Overview of psychiatry
• Psychiatry is, in fact, fundamentally similar to the rest of medicine: the treatments used are primarily evidence-based.
• Psychiatric disorders may be defined as illnesses that are conventionally treated with treatments used by psychiatrists, just as surgical conditions are those thought best treated by surgery.
Studying psychiatry is worthwhile for all trainee doctors, and other health practitioners.
Studying psychiatry will give you:
1. A basic knowledge of the common and the ‘classic’ psychiatric disorders.
2. A working knowledge of psychiatric problems encountered in all medical settings.
3. The ability to effectively assess someone with a ‘psychiatric problem’. Skills in the assessment of psychological aspects of medical conditions.
The first, key skill to learn is how to listen and talk to patients
interview has two functions:
1. It forms the main part of the psychiatric assessment by which diagnoses are made.
2. It can be used therapeutically – in the psychotherapies, the communication between patient and therapist is the currency of treatment.
Has three goals:
1. To elicit the information needed to make a diagnosis.
2. To understand the causes and context of the disorder.
3. To form a therapeutic relationship with the patient.
1. International Classification of Diseases, 10th revision (ICD-10).
2. Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5)
1. 2. • 1. 2. • 1. 2. 3. 4. 5. 6. 7. 8.
The basic psychiatric assessment
Before you begin
Information (referral letters, notes), location, safety Introduction, consent, establish expectations
Method of referral
Age, marital status, occupation, current living arrangements
Basic history: current problems and background history Presenting complaint(s), and their history
Past psychiatric history
Personal history and premorbid personality Social history (current circumstances) Substance use: smoking, alcohol and illicit drugs Forensic history
Past medical history and drug history
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• Basic mental state examination
1. Appearance and behaviour
• Risk assessment
• Physical examination if necessary • Corroborative history if possible • Investigations as necessary
Completing and communicating the assessment
The process of psychiatric assessment described above provides diagnostic information and an understanding of the patient in their context. This evidence is now combined to allow you to make a diagnosis, identify the causative factors, plan your management and consider the patient’s prognosis.
Your history and mental state examination will suggest a number of possible diagnoses and rule out others.
1. Sometimes the diagnosis will be clear-cut • DD
• Weighing the diagnostic evidence
making a psychiatric diagnosis is an important step with consequences it has drawbacks (e.g. stigmatization) as well as benefits (e.g. effective treatment
Having made a provisional diagnosis, you should consider the contextual information collected during your assessment, particularly those factors that appear to help explain the origins and evolution of the disorder.
The two key variables of aetiology are:
1. The type of factor – usually divided into biological, psychological and social.
2. The time at which the factor operates. A useful mnemonic for this is ‘the four Ps’: predisposing, precipitating, perpetuating and protective.
Timing causal factors can be:-
1. Predisposing: factors that exert a long-term or distant causal effect such as family history and early childhood experiences.
2. Precipitating: factors that explain why the disorder has occurred now. They include recent life events, injuries, new medical conditions
3. Perpetuating (or maintaining): factors affecting the course of a disorder. Common ones include ongoing marital problems, social problems.
4. Protective: factors that protect against the development of psychiatric disease, or aid its resolution, e.g. strong social support networks
Having made a diagnosis and investigated the causative factors, move on to consider the management and the prognosis.
• will need to be mentioned in the summary, letter or phone call that will follow the assessment.
Management in psychiatry involves making a number of decisions, which may need to be made rapidly:
1. Is treatment indicated?
2. How urgent is the problem?
3. Where should treatment take place.
Once you have a diagnosis and a reasonable understanding of the context, a provisional judgement about prognosis should be possible. Together with the diagnosis, the prognosis that is of most concern to the patient, their relatives and the referrer .
1. Short-term prognosis depends mainly on the natural history of the disorder and, particularly, the treatment response.
2. Long-term prognosis is much more difficult to predict
each condition has its own prognostic indicators:-
indicators of poor prognosis are common to all psychiatric conditions:
1. Insidious onset.
2. Longer duration of disorder prior to treatment
3. Comorbid personality disorder.
4. Comorbid substance misuse.
5. Lack of close relationships.
6. History of non-adherence to treatment.