Rapid Psychiatry E-Book

Clare Oakley

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Rapid
• Sprache: Englisch

Seitenzahl: 188

Veröffentlichungsjahr: 2011

Beschreibung

This pocket guide is a must for all clinical medical students and junior doctors and provides an excellent revision tool in the run-up to exams. It is also perfect for when working on the psychiatric attachment, as it covers many of the conditions encountered on the wards, in clinics, and in general practice. Now thoroughly updated, it includes new sections on Neuropsychiatry, the Psychiatry of Learning Disability, Forensic Psychiatry, and Psychotherapy, as well as common disorders, their assessment and their treatment. Featuring the key points of the Mental Health Act, along with a glossary of terms, Rapid Psychiatry is the ideal refresher, covering just the basic relevant facts.

Leseprobe

Contents

Preface

Acknowledgements

List of Abbreviations

Introduction to Psychiatry

Summary

Psychiatric history

Mental state examination

Signs and symptoms

Psychiatric history

Patient’s personal details

Presenting complaint

History of presenting complaint

Past psychiatric history

Past medical history

Drug history

Family history

Personal history

Premorbid personality

Mental state examination

Appearance and behaviour

Speech

Mood

Thought

Perception

Cognition

Insight

Formulation

Classification systems for mental disorders

International classification of diseases (ICD-10)

Diagnostic and statistical manual of mental disorders (DSM-IV)

Assessment of suicide risk

Eliciting a sense of hopelessness

Suicidal thoughts

Previous attempts

Social support

Identifying stressors that increase the risk

Preventing factors

Health problems

Deliberate self-harm

Suicide

Multidisciplinary team

Ethical issues

Respect for autonomy

Beneficence

Non-maleficence

Justice

Mental Capacity Act

Principles of mental capacity

Assessment of mental capacity

Lasting power of attorney (LPA)

Court of Protection

Advance decision

Adults With Incapacity (Scotland) Act 2000

Mental health legislation

Mental health legislation varies in different countries

Criteria for detention

Professionals involved

Mental health review tribunals

Section 5(2)

Section 2

Section 3

Sections 47, 48 and 49

Sections 37 and 41

Community treatment orders

Other powers

Criteria for detention

Exclusions for detention

Professionals involved

Emergency detention certificate (EDC/Section 36)

Short-term detention certficate (STDC/Section 44)

Compulsory treatment orders (CTOs/Section 63)

Other powers

Differential Diagnosis

The anxious patient

Symptoms

Management

The depressed patient

Symptoms

Differential diagnosis

Management

The elated patient

Symptoms

Differential diagnosis

Management

The hallucinating patient

Symptoms

Differential diagnosis

Management

The patient with obsessions/compulsions

Symptoms

Differential diagnosis

Management

The unresponsive patient

Symptoms

Differential diagnosis

Management

General Adult Psychiatry

Anxiety disorders – agoraphobia

Anxiety disorders – generalised anxiety disorder

Anxiety disorders – social phobia

Anxiety disorders – specific phobia

Chronic fatigue syndrome

Dissociative disorders

Eating disorders – assessment

Weight

Eating

Body image

Physical problems associated with weight loss

Eating disorders – anorexia nervosa

Eating disorders – bulimia nervosa

Mood disorders – bipolar affective disorder

Mood disorders – depression

Obsessive-compulsive disorder

Personality disorders

Postnatal mental disorders – postnatal blues

Postnatal mental disorders – postnatal depression

Postnatal mental disorders – puerperal psychosis

Reactions to stressful events – abnormal grief reactions

Reactions to stressful events – acute stress disorders

Reactions to stressful events – adjustment disorder

Reactions to stressful events – post-traumatic stress disorder

Schizophrenia

Schizoaffective disorder

Delusional disorder

Somatisation disorder

Substance misuse – assessment

CAGE

Full alcohol history

Full drug history

Substance misuse – alcohol

Substance misuse – illicit drugs

Neuropsychiatry

Epilepsy

Non-epileptic attack disorder

Head injury and associated psychiatric sequelae

Huntington’s disease

Motor neurone disease

Multiple sclerosis

Parkinson’s disease

Syphilis

Wilson’s disease

Child and Adolescent Psychiatry

Special considerations for assessment

Interviewing the family

Interviewing the child alone

Gathering information from other professionals

Attachment and development

Attachment theory

Normal attachment behaviours (6 months to 3 years)

Abnormalities of attachment

Development

Attention deficit hyperactivity disorder

Child abuse

Conduct disorder

Other psychiatric disorders of childhood and adolescence

Bipolar affective disorder

Depression

Obsessive-compulsive disorder

Schizophrenia

School refusal

Sleep disorders

Tourette’s syndrome

Old Age Psychiatry

Special considerations for assessment

Delirium

Dementia

Depression

Very late-onset schizophrenia

Psychiatry of Learning Disability

Learning disability

Autism

Down’s syndrome

Genetic disorders

Fragile X

Phenylketonuria

Prader-Willi syndrome

Tuberous sclerosis

Velocardiofacial syndrome

Forensic Psychiatry

Special considerations for assessment

Violence and mental disorder

Schizophrenia

Personality disorders

Risk assessment

Structure of forensic services

The different types of psychiatric inpatient care

Legal terms and criminal proceedings

Fitness to plead

Insanity defence

Diminished responsibility

Infanticide

Automatism

Psychotherapy

Special considerations for assessment

Cognitive-behavioural therapy

Cognitive methods

Behavioural methods

Indications

Psychodynamic psychotherapy

Transference and countertransference

Defence mechanisms

Indications

Relative contraindications

Supportive psychotherapy

Elements of supportive psychotherapy

PsychopharmacoIogy

Introduction – general points on prescribing

Antidepressants – selective serotonin reuptake inhibitors

Examples

Indications

Side effects

Contraindications

Prescribing notes

Antidepressants – tricyclic antidepressants

Examples

Indications

Side effects

Contraindications

Prescribing notes

Antidepressants – monoamine oxidase inhibitors

Examples

Indications

Side effects

Contraindications

Prescribing notes

Antidepressants – others

Examples

Indications

Side effects

Contraindications

Prescribing notes

Antipsychotics – atypicals

Examples

Indications

Side effects

Contraindications

Prescribing notes

Antipsychotics – typicals

Examples

Indications

Side effects

Prescribing notes

Antipsychotics – clozapine

Indication

Side effects

Contraindications

Prescribing notes

Anxiolytics

Examples

Indications

Side effects

Contraindications

Prescribing notes

ADHD medication

Examples

Indications

Side effects

Contraindications

Prescribing notes

Electroconvulsive therapy

Special preparations

Practitioners involved

Side effects

Complications

Contraindications

Transcranial magnetic stimulation (TMS)

Dementia medication

Examples

Indications

Side effects

Contraindications

Prescribing notes

Hypnotics

Examples

Indications

Contraindications

Prescribing notes

Medication for alcohol dependence

Examples

Indications

Side effects

Contraindications

Prescribing notes

Medication for opioid dependence

Examples

Indications

Side effects

Contraindications

Prescribing notes

Mood stabilisers – carbamazepine

Indications

Side effects

Contraindications

Prescribing notes

Mood stabilisers – lithium

Indications

Side effects

Contraindications

Prescribing notes

Lithium toxicity

Mood stabilisers – sodium valproate

Indications

Side effects

Contraindications

Prescribing notes

Rapid tranquillisation

Examples

Indications

Side effects

Contraindications

Prescribing notes

Appendices

Culture-specific disorders

Eponymous syndromes

Asperger’s syndrome

Briquet’s syndrome

Capgras syndrome

Cotard’s syndrome

Couvade syndrome

De Clérambault’s syndrome

Down’s syndrome

Ekbom’s syndrome

Folie à deux

Frégoli syndrome

Ganser syndrome

Gerstmann syndrome

Tourette’s syndrome

Munchausen syndrome

Othello syndrome

Wernicke-Korsakoff syndrome

Physical disorders – psychological consequences

Medication – psychological consequences

Glossary

This edition first published 2010, © 2010 by C. Oakley and A. Malik

Previous editions: 2004

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

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Library of Congress Cataloging-in-Publication Data

Oakley, Clare.Rapid psychiatry / Clare Oakley, Amit Malik. – 2nd ed.p. ; cm. – (Rapid series)ISBN 978-1-4051-9557-71. Brief psychotherapy–Handbooks, manuals, etc. I. Malik, Amit. II. Title.III. Series: Rapid series.[DNLM: 1. Mental Disorders–Handbooks. 2. Psychiatry–methods–Handbooks.WM 34 O11r 2010]RC480.55.H53 2010616.89′14-dc222010015125ISBN: 9781405195577

Preface

It has been an absolute joy and challenge to complete this book for undergraduate medical students. Rapid Psychiatry is set out in 11 different sections. In addition to the introduction, differential diagnosis, psychopharmacology and the appendices which cover topics that are relevant across the range of patient groups and clinical settings, the book contains sections on the main areas of specialism within psychiatry. Within most sections, the chapters are arranged in alphabetical order except for the introduction and appendices chapter which do not lend themselves well to such an arrangement. We hope that this book will make the undergraduate experience more enjoyable for all medical students and that many more will decide to choose psychiatry as their future career.

Acknowledgements

We are both grateful to Allison Hibbert, Alice Goodwin and Frances Dear whose excellent original work provided the inspiration for this second edition. We would also like to thank Dr Helen Smith for her invaluable contributions regarding the Scottish mental health legislation. This book would not have been possible without our own teachers and the authors of many reference textbooks and scientific papers whose wisdom has been sieved in the subsequent pages. Whilst the format of the book did not lend itself to referencing every expert and publication, we thank them all. The team at Wiley-Blackwell have supported us throughout this process, from Joan Marsh, who first introduced us to the publication house, to Ben Townsend, whose enthusiasm convinced us to take on this project, and finally to Laura Murphy, whose patience and support have guided this book through its many revisions. And finally we thank our families for their patience and support through our hours of writing and revising the text.

List of Abbreviations

5-HIAA

5-hydroxyindoleacetic acid

5-HT

5-hydroxytryptamine (serotonin)

AA

Alcoholics Anonymous

ABC

Airway, breathing, circulation (basic life support)

ABG

Arterial blood gases

ACE

Angiotensin-converting enzyme

ADHD

Attention deficit hyperactivity disorder

AMHP

Approved mental health practitioner

AMP

Approved medical practitioner

APP

Amyloid precursor protein

AV

Atrioventricular

AWI

Adults with Incapacity (Scotland) Act 2000

BMI

Body Mass Index

BNF

British National Formulary

BP

Blood pressure

Ca

Calcium

CBT

Cognitive-behavioural therapy

CJD

Creutzfeldtlakob disease

CMHT

Community Mental Health Team

CNS

Central nervous system

CPN

Community psychiatric nurse

CRP

C-reactive protein

CSF

Cerebrospinal fluid

CT

Computed tomography

CTO

Compulsory Treatment Order

CVA

Cerebrovascular accident/stroke

CXR

Chest X-ray

DKA

Diabetic ketoacidosis

DSM

Diagnostic and Statistical Manual of Mental Disorders (US diagnostic guidelines)

DZ

Dizygotic

ECG

Electrocardiogram

ECT

Electroconvulsive therapy

EDC

Emergency Detention Certificate

EEG

Electroencephalogram

EMDR

Eye Movement Desensitisation and Reprocessing

EPSE

Extrapyramidal side effect

ESR

Erythrocyte sedimentation rate

EtOH

Ethanol (alcohol)

FBC

Full blood count

FTA

Fluorescent treponemal antibody test

GABA

γ-aminobutyric acid

GAD

Generalised anxiety disorder

GCS

Glasgow Coma Scale

GGT

γ-glutamyl transferase

GI

Gastrointestinal

GP

General practitioner

GPI

General paresis of the insane

HIV

Human immunodeficiency virus

HR

Heart rate

IBS

Irritable bowel syndrome

ICD

International Classification of Diseases (WHO diagnostic guidelines)

ICP

Intracranial pressure

IM

Intramuscular

IQ

Intelligence quotient

ITU

Intensive therapy unit

IV

Intravenous

LD

Learning disability

LFT

Liver function test

LP

Lumbar puncture

LSD

Lysergic acid diethylamide

MAOI

Monoamine oxidase inhibitor

MDT

Multidisciplinary team

MHA

Mental Health Act (1983)

MHO

Mental health officer

MI

Myocardial infarction

MMR

Measles, mumps and rubella

MMSE

Mini mental state examination

MRI

Magnetic resonance imaging

MSE

Mental state examination

MSU

Midstream urine

MZ

Monozygotic

NA

Noradrenaline (norepinephrine)

NSAID

Non-steroidal anti-inflammatory drug

OCD

Obsessive-compulsive disorder

OT

Occupational therapy

PD

Personality disorder

PTSD

Post-traumatic stress disorder

RC

Responsible clinician

RMO

Responsible medical officer

SOAD

Second opinion approved doctor

SSRI

Selective serotonin reuptake inhibitor

STDC

Short-Term Detention Certficate

TCA

Tricyclic antidepressant

TFT

Thyroid function test

TIA

Transient ischaemic attack

TMS

Transcranial magnetic stimulation

TPHA

Treponema pallidum haemagglutination assay (test for syphilis)

U&E

Urea and electrolytes

UTI

Urinary tract infection

VDRL

Venereal Diseases Reference Laboratory

WHO

World Health Organization

Introduction to Psychiatry

Summary

The following are the broad headings of a standard psychiatric assessment, which are discussed in detail later in the chapter. Special considerations for specific patient groups (children, older people, etc.) are discussed at the beginning of relevant chapters.

Psychiatric history

Patient’s personal detailsPresenting complaintHistory of presenting complaintPast psychiatric historyPast medical historyDrug historyFamily historyPersonal history:ChildhoodSchoolOccupationsPsychosexual historyAlcohol and substance useForensic historySocial situationPremorbid personality

Mental state examination

Appearance and behaviourSpeechMoodThoughtPerceptionCognitionInsight

Signs and symptoms

Affect is the observable behaviour of a subjectively experienced emotion. It is variable over time (in comparison to mood which is a pervasive and sustained emotional state). Affect may be:

blunted – lack of appropriate emotional response to eventsflat – absence of expression of affectinappropriate – affect is inappropriate to the thought or speech it accompanieslabile – rapid changes in affect.

Anxiety is a feeling of apprehension, uneasiness or tension. It is accompanied by somatic sensations including sweating, palpitations and shortness of breath. Anxiety may be freefloating (pervasive) or related to a specific fear (phobic).

Compulsions are stereotyped acts, recognised as excessive, unreasonable or exaggerated. If the patient tries to resist doing them, there is a sense of mounting tension that can be immediately relieved by yielding to the compulsion. Often involve:

cleaningcheckingcountinghoarding.

Delusions are abnormal beliefs which are held with absolute certainty. They are based on incorrect inferences about external reality and are firmly held despite proof or evidence to the contrary. They are not beliefs which can be understood as part of their cultural or religious background. The beliefs are usually but not always false – for example, the patient’s spouse may actually be having an affair. It is the abnormal thought processes that define a delusion, not whether the belief is true.

Delusions may be classified as primary or secondary.

Primary delusions do not have any identifiable connection with previous events and are a direct result of the psychopathology. Types of primary delusion are: autochthonous – ‘out of the blue’, fully formed beliefsdelusional memory – arising from a memorydelusional mood – arising from a period of anticipatory anxiety and the sense that something was about to happendelusional perception – an abnormal belief arising from a normal perception (e.g. the traffic lights turn red and the patient realizes that is a sign they are the next Messiah).Secondary delusions arise out of another primary psychiatric symptom (e.g. low mood) and are understandable in the context. They are a product of an attempt to understand the primary morbid experience.

Common types of delusion include the following.

Persecutory – being conspired against, attacked or persecuted.Grandiose – inflated self-worth, special powers or abilities, relationships with important and special people, having a mission.Reference – events have a particular and unusual significance for the patient, they are being referred to on television and in the newspapers.Delusions of control (passivity phenomena) – being controlled by an external agent: emotionsimpulsesactionssomatic passivity (bodily sensations).Thought interference (passivity phenomena) – thoughts are controlled by an external agency: thought withdrawalthought broadcastthought insertion.Misidentification – certain individuals are not who they appear to be. Familiar people have been replaced with outwardly identical strangers (Capgras syndrome) or strangers are really familiar people (Fregoli syndrome).Guilt – believe they deserve punishment.Nihilistic – they have died or no longer exist or that the world has ended.Hypochondriacal – believe they have a serious physical illness.Jealousy – partner is being unfaithful (Othello syndrome).Love – another person, usually of higher status, is deeply in love with them (deClerambault syndrome).Infestation – their skin is infested with multiple insects or parasites (Ekbom syndrome).

Delusions may be mood congruent, e.g. grandiose in elated mood states and nihilistic in depressed mood states, or mood incongruent, e.g. grandiose in depressed states.

Depressed mood is the core feature of a depressive illness. Patients describe a pervasive unhappiness, being unable to feel happy, hopelessness, helplessness and negative thoughts about themselves, the world and the future. Other features of a depressive illness are discussed in the relevant section.

Elevated mood is the core feature of a manic illness. Patients describe feeling very happy, being positive about everything, feeling indestructible, feeling more creative, being able to think more quickly and achieve more tasks than usual. Other features of a manic illness are discussed in the relevant section.

Formal thought disorder refers to an abnormality of the form of thought.

Circumstantiality – irrelevant and unnecessary details are incorporated into the thinking, meaning that the goal of the thought is reached very slowly.Flight of ideas – accelerated thoughts with abrupt changes to related thoughts. The connections between the thoughts may be based, for example, on puns, rhyming words or alliteration.Loosening of associations – lack of meaningful connection between thoughts: derailment – thought derails onto a subsidiary thoughtdrivelling – disordered mixture of the constituent parts of one thoughtfusion – two or more unrelated concepts are brought togetheromission – part of a thought is omittedsubstitution – a thought is substituted by a subsidiary thought.Neologism – a new word constructed by the patient or an existing word used in a new way.

Hallucinations are perceptions without the corresponding external object. The subjective experience is a normal perception in that sensory modality (i.e. voices sound like ‘real’ voices). A true hallucination will be perceived in external space and be outside conscious control.

Auditory:second-person – voices directly addressing the patient (e.g. ‘you are useless’)third-person – two or more voices discussing the patient (e.g. ‘he’s very powerful’)thought echo – voices echo thoughts before or after they happenrunning commentary – voices comment on action (e.g. ‘he’s going out of the door now’).Visual – e.g. small figures seen in delirium.Olfactory – usually an unpleasant smell.Gustatory – commonly a feeling that something tastes differently and this is often interpreted as being the result of poisoning.Somatic – e.g. sensation of insects under skin or movement of joints.

Illusions are false perceptions of a real external stimulus. There are three types:

affect – during heightened emotion (e.g. when walking alone on a dark night, seeing a shadow as an attacker)completion – ‘filling in’ of presumed missing parts of an image (e.g. optical illusions)pareidolic – produced when experiencing a poorly defined stimulus (e.g. seeing faces in the clouds).

Obsessions may be persistent thoughts, images, doubts or impulses. They are acknowledged as originating in the mind and are repetitive and intrusive. The patient tries to resist them. The obsessions cause distress and interfere with functioning. Common content includes:

contaminationbodily fearsaggressionorderliness/symmetry.

Overvalued ideas are an unreasonable and sustained intense preoccupation. It is not of delusional intensity (the person can acknowledge that it is possible the belief may not be true). The ideas can be understood but are incorrect and can come to dominate the person’s life.

Pseudo-hallucinations are a form of imagery arising in the subjective inner space of the mind and not perceived as part of the external world. They do not have the same quality as normal perceptions. They can occur in any sensory modality but are most commonly auditory.

Psychiatric history

Patient’s personal details

NameAgeGenderMarital statusOccupationReligion/ethnic group

Presenting complaint

Document this in the patient’s own words.Document how long the patient has had the problem, e.g. ‘feeling low for the last few months’.Use open-ended questions to elicit these, e.g. ‘Can you tell me about the problems that brought you here?’.Let the patient speak uninterrupted for the first few minutes before continuing questioning.

History of presenting complaint

When did the problem start?Has it changed over time? If so, how?Were there any precipitating events, e.g. bereavement, divorce?Any psychological/drug treatments for the current problem? If so, did they help?Screen for any other problems. All patients should be asked about suicidal ideation, depression, anxiety, obsessional behaviour and psychosis.

Past psychiatric history

Have they seen a psychiatrist before?Have they been treated by their GP for any mental health problems?Have they been treated in hospital before?Were they detained under mental health legislation?Are there any previous risk behaviours (deliberate self-harm, violence, aggression, etc.) related to their previous mental health problems?

Past medical history

Enquiry regarding any significant illnesses, operations or accidents.

Drug history

Do they take any regular medication?What medication have they taken previously for their mental health and was it effective?

Family history

Is there a family history of mental illness?Collect information about parents, siblings and other significant relatives.Enquire about age, occupation, social circumstances and quality of the relationship with the patient.Make a genogram (family tree) of the information.

Personal history

Childhood – birth history (difficulties, prematurity); developmental milestones, delay in particular; description of early childhood; family and home atmosphere.School – leaving age; any truancy or school refusal, bullying; relationships with peers, teachers; exams taken and qualifications, further education.Occupations – list all jobs and duration of employment, reasons for leaving and any periods of unemployment.Psychosexual history–current relationship if any, sexual orientation, any sexual difficulties, first sexual experience, any sexual abuse, past significant relationships-reasons why they ended.Alcohol and substance use–alcohol, tobacco and illicit drugs; record amount, e.g. units of alcohol per week; current and previous use; patterns of use; symptoms/signs of dependency and withdrawal; associated problems, e.g. financial difficulties.Forensic history – record all offences whether convicted or not (especially note violent crimes, sexual crimes and persistent offending).Social situation – type of housing, who else is at home; financial circumstances including income, benefits, debts; social support – friends, relatives, social services.

Premorbid personality

Difficult to assess in a short interview. Focus on consistent patterns of behaviour throughout life. This part should include an account from an informant, as no individual can objectively describe their own personality. Useful questions include ‘How would you describe yourself when well?’ and ‘How would others describe you?’.Areas to include – attitudes to others in relationships; attitudes to self; predominant mood; leisure activities and interests; reaction to stress, coping mechanisms.