00_Semple_Prelims.indd xxii 12/10/2012 3:38:28 PM SYMBOLS AND ABBREVIATIONS CONTENTS xxiii NIDDM NIH NIMH NMD NMDA NMR NMRS NMS NNT NO NP NPH NPV NR NSAIDs nvCJD OASys OCD OCP od OD ODD OFC OGRS OGTT OPD OPG OR OSA OT PaCO2 PAG PAN PANDAS Non-insulin dependent diabetes mellitus National Institutes of Health National Institute of Mental Health (US) Neurosurgery for mental disorder N-methyl-D-aspartate Nuclear magnetic resonance Nuclear magnetic resonance spectroscopy Neuroleptic malignant syndrome Number nee ded to treat Nitric oxide Nocturnal panic attacks Normal pressure hydrocephalus Negative pr edictive values Nearest relative Non-steroidal anti-in \202 ammatory drugs New variant Cre utzfeldt \200\223Jakob disease Offender assessment system Obsessive \200\223compulsive diso rder Oral contraceptive pills Omni dei (once daily) Overdose Oppositional de \201 ant diso rder Orbitofrontal cortex Offender Group Reconviction Scale Oral glucose tolerance test Out patient department Of \201 ce of the Public Guardian Odds ratio Obstructive sleep apnoea O ccupational therapy Partial pressure of carbon dioxide in arterial blood Periaqueductal gra y matter Polyarteritis nodosa Pediatric autoimmune neurological disorder associated with st reptococcus Positive and Negative Symptom Scale Partial pressure of oxygen in arterial bloo d Personal assessment schedule Psychopathy checklist \200\224revised Psychopathy checklist \200\224screening version Pneumocystis carinii pneumonia; phencyclidine PANSS PaO2 PAS PCL-R PCL-SV PCP 00_Semple_Prelims.indd xxiii 12/10/2012 3:38:29 PM xxiv SYMBOLS AND ABBREVIATIONS PD PDD Personality disorder; panic disorder; Parkinson \200\231s disease Pervasive developmental d isorder; premenstrual dysphoric disorder Personality Disorder Questionnaire IV Pulmonary em bolism Picture exchange communication system Positron emission tomography Plasma homovanill ic acid Phenylketonuria Prolactin Periodic limb movement (in sleep) Premenstrual dysphoric disorder Past medical history Premenstrual syndrome Parent management training; premenstrua l tension Paroxysmal nocturnal dyspnoea; postnatal depression Per os (by mouth, orally) Pho sphate Positive predictive values Per rectum (by the rectum); pulse rate PDQ-IV PE PECS PET pHVA PKU PL PLMS PMDD PMH PMS PMT PND PO PO4 PPV PR PRIME-MD Primary Car e Evaluation of Mental Disorder PRISM Prospective record of the impact and severity of menstruation Prolactin (or PrL) Pro re nat a (as required) Prion protein Prostate-speci \201 c antigen Present state examination Prog ressive supranuclear palsy Post-traumatic amnesia Post-traumatic delirium Post-traumatic ep ilepsy Parathyroid hormone Post-traumatic stress disorder Prothrombin time Per vagina (by t he vagina) Prader \200\223Willi syndrome Fourth die sumendus (four times daily) Fourth in d ie (four times daily) Quality of Life Interview PRL PRN PrP PSA PSE PSNP PTA PTD PTE PTH PTSD PTT PV PWS qds qid QOLI 00_Semple_Prelims.indd xxiv 12/10/2012 3:38:29 PM SYMBOLS AND ABBREVIATIONS xxv R RA RAGF RAMAS RAS RBC rCBF RCP RCT RDC REM RET RIMA RMO ROR RPG RPS RR RRASOR RRR RSBD RS VP RTA RTI rTMS Rx s S SAD SANS SAP SAPS SARA SARI SBE SC SCARED Right Rheumatoid arthritis; retrograde amnesia Risk assessment guidance framework Risk asse ssment, management, and audit systems Reticular activating system Red blood cell Regional c erebral blood \202 ow Royal College of Psychiatrists Randomized controlled trial Research diagnostic criteria Rapid eye movement (sleep) Rational emotive therapy Reversible inhibit or of monoamine oxidase Responsible medical of \201 cer Risk of reconviction (score ) Rand om plasma glucose Reconviction prediction score Relative risk Rapid risk assessment of sex offender recidivism Relative risk reduction REM sleep behavior disorder Risk of sexual viol ence protocol Road traf \201 c accident Respiratory tract infection Repetitive transcrania l magnetic stimulation Recipe (treat with) Second (or sec) Section (of MHA) Seasonal affect ive disorder Scale for the Assessment of Negative Symptoms Standardized assessment of perso nality Scale for the Assessment of Positive Symptoms Spousal assault risk assessment Seroto nin antagonist and reuptake inhibitor Subacute bacterial endocarditis Subcutaneous Anxiety Screen for Child Anxiety-Related Emotional Disorders Structured Clinical Interview for DSM- IV personality disorder Supervised community treatment SCID-II SCT 00_Semple_Prelims.indd xxv 12/10/2012 3:38:29 PM xxvi SYMBOLS AND ABBREVIATIONS SD SDH SDQ SE SGA SIADH SIB SIDP-IV SL SLE SLL SM SNOAR SNRI SOAD SORAG SOREMP SP SPECT SPE T SR SRS SS SSP SSPE SSRI SST STAR*D stat STD STDO STI STM SWS SXR T t1/2 T3 T4 TA Standard deviation Subdural hematoma Strengths and differences questionaire Sleep ef \201 ciency Second generation antipsychotic Syndrome of inappropriate antidiuretic hormone secre tion Structured interview for borderlines Structured interview for DSM-IV personality disor der Sublingual Systemic lupus erythematosus Stereotactic limbic leucotomy Selective mutism Sleep and nocturnal obstructive apnoea redactor Serotonin and noradrenaline reuptake inhibi tor Second opinion appointed doctor Sexual offending risk appraisal guide Sleep onset REM p eriod Social phobia Single photon emission computed tomography Single photon emission tomog raphy Systematic review Sex reassignment surgery Serotonin syndrome Schedule for schizoid p ersonalities Subacute sclerosing panencephalitis Selective serotonin reuptake inhibitor Ste reotactic subcaudate tractotomy Sequenced Treatment Alternatives to Relieve Depression Stat im (immediately) Sexually transmitted disease Short-term detention order Sexually transmitt ed infection Short-term memory Slow wave sleep Skull X-ray Temperature Biological half-life Tri-iodothyronine Thyroxine Total abstinence 00_Semple_Prelims.indd xxvi 12/10/2012 3:38:29 PM SYMBOLS AND ABBREVIATIONS xxvii TB TCA TD tds TeCA TENS TFTs TG TGA THC TIA tid TLE ToRCH Tuberculosis Tricyclic antidepressant Tardive dyskinesia Ter die sumendus (three times dail y) Tetracyclic antidepressant Transcutaneous electrical nerve stimulation Thyroid function tests Triglycerides Transient global amnesia Tetrahydrocannabinol Transient ischaemic attac k Ter in die (three times daily) Temporal lobe epilepsy Toxoplasmosis, rubella, cytomegalov irus, herpes simplex virus Temperature, pulse, respirations (general observations) Thyroid- releasing hormone Treatment-resistant schizophrenia (Gilles de la) Tourette \200\231s syndr ome Tuberous sclerosis Thyroid-stimulating hormone Total sleep time Units Urea and electrol ytes Urine glucose Uvulopalatopharyngoplasty Unconditioned response Upper respiratory tract Upper respiratory tract infection Unconditioned stimulus Ultrasound (scan) Urinary tract i nfection Variant Creutzfeldt \200\223Jakob disease Venereal Disease Research Laboratory (te st for syphilis) Visual evoked potential Von Hippel \200\223Lindau Vanillyl mandelic acid V entromedial prefrontal cortex Vagus nerve stimulation White blood cell TPR TRH TRS TS TSC TSH TST U U&Es UG UPPP UR URT URTI US US(S) UTI vCJD VDRL VEP VHL VMA vm PFC VNS WBC 00_Semple_Prelims.indd xxvii 12/10/2012 3:38:29 PM SYMBOLS AND ABBREVIATIONS xxviii WCC WD WFMH WHO WISPI wk(s) WM WPA XR Y \200\223BOCS YMRS yr(s) ZTAS White cell count Wilson \200\231s disease World Federation for Mental Health World Health O rganization Wisconsin Personality Inventory Week(s) Working memory World Psychiatric Associ ation X-ray Yale \200\223Brown Obsessive \200\223Compulsive Scale Young Mania Rating Scale Year(s) Zaponex Treatment Access System 00_Semple_Prelims.indd xxviii 12/10/2012 3:38:29 PM 1 Chapter 1 Thinking about psychiatry First thoughts 2 What is disease? 4 The role of the psychiatrist 6 Diagnosis in psychiatry 8 Why don \200\231t psychiatrists look at the brain? 10 Can psychotherapy change the brain? 12 The power of placebo 14 Treating patients against their will 16 Perceptions of psychiat ry 18 Psychomythology 20 Stigma 22 Anti-psychiatry 24 A brief history of psychiatry 26 The future 30 01_Semple_Chap01.indd 1 12/10/2012 6:23:39 PM CHAPTER 1 Thinking about psychiatry 2 First thoughts In the stanzas (Box 1.1) satirist Alexander Pope captured the essence of the then ongoing European Enlightenment, inspiring his readers to use their sense of reason to replace irrationality in their exploration of the world. This period also saw the re-emerg ence of attempts to use the same methods of thinking to study mental illness, whose suffere rs had then spent more than a thousand years as objects of fear and superstition. Pope \200 \231s words resonate even today, nearly three centuries later, when \200\224 confronted wit h patients thinking \200\230too little or too much \200\231 or in \200\230chaos of though t and passion all confused \200\231 \200\224we are still struggling to use science to guide the exploration of this \200\230riddle of the world \200\231. Psychiatry has often been derided as the Cinderella specialty: poorly funded, exiled to out side hospitals, a victim of rushed political experi- ments, castigated by anti-psychiatrist s, its intellectual basis ridiculed, and the self-con \201 dence of its practitioners lowe red. As a trainee psychiatrist you will have to cope with questions like \200\230are you a real doctor? \200\231 In addi- tion, the general public (and sometimes other medical profe ssionals) fre- quently misunderstand the types and severity of illnesses that you deal with . Either they picture you spending all of your time tending to Woody Allen-like self-obsess ed, befuddled neurotics, or guarding Hannibal Lecter- like murdering psychopaths. The reali ty is that psychiatrists deal with the most common human disorders which cause the greatest morbidity worldwide. Psychiatry considers all aspects of human experience over the whole of the lifespan: elatio n, grief, anxieties, \202 ights of fancy, confusion, despair, per- ception and mispercept ion, and memory and its loss. We see the mother with a healthy baby, perplexed and frighten ed by her tearfulness and inability to cope, and terri \201 ed by her thoughts of harming her child. We see the family of a young man who have watched him become a stranger, mutteri ng wild accusations about conspiracies, and we aim to be the doc- tors who know what best t o do in these circumstances. The specialty of psychiatry is (or should be) the most \200 \230human \200\231 specialty \200\224devoted to the understanding of the whole person in he alth and illness. Indeed, it is the only medical specialty without a veterinary counterpart . It is certainly true that the level of knowledge about causation and treatment of mental di sorders is less advanced than for other branches of medicine. In some ways, however, this i s an attraction. In other spe- cialties much of what was formerly mysterious is now underst ood, and interventions and diagnostic methods once fantastic are now quotidian. Psychiatry offers a \201 nal frontier of diagnostic uncertainty and an undiscov- ered country of eti ology to explore. Perhaps the lack of progress made in psychiatry, compared with the other specialties, is not because of lack of will or intelligence of the practitioners but due to the inherent tough- ness of the problems. To put this another way, all scientists \200 \230stand on the shoulders of giants \200\231: in psychiatry we have no fewer and no shorte r giants, just a higher wall to peer over. 01_Semple_Chap01.indd 2 12/10/2012 6:23:39 PM FIRST THOUGHTS 3 Box 1.1 The proper study of mankind Know then thyself, presume not God to scan The proper s tudy of mankind is man Placed on this isthmus of a middle state A being darkly wise, and ru dely great With too much knowledge for the skeptic side With too much weakness for the stoi c \200\231s pride He hangs between, in doubt to act, or rest In doubt to deem himself a God , or Beast In doubt his mind or body to prefer Born but to die, and reasoning but to err Al ike in ignorance, his reason such Whether he thinks too little, or too much Chaos of though t and passion, all confused Still by himself abuse, or disabuse Created half to rise, and h alf to fall Great lord of all things, yet a prey to all Sole judge of truth, in endless err or hurled The glory, jest, and riddle of the world Go, wondrous creature! Mount where Scien ce guides Go, measure earth, weigh air and state the tides Instruct the planets in what orb s to run Correct old time, and regulate the sun Go, soar with Plato to the empyreal sphere To the \201 rst good, \201 rst perfect, and \201 rst fair Or tread the mazy round his followers trod And quitting sense call imitating God As Eastern priests in giddy circles r un And turn their heads to imitate the Sun Go, teach Eternal Wisdom how to rule Then drop i nto thyself, and be a fool Superior being, when of late they saw A mortal man unfold all Na ture \200\231s law Admired such wisdom in an earthly shape And showed a Newton as we show a n Ape Could he, whose rules the rapid comet bind Describe or \201 x one movement of his m ind Who saw its \201 res here rise, and there descend, Explain his own beginning, or his end? Alas what wonder! Man \200\231s superior part Unchecked may rise, and climb from art t o art But when his own great work is but begun What reason weaves, by passion is undone Tra ce science then, with modesty thy guide First strip off all her equipage of pride Deduct wh at is but vanity, or dress Or learning \200\231s luxury, or idleness Or tricks to show the stretch of human brain Mere curious pleasure, ingenious pain Expunge the whole, or lop the excrescent parts Of all, our vices have created arts Then see how little the remaining sum Which served the past, and must the times to come! From Alexander Pope (1688 \200\2231744). An Essay on Man. As reproduced in Poetical Works, ed. Cary HF (London: Routledge, 1870), 225 \200\2236. 01_Semple_Chap01.indd 3 12/10/2012 6:23:39 PM CHAPTER 1 Thinking about psychiatry 4 What is disease? Most mental diagnoses have had their validity questioned at several points in their history. Diagnosed by doctors on the basis of symptoms alone, some people \201 nd their presence dif \201 cult to accept in a \201 eld which has been almost universall y successful in \201 nding demonstrable physical pathology or infection. Disease in medicine as a whole was not always based on pathology. The microscope was develo ped long after doctors began to make disease attribu- tions. Thomas Sydenham developed the medico-pathological model based on symptoms, but it has grown to incorporate information ob tained from post-mortem and tissue examination. This model of disease has become synonymous in many people \200\231s minds with a model based solely on demon- strably abnormal struct ure. Thomas Szasz (b p. 25) has criticized psychiatry in general by suggesting that its dis eases fail when this model is applied. This argument that psychiatric diagnoses are invalid still strikes a chord with many doctor s and non-medical academics. When the BMJ conducted a survey of non-disease1,2 (see Fig. 1. 1), many people thought depression to be a non-disease, although schizophrenia and alcoholi sm fared somewhat better. It is clear from the graph that many conditions rated as real dis - eases have a characteristic pathology, although some do not (alcoholism, epilepsy). Simil arly, many people regard head injury and duodenal ulcer as non-disease, although their path ology is well described. There are several models of disease in existence (see Table 1.1). No single model is adequa te by itself and diseases may move from one group to another. Models based on etiology or p athology have been found to be the most useful, but the reality may be that \200\230diseas e \200\231 is a concept which will tend to change over time and has no real existence in it self. Table 1.1 Models of disease Model Summary of assumptions Assumes diseases are associated with a necessary cause (e.g. bacterial infection) or have a replicable morbid anatomy. Medical-pathological de \201 nition (Sydenham 1696; Szasz 1960) Biological disadvantage (Scadding 1972) Assumes that sufferers from a disease have a common characteristic to place them at a biolo gical disadvantage. Plan of action (Linder 1965) Assumes disease labels are justi \201 cations for treatments and further investigations. Syndrome with characteristic symptoms/ outcome (Kendell 1975) Assumes diseases represent circumscribed concepts distinguished from others by a bimodal di stribution of scores on a discriminant function. Disease as imperfection (Cohen 1943, 1953) Assumes diseases are quantitative or qualitative deviations from a desirable norm. Disease as \200\230concept \200\231 (Aristotle) Assumes diseases are man-made abstractions with no independent existence. 01_Semple_Chap01.indd 4 12/10/2012 6:23:39 PM WHAT IS DISEASE? 5 Malaria Tuberculosis Cancer of the lung Syphilis Poliomyelitis Emphysema Measles Diabetes m ellitus Multiple sclerosis Muscular dystrophy Pneumonia Cirrhosis of the liver Asthma Hemop hilia Alcoholism Epilepsy Coronary thrombosis High blood pressure Schizophrenia Hypertensio n Acne vulgaris Gallstones Hay fever Duodenal ulcer Depression Piles (hemorrhoids) Lead poi soning Carbon monoxide poisoning Senility Hangover Fractured skull Heatstroke Tennis elbow Color blindness Malnutrition Barbiturate overdose Drowning Starvation Non-medical academic (reference group) Secondary school students Medical academics General practitioners 0 10 20 30 40 50 60 70 80 90 100 Percentage of respondents classifying condition as disease Fig. 1.1 Percentage of respondents classifying a condition as a disease. Reproduced from Sm ith (2002)1 with permission of BMJ Publishing Group. 1 Smith R (2002) In search of \200\230non-disease \200\231. Br Med J 324: 883 \200\2235. 2 Campbell EJ, Scadding JG, Roberts RS (1979) The concept of disease. Br Med J 2(6193): 757 \200\22362. 01_Semple_Chap01.indd 5 12/10/2012 6:23:39 PM CHAPTER 1 Thinking about psychiatry 6 The role of the psychiatrist What is illness? Doctors, being generally practical people, bu sy themselves with the diag- nosis and treatment of various types of illness. They rarely a sk \200\230what is illness? \200\231 or \200\230what is health? \200\231 For several reas ons this type of questioning is more germane for psychiatrists: \200 While all illnesses have subjective components, psychiatric disorders are usually completel y diagnosed by the patient \200\231s subjective experiences rather than objective abnormali ties. There is a non-absolute, value judgment involved in the diagnosis of mental disorder \200\224e.g. wheeze and dyspnoea are abnormal and a sign of disease, but some degree of anx iety at times is a common experience and the point at which it is pathological is debatable . Mental illnesses have legal consequences. It is important that psychiatrists are clear in themselves about which behaviors and abnormalities are their province. Psychiatrists have been involved in human rights abuses in states around the world when the de \201 nitions o f mental illness were expanded to take in political insubordination. \200 Disease, sickness, and illness behavior The distinction between disease (or disorder) and s ickness should be understood. Disease encompasses either the speci \201 c tissue lesion or char- acteristic constellation of symptoms. Sickness, on the other hand, encom- passes the suffering and functional de \201 cit consequent on symptoms. One may exist without the ot her \200\224e.g. a patient with undiagnosed, asympto- matic breast cancer undoubtedly has d isease but is not sick; a patient with chronic fatigue syndrome may see themselves (and be considered) as sick, but does not have an identi \201 able lesion. Patients generally present complaining of symptoms, and this process is called illness or i llness behavior. Patients need not be suffering from a disease or disorder in order to do t his, and sometimes illness behavior may be abnormal (even when the patient does have a dise ase). Subject to certain social conventions (e.g. attending a doctor), they are then afford ed the \200\230sick role \200\231 which allows them to relinquish some of their normal obl i- gations. This is a man-made concept, encompassing the special rights and expected behavi or of both someone who is sick and the doctor who is treating them (see Table 1.2). Dif \201 culties arise when a person adopts the sick role to gain the rights afforded to them, whilst neglecting their duties. Another concern relates to the process of diagnosis \200 \224causing someone who is not currently ill to adopt the \200\230sick role \200\231. Doct ors should understand their special responsibility to act in the patient \200\231s best int erests and not to stray outside their area of expertise. Clarity of roles It is all too easy for psychiatrists to slip into other roles than that wh ich is properly theirs \200\224an expert in mental disorder. These may include: substi- tut e parent, \200\230friend \200\231, guardian of public morals, predictor of future crimi- n ality, arbiter of normal behavior. Psychiatrists have special training and 01_Semple_Chap01.indd 6 12/10/2012 6:23:39 PM THE ROLE OF THE PSYCHIATRIST 7 Table 1.2 The rights and duties of patients and doctors Patient Doctor Rights Exemption from blame To be considered an expert Exemption from normal duties whilst in the sick role To have privileged access to patient information and person To expect the doctor to act in their best interests To direct (and sometimes insist on) a course of action To validate the sick role Duties To seek help To act in the patient \200\231s best interests To be open and honest To maintain con \201 dentiality To comply with treatment To keep up to date To give up the sick role once well To act, where possible, in society \200\231s interests experience in mental disorder, and should avoid being drawn outside this remit in their pro fessional role. Mental health and mental illness Psychiatrists are properly occupied in the business of dia gnosing and treating signi \201 cant psychiatric disorders. As gatekeepers to mental healt h resources there are often pressures to validate distress or medicalize normal experience. Saying that someone does not satisfy criteria for a speci \201 c mental disorder does not mean that they do not have signi \201 cant problems; rather, the problems do not fall wit hin the scope of psychiatry and would probably be best dealed with by help or advice elsewh ere. In general, psychiatrists should not spend their time advising people on \200\230good mental health \200\231 or how to live their lives \200\224this is the self-appointed remit of popular psychology. Good mental health is more than simply the absence of mental disorder, it requires: \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 A sense of self-suf \201 ciency, self-esteem, and self-worth. The ability to put one \200 \231s trust in others. The ability to give and receive friendship, affection, and love. The ability to form enduring emotional attachments. The ability to experience deep emotions. T he ability to forgive others and oneself. The ability to examine oneself and consider chang e. The ability to learn from experience. The ability to tolerate uncertainty and take risks . The ability to engage in reverie and fantasy. 01_Semple_Chap01.indd 7 12/10/2012 6:23:39 PM CHAPTER 1 Thinking about psychiatry 8 Diagnosis in psychiatry Labels People have a natural enthusiasm to be seen as individuals r ather than members of a class: \200\230I \200\231m a person, not a label \200\231. This de sire for the recognition of individuality and uniqueness is a part of the public reaction a gainst race-, class-, and gender-related value judgements. Doctors, on the other hand, appe ar to love labels and classi \201 cation, and in their enthusiasm can sometimes appear lik e the stereotypical Victorian butter \202 y collector who cannot deal with life unless it is named, categorized, and safely inert behind glass. Labels in medicine are based on chara cteristic combinations of symptoms and signs, but these are viewed differently by patient a nd doctor. Symptoms are important to patients because of their individual nature; that this strange and atypical thing is happening to them. Symptoms are important to doctors because they indicate diagnosis and are features which make this patient similar to others we have seen or read about. Diagnosis The naming of a thing is the \201 rst step towards underst anding it. We seek to identify disorders (diagnosis) in order that we should be able to sug gest treatments (management) and predict their course (prognosis). Ultimately, the aim is t o identify the physical abnormality (pathology) and the cause of the disease (etiology) and so develop means of prevention and cure. The ideal diagnostic system labels diseases accor ding to aetiol- ogy. The etiology of most mental disorders is unknown and so we tend toward s a diagnostic system based upon common clinical features, shared natural history, common t reatment response, or a combination of all three. Diagnosis leads to the consideration of i ndividual diseases as members of groups contained within a hierarchy: a form of classi \201 cation system. Why make a diagnosis? Why allocate the patient, with his individual and unique history, experience, and range of signs to a single label, with the inevitable comp romises and loss of information this entails? Diagnosis must be justi \201 ed on a general and an individual basis. Generally, the process of establishing a diagnosis is essential t o allow succinct communication with colleagues, to help predict prognosis, and to carry out valid research on pathological mechanisms and on treatments. Remember, however, that alloc ation of a patient to a diagnostic category can only be justi \201 ed if it will bring him bene \201 t, not harm. Classi \201 cation in psychiatry Over the past century within psy chiatry there has been a debate about the value of, and method of, psychiatric classi \201 cation. On one hand the academic and biological psychiatrists wor- ried that psychiatric d iagnosis was insuf \201 ciently reliable and valid, with a wide variety of terms being use d in imprecise or idiosyncratic ways; on the other hand psychodynamic practitioners emphasi zed the importance of unique patient factors and the degree of detail lost by the reduction ism of the diagnostic method. The \201 rst concern was tackled by the development of oper ational criteria \200\224clearly de \201 ned clinical descriptions of the disor- ders, tog ether with explicit inclusion and exclusion criteria and details of the number and duration of symptoms required for diagnosis. The second concern was met by the development of multi -axial diagnosis, where, in addition to the primary mental disorder coded on axis-I, additi onal axes code information about the patient \200\231s psychosocial problems, personality f actors, medical health, and degree of disability (Box 1.2). 01_Semple_Chap01.indd 8 12/10/2012 6:23:40 PM DIAGNOSIS IN PSYCHIATRY 9 Box 1.2 International classi \201 cation In psychiatric classi \201 cation, there are two systems in use worldwide: the Internation al Classi \201 cation of Diseases (ICD-10), produced by the World Health Organization; and the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), produced by the American Psychiatric Association. The International Classi \201 cation of Diseases (ICD-10) The ICD-10 is a general medical classi \201 cation system intended for world- wide, multi-specialty use. It includes 21 ch apters, each identi \201 ed by a roman numeral and a letter. Psychiatric disorders are des cribed in chapter V, and are identi \201 ed by the letter F. An index of the disorders des cribed in this book, together with their ICD-10 coding, is given on b pp. 1023 \200\22342. Coding The disorders are identi \201 ed using an open alpha-numeric sys- tem in the form F xx.xx. The letter \200\230F \200\230identi \201 es the disorder as a mental or behaviora l disorder; the \201 rst digit refers to the broad diagnostic grouping (e.g. psychotic, o rganic, substance-induced); and the second digit refers to the individual diagnosis. The di gits which follow the deci- mal point code for additional information speci \201 c to the disorder such as subtype, course, or type of symptoms. When used as second or third digits, 8 codes for \200\230other \200\231 disorders while 9 codes for \200\230unspeci \201 ed \200\231. Versions Four versions of the ICD-10 classi \201 cation of mental disorders exist, suitabl e for different purposes. ICD-10: Clinical descriptions and diagnostic guidelines ( \200 \230the blue book \200\231) is used by psychiatric practition- ers and gives clinical descr iptions of each disorder together with the diagnostic criteria. ICD-10: Diagnostic criteria for research ( \200\230the green book \200\231) contains more restrictive and clearly de \201 ned clinical features with explicit inclusion, exclusion, and time-course criteria, an d is suitable for identi \201 cation of homogeneous patient groups for research purposes. The primary care version focuses on those disorders prevalent in primary care settings and contains broad clinical descriptions, diagnostic \202 ow- charts, and treatment recommend ations. A short glossary containing the coding together with brief descriptions can be used as a quick reference by practitioners, as well as by administrative and secretarial staff. Axial-diagnosis The multi-axial version of ICD-10 uses three axes to broaden the assessment of the patient \200\231s condition. Axis 1 describes the mental disorder (including person ality disorder and mental handicap); axis 2 describes the degree of disability; and axis 3 describes current psychosocial problems. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) While ICD-10 is a wider general medical classi \201 cation, DSM-IV describes only mental disorders. The two classi \201 cations are broadly similar, having undergone a degree of convergence and cross-fert ilization with subsequent revisions. Relevant DSM-IV codes corresponding to ICD-10 disorder s are given on b pp. 1023 \200\22342. DSM-IV uses a closed, numeric coding system of the fo rm xxx.xx (mostly in the range 290 \200\223333.xx). A single version of DSM-IV is used for both clinical and research purposes. DSM-IV is a multi- axial diagnostic system using \201 ve axes. Axis 1 describes the clinical disorder or the current clinical problem; axis 2 describes any personality disorder and any mental handicap; axis 3, general medical condi tions; axis 4, current psychosocial problems; and axis 5, a global assessment of functionin g. 01_Semple_Chap01.indd 9 12/10/2012 6:23:40 PM CHAPTER 1 Thinking about psychiatry 10 Why don \200\231t psychiatrists look at the brain? Psychiatrists, with the exception of tho se doing academic research projects, are the only medical specialists who rarely directly e xamine the organ they treat. The chances that a patient with a serious psychiatric disorder (e.g. schizophrenia, bipolar disorder, severe depression) has ever had a brain scan are fa irly slim. Psychiatrists prescribe antipsychotics, antidepressants, mood stabilizers, elect roconvulsive therapy (ECT) \200\224all of which have a major impact on brain function \200 \224but do not know beforehand which areas of the brain are working well, and which are not functioning properly. Why is this? As a medical student, a medical practitioner, or even as a trainee psy- chiatrist, this sit uation does seem somewhat at odds with the medical train- ing we receive. Imagine the outcr y if an orthopedic surgeon were to set fractures without \201 rst taking an X-ray, or a c ardiologist diagnosed coronary artery disease without an electrocardiogram (ECG), angiograp hy, or com- puted tomography (CT). Imagine if, based on your description of the prob- lem, a car mechanic replaced the radiator in your car (at great expense to you) without even bot hering to look under the bonnet \201 rst. How can it be that the state of the art in psyc hiatry is not to look at the brain? Looking at this issue another way it is perhaps not surprising. If I were a patient, who pr esented to a psychiatrist with a catalog of recent losses (including both my parents, and a recent redundancy), low mood, sleep problems, loss of appetite, and a feeling of general h opelessness about the future, I would probably be somewhat perturbed if my psychiatrist dec lared that they could not help me until they had taken half an arm- ful of blood, performed a painful lumbar puncture (LP), and arranged a magnetic resonance image (MRI)/single photo n emission computed tom- ography (SPECT) of my brain (which might take a few months). I mig ht be impressed at their thoroughness, but over the following weeks as I fretted even more about the results of my brain scan, I might contemplate the wisdom of approaching someone w ho just seems to have added to my worries. When the \201 nal results came in and the psyc hiatrist declared that I was suffering from depression, I might seriously question their ab ilities, when I could have told them that 3mths ago! In the main, psychiatrists base diagnosis and treatment on symptom clusters, not brain imag ing or other investigations. This is not to say that it is not good clinical practice to pe rform a physical examination and some routine blood tests (or even an electroencephalograph [EEG] or CT/MRI when indicated by the history or clinical signs). Rather, these are genera lly investigations of exclusion (sometimes a negative result can be useful \200\224a point that is often lost on other clinicians when psychiatrists do request investigations which a re reported as \200\230normal \200\231). Psychiatric disorders (with the exception of the organic brain disorders, e.g. dementia) are predomi- nantly disorders of brain function; th ere are rarely observable changes in brain structure which would aid diagnosis. At present there are no gold standard diagnostic tests for psychiatric disorders. This is not to say t hat in the future functional imaging of the brain might not play a role in psychiatric 01_Semple_Chap01.indd 10 12/10/2012 6:23:40 PM WHY DON \200\231T PSYCHIATRISTS LOOK AT THE BRAIN? 11 diagnosis, but at present (and despite the fact that high-resolution SPECT and positron emi ssion tomography [PET] scans of the brain have been available for more than 20yrs) it \200 \231s not yet time to use these imaging tools in routine psychiatric practice. More researc h is needed to determine the speci \201 city and sensitivity of these imaging tools, even though there are hundreds of articles on functional brain imaging in a variety of psychiatr ic disorders (as a Medline search will quickly reveal). Does this relegate psychiatry to the lower divisions of medical special- ties? No. Rather, the doctor practicing in psychiatry needs a \201 rm grounding in general medicine (to rec ognize when a condition may have an organic basis), sharply honed interviewing skills (to e licit important psychiatric symptoms), a \201 rm grasp of psychopharmacology (to differen tiate between symptoms of disease and drug-related problems), and an appreciation of the ps ychosocial problems that may affect an individual in the society in which they live. Psychiatry is not about medicalizing normal experience; it is the ability to recognize symp toms of disease, as they are manifest in abnormalities of emotion, cognition, and behavior. Psychopathology reveals as much to a trained psychiatrist as pathology does to his medical or surgical colleagues. Psychiatrists may not (yet) examine the brain directly, but they a re cer- tainly concerned with the functioning of the brain in health and disease. 01_Semple_Chap01.indd 11 12/10/2012 6:23:40 PM CHAPTER 1 Thinking about psychiatry 12 Can psychotherapy change the brain? Descartes \200\231 error is never more apparent than wh en confronted with expla- nations of how exactly the psychotherapies bring about often prof ound changes in a patient \200\231s beliefs, ways of thinking, affective states or behav- i our. If we are ever to bridge the mind \200\223brain divide, then a neurobiological underst anding of the mechanisms by which the psychotherapies exert their actions is vital. This wo uld not only provide a sound theoretical foundation for these treatment approaches, but als o aid the improvement of psycho- therapeutic interventions by opening up the possibility of objectively meas- uring potential bene \201 ts and comparing one approach with another. Psychotherapy has been beset with accusations of being non-scienti \201 c. Even Freud had the good sense to abandon his Project for a Scienti \201 c Psychology which he started in 1895. He just did not have the tools he needed to detect functional changes in the living b rain. However, Freud \200\231s early experiments with cocaine \200\224mainly on himself \200\224convinced him that his putative libido must have a speci \201 c neurochemical foun dation. Now that we do have the ability to reliably detect training- and learning-related c hanges in brain acti- vation patterns using non-invasive functional imaging,1 Freud \200 \231s un \201 nished Project may be \201 nally realizable. Research in this area is neve r likely to attract the funding that major drug companies can invest in neurobiological res earch. Nevertheless, evidence is emerging for alterations in brain metabolism or blood \202 ow that relate to therapeutic effects. A recent review article2 identi- \201 ed a nu mber of studies assessing the effects of cognitive behavioral therapy (CBT) in obsessive \200\223compulsive disorder (OCD) and phobic disorders and of CBT and interpersonal therapy in depression. In OCD, psychological intervention led to reduced metabolism in the caudate and a decreased correlation of right orbitofrontal cortex with ipsi- lateral caudate and thalamus. Interes tingly, similar changes are observed in OCD treatment with \202 uoxetine, suggesting comm on or at least converging mechanisms in the therapeutic bene \201 ts of psycho- and pharma cothera- pies. In phobia, the most consistent effect of CBT was reduced activation in limbi c and paralimbic areas. Reducing amygdala activation appears to be a common \201 nal path way for both psycho- and pharmacotherapy of phobic disorders. Whether different functional networks are responsible for this common end point remains to be determined, although anima l research does suggest this may well be the case. Studies of depression are more dif \201 cult to interpret, showing both increases and decr eases in prefrontal metabolism associated with successful treatment. It does appear that de pression is a much more heterogeneous disorder and the functional networks implicated in th e treatment effects of the different therapies are not as straightforward as for the anxiet y disorders.