Revision Notes in Psychiatry This page intentionally left blank Revision Notes in Psychiatry 2nd edition BASANT K. PURI MA, PhD, MB, BChir, BSc (Hons) MathSci, MRCPsych, DipStat, MMath Senior Lecturer/Consultant in Psychiatry and Imaging, MRC CSC, Imperial College London; Honorary Consultant in Imaging, Department of Imaging, Hammersmith Hospital, London ANNE D. HALL BA, MB, BCh, MRCPsych Consultant Psychiatrist, South Kensington and Chelsea Mental Health Centre, Chelsea and Westminster Hospital, London A member of the Hodder Headline Group LONDON First published in Great Britain in 1998 Second edition published in 2004 by Arnold, a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.arnoldpublishers.com Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2004 BK Puri and AD Hall All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher, or a licence permitting restricted copying. In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1T 4LP. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 0 340 76131 8 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Serena Bureau Development Editor: Layla Vandenbergh Production Controller: Deborah Smith Cover Design: Stewart Larking Typeset in 10/12pt Minion by Phoenix Photosetting, Chatham, Kent Printed and bound in Malta What do you think about this book? Or any other Arnold title? Please send your comments to [email protected] Contents Preface to the second edition vii Preface to the first edition ix 1 Basic psychology 1 2 Social psychology 49 3 Neuropsychological processes 57 4 Human growth and development 63 5 Psychological assessment 89 6 Principles of evaluation and psychometrics 105 7 Social sciences 129 8 Descriptive psychopathology 147 9 Psychoanalytic theories 159 10 Neuroanatomy 171 11 Neuropathology 193 12 Neuroimaging techniques 207 13 Neurophysiology 211 14 Neurochemistry 225 15 General principles of psychopharmacology 235 16 Pharmacokinetics 243 17 Pharmacodynamics 251 18 Adverse drug reactions 259 19 Genetics 273 20 Epidemiology 287 21 Medical ethics and principles of law 295 22 Legal aspects of psychiatric care 301 23 Classification 309 24 Physical therapies 317 25 Organic psychiatry 327 26 Psychoactive substance use disorders 333 27 Schizophrenia and delusional (paranoid) disorders 367 28 Mood disorders, suicide and parasuicide 387 29 Neurotic, stress-related and somatoform disorders 405 30 Disorders specific to women 427 vi Contents 31 Sexual disorders 441 32 Sleep disorders 459 33 Personality disorders 465 34 Child and adolescent psychiatry 483 35 Learning disability 497 36 Eating disorders 505 37 Cross-cultural psychiatry 519 38 Old-age psychiatry 529 39 Forensic psychiatry 569 Appendix 1 575 Appendix 2 579 Index 581 Preface to the Second Edition In preparing the second edition of this book, we have taken the opportunity to update much of the information contained therein. As is evident from the increased size of this edition, we have also greatly expanded many chapters; this has happened partly to furnish the reader with more background material that puts the key facts in their proper context, and partly in line with the latest syllabi for the examinations for Parts I and II of the Membership of the Royal College of Psychiatrists. These Revision Notes should also prove useful in preparing for similar postgraduate examinations in psychiatry in other parts of the English-speaking world. BKP ADH This page intentionally left blank Preface to the First Edition This book aims to provide detailed revision notes covering all the important basic sciences and clinical topics required for postgraduate psychiatry examinations. To this end, the current syllabus for both parts of the examinations for the Membership of the Royal College of Psychiatrists has been followed closely. It should be emphasized, however, that this book is not meant to be a replacement for either wider reading, or, more importantly, clerking and following-up patients. BKP ADH This page intentionally left blank 1 Basic psychology PRINCIPLES OF LEARNING THEORY Definition of learning Learning is a change in behaviour as a result of prior experience. It does not include behaviour change caused by maturation or temporary conditions (e.g. drug effects or fatigue). Learning may occur through associations being made between two or more phenomena. Two forms of such associative learning are recognized: classical conditioning and operant conditioning. Cognitive learning is a more complex process in which current perceptions are interpreted in the context of previous information in order to solve unfamiliar problems. Evidence that learning can also take place through the observation and imitation of others has led to the development of the observational learning theory. Classical conditioning DEFINITION AND INTRODUCTION Classical conditioning (respondent learning) was first described by the Russian physiologist Ivan Petrovich Pavlov (1849–1936) in 1927. (Although Pavlov was awarded a Nobel prize, that was in 1904 for his work on digestion.) Following several repetitions of pairing of light (or a bell sounding) followed by the presentation of food to a dog, it was found that just switching on the light led to salivation. The dog had been conditioned to associate the light with food. Food was acting as the unconditioned stimulus (US), eliciting the reflex response of salivation without new learning being involved. The response to the unconditioned stimulus is known as the unconditioned response (UR). The light would not normally have elicited the response of salivation, but was now a conditioned stimulus (CS) that had elicited the response through its association with an unconditioned stimulus. The conditioned response (CR) is the learned or acquired response to a conditioned stimulus. This is shown diagrammatically in Figure 1.1. Thus, in Pavlov’s experiments, salivation was both an unconditioned response before conditioning, and a conditioned response after conditioning. 2 Basic psychology US UR CS CR Figure 1.1 Diagram showing the processes associated with classical conditioning. US = unconditioned stimulus; UR = unconditioned response; CS = conditioned stimulus; CR = conditioned response. CONCEPTS Acquisition stage The acquisition stage of conditioning is the period during which the association is being acquired between the conditioned stimulus and the unconditioned stimulus with which it is being paired. Timing ∑ Delayed conditioning. In delayed conditioning the onset of the conditioned stimulus precedes that of the unconditioned stimulus and the conditioned stimulus continues until the response occurs. Delayed conditioning is optimal when the delay between the onsets of the two stimuli is around half a second. ∑ Simultaneous conditioning. In simultaneous conditioning the onset of both stimuli is simultaneous and the conditioned stimulus continues until the response occurs. It is less successful than delayed conditioning. ∑ Trace conditioning. In trace conditioning the conditioned stimulus ends before the onset of the unconditioned stimulus and the conditioning becomes less effective as the delay between the two increases. ∑ Backward conditioning. In backward conditioning the presentation of the conditioned stimulus occurs after that of the unconditioned stimulus. Higher-order conditioning In higher-order conditioning the conditioned stimulus is paired with a second (or third, etc.) conditioned stimulus, which on presentation by itself elicits the original conditioned response. In other words, the original conditioned stimulus now acts as the unconditioned stimulus in the new pairing. If there is just a second conditioned stimulus, then this gives rise to second-order conditioning. A third conditioned stimulus gives rise to third-order conditioning, and so on. Higher-order (that is, second-order or above) conditioning is weaker than first-order conditioning; in general, the higher the order, the weaker the conditioning. Extinction Extinction is the gradual disappearance of a conditioned response and occurs when the conditioned stimulus is repeatedly presented without the unconditioned stimulus. It does not entail the complete loss of the conditioned stimulus. Following extinction, if an experimental