DTS, Rape

DELIRIUM TREMENS
RAPE AND SEXUAL ABUSE
Presenter:-Dr. Gizachew A.(RI)

Moderator :- Dr. Enque (psychiatrist )
SPHMMC
Department of psychiatry
Feb,2017
BY Gizachew @ R1 December 28, 2017
OUTLINE
2
OBJECTIVES
INTRODUCTION
EPIDEMIOLOGY
DIAGNOSIS AND CLINICAL FEATURES
DIFFERENTIAL DIAGNOSIS
TREATMENT
REFERRENCES

Objectives
3
 To discuss clinical feature ,diagnosis and

management of patients with delirium tremens
 To understand the prevalence of rape and sexual
abuse
 To discuss the consequences of saxual abuse

INTRODUCTION
4
 Delirium tremens (DT) :-

 is defined by hallucinations, disorientation, tachycardia,
hypertension, fever, agitation, and diaphoresis in the setting
of acute reduction or abstinence from prolonged use of
alcohol.
 DTs are most likely to develop if the patient has had an

alcohol withdrawal seizure or a concomitant medical
disorder.

Epidemiology and risk factors
5
 About 5 % of persons with alcohol-related

disorders who are hospitalized have DTs.
 Episodes of DTs usually begin in a patient’s 30s or

40s after 5 to 15 years of heavy drinking, typically
of the binge type.

6
 Physical illness (e.g., hepatitis or pancreatitis)

predisposes to the syndrome
 A person in good physical health rarely has DTs

during alcohol withdrawal

Risk factors for the development of DT
7
 A history of sustained drinking

 A history of previous DT
 Age greater than 30
 The presence of a concurrent illness
 The presence of significant alcohol withdrawal in
the presence of an elevated alcohol level
 A longer period since the last drink

Diagnosis and Clinical Features
8
 Patients with recognized alcohol withdrawal

symptoms should be carefully monitored to prevent
progression to alcohol withdrawal delirium.
 Alcohol withdrawal delirium is a medical emergency.
 Patients with delirium are a danger to themselves

and to others

9
 May be assaultive or suicidal or may act on

hallucinations or delusional thoughts as if they were
genuine dangers
 Untreated, DTs has a mortality rate of 20 %.
 Although withdrawal seizures commonly precede

the development of alcohol withdrawal delirium,
delirium can also appear unheralded
10

11

12

13

Differential Diagnosis
14
 Psychotic disorders and bipolar and

depressive disorders with psychotic features
 Acute stress disorder
 Malingering and factitious disorder

 Other neurocognitive disorders
 medical conditions
 Sedative, hypnotic, or anxiolytic withdrawal

Treatment
15
 The best treatment for DTs is prevention
 Patients withdrawing from alcohol who exhibit

withdrawal phenomena should receive a
benzodiazepine, until they seem to be out of
danger
 Antipsychotic medications that may reduce the

seizure threshold in patients should be avoided
16
 A high-calorie, high-carbohydrate diet

supplemented by multivitamins is also important.
 Physically restraining patients with the DTs should be

avoided.
 When patients are disorderly and uncontrollable, a

seclusion room can be used.

17
 Dehydration, often exacerbated by diaphoresis and

fever, can be corrected with fluids given by mouth or IV
 The emergence of focal neurological symptoms,

 lateralizing seizures
 increased intracranial pressure,
 evidence of skull fractures
 other indications of CNS pathology should prompt clinicians
to examine a patient for additional neurological disease

18
 Warm, supportive psychotherapy in the treatment

of DTs is essential
 Patients are often bewildered, frightened, and

anxious because of their tumultuous symptoms, and
skillfull verbal support is imperative

Benzodiazepines
19
 Orally administered chlordiazepoxide (50 mg

every 2–4 hours),
 diazepam (10 mg every 2–4 hours),

 oxazepam (60 mg q2h),
 and lorazepam (1 mg q2h) are commonly used

20
 Patients in severe withdrawal-related symptoms,

may require up to 10 days of treatment before
benzodiazepines can be completely withdrawn
 Benzodiazepine administration should be

discontinued once detoxification is completed

21
 For patients who have

 severe hepatic disease,
 are elderly, dementia,
 or another cognitive disorder,
 short-acting benzodiazepines such as oxazepam or

lorazepam are preferred.

22
Adrenergic agonists and antagonists
 Beta-adrenergic antagonists
 (e.g., propranolol, 10 mg p.o. q6h) have been used to
reduce signs of autonomic nervous system hyperactivity
and, at higher doses, arrhythmias

23
 Atenolol has been used for a similar purpose,

usually in combination with benzodiazepines ,
 thus allowing the use of lower doses of

benzodiazepines and thereby reducing the sedation
and cognitive impairment often associated with
benzodiazepine use

24
 Clonidine:-
 an α-adrenergic agonist (0.5 mg PO BID or TID has
been shown to reduce tremor, heart rate, and blood
pressure
 However, the use of beta-blockers or clonidine

alone for the treatment of alcohol withdrawal is not
recommended because of their lack of efficacy in
preventing seizures.

25
Antipsychotic agents
 For patients manifesting delirium, delusions, or

hallucinations, antipsychotic agents, particularly
haloperidol (0.5–2.0 mg i.m. q2h, as needed) are
recommended

26
 Because antipsychotic agents are not effective for

treating the underlying withdrawal state they
should be used as an adjunct to benzodiazepines
 Most patients will require <10 mg of haloperidol

every 24 hours, although some patients may require
considerably more.

Intravenous ethanol
27
 There is no clear evidence for the effectiveness of

ethanol in this application
 The use of intravenous ethanol is not supported by
the current published data
 Thiamine
 100mg BID or TID iv/po 1-2 weeks.

Refractory DT
28
 Barbiturates may be useful in reducing withdrawal

symptoms in patients whose symptoms are
refractory to benzodiazepines
 Phenobarbital
 Propofol
 0.3-1.25mg/kg/body wt upto 4mg /kg/body wt

29
RAPE AND SEXUAL ABUSE

30
 Sexual violence is defined as:

any sexual act, attempt to obtain a sexual act,
unwanted sexual comments or advances,or acts to
traffic, or otherwise directed, against a person’s
sexuality using coercion,by any person regardless
of their relationship to the victim, in any setting,
including but not limited to home and work.

RAPE
31
 Rape is the forceful coercion of an unwilling victim

to engage in a sexual act, usually sexual intercourse,
although anal intercourse and fellatio can also be acts
of rape.
 The legal definition of rape varies from state to state
 male rape is legally defined as sodomy.

32
 Rape is categorized according to the relationship

between the perpetrator and the victim.
 Stranger rape:-
 describes nonconsensual sexual penetration between
individuals who do not know each other before the
sexual act.

33
 Acquaintance rape
 describes nonconsensual sexual penetration between
individuals who know each other in some capacity
before the sexual act.
 Date rape
 is a subset of acquaintance rape in which
nonconsensual sexual penetration occurs between two
people who are in a romantic relationship.

34
 Gang rape
 Rape involving at least two or more perpetrators.
 Sexual trafficking:-
 Each year hundreds of thousands of women and
girls through out the world are bought and sold into
prostitution or sexual slavery.

35
 Sexual coercion
 is a term used for incidents in which a person dominates
another by force or compels the other person to perform a
sexual act.
 Sexual harassment
 refers to sexual advances, requests for sexual favors, or
verbal or physical conduct of a sexual nature all of which
are unwelcomed by the victim.

Prevalence
36
 Accurate statistics are difficult to obtain.
 The Rape, Abuse, and Incest National Network (RAINN)

estimates that over half of rapes go unreported.
 In USA, an average of 207,754 rapes and sexual

assaults per year.

37
 1 in 6 US women and 1 in 33 US men are victims of

sexual assault.
 Most men who commit rapes are between 25 and 44
years of age
 51% are white and tend to rape white victims

 47%are black and tend to rape black victims
 Remaining 2 % come from all other races

 Homosexual rape is much more frequent among men.

38

39

40

In Ethiopia
41
 A cross sectional school based survey was done in

Addis Ababa and western shoa.
 1401 female students were involved.
 Results:-
 Completed and attempted rape 5% and 10% respectively

42
 Sexual harassment – 74% of female students.
 Among those who reported being raped, 17(24%) had

vaginal discharge and 12(17%) became pregnant.
 Social isolation ,fear and phobia, hoplessness and suicide

attempt were reported in 33%,22% ,6% of rape victims
respectively.
Ethiopian medical journal(1998,36(3): 167-174)

Risk Factors
43
 Factors influencing the risk of sexual violence include:

 being young;
 consuming alcohol or drugs;
 having previously been raped or sexually abused;
 having many sexual partners;
 involvement in sex work;
 becoming more educated and economically empowered,
 poverty.

Risk factors….
44
 Acceptance of rape myths

 Rape myths are prejudiced, stereotyped, or false
beliefs about rape, rape victims, and rapists.
 Acceptance of rape myths perpetuates unwanted
sexual contact by encouraging and reinforcing
coercive sexual behavior

Examples of rape myths include
45
 “Acquaintance rape is not ‘real rape’ and does not

harm the victim.”
 “All women want to be raped.”
 “No means yes.”
 “Only bad girls get raped.”
 “A woman who goes to a man’s home on their first date
implies that she is willing to have sex.”

46

47

Perpetrators
48
 Rape is considered a crime of power and aggression
 Male rapist can be categorized into separate

groups:
 Sexual sadists
 Exploitive predators
 Inadequate men
Perpetrators……
49
 7% of all rapes are perpetrated by close relatives of

the victim
 10% of rapes involve more than one attacker
 Often accompanies another crime
 Rapists always threaten victims
 Substance abuser
 The victim is usually smaller than the rapist

consequences of
sexual violence
50
 Among the more common consequences of sexual

violence are those related to:-
 reproductive,
 mental health and

 social wellbeing.

Pregnancy and gynaecological
51
complications
 Pregnancy may result from rape, though the rate

varies between settings
 in the United States ,rape related pregnancy rate was 5.0%
 A study of adolescents in Ethiopia found that among

those who reported being raped
 17% became pregnant after the rape ,
 a figure which is similar to the 15–18% reported by rape crisis centres in
Mexico.

52
 Gynaecological complications have been consistently

found to be related to forced sex.
 These include:-
 vaginal bleeding or infection,
 fibroids,
 decreased sexual desire,
 genital irritation,
 pain during intercourse,
 chronic pelvic pain and urinary tract infections.

Sexually transmitted diseases
53
 HIV infection and other sexually transmitted

diseases are recognized consequences of rape.
 Violent or forced sex can increase the risk of

transmitting HIV.
 In forced vaginal penetration, abrasions and cuts

commonly occur, thus facilitating the entry of the virus
when it is present through the vaginal mucosa.

Mental health disorders
54
 In one population-based study, the prevalence of

symptoms or signs suggestive of a psychiatric
disorder was:-
 33% in women with a history of sexual abuse as
adults,
 % in women with a history of physical violence by an
intimate partner and
 6% in non-abused women.

55
 The most common reported psychiatric disorders

after sexual assault in women are:-
 Posttraumatic stress disorder (PTSD)
 Mood disorders
 Suicidal behavior
 Substance abuse
 Eating disorders
 Sexual dysfunction

56
 A study of adolescents in France also found a

relationship between having been raped and
 currentsleep difficulties,
 depressive symptoms,
 somatic complaints,
 tobacco consumption
 and behavioural problems

Suicidal behaviour
57
 Women who experience sexual assault in childhood

or adulthood are more likely to attempt or commit
suicide than other women.
 The association remains, even after controlling for

sex, age, education, symptoms of post-traumatic
stress disorder and the presence of psychiatric
disorders.

58
 In Ethiopia, 6% of raped school girls reported

having attempted suicide.
 A study of adolescents in Brazil found prior

sexual abuse to be a leading factor predicting
several health risk behaviours, including suicidal
thoughts and attempts.

59
MANAGMENT

Initial Evaluation
60
 Any concerning injuries as being a potential stigmata

of assault
 The patient may initially be avoidant

 Complete a thorough evaluation
 It is important to reduce the victim’s stress and

anxiety regarding discussion of the event

61
 The initial evaluation process should be explained to

the patient before beginning
 The physician should remain attuned to nonverbal

patient responses

Safety
62
 After an assault, it is imperative that a safety

assessment be performed on the victim.
 Evaluate for suicidal and homicidal ideation
 The patient’s safety from further assault also needs to

be addressed
 Screen for severe psychological symptoms that

would cause difficulty in self-care
63
 Look for:
 Acute mood deterioration or affective instability
 Self-destructive behaviors
 Dissociative symptoms
 Psychosis

Hospitalization
64
 Common indications for hospitalization include

 Severe medical injuries
 Suicidality or homicidality
 Dissociative or psychotic symptoms
 Mood instability or affective dysregulation
 Self-destructive behaviors
 A continued serious threat to the patient’s life or well-

being.

Legal Issues
65
 A physician evaluating an assault victim needs to

adhere to mandatory reporting requirements for the
state in which he or she is practicing.
 Mandatory reporting of female and child abuse

 Abuse of developmentally disabled children
 Abuse of the elderly

Psychotherapy
66
Cognitive-behavioral approaches
 Exposure therapy has been shown to help victims

emotionally process the assault by decreasing their
fear to memories or cues of the event.
 Brief early CBT may accelerate recovery in victims

manifesting acute PTSD.

Psychotherapy ……
67
 These individual psychotherapies may be

augmented with
 Group psychotherapy
 Art therapy, dance and movement therapy
 Music therapy
 Body-oriented approaches if they prove beneficial to

the patient.

Psychopharmacological Treatment
68
 Medication may be beneficial in certain

circumstances.
 The patient’s safety and the safety of those around

the patient will help to decide the need for
pharmacologic intervention.

69
 Medicate a patient with

 Incapacitating
anxiety
 Extreme aggression toward themselves or others, or
dissociation
 Psychoses immediately after the assault

70
 Most medication treatment will be initiated much

later after the assault as the patient develops
symptoms of
 PTSD
 Depression
 Anxiety
 Obsessive-compulsive disorder, or psychosis

In our setup
71
 Recording a full history and description of the incident,

listing all the assembled evidence;
 Thorough physical examination;
 Assessment of the risk of pregnancy;
testing for and treating sexually transmitted
diseases, including, where appropriate, testing for HIV;
 providing emergency contraception and, counselling on
abortion;
 Psychiatrist evaluation
 Report to police the medical finding

REFERENCES
72
 Synopsis of psychiatry 11th edition

 Kaplan and Sadock’s comprehensive text book of
psychiatry 9th edition
 Uptodate 21.2
 Pubmed
 World report on violence and health,WHO,2002

THANK YOU

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DELIRIUM TREMENS

RAPE AND SEXUAL ABUSE

Presenter:-Dr. Gizachew A.(RI)

BY Gizachew @ R1 December 28, 2017

 To discuss clinical feature ,diagnosis and

BY Gizachew @ R1 December 28, 2017

 Delirium tremens (DT) :-

 DTs are most likely to develop if the patient has had an

BY Gizachew @ R1 December 28, 2017

 About 5 % of persons with alcohol-related

 Episodes of DTs usually begin in a patient’s 30s or

BY Gizachew @ R1 December 28, 2017

 Physical illness (e.g., hepatitis or pancreatitis)

 A person in good physical health rarely has DTs

BY Gizachew @ R1 December 28, 2017

 A history of sustained drinking

BY Gizachew @ R1 December 28, 2017

 Patients with recognized alcohol withdrawal

 Alcohol withdrawal delirium is a medical emergency.

 Patients with delirium are a danger to themselves

BY Gizachew @ R1 December 28, 2017

 May be assaultive or suicidal or may act on

 Untreated, DTs has a mortality rate of 20 %.

 Although withdrawal seizures commonly precede

BY Gizachew @ R1 December 28, 2017

BY Gizachew @ R1 December 28, 2017

BY Gizachew @ R1 December 28, 2017

BY Gizachew @ R1 December 28, 2017

 Psychotic disorders and bipolar and

 Malingering and factitious disorder

BY Gizachew @ R1 December 28, 2017

 The best treatment for DTs is prevention

 Patients withdrawing from alcohol who exhibit

 Antipsychotic medications that may reduce the

 A high-calorie, high-carbohydrate diet

 Physically restraining patients with the DTs should be

 When patients are disorderly and uncontrollable, a

BY Gizachew @ R1 December 28, 2017

 Dehydration, often exacerbated by diaphoresis and

 The emergence of focal neurological symptoms,

BY Gizachew @ R1 December 28, 2017

 Warm, supportive psychotherapy in the treatment

 Patients are often bewildered, frightened, and

BY Gizachew @ R1 December 28, 2017

 Orally administered chlordiazepoxide (50 mg

 diazepam (10 mg every 2–4 hours),

 and lorazepam (1 mg q2h) are commonly used

BY Gizachew @ R1 December 28, 2017

 Patients in severe withdrawal-related symptoms,

 Benzodiazepine administration should be

BY Gizachew @ R1 December 28, 2017

 For patients who have

 or another cognitive disorder,

 short-acting benzodiazepines such as oxazepam or

BY Gizachew @ R1 December 28, 2017

Adrenergic agonists and antagonists

BY Gizachew @ R1 December 28, 2017

 Atenolol has been used for a similar purpose,

 thus allowing the use of lower doses of

BY Gizachew @ R1 December 28, 2017

 However, the use of beta-blockers or clonidine

BY Gizachew @ R1 December 28, 2017

 For patients manifesting delirium, delusions, or