Medicine (Abingdon, England : UK ed.)最新文献

Psychological therapies have been significantly developing in terms of theory and evidence over the past 30 years. They can be categorized into four broad families, defined by distinct theories of the person, psychopathology and change: cognitive behavioural, psychodynamic, person-centred and family/couples therapies. The underpinning theory and therapeutic approach of each form of therapy are briefly described, together with current outcome evidence with key references. Appropriate electronic resources are cited for each of the approaches described, and the wider literature on psychological approaches and current UK NHS planning is briefly covered.

Functional disorders (FDs) are characterized by physical symptoms that trigger the individual to seek healthcare but remain unexplained after appropriate medical assessment. They are common and cause significant distress and disability. What doctors say and do, and the design of the healthcare system, play key roles in their aetiology. When patients present with physical symptoms, it is important to rule out serious physical pathology. However, an early ‘positive’ diagnosis of FDs can lead to better outcomes than diagnosis by exclusion. Commonly associated psychiatric conditions include depression, anxiety and alcohol/substance abuse. If reassurance and simple reattribution techniques do not lead to symptom resolution, consider cognitive behavioural therapy or the use of antidepressants as neuromodulating agents (rather than as antidepressants per se).

Depression is an under-recognized, undertreated, common relapsing disorder that causes significant distress and impairment in social and occupational functioning. It is associated with an increased risk of death, not only through suicide, but also from physical illnesses such as cardiovascular disease. High-risk groups such as those suffering from chronic physical health problems should be screened for depression. Its aetiology is multifactorial, and co-morbidity with other psychiatric disorders is common. The assessment of depression requires determining the duration, symptom severity, suicide risk and functional impairment of the current episode, co-morbid diagnoses, past mood and treatment history, as well as obtaining a developmental, social and family history. Treatment is guided by illness severity, presentation and previous history, and includes psychosocial interventions, with antidepressant medication reserved for persistent and moderate to severe depression. Prevention of relapse is a priority, and risk factors for this should be assessed and used to guide prophylactic drug and psychological treatment.

Psychiatric assessment in elderly individuals requires a particular focus on cognition and co-morbid physical illness. There can be differences in psychiatric manifestation between younger and older adults. A structured approach to history-taking with a good understanding of the diagnostic hierarchy of psychiatric disorders allows for a clear biopsychosocial formulation. For organic conditions, particularly with cognitive and neurobehavioural deficits, management must be informed by the real-world impact of these problems.

Eating disorders are common, affecting 5–10% of young people, with >50% of these having an illness that persists for >5 years. The main eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder. Eating disorders with binge eating now dominate. New diagnostic categories have been introduced (avoidant/restrictive food intake disorder, pica, rumination disorder). Genetic factors interacting with environmental stress (some shared with other psychiatric disorders, others relating to metabolism and eating) increase the risk. Self-management strategies, including a focus on social emotional functioning and behavioural change skills to manage fears and habits, are moderately effective. Olanzapine shows some evidence in anorexia nervosa but cannot be generally recommended, fluoxetine is approved in bulimia nervosa, and lisdexamfetamine has been approved for binge-eating disorder in some countries, although not the UK. Inpatient care and family involvement are important in the management of anorexia nervosa.

Anxiety symptoms and disorders are common in community settings and primary and secondary care. Symptoms can be mild and transient, but many people are troubled by severe symptoms causing great personal distress and impairing social and occupational function. The societal burden from anxiety disorders is considerable, but many who might benefit from treatment are not recognized or treated. Recognition relies on a keen awareness of the psychological and physical symptoms of all anxiety disorders, and accurate diagnosis on identifying the specific features of particular disorders. All anxiety disorders have a range of contributory causes. The need for treatment is determined by the severity and persistence of symptoms, level of associated disability, impact on everyday life, presence of coexisting depressive symptoms and other features such as good response to or poor tolerability of previous treatments. The choice of treatment is influenced by patient characteristics and patient and doctor preferences. There is much overlap between different anxiety disorders in evidence-based and effective therapies (e.g. prescription of a selective serotonin reuptake inhibitor, course of cognitive behavioural therapy), but there are important differences. It thus helps to become familiar with the characteristic features and evidence base for each disorder.

Migration and asylum occur for a range of personal and geopolitical reasons. In an increasingly globalized world, migrants, refugees and asylum seekers show higher than expected rates of mental illness. Cultures and cultural identities strongly influence presentation, help-seeking and therapeutic alliance. Minority ethnic groups have higher than expected rates of psychiatric disorders, and their idioms of distress and pathways to care often vary compared with the majority population: thus, they need particular consideration in terms of their mental healthcare. Clinicians dealing with minority ethnic groups must use a culturally sensitive and appropriate approach. This paper highlights some of the factors that clinicians need to be aware of and take into account while planning therapeutic interventions. The authors make recommendations regarding assessment and management. Assessment must incorporate factors including primary language, religion, cultural identity and, where applicable, migration history. ‘Cultural competence’ must be a priority in developing and delivering services.

Impulsive and compulsive disorders are common in young people, present in many medical settings, but frequently overlooked and left untreated. This article provides a primer on impulsivity and compulsivity, focusing on attention-deficit hyperactivity disorder (the archetypal impulsive disorder), obsessive–compulsive disorder (the archetypal compulsive disorder) and gambling disorder (a condition involving both features). We focus on their presentations, epidemiology, pathogenesis and usual course, how to recognize them clinically (including brief screening tools) and management approaches. Finally, we highlight other types of impulsive and compulsive symptom that are common but require more research to establish optimal assessment and treatment approaches.

Schizophrenia is a severe mental illness affecting several domains of cognition and behaviour. The illness commonly manifests in late adolescence to early adulthood and often follows a prolonged course. It is associated with a high degree of morbidity and mortality, and is a leading contributor to disease burden and health and social care costs throughout the world. Antipsychotic medication are the mainstay of treatment but are limited by significant adverse effects, and around one-quarter of patients do not respond to standard antipsychotic treatment. Schizophrenia is associated with a range of adverse physical health outcomes, which can be compounded by lifestyle factors, barriers to health and social care, and the adverse effects of treatment. Psychological and social interventions are a crucial element of care, particularly in alleviating negative psychotic symptoms. Current theories view schizophrenia as a disorder of early brain development, with interacting genetic and environmental risk factors.