Psychiatrydownload.e- · PDF file 2013. 7. 23. · 7 Neurotic, stress-related, and somatoform disorders (anxiety disorders), 117 8 Personality disorders, 133 9 Organic psychiatric

Psychiatry

Psychiatry Second edition

Neel Burton BSc, MBBS, MRCPsych, MA (Phil), AKC Green Templeton College University of Oxford, Oxford, UK

A John Wiley & Sons, Ltd., Publication

This edition fi rst published 2010, © 2006, 2010 by Neel Burton

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientifi c, Technical and Medical business to form Wiley-Blackwell.

Registered offi ce: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, 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

The right of the author to be identifi ed as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.

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 or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

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.

While every effort has been made to ensure the accuracy of the information contained in this book, no responsibility for loss or injury occasioned to any person acting or refraining from action as a result of it can be accepted by the author or publisher.

Library of Congress Cataloging-in-Publication Data Burton, Neel L. Psychiatry / Neel Burton. – 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-9096-1 1. Psychiatry. I. Title. [DNLM: 1. Psychiatry–methods. 2. Mental Disorders. 3. Mental Health Services. WM 30 B974p 2010] RC454.B844 2010 616.89–dc22

2009021670

ISBN: 9781405190961

A catalogue record for this book is available from the British Library.

Set in 9.5 on 11.5 pt Minion by Toppan Best-set Premedia Limited Printed and bound in Singapore

1 2010

Contents

Preface to the second edition, vii Preface to the fi rst edition, viii Foreword, ix

Part 1

1 A brief history of psychiatry, 3

2 Patient assessment, 11

3 The delivery of mental health care, 35

Part 2

4 Schizophrenia and other psychotic disorders, 51

5 Affective (mood) disorders, 77

6 Suicide and deliberate self-harm, 109

7 Neurotic, stress-related, and somatoform disorders (anxiety disorders), 117

8 Personality disorders, 133

9 Organic psychiatric disorders (delirium and dementias), 145

10 Mental retardation (learning disabilities), 159

11 Substance misuse, 165

12 Eating, sleep, and sexual disorders, 183

13 Child and adolescent psychiatry, 197

So, why a career in psychiatry?, 207

Self-assessment EMQs, 209

Answers to self-assessment, 216

Answers to EMQs, 221

Appendix: Some psychiatric questionnaires and rating scales, 222

Index, 224

v

True, we love life, not because we are used to living, but because we are used to loving. There is always some madness in love, but there is also always some reason in madness.

Friedrich Nietzsche, Thus Spake Zarathustra

Preface to the second edition

This second edition of Psychiatry is the product of exten- sive feedback from students and lecturers, both from the UK and other English - speaking countries. Whilst I have made a large number of changes and additions, I have also tried to preserve what was most liked about the original edition: its clear style and presentation, its appropriate balance of breadth and depth, and its strong ‘ character ’ .

Psychiatry continues to include a fair bit of material from the arts and humanities. This material aims to help the student engage with the subject; better understand human emotions, behaviours, and thoughts; and question commonly held assumptions about mental disorders and the people who suffer from them. This is important, fi rst, because students (and the professionals that they eventu-

ally become) often stigmatise people with a mental disor- der; and second, because this stigma extends to psychiatry and to psychiatrists, and has a deleterious effect on the recruitment of talent into the profession.

Of the medical specialties, psychiatry is by far the most fascinating, the most challenging, and the most obviously relevant to us as thinking and feeling human beings who, in reality, aim at nothing more than happiness. Students often tell me that this book stops them from falling asleep: if so, this has little to do with me, and much to do with the subject matter of psychiatry – namely, human life.

Neel Burton Oxford, August 2009

[email protected]

vii

Preface to the fi rst edition

Art is long, and Time is fl eeting, And our hearts, though stout and brave, Still, like muffl ed drums, are beating Funeral marches to the grave.

Henry Wadsworth Longfellow, A Psalm of Life

‘ Psychiatry ’ derives from the Ancient Greek, psyche and iatreia , and means ‘ healing of the soul ’ . Just like philosophy differs from other academic disciplines, so psychiatry differs from other medical specialties. Psychia- trists train medically because an understanding of the body is integral to the practice of psychiatry, but psychia- try is about more than just an understanding of the body. It is, indeed, about the very essence of what it means to be human.

Like philosophy then, psychiatry faces empirical and conceptual challenges that hinder its progress and leave it exposed to criticism. Yet it is precisely these challenges that make psychiatry such a satisfying and meaningful

pursuit. For in psychiatry each patient is unique, and each patient has something unique to return to the psychiatrist.

Having been a medical student not long ago, I have tried to make this book as readable as possible: clear and concise yet comprehensive and detailed. I have empha- sised important areas such as suicide risk assessment but have also included a fair bit of material from the arts and humanities that is not on the core curriculum. In so doing my aim has been to make psychiatry ‘ come alive ’ by highlighting some of its more interesting or challenging aspects, and to challenge the stigmatisation of mental dis- orders that continues to prevail even amongst healthcare professionals.

I hope that you enjoy reading this book, and that it inspires you to get the most out of your necessarily short rotation. Art is long, and Time is fl eeting .

Neel L. Burton Oxford, August 2005

Foreword

Welcome to Neel Burton ’ s fascinating and beautifully put together book and, even more importantly, welcome to the world of psychiatry. Perhaps you are approaching the subject with excitement and enthusiasm – as a chance to put into practice what you ’ ve learned about communica- tion skills and rapport or to see the reality of how neuro- science maps onto feeling and thinking. Alternatively, psychiatry might be something you are dreading. Will the patients be frightening and dangerous? Will the psychia- trists be only a little better?

Spend a little time browsing this book – stop and read the sections that seem most interesting to you – and you ’ ll have picked up a roadmap to psychiatry. When you ’ ve seen a patient with a particular diagnosis, skim the section that relates to him or her. Ask yourself what you learned from the patient that wasn ’ t in the book. For this is what psychiatry is all about – extending the boundaries of understanding of people and conditions beyond the very patchy written knowledge base. I have found a lifetime of fascinating learning and discovery in psychiatry and that the stories of my patients are better than going to the theatre.

So, surprise yourself. Allow yourself to enjoy your placement in psychiatry. You ’ ll get out more or less exactly what you put into it. You ’ ll probably also fi nd out some interesting things about yourself. What could be more fascinating?

If you think you want to train as a GP, consider psychia- try as a specialty within which you will really get to know your pati