PSYCHOMYTHOLOGY 21 suicide; I can make you do X,Y and Z; this is what your dreams really mean. There are many reasons why myths persist (see Box 1.4) and they are very dif \201 cult to challenge once they are established. This is one reason why psy- choeducation is a vital component of most psychological therapies. Most people \201 nd that the antidote to the in \202 uence of pseudoscience on them is knowledge of real science. The twist in all of this is that unders tanding the truth of how the brain functions in health and disease is more remarkable, more amazing, and more life-changing than any \201 ction could ever be. Box 1.4 Mythbusting The 10 sources of error:2 \200 Word of mouth begin to believe it is true. Desire for easy answers and the quick \201 x g ood to be true, it probably is. We all suffer from na ve realism Selective perception an d memory and believe that how we see the world is exactly how it is. We also have a tendenc y to remember hits and forget misses which leads to illusionary correlation: the mistaken p erception that two statistically unrelated event are actually related. Inferring causation from correlation For example, although it may be true that a history of CSA is highly corre lated with schizophrenia it does not necessarily follow that schizophrenia is caused by CSA . Post hoc, ergo propter hoc reasoning because of this \200\231) Just because someone appea rs to get better after receiving a homeopathic remedy does not necessarily mean the remedy was effective. Exposure to a biased sample resistant patients and may assume treatment is l ess effective than it actually is for the majority of patients. Reasoning by representative ness similar does not make them the same. Misleading \201 lm and media portrayals recover ed from One Flew Over the Cuckoo \200\231s Nest. Exaggeration of a kernel of truth Terminol ogy confusion can lead to confusion with most people believing it means patients have multi ple personalities. If we hear something repeated enough times, we If something sounds too ( \200\230after this, therefore Psychiatrists usually see treatment- Just because two things appear ECT perceptions have never \200 The etymology of words like \200\230schizophrenia \200\231 1 \200\230 and most popular psychology is from Uranus. \200\231 When John Gray, autho r of \200\230Men are from Mars, Women are from Venus \200\231 appeared on Season 2, Episod e 3 of Penn & Teller \200\231s Bullshit! Penn quipped \200\230I guess the title \200\234W e \200\231re all people and should be treated with love and respect \200\235 just wouldn \200\231t \201 t on the book spine \200\231. 2 Adapted from the Introduction of So, Lynn SJ, Ruscio J, Beverstein BL (2010) Lilienfeld 50 Great myths of popular psychology. Oxford: Wiley-Blackwell. 01_Semple_Chap01.indd 21 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 22 Stigma Stigma is a Greek word meaning \200\230mark \200\231 and originally referred to a s ign branded onto criminals or traitors in order to identify them publicly. The plural, stig mata, when used in medical settings, means the collection of symptoms and signs by which a particular disorder may be identi \201 ed. In its wider, modern sense, stigma refers to th e sense of collective disapproval and group of negative perceptions attached to a particula r people, trait, condition, or lifestyle. Stigmatization describes the process by which the characteristics of the group in question are identi \201 ed and discriminated against. Stigmatization can be thought of as a three-stage process: \201 rst, the indi- vidual is marked out as different by his actions or appearance; secondly, society develops a series o f beliefs about the affected individual; \201 nally, society changes its behavior towards these individuals in a way consistent with those beliefs, often to the detriment of the st igmatized individuals. Stigma can become self-reinforcing as it can be associated with avoi dance of the stigmatized individuals, leaving no opportunity for society to con- front and change its beliefs. Fear of the unknown, fear of contamination, and fear of death or the sight of death have le d to diseases of all kinds being stigmatized through- out history. This is particularly tru e of infectious diseases, diseases caus- ing dis \201 gurement, and mental disorders. As t he infectious and dis \201 guring diseases have become both more treatable and better unde rstood, suf- ferers from mental disorders have remained uniquely vulnerable to stigmatizati on. One marker of this has been the ease with which originally neutral, descriptive terms for m ental disorders have taken on a pejorative and disparaging meaning: cretin, maniac, spastic , imbecile. All have been aban- doned in an attempt to free affected individuals from the a pprobation the name had acquired. Unfortunately, stigmatization involves fundamental and wi dely held beliefs and is not usually amenable to simple cures such as changes of name of co nditions or organizations. For the person affected by mental illness, the name of the condition and their abnormalitie s of experience and behavior will mark them out as different, and are the root cause of the ir distress. However, the wider societal beliefs, expressed as stigmatization, will add to the burden of morbidity, and may in themselves prolong the condition. For example, the beli ef that depression is \200\230all in the mind \200\231 and could be resolved if the affect ed individual would only \200\230pull themselves together \200\231 may cause people to beh ave less sympathetically towards the sufferer, but it may also hinder the sufferer from see king appropriate help. There is no simple answer to the problem of stigma. We can certainly learn from the increas ingly successful approach to the problem of the stigmatization which initially attached to those individuals suffering from HIV infection. Increased public awareness of the cause of the disease, its method of transmission, the plight of its sufferers, and its means of trea tment appear to be associated with less, not more stigmatization. The Royal College of Psyc hiatrists, with its \200\230Defeat Depression \200\231 campaign, has been active in this r egard. 01_Semple_Chap01.indd 22 12/10/2012 6:23:41 PM STIGMA 23 On an individual basis we can: \200 Challenge our own prejudices connection with patients with personality disorder and patient s with substance misuse problems. Avoid stigmatizing language There is no place for forced political correctness in medicine, but we should consider whether calling an individual \200\230a schizophrenic \200\231 describes them as a single, unfavorable characteristic, ra ther than as a person with an illness. Challenge lack of knowledge within the profession la ck of knowledge of mental disorders is often seen in our colleagues in other specialties. T his may be expressed in, for example, a lower aspiration for treatment in individuals with mental handicap or chronic psychotic illness. Be advocates for political change not halt us from being at the forefront of moves to improve the autonomy of patients, their involvemen t in society, and their legal protection. These may exist, particularly in A surprising Professional conservatism should 01_Semple_Chap01.indd 23 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 24 Anti-psychiatry One view of medicine is that it is an applied science whose object of sci- enti \201 c curiosity is the understanding of the causes and processes of human illness an d the study of methods of preventing or ameliorating them. In the scienti \201 c method th ere are no absolute truths, only theories which \201 t the observed facts as they are cur rently known. All scientists must be open to the challenging of \201 rmly established the ories as new observations are made and new experiments reported. All psychiatrists should retain this healthy scienti \201 c skepticism and be prepared to question their beliefs about the causes and cures of mental illness. Developments (and henc e improvements in patient care) come from improvement in observation methods and trials of new treatment modalities. A result of this may be the enforced abandonment of cher- ished b eliefs and favored treatments. Always remember that insulin coma therapy1 was at one time b elieved to be an effective treatment for psy- chotic illnesses. While rigorous examination of the basic and clinical sciences of psy- chiatry is essential if the specialty is to progress, psychiatry as a medical specialty has, over the last 50yrs , been subject to a more fundamental criticism \200\224that the empirical approach and the medical model are unsuited to the understanding of mental disorder and that they cause harm to the individuals they purport to treat. This basic belief, known as \200\230anti-psychi a- try \200\231, has been expressed by a variety of individuals over the years, reaching a peak in the late 1960s. Although the central arguments of the anti-psychi- atry movement ha ve largely been discredited in the mainstream scienti \201 c literature, they have retaine d currency in some areas of the popular press, within some patient organizations, and in ce rtain religious cults. They are presented here for historic interest and so that the source s for modern- day advocates of these ideas can be identi \201 ed (see Box 1.5). Central anti-psychiatry beliefs \200 \200 The mind is not a bodily organ and so cannot be diseased. The scienti \201 c method cannot explain the subjective abnormalities of mental disorder as no direct observation can take place. Mental disorder can best be explained by social, ethical, or political factors. The labeling of individuals as \200\230ill \200\231 is an arti \201 cial device used by socie ty to maintain its stability in the face of challenges. \200 Medication and hospitalizati on are harmful to the individual so treated. The anti-psychiatry movement did raise some va lid criticisms of then contemporary psychiatric practice; in particular, pointing out the n ega- tive effects of institutional living, criticizing stigma and labeling, and alert- ing psychiatrists to the potential use of political change in improving patient care. 01_Semple_Chap01.indd 24 12/10/2012 6:23:41 PM ANTI-PSYCHIATRY 25 It was, however, fatally \202 awed by a rejection of empiricism, an over-reli- ance on si ngle case reports, domination by a small number of personalities with incompatible and deep ly held beliefs, and an association with half- baked political theory of the Marxist \200 \223Leninist strain. Box 1.5 Prominent anti-psychiatrists \200 Szasz Rejected compulsory treatment. Author of Pain and pleasure and The myth of mental ill ness. Viewed disease as a bodily abnormality with an observable pathology to which, by its nature, the brain was immune. Saw mental illness as con \202 ict between individuals and s ociety. Rejected the insanity defense and committal to hospital. Accepted patients for volu ntary treatment for drug-free analysis on payment of fee and acceptance of treatment contra ct. Worked in labeling theory. Wrote Being mentally ill. Scheff Hypothesized that mental il lness was a form of social rule-breaking. Labeling such individuals as mentally ill would s tabilize society by sanctioning such temporary deviance. Goffman as a result of an undercov er study. Commented on the negative effects of institutions segregated from the rest of soc iety and subject to different rules. Laing and The politics of experience. Developed probab ly the most complete anti-psychiatry theory. He saw the major mental illnesses as arising f rom early family experiences, in particular from hostile communication and the desire for \200\230ontological security \200\231. He saw newborns as housing potential which was dimin ished by the forced conformity of the family and the wider society. Viewed normality as for ced conformity and illness as \200\230the reality which we have lost touch with \200\231. Cooper schizophrenia as a form of social repression. Buscaglia Wrote The deviant majority. Held that diagnosis didn \200\231t aid understanding of the patient \200\231s experience. B elieved that social and economic factors were crucial. Successful in pressing for signi \201 cant reform of the Italian mental health system. Scull of \200\230the machinery of th e capitalist system \200\231. Breggin psychiatry which views psychopharmacology as \200 \230disabling normal brain function \200\231. Rejects results of systematic reviews. Wrote Asylums. Described the \200\230total institution \200\231 observed Author of The divided self, Sanity, madness and the family, Revived anti-psychiatry ideas. A committed Marxist, he saw Wrote Museums of madness. Saw mental health systems as part Modern advocate of anti-psychiatry views. Author of Toxic 1 In 1933 Manfred Sakel introduced insulin coma therapy for the treatment of schizophrenia. This involved the induction of a hypoglycaemic coma using insulin, the rationale being tha t a period of decreased neuronal activity would allow for nerve cell regeneration. In the a bsence of alterna- tive treatments, this was enthusiastically adopted by practitioners worl dwide. However, with the advent of antipsychotics in the 1950s and the emergence of randomi zed controlled trials (RCTs), it became clear that the treatment had no effect above placeb o and it was subsequently abandoned. 01_Semple_Chap01.indd 25 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 26 A brief history of psychiatry Ancient times 4000 BC Sumerian records describe the euphoria nt effect of the poppy plant. 1700 BC First written record concerning the nervous system. 460 \200\223379 BC Hippocrates discusses epilepsy as a brain disturbance. 387 BC Plato teac hes that the brain is the seat of mental processes. 280 BC Erasistratus notes divisions of the brain. 177 Galen lectures On the brain. Pre-modern 1649 Descartes describes the pineal gland as a control center of body and mind. 1656 Bic tre and Salp tri re asylums estab- lished by Louis XIV in France. 1755 Perry publishes A mechanical account and explication of the hysteric passion. 1758 Battie publishes his Treatise on madness. 1773 Cheyne publishes his book English malady, launching the idea of \200\230nervous illness \200\231. 1774 Mes mer introduces \200\230animal magnetism \200\231 (later called hypnosis). 1793 Pinel is ap pointed to the Bic tre and directs the removal of chains from the \200\230madmen \200\231 . 1794 Chiarugi publishes On insanity, specifying how a therapeutic asylum should be run. 1 800 \200\2231850 1808 Reil coins the term \200\230psychiatry \200\231. 1812 Rush publishes Medical inquiries and observations upon the diseases of the mind. 1813 Heinroth links life circumstances to mental disorders in the Textbook of mental hygiene. 1817 Parkinson publis hes An essay on the shaking palsy. - Esquirol lectures on psychiatry to medical students. 1 825 Bouillaud presents cases of aphonia after frontal lesions. - Todd discusses localiza- t ion of brain functions. 1827 Heinroth appointed as the \201 rst professor of psychologica l therapy in Leipzig. 1832 Chloral hydrate discovered. 1843 Braid coins the term \200\230h ypnosis \200\231. 1848 Phineas Gage has his brain pierced by an iron rod with subsequent pe rsonality change. 1850 \200\2231900 1856 Morel describes \200\230d mence pr coce \200 \231 \200\224deteriorating adolescent psychosis. 1863 Kahlbaum introduces the term \200 \230catatonia \200\231. - Friedreich describes progressive hereditary ataxia. 1864 Hughling s Jackson writes on aphonia after brain injury. 1866 Down describes \200\230con- genital i diots \200\231. 1868 Griesinger describes \200\230primary insanity \200\231 and \200\230u nitary psychosis \200\231. 1869 Galton claims that intelligence is inherited in Hereditary genius. 1871 Hecker describes \200\230hebephrenia \200\231. 1872 Huntington describes symp toms of a hereditary chorea. 1874 Wernicke publishes Der aphasische symptomenkomplex on aph asias. 1876 Ferrier publishes The functions of the brain. - Galton uses the term \200\230n ature and nurture \200\231 to describe heredity and environment. 1877 Charcot publishes Lec tures on the diseases of the nervous system. 1883 Kraepelin coins the terms \200\230neuros es \200\231 and \200\230psychoses \200\231. 1884 Gilles de la Tourette describes several m ovement disorders. 1885 Lange proposes use of lithium for excited states. 1887 Korsakoff de scribes characteristic symptoms in alcoholics. 1892 American Psychological Association form ed. 1895 Freud and Breuer publish Studies on hysteria. 1896 Kraepelin describes \200\230de mentia praecox \200\231. 1899 Freud publishes The interpretation of dreams. 1900s 1900 Wern icke publishes Basic psychiatry in Leipzig. 1903 Barbiturates introduced. - First volume of Archives of neurology and psychi- atry published in USA. - Pavlov coins the term \200\230 conditioned re \202 ex \200\231. 1905 Binet and Simon develop their \201 rst IQ test. 19 06 Alzheimer describes 01_Semple_Chap01.indd 26 12/10/2012 6:23:41 PM A BRIEF HISTORY OF PSYCHIATRY 27 \200\230presenile degeneration \200\231. 1907 Adler \200\231s Study of organ inferiority a nd its physi- cal compensation published. - Origins of group therapy in Pratt \200\231s wor k supporting TB patients in Boston. 1909 Brodmann describes 52 cortical areas. - Cushing el ectrically stimulates human sensory cortex. - Freud publishes the case of Little Hans in Vi enna. 1910s 1911 Bleuler publishes his textbook Dementia praecox or the group of schizophre nias. 1913 Jaspers describes \200\230non-understandability \200\231 in schizo- phrenia thi nking. - Syphilitic spirochaete established as cause of \200\230general- ized paresis of t he insane \200\231. - Jung splits with Freud forming the school of \200\230analytic psycho logy \200\231. - Mental De \201 ciency Act passed in UK. - Goldmann \201 nds blood \200 \223brain barrier impermeable to large molecules. 1914 Dale iso- lates acetylcholine. - The term \200\230shell shock \200\231 is coined by British soldiers. 1916 Henneberg coins the term \200\230cataplexy \200\231. 1917 Epifanio uses barbitu- rates to put patients with m ajor illnesses into prolonged sleep. - Wager- Jauregg discovers malarial treatment for neur osyphilis. 1920s 1920 Moreno develops \200\230psychodrama \200\231 to explore individual p roblems through re-enactment. - Watson and Raynor demonstrate the experimental induction of phobia in \200\230Little Albert \200\231. - Crichton-Miller founds the Tavistock Clinic i n London. - Klein conceptualizes develop- ment theory and the use of play therapy. - Freud \200\231s Beyond the pleasure principle published. 1921 Rorschach develops the inkblot test . 1922 Klaesi publishes results of deep-sleep treatment, which is widely adopted. 1923 Freu d describes his \200\230structural model of the mind \200\231. 1924 Jones uses the \201 rst example of systematic desensitization to extinguish a phobia. 1927 Jacobi and Winkler \201 rst apply pneumoencephalography to the study of schizophrenia. - Wagner-Jauregg award ed the Nobel Prize for malarial treatment of neurosyphilis. - Cannon-Bard describes his \200\230theory of emo- tions \200\231. 1929 Berger demonstrates \201 rst human electroenc ephalogram. 1930s 1930 First child psychiatry clinic established in Baltimore, headed by Ka nner. 1931 Hughlings-Jackson describes positive and negative symp- toms of schizophrenia. - Reserpine introduced. 1932 Klein publishes The psychoanalysis of children. 1933 Sakel intr oduces \200\230insulin coma treatment \200\231 for schizophrenia. 1934 Meduna uses chemica l convulsive therapy. 1935 Moniz and Lima \201 rst carry out \200\230prefrontal leucotom y \200\231. - Amfetamines synthesized. 1936 Mapother appointed as England \200\231s \201 rst Professor of Psychiatry. - Dale and Loewi share Nobel Prize for work on chemical nerve transmission. 1937 Kluver and Bucy publish work on bilateral tem- poral lobectomies. - Pape z publishes work on limbic circuits and develops \200\230visceral theory \200\231 of emoti on. 1938 Cerletti and Bini \201 rst use \200\230electrocon- vulsive therapy \200\231. - Skinner publishes The behavior of organisms describing operant conditioning. - Hoffmann syn thesizes LSD. 1940s 1942 Freeman and Watts publish Psychosurgery. 1943 Antihistamines used in schizophrenia and manic depression. 1946 Freeman introduces \200\230transorbital leucot omy \200\231. - Main publishes Therapeutic communities. 1948 Foulkes \200\231 Introduction to group analytical psychotherapy published. - International classi \201 cation of disease s (ICD) \201 rst published by WHO. - Jacobsen and Hald discover the use of disul \201 ra m. 1949 Cade introduces lithium for treatment of mania. - Penrose publishes The biology of men- tal defect. - Moniz awarded Nobel Prize for treatment of psychosis with 01_Semple_Chap01.indd 27 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 28 leucotomy. - Hess receives Nobel Prize for work on the \200\230interbrain \200\231. - Mago un de \201 nes the reticular activating system. - National Institute of Mental Health is e stablished. - Hebb publishes The organization of behav- iour: a neuropsychological theory. 1950s 1950 First World Congress of Psychiatry held in Paris. - Chlorpromazine (compound 456 0 RP) synthesized by Charpentier. - Roberts and Awapara independently identify GABA in the brain. 1951 Papaire and Sigwald report ef \201 cacy of chlorpromazine in psychosis. 1952 D iagnostic and statistical manual (DSM-I) introduced by the APA. - Eysenck publishes The eff ects of psychotherapy. - Delay and Deniker treat patients with psychological disturbance us ing chlorpromazine. - Delay, Laine, and Buisson report isoniazid use in the treatment of de pression. 1953 Lurie and Salzer report use of isoniazid as an \200\230antidepressant \200 \231. 1954 Kline reports that reserpine exerts a therapeutic bene \201 t on both anxiety a nd obsessive \200\223 compulsive symptoms. - Delay and Deniker, Noce and Steck report favor - able effects of reserpine on mania. - First community psychiatric nurse post established in UK. 1955 Chlordiazepoxide, the \201 rst benzodiazepine, syn- thesized by Sternbach for Roche. - Kelly introduces his \200\230personal construct therapy \200\231. - Shepherd and Davies conduct the \201 rst prospective placebo- controlled, parallel-group randomized c ontrolled trial in psychiatry, using reserpine in anxious-depressive outpatients (with de \201 nite bene \201 t). 1957 Imipramine launched as an antidepressant. - Iproniazid launch ed as an anti- depressant. - Delay and Deniker describe the characteristics of neuroleptics . 1958 Carlsson et al. discover dopamine in brain tissues and identify it as a neurotransmi tter. - Janssen develops haloperidol, the \201 rst butyrophenone neuroleptic. - Lehman re ports \201 rst (successful) trial of imipramine in USA. 1959 Russell Barton \200\231s Ins titutional neurosis in England draws attention to the adverse effects of institutional regi mes. - Diazepam \201 rst synthesized by Roche. - Schneider de \201 nes his \200\230 \201 rst-rank symptoms \200\231 of schizophrenia. - English Mental Health Act of 1959 allow s voluntary admission to psychiatric hospitals. 1960s 1960 Merck, Roche, and Lundbeck all l aunch versions of amitriptyl- ine. 1961 Knight, a London neurosurgeon, pioneers stereotacti c sub- caudate tractotomy. - Founding of the World Psychiatric Association. - Thomas Szasz publishes The myth of mental illness. 1962 Ellis introduces \200\230rational emotive thera py \200\231. - US Supreme Court declares addiction to be a disease and not a crime. 1963 Be ck introduces his \200\230cognitive behavioral therapy. \200\231 - Carlsson shows that neu roleptics have effects on catecholamine systems. 1966 Gross and Langner demonstrate effecti veness of clozap- ine in schizophrenia. 1968 Str mgren describes \200\230brief reactive p sychosis \200\231. - Ayllon and Azrin describe the use of \200\230token economy \200\231 t o improve social functioning. - Publication of DSM-II and ICD-8. 1970s 1970 Laing and Ester son publish Sanity, madness and the family. - Rutter publishes the landmark Isle of Wight s tudy on the mental health of children. - Janov publishes Primal scream. - Maslow describes his \200\230hierarchy of needs \200\231. - Axelrod, Katz, and Svante von Euler share Nobel Prize for work on neurotransmitters. 1971 British Misuse of Drugs Act passed. - Carlsson, Corrodi et al. develop zimeldine, the \201 rst of the SSRIs. 1972 Feighner et al. describ e the St Louis criteria for diagnosis of schizophrenia. 1973 01_Semple_Chap01.indd 28 12/10/2012 6:23:41 PM A BRIEF HISTORY OF PSYCHIATRY 29 International pilot study of schizophrenia uses narrow criteria and \201 nds similar inci dence of schizophrenia across all countries studied. 1974 Hughes and Kosterlitz discover en kephalin. 1975 Research diagnostic criteria (RDC) formulated by Spitzer et al. in the USA. - Clozapine withdrawn following episodes of fatal agranulocytosis. 1976 Johnstone uses CT t o study schizo- phrenic brains. 1977 Guillemin and Schally share Nobel Prize for work on pe ptides in the brain. 1979 Russell describes bulimia nervosa. 1980s 1980 DSM-III published b y the APA. - Crow publishes his two- syndrome (type I and type II) hypothesis of schizophre nia. 1984 Klerman and Weissman introduce \200\230interpersonal psychotherapy \200\231. - S mith et al. \201 rst use MRI to study cerebral structure in schizophrenia. - Andreasen de vel- ops scales for the assessment of positive and negative symptoms in schizo- phrenia (SA PS/SANS b p. 81). 1987 Liddle describes a three-syndrome model for schizophrenia. - Fluvoxa mine introduced. - Mednick publishes \201 rst prospective cohort study of schizophrenia u sing CT. 1988 The \200\230harm minimization \200\231 approach to drug misuse introduced in Britain. - Kane et al. demonstrate ef \201 cacy of clozapine in treatment-resistant schiz ophrenia. 1990s 1990 Sertraline introduced. - Ryle introduces \200\230cognitive analyti- c al therapy \200\231. 1991 Paroxetine introduced. 1992 Moclobemide introduced as \201 rst reversible inhibitor of monoamine oxidase (RIMA). - The False Memory Syndrome Society Found ation formed in the USA. - Publication of ICD-10. 1993 Huntington \200\231s disease gene id enti \201 ed. - Launch of risperi- done as an \200\230atypical \200\231 antipsychotic. - Linehan \201 rst describes her \200\230dialectical behavior therapy \200\231. 1994 Publi cation of DSM-IV. - Launch of olanzapine. - Gilman and Rodbell share the Nobel Prize for th eir discovery of G-protein coupled receptors and their role in signal transduction. 1995 Ci talopram, a selective serotonin reuptake inhibitor (SSRI), nefazodone (dual-action SSRI), v enlafaxine, a serotonin and noradrenaline reuptake inhibitor ( \201 rst SNRI) all introduc ed. 1999 Hodges publishes \201 rst results from prospective Edinburgh High Risk (Schizoph renia) Study using MRI. 2000s 2000 Carlsson, Greengard, and Kandel share Nobel Prize for th eir work on neurotransmitters. 2002 Neuregulin-1 and dysbindin identi \201 ed as susceptib ility genes for schizophrenia. 2003 Aripiprazole, the \201 rst dopamine partial agonist a ntipsychotic, launched. - Caspi and colleagues show that genetic and environmental factors interact to modulate risk for depression and antisocial behavior. 2005 The DISC1 gene, impl icated in psychotic and affective illness, is shown to regulate cyclic adenosine monophosph ate (cAMP) signaling. - The \201 rst non-commercial large-scale trial compares new and ol d antipsychotics \200\224Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE ). 2006 Hall and co-workers show that the Neuregulin-1 gene is associated with changes in b rain function and psychosis in the Edinburgh High Risk (Schizophrenia) Study. 2007 A glutam ate agonist (LY2140023) is found by Patel and colleagues to have antipsychotic effects in p atients with schizophrenia \200\224potentially the \201 rst genuinely new (i.e. non-dopam ine-based) treatment for psychosis. 2009 Genome-wide genetic analysis reveals both common a nd rare genetic variants involved in schizophrenia. 2011 Neural stem cells derived from per ipheral samples reveal cellular changes in patients with schizophrenia and related disorder s. 01_Semple_Chap01.indd 29 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 30 The future Attempting to predict the future is a dangerous business. Predictions tend to be based upon contemporary ideas and have a tendency to overesti- mate some types of change a nd underestimate others. Wild inaccuracy is the usual rule. This is particularly so in medi cal science where change is often a result of chance discoveries (e.g. penicillin) and swee ping reforms which make most then-current knowledge redundant (e.g. the germ the- ory of di sease). Currently practicing psychiatrists are (or should be) keenly aware of the de \201 ciencies of current psychiatric practice. We lack knowledge of the etiology and pathogenesis of mos t psychiatric disorders; we have no objective diagnostic or prognostic investigations; and our drug and psy- chological treatments are often minimally or only partially effective. Wh ile we welcome the ongoing gradual progress in knowledge and treatments, we are naturally i mpatient for rapid and fundamental improvements \200\224we hope to join the other medical s pecialties in moving \200\230from the descriptive to the analytical \200\231. Now at last it seems the tools are becoming available to develop a true understanding of psychiatric di sease. We are, however, cautious \200\224there have been false dawns before. The insights into men tal mechanisms provided by the psychoanalytical pioneers in the \201 rst half of the twen tieth century gave rise to hope that these meth- ods would prove therapeutic in many mental illnesses. The discovery of effective antipsychotic and antidepressant drugs in the 1950s raised hopes that examination of drug effects would reveal the pathological mecha- nisms of the underlying diseases. The move to community care which followed Enoch Powell \200\231s \200\230Water Tower Speech \200\231 in 1961 was driven by the hope that many of the de \201 cits experienced by sufferers from mental disorder were not intrinsic to the disorders themselves, but were related to institutional living. None of these hopes were ful \201 l led. However, in the \201 rst decades of the twenty- \201 rst century, we have a number of genuine reasons for optimism and excitement. Genetics The information provided by the Human Genome Project, and large link- age and asso ciation studies, combined with techniques of high-throughput genetic screening, allow ident i \201 cation of susceptibility genes for complex polygenic disorders. Advances in molecul ar biology will allow the func- tions of these gene products to be understood, potentially generating new therapies. We are increasingly coming to understand how susceptibility genes interact with the environment to cause illness, including the poten- tial role of epigenet ic factors in mediating the impact of environmental stresses on gene expression. Novel treatment approaches In the last century discovery of effective treatments led to aet iological hypotheses. In this century the hope is that understanding of the molecu- lar and chemical pathways involved in risk for illness will lead to the devel- opment of novel tre atment approaches, therapeutics becoming hypothesis driven rather than hypothesis creating. Rational drug design will be aided 01_Semple_Chap01.indd 30 12/10/2012 6:23:42 PM THE FUTURE 31 by computer modeling and screening of large numbers of potential drug molecules. There will be further investigation of stem cell therapy in neu- rodegenerative disorders. Functional and diagnostic imaging Current structural scanning methods (e.g. CT and MRI) rev eal changes across cohorts of patients with major mental disorders but do not allow objecti ve diagnosis in individuals. Many psychiatric disorders show no measurable abnormalities at all using current structural methods. In the future, functional imaging (e.g. PET, functio nal MRI), either alone or in combination with structural scanning, may allow an understandi ng of how changes in neural systems contribute to illness and possibly true diagnostic imag ing. Large-scale treatment trials In current practice, even relatively common treatment decision s are not clearly evidence-based. The current evidence base is overly reliant on small rand omized trials, uncontrolled trials and \200\230expert opinion \200\231. Now, however, psyc hiatry researchers are following their peers in cardiology and oncology and recruiting to l arge-scale treatment trials. Every generation enjoys the use of a vast hoard bequeathed to it by antiquity, and transmit s that hoard, augmented by fresh acquisitions, to future ages. Thomas Babington Macaulay I like the dreams of the future better than the history of the past. Thomas Jefferson There are \201 sh in the sea better than have ever been caught. Irish proverb 01_Semple_Chap01.indd 31 12/10/2012 6:23:42 PM This page intentionally left blank 33 Chapter 2 Psychiatric assessment The clinical interview 34 Setting the scene 36 Interviewing psychiatric patients 38 Discuss ing management 40 History 42 Mental state examination 44 Case summary 46 Observations of ap pearance and behavior 47 Speech 48 Abnormal mood 49 Asking about depressed mood 50 Asking a bout thoughts of self-harm 51 Asking about elevated mood 52 Anxiety symptoms 53 Asking abou t anxiety symptoms 54 Abnormal perceptions 56 Asking about abnormal perceptions 58 Abnormal beliefs 59 Asking about abnormal beliefs 60 Asking about the \201 rst-rank symptoms of s chizophrenia 62 Disorders of the form of thought 64 Abnormal cognitive function 66 Assessin g cognitive function 1 68 Assessing cognitive function 2 70 Supplementary tests of cerebral functioning 72 Insight 74 Physical examination 75 Some physical signs in psychiatric illne ss, and possible causes 76 Clinical investigation 78 Common assessment instruments 1 80 Common assessment instruments 2 82 02_Semple_Chap02.indd 33 12/7/2012 7:03:18 PM CHAPTER 2 Psychiatric assessment 34 The clinical interview In most branches of clinical medicine, diagnoses are made largely on the basis of the patient \200\231s history, with physical examination and investigation pl aying important but subordinate roles. In psychiatry, physical examina- tion and investigat ions are of lesser diagnostic value and diagnosis is based on the clinical interview and, t o a lesser extent, the later course of the patient \200\231s illness. Clinical interviewing is thus the central skill of the psychia- trist and development of clinical interviewing s kills is the main aim of basic psychiatric training. The clinical interview includes both history taking and mental state examination. The menta l state examination is a systematic record of the patient \200\231s current psychopathology . In addition to its role in diagnosis, the clinical interview begins the development of a therapeutic relationship and is, in many cases, the beginning of treatment. Clinical interview skills cannot be learned from a textbook. This chapter is intended as a guide to the doctor developing skills in interviewing psychi- atric patients. As a trainee psychiatrist you should also take the opportu- nity to observe experienced clinicians as th ey interview patients; to review your own videotaped consultations with a tutor; and most i mportantly, carry out many clinical interviews and present the results to your seniors. Ski lls in this area, as with all others, come with experience and practice. This chapter describes a model for the assessment of general adult and old-age psychiatry p atients on the wards or in the outpatient clinic. For special patient populations, modi \201 cations or extensions to the standard interview are described in the appropriate chapt er: alcohol and drug prob- lems (b p. 552, p. 592); forensic (b p. 692, p. 710); child and adoles- cent (b pp. 612 \200\22317); learning disability (b p. 738); and psychotherapy (b p . 822). The student or doctor coming to psychiatric interviewing for the \201 rst time is likely to be apprehensive. The symptoms which the patient describes may seem bizarre or incomprehe nsible, and the examiner may struggle for understanding and knowledge of which further ques tions to ask. Remember that the interviewer is not like a lawyer or policeman try- ing to \200\230get at the truth \200\231 but rather an aid to the patient telling the story in the ir own words. Start by listening, prompting only when necessary, and aim to feel at the end of the interview that you really understand the patient \200\231s problems and their perce ption of them. The following pages describe the standard structure for a routine his- tory, mental state e xamination, and case summary; there are then pages devoted to the different symptom areas i n adult psychiatry with suggested probe questions. These are intended as guides to the sort of questions to ask the patient (or to ask yourself about the patient) and may be rephrase d in your own words. See Box 2.1 for advice on personal safety. 02_Semple_Chap02.indd 34 12/7/2012 7:03:18 PM THE CLINICAL INTERVIEW 35 Box 2.1 Always consider your personal safety when interviewing There is a risk of aggression or violence in only a small minority of psychiatric patients. In the vast majority of patients the only risk of vio- lence is towards themselves. Howeve r, the fact that violence is rare can lead to doctors putting themselves at risk due to tho ughtlessness. To combat this it is important to think about the risk of violence before eve ry consultation with a new patient or with a familiar patient with new symptoms. Before interviewing a patient, particularly for the \201 rst time, consider: who you are interviewing, where you are interviewing, and with whom. Ensure that the nursing staff have this information. \200 If possible, review the patient \200\231s records noting previous symptomatology and episod es of previous violence (the best predictor of future violence). A number of factors will i ncrease the risk of violence, including: previous history of violence, psychotic illness, i ntoxication with alcohol or drugs, frustration, feeling of threat (which may be delusional or relate to real-world concerns). The ideal interview room has two doors, one for you and one for the patient. If this is not available sit so that the patient is not between you an d the door. Remove all potential weapons from the interview room. Familiarize yourself with the ward \200\231s panic alarm system before you \201 rst need to use it. If your hospit al organizes break-away or aggression management training courses, attend these regularly t o keep your skills up to date. 02_Semple_Chap02.indd 35 12/7/2012 7:03:18 PM CHAPTER 2 Psychiatric assessment 36