Table Of ContentPsychiatry
CLINICAL CASES UNCOVERED
Psychiatry
CLINICAL CASES UNCOVERED
Peter Byrne
MA, MB, MRCPsych
Consultant Liason Psychiatrist
Newham University Hospital
London
Nicola Byrne
MBChB, BSc, MSc, MRCPsych
Consultant Psychiatrist
Lambeth Adult Mental Health
The Maudsley Hospital
London
A John Wiley & Sons, Ltd., Publication
This edition fi rst published 2008, © 2008 by P. Byrne and N. Byrne
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Library of Congress Cataloguing-in-Publication Data
Byrne, Peter, MA.
Psychiatry : clinical cases uncovered / Peter Byrne, Nicola Byrne.
p. ; cm.
Includes index.
ISBN 978-1-4051-5983-8
1. Psychiatry–Examinations, questions, etc. 2. Psychiatry–Case studies. I. Byrne,
Nicola. II. Title.
[DNLM: 1. Mental Disorders–Problems and Exercises. WM 18.2 B995p 2008]
RC465.B97 2008
616.890076–dc22
2008009431
ISBN: 978-1-4051-5983-8
A catalogue record for this book is available from the British Library
Set in 9/12pt Minion by SNP Best-set Typesetter Ltd., Hong Kong
Printed in Singapore by COS Printers Pte Ltd
1 2008
Contents
Introduction, vii
How to use this book, x
Part 1 Basics, 1
Approach to the patient, 1
Mental health treatments, 12
Part 2 Cases, 36
Case 1 A 20-year-old student who collapses in the supermarket, 36
Case 2 A 47-year-old woman who lives in fear that God will punish her, 44
Case 3 An 18-year-old college drop-out gets an eviction order from his parents, 52
Case 4 An 18-year-old trainee chef who cannot go to work, 59
Case 5 Sudden deterioration of a 78-year-old woman in a nursing home, 66
Case 6 A 72-year-old woman with antisocial behaviour, 74
Case 7 A 64-year-old retired teacher’s depression is getting worse, 81
Case 8 A 17-year-old man has been cutting his arms, 88
Case 9 A 9-year-old disruptive child faces expulsion from school, 96
Case 10 A 48-year-old security guard with new symptoms every day, 104
Case 11 A 28-year-old man has been arrested at the airport, 111
Case 12 A 24-year-old new mother in distress, 119
Case 13 A 15-year-old head prefect with pneumonia is behaving secretly, 128
Case 14 Insomnia in a 26-year-old successful City man, 135
Case 15 A 15-year-old child assaults his foster mother, 143
Case 16 A 42-year-old woman insists she is pregnant, 150
Case 17 The wife of a 66-year-old GP with Parkinson’s disease is worried about him, 157
Case 18 Complete loss of memory in a fi t middle-aged man, 164
v
vi Contents
Case 19 A 32-year-old woman puts her GP under pressure, 171
Case 20 The 21-year-old critical medical student, 182
Case 21 A 24-year-old legal secretary with depressed mood and suicidal thoughts, 188
Case 22 A 41-year-old woman with epilepsy develops a different pattern of fi ts, 195
Part 3 Self-assessment, 203
MCQs, 203
EMQs, 207
SAQs, 211
Answers, 214
Index of cases by diagnosis, 223
Index, 224
Introduction
Psychiatry is the ultimate clinical speciality. No other
Box A The duties of a doctor
branch of medicine relies so much on empathic listening
skill and the integration of biological, psychological and
Patients must be able to trust doctors with their lives and
sociological theory to unravel a patient’s story into a
health (General Medical Council: www.gmc-uk.org). To
coherent aetiological formulation. Whether you hope to justify that trust you must show respect for human life
call yourself a psychiatrist or are just passing through, be and you must:
aware that this is a golden opportunity to acquire com- (cid:129) Make the care of your patient your fi rst concern
petencies that will serve as foundations for your working (cid:129) Protect and promote the health of patients and the
life (e.g. understanding reactions to illness and adversity, public
the relationships between physical and mental health, (cid:129) Provide a good standard of practice and care
(cid:129) Keep your professional knowledge and skills up to date
working with ‘diffi cult’ patients and relatives, and keeping
(cid:129) Recognize and work within the limits of your
your cool in unpredictable situations).
competence
The focus throughout the book is on developing your
(cid:129) Work with colleagues in the ways that best serve
clinical reasoning and core competencies up to a stan-
patients’ interests
dard of passing undergraduate examinations, workplace-
(cid:129) Treat patients as individuals and respect their dignity
based assessments of your early years as a doctor, and (cid:129) Treat patients politely and considerately
beyond. Part 1 is a guide to psychiatric assessment and (cid:129) Respect patients’ right to confi dentiality
introduces the range of treatment options, Part 2 is a (cid:129) Work in partnership with patients
collection of case studies covering the range of mental (cid:129) Listen to patients and respond to their concerns and
disorders, and Part 3 is for self-assessment. Ultimately, preferences
clinical judgement comes from experience, and the more (cid:129) Give patients the information they want or need in a
way they can understand
patients you encounter, the more skilled you will become.
(cid:129) Respect patients’ right to reach decisions with you
Some clinical dilemmas have no ‘textbook’ right answer.
about their treatment and care
Medical professionalism is based on working within our
(cid:129) Support patients in caring for themselves to improve
shared ethical framework (Box A); whenever the rights
and maintain their health
and wrongs of a situation are opaque, it can be helpful
(cid:129) Be honest and open and act with integrity
to return to these fi rst principles to determine your (cid:129) Act without delay if you have good reason to believe
action. that you or a colleague may be putting patients at risk
You will get the most from the case studies by stopping (cid:129) Never discriminate unfairly against patients or colleagues
to answer every question posed as the responsible doctor. (cid:129) Never abuse your patients’ trust in you or the public’s
The cases vary in complexity, beginning with easier ones. trust in the profession
An index of cases by diagnosis is provided on p. 223 You are personally accountable for your professional
practice and must always be prepared to justify your
– useful for revision or if you want to select a case for
decisions and actions.
peer group learning or tutorials. All cases are amalgams
of patients and situations we have come across, and none
describe identifi able individuals.
In relation to diagnoses, we have used the World The terms here are used to describe disorders, not people:
Health Organization’s categorization of mental disorder, people with borderline personality disorders or schizo-
the ICD-10 (International Classifi cation of Diseases). phrenia are not ‘borderlines’ or ‘schizophrenics’.
vii
viii Introduction
Diagnoses do not defi ne identity, and they need to be Drinking: A Love Story. Caroline Knapp (1999) Quartet
used sensitively in mental health. Books, London. An account of alcohol addiction from
We have both been lucky enough to learn through the perspective of a highly functioning journalist from
great clinicians we have been taught by and worked with, a ‘respectable’ middle-class background, who goes on
and from the generosity of our patients. None of us can to seek help from Alcoholics Anonymous (AA). Pro-
fully understand what something is like until we experi- vocative reading for those who drink to excess socially
ence it ourselves, and fi rst-hand accounts of mental dis- or to relieve stress, and for whom the line between
orders that we have found valuable are listed in Further harmless and harmful drinking may not always be
reading below. You will not need them to pass exams, but clear.
they are worth reading to balance your clinical experi- Beyond Crazy: Journeys Through Mental Illness. Julia
ence and reading with the realities of mental illness and Nunes and Scott Simmie (2002) McClelland and
its consequences. Stewart, Toronto. Compiled by two successful Cana-
Peter and Nicola Byrne dian journalists, the whole range of mental disorders
2008 is presented, written in different styles and from many
perspectives, but the book ends with clear explanations
Further reading and useful advice. Almost every account moves logi-
Sunbathing in the Rain: A Cheerful Book about Depression. cally from setting out painful, real experiences to dis-
Gwyneth Lewis (2007) HarperCollins. The author is a covering universalities that promote understanding
poet, and her experience of a severe depressive episode and recovery.
is charted as her investigation into the mystery of how Speaking Our Minds: An Anthology. Jim Read and Jill
she came to arrive at the point of psychological col- Reynolds (1996) MacMillan, London. An anthology of
lapse. She re-evaluates assumptions about depression writing from over 50 individuals, from diverse per-
as simply a problem, exploring its meaning for her and spectives and backgrounds, who have experienced
its potential role as a signal that her life needed to mental distress and have had various forms of treat-
change. Comprising a series of short sections which ment. Useful to understand the nature of their diffi cul-
can be dipped into, she speaks to those involved in ties and what authors did and (frequently) did not fi nd
caring for depressed people, and those currently useful from mental health services.
depressed themselves and unable to digest long tracts Is That Me? My Life With Schizophrenia. Anthony Scott
of text. (2002) A. & A. Farmer, Dublin. A deeply personal
An Unquiet Mind. Kay Redfi eld Jamison (1995) Vintage. account of a life punctuated by schizophrenia. Written
A psychiatric ‘classic’, the author is an eminent in an honest and direct style, the author is generous to
American professor of psychiatry who describes her the people who helped him along the way and refl ec-
experience of bipolar affective disorder. With tive about the obstacles to his full recovery.
frequent intersections between the personal and the Born on a Blue Day. Daniel Tammet (2006) Hodder. A
scientifi c, it is widely read by professionals and unique account of how a man with Asperger’s syn-
patients. drome experiences reality, fi ltered through his rela-
Smashed: Growing Up a Drunk Girl. Koren Zailckas tionship with words and colours. Unusually, he is able
(2005) Ebury Press, London. A young woman’s expe- to explain the nature of his ‘savant’ mathematical abili-
rience of using alcohol to avoid social anxiety and ties and to describe the mutual incomprehension
uncomfortable emotions in the transition into adult- between him and those around him growing up. It is
hood. Gives a good – albeit retrospective – account of also an impressive account of someone transcending
her innate predisposition to becoming addicted, illus- their own limitations.
trating how some people might powerfully ‘take’ to a Stuart: A Life Backwards. Alexander Masters (2005)
substance after only limited exposure, which can seem Fourth Estate, London. Strictly speaking a biography,
bewildering to people with no such inclination. The this is a life story traced backwards, starting from
collateral damage of substance misuse to her close rela- Stuart’s adult position as a chaotic, homeless, ‘person-
tionships and the striking descriptions of her physical ality-disordered’ and at times violent drug-user exist-
and sexual vulnerability when drunk are complicated ing in a social underclass. The author is one of his
by the blank horror of her alcohol-induced amnesia. care-workers and (like most doctors) hails from a
Introduction ix
background of relative advantage and security that is Telling is Risky Business: Mental Health Consumers
in marked contrast to Stuart’s. The book is simultane- Confront Stigma. Otto Wahl (1999) Rutger’s Univer-
ously an account of his relationship with Stuart, often sity Press, New Brunswick. This is a catalogue of peo-
characterized by mutual irritation and exasperation. ple’s experiences of isolation and misunderstanding by
Stuart’s behaviour initially appears bewildering, but others as a result of their mental illness. Drawing on
increasingly makes sense as we are led backwards to its fi rst-hand accounts of stigma, it demonstrates how
origins. In turns hilarious and terrifying, his story is a negative stereotypes have invaded every aspect of
challenge to instinctive reactions to reject this type of Western culture to make discrimination against ‘those
‘diffi cult’ patient. people’ the norm, not the exception.
