Shorter Oxford textbook of psychiatry

892 Pages·2018·7.444 MB·English

by  Tom Burns, Mina Fazel, Philip Cowen, Paul J. Harrison

iii
Shorter Oxford

Textbook of
Psychiatry
SEVENTH EDITION
Paul Harrison
Philip Cowen
Tom Burns
Mina Fazel
1
iv
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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First Edition published in 1983
Second Edition published in 1989
Third Edition published in 1996
Fourth Edition published in 2001
Fifth Edition published in 2006
Sixth Edition published in 2012
Seventh Edition published in 2018
Impression: 1
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v
Preface to the seventh edition
In the 5 years since the sixth edition of this book, psy- Textbook of Psychiatry, the third edition of which is near-
chiatry has seen important advances in understanding ing completion.
and treatment of its disorders, as well as the publication We welcome Mina Fazel. Mina is the first child psy-
of revised diagnostic criteria in DSM-5 . These devel- chiatrist, and the first woman, to be an author of the
opments have been incorporated into this substan- Shorter Oxford Textbook of Psychiatry since its inception.
tially rewritten edition, which includes a new chapter We are delighted that both these unfortunate omissions
on global mental health, and division of mood disor- have been corrected, and this edition benefits greatly
ders into separate chapters on depression and bipolar from her contributions.
disorder. We thank Sarah Atkinson, Linda Carter, and Sue
As in previous editions, we have sought to provide Woods- Gantz for secretarial assistance. We are very
information in a format, and at a level of detail, to grateful to Charlotte Allan, Chris Bass, Christopher
assist those training in psychiatry. We hope the book Fairburn, and Kate Saunders for their expert advice and
will also continue to be useful to medical students and helpful comments.
other health professionals, including those working in PH
primary care, community health, and the many profes- PC
sions and groups contributing to multidisciplinary men- TB
tal health care. More detailed information can be found MF
in the companion reference textbook, the New Oxford Oxford, March 2017
vii
Contents
1 Signs and symptoms of psychiatric disorders 1
2 Classification 21
3 Assessment 35
4 Ethics and civil law 71
5 Aetiology 87
6 Evidence- based approaches to psychiatry 119
7 Reactions to stressful experiences 135
8 Anxiety and obsessive– compulsive disorders 161
9 Depression 193
10 Bipolar disorder 233
11 Schizophrenia 253
12 Paranoid symptoms and syndromes 299
13 Eating, sleep, and sexual disorders 313
14 Dementia, delirium, and other neuropsychiatric disorders 345
15 Personality and personality disorder 391
16 Child psychiatry 415
17 Intellectual disability (mental retardation) 485
18 Forensic psychiatry 513
19 Psychiatry of the elderly 539
20 The misuse of alcohol and drugs 563
21 Suicide and deliberate self- harm 609
22 Psychiatry and medicine 631
23 Global psychiatry 675
24 Psychological treatments 681
25 Drugs and other physical treatments 709
26 Psychiatric services 777
References 801
Index 859
1
CHAPTER 1
Signs and symptoms
of psychiatric disorders
Introduction 1 Descriptions of symptoms
General issues 2 and signs 4
Introduction
Psychiatrists require two distinct capacities. One is the psychiatric patients. In other words, he decides whether
capacity to collect clinical data objectively and accur- the clinical features conform to a recognized syndrome.
ately, and to organize and communicate the data in a He does this by combining observations about the
systematic and balanced way. The other is the capacity patient’s present state with information about the history
for intuitive understanding of each patient as an indi- of the condition. The value of identifying a syndrome is
vidual. When the psychiatrist exercises the first cap- that it helps to predict prognosis and to select an effect-
acity, he draws on his skills and knowledge of clinical ive treatment. It does this by directing the psychiatrist
phenomena; when he exercises the second capacity, to the relevant body of accumulated knowledge about
he draws on his knowledge of human nature and his the causes, treatment, and outcome in similar patients.
experience with former patients to gain insights into the Diagnosis and classification are discussed in the next
patient he is now seeing. Both capacities can be devel- chapter, and also in each of the chapters dealing with the
oped by listening to patients, and by learning from more various psychiatric disorders. Chapter 3 discusses how to
experienced psychiatrists. A textbook can provide the elicit and interpret the symptoms described in this chap-
information and describe the procedures necessary to ter, and how to integrate the information to arrive at a
develop the first capacity. The focus of the chapter on syndromal diagnosis, since this in turn is the basis for a
the first capacity does not imply that intuitive under- rational approach to management and prognosis.
standing is unimportant, but simply that it cannot be As much of the present chapter consists of defini-
learned directly or solely from a textbook. tions and descriptions of symptoms and signs, it may
Skill in examining patients depends on a sound know- be less easy to read than those that follow. It is sug-
ledge of how symptoms and signs are defined. Without gested that the reader might approach it in two stages.
such knowledge, the psychiatrist is liable to misclassify The first reading would be applied to the introductory
phenomena and thereby make inaccurate diagnoses. For sections and to a general understanding of the more
this reason, this chapter is concerned with the defin- frequently observed phenomena. The second reading
ition of the key symptoms and signs of psychiatric dis- would focus on details of definition and the less com-
orders. Having elicited a patient’s symptoms and signs, mon symptoms and signs, and might be done best in
the psychiatrist needs to decide how far these phenom- conjunction with an opportunity to interview a patient
ena fall into a pattern that has been observed in other exhibiting these.
2
2 Chapter 1 Signs and symptoms of psychiatric disorders
General issues
Before individual phenomena are described, some gen- of mental processes of which the patient is unaware (i.e.
eral issues will be considered concerning the methods they are ‘unconscious’). For example, Freud explained
of studying symptoms and signs, and the terms that are persecutory delusions as being evidence, in the con-
used to describe them. scious mind, of activities in the unconscious mind,
including the mechanisms of repression and projection
Psychopathology (see p. 277).
Subsequently, experimental psychopathology has
The study of abnormal states of mind is known as psycho- focused on empirically measurable and verifiable con-
pathology. The term embraces two distinct approaches to scious psychological processes, using experimental
the subject— descriptive and experimental. This chapter is methods such as cognitive and behavioural psych-
concerned almost exclusively with the former; the latter ology and functional brain imaging. For example, there
is introduced here but is discussed in later chapters. are cognitive theories of the origin of delusions, panic
attacks, and depression. Although experimental psycho-
Descriptive psychopathology
pathology is concerned with the causes of symptoms,
Descriptive psychopathology is the objective description of it is usually conducted in the context of the syndromes
abnormal states of mind avoiding, as far as possible, pre- in which the symptoms occur. Thus its findings are dis-
conceived ideas or theories, and limited to the descrip- cussed in the chapter covering the disorder in question.
tion of conscious experiences and observable behaviour.
It is sometimes also called phenomenology or phenomeno-
Terms and concepts used in
logical psychopathology, although the terms are not in
descriptive psychopathology
fact synonymous, and phenomenology has additional
meanings (Berrios, 1992). Likewise, descriptive psycho-
Symptoms and signs
pathology is more than just symptomatology (Stanghellini
and Broome, 2014). In general medicine there is a clear definition of, and
The aim of descriptive psychopathology is to eluci- separation between, a symptom and a sign. In psych-
date the essential qualities of morbid mental experiences iatry the situation is different. There are few ‘signs’ in
and to understand each patient’s experience of illness. It the medical sense (apart from the motor abnormalities
therefore requires the ability to elicit, identify, and inter- of catatonic schizophrenia or the physical manifesta-
pret the symptoms of psychiatric disorders, and as such tions of anorexia nervosa), with most diagnostic infor-
is a key element of clinical practice; indeed, it has been mation coming from the history and observations of
described as ‘the fundamental professional skill of the the patient’s appearance and behaviour. Use of the word
psychiatrist’. ‘sign’ in psychiatry is therefore less clear, and two dif-
The most important exponent of descriptive psycho- ferent uses may be encountered. First, it may refer to
pathology was the German psychiatrist and philosopher, a feature noted by the observer rather than something
Karl Jaspers. His classic work, Allgemeine Psychopathologie spoken by the patient (e.g. a patient who appears to be
(General Psychopathology), first published in 1913, still responding to a hallucination). Secondly, it may refer
provides the most complete account of the subject, and to a group of symptoms that the observer interprets in
the seventh edition is available in an English transla- aggregation as a sign of a particular disorder. In prac-
tion (Jaspers, 1963). A briefer introduction can be found tice, the phrase ‘symptoms and signs’ is often used
in Jaspers (1968), and Oyebode (2014) has provided interchangeably with ‘symptoms’ (as we have done in
a highly readable contemporary text on descriptive this chapter) to refer collectively to the phenomena of
psychopathology. psychiatric disorders, without a clear distinction being
drawn between the two words.
Experimental psychopathology
Subjective and objective
This approach seeks to explain abnormal mental phe-
nomena, as well as to describe them. One of the first In general medicine, the terms subjective and objective are
attempts was psychodynamic psychopathology, originating used as counterparts of symptoms and signs, respectively,
in Freud’s psychoanalytic investigations (see p. 91). It with ‘objective’ being defined as something observed
explains the causes of abnormal mental events in terms directly by the doctor (e.g. meningism, jaundice)— even
3
General issues 3
though, strictly speaking, it is a subjective judgement on content, not the form, that is of concern to the patient,
his part as to what has been observed. whose priority will be to discuss the persecution and its
In psychiatry, the terms have broadly similar mean- implications, and who may be irritated by what seem
ings as they do in medicine, although with a blurring to be irrelevant questions about the form of the belief.
between them, just as there is for symptoms and signs. The psychiatrist must be sensitive to this difference in
‘Objective’ refers to features observed during an inter- emphasis between the two parties.
view (i.e. the patient’s appearance and behaviour). The
Primary and secondary
term is usually used when the psychiatrist wants to com-
pare this with the patient’s description of symptoms. For With regard to symptoms, the terms primary and sec-
example, in evaluation of depression, complaints of low ondary are often used, but unfortunately with two dif-
mood and tearfulness are subjective features, whereas ferent meanings. The first meaning is temporal, simply
observations of poor eye contact, psychomotor retarda- referring to which occurred first. The second meaning
tion, and crying are objective ones. If both are present, is causal, whereby primary means ‘arising directly from
the psychiatrist might record ‘subjective and objective the pathological process’, and secondary means ‘arising
evidence of depression’, with the combination provid- as a reaction to a primary symptom’. The two meanings
ing stronger evidence than either alone. However, if the often coincide, as symptoms that arise directly from
patient’s behaviour and manner in the interview appear the pathological process usually appear first. However,
entirely normal, he records ‘not objectively depressed’, although subsequent symptoms are often a reaction to
despite the subjective complaints. It is then incumbent the first symptoms, they are not always of this kind, for
on the psychiatrist to explore the reasons for the dis- they too may arise directly from the pathological pro-
crepancy and to decide what diagnostic conclusions cess. The terms primary and secondary are used more
he should draw. As a rule, objective signs are accorded often in the temporal sense because this usage does not
greater weight. Thus he may diagnose a depressive dis- involve an inference about causality. However, many
order if there is sufficient evidence of this kind, even if patients cannot say in what order their symptoms
the patient denies the subjective experience of feeling appeared. In such cases, when it seems likely that one
depressed. Conversely, the psychiatrist may question the symptom is a reaction to another— for example, that
significance of complaints of low mood, however promi- a delusion of being followed by persecutors is a reac-
nent, if there are none of the objective features associ- tion to hearing accusing voices—it is described as sec-
ated with the diagnosis. ondary (using the word in the causal sense). The terms
primary and secondary are also used in descriptions of
Form and content
syndromes.
When psychiatric symptoms are described, it is useful
Understanding and explanation
to distinguish between form and content, a distinction
that is best explained by an example. If a patient says Jaspers (1913) contrasted two forms of understanding
that, when he is alone, he hears voices calling him a when applied to symptoms. The first, called Verstehen
homosexual, the form of the experience is an auditory (‘understanding’), is the attempt to appreciate the
hallucination (see below), whereas the content is the patient’s subjective experience: what does it feel like?
statement that he is homosexual. Another patient might This important skill requires intuition and empathy.
hear voices saying that she is about to be killed. Again The second approach, called Erklären (‘explanation’),
the form is an auditory hallucination, but the content accounts for events in terms of external factors; for
is different. A third patient might experience repeated example, the patient’s low mood can be ‘explained’
intrusive thoughts that he is homosexual, but he realizes by his recent redundancy. The latter approach requires
that these are untrue. Here the content is the same as knowledge of psychiatric aetiology (Chapter 5).
that of the first example, but the form is different.
The significance of individual symptoms
Form is often critical when making a diagnosis. From
the examples given above, the presence of a hallucina- Psychiatric disorders are diagnosed when a defined
tion indicates (by definition) a psychosis of one kind or group of symptoms (a syndrome) is present. Almost any
another, whereas the third example suggests obsessive– single symptom can be experienced by a healthy per-
compulsive disorder. Content is less diagnostically son; even hallucinations, often regarded as a hallmark
useful, but can be very important in management; for of severe mental disorder, are experienced by some
example, the content of a delusion may suggest that the otherwise healthy people. An exception to this is that
patient could attack a supposed persecutor. It is also the a delusion, even if isolated, is generally considered to
4
4 Chapter 1 Signs and symptoms of psychiatric disorders
be evidence of psychiatric disorder if it is unequivocal subject. This way of understanding is sometimes called
and persistent (see Chapter 11). In general, however, the life- story approach. It is not something that can be
the finding of a single symptom is not evidence of psy- readily assimilated from textbooks; it is best learned by
chiatric disorder, but an indication for a thorough and, taking time to listen to patients. The psychiatrist may
if necessary, repeated search for other symptoms and be helped by reading biographies or works of literature
signs of psychiatric disorder. The dangers of not adher- that provide insights into the ways in which experi-
ing to this principle are exemplified by the well- known ences throughout life shape the personality, and help
study by Rosenhan (1973). Eight ‘patients’ presented to explain the diverse ways in which different people
with the complaint that they heard the words ‘empty, respond to the same events.
hollow, thud’ being said out loud. All eight individuals
Cultural variations in psychopathology
were admitted and diagnosed with schizophrenia, des-
pite denying all other symptoms and behaving entirely The core symptoms of most serious mental disorders
normally. This study also illustrates the importance of are present in culturally diverse individuals. However,
descriptive psychopathology, and of reliable diagnos- there are cultural differences in how these symp-
tic criteria (see Chapter 2), as fundamental aspects of toms present in clinical settings and to the meanings
psychiatry. that are attributed to them. For example, depression
can present with prominent somatic symptoms in
The patient’s experience
many Asian populations, such as those from India
Symptoms and signs are only part of the subject mat- and China. The content of symptoms can also differ
ter of psychopathology. The latter is also concerned between cultures. For example, for sub-S aharan African
with the patient’s experience of illness, and the way populations, delusions not infrequently centre upon
in which psychiatric disorder changes his view of him- being cursed, a rare delusional theme in Europeans.
self, his hopes for the future, and his view of the world Cultural differences also affect the person’s subjective
(Stanghellini and Broome, 2014). This may be seen as experience of illness, and therefore influence that per-
one example of the understanding (verstehen) men- son’s understanding of it (Fabrega, 2000). In some cul-
tioned above. A depressive disorder may have a very tures, the effects of psychiatric disorder are ascribed to
different effect on a person who has lived a satisfying witchcraft— a belief that adds to the patient’s distress.
and happy life and has fulfilled his major ambitions, In many cultures, mental illness is greatly stigmatized,
compared with a person who has had many previous and can, for example, hinder prospects of marriage. In
misfortunes but has lived on hopes of future success. such a culture the effect of illness on the patient’s view
To understand this aspect of the patient’s experience of himself and his future will be very different from
of psychiatric disorder, the psychiatrist has to under- the effect on a patient living in a society that is more
stand him in the way that a biographer understands his tolerant of mental disorder.
Descriptions of symptoms and signs
Disturbances of emotion The former usage is now uncommon. The latter usage is
and mood emphasized by the fact that, in current diagnostic sys-
tems, ‘mood disorders’ are those in which depression and
Much of psychiatry is concerned with abnormal emo- mania are the defining characteristics, whereas disorders
tional states, particularly disturbances of mood and defined by anxiety or other emotional disturbances are
other emotions, especially anxiety. Before describing the categorized separately. In this section, features common
main symptoms of this kind, it is worth clarifying two to both ‘mood’ and ‘other emotions’ are described first,
areas of terminology that may cause confusion, in part before the specific features of anxiety, depression, and
because their usage has changed over the years. mania are discussed separately.
First, the term ‘mood’ can either be used as a broad The second point concerns the term ‘affect’. This is
term to encompass all emotions (e.g. ‘anxious mood’), now usually used interchangeably with the term ‘mood’,
or in a more restricted sense to mean the emotion that in the more limited meaning of the latter word (e.g.
runs from depression at one end to mania at the other. ‘his affect was normal’, ‘he has an affective disorder’).
5
Descriptions of symptoms and signs 5
However, in the past, these words had different nuances Anxiety
of meaning; mood referred to a prevailing and prolonged
Anxiety is a normal response to danger. Anxiety is
state, whereas affect was linked to a particular aspect or
abnormal when its severity is out of proportion to the
object, and was more transitory.
threat of danger, or when it outlasts the threat. Anxious
Emotions and mood may be abnormal in three ways:
mood is closely coupled with somatic and autonomic
● Their nature may be altered components, and with psychological ones. All can be
thought of as equivalent to the preparations for deal-
● They may fluctuate more or less than usual
ing with danger seen in other mammals, ready for flight
● They may be inconsistent with the patient’s thoughts
from, avoidance of, or fighting with a predator. Mild- to-
or actions, or with his current circumstances.
moderate anxiety enhances most kinds of performance,
Changes in the nature of emotions and mood but very high levels interfere with it.
The anxiety response is considered further in
These can be towards anxiety, depression, elation, or
Chapter 8. Here its main components can be summa-
irritability and anger. Any of these changes may be asso-
rized as follows.
ciated with events in the person’s life, but they may arise
without an apparent reason. They are usually accom- ● Psychological. The essential feelings of dread and appre-
panied by other symptoms and signs. For example, an hension are accompanied by restlessness, narrowing of
increase in anxiety is accompanied by autonomic over- attention to focus on the source of danger, worrying
activity and increased muscle tension, and depression thoughts, increased alertness (with insomnia), and
is accompanied by gloomy preoccupations and psycho- irritability (that is, a readiness to become angry).
motor slowness. ● Somatic. Muscle tension and respiration increase. If
Changes in the way that emotions these changes are not followed by physical activity,
and mood vary they may be experienced as muscle tension tremor, or
the effects of hyperventilation (e.g. dizziness).
Emotions and mood vary in relation to the person’s
● Autonomic. Heart rate and sweating increase, the
circumstances and preoccupations. In abnormal states,
mouth becomes dry, and there may be an urge to uri-
this variation with circumstances may continue, but the
nate or defaecate.
variations may be greater or less than normal. Increased
variation is called lability of mood; extreme variation is ● Avoidance of danger. A phobia is a persistent, irrational
fear of a specific object or situation. Usually there is
sometimes called emotional incontinence.
also a marked wish to avoid the object, although this
Reduced variation is called blunting or flattening.
is not always the case— for example, fear of illness
These terms have been used with subtly different
(hypochondriasis). The fear is out of proportion to the
meanings, but are now usually used interchangeably.
objective threat, and is recognized as such by the per-
Blunting or flattening usually occurs in depression and
son experiencing it. Phobias include fear of animate
schizophrenia. Severe flattening is sometimes called
objects, natural phenomena, and situations. Phobic
apathy (note the difference from the layman’s meaning
people feel anxious not only in the presence of the
of the word).
object or situation, but also when thinking about it
Emotion can also vary in a way that is not in keep-
(anticipatory anxiety). Phobias are discussed further in
ing with the person’s circumstances and thoughts, and
relation to anxiety disorders in Chapter 5.
this is described as incongruous or inappropriate. For
example, a patient may appear to be in high spirits and
laugh when talking about the death of his mother. Such Clinical associations
incongruity must be distinguished from the embarrassed Phobias are common among healthy children, becom-
laughter which indicates that the person is ill at ease. ing less frequent in adolescence and adult life. Phobic
Clinical associations of emotional symptoms occur in all kinds of anxiety disorder, but are
the major feature in the phobic disorders.
and mood disturbances
Depression
Disturbances of emotions and mood are seen in essen-
tially all psychiatric disorders. They are the central fea- Depression is a normal response to loss or misfortune,
ture of the mood disorders and anxiety disorders. They when it may be called grief or mourning. Depression
are also common in eating disorders, substance-i nduced is abnormal when it is out of proportion to the misfor-
disorders, delirium, dementia, and schizophrenia. tune, or is unduly prolonged. Depressed mood is closely