Problem Based Psychiatry

Volume 3, Treatment

Ben Green, Steph Chambers

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315343242
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This revised text presents student doctors, mental health nurses, social workers, occupational therapists, mental health advocates and mental health therapists with a problem-based approach to psychiatry. It contains numerous case studies, allowing a problem-based approach to core information and reflecting the processes that underlie clinical decision making. This second edition is upgraded, expanded and updated, including details of the best modern web based resources. Its problem-based approach to teaching is at the forefront of the delivery of modern medical school curricula, and includes additional new case scenarios and current opinion on mental disorders and their treatment using both drug therapy and psychotherapy. It fully reflects the latest practice and recent changes in mental health provision.

CHAPTER 1

The fundamentals of psychiatry

Psychiatry is a rich and diverse medical specialty concerned with abnormalities of the mind, namely abnormal emotions and thoughts, which may result in abnormal behaviour. Psychiatric illness may have social, psychological and biological causes. The symptoms and signs of mental disorder are known as psychopathology. Doctors analyse a patient’s psychopathology using the psychiatric history and the mental state examination.

CONTENTS

Introduction

Case History 1

Case History 2

Case History 3

Case History 4

The psychiatric assessment

Psychopathology

Abnormal movements

Interview skills

The psychiatric history

Case History 5

Case History 6

The mental state examination

Physical examination and investigations

Putting the information together

Classification

ICD-10

Learning points

Self-assessment

Explorations

Further reading and references

Glossary

Introduction

Psychiatrists use four methods of assessment: the psychiatric history, the mental state examination, a physical examination and relevant medical, social and psychological investigations. Information from these assessment methods is built into a differential diagnosis from which a management plan is formulated. The assessment is a holistic one in that it incorporates physical, social and psychological components. Similarly, treatments for mental illness may involve physical, social and psychological treatments.

• ➣ Physical treatments may include drugs such as antidepressants and antipsychotics, electroconvulsive therapy (ECT) and, very rarely, psychosurgery.
• ➣ Social treatments may involve rehousing in special rehabilitation settings, attendance at day hospital or day centres, some family interventions such as giving information and counselling to relatives and socio-legal advice.
• ➣ Psychological treatments may include one-to-one psychotherapy, group psychotherapy and family therapy. One-to-one psychotherapy is sometimes called interpersonal therapy There are many different forms, such as psychoanalysis and cognitive behavioural therapy (CBT).

However, such treatment plans can only be put into place once a diagnosis is made. Before a doctor can make a diagnosis, he or she must first recognise the symptoms and signs of mental illness. Such symptoms and signs are referred to as psychopathology.

The Psychiatric Assessment

The four cases here demonstrate that mental illness can occur at any age and that it can have a rich variety of presentations. Making a full assessment helps make sense of these different presentations and helps psychiatrists avoid dangerous diagnostic errors such as missing treatable organic disease (like hypothyroidism) and preventing suicide (by assessing whether the patient has suicidal thoughts or plans).

Case History 1

A 24-year-old man is brought to accident and emergency by the police after picking a fight with a taxi driver. He paces up and down restlessly and talks non-stop about an alien space craft from Betelgeuse which is transmitting thoughts into his head. His speech is difficult to understand. From his appearance it looks as if he has not changed his clothes or washed for several weeks.

Case History 2

A 72-year-old woman is seen by her family doctor. She complains of not being able to sleep because of ‘the people upstairs’. They keep her awake all night with their conversations about her. Sometimes they sing rude limericks about her virginity. The family doctor protests that she lives on the top floor of a block of flats and so there is nobody living above her. However, the old lady is adamant: ‘They must be living in the roof space then. I hear them all day long.’

Case History 3

A 20-year-old man goes to see his primary care doctor with feelings of panic and anxiety that have come on since the death of his mother four weeks before. He is finding it difficult to concentrate on his work and is crying most days. Sometimes he walks round the house expecting to see her. Sometime he thinks he catches glimpses of her out of the corner of his eye.

Case History 4

A 70-year-old man is reluctantly brought to the surgery by his wife. He denies that there is anything wrong, but when alone with the doctor his wife says that his memory is rapidly failing him and recently he has been doing ‘odd things’ like putting his shoes in the fridge and wearing his vest outside his shirt.

Traditionally, the psychiatrist then draws the information from this assessment together into a formulation which includes a summary, a differential diagnosis and a management plan.

The differential diagnosis depends upon the psychiatrist being aware of how different psychiatric illnesses are classified. The most important or likely diagnoses are considered first and are usually followed by a brief summary of evidence for and against each diagnosis. The differential diagnosis should cover any possible organic causes of symptoms together with the contribution that the patient’s personality makes.

In order to ensure that all possibilities are covered, the psychiatrist may use a diagnostic hierarchy. Later chapters will explain the differences between the categories in the hierarchy. The first group considered in the hierarchy approach are organic disorder candidates, then possible psychotic disorders, then affective disorders, then neurotic disorders and finally personality disorders.

A glossary is placed at the end of this chapter, but before we go any further, we need to explore some of the range of symptoms and signs that occur in everyday psychiatry in more depth.

Psychopathology

Abnormal Mood

Affect is our emotional state at any particular time. Mood is our prevailing emotional state over a longer period of time. Generally, people’s mood does vary according to events (that is to say it is reactive). Welcome events, like passing exams or getting promotion, make us feel happy. Untoward events, like sudden bereavement or failure, make us feel sad. On the whole, our mood is fairly constant, equable and euthymic. Dysthymia suggests an abnormality of mood. Abnormal mood is usually very different from normal in severity and persistence and may be low (depression) or high (mania or hypomania, a lesser form of mania).

Depression is associated with pervasive feelings of sadness, which are persistent. Bouts of crying or feeling like crying may be frequent. A depressed person’s thoughts are usually gloomy. Depressed people think the worst of themselves, the world around them and the future. Usually enjoyable activities are no longer of interest or enjoyment (this is a symptom known as anhedonia). Concentration on tasks, such as reading, is difficult for the depressed individual, leading to poor function at work or home. Thoughts themselves may seem slowed down and the depressed person may even move less (psycho-motor retardation), to such an extent that they may become stuporose. Important symptoms associated with depression are the so-called biological features of depression which usually include:

• ➣ insomnia (particularly intermittent waking through the night and waking earlier in the morning and being unable to return to sleep)
• ➣ anorexia (a loss of appetite and subsequently reduced food intake)
• ➣ weight loss
• ➣ diurnal mood variation – variation in mood through the day, e.g. feel low and slowed down in the morning and brightening towards the evening)
• ➣ reduced sex drive (reduced sexual appetite/ libido)
• ➣ constipation.

Feelings that life is not worth living or thoughts about ending one’s life are very common among depressed people and must be asked about in clinical encounters. Asking about these thoughts does not provoke suicidal thoughts or acts, but may allow the patient to express some difficult ideas, feel better understood and ultimately may help prevent suicide. Indeed, failure to ask would be negligent.

Mania (or its lesser form hypomania) is usually associated with an elated mood in marked contrast to the depressive’s gloom. The manic patient’s thoughts and feelings correspond with elation and are expansive and generally exceedingly positive. Instead of being psycho-motor retarded as in depression, the manic patient’s thoughts seem to race along; their activity may be greater than normal, even frantic. The rapid pace of thoughts may lead to very rapid speech (pressure of speech) and a rapid flow of connected ideas (flight of ideas), usually of a grandiose kind. The manic patient often exhibits poor judgement and might have grandiose plans based on an overvaluation of their own potential or abilities. They may feel that they are inordinately wealthy. This lack of judgement may lead to overspending or other errors at work or business. Sexual disinhibition may lead to risky sexual encounters. The elated mood exhibited by such patients can be temporarily enjoyable for those around them, but the elation may also be associated with irritability When confronted the disinhibited manic patient may become violent. Mood swings are possible and the previously elevated mood may easily switch into a depressed one. Suicidal feelings may occur.

Insomnia is nearly always present and patient may give a history of intense activity at times when they would normally be asleep, e.g. spring cleaning the entire house at 3 a.m.

Abnormal Thoughts

Through the course of a normal day a variety of thoughts and fantasies pass through the average person’s mind. Sometimes people are preoccupied with certain thoughts and these may be relevant and understandable, e.g. often thinking about a driving test in the days beforehand. Occasionally, some thoughts may enter a person’s mind unbidden and, though the person knows that these thoughts of theirs are irrational or nonsensical, the thoughts keep on recurring no matter how hard they try to resist them. Such thoughts are obsessions. An example might be a vicar who has a repeated intrusive thought that someone has urinated in the holy water in the church font. Sometimes a person may dwell on an unusual topic to a morbid degree, e.g. a sweet shop owner who campaigns outside Parliament every day to say that chocolate should be recommended by doctors for its mood-enhancing properties. Such a thought could be described as an overvalued idea. It is sometimes difficult to fault the detail of an overvalued idea. After all, as in the example, chocolate is reputed to have some mood-enhancing properties, but is the idea worth campaigning about to the exclusion of other pursuits?

Where a person holds a belief that is manifestly untrue, is not culturally accepted, and holds it with an intensity that cannot be argued against, then this is a delusion. A delusion is an ex...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface to the second edition
• About the author
• 1 The fundamentals of psychiatry
• 2 Organic psychiatry
• 3 Mood disorders
• 4 Anxiety disorders
• 5 Schizophrenia
• 6 Eating disorders
• 7 Addiction
• 8 Post-traumatic stress disorder
• 9 Suicide and deliberate self-harm
• 10 Psychiatry in old age
• 11 Child and adolescent psychiatry
• 12 Personality
• 13 Physical treatments
• 14 Psychotherapy
• 15 Mental retardation
• 16 The history of psychiatry
• 17 Sexual aspects of psychiatry
• 18 Psychiatry: ethics and the law
• Index