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v
Preface
This book is aimed at medical students, but should be suitable and revise your learning. We have tried to produce a book that
for anyone learning about psychiatry for the first time, or is stimulating and easy to read. Psychiatry is a fascinating and
needing to refresh their knowledge. What makes it different highly rewarding field and we hope this book will help you
from other introductory psychiatry texts is its format, which make the most of it. If we encourage you to meet and work
will be familiar to readers of other books from the Illustrated with psychiatric patients and their families, and give you the
Colour Text series. There are illustrations and clinical exam- knowledge you need to do this effectively, then we will have
ples throughout, and each topic is covered in two facing pages. succeeded.
This has allowed us to keep the book relatively brief and still
cover a wide range of information. There are summary boxes, Lesley Stevens
questions and answers about clinical problems, and a new Ian Rodin
self-assessment section, all of which should help you monitor 2011
vi
Acknowledgements
We wrote the first edition of the book when we were lecturers invaluable. We couldnt have written this second edition
in psychiatry at the University of Southampton and continue without the advice of Alison Taylor and Sheila Black at Elsevier
to teach students from the School of Medicine. This experi- and, once again, the tolerance and support of our partners, Joe
ence, and the encouragement and guidance given to us by and Deborah.
Chris Thompson, Robert Peveler and David Baldwin, has been
vii
Contents
Introduction 2
Mental health services I 2 History and aetiology 8 Management plan and formulation 14
Mental health services II 4 Mental state examination 10 Mental capacity 16
Classification in psychiatry 6 Assessment of risk 12 The Mental Health Act 18
Treatment in psychiatry 20
Introduction to drug treatments 20 Mood stabilisers and ECT 28 Psychological treatments 32
Prescribing psychotropic drugs 22 Benzodiazepines and drugs for Family and social treatments 34
Antipsychotic drugs 24 dementia 30 Recovery and social inclusion 36
Antidepressant drugs 26
Schizophrenia 38
Diagnosis and classification of Epidemiology and aetiology of Acute and chronic schizophrenia 42
schizophrenia 38 schizophrenia 40 Management of schizophrenia 44
Mood disorders 46
Classification of mood disorders 46 Bipolar disorder clinical presentation Depressive disorder clinical
Epidemiology and aetiology of mood and management 50 presentation 52
disorders 48 Depressive disorder management 54
Neurotic disorders 56
Anxiety disorders clinical Obsessivecompulsive disorder 60 Dissociative and somatoform
presentation and aetiology 56 Reactions to stress 62 disorders 64
Anxiety disorders management 58
Personality disorders 80
Personality disorders introduction and classification 80 Personality disorders management 82
Self-assessment 104
Index 113
2 INTRODUCTION
Number
Health
of psychiatric Formation of Introduction of
beds NHS 1948 Chlorpromazine
Psychiatry 1952
Primary care Lunatics Act ECT
A and E Local authorities 1845 1938
Family General Social services 140,000
and hospital Housing
friends NHS and
Benefits
100,000 Community
Criminal justice Care Act 1990
PATIENT Leisure and recreation
system services
Police 60,000
Courts Voluntary agencies
Probation Help-lines
Support groups 20,000
Employment Advocacy
agencies Accommodation 1850 1900 1950 2000 Year
Custodial care New treatments, Care in the
unlocked wards community The future?
in asylums
Fig. 1 Agencies involved in mental health
services. Fig. 2 Changes in psychiatric services.
Mental health services I 3
of clozapine, will often require a period members are comfortable with the lead- and increasingly in the community
of admission, although services are ership arrangements. Open discussion assisting mentally ill patients to develop
increasingly flexible in delivering even of the issues by all members of the team confidence and skills in social and occu-
the most complex treatments outside is important. pational environments using a wide
hospital. The role of each team member and range of activities.
the skills they can contribute must be
Outpatient clinics Social workers have a general qualifi-
clearly understood by all. There is likely
Outpatient clinics tend to be run in com- cation in social work and may specialise
to be some overlapping of roles, and it is
munity settings, such as GP surgeries and in mental health. Social workers in
essential that the responsibilities of each
community mental health centres, rather mental health teams often act as Approved
individual in caring for a particular
than in hospitals. Most non-urgent refer- Mental Health Practitioners, exercising
patient are made clear to all concerned.
rals to psychiatrists are assessed and responsibilities under the Mental Health
Act, 2007. They have a wide ranging role,
treated in these clinics. Some offer spe- Who is in the MDT?
cialist services (e.g. lithium or clozapine applying a social perspective to the prob-
clinics or depot injection clinics). Often Psychiatrists are doctors who have lems they encounter.
these clinics are run by other mental undertaken a specialist training in
Support, Time and Recovery (STR)
health practitioners. mental health that is accredited by the
Workers are so called because their
Royal College of Psychiatrists. They are
responsible for the medical care of men- role is to offer support and give time to
Day hospitals the patient on their journey to recovery.
Day hospitals are staffed by multidisci- tally ill patients, including assessment,
diagnosis and management, and are the They work under the supervision of the
plinary teams and can provide a compre- care co-ordinator.
hensive service. They may be used as an only member of the team able to pre-
alternative to admission for patients scribe drugs. They also have responsibili-
ties under the Mental Health Act, 1983 Care Programme Approach
requiring a high level of support and The Care Programme Approach (CPA)
monitoring but considered to be well (see p. 18).
is an important part of mental health
enough to go home for evenings and Psychiatric nurses are Registered policy in the UK. It was first imple-
weekends. This is often made possible Mental Nurses (RMNs) who have com- mented in 1991 following concerns that
through the support of relatives and pleted a 3-year training in mental health. some patients were falling through the
carers. Their use has declined in adult Their roles are varied, and they may network of services. It is designed to
services, but they are still often used in work in many different settings, includ- ensure that the various agencies and pro-
Older Persons Mental Health services. ing wards, day hospitals, outpatient fessionals involved in the care of the
clinics and the community. In hospitals vulnerable mentally ill work with the
Community Mental Health Teams they have responsibility for ensuring the patient and their family to develop co-
(CMHTs) environment is therapeutic and safe, and ordinated management plans (Fig. 3). A
CMHTs consist of psychiatrists, commu- for observing and monitoring patients. Care Co-ordinator is appointed from
nity mental health nurses, social workers,
the multidisciplinary team to ensure the
psychologists, occupational therapists Community psychiatric nurses
plans are put into action. In 2008 the
and support workers who work together (CPNs) are RMNs who have been
CPA policy was modified so that only
to provide a community service. They trained in community nursing. They
those with more complex needs come
are based in centres away from the hos- usually work in CMHTs. Their role
under CPA. All other patients must have
pital and convenient for the community includes provision of psychological ther-
their care planned and documented by a
they serve. They see patients in their apies, long-term support for the chroni-
Lead Professional.
own homes and in clinics. This model cally mentally ill, counselling and
has been adapted to develop specialist administration of injected depot
Assess patient's
teams, described overleaf. medication. health and
social needs
Clinical psychologists have a degree
The Multidisciplinary Team in psychology and a postgraduate quali- Family
(MDT) fication in clinical work, usually an MSc. and friends
Psychiatrists routinely work as part of an Their role is in assessment of patients
MDT, in order to be able to offer patients and provision and supervision of psy- Develop
comprehensive care that addresses their chological therapies. Special skills enable Review Patient plan to
medical, social and psychological needs. them to test intelligence, personality and address
Ideally, an MDT works closely together, needs
neuropsychological functioning of
with regular meetings to discuss patients Care
patients with suspected brain damage or MDT coordinator
in their care. Referrals are discussed and dementia.
allocated to the most appropriate team
member for assessment. Some patients Occupational therapists (OTs) have Implement
a 3-year specialist training in occupa- plan
will only require contact with one
member of the team, while others with tional therapy. They work in hospital Fig. 3 The Care Programme Approach.
more complicated needs may have direct
contact with several.
Teams work most efficiently if they Mental Health Services
share a common goal, communicate
well with each other and have clear lead- n The medical, psychological and social needs of mentally ill patients must be considered
ership. In most cases, the consultant psy- n Psychiatricservices work with other agencies to provide for their patients needs,
chiatrist has a leadership role in the including social services, housing departments and voluntary agencies
team. There is unlikely to be a clear
n Psychiatrists
work in multidisciplinary teams including nurses, social workers,
hierarchy across the professional groups
psychologists and OTs
involved and there may be some conflict
about leadership. It is vital that the
4 INTRODUCTION
n Gatekeeping inpatient beds this later traumatic first contact with mental harm to themselves or others, and do
means that they are the final arbiters health services (i.e. admission under a not want to engage with mental health
of whether a patient can be admitted section of the Mental Health Act), and services. Typically their patients will
to an acute inpatient bed. They will increases the likelihood of the patient have schizophrenia, complicated by sub-
consider whether the treatment continuing to take treatment and stay stance abuse, and have a history of
required can be delivered at home engaged with services in the long term. aggressive behaviour when unwell, and
instead of in hospital, and if so will EIP teams generally work with people will have had repeated admissions to
provide the necessary care. between the ages of 14 and 35 years who hospital under a section of the Mental
n Home Treatment CRHT teams are experiencing their first psychotic Health Act. They often have no insight
care for people in their own homes episode, therefore crossing traditional into their illness, do not believe that they
who, without this intervention, barriers between Child and Adolescent have a mental illness, and therefore do
would need an admission to hospital. services and Adult services. The teams not want to take medication or see
They are able to prevent admission, include consultant psychiatrists who mental health staff. AOT overcome these
by providing intensive and flexible may be trained as either adolescent or difficulties by working intensively with
support to acutely unwell people, adult specialists. The team members act small case loads. They focus on engaging
visiting several times a day if as care co-ordinators for their patients, with the patient in order to be able to
necessary, supervising medication, and tend to have much smaller case deliver effective treatment (Fig. 2). This
and supporting the family. They also loads than CMHT workers, so that they is often achieved by taking the focus
work with inpatient units to ensure can provide a more intensive input. They away from talking about mental health
that inpatients are discharged at the usually work with patients for about 3 issues, and providing practical help
earliest opportunity, and continue years before handing over to CMHTs or with finance, housing or other difficul-
their acute care at home. There AOTs. ties, or helping with providing day to
ought to be a seamless transition day needs and befriending. AOTs act as
from inpatient treatment to home Assertive Outreach teams (AOT) care co-ordinators for their patients, and
treatment. AOTs work with patients who have will often work with them for several
n Crisis Resolution CRHTs are able a serious mental illness, usually schizo- years before transferring back to the
to respond to psychiatric phrenia, and are at high risk of causing CMHTs.
emergencies in the community at
any time of the day or night, and any
day of the week. During office hours
Advocate on patients
CMHTs usually do this work, but
Support behalf with other
out of hours it will come to the carers agencies
CRHT. They can take referrals from
Be persistent and
GPs, directly from known patients, Provide practical creative
and from general hospitals. They can support to improve
also attend Mental Health Act living conditions ENGAGEMENT
assessments, in order to look for Focus on patients
alternatives to admission. strengths
Make frequent
CRHTs do not usually take the role of contact Reiterate benefits of
care co-ordinator, but instead work engaging
alongside a care co-ordinator from Fig. 2 AOT techniques in engagement.
another community team. Their input is
intensive, but short term. The teams are
multidisciplinary, and include consul-
tant psychiatrists. The staff within the
team work closely together to ensure
they are providing a consistent approach Mental Health Services
to treatment even when several different n Mentalhealth services are organised with a focus on caring for people in their own
members of staff are involved. homes as far as is safely possible
n CRHT teams care for people who, without this intervention, would need an admission to
Early Intervention in Psychosis
teams (EIP) hospital, and support inpatients to be discharged home at the earliest opportunity
These teams are founded on the princi- n EIPteams generally work with young people who are experiencing their first psychotic
ple that the earlier and more effectively episode, with the aim of improving their long-term prognosis
psychotic illnesses such as schizophre- n AOTs work with patients who have a serious mental illness, are at high risk of causing
nia are treated the better the long-term harm to themselves or others, and do not want to engage with mental health services
outcome for the patient. Engagement at
an early stage in the illness can avoid a
6 INTRODUCTION
Classification in psychiatry
blood pressure and serum glucose and
Case history 3 lipids. In psychiatry, there are scales that
From the age of 18 years, Emily has always manipulated situations so that other people sort can be used, for example, to give dimen-
things out for her. If they refuse to do this she becomes angry and tearful. From the age of sional measures of psychosis, mood,
30, she has experienced panic attacks when in crowds or shops. When 45, she had an anxiety and traits of personality, and
episode of depression and obsessional symptoms occurring and remitting at the same these can be used as an alternative or,
time. She had a further episode of depression when given steroids for treatment of COAD perhaps more pragmatically, as an
when 54. adjunct to categorical diagnosis.
a. What psychiatric disorders do you think Emily has experienced? Psychiatric diagnosis
It is important not to confuse symptoms
with diagnosis in psychiatry. This is
often done in the case of symptoms,
Before the 1970s, it was thought that the International Classification of such as depression or anxiety, which also
schizophrenia was more common in the Disease, 10th version (ICD10), devised give their name to a diagnosis (depres-
US than the UK. However, when this was by the World Health Organization in sive disorder, anxiety disorder). To make
properly researched, it turned out that 1993. The second classification system is these diagnoses, other symptoms have
there was no real difference in preva- the Diagnostic Systems Manual, cur- to be present. In addition, a minimum
lence. The reason for the previously rently in its 4th version (DSM IV), which duration of symptoms is usually speci-
observed difference was that psychia- has been produced by the American Psy- fied. In other words, most psychiatric
trists in the two countries had different chiatric Association. The two systems diagnoses are made on the basis of a
views about the nature of the condition: are broadly similar and in this book we particular collection of symptoms, or
American psychiatrists were more likely have mostly followed ICD10. Table 1 syndrome, being present for a minimum
to diagnose schizophrenia and British outlines the ICD10 classification of psy- period of time. These principles are rep-
psychiatrists more likely to diagnose chiatric disorders. resented in Figure 2.
manic-depression. DSM V is due in 2012 and ICD11 in
The development of standardised 2014. The greatest change is likely to be Diagnostic categories
methods of classifying psychiatric dis the introduction of dimensional mea- The standard categories of psychiatric
orders has improved communication sures for some conditions, in contrast diagnosis are shown in Figure 3. When
between clinicians and has made it pos- to the sole use until now of categorical you are making a differential diagnosis
sible to research the aetiology, manage- diagnoses. In general medicine, blood it is helpful to run through these catego-
ment and prognosis of a particular pressure is a dimensional measure, ries one by one to check you havent
diagnosis, thereby providing an empiri- hypertension a category. Metabolic syn- forgotten any relevant disorders. You
cal basis for clinical practice. As a result, drome is a categorical construct that is may be familiar with the surgical sieve
diagnosis becomes a useful procedure based on a number of dimensional mea- (inflammatory, infective, neoplastic, etc.)
rather than just a way of labelling people sures, such as waist circumference, which provides a similar structure for
(Fig. 1).
Classification systems
There are two major classification
systems used in psychiatry. The first is
Depresssive
disorders
Disorders
Anxiety
Fig. 2 Symptoms versus diagnosis. The sea of symptoms represents the high prevalence of
symptoms in a normal population. Disorders occur when particular symptoms occur at the same time.
Doctor
Delayed development
Frequent GP Behavioural problems
Childhood neglect attender with Infant/
Happy childhood Previously well Poor peer relationships
and abuse minor physical child Parental neglect
complaints Physical abuse
I feel empty I feel empty Sexual abuse
and sad and sad
Pre-disposed
Adult
adult
Precipitating factors
Disorder
mine their nature and duration. Find out n Have you ever needed to have blood and achievements from conception to
if anything makes them better or worse tests to check on the tablets you were the present. The main areas to cover are
and ask about possible precipitants such taking? listed in Table 1. Compare these with
as stressful life events or poor compli- n Have you ever had ECT? Figure 2 and it will be obvious that one
ance with medication. Once you have a of the aims of the personal history is to
Always ask whether the patient has
clear picture of these symptoms, try to identify predisposing factors for psychi-
seen a psychiatrist before or has required
think of all the conditions which could atric illness. The personal history also
psychiatric admission. Also ask directly
give rise to them. If you cannot remem- gives a baseline level of function so that
about any history of self-harm and try to
ber many causes, try to jog your memory the effect of illness can be assessed. For
get an idea of the seriousness of any
by running through the diagnostic cate- example, losing a job because of lethargy
suicide attempts. In some cases, it may
gories listed in the previous chapter. and apathy is of greater significance if
be appropriate to ask direct questions to
This process should lead you to enquire the previous work record has been
find out whether particular symptoms
about symptoms of schizophrenia, flawless.
have occurred in the past, such as a
depressive illness and drug and alcohol
history of mania in someone presenting
problems. Once you have asked all these Premorbid personality
with depression, or psychotic symptoms
questions, you will hopefully have a This is conventionally divided into char-
if a psychotic illness is suspected.
good idea of likely diagnoses. The rest of acter, habits and interests. It is very
the history will help you put this infor- important to know what the patients
mation in context.
Past medical history character was like before the onset of
Organic disease, especially if it causes
illness as it helps assess the severity of
disability or pain, may precipitate or
Medication symptoms. For instance, anxiety symp-
maintain psychiatric illness. Some
Enquire about the type and dose of all toms in a usually outgoing, self-confi-
organic diseases cause psychiatric as
medication. Find out how long the dent patient should be viewed differently
well as physical symptoms. Alternatively,
patient has been taking each drug, as to identical symptoms in a patient who
psychiatric illness, such as somatoform
most psychiatric medication takes at admits to lifelong nervousness. Assess-
disorders, may masquerade as organic
least two weeks to start working. Do not ment of character should include a
disease. Finally, it is important to identify
forget to ask about medication being forensic history (history of criminal
organic disease as it may be exacerbated
prescribed for non-psychiatric problems, behaviour). A history of violence is par-
by some psychiatric treatments. For
as it may have important interactions ticularly important as it increases the
example, tricyclic antidepressants should
with psychiatric treatments or may even risk of violence in the future. Enquiry
be used with caution in patients with
be the cause of psychiatric symptoms. about habits should include alcohol and
prostatism because of antimuscarinic
illicit drugs.
effects on the urinary tract.
Past psychiatric history
Find out about the date, duration and Social circumstances
nature of all previous episodes of illness.
Family history You may have covered many of these in
Many psychiatric illnesses have a genetic
Episodes serious enough to require earlier sections of the history but make
basis, so family history of mental illness
treatment are of particular interest, sure you know the type of accommoda-
should be determined in as much detail
although it is worth remembering that tion the patient lives in, who they live
as possible. Early relationships within
doctors often fail to recognise or ade- with, what kind of support they have
the family are considered important in
quately treat mental illness. If treatment and whether they have any financial
the aetiology of some psychiatric
was given, find out what it was and problems.
illnesses, especially in depressive
whether it helped as this may clarify the
illness where strong associations with
diagnosis and also may indicate whether
parental neglect and abuse have been Table 1 Personal history
similar treatments are likely to be effec-
demonstrated. Gestation and delivery
tive for the current episode. If the patient
Childhood milestones
has difficulty remembering previous
treatment, try to jog their memory by Personal history Family relationships and upbringing
asking direct questions like: The personal history is the main differ- Peer relationships
ence between history taking in psychia- Schooling and academic achievements
n Have you ever been given regular Occupational history
try and in other medical specialities. It
Marital and sexual history
injections? aims to trace the patients development
Assessment of risk
Assessment of patients with mental UK the commonest methods are identified, although there is considerable
illness is not complete without an assess- hanging, self poisoning (most often overlap:
ment of risk. The following risks should painkillers or antidepressants), jumping
n Failed suicide attempt. These
be considered in every case: and drowning. In the USA, firearms are
individuals are likely to be similar to
the commonest means of suicide.
n suicide those who succeed in completing
Deliberate self harm (DSH) is much
n deliberate self harm suicide (see Table 1) and are at high
more common than suicide. The annual
n aggressive behaviour risk of repeating the attempt, with
rate is about 3 per 1000. In contrast with
n neglect or exploitation by others fatal results. They are likely to have a
suicide, DSH is most common in young
n self neglect. mental illness.
women, and drug overdose is the most
n Impulsive self harm, with ambivalence
Assessing risk needs a systematic and frequently used method. A significant
about the wish to die. Often an
holistic approach. There are question- number of people who harm themselves
overdose is taken immediately after a
naires available to help in the assess- go on to commit suicide, with 1% of
stressful event, with no advance
ment, but they are no substitute for those presenting to hospital following a
planning and help is sought quickly.
taking a thorough history and detailed suicide attempt dying by suicide in the
There may be a genuine wish to die
mental state examination, and carefully following year, and 5% over the follow-
at the time of the act or lack of
weighing up the various risk and protec- ing 10 years.
concern about the outcome. Often
tive factors that are present. The physi-
there is no real suicidal intent, but
cal, psychological and social influences
on the individual should be considered,
Aetiology instead an attempt to cope with a
Mental illness is by far the most impor- difficult situation by gaining
along with the likelihood of them chang-
tant cause of suicide, present in about attention, self-punishment or
ing. Past history of high-risk behaviour
90% of cases. In 70% of suicides the manipulation of others. The
is important, and if present the current
mental illness is depressive disorder. It characteristics of such individuals are
risk should be considered to be greater.
is important to be aware that the early quite different from those with
Assessing risk can be a difficult and
stage of recovery from depression is a serious suicide intent. They are
highly skilled task. If you ever find your-
vulnerable time as energy and motiva- unlikely to be mentally ill, and tend
self in doubt about the risk faced by a
tion may return before the mood lifts, so to be young and female (Fig. 1).
patient it is essential to seek advice from n Repeated self harm with no suicide
the person is more able to act on con-
an experienced psychiatrist.
tinuing suicidal ideas. Up to 15% of intent. There are a small group of
The emphasis here will be on assess-
people with severe mood disorders will individuals who repeatedly act on
ing and managing risk of suicide and
kill themselves. About 20% of those impulses to harm themselves, most
deliberate self harm. The principles of
dying by suicide are alcoholics, and alco- often by cutting their arms
this form of risk assessment can be
holics have a suicide rate of 10%. As superficially or taking small
applied to assessing other risks. In par-
schizophrenia is relatively uncommon it overdoses. This behaviour is usually
ticular, it is important to ask the patient
is present in only 23% of suicides but, due to a severe personality disorder.
directly about the risk faced by them-
of those suffering from schizophrenia,
selves or others, and to ask in detail
10% die by suicide, with the greatest risk Assessing suicide risk
about any incidents that have occurred.
in the earlier stages of the illness when Suicide risk is not easily quantifiable and
the patient is struggling to come to terms can fluctuate. Some patients will describe
Suicide and deliberate with the potentially devastating effects of suicidal thoughts, accompanied by a
the condition. plan to put the thoughts into action, and
self harm a definite intention to act on the plan.
A number of social and medical factors
Suicide is deliberate self murder, and the are associated with suicide. These are They clearly have a very high risk of
cause of at least 1% of all deaths in the listed in Table 1. They are not necessarily committing suicide and urgent action is
UK. The annual rate has steadily fallen causes of suicide and are not present in required. However, it is not usually this
to around 8.5 per 100,000 and is highest all cases, but it is useful to bear them in clear cut. For most patients there are
in men and the elderly. In the 1980s and mind when assessing a patient who may protective factors that make it less likely
1990s there was a dramatic increase in be at risk of committing suicide. that they will act on suicidal thoughts.
the suicide rate in young men, however The causes and motivations for DSH The protective factors will vary from one
this trend is now reversing, and the vary enormously. Three groups may be individual to another, but often include
suicide rates in this group are falling year
on year. But suicide remains the second
most common cause of death in 15- to
44-year-old men (accidental death is the
Table 1 Factors associated with suicide
most common cause). Over all ages men
n Male
are three times more likely to die by
n Older age the greatest risk is in men over 75
suicide than women, and for the 20 to
n Previous attempts up to 30% of people who commit suicide have attempted suicide previously
24 years age group men are four times
n Mental illness present in 90%, mainly depressive disorder
more likely than women to die in this n Divorced, single, or widowed
way. Young Asian women have been n Bereavement in particular loss of a spouse
identified as particularly vulnerable, n Social isolation
with a suicide rate that is twice the n Living in urban environment
national average. The method for com- n Physical ill-health chronic, painful and life-threatening illnesses
mitting suicide is determined to some n Unemployment the rate increases with duration of unemployment and is also raised in the wives of
concern about the impact of suicide on All doctors should be able to assess has been the reaction of friends and
family, a religious belief that suicide is suicide risk in order to take the neces- family? Has anything changed as a
sinful, or fears about dying painfully or sary precautions to prevent a high-risk consequence of the self harm?
being left in a worse situation as a con- patient from harming themselves. Discharging a patient back into the
sequence of the suicide attempt. These The following questions are useful in stressful environment that prompted
protective factors will vary with changes considering whether the DSH was a the self harm may be risky. Do they
in social circumstances and the severity serious attempt at suicide: think they might repeat the act?
of mental illness. For example, with a
n Events preceding the act. Why did
worsening of a depressive disorder a
mother may move from resisting suicide
they harm themselves? Was there a Management
single specific incident or a build up When the suicide risk assessment has
for the sake of her children to feeling
of stressors over time and, if so, what been completed, a management plan can
that they would be better off without
was the final straw? Was the be developed. The priority must be to
her. It is therefore important to reassess
attempt planned and, if so, how ensure the patients safety.
suicide risk in vulnerable patients at fre-
detailed were the plans and how Medical treatment for the effects of the
quent intervals, and look for and promote
long ago were they made? A planned self harm may be needed before starting
protective factors. Assessment must
episode of DSH is likely to have been psychiatric treatment. The place of treat-
include an exploration of the suicidal
a serious suicide attempt. ment should be carefully considered.
ideas and DSH if present. It is also
n The act itself. What method was Patients with high risk are likely to need
important to complete a full psychiatric
used? Consider the potential fatality admission to the safe environment of a
history and mental state examination,
of the method objectively and from psychiatric inpatient unit. In some cases
looking for factors associated with
the patients view. The attempt is compulsory admission under the Mental
suicide (Table 1).
serious if the patient believed the Health Act 1983 (see p. 18) will be needed.
method used to be highly dangerous, General medical wards are not safe
Asking about suicide
even if in reality it was unlikely to be places for patients at high risk of suicide.
Asking about suicidal thoughts is a skill
so. For example, benzodiazepines are If it is essential to care for them in this
that requires practice and can raise
relatively safe in overdose but are environment then constant nursing
anxiety initially. It is vital that you put
frequently perceived as dangerous by attendance must be arranged.
your anxieties aside and ask these ques-
patients, while many believe that the It is possible to manage a patient with
tions of all psychiatric patients and any
potentially lethal paracetamol is safe. moderate suicide risk in the community
other patients who appear to be low in
What were the circumstances of the if they are prepared to accept treatment,
mood or have harmed themselves.
act? Did they intend to die? If not, rapid follow-up can be arranged and
Asking about suicide in a sensitive way
what was their intention? Did they they have support at home. Involvement
is very unlikely to cause offence, and
write a suicide note? How did they of the Crisis Resolution and Home
may give a distressed patient their first
reach medical care? Did they try to Treatment team to provide support
opportunity to voice thoughts about
avoid being found? immediately following discharge can be
which they have felt guilty, ashamed or
n Current thoughts about suicide. What invaluable, and some patients need
afraid. This can be a great relief for some
is their view about the self harm ongoing support from mental health
patients and those with no suicidal ideas
now? Do they wish they had services.
will not become suicidal simply because
succeeded or are they relieved to still Once safety has been ensured any
you have raised the subject with them.
be alive, or are they not sure? What underlying mental illness may be treated
There are many ways of asking about
in the usual way.
suicide, and you should find a form of
questioning that you feel comfortable
with and then use it routinely. Examples Assessment of risk
are given in Figure 2. n 90% of all those who die by suicide are mentally ill
Assessment following DSH n Those who deliberately harm themselves are 100 times more likely to die by suicide in
The aims of a psychiatric assessment the next year than the general population
following DSH are to evaluate the suicide n Itis important to routinely ask all psychiatric patients, and all other patients who are low
risk, determine whether a mental illness in mood, about suicide
is present and develop a management
plan that will ensure the patients safety.
14 INTRODUCTION
Differential diagnosis
Respite functional
from Specialist organic
home treatment personality disorder
medical
Investigations
information gathering
Unable to make Specialist Failure to respond psychological
a diagnosis investigations to treatment physical
Mental capacity
in this area these are summarised out the intervention under consider-
Case history 4 in Figure 2. If you dont apply these prin- ation to decide whether to go ahead. In
Sarah, a 75-year-old widowed woman, ciples to the assessment of capacity and the case of healthcare, this will usually
has rheumatoid arthritis and recently told to decisions concerning people who lack be the doctor or nurse in charge of
her daughter that death would be a capacity in England and Wales, then you the persons treatment. Their decision
welcome escape from a life of chronic will be breaching peoples statutory should be made on the basis of what is
pain and limited mobility. She is admitted rights. known as a best interests assessment,
to hospital in a confused state and a chest the aim of which is to determine, as best
X-ray shows a mass in her right lung and Best interests as possible, what the person would have
a lobar pneumonia. When a person doesnt have capacity to decided for themselves if they had the
make a decision, other people must act capacity to do so. The Mental Capacity
a. How do you decide whether to treat in their best interests. It is the responsi- Act specifies several ways of seeking the
her with antibiotics? bility of the person who will be carrying information required to make this deci-
sion, as illustrated in Figure 3. The deci- covered by a valid Advance Decision and there will not always be time to do so.
sion maker, for example the doctor so the decision maker will need to find Treatment that is required urgently
treating the person concerned, must people who can speak on the persons should not be delayed if the person will
follow this process and take into account behalf. It may be that the person has be harmed as a result. In such circum-
all the views expressed, as well as their given someone the power to make deci- stances, the doctor making the decision
own, before making a decision about sions on their behalf, in the form of will have to do so on the basis of the
what to do. Lasting Power of Attorney (LPA). These information available to them at the
powers can cover Personal Welfare, time.
Advance Decisions Property and Affairs or both, so in the
The Mental Capacity Act allows case of decisions about medical treat- The Court of Protection
people to specify in advance treatments ment, it is important to establish whether If decisions need to be made about a
they would not want in certain circum- a LPA for Personal Welfare has been persons Property and Affairs and they
stances, in case they lose the capacity to conferred. do not have the capacity to do so, and if
make the decision for themselves. These If there is no valid Advance Decision there is nobody with LPA for these
are known as Advance Decisions. For or person with LPA, then the decision matters, then the case must be referred
example, a man with Motor Neurone maker will seek the views of relatives to The Court of Protection. Decisions
Disease might make an Advance Deci- and close friends. If there is nobody to regarding medical treatment and other
sion refusing life-prolonging treatment speak on behalf of the person without matters of Personal Welfare can usually
of any sort. If he later developed pneu- capacity, then an Independent Mental be resolved in the ways described earlier
monia, for example, and as a result lost Capacity Advocate (IMCA) should be but, if there is substantial disagreement,
consciousness and so couldnt make asked to do so. IMCAs are people who The Court of Protection can be asked to
decisions for himself, the implication of have been trained to speak on behalf of rule on the case.
the Advance Decision would be that pal- people without capacity. It is also helpful
liative treatment should be given, but to involve them when there is disagree- Deprivation of Liberty
antibiotics should not. ment over what is in the best interests of Safeguards (DOLS)
the person concerned. The Mental Capacity Act does not autho-
Who should speak on a The decision maker should do their rise the deprivation of a persons liberty,
persons behalf? best to seek other peoples views, in the in contrast to legislation such as The
Most decisions that need to be made in ways described above and in Figure 3, Mental Health Act. Usually, the steps
a persons best interests will not be but when people are acutely unwell taken to act in the best interests of a
person without capacity do not involve
Has the person Yes Yes Follow the Advance
depriving them of their liberty. For
Did the person have
made an Decision example, making sure someone without
capacity when they
Advance Decision? made the advance capacity stays in a general hospital for a
decision? If treatments short period of time and receives treat-
or their circumstances ment for an acute medical condition is
have changed, would A LPA takes precedence considered to be a restriction of liberty,
they make the same if it was granted after not a deprivation. If, though, a person
decision now? an Advance Decision without capacity is deprived of their
No No was made liberty, for example during a prolonged
hospital admission in which their move-
ments and contact with the outside
world are curtailed, then authorisation is
Is there someone Yes Follow decision required. This is obtained by the hospital
Yes Is the person with
with a Lasting Power of person making an application for a Deprivation
LPA using it in an
of Attorney for with LPA
appropriate manner? of Liberty assessment, which will usually
Personal Welfare?
be carried out by a Best Interests Asses-
No sor, who typically will be a psychiatric
No nurse or social worker, and a psychia-
trist. Those doing these assessments will
have had special training and will assess
Involve The Court the persons mental health, mental
Are there relatives Protection
No Involve an Independent capacity and best interests before decid-
or close friends who
Mental Capacity Advocate ing whether the deprivation of liberty
can speak on behalf
(IMCA) should be authorised.
of the person
without capacity?
Yes No No
Mental capacity
Can you reach a decision? Can you reach a decision? n Always assess capacity when making
decisions about medical treatment
Yes Yes
n Ifsomeone lacks capacity, determine
what is in their best interests by
Make the decision talking to the people who know them
best
Fig. 3 How to determine best interests when making decisions about medical treatment.
18 INTRODUCTION
safe to wait, then there are other sections Table 1 Compulsory admission procedures under the Mental Health Act
that can be used to detain the person in Section Powers Recommendation Applicant Duration Termination
hospital until an assessment for Section 2 Admission for assessment Two doctors, one AMHP or 28 days 1. Regrade informal
2 or Section 3 can take place. Section 4 and treatment approved nearest relative 2. Section 3
and Section 136 can be used to admit 3 Admission for treatment Two doctors, one AMHP or 6 months 1. Regrade informal
people from the community and Sec- approved nearest relative 2. Renew Section 3
tions 5(2) and 5(4) to detain informal 4 Emergency admission Any doctor AMHP or 72 hours 1. Regrade informal
inpatients who want to leave the ward; nearest relative 2. Section 2 or 3
details of these powers are shown in 136 Removal to a place of Any police officer None 72 hours 1. Regrade informal
Table 1. safety 2. Section 2 or 3
5(2) Detention of inpatient Doctor in charge or None 72 hours 1. Regrade informal
Right of appeal and other nominated deputy 2. Section 2 or 3
safeguards 5(4) Detention of inpatient Qualified nurse None 6 hours 1. Regrade informal
Patients can appeal against being 2. Section 5(2)
detained under Section 2 or Section 3.
Their appeal will be heard by a Mental
Health Review Tribunal, which consists
of a lawyer, a psychiatrist and a lay Powers available for supervision outside hospital
person. The Tribunal will hear evidence
from the patient, their legal representa- n Section 17. Gives the Responsible Medical Officer power to place the patient
tive, the responsible medical officer, an on leave. Used to allow a gradual transition from hospital to community as
AMHP or other professional able to the patient begins to recover. If periods of Section 17 leave of more than seven
comment on their social circumstances, days are being considered, then a CTO may be more appropriate.
n Community Treatment Order (CTO). Sets conditions under which a
and other relevant parties and has the
power to discharge the patient from patient detained under Section 3 can be allowed to leave hospital, such as
their section. A detained persons nearest compliance with medication and attendance of appointments. If the conditions
relative can also request they are dis- are breached, the patient can be recalled to hospital, following which a decision
charged from a Section this can be about whether to continue the CTO must be made within 72 hours. If the
blocked by the responsible clinician in CTO is revoked, the patient reverts to being detained under Section 3.
n Guardianship (Section 7). Gives power to specify where the patient lives
the case of Section 2, but the only way in
which a nearest relative can be prevented and compels them to give professionals involved in their care access to the
from having Section 3 revoked is for home.
an application to be made to a Court
to have them displaced from this
role. A hospitals use of the MHA is treatment for conditions other than hearing the case would consider previ-
monitored by regular visits from the mental disorder, even if they are refusing ous rulings in similar cases and, if there
Care Quality Commission, which also it because of their abnormal mental was no legal precedent, would base their
appoints second opinion appointed state. In such situations, the Mental decision on the likely opinion of an
doctors (SOADs, see Fig. 2). Capacity Act 2005 (MCA) will often average person. Courts are much more
apply (see pages 1617). likely to find health professionals negli-
Limits of the MHA gent for allowing serious harm to come
The extent of powers contained in the Common law to their patients than they are to rule
MHA is shown in Figure 2. Two aspects Occasionally, there will be situations not against those who have documented in
of this merit further discussion. The first covered by the MHA, the MCA or other their notes why the MHA and MCA did
is that the MHA contains no power to powers created by Acts of Parliament, not apply to the situation they faced and
forcibly give treatment outside hospital. where it may be necessary to force why they felt it necessary to act against
There are however powers that can be someone to do something against their the patients will on a common law basis.
used to supervise detained patients will. A simple example would be staff in
outside hospital and these are described a Casualty Department preventing a
in the Box on this page. person leaving, because they believed the
Another important limit of the MHA person was at immediate risk as a result The Mental Health Act
is that it only allows for compulsory of mental disorder and were waiting for
treatment of mental disorder. Court an AMHP and psychiatrist to arrive. n TheMental Health Act is used to
rulings have determined that manifesta- Such circumstances, in which statutory admit people with mental disorders
tions of a mental disorder can be treated (or parliamentary) law doesnt apply, are to hospital against their will
under the MHA, which allows for the governed by common law. In practice, n These powers can be used in the
treatment of self harm and the force this means that if the person held against interests of the persons health or
feeding of people with anorexia nervosa. their will in Casualty in the example safety, or for the protection of others
However, the MHA cannot be used to above brought a prosecution for assault
force people to have medical or surgical against the staff involved, the Court
20 TREATMENT IN PSYCHIATRY
serotonin receptors: 5HT-1, 5HT-2, and between the effects of glutamate and likely that the neuron will fire an action
5HT-3. The first two are thought to be of GABA plays a key role in modulating potential. Benzodiazepines bind to
most importance to psychiatry. much of the work of the brain, including GABA-A receptors, and increase the
the overall state of arousal. effects of GABA at these sites, resulting
Monoamine theory of depression GABA binds to two receptors, GABA-A in an inhibitory effect. This explains the
Like the dopamine hypothesis, the and GABA-B, and causes hyperpolarisa- tranquillising and sedating effects of
monoamine theory was developed from tion of the receptor site, making it less benzodiazepines.
an understanding of the mode of action
of antidepressant medication. Antide-
pressants increase monoamine activity
Tyrosine L-dopa Dopamine
in the brain. Some increase levels of sero-
tonin alone (e.g. fluoxetine), some
Tyrosine Dopa
increase the levels of noradrenaline hydroxylase decarboxylase
alone (e.g. reboxetine), and others A
increase both noradrenaline and sero-
tonin (e.g. venlafaxine). This suggests
that depression is associated with a
Dopamine Noradrenaline
depletion in the levels of serotonin and
noradrenaline in the central nervous Dopamine
system. b-hydroxylase
Acetylcholine system
Acetylcholine is an excitatory neu-
rotransmitter found in both the periph- Tryptophan 5-Hydroxytryptophan Serotonin
eral and central nervous systems.
Synthesis and deactivation of acetylcho- Tryptophan 5-HTP
line is shown in Figure 2C. It stimulates hydroxylase decarboxylase
B
muscle movement in the peripheral
sympathetic, parasympathetic systems
and somatic nervous systems. It is found
in several sites in the brain. Acetylcho-
line pathways form part of the reticular Acetyl CoA + Choline Acetylcholine Acetate and
activating system, which control alert- Choline
Choline
ness, and also have projections to the Acetylcholinesterase
acetyltransferase
hippocampus, which has a role in
memory. There are acetylcholine C
neurons in the striatal complex. This is
the site of action of anticholinergic medi- Fig. 2 (A) Synthesis of dopamine. (B) Synthesis of noradrenaline and serotonin. (C) Synthesis
cations used for Parkinsonian side and deactivation of acetylcholine.
effects of antipsychotic drugs.
Dopaminergic systems and side effects
Acetylcholine in Alzheimers disease of typical antipsychotics
The dopamine and monoamine theories
described above were developed from
observation of drug effects, resulting in
development of theoretical mechanisms Mesocortical Tuberoinfundibular
and leading to a search for supporting cognitive prolactin (inhibtion
evidence. The opposite is true of processes results in
Alzheimers, where anatomical discover- hyperprolactinaemia
ies led to a search for effective drug treat- galactorrhoea and
ments. A loss of cholinergic neurons is gynaecomastia)
a consistent finding on post-mortem
examination of the brains of individuals Mesolimbic Substantia nigra
who had died from Alzheimers disease. behavioural movement and
This observation leads to the use of cho- and emotional muscle tone
linesterase inhibitors in treatment. They responses (inhibition results
work by reducing the breakdown of in extrapyramidal
acetylcholine in the synaptic cleft, maxi- side effects)
mising the effects of the remaining cho-
linergic neurons. This has been shown Fig. 3 Dopaminergic systems and side effects of typical antipsychotic drugs.
to have benefits in reducing the symp-
toms and slowing the progress of
Alzheimers disease for a period.
Drug treatments
n Psychotropic drugs work on neurotransmitter systems in the central nervous system
Gamma-aminobutyric acid
n The neurotransmitters dopamine, serotonin (5HT), noradrenaline (norepinephrine) and
(GABA) and glutamate
GABA is found throughout the brain, acetylcholine have particular significance in the aetiology and treatment of mental illness
and is the principal inhibitory neu- n Theeffects of antipsychotic and antidepressant drugs led to the development of the
rotransmitter in the CNS. It is synthe- dopamine hypothesis of schizophrenia and the monoamine theory of depression
sised from glutamate, which is itself an
excitatory neurotransmitter. The balance
22 TREATMENT IN PSYCHIATRY
Antipsychotic drugs
Antipsychotic drugs are also known as schizophrenia, antipsychotics control effects; haloperidol and the newer
major tranquillisers or neuroleptics. continuing symptoms and prevent acute drugs are relatively free of them.
There are now two distinct groups of relapse. n Endocrine effects. Raised prolactin
antipsychotics: the older typical drugs levels may cause galactorrhoea in
such as chlorpromazine and haloperi- How do antipsychotics work? women, or gynaecomastia in men.
dol, and the newer atypical drugs, such The older antipsychotics act by blocking n Raised seizure threshold may result
as risperidone and olanzapine. They are dopamine receptors in the brain. The in fits.
used to treat psychotic disorders, such as mechanism of action of the atypical anti-
psychotics varies from drug to drug. The side effect profiles for atypicals
schizophrenia, psychotic depression and
They generally have a specific dopami- varies enormously (Fig. 2). They tend to
mania, and to calm severe agitation. The
nergic action, blocking a subtype of be well tolerated, but most can cause
atypical antipsychotic drugs also have
dopamine receptors known as D2. They sedation and weight gain (aripiprazole is
mood stabilising effects, and are increas-
also have serotonergic and alpha-adren- the exception to this, and can cause
ingly used in the treatment of bipolar
ergic effects, and some work selectively insomnia, restlessness and weight loss).
disorder, both in the acute phase and
in the mesolimbic cortex. This gives They can also cause postural hypoten-
prophylactically.
them a significant advantage over the sion, particularly when they are first pre-
Antipsychotic drugs were first discov-
older drugs in that they produce few or scribed, and the dose is increasing.
ered in the 1950s. The tranquillising
no extrapyramidal effects (see below). Extra-pyramidal side effects are rare, but
properties of chlorpromazine were
However they do have other side effects can occur. Amisulpride, risperidone and
noticed when it was used as a sedative
that can limit their use in some patients, zotepine can all raise prolactin levels.
prior to surgery, and this led to trials of
and are significantly more expensive Olanzapine and risperidone are associ-
its effects in patients with mental illness.
than typical antipsychotics. In general ated with increased risk of stroke in the
The results were startling, with patients
the atypicals are no more effective than elderly with dementia, and should not
who had been chronically ill and untreat-
the older drugs in treating psychotic be used in these patients. Side effects of
able in some cases able to recover normal
symptoms. The important exception to clozapine are described further below.
functioning. The use of chlorpromazine,
this is clozapine, which is reserved for Both typical and atypical antipsychot-
and other drugs that were rapidly devel-
treatment-resistant schizophrenia (see ics can, rarely, cause prolongation of the
oped, became widespread. The impact of
below). QT interval. The QT interval is the time
this, the first effective treatment for
from the start of the Q wave to the end
schizophrenia, was profound. It made
possible the closure of psychiatric inpa- Side effects of the T wave on the ECG. There is a rare
Typical antipsychotics have a character- link between prolonged QT interval and
tient beds, and the move to treatment of
istic side-effect profile, as follows: ventricular arrhythmia that may cause
patients with serious mental illness in
sudden death.
their own homes, that continues today. n Extrapyramidal effects. There are Neuroleptic malignant syndrome is a
In the 1990s the atypical drugs were four types: rare side effect of treatment with antipsy-
developed, and in general were better n Acute dystonia: severe muscle
chotic drugs. It is more likely to occur if
tolerated, and therefore more acceptable spasms occur, often affecting the high doses are used, or the doses are
to patients. They are now more com- neck or eyes (oculogyric crisis). escalated rapidly. It presents with a
monly prescribed than typical antipsy- This can be painful and distressing raised temperature, fluctuating level of
chotics. Typicals are still used in depot and occurs in up to 10% or consciousness, muscle rigidity, and auto-
medications, as there are limited atypical patients, usually in the first few nomic dysfunction. It is associated
alternatives, and for patients who have days of treatment. with elevated creatinine phosphokinase
been well on typical medications over n Parkinsonian symptoms: lack of
(CPK). This syndrome is associated with
many years. It is now considered to be facial expression, increased muscle a mortality rate of up to 20%, and needs
good practice to offer atypicals to patients tone and tremor, occurring in to be treated as a matter of urgency. The
starting on antipsychotic drugs for the about a third of patients. antipsychotic drug must be stopped, and
first time. The most effective antipsy- n Akathisia: a distressing side effect
general medical admission is usually
chotic, clozapine, is an atypical that was characterised by physical and required.
first discovered in the 1950s, but was psychological restlessness. It is
thought to be too dangerous to use present in up to a third of patients.
because it can cause agranulocytosis. n Tardive dyskinesia: a late onset
The development of effective systems for side effect in which involuntary Blurred
monitoring patients on clozapine has movements of the tongue and vision Dry mouth
allowed this drug to be reintroduced for mouth occur. It emerges in about a
the treatment of patients who do not fifth of patients on continuous Postural
respond to other antipsychotic drugs. treatment for five years or more. In hypotension
All antipsychotics have a calming some cases it is irreversible. The Constipation
effect which begins quickly, and they can best management for tardive Urinary
provide rapid relief for an extremely dis- dyskinesia is to reduce or stop the Sexual retention
tressed patient. The action on psychotic dysfunction
antipsychotic drug, but this may
symptoms is slower, over a period of one not be possible in all patients.
or two weeks. In treatment of acute n Autonomic effects. These are shown
symptoms low doses are used initially, in Figure 1 and may be particularly
either orally or by intramuscular injec- problematic in the elderly.
tion, and increased according to the Chlorpromazine and thioridazine
patients response, and side effects. In have prominent autonomic side
the long-term treatment of chronic Fig. 1 Autonomic side effects.
Antipsychotic drugs 25
Antidepressant drugs
ally during the first few weeks of treatment. Alternatively, it
Case history 6 may be that increases in monoamine transmission have sec-
Nilanjan is a 52-year-old year old man who presents with a ondary effects that help relieve depression, such as regulation
moderate to severe depressive episode. He is despondent and of the hypothalamic pituitary axis, or production of neuro-
hopeless, with fatigue, poor motivation and impaired sleep. He trophic factors that promote healing of damaged neurones.
smokes cigarettes and is overweight. He found amitriptyline
helpful during a previous depressive episode and wants to take SSRIs
antidepressants again. He was prescribed citalopram a few weeks The introduction of these drugs during the 1980s was an
ago but stopped it because of nausea and agitation. important development in the treatment of depression. The
a. What options would you discuss with him? four most widely prescribed SSRIs are sertraline, citalopram,
fluoxetine and paroxetine. They are generally better tolerated
than tricyclics and are less dangerous in overdose. Their main
Antidepressant drugs, as their name suggests, were developed disadvantage at first was cost, but patent expiry means that
for the treatment of depressive disorders. They are most effec- they have become relatively cheap. The SSRIs are not without
tive in the treatment of moderate and severe depressive epi- problems. Gastrointestinal effects such as nausea and diar-
sodes. It is uncertain whether they are helpful in mild depressive rhoea are common, particularly early in treatment, although
episodes and any efficacy they have in this condition is prob- less so if the drug is taken after food and the dose is increased
ably outweighed by the risk of adverse effects, as these milder gradually. Sweating, headaches and sexual dysfunction can all
illnesses often improve spontaneously or with simple non- occur. Anxiety and agitation may occur in the early stages of
pharmacological interventions (see p. 54). Antidepressants treatment and occasionally are severe.
are also effective in the treatment of anxiety disorders and
obsessivecompulsive disorder. Tricyclic antidepressants are Tricyclics
used in low doses for the treatment of some chronic pain For many years, tricyclics were the most commonly prescribed
syndromes. antidepressant drugs, but their use was limited by a number
There are three main classes of antidepressants: tricyclics, of adverse effects, which are summarised in Figure 3. They
selective serotonin reuptake inhibitors (SSRIs) and mono- include amitriptyline, clomipramine, dosulepin, imipramine,
amine oxidase inhibitors (MAOIs). There are other drugs that and lofepramine. Most tricyclics are sedating, with the excep-
have similar modes of action to tricyclics but are said to have tion of lofepramine and, to a lesser extent, imipramine. This
a better side effect profile, such as serotonin and noradrenaline can be helpful when sleep disturbance or anxiety is a particular
reuptake inhibitors (SNRIs), venlafaxine and duloxetine, and problem, but daytime sedation is a common reason for people
the noradrenaline reuptake inhibitor (NARI) reboxetine. stopping these drugs. They have antimuscarinic effects and so
can exacerbate glaucoma, prostatism and problems associated
How do antidepressants work? with reduced gastrointestinal motility, such as constipation.
In 1954, trials of iproniazid for tuberculosis showed that the Weight gain and erectile dysfunction also occur. Tricyclics
mood of some subjects improved during treatment. Iproniazid cause hypotension, tachycardia and arrhythmias, so can be
was found to inhibit monoamine oxidase activity and other problematic for people with cardiovascular disease or cardio-
drugs that replicated this effect turned out to have an antide- vascular risk factors. The tricyclics are dangerous in overdose,
pressant action. Monoamine oxidase was known to be involved because of their cardiotoxic effects the overdose risk is great-
in the breakdown of monoamine neurotransmitters in the est for dosulepin and amitriptyline and so these drugs should
brain and the theory that increases in serotonin activity were be prescribed only under specialist supervision. Lofepramine
important in the treatment of depression was suggested by the
finding that the antidepressant effect of MAOIs was enhanced
by oral supplements of the serotonin precursor, tryptophan. MAOI Noradrenaline
In 1958, trials of a tricyclic drug, imipramine, in schizophre- Inhibition of monoamine Serotonin (5HT)
nia, showed it to be of no help in the treatment of psychotic metabolism
symptoms but to have an antidepressant effects in subjects Breakdown products
with depressive symptoms. Imipramine was found to inhibit MAO MAO of monoamines
the reuptake of noradrenaline into presynaptic neurons, which MAO monoamine
suggested that noradrenaline was also involved in depression. oxidase
All the antidepressants developed since have an effect on
either noradrenaline or serotonin, as illustrated in Figure 1.
The relative effects of the monoamine reuptake inhibitors are
shown in Figure 2. Some antidepressant drugs affect mono-
amines in novel ways, such as mirtazapine, which antagonises
the presynaptic adrenergic autoreceptors that inhibit sero- SSRI
tonin and noradrenaline release.
There is a problem with the theory that antidepressants Prevention of
serotonin reuptake
work as a result of their effect on serotonin and noradrenaline.
The levels of these monoamines in the synaptic cleft increase
within a few hours of the first dose of reuptake inhibitors,
whereas it usually takes one or two weeks of treatment before Tricyclic
any antidepressant effect is apparent clinically. One explana-
Prevention of noradrenaline
tion for this is that the therapeutic effect of antidepressants and serotonin reuptake
depends on a decrease in the sensitivity of some receptors, such
as presynaptic serotonergic autoreceptors, that occurs gradu- Fig. 1 Antidepressant drug action.
Antidepressant drugs 27
MAOIs
The antidepressant effect of MAOIs occurs through the inhibi-
tion of monoamine oxidase A within neurones. This enzyme
is involved in the breakdown of serotonin, noradrenaline and Antidepressant drugs
adrenaline. It can also break down dopamine, but in vivo this n SSRIs are usually well tolerated and safe in overdose
is achieved mostly by monoamine oxidase B. The MAOIs first
n Antidepressants, particularly SSRIs, can cause agitation and
developed for use in depression include phenelzine and tran-
ylcypromine. These drugs are non-selective and bind irrevers- increased suicidality
ibly to both types of monoamine oxidase. They can cause a n Tricyclics and SNRIs are commonly used second line drugs
potentially life-threatening hypertensive crisis if taken with
28 TREATMENT IN PSYCHIATRY
Anticonvulsant drugs
Sodium valproate and valproic acid are effective antimanic 0
drugs with a relatively fast onset of action, particularly if the Fig. 1 Side effects and toxic effects of lithium.
Mood stabilisers and ECT 29
Table 1 Monitoring of people taking lithium week, with improvement usually begin-
Test When? Why? ning after two or three treatments. On
Lithium level 57 days after initiation Narrow therapeutic range average, a course of six to eight treat-
Following change of dose Risk of toxicity ments is needed to achieve a full
If drug interactions possible response. ECT is only effective in the
Routinely every six months acute phase of the conditions for which
Serum creatinine Before initiation Risk of chronic kidney disease it is used, so when the course of treat-
Routinely every six months Renal function affects lithium levels ment has finished, medication is usually
Thyroid function Before initiation Risk of hypothyroidism continued to improve the persons
Routinely every six months chances of staying well. Very occasion-
ECG Before and after initiation Risk of conduction defects ally, maintenance ECT is used when
Serum calcium Routinely every year Risk of hyperparathyroidism/hypercalcaemia medication does not prevent relapse.
Urine volume If polyuria occurs Risk of diabetes insipidus The main side effect of treatment is
loss of memory for recent events occur-
ring over a short period before and after
treatment. This usually resolves within
two weeks of treatment ending, but can
Is the diagnosis one of the persist, usually to a mild degree, for
following? Does the person have capacity to several months. The only permanent
Severe depression consent to treatment? cognitive impairment that can be caused
Catatonic schizophrenia by ECT is deficits in autobiographical
Severe mania
memory. This is not usually problematic
Yes No but causes some people to regret having
ECT. Other side effects encountered are
Yes headaches, muscle pains and those due
Have adequate trials of medication Yes Consider use of to the general anaesthetic.
and other treatments been given? Mental Health Act Normally, a person must give written
(see text) consent before undergoing a course of
No ECT. If the person does not have the
mental capacity to give such consent,
GIVE FULL EXPLANATION OF RISKS
treatment can be given under Section 3
Is the condition life-threatening? AND BENEFITS
Yes
of the Mental Health Act, but only if
e.g. suicide risk that cant be authorised by an independent consul-
safely managed in other ways, tant psychiatrist.
refusal to eat and drink
daffodil bulbs, but is now produced syn- patients may therefore be reduced. of these new drug treatments. They are
thetically. Rivastigmine is an acetylcho- However, the prospect of treatment for community based services, run by mul-
linesterase and butyrylcholinesterase what was in the past an untreatable con- tidisciplinary teams including psychia-
inhibitor. dition may result in many more patients trists, community mental health nurses,
being diagnosed and referred to second- support workers and psychologists.
Prescribing drugs for dementia ary care than before, pushing up costs Their role is to assess patients referred
The acetylcholinesterase inhibitors for the health service. by GPs, establishing a diagnosis of
donepezil, galantamine and rivastigmine dementia, and excluding other potential
are used in the management of Alzheim- Side effects causes for memory impairment. They
ers disease. In general they are pre- The most common side effects are work closely with patients and their
scribed in clearly defined circumstances nausea and vomiting. Although these carers, providing information, advice
by specialist services in secondary care effects are usually short-term they may and support. Treatment is planned and
(including psychiatric, learning disabil- lead to non-adherence. delivered by the memory clinics, and
ity, neurology and medical services). includes but is not limited to treatment
Their use is limited to patients with an Memory clinics with acetylcholinesterase inhibitors.
illness of moderate severity. Severity of Memory clinics have been established to Those who are prescribed these drugs
illness is assessed in various ways (Fig. manage the increasing demand for treat- are carefully monitored at regular
1), and usually includes the use of a ment for dementia following the advent intervals.
standardised tool to measure cognitive
function. This provides an objective
measure that can be used to track prog-
ress. These assessments must be
repeated at least every 6 months. When Mental state examination
the assessments indicate that the illness behaviour, including agitation,
Cognitive assessment aggression, wandering
is severe, or the drug no longer appears
orientation mood disturbance
to be having a worthwhile effect on the concentration psychosis
functioning or behaviour of the patient, attention
the acetylcholinesterase inhibitor should short and long term
be stopped. memory
There is some evidence for the benefits language
of acetylcholinesterase inhibitor drugs in executive function
other forms of dementia, particularly
Lewy body dementia, and research is
continuing into this area to establish
whether they should be used, and if so
how. Until this research is completed
these drugs are, in the main, restricted to
treatment of Alzheimers disease.
There is good evidence to show that
acetylcholinesterase inhibitors can cause
improvements in cognitive functioning,
and other aspects of general functioning
Functional assessment
and behaviour. However the effects are
activities of daily living
often relatively small, and can be short- independence
term. There is evidence from placebo mobility
controlled trials that improvement in Structural imaging
cognitive function can be maintained (e.g. MRI scan)
over a period of 2 years. These medica- Fig. 1 Assessing severity of dementia.
tions do not appear to alter the underly-
ing disease process, and this is apparent
when they are withdrawn in drug trials,
as the patients condition deteriorates to
that of those in the placebo group within Benzodiazepines and drugs for dementia
6 weeks of stopping treatment. It is also
Benzodiazepines
clear that some patients respond better n should only be used to manage acute emotional distress, withdrawal from alcohol,
to treatment than others. Currently it is
treatment of the acute phase of severe mental illness, and for patients with chronic
not possible to predict which patients
dependence
are likely to be in this group.
n withdrawal should be managed by switching to an equivalent dose of diazepam and
The high costs of these treatments
have led to controversy about how they reducing the dose slowly
should best be used. It is thought that Drugs for dementia
life expectancy is not changed with treat- n increase the availability of acetylcholine in the central nervous system by inhibiting the
ment, but as functioning is improved for enzyme acetylcholinesterase
a period it is likely that treated patients n can improve the cognitive and behavioural functioning of patients with Alzheimers
will maintain a degree of independence
disease over a period of 2 years, but do not alter the underlying disease process
for a greater proportion of their illness.
The overall cost of caring for treated
32 TREATMENT IN PSYCHIATRY
Psychological treatments
model used in cognitive therapy. This
Case history 7 process can often become self-perpetuat-
Mary is a 32-year-old woman who presents with despondency, low self-esteem, lethargy ing. In the example above, if you had
and other depressive symptoms following a period of prolonged marital and financial become frightened, you would be more
difficulties. She has fallen behind at work and has panic attacks when colleagues appear to likely to attribute any further noises to a
be observing her. She was brought up by her father and stepmother after her mothers burglar.
death and always felt her half-sisters needs were put ahead of her own. The first stage of cognitive therapy is
to teach patients to recognise their symp-
a. What psychological treatments would be useful in this case? toms and then to apply the ABC model.
This will reveal a number of thinking
errors that cause them to appraise events
in a way that leads to unpleasant conse-
Psychological treatments may be used Operant conditioning is also impor- quences. For instance, a patient with an
alone or in combination with physical tant during treatment. For instance, in anxiety disorder will tend to view situa-
treatments. They provide some of the exposure therapy for agoraphobia, the tions as threatening. As a result, they will
most powerful means of treating many therapist will explain to the patient that, become anxious, which will increase the
types of mental illness. The three main if they force themselves to endure the chances of them viewing subsequent
types of psychological treatment are anxiety associated with going out, it will events in a similar way. Patients with
dynamic psychotherapy, behavioural eventually subside. When the patient depressive disorder will favour negative
psychotherapy and cognitive psycho- discovers this to be true, negative rein- rather than positive explanations of
therapy. There is much debate about the forcement occurs, and they become less events. This causes low mood which
relative merits of these and, as will be likely to give in to the anxiety next time makes them view events in an even more
seen in this section, all appear to have a it occurs. Common ways in which negative way. Learning to spot and chal-
role. In deciding which psychotherapy, if operant conditioning is applied to clini- lenge these thinking errors is the key
any, to recommend to patients, it is cal situations are shown in Table 1. process in cognitive therapy. Patients
important to consider the nature of their keep diaries, to enable them and their
problems, as well as how receptive they Cognitive therapy therapist to monitor their progress and
are likely to be to the different approaches. Cognitive therapy is based on the prin- to discuss the issues that arise between
ciple that the way people perceive events treatment sessions when they put cogni-
Behavioural psychotherapy has more effect on how they feel than tive techniques into practice.
The term behavioural psychotherapy the event itself. For instance, if you are Thinking errors are a reflection of
covers a range of treatments, all of which woken by a banging noise during the peoples assumptions about themselves
make unwanted behaviours the focus of night, you may believe that a burglar and their world, which are also known
treatment. They include relatively simple is breaking into your house and so as cognitive schema. Understanding such
techniques such as relaxation training, in feel frightened. Alternatively, you may schema and how they originated helps
which participants learn to reduce the believe that a housemate has returned people avoid thinking errors. Diagrams
somatic symptoms of anxiety through home drunk and so feel angry, or you like the one in Figure 1 are used to help
controlled breathing and muscle relax- may believe that a draught has caused a patients gain this understanding.
ation. Most other behavioural techniques door to slam, in which case you probably Cognitive behaviour therapy com-
are based on the psychological theory of wont feel any particular emotion. This bines cognitive and behavioural tech-
operant conditioning which states that a shows how the same Antecedent has niques. For instance, a patient with
behaviour is reinforced (i.e. is more been responded to with different Beliefs, agoraphobia would be helped by expo-
likely to be repeated) if it has positive each resulting in different Conse- sure therapy and cognitive techniques
consequences. Positive reinforcement is quences, and is an example of the ABC that address the thinking errors that lead
when a behaviour increases because
something good happens as a result,
whereas with negative reinforcement a
behaviour increases because it causes Table 1 Use of operant conditioning in behaviour therapy
something unpleasant to go away. It will Technique Indications Process
be seen from this description that nega- Exposure therapy Simple phobia, agoraphobia Identify things or places which lead to anxiety
tive reinforcement is not the same as List these in order, i.e. a hierarchy with most anxiety-
punishment. When operant condition- provoking situations at the top
ing is involved in the development of Expose patient to situation at bottom of hierarchy
mental illness, it is usually through nega- until no longer causes anxiety
tive conditioning. For instance, avoid- Move on to next situation in hierarchy
ance of going outside in agoraphobia or Response prevention Obsessivecompulsive disorder Gradually reduce the number of times the person
carrying out compulsions in obsessive carries out the unwanted act, e.g. for compulsive
compulsive disorder are associated with handwashing, make the patient repeatedly
a reduction in levels of anxiety and so contaminate their hands and gradually reduce the
time they spend washing them afterwards
these behaviours increase in frequency.
Similarly, during depressive episodes, Behavioural activation Depressive disorder Patient avoids doing things as they think they will
routine activities can lead to increased not enjoy them or will feel a failure if they do not
complete them
fatigue and feelings of failure if the
Make realistic and achievable plans to carry out
patient finds them difficult to complete.
activity each day
In such cases, activity levels decrease
Gradually increase the amount of activity
because of negative reinforcement.
Psychological treatments 33
to anxiety when they go out. A patient and the practice of dynamic psychother- themselves and others. Situations similar
with depression would be helped by apy have been adapted considerably and to those which caused the original dis-
both behavioural activation and cogni- there are now many different forms of tress may cause the repressed feelings to
tive techniques that deal with their nega- treatment available. It is only possible to re-enter the conscious mind. Alterna-
tive thinking style. In cognitive analytic describe here the key components of tively, the conscious mind may respond
therapy, a psychodynamic approach is these therapies. by using other defence mechanisms,
used to help the patient understand why Psychodynamic theory states that the such as projection in which the distress-
they developed interpersonal difficulties mind is divided into conscious and sub- ing feelings are attributed to other
and problematic cognitive schemata, conscious parts. When faced with people, thereby reducing the distress
with cognitive techniques being used to overwhelming anxiety or distress, the that would be caused if the person
change these ways of thinking. conscious mind uses psychological acknowledged that these feelings actu-
defence mechanisms, such as repres- ally related to him or herself.
Dynamic psychotherapy sion, to push these feelings into the sub- A psychodynamic therapist helps the
Dynamic (or analytic) psychotherapy is conscious. These feelings may remain in patient to understand and alter these
derived from Sigmund Freuds descrip- the subconscious for many years and yet processes. At the centre of this therapeu-
tions of psychoanalysis. Freuds theories still influence the way the person views tic process is the assumption that the
way the patient interacts with the thera-
pist reflects the way they interact with
others outside therapy, a process known
as transference. Therapists are affected
I've been so upset this
by the powerful emotions felt by the
What's the point of this. I'm feeling a bit better,
You never seem to care week thinking how a bit less angry with patient during therapy, which means
about my problems lonely I felt as a child other people that feelings the therapist has about the
patient actually reflect what the patient
You think I'm not here You must have is feeling. This is known as counter-
for you, like your mother missed your mother transference. As the therapeutic relation-
wasn't there for you terribly after she died
ship becomes more trusting and secure,
the therapist is able to use transference
and counter-transference to help the
patient discover the repressed reasons
for their current distress. An example of
this process is given in Figure 2.
The shortest form of dynamic psycho-
therapy is brief focal therapy, which con-
sists of 1230 weekly sessions, each
1 2 3
lasting 50 minutes. In some cases, treat-
ment can continue for years. There is
Fig. 1 How childhood experience leads to cognitive schemata which increase the chance of evidence that shorter forms of treatment
thinking errors. The alternative belief could be used to challenge the thinking errors.
are effective but longer-term therapy has
not been properly evaluated.
Psychological treatments
'I'm useless'
Criticism by 'I'm going to lose my job' Depression n Dynamic psychotherapy helps
boss at work Thinking errors Anxiety patients understand how
relationships and events from the
past affect them in the present
'The only way people will
n Behaviouralpsychotherapy focuses
like me is if I succeed in
everything I do' on dysfunctional patterns of
behaviour
n Cognitive therapy helps patients
Critical parents with identify and challenge thinking errors
high expectations
Fig. 2 Helping the patient come to terms with repressed emotions by interpreting
transference towards the therapist in dynamic psychotherapy.
34 TREATMENT IN PSYCHIATRY
Vacancies
employers are less likely to employ someone with a history of mental health and other agencies, many people with mental
mental health problems than someone with a physical dis- illness are able to participate in mainstream education.
ability. Many mental health services have tackled some of these 5. Ethnic minorities. The prevalence of most severe mental
issues by employing vocational advisors who work both with illnesses is similar across different ethnic groups. However
individuals to identify and support appropriate employment, there is evidence that people from black and minority ethnic
and with employers to tackle negative attitudes. groups access help from services late, and are more likely to
3. Lack of secure housing. The majority of people with be detained under the Mental Health Act than white people.
severe mental illness live in independent housing, with fewer In general terms people from ethnic minority groups are more
than 20% living in accommodation that includes some form likely to experience social deprivation, social isolation and
of residential support. Of those living independently about racism, which may act as precipitating and maintaining factors
half live alone. They are more likely than the general popula- in mental illness. Refugees may have particularly complex or
tion to live in rented accommodation and to feel their housing severe mental health issues. They may have come from war
is not secure. About one in five of all homeless people has a zones, and been subject to torture or other traumatic experi-
mental illness often complicated by substance misuse, and of ences. Language barriers can make assessment and treatment
those who sleep rough about half are mentally ill. Mental difficult, and access to interpreters is essential. Family members
health services work with housing departments and housing and friends are rarely able to interpret for someone with
associations to support patients to stay in their accommoda- mental illness in a reliable way. Ideally interpreters should
tion, and some have specialist homeless teams that provide have some training in mental illness so that they are able to
flexible outreach services. communicate abnormalities in the mental state. An holistic,
4. Low educational achievement. About a third of people person-centred approach that is sensitive to the cultural and
with mental health problems have no academic qualifications. spiritual needs of all patients is needed to overcome some of
The barriers to accessing education or training are similar to these difficulties.
those for employment. Low expectations, lack of confidence
and false assumptions about the potential benefits of educa- Advance decisions and statements
tion all play a part. With encouragement and support from One of the key principles of the recovery model of mental
within educational institutions, and provided externally by health care is that patients regain control over their lives.
However, for people with severe mental illness there may be
an ongoing risk of relapsing into acute mental illness, and as
a consequence losing the capacity to make appropriate deci-
sions. They risk losing control at these times, as services may
step in and impose treatment under the Mental Health Act or
This is my Advance Statement in case I have a manic episode Mental Capacity Act (see pp. 1619). Advance decisions and
and cannot make decisions about my care: statements (sometimes called living wills) have been devel-
oped as tools to allow patients to state what type of treatment
I prefer to be treated at home if at all possible. they wish to receive in these circumstances. Advance decisions
Previously treatment with quetiapine and diazepam are defined in the Mental Capacity Act, and allow the patient
has worked well.
to make a decision in advance to refuse a specified type of
Treatment with valproate has not worked well in
the past, and I prefer to avoid it. medical treatment. Advance statements do not carry the same
statutory power, but can contain positive decisions about treat-
If I do need to be admitted to hospital: ments or broader aspects of care they wish to receive. Ideally
they should be developed with support from the care co-
I would like my friend, David Smith, and my neighbour ordinator or other mental health professional, and a copy
June Taylor to be informed immediately. should be kept in the clinical notes, so that it can be taken into
David Smith will contact my work. I do not want account when decisions about treatment are being made. The
any health professionals to contact my work. issues that may be included in an advance statement are shown
I have a dog, and prefer that he go to my neighbour, in Figure 3.
June Taylor, during my time in hospital.
I do not want my parents to be informed of any
admissions.
I am a vegetarian, and it is important to me to Recovery and social inclusion
maintain a strict vegetarian diet throughout any stay in hospital,
even if I say this is not important when I am ill. n Recovery is the term used to describe the personal journey of
My neighbour, June Taylor, has a key to my house, individuals in coping with the effects of mental illness
and will make sure my home is secure.
n A positive and optimistic attitude on the part of mental health
Signed: Mark Evans professionals is essential to promoting recovery
n Stigma and discrimination against people with mental illness
results in social exclusion, and prevents recovery
Schizophrenia is the illness most readily prodromal period are non-specific and phrenia, most commonly a mood disor-
associated with psychiatry. It has a vari- so basing a diagnosis on these will often der. Two symptoms also considered
able course and in some cases may lead to mistakes. to be diagnostic of schizophrenia were
involve only a few short episodes of not described by Schneider: hallucina-
illness. However, in about one-third of tory voices which appear to emanate
cases the illness is severe, chronic and Symptoms from a body part and bizarre delusions.
disabling. Because of this, care for people Symptoms required to make the diagno- Schizophrenia can also be diagnosed
with schizophrenia accounts for a large sis of schizophrenia are shown in Figure if at least two of the other symptoms
proportion of the workload of mental 1. It will be seen from this that some shown in Figure 1 are present. There are
health services. symptoms are virtually pathognomonic also symptoms which are very common
Schizophrenia is characterised by two of schizophrenia. Most of these were in schizophrenia but are not diagnostic
types of symptoms: positive (type 1) and described by Schneider and are known because they occur relatively often in
negative (type 2). Positive symptoms are as Schneiders first rank symptoms. If any other conditions. The most common of
those which are added on to pre-existing of these symptoms are clearly present these are persecutory delusions and
functions, whereas negative symptoms for at least one month and there is no delusions of reference, and examples of
are those which involve a loss of func- organic cause, then the likely diagnosis these are given in Table 1, along with
tion. There are four main groups of posi- is schizophrenia, although 15% will turn examples of some of the symptoms
tive symptoms: out to have an illness other than schizo- described above.
n delusions (false beliefs)
n hallucinations (false perceptions) Delusions Thought Hallucinations
n thought disorder (disorganised
insertion
thinking) Thought Thought
n catatonic symptoms (abnormalities broadcasting withdrawal
of movement and muscle tone). Thought echo
(thoughts spoken out loud)
The main negative symptoms are Delusional !! Bizarre
apathy, avolition, alogia and affective perception delusions !!
blunting or incongruity (best remem- Voices discussing patient
bered as the four As). Apathy is lack of Voices giving a running commentary
interest in personal and other events. on patients behaviour
Delusions of
Avolition describes an inability to initiate
control
tasks or see them through, which causes
the patient to avoid activities and spend
long periods of time doing nothing.
Alogia is another term for poverty of Voices coming from
some part of the body
speech in which the patient says little
spontaneously and gives brief replies to
questions. Blunting of affect is a reduc-
tion in emotional expression which is At least one of the above symptoms or two of the following:
manifested by a reduction in facial expres- persistent hallucinations without clear affective content
sion, eye contact and body language. breaks in train of thought resulting in incoherent or irrelevant speed or neologisms
Incongruity of affect is the exhibition of catatonic behaviour
emotions which are clearly inappropriate negative symptoms
to the situation, often leading the person significant and consistent change in behaviour
to appear silly or strange. Fig. 1 Symptoms of schizophrenia. Schneiders first rank symptoms are in red; other symptoms are
in black.
Diagnosis
Duration Schizophrenia Symptoms of
In ICD10, symptoms must have been Mood symptoms schizophrenia
present for at least one month before a not prominent Symptoms of
diagnosis of schizophrenia can be made. mood disorder
If symptoms have been present for less Mood disorder
than this time, a diagnosis of acute Schizophrenic symptoms occur
schizophrenia-like psychotic disorder after mood symptoms and appear
should be made with the diagnosis being to be secondary
revised to schizophrenia if symptoms
persist beyond one month. Schizoaffective disorder
There is often evidence of changes in Schizophrenic and mood symptoms
behaviour and mood for months or even equally prominent
years before the onset of clear cut symp-
toms but this should not be taken into
Post-schizophrenic depression
account when deciding whether the Depressive symptoms emerge as
illness has lasted long enough to make schizophrenic symptoms are resolving
the diagnosis of schizophrenia. This is
because symptoms occurring during the Fig. 2 Differential diagnosis between schizophrenia and mood disorders.
Diagnosis and classification of schizophrenia 39
Neurochemical abnormalities
Amphetamines, which cause increased
dopamine release, can cause psychotic
symptoms very similar to those seen Fig. 3 Different levels of expressed emotion.
in acute schizophrenia. Antipsychotic
drugs, the most effective treatment
for acute schizophrenia, are dopamine factors. Stress also can play a role in chological stimulation to which patients
antagonists. These observations have precipitating episodes. Once the illness with schizophrenia are exposed influ-
given rise to the dopamine hypothesis of has developed, it may be maintained by ences whether they have positive or
schizophrenia, which postulates that stress and illegal drug use. A particular negative symptoms. Patients in a hospi-
positive symptoms are caused by overac- type of stress known to maintain the tal with an active rehabilitation pro-
tivity of dopamine in the mesolimbic illness is living in an emotionally charged gramme in which they were encouraged
area of the brain. Modern neuroimaging environment in which people display to do as much as possible had more posi-
techniques such as positron emission high levels of what is known as expressed tive symptoms and fewer negative symp-
tomography provide the opportunity to emotion. This is shown in Figure 3. toms. In the hospital where patients
measure the activity of dopamine and its An interesting study of hospitals with received little encouragement and did
receptors in the brain and this approach very different treatment regimes showed very little as a result, there were more
has produced evidence to support the that the amount of emotional and psy- negative and fewer positive symptoms.
dopamine hypothesis. However, meso-
limbic dopamine activity is regulated by
other areas of the brain and, given that Case history 10
dopamine does not appear to have an
important role in the development of The parents of Peter (see Case history 9) ask you what has caused his illness, as they are
negative symptoms, it is likely that concerned that they are to blame.
abnormalities of dopamine in schizo- a. What should you tell them?
phrenia are secondary to other abnor-
malities, perhaps in the frontotemporal
region (see Fig. 2).
Acute schizophrenia
The first presentation of schizophrenia
is usually with an acute episode, consist-
ing of positive symptoms. In some cases,
the patient has been well prior to the
onset of these symptoms. In many,
however, there will have been a prodro-
mal phase lasting months or years, in
which non-specific changes of behaviour
such as social withdrawal and reduced
level of function occur.
The acute episode often starts with
delusional mood, in which the patient
believes that something strange is going
on but doesnt know what it is. The
patient then begins to experience other
positive symptoms. The most common
are delusions, especially of reference and
persecution, and auditory hallucina-
tions, which may be in the 2nd or 3rd Fig. 1 Mental state examination of patient with acute onset schizophrenia.
person. However, any combination of
positive symptoms can occur.
Patients behaviour can be affected by
their positive symptoms in a number of
different ways. If the patient is thought-
disordered, their behaviour may become Illness factors
disorganised as a result. Unusual behav-
Sudden Onset Insidious
iour in acute schizophrenia may also be
Short duration Current episode Long duration
an understandable response to delu- Affective symptoms Symptoms Negative symptoms
sions and hallucinations. For instance, a Paranoid Subtype Hebephrenic
patient may be suspicious or aggressive Good Response to treatment Poor
because of persecutory delusions, or
may refuse medication they think is poi-
soned. They may smash a television Good Prognosis Poor
because of frightening delusions of refer-
ence. They may refuse to remove a cycle Patient factors
helmet, feeling a need to protect them-
selves because of delusions of control. Older Age at onset Young
They may talk or laugh to themselves or Female Gender Male
appear preoccupied as a result of audi- Married Marital status Single/divorced
Good Premorbid personality / Function Poor
tory hallucinations.
No Illicit drug use Yes
An example of a mental state examina- Compliance Poor
Good
tion of a patient with acute schizophre-
nia is shown in Figure 1. While most
Fig. 2 Prognostic factors in schizophrenia.
patients present with some of these
abnormalities, it would be unusual for
them to have quite so many. In fact,
some patients may appear completely
normal until they begin to discuss their Negative symptoms tory sentences. They may show
delusions or hallucinations. Different combinations of the negative incongruity of affect, smirking or gig-
symptoms described in the previous gling inappropriately, or looking very
Chronic (residual) schizophrenia pages occur in chronic schizophrenia. sad and upset for no apparent reason.
Some patients make a good recovery They develop insidiously and their sever- Their affect may be blunted, with little
from episodes of acute schizophrenia. ity varies. In some cases, they are mild variation in emotion.
Others are less fortunate, going on to but in others they dominate the patients
develop a chronic unremitting illness in life. The patient will spend increasing Positive symptoms
which function is markedly reduced. As amounts of time on their own, often Thought disorder is common in chronic
discussed below, positive symptoms doing very little. They avoid social schizophrenia and will often be the most
often continue in such patients but the contact and lose the ability to respond to obvious abnormality in the mental state
clinical picture is usually dominated by verbal and non-verbal social cues. Their examination. Hallucinations may persist
the gradual emergence of negative symp- social skills deteriorate and they lose the and in some cases may continue to
toms and it is these which are usually the ability to plan and carry out even simple distract or distress the patient. More
greatest cause of disability. Illnesses tasks. They rarely make conversation often, they will become less prominent,
which run this chronic course are known spontaneously and their replies to ques- either because their intensity reduces or
as chronic or residual schizophrenia. tions are often limited to short, perfunc- because the patient adapts to their pres-
Acute and chronic schizophrenia 43
Case history 11
ence. Delusions may also occur but tend not to be a prominent
feature. In many patients, delusions and hallucinations will Mr Dylan, a 20-year-old man who was previously well, presents
become prominent again during acute exacerbations of the acutely with persecutory delusions, delusions of thought insertion
illness. Such acute exacerbations occur most often early on in and third person auditory hallucinations.
the course of illness, becoming less frequent with time. a. Are these symptoms common in schizophrenia?
There are two reasons why delusions and hallucinations b. How is this illness likely to develop over the next 10 years?
become less prominent in chronic schizophrenia. The first is c. What factors determine his prognosis?
that they are the symptoms which respond best to antipsy-
chotic medication. However, even before the development of
antipsychotic drugs, chronic schizophrenia followed the
course described here, which suggests that the change in the
balance of symptoms is part of the natural course of the illness.
Acute and chronic schizophrenia
Prognosis
Prognostic factors for schizophrenia are shown in Figure 2. An n Patients with schizophrenia have acute episodes consisting of
easy way of remembering most of these factors is that patients positive symptoms from which they usually make a good
who present with acute episodes of positive symptoms but recovery
appear to have been functioning well previously have a good n Some patients regain premorbid levels of function between
prognosis. Their positive symptoms are likely to respond well episodes but others develop chronic schizophrenia in which
to treatment and they should return to their previous level of their function is impaired by negative symptoms
function. They will be at risk of acute episodes in the future,
especially following life events or periods of stress and high
44 SCHIZOPHRENIA
Management of schizophrenia
Table 1 Drugs given intramuscularly for rapid tranquillisation these symptoms. As some patients continue to hear voices
Lorazepam (benzodiazepine)
despite taking medication, helping them alter their cognitive
Less accumulation than diazepam response is a valuable treatment option. Cognitive therapists
Cardiorespiratory depression also use cognitive techniques to challenge delusions or alter
Little effect on cardiac conduction the way in which patients respond to them. Positive symptoms
Can cause disinhibition can also be reduced by identifying activities and situations
Other than sedation, effects usually acceptable which exacerbate or relieve symptoms, and modifying these
Can accentuate effects of alcohol accordingly. There is evidence that this form of therapy can
Haloperidol (conventional antipsychotic) reduce distress and improve functioning.
Little cardiorespiratory depression
Movement side effects Family treatments
Less hyopotensive effects than other antipsychotics
Carers of patients with schizophrenia tend to be family
Small risk of arrhythmias
members, most commonly parents. Because schizophrenia is
Olanzapine (atypical antipsychotic)
difficult to understand and can cause behaviour that is distress-
Few movement side effects
ing, threatening or socially embarrassing, the burden on carers
Cannot be given within 1 hour of benzodiazepine
can be immense. Education and support is clearly important
? smaller risk of arrhythmias than haloperidol
More sedating than haloperidol and carer groups, at which experiences and coping strategies
can be shared, are particularly useful.
As discussed in the previous section, symptoms of schizo-
phrenia can be exacerbated by households in which there are
' Look at him
doing the washing up. high levels of expressed emotion. This is usually reduced by
It's about time he got helping carers understand and cope with the effects of the
off his backside ' illness, using the measures outlined above. In addition, family
Anger therapy can be used to teach family members (or other
They're trying They want to Distress members of the household) to recognise and reduce expressed
to annoy me ruin my life Despair emotion.
Acceptance
It's my They're giving (but still Social treatments
friends again me advice distracted Patients with schizophrenia often neglect themselves because
from reality) of negative symptoms, or because they are distracted by posi-
tive symptoms. They may spend many years having their basic
Acceptance
I'm having Encourages needs attended to by others, either in hospital or at home, and
It's my illness development
hallucinations so may have forgotten or never have learned how to look after
of coping
strategies themselves. If they live in an understimulating environment,
then any negative symptoms will worsen, but if the environ-
Fig. 2 Examples of how cognitive response to auditory ment is overstimulating, then positive symptoms will become
hallucinations influences their consequences.
more of a problem. For all these reasons, it is essential that the
should only be done by appropriately trained staff. The aim is full range of social treatments described on pages 3437 is
to reduce distress and arousal, not to send the patient to sleep. available to patients with schizophrenia.
Following rapid tranquillisation, there is a risk of hypotension,
arrhythmias and cardiorespiratory depression, so pulse, blood
pressure and respiratory rate should be monitored regularly.
Case history 12
Continuation treatment and prophylaxis Dylan, the 20-year-old man described in the previous section, is
Once the acute episode has responded to treatment, it is
admitted to hospital and treated with olanzapine. His positive
important to continue with antipsychotic medication at normal
symptoms respond partially to this treatment but he complains of
therapeutic doses to prevent relapse. Even patients with a good
weight gain and sedation. His family is supportive, but he does not
prognosis should be advised to continue maintenance treat-
want to live with them when he leaves hospital.
ment for 1 to 2 years, before cautiously reducing and stopping
it. In patients with a poorer prognosis, and those who relapse a. Devise a management plan for Dylan.
following cessation of treatment, long-term prophylaxis is
required. In some cases it will be necessary for the patient to
continue taking antipsychotic drugs for the rest of their lives.
Antipsychotic drugs given by long-acting (depot) injections
are often used for maintenance and prophylactic treatment. The Management of schizophrenia
pros and cons of depot antipsychotics are summarised in Figure
3 on page 23. Depots can be useful in the treatment of acute n Antipsychotic drugs are an essential part of treatment and often
episodes if compliance is poor, especially if the dose required is need to be given long-term
known from previous episodes. n Cognitivetherapy has an important role in reducing distress
and improving functioning
Psychological treatment
n Family and social treatments are particularly important in
All patients with schizophrenia should be offered cognitive
behavioural therapy. Figure 2 shows how a patients response schizophrenia, especially for patients with negative symptoms
to auditory hallucinations can influence the consequences of
46 MOOD DISORDERS
Many physical and mental disorders are accompanied by Table 1 ICD10 classification of mood disorders
changes in mood. The term mood disorder, also known as Single episode
affective disorder, is reserved for conditions in which an endur- Manic episode Hypomania
ing change in mood is the predominant symptom. The mood Mania, without psychotic symptoms
state may be depression, occurring in depressive episodes, or Mania, with psychotic symptoms
elation, occurring in manic episodes. What follows is a general Depressive episode Mild
overview of the classification of mood disorders and more Moderate
detail about the clinical presentation of depressive and manic Severe, without psychotic symptoms
episodes will be given in the following chapters. Severe, with psychotic symptoms
Mixed affective episode
Bipolar affective disorder Recurrent episodes
In the most commonly used classification system of mood Bipolar affective disorder Current episode mania
disorders, depression and mania are viewed as representing Current episode depressive
polar extremes, as illustrated in Figure 1. Bipolar disorders Current episode mixed
are those in which both extremes of depression and elation Recurrent depressive disorder Current episode mild, moderate or severe
occur, usually in separate depressive and manic episodes, but (Major Depressive Disorder in DSM4)
In the past, a distinction was made between endogenous September March September March
and reactive depressive episodes. Endogenous depression was
thought to be a more severe condition that tended to occur
without precipitating factors, presented with somatic (or bio- Mania Bipolar Affective
logical) symptoms such as weight loss, early morning waking Disorder, seasonal
and diurnal variation of mood, and responded well to physical type
treatments such as drugs or ECT. In contrast, reactive depres- Depression
sion was seen as being a milder condition that occurred in
response to a specific stress and responded better to psycho-
social treatments. This categorisation of depression is not valid Mania
and the somatic syndrome can occur in depressive episodes of Major Depressive
all severities, regardless of whether there were precipitating Disorder, seasonal
factors. You should always find out whether a depressive type
Depression
episode appears to have been a reactive response to adverse
life events and other social factors, because this can have a
considerable bearing on treatment and prognosis, but diagno-
sis should be made solely on the basis of symptoms and their
severity.
Occasional non- Atypical depressive Winter depression may
seasonal episodes symptoms common be helped by daily light
Other persistent mood disorders do not invalidate (eg increased appetite, treatment, as well as
Cyclothymia is a condition in which there is a persistent insta- the diagnosis hypersomnia, severe antidepressants
bility of mood, involving numerous periods of mild depression fatigue)
and mild elation that fall short of meeting diagnostic criteria
for depressive and manic episodes. It usually develops in early
Fig. 2 Seasonal affective disorder (DSM4 classification).
adult life and tends to run a chronic course. Cyclothymia is
more common among relatives of people with bipolar affective
disorder and some affected individuals will go on to develop
mind that would enable her to earn a fortune and relieve
bipolar disorder.
famine throughout the world. This combination of symptoms
Some people experience chronic depressive symptoms of a
meeting diagnostic criteria for a manic episode with psychotic
severity that falls short of diagnostic criteria for depressive
symptoms and delusions of thought insertion should prompt
episodes. This condition is known as dysthymia and onset is
a diagnosis of schizoaffective disorder, manic type. A man
typically during adolescence or early adulthood. When the
who presents with loss of interest, severe fatigue, impaired
onset is later in life, the disorder often occurs in the aftermath
sleep and appetite and auditory hallucinations consisting of
of a depressive episode, usually associated with bereavement
several voices discussing his faults in the third person should
or other obvious stress. Depressive episodes sometimes occur
be given a diagnosis of schizoaffective disorder, depressive
in the course of dysthymia and the combination of dysthymia
type. A woman who had the bizarre delusion that she had
and recurrent depressive disorder is sometimes referred to as
become pregnant by the long deceased King George III of
double depression.
England, as a result of reading an article in The Daily Mail
newspaper, and who presented with agitation, tearfulness,
Seasonal affective disorder
marked emotional lability and a superior attitude towards
Some people experience recurrent mood disorder at particular
others would be diagnosed as having schizoaffective disorder,
times of year and in the DSM4 classification the course speci-
mixed type. Schizoaffective disorder is usually classified along-
fier of seasonal type can be added to a diagnosis of mood
side schizophrenia, but represents part of a continuum
disorder. The only well established form of seasonal affective
between non-affective and affective psychoses, hence our
disorder is winter depression, which is described in Figure 2.
mention of it here.
Schizoaffective disorder
When people present with a disturbance of mood that meets
diagnostic criteria for a manic, mixed or depressive episode, Classification of mood disorders
and at the same time have one or more of the pathognomonic
symptoms of schizophrenia (see Fig. 1 on p. 38), a diagnosis n People with bipolar affective disorder have manic episodes and
of schizoaffective disorder is made. The nature of the mood usually episodes of depression
disturbance experienced by the patient determines the type of n Recurrent depressive disorder is also known as unipolar mood
schizoaffective disorder diagnosed. For example, a woman
disorder
might present with elated mood, increased energy, reduced
sleep and the belief that ideas were being inserted into her
48 MOOD DISORDERS
Epidemiology
Bipolar disorder is much less common than unipolar depres-
Baby Predisposing factors
sive disorder, with a lifetime risk of around 1%. Women and
men are at equal risk of developing bipolar disorder type I, but
women are over-represented among type II cases. While some Genetic factors
people are particularly creative and capable of high levels of Infant/child Physical or sexual abuse
achievement during periods of elevated mood, in general 'Vulnerability factors' described
bipolar disorder is associated with high levels of functional in working class women
impairment and is more common among people with low Adult 3 or more children under 14 years
household incomes. Relatives of people with bipolar disorder no work outside the home
are more likely to be high achievers than those of people with no confiding relationship
unipolar depression. Cardiovascular disease
lessly and wake during the night. people. Many patients lose their sex
Another form of sleep disturbance is drive when depressed.
early morning waking, defined as waking Loss of concentration is common Depressive disorder
at least two hours earlier than usual and and can be distressing. An inability to
A depressive episode is characterised by:
then not being able to return to sleep. concentrate can lead to forgetfulness
n depressed mood, anhedonia and
These different forms of sleep distur- and older people sometimes present
bance often coexist. Change of appetite with depressive pseudodementia, in fatigue
is also a common feature of depressive which an apparent memory loss leads n thepatient thinking negatively about
disorders. Some patients lose their appe- to misfounded concerns that they are themselves and their future
tite and consequently lose weight; others developing dementia. People with pseu- n altered biological functions
have an increased appetite, and describe dodementia are usually worried about
n duration of at least two weeks
comfort eating, which may be accompa- their cognitive function. They will tend
nied by weight gain. Constipation can to avoid testing of cognition because
occur in depression, particularly in older they believe they will not be able to give
54 MOOD DISORDERS
ning in early adulthood. It tends to be a chronic disorder that them, will be involved in an accident or become unwell. GAD
fluctuates in severity. occurs in about 2% of the population and is more common in
women than men, with onset usually in early adult life.
Social phobia
In social phobia, anxiety is provoked by social situations in
which one feels on display in some way, such as meeting new
Aetiology
Twin studies have shown that genetic factors play a small but
people or speaking in social groups or during meetings at
significant role in predisposing individuals to anxiety disor-
work. The impact of the phobia depends upon the job and
ders, particularly panic disorder. Environmental stress, such
lifestyle of the individual. For example, a teacher who is unable
as adverse life events or chronic social problems, is
to speak in public will be severely disabled, whereas a farmer
the most important aetiological factor and may precipitate
may not be greatly affected. Unlike the other phobias it occurs
episodes of anxiety disorder, and perpetuate them once estab-
as frequently in men as women and usually begins in child-
lished. Psychological theories of anxiety disorders suggest they
hood or early adult life. Alcohol is often used by people with
may arise as a result of learned behaviour, or cognitive pro-
social phobia to reduce the anxiety they develop in social set-
cesses. These theories and the treatments that have been
tings and this can become a problem in itself.
developed from them are described on the following pages.
Specific phobia
In specific phobias, anxiety is aroused by a particular object.
The object can be virtually anything, although thunderstorms Mixed depression and anxiety
and animals are most often implicated. This is the commonest, There is considerable overlap between depressive disorders
and generally the least serious or disabling of the phobic and anxiety disorders. People who have had an episode of one
anxiety disorders. However, the degree of disability depends condition have a raised risk of developing the other sometime
upon the ease with which the phobic object can be avoided. in the future. During episodes, symptoms of anxiety are
common in depressive disorder and vice versa. Sometimes, it
Panic disorder will be obvious which is the more severe or primary condition
Panic disorder is characterised by recurrent panic attacks. The but if both sets of symptoms seem equally important and
diagnosis is made if several panic attacks occur within a period diagnostic criteria for a depressive episode and anxiety disor-
of one month, but it is not uncommon for people to experience der are met at the same time, then both conditions should be
several attacks each day. Anxiety is less severe between attacks diagnosed and treatment should address both sets of symp-
and in many cases resolves completely. Some people develop a toms. Many patients, particularly in primary care, have symp-
persistent fear of having further panic attacks. Unlike the panic toms of both depression and anxiety without meeting full
attacks that can occur in phobic anxiety disorders, they are not diagnostic criteria for either. In these cases mixed anxiety and
predictable or a response to a particular stressor. Panic disorder depressive disorder is diagnosed.
occurs in about 0.8% of the population and is slightly more
common in women than men. It is most likely to begin in early
adulthood.
Case history 18
Generalised anxiety disorder
In generalised anxiety disorder (GAD), symptoms of anxiety Anton is a 36-year-old business man who presents as an
are present most of the time over a period of at least two weeks, emergency to Casualty complaining of shortness of breath and
and often considerably longer. There does not seem to be a chest pain. He has no previous medical or psychiatric history of
direct cause for the anxiety, which is often as severe when the note. He is accompanied by work colleagues who report that he
patient is at home as when they are out. The focus of the collapsed just before an important presentation that he had been
anxiety is variable, moving from one topic to another, but the preparing for over several weeks.
affected person will often worry that they, or someone close to a. What questions would you ask in order to establish whether
Antons symptoms are due to anxiety?
b. If anxiety is the principal cause of his symptoms, what is the
most likely diagnosis?
Anxiety disorders
n Anxiety is a normal reaction to stress
n Anxiety is abnormal if it is excessive, severe or prolonged, or
Performance
Obsessivecompulsive disorder
with the patient. Many patients will require a combination of rituals often fear that something dreadful will happen if
all three. they dont follow their compulsive urge and such thoughts
can be challenged using cognitive techniques. Similarly,
Drug treatment patients can learn to question the obsessional doubt that
Antidepressants which act on serotonin, such as SSRIs and the causes their compulsion to engage in checking rituals.
tricyclic clomipramine, are effective in some cases, even if there
is no depression present. High doses are often needed and the Social treatment
therapeutic effect can take up to 12 weeks to develop. The OCD can be a chronic and very disabling condition that can
combination of antidepressants and psychological treatment result in social isolation, unemployment and financial prob-
is the most effective. lems. The urge to carry out rituals can lead to self-neglect and
the persons accommodation can become run down. Certain
Psychological treatment compulsions can cause damage, for example washing rituals
All patients with OCD should be offered cognitive behavioural can result in bathroom floors becoming damp and starting to
therapy (CBT). Treatment sessions usually take place in clinic rot. All these issues may need addressing. A persons rituals
settings, but can involve going into patients homes and are can come to dominate their home and family members can
sometimes supported by co-therapists, who could be a nurse sometimes go along with the compulsive behaviours, rather
or a member of the patients family. Inpatient treatment in than add to the persons anxiety. It is therefore important to
specialist units is sometimes needed for severe cases. CBT will provide support and education to families of people with
usually involve the following components: OCD.
n Exposure and response prevention (ERP). This
Course and prognosis
technique is used in the prevention of rituals. The patient
OCD tends to be a chronic illness, with fluctuations in severity.
is exposed to an anxiety inducing situation and prevented
If treatment is effective it is important to consider the long-
from acting on the compulsive urge with the support of
term prevention of relapse. Education of the patient and their
the therapist. For example, someone with an obsessional
family about the disorder, and identification of the early signs
fear of contamination might be asked to touch a door
of relapse with rapid reintroduction of treatment is helpful.
handle and then resist the urge to wash their hands. The
principles underlying this treatment are similar to those
described for the treatment of phobic disorders on pages
5859. ERP is the treatment for OCD with the strongest
evidence base. Case history 20
n Cognitive techniques. It is not usually the obsessional
Mary is a 42-year-old single woman who lives with her mother and
thought itself that is most problematic for the sufferer, but
works as an accountant. For most of her adult life she has been
the anxiety and negative thoughts evoked. A patient who
preoccupied by thoughts about dirt. She worries that things may
had recurrent thoughts about killing their child would
be contaminated and has developed elaborate rituals to avoid
find these repugnant and highly distressing. They might
contact with anything others may have touched. She washes her
think of themselves as a terrible person and be frightened
hands 5060 times a day. She works alone in an office, and
of acting on the thoughts. A cognitive approach would
generally can limit her rituals to home, but at times her symptoms
help them realise that the thought is merely a product of
become worse and she is unable to touch paperwork that has
an illness, OCD, and is harmless. People with obsessional
been handled by other people.
a. What is Marys differential diagnosis?
b. Devise a treatment plan considering drug, psychological and
social treatments.
Always think of:
depressive disorder
schizophrenia
Obsessivecompulsive disorder
Less commonly: n Obsessions are repeated unpleasant thoughts that persist
Tourettes despite attempts to resist them
dementia
n Compulsions are irresistible urges to repeatedly perform an
epilepsy
head injury action or ritual
n Depressive disorder is common in patients with OCD
Reactions to stress
Traumatic event
Anger Searching Guilt Sadness
'Why did he for his face in a 'If only I had With many of
leave me crowd, and vivid called the the features
Anxiety Avoidance behaviour when I dreams that he is doctor earlier' of depression
autonomic arousal avoids reminders need him' alive again
insomnia of trauma
irritability loss of interest in
poor concentration normal activities
exaggerated startle detachment from family
response and friends Acceptance
Fig. 2 Symptoms of PTSD. Gradual return to normal life
Fig. 3 Normal grief.
Management
Dissociative disorder must always be a positive diagnosis, Dissociative disorders usually remit within a few weeks,
based upon a history that provides some reasonable psycho- particularly if their onset was associated with a traumatic
logical explanation of how and why the problem developed. event. Chronic forms are less common and tend to be associ-
The patient may deny recent stressful events and problems or ated with insoluble problems and interpersonal difficulties.
disturbed relationships, so it is important to seek information
from others. Great care must be taken to exclude organic Somatoform disorders
pathology and it should be remembered that follow-up studies Somatoform disorders present with physical symptoms that
of people diagnosed with dissociative disorders have found have no physical cause and do not have the abrupt onset associ-
that many turned out to have an underlying physical condi- ated with dissociative disorders. The sufferer repeatedly seeks
tion. Catatonic schizophrenia and severe depressive episodes medical treatment or investigations, even when these have
should be considered in cases of stupor. Two further differen- consistently failed to be of benefit to them. ICD10 describes
tial diagnoses are factitious disorder, also known as Munchau- several different types.
sens syndrome, and malingering, the major features of which Somatisation disorder is a condition in which the patient
are shown in Figure 2. presents recurrent, frequently changing physical symptoms
Treatment for dissociative disorder is psychological and that cannot be explained by organic pathology. Symptoms may
social. Stressful events and problems should be gently explored involve any part of the body, but most often are gastrointestinal
and discussed. Practical sources of distress and interpersonal (pain, nausea, vomiting), and abnormal skin sensations
problems should be addressed. Sources of secondary gain (burning, itching, tingling). Consultations with doctors tend to
should be reduced as much as possible. focus on the patients demands that some treatment be found
Dissociative and somatoform disorders 65
Liaison psychiatry
Very few disorders can be considered to psychiatry team in a general hospital psychiatric emergencies only. The inte-
wholly affect the body but not the mind, would usually include a psychiatrist, a grated liaison model of service, where it
and vice versa. The majority of psychiat- psychologist, psychiatric nurses and exists, is usually focused on specific
ric disorders have some impact upon the social workers, and sometimes other areas where psychiatric morbidity is
patients physical wellbeing. For example, mental health professionals. They highest and has most impact on the
depression can result in weight loss, con- provide input to patients in the hospital management of the physical illness.
stipation and tiredness, in addition to in two ways: This may include pain clinics,
having an impact on the individuals n consultation,
oncology wards, paediatric and geriatric
in which patients are
ability to cope with any existing physical departments.
assessed by members of the liaison
illness. Pain from arthritis is often worse
psychiatrist at the request of the
during a depressive episode. Similarly,
physician or surgeon caring for them
Psychological causes of
physical disorders will often affect n liaison, in which members of the
physical illness
the emotional state of the patient. There is good evidence that stress plays
liaison psychiatry team have a
Feelings of anxiety, depressed mood, an important role in the aetiology of
broader role and become integrated
anger and frustration are common many physical disorders. For example,
into the work of their general
accompaniments to physical illness. studies have demonstrated an increase
hospital colleagues. They may attend
They will impact upon the recovery in stressful life events in the weeks
ward rounds or take part in
process (Fig. 1), and mental illness may prior to myocardial infarction, acute
assessment or follow-up of patients
be precipitated. abdominal pain and acute subarachnoid
attending outpatient clinics. This
High rates of mental illness have been haemorrhage.
approach is time-consuming but
found in general hospitals, even when Mental illness is also associated with
improves joint working between
those patients being treated for overdose increased morbidity and mortality from
general hospital and mental health
and other forms of deliberate self harm a wide range of physical disorders. This
staff. It also reduces the stigma of a
are excluded from the figures. Up to 60% continues to be true even when disor-
psychiatric referral, which can be a
of medical inpatients have a mental dis- ders directly associated with the mental
problem with the consultation
order, and up to half of all medical illness are not included in the figures,
model, particularly for patients with
outpatients. A quarter of male medical such as deliberate self harm and the
conditions such as somatisation
inpatients have problems associated effects of alcohol abuse. This is likely to
disorder, in which psychological
with alcohol abuse. The reasons for be due to a combination of factors,
explanations for symptoms are
these high rates are illustrated in including the effects of stress, increased
actively resisted.
Figure 2. tendency to smoke and take illicit drugs,
The consultation model of service is harmful effects of prescribed drugs and
Liaison psychiatry the most widely practised, and at the failure to seek medical help.
Liaison psychiatry is a sub-specialty of most basic level psychiatrists may Mental illness may present with physi-
psychiatry in which a service is offered provide consultations for patients admit- cal symptoms, thereby obscuring the
to patients of a general hospital. A liaison ted following deliberate self harm and primary diagnosis, and in some cases
1. Coincidental occurrence
Stress
Drug/alchohol abuse
Previous psychiatric Social problems Deliberate self harm
history/ personality Accidents (due to
disorder impulse control, concentration, medication)
Experience pain Motivation Psychotropic medication side-effects
Anxiety / Depression
resulting in unnecessary and potentially result of withdrawal, with most often adjustment disorders or
harmful investigations and treatment. convulsions and acute confusional depression. They are more likely to
For example: states. All patients, whether they are occur in patients with a personal or
seen in medical, surgical or family history of mental illness, person-
n Depressive disorder may present
psychiatric settings, should be asked ality disorder or chronic social problems.
with biological symptoms including
about alcohol consumption. Factors such as previous negative experi-
sleep disturbance, loss of energy and n Dissociative disorders present ence of illness, lack of social support,
lethargy, sexual dysfunction, loss of
with physical signs that have no compensation claims or other forms of
appetite and weight loss and loss of
organic cause, but instead are due to litigation can have a significant impact
concentration with apparent memory
psychological factors of which the on the patients ability to cope with their
loss resulting in a misdiagnosis of
patient has no conscious awareness illness, and their emotional response.
dementia (known as
(see p. 64). The majority of emotional reactions to
pseudodementia). n Somatoform disorders present illness can be managed without referral
n Anxiety disorders frequently
with physical symptoms that have no to a psychiatrist. Good communication
present with predominantly physical
organic cause. People with the between staff and patient is essential.
symptoms. They include sweating,
condition often end up being seen in Anxieties often respond to open discus-
palpitations, tremor, urinary
specialist clinics, in the hope that an sion about the illness, investigations,
frequency, diarrhoea,
underlying physical illness will be treatment and prognosis. Patients and
hyperventilation, muscular pain, dry
found and some will end up being their carers need to have information
mouth, muscle tension, restlessness,
admitted to general hospitals because presented in a meaningful way, and an
dizziness, syncope, chest pain, chest
of their demands that something be opportunity to ask questions and talk
tightness, shortness of breath,
done about their symptoms. They about their worries.
paraesthesia and headache. Anxiety
are very difficult to engage in Some physical illnesses can present
symptoms may occur in other
treatment, because they are with psychological symptoms, and cause
mental illnesses such as depression,
convinced there is a physical cause of diagnostic difficulties (see Table 1).
schizophrenia and obsessive
their problems, and liaison
compulsive disorder.
psychiatry teams develop expertise in
n Eating disorders may present with
their management.
weight loss and its consequences, n Factitious disorder
which include bradycardia, Table 1 Physical illness may present with
(Munchausens syndrome) is a
hypotension, constipation, psychological symptoms
condition in which the person
amenorrhoea, muscle weakness, Symptom Physical disorder
manufactures symptoms and
peripheral oedema, osteoporosis and Depressed mood Drugs
sometimes signs of physical illness,
fractures (p. 76). Carcinoma
so that they are admitted to hospital.
n Dependence on alcohol can have Infections
Their underlying problem is a need
an impact on virtually any body Neurological disorders
to be cared for and many have Diabetes
system. Effects on the cardiovascular
emotionally unstable personality Thyroid disorders
system include hypertension and
disorder, borderline type. Cushing disease
atrial fibrillation. The gastrointestinal
Anxiety Hyperthyroidism
system is often profoundly affected,
Hyperventilation
with increased risk of carcinomas of Psychological consequences Phaeochromocytoma
the gastrointestinal tract, gastritis, of physical illness Hypoglycaemia
pancreatitis, nutritional deficiencies Almost all physical illnesses evoke some Drug withdrawal
and hepatic disorders including form of psychological reaction, but in Disturbed behaviour Epilepsy
cirrhosis, cancer and hepatitis. most cases this is not distressing, and has Hypoglycaemia
Infertility, impotence and loss of minimal impact on the patients life. Toxic states
secondary sexual characteristics are More severe reactions usually manifest
common. Alcoholics are prone to themselves as depressive symptoms,
accidents, including those involving anxiety or anger, and in most cases are
road traffic. Problems also arise as a transient. Mental illness may occur,
Liaison psychiatry
The majority of people who are diag- drinkers can be achieved by the GP rou- exacerbation of an existing physical
nosed with a mental illness have no tinely asking about alcohol consump- illness. Pain, discomfort and disability
contact with the psychiatric services; tion and giving appropriate advice. may be more difficult to bear when
instead they are treated by their general depressed. In these circumstances it is
practitioner (GP) and other members of up to the doctor to be alert to any indica-
the primary healthcare team. The most Recognising mental illness tions of emotional distress demonstrated
common mental illnesses treated by GPs in primary care during the consultation (see Fig. 2), and
are depressive disorder, generalised Only half of the patients presenting with to ask direct questions about psychologi-
anxiety disorder and mixed depression the most common conditions found in cal symptoms, for example:
and anxiety. Many more patients have primary care, depression and anxiety,
are recognised as mentally ill by their n You seem tense (angry, unhappy,
emotional problems, such as low mood,
GP. The reasons and some possible ways worried ), can you tell me about
and worries that do not amount to a
of addressing them are summarised in that?
mental illness. Many will also have a
Figure 1. In part this is because patients n How have you been feeling in
coexisting physical illness and will not
frequently present with physical rather yourself recently?
complain directly about their psycho-
than psychological complaints. Patients n Have you been worried about
logical symptoms. Recognising mental
come to psychiatric outpatient clinics anything in particular?
illness in these circumstances poses a
special challenge and is described in expecting to talk about their feelings,
Some doctors are more sensitive to
more detail below. and will often have had an opportunity
patients emotions and are more com-
to think about their emotional state in
fortable talking about feelings than
preparation for this. The expectations of
others. It has been shown that the doc-
a GP consultation are quite different.
Psychiatric disorders in Patients often believe that the doctor will
tors behaviour has a great effect on the
primary care be interested in physical symptoms only
likelihood of a patient revealing any feel-
ings of distress. Patients disclose more to
Mood disorders and may not consider their emotions to
doctors who:
Depressive disorder is the most common be relevant to any diagnosis, and so omit
psychiatric disorder treated in primary to mention them. Instead, the complaint n appear to be unhurried, with time to
care and is present in about 10% of all may be of the biological symptoms of talk about problems
GP attenders, with a further 10% having depression (insomnia, anorexia, weight n make eye contact as the patient
depressive symptoms. In comparison loss) or health concerns due to hypo- enters the room and maintain
with depressed patients seen by psychi- chondriacal preoccupations, or of an regular eye contact
atric services those in primary care tend
to be less severely ill and have more
anxiety symptoms. The presentation is
often with physical symptoms rather Use screening questionnaires
than depressed mood. The treatment Book double slots
should be with antidepressant drugs in Book follow-up appointment
to ensure continuity
moderate or severe cases. Mild cases will
often resolve with support and help to
address social problems. Psychological
treatments that are known to be effective Consultation
in depression, such as cognitive therapy, lack of time
are rarely available in primary care. The lack of continuity
effectiveness of non-specific counsel- of care
ling in depression is not known. GPs can
expect one of their patients to commit
suicide every 4 years. Up to 40% of
patients who die by suicide have seen
their GP in the month before death, and
half of these in the week before death.
Anxiety disorders
Patient Doctor
There is a great overlap between depres- presentation with lack of appropriate
sion and anxiety disorders in primary somatic symptoms interview skills
care, and patients presenting with concern about stigma personality traits
anxiety symptoms should be asked authoritarian, lacking empathy
about mood symptoms. Many cases are
mild and will respond to advice, reassur-
ance and support. Public health education
Information leaflets Postgraduate education
Guidelines for management
Alcohol abuse of depression
There is evidence that patients act on Liaison with mental health
advice from their GP to reduce their services
alcohol consumption, and reductions of
up to 20% of the number of problem Fig. 1 Reasons and potential solutions for non-recognition of mental illness in primary care.
Psychiatry in primary care 69
Non-Verbal
Agitated
Tense Patient fails to respond to Patient has manic
Reduced movement a six-week course of drug depressive
Slumped posture therapy (first check (bipolar) disorder
Little eye contact compliance and dose)
n talkless and listen more scription. Compliance with these drugs anxiety disorders and alcohol abuse
n ask open questions about is known to be very poor in primary care. should be a part of this work. They may
psychological and social issues Up to two-thirds of patients will no also monitor patient compliance and
n demonstrate empathy longer be taking the tablets one month progress with drug treatment. Health
n notice and comment on verbal and after the initial prescription. visitors are ideally placed to detect post-
non-verbal signs of distress. Many psychological treatments for natal depression, and district nurses
mental illness are now provided by prac- work with the elderly and chronically
Time constraints are a great problem titioners working in primary care. The physically ill and disabled patients, who
in primary care. Consultations last 510 stepped care of depression, described on also have an increased risk of depressive
minutes on average, and it is difficult pages 5455, is an example of this. The illness.
to manage an unhurried, open and practitioners who provide psychological
empathic interview in this time. Patients treatments for depression in primary Referral to secondary mental
with mental illness are likely to need care also work with people with anxiety health services
longer than average consultations, and it disorders, OCD, PTSD and adjustment There is an increasing trend towards
is often helpful to book them into a disorders. secondary mental health services moving
double slot to avoid holding everyone Other members of the primary health- out to the community and in some cases
else up. Assessments may also be done care team have important roles in the locating outpatient clinics in primary
over several visits, and this may be sup- detection and treatment of mental care surgeries. Community psychiatric
plemented with information leaflets for illness. Practice nurses are often actively nurses may also use the surgeries as a
patients to read between visits that will involved in health promotion, screening base. There are therefore increasing
provide a useful focus for discussion of new patients and the elderly for early opportunities for face to face liaison
symptoms at later consultations. signs of preventable or treatable condi- between psychiatrists, CPNs and GPs.
tions, and providing information and The common reasons for referral to psy-
Management of mental illness advice. Screening for depressive illness, chiatric services are shown in Figure 3.
in primary care
The GPs role in the management of
mental illness includes assessment, diag- Case history 24
nosis and development of a manage-
ment plan with the patient. Some Jane is a 26-year-old single mother of two children aged 3 years and 6 months. The
patients are reluctant to accept a diagno- childrens father left her before the birth of the baby and has had no contact with them and
sis of mental illness, and it is worth provided no financial support. Jane attends her GP very frequently, usually with concerns
spending some time with them to about the childrens health and complaints that she feels run down and tired all the time.
explain the reasons for making the diag- Her GP thinks she has postnatal depression.
nosis and the opportunities for treat- a. How should the GP manage her depression?
ment. Information leaflets and videotapes b. Which other members of the primary healthcare team may have a role in managing
are often useful in reinforcing this Janes problems?
message. It is important to avoid the situ-
ation where a patient who talks about
worries feels he has not been heard and
simply sent away with a prescription of Psychiatry in primary care
antidepressants. The patient may not
realise that the doctor has recognised n 90% of patients diagnosed with mental illness are managed exclusively in primary care
evidence of an illness that if treated may n 20% of all patients consulting in primary care are depressed
allow him to cope more effectively with
n About half of these patients are not recognised as mentally ill by their GP
the problem. The prescription is likely to
be thrown away in these circumstances. n The commonest disorders are depressive disorder, generalised anxiety disorder and
Patients with depressive disorder and alcohol abuse
generalised anxiety disorder are likely to
benefit from antidepressant drug pre-
70 PSYCHIATRY AND MEDICINE
thing at a time. Persecutory ideas may develop, often as a merly known as Korsakoff s syndrome. When caused by thia-
consequence of poor memory and disorientation. mine deficiency, the syndrome is usually preceded by a form
n Abstract thinking and judgement are impaired, leaving of delirium known as Wernickes encephalopathy; if treatment
the person unable to deal with problems or unfamiliar with parenteral thiamine is given at this point, the develop-
situations. ment of amnesic syndrome may be prevented. The pathology
n Personality changes are common, often involving a of Wernickes encephalopathy and amnesic syndrome caused
coarsening of pre-existing personality traits. by thiamine deficiency is similar, with small haemorrhagic
n Social behaviour deteriorates, often becoming shallow lesions in the mamillary bodies, thalamic nuclei and the floor
or inappropriate. of the third ventricle. Other conditions that cause localised
n Mood changes are common with depression, irritability lesions in this part of the brain can also present with amnesic
and anxiety all occurring in some cases. syndrome, as summarised in Figure 1.
For a diagnosis of dementia to be made with certainty, there
Other syndromes caused by focal brain damage
must be evidence of deficits in several of these areas. Once the
Common signs of damage to the frontal, parietal, temporal
diagnosis is made, it is important to try to establish the cause
and occipital lobes are shown in Figure 2.
of the dementia as this will influence treatment and prognosis.
As with delirium, dementia is a syndrome with a variety of
causes, as shown in Table 3. The three commonest causes
(Alzheimers disease, vascular dementia and Lewy body
Thiamine deficiency Encephalitis (eg HIV, TB)
dementia) are discussed on page 90. Less common neurologi- Alcohol dependence Carbon monoxide poisoning
cal causes of dementia are described on pages 7273. Severe malnutrition Space occupying lesion in and
Severe vomiting around floor of third ventricle
Syndromes caused by focal brain damage
Amnesic syndrome
Amnesic syndrome is a disorder of memory in which other
aspects of cognitive function remain relatively unaffected. This
distinguishes it from dementia, in which there is a global Wernickes encephalopathy Amnesic syndrome
impairment of cognitive function. Patients with amnesic syn- Delirium Impaired recent memory
drome have normal instant recall but cannot learn new infor- Ataxia Relative sparing of other
Ophthalmoplegia cognitive functions
mation and have marked impairment of 5 minute recall. There
is poor memory of recent and past events, with memory for
Fig. 1 Wernickes encephalopathy and amnesic syndrome.
more recent events being worse than distant memory. Social
skills and other aspects of cognitive function are relatively well
preserved. Confabulation, in which the patient makes up plau-
sible answers to questions, is sometimes said to be a specific Personality change Object agnosia
feature of amnesic syndrome but also occurs in delirium and (disinhibition, impaired Disturbance of
other forms of memory loss. judgement, euphoria) Pari body image
In developed countries, amnesic syndrome is most com- e t a Dyspraxia
al l
monly caused by the thiamine deficiency associated with Spatial
nt
Fro
alcohol dependence and this variant of the condition was for- disorientation
Occ
ipital
Table 3 Causes of dementia
Neurological Systemic
Degenerative Endocrine
l
Dysphasias pora
Tem
Alzheimers disease Hypothyroidism
Lewy body dementia Cushings disease Amnesic syndrome Blindness
Parkinsons disease Hypopituitarism Temporal lobe epilepsy Visual
Huntingtons disease Metabolic ( disturbance of mood and behaviour) agnosias
Picks disease Anaemia Fig. 2 Common signs of damage to the frontal, parietal, temporal
Normal pressure hydrocephalus Hypoxia and occipital lobes.
Vascular Renal failure
Vascular dementia (sudden onset suggests arteritis or Liver failure
carotid artery occlusion) Deficiency of vitamin B
Vitamins and folate Carcinomatosis Syndromes of cognitive impairment
Infections Toxic
CreutzfeldtJakob disease Chronic alcohol abuse n In delirium there is a fluctuating level of consciousness and
Neurosyphilis Heavy metal poisoning attention, with global impairment of cognitive function
HIV Other
n Dementia is a global impairment of intellect, memory and
Cerebral abscess SLE
Space-occupying lesion n Sarcoidosis personality, occurring in clear consciousness
Tumour n Amnesic syndrome is usually due to thiamine deficiency and is
Subdural haematoma characterised by an inability to learn new information
Traumatic
Severe or repeated head injury
72 PSYCHIATRY AND MEDICINE
Raised risk of depressive Biological, psychological and Table 1 CNS infections and psychiatric symptoms
or anxiety disorders but social effects of epilepsy can
no greater than in other lead to abnormal personality HIV n See text
chronic illnesses development Syphilis n Presents 525 years after primary infection
Raised risk of schizophrenia- n May present with mood symptoms (depressive or manic)
like illness in temporal n Progresses to dementia
lobe epilepsy
n ArgyllRobertson pupils in 50% of cases
Inter-ictal Tuberculous n Typical signs of meningitis late to develop
meningitis n May be preceded by apathy, irritability and personality change
Prodromal irritability Automatic n Tuberculosis increasingly common among homeless people
and dysphoria may behaviour
occur and can last
Pre-ictal Post-ictal Encephalitis n May present with delirium or, very rarely, with cognitive
Delirium
from minutes to days Psychosis impairment in clear consciousness or psychosis
n Medium- to long-term complications of infection include
HIV disease and other infections course in some cases. Depression and the epigastrium) which are
Mild cognitive impairment is common anxiety are also common and mania and sometimes called an aura. Impaired
in HIV infection. Typical symptoms schizophrenia-like illnesses are more consciousness and a variety of partial
include apathy, reduced spontaneity, likely than in the general population. seizures then develop.
mental slowness, poor concentration Social and family treatments are often
Epilepsy can present to psychiatrists in
and forgetfulness. Dementia is an required for patients with psychiatric
a number of different ways, as shown in
uncommon complication and can occur complications of head injury. Behav-
Figure 2. The diagnosis is usually sug-
in patients with or without AIDS. A rare ioural and cognitive therapy may be
gested by the history and if it is sus-
presentation of HIV infection is with useful for symptoms of personality
pected, an EEG should be performed.
affective or psychotic symptoms. It is change such as apathy or aggression.
Treatment depends on the relationship
important to distinguish this from the Anticonvulsants are needed in patients
of the psychiatric disturbance to the
depressive and anxiety symptoms which who develop seizures and are sometimes
seizures:
commonly occur in patients being tested helpful in reducing aggression. Standard
for HIV infection. treatments for psychiatric symptoms n Pre-ictal, ictal and post-ictal
Infections of the central nervous should be used. disorders are a direct consequence
system which may present with cogni- of seizure activity and so
tive impairment and psychiatric symp- Epilepsy anticonvulsant treatment should be
toms are summarised in Table 1. They There are four types of epilepsy that are reviewed in an attempt to reduce
are all uncommon but are worth keeping likely to present to psychiatrists: further seizure activity. If acute
in mind as potentially treatable causes of control of symptoms is required,
cognitive impairment and psychiatric n Absence seizures are characterised benzodiazepines should be used.
symptoms. by sudden loss of consciousness, Antipsychotic drugs lower seizure
making the patient seem threshold and so they should only be
Brain tumours unresponsive to others. Automatisms used to control severe behavioural
Brain tumours commonly cause cogni- may occur and there is a sudden disturbance, and then only in
tive impairment and psychiatric symp- recovery with no post-ictal phase. combination with benzodiazepines.
toms, but neurological symptoms are Absence seizures usually last only a n Inter-ictal psychiatric problems
usually the most prominent feature. few seconds but absence status may are not caused by seizure activity, so
Delirium may be an early feature of be confused with mental illness, standard psychiatric treatments
fast-growing tumours. Slow-growing especially dissociative fugue. should be used. If medication is
tumours, especially of the frontal lobes, n Generalised motor seizures can required, it is important to
may rarely present with personality feature psychiatric symptoms in the remember that some antidepressants,
change and cognitive impairment before post-ictal phase. especially tricyclics, and
the onset of neurological signs. Psychiat- n Simple partial seizures consist of antipsychotics lower seizure
ric symptoms alone, such as depression involuntary movements or abnormal threshold. There are also many
or psychosis, are an even rarer form of sensory experiences that occur in interactions between psychiatric
presentation. clear consciousness. drugs and anticonvulsants. It is
n Complex partial seizures are the important to ensure that patients
Head injury form of epilepsy most commonly receive good care for their epilepsy
Delirium often occurs following head associated with the ictal phenomena as poor seizure control is likely to
injury. The risk of long-term psychiatric listed in Figure 2. Therefore, they exacerbate any psychiatric problems.
consequences is closely related to the constitute the form of epilepsy most
duration of post-traumatic amnesia, likely to be misdiagnosed as a
Neurology and psychiatry
which is the time taken to regain the psychiatric disorder. Temporal lobe
ability to learn new information follow- epilepsy is the most common type of n Psychiatric
symptoms are common in
ing the injury. Cognitive impairment is complex partial seizure but seizure some neurological illnesses
common and any of the features of activity can arise anywhere in the
n Psychiatricsymptoms can occur
dementia described on page 70 may brain. Complex partial seizures are
alone, but usually neurological
occur, depending on the extent and loca- often preceded by a simple partial
symptoms are also present
tion of brain damage. Cognitive function seizure (most commonly a churning
improves gradually but runs a chronic sensation spreading upwards from
74 PSYCHIATRY AND MEDICINE
ance and brisk deep tendon reflexes, in Depression Most dementias Hypothyroidism Anaemia Corticosteroids
which case hyperthyroidism should be (especially vascular Cushings syndrome Infections Beta-blockers
considered. An unusual description of and Huntingtons)
symptoms might also suggest a medical Parkinsons disease Addisons disease Carcinomatosis Calcium channel blockers
cause. For instance, if their anxiety was Multiple sclerosis Hypopituitarism SLE Anticonvulsants
mild and seemed to be secondary to Neurosyphilis Hyperparathyroidism Acute porphyria L-dopa
their breathlessness, a cardiac or respira- Oral contraceptive pill
tory cause should be considered. An Elation Multiple sclerosis Cushings syndrome Corticosteroids
unusual presentation should also lead Neurosyphilis Antidepressants
you to suspect a medical cause. For Anxiety Hyperthyroidism SSRI antidepressants
instance, first onset of panic disorder
Hypoglycaemia
would be very unusual in a 50-year-old
Phaeochromocytoma
man with no previous psychiatric history
Psychosis Huntingtons disease SLE Corticosteroids
and no recent stresses or adverse life
Multiple sclerosis Acute porphyria Beta-blockers
events. With such a presentation, organic
Space occupying L-dopa
causes should be investigated fully.
lesion
Recognition of medical disorders pre-
CNS infections Sympathomimetics
senting with psychiatric symptoms is
Organic causes of psychiatric symptoms 75
vious job, raising the risk of depression. Table 2 Organic conditions exacerbated
A stomach ulcer in a patient whose Case history 25 by psychotropic drugs
father died of gastric cancer might leave A 45-year-old woman with multiple Drugs with antimuscarinic effects (tricyclic and MAOI
him terrified of suffering a similar fate, sclerosis is admitted to a neurological antidepressants, some antipsychotics)
with consequent panic attacks. ward following an acute relapse. During n cardiovascular disease
Once a psychiatric illness has devel- this admission, she is referred to a liaison n glaucoma
oped, it can often exacerbate symptoms psychiatrist after developing symptoms of
n constipation
and what can be done to help them, Organic and psychiatric illness are both
paying particular attention to any spe- common and so it is not surprising that
cific fears the patient may have. Practical they often occur together by chance. Psychiatric side effects
advice about how they can cope with the When they do occur together, each can of medication
consequences of the illness is also useful. make the other worse, as described Drugs which cause psychiatric side
Involving patients families in this above. The physical and psychiatric con- effects are shown in Table 1. If such side
process will clarify the support they need ditions should be treated separately in effects occur, the dose should be reduced
to give the patient and allow them to the usual way, bearing in mind the or an alternative drug should be used.
voice any concerns of their own. All this medical side effects of psychiatric drugs, Occasionally, the risks of doing this out-
is best carried out by members of the the psychiatric side effects of drugs used weigh the benefits and in such cases the
medical team dealing with the patient to treat organic illness, and the risk of psychiatric symptoms may require sepa-
and some specialist services, such as drug interactions. rate treatment.
breast clinics or diabetic clinics, have des-
ignated members of staff to do this.
In addition to these general measures,
specific treatments for the psychiatric
disorder will be required in some cases.
Standard treatments should be used,
provided they are not contraindicated by Organic causes of psychiatric symptoms
the medical illness. This is most likely to
be the case for drug treatments and a list n Psychiatric symptoms are a direct consequence of some organic diseases
of medical conditions which can be exac- n Organic disease can have an enormous impact on patients lives and so may precipitate
erbated by psychiatric drugs is given in functional psychiatric illness
Table 2. It is also important to be aware
n Psychotropic drugs should be prescribed cautiously in patients with organic illness,
of the potential for drug interactions in
because of side effects and interactions
patients receiving treatment for physical
and psychiatric illness.
76 PSYCHIATRY AND MEDICINE
Eating disorders
Anorexia nervosa was first described by items such as biscuits, cakes and bread. Western society has developed a
William Gull in 1868 and is character- They often take place in secret, and away stereotyped view of physical
ised by deliberate and extreme weight from meal times. Some bulimics will eat attractiveness which equates thin
loss. In bulimia nervosa, episodes of normally at other times, although calo- with beautiful, and promotes
overeating are followed by self-induced rie-controlled diets are common. A small negative attitudes about obesity. The
purging, usually in the form of vomiting. number also have anorexia nervosa. In media bombard us with idealised
There is considerable overlap between bulimia nervosa, binges provoke feelings images of underweight models
these two eating disorders. of guilt and disgust and a sense of being alongside advertisements for
out of control. These feelings lead to a confectionery. Adolescents are
Anorexia nervosa desire to get rid of the food, usually particularly vulnerable to these
Concerns about weight, and dieting in achieved by putting fingers down the cultural pressures to conform and to
order to lose weight are extremely throat to induce vomiting. Many bulim- be attractive.
common in the general population, par- ics are eventually able to spontaneously n Genetic factors. Twin studies have
ticularly among young women. Anorexia vomit. As in anorexia, laxative and shown that genetic factors do play a
nervosa represents an extreme form of diuretic abuse may be further threats to role, probably by creating a
this behaviour. Fear of being fat leads to health. Despite a dread of weight gain, vulnerability to weight loss so that in
the adoption of a starvation diet. Weight many maintain a normal weight and the presence of environmental
falls to at least 15% below normal, so that may even be overweight. Menstruation pressures an eating disorder may
the body mass index (BMI) is 17.5 or less is often normal. develop.
(Fig. 1). Despite this, anorexics continue n Hypothalamic dysfunction. The
to believe they are overweight, even Epidemiology hypothalamic area of the brain
when faced with their emaciated reflec- Bulimia is more common than anorexia controls feeding behaviour,
tion in the mirror. This distorted body nervosa. Anorexia nervosa usually starts temperature regulation and fluid
image drives them to continue to lose in adolescence, and bulimia a few years balance. There are marked changes
weight, and they may adopt other later. Surveys of young women have in the functioning of the endocrine
methods such as excessive exercise, self- found a prevalence of 34% for bulimia system in anorexia (Fig. 2). In the
induced vomiting or abuse of laxatives, and 12% for anorexia nervosa. Both are main these changes are secondary to
diuretics or appetite suppressants such more common in women than men. the weight loss, but the early onset of
as amphetamine. They may become pre- Occupations that depend upon keeping amenorrhoea in some anorexic
occupied with food, hoarding it, or a low body weight, such as ballet dancing women suggests that some changes
becoming very interested in cookery, and modelling, have a particularly high may be primary.
creating elaborate meals for their family risk of anorexia.
while still refusing to eat. Amenorrhoea Precipitating and
occurs in the early stages of weight loss Aetiology maintaining factors
and is an indication of a widespread The aetiology for both anorexia nervosa n Family issues. Preparing and
endocrine disorder. Figure 2 shows the and bulimia nervosa is similar. There are sharing food plays an important role
signs and symptoms found in anorexia many factors thought to be important in family relationships. The conflicts
nervosa. and most cases will be due to a combina- that often arise between adolescents
tion of causes. and their parents can be acted out at
Bulimia nervosa meal times, with refusal to eat
In bulimia nervosa there is also a fear of becoming an act of rebellion. There
fatness, but the characteristic symptom Predisposing factors
is often some abnormality in family
is binge eating. Binges are the consump- n Cultural factors. Anorexia nervosa relationships, although the problems
tion of huge quantities of food at a single and bulimia nervosa are disorders of may be a result of the eating
sitting, particularly carbohydrate-rich the food-rich developed world. disorder, rather than the cause of it.
Endocrine
Growth hormone
Cortisol
Gonadotrophin
T3
Obese Cardiovascular
30
Bradycardia
Overweight Hypotension
25
Normal Constipation
20 Amenorrhoea
Underweight Lanugo hair on body
17.5 Psychological
Sensitivity to cold Fear of fatness
Severely underweight Muscle weakness Distorted body image
Preoccupation with food
Weight in kg
BMI = Oedema
(Height in m) 2
Fig. 1 Body mass index (BMI). Fig. 2 Signs and symptoms of anorexia nervosa.
Eating disorders 77
It is common for the mother to have change thought processes underlying ously low level, admission may become
some concerns about weight and the abnormal behaviour. Therapy necessary, ideally to the shared care of
dieting, and in some cases to also may include keeping a diary, for both a psychiatrist and physician. Weight
have an eating disorder. example recording binges or gain is achieved with a diet of regular
n Psychological issues. Adolescence vomiting and the thoughts and meals, supplemented if necessary with
may be a time of conflict with feelings that occur before, during high calorie drinks and snacks. The
parents and others. Feelings of and after this behaviour. The diary is nursing staff has an important but diffi-
having little control over events, lack used in therapy sessions for the cult role in management. They must
of confidence and poor self image patient and therapist to work strike a balance between building a trust-
are common. In some cases anorexia together to find a strategy to change ing relationship with the patient and
nervosa can be a way of coping with the behaviour. adopting a monitoring role, supervising
some of these psychological n Self-help programmes. There are a meal times, ensuring there is no self-
pressures, by creating an illusion of number of structured self-help induced vomiting, and recording weight
being in control. Another theory is programmes available that can be gain.
that the amenorrhoea and arrested very effective in the treatment of
physical development of anorexia bulimia nervosa. The role of the Course and prognosis
nervosa fulfils a wish to escape the professional is to provide support The course of eating disorders tends to
problems of adolescence and avoid and encouragement, and for many be variable and fluctuating. In general
adulthood. Parents who do not want patients this will be all that is about 65% have a good outcome and
their little girl to grow into a woman required. Provision of information to maintain normal weight, 20% remain
and leave home may collude in this the patient and their carers is very moderately underweight long term and
illusion of prolonged childhood. helpful in managing all eating 15% have a poor outcome, with persist-
disorders. ing seriously low weight. Poor outcome
n Family therapy. This may be the is associated with very early or late onset
Management
Patients with eating disorders are often treatment of choice if abnormal of illness, a chronic course, severe weight
very reluctant to accept that they are ill, family relationships are thought to loss, coexisting anorexia and bulimia
and have the realistic fear that the main have a role in the eating disorder. and persisting relationship difficulties.
aim of treatment will be weight gain. There are many different models of Men generally have a worse prognosis.
Therefore the first challenge in manag- family therapy. In most cases two
ing eating disorders is engaging the therapists work together with the
patient in treatment. It may take many family. The family as a whole is seen Case history 26
hours over several appointments to gain as the source of the problems rather
Sarah is a 17-year-old school girl with a
the patients trust, complete an assess- than the individual with the eating
2-year history of weight loss. She is 1.7m
ment and build a therapeutic relation- disorder, and it is acknowledged all
tall and 48kg in weight. She has set a
ship that will allow change to begin to members of the family will be
target weight of 40kg and in order to
happen. affected in some way. Family
achieve this more rapidly has limited her
Assessment begins with a full psychi- relationships are examined, and
diet to raw vegetables and water for
atric history and mental state examina- conflicts may be acted out in the
several months, and works out in the gym
tion and an informant from the family therapy sessions, giving the family
twice a day. Sarah believes that she is
can often provide valuable information. an opportunity to understand the
currently overweight, and is disgusted by
The main psychiatric differential diagno- way the family functions and make
her reflection in the mirror.
sis to consider is depressive disorder. A changes.
detailed physical examination is impor- a. What is her body mass index (BMI)?
tant, looking for evidence of malnutri- Physical treatment b. What would be a normal weight for
tion and effects of repeated vomiting. There is only a limited role for drug her height?
Physical illnesses that present with treatment in the management of eating c. What is the diagnosis?
weight loss must be excluded, in particu- disorders. Fluoxetine, a specific sero- d. What impact is the weight loss likely to
lar chronic debilitating diseases, malab- tonin reuptake inhibitor (SSRI) which is have on her physical health?
sorption syndromes and thyrotoxicosis. usually used in the treatment of depres-
Investigations may include full blood sion, is also used in bulimia to suppress
count, urea and electrolytes, creatinine, the appetite and limit bingeing. It is not
an adequate treatment for bulimia in Eating disorders
liver function tests, ECG and chest X-ray.
The aim of a treatment programme itself and must be used alongside psy-
Anorexia nervosa is characterised by:
must be to achieve a healthy weight, at a chological therapies.
n deliberate weight loss, with BMI of
weekly rate of about 0.5kg, and reduce
Social treatment 17.5 or less
behaviour that puts health at risk. It is
helpful to work towards a realistic target Some patients will require social inter- n distorted body image
weight that is reached through negotia- ventions, in particular help to gain con- n fear of fatness
tion with the patient. Psychological, fidence and independence. Social and
n amenorrhoea
physical and social treatments should be self-help groups, advice about housing
and finances and occupational therapy Bulimia nervosa is characterised by:
considered.
may be useful. n episodes of binge eating
Psychological treatment n self-induced vomiting
Hospital treatment
n fear of fatness
n Cognitive therapy. This has been The majority of anorexic and bulimic
shown to be successful in research patients can be managed as outpatients.
studies. It aims to examine and However, if the weight falls to a danger-
78 PSYCHIATRY AND MEDICINE
Perinatal psychiatry
has been helpful in promoting the accep- sideration of drug treatments should
Case history 27 tance of depression in the postnatal take into account the problems that may
Bronwyn is 32 years old. She has two period and reducing the feelings of be encountered during breast-feeding,
children and is in the tenth week of shame felt by women who are not expe- which are summarised below. Drugs
pregnancy. She has a history of recurrent riencing the happiness babies are with sedative effects should be pre-
depression, including an episode expected to bring. scribed with caution if there are not
following the birth of her second child. The epidemiology of depression in the other people available to care for the
She stopped sertraline four months ago, postnatal period suggests the condition baby.
prior to conception. She now presents is not distinct from other depressive dis-
with low mood, tearfulness, poor sleep, orders. While the baby blues, consist- Puerperal psychosis
fatigue and impaired concentration that ing of a brief period of tearfulness, In contrast to postnatal depression, it
has caused her to make uncharacteristic anxiety, irritability and fatigue, occurring seems likely that the psychotic illnesses
mistakes at work. in mothers typically around four days that occur following childbirth have a
after delivery, may well be linked to hor- biological cause. There is a dramatic
a. What additional information is monal changes, this does not seem to be increase in the risk of severe mental
needed? the case with depression. There is no illness following childbirth, with differ-
b. Should she restart sertraline? peak of new cases of depression in the ent studies showing a 1030-fold
first few weeks of the postnatal period, increase in the risk of psychiatric admis-
and the period of raised risk extends sion in the early postnatal period. Onset
throughout the first year. Hormonal is usually within two weeks of delivery.
Perinatal psychiatry involves the recogni- treatments, such as progesterone, do not Although schizophrenia-like illnesses
tion, assessment and management of appear to be effective. There is also no can occur, puerperal psychosis is typi-
mental disorders during pregnancy and difference between the symptoms of cally affective in nature, presenting with
the postnatal period. Traditionally, the depression in the postnatal period and mania or severe depression. Symptoms
focus has been on the period following those occurring at other times of life, and are often florid and changeable. A
delivery, during which there is a raised risk factors are also similar. common feature is confusion and so
risk of depression and psychosis, and it It seems more likely that raised rate of delirium needs to be excluded. Women
is the postnatal conditions, outlined in depression in the postnatal period is the with a history or family history of bipolar
Figure 1, that will be discussed in detail result of psychological and social factors. disorder are at greatest risk and most
here. However, mental illness also occurs Looking after a baby is challenging and women who develop puerperal psycho-
during pregnancy and, when present, the risk of depression is increased in sis will experience puerperal and
will often persist postnatally. cases of neonatal illness. The arrival of a non-puerperal episodes of mania and
new child has a great effect on relation- depression in the future.
Postnatal depression ships and family finances, and social iso- Drug treatments are usually required,
There is a high rate of depression among lation may occur. Notably, postnatal with prescribing following guidelines for
women in the 12 months following depression is more common following the type of psychosis with which the
childbirth. Community surveys have the birth of a first child and unwanted woman presents. Lithium is often
shown a prevalence of up to 20% and pregnancies, which suggests that adjust- advocated for the prevention of affective
around 5% of women will consult their ment to motherhood is an important episodes in women at high risk. Electro-
GP regarding depression during the factor. convulsive therapy (ECT) is usually
postnatal period. These findings have Standard treatments for depression effective for puerperal mania and depres-
given rise to the concept of postnatal should be offered. Specific interventions, sion and has a relatively rapid onset of
depression as a discrete disorder, such as mother and baby groups, may be action.
somehow different to other depressive particularly helpful for women strug-
illnesses, perhaps as a result of hormonal gling to adjust to motherhood and those Organisation of services
changes occurring after childbirth. This who have become socially isolated. Con- Women encounter a variety of services
and professionals during pregnancy and
the postnatal period. Good communica-
'Baby blues' Postnatal depression tion and interdisciplinary working is
Occurs in 50% Occurs in 10% essential. All professionals involved
Onset 2-6 days after delivery Increased risk in women with: in routine antenatal and postnatal care
Transient low mood, previous psychiatric history should be able to screen for depression
no treatment required family psychiatric history and be alert for signs of other mental
chronic social difficulties disorders. Suggested screening questions
unwanted pregnancy
for depression are shown in Figure 2.
first child
ill baby The treatment of mild to moderate
Often missed by health depression will usually be provided in
professionals primary care, with health visitors, who
by the nature of their work become very
Puerperal psychosis experienced in dealing with the condi-
tion, often taking a lead role. For more
Occurs in 0.5% severe conditions, mental health teams
Very high risk in women with
history of schizophrenia, will collaborate with health visitors, col-
mania or severe depression leagues in primary care and, when neces-
sary, Child and Family Social Services
Fig. 1 Postnatal mood changes. teams. In some areas, specialised perina-
Perinatal psychiatry 79
Women answering yes to any of these Valproate(E) Neural tube defects 100200 per 10,000 6 per 10,000
questions should at least be discussed Carbamazepine (E) Neural tube defects 50 per 10,000 6 per 10,000
with mental health services and in many Lamotrigine (E) Oral cleft 9 per 1000 1 per 600
cases referred. Lithium (E) Heart defects 60 per 1000 8 per 1000
Some women will be vulnerable to (Epsteins anomaly) (10 per 20,000) (1 per 20,000)
depression but unlikely to become so Clozapine Agranulocytosis Unknown risk in adults taking
unwell that they require input from clozapine is 0.5%
mental health services. Factors such as SSRIs (E) Heart defects 9 per 1000 5 per 1000
lack of family support, social isolation, SSRIs (L) Persistent pulmonary 610 per 1000 12 per 1000
financial and social problems, caring for hypertension
other young children and a history of Benzodiazepines (E) Oral cleft & other Risk demonstrated in case-control
depression increase the risk of depres- major malformations but not cohort studies
sion in the perinatal period. In such
cases, it is worth considering measures
such as increased input from commu-
nity midwives and health visitors, atten- Perinatal psychiatry
dance of mother and baby groups, n Postnatal depression is common and is often missed by health professionals
improved childcare arrangements for
n Puerperal psychosis is uncommon but women with a history of mania or psychosis are
older children and advice and advocacy
regarding issues such as finances and at high risk
accommodation.
80 PERSONALITY DISORDER
manifested
formed by
Personality is... stable over time in different
adolescence
circumstances
Fig. 2 Crisis management for personality disorder without (and with) mental illness.
Exacerbates abnormal
Symptoms stable Episodic symptoms behaviour and emotion. Case history 29
over time Good function
Chronic impairment between episodes Following his presentation described in
of function Meet diagnostic the previous pages, David is placed on
Don't meet diagnostic criteria for Personality Mental the waiting list for an anxiety
criteria for mental illness mental illness disorder illness
Limited response to Good response to Slower response management group. While waiting for a
drug treatment drug treatment to treatment place to become available, his condition
Increased risk deteriorates. He presents to his doctor
Poor coping saying that he feels like he is about to
skills
Personality Mental explode and that everyone looks down
disorder illness Adverse life on him. He is facing homelessness after
events being asked to leave by his girlfriend and
Fig. 3 Distinguishing between personality is likely to lose his job because of
disorder and mental illness. Fig. 4 Relationship between personality arguments with his boss.
disorder and mental illness.
a. What treatment should be offered?
Learning disability
As with many other areas of psychiatry, the terminology used psychological and physical development. Institutional care can
to describe what ICD10 classifies as mental retardation has have a similar effect.
changed regularly, to reflect changing philosophies of care and Two of the more common clinical syndromes that cause
in an attempt to reduce stigma. The term Learning disability learning disability are described below.
is generally used in the UK and so is the one we have adopted
in this book. An alternative term still used occasionally is Downs syndrome
mental handicap. Downs syndrome occurs in about 0.2% of all births and 1%
In learning disability there is impaired intellectual and social of children born to women over 40 years. It is caused by a
functioning that is apparent from early childhood. Intelligence chromosomal abnormality, trisomy 21, in which there is an
is a broad concept that includes the ability to reason, compre- extra chromosome 21. People with Downs syndrome have a
hend and make judgements. It is measured with standardised characteristic facial appearance (Fig. 2). Congenital cardiac
tests such as the Wechsler Intelligence Scale, which has both abnormalities are found in 40%. Nearly all have moderate or
performance and verbal sub-scales that can be reported sepa- severe learning disability. It used to be thought that Downs
rately or combined to produce a single IQ (intelligence quo- syndrome was associated with a particularly compliant and
tient) score. An IQ of 70 and over is considered to be normal. cheerful personality, but this is no longer considered to be the
Some 23% of the population have an IQ below 70, although case and it is possible that these characteristics were due to the
half of these have a reasonable level of social functioning and style of institutional care provided. In fact, children with
can live independently without extra support. About 0.4% of Downs syndrome have more behavioural problems than chil-
adolescents have an IQ of less than 50. dren of normal intelligence, although generally less than
others with a comparable IQ.
Classification
Learning disability is classified as mild (IQ 5069), moderate Fragile X syndrome
(IQ 3549), severe (IQ 2034) or profound (IQ under 20). The Fragile X syndrome was first discovered in 1991 and is now
division into these four groups is fairly arbitrary and there is thought to be the most common hereditary cause of learning
a great deal of overlap between them. The spectrum of disability. Affected individuals have an abnormal X chromo-
disability for the key areas of language skills, self care, mobility, some which has a fragile site, visible as a constriction near one
academic achievement and ability to work are shown in end of the chromosome. Males are more severely affected by
Table 1. Fragile X because females have a second normal X chromo-
some. The syndrome is characterised by learning disability and
Aetiology language impairment. Girls may be of normal intelligence. Up
The cause of mild learning disability is unknown in about half to 20% of autistic boys have Fragile X.
of cases. Many of these simply represent the lower end of the
normal distribution of intelligence. With increasing severity of
learning disability, the likelihood of finding a cause increases,
with at least 80% of severe cases having some evidence of
organic brain damage or disease. Some of the aetiological
factors are listed in Figure 1. Genetic
It is clear that social factors also play a role in causing learn- Chromosome abnormalities: Down's syndrome, Fragile X,
ing disability. It has been estimated that up to 5% of cases are Klinefelter's syndrome, Turner's syndrome
Metabolic disorders: phenylketonuria, TaySachs,
due to child abuse, with many being a consequence of brain Gaucher's, LeschNyhan syndrome
damage, occurring as a direct result of physical assaults, usually Tuberous sclerosis
by the parents. Other forms of abuse also appear to have an Neurofibromatosis
impact on intellectual performance. Emotional abuse by cruel Hydrocephaly
and neglectful parents who fail to provide a stimulating and Microcephaly
nurturing environment for their child results in impaired
Intrauterine
Infections: rubella, lysteria, CMV, syphilis
Toxins: alcohol, lead
Physical damage: injury, radiation, hypoxia
Placental dysfunction: toxaemia
Table 1 Intellectual and social functioning in learning disability
Profound Severe Moderate Mild
Case history 30
Jane is a 34-year-old woman with Downs syndrome and
moderate learning disability. She has lived in a staffed hostel with
four other residents for the past year since her elderly mother has
been unwell and unable to care for her. Her mother died a month
ago. She was told of this and went to the funeral but has not
spoken of it again. Since then staff report she has been difficult to
manage eating little, irritable and lashing out at times and
refusing to take part in her usual activities.
a. What is the cause of Janes change of behaviour?
Face Hands b. What could be done to help her?
Epicanthic folds Single palmar crease
Inward slanting eyes Fifth finger curves inwards
Small head
Short neck
Small, low set ears
Protruding tongue should be approached to complete the picture, including other
Fig. 2 Features of Downs syndrome. doctors involved (GP, neurologist, paediatrician, etc.), the
school and social services.
A treatment package might include the following:
Mental illness and learning disability n Education in special schools. Assessment of needs should
About 40% of all children and adults with learning disability
be completed by an educational psychologist.
have a mental illness. The risk increases with the severity of n Support for families. The birth of a child with learning
the learning impairment. The presence of organic brain disease
disability can have a devastating effect on a family. The
increases vulnerability to mental illness, but emotional factors
parents often experience grief over the loss of the
also play an important role and must not be overlooked. Chil-
anticipated perfect child and may have prolonged feelings
dren with learning disability often have a sense of being a
of depression, guilt, shame or anger. The majority of
disappointment to their parents and different from other
families adjust well with support, although a few reject the
people. They may be isolated from their family and the com-
child or become over-involved, and this can be associated
munity, stigmatised, bullied or abused. They may lack the
with marital disharmony.
skills to express their feelings of sadness or anger, and so these n Recognition of emotional needs. As mentioned above, a
feelings will go unrecognised.
person with learning disability may have powerful feelings
The commonest forms of mental illness found in children
of sadness or anger that they find difficult to express.
with learning disability are hyperkinetic disorder and conduct
Creative therapies, such as art or music, can allow
disorders. They are also at increased risk of exploitation and
communication through media other than words.
abuse. n Employment opportunities. Many people with mild to
In adults, schizophrenia, affective disorders, neurotic disor-
moderate learning disability have practical skills that can
ders and personality disorders are all found more frequently
be developed in sheltered workshops and supported work
than in the general population. Diagnosis can present a chal-
placements.
lenge as they may not be able to describe their feelings and n Institutional care is only needed for a minority. It is usually
experiences, and when making a diagnosis it is often necessary
provided in small well-staffed community units near the
to rely on behavioural changes such as psychomotor retarda-
childs family.
tion, agitation or possible responses to hallucinations. It is
sometimes worth giving a trial of medication if the diagnosis
is uncertain. Treatment of mental illness is the same as for
other patients, although psychological treatments will need to
be delivered in a way that takes into account the patients intel-
lectual and social abilities. Learning disability
Management of learning disability n In learning disability (mental retardation in ICD10) both
Assessment begins with taking a full psychiatric and medical intellectual and social functioning is impaired from early
history from informants, usually the parents or other carers. childhood
The family history, achievement of developmental milestones n 23% of the population have an IQ below 70 and half of these
and problem behaviours are particularly important. Mental
require input from specialist services
state examination will rely largely upon observation of the
patients behaviour during the interview, although some will n Brain disease or damage may occur as a result of genetic, intra-
be able to participate in the interview. A thorough physical uterine, perinatal, postnatal and social factors
examination is required, remembering to assess vision and n About 40% of all children and adults with learning disability
hearing. Finally, a developmental assessment is needed, includ- have a mental illness
ing standardised measures of intelligence, language, motor
performance and social skills. Other sources of information
86 THE PSYCHIATRIC SPECIALITIES
Child psychiatry I
The psychiatric disorders that present in childhood are distinct n Personal history pregnancy, birth, milestones (motor,
from those in adults because they arise within complex and speech, feeding, toilet training, social behaviour), medical
intimate family relationships, and are influenced by the devel- history, separations from parents, schools attended and
opmental stage of the child. Children also present special progress in them.
challenges for assessment and treatment. The psychiatric dis- n Family structure and function construction of a
orders that present in childhood or adolescence are listed in genogram is often useful (see Fig. 2 for the genogram
Table 1. constructed for the Case history, Liam). Relationships
between family members should be asked about, and the
Normal childhood development interactions during the interview observed.
Some of the features of normal child development are shown n Temperamental traits traits such as activity level,
in Figure 1. It is essential to consider the developmental stage regularity of functions (sleep, bowels, eating), adaptability
of the child during a psychiatric assessment, as what is accepted to new circumstances, willingness to approach new people
as normal at one stage would be abnormal at another. or situations, quality and intensity of mood, quality of
Early childhood experiences play an important role in deter- relationships within and outside the family, attention and
mining what type of person we become in adulthood. The role persistence can be observed from a very young age.
of parents in this is central. The child with parents (or parent)
A mental state examination of the child should be com-
who are loving and tolerant, yet able to set and enforce clear
pleted, although this will often rely on watching behaviour and
and reasonable limits is likely to develop a high self esteem,
play. The following should be considered:
and secure attachment to the parents that will provide a tem-
plate for secure attachments to others in later life. The theory n Appearance looking for any abnormality, bruises, cuts,
of attachment was first described by John Bowlby in the or grazes and appropriateness of dress.
1950s. It derived from his study of young children separated n Behaviour activity level, interactions with parents,
from their mother in hospital. Attachment behaviour begins motor function, attention and persistence with tasks.
at around 7 months and consists of clinginess and unwilling- n Talk articulation, vocabulary and use of language.
ness to be separated from the main carer, usually mother. It n Mood happy, elated, unhappy, depressed, anxious,
serves to strengthen the bond between mother and child and hostile or resentful.
has the evolutionary function of ensuring the child is protected n Thoughts content of speech and fantasy life, for
from predators. A securely attached child is able to use the example by asking for three magic wishes.
mother as a safe base from which exploration of the outside
world can begin, and will also be able to cope well with brief The assessment should be completed with a physical exami-
separations. If the attachment is insecure, because the parent nation and by speaking to other informants involved with the
fails to respond to the childs need for attention or holding, or child or family, such as the family doctor, school teacher, edu-
is inconsistent, the child will have difficulty exploring and cational psychologist, or social services. Investigations may be
separating. This pattern of insecure attachment may persist performed, most commonly intelligence tests and tests of
throughout life, affecting adult relationships. academic attainment, such as standardised reading tests.
Totally dependent
0-1 year Rapid motor development walking by one year
Case history 31
Attachment behaviour from 7 months Liam is a 6-year-old boy who lives with his mother, step-father,
Begins to talk older brother and baby sister. He has always been a noisy, active
Dry by day and demanding child, difficult to engage in any activity for more
1-2 years Temper tantrums than a few minutes. He is having great difficulty at school, finding
Separation anxiety it almost impossible to sit still and frequently disrupting the class.
Complex language skills He has temper tantrums if frustrated and has to be carefully
Sociable monitored with his sister as he has been aggressive towards her at
Development of sexual identity times. He has no friends at school because he is unable to settle to
2-5 years Identification with parents play with them. His mother feels unable to cope, she thinks her
Beginning of conscience formation husband is too strict with Liam and she tries to compensate for
Vivid fantasy life this and avoid confrontations. Liams family tree (genogram) is
See themselves as the centre of their world shown in Figure 2.
Well-defined identity as girl or boy a. What is the most likely diagnosis?
Able to separate well from mother b. What factors may be contributing to Liams problems?
5-10 years Personality attributes acquired by the end c. What practical advice could you give his mother about
of this period persist into adulthood handling his difficult behaviour?
Less egocentric
Child psychiatry II
Conduct disorder from the attachment figure (usually mother) and great distress
The main features of conduct disorders are persistent antiso- if forced to do so. Some will refuse to go to sleep without their
cial behaviours such as fighting, bullying, severe temper tan- mother nearby and have nightmares about separation. Paren-
trums, damaging property, starting fires, stealing, truancy, and tal overprotection is commonly present and other causes
persistent and defiant disobedience. The childs age must be include the childs temperament and stressful events, particu-
taken into account, and normal naughtiness should not be larly those involving separation such as family breakdown,
considered a sign of conduct disorder. A third of cases have bereavement or illness.
specific reading disorder, and there is considerable overlap
with hyperactivity disorder. Conduct disorders are common. Anxiety disorders of childhood
Among adolescents about 8% of boys and 5% of girls have a Specific phobias about animals, the dark or strangers are
conduct disorder. It is less common in younger children, par- normal in young children and rarely need treatment. Gener-
ticularly in girls. alised anxiety disorder can occur and is frequently character-
There are two types of conduct disorder: ised by somatic symptoms, particularly abdominal pain.
Pad placed beneath the sheets attached to the age of 3 years. At 8 years, 2% of boys and 1% of girls have
Bell which rings when pad becomes wet and encopresis. This may be due to inadequate toilet training or
Wakes the child. may have a psychological cause with the behaviour represent-
ing the childs feelings of anger or regression at a time of stress.
Effective in 80% within one month.
Constipation with overflow incontinence is the main differen-
tial diagnosis to be excluded.
Fig. 2 Pad and bell a behavioural treatment for nocturnal enuresis. Adolescence
Adolescents have difficult social and emotional issues to deal
with. For example, there is frequently conflict over the degree
There are many contributory factors in the abuse of chil- of independence they wish for and are allowed to have from
dren. Some children are more vulnerable than others, for their parents. The peer group becomes very important and
example those who are unwanted, have early separation from influential, and can provide valuable support for individuals to
the mother, are mentally or physically handicapped, or have try new things away from the family. They can also arouse a
temperamental characteristics that make them difficult to great deal of anxiety about rejection from the group, and may
handle. Some parents are more likely to be abusive, particu- promote delinquent behaviour. Development of sexual rela-
larly those who have themselves been abused as children, live tionships is another potential source of confusion, anxiety and
in poor socioeconomic circumstances and have unrealistic conflict.
styles of disciplining their children. The pattern of psychiatric disorders changes as children
The most common form of sexual abuse is fatherdaughter become adolescents. There is a marked increase in depressive
incest. Sexually abused children may present with a sudden disorder, particularly in girls, and schizophrenia becomes
change in their social behaviour or academic performance, or much more common in late adolescence. Problems with
with conduct disorders. Some engage in repetitive sexual play alcohol and drug abuse and eating disorders also tend to
and are sexually precocious. It is important to give these chil- emerge at this time. Development disorders have usually
dren an opportunity to disclose their abuse, but great care resolved.
must be taken to avoid adding to their trauma. Social services
must be informed of any disclosure of sexual abuse by a child
and have responsibility for ensuring the safety of the child and
instigating childcare proceedings. The emotional effects of
childhood sexual abuse may be addressed in individual psy- Case history 32
chotherapy with the child. Adolescents and adults may also be
Charlotte is a 7-year-old-girl who lives with her mother and two
offered group therapy which has the advantages of reducing
younger sisters. Her parents have recently separated and she has
the sense of isolation and allowing development of trust and
weekly contact with her father. She has started to wet the bed
self esteem. One-third of sexually abused children have no
after being dry at night for 4 years. Her mother is angry with her,
long-term negative effects, the rest are prone to depressive
believing that the bed wetting is deliberate defiance.
illness, low self esteem, sexual problems and have a tendency
to re-victimisation in adulthood. a. What is the most likely diagnosis?
b. What other causes should be excluded?
Disorders of elimination c. How would you advise Charlottes mother to manage this
Enuresis problem?
Enuresis is involuntary emptying of the bladder occurring
after the age of 5 years in the absence of an organic cause.
Bedwetting (nocturnal enuresis) is common, occurring in 10%
of 5-year-olds, 5% of 10-year-olds and 1% of 15-year-olds.
Daytime enuresis is less common. The enuresis is considered
Child psychiatry 2
to be primary if there has been no preceding period of bladder
control, and secondary if it follows a period of continence. It n Conduct disorders are more common in boys than girls, and
is twice as common in boys than girls, and most cases are are most likely to occur in 1216-year-olds
thought to be due to delayed neurological maturation which
n Conduct disorders may be socialised, in which the problem
simply corrects itself with time. There is often a positive family
history of the same problem. Secondary enuresis may occur behaviour occurs within a peer group, or unsocialised in
as a feature of regressive behaviour at times of stress. Manage- which the behaviour occurs alone
ment consists of excluding a physical cause, particularly a n Emotional disorders are more common in girls than boys and
urinary tract infection, reassuring the parents and encouraging include separation anxiety, phobias, depression and school
them to handle the problem calmly and gently. Instituting a refusal
simple behavioural programme such as a star chart or pad and
bell (see Fig. 2) can be used. n Itis important to be alert to the possibility of childhood
neglect or abuse, which may be physical, emotional or sexual
Encopresis in nature
Encopresis is defecation in inappropriate places despite having
normal bowel control. Most children are fecally continent by
90 THE PSYCHIATRIC SPECIALITIES
Dementia correlates well with the degree of cogni- atrophy of the brain which results in
tive impairment observed clinically. enlarged ventricles. The distinctive path-
The prevalence of dementia rises sharply Both neurofibrillary tangles and senile ological finding is areas of infarction,
in old age, with 5% of people over 65 plaques occur in normal ageing but are usually in several parts of the brain.
years and 20% of people over 80 years more numerous and widespread in Reduced cholinergic function is not a
being affected. The commonest causes Alzheimers disease. cause of cognitive impairment in vascu-
of dementia in old age in the UK are lar dementia. Now that cholinergic
Alzheimers disease (up to 65% of cases), Presenting features drugs are being advocated for the treat-
vascular dementia (up to 20%) and Lewy In many ways, Alzheimers disease is a ment of Alzheimers disease, it is impor-
body disease (up to 10%). Alzheimers diagnosis of exclusion, being made when tant to be able to differentiate between
disease is also the commonest form of features of other causes of dementia are the two conditions. Establishing the
presenile dementia (dementia present- not present. Any combination of the fea- diagnosis also affects prognosis as the
ing before the age of 65), but is usually tures of dementia described on page 70 life expectancy of 45 years in vascular
managed by old age psychiatrists what- may occur, but many cases present with dementia is shorter than in Alzheimers
ever the age of presentation. Picks a characteristic clinical picture which disease. The clinical features of Alzheim-
disease is included in this section for the includes: ers and vascular dementia are contrasted
same reason, even though the majority in Table 1.
n poor memory
of cases present before the age of 65.
n disorientation as an early sign which
Other causes of presenile dementia are Lewy body dementia
described on pages 7071. can lead to perplexity, fear and This is the third most common cause of
wandering as the illness progresses dementia. It is characterised histologi-
n coarsening of premorbid personality
Alzheimers disease cally by intracellular inclusion bodies
traits, e.g. a person who has always (Lewy bodies) in the cerebral cortex.
Epidemiology and aetiology
been stuck in their ways may Lewy bodies are also found in subcorti-
Women develop Alzheimers disease
become much more rigid and cal areas, particularly the substantia
slightly more often than men. There is a
inflexible nigra which explains why Parkinso-
strong genetic component with the risk
n gradual deterioration of social skills
being three times higher in people with nian signs are common in this form of
and behaviour dementia. This pathology also explains
an affected first-degree relative. In the
n non-specific mood changes:
early onset form, there is sometimes an why there is extreme sensitivity to the
depressed, euphoric, flattened or side effects of antipsychotic drugs, with
autosomal dominant pattern of inheri-
labile some patients becoming very unwell fol-
tance. Abnormalities of the amyloid pre-
n frontal and parietal lobe signs.
cursor gene on chromosome 21 have lowing relatively low doses. The other
been established in some pedigrees features that help distinguish Lewy body
which is not surprising for two reasons Picks disease disease from Alzheimers disease are a
amyloid peptide is found in senile Recent claims that Picks disease is the fluctuating rather than gradual course
plaques and Alzheimers disease devel- cause of up to 20% of cases of presenile and the occurrence of hallucinations,
ops in up to 50% of patients with Downs dementia are probably exaggerated but which are usually visual and can lead to
syndrome who survive beyond the age it is certainly an important cause of a mistaken diagnosis of delirium.
of 40 years. Linkage with a site on chro- dementia in younger people. It usually There is a considerable overlap
mosome 14 has also been established in presents between the ages of 50 and 60 between Lewy body dementia and Par-
other early onset cases and loci on other years. In the small number of cases with kinsons disease in which Lewy bodies
chromosomes are almost certainly a family history, the inheritance appears are also found, predominantly in the
involved. In contrast, late-onset Alzheim- to be autosomal dominant but in most substantia nigra rather than in the cere-
ers disease is familial but does not show cases there is no identifiable cause. The bral cortex. Some patients with Parkin-
a Mendelian pattern of inheritance, characteristic pathology is of cortical sons disease go on to develop dementia
which suggests a polygenic aetiology, atrophy, known as knifeblade atrophy and in these cases there is considerable
perhaps in combination with environ- because of the appearance of the atro- Lewy body disease in both the substantia
mental factors. Association with a phic gyri. Within the atrophic areas are nigra and the cerebral cortex.
number of genes has been demon- silver staining intracellular inclusions
strated, one example being the E4 allele known as Pick bodies and swollen neu-
Is it dementia?
of apolipoprotein E on chromosome 19 rones known as Pick cells. This atrophy
Exclude other diagnosis, especially normal
which is found in up to 50% of cases of is usually confined to the frontal and ageing, delirium and depression
Alzheimers disease but in only 10% of temporal lobes and as a result, the clini-
the general population. cal picture in the early stages is often
dominated by apathy, disinhibition and
Pathology other changes in personality and social Is it treatable?
The characteristic pathology of Alzheim- behaviour, with abnormalities of speech Try to identify reversible causes of dementia
ers disease consists of progressive developing as the disease progresses.
atrophy of cortical and subcortical struc-
tures. Histologically, there are neurofi- Vascular dementia
brillary tangles and amyloid containing This is the second most common cause
What support is needed?
senile plaques throughout the brain. of dementia. It was previously known as Identify unmet needs of patient and carers
While many neurotransmitters are multi-infarct dementia but this term has
affected, there is widespread loss of neu- been replaced by vascular dementia in Fig. 1 Assessment of patients with
rones containing acetylcholine which ICD10. There is generalised or localised suspected dementia.
Old age psychiatry I 91
Table 1 Clinical differences between vascular dementia and Normal pressure Hypothyroidism
Alzheimers disease hydrocephalus Hair loss Eye signs
Vascular dementia Alzheimers disease
Goitre Coarse
Step-wise course with relatively sudden Insidious onset, gradual course complexion
onset/deterioration following infarction
Bradycardia
Insight and personality deteriorate later Insight and personality deteriorate earlier
Depression and anxiety common Depression and anxiety less common
Patchy cognitive deficits, i.e. only a few Global cognitive deficits, i.e. many aspects Urinary
aspects of cognitive function affected of cognitive function affected incontinence
Hard neurological signs (e.g. old CVA, Soft signs only Obesity
Parkinsonism) Unsteady
broad-based Sluggish deep
History of cardiovascular disease
gait tendon reflexes
Management of dementia
Clinical assessment Chronic subdural Neurosyphilis
Assessment and management of patients with suspected haematoma
dementia is a three-stage process, as shown in Figure 1. As Headache, fits
patients with dementia are often unable to give a full account Argyll-Robertson
pupils
of their problems, mental state examination and history from
informants are particularly important. Physical examination Slurred speech
Tremor in lips
and investigations are essential, to exclude possible causes of and tongue
delirium (p. 70) and treatable causes of dementia. Physical
Evidence of
investigations required are shown in Table 2 and some impor- primary infection
tant treatable causes of dementia are illustrated in Figure 2. Spastic weakness
Case history 33
Old age psychiatry 1
Frank is 74 years old. He has hypertension and smokes a pipe. His daughter says that his
memory has been gradually deteriorating. He struggles to think of words when talking. He n Dementia is a syndrome with many
is having trouble dressing himself and has become apathetic and disengaged. He is causes
unsteady on his feet. He becomes lost when away from his home environment. He has n Some causes are treatable
been incontinent a few times. He seems indifferent to these problems.
n Social
treatments ease the burden of
a. What is the likely diagnosis? dementia for patients and their carers
b. Is there any treatment likely to improve his condition?
92 THE PSYCHIATRIC SPECIALTIES
Adult
Institutionalisation
Always think of:
dementias Cognitive impairment
delirium
alcohol abuse
Precipitating factors
drug effects
neurological disorders
Physical ill health
Diagnosis: Depressive disorder Social isolation
Functional Loss of role and status
mental illness
Maintaining factors
Fig. 1 Differential diagnosis of functional illness in the elderly. Fig. 3 Aetiology of depression in the elderly.
Old age psychiatry II 93
Along with these benefits, it is important to remember the to hot drinks but do not include this when asked about their
problems associated with prescribing in the elderly (Fig. 2). alcohol consumption.
ECT is a safe procedure in the elderly provided they are fit to Some patients who present in old age have had lifelong
receive an anaesthetic. Social treatments are important when alcohol problems. They may become worse following retire-
there are social factors precipitating or perpetuating depressive ment because of having more time in which to drink alcohol.
episodes. Apart from supportive psychotherapy, psychological They may present with the medical complications of alcohol
treatments are used less often than in younger patients. abuse, which are more likely to affect older people. Patients
The exception to this is bereavement counselling, for without a history of alcohol problems earlier in life will usually
obvious reasons. Prognosis is not as good as in younger have started drinking excessively in response to adverse life
patients, and is determined by a number of factors as sum- events, difficult social circumstances or the pain and disability
marised in Figure 4. caused by physical illness. It is especially important to check
for symptoms of an underlying mental illness in this late-onset
Hypomania group, particularly depression.
The clinical presentation and treatment of hypomania is
similar for all age groups. When it occurs in the elderly, there Suicide and deliberate self-harm
is nearly always a past history of bipolar affective disorder. If Suicide rates are highest among people aged 4060 years but
hypomanic symptoms occur for the first time in old age, an they are much higher among the over-60s than the under-40s.
organic cause should be strongly suspected. Full-blown manic As in other age groups, depressive disorder and alcohol depen-
episodes are unusual in the elderly. dence are the disorders most commonly associated with
suicide in elderly people. Concurrent physical illness is found
Schizophrenia and delusional disorder in about 60% of deaths which highlights the fact that elderly
Patients with schizophrenia that starts in early adult life have people with both mental and physical illness are at particularly
a reduced life expectancy. There are a number of reasons for high risk of suicide. Social isolation and being widowed or
this, including their increased risk of suicide and their high separated also increase the risk.
rate of cigarette smoking. As a result, a relatively low propor- Deliberate self harm is uncommon among the elderly.
tion survives into old age. Those that do may still present with When it occurs it is considerably more likely to be a failed
acute psychotic episodes but more often will have developed suicide attempt than a cry for help. As a result, great care
chronic schizophrenia with predominantly negative should be taken when assessing suicide risk in this group,
symptoms. particularly as older patients are often embarrassed to admit
It is relatively uncommon for paranoid illnesses to present to suicidal motives.
for the first time in old age. When they do, loss of vision and
hearing, and social isolation often play a significant role in the
aetiology. In the past, late-onset paranoid illnesses were
labelled paraphrenia, but this term is not included in ICD10.
The same diagnostic criteria are therefore used regardless of
Case history 34
age of onset. Elsie is an 82-year-old woman who lives alone and has been
widowed for 8 years. She has atrial fibrillation and her mobility is
Alcohol problems limited by rheumatoid arthritis. She presents with a 2-month
Alcohol consumption tends to decrease with age. Elderly history of psychomotor retardation, loss of interest in her usual
people may reduce their alcohol intake because they are less activities, self neglect and loss of appetite with weight loss. In the
tolerant to the effects of alcohol and worry more about the past 24 hours she has refused to eat or drink because she believes
consequences of intoxication, especially falls. They also spend her insides have rotted away.
less time in social environments where alcohol consumption
takes place. Because of this, alcohol problems are less common a. What is the diagnosis?
than among younger people. However, they still occur in the b. How would you treat her?
elderly and so it is important to overcome the embarrassment
that is often felt about asking older people about their alcohol
consumption. It is also necessary to acknowledge differences
in the way some elderly people view alcohol. For instance,
some may drink for what they consider to be medicinal pur-
poses and might not mention this if not directly asked. Also,
Old age psychiatry 2
some of the current generation of elderly people add alcohol n Cautionis required in prescribing for the elderly, as they are
more sensitive to drug effects and suffer more side effects
n Ratesof depression in the elderly are similar to those in
Good prognosis Poor prognosis younger people
Before 70 years Onset After 70 years n Schizophrenia presenting for the first time in old age is
uncommon
Short Duration Long
n Itis important to ask elderly patients directly and in detail
Good Previous adjustment Poor about alcohol consumption
Absent Physical disability Present n Deliberate
self harm is relatively uncommon, and suicide more
Good Outcome from previous episodes Poor common amongst the elderly as compared to young people
Fig. 4 Outcome of depression in the elderly.
94 THE PSYCHIATRIC SPECIALTIES
Forensic psychiatry
Forensic psychiatry is a sub-speciality no longer require conditions of medium psychiatric treatment is to be offered.
concerned with the assessment and security. Alternatively, the magistrate hearing the
treatment of mentally disordered offend- A minority of patients in Regional case will take psychiatric recommenda-
ers. A large part of the work of forensic Secure Units and Special Hospitals are tions into account when deciding on
psychiatrists is the assessment of people referred directly from district psychiatric a sentence. This work is usually done
held at various stages of the criminal units rather than the criminal justice by local psychiatric services, rather than
justice system, which is portrayed in system. These are patients whose risk to forensic psychiatrists. In many areas,
Figure 1. They may also be asked to themselves or others cannot safely be court diversion schemes operate in which
assess patients under the care of general managed within their local psychiatric psychiatrists, psychiatric nurses or social
psychiatric services who are thought to hospital. workers are available each day to carry
be at high risk of committing an offence. out assessments at the request of the
In some areas, there are community Diversion of mentally police or the magistrates court.
forensic psychiatry teams that work with disordered offenders Forensic psychiatrists are usually
psychiatric patients likely to commit The need for forensic psychiatry is based involved in the assessment of people
criminal offences. on two important principles. The first is who have committed more serious
Forensic psychiatrists also provide that if someone commits a crime because crimes that require trial by jury in a
inpatient care in conditions of high, of a mental disorder, then treatment of Crown court. These assessments usually
medium or low security. Until 1980, the the mental disorder is in the best inter- take place at points B and C of Figure 1.
main provision for forensic inpatient ests of the individual and society. Table 1 The forensic psychiatrist will determine
treatment in England and Wales was in summarises the common ways in which whether a mental disorder is present
three Special Hospitals which provided mental disorder leads to crime. Secondly, and whether treatment will reduce the
psychiatric care in conditions of high imprisonment usually exacerbates risk of reoffending, or help the offender
security. A series of scandals following mental disorder and reduces the chance in other ways. If mental disorder is
revelations of security breaches and of rehabilitating the offender, and may present, they will make recommenda-
abuses emerged, and led to reform of the result in unnecessary suffering. There- tions about where treatment should be
way inpatient care was delivered, and a fore, it is often best for mentally disor- given based on their assessment of the
move towards treating mentally disor- dered offenders to be dealt with by level of risk the offender poses to the
dered offenders in Regional Secure psychiatrists rather than remain within public. Often assessments will be made
Units, which provide conditions of the criminal justice system. The process by more than one psychiatrist. If, after
medium security. Patients are either of getting them out of the criminal justice considering the psychiatric evidence, the
admitted to these directly, or are trans- system is usually referred to as diversion judge believes that psychiatric treatment
ferred there from one of the High Secure of mentally disordered offenders. is required, then one of a number of
Hospitals when they no longer require Most crime is petty and this is true of options (Table 2) will be chosen, depend-
this level of security. Regional Secure crimes committed by people with mental ing on the offence and the level of
Units have the advantage of keeping disorder. Because of this, point A on risk. These options for sentencing are
patients closer to their family and friends Figure 1 is an important point of diver- also available to magistrates, except for
and, because they are much smaller than sion. Most police officers now receive restriction orders which can only be
the High Secure Hospitals, have fewer of training in the recognition of mental dis- applied by a Crown court.
the problems associated with large insti- order. They are encouraged to seek a While the sentence in a criminal trial
tutions. They are also able to work more psychiatric opinion if they suspect is influenced considerably by psychiatric
closely with the local psychiatric services someone in their custody to have a evidence, the same is not usually true of
in their region, which makes it safer and mental disorder. For minor offences, they the verdict. This is because psychiatric
easier to transfer the care of patients who will often choose not to press charges if evidence does not usually help a jury
decide whether the accused committed
Arrest the act they are being tried for. The
exception to this is in cases of homicide,
where psychiatric evidence about the
offenders state of mind at the time of
A Police custody Not charged
the offence may result in a verdict of
B manslaughter on grounds of diminished
responsibility rather than murder. This
Bail Charged
is an important distinction, as murder
carries a mandatory life sentence
whereas sentencing for other offences is
Magistrates court Verdict Not guilty
at the discretion of the judge.
Table 2 Possible sentences for offenders requiring psychiatric treatment sible to eliminate the desire to offend
Custodial sentence with treatment in prison
and so it will be necessary for the
some prisons have hospital wings
offender to learn to control these urges
n some prisons offer specific treatment programmes, e.g. for sex offenders, substance abuse and avoid situations which exacerbate
Hospital order (Section 37 of Mental Health Act) them. Antilibidinal drugs such as cyprot-
n broadly similar to Section 3 erone acetate are sometimes used.
n can be used in any case of mental illness or severe mental impairment Whether any of these treatments are
n can be used in cases of psychopathic disorder or mental impairment only if treatment will result in improvement effective is controversial.
or prevent deterioration Indecent exposure is committed when
n requires recommendations from two doctors, one approved under Section 12 a woman or, nearly always, a man
n treatment in Special Hospital, Regional Secure Unit or district psychiatric hospital, depending on level of risk
exposes their genitals to another person
n renewable, so patient remains in hospital while still a risk to public or him/her self
in a public place. The majority of cases
n patient may appeal to Mental Health Review Tribunal which has the power to discharge them
are emotionally and sexually inhibited
Restriction order (Section 41 of Mental Health Act)
men who are more likely to offend
n added to Section 37, only if restrictions are necessary to protect the public from serious harm
n means the patient cannot be moved to less secure facilities or given leave from hospital without the permission of
during times of stress. A minority of
the Justice Minister offenders progress to more serious
Probation, conditional on attendance for treatment
sexual offences. Rarely, indecent expo-
n requires patients consent sure may be a feature of mental retarda-
n patient returned to court for resentencing if breaches conditions tion, dementia or other mental illnesses.
sions and hallucinations, and sometimes sexually abused during their own child-
as a cry for help or as a genuine suicide hood. Mental illness is uncommon.
attempt. Sexual offending also suggests
Case history 35
Rape is defined as penetration by the
psychological abnormalities although, as penis of the vagina, anus or mouth of A 28-year-old man with schizophrenia is
will be seen in the following description, another person without consent. Perpe- arrested for shoplifting.
mental illness is rarely a cause. trators are often under the influence of
a. What should happen to him?
alcohol and, sometimes, illegal drugs. As
Sexual offences b. Would this be any different if he had
with child sexual abuse, they often have
Child sexual abuse includes a variety of commited a serious crime?
difficulty forming normal sexual rela-
sexual offences against boys and girls tionships. Men may sometimes resort to
under the age of 16 years. Intra-familial violence, including rape, when stressed
child sexual abuse is known as incest, or facing a threat to their status. Some
extra-familial as paedophilia. There is a men rape in order to act out violent Forensic psychiatry
considerable overlap between these two sexual fantasies. Mental illness is not
groups, with up to half of incestuous common among rapists. n Most patients with mental disorders
fathers molesting children outside their About 25% of rapists commit a further never commit an offence
own family. Some men are drawn to sexual assault and reoffending by child n Mental disorder increases the
children because they are unable to form abusers is even more common. Because likelihood of some offences
satisfactory relationships with adults, of this, various treatment approaches
n Offenders with a mental illness
because of personality difficulties or low have been devised. Social skills training
intelligence. Others have a sexual prefer- should usually be diverted from
and education about why sexual offences
ence for children and may not believe the criminal justice system to
are wrong are often used. Behavioural
that what they are doing is wrong. A psychiatric care
techniques may be used to try to alter
significant proportion will have been sexual fantasies. Often it will not be pos-
96 THE PSYCHIATRIC SPECIALTIES
Alcohol dependence I
Introduction n Tolerance of the effects of alcohol. Increasing
Alcohol is the most popular of the psychoactive substances quantities are required to produce the same effect.
available for recreational use. In small quantities it has a stimu- n Withdrawal symptoms which appear within 6 hours
lating effect, lifting the mood and causing disinhibition, but if of the last drink. Typically this occurs overnight,
larger amounts are taken sedation and depression result. Con- resulting in withdrawal symptoms first thing in the
centration, speech and movement are also affected. Behaviour morning. The earliest symptom to occur is usually tremor.
after drinking large amounts of alcohol is often impulsive, ill- If alcohol is not drunk quickly other symptoms follow,
judged and may be aggressive. As a consequence alcohol can including anxiety, agitation, nausea, vomiting and
be an extremely damaging drug. Regular heavy drinkers can sweating. Generalised convulsions can occur, and one in
suffer devastating physical, mental and social damage, and 20 will develop delirium tremens (DTs). Withdrawal
their families are also profoundly affected. Alcohol is impli- symptoms can continue for up to a week if untreated.
cated in 40% of all road traffic accidents, 50% of murders n Relief drinking and a regular pattern of alcohol
and 80% of suicides. In very large quantities it can be fatal consumption. Alcohol is consumed to relieve withdrawal
because it depresses brain centres controlling circulation and symptoms. There is regular topping up, often beginning
breathing. early in the morning and continuing throughout the day.
About 90% of the adult population drinks alcohol at some A routine becomes established and all other aspects of life
time. There is a continuum between normal social drinking, must fit around it.
problem drinking and dependence on alcohol, and it can be n Rapid reinstatement after abstinence. The full
difficult to distinguish between these states (Fig. 1). Maximum dependence syndrome returns remarkably quickly, even
safe levels of consumption have been recommended, above after a long period off alcohol.
which the risk of sustaining some social or physical damage
rises considerably. These levels are 21 units per week for men, Some alcoholics present to medical services with a direct
and 14 per week for women (Fig. 2). At least 25% of men and request for help with their drinking. More often the presenta-
15% of women exceed these quantities. About one in ten of tion will be with one of the physical, psychological or social
these will experience some significant difficulties in their phys- consequences, and the underlying cause may not be immedi-
ical or mental health, relationships, ability to work or some ately obvious. Sustained heavy drinking can have an impact on
other aspect of their lives. Twenty percent of all admissions to virtually every body system, as shown in Figure 3. Comorbidity
psychiatric units are for alcohol-related problems. with mental illness is common. A detailed history of alcohol
use must therefore be included in all medical and psychiatric
Clinical features assessments.
The main characteristic of dependence on alcohol is that the
drinking takes priority over all other aspects of life. The threat Aetiology
of a marital breakdown or unemployment is not enough to Social and cultural factors play an important role in the aetiol-
convince the dependent drinker to cut down or stop, instead ogy of alcoholism. Overall consumption of alcohol by the
they will continue to drown the sorrows that have been pro- population depends upon its availability, which is determined
duced by the alcohol in the first place. Other typical features by the number and type of outlets selling it, the legal restric-
of dependence on alcohol include: tions on purchasing it and price. In the western world alcohol
is widely available, relatively cheap, and its consumption is
n Feeling compelled to drink. There is such a strong highly socially acceptable. The more it is consumed by the
desire to drink that alcoholics often feel they have no population as a whole, the greater the number of alcoholics.
control over their drinking behaviour, and if alcohol is not On an individual level, there is good evidence that dependence
available it is craved for. Many dependent drinkers want to on alcohol runs in families, and this is likely to be due to both
stop but feel they cannot. genetic and environmental factors.
Social drinking
At risk drinking
regularly exceeding 21 units/week for men, 30 units
or 14 units/week for women
8 units
Problem drinking
serious family and social problems 1 unit
occur as a result of drinking 1 Pint Beer
2 units
1 unit
Alcohol dependence 4 units
Fig. 1 Continuum of alcohol consumption. Fig. 2 Units of alcohol.
Alcohol dependence I 97
Depression
Alcohol dependence and depressed mood often go together,
and it can be difficult to decide which came first. Both cause Case history 36
poor sleep, reduced appetite, feeling worse in the morning,
loss of concentration, loss of interest in usual activities and low Edward is a 45-year-old businessman who presents to his GP with
mood. Some patients with a primary depressive episode will depression. He describes a disastrous year in which he has
begin to drink in an attempt to lift their mood or to blot out separated from his wife, accumulated large debts and in the past
unbearable feelings. However, this does not usually result in week been notified that he is to be made redundant from his job.
problem drinking or dependence, and there is even some He has been consistently depressed for several months, with
evidence that alcohol consumption overall is reduced during recurrent suicidal thoughts, loss of appetite, sleep disturbance and
a depressive episode. Most commonly the depression is sec- poor concentration. He says that he has been drinking alcohol in
ondary to the alcohol dependence 40% of alcoholics who order to relieve his distress and forget his problems. His
present to psychiatrists for treatment meet the criteria for a consumption has crept up to half to one bottle of whisky per day.
diagnosis of depressive disorder. In at least three-quarters of a. How would you establish whether he is dependent on alcohol?
these cases the depression resolves within two weeks of stop- b. What is the relationship between his depression and alcohol
ping drinking. It is only those patients who are still depressed abuse?
when no longer drinking that will benefit from treatment with c. How would you treat the depression?
antidepressant medication.
Suicide
Ten percent of alcoholics die by suicide due to a variable com-
bination of the depressant and disinhibiting effects of alcohol, Alcohol dependence 1
social problems and poor physical health.
Alcohol dependence is characterised by:
Alcoholic hallucinosis n priority of drinking over all other aspects of life
This is an uncommon disorder in which auditory hallucina-
n tolerance of the effects of alcohol
tions occur in clear consciousness in an alcoholic who contin-
ues to drink. The hallucinations may be simple noises that last n withdrawal symptoms on abstinence
a few days only, or in more severe cases are of voices speaking n physical, psychiatric and social problems
in the second or third person, and persisting for many months
or years. In contrast with schizophrenia there are no delusions,
98 THE PSYCHIATRIC SPECIALTIES
Alcohol dependence II
Assessment recognises that he has an alcohol problem and wishes to stop
All patients should be asked about their alcohol consumption, drinking. In these circumstances the withdrawal can often be
and specific quantities recorded. Vague responses, such as I managed at home with daily visits from the GP or Community
only drink socially, are not acceptable; many alcoholics con- Alcohol Team to monitor progress, and medication to control
sider themselves to be very sociable drinkers. As alcohol con- the symptoms. Hospital admission is only indicated if there is
sumption varies for most people, it is usually easiest to enquire a history of serious problems during previous withdrawals,
about a typical week and calculate the number of units con- such as convulsions or delirium tremens.
sumed. Remember that measures poured at home are usually Many withdrawals are not planned and happen after a
larger than the standard measures provided in bars. The period of enforced abstinence from alcohol. This may occur
pattern of alcohol consumption is important. Alcoholics typi- following admission to hospital and should always be consid-
cally have a rigid pattern, with regular consumption through- ered in a patient who becomes tremulous or confused within
out the day, beginning with an early morning drink to alleviate a few days of admission. Symptoms of the withdrawal syn-
withdrawal symptoms. The CAGE questionnaire is commonly drome are summarised in Figure 2. They are usually treated
used as a quick screening tool for alcohol dependence (Fig. 1). with benzodiazepines (e.g. chlordiazepoxide) which, like
If there is evidence of dependence, a detailed history of past alcohol, increase the activity of the neurotransmitter GABA.
and current drinking behaviour and its social, physical and The drug is given in sufficient doses to control the symptoms,
psychological consequences should be obtained. It is impor- and the dose is then gradually reduced and stopped over the
tant to ask about the patients attitude to their drinking: do course of a week, by which time the symptoms will have
they consider it to be a problem and if so are they prepared to resolved. Parenteral thiamine should be given to all patients to
accept help to stop drinking? Motivation to stop is a vital pre- prevent Wernickes encephalopathy. Detoxification should be
requisite of any treatment package. Those who have no such offered to all alcoholics expressing a wish to stop drinking,
motivation should be informed of the risks they are taking, including those who have been through this process many
and advised about the services available should they wish to times in the past.
seek help in the future. Delirium tremens, commonly known as DTs, is a serious
Assessment of those with symptoms of alcohol dependence condition that occurs within four days of stopping drinking.
should include a full psychiatric history and mental state It usually begins suddenly with intense anxiety, agitation,
examination, looking particularly for depression, suicidal tremulousness, confusion, a fluctuating level of consciousness
thoughts and cognitive impairment. A thorough physical and reduced awareness of the surroundings. Visual illusions
examination will be necessary to search for the many medical and hallucinations are common and are typically fleeting
complications of alcoholism, and this should be supported by visions of small animals but can be more complex. Dehydra-
investigations, including full blood count and liver function tion occurs and autonomic disturbance causes sweating, a
tests. The mean corpuscular volume (MCV) and serum weak rapid pulse and often mild pyrexia. Without treatment
gamma-glutamyl transpeptidase (GGT) are useful screening the symptoms will settle within 3 days, but there is a mortality
tests for alcohol abuse, as both are raised with chronic heavy rate of 5% due to cardiovascular collapse, intercurrent infec-
alcohol consumption. A corroborative history may be useful tion, such as a pneumonia, or hyperthermia. DTs usually
to complete the assessment, but many alcoholics attempt to
hide the full extent of their drinking from their families and
may be unwilling to have them involved in the assessment.
Treatment
Treatment of alcohol dependence consists of management of
withdrawal from alcohol and prevention of relapse. It is rela-
tively easy to persuade an alcoholic to stop drinking and treat
the subsequent withdrawal symptoms; maintaining absti-
nence from alcohol is the real challenge.
6 12 hours
Withdrawal from alcohol Abstinence
Management of withdrawal from alcohol, or detoxification,
may be done in a planned, controlled way, with a patient who 12 18 hours Tremor
Convulsions 12 24 hours
Resolution
3 4 days of symptoms
Fig. 1 The CAGE questionnaire. Fig. 2 Withdrawal syndrome.
Alcohol dependence II 99
require treatment in hospital and, in enhance patients motivation to not worldwide. AA relies on the
most circumstances, a general medical drink. It works by interfering with principles of open self-scrutiny, help
ward is better equipped to manage the the metabolism of alcohol, resulting to others and fellowship, and the
disorder than a psychiatric ward. Close in the build up of acetaldehyde if only membership requirement is a
nursing observations are required and alcohol is drunk. This has extremely desire to stop drinking. Two parallel
the patient should be examined for any unpleasant effects, with flushing, organisations, Al-Anon for the
evidence of infection, head injury or headache, nausea, increased heart spouses of alcoholics and Al-Ateen
other physical disorder that may compli- rate and hypotension. The patient for their children, are also available.
cate the clinical picture. Relevant investi- will therefore have an additional 4. Voluntary organisations. Many
gations should be performed, and reason to not drink after taking their organisations are available to
appropriate treatment started quickly. medication each day and a provide advice and support either
The delirium should be treated with powerfully reinforcing aversive effect individually or in groups for
benzodiazepines, such as chlordiazepox- if they do drink. However, there alcoholics and their families. Some,
ide, titrating the dose against the symp- have been a few cases of people such as the Salvation Army, also
toms. Fluid replacement is important taking disulfiram who have died provide centres for detoxification
and may need to be provided intrave- after consuming alcohol, so it should and Dry Houses for alcoholics to
nously. Parenteral thiamine should be be prescribed with caution. live in following detoxification.
given in every case. Acamprosate is thought to reduce
craving for alcohol through its effect
Prevention of relapse on NMDA and GABA receptors in
A great variety of treatments are avail- the brain, but has only been shown
able for alcoholism, and it is best to tailor to be effective among people Case history 37
a package to suit the individual as far as attending alcohol support groups.
is possible. Factors such as past experi- 2. Residential rehabilitation Mark is a 24-year-old man who was
ence of treatment, social supports and programmes. These are provided admitted to hospital following a fight in
the amount of physical and psychologi- by the NHS and the private sector. the street in which he was stabbed in the
cal damage already sustained will influ- Most use the Minnesota model of chest and sustained a pneumothorax.
ence the management plan (Fig 3). The treatment, which consists of Three days after his admission he
goal of treatment for the majority of education, multiple group meetings deteriorated suddenly. He did not appear
patients is lifelong abstinence from and individual psychotherapy. to be aware of his surroundings, and had
alcohol. A return to controlled drinking Groups are important in the periods of drowsiness interspersed with
is not a realistic possibility for most, as prevention of relapse and allow extreme agitation. He was convinced that
rapid reinstatement of the full depen- members to share their experiences there were insects covering his bed, and
dence syndrome is characteristic of and gain insight by seeing their own was terrified by them.
alcoholism. problems mirrored by others. They a. What is the likely diagnosis?
Treatments are provided by the health offer mutual support and work b. What would be your short-term
service, private sector and voluntary together to find strategies to cope management plan?
organisations, and a combination of without alcohol.
approaches is often helpful. Treatment 3. Self-help organisations.
options include: Alcoholics Anonymous (AA) is
probably the best known of all self-
1. Pharmacological. The drug help groups. It was founded in
disulfiram (Antabuse) is used to Akron, Ohio in 1935 and is now Alcohol dependence 2
n Allpatients should be asked about
alcohol consumption
Alcohol dependence n The CAGE questions and MCV and
GGT blood tests are useful screening
Specific treatments Individual factors
tests
Drug treatments Motivation
n Uncomplicated withdrawals
Counselling Social supports
from alcohol can be managed at
Residential rehabilitation Extent of physical and home
psychological damage
n Delirium tremens is a serious
Past experience of treatment condition that requires treatment in
Prepared to attend self-help hospital
groups, voluntary organisations n A programme of care to prevent
Lifelong abstinence relapse is required following
from alcohol withdrawal
Fig. 3 Prevention of relapse.
100 THE PSYCHIATRIC SPECIALTIES
Substance misuse
Psychoactive drug users come into individuals psychological, social or supplement or replace this with others
contact with medical services when occupational functioning. depending upon availability. Other
acutely intoxicated, dependent or men- Substance misuse occurs in all social aspects of the history to consider are
tally ill. Acute intoxication is a transient classes, and there is little evidence that previous treatment for drug abuse, social
alteration in the level of consciousness, its onset is associated with social depriva- circumstances, legal issues including
accompanied by changes in behaviour, tion. There is though likely to be down- pending court cases and probation, and
mood, perceptions and cognition, occur- ward social drift as a consequence of motivation for change. Physical exami-
ring after taking the drug. Dependence dependence on drugs and those pro- nation should include a search for injec-
on a psychoactive substance generally tected by social advantage are less likely tion sites and investigations should
occurs after prolonged and regular use, to suffer adverse consequences. Most include urinary drug screen, and, follow-
and shares many of the characteristics of users of illegal drugs are young and a ing counselling, blood tests for HIV and
alcohol dependence, including primacy Merseyside study found that 92% of the hepatitis B and C.
of drug taking over other activities, toler- opiate abusers were less than 30 years
ance and withdrawal symptoms follow- old. The middle-aged are more likely to Treatment of drug misuse
ing abstinence. be dependent on prescribed medication Drug services are provided by the health
The majority of adults in the devel- such as benzodiazepines. Men are twice service, social services, probation service
oped world use psychoactive drugs at as likely to use illicit drugs as women, and voluntary sector. A number of dif-
some time in their life. The legally avail- and most are single and unemployed. ferent approaches are available, and
able drugs, such as alcohol and tobacco, Up to 50% of people attending drug packages of care should be designed
are the most widely used but a substan- treatment centres have a history of con- to meet individual needs. Treatment
tial proportion of young people regu- viction, and the rate of criminal activity options include the following.
larly use illicit drugs such as cannabis is inevitably much higher than this.
and ecstasy, and up to a third of people The most commonly used drugs are Harm reduction measures
will use an illicit drug at some time in described in Table 1. In many cases it is not substance misuse
their lives. The point at which use of itself that causes problems, but the life-
these drugs becomes misuse or abuse Assessment style that accompanies it, in particular
is unclear, and the various agencies Assessment of an individual seeking criminal activity to finance the drugs and
involved apply different criteria. It is help for drug abuse or dependence other behaviour such as use of dirty
important to distinguish between begins with a thorough history, which needles to inject and unprotected sex.
unsanctioned drug use (use that is not must include a detailed account of Prescribing a substitute for abused drugs
approved of by society) and hazardous current drug use. Quantities may be dif- reduces the need for users to fund their
drug use that has harmful consequences ficult to judge, but the amount of money habit and the harm associated with use
for the user. It is the latter that mental spent on drugs will give some indication. of street drugs and intravenous injection.
health services are concerned with, in Many drug users take a variety of drugs. Heroin addicts are prescribed the opiates
particular if the drug use impacts on the They may have one preferred drug but methadone or buprenorphine, which
Psychosexual disorders
Psychosexual disorders fall into three relationship and so it is important to Sexual dysfunction in women
main groups in ICD10: sexual dysfunc- find out if there are any such problems.
tion, gender identity disorders and dis- Enquiry should be made about sexual Lack or loss of sexual desire
orders of sexual preference (Table 1). experience and beliefs and it is helpful to This has a number of psychological
Sexual dysfunction is the most common know whether the problem has occurred causes. It is common for sexual desire
of these groups, and so will be discussed during other relationships. Clinical within a relationship to decrease over
in detail. assessment should involve both part- time. Women often have to fulfil a
ners if possible, as they may have differ- number of different roles such as worker,
Sexual dysfunction, not caused ent views about the problem and may homemaker, parent, child and friend
by organic disorder or disease both contribute to the problem. Treat- and as these roles expand it may be dif-
The title of this category in ICD10 is ment is more likely to be successful if ficult to maintain the role of lover. Sexual
misleading. It implies that sexual dys- both partners are involved. desire is reduced by fatigue, stress,
function is caused either by organic A problem often encountered when depression, relationship problems and
illness and disease or by psychological taking a sexual history is that many previous adverse sexual experiences.
factors when, in fact, it is often caused by people are not used to discussing sexual These causes should be addressed
a combination of the two. An example of matters and feel embarrassed about during treatment. It is particularly
this is given in Figure 1 which also dem- doing so. If the person taking the history helpful for couples to set aside time to
onstrates how sexual dysfunction is appears embarrassed, this will make spend together in surroundings that
often the result of problems in both matters worse. A particular problem is encourage them to relax and talk as this
partners. knowing what words to use and feeling can often lead to a rejuvenation of sexual
comfortable in saying them. For example, desire. It is important to help couples
Clinical assessment terms such as ejaculation and orgasm discuss what they like and dont like
The structure of a sexual history is are stilted and may not be familiar to about their lovemaking as differences
similar to the history of other presenting some people. An alternative term like can lead to reduced sexual desire.
complaints. It is important to help the come is more likely to be understood
patient describe their problems by and using colloquial terms like this Failure of genital response
asking open questions. Once you have usually puts people at ease and encour- In women this consists of vaginal dryness
clarified the nature of the problem, it is ages open discussion. Because of this, it and failure of lubrication. By far the most
important to establish how long it has is important to become confident in common cause is postmenopausal oes-
been going on and whether there have speaking about sexual matters using trogen deficiency.
been any precipitating or maintaining terms people understand.
factors. Sexual problems are often a Orgasmic dysfunction
manifestation of other problems in a General principles of management This is more commonly known as anor-
It is important to investigate and treat gasmia. It is defined as failure to achieve
any suspected organic illness or disease orgasm despite adequate stimulation.
Table 1 ICD10 classification of
that may be contributing to the sexual While orgasm is central to many
sexual disorders womens enjoyment of sexual inter-
problems. Common conditions to look
Sexual dysfunction not caused by organic illness for are summarised in Figure 2. It is also course, some women derive satisfaction
or disease
essential to check whether either partner from other parts of lovemaking.
Lack or loss of sexual desire
has a mental illness, particularly depres- However, because most men cannot
Sexual aversion and lack of sexual enjoyment
Failure of genital response sion which is a common cause of loss
Orgasmic dysfunction of sexual desire. If sexual problems are
Premature ejaculation just one aspect of more general relation- Drugs Neurological
Non-organic vaginismus ship problems, these should be addressed Alcohol Peripheral or
Non-organic dyspareunia through relationship counselling. Anticholinergics spinal nerve
Excessive sexual drive Antiadrenergics damage (e.g. MS,
Gender identity disorders Antiandrogens tumour, tabes)
Transsexualism. Desire to live and be accepted as a Temporal or frontal
member of the opposite sex lobe damage
Dual-role transvestism. Wearing clothes of the opposite Male partner Female partner
sex in order to temporarily feel like a member of that
sex Vascular disease Post-menopausal
Disorders of sexual preference
Fetishism. Reliance on an inanimate object for sexual
arousal
Fetishistic transvestism. Wearing clothes of the Impaired erections Vaginal dryness Genital
opposite sex to achieve sexual arousal Dyspareunia Urethritis
Exhibitionism. Recurrent exposure of genitals to Penile or
strangers, usually leading to sexual arousal vagina
Hepatic disease
Voyeurism. Recurrent, secretive observation of people Feels sexually Feels sexually trauma
involved in sexual or intimate behaviour such as
Diabetes mellitus
inadequate inadequate Renal disease
undressing
Paedophilia. Sexual preference for children
Sadomasochism. Preference for sexual activity that Relationship
involves bondage or infliction of pain or humiliation problems
Multiple disorders of sexual preference. Combinations
of above disorders
Fig. 1 An example of the complexity of Fig. 2 Organic disorders causing sexual
some sexual problems. problems.
Psychosexual disorders 103
fully enjoy sexual activity without achiev- insert vaginal trainers of increasing size prostatectomy and is a common side
ing orgasm, they assume that the same while carrying out the relaxation exer- effect of antipsychotic drugs and antide-
is true of a female partner. Therefore, cises. Trainers can be fingers or spe- pressants, particularly specific serotonin
even if a woman does not consider anor- cially designed specula. The next step is reuptake inhibitors. With SSRIs, the
gasmia to be a problem, it may still cause insertion of a penis under the womans serotonergic antagonist cyproheptadine
problems in her sexual relationship. control before finally transferring control can be given prior to intercourse
Encouraging partners to discuss these to the partner. although this can precipitate a relapse
issues is a useful first step in treatment of depression. Otherwise, treatment
and behavioural therapy, in which inter- Dyspareunia involves advice about increasing the
course is initially prohibited (sensate This is genital pain occurring during amount of genital stimulation.
focus technique, Fig. 3), can be used to sexual activity. Non-organic dyspareunia
remove the pressure for a woman to is a misleading term as most cases are Premature ejaculation
achieve orgasm and allow couples to the result of both organic and psycho- This can be defined in different ways.
explore other sources of sexual pleasure. logical factors. Commonly, pain is caused Ejaculation occurring before or shortly
Encouraging masturbation and use of initially by an organic problem and after penetration certainly constitutes
sexual fantasy may help women learn non-organic dyspareunia then develops premature ejaculation. A broader defini-
ways to heighten their sexual arousal because of fear of the pain recurring. tion is that it is an inability to control
and achieve orgasm. Treatment should start with investiga- ejaculation sufficiently for both partners
tion and treatment of the organic causes. to enjoy sexual intercourse. It occurs in
Non-organic vaginismus Often, no further treatment is required. about 20% of men. It is much more
This is an involuntary spasm of the If the problem persists, a programme common in young men and usually
muscles surrounding the lower third of similar to that used for vaginismus is improves with increased sexual experi-
the vagina. As well as causing sexual likely to be successful. ence. There are a variety of treatments.
problems, it makes use of tampons dif- Performance anxiety has an important
ficult and may prevent women from Sexual dysfunction in men role in premature ejaculation and this
attending for cervical smear tests. It is Lack or loss of sexual desire can be reduced by advice and discussion,
caused by a fear of vaginal penetration. This is less common in men than women preferably involving both partners. The
In some cases this fear develops as a but its causes and treatment are similar stop and squeeze technique involves
result of dyspareunia and continues to those described above. squeezing the base of the penis firmly
even when pain is no longer a problem. just before ejaculation and then resum-
In other cases, the fear develops in the Failure of genital response ing intercourse once the sensation of
absence of pain. Treatment has a high This is more commonly known as erec- being about to ejaculate has subsided.
success rate. It starts with relaxation tile dysfunction or erectile impotence. It An alternative is for the man to work his
exercises that help the women learn to refers to the failure to achieve or main- way through a variety of masturbation
relax her vaginal muscles and reduce tain an erection. It affects about 40% of exercises that teach him to recognise
anxiety levels. The next step is to gently men over 40 and 70% of men over 70. when ejaculation is imminent and
Up to 25% of cases are caused by psy- develop techniques for delaying it.
chological factors alone, 25% by physical
factors alone and the rest by a combina-
Spend time together regularly tion of the two. Psychological factors are
Talk about relationship likely if a man is unable to achieve an
Do enjoyable things erection during intercourse but does so
No sexual contact at other times, such as on waking in the
morning or when masturbating. Psycho- Psychosexual disorders
logical aspects of the problem are often n Psychosexual disorders are classed
helped by the process of sensate focus into: sexual dysfunction, gender
Gradually reintroduce components
of sexual activity
which is outlined in Figure 3. Giving up identity disorders and disorders of
Kissing/cuddling smoking and reducing alcohol and illicit sexual preference
Caressing (non-genital) drug use can result in considerable
n Sexual
dysfunction is the most
Caressing (genitals) improvement. The most commonly
used physical treatment are phosphodi- common and is caused by physical,
Talking about likes / dislikes at each stage
esterase inhibitors, which improve blood psychological and relationship
flow to the penis by reducing the break- problems, sometimes alone and
down of cyclic GMP in smooth muscle sometimes in combination
Resume sexual intercourse cells that line blood vessels in the corpus n Gender identity disorders and
Use activities listed above as foreplay cavernosum. disorders of sexual preference are
Don't expect to be successful first time or uncommon and require specialist
every time Orgasmic dysfunction management
This takes the form of delayed or retro-
Fig. 3 Sensate focus. grade ejaculation. It can occur following
104
Self-assessment
All the following statements are either c) they bind to pre- and post- c) May present with a mixed
true or false synaptic receptors affective state
d) receptor binding causes a d) Can be made worse by
1. Regarding mental health services: biological effect antidepressants
a) CMHTs are multidisciplinary e) they pass into the postsynaptic e) Is often treated with
teams cell carbamazepine
b) Occupational therapists act as 8. The following are associated with 15. The following interventions are
care co-ordinators an increased risk of violence: recommended for the treatment of
c) Most cases of mental illness are a) Male gender depressive episodes in primary
seen by CMHTs b) Past history of violence care:
d) CPA is a specific social care c) PTSD a) Computerised CBT
intervention d) Substance misuse b) Problem solving
e) Home treatment teams control e) Cluster B personality disorders c) Exercise programmes
hospital admissions 9. In assessing the suicide risk of a d) Guided reading
2. Early Intervention in Psychosis patient following an overdose: e) Antidepressant medication
Teams: a) impulsive overdoses suggest 16. The following are features of
a) Work with recent onset cases, high suicide risk manic episodes:
regardless of age b) the number of tablets taken is a a) Emotional lability
b) Get involved once a diagnosis key factor b) Increased productivity at work
has been confirmed c) writing a suicide note suggests c) Flight of ideas
c) Avoid using medication in the higher risk of suicide d) Persecutory delusions
early stages of illness d) if they called for help, the e) Irritability
d) Act as care co-ordinators for suicide risk must be low 17. SSRI antidepressants are
their patients e) a history of previous self harm commonly used in the following
e) Work with patients until suggests a low risk conditions:
psychosis has resolved 10. Third person auditory a) Hebephrenic schizophrenia
3. Assertive Outreach Teams: hallucinations: b) Generalised anxiety disorder
a) Work primarily with homeless a) Are usually experienced as c) OCD
patients being inside the head d) PTSD
b) Display a forceful attitude b) By definition consist of three e) Somatoform pain disorder
towards patients separate voices 18. Mental state examination of a
c) Work most with people with c) May suggest the patient should patient with obsessivecompulsive
schizophrenia kill himself disorder will typically reveal:
d) Do housework with patients to d) Are often associated with a a) Dishevelled appearance
try to engage them diagnosis of schizophrenia b) Depressed affect
e) Are ineffective when substance e) May comment on the patients c) Delusions of contamination
misuse is present actions d) Mood congruent auditory
4. The following are examples of 11. The following factors contribute to hallucinations
functional mental illnesses: non-adherence with psychotropic e) Disorientation in time and
a) Bipolar affective disorder drugs: place
b) Schizophrenia a) Side effects of medication 19. The following are typical of
c) Borderline personality b) Good insight into the illness bulimia nervosa:
disorder c) Stigma a) Disregard for calorific intake
d) Korsakoff s psychosis d) Financial concerns between binges
e) Somatisation disorder e) Complex drug regimes b) Amenorrhoea
5. The following demographic factors 12. The following concepts are c) Good response to treatment
are associated with suicide: typically used in Cognitive with SSRIs alone
a) Female Therapy: d) 40% of cases have onset after
b) Older age a) Defence mechanisms age 40 years
c) Living in rural environment b) Counter-transference e) Better prognosis in men
d) Working as an anaesthetist c) ABC model 20. The following are correctly paired:
e) Unemployment d) Thinking errors a) Paranoid personality disorder:
6. The following health and social e) Cognitive schemata delusions of persecution
factors are associated with 13. The following suggest a diagnosis b) Dissocial personality disorder:
suicide: of schizophrenia rather than social withdrawal
a) Chronic arthritis psychotic depression: c) Borderline personality disorder:
b) Married a) Second person auditory rejection sensitivity
c) Schizophrenia hallucinations d) Histrionic personality disorder:
d) Alcohol dependence b) Thought broadcasting shallow affect
e) Bereavement c) Loosening of association e) Anankastic personality disorder:
7. Neurotransmitters have the d) Delusions of guilt feelings of ineptitude
following characteristics: e) Nihilistic delusions 21. In older people:
a) precursors are present in the 14. Bipolar disorder: a) Deliberate self-harm is often a
synaptic cleft a) Is a form of cyclothymia cry for help
b) presynaptic excitation causes b) Type 2 causes hypomanic and b) Early dementia is the condition
synthesis depressive episodes most likely to cause suicide
Self-assessment 105
c) Hearing impairment protects 30. The following are often used to e) School refusal is a common
against auditory hallucinations treat chronic (residual) manifestation
d) Alzheimers disease is the most schizophrenia: 37. The following conditions are likely
common form of dementia a) Antidepressant medication to be made worse by tricyclic
e) Antipsychotic drugs are helpful b) Family therapy antidepressants:
in Lewy body dementia c) Psychiatric rehabilitation a) Glaucoma
22. The following suggest a diagnosis d) Dynamic psychotherapy b) Prostatic hypertrophy
of delirium over dementia: e) Occupational therapy c) Ischaemic heart disease
a) Acute onset 31. The following are typical of d) COPD
b) Hallucinations alcohol dependence: e) Myaesthenia gravis
c) Personality change a) Intoxication early in the day 38. The Mental Health Act can be
d) Varying impairment of b) Able to maintain work and used:
attention relationships a) To detain a patient in a general
e) Evidence of acute physical c) Opportunistic drinking of hospital
illness alcohol b) By a police officer
23. Dementia is a common feature of d) Slow rate of relapse because of c) To force a patient to accept
the following conditions: tolerance medication at home
a) Huntingtons disease e) Delirium tremens occurs within d) As an alternative to a prison
b) HIV infection 24 hours of abstinence sentence
c) Normal pressure hydrocephalus 32. The following increase the e) To give antibiotics to an
d) Parkinsons disease likelihood of recognising incapacitous patient
e) Multiple sclerosis depression in primary care: 39. The following conditions are
24. The following are usually of a) Ask open questions psychotic in nature:
benefit in the management of b) Respond to emotional cues a) Schizotypal disorder
acute alcohol withdrawal: c) Save time with closed questions b) Schizoaffective disorder
a) Antipsychotic drugs d) Ask directly about emotions c) PTSD
b) Antidepressants e) Maintain eye contact for around d) Body dysmorphic disorder
c) Benzodiazepines 50% of time e) Anorexia nervosa
d) Buprenorphine 33. The following are features of 40. The following are correctly
e) Oral thiamine mental incapacity: paired:
25. The following processes maintain a) Mental retardation a) Phobias: Anticipatory anxiety
anxiety disorders: b) Decisions most people would b) Generalised anxiety disorder:
a) Avoidance consider foolish Fear of illness
b) Response prevention c) Not weighing evidence in the c) Social phobia: Worse in shops
c) Thinking biases balance d) Panic attacks: Metabolic acidosis
d) Extinction d) Decision not supported by the e) Depressive episodes: High rate
e) Operant conditioning nearest relative of anxiety symptoms
26. The following conditions e) Unable to communicate
often present with physical decision Answers
symptoms: 34. Autism: 1. TTFFT. CMHTs are
a) Delirium a) Causes narrow repetitive multidisciplinary teams in which
b) Depressive episodes patterns of behaviour all qualified staff act as care
c) Somatisation disorder b) Is often associated with learning coordinators, using the CPA
d) Dissociative fugue disability process to review and plan care.
e) Factitious disorder c) Is a specific developmental Most cases of mental illness are
27. Obsessions: disorder seen in primary care. Home
a) Seem to the sufferer to be d) Is characterised by excessive treatment teams are best placed to
inserted in their head make believe play decide whether admission is
b) Sometimes consist of images e) Typically features language needed.
c) If violent, suggest a high risk to problems 2. FFFTF. EIP teams work with
others 35. The following are true of ADHD: people aged 1435 years, for up to
d) Are usually resisted by the a) Also known as hyperkinetic 3 years, assessing suspected
sufferer disorder psychosis and coordinating care
e) Suggest a diagnosis of OCD b) Persistence into adulthood in for established cases, and starting
rather than depression most cases antipsychotic medication at an
28. The following are typical adverse c) Good response to mild early stage.
effects of most antipsychotic tranquillisers 3. FFTFF. Assertive outreach teams
drugs: d) Impulsivity is typical of the work in a highly patient-centred
a) Dry mouth condition manner with people who would
b) Diarrhoea e) Helped by behavioural otherwise disengage from
c) Agitation interventions treatment, typically people with
d) Tremor 36. Regarding conduct disorder: schizophrenia, often with
e) Acute dystonia a) It is usually diagnosed in comorbid alcohol or substance
29. The following are early signs of primary school misuse. Homelessness is an issue
lithium toxicity: b) Genetic factors are the main for some of their patients.
a) Slurred speech cause 4. TTFFT. Mental disorders are either
b) Fine tremor c) Having friends makes the organic, i.e. have a demonstrated
c) Ataxia diagnosis unlikely physical cause, or functional.
d) Ophthalmoplegia d) Many go on to exhibit dissocial Korsakoff s psychosis results from
e) Nausea and vomiting behaviour as adults brain lesions caused by thiamine
106 Self-assessment
deficiency. Personality disorders association is the thought disorder the most common form of
are mental disorders, not illnesses. typical of schizophrenia. Delusions dementia, followed by vascular
5. FTFTT. Middle aged and older of guilt and nihilistic delusions are dementia. Antipsychotic drugs
men living in cities are at greatest typical of psychotic depression. make Lewy body dementia worse
risk. Employment is a protective 14. FTTTF. Cyclothymia involves less and are associated with an
factor, except for a few high risk severe mood changes. Bipolar increased risk of stroke in all
professions, usually those that disorder, type 1 is diagnosed if forms of dementia.
provide easy access to methods of mania or mixed affective states 22. TTFTT. Delirium is caused by the
suicide. occur, with or without depression; toxic effects of physical illness on
6. TFTTT. Mood disorders and type 2 if only hypomania and the brain. It typically has an acute
alcohol and substance misuse carry depression occur. Antidepressants onset and causes fluctuating levels
the highest risk, but rates are may cause conversion to of confusion and perceptual
raised in most forms of mental hypomania and rapid cycling. disturbance, including
disorder. Marriage is protective, Carbamazepine is used less often hallucinations. Personality change
separation and bereavement than lithium, valproate and is typical of dementia.
increase the risk. antipsychotics. 23. TTTTT. These five conditions can
7. FFTTF. Neurotransmitters are 15. TTTTT. These are all available in all present with dementia, in
synthesised in the presynaptic primary care, as part of the addition to their other
neurone, stimulation of which stepped care of depression. manifestations. In the case of HIV
causes their release into the 16. TFTTT. Emotional lability and and normal pressure
synaptic cleft, where they exert flight of ideas are typical of mania, hydrocephalus, the dementia will
their biological effects by binding as are grandiose delusions, but improve with treatment of the
to pre- and post-synaptic receptors. persecutory delusions also occur. underlying condition.
8. TTFTT. Risk factors for violence Patients are often irritable as well 24. FFTFF. Benzodiazepines and
are male gender, alcohol and as elated. Mania is only diagnosed alcohol both activate GABA
substance misuse and, as is often if the patient is too unwell to receptors and each reduces
found in cluster B personality function normally. withdrawal from the other.
disorders, a history of violence and 17. FTTTF. SSRIs should be offered to Antipsychotic drugs are
impulsivity. Once these factors are patients with GAD, OCD and occasionally needed for rapid
taken into account, the effect of PTSD, but psychological treatment tranquillisation, but can reduce the
mental illness on rates of violence is often more effective. seizure threshold, as can
is small. Hebephrenic schizophrenia is antidepressants. Buprenorphine is
9. FFTFF. Planned overdoses, with treated with antipsychotic drugs, an opiate agonist used in opiate
evidence of suicidal intent, that the somatoform disorders with dependence. Oral thiamine takes
person thought would kill them psychological treatment. too long to restore levels to be
are the most concerning. Calling 18. FFFFF. Poor self care and helpful acutely.
for help suggests ambivalence but depression occur in OCD but are 25. TFTFT. Operant conditioning
this is not the only factor that not typical. Some patients fear maintains anxiety disorders by
determines subsequent risk. contamination but recognise their causing avoidance. Thinking errors
Previous DSH suggests a high risk concerns are misfounded, so are can cause anxiety. Response
of repetition and a raised risk of not deluded. Hallucinations and prevention is a form of treatment
suicide. cognitive impairment are not a and extinction is the abatement of
10. FFTTT. Hallucinations are heard feature. anxiety that occurs if a person
from external space. Third person 19. FFFFF. Most restrict calories manages to stay in a feared
hallucinations refer to the patient between binges. Most cases are not situation.
as he or she, e.g. He should kill underweight so amenorrhoea is not 26. FTTFT. Delirium is a psychiatric
himself and are a first rank typical. SSRIs can reduce the urge presentation of a physical
symptom of schizophrenia, as are to binge but should be used to condition. Physical symptoms
voices giving a running augment psychological treatments. are common in depression.
commentary on the patients Onset is in adolescence or early Medically unexplained physical
actions, usually in the third person. adulthood in the vast majority of symptoms are typical of
11. TFTTT. People are less likely to cases. Male cases are less common somatisation disorder and
take medication if they dont but have a worse prognosis. symptoms are fabricated in
believe they need to take it or feel 20. FFTTF. Mistrust and factitious disorder. Dissociative
stigmatised by doing so, have side suspiciousness are typical of fugue presents with amnesia.
effects, have to pay for it, or have paranoid PD, but delusions are not 27. FTFTF. Obsessions are recognised
to deal with complex regimes. a feature of personality disorders. by the sufferer as a product of
12. FFTTT. Defence mechanisms and People with dissocial PD engage their own mind and can be
transference are concepts used in with the world, but in an abrasive thoughts, images or impulses. The
dynamic psychotherapy. CBT way. Rejection sensitivity is typical sufferer finds them unpleasant and
teaches people that cognitive of borderline PD, as is a shallow often repugnant, and resists them
schemata lead to thinking errors, affect of histrionic PD. Feelings of and doesnt act on them, unlike
so that Antecedents result in ineptitude are typical of anxious compulsions. They occur in
unhelpful Beliefs and PD. depressive episodes as well as
Consequences. 21. FFFTF. DSH in older people is OCD.
13. FTTFF. Second person auditory usually a failed suicide attempt. 28. FFTTT. Antimuscarinic effects
hallucinations occur in both Dementia is not usually a cause of such as dry mouth are caused by
schizophrenia and depression. suicide. Auditory hallucinations are some antipsychotics, but are more
Thought broadcasting is a first more likely with hearing typical of tricyclic antidepressants.
rank symptom and loosening of impairment. Alzheimers disease is Diarrhoea is typical of SSRIs.
Self-assessment 107
Akathisia, Parkinsonism, dystonia information, weighing it in the only to enforce the treatment in
and tardive dyskinesia are typical balance and communicating the hospital of mental disorder and its
of antipsychotics and can occur decision. It should not be assessed manifestations. The MHA can be
even with atypicals other than on the basis of a diagnosis, such as applied to people at all stages of
clozapine. learning disability (mental the Criminal Justice System.
29. FFFFT. Nausea, vomiting and retardation), or the decision that is Section 136 allows a police officer
coarse tremor are the early signs, made. to take a person to a place of
slurred speech and ataxia occur 34. TTFFT. Autism is a pervasive safety if they pose a risk to
later. Fine tremor is a benign effect developmental disorder, themselves or others as a result of
that occurs at therapeutic levels. characterised by restricted and mental disorder.
Ophthalmoplegia is typical of repetitive behaviour and impaired 39. FTFFF. Brief periods of psychosis
Wernickes encephalopathy. social interaction and can occur in schizotypal disorder
30. FTTFT. Antipsychotic drugs are communication. Learning disability but the core features are not
still needed, but antidepressants occurs in 75% of cases. psychotic in nature. Schizoaffective
are seldom required. Family 35. TFFTT. ADHD is classified as disorder is only diagnosed if
therapy to educate carers and hyperkinetic disorder in ICD10. It psychotic symptoms typical of
reduce expressed emotion is is characterised by hyperactivity, schizophrenia and mood
helpful and rehabilitation and inattention and impulsivity. Most disturbance occur simultaneously.
occupational therapy can improve cases remit by adulthood. Flashbacks in PTSD are not
function. Dynamic psychotherapy Stimulant drugs and behavioural considered psychotic in nature and
would not help. and family interventions are distorted body image in anorexia
31. FFFFF. Early morning drinking is effective. nervosa is thought to be caused by
typical, but not intoxication 36. FFFTF. It is usually diagnosed in culturally determined views of
because of tolerance. The person secondary school. Genes play a thinness and the effects of
continues to drink despite part but family and environmental starvation on self-perception.
damage to work and relationships. factors are more important. Delusional disorder and not body
There is a regular pattern of Friendships with similar children dysmorphic disorder should be
drinking, not an opportunistic one are typical of the socialised form. diagnosed if concerns about
and rapid relapse is typical. Truancy occurs, not school refusal. appearance are of delusional
Withdrawal symptoms occur 50% exhibit dissocial personality intensity.
within hours but DTs usually after disorder as adults. 40. TTFFT. Anxiety about being
23 days. 37. TTTFF. TCAs have antimuscarinic exposed to the feared situation is
32. TTFTF. Best practice is to be effect that exacerbate glaucoma typical of phobias, as are health
empathic, maintain good levels of and prostatism and, in addition, concerns in GAD. Social phobia
eye contact, respond to emotional affect the cardiovascular system will only be worse in crowded
cues, ask open questions that because of anti-adrenergic places if it is likely the sufferer will
directly address the patients and membrane stabilising have to interact with others.
emotional state. properties. Metabolic alkalosis occurs in panic
33. FFTFT. Mental capacity involves 38. TTFTF. The MHA can be used to attacks. Depression and anxiety
understanding and retaining detain a person in any hospital but commonly coexist.
108
possible to help the family reduce treatments most likely to be of diagnoses by asking about alcohol
the level of expressed emotion in benefit. consumption, physical health and
the home. use of both prescribed and illicit
Case history 14 drugs.
Case history 11 a. Kwames children are at raised risk
a. The three symptoms described are of bipolar and unipolar mood Case history 17
common positive symptoms of disorders, but are more likely than a. Janet is likely to be helped by
schizophrenia. not to remain free of either interventions from step 2 and step 3
b. The course of schizophrenia is very condition. If they do develop a mood of the stepped care model for
variable; however, it is likely that he disorder, effective treatment is depression. CBT and
will experience further acute available. There is no evidence of antidepressants should be offered.
episodes of illness and he may measures that can be taken to Problem solving may be relevant if
develop negative symptoms. prevent the onset of mood disorders, the end of her relationship has led
c. His prognosis is likely to be but most people feel better for to practical problems. An exercise
much worse if he fails to comply maintaining regular sleep patterns programme may be of benefit.
with antipsychotic medication, and find it helpful to read self-help b. The treatment options should be
abuses illicit drugs, has little social books based on the principles of explained to Janet and she should
support or lives in an environment CBT. It would be important to bear decide, with advice if necessary,
with high levels of expressed the family history in mind if one of what are the best options for her.
emotion. his children developed any persistent
mood disturbance, and if he has a Case history 18
Case history 12 daughter who becomes pregnant, a. It is important to exclude physical
a. Antipsychotic treatment should be she should mention it to the causes for his symptoms by taking a
changed to a drug with less antenatal team. full medical history, and performing
antimuscarinic and sedative effects. a physical examination and relevant
If he doesnt respond to this, Case history 15 investigations. You should ask about
consider switching to clozapine. a. The diagnoses to consider are: psychological symptoms of anxiety,
Cognitive therapy targeting n manic episode of bipolar disorder such as feelings of fear, dread or
delusions and hallucinations should n intoxication with alcohol or illicit panic. Physical symptoms of anxiety
be considered, especially if there is drugs (such as amphetamines or include dry mouth, sweating,
only a partial response to cocaine) tremor and diarrhoea in addition to
medication. His daily living skills n normal variation in mood (she the shortness of breath and chest
should be assessed to determine may be excited about going to the pain that he complains of. If the
whether he needs rehabilitation, very important meetings). shortness of breath is due to anxiety
supported accommodation or other b. Further evidence of mania should it is likely that he is
community support. His financial be sought, such as difficulty hyperventilating. And this would
situation should be reviewed and sleeping, racing thoughts, poor resolve if he breathed into a paper
optimised. He should be helped to judgement (e.g. spending too much bag.
establish meaningful activity and to money) and psychotic symptoms. b. Social phobia is most likely because
stay involved with his local The GP should also ask about the symptoms were precipitated by
community. It is important to alcohol and illicit drug use. A the prospect of a public
explain the nature of his illness history from an informant (e.g. performance.
and treatment to him and his family parent, friend) may be useful. Risks
and let them know how to obtain associated with disinhibited Case history 19
help if needed in the future. His behaviour, such as overspending, a. Management of Antons social
mental state and treatment should sexual disinhibition and dangerous phobia should start with
be monitored by his care driving must be considered. reassurance and explanation of
co-ordinator from the CMHT and the symptoms he is experiencing.
by outpatient appointments with a Case history 16 CBT is the treatment of choice.
psychiatrist. His care should be a. Sharon is low in mood with His specific fears about public
co-ordinated through regular CPA tearfulness. She has psychological speaking could be addressed by a
meetings. symptoms of depression, as she is programme of systematic
taking a pessimistic view of things desensitisation, combined with
Case history 13 and has lost confidence. Biological anxiety management and challenges
a. Tell Sarah she is correct in her view symptoms are also present with of any thinking errors underlying
that her depressive episodes have sleep disturbance, loss of energy his anxiety. There may be a limited
been a response to life events and and forgetfulness and difficulty role for drug treatments. SSRIs are
explain that it was the symptoms coping at work probably due to effective in some cases of social
she developed at the time, their poor concentration. phobia and taking beta-blockers
duration and the extent to which b. You would need to know how long prior to doing a presentation may
they affected her life that led to the the symptoms had been present, be helpful.
diagnosis. She describes what and what had precipitated them.
sounds like hypomanic episodes, You should also look for other Case history 20
but check that she didnt experience symptoms of depression such as a. Marys differential diagnosis should
the disruption of normal function suicidal ideas, changes in appetite include:
or the psychotic symptoms that and diurnal variation in mood. A n obsessivecompulsive disorder
occur during manic episodes. Her past history and family history of n depressive disorder with
diagnosis is probably bipolar depression would help confirm the secondary obsessional symptoms
affective disorder, type 2, and this diagnosis. It is also important to n schizophrenia.
should help her by identifying the exclude common differential n In addition, it is likely that she
110 Case history comments
opportunity to discuss the problems Case history 32 decide not to press charges, and he
with his girlfriend, and if necessary a. Secondary nocturnal enuresis will be diverted out of the criminal
he could be given advice about bedwetting occurring after a period justice system at this stage.
where to seek help with rehousing. of being dry. It is most likely to be b. If a serious crime has been
A sick note allowing him to take a due to the stress and worry of her committed then the police will
period of leave from work may parents separating. usually press charges, and a forensic
allow the problem with his boss to b. Urinary tract infection is the psychiatry opinion will be sought
be resolved. The GP should arrange commonest differential diagnosis. prior to trial by jury in a crown
to see him at regular intervals to c. The mother should be reassured that court. If found guilty the judge may
offer support throughout the crisis this is a common problem, due to decide that the patient should
period. stress, and cannot possibly be receive psychiatric treatment under
deliberate as it is occurring in a hospital order.
Case history 30 Charlottes sleep. Mother has clearly
a. She is grieving for her mother. This also been through a stressful time, Case history 36
is, of course, a normal and and may find it easier to deal with a. If he is dependent on alcohol he
appropriate reaction, although Charlotte calmly if she has an would feel compelled to drink, and
not expressed in an entirely normal opportunity to express her feelings have a regular pattern of
way because of her mental of anger and distress elsewhere. consumption. He would also
retardation. Charlotte should not be punished for experience withdrawal symptoms,
b. At this stage no formal treatment is the bedwetting; instead the mother usually in the mornings, and may
required, but the staff may be able should work with her gently to sort drink to relieve them. He would
to help her grieve by giving her the problem out. A star chart is likely also be increasingly tolerant to the
opportunities to talk about her to be effective. Charlotte would earn effects of the alcohol.
mother, look at photographs and one star for each dry night, possibly b. It is not clear whether the
have access to some of her personal with the added inducement of a depression or alcohol abuse came
possessions as mementoes. If things present of her choice after one full first, but each is likely to make the
do not settle over the following week of being dry. other worse. It is possible that the
months, or if her behaviour social problems he describes
escalates (for example, with self Case history 33 (marital breakdown, debts and loss
harm), then treatment needs to be a. Frank probably has dementia. The of employment) could all be a direct
considered, including antidepressant gradual onset and global nature of result of his alcohol abuse. This
medication and referral to a his presentation is suggestive of accumulation of problems in
therapist who is skilled at Alzheimers disease, but his vascular addition to the alcohol could then
working with people with learning risk factors and abnormal gait raise precipitate a depressive episode.
disability. the possibility of vascular dementia. c. It is not advisable to treat a
Normal pressure hydrocephalus depressive episode in the usual way
Case history 31 causes dementia, ataxia and urinary (with antidepressant drugs and/or
a. Hyperkinetic disorder is the most incontinence and must be excluded. psychotherapy) in the face of this
likely diagnosis, but unsocialised b. If psychometric testing and considerable alcohol consumption.
conduct disorder should also be neuroimaging support a diagnosis The first step in treatment should
considered. of Alzheimers disease, then a be to address the alcohol abuse. If
b. Difficulties in family relationships cholinesterase inhibitor may help. he remains depressed after several
may well be contributing to Liams Normal pressure hydrocephalus, if weeks of abstinence from alcohol,
difficult behaviour. His parents present, is treatable. Check there is then specific treatment should be
divorced when he was 3 years old, no prescribed medication, alcohol started.
and he has a new step-father. There use or physical illnesses that may be
is clearly inconsistency between his exacerbating his condition. Person- Case history 37
mother and step-father in their centred non-drug interventions are a. The timing and presentation is
parenting styles, and his step-father most likely to be of benefit. suggestive of delirium tremens.
may be overly strict. He has a new Other causes of delirium should
baby sister, with whom he will be Case history 34 also be considered.
competing for his mothers a. Depressive disorder with nihilistic b. The following should be considered:
attention. It is also possible that his delusions (also known as Cotards n medication to reduce his distress
mother may be feeling unable to syndrome). and agitation and allow him to be
cope because she has postnatal b. As she has stopped eating and nursed safely; a benzodiazepine
depression. drinking, urgent treatment is such as chlordiazepoxide would
c. It is important that the mother and necessary, under the Mental Health be most appropriate for treatment
step-father are united and consistent Act if necessary. ECT should be of DTs
in their approach to Liam. Wherever considered, because of the rapid n nurse in separate room that is
possible any good behaviour (or onset of action. well lit and quiet
even absence of bad behaviour) n physical examination and
should be rewarded, and Case history 35 investigations to confirm the
undesirable behaviour ignored. a. The police should request a cause of the delirium
Having some one-to-one time with psychiatric opinion before pressing n give parenteral thiamine to
Liam each day may help address charges, ideally from the psychiatrist prevent Wernickes
some of the frustration and jealousy who has been treating the man. If encephalopathy.
he may feel following the birth of the psychiatric opinion is that the
his sister. The mother should also crime was committed because of Case history 38
be advised to liaise closely with the the schizophrenia, and treatment is a. Active treatment is desirable for this
school. offered, the police will usually man, as he poses a risk of violence
112 Case history comments
when unwell. Both the misuse. An assertive outreach measures such as provision of clean
schizophrenia and drug abuse will approach is likely to be necessary, needles and advice about sexual
need to be managed, ideally with i.e. services will have to go to him behaviour may be helpful. Depot
involvement of specialist services. In rather than wait for him to attend antipsychotic medication should be
some areas there are dual diagnosis clinics. The emphasis should be on considered, as he is unlikely to take
services aimed specifically at treating building a relationship with him prescribed oral medication
individuals with a combination of that will encourage him to engage consistently.
severe mental illness and drug with treatment. Harm minimisation
113
Index
A Amisulpride, 24
Amitriptyline, 2627
elderly people, 92
physical symptoms, 67
Bereavement therapy, 63
Best interests principle, 1617
ABC model of cognitive therapy, 32 Amnesia, dissociative, 64 primary care, 6869 Beta-blockers, 58
Absence seizures, 73 Amnesic syndrome, 71, 97 psychological treatment, 5859 Bipolar affective disorder, 4647
Acamprosate, 99 Amphetamine, 101 Anxiety symptoms, 56, 58, 67 aetiology, 48
Accommodation, 3435, 37 Anankastic personality disorder, 81, Appearance, 1011 clinical presentation, 5051
Acetylcholine, 2021, 30 83 children, 86 course of illness, 48
Alzheimers disease, 21, 90 Anorexia nervosa, 7677 Approved Mental Health depressive episodes, 4648,
neural systems, 21 see also Eating disorders Practitioner, 3, 18 5051
Acetylcholinesterase inhibitors, 21, Anorgasmia, 102103 Aripiprazole, 24 epidemiology, 48
3031, 91 Anticipatory anxiety, 56 Arousal, 56 management, 5051, 51b
prescribing, 31 Anticonvulsants, 28 Arson, 9495 physical treatments, 51, 51t
side effects, 31 epilespy, 73 Aspergers syndrome, 86 prophylaxis, 51
Activity scheduling, 55 Antidepressants, 2627, 27b Assertive Outreach Team (AOT), psychological/social interventions,
Acute stress reaction, 62 anxiety disorders, 58 45, 44 51
Adherence, 2223 bipolar affective disorder, 51 Attachment, 86 rapid cycling, 46, 48
Adjustment disorder, 62, 67, 69 breast-feeding, 79 Attention, 11 suicide risk, 5051
Adolescence, 89 children, 88 Attention deficit hyperactivity type I, 46, 48, 51
Advance decisions and statements, continuation treatment, 55 disorder see Hyperkinetic type II, 46, 48, 51
17, 37 dementia, 91 disorder Body dysmorphic disorder, 65
Aetiological factors, 89 depression, 55, 6869 Attitudes, 3637 Body mass index (BMI), 76f
Affect, 10 discontinuation syndrome, 27 Atypical antipsychotic drugs, 24 Borderline personality disorder,
Affective disorders see Mood generalised anxiety disorder, 69 depression, 55 8182
disorders mode of action, 21, 2627 mode of action, 24 Brain tumours, 73
Aggressive behaviour, assessment of neonatal discontinuation schizophrenia, 44 Breast-feeding, risks of drug
risk, 12 syndrome, 79 side effects, 24 treatment, 79
Agitation, 10 obsessivecompulsive disorder, 61 Auditory hallucinations, 11, 42, 45, Brief focal dynamic psychotherapy,
Agoraphobia, 5657 onset of action, 55, 58 50, 52, 97 33
Akathisia, 24 pregnancy, 79 Aura, 73 Bulimia nervosa, 76
Alcohol consumption levels (units), prescription in primary care, 69 Autism see Pervasive developmental drug treatment, 77
96 seizure threshold reduction, 73 disorder self-help programmes, 77
Alcohol problems, 9699, 97b, 99b side effects, 55, 103 Autonomic side effects, 24 see also Eating disorders
adolescents, 89 suicidality association, 27 Avoidance behaviour (phobic Buprenorphine, 100101
aetiology, 96 Antilibidinal drugs, 95 avoidance), 56, 58
anxiety disorders association, 58 Antipsychotic drugs, 2425, 25b
C
assessment, 9899
clinical features, 96
atypical see Atypical antipsychotic
drugs
B CAGE questionnaire, 98
dementia, 97 breast-feeding, 79 Baby blues, 78 Cannabis, 41, 100101
depression association, 54, 97 compulsory treatment, 23 Bedwetting (nocturnal eneuresis), 89 Carbamazepine, 28
elderly people, 93 delerium, 70 Behaviour, 1011 Care co-ordinator, 35, 37
hallucinosis, 97 delusional disorder, 39 children, 86 Care Programme approach (CPA),
physical symptoms, 67, 97f dementia, 91 dementia, 71 34
post-traumatic stress disorder depot medication, 2223, 25, 45 primary care doctors, 6869 Carer support, 34
association, 62 diabetes association, 25 Behavioural activation, 55 dementia, 91
primary care, 6869 high dose treatment, 25 Behavioural psychotherapy, 3233, schizophrenia, 45
residential rehabilitation historical background, 24 32t Catatonic symptoms, 38
programmes, 99 intramuscular injection, 4445 Behavioural therapy Categorical diagnosis, 6
social phobia association, 57 manic episodes, 51 anorgasmia, 102103 Central nervous system infections,
suicide risk, 97 mode of action, 2425 anxiety disorders, 5859 73t
thiamine deficiency, 71, 97 monitoring, 25 hyperkinetic disorder, 87 Character, 9
treatment, 9899 personality disorders, 82 see also Cognitive behaviour Child abuse, 84, 8889
withdrawal management rapid tranquillisation, 4445 therapy Child development, 8687
(detoxification), 30, 9899 schizophrenia, 4445 Benzodiazepines, 13, 3031, 62, 70, Child psychiatry, 8689, 87b, 89b
withdrawal symptoms, 96, 98 seizure threshold reduction, 73 9899 history-taking, 86
Alcoholics Anonymous (AA), 99 side effects, 20, 24, 103 anxiety disorders, 58 psychiatric disorders classification,
Alzheimers disease, 90 typical, 24 compulsory treatment, 23 86t
acetylcholine, 21, 90 Anxiety disorders, 5657, 57b contraindication during breast- Child sexual abuse, 8889, 95
acetylcholinesterase inhibitors, 31, aetiology, 57 feeding, 79 Chlordiazepoxide, 30, 9899
91 bipolar affective disorder hypnotics, 30 Chlorpromazine, 2, 24
aetiology, 90 association, 48 indications, 30 autonomic side effects, 24
drug treatment, 91 childhood, 88 intramuscular injection, 4445 Citalopram, 26, 79
epidemiology, 90 classification, 5657 misuse, 100101 Classical conditioning, 58
memory clinics, 31 clinical assessment, 58, 59b mode of action, 21, 30 Classification, 67, 7b
pathology, 90 clinical presentation, 5657 rapid tranquillisation, 4445 Clinical exam technique, 15
presenting features, 90 depressive disorder association, side effects, 30 Clinical psychologist, 3
vascular dementia differentiation, 57 withdrawal management, 30 Clomipramine, 2627, 6061
91t drug treatment, 58 Bereavement, 6263 Clonidine, 101
Clozapine, 23, 2225, 44 Delayed ejaculation, 103 recurrence, 49 Eating disorders, 7677, 77b, 89
monitoring, 25 Delerium, 7071 recurrence prophylaxis, 55 aetiology, 7677
side effects, 25 causes, 70t sexual dysfunction association, 102 course, 77
Clozapine Patient Monitoring comparison with dementia, 70t stepped care model, 54, 69 epidemiology, 76
Service, 25 Delerium tremens, 9899 suicide risk, 5253 hospital treatment, 77
Cognitive analytic therapy, 3233 Deliberate self harm, 1213 see also Bipolar affective disorder management, 77
Cognitive behaviour therapy, 3233 aetiology, 12 Depressive pseudodementia, 53, 92 physical symptoms, 67
computerised, 54 assessment of risk, 1213 Deprivation of Liberty Safeguards prognosis, 77
depressive disorder, 5455 elderly people, 93 (DOLS), 17 Ecstasy, 100
obsessivecompulsive disorder, 61 impulsive, 12 Dexamphetamine, 100101 Educational achievement, 37
personality disorders, 82 repeated, 12 Diabetes, antipsychotic drugs Elderly people
post-traumatic stress disorder, 62 Delusional disorder, 39 association, 25 alcohol problems, 93
schizophrenia, 45 elderly people, 93 Diagnosis, 67, 14 delerium, 70
Cognitive impairment syndromes, Delusions, 10, 11t primary care consultations, 6869 deliberate self-harm, 93
7071 depressive disorder, 52 standard psychiatric categories, delusional disorder, 93
Cognitive schemata, 32, 59 schizophrenia, 38, 4243, 45 67 dementia, 7071, 90
Cognitive state, 11 Delusions of reference, 10, 38, 42 Diagnostic Systems Manual, 4th depressive disorders, 9293
Cognitive therapy, 3233 Dementia, 7071, 9091 version see DSM IV hypomania, 93
anxiety disorders, 59 alcohol dependence-related, 97 Dialectic behaviour therapy, 82 schizophrenia, 93
depressive disorder, 5455 causes, 71, 71t Diazepam, 30, 101 suicide, 93
eating disorders, 77 clinical assessment, 91 Differential diagnosis, 14 see also Old age psychiatry
mindfulness based, 55 comparison with delerium, 70t clinical exam technique, 15 Electroconvulsive therapy, 23, 28
obsessivecompulsive disorder, 61 drug treatment, 3031, 91 Dimensional measures, 6 29, 29b
Common law, 19 investigations, 91t Discrimination, 3637 consent, 29
Community Alcohol Team, 98 memory clinics, 31 Dissocial personality disorder, 81 depressive disorder, 55
Community Mental Health Teams neurological conditions, 7273 Dissociation, 64 elderly people, 9293
(CMHTs), 34 person-centred treatment, 91 Dissociative amnesia, 64 puerperal psychosis, 78
Community psychiatric nurse, 3, 69 presenile, 90 Dissociative (conversion) disorders, Elimination disorders of childhood,
Community treatment, 4 symptoms, 7071 6465, 65b 89
historical aspects, 2 treatable causes, 91 aetiology, 64 Emotional disorders of childhood,
mental health services, 69 Dependent personality disorder, management, 64 88
Community Treatment Order, 3435 8182 physical symptoms, 67 Encopresis, 89
Complex partial seizures, 73 Depot antipsychotic drugs, 2223, Dissociative convulsions Endocrine side effects, 24
Compulsions, 60 25, 45 (pseudoseizures), 64 Endogenous depression, 47
Compulsory admission, 1819, 19t Depression, 52 Dissociative disorders of movement Eneuresis, 89
mania, 51 monoamine theory, 21 and sensation, 64 Epilespy, 73
Compulsory treatment, 1819, 23 symptoms, 52 Dissociative fugue, 64 Erectile dysfunction, 103
Computerised cognitive behaviour Depressive disorder, 4647, 5455, Dissociative stupor, 64 Ethnic factors, 37
therapy, 54 55b District nurse, 69 schizophrenia, 40
Concentration, 11 adolescents, 89 Disulfiram (Antabuse), 99 Exercise, 54, 58
depressive disorder, 53 aetiology, 49 Donepezil, 3031 Exploitation by others, assessment
Concordance, 22 agoraphobia association, 5657 Dopamine, 20, 24, 48 of risk, 12
Conduct disorder, 8889 alcohol dependence association, hypothesis of schizophrenia, 20, Exposure and response prevention
learning disability association, 85 97 41 (ERP), 61
socialised, 88 anxiety disorders association, 57 neural systems (dopaminergic Exposure therapy, 32
unsocialised, 88 biological symptoms, 5253 systems), 20 Expressed emotion, 41, 43, 45
Confabulation, 71 children, 88 Dosulepin, 2627 Extinction, 5859
Consent, electroconvulsant therapy, classification based on severity, 46 Double depression, 47 Extrapyramidal side effects, 20, 24
29 clinical presentation, 50, 5253, Downs syndrome, 84, 90
Conversion, 64
Conversion disorders see
53b
core symptoms, 5253
Drug history, 9
Drug treatment, 2021, 21b
F
Dissociative disorders course of illness, 49 interactions, 75 Factitious disorder (Munchausens
Counselling, 68 diagnostic criteria, 52, 52f medical conditions exacerbation, syndrome), 64
Counter-transference, 33 drug treatment, 55 75, 75t physical symptoms, 67
Couples therapy, 34, 55 elderly people, 9293 monitoring, 2223, 25 Family history, 9
Court of Protection, 17 electroconvulsive therapy, 55 side effects, 74t Family structure, child history-
CreutzfeldtJakob disease, 7273 epidemiology, 49 teratogenicity, 79, 79t taking, 86
Crime, mental disorder relationship, high intensity psychological Drug-induced psychosis, 101 Family therapy, 3435, 35b
9495, 95t treatments, 5455 Drugs of abuse, 100t eating disorders, 77
Criminal justice system, 94 low intensity psychosocial DSM IV, 67 schizophrenia, 45
Crisis management, 5 interventions, 54 depressive episodes, 52 Fight or flight response, 56
personality disorders, 8283 management, 51 DSM V, 6 Financial problems, 35
Crisis Resolution and Home mental state examination, 53 Duloxetine, 2627 Flight of ideas, 50
Treatment team (CRHT), 45, obsessional symptoms, 60 Dynamic psychotherapy, 33 Flumazenil, 30
13, 44 obsessivecompulsive disorder personality disorders, 82 Fluoxetine, 21, 26, 77, 79
Cruse, 63 association, 60 Dyspareunia, 103 Focal brain damage, syndromes, 71
Cyclothymia, 47, 80 physical illness response, 67 Dysphoric mania, 50 Forensic psychiatry, 9495, 95b
Cyproheptadine, 103 physical symptoms, 67 Dysthymia, 47, 80 see also Offenders, mentally
Cyproterone acetate, 95 post-traumatic stress disorder Dystonia, 24 disordered
association, 62 Formal thought disorder, 10
D postnatal depression, 7879
primary care, 6869
E Formication, 11
Formulation, 15
Day hospitals, 3 psychological symptoms, 52 Early Intervention in Psychosis Fragile X syndrome, 84
Debriefing, 62 puerperal psychosis, 78 team (EIP), 45, 44 Frontal lobe damage, 71
Index 115
Fugue, dissociative, 64
Functional mental illness, 7, 14
I Lofepramine, 2627
Lofexidine, 101
Monoamines, 2021
theory of depression, 21
ICD10, 67, 6t, 56, 70 Long-term treatment, 15 Mood, 10
G depressive episodes, 52
dissociative disorders, 64
Lorazepam, 30
LSD-induced psychosis, 101
children, 86
dementia, 71
Galantamine, 3031 learning disability, 84 Lunatics Act (1845), 2 Mood disorders
Gamma-aminobutyric acid (GABA), organic disorders, 74 aetiology, 4849, 49b
2021
Gamma-aminobutyric acid (GABA)
personality disorders, 80, 81t
psychosexual disorders, 102, 102t
M classification, 4647, 46t, 47b
epidemiology, 4849
receptors, 21 schizophrenia, 3839 Maintaining factors, 2, 8 learning disability association, 85
benzodiazepines mode of action, somatoform disorders, 64 eating disorders, 7677 primary care, 68
30 ICD11, 6 schizophrenia, 41 schizophrenia differential
Z drug mode of action, 30 Ideational apraxia, 70 Major tranquillisers see diagnosis, 39
Generalised anxiety disorder, 5657 Ideomotor apraxia, 70 Antipsychotic drugs Mood stabilisers, 2829, 29b
children, 88 Illusions, 1011 Malingering, 64 Movement disorders, dissociative,
primary care, 6869 Imipramine, 2627, 79 Management plan, 1415 64
Generalised motor seizures, 73 Immediate recall, 11 clinical exam technique, 15 Multidisciplinary team, 23
Genetic factors Incest, 89, 95 Mania, 46, 48, 5051 liason psychiatry, 66
alcohol dependence, 96 Indecent exposure, 95 bipolar affective disorder, 4647 primary healthcare, 69
Alzheimers disease, 90 Independent Mental Capacity clinical presentation, 5051 Multiple sclerosis, 72
autistic spectrum disorders, 86 Advocate (IMCA), 17 drug treatment, 51 Munchausens syndrome see
bipolar affective disorder, 48 Infections, central nervous system, precipitating factors, 48 Factitious disorder
depressive disorders, 49 73t puerperal psychosis, 78
eating disorders, 76
obsessivecompulsive disorder,
Information for patients, 22
anxiety disorders, 58
risk assessment, 5051
Manic depression see Bipolar
N
60 medical illness, 75 affective disorder Narcotics Anonymous, 101
personality, 8081 Inpatient treatment, 23, 5 Manic-Depressive Fellowship, 51 Negative reinforcement, 5859
schizophrenia, 40 Insight, 11 Medical disorder, 14 Neglect, assessment of risk, 12
Genetic testing, Huntingtons Insomnia, 30, 30t Memory clinics, 31 Neuroleptic malignant syndrome,
disease, 72 rebound, 30 Memory loss 24
Genital response failure see also Sleep disturbance alcohol-induced amnesic Neuroleptics see Antipsychotic
men, 103 Institutionalisation, 35 syndrome, 71, 97 drugs
women, 102 Intelligence, 84 dementia, 70, 90 Neurological conditions, 7273
Genogram, 86 Interests, 9 Mental capacity, 1617, 17b Neurotic disorders, 7, 56
Glutamate, 2021 International Classification of assessment, 1617 learning disability association,
Graded exposure, 55 Disease, 10th version see ICD10 principles, 16 85
Grandiose delusions, 10, 5051 Interpersonal Social Rhythm Mental Capacity Act (2005), 1617, Neurotransmitters, 20
Grief, 62 Therapy (IPSRT), 51 19, 37 Noradrenaline (norepinephrine),
abnormal, 6263 Interpreters, 37 Mental disorder, 1819 2021, 26, 48
Guardianship order, 3435 Intramuscular injection, rapid Mental Health Act, 1819, 19b, 23, neural systems, 20
Guided self-help, 54 tranquillisation, 4445 3435, 37, 51 Noradrenaline reuptake inhibitor
Gustatory hallucinations, 11 Investigations, 14 compulsory admission, 1819, 19t (NARI), 26
children, 86 compulsory treatment, 1819
H clinical exam technique, 15
Iproniazid, 26
limits, 19
right of appeal against detention,
O
Habits, 9 IQ (intelligence quotient), 84 19 Obsessions, 10, 60
Hallucinations, 11 Mental Health review tribunal, 19 Obsessivecompulsive disorder, 60
alcohol dependence, 97
schizophrenia, 38, 4243
K Mental health services, 25, 3b, 69
forensic psychiatry, 94
61, 61b
aetiology, 60
Haloperidol, 24, 70 Korsakoff s syndrome, 71, 97 liason psychiatry, 66 course of illness, 61
Head injury, 73 perinatal psychiatry, 7879 drug treatment, 61
Health visitor, 69
Historical aspects, 23
L service user involvement, 36
Mental retardation see Learning
epidemiology, 60
primary care management, 69
History-taking, 89 Lamotrigine, 28, 51 disability prognosis, 61
asking about suicidal thoughts, Language Mental state examination, 1011, psychological treatment, 61
13 children, 86 11b social treatment, 61
background information, 8 dementia, 70 children, 86 Occipital lobe damage, 71
children, 86 Lasting Power of Attorney (LPA), 17 Methadone, 100101 Occupational therapist, 3
Histrionic personality disorder, 83 Learning disability, 7, 14, 8485, Methylphenidate, 87 Occupational therapy, 35
HIV infection, 73 85b Mindfulness based cognitive Oculogyric crisis, 24
Home treatment, 5 aetiology, 84 therapy, 55 Offenders, mentally disordered, 94
Homelessness, 2, 37 classification, 8485, 84t Minor tranquillisers see assessment, 94
Homicide, 94 management, 85 Benzodiazepines diversion, 9495
Housing services, 2 mental illness association, 85 Mirtazapine, 2627 sexual offences, 9495
Huntingtons disease, 72 Lewy body dementia, 31, 9091 Mixed affective episodes, 46 types of crime, 9495, 95t
Hyperkinetic disorder, 8788 Liason psychiatry, 6667, 67b Mixed anxiety and depressive see also Forensic psychiatry
drug treatment, 87 Lithium, 2223, 28 disorder, 57 Olanzapine, 2425
learning disability association, 85 contraindication during breast- primary care, 68 Old age psychiatry, 9093, 91b, 93b
Hypnotic drugs, 30 feeding, 79 Moclobemide, 27 see also Elderly people
Hypochondriacal disorder, 65 depression, 55 Monitoring drug treatment, 2223 Older Persons Mental health
Hypomania, 46, 50 manic episodes, 51 antipsychotic drugs, 25 services, 3
elderly people, 93 monitoring, 28, 29t Monoamine oxidase, 2627 Olfactory hallucinations, 11
Hypothalamic dysfunction, eating puerperal psychosis, 78 Monoamine oxidase inhibitors Operant conditioning, 32, 55,
disorders, 76 toxicity, 28 (MAOIs), 2627 5859
116 Index
Opiate abuse, 100 Postnatal depression, 7879 Rapid Response Team see Crisis Seasonal affective disorder, 47
harm reduction measures, risk factors, 79 Resolution and Home Secondary gain, 64
100101 screening, 78 Treatment team (CRHT) Selective migration, 40
medical detoxification, 101 Post-schizophrenic depression, 39 Rapid tranquillisation, 4445, 45t Selective serotonin reuptake
Organic disorders, 7, 14, 7475, Post-traumatic stress disorder, 62 Reactive depression, 47 inhibitors (SSRIs), 26
75b primary care management, 69 Reading problems see Specific anxiety disorders, 58
psychiatric symptoms, 7475, Practice nurse, 69 reading disorder depression, 55
74t Praxis, dementia, 70 Reboxetine, 21, 2627 obsessivecompulsive disorder,
Orgasmic dysfunction Precipitating factors, 2, 8 Recovery model, 3637 6061
men, 103 eating disorders, 7677 Refugees, 37 personality disorders, 82
women, 102103 schizophrenia, 41 Refusal of drug treatment, 23 post-traumatic stress disorder, 62
Orientation, 11 Predisposing factors, 89 Regional Secure Units, 94 side effects, 26, 103
dementia, 70, 90 eating disorders, 76 Rehabilitation, 35 Self esteem, 86
Outpatient clinics, 3 Pregnancy, risks of drug treatment, residential programmes for Self neglect, 10, 45
79, 79t alcoholics, 99 assessment of risk, 12
P Premature ejaculation, 103
Premorbid personality, 89
Relationship counselling, 102
Relaxation training, 32
Self-assessment, 104
Self-help programmes
Paedophilia, 95 Presenile dementia, 90 Restraint, 4445 alcohol dependence, 99
Panic attacks, 5657 Presenting complaint, 89 Retrograde ejaculation, 103 eating disorders, 77
Panic disorder, 5657 children, 86 Risk assessment, 1213, 13b Sensate focus technique, 102103
Paracetamol, 13 Pressure of speech, 10 mania, 5051 Sensation disorders, dissociative,
Paranoid personality disorder, Primary care, 6869, 69b mentally disordered offenders, 94 64
8182 alcohol problems, 68 Risperidone, 2425 Separation anxiety disorder, 88
Parental support, 34 anxiety disorders, 68 Rivastigmine, 3031 Serotonin (5-hydroxytryptamine),
Parenting resources, 34 consultation time, 69 2021, 26, 48, 6061
Parietal lobe damage, 71
Parkinsonian side effects, 2021
doctors behaviour, 6869
management of mental illness, 69
S neural systems, 2021
receptors, 2021
Parkinsonian symptoms, 24, 90 mood disorders, 68 Schizoaffective disorder, 39, 47 Serotonin and noradrenaline
Parkinsons disease, 72, 90 recognition of mental illness, mood disturbance, 47 reuptake inhibitors (SNRIs),
Paroxetine, 26 6869 Schizophrenia, 3841 2627
Past medical history, 9 referral to secondary mental acute, 4245, 43b side effects, 27
Past psychiatric history, 9 health services, 69 adolescents, 89 Serotonin syndrome, 27
Perceptions, 1011 Primary gain, 64 aetiology, 4041, 41b Sertraline, 26, 79
Perinatal psychiatry, 7879, 79b Problem solving approaches, 34 Assertive Outreach team (AOT) Sexual desire loss
identification of women at risk, depressive disorder, 55 engagement, 5 men, 103
79 Prolactin level elevation, 24 chronic (residual), 4243, 43b women, 102
organisation of services, 7879 Pseudodementia, 67, 92 clinical assessment, 4445 Sexual dysfunction, 102103
Persecutory delusions, 10, 38, 42, 50 Pseudoseizures (dissociative community treatment, 44 men, 103
Persistent somatoform pain convulsions), 64 diagnosis, 3839 women, 102103
disorder, 65 Psychiatric nurse, 3 dopamine hypothesis, 20, 41 Sexual history-taking, 102
Personal history, 89, 9t Psychiatric services, 2 drug treatment, 4445 Sexual offences, 9495
children, 86 Psychiatrist, 3 elderly people, 93 Short-term treatment, 14
Personality, 80 Psychodynamic therapy, 55 environmental factors, 40, 41t Simple partial seizures, 73
dementia-related changes, 71, 90 Psychological treatments, 3233, 33b epidemiology, 4041, 41b Sleep disturbance
Personality disorders, 7, 14, 8083, bipolar affective disorder, 51 family treatments, 45 dementia, 91
81b, 83b dementia, 91 genetic factors, 40 depressive disorder, 5254
aetiology, 81 depressive disorder, 5455 high expressed emotion as Sleep hygiene, 54
classification, 80, 81t eating disorders, 77 stressor, 41, 43, 45 Social drift, 40
clinical assessment, 8283 obsessivecompulsive disorder, 61 inpatient treatment, 44 Social history, 9
crisis management, 8283 personality disorders, 82 learning disability association, 85 Social inclusion, 3637, 37b
drug treatment, 82 post-traumatic stress disorder, 62 maintaining factors, 41 Social phobia, 5657
epidemiology, 81 primary care services, 69 maintenance treatment, 45 Social services, 2
interactionist model, 80 schizophrenia, 45 management, 4445, 45b Social treatments, 3435, 35b
learning disability association, 85 Psychosexual disorders, 102103, mood changes, 39 bipolar affective disorder, 51
mental illness association, 83 103b negative symptoms, 38, 4145 dementia, 91
psychological treatments, 82 Psychotic disorder, 7 neurochemical abnormalities, 41 depression in elderly people,
situationist model, 80 Psychotropic drugs, 20 neurodevelopmental hypothesis, 9293
social treatments, 82 adherence, 2223 40 depressive disorder, 54
trait model, 80 medical conditions exacerbation, neurological abnormalities, 41 eating disorders, 77
treatment principles, 82 75, 75t positive symptoms, 3839, 39t, obsessivecompulsive disorder, 61
type model, 80 monitoring, 2223 4145 personality disorders, 82
Pervasive developmental disorder old age psychiatry, 92 precipitating factors, 41 schizophrenia, 45
(autism), 86 prescribing, 2223 prognosis, 43 Social worker, 34
Phenelzine, 27 Puerperal psychosis, 78 psychological treatment, 45 Sodium valproate, 28, 51
Phobic anxiety disorders, 5657 rapid tranquillisation, 4445, 45t Somatisation disorder, 6465
Phosphodiesterase inhibitors, 103
Physical illness
Q Schneiders first rank symptoms,
38
Somatoform autonomic
dysfunction, 65
psychological causes, 6667 QT interval prolongation, 24 selective migration, 40 Somatoform disorders, 6465, 65b
psychological/psychiatric Quetiapine, 28, 51 social drift, 40 aetiology, 65
consequences, 67, 7475 social treatments, 45 management, 65
psychological/psychiatric
symptoms, 67t, 74, 74t
R subtypes, 39, 39t
suicide risk, 43
physical symptoms, 67
Special Hospitals, 94
Picks disease, 90 Racism, 37 Schizotypal disorder, 39, 80 Specific developmental disorders,
Positive reinforcement, 55 Rape, 95 School refusal, 88, 88t 8687
Index 117