitive functioning.

### **3.1. Prodromal phase**

Prodromal symptoms may be observed for hours to a few days in some patients. These symptoms include restlessness, anxiety, irritability, hypervigilance, drowsiness, transient hallucination, nightmare and etc. Because these symptoms are not specific for delirium, they may be overlooked by health care providers.

#### **3.2. Fluctuating course**

Most patients have rapidly changes of emotion and cognition. The diurnal fluctuation is common. Because the patient's condition is usually worse at night time, this clinical feature may be called "sundowner's syndrome". During thi speriod of time, delusion, hallucination, depression, irritability and anxiety are frequently prominent.

### **3.3. Disorientation**

This chapter aims to summarize current strategies for managing and preventing delirium caused by a variety of etiology, except substance withdrawal delirium. In addition, etiolo‐

According to the *Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revi‐ sion* (DSM-IV-TR), delirium due to a general medical condition is defined by four criteria: a. disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with re‐ duced ability to focus, sustain, or shift attention; b. a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturb‐ ance that is not better accounted for by a preexisting, established, or evolving dementia; c. the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day; d. there is evidence from the history, physical exami‐ nation, or laboratory findings that the disturbance is caused by the direct physiological con‐

sequences of a general medical condition(American Psychiatric Association, 2005).

severity ranges from mild to very severe (World Health Organization, 1993).

For the ICD-10, delirium not induced by alcohol and other psychoactive substances is de‐ fined as an etiologically nonspecific organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behavior, emotion, and the sleep-wake schedule. The duration is variable, and the degree of

The hallmark of delirium is rapid and fluctuated disturbance of consciousness, orientation

Prodromal symptoms may be observed for hours to a few days in some patients. These symptoms include restlessness, anxiety, irritability, hypervigilance, drowsiness, transient hallucination, nightmare and etc. Because these symptoms are not specific for delirium, they

Most patients have rapidly changes of emotion and cognition. The diurnal fluctuation is common. Because the patient's condition is usually worse at night time, this clinical feature may be called "sundowner's syndrome". During thi speriod of time, delusion, hallucination,

gies, clinical manifestations and risk factors are also addressed.

86 Mental Disorders - Theoretical and Empirical Perspectives

**2. Definition**

**3. Clinical manifestation**

and global cognitive functioning.

may be overlooked by health care providers.

depression, irritability and anxiety are frequently prominent.

**3.1. Prodromal phase**

**3.2. Fluctuating course**

Most patients are disoriented to time, place and/or person.

### **3.4. Sleep-wake cycle abnormality**

Sleep-wake disturbance is usually noted in delirium. The patients may be sleepy during the day and stay awake at night. The sleep pattern is characterized by brief and fragmented pe‐ riods of sleeping time.

### **3.5. Psychomotor disturbance**

Arousal disturbance is common and usually related to the abnormality of reticular activat‐ ing system. Currently, psychomotor behavior of delirium is categorized into four subtypes, including normal, hypoactive, hyperactive, and mixed (Yang et al., 2009). Hyperactive delir‐ ium is characterized by agitation, restlessness and hypervigilance. Lethargy, somnolence, apathy, depression, catatonia and quiet confusion are common for hypoactive delirium. For the mixed subtype, it manifests both psychomotor hypoactivity and hyperactivity.

### **3.6. Perceptual disturbance**

Because most delirious patients cannot discriminate and integrate the sensory stimuli around them, illusions and hallucinations are common in this population. The patients are easily frustrated or distracted when they encounter new information.

### **3.7. Dysfunction of higher cortical function**

Although the DSM IV-TR does not include language difficulties, most patients have speech abnormality, such as rambling, irrelevancy and incoherent. Impairment of memory, espe‐ cially the short-termone, can be found in most patients. The impaired short-term memory may be explained by the loss of concentration, perceptual disturbance, and/or malfunction of the hippocampus. Since delirium is a global cerebral dysfunction, higher cortical dysfunc‐ tion such as dysphasia, dyspraxia, dysgraphia, is also common. In addition, the patients may have other neurological signs, e.g., tremor, asterixis, incoordination and urinary incon‐ tinence.

### **4. Predisposing and risk factors**

Individuals are differently susceptible to delirium. Despite the exposing to the same causa‐ tive factor, individuals are not equally prone to develop delirium. Predisposing and risk fac‐ tors appear to play a role in the susceptibility to delirium. There have been numerous studies on predisposing and risk factors of delirium. For instance, Inouye and Charpentier (1996) demonstrated the five independent precipitating factors for delirium, including use of physical restraints, malnutrition, more than three medications taken, use of bladder catheter and any iatrogenic event. Recently, risk factors for delirium have been established in four domains, including patient characteristics, chronic pathology, acute illness, and environ‐ mental factors (Van Rompaey et al., 2009). Another study in elderly patients receiving hip surgery found that early symptoms of memory impairments, incoherence, disorientation and underlying somatic illness were predictors of delirium (de Jonghe et al., 2007).

**5.4. Metabolic disorders**

**5.5. Vitamin deficiency**

**5.6. Endocrine abnormalities**

**5.7. Withdrawal syndrome**

**5.8. Substance abuse**

**5.9. Toxin exposure**

**6. Pathophysiology**

2011).

et al., 2011).

Metabolic disturbances are frequently associated with delirium (Khurana et al., 2011, Grover et al., 2012). Common metabolic abnormalities consist of hepatic encephalopathy, hypo- or hyperglycemia, hypoxia, hypo- or hypernatremia, hypo- orhypercalcemia, hypo- orhyper‐ magnesemia, acidosis, uremia and metabolic acidosis (Aldemir et al., 2001, Khurana et al.,

Management of Delirium http://dx.doi.org/10.5772/52756 89

Vitamin deficiency, such as thiamine, B12, nicotinic acid, folic acid, is a common factor con‐ tributing to the development of delirium (Kane et al., 1993, O'Keeffe et al., 1994, Harrington

Several lines of evidence suggest that endocrine disturbances may be a cause of delirium (Olsson, 1999, Grover et al., 2012). Common abnormalities include hypo- or hyperthyroid‐ ism, hypo- or hyperparathyroidism, Cushing's syndrome, Addison's disease, pheochromo‐

The withdrawal of some drugs or substances could precipitate the phenomena of delirium. Those possible causative agents are alcohol, benzodiazepines, barbiturates, other sedatives

Numerous substances, for instance methamphetamine, cocaine, hallucinogens, inhalants, opioids and bath salts may be a cause of delirium (Nakatani and Hara, 1998, Maldonado,

Toxin exposure is also a significant contributor in the development of delirium. Example

Since there have been only a few studies on the mechanism of delirium, its pathophysiology are still poorly understood. However, some recent findings suggest several mechanisms possibly related to the development of delirium, including abnormality in neurotransmit‐ ters, inflammatory response, the blood-brain barrier permeability, cerebral oxidative metab‐ olism and the hypothalamic-pituitary adrenal axis (Flacker and Lipsitz, 1999, van der Mast,

and hypnotics (Saitz, 1998, Trevisan et al., 1998, Maldonado, 2008a, Yu et al., 2012).

2008a, Fadel and Serra, 2009, Kasick et al., 2012 Burapakajornpong et al., 2012).

toxic agents are heavy metals and toxins (Maldonado, 2008a).

cytoma and hypopituitary diseases (Olsson, 1999, Maldonado, 2008a).

In general, the common predisposing and risk factors for delirium that have been recog‐ nized are age of 60 years or over, brain damage (e.g., stroke, brain injury), chronic organic brain syndrome (e.g., dementia of Alzheimer type), postoperative patients, history of deliri‐ um, diabetes, malignancy, sensory impairment (e.g., blindness, deafness) and HIV infection.

### **5. Etiology**

Common causes of delirium include central nervous system (CNS) diseases, systemic dis‐ eases, intoxication or withdrawal from substance and toxic agent. Most delirious patients of‐ ten encounter with multiple causes.

### **5.1. Medications**

The use of medication is one of the most common causes of delirium. Medications that have been identified are antibiotics, antidepressants, antihistamines, anticholinergic agents, anti‐ parkinson agents, antipsychotic medications, antineoplastics, anticonvulsants, antitubercu‐ losis agents, cardiac drugs, diuretics, non-steroidal anti-inflammatory drugs, L-dopa, lithium, opiates, sedative-hypnotics, steroids, sympathomimetic agents. It has been found that the administration of three medications or more is a risk factor for delirium. Because elderly patients tend to take multiple medications, they are a population at particular risk for delirium (Inouye, 2004, Clegg and Young, 2011, Catic, 2011).

#### **5.2. Neurological causes**

Delirium is a state of global cerebral dysfunction. Therefore, any pathology in the CNS may cause this syndrome. Common neurological contributors for delirium consist of head injury, stroke, hypertensive encephalopathy, intracranial neoplasm and epilepsy (Ramirez-Bermu‐ dez et al., 2006, Martin, 2012).

### **5.3. Infection**

Infection, in particular sepsis, can be a cause of delirium (Rahkonen et al., 2000, Srinonpra‐ sert et al., 2011, Zampieri et al., 2011). Other infectious diseases commonly found, including CNS infection (Ramirez-Bermudez et al., 2006); meningitis, encephalitis, brain abscess, neu‐ rosyphilis, HIV encephalopathy and other systemic infection (Warshaw and Tanzer, 1993, Eriksson et al., 2011, van Gool et al., 2010).

### **5.4. Metabolic disorders**

and any iatrogenic event. Recently, risk factors for delirium have been established in four domains, including patient characteristics, chronic pathology, acute illness, and environ‐ mental factors (Van Rompaey et al., 2009). Another study in elderly patients receiving hip surgery found that early symptoms of memory impairments, incoherence, disorientation

In general, the common predisposing and risk factors for delirium that have been recog‐ nized are age of 60 years or over, brain damage (e.g., stroke, brain injury), chronic organic brain syndrome (e.g., dementia of Alzheimer type), postoperative patients, history of deliri‐ um, diabetes, malignancy, sensory impairment (e.g., blindness, deafness) and HIV infection.

Common causes of delirium include central nervous system (CNS) diseases, systemic dis‐ eases, intoxication or withdrawal from substance and toxic agent. Most delirious patients of‐

The use of medication is one of the most common causes of delirium. Medications that have been identified are antibiotics, antidepressants, antihistamines, anticholinergic agents, anti‐ parkinson agents, antipsychotic medications, antineoplastics, anticonvulsants, antitubercu‐ losis agents, cardiac drugs, diuretics, non-steroidal anti-inflammatory drugs, L-dopa, lithium, opiates, sedative-hypnotics, steroids, sympathomimetic agents. It has been found that the administration of three medications or more is a risk factor for delirium. Because elderly patients tend to take multiple medications, they are a population at particular risk

Delirium is a state of global cerebral dysfunction. Therefore, any pathology in the CNS may cause this syndrome. Common neurological contributors for delirium consist of head injury, stroke, hypertensive encephalopathy, intracranial neoplasm and epilepsy (Ramirez-Bermu‐

Infection, in particular sepsis, can be a cause of delirium (Rahkonen et al., 2000, Srinonpra‐ sert et al., 2011, Zampieri et al., 2011). Other infectious diseases commonly found, including CNS infection (Ramirez-Bermudez et al., 2006); meningitis, encephalitis, brain abscess, neu‐ rosyphilis, HIV encephalopathy and other systemic infection (Warshaw and Tanzer, 1993,

for delirium (Inouye, 2004, Clegg and Young, 2011, Catic, 2011).

and underlying somatic illness were predictors of delirium (de Jonghe et al., 2007).

**5. Etiology**

**5.1. Medications**

**5.2. Neurological causes**

dez et al., 2006, Martin, 2012).

Eriksson et al., 2011, van Gool et al., 2010).

**5.3. Infection**

ten encounter with multiple causes.

88 Mental Disorders - Theoretical and Empirical Perspectives

Metabolic disturbances are frequently associated with delirium (Khurana et al., 2011, Grover et al., 2012). Common metabolic abnormalities consist of hepatic encephalopathy, hypo- or hyperglycemia, hypoxia, hypo- or hypernatremia, hypo- orhypercalcemia, hypo- orhyper‐ magnesemia, acidosis, uremia and metabolic acidosis (Aldemir et al., 2001, Khurana et al., 2011).

### **5.5. Vitamin deficiency**

Vitamin deficiency, such as thiamine, B12, nicotinic acid, folic acid, is a common factor con‐ tributing to the development of delirium (Kane et al., 1993, O'Keeffe et al., 1994, Harrington et al., 2011).

### **5.6. Endocrine abnormalities**

Several lines of evidence suggest that endocrine disturbances may be a cause of delirium (Olsson, 1999, Grover et al., 2012). Common abnormalities include hypo- or hyperthyroid‐ ism, hypo- or hyperparathyroidism, Cushing's syndrome, Addison's disease, pheochromo‐ cytoma and hypopituitary diseases (Olsson, 1999, Maldonado, 2008a).

#### **5.7. Withdrawal syndrome**

The withdrawal of some drugs or substances could precipitate the phenomena of delirium. Those possible causative agents are alcohol, benzodiazepines, barbiturates, other sedatives and hypnotics (Saitz, 1998, Trevisan et al., 1998, Maldonado, 2008a, Yu et al., 2012).

### **5.8. Substance abuse**

Numerous substances, for instance methamphetamine, cocaine, hallucinogens, inhalants, opioids and bath salts may be a cause of delirium (Nakatani and Hara, 1998, Maldonado, 2008a, Fadel and Serra, 2009, Kasick et al., 2012 Burapakajornpong et al., 2012).

#### **5.9. Toxin exposure**

Toxin exposure is also a significant contributor in the development of delirium. Example toxic agents are heavy metals and toxins (Maldonado, 2008a).

### **6. Pathophysiology**

Since there have been only a few studies on the mechanism of delirium, its pathophysiology are still poorly understood. However, some recent findings suggest several mechanisms possibly related to the development of delirium, including abnormality in neurotransmit‐ ters, inflammatory response, the blood-brain barrier permeability, cerebral oxidative metab‐ olism and the hypothalamic-pituitary adrenal axis (Flacker and Lipsitz, 1999, van der Mast, 1998, Gunther et al., 2008, Marcantonio et al., 2006). However, the heterogeneity of the delir‐ ium syndrome and the populations are the major challenges. The mechanism may differ in the various clinical settings and individual risk factors (Chaput and Bryson, 2012).

et al., 2001). In addition, the elevation of cerebrospinal fluid (CSF) and plasma cortisol levels observed in hip fracture patients with delirium also support the hypothesis that high brain

Management of Delirium http://dx.doi.org/10.5772/52756 91

Once delirium is diagnosed, prompt and appropriated interventions should be implement‐ ed. Other than the DSM IV-TR criteria for delirium, several measures are helpful to confirm the diagnosis and determine the progress of illness course. Since common causes of delirium are medical/surgical conditions and medications, priority should be given to specific treat‐ ment for the removal of these causes. Frequently, delirium is associated with multi-factorial etiology, all possible causes, therefore, should be investigated and corrected. Because behav‐ ioral and other psychiatric disturbances are also common, psychopharmacological and psy‐ chosocial interventions are also needed in most patients. Those include the control of behavioral disturbances, preventing complications (e.g., accident, falling) and supporting

Physicians should review all possible contributed factors for the development of delirium, including histories of medical/psychiatric illness, prescribed or over-the-counter medica‐ tions and substance uses. Physical examination should address in all systems, especially the one possibly causing or contributing to the development of delirium. Mental status exami‐ nation should focus on cognitive function, such as orientation, memory, concentration, at‐

The use of screening tests or tools prior to the occurrence of delirium or in patients suspect‐ ed of having delirium is very helpful for the early detection of delirium. In addition, some measures can be used to determine the progress of delirium. Bedside cognitive screening tests, such as the three-item registration, the three-item delayed recall test, the clock drawing test, the problem-solving task and the ability of abstraction, can determine the cognitive im‐ pairment (de Wet et al., 2007). Example measures of delirium are the Mini-Mental State Ex‐ amination (MMSE), the original and revised versions of Delirium Rating Scale (DRS and DRS-98), the Memorial Delirium Assessment Scale (MDAS) and the Confusion Assessment Method (CAM) recommended (Breitbart et al., 1997, Trzepacz et al., 2001, Salawu et al.,

To identify the causes of delirium, laboratory studies are essential. Generally, basic investi‐ gation for delirium includes a routine blood test, including complete blood count, electro‐ lytes, glucose levels, liver function test, thyroid function test, renal function test, blood alcohol, blood ammonia, calcium/magnesium/phosphate levels, pulse oximetry, urinalysis, urine drug screen, electrocardiogram (ECG), CSF study, radiological studies (e.g., chest xray and computed tomography (CT) the head) (Salawu et al., 2009, Lorenzl et al., 2012). However, further studies to verify infection, hypoxia and etc are also important for some pa‐

tention, language ability, mood/affect and psychotic symptoms.

2009, Wongpakaran et al., 2011, Inouye et al., 1990).

cortisol levels are related to delirium development (Pearson et al., 2011).

**7. Management**

**7.1. Assessment**

functional needs (Burns et al., 2004).

### **6.1. Neurotransmitter abnormalities**

According to the neurotransmitter hypothesis, delirium is a result of complex interacting neurotransmitter systems that modulate the control of cognition, behavior, and emotion and pathologic processes. The decreased oxidative metabolism of the brain causes cerebral dys‐ function due to abnormalities of many neurotransmitter systems. Various symptoms and clinical manifestations of delirium may be associated with numerous neurotransmitter activ‐ ities (van der Mast, 1998). More specifically, the pathogenesis of delirium may include the decreased cholinergic activity; both decreased and increased serotonergic and gamma-ami‐ nobutyric acid activities and excessive release of dopamine, norepinephrine and/or gluta‐ mate (Flacker and Lipsitz, 1999).

### **6.2. Reduction of cerebral oxidative metabolism**

Impaired oxidative metabolism is related to the development of delirium (Seaman et al., 2006). Its dysfunction is often associated with a decrease of oxygen supply to the brain, which leads to the widespread of cerebral dysfunction. Therefore, patients with oxygen ex‐ change dysfunction, such as cardiac diseases, intraoperative hypotension, perioperative fac‐ tors, intrinsic lung diseases and anemia may be important causes of delirium (Maldonado, 2008b, Ali et al., 2011).

#### **6.3. Inflammatory response**

Delirium is high prevalence in patients with systemic inflammatory diseases, including in‐ fection, malignancy, and the postoperative state (Marcantonio et al., 2006). Recent findings suggest the association between cytokines and the development of delirium. Cytokine dys‐ regulation can cause neuronal injury by means of (1) abnormal neurotransmission, (2) apop‐ tosis and (3) activation of microglia and astrocytes producing free radicals, complement factors, glutamate, and nitric oxide (Wilson et al., 2002, Simone and Tan, 2011).The cytokines considered as proinflammatory factors (e.g., interleukin-1, interleukin-6 and interleukin-8, tumor necrosis factor-alpha, interferon gamma and C-reactive protein) and anti-inflammato‐ ry factors (e.g., interleukin receptor antagonist and insulin-like growth factor -1) have been hypothesized as factors related to the pathogenesis of delirium (Gunther et al., 2008, van den Boogaard et al., 2011).

#### **6.4. Increased activity of the hypothalamic-pituitary adrenal axis**

The disturbance of hypothalamic-pituitary-adrenal (HPA) axis is another hypothesis rele‐ vant to the pathogenesis of delirium. It has been known that excessive cortisol or glucocorti‐ coid affect memory and mood in delirium (Maldonado, 2008b). The association between delirium and disturbance of dexamethasone suppression (DST) has been noted (Robertsson et al., 2001). In addition, the elevation of cerebrospinal fluid (CSF) and plasma cortisol levels observed in hip fracture patients with delirium also support the hypothesis that high brain cortisol levels are related to delirium development (Pearson et al., 2011).

### **7. Management**

1998, Gunther et al., 2008, Marcantonio et al., 2006). However, the heterogeneity of the delir‐ ium syndrome and the populations are the major challenges. The mechanism may differ in

According to the neurotransmitter hypothesis, delirium is a result of complex interacting neurotransmitter systems that modulate the control of cognition, behavior, and emotion and pathologic processes. The decreased oxidative metabolism of the brain causes cerebral dys‐ function due to abnormalities of many neurotransmitter systems. Various symptoms and clinical manifestations of delirium may be associated with numerous neurotransmitter activ‐ ities (van der Mast, 1998). More specifically, the pathogenesis of delirium may include the decreased cholinergic activity; both decreased and increased serotonergic and gamma-ami‐ nobutyric acid activities and excessive release of dopamine, norepinephrine and/or gluta‐

Impaired oxidative metabolism is related to the development of delirium (Seaman et al., 2006). Its dysfunction is often associated with a decrease of oxygen supply to the brain, which leads to the widespread of cerebral dysfunction. Therefore, patients with oxygen ex‐ change dysfunction, such as cardiac diseases, intraoperative hypotension, perioperative fac‐ tors, intrinsic lung diseases and anemia may be important causes of delirium (Maldonado,

Delirium is high prevalence in patients with systemic inflammatory diseases, including in‐ fection, malignancy, and the postoperative state (Marcantonio et al., 2006). Recent findings suggest the association between cytokines and the development of delirium. Cytokine dys‐ regulation can cause neuronal injury by means of (1) abnormal neurotransmission, (2) apop‐ tosis and (3) activation of microglia and astrocytes producing free radicals, complement factors, glutamate, and nitric oxide (Wilson et al., 2002, Simone and Tan, 2011).The cytokines considered as proinflammatory factors (e.g., interleukin-1, interleukin-6 and interleukin-8, tumor necrosis factor-alpha, interferon gamma and C-reactive protein) and anti-inflammato‐ ry factors (e.g., interleukin receptor antagonist and insulin-like growth factor -1) have been hypothesized as factors related to the pathogenesis of delirium (Gunther et al., 2008, van

The disturbance of hypothalamic-pituitary-adrenal (HPA) axis is another hypothesis rele‐ vant to the pathogenesis of delirium. It has been known that excessive cortisol or glucocorti‐ coid affect memory and mood in delirium (Maldonado, 2008b). The association between delirium and disturbance of dexamethasone suppression (DST) has been noted (Robertsson

**6.4. Increased activity of the hypothalamic-pituitary adrenal axis**

the various clinical settings and individual risk factors (Chaput and Bryson, 2012).

**6.1. Neurotransmitter abnormalities**

90 Mental Disorders - Theoretical and Empirical Perspectives

mate (Flacker and Lipsitz, 1999).

2008b, Ali et al., 2011).

**6.3. Inflammatory response**

den Boogaard et al., 2011).

**6.2. Reduction of cerebral oxidative metabolism**

Once delirium is diagnosed, prompt and appropriated interventions should be implement‐ ed. Other than the DSM IV-TR criteria for delirium, several measures are helpful to confirm the diagnosis and determine the progress of illness course. Since common causes of delirium are medical/surgical conditions and medications, priority should be given to specific treat‐ ment for the removal of these causes. Frequently, delirium is associated with multi-factorial etiology, all possible causes, therefore, should be investigated and corrected. Because behav‐ ioral and other psychiatric disturbances are also common, psychopharmacological and psy‐ chosocial interventions are also needed in most patients. Those include the control of behavioral disturbances, preventing complications (e.g., accident, falling) and supporting functional needs (Burns et al., 2004).

#### **7.1. Assessment**

Physicians should review all possible contributed factors for the development of delirium, including histories of medical/psychiatric illness, prescribed or over-the-counter medica‐ tions and substance uses. Physical examination should address in all systems, especially the one possibly causing or contributing to the development of delirium. Mental status exami‐ nation should focus on cognitive function, such as orientation, memory, concentration, at‐ tention, language ability, mood/affect and psychotic symptoms.

The use of screening tests or tools prior to the occurrence of delirium or in patients suspect‐ ed of having delirium is very helpful for the early detection of delirium. In addition, some measures can be used to determine the progress of delirium. Bedside cognitive screening tests, such as the three-item registration, the three-item delayed recall test, the clock drawing test, the problem-solving task and the ability of abstraction, can determine the cognitive im‐ pairment (de Wet et al., 2007). Example measures of delirium are the Mini-Mental State Ex‐ amination (MMSE), the original and revised versions of Delirium Rating Scale (DRS and DRS-98), the Memorial Delirium Assessment Scale (MDAS) and the Confusion Assessment Method (CAM) recommended (Breitbart et al., 1997, Trzepacz et al., 2001, Salawu et al., 2009, Wongpakaran et al., 2011, Inouye et al., 1990).

To identify the causes of delirium, laboratory studies are essential. Generally, basic investi‐ gation for delirium includes a routine blood test, including complete blood count, electro‐ lytes, glucose levels, liver function test, thyroid function test, renal function test, blood alcohol, blood ammonia, calcium/magnesium/phosphate levels, pulse oximetry, urinalysis, urine drug screen, electrocardiogram (ECG), CSF study, radiological studies (e.g., chest xray and computed tomography (CT) the head) (Salawu et al., 2009, Lorenzl et al., 2012). However, further studies to verify infection, hypoxia and etc are also important for some pa‐

tients. In equivocal case, electroencephalography (EEG) can be helpful. While the EEG pat‐ tern of alcohol or sedative withdrawal delirium usually presents with the prominence of beta activity, diffuse bilateral slowing records are typical for delirium due to a general medi‐ cal condition. This later pattern of the EEG is also helpful for being used as a confirm test for the delirious state (Jacobson and Jerrier, 2000, Salawu et al., 2009, Sidhu et al., 2009).

in the lorazepam group. At the study end, cognitive function of the haloperidol group was

Management of Delirium http://dx.doi.org/10.5772/52756 93

Several RCTs have been conducted in comparing the efficacy and tolerability between halo‐ peridol and atypical antipsychotic medications. An RCT compared the efficacy and safety of haloperidol and olanzapine for the treatment of delirium in the medical and surgical inten‐ sive care unit. A total of 80 delirious patients were randomized to receive either haloperidol or olanzapine, administered orally. Measured by Delirium Index, the findings indicated that haloperidol (a mean dose of 6.5 mg/day, range: 1–28 mg), was as effective as olanzapine (a mean dose of 4.54 mg/day, range: 2.5–13.5 mg) in the treatment of delirium. However, the EPS measured by Ross-Chouinard and Angus-Simpson scales was significantly more severe

There was a double-blind trial comparing haloperidol and risperidone for the treatment of delirium. A total of 28 patients with delirium were enrolled and randomly assigned to re‐ ceive either a flexible-dose regimen of haloperidol or risperidone for 7 days. The measure in efficacy is the reduction of the MDAS scores. Significant reduction of delirious symptoms was observed in both haloperidol and risperidone groups. The average resolution times, measured by the MDAS score of 13 or lower, were 4.22±2.48 days in the haloperidol group and 4.17±2.14 days in the risperidone group. At the study end, the mean daily doses of the haloperidol and the risperidone groups were 1.71±0.84 and 1.02±0.41mg, respectively. No patient reported clinically significant side effects, except one patient in the haloperidol

Grover et al. (2011) conducted an RCT to compare the efficacy and safety of haloperidol, olanzapine and risperidone in medical and surgical in patients with delirium. A total of 64 patients (20 in the haloperidol group, 21 in the risperidone group and 23 in the olanzapine group) participated in the study. The patients were randomly assigned to receive the flexible dose regimens, including 0.25 to 10 mg of haloperidol, 0.25 to 4 mg of risperidone and 1.25 to 20 mg of olanzapine. The efficacy measures were the DRS-R 98 and MMSE. The mean doses of haloperidol, olanzapine and risperidone were 0.88±0.98 mg (range: 0.25–5 mg), 3.05±1.44 mg (range: 1.25–10 mg) and 0.95±0.28 mg (range: 0.5-2 mg), respectively. Accord‐ ing to DRS-R98 and MMSE scores, haloperidol was significantly superior for the reduction of delirious symptoms on day 6. However, the efficacy of all three regimens was not signifi‐ cantly different from other days. Four patients in a haloperidol group had some side effects. Maneeton and colleagues conducted an RCT comparing the efficacy and tolerability be‐ tween quetiapine and haloperidol in delirious inpatients. All participants, aged 18-75 years, were delirious patients who were consulted to a psychiatric department. The diagnoses of all patients with DSM-IV delirium were confirmed by using the CAM. The primary efficacy outcome was the DRS-R-98. The other efficacy measures were the Clinical Global Impres‐ sion (CGI) and hours of night sleep. The EPS was assessed by using the Modified (9-item) Simpson-Angus Scale (MSAS). All measures were applied daily. Thirty-eight patients were randomly to receive either a flexible dose regimen of quetiapine and haloperidol. Mean (SD) doses of the quetiapine and haloperidol groups were 34.0±12.8 and 0.9±0.5 mg/day, respec‐ tively. Based on the DRS-R-98 and CGI scores, both haloperidol and quetiapine significantly

significantly improved. No patient developed extrapyramidal symptoms.

in the haloperidol group (Skrobik et al., 2004).

group experienced mild akathisia (Han and Kim, 2004).

#### **7.2. Specific and supportive treatment**

The specific treatment for delirium is the removal of all possible causes. Therefore, the pre‐ cipitating factors must be promptly addressed and corrected (Burns et al., 2004). However, the etiology may not be identifiable when the patient is diagnosed, sometimes cannot be identified until the patient is recovery, and, for rare cases, cannot be identified at all. Conse‐ quently, the initially supportive and symptomatic treatments are, therefore, essential in all patients with delirium.

#### **7.3. Psychopharmacological treatment**

### *7.3.1. Antipsychotics*

#### *7.3.1.1. Typical antipsychotics*

To our knowledge, only two RCTs of typical antipsychotics, including haloperidol and chlorpromazine, have been carried out.

### *7.3.1.1.1. Haloperidol*

Haloperidol, a dopamine antagonist, has been used in various neuropsychiatric conditions. It is considered as a first-line medication for the symptom control of delirium (American Psychiatric Association, 1999). The advantages of this medication are that it can be adminis‐ tered through several routes. In addition, it has fewer active metabolites, less anticholinergic effect and fewer sedative or hypotensive effects compared with other antipsychotics (Attard et al., 2008).

Breitbart et al. (1996) conducted an RCT to compare the efficacy and safety among haloperi‐ dol, chlorpromazine and lorazepam in adult AIDS patients with delirium. Thirty patients met the DSM-III-R criteria for delirium and scored 13 or more on the DRS. The measures used included the DRS, the Mini-Mental State and the extrapyramidal symptoms (EPS). The sample size was relatively small (n's for haloperidol = 11,chlorpromazine = 13 and loraze‐ pam = 6). Based on the DRS scores, haloperidol (2.8±2.4 mg)and chlorpromazine (50±23.1 mg) were significantly superior to lorazepam for controlling the symptoms of delirium in the first 24 hours, usually before the underlying medical causes of delirium could be identi‐ fied. The improvement of delirious symptoms was continued until the study end. The doses of haloperidol from day 2 to the study end were decreased for an average of 1.4±1.2 mg/day. While cognitive improvement, as measured by the Mini-Mental State, was observed as soon as day 2 of haloperidol or chlorpromazine treatment, no cognitive improvement was found in the lorazepam group. At the study end, cognitive function of the haloperidol group was significantly improved. No patient developed extrapyramidal symptoms.

tients. In equivocal case, electroencephalography (EEG) can be helpful. While the EEG pat‐ tern of alcohol or sedative withdrawal delirium usually presents with the prominence of beta activity, diffuse bilateral slowing records are typical for delirium due to a general medi‐ cal condition. This later pattern of the EEG is also helpful for being used as a confirm test for

The specific treatment for delirium is the removal of all possible causes. Therefore, the pre‐ cipitating factors must be promptly addressed and corrected (Burns et al., 2004). However, the etiology may not be identifiable when the patient is diagnosed, sometimes cannot be identified until the patient is recovery, and, for rare cases, cannot be identified at all. Conse‐ quently, the initially supportive and symptomatic treatments are, therefore, essential in all

To our knowledge, only two RCTs of typical antipsychotics, including haloperidol and

Haloperidol, a dopamine antagonist, has been used in various neuropsychiatric conditions. It is considered as a first-line medication for the symptom control of delirium (American Psychiatric Association, 1999). The advantages of this medication are that it can be adminis‐ tered through several routes. In addition, it has fewer active metabolites, less anticholinergic effect and fewer sedative or hypotensive effects compared with other antipsychotics (Attard

Breitbart et al. (1996) conducted an RCT to compare the efficacy and safety among haloperi‐ dol, chlorpromazine and lorazepam in adult AIDS patients with delirium. Thirty patients met the DSM-III-R criteria for delirium and scored 13 or more on the DRS. The measures used included the DRS, the Mini-Mental State and the extrapyramidal symptoms (EPS). The sample size was relatively small (n's for haloperidol = 11,chlorpromazine = 13 and loraze‐ pam = 6). Based on the DRS scores, haloperidol (2.8±2.4 mg)and chlorpromazine (50±23.1 mg) were significantly superior to lorazepam for controlling the symptoms of delirium in the first 24 hours, usually before the underlying medical causes of delirium could be identi‐ fied. The improvement of delirious symptoms was continued until the study end. The doses of haloperidol from day 2 to the study end were decreased for an average of 1.4±1.2 mg/day. While cognitive improvement, as measured by the Mini-Mental State, was observed as soon as day 2 of haloperidol or chlorpromazine treatment, no cognitive improvement was found

the delirious state (Jacobson and Jerrier, 2000, Salawu et al., 2009, Sidhu et al., 2009).

**7.2. Specific and supportive treatment**

92 Mental Disorders - Theoretical and Empirical Perspectives

**7.3. Psychopharmacological treatment**

chlorpromazine, have been carried out.

patients with delirium.

*7.3.1. Antipsychotics*

*7.3.1.1.1. Haloperidol*

et al., 2008).

*7.3.1.1. Typical antipsychotics*

Several RCTs have been conducted in comparing the efficacy and tolerability between halo‐ peridol and atypical antipsychotic medications. An RCT compared the efficacy and safety of haloperidol and olanzapine for the treatment of delirium in the medical and surgical inten‐ sive care unit. A total of 80 delirious patients were randomized to receive either haloperidol or olanzapine, administered orally. Measured by Delirium Index, the findings indicated that haloperidol (a mean dose of 6.5 mg/day, range: 1–28 mg), was as effective as olanzapine (a mean dose of 4.54 mg/day, range: 2.5–13.5 mg) in the treatment of delirium. However, the EPS measured by Ross-Chouinard and Angus-Simpson scales was significantly more severe in the haloperidol group (Skrobik et al., 2004).

There was a double-blind trial comparing haloperidol and risperidone for the treatment of delirium. A total of 28 patients with delirium were enrolled and randomly assigned to re‐ ceive either a flexible-dose regimen of haloperidol or risperidone for 7 days. The measure in efficacy is the reduction of the MDAS scores. Significant reduction of delirious symptoms was observed in both haloperidol and risperidone groups. The average resolution times, measured by the MDAS score of 13 or lower, were 4.22±2.48 days in the haloperidol group and 4.17±2.14 days in the risperidone group. At the study end, the mean daily doses of the haloperidol and the risperidone groups were 1.71±0.84 and 1.02±0.41mg, respectively. No patient reported clinically significant side effects, except one patient in the haloperidol group experienced mild akathisia (Han and Kim, 2004).

Grover et al. (2011) conducted an RCT to compare the efficacy and safety of haloperidol, olanzapine and risperidone in medical and surgical in patients with delirium. A total of 64 patients (20 in the haloperidol group, 21 in the risperidone group and 23 in the olanzapine group) participated in the study. The patients were randomly assigned to receive the flexible dose regimens, including 0.25 to 10 mg of haloperidol, 0.25 to 4 mg of risperidone and 1.25 to 20 mg of olanzapine. The efficacy measures were the DRS-R 98 and MMSE. The mean doses of haloperidol, olanzapine and risperidone were 0.88±0.98 mg (range: 0.25–5 mg), 3.05±1.44 mg (range: 1.25–10 mg) and 0.95±0.28 mg (range: 0.5-2 mg), respectively. Accord‐ ing to DRS-R98 and MMSE scores, haloperidol was significantly superior for the reduction of delirious symptoms on day 6. However, the efficacy of all three regimens was not signifi‐ cantly different from other days. Four patients in a haloperidol group had some side effects.

Maneeton and colleagues conducted an RCT comparing the efficacy and tolerability be‐ tween quetiapine and haloperidol in delirious inpatients. All participants, aged 18-75 years, were delirious patients who were consulted to a psychiatric department. The diagnoses of all patients with DSM-IV delirium were confirmed by using the CAM. The primary efficacy outcome was the DRS-R-98. The other efficacy measures were the Clinical Global Impres‐ sion (CGI) and hours of night sleep. The EPS was assessed by using the Modified (9-item) Simpson-Angus Scale (MSAS). All measures were applied daily. Thirty-eight patients were randomly to receive either a flexible dose regimen of quetiapine and haloperidol. Mean (SD) doses of the quetiapine and haloperidol groups were 34.0±12.8 and 0.9±0.5 mg/day, respec‐ tively. Based on the DRS-R-98 and CGI scores, both haloperidol and quetiapine significantly reduced the symptoms of delirium from baseline to day 7. The mean hours of night-time sleep in haloperidol and quetiapine group were 6.9±3.5 and 7.8±1.8 hours (not significantly different). In the respect of EPS, the MSAS scores were not significantly different between groups (Maneeton et al., 2011).

*7.3.1.1.2. Chlorpromazine*

cally significant extrapyramidal symptoms.

effects should be monitored.

*7.3.1.2. Atypical antipsychotics*

symptoms.

*7.3.1.2.1. Risperidone*

Chlorpromazine is the first antipsychotic drug widely used in various psychotic disorders. The only one RCT demonstrated that it is effective for controlling delirious symptoms. Breit‐ bart et al. (1996) suggested that the low doses of chlorpromazine (50±23.1 mg) may rapidly reduce the delirious symptoms in AIDS patients in the first 24 hours and continuously im‐ proved the symptoms until the study end. This efficacy was comparable to haloperidol but significantly superior to lorazepam. After the first 24 hours of treatment, the average dose of chlorpromazine from day 2 to the study end was decreased for 36±18.4 mg/day. Although the cognitive improvement could be observed in the first two days of chlorpromazine treat‐ ment, it is slightly declined from day 2 until the treatment end. This phenomenon may be caused by the high anticholinergic property of chlorpromazine. No patient developed clini‐

Management of Delirium http://dx.doi.org/10.5772/52756 95

These findings show that chlorpromazine is effective and tolerable for treating delirium. However, due to its anticholinergic effects, cognitive function and other anticholinergic side

Although typical antipsychotic medications are the mainstay for managing behavioral dis‐ turbance in delirium, its side effects, in particular EPS and anticholinergic effects are an is‐ sue of concern. The use of atypical antipsychotic medications with less propensity to induce EPS or cause anticholinergic effects is, therefore, an alternative. Several studies have demon‐ strated the efficacy and tolerability of atypical antipsychotic agents for controlling delirious

Risperidone is probable the first atypical antipsychotic agent used for controlling delirious symptoms. An RCT comparing risperidone with haloperidol demonstrated that risperidone is as effective as haloperidol in reducing delirious symptoms. No patient receiving risperi‐

In a 7-day, RCT comparing the efficacy of risperidone and olanzapine in the treatment of delirium. The outcomes included the DRS-R-98, reported adverse events and EPS. Patients with dementia, serious hepatic problems, or bone marrow suppression, as well as those al‐ ready taking antipsychotics for behavioral problems, were excluded. Thirty-two patients, aged 36-82 (median = 72) years, were included and randomly assigned to receive either ris‐ peridone (n = 17) or olanzapine (n = 15). Twenty-three patients had malignant cancer, and the rest had femur fracture, head trauma, or pneumonia. The mean initial doses of risperi‐ done and olanzapine were 0.6±0.2 and 1.8±0.6 mg/day, respectively. However, the mean doses of risperidone and olanzapine at the last observation were 0.9±0.6 and 2.4±1.7 mg/day, orderly. With respected to the decreased DRS-R-98 scores, risperidone as well as olanzapine were significantly superior in reducing delirious symptoms over the 7 days of study. How‐ ever, the response rates were not significantly different between groups (risperidone group:

done developed significant side effects (Han and Kim, 2004).

Intravenous (IV) haloperidol should be used only if the oral administration is unlikely acces‐ sible, or a rapid resolution is needed. Although some previous findings suggest the use of IV haloperidol in these patients, most studies have low methodological quality. Two prospec‐ tive studies with small sample sizes demonstrated the efficacy of intravenous haloperidol in disturbed behavioral control. The patients experienced a low risk of EPS (Menza et al., 1987, Moulaert, 1989). Another prospective, controlled study of EPS in delirious patients found that the combination of IV haloperidol and IV benzodiazepine reduced a risk of EPS com‐ pared with IV haloperidol mono therapy (Menza et al., 1988).

Although IV haloperidol appears to be effective for delirium, it should be used with great caution. Its incidence of QT prolongation (QTP) and torsades de pointes (TdP) has been in‐ creasing reported.

Meyer-Massetti et al. (2010) summarized 54 and 42 cases with intravenous haloperidol-relat‐ ed TdP and QTP, respectively. A cumulative dose in TdP cases ranged from 5 to 645 mg, while a that in patients with QTP alone was 2 to 1540 mg. this serious adverse event fre‐ quently occurred in the patients with concomitant risk factors. These findings suggest that a total cumulative dose of IV haloperidol less than 2 mg appears to be safely administered. At this cumulative dose range (<2 mg), ECG monitoring may not be needed for delirious pa‐ tients who have no concomitant risk factors.

The administration of IV haloperidol may not be possible in severe delirious and aggressive patients. Therefore, intramuscular injection (IM) may be an alternative route for this condi‐ tion. In addition, several settings cannot routinely monitor ECG in these cases. Based on some pharmacokinetic studies, IM haloperidol also had more rapid onset of action than that of oral administration (Schaffer et al., 1982, Froemming et al., 1989, Wang et al., 2012).

So far, there has been promising evidence that haloperidol is effective and safe for the man‐ agement of delirium. However, a few patients may experience EPS. In the respect of effica‐ cy, haloperidol is comparable to atypical antipsychotic medications (e.g., risperidone, olanzapine and quetiapine) but superior to lorazepam. Parenteral route for haloperidol is widely used for the management of acute delirium. Although the IV haloperidol may rapid‐ ly control disruptive behavior of delirious patients, it also increases the incidence of TdP and QTP. ECG monitoring may be needed for patients with concomitant risk factors or re‐ ceived a total cumulative dose of 2 mg or more for IV haloperidol. Alternatively, the admin‐ istration of IM haloperidol is effective and safe for the treatment of severe delirium. Although it has been widely used, there has been no RCT comparing haloperidol and place‐ bo in delirious patients. Further randomized, placebo-controlled trials are useful to confirm its efficacy and tolerability.

### *7.3.1.1.2. Chlorpromazine*

reduced the symptoms of delirium from baseline to day 7. The mean hours of night-time sleep in haloperidol and quetiapine group were 6.9±3.5 and 7.8±1.8 hours (not significantly different). In the respect of EPS, the MSAS scores were not significantly different between

Intravenous (IV) haloperidol should be used only if the oral administration is unlikely acces‐ sible, or a rapid resolution is needed. Although some previous findings suggest the use of IV haloperidol in these patients, most studies have low methodological quality. Two prospec‐ tive studies with small sample sizes demonstrated the efficacy of intravenous haloperidol in disturbed behavioral control. The patients experienced a low risk of EPS (Menza et al., 1987, Moulaert, 1989). Another prospective, controlled study of EPS in delirious patients found that the combination of IV haloperidol and IV benzodiazepine reduced a risk of EPS com‐

Although IV haloperidol appears to be effective for delirium, it should be used with great caution. Its incidence of QT prolongation (QTP) and torsades de pointes (TdP) has been in‐

Meyer-Massetti et al. (2010) summarized 54 and 42 cases with intravenous haloperidol-relat‐ ed TdP and QTP, respectively. A cumulative dose in TdP cases ranged from 5 to 645 mg, while a that in patients with QTP alone was 2 to 1540 mg. this serious adverse event fre‐ quently occurred in the patients with concomitant risk factors. These findings suggest that a total cumulative dose of IV haloperidol less than 2 mg appears to be safely administered. At this cumulative dose range (<2 mg), ECG monitoring may not be needed for delirious pa‐

The administration of IV haloperidol may not be possible in severe delirious and aggressive patients. Therefore, intramuscular injection (IM) may be an alternative route for this condi‐ tion. In addition, several settings cannot routinely monitor ECG in these cases. Based on some pharmacokinetic studies, IM haloperidol also had more rapid onset of action than that

So far, there has been promising evidence that haloperidol is effective and safe for the man‐ agement of delirium. However, a few patients may experience EPS. In the respect of effica‐ cy, haloperidol is comparable to atypical antipsychotic medications (e.g., risperidone, olanzapine and quetiapine) but superior to lorazepam. Parenteral route for haloperidol is widely used for the management of acute delirium. Although the IV haloperidol may rapid‐ ly control disruptive behavior of delirious patients, it also increases the incidence of TdP and QTP. ECG monitoring may be needed for patients with concomitant risk factors or re‐ ceived a total cumulative dose of 2 mg or more for IV haloperidol. Alternatively, the admin‐ istration of IM haloperidol is effective and safe for the treatment of severe delirium. Although it has been widely used, there has been no RCT comparing haloperidol and place‐ bo in delirious patients. Further randomized, placebo-controlled trials are useful to confirm

of oral administration (Schaffer et al., 1982, Froemming et al., 1989, Wang et al., 2012).

pared with IV haloperidol mono therapy (Menza et al., 1988).

tients who have no concomitant risk factors.

its efficacy and tolerability.

groups (Maneeton et al., 2011).

94 Mental Disorders - Theoretical and Empirical Perspectives

creasing reported.

Chlorpromazine is the first antipsychotic drug widely used in various psychotic disorders. The only one RCT demonstrated that it is effective for controlling delirious symptoms. Breit‐ bart et al. (1996) suggested that the low doses of chlorpromazine (50±23.1 mg) may rapidly reduce the delirious symptoms in AIDS patients in the first 24 hours and continuously im‐ proved the symptoms until the study end. This efficacy was comparable to haloperidol but significantly superior to lorazepam. After the first 24 hours of treatment, the average dose of chlorpromazine from day 2 to the study end was decreased for 36±18.4 mg/day. Although the cognitive improvement could be observed in the first two days of chlorpromazine treat‐ ment, it is slightly declined from day 2 until the treatment end. This phenomenon may be caused by the high anticholinergic property of chlorpromazine. No patient developed clini‐ cally significant extrapyramidal symptoms.

These findings show that chlorpromazine is effective and tolerable for treating delirium. However, due to its anticholinergic effects, cognitive function and other anticholinergic side effects should be monitored.

### *7.3.1.2. Atypical antipsychotics*

Although typical antipsychotic medications are the mainstay for managing behavioral dis‐ turbance in delirium, its side effects, in particular EPS and anticholinergic effects are an is‐ sue of concern. The use of atypical antipsychotic medications with less propensity to induce EPS or cause anticholinergic effects is, therefore, an alternative. Several studies have demon‐ strated the efficacy and tolerability of atypical antipsychotic agents for controlling delirious symptoms.

### *7.3.1.2.1. Risperidone*

Risperidone is probable the first atypical antipsychotic agent used for controlling delirious symptoms. An RCT comparing risperidone with haloperidol demonstrated that risperidone is as effective as haloperidol in reducing delirious symptoms. No patient receiving risperi‐ done developed significant side effects (Han and Kim, 2004).

In a 7-day, RCT comparing the efficacy of risperidone and olanzapine in the treatment of delirium. The outcomes included the DRS-R-98, reported adverse events and EPS. Patients with dementia, serious hepatic problems, or bone marrow suppression, as well as those al‐ ready taking antipsychotics for behavioral problems, were excluded. Thirty-two patients, aged 36-82 (median = 72) years, were included and randomly assigned to receive either ris‐ peridone (n = 17) or olanzapine (n = 15). Twenty-three patients had malignant cancer, and the rest had femur fracture, head trauma, or pneumonia. The mean initial doses of risperi‐ done and olanzapine were 0.6±0.2 and 1.8±0.6 mg/day, respectively. However, the mean doses of risperidone and olanzapine at the last observation were 0.9±0.6 and 2.4±1.7 mg/day, orderly. With respected to the decreased DRS-R-98 scores, risperidone as well as olanzapine were significantly superior in reducing delirious symptoms over the 7 days of study. How‐ ever, the response rates were not significantly different between groups (risperidone group: 64.7%, olanzapine group: 73.3%). The response to risperidone was poorer in the older age group. The median times to the recovery of delirium in the risperidone and olanzapine groups were 5 and 3 days, respectively. Risperidone, like olanzapine, was well tolerated. Al‐ though a few patients developed extrapyramidal symptoms, they were tolerable (Kim et al., 2010).

Lee et al. (2005) conducted an open, randomized, prospective trial to investigate the effec‐ tiveness and tolerability of quetiapine and amisulpride in delirious patients. Forty patients with delirium were randomly assigned to receive a flexible dose of amisulpride or quetia‐ pine. Outcome measures included the DRS-R-98 and CGI-Severity (CGI-S), the total sleep time and the quality of sleep. The mean doses of quetiapine and amisulpride were 113 mg/day and 156.4 mg/day, respectively. The DRS-R-98 scores of both groups decreased over time. Time to recovery for the quetiapine group was 7.4±4.1 days. The quality of sleep and the total sleep time were not significantly different between groups. Both quetiapine and

Management of Delirium http://dx.doi.org/10.5772/52756 97

After the reveal of promising benefits of quetiapine for delirium in an open-label study (Maneeton et al., 2007b), Maneeton and colleagues conducted an RCT to compare the effica‐ cy and tolerability of quetiapine and haloperidol in the management of delirium. Based on the DRS-R-98 and CGI scores, quetiapine was as effective as haloperidol in the treatment of delirium. The mean of night time sleep was 7.8±1.8 hours for the quetiapine group. Quetia‐ pine and haloperidol were well tolerated. In addition, the incidence rates of extrapyramidal

The above mentioned findings suggest that low doses of quetiapine are effective and safe in the treatment of delirium. Its efficacy is, at least, comparable to typical and other atypical antipsychotic agents. Compared with other antipsychotic agents, only quetiapine has been shown its superiority to placebo in the management of delirium. It also causes only few ad‐ verse events, including EPS and QTc prolongation, which may be comparable to placebo.

Olanzapine is, also, an atypical antipsychotic medication approved in the treatment of schiz‐ ophrenia and bipolar disorder. There have been a few RCTs of this agent in patients with delirium.The RCT carried out by Skrobik et al. (2004) compared the safety and efficacy of olanzapine and haloperidol in delirious patients admitted in a critical care unit. The results indicated that olanzapine was as effective as haloperidol in controlling delirious symptoms. Olanzapine was a safe alternative agent, especially for delirious patients contraindicated to

The study of Kim and colleagues demonstrated that olanzapine was effective for delirium. This agent also had low incidence of adverse events, especially EPS. Its efficacy is equal to

Elsayem et al. (2010) conducted a prospective, open-label study to investigate the safety, tol‐ erability and efficacy of subcutaneous (SC) olanzapine for hyperactive or mixed delirium in the cancer patients. The subjects had the MMSE scores of 24 or higher and agitation with Richmond Agitation Sedation Scale (RASS) score of 1 or more. In addition, they were those who had not responded to 10 mg or more of parenteral haloperidol over 24 hours. All sub‐ jects received olanzapine 5mg SC every eight hours for three days and continued haloperi‐ dol for controlling agitation. Twenty-four patients, aged 49 to 79, were evaluated. The

side effects were very low in both groups (Maneeton et al., 2011).

amisulpride were well tolerated.

*7.3.1.2.3. Olanzapine*

haloperidol.

the effects of risperidone (Kim et al., 2010).

Another RCT conducted by Grover et al.(2011) compared the efficacy and safety of olanza‐ pine, risperidone and haloperidol in medical and surgical inpatients with delirium. The findings indicated that risperidone, like olanzapine, was as effective as haloperidol.

Several findings support that low doses of risperidone are effective and tolerable for deliri‐ ous patients. Its efficacy is comparable to other typical and atypical antipsychotic medica‐ tions. To our knowledge, there has not been a randomized, placebo-controlled trial of risperidone in delirious patients.

### *7.3.1.2.2. Quetiapine*

Quetiapine is an atypical antipsychotic agent approved for the treatment of schizophrenia, bipolar disorder and major depressive disorder. However, its evidence in controlling deliri‐ ous symptoms has been increased. There have had several RCTs conducted to determine the efficacy and safety of quetiapine in the management of delirium.

There was a randomized, double-blind, placebo-controlled trial of quetiapine in critically ill patients with delirium. A total of 36 delirious adult patients admitted in intensive care units were enrolled. All patients had a score of 4 or more on the Care Delirium Screening Check‐ list, were tolerable to enteral nutrition and had no neurologic condition. The patients were randomly assigned to receive either quetiapine 50 mg every 12 hours (n = 18) or placebo (n = 18). The doses of quetiapine were increased every 24 hours for up to 200 mg/day. The results showed that quetiapine was superior to placebo in the respects of time to resolution of delir‐ ium, [1.0 (0.5-3.0) vs. 4.5 days (2.0-7.0), p =0.001], duration of delirium [36 (12-87) vs. 120 hours (60-195, p =0.006], and duration of agitation [6 hours (0-38) vs. 36 hours (11-66), p =0.02)]. However, the length of hospitalization was similar in both groups (16 days vs. 16 days). The incidence of QTc prolongation and EPS were not significant different between groups. However, somnolence was more common in the quetiapine groups (22% vs. 11%, p =.66). In addition, the rate of discharge to home or rehabilitation was greater in the quetia‐ pine group (89% vs. 56%, p =0.06) (Devlin et al., 2010).

Tahir et al. (2010) conducted an RCT to investigate the efficacy and acceptability of quetia‐ pine for the control of delirious symptoms. Forty-two patients (21 in each group) were ran‐ domly received either quetiapine or placebo. The DRS-R-98 was used as the primary outcome. The results demonstrated that improvement for quetiapine, as measured by DRS-R-98 severity score, was faster than that of placebo. Based on DRS-R-98 severity score, the quetiapine group recovered faster than the placebo group (P=0.026). In addition, the noncognitive items of the DRS-R-98, including restlessness, agitation, thought disorder and per‐ ceptual impairment in the quetiapine group were significantly improved faster than that of placebo group (p=0.048).

Lee et al. (2005) conducted an open, randomized, prospective trial to investigate the effec‐ tiveness and tolerability of quetiapine and amisulpride in delirious patients. Forty patients with delirium were randomly assigned to receive a flexible dose of amisulpride or quetia‐ pine. Outcome measures included the DRS-R-98 and CGI-Severity (CGI-S), the total sleep time and the quality of sleep. The mean doses of quetiapine and amisulpride were 113 mg/day and 156.4 mg/day, respectively. The DRS-R-98 scores of both groups decreased over time. Time to recovery for the quetiapine group was 7.4±4.1 days. The quality of sleep and the total sleep time were not significantly different between groups. Both quetiapine and amisulpride were well tolerated.

After the reveal of promising benefits of quetiapine for delirium in an open-label study (Maneeton et al., 2007b), Maneeton and colleagues conducted an RCT to compare the effica‐ cy and tolerability of quetiapine and haloperidol in the management of delirium. Based on the DRS-R-98 and CGI scores, quetiapine was as effective as haloperidol in the treatment of delirium. The mean of night time sleep was 7.8±1.8 hours for the quetiapine group. Quetia‐ pine and haloperidol were well tolerated. In addition, the incidence rates of extrapyramidal side effects were very low in both groups (Maneeton et al., 2011).

The above mentioned findings suggest that low doses of quetiapine are effective and safe in the treatment of delirium. Its efficacy is, at least, comparable to typical and other atypical antipsychotic agents. Compared with other antipsychotic agents, only quetiapine has been shown its superiority to placebo in the management of delirium. It also causes only few ad‐ verse events, including EPS and QTc prolongation, which may be comparable to placebo.

### *7.3.1.2.3. Olanzapine*

64.7%, olanzapine group: 73.3%). The response to risperidone was poorer in the older age group. The median times to the recovery of delirium in the risperidone and olanzapine groups were 5 and 3 days, respectively. Risperidone, like olanzapine, was well tolerated. Al‐ though a few patients developed extrapyramidal symptoms, they were tolerable (Kim et al.,

Another RCT conducted by Grover et al.(2011) compared the efficacy and safety of olanza‐ pine, risperidone and haloperidol in medical and surgical inpatients with delirium. The

Several findings support that low doses of risperidone are effective and tolerable for deliri‐ ous patients. Its efficacy is comparable to other typical and atypical antipsychotic medica‐ tions. To our knowledge, there has not been a randomized, placebo-controlled trial of

Quetiapine is an atypical antipsychotic agent approved for the treatment of schizophrenia, bipolar disorder and major depressive disorder. However, its evidence in controlling deliri‐ ous symptoms has been increased. There have had several RCTs conducted to determine the

There was a randomized, double-blind, placebo-controlled trial of quetiapine in critically ill patients with delirium. A total of 36 delirious adult patients admitted in intensive care units were enrolled. All patients had a score of 4 or more on the Care Delirium Screening Check‐ list, were tolerable to enteral nutrition and had no neurologic condition. The patients were randomly assigned to receive either quetiapine 50 mg every 12 hours (n = 18) or placebo (n = 18). The doses of quetiapine were increased every 24 hours for up to 200 mg/day. The results showed that quetiapine was superior to placebo in the respects of time to resolution of delir‐ ium, [1.0 (0.5-3.0) vs. 4.5 days (2.0-7.0), p =0.001], duration of delirium [36 (12-87) vs. 120 hours (60-195, p =0.006], and duration of agitation [6 hours (0-38) vs. 36 hours (11-66), p =0.02)]. However, the length of hospitalization was similar in both groups (16 days vs. 16 days). The incidence of QTc prolongation and EPS were not significant different between groups. However, somnolence was more common in the quetiapine groups (22% vs. 11%, p =.66). In addition, the rate of discharge to home or rehabilitation was greater in the quetia‐

Tahir et al. (2010) conducted an RCT to investigate the efficacy and acceptability of quetia‐ pine for the control of delirious symptoms. Forty-two patients (21 in each group) were ran‐ domly received either quetiapine or placebo. The DRS-R-98 was used as the primary outcome. The results demonstrated that improvement for quetiapine, as measured by DRS-R-98 severity score, was faster than that of placebo. Based on DRS-R-98 severity score, the quetiapine group recovered faster than the placebo group (P=0.026). In addition, the noncognitive items of the DRS-R-98, including restlessness, agitation, thought disorder and per‐ ceptual impairment in the quetiapine group were significantly improved faster than that of

efficacy and safety of quetiapine in the management of delirium.

pine group (89% vs. 56%, p =0.06) (Devlin et al., 2010).

findings indicated that risperidone, like olanzapine, was as effective as haloperidol.

2010).

risperidone in delirious patients.

96 Mental Disorders - Theoretical and Empirical Perspectives

*7.3.1.2.2. Quetiapine*

placebo group (p=0.048).

Olanzapine is, also, an atypical antipsychotic medication approved in the treatment of schiz‐ ophrenia and bipolar disorder. There have been a few RCTs of this agent in patients with delirium.The RCT carried out by Skrobik et al. (2004) compared the safety and efficacy of olanzapine and haloperidol in delirious patients admitted in a critical care unit. The results indicated that olanzapine was as effective as haloperidol in controlling delirious symptoms. Olanzapine was a safe alternative agent, especially for delirious patients contraindicated to haloperidol.

The study of Kim and colleagues demonstrated that olanzapine was effective for delirium. This agent also had low incidence of adverse events, especially EPS. Its efficacy is equal to the effects of risperidone (Kim et al., 2010).

Elsayem et al. (2010) conducted a prospective, open-label study to investigate the safety, tol‐ erability and efficacy of subcutaneous (SC) olanzapine for hyperactive or mixed delirium in the cancer patients. The subjects had the MMSE scores of 24 or higher and agitation with Richmond Agitation Sedation Scale (RASS) score of 1 or more. In addition, they were those who had not responded to 10 mg or more of parenteral haloperidol over 24 hours. All sub‐ jects received olanzapine 5mg SC every eight hours for three days and continued haloperi‐ dol for controlling agitation. Twenty-four patients, aged 49 to 79, were evaluated. The findings indicated that the patients tolerated well with the SC olanzapine. In the respect of agitation, only 37.5% of the subjects were rated as responders.

piprazole was 8.9±3.5 mg/day. The adverse events were rare.The finding suggested that ari‐

The above-mentioned findings demonstrate that aripiprazole is safe and effective for deliri‐ um. As a non sedating antipsychotic agent, it may be suitable for hypoactive delirium. How‐

Amisulpride is an atypical antipsychotic agent used for the treatment of psychoses and manic episode. Its low doses may be effective for the treatment of depression. However, some studies have been carried out to examine its efficacy for controlling delirious symp‐

There was an RCT comparing the efficacy, tolerability and sleep quality of amisulpride and quetiapine in controlling delirious symptoms. The findings showed that, similar to quetia‐ pine, amisulpride was safe and effective for delirious patients. The mean time to stabiliza‐ tion in the amisulpride group was 6.3±4.4 days (Lee et al., 2005). The finding suggested that amisulpride, like quetiapine, appear to be effective and tolerable for the management of de‐

lirium. However, further studies are still needed to confirm its efficacy and safety.

**Resolution or response time (days)**

**Chlorpromazine** Oral - Ib worsen the cognitive impairment

**Olanzapine** Oral, SC <sup>3</sup> Ib limited efficacy in agitated delirium

**Risperidone** Oral 4-5 Ib as effective as haloperidol

**Quetiapine** Oral 1-7 Ib effective with low risk of EPS

**Aripriprazole** Oral - IIIb effective in hypoactive delirium

Lorazepam is primary used as hypnotics and anxiolytics. It has rapid onset and shorter du‐ ration of action, a low risk of accumulation and no major active metabolites. Its bioavailabili‐

\* Gray and Taylor (2010), IM: intramuscular injection; IV: intravenous injection; SC; subcutaneous injection

**Level of evidence\***

**Comments**

Management of Delirium http://dx.doi.org/10.5772/52756 99

IV administration increases risk of the QT prolongation and torsades

de pointes

for SC administration

piprazole appeared to be effective and safe in the treatment of hypoactive delirium.

ever, its evidence in delirious patients is still limited.

**Treatment route**

**Haloperidol** Oral, IM, IV 4 Ib

**Amisulpride** Oral 6 Ic

**Table 1.** Summary of evidence on antipsychotic agents for managing delirium

*7.3.1.2.5. Amisulpride*

**Drug**

*7.3.2. Benzodiazepine*

toms.

There was an RCT comparing the efficacy of olanzapine, risperidone and haloperidol in de‐ lirious patients. The findings suggested that olanzapine was comparable to risperidone and haloperidol (Grover et al., 2011).

Olanzapine appears to be an effective and tolerable antipsychotic medication in the control of delirious behavior. It can be administered in several routes, such as oral, intramuscular and subcutaneous administration. Further well-defined studies should be conducted to con‐ firm these findings.

### *7.3.1.2.4. Aripriprazole*

Aripiprazole is a dopamine partial agonist approved in the treatment of schizophrenia and bipolar disorder. Similar to other antipsychotic medications, it is widely used for controlling the behavioral disturbances and psychotic symptoms in patients with dementia and deliri‐ um. As an agent with little sedative and anticholinergic effects, it may have a few adverse effects on attention, concentration and sleep-wake cycle. In addition, it may be beneficial for hypoactive delirium (Straker et al., 2006). However, only a few studies of this agent have been carried out in delirious patients.

The study of Boettger et al. (2011) compared the efficacy and tolerability between aripipra‐ zole and haloperidol for the reduction of delirious symptoms. The subjects were 21 delirious patients treated with aripiprazole and 21 case-matched, delirious patients treated with halo‐ peridol. The measures consisted of the MDAS, the Karnofsky Performance Scale (KPS) and the abbreviated Udvalg Kliniske Undersogelser Side Effect Rating Scale (UKU). With respect to the MDAS, both groups improved significantly from baseline to day 7. The resolution rates of delirium were 76.2% for both groups. Both hypoactive and hyperactive deliriums significant improved. For those with hypoactive delirium, the rates of delirium resolution in the aripiprazole and haloperidol groups were 100 and 77.8%, respectively. For those with hyperactive delirium, such rates were 58.3% and 75%, respectively. However, the haloperi‐ dol group had more side effects.

Boettger and Breitbart (2011) conducted an open-label study to determine the efficacy and safety of aripiprazole for controlling delirious symptoms in hospitalized cancer patients. Twenty-one patients were treated with aripiprazole. Based on the changed MDAS scores, the aripiprazole group improved significantly. The mean dose of aripiprazole was 18.3 (range 5-30) mg/day at the end of study. The rates of delirium resolution were 100% for hy‐ poactive delirium and 58.3% for hyperactive delirium. The patients with pre-morbid cogni‐ tive deficits and the hyperactive subtype of delirium did not respond well to aripiprazole treatment. The clinically significant adverse events were not found.

The case series of Straker et al. (2006) also demonstrated the efficacy of aripiprazole in the treatment of delirium. Fourteen patients, aged 18 to 85 and met DSM-IV-TR criteria for a di‐ agnosis of delirium, were included. The results found that 12 patients had ≥ 50 % reduction in DSR-R-98, and 13 patients showed improvement on the CGI scores. The mean dose of ari‐ piprazole was 8.9±3.5 mg/day. The adverse events were rare.The finding suggested that ari‐ piprazole appeared to be effective and safe in the treatment of hypoactive delirium.

The above-mentioned findings demonstrate that aripiprazole is safe and effective for deliri‐ um. As a non sedating antipsychotic agent, it may be suitable for hypoactive delirium. How‐ ever, its evidence in delirious patients is still limited.

### *7.3.1.2.5. Amisulpride*

findings indicated that the patients tolerated well with the SC olanzapine. In the respect of

There was an RCT comparing the efficacy of olanzapine, risperidone and haloperidol in de‐ lirious patients. The findings suggested that olanzapine was comparable to risperidone and

Olanzapine appears to be an effective and tolerable antipsychotic medication in the control of delirious behavior. It can be administered in several routes, such as oral, intramuscular and subcutaneous administration. Further well-defined studies should be conducted to con‐

Aripiprazole is a dopamine partial agonist approved in the treatment of schizophrenia and bipolar disorder. Similar to other antipsychotic medications, it is widely used for controlling the behavioral disturbances and psychotic symptoms in patients with dementia and deliri‐ um. As an agent with little sedative and anticholinergic effects, it may have a few adverse effects on attention, concentration and sleep-wake cycle. In addition, it may be beneficial for hypoactive delirium (Straker et al., 2006). However, only a few studies of this agent have

The study of Boettger et al. (2011) compared the efficacy and tolerability between aripipra‐ zole and haloperidol for the reduction of delirious symptoms. The subjects were 21 delirious patients treated with aripiprazole and 21 case-matched, delirious patients treated with halo‐ peridol. The measures consisted of the MDAS, the Karnofsky Performance Scale (KPS) and the abbreviated Udvalg Kliniske Undersogelser Side Effect Rating Scale (UKU). With respect to the MDAS, both groups improved significantly from baseline to day 7. The resolution rates of delirium were 76.2% for both groups. Both hypoactive and hyperactive deliriums significant improved. For those with hypoactive delirium, the rates of delirium resolution in the aripiprazole and haloperidol groups were 100 and 77.8%, respectively. For those with hyperactive delirium, such rates were 58.3% and 75%, respectively. However, the haloperi‐

Boettger and Breitbart (2011) conducted an open-label study to determine the efficacy and safety of aripiprazole for controlling delirious symptoms in hospitalized cancer patients. Twenty-one patients were treated with aripiprazole. Based on the changed MDAS scores, the aripiprazole group improved significantly. The mean dose of aripiprazole was 18.3 (range 5-30) mg/day at the end of study. The rates of delirium resolution were 100% for hy‐ poactive delirium and 58.3% for hyperactive delirium. The patients with pre-morbid cogni‐ tive deficits and the hyperactive subtype of delirium did not respond well to aripiprazole

The case series of Straker et al. (2006) also demonstrated the efficacy of aripiprazole in the treatment of delirium. Fourteen patients, aged 18 to 85 and met DSM-IV-TR criteria for a di‐ agnosis of delirium, were included. The results found that 12 patients had ≥ 50 % reduction in DSR-R-98, and 13 patients showed improvement on the CGI scores. The mean dose of ari‐

treatment. The clinically significant adverse events were not found.

agitation, only 37.5% of the subjects were rated as responders.

haloperidol (Grover et al., 2011).

98 Mental Disorders - Theoretical and Empirical Perspectives

been carried out in delirious patients.

dol group had more side effects.

firm these findings.

*7.3.1.2.4. Aripriprazole*

Amisulpride is an atypical antipsychotic agent used for the treatment of psychoses and manic episode. Its low doses may be effective for the treatment of depression. However, some studies have been carried out to examine its efficacy for controlling delirious symp‐ toms.

There was an RCT comparing the efficacy, tolerability and sleep quality of amisulpride and quetiapine in controlling delirious symptoms. The findings showed that, similar to quetia‐ pine, amisulpride was safe and effective for delirious patients. The mean time to stabiliza‐ tion in the amisulpride group was 6.3±4.4 days (Lee et al., 2005). The finding suggested that amisulpride, like quetiapine, appear to be effective and tolerable for the management of de‐ lirium. However, further studies are still needed to confirm its efficacy and safety.


\* Gray and Taylor (2010), IM: intramuscular injection; IV: intravenous injection; SC; subcutaneous injection

**Table 1.** Summary of evidence on antipsychotic agents for managing delirium

#### *7.3.2. Benzodiazepine*

Lorazepam is primary used as hypnotics and anxiolytics. It has rapid onset and shorter du‐ ration of action, a low risk of accumulation and no major active metabolites. Its bioavailabili‐ ty is predictable when it is administered either orally or intramuscularly (Attard et al., 2008). Due to these preferable pharmacokinetic profiles, it is alternatively administered for control‐ ling disruptive behavior in several clinical settings.

erative delirium for the donepezil and placebo groups were 1.0 and 1.3 days, respectively

Management of Delirium http://dx.doi.org/10.5772/52756 101

Marcantonio et al. (2011) conducted an RCT comparing the efficacy and safety of donepezil and placebo in reduction of the prevalence and severity of delirium in older adults undergo‐ ing hip fracture repair. Seventeen patients aged 70 or more were randomized to receive a daily donepezil 5 mg or placebo, initiated on the day before surgery or unless possible, ad‐ ministered within 24 hours after surgery. The treatment was continued for 30 days, unless side effects occurred. The presence and severity of delirium were measured by using the CAM and MDAS. Patients in the donepezil group had significantly more adverse events. With regard to delirium presence over time or the CAM scores over time, there were no sig‐ nificant differences between the donepezil and placebo groups in terms of delirium inci‐

A pilot study of Oldenbeuving et al. (2008) investigated the efficacy and tolerability of riva‐ stigmine in the treatment of delirium after stroke. Seventeen patients with delirium (DRS≥12) were treated with oral rivastigmine within the dose range of 3-12 mg a day. Based on the DRS scores, 16 of 17 patients had a decrease in severity of delirium after rivastigmine treatment. The mean duration of the delirium for 16 patients was 6.7 (2-17) days. No signifi‐

Based on the findings, there has been no strong evidence supporting the use of cholinester‐ ase inhibitors in the treatment of delirium. Conversely, these agents may cause a greater risk

Delirious symptoms are likely to be improved by themselves after the recovery of underlin‐ ing diseases. Judgment on the severity of these behavioral symptoms is easily biased by raters. In addition, placebo effects are noted in all area of therapeutic approach (Kradin, 2011). The percentage of placebo effect on psychiatric illness, such as anxiety and depression is often high (Raz et al., 2011). According to the nature of this medical condition, a random‐ ized, placebo-controlled trial of a medication for controlling delirious symptoms is desper‐

Among the medications mentioned above, only quetiapine has been examined in a placebocontrolled study. The superiority of quetiapine to placebo may suggest that the agents may be considered as first-line treatment for controlling the disruptive behavior of delirium. Low dose of other typical and atypical antipsychotics may be also effective. The evidence so far also suggests that haloperidol may be associated with EPS, and chlorpromazine has a risk for anticholinergic side effects. Other atypical antipsychotics that appear to be effective and tolerable in the management of delirium are risperidone, olanzapine, amisulpride and aripi‐ prazole. Only aripiprazole may be effective for hypoactive delirium. Although benzodiaze‐ pine, especially lorazepam, is widely used in delirium, there is no evidence supporting its efficacy for the treatment of non-withdrawal delirium. Therefore, the use of benzodiazepine should be limited to alcohol or benzodiazepine withdrawal delirium only. Similarly, there has not been evidenced to demonstrate the efficacy of cholinesterase inhibitors, including

of adverse events in this population. Further studies should be carried out.

ately needed to assess the efficacy and safety of a particular agent.

donepezil and rivastigmine, in the treatment of delirium.

(Liptzin et al., 2005, Overshott et al., 2008).

dence or severity.

cant adverse event was observed.

There was a prospective study suggested that intravenously administration of benzodiaze‐ pine added haloperidol can reduce the risk of EPS (Menza et al., 1988). An RCT of loraze‐ pam monotherapy (3.0±3.6 mg for first 24 hours and 4.6±4.7 mg/day after day 2 ) did not show its efficacy in controlling delirious symptoms in AIDS patients. In addition, it continu‐ ously decreased cognitive function, as measured by the MMSE. Due to these preliminary re‐ sults, this study was prematurely stopped (Breitbart et al., 1996).

Based on the results of a systematic review, there has been no adequate RCT to support the use of benzodiazepines in the management of non-alcohol withdrawal related delirium in patients admitted in the hospital (Lonergan et al., 2009). Although benzodiazepines are the first-line treatment for alcoholic withdrawal delirium, their evidence in the treatment of non-alcoholic delirium is very limited.

### *7.3.3. Cholinesterase inhibitors*

Presumably, cholinergic deficiency (Mussi et al., 1999, Trzepacz, 2000) is postulated as neu‐ rochemical correlates of delirium. In addition, anticholinergic medications are correlated to drug-induced delirium (Han et al., 2001), and cholinergic medications can reduce symptoms of delirium in dementia (Wengel et al., 1998). It has been hypothesized that cholinesterase inhibitors may be beneficial for treating cholinergic deficiency in delirium.

Overshott et al. (2010) conducted a double-blind, placebo-controlled randomized trial of ri‐ vastigmine in the management of delirious patients hospitalized in medical settings. Pa‐ tients (age≥ 65 years) were diagnosed as delirium by using the CAM. After entry, the patients in each group were assessed by using the CAM daily. Patients with delirium were randomly assigned to receive either rivastigmine 1.5 mg once a day and increased to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days). A total of 15 patients were included in the study. Eight patients received rivastigmine, and seven pa‐ tients received placebo. With regarded to the CAM scores, all patients in the rivastigmine group and 3 patients in the placebo group had a resolution of delirium when they exited the trial. However, there was no significant difference between groups on the duration of deliri‐ um (rivastigmine group 6.3 days versus placebo group 9.9 days).

There was an RCT comparing the efficacy and tolerability of donepezil and placebo. A total of 80 patients were randomly assigned to orally administered donepezil 5 mg once a day or a placebo capsule once a day, commenced 14 days before the surgery and continued taking for 14 days following the surgery. The delirium was identified with the Delirium Symptom Interview, the CAM, daily medical record, nurse-observation reviews, and the DSM-IV di‐ agnostic criteria for delirium. With respect to DSM-IV criteria, patients diagnosed as deliri‐ um were suggested to receive a double dose of donepezil or placebo treatments. No measure outcome was used to assess in severity of delirium. The mean duration of postop‐ erative delirium for the donepezil and placebo groups were 1.0 and 1.3 days, respectively (Liptzin et al., 2005, Overshott et al., 2008).

ty is predictable when it is administered either orally or intramuscularly (Attard et al., 2008). Due to these preferable pharmacokinetic profiles, it is alternatively administered for control‐

There was a prospective study suggested that intravenously administration of benzodiaze‐ pine added haloperidol can reduce the risk of EPS (Menza et al., 1988). An RCT of loraze‐ pam monotherapy (3.0±3.6 mg for first 24 hours and 4.6±4.7 mg/day after day 2 ) did not show its efficacy in controlling delirious symptoms in AIDS patients. In addition, it continu‐ ously decreased cognitive function, as measured by the MMSE. Due to these preliminary re‐

Based on the results of a systematic review, there has been no adequate RCT to support the use of benzodiazepines in the management of non-alcohol withdrawal related delirium in patients admitted in the hospital (Lonergan et al., 2009). Although benzodiazepines are the first-line treatment for alcoholic withdrawal delirium, their evidence in the treatment of

Presumably, cholinergic deficiency (Mussi et al., 1999, Trzepacz, 2000) is postulated as neu‐ rochemical correlates of delirium. In addition, anticholinergic medications are correlated to drug-induced delirium (Han et al., 2001), and cholinergic medications can reduce symptoms of delirium in dementia (Wengel et al., 1998). It has been hypothesized that cholinesterase

Overshott et al. (2010) conducted a double-blind, placebo-controlled randomized trial of ri‐ vastigmine in the management of delirious patients hospitalized in medical settings. Pa‐ tients (age≥ 65 years) were diagnosed as delirium by using the CAM. After entry, the patients in each group were assessed by using the CAM daily. Patients with delirium were randomly assigned to receive either rivastigmine 1.5 mg once a day and increased to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days). A total of 15 patients were included in the study. Eight patients received rivastigmine, and seven pa‐ tients received placebo. With regarded to the CAM scores, all patients in the rivastigmine group and 3 patients in the placebo group had a resolution of delirium when they exited the trial. However, there was no significant difference between groups on the duration of deliri‐

There was an RCT comparing the efficacy and tolerability of donepezil and placebo. A total of 80 patients were randomly assigned to orally administered donepezil 5 mg once a day or a placebo capsule once a day, commenced 14 days before the surgery and continued taking for 14 days following the surgery. The delirium was identified with the Delirium Symptom Interview, the CAM, daily medical record, nurse-observation reviews, and the DSM-IV di‐ agnostic criteria for delirium. With respect to DSM-IV criteria, patients diagnosed as deliri‐ um were suggested to receive a double dose of donepezil or placebo treatments. No measure outcome was used to assess in severity of delirium. The mean duration of postop‐

inhibitors may be beneficial for treating cholinergic deficiency in delirium.

um (rivastigmine group 6.3 days versus placebo group 9.9 days).

ling disruptive behavior in several clinical settings.

100 Mental Disorders - Theoretical and Empirical Perspectives

non-alcoholic delirium is very limited.

*7.3.3. Cholinesterase inhibitors*

sults, this study was prematurely stopped (Breitbart et al., 1996).

Marcantonio et al. (2011) conducted an RCT comparing the efficacy and safety of donepezil and placebo in reduction of the prevalence and severity of delirium in older adults undergo‐ ing hip fracture repair. Seventeen patients aged 70 or more were randomized to receive a daily donepezil 5 mg or placebo, initiated on the day before surgery or unless possible, ad‐ ministered within 24 hours after surgery. The treatment was continued for 30 days, unless side effects occurred. The presence and severity of delirium were measured by using the CAM and MDAS. Patients in the donepezil group had significantly more adverse events. With regard to delirium presence over time or the CAM scores over time, there were no sig‐ nificant differences between the donepezil and placebo groups in terms of delirium inci‐ dence or severity.

A pilot study of Oldenbeuving et al. (2008) investigated the efficacy and tolerability of riva‐ stigmine in the treatment of delirium after stroke. Seventeen patients with delirium (DRS≥12) were treated with oral rivastigmine within the dose range of 3-12 mg a day. Based on the DRS scores, 16 of 17 patients had a decrease in severity of delirium after rivastigmine treatment. The mean duration of the delirium for 16 patients was 6.7 (2-17) days. No signifi‐ cant adverse event was observed.

Based on the findings, there has been no strong evidence supporting the use of cholinester‐ ase inhibitors in the treatment of delirium. Conversely, these agents may cause a greater risk of adverse events in this population. Further studies should be carried out.

Delirious symptoms are likely to be improved by themselves after the recovery of underlin‐ ing diseases. Judgment on the severity of these behavioral symptoms is easily biased by raters. In addition, placebo effects are noted in all area of therapeutic approach (Kradin, 2011). The percentage of placebo effect on psychiatric illness, such as anxiety and depression is often high (Raz et al., 2011). According to the nature of this medical condition, a random‐ ized, placebo-controlled trial of a medication for controlling delirious symptoms is desper‐ ately needed to assess the efficacy and safety of a particular agent.

Among the medications mentioned above, only quetiapine has been examined in a placebocontrolled study. The superiority of quetiapine to placebo may suggest that the agents may be considered as first-line treatment for controlling the disruptive behavior of delirium. Low dose of other typical and atypical antipsychotics may be also effective. The evidence so far also suggests that haloperidol may be associated with EPS, and chlorpromazine has a risk for anticholinergic side effects. Other atypical antipsychotics that appear to be effective and tolerable in the management of delirium are risperidone, olanzapine, amisulpride and aripi‐ prazole. Only aripiprazole may be effective for hypoactive delirium. Although benzodiaze‐ pine, especially lorazepam, is widely used in delirium, there is no evidence supporting its efficacy for the treatment of non-withdrawal delirium. Therefore, the use of benzodiazepine should be limited to alcohol or benzodiazepine withdrawal delirium only. Similarly, there has not been evidenced to demonstrate the efficacy of cholinesterase inhibitors, including donepezil and rivastigmine, in the treatment of delirium.

#### **7.4. Environmental intervention**

The reticular formation and its connections, the main sites of arousal and attention, are in‐ volved in delirium. Dysfunction of this system may affect the perception and interpretation of environmental stimuli in delirious patients. The reduction or over activity of the environ‐ mental factors may exacerbate the symptoms of delirium. Several studies, especially multi‐ component programs, have supported that an environmental intervention is also effective in the management of delirium.

with high prevalent or incident delirium participated in the study. Significant differences between groups were not observed within the eight weeks after enrolment in terms of time to and rate of improvement of the Delirium Index, the Barthel Index, length of stay, rate of discharge into the community, living arrangements after discharge or survival. Based on the findings, systematic detection and multidisciplinary care of delirium did nots how a benefit

Management of Delirium http://dx.doi.org/10.5772/52756 103

A prospective intervention study conducted by Lundstrom et al. (2005) determine an educa‐ tion program and a reorganization of nursing and medical care for improving the symptoms of delirium in elderly patients. A total of 400 patients, aged 70 or older, were consecutively admitted to either an intervention or a control ward. The intervention program composed of staff education emphasizing on the assessment, prevention, and treatment of delirium, as well as caregiver-patient interaction. The Organic Brain Syndrome Scale and the MMSE were used as outcome measures. Fewer patients in the intervention ward had delirious symptoms on day 7 compared with the control group (30.2% vs 59.7%, p=0.001). The mean length of hospitalization was significantly shorter in the intervention patients as compared with the control ones (9.4±8.2 vs 13.4±12.3 days, P< 0.001), especially for the delirious pa‐

Inouye et al. (2006) conducted a cross-sectional survey of the Hospital Elder Life Program (HELP) dissemination in 17 study sites. The trained interdisciplinary teams assessed and in‐ tervened on six delirium risk factors, including orientation, therapeutic activities, early mo‐ bilization, vision/hearing optimization, oral volume repletion and sleep enhancement. The finding that the HELP improved hospital outcomes in delirium was promising in this popu‐

There was a prospective analysis to determine the pattern and frequency of implementation of environmental intervention in managing delirious patients admitted in an acute hospital service. Forty-six patients meeting the ICD-10 criteria for delirium were studied. The pa‐ tients were categorized into hyperactive, hypoactive or mixed subtypes of delirium. The en‐ vironmental strategies were the eight basic nursing strategies for delirium, including (1) frequent observation; (2) efforts by staff to re-orientate the patient to the surroundings; (3) effort made to avoid excessive staff changes; (4) nurse in single room; (5) uncluttered nurs‐ ing environment; (6) use of an individual night light; (7) specific effort to minimize noise levels and (8) relatives or friends specifically requested to visit regularly in an effort to en‐ hance re-orientation. The study found that these environmental strategies were more benefi‐ cial in the management of behavioral difficulties, such as overall severity of delirium, agitation, mood lability and sleep-wake cycle disturbance, than the core features of deliri‐ um, such as severity of disorientation, disturbed perception/thinking (Meagher et al., 1996). The above-mentioned studies suggest the benefits ofthe environmental interventions for de‐ lirium, and, therefore, should be recommended in all patients with delirium. Those inter‐ ventions aim to correct or reduce the sensory impairment, and to improve the patient's perception, by using eyeglasses and hearing aids. Optimal sensory stimulation is helpful to decrease the behavioral disturbance of delirium. While sensory deprivation may exacerba‐ tethe behavioral disturbance, over stimulation, such as loud noise, should be also avoided.

over usual care for elderly patients in medical settings.

tients (10.8±8.3 vs 20.5±17.2 days, P< 0.001).

lation.

Cole et al. (1994) conducted an RCT to determine a systematic intervention in elderly inpa‐ tients with DSM-IV delirium. Eighty-eight patients, aged 75 years or more, were enrolled in the study. The patients were randomized to either the treatment group (n=42) or the control group (n=46). Each treatment patient received a consultation by a geriatric internist or psy‐ chiatrist and followed up by a liaison nurse. Regular medical care was provided in the con‐ trol group. The environmental intervention, used in this study, was the nursing intervention protocol, including the interventions for (1) environment: appropriate sensory input, only one stimulus or task background stimulation at a time, and medication not interrupting sleep, (2) orientation: environmental cues, such as clock, calendar and etc., verbal reminders of time, place and person, and needs of eye glasses or hearing aids, (3) familiarity: familiar possession from home, family members to stay with the patients, and the same staff to care for them (4) communication: clear, slow paced, simple and repetitive instructions and ex‐ planations, use of face-to-face contact, a warmth attitude and kind firmness, identification by name and information, acknowledgement of their emotions and encouragement of verbal expression, (5) activities: avoidance in physical restraint, free movement, provision of safety, encouragement of self-care and other personal activities. Two weeks after hospitalization, as measured by the Short Portable Mental Status Questionnaire (SPMSQ), the improvement was observed in the intervention group, while deterioration was observed in the control group. However, the difference was not reported by the end of 8-week period. There were statistically significant differences between the groups in terms of the use of restraints, length of hospital stay, discharges to a setting providing more care than needed before ad‐ mission or mortality rate.

Milisen et al. (2001) developed and investigated the effectiveness of a nurse-led interdiscipli‐ nary intervention program for delirium. A total 120 participants (60 for intervention cohort, 60 for a usual care/non-intervention cohort) were included. The intervention protocol con‐ sisted of education for the nursing staff; systematic cognitive screening; consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician; use of a scheduled pain protocol. The findings showed that the intervention cohort group had short‐ er duration of delirium (p=0.3), less severity of delirium (p=0.049) and less memory impair‐ ment (p=0.046) than those of the control group. The length of hospital stay tended to be decreased in the intervention cohort compared with the control (p=0.09). The study suggest‐ ed that this intervention was beneficial for older hip-fracture patients with delirium.

Cole et al. (2002) conducted an RCT to investigate the effectiveness of systematic detection and multidisciplinary care of delirium in reducing time to improvement of cognitive status in older patients admitted to general medical settings. Two hundred twenty-seven patients with high prevalent or incident delirium participated in the study. Significant differences between groups were not observed within the eight weeks after enrolment in terms of time to and rate of improvement of the Delirium Index, the Barthel Index, length of stay, rate of discharge into the community, living arrangements after discharge or survival. Based on the findings, systematic detection and multidisciplinary care of delirium did nots how a benefit over usual care for elderly patients in medical settings.

**7.4. Environmental intervention**

102 Mental Disorders - Theoretical and Empirical Perspectives

the management of delirium.

mission or mortality rate.

The reticular formation and its connections, the main sites of arousal and attention, are in‐ volved in delirium. Dysfunction of this system may affect the perception and interpretation of environmental stimuli in delirious patients. The reduction or over activity of the environ‐ mental factors may exacerbate the symptoms of delirium. Several studies, especially multi‐ component programs, have supported that an environmental intervention is also effective in

Cole et al. (1994) conducted an RCT to determine a systematic intervention in elderly inpa‐ tients with DSM-IV delirium. Eighty-eight patients, aged 75 years or more, were enrolled in the study. The patients were randomized to either the treatment group (n=42) or the control group (n=46). Each treatment patient received a consultation by a geriatric internist or psy‐ chiatrist and followed up by a liaison nurse. Regular medical care was provided in the con‐ trol group. The environmental intervention, used in this study, was the nursing intervention protocol, including the interventions for (1) environment: appropriate sensory input, only one stimulus or task background stimulation at a time, and medication not interrupting sleep, (2) orientation: environmental cues, such as clock, calendar and etc., verbal reminders of time, place and person, and needs of eye glasses or hearing aids, (3) familiarity: familiar possession from home, family members to stay with the patients, and the same staff to care for them (4) communication: clear, slow paced, simple and repetitive instructions and ex‐ planations, use of face-to-face contact, a warmth attitude and kind firmness, identification by name and information, acknowledgement of their emotions and encouragement of verbal expression, (5) activities: avoidance in physical restraint, free movement, provision of safety, encouragement of self-care and other personal activities. Two weeks after hospitalization, as measured by the Short Portable Mental Status Questionnaire (SPMSQ), the improvement was observed in the intervention group, while deterioration was observed in the control group. However, the difference was not reported by the end of 8-week period. There were statistically significant differences between the groups in terms of the use of restraints, length of hospital stay, discharges to a setting providing more care than needed before ad‐

Milisen et al. (2001) developed and investigated the effectiveness of a nurse-led interdiscipli‐ nary intervention program for delirium. A total 120 participants (60 for intervention cohort, 60 for a usual care/non-intervention cohort) were included. The intervention protocol con‐ sisted of education for the nursing staff; systematic cognitive screening; consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician; use of a scheduled pain protocol. The findings showed that the intervention cohort group had short‐ er duration of delirium (p=0.3), less severity of delirium (p=0.049) and less memory impair‐ ment (p=0.046) than those of the control group. The length of hospital stay tended to be decreased in the intervention cohort compared with the control (p=0.09). The study suggest‐

ed that this intervention was beneficial for older hip-fracture patients with delirium.

Cole et al. (2002) conducted an RCT to investigate the effectiveness of systematic detection and multidisciplinary care of delirium in reducing time to improvement of cognitive status in older patients admitted to general medical settings. Two hundred twenty-seven patients A prospective intervention study conducted by Lundstrom et al. (2005) determine an educa‐ tion program and a reorganization of nursing and medical care for improving the symptoms of delirium in elderly patients. A total of 400 patients, aged 70 or older, were consecutively admitted to either an intervention or a control ward. The intervention program composed of staff education emphasizing on the assessment, prevention, and treatment of delirium, as well as caregiver-patient interaction. The Organic Brain Syndrome Scale and the MMSE were used as outcome measures. Fewer patients in the intervention ward had delirious symptoms on day 7 compared with the control group (30.2% vs 59.7%, p=0.001). The mean length of hospitalization was significantly shorter in the intervention patients as compared with the control ones (9.4±8.2 vs 13.4±12.3 days, P< 0.001), especially for the delirious pa‐ tients (10.8±8.3 vs 20.5±17.2 days, P< 0.001).

Inouye et al. (2006) conducted a cross-sectional survey of the Hospital Elder Life Program (HELP) dissemination in 17 study sites. The trained interdisciplinary teams assessed and in‐ tervened on six delirium risk factors, including orientation, therapeutic activities, early mo‐ bilization, vision/hearing optimization, oral volume repletion and sleep enhancement. The finding that the HELP improved hospital outcomes in delirium was promising in this popu‐ lation.

There was a prospective analysis to determine the pattern and frequency of implementation of environmental intervention in managing delirious patients admitted in an acute hospital service. Forty-six patients meeting the ICD-10 criteria for delirium were studied. The pa‐ tients were categorized into hyperactive, hypoactive or mixed subtypes of delirium. The en‐ vironmental strategies were the eight basic nursing strategies for delirium, including (1) frequent observation; (2) efforts by staff to re-orientate the patient to the surroundings; (3) effort made to avoid excessive staff changes; (4) nurse in single room; (5) uncluttered nurs‐ ing environment; (6) use of an individual night light; (7) specific effort to minimize noise levels and (8) relatives or friends specifically requested to visit regularly in an effort to en‐ hance re-orientation. The study found that these environmental strategies were more benefi‐ cial in the management of behavioral difficulties, such as overall severity of delirium, agitation, mood lability and sleep-wake cycle disturbance, than the core features of deliri‐ um, such as severity of disorientation, disturbed perception/thinking (Meagher et al., 1996).

The above-mentioned studies suggest the benefits ofthe environmental interventions for de‐ lirium, and, therefore, should be recommended in all patients with delirium. Those inter‐ ventions aim to correct or reduce the sensory impairment, and to improve the patient's perception, by using eyeglasses and hearing aids. Optimal sensory stimulation is helpful to decrease the behavioral disturbance of delirium. While sensory deprivation may exacerba‐ tethe behavioral disturbance, over stimulation, such as loud noise, should be also avoided. Providing environmental cues, such as calendar, clock, family pictures, windows, should be encouraged to facilitate orientation. In addition, supportive interventions, including re-ori‐ entation, reassurance and explanation about delirium, could reduce fear and anxiety.

the most efficacious in reducing the incidence, both in surgical and medical patients. In ad‐ dition, some additional effects of preventive intervention were observed in the duration and severity of delirium, as well as functional status. The review suggested that multicomponent

Management of Delirium http://dx.doi.org/10.5772/52756 105

Yang et al. (2008) conducted a prospective cohort study to investigate the mediating role of activity participation between educational attainment and risk of delirium. The contribu‐ tions of participation in specific activities for the development of delirium were also deter‐ mined. Seven hundred seventy-nine newly admitted patients without dementia, aged 70 or older, were studied. The findings showed that activity participation before hospitalization mediated the relationship between education and risk for delirium in elderly persons with‐ out dementia. It also suggested that participation in regular exercise was a significantly pro‐

Another study examined the efficacy of multicomponent intervention for preventing deliri‐ um. Inpatients with an intermediate or high risk for delirium were randomly assigned to re‐ ceive either a non-pharmacological intervention delivered by family members (144 patients) or standard management (143 patients). The outcome measure was the occurrence of deliri‐ um during hospitalization. The incidence rates of delirium in the intervention group and the control group were 5.6% and 13.3% (relative risk:0.41; 95% CI: 0.19–0.92; P = 0.027), respec‐ tively. The findings suggested that the non-pharmacological prevention of delirium given by family members, as compared with standard management, could reduce the patients'

These findings suggest that non-pharmacological interventions can reduce the incidence of delirium. Effective interventions, including multicomponent approach frequently focuses on predisposing factors in an individual patient. However, environmental prevention, such as re-orientation and environmental stimulation, are also effective for preventing delirium. A strong protective factor against delirium is the routinely participation in exercise. The use of multicomponent interventions by family members can also reduce the risk of delirium.

There have been several studies examining the effectiveness of antipsychotic medications for preventing delirium. Kalisvaart et al. (2005) conducted an RCT comparing haloperi‐ dol and placebo for preventing postoperative delirium in elderly hip-surgery patients, who were at risk for delirium. A number of 430 hip-surgery patients, aged 70 and older, at risk for postoperative delirium were randomly assigned to receive haloperidol 1.5 mg/d or placebo, started before surgery and continued for up to 3 days after surgery. The incidence rates of postoperative delirium in both groups were not significantly dif‐ ferent (haloperidol vs placebo, 15.1% vs. 16.5%). The means of delirium duration in halo‐ peridol and placebo treatment groups were 5.4 vs 11.8 days, orderly (mean difference 4.0, 95% CI=2.0-5.8, P<.001), and the means of hospital stay were 17.1±11.1 and 22.6±16.7 days, respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). The adverse events were not significantly different between groups. These results suggested that low doses of haloperidol might not be able to prevent postoperative delirium. However, it is safe

strategies are effective for preventing delirium.

tective factor of delirium.

risk of delirium (Martinez et al., 2012).

**8.2. Psychopharmacological interventions**

### **8. Prevention**

Once a patient with high risks of delirium is hospitalized, all risks should be addressed, fol‐ lowed by the employment of effective preventive strategies (Salawu et al., 2009). Some stud‐ ies have shown the benefits of some preventive interventions for delirium. In general, those strategies usually include the multidisciplinary and psychopharmacological interventions.

#### **8.1. Non-pharmacological interventions**

Multi-factors, including patient vulnerabilities, predisposing factors at admission and pre‐ cipitating factors during hospitalization can interactively cause syndrome of delirium.

Inouye (2000) conducted a controlled clinical trial in 852 subjects to prevent delirium in eld‐ erly inpatients. Significant predisposing factors for delirium included vision impairment, se‐ vere illness, cognitive impairment and dehydration. Precipitating factors were physical restraint use, malnutrition, adding more than three drugs, bladder catheter use, and any ia‐ trogenic event. The findings showed that the incidence of delirium was significantly re‐ duced in the intervention group compared with usual care (9.9% vs. 15.0%, 95% CI: 0.39-0.92). The total number of days and episodes of delirium were also significantly smaller in the intervention group. These findings suggested that delirium prevention is useful and could reduce the morbidity and mortality associated with delirium in elderly patients.

Colombo et al. (2012) conducted a two-stage prospective observational study to deter‐ mine the epidemiology, risk factors and predictors of delirium. The subjects were all pa‐ tients admitted to the ICU settings over a year. The first phase was the observational stage, while the second one was the interventional phase. Delirium assessment was per‐ formed by using of the CAM twice daily after the sedation interruption. For the second phase, the patients were received both a re-orientation and environmental manipulations (e.g., acoustic and visual stimulation). The patients in phase 1 and 2 were 170 and 144, respectively. The incidence rate of delirium was significantly lower in the interventional group (phase-I vs. phase-II: 22% vs. 35.5%, p = 0.020). Based on the Cox's Proportional Hazard model, the use of re-orientation strategy was the strongest protective factor of delirium: (HR 0.504, 95% C.I. 0.313-0.890, p=0.034), while age (HR 1.034, 95% CI: 1.013-1.056, p=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI: 2.247-4.032, p=0.018) were negative predictors.

Milisen et al. (2001) conducted a systemic review to investigate the characteristics and effica‐ cy of various multicomponent programs for managing older patients with delirium admit‐ ted in hospitals. Three RCTs, three controlled trials and one before-after study were included in the review. The multicomponent strategies for preventing delirium appear to be the most efficacious in reducing the incidence, both in surgical and medical patients. In ad‐ dition, some additional effects of preventive intervention were observed in the duration and severity of delirium, as well as functional status. The review suggested that multicomponent strategies are effective for preventing delirium.

Yang et al. (2008) conducted a prospective cohort study to investigate the mediating role of activity participation between educational attainment and risk of delirium. The contribu‐ tions of participation in specific activities for the development of delirium were also deter‐ mined. Seven hundred seventy-nine newly admitted patients without dementia, aged 70 or older, were studied. The findings showed that activity participation before hospitalization mediated the relationship between education and risk for delirium in elderly persons with‐ out dementia. It also suggested that participation in regular exercise was a significantly pro‐ tective factor of delirium.

Another study examined the efficacy of multicomponent intervention for preventing deliri‐ um. Inpatients with an intermediate or high risk for delirium were randomly assigned to re‐ ceive either a non-pharmacological intervention delivered by family members (144 patients) or standard management (143 patients). The outcome measure was the occurrence of deliri‐ um during hospitalization. The incidence rates of delirium in the intervention group and the control group were 5.6% and 13.3% (relative risk:0.41; 95% CI: 0.19–0.92; P = 0.027), respec‐ tively. The findings suggested that the non-pharmacological prevention of delirium given by family members, as compared with standard management, could reduce the patients' risk of delirium (Martinez et al., 2012).

These findings suggest that non-pharmacological interventions can reduce the incidence of delirium. Effective interventions, including multicomponent approach frequently focuses on predisposing factors in an individual patient. However, environmental prevention, such as re-orientation and environmental stimulation, are also effective for preventing delirium. A strong protective factor against delirium is the routinely participation in exercise. The use of multicomponent interventions by family members can also reduce the risk of delirium.

### **8.2. Psychopharmacological interventions**

Providing environmental cues, such as calendar, clock, family pictures, windows, should be encouraged to facilitate orientation. In addition, supportive interventions, including re-ori‐

Once a patient with high risks of delirium is hospitalized, all risks should be addressed, fol‐ lowed by the employment of effective preventive strategies (Salawu et al., 2009). Some stud‐ ies have shown the benefits of some preventive interventions for delirium. In general, those strategies usually include the multidisciplinary and psychopharmacological interventions.

Multi-factors, including patient vulnerabilities, predisposing factors at admission and pre‐ cipitating factors during hospitalization can interactively cause syndrome of delirium.

Inouye (2000) conducted a controlled clinical trial in 852 subjects to prevent delirium in eld‐ erly inpatients. Significant predisposing factors for delirium included vision impairment, se‐ vere illness, cognitive impairment and dehydration. Precipitating factors were physical restraint use, malnutrition, adding more than three drugs, bladder catheter use, and any ia‐ trogenic event. The findings showed that the incidence of delirium was significantly re‐ duced in the intervention group compared with usual care (9.9% vs. 15.0%, 95% CI: 0.39-0.92). The total number of days and episodes of delirium were also significantly smaller in the intervention group. These findings suggested that delirium prevention is useful and could reduce the morbidity and mortality associated with delirium in elderly patients.

Colombo et al. (2012) conducted a two-stage prospective observational study to deter‐ mine the epidemiology, risk factors and predictors of delirium. The subjects were all pa‐ tients admitted to the ICU settings over a year. The first phase was the observational stage, while the second one was the interventional phase. Delirium assessment was per‐ formed by using of the CAM twice daily after the sedation interruption. For the second phase, the patients were received both a re-orientation and environmental manipulations (e.g., acoustic and visual stimulation). The patients in phase 1 and 2 were 170 and 144, respectively. The incidence rate of delirium was significantly lower in the interventional group (phase-I vs. phase-II: 22% vs. 35.5%, p = 0.020). Based on the Cox's Proportional Hazard model, the use of re-orientation strategy was the strongest protective factor of delirium: (HR 0.504, 95% C.I. 0.313-0.890, p=0.034), while age (HR 1.034, 95% CI: 1.013-1.056, p=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI:

Milisen et al. (2001) conducted a systemic review to investigate the characteristics and effica‐ cy of various multicomponent programs for managing older patients with delirium admit‐ ted in hospitals. Three RCTs, three controlled trials and one before-after study were included in the review. The multicomponent strategies for preventing delirium appear to be

entation, reassurance and explanation about delirium, could reduce fear and anxiety.

**8. Prevention**

**8.1. Non-pharmacological interventions**

104 Mental Disorders - Theoretical and Empirical Perspectives

2.247-4.032, p=0.018) were negative predictors.

There have been several studies examining the effectiveness of antipsychotic medications for preventing delirium. Kalisvaart et al. (2005) conducted an RCT comparing haloperi‐ dol and placebo for preventing postoperative delirium in elderly hip-surgery patients, who were at risk for delirium. A number of 430 hip-surgery patients, aged 70 and older, at risk for postoperative delirium were randomly assigned to receive haloperidol 1.5 mg/d or placebo, started before surgery and continued for up to 3 days after surgery. The incidence rates of postoperative delirium in both groups were not significantly dif‐ ferent (haloperidol vs placebo, 15.1% vs. 16.5%). The means of delirium duration in halo‐ peridol and placebo treatment groups were 5.4 vs 11.8 days, orderly (mean difference 4.0, 95% CI=2.0-5.8, P<.001), and the means of hospital stay were 17.1±11.1 and 22.6±16.7 days, respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). The adverse events were not significantly different between groups. These results suggested that low doses of haloperidol might not be able to prevent postoperative delirium. However, it is safe and can decrease the severity, duration, and the length of hospitalization for these pa‐ tients.

**Drug**

\* Gray and Taylor (2010)

risk or subsydrome of delirium.

**9. Further studies**

terventions.

**Route administration**

Haloperidol IV 0.1 mg/hr 1b

Risperidone Oral 1 mg/day 1b Olanzapine Oral 5 mg/day 1b

**Dose**

Melatonin Oral 0.5 mg/day 1b Administer at night

There was a randomized, double-blinded, placebo-controlled trial of low dose exogenous melatonin in preventing delirium. A total of 145 patients, aged 65 years or older, hospital‐ ized in a medical unit were randomly assigned to receive either 0.5 mg of melatonin or pla‐ cebo every night for 14 days or until discharge. Based on the CAM, the incidence rate of delirium in the melatonin group was significant lower than that in the placebo group (12% vs 31%, p=0.014). The findings suggested that exogenous low dose melatonin may be of ben‐

The above-mentioned findings demonstrate the benefits low-dose risperidone and olanza‐ pine in preventing delirium. While they can reduce the incidence rate of delirium, their ad‐ verse events, in particular EPS, appear to be comparable to placebo. Similarly, exogenous low-dose melatonin administered at night time may be able to prevent delirium. Although haloperidol can reduce severity, duration and length of hospital stay in postoperative deliri‐ um, it might not be able to prevent the occurrence of this condition. However, cholinesterase inhibitors, including donepezil and rivastigmine may have no efficacy in this regard. There‐ fore, at low doses, high-potency antipsychotic agents, atypical antipsychotic medications or exogenous melatonin may be beneficial for the prevention of delirium in patients at high

Several lines of evidence indicate that pharmacological and environmental interventions are effective in the management and prophylaxis of delirium. However, those studies still have some limitations, including methodological weakness, small sample sizes, lack of placebo control in several studies and the specific patients. Further randomized, placebo-controlled trials and systemic reviews with well-defined methodology, large sample sizes, consistent outcomes and various clinical settings may be helpful in clarifying the benefits of these in‐

**Table 2.** Summary of evidences relevant to the pharmacological prophylaxis of delirium

efit in preventing delirium in this population (Al-Aama et al., 2012).

**Level of evidence\***

**Comment**

Management of Delirium http://dx.doi.org/10.5772/52756 107

0.5 mg intravenous bolus injection followed by continuous infusion at a rate of

0.1 mg/h for 12 hrs

Wang et al. (2012) conducted an RCT to determine the efficacy and safety of intravenous haloperidol for preventing delirium in critically ill elderly patients who had undergone non‐ cardiac surgery. A total of 457 patients, aged 65 years older, who were admitted to the inten‐ sive care unit after non cardiac surgery, were included and randomized to receive either haloperidol (0.5 mg intravenous bolus injection followed by continuous infusion at a rate of 0.1 mg/h for 12 hours; n = 229) or placebo (n = 228). The incidence rates of delirium were significantly lower in the haloperidol group(15.3% vs 23.2%, p = 0.031) during the first seven day after surgery. No drug related adverse event was noted. A short-term, low-dose intrave‐ nous haloperidol prophylaxis appeared to reduce the incidence rate of postoperative deliri‐ um.

Prakanrattana and Prapaitrakool (2007) conducted an RCT to determine the effects of risper‐ idone in preventing postoperative delirium after cardiac surgery with cardiopulmonary by‐ pass. A total of 126 adult patients underwent elective surgery were randomized to receive risperidone 1 mg or placebo after regained consciousness. With regard to the using of CAM, the incidence of postoperative delirium in the risperidone group was significantly lower than that in the placebo group (11.1% vs. 31.7% respectively, P=0.009, relative risk: 0.35, 95% CI: 0.16-0.77).

Larsen et al. (2010) conducted an RCT comparing the efficacy of olanzapine and placebo in preventing postoperative delirium in elderly patients after joint-replacement surgery. A to‐ tal of 400 elderly patients, aged 65 years or more, who had undergone elective knee- or hipreplacement surgery, were randomly assigned to receive either 5 mg of orally-disintegrating olanzapine or placebo before and after surgery. The findings showed that the olanzapine group had a significantly lower incidence of delirium.

There have been a few studies of cholinesterase inhibitors for preventing delirium. Liptzin et al. (2005) conducted an RCT comparing donepezil and placebo for the prophylaxis of postoperative delirium in elderly patients, who had undergone elective total joint-replace‐ ment surgery. Eighty patients without dementia were randomly assigned to receive either donepezil or placebo for 14 days before surgery and 14 days afterward. The findings did not show any benefit of donepezil in preventiong delirium in this population.

Gamberini et al. (2009) conducted an RCT to compare rivastigmine and placebo for pre‐ venting delirium in elderly patients during the first six days after elective cardiac sur‐ gery. A total of 120 patients, aged 65 or older, underwent the surgery with cardiopulmonary bypass were randomized to receive either placebo or rivastigmine. The incidence rates of delirium were not significantly between groups (30% vs 32%, p = 0.8). The findings did not support a short-term oral administered rivastigmine for delirium prophylaxis in this population.


**Table 2.** Summary of evidences relevant to the pharmacological prophylaxis of delirium

There was a randomized, double-blinded, placebo-controlled trial of low dose exogenous melatonin in preventing delirium. A total of 145 patients, aged 65 years or older, hospital‐ ized in a medical unit were randomly assigned to receive either 0.5 mg of melatonin or pla‐ cebo every night for 14 days or until discharge. Based on the CAM, the incidence rate of delirium in the melatonin group was significant lower than that in the placebo group (12% vs 31%, p=0.014). The findings suggested that exogenous low dose melatonin may be of ben‐ efit in preventing delirium in this population (Al-Aama et al., 2012).

The above-mentioned findings demonstrate the benefits low-dose risperidone and olanza‐ pine in preventing delirium. While they can reduce the incidence rate of delirium, their ad‐ verse events, in particular EPS, appear to be comparable to placebo. Similarly, exogenous low-dose melatonin administered at night time may be able to prevent delirium. Although haloperidol can reduce severity, duration and length of hospital stay in postoperative deliri‐ um, it might not be able to prevent the occurrence of this condition. However, cholinesterase inhibitors, including donepezil and rivastigmine may have no efficacy in this regard. There‐ fore, at low doses, high-potency antipsychotic agents, atypical antipsychotic medications or exogenous melatonin may be beneficial for the prevention of delirium in patients at high risk or subsydrome of delirium.

### **9. Further studies**

and can decrease the severity, duration, and the length of hospitalization for these pa‐

Wang et al. (2012) conducted an RCT to determine the efficacy and safety of intravenous haloperidol for preventing delirium in critically ill elderly patients who had undergone non‐ cardiac surgery. A total of 457 patients, aged 65 years older, who were admitted to the inten‐ sive care unit after non cardiac surgery, were included and randomized to receive either haloperidol (0.5 mg intravenous bolus injection followed by continuous infusion at a rate of 0.1 mg/h for 12 hours; n = 229) or placebo (n = 228). The incidence rates of delirium were significantly lower in the haloperidol group(15.3% vs 23.2%, p = 0.031) during the first seven day after surgery. No drug related adverse event was noted. A short-term, low-dose intrave‐ nous haloperidol prophylaxis appeared to reduce the incidence rate of postoperative deliri‐

Prakanrattana and Prapaitrakool (2007) conducted an RCT to determine the effects of risper‐ idone in preventing postoperative delirium after cardiac surgery with cardiopulmonary by‐ pass. A total of 126 adult patients underwent elective surgery were randomized to receive risperidone 1 mg or placebo after regained consciousness. With regard to the using of CAM, the incidence of postoperative delirium in the risperidone group was significantly lower than that in the placebo group (11.1% vs. 31.7% respectively, P=0.009, relative risk: 0.35, 95%

Larsen et al. (2010) conducted an RCT comparing the efficacy of olanzapine and placebo in preventing postoperative delirium in elderly patients after joint-replacement surgery. A to‐ tal of 400 elderly patients, aged 65 years or more, who had undergone elective knee- or hipreplacement surgery, were randomly assigned to receive either 5 mg of orally-disintegrating olanzapine or placebo before and after surgery. The findings showed that the olanzapine

There have been a few studies of cholinesterase inhibitors for preventing delirium. Liptzin et al. (2005) conducted an RCT comparing donepezil and placebo for the prophylaxis of postoperative delirium in elderly patients, who had undergone elective total joint-replace‐ ment surgery. Eighty patients without dementia were randomly assigned to receive either donepezil or placebo for 14 days before surgery and 14 days afterward. The findings did not

Gamberini et al. (2009) conducted an RCT to compare rivastigmine and placebo for pre‐ venting delirium in elderly patients during the first six days after elective cardiac sur‐ gery. A total of 120 patients, aged 65 or older, underwent the surgery with cardiopulmonary bypass were randomized to receive either placebo or rivastigmine. The incidence rates of delirium were not significantly between groups (30% vs 32%, p = 0.8). The findings did not support a short-term oral administered rivastigmine for delirium

show any benefit of donepezil in preventiong delirium in this population.

group had a significantly lower incidence of delirium.

prophylaxis in this population.

tients.

106 Mental Disorders - Theoretical and Empirical Perspectives

um.

CI: 0.16-0.77).

Several lines of evidence indicate that pharmacological and environmental interventions are effective in the management and prophylaxis of delirium. However, those studies still have some limitations, including methodological weakness, small sample sizes, lack of placebo control in several studies and the specific patients. Further randomized, placebo-controlled trials and systemic reviews with well-defined methodology, large sample sizes, consistent outcomes and various clinical settings may be helpful in clarifying the benefits of these in‐ terventions.

### **10. Conclusion**

Delirium is a condition in medical emergency, common in medical or surgical settings and highly incident in intensive care units. Several causative factors for the development of de‐ lirium have been identified. Specific treatment for curing or removing the causes is an effec‐ tive approach. Initially, the precipitating factors are often overlooked or unidentified. Therefore, supportive and symptomatic managements are beneficial. For hyperactive type of delirium, all antipsychotic medications may help relief the behavioral disturbance, in‐ cluding psychotic symptoms. Although haloperidol is considered as the first-line treatment, it may increase the risk of adverse events, especially EPS. Alternatively, atypical antipsy‐ chotic agents, which have low propensity to induce EPS, may be useful in this condition. In‐ travenous haloperidol may be associated with QT prolongation and torsades de pointes. To avoid these serious adverse events, only low doses of IV haloperidol (a total cumulative dose < 2 mg) should be administered in delirious patients without concomitant risk factors. Based on its pharmacokinetic profile, IM haloperidol can be an alternative for the behavioral control of acute or severe delirium. For hypoactive delirium, only aripriprazole, a non seda‐ tive antipsychotic agent, is evidently beneficial. In addition to psychopharmacological inter‐ ventions, environmental manipulation is also necessary in the management of delirium and should be used in all delirious patients. Preventing delirium is challenging. A number of studies demonstrate the efficacy of some interventions in preventing delirium. The multi‐ component strategy, systemically focusing on predisposing factors in individual patients is one of the highly effective approaches. Pharmacological prophylaxis is another strategy in preventing delirium. The evidence so far suggests that risperidone, olanzapine and melato‐ nin may be effective in preventing delirium.

placebo-controlled trial. *International journal of geriatric psychiatry,* Vol. 26, No. 7, pp.

Management of Delirium http://dx.doi.org/10.5772/52756 109

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ISSN1364-8535

### **Acknowledgement**

We thank Professor Manit Srisurapranont, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Thailand for reviewing and editing this chapter.

### **Author details**

Narong Maneeton and Benchalak Maneeton

Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Thailand

### **References**

[1] Al-Aama, T., Brymer, C., Gutmanis, I., Woolmore-Goodwin, S. M., Esbaugh, J. & Dasgupta, M. (2012). Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. *International journal of geriatric psychiatry,* Vol. 26, No. 7, pp. 687-694, ISSN1099-1166

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**10. Conclusion**

108 Mental Disorders - Theoretical and Empirical Perspectives

nin may be effective in preventing delirium.

Narong Maneeton and Benchalak Maneeton

**Acknowledgement**

**Author details**

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Delirium is a condition in medical emergency, common in medical or surgical settings and highly incident in intensive care units. Several causative factors for the development of de‐ lirium have been identified. Specific treatment for curing or removing the causes is an effec‐ tive approach. Initially, the precipitating factors are often overlooked or unidentified. Therefore, supportive and symptomatic managements are beneficial. For hyperactive type of delirium, all antipsychotic medications may help relief the behavioral disturbance, in‐ cluding psychotic symptoms. Although haloperidol is considered as the first-line treatment, it may increase the risk of adverse events, especially EPS. Alternatively, atypical antipsy‐ chotic agents, which have low propensity to induce EPS, may be useful in this condition. In‐ travenous haloperidol may be associated with QT prolongation and torsades de pointes. To avoid these serious adverse events, only low doses of IV haloperidol (a total cumulative dose < 2 mg) should be administered in delirious patients without concomitant risk factors. Based on its pharmacokinetic profile, IM haloperidol can be an alternative for the behavioral control of acute or severe delirium. For hypoactive delirium, only aripriprazole, a non seda‐ tive antipsychotic agent, is evidently beneficial. In addition to psychopharmacological inter‐ ventions, environmental manipulation is also necessary in the management of delirium and should be used in all delirious patients. Preventing delirium is challenging. A number of studies demonstrate the efficacy of some interventions in preventing delirium. The multi‐ component strategy, systemically focusing on predisposing factors in individual patients is one of the highly effective approaches. Pharmacological prophylaxis is another strategy in preventing delirium. The evidence so far suggests that risperidone, olanzapine and melato‐

We thank Professor Manit Srisurapranont, Department of Psychiatry, Faculty of Medicine,

[1] Al-Aama, T., Brymer, C., Gutmanis, I., Woolmore-Goodwin, S. M., Esbaugh, J. & Dasgupta, M. (2012). Melatonin decreases delirium in elderly patients: a randomized,

Chiang Mai University, Thailand for reviewing and editing this chapter.

Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Thailand


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**Chapter 6**

**Racism and Mental Illness in the UK**

Apu Chakraborty, Lance Patrick and Maria Lambri

There is substantial evidence of differential outcomes for different racial and ethnic groups in many health, social and economic arenas in the United Kingdom today, ranging from dis‐ ease prevalence and outcome, hiring and promotion in the labour workforce, to loan appro‐ vals in mortgage lending, to rate of arrest and detention in the criminal justice system. These disparities – and others – describe social conditions that most Britons believe deserve some measure of attention. To understand such conditions and to fashion appropriate responses, it is important to assess whether and how racism and racial discrimination, along with other factors, may contribute to observed disparities in mental health outcomes among racial and

The focus on measuring racial discrimination in this study raises an initial question of "what is race?" Defining race is a task far more complex than can be accomplished here. In fact, there is little consensus on what race actually means. The term "race" was used to distin‐ guish populations in different areas on the basis of differing physical characteristics that had developed over time, such as the colour of skin, facial features, and other features (Zucker‐

Recently, genetics researchers have found evidence of genetic clusters that correspond to geographically similar populations and yield the kind of variations in phenotype that have been used to construct concepts of race. Recent developments in the fields of genetics and

and reproduction in any medium, provided the original work is properly cited.

© 2013 Chakraborty et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/46217

**1. Introduction**

ethnic groups.

**2. Race**

man 1990).

**2.1. Biological definition of race**

