Shorter Oxford Textbook of Psychiatry 7th Edition PDF

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m m m m eb eb eb eb oo oo oo oo ks ks ks ks f re fre fre f re.c e. e. e. e. om co c co co m om m m m m m m eb eb eb eb oo oo oo o ks ks k sf ok s fre fre re fre.c e. e. e. e. o c co co c m om m m om m m m m eb eb eb eb o ok oo oo oo s fre ks fre ks fre ks fre.c e. e. e. e. om co co co co m m m m m m m m eb eb eb eb oo oo oo oo  i m m m m eb eb eb eb oo oo oo oo ks ks ks ks f re f re fre f re.c e. e. e. e. co c co co of Psychiatry om m om m m m m m m Shorter Oxford Textbook eb eb eb eb oo oo oo o ok ks ks ks s fre fre fre fre.c e. e. e. e. o co co co c m m m m om m m m m eb eb eb eb o ok oo oo oo s k sf ks ks fre re fre fre.c e. e.c e. e. om co co co m om m m m m m m eb eb eb eb oo oo oo oo  ii m m m m eb eb eb eb oo oo oo oo ks ks ks ks f re f re fre f re.c e. e. e. e. om co c co co m om m m m m m m eb eb eb eb oo oo oo o ok ks ks ks s fre fre fre fre.c e. e. e. e. o co co co c m m m m om m m m m eb eb eb eb o ok oo oo oo s k sf ks ks fre re fre fre.c e. e.c e. e. om co co co m om m m m m m m eb eb eb eb oo oo oo oo  iii m m m m eb eb eb eb oo oo oo oo ks ks ks ks fre f re fre f re.c e. e. e. e. c Tom Burns Mina Fazel om co co co m om m m 1 Philip Cowen Paul Harrison m m m m eb eb eb eb oo oo oo o SEVENTH EDITION ks ks ks ok fre fre fre s fre Psychiatry.c e. e. e. e. c Textbook of o m co m co m co m om m m m m Shorter Oxford eb eb eb eb o ok oo oo oo s k sf ks ks fre re fre fre.c e. e.c e. e. om co co co m om m m m m m m eb eb eb eb oo oo oo oo iv m om m co co c e. e. e. 1 re fre fre f ks s ks ok Great Clarendon Street, Oxford, OX2 6DP, oo oo oo United Kingdom o Oxford University Press is a department of the University of Oxford. eb eb eb eb It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of m m m m Oxford University Press in the UK and in certain other countries © Oxford University Press 2018 The moral rights of the authors‌have been asserted m m m First Edition published in 1983 co co co Second Edition published in 1989 Third Edition published in 1996 e. e. e. Fourth Edition published in 2001 Fifth Edition published in 2006 fre fre fre Sixth Edition published in 2012 Seventh Edition published in 2018 ks ks ks Impression: 1 oo oo oo oo 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, without the eb eb eb eb prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics m m m m rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form om m om and you must impose this same condition on any acquirer co Published in the United States of America by Oxford University Press c.c 198 Madison Avenue, New York, NY 10016, United States of America e. e. e British Library Cataloguing in Publication Data re fre re Data available f Library of Congress Control Number: 2017932616 sf ks ks k ISBN 978–​0–​19–​874743–​7 oo oo oo oo Printed in Great Britain by Bell & Bain Ltd., Glasgow eb eb eb eb Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check m m m m the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the m m m text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-​pregnant co co co adult who is not breast-​feeding e. e. e. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials re fre fre contained in any third party website referenced in this work. f ks ks s ok oo oo oo o eb eb eb eb m m m m om m om o.c.c.c v m om m co co c e. e. e. Preface to the seventh edition re fre fre f ks s ks ok oo oo oo o In the 5 years since the sixth edition of this book, psy- Textbook of Psychiatry, the third edition of which is near- eb eb eb eb chiatry has seen important advances in understanding ing completion. m m m m 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 m m m on global mental health, and division of mood disor- have been corrected, and this edition benefits greatly co co co ders into separate chapters on depression and bipolar from her contributions. disorder. We thank Sarah Atkinson, Linda Carter, and Sue e. e. e. As in previous editions, we have sought to provide Woods-​ Gantz for secretarial assistance. We are very fre fre fre information in a format, and at a level of detail, to grateful to Charlotte Allan, Chris Bass, Christopher ks ks ks 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. oo oo oo oo other health professionals, including those working in PH primary care, community health, and the many profes- PC eb eb eb eb sions and groups contributing to multidisciplinary men- TB m m m m tal health care. More detailed information can be found MF in the companion reference textbook, the New Oxford Oxford, March 2017 om m om co c.c e. e. e re fre re f sf ks ks k oo oo oo oo eb eb eb eb m m m m m m m co co co e. e. e. re fre fre f ks ks s ok oo oo oo o eb eb eb eb m m m m om m om o.c.c.c  vi m m m m eb eb eb eb oo oo oo oo ks ks ks ks f re f re fre f re.c e. e. e. e. om co c co co m om m m m m m m eb eb eb eb oo oo oo o ok ks ks ks s fre fre fre fre.c e. e. e. e. o co co co c m m m m om m m m m eb eb eb eb o ok oo oo oo s k sf ks ks fre re fre fre.c e. e.c e. e. om co co co m om m m m m m m eb eb eb eb oo oo oo oo vi m om m co co c e. e. e. Contents re fre fre f ks s ks ok oo oo oo o 1 Signs and symptoms of psychiatric disorders 1 eb eb eb eb 2 Classification 21 m m m m 3 Assessment 35 4 Ethics and civil law 71 m m m 5 Aetiology 87 co co co 6 Evidence-​based approaches to psychiatry 119 e. e. e. fre fre fre 7 Reactions to stressful experiences 135 8 Anxiety and obsessive–​compulsive disorders 161 ks ks ks oo oo oo oo 9 Depression 193 10 Bipolar disorder 233 eb eb eb eb 11 Schizophrenia 253 m m m m 12 Paranoid symptoms and syndromes 299 13 Eating, sleep, and sexual disorders 313 om m om co 14 Dementia, delirium, and other neuropsychiatric disorders 345 c.c e. e. 15 Personality and personality disorder 391 e re fre re 16 Child psychiatry 415 f sf ks ks 17 Intellectual disability (mental retardation) 485 k oo oo oo oo 18 Forensic psychiatry 513 eb eb eb eb 19 Psychiatry of the elderly 539 m m m m 20 The misuse of alcohol and drugs 563 21 Suicide and deliberate self-​harm 609 22 Psychiatry and medicine 631 m m m co co co 23 Global psychiatry 675 e. e. e. 24 Psychological treatments 681 re fre fre 25 Drugs and other physical treatments 709 f ks ks s 26 Psychiatric services 777 ok oo oo oo o eb eb eb eb References 801 Index 859 m m m m om m om o.c.c.c  vi m m m m eb eb eb eb oo oo oo oo ks ks ks ks f re f re fre f re.c e. e. e. e. om co c co co m om m m m m m m eb eb eb eb oo oo oo o ok ks ks ks s fre fre fre fre.c e. e. e. e. o co co co c m m m m om m m m m eb eb eb eb o ok oo oo oo s k sf ks ks fre re fre fre.c e. e.c e. e. om co co co m om m m m m m m eb eb eb eb oo oo oo oo 1 m om m co co c e. e. e. re fre fre f ks s ks CHAPTER 1 ok oo oo oo Signs and symptoms o eb eb eb eb m m m m of psychiatric disorders m m m co co co e. e. e. Introduction 1 Descriptions of symptoms fre fre fre General issues 2 and signs 4 ks ks ks oo oo oo oo eb eb eb eb Introduction m m m m Psychiatrists require two distinct capacities. One is the psychiatric patients. In other words, he decides whether om m om capacity to collect clinical data objectively and accur- the clinical features conform to a recognized syndrome. co ately, and to organize and communicate the data in a He does this by combining observations about the c.c systematic and balanced way. The other is the capacity patient’s present state with information about the history e. e. e for intuitive understanding of each patient as an indi- of the condition. The value of identifying a syndrome is re fre re vidual. When the psychiatrist exercises the first cap- that it helps to predict prognosis and to select an effect- f acity, he draws on his skills and knowledge of clinical sf ive treatment. It does this by directing the psychiatrist ks ks phenomena; when he exercises the second capacity, to the relevant body of accumulated knowledge about k oo oo oo oo 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 eb eb eb eb 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 m m m m 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 m m m the first capacity does not imply that intuitive under- rational approach to management and prognosis. co co co 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 e. e. e. Skill in examining patients depends on a sound know- be less easy to read than those that follow. It is sug- re fre fre ledge of how symptoms and signs are defined. Without gested that the reader might approach it in two stages. f such knowledge, the psychiatrist is liable to misclassify The first reading would be applied to the introductory ks ks s ok phenomena and thereby make inaccurate diagnoses. For sections and to a general understanding of the more oo oo oo this reason, this chapter is concerned with the defin- frequently observed phenomena. The second reading o ition of the key symptoms and signs of psychiatric dis- would focus on details of definition and the less com- eb eb eb eb orders. Having elicited a patient’s symptoms and signs, mon symptoms and signs, and might be done best in m m m m 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. om m om o.c.c.c 2 m om m 2 Chapter 1 Signs and symptoms of psychiatric disorders co co c e. e. e. General issues re fre fre f ks s ks ok Before individual phenomena are described, some gen- of mental processes of which the patient is unaware (i.e. oo oo oo eral issues will be considered concerning the methods they are ‘unconscious’). For example, Freud explained o of studying symptoms and signs, and the terms that are persecutory delusions as being evidence, in the con- eb eb eb eb used to describe them. scious mind, of activities in the unconscious mind, m m m m including the mechanisms of repression and projection (see p. 277). Psychopathology Subsequently, experimental psychopathology has The study of abnormal states of mind is known as psycho- focused on empirically measurable and verifiable con- m m m pathology. The term embraces two distinct approaches to scious psychological processes, using experimental co co co 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 e. e. e. is introduced here but is discussed in later chapters. are cognitive theories of the origin of delusions, panic fre fre fre attacks, and depression. Although experimental psycho- Descriptive psychopathology pathology is concerned with the causes of symptoms, ks ks ks Descriptive psychopathology is the objective description of it is usually conducted in the context of the syndromes oo oo oo oo 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. eb eb eb eb tion of conscious experiences and observable behaviour. m m m m It is sometimes also called phenomenology or phenomeno- logical psychopathology, although the terms are not in Terms and concepts used in fact synonymous, and phenomenology has additional descriptive psychopathology meanings (Berrios, 1992). Likewise, descriptive psycho- om m om pathology is more than just symptomatology (Stanghellini Symptoms and signs co and Broome, 2014). In general medicine there is a clear definition of, and c.c separation between, a symptom and a sign. In psych- e. e. The aim of descriptive psychopathology is to eluci- e date the essential qualities of morbid mental experiences iatry the situation is different. There are few ‘signs’ in re fre and to understand each patient’s experience of illness. It re the medical sense (apart from the motor abnormalities f sf ks ks therefore requires the ability to elicit, identify, and inter- of catatonic schizophrenia or the physical manifesta- k pret the symptoms of psychiatric disorders, and as such tions of anorexia nervosa), with most diagnostic infor- oo oo oo oo 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 eb eb eb eb psychiatrist’. ‘sign’ in psychiatry is therefore less clear, and two dif- m m m m 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 responding to a hallucination). Secondly, it may refer m m m (General Psychopathology), first published in 1913, still provides the most complete account of the subject, and to a group of symptoms that the observer interprets in co co co the seventh edition is available in an English transla- aggregation as a sign of a particular disorder. In prac- e. e. e. tion (Jaspers, 1963). A briefer introduction can be found tice, the phrase ‘symptoms and signs’ is often used interchangeably with ‘symptoms’ (as we have done in re fre fre in Jaspers (1968), and Oyebode (2014) has provided a highly readable contemporary text on descriptive this chapter) to refer collectively to the phenomena of f ks ks s psychopathology. psychiatric disorders, without a clear distinction being ok drawn between the two words. oo oo oo Experimental psychopathology o Subjective and objective eb eb eb eb 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 m m m m 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 om m om o.c.c.c 3 m om m General issues 3 co co c e. e. e. though, strictly speaking, it is a subjective judgement on content, not the form, that is of concern to the patient, re fre fre his part as to what has been observed. whose priority will be to discuss the persecution and its f In psychiatry, the terms have broadly similar mean- implications, and who may be irritated by what seem ks s ks ok ings as they do in medicine, although with a blurring to be irrelevant questions about the form of the belief. oo oo oo between them, just as there is for symptoms and signs. The psychiatrist must be sensitive to this difference in o ‘Objective’ refers to features observed during an inter- emphasis between the two parties. eb eb eb eb view (i.e. the patient’s appearance and behaviour). The Primary and secondary m m m m 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 m m m observations of poor eye contact, psychomotor retarda- referring to which occurred first. The second meaning co co co 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 e. e. e. evidence of depression’, with the combination provid- as a reaction to a primary symptom’. The two meanings fre fre fre 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, ks ks ks entirely normal, he records ‘not objectively depressed’, although subsequent symptoms are often a reaction to oo oo oo oo 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- eb eb eb eb crepancy and to decide what diagnostic conclusions cess. The terms primary and secondary are used more m m m m 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 om m om depressed. Conversely, the psychiatrist may question the symptom is a reaction to another—​for example, that co significance of complaints of low mood, however promi- a delusion of being followed by persecutors is a reac- c.c e. e. nent, if there are none of the objective features associ- tion to hearing accusing voices—​it is described as sec- e ated with the diagnosis. ondary (using the word in the causal sense). The terms re fre re primary and secondary are also used in descriptions of f sf Form and content ks ks syndromes. k When psychiatric symptoms are described, it is useful oo oo oo oo to distinguish between form and content, a distinction Understanding and explanation eb eb eb eb 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 m m m m 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. m m m 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 co co co is different. A third patient might experience repeated example, the patient’s low mood can be ‘explained’ e. e. e. intrusive thoughts that he is homosexual, but he realizes by his recent redundancy. The latter approach requires re fre fre 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. f The significance of individual symptoms ks ks s Form is often critical when making a diagnosis. From ok the examples given above, the presence of a hallucina- Psychiatric disorders are diagnosed when a defined oo oo oo o tion indicates (by definition) a psychosis of one kind or group of symptoms (a syndrome) is present. Almost any eb eb eb eb 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 m m m m 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 om m om o.c.c.c 4 m om m 4 Chapter 1 Signs and symptoms of psychiatric disorders co co c e. e. e. be evidence of psychiatric disorder if it is unequivocal subject. This way of understanding is sometimes called re fre fre and persistent (see Chapter 11). In general, however, the life-​story approach. It is not something that can be f the finding of a single symptom is not evidence of psy- readily assimilated from textbooks; it is best learned by ks s ks ok chiatric disorder, but an indication for a thorough and, taking time to listen to patients. The psychiatrist may oo oo oo if necessary, repeated search for other symptoms and be helped by reading biographies or works of literature o signs of psychiatric disorder. The dangers of not adher- that provide insights into the ways in which experi- eb eb eb eb ing to this principle are exemplified by the well-​known ences throughout life shape the personality, and help m m m m 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 were admitted and diagnosed with schizophrenia, des- Cultural variations in psychopathology m m m pite denying all other symptoms and behaving entirely The core symptoms of most serious mental disorders co co co 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- e. e. e. tic criteria (see Chapter 2), as fundamental aspects of toms present in clinical settings and to the meanings fre fre fre psychiatry. that are attributed to them. For example, depression can present with prominent somatic symptoms in ks ks ks The patient’s experience many Asian populations, such as those from India oo oo oo oo 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-​Saharan African eb eb eb eb with the patient’s experience of illness, and the way populations, delusions not infrequently centre upon m m m m 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- om m om tioned above. A depressive disorder may have a very tures, the effects of psychiatric disorder are ascribed to co different effect on a person who has lived a satisfying witchcraft—​a belief that adds to the patient’s distress. c.c e. e. and happy life and has fulfilled his major ambitions, In many cultures, mental illness is greatly stigmatized, e compared with a person who has had many previous and can, for example, hinder prospects of marriage. In re fre misfortunes but has lived on hopes of future success. re such a culture the effect of illness on the patient’s view f sf ks ks To understand this aspect of the patient’s experience of himself and his future will be very different from k of psychiatric disorder, the psychiatrist has to under- the effect on a patient living in a society that is more oo oo oo oo stand him in the way that a biographer understands his tolerant of mental disorder. eb eb eb eb m m m Descriptions of symptoms and signs m m m