309 y g o o c e a n y G l Chronic pelvic pain This is intermittent or constant lower abdominal pain of >6 months \200 \231 duration not associated exclusively with menstruation, intercourse, or pregnancy. Pain may cause, or be exacerbated by, emotional problems. She may be depressed. Adequate time n eeds to be given to allow women to tell their story, express their views as to the cause of pain, and explore psychological aspects and past abuse. A multidisciplinary approach eff e cts most all round improvement. 184 310 \200 Laparoscopy may reveal a likely cause: chronic pelvic infection, endome- triosis, adenomyos is, adhesions (eg residual ovarian syndrome and trapped ovarian syndrome), \200\225185 or congested pelvic veins. Consider also irritable bowel syndrome (OHCM p268), and interstitia l cystitis (p306). If pain is quite cyclical ovarian suppression (Pill/Zoladex ) may help. Pelvic congestion Congested lax pelvic veins (seen at laparoscopy) cause pain worse on stan ding, walking, and premenstrually. Typically variable in site and intensity, there may be u npleasant postcoital ache. Deep palpation reveals maximal tenderness over ovaries. Vagina a nd cervix may look blue as congestion. Look for associated posterior leg varicosities. Remedies include explanation ( \200\230pelvic migraine \200\231), ovarian supression, mi- g raine remedies (OHCM p450) and relaxation techniques. For severe symptoms bilateral ovarian vein ligation, radiological embolization, or hysterectomy with salpingo-oophorectomy ( HR T) may cure. Mittelschmerz This is mid-cycle menstrual pain which may occur in teenag- ers and older women around the time of ovulation \200\224from the German mittel (=middle) and S chmerz (=pain). y g o o c e a n y G l Dyspareunia This means pain during intercourse. There may be a vicious circle in which anti cipation of pain leads to tense muscles and lack of lubrication, and so to further pain. \200\207The patient may not volunteer the problem so ask about intercourse. Her attitude to pelvic examination may tell you as much as the examination itself. Ask her to show you whe re the problem is. If the problem is actually vaginismus do not insist on examination and c onsider counseling and sex therapy (p384). Was there \200\230female circumcision \200\231 (p247)? \200 Dyspareunia may be super \201 cial (introital) eg from infection so look for ul- ceration and discharge. Is she dry? If so is the problem estrogen de \201 ciency (p256) or lack of sexual stimulation? Has she had a recent postpartum per- ineal repair? A suture or scar can cause well-localized pain which is cured by massage or by removing the suture and injectio n of local anesthetic. If the introitus has been rendered too narrow, she may need surgery. Deep dyspareunia is felt internally (deep inside). It is associated with en- dometriosis an d pelvic sepsis; treat the cause if possible. Ovaries lying in the rectovaginal pouch (or a fter hysterectomy) may be subject to coital thrusts; try other positions or ventrosuspensio n if a \200\230cure \200\231 can be obtained with trial use of a Hodge pessary. Dermatographism is a rare cause of dyspareunia: look for itchy vulval wheals some minutes a fter calibrated dermatographometer application. It can occur on any surface. It is the comm onest physical cause of urticaria, and the clue to its presence is linear wheals with a sur rounding bright red \202 are (but no angio-oedema) elsewhere on the skin, in response to a \201 rm stroke. Cause is unknown. Relief of dyspareunia in these cases has been achieve d by 2% adrenaline (epinephrine) cream, and cetirizine 10mg/24h PO. 311 Ovarian hyperstimulation This is a systemic disease resulting from vaso- active products re leased by hyperstimulated ovaries. The incidence for severe cases is 3 \200\2238% in women having ovarian stimulation (mild cases occur in 22 \200\22333% of treatment cycles). It is com- moner in conception cycles, especially if multiple pregnancy. Other risk factors: see MINIBOX. Asso- ciated complications are ascites, reduced intra- vascular volume, pulmonary eff usions and (rare) pericardial eff usions. Thromboembolic compli- cations may ensue (esp ecially in upper limb and cerebral vessels). Presentation Abdominal discomfort, nausea, vom iting, and abdominal dis- tension dyspnoea. Presentation is usually 3 \200\2237 days aft er human chorionic gonadotrophin (HCG) administration, or 12 \200\22317 days, if pregnancy has ensued. Prevention Note: In vitro maturation (IVM, p293) avoids the need for ovar- ian stimulation so is especially suitable for women with polycystic ovaries. In those in whom h yperstimulation is suspected (peak serum oestradiol >6000pg/mL and >30 follicles stimulated ), the surest way to avoid hyperstimu- lation is to avoid administration of HCG so the stim ulated follicles do not ovu- late, thereby canceling the cycle of treatment (or discontinue gonadotrophins and delay HCG injections until the serum oestradiol returns to \200\230saf e \200\231 levels). Some selectively cryopreserve embryos for later transfer. Management Ad mit to hospital unless just mild pain. Give adequate anal- gesia (opiates if necessary, avo id NSAIDs). Check FBC, U&E, creatinine, LFT, and coagulation pro \201 le. Do CXR if chest pathology suspected; ECG and echo if pericardial eff usion suspected; blood gasses if tachy pnoeic or dyspnoeic. Chart urine output (if oliguria suspected catheterize and measure \202 uid output hour- ly). Measure abdominal girth and weigh daily. Ovarian size is a guide to sever- ity unless oocytes have been harvested (eg, mild, ovarian size <8cm; moderate 8 \200\22312cm; severe >12cm). To avoid thromboembolism use antiembolic stockings, encourage leg mobility, and use heparin (p16) during inpatient stay 186 and pos- sibly for 1st trimes ter if pregnancy ensues. \200\225187 Risk factors \200 Age <30yrs \200 Asthenic habitus \200 Pregnancy \200 Luteal phase HCG stimulation Polycystic ovarian syn \200 Serum oestradiol >4000pg/mL Multiple follicles (>35) \200 Previous hyperstimula- y g o o c e a n y G tion l Hyperstimulation is severe if haematocrit is >45%, WCC >15 \211\210109/L, there is massive ascites, oliguria, mild renal, or liver dysfunction. Put up IVI, and con- sider CVP monitor ing. Fluid replacement may be required, eg 500mL albumin over 2 hours. Paracentesis of asci tes using ultrasound to avoid cysts may be needed to reduce discomfort, relieve breathing a nd for persistent oliguria (can improve renal function). The situation is critical if the h aematocrit is >55% and WCC >25 \211\210109/L, there is tense ascites and renal failure, thr omboembolic phenomena, and acute res- piratory distress syndrome (OHCM p178). Admit to ITU. Symptomatic pleural eff usions may need drainage. Use antiembolic measures as above. Pay m eticu- lous attention to \202 uid balance. Aim to maintain intake at 3L/24h using normal saline if unable to tolerate oral \202 uids. Beware hyponatraemia. The severity of eff us ions determines the time to recovery. In non-conception cycles with little ascites there wi ll be resolution with menstruation. In con- ception cycles cysts may persist for weeks. Res olution usually occurs, but exceptionally termination of pregnancy may be needed. Deaths ha ve been reported but are extremely rare ( 1 : 500,000 stimulated cycles). 312 4 Psychiatry s d n m g n g n a h C i Part I: First principles 314 i Dignity on psychiatric wards 315 Odd ideas (hallucinations, delusions, etc.) 316 Part II: Skills Introduction/listening 318 \200\22320 How to elicit the history 322 How to do a mental state exam 324 How to avoid doctor-depende ncy 326 How to improve quality of care 327 How to talk about sex 328 How not to be manipula ted 330 How to recognize and treat your own mental illness 332 How to help the patient in d isgrace (also includes dissociation/hysteria) 334 How to use the right service 329 How to help patients be less lonely 331 Part III: The major disorders and their physical treatments Suicide and attempted suicide 338 Electroconvulsive therapy 342 Other neurotic disorders, e g OCD 346 (hypochondriasis 334) Delirium & Dementia 350 \200\2233 Psychosis and mania 354 D rug and other addictions 362 Intellectual disability 364 Withdrawing psychotropics 368 Depression 336 Antidepressant drugs 340 Anxiety neurosis 344 Stress and PTSD 347 Anorexia a nd bulimia 348 The mental test score 353 Schizophrenia 356 \200\22361 Alcohol-related probl ems 363 Personality disorders 366 Part IV: The psychotherapies 370 Behavioral therapy 372 Group psychotherapy 376 Art therapy 377 Counseling 380 Dynamic psych otherapy 382 Systemic/family therapy 386 Cognitive therapy 374 Play therapy 377 Crisis intervention 378 Supportive psychotherapy 380 Sex therapy for couples 384 Comparing psychotherapies 388 Part V: Child psychiatry (adolescent mental health, depression, psychosis, sleep disorders, autism, bullying, dyslexia, and related topics) 390 \200\2237 Part VI: Compulsory treatment 398 \200\223401 Consent to treatment 402 Seasonal aff ective disorder 404 Poverty and mental illness 406 Community care 405 Postnatal depression 408 uite a few doctors hope to make patients better by taking responsibility for ordering the m ileau interieur, and the credit when things go well. In psychiatry this approach is wrong. Mental health is about people (not patients) taking responsibility for themselves and their program of change. The psychiatrist knows that his or her job is done, not when the patien t is cured but when he becomes self-actuating, insightful, and interacting with the world i n creative (not necessarily satisfactory) ways. So if you are hoping for a chapter dealing with mental disorders as if they were lung diseases with cer- tain signs and agreed treatme nts this chapter will disappoint. Isn \200\231t it wooly, a reader complained, to have page s on listening, dignity, etc? \200\234Just tell me what to do. \200\235 Well, here goes. I nterpersonal problems: just do what you think you should do. Anxious? Get on with it: relax ; try \200 -blockers. Depressed? SSRIs, tri- cyclics or get wired (ECT); think positive. M anic? Try lithium. Psychopathic? Tough luck. Schizophrenic? Antipsychotics; if dangerous, l ock up. Psychothera- py for everything else. Phew! That \200\231s got it over with. Now sit back and rest. Or sit back and listen if you listen, you may be able to help, rather tha n beat peo- ple over the head with formulaic solutions to problems they don \200\231t quite have. \201\201Read this chapter with DSM-V: a diagnostic and statistical manual that codi \201 es all mental illness, but note that this \202 awed book ignores the social context of symptoms, and over-medicalize s them.1 We thank Dr Anish Patel, our Specialist Reader, and Dr Rashmi Singh, our Junior Re ader, for their contribution to this chapter. octors have never been very important because nothing that happens to our bodies ever reall y matters. In historical terms, what happens to our bodies rarely outlives our own times. E ven the exceptions to this prove a diff erent rule: we recall forever human images burnt on to stone at their moment of immolation in Nagasaki and Hiroshima. What happened to these p eople was important, and transcended their times. But it is all the more true that it isn \200\231t the way they lived, but the way they died that is impor- tant, and it is not the body or its image on stone which is important, but the image left on our minds. And so it i s with psychiatrists, psychologists, and psychiatric nurses who play such vital roles in co loring our lives with hope or despair, who mitigate our madness, giving meaning, purpose, a nd dignity to the mental suff erings of so many of us. So when we think of them going about work, think of them burnishing humanizing images not on stone, but on the mind itself. How they do it is the subject of this chapter. 313 y r t a i h c y s P Fig 1. Screaming but unheard: images born of paranoid schizophrenia. Neil Houghton, the art ist, says: \200\234I was born in Bolton with a pencil in my hand. Always deep in thought a nd not mixing much with others. I have always been troubled with confusing and scary though ts diagnosed as schizophrenia. This painting is from a series chronicling a bad episode. \200\235 Neil Houghton Gallery. When we asked him what message he would like to send doct ors learning about mental illness, he replied \200\234Patients can off er a valuable insig ht into their own illness. \200\235 This value he points to is troubling, hard-won, but, ul timately, liberating. \201\201 \200\234Terror grips when these things happen ; the signs, the lights, the storm within: death by installments I \200\231m a daily subscriber. \200\235 First principles Chaque homme porte la forme enti re de l \200\231humaine condition (Each of us bears the complete stamp of the human condition) This is the \201 rst principle of psychiatry and was proclaimed by Michel De Montaigne in 1580.2 The second principle has yet to be agreed but will probably include reference to the idea that the bond between therapi st and patient is unbreakable by any fact or revelation and exists entirely to foster growt h and development. A thought experiment Before reading further, cover the next paragraph wi th a card and write on it what you are trying to achieve as a mental health worker. Next, t urn the card over and write down what was actually in your mind as unstated goals when you were last treating someone. So often our unconscious aim is just symptom control, obedience , or simply (simply!) normality. But if you were the patient (luck changes in a moment) wha t would you want? The aim of this page is to help you \201 nd out, by considering one per son \200\231s answer. The essence of mental health Healthy (lucky!) humans are able: \200 To love and be loved; without this asset, humans, more than all other mammals, fail to thri ve. \200 To embrace change \200\224and face fear in a spirit of practical optimism. \200 To take risks, free from endless worst-case-scenario-gazing. \200 To satisfy the requir ements of the group \200\224if the person so desires. \200 To deploy joie de vivre, and a wide range of emotional responses, includ- ing negative emotions, such as anger (pain \200 \231s most motivating antidote). 314 y r t a h c y s P Go, go, go, said the bird: human kind Cannot bear very much reality. i Time past and time future What might have been and what has been Point to one end, which is always present. Four Quartets, TS Eliot \200 To make contact with reality: not too rarely or too often. Human kind cannot bear very much reality. \200 To say \200\234I was wrong \200\235 and learn from life and to have enough self-kno wledge to heal the self and others, but not so much as to become demoralized. \200 To inhabit fantasy worlds, enabling hope and creativity to \202 ourish. \200 To feel a sense of security, not always predicated on one \200\231s status in society. \200 To enjoy self-expression \200\224balanced by sensitivity to others \200\231 vulnerabilities . \200 To feel a sense of awe and to risk enchantment (and hence disenchantment). \200 To gratify bodily desires and eventually to be free from desire.3 He who no longer desires anything for himself is both free and good, yet not superior. \200 To have a sense of humor to compensate if the foregoing is unavailable. Happiness1 \201\201 need not be an ingredient of mental health, as the merely happy are supremely vuln erable to events. The essence of mental illness Whenever a person \200\231s thoughts, feeli ngs, or sensory impressions cause him objective or subjective harm that is more than transi tory, a mental illness may be said to be present. Often the harm is to society, but this is not part of the de \201 nition of mental illness, as to include it would open the door to saying that, for example, all rapists or all those op- posing the society \200\231s aims a re mentally ill. One feature of mental illness is that one cannot rely on patients \200\231 judgment, and the judgment of family, GP, or psy- chiatrist has a role. If there is dispar ity, let it be \200\230one person one vote \200\231, if voters are acting solely in the in terests of the patient. Psychiatrists have no special voting rights (or else concepts of me ntal illness get too medicalized). Just be- cause psychiatrists and GPs are not allowed mor e than one vote, this does not stop them from illuminating the debate by virtue of their sp ecial knowledge. For convenience, English law saves others from the bother of specifying who has a mental il lness by authorizing doctors to act for them. This is a healthy state of aff airs only in s o far as doctors remember that they have only a small duty to society, but a larger duty to their patient. Learning disability (mental impairment) This is a condition of arrested or incomplete development of mind owing to low intelligence, p364. \201\201The external recipe for happiness \211\210 stable family life + a good marriage + more wealth than your neighbors (absolute wealth is irrelevant)4 + health + a cohesive trusting community.5 The internal re cipe is elusive. \201\201 Dignity on psychiatric wards Apart from showing sympathy, nothing is more to be d esired than giving our patients dignity \200\224not the dignity that they deserve (who amon g us would merit an ounce of dignity on this measure?) but the dignity that con- \201 rms to our patients that, mad, bad, or rambling, they are, root and branch, body and mind, jus t as human as their doctors \200\224perhaps more so, because they are suff ering.1 Let pati ents \200 Decide on modes of address, \200\230Miss Hudson \200\231 may be preferred to \200\230Amy, 315 . \200\235 g n i h t dear \200\231. Dignity entails giving choices, and then respecting them. a l e e f Know who we are (eg wear name badges). But don \200\231t label patients ( \200\234Go and se e the new schizophrenic on Mary ward \200\235). If you put a patient in a box the next thin g you \200\231ll do is put a lid on it \200\224and stop thinking. t n o w u o y \200 k c a b y r t a i h c y s P Wear their own clothes \200\224and clothe them decently if they have none. \200 Choose wh ether to take part in research \200\224and whether to see students. \200 Have personal sp ace \200\224both to stow their belongings, and to walk in, in private, whether alone, or with visitors. r u o y Participate in their treatment plans; explain about common side eff ects. \200 Know what to do if a crisis develops. It \200\231s a great help to know that you n i e l d e e n will be seen in 4 hours rather than be left to molder all weekend. These 7 points are congruent with NICE (2012) and Human Rights law which lays out the right to life, freedom from inhuman or degrading treatment and torture, respect for privacy, the right to a fair hearing and freedom of expression. Some of these rights are inalienable, a nd unrevokable, even in time of war (on UK soil). So defenses such as \200\230the ward was busy that day \200\231 or \200\230there was no money to buy this service \200\231 are unl ikely to impress judges. e l t t i l y n i t a t u p o t In practice, many mental health wards may do more harm than good g n i o g (violence, verbal abuse, and sexual harassment eg from other patients). Patients \200\231 o ther needs: Maslow \200\231s hierarchy and mental health Maslow states that a healthy perso nality (ie fully functioning and self-actu- alizing) entails the meeting of a hierarchy of needs: 1 Biological needs (eg oxygen, food, water, warmth). 2 Safety needs (no present thre ats to safety); no pain. (Items 3 \200\2235 apply if this comfortable numbness, this \200 \230stye of contentment \200\2316 is inadequate). t s u j e r a e w , r a e d , y m A \200\234 \200 d r a w p l 3 Love, aff ection, and \200\230belongingness \200\231 needs. 4 Esteem needs (self-respect , and need for respect from others: see top box). The latter is 2-fold: being valued for wh at you can do or bring to your community or family \200\224and, above all, to be valued for who you are. 5 Self-actualization needs to follow one \200\231s calling and affi rm \200 \234What I do is If such needs are unmet, restlessness and e h t n o me: for that I came. \200\235 Gerard Manley anxiety result. To meet this need we might teac h ourselves: \200 To be aware of the inner self and to understand our inner nature. \200 To transcend cultural conditioning. \200 To transcend the tri \202 ing and to grapple wit h life \200\231s serious problems. \200 To refresh consciousness by appreciating beauty an d all good things. \200 To feel joy and the worth of living. www.connect.net/georgen/maslo w.htm Hopkins b m u n y l b a t r o f m o c n U 1 Do our suff erings make us more human? Only if we can breathe meaning into them. Toothach e doesn \200\231t make us more human because it has no meaning beyond the obvious and banal ; but there is a kind of suff ering \200\230which is a more eff ective key, a more rewardi ng principle for exploring the world in thought and action than personal good fortune \200 \231. (Deitrich Bonhoeff er). This suff ering makes our souls. Not all our patients regret their psychological illnesses: sometimes, in retrospect, these patients refer to their brea k- through, not their breakdown. It is this power to grow and to transform experience which is human and humanizing. This is also why, paradoxically, illness is not the opposite of h ealth. For humans, the true opposite to health is being stuck In Status Quo \200\224that st ate which brooks no development. So if you \201 nd yourself writing ISQ (in status quo) i n patients \200\231 notes you are invoking a kind of death. Odd ideas It is important to decide if a patient has delusions, hallucinations (that the pa tient believes are real), or a major thought disorder (see below), because if present the d iagnosis must be: schizophrenia, an aff ective disorder, an organic disorder, or a paranoid state (or a culturally determined visionary or spiritual experience), and not a neurosis o r a personality disorder. 316 \200 Patients may be reluctant to reveal odd ideas. Ask gently: \200\234Have you ever had any t houghts which might now seem odd; perhaps that there is a con- spiracy against you, or that you are controlled by outside voices or the radio? \200\235 Hallucinations are auditory, v isual, gustatory, or tactile sensations occurring without any stimulus. Common hypnagogic/h ypnopompic hallucinations (on falling asleep or waking) do not indicate pathology. A pseudo -hallucina- tion is one in which the person knows the stimulus is in the mind (eg a voice h eard within him- or herself, rather than over the left shoulder). They are more common, and needn \200\231t indicate mental illness, but they may be a sign that a genuine hallucinati on is waning. Tactile or visual hallucinations (without auditory hallucinations) suggest an organic disorder (eg alcohol withdrawal, or Charles Bonnet syndrome, p438). NB: 2 \200\223 4% of the general population expe- rience auditory hallucinations, but only 30% of these h ave a mental illness (more likely if associated with distressing delusions).7 Delusions are beliefs held unshakably, irrespective of counter-argument, that are unexpected, given the patient \200\231s cultural background. If the belief arrives fully formed, and with no ante cedent events or experiences to account for it, it is said to be primary, and is suggestive of schizophrenia (or genius1). Such delusions form around a \200\230delusional perception \200\231, as illustrated by the patient who, on seeing the traffi c lights go green (the d elusional perception) knew that he had been sent to rid his home town of materialism. A car eful history will reveal that delusions are often secondary \200\224eg a person who is psyc hoti- cally depressed may come to think of himself as being literally worthless. De- lusion s are especially relevant if they involve persecution and loss of control.7 Ideas of refere nce Sometimes we cannot help feeling that others are notic- ing the very thing we are asham ed of. If we know the thoughts come from ourselves, and are excessive, it is an obsession, not a delusion. NB: ideas of reference have poetic as well as pathological causes, as in dr amatic storms, when thunder and lightning speak to us directly, in personal messages \202 ashed onto to sky in some cosmic rendering of our own vision.Chimes of Freedom Ways to dis tinguish delusions/hallucinations from obsessional thoughts 1 Hearing the thought as a voic e (a hallucination) \200\224eg from a psychosis. 2 The voice is \200\230put into my head \200\231 \200\224thought insertion (hallucination + delusion). 3 The voice is \200\230my o wn voice \200\231 but intrusively persistent (obsessional neurosis). Major thought disorder This entails bizarre thoughts, or incongruent transition from one idea to another. (Mania \200\224 \202 ight of ideas, p354; schizophrenia, p358). If hallucinations/delusions are p resent, ask: 1 What other evidence is there of mental illness? Hearing the voice of one \200\231s dead spouse is common, and does not mean pathology. 2 Could the odd ideas be adap tive, and the patient be better off \200\230ill \200\231? A woman once believed she saw pl anes \202 ying over her home, and that this data was taken from her head by the Ministry of Defense. She \200\230knew \200\231 she was playing a key role in defending Britain. Whe n she was cured of her delu- sions (Ibsen \200\231s \200\230life-lie \200\2312) she killed herself. An odd story; or is it so odd? Accord- ing to the great poets, everything we cher ish is an illusion, even our sense of distinctive self-hood, and without this primordial de lusion, madness beckons. y r t a h c y s P i Bob Dylan; 1964 1 \200\230The moment I put my foot on the step the idea came to me without anything seemin g to have paved the way for it, that the transformations I \200\231d used to de \201 ne th e Fuchsian functions were identical with those of non-Euclidean geometry \200 the idea came with suddenness, and immediate certainty. \200\231 A Koestler The Act of Creation 2 If p sychiatrists have no authority to cure us of our life-lie (livslognen),8 who has? Only dram atists who com bine tragedy with comedy to awake us from our sleepwalking, and inoculate us against self-contempt.Ibsen The Wild Duck 317 Some causes of odd ideas A typical problem is trying to diagnose a young man presenting wit h hallu- cinations and/or delusions. The question often is: Are these odd ideas due to schi zophrenia, drug abuse, or physical illness? 1 Most auditory hallucinations not associated w ith falling asleep or wak- ing up are caused by schizophrenia or depression. 2 In 90% of those with non-auditory hallucinations (eg seeing things), the cause is substance abuse, drug withdrawal, or physical disease. 3 Evidence that substance abuse is to blame includes: The history: Ask the patient, the family, and friends about abuse. Be precise about timing. If \211 4 weeks elapse between abuse and start- ing of odd ideas, substance abuse is an u nlikely cause (but substance abuse may be an enabling factor promoting later psychosis).1 \200 Severity of symptoms: If symptoms are severe, and the quantity of drug ingested is tri vial, the drug is unlikely to be causative. \200 Drug-seeking behavior: Be on the lookout for this. \200 Physical examination: This may reveal signs of drug abuse (eg injec- tion m arks cellulitis), chronic alcohol abuse (eg spider naevi, liver palms, atrophic testes), or a physical medical illness (eg brain tumor). \200 Blood or urine tests may disclose th e substance abused or give a hint of abuse (MCV \200\200 and gamma GT \200\200 in alcohol a buse). \200 Imaging: Consider CNS imaging if the patient is elderly with nothing to sugges t substance abuse, or if there are CNS signs. . h t o b r o e n a s y r t a i h c y s P r o d a m e r a h c i h w m e h t t u o b a s f e i l e b d n a m e h t o t NB: middle-age is not a typical time for schizophrenia to present: alcohol abuse or a prima ry CNS condition is more likely. Diagnosing a substance-induced psychotic disorder implies that the patient responds to the hallucinations or delusions as if they were real. If the patient recognizes the hallucinato ry nature of the experience, then consider diagnosing substance intoxication, substance wit hdrawal or, if there is past but no current exposure to hallucinogens, the diagnosis may be \200\230 \202 ashbacks \200\231 \200\224ie hallucinogen persisting perception disorder. This con- dition presents episodically up to 5 years after exposure to an hallucino- gen, w ith \202 ashback hallucinations \200\224or phenomena such as geometric visual hallucinati ons, seeing colored \202 ashes, or intensi \201 ed colors, dots, spots, or \202 ashes, seeing trailing images or after-images, seeing complementary colored images of objects gon e from view, seeing halos, seeing things too small (micropsia), or seeing things too big (m acropsia). These phenomena may be self-induced or triggered by darkness, stress, or fatigue . DSM IV 313 s n o i t c a e r r u o s \200\231 t i : s a e d i d d o e v a h l l a e W What \200\231s it like having hallucinations? Try virtual reality to \201 nd out \201\201Doctors are always getting hung up on hallucinations, those tokens . \200\231 S C H O used in games of clever diagnosis, without bothering to acquire real knowledge of what it \200\231s like to have them. For doctors who have never ex- perienced hallucinations, Profe ssor Yellowlees has devised a virtual reality experience on Second Life: a complex, unruly 3D world where we doctors and our avatars get sucked into virtual clinics \200 Floors can fall away, leav- ing us walking riskily on stones above clouds. The eyes of a portrait \202 ash \200\230shitface \200\231 as we pass, and a politician on an in-world TV might mo ve in a sin- gle breath from platitudes to shouting \200\234Go and kill yourself, you wret ch! \200\235. When it gets to the stage of our re \202 ection in a mirror bleeding its eye s out before expiring, most of us switch off .9 But our patients cannot quit so eas- ily. V irtual reality is just one way of sensitizing us to their struggles: other ways are through blogs, painting (p313), and tragedy (the Ophelia eff ect).10 , t s o l t e g \200\230 g n i y a s e r a n i g r a m e h t n i s e c i o V 1 Moderate cannabis use \200\200 risk of psychotic symptoms in young people but has a much stronger eff ect in those with a pre-existing predisposition to psychosis.11,12 High-yield cannabis ( \200\230skunk \200\231) can cause thought broadcasting, paranoia, depersonaliza tion & visual/auditory hallucinations.13 Introduction to psychiatric skills Only people can change people: \200\230Alyosha \200\231 s arrival seemed to have a sobering ef- fect on him \200 as though something had awakened i n this prematurely aged man that had long been smothered in his soul \200 \200\234For you see, my dear boy, I feel that you are the only man in the world who has not condemned me \200\235. \200\231 Brothers Karamazof Dostoevsky; page 25 On starting psychiatry you may fe el unskilled. A medical problem will come as a relief \200\224you know what to do. Do not b e discouraged: you already have plenty of skills (which you will take for granted). The aim of this chapter is to build on these. No one can live in the world very long without obser ving or feeling mood swings, and without devising ways to minimize what is uncom- fortable, and maximize what is desirable. Anyone who has ever sat an impor- tant exam knows what anx iety is like, and anyone who has passed one knows how to master anxiety, at least to some e xtent. We have all survived periods of being \200\230down \200\231, and it is interesting to ask how we have done this. The \201 rst element is time. Simply waiting for time to go by is an important psychothera- peutic principle. (Voltaire teasingly remarked that the ro le of the doctor is to amuse the patient until nature eff ects a cure.) Of course, there ar e instances when waiting for time to go by leads to fatal consequences. But this does not p revent the principle from being useful. 318 y r t a h c y s P Another skill with which we are all more or less adept is listening. One of the central ten ets of psychiatry is that it helps our patients just to be listened to. Just as we all are helped by talking and sharing our problems, so this may in itself be of immense help to our patients, especially if they have been isolated, and feel alone \200\224which is a very co mmon experience. i Just as spontaneous regeneration and improvement are common occur- rences in psychiatry, so is relapse. Looking through the admissions register of any acute psychiatric ward is likel y to show that the same people keep on being re-admitted. In one sense this is a failure of the processes of psychiatry, but in another sense each (carefully planned) discharge is a success, and a complex infrastructure often exists for maintaining the patient in the commu - nity. These include group support meetings, group therapy sessions, and social trips out of the hospital. We all have skills in the simple aspects of daily living, and in re-teachi ng these skills to our patients we may enable them to take the \201 rst steps in rebuildi ng their lives after a serious mental illness. So time, listening, and the skills of daily living are our chief tools, and with these simp le devices much can be done to rebuild the bridges between the patient and his outside worl d. These skills are simple compared with the highly elaborate skills such as psychoa- nalys is and hypnosis for which psychiatry is famous. The point of bringing them to the fore is s o that the newcomer to psychiatry need not feel that there is a great weight of theoretical work to get through before he starts doing psychiatry. You can engage in the central proce ss of psychiatry from day 1. Use the knowledge and ex- perience gained as a foundation on w hich to build the constructs required for the more speci \201 c and eff ective forms of ps ychotherapy. Fig 1. Listening, not judging. So often when we listen the fact that we are also judging le aks out in an unconscious disapproving gaze \200\224 and our patient clams up. This mythica l ward round has adopted an extreme method to prevent this. Words waft up on thermals of ho t air, unimpeded by cold or quizzical or uncomprehending gazes. So don \200\231t let ward rounds descend into fact-based inquisitions. \201\201As one history-taker said, \200\234 They wanted facts. Facts! They demanded facts as if facts could explain anything! \200 \235 Joseph Conrad Lord Jim \201\201 Suspending judgment If we knew more about ourselves, we would understand more abo ut our fel- low patients, bearing in mind that \200\230all gods and devils that have ever existed are within us as possibilities, desires, as ways of escape \200\231. Herman Hesse 1 919.14 What we want our patients to achieve is insight. Our judging does not help this. Jud gment turns patients away from us. We cannot expect our patients to be honest with us if th ey know that we are judging them. \200 The good listener is not silent, but re \202 ecti ve \200\224a mirror not a message. Mirrors do not judge but they enable self-judgment. Unle ss some criminal act is underway, it really does not matter what we think about our pa- tie nts. What matters is how the patient thinks about him- or herself and his or her near-ones \200\224and how these thoughts can be transformed. \200 If we judge people they will not trust us. No trust \211\210 no healing. \200 If we judge, patients will leave us for oth ers perhaps less well quali \201 ed. \200 There is no evidence that judging improves out comes. Worse outcomes 319 . s i p m e K s a m o h T \200 t \201 o r p r u o o t s y a w l a s i y r t a i h c y s P r u o b a l are likely if the patient feels alienated. Patients know if we feel bad about them. They may internalize this, and assume that things will always be bad because they themselves are bad. Despite these bullets, there is a probl em that won \200\231t go away. If we \201 nd our- selves talking to perpetrators rather t han victims, we may not be wise to suspend judgment forever. If a crime is afoot putting ot hers at risk, you may need to break con \201 dentiality. Discuss this with a colleague. As k yourself whether Nazi and Rwandan doctors were too nonjudgmental with their fel- low pati ents. If \200\230tout comprendre c \200\231est tout pardonner \200\2311, then to pardon al l actions is to abdicate our moral selves. What is the consequence of this \200\224for us, and for our patients? Unless we exercise judgment, it might be thought, we may be condoning evil. \200\230For evil to \202 ourish in the world, all that is required is for the goo d to remain silent \200\231. If we remain silent long enough, then will our own moral sense sicken, and die? What human duties do doctors have which trump anything that goes on in th e consulting room? Whenever you think the time may have come to judge, check with yourself that it is not from outrage, or disgust, or through the exercise of pride, or from a positi on of power that you are judging \200\224but reluctantly, and from duty. The dreadful histo ry of some doctors in the twentieth century teaches that we must be human \201 rst, and p hysician-scientists second. Dr. Quarrell \200\231s letter \200\224 \200\234My dear Elvet \200 Phosphorescent patients I am growing suspicious about the extent to which I need yr p ermission to have feelings about my patients. Clinical detachment is a profoundly un- natur al state of mind and all sorts of evil can come of it \200 In Casualty amongst all that bat tered \202 esh \200 it was a survival tool. So it gets carried over into psychiatry. We o ff er our patients what appears to be human contact, human warmth \200\224and we give them a calculated simulacrum of human contact, with no \202 esh, no blood, no love, no desire \200 I do not know how to proceed \200 help \200 this [patient] is slightly phosphorescen t. \200\235AS Byatt 2003 p75 of A Whistling Woman r u o , s e v l e s r u o e g d u j e w f i t u b \200 e s o p r u p o n o t y g r e n e d n e p x e e w , s r e h t o g n i g d u j n I