Psychiatry (Abingdon, England)最新文献

Fabricated or induced illness (FII) is a rare form of child abuse that is usually, but not exclusively, perpetrated by mothers of children under 5 years of age. Detection and assessment require painstaking and detailed enquiry, and should not be attempted without full information from medical, social care, and other records. Suspected cases of FII often lead to family justice court orders to safeguard the child, appoint a guardian for him or her, and commission assessments. More than half of perpetrators have chronic somatoform and/or factitious disorders, often coexisting with a personality disorder. This article describes case characteristics suggesting that reunification with the child may be possible. These include: (a) acknowledgement of the fabrications; (b) an ability to work collaboratively with health and social services; (c) cessation of somatoform presentations to primary and tertiary care services; (d) reduction in frequency of any self-harming or substance misuse; (e) remaining in a stable relationship with social supports. Treatment phases are described; better outcome has been demonstrated where changes in the family system and a therapeutic alliance with the fabricator’s partner and extended family could be established. The time-frame for intervention must be sensitive to the developmental needs of the child. Successful outcome is dependent upon coordinated efforts by more than one mental health team, working closely with children’s social care, primary health care, and central paediatric involvement, to ensure the child’s safety and future well-being.

The UK Armed Forces comprise some 190,000 personnel who have most of their healthcare provided ‘in-house’ by dedicated medical personnel and facilities. Historically, military personnel deployed on operational duties have been affected by a variety of constellations of medically unexplained symptoms associated with their service. The most recent of these is Gulf War syndrome, a phrase coined after the 1991 Gulf War. This article examines the many hypotheses that have been put forward about the origins of the concept and gives an overview of studies that have attempted to explain the lasting health effects associated with Gulf service. It also examines the attempts that have been made to treat the condition and considers the implications for current psychiatric practice.

This article defines chronic fatigue syndrome (CFS) and describes various factors that have been associated with it. Two models of understanding CFS, a cognitive behavioural model and a deconditioning model, are then introduced alongside the treatments on which they are based. Both cognitive behavioural therapy and graded exercise therapy have been recommended by the National Institute for Health and Clinical Excellence as they are the treatments for which there is most evidence.

High rates of sickness absence and incapacity benefits constitute an increasing social and economic problem in most developed countries. Psychiatric disorders are now the leading reason for long-term sickness absence and incapacity benefits in the UK. Most of the work-associated costs of psychiatric disorder are due to common mental disorders such as depression and anxiety. Psychiatric disorders can also have a marked effect on workplace performance. Individuals suffering from mental illness are stigmatized in the workplace and often excluded from the various benefits paid employment can provide. There is good evidence that being in employment is associated with better mental health, including improved self-esteem and a lower risk of suicide. There is some evidence that an employee’s perception of their workplace can be associated with an increased risk of psychiatric disorder, particularly if they perceive high job strain. It seems likely that some of this effect may be mediated via factors such as personality and individual perceptions. A good occupational history should be part of any full psychiatric assessment. There is limited evidence regarding work-focused interventions for common mental disorders. The apparent lack of an occupational effect of standard treatments for depression suggests that additional specific interventions addressing return-to-work issues may be needed. There is good evidence that Individual Placement and Support (IPS) programmes are effective in helping individuals with schizophrenia find paid employment. Early detection, prompt focused management, and evidence-based rehabilitation should reduce the occupational impact of any psychiatric disorder.

Symptoms are a major reason for patients to see doctors. Modern medicine and modern psychiatry both conceptualize symptoms in terms of pathology. For medicine it is organic bodily pathology and for psychiatry it is psychopathology. However, these simple pathology-based approaches to symptoms are increasingly found to be both scientifically and clinically inadequate. An alternative is to regard symptoms not simply as a manfestation of pathology but rather as the expression of a combination of biological, psychological and social factors. This comprehensive approach transcends the traditional division of symptoms into medical and psychiatric, has major implication for the organization of services and provides new opportunities for research.

The condition now known as conversion disorder has been described since the time of Hippocrates. It was of great interest to many pioneers of neurology and psychiatry in the late 19th and early 20th century, such as Charcot and Freud. Since this time, despite being a relatively common condition often leading to severe and persistent disability, it has received relatively little attention from the scientific community. Consequently there has been little progress in understanding its pathogenesis and in finding effective treatments. The focus of this article is the management of motor and sensory conversion disorder, primarily from the perspective of the psychiatrist. The historical context and terminology of the condition are reviewed to minimize confusion and aid communication with both patients and other professionals. Diagnostic issues are explored along with potential psychological and neural mechanisms, revealing evidence for previous emotional trauma as a risk factor and the possible role of stressful life events preceding symptom onset. A guide to assessing suspected conversion disorder is provided, paying particular attention to what it is necessary to check before the assessment begins In order to maximize the chances of therapeutic engagement. The clinical features that help exclude neurological disorder and support conversion disorder are explained. There are no proven treatments specifically for conversion disorder, but current practice is reviewed along with the limited evidence base.

Medically unexplained symptoms (MUS) are physical symptoms that doctors cannot explain by organic pathology, which distress or impair the functioning of the patient. Patients with MUS account for around 50% more visits to primary care doctors, one-third more secondary care contacts than patients without MUS. MUS are often precipitated or exacerbated by psychosocial stress, depression and anxiety. Primary care consultations can take the form of a contest between the patient with MUS and the doctors: the doctor tries to reassure the patient, the patient provides more evidence of their distress or information that challenges the authority of the doctor, and the consultation often ends in collusion with an investigation, prescription, or referral that neither patient nor doctor is content with. Patients with MUS seek doctors who take their concerns seriously and legitimize their complaints. They do not necessarily expect a cure, but they seek an alliance to help them understand their health problems. Provision of emotional support, modification of symptom beliefs, explanations linking physical problems to psychosocial issues when they are relevant, antidepressants, and graded exercise for some types of MUS seem to be worth trying by doctors for patients with MUS. A four-stage model to help doctors manage MUS is provided. Some patients with chronic MUS and high consultation behaviour will require regular consultations with a single doctor who restricts the use of investigations, prescriptions, and referrals. Cognitive behavioural therapy may be helpful for patients with MUS who are willing to seek further psychological help.

Medically unexplained symptoms present a difficult management problem for doctors. Highlighting a concrete example and using a phenomenological approach, the author claims that at least part of this difficulty lies in the way doctors and their patients understand the concept of health. The prevalent biomedical model of illness employs a negative definition of health that, despite conferring operational validity to the concept, tends to be associated with an oppressive phenomenology. Re-attribution, when it is successful, works by engaging concretely with and restoring a prior phenomenological understanding of health. It is the latter that, the author argues, confers intelligibility upon what we mean by the concept.

This contribution is aimed at potential prescribers of electroconvulsive therapy (ECT) and covers the place of ECT in the treatment of major depression and mania in contemporary practice. The prescribing cycle is discussed: the selection of electrode placement, and the frequency and number of treatments. Adverse effects, outcome, and continuation treatment after ECT are also considered.

Lithium is the ‘gold standard’ of the many drug treatments used in bipolar disorder. It has efficacy in the treatment of mania, prophylaxis against manic relapses, and, to a lesser extent, prophylaxis against depressive relapses. It decreases suicidal risk. Blood monitoring of lithium is essential. In addition to side effects, problems include rebound mania on abrupt cessation of lithium and teratogenetic risks. Carbamazepine, valproate, and lamotrigine are anticonvulsants with an evidence base in bipolar disorder. Carbamazepine is anti-manic, but is poorly tolerated and associated with many pharmacokinetic interactions. Valproate is also anti-manic and is prophylactic, especially against mania, but its antidepressant effects in bipolar disorder are unclear. It is associated with many problems when used during pregnancy, and should be avoided in women of childbearing potential. Lamotrigine is not licensed for use in bipolar disorder in the UK, but has some evidence for effectiveness in bipolar depression and, more particularly, prophylaxis against depressive relapse. It must be introduced slowly to avoid dangerous skin reactions. Other anticonvulsants have no evidence supporting their use. Antipsychotics, including the atypicals, are effective in treating mania. Olanzapine and aripiprazole are also licensed for continuation treatment in acute responders. Quetiapine has evidence for effectiveness in both bipolar mania and bipolar depression. The efficacy of antidepressants in bipolar disorder is unclear. Tricyclic antidepressants and mono-amine oxidase inhibitors should probably be avoided, owing to a possible risk of switching to mania. In general, antidepressants should be used in conjunction with a mood stabilizer and for the shortest period necessary.