SUBSTANCE USE AND ADDICTIVE DISORDERS😊

SUBSTANCE USE AND ADDICTIVE DISORDERS

Dependence

• Craving:
• Strong desire or compulsion to take a substance.

• Withdrawal Symptoms:
• Develop after reducing or stopping the substance.
• Physical symptoms: tremors.
• Psychological symptoms.

• Tolerance:
• Increased amount of substance needed for same effect.
• Tolerance and withdrawal suggest physical dependence.

• Difficulty controlling substance-taking behaviour.

• Progressive neglect of alternative pleasures or interests.

• Persistence despite clear evidence of harmful consequences.

• DSM-5 uses the diagnosis of Substance Use Disorder.

Inebriant

• CNS depressants.

• Order of toxicity: Ethanol < Methanol < Isopropyl alcohol

• Effects: Male < Female (D/t ↓water, ↑fat).

Alcohol

• Active ingredient: Ethyl alcohol or ethanol (C2H5OH).

Issue of drunkenness certificate:

The stages of change model (cyclical):

• Mnemonic: PC addicted says DARM

• Stages
1. Enter
2. Precontemplation
• No
• Affected by motivation → can change to maybe
3. Contemplation
• Maybe
4. Determination (Exit & re-enter at any stage)
• Prepare
5. Action
• Action
6. Relapse (Exit & re-enter at any stage)
7. Maintenance

Screening Test

• CAGE Questionnaire:
• Positive on ≥2 suggests Alcohol Use Disorders.
• Cut down on Drinking.
• Annoyance when asked about drinking.
• Guilty about drinking.
• Eye-opener needed in the morning.

• AUDIT: Alcohol use disorder identification test.

• MAST: Michigan alcoholism screening test.

• SADQ:
• Severity of alcohol dependence questionnaire.

Alcohol Intoxication

• McEwan sign
• > 250 mg% → Altered constriction and dilatation of pupil
• Mceven - Uneven



• Hippus drinking alcohol (), with barbie () eating a cone (aconitase)

• Morbid Jealosy

• Munich-Beer heart: DCM/ A Fib

• Mellanby effect → Urge to Drink more and more → till blackout
• Me ila -but Buy more

• Markers
• CDT = Carbohydrate-Deficient Transferrin
• Most specific
• GGT → Sensitive

• High blood alcohol concentration after consumption.

• Alcohol is a CNS depressant.

• Anterograde amnesia is seen during intoxication.
• Patient can't remember events after intoxication

Holiday heart syndrome:

• Sudden arrhythmia

Punishment for crime under:

Alcohol Withdrawal Symptoms

• Develop after reducing or stopping alcohol intake.

6-8 hours:

• Most common sign:
• Tremulousness (coarse tremors).

• Other symptoms:
• GI:
• Nausea, Vomiting.
• Autonomic Hyperactivity:
• Anxiety, Sweating, Mydriasis, Tachycardia, Hypertension.

8-12 hours:

• Alcoholic hallucinosis.
• Auditory Hallucinations >> Visual / Tactile
• Occurs in clear consciousness.

12-24 hours:

• Seizures.
• Generalized Tonic-Clonic Seizures (GTCS).
• Known as Rum fits.

Within 72 hours (Peak: 48-72 hrs):

• Delirium tremens.
• Present after 72 hours
• Mental manifestations (GHN mnemonic):
• Global confusion.
• Disoriented (Time, place, person).
• Hallucinations.
• Visual > Auditory
• Nightmares.
• Physical manifestations show autonomic hyperactivity:
• High blood pressure.
• High heart rate.
• High body temperature.
• Diaphoresis.
• Most severe form of alcohol withdrawal.
• A medical emergency.
• Untreated mortality rate: 20%.
• Chlordiazepoxide is Rx

Treatment

1. Detoxification.

2. Maintenance.

Detoxification

• Manages withdrawal symptoms.

• Duration: 7-14 days.

• Drug of choice:
• Benzodiazepines (BZD) + Thiamine.
• Short-acting: Lorazepam.
• Long-acting: Chlordiazepoxide, Diazepam.

• For withdrawal Hallucinosis, Seizures, or Delirium Tremens:
• Acute infection can trigger delirium tremens
• DOC: Chlordiazepoxide
• Requires higher initial doses, then tapered.
• Dose reduction: 20% daily from the first day's dose.
• BZD is stopped by day 7-14.

• Treatment in Liver Disease (Deranged LFTs):
• Preferred drugs:
• Lorazepam > Oxazepam > Temazepam
• (Mnemonic: Liver OK).
• Undergo Glucuronidation
• No active metabolites.
• Avoid Chlordiazepoxide, Diazepam.

Maintenance

• Goal: Maintain Abstinence.

• Includes Pharmacological and Non-Pharmacological Treatment.

Pharmacological Treatment

1. Deterrent Agent (Aversive Agent):
• Drug: Disulfiram.
• MOA:
• Irreversibly inhibits Aldehyde Dehydrogenase (ALDH).

• Effect:
• Inhibits acetaldehyde metabolism.
• Increases acetaldehyde concentration.
• Acetaldehyde is toxic.
• Produces unpleasant symptoms:
• nausea, vomiting, burning sensation.
• Severe reaction:
• MI or respiratory depression.
• Use in motivated patients only.

2. Anticraving agents:
• Mnemonic: Alcohol NOT BF
• Alcohol: Acamprosate.
• N: Naltrexone > Acamprosate
• O: Ondansetron.
• T: Topiramate.
• Best: Baclofen.
• Friend: Fluoxetine.
• Acamprosate: NMDA (Glutamate) receptor antagonist.
• Naltrexone: Opioid antagonist (mu).

Non-pharmacological treatment

• Cognitive Behavioural Therapy (CBT).

• Alcohol Anonymous (AA):
• Self-help groups.
• Follow a 12-step approach.

Alcohol Induced Neurocognitive Disorders

• Associated with long-term alcohol use.
1. Wernicke's encephalopathy.
2. Korsakoff psychosis/syndrome.

Methanol:

• Illicit liquor, AKA wood alcohol.

• Mass poisoning: Hooch tragedy.

• Symptoms:
• Abdominal pain/vomiting.
• Blurring of vision.
• Blindness (Optic atrophy).

• Only High anionic gap metabolic acidosis (HAGMA).

• Antidote:
• Fomepizole 
• Inhibit - Alcohol dehydrogenase
• Ethanol.
• Compete with methanol for aldehyde dehydrogenase
• ↓ formation of Formaldehyde (toxin)

Ethylene Glycol:

• Anti-freeze solution.

• Oxalic acid:
• Hypocalcemia.
• Urine cast
• Renal tubular damage.
• Calcium monohydrate stones (envelope)

• Glycolic acid
• HAGMA

• Net:
• Ethylene glycol → HAGMA + Hypocalcemia
• Methanol → HAGMA only

• Treatment:
• Fomepizole.
• Ethanol.
• Calcium gluconate.

Methanol Metabolites

1. formaldehyde

2. formic acid

3. lactic acid

 

Ethylene glycol metabolites

• Glycoaldehyde

• Glycolic acid (Toxic)

• Oxalic acid + α Hydroxy β Ketoadipate

Opioids

• Source: Opium poppy plant - Papaver somniferum.

• Most common abused opioid: Heroin (Diacetyl Morphine).

• Street names: Smack, Brown sugar.

Opioid Intoxication

• Clinical triad:
1. Respiratory depression.
2. Pinpoint pupils (Miosis).
3. Coma.

• Treatment:
• IV Naloxone (short-acting opioid antagonist).

Opioid Withdrawal

1. Detoxification

• Manages withdrawal symptoms.

• Agonist Therapy:
• Methadone:
• Opioid Agonist (mu).
• Mnemonic: Methadone is method number 1 to treat
• Buprenorphine:
• Partial mu agonist + κ Antagonist
• NOTE:
• Morphine → More μ & κ + → Morphine more (μ & κ )
• Pentazocine → Partial μ & κ +
• Buprenorphine → bU → μ → Partial μ, Antagonist at κ

• Symptomatic Treatment:
• Clonidine:
• α-2 Adrenergic Agonist
• Reduces autonomic symptoms (Sweating, Restlessness, Tremor).
• Pain: NSAIDs.
• Sleep: Benzodiazepines.

2. Maintenance

• Prevents relapse.

A. Pharmacological treatment

• Opioid Substitution Therapy (OST):
• Substitute illicit, short-acting opioid with a safe, longer-acting one.
• Drugs:
• Methadone
• Buprenorphine.

• Opioid Antagonist Treatment:
• Drug:
• Naltrexone
• mu receptor antagonist
• Blocks opioid receptors,
• preventing euphoria from external opioid use.

B. Non-Pharmacological Treatment

• Cognitive Behaviour Therapy (CBT).

• Narcotic Anonymous (NA):
• 12-step,
• self-help group.

Cannabis

• Most common illicit substance (India and World).

• Some of the most common substances used:
• In India, Tobacco>Alcohol
• In world, Alcohol>Tobacco

• Now, the most common substance is Caffeine

• AKA Grass/Rope/Hash/Joint/Weed/Indian hemp/MJ/Charas/Marijuana
• Burnt rope smell → Cannabis
• Can full of grass
• Can full of rope
• Can with Charakk MJ

• Active principle: ∆-9 Tetrahydrocannabinol (∆-9 THC).
• Mnemonic: Teach (TH) to take cannabis (C)

Preparation	Part of plant	Active principal %
Bhang	Dried leaves	< 15 %
Ganja (Joint/Reefer)	Dried flower (Female plant)	15 - 25 %
Charas/Hashish	Dried resin	25 - 40 %
Hash oil	Resin	Most potent: 60 - 70 % Highest concentration of TetraHydroCannabinol
Majoon	Sweet prepared with Bhang	ㅤ

• Mnemonic:
• Bank(bhang) il ninn leave (leaf) eduth flower(dried flower) kond gancha() yude aduth poyi. Dry (dried resin) aayirunna charakkine (charas) rasippikan(resin) oil( hash oil) itt

• Source:
• Hemp plant or Cannabis Sativa.

Cannabis Intoxication

• Symptoms:
• Euphoria.
• Sense of Time Distortion (slowing down).
• Redness of Conjunctiva.
• Increased Appetite.
• Vivid dreams
• "stoned" or "high."
• Hallucinations.
• High dose: Delirium.

Cannabis Withdrawal

• Symptoms:
• Irritability, Anxiety.
• Sleep difficulty (Insomnia, disturbing dreams).
• Decreased Appetite,
• Decreased Mood.
• Only Mild Physical:
• Tremors, sweating, Fever, Abdominal Pain.

Associated Phenomena with Cannabis

Chronic cannabis abuse:

• Mnemonic: AIR

• CanaBIS ⇒ BUS (hindi) ⇒ Stop → Amotivation → amok
• Amotivational syndrome.
• Unwillingness to persist in tasks.
• Apathetic, Lethargic, weight gain.
• Occurs after chronic use.
• Insanity:
• Hashish/Hemp insanity.
• Psychotic symptoms (Delusions, Hallucinations).
• Disappear within a month of stopping use.
• Cannabis is a risk factor for Schizophrenia.
• Run amok:
• Homicidal f/b suicidal
• Homicidal impulse.
• Development of Rage
• may hurt or kill others.
• Not criminally liable: 22 BNS
• Two two loose screws → Not liable

• Bad Trip
• Restlessness
• Fearful
• Panic Symptoms

• Flashback:
• Re-experiencing symptoms days or weeks after last use.

Treatment

• Mild withdrawal:
• Supportive care.

• Moderate to severe:
• Short-term Benzodiazepines.

Hallucinogens

• Cause hallucinations and delusions.

Examples:

• Phencyclidine (PCP): Angel Dust → Ketamine analogue → Dissociation

• Ketamine → Dissociation

• LSD: Lysergic Acid Diethylamide.
• Reflex Hallucination (Morbid Synasthesia):
• Real stimulus in one sense produces hallucination in another.
• Smelling colours and seeing sound? Think LSD
• Flashbacks:
• flashes of color, visual distortion
• Bad Trip

• Mescaline: From Cactus.

• Psilocybin: From Mushrooms.

• MDMA (Ecstasy)
• Paranoid hallucinatory syndrome
• Violent behavior
• Choreiform movements

Withdrawal Symptoms

• Lacks withdrawal symptoms.

• Therefore, lacks physical dependence.

Club Drugs

• Also called Rave Drugs

• Mnemonic: Club drug → KFG →ELM
• Ecstasy (MDMA).
• Flunitrazepam (Rohypnol).
• Gamma Hydroxy Butyrate (GHB).
• Ketamine,
• LSD,
• Methamphetamine.

• Date Rape Drugs: KGF
• Cause disorientation and sedation.
• K: Ketamine.
• G: Gamma Hydroxy Butyrate (GHB)
• F: Flunitrazepam.

Stimulants

1. Cocaine.

2. Amphetamine (Superman drug, Eve)

Cocaine

• Source: Erythroxylum coca plant.

• Excited delirium.

• AKA Coke/snow white lady/she/crack smokable.

• M/c route of abuse: Snorting.
• Huffing:
• Drug inhaled from a cloth

• Effects of Vasoconstriction:
• Rhinorrhea,
• nose bleed,
• Nasal Septal Perforation.
• Jet Black Pigmentation of tongue (long-term use).

Acute poisoning:

Body packer syndrome.

• Accidental rupture of swallowed cocaine (Smuggling).

• Sympathomimetic action (↑HR, ↑BP, ↑temp, ↑sweating, dilated pupils).
• u can remember it as a coconut fell on head of a guy with fever..
• he will be agitated
• hyper reflexive 
• heart rate increased
• pupil dilated and restless 

• Feeling of well-being.

• Treatment
• Amyl nitrate
• Mnemonic: Coconut Amy de thalayil veenu

Chronic abuse:

• Septal perforation (snorting).

• Black staining: Tongue/Teeth.

• Peripheral gangrene (peripheral vasoconstriction).

• Cocaine bugs/Magnan syndrome/formication.

• Tactile hallucination.

Adverse Effects of Cocaine

• Potent Sympathomimetic.

• Causes Vasoconstriction:
• Leads to Hypertension, end-organ damage.
• Increases heart rate.
• Can cause Myocardial infarction.

Cocaine Intoxication

• Euphoria, Mydriasis, Tachycardia, Hypertension.

• Cardiac Arrhythmias, Seizures.

• Auditory Hallucinations, Paranoid Ideations.

• Cocaine bugs (Formication):
• Tactile Hallucinations of insects crawling under the skin.
• Leads to scratch marks.

• Dependence:
• Strong Psychological Dependence.
• Mild Physiological dependence.

Cocaine Induced Psychotic Disorder

• Hallmark:
• Paranoid Delusions,
• Auditory Hallucinations.

• Mimics Schizophrenia.

Treatment

• Withdrawal is usually mild.

• No pharmacologic agents reduce withdrawal intensity.

Speed Ball

• Combination of Cocaine + Heroin.

Tobacco

• Most common substance use disorder in India (excluding caffeine).

• Active ingredient: Nicotine.

• Forms: Beedi, Cigarettes (inhalational), Gutka (tubal).

Tobacco Withdrawal

• Symptoms:
• Intense Craving.
• Irritability, Anxiety.
• Difficulty concentrating.
• Insomnia.
• Bradycardia.
• Increased appetite, weight gain.

Treatment

1. Nicotine Replacement Therapy (NRT)

• Most common

• Long acting
• Patch (16 - 24 hrs)
• For Maintenance

• Short Acting
• For breakthrough carving
• Nasal spray > Lozenge > Gums
• Nasal spray → (Schedule H) → most effective.
• Lozenges
• Higher bioavailability than gums

• Avoid tea or coffee for 15 min post-NRT
• Gums and Lozenge require alkaline saliva for absorption
• should not be used within 15 minutes of drinking anything

• e-Cigarettes are now banned in India.

2. Bupropion

• Antidepressant (NDRI).

• Anti-smoking
• Mnemonic: Pion is a Smoker

• Vs. Buspirone (anti-anxiety)
• Mnemonic: Rona → with anxiety

• Contraindications:
• Seizure Disorders.
• Bulimia or Anorexia Nervosa.

• Uses:
1. Antidepressant,
2. Smoking cessation,
3. ADHD

3. Varenicline

• DOC

• Most effective for maintenance.

• Partial agonist at the NE receptor (α4β2) → Nicotinic receptor

• Full agonist → α7

• Derived from Cytisine (Plant derivative)
• Mnemonic: Varane A4B2 sitil ninn kitti

• Adverse Effects:
• Neuropsychiatric:
• Somnambulism
• Vomiting
• Depression,
• suicidal ideations.
• Cardiovascular:
• CCF,
• Arrhythmia (in at-risk patients).

• Mneumonic:
• Varan akumbo smoking nirthum
• Suicide cheyyan thonnum, depression avum

Gambling Disorder

• Persistent, recurrent gambling behaviour.

• Characterized by:
• Impaired control over gambling.
• Gambling takes precedence over daily activities.
• Continuation despite negative consequences.

Gaming Disorder

• New diagnosis in ICD-11.

• Persistent or recurrent gaming behaviour.

• Characterized by:
• Impaired control over gaming.
• Gaming takes precedence over daily activities.
• Continuation despite negative consequences.

CHILD PSYCHIATRY

Attention Deficit Hyperactivity Disorder (ADHD)

• Neurodevelopmental disorder.

• Older name: Minimal brain damage/dysfunction.

Epidemiology & Course

• More common in boys.

• 40% remit at puberty or early adulthood.

• Symptom Remission Order:
• Hyperactivity remits first.
• Inattention remits last.

• Others are at risk for antisocial personality disorder & conduct disorder
• substance use disorder.

Clinical Features

1. Inattention:
• Fails to give close attention, makes careless mistakes.
• Difficulty sustaining attention.
• Fails to finish work.
• Easily distracted and bored

2. Hyperactivity & 3. Impulsivity:
• Hyperenergetic
• Fidgets or taps hands/feet.
• Leaves seat when expected to remain seated.
• Always "on the go," acts as if "driven by a motor."
• Talks excessively.
• Interrupts others, difficulty waiting for turn.

In Adults

• Anger management problems

• Dysfunctional relationships

• Symptoms of anxiety

• Substance use disorders

• Mood fluctuations

Diagnostic Criteria

• ≥ 6 attention symptoms +

• ≥ 6 hyperactivity/impulsivity symptoms:
• Duration > 6 months
• Present in ≥ 2 settings
• Onset < 12 years of age

• In adults:
• ≥ 5 attention symptoms
• ≥ 5 hyperactivity/impulsivity symptoms

• ADHD persists into adulthood in 40–50% of children (↓ hyperactivity with age)

DSM-5 Criteria

1. Onset of symptoms before 12 years of age.

2. Symptoms present in two or more settings (e.g., home, school) and is documented independently.

3 Subtypes

1. Combined presentation.

2. Predominantly inattentive presentation.

3. Predominantly hyperactive/impulsivity presentation.

Treatment

• Pharmacotherapy is first-line.
• (Mnemonic: MAM teaches A2 B)

1. CNS Stimulants

• First choice of agents.

• Avoid in patients with cardiac risks.
1. Methylphenidate:
• FDA approved.
• Drug of choice for ADHD.
• Dopamine agonist.
• Side effects:
• Growth suppression.
• For growth suppression: drug holiday.
• Exacerbation of tics,
• Headaches,
• Nausea,
• Insomnia,
2. Amphetamine:
• 2nd drug of choice.
• Dopamine agonist.
• FDA approved.
• Superman drug
3. Modafinil:
• α-1 agonist.
• Not FDA approved for ADHD.

2. Non-stimulants

• Used if poor response or side effects to stimulants.
1. Atomoxetine:
• Norepinephrine reuptake inhibitor.
• Increased risk of suicidal ideation.
• Mnemonic: NRI () kk atmosphere () pidichillenkil suicide () cheyyum
2. Viloxazine
• New drug
3. Alpha-2 agonists:
• Clonidine, Guanfacine.
• Adverse effects: Sedation, headache, hypotension.
• Preferred in comorbid tic disorder
4. Bupropion:
• Norepinephrine-Dopamine reuptake inhibitor (NDRI).
• Risk of seizures at higher doses.
• Not FDA approved for ADHD.

Oppositional Defiant Disorder (ODD)

• Seen in children < 10 years (onset in adolescence → Adolescent-onset ODD).

Features

• (≥ 6 months):

• Opposing nature, argumentative

• Vindictive (vengeful)

• Defiant

• Irritable → throw tantrums

Conduct Disorder (CD)

• Can develop in children with ODD

• Onset: 10–18 years

• Symptoms lasting > 6 months

Features:

• Defiant

• Destructive to people, animals, property

• Deceitful:
• Lying, manipulation
• Cheating, stealing
• Truancy → skipping classes < 13 years

Tourette Syndrome

• Definition
• Neurodevelopmental disorder
• Multiple motor tics + ≥1 vocal tic
• Duration > 1 year
• Onset < 18 years age
• Male >> Female
• Normal Intelligence

Tics

• Associations
• ADHD >> OCD

• Treatment
• First line
• Behavioral therapy
• Drugs
• Haloperidol
• Risperidone

Autism Spectrum Disorder

• Neurodevelopmental disorder.

• Onset usually before 3 years.

• M > F

• Some domains may improve with age.

• DSM-5 & ICD-11 use this single diagnosis.

• Previous term: Pervasive developmental disorder (PDD).

• Language impairment:
• Removed as a core symptom.

• Screening is recommended to all children b/w 18 - 24 months

• M-CHAT – Autism Screening
• Most appropriate screening tool
• Two-stage, parent-completed screening tool
• Scoring
• Score ≥ 8
• High risk for ASD
• Score 3–7
• Follow-up interview

Two Core Symptoms

1. Deficits in Social Communications:
• Poor reciprocal social skills.
• Lack of social smiles, poor eye contact.
• Poor attachment behaviour.
• Difficulty making friends.

2. Restricted, Repetitive Behaviors:
• Rigid, repetitive, monotonous activities.
• Stereotypies, mannerisms.
• Upset by changes in routine.

Associated Features & Genetics

• Associated:
• Intellectual disability (30%), Irritability.

• Genetic Factors:
• Most common: Fragile X syndrome.
• Second most common: Tuberous sclerosis.

Overlapping Disorders (Now under ASD)

• Autistic disorder

• Rett syndrome

• Childhood disintegrative disorder

• Asperger disorder

• PDD-NOS.

Asperger Syndrome

• More common in male children.

• Speech preservation.

• Key word: focus

• Focused skills & interests:
• Drawing, mathematics, painting, music.

• In current diagnostic criteria,
• No longer recognized as a separate diagnosis
• overlap with autism

Rett Syndrome

• F > M

• Mutation in MECP2 gene on chromosome Xq28.

Course:

• Normal development for the first 5 months.

• 6 months - 2 years:
• Loss of acquired motor skills,
• replaced by stereotypic hand movements
• hand wringing
• Loss of acquired speech.
• Head growth decelerates (microcephaly).
• Poor coordination, ataxia.
• Seizures in 75%.

Treatment:

• Trofinitide (FDA approved 2023).
• For treatment of Rett syndrome in
• adults & paediatric patients
• ≥ 2 years
• It is a Tripeptide
• Synthetic analog of
• Glycine-Proline-Glutamate of N-Terminal Tripeptide of IGF-1

Specific Learning Disorder

• Neurodevelopmental disorder.

• ICD-11: Developmental learning disorder.

• Persistent difficulty in learning academic skills.

• Inconsistent with the child's intellectual ability.

• IQ is usually normal.

Subtypes

• With impairment in reading (Dyslexia):
• Difficulty recognizing words, poor comprehension, poor spelling.

• With impairment in written expression (Dysgraphia):
• Poor writing, spelling, and handwriting.

• With impairment in mathematics (Dyscalculia):
• Difficulty with numbers, signs (+, -), and calculations.

Intellectual Disability

• DSM-5: Intellectual Disability / Intellectual Development Disorder.

• ICD-11: Disorder of Intellectual Development.

• Previous term: Mental Retardation.

• Core Deficits:
1. Intellectual functioning (reasoning, learning).
2. Adaptive behaviour (conceptual, social, practical skills).

• Onset before 18 years.

IQ

• IQ = (Mental age / Chronological age) x 100.
• Denominator (Chronological age) should not exceed 15.

• Ranges:
• Normal: 90-109.
• Borderline: 70-89.
• Intellectual Disability: IQ < 70.

Severity Levels (Mental Retardation)

1. Mild: IQ 50-69.

2. Moderate: IQ 35-49.

3. Severe: IQ 20-34.

4. Profound: IQ <20.

• Severity also determined by adaptive behaviour.

Genetic Factors

• Most common overall:
• Down syndrome.

• Most common single gene cause:
• Fragile X syndrome.

Treatment

• Focus on psychosocial interventions.
1. Behavioral therapy:
• Contingency management:
• Reward desired behaviors,
• punish undesired ones.
2. Pharmacotherapy:
• Symptomatic treatment only.
• Antipsychotics for aggression.
• SSRIs for depression.