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Hughes’ Outline of Modern Psychiatry Fifth Edition Hughes’ Outline of Modern Psychiatry Fifth Edition David Gill Consultant Psychiatrist Lister Hospital Stevenage: Hertfordshire Partnership NHS Trust John Wiley & Sons, Ltd Copyright © 2007 John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO 19 8SQ, England Telephone (+44) 1243 779777 Email (for orders and customer service enquiries): [email protected] Visit our Home Page on www.wileyeurope.com or www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1T 4LP, UK, without the permission in writing of the Publisher. Requests to the Publisher should be addressed to the Permissions Department, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO 19 8SQ, England, or emailed to [email protected], or faxed to (+44) 1243 770620. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The Publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the Publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Other Wiley Editorial Offi ces John Wiley & Sons Inc., 111 River Street, Hoboken, NJ 07030, USA Jossey-Bass, 989 Market Street, San Francisco, CA 94103-1741, USA Wiley-VCH Verlag GmbH, Boschstr. 12, D-69469 Weinheim, Germany John Wiley & Sons Australia Ltd, 33 Park Road, Milton, Queensland 4064, Australia John Wiley & Sons (Asia) Pte Ltd, 2 Clementi Loop #02-01, Jin Xing Distripark, Singapore 129809 John Wiley & Sons Canada Ltd, 6045 Freemont Blvd, Mississauga, Ontario, L5R 4J3 Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Anniversary Logo Design: Richard J. Pacifi co Library of Congress Cataloging-in-Publication Data Gill, D. (David), Dr. Hughes’ outline of modern psychiatry / David Gill. – 5th ed. p. ; cm. Rev. ed. of: Hughes’ outline of modern psychiatry / Jennifer Barraclough and David Gill. 4th ed. c1996. Includes bibliographical references and index. ISBN 978-0-470-03392-0 (pbk. : alk. paper) 1. Psychiatry–Handbooks, manuals, etc. I. Barraclough, Jennifer. Hughes’ outline of modern psychiatry. II. Title. III. Title: Outline of modern psychiatry. [DNLM: 1. Mental Disorders–Handbooks. WM 34 G475h 2007] RC456.H84 2007 616.89 – dc22 2007010266 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-0-470-03392-0 Typeset in 10½ / 12½ pt Minion by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in Great Britain by TJ International, Padstow, Cornwall This book is printed on acid-free paper responsibly manufactured from sustainable forestry in which at least two trees are planted for each one used for paper production. Dedication I am grateful to all my teachers, especially Roger Chitty, Neil Davies and Chris Bass, and to my colleagues and patients. For Mandy and Bertie. Contents Preface xv PART I: THE NATURE AND ASSESSMENT OF PSYCHIATRIC DISORDER 1 1 Classifi cation 3 The basis of classifi cation 4 Reliability and validity 4 Limitations and problems of classifi cation 5 Common terms in psychiatric classifi cation 6 Classifi cation systems 7 2 Causes and Prevention 11 Causation in clinical practice 11 Historical background 12 Genetics 12 Neurochemistry 14 Neuroradiology 15 Epidemiology 15 Individual life experience 18 Prevention of psychiatric disorder 19 3 Assessment 23 Circumstances of referral 23 The psychiatric interview 24 viii CONTENTS Mental state examination 28 Physical examination 32 Structured interviews and questionnaires 34 Further assessments 35 Physical investigations 36 PART II: CLINICAL SYNDROMES 39 4 Schizophrenia 41 Defi nition 41 Frequency 41 Epidemiology 42 Causation 42 Clinical features 48 Clinical types 55 Diagnostic criteria 58 Differential diagnosis 60 Treatment 61 Prognosis 66 5 Mood Disorders: Depressive Illness and Mania 69 Frequency 70 Epidemiology 71 Causes 71 Clinical features of depressive illness 76 Types of depressive illness 79 Diagnosis of depressive illness 85 Clinical features of mania 85 Differential diagnosis of mood disorders 86 Treatment of depressive illness 87 Treatment of mania 92 Prophylaxis of affective disorder 92 6 Anxiety and Stress-Related Disorders 95 Boundaries of anxiety disorder 96 Hierarchy of diagnosis 96 Frequency 96 Epidemiology 97 Causes 97 Clinical features 98 Differential diagnosis 100 CONTENTS ix Treatment 100 Prognosis 103 Generalized anxiety disorder (anxiety state) 104 Panic disorder 105 Agoraphobia 105 Social phobia 106 Simple phobias (specifi c phobias, monophobias) 106 Obsessive-compulsive disorders 106 Post-traumatic stress disorder (PTSD) 107 Adjustment disorders 111 Bereavement 111 7 Personality Disorders 113 Defi nition 113 Classifi cation 113 Types of personality disorder 115 Epidemiology 117 Differential diagnosis 118 Treatment 119 Prognosis 121 Sociopathic (dissocial) personality disorder 121 8 Paranoid States 125 Defi nition 125 Predisposing factors 125 Differential diagnosis of paranoid states 126 Management 127 Culture-bound syndromes 127 9 Physical Symptoms and Psychiatric Disorder 129 Introduction 129 Assessing physical symptoms in psychiatric practice 130 Unexplained physical symptoms 131 Management 137 Malingering and exaggeration 139 10 Organic Brain Syndromes 143 Causes 144 Clinical features 145 Delirium 145 x CONTENTS Dementia 147 Focal brain damage 159 11 Liaison Psychiatry 163 Psychological infl uences on the course of physical disease 164 The stresses of physical illness 165 Adjustment and coping 165 Clinical depression in medically ill patients 166 Management and prevention 167 Liaison psychiatric services 168 12 Drug Misuse 171 Defi nitions 171 Epidemiology 172 Causes 172 Psychiatric and physical complications 172 Legal aspects 173 Pharmacology 174 Prevention 174 Treatment 175 Opiates 176 Amphetamines (speed) 179 Cocaine and crack 180 Cannabis (Indian hemp, hashish, pot) 181 Lysergic acid diethylamide (LSD, acid) 182 MDMA (Ecstasy) 183 Glues and solvents 184 Tobacco 184 Caffeine 185 Barbiturates 186 Benzodiazepines 187 13 Alcohol Misuse 189 Safe limits of drinking 189 Frequency 190 Epidemiology 190 Causes 191 Effects of alcohol 192 Course of alcohol abuse 195 Recognition 195 Treatment 196 CONTENTS xi Prognosis 198 Prevention 198 14 Deliberate Self-Harm 199 Suicide 199 Non-fatal deliberate self-harm (parasuicide, attempted suicide) 205 15 Eating Disorders: Anorexia Nervosa and Bulimia Nervosa 211 Introduction 211 Anorexia nervosa 211 Bulimia nervosa 216 Obesity 217 16 Disorders of Female Reproductive Life 219 Pregnancy 219 Puerperal psychosis 220 Post-natal depression and other neurotic syndromes 222 Abortion 225 Stillbirth and perinatal death 225 Premenstrual syndrome 225 The menopause 226 Hysterectomy 226 17 Sexual Problems 227 Sexual dysfunctions 227 Sexual deviations 231 Gender-identity disorders 235 Homosexuality 236 18 Child and Adolescent Psychiatry 237 Predisposing factors 237 Classifi cation 238 History taking and examination 239 Treatment 241 Relationship with adult disorder 241 Neurotic (emotional) disorders 242 Conduct disorders 243 Attention defi cit disorder 243 Psychoses 244 Delays in development 244 xii CONTENTS Symptomatic disorders 246 Child abuse 247 Psychiatry of adolescence 249 19 Learning disability 251 Frequency 251 Causes 251 Diagnosis of learning disability 252 Associated phenomena 253 Management 254 Prognosis 255 Prevention 255 Chromosomal abnormalities 258 Gene abnormalities 259 Acquired handicap 261 Miscellaneous 261 20 Psychiatry of Old Age 263 Frequency 263 Clinical syndromes 264 Assessment 266 Specifi c treatments 267 Organization of services 269 21 Forensic Psychiatry 271 Offending behaviour 272 Predicting violence and dangerousness 273 Psychiatric aspects of specifi c offences 274 Treatment: general considerations 278 Facilities for mentally disordered offenders 279 Psychiatric reports: criminal 282 PART III: TREATMENT 287 22 Psychological Treatment 289 Historical background 289 Principles of psychotherapy today 292 Counselling 294 Cognitive-behavioural therapy (CBT) 295 Psychodynamic psychotherapy 301 CONTENTS xiii Group therapy 303 Family and marital therapy 303 Recent advances 305 23 Psychopharmacology 307 General principles of using psychotropic drugs 307 Antipsychotics 310 Antidepressants 315 Antidepressants: tricyclic group 316 Antidepressants: SSRI group 319 Antidepressants: MAOI group 322 Other antidepressant drugs 323 Benzodiazepines 324 Mood stabilizers 328 Other drugs 331 24 Electroconvulsive Therapy (ECT) and Psychosurgery 333 Indications 334 Mode of action 334 Effi cacy and prediction of response 335 Timing and number of treatments 335 Practicalities of treatment 335 Contraindications 336 Bilateral versus unilateral
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