PSYCHIATRYLecture Notes

Gautam GulatiMary-Ellen LynallKate Saunders

11th Edition LNwith extended material online'

PsychiatryLecture Notes

PsychiatryLecture Notes

Gautam GulatiMBBS, MRCPsych, PGDipLATHE(Oxon), FHEA

Honorary Senior Clinical Lecturer in Forensic Psychiatry,

University of Oxford & Consultant Forensic Psychiatrist,

Oxford Health NHS Foundation Trust, UK

Mary-Ellen LynallMA (Cantab.)

Graduate-entry medical student, Magdalen College, University of Oxford, UK

Retained Lecturer in Neuroscience, Somerville College, University of

Oxford, UK

Kate SaundersBM, BCh, MA, MRCPsych, PGDipLATHE, FHEA

University of Oxford Department of Psychiatry, Warneford Hospital, UK

Eleventh Edition

Th is edition fi rst published 2014 © 2014 by John Wiley & Sons, Ltd

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Library of Congress Cataloging-in-Publication DataGulati, Gautam, 1979- author. Lecture notes. Psychiatry / Gautam Gulati, Mary-Ellen Lynall, Kate Saunders. — Eleventh edition. p. ; cm. Psychiatry Preceded by: Lecture notes. Psychiatry. 10th ed. / Paul Harrison, John Geddes, Michael Sharpe. 2010. Includes bibliographical references and index. ISBN 978-1-118-37820-5 (pbk.) I. Lynall, Mary-Ellen, 1986- author. II. Saunders, Kate, 1978- author. III. Harrison, P. J. (Paul J.), 1960- Lecture notes. Psychiatry. Preceded by (work): IV. Title. V. Title: Psychiatry. [DNLM: 1. Mental Disorders–Handbooks. 2. Psychiatry–Handbooks. WM 34] RC457.2 616.89–dc23 2013023531

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1 2014

Contents

Foreword by Professor John Geddes, vi

Preface, vii

Acknowledgements, viii

Quick guides, 1

History-taking checklist, 1

Mental State Examination checklist, 2

Structure of a psychiatric case presentation, 3

1 Getting started, 5

2 The basic psychiatric assessment, 9

3 Diagnosis-specifi c assessments, 19

4 Risk: harm, self-harm and suicide, 40

5 Completing and communicating the assessment, 47

6 What causes mental health problems?, 55

7 Treatment, 63

8 Psychiatric services and specialties, 82

9 Mood disorders, 92

10 Neurotic, stress-related and somatoform disorders, 103

11 Eating, sleep and sexual disorders, 115

12 Schizophrenia, 124

13 Dementia, delirium and neuropsychiatry, 138

14 Substance misuse, 154

15 Personality disorders, 165

16 Childhood disorders, 172

17 Learning disability (mental retardation), 185

18 Psychiatry in other settings, 193

19 Mental health and the law, 200

Self-assessment answers, 205

Appendix 1: ICD-10 classifi cation of psychiatric disorders, 209

Appendix 2: Keeping up to date and evidence-based, 210

Index, 211

Foreword

When Paul Harrison, Mike Sharpe and I were off ered the chance to take over the eighth edition of Lecture Notes in Psychiatry in 1997, we spent a great deal of time together thinking through the structure of a book that would portray psychiatry as the evidence-based, patient-oriented branch of medicine that we knew it could be. Our thinking was inspired by the advances in evidence-based medicine led in Oxford by David Sack-ett, Muir Gray and Iain Chalmers and the Cochrane Collaboration. We wanted to apply the principles of clinical epidemiology – not just in our recommen-dations around use of treatments but also to challenge traditional approaches to history and examination taking in psychiatry. For decades, students had been taught that the only way to do a proper psychiatric as-sessment was to do a ‘full’ history and examination – an approach that is both ineffi cient and incompatible with real-world clinical practice.

Th e Oxford University Department of Psychiatry is proud of its heritage of producing and updating

its suite of textbooks, a process initiated by Michael Gelder when he was the fi rst Head of Department. We are therefore delighted that Gautam Gulati, Mary-Ellen Lynall and Kate Saunders have taken on the task of updating and revising Lecture Notes in Psychiatry. To an extent, all textbooks are out of date as soon as they are published but even with the developments in information technology, a concise, portable, pa-per textbook containing an up-to date synthesis of current knowledge occupies its own niche and still has a major role in training. Frequent revisions and updating are, however, critical to keep them accurate and useful. Th is is hard work of course and after three editions, Paul, Mike and I felt that we could not face revising the book again! It is marvellous to see that Gautam, Mary-Ellen and Kate have done so with such aplomb, keeping what remains useful from earlier editions but updating it with great skill.

John Geddes

Preface

Th e skills, attitudes and knowledge inherent in learn-ing psychiatry are relevant to all doctors – and to all other health professionals. We have written this book with medical students and psychiatric trainees in mind, but anticipate it being a useful resource for any health professional interested in the subject.

We describe a practical approach towards psy-chiatry. Chapter 1 outlines the principles behind the practice of modern psychiatry and introduces the psychiatric assessment. Our guide to assessment comprises a basic psychiatric assessment (Chapter 2), followed by diagnosis-specifi c assessments (Chapter 3) and a guide to risk assessment (Chapter 4). Chapter 5 describes how to draw everything together and com-municate the information to others. Th e recommen-dations in these chapters are summarized in a set of ‘quick guides’, included at the front of the book for easy reference.

Th e middle chapters cover the principles of aetiol-ogy (Chapter 6), treatment (Chapter 7) and psychiat-ric services (Chapter 8). Th e main psychiatric disor-ders of adults are covered in Chapters 9–15, followed by childhood disorders (Chapter 16) and learning disability (Chapter 17). Chapter 18 discusses psychia-try in non-psychiatric medical settings – the place where most psychiatry actually happens. Chapter 19 (Mental health and the law) is a new addition to the book and one you are likely to fi nd useful in which-ever setting you work.

Given our illustrious predecessors, we were hum-bled to be asked to write the 11th edition of Lecture Notes. Indeed we aimed to build upon the last edition of the book written so eloquently by Paul Harrison, John Geddes and Michael Sharpe.

To facilitate learning, we have added learning ob-jectives at the start of each chapter and highlighted key points towards the end. Multiple-choice ques-tions have been added, along with detailed explana-tions of the answers, to allow the reader to consoli-date key points. Links to key papers and guidelines have been added for readers keen to know more about a particular disorder.

We hope we have done justice to the work started by Paul, John and Michael in keeping this Lecture Se-ries book both informative and enjoyable.

We thank Jonathan Price, who was instrumental in drawing our team together and in setting the direc-tion in the early days of our writing. We are grateful to colleagues who have generously shared their exper-tise with us.

Th e book is dedicated to Annette Lynall, John Con-way, Catherine Sage, and the memory of Graham (Matthew) Jay and Colonel S. Gulati.

Gautam GulatiMary-Ellen Lynall

Kate Saunders

Acknowledgements

We would like to thank the following people for their contribution to this book.

Professor Paul Harrison (University of Oxford), Professor John Geddes (University of Oxford) and Professor Michael Sharpe (University of Edinburgh) who edited the 10th edition of this book.

Dr Jonathan Price (University of Oxford) for bring-ing the author team together, and for helping set the direction in the early days of our work on this edition of the book.

Dr Ruth Reed (Oxford Health NHS Foundation Trust) for her contribution to the chapter on Child-hood disorders.

Dr Valerie Elizabeth Murphy (Southern Health NHS Foundation Trust and University of Oxford) for her contribution to the chapter on Learning disabilities.

Dr Robert Cornish (Oxford Health NHS Foundation Trust) for his contribution to the chapter on Psychi-atric specialties.

Dr Borys Borvin (Oxford Health NHS Foundation Trust) for his contribution to the chapter on Sub-stance misuse.

Dr Suzanne Coghlan (Oxford Health NHS Foun-dation Trust) for her contribution to the chapter on Neuroses.

Dr Elizabeth Naomi Smith (Oxford Health NHS Foundation Trust) for her contribution to the chapter on Psychiatry in other settings.

Dr Charlotte Allan (Oxford Health NHS Foundation Trust) for her contribution to the chapter on Demen-tia, delirium and neuropsychiatry.

Karen Moore (Senior Development Editor at Wiley) for her help and advice with editorial aspects.

Psychiatry Lecture Notes, Eleventh Edition. Gautam Gulati, Mary-Ellen Lynall and Kate Saunders. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Quick guides

History-taking checklist

Before you begin: • Information (referral letters, notes), location, safety

• Introduction, consent, establish expectations

Basic details: • Method of referral, status under the Mental Health Act (where appropriate)

• Age, marital status, occupation, current living arrangements

Presenting complaint(s): • Main symptom: ‘NOTEPAD’: Nature, Onset, Triggers, Exacerbating/relieving, Progression, Associated

symptoms, Disability

• Other symptoms or problems, important negatives

• Impact of symptoms (biological, psychological, social)

• How others perceived symptoms/state

• Treatment received to date

Past psychiatric history:• Formal care: community psychiatric care? In-patient treatment? Detention?

• Treatments and response

• Self-harm or harm to others

Treatment/drug history:• Prescribed biological and psychological treatments

• Non-prescribed treatments

• Adherence, side effects

• Any recent changes?

• Allergies

Family history:• Parents, siblings and children: age, occupation, health and quality of relationship with patient

• For children: name, DOB, school, any other professional involvement

• Family history of mental illness, suicide, self-harm or substance misuse

• Any recent family events

Personal history and premorbid personality:• Pregnancy, birth and developmental milestones normal?

• Childhood: emotional problems, serious illnesses, parental separation

• Education: enjoyed school, bullying, fi nished school, special education classes?

• Occupational history: job changes, military service

• Intimate relationships (psychosexual history): partners, quality of relationships, sexual problems, abuse

• Traumatic events including exposure to self-harm/suicide

• Premorbid personality: character, interests, beliefs, habits

(continued)

2 Quick guides

Social history (current circumstances):

• Self-care

• Family and social support

• Caring responsibilities

• Living arrangements

• Finances: problems? benefi ts?

• Description of a typical day

Substance use: smoking, alcohol, illicit drugs:• Which substances, quantity, how and when?

• Evidence of dependence? Periods of abstinence?

• Impact on life, esp. related offences

Forensic history:• Contact with police, charges, convictions, imprisonment

• How do these relate to episodes of illness?

Past medical history:• Current and past illnesses, surgery, admissions

• (Menstrual and obstetric history)

Risk assessment:• Risks to self (self-harm, self-neglect…)

• Risks to others (staff, family, work…)

• Driving

• Child protection considerations

Corroborative history if appropriate

Proceed to Mental State Examination

Mental State Examination checklist

Appearance and behaviour• Appearance

• Body language/abnormal movements

• Eye contact/rapport

Speech• Quantity and spontaneity

• Volume and rate

• Tone, prosody

• Articulation and intelligibility

Mood• Subjective

• Objective: mood, constancy, congruity

Thoughts• Form/fl ow: any classic patterns? (formal thought disorder, fl ight of ideas)

• Content:

abnormal beliefs: delusions and over-valued ideas

preoccupations and obsessions

phobias

morbid thoughts: harm to self or others

Quick guides 3

Perceptions• Illusions and hallucinations (esp. visual, auditory)

• Derealization and depersonalization

Cognition• Orientation (time, place, person)

• Conscious level

• Specifi c domains: attention, memory, language, visuo-spatial

Insight• That they are unwell

• That they recognize their symptoms to be those of illness

• That the illness needs treatment

• Willingness to comply with treatment plan

• Capacity to consent to treatment plan

Structure of a psychiatric case presentationFor an example of a case presented in both oral and written form, see pages 51–52.

Demographic details:• Name, age, sex, occupation

• Dates of referral, assessment, admission, detention, discharge

• Current Mental Health Act status

Presenting complaint(s):• Nature, onset, progression, treatments to date

• Mental state at presentation

Background history:• Past psychiatric history and past medical history: diagnoses, admission and treatments

• Family history

• Personal and social history including job record, relationships, children, premorbid personality

• Use of alcohol and drugs

• Forensic history

Mental State Examination:• Appearance and behaviour

• Speech

• Mood

• Thoughts

• Perceptions

• Cognition

• Insight

Risk assessment:• Risks to self

• Risks to others

Physical examination

Investigations

Differential diagnosis: List the possible diagnoses, giving the most likely diagnosis fi rst and citing evidence for

and against the top differentials

(continued)

4 Quick guides

Aetiology, divided into either or both of:

• Predisposing, precipitating, perpetuating and protective factors

• Biological, psychological and social factors

Management and progress:• General aspects of management including setting of care

• Acute management: biological, psychological and social aspects

• Maintenance (long-term) management

• Current symptoms and problems

Prognosis:• Short-term

• Long-term

Psychiatry Lecture Notes, Eleventh Edition. Gautam Gulati, Mary-Ellen Lynall and Kate Saunders. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Similarly, conditions such as dementia may move be-tween psychiatry and neurology.

Th e conditions in which psychiatrists have devel-oped expertise have tended to be those that either manifest with disordered psychological function-ing (emotion, perception, thinking and memory) or those that have no clearly established biological ba-sis. However, scientifi c developments are showing us that these so-called psychological disorders are associated with abnormalities of the brain, just as so-called medical disorders are profoundly aff ected by psychological factors. Consequently, the delinea-tion between psychiatry and the rest of medicine can increasingly be seen as only a matter of convenience and convention.

Traditional assumptions, however, continue to in-fl uence both service organization (with psychiatric services usually being planned and often situated separate from other medical services) and terminol-ogy (see below).

Where is psychiatry going?Psychiatry is evolving rapidly, and three themes per-meate this book:

• Psychiatry, like the rest of medicine, is becoming less hospital based. Most psychiatric problems are seen and treated in primary care, with many oth-ers handled in the general hospital. Only a minor-ity are managed by specialist psychiatric services. So psychiatry should be learned and practised in these other settings too.

• Psychiatry is becoming more evidence-based. Diag-nostic, prognostic and therapeutic decisions should, of course, be based on the best available evidence. It may come as a surprise to discover that current psy-chiatric interventions are as evidence-based (and sometimes more so) as in other specialties.

Psychiatry can seem disconcertingly diff erent from other specialties, especially if your fi rst experience is on a psychiatric in-patient unit. How do I approach a patient? What am I trying to achieve? Is he or she dangerous? How does psychiatry relate to the rest of medicine? Th is chapter is meant to help orientate anyone facing this situation. Like the rest of the book, it is based on three principles:

• Psychiatry is part of medicine.• Psychiatric knowledge, skills and attitudes are rel-

evant to all doctors.• Psychiatry should be as eff ective, pragmatic and

evidence-based as every other medical specialty.

What is psychiatry?‘Psychiatry is … weird doctors in Victorian asylums using bizarre therapies on people who are either un-treatably mad or who are not really ill at all.’ Although remnants of such ill-informed stereotypes persist, the reality of modern psychiatry is very diff erent and rather more mundane! Psychiatry is, in fact, funda-mentally similar to the rest of medicine: the treat-ments used are primarily evidence-based, with suc-cess rates comparable with those in other specialties. Psychiatric patients are not a breed apart – psychiatric diagnoses are common in medical patients, and most patients with psychiatric disorders are treated in pri-mary care. And psychiatrists are no stranger than other doctors, probably.

Psychiatric disorders may be defi ned as illnesses that are conventionally treated with treatments used by psychiatrists, just as surgical conditions are those thought best treated by surgery. Th e specialty desig-nation does not indicate a profound diff erence in the illness or type of patient. In fact it can change as new treatments are developed; peptic ulcer moved from being a predominantly surgical to a medical condi-tion once eff ective drug treatments were developed.

Getting started

1