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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance
- Sprache: Englisch
Psychiatry at a Glance is an up-to-date, accessible introductory and study text for all students of psychiatry. It presents ‘need-to-know’ information on the basic science, treatment, and management of the major disorders, and helps you develop your skills in history taking and performing the Mental State Examination (MSE).
This new edition features:
• Thoroughly updated content to reflect new research, the DSM 5 classification and NICE guidelines
• All the information required, including practice questions, for the written Psychiatry exams
• Extensive self-assessment material, including Extending Matching Questions, Single Best Answer questions, and sample OSCE stations, to reinforce knowledge learnt
• A companion website at ataglanceseries.com/psychiatry featuring interactive case studies and downloadable illustrations
Psychiatry at a Glance will appeal to medical students, junior doctors and psychiatry trainees, as well as nursing students and other health professionals and is the ideal companion for anyone about to start a psychiatric attachment or module.
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Veröffentlichungsjahr: 2015
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This edition first published 2016 © 2016 by John Wiley & Sons Ltd. Previous editions © 1995, 2000, 2005, 2008, 2012 by Cornelius Katona, Claudia Cooper, Mary Robertson
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Library of Congress Cataloging-in-Publication DataKatona, C. L. E. (Cornelius L. E.), 1954- , author. Psychiatry at a glance / Cornelius Katona, Claudia Cooper, Mary Robertson. – Sixth edition. p. ; cm. – (At a glance) Includes bibliographical references and index. ISBN 978-1-119-12967-7 (pbk.) I. Cooper, Claudia, author. II. Robertson, Mary M., author. III. Title. IV. Series: At a glance series (Oxford, England) [DNLM: 1. Mental Disorders. 2. Psychiatry. WM 140] RC454 616.89–dc23
2015024744
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Cover image: © Don Farrall/Getty Images
Contents
Preface
Contributors to Chapter 44
About the Companion Website
Part 1 Assessment and Management
1 Psychiatric History
Introduction and presenting complaint
History of the present illness
Previous psychiatric history
Past medical/surgical history
Drug history and allergies
Family history
Personal history
Substance use
Forensic history
Social history
Premorbid personality
2 The Mental State Examination
Appearance and behaviour
Speech
Mood and affect
Disorders of thought content
Perception
Cognition
Insight
3 Diagnosis and Classification in Psychiatry
History
The concept of mental illness
Aims of classification in psychiatry
Categorical versus Dimensional
Comorbidity
4 Risk Assessment and Management in Psychiatry
Risk assessment
Managing violence
Breaking confidentiality
5 Suicide and Deliberate Self-harm
Suicide
DSH
Part 2 Mental Disorders
6 Psychosis: Symptoms and Aetiology
Schizophrenia
Other psychoses
7 Schizophrenia: Management and Prognosis
Medication
Psychological treatment
Social support
Prognosis
8 Depression
Definitions and classification
Clinical features
Differential diagnosis
Epidemiology
Aetiology
Management
Prognosis
9 Bipolar Affective Disorder
Definitions and classification
Clinical features
Differential diagnosis
Epidemiology
Aetiology
Management (NICE guideline 2014)
Prognosis
10 Stress Reactions (Including Bereavement)
Acute stress reactions
Adjustment disorders
PTSD
Bereavement and grief
11 Anxiety Disorders
Anxiety
Anxiety disorders
Epidemiology
Aetiology
Panic disorder
Generalised anxiety disorder (GAD)
Phobic disorders
12 Obsessions and Compulsions
Obsessions and compulsions
Obsessive–compulsive disorder (OCD)
Body dysmorphic disorder (BDD)
Management of OCD and BDD
13 Eating Disorders
Epidemiology
Aetiological factors
Anorexia nervosa
Bulimia nervosa
Binge-eating disorder and obesity
14 Personality Disorders
Definition
Epidemiology
Aetiology
Classification and characteristics
Management
Prognosis
15 Psychosexual Disorders
Disorders of sexual function
Disorders of sexual preference
Disorders of sexual identity (transsexuality)
16 Unusual Psychiatric Syndromes
Psychotic syndromes
Non-psychotic syndromes
Part 3 Substance and Alcohol Misuse
17 Substance Misuse
Epidemiology
Classification
Aetiological factors
Management
Specific substances
18 Alcohol Misuse
Safe limits
Classification
Epidemiology
Detection and screening
Aetiology
Complications
Management
Prognosis
Part 4 Psychiatry of Demographic Groups
19 Child Psychiatry I
Classification
Psychiatric assessment of children
Epidemiology
Hyperkinetic disorders (ICD-10); Attention-Deficit Hyperactivity Disorder (ADHD) (DSM-5)
Conduct disorders
Emotional disorders
20 Child Psychiatry II
Social functioning disorders
Other disorders
Developmental/Neurodevelopmental disorders
Psychotic disorders
Sleep problems
Links between child and adult mental health
21 The Psychiatry of Adolescence
Adolescence
Psychiatric assessment in adolescence
Conduct disorder
Eating disorders (also see Chapter 13)
Mood disorders
Anxiety, stress-related disorders
Obsessive–compulsive disorder (OCD)
Schizophrenia
Self-harm
Substance abuse
Capacity and confidentiality
22 Learning Disability (Mental Retardation)
Definition and epidemiology
Aetiology
Classification and clinical features
Psychiatric illness
Antenatal detection and prevention
Management
23 Cross-cultural Psychiatry
How culture can influence mental illness presentation and treatment
Culture and standardised diagnosis
Mental illness and minority ethnic groups living in Western countries
Racial differences in pharmacological response
Culture-bound syndromes
24 Psychiatry and Social Exclusion
Homeless people (Figure 24.1)
Refugees
Prisoners
25 Psychiatry and Female Reproduction
Mental illness during pregnancy
Postpartum disorders
Premenstrual Dysphoric Disorder (PDD)
26 Functional Psychiatric Disorders in Old Age
Depression in old age
Anxiety disorders
Mania in old age
Psychotic disorders
Part 5 The Interface of Psychiatry and Physical Illness
27 Psychiatry and Physical Illness
Comorbidity of psychiatric and physical illness
Liaison psychiatry
Medically unexplained symptoms
Somatoform disorders
Dissociative disorders (also termed ‘conversion disorders’)
Factitious disorder
Managing pain and fatigue
28 Neuropsychiatry I
Focal neurological disorders: traumatic brain injuries and strokes
Post-concussional syndrome
Epilepsy
Tumour
29 Neuropsychiatry II
Autoimmune and inflammatory disorders
Disorders of the basal ganglia
Sleep disorders
Tic disorders
30 Neuropsychiatry III
Infectious causes of neuropsychiatric symptoms
Metabolic disturbance
Endocrine
Nutritional disorders
31 Acute Confusional States
Clinical features
Aetiology
Differential diagnosis
Investigations
Prevention
Management
Prognosis
32 The Dementias
Definition and clinical presentation
Epidemiology
Classification
Management
Prognosis
Cognitive impairment in people without dementia
Part 6 Assessment and Management
33 Psychological Therapies
How therapies work
Types of therapy (see Figure 33.1)
34 Antipsychotics
Types of antipsychotic
How do antipsychotics work?
Mode of administration
Indications
Side effects
Stopping antipsychotics
Physical health monitoring
35 Antidepressants
How they work (see Figure 35.1)
Indications
Mode of administration
Side effects
Stopping antidepressants
Serotonin syndrome
36 Other Psychotropic Drugs
Antimanic drugs (mood stabilisers)
Hypnotics and anxiolytics
Stimulants
Antidementia drugs
37 Electroconvulsive Therapy and Other Physical Treatments
Electroconvulsive therapy (ECT)
New methods of brain stimulation
Neurosurgery for mental disorder
38 Psychiatry in the Community
Psychiatry in primary care
Community care of severe psychiatric illness
Patient-centred care
Accommodation
Daytime activity
39 Forensic Psychiatry
Crime and mental disorder
Managing violence (see also Chapter 4)
Prostitution
40 Mental Capacity
Assessing capacity
The Mental Capacity Act (England and Wales)
Legal competence
41 Mental Health Legislation in England and Wales
Sectioning (compulsory admission)
How ‘sectioning' is carried out
42 Mental Health Legislation in Scotland
Compulsory orders
Mental health law relating to prisoners
Medical treatment
43 Mental Health Legislation in Northern Ireland
Criteria for detention
Compulsory admission to hospital
Police powers
Informal hospital patients
Guardianship
Patients involved in criminal proceedings
Appeal
Consent to treatment
44 Mental Health Legislation in Australia and New Zealand
Community treatment orders (CTOs) and the role of medical practitioners
45 Preparing for Clinical Examinations in Psychiatry
Introduction
Interview stations
Video stations
Pencil and paper stations
Self-assessment
Objective Structured Clinical Examinations (OSCEs)
Section 1: Assessment and Management
Section 2: Mental Disorders
Section 3: Substance and Alcohol Misuse
Section 4: Psychiatry of Demographic Groups
Section 5: The Interface of Psychiatry and Physical Health
Section 6: Psychiatric Management
Extended Matching Questions (EMQs)
Chapters 1–5: Assessment and management
Chapters 6–16: Mental disorders
Chapters 17–18: Substance and alcohol misuse
Chapters 19–26: Psychiatry of demographic groups
Chapters 27–32: The interface of psychiatry and physical illness
Chapters 33–44: Psychiatric management
Single Best Answer (SBA) Questions
Chapters 1 and 2 (history and examination)
Chapter 3 Diagnosis and Classification
Chapter 4 Risk Assessment and Management
Chapter 5 Suicide and Deliberate Self-harm
Chapter 6 Schizophrenia – Symptoms and Aetiology
Chapter 7 Schizophrenia: Management and Prognosis
Chapter 8 Depression
Chapter 9 Bipolar Affective Disorder
Chapter 10 Stress Reactions (Including Bereavement)
Chapter 11 Anxiety Disorders
Chapter 12 Obsessions and Compulsions
Chapter 13 Eating Disorders
Chapter 14 Personality Disorders
Chapter 15 Psychosexual Disorders
Chapter 16 Unusual Psychiatric Syndromes
Chapter 17 Substance Misuse
Chapter 18 Alcohol Misuse
Chapters 19 and 20 Child Psychiatry
Chapter 21 The Psychiatry of Adolescence
Chapter 22 Learning Disability (Mental Retardation)
Chapter 23 Cross-cultural Psychiatry
Chapter 24 Psychiatry and Social Exclusion
Chapter 25 Psychiatry and Female Reproduction
Chapter 26 Functional Psychiatric Disorders in Old Age
Chapter 27 Psychiatry and Physical Illness
Chapters 28–30 Neuropsychiatry
Chapter 31 Acute Confusional States
Chapter 32 The Dementias
Chapter 33 Psychological Therapies
Chapter 34 Antipsychotics
Chapter 35 Antidepressants
Chapter 36 Other Psychotropic Drugs
Chapter 37 Electroconvulsive Therapy and Other Treatments
Chapter 38 Psychiatry in the Community
Chapter 39 Forensic Psychiatry
Chapter 40 Mental Capacity Act
Chapter 41 Mental Health Legislation in England and Wales
Chapter 42 Mental Health Legislation in Scotland
Chapter 43 Mental Health Legislation in Northern Ireland
Chapter 44 Mental Health Legislation in Australia and New Zealand Australia
New Zealand
OSCE Examiner Mark Sheets
Section 1: Assessment and Management
Section 2: Mental Disorders
Section 3: Substance and Alcohol Misuse
Section 4: Psychiatry of Demographic Groups
Section 5: The Interface of Psychiatry and Physical Health
Section 6: Psychiatric Management
Answers to EMQs
1 Mental state
2 Delusions
3 Diagnosis
4 Anxiety disorders and stress reactions
5 Personality disorders
6 Unusual syndromes
7 Substance and alcohol misuse
8 Diagnoses in childhood and early adulthood
9 Epidemiology of psychiatry of demographic groups
10 Cognitive impairment
11 Psychiatric disorders and physical symptoms and signs
12 Psychological therapies
13 Treatment of psychosis and depression
14 Treatment in psychiatry
15 Psychiatry and the English law
Answers to Single Best Answer (SBA) Questions
Further Reading
Glossary
Index
EULA
List of Tables
Chapter 21
Table 21.1
Chapter 22
Table 22.1
Chapter 25
Table 25.1
Chapter 27
Table 27.1
Table 27.2
Chapter 29
Table 29.1
Table 29.2
Table 29.3
Table 29.4
Chapter 30
Table 30.1
Chapter 31
Table 31.1
Chapter 32
Table 32.1
Chapter 34
Table 34.1
Chapter 36
Table 36.1
Chapter 38
Table 38.1
Chapter 41
Table 41.1
Table 41.2
Table 41.3
Chapter 42
Table 42.1
Table 42.2
Chapter 44
Table 44.1
List of Illustrations
Chapter 2
Figure 2.1
Types of delusion
Figure 2.2
Asking about suicide
Chapter 3
Figure 3.1
ICD-10 and DSM-IV-TR diagnosis and classification
Figure 3.2
Diagnostic hierarchy
Chapter 4
Figure 4.1
Balancing risks and patients’ rights
Chapter 5
Figure 5.1
Key facts about suicide and deliberate self-harm
Chapter 6
Figure 6.1
ICD-10: symptoms required for diagnosis of schizoprenia
Figure 6.2
Aetiology of schizophrenia
Chapter 7
Figure 7.1
Management of psychosis
Chapter 8
Figure 8.1
Depressive thoughts
Figure 8.2
Aetiology of depression
Figure 8.3
Management of depression
Chapter 9
Figure 9.1
Aetiology of bipolar affective disorder
Chapter 10
Figure 10.1
A summary of stress reactions
Figure 10.2
Stages of grief
Chapter 11
Figure 11.1
Aetiology of anxiety disorders
Figure 11.2
The vicious cycle that leads to somatic anxiety symptoms (e.g. in panic attacks)
Chapter 12
Figure 12.1
Key facts about obsessions and compulsions
Figure 12.2
Aetiology of OCD
Figure 12.3
How CBT reduces anxiety levels
Chapter 13
Figure 13.1
Comparison of anorexia nervosa and bulimia nervosa
Figure 13.2
Aetiology of eating disorders
Chapter 14
Figure 14.1
The clusters of personality disorders
Figure 14.2
How people with and without personality disorder might manage stress
Figure 14.3
Aetiology of personality disorders
Chapter 15
Figure 15.1
Key facts about psychosexual disorders
Chapter 16
Figure 16.1
Key facts about unusual psychiatric syndromes
Chapter 17
Figure 17.1
Key facts about substances and their misuse
Figure 17.2
Signs of dependence
Figure 17.3
Aetiology of substance misuse
Figure 17.4
Substance misuse and the UK law
Chapter 18
Figure 18.1
Signs of alcohol dependence
Figure 18.2
Screening tests.
Figure 18.3
Aetiology of alcohol misuse
Figure 18.4
Possible psychiatric effects of thiamine deficiency
Chapter 19
Figure 19.1
ICD-10 classification of childhood psychiatric disorders
Figure 19.2
Child abuse (physical, emotional, sexual) and neglect
Figure 19.3
Epidemiology of the main childhood disorders
Chapter 20
Figure 20.1
Links between childhood and adult mental health
Chapter 21
Figure 21.1
The challenges of adolescence
Figure 21.2
Mental disorders are often comorbid with each other, and with substance misuse and self-harm in adolescence
Chapter 22
Figure 22.1
The two most common specific causes of LD
Chapter 23
Figure 23.1
How culture affects the presentation, diagnosis and outcome of mental illness
Chapter 24
Figure 24.1
Homelessness and mental illness
Figure 24.2
Reasons for increased mental illness in refugees
Figure 24.3
Reasons for and extent of increased mentalillness in prison
Chapter 25
Figure 25.1
Mental illness in pregnancy and postpartum period
Figure 25.2
Risk factors for postpartum depression
Chapter 26
Figure 26.1
Aetiology of late onset depression
Figure 26.2
Management of depression in old age
Figure 26.3
Aetiology of late-onset psychosis.
Chapter 27
Figure 27.1
The links between physical and mental illness
Figure 27.2
Differential diagnosis of medically unexplained symptoms
Figure 27.3
How somatic symptoms can arise
Chapter 28
Figure 28.1
Psychiatric symptoms in people with focal neurological disorders
Figure 28.2
Relationship of depression and psychosis to seizures
Chapter 30
Figure 30.1
Links between HIV and mental illness
Chapter 31
Figure 31.1
Requirements for DSM5/ICD-10 diagnosis of delirium
Figure 31.2
Possible precipitants of acute confusional states
Figure 31.3
Measures that may help with delirium
Chapter 32
Figure 32.1
Diagnostic criteria and common symptoms of dementia
Figure 32.2
How the prevalence of dementia increases with age
Figure 32.3
Prevalences of the most common types of dementia
Figure 32.4
The amyloid cascade hypothesis
Chapter 33
Figure 33.1
The three areas of psychological therapy
Figure 33.2
CBT: automatic negative thoughts and core beliefs
Figure 33.3
How CBT can decrease anxiety
Chapter 34
Figure 34.1
Actions of antipsychotics at brain receptors
Figure 34.2
Side effects of antipsychotics
Chapter 35
Figure 35.1
The main groups of antidepressants and their side effects
Chapter 36
Figure 36.1
Effects of lithium dosages
Chapter 37
Figure 37.1
How ECT may work
Figure 37.2
When does English Mental Health Act permit ECT to be given?
Figure 37.3
Procedure for giving ECT
Chapter 38
Figure 38.1
How common are mental illnesses in the UK general population?
Chapter 39
Figure 39.1
Percentage ever convicted for violent crime
Figure 39.2
Mental illness and arson
Figure 39.3
Mental illness and violent crime
Figure 39.4
Who provides psychiatric care to mentally disordered offenders?
Chapter 40
Figure 40.1
What does the Mental Capacity Act (2005) (England and Wales) do?
Figure 40.2
Possible outcomes in trial of people who may be mentally ill
Chapter 43
Figure 43.1
Compulsory detention in Northern Ireland
Guide
Cover
Table of Contents
Preface
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Preface
We are delighted that medical students, psychiatrists and GPs in training and other mental health professionals (as well as their trainers) continue to benefit from the concise summary of key practical information about the practice of psychiatry which Psychiatry at a Glance provides. We have updated the sixth edition to ensure that it is up to date with regard to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and with current National Institute of Health and Care Excellence (NICE) guidelines.
We would like to thank Philippa Katona and Mike Carless for their continuing patience and support.
Cornelius KatonaClaudia CooperMary Robertson
Contributors to Chapter 44
Peter Bazzana
RPN, BHSc (Nursing), M. Suicidology, Member MHRT Lecturer, New South Wales Institute of Psychiatry, Sydney, Australia
Valsamma Eapen
MBBS, DPM, PhD, FRCPsych, FRANZCP
Chair of Infant Child and Adolescent Psychiatry, University of New South Wales
Head, Academic Unit of Child Psychiatry, South Western Sydney LHD, Sydney, Australia
Ian Ellis-Jones
BA, LLB, LLM, PhD, Dip Relig Stud Solicitor of the Supreme Court of New South Wales and the High Court of Australia Lecturer, New South Wales Institute of Psychiatry, Sydney, Australia
About the Companion Website
Don't forget to visit the companion website for this book:
www.ataglanceseries.com/psychiatry
There you will find valuable material designed to enhance your learning, including:
Interactive case studies
Downloadable illustrations
Scan this QR code to visit the companion website:
Part 1Assessment and Management
Chapters
1 Psychiatric History
2 The Mental State Examination
3 Diagnosis and Classification in Psychiatry
4 Risk Assessment and Management in Psychiatry
5 Suicide and Deliberate Self-harm
1Psychiatric History
An example psychiatric history
Introduction and presenting complaint: Mr John Smith is a 36-year-old Caucasian man, a mechanic, admitted to Florence Ward three days ago after police detained him on Section 136 for acting bizarrely in the street. He is now on Section 2. He thinks his neighbours are plotting to kill him.
History of presenting complaint: Mr Smith last felt free from worry four months ago. Since witnessing his neighbour staring at him, he has believed this neighbour and his wife are intercepting his mail, using a machine so no one can tell that the letters have been opened. He sees red cars outside, which he thinks the neighbours use to monitor his movements. After an altercation on the street three days ago in which he accused these neighbours of pumping gas into his flat, he has believed that they want to kill him or force him to move out so that they can purchase the property. He denies low mood. He cannot rule out the possibility he might defend himself against the neighbours but denies specific plans to retaliate. He denies hearing the neighbours or others talking about him or feeling that they can control him or his thoughts. He has been sleeping poorly. His appetite is reasonable.
Collateral history: Mrs Smith confirmed that her husband had been very preoccupied for the past month with worries about the neighbours intercepting mail and pumping gas into the flat. She witnessed the recent altercation in which her husband was verbally but not physically aggressive to the neighbours. The neighbours are a retired couple who are polite and considerate. Mr Smith has become withdrawn, staying mostly in the kitchen, the only room he believes is ‘safe'. He has been hostile to his wife at times this week, which is unusual. This occurred when she questioned his beliefs. He has never threatened her or their daughter.
Past psychiatric history: Mr Smith has seen a psychiatrist once before, aged 8, when he was diagnosed with ‘emotional problems'. His GP diagnosed depression when he was 24 and prescribed fluoxetine, which he never took. He believes he was depressed for a couple of years in his mid-20s but denies mental health problems since then. No previous psychiatric admissions. He has never taken medication for mental illness.
Past medical/surgical history: Mild asthma. Nil else of note.
Drug history and allergies: No current medication. No known allergies.
Family history: When Mr Smith was 28, his father died from lung cancer aged 60. His mother and brother, who is eight years younger, live nearby. Both are well, in regular contact and supportive. No known family psychiatric history.
Personal history – early life and development: Normal vaginal delivery, no known complications, no developmental delay. Mr Smith lived in the same house in Doncaster throughout his childhood. His father was a shopkeeper, and his mother a housewife. His parents were happily married, and there were no financial problems at home. No childhood abuse.
Educational history: Mr Smith left school at 16 with five GCEs. He had good friends from school. He was often in trouble with his teachers; he was suspended once for cheating in an exam but was never expelled.
Occupational history: On leaving school Mr Smith worked in the family plumbing business for a few years, then trained and worked as a mechanic. He has never been sacked and has been in his current job for three years. He has been on sick leave for the last two weeks because of ‘stress'.
Relationship history: Happily married for 10 years. He has one daughter, aged 5, who is well.
Substance use: Mr Smith drinks 30 units of alcohol a week, mainly wine in the evenings. There is no history of alcohol dependence. He has used cannabis regularly in the past (aged 16–28) but no illicit drug use since this time.
Forensic history: Conviction and fine for driving without due care aged 21. No other arrests or convictions.
Social history: Mr Smith owns his three-bedroom detached house. He usually sees his mother, brother and work friends regularly, but not in the past month. No current financial difficulties.
Premorbid personality: Mr Smith described himself as a sociable, calm person who thought the best of people and didn't tend to get into disputes with others until his current difficulties. He is a keen cyclist and member of a local cycling club.
The psychiatric history and mental state assessment (discussed in Chapter 2) are undertaken together in the psychiatric interview. This is a critical time for establishing rapport as well as systematically obtaining this information. In this chapter and the next, we present a format for written documentation; greater flexibility is clearly required during the actual interview. You should always do a physical examination too.
Introduction and presenting complaint
Patient's name, age, occupation, ethnic origin, circumstances of referral (and, in the case of inpatients, whether voluntary or compulsory) and presenting complaint (in the patient's own words).
History of the present illness
Start with open questions, e.g. ‘Can you tell me what has been happening?'
Establish when the illness first began (and, if a relapsing/remitting illness, when this illness episode began), e.g. ‘When did you last feel well?
What does the patient think might have caused the illness as a whole or this relapse/recurrence, and what makes it better or worse?
What has been the effect on daily life/relationships/work?
Depending on the presenting complaint, you will need to ask follow-up questions about other symptoms to help you make a diagnosis. Your questions should be guided by the diagnostic criteria for the individual disorders (discussed in later chapters). For example, if the patient describes feeling anxious, you would ask questions to establish if the anxiety is situational and if panic attacks occur.
Enquire about mood, sleep and appetite, even if they appear normal, and whether there are risks of harm to self or others (see Chapters 4 and 5).
Especially in psychosis or dementia, the patients' views of events might differ from those of their family, friends or other collateral sources. In this case, you can record their accounts, followed by any collateral information available.
Previous psychiatric history
Dates of illnesses, symptoms, diagnoses, treatments.
Hospitalisations, including whether treatment was voluntary or compulsory.
Past medical/surgical history
Dates of any serious medical illnesses.
Dates of any surgical operations.
Dates of any periods of hospitalisation.
Drug history and allergies
All current medication.
Note psychotropic medications that patients have received previously, their dosage and duration, and whether or not they helped. It may be necessary to obtain this information from the patients' GP or hospital notes.
Family history
Parents' and siblings' physical and mental health, their frequency of contact with, and the quality of their relationship with the patient.
If a close relative is deceased, note the cause of death, the patient's age at the time of death and their reaction to that death (see Chapter 10).
Ask about family history of psychiatric illness (‘nervous break-downs'), suicide or drug and/or alcohol abuse, forensic encounters and medical illnesses.
Personal history
Early life and development:
Include details of the pregnancy and birth (especially complications), any serious illnesses, bereavements, emotional, physical or sexual abuse, separations in childhood or developmental delays. Describe the childhood home environment (atmosphere and any deprivation). Note religious background and current religious beliefs/practices.
Educational history:
Include details of school, academic achievements, relationships with peers (did they have any friends?) and conduct (whether suspended, excluded or expelled). Bullying and school refusal or truancy should be explored.
Occupational history:
List job titles and duration, reasons for change; note work satisfaction and relationships with colleagues. The longest duration of continuous employment is a good indicator of premorbid functioning.
Relationship history:
Document details of relationships and marriages (duration, gender of partner, children, relationship quality, abuse); sexual difficulties; in the case of women, menstrual pattern, contraception, history of pregnancies. Those who are in a long-term relationship should be asked about the support they receive from their partner and the quality of the relationship – e.g. whether there is good communication, aggression (physical or verbal), jealousy or infidelity.
Substance use
Alcohol, drug (prescribed and recreational) and tobacco consumption.
Forensic history
Any arrests, whether they resulted in conviction and whether they were for violent offences.
Any periods of imprisonment, for which offences and the length of time served.
Social history
Describe current accommodation, occupation, financial situation and daily activities.
Premorbid personality
A description of the patient's character and attitudes before they became unwell (e.g. character, social relations). You could ask:
How would you describe yourself before you became unwell?
How would your friends describe you?
What do you enjoy doing?
How do you usually cope when things go wrong?
2The Mental State Examination
An example mental state
Appearance and behaviour: Mr Smith was a thin gentleman, appropriately dressed in casual clothes, with no evidence of poor personal hygiene or abnormal movements; he was not objectively hallucinating. He was polite, appropriate, maintained good eye contact and, although it was initially difficult to establish a rapport, this improved throughout the interview.
Speech: Normal in tone, rate and volume. Relevant and coherent, with no evidence of formal thought disorder.
Mood: Subjectively ‘fine'; objectively euthymic.
Affect: Suspicious at times, particularly when discussing treatment; reactive.
Thoughts: Persecutory delusions and delusions of reference elicited (see ‘History of the present illness', Chapter 1). Could not ‘rule out' retaliating against neighbour, but no current thoughts, plans or intent to harm neighbour, self or anyone else. No evidence of depressive cognitions or anxiety symptoms. No suicidal ideation.
Perception: No abnormality detected.
Cognition: Alert, orientated to time, place and person. No impairment of concentration or memory noted during interview.
Insight: Patient feels stressed; he is aware that others think he has a psychotic illness but he disagrees with this. He does not want to receive any treatment and does not think he needs to be in hospital. He would be willing to see a counsellor for stress.
Appearance and behaviour
Here you should note:
Their general health, build, posture, unusual tattoos or clothing, piercings, injection sites, lacerations (especially on the forearm).
Whether they have good personal hygiene?
Whether they are tidily dressed/well-kempt or unkempt?
Their manner, rapport, eye contact, degree of cooperation, facial expression, whether responding to hallucinations.
Motor activity may be excessive (psychomotor agitation) or decreased (psychomotor retardation).
Abnormal movements may be antipsychotic side effects such as
tremor
bradykinesia: slowness of movement
akathisia: restlessness
tardive dyskinesia: usually affects the mouth, lips and tongue (e.g. rolling the tongue or licking the lips)
dystonia: muscular spasm causing abnormal face and body movement or posture.
Other abnormal movements include:
tics
chorea
stereotypy: repetitive, purposeless movement (e.g. rocking in people with severe learning disability)
mannerisms: goal-directed, understandable movements (e.g. saluting)
gait abnormalities.
Speech
Describe tone (variation in pitch), rate (speed) and volume (quantity). In pressure of speech, rate and volume are increased and speech may be uninterruptible. In depression, tone, rate and volume are often decreased.
‘Normal' speech can be described as ‘spontaneous, logical, relevant and coherent'.
‘Circumstantial' speech takes a long time to get to the point.
Perseveration (repeating words or topics) is a sign of frontal lobe impairment.
Neologisms (made up words e.g. ‘headshoe' to mean ‘hat') can occur in schizophrenia.
Thought form
Normal speech consists of a series of phrases/statements connected by their meanings:
I am reading this book ⇒ because I want to pass my exam.
In flight of ideas there is an abnormal connection between statements based on a rhyme or pun rather than meaning:
I read this book ⇒ because it was red and blue ⇒ I feel blue.
In ‘loosening of associations' there is no discernible link between statements:
I am reading ⇒ climate change ⇒ where's the piano?
If you think a patient has abnormal thought form, record some examples of what they say.
In thought block, the patient's subjective experience of thought is abnormal (thoughts disappear: ‘my mind goes blank').
Mood and affect
Mood
is the underlying emotion; report subjective mood (in patient's own words) and objective mood (described as dysthymic (low), euthymic (normal) or hyperthymic (elated)).
Affect
is the observed (and often more transient) external manifestation of emotion. Mood has been compared to climate and affect to weather. An abnormal affect may be described as:
blunted/unreactive (lacking normal emotional responses – e.g. negative symptoms of schizophrenia)
labile (excessively changeable)
irritable (which may occur in mania, depression)
perplexed
suspicious; or
incongruous (grossly out of tune with subjects being discussed – e.g. laughing about bereavement).
Where no abnormality is detected, affect is described as reactive (appropriate response to emotional cues).
Disorders of thought content
Record:
Negative (depressed) cognitions (e.g. guilt, hopelessness).
Ruminations (persistent, disabling preoccupations) that may occur in depression or anxiety (e.g. worrying about redundancy, illness or death).
Obsessions (Chapter 12) and phobias (Chapter 11).
Depersonalisation or derealisation: these often occur with anxiety; they are not psychotic phenomena.
Depersonalisation – feeling detached, unreal, watching oneself from the outside: ‘as if cut off by a pane of glass'.
Derealisation – the world or people in it seeming lifeless: ‘as if the world is made out of cardboard'.
Abnormal beliefs. These are:
overvalued ideas: acceptable and comprehensible but pursued by the patient beyond the bounds of reason and to an extent that causes distress to them or others (e.g. an intense, non-delusional feeling of responsibility for a bereavement)
ideas of reference: thoughts that other people are looking at or talking about them, not held with delusional intensity
delusions: fixed, false, firmly held beliefs, out of keeping with the patient's culture and unaltered by contrary evidence.
Figure 2.1 Types of delusion
Ask about suicidal or homicidal ideation, plans and intent:
Figure 2.2 Asking about suicide
Perception
Ask ‘Have you seen or heard things that other people can't see or hear? Can you tell me more about that?'
Illusions
are misinterpretations of normal perceptions (e.g. interpreting a curtain cord as a snake). They can occur in healthy people.
Hallucinations
are perceptions, in the absence of an external stimulus, that are experienced as true and as coming from the outside world. They can occur in any sensory modality, although auditory and visual are the most common. Some auditory hallucinations occur in normal individuals when falling asleep (hypnagogic) or on waking (hypnopompic).
Pseudohallucinations
are internal perceptions with preserved insight (e.g. ‘A voice inside my head tells me I'm no good.'
Cognition
Note at least the level of consciousness, memory, orientation, attention and concentration. More formal testing is needed for those who may have cognitive impairment and everyone aged 65 and over. This may involve completing a Mini-Mental State Examination (MMSE) with additional tests of frontal lobe function.
You should test:
memory (e.g. repeating a list of three or more objects or an address – immediately and after 5 minutes)
orientation in time (day, date, time), place, person (e.g. knowing their name, age and identity of relatives)
attention and concentration (e.g. counting backwards)
dyspraxia (e.g. drawing intersecting pentagons)
receptive dysphasia (following a command)
expressive dysphasia (naming objects)
executive (frontal lobe) functioning tests such as:
approximation (e.g. height of a local landmark)
abstract reasoning (e.g. finding the next number or shape in a sequence)
verbal fluency (can they think of >15 words beginning with each of the letters F, A or S in a minute?)
proverb interpretation.
Insight
The patient's understanding of their condition and its cause as well as their willingness to accept treatment.
3Diagnosis and Classification in Psychiatry
Figure 3.1 ICD-10 and DSM-IV-TR diagnosis and classification
History
Before the 1950s, diagnoses were unreliable and had meanings that varied across the world. In the 1960–1970s ‘antipsychiatrists', including R. D. Laing and Thomas Szasz, suggested that psychiatric diagnoses should be abandoned, together with the concept of mental illness.
The International Classification of Diseases (ICD) is a system developed by the World Health Organization (WHO) aimed at improving diagnosis and classification of disorders. The mental health section is currently in its tenth edition (ICD-10). Look online at some of the diagnostic criteria (
http://apps.who.int/classifications/apps/icd/icd10online/
). ICD 11 is scheduled for publication in 2017.
The American Psychiatric Association developed its own classificatory system, the Diagnostic and Statistical Manual of Mental Disorders (DSM); the current classification, DSM 5 was released in May 2013.
ICD-10 and DSM-5 are broadly similar.
Figure 3.1
shows the main differences.
The concept of mental illness
In medicine, a distinction is made between
disease
(objective physical pathology and known aetiology) and
illness
(subjective distress). Psychiatric conditions without known organic cause, such as depression, are described as illnesses or disorders not
diseases
since in many there is no demonstrable pathology. New techniques (e.g. neuroimaging) may identify definable psychiatric diseases.
The concept of mental
illness
is useful in defining a level of subjective distress greater in severity or duration than occurs in normal human experience. The legislation in many countries requires psychiatrists to diagnose defined ‘mental illness' when certifying the need for compulsory hospital treatment and in forensic (legal) psychiatry.
Diagnostic criteria set thresholds to define the level of symptoms that constitute mental illness. These thresholds can be controversial. For example, compared to DSM-IV, DSM-5 criteria for ADHD are more inclusive – requiring symptoms before age 12 rather than age 7. In the USA, 20% of boys aged between 14 and 17 have been diagnosed with ADHD and 2/3 take medication. Critics claim this as the medicalization of childhood, proponents that it is right that those who may benefit from treatment receive it.
Decisions about what constitutes mental illness change over time, influenced by:
Latest research findings e.g. gambling disorder is newly classified in DSM-5 among substance abuse/addictions as it has been found to have more in common with these disorders than with impulse control disorders where classified in DSM-IV.
Sociopolitical thinking: homosexuality was removed from the DSM in the 1970s. DSM-IV, gender identity disorder was changed to gender dysphoria in DSM-5 because ‘gender incongruence' rather than cross-gender identification per se is considered a disorder.
Aims of classification in psychiatry
To identify groups of patients who are similar in their clinical features, course of disease, outcome and response to treatment, aiding individual clinical management.
To provide a common language for communication between patients, professionals and researchers.
To improve the
reliability
(reproducibility among different settings) and
validity
(correctness) of diagnoses. Validity is more difficult to confirm but attempts have been made, including the examination of consistency of symptom patterns and demonstration of consistent treatment responses, long-term prognoses, genetic and biological correlates.
Categorical versus Dimensional
ICD-10 and DSM-5 are
categorical systems
. They describe a group of discrete conditions. They give
operational definitions
specifying inclusion and exclusion criteria. These state which symptoms must be present for each diagnosis to be made (often quantifying their number and requiring a minimum duration).
Dimensional systems
use a continuum rather than categories and have been used mainly to classify personality. For example, Hans Eysenck proposed three dimensions of personality: introversion/extroversion, neuroticism (mental distress in which ability to distinguish between symptoms originating from patient's own mind and external reality is retained; includes most depressive and anxiety disorders) and psychoticism (severe mental disturbance characterised by a loss of contact with external reality). DSM-5 includes a suggested model for defining personality disorders that allows dimensional assessment of traits in its section for further study, although the main manual still defines personality disorders categorically.
Comorbidity
Psychiatric diagnoses are made in ICD-10 (and to a lesser extent in DSM-5) using a diagnostic hierarchy, which is often illustrated as a triangle.
Figure 3.2 Diagnostic hierarchy
Organic disorders are at the top of the triangle and take precedence when making diagnoses. For example, if a person with dementia is agitated and anxious, the anxiety would be classified as a neuropsychiatric symptom of the dementia rather than being diagnosed separately as anxiety disorder.
Similarly, a person who met criteria for both a depressive episode and generalised anxiety disorder would be diagnosed with depression alone.
Comorbidity (co-occurrence of two psychiatric disorders) is allowed in either system if a person is experiencing symptoms not explained by one diagnosis alone. For example, a person with an emotionally unstable personality disorder may be diagnosed with depression.
4Risk Assessment and Management in Psychiatry
Figure 4.1 Balancing risks and patients’ rights
Clinicians need to balance the need to reduce risk as far as possible with the duty to respect patients' rights and freedom; risk cannot be eliminated completely. This continuing process is called risk assessment and management.
