Professional Documents
Culture Documents
CRASH COURSE
SERIES EDITORS
Philip Xiu
MA, MB BChir, MRCP
GP Registrar
Yorkshire Deanery
Leeds, UK
Shreelata Datta
MD, MRCOG, LLM, BSc (Hons), MBBS
Honorary Senior Lecturer
Imperial College London,
Consultant Obstetrician and Gynaecologist
King's College Hospital
London, UK
FACULTY ADVISOR
Steven Birrell
MBChB, MRCPsych, PGCertClinEd, AFHEA
Consultant Psychiatrist
Queen Margaret Hospital, Dunfermline, Fife, UK
Psychiatry
Katie Marwick
MA (Hons), MB ChB (Hons), MRCPsych, PhD
Honorary Specialty Registrar in General Adult Psychiatry,
NHS Lothian
Clinical Lecturer in Psychiatry, University of Edinburgh
Edinburgh, UK
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ISBN: 978-0-7020-7383-0
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Series Editors’ foreword
The Crash Course series was conceived by Dr Dan Horton-Szar who as series
editor presided over it for more than 15 years – from publication of the first
edition in 1997, until publication of the fourth edition in 2011. His inspiration,
knowledge and wisdom lives on in the pages of this book. As the new series
editors, we are delighted to be able to continue developing each book for the
twenty-first century undergraduate curriculum.
The flame of medicine never stands still, and keeping this all-new fifth series
relevant for today's students is an ongoing process. Each title within this new
fifth edition has been re-written to integrate basic medical science and clinical
practice, after extensive deliberation and debate. We aim to build on the success
of the previous titles by keeping the series up-to-date with current guidelines for
best practice, and recent developments in medical research and pharmacology.
We always listen to feedback from our readers, through focus groups and
student reviews of the Crash Course titles. For the fifth editions we have
reviewed and re-written our self-assessment material to reflect today's ‘single-
best answer’ and ‘extended matching question’ formats. The artwork and layout
of the titles has also been largely re-worked and are now in colour, to make it
easier on the eye during long sessions of revision. The new on-line materials
supplement the learning process.
Despite fully revising the books with each edition, we hold fast to the principles
on which we first developed the series. Crash Course will always bring you all
the information you need to revise in compact, manageable volumes that still
maintain the balance between clarity and conciseness, and provide sufficient
depth for those aiming at distinction. The authors are junior doctors who have
recent experience of the exams you are now facing, and the accuracy of the
material is checked by a team of faculty editors from across the UK.
v
Preface
Author
The ability to diagnose and manage mental health problems is an increasingly
valued skill. Greater scientific understanding of mental illness is reducing the
stigma associated with it, in turn allowing its impact to be greater recognised:
mental illness is the single largest cause of disability in the UK (28%), the leading
cause of sickness absence, costs the UK economy 4.5% of GDP, and the life
expectancy of people with severe mental illness is reduced by 15–20 years.
Despite its importance, mental illness is typically under-recognised and
undertreated: around three quarters of people with a mental illness in England
receive no treatment (compared with around a quarter of people with a physical
illness). Mental and physical health problems are frequently comorbid and
exacerbate each other, meaning you will have the opportunity to improve the
lives of people with mental illness in almost any branch of medicine you choose.
This book is designed to equip you with the core knowledge and skills you need
to help people with mental health problems, both to pass your exams and to be a
holistic and skilled future doctor. The already popular 4th edition has been updated to
be in line with contemporary guidelines, classification systems and self-assessment
formats. This edition also includes two brand new chapters on neurodevelopmental
disorders, an increasingly common clinical presentation in children and adults.
Psychiatry can be a challenging speciality but it is also one where you can make
a real difference to people’s lives – old or young, rich or poor, in hospital or at
home. Psychiatry is also a rapidly changing speciality, however, I have done my
best to ensure this book will provide a solid foundation to help you effectively
diagnose and treat mental illness in the patients and people you care for in the
future. I wish you the best of luck!
Katie Marwick
Faculty Advisor
As a proud co-author of the fourth edition of the book, it has been a privilege to
work in an advisory role on this title. The fifth edition of Crash Course: Psychiatry
builds upon the success of previous incarnations of the book, being fully up to date
with regards contemporary psychiatric practice, the current classification systems,
evidence base and guidelines, and medico-legal information. It also includes
an expanded and improved self-assessment section. As with all titles within
the Crash Course series, the perfect balance of attention to detail and concise
accessibility means this book will be perfect for you whether you are a medical
student on placement or studying for exams, a junior doctors hoping to refresh their
knowledge, or indeed anyone interested in a career in psychiatry. Enjoy!
Steven Birrell
vi
Acknowledgements
I would firstly like to thank my faculty advisor, Dr Steve Birrell, who has provided
consistently sound and sensible advice on all topics as well as being a
supportive and kind colleague.
This textbook has drawn strength from expert feedback on specialist chapters
on a goodwill basis; I have done my best to accurately convey the reviewers’
expertise and judgement. I am very grateful to: Dr Lucy Stirland (Clinical
Research Fellow in Older Adult Psychiatry, University of Edinburgh),
Dr Rebecca Lawrence (Consultant Psychiatrist in Addictions, NHS Lothian),
Dr Rachel Petrie (Consultant Psychiatrist in Addictions, NHS Lothian), Dr Premal
Shah (Consultant Psychiatrist, Adult ADHD and ASD team, NHS Lothian),
Dr Rob Stewart (Consultant Perinatal Psychiatrist, NHS Lothian), Dr Leah Jones
(ST5 in Forensic Psychiatry, NHS Lothian) and Dr Senem Sahin (ST4 General
Adult Psychiatry, Camden & Islington NHS Foundation Trust). I am particularly
grateful to Dr Jennifer Cumming (ST6 in Child and Adolescent Psychiatry,
NHS Lothian) who also co-authored the Child and Adolescent Mental Health
chapter. Representatives of the Royal College of Psychiatrists (RCPsych) were
very helpful in providing detailed advice on some specific aspects of UK Mental
Health Acts (Dr Gerry Lynch, Consultant Psychiatrist, Chair of RCPsych in
Northern Ireland and Vice President of RCPsych, and Helen Phillips, Senior
Policy Administrator, RCPsych). I am also grateful to Dr Liana Romaniuk
(CT1 Psychiatry, NHS Lothian) who provided early input into the book’s
reorganisation.
This is the first edition of this textbook to contain Objective Structured Clinical
Exams (see accompanying resources on studentconsult.com). I have been
greatly helped in crafting their structure and content by the other members of the
Edinburgh University Psychiatry Undergraduate OSCE writing team (2015-2017),
in particular my co-chair Dr Chris O’Shea (Clinical Teaching Fellow, NHS Lothian)
and Dr Jennie Higgs (Clinical Teaching Fellow, NHS Lothian).
I am also grateful to those who have taught me, those whom I have taught, and
patients I have met. I hope I have distilled some of their wisdom and outlook into
the clinical cases and tips throughout the book.
Katie Marwick
vii
Dedication
Author
To my mother, Dr Helen Marwick (Developmental Psychologist and Senior Lecturer,
University of Strathclyde), who helped to shape my early interest in understanding
people and neuroscience and who has been much in my thoughts during the
preparation of this book.
Katie Marwick
Faculty Advisor
To my wife, children, family, friends, colleagues, and patients who all continue to
inspire, challenge, and support me.
Steven Birrell
viii
Series Editors’ acknowledgements
We would like to thank the support of our colleagues who have helped in the
preparation of this edition, namely the junior doctor contributors who helped
write the manuscript as well as the faculty editors who check the veracity of the
information.
We are extremely grateful for the support of our publisher, Elsevier, whose staffs’
insight and persistence has maintained the quality that Dr Horton-Szar has
set-out since the first edition. Jeremy Bowes, our commissioning editor, has
been a constant support. Alex Mortimer and Barbara Simmons our development
editors has managed the day-to-day work on this edition with extreme patience
and unflaggable determination to meet the ever looming deadlines, and we are
ever grateful for Kim Benson’s contribution to the online editions and additional
online supplementary materials.
Contributor:
Jennifer Cumming
Dr Jennifer Cumming BSc (Hons) MBChB MRCPsych AFHEA
ST6 Child and Adolescent Psychiatry & NHS Lothian Clinical Educator
Royal Edinburgh Hospital
Edinburgh, UK
Chapter 30. Child and Adolescent Psychiatry
ix
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Contents
xi
Contents
xii
GENERAL
Chapter 1
Psychological therapy�������������������������������������������������������������������������������� 29
Chapter 4
Psychiatric history
• Identifying information
• Presenting complaint
• History of presenting complaint
• Past psychiatric history
• Past medical history
• Current medication
• Family history
• Personal history
• Social circumstances
Psychiatric history • Alcohol and substance use
Mental state examination • Forensic history
• Premorbid personality
Physical examination
Risk assessment
Risk assessment
Formulation • Self: self-harm, self-neglect, exploitation
• Description of the patient • Others: aggression, sexual assault, children
• Differential diagnosis
• Aetiology
• Management
• Prognosis
3
Psychiatric assessment and diagnosis
prove helpful to explain to patients that you may need Identifying information
to interrupt them due to time constraints.
• Keep track of and ration your time appropriately. • Name
• Flexibility is essential (e.g. it may be helpful to put • Age
a very anxious patient at ease by talking about their • Marital status and children
background before focusing in on the presenting • Occupation
complaint). • Reason for the patient’s presence in a psychiatric setting
(e.g. referral to out-patient clinic by family doctor,
admitted to ward informally having presented at casualty)
HINTS AND TIPS • Legal status (i.e. if detained under mental health
legislation)
Arrange the seating comfortably, and in a way that
For example:
allows everyone a clear exit, before inviting the
Mrs LM is a 32-year-old married housewife with two chil-
patient into the room.
dren aged 4 and 6 years. She was referred by her family doctor
to a psychiatric out-patient clinic.
Make use of both open and closed questions when Presenting complaint
appropriate:
Closed questions limit the scope of the response to one- or Open questions are used to elicit the presenting complaint.
two-word answers. They are used to gain specific informa- Whenever possible, record the main problems in the pa-
tion and can be used to control the length of the interview tient’s own words, in one or two sentences, instead of using
when patients are being over-inclusive. For example: technical psychiatric terms. For example:
Mrs LM complains of ‘feeling as though I don’t know who
• Do you feel low in mood? (Yes or no answer)
I am, like I’m living in an empty shell’.
• What time do you wake up in the morning? (Specific
Patients frequently have more than one complaint, some of
answer)
which may be related. It is helpful to organize multiple pre-
Note that closed questions can be used at the very begin- senting complaints into groups of symptoms that are related;
ning of the interview, as they are easier to answer and help for instance, ‘low mood’, ‘poor concentration’ and ‘lack of en-
to put patients at ease (e.g. ‘Do you live locally?’; ‘Are you ergy’ are common features of depression. For example:
married?’; see Identifying information later). Mrs LM complains firstly of ‘low mood’, ‘difficulty sleeping’
Open questions encourage the patient to answer freely and ‘poor self-esteem’, and secondly of ‘taking to the bottle’
with a wide range of responses and should be used to elicit associated with withdrawal symptoms of ‘shaking, sweating
the presenting complaint, as well as feelings and attitudes. and jitteriness’ in the morning.
For example: It is not always easy to organize patients’ difficulties into
• How have you been feeling lately? a simple presenting complaint in psychiatry. In this case,
• What has caused you to feel this way? give the chief complaint(s) as the presenting complaint, and
cover the rest of the symptoms or problems in the history of
the presenting complaint.
COMMUNICATION
4
Psychiatric history 1
Current medication
HINTS AND TIPS Note all the medication patients are using, including psy-
chiatric, nonpsychiatric and over-the-counter drugs. Also
It is useful to learn how to screen patients for
enquire how long patients have been on specific medication
common symptoms. This is especially so with and whether it has been effective. Nonconcordance, as well
patients who are less forthcoming with their as reactions and allergies, should be recorded.
complaints. Remember to ask about:
• Low mood (depression) Family history
• Elevated mood and increased energy
(hypomania and mania) • Enquire about the presence of psychiatric illness
(including suicide and substance abuse) in family
members, remembering that genetic factors are
5
Psychiatric assessment and diagnosis
Forensic history
Relationship, marital and sexual history
• Puberty: significant early relationships and experiences, Enquire about the details and dates of previous offences
as well as sexual orientation and antisocial behaviour, including prosecutions, convic-
• Details and duration of significant relationships tions and prison sentences. It is important to ask specifi-
Reasons for break-ups cally about violent crime, the age of the patient’s first violent
• Marriage/divorce details. Children. offence and whether the patient has any charges pending.
• Ability to engage in satisfactory sexual relationships. Pending charges may be a source of stress for the patient,
Sexual dysfunction, fetishes or gender identity and in some cases a reason to report mental health symp-
problems (only enquire if problem is suspected). toms with a view to secondary gain.
6
Mental state examination 1
Premorbid personality By the time you have finished the psychiatric history, you
should have completed many aspects of the MSE, and you
The premorbid personality is an indication of the patient’s should just need to ask certain key questions to finish this
personality and character before the onset of mental illness. process off. The individual aspects of the MSE, which
It can be difficult to ascertain retrospectively. Indirect evi- are summarized in Fig. 1.1, are discussed in more detail
dence of it can be provided from the personal history (e.g. below.
Have they ever been able to hold down a job or been in a There is some variation in the order in which the MSE is
long-term relationship? Have their interests changed?). reported (e.g. speech is sometimes described before mood,
Patients may be asked directly about their personality be- and sometimes before thought form). As long as you in-
fore they became ill, or it may be useful to ask a close family clude the information, the exact order is not important.
member or friend about a patient’s premorbid personality.
For example:
A young man with schizophrenia, with prominent negative HINTS AND TIPS
symptoms of lack of motivation, lack of interest and poverty
Don’t just ask questions and write down answers!
of thought, was described by his mother as being outgoing,
intelligent and ambitious before becoming ill. Appearance and behaviour are vital to the mental
state examination, especially with less communicative
patients. Posture, facial expression, tone of voice,
COMMUNICATION
spontaneity of speech, state of relaxation and
One way to explore premorbid personality in a movements made are all important. You may find
patient with some insight is to ask questions it helpful to practise with a colleague – try writing
such as: ‘How would people have described you down 10 points that describe their appearance and
before?’ ‘How about now?’ behaviour.
7
Psychiatric assessment and diagnosis
when talking about her lack of self-esteem. After this her pos-
ture relaxed, her eye contact improved and there were mo- COMMON PITFALLS
ments when she smiled. There were no abnormal movements.
Note that disorganized, incoherent or bizarre
The term ‘psychomotor’ is used to describe a patient’s
speech (e.g. flight of ideas) is usually regarded as
motor activity as a consequence of their concurrent mental
processes. Psychomotor abnormalities include retardation a thought disorder and is described later in the
(slow, monotonous speech; slow or absent body move- thought form section.
ments) and agitation (inability to sit still; fidgeting, pacing
or hand-wringing; rubbing or scratching skin or clothes).
Note whether you can establish a good rapport with pa-
tients. What is their attitude towards you? Do they make
good eye contact, or do they look around the room or at
Mood and affect
the floor? Patients may be described as cooperative, cor- Mood refers to a patient’s sustained, subjectively experi-
dial, uninterested, aggressive, defensive, guarded, suspi- enced emotional state over a period of time. Affect refers to
cious, fearful, perplexed, preoccupied or disinhibited (that the transient ebb and flow of emotion in response to stimuli
is, a lowering of normal social inhibitions; e.g. being over- (e.g. smiling at a joke or crying at a sad memory).
familiar or making sexually inappropriate comments), Mood is assessed by asking patients how they are feel-
amongst many other adjectives. ing and might be described as depressed, elated, anxious,
guilty, frightened, angry, etc. It is described subjectively
(what the patient says they are feeling) and objectively
HINTS AND TIPS (what your impression of their prevailing mood is during
Observations of appearance and behaviour the interview) For example, her mood was subjectively ‘rock
bottom’ and objectively low. Affect is assessed by observing
may also reveal other useful information (e.g.
patients’ posture, facial expression, emotional reactivity
extrapyramidal side-effects from antipsychotic
and speech. There are two components to consider when
medication). It is useful to remember to look for: assessing affect:
• Parkinsonism: drug-induced signs are most
1. The appropriateness or congruity of the observed
commonly a reduced arm swing and unusually affect to the patient’s subjectively reported mood (e.g.
upright posture while walking. Tremor and a woman with schizophrenia who reports feeling
rigidity are late signs, in contrast to idiopathic suicidal but has a happy facial expression would be
parkinsonism. described as having an incongruous affect).
• Acute dystonia: involuntary sustained muscular 2. The range of affect or range of emotional expressivity.
contractions or spasms. In this sense, affect may be:
• Akathisia: subjective feeling of inner restlessness • Within the normal range
and muscular discomfort, often manifesting • Blunted/flat: a noticeable reduction in the normal
with an inability to sit still, ‘jiggling’ of the legs
intensity of emotional expression, as evidenced by a
monotonous voice and minimal facial expression
(irregularly, as opposed to a tremor, which would
Note that a labile mood refers to a fluctuating mood state
be regular) or apparent psychomotor agitation.
that alternates between extremes (e.g. a young man with
• Tardive dyskinesia: rhythmic, involuntary a mixed affective episode alternates between feeling over-
movements of head, limbs and trunk, especially joyed, with pressure of speech, and miserable, with suicidal
chewing, grimacing of mouth and making ideation).
protruding, darting movements with the tongue.
Thoughts
Problems with thinking are considered under two headings:
Speech thought form (abnormal patterns of thinking) and thought
Speech should be described in terms of: content (abnormal beliefs).
• Rate of production: pressure of speech in mania; long
pauses and poverty of speech in depression Thought form
• Quality and flow of speech: volume, dysarthria Disordered thinking includes circumstantial and tangen-
(articulation difficulties), dysprosody (unusual speech tial thinking, loosening of association (derailment/knight’s
rhythm, melody, intonation or pitch), stuttering move thinking), flight of ideas and thought blocking (see
• Word play: punning, rhyming, alliteration (generally Chapter 9 for the definitions of these terms). Whenever
seen in mania) possible, record patients’ disorganized speech word for
8
Risk assessment 1
word, as it can be very difficult to label disorganized think- listening or quizzically looking at hallucinatory objects
ing with a single technical term, and written language may around the room.
be easier to evaluate than spoken language.
RED FLAG
Thought content: delusions, obsessions
Elementary hallucinations are more common
and overvalued ideas
in delirium, migraine and epilepsy than in primary
It is diagnostically significant to classify delusions as:
psychiatric disorders.
• Primary or secondary
• Mood congruent or mood incongruent
• Bizarre or nonbizarre
• According to the content of the delusion (summarized
in Table 9.1)
Cognition
See Chapter 9 for a detailed description of these terms. The cognition of all patients should be screened by check-
An obsession is an involuntary thought, image or im- ing orientation to place and time. Depending on the cir-
pulse that is recurrent, intrusive and unpleasant and enters cumstances, a more thorough cognitive assessment may
the mind against conscious resistance. Patients recognize be required. Cognitive tests, including tests of generalized
that the thoughts are a product of their own mind. See cognitive abilities (e.g. consciousness, attention, orienta-
Chapter 13 for more information. tion) and specific abilities (e.g. memory, language, exec-
utive function, praxis, perception), are discussed fully in
Chapter 7. Figure 7.1 and Tables 7.1, 7.2 and 7.6 describe
COMMUNICATION methods of testing cognition.
Some psychiatrists include thoughts of self-harm,
suicide or harm to others under thought content, Insight
while others mention it only under risk assessment. Insight is not an ‘all or nothing’ attribute. It is often de-
As long as you mention it, it doesn’t matter where. scribed as good, partial or poor, although patients really
lie somewhere on a spectrum and vary over time. The key
questions to answer are:
• Does the patient believe they are unwell in any way?
Perception • Do they believe they are mentally unwell?
Hallucinations are often mentioned during the history. • Do they think they need treatment (pharmacological,
However, this is not always the case, so it is important that psychological or both)?
you specifically enquire about abnormal perceptual experi- • Do they think they need to be admitted to hospital (if
ences (perceptual abnormalities are defined and classified relevant)?
in Chapter 9). If patients admit to problems with percep-
tion, it is important to ascertain:
• Whether the abnormal perceptions are
hallucinations, pseudohallucinations, illusions or RISK ASSESSMENT
intrusive thoughts
• From which sensory modality the hallucinations Although it is extremely difficult to make an accurate as-
appear to arise (i.e. are they auditory, visual, olfactory, sessment of risk based on a single assessment, clinicians are
gustatory or somatic hallucinations – see Chapter 9) expected, as far as is possible, to establish some idea of a
• Whether auditory hallucinations are elementary (a patient’s risk to:
very simple abnormal perception; e.g. a flash or a • Self: through self-harm, suicide, self-neglect or
bang) or complex. If complex, are they experienced exploitation by others. Chapter 6 explains the
in the first person (audible thoughts, thought echo), assessment of suicide risk in detail.
second person (critical, persecutory, complimentary • Others: includes violent or sexual crime, stalking and
or command hallucinations) or third person (voices harassment. Chapter 32 discusses key principles in
arguing or discussing the patient, or giving a running assessing dangerousness.
commentary)? • Children: includes physical, sexual or emotional
It is also important to note whether patients seem to be abuse, as well as neglect or deprivation. Child abuse is
responding to hallucinations during the interview, as evi- discussed in more detail in Chapter 30.
denced by them laughing inappropriately as though they are • Property: includes arson and physical destruction of
sharing a private joke, suddenly tilting their head as though property.
9
Psychiatric assessment and diagnosis
Aetiology
The exact cause of most psychiatric disorders is often un-
THE FORMULATION: PRESENTING known, and most cases seem to involve a complex interplay
THE CASE of biological, social and psychological factors. In clinical
practice, psychiatrists are especially concerned with the
‘Formulation’ is the term psychiatrists use to describe the question: ‘What factors led to this patient presenting with
integrated summary and understanding of a particular pa- this specific problem at this specific point in time?’ That is,
tient’s problems. The formulation usually includes: what factors predisposed to the problem, what factors pre-
• Description of the patient cipitated the problem, and what factors are perpetuating the
• Differential diagnosis problem? Table 1.2 illustrates an aetiology grid that is very
• Aetiology helpful in structuring your answers to these questions in
• Management terms of biological, social and psychological factors – the
• Prognosis emphasis should be on considering all the blocks in the grid,
not necessarily on filling them.
Description of the patient
The patient may be described: (1) in detail by recounting
Management
all the information obtained under the various headings Investigations
in the psychiatric history and MSE; or (2) in the form of Investigations are considered part of the management plan
a case summary. The case summary consists of one or two and are performed based on findings from the psychiatric
paragraphs and contains only the salient features of a case, assessment. Appropriate investigations relevant to specific
specifically: conditions are given in the relevant chapters. Familiarize
• Identifying information yourself with these, as you should be able to give reasons for
• Main features of the presenting complaint any investigation you propose.
10
The formulation: presenting the case 1
11
Psychiatric assessment and diagnosis
Chapter Summary
• A psychiatric history is like any other history, except that more attention is given to
personal and social circumstances, and a mental state examination is conducted during it.
• A mental state examination, like a physical examination, is a snapshot of how the person
presents at the time you meet them.
• Physical examination is still important, even in patients who don’t report physical
symptoms.
• Psychiatric diagnostic systems are evolving in light of new understanding of mental
disorder aetiology.
13
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Pharmacological therapy and
electroconvulsive therapy 2
Psychotropic (mind-altering) medications can be divided 5-HT2C (serotonin 2C) receptor antagonist, but neither of
into the following groups: these actions alone have an antidepressant effect. Fig. 2.1
• Antidepressants illustrates the mechanism of action of antidepressants at
• Mood stabilizers synapses, and Table 2.1 summarizes their classification
• Antipsychotics and pharmacodynamics.
• Anxiolytics and hypnotics The latest research has focused on monoamine neu-
• Other rotransmitter activation of ‘second messenger’ signal
Despite its simplicity, this method of grouping drugs by transduction mechanisms. This results in the production
the disorder they were first used to treat is flawed, because of transcription factors that lead to the activation of genes
many drugs from one class are now used to treat disorders controlling the expression of downstream targets such as
in another class (e.g. antidepressants are first-line therapies brain-derived neurotrophic factor (BDNF). BDNF is neu-
for many anxiety disorders, and some antipsychotics also roprotective, and might be a key target of antidepressant
have mood stabilizing and antidepressant effects). action.
15
Pharmacological therapy and electroconvulsive therapy
SEROTONERGIC OR NORADRENERGIC
NERVE TERMINAL
Monoamine oxidase inhibitors (MAOI)
• Phenelzine
• Tranylcypromine
Metabolites
Reversible inhibitors of monoamine
oxidase A (RIMA)
• Moclobemide Noradrenergic
and specific
serotonergic
– antidepressant
MONOAMINE SYNTHESIS
Degradation (NaSSA)
Tryptophan Tyrosine • Mirtazapine
Specific serotonin reuptake Monoamine DOPA
inhibitors (SSRI) oxidase A
• Fluoxetine Dopamine
• Sertraline
–
• Paroxetine Serotonin (5-HT) Noradrenaline
• Citalopram
– –
no rece
–
rad pt
α2 nalin
re or
e
Serotonin reuptake pump
Note: the serotonin and noradrenaline (norepinephrine) pathways are presented together for convenience;
they do not occur in the same nerve terminal
Fig. 2.1 Mechanism of action of antidepressants at the synaptic cleft.
16
Antidepressants 2
Side-effects and contraindications in young people). Due to their low cardiotoxicity, SSRIs are
the antidepressant of choice in patients with cardiac dis-
SSRIs and SNRIs ease and in those who are at risk for taking an overdose.
SSRIs have fewer anticholinergic effects than the TCAs and However, they do have their own side-effects that may be
are not sedating. The majority of patients find them alert- unacceptable to some patients. These are summarized in
ing, so they are prescribed to be taken in the morning. Soon Box 2.1. Selective serotonin and noradrenaline reuptake
after initiation, or when taken at high doses, some patients inhibitors (SNRIs) such as venlafaxine have similar side-
can feel alerted to the point of agitation/anxiety. This may effects to SSRIs, but they tend to be more severe.
be associated with an increased risk for suicide, particularly Contraindications: mania, poorly controlled epilepsy and
in adolescents (see Chapter 30 for recommendations on use prolonged QTc interval (for citalopram and escitalopram).
17
Pharmacological therapy and electroconvulsive therapy
Trazodone
BOX 2.1 COMMON SIDE-EFFECTS OF SSRIs
Trazodone is a relatively weak antidepressant but a good
Gastrointestinal disturbance (nausea, vomiting, sedative. It is relatively safe in overdose and has negligible
diarrhoea, pain) – earlya anticholinergic side-effects. It is often used as an adjunctive
antidepressant in those receiving a nonsedative primary an-
Anxiety and agitation – earlya
tidepressant (e.g. an SSRI).
Loss of appetite and weight loss (sometimes
Contraindications: as TCAs (closely related structurally).
weight gain)
Insomnia
Sweating
RED FLAG
Sexual dysfunction (anorgasmia, delayed
ejaculation) Antidepressants should be used with caution in
a
Gastrointestinal and anxiety symptoms occur on initiation of patients with epilepsy, as they can increase seizure
treatment and resolve with time. frequency, either by directly lowering the seizure
threshold or by interacting with the metabolism of
antiepileptics. However, depression is common
and often undertreated in patients with epilepsy,
Mirtazapine so it is important not to avoid antidepressants if
Mirtazapine is very commonly associated with increased they are indicated. SSRIs or SNRIs are usually
appetite, weight gain and sedation (via histamine antago- recommended as first-line treatments.
nism). These side-effects can be used to advantage in many
patients. It is also associated with headache, dry mouth and,
less commonly, dizziness, postural hypotension, tremor and
peripheral oedema. It has negligible anticholinergic effects.
Contraindications: mania. MAOIs/RIMAs
Due to the risk for serious interactions with certain foods
and other drugs, the MAOIs have become second-line an-
Tricyclic antidepressants tidepressants. Their inhibition of monoamine oxidase A
Table 2.2 summarizes the common side-effects of TCAs, most
results in the accumulation of amine neurotransmitters
of which are related to the multireceptor blocking effects of
and impairs the metabolism of some amines found in cer-
these drugs. The sedative side-effect can be useful if patients
tain drugs (e.g. decongestants) and foodstuffs (e.g. tyra-
have insomnia. TCAs with prominent sedative effects include
mine). Because MAOIs bind irreversibly to monoamine
amitriptyline and clomipramine. Those with less sedative ef-
oxidase A and B, amines may accumulate to dangerously
fects include lofepramine and imipramine. Due to their car-
high levels, which may precipitate a life-threatening hy-
diotoxic effects, TCAs are dangerous in overdose, although
pertensive crisis. An example of this occurs when the in-
lofepramine (a newer TCA) has fewer antimuscarinic effects,
gestion of dietary tyramine results in a massive release of
and so is relatively safe compared with other TCAs.
noradrenaline (norepinephrine) from endogenous stores.
Contraindications: recent myocardial infarction, ar-
This is termed the ‘cheese reaction,’ because some mature
rhythmias, acute porphyria, mania and high risk for
cheeses contain high levels of tyramine. Box 2.2 lists the
overdose.
drugs and foodstuffs that should be avoided in patients
taking MAOIs.
Table 2.2 Common side-effects of tricyclic
antidepressants
Mechanism Side-effects RED FLAG
18
Mood stabilizers 2
BOX 2.2 DRUGS AND FOODS THAT MAY HINTS AND TIPS
PRECIPITATE A HYPERTENSIVE CRISIS IN
COMBINATION WITH MAOIS The abrupt withdrawal of any antidepressant
may result in a discontinuation syndrome with
Tyramine-rich foods symptoms such as gastrointestinal disturbance,
Cheese – especially mature varieties (e.g. Stilton) agitation, dizziness, headache, tremor and
Degraded protein: pickled herring, smoked fish, insomnia. SSRIs with short half-lives (e.g.
chicken liver, hung game paroxetine, sertraline) and venlafaxine are particular
Yeast and protein extract: Bovril, Oxo, Marmite culprits. Therefore all antidepressants (with the
Chianti wine, beer exception of fluoxetine, which has a long half-life
Broad bean pods and many active metabolites) should be gradually
Soya bean extract tapered down before being withdrawn completely.
Overripe or unfresh food
Medication or Substances
Adrenaline (epinephrine), noradrenaline
(norepinephrine) COMMUNICATION
Amphetamines
Cocaine Although certain antidepressants may cause a
Ephedrine, pseudoephedrine, phenylpropanolamine discontinuation syndrome, they do not cause
(cough mixtures, decongestants) a dependence syndrome or ‘addiction,’ in that
L-dopa, dopamine patients do not become tolerant to them or
Local anaesthetics containing adrenaline crave them.
(epinephrine)
Note: the combination of MAOIs and antidepressants or opiates
(especially pethidine or tramadol) may result in serotonin
syndrome. Opiates have some serotonin reuptake inhibitory MOOD STABILIZERS
activity.
Mechanism of action
It is not known how any of the mood stabilizers work.
MAOIs may have further side-effects similar to those Lithium appears to modulate the neurotransmitter-
induced by TCAs, including postural hypotension and an- induced activation of second messenger systems. Valproate,
ticholinergic effects. carbamazepine and lamotrigine all inhibit the activity
Contraindications (MAOIs): phaeochromocytoma, voltage-gated sodium channels, and also enhance GABA-
cerebrovascular disease and mania. ergic neurotransmission.
19
Pharmacological therapy and electroconvulsive therapy
20
Antipsychotics 2
21
Pharmacological therapy and electroconvulsive therapy
Striatum
Nucleus
Accumbens
Prefrontal
Cortex
Hypothalamus
Anterior pituitary
Ventral
Tegmental
Area
Pathways
Substantia Chemoreceptor
Mesolimbic Nigra
Trigger zone
Mesocentral
(Detects
Nigrostriatal substances
Tuberoinfundibular in blood
(Dopamine synthesized in and CSF)
Infundibular (arcuate)
Nucleus in tuberal region
of hypophyseal portal
region to reach anterior
pituitary)
22
Antipsychotics 2
23
Pharmacological therapy and electroconvulsive therapy
Table 2.7 summarizes the antipsychotic-induced EPSEs and Contraindications/cautions: severely reduced conscious-
treatment. See also Table 2.8. ness level (sedating), phaeochromocytoma, basal ganglia
Certain antipsychotics are available in a slow-release disorders (e.g. Parkinson disease or Lewy Body dementia
form as an intramuscular depot preparation that can be (can exacerbate)), arrhythmias (can prolong QTc, consider
administered every 1–12 weeks (e.g. flupentixol (Depixol), baseline electrocardiogram).
zuclopenthixol (Clopixol) and paliperidone). They are used
for patients who are poorly concordant with oral therapy or
who prefer the simplicity of an infrequent injection. Indications
• Schizophrenia, schizoaffective disorder, delusional
disorder
RED FLAG
• Prophylaxis in bipolar affective disorder
Clozapine is a very effective antipsychotic, but is • Depression or mania with psychotic features
only used in treatment-resistant schizophrenia, • Psychotic episodes secondary to a medical condition or
due to the life-threatening risk for bone marrow psychoactive substance use
suppression with agranulocytosis (0.8% of • Delirium
• Behavioural disturbance in dementia (caution is
patients). Patients should be registered with
recommended, as there is an increased risk for
a clozapine monitoring service and have a full
cerebrovascular events)
blood count (FBC) prior to starting treatment. • Severe agitation, anxiety and violent or impulsive
This is followed by weekly FBCs for several behaviour
weeks, followed by monthly FBCs for the duration • Tics (Tourette syndrome)
of treatment. With monitoring, fatalities from • Nausea and vomiting (e.g. prochlorperazine)
agranulocytosis are very rare (less than 1 in 5000 • Intractable hiccups and pruritus (e.g. chlorpromazine,
patients on clozapine). haloperidol)
24
Anxiolytic and hypnotic drugs 2
ANXIOLYTIC AND HYPNOTIC because: (1) these drugs are not pharmacologically
DRUGS related; (2) the antipsychotics do far more than just
tranquillize; and (3) the effect and use of anxiolytics
A hypnotic drug is one that induces sleep. An anxiolytic is in no way minor.
drug is one that reduces anxiety. This differentiation is not
particularly helpful, as anxiolytic drugs can induce sleep
when given in higher doses, and hypnotics can have a calm-
ing effect when given in lower doses (e.g. the benzodiaz- History
epines, which are anxiolytic in low doses and hypnotic in
high doses). This is reflected in the term ‘sedative,’ which In the 1960s, the benzodiazepines replaced the
refers to both these effects and is generally used to refer to a often-abused barbiturates as the drugs of choice for the
drug with hypnotic and/or anxiolytic effects. All such drugs treatment of anxiety and insomnia. However, this initial
can result in tolerance, dependence and withdrawal symp- enthusiasm was tempered by the observations that they
toms. Furthermore, their effects, when used in combination were associated with serious dependence and withdrawal
or with alcohol, are additive. The most important drugs in syndromes and had gained a market as drugs of abuse.
this group are the benzodiazepines and ‘Z drugs’ (zopiclone, Z drugs were introduced in the 1990s and were initially
zolpidem and zaleplon), which have very similar actions thought to be less likely to cause dependence – this is
and indications. not true. Today, benzodiazepines and Z drugs are recog-
nized as highly effective and relatively safe drugs when
prescribed judiciously, for short periods and with good
patient education.
HINTS AND TIPS
Classification
In the past, the antipsychotics have been referred
to as the ‘major tranquillizers,’ and the anxiolytics From a clinical perspective, it is useful to group benzodiaze-
as the ‘minor tranquillizers’. This is misleading pines and Z drugs according to their duration of action and
route of administration. Table 2.9 summarizes these quali-
ties in some common drugs.
25
Pharmacological therapy and electroconvulsive therapy
26
Electroconvulsive therapy 2
27
Pharmacological therapy and electroconvulsive therapy
Contraindications ETHICS
There are no absolute contraindications to ECT. Relative
contraindications include: Media portrayals of ECT have included its use as
a punishment, given without patient consent. In
• Heart disease (recent myocardial infarction, heart
modern practice, a patient with capacity will make
failure, ischaemic heart disease)
• Raised intracranial pressure his or her own decision about commencing ECT
• Risk for cerebral bleeding (hypertension, recent stroke) or not. A patient who lacks capacity may be given
• Poor anaesthetic risk. ECT without his or her consent if it is felt to be in
his or her best interests; however, this requires a
second opinion from an independent psychiatrist.
Chapter Summary
• Psychotropic medications are classed by the indication for which they were first licensed,
but many medications are of benefit in other disorders.
• Antidepressants influence the serotonin, noradrenaline and dopamine systems.
• Many antidepressants are well tolerated.
• Lithium requires regular monitoring of blood levels because high levels are toxic.
• Antipsychotics antagonize dopamine D2 receptors.
• Antipsychotics often have unpleasant and debilitating side-effects.
• Benzodiazepines and Z-drugs both increase the activity of GABAA receptors.
• Medications with shorter half-lives are more likely to cause discontinuation symptoms.
• Electroconvulsive therapy is a highly effective and safe treatment for severe mental
illness.
28
Psychological therapy
3
Psychological therapy describes the interaction between
a therapist and a client that aims to impart beneficial in the management of less severe psychological
changes in the client’s thoughts, feelings and behaviours. difficulties or as an adjunct to other forms of
Psychological therapy, which is often known as ‘psycho- treatment. Group-based peer support is a form
therapy’ or ‘talking therapy,’ may be useful in alleviating of self-help delivered to groups of patients with
specific symptoms (e.g. social phobia) or in helping a client shared symptoms, during which experiences can
improve their overall sense of well-being. be shared and progress reviewed by a facilitator.
Members of different professional disciplines, including
clinical psychologists, psychiatrists, occupational therapists,
mental health nurses, art and drama therapists and counsel-
lors, may all practise psychotherapy, provided they have had
adequate training and supervision.
HINTS AND TIPS
29
Psychological therapy
mild anxiety and depression; however, they tend not to be patients are unaware), and to facilitate their understand-
as useful for more severe mental disorders. ing of unconscious processes in the context of a safe, car-
ing relationship. Historically, various methods have been
used (free association; hypnosis; interpretation of dreams
Psychodynamic psychotherapy and fantasy material; analysis of defence mechanisms –
Psychoanalysis and psychodynamic therapy have changed see Table 3.1). However, modern psychodynamic psycho-
substantially since Sigmund Freud introduced psychoan- therapy mainly relies on the analysis of transference and
alytic theory in the late 19th century. Fig. 3.1 summarizes counter-transference:
some of his ideas regarding personality. The contributions • Transference is the theoretical process by which
of many other influential theorists (e.g. Melanie Klein, Carl the patient (inappropriately and unconsciously)
Jung, Alfred Adler, John Bowlby, Donald Winnicott), along- transfers feelings or attitudes experienced in an earlier
side the introduction of evidence-based practice, has meant significant relationship onto the therapist (e.g. a male
the continued evolution of theory and technique. However, patient becomes angry with his therapist, whom he sees
the basic assumptions of psychoanalytic theory remain con- as cold and uncaring, unconsciously reminding him of
sistent: namely, that it is mainly unconscious thoughts, feel- his mother).
ings and fantasies that give rise to distressing symptoms, and • Counter-transference refers to the feelings that are
that these processes are kept unconscious by defence mecha- evoked in the therapist during the course of therapy.
nisms (which are employed when anxiety-producing aspects The therapist pays attention to these feelings, as they
of the self threaten to break through to the conscious mind, may be representative of what the patient is feeling,
potentially giving rise to intolerable feelings (Table 3.1)). and so help the therapist to empathize with the patient.
The essential aim of psychoanalysis or psychodynamic Often, therapists have undergone therapy themselves as
psychotherapy is to facilitate conscious recognition of part of their training – this helps them to separate out
symptom-causing unconscious processes. It is the thera- what feelings belong to them and what feelings belong
pist’s role to identify and interpret these processes (of which to the patient.
Unconscious
Id
Id (’the pleasurable’):
Governed by the pleasure
principle. Demands immediate
Superego (’the ideal’):
satisfaction. Primitive, instinctive,
Ethical and moral part that
animalistic, hedonistic.
sets rigid standards for
behaviour. Usually internalized
from the parents’ moral code and
gives rise to feelings of guilt.
Often referred to as
‘the conscience’.
Fig. 3.1 The ‘iceberg metaphor,’ summarizing some of Freud’s ideas of personality. The iceberg itself represents the
‘structural’ model of the mind, while the sea represents the ‘topographical model.’
30
Psychotherapeutic approaches 3
• Although the terms psychoanalytic and psychodynamic minutes per session, during which time the patient
are often used interchangeably, they differ in the and therapist sit face-to-face. Duration of therapy
following ways: varies depending on the patient’s individual needs,
• Psychoanalysis describes the therapy where but it can range from a few months to several
clients see their analyst several times per week years. Psychodynamic psychotherapy may be
for a nonspecified period of time. Psychoanalysis conducted on an individual basis or in a group
is conducted with clients lying on a couch, with setting.
the analyst sitting behind them out of view. The
analyst may be quieter than in psychodynamic Due to the time- and resource-intensive nature (for both
therapy, and there is space for the patient to the health service and the patient) of classical psycho-
explore what comes into their mind and for the analysis, this is very seldom offered within the National
analyst to help the client understand how they Health System, with weekly psychodynamic therapy being
relate to the therapist (the transference) and to favoured. However, psychoanalysis is still practised within
others. the private sector.
• Psychodynamic psychotherapy is based on Mentalization-based therapy is one example of a therapy
psychoanalytical theory; however, it tends to be derived from psychodynamic psychotherapy and is summa-
more interactive and occurs once weekly for 50 rized in Table 3.4.
31
Another random document with
no related content on Scribd:
gewaande verpleegster keek, waaruit hij terecht kon afleiden, dat het
drietal het over hem had.
De taak van deze beide vrouwen bestond slechts hierin dat zij acht
moesten geven dat geen zieke de zaal zou verlaten en om in dringende
gevallen bij een plotselinge verergering den dienstdoenden geneesheer
te waarschuwen.
En voor de rest behoefden zij slechts aan [27]patiënten, die dit noodig
hadden, op gezette tijden geneesmiddelen ingeven.
De groote zaal werd nu dus slechts verlicht door het flakkerend schijnsel
der beide kaarslantaarns en zij maakten een troosteloozen, bijna
somberen indruk op den man naast het bed van Beaupré, met al die
bedden, met hun vage witte omtrekken, en hier en daar een donkere
plek van een hoofd op een kussen.
En Charly zelf, hoezeer hij zich ook inspande, vocht slechts met moeite
tegen den slaap die hem dreigde te overmannen.
Ook den vorigen nacht had hij zeer weinig kunnen slapen—en hij
beschikte niet over de ijzeren wilskracht van een John Raffles, die
desnoods drie dagen en drie nachten zonder slaap kon blijven!
Maar eensklaps werd hij uit zijn halven dommel gewekt door een heel
licht geraas!
Hij hief het hoofd op—en eensklaps was hij klaar wakker, zoo wakker,
als hij zich in geen tijden gevoeld had, naar hij meende.
Hij luisterde met de grootste aandacht, maar het geluid herhaalde zich
niet.
Hij nam een lantaarn met een zeer sterk licht tik zijn zak, en bevestigde
deze met een haak voor op de borst.
In een oogwenk was het door zijn hoofd gegaan, dat de koude
luchtstroom, welken hij zooeven gevoeld had, onmogelijk verwekt kon
zijn doordat de deur open ging—want dat had hij stellig moeten hooren,
en bovendien, de surveillant zat daar nog altijd even rustig als daar
straks, met gekruiste armen, en het hoofd op de borst gezonken.
Hij kon zich niet vergissen—een van die gordijnen had heel licht
bewogen alsof er een tochtje langs streek—of alsof daarachter iemand
het met de hand aanraakte.….
Hij stond nu slechts een paar decimeter van het gordijn af.…..
Toen drukte hij op den knop van zijn electrische zaklantaarn, en een
onderdeel van een seconde later rukte hij het gordijn terzijde, hief zijn
revolver op, en beval mat gedempte, maar dringende stem:
—Handen op!
Dit bevel was gericht tot een man, met een bleek vertrokken gelaat,
waarin twee boosaardige oogen fonkelden, en die blijkbaar eenige
minuten te voren door het raam was binnengeklommen. Een hoog,
dubbel raam, dat bij wijze van een deur open ging, en evenals andere
ramen uitkwam op een smal bordes.
De man achter het gordijn liet een sissenden klank hooren, maar zijn
handen gingen de hoogte in.
De surveillanten waren wakker geworden, door het onverwachte, sterke
lichtschijnsel, en door het terzijde rukken van het linnen gordijn en
snelden nu in de hoogste verbazing en schrik toe.
—Wat moet dat beteekenen, Miss? riep een hunner, schor van
ontroering uit.
—Dat zult gij aanstonds zien, zeide Charly kortaf. Onderzoek zijn
zakken, maar doe het voorzichtig! Ik zal hem intusschen in bedwang
houden en ik zweer u [28]dat ik den kerel neerschiet als hij ook maar een
vinger durft verroeren. Hij had het gemunt op het leven van mijnheer
Dubois!
—Open het maar eens, gelastte Charly, zonder den schurk uit het oog
te verliezen, maar wees op uw hoede.
—Houdt dat gevaarlijke ding maar hier en laat het onderzoeken! ging
Charly voort, ik ben er van overtuigd dat die naald gevuld is met een
snelwerkend vergif! Maar eerst zullen wij dezen ellendeling machteloos
maken! Snijd een stuk van het gordijnkoord af, en bind hem stevig de
polsen bijeen.
—Gij zijt getuigen van dezen laaghartigen overval geweest en gij zult er
wel voor zorgen dat hij aan de politie wordt overgeleverd, welke ik
zooeven heb opgebeld, ik zelf ga aanstonds Madame Dubois op de
hoogte brengen en wat den patiënt betreft, als hij maar even vervoerd
kan worden, breng hem dan morgen onmiddellijk naar een vertrek, waar
dergelijke aanrandingen tot de onmogelijkheden behooren. Bewaak dien
kerel goed, want ik acht een sluipmoordenaar tot alles in staat! Ik geloof
dat ik zijn gezicht ken en de politie zal hem zeker ook wel kennen!
Met deze woorden snelde Charly weg en hij had het gebouw reeds
verlaten toen de politie daar aankwam om den moordenaar in ontvangst
te nemen.
[Inhoud]
HOOFDSTUK VII.
De inbraak.
Den volgenden dag, omstreeks vier uur in den middag, hield er een
huurauto stil voor een prachtig huis in de Drury Lane, het verblijf van Sir
Roger Maxwell.
Hij wierp den bezoeker een verbaasden blik toe, maar haastte zich met
het kaartje weg, na hem te hebben verzocht plaats te nemen in de
prachtige marmeren hall.
Na eenige minuten keerde hij terug en vroeg den detective hem te willen
volgen.
Een oogenblik later stond Greenwood tegenover een man van een jaar
of zestig met een geel gelaat, dikke lippen, paarse wallen onder de
oogen en zoo goed als geheel kaal.
Die man was Sir Roger Maxwell, zeer bekend in de uitgaande wereld en
in sportkringen.
Hij wendde zijn waterige blauwe oogen naar Greenwood terwijl hij het
kaartje tusschen zijn vingers heen en weer draaide en vroeg, terwijl hij
zijn woorden als met een scheermes afsneed:
—Greenwood? Nooit van gehoord. Ga zitten. Wat wenscht gij? Zaak
van belang? Nooit iets met politie uitstaande gehad! Port? Madera?
Sigaren?
Greenwood was kalm gaan zitten en antwoordde, terwijl hij zijn heldere
grijze oogen op het schatrijke Hoogerhuislid vestigde:
—Ik zal geen misbruik maken van uw tijd, Sir! Sterken drank gebruik ik
niet, en ik rook ook nooit als er werk voor den boeg is. Ik zal zeer kort
zijn. Men komt hedennacht bij u inbreken!
—Zij komen waarschijnlijk met vier of vijf man, zij zijn gevaarlijk en zij
komen om half twee!
—Heel snugger! Heel snugger! Dan is hier alles naar bed. Vervloekte
schurken! Hoe weet gij dit alles?
De edele Lord stak den detective die hem aldus kwam waarschuwen,
twee vingers toe, welke deze echter niet scheen te zien.
Hij stond op, maakte een korte buiging voor het lid van het Hoogerhuis
en verliet het vertrek.
—Ik ben precies zeven minuten binnen geweest. Nu, die Sir Maxwell
mag een leeghoofdige, schatrijke en oude doordraaier zijn, hij is
tenminste geen kletsmeier. En ik moet tot zijn eer opmerken dat hij de
zaak tamelijk flegmatiek behandeld heeft. Wij zullen eens zien hoe onze
vriend zich vannacht houdt!
Juist toen het middernacht sloeg ging een deur in den muur van den tuin
achter het groote huis van Sir Maxwell open, en verleende doorgang
aan een tiental agenten, onder aanvoering van een inspecteur.
Een oude bediende, trillend van zenuwen, verzocht hen met schorre
stem hem te volgen en bracht hen naar de vestibule, terwijl de
inspecteur zich naar het werkvertrek van Sir Maxwell begaf dat op de
eerste verdieping was gelegen.
Binnen een kwartier waren alle maatregelen genomen, en wie onkundig
was van het veldtochtplan, zou, indien hij de vestibule ware
binnengetreden, zeker niet vermoed hebben dat er achter alle deuren,
achter een gordijn, en achter een zware pilaar, agenten verborgen
stonden, gereed om toe te springen!
De tijd verstreek langzaam, terwijl Sir Maxwell dien verdreef met het
drinken van eenige glazen rooden wijn, en het rooken van eenige fijne
import-sigaren.
De inbrekers mochten komen, zij zouden het niet eens tot aan de trap
brengen.
Zoo werd het half twee—en toen had iemand met een scherp gehoor,
beneden in de groote hall een zacht geklikklak van metaal op metaal
kunnen hooren en kort daarop het langzaam opengaan van een zwaar
ijzeren luik.
Men tilde Dr. Fox, die blijkbaar zwaar gewond was, en die door een
kogel in het voorhoofd getroffen was, behoedzaam op en droeg hem
naar buiten waar een groote politieauto, die inmiddels gewaarschuwd
was, kwam aanrijden.
Maar juist toen het portier geopend was, en men den zwaargewonde
naar binnen wilde dragen, richtte Fox zich eensklaps overeind, rukte
zich los, schoot een der agenten neder die het dichtst bij hem stond met
een kleine revolver, welke hij in zijn mouw verborgen had gehouden, en
snelde zoo vlug zijn beenen hem wilden dragen, in de duisternis weg.
Zijne lordschap vond het blijkbaar niet meer dan natuurlijk, dat een
inbraak in zijn huis iets onmogelijks was, en van te voren tot mislukking
gedoemd.
Sir Roger Maxwell keerde weder in zijn werkkamer terug om nog enkele
papieren te ordenen, toen hij plotseling als aan den grond genageld
bleef staan.
Tegenover de plek, waar hij zooeven aan zijn schrijftafel gezeten had,
aan de andere zijde van dit meubel, zat een man in een gemakkelijken
leunstoel, die heel op zijn gemak een sigaret rookte, blijkbaar zooeven
uit een zilveren doos genomen, die midden op de tafel stond.
—Ik zat in die kast daar, Sir Maxwell, antwoordde Raffles kalm.
—O, zoo weinig! zeide Raffles glimlachend. Men mag het werkelijk geen
naam geven! Neen, de hoofdsom denk ik van u te ontvangen!
—Zeer vriendelijk! hernam Raffles spottend. Maar ik vind het wel wat
weinig!
—Weinig! riep sir Maxwell nu toornig uit. Hoeveel dacht gij dan wel te
vragen?
—Tien duizend!
—Tien duizend pond sterling? kwam Mylord, en hij werd vuurrood. Zeg
eens, mijnheer—ik vind, dat uw grapjes wat ver gaan!
—Het is geen grapje, Sir Maxwell, maar bittere ernst! zeide Raffles,
terwijl hij opnieuw een dichte tabakswolk deed opstijgen.
—Maar—wie zijt gij dan? riep Mylord, schor van drift nu, en een geheel
ander man, dan toen hij er zoo zeker van was, dat zijn bezit geen
gevaar liep.
Toen koos hij, zooals men dat noemt, eieren voor zijn geld, stapte op de
kast toe, na de sleutels te hebben genomen, opende de zware deur,
telde haastig een pak bankbiljetten af en stak het Raffles toe.
Deze ging vluchtig den inhoud van het kostbare pak na, stond op, en
wierp zijn sigaret in den aschbak.
—Mijn taak is gedaan, Sir Maxwell! zeide hij, op zijn gewone rustige
manier. Het spijt mij, dat ik u langer heb moeten ophouden, dan mijn
bedoeling was. En tot mijn leedwezen zal ik nu genoodzaakt zijn, u even
in uw eigen kamer op te sluiten—om begrijpelijke redenen! Gij zoudt het
mij nog al te warm kunnen maken! En wat het geld betreft, dat ik u
zooeven ontnomen heb—wees er zeker van, dat het een betere
bestemming zal krijgen, dan gij er met mogelijkheid aan zoudt hebben
kunnen geven!
Nog een hoffelijke buiging—en Raffles had het vertrek verlaten, na den
sleutel uit het slot te hebben genomen.
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Metadata
Lord Lister
Titel: No. 305: De
schijndooden
Theo von
Blankensee
[Pseudoniem
Auteur: Info https://viaf.org/viaf/8133268/
van Mathias
Blank (1881–
1928)]
Felix
Info
Auteur: Hageman
https://viaf.org/viaf/5168161211441040070000/
(1877–1966)
Kurt Matull
Auteur: (1872– Info https://viaf.org/viaf/56770919/
1930?)
Jan
Illustrator: Wiegman Info https://viaf.org/viaf/65074834/
(1884–1963)
2023-09-22
Aanmaakdatum
20:58:09
bestand:
UTC
Taal: Nederlands
(Spelling De
Vries-Te
Winkel)
Oorspronkelijke
[1920]
uitgiftedatum:
Detective
and mystery
Trefwoorden:
stories --
Periodicals
Dime novels
-- Periodicals
Codering
Documentgeschiedenis
2023-09-21 Begonnen.
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