Psychiatric morbidity in two urban communities in Nigeria.

BACKGROUND: There is a welter of evidence for an inverse relationship between socio-economic status (SES) and mental health. The relationship is grossly under researched in the developing countries. OBJECTIVE: To ascertain rates of gross psychiatric morbidity and some demographic correlations in two communities with different socio-economic standards. DESIGN: A cross-sectional community based study. SUBJECTS: Random samples of two socio-economically dissimilar communities (N1 = 189, N2 = 148) were assessed for psychiatric morbidity. RESULTS: Rates of psychiatric morbidity obtained for the lower status community (Ajegunle) and the higher status community (Victoria Island/Ikoyi) on the GHQ-12 were 26.5 and 14.2 respectively and the corresponding figures on the SRQ (non-psychosis) were 41.8 and 18.2 and on the SRQ (psychosis) 61.5 and 31.7. A large number of positive socio-demographic correlations between cases and non-cases were obtained on SRQ and GHQ-12 in both communities. Family history of psychiatric illness significantly differentiates cases from non-cases on all measures of morbidity. CONCLUSION: The socio-economic inequality demonstrated should be minimised by evolving a social welfare policy in Nigeria and other developing countries that is responsive to the survival needs of the populace and ensures equitable distribution of resources across socio-economic strata. There is dire need for further research into the complex bearings of the link between social status and psychological wellness in the developing world.

A case report of body dysmorphic disorder and literature review.

BACKGROUND: Body dysmorphic disorder (BDD) is an obsessive preoccupation with a perceived defect in one's physical appearance which the individual persistently seeks medical attention to correct surgically. BDD often goes unrecognized and undiagnosed, due to patients' reluctance to divulge their symptoms because of secrecy and shame. OBJECTIVE: To present the case of a patient who presented with an extreme form of dysmorphophobia. METHODS: A 22-year-old university graduate presented with complaints of not "looking like herself any more" and of looking ugly. Patient was fully clinically and psychologically assessed. Psychological and dental surgical treatment were offered to the patient. RESULTS: She was a young woman who was complaining seriously of how her teeth made her ugly and of hating herself. She chiseled and filed her tooth to make them appear better but to no avail. She had thought of committing suicide. She appeared distressed, tearful and remorseful of her actions. The teeth were chipped and stained. She refused treatment modalities offered, and would not accept a psychological support. CONCLUSION: The case highlights the need for the dentist to be educated on these disorders so that they can recognize and refer accordingly. There is also need for interdisciplinary interactions between the dentists and the psychologist.

Clinical neuropsychiatric correlates and EEG findings among children with developmental disorders in Lagos, Nigeria.

OBJECTIVE: Developmental disorders with or without associated neuropsychiatric complications continue to be one of the major health problems in Africa. The grossly inadequate management/ rehabilitative facilities further worsen this. A prospective study aimed at finding the types of developmental disorders and associated neuropsychiatric complications among children aged

Ogun Oru: a traditional explanation for nocturnal neuropsychiatric disturbances among the Yoruba of Southwest Nigeria.

This article describes three cases of ;ogun oru' (nocturnal warefare), a condition reported in southwest Nigeria involving an acute night-time disturbance that is culturally attributed to demonic infiltration of the body and psyche during dreaming. Ogun oru is characterized by its occurrence, a female preponderance, the perception of an underlying feud between the sufferer's earthly spouse and a ;spiritual' spouse, and the event of bewitchment through eating while dreaming. The condition is believed to be treatable through Christian prayers or elaborate traditional rituals designed to exorcise the imbibed demonic elements. Ogun oru may be a label applied to medical problems. The differential diagnosis includes mainly parasomnias, for example, sleep terror, sleepwalking and sleep paralysis and, to a lesser extent, nocturnal or sleep epilepsy.

Emotional reactions of relatives to schizophrenic patients in Lagos, Nigeria.

Unlike what obtains in the developed countries, not much is known about the expressed emotions (EE) of the family to mental illness in developing nations, including Nigeria. Therefore, the objective of this study is to investigate the EE among family members to schizophrenics in Lagos, Nigeria. The Camberwell Family Interview was conducted with Nigerian family members of 19 schizophrenics whose symptoms were further ascertained using the Present State Examination. Sixty-three percent of the family sample showed high expressed emotions (HEE). The proportion of HEE families increased progressively with the number of previous hospitalization (r = 1, p = 0.000). The mean ratings of Critical Comment, Warmth and Positive Remarks were, respectively, 6.1 (+/- 3.8), 2.6 (+/- 0.9) and 2.2 (+/- 0.9) and 2.2 (+/- 1.3). The proportions of relatives showing Emotional Over-Involvement and Hostility were, respectively, 26.3% and 31.6%. The correlation between Warmth and Critical Comment was -0.39. The findings were compared with those of a key cross-cultural study of EE and the implications highlighted.

Reliability and validity of a psycho-social problem inventory for childhood epilepsy.

In response to the need for formal psychosocial assessment in childhood epilepsy, a 25-question inventory was constructed from raw items based on multidisciplinary inputs and tested for practicality, and psychometric attributes. Weighted inter-rater and test-retest reliability estimates were 61.8% and 63.9% respectively. A measure of concurrent validity was satisfactory though a modest discrepancy was observed between two raters (P = 0.019 and 0.0064). Discriminant validity was very satisfactory (average P 0.001) based on compared means of ratings from two groups of subjects with disparate prognosis. The inventory should be useful in the assessment of similar chronic childhood disabilities but interpretations of data should be in a wider clinical context including inputs of informant and school authorities as indicated.

Localization and sex steroid regulation of androgen receptor gene expression in rhesus monkey uterus.

OBJECTIVE: To characterize the cellular sites and hormonal regulation of uterine androgen receptor gene expression in the monkey. METHODS: Ovariectomized rhesus monkeys (five in each group) were treated with placebo (the control group), estradiol (E2), E2 plus progesterone, or E2 plus testosterone by sustained-release pellets administered subcutaneously. After 3 days of treatment, uteri were removed and uterine sections were analyzed by in situ hybridization for androgen receptor messenger RNA (mRNA). RESULTS: Androgen receptor mRNA was detected in endometrial stromal cells and myometrial smooth muscle cells, with lesser expression in endometrial epithelial cells. Both E2 and E2 plus progesterone treatment doubled androgen receptor mRNA levels in stromal cells (P < .01), whereas E2 plus testosterone treatment increased stromal androgen receptor mRNA levels by about five-fold (P < .001) compared with placebo treatment. In the endometrial epithelium, E2 alone did not increase androgen receptor mRNA levels significantly. However, the E2 plus progesterone and E2 plus testosterone treatments increased epithelial androgen receptor mRNA levels by 4.3 and 5 times, respectively (P = .008 and P < .002, respectively). Androgen receptor mRNA was distributed homogeneously in smooth muscle cells across the myometrium. Estradiol treatment alone did not increase myometrial androgen receptor mRNA levels significantly, but the E2 plus progesterone and E2 plus testosterone treatments increased myometrial androgen receptor mRNA levels by 1.8 and 2 times, respectively (P = .001 and P < .001, respectively). CONCLUSION: Androgen receptor gene expression was detected in all uterine cell compartments where it was subject to significant sex steroid regulation. The fact that androgen receptor mRNA levels were consistently up-regulated by a combined E2 plus testosterone treatment while E2 treatment alone had little or no effect shows that a collaborative action of E2 and testosterone enhances androgen receptor expression in the monkey uterus.

Serious hand sepsis and diabetes mellitus: specific tropical syndrome with western counterparts.

Infection in the extremities of diabetic patients most commonly involves the feet and, at least in western societies, is often associated with chronic complications of diabetes. Severe hand infection, often culminating in amputation and even death, is, however, well-described in tropical countries, where it may not be associated with any evidence of neuropathy or arterial insufficiency. Similar cases are described in the western literature but are more often associated with more severe antecedent trauma. The literature describing hand sepsis in diabetic patients both in tropical and in western practice is reviewed and we draw some conclusions about pathogenesis and treatment from the literature and from original data documenting the varying experience of hand sepsis in diabetic practice throughout Africa.

Psychosocial assessment methods in childhood epilepsy: focus on sub-Saharan Africa.

The scale of evidence tilts towards the contention that epileptic children as a group are at a disadvantage regarding intellectual and emotional development and have higher rates of behavioural abnormalities than their non-epileptic peers. Differentiating factors logically point to the problem areas which should be enquired into in a comprehensive assessment of a child with epilepsy and should facilitate formulation of viable intervention stratagems. A critical review of the literature reveals that, of five major assessment methods, the use of a standardised and valid questionnaire is likely to yield the most reliable clinical information. However, a complete assessment package should include drug use monitoring, evaluation of cultural milieu and family psychodynamics.

Intra-city differences in psychotropic drug use: a Nigerian scene.

In a study of prescribing practice in 3 psychiatric institutions in Lagos, Nigeria, patterns of psychotropic drug use were generally unsatisfactory in terms of poly-pharmacy, high frequency of daily multiple administrations and prolonged use of minor tranquillisers. These deficiencies were noticeable in one of the hospitals that had the lowest doctor:patient ratio with consequent greatest workload, employed the 'medical model' as its main practice-orientation and that bore responsibility for a large part of community psychiatric morbidity. The widespread use of anti-parkinsonian agents had some rationality in view of the grossly inadequate community-based facilities needed to control drug induced extra-pyramidal side-effects. Improving psychiatric services, through personnel training, sufficient funding and the realisation of the need for therapists to conform to acceptable rules of drug prescribing, would help tremendously to minimise the vagaries and anomalies of drug use observed.

Carbohydrate tolerance in patients with tropical ataxic neuropathy--A human model of chronic cyanide intoxication.

Patients with tropical ataxic neuropathy (TAN) have been shown to have chronic cyanide intoxication. Glucose tolerance test data in a group of 88 patients with TAN and 88 matched controls who were studied several years ago were analysed. A standard glucose tolerance test (SGTT) with 50 gm dextrose preceded by 50 mgs cortisone acetate orally 8 1/2 and 2 hours before the tests were performed. The SGTT was considered abnormal if the capillary blood glucose at 0.60 and 120 were greater than 120, 200 and 140 mg/100 ml (6.6, 11.1, 7.8 mmol/l) respectively. Capillary blood glucose considered abnormal for CGTT were 205 and 155 mg/100 ml at 60 and 120 (113 and 8.6 mmol/I) respectively. The SGTT was abnormal in 1 of the TAN patients and 2 controls while CGTT was abnormal in 9 TAN patients and 7 controls. However, all controls with abnormal CGTT were older than 50 years while only 1 TAN patient was older than 50 and 6 were 30 years or younger (p = 0.0105), Fischer's probability test. The results suggest a greater statistical risk for subjects with TAN 30 years or younger to have an abnormal CGTT. While this does not predict the future development of diabetes, our observation indicates the need for better designed prospective studies among such patients in developing countries.

The efficacy of traditional medicine in the management of diabetes mellitus in southwestern Nigeria.

A survey of traditional healers in Ibadan, Nigeria, demonstrated that fewer than 10% of them were involved in the treatment of patients with diabetes mellitus and the total number of such patients under their care was less than 100, compared to those receiving western-type of medical treatment (up to 1000 at the University College Hospital, Ibadan, alone). An interview of 20 native practitioners revealed that they had little understanding of the nature of diabetes mellitus. Their diagnosis of diabetes was based largely on intuition and the disease was often confused with other medical problems like urinary tract infection or venereal disease. In a parallel study, 10 diabetic patients being treated exclusively by traditional healers were followed up on an ambulatory basis for periods of up to 16 weeks and another group of 8 patients had a hospital-based trial of traditional anti-diabetic medicines for about 4 weeks. Most of the patients reported improvement in their symptoms with less polyuria and improved sense of well-being. However, no objective improvement in the blood glucose was demonstrated. For the hospitalized group, n = 8, pre and post-treatment blood glucose respectively were, mean (+ SD), 13.9 (3.5) mmols/l and 14.9 (4.3) mmols/l, P > 0.50. It is concluded that the effectiveness of traditional anti-diabetic drugs in lowering blood glucose still remains to be demonstrated. Any claims of "cure" of diabetes using native medicines can be firmly rejected. However, further studies into the potential usefulness of native herbs in the treatment of diabetes must be pursued.

The effects of chronic cassava consumption, cyanide intoxication and protein malnutrition on glucose tolerance in growing rats.

Intraperitoneal glucose tolerance tests were performed at 4-week intervals in groups of weanling rats before and after feeding with maize- or cassava-based diets with and without adequate protein and sublethal cyanide supplementation. Weaning weights were doubled (increase of about 50 g) after 4 weeks on control (maize-based with adequate protein) and protein-replete diets. Weight gain on the protein-deficient diets was much less (22 g or 50%), a pattern maintained by the rats on these diets until the age of 12 weeks. Plasma thiocyanate levels were identical at weaning and after 8 weeks of the control diet but increased by 200-300% after 4 weeks intake of the cassava or cyanide-supplemented feeds. Levels returned to normal in all groups after a further 4 weeks feeding with the control diet. Glucose tolerance (as assessed by the area under the 2 h glucose v. time curve) was impaired to a varying extent in the rats after 4 weeks on the various diets: protein-replete cassava and protein-deficient maize diets by 50% protein-deficient cassava diet by 300%, and cyanide-supplemented protein-deficient maize diet by 150%. The derangement in the rats on the protein-replete cassava diet was unaffected by a further 4 weeks intake of the control diet, unlike in the other groups where there was significant improvement in the glucose tolerance indices at the same time. It is concluded that in growing rats: (1) cassava intake and protein malnutrition may have independent and additive effects on the genesis of glucose intolerance, (2) cyanide supplementation of a cassava-free protein-replete diet has no effect on glucose tolerance.

Pattern of adrenocortical response to the stress of severe illness in Nigerians.

Twenty-eight severely ill, hospitalized Nigerian patients, 18 males and 10 females with a median age of 41 years (group I) and 20 stable ambulatory patients, 11 males and 9 females with a median age of 42.5 years (group II), had early morning plasma cortisol measurements. Ten healthy young Nigerian males with a mean age of 22.1 years (group III) had plasma cortisol estimations during insulin tolerance test. The mean (+/- SD) cortisol values for the three groups in nmols/l were as follows: group I--389.3 (202.4), group II--267.1 (67.4), group III-624.5 (81.1). The results for the group III healthy controls represent the peak (60 mins) value during insulin induced hypoglycemic stress. A one way analysis of variance (ANOVA) demonstrated a statistically significant difference between the three mean cortisol values, P < 0.001. A pair-wise comparison using the t-test also showed significant differences between the groups, P < 0.05 in each case. An important observation was the variable pattern of cortisol stress response in different types of illnesses. Cases of stroke appeared to be associated with increased cortisol stress values (Z-score + 5.67) while patients with hypotension (B.P. < or = 90/60) and those on Rifampicin had reduced cortisol responses (Z-scores - 3.66 and 3.51 respectively). However, no firm recommendations can as yet be made regarding the usefulness of corticosteroids in life-threatening illnesses among Nigerians, other than those for which steroids are known to beneficial.

Computerised axial tomographic scanning in neuropsychiatric disorders.

The invention of the computerised tomography scanner - a product of modern bio-medical technology has significantly enhanced the diagnostic capability of physicians in the management of brain disorders such as cerebral atrophy, subdural haematoma, tuberous sclerosis, small calcifications and small intravascular clots. It is also useful in radiotherapy planning. The advantages of the CT scanner over the older conventional techniques, namely pneumoencephalography and arteriography are accuracy, reliability, and simplicity of operation. The major limitation is its diminished ability relative to angiography to precisely detect vascular disease, e.g. aneurysm. Furthermore, it is expensive and not precise in the differentiation of benign from malignant lesions. Despite the development of newer neuro-radiological equipment such as position emission tomography (PET) and nuclear magnetic resonance, the CT scanner remains a most invaluable diagnostic tool and should be given priority consideration in health vote allocation.

Diabetes mellitus in Saudi Arabia: The clinical pattern and complications in 1,000 patients.

A retrospective and prospective study of 1,000 ambulatory and hospitalized diabetic patients was done in Riyadh, Saudi Arabia. Saudis completed 777 (77.7%) and non-Saudis 223 (22.3%). Sex distribution was equal among Saudis, males 389 (50.1%) and females 388 (49.9%), but non-Saudi males were predominant at 153 (68.6%), non-Saudi females 70 (31.4%) reflecting the preponderant male expatriate labor force. A proportion of different types of diabetes was: IDDM 115 (11.7%), non-obese non-insulin dependent diabetes mellitus (NIDDM) 405 (41.0%), obese NIDDM 412 (42.1%), and early onset non-insulin dependent diabetes (diagnosis under 30 years of age), 43 (4.4%). Regarding treatment, 388 (40.6%) received insulin followed by sulfonylurea, alone in 330 (33.5%), diet only 117 (12.0%), combination sulfonylurea and biguanide in 113 (11.6%), biguanide alone in 13 (1.3%) and insulin plus tablets in 7 (0.8%). Of 472 and 426 patients, 29.7% and 30.0% had elevated total cholesterol or triglycerides respectively, while 77.2% of 373 patients had elevated glycosylated hemoglobin (HbA1). At least once in 998 patients, diabetic ketoacidosis occurred in 7.6%.

Short stature at the University College Hospital, Ibadan, Nigeria.

Twenty four patients were evaluated for short stature at the University College Hospital, Ibadan, Nigeria, over a seven year period. Fourteen were males, 10 were females and their ages ranged from 6 to 23 years at first presentation. Nine out of the 10 females came to the hospital primarily because of failure of sexual development whereas only 1 of the 14 males presented with this complaint. The causes of short stature were as follows: idiopathic hypopituitarism in 5 (20.8%) patients (4 males, 1 female), gonadal dysgenesis in 5 patients (all females), syndrome of hepatosplenomegaly, dwarfism and poor sexual development in 5 patients (all males); 2 (8.3%) patients had hypothalamic-pituitary lesions, 2 had juvenile hypothyroidism and 1 (4.2%) had sickle cell hemoglobinopathy; the cause of the short stature was not certain in 4 (16.7%) patients. This is perhaps the first time that the syndrome of hepatosplenomegaly of uncertain etiology with delayed growth and sexual maturation previously reported in Iranian and Egyptian adolescents, is being described in black Africans. Although comprehensive hormonal data were not available in most of these patients, this clinical descriptive study is the first attempt at reporting some of the causes of short stature in Nigerians.

Sheehan's syndrome in a developing country, Nigeria: a rare disease or problem of diagnosis?

Over a five year period, 11 cases of Sheehan's syndrome were seen in the Endocrinology Unit of a teaching hospital in Ibadan, Nigeria. The mean age at diagnosis was 35.1 years; the mean parity was four and the average interval between the obstetric injury and diagnosis was 6.9 years. Four patients were in middle socio-economic class and seven were in low socio-economic class. The most frequent presenting symptoms were failure of lactation (11 out of 11 patients) and amenorrhoea (9 out of 11 patients). Seven patients had multiple endocrine insufficiency involving essentially all pituitary cell types. Six out of 8 patients were lost to follow-up. In a review of autopsy records over a 5-year period at the same institution, out of 1,951 post-mortem examinations, no additional cases of Sheehan's were found. With an average of about two clinical cases per year, it would seem that Sheehan's syndrome is still a relatively rare entity in this part of the world in spite of the poor level of obstetric care generally available. There is a need for increased awareness about this disease on the part of practitioners in developing countries in order to establish whether this rarity is real or it is due to missed diagnosis.