Psychiatry: A Clinical Handbook

Chapter   

1

Introduction

to psychiatry

What is psychiatry?

Psychiatry is the branch of medicine that deals with the diagnosis, treatment and prevention of mental, emotional and behavioural disorders.

It is one of the most varied specialties in medicine. Psychiatrists can work in a number of settings including the hospital, nursing homes, community settings, people’s own homes and even prisons.

Different areas of psychiatry include: general adult psychiatry; child and adolescent psychiatry; psychiatry of old age; learning disability psychiatry; forensic psychiatry; addiction psychiatry; social and rehabilitation psychiatry; psychotherapy; eating disorder psychiatry; and liaison psychiatry.

Mental illness is very common. Research suggests that 1 in 4 people will experience a mental health problem over the course of a year. The prevalence of this set of conditions ranks alongside cardiovascular diseases and malignancies.

History of psychiatry

The history of psychiatry dates back to as early as the Ancient Egyptian Empire. However, it is only since the turn of the twentieth century that psychiatry as we know it today, has begun to take shape. See Fig. 1.1 for notable events in psychiatry.

The late 1940s, with the discovery of lithium to stabilize moods, and the early 1950s, with chlorpromazine as the first antipsychotic, ushered in the new era of psychopharmacology.

Fig. 1.1: Notable events in the history of psychiatry.

Why study psychiatry?

Psychiatry is an enthralling and dynamic specialty. Studying psychiatry is important for medical students as it is a frequent exam topic both in written papers and the practical assessment.

Moreover, psychiatric issues, for instance depression, anxiety and personality disorders, are prominent in many areas of medicine, but often overlooked. Therefore it is imperative for all healthcare professionals to have knowledge of the impact of mental health disorders.

General practice and A&E are areas of medicine where psychiatric conditions are common. In primary care, roughly 20–25% of patients seen suffer from a psychiatric disorder, either in isolation or accompanying physical illness.

Psychiatric illness can also affect physical health. There is a 10–25 year reduction in life expectancy (premature mortality) for patients with severe psychiatric disorders (WHO) (Fig. 1.2). The vast majority of these deaths are due to chronic physical health conditions such as cardiovascular, respiratory and infectious diseases, diabetes and hypertension. Suicide is another important cause of death. Health risk behaviours such as smoking are more common.

Fig. 1.2:↑ risk of mortality in the major psychiatric disorders vs. the general population.

The content in this textbook will provide useful information not only for medical students, but for junior doctors, GP trainees and psychiatric nurses. The information in this book will provide you with:

A basic understanding of the common psychiatric disorders encountered not only by psychiatrists, but rather in a variety of healthcare settings.

Knowledge of how to perform a comprehensive and efficient psychiatric assessment including the psychiatric history and mental state examination.

Information on how to manage a patient holistically by adopting the mantra of the bio-psychosocial approach, which is a transferable skill amongst all specialties.

Psychiatric classification

The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes (World Health Organization).

The two main classification systems for mental disorders are the ICD-10 and DSM-V (produced by the American Psychiatric Association).

NOTE: For the purposes of this textbook, we will be strictly using ICD-10 criteria as this system predominates in the UK.

ICD-10 divides mental and behavioural disorders into ten categories: (1) F00–F09Organic, including symptomatic, mental disorders; (2) F10–F19Mental and behavioural disorders due to use of psychoactive substances; (3) F20–F29Schizophrenia, schizotypal and delusional disorders; (4) F30–F39Mood [affective] disorders; (5) F40–F48Neurotic, stress-related and somatoform disorders; (6) F50–F59Behavioural syndromes associated with physiological disturbances and physical factors; (7) F60–F69Disorders of personality and behaviour in adult persons; (8) F70–F79Mental retardation; (9) F80–F89 Disorders of psychological development; (10) F90–F98Behavioural and emotional disorders with onset usually occurring in childhood and adolescence.

Areas of psychiatry

Psychiatry is a broad specialty with many distinct and varying conditions (Fig. 1.3).

Fig. 1.3: Mind map of all the psychiatric disorders.

Psychiatric assessment

Formulating a psychiatric diagnosis is a structured process involving an initial assessment, generating differential diagnoses, and then performing investigations to come to a diagnosis.

Initial assessment

Psychiatric history: see Section 2.1.

Mental state examination: see Section 2.2.

Physical examination: Certain medical conditions (e.g. anaemia, thyroid abnormalities) can present with psychiatric features. If alcohol abuse is suspected, the physical signs which accompany it must be assessed for.

Differential diagnosis

Organic: Due to demonstrable pathology of the brain, e.g. delirium, dementia and substance related disorders.

Functional: Any non-organic condition. Have predominantly psychological causes, e.g. psychoses such as schizophrenia or mood disorders such as depression.

Personality disorders.

Investigations

Biochemical testing: Include blood tests or urine tests (e.g. for substance misuse).

Imaging: Such as CT head (in dementia) or chest radiograph (in delirium where underlying pneumonia is suspected).

Questionnaires: Various questionnaires exist for conditions such as depressive disorders, anxiety disorders and dementia.

The multidisciplinary team (MDT)

In the UK, psychiatric care is becoming more community based with patients being treated in outpatient clinics, day hospitals or their own homes where possible (Fig. 1.4).

Fig. 1.4: Key psychiatric concepts in the community.

A key concept is that of the Community Mental Health Team (CMHT) which is a multidisciplinary team designed to manage patients with psychiatric conditions in the community, and ultimately to prevent emergency admission to hospital. There is a designated care coordinator (or key worker) and a care plan records identified needs. Both General Adult Psychiatry and Older Persons Psychiatry services may have CMHTs as part of their community mental health provision (see Table 1.1).

Bio-psychosocial approach

The bio-psychosocial model, theorized by the psychiatrist George Engel, is the mainstream ideology of contemporary psychiatry.

According to the model, health is best understood as a combination of biological, psychological and social factors as opposed to earlier, purely biological ideas.

Throughout this book we will utilize the bio-psychosocial approach, particularly in the context of management of psychiatric illness (Fig. 1.5).

Fig. 1.5: Bio-psychosocial approach to management in psychiatry.

Chapter  

2

Assessment in

psychiatry

².¹  Psychiatric history taking

Introduction to psychiatric history taking

Before the interview (the 4 S’s)

Site: Ideally the room should be as comfortable and sound proof as can be, but this is not always possible on wards or in the emergency department.

Safety: It is important that you sit closer to the door than your patients and in some cases, a chaperone may be required. Check local added precautions such as panic buttons and alarms.

Setting: It is best to arrange chairs at 90° to each other. If a desk is required to make notes, this should not be directly in between the patient and the interviewer such that it is obstructing. Sit in a relaxed posture. Ensure that there are no interruptions by turning mobile phones off and handing bleeps to colleagues.

Study: Read any referral letter or previous notes to familiarize yourself with the case.

Take any appropriate collateral history from a member of staff or family.

Introduction

Introduce yourself including your name and your role.

Explain the purpose of the consultation and how long you have to interview the patient.

Gain consent to take a history and ask for permission to take notes.

Identifying information (‘NAG MORE’)

Reason for referral

WHEN was the patient admitted (date and time)?

WHY was the patient admitted?

WHO was involved in the patient’s admission, e.g. GP, A&E, police, social worker?

Is the patient in hospital voluntarily or detained under the Mental Health Act?

Presenting complaint

Start with an open-ended question, for example ‘How can we help you?’ or ‘How have you been feeling?’

Onset: ‘When did you realize things have changed?’

Severity: ‘How has this affected your life?’

Duration: ‘How long has this been going on for?’

Progression: ‘Have you had any fluctuations in the way you have been feeling?’

Precipitating events/Aggravating and relieving factors: ‘Has anything occurred in your life recently which could explain how you are feeling?’

Associated symptoms: Always screen for depression, psychosis and suicidal ideation.

Ideas, concerns and expectations (ICE)

ICE is a crucial part of the history. Eliciting health beliefs and concerns in a sincere and fluent manner will enable you to build a strong rapport with the patient.

Ideas: ‘Do you have any thoughts as to what could be making you feel this way?’

Concerns: ‘Is there anything that is particularly concerning or worrying you at the moment?’

Expectations: ‘Do you have any thoughts as to the best way in which you feel we can help you?’

Past psychiatric history

Have there been any similar problems to the presenting complaint, in the past? Previous or ongoing psychiatric diagnoses – ‘Do you have any psychiatric illness that you are aware of?’

Dates and duration of previous episodes of mental illness.

Whether or not the Mental Health Act was ever implemented.

Details of previous hospitalization and treatment including medications, psychotherapy and electroconvulsive therapy. Ask about response to treatment and about side effects.

Past medical history and drug history

Ask about any current or previous medical illnesses or any past surgical procedures: ‘Is there anything that you are currently seeing the doctor for?’

Ask particularly about head injuries and previous cranial surgery, neurological conditions (e.g. epilepsy) and endocrine abnormalities (e.g. thyroid disease).

Find out about medication the patient is using (both prescription and over-the-counter). Also, ask specifically about previous use of psychotropic medication, and whether the reported medication helped symptoms or caused side effects.

Enquire about allergies, including the nature of any allergy (e.g. rash, anaphylaxis).

Family history

Presence of psychiatric illness in family members: ‘Has anyone in your family ever suffered from problems like you’re having now?’

Quality of family relationships: Collect information about parents, siblings and other significant relatives. ‘How do you get on with your family?’, ‘Are there any recent significant events that have occurred in the family?’

Brief medical history of family: ‘Are there any medical conditions which run in the family?’

It can be very useful to draw a genogram to represent information appropriately.

Personal history (Table 2.1.2)

The personal history is crucial in identifying predisposing factors to the patient’s psychiatric illnesses (Fig. 2.1.2).

NOTE: In the case of women the interviewer should ask about menstrual patterns and previous miscarriages, stillbirths or terminations.

Fig. 2.1.2: Aetiological factors in psychiatric illness can be divided into the three Ps (Predisposing, Precipitating and Perpetuating factors). The predisposing factors highlight the importance of taking a personal history.

Social history

This includes current accommodation (state of housing, heating, living conditions), social support (friends and family), financial circumstances (any debts or benefits) and hobbies or leisure activities.

Alcohol and substance misuse

The CAGE questionnaire is a useful tool to screen for alcohol dependence→ if two or more positive, see if they meet alcohol dependence syndrome (see Section 7.2, Alcohol abuse).

How much alcohol in a day (units consumed) and type of alcohol.

Use of illicit drugs: ‘Have you ever used any recreational drugs?’

Record drug names, routes of administration and years/frequency of use: ‘How much do you spend on this in a week?’

Smoking status: Calculate the pack-year smoking history

(Number of cigarettes smoked per day × duration of smoking in years) ÷ 20

NOTE: The 20 in this equation is the number of cigarettes in a pack.

Premorbid personality

The premorbid personality is an assessment of the patient’s personality and character before the onset of mental illness.

‘How would people have described you before?’, ‘Would they describe you differently now?’

It may be useful to gain a collateral history from a family member or friend about premorbid personality in order to corroborate the patient’s account.

Summary

Succinctly summarize your understanding of what the patient has told you.

Provide an opportunity for the patient to ask questions.

².²  Mental state examination

Introduction

The mental state examination (MSE) is a systematic appraisal of the appearance, behaviour, mental functioning and overall demeanour of a person. In other words, it reflects a person’s psychological functioning at a given point in time.

The MSE is usually put into a time frame (e.g. the preceding 2 weeks).

The history and mental state examination will lead to the formation of differential diagnoses.

Most of us inherently perform many aspects of the MSE every time we interact with, or observe others.

Observations of the mental state are important in determining a person’s capacity to function, and whether psychiatric follow-up is