PSYCHIATRY Lecture Notes LN Gautam Gulati Mary-Ellen Lynall Kate Saunders 11th Edition with extended material online' Psychiatry Lecture Notes Psychiatry Lecture Notes Gautam Gulati MBBS, 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 Lynall MA (Cantab.) Graduate-entry medical student, Magdalen College, University of Oxford, UK Retained Lecturer in Neuroscience, Somerville College, University of Oxford, UK Kate Saunders BM, 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 Previous editions 1964, 1968, 1972, 1974, 1979, 1984, 1989, 1998, 2005, 2010 Registered offi ce: John Wiley & Sons, Ltd, Th e Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UK Th e Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 350 Main Street, Malden, MA 02148-5020, USA For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell Th e right of the author to be identifi ed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. 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No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Gulati, 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 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. 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Cover image: iStockphoto.com/geopaul Cover design by Grounded Design Ltd Set in 8.5/11pt Utopia Std by Aptara® Inc., New Delhi, India 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 its suite of textbooks, a process initiated by Michael the chance to take over the eighth edition of Lecture Gelder when he was the fi rst Head of Department. Notes in Psychiatry in 1997, we spent a great deal of We are therefore delighted that Gautam Gulati, Mary- time together thinking through the structure of a book Ellen Lynall and Kate Saunders have taken on the task that would portray psychiatry as the evidence-based, of updating and revising Lecture Notes in Psychiatry. patient-oriented branch of medicine that we knew it To an extent, all textbooks are out of date as soon as could be. Our thinking was inspired by the advances in they are published but even with the developments evidence-based medicine led in Oxford by David Sack- in information technology, a concise, portable, pa- ett, Muir Gray and Iain Chalmers and the Cochrane per textbook containing an up-to date synthesis of Collaboration. We wanted to apply the principles of current knowledge occupies its own niche and still clinical epidemiology – not just in our recommen- has a major role in training. Frequent revisions and dations around use of treatments but also to challenge updating are, however, critical to keep them accurate traditional approaches to history and examination and useful. Th is is hard work of course and after three taking in psychiatry. For decades, students had been editions, Paul, Mike and I felt that we could not face taught that the only way to do a proper psychiatric as- revising the book again! It is marvellous to see that sessment was to do a ‘full’ history and examination – Gautam, Mary-Ellen and Kate have done so with such an approach that is both ineffi cient and incompatible aplomb, keeping what remains useful from earlier with real-world clinical practice. editions but updating it with great skill. Th e Oxford University Department of Psychiatry is proud of its heritage of producing and updating John Geddes Preface Th e skills, attitudes and knowledge inherent in learn- Given our illustrious predecessors, we were hum- ing psychiatry are relevant to all doctors – and to all bled to be asked to write the 11th edition of Lecture other health professionals. We have written this book Notes. Indeed we aimed to build upon the last edition with medical students and psychiatric trainees in of the book written so eloquently by Paul Harrison, mind, but anticipate it being a useful resource for any John Geddes and Michael Sharpe. health professional interested in the subject. To facilitate learning, we have added learning ob- We describe a practical approach towards psy- jectives at the start of each chapter and highlighted chiatry. Chapter 1 outlines the principles behind key points towards the end. Multiple-choice ques- the practice of modern psychiatry and introduces tions have been added, along with detailed explana- the psychiatric assessment. Our guide to assessment tions of the answers, to allow the reader to consoli- comprises a basic psychiatric assessment (Chapter 2), date key points. Links to key papers and guidelines followed by diagnosis-specifi c assessments (Chapter 3) have been added for readers keen to know more and a guide to risk assessment (Chapter 4). Chapter 5 about a particular disorder. describes how to draw everything together and com- We hope we have done justice to the work started municate the information to others. Th e recommen- by Paul, John and Michael in keeping this Lecture Se- dations in these chapters are summarized in a set of ries book both informative and enjoyable. ‘quick guides’, included at the front of the book for We thank Jonathan Price, who was instrumental in easy reference. drawing our team together and in setting the direc- Th e middle chapters cover the principles of aetiol- tion in the early days of our writing. We are grateful to ogy (Chapter 6), treatment (Chapter 7) and psychiat- colleagues who have generously shared their exper- ric services (Chapter 8). Th e main psychiatric disor- tise with us. ders of adults are covered in Chapters 9–15, followed Th e book is dedicated to Annette Lynall, John Con- by childhood disorders (Chapter 16) and learning way, Catherine Sage, and the memory of Graham disability (Chapter 17). Chapter 18 discusses psychia- (Matthew) Jay and Colonel S. Gulati. try in non-psychiatric medical settings – the place where most psychiatry actually happens. Chapter 19 Gautam Gulati (Mental health and the law) is a new addition to the Mary-Ellen Lynall book and one you are likely to fi nd useful in which- Kate Saunders ever setting you work. Acknowledgements We would like to thank the following people for their Dr Borys Borvin (Oxford Health NHS Foundation contribution to this book. Trust) for his contribution to the chapter on Sub- stance misuse. Professor Paul Harrison (University of Oxford), Professor John Geddes (University of Oxford) and Dr Suzanne Coghlan (Oxford Health NHS Foun- Professor Michael Sharpe (University of Edinburgh) dation Trust) for her contribution to the chapter on who edited the 10th edition of this book. Neuroses. Dr Jonathan Price (University of Oxford) for bring- Dr Elizabeth Naomi Smith (Oxford Health NHS ing the author team together, and for helping set the Foundation Trust) for her contribution to the chapter direction in the early days of our work on this edition on Psychiatry in other settings. of the book. Dr Charlotte Allan (Oxford Health NHS Foundation Dr Ruth Reed (Oxford Health NHS Foundation Trust) for her contribution to the chapter on Demen- Trust) for her contribution to the chapter on Child- tia, delirium and neuropsychiatry. hood disorders. Karen Moore (Senior Development Editor at Wiley) Dr Valerie Elizabeth Murphy (Southern Health for her help and advice with editorial aspects. 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.